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A  Reference  Handbook 


OF 


THE  MEDICAL  SCIENCES 


EMBRACING  THE  ENTIRE  RANGE  OF 


SCIENTIFIC  AND  PRACTICAL  MEDICINE 


AND 


ALLIED  SCIENCE 


BY   VARIOUS   WRITERS 


FIRST  AND  SECOND  EDITIONS  EDITED  BY 
ALBERT  H.  BUCK,  M.  D. 


THIRD  EDITION 

COMPLETELY  REVISED  AND  REWRITTEN 
Edited  by  THOMAS  LATHROP  STEDMAN,  A.  M.,  M.  D. 


COMPLETE  IN  EIGHT  VOLUMES 


VOLUME  ONE 


ILLUSTRATED  BY  NUMEROUS  CHROMOLITHOGRAPHS  AND  SIX  HUNDRED 
AND  ELEVEN  FINE  HALF-TONE  AND  WOOD  ENGRAVINGS 


NEW    YORK 
WILLIAM  WOOD  AND  COMPANY 

MDCCCCXIII 


5 


Copyright,  1913 
Bt  WILLIAM  WOOD  AND  COMPANY 


TIIE.MAIM.B.  PRESS*  YORK.  PA 


PREFACE. 

A  generation  since  a  wise  and  far-seeing  medical  publisher,  the  late  Mr. 
William  H.  S.  Wood,  and  an  accomplished  medical  editor,  Dr.  Albert  II.  Buck, 
conceived  the  happy  idea  of  the  Reference  Handbook.  There  were  at 
that  time  several  "systems"  covering  special  subjects  in  internal  medicine  and 
surgery,  but  none  which  satisfied  the  needs  of  the  profession  as  a  whole.  It 
was  to  meet  the  want  of  a  work  of  general  information  on  all  subjects  relating 
to  medicine  in  all  its  branches  that  this  encyclopedia  was  designed,  and  how  well 
it  did  so  was  evidenced  by  the  cordial  reception  it  received  from  the  medical  men 
of  the  country.  The  first  volume,  published  in  1884,  was  followed  at  regular 
intervals  by  others  until,  in  1887,  the  eighth  and  final  volume  was  delivered  to 
the  subscribers.  In  1893  a  supplementary  volume  covering  the  progress  made 
in  the  preceding  six  years  was  published.  During  the  years  1900-1904  a  second 
edition  of  the  work  appeared,  still  under  the  management  of  Dr.  Buck,  and  met 
with  an  equally  favorable  reception  from  the  medical  public.  An  Appendix, 
treating  of  Anaphylaxis,  Opsonin  Therapy,  and  other  new  subjects,  was  pub- 
lished, under  the  supervision  of  the  present  editor,  in  1908. 

For  a  third  edition  of  a  work  with  this  history  of  successful  endeavcr 
behind  it,  no  apology  is  called  for,  though  a  few  words  in  the  way  of  explanation 
may  net  be  amiss.  Dr.  Buck,  to  whose  rare  editorial  skill,  aided  by  the  loyal 
cooperation  of  over  five  hundred  contributors,  the  success  of  the  former  editions 
was  due,  was  reluctant  to  undertake  the  labor  of  seeing  a  third  edition  through 
the  press,  and  the  present  editor,  whose  privilege  it  was  to  have  assisted  in  the 
preparation  of  the  first  edition,  was  invited  to  assume  the  task. 

The  general  plan  of  the  original  work  is  followed  in  the  present  edition,  but 
the  editor  has  profited  by  the  fact  that  the  old  plates  have  been  destroyed  to 
introduce  some  new  features.  The  system  of  cross  references  has  been  largely 
extended  and  here  and  there  these  references  have  been  amplified  to  full  defini- 
tions or  miniature  treatises,  in  many  cases  thus  affording  all  the  information 
desired  by  the  consulter  without  the  necessity  of  searching  through  the  main 
article.  Considerable  space  has  been  given  to  the  history  of  medicine,  and  in 
line  with  this,  brief  biographies  of  the  leaders  in  medical  thought  and  progress 
have  been  introduced.  Most  of  these,  signed  A.  H.  B.,  have  been  contributed 
by  Dr.  Buck,  who  in  this  and  many  other  ways  has  manifested  his  continued 
interest  in  the  work.  The  series  of  amplified  cross  references  on  zoological 
subjects,  signed  A.  S.  P.,  have  been  written  by  Professor  Arthur  S.  Pearse  of  the 
University  of  Wisconsin.  The  articles  on  the  mineral  springs  of  the  United 
States  in  the  second  edition  of  the  work  were  written  by  the  late  Dr.  James  K. 
Crook.  These  have  been  so  thoroughly  revised,  in  many  cases  entirely  rewritten, 
by  Dr.  Emma  E.  Walker,  that  her  name  alone  is  signed  to  the  articles. 

The  thanks  of  the  editor  are  due  to  the  many  contributors  to  the  former 
editions  of  this  work  who  have  revised  their  articles,  preserving  the  framework 
but  rewriting  them  with  the  ripened  experience  of  thirteen  years  of  added  work 
in  their  special  lines.  To  those  also  who  have  contributed  for  the  first  time  to 
this  edition  or  have  added  to  the  number  of  their  former  contributions,  the 
editor  desires  to  express  his  gratitude  for  their  prized  assistance.  And  finally 
he  wishes  to  record  his  obligation  to  the  many  friends  who  have  aided  him  by 
suggestions  of  articles  and  of  writers,  and  especially  to  Dr.  Buck  for  encourage- 
ment and  advice  on  many  points.  The  Publishers,  by  their  ready  acceptance  of 
his  suggestions,  sometimes  involving  greatly  increased  expense,  have  lightened 
his  labors  in  no  small  measure. 

T.  L.  S. 
iii 


Authority  to  use  for  comment  the  Pharmacopeia  of  the  United  States  of  America,  eighth 
decennial  revision,  in  this  volume,  has  been  granted  by  the  Board  of  Trustees  of  the  United 
States  Pharmacopeial  Convention,  which  Board  of  Trustees  is  in  no  way  responsible  for  the 
accuracy  of  any  translations  of  the  official  weights  and  measures,  or  for  any  statement  as 
to  the  strength  of  official  preparations. 


LIST  OF  CONTRIBUTORS  TO  VOLUME  I. 


LEONARD  W.  BACON,  M.D.,  New  Haven,  Conn. 
Instructor  in  Operative  Surgery,  Medical  Depart- 
ment, Yale  University. 

JAMES  B.  BAIRD,  M.D Atlanta,  Ga. 

Formerly  Professor  of  Clinical  Medicine,  Southern 
Medical  College;  Attending  Physician,  Grady 
Hospital. 

FRANK  BAKER,  M.D.,  Ph.D.,  Washington,  D.  C. 
Professor    of     Anatomy,     Georgetown     University 
School  of  Medicine,   Washington,   D.   C;  Supt., 
National  Zoological  Park,  Smithsonian  Institu- 
tion. 

EDWARD    R.    BALDWIN,   M.D..  .Saranac  Lake, 
N.  Y. 
Assistant,  Saranac  Laboratory;  Examiner,  Adiron- 
dack   Cottage  Sanitarium;   Director,   Reception 
Hospital. 

WALTER  A.  BASTEDO,  M.D..  .New  York,  N.  Y. 
Associate  in  Pharmacology  and  Therapeutics, 
Columbia  University;  Assistant  Attending  Phy- 
sician, St.  Luke's  Hospital,  New  York;  Consulting 
Physician,  St.  Vincent's  Hospital,  Staten  Island; 
Fifth  Vice  President,  National  Convention  for 
the  Revision  of  the  Pharmacopoeia. 

A.  L.  BENEDICT,  A.M.,  M.D.. ..  Buffalo,  N.  Y. 
Editor  of  The  Buffalo  Medical  Journal;  Consultant 
in  Digestive  Diseases,  City  and  Columbus  Hos- 
pitals; Attendant,  Mercy  Hospital;  Author  of 
"Golden  Rules  of  Dietetics";  Charter  Member 
of  the  American  Gastroenterological  Association. 

ROBERT   PAYNE    BIGELOW,  Ph.D Boston. 

Assistant  Professor  of  Zoology  and  Parasitology, 
Massachusetts  Institute  of  Technology. 

ALBERT  N.    BLODGETT,  M.D..  ..  Boston,  Mass. 

PERCIVAL  R.  BOLTON,  M.D... New  York,  N.  Y. 
Formerly  Instructor  in  Surgery,  Cornell  University 
Medical  College  in  New  York  City. 

JOHN  T.   BOWEN,  M.D Boston,  Mass. 

Edward  Wigglesworth  Professor  of  Dermatology, 
Emeritus,  Harvard  University;  Chief  of  Service, 
Department,  of  Dermatology,  Massachusetts 
General  Hospital;  Consulting  Physician,  Chil- 
dren's and  Infants'  Hospitals,  Boston. 

ALBERT  H.   BUCK,  M.D New  York,  N.  Y. 

C.  N.   B.  CAMAC,  M.D New  York,  N.  Y. 

Assistant  Professor  of  Clinical  Medicine,  College  of 
Physicians  and  Surgeons,  Columbia  University; 
Physician  to  New  York  City  Hospital;  Formerly 
Professor  of  Clinical  Medicine,  Cornell  University 
Medical  College  in  New  York  City. 

W.    B.   CANNON,  A.M.,  M.D Boston,  Mass. 

George  Higginson  Professor  of  Physiology,  Harvard 
University. 

RAYMOND   C.   COBURN,   M.A.,   M.D New 

York,  N.  Y. 
Anesthetist,  City  Hospital;  Consulting  Anesthetist, 
Beth  Israel  Hospital,  New  York  City. 


BENSON  AMBROSE  COIIOE,  B.A.,  M.  B.  (Tor.), 
Pittsburgh,   Pa. 
Late  Professor  of  Anatomy,   LTniversity  of  Pitts- 
burgh;    Associate     Professor     of     Therapeutics, 
University  of  Pittsburgh;   Attending  Physician, 
St.  Francis  Hospital,  Pittsburgh. 
THOMAS  D.  COLEMAN,  A.M.,  M.D Augusta, 

(  i  \. 

Professor  of  Principles  and  Practice  of  Medicine, 
Medical  Department  of  the  University  of  Georgia; 
Attending  Physician,  Augusta  City  and  Lamar 
Hospitals. 

W.  J.  CONKLIN,  M.D Dayton,  O. 

Formerly  Professor  of  Diseases  of  Children,  Star- 
ling Medical  College;  Consulting  Physician  to  St. 
Elizabeth's  and  Miami  Valley  Hospitals. 

LUZERNE  COVILLE,  M.D Ithaca,  N.  Y. 

Formerly  Lecturer  and  Demonstrator  in  Anatomy, 
Cornell  University  at  Ithaca. 
MONTGOMERY   A.   CROCKETT,  M.D. .  .  Bedford 
City,   Va. 
Formerly    Adjunct    Professor    of    Obstetrics    and 
Gynecology,     University     of     Buffalo     Medical 
School. 

EDWARD  CURTIS,  M.D New  York,  N.  Y. 

Late  Emeritus  Professor  of  Materia  Medica  and 
Therapeutics,  College  of  Physicians  and  Surgeons, 
Columbia  University. 

CHARLES  TOWNSHEND  DADE,  M.D New 

York,  N.   Y. 
Consulting     Dermatologist,     Roosevelt     Hospital, 
Englewood  Hospital,  N.  J.,  and  Vassar  Brothers 
Hospital,   Poughkeepsie,   N.   Y.;   Dermatologist, 
St.  Luke's  Hospital  Clinic. 

CHARLES  L.  DANA,  M.D New  York,  N.  Y. 

Professor  of  Diseases  of  the  Nervous  System, 
Cornell  University  Medical  College  in  New  York 
City;  Physician  to  Bellevue  Hospital;  Neurologist 
to  the  Montefiore  Homo;  Ex-president  N.  Y. 
Academy  of  Medicine;  President  New  York 
Psychiatrical  Society. 
ROBERT  H.  S.  DAWBARN,  M.D. .  .New  York. 
Senior  Attending  Surgeon,  City  Hospital;  Professor 
of  Surgery,  Fordham  University  Medical  School; 
Emeritus  Professor  of  Surgery,  New  York 
Polyclinic  Medical  School;  Consulting  Surgeon, 
New  York  Polyclinic  Hospital. 

UEORGE  V.  N.  DEARBORN,  A.M.,  M.D.,  Ph.D., 
Boston,  Mass. 
Professor  of  Physiology,  Tufts  Medical  and  Dental 
Schools,  Boston;  Professor  of  the  Philosophy  of 
Physical  Education,  Sargent  Normal  School, 
Cambridge;  Author  of  "The  Emotion  of  Joy," 
"A  Textbook  of  Human  Physiology,"  "Moto- 
sensory  Development,"  etc. 

D.  BRYSON  DELAVAN,  M.D.  .  .New  York,  N.  Y. 
Professor  of  Laryngology,  New  York  Polyclinic 
Medical  School:  Consulting  Laryngologist,  Gen- 
eral Memorial  Hospital,  Hospital  for  Ruptured 
and  Crippled  and  Vassar  Brothers  Hospital, 
Poughkeepsie;  Surgeon,  New  York  Polyclinic; 
Consulting  Physician,  Stony  Wold  Sanatorium. 


LIST  OF  CONTRIBUTORS  TO  VOLUME  I. 


FRANCIS  X.  DERCUM,   M.D.  .Philadelphia,  Pa. 

Professor  of  Nervous  and  Mental  Diseases,  Jefferson 
Medical  College;  Consulting  Neurologist  to  the 
Philadelphia  General  Hospital;  Foreign  Corre- 
sponding Member  of  the  Neurological  Society  of 
Paris,  and  Corresponding  Member  of  the  Psychia- 
tric and  Neurological  Society  of  Vienna. 

WILLIAM  A.  NEWMAN  DORLAND,  M.  D. . .  .Chi- 
cago, III. 
Professor  of  Obstetrics,  Medical  Department, 
Loyoia  University;  Visiting  Obstetrician,  Cook 
County  Hospital;  Visiting  Obstetrician  and  Gyne- 
cologist, Jefferson  Park  Hospital;  First  Lieu- 
tenant Medical  Reserve  Corps,  U.  S.  A.;  Member 
Committee  on  Nomenclature  and  Classification 
of  Diseases  of  the  American  Medical  Association. 

HENRY  DUFFY,  ESQ Baltimore,  Md. 

Lately  State's  Attorney. 

ISADORE  DYER,  Ph.B.,  M.D.  .New  Orleans,  La. 
Dean  and  Professor  of  Diseases  of  the  Skin,  Medical 
Department,    Tulane    University    of    Louisiana; 
Editor  New  Orleans  Medical  and  Surgical  Jour- 
nal, etc. 

R.  G.  ECCLES,  M.D.,  Ph.D Brooklyn,  N.  Y. 

Ex-Dean  Brooklyn  College  of  Pharmacy;  ex- 
Chairman  Section  of  Active  Principles  of  Com- 
mittee of  Revision  U.  S.  Pharmacopoeia. 

MAX  EINHORN,  M.D New  York,  N.  Y. 

Professor  of  Medicine,  New  York  Post-Graduate 
Medical  School;  Visiting  Physician,  German 
Hospital;  Consulting  Physician,  White  Plains 
and  Hackensack  Hospitals. 

GEORGE  THOMSON  ELLIOT,  M.D..New  York. 
Clinical  Professor  of  Dermatology,  Cornell  Univer- 
sity Medical  College  in  New  York  City;  Consulting 
Dermatologist,  St.  Luke's,  Columbus,  and  New 
York  Lying-in  Hospitals,  and  New  York  Eye  and 
Ear  Infirmary. 

LEONARD  W.  ELY,  M.D Denver,  Colo. 

Orthopedic  Surgeon  to  the  County,  Children's,  and 
St.  Joseph's  Hospitals. 

L.  W.  FAMULENER,  M.D New  York,  N.  Y. 

Assistant  Director,  Research  Laboratory,  Depart- 
ment of  Health,  New  York  City. 

FREDERICK  G.  FINLEY,  M.D Montreal, 

Canada. 

Professor  of  Medicine,  McGill  University;  Physician 
to  the  Montreal  General  Hospital. 

JOHN  ADDISON  FORDYCE,  A.M.,  M.D New 

York,  N.  Y. 
Professor   of   Dermatology   and    Syphilology,   The 
University  and   Bellevue  Hospital  Medical  Col- 
lege; Visiting  Dermatologist,  City  Hospital. 

WILLIAM  WHITWORTH  GANNETT,  M.D..  Bos- 
ton, Mass. 
Formerly  Instructor  in  Clinical  Medicine,  Harvard 
University  Medical  School. 

JOHN  H.  GIBBON,  M.D Philadelphia,  Pa. 

Professor  of  Surgery,  Jefferson  Medical  College; 
Surgeon  to  the  Pennsylvania  and  Bryn  Mawr 
Hospitals;  Consulting  Surgeon  to  the  Woman's 
Hospital. 

CHARLES  L.  GIBSON,  M.  D.. .  .New  York,  N.  Y. 
Adjunct  Professor  of  Surgery,  Cornell  University; 
Surgeon  to  St.  Luke's  Hospital;  Consulting  Sur- 
geon to  the  City  Hospital. 

A.   II.  CORDON,  M.D Montreal,  Canada. 

Demonstrator  of  Clinical  Medicine,  McGill  Univer- 
sity; Out-patient  Physician,  Montreal  General 
11"  ipital. 


JOHN  GREEN,  M.D St.  Louis,  Mo. 

Emeritus  Professor  of  Ophthalmology,  Medical 
Department  of  Washington  University,  St.  Louis. 

ARTHUR  R.  GUERARD,  M.A.,  B.S.,  M.D... Flat 
Rock,  N.  C. 
Formerly  Instructor  in  Therapeutics,  The  Univer- 
sity and  Bellevue  Hospital  Medical  College,  and 
Assistant  Bacteriologist,  New  York  City  Health 
Department. 

LEWIS  WENDELL  HACKETT,  M.D....   Boston. 

Assistant,  Department  of  Preventive  Medicine  and 
Hygiene,  Harvard  Medical  School. 

ALLAN  McLANE  HAMILTON,  M.D.,  LL.D.,  F.R.S 

(Edin.),  New  York,  N.  Y. 
Consulting  Neurologist  to  the  Manhattan  State 
Hospital  for  the  Insane;  Formerly  Professor  of 
Clinical  Psychiatry  at  Cornell  University  Medical 
College  and  Consulting  Neurologist  to  the  Hos- 
pital for  Ruptured  and  Crippled;  Author  of  "A 
System  of  Legal  Medicine." 

H.  F.   HANSELL,   A.M.,  M.D..  .Philadelphia,  Pa. 
Professor    of    Ophthalmology,    Jefferson    Medical 
College;  Emeritus  Professor  Diseases  of  the  Eye, 
Philadelphia     Polyclinic;     Attending     Ophthal- 
mologist, Philadelphia  General  Hospital. 

WILLIAM  A.  HARDAWAY,  M.D..  .  St.  Louis,  Mo. 
Honorary  Member  of  the  American  Dermatological 
Association. 

LUDVIG  HEKTOEN,   M.D Chicago,   III. 

Director  of  the  Memorial  Institute  for  Infectious 
Diseases;  Professor  of  Pathology,  University  of 
Chicago  and  Rush  Medical  College. 

FREDERICK  P.  HENRY,  A.M.,  M.D Phila- 
delphia, Pa. 
Professor  of  the  Principles  and  Practice  of  Medicine 
in  the  Women's  Medical  College  of  Pennsylvania; 
Attending  Physician,  Philadelphia  Hospital; 
Consulting  Physician,  Woman's  Hospital  of 
Philadelphia. 

CHARLES   ADAMS  HOLDER,  M.D Phila- 
delphia, Pa. 
Formerly     Assistant     in     Therapeutics,     Jefferson 
Medical  College. 

JOHN  HOWLAND,  M.D Baltimore,  Md. 

Professor  of  Pediatrics,  Johns  Hopkins  University. 

JOHN  B.  HUBER,  A.M.,  M.D..New  York,  N.  Y. 
Professor  of  Pulmonary   Diseases,   Fordham   Uni- 
versity  Medical   School;    Visiting  Physician,  St. 
Joseph's  Hospital  for  Consumptives. 

GEORGE  THOMAS  JACKSON,  M.D New 

York,  N.  Y. 
Professor   of   Dermatology,   College   of   Physicians 
and  Surgeons,  Columbia  University;  Consulting 
Dermatologist,   Presbyterian    Hospital   and    the 
New  York  Infirmary  for  Women  and  Children. 

SMITH  ELY  JELLIFFE,  A.M.,  M.D.,  Ph.D.  .  .New 

York,  N.  Y. 
Professor  Clinical  Psychiatry,  Fordham  University; 
Adjunct  Professor  Diseases  of  the  Nervous  Sys- 
tem, Post-Graduate  Medical  School;  Visiting  Neu- 
rologist, City  Hospital;  Physician,  Neurological 
Hospital,  New  York. 

JEFFERSON   R.   KEAN,   M.D United  States 

Army. 
Lieutenant-Colonel,   Medical   Corps,   U.   S.   Army; 
Assistant  to  the  Surgeon-General. 

OTTO  KILIANI,  M.D New  York,  N.  Y. 

Professor  of  Clinical  Surgery,  Columbia  University; 
Surgeon  to  the  German  Hospital. 


LIST  OF  CONTRIBUTORS  TO  VOLUME  I. 


CHARLES    LESTER    LEONARD,     M.D.  ..  .Phila- 
delphia, Pa. 
Professor    of    Roentgenology,    Philadelphia    Poly- 
clinic;  Ex-President,    American   Roentgen   Ray 
Society. 

J.  F.  LEYS,  M.I) United  States  N  wy. 

Formerly  Superintendent  Colon  Hospital,  Isthmian 
Canal  Commission,  and  President  Medical  Asso- 
ciation of  the  Canal  Zone. 

GEORGE    BURGESS   MAGRATH,    M.D..  Boston. 
Formerly   Assistant   in   Pathology,    Harvard    Uni- 
versity Medical  School. 

MATTHEW  D.  MANN,  M.D Buffalo,  N.  Y. 

Emeritus  Professor  of  Obstetrics  and  Gynecology, 
Medical  Department,  University  of  Buffalo; 
Consulting  Gynecologist,  Buffalo  General  and 
Erie  County  Hospitals. 

CHARLES  F.  MARTIN,  M.D.    Montreal,  Canada. 
Professor  of  Medicine  and  Clinical  Medicine,  McGill 
University;  Physician  Royal  Victoria  Hospital. 

PHILIP  MARVEL.  M.D Atlantic  City,  X.  J. 

WILLY  MEYER,  M.D New  Yobk,  X.  Y. 

Professor  of  Surgery,  N.  Y.  Post-Graduate  Medica 
School;  Surgeon  to  the  German  and  Post-Gradu- 
ate  Hospitals;  Consulting  Surgeon,  X.  Y.  Infir- 
mary for  Women  and  Children,  Skin  and  Cancer 
Hospital,  Har  Moriah  Hospital,  and  Hospital  for 
Deformities  and  Joint  Diseases. 

BENJAMIN  MICHAILOVSKY,   B.S.,  M.D... New 
York,   N.  Yr. 
Deputy  Physician,  New  York  Hospital,  O.P.D. 

T.  WESLEY  MILLS,  M.A.,  M.D.,  L.R.C.P.  (Lond.), 
London,   England. 
Emeritus  Professor  of  Physiology,  McGill  Univer- 
sity, Montreal,  Canada. 

WILLIAM  OLIVER  MOORE,  M.D.,  LL.B...New 
York,  N.  Y. 
Professor  Emeritus  of  Diseases  of  the  Eye  and  Ear, 
New  York  Post-Graduate  Medical  School;  Oph- 
thalmic Surgeon  to  the  Protestant  Orphans' 
Home  and  Asylum;  Consulting  Ophthalmic 
Surgeon,  Flushing  Hospital. 


.  Montreal, 


WILLIAM  S.  MORROW,  M.D. 
Canada. 


EDWARD  L.  MUNSON,  M.D United  States 

Army. 
Major,  Medical  Corps,  U.  S.  Army;  Director,  Field 
Service  School  for  Medical  <  (fficers,  Army  Service 
Schools,  Fort  Leavenworth,  Kansas. 

RICHARD  COLE  NEWTON,   M.D Montclaih, 

N.  J. 
Consulting      Physician,      Mountainside      Hospital, 
Montclair;  Member  New  Jersey  State  Board  of 
Health. 

JOHN    BENJAMIN    NICHOLS,    M.D Wash- 
ington, D.  C. 
Lecturer   on    Dietetics,    George    Washington    Uni- 
versity;   Pathologist,    Episcopal    Hospital;    At- 
tending Physician,  Freedmen's  Hospital. 

FREDERICK  G.  NOVY,  Sc.D.,  M.D.    Ann  Arbor, 

Mich. 
Professor    of    Bacteriology    and    Director    of    the 
Hygienic  Laboratory,  University  of  Michigan. 

THOMAS  A.  OLNEY,  M.D South  Bend, 

Indiana. 
Surgeon  to  St.  Joseph  Hospital. 


I  W.I  VER  T.  OSBORNE,  M.A.,  M.D New 

Haven,  Conn. 
Professor  of  Therapeutics,  Medical  Department, 
Yale  University;  Member  of  the  Revision  Com- 
mittee of  the  United  states  Pharmacopoeia; 
Member  of  t  he  ( 'oiineil  on  Pharmacy  and  ( Ihemis- 
try  of  the  American   Medical  Association. 

EDWARD  0.  OTIS.  M.  D Boston,  Mass, 

Professor  of  Pulmonary  Diseases  and  Climatology, 
Tufts  College  Medical  School;  Late  Visiting  and 
Consulting  Physician  to  the  Massachusetts  State 
Sanatorium;  Ex-President,  of  the  American 
Climatological  Association;  Physician  to  the 
Department  of  Tuberculosis  of  the  Lungs, 
Boston  Dispensary. 

WILLIAM  H.  PARK,  M.D New  York,  N.  Y. 

Professor  of  Bacteriology  and  Hygiene,  The  Uni- 
versity and  Bellevue  Hospital  Medical  College; 
Director  of  the  Research  Laboratories  of  the 
Department  of  Health  of  the  City  of  New  York. 

RICHARD  MILLS  PEARCE,  M.D .. Philadelphia. 

Professor  of  Research  Medicine,  University  of 
Pennsylvania. 

ARTHUR  S.  PEARSE,   Ph.D Madison,   Wis. 

Assistant  Professor  of  Zoology,  University  of  Wis- 
consin; Instructor  in  Zoology,  Marine  Biological 
Laboratory,  Woods  Hole,  Mass. 

JULIUS  POHLMAN,    M.D Buffalo,   N.   Y. 

Late  Professor  of  Physiology,  Medical  Department, 
University  of  Buffalo. 

SIOMUND  POLLITZER,  M.D..New  York,  N.  Y. 
Professor  of  Dermatology,  New  York  Post-Graduate 
Medical  School;  Physician  to  the  German  Dis- 
pensary, Class  of  Skin  Diseases. 

EDWARD  PREBLE,  M.D New  Y'ork,  N.  Y. 

ROBERT   B.  PREBLE,   M.D Chicago,   III. 

Professor  of  Medicine,  Northwestern  LTniversity 
Medical  School;  Attending  Physician,  Cook 
County  and  German  Hospitals,  Chicago. 

JOSEPH     RANSOHOFF,     M.D.,    F.R.C.S.     (Eng.), 
Cincinnati,  O. 
Professor  of  Surgery,  University  of  Cincinnati. 

ANDREW  ROSE   ROBINSON,   M.D.New  York. 

Professor  of  Dermatology,  New  York  Polyclinic; 
Attending  Physician,  New  York  Polyclinic 
Hospital;  Consulting  Dermatologist,  Perth 
Amboy  Hospital. 

HENRY  H.  RUSBY,  M.D Newark,  N.  J. 

Dean  and  Professor  of  Botany,  Physiology,  and 
Materia  Medica,  New  York  College  of  Pharmacy; 
Pharmacognosist  at  the  Port  of  New  York  for  the 
U.  S.  Department  of  Agriculture;  Chairman 
Scientific  Directors,  N.  Y.  Botanical  Garden. 

T.     E.    SATTERTHWAITE,     A.B.,     M.D.,     LL.D., 
Sc.D.,  New  York,  N.  Y. 
Consulting   Physician,    Post-Graduate,    Manhattan 
State,  Orthopaedic,  Babies',  and  Champlain  Val- 
ley Hospitals;  First  Lieutenant,  U.  S.  A.  (Medical 
Reserve  Corps). 

OTTO  SCHULTZE,  M.D New  York,  N.  Y. 

Professor  of  Medicolegal  Pathology  and  Assistant 
Professor  of  Pathological  Anatomy,  Cornell  Uni- 
versity Medical  College  in  New  York  City;  Coro- 
ner's Physician  in  the  Borough  of  Manhattan, 
New  York  City. 

R.  J.  E.  SCOTT,  M.D New  York,  N.  Y. 

Formerly  Gynecologist,  Demilt  Dispensary;  and 
\i  lending'  Physician,  Out-Patient  Department, 
Bellevue  Hospital,  New  York. 


vn 


LIST  OF  CONTRIBUTORS  TO  VOLUME  I. 


FRANCIS  J.  SHEPHERD,  M.D.,  LL.D.,  F.R.C.S. 
(Ed.),  Montreal,  Canada. 
Professor  of  Anatomy,  Medical  Department, 
McGill  University;  Senior  Surgeon,  The  Montreal 
General  Hospital;  Consulting  Surgeon  to  the 
Royal  Victoria  Hospital. 

J.  G.  SHERRILL,  M.D Louisville,   Ky. 

Professor  of  Surgery,  University  of  Louisville; 
Visiting  Surgeon,  Louisville  City  Hospital. 

CHAXXING  C.  SIMMONS,   M.D.  ..  Boston,  Mass. 

Surgeon  to  Out-Patients,  .Massachusetts  General 
Hospital;  Assistant  in  Surgery,  Harvard  Medical 
School. 

H.   BEAUMONT  SMALL,  M.D .  .  Ottawa,  Canada. 
Attending  Physician,  St.  Luke's  Hospital,  Ottawa; 
Late   Examiner   in    Materia    Mediea,   College   of 
Physicians  and  Surgeons,  Ontario. 

EDMOND   SOUCHON,  M.D... New  Orleans,   La. 
Formerly  Professor  of  Anatomy  and  Clinical  Sur- 
gery, Medical  Department,  Tulane  University  of 
Louisiana;  Curator  Souchon  Museum  of  Anatomy. 

ALEXANDER  SPINGARN,   A.M.,   M.D..  Brook-. 

lyn,  N.  Y. 
Assistant  Editor,  Medical  Record;  Attending  Pedi- 
atrist  to  the  Bushwick  and  East  Brooklyn  and 
Jewish  Hospital  Dispensaries. 

HEIXRICH  STERX,  M.D New  York,  N.  Y. 

Visiting  Physician,  St.  Mark's  Hospital  and  the 
.Methodist  Deaconess'  Home;  Consulting  Physi- 
cian, Methodist  Episcopal  (Seney)  Hospital, 
Central  Islip  State  Hospital,  Portchester  Hos- 
pital, and  Glens  Falls  Hospital;  Editor,  Archives 
of  Diagnosis. 

RALPH  G.  STILLMAN,  M.D... New  York,  N.  Y. 
Clinical  Pathologist,  Attending  Physician  for  Con- 
tagious Diseases,  First  Deputy  Attending  Physi- 
cian to  the  Out-Patient  Department,  New  York 
Hospital;  Attending  Physician,  Seton  Hospital; 
Instructor  in  Clinical  Medicine,  Cornell  Univer- 
sity Medical  College  in  New  York  City. 

LEWIS  A.  STIMSON,  M.D.,  LL.D...  New  York. 
Professor  of   Surgery,   Cornell   University   Medical 
College  in  New  York  City;  Consulting  Surgeon, 
New  York  and  Bellevue  Hospitals. 

E.  W.  TAYLOR,  A.M.,  M.D Boston,  Mass. 

Assistant  Professor  of  Neurology,  Harvard  Medical 
School;  Chief-of-Service,  Neurological  Depart- 
ment, Massachusetts  General  Hospital;  Visiting 
Neurologist,  Long  Island  Hospital,  Boston. 

WILLIAM   H.  THOMSON,   M.D New  York. 

Visiting  Physician,  Roosevelt  Hospital. 

PAUL  THORNDYKE,   M.D Boston,   Mass. 

Surgeon-in-Chief,  Boston  City  Hospital;  Assistant 
Professor  of  Genito-Urinary  Surgery  Harvard 
Medical  School. 


FRANK  P.  UNDERHILL,  Ph.D.,  New  Haven,  Conn. 
Assistant  Professor  of  Physiological  Chemistry, 
Sheffield  Scientific  School  of  Yale  University; 
Professor  of  Pathological  Chemistry,  Department 
of  Medicine,  Yale  University;  Chemist  to  the 
New  Haven  Hospital. 

CARL  VON  RUCK,  M.D Asheville,  N.  C. 

Consulting  Physician  to  the  Winyah  Sanatorium; 
Director  of  the  von  Ruck  Research  Laboratory 
for  Tuberculosis. 

EMMA    ELIZABETH    WALKER,    M.D New 

York,  N.  Y. 
Assistant  Surgeon,  Hospital  for  the  Relief  of  the 
Ruptured  and  Crippled. 

HENRY  BALDWIN  WARD,  Ph.D.,  Urbana,  III. 
Professor  of  Zoology  and  Chief  of  the  Research 
Laboratory  of  Parasitology,  University  of  Illinois; 
Formerly  Dean  of  the  College  of  Medicine  and 
Professor  of  Zoology,  University  of  Nebraska, 
and  Zoologist  to  the  State  Board"  of  Agriculture. 

JOHN   COLLINS    WARREN,    M.D.,    LL.D.,    Hon. 
F.R.C.S.,   Boston,  Mass. 
Professor  of  Surgery  Emeritus,  Harvard  University 
Medical     School;    Consulting    Surgeon,    Massa- 
chusetts General  Hospital. 

ALDRED  SCOTT  WARTHIN,  Ph.D.,  M.D Ann 

Arbor,  Mich. 
Professor  of  Pathology  and  Director  of  the  Patho- 
logical Laboratories,  University  of  Michigan. 

II.  GIDEON  WELLS,  M.D Chicago,  III. 

Associate  Professor  of  Pathology,  University  of 
Chicago. 

WILLIAM  A.  WHITE,  M.D.,  Washington,  D.  C. 
Superintendent,  Government  Hospital  for  the  In- 
sane; Professor  of  Nervous  and  Mental  Diseases, 
George  Washington  University  Medical  College 
and  Georgetown  University  Medical  College; 
Lecturer  on  Insanity,  U.  S.  Army  and  U.  S. 
Navy  Medical  Schools. 

H.  AUGUSTUS  WILSON,  M.D...  Philadelphia,  Pa. 
Professor  of  Orthopedic  Surgery,  Jefferson  Medical 
College;  Orthopedic  Surgeon  to  St.  Agnes 
Hospital  and  to  the  Philadelphia  General  Hos- 
pital; Consulting  Orthopedic  Surgeon,  Kensing- 
ton Hospital  for  Women  and  the  Philadelphia 
Lying-in  Charity. 

CHARLES    F.    WITHINGTON,  M.D Boston. 

Visiting  Physician,  Boston  City  Hospital;  Formerly 
Instructor  in  Clinical  Medicine,  Harvard  Medical 
School. 

C.  G.  L.  WOLF,  B.A.,  M.D.,  CM.,  New  York,  N.  Y. 
Formerly    Instructor   in   Physiological   Chemistry, 
Cornell  University  Medical  College. 

JAMES  HOMER  WRIGHT,  A.M.,  M.D.,  S.D.,  Bos- 
ton, Mass. 
Director  of   the   Pathological   Laboratory,   Massa- 
chusetts General  Hospital;  Assistant  Professorof 
Pathology,  Harvard  University  Medical  School. 


A  REFERENCE  HANDBOOK 


OF 


THE  MEDICAL  SCIENCES 


Aachen 


Abdomen 


Aachen. — See  Aix-la-Chapelle. 

Abdomen, Surgical  Anatomy of  the. — Theabdomenis 
the  region  of  the  body  lying  between  the  thorax  and  the 
pelvis.  It  includes  theabdominal  wall,  theabdominal  cav- 
ity, and  its  contents,  the  latter  comprising  almost  the 
whole  of  the  digestive  apparatus  andapart  of  theurinary. 
Above,  theabdominal  \vallisseparated  from  the  thorax  by 
the  costal  arch.  Below,  it  is  continued  into  the  pelvis 
and  thighs,  the  line  of  separation  on  either  side  being  the 
iliac  crest  (crista  iliaca)  laterally  and  Poupart's  ligament 
(ligamentum  inguinale)  mesially.  These  superficial 
boundaries  of  the  wall  are  not  coextensive  with  those 
of  the  cavity,  for  it  extends  above  into  the  vault  of  the 
diaphragm,  corresponding  superficially  to  the  fourth 
intercostal  space  on  the  right  side  and  the  fifth  on  the  left. 
Below,  it  passes  into  the  pelvic  cavity,  the  line  of  sep- 
aration between  abdomen  and  pelvis  being  the  linea 
iliopectinea.  Here  the  lower  limit  is  the  upper  surface 
of  the  levator  ani  and  coccygeus  muscles. 

The  form  and  external  appearance  of  the  abdomen 
van-  with  sex.  age,  and  the  condition  of  the  abdominal 
wall  and  underlying  organs.  In  infancy,  as  the  pelvis 
is  undeveloped  and  the  organs  in  the  upper  part  of  the 
cavity  are  relatively  large,  the  abdomen  is  cone-shaped, 
the  apex  of  the  cone  being  directed  downward.  In 
adult  males  the  region  is  cylindrical  and  slightly 
flattened  from  before  backward.  In  females  it  is  again 
cone-shaped,  but  the  apex  of  the  cone  is  above,  as  the 
diameter  of  the  lower  circumference  of  the  thorax  is 
always  less  than  that  of  the  pelvis. 

The  abdominal  wall  presents  anterolateral  and 
posterior  aspects.  It  differs  from  the  walls  of  other 
cavities  in  being,  for  the  most  part,  devoid  of  skeleton, 
which,  with  the  elastic  character  of  the  tissues  com- 
posing it,  allows  the  cavity  to  vary  in  capacity  accord- 
ing to  the  size  of  the  contained  viscera.  At  "all  times 
it  exerts  upon  them  a  gentle  pressure,  supporting  them, 
and  causing  the  more  solid  to  impress  the  softer.  This 
pressure  may  be  appreciated  in  any  laparotomy 
wound,  when  the  omentum  and  more  movable  intes- 
tines are  retained  with  difficulty.  The  anterolateral 
wall  is  composed  of  the  following  layers  of  tissue, 
which  must  be  considered  in  detail: 
Skin, 

Superficial  fascia  {^^^ 

External  oblique  muscle, 

Internal  oblique  muscle, 

Transversalis  muscle, 

Rectus  muscle, 

Transversalis  fascia, 

Preperitoneal  tissue, 

Parietal  peritoneum. 
In  addition  to  this  general  description,  certain  regions 
which  are  commonly  the  seat  of  hernia  must  receive 
especial  study.     These  are: 

The  inguinal  region, 

The  inguinofemoral  region. 
Vol.  I.— 1 


The  Skin  of  the  abdominal  wall  is  thin  and  movable 
except  in  the  region  of  the  navel,  where  it  is  attached  to 
the  underlying  tissue.  Corresponding  to  the  linea  alba 
is  a  furrow  which  indicates  the  space  between  the  recti 
muscles.  Two  transverse  flexion  folds  are  usually 
present,  one  at  the  level  of  the  umbilicus,  a  second,  one 
inch  above  the  pubis.  This  latter  marks  the  summit 
of  the  moderately  distended  bladder.  In  pregnancy, 
or  during  the  growth  of  large  intraabdominal  tumors, 
the  stretching  of  the  skin  may  give  rise  to  a  series  of 
longitudinal  lines,  called  stria?  gravidarum. 

Superficial  Fascia. — Of  this  there  are  two  layers. 
The  superficial  layer  varies  in  thickness  according  to 
the  amount  of  fat  deposited  in  it.  Both  above  and 
below-  it  is  continuous  with  the  corresponding  layer  of 
tissue  in  adjacent  regions.  In  the  pubic  region  it 
passes  into  the  scrotum,  losing  the  fat,  and,  joining  the 
deep  layer,  it  assists  in  the  formation  of  the  dartos. 
At  the  posterior  border  of  the  scrotum  it  becomes  con- 
tinuous with  the  same  layer  of  the  perineum.  The 
amount  of  fat  deposited  in  this  layer,  together  with 
that  in  the  omentum  and  mesenteries,  is  the  principal 
factor  in  determining  the  external  appearance  of  the 
abdomen.  Accordingly,  all  gradations  occur,  from 
the  thin  concave  abdomen  of  the  emaciated  to  the 
thick  pendulous  one  of  the  obese.  These  variations 
become  of  importance  in  examinations  of  abdominal 
organs  or  in  operations  upon  them.  The  thick  wall 
renders  the  task  more  difficult. 

The  deep  layer  is  thin  and  more  fibrous  in  structure. 
It  can  be  separated  distinctly  only  in  the  lower  half  of 
the  wall;  above,  it  is  lost  in  the  superficial  layer. 
Below,  externally,  it  is  connected  with  the  iliac  crests: 
anteriorly,  it  passes  over  Poupart's  ligaments,  to  be 
attached  to  the  fascia  lata  half  an  inch  below  them. 
In  the  pubic  region,  together  with  the  superficial  layer 
it  passes  into  the  scrotum  to  form  the  dartos.  At  the 
posterior  border  of  the  scrotum  the  layers  again 
separate,  the  deeper  one  forming  the  corresponding 
fascia  of  the  perineum.  This  latter  fascia  is  attached 
on  each  side  to  the  rami  of  the  pubis  and  ischium,  and 
turning  around  the  posterior  border  of  the  transverse 
perineal  muscles,  it  becomes  continuous  with  the  deep 
perineal  fascia.  It  is  beneath  this  layer  of  tissue  that 
urine  or  an  infection  is  guided  from  the  perineum 
through  the  scrotum  upon  the  abdomen.  The  attach- 
ment of  the  fascia  to  the  bony  margin  of  the  pelvis 
prevents  the  spread  into  the  thighs  on  their  inner  sides, 
while  the  attachment  to  the  fascia  lata  prevents  a 
similar  spread  from  in  front.  The  deep  superficial 
fascia  is  separated  from  the  aponeurosis  of  the  external 
oblique  by  loose  areolar  tissue  except  along  the  linea 
alba,  where  the  attachment  is  more  intimate. 

External  Oblique  Muscle  (musculus  obliquus  externus 
abdominis)  (Figs.  1  and  2). — This,  the  strongest  and 
most  superficial  of  the  abdominal  muscles,  arises  by 
fleshy  digitations  from  the  eight  lower  ribs,  interdigi- 
tating  in  the  upper  half  with  the  serratus  magnus,  in 
the  lower  with  the  latissimus  dorsi.     The  fibers    are 


Abdomen,  Surscical  Anatomy 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


ir: 


m  I 


\ 

k 


Fig.  1. — On  the  Left  Side,  the  External  Oblique  and  the  Anterior 
Layer  of  the  Rectus  Sheath  are  Removed;  on  the  Right  Side,  the 
External  and  Internal  Oblique  and  the  Lower  Half  of  the  Rectus. 
The  deep  epigastric  artery  is  shown  through  the  wall.  (Joessel.) 
a.  Rectus  abdominis;  b,  inseriptio  tendinea;  c,  external  oblique; 
d,  linea  alba;  c,  internal  oblique;  /,  fascia  transversalis;  (7,  internal 
abdominal  ring;  h,  Poupart's  ligament;  £,  anterior  crural  nerve; 
3,  femoral  artery;  k,  femoral  vein;  I,  spermatic  cord;;m,  fossa  ovalis; 
n,  deep  epigastric  artery,  shown  through  abdominal  wall;  o,  trans- 
versalis muscle;  p,  linea  semilunaris;  q,  semilunar  fold  of  Douglas. 


directed  downward,  forward,  and  inward, 
those  from  the  last  two  ribs  almost  verti- 
cally downward  to  their  insertion  in  the 
anterior  two-thirds  of  the  external  lip  of  the 
iliac  crest.  The  remaining  fibers,  more 
oblique  in  direction,  terminate  in  a  broad 
aponeurosis,  which  at  the  mid-line  joins  with 
the  aponeurosis  of  the  remaining  muscles  in 
the  linea  alba.  The  following  structures  in 
the  aponeurosis  of  the  external  oblique  re- 
quire especial  mention: 

Poupart's  Ligament  (ligamentum  in- 
guinale), formed  by  the  thickened  lower 
border  of  the  aponeurosis,  stretched  be- 
tween the  anterior  superior  iliac  spine  and 
the  pubic  spine.  Attached  to  it  below  is  the 
fascia  lata,  which  gives  to  the  ligament  an 
outline,  convex  downward.  The  flexor  mus- 
cles of  the  thigh,  the  femoral  vessels,  and 
the  anterior  crural  nerve  pass  behind  the 
ligament  in  their  course  downward. 

(iimli, ■nml's  Ligament  (ligamentum  lacu- 
nare)  (Fig.  5). — Reflected  from  the  pubic 
end  nf  Poupart's  ligament  to  the  linea  iliopec- 
tinea  for  about  three-quarters  of  an  inch,  is 
a  triangular  layer  of  fibrous  tissue  termed 
Gimbernat's  ligament.  It  has  upper  and 
lower  free  surfaces,  and  a  concave  external 
border,  bounding  the  femoral  ring  internally. 

External  Abdominal  or  Inguinal  Ring  (an- 
nulus  inguinalis  subcutaneus)  (Fig.  2). — 
Situated  in  the  lower  and  inner  part  of  the 
aponeurosis  is  an  oval  opening,  formed  by 
the  separation  of  the  fibers  composing  this 
part  of  the  aponeurosis  from  the  fibers  of 


m-t 


Poupart's  ligament.  The  long  axis  of  the  ring  corre- 
sponds in  direction  to  that  of  the  fibers  of  the  aponeu- 
rosis. Its  base  is  formed  by  the  pubic  crest,  its  sides 
by  the  diverging  fibers,  which  are  called  the  pillars  of 
the  ring.  The  superior  or  internal  pillar,  thin  and  flat, 
is  attached  to  the  anterior  surface  of  the  symphysis 
pubis,  while  the  inferior  or  external,  thick  and  pris- 
matic, essentially  the  inner  end  of  Poupart's  ligament, 
curves  inward  to  terminate  at  the  pubic  spine.  Further 
facts  concerning  the  external  ring  will  be  mentioned 
in  the  special  description  of  the  inguinal  region. 

Inter  columnar  Fascia  (fibras  intererurales). — Binding 
together  the  fibers  of  the  aponeurosis  above  the 
inguinal  opening  is  a  set  of  fibers  which  arch  trans- 
versely inward  from  the  outer  half  of  Poupart's  liga- 
ment, thus  closing  the  angular  interval  left  between 
the  diverging  pillars.  At  the  margins  of  the  opening 
these  fibers  are  continued  over  the  spermatic  cord 
and  testicle  as  a  fine  fascia,  the  intercolumnar  or 
spermatic  fascia. 

Internal  Oblique  Muscle  (musculus  obliquus  interims 
abdominis)  (Fig.  1). — The  general  direction  of  the 
fibers  composing  this  muscle  is  the  opposite  of  that  of 
the  external  oblique.  It  arises  below  from  the  outer 
half  or  two-thirds  of  Poupart's  ligament,  from  the 
anterior  two-thirds  of  the  middle  lip  of  the  crest  of  the 
ilium,  and  from  the  lumbar  fascia  in  the  angle  between 
the  crest  of  the  ilium  and  the  outer  border  of  the  erector 
spinoe  muscle.  From  this  origin  the  fibers  ascend  over 
the  side  of  the  abdomen  to  be  disposed  of  as  follows: 
the  most  posterior  fibers  pass  upward  to  be  inserted 
into  the  outer  surfaces  of  the  three  lower  ribs;  those 
from  the  crest  anteriorly,  the  spine,  and  Poupart's 
ligament  end  in  a  broad  aponeurosis  which  extends 
from  the  thorax  to  the  pubis,  and  at  the  outer  border 
of  the  rectus  divides  into  two  layers,  to  enclose  this 
muscle,  uniting  again  at  the  linea  alba.  The  anterior 
layer  is  inseparably  united  with  the  aponeurosis  of  the 
external  oblique,  the  posterior  with  that  of  the  trans- 
versalis, and  above  with  the  seventh  and  eighth  costal 
cartilages  and  the  ensiform  process.  This  arrangement 
obtains  only  in  the  upper  two-thirds  of  the  aponeurosis. 


Fig.  2. — On  theLeftSide,  the  Aponeurosis  of  the  External  Oblique  and  the 
Course  of  the  Deep  Epigastric  Artery  on  the  Rear  Surface  of  the  Abdominal 
Wall  are  Shown;  on  the  Right,  the  External  Oblique  is  Removed,  Opening  the 
Inguinal  Canal.  (Joessel.)  a,  Poupart's  ligament;  6,  spermatic  cord;  c, 
anterior  crural  nerve;  d,  free  edge  of  iliac  portion  of  fascia  lata;  e,  femoral 
artery;/,  femoral  vein;  g,  saphenous  vein;  Ji.  fossa  ovalis;  i,  reflected  portion 
nf  Gimbernat's  ligament;  /,  fascia  transversalis;  /,-,  lymph  gland  in  femoral 
canal;  I,  fascia  lata;  m,  pubic  portion  of  fascia  lata;  n,  cremaster  muscle; 
o,  internal  oblique;  p,  external  oblique;  q,  deep  epigastric  vessels;  r,  superior 
pillar  of  tin-  external  ring;  s,  inferior  pillar  of  the  external  ring;  t,  inter- 
columar  fascia. 


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MmIoiikm,  Surgical  Anatomy 


In  (he  lower  third  there  is  no  division  into  layers,  l»>ih 
internal  oblique  and  transversalis  passing  in  front  of 
the  rectus  wiih  the  external  oblique.  The  deficiency 
resulting  in  the;  sheath  of  the  rectus  is  marked  above 
by  a  semilunar  edge,  known  as  the  semilunar  fold  of 
Douglas  (linea  semicircularis).  The  lowest  fibers 
which  arise  from  I'oupart's  ligament  arch  downward 
and  inward,  and,  joining  similar  libers  from  the 
transversalis,  form  the  conjoined  tendon  of  these  two 
muscles,  by  which  they  are  inserted  into  the  anterior 
surface  of  the  pubis  and  the  inner  part  of  the  ilio- 
peetineal  line,  behind  (iimbernat's  ligament. 

The  Transversalis  Muscle  (musculus  transversus 
abdominis)  (Fig.  1),  situated  beneath  the  internal 
oblique,  arises  from  the  inner  surfaces  of  the  six  lower 
ribs,  from  the  transverse  processes  of  the  lumbar 
vertebnE  by  an  aponeurosis,  and  from  the  anterior 
two-thirds  of  the  inner  lip  of  the  crest  of  the  ilium. 
Passing  horizontally  inward,  the  fibers  terminate  in  an 
aponeurosis  about  an  inch  external  to  the  border  of 
the  rectus,  except  at 
the  upper  extremity, 
where  the  fibers  pass 
behind  the  rectus  al- 
most to  the  middle 
line.  The  arrange- 
ment of  the  aponeuro- 
sis was  described  with 
that  of  the  internal 
oblique. 

Rectus  Abdominis 
Muscle  (musculus  rec- 
tus abdominis)  (Fig. 
1). — This  muscle  con- 
sists of  vertical  fibers 
lying  within  the  sheath 
formed  by  the  internal 
oblique  as  described 
above.  Situated  on 
either  side  of  the  mid- 
line of  the  abdomen, 
it  arises  from  the  an- 
terior surface  and  crest 
of  the  pubis.  Expand- 
ing and  becoming  thin- 
ner as  it  ascends,  it  is 
inserted  into  the  carti- 
lages of  the  fifth,  sixth, 
and  seventh  ribs,  as 
well  as  the  bone  of  the 
fifth.  The  fibers  of  the 
muscle  are  interrupted 
by  three  or  more  ten- 
dinous intersections 
(inscriptiones  tendi- 
nece)  placed,  the  first 
at  the  umbilicus,  the  second  at  the  lower  end  of  the 
ensiform  process,  the  third  midway  between  them. 
They  are  confined  chiefly  to  its  anterior  fibers  and 
are  firmly  united  to  the  anterior  wall  of  the  muscle 
sheath.  When  additional  transverse  lines  occur,  they 
are  usually  incomplete  and  are  placed  below  the 
umbilicus. 

The  Linea  Alba,  formed  by  the  union  of  the  aponeu- 
roses of  the  two  oblique  and  transverse  muscles,  extends 
in  the  mid-line  from  the  ensiform  process  to  the  pubis. 
A  little  below  the  middle  it  is  widened  into  a  circular 
space,  in  the  center  of  which  is  the  umbilicus.  Above 
the  umbilicus  the  recti  muscles  diverge  and  the  linea 
alba  broadens.  Below  the  umbilicus  the  recti  muscles 
converge  and  the  linea  becomes  narrower  and  passes 
in  front  of  the  conjoined  inner  heads  of  the  recti 
muscles  to  the  pubis.  Passing  from  the  linea,  behind 
the  conjoined  heads,  is  a  small  band  of  longitudinal 
fibers,  the  adminiculum  linea?  alb*,  which  spreads  out 
below  into  a  triangular  expansion  attached  to  the 
upper  border  of  the  pubis  behind  the  external  head  of 
the  rectus.     During  pregnancy,  or  when  the  abdomen 


Fig.  3  — 

(Jurssi'l    ) 

d,   middle 
ff,   bladder 


inguinal    fossa; 

h,  wis  deferens; 


ht  anterior    crural    nerve;    lt   iliac    muscle; 
hypogastrica;  o,  plica  urachi ;  p,  peritoneum. 


is  distended  by  disease,  the  linea  alba  is  much  increased 
in  breadth. 

The  Linea  Semilunaris,  situated  along  the  outer 
border  of  the  rectus  muscle,  is  a  curved  linear  depre    ton 

Corresponding  to  the  narrow  portion  of  the  aponeurosis 

of  the  internal  oblique,  between  the  termination  of  the 

muscular  liber-  and   tie-  division  of  the  aponeurosis  to 
form  the  rectus  sheath. 

Fascia  Transversalis. — This  thin  layer  of  fascia 
lines  the  posterior  surface  of  the  transversalis  muscle 
and  is  continued  on  to  the  under  surface  of  the  dia- 
phragm. Above  the  umbilical  line  it  is  exceedingly 
thin,  but  below,  especially  in  the  inguinal  region,  it  is 
more  strongly  developed  and  is  attached  to  I'oupart's 
ligament.  Laterally,  it  is  attached  to  the  inner  lip  of 
the  crest  of  the  ilium  and  is  continuous  with  the  iliac 
fascia.  An  opening  in  the  transversalis,  the  internal 
abdominal  ring,  will  be  described  below. 

Preperitoneal  Tissue  and  Parietal  Peritoneum. — The 
properitoneal  tissue  is  a  variable  layer  which  is  situated 

between  the  transver- 
salis fascia  and  the 
peritoneum,  and  is 
more  highly  developed 
in  the  inguinal  regions. 
Farther  up  on  the  ab- 
dominal wall  it  is  fre- 
quently absent.  In 
this  layer  are  situated 
the  most  important 
blood-vessels  of  the 
abdominal  wall.  The 
parietal  peritoneum 
will  be  more  especially 
noted  below.  For  the 
most  part  it  is  sepa- 
rated from  the  fascia 
transversalis  by  the 
properitoneal  tissue, 
but  along  the  linea 
alba  and  the  umbilical 
region  the  two  are 
united. 

Blood-vessels  of  the 
Anterior  Abdominal 
Wall. — The  Arteries  of 
the  abdominal  wall  are 
in  two  sets,  superficial 
and  deep.  The  super- 
ficial vessels  are  situ- 
ated in  the  superficial 
fascia.  They  are  the 
superficial  epigastric 
and  the  superficial 
circumflex  iliac,  de- 
rived from  the  femoral. 
The  deep  set  comprises  the  six  lower  intercostals,  the 
lumbar,  the  deep  circumflex  iliac,  the  superior  epigas- 
tric, and  the  deep  epigastric  artery  (arteria  epigastrica 
inferior).  Of  these,  the  latter  requires  especial 
description. 

Arising  from  the  distal  end  of  the  external  iliac,  the 
deep  epigastric  artery  passes  upward  and  inward  across 
the  rear  wall  of  the  inguinal  canal  to  the  posterior  sur- 
face of  the  rectus;  entering  the  sheath  of  the  rectus  it 
continues  its  course  upward  to  anastomose  with  the 
superior  epigastric,  a  branch  of  the  internal  mammary. 
It  lies  between  the  fascia  transversalis  and  the  parietal 
peritoneum  in  the  properitoneal  tissue.  In  the  begin- 
ning of  its  course  it  encircles  the  lower  and  internal 
boundaries  of  the  internal  inguinal  ring. 

Two  small  branches  arise  from  the  deep  epigastric 
artery:  the  cremasteric,  which  accompanies  the  sper- 
matic cord,  and  the  pubic  branch,  which  ramifies  on  the 
superior  surface  of  Gimbernat's  ligament  and  the 
posterior  surface  of  the  pubic  bone.  On  the  surface  of 
the  abdomen  the  course  of  the  artery  may  be  indicated 
by  a  line  drawn  from  the  junction  of  the  inner  third 


Rear  View  of  the  Anterior  Abdominal  Wall  in  the  Inguinal  Region. 

a,  Poupart's  ligament;  b,  external  inguinal  fossa;  c,  femoral  fossa; 

internal  inguinal  fossa;  /,  umbilical  artery  ; 

i,  external  iliac  vein;  ;,  external  iliac  artery; 


plica  epigastrica; 


plica 


Abdomen,  Sureical  Anatomy 


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with    the    outer    two-thirds    of    Poupart's    ligament, 
obliquely  upward  to  the  umbilicus. 

The  veins  are  likewise  divisible  into  a  superficial  and 
a  deep  set.  The  superficial  include  the  superficial 
epigastric,  the  superficial  circumflex  iliac,  and  the  vena 
tegumentosa.  The  latter  connects  the  axillary  with 
either  the  superficial  epigastric  or  the  femoral  veins. 

The  deep  veins  accompany  the  corresponding  arteries 
and  are  double.     They  anastomose  with  one  another, 
and  also  with  the  superficial  veins  on  one  side  and  with 
the  portal   system   on   the  other,    through   the  para- 
umbilical veins  which  run  in  the  falciform  ligament  of 
the  liver.     In  pathological  states  which  interfere  with 
the  circulation  in  either  the  vena  cava  inferior  or  the 
porta]  system,  the  superficial  veins  may  be  much  more 
prominent  than  is  usual.     In  the  former  ease,  the  blood 
current   is  upward,   toward   the  umbilicus,   the  veins 
assisting  in  the  formation  of  a  collateral  circulation. 
In  the  latter  case  the 
current  is  downward, 
away  from  the  umbil- 
icus,  and   the  dilata- 
tion is  due  to  direct 
stasis. 

Above  the  umbilicus 
the  superficial  lymph- 
atics empty  into  the 
axillary  glands;  below 
it,  into  the  inguinal 
glands.  The  deep 
lymphatic  vessels 
empty  into  the  sternal 
glands  above  and  into 
the  iliac  glands  below. 

Nerves.  —  The  ab- 
dominal muscles  are 
supplied  by  the  six 
lower  intercostal 
nerves;  the  skin  of  the 
abdomen,  by  cutane- 
ous branches  of  the 
same  together  with  the 
ilio-hypogastric  and 
the  ilio-inguinal  from 
the  first  lumbar.  The 
nerves  are  situated  be- 
tween the  transver- 
salis  and  the  internal 
oblique,  and  pursue  a, 
course  corresponding 
to  the  intercostal 
space,  from  which 
they  emerge  as  far  as 
the  sheath  of  the  rec- 
tus, which  they  pierce 
to  become  cutaneous. 
Laterally,  between  the 
origins  of  the  external 
oblique,  the  latissimus 
dorsi,  and  the  serratus  magnus,  arises  a  series  of  lateral 
cutaneous  branches  which  supply  the  skin  of  the  lateral 
aspect  of  the  abdomen. 

In  this  connection  it  is  interesting  to  note  the  rela- 
tionship existing  between  the  nerve  supply  of  the 
abdominal  wall  on  the  one  hand,  and  that  of  the  abdom- 
inal viscera  and  peritoneum  on  the  other.  The  viscera 
derive  their  principal  nerve  supply  from  the  three 
splanchnics,  which  are  formed  by  the  union  of  the 
rami  communicantcs  of  the  six  lower  intercostals. 
Therefore  the  abdominal  viscera  and  the  abdominal 
walls  are  all  connected  with  the  same  segments  of  the 
central  nervous  system. 

In  disease  these  nerve  connections  may  serve  to 
explain  many  of  the  symptoms  and  signs,  such  as 
reflected  pains  and  rigid  abdominal  muscles  in  acute 
inflammatory  stairs. 

The  surgeon  is  frequently  called  upon  to  open  the 


Fig.  4. — Rear  View  of  Anterior  Abdominal  Wall,  the  Peritoneum  having 
been  Removed.  (Joessel.)  a,  Anterior  crural  nerve;  b,  external  iliac 
artery;  c,  external  iliac  vein;  d,  obturator  artery;  e,  obturator  nerve;  /, 
umbilical  artery;  q,  ureter;  h,  seminal  vesicle;  7,  bladder;  j,  adminiculura 
linear  alb®;  k,  vas  deferens;  I,  spermatic  vessels;  m,  transversalis  fascia; 
n,  iliacus;  o,  Poupart's  ligament;  p,  semilunar  fold  of  Douglas;  q,  obliterated 
umbilical  arterv:  r,  urachus;  s,  suspensory  ligament  of  liver;  t,  rectus  muscle; 
u,  deep  epigastric  vessels;  v,  internal  abdominal  ring. 


abdominal  cavity  through  the  anterolateral  wall.  The 
incisions  should  be  carefully  planned,  first,  to  give 
ample  room  for  the  necessary  intraabdominal  manipu- 
lations; second,  to  do  the  least  possible  injury  to  the 
abdominal  wall,  thus  reducing  to  a  minimum  the 
liability  of  a  subsequent  ventral  hernia. 

The  most  common  line  of  incision  is  through  the  linea 
alba,  this  route  being  chosen  in  most  pelvic  operations, 
in  those  upon  the  intestines  in  general,  and  in  many  of 
those  upon  the  stomach.  The  line  is  easily  followed 
above  the  umbilicus,  where  the  linea  alba  is  broad,  but 
below,  where  it  is  narrow,  the  line  is  followed  with 
difficulty.  In  incisions  above  the  umbilicus  the 
position  of  the  falciform  ligament  of  the  liver  should  be 
remembered. 

Many  surgeons  prefer  an  incision  slightly  to  one  side 
of  the  linea — one  which  opens  the  sheath  "of  the  rectus 
muscle  and  separates  its  fibers.     They  believe   that 

such  a  wound  heals 
more  solidly  than  one 
s  that  divides  the  linea 

alba,  formed  as  it  is 
by  the  interlacement 
of  numerous  aponeu- 
rotic layers.  Certainly 
the  linea  has  but  one 
possible  advantage, 
that  is,  nonvascu- 
lar! ty.  The  rectus 
should  be  separated 
only  in  its  inner  half, 
because  of  the  position 
of  the  nerve  trunks  in 
its  outer  half.  For 
this  reason  a  trans- 
verse incision  will  do 
less  damage  than  a 
longitudinal  one  in  the 
outer  half  of  the  rec- 
tus. 

In  lateral  incisions 
three  points  must  be 
borne  in  mind:  (l)The 
direction  of  muscular 
or  aponeurotic  fibers; 
(2)  the  course  of 
nerves;  (3)  the  course 
of  blood-vessels. 

All  longitudinal  or 
oblique  incisions  will 
divide  one  or  more 
layers  of  muscular 
fibers  which,  in  many 
instances,  it  is  impos- 
sible to  avoid.  How- 
ever, when  possible 
the  plan  of  McBurney 
should  be  followed — ■ 
namely,  that  of  sepa- 
rating each  aponeurotic  layer  in  the  direction  of  its 
fibers.  When  the  fibers  of  all  the  layers  cannot  be 
separated  in  this  manner,  it  is  advisable  to  separate 
those  of  the  external  oblique  and  divide  the  remaining 
layers.  The  separation  of  the  fibers  possesses  many 
advantages — it  is  almost  bloodless,  no  large  nerves  are 
injured,  and  the  edges  of  the  wound,  instead  of  tending 
to  separate,  tend  to  approximate.  It  has  the  dis- 
advantage of  requiring  a  larger  number  of  assistants 
and  of  not  giving  as  free  an  opening  as  direct  incision. 
When  it  becomes  necessary  to  incise  the  entire  thick- 
ness of  the  abdominal  wall,  the  incision  should  be 
planned  with  due  regard  to  the  nerves,  remembering 
that  they  are  continued  forward  from  the  intercostal 
spaces  between  the  transversalis  and  the  internal 
oblique.  For  this  reason,  lateral  longitudinal  incisions 
along  the  rectus  are  objectionable,  division  of  the  nerves 
being  followed  by  more  or  less  paralysis,  which  is  an 


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Abdomen,  Surgical  Anatomy 


important  predisposing  factor  in  the  development  of  a 
hernia. 

Transverse  incisions  in  the  lower  abdominal  region 
must  avoid  the  deep  epigastric  artery  the  course  of 

which  is  indicated  above.       In  the  upper  half  they  must 
avoid   the   superior   epigastric   artery,   which,   however, 

i~  of  less  importance  than  the  deep  vessel. 

The  inguinal  region  is  bounded  below  by  Pouparl  's 
ligament,  internally  by  the  median  line  indicated  by 
the  lineaalba,  and  above  by  a  horizontal  line  extending 
from  the  anterior  superior  iliac  spine  to  the  median  line. 

The  tissue  layers  composing  the  wall  are  the  same  as 
those  of  the  abdominal  wall  in  general. 

Piercing  the  region  in  an  oblique  direction  from 
behind  forward,  downward,  and  inward  is  the  sper- 
matic cord  (funiculus  spermaticus)  in  the  male  and  the 
round  ligament  (ligamentum  teres  uteri)  in  the  female. 
The  track  which  the  spermatic  cord  pursues  in  the 
abdominal  wall  is  known  as  the  inguinal  canal,  but  it 
must  be  understood  that  a  true  canal  exists  only  in  a 
pathological  state. 

The  canal  presents 
for  description  an  ex- 
ternal opening,  an  in- 
ternal opening,  and 
four  walls.  As  men- 
tioned, the  external 
opening  (annulus  in- 
guinalis  subcutaneus) 
is  formed  by  the  sepa- 
ration of  the  lower  and 
the  inner  fibers  of  the 
aponeurosis  of  the  ex- 
ternal oblique.  The 
ring  is  closed  by  the 
intercolumnar  fascia 
(libra'  intercrurales) 
which  is  continued 
over  the  cord  and 
testicle  and  must  be 
teased  from  the  cord 
before  the  ring  is 
plainly  visible.  At 
the  upper  angle,  it 
binds  the  columns  to- 
gether, thus  strength- 
ening the  ring  above. 
The  externa!  ring 
varies  in  size,  depend- 
ing upon  the  develop- 
ment of  the  intercol- 
umnar fibers.  Nor- 
mally, the  opening  will 
admit  the  end  of  the 
finger,  but  this  is 
modified  by  the  posi- 
tion of  the  body.  ~ 


Fk:.  5. — On  the  Right  Side  arc  Shown  the  Location  and  Relations  of  an 
External  Inguinal  Hernia;  on  the  Left  Side,  those  of  a  Femoral  Hernia.  The 
obturator  artery  is  shown  arising  from  the  deep  epigastric.  Us  course 
along  the  free  edge  of  Gimbemat's  ligament  is  diagrammatically  shown 
on  the  left  side.  (Joessel.)  a.  Deep  circumflex  iliac  artery;  o,  external 
iliac  artery  and  vein;  c,  lymphatic  glands;  </,  iliopsoas  muscle;  e,  vas 
deferens;  /,  ureter;  g,  bladder;  h,  seminal  vesicles;  i,  obturator  nerve; 
j,  abnormal  obturator  artery,  internal  to  sac  of  femoral  hernia;  /.-,  abnormal 
obturator  artery,  external  to  neck  of  femoral  hernia;  I,  Gimbernat's  liga- 
ment; m,  Poupart's  ligament;  n,  internal  abdominal  ring;  o,  sac  of  a  femoral 
hernia;  p,  rectus  muscle;  q,  upper  border  of  pubis;  r,  deep  epigastric  vessels; 
s,  sac  of  an  external  inguinal  hernia;  /,  transversalis  fascia. 


Flex- 
ion and  external  rotation  of  the  thigh  relax  the  opening, 
extension  of  the  thigh  or  contraction  of  the  abdominal 
muscles  contracts  the  opening — facts  which  should  be 
remembered  in  the  reduction  of  hernia  by  taxis.  In 
corpulent  persons  and  in  women  it  is  sometimes  diffi- 
cult to  locate  the  ring,  but  it  should  be  remembered 
that  it  is  immediately  above  and  external  to  the  spine 
of  the  pubis.  When  the  spine  cannot  be  located,  the 
tendon  of  the  adductor  longus  will  serve  as  a  guide,  as 
it  lies  immediately  beneath  the  pubic  spine  and  can  in 
all  cases  be  easily  recognized. 

The  internal  abdominal  ring  (annulus  inguinalis 
abdominalis)  is  situated  half  an  inch  above  the  middle 
of  Poupart's  ligament.  Here,  on  the  posterior  surface 
of  the  transversalis  fascia,  the  spermatic  cord  enters 
the  inguinal  canal,  being  invested  throughout  its  entire 
length  by  a  process  of  the  fascia  known  as  the  processus 
vaginalis  fascia;  transversalis  or  the  infundibulifonn 
fascia.  Thus  it  is  seen  that  the  transversalis  fascia 
is  not  perforated  by  the  cord,  but  is  pushed  forward  as 
an  investing  membrane. 


The  anterior  wall  of  the  canal  is  formed  by  the  apo 
neurosis  of  the  external  oblique,  the  libers  of  w  Ineli  are 
here  crossed  by  the  intercolumnar  libers. 

The  posterior  wall   of   the  canal   is  composed  of  the 

aponeurosis  of  the  internal  oblique  and  file  transver- 
salis, and  of  the  fascia  transversalis.  It  is  divisible  into 
two  parts:  a  lateral,  formed  by  the  transversalis  fascia, 
and  an  inner,  formed  by  the  conjoined  tendon  of  the 
internal  oblique  and  the  transversalis. 

The  upper  wall  of  (he  canal  is  bounded  by  the  lower 
libers  of  the  internal  oblique  and  I  he  I  ninsversalis. 
When  the  origin  of  these  muscles  from  Poupart's 
ligament  extends  far  inward,  the  cord  runs  for  a  short 
distance  between  them  before  taking  its  usual  position 
in  the  canal.  From  the  lower  border  of  the  internal 
oblique  a  series  of  loops  of  muscular  fibers  connected 
by  fine  fascia  is  again  prolonged  over  the  cord.  The 
libers  form  the  cremasteric  muscle  and  the  connecting 
fascia  is  the  cremasteric  fascia. 
The  low-er  wall  or  floor  of  the  canal  is  Poupart's  liga- 
ment. The  subserous 
fatty  tissue  in  this  re- 
gion is  well  developed 
and  forms  one  of  the 
layers  investing  a 
hernia. 

Rear  View  of  tlie  An- 
In-ior  A  bdominal 
Wall  in  the  Inguinal 
Region. 

The  parietal  perito- 
neum covering  this  re- 
gion of  the  abdominal 
wall  is  thick  and  freely 
movable.  It  presents 
a  median  and  two 
lateral  longitudinal 
folds  separating  as 
many  depression  s. 
The  median  fold,  ex- 
tending from  the  sum- 
mit of  the  bladder  to 
the  umbilicus,  i  s 
caused  by  theurachus 
and  is  known  as  the 
plica urachi  (plica  uni- 
bilicalis  media).  On 
either  side  of  it  lies  the 
internal  inguinal  fossa 
(fovea  supra-vesi- 
calis).  Of  the  two 
lateral  folds  the  me- 
dian is  formed  by  the 
lateral  ligament  of  the 
bladder,  the  obliter- 
ated hypogastric  artery  of  the  fetus.  It  is  known  as 
the  plica  hypogastrica  (plica  umbilicalis  lateralis),  and 
separates  the  internal  inguinal  (supravesical)  fossafrom 
a  second,  the  middle  inguinal  fossa.  The  external  of 
the  lateral  folds  corresponds  to  the  deep  epigastric 
artery,  and  separates  the  middle  inguinal  fossa  (fovea 
inguinalis  medialis)  from  a  third,  the  external  fossa 
(fovea  inguinalis  lateralis).  This  fold  is  the  plica 
epigastrica. 

In  the  floor  of  the  external  inguinal  fossa  is  situated 
the  internal  abdominal  ring  bounded  internally  by  the 
deep  epigastric  artery.  The  floor  of  the  middle  inguinal 
fossa  is  the  posterior  wall  of  the  inguinal  canal.  The 
floor  of  the  internal  inguinal  fossa  corresponds  to  a 
point  in  the  abdominal  wall  immediately  external  to 
the  outer  border  of  the  rectus  muscle. 

The  floor  of  each  fossa  may  be  the  exit  of  one  of  the 
varieties  of  inguinal  hernia.  The  most  important 
landmark  of  the  above  is  the  plica  epigastrica,  formed 
by  the  deep  epigastric  artery  separating  the  external 
from  the  middle  inguinal  fossa.     Two  forms  of  inguinal 


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hernia  are  described  according  to  their  relation  to  the 
deep  epigastric  artery. 

Thus,  a  hernia  emerging  through  the  external  in- 
guinal fossa  is  an  oblique  or  external  inguinal  hernia. 
It  travels  the  entire  length  of  the  inguinal  canal,  and 
the  neck  of  the  hernial  sac  lies  external  to  the  deep 
epigastric  artery. 

A  hernia  emerging  through  the  middle  or  internal 
inguinal  fossa  is  an  internal  or  direct  inguinal  hernia. 
Instead  of  traversing  the  entire  length  of  the  canal,  it 
passes  through  the  lower  portion  only,  to  emerge  at  the 
external  ring.  The  deep  epigastric  artery  is  external 
to  the  neck  of  the  sac.  A  hernia  emerging  through 
the  internal  inguinal  fossa  is  rare  and  is  described  by 
Joessel  as  an  internal  oblique  inguinal  hernia.  Quain, 
however,  dismisses  this  variety  with  the  simple  state- 
ment that  it  is  rare,  and  reserves  the  term  internal 
oblique  inguinal  hernia  for  those  cases  of  internal  hernia 
which  emerge  between  the  conjoined  tendon  and  the 
deep  epigastric  artery,  and  so  traverse  a  considerable 
portion  of  the  inguinal  canal  before  reaching  the  exter- 
nal ring. 

External  or  oblique  inguinal  hernia  may  be  congeni- 
tal or  acquired.  In  describing  the  congenital  variety, 
it  is  necessary  to  state  that  the  testicle  in  its  descent 
from  the  abdomen  into  the  scrotum  is  accompanied  by 
a  pouch  of  peritoneum  (processus  vaginalis  peritonei) 
which,  about  the  time  of  birth,  is  separated  by  the 
adhesion  of  its  walls  from  the  general  peritoneal  cavity 
The  obliteration  extends  normally  from  the  internal 
abdominal  ring  to  the  epididymis,  the  lower  portion  of 
the  pouch  remaining  as  the  tunica  vaginalis  testis 
(tunica  vaginalis  propria  testis),  the  upper  portion  being 
gradually  converted  into  a  fibrous  cord.  However,  the 
obliteration  may  fail  wholly  or  in  part.  Thus  the 
pouch  may  be  obliterated  only  at  the  internal  ring  or 
immediately  above  the  testicle,  or  it  may  remain  in 
complete  communication  with  the  general  peritoneal 
cavity.  When  the  latter  condition  obtains,  it  is  an 
easy  matter  for  a  loop  of  intestine  to  enter  the  processus 
vaginalis  peritonei  and  so  form  a  hernia.  Such  a  hernia 
usually  develops  before  or  soon  after  birth,  and  is 
distinguished  by  the  fact  that  the  hernial  contents  are 
in  direct  relation  with  the  testicle,  and  that  the  hernial 
sac  is  a  preformed  one.  Again,  such  a  hernia  first 
shows  itself  in  more  adult  age  and  may  be  suspected  in 
rapidly  developing  cases.  Thus  it  is  seen  that  the  term 
congenital  applies  rather  to  the  conditions  existing  than 
to  the  time  of  life  at  which  the  hernia  appears.  Should 
the  congenital  hernia  reach  the  scrotum,  it  passes  below 
the  testicle,  surrounding  it  so  that  it  is  necessary  to 
examine  carefully  in  order  to  find  this  organ.  This 
may  serve  to  differentiate  between  congenital  and 
acquired  hernia.  Should  the  obliteration  fail  in  the 
upper  portion  of  the  processus  vaginalis  peritonei,  but 
below  form  a  normal  tunica  vaginalis,  then  the  con- 
ditions are  present  which  allow  the  development  of  a 
variety  of  hernia  described  as  hernia  into  the  funicular 
process.  It  resembles  the  congenital  form  in  all  par- 
ticulars except  in  that  of  coming  into  direct  contact 
with  the  testicle. 

In  early  childhood  the  inguinal  canal  pursues  a  very 
direct  course  through  the  abdominal  wall,  but  as  devel- 
opment proceeds,  the  pelvis  widens  and  the  canal 
acquires  an  oblique  course,  the  internal  ring  receding 
from  the  external.  This  change  in  the  direction  of  the 
canal  may  be  followed  by  spontaneous  healing  of  the 
hernia. 

Acquired  External  Inguinal  Hernia. — This  variety, 
not  having  a  congenital  sac,  provides  itself  with  one 
from  the  parietal  peritoneum,  Entering  the  internal 
opening  (annulus  inguinalis  abdominalis),  it  passes 
slowly  along  the  canal  to  the  external  opening  (annulus 
inguinalis  subcutaneus)  and  follows  the  cord  into  the 
scrotum,  being  always  separated  from  the  testicle  by  its 
own  sac  and  the  outer  layer  of  the  tunica  vaginali 
Such  a  hernia  is  of  slow  development  and  may  remain 
for  a  long  time  within  the  canal  before  emerging  from 


the  outer  opening  and  passing  into  the  scrotum. 
During  the  first  stages  the  canal  retains  its  obliquity. 
As  the  hernia  increases  in  size  and  weight  the  internal 
ring  approaches  the  external,  so  that  the  sac  passes 
almost  directly  through  the  abdominal  wall.  However, 
the  neck  of  the  sac  is  still  encircled  on  its  inner  side  by 
the  deep  epigastric  artery.  As  the  hernia  traverses  the 
inguinal  canal  it  is  invested  by  the  coverings  given  to 
the  spermatic  cord  from  the  several  layers  of  the 
abdominal  wall.  These  coverings  are:  (1)  skin,  and 
superficial  fascia;  (2)  fascia  propria,  composed  of,  (a) 
intercolumnar  fascia,  (6)  cremasteric  muscle  and 
fascia;  ('■'>)  infundibuliform  fascia;  (4)  the  preperitoneal 
tissue  and  peritoneum  composing  the  hernial  sac.     In 


Fig.  6. — Rear  View  of  Internal  Inguinal  Hernia.  (Joessel.) 
a,  Rectus;  6,  sac  of  internal  inguinal  hernia:  c,  bladder;  d,  vas 
deferens;  e,  seminal  vesicle;  f,  obturator  foramen;  g,  Poupart'g 
ligament;  h,  external  iliac  artery  and  vein;  i,  obliterated  umbilical 
artery;  ;',  spermatic  vessels;  /.■,  crural  nerve;  I,  iliac  muscle;  m,  deep 
circumflex  iliac  vessels;  n,  transversalis  fascia;  o,  internal  abdominal 
ring;  p,  deep  epigastric  vessels. 

congenital  hernia  this  is  the  processus  vaginalis  perito- 
nei, and  may  be  distinguished  from  the  acquired  peri- 
toneal coat  by  its  relation  to  the  testicle,  the  testicle 
being  within  the  sac,  and  its  firm  adherence  to  the  fascia 
propria.  The  acquired  sac  is  easily  separated  from  the 
fascia  propria,  while  the  congenital  is  separated  with 
difficulty.  The  aci  [uired  hernial  sac,  like  the  congenital, 
lies  directly  in  front  of  and  in  contact  with  the  vessels  of 
the  spermatic  cord,  but  does  not  pass  below  the  testicle. 

Two  additional  forms  of  acquired  external  inguinal 
hernia  are  described,  and  though  both  are  associated 
with  incomplete  obliteration  of  the  processus  vaginalis 
peritonei,  they  are  not  provided  with  a  congenital  sac. 
The  first  is  the  infantile  variety,  in  which  the  processus 
vaginalis  peritonei  is  obliterated  only  at  the  internal 
ring,  leaving  a  large  tunica  vaginalis  testis,  behind 
which  the  newly  formed  hernial  sac  descends. 

In  the  second  form,  that  of  encysted  hernia,  the  con- 
dition of  the  processus  vaginalis  peritonei  is  the  same; 
but  the  septum  which  is  undergoing  obliteration  yields, 
and,  passing  down  into  the  tunica  vaginalis  testis, 
invests  the  new  sac.  In  a  dissection  of  the  first,  three 
layers  of  peritoneum  must  be  divided;  in  a  dissection  of 
the  latter  only  two,  before  the  hernial  contents  are 
exposed. 

Internal  inguinal  hernia  is  of  much  less  frequent 
occurrence  and  differs  from  the  oblique  variety,  (1)  in 
passing  through  the  abdominal  wall  in  the  floor  of  the 


6 


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Abdomen,  Surgical  Anatomy 


middle  or  internal  inguinal  fossa,  and  consequently 
always  lying  on  the  inner  side  of  the  deep  epigastric 
artery;  ('-')  in  not  passing  along  the  entire  canal;  (3)  in 
external  appearance,  being  smaller  and  more  globular 
in  form;  (4)  in  being  situated  over  the  os  pubis  and  not 
in  the  course  of  the  inguinal  canal.  The  most  valuable 
differential  point  is  the  position  of  the  dee])  epigastric 
artery.  The  floor  of  the  middle  inguinal  fossa  is  The 
rear  wall  of  the  inguinal  canal.  It  is  divisible  into  two 
parts:  An  inner  part,  the  conjoined  tendon  of  the  inter- 
nal oblique  and  transversalis;  an  outer  part,  the  trans- 
versalis  fascia.  The  conjoined  tendon  (falx  inguinalis) 
varies  greatly  in  its  development.  In  many  cases  it  is 
slight  and  scarcely  discernible,  while  in  others  it  is 
strongly  developed,  especially  in  its  deeper  portion 
which  is  derived  from  the  transversalis  muscle,  and 
which  may  bound  the  canal  as  far  outward  as  the 
internal  ring. 

There  are  two  forms  of  internal  hernia  which  pass  out 
through  the  middle  fossa.  The  first  and  most  common 
form  protrudes  in  the  inner  part  of  the  fossa,  either 
separating  or  pushing  before  it  the  conjoined  tendon. 
It  traverses  only  the  lower  end  of  the  canal,  to  emerge 
at  the  external  ring.  The  coverings  of  this  variety, 
from  within  outward,  are  the  peritoneum  and  subperi- 
toneal tissue,  the  fascia  transversalis,  and  the  conjoined 
tendon,  except  in  those  cases  in  which  the  sac  passes 
between  the  fibers  of  the  tendon,  the  intercolumnar 
fascia,  the  superficial  fascia,  and  the  skin.  The  sper- 
matic cord,  placed  behind  and  on  the  outer  side,  is  not 
in  contact  with  the  sac,  the  cremasteric  and  the  infun- 
dibuliform  fascia  being  interposed. 

The  second  form  of  internal  hernia  passes  into  the 
inguinal  canal  through  the  outer  portion  of  the  rear  _ 
wall,  and  lies  between  the  conjoined  tendon  internally 
and  the  deep  epigastric  artery  externally.  It  passes  for 
a  considerable  distance  along  the  canal,  which  gives  it 
a  certain  degree  of  obliquity.  The  coverings  of  this 
hernia  are  the  same  as  those  of  the  first  variety,  with 
the  exception  of  the  conjoined  tendon,  which  is  replaced 
by  a  layer  derived  from  the  cremasteric  fascia. 

The  Inguinofemoral  Region. — Upon  removing 
the  skin  of  the  inguinofemoral  region  the  superficial 
fascia  of  the  thigh  is  exposed,  ascending  as  a  continuous 
layer  upon  the  abdomen,  descending  upon  the  thighs, 
and  internally  passing  into  the  dartos  of  the  scrotum 
and  the  superficial  fascia  of  the  perineum.  A  deep 
layer  of  superficial  fascia,  thin  and  membranous,  can 
also  be  distinguished.  It  is  this  layer  which  is  attached 
to  the  margins  of  the  saphenous  opening,  closing  it  and 
receiving  in  this  locality  the  special  name  of  cribriform 
fascia.  Between  the  two  layers  are  the  superficial 
blood-vessels  and  the  lymphatics  of  the  thigh. 

The  deep  fascia  of  the  thigh,  the  fascia  lata,  strong 
and  aponeurotic,  concerns  us  only  in  its  anterior  and 
upper  regions,  where  it  is  described  as  consisting  of 
two  portions,  the  iliac  and  the  pubic.  The  iliac  portion, 
attached  throughout  to  Poupart's  ligament,  lies  in 
front  of  the  femoral  sheath,  and,  at  the  inner  end  of 
Poupart's  ligament,  terminates  in  a  free  edge,  which, 
passing  downward  and  outward  and  then  inward,  in 
the  angle  between  the  internal  saphenous  and  femoral 
veins,  becomes  continuous  with  the  pubic  portion. 
The  pubic  portion,  continued  upward  behind  the 
femoral  sheath  to  which  it  is  attached,  ends  at  the  linea 
iliopectinea. 

Thus  is  formed  the  saphenous  opening  through  which 
the  internal  saphenous  vein  passes  to  join  the  femoral 
vein.  Its  upper  extremity  lies  about  an  inch  external 
to  the  pubic  spine.  Its  vertical  diameter  is  about  an 
inch  and  a  half  or  two  inches.  Only  the  outer  side  of 
the  opening  is  well  marked,  where  the  free  edge  of 
the  iliac  portion  of  the  fascia  forms  a  distinct  falciform 
border,  ending  above  and  below  in  superior  and 
inferior  cornua.  On  the  inner  side,  the  pubic  portion 
does  not  form  a  well-marked  edge,  but,  after  covering 
the  pectineus  muscle,  passes  upward  behind  the 
femoral  sheath  to  which  it  is  connected,  to  the  linea 


iliopectiiH-a  where  ii  is  ci nit ii ii    with  the  iliac  fascia. 

The  deep  layer  of  the  superficial  fascia  is  attached  to 
the  margin  of  the  opening  which  it  closes,  and,  becau  e 
it  is  perforated  by  the  internal  saphenous  vein  and 
numerous  small  arteries  and  veins,  is  known  as  the 
cribriform  fascia. 

Poupart's  Ligament  (ligamentum  inguinale). — The 
defect  in  the  anterior  wall  of  the  pelvis  between  the 

anterior  superior  spine  of  the  ilium  and  the  spine  of  the 
pubis  is  bridged  over  by  Poupart's  ligament.  The 
space  between  the  ligament  and  the  pelvic  bones  serves 
for  the  passage  of  certain  structures  from  the  abdomen 
into  the  thigh,  and  is  divided  into  three  compartments 
by  the  fascia1  investing  them. 

The  first  or  iliac  compartment,  situated  externally,  is 
formed  anteriorly  by  Poupart's  ligament  and  the  iliac 
fascia,  posteriorly  by  the  ilium,  and  internally  is  sepa- 
rated from  the  second  or  pectineal  compartment  by  an 
intermuscular  septum.  This  compartment  transmits 
the  iliopsoas  muscle  and  anterior  crural  nerve. 


Fig. 7. — Rear  View  of  Femoral  Hernia,  Showing  Normal  Obturator 
Artery.  (Joessel.)  a,  Rectus  muscle;  b,  transversalis  fascia; 
c,  deep  circumflex  iliac  artery;  d,  deep  epigastric  artery;  ft,  cre- 
masteric artery;  /,  Poupart's  ligament;  g,  pubic  branch  of  deep 
epigastric;  h,  hernial  sac;  i,  Gimbernat's  ligament ;  ;',  pubic  branch 
of  obturator  artery;  k,  abnormal  obturator  artery;  I,  obturator 
nerve;  m,  external  iliac  vein;  n,  external  iliac  artery:  o,  psoas 
muscle;  p,  anterior  crural  nerve;  q,  iliac  muscle;  r,  iliac  fascia. 

The  second  or  pectineal  compartment,  lodging  the 
upper  end  of  the  pectineus  muscle,  does  not  communi- 
cate with  the  abdomen,  but  corresponds  to  the  space 
between  the  pubic  portion  of  the  fascia  lata  and  the 
pectineal  surface  of  the  os  pubis. 

The  third  or  vascular  compartment  is  the  most 
important.  It  is  situated  in  front  of  the  other  two, 
being  bounded  anteriorly  by  Poupart's  ligament,  and 
posteriorly  by  the  continuous  iliac  and  pectineal 
fascia?.  It  transmits  into  the  thigh  the  external  iliac 
vessels  and  the  crural  branch  of  the  genitocrural  nerve. 

Femoral  Sheath. — As  the  external  iliac  vessels  become 
the  femoral,  they  are  enclosed  within  the  femoral  or 
crural  sheath,  which  accompanies  them  into  the  thigh. 
The  anterior  wall  of  the  sheath  is  derived  from  the 
transversalis  fascia,  the  posterior  wall  from  the  iliac 
fascia.  On  the  outer  side  of  the  artery  the  two  layers 
are  continuous  and  closely  embrace  it;  but  on  the  inner 
side,  while  they  are  continuous,  a  space  is  left  between 
them  and  the  vein.  Furthermore,  both  the  anterior 
and  posterior  walls  are  attached  to  the  iliac  and  pubic 
portions  of  the  fascia  lata,  respectively. 

Within  the  sheath  the  artery  lies  external  to  the  vein, 
and  is  separated  from  it  by  a  thin  septum  stretched 


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from  the  anterior  to  the  posterior  wall.  A  second 
septum  completes,  on  the  inner  side,  the  compartment 
for  the  vein,  and  cuts  off  a  third  space,  about  one-half 
inch  in  length,  between  the  vein  and  the  inner  wall  of 
the  sheath.  This  is  the  funnel-shaped  crural  canal, 
through  which  a  femoral  hernia  descends.  Thus  each 
vessel  has  its  separate  compartment,  and  there  remains 
a  small  internal  compartment  containing  only  areolar 
and  lymphatic  tissue. 

The  Femoral  or  Crural  Canal  (canalis  femoralis). — 
The  size  of  the  femoral  canal  varies  in  different  persons, 
being  larger  in  the  female  than  in  the  male.  Like  the 
external  abdominal  ring,  the  size  of  the  femoral  canal 
and  the  degree  of  tension  of  its  orifices  are  markedly 
influenced  by  the  position  of  the  thigh.  Extension, 
abduction,  and  external  rotation  contract  the  opening, 
while  flexion,  adduction,  and  internal  rotation  relax 
the  femoral  canal  and  its  orifice;  consequently  this 
latter  position  should  be  used  in  the  application  of 
taxis  to  a  femoral  hernia. 

The  four  walls  of  this  canal  will  be  understood  from 
the  above  description.  Below,  it  terminates  beneath 
the  saphenous  opening  (fossa  ovalis),  while  above,  it 
opens  on  the  anterior  abdominal  wall  by  an  aperture 
known  as  the  femoral  or  crural  ring  (annulus  femoralis). 
This  aperture  is  oval,  and  is  larger  in  the  female;  its 
long  diameter,  directed  transversely,  is  about  one-half 
inch. 

The  ring,  covered  by  the  parietal  peritoneum,  shows 
a  slight  depression,  which,  if  not  visible,  can  easily  be 
felt.  Beneath  the  peritoneum  is  a  thin  layer  of  con- 
densed properitoneal  tissue,  the  septum  crurale,  which 
closes  the  ring.  The  ring  is  bounded  anteriorly  by 
Poupart's  ligament  and  the  deep  crural  arch;  posteri- 
orly, by  the  os  pubis,  covered  by  the  pectineus  muscle 
and  the  pubic  portion  of  the  fascia  lata;  externally,  by 
the  external  iliac  vein.  Internally  to  the  ring  are 
the  sharp  margins  of  Gimbernat's  ligament,  the  con- 
joined tendon,  and  the  deep  femoral  arch.  With  the 
exception  of  the  external,  the  boundaries  of  the  ring 
arc  formed  by  very  unyielding  structures. 

Relations. — The  position  of  the  external  iliac  vein  has 
been  noted.  The  deep  epigastric  vessels  cross  the  supe- 
rior and  external  angle.  A  small  communicating 
branch  between  the  deep  epigastric  and  obturator 
arteries  is  usually  found  on  the  superior  aspect  of 
Gimbernat's  ligament. 

Obturator  Artery. — In  two  out  of  every  five  subjects, 
the  obturator  arises  from  the  deep  epigastric  on  one 
or  both  sides.  It  then  turns  backward  into  the  pelvis 
to  reach  the  thyroid  foramen.  In  doing  so  it  may 
pursue  one  of  two  courses:  First,  it  may  turn  backward 
close  to  the  external  iliac  vein,  and  will  then  be  on  the 
outer  side  of  the  femoral  ring;  second,  it  may  first  run 
inward,  then  arch  backward  along  the  free  edga  of 
Gimbernat's  ligament,  and  will  then  be  on  the  inner 
side  of  the  ring.  This  inner  position  is  more  frequent 
in  males  than  in  females,  though  the  epigastric  origin  on 
the  whole  is  somewhat  more  common  in  females  than 
in  males. 

These  anomalies  can  be  detected  in  a  given  case  only 
by  palpation  of  the  artery  through  the  femoral  canal. 
"  Femoral  hernia  is  rare  as  compared  with  the  inguinal 
variety.  It  occurs  more  frequently  in  females,  and  is 
always  acquired.  Entering  through  the  femoral  ring, 
it  passes  vertically  downward  along  the  femoral  canal 
as  far  as  the  end,  carrying  before  it  a  sac  of  peritoneum 
and  the  septum  crurale.  Having  reached  this  point, 
the  hernia  turns  forward  through  the  saphenous  open- 
ins,  where  it  derives  a  covering  from  the  cribriform 
fascia,  and  then  ascends  beneath  the  superficial  fascia 
of  the  groin  as  far  as,  or  above,  Poupart's  ligament. 
The  fascia  propria  is  composed  of  the  septum  crurale 
and  the  femora]  sheath,  but  at  times,  instead  of  dis- 
tending  the  sheath,  it  passes  through  an  opening  in  it. 

Within  the  canal  the  hernia  is  small,  as  it  is  sur- 
rounded by  unyielding  structures;  but  having  passed  the 
saphenous  opening,  it  rapidly  enlarges.     The  direction 


of  a  femoral  hernia  and  the  position  of  the  body  should 
be  borne  in  mind  during  attempts  at  reduction  by 
taxis.  Thus  the  lower  limb  should  be  flexed,  adducted, 
and  rotated  inward.  The  pressure  should  be  first 
downward,  then  backward,  and  finally  upward. 

A  femoral  hernia  may  be  strangulated  at  any  part 
of  the  canal  or  at  the  saphenous  opening,  the  most 
frequent  point  being  the  femoral  ring.  In  all  cases  the 
stricture  may  be  safely  divided  in  an  upward  direction. 
At  the  femoral  ring,  the  least  damage  will  be  done  by 
dividing  Gimbernat's  ligament,  except  in  cases  of 
anomalous  obturator  artery. 

The  coverings  of  a  femoral  hernia,  from  without 
inward,  are  the  skin,  the  superficial  fascia,  the  cribri- 
form fascia,  the  fascia  propria,  consisting  of  the  femoral 
sheath  and  the  septum  crurale,  and  the  peritoneum. 

The  Posterior  Abdominal  Wall. — The  posterior 
abdominal  wall  is  of  simpler  construction  and  of  less 
extent  than  the  anterolateral.  In  its  center  is  the 
portion  of  the  spinal  column  composed  of  the  five  lum- 
bar vertebra  with  their  connecting  ligaments  and  carti- 
lages. On  each  side  are  arranged  the  muscles — ilio- 
psoas, quadratus  lumborum,  and  erector  spina1— 
enclosed  within  sheaths  of  fascia,  that  of  the  ilio- 
psoas muscle  being  of  especial  importance.  This 
fascia  is  attached  to  the  spinal  column  about  the  origin 
of  the  muscle;  to  the  ligamentum  arcuatum  internum 
and  to  the  anterior  layer  of  the  lumbar  aponeurosis 
along  the  outer  border  of  the  muscle.  Below,  it 
firmly  binds  the  iliac  portion  of  the  muscle  into  the 
false  pelvis,  being  attached  about  its  entire  circum- 
ference, with  the  exception  of  the  space  where  it  passes 
beneath  Poupart's  ligament  to  form  the  posterior  wall 
of  the  femoral  sheath.  It  follows  the  tendon  of  the 
iliopsoas  to  its  insertion,  and  ends  by  blending  with 
the  fascia  lata.  Beneath  this  fascia  collections  of  pus 
resulting  from  caries  of  the  spine  or  of  the  ilium  may 
be  guided  into  the  thigh,  to  appear  just  below  the  groin 
on  the  outer  side  of  the  femoral  vessels.  These 
collections  of  purulent  fluid  should  be  distinguished 
from  those  situated  beneath  the  transversalis  fascia  or 
in  the  subperitoneal  tissue.  In  the  first  instance,  the 
pus  can  spread  no  farther  backward  than  the  outer 
edge  of  the  psoas,  and  no  farther  downward  than  the 
iliac  crest  and  Poupart's  ligament;  internally,  it  is 
arrested  at  the  mid-line.  In  the  second  instance,  an 
abscess  is  in  close  contact  with  the  cecum  or  sigmoid 
flexure,  and  may  open  into  one  of  them;  or  it  may 
follow  the  iliac  blood-vessels  into  the  thigh.  In  any 
case  the  typical  picture  may  be  lost  should  an  abscess 
penetrate  the  layer  of  fascia  beneath  which  it  originally 
developed. 

The  incisions  through  the  posterior  abdominal  wall 
are  made  to  expose  the  kidney  and  colon.  They  are 
noted  in  the  article  on  Abdominal  Organs. 

Thomas  A.  Olnet. 

Abdominal  Injuries. — The  abdominal  viscera,  un- 
like those  of  the  cranium  and  thorax,  are  contained 
within  a  cavity  whose  walls  are  composed  chiefly  of 
soft  tissues  and  to  a  relatively  slight  extent  of  bony 
and  cartilaginous  structures.  The  viscera  of  the 
upper  abdomen  are  protected  in  some  degree  by  the 
lower  ribs  and  their  cartilages,  and  those  of  the  lower 
abdomen  by  the  pelvic  bones,  while  posteriorly  there 
is  the  lumbar  spine. 

The  muscular  wall  of  the  abdomen,  too,  varies  in 
thickness,  and  hence  in  its  protecting  properties,  in 
different  regions,  being  heavy  and  solid  in  the  loins, 
and  relatively  thin  at  the  sides  and  front.  These 
defences  are  more  apparent  than  real,  for  while 
viscera  may  be  shielded  by  them  from  the  effects  of 
violence  acting  in  certain  directions,  practically  all  the 
abdominal  contents  are  exposed  to  violence  acting 
from  in  front. 

The  dangers  of  abdominal  injuries  depend  also  in  no 
small  measure  upon  the  character  of  some  of  the  viscera 
themselves. 


8 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Abdominal  Injuries 


The  gastrointestinal  canal,  although  its  mobility 
within  the  abdomen  unquestionably  enables  it  in 
many  instances  to  escape  the  effects  of  violence,  yet 

contains  matter  in  a  high  degree  infect  ions,  which, 
finding  its  way  into  the  peritoneum,  regularly  excites 
a  dangerous  and  usually  fatal  peritonitis. 

Distention  of  the  hollow  viscera  also  favors  injury 
of  them,  for  not  only  is  there  thus  a  larger  mark  for 
violence  to  act  upon,  but  the  increased  tension  of 
their  walls  facilitates  the  rupturing  effect  of  violence. 
Others  of  the  viscera,  as  the  liver,  spleen,  kidney. 
and  great  vessels,  are  practically  fixed  and  immovable, 
and  therefore  are  subject  to  injury  from  a  degree  of 
violence  sometimes  comparatively  slight. 

The  abdominal  walls  are  lined  by,  and  the  viscera 
wholly  or  partially  covered  by,  the  peritoneum.  This 
membrane,  by  rendering  the  movements  of  the  abdom- 
inal organs  upon  one  another  and  beneath  the  abdom- 
inal walls  easy,  no  doubt  often  facilitates  their  escape 
from  the  results  of  violence  which  would  otherwise 
inevitably  produce  injury  of  them,  and  thus  it  be- 
comes a  conservative  agent. 

On  the  other  hand,  peritonitis,  however  produced, 
is  the  most  dangerous  and  oftenest  fatal  of  the  'con- 
sequences of  abdominal  injuries. 

Peritonitis  developing  as  the  consequence  of  inju- 
ries assumes  one  or  other  of  three  types.  First,  it 
results  in  the  formation  of  adhesions  between  con- 
tiguous peritoneal  surfaces,  without  pockets  contain- 
ing fluid  of  any  kind;  or,  second,  the  adhesions  form 
pockets  shutting  in  collections  of  pus  of  greater  or 
less  size.  In  both  of  these  types  the  peritonitis  is 
confined  to  some  particular  region  of  the  abdomen  and 
involves  only  a  part  of  the  peritoneum,  the  rest  of  it 
remaining  uninflamed.  Such  types  are  distinctly 
conservative. 

In  contrast  to  them  there  is  a  third  type  in  which  the 
inflammation,  instead  of  being  circumscribed,  spreads 
quickly  and  soon  involves  the  whole  peritoneum. 
Such  a  type  of  peritonitis  is  usually  fatal,  while  the 
first  two  are  by  no  means  necessarily  so. 

Peritonitis  is  invariably  the  result  of  infection  by 
pus-producing  bacteria  either  from  without,  through 
lesions  of  the  abdominal  walls,  or  from  within,  through 
lesions  of  the  viscera,  particularly  of  the  gastrointesti- 
nal canal. 

Why,  in  different  instances,  different  forms  of 
peritonitis  are  produced,  does  not  as  yet  seem  evident. 
We  have  not  the  means  for  determining  what  is  the 
role  of  the  peritoneal  cells  and  other  defensive  factors 
in  combating  infection.  Several  facts  are  apparent, 
however.  Numerous  experiments  and  observations 
have  shown  that  the  development  of  peritonitis  is 
greatly  promoted  by  the  presence  of  blood  in  the 
peritoneal  cavity;  it  is  known  also  that  infection  by 
the  contents  of  the  intestine  high  up  is  milder  than 
when  escape  of  the  contents  of  the  colon  occurs;  and, 
finally,  it  is  known  that  small  fecal  extravasations 
may  be  encapsulated,  while  large  ones  are  usually 
followed  by   a  general  peritonitis. 

Bile  in  moderate  quantities  may  cause  only  an 
adhesive  peritonitis;  less  frequently  a  general  periton- 
itis follows.  The  same  is  true  of  perfectly  normal 
urine;  but  decomposing  urine,  or  urine  containing 
inflammatory  products  or  contaminated  by  unclean 
instruments — all  of  which  are  conditions  implying 
the  presence  of  bacteria — quickly  excites  a  septic 
peritonitis. 

Abdominal  Wall. — It  is  convenient  to  classify  in- 
juries of  the  abdomen  into  two  groups:  (1)  The  sub- 
cutaneous, including  contusions;  (2)  the  open  wound-. 

Subcutaneous  injuries  may  be  confined  to  the  ab- 
dominal wall,  or  there  may  be  lesions  of  the  viscera  also. 

The  open  injuries  may  be  confined  to  the  abdominal 
wall  without  penetrating  it,  or  they  may  simply 
penetrate  the  abdomen  without  injuring  any  of  the 
viscera,  or  there  may  be  a  prolapse  or  a  wound  of 
the  viscera. 


Subcutaneous  injuries  of  the  abdominal  wall  result 
from  the  infliction  of  direct  violence  by  blows,  kicks, 
falls  against,  obstructions,  spent  balls,  pas-age  across 
the  abdomen  of  wheels,  crushing  by  machinery,  etc. 
In  this  group,  too,  are  included  those  cases  of  over- 
exertion in  which  muscles  are  ruptured.  This  acci- 
dent is  api  to  occur  in  the  recti,  the  diaphragm,  or  the 
elector  spina',  particularly  in  the  presence  of  degenera- 
tive changes  in  these  muscle 

Blood  is  extra vy  ated  bet  ween  the  retracted  ends  of 
the  muscle  torn  by  overact  ion  or  crushed  by  direct 
force;  and  after  its  absorption,  repair  occurs  by 
cicatricial  tissue,  which  may  occasionally  yield  to 
intraabdominal  pressure  and  become  the  site  of  hernia. 
Ecchymosis  also  occurs  over  wide  areas  beneath  the 
skin  or  in  the  subserous  connective  tissue. 

Wounds  of  the  abdominal  wall  which  do  not  pene- 
trate are  not  in  themselves  peculiar  injuries.  With 
proper  treatment  they  heal  readily;  but  care  must  be 
exercised  in  the  accurate  approximation  of  the  cut 
muscles  to  prevent  the  subsequent  development  of 
hernia. 

Another  condition  and  one  totally  different  pre- 
sents itself  the  moment  the  peritoneum  is  penetrated; 
then  the  wound  becomes  a  grave  injury,  with  the 
possibility  of  peritoneal  infection  and  septic  perito- 
nitis; but  the  dangers  of  such  wounds  depend  upon 
their  size,  upon  the  implement  by  which  they  are 
inflicted,  and  upon  the  presence  or  absence  of  foreign 
bodies. 

Small  wounds  inflicted  by  narrow,  sharp  blades  are 
relatively  innocuous  and  are  usually  recovered  from; 
the  visceral  peritoneum,  especially  the  omentum, 
becomes  adherent  to  the  abdominal  wall  in  the  region 
of  the  wound,  the  general  cavity  is  shut  off,  and  heal- 
ing occurs  without  incident.  In  the  case  of  larger 
wounds  in  which  there  is  more  or  less  gaping,  or  in 
those  inflicted  by  dirty  implements  or  complicated 
by  the  presence  of  foreign  bodies,  so  great  a  surface 
of  peritoneum  is  infected  that  no  adequate  adhesion 
occurs  and  a  septic  peritonitis  follows.  This  may  be 
prevented,  however,  in  a  certain  proportion  of  cases 
at  any  rate,  by  proper  wound  treatment. 

Through  wounds  of  the  abdominal  wall,  even  if  of 
small  or  moderate  size,  and  almost  certainly  through 
those  of  any  considerable  dimensions,  prolapse  of 
one  or  other  viscus,  or  of  parts  of  viscera,  is  apt  to 
occur.  The  omentum  is  most  apt  to  escape;  next  the 
small  intestine;  and,  when  separated  from  their 
attachments,  parts  of  the  liver  and  the  whole  or 
portions  of  the  spleen  and  kidney  have  been  known  to 
undergo  a  prolapse. 

The  viscus,  especially  if  prolapsed  through  a  small 
wound,  soon  becomes  congested  and  edematous,  and 
adherent  at  the  margins  of  the  wound;  it  may 
then  remain  fixed  there,  or  become  wholly  or  partly 
necrotic. 

Occasionally,  as  in  the  case  of  the  omentum,  the 
wound  is  plugged  and  permanently  sealed;  or  a 
peritonitis  spreads  from  the  wound  and  destroys  the 
patient's  life. 

The  dangers  which  prolapse  of  viscera  thus  adds  to 
those  inherent  in  the  penetrating  wound  of  the  abdo- 
men, are  the  increased  risk  of  peritonitis,  unavoidable 
from  the  necessity  of  returning  a  prolapsed  area  of 
peritoneum  almost  certainly  infected,  and  the  likeli- 
hood of  injury  or  of  strangulation  of  the  prolapsed 
viscera. 

The  Liver  and  Its  Ducts. — While  the  liver  is 
protected  within  certain  limits  by  its  position  beneath 
the  ribs  and  their  cartilages,  its  relative  fixity  renders 
traumatic  lesions  fairly  frequent. 

Subcutaneous  injuries  are  oftenest  the  result  of 
crushing  violence  or  of  blows  inflicted  directly  over 
the  liver,  and  are  not  infrequently  associated  with 
fractures  of  the  ribs,  under  which  circumstances  the 
bony  fragments  may  be  the  agents  by  which  the  liver 
lesion  is  produced. 


Abdominal  Injuries 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


The  lesion  varies  from  slight  subperitoneal  lacera- 
tion to  fissures  of  some  depth  and  extent,  or  even 
pulpification  of  the  affected  region  or  separation  of 
masses  of  liver  tissue. 

The  lesion  occurs  oftener  in  the  right  lobe  than 
elsewhere. 

Open  injuries  of  the  liver  are  usually  the  result  of 
bullet  or  stab  wounds,  and  the  lesion  itself  varies 
from  a  small  puncture  to  a  large  incision  or  hole. 

In  all  these  lesions,  except  those  which  are  subperi- 
toneal, bleeding  is  free  and  often  profuse,  and  consti- 
tutes the  main  danger  to  life.  Healing  of  the  injured 
liver  tissue  occurs  readily;  but  it  may  be  interfered 
with  by  infection  conveyed  by  the  blood  current  or 
introduced  from  without. 

The  prognosis  is  modified  in  great  measure  by  the 
presence  or  absence  of  associated  injuries  of  other 
viscera.  The  mortality  is  reckoned  by  Edler  at 
So. 7  per  cent,  for  contusions,  55  per  cent,  for  gunshot 
wounds,  04. S  per  cent,  for  stab  wounds — average,  66.S 
per  cent.;  for  uncomplicated  injuries,  5-1.6  per  cent. 

With  or  without  injury  of  the  liver  itself  the  gall 
bladder  or  the  ducts  may  be  injured,  and  this  may  be 
followed  by  the  escape  of  bile  into  the  peritoneum  in 
quantities  more  or  less  great. 

Peritonitis  regularly  follows,  but  there  are  on  record 
a  considerable  number  of  cases  which  are  exceptions. 
In  them,  in  subcutaneous  injuries,  the  extravasated 
bile  has  been  encapsulated,  and  the  patient  has  been 
saved  by  repeated  aspirations;  or  the  bile  has  escaped 
externally  through  fistuke  formed  in  the  tract  of 
wounds,  the  flow  gradually  diminishing  as  these 
closed. 

Treatment  of  injuries  of  the  liver  is  directed  chiefly 
to  the  control  of  the  bleeding  from  them,  and  ought 
not  to  be  delayed  if  the  symptoms  of  loss  of  blood  are 
increasing.  It  should  be  undertaken  before  exsan- 
guination  has  proceeded  far  enough  to  make  the  addi- 
tional shock  of  the  necessary  operative  procedures  a 
source  of  serious  danger. 

Hemorrhage  from  the  liver  may  be  stopped  by 
gauze  packing  or  by  deep  sutures;  the  cautery  is 
useless. 

The  liver  and  its  ducts  are  most  accessible  through 
incisions  of  the  abdominal  wall,  made  parallel  with 
the  margin  of  the  costal  cartilages;  but  it  may  be 
necessary  to  cut  through  the  latter,  or  even  to  approach 
the  liver  through  the  pleural  cavity  and  diaphragm. 

Wounds  of  the  gall-bladder  are  to  be  sutured;  in 
only  the  rarest  cases  is  extirpation  indicated.  Incom- 
plete divisions  of  any  of  the  ducts  should  be  closed  as 
far  as  possible  by  suture,  and  in  any  case  adequate 
provision  for  the  escape  of  bile  should  be  made  by 
means  of  gauze  packing. 

In  a  case  of  complete  division  of  the  common  duct, 
if  approximation  of  the  severed  ends  by  suture  seems 
impracticable,  anastomosis  between  the  gall-bladder 
and  intestine  is  clearly  necessary. 

The  Spleen. — The  deep-seated  position  of  the 
spleen  in  the  abdomen  makes  injuries  of  this  organ 
relatively  rare.  Its  injuries  are  the  result  of  much 
the  same  sorts  of  violence  as  produce  lesions  of  the 
liver.  OfEdler's1  ICO  cases,  S3  were  subcutaneous, 
42  were  bullet  wounds,  and  35  were  stabs. 

It  goes  without  saying  that  an  enlarged  spleen  is 
much  more  liable  to  damage  than  one  of  normal  size. 

The  intimate  relation  of  the  spleen  to  other  abdom- 
inal (and  thoracic)  viscera  makes  associated  injuries 
of  these  organs  of  frequent  occurrence. 

The  great  danger  in  injury  of  the  spleen  itself  is 
from  hemorrhage. 

Suppuration  and  abscess  of  the  spleen  have  been 
known  to  follow  even  subcutaneous  injuries  of  the 
organ. 

The  prognosis  is  therefore  grave.  Of  the  subcu- 
taneous  injuries,  Edler  e.-timates  that  S6.7  per  cent, 
are  fatal;  of  the  shot,  wounds,  83.3  per  cent.  The 
presence  of  associated  injuries  adds  greatly  to  the 


dangers  qf  the  situation  and  increases  the  mortality. 

The  treatment  of  injuries  of  the  spleen  is  chiefly 
directed  to  the  control  of  hemorrhage.  It  should  there- 
fore be  carried  out  at  the  earliest  possible  moment. 
The  spleen  is  easily  reached  through  an  incision  carried 
from  the  free  border  of  the  costal  cartilages  vertically 
downward  through  the  outer  margin  of  the  rectus 
muscle.  For  relatively  small  wounds  or  ruptures  of 
the  spleen  deep  sutures  may  be  used  to  stop  the  bleed- 
ing, but  for  more  extensive  injuries  one  should  proceed 
without  delay  to  extirpation. 

_  The  Kidneys  and  Ureters. — Contusions  of  the 
kidney  may  occur  as  the  result  of  violence  acting  upon 
the  loins  in  the  form  of  kicks,  blows,  and  falls.  The 
lesion,  in  the  mildest  cases,  consists  in  small  subcap- 
sular lacerations  or  in  more  extensive  tears,  particu- 
larly at  the  bases  of  the  pyramids,  while  in  the  most 
severe  cases  the  kidney  is  ruptured,  split  into  two  or 
more  fragments,  or  reduced  to  pulp. 

Lacerations  without  open  wound  are  rare.  [Bell2 
states  that  in  the  Royal  Victoria  Hospital,  Montreal, 
9,920  surgical  cases  were  treated  in  the  years  1903  to 
1910,  and  among  them  were  only  seven  cases  of  lacera- 
tion of  the  kidney  without  open  wound.] 

Bleeding  from  the  torn  kidney  tissue  is  apt  to  be 
profuse,  and  the  extravasated  blood  infiltrates  the 
retroperitoneal  tissue  or  finds  its  way  into  the  peri- 
toneum if  rents  of  this  membrane  are  also   present. 

Wounds  of  the  kidney  are  rare  in  civil  practice, 
but  they  present  in  themselves  no  anatomical  peculi- 
arities that  distinguish  them  from  the  subcutaneous 
injuries. 

Repair  of  traumatic  lesions  of  the  kidney  occurs 
with  great  readiness  and  completeness.  Rarely, 
cysts  persist  at  the  site  of  injury  or  the  kidney  goes 
on  to  atrophy. 

<  The  danger  to  life  in  injury  of  the  kidney  lies  first 
in  the  hemorrhage  and  then  in  suppuration.  But 
the  close  relation  of  this  organ  to  other  viscera  makes 
associated  injuries  of  one  or  other  of  them  of  frequent 
occurrence,  and  thus  the  prognosis  may  be  greatly 
modified. 

Of  10S  cases  of  contusion  of  the  kidney  collected 
by  Grawitz,3  50,  or  46.3  per  cent..,  were  fatal.  Of 
these  50  cases,  IS  were  complicated  by  injury  of  more 
important  viscera;  in  17,  suppuration  occurred,  with 
7  deaths.  Of  the  32  uncomplicated  cases,  14  died  of 
the  primary  hemorrhage,  S  of  secondary  hemorrhage, 
7  of  suppuration,  and  3  of  urinary  retention. 

Of  50  cases  of  stab  wound  of  the  kidney,  15  were 
complicated  by  injuries  of  other  viscera,  35  were 
uncomplicated.  Of  the  35  uncomplicated  cases,  11 
patients  died — 1  from  primary  bleeding,  1  from  sec- 
ondary hemorrhage,  6  from  suppurative  nephritis  of 
the  injured  kidney,  2  from  suppuration  of  the  uninjured 
kidney,  1  not  stated.  Of  the  15  complicated  cases, 
3  were  complicated  by  injury  of  the  spine,  and  all 
were  fatal;  1  by  laceration  of  the  peritoneum,  fatal; 
2  by  injury  of  the  liver,  both  patients  died;  3  by 
injury  of  the  intestine,  2  died;  6  by  injury  of  the 
chest,  4  died;  thus  12  died  and  3  recovered. 

Of  50  bullet  wounds  of  the  kidney  collected  by 
Edler,  22  resulted  fatally.  Of  the  50,  but  20  were 
uncomplicated  by  injuries  of  other  viscera,  and  of 
these  only  3  were  fatal. 

Injuries  of  the  ureter  occur  infrequently,  most 
often  perhaps  as  accidents  in  operations  upon  the 
pelvic  viscera.  Extravasated  urine  collects  behind 
the  peritoneum,  exciting  a  cellulitis  there,  or  it  enters 
the  peritoneal  cavity  and  produces  a  fatal  peritonitis. 

The  treatment  of  injuries  of  the  kidney  turns  upon 
the  control  of  bleeding,  upon  the  provision  for  the 
escape  of  extravasated  urine,  and  upon  the  avoidance 
of  infection. 

In  contusions,  therefore,  if  catheterism  is  practised 
at  all,  it  must  be  done  with  every  care  to  avoid  intro- 
ducing infection.  For  the  less  severe  cases  rest  in 
bed  is  all  that  is  required.     For  the  more  severe  cases 


10 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Abdominal  Injuries 


no  delay  is  to  be  allowed  in  temporizing  with  urinary 
astringents,  cold  enemata,  etc.;  the  kidney  should 
be  exposed  and  the  bleeding  controlled  by  suture, 
by  gauze  packing,  or  by  partial  or  total  nephrectomy. 

The  external  wound  must  be  freely  drained. 

The  Bladder. — The  position  of  the  bladder  behind 
the  symphysis  renders  injuries  of  this  viscus  fairly 
infrequent.  Whether  the  wound  be  subcutaneous 
or  open,  the  presence  of  the  peritoneum  over  a  portion 
of  the  bladder  wall  is  of  capital  importance,  and  it  is 
convenient  therefore  to  divide  injuries  of  the  bladder 
into  two  groups — extra-  and  intraperitoneal. 

Of  the  intraperitoneal  injuries  of  the  bladder, 
wounds  may  occur  in  any  position,  while  the  sub- 
cutaneous injuries  or  ruptures  are  usually  transverse 
or  oblique,  of  variable  size,  and  occur  oftenest  Low 
down  in  the  posterior  wall,  and  least  often  at  the 
summit.  They  are  usually  due  to  blows  or  falls  upon 
the  hypogastrium,  especially  when  the  bladder  is 
distended  and  the  abdominal  walls  are  lax. 

There  is  free  bleeding  from  the  bladder  lesion  and 
escape  of  urine  into  the  peritoneum;  and  sooner  or 
later,  generally  within  two  or  three  days, a  peritonitis 
is  produced  that,  once  established,  has  no  tendency 
to  remain  circumscribed,  but  spreads  and  is  regularly 
fatal.  The  promptness  with  which  peritonitis  devel- 
ops depends  in  great  measure  upon  the  character  of 
the  extravasated  urine  and  upon  the  presence  or 
absence  of  infection  introduced  from  without  by 
instrumentation. 

The  extraperitoneal  injuries  occur  in  the  anterior 
wall  of  the  bladder,  and  vary  in  size  from  mere  punc- 
tures to  considerable  rents.  They  are  due  to  much 
the  same  sort  of  accidents  that  cause  intraperitoneal 
injuries,  and  are  not  infrequently  the  result  of  fracture 
of  the  pubic  bones,  in  which  accident  fragments  are 
displaced  and  perforate  the  bladder  wall. 

In  these  cases  there  is  also  free  bleeding  and  an 
escape  of  urine  into  the  cellular  tissue  of  the  prevesical 
space  and  into  the  subserous  connective  tissue;  and, 
as  a  result  of  this,  cellulitis  develops  in  these  tissues, 
and  is  practically  always  fatal. 

As  to  the  relative  frequency  of  extra-  and  intra- 
peritoneal ruptures  of  the  bladder,  the  latter  are 
much  more  numerous,  being  estimated  by  Fenwick* 
at  SS  per  cent.,  as  against  12  per  cent,  for  the  former. 
[Ferguson5  states  that  of  109  cases  collected  from  the 
literature,  in  only  49  was  the  rupture  extraperitoneal.] 

The  prognosis  of  injuries  of  the  bladder,  even  if 
uncomplicated  by  injuries  of  other  viscera,  is  always 
most  grave.  Bartel0  collected  504  cases  with  a  general 
mortality  of  45  per  cent.  Of  these,  373  were  extra- 
peritoneal, with  a  mortality  of  20  per  cent.,  and  131 
intraperitoneal,  with  a  mortality  of  99.2  per  cent. 

Arranged  according  to  the  presence  or  absence  of 
an  external  wound,  169  eases  were  subcutaneous 
injuries  and  90  per  cent,  died,  while  335  were  open 
injuries  and  22.7  per  cent.  died.  Of  the  109  subcuta- 
neous injuries,  131  were  intraperitoneal,  with  a 
mortality  of  99.2  per  cent.;  3S  were  extraperitoneal, 
with  a  mortality  of  58  per  cent.  Of  the  335  open 
injuries,  50  were  stab  wounds,  with  a  mortality  of 
22  per  cent. ;  285  were  bullet  wounds,  with  a  mortality 
of  24.5  per  cent. 

But  these  figures  do  not  indicate  the  present  mor- 
tality rate,  which  has  undergone  marked  improve- 
ment with  the  advance  of  aseptic  technic  and  the 
general  adoption  of  earlier  operative  interference. 
Thus  Schlange  has  collected  32  cases,  with  15  deaths 
and  17  recoveries.  Of  these,  22  were  intraperitoneal 
with  10  recoveries,  and  10  extraperitoneal  with  7 
recoveries. 

The  treatment  of  injuries  of  the  bladder  is  designed 
to  provide  for  the  escape  of  urine  and  to  close  the 
bladder  lesion  itself,  thus  preventing  infiltration  of 
urine  and  the  development  of  those  inflammations 
which  otherwise  follow,  and  which  are  the  immediate 
cause  of  death. 


Suprapubic  cystotomy,  then,  should  be  done  at  the 
earliest  moment  possible.  In  extraperitoneal  injuries 
the  lesion  should  be  closed  by  suture,  wholly  or  in  part, 
Retzius'  space  should  be  thoroughly  drained  by  gauze 
(lacking,  and  the  bladder  itself  should  be  drained  by 
a  perineal  t  ube. 

In  a  case  of  intraperitoneal  injury  the  abdomen 
should  be  entered  just  above  the  bladder,  and  thor- 
oughly flushed,  and  the  bladder  itself  should  be  closed 
by  appropriate  suture;  a  Mikulicz  drain  being  passed 
into  the  depth  of  the  pelvis  and  the  bladder  being 
drained  by  perineal  tube. 

If  the  ureter  has  been  severed  the  divided  ends  may 
be  brought  together  by  the  method  of  Hochenegg 
or  of  Kelly,  or  the  kidney  may  be  removed.  Implan- 
tation of  the  ureter  into  the  intestine  is  a  hazardous 
expedient,  as  is  also  implantation  into  the  bladder. 

Tin;  Gastrointestinal  Tract. — Injuries  of  the 
stomach  occur  less  often  than  those  of  the  intestine, 
and  injuries  of  the  large  intestine  are  less  frequent 
than  tliose  of  the  small.  They  may  be  single  or 
multiple.  Such  injuries  vary  in  extent,  being  either 
incomplete  (involving  only  one  or  two  of  the  layers 
of  the  tract)  or  complete  (involving  all  of  them). 

The  former  group  includes  those  cases  in  which  the 
mucous  membrane  is  lacerated  by  foreign  bodies 
passing  through  the  canal;  those  in  which  the  intes- 
tinal wall  is  contused  by  violence  acting  from  without, 
and  in  which  the  injury  is  accompanied  by  hemor- 
rhage between  the  component  layers  of  the  intestine, 
and  those  in  which  there  is  laceration  of  the  peritoneal 
or  peritoncomuscular  layers. 

Such  injuries  are  relatively  unimportant.  Per- 
foration may  be  a  consequence  but  it  probably  occurs 
very  infrequently.  The  complete  lacerations  are  the 
important  ones.  They  are  of  variable  extent.  In 
the  stomach  the  lesion  may  be  a  minute  perforation 
or  a  tear  several  inches  in  length;  in  the  intestine  also 
the  injury  may  be  a  small  puncture  or  a  total  trans- 
verse division  of  the  bowel.  There  is  more  or  less 
hemorrhage  from  the  margins  of  the  injured  spot 
into  the  canal  and  into  the  peritoneum,  and,  most 
important,  there  is  likely  to  be  an  escape  of  the  con- 
tents of  the  intestine,  the  amount  varying  according 
to  the  dimensions  of  the  opening. 

The  consequence  may  be  either  a  peritonitis  of 
small  and  limited  extent,  resulting  substantially  in 
nothing  more  than  adhesions;  or  a  circumscribed 
peritonitis,  with  abscess  of  greater  or  less  size;  or  a 
generalized  septic  peritonitis. 

In  the  smaller  lesions,  at  least,  extravasation  of 
intestinal  contents  does  not  occur  at  once  on  the  inflic- 
tion of  the  injury,  for  one  commonly  finds,  in  opera- 
tions done  for  bullet  wounds  of  the  intestine,  that  for 
some  hours  the  opening  is  occupied  and  practically 
occluded  by  prolapsed  mucous  membrane.  The 
mechanism  of  this  occlusion  was  studied  by  Griffith, 
who  found  that  in  transverse  wounds  of  one-third  of 
an  inch  in  length,  the  mucous  membrane  is  extruded 
by  the  contraction  of  the  longitudinal  fibers  of  the 
intestine,  and  that  in  small  longitudinal  wounds  the 
contraction  of  the  circular  fibers  causes  the  margins 
of  the  wound  to  roll  in,  expresses  the  mucous  mem- 
brane, and  produces  the  same  occlusion.  Such  ob- 
struction to  the  escape  of  intestinal  contents  is  best 
seen  in  the  small  intestine,  as  it  does  not  occur  in  the 
relatively  thinner-walled  parts  of  the  colon. 

Injuries  of  the  gastrointestinal  tract  result  from 
contusions  of  the  abdomen  due  to  blows,  falls,  kicks, 
etc.,  which  crush  the  intestine  against  the  spine;  arid 
if  this  part  of  the  canal  happens  to  be  distended  when 
the  injury  is  inflicted,  an  actual  bursting  of  its  walls 
may  result.  Penetrating  bullet  and  stab  wounds  of 
the  abdomen  are  a  common  cause  of  injuries  of  the 
intestines,  and  the  latter  may  also  result  from  the 
passage  of  a  foreign  body  through  the  intestinal  tract. 

The  prognosis  is  always  grave  and  the  chief  danger 
is  peritonitis.     But   the  development  of  peritonitis 


11 


Alnl.iiniii.il  Injuries 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


varies  with  the  extent  of  the  lesion,  with  the  ability  of 
the  patient  to  circumscribe  peritoneal  infection  by 
forming  adhesions,  and  with  the  promptness  with 
which   surgical  intervention  is  undertaken. 

According  to  Petry,  of  199  cases  of  rupture  of  the 
intestine,  4.8  per  cent,  recovered  through  the  develop- 
ment of  adhesions  to  neighboring  structures;  in  8.5 
per  cent,  a  circumscribed  fecal  abscess  formed.  The 
general  mortality  of  ruptures  of  the  intestine  was 
SG  per  cent.;  of  rupture  of  the  stomach,  80  per  cent. 

The  seriousness  of  wounds  of  the  gastrointestinal 
canal  will  appear  more  clearly  when  I  state  that  they 
are  specially  apt  to  be  multiple  and  that  other  organs 
an-  apt  to  be  w-ounded  at  the  same  time.  Of  4,958 
cases  grouped  by  Coley,'  the  mortality  was  SI  per 
cent.  Of  105  cases  treated  bjr  operation  the  mortal- 
ity was  (17. 2  per  cent.;  and  of  these,  81  concerned  the 
small  intestine  (mortality.  67.5  percent.) ;  24  the  stom- 
ach (mortality,  75  per  cent.);  36  the  colon  (mortality, 
66.0  per  cent.). 

The  treatment  should  be  undertaken  at  the  earliest 
moment.  But  here  there  is  not  the  positive  indica- 
tion for  instant  operation  that  exists  when  the  control 
of  hemorrhage  is  the  object  in  view.  Nevertheless 
there  should  be  no  unnecessary  delay  in  intervention, 
and  the  guide  to  the  time  of  operation  lies  in  the  degree 
of  shock  present.  The  rule  should  be  to  operate  the 
moment  the  general  condition  of  the  patient  will 
admit  of  the  procedures  necessary,  and  before  periton- 
itis has  developed.  In  fact,  after  a  peritonitis  is 
under  way  and  is  spreading,  no  surgical  measure  is 
likely  to  be  of  avail  in  any  but  the  most  exceptional 

cases. 

The  lesions  are  to  be  sought  systematically,  and  any 
existing  tears  should  be  closed  by  some  one  of  the 
recognized  forms  of  intestinal  suture;  or  the  intestine 
should  be  resected,  or  anastomoses  should  be  made. 
Then  the  neighboring  peritoneum  should  be  cleaned: 
or  the  entire  peritoneal  cavity  should  be  flushed  until 
it  is  perfectly  clean  ami  then  should  be  sponged  dry. 
In  most  cases  the  judicious  placing  of  gauze  drains 
will  be  advantageous. 

The  Mesentery  axd  Great  Blood-vessels. — In- 
juries of  these  structures  are  exceedingly  uncommon 
in  subcutaneous  injuries  of  the  abdomen,  but  they 
occur  with  some  frequency  as  the  consequence  of  penc- 
trating  wounds.  The  great  danger  entailed  is  from 
hemorrhage,  which  is  considerable  in  wounds  of  the 
me  'ntery  even  of  small  size,  while  in  those  inflicted 
at  the  root  of  this  structure  or  involving  one  or  other 
of  the  named  brandies  of  the  aorta  or  vena  cava,  the 
bleeding  is  profuse  and  usually  quickly  fatal. 

Treatment,  if  available  at  all,  is  practically  so  only 
in  those  cases  in  which  the  wound  involves  the  smaller 
vessels,  which  may  be  clamped  and  ligatured,  or  sur- 
rounded by  suture,  and  so  closed. 

Symptoms  of  Abdominal  Injuries. — To  arrive  at 
the  proper  conclusion  in  estimating  the  consequences 
of  abdominal  injuries  it  is  essential  to  study  the  in- 
dividual case  from  every  point  of  view,  beginning 
with  the  history  of  the  injury  itself,  the  degree  of  vio- 
lence exercised,  the  attitude  of  the  patient  at  the 
time  of  the  occurrence,  and  the  state  of  his  abdominal 
viscera — empty  or  full,  normal  or  diseased.  Tien, 
besides,  one  must  note  the  sequence  of  symptoms, 
both  the  addition  and  the  disappearance  of  local  evi- 
dences, and  the  general  condition  of  the  individual 
considered  as  a  whole. 

()f  the  general  symptoms,  shock  is  apparent  from 
the  beginning  in  most  cases  of  abdominal  injury, 
although  it  varies  in  degree.  It  is  most  profound 
after  severe  contusions,  and  may  be  but  slightly 
developed  in  a  considerable  number  of  cases  of  pene- 
trating wounds  of  the  abdomen,  so  that  the  absence 
of  very  marked  shock  should  not  be  construed  to  mean 
absence  of  visceral  lesions  of  serious  or  even  fatal 
character;  although  profound  shock  must  usually  be 
interpreted  to  be  indicative  of  grave  injury. 


The  symptoms  of  hemorrhage  are  practically 
identical  with  those  of  shock,  but  they  are  gradually 
developed;  and  very  often  the  similarity  of  the  symp- 
toms of  the  two  conditions  makes  their  distinction 
impossible,  at  least  with  any  degree  of  certainty. 
Peritonitis  at  its  outset,  which  may  occur  within  a 
few  hours  of  the  reception  of  an  injury,  sometimes 
closely  resembles  shock  or  hemorhage  in  its  symp- 
toms, but  when  fully  established  it  can  hardly  be 
mistaken  for  any  other  condition. 

There  are  certain  local  symptoms  which  appear 
after  injuries  of  any  of  several  viscera,  and  there  are 
others  which  are  peculiar  to  lesions  of  special  viscera 
alone. 

Hemorrhage  in  any  volume  from  the  liver,  spleen, 
or  kidney — extraperitoneal  or  intraperitoneal — or 
from  the  mesentery,  is  accompanied  by  great  pain,  by 
distention  of  the  abdomen,  by  great  rigidity  of  its 
walls,  by  dulness  in  the  flanks  in  some  cases;  but  by  no 
means  all  of  these  symptoms  are  present  in  every  case 
in  marked  degree,  and  often  one  or  more  of  them  are 
absent  altogether. 

The  presence  of  gas  in  the  peritoneal  cavity  is  indi- 
cated by  loss  of  liver  dulness  and  by  a  peculiar,  non- 
resistant  feeling  of  the  abdominal  wall  on  palpation 
and  percussion.  Here,  again,  exceptions  are  numer- 
ous in  both  the  positive  and  the  negative  sense.  Per- 
forations of  the  intestine  occur  without  loss  of  liver 
dulness,  and  liver  dulness  may  be  absent  without  per- 
foration of  the  intestine. 

Distention  of  the  abdomen  following  injury  is 
usually   evidence   of   peritonitis. 

Pain  is  often  experienced  at  the  site  of  injur3r,  but 
is  a  better  index  of  the  location  of  injuries  of  the 
abdominal  wall  than  of  visceral  injuries;  it  may  be 
entirely  absent  or  may  be  referred  to  another  region, 
and  is  of  little  value  in  determining  any  of  the 
features  of  visceral  lesions. 

Tenderness,  on  the  other  hand,  is  of  great  value, 
and  as  a  rule  is  felt  only  in  the  region  injured,  and  is 
thus  often  an  accurate  guide  to  the  location  of  the 
intraabdominal  trouble. 

With  injuries  of  the  liver  there  is  a  history  of  wound 
or  contusion  in  the  region  of  the  liver,  followed  by 
the  local  and  general  symptoms  of  hemorrhage. 

With  injuries  of  the  spleen  there  is  a  history  of 
wound  or  contusion  in  the  region  of  the  spleen, 
followed  by  the  local  and  general  symptoms  of 
hemorrhage. 

With  injuries  of  the  stomach  there  is  a  history  of 
wound  or  contusion  in  the  region  of  the  stomach,  or 
of  the  ingestion  of  a  foreign  body,  followed  by  loss  of 
liver  dulness,  by  hematemesis,  and  by  peritonitis. 

With  injuries  of  the  intestine  there  is  a  history  of  a 
wound  or  contusion  of  the  abdomen  followed  by  loss 
of  liver  dulness,  by  bloody  stools  in  some  cases,  and 
by  peritonitis. 

With  injuries  of  the  kidney  there  is  a  history  of  a 
wound  or  contusion  in  the  region  of  the  kidney, 
followed  by  evacuation  of  bloody  urine,  probably  by 
tumefaction  in  the  loin,  and  very  often  by  the  symp- 
toms of  suppurative  nephritis  and  perirenal  cellulitis. 

With  injuries  of  the  bladder  there  is  a  history  of  a 
wound  or  contusion  in  the  region  of  this  organ.  The 
symptoms  and  the  conditions  observed  are  the  follow- 
ing: The  bladder  is  very  often,  although  not  always, 
empty,  and  this  condition  is  associated  with  apparent 
suppression  of  urine,  with  tenesmus,  with  evacuation 
of  small  amounts  of  blood  through  the  catheter,  with 
non-distensibility  of  the  bladder  by  means  of  injec- 
tions or  with  the  return  of  smaller  volumes  than  those 
injected,  and,  finally,  with  perivesical  cellulitis  or 
with  peritonitis. 

With  injuries  of  the  mesentery  there  is  a  history  of 
a  wound  or  contusion  of  the  central  region  of  the 
abdomen,  followed  by  the  local  and  general  symp- 
toms of  hemorrhage  or  of  intestinal  obstruction  and 
peritonitis. 


12 


REFERENCE    HANDBOOK    OF    Til  10    MEDICAL   SCIENCES 


Abdominal  Injuries 


Willi  injury  of  any  of  the  good-sized  vessels  of  the 

abdomen  there  are  the  symptoms  of  hemorrhage. 

Diagnosis. — In    most    instances   it    is   practically 

impossible  to  make  a  correct  diagnosis  of  the  viscera 
injured,   and   of   the   extent    of   the   lesions  present    ill 

consequence  of  injuries  of  the  abdomen.  It  com- 
paratively rarely  happens  that  such  injuries  are 
confined  to  a  single  viscus,  and  in  the  combination 
of  symptoms  thai  regularly  ensue,  some  are  over- 
shadowed by  others.  This  fact,  together  with  the 
unreliability  of  many  of  the  symptoms  which  should 
be  pathognomonic  of  special  injuries,  renders  the 
diagnosis  always  one  of  probability.  Nevertheless, 
in  a  considerable  number  of  cases  the  lesions  probably 
present  may  be  estimated  with  a  fair  degree  of 
accuracy,  and  in  a  small  number  the  diagnosis  may 
be  made  with  certainty;  but  it  should  be  emphasized 
that  this  number  is  small,  and  that  in  these  particular 
cases  the  injuries  present  are  relatively  slight.  All 
the  factors  possible  must  be  duly  considered:  the 
character  of  the  violence;  its  degree  and  the  par- 
ticular region  which  it  affects;  the  viscera  present  in 
this  region  and  their  condition  at  the  time  of  injury  ; 
and  both  the  immediate  and  the  later  symptoms 
produced.  To  all  of  these  features  proper  value  must 
be  assigned  before  the  final  conclusion  can  safely  be 
formulated. 

Prognosis  and  Complications. — For  the  same 
reasons  any  statement  in  regard  to  the  prognosis  of 
abdominal  injuries  must  be  made  with  great  caution. 
It  may  be  said,  however,  that  of  those  cases  that  re- 
cover after  abdominal  injuries,  there  are  some  in 
which  the  recovery  is  complete,  and  others  in  which 
it  is  incomplete  (through  the  persistence  of  fistulas 
or  of  peritoneal  adhesions,  or  through  the  development 
of  hernia;). 

Of  the  complications  of  abdominal  injuries,  hemor- 
rhage is  perhaps  the  most  important.  It  may  accom- 
pany almost  any  of  the  visceral  injuries. 

Peritonitis  is  an  almost  equally  grave  complication. 
It  is  particularly  apt  to  accompany  injuries  of  the 
gastrointestinal  tract,  the  bladder,  and  the  biliary 
ducts. 

Later  complications,  as  mentioned  under  prognosis, 
are:  fistula?  communicating  with  the  alimentary  canal, 
the  biliary  passages,  and  the  kidney;  adhesions  which 
possibly  give  rise  to  functional  disturbances  of  the 
viscera  and  especially  to  intestinal  obstruction; 
herniae  due  to  yielding  of  cicatrices  of  the  abdominal 
wall;  and,  finally,  the  protrusion  of  one  or  other  or 
several  of  the  abdominal  organs. 

Treatment. — The  treatment  of  patients  suffering 
from  the  results  of  abdominal  injuries  is  of  a  twofold 
character:  it  comprises  the  treatment  of  the  general 
symptoms — those  of  shock,  hemorrhage,  or  peritonitis 
— and  the  treatment  of  the  local  lesions  present. 

So  far  as  the  treatment  of  shock  is  concerned,  the 

Eatient  should  be  placed  in  bed  and  the  foot  of  the 
ed  should  be  elevated.  He  should  be  warmly 
covered,  and  artificial  heat  should  be  applied  exter- 
nally by  hot  bottles,  etc.  Heart  action  is  to  be 
stimulated  by  the  application  of  heat  or  mustard 
paste  over  the  precordium,  by  subcutaneous  in- 
jections of  strychnine,  of  morphine,  of  atropine,  or  of 
whiskey,  and  by  enemata  of  hot  water,  fluid  extract 
of  coffee,  and  whiskey.  In  many  cases,  and  in  those 
particularly  in  which  the  symptoms  are  due  to  hem- 
orrhage, the  infusion  of  the  patient  with  from  forty  to 
sixty  ounces  of  physiological  salt  solution  is  of  the 
greatest  possible  service;  but  it  should  be  borne  in  mind 
that  the  effect  of  the  infusion  will  subside  in  about 
four  hours,  and  that  then  the  injection  may  have  to 
be  repeated. 

All  that  it  is  necessary  to  say  in  this  place  in  regard 
to  the  treatment  of  peritonitis  has  reference  to  its 
prevention,  and  this  end  is  best  served  by  the  rigid 
observance  of  the  rules  which  have  been  formulated 
for  the  aseptic  or  antiseptic  treatment  of  wounds. 


In  the  ease  of  a  wound  of  the  abdominal  wall, 
whether  penetrating  or  not,  the  object  of  the  local 
treatment  is  to  secure  union  in  the  shortest  time 
possible  and  in  such  a  way  that  hernial  protrusions 
are  least,  likely  to  OCCUT.  For  this  purpose  surgeons 
are  fairly  agreed  that  suturing  must   be  done  in  layers, 

that  is,  thai  identical  structures  in  each  margin  of 
the  wound  are  to  !«■  united  again;  further,  that  such 
union  is  best  accomplished  by  buried  absorbable 
suture  material,  namely,  catgut.  But  since  catgul 
is    absorbed    within    a    few   days,  some  other   more 

enduring  suture  material  must  be  used  to  preserve 
the  apposition  and  beginning  union,  started  between 
structures  brought  together  by  catgut.  For  this 
purpose,  then,  it  is  conventional  to  use  deep  suture-, 
embracing  all  the  layers  except  the  peritoneum, 
composed  of  silk,  of  silkworm  gut,  or  of  silver  wire, 
Finally,  accurate  union  along  the  skin  incision  is 
obtained  by  a  continuous  suture  of  fine  silk. 

For  subcutaneous  injuries  of  the  abdominal  wall  in 
which  no  rupture  of  muscle  occurs,  no  special  treat- 
ment is  required  beyond  promoting  the  disappearance 
of  extravasated  blood  by  massage  or  aspiration. 

When  rupture  of  muscle  occurs  the  overlying  skin 
is  to  be  incised  and  the  injury  treated  as  a  wound  by 
successive  tiers  of  sutures. 

When  injury  of  one  or  of  several  of  the  abdominal 
viscera  is  certain  or  seems  probable,  no  delay  in 
instituting  active  treatment  is  permissible.  It  is  far 
and  away  the  better  scheme  to  make  explorative 
incisions  through  the  abdominal  wall,  to  render  the 
diagnosis  certain,  than  to  subject  the  patient  to  the 
dangers  of  peritonitis  or  fatal  exsanguination  by 
waiting  for  a  confirmation  of  the  diagnosis  of  some 
doubtful  or  probable  lesion  by  the  development  of 
positive  symptoms.  Many  patients  have  without 
doubt  been  saved  in  consequence  of  this  practice, 
and  it  is  equally  evident  that  many  have  been  lost 
through  hesitation  in  carrying  out  this  scheme. 
There  is  little  or  no  risk  involved  in  the  simple  incision 
itself. 

But  no  operative  procedure  may  be  undertaken  in 
states  of  profound  shock  or  in  cases  in  which  the 
injuries  are  so  extensive  or  so  complicated  as  to  make 
their  treatment  practically  impossible;  nor  should 
interference  be  resorted  to  in  the  presence  of  well- 
marked  peritonitis.  On  the  other  hand,  in  the  pres- 
ence of  a  beginning  peritonitis  there  still  remains  some 
possibility  of  success. 

If  decided  shock  is  present,  energetic  measures  for 
its  relief  are  called  for,  and  only  when  the  patient  has 
begun  to  rally,  that  is,  when  the  pulse  becomes  slower 
and  stronger  and  the  temperature  begins  to  approach 
normal,  may  an  operation  be  contemplated.  The 
exception  to  this  rule  is  met  with  in  those  cases  in 
which  the  symptoms  of  apparent  shock  are  due  to 
hemorrhage.  In  such  cases  no  substantial  im- 
provement is  likely  to  result  from  stimulation,  and 
the  patient's  best  if  not  only  hope  lies  in  immediate 
intervention,  during  which  active  stimulation  should 
be  carried  on. 

For  the  treatment  of  any  visceral  lesion  that  is  a 
consequence  of  a  non-penetrating  injury  of  the  abdo- 
men it  is  necessary  to  incise  the  abdominal  wall,  the 
position,  direction,  and  extent  of  the  incision  being 
determined  by  the  viscus  to  be  reached. 

To  expose  the  liver  and  biliary  ducts,  an  oblique 
incision  parallel  with  the  free  border  of  the  ribs,  with 
its  center  about  opposite  the  tenth  cartilage,  is  con- 
ventional, while  a  similar  incision  on  the  left  side 
exposes  the  stomach.  But  for  either  purpose  a  ver- 
tical incision  through  the  outer  part  of  the  rectus 
downward,  for  variable  distances  from  the  free  border 
of  the  ribs,  serves  equally  well,  and  has  the  advantage 
that  on  the  right  side  the  kidney  may  be  explored  and 
attacked  through  it,  while  on  the  left  side  the  spleen 
may  also,  if  necessary,  be  reached. 

To  expose  the  kidney  by  the  transperitoneal  route, 


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Abdominal  Injuries 


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the  incision  just  described  is  the  best;  but  for  general 
purposes  the  Konig  incision  of  the  loin  is  much  to  be 
preferred  in  every  way,  since  in  itself  it  is  extra- 
peritoneal, but  at  the  same  time  it  allows  the  perito- 
neal cavity  to  be  entered  very  readily  by  extending 
the  incision  forward  but  a  short  distance. 

For  the  purpose  of  reaching  the  bladder  an  incision 
carried  upward  from  the  symphysis  between  the 
rectus  muscles  for  the  necessary  distance,  with  the 
patient  in  the  Trendelenburg  position,  exposes  this 
organ  perfectly;  and,  in  order  still  further  to  enlarge 
the  working  space,  the  insertions  of  the  recti  into  the 
symphysis  may  be  divided  for  a  short  distance.  Then, 
by  the  aid  of  retractors  placed  so  as  to  draw  the  mar- 
gins of  the  wound  apart,  one  may  obtain  a  perfect 
view  of  the  bladder,  and  ample  room  may  be  gained  for 
any  suturing  operation. 

To  gain  access  to  the  intestine  and  mesentery  a 
median  incision  through  the  linea  alba,  of  variable 
length  and  carried  around  the  left  side  of  the  umbilicus 
will  answer  the  purpose  best.  In  this  way  the  small 
intestine  and  mesentery,  the  rectum,  and  the  sigmoid 
flexure  may  readily  be  reached,  and  by  use  of  vigorous 
retraction  the  rest  of  the  colon  may  be  exposed,  as  well 
as  the  first  and  second  parts  of  the  duodenum. 

In  making  incisions  through  the  abdominal  wall,  no 
time  should  be  lost  in  using  a  director.  The  incision 
should  be  rapidly  carried  through  the  skin,  the  super- 
ficial and  deep  layers  of  fascia,  and  the  muscles — 
clamps  being  applied  to  all  bleeding  points — until  the 
transversalis  fascia  is  reached.  This  is  to  be  nicked 
with  the  knife  and  then  divided  along  the  length  of  the 
wound  by  scissors,  thus  exposing  the  peritoneum. 
The  latter  in  turn  is  then  to  be  pinched  up  by  two 
pairs  of  forceps,  a  nick  is  to  be  made  between  them, 
and  the  membrane  is  then  to  be  divided  by  scissors  on 
a  finger  thrust  beneath  it  through  the  small  primary 
opening.  It  is  optional  whether  bleeding  points  are 
to  be  tied  before  entering  the  cavity  or  whether 
clamps  are  to  be  left  in  situ. 

In  the  operative  treatment  of  ■penetrating  wounds  of 
the  abdominal  wall  it  is  best  to  enlarge  the  wound  of 
entrance  with  the  same  precautions  that  are  usually 
observed  in  formally  opening  the  abdomen.  Having 
done  so,  one  should  inspect  the  subjacent  viscera,  and 
then  upon  ascertaining  the  extent  and  character  of 
the  lesions  to  be  treated,  should,  if  necessary,  make 
additional  incisions  through  the  abdominal  wall  in 
one  or  other  of  the  positions,  and  in  the  manner  just 
described,  orthe  wound  should  be  still  further  enlarged. 
The  treatment  of  the  injuries  of  different  viscera  has 
been  referred  to  under  the  description  of  their  lesions. 

Here  it  is  proper  to  indicate  (he  method  of  caring 
for  prolapse  of  viscera,  and  for  blood  and  foreign 
material  which  may  be  present  in  the  peritoneal 
cavity. 

Almost  any  of  the  viscera,  whether  injured  or  not, 
may  prolapse  through  wounds  of  the  abdominal  wall, 
and  then  be  injured,  or  infected,  or  become  strangu- 
lated; and  the  procedure  to  be  adopted  depends  upon 
which  of  these  events  has  occurred. 

In  general  terms,  for  purposes  of  treatment,  it  is 
always  to  be  assumed  that  prolapsed  viscera  are 
infected;  and  whether  a  given  viscus  is  to  be  returned 
or  not  will  be  decided  by  the  possibility  of  rendering 
it  practically  aseptic  or  not,  of  repairing  injuries  pres- 
ent in  it,  or  of  restoring  its  circulation. 

Prolapsed  omentum  should  in  any  case  be  tied  off 
and  removed. 

Prolapsed  intestine,  if  strangulated,  may  be  sutured 
in  situ,  or  may  be  opened  in  such  a  manner  as  to 
form  a  fecal  fistula  which  is  to  be  closed  subsequently, 
or  it  may  be  resected  at  once.  If  it  has  become  in- 
fected it  is  to  be  subjected  to  very  thorough  mechan- 
ical cleansing  with  0.5-per-cent.  salt  solution,  and 
then  returned  after  any  injuries  possibly  present  in  it 
have  been  repaired. 

Prolapse  of  the  spleen  calls  for  its  removal  if  stran- 


gulated or  irreparably  injured,  or  for  its  return  if  it 
can  be  thoroughly  cleaned  and  repaired. 

Prolapsed  portions  of  the  liver  are  to  be  removed. 

Prolapse  of  the  kidney  should  be  managed  by 
removal  if  it  is  necrotic  or  very  greatly  injured;  by 
mechanical  cleansing,  repair,  and  replacement  of  the 
organ  if  it  be  possible.  However,  in  any  case  ample 
drainage  must  be  provided  by  gauze  leading  from  the 
site  of  the  returned  viscus  to  the  surface. 

Blood  is  to  be  completely  removed  from  the  ab- 
dominal cavity.  This  is  done  by  scooping  out  clots 
with  the  hand  and  sponge,  and  by  copious  douch- 
ings  with  hot  salt  solution.  Provision  for  subse- 
quent drainage  need  not  necessarily  be  supplied. 

The  entrance  of  foreign  bodies  from  without  or 
from  the  intestine,  or  the  entrance  of  intestinal  con- 
tents into  the  peritoneal  cavity,  is  a  fruitful  source 
of  peritonitis,  and  measures  should  be  taken  to  pre- 
vent its  occurrence.  But  once  they  have  invaded  the 
cavity  and  infected  it,  no  time  is  to  be  lost  in  remov- 
ing them  and  in  neutralizing  their  conseqences. 

Intestinal  contents  are  to  be  removed  by  scooping 
and  sponging,  and  then  not  only  the  visibly  soiled 
areas  of  peritoneum  must  be  cleansed  by  the  liberal 
use  of  salt  solution,  but  the  same  procedure  must  be 
carried  out  with  regard  to  the  whole  peritoneum, 
especially  if  considerable  quantities  of  foreign  ma- 
terial have  escaped;  and,  if  necessary,  evisceration 
must  be  resorted  to.  Drainage  must  of  course  be 
provided  in  every  case. 

Drainage  of  areas  of  the  peritoneum  is  best  accom- 
plished by  the  use  of  gauze — ordinary  absorbent 
gauze  sterilized,  or  gauze  impregnated  with  iodoform. 
Gauze  has  the  advantage  over  tubes  of  various  kinds 
in  several  respects.  Besides  the  perfect  manner  in 
which  it  enables  all  exudate  to  be  carried  to  the  sur- 
face, it  decidedly  promotes  the  formation  of  adhesions 
about  itself,  and  consequently  about  the  region 
drained,  which  is  often  infected,  and  further  oozing 
is  best  checked  by  the  pressure  exerted  by  the  gauze 
packing. 

Gauze  introduced  for  drainage  purposes  is  used  in 
ribbons,  one  or  more  of  which  are  so  placed  as  to  lead 
from  the  area  drained;  or  larger  pieces  of  gauze  may 
be  packed  into  the  region  to  be  drained  and  brought 
out  of  the  abdominal  wound;  or  the  Mikulicz  dressing 
may  be  used.  This  consists  of  a  piece  of  iodoform 
gauze  about  fifteen  inches  square,  doubled  back  from 
its  center  like  an  umbrella,  and  containing  strips  of 
gauze  so  arranged  that  one  after  another  can  be 
withdrawn  without  disturbing  the  enveloping  skirt, 
which  is  last  to  be  removed. 

The  period  for  withdrawing  drains  varies  somewhat 
with  the  purpose  for  which  they  have  been  intro- 
duced; gauze  placed  to  stop  oozing  should  be  removed 
in  from  twenty-four  to  forty-eight  hours,  while 
that  used  to  drain  infected  or  inflamed  areas  is  allowed 
to  remain  in  place  some  days  longer. 

The  treatment  of  the  sequeUe  of  injuries,  as  fistula?, 
ventral  hernia,  etc.,  does  not  naturally  come  under 
the  present  title.  Pebcival  R.   Bolton. 

References. 

1.  Edler:    Langenbeck's  Archiv,  vol.  xxxiv. 

2.  Bell:    American  Practice  of  Surgery,  vol.  viii,  1911. 

3.  Grawitz:   Archiv  fur  klinische  Chirurgie,  No.  2,  18S7. 

■1.  Fenwick:  Quoted  in  Traite  de  Chirurgie,  Duplay  et  Reclus, 
vol.  vii.,  p.  686. 

.">.   Ferguson:    American  Practice  of  Surgery,  vol.  viii,  1911. 

6.  Bartel:    Deutsche  Chirurgie.  Lieferung  52,  p.  67. 

7.  Coley:   Am.  Journal  of  the  Medical  Sciences,  March,  IS91. 

Abdominal  Organs,  Regional  and  Surgical  Anatomy 
of  the. — The  abdominal  cavity  is  arbitrarily  divided 
into  nine  regions  by  two  horizontal  and  two  vertical 
lines.  The  superior  horizontal  line  extends  between 
the  cartilaginous  ends  of  the  tenth  ribs,  the  inferior 
between  the  anterior  superior  iliac  spines.  These  two 
lines  divide   the  cavity  into   three  zones,   epigastric, 


14 


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Abdominal  Organs!  Regional 
Anatomy 


nasogastric,  and  hypogastric,  each  of  which  is  sub- 
divided into  three  regions  by  vertical  lines  passing 
upward  from  the  ilio-pcctineal  eminences  to  the  higher 
horizontal  line.  The  epigastric  zone  contains,  in  order, 
the  right  hypochondrium,  epigastrium,  and  left 
hypochondrium.  The  nasogastric  zone  contains  the 
right  lumbar,  umbilical,  and  left  lumbar  regions.  The 
hypogastric  zone  contains  the  right  iliac,  hypogastric, 
and  left  iliac  regions.  The  boundaries  of  I  he  several 
zones  according  to  the  B.N. A.  nomenclature  differ 
somewhat  from  those.  The  two  may  be  compared  by 
reference  to  Figs.  S  and  9. 


Fig.  S. — Regions  of  the  Abdomen  in  the  Old  Nomenclature. 

The  viscera  situated  in  each  region  are  shown  in  the 
following  table: 


Right  Hypochon- 

Epigastrium. 

Left  Hypochun- 

drium. 

drium. 

Liver. 

Liver. 

Stomach. 

Right  kidney. 

Stomach. 

Spleen. 

Hepatic  flexure. 

Gal]  bladder. 

Left  kidney. 

Colon. 

Duodenum. 

Splenic  flexure. 

Pancreas. 

Colon. 

Right  Lumbar. 

Umbilical. 

Left  "Lumbar. 

Right  kidney. 

Transverse  colon. 

Small    part    of    left 

Ascending  colon. 

Duodenum  and  .small 

kidney. 

Ileum. 

intestines. 

Descending  colon. 

<  Ireat  omentum. 

Small  intestines. 

Right  Iliac. 

Hypogastric. 

Left  Iliac. 

Cecum. 

Small  intestines. 

Sigmoid  colon. 

Appendix. 

Bladder  in  children. 

Small  intestines. 

Laal  .oil  of  ileum. 

Distended  bladder  in 

adults. 
Pregnant  uterus. 
Sigmoid  colon. 

Liver  (hepar). — The  liver  occupies  the  right  hypo- 
chondriac region  and  part  of  the  epigastric,  and  extends 
into  the  left  hypochondriac  region  as  far  as  the  mam- 
millary  line;  at  times  it  descends  into  the  right  lumbar 
region.  With  the  exception  of  a  small  part  of  the 
right  and  left  lobes,  which  come  in  contact  with  the 
anterior  abdominal  wall  in  the  subcostal  angle,  it  lies 
behind  the  ribs  and  costal  cartilages. 


Surface  Outline. — The  outlil f   the  liver  may  be 

indicated  on  die  surface  of  the  body  as  follows:  Supe- 
riorly, a  line  beginning  in  the  mammillary  line  in  the 
fifth  lefl  intercostal  space,  extending  toward  the  right, 
through  the  lower  end  of  the  sternum,  gradually  rising 

to  the  fourth  right  interspace  just  inside  the  nipple  line, 

then  sloping  downward  behind  the  iifth  and  sixth  ribs, 

where  the  superior  surface  is  continuous  with  the  right 
surface.  Interiorly,  beginning  on  the  right  side  at  the 
upper  border  of  the  third  lumbar  vertebra,  the  line 
runs  directly  to  the  costal  arch,  which  it  follows  as  far 
upward  as  the  tip  of  the  ninth  costal  cartilage.     Here 


Fig.    9. — Regions    of    the   Adbomen,    in    the    Basle     Anatomical 
Nomenclature. 


it  crosses  the  subcostal  angle  to  the  eighth  left  cartilage, 
then  gradually  rises  to  terminate  at  the  beginning  of 
the  superior  line.  The  right  surface,  lying  behind  the 
seventh,  eighth,  ninth,  and  tenth  ribs,  is  separated 
from  them  only  by  the  thin  edge  of  the  lung,  the 
diaphragm,  and  the  pleura.  It  is  thus  apparent  that 
I  he  lower  border  is  most  accessible  to  examination,  and 
especially  that  part  of  it  which  lies  across  the  subcostal 
angle.  Here  it  usually  reaches  a  point  midway  between 
the  end  of  the  sternum  and  the  umbilicus.  When  the 
lower  border  in  the  remainder  of  its  extent  is  easily 
palpable,  the  liver  is  either  displaced  or  enlarged.  The 
superior  extent  can  be  determined  only  by  percussion, 
but  the  line  of  .absolute  dulness  does  not  correspond  to 
the  line  above  given,  for  the  reason  that  the  anterior, 
right,  and  posterior  surfaces  are  considerably  over- 
lapped by  the  lower  edge  of  the  lung.  This  line  in  the 
mid-line  falls  at  the  end  of  the  sternum,  in  the  right 
nipple  line  at  the  sixth  rib,  in  the  mid-axillary  line  at 
the  eighth  rib,  and  in  the  scapular  line  at  the  tenth  rib. 
When  the  border  of  the  liver  can  be  palpated  this 
method  of  determining  its  lower  limit  will  be  found  more 
accurate  than  that  by  means  of  percussion. 

Relations. — The  liver  presents  superior,  anterior,  pos- 
terior, inferior,  and  right  surfaces. 

The  superior  surface  is  accurately  moulded  to  the  dia- 
phragm, which  separates  it  from  the  pleura?,  lungs,  peri- 
cardium, and  heart. 

The  anterior  surface,  also  in  contact  with  the  dia- 
phragm, with  the  exception  of  the  small  region  coming 
in  contact  with  the  abdominal  wall  in  the  subcostal 


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Anatomy 


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angle,  lies  behind  the  fifth  to  the  ninth  costal  cartilages 
and  adjacent  portions  of  the  ribs.  In  its  upper  part  it 
is  overlapped  by  the  lower  margin  of  the  lung. 

The  posterior  surface,  also  in  contact  with  the  dia- 
phragm and  overlapped  by  the  lung,  covers  in  turn  the 
right  suprarenal  capsule,  the  vena  cava,  the  thoracic 
duct,  and  the  esophagus. 

The  inferior  surface  is  plainly  impressed  by  the  fol- 
lowing organs:  Beginning  at  the  right,  in  front,  the 
hepatic  flexure  of  the  colon;  behind,  the  right  kidney, 
immediately  to  the  left  of  which  is  the  impression  of  the 
duodenum,  and  to  the  left  of  both  the  impression  of  the 
gall  bladder.  The  succeeding  part  of  the  liver  is  the 
quadrate  lobe,  lying  in  front  of  the  lesser  omentum. 
Finally,  the  under  surface  of  the  left  lobe  overlaps  the 
lesser  curvature  and  upper  part  of  the  anterior  surface 
of  the  stomach. 


Regions  of  the  Abdomen,  Posterior  View.     (Joessel.) 


The  right  surface  lies  internal  to  the  seventh,  eighth, 
ninth,  tenth,  and  eleventh  ribs,  being  separated  from 
them  by  the  diaphragm,  and  being  overlapped  above  by 
the  lung.  Many  clinical  facts  of  importance  can  be 
learned  by  a  close  study  of  these  relations.  In  gunshot 
and  stab  wounds  of  the  lower  part  of  the  thoracic  wall, 
lung,  pleura,  diaphragm,  peritoneum,  and  liver  may  all 
be  involved.  The  end  of  a  fractured  rib  may  penetrate 
the  liver.  Abscesses  of  the  liver  may  extend  through 
the  diaphragm  and  open  into  the  pleural  cavity,  or, 
u  hen  this  is  obliterated  by  adhesions,  into  the  lung,  and 
a  bronchus.  Behind,  an  enlargement  of  tne  liver  may 
retard  the  circulation  in  the  aorta,  the  vena  cava,  or  the 
thoracic  duel.  Below,  the  close  relations  of  the  stom- 
ach, duodenum,  and  colon  explain  the  ease  with  which 
adhesions  develop  between  these  organs,  and  disease 
spreads  from  one  to  the  others. 

16 


During  inspiration,  the  liver  descends  about  the 
breadth  of  one  intercostal  space.  The  lower  border  is 
more  easily  palpable  in  the  erect  posture  than  in  the 
recumbent,  as  in  the  latter  it  recedes  somewhat  behind 
the  costal  arch.  These  changes  in  position,  especially 
the  first,  may  serve  to  distinguish  a  tumor  or  swelling  of 
the  liver  from  one  of  the  stomach,  kidney,  adrenal  gland, 
or  pancreas.  The  peritoneal  relations  of  the  liver  are 
extensive  and  important.  For  the  most  part  its  surface 
looks  into  the  general  peritoneal  cavity,  and  the  reflec- 
tions of  the  peritoneum  from  the  abdominal  wall  and 
diaphragm  are  the  principal  agents  in  supporting,  or 
rather  suspending,  the  organ.  A  small  part  of  its 
posterior  surface  is  not  visible  from  the  greater  cavity, 
as  it  looks  into  the  lesser.  This  corresponds  in  extent 
to  the  Spigelian  lobe.  A  second  area  of  the  posterior 
surface,  between  the  layers  of  the  right  coronary  liga- 
ments, is  not  covered  by  peritoneum;  it  lies  in  contact 
with  the  diaphragm.  This  locality  is  the  favorite  seat 
of  subphrenic  abscesses,  and  here  they  most  easily 
spread  to  the  pleura  and  lung. 

Blood-vessels. — The  artery  of  the  liver  is  the  hepatic 
branch  of  the  celiac  axis.  It  reaches  the  organ  be- 
tween the  layers  of  the  lesser  omentum,  and  entering 
at  the  transverse  fissure  its  branches  accompany  those 
of  the  portal  vein. 

The  portal  vein,  formed  behind  the  head  of  the  pan- 
creas by  the  union  of  the  superior  mesenteric,  splenic, 
inferior  mesenteric,  and  the  veins  of  the  stomach,  also 
ascends  in  the  lesser  omentum  to  the  transverse  fissure. 
In  the  substance  of  the  liver  its  branches  are  situated 
within  the  portal  spaces,  i.e.  outside  the  lobules,  before 
entering  the  intralobular  capillaries.  They  are  dis- 
tinguished by  their  relatively  thick  walls  and  collapsed 
state  on  cross  section.  An  infective  thrombophlebitis 
in  a  distant  part  of  the  abdomen  or  pelvis  may  be  fol- 
lowed by  a  metastatic  abscess  or  abscesses  in  the  liver, 
a  phenomenon  explained  by  the  anatomy  of  the  portal 
circulation. 

The  hepatic  veins  are  remarkable  for  their  thin  walls, 
which,  closely  connected  with  the  surrounding  liver 
substance,  stand  widely  open  on  section.  Consequently 
a  rupture  or  incised  wound  of  the  liver  bleeds  with 
great  freedom  and  the  bleeding  has  little  tendency  to 
cease  spontaneously.  The  hepatic  veins  emerge  on  the 
posterior  surface  of  the  liver,  entering  immediately  the 
inferior  vena  cava  within  half  an  inch  to  an  inch  "from 
its  termination  in  the  right  auricle.  They  have  no 
valves;  consequently  the  circulation  in  them  is  easily 
impeded.  In  some  forms  of  valvular  heart  lesions — 
e.g.  tricuspid  insufficiency — the  pulsation  of  the  heart 
may  be  transmitted  through  them  to  the  liver. 

The  excretory  apparatus  of  the  liver  consists  of  the 
hepatic  duct  (ductus  hepaticus),  the  cystic  duct  (ductus 
eysticus),  and  gall  bladder  (vesica  fellea),  and  the 
common  duct  (ductus  choledochus).  The  gall  bladder, 
three  or  four  inches  in  length  and  with  a  capacity  of 
from  one  to  two  ounces,  is  held  in  position  on  the  under 
surface  of  the  liver  by  the  peritoneum.  As  a  rule,  it  is 
closely  applied  to  the  liver  substance,  lying  in  a  dis- 
tinct fossa;  but  it  may  hang  free,  completely  invested 
by  peritoneum  and  suspended  by  a  mesentery.  Its 
fundus  projects  beyond  the  lower  border  of  the  liver 
opposite  the  ninth  costal  cartilage.  It  is  directed 
downward,  forward,  and  to  the  right,  while  the  neck  is 
in  the  opposite  direction.  Immediately  below  it  are 
the  transverse  colon,  duodenum,  and  sometimes  the 
pylorus  of  the  stomach.  The  relation  to  the  colon  is 
most  constant  and  important.  An  artificial  opening  is 
sometimes  formed  between  the  two  organs,  and  through 
it  gall  stones  may  be  passed. 

The  ducts  are  all  situated  between  the  layers  of  the 
lesser  omentum,  and  can  be  easily  exposed  by  removal 
of  its  anterior  layer.  The  portal  vein,  hepatic  artery 
and  hepatic  nerves  are  found  in  the  same  space,  but  the 
ducts  are  anterior  to  them,  and  occupy  the  right  free 
edge  of  the  omentum.  In  making  a  dissection,  or  in  an 
operation,    the  foramen  of   Winslow   should   first  be 


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REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Abdominal  Organs,  Regional 
Anatomy 


located,  and,  with  the  fingers  of  the  left  hand  in  it  for  a 
guide,  an  exposure  can  be  easily  accomplished.  The 
cystic  duct,  arising  at  the  neck  of  the  gall  bladder,  is  an 
inch  and  a  half  in  length.  It  is  directed  downward, 
backward,  and  to  the  left,  to  join  the  hepatic  duct  at  an 
acute  angle.  The  hepatic  duct,  about  two  inches  in 
length,  is  directed  downward,  backward,  and  to  the 
right.  It  arises  at  the  liver  by  two  main  branches. 
The  common  bile  duct,  formed  by  the  union  of  these 
two,  continues  the  direction  of  the  hepatic  along  the 
right  free  edge  of  the  lesser  omentum  on  the  anterior 
surface  of  the  portal  vein,  and  to  the  right  of  the  hepatic 
artery.  Approaching  the  duodenum,  the  vein  tends 
to  the  left,  the  duct  to  the  right.  This  relation  of  the 
vein  to  the  duct  is  remarkably  constant,  but  the  hepatic 
artery  and  its  branches  are  subject  to  frequent  varia- 
tions which  should  be  guarded  against.  As  the  com- 
mon duct  reaches  the  duodenum,  it  passes  behind  its 
first  portion,  then  downward,  between  the  second  por- 
tion and  the  head  of  the  pancreas;  or  it  is  embedded  in 
the  latter,  from  which  point  onward  it  accompanies  the 
pancreatic  duct  into  the  lower  part  of  the  second  por- 
tion of  the  duodenum.  The  duodenal  orifice  is  mark- 
edly constricted,  but  just  proximal  to  it  the  duct  is 
dilated,  forming  a  well-marked  diverticulum.  Conse- 
quently a  calculus  may  successfully  pass  the  entire  duct, 
to  be  arrested  at  the  terminal  orifice.  To  cause  a 
jaundice,  calculi  must  be  situated  in  either  the  hepatic 
or  the  common  duct,  for  any  number  may  occupy  the 
gall-bladder  or  the  cystic  duct,  yet  give  rise  to  few  or  no 
symptoms  as  long  as  they  remain  there  and  the  gall 
bladder  is  not  infected.  Not  all  cases  of  obstructive 
jaundice  are  due  to  gallstones.  Enlarged  lymphatic 
glands  in  the  lesser  omentum,  tumors  of  adjacent 
organs,  especially  of  the  head  of  the  pancreas,  hydatids, 
ascaris,  adhesions  producing  flexures  of  the  ducts,  and 
many  other  causes  have  been  noted. 

Stomach  (ventrieulus). — This  varies  in  position  and 
relations  according  to  the  degree  of  distention.  When 
empty,  it  lies  in  the  left  hypochondrium  and  left  half  of 
the  epigastrium,  the  cardiac  orifice  being  four  to  five 
inches  posterior  to  the  interval  between  the  seventh  left 
costal  cartilage  and  the  ensiform  process,  on  a  level 
with  the  eleventh  or  twelfth  dorsal  vertebra.  This  is 
the  most  fixed  portion  of  the  stomach,  and  participates 
only  slightly  in  any  changes  of  position.  The  pylorus 
is  in  or  near  the  mid-line,  at  the  level  of  the  last  dorsal 
or  first  lumbar  vertebra.  It  looks  toward  the  right, 
and  is  the  most  movable  portion  of  the  stomach.  Thus 
a  tumor  of  the  pylorus  may  be  found  in  the  central  or 
lower  part  of  the  abdomen.  The  anterior  and  posterior 
surfaces  are  separated  by  sharp  borders,  and  the  entire 
viscus  recedes  from  the  anterior  abdominal  wall  behind 
the  liver. 

When  distended,  the  fundus  fills  the  left  cupola  of 
the  diaphragm,  impinging  upon  the  liver  and  heart. 
The  great  curvature  comes  in  contact  with  the  anterior 
abdominal  wall  in  the  subcostal  angle,  and  may  enter 
the  left  lumbar  and  umbilical  regions.  Immediately 
below  it  is  the  transverse  colon.  The  pylorus  moves  to 
the  right  as  much  as  two  or  three  inches,  and  rotates  so 
that  it  is  directed  backward,  being  concealed  from  in 
front  by  the  dilated  lesser  cul-de-sac. 

Relations. — The  anterior  surface  is  divisible  into  two 
regions;  the  upper  and  right  region,  which  includes  the 
pylorus  and  cardia,  and  is  overlapped  by  the  right  and 
left  lobes  of  the  liver;  and  the  lower  and  left  region,  which 
may  be  subdivided  into  two,  viz.,  the  small  triangular 
portion  in  contact  with  the  anterior  abdominal  wall, 
and  above  this  the  portion  lying  behind  the  costal  arch 
and  diaphragm.  The  fundus  is  also  overlapped  by  the 
lung  and  pleura  in  the  fifth  and  sixth  intercostal  spaces. 
Here,  again,  a  wound  may  involve  both  thoracic  and 
abdominal  viscera.  Posteriorly,  the  stomach  is  in 
relation  with  the  diaphragm,  spleen,  left  kidney  and 
capsule,  pancreas,  and  the  splenic  flexure  of  the  colon, 
all  of  which  taken  together  form  for  it  a  concave  bed. 
The  peritoneal   relations  of  the  stomach  are  compli- 


cated. Its  anterior  surface  faces  the  greater  peritoneal 
cavity,  but  the  posterior  surface  is  concealed  behind 
the  great  oment  uin,  which  hangs  from  its  greater  curva- 
ture. Furthermore,  joined  to  the  posterior  surface  of 
the  omentum  are  the  transverse  colon  and  the  meso- 
colon. When  the  omentum  is  raised  these  structures 
are  carried  with  it.  Only  by  passing  the  finger  through 
the  foramen  of  Winslow  can  the  posterior  surface  of  the 
stomach  be  reached.  In  a  dissection,  however,  one  of 
two  routes  may  be  chosen.  The  first  lies  between  the 
greater  curvature  and  the  transverse  colon;  the  second 
passes  through  the  transverse  mesocolon.  A  periton- 
itis arising  from  perforation  of  the  posterior  wall  of 
the  stomach,  whether  due  to  trauma  or  to  disease,  will 
at  first  involve  the  lesser  cavity  only  and  may  be  limited 
entirely  to  it.  In  operating  for  wounds  of  the  stomach, 
the  posterior  surface  should  always  be  examined  in  the 
manner  indicated.  The  lesser  omentum  is  attached  to 
the  entire  lesser  curvature,  while  the  gastrosplenic  and 
gn  ■:  1 1  er  omenta  are  continued  from  the  greater  curvature. 

The  arteries  of  the  stomach  are  derived  from  the  three 
branches  of  the  celiac  axis,  and  reach  the  organ  between 
the  layers  of  the  omenta.  On  the  lesser  curvature  an 
inch  is  formed  by  the  gastric  and  pyloric  branches  of  the 
hepatic;  on  the  greater,  a  similar  arch  is  formed  by  the 
gastroepiploica  dextra  and  sinistra.  From  these  arches 
transversely  directed  branches  arise  which  anastomose 
near  the  center  of  the  surfaces.  Incisions  in  the  stom- 
ach wall  are  best  made  in  the  direction  of  the  transverse 
branches,  with  the  exception  of  the  central  region  where 
the  sets  anastomose. 

Small  Intestine  (intestinum  tenue). — With  the  ex- 
ception of  the  duodenum,  the  small  intestines  are  sur- 
rounded throughout  by  peritoneum,  and  are  suspended 
from  the  posterior  abdominal  wall  by  a  mesentery. 

The  line  of  attachment  of  the  mesentery  extends  from 
the  left  side  of  the  second  lumbar  vertebra  obliquely 
across  the  vertebral  column,  aorta,  vena  cava,  and  third 
portion  of  the  duodenum  to  the  right  sacroiliac  articula- 
tion. Although  this  line  is  only  six  or  eight  inches  in 
length,  and  the  average  width  of  the  mesentery  is  eight 
or  ten  inches,  it  reaches  at  its  convex  intestinal  edge  a 
length  of  some  twenty  feet.  The  middle  or  lower 
intestinal  loops  have  the  widest  mesentery  and  are 
therefore  most  likely  to  enter  a  hernia.  Between  the 
layers  of  the  mesentery  are  the  blood-vessels,  lymph- 
atics, and  nerves  of  the  intestine. 

The  duodenum  is  for  the  most  part  situated  behind 
the  peritoneum,  a  position  which  it  acquired  when  the 
large  intestine  of  the  embryo  crossed  the  small.  Up  to 
this  time  it  possessed  a  mesentery,  which  then  fused 
with  the  posterior  body  wall.  The  first  portion  of  the 
duodenum  is  movable  except  at  its  distal  end.  With 
an  empty  stomach  it  is  directed  transversely;  with  a 
distended  stomach,  anteroposteriorly.  Above,  it  is  in 
relation  with  the  liver  and  gall  bladder;  below,  with  the 
pancreas;  behind,  with  the  portal  vein  and  common  bile 
duct.  Beneath  the  neck  of  the  gall  bladder,  at  a  point 
opposite  the  first  lumbar  vertebra,  it  turns  downward 
as  far  as  the  fourth  vertebra,  in  front  of  the  right  kidney 
and  vena  cava,  being  crossed  anteriorly  by  the  meso- 
colon, above  and  below  which  it  is  covered  by  visceral 
peritoneum.  Internally  is  the  head  of  the  pancreas, 
whose  duct  opens  with  the  bile  duct  into  the  lower 
portion  of  the  duodenum.  This  constitutes  the  second 
portion,  at  the  end  of  which  the  duodenum  turns  to 
the  left  across  the  spinal  column  and  great  vessels  to 
ascend  a  short  distance  and  end  in  the  jejunum 
opposite  the  first  or  second  lumbar  vertebra.  Note  its 
relations  to  surrounding  organs  in  connection  with  the 
spread  of  disease.  It  may  be  involved  and  the  peri- 
toneal cavity  may  escape.  Wounds  are  serious  because 
of  its  inaccessibility  and  its  fixed  position.  With  the 
exception  of  the  first  part,  it  cannot  be  raised  into  a 
laparotomy  wound.  Its  arteries,  forming  an  arch 
within  the  concavity,  may  be  opened  in  a  duodenal 
ulcer  and  may  allow  a  fatal  hemorrhage. 

The  jejunum  and  ileum  include  the  remainder  of  the 


Vol.  1—2 


17 


Abdominal  Organs,  Regional 
Anatomy 


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small  intestine,  called  intestinum  tenue  mesenterfale — 
two-fifths  jejunum,  three-fifths  ileum.  Although  there 
is  no  distinct  line  separating  them,  each  has  distinctive 
characteristics.  The  walls  of  the  jejunum  are  thicker 
and  more  vascular,  the  valvulae  conniventes  are 
numerous  and  perfectly  developed,  and  the  caliber  is 
greater.  Peyer's  patches  are  larger  and  more  numer- 
ous in  the  ileum.  The  coils  of  the  small  intestines 
have  no  fixed  position,  but  one  may  expect  to  find 
jejunum  in  the  umbilical,  left  lumbar,  and  left  iliac 
regions,  while  the  ileum  tends  more  to  the  right  side, 
toward  the  hypogastric  region  and  toward  the  pelvis. 

Because  of  their  wide  extent  and  exposed  position 
the  small  intestines  are  frequently  injured.  The 
degree  of  injury  may  vary  from  slight  contusion  to 
complete  rupture,  and  is  greater  the  nearer  it  ap- 
proaches the  stomach  and  the  more  distended  the  coils 
happen  to  b».  The  extent  to  which  the  abdominal 
wall  is  injured  does  not  indicate  the  severity  of  the 
visceral  injury,  for  the  most  extensive  laceration  may 
follow  a  blow  which  scarcely  leaves  a  mark  upon  the 
skin.  The  great  dangers  are  hemorrhage  and  fecal 
extravasation,  especially  the  latter.  It  occurs  more 
rapidly  from  distended  coils,  and  they  are  the  ones 
most  frequently  injured.  A  longitudinal  wound  gapes 
more  widely  than  a  transverse,  the  edges  being  sepa- 
rated by  the  strong  circular  muscular  fibers.  A  small 
penetrating  wound  may  be  plugged  by  everted  mucous 
membrane.  A  wound  in  the  mesenteric  border  is  most 
difficult  to  repair.  A  gunshot  wound  in  the  lower  left 
quarter  of  the  abdomen  will  certainly  inflict  multiple 
intestinal  injuries.  As  a  rule,  however,  they  will  be 
found  in  a  comparatively  short  loop  of  intestine,  with 
a  few  scattered  in  distant  coils. 

Large  Intestine  (intestinum  crassum). — Of  this 
there  are  the  following  divisions:  cecum,  ascending, 
transverse,  and  descending  colon,  sigmoid  flexure, 
and  rectum. 

It  is  distinguished  from  the  small  intestine  by  its 
larger  size,  by  its  more  fixed  position,  and  by  the  appen- 
dices epiploic®.  Furthermore,  the  longitudinal  muscu- 
lar fibers  which  are  spread  in  an  even  layer  over  the 
small  intestine  are  gathered  into  three  well-marked 
bundles  on  the  surface  of  the  colon.  These  are  about 
one-half  the  length  of  the  remaining  colon  layers,  and  so 
throw  it  into  sacculations  separated  by  transverse 
constrictions,  which  project  into  the  lumen  of  the  bowel 
as  plicae  or  valvulae  sigmoidse.  The  length  of  the  large 
intestine  is  five  or  six  feet;  its  capacity  is  about  one 
gallon. 

The  cecum — that  part  of  the  large  intestine  below 
the  ileocolic  opening — is  situated  in  the  right  iliac 
fossa,  upon  the  iliopsoas  muscle.  Anteriorly,  it  is 
in  contact  with  the  anterior  abdominal  wall  above  the 
outer  half  of  Poupart's  ligament,  except  when  the 
omentum  is  interposed.  Its  exact  position  depends 
upon  its  peritoneal  relations.  As  a  rule,  it  is  completely 
invested  by  peritoneum,  though  it  has  no  mesocecum. 
In  a  small  percentage  of  cases  the  upper  part  of  the  pos- 
terior surface  is  not  covered  by  peritoneum,  and  so 
comes  in  contact  with  the  areolar  tissue  of  the  posterior 
abdominal  wall.  It  may  be  long  and  movable,  its  free 
extremity  hanging  into  the  pelvis  or  projecting  across 
the  mid-line  to  the  opposite  side  of  the  body.  Or  it  may 
be  situated  at  any  point  between  the  iliac  fossa  and  a 
position  immediately  beneath  the  liver,  this  bcint;  its 
location  in  the  embryo  of  three  months.  The  latter 
variation  occurs  in  consequence  of  an  arrest  of  its  nor- 
mal descent  into  the  false  pelvis.  When  the  posterior 
wall  of  the  cecum  is  not  entirely  covered  by  peritoneum, 
an  infection  readily  travels  from  it  to  the  areolar  tissue 
about  the  right  kidney. 

The  appendix  vermiform  is  (processus  vermiformis) 
originally  arose  from  the  apex  of  the  cecum,  but,  as  the 
right  half  of  the  hitler  exceeds  the  left  in  development, 
tin-  iiluli  appendix  arises  from  its  inner  and  posterior 
surface  a  little  below  the  ileocolic  opening.  Its  average 
length  is  between  three  and  four  inches,  but  it  may  vary 

18 


from  one  to  nine.  Its  cavity,  lined  by  mucous  membrane 
continuous  with  that  of  the  cecum,  tends  to  undergo 
obliteration  with  advancing  age.  The  lumen  is  narrow- 
est at  the  orifice,  which  is  guarded  by  a  valve  of  mucous 
membrane.  It  is  enveloped  by  peritoneum  throughout, 
and  is  provided  with  a  triangular  mesentery  derived 
from  that  of  the  small  intestines.  The  mesentery  is 
rarely  complete,  allowing  the  end  to  hang  free.  Within 
the  mesentery  is  a  branch  of  the  ileocolic  artery,  fur- 
nishing its  blood  supply.  The  exact  position  of  the 
appendix  is  variable,  but  it  will  always  be  found  by 
following  one  of  the  longitudinal  bands  of  muscular 
fibers  seen  on  the  surface  of  the  colon.  Two  main  posi- 
tions are  observed.  In  one,  the  appendix  is  truly  an 
intraperitoneal  organ  hanging  free  from  the  cecum.  It 
may  be  directed  inward  and  upward,  or  downward;  it 
may  be  curled  on  the  brim  of  the  pelvis  or  may  hang 
into  the  pelvic  cavity;  or  it  may  occupy  one  of  the 
fossae  about  the  cecum.  In  the  second  position  the 
appendix  is  practically  an  extraperitoneal  organ,  lying 
between  the  posterior  surface  of  the  cecum  and  the 
colon.  The  base  of  the  appendix,  as  indicated  by 
McBurney's  point,  lies  two  inches  from  the  spine  of  the 
ilium  on  a  line  drawn  from  the  spine  to  the  umbilicus. 

Colon. — The  ascending  colon  (colon  ascendens) 
reaches  from  the  cecum  to  the  under  surface  of  the 
liver,  passing  through  the  right  lumbar  region  into  the 
hypochondrium.  Here  it  turns  to  the  left  forming  the 
hepatic  flexure  (flexura  coli  dextra)  and  becomes  the 
transverse  colon  (colon  transversum).  As  a  rule,  it  has 
no  mesentery,  being  held  in  position  by  the  peritoneum 
which  covers  its  anterior  surface  and  sides.  Behind,  it  is 
separated  by  loose  areolar  tissue  from  the  quadratus 
lumborum  and  transversalis  muscles  and  the  lower  and 
inner  part  of  the  right  kidney.  In  front  it  is  in  contact 
with  the  anterior  abdominal  wall,  omentum,  and  a  few 
coils  of  the  small  intestines.  The  relation  to  the  ante- 
rior surface  of  the  kidney  is  most  important.  An  ab- 
scess of  the  kidney  or  a  perinephritic  abscess  may  open 
into  it  without  involving  the  peritoneum.  A  kidney 
enlarged  from  infection  or  a  tumor  carries  the  colon 
forward  on  its  anterior  surface.  This  may  be  deter- 
mined by  inflation  of  the  colon. 

The  transverse  colon  suspended  by  a  mesocolon  is 
deeply  placed  at  its  ends,  but  comes  in  close  contact 
with  the  anterior  abdominal  wall  in  the  remainder  of 
its  course.  As  a  rule,  it  lies  along  the  subcostal  line, 
but  may  descend  as  far  as  the  pelvis.  Above,  it  is 
first  close  to  the  fundus  of  the  gall  bladder;  adhesions 
between  the  two  are  common,  and  calculi  may  ulcerate 
into  it  from  this  viscus.  The  greater  curvature  of 
the  stomach  and  the  lower  end  of  the  spleen  lie  above 
in  the  remainder  of  its  course. 

The  descending  colon  (colon  descendens)  begins  at 
the  splenic  flexure  (flexura  coli  sinistra),  at  which  point 
it  is  situated  deeply  in  the  left  hypochondrium.  From 
here  it  descends  through  the  left  lumbar  region  along 
the  outer  border  of  the  kidney.  Its  peritoneal  relations 
resemble  those  of  the  ascending  colon.  A  relation 
worthy  of  not  ice  is  that  to  the  kidney.  The  left  kidney 
lies  more  internal  to  the  descending  colon  than  the 
right  does  to  the  ascending  colon.  Anteriorly,  the 
descending  colon  is  more  constantly  covered  by  omen- 
tum and  small  intestine  than  is  the  ascending. 

Fecal  matter  may  accumulate  in  the  colon  in  any 
part  to  such  an  extent  as  to  simulate  a  true  tumor; 
consequently  colonic  flushing  is  always  a  wise  procedure 
in  the  examination  of  an  intraabdominal  growth. 

The  sigmoid  flexure  (colon  sigmoideum),  continuing 
the  descending  colon,  extends  from  the  iliac  crest  to  the 
third  sacral  vertebra,  at  which  point  it  becomes  the  rec- 
tum (intestinum  rectum).  It  is  provided  with  a  mes- 
entery attached  transversely  in  front  of  the  psoas  muscle. 
Its  length  and  position  are  variable.  It  may  form  a  per- 
fect loop  occupying  the  pelvis,  or,  when  the  bladder  and 
rectum  are  distended,  lying  near  the  umbilicus.  At  times 
it  tests  in  the  left  iliac  fossa.  It  is  this  loop  which  sur- 
geons open  in  a  left  inguinal  colostomy.     In  the  descend- 


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Abdominal  Orcans,  Regional 
Anatomy 


ing  colon,  the  opening  may  be  through  the  posterior  ab- 
dominal wall  without  exposing  the  peritoneal  cavity, 
but  as  the  position  of  the  artificial  anus  is  an  awkward 
one  for  the  patient  the  operation  has  been  abandoned. 

The  remaining  portion  of  the  large  intestine  is  the 
rectum,  situated  within  the  true  pelvis,  with  which 
it  is  usually  described. 

The  spleen  (lien)  is  situated  obliquely  behind  the 
stomach  in  the  epigastric  and  left  hypochondriac  regions. 
It  lies  beneath  the  eighth,  ninth,  tenth,  and  eleventh 
ribs;  its  long  axis,  measuring  five  or  six  inches,  corre- 
sponds in  direction  with  the  tenth  rib.  It  is  separated 
fn  mi  these  ribs  above  by  the  lower  border  of  the  lung 
and  pleura,  and  throughout  by  the  peritoneum  and 
diaphragm.  A  normal  spleen  cannot  be  palpated. 
The  enlarged  spleen  appears  beneath  the  costal  arch  at 
the  level  of  the  tenth  and  eleventh  ribs.  It  may  be 
distinguished  by  the  notches,  one  or  two,  in  it<  anterior 
border  and  by  its  respiratory  movement.  Unlike  the 
movement  of  the  liver,  which  is  vertical,  the  movement 
of  the  spleen  is  oblique,  that  is,  toward  the  umbilicus. 
The  dulness  of  the  spleen  as  outlined  by  percussion  is 
an  oval  area  extending  from  the  ninth  to  the  eleventh 
rib  in  the  posterior  axillary  line.  Four  surfaces  are 
described  on  the  organ,  each  indicating  a  relation  to  a 
neighboring  viscus.  The  phrenic  surface  is  in  contact 
with  the  diaphragm.  The  renal  surface,  directed 
downward  and  inward,  is  in  contact  with  the  left 
kidney.  The  gastric  surface  faces  forward  and  in- 
ward and  is  iii  contact  with  the  posterior  surface  of 
the  stomach;  on  this  surface  is  the  hilum.  Finally, 
the  lower  blunt  end  is  the  basal  surface  upon  the  splenic 
flexure  of  the  colon  and  the  tail  of  the  pancreas. 

The  peritoneal  relations  of  the  spleen  are  extensive. 
With  the  exception  of  the  small  region  corresponding  to 
the  hilum  it  is  covered  by  the  visceral  peritoneum  of 
the  greater  sac.  The  blood-vessels  and  nerves  reach 
the  organ  between  the  layers  of  the  gastrosplenic 
omentum. 

Wounds  of  the  spleen  are  accompanied  by  severe 
hemorrhage.  When  it  is  extreme  it  may  become 
necessary  to  remove  the  organ  for  this  reason. 

The  pancreas,  situated  behind  the  stomach,  in  front 
of  the  first  and  second  lumbar  vertebrae,  reaches  from 
the  concavity  of  the  duodenum  on  the  right  to  the 
spleen  on  the  left.  On  the  surface  of  the  abdomen  its 
position  is  from  two  and  one-half  to  five  inches  above 
the  umbilicus.  To  expose  the  pancreas  the  lesser 
peritoneal  cavity  must  be  opened.  It  is  then  seen 
lying  behind  the  posterior  layer  of  this  cavity.  It  can 
be  palpated  only  when  pathologically  enlarged,  as  by  a 
carcinoma  or  cyst.  The  organ  -does  not  move  with 
respiration. 

The  anterior  surface  of  the  pancreas  is  in  contact 
with  the  posterior  surface  of  the  stomach,  while  the 
posterior  surface  lies  in  front  of  the  aorta,  the  superior 
mesenteric  artery,  the  splenic  vein,  and  the  left  kidney 
with  its  vessels.  The  head  is  encircled  by  the  duo- 
denum. The  pancreatic  duct  crosses  the  gland  from 
left  to  right,  and  is  buried  in  its  substance  close  to  the 
posterior  surface.  Its  course  is  straight  until  it  reaches 
the  head,  at  which  point  it  turns  obliquely  downward 
to  enter  the  second  portion  of  the  duodenum,  close  to 
or  in  common  with  the  bile  duct.  Retention  cysts  of 
the  duct  or  of  some  of  its  smaller  branches  occur,  and 
may  attain  a  large  size.  In  general  appearance  such 
a  cyst  resembles  a  solid  or  a.  cystic  tumor  of  the  kidney, 
the  differential  diagnosis  being  at  times  impossible. 

Kidneys  (renes) . — For  the  greater  part  the  kidneys 
are  situated  deeply  in  the  hypochondriac  regions,  their 
lower  ends,  however,  extending  into  the  adjacent 
lumbar  and  umbilical  regions.  In  consequence  of  the 
position  of  the  liver  on  the  right  side,  the  right  kidney 
is  somewhat  lower  than  the  left.  As  regards  the 
vertebral  column,  the  kidneys  are  opposite  the  twelfth 
dorsal,  the  first  and  second,  and  sometimes  the  third 
lumbar  vertebra?.  The  upper  end  of  the  right  kidney 
reaches  a  line  drawn  transversely  outward  from  the 


tip  of  the  spine  of  the  eleventh  dorsal  vertebra.  Its 
lower  border  reaches  a  similar  line  drawn  from  the 
lower  edge  of  the  spine  of  the  second  lumbar  vertebra. 
This  line  is  usually  about  an  inch  and  a  half  above  the 
iliac  crest.  Its  upper  end  is  nearer  the  spinal  column 
than  the  lower.  The  pelvis  of  the  organ  is  opposite 
the  transverse  process  of  the  second  lumbar  vertebra. 

A'i  laiimix.  -The  posterior  surfaces  are  similar,  but  the 
anterior  surfaces  differ  on  the  two  sides.  Posteriorly, 
the  kidneys  are  not  covered  by  peritoneum,  being  con- 
nected by  areolar  tissue  with  the  diaphragm,  the 
anterior  layer  of  the  lumbar  aponeurosis  covering  the 
quadratus  lumborum,  and,  more  internally,  the  psoas 
magnus  muscles.  Above,  the  relation  to  the  dia- 
phragm is  important,  as  this  structure  separates  the 
kidney  from  the  twelfth  rib,  and  sometimes,  on  the 
hit  side,  from  the  eleventh.  An  inspection  of  Plate  1 
will  show  that  the  pleura  descends  over  the  inner  ends 
of  these  ribs,  and  so  lies  between  the  upper  ends  of  the 
kidneys  and  the  surface  of  the  body.  Notice  especially 
that  the  pleura  does  not  descend  below  the  angle  formed 
by  the  lower  border  of  the  twelfth  rib  and  the  outer 
edge  of  the  quadratus  lumborum  muscle.  However, 
the  development  of  the  twelfth  rib  is  not  constant,  it 
being  incompletely  developed  or  entirely  absent  in 
many  cases.  The  individual  cases  can  be  recognized 
only  by  counting  the  ribs.  On  the  other  hand,  the 
lower  limit  of  the  pleura  and  its  relation  to  the  kidney 
are  constant,  and  in  a  case  of  anomalous  twelfth  rib  the 
pleura  will  lie  unprotected  by  rib  in  this  locality.  The 
importance  of  this  condition  will  be  appreciated  later. 

Anteriorly,  the  right  kidney  has  the  following  rela- 
tions: At  the  extreme  upper  end  is  a  small  non-peri- 
toneal surface  in  contact  with  the  suprarenal  capsule, 
below  and  external  to  which  is  a  large  peritoneal  surface 
in  contact  with  the  liver.  The  area  about  the  hilum 
is  non-peritoneal  and  is  in  contact  with  the  descending 
portion  of  the  duodenum.  Below  this  region  and 
internal  to  the  liver  area  are  two  regions:  an  outer  non-  • 
peritoneal  covered  by  the  colon,  and  an  inner  peritoneal 
covered  by  coils  of  small  intestine. 

The  anterior  surface  of  the  left  kidney  is  crossed  just 
above  its  center  by  the  pancreas,  no  peritoneum  inter- 
vening. Above  the  pancreatic  surface  three  organs  are 
in  relation  with  the  kidney:  the  suprarenal  capsule,  the 
stomach,  and  the  spleen — the  first  being  the  only  organ 
not  separated  by  peritoneum.  Below  the  pancreas  the 
surface  is  largely  covered  by  peritoneum  and  small  in- 
testine, the  exception  being  the  outer  border,  which 
lies  behind  the  colon.  From  the  description  of  the 
situation  and  relations  of  the  kidney  a  number  of 
practical  points  are  evident.  As  a  general  rule,  it  is 
safe  to  say  that  a  palpable  kidney  is  enlarged  or  dis- 
placed. Only  in  very  favorable  subjects,  especially 
thin  women,  in  whom  the  organ  is  frequently  lower 
than  normal,  can  we  certainly  feel  the  normal  kidney, 
and  then  only  the  lower  third,  as  the  upper  two-thirds 
lie  behind  the  lower  ribs.  Bimanual  palpation  should 
be  used,  the  hand  placed  in  the  loin  being  depended 
upon  to  lift  the  kidney  against  its  fellow  which  presses 
upon  the  abdomen.  In  this  connection  note  the  posi- 
tion of  the  colon;  it  is  nearly  over  the  center  of  the  right 
kidney,  but  to  the  left  of  or  outside  the  left  kidney. 
The  kidney  has  no  respiratory  movement.  It  is 
recognized  by  its  characteristic  shape,  and  by  the 
large  artery  which  enters  the  hilum.  The  kidney  may 
be  reached  through  the  loin  or  by  way  of  the  perit- 
oneal cavity.  In  the  former  method  various  incisions 
are  employed.  The  most  important  landmarks  are  the 
outer  edge  of  the  quadratus  lumborum  muscle  and 
the  twelfth  rib.  In  all  incisions  it  should  be  remem- 
bered that  the  pleural  cavity  is  near,  and  it  should  be 
avoided.  As  indicated  above,  when  the  twelfth  rib  is 
of  normal  development,  an  incision  may  be  carried 
closely  into  the  angle  between  this  muscle  and  the 
ribs.  When  the  rib  is  short  or  absent,  which  is  to  be 
determined  only  by  careful  examination,  then  the 
location  of  the  normal  rib  should  be  borne  in  mind, 


19 


Abdominal  Organs,  Regional 
Anatomy 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


and  the  incision  should  be  carried  no  farther  than 
the  normal  angle.  The  attachment  of  the  quadratus 
to  the  eleventh  rib  in  these  cases  should  not  mislead 
one. 

The  ureters  occupy  a  position  in  the  hilum  pos- 
terior to  the  artery  and  vein.  Their  average  length 
is  seventeen  inches.  Beginning  as  a  well-marked 
dilatation,  called  the  pelvis  of  the  kidney,  the  ureter 
passes  downward  on  the  psoas  magnus  as  far  as  the 
brim  of  the  true  pelvis,  which  it  enters  by  crossing 
either  the  common  or  the  external  iliac  artery.  It  is 
accompanied  by  the  spermatic  vessels  in  the  male,  and 
by  the  ovarian  in  the  female.  This  portion  of  the  ureter 
may  be  reached  through  the  postperitoneal  space. 
In  searching  for  it  the  operator  must  raise  the  parietal 
layer  of  the  peritoneum,  to  which  structure  it  will  be 
found  adherent. 

The  peritoneum  is  a  closed  serous  sac  with  the  excep- 
tion of  the  tubal  openings  in  the  female.  It  appears  as 
though  placed  within  the  abdominal  cavity  in  front  of 
the  viscera,  the  anterior  or  parietal  layer  of  the  sac 
lining  the  posterior  surface  of  the  anterolateral  wall, 
while  the  posterior  or  visceral  layer  is  tucked  about  the 
viscera,  enclosing  them  more  or  less  completely,  and 
attaching  them  to  the  abdominal  walls.  The  exact 
relations  of  the  membrane  to  the  individual  viscera 
have  been  noted  in  the  descriptions  of  the  latter  ,  and 
are  of  importance  in  the  spread  of  disease  from  viscera  to 
peritoneum.  Many  injuries  and  diseases  of  the  abdom- 
inal viscera  are  dangerous  only  as  they  involve  the 
peritoneum.  It  is  a  well-known  fact  that  an  infection 
approaching  the  membrane  from  its  outer  surface  is  of 


_    .  ,  ,  D    ■.  Outline  of  Diaphragm 

Parietal  Peritoneum    ,  6 


Gastro-hepatic  Omentum 


Transverse  Meso-colon 
Great  Omentum 


Parietal  Peritoneu 


Vesicula  Seminalis 

Fin.  11. — Diagram  of  the  Peritoneum  in  the  Adult  Male 
(vertical  .section).  S,  stomach;  P,  pancreas;  D,  duodenum: 
H,  urinary  bladder;  A',  rectum;  Tt\  transverse  colon;  .S7,  small 
intestine;  the  arrow  is  through  the  foramen  of  Winslow. 
(Buchanan.) 

much  less  danger  lhan  one  approaching  from  the  inner. 
The  former  is  soon  localized  and  results  in  the  formation 
tit  an  abscess;  absorption  of  toxins  is  slight.  When  the 
inner  surface  is  infected,  the  tendency  of  the  disease  is 
to  spread  rapidly,  and  the  absorption  of  septic  toxins 
is  intense.  These  phenomena  are  explained  by  the 
microscopical  structure  of  the  peritoneum.  It  consists 
e  entially  of  two  layers.  The  outer  layer  is  composed 
of  fibrous  ami  elastic  tissue.  It  supports  the  inner 
layer,  which  is  composed  of  flat  endothelial  cells. 
Between  the  margins  of  the  cells  are  numerous  openings 


of  lymphatic  vessels,  stomata,  which  are  the  active 
absorbents  of  the  peritoneum.  Some  regions,  as  those 
of  the  diaphragm  and  small  intestines,  are  especially 
rich  in  lymphatic  vessels,  while  in  others,  as  the 
omentum,  the  number  is  small.  For  this  reason  a 
peritonitis  is  more  dangerous  in  certain  localities  than 
in  others. 

When  the  anterolateral  abdominal  wall  is  opened, 
the  peritoneal  cavity  is  also  opened.  In  the  living 
body,  however,  no  cavity  exists,  parietal  and  visceral 
layers  being  held  in  contact  by  muscular  action  and 


Visceral  Pentone 


■hepaiic  Omentum 

Hepatic  Aitery 
Vena  Porta: 

^\< 

SV\    Common  Bile-duct 


Fir,.   12.- 


-Diagram  of  the  Peritoneum  at  the  head  of  the  Foramen 
of  Winslow  (transverse  section;.      tBuchauan  ) 


atmospheric  pressure.  The  great  omentum  is  seen 
hanging  from  the  greater  curvature  of  the  stomach, 
covering  more  or  less  completely  the  viscera  in  the 
lower  half  of  the  cavity.  Normally  it  should  do  so 
quite  completely,  but  it  may  be  found  collected  in  a 
roll  about  some  organ  or  loop  of  intestine.  This  is 
especially  the  case  when  there  has  been  a  former 
peritonitis.  The  omentum  serves  to  protect  the  in- 
testines, and  also  as  a  storehouse  for  fat,  but  its  most 
important  function  is  that  of  limiting  an  infection.  It 
readily  contracts  adhesions  about  organs,  such  as  an 
inflamed  appendix  or  a  perforated  intestinal  coil,  and 
so  prevents  infection  of  the  general  peritoneal  cavity. 
In  extensive  pelvic  suppuration,  the  omentum  may 
completely  exclude  the  pelvic  from  the  general  abdom- 
inal cavity.  Behind  the  omentum  are  the  small 
intestines,  and,  on  either  side  of  the  posterior  wall,  the 
ascending  and  descending  colon. 

The  mesentery  of  the  transverse  colon  is  raised  with 
the  great  omentum.  As  it  is  attached  transversely 
across  the  posterior  abdominal  wall,  it  divides  the 
cavity  into  two  compartments.  The  upper  contains 
the  liver,  stomach,  and  spleen.  It  also  includes  the 
lesser  peritoneal  cavity.  The  lower  compartment  con- 
tains the  small  intestines  and  the  colon.  It  is  sub- 
divided by  the  mesentery  into  an  upper  right  and  a 
lower  left  portion.  The  upper  portion  ends  below  in 
the  right  iliac  fossa.  Consequently  a  fluid  effused  in 
this  region  or  on  the  upper  surface  of  the  mesentery 
will  gravitate  into  the  right  iliac  region.  The  left  and 
lower  portion  passes  to  the  pelvis,  into  which  cavity 
fluid  will  descend  when  it  originates  below  and  to  the 
left  of  the  mesentery. 

The  relations  of  the  lesser  peritoneal  cavity  are  de- 
scribed with  those  of  the  stomach. 

Thomas  A.  Olney. 

Abdominal  Section. — The  large  number  of  abdom- 
inal operations  permit  of  a  selection  of  the  incision 
best  suited  for  the  purpose.  A  good  incision  must 
possess  the  following  requisites. 

1.  It  must  give  the  best  possible  access  to  the 
region  to  be  operated  on. 

2.  It  must  injure  least  other  organs. 

3.  It  must  promise  the  strongest  possible  scar  for 
the  prevention  of  hernia. 


3) 


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\inii.iiiiii.ii  Section 


4.  In  woman,  at  least,  the  cosmetic  effect  of  the 
scar  is  to  be  considered  to  a  certain  extent. 

There  are  other  desiderata  to  be  fulfilled.  For 
instance,  in  certain  operations,  like  appendicitis, 
gall-bladder  operations,  and  so  on,  one  may  wish  to 
make  a  smaller  incision  which  will  suffice  only  if  the 
case  does  not  prove  too  difficult.  If  difficulties  arise, 
and  a  larger  incision  is  needed,  the  selected  incision 
must  permit  of  this  enlargement  to  obtain  free  access 
without  sacrificing  any  of  the  tissues  so  far  saved. 
The  incision  must  also  permit  of  subsequent  drainage, 
if  necessary,  in  any  of  its  parts,  without  too  much 
probability  of  the  formation  of  a  hernia. 

There  are  certain  abdominal  affections  in  which 
there  is  no  choice  as  regards  the  situation,  at  least, of 
the  incision,  as,  for  instance,  in  the  case  of  solid  immov- 
able tumors,  abscesses,  hernias,  fistulas,  and  so  on. 
Then  only  the  direction  of  the  incision  will  have  to  be 
considered. 

For  all  other  operations  there  was  a  time  when 
laparotomy  as  such  meant  the  median  incision,  be- 
cause that  gives  access  to  practically  every  region  of  the 
abdomen,  inflicts  practically  no  injury  on  the  tissues, 
and  is  attended  with  the  least  possible  hemorrhage. 

The  conditio  sine  qua  non  for  a  sound  scar,  to 
prevent  hernia,  is  primary  union;  but  it  has  been 
found  that  even  where  such  was  the  case,  quite  a 
large  percentage  (some  statistics  claim  as  many  as 
ten  per  cent.)  of  hernias  resulted  from  a  median  inci- 
sion. This  is  especially  true  in  cases  of  older  women, 
who  have  borne  children,  with  a  resulting  diastasis 
of  the  rectus  muscles.  The  reason  for  this  is  appar- 
ent. The  median  incision  severs  practically  only  one 
layer  of  tissue,  that  is,  the  aponeurosis,  which  is 
poorly  nourished  by  vessels,  like  all  tendinous  tissues 
of  the  body.  And  thus  its  very  simplicity  is  its 
disadvantage;  namely,  that  the  whole  abdominal 
wall  at  this  part  of  the  body  consists  of  only  one  layer. 
In  any  other  part  of  the  abdomen  the  operator  has  to 
go  through  several  layers  which,  as  modern  surgery 
has  taught  us,  are  to  be  united  by  separate  sutures  in 
layers. 

For  this  reason,  chiefly  in  all  abdominal  gyneco- 
logical operations,  the  median  incision  has  been  aban- 
doned entirely  by  a  great  many  of  the  best  operators. 
Special  incisions  have  been  advised  for  a  number  of 
typical  operations,  as  diseases  of  the  appendix,  gall 
bladder,  stomach,  spleen,  and  so  on.  So  that  the 
median  incision,  either  above  or  below  the  navel,  is 
employed  practically  only  in  so-called  exploratory 
operations,  where  either  the  nature  of  the  disease 
cannot  be  diagnosed  with  sufficient  certainty  before 
the  operation,  or  where  its  exact  location  cannot  be 
ascertained,  as  in  ileus,  volvulus,  and  like  conditions. 

The  preparation  of  the  patient  for  abdominal  sec- 
tion has  become  extremely  simple.  I  will  omit,  of 
course,  all  special  preparations  which  may  be  neces- 
sitated by  the  nature  of  the  disease  for  which  the 
patient  is  to  be  operated  on,  and  will  mention  only 
those  preparations  that  are  essential  for  abdominal 
section  as  such. 

The  preparation  of  the  operative  field  is  now  done 
almost  entirely  by  simply  painting  the  skin  of  the 
abdomen  (after  the  same  has  been  shaved)  with  a 
ten  per  cent,  tincture  of  iodine.  Care  should  be 
taken  that  the  skin  is  absolutely  dry  when  the  tinc- 
ture is  applied.  This  is  achieved  by  rubbing  the 
skin  either  with  ether  or  with  iodine  benzine.  A 
great  many  operators  apply  this  one  and  only  coat  of 
iodine  immediately  before  the  operation,  when  the 
patient  is  on  the  operating  table,  without  any  other 
preparation  at  all,  while  others  first  have  the  patient 
bathe,  after  which  the  skin  is  well  dried,  and  then  the 
evening  before  the  operation  a  good  coat  of  iodine  is 
applied;  this  is  repeated  the  next  day  on  the  operat- 
ing table.  It  has  been  found,  however,  that  the  one 
single  application  of  iodine  is  sufficient.  Care  has  to 
be   taken   not   to   bring   the   peritoneal   covering   of 


internal  organs,  especially  intestines,  into  contact 
with  the  iodinized  skin  as  this  is  liable  lo  produce 
adhesions.  If  intestines  or  other  organs  have  to  be 
brought    out    of   the  abdominal  cavity   and    laid    for  a 

while  on  the  abdominal  wall,  the  skin  should  be 
covered  u  it  h  ei!  her  rubber  I  issue  or  gauze  pads  which 
are  attached  with  Mikulicz,  or  Michel  clamps  to  I  lie 
peril oneal  edge. 

The  simple  preparation  of  the  skin  of  the  field  of 

operation   being  i lpleted,    I  lie   patient    is  either  left 

in  the  horizontal  position  on  tin-  table  or  put  into 
Trendelenburg's  <>r  any  other  position,  according  to 

the  nature  of  t  he  operation.      A  Her  I  he  en  I  ire  patient, 

with  the  except  ion  of  the  immediate  field  of  opera! ion. 
has  been  covered  in  the  usual  v.  ay  by  sterile  sheets  and 

towels,  thi'  actual  incision  is  made  by  the  operator. 
I  ii-t  the  skin  and  the  underlying  tissue  are  severed 
down  to  the  aponeurosis  in  one  or  several  strokes 
according  to  the  thickness  of  fat.  The  further  details 
of  the  incision  vary  in  accordance  with  the  type  of 
incision  selected,  and  will  be  described  presently. 
The  last  step,  incision  of  the  peritoneum,  is  again 
alike  in  all  types  of  incisions;  it  should  be  made  by 
catching  the  peritoneum  and  lifting  it  up  by  two 
surgical  forceps  or  clamps,  between  which  the  incision 
is  made.  Thus  any  injury  of  the  underlying  intes- 
tines is  avoided.  The  free  edges  are  at  once  caught 
by  Mikulicz  clamps,  which  are  applied  on  each  side 
as  the  incision  in  the  peritoneum  is  enlarged  with 
scissors  over  the  introduced  finger  as  a  guide,  or  over 
one  of  the  peritoneal  spoons.  After  this  retractors 
are  introduced  and  the  exposed  viscera  covered  by  an 
abdominal  pad  of  large  flat  layers  of  gauze,  hemmed 
together.  To  avoid  losing  any  of  these  pads  in 
the  abdominal  cavity,  many  surgeons  have  a  tape 
(about  twelve  inches  long),  sewed  into  one  of  the 
corners  of  the  pad ;  the  free  end  of  the  tape  is  grasped 
by  a  clamp  which  remains  outside  the  wound. 

I  shall  now  describe  the  different  methods  of  inci- 
sions for  different  operations. 

Probatory  or  Exploratory  Laparotomy. — Incisions 
4  and  6  of  Plate  II,  Fig.  1  show  the  median  incision, 
either  epigastric  or  hypogastric.  Either  can  be 
lengthened,  if  necessary.  In  the  latter  case  the  navel 
is  to  be  passed  around  on  the  left  side,  or  even 
excised,  as  some  operators  prefer. 

Appendicitis  Operation. — Two  incisions  are  chiefly 
known  and  practised  in  this  country — the  McBurney 
and  what  is  commonly  known  as  the  Kammerer 
incision.  The  former  is  seen  in  Plate  II.,  Fig.  2, 
incision  5,  the  latter  in  Fig.  1,  incision  5.  The  Mc- 
Burney  incision  is  doubtless,  physiologically,  abso- 
lutely proper.  It  is,  technically,  not  very  easy,  and 
gives  exceedingly  little  room  after  it  has  been  com- 
pleted. While  it  suffices  in  simple  interval  eases,  it 
is  absolutely  impracticable  even  when  only  adhesions 
are  found,  and  especially  if  other  difficulties  arise, 
like  the  retrocecal  situation  of  the  appendix,  very 
dense  adhesions,  or  unsuspected  encapsulated  old 
abscesses.  To  gain  enough  room,  then,  one  has  either 
to  destroy  the  carefully  prepared  gridiron  by  incisions 
across  the  fibers  of  the  muscles,  or  one  has  to  follow 
the  advice  of  Sprengel,  and  cut  across  the  anterior 
sheath  of  the  rectus,  retract  the  rectus  muscle  with 
the  epigastric  vessels  toward  the  median  line,  and 
then  incise  the  peritoneum,  plus  transverse  fascia. 
There  is  no  trouble  in  uniting  such  an  incision,  and 
drainage  in  any  of  the  corners  of  the  wound  can  easily 
be  carried  out  if  necessary. 

In  the  other  incision,  known  as  Kammerer's,  the 
anterior  sheath  of  the  rectus  is  divided,  and  the  muscle 
itself,  together  with  the  vessels,  drawn  toward  the 
median  line.  Before  incising  the  posterior  sheath 
with  the  attached  peritoneum,  the  nerve  branch  which 
appears  in  the  wound,  is  also  drawn  aside  in  the 
median  direction  by  a  blunt  hook.  In  order  to  do 
this,  one  usually  has  to  liberate  the  nerve  by  scratch- 
ing along  its  edge  with  a  sharp-pointed  knife.     This 


21 


Abdominal  Section 


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incision  gives  good  access.  If  difficulties  arise,  the 
incision  can  easily  be  lengthened  to  any  desired 
degree.  Its  closure — of  course  in  layers — is  easy; 
it  permits  drainage  in  either  angle  of  the  wound. 
In  the  very  latest  literature  a  great  deal  of  objection 
has  been  raised  against  this  incision  on  account  of  its 
not  being  physiological,  and  also  by  reason  of  the  fact 
that  it  necessitates  severing  the  nerves  supplying  the 
different  parts  of  the  rectus  muscle.  In  those  cases 
where  the  nerve  or  nerves,  according  to  the  length  of 
the  incision,  had  been  severed,  paralysis  of  that  part 
of  the  rectus  muscle  has  been  observed,  with  a  hernia 
as  a  result.  But  this  can  happen  only  when,  on  ac- 
count of  unusual  difficulties  arising  during  the  opera- 
tion, the  incision  has  to  be  lengthened  unduly.  Other. 
\\  ise,  the  results  of  this  incision  are  very  good  indeed- 


Fig.  13. — Lines  of  Abdominal  Incisions.  1,  Sprengel's  gas- 
trotomy  incision;  the  same,  when  on  the  right  side,  is 
Bakes's  gall-bladder  incision.  2,  Sprengel's  incision  for  major 
operations  on  the  stomach,  also  for  operations  on  the  transverse 
colon.  3,  For  operations  on  the  spleen.  4,  Bakes's  incision  for 
liver  operations.  5,  Bakes's  new  plastic  kidney  incision.  6,  Rep- 
resents Mackenrodt's  incision  of  the  sigmoid  flexure  and  trans- 
peritoneal operations  on  the  rectum.  7,  Resection  of  the  cecum. 
8,  Pfannenstiel's  incison  for  gynecological  abdominal  operations. 
(Figure  after  Bakes.) 

Operations  on  Gall  Bladder  and  Duels. — For  these 
operations  we  need  very  free  access  to  the  seat  of 
the  disease,  especially  in  fat  patients,  in  whom  the 
wound  becomes  exceedingly  deep.  At  the  same  time, 
the  structure  of  the  abdominal  wall  should,  according 
to  modern  ideas,  be  preserved  as  much  as  possible. 
To  achieve  this  a  number  of  incisions  have  beeD 
advised.  The  simplest  is  Kocher's,  shown  in  Plate  II., 
Fig.  2  as  incision  1,  and  he  claims  that  in  his  large  ex- 
perience he  has  always  had  verj'  good  results  from  this 
incision.  Incision  1  in  Fig.  1  shows  Robson's  modifi- 
cation of  Arthur  Deane  Bevan's.  It  is  very  good. 
Incision  2,  Fig.  1,  shows  Kehr's  bayonet  incision,  as 
he  used  to  make  it — an  excellent  incision. 

Following  the  clamor  for  more  physiological  inci- 
sions, Kehr  has  now  devised  an  incision,  which  is 
shown  as  No.  2  in  Fig.  2.  He  claims  all  the  advantages 
for  this  incision,  with  the  least  possible  injury  in  an 
anatomical  sense. 

22 


In  a  rather  heated  controversy,  whose  fervor  it  is 
not  very  easy  for  outsiders  to  understand,  Sprengel, 
of  Braunschweig,  recommends  his  incision,  No.  8, 
Fig.  2.  •  Both  are  about  equally  good.  Bakes  recom- 
mends for  simple  gall-bladder  cases,  an  incision  on 
the  right  side,  similar  to  the  one  on  the  left  side, 
shown  as  No.  1  in  Fig.  13.  For  more  difficult  operations 
on  the  liver,  he  recommends  incision  4,  Fig.  13.  The 
principal  difficulty  offered  by  any  incisions  carried 
across  the  rectus  muscle  consists  in  uniting  the  re- 
tracted fibers  of  the  muscle  by  suture.  If  the  fascia 
and  peritoneum  are  sewed  in  a  layer,  and  then  the  two 
angles  of  the  wound  elevated  by  single  hooks  or 
inserted  threads,  the  suture  of  the  retracted  fibers  of 
the  muscle  is  somewhat  protracted,  but  not  too  diffi- 
cult, and  is  in  all  cases  absolutely  secure.  Especially 
is  there  less  difficulty  in  fighting  the  protruding 
intestines,  as  so  frequently  happens  in  lengthy  in- 
cisions. 

Operations  on  the  Stomach. — Formerly,  the  median 
epigastric  incision  was  nearly  universal;  then  a  para- 
rectal incision  was  adopted,  shown  as  No.  3  in  Plate  II., 
Fig.  2.  Very  lately  Bakes  and  Sprengel  recommend 
incisions  as  shown  in  Fig.  13,  Nos.  1  and  2;  No.  1  for 
simple  gastrostomies  and  No.  2  for  the  more  difficult 
operations  on  the  stomach.  A  very  agreeable  feature 
of  the  cross  incision  is  that  the  patients  complain  of 
less  suffering  from  retching,  vomiting,  and  coughing 
after  operations. 

Operations  on  the  Pancreas. — Since  the  diagnosis  of 
diseases  of  the  pancreas,  acute  or  chronic,  has  become 
more  certain  or,  at  least,  more  probable,  median 
incisions  as  formerly  used,  or  as  employed  for  ex- 
ploratory incisions,  will  be  gradually  abandoned  and 
cross-sections  will  be  preferred.  An  incision  like 
No.  2  in  Fig.  13,  will  be  extremely  well  adapted  to  such 
a  purpose. 

Laparotomy  for  Operations  on  the  Female  Organs. — 
Pfannenstiel's  incision,  No.  8  in  Fig.  13,  has  become 
the  incision  par  excellence  for  gynecological  abdominal 
operations.  It  not  only  is  important  for  its  cosmetic 
effect,  but  it  prevents,  with  practically  absolute 
certainty,     the    formation    of  postoperative  hernia. 

The  incision  through  the  skin  is  made  as  indicated  in 
the  drawing,  and  the  fascia  is  also  incised  crosswise. 
In  the  middle  line  the  fascia  has  to  be  dissected  with 
scissors,  while  the  rest  of  the  fascia  can  be  split  and 
drawn  aside  without  cutting.  After  that  the  recti 
muscles  are  divided  in  the  middle  line  and  the  perito- 
neum is  then  opened.  No  nerves  whatsoever  are 
severed  by  this  incision,  therefore  atrophy  of  the 
recti  muscles  is  impossible. 

It  has  been  claimed  that  the  Pfannenstiel  incision 
does  not  give  enough  room  for  difficult  operations  on 
the  uterus  and  its  adnexa;  therefore  a  number  of 
authors  have  used  instead  of  a  cross  incision  into  the 
fascia,  a  curved  incision  with  the  concavity  upward. 
This  fascia  incision  can  be  carried  as  far  to  both  sides 
as  may  appear  necessary.  No  necrosis  of  fascia  in 
aseptic  cases  has  ever  been  observed. 

As  in  all  incisions  that  follow  physiological  rules,  the 
adaptation  of  the  severed  tissues  is  so  much  better 
that  the  patients  can  be  permitted  to  get  up  much 
sooner  than  formerly.  No  abdominal  binder  is 
necessary  after  the  Pfannenstiel  incision. 

For  extremely  difficult  operations  in  the  small 
pelvis,  Bardenheuer's  incision  may  be  used,  as  seen  in 
No.  S  of  Plate  II.,  Fig.  1.  The  incision  severs  skin 
and  fascia  in  the  same  direction,  and  the  recti  are  cut 
off  shortly  above  their  insertion  on  the  symphysis. 

I  have  omitted  any  discussion  of  operations  on  the 
bladder,  kidneys,  and  ureters,  as  these  organs  are 
extraperitoneal.  I  will  mention  only  the  new  plastic 
kidney  incision  of  Bakes,  as  seen  in  No.  5  of  Fig.  13. 

For  operations  on  the  spleen  a  V-shaped  incision, 
on  the  left  side,  as  shown,  on  the  right  side,  in  No.  8 
of  Plate  II.,  Fig.  2,  may  be  applied  with  advantage; 
or  incision  No.  3  in  Fig.  13. 


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OF  THE 

MEDICAL  SCIENCES 


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Abdominal  Tumors, 
Diagnosis 


For  inguinal  hernia  or  the  Alexander  operation, 
incision  No.  7  of  Plate  II.,  Fig.  1,  is  proper. 

Operations  on  the  Intestines. — Incision  No.  C, 
Fig.  13,  represents  Mackenrodt's  incisionfor  operations 
on  the  sigmoid  flexure  and  transperitoneal  operations 
on  the  rectum.  Resection  of  the  cecum  is  well 
accomplished  by  using  an  incision  like  No.  7  in 
Fig.  13.  For  operations  on  the  transverse  colon, 
incision  No.  2  in  Fig.  13  is  indicated.  For  operations 
on  the  splenic  flexure  of  the  colon,  Kocher  advises  an 
incision  like  No.  3  in  Plate  II.,  Fig.  1,  while  No.  7  in 
Fig.  '_'  is  for  inguinal  colostomy. 

An  incision  for  a  large  umbilical  hernia,  according 
to  Mayo's  method,  is  shown  in  No.  -1,  Plate  II.,  Fig.  _'. 

I  have  mentioned  previously  that  the  principal 
requisites  for  success  in  performing  these  operations, 
so  far  as  abdominal  section  itself  is  concerned,  are: 
absolute  asepsis,  complete  hemostasis,  and  the  most 
exact  suture,  with  the  avoidance  of  dead  spaci 
Wherever  drainage  is  necessary,  either  because  the 
hemostasis  cannot  be  as  exact  as  desired,  or  by  reason 
of  the  presence  of  pus,  the  entire  abdominal  section 
should  be  closed  with  the  exception  of  a  small  part  in 
one  of  the  corners,  where  a  cigarette  or  other  drain 
may  be  inserted.  For  suture  material  most  operators 
now  use  plain  catgut  for  the  peritoneum,  chromicized 
catgut  in  interrupted  sutures  for  the  fascia  and 
muscles,  and  silkworm  sutures  or  Michel's  clamps  for 
the  skin;  the  latter  can  be  applied  only  where  the  skin 
is  not  too  thick. 

For  dressing  the  wound  most  operators  now  use  adhe- 
sive plaster  strips  to  hold  the  dressing  in  place,  and  at 
the  same  time  compress  the  wound,  also  to  relieve  some 
of  the  strain  on  the  wound  produced  by  vomiting, 
retching,  coughing,  and  so  on.  Over  this  a  binder  is 
applied  which  is  made  to  conform  to  the  contours  of 
the  body  by  the  application  of  safety-pins  where 
necessary.  Thigh-straps  may  be  combined  with  the 
same.  Some  operators  place  a  sand-bag  over  the 
operated  region  to  prevent  the  accumulation  of  blood 
in  possible  dead  spaces.  Otto  Kiliani. 


Abdominal  Tumors,  Diagnosis  of. — The  word 
tumor  is  used  here  not  in  the  restricted  sense  of  a  neo- 
plasm but  in  the  etymological  sense  of  a  swelling.  It  is 
at  once  evident  from  this  that  a  large  number  of 
pathological  processes  affecting  all  the  organs  con- 
tained in  the  abdomen  and  the  tissues  making  up  the 
abdominal  walls  must  be  considered.  This  was 
deemed  necessary  because  we  start  with  the  assump- 
tion that  in  a  certain  given  case  a  tumor  has  been 
found  in  the  abdomen  and  it  is  necessary  to  discover 
what  and  where  it  is.  All  details  of  etiology,  path- 
ology, and  symptomatology  have  been  omitted  except 
in  so  far  as  they  have  a  direct  bearing  upon  the  dif- 
ferential diagnosis.  For  such  details  reference  must 
be  made  to  more  special  articles.  Furthermore,  the 
diagnosis  of  conditions  which  ultimately  lead  to  the 
formation  of  demonstrable  tumors  has  been  omitted, 
and  the  discussion  of  such  conditions  will  be  limited 
to  their  course  after  the  formation  of  a  tumor.  For 
example,  when  speaking  of  cancer  of  the  stomach  it 
will  be  assumed  that  a  tumor  has  been  discovered. 

When  confronted  with  an  abdominal  tumor,  it 
must  be  remembered  that  the  diagnosis  should  go 
beyond  the  mere  recognition  of  the  existence  of  a 
tumor  in  the  abdomen.  We  must  determine  first 
the  organ  or  tissue  in  which  the  tumor  is  located, 
and  second  the  nature  of  the  tumor.  If  the  tumor  is 
believed  to  be  a  malignant  neoplasm,  we  must  decide 
if  possible,  whether  the  tumor  arose  in  the  organ  in 
which  it  is  discovered  or  is  merely  a  tumor  secondary 
to  a  primary  tumor  in  some  organ  yet  to  be  deter- 
mined. If  the  tumor  found  is  believed  to  be  primary, 
secondary  deposits  in  other  organs  must  be  sought. 
In  other  cases  we  must  hunt  for  the  cause  of  the  tumor. 


If,  for  example,  a  certain  tumor  is  thought  to  be  a 
gal]  bladder  distended  with  fluid,  effort  Bhould  be 
made  to  ascertain  the  character  of  the  fluid  and  the 
cause  and  site  of  the  obstruction  which  prevents 
the  escape  of  the  fluid  from  the  gall-bladder.  With 
so  broail  a  subject  it  is  evident  that  only  the  more 
important  methods,  facts,  and  pathological  condi- 
tions can  be  included. 

After  a  brief  discussion  of  the  methods  of  examina- 
tion employed,  we  will  consider  what  miiilit  be  called 
tumors  of  the  abdomen  as  a  whole,  such  as  ascites, 
diffuse  peritonitis,  lipomatosis.  Then  the  various 
organs  will  be  grouped  according  to  their  relations 
to  the  colon,  and  each  group  considered  in  turn. 
The  organs  situated  to  the  cephalic  side  of  the  trans- 
verse colon,  the  liver  and  gall-bladder,  the  stomach, 
pancreas,  and  spleen,  will  be  described  first;  then 
will  follow  the  organs  behind  the  colon,  the  kidney, 
adrenal  bodies,  and  perirenal  tissue;  next  will  come 
the  organs  within  the  arch  of  the  colon,  the  small 
intestines,  mesentery  and  omentum,  peritoneum, 
lymph  glands,  aorta,  uterus,  ovaries,  bladder,  spinal 
column,  and  lastly  the  colon,  appendix,  and  walls  of 
the  abdomen.  With  each  organ  we  shall  so  far  as 
possible  take  up  first  the  circulatory  disturbances, 
then  the  inflammatory  processes,  cysts,  neoplasms, 
and  malpositions.  It  is  not  necessary  to  state  that 
this  order  cannot  be  followed  absolutely,  but  it  can 
be  approximately,  and  will  be  found  greatly  to  fa- 
cilitate a  grasp  of  this  subject,  probably  the  most  diffi- 
cult matter  handled  by  the  diagnostician. 

Methods  of  Examination  employed  include  the 
physical,  chemical,  and  microscopical:  the  first  hav- 
ing in  general  an  especial  bearing  upon  the  localiza- 
tion of  the  tumor,  while  the  second  and  third  are  of 
more  value  in  determining  the  nature  of  the  tumor. 

Physical  Methods. — Inspection. — The  patient 
should  be  placed  on  a  firm  narrow  bed  or  table  in  such 
a  way  that  the  source  of  the  light  lies  in  a  line  with 
the  median  line  of  the  body,  either  directly  above  or 
at  the  head  or  foot  of  the  patient.  The  purpose  of 
this  is  to  avoid  any  uneven  distribution  of  the  shad- 
ows. The  kind  of  light  employed  is  usually  a  matter 
of  indifference,  but  in  eases  in  which  there  is  reason 
to  suspect  the  possibility  of  a  jaundice  the  patient 
must  be  examined  by  daylight,  for  the  well-known 
reason  that  no  artificial  light  shows  even  the  deepest 
shades  of  jaundice. 

Take  note  first  of  the  size  of  the  abdomen,  especially 
of  any  disproportion  between  the  size  of  the  abdomen 
and  that  of  the  other  portions  of  the  body.  Next, 
note  the  shape  of  the  abdomen.  Is  the  abdomen 
symmetrical?  Are  there  any  portions  more  prom- 
inent than  the  corresponding  ones  of  the  other  side, 
or  is  the  upper  half  out  of  proportion  to  the  lower 
half?  If  any  part  appears  large,  does  it  appear 
sharply  outlined  or  does  it  merge  gradually  into  the 
surrounding  parts?  Does  the  surface  of  the  enlarge- 
ment appear  smooth  or  nodular,  and  are  the  outlines 
rounded  or  irregular?  Does  the  mass  move;  and  if 
so,  does  it  move  with  the  respiration,  the  pulse,  or 
independently  of  either?  Almost  any  tumor  of  the 
abdomen  may  show  respiratory  or  pulsatile  move- 
ments (the  exceptions  will  be  stated  later),  but  only 
a  few  show  independent  movements.  These  are 
tumors  from  the  stomach,  intestines,  and  uterus. 
Visible  vermicular  movements  of  the  stomach  and 
intestines  are  commonly  seen  in  patients  with  thin 
abdominal  walls  and  are  not  in  themselves  patholog- 
ical. It  is  only  when  they  are  usually  intense  and 
continuous  and  in  combination  with  distinctly  path- 
ological symptoms  that  they  need  attention.  The 
word  vermicular  quite  accurately  describes  the  motion, 
for  it  looks  exactly  as  if  some  large  worm  were 
moving  under  the  skin.  The  site  and  direction  of  the 
movement  should  be  noted.  In  general  the  pcris- 
talic  movements  of  the  stomach  are  limited  to  the 
upper  and  median  portion  of  the  abdomen  and  pass 


23 


Abdominal    Tumors, 
Diagnosis 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


from  left  to  right.  Peristaltic  movements  of  the 
stomach  from  right  to  left  are  pathological.  The 
movements  of  the  small  intestines  are  central  and 
irregular  in  direction.  Those  of  the  large  intes- 
tine correspond  to  the  relatively  fixed  position  of 
the  colon  and  vary  in  direction  with  the  portion  of 
the  colon  affected.  The  peristaltic  movements 
above  the  site  of  any  stricture  in  the  gastrointes- 
tinal tract,  either  acute  or  chronic,  are  more  active 
than  normal,  and  therefore  persistently  exaggerated 
movements  point  to  some  obstruction,  but  do  not 
in  t hem-elves  prove  such  obstruction. 

The  independent  movements  of  the  uterus  are  of 
two  sorts:  fetal  and  uterine.  The  presence  of  the  fetal 
movements  is  at  times  a  most  important  point  in  the 
differentiation  of  abdominal  tumors.  The  move- 
ment- arc  altogether  irregular  in  time  and  intensity, 
and  may  be  simulated  by  the  peristalsis  of  the  small 
intestines.  The  expulsive  contractions  of  the  uterus 
are  not  often  visible,  but  may  be  so. 

Inspection  of  the  abdomen  includes  attention  also 
to  any  subcutaneous  collateral  circulation,  either 
arterial  or  venous.  Such  circulation  often  gives 
the  clew  to  the  site  of  the  Obstruction,  which  neces- 
sitates a  collateral  circulation  and  may  give  some 
idea  of  the  degree  of  the  obstruction.  Note  also 
any  localized  edema  or  inflammatory  process. 

Often  much  valuable  information  may  be  gained 
by  changing  the  amount  of  gas  in  the  stomach  and 
intestines.  Not  only  do  we  gain  information  as  to 
the  exact  location  and  size  of  these  organs,  but  we 
learn  much  of  their  relation  to  the  tumor  found. 
Various  methods  have  been  employed  for  this  pur- 
pose, but  the  following  require  only  such  apparatus 
as  should  be  in  the  armamentarium  of  every  physi- 
cian. The  stomach  may  be  inflated  by  means  of  a 
Seidlitz  powder  mixed  after  drinking  instead  of  be- 
fore, or  one  can  use  saleratus  in  solution  followed  by 
a  little  vinegar.  This  method  is  not  entirely  without 
danger,  because  the  pressure  resulting  from  the  gas 
envolved  cannot  be  accurately  estimated.  Acci- 
dents, however,  are  rare.  Another  method  consists 
in  the  passage  of  the  stomach  tube  and  inflation  of 
the  viscus  by  means  of  a  pump.  This  has  the  advan- 
tage of  enabling  one  to  use  as  much  or  as  little  gas  as 
desired,  and  permits  the  immediate  removal  of  the 
gas  if  necessary. 

The  colon  is  inflated  by  passing  the  rectal  tube  well 
up  into  the  descending  colon  and  forcing  in  air  by  means 
of  a  pump,  the  ordinary  bicycle  pump  being  perfectly 
adapted  to  the  purpose.  A  rather  large,  cone- 
shaped  rectal  tip  is  better  than  the  rectal  tube,  for  it 
prevents  the  escape  of  the  air,  but  is  not  so  easily 
supplied  as  the  tube.  As  the  air  passes  upward  and 
distends  the  colon  we  are  able  to  learn  the  exact 
course  of  the  colon  and  its  relations  to  the  tumor. 

Harris,  of  Chicago,  has  drawn  especial  attention  to 
the  value  of  the  relation  of  the  colon  to  abdominal  tu- 
mors in  the  differential  diagnosis  of  such  tumors.  He 
substitutes  for  the  old  and  superficial  division  of  the  ab- 
domen into  nine  areas — the  right  and  left  hypochon- 
driac, lumbar,  and  inguinal  regions,  the  epigastric, 
umbilical,  and  hypogastric  regions — an  anatomical 
division  into  fourareas.  The  borders  of  these  areas  are 
not  fixed  by  external  points,  but  are  located  by  the 
inner  or  mesial  layer  of  the  longitudinal  colon  and  the 
inferior  or  caudal  layer  of  the  transverse  colon.  The 
resulting  areas  are  a  central  area,  surrounded  by  meso- 
colon; aright  and  left  posterolateral  area,  lying  external 
to  and  behind  the  mesocolon;  and  a  superior  area, 
lying  above  the  transverse  mesocolon.  While  the  boun- 
daries of  these  areas  are  not  fixed,  their  position  is 
easily  ascertained  by  determining  the  position  of  the 
colon  by  air  distention. 

In  the  central  area,  surrounded  by  the  distended 
colon,  are  found  tumors  of  the  omentum  and  mesen- 
tery, retroperitoneal  tumors,  localized  peritoneal 
exudates,   tumors  of  the  small  intestines,  tumors  of 


displaced  and  movable  kidneys,  and  all  tumors  of 
the  female  generative  organs  rising  into  the  abdomen. 

In  the  superior  region  we  find  tumors  of  the  liver, 
gall  bladder,  stomach,  lesser  omentum,  pancreas, 
retroperitoneal  lymph  glands,  and  aneurysms  of  the 
celiac  axis. 

Tumors  of  the  spleen  pass  forward  close  to  the 
anterior  wall,  in  front  of  the  splenic  flexure  of  the 
colon  and  the  neighboring  parts  of  the  transverse 
and  descending  colon. 

Tumors  of  the  kidneys,  suprarenal  bodies,  and  the 
connective  tissue  bordering  on  these  organs,  tumors 
from  remains  of  the  Wolffian  bodies,  carry  the  colon 
inward  and  forward.  But  tumors  from  floating 
kidneys  may  appear  in  the  central  area,  i.e.  sur- 
rounded by  the  colon. 

Skiagraphy. — To  these  methods  of  inspection 
there  has  in  recent  years  been  an  important  addition, 
namely,  the  inspection  of  bismuth  suspensions  by 
means  of  the  z-ray.  While  this  method  is  of  but 
little  value  in  the  great  majority  of  the  cases  of 
abdominal  tumors,  in  some  it  is  of  almost  major  im- 
portance. A  suspension  of  bismuth  salts  is  given 
by  mouth  or  per  rectum  or  both  and  inspection  made 
at  once  by  means  of  the  fluorescent  screen.  Plates 
should  also  be  made  at  varying  intervals  over  a  period 
of  twenty-four  hours.  When  the  bismuth  is  given  by 
mouth  the  intervals  between  the  plates  should  be 
short,  at  first  only  minutes  long,  but  after  the  first 
hour,  the  intervals  should  be  gradually  lengthened. 
In  this  way  accurate  information  as  to  the  size. 
location,  and  motility  of  the  stomach  maybe  obtained 
and  in  some  cases,  the  presence  and  size  of  a  carcin- 
oma can  be  accurately  proven. 

The  colonic  injections  enable  one  to  ascertain,  the 
location  of  the  colon  and  the  presence  of  kinks, 
strictures,  and  dilatations. 

Work  of  this  sort  requires  first,  a  good  x-ray  operator 
and  second,  considerable  experience  in  the  interpre- 
tation of  the  results  obtained. 

Palpation. — This  method  of  examination  is  of 
much  more  general  application  than  inspection,  for 
many  tumors  easily  palpable  are  not  visible.  Pal- 
pation should  always  be  preceded  by  thorough  and 
certain  evacuation  of  the  bowels,  otherwise  fecal 
masses  may  lead  to  errors.  The  patient  should  be 
examined  first  in  the  dorsal  position,  but  in  some 
cases  a  lateral,  a  knee-chest,  or  an  erect  position  will 
yield  results  not  otherwise  obtainable.  The  patient 
should  relax  the  abdominal  muscles  as  completely 
as  possible.  This  is  often  easier  when  the  thighs  are 
flexed  on  the  abdomen  and  the  mouth  held  open.  In 
difficult  cases  better  relaxation  is  obtained  if  the 
patient  is  placed  in  a  bath  of  warm  water  and  exam- 
ined in  the  bath.  In  still  more  difficult  cases  general 
anesthesia  must  be  employed.  Palpation  should  be 
made  gently  but  firmly,  and  any  pressure  used  should 
be  applied  gradually;  counter-piessure  from  behind 
is  often  a  help.  Sometimes,  and  this  is  especially 
true  when  there  is  considerable  fluid  in  the  abdominal 
cavity,  one  obtains  the  best  results  by  dipping  the 
stiffly  held  fingers  suddenly  downward,  depressing 
the  abdominal  walls  to  varying  depths.  Bodies  can 
often  be  felt  and  outlined  in  this  way  that  cannot 
be  felt  at  all  by  the  ordinary  method  of  palpation. 

Attention  should  be  given  to  the  following  points: 
the  location,  size,  shape,  motility,  and  tenderness  of 
the  tumor.  Note  also  any  change  in  position  or  ease 
of  palpation  caused  by  distention  of  stomach  and 
colon. 

In  all  cases  in  which  it  is  impossible  absolutely 
to  exclude  a  neoplastic  origin  for  the  tumor  palpated, 
the  rectum  and  vagina  should  be  examined. 

Percussion. — This  method  is  far  less  valuable  here 
than  in  examination  of  the  chest,  but  should  never 
be  omitted,  and  in  certain  cases  exceeds  the  other 
methods  of  examination  in  value.  Its  main  uses  are 
the  determination  of  the  position  of  the  diaphragm, 


21 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Abdominal  Tumors, 
Diagnosis 


the  .shape  of  the  upper  border  of  the  liver,  the  pres- 
or  absence  of  free  tluul  in  the  abdominal  cav- 
ity, and  the  position  and  approximate  size  and  shape 
of  the  stomach  and  (-(111111  alter  they  have  been  dis- 
tended by  gas  or  fluid.  Percussion  is  the  main  means 
of  determining  the  relation  of  the  colon  and  stom- 
ach to  the  tumor  found,  and  what  was  said  under  the 
heading  of  I  aspection  in  this  regard  could  be  repeated 
here;  it  might  perhaps  have  been  more  properly  placed 
here,  for  percussion  is  used  much  more  often  than 
inspection  for  this  purpose. 

Tumors  of  the  abdominal  organs  caus 
areas  of  dulness  only  when  superficially  located  or  of 
large  size,  and  the  resulting  area  of  dulness  is  always 
smaller  than  the  tumor. 

Percussion  is  valuable  in  demonstrating  thi 
of  areas  of  dulness  normally  present.     Disappearance 
or   reduction   of   the   hepatic   and   splenic   dulne 
often   of   the   highest    diagnostic   value.     Disappear- 
ance of  the  posterior  renal  dull 

In  isolated  cases  auscultatory  percussion  gives 
valuable  results. 

.1  iscultation. — Almost  no  results  are  obtained  by 
this  method.  Peritoneal  friction,  either  Idealized  or 
diffuse,  is  sometimes  heard.  Arterial  and  venous 
tones  and  murmurs  are  common  and  usually-  of  but 
little  significance. 

The  presence  of  fetal  heart  tones  is  obviously 
significant. 

Exploratory  Puncture  is  often  01  the  very  greatest 
value,  especially  in  determining  the  nature  of  the 
tumor.     The  details  will  be  given  'ater. 

Exploratory  Laparotomy. — In  certain  cases  a  com- 
plete diagnosis — i.e.  one  which  localizes  the  tumor 
and  determines  its  nature — is  impossible  even  after  the 
most  careful  examination.  In  such  cases  an  explora- 
tory laparotomy  is  often  justifiable,  providing  it  can 
be  made  by  a  competent  surgeon  under  favorable 
circumstances.  Unless  the  patient  presents  some 
obvious  contraindication  to  the  operation,  it  can  be 
done  with  almost  no  danger  and  often  gives  informa- 
tion which  leads  to  definite  curative  treatment. 

The  chemical  and  microscopical  methods  of  exami- 
nation can  be  more  profitably  discussed  in  the  spe- 
cial paragraphs  referring  to  the  different  organs. 

Before  taking  up  the  various  diseases  of  the  abdom- 
inal organs  leading  to  tumor  formation,  it  should  be 
expressly  and  emphatically  stated  that  any  exam- 
ination of  an  abdominal  tumor  which  omits  a  com- 
plete and  careful  examination  of  the  entire  body  is 
criminally  incomplete.  Abdominal  tumors  are  often 
merely  synnptoms  of  diseases  of  organs  remote  from 
the  abdomen,  and  such  primary  disease  can  be  dis- 
covered only  byT  a  complete  examination  of  the  body. 

Enlargement  of  the  Abdomen  as  a  Whole. — 
Thi-  may  occur  as  the  result  of  accumulations  of  gas 
or  fluid  in  the  peritoneal  cavity,  from  large  amounts 
of  gas  in  the  intestines,  from  deposits  of  fat  in  the 
abdominal  walls,  omentum,  and  mesentery,  and  in 
rare  instances  from  very  large  tumors. 

Ascites. — This  is  the  only  common  cause  for  extreme 
enlargements  of  the  abdomen.  The  abdomen  is 
enlarged  in  all  diameters,  but  when  the  cavity7  is  not 
completely  filled,  as  is  ordinarily  true,  the  horizontal 
diameter  when  the  patient  is  in  the  dorsal  decubitus 
will  be  found  considerably  greater  than  the  perpen- 
dicular diameter.  The  flanks  are  bulging  while  the 
umbilical  region  is  flattened.  The  skin  is  often  tense 
and  shining,  and  under  it  can  be  seen  the  overdis- 
tended  veins.  Such  veins  are  present  in  all  well- 
marked  cases  of  ascites  irrespective  of  its  cause,  but 
are  usually  better  marked  in  cases  due  to  atrophic 
cirrhosis  of  the  liver  than  in  others.  The  umbilicus 
is  flattened  out  or  even  bulging.  Sometimes  when  the 
patient  changes  position,  one  sees  the  fluid  changing 
position  also,  and  one  is  reminded  of  the  appe^rance 
of  an  incompletely  filled  sack  when  it  is  shaken. 
On  palpation  the  fluid  waves  can  be  felt  when  the 


hand  is  placed  Hat  on  one  side  of  the  abdomen  and 

the  other  side  is  percussed  gently.      If  one  lay-  the 
hand   lightly   over  the   region   of   the  abdomen   which 
percussion   shows   to  lie   tympanitic  and   at 
time   percusses    the   Hank,    the    fluid    will    flap    up 
strike   the  hand,    i.e.   the  fluctuation   is  felt    over  the 

Percussion  shows  dulness  over  the  dependent  por- 
tions of  (he  abdomen  but  usually  about  the  umbil 

ads  an  area  of  tympany.     The  borders  of  this  area 

are  no  ir,  but  wavy.     If  one  outlines  thi-  area 

very   carefully   he   will   find   that    though   the   borders 
avy,  they  are  at  all  point  ame  horizontal 

plane.      When  the  position  of  the  patient  is  changed, 
the  level  of  the  fluid  changes  very  promptly   to  cor- 

md   to  the  altered   position.      When   tin 
of    the    fluid    is    very  great,   the  entire  abdomen  will 
be  dull  on  percussion,  even  fit  the  highest   level. 

Auscultation  yields  no  results,  except  in  cases  to  be 
stated  la 

Such  free  fluids  in  the  abdomen  are  usually  transu- 
but  they  may  be  exudates,  and  the  first  question 
is  to  determine  which.  Usually  thi-  can  be  done  with 
a  great  degree  of  certainty  even  without  actual  ex- 
amination of  the  fluid.  If  the  patient  has  a  perfectly 
manifest  disease  of  the  heart,  kidney,  or  liver,  the 
fluid  is  very  probably  a  transudate.  If  there  is  fluid 
in  the  subcutaneous  tissues  and  the  other  serous  sacs 
also,  this  probability  becomes  a  certainty. 

If  doubt  remains,  enough  fluid  must  be  withdrawn 
to  ascertain  its  character.  In  these  cases  it  is  best 
to  remove  at  first  only  sufficient  for  examination, 
for  when  the  fluid  is  chylous  it  is  best  not  to  withdraw 
it  except  upon  the  most  urgent  indications.  A  trans- 
udate is  a  clear,  straw-colored  fluid,  of  low  specific 
gravity,  less  than  1.015,  containing  a  small  amount 
of  albumin  up  to  two  per  cent,  and  showing  almost 
no  cellular  elements.  An  exudate  may  be  equally 
clear,  but  is  usually  cloudy  from  cells  and  fibrin. 
The  specifie  gravity  is  above  1.015,  usually  consider- 
ably above.  The  amount  of  albumin  is  higher,  over 
four  per  cent.  The  cellular  elements  vary  greatly 
in  number  and  in  character,  but  are  always  more 
abundant  than  in  the  transudate. 

The  rather  rare  cases  of  adipose  and  chylous 
ascites  show  a  turbid,  milky  fluid,  very  different  from 
the  ordinary  ascitic  fluid.  The  adipose  ascites  is 
usually  of  high  specific  gravity,  for  it  is  merely  an 
altered  exudate,  contains  a  good  deal  of  fat  which  is 
in  both  large  and  fine  droplets,  and  is  free  from  sugar. 
The  chylous  ascites  contains  fat,  but  only  in  fine 
droplets;  sugar  is  present  in  most,  but  not  in  all  cases; 
the  specific  gravity  is  low. 

When  it  is  settled  that  the  enlargement  of  the 
abdomen  is  due  to  free  fluid,  and  the  nature  of  the 
fluid,  whether  exudate  or  transudate,  has  been  dis- 
covered, it  yet  remains  to  determine  the  cause  of  the 
trouble.  Large  peritoneal  transudates  may  come 
from  a  disease  of  heart,  kidney,  or  liver.  If  due  to 
heart  or  kidney,  the  ascites  is  usually  a  part  of  an 
anasarca;  if  due  to  the  liver,  the  ascites  exists  alone 
or  preceded  the  edema  elsewhere  by  days  or  weeks.  A 
well-marked  collateral  circulation  on  the  abdomen 
and  an  enlarged  spleen  speak  for  a  primary  hepatic 
process,  but  it  may  be  necessary  to  withdraw  the 
fluid  before  the  spleen  can  be  palpated. 

Large  exudates  in  the  abdomen  are  almost  always 
due  either  to  tuberculosis  or  to  carcinoma.  The 
physical  signs  often  differ  somewhat  from  those  of  the 
transudate,  because  as  a  rule  the  fluid  is  not  perfectly 
free  and  for  this  reason  does  not  change  its  level  so 
promptly  as  does  the  transudate,  and  oftentimes 
certain  portions  of  the  intestines  become  adherent  to 
the  abdominal  wall,  so  that  tympany  is  found  even 
over  the  most  dependent  part  of  the  abdomen.  The 
clinical  differentation  of  tuberculous  from  carcinoma- 
tous peritonitis  is  often  very  difficult.  If  the  patient 
is  too  young  for  carcinoma  or  there  is  a  manifest 


25 


Abdominal  Tumors, 
Diagnosis 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


carcinoma  or  tuberculosis  of  some  organ,  then  it  is 
easy;  but  there  are  many  times  when  it  is  difficult. 
The  positive  reaction  to  the  Koch  tuberculin  speaks 
for  tuberculosis,  a  leucocytosis  speaks  for  cancer,  but 
these  two  sometimes  contradict  each  other.  The 
development  of  cachexia  speaks  for  cancer.  In 
doubtful  cases  the  patient  should  be  laparotomized 
for  purposes  of  diagnosis  and  treatment,  if  the  latter 
is  found  possible. 

There  have  been  numerous  instances  of  confusion 
of  ovarian  cysts  with  free  fluid  in  the  abdomen, 
both  transudates  and  exudates.  There  is  little  excuse 
for  this  error  unless  the  ovarian  cyst  is  so  large  as 
to  fill  completely  the  abdomen.  Here  attention  to 
the  history,  which  in  these  cases  runs  back  for  years, 
together  with  the  absence  of  any  demonstrable  cause 
for  free  fluid,  will  usually  enable  one  to  make  the 
diagnosis.  As  a  further*  aid  one  may  make  an  ex- 
ploratory puncture.  The  fluid  of  ovarian  cysts 
presents  characteristics  to  be  described  in  a  later 
paragraph. 

Sometimes  great  dilatation  of  the  stomach  has  been 
mistaken  for  ascites,  the  air  and  fluid  in  the  stomach 
giving  the  same  physical  signs  as  free  fluid  in  the  ab- 
dominal cavity.  The  history  of  this  condition  differs 
from  that  of  the  ascites.  In  cases  of  any  doubt,  the 
stomach  tube,  by  withdrawing  any  fluid  in  the 
stomach,  will  enable  one  to  make  the  diagnosis  with 
certainty. 

Collection  of  gas  in  the  free  peritoneal  cavity  often 
causes  a  very  considerable  increase  in  the  size  of  the 
abdomen,  but  percussion  and  the  tympany  thus  de- 
veloped clearly  prove  the  nature  of  the  enlargement. 
Whether  the  gas  is  in  the  intestines  or  in  the  peritoneal 
cavity  is  often  difficult  to  decide  when  both  are  possi- 
ble, as  after  trauma  or  in  the  course  of  some  ulcerative 
process  in  the  gastrointestinal  tract.  Here  the  progres- 
sive decrease  in  the  size  of  a  liver  dulness,  known  from 
former  examinations  to  be  present,  speaks  for  gas  in 
the  peritoneal  cavity.  It  is  usually  associated  with 
shock  and  symptoms  of  peritonitis. 

Enlargement  of  the  abdomen  from  fat  is  common, 
and  is  readily  recognized,  as  a  rule.  We  sometimes 
see  lipomata  of  the  mesentery  or  omentum,  which 
present  themselves  as  tumors  of  the  abdomen  and 
are  really  such,  but  it  is  not  to  these  that  we  refer. 
Careful  examination  of  this  very  common  condition 
will  protect  one  from  error. 

Tumors  of  the  Liver. — The  pathological  process 
causing  enlargement  of  the  liver  may  be  well  placed 
in  two  groups,  according  as  the  enlargement  is  diffuse 
or  circumscribed.  It  must,  however,  be  stated  that 
this  division,  like  most  other  divisions  in  medicine, 
is  not  at  all  sharply  marked,  for  most  of  the  patholog- 
ical processes  may  occur  in  either  group.  For  example, 
amyloid  infiltration  usually  causes  a  diffuse  enlarge- 
ment of  the  liver,  but  may  cause  sharply  circum- 
scribed masses;  while,  on  the  other  hand,  carcinoma 
usually  causes  localized  masses,  but  may  cause  diffuse 
enlargements. 

Diffuse  enlargements  of  the  liver,  no  matter  what  the 
cause,  bring  about  no  change  in  the  general  shape;  the 
liver  is,  so  to  speak,  merely  magnified.  The  borders 
lose  their  normal  sharpness  and  become  rounded  and 
thickened.  The  notch  in  the  anterior  border  for 
the  gall-bladder  is  retained.  The  consistency  of  the 
liver  is  often  altered,  usually  becoming  firmer,  but 
sometimes  it  feels  softer.  The  surface  may  be  per- 
fectly smooth  or  slightly  granular,  depending  upon 
the  pathological  process  in  play.  A  granular  surface 
may  be  simulated  by  the  presence  in  the  subcutane- 
ous tissues  of  partially  atrophied  adipose  tissue,  but 
under  such  circumstances  the  granules  can  be  felt 
all  over  the  abdomen,  and  they  feel  more  superficial 
than  granules  in  the  liver. 

Diffuse  enlargements  of  the  liver  generally  take 
place  downward  rather  than  upward.  Percussion 
shows  that  the  upper  border  of  the  liver  occupies  its 


normal  position;  presents  its  normal  shape,  that  of  a 
straight  line  perpendicular  to  the  surface  on  which 
the  patient  is  lying;  and  shows  only  a  slightly  decreased 
respiratory  mobility. 

Passive  Congestion  of  the  Liver. — This  is  the  com- 
monest example  of  a  diffusely  enlarged  liver,  and 
inasmuch  as  the  subjective  symptoms  from  which 
the  patient  suffers  may  be,  and  often  are,  entirely 
limited  to  the  hepatic  region,  the  tumor  of  the  liver 
is  often  mistaken  for  some  primary  condition,  while 
in  reality  it  is  not  primary  but  always  a  mere  symp- 
tom of  some  disease  causing  obstruction  to  the  venous 
circulation  at  a  point  above  the  juncture  of  the 
hepatic  veins  with  the  inferior  vena  cava. 

The  subjective  symptoms  are  pain,  fulness,  ten- 
sion, and  weight  in  the  right  hypochondriac  region, 
cither  constant  or  intermittent.  These  symptoms 
may,  and  often  do,  overshadow  all  other  symptoms 
of  the  primary  disease.  Examination  shows  a  uni- 
formly enlarged  liver,  reaching  usually  only  a  few 
centimeters  below  the  costal  arch,  but  sometimes 
extending  to  or  beyond  the  umbilicus.  The  surface 
is  smooth,  the  borders  are  regular  but  rounded. 
Usually,  but  by  no  means  always,  the  liver  is  tender. 
Percussion  shows  a  regular  upper  border  with  normal 
respiratory  motility. 

The  patients  often  show  a  moderate  degree  of 
jaundice,  usually  both  conjunctival  and  cutaneous. 
The  jaundice  is  practically  never  intense  unless  there 
is  some  complication.  This  jaundice  is  apt  to  still 
further  strengthen  the  idea  that  the  patient  has  a 
primary  disease  of  the  liver.  Examination  of  the  ab- 
domen shows  an  absence  of  ascites  and  no  enlargement 
of  the  spleen.  Exceptionally  both  these  are  found, 
but  in  these  cases  the  symptoms  of  cardiac  insuffi- 
ciency are  so  marked  that  only  the  most  careless  can 
mistake  them. 

Examination  of  the  chest  will  in  most  instances 
show  that  the  primary  disease  is  oftenest  a  disease 
of  the  heart,  endopericardial  or  myocardial.  The 
cardiac  insufficiency  may,  however,  be  secondary  to 
some  disease  of  the  lungs  or  pleura,  oftenest  an 
emphysema  or  an  obliterative  pleuritis. 

All  patients  who  present  an  enlarged  liver,  especially 
when  the  liver  is  painful  or  tender,  should  be  examined 
for  some  disease  of  the  heart,  lungs,  or  pleura  as  a 
possible  cause  for  a  passing  congestion;  and  if  such 
disease  is  found,  the  liver  should  be  regarded  as  a 
liver  of  passive  congestion;  and  this  diagnosis  should 
be  given  up  only  on  the  strongest  evidence  pointing 
to  some  other  disease  causing  diffuse  enlargement 
of  the  liver. 

Passive  congestion  of  the  liver  is  liable  to  rapid 
fluctuations,  so  that  marked  changes  in  the  size  of 
the  fiver  can  occur  in  the  course  of  a  few  days  or 
even  hours.  Such  fluctuations  do  not,  however, 
always  occur,  and  the  enlargement  may  remain  sta- 
tionary over  weeks  and  months. 

Active  Congestion  of  the  Liver. — This  occurs  in  a 
variety  of  conditions,  but  is  usually  of  so  slight  a  degree 
as  to  pass  unrecognized,  or  if  found,  is  so  minimal  or 
so  manifestly  of  secondary  importance  as  to  attract, 
little  attention.  It  occurs  in  a  variety  of  infectious 
diseases,  the  most  important  examples  being  scarlet 
fever,  smallpox,  the  various  forms  of  sepsis,  typhoid 
fever,  and  malaria.  Malaria,  especially  estivo- 
autumnal  malaria,  may  cause  a  marked  and  persistent 
enlargement  of  the  liver  which  may  be  difficult  to 
diagnose.  Such  cases  may  present  an  icteric  dis- 
coloration of  the  skin,  with  marked  enlargement  of 
the  spleen,  thus  closely  resembling  the  hypertrophic 
cirrhosis  of  the  liver,  a  disease  which  often  gives  rise 
to  an  intermittent  fever  resembling  the  fever  of 
malaria.  The  differentiation  between  the  two  is 
made  by  an  examination  of  the  blood  for  the  Plasmo- 
<l in m  miliaria.  Malarial  enlargement  of  the  liver 
may  persist  after  the  plasmodium  has  disappeared 
from    the   blood,   in   which   case   attention   must   be 


26 


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Abdominal  Tumors, 
Diagnosis 


paid  to  a  history  of  prolonged  and  irregular  malarial 
fever. 

A  variety  of  poisonings,  especially  those  by  phos- 
phorus and  arsenic,  may  cause  acute  congestive  en- 
largement of  the  liver. 

Biliary  obstruction  due  to  obstruction  of  the  com- 
mon duct,  when  continued  for  any  length  of  time, 
often  causes  a  marked  enlargement  of  the  liver.  The 
enlargement  is  perfectly  uniform  and  is  accompanied 
by  pain  and  tenderness.  The  jaundice  is  intense  and 
progressive.  The  stools  are  usually  acholic.  The 
constitutional  and  other  symptoms  present  are  due 
in  part  to  the  jaundice  and  in  part  to  the  cause  of  the 
obstruction.  The  only  disease  of  the  liver  liable  to 
be 'confused  with  the  swelling  due  to  biliary  retention 
is  the  hypertrophic  cirrhosis,  for  both  present  a 
uniform  enlargement  of  the  liver  plus  jaundice,  and 
both  may  be  accompained  by  fever.  There  are  these 
points  of  difference:  The  hypertrophic  cirrhosis  is 
accompanied  by  a  splenic  tumor:  the  jaundice  is 
usually  not  complete,  i.e.  the  stools  still  contain  bile; 
and  pain  and  tenderness  are  absent  as  a  rule.  With 
biliary  retention  there  is  no  splenic  tumor,  the  stools 
contain  no  bile,  and  there  are  also  present  the  symp- 
toms of  the  primary  condition  causing  the  obstruc- 
tion, such  as  gallstones,  acute  catarrhal  jaundice,  a 
tumor  at  the  porta,  etc.;  ascites  is  more  common 
than  with  hypertrophic  cirrhosis. 

Hypertrophic  Cirrhosis  of  the  Liver. — This  gives  rise 
to  a  universal  enlargement  of  the  liver,  exactly  re- 
sembling the  enlargements  just  considered,  so  far 
as  the  shape  of  the  swelling  is  concerned.  The 
enlargement  is  in  general  greater,  but  the  size  is  of  no 
value  in  the  differentiation.  There  is  usually  no 
pain  or  tenderness,  merely  an  uncomfortable  sense 
of  weight  and"  fulness.  The  patient  usually  gives  a 
history  of  one  or  more  attacks  of  jaundice,  brought 
on  by  slight  indiscretions  in  diet  or  occurring  spontane- 
ously. Each  succeeding  attack  is  longer,  and  the 
intervals  between  the  attacks  become  progressively 
shorter.  Usually  these  cases  appear  for  treatment 
because  of  a  jaundice,  the  intensity  of  which  varies 
greatly,  but  in  general  is  not  so  intense  in  this  disease 
as  in  others  to  be  mentioned  later.  The  stools  are  not 
acholic  as  a  rule,  although  they  are  often  lighter 
colored  than  normal,  and  in  some  instances  are  com- 
pletely acholic. 

Examination  shows  an  enlarged  liver  and  practically 
always  an  enlarged  spleen.  This  enlargement  of  the 
spleen  is  very  constant  and  is  often  extreme,  so  that 
the  spleen  reaches  a  hand-breadth  or  more  below  the 
costal  arch.  The  spleen,  like  the  liver,  is  not  tender 
and,  like  it,  feels  hard  and  dense.  Inasmuch  as  this 
form  of  cirrhosis  respects  the  portal  veins,  there  are  no 
signs  of  passive  congestion  of  the  abdominal  viscera. 
There  are  no  evidences  of  a  collateral  circulation. 
Ascites  does  not  appear  until  the  terminal  stage. 

Hypertrophic  cirrhosis  is  sometimes  accompanied 
by  irregular  fever  or  by  fever  regularly  intermittent, 
and  under  such  circumstances  may  require  differentia- 
tion from  malaria  and  from  infections  of  the  bile 
tracts.  The  history  of  previous  attacks  of  malaria 
or  of  residence  in  malarious  regions  is  important. 
The  blood  should  be  examined  for  the  Plasmodium 
malaria'.  In  these  cases  the  demonstration  of  the 
malarial  organism  often  requires  repeated  examination 
of  the  blood,  and,  in  case  of  repeated  failure,  an  explor- 
ing needle  should  be  put  in  the  liver  or  spleen  and  the 
blood  thus  obtained  examined.  The  plasmodia  are 
often  found  in  the  blood  of  these  organs  when  they 
cannot  be  found  in  the  circulating  blood. 

Infections  of  the  bile  tracts,  even  when  acute,  may 
resemble  the  hypertrophic  cirrhosis  by  causing 
marked  enlargement  of  the  liver,  with  jaundice  and 
splenic  tumor.  The  liver  is,  however,  often  tender, 
and  the  enlargement  may  be  irregular;  the  spleen 
often  feels  soft,  the  fever  is  usually  more  marked, 
the  chills  are  more  prominent,     An  examination  of 


the  blood  will  in  many  cases  show  a  leucocytosis  and 
sometimes  bacteria.  The  difficulty  of  differentiation 
is  still  further  increased  by  the  fact  that  many  patients 
with  hypertrophic  cirrhosis  suffer  during  the  later 
stages  from  infections  of  the  biliary  tracts. 

Syphilis  of  the  liver  occurs  in  various  forms,  but 
we  are  concerned  only  with  those  forms  which  lead 
to  enlargement  of  the  liver.  Either  the  acquired 
or  the  hereditary  variety  of  syphilis  may  cause  an 
increase    in    the   si/e  of    the   liver,    though   they  do  SO 

by  different  proce  ses. 

Tertiary  syphilis,  the  stage  in  which  the  liver  is 
oftenest  enlarged,  leads  to  the  development  of  gum- 

mata  in  varying  number  and  arrangements.  These, 
gummata,  undergoing  absorption,  lead  to  gross 
irregularities  in  the  configuration  of  the  liver.  Much 
liver  tissue  is  destroyed,  and  the  remaining  portions 
undergoing  hypertrophy  to  counterbalance  the  loss, 
still  further  increase  the  deformity.  The  symptoms 
resulting  from  gummata  in  the  liver  are  very  variable, 
as  may  be  readily  imagined  when  one  recalls  that 
there  may  be  any  number  of  gummata  in  the  liver, 
and  that  they  may  be  located  about  the  porta  or 
be  scattered  more  or  less  indifferently  through  the 
liver. 

The  marked  peculiarity  of  this  form  of  syphilitic 
liver  is  its  moderate  increase  in  size  plus  the  very 
gross  and  irregular  lobulations.  The  constitutional 
symptoms  may  be  marked  or  slight,  but  there  are 
usually  some  gastrointestinal  symptoms.  Ascites 
is  rare  and  usually  does  not  appear  until  late.  When 
present,  it  may  be  moderate  or  excessive,  and  it  is 
liable  to  marked  spontaneous  variation  in  amount. 
It  reappears  rapidly  if  withdrawn  by  paracentesis. 

There  is  not  usually  any  subcutaneous,  abdominal, 
collateral  circulation. 

Jaundice  is  exceptional.     Splenic  tumor  is  common. 

Irregular,  and  often  high  temperature  may  be 
present. 

The  diagnosis  is  based  mainly  upon  the  irregular 
liver,  residua  or  a  history  of  syphilis,  which  was 
either  not  treated  at  all  or  treated  but  imperfectly. 

The  presence  or  absence  of  the  Wassermann 
reaction  is  of  major  significance. 

Hereditary  syphilis  may  affect  the  liver  in  a  variety 
of  ways,  but  in  contrast  to  the  effects  of  acquired 
syphilis  it  is  much  more  often  a  diffuse  instead  of  a 
circumscribed  process.  The  changes  in  the  liver  may 
be  apparent  at  birth,  or  appear  during  early  child- 
hood, or  be  delayed  until  adolescence.  The  earlier 
they  appear  the  more  easily  the  nature  of  the  process 
is  recognised,  for  in  the  young  other  processes  in  the 
liver  are  rare  as  compared  with  syphilis.  The  symp- 
toms are  often  indefinite.  The  children  are  poorly 
nourished  weaklings,  suffering  from  gastrointestinal 
disturbances,  often  rachitic.  The  spleen  is  usually 
enlarged;  ascites  is  not  uncommon,  but  icterus  is 
the  exception.  The  manifestations  of  syphilis  on 
the  skin  and  mucous  membranes  are  often  minimal. 
The  diagnosis  is  based  mainly  upon  the  recognition 
of  the  opportunity  for  the  existence  of  hereditary 
syphilis;  in  other  words,  the  diagnosis  is  based  upon 
an  examination  of  the  parents. 

Fatty  hirer. — There  are  a  considerable  number  of 
pathological  conditions  in  which  the  liver  is  enlarged 
from  the  presence  of  fat,  either  deposited  or  formed 
in  situ.  Such  a  liver  is  enlarged,  usually  only  to  a 
moderate  degree;  retains  its  shape;  is  not  tender  or 
painful.  It  does  not  cause  jaundice  or  ascites,  or 
lead  to  the  development  of  a  collateral  circulation. 

The  recognition  of  the  nature  of  the  process  caus- 
ing the  enlargement  of  the  liver  rests  on  a  recognition 
of  the  cause  for  fatty  degeneration  or  infiltration. 
The  commoner  causes  are  overeating  and  the  exces- 
sive use  of  alcohol,  especially  when  combined  with 
insufficient  exercise.  Enlargement  of  the  liver  is 
frequently  found  in  alcoholics  without  the  pathological 
process  in  play  being  manifest.     The  liver  will  be 


27 


Abdominal  Tumors, 
Diagnosis 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


found  enlarged,  the  patient  suffering  from  moder- 
ate gastrointestinal  symptoms,  and  examination 
fails  to  show  any  change  in  the  other  organs.  In 
such  cases  it  is  impossible  to  decide  whether  the  pa- 
tient has  a  fatty  liver,  a  congested  liver  from  the 
gastrointestinal  irritation,  or  a  begining  hypertrophic 
or  atrophic  cirrhosis.  Any  of  these  conditions  will 
disappear  if  the  alcoholic  abuses  are  stopped.  If 
this  is  not  done,  a  few  years  will  settle  the  question. 
If  the  spleen  is  found  enlarged  the  condition  is  prob- 
ably one  of  cirrhosis. 

Diseases  which  interfere  with  oxidation,  either  by 
reduction  of  the  hemoglobin  or  by  reduction  of  the 
breathing  surface  of  tiie  lungs,  often  cause  a  fatty 
liver.  Thus  fatty  liver  is  seen  in  many  cases  of 
primary  anemia — in  chlorosis,  for  example — and  in 
many  cases  of  pulmonary  tuberculosis.  It  occurs 
also  in  cases  of  other  exhausting  diseases,  such  as 
prolonged  suppuration,  chronic  dysentery,  and  perni- 
cious anemia.  A  variety  of  toxic  bodies,  notably 
phosphorus,  arsenic,  and  antimony,  cause  fatty  liver. 

Amyloid  Liver. — The  diagnosis  of  this  condition 
rests  upon  two  factors:  the  recognition  of  a  sufficient 
cause  for  the  amyloid,  and  the  recognition  of  amyloid 
changes  in  other  organs.  The  liver  is  enlarged,  often 
enormously  so,  and  the  enlargement  is  usually  gen- 
eralized but  exceptionally  the  deposits  of  amyloid 
are  localized,  forming  large  and  sharply  circum- 
scribed tumors.  The  surface  of  the  liver  is  smooth 
and  regular.  It  feels  firm  and  dense,  and  is  not  ten- 
der or  painful.  Jaundice  does  not  occur,  and  ascites 
when  present  develops  late  and  is  the  ascites  of 
cachexia,  preceded  by  edema  of  the  extremities.  The 
amyloid  process  does  not  often  reach  a  high  degree 
in  one  organ  before  it  begins  in  other  organs  also. 
For  this  reason  we  do  not  find  the  amyloid  liver  with- 
out similar  changes  in  spleen,  kidney,  and  intestines. 
The  spleen  is  enlarged;  the  urine  is  abundant  and 
contains  considerable  albumin  with  granular  and 
waxy  cysts;  and  there  are  often  gastrointestinal 
disturbances,  especially  a  diarrhea  due  to  the  amyloid 
changes  in  the  intestines. 

The  cause  of  the  amyloid  may  lie  in  any  chronic 
infectious  disease,  oftenest  chronic  suppuration  of 
the  bones  and  joints  and  pulmonary  tuberculosis. 
It  occurs  also  in  syphilis,  chronic  malaria,  chronic 
dysentery,  and  sometimes  in  the  later  stages  of  car- 
cinoma and  other  malignant  tumors. 

Amyloid  changes  must  most  often  be  distinguished 
from  the  fatty  liver  seen  in  many  of  these  conditions 
because  of  the  common  etiology,  and  from  hypertro- 
phic cirrhosis  because  of  coincident  changes  in  spleen 
and  gastrointestinal  tract.  The  fatty  liver  in  gen- 
eral feels  softer  than  the  amyloid  liver,  and,  what  is 
more  important,  is  not  accompanied  by  enlargement 
of  the  spleen,  albuminuria,  and  diarrhea. 

The  hypertrophic  cirrhosis,  while  presenting  an  en- 
larged spleen  and  gastrointestinal  symptoms,  is  asso- 
ciated with  recurring  attacks  of  jaundice,  something 
never  seen  as  the  result  of  amyloid,  and  the  causal  con- 
ditions for  amyloid  are  absent. 

Resume  of  the  Uniform  Enlargements  of  the  Liver. — 

Passive  Congestion. — Liver  enlarged,  painful,  ten- 
der, liable  to  sudden  variations  in  size;  spleen  not 
enlarged;  jaundice  moderate  or  absent  and  altered 
in  tint  by  the  usually  accompanying  cyanosis;  ascites, 
if  present,  preceded  by  edema  of  the  feet;  examina- 
tion of  thorax  will  show  cause  for  passive  congestion. 

Biliary  Retention. — Liver  enlarged,  painful,  ten- 
der; spleen  not  enlarged;  jaundice  intense  and  the 
stools  acholic;  may  or  may  not  be  fever;  ascites  pres- 
ent or  absent;  symptoms  of  the  condition  causing 
obstruction,  sUch  as  gallstone,  catarrhal  inflammation, 
or  tumor,  present. 

Hypertrophic  or  Biliary  Cirrhosis. — Liver  enlarged, 
not  tender  or  painful;  spleen  enlarged;  jaundice  actu- 
ally present  or  found  one  or  more  times  in  history; 
ascites  only  in  terminal  stage. 


Syphilis  of  the  Liver. — Acquired:  enlargement  gen- 
eral, I  nit  grossly  irregular;  may  be  pain  and  tenderness; 
jaundice  and  ascites  usually  absent;  spleen  not 
enlarged;  history  and  residua  of  syphilis.  The 
Wassermann  reaction  is  usually  positive.  Heredi- 
tary: enlargement  uniform,  without  pain  or  tender- 
ness; jaundice  and  ascites  usually  absent:  spleen 
enlarged;  other  marks  of  hereditary  syphilis  and 
existence  of  syphilis  in  the  parents. 

Fatty  Liver. —  Liver  large,  smooth,  soft;  spleen  not 
enlarged;  no  jaundice  or  ascites;  presence  of  cause, 
Mieii  as  general  lipomatosis,  alcoholism,  anemia,  etc 

Amyloid  Liver. — Liver  enlarged,  smooth,  firm,  not 
tender  or  painful;  spleen  enlarged;  jaundice  and 
ascites  absent;  diarrhea  and  albuminuria  present; 
presence  of  a  cause  for  amyloid,  such  as  prolonged  sup- 
puration, tuberculosis,  syphilis,  etc. 

This  practically  completes  the  list  of  processes 
causing  diffuse  enlargements  of  the  liver,  except  the 
enlargements  seen  in  leukemia  and  pseudoleukemia. 
These  will  be  considered  in  the  paragraphs  upon 
tumors  of  the  spleen. 

Localized  Enlargements  of  the  Lii'er.—Oi  the  proc- 
esses which  cause  circumscribed  enlargements  of 
the  liver,  there  are  three  which  far  exceed  all  others 
in  importance.  These  are  the  abscess,  the  cancer, 
and  the  hydatid  cyst.  Any  one  of  these,  however, 
may  cause  diffuse  enlargements,  just  as  most  of  the 
processes  usually  causing  diffuse  enlargements  may 
at  times  cause  circumscribed  tumors. 

Ahscess  of  the  Liver. — The  pyogenic  organisms, 
streptococci,  staphylococci,  pneumococci,  colon  ba- 
cilli, amebas,  etc.,  may  reach  the  liver  through  any  of 
its  five  sets  of  vessels,  but  oftenest  through  the  por- 
tal vein,  the  biliary  ducts,  or  the  hepatic  artery. 
Infections  through  the  hepatic  artery  are  usually 
part  of  a  general  septicopyemia  which  so  over- 
shadows the  infection  of  the  liver  that  the  latter  has 
only  a  pathological  interest. 

Most  often  the  organism  enters  through  the  portal 
vein.  The  infection  atrium  in  the  intestines  is  fur- 
nished oftenest  by  dysenteric  ulcers,  and  for  this 
reason  abscesses  of  the  liver  are  commonest  in  south- 
ern countries,  where  dysentery  is  commonest.  In  the 
temperate  zones  the  primary  disease  most  common  is 
appendicitis,  but  ulcerative  processes  anywhere 
along  the  intestinal  tract,  especially  along  the  large 
intestine,  may  cause  infection  through  the  portal 
vein. 

Bacteria  may  enter  the  liver  from  the  bile  ducts 
either  directly  from  ulceration  of  the  ducts,  excited 
by  gallstones  or  other  causes,  by  extension  up  along 
the  bile  ducts,  or  by  entering  the  vessels  of  the  bile 
ducts  and  thence  reaching  the  portal  vein. 

The  symptoms  are  both  constitutional  and  local. 
The  patients  are  often  emaciated,  cachectic,  with 
yellow  colored  skin  (not  often,  however,  due  to  jaun- 
dice), and  marked  anemia,  usually  accompanied  by 
leucocytosis.  Fever  occurs  in  most  cases,  at  least  at 
Mine  time  during  the  course  of  the  disease,  and  may 
be  continuous,  intermittent,  remittent,  or  hectic  in 
type.     Chills  may  or  may  not  be  present. 

Locally,  there  is  pain,  usually  preceded  by  a  sense 
of  weight  and  fulness.  The  exact  location  of  the 
pain  varies  with  the  site  of  the  abscess — oftenest  in 
I  he  right  hypochondriac  region.  It  varies  greatly 
in  character  as  it  does  in  intensity,  but  in  general  is 
more  severe  if  the  abscess  is  located  near  the  surface 
of  the  liver.  Radiation  of  the  pain  to  the  right  shoul- 
der is  quite  common. 

Examination  of  the  liver  shows  it  to  be  enlarged, 
and  the  general  tendency  is  for  the  liver  to  enlarge 
upward  instead  of  downward.  The  border  between 
the  liver  and  lung  is  no  longer  a  straight  line,  but  one 
curving  upward  to  a  varying  degree.  The  respira- 
tory excursion  of  this  line  is  retained,  unless  there  is 
an  old  pleuritis  with  adhesions  complicating  the  he- 
patic condition.     If  the  abscess  is  located  in  the   left 


28 


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Abdominal  Tumors, 
Diagnosis 


lobe  of  the  liver  there  may  be  marked  dislocation  of 

the  heart. 

If  the  abscess  points  toward  the  skin  there  may  In- 
localized  bulging  of  the  abdominal  wall  with  edema 
of  the  skin. 

Jaundice  is  rare  with  liver  abscesses.  a-  i-  abo  the 
ascites.  When  the  latter  is  found,  it  may  be  due  to 
pressure  on  the  portal  vein,  or  to  the  general  ca- 
chexia, and  be  merely  a  part  of  a  general  anasarca. 

The  spleen  is  not  enlarged  with  the  chronic  abscess 
unless  it  has  become  amyloid. 

Exploratory  puncture  will  often  settle  any  doubts 
as  to  the  nature  of  the  process,  but  one  must  remem- 
ber that  there  are  some  dangers  in  making  the  punc- 
ture. The  greatest  danger  is  that  of  infecting  the 
peritoneal  or  pleural  cavity  on  withdrawing  the 
needle  from  the  abscess  cavity. 

The  diagnosis  will  often  be  cleared  by  the  rupture 
of  the  abscess  into  some  organ,  as  the  lungs,  stomach, 
or  intestine,  and  the  escape  of  the  pus  outward. 

The  diagnosis  of  the  solitary  abscess  of  the  liver 
is  based  mainly  upon  the  symptoms  of  sepsis,  with 
local  pain  and  tenderness,  with  physical  signs  of  a 
localized  enlargement  of  the  liver,  with  history  of 
dysentery,  appendicitis,  hemorrhoids,  or  gallstones. 
The  diagnosis  is  certain  when  pus  is  obtained  by 
aspirations. 

When  the  abscess  is  very  large  and  the  enlarge- 
ment of  the  liver  mainly  or  solely  upward,  the  condi- 
tion may  be  mistaken  for  pleurisy :  but  attention  to  the 
history  of  the  case,  and  especially  to  the  respiratory 
motility  of  the  upper  border  of  the  dulness,  will  set- 
tle the  question. 

Cancer  of  the  Liver. — While  other  neoplasms  occur 
in  the  liver  cancer  is  so  much  more  common  than  all 
others  combined  that  it  alone  will  be  considered. 
Cancer  may  occur  primarily  in  the  liver,  but  this  is 
decidedly  exceptional  while  secondary  cancer  of  the 
liver  is  comparatively  frequent.  The  cancer  is 
oftenest  primary  in  some  organ  in  connection  with 
the  portal  system — the  stomach/ rectum,  pancreas, 
uterus — but  the  primary  tumor  may  be  anywhere. 
The  secondary  tumor  or  tumors  may  far  exceed  the 
primary  in  size. 

Examination  shows  the  liver  enlarged,  often  to  an 
extreme  degree,  and  in  suitable  cases  the  liver  can 
be  seen  to  enlarge  from  day  to  day.  The  enlarge- 
ment may  be  nearly  uniform,  but  in  most  cases  it  is 
plain  that  the  enlargement  is  irregular.  Sometimes 
the  prominences  in  the  liver  can  be  seen  and  then- 
respiratory  motility  followed  by  the  eye.  More 
often  they  can  be  felt  as  round,  usually  firm,  hard 
prominences,  sometimes  distinctly  umbilicated  on  the 
surface.  They  may  be  tender.  Sometimes  the 
peritoneal  covering  is  inflamed  and  the  resulting 
friction  can  be  palpated.  Percussion  shows  the 
irregular  enlargement  of  the  liver,  and  here  also 
especial  attention  should  be  paid  to  the  upper 
border  of  both  the  superficial  and  deep  hepatic 
dulness. 

In  addition  to  these  symptoms  due  to  the  presence 
of  the  tumor  we  may  find  symptoms  due  to  the  pres- 
sure which  the  tumors  may  exert  upon  neighboring 
organs.  Thus  the  common  bile  duct  may  be  ob- 
structed and  icterus  result.  The  icterus  tends  to  be- 
come rapidly  and  steadily  worse. 

The  spleen  is  found  enlarged  in  about  ten  per  cent, 
of  the  cases. 

Ascites  is  not  uncommon  and  may  be  due  to  com- 
pression of  the  portal  vein,  to  an  accompanying  car- 
cinomatous peritonitis,  or  to  the  general  exhaustion. 
The  ascites  is  often  sufficiently  marked  to  mask  en- 
tirely the  tumors  in  the  liver,  which  can  be  discovered 
only  after  the  removal  of  the  fluid,  which  may  be 
either  serous  or  hemorrhagic.  The  patient  with  can- 
cer of  the  liver  show  a  progressing  secondary  anemia 
with  leucocytosis,  together  with  a  rapidly  developing 
cachexia,  accompanied  usually  by  considerable  pain 


in  the  right  side.  There  are  no  febrile  symptoms 
unless  caused  by  some  complication. 

Having  found  a  tumor  of  the  liver,  a  circumscribed 
enlargement  which,  from  the  general  condition  and 
age  of  the  patient,  and  from  the  absence  of  symp- 
toms of  abscess  or  colli:  n  I  eems  to  lie  a 
cancer,  one  should  search  for  the  site  of  the  primary 

tumor,  jiaying  especial  attention  to  symptoms  point- 
ing to  disease  of  the  stomach;  pancreas,  rectum,  uterus, 

or  to  any  of  the  other  common  sites  for  carcinoma, 
as  the  breast,  etc.  Even  in  the  absence  of  such 
symptoms  it   is  probable  that   the  cancer  of  the  liver 

i     ei  ondary. 

nocoi  '  ■. — Many  cases  cause  no  symptoms 
whatsoever  and  are  therefore  unrecognized  until  the 
cysts  reach  considerable  size,  and  even  then  may  lie 
purely  accidental  findings.  When  small  they  r. 
no  functional  disturbances  unless  located  at  the  porta 
or  superficially,  where  they  may  excite  a  painful  peri- 
hepatitis. Usually  the  first  thing  to  attract  attention 
is  a  palpable  tumor  or  symptoms  resulting  from 
ire  upon  some  organ. 

Hydatid  cysts  enlarging  downward  are  much  more 
palpated  than  those  enlarging  upward.  The 
cyst  is  round,  firm,  elastic,  sometimes  fluctuating, 
although  in  many  cases,  when  the  tension  of  the 
walls  is  great,  there  is  no  fluctuation.  The  size  of  the 
tumor  varies  over  a  wide  range,  but  may  be  so  large 
ej  tend  even  into  the  pelvis  or  far  upward  into 
the  thorax. 

Percussion  shows  the  tumor  to  be  dull,  and  in  a  cer- 
tain number  of  cases  gives  the  s, .-called  hydatid 
thrill,  which  is  probably  a  fluctuation  phenomenon 
in  which  the  individual  waves  are  very  short  because 
of  the  tension  of  the  fluid,  the  elasticity  of  the  walls, 
and  the  homogeneity  of  the  cyst  contents.  The 
phenomenon  is  not  found  in  all  cases  of  hydatid  cyst 
and  is  not  absolutely  peculiar  to  it,  for  it  is  found 
with  other  forms  of  cyst  when  the  peculiar  physical 
conditions  are  present. 

Percussion  is  especially  valuable  when  the  cyst 
enlarges  upward  into  the  thorax.  It  enables  us  to  de- 
termine the  upper  border  of  the  cyst.  The  upper 
hepatic  border  is  no  longer  straight,  but  presents  a 
bulging  upward  corresponding  to  the  cyst.  The 
respiratory  motility  of  the  borders  is  unimpaired  unless 
there  is  or  has  been  a  complicating  pleuritis,  some- 
thing which  i<  not  uncommon. 

Functional  disturbances  resulting  from  pressure 
upon  the  various  abdominal  and  thoracic  organs  vary 
with  the  organs  affected  and  with  the  degree  of  the 
pressure.  These  symptoms  are  often  far  more 
marked  than  those  from  the  liver  itself. 

Compression  of  the  portal  vein  or  the  inferior  vena 
cava  may  cause  ascites  and  other  circulatory  disturb- 
ances, which  may  entirely  obscure  the  presence  of 
the  cyst.  Icterus  may  result  from  compression  of 
the  common  duct. 

Constitutional  disturbances  from  these  cysts  are 
practically  wanting,  except  as  the  result  of  pressure 
upon  neighboring  structures,  or  of  secondary  infection 
of  the  cysts  with  pyogenic  organisms  and  the  conver- 
sion of  the  cysts  into  an  absciss. 

From  this  brief  outline  it  is  evident  that  the  clinical 
picture  of  the  echinococeus  cyst  varies  greatly,  and 
the  diagnosis  is  often  difficult.  The  main  elements  in 
the  diagnosis  are  the  demonstration  of  a  circumscribed 
enlargement  of  the  liver,  unaccompanied  usually  by 
marked  constitutional  disturbances,  and  yielding  to 
exploratory  puncture  a  fluid  which  may  vary  in 
character,  but  which  contains  elements  which  are  ab- 
solutely peculiar,  namely,  the  echinococeus  hooklets 
and  scolices.  These  are  so  peculiar  that  they  will  be 
immediately  recognized  by  any  one  who  has  ever  seen 
the  pictures  found  in  all  text-books  upon  diagnosis. 

When  small,  the  cyst  must  be  differentiated  from 
other  processes  which  cause  localized  enlargements, 
particularly    abscess    and    cancer.     Both    these    are 


29 


Abdominal  Tumors, 
Diagnosis 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


accompanied  by  marked  constitutional  disturbances, 
which  in  the  case  of  a  cyst  are  conspicuously  absent. 

Pain  is  usually  present  with  abscess  or  -with  cancer, 
■while  it  is  usually  absent  with  cyst.  The  history  of  a 
residence  in  certain  parts  of  the  world,  notably  Iceland, 
or  of  constant  association  with  dogs,  is  a  point  in 
favor  of  the  cyst. 

Exploratory  puncture  will  remove  all  doubt,  but 
here,  as  with  the  abscess,  this  is  not  entirely  free 
from  danger. 

A  very  sharply  localized  cyst  might  by  enlarging 
downward,  simulate  a  distended  gall-bladder,  but 
could  not  assume  the  peculiar  pear-shape  of  the  gall- 
bladder, nor  would  it  present  the  motility  of  the  gall- 
bladder. The  history  of  the  patient  would  moreover 
be  different. 

When  the  cyst  is  larger  and  grows  downward  it 
needs  differentiation  from  cysts  of  other  organs,  such 
as  the  pancreas,  ovaries,  or  kidneys.  Usually  the 
differentiation  is  easy  from  the  history  and  from  the 
shape  and  location  of  the  tumor.  In  the  exceptional 
cases,  close  attention  should  be  given  to  the  relation 
of  the  colon  to  the  tumor.  This  is  pushed  down  and 
usuallv  back  by  cysts  of  the  liver,  forward  by  cysts 
of  the"  kidney,  iipwrard  by  cysts  of  the  pancreas  and 
ovaries. 

When  the  cyst  enlarges  upward,  it  may  require 
differentation  from  a  pleuritis  exudativa.  Ordinarily 
the  history  of  an  acute  onset  with  pain,  fever,  and 
the  peculiar  shape  of  the  dulness  will  speak  for  a 
pleuritis.  In  cases  of  pleurisy  with  insidious  onset, 
when  the  exudate  is  large  and  unaccompanied  by 
manifest  constitutional  symptoms,  especial  attention 
should  be  paid  to  pressure  effects  on  the  heart.  With 
pleurisv  the  heart  is  dislocated  outward,  with  cysts 
the  displacement  is  more  often  upward  and  outward. 
In  cases  which  are  doubtful  the  exploratory  puncture 
will  decide. 

The  true  nature  of  the  cyst  is  often  learned  from 
its  rupture  into  some  neighboring  organ,  such  as  the 
stomach,  colon,  lungs,  when  the  hooklets,  scolices, 
and  daughter  cysts  may  appear  in  vomitus,  feces,  or 
sputum. 

The  multilocular  echinococcus  is  even  less  common 
than  the  cvstic  form,  except  in  certain  parts  of  Europe, 
where  it  is  not  infrequent.  The  onset  is  insidious 
and  usually  without  symptoms  until  the  disease  has 
made  great  progress;  then  weight  and  pain  in  the 
epigastrium  and  right  hypochondrium  appear,  with 
gastrointestinal  disturbances.  Icterus  and  ascites 
are  common  and  often  appear  early.  The  liver  is 
often  greatly  enlarged,  hard,  with  irregularly  dis- 
tributed tumor  masses,  so  that  the  surface  is  grossly 
lobulated.  The  border  is  often  irregular  and  very 
hard.  The  liver  usually  shows  its  normal  respiratory 
motility.     The  spleen  is  often  enlarged. 

The  condition  must  be  differentiated  from  multiple 
carcinomata  of  the  liver,  which  differ  in  their  more 
rapid  course,  marked  cachexia,  blood  changes,  and 
age  of  the  patient,  and  show  also  the  symptoms 
caused  by  the  primary  cancer.  In  most  parts  of  the 
world,  cancer  of  the  liver  is  of  almost  daily  occurrence, 
while  the  multilocular  echinococcus  cyst  is  extremely 
rare.  In  cases  which  cannot  be  differentiated  in 
this  way,  make  an  exploratory  puncture. 

Hypertrophic  cirrhosis  and  syphilis  of  the  liver 
maybe  simulated.  Both  these  conditions  are  rela- 
tively common.  With  cirrhosis,  the  jaundice  is 
usually  not  so  intense  and  it  varies  from  time  to  time, 
the  splenic  tumor  is  more  common,  an  ascites  is 
rare,  ami  the  enlargment  of  the  liver  is  more  uniform. 
With  syphilis  of  the  liver  the  individual  enlargement  - 
in  the  liver  are  not  so  large  or  hard,  and  the  liver  is 
more  irregular;  jaundice,  ascites  and  splenic  tumor 
are  less  common.  Here  also  exploratory  puncture 
may  be  necessary. 

There  are  a  number  of  other  pathological  processes 
which  cause  localized  enlargements  of  the  liver,  such 


as  sarcoma,  fibroma,  adenoma,  and  cysts,  but  they 
are  so  exceptional  that  their  consideration  may  be 
omitted  from  an  article  of  this  sort. 

Corset  Liver. — Tight  lacing,  either  by  means  of  a 
corset  or  by  a  string  about  the  waist,  often  causes  a 
deformity  of  the  liver,  which  in  extreme  cases  may 
cause  a  condition  simulating  a  tumor.  This  may  be 
due  to  an  elongation  of  the  liver  because  of  the 
pressure  to  which  it  has  been  subjected,  and  its  true 
nature  is  then  easily  recognized.  Sometimes,  and 
this  is  more  often  when  the  constriction  of  the  waist 
has  been  made  with  a  string  instead  of  a  corset,  the 
right  lobe,  rarely  the  left,  is  elongated  and  the  part 
directly  below  the  pressure  is  atrophied  so  that  a 
larger  or  smaller  mass  of  liver  tissue  is  separated  from 
the  liver  and  connected  with  it  by  a  band  of  fibrous 
tissue.  The  shape,  size,  and  motility  of  such  a  mass 
vary  in  the  different  cases.  It  must  often  be  differ- 
entiated from  movable  right  kidney.  It  differs  in 
shape  from  the  kidney,  lies  nearer  the  front  wall  of 
the  abdomen,  and  lies  in  front  of  the  colon  instead  of 
behind  it.  Attention  to  the  shape  of  the  thorax  and 
to  the  history  of  lacing  is  also  of  assistance. 

Movable  Lira: — This  forms  a  tumor  on  the  right 
side,  one  which  may  extend  downward  to  the  pelvis 
or  far  over  to  the  left  of  the  median  line.  At  the 
same  time  the  liver  tilts  so  that  the  convex  surface 
lies  forward.  The  form  of  the  liver  is  unchanged. 
This,  together  with  the  absence  of  liver  dulness  in  the 
normal  site  and  the  fact  that  in  most  eases  the  liver 
can  be  returned  to  the  normal  site  when  the  patient 
is  in  the  dorsal  decubitus,  makes  the  diagnosis  easy. 

Tumors  of  the  Gall-bladder. — With  occasional 
exceptions  these  are  merely  distentions  of  the  gall- 
bladder with  bile,  mucus,  or  pus,  either  alone  or  in 
combination  with  stones.  The  degree  of  distention 
varies  from  .just  sufficient  to  admit  of  palpation  of  the 
gall-bladder,  as  a  small  rounded  projection  below  the 
edge  of  the  liver  in  the  parasternal  line,  to  a  sac 
capable  of  holding  a  liter  or  more.  The  larger  the 
bladder  the  more  it  assumes  a  long,  pear-shaped 
form — extending  downward  from  the  liver  just 
beneath  the  abdominal  wall.  With  increasing  size, 
the  motility  increases  until  the  bladder  can  be  moved 
freely  from  side  to  side  and  backward,  but  it  always 
tends  to  return  to  its  pi  .sition  just  beneath  the  abdom- 
inal wall.  It  also  shows  distinct  respiratory  motility. 
The  tumor  feels  smooth,  elastic,  and  sometimes 
fluctuation  can  be  made  out.  Rarely  the  friction  of 
stones  moving  over  one  another  can  be  felt. 

Usually  palpation  alone  shows  the  presence  of  the 
tumor,  but  in  favorable  cases,  when  the  abdominal 
walls  are  thin,  its  presence,  shape,  form,  and  respira- 
tory motility  are  visible.  Percussion  also  may  show 
its  presence. 

An  enlarged  gall-bladder  practically  always  lies  in 
front  of  the  colon  and  intestines,  and  to  the  right  and 
partially  in  front  of  the  stomach.  Inflation  of  the 
colon  and  stomach  is  sometimes  necessary  in  making 
the  diagnosis. 

Usually  the  anatomical  location  of  the  tumor,  its 
shape,  motility,  and  manifest  relation  to  the  liver 
facilitate  the  recognition  of  the  tumor  as  one  from 
the  gall-bladder,  but  when  the  distention  is  extreme 
it  may  be  confused  with  a  hydronephrosis  or  a  cys- 
tic ovary.  Attention  to  any  history  of  disturbances 
of  the  urinary  or  genital  tract  and  the  demonstration 
of  the  relation  of  the  tumor  to  the  colon — which  lies 
behind  a  distended  gall-bladder,  in  front  of  a  hydro- 
nephrosis, and  above  a  cystic  ovary— will  remove  all 
doubt.  In  addition  to  these  points  the  gall-bladder  is 
attached  above  to  the  liver  and  is  free  below,  while  an 
ovarian  cyst  is  attached  below  and  remains  free 
above.  The  hydronephrosis  arises  manifestly  from 
behind. 

The  diagnosis  of  the  cause  of  the  dilatation  of  the 

gall-bladder  ami  the  finding  of  the  site  of  the  obstruc- 

I   tion  may  be  a  simple  or  a  difficult  matter.     Repeated 


30 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


\lnli)iiilii:il   Turners, 

Diagnosis 


attacks  of  biliary  colic  would  suggest  a  stone;  acute 
gastrointestinal  symptoms  with  jaundice  would 
suggest  an  acute  catarrh  of  the  ductus  choledochus; 
and  progressive  cachexia  with  gastrointestinal  symp- 
toms would  suggest  a  carcinoma  of  some  of  tne 
organs  near  the  porta. 

The  diagnosis  of  the  nature  of  the  fluid  in  the  cystic 
bladder  (pus,  bile,  or  mucus)  is,  like  the  diagnosis 
of  the  cause,  easy  or  hard.  If  accompanied  by 
jaundice,  it  is  probably  bile,  and  the  obstruction  is  in 
the  common  duct.  If  there  is  no  jaundice,  the 
fluid  is  probably  mucus,  but  may  be  bile  or  pus,  and 
the  site  of  the  obstruction  is  at  the  neck  of  the  blad- 
der or  in  the  cystic  duct.  An  empyema  of  the  gall- 
bladder is  accompanied  by  the  ordinary  constitu- 
tional disturbances  of  suppuration,  but  the  pre  - 
ence  of  such  symptoms,  when  the  gall-bladder  is  dis- 
tended, does  not  in  itself  prove  that  the  fluid  is  pus. 

Exploratory  puncture  of  the  gall-bladder  is  ordi- 
narily too  dangerous  to  be  justifiable. 

Cancer  of  the  Gall-bladdt  r. — This  is  on  the  whole  a 
rare  disease,  and  the  diagnosis  is  based  upon  the 
demonstration  of  a  hard,  nodular,  slowly  growing 
tumor  in  the  region  of  the  gall-bladder,  accompanied 
by  cachexia  and  anemia.  The  diagnosis  is  strength- 
ened by  a  history  of  biliary  colic,  and  by  the  exclusion 
of  carcinoma  of  any  of  the  organs  frequently  causing 
metastases  in  the  liver. 

Tumors  of  tiu<:  Stomach. — The  methods  employed 
in  the  examination  of  the  abdominal  tumors  so  far 
Ci  isidered  have  been  almost  entirely  physical,  aided 
sometimes  by  microscopical  examination  of  the  blood. 
With  cases  of  tumors  of  possible  gastric  origin, 
chemical  methods  of  examination  become  prominent; 
but  unfortunately,  in  spite  of  the  immense  amount 
of  study  and  work  which  has  been  put  upon  them, 
their  results  are  often  uncertain  and  contradictory, 
so  that  they  no  longer  receive  the  respect  formerly 
paid  them. 

The  pathological  processes  which  can  cause  a 
tumor  of  the  stomach  are  very  numerous,  but  most 
of  them  are  so  uncommon  that  they  need  no  mention 
in  an  article  of  this  sort.  The  processes  which  demand 
our  attention  are  the  cancer,  the  ulcer  with  scar  for- 
mation, and  dilatation  of  the  stomach.  We  would 
remind  the  reader  that  it  is  assumed  throughout 
this  article  that  a  tumor  is  palpable.  Considera- 
tions relating  to  the  diagnosis  of  these  conditions 
previous  to  the  appearance  of  a  palpable  tumor 
must  be  sought  in  more  special  articles 

When  a  tumor  is  found  in  the  neighborhood  of  the 
stomach,  two  questions  must  be  answered:  Does  the 
tumor  arise  from  the  stomach,  and  what  is  its  nature? 

Cancer  of  the  Stomach. — The  subjective  symptoms 
resulting  from  cancer  of  the  stomach  vary  greatly — 
in  one  case  being  prominent,  in  another  almost 
wanting.  There  is,  moreover,  no  necessary  propor- 
tional relation  between  the  size  of  the  tumor  and  the 
intensity  of  the  symptoms.  The  symptoms  also 
vary  with  the  site  of  the  carcinoma;  in  fact,  this  has 
a  very  marked  influence  upon  the  intensity  of  the 
symptoms.  Cancer  at  the  cardia  or  pylorus  need  not 
be  large  to  cause  very  marked  symptoms,  while  one 
on  the  curvatures  of  "the  stomach  may  be  very  large 
and  yet  cause  almost  no  subjective  symptoms. 

In  general  there  are  symptoms  pointing  distinctly 
to  the  stomach,  but  these  symptoms  are  not  peculiar, 
for  they  consist  of  a  loss  of  appetite,  especially  a  loss 
of  appetite  for  meats,  distress  and  fulness  after  eating, 
eructations  both  gaseous  and  acid,  pain  either  con- 
stant or  after  eating,  nausea,  and  vomiting.  These 
are  symptoms  which  may  occur  with  any  disease  of 
the  stomach,  but  when  they  begin  late  in  life,  espe- 
cially if  the  patient  has  always  been  free  from  gastric 
disturbances,  they  should  always  suggest  the  possi- 
bility of  a  cancer  of  the  stomach.  When  in  addi- 
tion to  these  the  patient  vomits  the  well-known 
coffee-ground  vomit,  the  possibility  becomes  almost 


a  probability.  Along  with  these  gastric  symptoms 
there  develops  a  progressive,  secondary  anemia, 
accompanied  by  leucocytosis,  and  in  time  the  can- 
cer cachexia,  with  its  peculiar  earthy-colored  skin, 

emaciation,  and  edema,  appears,  and  gives  the  pa- 
tient so  peculiar  a  look  that  the  diagnosis  can  often 
be  made  on  sight. 

Examination  of  the  functions  of  the  stomach  often 
gives  most  valuable  assistance  in  the  diagnosis.  .More 
attention  has  been  paid  to  the  secretory  function  of 
the  stomach  than  to  its  other  functions,  although  a 
consideration  of  all  three  is  important.  Briefly 
summarized,    the   result   of   the   study   of   the   gastric 

secretion  is  as  follows:      In  al st   all  cases  of  cancer 

of  the  stomach  the  hydrochloric  acid  eventually 
disappears,  but  is  often  present  until  late,  and  may 
he  present  until  death.  It  may  be  present  even  in 
excessive  amounts.  There  are  a  large  number  of 
other  diseases  of  the  stomach  in  which  also  no  hydro- 
chloric acid  is  found;  one  might  even  say  that  there 
is  no  disease  which  may  not  cause  absence  of  hydro- 
chloric acid.  One  must,  therefore,  give  up  the  idea 
formerly  current  that  an  absence  of  hydrochloric 
acid  is  pathognomonic  of  cancer  of  the  stomach,  and 
be  content  with  the  fact  that  it  is  more  frequently 
absent  with  cancer  than  with  any  other  one  disease 
of  the  stomach.  The  inverse  statement  of  this  pro- 
position is  of  much  more  practical  value.  The  con- 
tinuous presence  of  hydrochloric  acid  speaks  strongly 
against  a  carcinoma,  but  does  not  absolutely  exclude 
it.  as  it  is  found  until  death  in  about  ten  per  cent, 
of  the  cases. 

Lactic  acid  is  found  in  many  cases  of  cancer,  but  is 
absent  in  many,  and  present  in  other  conditions  in 
which  the  food  stagnates  and  ferments,  so  that  the 
presence  of  lactic  acid  does  not  have  the  diagnostic 
value  at  first  assigned  to  it. 

The  absorption  time  is  prolonged  in  most  cases  of 
cancer.     The  motive  power  is  lessened. 

Far  more  significant  than  all  of  the  symptoms  so  far 
enumerated  is  the  demonstration  of  a  tumor  in  the 
region  of  the  stomach.  Such  a  tumor  mass  can  be 
found  in  about  eighty  per  cent,  of  all  cases,  but 
unfortunately  its  demonstration  often  occurs  late, 
long  after  the  time  when  surgical  interference  is 
advisable.  When  a  tumor  connected  with  the  stom- 
ach is  found  in  a  person  who  is  over  thirty  and  who 
has  beginning  cachexia,  the  diagnosis  of  cancer 
becomes  certain.  Without  the  demonstration  of  a 
tumor  the  diagnosis  of  a  cancer  of  the  stomach  is 
merely  one  of  greater  or  less  probability.  The  more 
advanced  the  age,  the  more  marked  the  cachexia,  the 
more  conspicuously  gastric  symptoms  are  present  and 
symptoms  of  other  diseases  are  absent,  the  greater 
this  probability  becomes. 

In  some  cases  the  tumor  manifests  itself,  upon 
inspection  of  the  abdomen,  as  an  irregular  mass  in  the 
epigastrium  or  lower  in  the  abdomen,  often  moving 
freely  up  and  down  with  the  respiratory  movements. 
The  distention  of  the  stomach  sometimes  has  an  effect 
upon  the  ease  with  which  the  tumor  is  seen.  It  may 
make  the  tumor  visible  or  may  completely  obscure  it. 
Inspection  often  gives  important  information  as  to 
tlie  size,  shape,  and  location  of  the  stomach  as  a 
whole.  Because  of  the  emaciation,  the  abdominal 
walls  are  thin  and  through  them  the  outlines  of  the 
stomach,  filled  either  with  gas  or  with  fluid,  are  often 
distinctly  seen. 

Palpation  shows  a  hard,  usually  irregular  tumor 
mass,  which  may  or  may  not  be  sharply  circumscribed. 
It  is  usually  tender  on  pressure,  but  not  so  much  so  as 
an  ulcer.  The  mass  is  usually  not  movable,  but  may 
be  so;  even  tumors  of  the  pylorus,  which  one  would 
expect  to  be  always  fixed,  are  sometimes  very  movable. 
It  is  often  stated  that  tumors  of  the  stomach  do  not 
move  up  and  down  with  respiration,  but  it  is  certain 
that  they  do  so  frequently,  even  when  not  adherent 
to  the  liver,  spleen,  or  diaphragm.     This  is  true  of 


31 


Abdominal  Tumors, 
Diagnosis 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


cancer  of  the  pylorus  as  well  as  of  cancer  of  the  body 
of  the  stomach. 

Having  demonstrated  a  tumor  which  might  arise 
from  the  stomach,  how  shall  we  determine  whether 
it  does  come  from  the  stomach  or  not?  Aside  from 
the  physical  signs  one  must  consider  the  subjective 
symptoms  of  the  disease,  and  whether  these  point  to 
a  disease  of  the  stomach  or  of  some  other  organ,  and 
must  never  forget  that  the  cancer  of  the  stomach  is 
by  far  the  most  common  tumor  in  this  region,  and  in 
general,  therefore,  the  diagnosis  of  a  cancer  of  the 
stomach  has  a  greater  degree  of  probability  than  a 
diagnosis  of  some  other  tumor  or  some  other  point  of 
origin  than  the  stomach. 

If  a  tumor  always  lies  within  the  borders  of  the 
stomach  dulness  or  tympany,  according  as  the  stom- 
ach is  filled  with  fluid  or  with  gas,  the-  tumor  arises 
from  the  stomach.  If  an  area  of  tympany  can  be 
demonstrated  between  the  tumor  and  the  liver,  the 
tumor  does  not  arise  from  the  liver  and  probably  not 
from  the  gall-bladder.  Cancer  of  the  gall-bladder, 
because  of  its  close  anatomical  relation  to  the  pylorus, 
may  be  confused  with  cancer  of  the  pylorus;  but  the 
symptoms  of  gastric  disturbances,  and  especially  the 
dilatation  of  the  stomach  almost  always  present  with  a 
cancer  of  the  pylorus,  are  absent,  and  a  history  of 
biliary  colic  is  often  present. 

Tumors  of  the  spleen  may  be  confused  with  tumors 
of  the  fundus  of  the  stomach,  but  their  regular  out- 
lines and  oval  shape,  smooth  surface,  and  extension 
up  under  the  ribs,  together  with  the  absence  of  gastric 
symptoms,  are  usually  sufficient  to  make  the  differen- 
tiation easy. 

Tumors  of  the  pancreas  lie  deeply  in  the  abdomen, 
are  not  movable,  and  are  apt  to  be  accompanied  by 
signs  of  compression  of  the  common  bile  duct  or  the 
portal  vein. 

The  following  table  from  Boas'  "Diseases  of  the 
Stomach"  shows  the  very  important  relations  of 
tumors  of  this  region  to  the  distended  stomach  and 
colon: 


Stomach, 
(a)   pylorus. 


(b)  anterior  wall 
and  greater 
curvature. 

(c)  lesser  curva- 
ture. 

Liver 


.Spleen . 


( lolon 
Kidney. 


Omentum. 
Pancreas  - 


Inflation  of  stomach. 


Inflatio 


af  Colo 


Displaced  to  the  rislit 

and  down. 
Feel  Iargei'  atul  borders 
less  distinct. 

Disappear  completely. 

Displaced  upward  and 
to  the  right,  and  bor- 
ders of  organ  more 
easily  palpable. 

Displaced  to  the  left 
and  often  downward 
also. 

I  displaced  down 


Displaced  downward. 
Disappear         behind 

stomach. 


Displaced  upward. 


Displaced  upward:  tu- 
mors of  gall-bladder 
also  forward :  very 
large  tumors  may  be 
unaffected. 

i  'i  -  placed  up  and  to 
the  left. 

Not  displaced  up. 

\i  first  dis]  ilaced  up  a 
lit  tie.  then  disappear 
backward.  The  mov- 
able kidney  returns 
to  place. 

Displaced  downward. 


In  some  cases  the  development  of  secondary  depos- 
ils  in  other  organs  is  the  first  thing  which  proves  the 
nature  of  the  gastric  process.  For  example,  tumors 
of  the  liver  are  common  in  the  course  of  cancer  of  the 
stomach,  and  because  of  their  size  they  may  distract 
the  attention  from  the  stomach  and  lead  to  an  errone- 
ous diagnosis  of  cancer  of  the  liver,  for  here  as  else- 
where  the  secondary  tumors  may  far  exceed  the  pri- 
mary in  size.     Another  site  for  secondary  deposits 

32 


which  may  lead  to  a  correct  diagnosis  of  the  primary 
disease,  is  a  lymph  gland  just  above  or  behind  the 
inner  end  of  the  left  clavicle.  This  gland  is  not  infre- 
quently the  site  of  secondary  cancer  that  has  devel- 
oped from  cancer  of  the  stomach. 

Finally  it  may  be  said  that  if  a  reasonable  sus- 
picion of  the  presence  of  a  cancer  of  the  stomach 
persists  after  careful  examination  of  a  patient  an 
exploratory  laparotomy  should  be  made. 

Ulcer  of  the  Stomach. — Ordinarily  there  is  no  need 
for  differentiation  between  this  disease  and  cancer  of 
the  stomach  after  demonstration  of  a  tumor  in  connec- 
tion with  this  organ,  for  this  usually  is  proof  of  the 
existence  of  a  cancer.  Sometimes,  however,  a  scar 
in  the  base  of  an  ulcer  or  an  hypertrophy  of  the 
neighboring  muscular  layer  of  the  stomach  may  cause 
a  palpable  tumor.  Under  such  circumstances  differ- 
entiation is  necessary  and  usually  difficult.  Attention 
must  be  given  to  the  following  points:  Ulcer  is  a 
disease  of  the  first  half  of  life  and  is  more  common  in 
women  than  in  men.  It  causes  a  good  deal  of  pain, 
which  is  much  influenced  by  the  taking  of  food. 
Generally  the  epigastrium  is  more  tender  from  an 
ulcer  than  from  a  cancer.  The  course  of  an  ulcer  is 
longer,  lasting  even  for  many  years.  It  causes  hemor- 
rhages which  are  usually  more  abundant  than  those 
caused  by  cancer.  Ulcer  causes  a  secondary  anemia, 
but  not  cachexia.  Inasmuch  as  a  tumor  from  cancer 
is  common  and  from  ulcer  very  uncommon,  there  must 
be  very  strong  evidence  in  favor  of  an  ulcer  over  a 
cancer,  in  any  case  in  which  a  tumor  in  connection 
with  the  stomach  is  palpated. 

Dilatation  of  the  Stomach. — This  often  causes  an 
easily  visible,  localized  bulging  of  the  abdomen  in  the 
region  of  the  stomach.  The  stomach  in  such  cases  is 
often  displaced  downward,  so  that  both  the  greater 
and  the  lesser  curvature  are  visible.  In  many  of  these 
cases,  notably  those  in  which  the  dilatation  of  the 
stomach  is  due  to  pyloric  stenosis,  there  are  very 
manifest  peristaltic  movements  of  the  stomach,  exag- 
gerated because  the  hypertrophied  muscle  layers  of 
the  stomach  are  trying  to  overcome  the  obstruction 
to  the  outflow  of  the  stomach  contents.  The  waves 
of  motion  pass  from  left  to  right.  They  may  appear 
spontaneously  or  only  after  stimulation.  Palpation 
of  this  bulging  area  gives  a  peculiar  resistance  and 
elicits  both  palpable  and  audible  splashing,  which, 
however,  is  not  peculiar  to  gastrectasia,  for  it  is  found 
also  in  health,  though  not  to  the  degree  present  when 
the  stomach  is  dilated.  Percussion  of  the  stomach, 
both  when  filled  with  gas  and  when  filled  with  fluid, 
is  our  most  valuable  means  of  determining  the  size 
and   location   of   the   stomach. 

These  physical  findings,  together  with  the  history  of 
gastric  symptoms  and  the  vomiting  of  large  amounts 
of  material — amounts  far  in  excess  of  the  normal 
rapacity  of  the  stomach — are  enough  to  demonstrate 
the  nature  of  the  bulging  of  the  epigastrium.  The 
diagnosis  of  the  cause  of  the  dilatation  of  the  stomach 
is  a  very  different  and  a  much  more  difficult  problem. 

Tumors  of  the  Pancreas. — Practically  the  only 
diseases  causing  palpable  tumors  of  the  pancreas  are 
the  cancer  and  the  cysts.  It  must,  however,  be 
remembered  that  when  (he  abdominal  walls  are  thin 
and  relaxed,  the  head  and  even  the  body  of  the  nor- 
mal pancreas  may  sometimes  be  palpated.  The  pan- 
creas lies  deeply  in  the  abdomen  and  is  so  attached 
I  hat  it  does  not  show  any  respiratory  or  passive  motil- 
ity. Its  anatomical  relation  to  the  transverse  colon 
and  its  mesentery  is  such  that  tumors  of  the  pancreas, 
when  large  enough  to  displace  the  colon,  displace  it 
downward,  rarely  directly  forward,  and  almost  never 
upward.  This  is  often  the  most  important  fact  in 
the  differentiation  of  tumors  of  the  pancreas  from 
tumors  arising  from  neighboring  organs. 

Cancer  of  the  Pancreas. — This  is  a  relatively  rare 
condition,  but  is  by  far  the  most  common  disease  of 
the  pancreas.     The  symptoms  consist  of  a  combina- 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Abdominal  Tumors, 
Diagnosis 


tion  of  the  effects  of  pressure  upon  the  neighboring 
organs,  of  alterations  in  the  function  of  the  pancreas, 
and,  in  about  twenty  to  twenty-five  per  cent,  of  the 
ca^es,  of  the  presence  of  a  tumor.  The  character  of 
the  symptoms  depends  in  part  upon  the  portion  of  tile 
pancreas  affected.  This  is  oftenest  the  head.  There 
are,  first,  symptoms  of  gastrointestinal  disturbances, 
such  as  anorexia,  dyspepsia,  vomiting,  and  other  man- 
ifestations of  gastrectasia;  fatty  stools;  often  very 
large  stools;  pain,  either  constant  or  in  the  form  of 
very  severe  colic;  gradually  developing  and  persistent 
jaundice,  often  with  no  increase  or  with  only  moderate 
increase  in  the  size  of  the  liver;  marked  distention  of 
the  gall-bladder;  ascites  with  enlargement  of  the 
spleen;  and  glycosuria  in  some  cases. 

When  a  tumor  is  palpable  it  lies  deeply,  varying 
greatly  in  size,  but  is  smooth  or  irregular,  not  sharply 
outlined,  and  usually  lies  to  the  right  of  the  median 
line.  In  most  cases  the  tumor  is  fixed,  and  shows 
neither  passive  nor  respiratory  motility.  Exceptions 
to  this  rule  do  occur,  especially  when  the  tumor  is  in 
the  tail  of  the  pancreas.  Inflation  of  the  colon  shows 
it  to  lie  below,  i.e.  on  the  caudal  side  of  the  tumor. 
Because  of  the  close  relation  to  the  aorta  the  tumor 
often  seems  to  pulsate,  but  the  pulsation  is  a  mere 
up-and-down  pulsation,  not  expansile.  When  ascites 
is  present,  paracentesis  is  often  necessary  before  the 
tumor  can  be  palpated. 

The  two  most  important  symptoms  are  the  icterus 
and  the  presence  of  a  tumor.  The  icterus  is  chronic, 
gradually  progressive,  intense,  and  once  established 
does  not  disappear.  The  tumor  must  be  differenti- 
ated from  tumors  of  other  organs  in  this  neighborhood. 
Cancer  of  the  transverse  colon  is  more  superficial,  is 
movable,  is  associated  with  difficult  movements  of 
the  bowels,  and  is  free  from  ascites  and  jaundice,  as  a 
rule;  stools  are  not  fatty.  Cancer  of  the  pylorus  lies 
more  superficially,  is  more  movable,  is  accompanied 
by  changes  in  the  gastric  secretions.  It  does  not 
cause  fatty  stools  and  is  less  often  associated  with 
icterus  and  ascites. 

Tumors  of  the  duodenum  and  of  the  ductus  chole- 
dochus  are  far  more  difficult,  often  impossible,  to 
differentiate  from   tumors  of  the  pancreas. 

It  is  said  that  cachexia  develops  much  earlier  with 
cancer  of  the  pancreas  than  with  cancer  of  other 
organs,  and  is  accompanied  by  more  severe  pain  than 
in  the  case  of  cancer  of  a  neighboring  organ. 

Cysts  of  the  Pancreas. — The  demonstration  of  a 
cyst  is  preceded  by  a  longer  or  shorter  period  of  ob- 
scure dyspeptic  disturbances,  pain,  and  emaciation. 
The  pain  is  either  paroxysmal  and  colic-like  or  con- 
stant. The  paroxysmal  pains  are  said  to  occur  with 
no  other  abdominal  cyst  than  the  pancreatic  cyst. 
Disturbances  in  the  bowel  movements,  fatty  stools, 
icterus,  and  ascites — in  short,  all  of  the  symptoms  of 
cancer  of  the  pancreas  except  those  resulting  from 
the  nature  of  the  cancerous  tumor — may  appear. 

The  cyst  usually  causes  some,  maybe  immense, 
enlargement  of  the  abdomen,  beginning  usually  in  the 
epigastrium,  but  later  it  may  sink  lower  in  the  abdo- 
men. The  surface  is  smooth,  often  fluctuating. 
Usually  the  cyst  shows  no  motility,  but  it  may  in 
some  cases.  The  stomach  may  lie  above,  in  front  of, 
or  below  the  cyst.  The  same  is  true  of  the  colon,  but 
almost  always  the  colon  lies  below,  i.e.  to  the  caudal 
side  of  the  cyst.  Puncture  of  the  cyst  yields  fluid 
varying  greatly  in  character,  and  showing  nothing 
absolutely  peculiar  except  in  those  cases  in  which  the 
pancreatic  ferments  are  found  in  the  fluid. 

These  cysts  must  be  differentiated  from  other  ab- 
dominal cysts,  especially  the  echinococcus  cysts,  the 
hydronephrosis,  and  the  ovarian  cysts.  The  echino- 
coccus cysts  will  be  recognized  by  the  demonstration  of 
the  hooklets  and  scolices  in  the  fluid.  Whether  the 
cyst  arises  from  the  pancreas  or  from  some  other 
organ,  is  usually  plain  when  the  relation  of  the  cyst  to 
the   colon   is   discovered.     Ovarian    and    pancreatic 


cysts  are  often  confused,  but  attention  to  the  history, 
e  penally  the  early  in  tory,  of  the  tumor,  ami  I.,  the 

portion  of  the  ahdi n  where  it  first  appeared,  and 

to  thi'  relations  between  cyst  and  colon,  will  remove 
any  doubt.  If  the  fluid  obtained  by  puncture  shows 
pancreatic  ferments,  the  cyst  must  be  from  the  pan- 
creas.     The  absence  of  these  ferments  does  not  prove 

that  I  he  cyst  is  not  from  t  he  pancreas. 

Hydronephrosis  usually  gives  a  history  of  urinary 
symptoms,  renal  colic,  and  lumbar  pain,  and  an 
appearance  of  the  tumor  in  the  flanks.  The  colon  lies 
in  front  of  the  hydronephrosis.  Fluid  from  the  hy- 
dronephrosis shows  urea,  sometimes  uric  acid,  and 
may  contain  cells  from  the  pelvis  of  the  kidney. 
Catheterization  of  the  ureters,  or  the  collection  of 
the  urine  which  conies  from  each  kidney  separately, 
may  assist. 

Tumors  of  the  Spleen. — These  are  of  two  sorts — ■ 
diffuse  splenic  tumors,  none  of  which  are  new  growths 
in  the  ordinary  use  of  this  term,  and  localized  tumors 
of  the  spleen.  The  former  group  is  common,  the  latter 
quite  uncommon.  The  diffuse  splenic  tumors,  although 
cue  to  widely  varying  pathological  processes,  have 
some  peculiarities  in  common,  i.e.  they  retain  the 
general  shape  of  the  normal  organ.  Even  when 
greatly  enlarged,  the  spleen  retains  its  elliptical  shape, 
with  a  notch  in  the  lower  part  of  the  anterior  border, 
and,  though  thickened,  is  still  much  greater  in  all 
dimensions  than  in  thickness.  The  long  axis  of  the 
spleen  passes  from  the  left  above,  downward  and  to 
the  right,  although  in  cases  in  which  there  is  much 
enlargement  the  long  axis  is  often  more  nearly  parallel 
to  the  long  axis  of  the  body  than  is  encountered  in  the 
normal  individual.  The  enlarged  spleen  usually 
occupies  the  upper  left-hand  quadrant  of  the  abdomen, 
but  it  may  be  displaced  to  any  other  portion,  when  it 
often  occasions  great  difficulty  in  diagnosis. 

The  methods  of  examination  are  in  general  as  out- 
lined above,  but  many  are  inclined  to  place  too  much 
value  upon  percussion  and  too  little  upon  palpation. 
The  size  of  the  splenic  dulness  may  be  decreased  by 
the  tympany  of  stomach  or  colon,  or  increased  by 
dulness  in  either  of  these  organs.  In  either  case  the 
percussion  of  the  spleen  is  valueless.  Palpation  of 
the  spleen  is  liable  to  fewer  errors  and  should  therefore 
be  preferred.  The  patient  should  lie  upon  the  back 
or  obliquely  upon  the  right  side;  the  physician  should 
stand  upon  the  left  of  the  patient,  with  the  left  hand 
making  pressure  forward  over  the  lumbar  region. 
The  right  hand  should  palpate  from  in  front  during 
both  quiet  and  forced  inspiration.  A  normal  spleen, 
unless  dislocated,  cannot  be  palpated.  Note  the 
shape,  size,  firmness,  tenderness,  and  motility  of  the 
organ.  The  shape,  position,  and  motility  of  the  organ 
are  so  peculiar  that  there  is  rarely  any  difficulty  in 
recognizing  that  a  splenic  tumor  is  really  what  it  is. 
In  doubtful  cases  the  relation  of  the  tumor  to  the 
colon  and  the  stomach  should  be  ascertained  by  dis- 
tention of  these  organs  with  gas.  The  spleen  lies 
external  to  the  stomach,  above  and  in  front  of  the 
colon.  It  is  very  rarely  that  the  colon  passes  in  front 
of  the  spleen. 

Auscultation  of  the  spleen  rarely  gives  any  results, 
but  sometimes  one  hears  venous  hums  similar  to  those 
heard  in  the  large  veins  of  the  neck.  In  cases  of  peri- 
splenitis one  sometimes  finds  localized  friction. 

Exploratory  puncture  of  the  spleen  is  at  times  a 
valuable  aid,  but  is  not  entirely  free  from  difficulties 
and  dangers. 

Acute  splenic  tumors  are  seen  in  a  very  wide  range  of 
acute  infectious  diseases;  in  fact,  there  is  no  one  of 
these  diseases  which  may  not  cause  acute  swelling  of 
the  spleen.  Certain  of  them,  like  typhoid  fever  and 
malaria,  do  so  with  such  constancy  that  the  want  of 
the  splenic  tumor  throws  some  doubt  on  the  correct- 
ness of  the  diagnosis.  Such  enlargements  of  the 
spleen  develop  rapidly  and  present  the  shape  and 
motility  of  the  normal  spleen.     The  degree  of  enlarge- 


Vol.  I.— 3 


33 


Abdominal  Tumors, 
Diagnosis 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


ment  varies,  but  may  be  very  considerable.     Usually 

there  is  no  tenderness  and  the  spleen  feels  soft,  but 
there  are  marked  exceptions  to  this  rule.  The  diag- 
nosis of  the  site  of  the  tumor  is  made  by  attention  to 
the  position  and  shape  of  the  tumor.  The  nature  of 
the  tumor  will  be  recognized  when  the  general  febrile 
disease,  of  which  the  splenic  tumor  is  a  symptom,  is 
recognized. 

Chronic  <  nlargements  of  the  spleen  occur  as  a  result 
of  certain  of  the  chronic  infectious  diseases,  notably 
malaria.  The  malarial  spleen,  or  so-called  ague-cake, 
is  seen  frequently  in  certain  regions  where  opportun- 
ities for  malarial  infection  are  constantly  present.  In 
such  regions  the  condition  is  well  known  and  readily 
recognized,  but  in  other  sections  where  malaria  is 
exceptional  the  malarial  spleen  may  be  taken  for 
other  conditions.  It  presents  the  characteristic  form, 
is  hard,  and  may  attain  almost  any  size,  not  infre- 
quently reaching  to  or  even  beyond  the  umbilicus. 
The  nature  of  the  enlargement  is  recognized  by  a 
history  of  prolonged  malarial  infection  and  by  the 
exclusion  of  other  causes  of  enlargement  of  the  spleen. 
Examination  of  the  blood  for  the  malarial  organisms 
is  usually  futile,  for  the  splenic  tumor  may  continue 
for  many  years  after  the  infection  lias  subsided. 

Syphilis,  either  the  tertiary  stage  of  the  acquired 
or  hereditary  syphilis,  may  cause  chronic  splenic 
tumors,  the  true  nature  of  which  can  be  learned  only 
by  attention  to  the  history. 

Cirrhosis  of  the  liver,  either  the  atrophic  or  the 
hypertrophic  form,  causes  a  chronic  enlargement  of 
the  spleen  which  does  not  differ  in  any  way  from 
other  chronic  splenic  tumors,  and  its  nature  can  be 
ascertained  by  recognition  of  the  hepatic  condition 
of  which  the  splenic  tumor  is  a  symptom.  In  general 
the  spleen  is  larger  with  the  hypertrophic  than  with 
the  atrophic  form.  The  enlarged  liver,  the  jaundice 
either  actually  present  or  repeatedly  present  in  the 
history,  the  prolonged  freedom  from  circulatory 
disturbances,  together  with  the  enlarged  spleen, 
make  a  clinical  picture  not  easily  mistaken.  The 
small  liver,  the  collateral  circulation  upon  the  abdo- 
men, the  ascites,  and  the  enlarged  spleen  make  up 
the  cardinal  symptoms  of  atrophic  cirrhosis. 

Amyloid  Spleen. — The  enlargement  is  similar  to  the 
other  diffuse  enlargements  of  the  spleen.  The  essen- 
tial points  in  the  diagnosis  of  the  nature  of  the  process 
are  the  same  as  those  given  under  the  heading 
Amyloid  Liver. 

Passh'e  congestion  of  the  spleen  occurs  when  the  out- 
flow of  blood  is  obstructed.  The  commonest  cause  of 
this  is  the  atrophic  cirrhosis  of  the  liver.  Less  often 
it  is  due  to  compression  of  the  veins  outside  the  liver 
by  tumors  or  adhesions.  Sometimes  the  spleen  is 
enlarged  from  obstruction  above  the  diaphragm, 
oftenesl  from  cardiac  insufficiency. 

Leukemia. — All  the  enlargements  of  the  spleen 
so  far  considered  have  been  merely  symptoms  of 
disease  elsewhere  in  the  body,  and  the  diagnosis  of  the 
nature  of  the  splenic  tumor  has  been  based  on  the 
recognition  of  the  primary  disease;  but  the  leukemic 
spleen  is  of  a  different  class,  for  it  constitutes  an  inte- 
gral part  of  the  disease.  The  enlargement  presents  no 
peculiarities  which  will  enable  one  to  distinguish  it 
from  other  diffuse  processes  in  the  spleen  except  for 
the  size  often  attained  by  the  leukemic  spleen.  It 
often  extends  to  the  median  line  and  downward  to 
the  ilium;  cases  even  larger  than  this  are  not  uncom- 
mon. The  liver  is  often  but  not  always  enlarged, 
and  when  it  occurs  the  increase  in  size  is  uniform. 
The  lymph  glands  throughout  the  body  are  often 
enlarged,  but  in  many  cases  not.  The  participation 
of  the  bone  marrow  in  the  leukemic  process  may  be 
shown  by  tenderness  or  pain  over  the  bones,  but  the 
lack  of  these  symptoms  does  not  mean  that  the  med- 
ulla has  escaped. 

The  symptom  upon  which  the  diagnosis  of  a  leu- 
kemia rests  is  (he  change  in  the  blood.     The  blood 


should  be  examined  in  all  cases  in  which  the  spleen 
is  found  enlarged  and  in  all  cases  in  which  an  abdom- 
inal tumor  found  may  by  any  possibility  involve  the 
spleen.  The  characteristic  blood  changes  consist  in 
a  marked  increase  in  the  number  of  white  cells,  while 
at  the  same  time  the  relative  percentage  of  the  differ- 
ent forms  of  white  blood  corpuscles  is  altered.  There 
is  an  absolute  increase  in  the  number  of  all  forms,  but 
the  polymorphonuclear  form  is  relatively  decreased 
in  number  often  far  below  the  normal  average  of 
eighty  per  cent.;  the  lymphocytes,  myelocytes,  and 
eosinophile  cells  are  relatively,  as  well  as  absolutely, 
increased.  The  degree  of  increase  of  each  form  differs 
in  the  different  cases  and  in  different  forms  of  leu- 
kemia. It  is  at  once  evident  that  these  blood  changes 
differ  widely  from  the  leucocytosis  in  which  the 
absolute  increase  in  the  number  of  white  blood  cells 
may  reach  as  high  a  figure  as  in  leukemia,  but  in 
leucocytosis  the  polymorphonuclear  leucocyte  is  the 
form  increased  in  number,  and  this  increase  is  both 
absolute  and  relative. 

The  changes  in  the  number  of  red  blood  corpuscles 
and  the  percentage  of  hemoglobin  are  in  no  way 
peculiar.  The  blood  changes  described  are  peculiar 
to  leukemia,  and  upon  them  alone  the  diagnosis  of 
leukemia  must  be  based. 

Pseudoleukemia  causes  an  enlargement  of  the  spleen 
which  is  uniform  and  often  extreme  in  degree.  Ordi- 
narily the  diagnosis  is  not  difficult,  for  the  changes  in 
the  spleen  are  accompanied  by  similar  changes  in  the 
lymph  glands  generally  and  in  the  liver,  thus  showing 
that  the  splenic  tumor  is  merely  a  part  of  a  consti- 
tutional disease.  The  diagnosis  becomes  more  diffi- 
cult when  the  case  is  one  of  splenic  pseudoleukemia, 
i.e.  one  in  which  the  spleen  alone  is  grossly  changed. 
There  are  no  characteristic  blood  changes  in  this 
disease,  the  blood  showing  only  the  findings  of  a 
severe  anemia.  The  red  blood  corpuscles  and  hem- 
oglobin are  greatly  decreased,  but  the  color  index  is 
less  than  one.  There  is  no  leucocytosis.  There  is 
often  a  temperature  of  the  chronic  recurrent  type. 

When  the  lymph  glands  generally  are  enlarged  the 
diagnosis  is  usually  simple.  Leukemia  is  excluded 
by  an  examination  of  the  blood.  Generalized  tuber- 
culosis of  the  lymph  glands  is  not  so  readily  excluded, 
but  this  is  a  very  rare  disease,  while  the  pseudoleu- 
kemia is  not.  In  the  cases  in  which  the  spleen  alone 
is  enlarged  the  diagnosis  must  be  reached  by  exclusion 
of  all  other  possible  causes  for  splenic  enlargement  in 
a  case  presenting  a  progressive  anemia.  Especial 
care  must  be  taken  to  exclude  the  chronic  splenic 
tumor  due  to  an  old  malaria. 

Chlorosis  and  pernicious  anemia  are  sometimes  asso- 
ciated with  enlargement  of  the  spleen.  This  is  only 
moderate  in  degree  and  is  so  insignificant  when  com- 
pared with  the  manifest  blood  changes  that  it  is  often 
overlooked. 

Abscess. — During  the  course  of  diseases  which  may 
cause  emboli,  such  as  endocarditis,  aortitis,  and  the  like, 
one  sometimes  finds  a  painful  and  tender  enlargement 
of  the  spleen  suddenly  developed.  It  is  often  accom- 
panied by  vomiting  and  chill.  These  are  the  symp- 
toms of  an  infarction  of  the  spleen,  and  if  the  embolus 
is  simple  they  all  disappear  in  a  short  time;  but  if  the 
embolus  is  septic  other  symptoms  soon  appear. 
There  are  repeated  chills  with  irregular  temperature, 
sweating,  and  emaciation — in  short,  the  constitu- 
tional disturbances  common  to  suppurative  processes 
anywhere  in  the  body.  The  spleen  increases  in  size, 
perisplenitis  with  friction  appears  in  many  cases,  and 
sometimes  we  find  fluctuation  and  changes  in  the 
abdominal  wall,  such  as  redness,  edema,  etc.  When 
the  abscess  of  the  spleen  is  large,  it  often  pushes  the 
diaphragm  high  up  into  the  thorax,  giving  signs 
which  may  easily  be  mistaken  for  pleurisy  with 
effusion.  The  upper  border  of  the  dulness  differs  in 
shape  from  that  ordinarily  assumed  by  pleural 
effusions,   and   the  respiratory  excursion  is  greater, 


34 


REFERENCE    HANDBOOK    0]     THE    MEDICAL    SCIENCES 


Abdominal  Tumors, 
Diagnosis 


even  though  less  than  normal  Exploratory  puncture 
shows  the  presence  of  pus. 

X,  oplasms  of  the  spleen  are  rare  and  are  difficult  to 
differentiate  from  simple  hypertrophy  of  the  spleen. 
They  may  '»'  suspected  when  the  enlargement  of  the 
spleen  is  irregular  and  nodular.  When  such  a  splenic 
enlargement  is  found,  tuberculosis,  syphilis,  carcin- 
oma, and  sarcoma  must  be  considered.  If  the  indi- 
vidual is  tuberculous,  the  spleen  is  probably  tuber- 
culous; if  he  is  syphilitic,  it  is  probably  a  minima. 
[f  there  is  a  carcinoma  of  some  other  organ,  such  as  the 
stomach  or  pancreas,  for  example,  it  is  probably  a 
secondary  carinoma.  If  no  other  explanation  is 
manifest,  it  may  be  a  sarcoma. 

cysts  occur  in  the  spleen,  causing  an 
enlargement  which  may  be  very  great.  Th<-  disease 
causes  no  peculiar  constitutional  disturbances,  and 
the  true  nature  of  the  process  can  be  learned  only  by 
exploratory  puncture  and  the  demonstration  of 
booklets  and  scolices. 

Wandering  Spit  en. —  Because  of  the  lengthening 
of  its  ligaments  the  spleen  may  become  very  movable 
and  be  found  anywhere  in  the  abdomen,  although  as 
a  rule  it  does  not  descend  below  the  umbilicus.  It 
retains  its  normal  oval  shape  with  one  or  more 
notches   in   the   anterior  border.     The   size  is  often 

considerably  increased  because  of  congestion.     S - 

times  the  pulsations  of  the  splenic  artery  are  felt  at 
the  hilus.  Percussion  shows  the  absence  of  the 
splenic  dulness  in  the  normal  site,  but  when  the  spleen 
is  pushed  back  into  the  left  hypochondrium,  as  can 
be  done  easily  in  most  cases,  the  splenic  dulness 
reappears.  The  peculiar  shape,  the  extreme  motility, 
and  the  presence  of  tympany  in  the  normal  site  of  the 
splenic  dulness  are  usually  enough  to  enable  one  to 
make  the  diagnosis.  A  mass  of  feces  in  the  splenic 
flexure  of  the  colon  may  give  an  area  of  dulness 
similar  in  site,  size,  and  shape  to  the  splenic  dulness, 
but  any  confusion  of  this  sort  is  avoided  by  clearing 
the  bowel.-,  as  should  be  done  before  examination  of 
any  obscure  abdominal  tumor.  Other  very  motile 
tumors,  when  about  the  size  and  shape  of  the  spleen, 
such  as  tumors  of  the  intestines,  wandering  kidney, 
movable  tumors  of  the  pylorus,  may  be  taken  for  a 
movable  spleen,  but  the  fact  that  there  is  an  area  of 
dulness  in  the  splenic  region,  no  matter  where  the 
tumor  is,  will  exclude  a  movable  spleen.  .  The  diffi- 
culties of  diagnosis  are  sometimes  increased  by  the 
spleen  becoming  fixed  in  the  spot  to  which  it  has  been 
dislocated. 

Tumors  of  the  Kidney. — The  normal  kidney  can- 
not be  palpated  unless  it  happens  to  be  displaced,  a 
condition  which  is  far  more  common  than  is  generally 
supposed.  If  palpation  is  employed  it  is  best  to  use 
both  hands;  the  patient  lying  first  on  the  back  and 
then  on  the  side.  In  making  such  an  examination 
one  must  remember  that  there  are  various  patholog- 
ical processes  which  cause  enlargement  of  the  kidney. 
The  diagnostician  must  therefore  not  only  establish 
the  fact  that  the  tumor  arises  from  the  kidney,  but  he 
must  also  ascertain  what  is  the  nature  of  the  underly- 
ing pathological  process. 

Tumors  of  the  kidney  usually  cause  first  a  fulness 
and  bulging  of  the  lumbar  region  and  lateral  abdomi- 
nal regions.  There  is  often  a  visible  fulness  behind. 
When  enlarging,  the  kidney  almost  always  pushes  the 
colon  and  intestines  forward  and  inward  toward  the 
median  line.  Their  peristaltic  movements  are  often 
visible  in  front  of  the  tumor  mass.  The  inner  borders  of 
the  tumor  may  plainly  be  seen  through  the  abdominal 
walls.  Enlarged  and  tortuous  subcutaneous  veins 
are  often  visible.  Pulsation  can  rareb/  be  seen,  and 
the  movements  caused  by  respiration  are  exceptional. 

The  size,  consistency,  and  character  of  surface  vary 
with  the  nature  and  duration  of  the  process.  Fluctua- 
tion is  not  uncommon.  The  vermicular  movements  of 
the  intestines  can  sometimes  be  felt  in  front  of  the 
tumor.     One  may  be  able  to  insert  the  fingers  between 


the  tumor  and  the  an-h  of  the  ribs,  or  outlim 
liver  or  spleen  separately  from  the  kidney. 

Percussion  is  important  as  showing  the  relation  of 
the  tumor  to  the  colon,  which  must  often  be  inflated 
with  air  < n-  na^  before  one  makes  percussion.  It  is 
also  valuable  in  differentiating  a  tumor  of  the  kidney 
from  one  of  tl»-  liver  or  spleen.  If  there  is  an  area  of 
tympany  between  the  tumor  and  the  liver  or  spleen, 
the  tumor  does  not  arise  from  either  of  these  organs. 

Auscultation  over  renal  tumors  shows  in  some 
cases  murmurs  exactly  like  the  hum  heard  over  an 

aneurysm. 

If  palpation  has  shown  fluctuating  areas  in  the 
tumor  or  if  it  is  suspected  that  fluid  is  present  in  the 
mass,  exploratory  puncture  can  be  made.  This  is  not 
entirely  without  danger,  but  it"  the  puncture  is  made 
from  behind  or  well  around  on  the  side  where  one 
cannot  enter  the  peritoneal  cavity,  the  danger  is  mini- 
mal. Any  fluid  obtained  will  be  found  to  vary  with 
the  pathological  process,  and  may  be  urine,  blood, 
pus,  echinoeoecus  fluid,  etc.  Sometimes  small  par- 
ticles of  the  tumor  may  be  obtained  in  this  way  and 
identified.  In  many  cases  in  which  there  is  suspicion 
of  a  disease  of  one  or  both  kidneys,  it  is  necessary  to 
study  the  urine  of  each  kidney  independently  of  that 
of  the  other.  This  requires  catheterization  of  the 
ureters. 

The  principal  tumors  that  require  to  be  differen- 
tiated from  tumors  of  the  kidney  are  tumors  of  the 
liver,  spleen,  ovaries,  gall-bladder,  suprarenals,  and 
perirenal  connective  tissue. 

Tumors  of  the  right  kidney  differ  from  those  of  the 
liver  in  the  following  respects:  There  is  often,  in  the 
case  of  the  former  tumors,  an  area  of  tympany  between 
the  two  areas  of  dulness — that  due  to  the  liver  and 
that  due  to  the  tumor.  Then  again,  in  renal  tumors 
the  fingers  can  often  be  pushed  in  between  the  ribs  and 
the  tumor,  whereas  this  cannot  be  done  when  the 
tumor  originates  from  the  liver.  Renal  tumors  show 
little  or  no  respiratory  motility,  while  hepatic  tumors 
move  freely  during  respiration.  Renal  tumors  lie 
behind  the  tympanitic  area  of  the  colon,  while  those  of 
the  liver  lie  in  front  of  or  above  this  area.  Renal 
tumors  may  cause  a  slight  displacement  upward  of  the 
upper  border  of  the  hepatic  dulness,  but  this  is  the 
only  change  which  they  can  effect  in  this  area.  He- 
patic tumors,  on  the  other  hand,  often  cause  the 
normally  straight  course  of  the  border  of  hepatic 
dulness  to  become  irregularly  curved. 

Hydrops  of  the  gall-bladder  may  sometimes  be  con- 
fused with  a  movable  kidney,  but  its  pear-like  shape, 
its  superficial  location  anterior  to  the  colon,  and  the 
fact  that  it  cannot  be  pushed  into  the  normal  location 
of  the  kidney  are  usually  sufficient  to  enable  one 
to  differentiate  the  two  conditions. 

Tumors  of  the  spleen  differ  from  tumors  of  the  left 
kidney  in  the  same  ways  as  do  the  liver  tumors  from 
those  of  the  right  kidney.  Then,  in  addition,  splenic 
tumors,  as  stated  elsewhere,  retain  the  shape  of  the 
normal  spleen. 

Cysts  of  the  ovaries  rise  from  below  upward  instead 
of  descending  from  above  downward,  and  bear  quite 
different  relations  to  the  colon.  They  lie  within 
instead  of  without  the  circle  of  the  colon,  and  in 
front  of  instead  of  behind  the  intestines,  as  the  renal 
tumors  do. 

Attention  to  these  physical  differences  in  the  tumors 
and  due  consideration  of  the  accompanying  symptoms 
will  almost  always  enable  one  to  differentiate  correct  ly 
between  the  different  conditions.  Differentiation  be- 
tween suprarenal  and  perirenal  tumors  and  tumors  of 
the  kidney-  is  practically'  impossible  unless  changes  in 
the  urine  are  present.  If  these  are  found  and  are  of 
such  a  nature  as  is  compatible  with  a  renal  tumor,  the 
adrenal  and  perirenal  tumors  may  be  excluded.  Very 
high  blood  pressure  with  normal  urine  is  sometimes 
seen  with  suprarenal   tumors. 

A  diagnosis  of  the  nature  of  a  tumor  recognized  as 

35 


Abdominal  Tumors, 
Diagnosis 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


renal  depends  more  upon  the  accompanying  symptoms 
than  upon  the  physical  characteristics  of  the  mass. 

Hydronephrosis. — In  addition  to  the  tumor,  which 
i~  essential  to  the  recognition  of  a  hydronephrosis,  we 
find  alterations  in  the  composition  of  the  urine  and  in 
the  quantity  excreted.  The  amount  of  the  urine 
varies  greatly,  being  normal  in  cases  in  which  only  one 
kidney  is  affected  while  the  other  is  normal,  and  in 
other  cases  varying  from  anuria  to  continuous  or 
intermittent  polyuria.  The  intermittent  polyuria 
or  anuria,  especially  when  accompanied  by  a  corre- 
sponding variation  in  the  size  of  the  kidney,  is  charac- 
teristic. The  urine  may  be  normal  or  it  may  be 
mixed  with  pus,  blood,  renal  elements,  and  crystals, 
especially  of  uric  acid.  Exploratory  puncture  of  the 
hydronephrosis  yields  fluid  of  varying  character 
according  as  we  have  normal  or  pathological  urine. 
The  presence  of  urea  and  uric  acid  in  the  fluid  speaks 
strongly  for  a  hydronephrosis  but  not  positively,  for 
these  substances  are  found  in  the  fluid  contents  of 
other  cysts — the  ovarian  cysts,  for  example — and 
may  be  absent  in  the  fluid  of  hydronephrosis. 

The  recognition  of  a  possible  cause  for  a  hydrone- 
phrosis is  always  an  important  item  in  the  diagnosis. 
Thus,  a  nephrolithiasis,  a  movable  kidney,  a  tumor  in 
the  abdomen  or  pelvis  which  might  compress  one  or 
both  ureters,  a  bladder  tumor,  an  enlarged  prostate, 
or  a  urethral  stricture,  in  a  case  which  might  be  one 
of  hydronephrosis,  is  a  fact  which  strongly  favors  this 
diagnosis. 

The  differentiation  between  hydronephrosis  and 
ovarian  cysts  has  been  sufficiently  considered.  The 
presence  of  echinococcus  hooklets  or  scolices  in  the 
aspirated  fluid  would  prove  the  existence  of  an  echino- 
coccus cyst.  The  differentiation  between  a  cystic 
kidney  and  a  hydronephrosis  is  often  impossible. 
The  absence  of  a  demonstrable  cause  would  speak 
against  the  hydronephrosis.  Early  life  speaks  for  the 
cystic  kidney. 

Pyelonephritis. — The  important  symptoms  in  this 
disease  are  alterations  in  the  character  and  quantity 
of  the  urine,  pain  and  other  signs  of  local  inflammation, 
tumor,  and  the  constitutional  disturbances  of 
suppuration.  The  quantity  of  the  urine  varies  from 
complete  anuria  to  polyuria,  the  latter  being  the  more 
common.  The  urine  contains  in  varying  quantities 
blood,  mucus,  pus,  crystals,  bacteria,  sometimes  bits 
of  kidney  tissue,  sometimes  casts.  Albumin  is 
always  present,  the  specific  gravity  is  lowered,  and  the 
reaction  varies  from  acid  to  alkaline.  Catheterization 
of  the  ureters  or  the  separate  collection  of  the  urine  is 
a  valuable  aid  in  the  diagnosis,  especially  if  carried  out 
early  in  the  course  of  a  unilateral  pyelonephritis. 
Exploratory  puncture,  is  an  aid,  but  it  is  not  often 
necessary  and  is  more  dangerous  in  this  than  in  other 
renal  affections. 

Perinephritis  and  Paranephritis. — The  important 
symptoms  of  these  processes  are  the  local  pain,  fever, 
and  tumor.  Of  these  the  tumor  is  the  most  import- 
ant, but  requires  time  for  its  development,  during 
which  pain  and  elevated  temperature  are  present, 
but  do  not  make  a  diagnosis  possible.  The  tumor 
increases  steadily,  often  rapidly,  in  size  and  presents 
the  characteristics  of  tumors  of  inflammatory  origin. 
It  is  painful,  tender,  usually  not  sharply  defined,  is 
not  movable,  often  fluctuates,  and  when  sufficiently 
superficial  is  accompanied  by  an  edema  of  the  skin. 
The  urine  is  not  changed  by  a  primary  parane- 
phritis, but  when  the  latter  is  secondary  to  suppura- 
tive processes  in  the  kidney,  as  it  often  is,  the  urine 
shows    changes    because    of    the    primary    process. 

The  rules  given  for  the  differentiation  of  renal 
tumors  from  tumors  of  neighboring  organs  apply 
here  also,  so  far  as  the  localization  of  the  process  is 
concerned.  The  nature  of  the  process  is  usually  at 
once  apparent  from  the  combination  of  the  local  and 
constitutional  disturbances  of  inflammatory  origin. 
If    there  is  still  doubt,  an -exploratory  puncture,  by 


demonstrating  the  presence  of  pus,  will  settle  the 
question.  It  is  often  difficult  or  impossible  to  learn 
whether  the  paranephritis  is  primary  or  secondary, 
but  the  chances  are  very  decidedly  in  favor  of  the 
latter  as  a  rule.  If  the  urine  contains  pus,  a  pyelo- 
nephritis is  probably  the  primary  process.  The 
paranephritis  may  be  secondary  to  appendicitis, 
parametritis,  or  some  other  suppurative  process  in  this 
region.  Sometimes  the  gravitation  abscess  from  a 
tuberculous  spine  is  taken  for  a  paranephritis,  but 
usually  an  examination  of  the  spine  and  the  nervous 
system  will  enable  one  to  make  the  differentiation 
readily. 

Tuberculosis  of  the  Kidney  (Chronic). — The  most 
important  symptoms  are  the  changes  in  the  urine,  the 
pain,  and  the  tumor.  The  urine  contains  blood,  pus, 
mucus,  and  cells  in  varying  amounts.  The  pain  is  in 
the  region  of  the  kidney,  but  may  radiate  to  the 
bladder,  to  the  genitalia,  and  to  the  thigh.  Some- 
times the  pain  is  distinctly  that  of  a  renal  colic.  The 
tumor  presents  the  usual  characteristics  and  relations 
of  a  renal  tumor. 

The  diagnosis  rests  not  on  these  symptoms,  but 
upon  the  demonstration  of  tubercle  bacilli  in  the 
urine  or  in  the  pus  obtained  by  exploratory  puncture 
of  the  tumor.  This  demonstration  requires  much 
patience,  but  it  has  been  rendered  decidedly  easier  by 
the  introduction  of  the  centrifugal  machine.  Another 
important  item  in  the  diagnosis  is  the  demonstration 
of  tuberculosis  in  some  other  organ,  especially  one  of 
the  sexual  organs. 

The  tuberculosis  of  the  kidney  must  be  differen- 
tiated from  nephrolithiasis  and  carcinoma  of  the 
kidney,  both  of  which  cause  hematuria,  pain,  and 
renal  tumor.  The  absence  of  renal  colic,  and  of 
gravel  in  the  urine,  together  with  the  presence  of 
evening  fever  and  of  tuberculosis  in  some  other 
organ,  usually'  excludes  the  renal  calculus.  The 
absence  of  cachexia  and  leucocytosis  and  the  pres- 
ence of  pus  in  the  urine  exclude  cancer.  In  cases 
which  are  still  doubtful,  an  injection  of  tuberculin, 
by  exciting  a  violent  reaction,  will  remove  all  doubt. 
The  important  question  as  to  whether  one  or  both 
kidneys  are  tuberculous  may  require  cystoscopic  ex- 
amination or  the  collection  of  the  urine  from  each 
kidney  separately. 

Carcinoma  and  Sarcoma  of  the  Kidney. — These  will 
be  considered  together,  for  the  clinical  differentiation 
between  them  is  never  certain,  and  practically  it  is  a 
small  matter  whether  the  tumor  is  carcinoma  or 
sarcoma.  Here  again  we  find  the  combination  of  pain, 
hematuria,  and  tumor.  The  pain  appears  early,  as  a 
rule,  but  is  in  no  way  peculiar.  The  hematuria  is 
present  in  about  one-half  of  the  cases,  and  may  be  an 
early  symptom  or  it  may  be  delayed  until  late  in  the 
course.  It  differs  greatly  in  amount  and  frequency 
in  the  individual  cases.  The  tumor  resembles  the 
other  tumors  of  the  kidney,  but  in  some  cases  it 
presents  an  expansile  pulsation  and  hum  exactly 
like  those  of  an  aneurysm.  Cachexia  and  anemia 
with  leucocytosis  appear  sooner  or  later.  The 
diagnosis  is  based  mainly  upon  the  exclusion  of  other 
renal  tumors,  the  absence  of  fever,  and  the  presence  of 
cachexia.  Both  carcinoma  and  sarcoma  are  espe- 
cially common  in  young  children,  at  which  time  of  life 
tumors  such  as  hydro-  and  pyonephrosis  and  tubercu- 
losis are  exceptional.  In  adults  the  differentiation  is 
more  difficult  and  errors  are  not  infrequent. 

Other  forms  of  renal  tumors,  such  as  the  cystic 
kidneys,  fibroma,  lipoma,  myoma,  etc.,  need  no  con- 
sideration here. 

Movable  Kidney. — This  is  one  of  the  most  common 
pathological  conditions  affecting  the  kidney,  and  it 
renders  a  kidney  otherwise  normal  easily  palpable. 
In  a  large  percentage  of  the  cases  there  are  no  sub- 
jective symptoms,  and  the  condition  is  discovered 
accidentally  during  an  examination  made  for  some 
other  purpose.     In  some  cases  there  are  subjective 


36 


REFERENCE    HANDBOOK   OF   THK    MEDICAL   SCIENI  I  - 


Abdominal  Tumors, 
Diagnosis 


symptoms  which  vary  greatly  in  the  individual  eases. 
These  are:  pain  of  varying  character  and  site,  gastro- 
intestinal symptoms,  symptoms  due  to  pressure  upon 
the  gall-duct  or  intestinal  tract,  and  periodica]  hydro- 
nephrosis. These  symptoms  occur  in  many  combina- 
tions and  degrees  and  present  nothing  characteristic. 

The  diagnosis  must  be  made  by  the  palpal  ion  of  the 
kidney.  Usually  the  peculiar  bean  shape  of  this 
organ  is  readily  recognized.  The  hilus  can  be  located 
and  sometimes  the  renal  artery  palpated.  The 
kidney  feels  smooth,  firm,  and  of  a  normal  size  in  most 
It  is  not  especially  tender,  but  when  it  is 
firmly  compressed  a  peculiar  sickening  pain  is  pro- 
duced. The  degree  of  motility  varies  from  a  minimal 
amount  which  just  permits  palpation  of  the  lower 
pole  of  the  kidney,  to  such  an  amount  that  the  kidne.3 
can  be  displaced  beyond  the  median  line.  In  most 
cases  the  kidney  can  readily  be  returned  to  its  normal 
location.  In  some  cases  the  movable  kidney  comes 
to  lie  within  the  circle  of  the  colon,  and,  when  it  is 
fixed  here,  the  diagnosis  is  a  very  difficult  matter. 
As   a   rule,    however, 'the   diagnosis   is   easily    made. 

The  characteristic,  shape  and  size  of  the  tumor  and 
the  ease  with  which  it  can  be  returned  to  the  normal 
I  nation  of  the  kidney  furnish  sufficient  evidence. 
Sometimes  highly  movable  tumors  of  the  intestines, 
omentum,  gall-bladder,  and  pylorus,  when  their  size  is 
about  the  same  as  that  of  the  kidney,  are  mistaken  for 
a  movable  kidney,  but  usually  attention  to  the  history, 
to  the  subjective  and  objective  symptoms,  and  es- 
pecially to  the  relations  of  the  tumor  to  the  colon,  will 
remove  all  doubt.  Sometimes  it  is  rather  difficult 
to  distinguish  between  a  movable  kidney  and  a 
tongue-like  projection  of  the  right  lobe  of  the  liver. 
Such  a  projection  is  often  quite  freely  movable,  so 
that  it  can  be  pushed  backward  into  the  location  of 
the  kidney.  Usually,  however,  it  has  a  different 
shape,  and  careful  palpation  will  show  it  to  be  in 
connection  with  the  liver.  The  colon  lies  behind 
instead  of  in  front  of  it.  Sometimes  differentiation  is 
aided  by  the  demonstration  of  the  kidney  in  its  nor- 
mal location.  This  may  be  done  by  percussion  of  the 
back,  which  procedure  shows  a  small  area  of  dulness 
on  each  side  of  the  spine,  continuous  above  with  the 
liver  or  spleen  dulness  and  bordering  externally 
upon  the  tympanitic  area  of  the  colon. 

Tumors  of  the  Small  Intestines. — These  tumors 
are  rare,  but  almost  any  kind  of  tumor  may  appear  in 
connection  with  the  intestines.  The  symptoms, 
which  are  mainly  those  of  more  or  less  complete  in- 
testinal obstruction,  vary  somewhat  with  the  site  of 
the  tumor.  The  commonest  tumor  of  the  small 
intestines  is  carcinoma  of  the  duodenum.  This  causes 
the  anemia  and  cachexia  which  commonly  accompany 
all  carcinomata,  and  at  the  same  time  pain  in  the 
right  hypochondriac  region.  In  favorable  cases  a 
tumor  develops  deeply  in  the  abdomen  and  shows  only 
slight  motility  or  none  whatever.  Because  of  the 
obstruction  to  the  onward  movement  of  the  intestinal 
contents  gastric  symptoms  due  to  dilatation  of  the 
stomach  are  prominent.  When,  as  may  easily  happen, 
the  common  duct  or  at  least  its  orifice  is  narrowed,  we 
find  jaundice  and  the  results  of  lack  of  the  pancreatic 
digestion.  Ascites  may  result  from  compression  of 
the  portal  vein. 

When  the  tumor  is  situated  lower  down  in  the 
jejunum  or  ileum,  the  gastric  symptoms,  jaundice,  and 
ascites  are  less  common,  and  we  find  the  symptoms 
of  gradually  increasing  intestinal  obstruction.  The 
tumor  when  felt  is  characterized  by  extreme  motility. 
The  lower  the  tumor  the  more  marked  the  effect  upon 
the  bowel  movements  and  the  more  easily  blood,  pus, 
and  the  like  appear  in  the  feces.  The  lower  the  tumor 
the  greater  the  distention  of  the  abdomen  with  gas  and 
material  accumulated  above  the  tumor.  The  col- 
lection of  the  gas  is  centrally  located  in  the  neighbor- 
hood of  the  umbilicus. 

It  is  only  in  rare  cases  that  the  intestinal  crises  of 


locomotor  ataxia  cause  localized  spasms  of  the  intes- 
tinal walls,  and  give  rise  to  hard  masses  that  may  easily 

lie   mistaken   for   multiple   tumors.      However,    if   the 
other  symptoms  of  tabes  are  carefully  sought  foi 
not    likely   that    an   error   in   diagnosis   will    be   m 
When   the  small  intestines  are   filled    villi   gas,   and 

especially  when  onward  movement  of  the  gas  i-  pre- 
vented by  an  obstruction  of  any  sort,  such  as  an  in- 
tussusception,    volvulus,    or    internal     strangulal 
they  are  often  visible  as  tumors.     They  differ  from 

other  tumors  in  their  spontaneous  motions,   which  in 

these  cases  are  exaggerated  beyond  the  normal,  even 
10  1  lie  p.  lint  of  being  felt  as  v.  ell  as  seen.  In  some  cases 
of  intussusception  the  invaginated  portion  of  the 
small    intestines    can    be    fell  ausage-shaped, 

motile  tumor.  Such  visible  peristalsis  i-  often  an  aid 
to  diagnosis  in  cases  in  which  other  symptoms  |"  int 
to  an  intestinal  obstruction. 

When  the  amount  of  gas  is  very  Large,  1  lie  abdi 
as  a  whole  is  greatly  swollen,  the  skin  bi  -  .nil 

shining,  and  often  showing  the  blue  veins  through. 
The  general  appearance  is  like  that  of  ascites, 
percussion  will  at  once  show  the  difference.  The 
shape  of  the  abdomen  differs  somewhat  from  that 
observed  in  ascites,  for  the  anterior  portion  about  the 
umbilicus  bulges  prominently,  while  in  ascites  this 
part  is  flattened  and  the  flanks  bulge.  The  degree  of 
distention  depends  mainly  upon  the  amount  of  the  gas, 
but  in  part  also  upon  the  tone  of  the  intestinal  Avails. 
If  this  is  lessened,  as  by  a  generalized  peritonitis,  the 
distention  is  much  greater.  The  liver  and  spleen  with 
the  diaphragm  are  pushed  upward,  thus  displacing 
the  heart  and  lower  pulmonary  border-.  The  area 
of  dulness  corresponding  to  the  liver  may  be  obscured 
by  the  intestines  rising   over    this    organ    in    front. 

Aneurysm  of  the  Abdominal  Aorta  or  Its 
Branches. — In  emaciated  individuals  the  abdominal 
aorta  may  often  be  felt,  and  its  pulsation  is  occasion- 
ally visible.  This  visible  pulsation,  however,  must 
not  be  interpreted  as  indicating  the  existence  of  an 
abdominal  aneurysm,  unless  an  expansile  tumor  is 
found.  The  indications  that  such  an  aneurysm  exists 
vary  with  the  site  and  size  of  the  tumor.  They  con- 
sist in  part  of  pressure  symptoms  and  in  part  of  the 
physical  signs  of  an  aneurysm.  The  pressure  symp- 
toms are  too  numerous  to  mention,  for  any  organ  or 
nerve  in  the  abdomen  may  be  compressed.  The 
essential  and  peculiar  characteristic  of  these  tumors 
is  the  expansile  pulsation.  Xo  other  tumor  shows 
this  except  under  extraordinary  conditions.  Solid 
tumors  about  large  vessels — for  example,  tumors  of 
the  retroperitoneal  lymph  glands — sometimes  show 
expansile  pulsations  and  may  for  this  reason  be  mis- 
taken for  aneurysms.  Very  vascular  neoplasms  may 
show  pulsation  and  murmurs.  Motile  spherical 
tumors  resting  upon  large  vessels  often  show  a  trans- 
mitted pulsation,  which,  upon  careless  examination, 
may  be  mistaken  for  an  expansile  pulsation.  The 
auscultation  of  abdominal  aneurysms  is  of  less  value 
than  might  be  expected,  for  murmurs  in  the  abdomi- 
nal vessels,  both  veins  and  arteries,  are  not  uncommon. 
Aneurysms  of  the  aorta  itself  lie  to  the  left  of  the 
median  line  and  because  of  their  deep  location  often 
enlarge  backward,  thus  causing  bulging  and  pulsation 
posteriorly.  Because  of  the  close  relation  of  the 
aneurysm  to  the  nerves  of  the  lumbar  plexus,  symp- 
toms of  pressure- on  the  nerves  (neuralgia,  anesthesia, 
paralyses)  are  often  early  and  prominent  symptoms. 
Aneurysms  of  the  celiac  axis  tend  to  enlarge  forward, 
and  because  of  their  close  relation  to  the  vena  porta? 
they  often  cause  jaundice  and  ascites. 

Tumors  of  the  Retroperitoneal  Lymph  Glands. 
— These  may  occur  either  as  primary  or  as  secondary 
processes.  There  may  be  several  small  tumors  or  one 
or  more  large  ones.  They  present  the  usual  character- 
istics of  tumors  of  lymph  glands,  being  round  or  egg- 
shaped  in  some  cases,  and  somewhat  nodular  in  others. 
They  lie  deep  in  the  abdomen,  behind  the  intestines. 


37 


Abdominal  Tumors, 
Diagnosis 


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and  .-lmw  neither  passive  nor  respiratory  motility. 
\\  In  n  resting  on  the  aorta  they  may  show  a  trans- 
mitted pulsation,  or  when  surrounding  it  they  may 
show  even  an  expansile  pulsation. 

There  are  numerous  pathological  processes  which 
can  cause  such  enlargements  of  the  retroperitoneal 
lymph  glands,  viz.,  tuberculosis,  leukemia,  pseudo- 
leukemia, and  lymphosarcoma.  They  may  represent 
metastases  from  malignant  tumors  located  elsewhere 
in  the  body.  The  diagnosis  of  the  nature  of  the  tumor 
is  based  mainly  upon  a  consideration  of  the  history 
and  upon  the  constitutional  disturbances  which  may 
be  present.  The  absence  of  anything  pointing  to 
disease  of  other  organs  in  the  abdomen  often  aids  the 
physician  in  making  a  correct  diagnosis.  Finally,  it 
may  be  found  impossible  to  learn  the  exact  situation 
and  true  nature  of  such  glandular  tumors  except  by 
means  of  an  exploratory  operation. 

Tumors  of  the  Peritoneum  and  Omentum. — 
These  occur  either  in  the  form  of  a  solid  tumor  (tuber- 
culous, carcinomatous,  or  sarcomatous  in  its  nature) 
or  in  that  of  a  circumscribed  exudate  of  one  sort  or 
another. 

Tuberculous  peritonitis  shows  itself  in  a  variety  of 
ways:  It  may  cause  diffuse  enlargements  of  the  abdo- 
men, or  localized  fluid  exudates,  or  separate  tumor 
masses.  The  diffuse  enlargements  have  been  con- 
sidered in  the  paragraphs  upon  ascites.  The  local- 
ized fluid  exudates  and  the  tumor  masses  may  occur 
anywhere  throughout  the  abdomen  and  may  be  single 
or  multiple.  It  is  usually  more  difficult  to  make  a 
correct  diagnosis  when  one  such  focus  of  disease  is 
present  than  when  there  are  several.  Because  of  the 
fart  of  their  varying  locations  nothing  can  be  said  as 
to  their  relations  to  the  other  abdominal  organs. 
Either  of  the  two  conditions  named  may  occur  separ- 
ately, but  in  many  cases  there  is  a  more  or  less  general- 
ized affection  of  the  peritoneum  accompanied  by  a  fluid 
exudate  which  lies  free  in  the  peritoneal  cavity  and 
which  is  often  sufficient  in  amount  to  cover  up  the 
localized  process.  When  there  is  such  a  collection  of 
fluid,  sufficient  should  be  withdrawn  to  enable  one  to 
determine  its  character.  If  it  is  an  exudate,  as  shown 
by  its  high  specific  gravity  and  percentage  of  albumin, 
the  case  is  one  of  chronic  peritonitis.  In  some  cases, 
although  not  many,  its  tuberculous  nature  can  be 
shown  by  the  demonstration  of  the  tubercle  bacilli 
or  by  inoculation  of  a  guinea-pig.  In  most  cases, 
however,  this  fails,  and  the  diagnosis  must  be  made  by 
a  close  scrutiny  of  the  other  organs  of  the  body.  The 
demonstration  of  a  tuberculous  process  elsewThere  in 
the  body,  as  in  the  lungs,  lymph  glands,  bones,  or 
testicles,  speaks  strongly  for  the  tuberculous  nature 
of  the  process  in  the  abdominal  cavity.  A  coincident 
inflammation  of  one  or  more  of  the  other  serous  sur- 
faces, such  as  the  pleura  or  pericardium,  also  speaks 
for  the  tuberculous  nature  of  the  process.  The  ab- 
sence of  symptoms  pointing  to  carcinoma  of  any  organ, 
especially  any  organ  in  the  abdomen,  such  as  the  stom- 
ach, uterus,  or  rectum,  is  an  additional  fact  in  favor 
of  the  tuberculous  nature  of  the  chronic  peritonitis. 

In  some  doubtful  cases  the  tuberculin  test  may  aid. 
A  positive  reaction  in  the  absence  of  manifest  tuber- 
culosis in  some  other  part  of  the  body,  speaks  strongly 
for  the  tuberculous  nature  of  the  abdominal  process, 
but  the  absence  of  the  reaction  does  not  exclude 
tuberculosis.  The  blood  should  be  examined,  and 
the  absence  of  any  increase  in  the  number  of  leuco- 
cytes speaks  for  tuberculosis,  because  it  speaks 
against  the  other  common  cause  for  chronic  peritoni- 
tis, viz.,  the  neoplasms. 

Tuberculosis  affecting  the  omentum  often  causes 
it  to  shrink  up  into  an  elongated,  sausage-shaped 
tumor  lying  transversely* across  the  upper  part  of  the 
abdomen.  Such  a  tumor  is  so  peculiar  that  its  origin 
is  at  once  manifest,  but  other  processes  than  the 
tuberculosis  can  cause  the  same  deformity  of  the 
omentum.     Attention  to  the  points  mentioned  above 


and  the  exclusion  of  cancer  of  the  organs  commonly 
affected  will  usually  establish  the  nature  of  the  tumor. 

Localized  fluid  tuberculous  exudates  have  often 
been  mistaken  for  ovarian  cysts  even  by  experienced 
observers,  but  attention  to  the  points  given  above, 
especially  to  the  character  of  the  fluid  obtained  on 
aspiration,  will  usually  make  the  correct  diagnosis 
possible. 

Localized  suppurative  processes  in  the  abdomen, 
such  as  an  appendicular  abscess,  often  produce  a  well- 
defined  tumor.  The  accompanying  constitutional 
symptoms — irregular  fever,  chills,  sweating,  leuco- 
cytosis,  etc. — together  with  the  local  pain  and  tender- 
ness, are  usually  sufficient  to  show  the  nature  of  the 
process,  and  careful  attention  to  the  history  will  show 
the  probable  point  of  origin.  Such  abscesses  may 
occur  anywhere  in  the  abdomen,  but  there  are  certain 
sites  of  predilection.  For  example,  they  are  common 
in  the  neighborhood  of  the  appendix,  but  the  appen- 
dicitis can  cause  abscesses  in  other  parts  of  the 
abdomen  remote  from  the  appendix.  They  also 
often  arise  from  various  infective  processes  in  the 
female  genitalia.  Perforating  ulcers,  especially  those 
of  the  stomach  and  duodenum,  may  also  furnish  a 
considerable  number  of  these  cases.  Infective  pro- 
cesses in  the  liver  and  bile  passages  do  the  same  thing. 

Neoplasms  of  the  peritoneum  are  far  more  frequently 
secondary  than  primary.  They  are  oftenest  second- 
ary to  carcinoma  of  the  abdominal  viscera,  but  the 
primary  tumor  may  be  remote,  as  in  the  breast. 
The  clinical  manifestations  are  almost  exactly  the 
same  as  those  of  tuberculous  peritonitis — viz.,  vomit- 
ing, hiccough,  and  intestinal  disturbances — together 
with  the  development  of  tumor  masses,  usually 
multiple  and  often  accompanied  by  large  amounts  of 
fluid  exudate,  either  lying  perfectly  free  in  the  per- 
itoneal cavity  or  partially  encapsulated.  The  effects 
on  the  omentum  are  often  exactly  like  those  produced 
by  tuberculosis.  The  fluid  obtained  by  puncture  has 
the  characteristics  of  an  exudate,  is  often  hemor- 
rhagic, and  may  be  fatty.  In  these  respects  it  is 
exactly  like  the  tuberculous  exudate.  It  never  con- 
tains tubercle  bacilli  and  does  not  excite  tuberculous 
peritonitis  in  the  guinea-pig,  but  sometimes  it  contains 
cancer  cells  either  singly  or  in  groups. 

If  the  primary  tumor  is  discovered,  the  diagnosis  of 
the  nature  of  the  process  is  easily  made.  When  no 
such  tumor  can  be  found,  the  diagnosis  will  rest  upon 
the  exclusion  of  tuberculous  peritonitis. 

Other  peritoneal  tumors,  such  as  lipoma,  fibroma, 
cysts  of  the  mesentery,  and  chylous  cysts,  are  so  rare 
that  they  need  nO  consideration,  and,  in  fact,  are 
seldom  diagnosed  except  by  the  aid  of  an  exploratory 
laparotomy. 

Tumors  of  the  Bladder. — The  true  neoplasms  of 
the  bladder  are  quite  rare  and  they  do  not  cause 
palpable  abdominal  tumors.  There  is  practically 
only  one  condition  which  renders  the  bladder  palp- 
able, and  that  is  retention  of  urine.  This  causes  a 
long  oval  tumor  which  rises  upward  from  the  pelvis 
to  almost  any  height,  even  beyond  the  umbilicus. 
It  is  rounded,  smooth,  tense,  and  usually  not  tender. 
It  lies  as  a  rule  exactly  in  the  median  line  and  is  dull 
on  percussion.  The  patient  may  or  ma3'  not  pass  any 
urine. 

The  diagnosis  is  manifest  when  the  patient  is  pass- 
ing no  urine,  but  it  is  not  always  so  clear  when  the 
urine  is  constantly  dribbling  away.  The  introduction 
of  a  catheter  and  the  disappearance  of  the  tumor 
upon  the  withdrawal  of  the  urine  make  the  diagnosis 
plain.  The  discovery  of  the  cause  of  the  retention 
is  a  different  problem. 

Iliopsoas  Abscess. — This  variety  of  abscess 
appears  as  a  tumor  on  one  side  of  the  spine  or  in  the 
iliac  fossa.  Its  size  and  shape  vary  greatly.  It  lies 
deeply  behind  the  intestines.  It  is  painful  and 
tender,  but  not  to  an  extreme  degree,  for  most  of 
these  abscesses  are  of  tuberculous  nature.     The  thigh 


AS 


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Abdominal  Tumors, 
Diagnosis 


is  flexed  and  rotated  outward.  Usually  the  nature  of 
such  abscesses  is  at  oner  manifest  because  of  the 
deformity  of  the  spine  and  of  the  disturbances  in  the 
function  of  the  spinal  cord.     This,  however,  is  not 

always  SO,  and  therefore  whenever  an  abscess  is  found 

in  tliis  region,  or,  for  that  matter,  in  any  region  in 
which  such  a  gravitation  abscess  may  occur,  the  spine 
and  the  areas  supplied  by  the  spinal  nerves  should  be 
carefully  examined.  Such  an  examination  will 
exclude  the  appendicular  abscesses  or  an  abscess 
arising  in  this  region  secondary  to  suppuration  in  the- 
pelvis. 

Tumors  of  the  Utehds. — There  is  usually  not 
much  difficulty  in  recognizing  a  tumor  of  the  uterus 
a-  such.  Its  situation  low  down  in  the  median  Hue. 
its  evident  origin  in  the  pelvis,  the  ease  with  which 
motion  i-  transmitted  from  the  tumor  to  the  cervix, 
anil  via  VI  rsa  — these,  together  with  the  alterations  in 
the  genital  functions  usually  found,  are  sufficient  in 
most  instances  to  show  that  the  tumor  docs  arise 
from  the  uterus.  A  diagnosis  of  the  nature  of  the 
tumor  is  a  far  more  difficult  matter,  and  even  the 
most  expert  often  err  in  their  judgment  a-  to  the 
nuiiire  of  a  tumor  which  plainly  arises  from  the 
uterus. 

Pregnancy. — This  causes  a  progressive  enlarge- 
ment of  the  uterus,  and  it  has  been  a  fruitful  source 
of  errors  in  diagnosis.  The  resulting  tumor  is  smooth, 
round,  and  not  tender;  menstruation  ceases;  the 
breast  undergo  changes;  and  in  course  of  time  the 
fetal  heart  tones  and  movements  appear.  The  com- 
monest difficulty  is  that  of  distinguishing  pregnancy 
from  uterine  fibromata.  These  cause  enlargement 
of  the  uterus,  often  associated  with  irregularity  in 
the  menstruation,  less  often  with  cessation  of  this 
function.  The  enlargement  of  the  uterus  is  not 
-.1  symmetrical  as  it  is  in  pregnancy,  and  the  rate  of 
growth  is  not  so  rapid.  In  pregnancy  the  size  of  the 
tumor  shows  a  nearly  constant  relation  to  the  dura- 
tion of  the  period  during  which  menstruation  cea 
It  is  not  permissible,  under  these  conditions,  to  resort 
to  a  measurement  of  the  uterine  cavity  by  means  of 
the  uterine  probe.  The  diagnosis  becomes  still  more 
difficult  when  the  two  conditions  (pregnancy  and  a 
tumor)  are  combined,  but  attention  to  the  shape  of 
the  uterus,  the  rate  of  enlargement,  and  the  ordinary 
signs  of  pregnancy  will  usually  enable  one  to  arrive 
at  a  correct  conclusion.  If  any  doubt  remains,  the 
diagnosis  must  be  reserved  until  the  time  arrives  for 
the  appearance  of  the  sure  signs  of  pregnancy. 

When  the  pregnancy  occurs  in  one  horn  of  a  bicor- 
nate  uterus,  the  resulting  tumor  differs  so  much  from 
the  ordinary  tumor  of  pregnane}-  that  error  may 
arise.  The  usual  symptoms  of  pregnancy  are  pres- 
ent, and  the  diagnosis  of  pregnancy  can  be  made  as 
early  here  as  in  a  normal  case.  Careful  bimanual 
examination  will  usually  make  the  correct  diagnosis 
possible.  Such  a  tumor  may  be  taken  for  an  ovarian 
tumor.  Ovarian  tumors,  however,  are  usually 
farther  removed  from  the  median  fine;  there  is  no 
relation  between  their  size  and  the  duration  of  the 
disturbances;  the  signs  of  pregnancy  are  usually 
entirely  absent;  and  the  motion  of  the  tumor  is  not 
transmitted  so  completely  to  the  cervix. 

Fibroid  Tumors  of  the  Uterus. — These  are  very  com- 
mon, especially  in  women  past  the  middle  point  of 
life.  They  cause  a  greater  or  lesser  increase  in  the  size 
of  the  uterus,  which  may  even  reach  such  a  bulk  as 
to  occupy  the  main  portion  of  the  abdomen.  They 
cause  irregular  and  often  profuse  uterine  hemor- 
rhages, and  are  associated  with  irritability  of  the 
bladder  and  rectum,  with  pain  in  the  pelvis  and  legs, 
and  often  with  edema  of  the  latter.  The  enlarge- 
ment of  the  uterus  is  usually  very  grossly  irregular 
and  nodular.  The  tumors  feel  hard,  and  in  rare 
cases  they  may,  from  cystic  degeneration,  yield 
fluctuation.  They  vary  greatly  in  size  and  shape, 
being    often    sessile    or    hemispherical.     Sometimes 


they  tire  pedunculated  and  shou  considerable  passive 

motility.  The  uterine  easily  is  lengthened  and 
irregular.  These  tumors  lie  in  front  "I  t  he  colon, 
sigmoid,  and  small  intestines. 

In  eases  sueh  as  we  are  now  considering,  the 
diagnosis  is  difficult  only  when  i  he  tumoi  are  so  small 
that  they  cannot  befell  fromabove.  The  main  points 
ni  differentiation  between  fibromata  and  preg- 
nancy have  been  already  mentioned.  In  the  case  of 
movable,  subperitoneal,  and  pedunculated  tumors  of 
the  uterus,  the  diagnosis  is  sometimes  quite  difficult, 
especially  when  the  tumor  is  single.  Fortunately  this 
i-  exceptional.  Such  movable  tumors  may  be  taken 
for  an  ovarian  cyst,  for  a  movable  kidney,  or  for  a 
tumor  of  the  intestine-,  but  attention  in  the  history 
and  a  careful  examination  will  enable  the  physician 
to  distinguish  between  them. 

Cancer  of  the  Uterus. — The  primary  uterine  tumor 
rarely  attains  sufficient  size  to  present  itself  as  an 
abdominal  tumor,  and  in  these  rare  instances  the 
condition  of  the  patient  is  sueh  that  the  diagnosis  is 
manifest  from  the  cachexia,  anemia,  and  profuse, 
fetid,  bloody  vaginal  discharge.  The  metastases  of 
uterine  carcinoma  frequently  present  themselves  as 
ah. luminal  tumors  of  either  the  liver,  the  peritoneum, 
or  the  lymph  glands,  and  since  the  secondary  tumor 
may  far  exceed  the  primary  tumor  in  size,  these 
metastases  may  be  mistaken  for  primary  tumors. 
It  is  therefore  wise  to  examine  the  uterus  in  all  ca  i 
of  abdominal  tumors  of  obscure  origin.  If  such 
tumors  may  by  any  possibility  be  secondary  to  a 
uterine  carcinoma,  and  the  uterus  is  found  enlarged, 
or  a  fetid  discharge  without  enlargement  of  the  uterus 
is  found,  scrapings  from  the  uterus  should  be  examined 

microscopically. 

Retention  of  Menstrual  Flu  ids.— This  may  cause 
very  great  enlargement  of  the  uterus.  The  diagnosis 
is  usually  simple.  The  cervix  is  found  obliterated, 
there  is  no  menstrual  flow,  but  the  patient  suffers  at 
regular  intervals  from  the  other  symptoms  of 
menstruation. 

Tumors  of  the  Ovaries. — Cysts. — The  diagnosis 
of  this  common  disease  of  the  ovary  is  based  almo 
entirely  upon  the  results  of  physical  examination, 
for  such  cysts  bring  about  no  characteristic  altera- 
tion in  the  function  of  the  genitalia.  Cysts  which 
are  so  small  that  they  remain  within  the  pelvis  do  not 
call  for  any  special  consideration  in    this  place. 

Confusion  between  an  ovarian  cyst  and  such  con- 
ditions as  collections  of  gas  in  the  intestines,  an  over- 
distended  bladder,  accumulations  of  feces  in  the 
colon,  pregnancy,  fat  abdominal  walls,  and  moderate- 
sized  collections  of  free  fluid  in  the  abdomen  can 
persist  only  when  the  examination  is  incomplete. 
Careful  palpation,  percussion,  and  auscultation  in  a 
patient  properly  prepared  for  examination  by  com- 
plete evacuation  of  the  bladder  and  rectum  will 
prevent  such  errors.  The  differentiation  between 
ovarian  cysts  and  localized  collections  of  fluid  in  the 
abdomen,  cysts  of  other  organs  in  the  abdomen,  and 
certain  tumors  of  the  uterus  is  far  more  difficult,  and 
sometimes  is  impossible  without  exploratory  incision. 

Encysted  peritoneal  exudates,  usually  of  a  tubercu- 
lous or  carcinomatous  origin,  may  very  closely 
resemble  the  ovarian  cyst.  In  many  of  these  cases 
the  results  of  the  physical  examination  are  such  as  to 
fit  as  well  with  one  condition  as  with  the  other,  but  in 
general  the  outlines  of  the  ovarian  cysts  are  sharper 
and  more  distinct,  and  the  tumors  themselves  are 
often  more  motile  in  response  to  the  changing  position 
of  the  patient.  Usually  there  is  no  fluid  free  in  the 
peritoneal  cavity,  in  the  case  of  an  ovarian  cyst,  while 
this  is  quite  common  in  both  the  tuberculous  and  the 
carcinomatous  varieties  of  peritonitis.  In  many 
ea-es  light  may  be  obtained  from  other  sources — 
the  history  of  the  case,  the  body  temperature,  the  pa- 
tient's general  condition,  her  behavior  under  the 
tuberculin   test,   and   an   examination   of   the   other 

39 


Abdominal  Tumors, 
Diagnosis 


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organs  of  the  body.  In  still  other  cases  it  is  necessary 
to  make  an  exploratory  puncture  in  order  to  ascertain 
the  character  of  the  fluid.  If  the  fluid  is  an  exudate, 
it  will  present  the  characteristics  described  above. 
The  fluid  of  different  ovarian  cysts  varies  considerably 
in  specific  gravity,  from  1.007  to  1.020  or  more.  In 
one  case  it  is  a  thin  serous  fluid;  in  another,  a  gelatin- 
ous material.  It  contains  considerable  albumin  and 
paralbumin.  Microscopically  there  is  nothing  peculiar 
to  these  cysts  except  the  cylindrical  epithelium 
occasionally  found. 

Localized  purulent  exudates  may  present  the  same 
physical  signs  as  an  ovarian  cyst,  but  the  constitu- 
tional disturbances  and  blood  changes  are  so  marked, 
and  the  history  of  the  onset  shows  such  an  acute 
beginning,  that  it  is  not  often  that  any  confusion 
arises  be!  win  the  two  conditions.  Exploratory 
puncture    will    remove    the   doubt,    if   any    exists. 

Echinococcus  cysts  developing  in  the  peritoneum  or 
tissues  near  the  ovaries  may  in  some  respects  resemble 
ovarian  cysts.  The  discovery  of  the  thrill  peculiar  to 
the  former  rvsts,  or  the  finding  of  the  hooklets  and 
scolices  in  the  fluid  evacuated  by  exploratory  punc- 
ture, would  naturally  remove  all  doubt. 

Hydronephrosis  is  at  times  confused  with  the 
ovarian  cyst.  It  presents,  however,  this  distinguish- 
ing feature:  it  lies  behind  and  to  the  side  of  the  colon 
and  small  intestines,  while  the  ovarian  cyst  forces 
these  upward  and  backward.  The  ovarian  cysts 
rise  out  of  the  pelvis,  while  the  hydronephrosis  comes 
forward  and  downward  from  the  lumbar  region. 
.Many  cases  of  hydronephrosis  present  urinary  changes 
and  in  some  cases  the  differentiation  can  be  made 
certain  by  the  demonstration,  by  palpation,  of  nor- 
mal ovaries.  Puncture  of  the  hydronephrosis  may 
yield  a  fluid  containing  urea. 

Pancreatic  cysts  can  almost  alwa}'s  be  distinguished 
by  the  fact  that  they  displace  the  colon  downward. 

The  recognition  of  pedunculated  fibroids  of  the 
uterus,  when  the  uterus  is  otherwise  free  from  fibro- 
mata, is  a  very  difficult  matter,  and  in  many  cases  the 
differentiation  can  be  made  by  exploratory  incision 
only. 

Cystic  fibromata  of  the  uterus  may  very  closely 
resemble  ovarian  cysts,  but  usualty  they  are  of  slower 
growth  and  excite  less  constitutional  disturbance. 

Tumors  of  the  liver  and  spleen  can  be  differentiated 
by  the  signs  described  in  the  paragraphs  devoted  to 
these  subjects.  Tumors  of  the  omentum,  mesentery, 
and  peritoneum  are  not  always  easily  distinguished 
from  ovarian  cysts,  but  in  most  cases  they  can  be 
shown  to  arise  above  instead  of  in  the  pelvis. 

Ascites  and  cysts  of  the  ovaries  have  quite  often 
been  confused,  but  this  error  is  possible  only  when 
the  cyst  is  so  large  as  completely  to  fill  the  abdomen 
or  the  ascites  is  so  great  that  there  is  no  central  area 
of  t  y mpany .  In  other  cases  the  error  arises  from  care- 
lessness. The  history  of  an  ovarian  cyst  is  far  longer 
than  that  of  an  ascites.  If  the  fluid  in  the  abdomen 
is  a  transudate,  it  is  a  symptom  of  some  disease  which 
ought  to  show  other  symptoms  as  well.  Usually  the 
primary  disease  is  of  the  liver,  but  it  is  possible  for 
either  a  heart  or  a  renal  disease  to  cause  an  ascites 
without  producing  any  edema  of  the  legs.  The 
various  forms  of  chronic  peritonitis  may  give  rise  to  as 
large  collections  of  fluid  in  the  abdomen,  but  the 
history  is  usually  brief,  and  the  constitutional 
symptoms  of  tuberculosis  or  carcinoma,  the  two 
common  causes  of  chronic  peritonitis,  are  either 
present  already  or  soon  develop.  Exploratory  punc- 
ture   is   a    valuable    aid    and    should    be    employed. 

Solid  Tumors  of  the  Ovaries. — There  is  a  large 
variety  of  these  tumors,  none  of  which  presents 
anything  especially  characteristic  in  its  clinical  course. 
The  most  important  are  the  carcinomata,  the  sar- 
comata, and  those  tumors  which  result  from  tubercu- 
losis. The  carcinomata  grow  rapidly,  producing 
irregular  nodular  tumors  in  the  pelvis  and  lower  pari 


of  the  abdomen,  and  accompanied  by  the  symptoms 
of  a  chronic  peritonitis,  by  cachexia,  and  by  anemia. 
Carcinoma  and  sarcoma  cannot  be  distinguished 
clinically.  The  differentiation  of  these  from  the 
tumors  produced  by  tuberculous  disease  is  often  very 
difficult,  especially  when  the  patient  is  of  such  an  age 
that  either  might  be  present.  A  positive  reaction 
to  the  tuberculin  test  speaks  for  tuberculosis,  but 
the  failure  of  such  reaction  does  not  exclude  it. 
Leucocytosis  speaks  for  cancer.  Before  a  correct 
diagnosis  can  be  made,  it  may  be  found  necessary  to 
resort  to  an  exploratory  operation. 

There  are  still  other  pathological  conditions  in  the 
pelvis  which  manifest  themselves  as  abdominal 
tumors;  such  are,  for  example,  a  collection  of  fluid  in  a 
Fallopian  tube,  a  pelvic  abscess,  and  an  extrauterine 
pregnancy.  The  resulting  abdominal  tumor  may  be  of 
considerable  size.  In  such  instances,  however,  the 
history  of  the  case  and  the  existing  symptoms  and 
evidences  usually  render  the  diagnosis  plain. 

Tumors  of  the  Colon. — These  tumors,  irrespec- 
tive of  their  nature,  induce  alterations  in  the  character 
and    frequency    of    the    movements    of    the    bowels. 

Fecal  Tumors. — These  are  very  common,  especially 
in  women,  and  have  been  the  source  of  many  em- 
I  larrassing  errors,  all  of  which  could  have  been  avoided 
if  a  thorough  evacuation  of  the  bowels  had  first  been 
secured.  The  fact  that  the  patient's  bowels  have 
moved  daily  should  not  lead  to  the  neglect  of  this 
precautionary  measure,  for  the  feces  may  accumulate 
in   large   masses  even  when  the  bowels  move  daily. 

The  feces  tend  to  accumulate  in  the  flexures  of  the 
colon — the  sigmoid,  the  splenic,  and  the  hepatic 
flexures — and  in  the  cecum,  but  they  may  accumu- 
late anywhere  in  the  course  of  the  large  intestine. 
The  resulting  tumor  may  be  of  large  size,  and  its 
outlines  are  usually  of  irregular  shape.  While  it 
possesses  a  certain  degree  of  solidity,  it  can  generally 
be  moulded  into  a  different  shape,  and  this  new  shape 
will  remain  permanently.  These  tumors  may  possess 
considerable  motility.  According  to  the  different  sites 
which  they  occupy  they  may  simulate  a  great  variety 
of  pathological  conditions,  but  in  all  such  instances 
the  simple  evacuation  of  the  bowels  will  quickly  clear 
up  the  diagnosis. 

Gas  in  the  Colon. — This  may  cause  a  great  distention 
of  the  abdomen,  and  this  enlargement,  at  least  at  first, 
is  limited  to  its  outer  and  upper  portions,  the  central 
portion  being  left  free.  The  fact  that  the  swelling  is 
due  to  gas  is  shown  at  once  by  percussion.  These 
accumulations  of  gas  are  often  of  great  significance  in 
cases  of  intestinal  obstruction,  giving  as  they  do  some 
clew  to  the  site  of  the  obstruction;  it  being  evident 
that  the  lower  the  obstruction  the  greater  will  be  the 
portion  of  the  colon  distended.  The  degree  of  dis- 
tention1 depends  mainly  upon  the  amount  of  gas,  but 
the  resistance  of  the  intestinal  walls  is  also  important, 
and  when  they  are  weak  and  have  lost  their  tone — as, 
for  example,  in  cases  of  generalized  peritonitis — the 
distention  is  often  extreme.  Usually  this  distention 
of  the  colon  with  gas  is  accompanied  by  a  like  con- 
dition in  the  small  intestines. 

Cancer  of  the  Colon. — The  clinical  picture  includes 
pain,  which  is  both  localized  and  radiating,  and  which 
often  occurs  in  the  form  of  attacks  of  colic.  In  most 
cases  there  is  constipation,  which  may  gradually  in- 
crease even  to  the  point  of  complete  obstruction;  but 
in  some  cases  there  may  be  diarrhea.  The  stools 
usually  become  small  and  ribbon-like,  and  are  often 
mixed  with  mucus,  blood,  and  pus,  ami  some- 
times contain  fragments  of  the  tumor  tissue.  These 
local  symptoms  are  accompanied  by  the  secondary 
anemia  and  cachexia  which  are  common  to  carci- 
noma, no  matter  what  organ  it  may  involve. 

The  presence  of  a  tumor  which  can  be  felt  is  by  all 
odds  the  most  important  symptom;  and  while  it 
does  not  exist  in  all  cases,  it  certainly  does  in  the 
great    majority    of    them.     The    size    of    the    tumor 


40 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Ahoriu-thy,  John 


varies,  and  may  reach  that  of  an  adult  head.  It  is 
hard,   irregularly  round  or  cylindrical  in  shape,  and 

furnished    with   a   s th   or   nodular  surface.      As   a 

rule  it  is  moderately  tender,  bnt  it  may  be  extremely 
tender  in  certain  cases. 

The  tumor  is  generally  very  movable,  especially 
when  it  involves  the  sigmoid  flexure  or  the  trans- 
verse colon;  but  it  may  also  be  movable  when  it 
involves  the  cecum  or  either  of  the  longitudinal  por- 
tions of  the  colon.  Such  tumors  may  be  moved 
by  the  hand  of  the  examiner,  by  the  peristaltic  move- 
ments of  the  intestines,  by  the  force  of  gravity,  and 
by  the  respiratory  motions.  The  passive  motility 
is  most  marked  in  the  case  of  tumors  of  the  sigmoid 
flexure  anil  of  the  transverse  colon,  on  account  of 
the  greater  length  of  their  mesocolon.  The  displace- 
ments due  to  the  force  of  gravity  are  often  considei 

able  and  may  render*  the  diagnosis  quite  difficult,  for 
the  reason  that  the  tumor  may  be  found  occupying  a 
position  remote  from  the  normal  site  of  tin-  colon. 
Thus,  for  example,  a  tumor  of  the  transverse  colon 
may  lie  at  the  pelvic  inlet,  or  one  of  the  sigmoid  flex- 
ure may  lie  close  to  the  cecum. 

The  accumulation  of  the  feces  above  the  point  where 
the  lumen  is  narrowed  by  the  carcinoma  leads  to  fre- 
quent errors  in  the  matter  of  estimating  the  size  of 
the  new  growth.  These  fecal  masses  may  feel  as 
hard,  linn,  and  irregular  as  the  cancer  itself,  and  the 
palpating  finger  may  not  be  able  to  distinguish  the  one 
from  the  other.  In  such  eases,  as  in  those  in  which  it 
is  necessary  to  distinguish  between  the  fecal  mass  and 
other  forms  of  tumor,  vigorous  and  repeated  purga- 
tion, and  Hushing  of  the  colon,  must  be  practised. 

Peritoneal  exudates,  especially  those  about  the 
appendix,  may  be  extremely  difficult  to  distinguish 
from  carcinoma  of  the  cecum.  They  may  form  hard 
anil  irregular  tumors,  which  may  obstruct  the  intes- 
tinal canal  and  may  cause  bloody  and  purulent  stools. 
The  presence  of  fever  and  an  edematous  condition 
of  the  skin,  taken  in  connection  with  the  history  of 
the  case,  will  point  to  peritonitis. 

Tumors  of  the  transverse  colon,  because  of  their 
close  anatomical  relations  to  the  stomach,  duo- 
denum, and  pancreas,  may  be  confused  with  tumors 
of  these  organs.  The  symptoms  of  tumors  of  the 
colon  are  chiefly  disturbances  in  defecation,  such  as 
constipation  or  diarrhea;  bloody,  mucous,  or  puru- 
lent stools,  and  ribbon-like  form  of  the  stools. 
These  tumors  are  also  more  movable  than  are,  as  a 
rule,  the  tumors  of  neighboring  organs.  Disten- 
tion of  the  colon  from  below  with  gas  or  fluid  can  be 
followed  upward  to  the  tumor  mass,  where  it  is 
stopped  or  retarded.  Inflation  of  the  stomach  throws 
the  tumor  downward  and  forward. 

In  cases  in  which  the  tumors  have  migrated  from 
the  normal  location  of  the  viscus.  their  relation  to  the 
colon  can  be  demonstrated  by  inflation  of  the  colon. 

Tumors  of  the  sigmoid  flexure  may  be  confused  with 
tumors  arising  from  the  ovaries,  tubes,  and  peri- 
uterine tissues,  but  the  symptoms  of  intestinal  dis- 
turbances are  more  marked  here  than  in  the  case  of 
tumors  situated  higher  up.  A  careful  physical  ex- 
amination will  reveal  differences  between  these  dif- 
ferent conditions. 

Tumors  situated  lower  down,  as  in  the  rectum,  are 
not  abdominal  tumors,  but  they  have  so  important 
a  bearing  upon  them  that  it  should  again  be  stated 
that  in  all  cases  which  are  in  the  least  obscure,  even 
when  there  are  no  symptoms  pointing  directly  to  the 
rectum,  the  latter  should  be  examined. 

Appendicular  Abscesses. — These  are  often  of 
large  size.  Disease  of  the  appendix  may  cause  an 
abscess  to  form  not  merely  in  the  immediate  vicinity 
of  that  organ,  but  also  in  some  remote  part  of  the 
abdomen.  These  more  remotely  situated  abscesses 
have  been  considered  in  the  paragraphs  devoted  to 
localized  and  encapsulated  peritonitis,  but  it  still 
remains  to  mention  the  abscess  in  the  region  of  the 


appendix.  While  it  is  true  that  the  diagnosis  of  ap- 
pendicitis prev  ous  to  the  formation  of  a  tumor  is 
often  difficult,  after  this  has  happened  the  diag- 
nosis is  easy.  The  size,  shape,  and  exact  location  of 
the  tumor  are  subject  to  u  ide  \  arial  ion- ,  but  the  his- 
tory of  a  sudden  onset  ami  the  existence  oi  local- 
ized pain,  associated  with  gastrointestinal  disturb- 
ances, with  a  chill,  and  with  elevated   temperature, 

suffice  to  show    the  nature'  of  the  process. 

Abscesses  in  this  region  arising  from  other  structures 

are  encountered,  but  they  are  decidedly  Less  common 
than  the  appendicular  abscesses.  Those  which  de- 
velop in  the  female'  genitalia  are  frequent,  but  the 
history  shows  disturbances  in  the  functions  of  these 
organs  and  opportunities  for  their  infection.  These 
fad  .  taken  in  conjunction  with  the  results  of  the 
pelvic  examination,  suffice  for  making  the  differen- 
tial diagnosis.  Sometimes  gravitation  abscesses  due 
to  disease  of  the  spine  are  mistaken  for  appendicular 
abscesses,  but  tins  error  may  be  avoided  by  exam- 
ining the  spine  and  by  noting  the  absence  of  the 
usual  history  of  appendicitis. 

Tumors  of  the  Abdominal  Wu.l. — All  forms  of 
tumors  may  occur  in  this  part  of  the  bod}-,  but  their 
relations  to  the  abdominal  walls  are  so  manifest 
that  they  need  no  consideration  here. 

Robekt    B.    Preble. 

Abenakis  Springs.  Location. — Near  the  St.  Law- 
rence River,  Quebec. 

Post  Office. — Abenakis     Springs,     Quebec. 

Hotel. — The  Abenakis  House. 

Access. — From  Montreal,  by  Richelieu  and  Ontario 
Navigation  Co.,  and  also  by  Grand  Trunk  and  South 
Shore  railways. 

Analysis. — The  following  is  an  analysis  of  the 
water  by  Milton  J.  Hersey: 

One  Imperial  Gallon  Contains 

Solids  drains 

Sodium  chloride 761 .32 

Lithium  chloride trace 

Calcium  chloride 67.13 

Magnesium  chloride 92. S3 

Sodium  iodide trace 

Sodium  bromide trace 

Sodium  sulphate 7.") .  7  1 

Potassium  sulphate 6.30 

Sodium  phosphate 0 .  07 

Sodium  nitrate 0.35 

Calcium  bicarbonate 44 .  94 

Ferrous  carbonate 1 .  75 

Alumina -  -  trace 

Silica 0.98 

Total  mineral  constituents  (grs.  per  imp.  gal.)     1.051.40 

These  springs  are  pleasantly  situated  on  the  west 
bank  of  the  St.  Francis  River,  near  its  confluence 
with  the  St.  Lawrence,  sixty  miles  east  of  Montreal. 
The  surrounding  country  is  elevated  and  dry  and 
well  settled.  The  hotel  is  new  and  well  ventilated, 
possesses  all  modern  conveniences,  and  is  well 
managed.     Hot   and    cold    baths   are   supplied. 

Beaumont  Small. 

Abernethy,  John. — Born  in  London,  April  3,  1704. 
In  1787  he  was  elected  assistant  surgeon  at  St.  Barthol- 
omew's Hospital.  While  still  holding  this  position  he 
gave  lectures  at  his  house  in  Bartholomew  Close,  and 
this  course  of  instruction  proved  so  popular  that  the 
governors  of  the  hospital,  in  1790-1791,  built  a  regular 
theater,  in  which  the  lectures  were  thereafter  delivered. 
Thus  Abernethy  became  the  founder  of  the  distinguished 
Medical  School  of  St.  Bartholomew's.  It  was  not  until 
1815,  after  he  had  held  the  position  of  assistant  for 
twenty-eight  years,  that  he  was  elected  principal 
surgeon.  In  1814  he  was  appointed  Lecturer  in 
Anatomy  to  the  Royal  College  of  Surgeons.  His  death 
occurred  April  20,  1831. 

41 


Abernethy,  John 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


The  writer  of  the  biographical  sketch  of  Abernethy 
in  the  "Encyclopaedia  Britannica"  says  of  him  that  he 
' '  was  not  a  great  opera  t  or,  t  hough  his  name  is  associated 
with  the  treatment  of  aneu- 
rysm by  ligature  of  the  ex- 
ternal    iliac     artery.        His 
'Surgical     Observations    on 
the     Constitutional     Origin 
-*<?(        and     Treatment     of     Local 
,\     Diseases'   (1S09)  was  one  of 
the  earliest  popular  works 

on  medical  science 

As  a   lecturer,   he  was  ex- 
ceedingly attractive,  and  his 
&■■'  '■?%  ~^-v   '  success     in     teaching     was 

\\         largely    attributable   to   the 
j     '    -x       persuasiveness    with    which 
w^s"^      ty  \      he     enunciated    his    views. 

f  wl   *-^_^\      The  celebrity  he 

^   -^  •-^P'     attained  in  his  practice  was 

r^''a-~>^\~7*i*3\       due   not   only   to   his   great 

<\  "-*»»  \      professional    skill,    but    also 

Fig.  14.— John  Abernethy.       in  ptu't   to  the  singularity  of 

his  manners.     He  used  great 

plainness   of   speech   in  his 

intercourse    with    his    patients,    treating    them    often 

brusquely  and  sometimes   even  rudely A 

collected  edition  of  his  works  was  published  in  1S30." 

A.  H.  B. 

Abietic  Acid  (C48H„05). — An  organic  acid,  which,  in 
its  anhydrous  state,  chiefly  composes  common  rosin. 
It  also  occurs  in  many  other  coniferous  plants. 

H.  H.  R. 

Abilena  Wells. — Dickinson  County,  Kansas 

Location. — On  a  ridge  of  high  land,  at  almost  the 
exact  geographical  center  of  the  United  States.  The 
wells  are  about  fourteen  miles  northwest  of  Abilene,  a 
station  on  the  Union  Pacific  and  the  Chicago,  Rock 
Island,  and  Pacific  Railroads. 

From  the  report  made  in  1902  by  Dr.  E.  R.  S. 
Bailey,  of  the  University  of  Kansas,  we  glean  the 
following  facts:  The  first  well  was  driven  in  1S97,  for 
the  purpose  of  securing  drinking  water  for  the  animals 
of  a  stock  farm.  It  was  found,  however,  that  the 
water  obtained  at  a  depth  of  ninety-five  feet  was  unfit 
for  the  purpose.  On  the  other  hand,  a  chemical 
analysis  revealed  the  fact  that  it  was  rich  in  salts 
possessing  cathartic  and  diuretic  properties;  and  accord- 
ingly a  company  was  organized  in  1900  for  the  further 
development  of  the  property  and  for  the  sale  and 
distribution  of  the  water.  In  1901  two  other  wells  were 
bored,  and  later  three  additional  wells  were  drilled,  all 
to  the  depth  of  130  feet. 

At  the  present  time  there  are  over  fifty  wells,  the 
water  of  which  is  filtered  through  sand  and  charcoal,  to 
remove  a  small  quantity  of  suspended  matter.  As  de- 
livered to  the  public,  in  bottles  of  a  convenient  size, 
this  water  is  perfectly  clear.  The  chemical  analysis, 
which  was  made  in  January,  1902,  by  the  late  Professor 
Albert  B.  Prescott,  of  the  University  of  Michigan,  is 
given  below. 

(In  Grains  per  U.  S.  Gallon,  231  Cubic  Inches,  at  Maximum 
Water  Density.) 

Sodium  bicarbonate S.  909 

Calcium  bicarbonate 10.733 

Iron  bicarbonate 0.917 

Sodium  nitrate 0.  56S 

Sodium  sulphate 3229 . 2SS     Anhydrous.  Equal 

to     7322.648      sodii 
sulphas,  U.  S.  P. 

Magnesium  sulphate 71 .345    Anhydrous.  Equal  to 

146.139         macnesii 
sulphas,  U.  S.  P. 

Calcium  sulphate 44  .  966 

Sodium  chloride 6.5. 176 

,Sili<-a 0.293 

Total  solids 3432 .  195 


"  The  specific  gravity  of  the  water  is  1.0G5  at  22.5°  C. 
As  seen  by  the  analysis  herewith  given  this  water  is 
remarkably  rich  in  cathartic  and  diuretic  salts,  and  is 
mildly  alkaline  with  bicarbonates.  It  is  an  extremely 
pure  water  in  respect  to  freedom  from  organic  con- 
tamination." 

Probably  the  most  valuable  feature  of  the  Abilena 
water  is  its  very  large  content  of  sodium  sulphate  in 
combination  with  a  correspondingly  small  percentage 
of  magnesium  sulphate. 

The  dose,  taken  preferably  one  hour  before  breakfast, 
is  from  one-quarter  to  one-half  of  an  ordinary  drinking 
glassful,  equal  to  about  two  ounces.  This  dose  should 
be  followed  by  a  liberal  drink  of  table  water. 

Emma  E.  Walker. 

Abiotrophy. — From  a-  privative,  /?fos,  life,  and  zpo<p-f), 
nourishment.  A  term  proposed  by  Cowers1  to  indicate 
defective  vital  endurance,  from  which  results  prema- 
ture wasting  or  degeneration  of  certain  cells  or  tissues. 
This  defective  vitality  is  innate  and  not  the  direct 
result  of  any  toxic  influence.  An  abiotrophic  consti- 
tution, or  inherent  tendency  to  presenile  exhaustion, 
has  been  advanced  as  the  underlying  cause  of  tabes 
dorsalis  (the  non-resistant  cells  giving  way  under  the 
devitalizing  action  of  the  syphilitic  poison)  and  of 
various  hereditary  or  familial  affections,  such  as 
Thomsen's  disease  and  Friedreich's  disease.  A  con- 
spicuous example  of  abiotrophy  is  the  premature 
baldness  occurring  in  the  males  of  certain  families. 
Another  form  is  optic  abiotrophy  seen  in  cases  in 
which  several  members  of  the  same  family  have  been 
blind  at  an  early  age  in  consequence  of  a  slow  but 
progressive  failure  of  the  optic  nerve  fibers.    T.  L.  S. 

1.  Gowers:  Lectures  on  Diseases  of  the  Nervous  System,  Second 
Series,  1904. 

Ablepharon. — From  a-  privative,  and  p\ltpapov,ey(- 
lid.  Congenital  abscess,  partial  or  complete,  of  the 
eyelids.  The  term  lias  been  applied  to  two  opposite 
conditions:  one  in  which  the  lids  are  too  small  or  rudi- 
mentary, not  sufficing  to  cover  the  eyeball,  the  condition 
being  then  called  lagophthalmos  (Xaj-ui^,  a  hare); 
another  in  which  the  skin  is  continuous  over  the  orbit, 
with  no  sign  of  tarsal  cartilage  or  eyelashes,  concealing 
entirely  the  eyeball,  the  condition  being  called  crypl- 
ophthalmos  (npun-ctK,  hidden,  dtpdaXpfc,  eye).  In  the 
latter  case  the  eyeball  is  often  rudimentary  or  only 
partially  developed.  Cryptophthalmos  is  to  be  dis- 
tinguished from  symblepharon,  in  which  the  inner 
surface  of  the  eyelids  is  adherent  to  the  eyeball,  and 
In ii n  ankyloblepharon,  in  which  the  margins  of  the  • 
two  lids  are  adherent.  T.  L.  S. 

Abortion. — While  most  Continental  writers  apply  the 
term  abortion  to  all  cases  in  which  the  product  of 
conception  is  expelled  from  the  uterus  at  any  time 
preceding  the  period  at  which  the  fetus  become  viable, 
that  is  to  say,  before  the  seventh  calendar  month  of 
gestation  in  the  human  subject,  many  American  and 
English  writers  make  a  distinction  between  abortion 
and  miscarriage,  restricting  the  former  term  to  the 
expulsion  of  the  ovum  prior  to  the  fourth  month,  and 
applying  the  latter  to  such  expulsion  during  the  second 
trimester  up  to  the  seventh  month.  This  distinction, 
although  more  or  less  arbitrary,  has  some  practical 
justification,  inasmuch  as  abortion,  thus  defined,  differs 
notably  in  several  particulars  from  the  process  of 
parturition  at  term — a  difference  that  becomes  trifling 
in  the  case  of  miscarriage.  Certain  qualifying  words 
are  occasionally  added,  such  as  "ovular,"  "embryonal," 
and  "fetal,"  but  they  are  of  little  real  significance. 

Causes. — These  attach  either  to  mechanical  injuries 
to  the  ovum  or  its  uterine  attachment,  to  morbid  con- 
ditions of  the  ovum,  or  to  diseases  of  the  maternal 
organism.  Under  the  first  head  must  be  included  not 
only  direct  traumatism,  but  also  hemorrhages  between 
the  fetal   and   the  maternal   layers  of   the  placenta, 


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Abortion 


whether  due  to  violence,  such  as  fulls,  blows,  and  the 
like,  or  to  a  diseased  state  in  either  the  mother  or  the 

ovum;  the  latter,  of  course,  falling  also  under  one  ol 
the  remaining  heads.  Strictly  speaking,  indeed,  the 
immediate  cause  of  almost  every  abortion  is  some  ab- 
normal state  of  the  ovum  resulting  in  the  death  of 
the  embryo,  but  this  in  turn  may  be  due  to  some 
defect  in  the  maternal  organism,  or.  for  that  matter, 
to  disease  in  the  father,  as  exemplified  by  the  fre- 
quency with  which  abortion  takes  place  as  the  result 
of  syphilitic  contamination  of  one  or  the  other  of  the 
parents.  Habitual  abortion,  it  is  well  known,  raises 
the  presumption  of  syphilis.  As  regards  pathological 
conditions  of  the  ovum,  it  is  generally  to  disease  of  the 
placenta,  or  a  crippling  of  its  respiratory  and  nutritive 
functions  by  effused  blood,  that  the  death  of  the  embryo 
is  to  be  traced,  although  cases  are  not  wanting  in  which 
the  circulation  in  the  umbilical  vessels  has  been  so 
interfered  with  as  to  produce  the  same  result. 

In  so  far  as  the  mother's  system  is  at  fault,  much 
stress  is  laid  by  certain  writers  on  the  "habit  of 
abortion."  This  means  that  when  several  successive 
pregnancies  in  the  same  subject  have  ended  in  abortion, 
no  matter  what  the  cause,  a  habit  is  thereby  established 
by  virtue  of  which  there  is  a  tendency  for  the  subse- 
quent pregnancies  to  end  in  the  same  way,  and  at 
about  the  same  period,  even  if  the  original  causes  are  no 
longer  operative.  The  exanthematous  fevers,  partic- 
ularly smallpox,  almost  inevitably  give  rise  to  abortion, 
either  by  infecting  the  embryo,  or  by  the  tendency  to 
hemorrhages,  uterine  among  the  others,  to  which  they 
give  rise.  Apart  from  these  acute  diseases,  various  de- 
praved conditions  of  health  on  the  part  of  the  mother 
may  occasion  abortion.  There  are  certain  medicinal 
substances  that,  when  taken  into  the  mother's  system, 
in  ay  induce  uterine  contraction,  and  thus  bring  about 
the  premature  expulsion  of  the  ovum,  such  as  spurred 
grain  (generally  ergot  of  rye)  and  cotton-root.  Ex- 
cessive purgation  also  may  lead  to  the  same  result. 
Surgical  operations  done  on  pregnant  women  involve 
a  certain  risk  of  abortion,  but  evidence  has  been 
accumulating  of  late  years  to  show  that  this  danger 
has  been  much  overrated.  A  striking  example  is  seen 
in  the  frequency  with  which  even  so  serious  an  operation 
as  ovariotomy  is  performed  during  pregnancy  without 
interrupting  the  process  of  gestation. 

Various  morbid  conditions  of  the  uterus  and  its  sur- 
roundings, however,  are  justly  credited  with  producing 
a  tendency  to  abortion,  but,  with  regard  to  lacerath  in  i  if 
the  cervix,  whereby  a  lack  of  retentive  power  is  said  to 
be  set  up,  more  has  been  assumed  than  the  facts  warrant. 
It  cannot  be  denied  that  lacerations  are  often  accom- 
panied by  conditions  unfavorable  to  the  due  continu- 
ance of  gestation,  or  that  they  tend  to  keep  up  such 
conditions,  even  if  not  directly  chargeable  with  their 
production;  but  this  is  quite  a  different  matter  from 
admitting  a  loss  of  mechanical  retentive  power  in  the 
cervix  as  a  cause  of  abortion,  for  it  should  be  borne  in 
mind  that  the  ovum  maintains  its  position  in  the  uterus 
by  the  implantation  of  its  chorionic  villi  in  the  uterine 
mucous  membrane,  and  not  in  any  sense  by  resting  on 
a  support  beneath,  as  on  a  shelf. 

Abortion  induced  for  therapeutic  purposes  will  be 
found  treated  of  in  another  article  under  its  own  title. 
Frequency. — Although  abortion  does  not  figure 
prominently  in  the  statistical  lists  of  public  insti- 
tutions, since  it  is  only  under  unusual  circumstances 
that  women  betake  themselves  to  a  hospital  during 
the  process,  the  general  experience  shows  that  its 
occurrence  is  common.  It  is  unquestionable  that 
many  abortions  occur  during  the  very  early  weeks  of 
gestation,  before  the  existence  of  that  condition  is  sus- 
pected, and  are  mistaken  for  a  mere  unusually  copious 
and  painful  menstruation.  As  to  the  period  of  gesta- 
tion at  which  it  oftenest  takes  place,  the  experience  of 
most  authorities  is  to  the  effect  that  it  is  on  the  com- 
pletion of  two  and  a  half  or  three  months  of  gestation, 
leaving  out  of  account  the  very  early  abortions  before 


alluded  to,  since  they  arc  involved  in  so  much  unci  r- 
tainty  that  it  is  impracticable  to  estimate  their 
frequency  with  any  approach  to  precision. 

Symptoms  and  Diagnosis.— Sometimes  the  ovum  is 
cast  oil'  rapidly,  with  scarcely  a  symptom  beyond  a 
sharp  onset  of  abdominal  pain,  and  a  few  gushe-  of 
blood.  In  such  cases,  either  the  diagnosis  is  e ■  l.ibli  tied 
very  promptly,  or  else  it  is  never  made  with  certainty; 
but  it  never  rests  on  symptoms.  These  so-Called 
"ovular"  cases,  however,  are  exceptional.     Usually  a 

considerable  period  is  occupied  by  certain  symptoms 
pointing  to  a  disturbance  going  on  within  the  pel.,,., 
notably,  uterine  hemorrhage  and  pains  resembling 
those  of  labor.  'When  these  two  phenomena  are  found 
to  coexist  in  a  marked  degree  in  a  woman  supposed  to 
be  pregnant,  the  inference  that  tin  abortion  is  impend- 
ing presents  itself  at  once.  Uterine  hemorrhage,  oi  al 
least  hemorrhage  from  the  cervix,  may  stimulate 
abortion.  Let  one  of  these  hemorrhages  coincide 
with  an  attack  of  colic,  or  of  lumbago,  and  the  symp- 
toms that  ordinarily  usher  in  an  abortion  may  be  very 
closely  counterfeited. 

Still,  with  every  allowance  for  these  exceptional  oc- 
currences, the  fact  remains  that  paroxysmal  uterine 
pain,  accompanied  by  a  flow  of  blood  from  the  vagina, 
almost  invariably,  when  met  with  in  a  pregnant 
woman,  presages  the  premature  expulsion  of  the 
ovum.  This  suspicion  once  aroused  in  the  practi- 
tioner's mind,  the  first  thing  to  be  settled  is  the  quest  ion 
of  the  existence  of  pregnancy.  The  diagnosis  of  preg- 
nancy will  be  found  treated  of  elsewhere  in  this  work, 
and  therefore  it  will  not  now  be  dwelt  upon.  Nor, 
for  practical  purposes,  is  it  necessary  to  give  much  more 
consideration  to  the  diagnosis  of  threatened  abortion. 
The  practical  rule  should  be,  in  all  cases  in  which  the 
two  symptoms,  uterine  pain  and  uterine  hemorrhage, 
are  marked  in  a  pregnant  woman,  to  treat  her  as  if 
an  abortion  were  impending.  There  are,  indeed, 
certain  cases  of  uterine  disease  that  may  simulate 
abortion  very  closely — notably  cases  of  submucous 
uterine  tumors  so  situated  and  so  attached  as  to 
cause  expulsive  pains  by  the  impediment  they  may 
offer  to  the  escape  of  the  flow  of  blood  to  which  their 
presence  gives  rise.  In  such  instances,  however,  we 
shall  usually  be  able  to  get  the  history  of  past  occur- 
rences of  the  sort — a  history  to  be  contrasted  with  the 
sharp  picture  of  suspended  menstruation  followed  by 
a  profuse  and  painful  flow  in  a  woman  previously  free 
from  such  troubles.  A  more  difficult  problem  is  pre- 
sented in  cases  in  which  an  abortion  is  really  in  process, 
but  has  been  arrested  in  its  course.  Perhaps  the 
simplest  form  of  this  condition  is  the  so-called  "  cervical 
pregnancy"  of  certain  German  writers,  in  which  the 
ovum  is  detached  from  its  connection  with  the  uterine 
wall,  and  is  forced  down  into  the  cervical  canal,  where 
it  is  retained  in  consequence  of  a  failure  of  the  os 
externum  to  dilate,  or  simply  by  reason  of  a  suspension 
of  the  uterine  contractions.  These  cases  commonly 
offer  no  special  diagnostic  difficulty,  and,  the  retention 
being  but  transitory,  any  doubt  is  speedily  cleared  up. 
A  threatened  abortion  becomes  inevitable  when  the 
ovum  becomes  detached  from  the  uterine  wall  and 
begins  to  descend  toward  the  cervix.  This  stage  will 
be  recognized  by  the  straightening  of  the  anterior 
uterine  wall;  that  is,  by  the  effacement  of  the  angle 
normally  existing  between  the  upper  and  lower 
uterine  segments  (Tarnicr's  sign).  A  more  common 
irregularity  is  the  rupture  of  the  fetal  membranes  and 
the  escape  of  the  fetus,  either  unperceived  or  unac- 
knowledged, before  medical  aid  is  summoned,  the 
placenta  still  being  retained  (incomplete  abortion). 
Under  such  circumstances,  it  happens  not  infre- 
quently that  the  patient  resumes  her  ordinary  course 
of  life,  seeking  treatment,  if  at  all,  only  on  account  of 
a  uterine  discharge,  which  is  generally  bloody  and 
grumous  and  more  or  less  fetid.  In  such  instances 
the  uterus  will  be  found  enlarged  and  especially 
elongated,   freely   movable,    with   its   os   patulous,    so 


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that  the  examining  finger  readily  traverses  the  cervix 
and  detects  the  retained  uterine  contents.  In  all  cases 
of  suspected  abortion,  everything  expelled  from  the 
vagina  should  be  saved  for  examination.  In  the 
absence  of  the  embryo,  the  recognition  of  chorionic 
villi  will  be  decisive.  These  will  often  be  found  on 
tin'  inner  side  of  the  bag-like  structure  expelled,  the 
membranes  having  been  turned  inside  out  in  the  process 
of  expulsion.  In  very  early  abortions  the  ovum  is 
usually  cast  oil'  entire. 

Prognosis  ami  Sequelce. — If  we  disregard  the  fetus, 
which  is  necessarily  sacrificed,  the  prognosis  for  the 
mother  is  always  a  matter  of  some  doubt,  but  generally, 
provided  the  case  is  well  managed,  favorable.  The  im- 
mediate danger  is  from  hemorrhage,  which  ceases  on  the 
complete  evacuation  of  the  uterus;  next,  and  much  more 
to  be  feared,  is  the  risk  of  septic  fever  from  the  absorp- 
tion of  decomposing  portions  of  the  ovum  retained  in 
the  uterus;  these  perils  passed,  inflammatory  complica- 
tions, subinvolution,  and  the  like  are  still  to  be  feared. 
Very  few  women  die  from  the  direct  effects  of  hem- 
orrhage occasioned  by  abortion,  but  many  are  ex- 
sanguinated to  a  degree  that  materially  deteriorates 
their  health;  more  often  they  succumb  to  septic  infec- 
tion. The  acute  inflammatory  sequelse  may  be  either 
peritonitis,  cellulitis,  oophoritis,  or  any  one  of  the 
various  forms  of  metritis.  Aside  from  the  part  played 
by  mild  septic  contamination,  these  affections  are 
largely  dependent  on  the  cause  of  the  abortion,  being 
uncommon  in  cases  not  occasioned  by  instrumental 
interference.  On  the  whole,  it  may  be  said  that,  the 
great  majority  of  women  escape  a  fatal  result.  At 
the  same  time,  abortion  is  one  of  the  most  fertile 
causes  of  chronic  pelvic  disease,  which  consequences 
may  be  avoided  by  careful  treatment. 

Treatment. — This  resolves  itself  into  the  prevention  of 
abortion,  the  management  of  the  process,  and  the  after- 
treatment.  If  we  admit  the  "habit"  of  abortion,  we 
must  usually  look  for  its  solution  in  some  degeneration 
of  the  placenta,  whereby  it  becomes  unfitted  to  carry  on 
the  processes  of  respiration  and  nutrition  for  the  embryo. 
This  occurrence  usually  is  due  to  syphilis;  in  that  case 
mercurial  treament  affords  the  main  chance  of  success; 
the  corrosive  chloride  of  mercury  in  doses  of  from  one- 
thirty-second  to  one-twenty-fourth  of  a  grain,  three 
times  a  day,  combined  with  potassium  iodide  in  suitable 
amounts,  will  commonly  give  excellent  results.  In  the 
absence  of  syphilitic  infection,  some  obstetricians 
believe  that  an  error  of  hematosis  is  often  at  the  bottom 
of  repeated  abortions,  and  on  this  theory  the  adminis- 
tration of  potassium  chlorate  has  been  recommended. 
As  for  the  use  of  so-called  uterine  sedatives,  it  is  not 
to  be  thought  of  until  the  process  of  abortion  is  actually 
threatened.  Of  course,  such  patients  as  are  now 
referred  to  should  be  instructed  to  refrain  from  all  the 
excesses  and  irregularities  that  have  been  mentioned 
as  among  the  exciting  causes  of  abortion. 

If  symptoms  are  present  showing  that  an  abortion  is 
imminent,    in    many    instances    the   process   may    be 

Erevented,  and  the  expectation  of  success  should  not 
e  abandoned  until  there  is  physical  evidence  that  the 
expulsion  of  the  ovum  is  going  on.  No  amount  of 
hemorrhage  and  no  amount  of  pain,  within  ordinary 
bounds,  should  be  taken  in  themselves  as  rendering 
attempts  at  prevention  absolutely  hopeless.  Perfect 
rest  is  to  be  enjoined;  the  moderate  use  of  opium  by 
rectal  suppository  (one  grain  of  the  aqueous  extract), 
or  one-fourth  grain  of  morphine  hypodermaticallv, 
and  the  application  of  heat  to  the  spinal  column,  at  the 
junction  of  the  dorsal  with  the  lumbar  portions,  are  the 
most  trustworthy  measures.  Viburnum  prunifolium 
has  been  recommended  as  a  uterine  sedative.  It 
.should  be  given  in  doses  of  half  a  teaspoonful  of  the 
fluid  extract  every  three  hours.  To  mitigate  its  un- 
pleasant taste,  it  may  be  combined  with  an  equal 
amount  of  tincture  of  cinnamon. 

When  it  has  become  evident  that  abortion  must  take 
place,  the  safe  conduct  of  the  case  calls  for  close  super- 


vision. Ordinarily,  manual  interference  is  quite  un- 
necessary, beyond  what  may  be  needed  to  keep  the 
physician  informed  of  the  progress  made,  and  to  check 
hemorrhage.  The  utmost  pains  should  be  taken  to 
maintain  the  integrity  of  the  ovum  as  long  as  possible, 
for  when  it  is  expelled  entire  there  is  commonly  an  end 
to  all  anxiety.  Herein,  in  great  measure,  lies  the  safety 
of  accidental  abortions  as  compared  with  those  induced 
by  criminal  practices,  in  which  the  fetal  envelopes  are 
almost  always  punctured,  with  the  result  of  allowing 
the  embryo  to  be  cast  off  early  in  the  process  of  abortion, 
while  the  secundines  nana  in  behind,  a  shapeless  mass, 
upon  which  the  uterus  has  to  act  at  a  great  mechanical 
disadvantage.  So  long  as  rupture  of  the  membranes 
can  be  prevented,  our  interference  should  be  limited  to 
controlling  pain  and  hemorrhage;  an  aseptic  vaginal 
tampon,  properly  introduced,  may  always  be  relied 
upon  to  fulfil  the  latter  indication.  It  should  be  in- 
serted  mto  and  around  the  cervix  by  means  of  a  dressing 
forceps  with  the  aid  of  a  Sims  speculum,  and  generally 
it  should  be  removed  at  the  end  of  twelve  hours,  when 
a  fresh  one  may  be  applied,  if  necessary,  after  treating 
the  vagina  with  an  antiseptic  douche.  To  allay  ex- 
cessive  pain,  there  is  nothing  equal  to  opium,  but  it 
should  not  be  pushed  to  narcotism  or  to  such  an  extent 
as  to  abolish  uterine  action;  ergot  in  small  amounts  may 
properly  be  given  if  the  hemorrhage  is  excessive  and 
accompanied  by  inertia,  but.  the  more  its  use  is  avoided, 
the  better  will  be  the  results  on  the  wdiole.  It  is  better 
to  rely  on  the  tampon,  as  that  of  itself  stimulates 
uterine  contraction. 

If,  unfortunately,  the  sac  of  the  ovum  has  been 
emptied  of  its  contents,  and  the  secundines  are  re- 
tained, the  question  of  their  removal  will  come  up.  In 
such  a  case,  the  best  practice  seems  to  be  not  to  resort 
to  forcible  removal  of  the  remnants  of  the  ovum  unless 
there  are  particular  reasons  for  doing  so.  These 
reasons  are  for  the  most  part:  (1)  Signs  of  septic  changes; 
(2)  the  undue  continuance  of  hemorrhage.  Under 
either  of  these  circumstances  there  should  be  no  hesita- 
tion; but  the  operation  should  be  don,e  by  means  of  the 
finger  only,  without  instruments,  if  possible.  In  some 
cases,  however,  a  dull  curette  is  necessary.  The 
patient  should  be  anesthetized,  and,  as  she  lies  across 
the  bed  or  on  the  operating-table,  on  her  back,  with 
the  hips  brought  well  to  the  edge  of  the  bed,  the  opera- 
tor, who  has  rendered  the  parts  about  the  patient's 
pudenda  thoroughly  aseptic,  should  pass  one  or  more 
of  his  rubber-gloved  fingers  as  far  as  may  be  necessary 
into  the  uterine  cavity  and  tease  away  the  retained 
portions  of  the  ovum.  The  work  will  be  decidedly 
facilitated  if  the  uterus  is  gently  but  firmly  depressed 
by  an  assistant,  who  should  make  pressure  on  it  through 
the  abdominal  wall.  As  a  preliminary  step,  dilatation 
of  the  cervix  may  be  necessary.  If  the  fingers  will  not 
answer,  graduated  metallic  or  hard-rubber  dilators 
should  be  employed,  and,  when  they  are  used,  the 
operator  should  himself  make  the  countcrpressure  on 
the  fundus.  The  placental  forceps  may  now  be  used 
advantageously  in  detaching  the  fragments  of  em- 
bryonic tissue.  After  the  operation  is  finished,  the 
uterine  cavity  should  be  painted  with  tincture  of  iodine, 
and  the  patient  returned  to  bed. 

The  after-treatment  in  cases  of  abortion  consists 
chiefly  in  enforcing  rest  for  a  length  of  time  equal  to 
that  usually  adopted  after  labor  at  term.  The  special 
indications  do  not  differ  from  those  met  with  after 
ordinary  parturition,  except  that  the  breasts  are  not 
apt  to  give  trouble. 

Misskd  Abortion. — This  term  was  applied  by  the 
late  Prof.  J.  -Matthews  Duncan,  of  Edinburgh,  to  the 
long-continued  retention  of  the  dead  ovum  in  the  uterus, 
where  it  becomes  macerated  or  mummified,  and 
whence  it  is  finally  expelled.  I  have  had  such  a  case 
in  which  the  fetus  was  retained  for  fourteen  months, 
when  the  skeleton  merely  of  a  two  months  embryo  was 
spontaneously  discharged  during  the  third  month  of  a 
subsequent  pregnancy.       W.  A.  Newman  Dorland. 


44 


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Abortion,  Criminal 


Abortion,  Criminal. —  In  most,  perhaps  all,  of  the 
United  States  will  1"'  found  statutes  making  it  a  crime 
to  produce,  or  to  attempt  i'>  produce,  an  abortion  or 
i„i  carriage  of  a  woman  by  artificial  means.  In  a  few 
this  applies  only  to  attempts  in  the  cases  of  women 
actually  pregnant;  but  inasmuch  as  crime  consists  of  a 
combination  of  a  forbidden  aci  and  a  wilful  and  un- 
lawful intent,  it  is  both  reasonable  and  just  that  an 
attempt  to  produce  an  abortion  should  be  prohibited 
even  when  the  woman  is  not  actually  pregnant, 
although  she  and  tin-  perpetrator  think  she  is.  In 
many  of  the  statutes  will  be  found  saving  clauses 
freeing  from  criminal  liability  the  person  who  produces 
:i  miscarriage  by  artificial  means,  under  circumstances 
from  which  it  must  appear  that  the  fetus  is  dead  or  that 
it  is  necessary  to  save  the  mother.  It  is  suggested  as  a 
precautionary  measure  to  any  medical  practitioner  who 
contemplates  arresting  gestation,  in  order  to  avoid 
suspicion,  to  consult  some  other  member  of  the  pro- 
fession of  unquestioned  standing,  and  to  obtain  the 
consent  or  approbation  of  some  one  or  more  of  the 
relatives  of  the  woman. 

The  statute  of  Pennsylvania  is  a  good  example  of  the 
best  of  those  passed  in  this  country.     It  is  as  follows: 

1.  "If  any  person  shall  unlawfully  administer  to  any 
woman,  pregnant  or  quick  with  child,  or  supposed  and 
believed  to  be  pregnant  or  quick  with  child,  any  drug, 
poison,  or  any  substance  whatsoever,  or  shall  unlawfully 
use  any  instrument  or  other  means  whatsoever,  with 
the  intent  to  procure  the  miscarriage  of  such  woman, 
and  such  woman,  or  any  child  with  which  she  may  be 
quick,  shall  die  in  consequence  of  either  of  said  un- 
lawful acts,  the  person  so  offending  shall  be  guilty  of 
felony,  and  shall  be  sentenced  to  pay  a  fine,  not  ex- 
ceeding five  hundred  dollars,  and  to  undergo  an  im- 
prisonment by  separate  or  solitary  confinement  at 
labor,  not  exceeding  seven  years." 

J.  "  If  any  person,  with  intent  to  procure  the  mis- 
carriage of  a  woman,  shall  unlawfully  administer  to  her 
any  poison,  drug,  or  substance  whatsoever,  or  shall 
unlawfully  use  any  instrument  or  other  means  whatso- 
ever, with  the  like  intent,  such  person  shall  be  guilty 
of  felony,  and  being  thereof  convicted,  shall  be  sentenced 
to  pay  a  fine,  not  exceeding  five  hundred  dollars,  and 
undergo  an  imprisonment  by  separate  or  solitary  con- 
finement at  labor,  not  exceeding  three  years." 

As  a  practical  matter,  it  is  but  rarely  that  the  prose- 
cuting power  has  the  opportunity  of  invoking  this  law 
against  a  violator  of  it,  for  the  reason  that  in  all  cases  of 
criminal  abortion  the  operation  is  performed,  or  the 
drug  is  administered,  at  the  request,  or  it  may  be  the 
earnest  solicitation,  of  the  woman  herself,  who  for  this 
reason  is  as  cautious  to  avoid  detection  as  is  the  perpe- 
trator of  the  crime.  It  will  be  found  that  almost  all  of 
the  cases  of  criminal  abortion  which  have  proceeded  as 
far  as  indictment  and  trial,  are  those  in  which  the 
patient  has  died  from  the  effects  of  the  operation  or  the 
administration  of  the  drug.  Even  in  these  cases  it 
has  been  a  rare  experience  to  obtain  a  conviction 
because  of  the  secrecy  with  which  this  crime  is  com- 
mitted, resulting  usually  in  the  absence  of  evidence  of 
those  facts  which  can  be  used  against  the  culprit. 
Persons  who  commit  offences  deliberately  always  avoid 
or  destroy  those  circumstances  which  are  incriminating, 
so  far  as  is  possible. 

Irrespective  of  the  above-mentioned  statutes,  both  in 
England  and  in  this  country  one  who  administers  to  a 
pregnant  woman  a  drug,  or  employs  upon  her  an  instru- 
ment for  the  purpose  of  procuring  a  miscarriage,  in 
consequence  of  which  she  dies,  or  the  child  dies  after 
birth,  by  reason  of  being  prematurely  delivered,  is  guilty 
of  murder.  The  culprit  will  be  indicted  for  murder  or 
manslaughter,  first  because  any  inferior  grade  of  crime 
of  which  he  may  be  guilty  will  be  merged  in  the  felo- 
nious homicide,  which  in  the  eyes  of  the  law  is  con- 
sidered the  gravest  of  all  offences;  and  secondly,  it 
may  be  that  a  dying  deposition  has  been  obtained  from 
the  patient. 


It  lias  been  held  that  if  there  be  no  intent  to  kill,  or  to 
inllict  grievous  bodily  harm,  and  the  means  employed 
lie  not  dangerou  .  although  used  for  an  unlawful  pur- 
pose, the  crime,  when  death  ensues,  may  be  man- 
slaughter, which  is  an  inferior  grade  of  homicide;  other- 
wise   the   crime    will    be   murder,    and    may    render    the 

accused,  if  convicted,  liable  to  the  death  penalty.     It  is 

sugge  led.  howevi  r,  thai  any  known  mean-,  when  used 
for  this  purpose,  will  be  dangerous  anil  should  li.  0 
considered.  This  question  is  really  dependent  upon  the 
judgment  of  the  criminal  prosecutor,  for  it  is  always 
compel,  nt  for  him,  unless  he  is  restricted  by  some 
statutory  provision,  to  elect  to  have  the  prisoner  in- 
dicted for  tin'  inferior  grade  of  the  offence,  and  abandon, 
on  behalf  of  the  state,  the  superior  grade. 

When  a  reputable  physician  takes  charge  of  a  patient 
upon  whom  he  discovers  an  abortion  has  been  per- 
formed, and  who  subsequently  dies,  he  is  bound  by  law 
to  certify  the  cause  of  death  to  the  Health  Department. 
In  this  it  may  be  necessary  for  him  to  disclose  the  fact 
of  the  perpetration  of  a  crime:  but  is  it  his  duty  to  in- 
form the  police  authorities  as  soon  as  he  has  discovered 
the  (rime?  This  is  an  ethical  question  which  need  not 
be  discussed  here— it  is  a  proposition  which  each  physi- 
cian should  consider  for  himself.  Auxiliary  to  it  is  this 
question:  Should  he,  when  the  opportunity  arises, 
obtain  from  the  patient  a  statement  which  could  be 
used  as  a  dying  deposition  in  a  criminal  prosecution 
against  the  abortionist? 

Dying  Depositions. — For  the  benefit  of  the  physician 
who' is  willing  to  aid  the  State  in  detecting  the  perpe- 
trator of  this  nefarious  crime,  it  may  be  stated  that  if 
the  patient  dies  and  the  perpetrator  of  the  abortion  is 
charged  with  either  murder  or  manslaughter,  it  will  be 
admissible  to  offer  in  evidence  the  dying  declaration 
of  the  patient,  if  she  made  one.  Statements  made 
under  such  circumstances  are  entitled  to  great  weight. 
It  hasbeen  wiselv  said  by  an  eminent  English  jurist,  Lord 
Chief  Justice  Baron  Eyre,  that  "such  declarations  are 
made  in  extremity,  when  the  party  is  at  the  point  of 
death,  and  when  every  hope  of  this  world  is  gone;  when 
every  motive  to  falsehood  is  silenced,  and  the  mind  is 
induced  by  the  most  powerful  considerations  to  speak 
the  truth;  a  situation  so  solemn  and  so  awful  is  con- 
sidered by  the  law  as  creating  an  obligation  equal  to 
that  which  is  imposed  by  a  positive  oath  in  a  court  of 
justice."  Such  declarations  are  admissible  in  evidence 
only  in  those  cases  in  which  the  indictment  charges  the 
culprit  with  the  murder  or  manslaughter  of  the  deceased, 
and  not  in  those  in  which  the  gravamen  of  the  charge  is 
a  violation  of  one  of  the  above-mentioned  abortion 
statutes.  The  declaration  should  also  be  confined  to  a 
statement  of  the  circumstances  of  the  death,  i.e.  the 
person  who  performed  the  operation,  the  method,  time, 
and  place  of  performance,  and  such  other  facts  as  are 
germane  to  these. 

To  render  such  a  declaration  admissible  in  evidence,  it 
is  requisite  that  the  declarant  should  be  in  actual 
danger  of  death  at  the  time  it  is  made,  that  she  should 
fully  realize  her  impending  danger,  and  that  death 
should  actually  ensue.  It  is  not  necessary  that  the 
declarant  should  state  that  she  realizes  that  her  speedy 
demise  is  impending;  it  is  sufficient  if  it  satisfactorily 
appears  from  any  other  circumstances,  such  as  taking 
leave  of  her  relatives,  or  receiving  extreme  unction  and 
the  like.  If,  however,  she  has  any  hope  of  recovers',  no 
matter  how  slight,  such  testimony  will  be  inadmissible, 
though  death  might  speedily  ensue.  Such  a  declaration 
was  rejected  where  the  dying  person  stated:  "I  have  no 
hope  of  recovery,  unless  it  be  the  will  of  God";  it  being 
held  by  the  court  that  such  statement  indicated  that  all 
hope  had  not  been  abandoned.  It  need  not  be  under 
oath,  as  the  solemnity  of  the  occasion  is  held  to  be 
equivalent  to  the  sanctity  of  an  oath.  It  may  be  taken 
orally,  but  if  reduced  to  writing,  it  should  be  carefully 
preserved  and  produced  at  the  proper  time.  It  should 
be  confined  to  a  statement  of  facts,  no  theories  or 
opinions. 

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Abortion,  Criminal 


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Criminality  of  the  Act. — So  far  as  the  culpability  of 
the  act  is  concerned,  it  is  immaterial  whether  or  not 
quickening  has  occurred,  and  whether  or  not  the  fetus 
in  utero  is  dead,  unless  there  is  a  saving  clause  in  the 
abortion  statute  as  above  stated.  The  criminality  is 
just  as  great  on  the  day  of  conception  as  at  any  other 
period  of  gestation.  Nor  is  it  a  defence  or  excuse  to  the 
criminal  charge  that  the  mother  consented  to,  or 
solicited  the  performance  of,  the  abortion.  It  has  been 
decided  by  some  courts  that  a  woman  who  consents  to 
the  performance  of  an  abortion  is  an  accomplice,  by 
others  that  she  is  not,  but  this  is  a  purely  legal  question. 
The  rule  of  law  generally  adhered  to  is,  that  where  a 
witness  is  held  to  be  an  accomplice  there  should  be 
some  corroboration  of  her  testimony  in  order  to  justify 
a  conviction  of  the  accused. 

Questions  in  Cases  of  Feticide. — In  every  case  of 
feticide  the  important  questions  for  consideration  are: 

1.  Has  the  fetus  in  utcro  been  destroyed? 

2.  Has  this  been  produced  by  natural  or  artificial 
causes? 

3.  If  by  artificial  means,  was  the  act  justifiable  or 
criminal? 

In  considering  the  first  question  an  examination 
should  be  made  of  the  clots  and  other  substances  ex- 
pelled from  the  genital  organs,  for  the  purpose  of  as- 
certaining if  they  contain  any  of  the  products  of  con- 
ception. If  the  fetus  be  found  it  will  be  necessary  to 
determine,  if  possible,  if  it  was  born  alive;  if  so,  its 
probable  age  and  the  cause  of  its  death.  A  careful 
scrutiny  of  it  may  disclose  punctures,  wounds,  or  in- 
juries which  indicate  the  unlawful  use  of  an  instrument. 

If  the  fetus  is  not  found  the  expelled  substances 
should  be  examined  under  water,  as  an  ovum,  if  one  is 
present,  is  more  easily  discovered  in  this  way.  Nor 
ought  the  investigator  trust  to  the  naked  eye,  as  much 
may  be  lost  without  the  use  of  a  microscope.  When  the 
criminal  operation  is  performed  in  the  early  stages  of 
pregnancy,  the  ovum  is  frequently  expelled  intact;  after 
the  formation  of  the  placenta,  the  extrusion  of  the 
ovum  usually  precedes  that  of  the  placenta,  the  time 
intervening  being  variable,  ranging  from  hours  to  weeks 
or  months. 

Did  the  abortion  result  from  natural  or  artificial  causes? 
— Both  criminal  and  spontaneous  abortion  occur 
generally  about  the  end  of  the  third  month.  The 
symptoms  discovered  will  vary  with  the  period  of 
ge<tation  and  with  the  time  since  the  performanceof  the 
operation  at  which  the  examination  is  made.  When 
the  operation  is  performed  in  the  early  stages  of  gesta- 
tion, the  appearances  are  not  different  from  those  in 
cases  of  tumors  and  some  other  troubles  The  nearer 
the  period  is  to  full  term,  the  greater  will  be  the  lacera- 
tion of  the  uterus  and  vagina. 

If  death  has  resulted,  a  postmortem  examination  will 
usually  determine  this  question  with  certaint_y.  An 
examination  of  the  woman  while  living  will  probably 
be  uncertain  in  its  results,  unless  the  evidence  of  in- 
strumental interference  is  palpable  or  the  woman  is 
frank  in  her  statement  of  the  case.  Finally,  when 
drugs  are  used  as  abortifacients  even  the  postmortem 
may  baffle  the  investigator.  The  most  popular  means 
of  attempting  criminal  abortion  is  by  aid  of  some 
instrument,  for  the  reason  that  unless  there  is  a  strong 
predisposition  on  the  part  of  the  woman  to  abort, 
the  result  can  rarely  be  accomplished  by  means  of 
drugs. 

In  every  case  these  methods  will  be  accompanied 
with  danger  to  the  mother,  and  not  infrequently  they 
result  in  the  mother's  death  without  effecting  a  dis- 
charge of  the  fetus. 

The  production  of  abortion  being  both  immoral  and 
criminal,  except  when  the  exigencies  of  the  case  require 
it  as  before  mentioned,  the  practice  in  prohibited  cases 
is  confined  to  medical  men  of  low  professional  standing, 
midwives,  and  other  unskilful  persons.  It  is  this,  no 
doubt,  which  makes  the  operation  unusually  dangerous. 
Were  this  branch  of  practice  reputable,  it  would  be  con- 


ducted by  a  competent  physician,  according  to  the 
principles  of  modern  surgery  and  would- result  fatally 
in  a  much  smaller  number  of  cases.  Just  what  per- 
centage of  these  cases  result  fatally  it  is  difficult  to 
ascertain  because  of  the  clandestine  method  of  treating 
them. 

It  has  been  noticed,  even  in  cases  of  natural  abortion, 
that  as  the  process  of  gestation  approaches  its  full  term 
the  muscles  of  the  uterus  grow  stronger  and  are  able  to 
fulfil  their  function  by  contracting  not  only  upon  the 
contents  of  the  womb  before  delivery,  but  also  upon  the 
bleeding  vessels  afterward.  In  cases  of  abortion  in  early 
stages  of  pregnancy  there  is  greater  danger  of  hemor- 
rhage and  of  septic  diseases  such  as  pyemia  and  puer- 
peral peritonitis,  because  these  muscles  respond  slowly 
and  thus  leave  the  uterine  canal  open  to  the  intro- 
duction of  germs  and  other  foreign  matter. 

When  consulted  in  a  suspicious  case,  the  physician 
should  examine  the  vagina  and  uterus  for  marks  of  in- 
jury, wounds,  perforations.  He  should  notice  if  there 
are  indications  of  irritants  in  the  stomach  and  intestines, 
or  inflammation  in  the  bladder  or  kidneys  resulting 
from  the  use  of  emmenagogues.  He  should  note  what 
drugs  or  instruments  are  in  her  possession  and  if  there 
are  any  marks  of  violence  upon  her  body,  for  abortion 
is  sometimes  attempted  by  the  woman  "herself  by  this 
means. 

Witthaus  and  Becker,  in  their  work  on  medical  juris- 
prudence, quote  from  Tidy's  work  on  the  same  subject 
the  following  table  suggesting  a  line  of  inquiry  for  the 
medical  practitioner  in  cases  of  suspected  criminal 
abortion: 

I.  Examination  of  the  Mother,  if  Living. 

1.  Temperature. 

2.  As  to  the  woman's  predisposition  to  abort  and  the 
period  at  which  abortion  has  commonly  occurred. 

3.  General  state  of  health.  (Note  existence  of 
Ieucorrhea,  excessive  menstruation,  syphilis,  asthma, 
malignant  diseases,  uterine  diseases,  etc.) 

4.  Whether  the  woman  be  well  or  ill  formed.  (Note 
pelvic  malformations,  effects  of  tight  lacing,  etc.) 

5.  Whether  or  not  there  be  signs  of  recent  delivery  or 
of  the  expulsion  of  the  uterine  contents. 

0.  Whether  any  cause  can  be  assigned  to  account  for 
the  abortion  (e.g.  violent  coughing,  blood-letting,  strain- 
ing at  stool,  violent  exercise,  undue  excitement,  septic 
poisoning,  violence,  administration  of  medicines,  etc.). 

7.  All  injuries  of  the  genital  organs  (consider  whether 
the  injuries  might  be  self-inflicted.) 

II.  Examination  of  the  Body  of  the  Mother,  if  Dead. 
Note — (a)  The  necessity  for  care  not  to  mistake  the 

effects  of  menstruation  for  those  produced  by  abortion. 
(b)  To  avoid  injuring  the  parts  by  the  knife  or  other- 
wise during  the  autopsy,  (c)  To  consider  the  possi- 
bility of  injuries  being  self-inflicted. 

1.  Note  the  existence  of  marks  of  violence  on  the 
abdomen  or  other  parts. 

2.  The  condition  of  the  genital  organs,  noting  all  in- 
flammations, rents,  tears,  perforations,  etc.  (if  the 
uterus  be  injured  it  should  be  preserved). 

Note  also — (a)  The  condition  of  the  passage  (relaxed 
or  otherwise).  (6)  The  condition  of  the  c.^  uteri  i  vir- 
ginal or  gaping,  etc.).  (c)  Vaginal  secretions,  and  if 
present  their  character.  ('/)  The  general  appearance 
of  the  breasts,  presence  of  milk,  etc. 

3.  Whether  there  be  any  signs  of  irritant  poisoning 
in  rectum,  etc.  (contents  of  stomach  to  be  preserved, 
if  necessary). 

4.  Whether  the  viscera  generally  indicate  loss  of 
blood  during  life. 

III.  Examination  of  the  Product  of  Conception. 

1.  Nature  of  the  supposed  product  of  conception. 

2.  Consider  whether  there  is  evidence  of  a  diseased 
condition  of  the  membranes  or  placenta,  e.g.  structural 
degeneration. 

3.  If  a  fetus  be  found,  determine  (a)  whether  it  was 
born  alive;  (6)  its  probable  age;  and  (c)  the  cause  of  its 
death. 


46 


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Abrus  Precatorlufl 


1.   Determine  whether,  if  there  be  wounds  or  other 
injuries,  they  were  inflicted  during  life  or  after  death. 
'IV.  Examination  of  All  Drugs,  Instruments,  etc. 

Hexky  Duffy. 

Abortion,  Therapeutic. — The  interruption  (if  preg- 
nancy before  the  period  at  which  the  child  is  viable; 
thai  is,  during  the  first  two  trimesters.  It  is  an  opera- 
tion performed  solely  in  the  interests  of  the  mother 
and  should  be  undertaken  as  reluctantly  as  justifiable 
homicide.  The  indications  are:  pernicious  vomiting, 
pulmonary  and  cardiac  disease,  nephritis,  chorea,  acute 

mania,  melancholia,  and  pernicious  anemia.  Preg- 
nancy may  have  a  very  deleterious  effect  upon  each 
of  the  above  disorders,  and  in  allowing  gestation  to  con- 
tinue, the  physician  may  sacrifice  the  lives  of  both 
mother  and  child;  the  induction  of  abortion  should  be 
regarded  only  as  the  last  resort  and  never  be  under- 
i  without  consultation.  Among  the  local  con- 
ditions which  may  call  for  the  termination  of  the  preg- 
nancy must  be  mentioned  incarceration  of  the  retro- 
flexed  uterus,  hemorrhage  from  the  normally  or  ab- 
normally situated  placenta,  and  excessive  contraction 
of  the  pelvic  canal.  In  this  last  condition  the  choice 
lies  between  abortion  and  cesarean  section;  the  claims 
of  each  operation  should  be  presented  to  the  mother. 

Methods  of  Inducing  Artificial  Abortion. — The  uncer- 
tain methods  of  drugs  and  electricity  are  to  be  con- 
demned. The  induction  of  artificial  abortion  should  be 
made  a  surgical  operation,  and,  if  possible,  completed  at 
one  sitting.  There  is  but  little  danger  if  the  procedure 
has  not  been  delayed  until  the  patient's  strength  is  ex- 
hausted and  if  careful  asepsis  is  observed  throughout. 
The  instruments  required  are:  rubber  pad,  leg-holders, 
weighted  speculum,  volsella  forceps,  steel-branched 
dilators,  a  large  intrauterine  curette,  placental  forceps, 
intrauterine  irrigating  tube,  and  fountain  syringe.  The 
patient,  having  been  anesthetized,  is  placed  in  the 
dorsal  position  with  knees  well  drawn  up  and  secured 
with  the  leg-holders;  the  parts  about  the  vulva  are 
shaved  and  cleansed,  the  vagina  is  scrubbed  with  soap 
and  irrigated  with  warm  sterilized  water.  By  means  of 
the  speculum  and  volsella  the  cervix  is  exposed  and 
secured;  with  the  dilators  the  cervix  is  gradually 
stretched  up  to  one  or  one  and  a  half  inches.  Owing  to 
the  softening  the  tissues  usually  yield  readily,  but  this 
part  of  the  operation  must  be  conducted  without  haste. 
The  finger  is  the  best  instrument  for  removing  the 
contents  of  the  uterus,  and  in  the  first  two  or  three 
months  of  pregnancy  there  is  but  little  trouble  in  reach- 
ing the  fundus,  especially  if  counterpressure  be  made 
upon  the  abdomen  with  the  other  hand  so  as  to  crowd 
the  womb  down  upon  the  internal  finger.  After  the 
attachments  of  the  ovum  have  been  freed  the  mem- 
branes are  drawn  out  over  the  hooked  finger.  In  case  of 
difficulty  the  curette  may  be  used  to  loosen  the  tissue 
and  the  pieces  may  be  removed  with  the  forceps,  but  the 
finger  is  the  guide  for  all  intrauterine  manipulation, 
and  touch  alone  will  determine  when  the  operation  is 
completed.  Finally,  an  intrauterine  irrigation  of  hot 
sterile  salt  solution  will  remove  clots  and  act  as  an  effi- 
cient stimulant  to  the  uterine  muscle.  Chemicals 
should  not  be  injected  into  the  uterus;  when  strong 
enough  to  affect  bacteria  they  become  poisonous  to  the 
woman.  Some  operators  advise  the  introduction  of  a 
gauze  drain,  but  this  should  be  unnecessary.  In  some 
cases  the  cervix  may  be  rigid  or  the  pregnancy  too 
advanced  for  the  operation  to  be  readily  completed  at 
one  time.  Under  these  circumstances  the  cervix  may 
be  partially  dilated  with  the  steel  dilators  and  then  the 
lower  uterine  segment  and  cervix  firmly  packed  with 
gauze  supported  by  a  vaginal  tampon  of  sterile  gauze. 
Such  treatment  controls  hemorrhage  and  stimulates 
the  uterus  so  that  at  the  end  of  twelve  hours  the  packing 
can  be  removed,  when  the  cervix  is  found  softened  and 
contractions  are  established.  If  there  is  no  haste  the 
case  may  be  allowed  to  progress  naturally  or  the  opera- 
tion can  be  completed,  but  in  all  cases  the  finger  must 


be  used  before  deciding  thai  the  uterus  is  empty. 
During  the  performance  of  artificial  abortion  there  may 
be  profuse  hemorrhage  which  usually  ceases  as  soon 
as  the  utcnis  is  emptied  and  stimulated  with  the  hot 
saline  solution.  Cf  oozing  continues  the  hypodermic 
administration  of  ergot  and  even  the  introduction  of 
the  intrauterine  tampon  of  gauze  are  indicated.  In 
bad  cases  of  retrolleved  uterus  it  may  be  impossible  to 
reach  the  cervix;  in  >uch  cases  the  fundus  should  not 

be  tapped  through  the  vagina,  as  some  I I     recom- 

ud.  bul  the  proper  treatment  i    abdominal  section 

and  manual  reposition  of  the  uterus. 

Montgomery  A.  Crockett. 
W.  A.  Newman  Dorland. 

Abrus  Prccatorius. — Jequirity,  T.m-r  Pea,  Prayer 
Beads,  Jumble  Beads,  Crabs  Eyes.  Abrus  L.  (fam. 
Leguminosce)  is  a  genus  of  six  species,  related  to  the 
lentil  and  the  pea,  known  to  medicine  by  the  species 
.1.  precatorius  L.,  which  is  indigenous  in  British 
India  and  very  widely  distributed  in  the  tropics 
of  both  hemispheres.  The  plant  prefers  a  light  or 
sandy  soil,  and  its  slender,  woody  stems  climb  high 
over  shrubbery  in  the  edges  of  forests.  The  fruit 
resembles  a  miniature  pea-pod,  a  little  more  than  an 
inch  in  length,  and  contains  from  four  to  six  seeds. 
The  roots  have  been  employed  as  a  substitute  for  lic- 
orice under  the  name  of  wild  or  Indian  licorice.  The 
leaves  possess  the  same  property,  containing  con- 
siderable glycyrrhizin.  The  seeds  are  better  known 
than  the  root,  under  the  name  Jequirity.  They  are  a 
quarter  of  an  inch  in  length,  elongated-globose,  smooth, 
shining,  bright  scarlet,  a  black  spot  surrounding  the 
hilum.  A  black  form,  with  white  spot,  and  a  white 
form  with  black  spot,  occasionally  occur.  They  are 
largely  employed  for  rosaries,  ornamental  beads, 
children's  toys,  and  in  India,  under  the  name  of  retti, 
(■  ir  weighing.  They  have  also  been  used  in  India  for 
criminal  poisoning,  usually  of  cattle.  For  this  purpose 
the  seeds  are  crushed  and  worked  into  a  paste  with 
water.  This  paste  is  rolled  into  a  needle-pointed 
form,  mounted  upon  a.stick  and  used  to  prick  the  skin 
of  the  fated  animal,  which  quickly  succumbs  to  heart 
failure. 

In  South  America  originated  the  practice  of  painting 
a  watery  infusion  upon  granulated  eyelids,  by  which 
suppuration  was  induced  and  the  granulations  were  re- 
moved. 

The  active  agent  was  at  first  supposed  to  be  the  bac- 
teria which  appear  after  a  time  in  the  infusion.  Later, 
this  theory  was  disproved,  and  the  properties  were  re- 
ported to  reside  in  an  albuminous  substance  called  abrin. 
This  was  later  found,  by  Drs.  Sidney  Martin  and  R. 
Xorris  Wolfenden,  to  be  a  mixture,  and  was  by  them 
separated  into  two  albuminous  bodies,  a  globulin  one- 
fifth  as  poisonous  as  the  venom  of  the  common  adder 
and  an  albumose  one-sixth  as  strong  as  the  globulin. 
These  poisons  are  destroyed  by  heat.  Their  effect  re- 
sembles that  of  snake  venom,  the  temperature  falling 
greatly  and  the  blood  remaining  semi-fluid  after  death. 
It  is  by  no  means  certain,  however,  that  this  resem- 
blance is  not  superficial. 

Jequirity  acts  as  a  powerful  irritant  to  mucous  mem- 
branes. If  taken  internally,  uncooked  and  concen- 
trated, it  produces  vomiting  and  purgation,  the  feces 
being  often  bloody.  Forty  seeds  produced  these 
symptoms,  with  partial  collapse,  but  recovery  followed. 
If  it  is  applied  to  the  eyelids,  inflammation  quickly 
ensues,  with  suppuration  usually  on  the  third  day. 
The  inflammation  is  characterized  by  great  swelling 
and  pain.  If  the  applications  are  continued,  there  is 
great  systemic  disturbance  also.  The  applications 
have  been  continued  by  most  practitioners  for 'from 
<hree  to  ten  days.  Upon  their  discontinuance,  the 
symptoms  usually  subside  quickly  and  then  disappear, 
with  the  removal,  or  great  reduction,  of  any  pre- 
viously existing  pannus.  The  effect  upon  conjunctival 
granules  is  not  so  great.     In  unfavorable  cases,  ulcera- 

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tion  of  the  cornea  and  sometimes  loss  of  the  eye  have 
resulted,  and  in  severe  cases  the  inflammation  has 
extended  over  the  entire  face  and  even  to  the  salivary 
glands.  Must  of  such  accidents  have  resulted  from  the 
use  of  too  concentrated  or  bad  preparations,  or  from 
careless  treatment.  Nevertheless,  the  remedy  has 
come  to  be  regarded  as  an  heroic  one,  and  is  now  not 
frequently  employed.  Either  an  infusion  or  a  powder 
may  be  employed,  the  strength  ranging  from  three  to 
six  per  cent.,  and  it  should  be  freshly  made.  The 
powder  should  be  dusted  upon  the  inner  surface  of 
the  lids,  or  the  infusion  applied  with  a  camel's-hair 
brush,  or  even  dropped  into  the  eye. 

Henky  H.  Rusby. 

Abscess. — (Latin,  absccssus,  from  the  verb  abscedo,  I 
depart;  abscedo  and  absccssus,  used  by  Celsus  in  the 
sense  of  the  gathering  of  the  corrupted  fluids  of  the.  body 
into  an  abscess.  Greek,  isiUsxjma.  French,  abe'es. 
German,  Eiterbeule,  though  the  Germans  more  com- 
monly use  the  word  abscess.)  By  the  term  abscess  is 
meant  a  collection  of  pus  within  the  body,  the  result  of 
liquefied  inflammatory  products.  This  may  occur  in 
one  of  the  preformed  spaces,  or  in  a  newly  formed 
cavity  in  solid  parts.  Certain  adjective  prefixes  are 
used  to  denote  duration,  character,  and  situation  of 
abscesses.  Thus,  as  regards  duration,  they  may  be 
acute,  subacute,  or  chronic.  As  regards  character,  the 
various  terms  used  will  be  mentioned  later.  As  regards 
situation,  some  of  the  following  are  the  most  frequent 
designations:  alveolar  (abscess  in  alveolus  of  tooth), 
axillary,  bursal,  cerebral,  hepatic,  ischiorectal,  mam- 
mary, mastoid,  ovarian,  pelvic,  perinephritic,  peri- 
typhlitic,  prostatic,  pulmonary,  retromammary,  retro- 
pharyngeal, splenic,  subdiaphragmatic,  subcutaneous, 
etc.  Abscesses  more  or  less  free  in  pre-existing  cav- 
ities usually  bear  special  names:  a  collection  of  pus 
in  the  pleural  cavity  is  generally  designated  as  empy- 
ema, and  this  term  is  also  applied  to  collections  of  pus 
in  the  gall  bladder,  the  frontal  sinuses,  and  other 
accessory  nasal  cavities  (empyema  of  the  gall  bladder, 
etc.).  Pyosalpinx  means  pus  in  the  Fallopian  tube; 
pyonephrosis,  accumulation  of  pus  in  the  pelvis  of  the 
kidney;  hypopyon,  pus  in  the  anterior  chamber  of  the 
eye.  In  other  serous  cavities  one  speaks  simply  of  a 
purulent  or  suppurative  pericarditis,  peritonitis,  epen- 
dymitis,  meningitis,  synovitis,  or  arthritis,  etc.,  as  the 
case  may  be.  Pelvic  abscess  means  a  collection  of 
pus  in  the  pelvis,  due  to  a  circumscribed  peritonitis,  the 
remainder  of  the  peritoneal  cavity  being  shut  off  by 
adhesions.  Whitlows,  felons,  boils,  carbuncles,  and 
furuncles  are  names  of  special  varieties  of  suppurative 
inflammation  which  greatly  resemble  abscesses,  and 
information  concerning  them  will  be  found  under  the 
appropriate  heads. 

i :,\  us,  s  of  A bscess. — Abscesses  are  the  result  of  a  kind 
of  inflammation  known  as  suppurative  or  purulent. 
Clinically,  this  form  of  inflammation  is  almost  without 
exception  the  result  of  infection  with  microorganisms  of 
various  kinds  which  lead  to  accumulation  of  leucocytes 
and  necrosis  and  liquefaction  of  cells  and  other  ele- 
ments. Experimentally,  it  is  quite  possible  to  produce 
suppuration  by  the  introduction  of  various  chemical 
and  other  substances,  which  directly  or  indirectly  exer- 
cise positive  chemotaxis  upon  the  hemal  and  other 
mobile  or  mobilizable  cells  of  the  body,  and  cause 
necrosis  of  cells.  Councilman,  Uskoff,  Grawitz,  Orth- 
mann,  and  others  have  by  their  experiments  shown 
that  this  so-called  chemical  suppuration  does  take 
place;  mercury,  croton  oil,  turpentine,  nitrate  of  silver, 
chloride  of  zinc,  etc.,  are  some  of  the  substances  used  in 
the  experiments,  in  which  the  action  of  bacteria,  intro- 
duced accidentally  or  latent  in  the  tissues,  has  been 
carefully  excluded.  Wyssokowitch  and  then  Buchner 
studied  the  effects  of  the  injection  of  dead  cultures 
of  divers  organisms;  Buchner  experimented  with  the 
bacterioproteins  of  numerous  species  of  bacteria,  and 
showed   to  general  satisfaction  that  pus  may  be  pro- 


duced by  protein  substances  in  the  bodies  of  the 
bacteria.  Animal  and  vegetable  proteins  also  have 
pyogenetic  properties. 

In  most  cases  abscess  is  the  result  of  the  presence  in 
the  tissues  of  some  one  or  more  of  the  common  pyo- 
genetic bacteria,  first  discovered  by  Ogston  in  1881, 
subsequently  isolated  by  Rosenbach  in  1884,  and 
completely  described  by  Passet  in  1SS5,  namely, 
Staphylococcus  aureus,  albus,  and  citrcus,  and  Strepto- 
coccus pyogenes.  Janowski  tabulates  827  cases  of 
abscess  and  suppuration  in  the  subcutaneous  tissue 
(the  most  frequent  seat  of  suppuration),  and  in  605 
the  staphylococci  occurred  alone,  in  154  the  strepto- 
cocci, and  in  OS  staphylococci  and  streptococci  were 
associated.  These  organisms  have  also  been  found  to 
produce  pus  in  man  under  experimental  conditions. 
But  abscess  frequently  follows  the  invasion  of  the 
tissues  by  organisms  that  are  not  constantly  or  gen- 
erally pyogenetic;  the  number  of  organisms  that  are 
facultatively  pyogenetic  is  quite  considerable.  The 
pneumococcus,  which  is  the  most  frequent  pus-producer 
after  the  common  pus  cocci,  may  cause  abscesses  in  the 
soft  parts,  suppurative  otitis  media,  suppurative  osteo- 
myelitis, synovitis,  peritonitis,  etc.  Bacillus  mucosus 
has  been  repeatedly  isolated  from  cases  of  suppuration 
in  the  tympanic  cavity,  the  antrum,  and  other  accessory 
nasal  cavities.  Bacillus  coli  is  frequently  found  in 
suppurative  cholangitis,  abscess  of  the  liver,  peritonitis, 
etc.,  and  is  pyogenic  in  animals.  Bacillus  typhosus, 
which  has  the  power  of  remaining  latent  in  the  tissues, 
especially  the  bone  marrow  and  the  gall  bladder,  long 
after  the  primary  attack  of  typhoid  fever,  is  now  and 
again  found  as  the  probable  cause  of  abscesses  in  bones 
(typhoid  osteomyelitis),  suppurative  cholecystitis, 
empyema,  abscesses  of  the  soft  parts,  etc.  The  typhoid 
bacillus  produces  pus  in  animals.  Bacillus  influenzal 
may  also  induce  purulent  inflammation. 

Among  other  bacteria  capable  of  producing  pus  may 
be  mentioned  Proteus  zenkeri,  bacillus  of  swine  plague, 
bacillus  of  chicken  cholera,  Micrococcus  tetragenus, 
Micrococcus  intraccllularis,  Bacillus  pyocyaneus,  Bacil- 
lus prodigiosus,  etc. 

Bacillus  pyocyaneus,  the  organism  of  blue  pus,  is  not 
merely  a  chromogenic  saprophyte;  for  it  has  been 
isolated  as  the  only  cause  of  otitis  media,  suppurative 
pericarditis,  hepatic  and  ovarian  abscesses,  ascending 
urinary  suppurations,  etc.  In  two  hundred  cases  of 
suppuration,  Janowski  found  this  bacillus  only  twice. 

Staphylococcus  epidermidis  (Welch)  is  the  most 
common  organism  on  the  surface  of  the  body,  being 
often  situated  deeper  than  can  be  reached  by  any  of 
the  present  methods  of  cutaneous  disinfection;  it  is 
closely  related  to  Staphylococcus  albus,  being  according 
to  Welch  an  attenuated  form  of  this  organism,  and  is 
probably  the  most  general  cause  of  "stitch-abscess." 

The  action  of  the  gonococcus  may  be  distinctively 
pyogenetic. 

Micrococcus  pyogenes  tenuis,  which  is  usually  men- 
tioned as  a  pus  coccus,  has  been  isolated  only  nine  times; 
in  six  instances  it  was  found  alone,  in  three  associated 
with  other  organisms.  The  identity  of  this  microbe  is 
not  fully  established,  and  the  question  has  been  raised 
as  to  the  probability  that  the  pneumococcus  is  an 
organism  mistaken  for  it. 

Bacillus  pyogenes  fa-tidus  is  a  rare  pus-producing 
organism  the  relation  of  which  to  the  colon  group  has 
not  been  settled. 

In  addition  to  being  caused  by  bacteria,  abscesses 
may  be  produced  by  divers  fungi,  such  as  the  ray  fungi 
(see  Actinomycosis),  in  which  case  the  pus  may  contain 
characteristic  fungous  clusters  or  granules;  Oidium 
albicans  and  various  forms  of  Blastomycetes  are  also 
pus-producers;  Trichophyton  tonsurans  may  cause 
cutaneous  and  subcutaneous  abscesses  (Sabouraud). 
Recently  certain  peculiar,  refractory,  subcutaneous 
abscesses  have  been  shown  to  depend  upon  the  presence 
of  a  fungus  belonging  to  the  sporotricha  and  called 
Sporothrix  schenckii. 


48 


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ibsci'ss 


A  form  of  abscess  which  is  observed  in  hot  climates 
and  occasionally  in  other  regions,  and  which  occurs  in 
the  liver,  has  received  the  name  of  tropical  or  amebic 
abscess  of  the  liver;  it  is  caused  by  the  transfer  of 
organisms  from  the  large  intestine  to  the  liver,  through 
the  portal  vein,  in  amebic  dysentery.  Tins  would 
seem,  therefore,  to  be  an  example  of  suppuration 
with  abscess  formation  due  to  an  animal  organism, 
the  anieba  coli,  but  the  exact  relation  of  this  parasite 
to  the  abscess  has  not  yet  been  established;  it  may  be 
that  other  microbes  play  an  essential  part,  the  presence 

of  the  anieba   being  largely  secondary  or  accidental. 

A  number  of  cocci  has  been  found  to  be  pyogenetic 
only  in  animals,  such  as  cattle,  horses,  etc. 

The  pyogenetic  qualities  of  most  of  the  organisms 
that  have  been  mentioned  have  been  satisfactorily 
established  by  experiments.  It  appears  that  of  the 
warm-blooded  animals,  man  is  the  most  disposed  to 
Suppuration.  Among  other  various  conditions  that 
especially  favor  suppuration  may  be  mentioned  the 
infectious  diseases,  both  acute  and  chronic;  conditions 
characterized  in  general  by  a  lowering  of  the  vital 
strength;  diabetes  mellitus,  etc.  The  common  pus 
microbes  are  normally  present  on  the  skin,  in  the  oral 
cavity,  and  in  the  vaginal  secretion.  Local  infections 
are  likely  to  occur  when  the  protective  covering  is 
injured  in  any  way  and  the  general  strength  reduced. 
The  disposition  to  pyogenic  infection  created  by  the 
infectious  diseases  such  as  typhoid  fever,  gonorrhea, 
influenza,  scarlatina,  variola,  diphtheria,  measles, 
dysentery,  etc.,  is  clearly  shown  by  the  frequency  with 
Which  secondary  mixed  infections  with  pus  microbes 
occur  in  these  diseases.  Secondary  infection  usually 
means  the  lodgment  and  pathogenic  action  of  bacteria 
in  the  tissues  and  the  blood  of  persons  rendered  especi- 
allv  susceptible  by  the  influences  of  pre-existing  infec- 
tions with  other  microbes.  The  resulting  abscesses 
may  contain  microbes  of  the  primary  disease  and  of 
the  secondary  infection,  or  the  latter  only  may  be 
present.  The  phrase  secondary  infection  is  generally 
used  in  this  sense.  Abscesses  may  be  the  result  of  a 
primary  polyinfection;  thus  staphylococci  and  strep- 
tococci not  infrequently  are  associated  in  the  same 
abscess. 

When  an  abscess  becomes  old  or  chronic  the  microbes 
present  are  usually  reduced  in  virulence,  but  by  several 
passages  through  susceptible  animals  the  virulence  may 
be  again  greatly  increased. 

Origin  of  Pus. — Pus  is  the  result  of  inflammation  in 
which  the  exudate  and  the  dead  cells  and  detritus  are 
liquefied  by  the  action  of  digestive  ferments  produced 
either  by  the  bacteria  themselves  or  by  the  cells  or 
both,  but  principally  from  the  leucocytes.  The  fer- 
ments either  hinder  the  coagulation  of  the  exuded 
serum  or  redissolve  the  fibrin  once  formed.  The 
various  factors  in  inflammation  are  therefore  in  full 
operation  in  the  early  stages  of  abscess  formation,  and 
the  classical  symptoms  of  acute  inflammation — rubor, 
calor,  dolor,  tumor,  functio  laesa — are  rarely  seen  to 
better  advantage  than  in  the  beginning  of  an  acute 
abscess  in  the  skin  or  subcutaneous  tissue.  As  a 
result  of  the  action  of  the  microbes  present  or  of  their 
products,  and  of  divers  chemical  substance's,  the  tissue 
cells  in  the  immediate  vicinity  are  injured,  and  this  is 
followed  by  the  well-known  vascular  changes  of  acute 
inflammation,  leading  to  exudation  of  serum  and  leu- 
cocytic  emigration.  In  response  to  the  positively 
chemotactic  substances,  produced  either  by  the 
bacteria  directly  (Leber),  or  by  the  action  of  broken-up 
necrotic  fragments  of  cells  destroyed  by  the  bacteria, 
or  by  other  causes  (Buchner),  the  mobile  cells  of  the 
blood  and  of  the  tissues  accumulate  in  the  inflammatory 
focus.  Many  of  these  cells  act  as  phagocytes,  and 
intracellular  and  extracellular  bactericidal  and  diges- 
tive ferments  are  produced.  As  a  result  of  the  dis- 
turbed intercellular  equilibrium  the  fixed  tissue  cells 
begin  to  multiply  and  caryocinetic  figures  are  seen  at 
the  borders  of  the  area;  the  migratory  cells  also  multi- 

Vol.  I.— 4 


ply.  Thus  is  produced  a  mass  which  at  lii  I  i  denser 
than  the  normal  tissue.     Under  the  influence  of  the 

toxic  substances  necrosis  of  cells  takes  place,   and,   as 

already  emphasized,   the  proteolytic  ferments  hinder 

coagulation  of  the  inflammatory   serum  and  dissolve 

the  dead   cells  and  shreds  of     tissue,   and  in   this  way 

pus  is  formed,     'tin-  proteolytic  action  of  ferments  of 

bacterial  origin  is  well  illustrated  by  liosciibach,  who 
showed  that  u in ler  anaerobic  conditions  Staphylococcus 

aun  us  dissolves  white  of  egg  and  meat.  It  i-  probable, 
however,  that  the  ferments  produced  by  the  bacteria 
play  an  insignificant  rdle  as  compared  with  thai  of  the 

ferments  from  the  leucocytes.  These  ferments  are  of 
at  least  two  varieties,  those  from  tin-  polymorpho- 
nuclear cells,  which  act  besl  in  an  alkaline  medium, 
and  those  from  the  mononuclear  cells,  which  act  in  an 
acid  medium. 

Physical,  Chemical,  and  Morphological  Characteristics 
of  Pus. — Typical  human  pus — the  pus  bonum  et  lauda- 
bile  of  the  Old  W  liters — is  a  creamy,  more  or  less  mucoid 
fluid,  usually  of  alkaline  but  not  rarely  of  acid  reaction, 
possessing  a  peculiar  sweetish  odor  and  a  specific 
gravity  of  t.030-1.033.  Atypical,  "thin"pus  ("ichor") 
may  have  a  much  lower  specific  gravity,  and  such  pus, 
mixed  with  fibrinous  flocculi  and  shreds,  and  smelling 
of  butyric  acid,  is  regarded  as  the  result  of  a  virulent 
infection,  and  as  indicating  a  cautious  prognosis. 
Allowed  to  stand,  pus  generally  separates  into  two 
layers,  the  upper  being  a  transparent,  yellowish  fluid — 
"liquor  puris" — and  the  lower,  an  opaque  mass  com- 
posed of  the  solid  constituents  of  the  pus.  The  liquor 
puris  is  much  like  blood  serum  and  lymph  in  its  com- 
position, being  somewhat  less  albuminous  and  not 
containing  any  fibrinogen;  it  contains  considerable 
globulin,  nucleoprotein,  albumoses,  peptone,  and 
various  extractives,  such  as  leucin  and  tyrosin,  more 
or  less  mucus,  fats,  and  cholesterin,  the  latter  especially 
in  the  case  of  old  pus;  among  the  mineral  constituents 
may  be  mentioned  sodium  chloride  and  the  phosphates 
of  magnesium  and  calcium;  finally,  the  serum  of  pus 
will  be  found  to  contain  digestive,  bactericidal,  and 
other  ferments  and  toxic  substances,  partly  of  bacterial, 
partly  of  cellular  origin,  the  amount  and  the  kind  vary- 
ing according  as  the  microbe  at  work,  its  virulence,  and 
the  age  of  the  pus  vary.  The  odor  and  the  color  of  pus 
are  also  subject  to  variation,  depending  on  the  cause 
and  the  situation  of  the  abscess  and  the  presence  of 
secondary  putrefactive  bacteria.  Pus  associated  with 
disease  of  the  middle  ear  and  of  the  brain  is  frequently 
fetid,  due  to  changes  of  a  putrefactive  nature.  In 
such  cases  lactic,  valerianic,  butyric,  and  other  acids, 
H.S,  etc.,  are  formed.  Purulent  accumulations  in 
the  vicinity  of,  or  in  connection  with,  the  intestines 
generally  acquire  a  fecal  odor,  which  sometimes  is 
intense.  Pus  may  be  mixed  with  blood  so  that  its 
color  on  that  account  varies  from  bright  red  to  brown  or 
chocolate  Green  or  blue  pus  is  the  result  of  suppuration 
caused  by  Bacillus  pyocyaneus,  which  produces  a  green 
pigment,  pyocyanin.  Abscesses  caused  by,  or  con- 
taminated with,  gasogenic  organisms,  such  as  the  colon 
bacillus,  Proteus  vulgaris,  and  Bacillus  ■melchii  (gas 
bacillus)  may  contain  a  more  or  less  frothy  pus. 

In  addition  to  pus,  abscesses  may  contain  other  sub- 
stances, as  blood,  shreds  of  tissue,  foreign  bodies,  para- 
sites, cheesy  and  calcareous  masses.  When  pre-exist- 
ing cysts,  such  as  retention  cysts  and  follicular  cysts, 
become  the  seat  of  purulent  infection,  the  resulting  pus 
is  mixed  with  the  cystic  contents. 

The  formed  elements  present  in  pus  are  migrated  leu- 
cocytes and  wandering  cells.  Strieker  insisted  that  the 
pus  corpuscles  were  modified  embryonal-tissue  cells, 
and  it  stands  to  reason  that  some  of  the  cells  in  pus 
may  be  of  this  origin;  but  it  is  now  agreed  that  leuco- 
cytes form  the  great  majority  of  the  cells  in  pus.  In 
acute  abscesses  the  greater  number  of  the  cells  are 
leucocytes  of  the  finely  granular,  polymorphonuclear 
type;  coarsely  granular  eosinophiles  and  hyaline  cells 
of  different  kinds  with  circular  and  oval  nuclei  are  also 

49 


Abscess 


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found,  and  to  what  extent  this  cell  comes  from  the  blood 
and  to  what  extent  from  the  tissues  is  unsettled. 
There  is  great  diversity  in  the  appearances  of  the  cells 
present  in  pus;  the  great  irregularity  in  the  shape  of 
the  nucleus  is  explained  as  due  in  some  cases  to  its 
being  fixed  while  the  cell  is  in  motion,  in  other  cases  to 
beginning  degeneration  and  disintegration  into  the 
nuclear  fragments  commonly  present.  Among  the 
disintegrating  cells  will  be  found  those  which  still 
retain  their  ameboid  movement.  The  protoplasm 
of  many  leucocytes  often  shows  extensive  fatty  and 
granular  changes.  In  chronic  abscesses  the  mononu- 
clear cells  are  relatively  more  numerous.  Janowski 
observed  that  the  cells  in  pus  are  of  the  same  general 
morphology  in  bacterial  and  in  purely  chemical  ab- 
scesses. In  the  case  of  most  abscesses,  especially  the 
acute,  pus  will  contain,  in  addition  to  cells  and  cellular 
detritus,  the  special  pus-producing  organisms,  whose 
presence  is  usually  readily  established  by  the  ordinary 
histological  and  bacteriological  methods.  In  some 
cases,  as  for  instance  in  abscesses  caused  by  ray  fungi, 
the  organisms  form  peculiar  grayish  or  yellowish 
granules  which  can  be  seen  with  the  naked  eye. 

In  domestic  animals  pus  presents  a  variable  macro- 
scopic appearance.  In  horses,  cattle,  and  swine  it  cor- 
responds in  the  main  with  human  pus;  in  dogs  it  is  gen- 
erally thinner  and  more  serous;  in  rabbits,  guinea-pigs, 
and  birds  it  is  much  thicker,  almost  caseous  in  appear- 
ance (Johne). 

Cold  Abscess. — Puruloid  fluids  are  produced  by 
softening  of  caseous  foci  and  by  the  so-called  bland  or 
aseptic  liquefaction  of  thrombi.  In  these  cases  the 
process  is  not  exactly  the  same  as  in  ordinary  suppu- 
ration, although  fluids  may  result  that  greatly  resemble 
pus. 

The  chronic,  so-called  "cold"  abscesses  are  in  reality 
collections  of  softened  tuberculous  material.  They  are 
observed  most  frequently  in  connection  with  tubercu- 
lous arthritis  and  osteomyelitis.  The  contents  of  the 
cavities  are  formed  slowly,  and  extension  often  occurs 
according  to  the  laws  of  gravity.  Thus  "cold"  ab- 
scesses  associated  with  tuberculosis  of  the  vertebra^ 
often  make  their  way  downward,  as  well  shown  in 
the  fluctuating  swellings  observed  above  or  below 
Poupart's  ligament,  which  originate  in  tuberculous  foci 
of  the  lower  dorsal  or  lumbar  vertebra  and  pass  down 
along  the  psoas  muscles. 

.Many  have  failed  to  find  bacteria  in  cold  abscesses 
(Billroth,  Ogston);  others  found  tubercle  bacilli  alone 
or  mixed  with  other  bacteria.  Hence  it  is  claimed  by 
some  authors  that  the  tubercle  germ  can  cause  suppu- 
ration, while  others  regard  the  process  as  only  appar- 
ently purulent  (Baumgarten).  Pure"  tuberculous  pus" 
consists  of  a  fine  granular  detritus  of  caseous  material, 
fatty  and  granular  cells,  and  few  leucocytes.  More 
typical  pus  is  produced  when  mixed  infection  occurs, 
or  when  leucocytes  enter  from  other  causes,  but  even 
then  the  microscopic  appearances  of  the  pus  are  differs 
ent  from  those  of  non-tuberculous  pus.  Tuberculous 
abscesses  are  usually  chronic,  and  perhaps  the  content- 
have  been  changed  by  the  long  stay.  Inoculated  into 
animals  such  as  guinea-pigs,  the  contents  of  "cold 
abscesses"  nearly  always  produce  tuberculosis. 

"Serous  abscesses"  occur  in  connection  with  certain 
inflammations  of  the  periosteum.  The  condition  is  also 
known  as  periostitis  albuminosa  and  as  periosteal  gan- 
glion. Flattened  cavities  form,  containing  a  varying 
quantity,  most  frequently  from  100  to  150  c.e.,  of  clear, 
transparent,  yellowish,  viscid  fluid  like  synovia  or  glyc- 
erin. The  fluid  contains  albumin  eoagulable  by  heat 
and  nitric  acid,  more  or  less  mucus,  and  some  fibrin. 
Pus  cells  are  absent.  Bruer,  who  collected  twenty-five 
ca  es,  found  the  femur  involved  twelve  times,  the  tibia 
eight  times,  the  humerus  twice,  the  ulna  twice,  and  a 
rib  once.  The  lesion  was  located  at  the  epiphyseal 
junction  seventeen  times  and  in  the  middle  of  the 
shaft  five  times.  It  is  thought  that  this  form  of  inflam- 
mation may  be  either  tuberculous  or  pyogenic  in  its 

50 


nature,  the  peculiar  morphology  of  the  exudate  de- 
pending on  a  secondary  mucoid  degeneration  of  pus 
cells  or  upon  reabsorption  of  the  leucocytes;  or  the 
exudate  may  be  primarily  serous,  due  to  the  peculiar 
action  of  the  microbes. 

The  Size,  Walls,  Fate,  etc.,  of  Abscesses. — In  size  ab- 
scesses vary  from  the  microscopic  to  those  containing  a 
liter  or  more  of  pus;  such  large  accumulations  are  ob- 
served especially  in  the  soft  subcutaneous  tissues  and  in 
preformed  cavities  like  the  pleural,  the  renal  pelvis,  etc. 
The  writer  once  opened  an  abscess  in  the  anterior  ab- 
dominal wall,  situated  between  its  layers,  which  con- 
tained no  less  than  four  liters  of  yellow,  creamy  pus. 
This  enormous  collection  developed  in  a  girl  seven  years 
of  age,  who  for  a  time  previously  had  presented  the 
symptoms  of  typhoid  fever;  gradually  the  abdomen  be- 
gan to  enlarge  and  soon  an  excessive  size  was  reached; 
the  summit  of  the  distention  corresponded  to  the  navel. 
The  cavity,  which  occupied  the  whole  extent  of  the  an- 
terior abdominal  wall,  did  not  appear  to  communicate 
with  the  peritoneal  cavity.  After  the  insertion  of  nu- 
merous drains,  which  converged  at  the  navel  and  passed 
out  at  the  pubes  and  the  flanks,  the  symptoms  began 
to  improve,  and  complete  recovery  took  place. 

When  pus  accumulates  in  a  preformed  cavity  the 
walls  of  the  abscess  are,  primarily  at  least,  those  of  the 
cavity.  Abscesses  in  solid  organs  or  tissues  after  a 
time  generally  become  walled  off  from  the  surroundings 
by  a  layer  of  granulation  tissue  and  fibrous  tissue,  to 
which  the  name  "pyogenic  membrane"  has  been  given, 
on  the  supposition  that  this  membrane  secreted  the 
pus.  Pus  may  form,  however,  without  any  such  mem- 
brane, which  in  reality  represents  the  effort  of  the 
organism  to  circumscribe  the  action  of  the  pyogenic 
agents  and  limit  the  destruction  of  tissue.  The  term 
pyogenic  membrane  is  therefore  an  ill-chosen  one. 

Often  there  is  not  this  tendency  to  definite  circum- 
scription, but  the  pus  wanders  or  "burrows"  in  the 
direction  of  least  resistance,  soft  parts  like  muscle 
yielding  readily,  whereas  dense  fibrous  structures,  like 
fascia?,  offer  more  resistance.  Abscesses  near  the 
surface  of  the  body  tend  toward  the  surface,  and  are 
then  said  to  "point";  eventually  spontaneous  rupture 
and  discharge  of  the  contents  may  take  place.  Ab- 
scesses in  organs  with  serous  coverings  often  reach  the 
surface,  perforate  the  covering,  and  by  the  discharge 
of  pus  into  the  cavity  cause  diffuse  inflammation  of  the 
serous  membrane.  Sometimes  previous  adhesive  in- 
flammation between  two  serous  surfaces  may  prevent 
the  escape  of  the  pus  into  the  cavity  in  which  the  organ 
lies,  the  pus  eventually  being  discharged  along  other 
routes.  Thus  adhesions  between  the  diaphragm  and 
the  lung  precede  the  discharge  of  abscesses  of  the  liver 
into  the  bronchi. 

Instead  of  pus  being  discharged  spontaneously,  or 
after  incision,  it  may  be  removed  by  absorption.  This 
presupposes,  in  the  first  place,  the  destruction,  neu- 
tralization, or  removal  of  the  pyogenic  agent  and  the 
subsidence  of  the  active  inflammatory  changes;  the 
fluid  parts  are  absorbed,  the  living  leucocytes  and  wan- 
dering cells  depart,  and  the  dead  cells  undergo  disin- 
tegration either  by  extra-  or  intracellular  digestion. 
Occasionally  the  solid  parts  of  the  abscess  contents  are 
not  removed,  but  undergo  inspissation  and  are  changed 
into  a  crumbling,  grayish  material,  which  later  may 
become  infiltrated  with  lime  salts  and  converted  into 
a  calcareous  mass;  it  is  also  possible  that  inspissated  pus 
may  later  undergo  liquefaction.  Absorptive  changes 
like  these  are  always  associated  with  the  formation  of  a 
well-marked  connective-tissue  capsule,  which  separates 
the  area  from  the  surrounding  tissue.  Abscesses  heal- 
ing spontaneously  may  leave  behind  a  mere  scar,  an 
encapsulated,  calcareous  mass,  or  more  rarely  a.  cyst. 
It  is  probable  that  pyogenic  microbes  may  persist  for 
some  time  in  such  areas  in  a  condition  of  latency. 

Embolic  Abscesses. — Secondary  or  metastatic  ab- 
scesses are  those  which  are  developed  at  a  distance  from 
the  point  of  primary   infection.     They  are  properly 


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Abscess,  Treatment 


called  embolic  also,  and  are  usually  multiple  and  small, 
hence  often  called  miliary  abscesses.  They  are  always 
due  to  infectious  organisms,  and  in  most  cases  the 
infected  emboli  are  derived  from  thrombi  undergoing 
septic  softening  or  from  fragments  of  endocardial  \ 
tations.  It  is  also  probable  that  the  circulation  of  pyo- 
genic organisms  in  the  blood  may  result  in  the  forma- 
tion of  multiple  abscesses,  in  the  same  manner  as  the 
intravenous  injection,  in  rabbits,  of  pure  cultures  of 
Staphylococcus  pyogenes  aureus  is  followed  by  miliary 
foci  of  suppuration.  The  presence  in  the  blood  of 
pyogenic  organisms,  with  the  formation  of  embolic  or 
metastatic  abscesses,  constitutes  the  much-feared  dis- 
pyemia.  If  one  wishes  to  find  the  source  of 
embolic  abscisses  in  a  given  case,  one  follows  back  the 
circulatory  current  and  searches  for  a  vessel  the  seat  of 
thrombosis  and  inflammation.  Thus,  if  such  abscesses 
are  present  in  the  lungs,  one  is  likely  to  find  the  source 
either  in  the  sinuses  of  the  brain,  in  the  venous  plexuses 
around  pelvic  organs,  or  in  the  peripheral  veins.  Em- 
bolic abscesses  of  the  brain,  heart,  spleen,  kidneys,  etc., 
commonly  have  their  origin  in  an  infectious  endocarditis 
— arterial  pyemia.  In  cases  of  multiple  abscesses  in 
which  careful  search  fails  to  disclose  the  primary  scat, 
the  pyemia  is  sometimes  spoken  of  as  cryptogenetic.  it- 
origin  remaining  hidden.  Embolic  abscesses  of  the  liver 
are  usually  derived  from  the  radicles  of  the  portal  vein 
which  become  involved  in  such  conditions  as  appendi- 
citis and  suppuration  associated  with  hemorrhoids  and 
with  dysenteric  and  other  ulcers  in  the  intestines; 
infected  emboli  may  also  reach  the  liver  through  tin- 
hepatic  artery  in  general  pyemia.  Embolic  absee--e- 
are  most  frequently  due  to  Staphylococcus  and  Strep- 
tococcus pyogenes,  but  Bacillus  mucosus,  the  pneu- 
mococcus,  and  other  bacteria  are  also  often  at  work 
in  such  cases.  Characteristic  multiple  abscesses,  whose 
pus  contains  the  fungus  granules,  also  develop  in  the 
metastases  of  actinomycosis. 

Symptoms. — The  general  symptoms  of  acute  abscesses 
are  those  of  a  local  infection,  the  intensity  of  the  infec- 
tion varying  according  to  the  virulence  of  the  organism. 
There  will  be  local  pain,  tenderness,  and  swelling,  and 
more  or  less  fever  and  general  disturbances  due  to  the 
absorption  of  toxic  substances.  In  streptococcus  infec- 
tion the  general  symptoms  are  often  severe.  It  should 
be  borne  in  mind  that  in  the  early  stages  of  abscess  for- 
mation the  swelling  may  be  firm  in  consistence,  and  that 
an  exact  etiological  diagnosis  is  possible  only  after 
careful  bacteriological  examination.  Chronic  abscesses, 
in  addition  to  the  purely  local  symptoms,  may  in  time 
induce    amyloid   degeneration   of  the  internal  organs. 

Ltjdwig  Hektoex. 

Bibliography. 

Buchner  und  Roemer :  Eiterung  und  Eitererreger.  Lubarsch 
and  Ostertag's  Ergebnisse  der  allgemeinen  Etiologie,   1S96,    463. 

Janowski:  Die  Ursachen  der  Eiterung  vom  heutigen  Standpunkte 
der  Wissensehaft  aus.     Ziegler's  Beitrage,  1S94,  xv.,  liS. 

Opie:  Inflammation,  Harvey  Lectures,  1909-10. 

Abscess,  Treatment. — Clinical  research  and  ob- 
servation combined  with  bacteriological  experimenta- 
tion have  demonstrated  that  the  presence  of  pus  is 
always  sure  to  be  accompanied  by  some  form  of 
bacteria.  That  these  pyogenic  bacteria  stand  in  the 
relation  of  cause  and  effect  to  the  pus  production  has 
not  been  absolutely  proved.  It  has,  however,  been 
shown  that  they  or  their  products,  that  is,  the  toxins 
which  their  chemical  action  produces,  are  capable  of 
inducing,  and  do  induce,  a  coagulation  of  tissue  and  a 
digestion  by  peptones  which  finally  result  in  the  for- 
mation of  the  abscess.  Abscess  formation  is  therefore 
the  result  of  their  action  upon  tissues  and  of  the 
reaction  which  is  induced  in  the  body  in  the  effort  of 
self-protection. 

The  severity  of  the  infection  depends  upon  the  char- 
acter of  the  infecting  microorganism  and  upon  the  at- 
tenuation which  age  or  environment  has  effected  in  the 
virulence  of  its  toxins,  while  the  reaction  is  proportion- 


ate to  the  resisting  power  or  the  vitality  of  the  indi- 
vidual  infected.     Thus  it    litis   been   found   that    the 

ion  which  results  from  the  rupture  of  an  abscess 

of  long  standing  into  the  peritoneum  is  in  b ec 

almost    in:  nd    the    reaction    very    slight,    al- 

though  the  pus  contain-  bacteria  which  are  endowed, 
under  other  circumstances,  with  a  virulence  that 
would  produce  a  fatal  infection.  Under  such  circum- 
stances and  in  operations  Upon  collection-  of  pus  that 
are  chronic  in  their  mode  of  development,  the  greatest 
aseptic  precautions  should  be  employed  to  prevent  in- 
fection by  more  virulent  germs  or  those  of  a  different 
character. 

Sinh  tin  advance  in  our  knowledge  of  the  causation 
and  pathology  of  abscess  formation  litis  revolutionized 
our  methods  of  treatment  and  necessitates  an  adapta- 
tion and  revision  of  the  nomenclature,  as  well  as  ot  the 
treatment,  of  these  results  of  infection. 

An  abscess,  when  considered  in  the  light  of  this  new 
pathology  cannot  be  comprehensively  defined  as  a  cir- 
cumscribed collection  of  pus.  That  definition  can  be 
applied  to  the  nidus  of  circumscribed  point  s  of  infection 
from  which  the  general  infection  may  spread,  but  the 
cause,  the  bacteria,  may  have  permeated  the  sur- 
rounding tissues  or  may  have  passed  on  farther  through 
the  lymphatics,  and  their  toxins  may  already  be  pro- 
ducing a  coagulation  necrosis.  The  abscess,  in  its 
incipient  stage,  may  thus  be  widespread  in  extent,  and 
yet  no  pus  be  formed  other  than  in  the  nidus. 

Treatment,  to  be  effective,  must  not  be  delayed  till 
the  abscess  is  fully  formed.  It  must  comprehend  the 
facts  demonstrated  by  pathology,  and  to  be  radical, 
thorough,  and  efficient  it  must  deal  with  the  incipient 
abscess.  The  cause  must  be  removed  before  the  in- 
fection expresses  itself  in  the  fully  developed  circum- 
scribed collection  of  pus  which  would  embrace  the 
whole  area  infected.  The  old  method  of  waiting  till  the 
abscess  has  formed  and  "pointing"  has  taken  place, 
has  had  to  give  way  to  methods  which  destroy  the 
infecting  agent  and  assist  nature  in  preventing  its 
spread.  The  results  justify  the  treatment.  Recovery 
is  more  rapid  and  the  drain  upon  the  system  is  lessened, 
while  in  cases  of  grave  infection  the  life  of  the  patient 
can  be  saved  in  no  other  way. 

From  the  surgical  standpoint  abscesses  are  classified 
in  accordance  with  their  situation,  in  reference  to 
structures  which  determine  their  development  and 
appearance,  or  in  reference  to  an  organ  the  vitality  of 
which  is  threatened  by  their  proximity.  These  relations 
influence  their  symptomatology  and  in  a  measure  the 
method  of  treatment. 

The  symptoms  that  aceompanj-  the  formation  of  an 
ali-cess  "are  those  of  a  localized  acute  suppurative  in- 
flammation. The  area  surrounding  the  point  of  infec- 
tion becomes  tensely  swollen  from  the  infiltration  of 
the  tissues  by  the  outpouring  of  leucocytes.  The  sur- 
face becomes  more  or  less  glazed  from  the  tension  and  is 
covered  by  a  slight  red  blush.  The  increasing  tension 
within  brings  ever-increasing  pain  in  the  nerves,  which 
finally  becomes  acute,  with  a  characteristic  throbbing  or 
boring  sensation.  As  the  pressure  increases  and  the 
tissues  become  thinned  out,  "fluctuation "is  recognized 
by  the  alternate  pressure  of  the  fingers.  If  the  process 
is  a  I  lowed  to  go  on,  the  integument  becomes  whitish  and 
thinned  at  one  spot,  that  is,  "pointing"  takes  place, 
and  finally  the  abscess  ruptures. 

The  constitutional  disturbance  is  great  throughout. 
There  may  be  a  rise  and  fall  in  temperature  on  alternate 
days  that  suggests  malaria,  from  which  the  differential 
diagnosis  has  frequently  to  be  made.  When  suppura- 
tion takes  place  there  is  either  a  chill  or  a  sudden  rapid 
rise  of  temperature.  Just  before  "pointing"  takes 
place  the  pain  and  febrile  disturbance  are  very  great. 
The  rupture  of  the  abscess  is  followed  by  a  subsidence 
of  both  local  and  constitutional  symptoms. 

The  tendency  of  all  abscesses  or  infections  is  to  spread 
in  the  direction  of  least  resistance.  They  have  therefore 
been  classified  in  relation  to  the  structures  which  tend  to 

51 


Abscess,  Treatment 


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limit  their  spreading  and  to  direct  their  development 
into  subcutaneous  or  superficial,  and  subfascial  or  deep 
abscesses. 

The  deep  or  subfascial  abscess  is  generally  limited  by 
the  deep  fasciae  and  extends  in  the  direction  of  least  re- 
sistance beneath  those  structures.  It  may  be  limited 
by  the  periosteum  of  the  bone,  in  which  case  it  forms  a 
subperiosteal  abscess.  It  may  dissect  its  way  between 
the  muscles,  since  the  loose  cellular  and  connective 
tissue  which  separates  them  readily  yields  and  forms 
the  path  of  least  resistance.  It  may  follow  the  sheaths 
of  blood-vessels  or  along  nerve  trunks.  In  dealing  with 
deep  abscesses  the  surgical  anatomy  of  the  part  must 
be  duly  considered,  and  the  directions  in  which  the  ab- 
scess  may  extend  examined  with  this  idea  in  view. 

The  symptoms  of  deep  suppuration  differ  from  those 
already  described  in  coming  on  more  gradually.  The 
first  symptoms  are  of  a  subjective  nature.  There  is  no 
immediate  superficial  swelling,  the  normal  contour  and 
outlines  of  the  part  are  not  altered.  An  edema  may  be 
the  first  superficial  sign,  followed  by  tenderness  and  red-  ' 
ness,  and  as  the  inflammation  approaches  the  surface  all 
the  symptoms  gradually  appear.  According  to  the  re- 
gion in  which  the  abscess  has  formed  and  the  extent  to 
which  adjacent  organs  are  involved,  the  pus  will  be 
found  to  contain  fragments  of  necrosed  bone,  or  urine,  or 
bile,  or  intestinal  contents,  with  frequently  an  odor  that 
is  very  characteristic. 

These  deeper  abscesses  are  generally  chronic.  An 
acute  deep-seated  suppuration  is,  however,  not  uncom- 
mon. The  chronic  abscess  is  most  frequently  the  result 
of  a  tuberculous  infection,  or  the  deep-seated  focus  may 
be  the  remnant  of  an  acute  disease.  Such  suppurations 
and  abscess  formations  are  seen  as  the  sequela?  of 
typhoid  fever,  of  influenza,  or  of  any  of  the  infectious 
diseases. 

Chronic  suppuration,  or  "  cold  abscess"  as  it  was  for- 
merly termed,  is  most  frequently  a  result  of  tuberculous 
infection.  The  psoas  abscess  illustrates  the  result  of  a 
tuberculous  infection  in  which  the  pus  enters  the  sheath 
of  the  psoas  muscle,  usually  from  a  focus  in  a  vertebra, 
and,  following  the  line  of  least  resistance,  burrows 
down  within  its  sheath  and  finally  "points"  just  above 
or  below  Poupart's  ligament,  often  on  the  inner  surface 
of  the  thigh.  Another  example  of  a  deep-seated  chronic 
abscess  of  this  character  is  seen  in  the  postpharyngeal 
region.  Here  it  arises  from  a  focus  of  tuberculous 
disease  in  the  cervical  vertebra  and  is  guided  by  the 
deep  fascia  af  the  neck  and  the  sheaths  of  the  blood- 
vessels, and  often  points  in  the  lower  portion  of  the 
neck.  The  abscesses  of  Pott's  disease  are  to  be  grouped 
in  this  category.  In  fact  all  foci  of  infection  which  are 
introduced  by  any  cause  beneath  the  deep  fascia?  may 
give  rise  to  suppuration  with  the  formation  of  abscesses, 
which  can  be  classified  only  as  deep  abscesses  or  given 
names  which  correlate  them  with  the  organs  the 
vitality  and  function  of  which  they  endanger. 

As  illustrations  of  this  method  of  nomenclature  we 
have  the  perinephritic  abscess,  the  ischiorectal,  the 
perityphlitic,  and  those  which  form  in  the  pericardium 
or  in  the  pleura. 

The  treatment  of  these  chronic  forms  of  suppuration, 
these  deep-seated  subfascial  abscesses,  is  identical  with 
that  of  abscesses  in  all  situations.  The  strictest  anti- 
sepsis and  asepsis  should  be  employed.  The  bacteria 
that  produced  these  abscesses  have  had  their  virulence 
attenuated  by  the  chronicity  of  their  development  and 
the  resistance  offered  bjr  the  tissues  that  surround  them. 
The  reacting  and  resisting  powers  of  the  tissues  have, 
however,  been  weakened,  while  the  conditions  present  in 
the  abscess  cavity  are  typical  for  the  rapid  develop- 
ment of  other  forms  of  pyogenic  bacteria.  A  mixed 
infection  should  be  carefully  guarded  against,  and  every 
precaution  employed  to  prevent  the  entrance  of  other 
more  active  and  more  virulent  forms  of  bacteria.  The 
parts  should  be  carefully  scrubbed  and  prepared  with 
antiseptic  washing.  The  operator's  hand  should  be  as 
clean  as  for  a  major  operation,  and  the  instruments  and 


surroundings  should  have  all  the  care  given  to  them 
which  is  essential  to  an  aseptic  operation. 

In  contrast  with  the  older  methods  of  treating 
abscesses  the  surgeon  does  not  wait  till  "pointing"  has 
taken  place.  That  means  that  the  abscess  and  in- 
fection have,  in  a  subfascial  abscess,  extended  in  the 
direction  of  least  resistance,  beneath  the  deep  fascia,  as 
far  as  is  possible,  and  have  at  last  been  forced  to  break 
through  that  fascia  and  come  to  the  surface.  As  a 
consequence  all  the  damage  that  is  possible  has  already 
taken  place,  and  the  full  extent  of  the  infection  has  been 
reached.  This  is  what  operation  should  prevent.  It 
must  therefore  be  early  and  radical.  As  soon  as  the 
presence  of  infection  and  the  danger  of  abscess  forma- 
tion are  evident,  operation  should  be  undertaken.  The 
detection  of  deep-seated  fluctuation  or  of  deep  in- 
duration, and  the  presence  of  localized  pain  and  con- 
stitutional symptoms,  are  sufficient  indications  for  early 
operation.  Such  intervention  is  essential  in  many 
cases  to  the  preservation  of  the  integrity  of  the  organ 
involved.  As  an  instance  the  ischiorectal  abscess  may 
be  cited.  Early  incision  in  these  cases  prevents  the 
rupture  of  the  abscess  into  the  bowel  and  the  subsequent 
formation  of  a  fistula.  It  also  prevents  the  involve- 
ment of  the  entire  region  and  the  formation  of  a 
horseshoe  abscess  cavity  about  the  rectum.  This  is 
especially  liable  to  occur  because  the  connective  tissue 
is  very  loose  and  its  blood-supply  limited. 

The  free  incision  is  planned  so  that  drainage  can  be 
provided  for  at  the  most  dependent  point:  that  is,  at  the 
point  where,  when  the  patient  is  in  the  position  assumed 
during  the  after-treatment,  the  drain  will  enter  at  the 
bottom  of  the  pocket.  Free  drainage  of  the  entire 
cavity  is  most  essential  in  the  treatment  of  abscesses. 
In  many  cases  it  is  necessary  to  make  more  than  one 
incision.  When  free,  dependent  drainage  cannot  be 
secured,  pressure  must  be  applied  so  that  no  pockets 
of  undrained  pus  shall  remain.  If  an  abscess  is  so 
situated  that  it  is  impossible  to  secure  dependent 
drainage,  the  thorough  evacuation  of  the  pus  may  be 
secured  by  employing  a  sterilized  boroglyceride.  This 
preparation  has  a  greater  specific  gravity  than  pus, 
and  will  displace  it  in  the  depths  of  a  sinus  or  abscess 
cavity.  I  have  thus  been  able  successfully  to  drain  a 
pelvic  abscess  and  the  sinuses  that  diverged  from  it,  in 
a  case  in  which  the  septic  condition  of  the  patient  made 
operation  impossible. 

After  the  incision  has  been  made  and  the  pus  evacu- 
ated the  cavity  should  be  carefully  inspected  and  its 
relation  to  vital  organs  and  structures  determined. 
Then  a  sharp  curette  is  employed  to  remove  all  sloughs 
and  the  infected  granulation  tissue  which  forms  the 
inner  wall  of  the  cavity.  The  thorough  removal  of  this 
infected  tissue  is  essential,  for  in  it  are  many  bacteria 
that  are  capable  of  setting  up  further  coagulation 
necroses  and  of  developing  new  abscess  cavities.  In 
acute  and  severe  infections  it  is  often  essential  to 
follow  up  this  infected  tissue  into  areas  that  are  simply 
infected  and  inflamed,  and  where  pus  and  abscess 
cavities  have  not  yet  been  formed. 

After  the  thorough  use  of  the  curette  bleeding  may  be 
checked  by  packing  the  cavity  with  sterile  gauze,  which, 
if  the  case  is  one  of  chronic  suppuration  and  the  symp- 
toms are  not  acute  or  the  infection  very  virulent,  can  be 
removed  and  the  wound  closed,  firm  pressvire  being  ap- 
plied to  hold  the  abscess  walls  in  close  apposition. 
This  method  of  treatment  in  suitable  cases  is  followed 
by  primary  union.  Perfect  asepsis  and  the  absence  of 
irritation  and  oozing  in  the  wound  are,  however, 
essential  to  its  success.  The  more  certain  plan  is  to 
provide  drainage.  Y\ "hen  the  infection  is  more  virulent 
it  is  necessary  to  use  antiseptic  solutions  to  destroy  the 
bacteria  in  the  wound.  Their  action  upon  the  tissues 
is,  however,  harmful,  and  drainage  thus  becomes 
essential.  Where  the  infection  is  still  more  severe  and 
there  is  great  induration,  the  wound  should  be  irrigated 
with  a  1:1,000  or  1:5.000  solution  of  bichloride,  to  be 
followed  by  sterile  water.     The  wound  is  then  packed 


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Abscess,  TriMlment 


with  wet  bichloride  g;uize  wrung  out  of  a  1  :  .1,000  solu- 
tion; over  this  is  applied  on  the  exterior  more  wet  gauze 
covered  by  oiled  silk,  mackintosh,  or  some  impervious 
material  which  forms  an  antiseptic  poultice  by  retaining 
the  heat  of  the  body.  When  a  less  vigorous  action  i- 
needed,  the  protective  may  be  omitted  and  the  moisture 
allowed  to  dry  out.  Or  simple  sterile  gauze  may  be 
employed  in  sufficient  quantity  to  absorb  the  exuded 
serum  and  keep  the  wound  dry.  Free  drainage  or 
packing  with  gauze  which  is  frequently  changed  effect  3 
the  same  purpose  by  absorbing  from  the  wound  the 
moisture  essential  to  the  development  of  the  bacteria. 
When,  however,  the  infecting  bacteria  are  very  virulent, 
this  is  insufficient  and  it  is  necessary  to  use  more  active 
germicidal  agents.  The  use  of  iodoform  gauze  should 
be  confined  to  tuberculous  abscesses.  In  these  it  has 
been  found  to  exert  an  apparent  specific  influence  upon 
the  bacteria.  The  action  of  the  wound  secretions 
liberates  from  it  free  iodine,  which  is  a  decided  irritant. 
It  would  therefore  seem  well  to  avoid  the  employment 
of  iodoform  gauze  in  cases  in  which  such  an  irritant 
action  is  not  desired. 

Of  the  acute  forms  of  abscess  formation  the  spreading 
abscess  accompanied  by  septic  lymphangitis  is  the  most 
dangerous  and  requires  the  most  prompt  radical  and 
thorough  treatment.  The  infection  usually  takes  place 
through  some  trifling  wound  of  the  extremities.  It 
spreads  through  the  lymphatics  and  may  go  unnoticed, 
and  the  primary  wound  may  heal  before  the  patient's 
attention  is  directed  to  the  condition  by  swollen  and 
painful  glands  that  have  become  hyperemic  from  their 
redoubled  activity  in  combating  the  poison.  The  glands 
are  found  swollen  at  the  elbow  and  in  the  axilla  in  case 
of  infection  in  the  hand,  while  the  courses  of  the 
lymphatics  are  marked  by  red  lines.  Although  the 
abscess  is  located  in  the  hand,  it  has  in  a  sense  spread 
throughout  the  lymphatics.  The  infection  is  there,  the 
bacteria  and  their  toxins  are  there,  and  the  incipient 
abscess,  unless  prompt  treatment  is  applied,  will 
develop  throughout  this  entire  area. 

The  treatment  is  identical  in  principle  with  that  of  all 
abscesses.  The  local  focus  of  infection  must  be  opened 
and  thoroughly  curetted;  other  foci  of  suppuration,  no 
matter  how  many  they  are,  should  be  opened  and  as 
much  of  the  infected  tissues  as  possible  removed.  The 
glands  should,  however,  be  respected  as  long  as  possible, 
until  suppuration  is  actually  present,  for  they  are  the 
bulwarks  which  nature  is  erecting  to  prevent  further 
invasion.  Their  swollen,  congested  condition  is  due  to 
their  increased  activity,  and  unless  their  vitality  is 
endangered  they  should  be  preserved. 

In  mild  cases  the  opening  of  the  original  focus  of  in- 
fection and  its  thorough  treatment  by  an  antiseptic 
Eoultice  dressing  often  prove  sufficient,  when  com- 
ined  with  the  application  externally  over  the  inflamed 
lymphatics  of  a  fifty-per-cent.  ichthyol  ointment. 
Severe  infections,  with  multiple  foci  of  suppuration, 
demand  multiple  incisions  with  wet  antiseptic  dressings 
frequentl3r  changed,  and,  in  some  instances,  continuous 
irrigation  with  antiseptic  solutions.  In  spite  of  all  of 
these  methods  of  treatment,  the  infection  may  become 
so  serious  that  amputation  is  necessary  to  save  the 

Eatient's  life.     Either  a  part  or  the  entire  limb  may 
ave  to  be  sacrificed  to  rid  the  system  of  the  source  of 
infection,  and  even  then  the  patient  may  succumb. 

The  essentials  in  the  treatment  of  abscesses  are, 
therefore,  free  incisions,  free  drainage,  thorough  cleans- 
ing and  curetting,  with  the  employment  of  aseptic  or 
antiseptic  washes  and  dressings,  as  the  severity  of  the 
infection  indicates.  In  all  cases  of  abscess  formation, 
tonic  systemic  treatment  is  indicated,  and  frequently, 
unless  such  treatment  is  carefully  carried  out,  recovery 
will  be  very  tedious,  especially  in  cases  of  chronic 
abscesses. 

Among  the  cutaneous  and  superficial  abscesses  are 
to  be  classed  those  that  lie  in  the  skin  itself,  such  as 
boils,  carbuncles,  and  the  less  serious  forms  of  pustules. 
The  latter  are  seen  as  the  acne  pustule,  and  they  range 


in  size  from  a  pin's  head  i  a  pea,  aci  ording  to  their 
period  of  development.     They  are  the  result  of  infection 

in  the  hair  follicles  or  sweat  glands,  with  the  blocking 
Up  of  I  he  duct. 

The  next  form  of  cutaneous  suppuration,  in  point  of 
frequency  and  freedom  from  serious  results,  is  the 
furuncle  or  boil.  It  differsfrom  the  pustule  only  in  the 
depth  to  which  the  infection  penetrates  and  the  se>  erity 
of  its  symptoms,  which  result  from  the  incn  I 
difficulty  in  "pointing"  and  the  severity  of  the  coagula- 
tion necrosis  which  the  toxins  of  the  infecting  bacti  ri  i 
produce.  The  symptoms  of  abscess  formation  are 
present,  but  in  a  mild  form.  As  the  process  of  destruc- 
tion and  the  breaking  down  of  the  tissues  proceed  the 

boil     beer. lues    mi|V    ;i!ii1     tender    nil     ]  He-- 1  ire.        A     el'll-t 

forms  over  the  duct.  When  it  is  removed  a  probe  can 
be  passed  down  into  the  abscess,  even  before  it  has 
begun  to  discharge.  The  suppuration  increases,  and 
finalty  the  core,  or  the  result  of  the  coagulation  necrosis, 
is  expelled,  when  the  cavity  heals  by  granulation. 
This  is  the  natural  process  without  treatment. 

Since  a  series  of  boils  may  follow  in  the  same  indi- 
vidual, a  condition  is  determined  called  furunculosis. 
Constitutional  and  prophylactic  treatment  are  therefore 
as  essential  in  many  instances  as  surgical  treatment. 
Frequent  baths  and  changing  of  underclothing,  with 
scrupulous  care  of  the  nails  and  the  avoidance  of 
scratching,  are  among  the  preventive  measures,  while, 
when  the  boils  are  in  process  of  formation,  antiseptic 
washes  should  protect  the  surrounding  skin.  An  ounce 
of  sulphonaphthol  in  a  bathtub  of  warm  water  makes 
a  mild  antiseptic  bath  that  is  not  injurious  and 
that  cleanses  the  skin  of  the  superficially  located 
bacteria. 

Boils  may  be  aborted,  when  they  are  small  and  are 
situated  superficially,  by  applying  a  few  crystals  of 
pure  carbolic  acid  on  a  glass  rod  or  piece  of  wood;  or, 
when  the  disease  is  further  advanced,  by  the  injection 
into  the  parenchyma  of  a  three-per-cent.  solution  of 
carbolic  acid  in  amounts  proportionate  to  the  size  of 
the  boil.  This  method  is  somewhat  painful  and  not 
always  successful. 

The  expectant  treatment  should  be  employed  only 
when  a  scar  is  to  be  avoided  and  no  organ  is  threatened, 
and  when  it  is  too  late  for  abortive  treatment.  An  anti- 
septic poultice,  gauze  or  cotton  wet  in  1:3,000  bichloride 
solution  under  a  protective,  should  be  applied  over  the 
boil  and  the  cavity  should  be  syringed  out  daily  until 
the  core  is  discharged,  when  the  cavity  may  be  packed 
and  an  occlusive  dressing  (cotton  held  in  place  by 
collodion)  applied. 

The  crucial  incision  will  frequently  abort  a  boil  and 
permit  an  antiseptic  in  the  dressing  to  reach  the  seat  of 
infection  and  destroy  the  bacteria.  When  the  disease 
is  further  advanced  free  opening,  curetting,  and  sub- 
sequent treatment  as  for  any  other  abscess  constitute 
the  most  rapid  and  radical  method  and  furnish  the 
best  results.  Any  of  these  operations  can  be  rendered 
painless  by  the  employment  of  infiltration  anesthesia 
or  by  the  subcutaneous  injection  of  a  two-per-cent. 
solution  of  eucaine  B  or  cocaine.  These  injections 
should  commence  outside  the  inflamed  area,  as  the 
increased  pressure  causes  great  pain. 

A  carbuncle  is  the  result  of  an  infection  by  bacteria 
that  enter  the  skin  in  the  same  manner  as  they  do  in 
the  case  of  a  boil.  The  conditions  under  which  they 
develop  are  responsible  for  the  difference  in  the  symp- 
toms and  the  gangrenous  inflammation  and  sloughing 
that  take  place  in  the  subcutaneous  cellular  tissue. 
The  conditions  which  predispose  to  carbuncle  forma- 
tion are  the  location  of  the  infection  in  the  thicker 
portions  of  the  skin,  where  it  is  difficult  for  the  pus  to 
find  a  mode  of  exit,  and  hence  it  spreads,  causing 
pressure  and  coagulation  necroses  over  large  areas, 
and  pointing  through  the  numerous  columna?  adiposae, 
which  offer  its  only  points  of  exit  through  the  toughened 
skin.  It  is  distinguishable  by  the  extent  of  the  tissues 
involved  and  by  the  multiple  points  or  heads  which 


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Abscess,  Treatment 


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first  show  themselves.  Pain  is  not  so  marked  a 
symptom  and  is  not  commensurate  with  the  extent  of 
the  suppurative  process. 

The  treatment  is  antiseptic,  and  always  should  be  in 
a  measure  operative  to  permit  the  outflow  of  pus  and 
the  action  of  an  antiseptic  on  the  foci  of  infection.  The 
amount  of  operative  interference  demanded  varies 
with  the  gravity  of  the  case,  from  a  deep  crucial  incision, 
with  or  without  curetting  and  an  antiseptic  poultice, 
to  complete  excision  of  the  entire  carbuncle.  The 
latter  is  of  course  reserved  for  the  severer  cases,  while 
there  are  varying  degrees  of  operating  which  depend 
on  the  extent  of  the  infection.  All  parts  should  be 
thoroughly  exposed  and  subjected  to  the  action  of 
antiseptics. 

Felons  (panaritium)  vary  in  degree  and  in  their  situa- 
tion. They  are  abscesses  that  form  in  the  fingers  and 
hands.  The  varieties  are  the  cutaneous,  tendinous,  and 
subperiosteal,  together  with  a  more  general  form  which 
is  known  as  a  palmar  abscess  and  may  be  either  super- 
ficial or  deep  according  to  its  relation  to  the  palmar 
fascia.  It  is  of  special  importance  because  it  endangers 
the  integrity  and  function  of  the  hand. 

The  various  forms  of  felon  are  named  according  to 
the  structures  in  which  they  originate.  Their  com- 
plications, sequela?,  and  gravity  depend  upon  these 
relations.  The  subperiosteal  felon  may  destroy  a 
phalanx  or  involve  an  articulation.  The  tendinous 
felon  may  spread  through  the  tendon  sheaths,  and 
involve  these  spaces  in  the  hand,  if  the  primary  disease 
is  in  the  thumb  or  little  finger.  The  cutaneous  felon  is 
liable  to  produce,  as  are  all  the  others,  lymphangitis  and 
possible  suppuration  in  the  glands  of  the  elbow  and 
axilla. 

All  of  these  panaritium  cases  demand  radical  anti- 
septic treatment:  early  deep  incision  down  to  the  seat 
of  the  suppuration,  curetting,  antiseptic  washing,  in 
many  cases  packing  with  gauze  wrung  out  of  a  1:2,000 
bichloride  solution,  and  the  application  of  an  antiseptic 
poultice  till  the  infection  is  gone.  Prompt  treatment 
of  this  character  will  save  many  fingers  and  hands  that 
are  of  the  utmost  value  to  those  most  generally  afflicted 
— the  working  classes.  Carbolic  solutions  have  a 
tendency  to  produce  gangrene  in  the  extremities  and 
should  be  avoided  in  these  cases.  Bichloride  solutions 
should  be  employed  according  to  the  dermal  irritability 
of  the  individual.  If  too  strong  they  may  produce  an 
irritation  of  the  skin,  and  even  poisoning. 

Charles  Lester  Leonard. 


Absinthism. — A  term  applied  to  the  train  of  morbid 
symptoms  following  the  abuse  of  the  liquor  called 
absinthe.  This  is  a  liquor  of  an  emerald  green  color, 
consisting  of  from  forty-seven  to  eighty  per  cent,  of 
alcohol,  highly  flavored  with  the  aromatics,  wormwood 
anise,  fennel,  coriander,  calamus  aromaticus,  hyssop, 
and  marjoram.  The  special  variety  of  this  drink 
depends  upon  the  proportions  and  kinds  of  these  flavors 
composing  it.  Its  quality  also  depends  upon  the 
quality  of  its  constituents.  Since  any  unpleasant 
taste  may  be  easily  concealed  by  the  strong  aromatic 
used,  the  alcohol  employed  in  this  liquor  is  frequently 
very  impure. 

Absinthe,  Artemisia  absinthium,  is  the  common 
wormwood,  the  bitterness  of  which  has  passed  into  a 
proverb.  It  is  said  to  contain  only  one-third  of  one 
per  cent,  of  the  oil  of  wormwood,  to  which  are  due  the 
characteristic  effects  of  the  beverage.  The  bitter 
principle  of  absinthium,  absinthin,  is  a  narcotic 
poison.  The  coloring  matters  used  in  absinthe  are 
often  very  deleterious;  in  fact  not  infrequently  cop- 
per salts  have  been  used  in  order  to  produce  the 
green  color. 

Absinthe  is  chiefly  used  in  France,  and  especially  in 
Paris.  It  was  introduced  there  after  the  Algerian  war 
of  184  1-7  by  the  soldiers,  who,  on  their  campaign,  had 
b  sen  advised   to  mix  absinthe  with   their  wine  as  a 


febrifuge.  Its  use  rapidly  increased  in  France  with 
such  disastrous  results  that  it  has  been  described  by 
French  physicians  as  constituting  a  graver  danger  to 
the  public  than  alcohol  itself. 

Symptoms. — Absinthism  develops  most  insidiously, 
and  the  habit  from  the  very  first  seems  almost  im- 
possible to  break.  The  symptoms  fall  naturally  into 
two  groups,  due  respectively  to  the  chief  ingredients  of 
the  liquor — alcohol,  and  the  essential  oil  of  wormwood 
which  has  a  special  affinity  for  the  brain  and  nervous 
system  in  general.  These  groups  may  be  subdivided 
according  to  their  physiological,  pathological,  and 
mental  effects. 

The  Physiological  Effects. — In  small  quantities  the 
oil  of  wormwood  quickens  the  heart's  action,  and  in 
larger  ones  it  is  a  narcotic.  It  slightly  increases  the 
secretions.  Amory,  in  his  experiments  with  absinthe, 
found  that  after  its  administration  the  nervous  centers, 
especially  the  cord,  were  congested.  Magnan  found  the 
cerebrum  and  spinal  cord  congested. 

The  Pathological  Effects. — Amory  found  an  infil- 
tration of  blood  in  some  places  in  the  nervous  centers. 
The  heart  was  soft  and  flaccid.  Phillips  states  that 
the  membranes  of  the  brain  and  cord  are  always 
injured.  The  lungs  are  congested,  and  extravasations 
of  blood  are  found  in  the  membranes  of  the  heart. 
Absinthe  drinking  is  followed  by  a  softening  of  the 
brain  and  general  paralysis  more  often  than  is  the 
drinking  of  alcohol. 

The  Mental  Effects. — Cadeac  and  Meunier  sum  up 
the  mental  effects  of  this  drug  as  follows:  Somnolence, 
torpor,  loss  of  memory,  intellectual  paralysis,  dul- 
ness,  complete  loss  of  will,  and  brutishness.  These 
effects  are,  as  a  rule,  observed  in  the  absinthe 
drinker. 

Absinthism  resembles  alcoholism,  except  that  certain 
features  are  exaggerated  and  some  new  features  are 
added,  for  absinthe  has  a  marked  physical  action  of  its 
own.  The  symptoms  of  absinthism  develop  far  more 
rapidly  than  those  of  alcohol.  What  has  been  said  of 
alcoholism  can  also  be  said  of  absinthism:  "  Alcoholism 
is  primarily  a  physiological  disease  comprising:  1. 
Paralysis  of  the  inhibitory  power  of  the  will;  2.  A 
temporary  amnesia;  3.  A  temporary  affective  and 
intellective  modification  of  the  personality." 

The  effects  of  a  small  dose  of  the  drug  are  giddiness, 
vertigo,  muscular  disorders,  and  convulsive  movements 
like  those  produced  by  successive  electric  shocks.  In 
a  stronger  dose  attacks  of  epilepsy,  more  or  less  violent, 
occur  which  are  not  produced  by  alcohol.  Brunton 
declares  that  these  convulsions  are  due  to  the  action 
of  absinthe  upon  the  medulla — not  upon  the  cerebrum. 
The  end  is  favorable,  as  a  rule,  but  may  be  fatal. 
Corning  has  investigated  the  action  of  absinthe  upon 
the  brain  and  other  nervous  centers,  and  confirms 
this  theory.  Brunton  says  that  absinthe  is  a  spinal 
stimulant 

Absinthe  Epilepsy. — Abel  says  that  absinthe  gives 
rise  to  hallucinations  from  the  very  first.  States  of 
delirium  are  often  observed  between  the  epileptic 
attacks,  and  there  may  be  delirium  without  epileptic 
seizures.  Marce  in  his  experimental  work  with  animals 
well  established  the  fact  that  the  principles  of  absinthe 
are  the  agents  in  causing  the  special  toxic  effects  noted 
in  absinthism.  The  epilepsy  may  develop  into  acute 
epileptic  insanity;  it  sometimes  occurs  without  any 
convulsive  attacks.  The  mania  may  begin  suddenly. 
The  return  to  sanity  is  usually  sudden,  and  is  accom- 
panied by  forgetfulness  of  the  acts  performed. 

Instead  of  ordinary  convulsive  attacks  of  epilepsy,  a 
person  may  have  a  variety  of  acute  mental  disturbances. 
The  delirious  attacks  of  absinthism  develop  suddenly. 
The  symptom-complex  appears  to  be  condensed  within 
the  shortest  possible  period. 

Amory  gives  a  comparative  table  of  the  temporary 
and  permanent  effects  of  absinthe  and  alcoholic  bever- 
ages generally,  founded  on  the  experiments  conducted 
by  Magnan  and  himself: 


54 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Absorption,  Nutritive 


Absinthe. 
Animal  perfectly  well  for 
fifteen  minutes,  at  the 
least,  after  the  ingestion, 
with  the  exception  of  a 
few  muscular  Switchings 

and  a  slight   uneasiness. 
Muscular   agitation,   com- 
mencing in  the  anterior 
portion  of  the  body. 

No  paralysis. 


Alcohol. 
In    a    very    few    minutes 
symptoms  of  inebriation, 
resulting  in  torpor. 


Epileptiform  convulsions 
and  rigidity,  resulting 
in  a  speedy  death. 

No  apparent  lesion,  ex- 
cept perhaps  a  slight 
cerebral  congestion, 
showing  the  cause  of 
death  to  be  intoxication 
by  the  poison. 


Paralysis,  commencing  in 
p  o  s  t  e  r  i  o  r  extremities, 

and  then  extending  to 
the  anterior. 

Paralysis  of  both  poste- 
rior and  anterior  ex- 
tremities  in   succession. 

No  convulsions.  Stupor, 
coma,  resolution,  and  a 
gradual  death. 

Lesions  of  the  brain  and 
of  the  alimentary  canal; 
gastritis  and  enteritis 
might  have  supervened, 
had  the  animals  lived 
long  enough  for  their 
development. 

In  general,  the  effects  of  absinthe  are  like  those  of 
alcohol,  but  the  former  develop  much  earlier,  and  arc 
of  a  severer  nature.  In  absinthism  there  is  also  a 
more  striking  disturbance  of  the  nervous  system. 

Emma  E.   Walker. 

Absorption,  Nutritive. — In  the  limited  sense  of  this 
article,  and  as  usually  accepted  in  physiology,  absorp- 
tion is  merely  the  process  by  means  of  which  nutritive 
material  is  taken  from  the  digestive  tract  into  the 
circulation.  [In  order  that  this  may  be  possible,  the 
food  must  undergo  a  process  of  digestion  by  which  the 
large  molecules  in  the  ingested  material  are  broken  up 
into  molecules  of  sufficiently  small  size  to  pass  through 
the  intestinal  mucous  membrane  into  the  Iacteals.] 

Certain  fluids  when  brought  into  contact  with  one 
another  will  mix  until  the  liquids  present  a  uniform 
composition,  and  the  passage  of  the  molecules  of  the  one 
liquid  into  the  intermolecular  spaces  of  the  other  has 
been  named  "diffusion."  When  the  same  or  similar 
two  liquids  are  separated  by  a  membrane,  this  diffusion 
takes  place  through  the  membrane  and  is  then  called 
"osmosis." 

For  a  long  time  osmosis  was  supposed  to  be  sufficient 
to  account  for  all  the  phenomena  of  absorption,  the 
process  seemed  so  delightfully  simple;  but  careful  studies 
revealed  the  fact  that  while  dead  membranes,  fluids, 
and  gases  under  certain  definite  conditions  obey  equally 
definite  laws,  osmosis  fails  to  explain  the  actions  of 
living  organs.  Theories  of  electrical  action  and  of 
differential  filtration  demonstrate  only  more  clearly  the 
complexity  of  the  function  of  living  absorbing  surfaces. 
Living  cells  obey  their  own  laws,  and  they  are  laws  of 
life,  not  of  mechanics.  As  the  unicellular  animal 
ingests,  digests,  absorbs,  and  excretes,  and  knows  what 
it  wants  and  w-hat  it  has  to  do,  so  in  the  complex  higher 
animal  each  cell  retains  all  these  functions,  while  the 
differentiation  of  the  organs  has  imposed  upon  each 
the  additional  labor  of  doing  something  for  the  general 
well-being  of  the  whole  organism.  The  work  assigned 
to  the  cells  of  the  different  parts  of  the  digestive  tract 
concerned  in  absorption  is  first  to  keep  themselves  in 
good  condition;  secondly,  to  pick  out  from  the  contents 
of  the  tract  such  substances  as  the  body  wants,  and 
pass  them  into  the  circulation.  It  is  safe  to  assert  that 
normal  absorption  is  a  living,  not  a  mechanical  act,  and 
that  osmosis,  as  a  factor  in  these  phenomena,  must  not 
be  alone  taken  into  account.  In  pathological  condi- 
tions, however,  in  conditions  in  which  the  separating 
membrane  has  been  injured  or  its  vitality  lowered, 
osmosis  may  well  come  in  as  a  strong  factor  in  swellings, 
effusions,  lymph  accumulations,  and  all  the  phenomena 
usually    designated  as  poor  absorption;  here  we  shall 


have  til  imagine  a  fight  between  the  Osmotic  and  the 
vital  processes,  the  latter  constantly  tending  In  check 
the  action  of  the  former,  until  recovery  takes  place 
ami  pure  osmotic  action  has  ceased. 

In  a  healthy  body  the  skin  can  be  excluded  as  an 
organ  of  absorption;  iii  spite  of  the  many  careful  experi- 
ments made  pin  and  con,  I  he  weight  of  authority  to-day 
rests  with   the  assertion  thai   under  normal  conditions 

the  skin  is  passive  so  far  as  absorption  i-  concerned. 

The  same  must  lie  said  about  the  muCOUS  membrane  of 

the  I ith  and  esophagus,  for  although   we  know    that 

violent  poisons  can  be  and  are  taken  up  by  the  mucous 

membrane  of  the  mouth,  under  ordinary  conditions  f I 

docs  not  stay  there  long  enough  to  allow  of  any  a  I  isorp- 
tion  to  take  place.  That  limits  the  absorbing  surfaces 
of  the  human  body  to  the  mucous  membranes  and  allied 
structures  of  the  stomach  and  of  the  small  and  large 
intestines. 

While  the  nature  of  the  food  eaten  determines  the 
length  of  the  digestive  tract  in  any  given  species,  the 
absorbing  surfaces  bear  a  definite  relation  to  the  bulk 
of  the  body  and  explain  why  the  body  stops  growing 
after  a  certain  size  has  been  attained.  During  a  given 
limit  of  time  the  absorbing  surfaces  increase  as  their 
square  while  the  body  increases  in  bulk  as  its  cube.  In 
other  words,  if  we  assume  that  the  absorbing  surface 
equals  2,  and  the  body  bulk  equals  2,  then  by  the  time 
the  former  has  grown  to  equal  4  the  latter  equals  S;  and 
when  the  former  has  increased  again  to  16,  the  hitter's 
bulk  is  512.  It  is  easy  to  see  how  the  growth  of  bulk  is 
checked  by  the  limitations  of  the  absorbing  surfaces. 

The  substances  to  be  absorbed  are  peptones,  glucose, 
and  emulsified  fat,  the  products  of  digestion,  besides 
water  and  different  salts  which  have  remained 
unchanged. 

The  stomach  has  no  specialized  organs  of  absorption, 
but  its  whole  mucous  membrane  may,  under  certain 
conditions,  absorb  materials  digested  in  its  cavity, 
peptones  and  glucose.  The  older  view  which  made  the 
stomach  practically  the  only  organ  worth  mentioning 
of  the  digestive  tract,  and  took  it  for  granted  that  its 
function  in  the  absorption  of  peptones,  glucose,  salts, 
and  water  was  of  proportionate  importance,  has  been 
slowly  changed  by  the  results  of  modern  experiments. 
Without  going  to  the  other  extreme  view  which  makes 
the  stomach  merely  the  temporary  receptacle  for  food, 
these  experiments  prove  that  absorption  of  the  above 
named  substances  may  take  place,  but  only  to  a  limited 
extent.  Of  the  carbohydrates,  dextrose,  lactose, 
maltose,  and  saccharose,  even  dextrin,  may  be  absorbed 
by  the  mucous  membrane  of  the  stomach,  and  the  more 
concentrated  the  solutions,  the  more  marked  is  the 
absorption.  Peptones  are  absorbed  slowly  and  appar- 
ently with  difficulty,  while  condiments  and  alcohol 
increase  distinctly  the  absorbing  power  of  the  stomach. 

Perhaps  the  most  interesting  and  least  noticed  fact 
brought  out  by  these  experiments  is  that  practically 
no  water  is  absorbed  by  the  stomach,  but  that  all  passes 
into  the  intestines;  on  the  other  hand,  alcoholic  solu- 
tions are  readily  taken  up.  This  fact  may  ultimately 
help  to  explain  why  water  is  the  beverage  most  desired 
when  men  are  thirsty,  and  why  something  mixed  with 
the  water  seems  necessary  when  people,  not  thirsty, 
gather  and  drink  for  social  enjoyment. 

Peptones,  glucose,  and  emulsified  fats  are  absorbed 
mostly  in  the  small,  and  to  a  limited  extent  in  the  large 
intestines.  Throughout  the  large  and  small  intestines 
w-e  find  organs  specialized  for  absorption,  viz.,  the  villi 
and  the  solitary  glands.  The  former  are  most  numer- 
ous in  the  duodenum  and  jejunum,  the  latter  in  the 
ileum.  Throughout  the  large  intestines  we  find  solitary 
glands,  but  no  villi,  irregularly  scattered,  the  largest 
numbers  in  the  cecum  and  appendix  vermiformis;  and 
their  limited  number,  together  with  the  well-known  high 
absorbing  power  of  the  large  intestine,  leads  us  to 
think  that  its  mucous  membrane  is  an  important  factor 
in  absorption. 

The  villi,  little  cone-shaped  protuberances  in  the 


55 


Absorption,  Nutritive 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


mucous  membrane,  have  a  dense  network  of  blood  capil- 
laries just  underneath  their  epithelial  covering,  while  a 
lacteal  duct  occupies  the  center  of  the  cone.  The  soli- 
tary glands  have  a  dense  lacteal  plexus  beneath  the 
membrane  and  a  limited  supply  of  blood  capillaries.  All 
the  blood  capillaries  of  the  intestinal  tract  are  radicles 
of  the  portal  vein,  while  the  lacteal  ducts  are  radicles 
of  the  abdominal  lymphatics.  The  villi,  however,  are 
the  principal  organs  and  carry  the  bulk  of  the  peptones 
and  sugars  into  the  circulation  directly,  while  the  emul- 
sified fats  absorbed  are  poured  by  the  way  of  the  lac- 
teals  and  abdominal  lymphatics  into  the  cisterna  chyii, 
and  from  there  through  the  thoracic  duct  into  the  left 
subclavian  vein. 

How  much  the  peptones  absorbed  are  changed  in  their 
passage  through  the  epithelial  cells  of  the  villi,  and  how 
much  additional  modification  takes  place  in  the  capil- 
laries and  veins  before  the  absorbed  material  enters  the 
liver,  is  as  yet  a  matter  of  conjecture.  [The  modern 
teaching  inclines,  however,  to  the  theory  that  the  pep- 
tones as  such  are  not  absorbed,  but  are  further  split  into 
aminoacids  which  are  synthetized  in  the  columnar  cells 
of  the  villi  into  serum-globulin  and  serum-albumin  and 
in  this  form  the  protein  is  carried  to  the  tissues.]  The 
knowledge  that  everything  ingested,  with  the  exception 
of  fat,  and  water  enough  to  emulsify  the  fat,  has  to  pass 
through  the  liver  before  the  body  can  make  use  of  it, 
will  probably  increase  our  respect  for  that  long-neglected 
and  much-abused  organ. 

The  emulsified  fats  are  split  up  into  fatty  acids  and 
glycerin  which  are  taken  up  by  the  epithelial  cells  and 
passed  into  the  stroma  of  the  villus,  there  to  be  recon- 
verted into  minute  fat  globules.  Whether  these  now 
pass  directly  into  the  delicate  lymph  channels  which 
traverse  the  villus  and  finally  unite  to  form  the  lacteal, 
or  whether  the  lymphocytes,  so  abundantly  found  in  the 
stroma,  carry  the  small  fat  globules  from  the  epithelial 
cells  directly  into  the  lacteal,  is  yet  an  unsettled  ques- 
tion. Under  ordinary  conditions  only  fat  enters  the 
lacteals,  while  peptones  and  sugar  find  their  way  into 
the  blood  capillaries;  but  that  does  not  preclude  the 
possibility  that  after  an  excessively  fat  meal,  a  trace  of 
fat  can  find  its  way  into  the  blood  capillaries,  as  well  as 
that,  in  cases  in  which  an  excess  of  meat  and  carbohy- 
drates has  been  eaten,  a  trace  of  either  can  be  found  in 
the  lacteals. 

[The  carbohydrates  of  the  food  are  converted  into  the 
small-molecular  glucoses  which  are  taken  into  the 
radicles  of  the  portal  vein  and  pass  into  the  liver.] 

The  absorbing  power  of  the  small  intestine  is  about 
equal  to  the  task  of  taking  up  the  quantity  of  fluid 
formed  by  the  action  of  the  digestive  ferments  plus  the 
quantity  of  fluids  secreted  by  the  pancreas,  liver,  and 
intestinal  glands,  and  thus,  as  these  quantities  com- 
bined do  not  represent  the  total  amount  of  fluid  present, 
the  contents  of  the  small  intestine  remain  fluid  through- 
out its  entire  length.  In  the  large  intestine  the 
conditions  change,  the  absorbing  power  is  high,  secre- 
tion and  digestion  are  limited,  and,  as  a  consequence, 
the  contents  become  more  and  more  pasty  as  they  near 
the  rectum,  until  finally  the  feces  contain  that  portion  of 
the  food  ingested  which  has  escaped  digestion  and 
absorption.  The  absorbing  power  of  the  large  intestine 
is  not  limited  to  substances  prepared  by  the  action  of 
the  digestive  fluids,  but  it  can  absorb  undigested  food, 
such  as  white  of  egg,  although  it  is  probable  that  even 
here  there  is  a  splitting  up  of  the  protein  molecule  into 
smaller  molecules  before  absorption  takes  place.  Nutri- 
ent enemata,  based  upon  this  knowledge,  have  saved  the 
lives  of  many  patients. 

The  final  test  of  the  activity  of  absorption  as  well  as 
of  digestion  is  a  chemical  ami  physical  examination  of 
the  f  sees,  for  the  details  of  which  the  reader  is  referred 
tn  the  article  cm  Fir,:,,  crniui 'nation  fftlir. 

Julius  Pohlman. 

Abstracta. — Abstracts  are  solid,  powdered  prepara- 
tions, no  longer  official.     They  were  introduced  into  the 


United  States  Pharmacopoeia  of  1SS0,  and  were  believed 
to  have  advantages  not  possessed  by  the  ordinary  ex- 
tracts, which  latter  preparations  they  were  designed  to 
supplant.  However,  in  spite  of  certain  good  qualities, 
they  did  not  come  into  general  use;  and  in  subsequent 
revisions  of  the  Pharmacopoeia  they  were  not  retained. 
Abstracts  possessed  the  advantage  of  definite  and  uni- 
form strength,  each  gram  of  the  abstract  being  equal 
to  two  grains  of  the  crude  drug  or  fluidextract.  The 
advantages  of  the  abstracts  are  given  by  Remington,  as 
follows:  "(1)  Each  abstract  represents  twice  the 
strength  of  the  drug  or  fluidextract  from  which  it  is 
prepared.  (2)  They  are  dry  powders,  if  properly 
made,  and  thus  are  permanent  and  portable;  not  sub- 
ject to  precipitation  as  fluidextracts  are;  not  liable  to 
become  hard,  tough,  and  variable  in  strength,  as  is  the 
case  with  extracts.  (3)  Injurious  exposure  to  heat  is 
entirely  avoided,  and  the  official  process  of  1SS0  requires 
no  apparatus  but  such  as  either  is  at  hand  in  the  phar- 
macy, or  can  be  easily  obtained  by  a  pharmacist  operat- 
ing on  a  small  scale.  (4)  The  final  thorough  tritura- 
tion of  the  dry  powder  reduces  the  soluble  and  active 
constituent  of  the  drug  to  a  pulverulent  condition,  the 
diluent  is  soluble,  and  the  fine  state  of  division  of  ab- 
stracts is  the  most  favorable  condition  that  a  powder 
can  possess  to  secure  efficient  medication."  Eleven 
abstracts  were  official  in  the  U.  S.  Pharmacopoeia  of 
1S80.  R.  J.  E.  Scott. 

Abulia. — From  a- privative,  and  flo>Sk-q,  will.  Paralysis 
of  the  will,  a  condition  in  which  the  subject  has  lost 
the  power  of  decision  or  initiation.  It  may  be  mistaken 
for  paralysis  in  certain  extreme  cases,  but  the  power  of 
movement  is  present,  the  motor  impulse  only  being  in 
abeyance. 

Abulkasim. — (Abul  Kasim  Chalaf  Ben  Abbas  el- 
Zahrawi.)  Arabian  physician  and  surgeon  born  in 
Zahra  near  Cordova,  Spain.  The  exact  dates  of  his 
birth  and  death  are  not  positively  known,  but  he  flour- 
ished in  the  tenth  century  and  was  physician  to  the 
Caliph  Abd-el-Rahman  III.  According  to  the  Arabian 
chronicles  he  died  in  the  year  1013  at  the  age  of  101 
years,  so  that  the  year  of  his  birth  was  912.  No  details 
of  his  life  are  known.  The  first  part  of  his  compendium 
of  medicine  ("  Altasrif")  was  published  in  Latin  in  the 
sixteenth  century  as  Liber  tkeoricm  nee  non  practices 
Alsaharavii  i  Augsburg,  1519).  The  second,  surgical, 
part  was  published  at  Venice  in  1497:  a  Latin  transla- 
tion appeared  at  Basle  in  1541;  an  edition  in  Arabic  and 
Latin,  edited  by  Channing,  was  published  at  Oxford  in 
1778.  A.  H.  B. 

Acacia. — Gum  Arabic,  Gum  Acacia,  Gum  Senegal. 
"A  gummy  exudation  from  Acacia  Senegal  Willd. 
and  other  species  of  Acacia  (fain.  Leguminosa)" 
(U.  S.  P.).  In  roundish  tears,  often  an  inch  or  more 
in  diameter,  transparent,  except  for  the  whitish 
fissures,  of  a  glassy,  veiny,  or  fissured  fracture, 
ranging  from  nearly  colorless  to  a  deep  reddish- 
yellow,  nearly  tasteless  and  odorless,  wholly  soluble 
in  two  parts  of  water,  to  form  a  thick  mucilage  of 
a  faintly  acid  reaction.  The  official  article  is  re- 
stricted to  a  color  not  darker  than  "pale  amber." 
The  presence  of  starch  in  powdered  acacia  is  detected 
by  a  blue  color  on  the  addition  of  iodine,  that  of 
dextrin  by  a  red  color.  A  pure  solution  will  not  be 
affected  by  neutral  lead  acetate. 

This  gum  was  formerly  yielded  by  other  species  of 
Acacia,  notably  -4.  vera  Willd.,  and  the  very  finest 
gum  of  commerce  still  proceeds  from  this  species. 
It  is  chiefly  in  smaller  tears,  which  are  more  brittle 
and  broken,  and  less  translucent  and  glassy,  owing 
to  the  much  more  numerous  fissures.  Both  species 
are  small  thorny  trees  of  northern  Africa,  A.  vera 
more  abundant  in  the  eastern,  A.  Senegal  in  the 
western  districts.  The  gum  is  a  decomposition 
product  from  cellulose  and  is  more  abundantly  pro- 


56 


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Acanthosis  Nigricans 


duced  by  unhealthy  trees.  It  exudes  from  natural 
fissures  and  artificial  incisions.  Gums  practically 
equivalent  to  acacia  are  produced  by  species  in 
related  genera.  An  excellent  article  is  produced  by 
species  of  Proaopis,  growing  in  the  southwestern 
United  States,  and  known  as  Mesquit  gum,  bu1  the 
supply  is  too  irregular  to  be  utilized.  Some  of  these 
substituted  articles,  as,  for  example,  Ghatti  gum,  are 
very  inferior.  The  varieties  of  acacia  are  now  little 
known  by  the  locality-names  formerly  applied  to 
them,  the  grading  being  done  almost  wholly  by 
number,  the  quality  depending  upon  whiteness  and 
solubility.  The  pure  gum  consists  wholly  of  com- 
pounds of  arabic  acid  with  potassium,  calcium,  and 
magnesium.  Acacia  has  no  physiological  action, 
except  that  of  a  mechanical  demulcent.  Its  pharma- 
ceutical uses,  as  an  excipient,  for  emulsionizing,  and 
for  suspending  insoluble  substances  or  those  the 
acridity  of  which  it  is  desired  to  mitigate,  are  very 
numerous  and  important.  Henry  H.  Rusby. 

Acanthaceae. — (Acanthus  family).  A  large  family, 
related  to  the  Mints  and  Vervains,  but  unimportant 
except  for  its  very  rich  ornamental  properties. 
Many  species  have  been  utilized  in  the  materia 
medica  of  British  India,  and  the  properties  of  Adha- 
toda  (see  Vasicine)  are  very  peculiar.  The  principles 
are  mostly  resinous  and  amaroidal,  with  a  few- 
alkaloids,  and  all  the  recorded  actions  and  uses, 
except  those  of  Adhatoda,  are  rather  indifferent. 

H.  H.  R. 

■Want hia. — A  genus  of  true  bugs,  Hemiptera,  para- 
sitic on  birds.  These  insects  are  sometimes  introduced 
into  human  habitations  and  attack  man.  They  are 
serious  house  pests  in  some  parts  of  Mexico.  See 
Insects,  parasitic.  A.  S.  P. 

Acanthocephala. — A  suborder  of  nematode  worms 
which  have  no  alimentary  canal.  The  adult  stage 
occurs  in  the  intestine  of  vertebrates,  as  a  rule  those 
which  live  in  or  near  water;  the  larva  are  found  in 
the  bodies  of  certain  invertebrates,  very  frequently 
small  Crustacea.  All  these  worms  possess  a  retrac- 
tile proboscis  armed  with  rows  of  hooks  by  means 
of  which  they  cling  to  the  intestinal  wall  of  their 
host;  hence  they  are  called  "hook-headed  worms." 
The  genus  Gigantorhi/nchus  occurs  commonly  in  pigs, 
mice,  rats,  etc.,  and  has  been  reported  in  man;  Echi- 
norhynchus  has  also  been  taken  from  the  human 
intestine.     See  Nematoda.  A.  S.  P. 

Acantholysis  Bullosa. — This  rare  dermatosis,  known 
formerly  as  epidermolysis  bullosa  hereditaria,  is  a 
typical  familial  anomaly,  capable  of  being  perpetuated 
through  several  generations,  manifest  in  infancy  or 
early  childhood  and  insusceptible  of  modification  by 
treatment.  Like  urticaria  factitia  and  hemophilia 
it  is  a  predisposition  only,  requiring  slight  external 
irritation  to  become  manifest.  As  some  eases  occur 
in  isolated  individuals  the  adjective  hereditary  cannot 
literally  be  used  to  designate  the  affection  as  a  whole. 

A  comparatively  new  disease,  acantholysis  bullosa 
has  very  probably  masqueraded  in  past  years  as 
pemphigus,  or  as  a  simple  idiosyncrasy,  since  it  is 
obvious  that  very  slight  irritation  will  raise  blisters  on 
certain  subjects. 

The  bulls  which  characterize  the  disease  vary 
considerably  in  size  and  aside  from  a  slight  tendency 
to  hemorrhage  present  no  peculiarities.  They  tend 
to  appear  wherever  the  clothing  bears  or  rubs  against 
the  skin  (neck  band,  wrists);  on  pressure  surfaces 
where  ordinary  blisters  and  callosities  tend  to  form; 
over  the  knees  and  elbows,  because  these  joints  when 
flexed  serve  for  support,  and  at  the  site  of  chance 
knocks,  etc.  It  is  asserted  confidently  that  blebs 
never  appear  spontaneously.  In  cases  in  which 
patients  use  certain   members   habitually  a  sort   of 


occupational  disease  may  !)!•  set  up.  A  draughtsman 
constantly  holding  a  pencil  bet  ween  his  fingers  and 
thumb  may  suffer  from  an  almost  Continuous  forma- 
tion of  bulla'  where  the  implement  presses  He  may 
even  as  a  result  undergo  slight  atrophy  of  the  linger 
lips  and  lii-s  of  the  nails.  Under  ordinary  circum- 
stances no  permanent  changes  occur  beyond  possible 
slight  scarring  and  pigmentation,  with  alopecia  in 
hairy  regions.  A  rare  sequela  is  miliary  retention 
cysts  from  occluded  sweat  glands. 

Nothing  is  known  of  the  nature  of  the  affection. 
Certain  features  suggest  a  vasomotor  lability,  such 
as  underlies  a  number  of  other  superficial  affections. 

The  trauma  acts  upon  the  supposedly  irritable  blood- 
vessels and  causes  an  effusion  into  the  rote. 

Treatment  may  be  summed  up  in  protection  of 
exposed  areas  as  far  as  practicable. 

Acanthoma  Adenoides  Cysticum. — This  affection  of 
the  skin,  to  which  many  designations  have  been 
applied,  is  most  commonly  spoken  of  as  multiple 
benign  cystic  epithelioma  or  simply  benign  epitheli- 
oma. It  is  characterized  by  the  formation  of  insensi- 
tive tubercles  or  nodules,  which  are  at  first  of  pin- 
head  size  and  seldom  exceed  that  of  a  pea.  They 
resemble  very  much  a  beginning  epithelioma,  having 
the  same  pearly  appearance,  varying  to  pinkish  or 
yellowish.  They  are,  however,  numerous  as  a  rule; 
and,  usually  discrete  in  distribution,  are  at  times 
clumped  together.  They  usually'  occur  on  the  face, 
especially  the  central  portion,  including  the  eyelids, 
root  of  the  nose,  lower  part  of  the  forehead,  and 
cheeks,  but  are  sometimes  seen  on  the  trunk  and 
arms.  Their  growth  is  slow,  and  has  a  well  defined 
limit.  More  or  less  colloid  transformation  may  ensue. 
Firmly  embedded  in  the  skin,  they  cannot  be  shelled 
out  and  when  punctured  only  a  little  serum  or  blood 
escapes,  unless  colloid  degeneration  has  occurred.  In 
rare  cases  in  which  epithelioma  has  developed  in  these 
growths  there  may  have  been  no  actual  transition 
from  benign  to  malignant,  for  this  is  always  extremely 
rare  in  benign  growths  of  any  sort. 

In  the  recorded  material  are  a  number  of  instances 
of  familial  incidence,  but  this  is  not  the  rule.  The 
affection  occurs  irrespective  of  age  and  sex,  but  has 
some  tendency  to  appear  at  puberty.  Some  forms 
have  evidently  been  classed  as  varieties  of  the  acne  of 
puberty,  for  both  milium  and  comedones  may  be 
closely  simulated  during  the  onset  of  the  affection. 
According  to  a  number  of  authors  some  of  the  cases 
reported  as  belonging  to  this  affection  should  have 
been  lymphangioma  tuberosum  multiplex,  an  un- 
related dermatosis  having  only  a  possible  clinical 
resemblance. 

Benign  epithelioma  is  purely  a  neoplasm,  the 
etiology  and  nature  of  which  are  no  clearer  than  those 
of  other  benign  growths.  Histologically  it  is  com- 
posed of  formless  masses  and  long  processes  of 
epithelial  cells  not  unlike  those  seen  in  true  epitheli- 
oma. Cell  nests  or  pearls  are  to  be  found.  The  irre- 
sponsible arrangement  of  the  cells  suggests  an  origin 
from  misplaced  embryonal  residues.  We  are  entirely 
in  the  dark  as  to  how  formations  so  generally  resem- 
bling true  epithelioma  can  be  benign,  but  the  latter 
is  a  disease  of  the  degenerative  period  of  life,  while 
benign  epithelioma  usually  develops  at  puberty. 
Practically  there  is  hardly  any  chance  of  confounding 
the  two  affections  in  the  clinic.  When  benign  epithe- 
lioma is  removed  with  the  curette,  incision  and 
evacuation,  or  electrolysis,  there  is  considerable 
tendency  toward  recurrence.  The  affection  should 
not  be  confounded  with  molluscum  contagiosum, 
simple  colloid  degeneration  of  the  skin,  or  cysts  of  the 
sweat  glands  (hydrocystadenoma). 

Acanthosis  Nigricans. — Synonym:  Dystrophie  pap- 
illaire  et  pigmentaire  (Darier).  A  disease  of  the 
skin     and     mucous     membranes     characterized     by 


57 


Acanthosis  Nigricans 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


hyperpigmentation  and  papillary  hypertrophy,  devel- 
oping, in  the  majority  of  cases,  in  the  course  of  an 
abdominal  cancer. 

The  first  recorded  case  of  this  disease  occurred  in 
a  patient  in  Unna's  Clinique  for  Skin  Diseases  in 
Hamburg,  and  was  described  by  the  present  writer 
in  the  "International  Atlas  for  Rare  Skin  Diseases," 
No.  4,  Plate  X.,  in  1889.  Since  then  cases  have  been 
observed  in  nearly  all  the  countries  of  Europe  and 
in  this  country.  Couillaud,1  in  a  monograph  pub- 
lished in  1S9G,  was  able  to  record  thirteen  cases.  In 
1909  the  writer  was  able  to  report'  fifty-two  cases  of 
the  disease  collected  from  the  literature. 

The  disease  usually  begins  with  a  slaty  or  brownish 
discoloration  of  the  skin  of  the  neck,  about  the  genital 
organs,  and  the  umbilicus.  In  other  cases  the  first 
symptom  to  attract  the  patient's  attention  is  the 
papillary  or  condylomatoid  proliferation  affecting  the 
mucous  membranes  of  the  mouth.  Other  regions 
that  may  be  affected  are  the  flexor  surfaces  of  the 
extremities,  the  axilla?,  and  the  inframammillary 
region,  the  anal  region,  and  in  women  the  vulval  and 
vaginal  mucosa?  A.  striking  feature  of  the  distribu- 
tion of  the  disease  is  its  almost  perfect  symmetry. 
The  pigmentation  varies  from  a  light  gray  to  a 
bluish-black  in  color.  It  occurs  over  large  areas  and 
fades  at  their  borders  into  the  normal  color  of  the 
skin.  It  is  generally  coextensive  with  the  papillary 
hypertrophy,  but  sometimes  appears  as  a  precursor 
of  this  condition.  It  has  never  been  noticed  on  the 
mucous  membranes. 

The  papillary  hypertrophy  varies  in  degree  from  a 
slight  prominence  of  the  normal  areas  of  the  cuticle  to 
warty  excrescences  that  may  attain  an  elevation  of  a 
centimeter.  It  occurs  in  extensive  patches  in  the 
regions  noted  and  its  borders  merge  insensibly  into 
the  normal  skin.  The  patches  are  always  dry,  there 
is  no  exudation  even  from  pronounced  filiform 
excrescences,  and  they  impart  a  harsh  grating  sensa- 
tion on  palpation.  On  pinching  up  the  skin  the 
epidermis  is  seen  to  have  lost  its  elasticity,  but  the 
affected  regions  are  freely  movable  over  the  subcutis. 
There  is  no  appreciable  desquamation  from  the 
affected  areas.  On  the  mucous  membranes  the 
papillary  elevations  may  be  discrete  or  they  may  occur 
in  patches.  The  excrescences  sometimes  attain  a 
very  considerable  size,  and  in  appearance  and  con- 
sistency are  strikingly  like  venereal  warts,  but,  unlike 
them,  do  not  bleed  readily  on  palpation. 

In  some  cases  of  long  duration,  changes  in  the 
appendages  of  the  skin  have  been  noted.  The  nails 
of  the  fingers  and  toes  become  dry,  cracked,  and  mis- 
shapen. The  hairs  on  the  head  and  over  the  entire 
body  become  dry  and  fragile  and  may  fall  out  spon- 
taneously, producing  a  total  alopecia. 

Anatomy  and  Pathology. — Under  the  microscope 
changes  corresponding  to  the  clinical  picture  are 
found.  The  horny  layer  appears  somewhat  thick- 
ened; the  granular  layer  shows  several  rows  of 
keratohyaline  cells;  the  rete  Malpighii  is  the  seat  of  an 
hypertrophy  which  in  some  sections  attains  the 
enormous  dimensions  seen  ordinarily  in  common 
warts,  and  its  lowest  layer  contains  great  quantities 
of  pigment.  The  papilla?  are  elongated,  sometimes 
attaining  a  length  of  six  or  eight  millimeters,  and 
often  ramify,  following  the  digitations  of  the  epithe- 
lium above  them.  They  show  no  evidence  of  increase 
in  width.  The  subpapillary  layer  and  the  cutis  itself 
show  but  very  slight  changes — a  moderate  increase 
in  the  number  of  emigrated  cells,  of  mast  and  pigment 
cells. 

In  considering  all  the  cases  recorded  we  may  divide 
them  into  two  groups:  those  occurring  in  children, 
the  juvenile  type,  and  those  occurring  in  adults. 
In  the  juvenile  type,  about  one-third  of  the  known 
cases,  the  disease  once  established  remains  stationary 
and  the  patients  seem  to  suffer  no  inconvenience 
except  from  the  disfigurement.     In  the  adult  cases, 


that  is,  those  developing  after  the  age  of  nineteen  or 
twenty  years,  an  abdominal  cancer  has  been  found 
or  strongly  suspected  on  clinical  grounds  in  a  pre- 
ponderating number,  not  less  than  eighty  per  cent. 
In  the  two  cases  in  which  an  autopsy  was  obtainable 
there  was  an  extensive  carcinosis  of  the  abdomen, 
which,  while  it  spared  the  adrenal  bodies,  was 
especially  noted  as  involving  the  lymph  glands  in 
close  proximity  to  the  large  sympathetic  ganglia. 
There  is  little  doubt  but  that  the  disease  is  directly 
dependent  on  the  existence  of  abdominal  cancer,  but 
whether  it  be  a  cutaneous  manifestation  of  a  peculiar 
cancer  intoxication  or  w-hether  it  be  due  to  changes 
induced  in  the  great  sympathetic  ganglia  through 
the  pressure  of  the  tumors  on  them,  or  to  the  com- 
bined action  of  both  these  causes,  is  a  matter  that 
future  investigation  must  determine,  but  from  the 
fact  that  acanthosis  nigricans  does  not  occur  in  the 
vast  majority  of  cases  of  cancer,  it  seems  reasonable 
to  ascribe  the  disease  to  a  special  localization  of  the 
tumor  which  deranges  the  functions  of  the  sympa- 
thetic ganglia  and  the  adrenals.  In  the  juvenile 
cases  there  is  some  ground  for  assuming  a  similar 
action  through  benign  tumors,  connective-tissue 
bands,  etc. 

i  Diagnosis. — Ichthyosis,  pityriasis  rubra  pilaris, 
and  keratosis  folliculorum  (Darier's  disease)  are  the 
only  diseases  which  may  bear  even  a  remote  resem- 
blance to  acanthosis  nigricans.  Ichthyosis  is  a  mild 
congenital  disease,  persists  throughout  life  without 
producing  any  general  disturbances,  is  most  pro- 
nounced on  the  extensor  surfaces,  never  affects  the 
mucous  membranes,  and  is  characterized  by  constant 
desquamation  in  more  or  less  extensive  scales. 
Pityriasis  rubra  pilaris,  sometimes  occurring  in 
extensive  sheets  about  the  great  flexures  and  pre- 
senting the  peculiar  discoloration  common  to  many 
hyperkeratoses,  may  suggest  acanthosis  nigricans,  but 
in  all  other  respects  there  are  more  points  of  difference 
than  of  resemblance  between  the  diseases.  Darier's 
disease  is  differentiated  by  the  limitation  of  the 
affection  to  the  follicles,  the  non-involvement  of  the 
mucosa,  the  peculiar  greasy  character  of  the  affected 
surfaces,  and  the  occasional  occurrence  of  large 
nodular  masses  from  which  a  foul  secretion  is  dis- 
charged. The  differentiation  from  the  various 
pigmentary  affections  of  the  skin  need  not  be  entered 
into. 

The  prognosis  of  the  disease  in  the  adult  cases  is,  of 
course,  that  of  the  underlying  cause — the  abdominal 
cancer;  that  is,  it  is  hopeless.  In  some  of  the  cases 
the  cutaneous  manifestations  have  undergone  a 
varied  course,  probably  depending  upon  changes  in 
the  location  or  size  of  the  tumors  in  the  abdomen. 
In  one  typical  case  the  cutaneous  lesions  disappeared 
in  the  course  of  six  months  after  a  radical  operation 
for  malignant  deciduoma.  In  my  own  case  there 
was  an  almost  complete  disappearance  of  the  affection 
of  the  skin  and  mucous  membranes  shortly  before 
the  patient  died.  Sigmund  Pollitzer. 

References. 

1.  Couillaud:  Dystrophie  pap.  et  pig.  ou  acanthosis  nigricans, 
Paris,  1896. 

2.  Pollitzer:  Journal  Am.  Med.  Assoc,  Oct.  23,  1909,  vol.  liii.,  p. 
1369. 

Acapnia. — From  a-  privative  and  na-rvbi,  smoke, 
vapor.  A  condition  in  which  the  amount  of  carbon 
dioxide  in  the  blood  is  reduced  below  the  normal.  This 
may  be  produced  voluntarily  by  taking  a  number  of 
deep  and  rapid  inspirations;  the  carbon  dioxide  in  the 
blood  is  thereby  reduced  in  amount,  and  as  this  gas  in 
the  blood  is  the  normal  stimulus  to  the  respiratory 
center,  the  result  is  apnea.  Persons  who  are  obliged 
to  hold  the  breath  for  a  long  time,  such  as  the  pearl 
divers  <>f  Ceylon,  are  aware  of  this  effect  of  rapid 
breathing  and  make  use  of  it  in  their  occupation.  The 
respiratory  paralysis  sometimes  occurring  under  ether 
anesthesia  is  attributed   by  Yandell   Henderson1  to 


;,.s 


iference  Handbook 

OF  THE 
lEDICAL    5CIENCES. 


Plate  IN 


Fig.  2.  Shows  the  discoloration  about  the  lips 
and  chin,  and  the  condylomatoid  proliferation  at 
the  angles  of  the  mouth. 


H 


Fig.  3.    Microscopic  section  through  one  of  the  condylomatoid  masses 
at  the  mouth. 

Acanthosis  Nigricans.     "Case  of  Dr.  S.    Pollitzerj  from  the  International  Atlas  of 

Rare  Skin  Diseases.' 


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Acclimatization 


acapnia  induced  by  the  excessive  pulmonary  ventila- 
tion in  the  primary  excitement  occurring  in  unskillful 
etherization.  The  same  investigator2  attributes  the 
shock  after  operation  largely  to  acapnia  resulting  from 
hyperpnea  during  beginning  etherization.  He  holds 
also  that  the  cessation  of  peristalsis  when  the  abdomen 
is  opened  is  due  to  local  acapnia  from  direct  exhala- 
tion of  CO,,  this  being  still  further  increased  by  laying 
hot  damp"  clothes  over  the  intestine.  Again  the 
uterine  contractions  of  normal  labor,  he  thinks,  arc 
stimulated  by  the  normal  carbon  dioxide  content  of 
the  blood;  and  the  ineffective  pains  of  tedious  labor 
arc  due  in  large  part  to  rapid  breathing  and  the  con- 
sequent acapnia.  The  conclusion  at  which  he  arrives 
as  a  result  of  numerous  observations  is  that  "C02 
tension  in  the  nerve  centers  and  in  the  tissues  and 
fluids  of  the  body  is  a  factor  in  the  maintenance  of 
tonus  (in  the  broad  sense  of  the  word)  of  the  same 
order  of  importance,  as  temperature,  oxygen  supply, 
osmotic  pressure,  and  the  equilibrium  of  anions  and 
cations."  (See  also  Anesthesia,  general  surgical,  sec- 
tion on  the  Role  of  carbon  dioxide. j  T.  L.  S. 

References. 

1.  Surgery,  Gynecology,  and  Obstetrics,  August,  1911. 

2.  American  Journal  of  Physiology,  April,  1909. 

Acardius. — See  Teratology. 

Acarina. — Acarida.  An  order  of  mites  of  the  class 
Arachnida.  These  arthropods  are  of  small  size,  are 
usually  ectoparasitic  in  habit,  and  their  structure 
shows  some  degeneration.  The  order  includes  a 
number  of  species  which  cause  various  dermal  dis- 
orders. Among  the  most  important  families  the 
following  may  be  mentioned:  Detnodicida:,  par- 
asitic in  hair  follicles;  Sarcoptidw,  the  itch-mites  of 
mammals;  Ixodidw,  the  ticks  temporarily  parasitic  on 
terrestrial  vertebrates.  Mites  usually  hatch  from 
eggs  in  an  immature  condition  and  undergo  a  meta- 
morphosis.    See  Arachnida.  A.  S.  P. 

Acaroides  gum.— See  Xanthorrhcea  Resin. 

Acarus. — An  old  name  for  the  genus  Sarcoptes 
which  includes  a  number  of  species  of  itch-mites. 
S.  scabiei  bores  galleries  in  the  human  skin,  pro- 
ducing itch,  and  may  also  be  a  cause  of  eczema.  See 
Arachnida.  A.  S.  P. 

Acinesia  Algera. — A  condition  characterized  by 
pain  on  movement.  This  is  purely  a  symptomatic 
designation  and  has  little  clinical  significance.  Most 
of  the  cases  previouslj'  called  by  this  name  are  of 
patients  suffering  from  myalgias,  indurative  myositis, 
or  intermittent  claudication.  S.  E.  J. 

Accidents. — See  Injuries,  and  Workingmen's  Com- 
pensation Acts. 

Acclimatization. — When  an3>-  animal,  brute  or 
human,  is  removed  from  the  environment  to  which  he 
and  his  ancestors  have  long  been  accustomed,  a  con- 
siderable disturbance  of  the  whole  economy  is  liable  to 
ensue.  The  process  of  evolution  has  developed 
certain  organs  and  certain  functions  in  accordance 
with  the  requirements  of  those  circumstances  under 
which  his  race  has  found  itself,  and  when  he  is  sud- 
denly transplanted  into  new  conditions  some  of  his 
faculties  become  without  occupation,  while  others 
hitherto  uncalled  upon,  and  therefore  undeveloped, 
are  suddenly  subjected  to  a  demand  to  which  they  are 
quite  unable  to  respond.  The  process  of  accommoda- 
tion of  the  individual  to  new  conditions  of  climate  is 
known  as  acclimatization  or  acclimation. 

No  other  animal  is  so  facile  in  his  accommodation  to 
changes  of  climate  as  man.  The  lower  animals  and 
plants  often  do  not  recover  for  several  generations 
from  the  effects  of  transplantation.     The  Society  d'- 


Acclimatisation  of  Paris  has  for  years  been  rallying 
on,  in  its  gardens,  an  extensive  zoological  experiment 
on  the  domestication  of  foreign  animals  and  plants 
which  it  is  believed  can   be  made  useful   to   European 

countries.     The  re <l  of  its  failures  and  successes  is 

embodied    in    the    numerous   volumes   of    its    reports. 

Man's  comparative   it unity   from    the   disastrous 

effects  of  changing  climate  is  due  in  part  to  his  ability, 
by  an  intelligent  prevision  of  the  dangers  which  are  to 
beset  him,  of  guarding  against   them. 

The  differences  in  the  facility  of  acclimatization  at 
various  points  in  the  -ami'  latitude  are  shown  by  an 
article  reprinted  in  the  Popular  Science  Monthly  for 
July.  1884.  Between  30°  and  :>>:>°  N.  latitude,  Euro- 
peans acclimate  much  less  readily  than  in  the  same 
latitudes  south.  Algiers,  for  instance,  is  vastly  more 
difficult  for  the  European  to  live  in  than  <  ape  ( lolony, 
yet  both  places  are  about  latitude  :i.">°.  The  Argentine 
( 'mi  federation  and  New  South  Wales  are  more  healthy 
than  the  East  and  West  Indies,  which  are  of  the  same 
latitude.  The  mortality  of  the  French  and  English 
troops  has  been  found  to  be  about  eleven  times  as 
great  at  foreign  stations  in  the  northern  as  at  those  in 
the  southern  hemisphere.  The  chief  cause  of  the  dif- 
ference is  in  the  prevalence  of  miasmatic  fevers  so 
deadly  to  Europeans.  Those  fevers  in  the  northern 
hemisphere  occur  even  in  high  altitudes,  while  south 
of  the  equator  they  do  not  extend  beyond  the  tropic. 
The  island  of  Tahiti,  for  instance,  about  latitude  18  S., 
is  quite  exempt  from  these  fevers.  The  records  of  the 
French  and  English  soldiers  on  foreign  service  show, 
in  South  America,  a  sickness  from  malarial  fevers  of 
L.6  in  1,000  men  per  annum;  while  in  a  similar  latitude 
in  the  northern  hemisphere,  the  number  of  such  cases 
annually  is  224  per  1,000. 

To  the  question,  "Can  Anglo-Saxons  ever  become 
completely  acclimatized  in  the  tropics?"  a  more  or 
less  guarded  negative  reply  has  been  given  by  proba- 
bly a  majority  of  the  most  eminent  authorities.  This, 
it  will  be  observed,  does  not  mean  that  Anglo-Saxons 
cannot  live  in  the  tropics  under  conditions  of  special 
caution.  It  does  imply,  in  the  minds  of  its  advocates, 
that  Europeans  can  never  expect  to  perform  the  same 
work  under  the  same  conditions  as  the  natives.  If  this 
be  the  case,  it  presupposes  the  continuance  of  a 
distinctively  menial  or  servile  class  as  a  permanency, 
which  appears  to  be  inconsistent  with  the  theory  of  a 
purely  democratic  colony. 

In  favor  of  the  pessimistic  view  regarding  tropical 
acclimatization  are  urged  the  high  death  rate,  the 
physical  deterioration,  and  the  reduced  fertility  of 
Europeans  in  the  tropics.  The  first  two  of  these 
considerations  are  certainly  matters  in  which  the 
improved  sanitation  of  recent  times  may  be  expected 
to  count  for  much.  In  fact,  the  annual  mortality  of 
European  troops  in  India,  which  prior  to  1S59  had 
been  69  per  1,000,  had  fallen  in  thirty  years  to  12  per 
1,000.  The  death  rate  of  European  children  in  India 
is  considerably  less  than  that  of  native  children,  and 
in  some  colonies  compares  favorably  with  that  in 
many  districts  of  Europe. 

Whether,  as  has  been  sometimes  claimed,  white 
families  in  the  tropics  are  likely  to  die  out,  is  difficult 
of  demonstration,  because  the  stock  is  liable  on  the 
one  hand  to  be  reinforced  by  fresh  European  immigra- 
tion, or  on  the  other  to  be  deteriorated  by  mixed 
marriages.  But  a  paper  presented  at  the  Seventh 
International  Congress  of  Hygiene  and  Demography 
by  Sir  Clements  Markham  shows  that  families  of  pure 
European  blood  had  been  settled  in  tropical  places  for 
more  than  two  centuries  without  any  deterioration, 
mentally  or  physically,  of  the  later,  as  compared  with 
the  earlier  representatives. 

Regarding  fertility  as  affected  by  removal  of  Euro- 
peans to  the  tropics,  great  diversity  of  opinion  has 
existed.  The  analogy  of  plants  seems  to  sugge-t  a 
loss  of  fertility,  at  least  temporarily,  from  a  change  of 
climate.     For  example,  the  chrysanthemum  is  said  to 


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have  remained  infertile  for  sixty  years  after  its  trans- 

Elantation  from  China  into  France,  so  that  the  seed 
ad  to  be  continually  imported.  But  after  that  time 
fertility  began  to  be  regained,  till  now  the  species 
propagates  itself.  European  fowls,  which  when  first- 
brought  to  Bolivia  became  sterile,  later  regained  their 
fecundity. 

Regarding  the  human  species,  however,  we  are  lia- 
ble to  error  in  judging  from  cases  in  which  infertility 
is  due  to  crossing  of  the  breed  with  inferior  races;  or 
when  possible  lack  of  fecundity  is  overcome  by  fresh 
European  admixture.  Yet,  as  against  a  permanent 
sterility  of  pure  European  families  in  the  tropics  there 
are  abundant  instances.  It  is  said  that  Spanish 
women  in  Guayaquil,  at  a  temperature  rarely  below 
S30  F.,  are  exceedingly  prolific,  and  that  the  French 
have  a  higher  birth  rate  in  Algeria  than  in  France. 

In  general,  we  may  say  that  it  is  not  temperature  or 
climate  intrinsically  which  is  the  obstacle  to  acclima- 
tization. Physiology  has  shown  the  marvellous 
adaptability  of  man  to  withstand  the  widest  ranges  of 
thermometric  variation.  Moreover,  anthropologists 
agree  that  mankind  is  all  descended  from  one  primi- 
tive stock.  Hence  man  has  acclimatized  himself,  as  a 
matter  of  fact,  wherever  by  successive  migrations  he 
has  permanently  occupied  new  fields. 

The  principal  climatological  changes  to  which  one 
must  accustom  himself  in  making  a  change  of  residence 
may  be  divided  into  those  of  (1)  barometric  pressure, 
(2)  humidity,  and  (3)  temperature;  of  these  the  last 
are  by  far  the  most  important. 

1.  Barometric  Pressure. — Leaving  out  of  account,  of 
course,  conditions  of  increased  atmospheric  pressure 
which  are  usually  artificial  (see  Caisson  Disease)  and 
if  not,  as  in  removing  from  a  high  altitude  to  a  low  one, 
are  of  little  practical  importance,  we  pass  at  once  to 
phenomena  accompanying  change  to  a  rarefied  atmos- 
phere, as  in  removing  from  the  sea-level  to  a  mountain- 
ous locality.  Persons  with  sound  hearts  and  arteries 
usually  experience  little  difficulty  in  accustoming 
themselves  to  altitudes  of  6,000,  7,000  or  even  10,000 
feet.  Many  of  the  most  thriving  cities  on  our  conti- 
nent are  at  such  heights  and  the  inhabitants  suffer  no 
inconvenience.  Mountain  climbers  inure  themselves 
to  elevations  of  upward  of  20,000  feet.  On  the  other 
hand,  people  with  weak  cardiac  muscles  may  be 
incapacitated  at  elevations  of  3.000  feet  or  less. 
Tuberculous  patients  visiting  high  altitudes  for  cure  are 
probably  somewhat  more  prone  to  pulmonary  hemor- 
rhages than  if  they  had  remained  at  a  lower  level. 

The  main  precaution  to  be  observed  for  those  who 
find  the  increased  respiratory  rate  embarrassing  is  to 
keep  perfectly  quiet  for  a  time  and  then  to  begin 
exercise  only  with  great  moderation.  Usually,  unless 
the  cardiac  insufficiency  is  considerable,  they  cam 
gradually  work  up  to  a  degree  of  activity  equal  to 
their  fellows.  If  they  return  to  a  lower  level,  however, 
and  from  thence  go  back  to  the  higher,  the  same  pre- 
cautions must  be  taken  as  in  the  original  instance. 

2.  Humidity. — This  is  generally  far  greater  in  the 
tropics  during  certain  seasons  than  in  temperate 
zones.  It  generally  goes  hand  in  hand  with  the 
amount  of  rainfall,  which  sometimes,  in  the  Philippine, 
for  instance,  rises  as  high  as  eighty  inches  in  two 
successive  days.  Independently  of  the  fact  that  a 
high  humidity  makes  heat  more  oppressive,  great 
moisture  is  liable  to  aggravate  rheumatic  affections. 
The  dangers  of  high  humidity  are  of  course  largelv 
unavoidable,  but  one  should,  if  possible,  make  his 
entrance  to  a  tropical  region  in  the  dry  rather  than 
the  rainy  season. 

3.  Temperature  Changes. — These  may  be  in  the 
direction  of  either  a  colder  or  a  warmer  climate. 
Regarding  the  former,  lit  lie  need  be  said.  Apart  from 
cases  of  starvation  and  freezing,  Arctic  explorers  usu- 
ally endure  cold  very  well.  The  facility  of  the 
acclimatization  of  the  negro  even  to  the  far  north  is 
shown   by   the   fact   that   among   the  few   men   who 


accompanied  Peary  nearly  or  all  the  way  to  the  north 
pole  was  a  negro.  Abundant  clothing  and  food  of  a 
high  caloric  value,  especially  fats,  are  the  obvious  and 
chief  fortifications  against  cold.  Four  thousand  or 
more  calories  per  day  are  requisite  for  an  adult. 

Acclimatization  against  Hot  Climates. — With  the 
great  expansion  in  late  years  of  our  country's  colonial 
possessions,  tropical  acclimatization  has  assumed  an 
importance  greater  than  ever  before,  and  fortunately 
nearly  coincidently  with  the  acquirement  of  new 
territory,  new  knowledge  has  come  to  us  of  how  to 
meet  many  of  the  dangers  hitherto  so  fatal. 

First  under  this  head  we  naturally  think  of  the 
effects  of  heat,  per  se.  The  precautions  to  be  ob- 
served here  differ  only  in  degree  from  those  we  are 
familiar  with  as  necessary  in  our  summers  at  home. 
Avoidance  so  far  as  may  be  of  the  direct  rays  of  the 
sun,  through  keeping  in  doors  in  the  middle  of  the  day, 
is  made  easier  by  the  tropical  custom  of  suspending 
business  for  three  or  four  hours  about  noon  and  con- 
cent  rating  work  in  the  morning  or  late  afternoon. 
Pleasure-seeking  is  naturally  confined  to  evening 
hours.  The  pith  helmet,  the  umbrella,  and  the  ha- 
bitual use  of  the  shady  side  of  the  street  (if  any)  are 
natural  protections  against  heat  stroke  and  sun  stroke. 
Quite  as  important  is  a  dietetic  regimen  which  will 
supply  less  calories  than  are  needed  in  a  temperate 
clime.  Two  thousand  or  less  calories  should  suffice 
the  average  adult.  Rice  as  a  staple  of  diet  has  long 
approved  itself  in  hot  countries.  Fruits  and  vege- 
tables may  largely  replace  protein  and  especially  fat 
foods.  Alcohol,  especially  in  its  stronger  forms, 
should  be  avoided  or  minimized.  The  free  use  of 
spirits  by  Englishmen  translated  to  India  has  long 
been  a  by-word  as  a  contributor  to  sickness.  Care 
must,  however,  be  exerted  in  the  use  of  drinking  water 
for  reasons  which  will  shortly  be  considered. 

We  come  now  to  the  greatest  dangers  in  the  way  of 
warm  acclimatization.  These  are  from  diseases 
many  of  them  caused  by  protozoa  which  find  inter- 
mediate hosts  in  insects. 

First  of  these  in  importance  is  the  group  of  malarial 
diseases.  It  is  these  that  have  made  large  tracts  of 
the  earth  uninhabitable  to  white  men  for  centuries. 
While  the  typical  tertian,  double  tertian,  and  quartan 
types,  characterized  by  more  complete  periodicity, 
are  found  in  many  temperate  climates  it  is  the  sub- 
tertian,  or  estivoautumnal  type  which  manifests  the 
greatest  malignancy  and  this  is  practically  limited  to 
tropical  and  subtropical  climates.  In  all  kinds  of 
malaria,  however,  the  microorganism  penetrating  to 
the  blood-corpuscles  develops  asexually  and  with  the 
pouring  forth  of  the  new-formed  organism  after  the 
rupture  of  the  blood-cell,  comes  the  chill. 

The  sexual  propagation  of  the  various  parasites 
takes  place  generally  in  the  body  of  the  mosquito, 
which  sucks  out  the  parasites  in  the  action  of  biting  a 
person  who  carried  them.  After  undergoing  develop- 
ment in  the  mosquito  they  are  again  injected  into 
the  next  person  when  that  insect  bites.  It  is  the 
Anophelina:  alone  among  mosquitos which  carry  the 
malaria  parasite.  They  take  it  from  man  and  recarry 
it  to  man. 

The  aim  in  preventing  this  infection  is  therefore  to 
protect  from  this  mosquito.  If  this  protection  is 
made  complete  the  otherwise  deadliest  malarial 
swamp  will  be  perfectly  safe.  In  the  attempt  to 
fortify  every  portion  of  the  line  one  seeks: 

(1)  To  limit  the  malarial-bearing  pabulum  of  the 
mosquito  by  treating  all  infected  persons  with  quinine 
to  kill  off,  as  far  as  possible,  the  organisms  from  their 
blood. 

(2)  To  prevent  the  mosquito  from  hatching  by 
(n)  removing  by  a  drainage-system  standing  water 
where  they  may  breed;  the  cultivation  of  soil  also 
tends  to  absorb  standing  water;  ('0  when  water  cannot 
be  got  rid  of,  by  covering  its  surface  with  petroleum, 
so  that  any  larva;  may  thus  be  killed;  (c)  screening 


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houses  and  also  beds  so  thai  any  mosquitos  if  they  are 
hatched  and  then  become  infected,  they  cannot  bite 

another  individual;  (</)  the  prophylactic  use  of  quinine 
to  prevent  the  growth  of  any  organism  which  t  trough 
some  slip  in  the  previous  precautions,  may  have  been 
injected  into  the  body. 

yellow  fever  is  known  to  be  also  transmitted  by  a 
mosquito,  in  this  case  the  Stegomyia  fasciala  (S. 
ealopus).  The  discovery  of  this  fact  and  the  vigorous 
war  on  the  insect  has  robbed  many  places  like  Cuba 
and  the  Panama  zone  of  most  of  the  perils  with  which 
they  were  formerly  associated.  The  successful 
accomplishment  of  the  Panama  canal  would  probably 
have  been  well  nigh  impossible  but  for  protection 
afforded  through  this  knowledge.  Though  the  specific 
organism  of  yellow  fever  has  not  yet  been  found  in  the 
blood,  it  is  certain  by  the  observations  of  Reed  and 
his  associates  that  it  exists  in  the  blood  during  the  first 
three  days,  that  the  specific  mosquito  (ami  it  alone! 
may  withdraw  it  during  this  time  and  after  ten  days 
is  capable  of  reinjecting  it  by  its  bite  into  a  second 
susceptible  person.  Hence  all  the  former  precau- 
tions as  to  discharges,  purity  of  drinking  water,  etc., 
however  admirable  on  other  h3-gienic  grounds,  are  of 
no  possible  use  in  protecting  the  individual  against 
yellow  fever. 

The  trypanosome  has  been  found  as  a  parasite  in 
the  urine  of  many  species  of  the  lower  animals.  In 
man  but  one  or  two  species  have  yet  been  discovered. 
The  most  important  is  the  Trypanosoma  gambiense, 
w  Inch  is  the  cause  of  the  dreaded  sleeping  sickness,  a 
malady  which  has  long  existed  in  Africa  and  which  since 
the  opening  up  of  that  continent  has  largely  increased. 
This  parasite  is  undoubtedly  carried  and  distributed 
by  certain  species  of  flies  belonging  to  the  genus  67ns- 
sina.  The  larva?  of  these  insects  are  found  in  decay- 
ing vegetation  and  the  pupa?  in  banks  covered  with 
trees  near  open  water.  Some  species  live  near  the 
ground  and  are  especially  prone  to  bite  the  legs  and 
feet  of  man.  Another  mosquito-borne  infection  is  fil- 
ariasis,  which  is  thus  readily  transmissible  from  man 
to  man.  The  Anophelince  which  carry  the  malaria 
pa  rasite,  and  the  Stegomyia  which  carry  yellow  fever  are 
both  comparatively  harmless  as  regards  filaria,  while 
two  other  species,  Culex  fatigans  and  Mansonia  uni- 
formis,  do  carry  it.  The  filariae  are  found  in  the  human 
blood  chiefly  at  night.  They  accumulate  chiefly  in  the 
lymphatics  which  they  may  occlude,  causing  lymph- 
scrotum.  If  they  break  through  into  the  urinary 
passages  there  will  be  chylous  urine.  It  is  alto- 
gether probable  that  the  widely  spread  elephantiasis 
is  due  to  a  blocking  of  lymphatics  with  Filaria  ban- 
crofti,  though  the  latter  are  not  usually  demonstrable 
in  the  hypertrophied  tissues.  Elephantiasis  is  liable 
to  involve  in  this  order  of  frequency — legs,  genitals, 
breasts.  A  person  who  has  been  infected  with  filari- 
asis  should  avoid  both  for  his  own  sake  and  that  of 
others  any  climate  where  the  two  varieties  of  mosqui- 
tos exist.  Obviously,  naked  bodies  present  the  fair- 
est mark  for  these  insects,  which  accounts  for  the  fact 
that  the  natives  suffer  more  than  Europeans  from 
the  disease.  Cleared  and  cultivated  land  affords  a 
less  favorable  breeding  place  for  insects.  Hence, 
the  newly  arrived  white  man  should  live  if  possible  on 
cleared  land  and  should  keep  the  body  covered  and 
should  protect  himself  against  flies  as  well  as  (for 
reasons  already  mentioned)  against  mosquitos. 

Kala-azar.  the  "black  disease  "or  "dum-dum  fever," 
which  has  caused  a  high  mortality  among  British 
soldiers  in  lower  Bengal  and  even  among  those  who- 
have  returned  thence  to  England,  is  due  to  a  blood- 
infection  with  flagellate  protozoan  organisms  which, 
however,  exist  chiefly  in  the  spleen,  liver,  and  other 
internal  organs,  so  that  examination  of  the  peripheral 
blood  is  often  futile.  There  is  a  considerable  anemia, 
with  leucopenia  and  a  relative  increase  of  mono- 
nuclear leucocytes  compared  with  the  polynuclears. 
There    is    enormous    enlargement   of   the   liver    and 


especially  of  the  spleen.  In  all  probability  the  eastern 
bedbug  plays  a  part  in  the  transmission  of  this  disease. 
Hence  the  practical  importance  of  cleanliness  and  the 
extermination  of  these  pests  by  fumigation  and  other 

measures. 

Various  types  of  relapsing  fever  exist,  due  to  the 
presence  "f  a  spirillum  in  i  he  circulating  blood.  One 
of  them,  Spirillum  obermeieri,  was  the  firs!  organism 
ever  demonstrated  to  he  the  cause  "i  di  ease  in  man 
(1868).  It  appears  in  be  conveyed  by  the  l>ii 
pediculi  and  also  by  certain  species  of  ticks.  Another, 
i he  African  relapsing  fever,  is  definitely  known  to  be 
conveyed  to  man  by  a  specific  tick,  so  that  the  dis- 
ea  e  i^  called  "tick  fever.''  Prophylaxis  for  Euro- 
peans is  easy  because  the  I  iek  cannot  climb  a  smooth 
surface  and  if  bedclothes  are  kept  from  touching  the 
floor  the  insects  cannot  get  upon  a  bed,  and  they  do 
not  bile  by  day.  Resting  or  sleeping  in  a  native  hut, 
however,  should  be  avoided,  as  the  ticks  might  get 
upon  the  clothing. 

The  acclimatizing  European  must  be  especially 
careful  of  the  drinking  water  and  it  is  safer  to  drink 
only  bottled  or  distilled  water  till  he  can  have  the 
benefit  of  a  careful  examination  of  the  local  supply. 
Among  his  dangers  from  this  source  are  the  ingestion 
of  Amoeba  coli.  This  is  a  common  cause  of  tropical 
dysentery  and  it  may  leave  the  intestinal  tract  and 
cause  abscess  of  the  liver.  The  Shiga  bacillus  is 
another  cause  of  dysentery.  Typhoid  fever  and 
cholera  are  of  course  due  to  their  specific  bacteria 
which  are  generally  absorbed  with  the  drinking 
w  ater. 

Certain  intestinal  parasites  constitute  a  danger  to 
be  reckoned  with  by  acclimatizing  strangers.  The 
ordinary  cestodes  or  tape-worms  require  only  a  pass- 
ing mention  as  their  cysticerci  can  be  readily  killed 
by  the  cooking  of  the  flesh  of  their  intermediate  hosts, 
swine  {Taenia  solium),  cattle  {T.  saginata)  and  fish 
(7\  bolhricephalus). 

A  schistosomum,  known  as  Bilharzia  ha-matobia 
(Schistosomum  haematobium),  is  common  in  most  parts 
of  Africa  and  was  brought  home  by  many  British  sol- 
diers from  the  Boer  war.  It  is  introduced  by  drinking 
water  and  possibly  through  bathing.  The  adult  worm 
causes  no  disease  but  the  irritating  effects  of  the  eggs 
upon  various  mucous  surfaces  when  they  are  deposited 
in  great  number,  are  most  serious.  In  the  intestinal 
tract  the  inflammation  thus  set  up  causes  bloody 
diarrhea.  But  the  worst,  effect  is  in  the  urinary  tract 
where  these  eggs  cause  hematuria,  cystitis,  and  oc- 
casionally calculi.  They  may  exist  also  in  the  lungs 
and  cause  hemoptysis. 

A  most  important  parasite  is  the  Ankylostonium 
duodenale  or  its  allied  Necator  americanus,  the  "hook- 
worm." This  requires  no  intermediate  host.  The 
eggs  when  passed  with  the  feces  and  spread  upon  the 
ground  under  conditions  of  warmth  and  moisture, 
develop  rapidly  and  may  in  moist  earth  remain  alive 
for  months  or  even  years.  If  introduced  into  another 
person  on  vegetables  or  by  the  dirty  fingers  of  him- 
self or  of  a  cook,  they  develop  in  this  new  person. 
Moreover,  if  a  person  goes  barefooted  upon  such 
infected  soil  the  larvoe  can  penetrate  the  skin  of  the 
foot-sole,  pass  in  the  blood-stream  to  the  lungs  thence 
into  the  trachea  thence  to  the  esophagus  and  so  to  the 
stomach.  In  the  duodenum  they  are  prepared  to 
hook  themselves  to  the  mucous  membrane.  From 
the  laceration  which  they  cause,  a  permanent  blood- 
drain  is  caused  and  the  patient  begins  to  suffer  from 
progressively  increasing  anemia  which  may  become 
as  profound  as  pernicious  anemia.  Fatty  degenera- 
tion of  viscera  follows.  The  patient  may  have 
constipation  or  dysentery,  but  in  either  case  is  always 
passing  the  eggs,  to  be  a  menace  to  others.  The 
prophylaxis  is  in  the  care  of  excrement,  precautions 
about  vegetables  and  drinking  water,  cleanliness  of 
the  hands  of  cooks,  and  of  course  always  going  with 
the  feet  shod.     Superficial  burials  must  be  forbidden. 


61 


Acclimatization 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Deposition  of  feces  in  sea-water  destroys  eggs  and 
larvae. 

Plague  has  been  endemic  in  the  Far  East  for  a 
number  of  years  though  the  disease  has  been  relatively 
harmless  compared  with  the  great  pandemics  of 
"Black  Death"  which  swept  Europe  in  previous 
centuries.  Before  a  fresh  outbreak  in  any  locality  it 
has  been  noted  that  an  increase  of  sickness  among 
rats  has  occurred.  Doubtless  these  animals  and  also 
perhaps  squirrels  serve  to  propagate  the  plague 
bacillus  and  to  infect  man.  Rats  with  open  ulcers 
are  especially  active  agents  in  keeping  the  disease  alive. 
In  this  condition  fleas  may  serve  to  convey  the  infec- 
tion from  the  rats  to  man.  From  the  end  of  winter 
to  the  beginning  of  the  rainy  season  is  the  term  of 
greatest  danger  (January  to  June).  The  destruction 
of  all  vermin  of  whatever  size  is  the  chief  element  of 
prophylaxis. 

It  will  be  noted  that  most  of  the  precautions  needed 
by  a  European  coming  into  the  tropics  center  about 
insects  and  vermin  which  are  the  most  important 
carriers  to  man  of  the  worst  tropical  diseases.  The 
antityphoid  vaccination  now  so  generally  practised 
among  large  bodies  of  men  in  our  own  country  is 
an  especially  wise  precaution  for  the  immigrant  into 
tropical  countries  where  enteric  fever  is  known  to  be, 
as  it  usually  is,  prevalent. 

Beyond  the  foregoing  considerations,  the  principal 
factors  conducing  to  acclimatization  are  those  of 
general  hygiene  and  social  environment.  Every 
means  should  be  taken  to  overcome  homesickness. 
If  society  is  wanting,  work  must  be  relied  upon  to 
take  up  the  mind.  It  is  said  that  the  workers 
acclimatize  more  readily  than  the  idlers  in  hot 
countries.  Of  the  various  forms  of  exercise,  which 
is  always  so  important  from  a  hygienic  point  of  view, 
riding  and  driving  are  especially  desirable  in  warm 
countries.  Cool  and  cold  baths  daily  are  of  use.  The 
advantages  of  hydrotherapy  are  often  combined  with 
those  of  high  elevation  in  the  sanatoria  which  are 
located  in  the  mountainous  districts  (where  such 
exist)  in  many  warm  countries,  and  whither  the  half- 
acclimated  European  repairs  from  time  to  time  with 
much  benefit  to  paludic,  dysenteric,  and  hepatic 
affections.  Finally,  if  dysentery  obstinately  recurs 
in  the  high  altitude,  or  if  the  system  does  not  throw 
off  miasmatic  impressions,  it  is  better,  after  a  reason- 
able time,  to  abandon  the  attempt  at  acclimatization 
and  return  to  a  temperate  climate.  The  ocean 
voyage  will  be  likely  to  cause  some  relief,  and  after 
a  reconstitution  of  the  bodily  powers  in  the  home 
country,  a  second  attempt  at  acclimatization  may  be 
more  successful.  Chakles  F.  Withington. 

Accommodation  and  Refraction. — Accommodation 
is  the  word  used  to  designate  the  adjustive  power  of 
the  eye  for  distinct  vision  at  different  distances:  in 
modern  ophthalmology  it  denotes  the  active  increase 
in  optical  power  by  which  the  eye  changes  its  adjust- 
ment from  longer  to  shorter  distance--. 

The  existence  of  an  active  accommodation,  effected 
through  an  increase  in  the  convexity  of  the  crystalline 
lens,  was  demonstrated  by  Thomas  Young  (Philo- 
sophical Transactions,  1801),  but  the  conclusiveness  of 
his  proofs  was  not  generally  recognized  until  fully 
half  a  century  later.  The  first  actual  observation  of 
th<>  change  in  curvature  at  the  anterior  surface  of  the 
crystalline  lens,  by  Maximilian  Langenbeck  (1849), 
was  confirmed  (1853)  by  A.  Cramer,  who,  by  the 
employment  of  more  refined  methods,  demonstrated 
an  associated  forward  displacement  of  the  anterior 
lens  surface.  Cramer's  observations  were  followed 
closely  in  time  by  the  wholly  independent  research 
of  H.  Helmholtz  (1S55),  which  definitively  estab- 
lished the  fundamental  theory  of  accommodation 
and  opened  the  way  for  the  exhaustive  investigations 
of  Donders,  as  presented  in  his  monumental  work 
"On  the  Anomalies  of  Accommodation  and  Refrac- 

62 


tion  of  the  Eye"  (1864).  Tscherning,  who  took  up 
the  subject  anew  (1S94,  1895),  brought  to  light  impor- 
tant additional  details. 

The  changes  in  the  eye  in  accommodation  consist 
essentially  in  (a)  a  notable  increase  of  curvature  in  a 
central  area  of  the  anterior  surface  of  the  crystalline 
lens,  (6)  a  much  smaller  but  positively  demonstrated 
increase  of  curvature  in  a  central  area  of  the  poste- 
rior surface  of  the  crystalline  lens,  and  (c)  an  increase 
in  the  axial  thickness  of  the  crystalline  lens,  measured 
by  the  central  displacement  of  its  anterior  surface; 
the  position  of  the  center  of  the  posterior  lens  surface 
remaining  unchanged. 

Accommodation  is  accompanied  by  active  contrac- 
tion of  the  pupil,  the  effect  of  which  is  to  stop  off  all 
but  a  comparatively  small  central  portion  of  the 
crystalline  lens,  with  exclusion  of  the  much  larger 
equatorial  zone  from  participation  in  the  formation 
of  the  retinal  image.  Both  accommodation  and  the 
accompanying  pupillary  contraction  are  essentially 
binocular  acts,  and  are  sensibly  equal  in  the  two  eyes. 
They  are,  moreover,  intimately  associated  with  con- 
vergence of  the  visual  axes,  thereby  making  it  possible 
to  see  near  objects  single,  as  well  as  distinctly,  with  the 
two  eyes. 

The  several  adjustments  which  go  to  make  up  the 
complex  act  of  binocular  accommodation  are  coordi- 
nated under  the  control  of  the  third  (oculomotor) 
pair  of  cranial  nerves.  Thus  the  impulse  to  accommo- 
date, in  order  to  see  a  small  near  object  distinctly, 
evokes  not  only  the  needful  lenticular  changes  with 
contraction  of  the  pupil,  in  both  eyes,  but  also  the 
correlated  action  of  the  exterior  muscles  of  both  eyes 
in  convergence  for  the  distance  of  the  object.  Con- 
versely, the  impulse  to  converge,  so  as  to  make  the  two 
retinal  images  fall  each  at  the  central  fovea  in  its  own 
eye  and  so  prevent  confusion  from  double  vision, 
evokes  commensurate  exercise  of  the  accommodation 
with  contraction  of  the  pupil,  in  both  eyes. 

The  physiological  bond  by  which  accommodation 
and  convergence  are  coordinated  is,  however,  elastic, 
within  certain  limits.  Thus  the  relation  of  the  two 
adjustments  may  be  altered,  for  the  time  being,  by 
looking  through  concave  or  convex  spectacles,  or 
through  divergent  or  convergent  prisms,  so  as,  with 
unchanged  convergence,  to  force  or  to  relax  the  accom- 
modation, or,  with  unchanged  accommodation,  to 
increase  or  to  diminish  the  convergence  of  the  visual 
axes.  Such  experiments  are,  however,  fatiguing, 
and  cannot,  as  a  rule,  be  long  continued  without 
giving  rise  to  a  sense  of  ocular  strain,  or  to  headache 
or  other  reflex  nervous  disturbance. 

Again,  accommodation  becomes  more  and  more 
difficult,  with  advancing  age,  as  a  result  of  progressive 
induration  of  the  crystalline  lens,  but  is  nevertheless 
maintained,  under  convergence  for  a  practicable  read- 
ing distance,  to  an  average  age  of  about  forty-five 
years  at  which  the  disability  of  old  sight  {presbyopia) 
ordinarily  asserts  itself. 

Again,  many  persons,  subjects  of  anomalies  which 
involve  notable  alteration  of  the  relation  of  accommo- 
dation to  convergence,  experience  no  difficulty  in 
near  work  or  perhaps  even  imagine  that  they  enjoy 
exceptionally  good  vision.  These  are  generally  cases 
either  of  congenital  anomaly  or  of  an  anomaly  of  so 
gradual  development  as  to  afford  time  for  a  corre- 
spondingly gradual  change  in  the  mutual  relation  of 
the  two  adjustments. 

The  accommodative  increase  in  the  optical  power 
of  the  eye,  designated  by  Donders  (1858)  as  the  range 
of  accommoiliilinn,  is  conveniently  estimated  in  units 
called  dioptries;  one  dioptric  (1  D)  denoting  the  power 
of  a  convex  lens  of  one  meter  focal  length,  2  D  the 
power  of  a  lens  of  one-half  meter  focal  length,  etc. 

The  maximum  range  of  accommodation  for  any  eye 
is  attained  when  the  fellow  eye  is  covered  or  otherwise 
excluded  from  participation  in  the  visual  act  and  is 
free  to  assume  a  position  of  extreme  convergence. 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


AcooniT lallon    and 

Refraction 


This  maximum  range  is  called  the  absolute  range  of 
accommodation.  The  range  of  accommodation  for 
the  two  eyes  together,  under  convergence  for  any 
particular  distance,  is  called  the  binocular  range  of 
accommodation;  and  the  range  "over  which  we  have 
control  at  a  given  convergence  of  the  visual  lines, 
[which]  represents  the  degree  in  which  accommodat  ion 
is  independent  of  convergence,"  is  called  the  relative 
range  of  accommodation. 

The  relative  range  of  accommodation  varies  greatly 
for  different  distances.  Thus  Donders  found  thai  in 
the  case  of  a  young  person,  of  the  age  of  fifteen  years 
it  was  possible  to  accommodate  with  either  eye 
singly  up  to  a  distance  of  3.69  Paris  inches  (about  10 
cm.  =T\T  meter),  indicating  an  absolute  range  of 
accommodation  of  about  10  D.  With  the  two  eyes 
together,  it  was  possible  to  see  distant  objects  dis- 
tinctly through  concave  glasses  of  any  power  up  to  a 
limit  of  eleven  Paris  inches  (negative)  focal  length 
(about  29.7  cm.  =r£,  meter),  indicating  a  relative 
range  of  accommodation  of  about  3.37  D  under 
parallelism  of  the  visual  axes.  Under  convergence 
for  a  distance  of  3.9  Paris  inches  (about  10.5  cm.  =  oH 
meter)  it  was  just  possible  to  accommodate  for  that 
distance,  but  it  was  also  possible  to  see  distinctly, 
with  the  two  eyes,  through  convex  glasses  up  to  a 
limit  of  nine  Paris  inches  (about  24.3  cm.  =  £i  meter 
focal  length,  indicating  a  negative  relative  range  of 
accommodation  of  about  —4.1  D.  Under  higher 
grades  of  convergence,  i.e.  for  distances  less  than  3.9 
Paris  inches  (10.5  cm.  =^j  meter),  it  was  impossible 
to  accommodate  with  the  two  eyes  for  the  distance  of 
the  point  of  intersection  of  the  visual  axes.  At  all 
distances  greater  than  10.5  centimeters  small  objects 
were  seen  distinctly  and  single  through  concave  glasses, 
and  also  through  convex  glasses;  in  other  words,  the 
relative  range  of  accommodation  was  in  part  positive 
and  in  part  negative.  "This  distinction  acquires 
practical  importance  from  the  fact  that  the  accommo- 
dation can  be  maintained  only  for  a  distance  at  which, 
in  reference  to  the  negative,  the  positive  part  of  the 
relative  range  of  accommodation  is  tolerably  great." 
(Donders.) 

Fig.  15  shows,  in  the  form  of  a  diagram,  a  series 
of  measurements  of  the  relative  accommodation  in  the 
ease  cited,  as  plotted  by  Donders;  the  ordinates  in- 
dicating dioptrics  of  accommodation,  and  the  abscissas 
the  distances  of  points  of  intersection  of  the  visual  axes, 
in  fractional  parts  of  a  meter. 

By  inspection  of  the  diagram  it  is  seen  that  the 
positive  part  of  the  relative  range  of  accommodation 
— i.e.  the  part  above  and  to  the  left  of  the  diagonal 
KK — appears  only  in  convergence  for  distances 
greater  than  about  rSr  meter  (10.5  cm.).  At 
a  distance  of  I  meter  (12.5  cm.)  the  positive  part 
is  about  four-tenths  as  great  as  the  negative;  at 
one-third  meter  (33.3  cm.)  the  positive  part  exceeds 
the   negative   in   the  ratio  of  about  16  to  10. 

These  observed  relations  of  the  positive  to  the 
negative  part  of  the  relative  range  of  accommodation 
are  in  close  accord  with  every-day  observation  of  the 
working  of  the  accommodation  in  young  persons. 
Thus  a  child  of  say  twelve  years  can  ordinarily  force 
his  accommodation  so  as  to  see  minute  objects  dis- 
tinctly for  a  short  time  at  a  minimum  distance  of  about 
10  centimeters,  using  about  10  D  of  accommodation. 
At  a  little  greater  distance,  about  12.5  centimeters, 
using  about  8  D  of  accommodation,  he  can  read  for  a 
much  longer  time,  although  not,  as  a  rule,  without 
consciousness  of  effort  leading  to  fatigue.  At  about 
20  centimeters,  using  about  5  D  of  accommodation, 
the  accommodation  can .  often  be  maintained  for 
hours  together  in  close  work,  but  not  without  in- 
curring the  risk  of  ultimate  injury  to  the  eyes  when 
reading  at  so  short  a  distance  has  become  habitual. 
The  limit  of  ease  and  safety,  for  young  persons,  in 
long-continued  use  of  the  eyes  in  reading  and  study,  is 
about  33  centimeters  (about  thirteen  English  inches), 


or  perhaps  a  little  less,  corresponding  to  an  habitual 

use  of  about  3  Dofaccon lation.     At  this  distance 

the  relative  range  of  accommodation  Is  ample,  and  the 
positive  part  is  al  about  its  maximum. 

The  letters  r,  r„  r„  and  p,  p„  p,  (Fig.  15)  indicate 
the  observed  absolute,  relative,  and  binocular  fait  he  I 
and  nearest  points,  respectively,  of  distinct  vi  ion. 
Under  parallelism  of  the  visual  axes  the  absolute  far 
point  (r)  and  the  binocular  far  point  (r2)  fall  together 
al  an  infinite  distance;  but  there  is  a  positive  relati  e 
accommodation  of  about  3.37  1).  Under  convergence 
for  a  distance  of  '.  meter  (10.5  cm.)  the  relative  near 
point    (p,)    and    the    binocular    near     point    (p..)    fall 


• 

>; 

r 

ft, 

'" 

P| 

M 

j 

'  , 

/ 

y 

/ 

//'. 

1 

y 

r, 

l     i     l_l_J_JLJ_J.iliii_L±AJ-XX-LJ 

0       1      £      3      4      5      0      7       8       9     10     11     12    13     14    15     10     17     18     l'J    £' 

Fig.  15. — Diagram  showing  the  relative  range  of  accommodation 
for  different  distances.      (After  Donders.)* 

together,  but  there  is  a  negative  relative  accommoda- 
tion of  about  4.1  D.  Under  increased  convergence, 
for  distances  less  than  10.5  centimeters,  at  which 
binocular  accommodation  is  no  longer  possible,  the 
i  negative)  relative  range  of  accommodation  decreases 
until,  under  forced  convergence  for  about  one- 
eighteenth  meter  (about  5.5  cm.),  the  relative 
near  point  (p,)  and  the  relative  far  point  (r,)  fall 
together    at    the    absolute    near   point    (p). 

Table  A. 

Accommodation  t  0   i234567S9  10  11  12  13  1115  1617  1819  20 
in  dioptries.     J 

Distances  in  1  «  uiiiitu    1    j     i      i      i     i     I     i    J     i     i 

\    00    1   2  3  i    5  u  7  S  §    ID   11    I:    13    II    IB    13    17  Ifl    i  Q 

meters.  J 

Table  A  represents,  in  parallel  series,  consecutive 
dioptries  of  accommodation  and  the  corresponding 
distances  of  the  points  of  intersection  of  the  visual  axes 
in  binocular  fixation.  It  will  be  remarked  that  the 
first  dioptrie  of  accommodation  covers  all  distances 
from  infinity  to  1  meter;  that  the  second  covers  a 
distance,  1-4  =\  meter;  the  third,  £-i=tj  meter; 
the  fourth,  £-i=TW  meter;  the  tenth,  | - TV  =  ^ 
meter;  etc. 

Designating  the  distance  of  the  farthest  point  (r) 
of  distinct  vision  for  any  eye  by  R,  and  the  distance 
of  the  nearest  point  (p)  of  distinct  vision  for  the 
same  eye  by  P,  the  distance,  R — P,  increases  at  a 
progressively  increasing  rate  as  R  approaches  infinity, 
and  decreases  at  a  progressively  decreasing  rate  for 

*  Fig.  15  has  been  slightly  changed  to  conform  to  the  metric  sys- 
tem, which  has  come  into  general  use  in  ophthalmology  since  the 
publication  of  Donders'  work. 

63 


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decreasing  values  of  R.  The  linear  distance  R — P, 
— the  region  of  accommodation  of  Donders — has  a 
significance  wholly  distinct  from  that  of  the  range  of 

accommodation,     (p — w)  dioptries,  as  will  appear  in 

connection  with  the  study  of  the  Anomalies  of 
Refraction  and  their  correction  by  spectacles. 

Refraction,  as  the  word  is  used  in  ophthalmology, 
denotes  either  the  absolute  optical  power  of  the  eye 
as  determined  by  the  radii  of  curvature  of  its  several 
surfaces  and  the  refractive  indices  of  its  several 
media,  or  the  power  estimated  as  deficient  or  ex- 
cessive according  as  the  focus  of  the  eye  for  parallel 
rays  falls  behind  or  in  front  of  the  retina.  The 
refraction  of  the  eye  as  a  whole  is  the  sum  of  consecu- 
tive refractions,  (a)  from  the  air  into  the  cornea,  (6) 
from  the  cornea  into  the  aqueous  humor,  (c)  from  the 
aqueous  humor  into  the  crystalline  lens,  (d)  from 
layer  to  layer  of  the  crystalline  lens,  through  a 
medium  of  progressively  increasing  refractive  power 
(index  of  refraction)  from  its  anterior  surface  toward 
its  center  and  of  decreasing  refractive  power  from  its 
center  to  its  posterior  surface,  and  (c)  from  the  crys- 
talline lens  into  the  vitreous  humor.  Inasmuch  as  the 
curvatures  of  the  several  refracting  surfaces  and  the 
indices  of  refraction  of  the  several  transparent  media 
remain  constant  or  nearly  constant,  after  the  eye  has 
once  attained  to  its  full  development,  the  absolute 
refraction  is  practically  constant  for  any  particular 
eye. 

The  principal  posterior  focus  of  the  eye  falls  at  an 
average  distance  estimated  as  14. SO  millimeters 
behind  its  second  nodal  point  (k"),  19. S7  millimeters 
behind  its  second  principal  point  (h"),  and  2_>._':i 
millimeters  behind  the  anterior  surface  of  the  cornea 
at  its  center;  the  last  measure  representing  the  distance 
of  the  retina  from  the  vertex  of  the  cornea  in  a 
normally  proportioned  eye  of  average  dimensions. 
Inasmuch  as  the  power  (in  dioptries)  of  a  compound 
refractive  system  is  the  reciprocal  of  the  distance 
(in  meters  or  decimal  parts  of  a  meter)  at  which  its 
principal   focus  falls  beyond  its  second  nodal  point 

(k"),    the    quotient,  ^-FTTToZ  =  67.29   represents,    the 

U.U14ou 

optical  power  of  the  average  human  eye,  in  dioptries.* 
Measurements  of  the  curvature  of  the  cornea  and  of 
the  two  surfaces  of  the  crystalline  lens  are  found  to 
vary  considerably  in  different  persons,  and  this  without 
giving  rise  to  any  related  functional  disturbance. 
The  explanation  is  found  in  a  corresponding  variation 
in  the  size  (length  of  axis)  of  the  eyeball.  In  a 
person  of  large  stature  all  the  measurements  of  the 
eye  are  apt  to  exceed  the  average;  the  absolute  re- 
fraction of  the  larger  eye  being  someu  hat  less  and  the 
size  of  the  inverted  retinal  image  somewhat  greater, 
than  in  the  case  of  a  smaller  eye.  A  larger  eye  is 
therefore,  ceteris  paribus,  of  somewhat  greater 
visual  acuity  than  a  smaller  eye,  just  as  a  photo- 
graphic lens  of  longer  focus,  in  a  larger  camera,  gives 

*  By  making  permissible  small  changes  in  the  computed  dis- 
tance of  the  second  principal  point  (A")  and  of  the  second  nodal 
point  (fc")  from  the  retina,  Donders  showed  that  it  is  possible  to 
reduce  the  several  refractions  in  the  eye  to  an  equivalent  single 
refraction  at  a  convex  spherical  surface  of  5  nun.  radius  of  curva- 
ture, bounding  a  refractive  medium  of  g  =  1.3  index.  In  this 
"reduced"  eye  the  focus  for  parallel  rays  falls  20  mm.  behind  the 
single  principal  point  (p)  at  the  vertex  of  the  spherical  surface,  and 
15  mm.  behind  the  single  nodal  point  (k)  at  its  center  of  curvature. 

The  power  of  the  reduced  eye,   n  „,  ^=66.6    dioptries,    and    the 

0.01  o 
ratio  of  the  size  of  a  distant  object  to  that  of  its  inverted  image, 

— ,    differ    negligibly    from    those    based    on  the 

measurement,  used  in  the  "schematic"  eye  of  Listing  as  revised 
by  Helmhobz.  The  easily  remembered  numbers,  5,  15,  20,  or 
their  ratios,  1  :  .'!  :  1,  may  therefore  be  used  without  appreciable 
error  in  numerical  calculations,  ami  in  geometrical  constructions 

illustrating  fundamental  problems  ifi  physiological  optics. 


a  larger  and  more  perfect  picture  than  a  lens  of  shorter 
focus,  in  a  smaller  camera. 

The  estimation  of  the  absolute  refraction  in  a 
particular  eye  involves  objective  measurements  too 
refined  to  be  attempted  in  clinical  work,  and  also  of 
no  practical  significance  unless  supplemented  by  a 
tin  ire  accurate  measurement  of  the  length  of  the  eye- 
ball than  is  possible  in  the  living  subject.  On  the 
other  hand,  estimates  in  terms  of  refractive  defi- 
ciency or  excess  are  readily  made  by  testing  with 
convex  or  concave  trial-glasses,  and  are  also  directly 
available  in  prescribing  spectacles. 

We  have,  therefore,  to  recognize,  first  of  all,  a 
standard  of  correct  proportion,  emmetropia,  E  (from 
epperpos,  proportionate,  and  Sxp,  eye),  in  which  a 
sharply  defined  image  of  a  distant  object  is  formed 
on  the  retina  without  the  exercise  of  any  part  of  the 
accommodation,  so  that  the  entire  range  of  accom- 
modation is  available  to  meet  the  requirements  of 
distinct  vision  for  near  objects.  The  region  of  accom- 
modation includes,  therefore,  all  distances  from 
infinity  to  a  near  point  (p)  which  is  near  enough  to 
the  eye  to  satisfy  exacting  requirements  in  close  work. 

The  definition  of  emmetropia  as  correct  proportion 
implies  the  negative  concept  of  incorrect  proportion, 
ametropia  (from  dpiTpos,  disproportionate,  and  &ii, 
eye),  in  which  the  principal  focus  of  the  eye  falls 
elsewhere  than  at  the  distance  of  the  retina.  Ame- 
tropia occurs  under  two  opposite  types,  according  as 
the  retina  lies  in  front  of  or  behind  the  principal  focus. 

Hypermetropia,  H  (from  v-(p,  over,  phpov,  meas- 
ure, and  &(,'■,  eye),  is  the  condition  in  which  the  prin- 
cipal focus  falls  behind  the  retina.  A  hypermetrope 
whose  range  of  accommodation  is  in  excess  of  that 
required  to  advance  the  focus  for  parallel  rays  to  the 
actual  position  of  the  retina,  is  able,  through  the 
exercise  of  some  part  of  his  accommodation,  to  see 
clearly  at  a  distance.  A  part  only  of  the  range  of 
accommodation  is  then  available  for  near  vision  and, 
by  reason  of  the  near  point  falling  too  far  from  the 
eye,  the  region  of  accommodation  is  commensurately 
curtailed.  In  the  higher  grades  of  hypermetropia 
the  normal  range  of  accommodation  is  often  insuffi- 
cient for  distinct  vision  even  at  a  distance;  in  the 
lower  grades  it  is  generally  possible  to  read,  but  pro- 
longed effort  is  apt  to  give  rise  to  a  feeling  of  strain  or 
fatigue,  with  blurring  or  "running  together"  of  the 
print.  With  the  progressive  recession  of  the  near 
point  incident  to  advancing  age,  these  (asthenopic) 
symptoms  and  disabilities  give  place  to  those  of  pre- 
mature old  sight  (presbyopia),  and  ultimately  to 
indistinctness  of  vision  at  all  distances. 

In  typical  hj-permetropia  the  disproportion  is  the 
expression  of  actual  deficiency  in  the  length  of  the 
anteroposterior  diameter  of  the  eyeball.  The  relative 
nearness  of  the  retina  to  the  second  nodal  point  of 
the  eye,  and  the  fact  that  hypermetropia  is  hereditary, 
suggest  reversion  to  structural  conditions  found  in 
the  lower  mammalia.  The  crucial  test  of  hyperme- 
tropia  is  the  ability  to  see  distinctly  at  a  distance 
through  convex  glasses;  its  measure,  in  dioptrics,  is 
the  strongest  convex  lens  through  which  vision  at  a 
distance   is   unimpaired.      (See    Hypermetropia.) 

Myopia,  M  (puunrlct,  puio-laois,  pou*,'',  from  piu),  to 
close  or  contract,  and  &ib,  eye),  so  named  by  early 
writers  from  the  habit  of  contracting  the  opening  of 
the  eyelids  in  looking  at  distant  objects,  is  the  exact 
opposite  of  hypermetropia  in  that  the  principal  focus 
of  the  eye  falls  in  front  of  the  retina.  A  myope  sees 
indistinctly  at  long  distances,  but  is  able  to  accom- 
modate for  a  distance  a  little  less  than  that  of  the 
near  point  in  emmetropia.  The  region  of  accom- 
modation is  greatly  curtailed  through  the  approach 
of  the  far  point  to  the  eye,  with  unimportant  com- 
pensation in  the  approach  of  the  near  point;  in  very 
high  grades  of  myopia  the  region  of  accommodation 
i~  reduced  to  insignificance.  In  myopia  of  low  grade 
the  disability  of  old  sight   (presbyopia)   first  asserts 


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Accommodation  and 
Refraction 


itself  at  a  later  period  of  life  than  in  emmetropia;  in 
the  higher  grades,  in  which  the  far  point  (r)  lies  well 
within  the  ordinary  reading  distance,  presbyopia, 
in  the  ordinary  acceptation  of  the  word,  is  an 
Impossibility. 

In  typical  myopia  the  disproportion  is  the  expres- 
sion of  axial  elongation  in  a  pathologically  distended 
eyeball.  Myopia  generally  appears  in  childhood, 
and  increases  progressively  during  the  period  of 
school  life;  the  increase  in  grade  being  in  direct 
relation  to  the  habitual  use  of  the  eyes  at  too  short  a 
working  distance.  Unlike  hypermetropia,  myopia 
is  the  visual  expression  of  disease  which,  in  later  life, 
may  progress  even  to  loss  of  sight.  The  test  of  myopia 
is  the  inability  to  see  distant  objects  distinctly  except 
through  concave  glasses;  its  measure,  in  dioptries, 
is  the  weakest  concave  lens  which  brings  distant  vision 
up  to  the  same  relative  acuteness  as  at  distances 
within  that  of  the  far  point.  (See  Myopia.) 

The  positions  of  the  far  point  (r)  and  the  near  point 
(p)  are  measured  from  the  first  nodal  point  (A-')  which 
is  situated  about  6.95  millimeters  behind  the  vertex 
of  the  cornea.  Representing  these  distances  by  R 
and  P,  respectively,  the  range  of  accommodation,  in 
dioptrics,  by  A,  and  the  degree  of  myopia  or  of  hyper- 
metropia, in  dioptries,  by  M  or  by  —  H,  we  have: 


In  emmetropia, 


in  myopia, 


in  hypermetropia. 


R  =infinity, 
P  =      meter; 


R  =,,  meter, 
M 


P  = 


1 


A  +  M 


meter; 


1 


R  =  —  ■'    meter, 
It 

P  =  -7 — ;.  meter. 
A  —  H 


From  a  comparison  of  these  equations  it  will  be  seen 
how,  for  the  same  range  of  accommodation,  the  region 
of  accommodation  is  most  extensive  in  emmetropia. 
In  myopia  the  region  of  accommodation  is  greatly 
curtailed  through  the  approach  of  the  far  point  (r), 
with  unimportant  compensation  in  the  approach  of  the 
near  point  (/>).  In  hypermetropia  of  low  grade,  in 
which  only  a  part  of  the  range  of  accommodation  is 
available  in  near  vision,  the  region  of  accommoda- 
tion is  curtailed  through  the  recession  of  the  near 
point  (p)  from  the  eye,  the  visual  far  point  falling, 
as  in  emmetropia,  at  infinity.  When  H  is  so  large,  or 
A  so  small,  that  A  is  less  than  H,  the  entire  range  of 
accommodation  becomes  negative,  and  distinct  vision 
is  impossible  at  any  distance. 

When  a  concave  spectacle  lens  of  an  effective  power 
equivalent  to  —  M  dioptries  is  worn  in  front  of  a  myopic 
eye,  or  a  convex  lens  of  +H  effective  power  is  worn 
in  front  of  a  hypermetropic  eye,  the  corrected  linear 
values 


in  myopia, 


in  hypermetropia, 


R     = 
P     = 


1 


= infinity, 


M  -  M      0 

1  1 

-j .-,- — ., ■=  ,  meter 

A  +  M  -  M      A 


R    =g-— g  =  p=infinity, 

P     =A-H  +  H  =  Ameter; 


are  the  same  as  in  emmetropia;  the  far  point  (r) 
falling  at  infinity,  and  the  near  point  (p)  at  a  dis- 
tance expressed  by  the  reciprocal  of  the  range  of 
accommodation. 

We  have   thus  far   considered  myopia  and  hyper- 
metropia from  the  standpoint  of  vision  with  one  eye, 


ignoring,  for  the  moment,  the  complications  which 
grow  out  of  the  participation  of  the  two  eyes  in 
binocular  vision.  In  brief,  it  may  be  said  that  in  order 
to  see  an  object  single  and  distinctly  with  the  two 
eyes  together,  the  eyes  must  be  directed  each  to  the 
same  point,  and  this  point  must  be  a  point  for  whose 
distance  each  eye  is  accommodated.  This  close 
interrelation  of  accommodation  and  convergence 
gives  rise  to  important  complications  both  in  myopia 
and  in  hypermetropia.  In  myopia,  there  is  com- 
paratively little  occasion  for  the  exercise  of  the  accom- 
modation, whereas  the  angle  of  convergence  for  the 
distance  of  most  distinct  near  vision  is  never  less  and 
may  be  notably  greater  than  in  emmetropia.  This, 
normal  or  excessive,  convergence  may  in  turn  evoke 
accommodation  for  a  shorter  distance,  thereby  neces- 
sitating increased  convergence.  Thus  through  vicious 
interaction  of  the  two  adjustments  the  grade  of 
myopia  may  appear  to  be  greater  than  it  really  is, 
and,  under  habitual  use  of  the  eyes  at  too  short  a 
distance,  the  distention  of  the  eyeballs  may  increase 
to  the  point  of  imminent  danger.  On  the  other  hand, 
a  myope  may  faL  into  the  habit  ot  relaxing  the 
accommodation  to  the  degree  requisite  for  distinct 
vision  at  or  near  his  far  point,  in  which  case  the  at- 
tendant relaxation  of  the  convergence  may  lead  to 
relative  insufficiency  of  the  recti  interni  muscles 
(muscular  asthenopia);  or  the  effort  to  maintain 
binocular  vision  may  be  abandoned,  and  actual 
muscular  insufficiency  (crossed  double  vision,  or 
divergent  strabismus)  ensue.  In  hypermetropia  the 
eyes  accommodate  even  in  distant  vision,  and  must 
accommodate  more  strongly  than  in  emmetropia  in 
order  to  see  near  objects  distinctly.  Accordingly, 
in  hypermetropia  one  of  two  complications  may  arise: 
either  convergence  may  be  maintained  for  the 
distance  of  the  object,  in  which  case  the  over-burdened 
accommodation  may  prove  unequal  to  the  demand 
made  on  it  in  sustained  near  work  (accommodative 
asthenopia),  or  the  accommodation  may  be  maintained 
under  excessive  convergence,  with  suppression  of 
binocular  vision,  which  may  be  the  forerunner  of 
convergent  strabismus. 

The  complications  growing  out  of  faulty  relation 
between  accommodation  and  convergence  have  been 
formulated  by  Donders  in  the  pregnant  antithesis: 

Hypermetropia  causes  accommodative  asthenopia, 
to    be    actively    overcome    by    strabismus    convergens. 

Myopia  leads  to  muscular  asthenopia,  passively 
yielding  to  strabismus  divergens. 

Astigmatism,  As  (from  a-  privative  and  ozlyiia.  a 
point),  is  a  very  common  structural  anomaly  in  which 
the  power  of  the  eye  is  unequal  in  different  meridians. 
This  inequality  is  greatest  in  two  ocular  meridians 
at  right  angles  to  each  other,  called  the  principal 
meridians.  An  astigmatic  eye  may  be  emmetropic 
in  one  of  its  principal  meridians,  in  which  case  it  is 
either  myopic  or  hypermetropic  in  the  other;  or  it 
may  be  myopic  or  hypermetropic  in  both  meridians; 
or  it  may  be  myopic  in  one  of  its  principal  meridians 
and  hypermetropic  in  the  other.  In  binocular 
hypermetropic  astigmatism  the  disabilities  are,  in 
general,  those  of  hypermetropia;  and  in  binocular 
myopic  astigmatism  are,  in  general,  those  of  myopia. 
As  the  acuity  of  vision  is  below  the  normal  at  all 
distances,  an  astigmatic  person  is  apt  to  fall  into  the 
habit  of  reading  at  too  short  a  distance,  and  may 
thus  awaken  or  revive  a  pre-existing  tendency  to 
myopia. 

The  correction  of  regular  astigmatism  together  with 
any  accompanying  ametropia,  by  wearing  appro- 
priate cylindrical,  spherico-cylindrical,  or  toric  spec- 
tacles, both  improves  vision  at  all  distances  and  mini- 
mizes the  incidental  disabilities  and  dangers  (see 
Astigmatism.) 

Anisometropia  (from  Jywos,  unequal,  fihpov,  meas- 
ure, and  Slip,  eye) — signifying  a  difference  in  the  meas- 
urements of  the  two  eyes — is  the  word  commonly  used 


Vol.  I.— 5 


65 


Accommodation  and 
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to  denote  inequality  of  refraction;  as  when:  (a)  one 
eye  is  emmetropic  and  the  other  eye  is  either  hyper- 
metropic or  myopic;  (6)  the  two  eyes  are  unequally 
hypermetropic  or  myopic;  or  (c)  one  eye  is  hyper- 
metropic and  the  other  myopic.*  As  the  increase 
of  power  in  accommodation  is  sensibly  equal  in  the 
two  eyes,  the  refractive  inequality  is  virtually  the 
same  in  vision  at  all  distances;  s<.  tiiat,  when  one  eye 
is  accommodated  for  any  particular  distance,  the 
fellow  eye  accommodates  for  some  other  distance 
and  the  image  formed  on  its  retina  is  imperfectly 
denned.  In  cases  of  small  or  medium  difference  in 
refraction  the  difference  in  definition  may  pass  un- 
noticed, and  cases  of  greater  difference  are  often 
vaguely  described  as  "something  wrong  with  one 
eye."  In  uncomplicated  anisometropia  both  images 
are  commonly  utilized  in  binocular  vision,  with 
more  or  less  perfect  conservation  of  the  faculty  of 
recognizing  differences  in  distance  and  the  forms  of 
solid  bodies  (stereoscopic  vision).  An  anisometrope 
with  one  emmetropic  or  moderately  hypermetropic  eye 
of  approximately  normal  acuity  of  vision  will 
generally  use  that  eye  in  distant  vision,  and  also  in 
reading  unless  the  other  eye  happens  to  be  myopic; 
in  either  case  he  may  remain  unconscious  of  the  fact 
that  he  does  not  see  distinctly  with  both  eyes  at  the 
same  time  until,  perhaps,  an  intercurrent  disabling  of 
the  eye  in  habitual  use  for  a  particular  distance  reveals 
a  previously  unrecognized  anomaly  in  the  fellow  eye. 
In  hypermetropia  of  unequal  grade  in  the  two  eyes, 
the  disabilities  and  complications  are  ordinarily  the 
same  as  in  binocular  hypermetropia  of  a  grade  equal 
to  that  in  the  less  hypermetropic  eye  (see  Hyperme- 
tropic!). In  myopia  of  unequal  grade  in  the  two  eyes 
the  more  important  complications  are  those  of  binoc- 
ular myopia  of  a  grade  equal  to  that  in  the  more 
myopic  eye  (see  Myopia). 

The  indications,  and  also  the  opportunity,  for 
prescribing  glasses  of  unequal  power,  with  a  view  to 
equalizing  the  adjustments  of  the  two  eyes  in  binocular 
vision,  vary  notably  for  different  cases.  An  aniso- 
metrope who  sees  clearly  at  a  distance,  and  also 
reads  ordinary  print  fluently,  seldom  thinks  of 
glasses,  and  when  one  eye  is  myopic  he  may  be  able 
to  read  without  glasses  far  beyond  the  age  at  which 

Eresbyopia  ordinarily  asserts  itself  as  a  disability.  In 
ypermetropia  of  unequal  grade  in  the  two  eyes,  an 
increasingly  disabling  asthenopia,  passing  gradually 
to  presbyopic  vision,  may  suggest  the  purchase  of  a 
pair  of  convex  glasses  which  afford  needed  help  in 
reading  and  which  may  be  found  to  be  helpful  also  in 
seeing  at  a  distance.  In  myopia  of  unequal  grade  in 
the  two  eyes  a  pair  of  concave  glasses,  which  ap- 
proximately correct  the  less  myopic  eye  for  distance 
and  partially  correct  the  fellow  eye,  may  be  accepted 
as  satisfying  recognized  needs,  and  when  the  uncor- 
rected part  of  the  myopia  in  the  more  myopic  eye  is 
rather  large  the  disability  of  presbyopic  vision,  even 
with  the  concave  glasses,  may  be  long  or  perhaps 
indefinitely  deferred.  In  any  of  these  cases  an 
ani-ometrope  may  see  cause  only  for  self-congratula- 
tion in  his  enjoyment  of  special  immunities,  and  may 
give  little  heed  to  less  obvious  disabilities  or  to  in- 
sidious changes  in  vision. 

The  complications  which  may  make  it  imperative 
to  prescribe  glasses  of  unequal  power  occur  oftenest 
in  myopia  of  one  eye  or  in  myopia  of  unequal  grade 
in  the  two  eyes.  In  both  of  these  cases  the  habitual 
relaxation  of  the  accommodation,  inhibiting  free 
exercise  of  the  convergence,  may  lead  to  relative 
insufficiency  of  the  recti  interni  muscles  (muscular 
asthenopia),  or  absolute  insufficiency  of  the  recti 
interni  (crossed  double  vision,  or  divergent  strabis- 
mus). On  the  other  hand,  habitual  convergence 
for  a  short  reading  distance  may  evoke  accommoda- 

*  The  name  antimetropin  has  been  proposed  for  the  particular 
form  of  anisometropia  in  which  one  eye  is  hypermetropic  and  the 
other  myopic. 

66 


tion  for  a  shorter  distance,  at  which  binocular  vision 
is  possible  only  under  increased  convergence,  and  the 
pathological  processes  which  find  expression  in  pro- 
gressive distention  of  the  eyeball  may  take  on  renewed 
and  perhaps  dangerous  activity.  In  any  one  of 
these  conditions  the  wearing  of  a  concave  glass 
chosen  with  reference  to  this  grade  of  myopia  in  the 
eye  habitually  used  in  reading  may  be  indicated,  but 
the  effect  of  a  second  concave  glass  of  the  same  power 
would  ordinarily  be  detrimental  by  creating  a  possibly 
disabling  artificial  hypermetropia  of  the  fellow  eye. 

In  general,  the  treatment  of  a  case  of  anisometropia 
by  glasses  involves  (a)  the  determination  of  the 
acuteness  of  vision  and  of  the  refraction,  including 
astigmatism,  in  both  eyes;  (6)  an  estimate  of  the 
range  of  accommodation  in  both  eyes;  (c)  the  detec- 
tion and  approximate  estimation  of  any  actual  or 
latent  error  in  the  direction  of  the  visual  axes  in 
distant  or  in  near  vision;  and  (d)  such  provisional 
or  final  correction  of  both  eyes  as  may  be  found  to  be 
most  helpful  in  binocular  vision.  In  many  cases  the 
best  results  are  attained  by  wearing  glasses  of  unequal 
power  corresponding  to  the  difference  in  refraction; 
in  other  cases  a  partial  equalization  of  the  refraction 
may  be  preferred  in  the  beginning,  and  a  full  equal- 
ization accepted  a  few  weeks  or  months  later.  In 
still  other  cases,  in  which  binocular  vision  has  perhaps 
never  been  established  or  has  been  long  abandoned, 
attempts  at  binocular  correction  may  be  rejected  as 
of  no  avail,  or  as  reviving  disabilities  from  w'hich  the 
patient  has  found  relief  through  the  habitual  exclu- 
sion of  one  eye  from  participation  in  the  visual  act. 

Aphakia  (from  a-  privative,  and  <l>ai<6s,  lens,  a 
lentil)  is  the  condition  in  which  the  crystalline  lens  is 
either  wholly  wanting  or  is  so  displaced  that  it  no 
longer  lies  in  the  axis  of  the  eyeball.  As.  a  result  of 
loss  of  the  crystalline  lens  the  first  and  second  prin- 
cipal points  of  the  eye  fall  together  in  a  single  princi- 
pal point  at  the  vertex  of  the  cornea,  and  the  first 
and  second  nodal  points  fall  together  in  a  single  nodal 
point  (optical  center)  at  its  center  of  curvature. 
Computing  the  principal  focal  length  from  the  aver- 
age radius  of  curvature  of  the  cornea  at  its 
center  (8  mm.)  and  an  assumed  common  index  of 
refraction  for  the  cornea  and  the  aqueous  and  vitre- 
ous humors   (^-  =  1.337) ,  the  principal  focus  of  the 

aphakial  eye  falls  31.7  millimeters  behind  the  vertex 
of  the  cornea,  and  23.7  millimeters  behind  the  (single) 
nodal  point  at  its  center  of  curvature.     The  absolute 

power  (    „.,„-.  =42.2   dioptries)  of  the  aphakial  eye 

is  therefore  about  twenty-five  dioptries  less  than 
thai  of  the  average  unmutilated  eye.  As  the  apha- 
kial eye  has  also  suffered  a  total  loss  of  accommoda- 
tion, it  requires  a  strong  convex  glass  in  distant 
vision  and  a  still  stronger  convex  glass  in  reading. 
The  effective  power  of  a  convex  spectacle  lens  in- 
creases, however,  for  every  increase  in  its  distance 
from  the  (first)  nodal  point  of  the  eye,  so  that  a  glass 
of  ten  to  twelve  dioptries  worn  about  15  millimeters 
in  front  of  the  cornea  of  an  aphakial  eye  ordinarily 
suffices  to  advance  its  focus  for  parallel  rays  to  the 
actual  position  of  the  retina.  The  convex  glass  also 
enlarges  the  retinal  image  by  advancing  the  (second) 
nodal  point  (of  the  corrected  eye)  to  a  position 
farther  from  the  retina  than  in  the  emmetropic  eye. 
A  partial  adjustment  for  the  near,  with  additional 
enlargement  of  the  retinal  image,  may  be  obtained 
by  wearing  the  convex  glass  still  farther  from  the  eye, 
but  as  such  increase  in  distance  is  limited  practically 
to  the  length  of  the  nose  it  is  generally  too  small  to 
afford  the  additional  help  required  in  reading.  In 
the  case  of  aphakia  in  a  previously  hypermetropic  eye 
stronger  convex  glasses,  and  in  the  case  of  aphakia 
in  a  previously  myopic  eye  weaker  convex  glasses, 
are  required  for  distance  and  in  reading.  In  a  case 
of  pre-existent  myopia  of  exceptionally  high  grade, 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   S(  1KN<  i;s 


\.  commoda Hon  and 

Kef  r.i.  1 1.  .11 


with  excessive  elongation  of  the  eyeball,  much  weaker 

convex  glasses  suffice;  a  fact  which  Ion;;  ago  SUg- 
ge  ted  tin-  surgical  removal  of  the  crystalline  lens  in 
cases  of  myopia  of  so  high  a  grade  as  to  constitute 
extreme  and  otherwise  irremediable  disability  (see 
M>i<>pia).  In  corrected  aphakia  of  one  eye  the 
retinal  image  is  notably  larger  than  in  the  fellow  eye, 
but  even  with  this  drawback  the  correction  is  gener- 
ally of  value  by  helping  to  keep  the  aphakia!  eye  in 
use  in  binocular  vision.  An  uncorrected  aphakial 
eye  may,  however,  continue  to  take  part  in  binocular 
vision,  and  it  is  also  an  important  safeguard  against 
the  danger  of  colliding  with  a  moving  object,  such  as 
a  horse  or  vehicle,  approaching  from  the  side  corre- 
sponding to  the  affected  eye.  A  considerable  grade 
el  astigmatism  is  frequently  present  in  aphakia, 
and  may  be  due  either  to  original  asymmetry  of 
the  cornea  or  to  acquired  asymmetry  following  the 
healing  of  a  corneal  wound  or  of  the  corneal  incision 
in  the  operation  for  the  extraction  of  cataract.  Low 
grades  of  astigmatism  are  often  overcome  by  looking 
obliquely  through  the  strong  convex  glasses  worn  to 
correct  the  aphakia;  higher  grades  may  require 
correction  by  a  special  lens.    (See  Astigmatism.) 

Disorders  of  accommodation-  occur  as  a  result 
either  of  progressive  induration  of  the  crystalline 
lens,  or  of  disordered  innervation. 

The  crystalline  lens,  which  in  a  young  child  is  of 
the  consistency  of  a  firm  jelly,  becomes  gradually 
harder  from  year  to  year.  With  increasing  indura- 
tion, the  range  of  accommodation  decreases  until, 
after  middle  life,  it  is  no  longer  possible  for  the 
emmetropic  eye  to  accommodate  for  the  ordinary 
reading  distance.  (See  Presbyopia.)  The  age  at 
which  the  failure  of  accommodation  is  recognized 
a-  a  disability  varies  according  to  the  refractive  con- 
dition. A  myope  whose  farthest  point  (r)  of  distinct 
vision  lies  well  within  a  reading  distance  of  thirty- 
three  centimeters  (thirteen  inches)  never  becomes 
presbyopic  in  the  sense  of  being  unable  to  read  with- 
out the  aid  of  convex  glasses;  but  whereas  in  youth 
he  reads  easily  with  the  concave  glasses  which  correct 
his  myopia,  he  is  compelled,  with  advancing  age, 
either  to  lay  aside  his  glasses  in  reading  or  to  exchange 
them  for  weaker  concave  glasses  than  those  through 
which  he  sees  well  at  a  distance.  In  hypermetropia 
the  loss  of  accommodation  shows  itself  by  an  early 
recession  of  the  near  point  (p),  so  that  help  is  sought 
from  convex  glasses,  perhaps  long  before  the  usual 
age  of  from  forty  to  forty-five  years.  The  young 
hypermetrope,  wearing  convex  glasses  which  correct 
his  hypermetropia,  sees  distinctly  at  all  distances, 
anil  it  is  only  at  the  age  of  about  forty-five  years  that 
he  finds  himself  compelled  to  make  use  of  stronger 
reading  glasses.  In  no  condition  of  the  refraction 
does  a  presbyope  see  clearly  at  a  distance  and  read 
easily  with  the  same  glasses.  Either  he  is  an  emme- 
trope,  in  which  case  he  requires  convex  glasses  for 
reading,  but  sees  imperfectly  through  them  at  a 
distance;  or  he  is  a  myope,  and  so  requires  concave 
glasses  for  distance,  and  weaker  concave  glasses,  or 
no  glasses  at  all,  or  possibly  weak  convex  glasses,  in 
reading;  or  he  is  a  hypermetrope,  and  so  sees  dis- 
tinctly at  a  distance  with  neutralizing  convex  glasses, 
but  requires  stronger  convex  glasses  for  reading. 

Paralysis  or  paresis  of  accommodation  from  defective 
innervation  may  be  the  result  of  an  affection  limited 
to  the  terminal  ramifications  of  the  ciliary  nerves,  or 
involving  the  oculomotor  nerve  in  any  part  of  its 
course  or  at  its  origin.  It  is  generally  accompanied 
by  dilatation  and  loss  of  mobility  of  the  pupil,  and  in 
many  cases  also  by  paralysis  or  paresis  of  one  or  more 
of  the  muscles  supplied  by  the  oculomotor  nerve, 
namely,  the  levator  palpebral  superioris,  the  rectus 
superior,  the  rectus  inferior,  the  rectus  internus,  and 
the  obliquus  inferior. 

A  typical  example  of  paralysis  of  accommodation 


dependent  on  suppression  of  the  function  of  the 
terminal  branches  of  the  ciliary  nerves  is  that  which 
follows  the  instillation  of  a  mydriatic  solution  into 
ilie  conjunctival  sac.  Within  fifteen  minutes  after 
the  instillation  of  a  drop  of  a  solution  of  atropine  sul- 
phate of  a  strength  of  one  per  cent.  (1 :100),  tne  pupil 

begins  to  dilate,  and  within  half  an  hour  the  dilata- 
tion reaches  its  maximum;  the  pupil  no  longer  con- 
tracting under  the  stimul  ong  light,     closely 

following   the  dilatation  of   the   pupil,    the   ileal    point 

i/ii  recedes  from  the  eye,  ami  the  paralysis  of  accom- 

i lation  is  generally  complete  at  the  end  of  about 

an  hour  and  a  half.  The  dilatation  of  the  pupil  and 
the  paralysis  of  accommodation  continue  without 
sensible  change  for  about  two  days,  after  which  both 
begin  to  pass  away,  the  former  very  gradually,  the 
latter  more  rapidly  for  two  or  three  days  and  after- 
ward more  slowly,  until  at  the  end  of  ten  or  twelve 
days  the  effect  of  the  drug  disappears  altogether.  A 
very  weak  solution  of  atropine,  say  of  a  strength  of 
one  one-hundredth  of  one  per  cent.  (1:10,000), 
dilates  the  pupil  in  the  course  of  an  hour  and  a  half 
or  two  hours,  but  without  rendering  it  immovable 
under  the  influence  of  strong  light,  and  without 
sensibly  affecting  the  accommodation.  Under  full 
action  of  atropine  the  near  point  (/>)  recedes  from  the 
eye  until  it  comes  to  coincide  with  the  far  point  (r). 
The  visual  disturbance  varies  greatly  according  to 
the  refractive  condition  of  the  eye.  In  emmetropia 
distant  vision  remains  clear,  but  it  is  impossible  to 
read  without  convex  glasses;  in  hypermetropia 
vision  becomes  indistinct  for  distance,  and  still  more 
so  for  the  near;  in  myopia  of  a  rather  high  grade 
there  may  be  no  trouble  in  reading  without  glasses 
and  the  recession  of  the  near  point  may  pass  unno- 
ticed. In  the  case  of  a  hypermetrope  or  a  myope 
wearing  neutralizing  glasses  the  visual  disturbance 
is  the  same  as  in  emmetropia.  Several  plants,  of 
the  natural  family  Solanacece,  yield  alkaloids  whose 
action  is  nearly  identical  with  that  of  atropine.  Hom- 
atropine,  a  derivative  of  atropine  or  of  hyosciamine, 
is  less  lasting  in  its  effect,  and  is  used  to  paralyze  the 
accommodation  in  measuring  errors  of  refraction. 
Cocaine,  the  active  alkaloid  of  Erythroxylon  coca,  and 
euphthalmin  hydrochlorate,  a  synthetic  product 
used  in  ophthalmic  practice,  dilate  the  pupil  without 
sensibly  affecting  the  accommodation. 

Concussion  of  the  eyeball  is  sometimes  followed  by 
more  or  less  persistent  dilatation  of  the  pupil  and  loss 
of  accommodation,  without  demonstrable  gross  ocular 
lesion. 

Paresis  of  accommodation,  oftenest  without  marked 
dilatation  or  loss  of  mobility  of  the  pupils,*  is  a 
frequent  complication  of  diphtheria.  It  appears 
late  in  the  disease,  after  recovery  from  the  throat 
affection,  and  is  generally  accompanied  by  paresis 
of  the  faucial  muscles  giving  rise  to  characteristic 
alteration  of  speech  with  difficulty  in  swallowing  solid 
food  and  regurgitation  of  liquids  through  the  nose. 
One  or  more  of  the  external  muscles  of  the  eyeball 
may  also  be  affected,  and  cases  of  true  convergent 
st  rabismus  have  been  observed  as  a  result  of  the  exces- 
sive effort  to  accommodate  in  the  weakened  condition 
of  the  accommodation.  The  paretic  symptoms  simu- 
late those  of  overloaded  accommodation  in  hyperme- 
tropia, and  convex  glasses  are  similarly  helpful  in 
reading.  The  instillation  of  a  drop  of  a  weak  solu- 
tion of  pilocarpine,  several  times  in  the  course  of  the 
day,  may  also  be  helpful. 

Paralysis  of  accommodation  with  dilatation  of  the 
pupil  (ophthalmoplegia  interna)  may  be  the  only 
symptom  of  a  circumscribed  cerebral  lesion.     Oftener 

*  Donders,  who  was  the  first  to  study  the  disturbance  of  vision 
in  diphtheria,  found  dilatation  with  sluggishness  of  the  pupils  in 
the  cases  observed  by  him  (1S60)  at  the  time  of  a  grave  epidemic 
in  Holland.  Binocular  paresis  of  accommodation  unaccom- 
panied by  dilatation  of  the  pupils  is  now  generally  regarded  as 
evidence  of  diphtheritic  intoxication. 

67 


Accommodation  and 
Refraction 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


the  paralysis  includes  one  or  more  of  the  muscles 
supplied  by  the  third  nerve,  or  it  may  extend  to  the 
fourth  nerve  (trochlearis)  and  to  the  sixth  nerve  (abdu- 
cens),  with  resultant  complete  immobility  of  the 
eyeball  (ophthalmoplegia  externa). 

An  overdose  of  one  of  the  more  active  mydriatic 
drugs  (belladonna,  stramonium,  hyoscyamus,  etc.)  is 
followed  by  wade  dilatation  of  the  pupils  and  paraly- 
sis of  accommodation.  With  the  elimination  of  the 
toxic   agent  the  ocular  symptoms  disappear. 

Spasm  of  accommodation,  with  spasmodic  contrac- 
tion of  the  pupil,  has  been  studied  almost  exclusively 
as  induced  by  Calabar  bean  {Physostigma  venenosum). 
The  instillation  of  one-fourth  minim  of  a  one-half  per 
cent,  solution  of  eserine  (physostigmine)  into  the  con- 
junctival sac  is  followed  after  five  to  ten  minutes 
by  spasmodic  "twitching,"  with  beginning  contrac- 
tion of  the  pupil  and  displacement  of  the  region  of 
accommodation  towards  the  eye.  In  the  course  of 
the  next  half-hour  the  pupil  is  reduced  to  a  diameter 
of  less  than  two  millimeters,  with  advancement  of  the 
farthest  point  of  distinct  vision  indicating  an  increase 
in  refraction  equal  to  about  two-thirds  of  the  absolute 
range  of  accommodation.*  Recession  of  the  far 
point  follows,  and  is  complete,  in  distant  fixation, 
after  a  little  more  than  an  hour,  but  excessive  accom- 
modation, in  convergence  for  the  near,  persists  for 
twelve  hours  or  longer;  near  objects,  seen  under 
consciously  relaxed  accommodation,  appearing  as 
if  farther  away,  and  therefore  larger,  than  under 
normal  conditions  (macropsia).t 

The  instillation  of  eserine  in  larger  quantity  or  in 
a  stronger  solution  is  followed  by  more  intense  and 
painful  spasm,  which  may  continue  for  several  hours; 
the  persistent  instillation  of  a  strong  solution  of  eser- 
ine, in  animals,  is  attended  by  general  toxic  manifes- 
tations ending  in  death. 

Pilocarpine  (the  active  alkaloid  of  Pilocarpus 
jaborandi)  acts  much  more  mildly  than  eserine,  but 
is,  nevertheless,  an  efficient  myotic  and  stimulant 
of  the  accommodation. 

Extreme  contraction  with  immobility  of  the  pupils 
is  a  typical  symptom  of  poisoning  by  opium,  and 
v.  Graefe  showed  (1S61)  that  the  hypodermic  injec- 
tion of  morphine,  in  therapeutic  doses,  is  followed  also 
by  a  temporary  increase  in  refraction  due  to  stimula- 
tion of  the  accommodation.  In  the  earlier  studies  of 
the  general  toxic  action  of  Calabar  bean,  in  animals, 
strong  contraction  of  the  pupil  was  noted  as  a  con- 
stant condition,  and  there  can  be  little  doubt  that  the 
myosis  is  accompanied  by  acute  spasm  of  accommoda- 
tion. The  hypodermic  injection  of  pilocarpine  in 
maximum  therapeutic  doses  is  not  followed  either  by 
contraction  of  the  pupils  or  by  stimulation  of  the 
accommodation. 

Stimulation  of  the  ophthalmic  division  of  the  fifth 
nerve  (trigeminus),  in  animals,  causes  contraction  of 
thr  pupil,  and  the  same  (reflex)  symptom,  accompan- 
ied by  photophobia,  is  generally  present  in  cases  of 
painful  abrasion,  phlyctenula,  etc.,  of  the  cornea. 
Spasm  of  accommodation,  with  strongly  myopic  vision 
and  a  sluggish  but  not  conspicuously  contracted  pupil, 
has  been  known  to  persist  after  apparently  perfect 
recovery   from   a   superficial   injury   of   the   cornea. 

Tension  of  accommodation  is  a  permanent  condi- 
tion in  young  hypermetropes,  who  necessarily  make 
use  of  some  part  of  their  accommodation  in  distant 
vision;  subjective  tests,  made  with  convex  glasses, 
showing  a  lower  grade  of  hypermetropia  than  is 
revealed    after    paralyzing    the    accommodation    by 

*  As  measured  by  Donders.  The  advancement  of  the  far  point 
i  I.  3 in  patients  wi th  restricted  than  with  large  range  of  accommo- 
dation. The  distance  of  the  advanced  far  point  from  the  eye  is 
greater  in  hypermetropia,  and  less  in  myopia,  than  in  emmetropia. 

t  Conversely,  as  remarked  by  Donders  (1851),  in  artificially 
induced  paresis  of  accommodation,  near  objects,  viewed  under 
consciously  increased  accommodation,  appear  smaller  than  under 
normal  conditions  (micropsia). 


atropine.  This  state  of  unconscious  tension  may  be 
maintained  for  many  years  in  a  person  with  normal 
acuteness  of  vision  and  ample  range  of  accommodation, 
his  hypermetropia  first  asserting  itself  as  a  recognized 
disability  under  the  aspect  of  premature  old  sight 
(presbyopia). 

Tension  of  accommodation  simulating  myopia, 
may  be  induced  in  a  young  person  by  excessive  use 
of  the  eyes  in  near  work.  Enforced  study  or  per- 
sistent reading  in  a  bad  light,  prolonged  strain  in  fine 
needlework  or  in  mechanical  drawing,  and  subnormal 
acuity  of  vision  in  which  compensation  for  imperfect 
definition  is  sought  by  shortening  the  reading  or 
working  distance,  are  among  the  more  obvious  excit- 
ing causes.  The  habitual  use  of  the  eyes  at  too 
short  a  distance  under  excessive  convergence,  inciting 
in  turn  to  increased  accommodation  and  convergence, 
is  a  principal  initial  and  continuing  factor  in  the 
development  and  progressive  increase  of  myopia, 
Under  atropine  the  acquired  tension  of  accommodation 
disappears;  and  the  correction  of  any  existing  ame- 
tropia, or  of  an  astigmatism  revealed  by  the  shadow- 
test  or  by  the  opthalmometer  and  verified  by  sub- 
jective tests,  may  be  all  that  is  needed  to  reestablish 
normal  conditions. 

Spasm  of  accommodation  in  near  work,  yielding 
promptly  to  atropine  but  recurring  with  the  passing  of 
the  mydriasis,  was  observed  by  Donders  in  three 
cases;  all  relieved  by  atropine  used,  at  intervals  of  a 
few  days,  for  several  months.  Such  cases  are  infre- 
quent, but  probably  not  as  rare  as  commonly  supposed. 

John  Green. 

Accouchement  force. — See  Labor,  Induction  of. 

Acephalus. — See  Teratology. 

Aceta. — Aceta,  or  vinegars,  are  liquid  preparations 
made  by  treating  vegetable  drugs  or  their  active  prin- 
ciples, with  dilute  acetic  acid.  Vinegar  is  no  longer 
used  as  a  menstruum,  it  place  being  taken  by  dilute 
acetic  acid.  There  are  only  two  aceta  official  in  the 
U.  S.  P.  of  1900;  they  are  of  uniform  strength,  ten  per 
cent.  The  B.  P.  contains  three  aceta  and  the  N.  F., 
three.  The  official  (U.  S.  P.)  aceta  are  acetum  opii 
(dose  rn  viii.)  and  acetum  scillre  (dose  nx  x.-xxx.). 

R.  J.  E.  Scott. 

Acetal. — Diethylaldehyde,  ethylidene -diethylic 
ether,  CH3.CH(OC2H5)2;  a  substance  produced  by 
the  imperfect  oxidation  of  alcohol,  distilled  from  a 
mixture  of  the  latter  with  manganese  dioxide, 
sulphuric  acid,  and  water.  It  is  a  colorless  volatile 
liquid  of  an  agreeable  odor  and  rather  sharp  but  not 
unpleasant  taste,  leaving  a  nutty  after-flavor.  It  is 
soluble  in  eighteen  parts  of  water  at  77°  F.,  somewhat 
less  at  a  lower  temperature,  and  freely  in  alcohol  and 
ether.  Acetal  possesses  sedative  and  mildly  hypnotic 
properties.  It  may  be  given  for  the  relief  of  headache 
and  nervous  excitement  and  as  an  hypnotic  in  mild 
degrees  of  insomnia,  especially  in  those  cases  in  which 
the  early  part  of  the  night  is  wakeful.  The  dose  is 
from  1  to  3  fluidrams  (4.0-12.0)  in  emulsion  with 
acacia  flavored  with  orange-flower  water.     T.  L.  S. 

Acetaminol. — Para-acetamidobenzoyl-eugenol ;  oc- 
curs in  the  form  of  a  whitish  crystalline  powder, 
soluble  in  alcohol,  but  very  slightly  in  water.  It 
possesses  antiseptic  and  mildly  hypnotic  properties, 
and  has  been  employed  as  an  intestinal  antiseptic  in 
doses  of  five  to  fifteen  grains  (0.3-1.0).        T.  L.  S. 

Acetanilide. — Acetanilidum  (U.  S.  P.).  Phenyl- 
acetamide,  antifebrin,  C„N5NH.CH3CO.  This  is  one 
of  the  earliest  of  the  antipyretic  and  analgesic  syn- 
thetic preparations,  introduced  as  a  remedy  by  Kahn 
and  Hoff  in  Germany  in  1SS6,  though  first  prepared  by 
Gerhard  in  1852.  It  is  a  monacetyl  derivative  of  ani- 
line, prepared  by  the  action  of  glacial  acetic  acid  on  ani- 
line, occurring  as  a  white  odorless  crystalline  powder, 
or  in  minute  shining  scales,  having  a  slightly  burning 


68 


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ArHIc  KtliiT 


taste,  soluble  in  200  parts  of  water,  in  4.2  parts  of  90 
per  cent,  alcohol,  in  IS  parts  of  ether,  and  freely  soluble 
in  chloroform. 

Acetanilide  is  antipyretic,  analgesic,  and  sedative, 
and  is  in  large  doses  a  cardiac  and  blood  poison.  Its 
first  employment  was  as  an  antipyretic,  but  it  is 
seldom  so  used  now  owing  to  its  depressing  effect. 
As  an  analgesic  it  is  still  largely  used,  being  given  to 
relieve  headache,  intercostal  and  other  formse  of  neu- 
ralgia, and  to  still  the  pains  of  tabetic  crises.  As 
an  analgesic  it  is  one  of  the  most  powerful  of  the 
synthetic  drugs,  but  at  the  same  time  one  of  the  most 
dangerous,  and  should  therefore  be  used  with  extreme 
caution.  It  acts  upon  the  hemoglobin  of  the  blood, 
reducing  it  to  methemoglobin  and  so  affecting  its 
oxygen-carrying  function  and  causing  cyanosis;  it 
depresses  the  action  of  the  heart  and  causes  excessive 
sweating  and  general  debility,  and  when  taken  con- 
tinuously for  some  time  tends  to  establish  a  habit. 
The  dose  as  an  anodyne  is  from  one  to  three  grains 
(0.00-0.2) ;  as  an  antipyretic,  two  to  four  grains 
(0.13-0.25).  It  possesses  antiseptic  properties  and 
may  be  used  as  a  dusting  powder  to  wounds,  chan- 
eroidal  and  other  ulcers,  and  is  also  used  as  an  errhine 
in  the  treatment  of  epistaxis. 

In  poisoning  from  an  overdose,  stimulants,  strych- 
nine, and  atropine  should  be  exhibited,  and  heat 
should  be  applied  to  the  extremities.  Strong  coffee 
may  be  of  service  and  bicarbonate  of  sodium  in  large 
doses  has  been  recommended. 

Acetanilide  is  largely  employed  as  the  active  agent 
in  many  of  the  much  advertised  headache  powders 
and  a  number  of  cases  of  acute  poisoning  from  its 
indiscriminate  employment  by  the  laity  have  been 
recorded,  as  also  cases  of  habituation  from  its  long 
continued  use.  For  this  reason  it  has  been  urged  that 
it  be  dropped  from  the  Pharmacopoeia,  but  it  is  doubt- 
ful whether  such  action  would  diminish  its  use  by 
the  laity,  and  its  really  great  service  as  an  anodyne 
in  severe  pain,  such  as  that  of  tabes,  gives  it  a  rank 
as  one  of  the  most  valuable  drugs  of  its  class. 

T.  L.  S. 

Acetic  Acid.— Acetic  acid,  CH,.COOH,  the  well- 
known  acid  of  vinegar,  is  a  liquid  at  ordinary  tem- 
peratures, and  miscible  in  all  proportions  with  water. 
Mixtures  of  the  acid  and  water  in  different  proportions 
constitute  the  different  grades  of  the  acid  in  commerce. 
Strong  acetic  acid  is  caustic,  largely  through  its  prop- 
erty of  dissolving  the  formed  material  of  the  connective 
tissues  to  a  pultaceous  translucent  substance.  Be- 
ing caustic,  it  is  of  course  irritant,  and  swallowed  in 
concentrated  condition  operates  as  a  corrosive  poison, 
the  effects  and  symptoms  being  substantially  the  same 
as  in  corrosion  by  the  strong  mineral  acids.  But  few 
cases  of  death  have  been  recorded.  The  treatment  is 
similar  to  that  to  be  employed  in  case  of  poisoning  by 
a  mineral  acid.  In  non-corrosive  strength  of  solution 
(five  or  six  per  cent.,  the  equivalent  of  vinegar),  acetic 
acid  produces  the  usual  local  effects  of  the  sour  acids 
— exciting  the  flow  of  saliva  and  tending  to  oppose  sour 
fermentation  of  the  food — and  is  also  distinctly  astrin- 
gent. Inhaled  the  fumes  are  reviving  in  faintness  and 
may  relieve  headache. 

Acetic  acid  has  many  uses  in  pharmacy.  It  has  been 
urged  that  the  Pharmacopoeia  should  substitute 
acetic  acid  largely  for  alcohol  as  a  menstruum  for  the 
preparation  of  extracts;  and  it  has  even  been  proposed 
that  this  class  of  extracts  shall  bear  the  special 
name  "Acetracts."  In  medicine  the  strong  acid 
may  be  employed  as  a  caustic,  as  to  warts  or  cancers, 
and  the  weak  acid  used  to  make  refreshing  acid 
draughts  in  fever,  or  cooling  lotions  in  inflammatory 
skin  affections.  Acetic  acid  is  official  in  the  U.  S. 
Pharmacopoeia  in  three  forms: 

Acidum  Aceticum  Glaciate,  Glacial  Acetic  Add. — This 
is  defined  to  be  "a  liquid  containing  not  less  than  ninety- 
nine   per   cent.,  by  weight,  of   absolute   acetic   acid 


(CH,.  COOH  =59.58),  and  not  more  than  one  per  cent, 
of  water."  It  is  "a  clear,  colorless  liquid,  of  a  strong, 
vinegar-like  odor,  and  a  very  pungent  arid  ta  te. 
At  a  temperature  somewhat  below  15°  C.  (.59°  F.), 
the  acid  becomes  a  crystalline  solid.  At  1 17°  to  1  lsJ 
C.  (242.0°  to  211.1 "  I'.j  it  boils,  evolving  inflammable 
vapors."  (U  S.  P.)  This  grade  of  the  acid  is  for 
pharinaeeul  ieal  uses. 

Acidum  Aceticum,  Acetic  Acid. — The  grade  of  acid 
thus  simply  named  is  a  "liquid  composed  of  not 
less  than  thirty-six  per  cent.,  by  weight,  of  absolute 
acetic  acid  and  about  sixty-four  per  cent,  of  water, 
obtained  by  the  oxidation  of  ethyl  alcohol  or 
by  the  destructive  distillation  of  wood."  It  is  "a 
clear,  colorless  liquid,  having  a  strong,  vinegar- 
like  odor,  a  purely  acid  taste,  and  a  strongly 
acid  reaction.  Specific  gravity,  about  1.04.5  at  25° 
C.  (77°  F.).  Miscible  with  water  or  alcohol  in  all 
proportions.  When  heated,  the  acid  is  volatil- 
ized without  leaving  a  residue"  (U.  S.  P.).  This  is  the 
acid  that  results  from  the  purification  of  the  crude 
acid — mult  pyroligneous  acid,  so  called — obtained  by 
the  destructive  distillation  of  wood.  This  is  sharply 
irritant  and  even  mildly  caustic.  Dangerous  symp- 
toms have  resulted  from  swallowing  it,  undiluted,  in 
quantity  of  two  or  three  ounces.  The  acid  maj'  be 
used  as  a  mild  caustic,  but  its  principal  uses  under  its 
own  form  are  pharmaceutical. 

Acidum  Aceticum  Dilutum,  Diluted  Acetic  Acid. — 
It  should  contain  not  less  than  six  per  cent.,  bv  weight, 
of  absolute  acetic  acid  (CTI3.COOH  =59.58),  and 
about  ninety-four  per  cent,  of  water.  Specific 
gravity,  about  1.009  at  25°  C.  (77°  F.  )  (U.  S.  P.) 
This  diluted  acid  is  of  the  strength  of  the  best  qualities 
of  vinegar,  and  is  better  than  vinegar  for  all  the  pur- 
poses of  the  same,  medicinal  or  dietetic.  Squibb 
says:  "  If  one  part  of  alcohol  be  added  to  about  two 
hundred  and  fifty-six  parts  of  this  diluted  acetic  acid — 
that  is,  about  half  a  fluidounce  to  the  gallon — and  the 
mixture  be  set  aside  for  a  few  weeks  (the  longer  the 
better),  enough  acetic  ether  is  generated  to  give  it  the 
full,  clean  aroma  of  fine  vinegar,  and  then  for  table  use 
it  is  very  far  superior  to  any  vinegar  made  in  the 
ordinary  way  by  fermenting  cider." 

Diluted  acetic  acid  is  the  most  convenient  grade  of 
the  acid  for  medicinal  use,  and  has  also,  in  the  U.  S. 
Pharmacopoeia,  superseded  vinegar  for  pharmaceuti- 
cal purposes.  For  an  acid  draught  a  five-per-cent. 
addition  to  water  is  appropriate,  and  for  a  lotion  a 
twenty-five-per-cent.  addition.  The  popular  notion 
that  the  habitual  use  of  vinegar  tends  to  deterioration 
of  nutrition  and  health  is  certainly  not  true  of  a 
moderate  indulgence,  if  indeed  it  be  true  at  all. 

Edward  Curtis. 
R.  J.  E.  Scott. 

Acetic  Ether. — Under  the  title  Mfher  Aceticus, 
Acetic  Ether,  the  U.  S.  Pharmacopoeia  makes 
official  a  preparation  consisting  of  the  ethereal  salt, 
ethyl  acetate  (about  ninety  per  cent.,  by  weight), 
with  a  little  contaminating  alcohol  and  water, 
Acetic  ether  is  described  as  "a  transparent,  colorless 
liquid,  of  a  fragrant,  and  refreshing,  slightly  acetous 
odor,  and  a  peculiar  acetous  and  burning  taste. 
Specific  gravity,  0.883  to  0.885  at  25°  C.  (77°  F.). 
Boiling-point,  about  72°  C  (161.0°  F.).  Soluble  in 
about  seven  parts  of  water  at  25°  C.  (77°  F.)  ;  miscible  in 
all  proportions  with  alcohol,  ether,  and  the  fixed  and 
volatile  oils.  Acetic  ether  is  readiljr  volatilized,  even 
at  a  low  temperature.  It  is  inflammable,  burning 
with  a  yellowish  flame  and  an  acetous  odor"  (TJ.  S.  P.). 
Acetic  ether  should  be  kept  in  well  stoppered  bottles 
and  away  from  lights  or  fire. 

The  effects  of  acetic  ether  upon  the  animal  economy 
are  similar,  in  a  general  way,  to  those  of  common 
ether,  the  most  important  point  of  difference  being 
that  acetic  ether  is  the  slower  in  operation.  For  this 
reason  this  ether  is  not  available  as  a  surgical  an- 

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esthetic;  but,  on  the  other  hand,  by  reason  of  its 
agreeable  odor,  it  makes  an  excellent  and  grateful 
cardiac  stimulant,  antispasmodic,  and  carminative, 
taken  internally.  Used  externally,  it  may  serve  to 
mask  disagreeable  odors.  It  may  be  given  internally, 
in  quantities  ranging  from  fifteen  to  thirty  drops, 
well  diluted  with  water  or  with  some  medicinal  prepa- 
ration, to  which  the  ether  is  added  as  an  adjuvant 
or  corrigent.  R.  J.  E.  Scott. 

Acetone. — Acetone,  CH,.CO.CH„  dimethyl  ketone, 
is  a  colorless  limpid,  and  inflammable  liquid  of  pungent 
quality,  miscible  in  all  proportions  with  water,  alcohol, 
and  ether.  Its  effects  upon  the  animal  system  are, 
doubtless,  of  the  general  nature  of  those  of  the  volatile 
alcohols  and  ethers,  but  the  substance  has  never  been 
systematically  employed  as  a  medicine. 

It  is  used  for  chemical  purposes  in  the  manufacture 
of  chloroform,  and  as  a  solvent  for  fats  and  resins. 

It  occurs  normally,  in  small  amounts,  as  an  ingre- 
dient of  blood,  urine,  etc.  R.  J.  E.  Scott. 

Acetonuria.  Definition. — The  presence  in  the 
urine  of  a  pathological  quantity  of  acetone,  CO(CH3)2. 

Historical. — Petters  in  1S57  discovered  acetone 
in  the  urine  of  a  patient  suffering  from  diabetic  coma, 
and  three  years  later  Kaulich  demonstrated  its 
occurrence  in  ordinary  cases  of  diabetes  and  added  a 
clinical  picture  of  the  condition  known  as  acetonemia. 

Kussmaul  in  1874,  writing  on  diabetic  coma,  first 
threw  doubt  on  the  previously  expressed  idea  that  a 
definite  relation  existed  between  diabetic  coma  and 
acetonuria,  while  Gerhardt  later  on  showed  the 
occurrence  of  diacetic  acid  in  the  urine,  a  substance 
which  has,  clinically,  even  greater  importance. 

Occurrence. — Physiologically,  acetone  occurs  in 
the  urine  in  very  minute  proportions,  probably  never 
more  than  .02  gram  being  excreted  in  twenty-four 
hours.  Pathologically,  more  than  5  grams  have 
been  in  the  daily  quantity  of  urine. 

The  main  conditions  under  which  increased  acetone 
is    found    may    be    briefly    summarized    as    follows: 

1.  Alimentary,  i.e.  according  to  diet;  withdrawal  of 
carbohydrates;  this  may  reach  0.7  gram  after  pro- 
longed dieting. 

2.  Diabetes,  especially  after  some  duration  of  the 
disease    and    with    protein    diet    or    increased    fats. 

3.  Fevers  (often  with  diacetic  acid  and  /3-oxybutyric 
acid  as  well);  infectious  diseases,  e.g.  enteric  fever, 
sepsis,  pneumonia,  exanthems,  tuberculosis,  acute  in- 
flammatory rheumatism;  in  the  fevers  it  occurs  only 
in  prolonged  cases,  probably  because  of  the  nature  of 
the  diet;  acute  fevers  present  no  increased  acetonuria. 

4.  Starvation  and  inanition;  cachexia;  early  car- 
cinoma of  stomach. 

5.  Digestive  disturbances  with  autointoxication; 
peritonitis. 

6.  Pregnancy  with  dead  fetus. 

7.  Nervous  lesions  and  mental  disease;  tabes; 
general  paralysis;  melancholia,  etc. 

S.  Artificially  induced  general  anesthesia  (chloro- 
form). 

9.  Experimental — after  extirpation  of  the  solar 
plexus  or  of  the  pancreas. 

10.  Medicinal — phlorizin;    chronic    morphinism. 
[For  a  discussion  of  the  source  and  mode  of  pro- 
duction of  the  acetone  bodies,  see  the  article  Acidosis.] 

Clinical  Significance. — In  all  probability  the 
acetone  per  se  is  harmless  and  the  toxic  symptoms  are 
produced  by  the  diacetic  and  /?-oxybutyric  acids; 
and  possibly  also  others,  e.^.  lactic  acid'  or  volatile  fatty 
acids,  come  into  action,  too,  at  times.  At  all  events, 
it  is  the  acid  intoxication  (or  excessive  acidosis,  as  it 
has  been  called)  that  induces  the  serious  changes  whioh 
occur.  Patients  manifesting  this  acid  intoxication 
usually  get  diabetic  coma  if  no  intercurrent  affection 
occur  to  carry  them  off. 

The    Prognosis,  then,  depends  rather  upon  the  evi- 


dence of  acidosis  than  of  acetonuria  to  a  large  extent, 
and  Hallervorden  has  for  this  reason  suggested  the 
importance  of  frequent  estimation  of  the  ammonia 
eliminated,  this  giving  a  fairly  accurate  idea  of  the 
acid  intoxication.  (More  than  three  grams  of  NH3 
in  twenty-four  hours  indicates  excessive  acidosis, 
while  if  more  than  four  grams  exist,  the  onset  of  dia- 
betic coma  is  almost  certain,  even  though  due  treat- 
ment temporarily  diminish  the  amount  of  NH3  elimi- 
nation.) This  theory  is  proven,  too,  by  Stadelmann's 
and  Minkowski's  observations,  that  diminished  COa 
was  in  the  blood  (i.e.  less  alkalinity),  and  by  the  fact, 
too,  that  in  severe  diabetes  the  sudden  restricting 
to  meat  diet  (i.e.  acid)  is  often  followed  by  coma. 

The  acetone  is  to  some  extent,  however,  in  definite 
ratio  to  the  intensity  of  the  diabetes,  and  the  presence 
of  a  large  quantity  is  of  grave  import — though  not  as 
a  prodrome  of  approaching  coma,  as  Hirschfeldt  once 
supposed.  Intercurrent  fevers,  e.g.  pneumonia,  may 
greatly  increase  the  acetone  temporarily,  and  with 
convalescence  the  quantity  may  return  to  its  previ- 
ous amount.  So  it  was  in  the  case  of  a  diabetic  whose 
urine  increased  during  an  intercurrent  pneumonia 
from  0.4  gram  to  4  grams  acetone,  daily,  and  with 
convalescence  the  amount  returned  to  0.4  gram  in 
the  twenty-four  hours;  coma  did  not  supervene  and 
the  patient  lived  for  months  afterward,  until  fatal 
marasmus  came  on.  It  is  well,  however,  to  follow  the 
acetone  excretion  in  diabetes,  for  its  increase  is  so 
frequent  with  threatening  symptoms;  hence  the  bene- 
fit, at  such  a  time,  of  judicious  administration  of 
carbohydrates. 

The  diagnostic  significance  of  acetonuria  lies  in  the 
fact  that  its  presence  to  any  extent  with  glycosuria 
renders  the  diagnosis  of  diabetes  certain. 

Tests. — Before  testing  for  acetone  one  should  ascer- 
tain the  possible  presence  of  diacetic  acid.  For  this, 
Gerhardt's  reaction  is  to  be  tried  and  the  following 
three  steps  must  be  taken:  Fifteen  cubic  centimeters 
of  urine  are  treated  with  dilute  (not  too  acid)  ferric 
chloride  so  long  as  it  gives  a  precipitate.  The  pre- 
cipitate (ferric  phosphate)  is  filtered  and  more  ferric 
chloride  added  to  the  filtrate.  In  presence  of  diacetic 
acid  a  claret-red  color  appears.  A  second  portion  of 
the  urine  is  boiled  and  the  same  test  repeated  after 
cooling.  A  negative  result  should  follow,  because  the 
diacetic  acid  was  decomposed  by  the  boiling.  (If  a 
positive  result  were  again  obtained  it  would  indicate 
the  presence  of  acetic  or  some  other  acid  in  the  urine.) 
A  third  portion  is  next  acidified  with  sulphuric  acid 
and  shaken  with  ether.  The  ether  is  removed  and 
shaken  with  a  very  dilute  aqueous  solution  of  ferric 
chloride,  when  the  watery  layer  becomes  violet  red  or 
claret  red.  The  color  disappears  on  warming  or  after 
standing  twenty-four  hours. 

In  the  absence  of  diacetic  acid  we  proceed  to  test 
directly  for  acetone.  No  single  test  for  acetone  is 
completely  satisfactory;  hence  the  necessity  of  employ- 
ing several  as  confirmatory  evidence.  One  may  use 
the  urine  as  it  is,  although  it  is  more  accurate  to  resort 
first  to  distillation.  About  250  c.c.  of  urine  are  boiled 
after  faintly  acidifying  with  sulphuric  acid,  and,  a 
good  condensation  being  secured,  all  the  acetone  will 
distil  in  the  first  20  c.c. 

When  diacetic  acid  is  present  the  urine  should  first 
be  rendered  faintly  alkaline  and  carefully  shaken  up 
in  a  separator  funnel  with  ether  (the  ether  must  be 
free  from  alcohol  and  acetone).  The  removed  ether 
is  then  shaken  up  with  water,  which  takes  up  the 
acetone,  and  this  watery  liquid  is  tested. 

Qualitative  Texts. — Lichen's  Iodoform  Test. — Treat  a 
few  cubic  centimeters  of  the  distilled  urine  (which 
should  be  freshly  voided  always)  with  some  sodium 
hydrate  and  iodine  potassic  iodide  solution  and  gently 
warm.  With  traces  of  acetone  a  yellow  precipitate 
of  iodoform  occurs,  and  this  will  be  recognized  by  its 
odor  and  by  the  hexagonal  plates  or  stellate  crystals. 
While  this  test  is  delicate  enough  for  acetone,  there  are 


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Acctplifncttdln 


many  other  constituents  of  the  urine  and  other  sub- 
stances (at  least  seventeen)  which  yield  a  similar  re- 
action. Among  them  is  alcohol;  hence  the  possibility 
of  error  from  using  an  alcoholic  solution  of  iodine  to 
make  up  one  of  the  reagents — which  must,  of  course, 
be  avoided. 

Gunning  modified  the  test  by  using  an  alcoholic  solu- 
tion of  iodine  and  ammonia  instead  of  the  mixture 
mentioned  above.  A  black  precipitate  of  iodide  of 
nitrogen  results,  and  this,  in  the  presence  of  acetone, 
gradually  disappears,  leaving  the  yellow  iodoform 
behind.  The  test,  though  not  quite  so  delicate,  is 
more  accurate,  neither  alcohol  nor  aldehyde  produc- 
ing a  similar  result;  and,  moreover,  it  is  eminently 
suited  for  clinical  purposes,  in  view  of  the  temptation 
to  test  without  the  time-absorbing  distillation. 

Legal's  Sodium  Nitroprusside  Test. — Treat  a  feu- 
cubic  centimeters  of  the  urine  with  two  or  three  drops 
of  a  freshly  prepared  concentrated  solution  of  sodium 
nitroprusside  and  add  a  thirty-per-eent.  solution  of 
caustic  potash.  A  ruby  red  color  appears,  which 
changes  to  yellow.  Any  urine  may  give  this  reaction. 
But  if  acetone  be  present  in  pathological  amount  the 
addition  of  acetic  acid  changes  the  color  to  a  purple- 
red  or  violet.  Paracresol  and  creatinin  give  some- 
what similar  reactions.  In  presence  of  the  former, 
however,  the  yellow  color  changes  to  pink  on  addition 
of  acetic  acid,  while  with  the  latter  a  saturation  with 
acetic  acid  gives  a  yellow  color,  soon  changing  to 
green  and  blue.  Acetone,  under  similar  conditions, 
gives  a  carmine  color. 

Fehr  modifies  this  test  by  floating  the  acetic  acid  on 
the  urine  as  the  color  changes  to  yellow.  A  violet  is 
produced  at  the  line  of  contact,  its  intensity  being 
proportionate  to  the  amount  of  acetone  present. 
Notwithstanding  its  frequent  commendation  for 
clinical  purposes,  Legal's  test  is  certainly  unreliable 
unless  the  urine  be  first  distilled. 

Le  Nobel's  test  is  similar.  One  adds  an  alkaline 
solution  of  sodium  nitroprusside  (so  dilute  as  merely 
to  give  a  faint  reddish  tint  to  the  solution)  to  the  urine; 
a  ruby  red  color  is  obtained,  soon  changing  to  yellow. 
On  boiling  and  adding  the  acid  a  greenish-blue  or 
violet  results. 

Penzoldt's  Indigo  Test. — Treat  the  urine  with  a 
warm  saturated  and  then  cooled  solution  of  ortho- 
nitrobenzaldehyde  and  add  caustic  soda.  If  acetone 
be  present  the  liquid  becomes  first  yellow,  then  green, 
and  finally  indigo  forms,  which  may  be  dissolved  in 
chloroform. 

Chautard  takes  fuchsin  solution  into  which  a  cur- 
rent of  sulphurous  acid  gas  has  been  passed.  This 
decolorizes  the  liquid  and  gives  it  a  clear  yellow  tint. 
When  added  to  urine  containing  acetone  a  deep  violet 
color  is  produced. 

Reynolds'  mercuric  oxide  test  depends  on  the  power 
of  acetone  to  dissolve  freshly  precipitated  mercuric 
oxide.  A  mercuric  chloride  solution  is  first  precipi- 
tated by  alcoholic  caustic  potash.  The  urine  is  added 
to  this  and  the  mixture  well  shaken  and  filtered.  If 
acetone  be  present  the  filtrate  contains  mercury,  which 
may  be  detected  by  the  black  color  on  adding  ammo- 
nium sulphide. 

Reynolds'  and  Gunning's  tests  are  particularly 
recommended  for  delicacy  and  reliability  combined. 

Quantitative  Test. — Huppert's  modification  of  Mes- 
singer's  is  that  most  recommended;  Lieben's  iodo- 
form test  being  the  method  on  which  it  is  based. 
Acetone  forms  iodoform  when  treated  in  an  alkaline 
solution  with  iodine.  By  treating  the  urine  with  a 
known  amount  of  iodine  one  need  simply  estimate  the 
quantity  unused  by  the  iodoform  to  know  how  much 
has  been  combined.  This  can  be  done  by  titration 
with  sodium  thiosulphate  solution.  For  the  details  of 
the  method,  as  well  as  for  the  methods  for  determin- 
ing ,3-oxybutyric  acid  quantitatively,  the  reader  is 
referred  to  Neubauer-Huppert's  "  Analyse  des  Harns," 
1910.  Charles  F.  Martin. 


Acctozone. — The   trade   name  of  a   grayish-white 

powder  e posed  of  equal  parts  by  weight  of  ben- 
zoyl-acetyl dioxide  ami  an  inert  absorbent  powder  of 
infusorial  earth.  The  active  ingredient,  C.ll  .<  '<  M  >.- 
(>.('<  )(  'II-,,  is  similar  in  structure  to  hydrogen  dioxide, 
the  hydrogen  atoms  being  replaced  by  acetic  and 
benzoic  acid  radicles.  It  occurs  as  a  white  crystalline 
powder,   very  slightly  soluble  in   water  or  alcohol, 

melting   at   98°    F.    (36.6°   C),   and    d mposed   by 

heat  and  by  alkalies.  It  decomposes  organic  material 
in  the  presence  of  water  and  is  consequently  anti- 
septic and  deodorant.  It  is  employed  externally  as 
an  antiseptic  in  gonorrhea,  ulcers,  tonsillitis,  corneal 
ulcers,  and  suppurative  nasal  and  aural  affections, 
being  applied  in  the  form  of  powder,  ointment  with 
petroleum  base,  or  solution  in  water  or  oils.  Its 
chief  use,  however,  is  as  an  intestinal  disinfectant 
in  typhoid  fever  and  dysentery;  in  the  former  con- 
dition especially  it  acts  very  favorably  in  reducing 
tympanites,  controlling  diarrhea,  and  destroying  the 
odor  of  the  stools.  For  this  purpose  the  powder  is 
added  to  warm  water  in  the  proportion  of  seven  and 
one-half  to  fifteen  grains  (0.5-1.0)  to  the  quart 
(1,000  c.c.  or  1  liter),  the  mixture  being  thoroughly 
shaken  and  then,  after  standing  for  an  hour  or  two, 
decanted.  The  dose  of  the  decanted  solution  is 
indefinite,  one  or  two  quarts  being  drunk  in  the 
course  of  twenty-four  hours. 

Acetozone  inhalant  is  a  mixture  of  benzoyl-acetyl 
dioxide  2,  chloretone  1,  and  liquid  petrolatum  107; 
it  is  employed  in  the  form  of  spray  in  diseases  of  the 
nose  and  throat.  Ointments  of  0.1  to  1  per  cent, 
strength  should  be  made  with  a  petroleum  base,  as 
acetozone  is  gradually  decomposed  by  animal  or 
vegetable  fats. 

Acetphenetidin. — Aoetphexetidinum  (U.  S.  P.), 
phenacetin,  CjHsO.CjHj.NHCOCH,;  "a  phenol  deriv- 
ative, acetparaphenetidin,  the  product  of  the  acetyl- 
ization  of  para-amidophenetol."  Occurs  in  the 
form  of  a  white  crystalline  powder  or  glistening 
scales,  without  odor  or  taste,  soluble  in  92.5  parts  of 
cold  water,  70  parts  of  boiling  water,  12  parts  of 
alcohol,  and  20  parts  of  chloroform.  Phenacetin, 
like  the  other  synthetic  members  of  its  class,  was 
introduced  as  an  antipyretic  but  has  found  its  chief 
employment  as  an  analgesic,  in  which  respect  it  is 
less  powerful,  but  safer  and  less  depressant  than 
acetanilide.  In  ordinary  doses  it  has  but  little 
depressant  effect  upon  the  heart,  but  in  overdose  it 
reduces  the  hemoglobin  of  the  blood  to  met  hemo- 
globin, whereby  the  oxygen  carrying  power  is  dimin- 
ished and  cyanosis  is  produced.  As  an  antipyretic 
it  may  be  of  service  in  sthenic  fevers,  but  in  cases  of 
adynamia  it  should  be  employed  with  caution  as  it 
is  apt  to  cause  profuse  sweating  and  is  debilitating. 
The  latter  effect  may  be  obviated  in  a  measure  by 
combining  the  drug  with  caffeine.  As  an  anodyne 
it  is  given  for  the  relief  of  headache,  neuralgia, 
gastralgia,  and  the  lightning  pains  of  tabes,  but  for 
the  latter  is  inferior  to  acetanilide.  It  is  sometimes 
useful  as  a  sedative  and  mild  hypnotic  in  cases  of 
sleeplessness  due  to  fatigue,  nervousness,  or  slight 
pain.  The  dose  as  an  antipyretic  or  analgesic  is  five 
grains  (0.3),  repeated  in  two  hours  if  necessary.  It 
is  best  given  in  powder,  in  capsules,  or  in  compressed 
tablets. 

In  the  treatment  of  poisoning  by  an  overdose  of 
acetphenetidin,  heat  should  be  applied  to  the  extremi- 
ties, and  stimulants,  strychnine  or  caffeine,  be  given; 
if  cyanosis  is  pronounced,  inhalation  of  oxygen  may 
be  serviceable. 

It  is  recommended  that  acetphenetidin  be  pre- 
scribed under  its  official  title,  and  not  as  phenacetin, 
the  latter  being  the  name  of  the  patented  German 
preparation  and  sold  at  a  much  higher  price.  It  is 
further  recommended  that,  when  prescribed  as  acet- 
phenetidin, care  be  taken  to  see  that  it  is  sold  at  the 

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price  of  this  drug  and  that  it  be  not  charged  for  at  the 
rate  of  the  expensive  phenacetin.  T.  L.  S. 

Acetum. — See  Aceta  and  Vinegar. 

Acetylene. — See  Gas,  Illuminating. 

Acetylsalicylic  acid. — See  Aspirin. 

Achondroplasia. — Chondrodystrophy.  See  under 
Na  n  is  m . 

Acidol. — See  Belaine  Hydrochloride. 

Acidosis  and  Acid  Intoxication.  Definition. — While 
acidosis  and  acid  intoxication  are  frequently  used  as 
synonymous  terms,  strictly  speaking  they  represent 
quite  distinct  entities. 

Acidosis  is  a  condition,  pathological  or  otherwise, 
in  which  an  excess  of  acid  products  is  indicated  by  an 
analysis  of  the  blood  or  of  the  urine.  It  is  impossible 
in  many  cases  to  distinguish  whether  an  excess  has 
really  been  formed,  or  whether  the  normal  amount  only 
has  been  formed  and  this  amount  has  been  inhibited 
from  undergoing  further  oxidation.  In  conditions 
such  as  diabetes  it  is  quite  certain  that  the  amount  of 
acid  products  eliminated  is  in  excess  of  what  may  be 
formed  during  normal  metabolism.  In  this  con- 
dition, at  least,  one  is  forced  to  assume  that  an  ex- 
cessive  production   of   acid   compounds   takes   place. 

Acid  intoxication,  on  the  other  hand,  distinctly  im- 
plies a  pathological  condition  of  toxic  character  pro- 
duced by  acid  products  formed  within  the  organism. 
Acid  intoxication  may  also  be  produced  by  the 
administration  of  acids,  chiefly  inorganic.  This 
form  of  poisoning  is  of  importance,  as  it  has  a  com- 
parative bearing  on  the  general  problem  of  acid 
intoxication. 

The  Compounds  Taking  Part  in  Acidosis. — The  com- 
pounds immediately  concerned  in  the  problem  of 
acidosis  are  three:  /3-oxybutyric  acid,  acetoacetic  acid 
(diacetic  acid),  and  acetone.  They  are  usually  termed 
the  acetone  compounds,  although  it  would  be  more  ad- 
visable to  speak  of  them  as  the  oxybutyric-acid  com- 
pounds, for  this  substance  is  the  starting-point  in  the 
formation  of  the  other  two. 

3-oxybutyric  acid  has  the  formula: 

COOH 

I 
H— C— H 

H— C— OH 

I 
H— C— H 

I 
H 

This  by  oxidation  is  converted  into  acetoacetic  acid: 
COOH 

I 
H— C— II 

I 

c=o 

I 

H— C— H 

I 
H 

which  by  losing  a  molecule  of  carbon  dioxide  from  the 
carboxyl  group  is  converted  into  acetone: 
COOH  H 


H— C— II 

■     I 
C=0 

I 

H— C— H 

I 
H 


H— C— H 

C=0 

I 
H— C— H 

k 


/3-oxybutyric  acid  was  discovered  simultaneously 
by  Minkowski  and  by  Kiilz,  although  Stadelmann  had 
previously  been  led  to  suspect  the  presence  of  an 
abnormally  large  amount  of  an  organic  acid  in 
diabetic  urines.  He  mistook  a  decomposition  prod- 
uct of  /3-oxybutyric  acid,  a-crotonic  acid,  for  the 
former.  /3-oxybutyric  acid  as  formed  in  the  body  is  a 
levorotatory  syrup,  which  has  been  obtained  by 
Magnus-Levy  in  a  crystalline  condition.  Ferric  chlo- 
ride does  not  give  a  red  color  with  this  acid. 

The  presence  of  acetoacetic  acid  in  the  urine  was  in- 
dicated by  the  reaction  discovered  by  Gerhardt,  who 
found  that  certain  urines  gave  a  Bordeaux-red  color 
when  treated  with  an  aqueous  solution  of  ferric 
chloride.  Further  investigation  of  this  color  reaction, 
especially  by  v.  Jaksch,  led  this  observer  to  believe 
that  he  had  isolated  acetoacetic  acid  from  the  urine. 
From  the  unstable  character  of  this  acid  it  is  safe  to 
say  that  it  has  never  been  separated  from  the  urine  in 
a  pure  condition.  There  is  no  doubt,  however,  that 
the  substance  giving  the  red  color  is  really  acetoacetic 
acid.  All  the  tests  which  urines  give  under  these  con- 
ditions are  those  of  aqueous  solutions  of  acetoacetic 
acid.  The  acid  is  extremely  unstable,  and  rapidly 
breaks  down  in  solution  into  carbon  dioxide  and 
acetone. 

Acetone  was  discovered  in  the  urine  by  Petters  and 
by  Kaulich  in  1S57,  and  was  the  first  of  the  acetone 
compounds  to  be  detected.  It  is  therefore  from  an 
historical  point  of  view  that  acetone  has  lent  its  name 
to  this  class  of  compounds. 

When  attention  was  first  drawn  to  the  connection 
between  /3-oxybutyric  acid,  acetoacetic  acid,  and  ace- 
tone, it  was  thought  that  acetone  was  the  first  sub- 
stance to  be  formed.  This  by  synthesis  with,  possibly, 
formic  acid  would  yield  acetoacetic  acid,  which  on  re- 
duction might  be  transformed  into  /3-oxybutyric  acid. 
This  has  since  been  shown  not  to  be  the  case.  The 
administration  of  acetone  has  never  been  followed  by 
an  increase  in  the  amount  of  either  acetoacetic  acid  or 
/3-oxybutyric  acid,  while  the  converse  almost  invari- 
ably happens.  The  administration  of  /3-oxybutyric 
acid  or  acetoacetic  acid  to  diabetics  or  to  persons  ab- 
staining from  food  is  followed  by  an  increase  in  the  ace- 
tone content  of  the  urine  and  of  the  breath. 

Furthermore,  these  compounds  make  their  appear- 
ance in  the  urine  in  the  following  order:  acetone,  aceto- 
acetic acid,  /3-oxybutyric  acid.  They  disappear  in  the 
reverse  order,  fl-oxybutyric  acid  being  the  first  to  van- 
ish. As  /3-oxybutyric  acid  is  the  last  to  appear  and  the 
first  to  leave,  one  can  only  conclude  that  its  appearance 
indicates  the  greatest  departure  from  normal  metabo- 
lism, and  that,  being  the  first  product  formed,  it 
appears  in  the  urine  only  when  the  capacity  of  the  or- 
ganism to  convert  it  to  acetoacetic  acid  and  acetone  is 
impaired. 

One  other  acid  product  of  metabolism  may  be 
mentioned  which  has  played  no  inconsiderable  role  in 
some  late  theories  of  acid  intoxication.  This  is 
-iarcolactic  acid.  It  may  be  connected  with  the  arc- 
inn,-  com] nds,  bul   Hi"  relation,  biologically,  is  not 

clear.  Its  place  in  acid  intoxication  will  be  discussed 
when  eclampsia  is  considered. 

The  Source  op  the  Acetone  Compounds. — 
Theoretically  all  three  classes  of  compounds  which 
enter  into  tissue  formation — carbohydrates,  fats,  and 
proteins — may  be  the  sources  from  which  the  acetone 
compounds  are  derived.  As,  however,  the  carbohy- 
drates occupy  such  an  exceptional  place  in  the 
mechanism  of  acetone-compound  formation,  only 
the  latter  two  classes,  viz.,  proteins  and  fats  can  be 
considered  as  being  acetone  formers. 

For  a  long  time  it  was  thought  that  the  fats  and  fatty 
acids  alone  were  the  source  of  the  acetone  compounds. 
[Von  Noorden  still  holds  to  this  theory.  Although 
no  doubt,  he  says,  a  certain  amount  of  the  acetone 
bodies  are  formed  within  the  organism  from  protein 
(amino  acids),  this  process  is  not  extensive  enough  to 


I 


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\i  IcIii-Ih 


account  for  all  or  even  a  considerable  part  of  the 
pathological  acetone  formation.  Hammarsten  also 
says  that  while  we  cannot  deny  the  possibility  of  a 
formation  of  acetone  from  proteins,  certain  facts  nega- 
tive the  theory  that  the  acetone  bodies  arise  entirely 
from  the  proteins.]  It  is  nevertheless  probable  that  the 
!  fatty  acids  occupy  a  more  or  less  secondary  place  and 
that  the  proteins,  or,  what  is  the  equivalent,  the 
amino  acids,  are  the  chief  source  of  these  compounds. 

According  as  a  substance  produces  or  inhibits  the 
formation  of  acetone,  it  is  classed  as  ketogenic  or 
ketoplastic,  or  antiketogenic  or  antiketoplastic.  Bor- 
chardt further  subdivides  the  ketogenic  compounds 
into  those  from  which  acetone  is  directly  derived, 
which  actually  break  down,  yielding  acetone  or  one  of 
its  forerunners,  and  those  which  are  merely  ketoplastic, 
that  is  to  say,  only  increase  the  output  of  these  com- 
pounds in  the  urine  or  the  breath,  without  having 
contributed  directly  to  their  formation. 

With  regard  to  the  fats,  their  action  is  complicated 
by  the  fact  that  they  consist  of  two  parts,  fatty  acid 
and  glycerol.  Glycerol  belongs  distinctly  to  the  class 
of  antiketogenic  compounds,  and  its  inhibitory  action 
may  be  so  great  as  to  prevent  any  ketogenic  action 
which  the  fatty-acid  moiety  may  have.  As  to  the 
tatty  acids  themselves,  the  results  of  feeding  these 
substances  to  diabetics  or  persons  in  a  state  of  inani- 
tion are  not  altogether  in  concordance.  Joslin, 
taking  into  account  the  absorption  of  these  substances 
by  the  intestinal  wall,  was  unable  to  attribute  to 
them  a  ketogenic  function,  and  this  was  particularly 
-  true  of  palmitic  and  stearic  acids.  Oleic  acid  was 
V  ketogenic.     His  results  are  confirmed  by  Geelmuyden. 

[Magnus-Levy,  who  regards  the  fatty  acids  as  the 
chief,  if  not  the  sole,  source  of  the  acetone  compounds, 
says  it  is  nevertheless  unnecessary  to  restrict  the  inges- 
tion of  fat  is  diabetes.  It  is  not  the  presence  of  a  large 
amount  of  fat  that  causes  acidosis,  but  only  the  in- 
creased decomposition  of  fat.  The  occurrence  of 
acidosis,  he  says,  depends  not  so  much  (if  at  all)  upon 
the  formation  of  acids  or  upon  their  combustion.] 

It  is  well  known  that  when  fatty  acids  or  soaps  are 
fed,  the  acids  pass  through  the  intestinal  wall  in  the 
form  of  soaps,  and  are  immediately  synthetized  to 
neutral  fats,  the  glycerol  for  this  purpose  being 
supplied  by  the  organism  itself.  Borchardt  considers 
that  the  greater  part  of  any  ketogenic  function  which 
the  fatty  acids  may  have  is  due  to  the  abstraction  of 
this  necessary  amount  of  glycerol,  and  they,  therefore, 
do  not  act  as  direct  acetone  formers.  In  a  control  of 
this  statement,  Waldvogel  has  injected  olive  oil  under 
the  skin,  and  found  no  increase  in  the  acetone  elimina- 
tion, although  when  this  substance  is  given  by  the 
mouth  the  acetonuria  is  increased.  Absolutely  neutral 
fats  have  been  shown  by  Geelmuyden  and  by  Hagen- 
berg  to  decrease  the  formation  of  acetone.  Hence, 
one  must  conclude  that  the  greater  part  of  the  ketogenic 
action  of  fats,  especially  those  of  the  higher  fatty 
acids,  is  due  to  their  content  in  free  fatty  acids,  which 
in  their  resorption  combine  with  the  antiketogenic 
glycerol,  and  so  remove  it  from  its  sphere  of  action. 

As  the  chief  source  of  the  acetone  compounds  come 
the  amino  acids  produced  by  the  breaking  down  of 
p^ytein  substances.  Between  many  of  the  secom- 
pounds — leucin,  arginin,  serin,  cystin,  etc. — and/3-oxy- 
butyric  acid  there  is  a  very  clear  chemical  relation- 
ship. Further  it  has  been  shown  by  Embden  that  the 
perfusion  of  blood  containing  leucin  through  the 
surviving  liver  results  in  a  prompt  increase  in  the 
amount  of  acetone  in  the  blood.  Baer  and  Blum  fed 
leucin  to  diabetics  and  obtained  an  increase  in  the 
amount  of  acetone  compounds  in  the  urine.  Bor- 
chardt fed  protamines  containing  a  large  amount  of 
arginin,  and  also  obtained  a  decided  increase  of 
acetone  in  the  urine.  Other  amino  acids  have  been 
fed  by  Embden  and  Salomon  with  like  results.  These 
are  tyrosin  and  phenylalanin.  On  the  other  hand, 
glycocoll,    alanin,    glutaminic    acid,    and    asparagin 


when  circulated  through  the  liver  did  not  increase  the 
acetone  content  of  the  blood. 

The  laws  which  govern  the  formation  of  acetone 
from  the  substances  above  mentioned  are  chemically 
somewhat  complicated,  and  even  yel  have  not  been 
completely  worked  out.  They  depend  in  part  on  the 
capacity  of  the  organism  to  remove  the  amino  group, 
and  effect  an  oxidation  at  the  5-carbon  atom  (the 
atom  next  that  carbon  atom  to  which  is  attached  the 
terminal  carboxyl-COOH  group).  One  example  will 
serve  perhaps  to  indicate  the  type  of  reaction  which 
may  occur. 

Leucin  has  the  following  formula: 
CH3      CH3 

V       ■ 

H— C— H 

C— NH, 


II 


C< 


I'OOH 

By  a  simultaneous  removal  of  the  amino  group,  re- 
moval of  COa  from  the  carboxyl  group,  and  subse- 
quent oxidation,  one  may  have  the  following  hypothet- 
ical series  of  changes  taking  place: 
CH3     CH3  CH3     CH3 

\y  CH,    CH, 

CHr  CHr 

I  I  CH 

H— C— H0 »    h— C— H3 >  I 

H— C— H 
II— C— NH,a  H— C  Ha 

|  I  COOH 

COOH  COOH 

The  final  step  here  is  isobutyric  acid.     If  now   this 
compound   be  oxidized   at   the  /?-carbon  atom,   one 
obtains  acetic  acid  and  acetone  as  follows: 
CH3     CH3  CH3     CH3 

\/  \/        Acetone 

CH  C=0 

J-H  — 


H- 


H 


COOH 


H — C  +  H  Acetic  acid 
COOH 


As  the  acetates  are  easily  destroyed  by  combustion 
in  the  organism,  the  acetic  acid  formed  in  the  reaction 
disappears,  and  acetone  is  left.  Similar  reactions  may 
be  made  out  for  the  other  amino  acids  which  produce 
acetone  compounds.  Arginin,  one  of  the  diamino 
acids,  is  markedly  ketogenic,  according  to  Borchardt, 
and  therefore  substances  containing  large  amounts  of  "}  -i 
protamines,  and  consequently  arginin,  such  as  thymus 
and  roe,  are  to  be  avoided  in  cases  of  acidosis. 

Reactions  in  which  the  /?-carbon  atom  is  attacked 
by  oxidation  have  been  very  completely  studied  by 
Knoop.  By  using  compounds  in  which  a  straight 
chain  of  a  fatty  acid  is  linked  to  a  benzene  group,  he 
was  able  to  show  that  in  every  instance  oxidation  was 
effected  at  this  place.  The  rule,  therefore,  seems  to  be 
a  general  one  in  the  catabolism  of  fatty  acids. 

The  quesion  whether  the  fatty  acids  or  proteins  are 
the  principal  source  of  the  acetone  compounds  is  thus 
fairly  well  settled,  for  it  is  seen  that  with  the  proteins 
the  intermediary  metabolism  must  take  place  through 
steps  involving  the  formation  of  a  lower  fatty  acid. 

Of  very  great  importance  from  the  standpoint  of 
acidosis  are  the  antiketoplastic  substances.  As  has 
already  been  defined,  these  are  the  substances  which 
prevent  the  excessive  formation  of  acetone  compounds, 
or  reduce  the  amount  which  is  excreted  by  the  urine  or 
the  breath.  As  v.  Noorden  remarks,  the  extension  of 
these  substances  is  one  of  the  most  practical  points  in 
the  therapy  of  diabetes. 


73 


Acidosis 


REFERENCE   HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Outside  of  the  alkalies,  such  as  sodium  carbonate, 
or  certain  salts  of  easily  oxidizable  organic  acids  such 
as  sodium  citrate,  the  chief  members  of  this  group  are 
the  carbohydrates.  Without  exception,  all  car- 
bohydrates have  the  property  of  decreasing  the 
amount  of  acetone  compounds,  whether  produced  by 
starvation  or  by  diabetes.  Owing  to  the  somewhat 
close  similarity  between  these  compounds  and 
glycerol,  the  latter  is  next  in  antiketogenic  action. 
It  is  unfortunate,  however,  that  its  use  in  diabetes  is 
attended  with  a  marked  increase  in  the  amount  of 
glucose  eliminated.  Another  member  of  this  class  is 
alcohol.  Neubauer  has  shown  beyond  question  that 
alcohol  diminished  acidosis  to  a  marked  degree,  and 
at  the  same  time  appeared  to  diminish  the  amount  of 
sugar  excreted. 

Besides  these,  certain  of  the  amino  acids  are  quite 
antiketoplastic.  Of  these  may  be  mentioned  alanin 
and  asparagin.  The  experiments  with  glycocoll  and 
glutaminic  acid  were  not  altogether  positive.  It  is 
worthy  of  note  that  Eppinger  gave  amino  acids  with 
what  would  have  been  fatal  doses  of  inorganic  acids, 
and  was  apparently  able  to  effect  recovery.  His 
results,  and  the  conclusions  which  he  has  drawn  from 
his  work,  will,  however,  bear  a  control. 

Basing  his  classification  on  the  content  of  antiketo- 
genic amino  acids,  Borchardt  arranges  the  proteins  in 
the  following  order:  Protamin,  histone,  egg-albumin, 
pancreas,  casein.  Protamin  gives  the  highest  amount 
of  acetone,  while  casein  gives  the  least. 

What  the  mechanism  is  whereby  the  carbohydrates 
and  certain  of  the  amino  acids  are  able  to  effect  a 
reduction  in  the  excretion  of  acetone  compounds,  is 
absolutely  unknown.  One  reason  for  this  lack  of 
knowledge  is  the  incompleteness  of  our  information 
regarding  the  normal  intermediary  metabolism  of  car- 
bohydrates and  of  fats.  These  are  two  of  the  most 
difficult  of  the  problems  of  biological  chemistry. 
Waldvogel  believes  that  the  carbohydrates  act  by 
sparing  the  fats  from  combustion,  but  it  has  been  shown 
repeatedly,  and  the  present  writer  has  confirmed  the 
results,  that  only  a  very  small  quantity  of  sugar  is 
needed  in  the  marked  acidosis  accompanying  the 
starvation  in  a  case  of  pernicious  vomiting  of  preg- 
nancy, for  example,  to  abolish  all  signs  of  acidosis 
from  the  urine,  and  this  without  in  the  least  affecting 
the  general  condition  of  the  patient.  The  amount  of 
carbohydrate  which  is  necessary  to  prevent  the  appear- 
ance of  these  compounds  in  the  urine  is  even  smaller 
than  that  used  to  abolish  them,  once  they  are  present, 
and  is  by  no  means  large  enough  to  protect  any  very 
considerable  quantity  of  body  fat. 

Nasse  some  years  ago  suggested  a  process  of  "sec- 
ondary oxidation"  of  the  fats  as  a  result  of  the  pri- 
mary oxidation  of  the  carbohydrates,  and  a  somewhat 
similar  idea  has  been  put  forward  by  Hirschfeld. 
None  of  these  theories  has  any  very  definite  experi- 
mental groundwork,  and  on  the  whole  they  are  quite 
inadequate. 

To  sum  up  as  briefly  as  possible  what  is  known  about 
the  source  of  the  acetone  compounds,  it  may  be  said 
that  the  higher  fats  probably  do  not  form  acetone 
compounds.  Some  of  the  lower  fats  and  fatty  acids 
have  this  property.  Certain  of  the  amino  acids  are 
probably  the  chief  source  of  these  substances,  and 
form  them  by  losing  the  amino  (NH„)  group,  with  the 
loss  of  carbon  dioxide,  and  oxidation  at  the  /?-carbon 
atom.  Thus,  in  effect,  the  amino  acids  are  trans- 
formed into  lower  fatty  acids,  which  are  changed  to 
/?-oxybutyric  acid  and  acetone. 

Substances  which  give  rise  to  glucose  in  the  organ- 
ism are  antiketoplastic.  The  exception  to  this  rule 
i<  alcohol,  which  apparently  has  the  most  useful  prop- 
erty of  diminishing  the  glucose  and  acetone  bodies  at 
tin-  same  t ime. 

As  in  the  combustion  of  proteins  large  amounts  of 
sulphuric  and  phosphoric  acids  arc  formed,  these  also 
probably  play  a  part  in  acidosis.      Salkowski  showed, 

74 


many  years  ago,  that  the  administration  of  taurin  to 
rabbits  was  sufficient  to  produce  enough  sulphuric 
acid  by  oxidation  to  poison  these  animals.  This  was 
a  case  of  endogenous  acid  intoxication  from  inorganic 
acids. 

The  Conditions  under  which  Acidosis  takes  Place. — 
In  the  healthy  subject  there  is  one  condition  which 
produces  the  elimination  of  acetone  compounds;  this 
is  starvation.  Not  only  complete  inanition  will  bring 
about  this  anomaly,  but  the  mere  abstention  of  the  in- 
dividual from  carbohydrates  is  almost  equally  effec- 
tive. The  length  of  the  fast  which  is  necessary  is 
very  short,  less  than  twenty-four  hours,  and  in  all 
subsequent  discussions  of  acidosis  and  the  pathologi- 
cal significance  of  acetone  compounds  in  the  urine 
this  fact  must  constantly  be  borne  in  mind.  Indeed, 
a  large  amount  of  the  clinical  importance  which  has 
been  attached  to  these  compounds  is  rendered  abso- 
lutely worthless  when  it  is  found  that  the  observations 
have  included  no  consideration  of  the  condition  of 
nutrition  of  the  patient  or  of  the  amount  and  kind  of 
nourishment  which  he  consumed. 

Abstention  from  food  for  twenty-four  hours  is 
usually  sufficient  to  cause  the  appearance  of  acetone 
in  the  urine,  so  that  it  can  be  detected  with  Lieben's 
test.  From  the  twenty-fourth  to  forty-eighth  hour 
acetoacetic  acid  makes  its  appearance,  and  at  the 
same  time  3-oxybutyric  acid  may  be  detected. 
Under-nourishment  for  any  length  of  time  may  also 
cause  acetone  to  appear,  especially  if  the  supply  of 
carbohydrates  has  been  insufficient  for  the  needs  of 
the  body.  That  simple  starvation  may  produce  a 
very  considerable  acidosis  is  shown  by  the  recent 
work  of  Brugsch  on  the  professional  faster  Succi. 
This  person  was  a  man  with  a  very  decided  amount  of 
body  fat.  During  the  twenty-fifth  day  of  his  fast 
he  eliminated  acetone  compounds  equivalent  to  13.6 
grams  of  /?-oxybutyric  acid.  Similarly  Satta  has 
shown  that  carbohydrate  starvation  alone  may  lead 
to  an  acidosis  equivalent  to  20.0  grams  of  oxybutyric 
acid.  This  is  a  degree  of  acidosis  which  would  be 
considered  high  even  in  cases  of  diabetes.  That  all 
fasting  subjects  do  not  react  with  the  same  degree 
of  acidosis  is  shown  by  a  parallel  case  reported  by 
Brugsch.  This  was  a  woman  suffering  from  stricture 
of  the  esophagus.  She  was  in  the  very  extreme  of 
emaciation,  as  was  shown  at  the  autopsy,  when  it  was 
found  that  even  the  plantar  fat  had  disappeared. 
This  patient  excreted  practically  no  acetone  com- 
pounds. From  these  two  observations  Brugsch  was 
led  to  conclude  that  the  source  of  the  acetone  com- 
pounds  was  the  abnormal  metabolism  of  body  fat. 
This  is  not  the  only  conclusion  which  can  be  drawn 
from  the  results.  It  is  also  possible  that  the  patient 
had  adapted  herself  to  an  extraordinarily  small 
caloric  need,  so  that  the  amount  of  tissue  which  she 
consumed  was  adequate  for  her.  Other  observers 
have  seen  similar  large  amounts  of  acetone  com- 
pounds appear  during  starvation.  Nebelthau's  case, 
in  which  sixty-six  per  cent,  of  the  total  nitrogen 
was  eliminated  as  ammonia,  must  be  included  in 
this  group. 

Having  shown  that  simple  inanition  may  produce 
large  amounts  of  acetone  compounds  in  the  urine,  one 
is  led  to  inquire  which  of  the  three  classes  of  food- 
stuffs it  is  that  the  abstention  from  is  most  effective 
in  causing  the  increased  elimination  of  acetone  com- 
pounds in  the  urine  when  it  is  withdrawn  from  the 
diet.  As  might  be  expected  from  their  marked  anti- 
ketogenic action,  the  carbohydrates,  and  they  alone, 
are  the  substances  whose  withdrawal  causes  the  fea- 
tures of  acidosis.  One  cannot  therefore  speak  in 
general  of  a  starvation  acidosis,  but  simply  of  a 
carbohydrate  starvation  acidosis.  The  reason  why, 
as  a  rule,  one  gets  a  less  severe  type  of  acidosis  in 
carbohydrate  inanition  than  in  complete  starvation  is 
due  largely  to  the  antiketogenic  constituents  of  the 
proteins,  and  to  the  glycerol  content  of  the  fats. 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Acidosis 


[Tests. — For  a  description  of  the  various  tests  for 
acetone,  the  reader  is  referred  to  the  article  Acctonunn. 

(3-Oxybutt/ric  Acid. — This  may  be  tested  for  quali- 
tatively by  I  he  method  (if  Hart.  Add  20  c.c.  of  water 
and  two  diups  of  acetic  acid  to  20  c.c.  of  mine. 
Boil  gently  until  the  volume  is  reduced  to  10  c.c.  Add 
enough  water  to  bring  the  volume  back  to  20  c.c. 
and  divide  the  fluid  equally  in  two  test-tubes.  Add 
1  c.c.  of  hydrogen  peroxide  to  one  of  the  tubes,  warm 
gently  for  about  a  minute  and  allow  to  cool.  Then 
add  to  each  tube  seven  drops  of  glacial  acetic  acid 
and  three  or  four  drops  of  freshly  prepared  solution 
of  sodium  nitroprusside.  Add  2  c.c.  of  concentrated 
ammonium  hydroxide  carefully  down  the  side  of  each 
tube,  so  as  to  make  a  layer  over  the  urine  mixture. 
At  the  end  of  four  hours  compare  the  tubes.  If 
/?-oxybutyric  acid  was  present  the  tube  to  which 
peroxide  was  added  will  show  a  purplish  red  ring  at 
the  junction  of  the  ammonia  with  the  urine,  while 
the  control  tube  will  show  no  ring  or  only  a  faint 
brown  in  case  there  was  much  creatinin  present.  If 
there  is  no  /9-oxybutyric  acid  in  the  urine  the  two 
tubes  will  show  no  difference.  Sugar  does  not  inter- 
fere with  the  reaction  but  albumin  should  be  removed.] 

Pathological.  Acidoses. — There  is  possibly  no  one 
urinary  diagnostic  feature  in  clinical  medicine  which 
has  been  called  upon  to  account  for  such  a  diversity 
of  symptoms  as  the  presence  of  acetone  and  its  allied 
compounds.  A  partial  list  of  the  affections  with 
which  they  have  been  associated  is  as  follows:  cyclic 
vomiting  in  children;  vomiting  in  pregnancy;  eclamp- 
sia; fetal  death;  postoperative  intoxications,  espe- 
cially associated  with  narcosis;  hyperthermia;  pul- 
monary tuberculosis;  malignant  growths;  asthma; 
toxic  conditions  following  the  use  of  antipyrin,  mor- 
phine,    atropine;  carbon-monoxide     poisoning,     etc. 

It  will  be  noted  that  almost  without  exception  the 
conditions  are  those  in  which  undernutrition  or  short 
starvation  is  prominent.  In  the  acetonuria  following 
narcosis  one  is  usually  dealing  with  abstention  from 
food  for  a  period  of  time  quite  sufficient  to  provoke 
the  appearance  of  acetone  in  the  urine  in  healthy 
Individuals. 

What  is  of  paramount  importance  in  the  considera- 
tion of  these  cases  is  a  statement  of  the  amount  of  the 
carbohydrate  intake  and  of  its  resorption.  It  is  quite 
possible,  for  example,  in  children  with  a  severe  gastror 
intestinal  derangement,  that  sufficient  carbohydrate 
may  have  been  given  to  protect  the  child  from  an 
acidosis,  but  owing  to  the  digestive  disturbance  the 
antiketoplastic  substance  is  not  resorbed,  and  so  one 
has  to  do  with  simple  carbohydrate  starvation. 

In  a  careful  analysis  of  the  clinical  literature  dealing 
with  acetonuria  in  its  relation  to  acid  intoxication 
one  is  struck  with  the  fact  that  little  attention  has 
been  paid  to  this  side  of  the  question.  Mohr,  in  his 
valuable  review  of  diabetic  and  non-diabetic  autoin- 
toxications with  acids,  has  come  to  a  similar  con- 
clusion, and  is  able  to  see  in  the  acetonurias  of  these 
various  conditions  nothing  but  the  acidosis  resulting 
from  an  insufficient  supply  of  carbohydrates.  Spe- 
cial mention  might  be  made  of  pernicious  vomiting 
in  pregnancy,  because  here  the  acidosis  as  revealed 
by  the  acetone  compounds,  and  more  especially  by 
the  relative  amount  of  ammonia  in  the  urine,  has  been 
made  a  criterion  whereby  nervous  vomiting  might  be 
distinguished  from  a  more  pernicious  type.  The 
present  writer  has  criticised  this  view  severely,  and 
since  that  time  his  attitude  has  been  supported  by 
others  who  have  had  occasion  to  consider  the  subject. 
Certain  it  is  that  it  is  physiologically  impossible  to 
indicate  operative  interference  in  cases  of  pernicious 
vomiting  in  pregnancy  from  either  an  analysis  of  the 
urine  for  ammonia  or  an  examination  of  the  acetone- 
compound  elimination. 

The  etiology  of  eclampsia  has  been  the  subject  of 
numerous  investigations  in  which  the  starting-point 
has   been   the   view   that   acid   intoxication   plays   a 


prominent  part,  and  quite  recently  Zweifel  has  nar- 
rowed down  the  toxic  agent  to  sarcolactic  acid,  which 
IS  found  in  the  urine  during  and  after  the  seizures. 
Dreyfus  has  repeated  and  confirmed  Zweifel's  results 
as  to  the  presence  of  lactic  acid  in  the  urine,  but  is 
quite  unable  to  find  any  etiological  relationship 
between  the  appearance  of  the  acid  in  the  urine  and 
the  convulsions.  It  is  altogether  probable  that 
lactic  acid  in  the  urine  in  eclampsia  i.--  the  result  of 
insufficient  oxidation  and  increased  muscular  effort, 
and  does  not  in  any  way  figure  as  a  cause  of  the  con- 
vulsive seizures.  It  has  been  repeatedly  found  by 
Araki  and  others  in  the  urine  in  cases  of  carbon-mon- 
oxide poisoning  and  other  conditions  where  its  forma- 
tion certainly  gave  rise  to  no  additional  toxic  effects. 

Diabetic  Acidosis. — When  one  comes  to  the  consid- 
eration of  diabetic  acidosis  one  is  confronted  with  a 
problem  of  singular  complexity.  Obviously  one  is 
dealing  with  a  condition-  which  is  most  favorable  to 
the  elimination  of  acetone  compounds.  There  is  in 
the  first  place  the  usual  strict  diet  of  fat  and  protein, 
which  induces  prompt  acidosis  in  the  normal  subject; 
there  is  secondly  the  incapacity  of  the  diabetic  to  util- 
ize the  carbohydrate  which  is  formed  in  the  body  from 
protein,  and  possibly  from  fat.  This  incapacity  is 
often  so  complete  that  on  a  strict  diet  containing  only 
fat  and  protein,  for  every  gram  of  nitrogen  excreted 
the  patient  excretes  3.5  to  4.0  grams  of  sugar.  One 
is  not  astonished,  therefore,  that  a  patient  in  this  con- 
dition, rejecting  unused  the  sum  total  of  the  antiketo- 
plastic substances,  excretes  very  large  amounts  of 
acetone  compounds. 

It  is  now  important  to  decide  whether  this  acidosis 
is  merely  a  carbohydrate  inanition  effect,  or  has  a 
specific  quality  not  seen  in  the  acidoses  previously 
discussed.  In  so  far  as  one  may  judge  at  present, 
one  must  acknowledge  that  diabetic  acidosis  presents 
features  which  seem  to  indicate  a  specific  nature  apart 
from  the  influence  of  carbohydrates.  The  literature 
on  the  subject  is  extremely  full,  but  v.  Noorden  has 
summed  up  the  evidence  in  favor  of  its  specific 
quality  as  follows. 

1.  Certain  diabetics  tolerating  a  diet  containing 
sixty  to  eighty  grams  of  carbohydrate  eliminate  no 
more  acetone  than  a  normal  person  on  full  diet.  On 
transferrence  to  a  carbohydrate-free  diet  the  amount 
of  acetone  compounds  increases,  but  finally  on  the 
same  strict  diet  diminishes. 

2.  Others  with  moderately  severe  diabetes  may 
eliminate,  on  a  diet  containing  carbohydrate  nearly 
to  the  limit  of  their  tolerance,  one  gram  or  more  of 
acetone.  By  transferrence  to  a  strict  diet  the  amount 
of  acetone  compounds  increases,  and  continues  to 
increase  so  long  as  the  strict  diet  is  adhered  to. 

3.  In  the  third  group,  one  may  have  individuals 
with  certain  characteristics  of  severe  diabetes. 
They  react  favorably,  so  far  as  the  disappearance  of 
glucose  from  the  urine  on  a  strict  diet  is  concerned; 
and  yet  under  all  circumstances  they  excrete  large 
quantities  of  acetone  compounds  in  the  urine.  In 
these  cases  one  also  gets  marked  variations  in  the 
amount  of  the  acetone  compounds  excreted  which 
have  apparently  no  causal  relation  with  the  type  of 
food  administered.  Von  Noorden  mentions  a  case 
in  which  fifty  to  sixty  grams  of  /3-oxybutyric  acid  were 
excreted  daily  over  a  very  long  period  of  time. 
Further,  there  are  marked  individual  differences  in 
the  way  patients  react  with  the  same  amounts  and 
qualities  of  food.  From  these  considerations  one  is 
forced  to  the  conclusion  that  the  acidosis  of  diabetes 
is  not  entirely  due  to  carbohydrate  inanition. 

Acid  Intoxication. — While  there  can  be  no  doubt 
as  to  the  nature  and  severity  of  an  acidosis  due  either 
to  carbohydrate  inanition  or  to  diabetes,  the  matter 
is  not  quite  so  clear  when  one  comes  to  connect  the 
appearance  of  the  acetone  compounds  in  the  urine 
with  definite  toxic  effects. 

Each  of  the  compounds  in  this  series  has  in  its  turn 

75 


Acidosis 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


been  the  subject  of  numerous  investigations  as  to  its 
toxicity.  Twenty  grams  of  acetone  produce  some 
drowsiness  in  a  man.  The  injection  of  one  gram  of 
acetone  hypodermically  had  no  effect  whatever  in 
the  general  condition  of  a  girl.  According  to  v. 
Jaksch,  acetoacetic  acid  is  not  toxic,  and  even  doses 
as  large  as  a  gram  have  been  given  to  a  frog  without, 
the  slightest  effect.  The  results  with  /3-oxybutyric 
acid  agree  in  most  respects  with  what  v.  Jaksch 
obtained  with  acetoacetic  acid.  Most  of  the  experi- 
ments, it  is  true,  have  been  performed  with  the 
inactive  acid,  while  the  acid  formed  in  the  organism 
is  the'levorotatory  modification.  Schwarz  was,  how- 
ever, unable  to  produce  any  toxic  symptoms  with 
eight  grams  of  the  active  acid  when  given  to  a  dog. 
Wilbur,  working  in  v.  Noorden's  laboratory,  has 
apparently  obtained  some  slight  degree  of  toxicity 
with  the  active  acid.  Very  recently  Desgrez  and 
Saggio  have  claimed  that  both  acetoacetic  acid  and 
/?-oxybutyric  acid  are  toxic  and  cause  a  "demineral- 
ization"  of  the  organism.  The  results  of  the  French 
authors  do  not  appear  to  be  well  enough  founded  to 
deserve  serious  consideration. 

So  far  as  positive  evidence  is  concerned,  we  have 
little  of  direct  value  to  indicate  that  the  toxemia 
which  leads  to  diabetic  coma,  or,  as  Naunyn  insists  it 
should  be  called,  dyspneic  coma,  is  an  intoxication 
produced  by  acid  products.  Nevertheless,  the  opin- 
ion in  favor  of  an  acid  origin  is  so  universal,  and  there 
is  so  little  to  supplant  it,  that  one  must  admit  a  weight 
of  opinion  in  place  of  a  weight  of  evidence. 
The  reasons  for  viewing  dyspneic  coma  as  an  acid 
intoxication  are  as  follows,  and  are  given  very  com- 
pletely by  Naunyn  in  his  work  on  diabetes. 

In  the  onset  of  coma,  the  percentage  of  carbon 
dioxide  in  the  blood  falls  markedly  below  the  normal 
thirty  to  forty  volumes  per  cent.  This  indicates  that 
the  amount  of  carbonates  present  in  the  blood,  by 
which  the  carbon  dioxide  is  transported  from  the 
other  tissues  to  the  lungs,  has  decreased.  It  has  also 
been  shown  that  preceding  the  coma  there  is  usually  a 
marked  rise  in  the  amount  of  acids,  both  acetoacetic 
and  oxybutyric,  but  this  is  not  always  the  case;  for 
numerous  cases  of  coma  are  on  record  in  which  the 
amounts  of  these  substances  were  lower  at  the  time  of 
the  attack  than  for  long  periods  previously.  Further, 
the  sudden  change  from  a  mixed  diet  to  one  contain- 
ing fat  and  protein  only  has  often  provoked  serious 
symptoms,  which  Naunyn  believes  are  due  to  the 
flooding  of  the  organism  with  acid  products  both  of 
inorganic  (sulphuric  and  phosphoric)  and  organic 
character.  The  clinical  observations,  too,  on  the  use 
of  sodium  carbonate  in  preventing  the  onset  of  coma 
have  many  features  which  cannot  be  ignored,  and  lead 
one  to  believe  that  this  type  of  therapy  is  of  very  real 
value.  As  much  cannot  be  said  for  the  use  of  carbon- 
ates during  the  coma  itself.  Here  the  reports  which 
can  be  relied  upon  are  almost  hopelessly  unfavorable. 

One  point  which  has  been  suggested  by  some  authors 
as  to  the  relation  between  the  acid  products  appearing 
in  the  urine  and  the  onset  of  the  coma  seems  worthy  of 
notice.  It  is  quite  possible  that  there  is  no  definite  re- 
lation between  the  urinary  products  and  the  onset  of 
the  attack,  for  the  reason  that  it  is  not  the  amount  of 
acids  which  appears  in  the  urine  which  conditions  the 
coma,  but  the  amount  which  is  retained  by  the  tissues. 
This  would  explain  why  patients  such  as  v.  Noorden's 
excreted  large  amounts  of  acid  in  the  urine  without 
having  any  symptoms  of  acid  intoxication.  The  pro- 
ducts were  eliminated  as  quickly  as  they  were  formed. 
On  the  other  hand,  a  patient  might  form  quantities 
of  acids  which  would  not  be  eliminated,  and  that 
which  was  retained  might  exert  its  toxic  effect. 
In  explanation  of  the  inefficacy  of  the  sodium  carbon- 
ate treatment,  it  has  been  urged  that  the  alkali  circu- 
lates in  the  fluids  which  bathe  the  cells,  but  does  in  it 
actually  reach  those  intimate  cell  structures  where  the 
toxic  action  of  the  acids  is  exerted. 


The  most  critical  analysis  of  the  theory  of  acid 
intoxication  has  recently  appeared  from  Tangl's 
laboratory.  Two  of  his  pupils,  Szili  and  Benedict, 
have  undertaken  to  compare  the  findings  obtained 
in  intoxication  with  inorganic  acids  with  those  got 
in  diabetes.  Szili  made  a  careful  study  of  the  effects 
of  inorganic  acids  on  rabbits,  dogs,  and  goats.  These 
animals  were  injected  with  solutions  of  acids,  and 
analyses  made  of  the  blood  by  titration,  and  by  the 
estimation  of  the  true  reaction  of  the  blood  by  means 
of  gas-chain  cells.  It  was  found  that  with  lethal 
doses  of  acids  the  blood  had  a  lower  concentration  of 
hydroxyl  ions  than  distilled  water;  that  is  to  say,  the 
blood,  compared  with  distilled  water,  had  actually 
become  acid.  At  the  same  time,  however,  it  reacted 
alkaline  to  lacmoid  paper.  Of  extreme  importance 
in  this  series  of  experiments  was  the  fact  that  it  was 
possible  to  bring  the  animals  immediately  from  a 
state  of  dyspneic  coma  by  the  intravenous  injection  of 
solutions  of  sodium  carbonate.  As  a  result  of  this 
work  Benedict  undertook  a  study  of  diabetic  coma, 
following  the  methods  employed  by  Szili. 

He  sums  up  the  reasons  which  have  been  given  for 
believing  that,  diabetic  coma  is  the  result  of  poisoning 
by  acids  as  follows: 

1.  Severe  diabetics  produce,  besides  the  normal 
acid  products  of  metabolism,  excessively  large  amounts 
of  organic  acids. 

2.  The  fixed  alkalies,  sodium,  potassium,  calcium, 
and  magnesium,  are  not  sufficient  to  combine  with  the 
continual  excess  of  acids  produced,  and  hence  large 
quantities   of   ammonia   are   used   for   this   purpose. 

3.  As  increased  acid  production  and  increased 
ammonia  elimination  almost  always  precede  the  onset 
of  dyspneic  coma,  and  as  /9-oxybutyric  acid  is  not 
toxic  in  itself,  one  must  assume  that  the  toxemia  is 
due  to  the  acid  character  of  the  compounds  when  the 
amount  of  alkali  formed  is  not  sufficient  for  their 
neutralization,  (o)  The  similarity  between  the  coma 
produced  by  inorganic  acids  and  the  dyspneic  coma  of 
diabetes  has  long  been  recognized.  (6)  Blood  investi- 
gations of  diabetics  have  led  to  the  assumption  of  a 
decreased  alkalinity  of  the  fluid.  The  carbon  dioxide 
content  is  lowered  even  to  four  volumes  per  cent, 
instead  of  the  normal  thirty  to  forty  volumes  per 
cent. 

The  points  which  stand  in  the  way  of  believing 
that  diabetic  coma  is  an  acid  intoxication  are  the 
following: 

1.  Between  the  dyspneic  coma  and  acid  intoxica- 
tion by  inorganic  acids  there  is  a  fundamental  differ- 
ence which  can  scarcely  be  explained  away.  While 
animals  poisoned  by  inorganic  acids  may  be  made  to 
recover  almost  immediately  by  the  intravenous  injec- 
tion of  alkalies,  this  is  practically  never  the  case  in  the 
coma  of  diabetes. 

2.  It  appears  impossible  to  define  accurately  a  dia- 
betic coma.  One  often  finds  cases  of  carcinoma,  inani- 
tion, or  hepatic  disease  in  which  the  terminal  coma  has 
all  the  clinical  signs  of  diabetic  coma. 

3.  The  assumption  of  an  acidification  of  the  tissues 
rests  on  the  finding  of  a  diminished  carbon-dioxide 
content  of  the  blood;  but  one  finds  a  similar  decrease 
in  this  value  in  other  conditions  without  coma  inter- 
vening. On  the  other  hand,  cases  of  coma  in  diabetes 
are  on  record  in  which  the  carbon-dioxide  content  of 
the  blood  was  scarcely  below  the  normal. 

In  a  control  of  these  differences,  Benedict  investi- 
gated the  actual  reaction  of  the  blood  in  cases  of  dia- 
betes by  means  of  the  gas-chain  cell.  The  amount  of 
titratable  alkali  was  also  estimated.  Eleven  cases  of 
diabetes  were  examined,  of  which  three  terminated 
fatally  in  coma.  In  the  three  cases  of  coma  the  con- 
centration  of  hydroxyl  ions  in  the  blood  was  from 
0.99X10-'  to  0.42X10-',  with  an  average  value  of 
0.74X10-'.  In  normal  subjects  there  is  a  variation 
from  4.1  X  10~'  to  0.41  X  10-'.  So  that  in  all  cases  the 
reaction  was  alkaline  within  what  has  been  found  to 


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Acids,  Organic 


be  normal  limits.  It  has  also  been  shown  that  in 
other  conditions,  e.g.  pregnancy,  the  alkalinity  may 
fall  to  0.2x10-'  without  any  danger  to  life.  He 
therefore  believes  that  neither  the  results  of  Szili  nor 
his  own  investigations  lend  any  support  to  the  view 
that  the  dyspneic  coma  of  diabetes  is  due  to  an  intoxi- 
cation by  acids. 

Folin  doubts  that  the  evidence  presented  by  Szili 
and  by  Benedict  is  sufficient  to  discredit  the  acid- 
intoxication  theory,  and  bases  his  conclusions  on  the 
fact  that  the  Hungarian  investigators  have  viewed  the 
intoxication  from  the  standpoint  of  the  physical  reac- 
tion of  the  blood,  and  that  poisoning  with  large 
amounts  of  acids  does  not  yield  comparable  results 
with  the  slow  toxemia  resulting  from  the  production 
of  an  excessive  amount  of  acid  in  daily  metabplism. 

While  the  latter  point  is  certainly  well  taken,  the 
present  writer  cannot  agree  that  the  former  criticism 
is  justified.  The  acid  effects  of  solutions  of  acids  are 
due  solely  to  the  concentration  of  hydrogen  ions. 
If  the  effects  of  the  organic  acids  produced  in  the  ab- 
normal metabolism  of  diabetes  are-  not  those  of 
hydrogen  ions,  one  must  assign  a  name  other  than 
acid  intoxication  to  the  toxemia  resulting  from  their 
action  in  the  organism.  C.  G.  L.  Wolf 

References. 

Naunyn:  Der  Diabetes  Mellitus. 

\\  aMvogel:  Die  Acetonkorper. 

v.  Noorden:  Handbueh  der  Pathologie  des  Stoffwechsels.  Bd. 
i.  and  ii. 

Borchardt:  Zentralblatt  fur  die  gesammte  Physiologie  und  Patho- 
logie des  Stoffwechsels,  N.  F.  1,  129  and  641,  1906. 

Folin:  Journal  of  the  American  Medical  Association,  49, 12S,  1907. 

Benedict:  Archiv  fur  cUe  gesammte  Physiologie  (Pfliiger),  115, 
106.  1906. 

Szili:  Archiv  fur  die  gesammte  Physiologie  (Pfliiger),  115,  82, 
1906. 

Wolf:  N.  Y.  Medical  Journal,  April,  1906. 

Embden:  Hofmeister's  Beitrage,  7,  121,  and  129,  1906. 

Mohr:  v.  Noorden's  Sammlung  klinischer  Beitrage,  No.  4,  1904. 

Joslin:  Journal  of  Medical  Research,  12,  433,  1904. 

Knoop:  Habilitationsschrift,  Freiburg,  1904;  Hofmeister's  Bei- 
trage, 6,  150.  1905. 

Dreyfus,  Biochemische  Zeitschrift,  190S 

v.  Noorden:  Die  Zuckerkrankheit  und  ihre  Behaudlung.  6th  Edi- 
tion, 1912. 

Hammarsten:  A  Text-book  of  Physiological  Chemistry.  English 
Translation,  6th  Edition.  1911. 

Magnus- Levy:  Johns  Hopkins  Hospital  Bulletin,  46,  1911. 

Acids,  Organic.  Drfi  nitrons. — Acids  are  compounds 
which  when  dissolved  in  water  are  dissociated,  yielding 
positively  charged  hydrogen  atoms;  these  hydrogen 
atoms  may  be  replaced  by  metals  with  the  formation 
of  salts.  Organic  acids  are  characterized  by  the 
presence  of  one  or  more  carboxyl  (COOH)  groups  in 
which  the  hydrogen  atoms  may  be  replaced  by  metals 
to  form  salts  or  by  organic  (alkyl)  radicals  to  form 
esters.  The  basisity  of  an  organic  acid  is  determined 
by  the  number  of  carboxyl  groups  it  contains: 

Fatty  Acid  Series,  CnH2nO,. — Fatty  acids  are  found 
in  the  body  chiefly  in  combination  with  glycerin  in 
the  glycerides  or  neutral  fats  of  adipose  tissue.  They 
are  also  found  combined  with  alkalies,  as  soaps,  and,  in 
small  quantities,  as  free  fatty  acids.  Free  fatty  acids 
occur  in  the  intestine  as  a  result  of  the  breaking  up  of 
neutral  fats  in  pancreatic  digestion.  Some  of  the 
lower  members  of  the  series  are  found  free  in  blood 
and  sweat.  As  we  ascend  the  series,  the  molecules 
become  more  complex  and  the  melting  and  volatilizing 
points  rise.  For  each  acid  they  vary  slightly,  accord- 
ing to  the  mode  of  preparation.  Many  fatty  acids 
crystallize  in  characteristic  forms.  The  following  are 
of  most  physiological  importance: 

Formic  acid,  H.COOH,  is  found  combined  as  salts 
in  minute  traces  in  normal  urine,  and  in  increased 
amount  in  certain  diseases  with  deranged  meta- 
bolism, such  as  leueocythemia  and  diabetes.  It  is 
present  in  the  stings  of  certain  insects,  giving  them 


their  irritating  qualities.  It  is  a  colorless  liquid,  of 
strong  odor,  volatilizing  at  100°  C. 

Acetic  acid,  CH..COOH,  is  found  in  the  intestine 
and  sometimes  in  the  stomach  as  a  result  of  fermenta- 
tion processes  occurring  in  carbohydrates  and  higher 
fatty  acids.  Its  salts  are  present  in  normal  urine  in 
t  races,  and  in  increased  amount  in  diabetes  and  leuco- 
cythemia. In  the  diseases  named,  it  is  also  found  in 
the  urine  combined  with  acetyl,  CH3.CO,  to  form 
diacetic  acid,  CH3.CO.CH2.COOH.  Acetic  acid  has 
a  characteristic  odor  like  vinegar,  a  sour  taste,  and 
forms  transparent  crystals  which  melt  at  17°  C. 

Propionic  acid,  CH3.CH2.COOH,  occurs  occasion- 
ally in  sweat.  It  is  present  in  the  blood,  urine,  and 
vomit  of  certain  diseases.  It  is  the  first  fatty  acid  to 
form  a  neutral  fat  with  glycerin.  It  has  an  odor  like 
acetic  acid  and  volatilizes  at  142°  C. 

Butyric  acid,  CH3.(CH2)2.COOH,  is  found  in  the 
intestines  and  occasionally  in  the  stomach,  as  a  result 
of  fermentations.  It  may  be  formed  from  the 
decomposition  of  proteins,  carbohydrates,  fatty  acids 
higher  in  the  series,  or  lactic  acid.  It  is  found  in  sweat, 
and  traces  have  been  demonstrated  in  blood  and 
urine.  It  is  present  in  milk  and  butter,  combined 
with  glycerin  as  butyrin.  Butyric  acid  is  an  oily 
liquid,  volatilizing  at  162.3°  C.  and  solidifying  at 
-19°  C. 

Isovalerianic  acid,  (CH3)2.CH.CH2.COOH,  is  found 
in  cheese,  the  sweat  of  the  foot,  and  the  urine  in  cer- 
tain diseases.  It  is  a  product  of  protein  decomposi- 
tion. It  is  found  combined  as  a  neutral  fat  in  dolphin 
blubber.  It  is  an  oily,  colorless  liquid,  smelling  like 
rotten  cheese,  and  volatilizing  at  176.3°. 

Caproic  acid,  CH3.(CH2),.COOH,  is  found  in  the 
feces  and  sweat,  also  in  cheese,  is  formed  from  putre- 
faction of  proteins,  and  occurs  as  a  glyceride  in  butter. 
It  is  an  oily,  colorless  liquid,  with  a  faint,  unpleasant 
smell.     It  volatilizes  at  205°  C.  and  solidifies  at  -  18°  C. 

Caprylic  acid,  CH3.(CH,)6.COOH,  and 

Capric  acid,  CH3.(CH,),COOH,  are  found  in 
sweat,  in  cheese,  and  as  glycerides  in  butter.  Ca- 
prylic melts  at  16.5°  C.  and  volatilizes  at  236°  C" 
Ca'pric  melts  at  30°  C.  and  volatilizes  at  270°  C. 

Laurie  acid,  CH3.(CH2),0.COOH,  and 

Myristic  acid,  CH,.(CH,)12.COOH,  are  present  as 
glycerides  in  human  fat  and  in  butter,  also  combined 
as  esters  in  spermaceti.  Laurie  acid  melts  at  43.6° 
and  myristic  at  53.8°  C. 

Palmitic  acid,  CH3.(CH2)14.COOH,  is  found  as  a 
glyceride  in  all  animal  fats  and  combined  as  esters 
of  cetyl  and  myricyl  alcohol  in  spermaceti  and  bees- 
wax respectively;  it  is  also  found  combined  with 
cholesterin  in  wool  fat  (lanolin).     It  melts  at  62°  C. 

Stearic  acid,  CH3.(CH,)i„.COOH,  is  found  combined 
like  palmitic  acid  in  animal  fats  and  spermaceti.  It 
melts  at  69.2°  C.  Margaric  acid  is  a  name  sometimes 
applied  to  a  mixture  of  palmitic  and  stearic  acids. 

Arachidic  acid,  CH3.(CH,)„.COOH,  is  found  in 
butter  as  a  glyceride.     It  melts  at  75°  C. 

Cerotic  acid,  CH3.(CH2)25.COOH,  is  found  free  in 
beeswax.  Combined  as  cetyl  ether,  it  forms  the 
principal  part  of  Chinese  wax.  The  free  acid  forms 
granular  crystals,  which  melt  at  78°  C. 

Acrylic  Acid  Series,  CnH2n2-20,. — Some  of  the 
higher  members  of  this  series  form  compounds  with 
glycerin,  resembling  the  neutral  fats.  The  most 
important  member  of  this  group  physiologically  is — 

Oleic  acid,  CH3.(CH,)„.(CH)2.COOH;  it  is  found 
united  with  glycerin  in  all  the  fats  of  the  body,  as  a 
liquid  fat,  olein,  which  holds  the  higher  fats  of  the 
fatty  acid  series  in  solution  at  the  body  temperature. 
It  is  more  abundant  proportionally  in  the  fats  of  cold- 
blooded animals  and  in  vegetable  oils. 

Gh/colic  Acid  Series,  CnH,n03. — Carbonic  acid, 
OH. COOH,  is  unknown  in  its  free  state,  being  doubt- 
less too  unstable  to  exist.  Its  salts,  however,  are 
present  in  large  quantities  in  the  body,  and  play  an 
important  part  in  the  alkalinity  of  the  tissues  and 

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fluids.  Its  corresponding  oxide,  C02,  is  the  principal 
form  in  which  carbon  leaves  the  body. 

Glycolic  acid,  H.CHOH.COOH,  does  not  occur  in 
tic  body. 

Lactic  acid  (better  distinguished  as  ethylidene- 
lactic  acid),  CH3.CHOH.COOH,  exists  in  three 
isomeric  varieties: 

1.  Fermentation  lactic  acid  is  present  in  sour  milk, 
and  in  the  stomach  and  intestines  during  digestion. 
It  is  also  found  in  small  quantities  in  the  muscles 
and  brain,  and  in  diabetic  urine.  It  is  a  colorless  or 
faintly  yellow  liquid  of  syrupy  consistency.  It  may 
be  regarded  as  a  mixture  of  the  two  following  from 
which  it  is  distinguished  by  being  optically  inactive. 

2.  Paralactic  or  sarcolactic  acid  is  the  principal 
acid  of  meat  extracts  and  of  muscle,  and  is  also  found 
in  numerous  glands.  It  is  present  in  the  sweat  in 
puerperal  fever,  and  in  the  urine  after  severe  fatigue, 
in  acute  yellow  atrophy  of  the  liver,  and  in  phos- 
phorus poisoning.  It  is  dextro-rotatory  to  polarized 
light. 

3.  A  third  levo-rotatory  lactic  acid  has  been 
obtained  by  the  fermentation  of  cane  sugar  by  a 
special  bacillus. 

Oxybutyric  acid,  CH3.CH2.CHOH.COOH,  found 
along  with  diacetic  acid  and  acetone  in  the  blood  and 
urine  of  diabetes,  is  an  odorless  syrupy  liquid,  which 
mixes  freely  with  water,  alcohol,  and  ether,  and 
rotates  polarized  light  to  the  left. 

Oxalic  Acid  Series,  CnH2n2— 0(. — Oxalic  acid, 
COOH.COOH,  is  found  in  small  quantities  in  the 
urine  as  calcium  oxalate,  and  often  occurs  in  excess 
after  the  ingestion  of  rhubarb,  strawberries,  or 
cabbage.  It  is  usually  increased  where  the  amount 
of  uric  acid  is  increased.  It  may  be  obtained  in  the 
laboratory  along  with  urea  and  carbonic  acid  gas 
from  the  oxidation  of  uric  acid,  and  it  is  believed  to 
be  formed  from  the  latter  in  the  body  to  some  extent. 
Oxalic  acid  is  a  violent  poison.  It  crystallizes  from 
aqueous  solutions  in  large,  transparent  prisms,  which 
effloresce  when  exposed  to  the  air. 

Succinic  acid,  COOH. (CH2),. COOH,  has  occasion- 
ally been  found  in  the  urine  after  the  ingestion  of 
asparagus  and  other  vegetables  and  fruits.  It  has 
also  been  detected  in  the  sweat,  the  intestinal  con- 
tents, and  in  the  thymus  and  thyroid  glands.  It 
forms  large  colorless  crystals  which  are  unaltered  by 
the  air  and  which  fuse  at  180°  C. 

Amino  Acids  are  cleavage  products  obtained  by 
the  decomposition  of  proteins  by  various  means  and 
represent  in  part  the  nuclei  making  up  the  protein 
molecule.  Chemically  they  are  organic  acids  which 
contain  one  (monoamino)  or  two  (diamino)  amino 
(NIL,)  groups.  They  may  also  contain  either  one 
(monobasic)  or  two  (dibasic)  carboxyl  (COOH) 
groups  in  which  the  hydrogen  is  capable  of  being 
replaced  by  a  metal  or  base.  The  most  common  and 
important  amino  acids  are  the  following: 

I.   Aliphatic  (fatty)  series  formed  from  acids  belong- 
ing to  or  derjved  from  the  fatty  acid  series  and  in 
which   the  arrangement  of  atoms  is  essentially 
in  an  open  chain. 
1.   Monoamino  acids. 
A.    Monobasic. 

Glycin,  glycocoll  or  ammo-acetic  acid,  CH,.- 

NIL.COOH. 

Alanin   hi-    ,i -amino-propionic  acid,  CH,.CH.- 

NIL.COoII. 

Serin,  oxyalanin  or  oxyamino-propionic  acid, 

CIL  0H.CH.NH2.C00H. 

Amino-isovaleric    acid,    (CH,).,.CH.CH.NH.„- 

COOH. 

Leucin      or      a-amino-isobut  vl-acetic      acid, 

(CH3)2.CH.CH2.CH.NHa.COOH. 

R.   Dibasic. 

\  partic  or  a-amino-succinic  acid,  COOH.CH.- 

NH2.CH2.CO()ll. 

78 


Glutamic  or  a-amino-glutaric    acid,  COOH  - 
CH.NIL.CIL.CLL.COOII. 

2.  Diamino  acids. 

Lysin  or  «-s-diamino-caproic  acid,  NH2.CH,.- 

CH2.CH,.CH2.CH.NH,.COOH. 

Arginin  or  guanidin-amino-valeric  acid,  NIL- 

NH2.CNH.CH,.CH2.CH2.CH.NH2.COOH. 

3.  Acids  containing  sulphur. 

Cystin  or  <*-diamino-;9-dithio-dilactylic  acid, 
(CH2.S.CH.NH2.COOH)2. 
Cystein    or     a-amino-^-thio-propionic    acid, 
SH.CH,.riL.\lL.C<M)H. 

Taurin  or  amino-ethyl-sulphonic  acid,  Nil  - 
CH2.CH2.S02.OH. 
II.  Aromatic  (cyclic)  series  derived  from  the 
benzene  nucleus  and  containing  six  or  more 
'carbon  atoms  arranged  around  a  closed  chain. 
Phenylalanine  or  phenyl-amino-propionic  acid 
C„H5.CH2.CH.NH,.COOH. 

Tyrosin  or  para-oxyphenyl-amino-propionic  acid 
C„H4.OH.CH2.CH.NH2.COOH. 
III.   Heterocyclic    series   arranged    around    a    closed 
chain  containing  less  than  six  carbon  atoms. 
Proline  or    a-pyrrolidin-carboxylic   acid,    C.H.  - 
NO... 

Oxyproline    or    oxypyrrolidin    carboxylic    acid, 
CaH8.NO,. 

Tryptophane  or  indol    a-amino-propionic    acid, 
C^H^.NO,. 

Histidine  or  «-amino-/3-imidazol-propionic  acid, 
C0H9N3.O,,   formerly     classed    with    lysin    ana 
arginin  as  the  hexone  bases. 

Bile  Acids. — Glycocholic  and  taurocholic  acids  are 
found  in  the  bile  combined  with  soda  to  form  the  bile 
salts.  They  consist  of  cholalic  acid  in  combination 
with  glycocoll  and  taurin  respectively. 

Glycocholic  acid,  C2aH13N06,  is  found  in  human 
and  ox  bile,  but  is  absent  or  nearly  so  from  that  of 
carnivora. 

Taurocholic  acid,  C20H45NSO7,  is  found  principally 
in  the  bile  of  the  carnivora  and  man,  but  is  also  present 
in  oxen,  sheep,  and  goats. 

Cholalic  acid,  C21H,0O5,  is  found  combined  in  the 
above-named  bile  acids.  It  is  insoluble  in  water, 
but  soluble  in  alcohol,  and  slightly  so  in  ether.  It 
crystallizes  in  rhombic  prisms  or  in  large  rhombic 
tetrahedra  or  octahedra.  Choleic  acid,  C21H.1(,0„ 
and  fellic  acid,  C,3HwO„  are  also  present  in  small 
quantities  in  human  bile,  combined  in  place  of 
cholalic  acid  in  the  bile  salts. 

Aromatic  Acids. — Acids  of  the  benzene  series.  A 
number  of  these  are  present  in  the  body  in  small  quan- 
tities. They  are  derived  partly  from  the  aromatic 
substances  contained  in  the  food,  and  partly  from  the 
breaking  up  of  proteins.  The  following  are  found 
principally  in  the  urine: 

Hippuric  acid,  C6HvCO.NH.CH,.COOH,  benzoyl- 
amidoace  tic  acid,  occurs  in  la  rye  quantities  in  the  mine 
of  herbivora,  but  only  in  small  quantities  in  the  car- 
nivora and  man.  The  quantity  in  the  urine  is  in- 
creased by  vegetable  food  containing  benzoic  acid 
compounds,  and  by  putrefactive  processes  in  the  in- 
testine. It  may  be  decomposed  into  benzoic  acid  and 
glycocoll. 

Ethereal  sulphuric  acids  include  the  following  four 
acids:  phenol-sulphuric  acid,  c,  1 1  .( ).S(  >.,.OH,  cresol- 
sulpnuric  acid,  C,H7.O.S02.OH,  indoxyl-sulphuric 
acid  or  indican,  ('  Jl.  .\.<>.SO„.OH,  and  skatoxyl-sul- 
phuric  acid,  C0H,.N.O.S<  >..<  HI. 

These  acids  are  all  found  in  the  urine,  and  are  de- 
rived from  the  phenol,  cresol,  indol,  and  skatol  which 
are  formed  in  the  intestines  as  a  result  of  the  putre- 
faction of  proteins.  Any  circumstances  favoring  the 
latter  process,  such  as  intestinal  diseases  accompanied 
by  obstruction,  increase  the  amount  of  these  acids  in 
the  urine. 

Aromatic  oxyacids,  of  which  the  principal  are 
paraoxyphenyl-acetic  acid,  C„H(.OH.CH2.COOH,  and 


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Acne 


paraoxyphenyl-propionio  acid,  C„H4.OH.CsH4.CO<  Ml, 
are  formed  from  tyrosin  in  small  quantities  in  the  in- 
testine and  pass  unchanged  into  the  urine. 

Nucleic  Acids. — These  are  acids  rich  in  phosphorus, 
of  complex  and  variable  composition,  found  among 
the  most  characteristic  constituents  of  cell  nuclei. 
They  combine  with  proteins  to  form  varieties  of  nu- 
olein  and  nucleoprotein.  Among  the  products  of 
their  decomposition,  the  most  important  are  phos- 
phoric acid  and  the  alloxuric  bases,  also  known  as  the 
tanthin  or  still  better  as  the  purin  bases. 

Uric  Acid. — CsHtN403,  trioxypurin,  is  found  in 
adult  human  urine  to  the  extent  of  from  seven  to  ten 
grains  per  day,  combined  with  bases  to  form  urates. 
In  birds  and  reptiles  it  replaces  urea  in  the  urine  as 
the  principal  end  product  of  protein  metabolism.  In 
man  it  is  derived  principally  from  the  nuclei  of  broken- 
down  cells  and  from  the  purin  bases  contained  in  the 
food.  The  extent  to  which  it  is  formed  from  pro- 
teins in  the  body  cannot  be  considered  settled.  For 
further  details  about  uric  acid,  see  Urine. 

Wesley  Mills. 
William  S.  Morrow. 

Acids,  Therapeutic  Action  of. — (See  also  under 
heading  of  each  individual  acid).  In  treating  of 
the  therapeutic  action  of  acids,  consideration  is 
given  to  the  stronger  acids  which  possess  all  the  chemi- 
cal characters  of  this  group  in  a  marked  degree.  The 
most  important  are  sulphuric,  nitric,  hydrochloric, 
phosphoric,  acetic,  citric,  and  tartaric  acids.  Of 
other  so-called  acids,  represented  by  boric,  benzoic,  ol- 
eic, carbolic,  salicylic  acid,  etc.,  the  chemical  charac- 
ters of  the  true  acid  are  either  absent  or  gradually 
diminish  until  they  are  over-shadowed  by  other 
important  therapeutic  properties. 

When  applied  to  the  tissues,  their  local  effect 
varies  from  the  powerful  corrosive  action  of  sulphuric 
acid  to  the  mild  irritation  of  the  vegetable  acids. 
Sulphuric  acid  is  destructive  to  all  tissues,  altering 
and  destroying  them  beyond  recognition.  It  is 
extremely  hygroscopic,  and  this  affinity  for  water  is 
the  cause  of  its  great  penetrating  and  diffused  action. 
It  combines  with  the  albumin,  fibrin,  etc,  producing  a 
jelly-like  mass  which  may  be  partially  discolored  and 
charred.  The  milder  solutions  simply  coagulate  and 
disorganize  the  albuminous  structures.  Nitric  acid 
acts  similarly,  but  is  less  severe.  In  addition  to  its 
corrosive  effects,  it  produces  a  characteristic  yellowish 
stain,  which  serves  to  distinguish  it  from  other  acids. 
A  somewhat  similar  stain  is  caused  by  bromine  and 
iodine,  but  marks  of  either  of  these  are  readily  re- 
moved by  a  little  caustic  potash,  while  the  nitric  acid 
stain  becomes  of  a  brighter  hue  by  the  action  of  the 
alkali.  Hydrochloric  acid  is  very  much  weaker. 
It  does  not  cause  the  same  destruction  of  tissue  as 
the  other  two  acids,  but  the  parts  become  white  or 
whitish  brown  by  its  coagulation  of  the  albumin;  at 
times  bulke  and  blisters  may  form.  On  the  soft 
mucous  surfaces,  the  strong  acid  may  produce  a 
swollen,  structureless  mass.  The  other  acids,  with 
the  exception  of  glacial  acetic  acid,  are  simply 
irritants. 

In  medicinal  doses,  the  beneficial  effects  of  dilute 
acids  are  marked,  but  how  far  this  is  due  to  their 
local  action  or  is  secondary  to  action  after  absorption, 
is  still  an  unsettled  question.  After  absorption  they 
lose  their  acid  character.  They  combine  with  the 
alkaline  bases  in  the  blood,  and  render  it  less  alkaline, 
but  never  produce  acidity.  They  are  excreted  as 
sulphates,  chlorides,  etc.  The  presence  of  hydroch- 
loric acid  in  the  gastric  juice  is  a  true  secretion  of  the 
gastric  glands.  As  eseharotics  the  strong  acids  are 
a  useful  adjunct  to  the  therapeutic  armamentarium. 
Sulphuric  acid  is  not  so  much  employed  as  it  was 
formerly,  when  it  was  a  favorite  reagent  for  removing 
morbid  growths.  Its  painful  effects  and  great  pene- 
trating power  are  objectionable,  and  it  is  replaced  by 


other  caustics  which  are  more  easily  controlled. 
This  penetrating  property,  however,  renders  ii ,  as  well 
as  nitric  acid,  of  value  in  bites  and  wounds  of  poison- 
ous animals.  Nitric  acid  is  always  selected  when 
any  destruction  of  tissue  is  desired.  It  removes  the 
necrosed  tissue  and  produces  a  healthy  growth  of 
granulations.  Hydrochloric  acid  is  seldom  used, 
although  it  was  at  once  time  often  employed  to 
destroy  the  membrane  in  diphtheritic  throats.  The 
use  of  acetic  arid  is  almost  limited  to  the  slow  removal 
of  warty  growths  and    the    treatment   of   ringworm. 

In  very  dilute  solutions  all  acids  possess  a  cooling  and 
refreshing  action  when  applied  to  the  surface  of  the 
body;  they  also  exert  an  astringent  effect  upon  the 
blood-vessels  and  sweat  glands,  as  when  employed  to 
prevent  or  lessen  the  night  sweats  of  phthisis.  Nitro- 
iiydrochloric  acid  baths  and  compresses  have  been  ex- 
tolled as  a  means  of  relieving  the  hepatitis  of  hot 
climates. 

When  administered  as  a  beverage  all  acids  are  most 
refreshing.  This  is  well  known  in  tropical  countries. 
Lemonade,  lime  juice,  dilute  phosphoric,  acetic, 
citric,  and  tartaric  acids  are  universally  employed. 
Their  effervescing  salts  are  particularly  useful.  They 
prove  refrigerant  and  disinfectant,  promote  digestion, 
and  if  there  is  any  diarrheal  tendency,  their  astrin- 
gent properties  become  of  service. 

Beaumont  Small. 

Acne. — Definition. — Acne  may  be  defined  as  a 
disease  of  the  sebaceous  glands  of  the  skin  and  of  the 
follicles  of  the  lanugo  hairs  attached  to  them,  thus 
being  both  a  folliculitis  and  a  perifolliculitis.  It  is 
characterized  by  their  inflammation  and  suppuration 
and  often  by  their  destruction,  with  a  resulting  scar. 

The  term  acne  has  been  qualified  in  accordance 
with  various  salient  features  presented  by  its  lesions 
or  with  certain  clinical  characteristics  predominant  in 
a  case,  and  there  are  therefore  found  in  literature 
such  terms  as  acne  vulgaris,  pustulosa,  punctata, 
juvenilis,  adolescentium,  etc.  All,  however,  rep- 
resent the  same  process.  In  addition  to  these,  the 
name  acne  has  also  been  applied  to  a  large  number  of 
affections,  which  have  nothing  whatever  in  common 
with  true  acne,  but  which  represent  totally  different 
pathological  entities,  and  among  these  are  included 
tuberculous  affections,  drug  eruptions  (iodine  and  bro- 
mine acne),  or  folliculitides  of  artificial  origin  (tar,  oils, 
and  grease,  etc).  For  the  sake  of  simplicity  and 
definiteness,  the  disease  will  be  treated  of  here  under 
the  heading  of  acne  simplex — the  more  superficial  form 
— and  of  acne  indurata — the  deeper-seated  variety. 
Acne  rosacea,  being  a  compound  process,  will  receive 
separate  mention. 

Symptomatology. — Acne  Simplex. — Acne  simplex 
possibly  represents  the  most  common  form  of  the 
disease,  as  it  is  the  one  developing  particularly  about 
the  age  of  puberty  and  in  young  people.  Instances 
have  also  been  seen  at  a  much  earlier  age,  and  like- 
wise later  in  life,  about  the  climacteric.  Apparently, 
it  occurs  more  often  in  the  female  than  in  the 
male  sex,  but  the  ratio  between  them  is  probably 
more  relative  than  exact.  The  lesions  characterizing 
the  affection  occur  without  regularity  or  symmetry, 
though  they  are  usually  distributed  bilaterally. 
Still,  variations  are  met  with,  such  as  one  side  of 
the  face  being  intensely  attacked,  and  the  other  side 
only  silghtly,  and  sometimes  it  is  found  unilateral. 
Acne  occurs  on  the  face  especially,  but  it  also  often 
appears  on  the  chest  and  shoulders,  and  sometimes 
on  the  upper  arms,  or  it  extends  down  the  back  even 
to  the  thighs. 

The  lesions  characterizing  acne  simplex  are  come- 
dones, papules,  and  pustules.  In  this  variety  of  the 
disease,  the  comedo,  or  popularly  the  blackhead,  as 
a  rule  constitutes  a  central  point  around  which  the 
inflammatory  changes  take  place.  These  can  usually 
be  seen  and  traced  in  every  case,  and  consist  of  redness 

79 


Acne 


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around  the  comedo,  then  formation  of  a  papule,  and 
lastly  transformation  into  a  pustule.  Lesions  may, 
however,  arise  independently  of  the  comedo.  The 
lesion  having  become  pustular,  remains  as  such  for  a 
few  days;  the  redness  then  begins  to  fade  and  a  crust 
forms,  which  falls  off  in  the  course  of  a  few  days  or 
more,  leaving  a  slight  stain,  or  a  scar,  or  a  pitting. 
The  pustular  transformation  does  not,  however,  take 
place  in  all  of  the  lesions.  Many  of  them  having 
reached  the  papular  stage,  remain  in  that  form  for 
a  variable  length  of  time  and  then  gradually  undergo 
involution.  Neither  do  all  the  comedones  become  im- 
plicated and  result  in  papules  or  pustules,  but  many 
persist  in  situ  unchanged.  In  consequence,  on  an 
affected  surface  all  stages  of  the  disease  are  usually  met 
with,  and  comedones,  papules,  pustules,  crusts, 
stains,  and  scars  are  seen  more  or  less  aggregated 


i^G^mm? 


Fig.  16. — Section  through  a  superficial  acne  lesion  (acne  simplex). 
(Author's  drawing.) 

together  without  order  or  regularity,  the  whole 
constituting  the  condition  known  under  the  name  of 
"pimply  skin"  or  "pimples." 

The  lesions  of  acne  simplex  present  no  especial 
subjective  symptoms,  though  when  handled  the 
inflamed  ones  are  sometimes  slightly  painful.  Occa- 
sionally a  burning  sensation  or  itching  is  complained  of. 

The  scars  and  stains  resulting  from  the  lesions  vary 
in  degree,  in  number,  and  in  size.  In  many  cases,  no 
scars  are  produced  and  the  subsidence  of  the  inflam- 
matory symptoms  marks  the  end  of  the  lesions. 
Others,  however,  leave  decided  stains  and  scars. 
The  stains  may  remain  for  a  few  weeks  only;  but  the 
writer  has  seen  them  persist  for  months  with  scarcely 
any  change.  As  a  rule,  they  gradually  fade  and 
ultimately  disappear  without  leaving  any  pigmenta- 
tion or  trace.  In  the  cases  in  which  scarring  takc^ 
place,  the  scars  often  remain  for  all  time,  though 
occasionally  the  skin  seems  to  smooth  out  entirely 
after  a  few  years.  These  differences  in  the  results  of 
the  lesions  are  naturally  dependent  upon  the  tissues 
of  the  individual  affected,  the  formation  of  scars 
being  commonly  found  in  strumous  subjects  and  in 
those  suffering  from  malnutrition  of  various  origin. 

When  an  acne  lesion  is  opened  and  its  contents 
evacuated,  these  will  be  found  to  consist  of  pus,  blood, 
sebaceous  matter,  and  the  comedo,  when  this  latter  is 
present.  After  evacuation,  the  lesion  heals  rapidly 
and  the  process  is  at  an  end.  Still  just  next  to  that 
gland,  another  may  become  attacked,  and  in  that  way 
the  disease  constantly  renews  itself,  lesions  appearing 
every  day  and  the  same  train  of  symptoms  repeating 
themselves  for  a  varying  period  of  time.  Acne 
always  runs  a  chronic  course;  that  is,  a  limit  of 
existence  within  which  it  ceases  to  recur  cannot  be 
made,  and  the  comforting  assurance  so  often  given 
to   young  patients   that  when  they  reach  legal  age 


their  affliction  will  disappear,  is  based  upon  fancy  and 
not  at  all  upon  fact.  The  simple  variety  of  acne  may 
be  present  during  the  entire  course  of  the  affection,  or  it 
may  become  of  the  severer  type — the  indurate  form — 
or  it  may  be  complicated  by  the  development  of  a 
rosacea.  The  simple  and  indurate  forms,  however, 
very  commonly  coexist,  one  or  the  other  preponderat- 
ing from  time  to  time. 

Acne  Indurata.— The  deeper-seated  variety  of  acne 
— the  indurate  form — presents  clinical  symptoms 
differing  in  degree  and  extent  from  those  which  occur 
in  the  type  just  described.  Comedones  are  often 
present,  but  they  do  not  constitute  an  essential 
portion  of  the  process,  nor  do  the  lesions  have  their 
origin  in  connection  with  them.  The  efflorescences  of 
acne  indurata  vary  in  size  from  a  pea  to  a  small  nut. 
They  originate  deep  in  the  tissues  and  enlarge  slow-ly 
or  rapidly,  requiring  some  days  and  even  a  week  be- 
fore softening.  The  inflammatory  reaction  is  not 
limited  to  the  gland  alone,  but  affects  the  surrounding 
tissues,  and  while  in  cases  in  which  the  lesions  arise 
acutely  their  color  may  be  a  bright  red,  in  others  it  may 
be  dull  red  and  even  purplish.  In  shape,  great 
variations  are  seen,  and  the  inflamed  lesion  may  be 
rounded,  or  elongated,  or  irregular,  and  it  may  also, 
by  the  implication  of  several  contiguous  glands,  give 
origin  to  a  furuncular  or  abscess-like  formation.     The 


Fig.  17. — Section     through     an     acne    indurata     pustule. 
(Author's  drawing.) 


occurrence  of  the  suppurative  change  is  in  some  cases 
very  active,  and  there  is  a  rapid  transformation  of  the 
indurated  area  into  a  pus  cavity;  but  in  others,  only  a 
small  amount  of  pus  forms  in  the  central  portion,  and 
the  hard  and  tense  condition  of  the  original  lesion 
persists.  Spontaneous  rupture  does  not  occur,  and 
unless  its  contents  are  evacuated  mechanically,  the 
lesion  may  remain  for  days  and  even  weeks,  slowly 
undergoing  involution.  After  it  has  been  opened,  it 
may  refill  again,  and  even  many  times,  or  until  thor- 
ough evacuation  of  all  its  contents  has  taken  place. 
Acne  indurata  is  much  more  apt  to  leave  scars  than 
acne  simplex.  The  scarring,  however,  occurs  most 
readily  in  subjects  of  lax  fiber,  or  who  have  strumous 
antecedents,  or  who  are  accustomed  to  empty  the 
lesions  by  hard  squeezing  or  other  irregular  mechani- 
cal  means.     The   scars   produced    have    no    charac- 


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Acne 


teristics  and  are  generally  at  first  purplish  and  livid, 
but  finally  they  become  white  in  color.  Keloidal  or 
fibroid  degeneration  has  been  seen  by  the  writer  as  a 
Bequela.  This  form  of  the  disease  attacks  the  same 
localities  as  have  been  mentioned  for  acne  simplex, 
but  it  occurs  on  the  trunk  more  frequently  than  the 
latter.  The  lesions  may  occur  singly,  discrete,  and 
only  few  in  number,  or  they  maybe  very  numerous  and 
more  or  less  aggregated  together.  In  fact,  patches 
may  occur  on  which  they  are  so  crowded  that  it  is 
difficult  to  make  out  the  separate  lesions. 

\rne  indurata  tends  to  run  a  chronic  course  and  to 
persist  for  a  number  of  years.  Only  a  few  lesions  may 
appear  from  time  to  time,  or  there  may  be  severe  out- 
breaks, and  crop  aftercrop  may  arise  until  the  affected 
surface  is  covered  with  the  manifestations  of  the  process 
— papules,  pustules,  crusts,  and  scars — and  every  stage 
of  evolution  and  involution  of  the  disease  be  present  at 
tin- same  time.  It  is  doubtful  if  spontaneous  disappear- 
ance of  the  indurate  form  ever  takes  place,  though 


Fig.   IS. — Acne  Cachecticorum  of   the   Face.      (From  a  photo- 
graph taken  by  Dr.  George  H.  Fox.) 

such  is  not  infrequent  for  the  simple  variety.  In 
connection  with  both  the  simple  and  the  indurate 
type  of  acne,  seborrhcea  oleosa  occurs  very  commonly, 
the  skin  then  presenting  a  greasy,  oily  aspect,  being 
yellowish  in  color,  with  most  usually  the  follicular 
orifices  dilated,  giving  the  surface  a  sieve-like  ap- 
pearance. The  process  known  as  seborrhoic  eczema 
{dermatitis  seborrheica)  is  also  a  frequent  com- 
plication, the  skin  then  presenting,  in  addition  to  the 
acne  lesions,  scaly  patches  of  irregular  outline  or 
patches  covered  with  thin  greasy  squamae  or  even 
fatty  crusts.  It  is  in  such  eases  that  itching  is 
generally  complained  of.  Besides  these,  any  other 
cutaneous  disease  may  coexist  with  an  acne. 

Acne  Cachecticorum. — The  form  of  cutaneous 
eruption  to  which  the  name  of  acne  cachecticorum  is 
given  occurs  in  poorly  nourished,  marasmic,  strumous 
individuals,  though  cases  have  been  recorded  which 
developed  in  those  perfectly  healthy.     The  process  is 

Vol.  I.— 6 


generally  associated  with  tuberculous  glands  of  the 
neck  and  with  lichen  scrofulosum.  The  trunk  and 
lower  extremities  tire  must  commonly  the-  seat  of  the 
eruption,  though  the  arms  may  be  affected  and  like- 
wise the  face.  The  Lesions  are  of  large  size — pea  to  a 
nut ;  they  are  dark  red,  purplish,  and  even  livid  in 
color;  they  are  not  tense  or  prominent,  but  fla'  ened 
and  flaccid.  No  sebaceous  plugs  are  present,  and  the 
contents  are  scanty,  consisting  of  a  seropurulent  fluid. 
They  form  crusts,  and  underneath  these  ulceration 
occurs.  In  some  cases,  the  lesions  become  hemor- 
rhagic. After  healing  has  taken  place,  a  livid  and 
purplish  scar  of  irregular  shape  persists  for  a  long  time, 
finally  becoming  white.  Occasionally,  the  hands  are 
affected  and  become  edematous  and  bluish-red,  and 
covered  with  nodules  and  pustules.  It  is  doubtful 
to-day  whether  this  process  should  be  regarded  as  an 
acne  at  all.  In  its  course  and  general  symptoms  it 
differs  greatly  from  acne  indurata,  though  it  is 
possible  that  the  differences  are  due  more  to  the  soil 


Fig.    19. — Acne  Cachecticorum  of  the   Back.      (From   a   photo- 
graph taken  by  Dr.  George  H.  Fox. J 

conditions  in  which  the  process  occurs  than,  to  any 
special  pathological  causative  factor.  Still,  owing  to 
the  presence  of  the  tuberculous  glands  and  the  coexist- 
ence of  lichen  scrofulosorum,  a  tendency  exists  to 
regard  it  as  a  form  of  "scrophuloderma"  and  of 
tuberculous  origin. 

Iodide  acne  and  bromide  acne  are  eruptions  caused  by 
these  drugs  when  taken  internally.  The  iodic  acne 
occupies  the  same  regions  as  acne  in  general,  though 
it  is  very  apt  to  be  more  disseminated  over  the  surface. 
There  are  no  comedones,  but  the  lesions  appear  as  an 
acute  eruption  of  hard  papules,  which  may  enlarge 
and  become  pustular.  General  symptoms  of  iodism  are 
usually  coexistent.  The  bromide  acne  appears 
often  on  the  face,  but  has  a  predilection  for  the  hairy 
surfaces — scalp  and  eyebrows.  The  lesions  are 
papules,  pustules,  and  tubercles.  They  often  form 
around  the  hair  follicle  and  the  lesion  is  pierced  by  a 
hair.     Both  of  these  may  be  caused  by  any  iodine  or 

81 


Acne 


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bromine  compound,  and  though  the  eruption  generally 
ceases  with  the  cessation  of  the  drug,  it  may,  however, 
persist  for  months  afterward. 

Acne  picea,  tar  acne,  occurs  in  those  regions  upon 
which  tar  has  been  used.  The  orifices  of  the  sebaceous 
glands  become  blocked  up  with  the  tarry  plug,  which 
acts  in  a  similar  manner  as  the  comedo  and  leads  to 
perifollicular  inflammation  and  the  formation  of  a 
papule.  Pustulation  also  takes  place  at  times.  The 
same  condition  may  result  from  the  use  of  chry- 
sarobin.  The  application  of  ointments,  particularly 
in  those  regions  in  more  or  less  constant  contact  with 
each  other — the  inguinal  and  the  axillary  regions,  for 
instance — very  often  produces  a  follicular  disturbance 
analogous  to  an  acne,  in  so  far  that  the  lesions 
implicate  the  sebaceous  glands  and  consist  of  papules 
which  become,  later,  pustules.  There  may  also  be 
referred  to  here  the  folliculitis  of  the  face  and  arms  of 
flax  spinners  (Purdon),  and  the  eruption  occurring 
on  the  thighs,  which  is  due  to  the  oils  and  grease  used 
by  spinners  in  their  vocation  (Leloir). 

Pathology. — The  pathological  changes  in  acne 
are  constituted  by  inflammation  of  a  sebaceous  gland, 
the  occurrence  of  suppuration,  and  in  a  greater  or 
lesser  degree  the  destruction  of  the  gland  and  the 
surrounding  tissue.  The  cause  of  these  changes  may 
be  of  various  origin  and  is  certainly  not  a  single  specific 
one.  It  may  be  the  comedo  or  other  agent  blocking 
up  the  follicular  orifice,  and  acting  as  a  foreign  body 
causing  perifollicular  congestion  and  inflammation 
through  some  chemical  change.  The  causal  agent 
may,  moreover,  be  some  pathogenic  microorganism 
present  in  the  follicle  prior  to  its  closure,  or  carried  to 
it  through  the  circulation.  The  fact  that  certain 
microorganisms  have  been  found  to  be  especially 
associated  with  the  production  of  pus  has  suggested 
that  the  acne  pustule  was  the  result  of  infection  of  the 
sebaceous  follicle  by  some  one  or  other  of  these  pyo- 
genic germs.  Most  text-books  on  diseases  of  the 
skin  give  Staphylococcus  albus  as  the  cause  of  acne 
vulgaris  in  addition  to  the  predisposing  causes. 
Many  investigators  could  get  only  Staphylococcus 
albus  in  cultures  from  acne  lesions  and  this  organism 
is  undoubtedly  an  active  factor  in  some,  if  not  all 
stages  of  the  disease.  Unna  in  1893  found  a  small 
bacillus  in  smears  and  sections  from  comedones 
together  with  the  bottle  bacillus  and  several  forms  of 
cocci.  Only  poorly  nourished  plate  cultures  of  the 
bacillus  could  be  obtained — no  subcultures.  Unna 
thought  these  bacilli  were  the  cause  of  acne.  Hodara 
in  1894  confirmed  Unna's  observations  and  grew  the 
bacilli  in  mixed  cultures  but  did  not  get  any  pure 
culture.  Sabouraud  in  1894  published  his  first  com- 
munication upon  his  microbacillus  of  seborrhea  but 
did  not  believe  the  organism  to  be  the  direct  cause  of 
acne.  Gilchrist  in  1899  isolated  a  bacillus  in  pure 
culture  from  acne  vulgaris  lesions  which  be  believed 
to  be  the  cause  of  the  disease.  In  1903  Gilchrist 
confirmed  his  previous  work  by  finding  the  Bacillus 
acnes  present  in  240  smears  from  86  patients;  and 
pure  cultures  of  the  organisms  were  obtained  from 
62  lesions.  He  also  found  that  the  sera  from  patients 
suffering  from  severe  acne  caused  clumping  or  agglu- 
tination of  the  Baccillus  acnes  even  when  diluted  1-100, 
which  led  him  to  think  that  the  anemia,  coated  tongue, 
and  constipation  were  probably  the  result  of  acne  and 
not  predisposing  causes  of  the  disease.  Engman  con- 
siders the  organisms  described  by  Unna,  Sabouraud, 
Gilchrist,  and  himself  to  be  identical.  He  found  the 
organism  was  grown  only  with  the  greatest  difficulty 
and  was  unable  to  obtain  subcultures.  Fleming, 
Western,  and  Lovejoy  have  since  noted  the  constant 
presence  of  Bacillus  acnes  in  the  lesions  of  acne. 
Smiley  reports  100  cases  of  acne  vulgaris  in  which  the 
acne  bacillus  was  present  in  all.  In  eighty-six  per 
cent,  of  his  cases  the  accompanying  organism  was  the 
Staphylococcus  albus;  in  ten  per  cent,  he  found  the 
Staphylococcus  albus  and  aureus  together;  in  three  per 

82 


cent,  the  Staphylococcus  aureus  alone;  and  in  one  per 
cent,  the  Staphylococcus  citreus  and  albus  together. 

In  the  writer's  opinion  Bacillus  acnes  may  be  the 
cause  of  the  acne  lesion,  but  it  certainly  is  not 
the  only  cause.  The  bacillus  can  frequently  be  iso- 
lated from  the  sebaceous  follicles  of  the  nose  of  people 
who  have  never  had  acne.  Experience  and  the  ob- 
servation of  a  great  many  cases  nave  shown  that  the 
various  functional  and  pathological  conditions  men- 
tioned in  the  paragraph  on  etiology  play  a  most 
important  part  in  the  production  of  the  eruption. 
Under  the  influence  of  these  various  etiological  factors 
the  resisting  power  of  the  skin  is  lowered.  As  a 
result  the  acne  bacillus  is  enabled  to  assume  patho- 
genic properties  where  before  it  had  existed  as  a 
harmless  saprophyte  of  the  skin. 

Pathological  Anatomy. — According  to  many 
writers  the  starting-point  of  the  inflammatory  change 
is  around  the  follicle  of  the  lanugo  hair  attached  to 
the  gland,  the  latter  becoming  only  secondarily  impli- 
cated in  the  process.  The  writer  has,  however, 
frequently  found  the  hair  follicle  absolutely  intact 
and  not  concerned  in  the  pustular  formation.  The 
inflammatory  changes  always  begin  around  the 
follicle — that  is,  it  is  primarily  a  perifolliculitis. 
The  tissues  are  infiltrated  with  round  cells  which 
are  located  at  first  around  the  network  of  blood- 
vessels supplying  the  sebaceous  gland  attacked. 
Unna  states  that  the  infiltration  consists  of  plasma, 
large  fusiform  "  mast "  and  a  few  giant  cells,  leucocytes 
being  found  only  when  suppuration  has  occurred. 
The  degree  of  infiltration  varies  in  different  lesions 
and  cases.  The  writer  has  found  that  in  acne  simplex 
lesions,  infiltration  is  more  superficial  and  located 
about  the  duct  and  upper  part  of  the  gland,  while 
in  the  indurate  form  it  is  deeper  and  around  the 
body  of  the  gland  especially.  It  may  also  extend 
widely  throughout  the  cutis;  and  several  contiguous 
glands  becoming  affected,  they  melt  together  into 
one  inflammatory  and  suppurating  area.  The  peri- 
follicular inflammation  having  extended  to  the  gland, 
its  parenchyma  becomes  infiltrated,  its  cavity  is 
distended,  and  its  walls  ruptured  in  places.  Its  con- 
tents are  then  composed  of  serofibrinous  fluid, 
sebaceous  debris  and  leucocytes,  some  intact  glandular 
epithelium,  and  often  the  comedo.  In  acne  simplex 
the  gland  is  not  always  destroyed,  but  in  acne  indu- 
rata  it  generally  is.  The  same  changes  may  affect 
the  follicle  of  the  lanugo  hair  attached  to  the 
gland. 

Etiology. — The  etiological  causes  active  in  the 
production  of  acne,  whether  of  the  simple  or  indurate 
variety  are  manifold,  and  the  process  cannot  in  any 
sense  of  the  term  be  regarded  as  of  specific  origin. 
Whether  the  many  disturbances  or  systemic  condi- 
tions found  in  connection  with  these  cases  are  to  be 
estimated  as  of  causative  importance,  or  as  simply  of 
predisposing  effect,  is  a  question  which  will  be  deter- 
mined when  the  pathological  origin  of  the  disease  is 
absolutely  established.  Until  then  it  can  only  be 
said  that  without  their  proper  valuation  and  con- 
sideration, no  case  of  acne  can  be  understood  or  its 
needs  correctly  estimated,  for  it  is  more  upon  these 
etiological  factors  that  treatment  should  be  based 
than  upon  any  other  feature  presented  by  the  proc- 
ess. Age  plays  an  important  part,  as  the  inception 
of  the  disease  in  the  large  majority  of  cases  is  at  or 
about  the  time  of  puberty.  Still  it  occurs  at  other 
ages,  and  the  writer  has  seen  it  develop  at  every 
period  of  life  between  puberty  and  the  climacteric, 
and  even  later.  In  youth,  acne  simplex  is  most 
common,  but  acne  indurata  occurs  most  frequently 
after  twenty-five.  That  it  tends  to  disappear  at  the 
age  of  twenty-one — a  belief  so  current  among  the 
laity  and  unfortunately  the  general  medical  profes- 
sion also— is  an  unwarranted  assumption,  due  to  the 
fact  that  many  patients  have  at  that  age  recovered 
from  one  or  another  disturbance  of  nutrition  incident 


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Arnr 


to  their  development,  and  occurring  during  the  pe- 
riod in  which  stability  of  their  tissues  was  in  a  stage  of 
transition;  that  is,  major  etiological  causes  of  the 
disease  had  by  that  time  been  removed  by  nature,  by 
general  treatment  for  other  systemic  condition':,  nr 
by  greater  care  of  the  functional  and  general  health 
on  the  part  of  the  individual  afflicted,  through  educa- 
tion and  possibly  observation  of  the  relation  existing 
between  the  eruption  and  some  deviation  from  normal 
health. 

Menstrual  and  uterine  disorders  are  frequently 
accused  as  predisposing  factors  in  the  production  of 
acne,  but  still  too  much  stress  should  not  be  laid  upon 
them  alone,  since  the  cause  of  the  menstrual  disturb- 
ance may  more  properly  be  the  important  factor. 
At  any  rate,  an  aggravation  of  an  existing  acne  will 
commonly  occur  before,  during,  or  after  a  menstrual 
epoch.  And  yet  the  abnormal  conditions  which 
affect  this  function  may  be  entirely  removed,  but 
the  eruption  will  persist;  or  the  acne  may  be  radically 
eured,  "hile  'he  functional  or  other  disturbances  of 
the  uterine  organs  remain  unchanged.  In  assocation 
with  the  process,  all  other  forms  of  functional  and  nutri- 
tive disturbance  are  also  met  with.  Constipation  is 
very  frequent  and  not  uncommonly  chronic  catarrhal 
forms  of  diarrhea.  Chlorosis  or  anemia  of  variable 
grades  and  debility  of  various  origin  are  often  the 
basic  factors.  Gastric  and  intestinal  dyspepsia  are 
common,  though  in  my  experience  it  is  most  usually 
fermentative  intestinal  indigestion  which  is  of  impor- 
tance. Dilatation  of  the  stomach  has  been  stated  to 
be  particularly  common  in  these  cases,  but  it  is 
undoubtedly  exceptional.  Mental  and  physical  ex- 
haustion, excesses  of  any  and  every  kind,  masturba- 
tion, urethral  irritation,  a  sedentary  life,  excessive 
exercise,  the  gouty,  rheumatic,  or  strumous  consti- 
tution, all  must  be  mentioned  as  causes  of  acne  in 
themselves  or  through  their  influence  upon  the  systemic 
health.  But  if  analysis  is  applied  to  all  of  these,  it 
cannot  be  evident  that  the  whole  may  be  comprised 
in  the  category  of  lowered  or  debased  nutrition,  as  all 
are  productive  of  more  or  less  marked  nutritive  disturb- 
ance of  the  organism.  In  consequence,  the  etiology 
of  acne  can  be  briefly  stated  to  depend  especially 
upon  some  disturbance  occurring  in  the  functional 
or  systemic  health  of  an  individual,  which  results  in 
disordered  or  lowered  nutrition.  External  and  local 
causes,  however,  also  play  a  certain  part  in  the  pro- 
duction of  the  disease.  Among  these,  there  may  be 
mentioned  exposure  to  cold  winds,  to  irritation  of 
various  kinds,  inattention  to  cleanliness,  etc.  The 
face,  the  locality  most  generally  affected,  is  that 
surface  especially  and  constantly  exposed  to  such 
factors  as  changes  of  temperature,  to  dust  and  drift 
of  every  description  carried  by  the  winds,  to  irritating 
influences  of  many  kinds,  and  the  fact  that  it  is 
attacked  so  disproportionately  in  frequence  to  other 
surfaces  equally  or  almost  as  rich  in  sebaceous  glands 
would  suggest  that  these  various  external  agents 
and  causes  have  an  influence  in  developing  or  at 
least  in  aggravating  many,  if  not  all,  cases  of  the 
disease. 

As  particular  causes  of  acne,  the  atrophic  form 
of  rhinitis  has  been  mentioned,  and  recently  a  German 
colleague  has  claimed  that  all  cases  of  the  process 
owe  their  origin  primarily  to  some  slight  or  severe 
ulcerative  or  erosive  process  in  the  nasal  cavities, 
which  allows  entrance  of  pyogenic  germs  into  the 
lymphatic  circulation. 

The  acne  due  to  the  use  of  iodine  and  bromine 
compounds  has  as  its  direct  inducing  cause  one  of 
those  substances,  and  is  a  drug  eruption;  not  an  acne 
in  a  strict  sense,  but  one  of  artificial  origin.  The 
same  may  be  stated  in  regard  to  the  folliculitis  due 
to  the  closure  of  the  follicle  by  tar — after  use  of  a 
tar  ointment — and  known  as  acne  picea;  while  the 
many  other  processes  dubbed  acne  of  one  kind  or 
other,  having  nothing  in  common  etiologically  with 


acne  simplex  and  indurata,  should  all  be  strictly 
disassociated  from   these. 

The  effect  of  diet  upon  the  disease  is  of  some 
importance,  since  it  may  originate  the  process,  through 
the  functional  disturbances  which  it  may  create,  or 
it  may  aggravate  an  already  existing  acne.  Among 
the  articles  of  diet  which  may  be  particularly  men- 
tioned are  sweets  of  all  kinds,  pastries,  oatmeal, 
cheese,  nuts,  highly  seasoned  and  rich  foods,  shell- 
fish, etc.  Milk  in  certain  individuals  appears  to 
have  the  effect  of  causing  an  outbreak  of  lesions; 
so  also  has  cream,  fermented  drinks,  such  as  beer, 
etc.,  champagne,  and  syrups  with  soda  or  natural 
waters. 

Diagnosis. — There  should  be  no  difficulty  in 
making  the  diagnosis  of  a  case  of  acne.  Popularly 
known  as  "pimples"  or  a  "pimply  face"  or  an  attack 
of  "blackheads,"  it  is  so  common  that  its  recognition 
should  be  immediate.  Especially  is  this  the  case 
with  acne  simplex,  in  which  the  comedo  plays  so 
important  a  role;  but  acne  indurata  may  at  times 
offer  some  points  of  doubt.  The  papular  form  of 
eczema  may  be  differentiated  by  its  occurrence  on 
the  extremities  as  well  as  on  the  face,  and  it  is  never 
limited  to  the  latter.  Its  lesions  are  smaller,  often 
crowned  with  a  minute  vesicle,  and  they  tend  to 
coalesce  into  patches;  they  are  very  itchy,  and  when 
opened  do  not  contain  sebaceous  debris.  The 
vesicular  or  pustular  elevation  is  superficial  and 
results  in  the  formation  of  epidermic  scales  and  small 
exudation  crusts.  The  pustular  syphilide  may  be 
mistaken  for  acne,  and  vice  versa;  and  so  much  is 
this  the  case  that  one  form  of  syphilitic  eruption  has 
been  named  acneiform.  These  lesions  may  be  limited 
to  the  face,  but  they  are  more  often  coincident  with 
syphilitic  manifestations  on  other  parts  of  the  body 
or  on  the  mucous  membranes.  They  tend  to  form 
groups,  to  dry  and  become  covered  with  crusts;  and 
when  these  are  removed,  a  punched-out  ulceration 
filled  with  seropurulent  fluid  and  bounded  by  a  more 
or  less  infiltrated  wall  is  found.  Many  mistakes 
in  diagnosis  are  made  between  an  indurate  acne  and  the 
superficial  gummatous  syphilide — the  so-called  tuberc- 
ular syphilide — especially  when  the  latter  is  situated 
on  the  nose.  But  the  error  should  not  occur  when 
it  is  borne  in  mind  that  the  syphilide  as  a  rule  is 
circumscribed  in  its  occurrence,  its  lesions  are  grouped, 
indolent,  undergo  softening  and  crust  formation, 
and  beneath  the  latter  ulceration  occurs.  The 
process  very  usually  extends  slowly  in  an  excentric 
or  serpiginous  manner,  leaving  more  or  less  marked 
cicatrices.  Acne  indurata,  on  the  other  hand,  runs 
a  more  acute  course,  is  painful  and  furuncular  in 
aspect,  occurs  here  and  there  without  reference  to 
preexisting  lesions,  does  not  tend  to  form  groups, 
heals  up  rapidly  after  evacuation,  does  not  ulcerate 
nor  tend  to  progress  in  a  serpiginous  manner,  and 
frequently  leaves  no  scar,  or  at  the  most  one  superficial 
and  ill  defined. 

There  is  a  papular  form  of  erythema  occurring  at  the 
menstrual  epoch  in  women  which  is  very  usually  con- 
founded with  acne.  It  is  papular  in  character, 
though  occasionally  a  pustule  occurs.  It  appears 
on  the  face  especially,  but  sometimes  over  the  neck 
and  shoulders.  Its  appearance  is  brusk,  a  few  days 
before,  during,  or  just  after  the  menstrual  epoch. 
It  may  consist  of  a  few  or  of  many  lesions,  which  are 
frankly  inflammatory  and  about  the  size  of  a  small 
pea.  They  do  not  contain  any  comedo  or  sebaceous 
matter;  they  itch  and  burn,  persist  for  a  few  days  to 
a  week,  and  then  subside,  to  reappear,  however, 
at  the  time  of  the  next  period.  This  eruption,  purely 
a  reflex  papular  erythema,  is  usually  regarded  as 
an  acne,  but  it  should  be  strictly  separated  from  it. 

Prognosis. — The  prognosis  of  an  acne  is  favorable, 
and  it  can  be  said  that  all  cases  of  the  disease  are 
curable,  provided  that  the  etiological  factors  existing 
in  any  given  case  are  correctly  estimated,  and  that 

83 


Acne 


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the  therapeutic  efforts  are  carried  out  carefully  and 
systematically  by  the  patient.  Acne  also  may  and 
does  disappear  spontaneously,  but  that  is  the  case 
when  the  one  or  other  cause  of  the  process  has  also 
been  removed  by  course  of  time,  improvement  of 
general  somatic  conditions,  etc.;  but  in  view  of  the 
disfigurement,  scarring,  and  changes  which  may  occur 
in  the  skin  from  the  disease,  it  is  not  advisable  to 
wait  for  a  spontaneous  involution  and  to  leave  the 
patient  without  such  proper  care  as  will  keep  the 
process  within  bounds  or  gradually  cause  its  entire 
cessation.  In  giving  to  a  patient  the  prognosis  of 
his  or  her  acne,  it  should  also  be  borne  in  mind  that 
the  same  causes  can  produce  the  same  effects,  and  that 
the  complete  or  lasting  cure  of  the  eruption  will 
therefore  depend  upon  the  individual's  avoidance  of 
the  particular  cause  or  causes  or  factors  which  have 
been  found  to  be  the  basis  for  the  existence  of  the 
disease  in  any  given  case.  As  to  the  length  of  time 
needed  to  cure  a  case,  definite  statements  should 
not  be  made,  since  the  duration  of  treatment  will 
have  to  depend  upon  the  response  of  the  patient  to  the 
remedial  agents  made  use  of,  the  care  and  system 
with  which  the  orders  of  the  physician  are  carried  out, 
the  age  of  the  patient,  and  particularly  upon  the  pos- 
sibility of  removing  the  etiological  factor  or  factors. 
Still,  if  not  absolutely  cured,  no  case  should  be 
dismissed  as  incuraDle,  as  all  can  be  very  materially 
benefited  by  proper  care. 

Treatment. — The  methods,  procedures,  and  reme- 
dies pertaining  to  the  treatment  of  acne  are  mani- 
fold and  various,  being  such  as  have  to  do  with  the 
general  systemic  health,  and  such  as  are  local  and 
applicable  to  the  lesions  themselves.  In  no  sense  of 
the  term  is  there  any  specific  medication  in  vogue  or 
any  drugs  which  can  be  regarded  as  specific,  but  every 
case  has  to  receive  such  treatment  as  is  indicated  by 
the  conditions  found  to  exist.  The  statement  just 
made  refers  especially  to  the  internal  and  general 
systemic  care,  and  in  these  particulars  there  is  no 
disease  in  which,  as  it  may  be  put,  "  individualiza- 
tion" of  treatment  is  so  necessary  and  called  for. 
As  a  rule,  no  two  cases  can  be  treated  alike,  but  each 
must  receive  such  special  advice  as  may  be  judged 
to  be  required,  after  a  thorough  investigation  into 
the  bodily  and  functional  health  of  the  patient,  his 
habits,  mode  of  life,  diet,  etc.  Under  these  circum- 
stances, should  constipation  be  the  factor  in  the  case, 
it  should  be  relieved  by  cascara  sagrada,  aloin,  or 
some  other  remedy  affecting  the  bowels,  or  by  means 
of  diet,  proper  exercise,  cold  douches,  etc.  Gastric 
or  intestinal  indigestion,  fermentative  processes, 
should  be  appropriately  combated  by  dietary  measures, 
the  mineral  acids,  pepsin,  etc.,  or  by  intestinal  an- 
tiseptics— resorcin,  sulphocarbolate  of  soda,  salicin, 
charcoal,  etc.,  and  by  such  other  measures  as  are  in- 
dicated for  these  conditions.  If  debility  or  anemia 
exists,  then  tonics  are  called  for:  iron,  mix  vomica, 
mercury,  the  vegetable  bitters,  feeding  up,  general 
hygienic  methods,  etc.  The  ferrum  reduetum,  the 
carbonate,  and  the  dry  sulphate  of  iron  have  proved 
the  best  in  my  experience;  hemogallol  is  particularly 
good  when  the  stomach  rebels  against  the  other 
forms  or  when  constipation  exists.  Except  to 
tuberculous  subjects,  the  iodide  of  iron  should  not  be 
given,  owing  to  the  possibility  of  the  iodine  causing 
an  eruption.  When  administering  iron  in  cases  of 
acne,  the  blood  should  be  tested  at  the  beginning  of 
its  use  for  the  percentage  of  hemoglobin,  and  retested 
every  two  to  three  weeks.  Only  in  this  way  can 
certainty  be  had  that  the  iron  given  is  being  assimilated 
and  the  blood  state  is  or  is  not  improving.  Practi- 
cally, Fleischl's  hemometer  answers  all  requirements 
for  testing.  For  strumous  subjects,  cod-liver  oil. 
the  hypopnosphites,  and  the  malt  preparations  are 
e  pecially  valuable.  If,  on  the  other  hand,  the  acne 
occurs  in  gouty  subjects,  in  those  who  are  rheumatic 
or  plethoric,  who  show  evidences  of  deficient  elimina- 

84 


tion,  then  alkaline  mixtures,  the  potassium  salts — ex- 
cept the  iodide  and  bromide — lithia,  saline  purgatives, 
colchicum,  the  salicylates,  strict  regimen,  etc.,  are  of 
the  greatest  service.  In  other  words,  every  indica- 
tion obtained  from  investigation  of  the  patient's 
history  should  be  duly  estimated  and  receive  such 
attention  as  it  requires.  It  is  useless  to  take  up  each 
seriatim,  but  all  should  be  considered  together  in  order 
to  obtain  as  rapid  progress  as  possible.  The  effects 
of  calcium  sulphide  are  illusory:  none  when  given 
alone;  but  when  exhibited  together  with  dietary 
regulations,  with  other  internal  and  local  treatment, 
then  improvement  is  seen  in  the  case.  But  the 
result  is  obtained  by  those  same  measures  when  no 
calcium  sulphide  is  administered.  Arsenic  is  of  use 
under  certain  conditions,  but  should  not  be  regarded 
as  a  specific.  As  a  rule,  more  harm  than  benefit 
is  done  by  it.  It  is  of  value  in  certain  cases  in  which 
anemia  or  debility  is  present.  In  acute  examples 
of  the  disease  it  is  contraindicated,  but  it  may  be  of 
benefit  in  those  which  are  chronic  in  type.  In  those 
acnes  which  are  complicated  by  a  seborrhea  oleosa, 
or  in  which  the  process  is  sluggish  and  the  lesions 
are  indolent  and  leave  congested  stains,  ichthyol 
internally  is  frequently  of  value.  Beginning  with 
five-grain  doses  three  times  a  day,  the  amount  may 
gradually  be  increased  until  gr.  xv.  ter  in  die  are 
being  taken.  The  drug  is  harmless,  and  for  its  best 
effects  should  be  continued  for  several  months.  The 
question  of  diet  is  of  some  importance,  but  yet  it 
should  not  be  carried  to  an  extreme,  nor  be  regarded 
as  the  keynote  of  the  treatment.  In  general,  it  may 
be  stated  that  the  diet  should  be  composed  of  nutri- 
tious and  easily  digested  food,  and  the  various  arti- 
cles chosen  or  forbidden  should  depend  to  the  greatest 
extent  upon  the  digestive  conditions  in  existence 
in  the  individual  case  under  care.  As  a  rule,  I  have 
found  that  it  is  advisable  to  forbid  in  all  cases  such 
articles  as  are  comprised  under  the  heading  of  sweets 
— desserts,  candies,  jams,  preserves,  pies,  rich  pud- 
dings, etc. — and  also  oatmeal,  cheese,  and  nuts. 
Besides  these,  the  diet  should  exclude  stimulating, 
highly  seasoned,  and  indigestible  foods  of  all  kinds. 
Oysters  are  allowable,  but  lobsters  and  crabs  will  be 
found  injurious.  Clear  soups,  plainly  cooked  fish, 
roast  and  broiled  and  boiled  meats,  poultry  and  game, 
vegetables  of  all  kinds,  salads  with  plain  vinegar  and 
oil  dressing  are  perfectly  allowable  for  all  cases,  but 
at  the  same  time  the  diet  in  these  as  well  as  in  all 
particulars  will  have  to  be  varied  according  to  the 
necessities  of  the  individual  case.  In  may  thus  be 
found  that  in  one  milk,  cream,  butter,  and  fats  will 
be  beneficial,  while  in  others  they  will  be  injurious; 
in  some,  a  light  claret  or  Rhine  wine  with  the  meals 
is  distinctly  beneficial,  but  in  others  all  wines  will 
be  harmful.  The  same  remarks  are  pertinent  as 
regards  beer,  alcohol,  tea  and  coffee;  and  on  the 
whole,  it  may  be  stated  that  so  far  as  diet  is  concerned, 
the  same  rule  should  be  followed  as  has  been  laid  down 
for  the  internal  medication  of  acne — that  is,  it  should 
be  made  to  conform  to  the  needs  and  the  require- 
ments of  the  individual  afflicted,  and  not  with  a 
view  of  furnishing  a  specific  regimen  which  shall  of 
itself  remove  the  affliction. 

General  hygienic  laws  should  also  be  enforced. 
Exercise  in  moderation,  but  not,  however,  to  the 
excessive  point  it  is  carried  to-day,  is  of  value,  and 
so  also  is  a  change  from  a  sedentary  to  an  active  life. 
Attention  to  personal  cleanliness,  to  bathing,  to 
early  hours  is  clearly  indicated,  and  dissipation  and 
excesses  of  all  kinds  should  be  avoided. 

The  local  treatment  of  acne  is  of  equal  importance 
with  the  internal  and  with  the  general  care  of  the 
patient,  for  by  these  means  the  lesions  of  the  disease 
ran  be  removed  and  a  healthy  action  of  the  skin 
can  be  brought  about,  and  that  even  before  the  pre- 
disposing causes  have  been  entirely  disposed  of. 
Many   cases,   moreover,   can  be   cured   by   external 


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Acne 


treatment  alone,  but  the  writer  has  failed  so  far  to 
obtain  such  a  result  from  exclusively  internal  care. 
Both,  in  reality,  should  go  hand-in-hand  in  order  to 
get  the  best  and  most  rapid  cure  of  the  process. 

The  first  requisite  in  the  local  treatment  is  the  use 
of  soap  and  water.  The  surface  of  the  skin,  the  seat 
of  an  acne,  should  be  thoroughly  washed  night  and 
morning.  Any  good  toilet  soap  is  all  that  is  neces- 
sary, but  a  marble  or  sand  soap  has  been  recom- 
mended, as  well  as  the  Tr.  saponis  viridis.  Super- 
fatted soaps  containing  resorein,  ichthyol,  sulphur,  or 
mercuric  chloride  are  also  advised  and  used,  but  unless 
left  on  the  surface  over  night,  for  instance,  they 
offer  little  advantage  over  a  plain,  pure  soap.  Tar 
soaps  are  decidedly  injurious  in  these  cases,  particu- 
larly  if  rubbed  info  and  left  on  the  skin,  inasmuch 
as  the  tar  may  lead  to  the  development  of  an  acne 
picea.  The  water  should  be  fresh  and  cool — about 
the  temperature  of  the  room;  and  in  the  writer's 
opinion  and  experience,  hot  water  is  injurious.  Still, 
it  is  recommended  by  many  as  of  value  when  applied 
for  a  number  of  minutes  every  night  at  as  high  a 
temperature  as  can  be  borne  by  the  patient.  Face 
straining  is  also  advised  by  some,  the  external 
remedy  ordered  being  afterward  rubbed  into  the  skin. 
The  writer  certainly  cannot  vouch  for  the  value  of 
either  one  of  these  procedures,  as  he  himself  has  never 
found  them  other  than  objectionable,  increasing  the 
amount  of  the  eruption,  inducing  often  a  seborrhoea 
oleosa,  accompanied  by  a  relaxed  condition  of  the 
skin  and  dilated  follicular  orifices,  and  causing  the 
skin  to  have  a  sieve-like  appearance.  He  has  also 
found  that  these  procedures  were  liable  to  cause  a 
persistence  of  the  process  and  to  occasion  frequent 
relapses.  The  same  statements  he  would  also  make 
in  regard  to  facial  massage,  so  frequently  recom- 
mended and  used  to-day,  as  in  his  experience  he 
has  found  that  it  often  causes  an  outbreak  of  acne 
and  invariably  aggravates  a  preexisting  one.  Still 
these  may  in  some  cases  be  beneficial,  but  they 
certainly  are  not  adapted  for  all,  and  should  not  be 
made  use  of  as  regular  modes  of  treatment. 

The  comedones  should  be  dealt  with  according  to 
the  directions  given  under  that  section.  Curetting, 
both  for  them  and  the  acne  lesions,  has  been  recom- 
mended by  various  writers — Hebra,  Jr.,  Fox,  Brocq;  a 
dermal  curette  is  used,  and  the  face  is  gone  over  and 
thoroughly  scraped  once  every  week  or  ten  days. 
The  operation  is  rather  painful,  and  though  at  times 
there  may  be  rapid  improvement,  yet  unless  the  pa- 
tient is  treated  locally  and  internally  at  the  same 
time,  the  relief  is  only  temporary  and  a  marked 
relapse  is  apt  to  follow.  I  wish  to  emphasize  this 
statement  because  in  a  large  number  of  cases  which 
have  come  under  my  observation  the  previous  treat- 
ment consisted  solely  of  repeated  curetting,  and  yet 
the  relief  afforded  had  been  only  temporary.  Inci- 
sion of  all  the  lesions  with  a  sharp-pointed  bistoury 
and  complete  evacuation  of  their  contents  constitute 
very  desirable  steps.  When  the  acne  lesion  has  been 
quite  large,  or  a  veritable  abscess  has  formed  (through 
the  coalescence  of  several  lesions),  or  such  an  abscess 
has  reformed  despite  repeated  openings  with  the 
knife,  it  is  advisable  to  swab  out  the  cavity  with 
pure  carbolic  acid  or  with  pure  or  fifty  per  cent, 
ichthyol.  An  ordinary  match  slightly  sharpened 
is  all  that  is  necessary  for  conveying  the  antiseptic 
into  the  cavity.  For  lesions  which  are  indurate, 
indolent,  and  obstinate,  not  containing  pus,  linear 
scarification  has  been  recommended  by  Vidal  and 
electrolysis  by  Brocq.  The  latter  procedure  invar- 
iably, however,  causes  more  or  less  marked  scars. 
For  the  obstinate  lesions,  the  writer  has  obtained 
good  results  from  the  emplastrum  hydrargyri,  or 
from  pure  ichthyol,  or  from  the  unguentum  hydrar- 
gyri nitratis  diluted  one-half  or  more.  The  local 
agents  and  remedies  which  have  been  used  and 
recommended   for  the   treatment  of  acne  are   innu- 


merable and  of  the  urn  I  various  kinds.  Yet  all 
which  will  be  found  beneficial  possess  some  degree 
of  antiseptic  action.  The  application  chosen  should 
vary  according  as  the  process  is  acute  in  character, 
or  partakes  rather  of  the  indolent  and  chronic  type. 
For  the  former,  soothing  applications  should  be 
used,  and  for  the  latter  those  which  are  stimulating 
and  capable  of  causing  a  certain  amount  of  active 
reaction  in  the  tissues.  In  all  cases,  liquid  agents, 
solutions,  etc.,  are  far  preferable,  and  only  occasion- 
ally are  salves  and  greases  advisable.  When  the 
eruption  is  acutely  inflamed,  there  can  be  used  a 
lotion  of  R  Magnesias  carbonatis,  Zinei  oxidi,  aa,  gr. 
xv.;  Acidi  carbolici,  gr.  x.  (or  Acidi  borici,  gr.  xv.j 
or  resorcini,  gr.  v.,  etc.);  Aquae  rosae,  gi.  M.  Cala- 
mine may  be  substituted  for  the  magnesia  in  the 
lotion,  or  aqua  calcis  can  be  used  instead  of  the  rose 
water.  Other  lotions  suitable  for  these  cases  are: 
Liquor  plumbi  subacetatis  diluti,  or  R  Bismuthi  sub- 
nitratis,  3ij.;  Ichthyoli,  gr.  xv.;  Aqua;  rosae,  aqua? 
calcis,  aa  5  ss.  M.  If  the  patient's  skin  is  a  dry  and 
harsh  one  and  a  seborrhea  oleosa  does  not  complicate 
the  acne,  then  an  ointment  can  be  used.  Suitable 
ones  would  be:  R  Acidi  salicylici,  gr.  xv.;  Zinci  oxidi, 
gr.  xl.;  Unguenti  aquae  rosae,  5i.;  or  a  two  per 
cent,  ichthyol  ointment,  or  one  containing  boric 
acid,  three  to  five  per  cent.,  etc.  The  remedy 
chosen  should  be  kept  more  or  less  constantly  on  the 
affected  surface,  in  order  to  obtain  the  best  results, 
and  if  possible  it  should  therefore  be  used  both  day 
and  night. 

The  large  majority  of  acne  cases  being,  however, 
of  the  chronic  type,  a  greater  choice  of  remedies  is 
needed,  and  they  are  also  required  when  the  acute 
stage  of  the  disease  has  subsided  and  the  case  has 
also  become  indolent  in  character  and  course.  Of 
especial  value  are  applications  containing  sulphur. 
It  may  be  used  in  powder  form  mixed  with  starch 
in  the  proportion  of  one  to  four,  or  as  high  as  one  to 
one,  that  is,  equal  parts,  But  it  is  in  lotions  that 
sulphur  is  most  useful,  though  many  recommend  it 
in  the  form  of  a  ten-per-cent.  ointment  or  paste.  R 
Sulphuris  sublimati,  gr.  1.  to  5%;  Crete  pra?parate, 
kaolini,  aa_5  ij-;  Unguenti  aquae  rosae,  §i.  M.  Apply 
freely  at  night  and  remove  with  soap  and  water  next 
morning,  and  then  rub  in  well  a  two-per-cent.  salicylic 
or  other  mild  ointment,  or  apply  a  three-  to  five-per- 
cent, boric-acid  lotion  several  times  through  the  day. 
A  very  strong  resorein  paste  is  also  of  benefit  at  times. 
Its  strength  may  be  from  ten  to  twenty-five  per  cent. 
or  even  more  according  to  the  indolent  nature  of  the 
case.  It  should  be  applied  by  the  physician  and  its 
effects  closely  watched,  as  resorein  has  a  very  power- 
ful reactionary  effect  on  the  skin,  and  will  cause  a 
diffuse  peeling  off  of  the  epidermis.  The  reaction 
produced  may  give  some  very  undesirable  results, 
but  when  the  procedure  is  carried  out  with  care  it  is 
usually  of  great  benefit.  The  number  of  applications 
necessary  will  vary  in  each  case,  and  the  paste  should 
be  discontinued  when  the  epidermis  has  a  seared, 
yellow  look,  and  exfoliation  is  imminent;  a  mild, 
soothing  salve  should  then  be  substituted  for  it.  The 
process  may  be  repeated  a  number  of  times,  but  a 
milder  resorein  paste  should  be  used  after  the  first 
peeling  has  occurred.  This  method,  which  is  rather 
heroic,  necessitating  the  patient's  confinement  to  the 
house,  is  of  great  value,  but  necessarily  of  restricted 
use,  and,  the  same  results  being  obtainable  by  milder 
measures,  it  should  be  reserved  for  obstinate  and 
rebellious  cases.  In  the  severe  forms  of  acne  indurata 
and  acne  pustulosa  Bier's  hyperemic  treatment  may 
be  found  useful.  Suitable  cupping  glasses  may  be 
applied  or  an  elastic  bandage  round  the  neck  may 
be  worn. 

There  are  a  large  number  of  lotions  in  use  for  acne, 
which,  together  with  other  ingredients,  contain  some 
proportion  of  sulphur.  Of  these,  there  may  be  men- 
tioned: R  Sulphuris  sublimati,   5   ij.;  JStheris,  spir- 


85 


Acne 


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itus  vini,  glycerini,  aa  .>  ij.;  Aqua  calcis,  aquas  rosas, 
aa  5  iv.  M.  (Crocker).  R  Sulphuris  lactis,  5  iv.; 
Tineturae  saponis  viridis,  5  x.;  Glycerini,  5  vi.;  Spir- 
itus vini,  3i.  M.  (Elliot).  R  Sulphuris  lactis, 
S  iss.;  Glycerini,  5  i.;  Spiritis  vini  camphorati,  5  x.; 
Aquas  rosae,  q.s.  M.  (Besnier).  These  various 
combinations  owe  their  efficacy  for  the  most  part  to 
the  sulphur  they  contain,  and  may  be  varied  according 
to  the  physician's  wishes.  One  of  the  most  useful 
will  be  found  to  be:  R  Zinci  sulphatis,  potassii  sul- 
phidi,  aa  gr.  xv.;  Sulphuris  lactis,  gr.  xx.;  Aquas 
rosae,  Si.  M.  When  made  with  fresh  drugs  and 
properly  prepared,  this  lotion  is  of  very  great  value. 
It  should  be  applied  at  night  after  the  face  has  been 
thoroughly  washed  with  soap  and  water,  and  allowed 
to  remain  all  night.  If  irritation  is  produced,  cold 
cream  can  be  used  during  the  day.  It  is  wise, 
however,  to  keep  up  the  effect  of  the  treatment  even 
during  the  day,  and  for  this  purpose  a  lotion  of  boric 
acid  can  be  used  or  a  one-  to  three-per-cent.  solution 
of  resorcin  in  water,  but  preferably  in  alcohol  and 
water,  equal  parts.  A  very  beneficial  lotion  is  R 
Acidi  borici,  gr.  xv.;  Resorcini,  gr.  x.;  Acidi  acetici 
ililnti,  5  ij;  Spiritus  vini,  5  vi.  M.  Potassium  sul- 
phide, o  i.,  in  rose  water,  5  iv.,  is  also  recommended. 
The  mercuric  salt  is  often  of  value,  but  it  should 
never  be  used  in  conjunction  with  sulphur  prepara- 
tions, owing  to  the  probable  formation  of  sulphurct 
of  mercury  on  the  surface.  Authors  recommend  P» 
Hydrargyri  bichloridi,  gr.  xv.;  Ammonii  chloridi, 
gr.  xxx.  to  lxx.;  Alcoholi,  5  iv.;  Aquas,  Oi.  M.  The 
formula  of  the  "Oriental  Lotion"  as  given  by  Hebra 
is:  R  Hydrargyri  bichloridi, 3  i.;  Aquae  destillatas, 
5  iv.;  Ovorum  iij  albumen;  Succi  citri  recentis,  oiij-l 
Sacchari,  oi-  M.  Another  formula  recommended 
by  the  writer  is:  R  Hydrargyri  bichloridi,  gr.  iij. 
to  vi.;  Acidi  salicylici,  gr.  xxx.;  Acidi  acetici  diluti, 
5  iss.;  Spiritus  vini,  o  iiss.  M.  When  using  any 
of  these  lotions,  it  should  be  remembered  that  more 
or  less  desquamation  and  peeling  of  the  horny  layer 
takes  place,  and  it  is  advisable  to  warn  patients  of 
the  fact.  When  this  occurs,  it  is  wise  to  discontinue 
the  application  and  to  use  an  indifferent  salve  until 
the  reaction  has  subsided,  and  then  to  begin  anew 
with  the  lotion. 

Ichthyol  as  an  external  agent  is  most  valuable  in 
certain  cases.  It  may  be  used  in  watery  solution — 
five  to  fifty  per  cent. — or  it  may  be  added  to  any  of 
the  foregoing  formulae,  with  the  exception  of  those 
containing  mercuric  chloride.  The  writer  has  found 
it  of  especial  benefit  in  cases  in  which  pustulation  was 
a  marked  feature;  and  in  full  strength  or  in  a  fifty- 
per-cent.  dilution  it  has  very  commonly  served  the 
purpose  of  aborting  a  beginning  lesion.  In  those 
instances  of  acne  in  which  from  time  to  time  one  or 
two  papules  begin  to  develop,  the  ichthyol  applica- 
tion, as  mentioned,  has  been  a  most  valuable  agent 
in  cutting  short  the  career  of  such  fresh  lesions. 

In  the  case  of  patients  in  whom  there  is  no  complica- 
tion of  a  seborrhea  oleosa,  but  who  have  a  natural 
dryness  of  the  integument,  ointments  are  especially 
of  use.  When  indicated,  they  should  be  such  as 
possess  antiseptic  properties,  and  may  contain  various 
remedial  agents.  Among  the  many  recommended, 
the  unguentum  hydrargyri  ammoniati,  five  to  ten  per 
cent.,  may  be  mentioned,  and  also  one  made  with 
the  red  or  yellow  oxide  of  mercury — three  to  ten  per 
cent.  A  ten-per-cent.  sulphur  ointment  may  be  of 
value,  or  the  hypochloride  of  sulphur  may  be  used — 
ten  to  fifteen  per  cent.,  or  the  iodide  of  sulphur — 
three  to  ten  per  cent.  At  times  the  following  for- 
mula will  be  found  a  good  one:  R  Unguenti  hydrar- 
gyri oxidi  rubri,  oij.;  Unguenti  sulphuris  (U.  S.  P.), 
7>  iij.;  Unguenti  aquas  rosae,  q.s.  ad  5i-  M.  In  ordi- 
nary cases  the  writer  would  advise:  R  Acidi  borici, 
gr.  x.;  Resorcini,  gr.  x.;  Acidi  acetici  diluti,  o iij- ; 
Lanolini,  ,~vi.;  Unguenti  aquas  rosae,  oij.  M.  In 
addition  to  these,  there  may  be  mentioned  calomel 


ointment,  three  to  ten  per  cent.,  /3-naphthol  oint- 
ment, five  per  cent.,  or  one  containing  dermatol, 
or  oxychlorate  of  bismuth,  etc.  In  cases  character- 
ized by  indolence,  the  unguentum  hydrargyri  nitratis, 
diluted  (1  to  8,  1  to  4,  or  1  to  2),  is  of  benefit.  Chrys- 
arobin,  pure  carbolic  acid,  tincture  of  iodine,  have 
also  been  used  in  individual  instances  with  benefit. 
That  is,  there  is  a  host  of  external  remedies  or  "cures" 
for  acne  embodied  in  literature,  but  when  dealing 
with  a  case  of  the  disease  it  should  always  be  kept 
in  mind  that  each  case  represents  an  individual,  and 
whatever  line  of  treatment  is  instituted  it  should 
involve  the  use  of  an  antiseptic,  should  be  adapted 
to  the  peculiarities  of  each  individual  patient's  skin, 
and  should  be  adjusted  in  accordance  with  the  inten- 
sity of  the  lesions  existing  in  each  case. 

Vaccine  Therapy. — The  vaccine  therapy  of  acne 
has  received  considerable  attention  of  late  and  nu- 
merous articles  are  to  be  found  in  the  literature  advo- 
cating its  use.  At  first  it  was  thought  necessary  to 
use  the  opsonic  index  as  a  guide  to  the  size  of  the  dose 
and  the  frequency  of  repetition.  Experience,  how- 
ever, has  shown  that  the  opsonic  index  is  unreliable 
and  impracticable  and  that  the  clinical  effect  upon  the 
patient  is  the  best  guide  as  to  the  size  and  frequency 
of  the  dose.  As  a  result  the  use  of  the  opsonic  index 
as  a  guide  in  vaccine  therapy  has  been  almost  uni- 
versally discontinued.  Stoner  in  1911  collected  139 
cases  of  acne  from  the  literature  which  had  been 
treated  by  bacterial  injections.  Practically  all  had 
received  injections  of  Staphylococcus  albus  alone. 
Of  these  139  cases  seventy-nine  were  reported  as 
cured,  forty-eight  as  improved,  nine  as  not  bene- 
fited, seven  had  discontinued  treatment,  and  one  was 
still  under  treatment. 

Gilchrist  considers  that  Staphylococcus  albus  vac- 
cine is  very  helpful  in  cases  of  acne  of  the  superficial 
pustular  type,  that  is,  when  the  Staphylococcus 
albus  as  a  secondary  invader  predominates.  Engman 
considers  that  albus  vaccine  alone  is  of  little  value 
in  the  treatment  of  acne  vulgaris.  He,  in  fact, 
rarely  uses  it  as  he  looks  upon  the  Staphylococcus 
albus  as  a  secondary  factor  of  no  therapeutic  impor- 
tance. Fleming  in  1909  was  the  first  to  present  any 
convincing  demonstration  of  the  use  of  acne  bacillus 
vaccine.  He  treated  three  cases  with  a  mixed  vac- 
cine of  Staphylococcus  albus  and  Bacillus  acnes, 
Fleming  claimed  that  while  the  staphylococci  are 
always  associated  with  the  pustular  lesions  of  acne, 
the  acne  bacillus  is  the  true  etiological  factor  and,  in 
order  to  produce  an  immunity  to  the  disease,  vaccines 
of  both  organisms  must  be  used.  Engman  claims 
that  treatment  with  acne  bacillus  vaccine,  provided 
a  proper  technique  is  adopted,  yields  most  brilliant 
results.  He  considers  that  indifferent  results  are  the 
fault  of  the  technique  and  not  the  fault  of  the  method. 
He  recommends  small  doses  sufficient  to  cause  a 
short  negative  phase.  His  initial  dose  is  three  to 
five  million  and  he  rarely  finds  it  necessary  to  give 
as  high  as  seven  to  ten  million.  The  dose  is  repeated 
at  five-  to  seven-day  intervals  and  the  treatment  is 
supplemented  by  means  to  produce  local  hyperemia, 
thus  bringing  an  increased  quantity  of  immune  serum 
to  the  part.  He  finds  stock  vaccines  very  reliable 
and  can  be  used  in  most  instances.  Gilchrist  recom- 
mends an  initial  dose  of  five  million  of  the  Bacillus 
acnes,  and  increases  gradually  each  week  to  thirty 
million  unless  the  negative  phase  becomes  pronounced., 
which  indicates  that  too  much  vaccine  is  being  given. 
He  uses  the  Bacillus  acnes  vaccine  alone,  unless  the 
secondary  invader  predominates  markedly.  King- 
Smith  found  in  cases  due  to  the  acne  bacillus  that 
treatment  with  Bacillus  acnes  vaccine  alone  was 
rather  disappointing;  in  cases  where  the  acne  bacillus 
and  Staphylococcus  albus  were  both  present  in  large 
numbers  treatment  with  vaccines  made  from  these 
organisms  gave  good  results — at  least  fifty  per  cent, 
showed   marked    improvement;    in   cases    in   which 


86 


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\t  nc  Necrotica 


Staphylococcus  albus  alone  was  found  the  correspond- 
ing vaccine  gave  excellent  results.  Lovejoy  reports 
fifty  cases  treated  with  acne  bacillus  and  a  polyvalent 
staphylococcus  vaccine  with  very  satisfactory  results. 
He  gave  from  three  to  five  million  of  the  acne  bacillus 
at  a  dose  and  from  150  to  2.30  million  of  the  staphy- 
lococcus vaccine.  Stock  vaccines  seemed  to  give  as 
good  results  as  autogenous.  Smiley  treated  100 
eases  of  acne  vulgaris  with  autogenous  mixed  vaccines 
with  such  uniformly  good  results  that  when  one 
can  control  the  patient  a  cure  of  the  condition  can 
be  promised  in  every  case.  The  associated  symptoms, 
such  as  headache,  constipation,  anemia,  mental  and 
phvsical  lassitude,  etc.,  were  greatly  modified  or 
entirely  disappeared  in  those  patients  thus  treated. 
In  consequence  Smiley  believes  with  Gilchrist,  that 
the  acne  bacillus  or  its  toxins  are  responsible  for  the 
associated  symptoms  and  conditions  occurring  in 
acne  infections.  Treatment  with  a  stock  vaccine 
was  not  satisfactory  in  regard  to  clearing  up  the 
sequel*  or  complications. 

It  will  be  seen  from  the  foregoing  that  the  more 
recent  workers  are  unanimous  in  reporting  beneficial 
results  in  the  treatment  of  acne  vulgaris  with  Bacillus 
acnes  vaccine.  They  all  recommend  small  increasing 
•  repeated  at  a  five-  to  seven-day  interval.  The 
initial  dose  is  usually  three  to  five  million  and  only 
Gilchrist  finds  it  necessary  to  increase  beyond  ten 
million  at  a  dose.  He  occasionally  gives  thirty 
million.  Opinions  vary  as  to  the  value  of  staphy- 
lococcus vaccine  in  the  treatment  of  acne  vulgaris. 
Most  reports  show  that  it  is  of  benefit  only  in  the  dis- 
tinctly pustular  cases. 

The  writer  cannot  agree  with  the  opinion  of  Gil- 
christ and  Smiley  that  the  headache,  anemia,  con- 
stipation, etc.,  so  often  associated  with  acne  are  due 
to  the  absorption  of  the  toxins  of  Bacillus  arms 
from  the  local  lesions.  If  these  symptoms  are  treated 
with  appropriate  remedies  as  outlined  when  dis- 
cussing the  internal  treatment  he  thinks  the  possibil- 
ities of  success  will  be  much  greater  than  if  vaccine 
treatment  alone  is  relied  upon. 

X-ray  Treatment. — Many  authorities  claim  that 
the  most  rapidly  effective  local  treatment  for  acne  is 
found  in  the  skilful  use  of  the  z-rays.  Recurrences 
are  said  to  happen  less  often.  Many  cases,  however, 
can  be  managed  just  as  well  without  it  and  it  would 
seem  best  to  reserve  its  use  for  persistent  rebellious 
cases,  especially  of  the  indurated  type.  The  use  of 
such  a  powerful  and  at  times  dangerous  remedy  as 
z-rays  for  such  a  simple  condition  as  acne,  which  can 
usually  be  successfully  treated  by  other  simple  and 
perfectly  safe  methods,  seems  unjustifiable.  More- 
over, when  relapses  occur  they  are  much  more  rebel- 
lious to  x-ray  or  any  other  form  of  treatment.  If 
used  at  all  its  use  should  be  limited  to  acne  indurata 
of  the  back  and  shoulders.  Frequently  one  sees  the 
development  of  an  atrophic  wrinkled  skin  with  tel- 
angiectases even  under  the  most  careful  use  of  the 
x-rays,  and  this  condition  would  of  course  be  of  less 
moment  on  the  back  than  on  the  face.  It  is  not 
necessary  to  produce  a  dermatitis  to  get  good  results. 
In  fact,  it  is  better  if  possible  to  attempt  to  get  the 
curative  effects  without  producing  the  slightest 
erythema  as  in  this  way  the  possibility  of  producing 
future  atrophy  is  much  lessened.  The  exposures 
should  always  be  made  most  carefully.  A  soft  to 
medium  tube  should  be  used  at  ten  to  fifteen  inches 
distance  and  for  three  to  four  minutes  duration  twice 
weekly.  If  improvement  is  shown  it  is  best  to  adhere 
to  such  cautious  technique.        Geoege  T.  Elliot. 

Acne  Necrotica. — Si/nonyms:  Acne  frontalis,  seu 
varioliformis;  acne  pilaris;  acne  rodens;  acne  atro- 
phica; folliculitis  varioliformis,  etc.  Perhaps  no  affec- 
tion has  so  many  different  designations  in  actual  daily 
use.  It  is  very  desirable  that  some  term  acceptable 
to   dermatologists   of   all   countries   be   selected    by 


agreement,  for  our  knowledge  of  this  disease  cannot 
but  be  retarded  by  this  lack  of  consensus.  At 
present  the  tendency  appears  to  be  toward  the  use 
of  the  terms  acne  varioliformis,  and  folliculitis  varioli- 
formis despite  the  fact  that  some  of  the  others  are 
more  logical. 

Definition. — A  chronic,  recurrent,  papulo-pustular 
affection,  having  its  seat  about  the  hair  follicles,  lead- 
ing to  necrosis  of  the  involved  tissues  and  terminating 
in  a  variola-like  scar. 

Symptomatology. — The  site  of  predilection  is  the 
forehead,  at  the  margin  of  the  hair,  and  it  is  this  fact 
which  gave  rise  to  the  name  acne  frontalis.  A  wider 
acquaintance  with  the  affection,  however,  has  shown 
that  it  involves  other  regions.  It  may  extend  to  the 
hairy  scalp,  the  face,  the  neck,  and  the  interscapular 
and  intermammary  regions.  Cases  of  more  or  less 
generalized  eruptions  of  papulo-pustules  terminating 
in  necrosis  and  scar  formation  have  been  described, 
which  present  many  of  the  clinical  features  of  this 
malady. 

The  primary  lesion  is  generally  stated  to  be  a 
papule  which  soon  becomes  encrusted  and  covers  an 
underlying  ulceration.  Sabouraud  describes  the 
elementary  lesion  as  an  umbilicated  vesicle  always 
seated  about  a  hair.  Within  two  or  three  days  it 
attains  its  full  dimensions,  about  three  millimeters 
in  diameter.  Its  central  portion  then  sinks  below 
the  level  of  the  surrounding  integument,  becomes 
harder,  encrusted,  and  gives  to  the  observer  the 
impression  that  it  is  mortised  into  the  skin.  The 
color  of  the  crust,  at  first  a  yellow  or  brownish  yellow, 
darkens  with  age.  The  lesion  may  remain  in  this 
state  for  several  weeks;  exceptionally  two  or  more 
pustules  may  become  confluent. 

On  removing  the  crust  or  after  its  spontaneous 
separation,  a  red,  moist,  or  dry  depression  is  left 
which  eventually  because  white  like  the  variola  scar. 
Superficial  lesions  healing  with  shallow  depressions, 
and  deeper  ones  leading  to  depressed  scars,  are 
generally  encountered  in  every  case  (Unna). 

The  presence  of  lesions  in  various  stages  of  evolu- 
tion, with  pigmented  and  non-pigmented  scars  of 
older  ones,  makes  up  the  peculiar  clinical  picture 
of  the  disease. 

Pathology  and  Morbid  Anatomy. — It  is  now  gen- 
erally conceded  that  acne  necrotica  is  a  perifolliculitis 
probably  of  locally  infectious  origin. 

Sabouraud  insists  that  the  affection  demands  for 
its  development  hair  follicles  previously  infected  with 
his  microbacillus  of  fatty  seborrhea.  It  is  not 
possible  to  have  acne  necrotica,  according  to  this 
writer,  unless  these  infected  follicles  are  invaded  by 
the  yellow  staphylococci  which  are  the  essential 
agents  in  producing  the  disease.  The  infection  takes 
place  at  the  follicular  opening,  and  from  this  point 
invades  the  epidermis  in  a  circular  manner,  giving 
rise,  as  the  process  increases,  to  an  intense  leucoeytosis 
in  the  papillary  and  subpapillary  dermal  regions. 
The  final  stage  is  characterized  by  a  dry  necrosis  of 
all  the  involved  tissues. 

Sabouraud  wTas  unable  to  differentiate  the  yellow 
staphylococcus,  which  he  found  in  all  lesions  of  acne 
necrotica,  from  ordinary  Staphylococcus  aureus  from 
other  sources.  The  distinct  clinical  lesion  to  which 
it  is  supposed  here  to  give  rise  may  be  due  to  the 
previous  damage  to  the  follicle  by  the  microbacillus 
of  seborrhea,  to  its  admixture  with  this  organism, 
to  a  change  in  the  virulency  of  the  staphylococcus, 
or  to  other  causes  which  we  are  at  present  unable  to 
determine. 

Microorganisms  had  been  previously  described  in 
these  lesions  by  Touton,  Unna,  myself,  and  others. 
Touton  was  not  inclined  to  attribute  to  them  any 
pathogenic  importance.  Unna,  however,  considers 
the  affection  due  to  a  mixed  infection  with  a  small 
bacillus  and  his  diplococci  of  seborrhoic  eczema. 

In    lesions    examined    by    myself,    staphylococci 


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Acne  Necrotlca 


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were  found  which  are  probably  identical  with  those 
described  by  Sabouraud. 

In  substance  it  may  be  stated  that  acne  variolifor- 
mis (Hebra)  is  an  inflammation  of  the  pilo-sebaceous 
system,  probably  microbic  in  origin,  leading  to 
destruction  of  these  organs  and  the  surrounding 
derma,  and  that  Bazin  was  correct  in  naming  the 
disease  acne  pilaris. 

Etiology. — Acne  necrotica  is  essentially  a  disease 
of  adult  life.  It  is  rarely  seen  before  the  age  of  thirty, 
and  may  develop  late  in  life.  Men  are  more  frequently 
affected  than  women. 

Some  of  the  older  dermatological  writers  attributed 
it  to  syphilis.  Although  sometimes  mistaken  for  a 
grouped  papulo-pustular  syphilide  on  the  forehead  or 
at  the  sites  of  acne  necrotica,  it  does  not  owe  its 
existence  to  that  infection. 

Its  more  frequent  occurrence  among  those  in  the 
lowTer  walks  of  life,  and  its  location  in  the  majority  of 
instances  on  the  forehead,  exposed  to  the  pressure  of 
unclean  hat  bands,  lend  weight  to  the  theory  of  local 
infection.  A  pre-existing  fatty  seborrhea  is,  according 
to  Sabouraud,  an  absolutely  essential  condition  for 
the  development  of  an  acne  necrotica  by  affording  a 
locus  minoris  resistentitc,  and  determining  the  clinical 
features  of  the  eruption. 

Diagnosis. — The  absence  of  comedones  and  the 
sites  affected,  together  with  the  depressed  encrusted 
lesions,  intermingled  with  white  and  pigmented  scars, 
easily  enables  one  to  differentiate  this  variety  of 
folliculitis  from  acne  vulgaris.  Its  differential 
diagnosis  from  a  papulo-pustular  or  a  grouped  pustulo- 
tubercular  syphilide  is  more  difficult.  The  history 
of  frequent  recurrences  extending  over  months  or 
years,  which  patients  with  acne  necrotica  give  us, 
together  with  the  absence  of  concomitant  manifesta- 
tions of  syphilis,  should  enable  one  to  separate  the 
two  diseases.  Syphilis  again  shows  no  predilection 
for  the  hairy  parts  of  the  face  which  the  former  affec- 
tion does  in  a  striking  manner. 

Other  varieties  of  pustular  affections  of  the  follicles 
do  not  give  rise  to  the  peculiar  and  rapid  tissue 
necrosis  with  its  resulting  variola-like  scar.  It  is 
questionable  whether  the  generalized  eruption  of 
papulo-pustules  resulting  in  scar  formation  like  that 
of  acne  necrotica  of  the  face  should  be  included 
with  this  disease  in  a  single  group. 

This  disseminated  eruption,  to  which  various  names 
have  been  given,  as  hydradenitis  suppurativa,  acnitis, 
necrotizing  granuloma,  etc.,  frequently  begins  as  a 
deep-seated  papule  about  the  coil  glands  or  in  the  con- 
nective tissue  of  the  derma  independently  of  the  gland- 
ular structures.  While  the  two  diseases  present  many 
similar  clinical  features,  it  is  quite  probable  that  they 
depend  on  different  infectious  agents.  Boeck  claims  for 
the  generalized  eruption  a  close  relationship  with  lupus 
erythematosus,  and  believes  that  both  affections  are 
due  to  the  toxic  products  of  the  tubercle  bacillus  ab- 
sorbed from  a  focus  in  some  part  of  the  body. 

Prognosis. — It  is  not  difficult  to  cure  a  single 
attack  of  the  eruption,  but  recurrences  are  the  rule. 
and  we  have  no  certain  means  of  preventing  them  or 
of  limiting  their  frequency. 

Treatment. — The  various  internal  remedies  recom- 
mended by  dermatological  writers  have  probably  no 
value  in  curing  the  attacks  or  preventing  relapses. 

The  lesions  are  quite  readily  healed  by  ointments 
containing  sulphur,  resorcin,  /3  naphthol,  salicylic  acid, 
ammoniated  mercury,  or  calomel.  These  drugs  may 
be  used  in  the  strength  of  two  to  five  per  cent,  or 
stronger. 

Careful  attention  should  be  paid  to  the  h}'giene  of  the 
scalp  and  to  personal  cleanliness,  as  the  agent  pro- 
ducing the  infection  is  probably  widely  scattered. 

The  scalp  should  be  frequently  washed  with  the 
ordinary  tincture  of  green  soap,  followed  by  lotions 
containing  bichloride  of  mercury,  1:1,000,  to  insure 
its   disinfection.     Resorcin   lotions   (two   to   ten   per 

88 


cent,  in  alcohol  and  water,  equal  parts),  with  the 
occasional  use  of  sulphur  or  salicylic-acid  ointment, 
may  be  used  alternately  with  the  bichloride  lotion. 
It  is  only  by  the  persistent  use  of  local  antiseptic 
applications,  not  only  to  the  eruption  itself,  but  to  the 
surrounding  skin,  that  we  may  hope  to  prevent  or 
delay  relapses.  J.  A.  Fordyce. 

Literature. 

Pick:  Archiv  f.  Dermat.  u.  Syph.,  p.  551,  1SS9. 

Touton:  Verhand.  der  Deutsch.  dermatol.  Gesellschaft.  Zweiter 
u.  Drifter  Congress,  p.  2S7,  1S92. 

Unna:  Histopathology  of  Skin  Diseases;  English  translation,  p. 
366. 

Fordyce:  Journal  of  Cutaneous  and  Genito-Urinary  Diseases,  voL 
xii.,  p.  152.  1S94. 

Sabouraud:  Ann.  de  derinat.  et  de  syph.,  tome  x.,  p.  841,  1899. 

Acne  Rosacea. — Synonyms:  Acne  erythematosa, 
gutta   rosacea;  acn6   rosee;  Couperose;    Kupfernase. 

Definition. — Acne  rosacea  represents  not  one 
disease,  but  a  rosacea  with  a  superimposed  acne. 
Rosacea  is  a  congestive  disturbance  affecting  the  nose 
and  portions  of  the  face,  transitory  at  first,  but  after- 
ward becoming  permanent,  and  represented  by  red- 
ness, dilatation  of  the  cutaneous  blood-vessels,  the 
formation  of  a  telangiectasis,  and  in  some  instances 
by  more  or  less  hypertrophy  of  the  connective  tissue 


Fig. 


20. —  Acne  Rosacea.       Showing  Dilated   Blood-vessels. 
(Author's  drawing.) 


and  the  glandular  elements  of  the  skin.  The  acne 
lesions  developing  in  the  course  of  the  process  are 
secondary  products,  and  are  expressions  of  an  inflam- 
matory process  affecting  the  sebaceous  glands. 

Symptomatology. — Rosacea  attacks  especially  the 
nose  and  the  neighboring  portions  of  the  cheeks,  though 
it  may  extend  laterally  to  the  malar  prominences,  or 
even  implicate  the  forehead  and  the  chin,  and  in 
some  eases  the  entire  face,  with  the  exception  of  the 
orbital  spaces.  The  symptoms  characterizing  the 
process  vary  in  degree  and  in  intensity  according 
to  the  stage  and  the  grade  of  the  affection.  In  the 
earlier  stages,  there  is  only  more  or  less  marked 
hyperemia  or  congestion  of  the  nose  and  cheeks, 
occurring  after  eating  or  drinking,  or  after  exposure 
to  cold,  or  at  the  time  of  menstruation.  The  symp- 
toms are  usually  transitory,  and,  remaining  in  exis- 
tence for  a  short  space  of  time,  disappear  without 
leaving  a  trace.  The  patients  generally  complain 
that  there  is  at  the  time  a  sensation  of  heat  or  of 


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Acne  Rosacea 


burning,  but  yet  the  skin  itself  is  cold  to  the  touch. 

This  recurrent  congestion  may  take  place  for  a  variable 
length  of  time,  alternating  with  a  return  to  normal 
conditions;  but  sooner  or  later  the  hyperemia  occurs 
more  often  and  apparently  without  cause  or  induce- 
ment, and  gradually  the  redness  becomes  a  stable 
and  permanent  fact,  varying  only  in  degree  from 
time  to  time.  The  congestive  disturbance,  when 
permanent,  is  diffuse  and  sluggish  in  character,  with- 
out definite  outlines,  and  the  redness  returns  only 
slowly  after  pressure.  At  times,  however,  it  may  be 
active  and  may  simulate  an  erysipelas  or  acute  der- 
matitis. When  exposed  to  the  cold,  the  affected 
surfaces  are  liable  to  become  bluish  and  cyanotic  in 
appearance. 

The  stage  of  permanent  congestion  may  persist 
for  a  variable  length  of  time  without  any  further 
change  occurring  in  the  skin.  But  sooner  or  later 
there  develops  upon  the  nose  and  other  surfaces  a 
condition  of  telangiectasia,  represented  by  fine, 
tortuous,  dilated  blood-vessels.  These  vary  in  size, 
being  usually  more  prominent  and  larger  on  the  alae 
nasi,  and  they  sometimes  present  in  their  course  dis- 
tinct varicosities.  The  telangiectatic  condition  may  be 
slight  or  severe,  and  in  some  cases  attains  such  a 
height  that  the  entire  nose  and  cheeks  are  covered 
with  distinctly  evident  tortuous  vascular  dilata- 
tions, varying  in  color  from  bright  red  to  purplish 
red,  according  to  the  temperature  and  the  somatic 
condition  of  the  affected  individual. 

The  process,  as  a  rule,  does  not  progress  beyond  this 
stage,  but  occasionally  and  after  long  existence,  a 
fibriod  degeneration  of  the  surface  attacked  takes 
place.  It  is  the  nose,  however,  which,  as  a  rule,  is  the 
seat  of  this  change,  the  other  portions  of  the  face  being 
affected  only  to  a  slight  degree  and  moderately  thick- 
ened. The  nose  under  these  conditions  becomes  hyper- 
trophied  as  a  whole,  and  on  portions  of  its  superficies 
there  may  in  addition  arise  lobulated  or  peduncu- 
lated, firm  growths  of  various  sizes,  which  sometimes 
attain  enormous  development  (rhinophyma). 

In  all  of  the  stages  of  rosacea  a  seborrhea  oleosa 
generally  coexists.  The  affected  surface  is  greasy, 
the  orifices  of  the  sebaceous  glands  are  dilated,  and 
minute  drops  of  oil  can  be  seen  exuding  from  them 
after  the  flushing  has  subsided,  and  even  independ- 
ently of  the  hyperemia.  When  the  congestion  has 
become  permanent,  these  orifices  may  be  so  exces- 
sively dilated  that  the  skin  has  a  sieve-like  appearance, 
but  it  is  in  the  hypertrophic  form  of  rosacea  that  the 
greatest  degree  of  dilatation  is  found.  In  other 
eases,  the  affected  surface  is  scaly  and  dry  or  covered 
with  small,  thin,  yellowish  scales,  or  with  larger 
greasy,  soft  crusts.  The  patients  complain  of  itching 
and  burning,  and  these  symptoms  are  invariably 
associated  with  a  yellow,  scaly  discoloration  of  the 
interpalpebral  space  and  with  a  certain  grade  of  what 
is  generally  called  pityriasis,  or  seborrhea  sicca  capi- 
tis. The  clinical  picture  presented  by  these  cases 
is  quite  distinct  from  that  of  the  others  described  and 
represents  a  complication  of  rosacea  and  dermatitis 
seborrhoica.  In  fact,  the  presence  of  the  latter 
process  alone  may  and  frequently  does  lead  to  the 
same  congestive  and  hyperemic  objective  appearances 
as  originate  from  other  and  different  internal  causes. 

A  further  and  very  common  complication  of  a 
rosacea  is  acne,  which,  in  the  majority  of  cases,  sooner 
or  later  arises  on  the  congested  surface.  It  is  when 
the  two  processes  are  combined  that  an  acne  rosa- 
cea may  be  said  to  exist.  The  lesions  may  be  either 
of  the  superficial  (simplex)  variety  or  of  the  deeper 
(indurata),  or  both  may  be  present.  They  will  be 
found  on  the  nose  and  cheeks,  singly  or  very  numerous, 
and  occurring  in  numbers  on  the  nose,  in  which 
organ  they  frequently  cause  considerable  defor- 
mity and  also  very  marked  pain.  In  themselves, 
the  lesions  differ  in  no  wise  from  those  others  which 
occur  independently  of  rosacea. 


The  course  of  the  process  is  always  a  slow  one.  and, 
having  developed,  it  persists  in  varying  degree  for  an 
indefinite  period  of  time,  or  until  its  inducing  cause  or 
causes  have  been  removed  by  appropriate  cure  or 
treatment.  Slight  subsidences  of  the  congestive 
disturbance  and  of  the  acne  lesions  are  generally 
seen  to  alternate  with  exacerbations. 

Pathology  and  Morbid  Anatomy. — Rosacea  is 
primarily  a  vasomotor  neurosis,  resulting  in  retarda- 
tion of  the  circulation  in  the  superficial  capillary 
plexus.  Although  at  first  transitory,  this  paretic 
condition  of  the  blood-vessels  becomes,  through  fre- 
quent repetition,  somewhat  fixed.  In  consequence 
the  congestive  redness  becomes  permanently  estab- 
lished, and  the  telangiectases  and  varicosities  gradu- 
ally become  evident.  The  implication  of  the  blood- 
vessels is  not  limited  to  the  superficial  ones,  but  may 
extend  to  the  deeper  plexus,  and  so  all  the  vessels 
throughout  the  skin  may  be  affected.  In  conse- 
quence of  the  congestion,  the  sebaceous  glands  are 
influenced  and  the  seborrhea  oleosa  arises.  The 
acne  lesions  owe  their  origin  to  the  resulting  debased 
nutrition  of  the  skin.  In  some  cases  new  connective 
tissue  forms  about  the  blood-vessels  and  the  folli- 
cles, thus  producing  a  thickening  of  the  corium  and 
causing  ultimately  either  the  hypertrophic  form  of  the 
disease,  or,  in  very  severe  cases,  rhinophyma.  On  the 
other  hand,  one  form  of  the  hypertrophic  stage  is 
attributed  to  an  increase  in  size  of  the  sebaceous 
follicles. 

The  histological  anatomy  of  the  first  stage  of  rosa- 
cea has  been  found  by  the  writer  to  be  represented  by 
a  dilatation  of  the  blood-vessels  in  the  upper  portion 
of  the  cutis  and  by  a  few  collections  of  round  cells 
about  them.  In  the  second  stage,  there  was  an 
increase  in  degree  in  these  features,  many  dilated 
vessels  having  thin  walls,  and  large  lumina  being 
found  widely  distributed  throughout  the  corium, 
which  was  also  slightly  thickened  and  edematous. 
In  the  third  stage  (rhinophyma),  marked  hyper- 
plasia of  the  connective-tissue  elements  of  the  skin 
had  taken  place,  and  the  sebaceous  glands  were  also 
somewhat  enlarged.  The  blood-vessels  were  large 
and  tortuous  and  their  coats  were  thickened.  Sub- 
stantially the  same  changes  have  been  found  by  others, 
but  Unna  also  ascribes  the  formation  of  the  growths 
in  some  cases  to  an  enlargement  and  multiplication 
of  the  sebaceous  glands,  which  thus  constitute  the 
major  part  of  the  rhinophymatous  change.  In  other 
cases  he  states  that  the  connective-tissue  hypertrophy 
predominates,  though  the  glandular  change  may 
also  be  a  prominent  feature.  The  investigations  of 
Hans  Hebra  led  to  practically  the  same  conclusions. 
The  histopathology  of  the  acne  lesions  occurring  in 
connection  with  rosacea  does  not  differ  from  that 
of  the  same  efflorescences  wdiich  arise  independently. 

Etiology". — Rosacea  develops  more  frequently  in 
women  than  in  men,  and  while  occurring  especially 
after  the  age  of  thirty  and  in  older  people,  yet  it  also  is 
not  infrequently  seen  in  younger  persons.  It  arises 
in  women  very  commonly  in  association  with  pu- 
berty, with  menstrual  and  utero-ovarian  irritation,  and 
especially  at  the  menopause.  It  also  is  liable  to 
appear  during  pregnancy,  in  sterile  women,  and  very 
frequently  among  those  others  who  come  in  the  cate- 
gory of  old  maids.  In  both  sexes,  disorders  of  the 
gastrointestinal  canal  are  potent  factors  in  the  pro- 
duction of  the  congestive  disturbance,  and  in  indi- 
vidual cases  there  will  therefore  be  found  such  dis- 
turbances as  constipation,  gastric  or  intestinal  indiges- 
tion, fermentative  processes,  etc.  Anemia  is  often 
the  basis  of  the  cutaneous  disease,  and  so  also  is 
plethora.  The  gouty  and  rheumatic  diatheses  are 
prone  to  favor  the  development  of  the  disease  both 
directly  and  through  those  functional  and  other  dis- 
turbances which  are  so  liable  to  occur  in  those  who 
are  subjects  of  these  constitutional  conditions.  Sed- 
entary habits  strongly  predispose  to  the  process,  and 


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Acne  Rosacea 


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hence  rosacea  and  its  accompanying  feature,  acne, 
very  commonly  affect  seamstresses,  sewing  girls,  and 
others  obliged  by  their  occupation  to  forego  outdoor  or 
physical  exercise.  In  connection,  however,  with  their 
confining  occupations,  it  should  also  be  mentioned  that 
these  same  individuals  are  usually  subjects  of  func- 
tional bodily  disturbances,  due  to  their  diet  and  poor 
hygiene.  The  morphine  habit  has  been  claimed  to 
produce  the  disease,  and  it  has  also  been  attributed 
to  various  intranasal  processes,  such  as  atrophic  and 
hypertrophic  rhinitis,  chronic  catarrhal  inflammations 
of  various  degrees,  and  sycosis  of  the  vibrissa.  Seb- 
orrheic dermatitis  is  claimed  by  Unna  to  be  a  most 
important  cause  of  rosacea  in  women.  It  would  be 
more  correct,  however,  to  regard  its  effects  when 
located  on  the  nose  as  in  the  line  of  producing  a  red- 
ness similar  to  rosacea,  through  the  inflammatory 
congestion  incident  to  its  presence,  than  to  claim 
that  it  causes  that  latter  disease  itself.  Exposure  to 
cold  and  bad  weather  is  an  external  factor  in  the 
etiology  of  the  process.  The  writer  has  seen  sun- 
burn determine  its  existence,  and  in  a  number  of 
cases  a  slight  chilblain  condition  of  the  nose  led  to 
objective  symptoms  simulating  accurately  a  mild 
rosacea.  Face  steaming,  use  of  very  hot  water,  con- 
tinual exposure  to  the  heat  of  a  fire — all  enter  into 
this  category.  The  effect  of  diet  and  abuse  of  spir- 
ituous liquors  is  generally  very  well  known.  The 
articles  of  diet  which  are  injurious  are  practically 
the  same  as  have  been  mentioned  for  acne,  and  their 
effects  are  not  so  much  in  themselves,  as  in  the  gastro- 
intestinal and  other  disturbances  which  they  may 
bring  about.  When  used  in  excess,  all  liquors  may 
lead  to  the  development  of  a  rosacea,  but  the  most 
pernicious  are  fermented  drinks,  such  as  ale,  beer, 
porter,  and  also  sweet  wines  and  liquors,  port,  etc. 
Tea,  when  improperly  used,  may  have  a  similar 
influence,  owing  to  the  injurious  effect  of  the  tannin 
on  the  gastrointestinal  canal.  The  influence  of  smok- 
ing in  itself  is  certainly  remote,  though  it  possibly 
may  indirectly  operate  through  the  production  of  a 
catarrhal  or  other  intranasal  irritation.  In  many 
cases,  however,  no  definite  etiological  cause  can  be 
discovered. 

Diagnosis. — The  diagnosis  of  rosacea  will  be 
obtained  from  the  history  of  its  development,  as  well 
as  from  the  clinical  symptoms  presented  by  it.  As 
the  disease  occupies,  as  a  rule,  the  nose  and  neighbor- 
ing portions  of  the  cheeks,  it  will  be  found  that  the 
persistent  redness  was  preceded  by  intermittent 
flushing,  and  was  followed  by  superficial  capillary 
dilatation  and  the  formation  of  telangiectases  and 
varicosites.  Lupus  erythematosus,  which  commonly 
occupies  the  same  surfaces,  may  be  differen- 
tiated from  a  rosacea  by  the  distinct  delimitation 
of  the  patches  constituting  it.  The  outlines, 
though  irregular,  are  sharply  defined,  the  edges  are 
usually  elevated  and  enclose  a  scaly  area.  The 
patches  tend  to  enlarge  by  peripheral  extension,  and 
as  a  rule  atrophic  changes  occur  over  the  affected 
area. 

Erythematous  eczema  should  also  be  differentiated 
from  rosacea.  It  occurrence  is  not  limited,  however,  to 
the  same  localities,  but  it  appears  anywhere  on  the 
face,  or  neck,  or- other  surface.  It  appears  bruskly 
as  an  acute  process,  which  in  time  may  become 
chronic  in  character.  The  affected  portions  are  some- 
what swollen  from  serous  exudation;  they  are  scaly 
and  rough  to  the  touch,  or  have  a  glazed,  varnished 
appearance,  and  there  is  much  burning  and  itching. 
When  syphilis  exists  on  the  nose,  either  in  the  form 
of  the  papulo-pustular  grouped  syphilide  or  when 
there  are  cutaneous  gummata,  errors  in  diagnosis 
are  not  only  possible,  but  are  not  infrequent.  If 
attention,  however,  is  paid  to  the  history  of  the 
development  of  the  redness  and  of  the  lesions  dis- 
cretely  located  or  aggregated  together  in  groups  upon 
it;  if  it  is  noted  that  beneath  the  crusts  distinct  ulcer- 


ation with  subsequent  scarring  occurs,  and  that  there 
is  a  tendency  as  regards  the  gummatous  lesions  to 
serpiginous  extension  with  consecutive  cicatrization, 
then  the  diagnostic  difficulty  should  give  no  trouble. 

The  term  erysipelas  is  used  very  loosely  both  by 
medical  men  and  by  patients,  and  it  is  a  most  common 
fact  to  hear  the  latter  complain  of  an  erysipelas, 
which  in  reality  is  a  rosacea  of  several  months'  or 
years'  standing.  They  often  state  that  their  diagnosis 
was  that  made  by  their  physician.  It  should,  how- 
ever, be  remembered  that,  though  erysipelas  does 
frequently  affect  the  nose  primarily,  yet  it  is  an  acute 
process,,  begins  with  slight  or  marked  chills,  and  is 
accompanied  by  elevation  of  temperature  and  such 
other  somatic  disturbances  as  are  never  associated 
with  a  rosacea. 

Prognosis. — The  prognosis  of  this  cutaneous 
affection  will  depend  to  a  great  extent  upon  the  possi- 
bility of  removing  its  inducing  cause  or  causes  in  any 
given  case  and  upon  the  ability  to  prevent  their 
recurrence.  An  entire  and  absolute  cure  is  obtain- 
able and  can  be  effected,  or  if  not  this  much,  at  any 
rate  a  most  decided  amelioration  of  the  symptoms. 

Treatment. — In  the  treatment  of  rosacea  or  acne 
rosacea,  very  much  the  same  procedures  are  called 
for  as  have  been  detailed  for  acne  simplex  and 
acne  indurata.  The  cases  require  both  internal  and 
external  care,  the  former  being  such  as  will  remove  or 
modify  that  defect  in  functional  or  physical  health 
which  may  be  found  in  the  case  under  consideration  at 
the  time,  and  the  latter  being  such  as  will  bring  back 
tone  and  vasomotor  control  to  the  paretic  blood-ves- 
sels, or  will  destroy  them,  or,  in  the  severest  grades  of 
the  disease,  will  remove  the  disfiguring  growths  which 
have  arisen.  In  general  it  may  be  said  that  all  inter- 
nal medication  should  be  such  as  will  correct  the  exist- 
ing constipation  or  gastrointestinal  disturbance 
present  in  the  case.  If  uterine  or  ovarian  irritation 
exists,  it  should  be  attended  to;  and  also  gout,  rheuma- 
tism, and  lithemic  conditions  should  receive  proper 
attention.  Anemia  or  plethora,  the  tuberculous 
diathesis,  and  every  other  factor  should  be  properly 
estimated  and  seen  to,  and  all  matters  pertaining  to 
errors  of  diet  should  be  diligently  investigated.  As  a 
rule,  cheese,  oatmeal,  sweets,  pastries,  nuts,  ferment- 
able articles,  and  such  as  are  highly  seasoned,  stimu- 
lating, and  liable  to  tax  the  digestive  powers,  should 
be  forbidden.  Beer  and  alcohol  and  all  sweet  bever- 
ages should  be  stopped,  though  a  light  claret  with 
water  or  a  dry  Moselle  wine  may  be  allowed  at  meals. 
Coffee  without  milk  is  perfectly  allowable,  but  tea 
should  be  cut  off,  unless  it  is  very  weak  and  freshly 
made.  With  these  exceptions,  the  diet  should  be  of  a 
simple,  easily  digested,  and  nutritious  character. 
The  needs  and  digestive  capabilities  of  each  patient 
should  be  studied,  and  the  food  taken  should  be  such 
as  is  found  appropriate. 

So  far  as  drugs  are  concerned,  it  may  be  stated  that 
in  many  of  the  cases  in  which  the  process  is  in  its 
inception,  in  which  the  redness  has  not  become 
persistent,  but  is  represented  by  periods  of  flushing 
and  of  retrogression,  the  mineral  acids  are  particularly 
useful.  Especially  is  this  the  case  with  the  dilute 
nitric,  muriatic,  or  nitromuriatic  acid.  Another 
class,  however,  may  require  alkaline  remedies  and 
diuretics,  the  citrate  and  acetate  of  potassium,  or  some 
of  the  more  recent  ones,  uricedin,  urotropin,  aspirin, 
etc.,  or  it  may  be  saline  purgatives  that  are  called 
for.  By  means  of  these  it  is  possible,  in  the  early 
cases,  to  divert  the  blood  current  from  the  face  to 
some  other  part  of  the  body.  When  the  congestive 
disturbance  of  the  nose  and  face  has  become  a  stable 
fact,  then  a  very  useful  remedy  is  ichthyol.  Begin- 
ing  with  doses  of  gr.  v.,  it  should  be  increased  until  gr. 
xv.  are  taken  t.i.d.  It  may  be  given  in  pill  or  capsule 
form,  or  simply  diluted  with  water  or  coffee.  Toler- 
ance to  its  peculiar  taste  is  quickly  established,  and 
only  rarely  have  I  found  the  remedy  to  be  objection- 


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Aconite 


able  or  distressing  to  the  patient.  Resides  these 
particular  remedies — and  they  should  be  given  in 
conjunction  with  those  others  demanded  by  the 
necessities  of  the  individual  case — ergot  and  ergotin 
have  been  recommended,  as  well  as  belladonna, 
digitalis,  quinine,  codliver  oil,  etc.  But  all  of  these  are 
intended  to  meet  indications  furnished  by  certain 
cases,  and  should  not  be  regarded  as  of  general  or 
extended  value.  Arsenic  may  be  said  to  be  al\v:i\  - 
injurious  in  rosacea.  The  local  treatment  is  of  the 
utmost  importance,  and  some,  if  not  many,  instances 
of  the  disease  may  be  relieved  by  it  alone.  In  acute 
cases,  characterized  by  active  hyperemia  and  burning, 
soothing  applications  are  to  be  used.  The  magnesium 
carbonate  and  zinc  oxide,  or  the  calamine  and  zinc 
lotin  referred  to  in  the  article  on  Acne,  is  indicated; 
or  a  lotion  of  R  Bismuthi  subnitratis,  gr.  xxx.; 
Bismuthi  oxychloratis,  gr.  xl. ;  Magnesia?  carbonatis, 
gr.  xx. ;  Aqua;  rosa;,  5  i.,  or  the  Liquor  soda;,  chlorinata;, 
diluted  1  :20,  or  less,  or  more,  may  be  applied.  A 
very  thin  boiled  starch  poultice  is  frequently  of  great 
value,  as  is  also  the  official  liquor  calcis. 

The  majority  of  the  cases  of  rosacea  coming 
under  treatment  are,  however,  of  the  chronic  type, 
have  passed  beyond  the  primary  stage,  and  require  a 
very  different  order  of  local  treatment — one  which  is 
stimulating  in  its  effects  and  which  is  intended  to 
improve  the  vasomotor  tone  of  the  paretic  vessels. 
For  this  purpose,  stronger  applications  than  are  needed 
in  acne  in  general  are  called  for,  and  a  stiff  paste  is 
often  useful — R  Resorcin,  gr.  1.  to  cl.;  Kaolin,  zinci 
oxidi,  aa  5  ij.;  Unguent,  aqua?  rosa;,  g  i.  M.  In  place 
of  the  resorcin,  ichthyol  may  be  substituted  in  the 
strength  of  ten  to  fifty  per  cent.,  or  the  ichthyol 
may  be  used  pure.  The  pastes  are  applied  every 
night  until  a  decided  reaction  has  been  produced 
and  the  horny  layer  has  a  glazed  appearance  and  is 
beginning  to  exfoliate.  The  paste  used  should  then 
be  replaced  by  a  mild,  soothing  ointment,  R  Acidi 
salicylici,  gr.  x.;  Zinci  oxidi.  '.)  ij.;  Unguent,  aqua; 
rosa;,  o  i-J  or  an>r  other  similar  salve.  When  the 
exfoliation  has  ceased,  the  surface  will  be  found 
much  improved  in  all  probability,  and  the  same  paste, 
or  a  weaker  one,  may  again  be  applied  and  the  same 
course  followed.  This  procedure  may  be  kept  up 
until  all  the  redness  has  disappeared,  or  toward  the  end 
the  lotion  given  under  Acne — R  Zinci  sulphatis, 
Potassii  sulphidi,  aa.  5  ss.;  Sulphuris  lactis,  5  i-,' 
Aqua;  rosa;,  o  i- — may  be  applied.  To  obtain  the 
same  result,  caustic  potash  solutions  (two  to  ten  per 
cent.)  have  been  recommended,  or  vigorous  washing 
with  green  soap.  Likewise  Vleminckx's  solution  in 
full  strength  or  diluted  one-half,  or  even  weaker,  is  at 
times  ot  benefit.  Chrysarobin  has  been  advised  and 
used,  but  the  danger  of  conjunctivitis  from  its  appli- 
cation on  the  face  renders  it  of  doubtful  service. 
When  seborrhoic  dermatitis  is  the  cause  of  the  rosacea, 
resorcin  and  sulphur  are  particularly  called  for. 
They  may  be  used  either  in  ointment  form  or  in 
water,  or  in  alcohol  and  water,  equal  parts. 

The  acne  lesions  which  may  be  coincident  with  the 
rosacea  do  not  require  any  special  treatment,  but  the 
telangiectasia  and  dilated  blood-vessels  remaining 
after  subsidence  of  the  congestive  disturbance  have 
to  be  dealt  with.  They  may  be  destroyed  by  multiple 
scarification,  care  being  taken  to  split  the  vessel 
longitudinally  with  a  fine-pointed  knife  and  then  to 
make  transverse  incisions.  It  has  been  recommended 
to  touch  the  open  vessel  along  its  length  with  nitrate 
of  silver,  but  that  usually  leaves  a  scar  as  a  result. 
Iodine  and  pure  carbolic  acid  have  also  been  advised, 
but  when  the  scarification  has  been  properly  done, 
none  of  these  measures  is  necessary.  Excellent 
results  are  obtained  from  electrolysis,  and  also  from 
the  use  of  the  thermocautery.  As  regards  the  former, 
the  needle  used  for  electrolytic  destruction  of  super- 
fluous hair  is  all  that  is  necessary.  The  needle  at- 
tached  to   the   negative   pole  of  a  galvanic  battery 


should  penetrate  the  vessel  before  the  circuit  is  closed 
— that  is,  before  the  electric  current  is  turned  on.  The 
positive  pole — sponge  moistened  with  water  or  salt 
solution — is  grasped  by  the  patient  after  the  needle 
has  been  introduced  into  the  vessel.  The  procedure 
IS  very  painful  and  requires  much  time,  and  scarring 
is  very  liable  to  result.  The  thermocautery  acts 
on  the  same  principle,  but  it  is  neither  as  painful 
nor  as  liable  to  cause  scars.  A  needle  point  should 
be  used,  such  as  is  furnished  with  the  Mikrobrenner 
introduced  into  practice  by  Unna  of  Hamburg. 
Much  the  same  result  may,  however,  be  obtained  if 
an  ordinary  sewing  needle  grasped  by  a  needle  holder 
be  heated  in  an  alcohol  flame  and  made  use  of  to 
puncture  the  dilated  blood-vessels  in  their  course. 
The  method  is  simple,  and  I  have  found  it  absolutely 
as  efficacious  as  the  more  showy  and  impressive 
ones  previously  mentioned. 

When  the  case  is  one  of  hypertrophic  rosacea,  in 
which  the  development  of  connective-tissue  growths 
in  greater  or  lesser  degree  has  occurred,  surgical 
interference  is  called  for.  Ablation  of  the  excrescences 
is  necessary  and  may  be  done  with  the  knife  or  the 
galvanocautery.  Electrolysis  has  been  recommended, 
but  is  of  uncertain  value,  if  not  entirely  without 
result. 

For  a  discussion  of  the  value  of  vaccine  and  i-ray 
treatment  the  reader  is  referred  to  the  article  on  acne 
where  these  questions  are  taken  up  fully.  In  acne, 
rosacea  Staphylococcus  albus  vaccine  is  more  generally 
called  for,  as  the  lesions  are  more  usually  of  the 
pustular  type.  George  T.  Elliot. 

Acoin. — A  synthetic  hydrochloride  of  dipara- 
anisylmonophenethyl-guanidine,  introduced  by 
Trolldenier,  in  ls.99,  as  a  safe  and  efficient  local 
anesthetic  substitute  for  cocaine.  It  occurs  as  a 
white  crystalline  powder,  soluble  in  about  fifteen 
parts  of  water.  Instilled  into  the  conjunctiva  it 
produces  anesthesia  without  increasing  intraocular 
pressure  or  exerting  any  cycloplegic  effect,  but  is 
somewhat  irritating  and  is  therefore  not  recommended 
when  inflammation  is  present.  It  is  said  to  be  free 
from  the  systemic  effects  of  cocaine.  It  is  also  used 
in  one  per  cent,  solution  for  subconjunctival  injection, 
in  which  use  it  is  less  painful  than  cocaine.  It  is 
recommended  in  1-1000  solution  in  physiological 
salt  solution  for  the  production  of  infiltration  anes- 
thesia by  the  Schleich  method.  In  one-per-cent. 
solution  it  has  been  employed  as  a  local  anesthetic 
in  dentistry. 

Aconite,  Aconittjm.  —  (Monkshood,  Wolfsbane.) 
"The  dried  tuberous  root  of  Aeon  Hum  Napellus  L. 
(fam.  Ranunculacece)  collected  in  autumn;  yielding, 
when  assayed  by  the  process  given  below,  not  less 
than  0.5  per  cent,  of  aconitine."  (IT.  S.  P.)  This 
definition  will  probably  be  amended  in  the  forthcom- 
ing revision  by  omitting  the  requirement  of  autumn 
collection,  and  permitting  a  short  piece  of  the  stem- 
base  to  be  attached  to  the  tuber. 

Aconitum  L.  is  a  genus  of  some  sixty  species,  dis- 
tributed almost  throughout  the  Northern  hemisphere. 
Many  of  the  species  resemble  one  another  so  closely 
that  even  from  the  examination  of  complete  speci- 
mens, with  flower  and  fruit,  botanists  have  reached 
diverse  conclusions  regarding  their  identity  or  dis- 
tinctness. It  is  therefore  not  remarkable  that  the 
detached  medicinal  portions  should  be  found  difficult 
of  differentiation,  or  that  various  species  should  have 
been  found  mixed  in  commerce.  As  the  chemical 
and  medicinal  properties  of  the  different  species  vary 
greatly  in  degree,  the  tubers  of  at  least  one  species 
being  used  for  food,  these  mixtures  become  serious 
in  the  case  of  such  an  important  drug.  Of  late,  much 
more  care  has  been  exercised  than  formerly,  so  that 
this  adulteration,  intentional  or  accidental,  has  be- 
come infrequent.     Partly  because  of  this  element,  and 

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Aconite 


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■  r 


f 


f^iYp. 


partly  because  experiment  has  proven  the  activity 
of  the  drug  to  increase  under  cultivation,  the  British 
Pharmacopoeia  now  requires  that  only  the  cultivated 
English  tuber  shall  be  supplied.  It  is  also  cultivated 
in  various  continental  localities.  These  cultivated 
products  are  much  more  expensive  than  the  ordinary 
drug,  but  their  specification  appears  fully  justified, 
except  when  a  standardized  drug  or  preparation  (see 
Constituents)  is  employed. 

The  official  species  occurs  abundantly  in  the  moun- 
tainous districts  of  Central  Europe,  extending  up  the 
mountain  sides  to  a  very 
high  elevation,  as  well  as 
deep  into  the  valleys.  The 
plant  is  cultivated  as  an 
ornamental  flower  in  the 
United  States,  where  occa- 
sionally it  escapes.  The 
tubers  used  in  medicine  are 
collected  in  Europe. 

Since  the  herb,  although 
unofficial,  is  much  used  in 
medicine,  the  entire  plant 
is  here  described.  The 
simple,  stiff,  upright  stem 
of  aconite  rises  from  50  to 
100  cm.  (20  to  40  inches) 
from  the  ground,  bearing 
numerous  alternate  leaves, 
and  a  long,  close,  terminal, 
spike-like,  raceme  (Fig.  21). 
The  leaves  are  sub- 
rotund,  from  5  to  20  cm. 
in  diameter  (2  to  8  inches), 
rather  stiff  and  thick, 
smooth,  shining,  and  dark 
Fig.  21. — Aconitum  napellus  L.  green  above  and  paler  be- 
low. The  blade  is  pal- 
mately  three-parted;  the  lateral  segments  are  again 
divided  nearly  to  the  base.  The  narrowly  wedge- 
shaped  divisions  are  further  three  or  two  lobed,  and 
these  lobes  are  again  incised,  or  cleft,  with  linear 
and  pointed  tips.  The  leaves  become  less  compound 
toward  the  upper  part  of  the  stem,  and  are  finally 
reduced  to  three-  or  several-cleft  bracts.  They  have 
no  marked  odor,  but  upon  being  chewed  produce,  like 
the  tuber,  a  persistent  stinging  sensation  in  the  mouth. 
They  are  poisonous  and  contain  a  small  and  uncertain 
amount  of  aconitine  and  considerable  aconitic  arid, 
the  latter  of  no  therapeutic  importance.  The  flowers 
are  of  striking  appearance;  the  corolla  is  nearly  want- 
ing, and  its  place  is  taken  by  a  large  colored  calyx, 
of  which  the  upper  sepal  is  developed  into  a  deep  cup- 
shaped  helmet,  that  sits  upon 
the  rest  of  the  flower  like  a 
bonnet  (Fig.  22).  The  pistils 
are  three,  containing  numerous 
small  ovules. 

The  form  of  the  mature  tuber 
gives  the  specific  name  to  the 
plant  (napellus,  a  little  turnip). 
It  is  a  simple,  conical,  tapering 
tuber,  ending  in  a  long,  slender, 
cylindrical  tap-root,  and  bearing 
numerous  rootlets  upon  its  sides 
(see  Fig.  23).  From  its  scaly 
crown  arises  the  flowering  stem, 
and  at  the  base  of  this  stem  a 
short  stolon  extends  horizontally  under  the  ground, 
and  bears  on  its  extremity  a  young  tuber,  more  or 
less  developed  according  to  the  season,  and  destined 
to  produce  the  plant  of  the  succeeding  year.  There 
may  also  remain  upon  the  other  side  of  the  crown  a 
similar  but  dead  connection  between  the  present  tuber 
and  the  remains  of  that  of  the  preceding  year.  This 
habit  of  growth  well  enables  us  to  determine  the  sea- 
sun  when  the  tuber  was  collected.  When  it  shall  be- 
come positively  determined  at  what  season  it  is  most 


Fig.  22. — Entire  Flower 
of  Aconitum  napellus. 


active,    this  knowledge  will   doubtless  prove   of   the 
greatest  value  to  us. 

Fresh  aconite  tuber  is  brown  externally,  white  within, 
and  has  a  biting  benumbing  "taste,"  which  has 
caused  it  to  be  occasionally  stupidly  mistaken  for 
horseradish. 

The  dried  tuber,  which  constitutes  the  usual  drug 
{Aconitum,  U.  S.  P.;  Aconiti  Radix,  B.  P.;  Tubera 
Aetiniti,  P.  G.;  Racine  d'aconit  impel,  Codex  Med., 
etc.),  is  from  1  to  2  cm.  in  diameter  at  the  base,  and 
from  5  to  7  cm.  in  length  (two-fifths  to  four-fifths 
inch,  by  2  to  3  inches) ;  more  or  less  shrivelled  and 
wrinkled  longitudinally  especially  below;  often  curved 
and  twisted,  or  broken.  The  external  color  is  dark 
brown;  internally  it  is  grayish,  showing,  after  being 
soaked  up,  in  a  transverse  section,  a  distinct,  five  to 
eight  pointed  stellate  cambium  ring,  in  each  angle  of 
which  is  a  well-developed  fibrovascular  bundle.  Fre- 
quently the  tubers  are  attached  in  pairs;    when  not, 

the  scar  where  they 
were  broken  apart  can 
be  seen.  The  taste  is 
similar  to  that  of  the 
fresh  root,  but  the 
stinging  sensation 
may  be  a  little  de- 
layed. Spanish  aco- 
nite is  large,  stout, 
and  of  a  light  dirty- 
brown  color.  It  is 
usually  deficient  in 
strength. 

Aconite,  even  when 
coming  solely  from 
Aconitum  napellus,  is 
variable  in  quality. 
The  age  of  the  root 
has  much  to  do  with 
this.  Grown  in  differ- 
ent countries,  or  un- 
der varying  circum- 
stances, it  is  subject 
to  considerable  varia- 
\  tion  in  quality. 

Composition. —  Its 
active  constituent  is 
the  alkaloid  Aconi- 
tine, described  below. 
The  determination  of 
its  aconitine  percent- 
age therefore  constitutes  a  perfect  method  of  esti- 
mating its  quality.  Owing  to  difficulties  in  its  extrac- 
tion, this  determination  was  formerly  impracticable, 
but  a  reliable  method  of  assay  is  now  given  in  the 
Pharmacopoeia.  It  has  also  been  proposed  to  deter- 
mine the  presence  of  the  normal  percentage  of  alka- 
loid by  securing  the  tingling  effect  upon  the  tongue 
and  lips  by  the  use  of  a  solution  of  a  specific  degree 
of  dilution;  but  the  personal  equation  is  so  great,  and 
the  effects  of  training  so  important,  that  this  method 
has  not  found  favor.  The  amount  of  aconitine,  in  a 
first-class  sample,  will  be  about  seven  one-hundredths 
of  one  per  cent.  In  addition  to  the  aconitine,  there 
is  a  small  quantity  of  picraconitine  or  isaconitine. 
Besides  the  alkaloid,  a  large  amount  of  aconitic  acid, 
combined  with  calcium,  is  present.  Resin  and  slight 
amounts  of  fat  and  sugar  are  also  found. 

The  aconites  were  known  to  the  ancients,  both  in 
Europe  and  Asia,  as  poisons,  and  are  said  to  be  still 
used  by  some  of  the  hill  tribes  of  India  to  envenom 
their  arrows.  They  were  employed  as  medicines  in 
Germany  in  the  twelfth,  and  on  the  islands  of 
Great  Britain  in  the  thirteenth  centuries,  but  after- 
ward fell  into  disuse  until  1762,  when  Stoerck  of 
Vienna  again  introduced  them  to  the  medical  pro- 
fession, since  which  time  they  have  been  constantly 
used. 

Physiological  Action. — There  is  nothing  in  the 


Fig. 


23. — Tubers  and  Roots  of 
Aconitum  napellus. 


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AronlCic  Acid 


composition  of  aconite  which  materially  modifies  the 
action  of  the  aconitine. 

Primary  Effects. — It  sharply  stimulates  certain  of 
the  nerve  endings  on  coming  into  contact  with  them, 
as  well  as  certain  of  the  encephalic  centers.  These 
effects  upon  the  nerve  endings  are  evidenced  by  a 
tingling  sensation  in  the  skin,  whether  the  aconite  be 
directly  applied  or  be  carried  there  in  the  circulation. 
A  similar  tingling  is  produced  upon  contact  with  the 
mucous  membrane,  ami  this  becomes  a  severe  irrita- 
tion when  the  drug  is  applied  in  concentrated  form, 
as  when  the  dust  of  the  alkaloid  is  inhaled  or  reaches 
tin-  eyes.  This  effect  of  aconite  upon  the  mouth  is 
markedly  to  increase  the  salivary  and  mucous  secre- 
tion. It  produces  some  increase  of  perspiration  in 
the  same  directly  stimulating  manner  on  being  carried 
to  the  skin.  Under  careful  observation,  spasmodic 
contractions  of  voluntary  muscular  fiber  can  be  seen, 
while  stimulation  of  the  vasomotor  mechanism 
(whether  central  or  peripheral  is  not  certainly  known) 
results  in  arterial  constriction,  when  other  and  antago- 
nistic influences  resulting  from  the  drug's  action  are 
excluded.  At  the  same  time,  the  pupil  is  temporarily 
contracted.  Under  the  same  conditions  of  control, 
increased  cardiac  action  is  observed.  A  slight  diu- 
retic effect,  in  spite  of  decreased  blood-pressure,  is 
probably  due  to  direct  renal  stimulation.  Stimu- 
lation of  the  medullary  centers  is  plainly  evidenced  by 
the  strong  cardiac  inhibitory  action  which  is  the  most 
prominent  effect  of  the  drug,  and  by  convulsions, 
which  in  poisoning  often  occur  before  the  respiration 
has  failed  sufficiently  to  produce  them.  There  is  a 
powerful  stimulation  of  the  respiratory  center, 
though  the  action  is  temporary,  irregular,  and  spas- 
modic. The  vomiting  which  is  often  present  may 
also  be  due  in  part  to  the  same  central  stimulating 
cause.  When  nausea  is  present,  the  diaphoresis  is 
increased.  The  powerful  action  on  the  vagus  results 
in  a  marked  slowing  of  the  heart,  and  as  the  systole  is 
much  the  more  abbreviated,  the  heart  is  weak  as  well 
as  slow,  and  blood-pressure  is  reduced.  The  tempera- 
ture falls,  partly  owing  to  this  cause,  partly  to  the 
perspiration,  and,  some  think,  partly  by  reason  of  the 
disturbance  of  the  heat  centers. 

Secondary  Effects. — The  secondary  effect  of  aconite 
i-  to  paralyze  the  parts  at  first  stimulated,  though 
these  are  affected  in  very  different  degrees  as  to  both 
strength  and  promptness.  Failure  of  the  sensory 
nerve  endings  produces  anesthesia  where  tingling 
before  existed,  so  that  a  sensation  of  numbni'-  is 
experienced.  The  stimulated  respiration  changes  to 
a  depressed  one,  and  convulsions  from  this  cause 
frequently  ensue  in  poisoning.  Vasomotor  con- 
striction disappears,  as  does  secretion  due  to  pe- 
ripheral stimulation.    The  pupil  often  becomes  dilated. 

The  promptness  with  which  these  secondary 
symptoms  appear  is  proportional  to  the  size  and  con- 
centration of  the  dose,  so  that  the  primary  symptoms 
may  be  almost  altogether  wanting.  In  all  cases,  they 
supervene  so  soon,  and  are  so  much  more  pronounced 
and  continuous,  that  they,  rather  than  the  primary, 
constitute  the  medicinal  effects  of  the  drug.  Of  all, 
the  cardiac  depression  and  lowered  arterial  pressure, 
which  are  continuous,  are  the  most  prominent 
effects. 

In  poisoning,  conspicuous  modifications  of  the 
medicinal  effects  occur.  The  tingling  in  the  ex- 
tremities may  become  extreme.  Constriction  of  the 
throat,  with  a  sensation  of  strangling  is  also  severe 
and  alarming.  Salivation  and  vomiting  are  prompt, 
the  latter  being  violent,  convulsive  in  character,  and 
persistent.  The  heart  becomes  very  erratic,  although 
upon  the  whole  weakness  is  rapidly  progressive. 
The  respiration  is  painfully  depressed  and  convulsive. 
Muscular  weakness,  which  may  be  quite  persistent 
even  after  recovery,  is  added  to  nerve  depression. 
After  a  very  brief  period  of  cardiac  stimulation  the 
pulse   becomes   slower,    more   feeble,    irregular,    and 


dicrotic,   then    flickering,   ami    finally  imperceptible; 

respiration  is  shallow  and  hurried;  there  are  chills  and 
subnormal  temperature.  There  is  great  weakness 
and  prostration;  slight  exertion  provokes  sym 
and  sometimes  cardiac  pain.  The  patient  is  in  fear 
of  death,  restless:  the  face  is  pale,  the  lips  arc  blue, 
and  the  surface  is  covered  with  cold  perspiration. 
The  extremities  are  cold,  sometimes  paralyzed,  and 
sometimes  affected  with  pains  in  the  joints.  The 
eyes  arc  staring,  glistening,  and  the  pupils  usually 
dilated,  with  more  or  less  complete  loss  of  sight  or 
diplopia.  In  some  instances  the  patient  becomes 
delirious,  though  generally  perfectly  conscious  to  the 
last;  sometimes  he  is  attacked  with  cramps  and  con- 
vulsions, and  sometimes  he  is  comatose.  The  urine 
is  generally  retained.  Respiratory  failure  is  the 
usual  cause  of  death.  This,  with  cardiac  paralysis,  is 
sometimes  almost  instantaneous  when  large  quant  i 
of  a  liquid  preparation  are  swallowed. 

Otherwise,  the  above-described  symptoms  come  on 
successively.  The  tingling  and  numbness  of  the 
mouth  are  very  characteristic,  and  are  succeeded  by 
similar  sensations  over  the  surface  of  the  body, 
especially  in  the  hands  and  feet.  The  skin  soon 
becomes  cold,  though  there  is  more  or  less  perspiration. 
There  is  dilatation  of  the  pupils.  There  is  progressive 
muscular  weakness,  accompanied  by  feebleness  and 
ultimately,  in  fatal  cases,  paralysis  of  respiration. 

Although  some  aconitine  is  excreted,  especially  by 
the  urine,  it  is  for  the  most  part  quickly  burned  up  in 
the  system,  so  that  if  a  fatal  result  is  not  prompt, 
recovery  is  apt  to  occur.  Vomiting  should  be  en- 
couraged, warm  water  containing  iodine  in  potassium 
iodide  solution  being  used  to  wash  out  the  stomach. 
Atropine  is  a  physiological  antidote,  as  is  digitalis. 
External  heat  is  very  important.  Alcohol  should  be 
used  cautiously.  Artificial  respiration  may  save  the 
patient  even  when  death  seems  to  be  impending. 

Aconite  is  one  of  the  most  useful  drugs  of  the  Phar- 
macopoeia. It  works  especially  well  with  children, 
and  even  very  small  doses  often  work  satisfactorily. 
Because  of  the  rapidity  with  which  it  is  destroyed  in 
the  system,  doses  should  be  small  and  often  repeated. 
The  "special  cases  in  which  it  is  useful  are  those  of 
sthenic  character,  in  the  relief  of  congestions.  It  is  a 
very  safe  and  moderate  agent  for  lowering  the  tempera- 
ture, as  well  as  for  relieving  tension.  It  tends  to 
lessen  inflammation  and  is  especially  useful  in  many 
forms  of  sore  throat.  All  forms  of  throbbing  pain, 
such  as  earache,  toothache,  and  headache,  are  likely 
to  be  relieved,  as  are  painful  disorders  of  the  respira- 
tory  organs,  such  as  pleurisy.  Great  relief  is  often 
experienced  from  its  use  in  inflammatory  rheumatism. 
Scarlet  fever  and  the  fever  of  measles  and  similar 
diseases  are  often  markedly  benefited  by  aconite,  but 
care  should  be  taken  to  avoid  excessive  depression. 
Neuralgic  pains  are  often  benefited  by  local  applica- 
tions, preferably  by  inunction.  It  must  never  be 
overlooked,  however,  that  fatal  absorption  may  thus 
take  place. 

The  official  preparations  and  their  doses  are  as  fol- 
lows: Fluid  extract,  one  to  two  minims;  tincture  (of 
ten-per-eent.  strength),  five  to  fifteen  minims.  The 
extract,  no  longer  official,  is  still  considerably  used,  in 
doses  of  one-half  to  one  grain.     (See  also  Aconitine.) 

Other  species  of  aconitum  having  similar  properties 
in  marked  degree  are  A.ferox  Wall,  of  India,  contain- 
ing pseudaconitine,  and  A.  Jiachcri  of  Japan,  con- 
taining apparently  aconitine,  but  which  has  been 
called  japaconitine.  H.  H.   Rushy. 

Aconitic  Acid,  C,He06l  occurs  in  large  amount  in 
combination  with  calcium  in  aconite,  also  in  adonis 
and  other  plants  of  the  Ranunciilacecv  and  elsewhere. 
Either  water  or  alcohol  will  dissolve  it.  It  deposits  in 
thin  plates.  This  acid  is  also  yielded  upon  heating 
citric  acid.     It  has  no  special  medicinal  properties. 

II     H.   R. 

03 


Aconitina 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Aconitina. — Aconitine.  "  An  alkaloid  obtained  from 
aconite  (C34H„NOu  =640.55).  As  the  Pharma- 
copoeia defines  aconite  as  proceeding  from  A.  napellus 
L.,  the  above  definition  is  equivalent  to  a  require- 
ment that  the  alkaloid  be  obtained  from  that 
species.  The  percentage  is  variable,  and  should  be 
stated  in  connection  with  every  lot  and  preparation 
of  the  drug.  Aconitine  occurs  in  white,  flat  or  pris- 
matic crystals  and  is  soluble  in  twenty-two  parts  of 
alcohol,  and  in  3200  parts  of  water.  When  heated 
rapidly,  it  melts  at  195°  C.  (3S3°  F.),  but  when  heated 
slowly,  it  decomposes  and  melts  at  182°  C.  (359.6°  F.). 
It  is  a  compound  of  acetic  acid  with  the  alkaloid 
benzoyl-aconine,  the  latter  being  a  compound  of 
benzoic  acid  with  the  alkaloid  aconine.  Both  of  the 
two  last-named  occur  to  a  greater  or  less  extent  in 
aconite,  as  derivatives  of  the  first.  Neither  possesses 
the  properties  of  aconitine,  nor  are  they  poisonous. 
To  the  incompatibilities  of  alkaloids  in  general, 
aconitine  adds  that  of  being  decomposed  by  alka- 
lies, owing  to  its  peculiar  composition,  as  above 
described. 

The  properties  and  uses  of  the  alkaloid  are  fully 
stated  under  the  title  Aconite.  Its  activity  is,  how- 
ever, so  intense  that  it  has  to  be  used  and  handled 
with  the  most  extreme  caution,  as  will  be  appreciated 
when  it  is  considered  that  there  is  but  a  half  pound  of  it 
in  a  ton  of  aconite,  yet  the  safe  dose  of  the  root 
is  limited  to  about  five  grains. 

Its  external  use  is  for  the  relief  of  rheumatic  and 
neuralgic  pain.  The  ordinary  commercial  alkaloid 
has  been  used  in  ointment  up  to  two-per-cent. 
strength,  but  that  of  the  pure  crystalline  alkaloid 
should  be  limited  to  0.2  of  one  per  cent.  There  is 
great  danger  of  absorption,  and  it  should  be  applied 
only  to  the  unbroken  skin.  Internally,  it  may  be 
used  in  pill  form  or  in  freshly  made  solution,  in  doses 
of  gram  0.0001  to  0.0003  (^  to  ^  grain),  and  not 
more  than  ten  times  these  amounts  per  day. 

Pseudaconitine,  from  Nepaul  or  Indian  aconite  (.4. 
ferox  Wall.),  is  equally  poisonous.  Its  properties  are 
under  investigation,  and  it  is  not  unlikely  that  it 
may  be  found  worthy  of  introduction. 

H.  H.  Rusbt. 

Acormus. — See  Teratology. 

Acoustic  nerve. — See  Ear,  Anatomy  and  Physiology 
of  the. 

Acrochordon. — From  &Kpov,  extremity,  and  yopS-fi, 
cord.  A  small  fibrous  growth,  usually  peduncular, 
of  the  skin,  especially  of  the  neck  or  eyelids.  It  may 
occur  at  any  period  of  life  but  is  more  common  in  the 
aged.     See  Fibroma  of  the  Skin,  under  Fibroma. 

Acrodermatitis  Chronica  Atrophicans. — This  term 
was  applied  by  Herxheimer  and  Hartmann  to  a  type 
of  affection  previously  included  under  idiopathic 
atrophy  of  the  skin.  It  is  also  held  to  be  a  form  of 
dermatitis  atrophicans  diffusa,  limited  to  the  extrem- 
ities; somewhat  as  sclerodactyl  is  a  local  type  of 
scleroderma.  Some  dermatologists  have  insisted 
that  these  forms  of  atrophy  of  the  skin  must  be 
minimal  forms  of  scleroderma,  a  possibility  barely 
mentioned  by  others,  who  merely  state  that  the  two 
processes  show  at  times  some  points  of  resemblance. 
The  initial  stage  shows  a  soft,  doughy  infiltration 
having  a  bluish-red  hue,  which  is  a  prelude  to  the 
atrophic  stage,  in  which  the  skin  becomes  smooth, 
shiny  and  tense.  These  lesions  do  not  as  a  rule 
appear  in  the  fingers  as  the  name  suggests,  but  are 
prone  to  arise  in  the  course  of  the  limbs,  especially 
on  the  knees  and  elbows.  Authors  mention  especially 
the  "ulnar  strip,"  a  narrow  atrophic  band  which 
Occupies  the  ulnar  side  of  the  arm.  Other  favorite 
Idealities  are  the  face  and  soles  of  the  feet.     Some 


cases  terminate  in  spontaneous  recovery  in  a  few 
weeks,  while  in  others  the  affection  may  last  for 
many  years,  yet  leave  no  permanent  atrophy.  About 
sixty  cases  are  on  record  (see  also  Atrophia  cutis 
idiopathica).  Edward  Preble. 

Acrodynia. — Epidemic  erythema,  a  somewhat 
obscure  disease,  said  to  bear  considerable  analogy  to 
pellagra.  It  was  first  observed  at  Paris  in  1828, 
occurring  there  as  an  outbreak  in  one  of  the  infirma- 
ries for  old  men.  The  epidemic  subsided  during  the 
winter  months  to  break  out  again  in  the  spring,  but 
was  considered  to  have  been  extinguished  during  the 
severe  winter  of  1S29-30.  A  few  cases,  however, 
were  noted  from  time  to  time  during  the  years  1830 
and  1831,  since  when  the  affection  has  not  again  been 
observed  in  Paris.  In  Mexico,  in  1866,  during  March 
and  April,  an  epidemic  said  to  be  acrodynia  broke 
out  among  the  Mexican  and  Algerian  soldiers  at 
Zitocuaro. 

On  the  Continent  it  had  been  observed  on  a  small 
scale  since  1831,  chiefly  among  Belgian  and  French 
soldiers  and  prisoners,  the  last  occasion  being  in  a 
French  regiment  stationed  at  Satory,  near  Versailles, 
in  1874.  This  epidemic  was  not  very  clearly  demon- 
strated, however,  to  have  been  one  of  acrodynia,  and 
of  late  the  existence  of  such  a  disease  has  even  been 
questioned.  The  general  symptoms  are  said  to  be  in 
some  respects  similar  to  those  of  chronic  arsenical 
poisoning.  Commencing  with  gastrointestinal  irri- 
tation, redness  of  the  conjunctiva,  edema  of  the  face 
or  limbs,  there  are  soon  added  formication,  pains  in 
the  fingers  and  toes,  a  burning  sensation,  and  pricking 
or  shooting  pains  in  the  palms  and  soles,  and  a  feeling 
of  weight  in  the  extremities,  especially  the  lower. 
Hyperesthesia  of  these  parts,  especially  the  soles  of 
the  feet,  and  sometimes  anesthesia,  are  present. 
Cramps,  spasms,  and  tetanic  contractures  are  almost 
always  constant  symptoms.  There  is  no  fever,  and 
the  disease  is  rarely  fatal,  except  in  the  old  and  feeble 
or  from  the  diarrhea  which  is  present  in  all  cases, 
recovery  taking  place  in  a  few  weeks  or  months. 

The  chief  cutaneous  manifestations  of  the  disease 
are  erythematous  and  pigmentary. 

The  erythema  makes  its  appearance  early  in  the 
course  of  the  disease  and  may  be  very  general, 
affecting,  however,  chiefly  the  extremities,  more 
particularly  the  hands  and  feet,  and  here  especially 
their  palmar  and  plantar  surfaces.  It  may  be  pre- 
ceded or  accompanied  by  the  formation,  chiefly  on 
the  hands  and  feet,  of  vesicles  or  bullae  filled  with  a 
clear  or  at  times  more  or  less  sanguinolent  effusion, 
and  is  followed  by  desquamation  or  exfoliation  of  the 
epidermis,  while  a  dark  brown  or  blackish  pigmenta- 
tion spreads  itself  over  the  abdomen,  chest,  axilla?, 
and  other  parts,  being  more  pronounced  in  the  warm 
regions  of  the  body.  Alibert,  in  his  description,  the 
only  one  coming  from  a  dermatologist,  says  ("  Mono- 
graphic des  dermatoses,"  Paris,  1S33,  p.  12)  that  what 
particularly  attracted  his  attention  in  most  of  those 
afflicted  with  the  disease  was  this  black  color  which 
affected  the  integument,  nearly  all  who  presented 
themselves  for  treatment  having  the  tint  of  a  chimney 
sweep. 

The  pathology  of  the  disease  is  obscure;  there  are  no 
special  postmortem  changes,  but  in  several  cases  in- 
flammation of  the  pia  mater  and  spinal  arachnoid  was 
found.  Though  the  disease  bears  a  close  resemblance 
to  pellagra,  the  general  and  cutaneous  symptoms  are 
more  varied  in  acrodynia  than  in  pellagra;  and  while 
in  the  latter  the  backs  of  the  hands  and  feet  are 
attacked,  it  is  the  palms  and  soles  that  are  affected 
in  the  former.  The  disease  was  regarded  (Chomel, 
Recamier,  etc.)  in  Paris  as  being  due  to  spoiled 
cereals,  but  nothing  positive  on  the  score  has  been 
proven.  The  most  efficient  treatment  was  claimed 
to  consist  in  counterirritation  of  the  spine. 

Charles  Townshend  Dade. 


94 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Acronwualy 


Acromegaly. — Synonyms:  Megalacria,  acromegalia, 
pachyacria,  Mane's  disease. 

Definition. — Acromegaly,  from  inpov,  extremity, 
and  uiyat  (fiej-aX-),  great,  is  a  chronic  disease,  charac- 
terized by  an  abnormal  increase  in  the  size  of  the 
extremities,  viz.,  hands,  feet,  and  generally  head, 
due  to  an  hypertrophy  of  the  bones  and  soft  parts 
of  these  regions. 

History. — The  first  to  recognize  this  disease  as  a 
Separate  entity  was  P.  Marie,  who  wrote  upon  the 
subject  in  the  Revue  de  Medecine,  vi.,  297,  1886, 
describing  two  cases  which  he  had  discovered  while 
assistant  to  Professor  Charcot.  The  first  cases  dis- 
covered and  reported  as  acromegaly  (in  1885  Wads- 
worth  reported  a  case  as  myxedema  which  was  un- 
doubtedly acromegaly)  in  America  were  those  of 
O'Connor  and  Adler,  both  of  which  were  published 
in  1888. 

For  the  early  bibliography  the  following  may  be 
consulted:  New  Sydenham  Society  Reports,  London, 
1891;  Joseph  Collins'  articles  in  the  Journal  of 
Nervous  and  Mental  Diseases,  December,  1892,  and 
January,  1S93,  the  alphabetical  bibliography  in  the 
writer's  article  in  the  Yale  Medical  Journal,  Decem- 
ber, 1S97;  Guy  Hinsdale's  monograph  in  Medicine, 
1898;  and  the  chronological  bibliography  of  Harlow 
Brooks  in  the  Archives  of  Neurology  and  Psycho- 
Pathology,  vol.  i.,  No.  4,  1S9S.  The  later  bibli- 
ography is  given  in  the  monograph  of  Bernhard 
Fischer,  "Hypophysis,  Akromegalie  und  Fettsucht," 
Wiesbaden,  1910. 

Symptomatology. — General  Condition. — The  acro- 
megalic patient  comes  to  the  physician  complaining 
of  headache,  disturbances  of  vision,  severe  joint  pains, 
and  sometimes  ringing  in  the  ears;  or  the  condition  is 
discovered  while  the  patient  is  under  treatment  for  an 
entirely  different  disease.  The  pain  in  the  head  is  the 
most  frequent  subjective  symptom,  and  is  often 
severe  and  even  terrific.  There  may  be,  and  fre- 
quently are,  pains  referred  to  various  parts  of  the 
body,  often  to  the  joints,  which  are  more  or  less  per- 
sistent but  neuralgic  in  character.  Frequently  there 
is  tingling  of  the  hands,  feet,  or  ears,  often  with 
numbness  of  the  fingers,  but  with  no  great  loss  of 
sensibility.  There  are  generally  increased  and  often 
ravenous  appetite,  increased  thirst,  dyspepsia  and 
polyuria,  and  generally  constipation.  As  a  rule,  in 
women  menstruation  is  absent  and  in  men  the 
sexual  appetite  is  diminished. 

The  weight  during  the  developing  period  of  the 
disease  always  increases,  and  so  does  the  height  to  a 
certain  extent,  at  least  till  the  period  when  kyphosis 
develops,  when  more  or  less  loss  of  height  takes 
place  The  gradual  increase  in  the  size  of  the  hats, 
shirts,  gloves,  and  shoes  worn  affords  evidence  of  the 
enlargement  of  the  head  and  extremities.  In  women 
the  increase  in  the  size  of  the  fingers,  as  shown  by  the 
inability  to  wear  the  wedding  ring,  is  a  positive  evi- 
dence of  growth.  In  most  cases  earlier  photographs 
of  the  patient  can  be  obtained  and  compared  with  the 
present  condition. 

Clinical  Inspection. — In  acromegaly  all  of  the  pro- 
jecting portions  of  the  body  are  greatly  enlarged — 
hands,  feet,  chin,  lips,  nose,  tongue,  ears,  and  often 
the  genitalia.  Of  these  parts  the  bones,  cartilages, 
and  soft  tissues  are  all  hypertrophied.  The  face  is 
oval,  the  cheeks  are  flattened,  the  forehead  is  retreat- 
ing and  low,  the  nose  enlarged  and  often  massive,  and 
exophthalmos  may  be  present.  The  ears  are  gener- 
ally enlarged  and  the  hair  of  the  head  is  strong  and 
thick.  The  intellectual  faculties  may  or  may  not  be 
impaired,  and  somnolency  is  sometimes  present. 
Taste  and  smell  are  rarely  affected,  while  hearing  is 
occasionally  disturbed  and  sight  is  frequently  im- 
paired. The  voice  is  loud  and  deep.  The  reflexes 
are  generally  normal,  at  least  not  markedly  impaired, 
and  the  electrical  reactions  are  normal. 


lhiul. — The  forehead  is  low  and  retreating,  due  to 
the  growth  forward  of  the  superciliary  ridges,  which, 
with  the  elongation  and  forward  projection  of  the 
lower  jaw,  gives  the  oval  or  elliptical  face  so  charac- 
teristic of  this  disease.  The  hair  is  thick  and  strong, 
and  the  eyebrows  are  often  heavy.  The  face  is 
entirely  too  large,  being  out  of  all  proportion  to  the 
cranium  proper.  The  skin  of  the  face  is  thickened  and 
of  a  yellowish-brown  color,  most  marked  on  the  eyelids, 
with  perhaps  here  and  there  a  molluscous  growth. 

The  skin  of  the  forehead  is  often  redundant  and 
thrown  into  many  transverse  wrinkles  and  folds. 
The  cheeks  are  flattened,  and  appear  sunken,  largely 
due  to  the  prominence  and  projection  of  the  malar 
bones.  The  circumferences  of  the  orbits  are  promi- 
nent, and  the  eyelids  are  large,  due  to  the  thickening 
and  widening  of  the  tarsal  cartilages,  with  more  or 
less  hypertrophy  of  the  skin,  especially  of  the  lower 
lid,  where  it  may  fall  in  folds,  with  occasionally  the 
appearance  of  edema.  The  eyeballs  are  large  and 
generally  more  or  less  prominent,  even  to  the  con- 
dition of  exophthalmos. 

The  nose,  even  for  the  size  of  the  face,  is  too  large, 
often  immense,  due  to  the  thickening  of  the  nasal 
cartilages  and  to  the  great  hypertrophy  of  the  soft 
parts.  It  is  wide,  thick,  and  may  be  pugged.  The 
mucous    membrane    is    often    thickened. 

The  superior  maxillary  bones  may  or  may  not  be 
enlarged,  but  are  frequently  lengthened  from  above 
downward;  however,  they  are  never  enlarged  to  the 
same  extent  as  is  the  lower  jaw.  The  upper  lip  is 
generally  thick  and  projecting,  but  never  attains  the 
size  of  the  lower  lip.  The  lower  lip  is  almost  in- 
variably thick,  everted,  and  projecting,  and  is  a 
characteristic  feature. 

The  enlargement  of  the  lower  jaw  is  one  of  the 
characteristic  changes  in  this  disease,  although  acro- 
megaly can  occur  without  it.  Sooner  or  later  prog- 
nathism generally  occurs;  it  is  due  not  only  to  the 
growth  of  the  body  of  the  lower  jaw,  but  also  to  the 
widening  of  the  angle  and  the  changes  in  the  glenoid 
fossa. 

The  external  ear  is  generally  increased  in  size. 
The  cartilages  and  the  soft  parts  both  take  part  in  the 
growth,  and  the  former  may  become  in  places  as  hard 
as  bone,  while  the  external  auditory  canal  may  be 
lengthened  by  the  growth  of  its  cartilage  and  nar- 
rowed by  exostoses  from  the  bony  wall. 

The  tongue  is  broad  and  thick  and  frequently 
double  its  normal  size,  almost  entirely  filling  the 
cavity  of  the  mouth,  so  that  the  sides  show  indenta- 
tions from  the  teeth.  The  upper  surface  of  the  tongue 
is  often  deeply  corrugated  and  marked  by  deep  lines 
and  fissures,  and  the  papilla?  may  be  prominent  and 
projecting.  The  speech  is  rendered  thick,  heavy, 
and  slow  by  the  massive  tongue,  while  the  prog- 
nathism allows  the  labial  and  dental  sounds  to  be  but 
poorly  articulated.  The  tongue  is  generally  clean, 
but  may  be  covered  with  a  grayish-yellow  coating. 

The  soft  palate  is  often  thickened,  the  uvula  may  be 
wide  and  long,  even  as  large  as  a  little  finger,  and  the 
epiglottis  has  been  found  considerably  thickened. 
The  larynx  is  enlarged,  either  as  a  whole  or  in  one  or 
more  sets  of  its  cartilages.  The  aryepiglottic  liga- 
ments may  be  thickened  and  the  vocal  cords  hyper- 
trophied. These  laryngeal  enlargements  cause  the 
voice  to  be  loud  and"  harsh,  while  the  pitch  is  much 
lowered  in  men  and  made  masculine  in  women.  The 
submaxillary  and  the  lymphatic  glands  of  the  neck 
may  be  enlarged.  The  thyroid  gland  nvay  be  normal 
in  size,  hypertrophied,  cystic,  or  so  atrophied  that  it 
cannot  be  found. 

The  neck  is  short  and  thick,  and  the  head  leans 
forward,  while  the  cervicodorsal  kyphosis  causes  the 
long  projecting  chin  almost  to  rest  on  the  sternum. 

Body. — Sooner  or  later  the  irregular  growth  of  bone 
in  the  spinal  column  causes  deformity  of  the  spine. 
This  deformity  is  almost  constantly  a  cervicodorsal 


95 


Acromegaly 


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kyphosis,  giving  a  humpback  appearance  which  is 
very  characteristic  of  this  disease.  Occasionally 
scoliosis  is  also  present,  and  sometimes  there  is  a 
compensatory  lumbar  or  dorsolumbar  lordosis.  The 
spinous  processes  of  the  vertebrae  may  be  abnor- 
mally prominent,  especially  the  lower  cervical. 

The  size  of  the  chest  is  greatly  increased,  especially 
at  the  level  of  the  ensiform  cartilage,  where  it  reaches 
its     o-reatest     circumference.     Laterally     the     chest 


Flu.   24. — Acromegaly.      (Author's  Case.) 

appears  flattened,  while  the  anteroposterior  diameter 
is  often  enormous,  due  to  the  forward  projection  of  the 
lower  end  of  the  sternum.  The  sternum  is  generally 
widened  and  thickened,  with  prominent  transverse 
ridges.  The  xiphoid  cartilage  is  hard,  wide,  ami 
projecting.  The  clavicles  are  most  enlarged  at  the 
sternal  extremity,  but  the  acromial  end  is  also  thick- 
ened. The  ribs  are  wide  and  very  oblique,  and  al 
their  junction  with  the  more  or  less  enlarged  and 
ossified  costal  cartilages  are  found  bony  nodules,  not 
unlike  the  rachitic  rosary,  and  nodosities  may  appear 
on  the  ribs  themselves.  The  hardening  of  the  liga- 
ments iiiid  cartilages  of  the  chest  causes  a  peculiar 
stiff    and    constrained    up-and-down    or    out-and-in 

96 


motion  of  the  lower  part  of  the  thorax  during  respira- 
tion,   and    the    abdominal    respiration    is    increased. 

The  abdomen  is  generally  flattened  and  even  ap- 
pears retracted  from  the  forward  projection  of  the 
sternum  and  costal  cartilages,  though  rarely  it  may 
be  large  and  pendant. 

The  pelvis  is  enlarged,  the  ilia  are  wide  apart,  the 
crests  broad  and  prominent,  and  the  pubic  bones  are 
especially  hypertrophied  at  the  symphysis. 

The  external  genitals  may  or  may  not  be  enlarged. 
The  clitoris  may  be  hypertrophied,  and  the  vagina 
may  be  lengthened,  but  the  uterus  is  generally  small 
and  atrophied. 

Upper  Extremity. — The  shoulder  joint  may  be,  but 
rarely  is,  much  enlarged;  the  elbow  joint  may  be  in- 
creased in  size;  the  forearm  is  often  enlarged  at  its 
lower  third,  especially  just  above  and  at  the  wrist; 
the  wrist  joint  is  almost  always  large.  The  hand, 
widened,  thickened,  and  often  lengthened,  is  massive 
and  enormous,  and  appears  heavy  and  cumbersome 
for  the  relatively  small  arm  to  carry.     The  ends  of 


Fig.  25. — Typical  Hand  in  Acromegaly.      (Author's  Case. ) 

the  metacarpal  bones  and  phalanges  are  enlarged, 
giving  prominent  joints.  The  skin  of  the  hand  and 
the  subcutaneous  tissues  are  greatly  hypertrophied, 
so  that  the  normal  lines  of  the  palm  are  greatly 
deepened.  At  the  upper  part  of  the  hand,  and  over 
the  metacarpal  bone  of  the  thumb,  and  on  the  ulnar 
border,  the  hypertrophy  of  the  soft  parts  is  excessive. 
The  fingers,  by  the  growth  of  phalanges  and  soft 
parts,  become  of  the  same  width  and  thickness  at  the 
tips  as  at  the  bases,  giving  the  appearance  called  "sau- 
sage-shape," which  is  a  characteristic  feature  of  this 
disease.  The  fingers  may  appear  somewhat  flattened, 
unci,  according  to  Marie,  there  is  often  a  swelling  at  the 
articulation  of  the  first  and  second  phalanges.  The 
nails  are  flattened,  short,  and  sometimes  widened, 
but  always  appear  too  small  for  the  enlarged  fingers, 
whose  redundant  flesh  laps  over  them  at  the  sides. 
There  are  strongly  marked  longitudinal  striatums, 
sometimes  even  with  ridges,  and  there  may  be  trans- 
verse  striations  on  the  nails.  They  are  often  brittle, 
breaking  off  or  cracking  easily. 


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Fig.  1.  Fig.  2.  Fig.  4. 

Acromegalic  Skeleton  (Osborne's  Case)  At  the  Yale  Medical  School 


Fig.  1. — Normal  skeleton. 

Fig.  2. — Skeleton  of  Acromegaly  showing  Kyphosis,  enormous 
anteroposterior  diameter  of  thorax,  great  obliquity  of  the  ribs, 
long  arms  reaching  almost  to  the  knees,  large  feet,  great  project- 
ing os  calcis,  etc.  (author's  case). 


Fig.  3. — Spine  of  Fig.  2;  shows  co-ossification  of  bodies  oi 
dorsal  vertebrae  and  many  bony  unions  of  spinous  and  transverse 
processes. 

Fig.  4. — Skull  of  Fig.  2,  showing  enormous  inferior  maxilla, 
prognathism,  projecting  supraorbital  ridges,  large  and  prominent 
malar  bones,  etc. 


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Acromegaly 


Lower  Extremity. — The  thighs  are  generally  not  in- 
creased in  size,  although  the  condyles  of  the  femurs 
may  be  prominent  and  enlarged,  which  with  the  hy- 
pertrophy of  the  patellar  causes  a  marked  enlarge- 
ment of  tin'  knees.  The  upper  ends  of  the  tibiae  and 
fibulae  may  or  may  not  be  enlarged,  but  the  lower  ends 
of  the  leg  bones  are  generally  found  hypertrophied, 
causing  prominent  malleoli  and  large  ankle  joints. 
The  tendo  Achillis  is  frequently  prominent  and  hard- 
ened. The  bones  of  the  feet  are  all  enlarged,  especially 
the  os  calcis,  which  projects  backward,  giving  a 
marked  prominence  to  the  heel.  The  foot  is  thick  and 
broad,  with  a  prominent  cushion  of  thickened  skin 
and  subcutaneous  tissue  on  the  external  border,  a 
characteristic  feature  of  the  foot  in  acromegaly.  The 
toes  are  all  large,  but  more  especially  the  big  toe, 
which  is  immense,  and  crowds  the  other  toes  together. 
The  skin  of  the  foot  is  redundant,  hypertrophied,  and 
thickened,  especially  on  the  toes.  The  nails  of  the  toes 
present  appearances  similar  to  those  of  the  fingers. 

Acromegaly  is  primarily  a  symmetrical  disease, 
one  part  enlarging  correspondingly  with  its  fellow  on 
the  other  side;  but  exceptionally  one  side  of  the  body, 
more  often  the  right,  is  larger  than  the  other.  Be- 
sides this  slight  asymmetry  of  the  two  sides  of  the 
body,  some  atypical  cases  have  occurred  in  which  one 
or  several  toes  or  fingers  were  found  to  be  larger  than 
their  fellows,  or  one  side  of  the  face  and  head  was 
much  larger  than  the  other  side. 

Muscles. — At  first  the  muscle  growth  and  muscular 
power  are  increased,  and  sometimes  the  development 
of  the  muscles  may  be  very  great.  Sooner  or  later, 
however,  the  muscles  become  atrophied  in  greater  or 
less  degree,  and  the  muscular  power  is  greatly  dimin- 
ished, even  to  the  point  of  compelling  the  patient  to 
remain  in  a  sitting  or  reclining  posture,  or  in  bed. 
There  may  be  intermittent  attacks  of  great  loss  of 
muscular  power,  followed  by  periods  of  improved 
strength. 

Skin. — The  subcutaneous  fat  may  be  increased  or 
diminished,  but  later  it  is  generally  found  diminished, 
except  perhaps  on  the  diseased  portions  of  the  body. 
The  skin  on  the  affected  parts  is  hypertrophied,  and 
where  exposed  is  olive  brown  or  yellowish  in  color. 
This  yellow  color  is  most  marked  on  the  face,  and 
here  most  noticeably  on  the  eyelids.  The  face  may, 
however,  be  pale,  or  the  nose  may  be  red,  and  the  skin 
may  be  dry  and  harsh  from  diminished  sebaceous 
secretion.  There  is  frequently  increased  perspiration, 
coming  on  with  slight  exercise,  or  even  without  ex- 
ercise, either  general  or  local  on  the  diseased  portion 
of  the  body,  and  especially  frequent  on  the  legs. 
This  perspiration  may  have  a  disagreeable  odor.  The 
growth  of  the  hair  all  over  the  body  is  increased, 
especially  on  the  legs,  and  on  the  head  it  is  thick, 
strong,  and  coarse.  There  may  be  pigmentations  on 
the  skin,  and  pendulous  growths  of  molluscum  fibro- 
sum  frequently  occur  on  the  face,  especially  on  the 
eyelids,  and  on  the  chest  or  back.  Multiple  fibro- 
mata of  the  skin  may  occur,  of  the  size  of  a  millet- 
seed,  and  fatty  nodules  may  be  found  beneath  the 
skin. 

Blood-Vessels . — There  are  always  vasomotor  dis- 
turbances of  the  affected  portions  of  the  body,  as 
shown  by  the  tingling,  flushing,  and  local  sweating. 
The  flushing  is  often  accompanied  by  a  "burning 
pain."  Besides  these  signs,  which  denote  the  dilata- 
tion of  the  small  blood-vessels,  there  is  a  marked 
tendency  to  a  dilated  and  varicose  condition  of  the 
Superficial  veins,  especially  of  the  legs.  Hemorrhoids 
are  often  present,  varicocele  may  be,  and  profuse 
epistaxis  may  occur,  while  the  arteries  may  show 
signs  of  beginning  atheroma. 

Albuminuria  or  peptonuria  may  be  present,  while 
polyuria  is  a  frequent  symptom.  Glycosuria  has 
been  so  many  times  present  as  to  suggest  some 
metabolic  connection  between  pituitary  disease  and 
disturbances  of  the  sugar  mechanism. 

Vol.  I.— 7 


Sight. — .More  than  half  of  all  cases  of  acromegaly 
show  deranged  vision  or  optic  signs  during  some  stage 
of  the  disease.  The  physical  cause  of  the  ocular 
disorder  is  largely  the  pressure  of  the  enlarged 
hypophysis  on  the  optic  chiasm.  That  in  some 
cases  one  eye,  in  others  both,  and  in  still  others  the 
ears  alone  are  affected  can  be  explained  by  the  con- 
dition of  the  bony  environments  of  the  sella  turcica 
in  the  individual  skull,  the  enlarging  pituitary  body 
tending  to  escape  in  the  direction  of  least  resistance. 
If  the  middle  clinoid  processes  are  small,  the  pressure 
will  be  exerted  early  on  the  optic  commissure;  or  if 
one  of  these  processes  is  smaller  than  the  other,  the 
pressure  will  first  be  exerted  on  that  side,  and  but  one 
eye  may  be  affected.  Exophthalmos  is  often  present, 
due  both  to  actual  enlargement  of  the  eyeballs  and  to 
bony  growth  in  the  orbital  cavities,  or  perhaps  to 
associated  thyroid  disease.  The  pupils  are  generally 
normal  in  size,  but  may  be  dilated,  and  the  reaction 
may  be  slow  to  light  but  normal  to  accommodation. 
Nystagmus,  both  rotary  and  vertical,  has  been  present, 
and  divergent  strabismus  has  been  noted  in  a  few 
cases.  Narrowing  of  the  visual  fields  has  been  found 
in  all  degrees,  even  to  bitemporal  hemianopsia,  and 
signs  of  optic  neuritis  due  to  pressure  may  be  found 
even  before  the  vision  is  much  impaired.  Optic 
atrophy,  partial  or  complete,  of  one  or  both  eyes,  is  of 
frequent  occurrence.  The  retina?  may  show  venous 
congestion,  and  the  arteries  may  be  small  or  they  may 
appear  pale,  or  a  congestion  as  of  a  neuroretinitis 
may  be  present. 

Hearing. — The  hearing  is  not  generally  affected,  but 
occasionally  there  has  been  decided  deafness,  and  in 
several  cases  there  has  been  continuous  and  unceasing 
tinnitus  aurium.  When  this  is  constantly  present 
there  is  either  pressure  on  the  cavernous  sinuses  by 
the  enlarged  pituitary  or  an  actual  growth  into  them 
of  the  pituitary  tumor.  The  ringing  is  often  in- 
creased on  lying  down,  so  that  the  patient  cannot 
sleep  except  in  the  sitting  position,  and  anything  that 
increases  the  blood  pressure  even  momentarily  will 
increase  the  tinnitus  and  often  give  it  a  pulsating 
character.  The  drum  membrane  may  be  hardened, 
thickened,  and  almost  immovable. 

Smell  and  Taste. — These  are  but  rarely  affected. 

Nervous  Phenomena. — A  most  constant  symptom 
is  pain  in  the  head,  which  may  be  referred  to  any 
region,  but  is  generally  frontal  or  vertical;  in  one  of  the 
writer's  cases  it  was  located  in  a  small  circumscribed 
spot,  tender  to  pressure,  over  the  region  of  the  anterior 
fontanelle.  This  pain  may  be  so  mild  that  it  is  hardly 
complained  of,  or  so  violent  as  almost  to  render  the 
patient  insane.  The  headache  is  often,  like  the 
tinnitus  aurium,  made  worse  on  lying  down  or  by 
anything  that  increases  the  cerebral  blood  pressure. 
Pain  may  be  present  in  the  joints,  especially  the  knees, 
and  is  often  severe  in  the  fingers.  Pain  is  frequently 
complained  of  in  the  chest  or  abdomen,  shooting 
around  the  body  or  confined  to  one  side,  or  it  may  be 
lumbar  or  sacral.  Almost  every  subject  of  acrome- 
galy has  pain,  more  or  less  constant  and  severe,  in 
some  part  of  the  body,  often  without  any  local  cause. 
Crepitations  may  be  found  in  some  of  the  joints, 
which,  of  course,  would  account  for  the  pain  there, 
though  there  is  no  swelling  or  any  evidence  of  acute 
inflammation. 

Sometimes  a  peculiar  nervous  sensation  is  com- 
plained of,  a  sensation  as  of  a  nervous  discharge  or 
electric  shower,  starting  from  the  top  of  the  head  and 
passing  quickly  over  the  body  to  the  feet.  This  is 
sometimes  described  as  giving  the  sensation  of  the 
rolling  of  shot;  hence  it  has  been  termed  the  "shot 
feel." 

There  are  no  marked  or  constant  paresthesias  in 
acromegaly,  though  slight  numbness  or  prickling  of 
the  affected  parts  is  often  complained  of,  most  fre- 
quently in  the  fingers.  The  tactile  sense  of  the 
fingers  may  be  impaired,  so  that  small  objects  can- 

97 


Acromegaly 


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not  be  readily  handled,  and  sewing,  knitting,  or  even 
dressing  becomes  difficult.  Sometimes  an  inter- 
mittent vasomotor  spasm  in  the  fingers  has  been 
noted,  causing  localized  anemia  with  severe  pain, 
while  formication  or  hyperesthesia  of  the  hyper- 
trophied  parts  may  occur.  General  numbness  anes- 
thesia, analgesia,  and  impaired  perception  of  heat  or 
cold,  are  rare  conditions  in  this  disease. 

The  electrical  responses  of  the  muscles  and  nerves 
are  rarely  abnormal,  and  the  reflexes,  both  deep  and 
superficial,  are  generally  unimpaired.  Occasionally 
the  patellar  reflex  is  diminished,  and  rarely  it  is 
absent  on  one  or  both  sides. 

The  mental  faculties  in  the  majority  of  cases  are  not 
affected,  but  loss  of  memory,  dulness  or  sluggishness 
of  the  mind,  apathy,  and  depression  have  all  been 
recorded.  Marie  says  that  there  may  be  a  state  of 
gnat  good  humor,  but,  on  the  contrary,  melancholia 
is  more  frequent.  There  may  be  great  irritability, 
while  there  may  be  delusions,  and  the  patient  may 
be  refractory  and  suspicious;  he  may  develop  de- 
cided insanity,  and  may  even  show  suicidal  and 
homicidal  tendencies.  This  condition  may  be  persis- 
tent or  intermittent,  or  may  last  for  a  short  time  and 
not  recur.  Another  interesting  condition  which 
seems  quite  frequently  to  occur  in  acromegaly  is  a 
persistent  drowsiness  even  to  somnolency.  Vertigo 
may  occasionally  occur  and  be  severe  enough  to 
cause  the  patient  to  grasp  something  for  support.  At- 
tacks of  syncope  are  sometimes  a  frequent  symptom. 
It  is  probable  that  the  conditions  showing  sudden 
and  serious  brain  trouble,  all  of  which  point  to  cere- 
bral tumor,  are  due  to  the  first  sharp  pressure  which 
the  enlarged  pituitary  body  exerts  upon  the  brain, 
having  perhaps  suddenly  burst  from  its  bony 
moorings. 

Pathological  Anatomy. — Hypophysis  Cerebri. — 
A  lesion  of  the  anterior  lobe  of  this  structure  is 
probably    always     present    in  cases    of  acromegaly.. 


Fia.  26. — Section  of  Parenchyma  of  the  Thyroid  filand.    The 
whole  gland  weighed  101  grams.      (Author's  Case.) 

Usually  there  is  a  distinct  enlargement,  or  hyperplasia 
(adenoma),  of  the  anterior  lobe,  but  it  may  be  normal 
in  size  or  there  may  be  cystic  or  other  form  of  de- 
generation, the  latter  being  probably  always  second- 
ary. The  changes  found  here  will  be  discussed  in 
the  section  on  Pathogenesis. 

98 


Thyroid. — The  thyroid  gland  is  not  infrequently  ab- 
normal in  acromegaly.  It  may  In-  hypertrophied  and 
give  a  hypersecretion  and  all  of  the  symptoms  of 
exophthalmic  goiter,  or  it  may  be  atrophied  and 
cause  some  myxedematous  symptoms,  or,  which  is 
probably  most  frequently  the  case,  the  gland  is  first 
hypertrophied  and  then  connective-tissue  growth 
displaces  the  glandular  parenchyma,  and  though  the 
gland  is  actually  enlarged,  it  is  producing  a  diminished 
secretion,  and  a  partial  myxedema  occurs.  This 
accords  with  the  symptoms  of  a  long-continued  acro- 
megalic   case,     and     with     the    frequent    autopsical 


" 

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■     ft ) 

Fig.  27. — Section  of  Thoracic  Thyroid  Gland.  The  whole  gland 
weighed  36.5  grams  and  contained  a  large  amount  of  iodine.  (Au- 
thor's Case.) 

finding  of  an  enlarged  and  heavy  thyroid  gland 
sometimes  containing  a  greatly  diminished  amount  of 
iodine.  This  gland  may  also  show  cystic  degenera- 
tion. In  one  of  my  cases  a  large  supernumerary 
thyroid  gland  was  found  in  the  upper  part  of  the 
thoracic  cavity,  which  contained  a  large  amount  of 
iodine. 

Thymus. — The  thymus  gland  has  several  times 
been  found  enlarged  and  in  one  instance  a  fatty  growth 
in  the  region  of  the  thymus  has  been  reported.  In 
these  cases  instead  of  thymus  glands  they  may  have 
been  supernumerary  thyroids.  A  thymus  gland 
contains  no  iodine  (Mendel). 

Brain. — The  brain  has  frequently  been  found  en- 
larged, but  may  not  be,  even  in  cases  which  show 
increase  in  size  of  almost  every  other  organ  of  the 
body.  The  pineal  gland  has  been  found  double  its 
ordinary  size,  and  little  tumor  growths  have  been 
found  attached  to  the  base  of  the  brain. 

Calcified  and  even  ossified  plates  have  been  found  in 
the  dura  mater,  and  its  attachments  to  the  skull  may 
be  ossified.  The  arteries  at  the  base  of  the  brain 
may  be  enlarged  and  thickened,  especially  some  one 
artery  in  the  circle  of  Willis,  while  another  artery  or 
another  part  of  the  same  artery  may  be  distinctly 
narrowed.  The  arteries  may  become  distorted  and 
tortuous,  and  the  posterior  cerebral  has  been  found 
knotted  and  imperforate.  The  cranial  nerves  have 
been  found  either  normal  or  enlarged.  The  nerve 
changes  in  the  brain  and  cord,  if  there  are  any,  are 
probably  secondary  to  the  Vascular  changes.  As  in 
this  disease  we  find  the  blood-vessels  almost  con- 
stantly changed,  we  may  expect  to  find  all  kinds  of 
changes  due  to  a  greatly  modified  blood  supply,  be 
it  in  an  organ  or  in  nervous  tissue. 

Spinal  Cord  and  Nerves. — The  medulla  and  spinal 


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Acromegaly 


cord  are  generally  normal,  but  the  pia  of  the  cord  has 
been  found  I  hickened,  and  some  of  the  columns  of  the 
,.,,i,l  may  be  degenerated.  Probably,  however,  as 
above  stated,  all  nerve  degenerations  of  the  brain  or 
spinal  cord  are  due  to  foregoing  vascular  changes. 

The  nerves  of  the  body,  and  especially  of  the 
extremities,  may  be  enlarged  generally,  this  change 
being  due  to  an  increase  in  the  interstitial  connects  e 
tisane.  They  may  show  sclerosis  in  some  places  and 
fat tv  changes  in  others,  and  their  vessels  may  show 
hyaline  degeneration. 


flu  i  -*'' 


< 


Fig.  2S. — Section  of  the  Pituitary  Body.     (Author's  Case.) 

The  ganglia  and  nerves  of  the  sympathetic  system 
show  no  special  changes,  though  they  may  beenlarged, 
and  from  the  same  cause  as  in  the  case  of  the  spinal 
nerves,  viz.,  from  connective-tissue  growth. 

Heart. — The  heart  is  probably  always  enlarged  in 
acromegaly,  by  reason  of  an  actual  hypertrophy, 
especially  of  the  left  ventricle;  this  being  due  to  the 
increased  work  which  it  must  perform  in  overcoming 
the  resistance  offered  by  the  thickened  blood-vessels. 
Later  the  heart,  though  hypertrophied,  becomes 
weakened  by  the  impaired  action  of  its  muscle  fibers 
due  to  connective-tissue  formation  or  perhaps  to  the 
presence  of  fat  globules,  or  else  to  the  impaired  blood 
supply  of  its  walls,  which  in  turn  is  due  to  thickening 
of  the  intima  of  its  own  nutrient  blood-vessels. 

Blood-Vessels. — The  vascular  changes  are  a  con- 
stant feature  of  acromegaly,  the  intensity  of  these 
changes  or  their  localization  causing  the  many 
variations  of  symptoms  or  conditions  seen  in  different 
cases  of  acromegaly.  More  or  less  generally  all  over 
the  body  the  coats  of  the  arterioles  are  thickened, 
the  intima  being  the  most  affected.  This  may  also 
be  true  of  the  veins,  although  in  many  places  the  vein 
walls  seem  to  be  thinned,  allowing  varicose  conditions 
to  take  place.  This  may  occur  in  the  lower  extremi- 
ties, or  as  hemorrhoids,  or  in  the  large  veins  of  the 
arms  and  neck.  The  epistaxis  noticed  in  some  cases 
is  probably  due  to  this  weakening  of  the  blood-vessels. 

The  blood  is  normal,  or  late  in  the  disease  it  may 
show  simple  anemia. 

Lungs. — The  lungs  are  not  often  affected,  but 
many  times,  both  in  autopsical  reports  and  in  clinical 
accounts  of  cases  of  acromegaly,  "phthisis"  has  been 
mentioned,  or  tuberculous  consolidation  has  been 
found.  Chronic  bronchitis,  edema,  or  passive  con- 
gestion can  develop  from  a  weak  heart  action  in  the 
later  stages. 

The  Digestive  System. — The  stomach  and  intestines 
present  no  specific  abnormalities.  The  pancreas 
often  shows  changes,  especially  in  those  cases  in 
which  glycosuria  has  been  present.  The  liver  is 
generally  enlarged,  sometimes  very  greatly,  and  mav 
show  a  great  increase  in  connective-tissue  growth 
(hypertrophic  cirrhosis).  There  may  be  a  passive 
congestion  or  fatty  degeneration  of  the  liver.  The 
spleen  may  be  enlarged  by  passive  congestion  and  an 
increase  in  its  connective  tissue. 


Genito-Urinary    System. — The    kidneys    are    often 

found  diseased  (chronic  nephritis),  or  I  hey  may  be 
cystic.  They  and  the  suprarenal  glands  may  be 
increased  in  size. 

Microscopical  examination  of  the  genitals  shows  an 
increase   in   connective-tissue   growth    and   even    al 

limes   the   formation   of  fibrous  tissue;   these   I'li.r 
being   accompanied   by   a   gradual    diminution   of   all 
functional  activity. 

Skin. — The  skin  is  hypertrophied  over  the  affected 
portions  of  the  body,  sometimes  in  a  marked  degree. 

This  is  especially  true  of  the  scalp,  hands,  and  feet, 
all  of  the  layers  of  the  skin  taking  part  in  this  thicken- 
ing. The  sweat  glands  may  have  a  double  layer  of 
epithelium.  Fibromata,  neuromata,  and  elephantia- 
sis of  the  skin  have  been  observed,  and  molluscous 
growths  are  of  frequent  occurrence.  The  sub- 
cutaneous fat  may  be  increased  or  decreased  in 
thickness,  but  in  the  later  stages  it  is  probably  nearly 
always  decreased. 

Muscles. — Many  of  the  muscles  at  the  time  of  death, 
unless  I  he  patient  dies  early  in  the  disease  from  some 
intercurrent  affection,  are  found  atrophied,  and  yet 
there  may  be  many  local  hypertrophies.  Certain 
muscles,  especially  the  deltoid  or  the  supraspinatus, 
may  become  greatly  hypertrophied,  forming  veritable 
muscle  tumors. 


Fir,.  29. — Section    of  Branches   of  Vessels  near  the  Posterior 
Tibial  Artery,  Showing  Thickened  Intima.      (Author's  Case.) 

Skeleton. — In  well-marked  cases  nearly  all  of  the 
bones  of  the  body  are  enlarged,  although  a  few 
individual  bones  may  not  take  part  in  this  increased 
growth.  The  long  bones  undoubtedly  show  the 
greatest  enlargement  and  growth  at  their  extremities, 
due  to  the  tendency  of  the  articular  cartilages  to 
ossify;  still  in  many  instances  the  shafts  of  the  bones 
are  also  decidedly  enlarged.  The  spongy  bones  of 
the  skeleton  are  all  more  or  less  thickened,  and  all 
articular  surfaces,  whether  of  long  or  spongy  bones, 
show  a  tendency  to  spread  out,  widen,  and  grow  more 
prominent.  The  flat,  thin  bones,  while  increasing  in 
extent  show  a  tendency  to  become  thinner  in  their 
plates.  This  is  not  true  of  the  cranial  bones,  because 
the  spongy  tissue  in  the  diploe  increases  in  thickness. 
We  sometimes  find  a  thinning  at  the  ends  of  the  long 
bones,  just  back  of  the  articular  surfaces,  while  they 
are  at  the  same  time  extending  their  articular  sur- 
faces.    This  growth  of  bone  is  an  hypertrophy,  the 


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Acromegaly 


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new  bone  growing  from  the  periosteum  and  also 
"within  the  medullary  spongy  tissue  at  the  ends  of  the 
long  bones.  In  the  early  part  of  the  disease  this 
growth  seems  to  be  more  especially  confined  to  the 
periosteum;  later  the  apophyses  and  epiphyses 
become  affected.  The  crests,  tuberosities,  and 
eminences  are  enlarged  and  grow  in  the  direction  of 
the  muscular  action,  a  portion  of  the  tendons  of  the 
muscles  becoming  ossified.  The  tendons  of  the 
muscles  are  often  found  in  deep  grooves  or  bony 
canals,  and  the  foramina  for  the  nutrient  arteries,  and 
especially  for  the  articular  arteries,  are  often  enlarged. 

Osteophytes  may  be  found  in  the  joints,  especially 
over  the  wrist  and  ankle  joints,  or  pieces  of  calcareous 
material  may  be  found  loose  in  a  joint.  The  spongy 
ends  of  the  long  bones  may  become  more  compact, 
through  eburnation  and  a  change  in  the  architecture 
of  the  part.  The  ends  of  the  bones  in  some  cases  have 
shown  condensing  osteitis.  This  laying  on  of  bone 
at  the  extremities,  the  articular  surfaces,  may  lengthen 
a  long  bone  without  the  shaft  being  at  all  affected. 

Head. — The  bones  of  the  cranium  are  always  more 
or  less  thickened,  this  change  being  due  largely  to  an 
increase  of  the  diploe.  The  ridges  and  crests  for  the 
attachment  of  the  muscles  and  fascia?  are  more  promi- 
nent, while  the  occipital  protuberance  has  been  found 
as  a  spicula-like  outgrowth,  an  exostosis.  The 
parietal  eminences  are  sometimes  abnormally  promi- 
nent, as  are  always  the  superciliary  ridges.  The  sella 
turcica  is  always  enlarged  and  deepened,  probably 
because  the  enlargement  of  the  pituitary  body  causes 
the  surrounding  bone  to  undergo  absorption. 

The  lengthening  of  the  face  is  largely  due  to  the 
increase  in  the  vertical  diameters  of  the  superior  and 
inferior  maxilla?.  The  maxillary  bones  and  the 
sphenoid  bones  contribute  the  principal  part  of  the 
total  enlargement  of  the  bones  of  the  skull. 

Many  of  the  sutures  of  the  cranium  and  of  the  face 
are  obliterated  by  complete  co-ossification.  The 
enlarging  malar  processes,  orbital  processes,  and  nasal 
processes  of  the  superior  maxillary  bones  cause  the 
pushing  outward  of  the  malar  bones,  the  lateral  widen- 
ing of  the  orbital  cavities,  and  the  pushing  upward  of 
the  nasal  bones,  thus  causing  the  prominence  of  the 
malar  bones,  the  quadrilateral  appearance  of  the 
orbital  cavities,  and  the  wide  nasal  openings  seen  in 
skulls  of  acromegaly. 

The  lower  jaw  is  massive,  the  chief  growth  being  in 
the  body,  which  is  found  lengthened  and  widened, 
especially  at  the  symphysis,  while  the  mental  process 
stands  out  with  undue  prominence.  The  alveolar 
process  is  widened  and  thickened,  and  the  rami  also 
may  take  part  in  the  growth,  while  the  angle  formed 
by  the  junction  of  the  body  and  the  rami  becomes 
more  obtuse.  The  coronoid  processes  are  often 
greatly  enlarged.  The  growth  of  the  alveolar  process 
is  rarely  participated  in  by  the  teeth,  they  remaining 
normal  in  size,  so  that  while  the  alveolar  cavities 
undergo  enlargement  we  frequently  have  spontaneous 
falling  out  of  the  teeth. 

The  hyoid  bone  may  be  enlarged  with  all  of  its 
ridges  very  prominent,  and  the  laryngeal  cartilages 
may  al>u  I nlarged. 

Spine. — Marked  changes  are  always  found  in  the 
spine,  the  degree  being  due  to  the  age  of  the  disease. 
The  bodies  of  the  vertebra?  are  enlarged,  especially 
from  the  laying  on  of  bone  on  the  anterior  part  in  the 
cervical  and  dorsal  regions.  The  increase  of  bone  in 
this  region  is  often  restricted  to  the  upper  part  of  the 
interarticular  cartilages,  while  in  the  lumbar  region 
the   increase   of  the  bone  is  more  general. 

The  irregular  thickening  of  the  intervertebral  carti- 
lages, with  the  irregular  growth  of  the  bodies  of  the 
vertebra?,  sooner  or  later  causes  deformities  of  the 
spine,  namely,  kyphosis,  lordosis,  or  scoliosis,  or  more 
than  one  deformity.  An  absorption  of  the  inter- 
vertebral discs,  especially  on  the  anterior  borders. 
with  bony  union  of  the  anterior  parts  of  the  bodies, 


and  ossification  of  the  anterior  ligaments,  which  often 
occurs,  may  cause  an  enormous  kyphosis,  the  anterior 
part  of  the  spine  appearing,  under  these  circumstances, 
as  if  formed  of  a  single  bone. 

The  transverse  processes  probably  always  are 
enlarged,  and  may  be  joined  together  by  the  ossifica- 
tion of  their  connecting  ligaments.  This  ossification 
may  take  place  along  the  interspinous  ligaments,  or 
we  may  find  ossification  of  the  posterior  intervertebral 
ligaments.  The  lumbar  vertebra?  are  sometimes  of 
great  size,  and  the  sacrum  may  have  its  lateral  masses 
much  enlarged. 

Thorax. — The  sternum  is  enlarged  and  thickened, 
and  the  ensiform  cartilage  is  ossified  and  generally 
projects  outward.  Large  transverse  ridges  are  often 
found  on  the  sternum;  also  a  hollow  or  depression 
may  be  seen  at  the  upper  part,  due  to  the  manu- 
brium not  enlarging  relatively  as  much  as  the  body  of 
the  sternum. 

The  costal  cartilages  are  large  and  more  or  less 
ossified,  and  often  show  prominent  nodes  at  their 
points  of  junction  with  the  ribs,  thus  simulating  the 
rachitic  rosary.  The  ribs  are  wide  and  thick,  and 
by  the  faster  growth  of  the  costal  cartilages  they 
become  abnormally  oblique,  while  the  sternum  itself 
is  pushed  forward,  giving  an  enormous  anteroposterior 
diameter  to  the  chest. 

Upper  Extremity. — The  clavicles  are  always  en- 
larged, often  enormously  so,  most  marked  at  their 
extremities,  and  especially  at  their  sternal  ends. 
Their  ridges  and  tubercles  are  very  prominent.  The 
scapula?  are  generally  enlarged,  especially  in  their 
transverse  diameters,  and  the  spines  may  be  enor- 
mous in  size. 


Fir,.  30. — .Skiagram  of  the  Right  Forearm  and  \\  rist.     (Author's 
Case  i 

The  articular  surfaces  of  all  the  long  bones  are  en- 
larged, due  to  ossification  of  the  articular  cartilages  or 
ligaments,  and  they  are  often  roughened.  There 
may  be  exostoses,  spongy  growths,  osteophytes,  or 
calcareous  deposits  in  and  around  the  joints. 

The  humerus  is  frequently  not  increased  in  size, 
though  its  extremities,  especially  the  head,  may  be. 
The  radius  and  ulna,  if  the  case  is  of  long  standing, 
are  found  enlarged,  especially  at  their  articular  sur- 
faces, and  more  especially  at  their  lower  extremities. 


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Acromegaly 


The  carpal  bones  are  always  more  of  less  enlarged, 
md  may  all  be  very  markedly  so.  The  metacarpal 
bones  and  phalanges  are  widened  and  thickened;  the 
former  especially  at  their  heads,  and  the  latter  at  each 
jxtremity,  thus  rendering  the  joints  prominent.  The 
listal  phalanges  are  generally  the  most  affected,  and 
nay  show  an  increase  of  spongy  tissue  at  their  ungual 

•IK  is. 

/',  (,-;*. — The  pelvis  is  always  enlarged,  with  the 
symphysis  of  the  pubic  bones  often  wide  and  deep, 
while  the  crests  of  the  ilia  are  wide  apart,  by  reason  of 


Fig.  31. — Skiagram  of  Part  of  an  Acromegalic  Hand,  Showing  Hy- 
>ertrophy  of  the  Soft  Parts  and  Increase  of  Spongy  Tissue  at  the 
Jngual  Ends  of  the  Distal  Phalanges.      (Author's  Case.) 

i  spreading  out  of  the  ilia.  Though  the  pubic  bones 
tnd  the  iliac  bones  may  be  enlarged,  with  their  ridges 
md  eminences  increased  in  size,  and  with  the  obtura- 
tor foramina  enlarged,  the  substance  of  the  bones 
hemselves  may  be  considerably  thinner  than  normal. 
rhe  acetabular  cavities  may  be  enlarged  and  rough- 
;ned  by  partial  ossification  of  the  cotyloid  ligaments. 
Lower  Extremity. — The  femurs  maybe  enlarged  at 
X)th  extremities,  as  may  also  be  the  heads  of  the 
ibia?  and  fibulae.  The  patella  are  often  hypertrophied 
uid  may  present  abnormal  spinous  processes.  The 
nalleoli  are  large.  All  of  the  tarsal  bones  may  be 
enlarged;  especially  is  the  os  calcis  often  enormous, 
m  account  of  the  laying  on  of  bone  at  the  attachment 
if  the  tendo  Achillis.  The  metatarsal  bones  and  the 
Dhalanges  of  the  toes  are  all  enlarged  similarly  to 
;hose  of  the  hands.     Thompson  found  several  of  the 


phalanges  of  the  toes  ossified  together.  The  distal 
phalanges  may  show    spongy  enlargements  at  both 

extremities,  and  there  may  be  spongy  spicules  of  bone 

which  reach  around  from  one  extremity  to  the  other, 
forming  foramina  or  incomplete  notches  on  the  sides 
of  the  bones. 

Pathogenesis. — Some  of  the  earlier  theories  of  the 
pathogeny  of  this  condition  may  be  mentioned,  but 
they  are  purely  of  historical  interest,  being  no  longer 
accepted  as  true  or  even  probable. 

Marie's  theory  was  that  acromegaly  is  dependent 
upon  a  diminished  pituitary  secretion,  this  resulting 
from  more  or  less  destruction  of  the  gland  by  a  new 
growth.  The  new  growth,  however,  is  usually  an 
adenoma  with  increased  secretion,  and  when  it  is  not, 
it  is  a  secondary  degenerative  lesion  occurring  late  in 
the  course  of  the  disease  after  the  mischief  has  been 
done. 

Freund  and  also  Campbell  suggested  that  acromegaly 
was  a  disease  of  puberty,  an  atavistic  anomaly  of 
development  manifesting  itself  at  this  period,  the 
body  in  its  entire  development  at  this  time  harking 
back  to  the  anthropoid  apes.  There  is,  however,  only 
the  very  faintest  superficial  resemblance  between  the 
p-athological  anatomy  in  acromegaly  and  the  normal 
anatomy  of  the  ape. 

Von  Recklinghausen,  Lancereaux,  and  others  have 
inclined  to  the  view  that  acromegaly  is  a  trophoneu- 
rosis. It  is  true  that  vasomotor  disturbances,  neu- 
roses, and  trophic  changes  are  present  in  acromegaly, 
but  they  are  dependent  immediately  upon  the  hypo- 
physeal overgrowth  or  oversecretion,  and  only 
remotely,  if  at  all,  upon  central  nerve  lesions. 

Klebs  believed  that  the  underlying  lesion  was  an 
angiomatosis,  basing  his  theory  on  the  undoubted 
fact  that  signs  of  vascular  disturbance  are  present  in 
acromegaly.  The  blood-vessels  are  increased,  it  is 
true,  but  only,  as  a  rule,  in  proportion  to  the  general 
hypertrophy  of  the  bones  and  soft  parts. 

Other  writers  have  ascribed  the  presence  of  acro- 
megaly to  lesions  of  the  thyroid  gland,  or  to  a  per- 
sistent thymus.  The  thymus  is  seldom  persistent 
in  acromegaly,  however,  and  many  cases  occur  with- 
out any  evidences  of  thyroid  lesions. 

Spitzer  offered  the  suggestion  that  the  disease  was 
due  to  an  error  in  development,  viz.,  an  inclusion  and 
subsequent  growth  of  spinal  cord  rests  in  the  hypo- 
physis cerebri.  This  theory  is  of  course  in  the  highest 
degree  fanciful  and  unsupported  by  anatomical 
findings. 

Another  fanciful  suggestion  is  that  of  Yu  Kon  that 
the  changes  in  acromegaly  are  due  to  pressure  upon 
some  as  yet  undiscovered  trophic  center  at  the  base 
of  the  brain  by  the  pituitary  tumor.  Aside  from  the 
gratuitous  assumption  of  the  existence  of  an  unknown 
center  here,  the  fact  that  cases  of  acromegaly  un- 
doubtedly occur  without  any  enlargement  of  the 
hypophysis  would  seem  to  dispose  of  this  theory. 

It  has  been  asserted  by  more  than  one  writer  that 
acromegaly  is  due  to  an  aplasia  or  degeneration  of 
the  sexual  glands,  this  view  being  supported  by  a 
supposed  resemblance  of  the  skeleton  in  a  castrated 
person  to  that  in  the  disease  in  question,  and  also 
by  the  undoubted  fact  that  there  is  frequently  more 
or  less  loss  of  the  sexual  function  in  the  subjects  of 
acromegaly.  In  such  a  theory  the  consequence  in 
mistaken  for  the  cause,  for  there  can  be  little  question 
that  the  sexual  disturbance  is  a  secondary  condition. 

At  the  present  time  it  is  quite  generally  accepted 
that  acromegaly  is  due  to  some  perversion  of  secretion 
of  the  hypophysis  cerebri,  but  what  this  perversion 
is,  whether  hyperpituitarism  or  hypopituitarism,  is 
even  yet  a  subject  of  dispute.  Because  of  the  fre- 
quent association  of  a  tumor  of  the  anterior  lobe  of 
the  hypophysis,  Marie  believed,  as  above  noted,  that 
the  condition  was  one  of  lessened  secretion;  but 
opinion  inclines  now  rather   to   the   opposite   view, 


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Acromegaly 


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namely  that  there  is  a  supersecretion  of  this  portion 
of  the  gland.  A  more  careful  study  of  the  so-called 
tumors  of  the  anterior  lobe  in  these  cases  has  shown 
that  the  condition  is  one  rather  of  hyperplasia  than 
of  degenerative  neoformation;  the  secreting  cells  are 
not  displaced  by  a  cystic  growth  or  neoplasm,  but 
are  increased  by  reason  of  an  adenomatous  develop- 
ment. In  some  instances,  it  is  true,  there  is  no  tumor 
or  hypertrophy  of  the  anterior  lobe  and  there  may 
even  be  an  apparent  atrophy.  In  order  to  reconcile 
such  findings  with  the  theory  of  supersecretion  three 
explanations  have  been  offered.  The  first  is  that 
though  no  gross  changes  are  evident  there  may 
nevertheless  be  found  microscopically  an  increase  in 
number  of  the  specific  secreting  (eosinophile)  cells, 
or  there  may  possibly  be  a  more  active  secretion 
without  increase  in  number.  Another  theory  is  that 
of  Tamburini  that  there  is  a  primary  hypertrophy  of 
the  anterior  lobe,  which  after  having  produced  the 
mischief,  is  succeeded  by  atrophy.  The  third 
hypothesis  rests  upon  the  recent  discovery  of  acces- 
sory hypophyseal  glands  in  the  vault  of  the  pharynx. 
Killian  (1888)  and  Eidheim  (1904)  noted  the  presence 
of  hypophyseal  tissue  in  the  vault  of  the  pharynx  in 
the  newborn,  and  Civalleri  (1907)  and  Haberfeld 
(1909)  showed  that  an  accessory  pituitary  gland  may 
exist  in  this  situation  in  the  adult.  Moreover, hypo- 
physeal rests  have  been  noted  by  Eidheim  and  Levi 
in  recesses  in  the  sphenoid  bone  in  connection  with 
a  persistent  craniopharyngeal  canal.  It  is  possible 
therefore  that  these  accessory  glands,  acting  with  a 
normal  pituitary  body,  may  produce  an  excess  of 
secretion  and  so  cause  acromegaly. 

While  either  one  or  all  of  these  hypotheses  may  be 
alleged  in  support  of  the  view  that  acromegaly  is  the 
result  of  a  superfunctioning  of  the  hypophyseal  cells, 
it  must  be  admitted  that  the  problem  is  not  yet 
satisfactorily  solved,  even  though  the  weight  of 
evidence  is  in  support  of  supersecretion  rather  than  of 
subsecretion.  One  of  the  strongest  arguments 
against  this  is  the  fact  that  there  may  be  a  true 
adenoma  of  the  hypophysis  without  any  signs  of 
acromegaly.  The  explanation  of  such  cases,  if  the 
theory  of  supersecretion  is  accepted,  is  difficult.  It 
has  been  suggested  that  the  increase  in  pituitary 
secretion  may  here  be  counteracted  by  a  coincident 
increase  in  the  internal  secretion  of  the  sexual  or 
some  other  glands;  but  this  is  a  supposition  only, 
not  an  explanation,  and  is  no  more  satisfactory  than 
a  simple  denial  of  the  fact. 

For  a  discussion  of  the  physiology  and  pathology 
of  the  pituitary,  body,  the  reader  is  referred  to  the 
article  on  Hypophysis  Cerebri. 

Diagnosis. — This  disease  must  be  diagnosed  from 
myxedema,  gigantism,  erythromelalgia,  elephantiasis, 
leontiasis  ossea,  chronic  rheumatism,  syringomyelia, 
rachitis,  osteitis  deformans,  arthritis  deformans, 
pulmonary  hypertrophic  osteoarthropathy,  local 
hypertorphies,  and  adiposis  dolorosa. 

The  principal-  clinical  differences  between  myxe- 
dema and  acromegaly  are  as  follows: 

Acromegaly. 

1.  Both  sexes  are  about  equally 
affected. 

2.  Begins  most  frequently  be- 
tween the  ages  of  twenty  and 
forty. 

3.  Bones  are  always  enlarged. 

4.  Face  is  oval  or  elliptical. 

5.  The  ends  of  the  fingers  are 
of  the  same  size  as  the  bases,  i.e. 
they  are  "sausage-shaped." 

6.  The  skin  is  yellowish, 
wrinkled,  and  hairy. 


Myxedema. 

1.  About  eighty  per  cent,  of 
all  cases  are  women. 

2.  Occurs  most  frequently  be- 
tween the  ages  of  forty  and  fifty. 

3.  Bones  are  never  enlarged. 

4.  Face  is  round  and  full. 

5.  The  ends  of  the  fingers  are 
swollen  and  clubbed. 

6.  The   skin    is   pale,   waxy, 
puffy,  boggy,  and  shiny. 


Gigantism,  or  giant  growth,  is  distinguished  from 
acromegaly  by  the  fact  that  in  the  former  there  is 
symmetrical  and  general  growth  all  over  the  body;  the 


cranium  grows  as  much  as  the  facial  bones,  and  the 
face  does  not  look  too  large  for  the  head,  nor  the  head 
too  large  for  the  body,  as  is  the  case  in  acromegaly. 
In  gigantism  the  ends  of  the  bones  are  not  enlarged 
out  of  proportion  to  the  size  of  the  shaft,  and  the 
hands  and  feet  are  not  enlarged  out  of  proportion  to 
the  arms  and  legs.  The  bones  increase  in  length  as 
well  as  in  width  and  thickness,  and  that  symmetrically, 
and  the  whole  growth  of  the  body  is  in  proportion, 
as  in  a  normal  individual,  all  of  which  is  quite  the 
contrary  of  what  is  observed  in  acromegaly. 

In  erythromelalgia,  a  vasomotor  neurosis  of  the 
extremities,  there  may  be  some  increase  in  the  size 
of  the  hands  and  feet  with  severe  pain,  and  there  is 
always  an  impaired  blood  flow,  giving  burning  sen- 
sations, local  redness,  and  even  cyanosis,  often  in 
patches  or  spots.  There  is,  however,  no  enlargement  of 
the  bones  or  soft  parts  of  the  face,  no  eye  symptoms, 
no  marked  change  in  the  speech,  and  the  hand  itself 
is  unlike  the  acromegalic  hand;  the  fingers  are  not 
sausage-shaped,  but  smaller  at  the  tip  than  at  the  base. 

Elephantiasis  Arabum  is  a  hypertrophic  disease  of 
the  skin  and  subcutaneous  tissue,  located  generally  in 
one,  occasionally  in  two  extremities  of  the  body. 
There  is  generally  a  history  of  several  attacks  of  local 
inflammation  of  the  part  affected,  followed  by  a  con- 
tinuous growth  and  hypertroph}'  of  the  skin,  until  an 
enormous  size  is  reached.  In  elephantiasis  the 
bones  are  not  enlarged,  the  skeleton  is  not  affected, 
and  the  nervous,  facial,  and  cerebral  phenomena  of 
acromegaly  are  not  present. 

Leontiasis  ossea  is  the  name  given  by  Virchow  to  the 
condition  in  which  osteophytes,  or  bony  tumors,  are 
formed  on  the  face  and  cranium.  These  bony  tumors 
are  of  irregular  distribution,  and  produce  great 
deformity  and  asymmetry.  There  is  no  hypertrophy 
of  the  extremities. 

During  the  first  stages  of  acromegaly  one  of  the  fre- 
quent symptoms,  and  often  a  prominent  one,  is  joint 
pain,  which  at  this  stage  might  lead  one  to  mistake 
the  disease  for  chronic  rheumatism.  The  joints  at  this 
time  are  tender  to  the  touch,  but  are  not  reddened  or 
swollen.  The  pain  is  not  permanent  in  any  one  or 
two  joints,  and  ankylosis  does  not  take  place,  although 
later  crepitations  are  often  present,  and  some  con- 
tractures  of  the  fingers  may  be  found,  due  to  the  flexor 
tendons  not  growing  as  rapidly  as  the  bones.  As 
soon  as  the  hands,  feet,  or  face  begin  to  enlarge,  the 
diagnosis  from   chronic  rheumatism   becomes  plain. 

Syringomyelia  is  a  disease  of  the  nervous  system 
which  generally  begins  before  twenty,  or  in  early 
adult  life,  and  in  its  slow  development  and  long  dura- 
tion simulates  acromegaly.  After  the  complete 
development  of  either  disease,  however,  the  amyo- 
trophic paralysis,  with  retention  of  tactile  and  loss  of 
thermic  and  painful  sensation  in  the  case  of  the 
syringomyelia,  and  the  enlarged  extremities  in  the 
case  of  the  acromegaly,  render  the  diagnosis  easy. 
Several  cases  of  acromegaly  have  shown  coincident 
symptoms  of  syringomyelia,  and  autopsical  examina- 
tions  have   revealed    gliomata   in    the    spinal    cord. 

Rachitis  is  a  disease  of  childhood,  or  rather  baby- 
hood, occurring  most  frequently  in  -children  under 
three  years  of  age.  This  alone  would  exclude  the 
possibility  of  confusion  with  acromegaly.  The  ends 
of  the  bones,  especially  the  epiphyses  of  the  wrist,  are 
enlarged  in  rickets,  while  the  hands  and  feet  may  be 
flattened  and  apparently  widened,  but  there  is  no  in- 
crease in  the  thickness  of  the  hands  or  feet.  The 
bones  of  the  head  show  no  malformation,  except 
flattening  and  lengthening  of  the  cranium  with  pro- 
jection of  the  occiput  and  the  softened  spots.  This 
causes  the  cranium  in  rickets  to  appear  too  large  for 
the  face,  while  in  acromegaly  the  face  appears  too 
large  for  the  cranium.  Softening  of  the  ribs  causes  a 
sinking  in  just  before  the  junction  with  the  cartilages, 
giving  the  formation  of  the  rachitic  rosary,  which 
from  another  cause  we  also  find  in  acromegaly.     Ky- 


Hi: 


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Acromegaly 


phosis,  when  it  occurs  in  rachitis,  is  in  the  dorsal 
region,  while  in  acromegaly  it  is  almost  invariably  in 
the  cervicodorsal  region. 

The  diagnosis  between  the  osteitis  deformans  of 
Paget  and  acromegaly  is  shown  in  the  following 
table: 


Ostein*  Deformans. 

1.  Rarely  occurs  before  fifty, 
never  before  forty  years  of  age. 

2.  The  long  bones  are  the 
ones  primarily  affected;  rarely 
arc  (he  hands  or  feet  affected. 

3.  The  long  bones  are  often 
curved,  giving  great  deformity. 


4.  Often  one  lirub  or  one  bone 
is  affected  long  before  another 
limb  or  bone. 

5.  The  cranial  hones  are  af- 
fected, rarely  the  facial. 

6.  The  lower  part  of  the  face 
id  narrow,  giving  it  a  triangular 
appearance. 


Acromegaly. 

1.  Very  generally  begins  before 
forty  years  of  age,  almost  never 
after  fifty. 

2.  The  hands  and  feet  are 
enormous;  long  bones  are  gener- 
ally not  affected  much. 

3.  The  long  bones  are  normal 
in   shape,  possibly  thickened  at 

the  extremities,  but  are  never 
curved. 

4.  The  hands,  feet,  arms,  and 
legs  are  generally  nearly  sym- 
metrical. 

.",.  The  facial  bones  are  affected, 
rarely  the  cranial. 

6.  The  lower  part  of  the  f is 

broad,  giving  it  an  elliptical  ap- 
pearance. 


In  arthritis  deformans  decided  changes  take  place 
in  the  articular  tissues,  and  are  accompanied  by  pain, 
with  sooner  or  later  great  deformity  and  ankylosis 
of  the  joints.  Tender  nodules  may  appear  in  the 
muscles,  while  the  muscles  themselves  become 
atrophied.  The  disease  is  apt  to  attack  the  same 
joints  on  both  sides  of  the  body  symmetrically,  but 
soon  spreads  to  all  of  the  joints.  The  hands  are 
thin  from  the  wasting  of  the  fat  and  muscles,  but  the 
ends  of  the  phalanges  and  metacarpal  bones  may  be 
enlarged  and  nodular.  The  fingers  are  more  or  less 
flexed  and  turned  toward  the  ulnar  side  of  the  arm, 
while  the  joints  of  the  hand  are  all  stiff  and  more 
or  less  completely  ankylosed.  Schulz  has  re- 
ported a  case  of  acromegaly  associated  with  arthritis 
deformans. 

Pulmonary  hypertrophic  osteoarthropathy  is  subse- 
quent to,  or  consequent  on,  some  affection  of  the  lungs, 
which  may  be  a  bronchitis,  an  empyema,  or  perhaps 
most  frequently  some  new  growth  located  primarily 
or  secondarily  somewhere  in  the  respiratory  tract. 
The  hands  are  enlarged,  but  principally  in  the  joints 
and  the  ends  of  the  fingers,  the  middle  of  the  hand  not 
being  attacked.  The  elbow,  shoulder,  and  knee  joints 
are  all  affected,  and  there  is  always  more  or  less  im- 
paired motion.  The  wrist  joint  is  large,  the  hand 
proper  not  much  enlarged,  while  the  fingers  are  in- 
creased in  size,  especially  the  last  phalanx,  but  the 
soft  parts  are  not  hypertrophied.  The  appearance 
of  the  finger  nails  is  also  quite  characteristic  of  this 
disease.  They  appear  too  large  for  the  fingers,  spread- 
ing out  at  the  sides,  and  even  curving  over  the  ends  of 
the  fingers,  often  giving  the  appearance  of  the  beak  of 
a  bird,  while  the  enlarged  ends  of  the  fingers  have 
caused  them  to  be  likened  to  "drum-sticks." 

Local  hypertrophies  are  not  instances  of  partial  acro- 
megaly. These  local  enlargements  of  one  extremity, 
or  one  finger,  or  one  toe  are  generally  congenital, 
though  they  may  increase  in  size  at  the  time  of 
puberty.  One  side  of  the  face  may  be  affected,  in- 
volving the  bones  and  soft  parts,  including  the  tongue, 
tonsil,  and  palate  on  that  side,  but  whatever  the 
enlargement  there  is  no  symmetry. 

Adiposis  dolorosa  is  characterized  by  an  enormous 
deposit  of  fat,  first  in  the  form  of  nodules,  either  in  one 
location  or  in  corresponding  places  on  the  upper  or 
lower  extremities.  These  deposits  soon  cause  pain, 
diminished  sensibility,  and  muscular  weakness,  and 
the  muscles  may  show  the  reaction  of  degeneration. 
The  absence  of  any  marked  enlargement  of  the  hands, 
feet,  and  face,  as  well  as  the  absence  of  increased 
bone  growth,   excludes  confusion  with  acromegaly. 


Prognosis. — The  duration  of  acromegaly  is  vari- 
ously estimated  from  ten  to  twenty  years.  The 
patient  may  die  of  some  intercurrent  disease,  or  may 
live  for  years  with  but  a  slow  progression  of  the 
disease,  but  no  case  of  complete  recovery  has  yet 
been  reported. 

This  disease  is  one  of  continuous  progression,  espe- 
cially in  the  growth  of  the  bones.  Under  treatment,  or 
without  treatment,  periods  of  apparent  quiescence  or 
periods  of  cessation  of  symptoms  occur,  and  the  soft 
parts  of  the  hypertrophied  portions  of  the  body  not 
only  may  not  enlarge,  but  may  actually  appear  to 
be  diminished  in  size.  Yet  even  in  such  cases  the 
bones  apparently  continue  to  grow.  These  periods, 
when  the  patient  may  say  that  he  feels  well,  are  sooner 
or  later  followed  by  marked  exacerbations  of  all  the 
symptoms,  often  coming  on  suddenly. 

Finally,  little  by  little  the  patient  falls  into  a  con- 
dition of  progressive  cachexia,  with  partial  or  nearly 
complete  loss  of  muscular  power.  This  condition 
may  last  for  several  years,  and  then  death  occurs 
unexpectedly  and  suddenly  from  syncope. 

It  is  possible  that  an  enlarged  pituitary  body  may 
cause  coma  and  death.  Most  subjects  of  acromegaly, 
however,  die  of  some  intercurrent  affection,  the  most 
frequent  of  which  are  cardiac  disease,  nephritis,  or 
diabetes,  all  of  which  are  the  results  of  the  connective- 
tissue  hyperplasia  of  the  involved  organs,  viz.,  heart, 
kidney,  or  pancreas  respectively. 

Treatment. — This  disease  is  incurable,  but  in  any 
given  case  we  can  safely  expect  to  ameliorate  many 
of  the  nervous  symptoms.  When  there  is  an  exacer- 
bation of  symptoms,  of  all  treatment  rest  is  the  most 
important,  under  which  all  the  phenomena,  except 
those  produced  by  actual  lesions,  will  improve.  Pain, 
the  most  frequent  cause  of  complaint,  has  been  vari- 
ously treated  by  all  of  the  analgesics,  but  with  only 
temporary  and  varied  success.  The  bromides  are 
often  of  service  in  relieving  the  headache  and  the 
feeling  of  pressure  in  the  head. 

The  constipation  should  be  treated,  while  dyspepsia, 
when  present,  can  be  best  helped  by  a  diet  that  re- 
quires but  little  mastication,  as  prognathism,  which 
is  so  frequently  present,  is  one  constant  cause  of  the 
dyspepsia. 

Any  tonic  treatment,  combined  with  rest,  will  often 
cause  a  cessation  of  the  acute  symptoms  and  an  appa- 
rent pause  in  the  disease,  except  in  the  last  stages. 
If  there  is  atrophy  of  the  muscles  with  great  loss  of 
muscular  power,  strychnine,  given  by  the  mouth  or 
hypodermically,  is  of  value,  especially  when  com- 
bined with  faradism. 

Cardiac  insufficiency  and  renal  insufficiency  should 
be  treated  as  though  they  were  primary  diseases, 
without  regard  to  the  acromegalic  condition. 

The  treatment  of  glycosuria  should  be  cautious, 
i.e.  the  true  diabetic  diet  should  be  assumed  with 
care,  if  at  all.  If  diabetes  is  present,  the  patient 
might  be  fed  on  pancreas,  as  in  acromegaly  diabetes 
seems  to  be  generally,  if  not  always,  of  pancreatic 
origin. 

The  specific  treatment  of  acromegaly  undoubtedly 
must  bear  some  relation  to  the  secretion  of  the  pitui- 
tary gland.  During  the  stage  of  almost  imperceptible, 
gradual,  and  perhaps  symmetrical  growth  of  the  bones, 
pituitary  feeding  would  probably  be  of  no  benefit,  and 
might  even  aggravate  or  precipitate  unpleasant 
symptoms,  such  as  headache.  But  when  a  case  of 
acromegaly  comes  into  our  hands  for  treatment  the 
hypophysis  disease  has  progressed  far  enough  to  give 
nervous  symptoms  and  selective  enlargements  so 
typical  of  the  disease.  At  this  time  we  are  probably 
having  a  diminished  amount  of  normal  secretion  or  a 
wholly  or  partially  perverted  secretion  from  the 
hypophysis.  At  this  time  pituitary  substance  will, 
I  believe,  often  be  found  of  marked  benefit. 

In  a  case  of  acromegaly  I  have  obtained  good  results 
from  pituitary  tablets,  the  dose  varying  from  six  to 


103 


Acromegaly 


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twelve  grains  a  day.  In  this  case  the  headache, 
which  had  been  continuous  for  two  years,  was  mark- 
edly relieved.  While  under  the  treatment  the  appe- 
tite improved,  the  muscular  weakness  disappeared, 
the  nervous  restlessness  subsided,  and  the  patient  was 
able  to  do  her  usual  work,  which  she  was  not  able 
(o  do  before  the  use  of  the  pituitary  substance.  Also, 
tin'  hypertrophy  of  the  soft  parts  of  the  face,  hands, 
and  feet  greatly  diminished.  On  stopping  the  treat- 
ment, the  headaches  and  muscular  weakness  again 
developed. 

In  cases  in  which  the  thyroid  gland  is  pathologically 
so  changed  that  it  cannot  furnish  its  normal  secretion, 
as  denoted  by  mild  myxedematous  symptoms,  the 
feeding  of  thyroid  extract  has  been  of  some  benefit. 

Little  benefit  has  been  derived  from  drugs.  Arse- 
nic has  been  given  without  effect,  but  apparent  im- 
provement has  been  noted  in  a  few  cases  under 
treatment  with  potassium  iodide;  possibly  there  was 
a   luetic  element  present  in   these  instances. 

Oliver  T.  Osborne. 

Actinomycosis. — This  disease  is  a  combination  of 
abscess  formation  and  new  growth  of  connective 
tissue.  In  most  cases  the  disease  has  the  character 
of  a  subacute  or  chronic  suppurative  process,  but  in 
some  cases  the  new  growth  of  connective  tissue  may 
be  so  marked  a  feature  of  the  process  that  it  may 
present  the  character  of  a  tumor  or  neoplasm.  The 
disease  affects  man  and  certain  domestic  animals, 
particularly  cattle,  in  which  it  is  probably  best  known. 
It  has  a  wide  geographical  distribution. 

In  cattle  it  most  commonly  affects  the  jaw  bones, 
where  it  may  take  origin  in  the  medulla  or  the  peri- 
osteum, and  may  lead  to  the  tumor-like  conditions 
which  have  been  long  known  as  medullary  sarcoma  or 
osteosarcoma  of  the  jaw,  or  as  "lumpy  jaw,"  etc. 
The  external  soft  parts  about  the  jaws  and  face,  the 
tongue,  the  peripharyngeal  tissue,  the  stomach,  the 
skin,  and  the  subcutaneous  tissues  in  various  places, 
may  also  be  the  seat  of  the  disease.  Anatomically, 
the  lesions  consist  in  general  of  an  overgrowth  of 
granulation  and  connective  tissues,  throughout  which 
are  distributed,  more  or  less  numerously,  small, 
yellowish,  soft  suppurative  areas  or  abscesses.  If  the 
seat  of  the  lesions  be  the  jaw,  there  is  usually  more  or 
less  new  growth  of  bone  as  well. 

In  swine  the  mamma?,  the  peripharyngeal  tissues, 
the  vertebra',  and  the  spleen  have  been  observed  to 
be  the  seat  of  the  disease.  In  horses  the  disease  may 
occur  in  the  spermatic  cord  after  castration,  as  well 
as  in  the  jaw  bones  and  in  the  bones  of  the  extremities. 
A  few  cases  of  the  disease  have  been  observed  in 
dogs. 

In  man  the  disease  is  probably  more  common  than 
is  generally  supposed.  It  most  frequently  affects  the 
tissues  in  and  about  the  oral  cavity,  the  pharynx,  and 
the  neck.  It  also  frequently  affects  the  lungs,  the 
bones  of  the  thorax,  and  the  intestinal  tract.  Almost 
any  organ  or  part  of  the  body  may  become  the  seat  of 
the  disease.  Anatomically,  actinomycosis  in  man  is 
essentially  a  destructive  suppurative  process  accom- 
panied by  a  new  growth  of  connective  tissue  which 
in  general  is  not  as  abundantly  developed  as  in  the 
disease  in  cattle,  so  that  in  man  the  tumor-like  lesions 
are  less  frequent. 

Pathology — The  disease  is  due  to  the  action  of  a 
vegetable  parasite  upon  tissues  which  are  suitably  sus- 
ceptible. This  parasite  is  an  organism  closely  allied  to 
the  bacteria,  but  belonging  to  a  higher  class.  Itoccurs 
in  the  lesions,  and  in  the  discharges  from  them,  as 
small  aggregations  or  colonies,  of  variable  size,  which 
in  most  cases  are  visible  to  the  naked  eye  as  grayish 
or  yellowish  granules  or  lobulated  bodies,  less  than  one 
millimeter  in  diameter.  The  presence  of  the  peculiar 
granules  in  the  lesion  or  in  the  pus  is  characteristic 
and  diagnostic  of  the  disease.  As  a  rule  they  are  soft, 
and  when  placed  on  a  slide  and  covered  with  a  cover 

104 


glass,  they  are  flattened  or  crushed  by  the  weight  of 
the  latter.  In  some  instances,  especially  in  cases  in 
cattle,  they  may  be  more  or  less  calcified.  Under  a  low 
magnifying  power  a  granule  crushed  beneath  a  cover 
glass  will  appear  as  an  aggregation  of  lobulated 
hyaline  masses,  with  rounded,  finely  serrated  borders 
which  may  have  a  slightly  brownish  tint.  In  some 
instances  a  fine  radial  striation  may  be  made  out  at 
the  margins.  As  a  rule  masses  of  pus  cells  will  be 
found  surrounding  the  hyaline  masses  and  making 
up  a  portion  of  the  bulk  of  the  granules.  Under 
a  higher  magnifying  power  the  hyaline  material  in 
places  will  have  the  appearances  of  being  made  up  of 
a  dense  feltwork   of   delicate   filaments   having   the 


Fig.  32. — Portion  of  the  Margin  of  an  Actinomycotic  Granule 
crushed  under  a  cover  glass,  as  it  appeared  under  a  moderately 
high  magnifying  power.  Various  forms  and  appearances  of  the 
"clubs"  are  shown. 

« 

diameter  of  bacilli  of  moderate  size  and  closely  packed 
together.  At  the  margins  these  filaments"  usually 
have  a  radial  arrangement,  and  some  of  them  project 
beyond  the  limits  of  the  hyaline  mass.  In  the  case  of 
some  granules,  the  margin  of  the  hyaline  mass  may 
be  formed  of  a  row  of  closely  set,  elongated,  finger- 
shaped,  or  club-shaped,  or  bulb-shaped  bodies,  com- 
posed of  a  hyaline  substance  and  arranged  radially 
(Figs.  32  and  33).  These  bodies  constitute  the  so- 
called  "clubs"  or  "rays"  on  account  of  which  the 
name  "ray  fungus"  has  been  applied  to  the  parasite. 
They  are  of  variable  size  and  width,  often  being  three 
or  four  times  the  width  of  the  filaments.  In  stained 
preparations  a  stained  filament  may  often  be  seen  in 
the  median  portions  of  the  "clubs"  or  "rays,"  which 
for  this  and  other  reasons  are  regarded  as  modifica- 
tions of  the  marginal  filaments  (Fig.  29).  These 
bodies  are  usually  better  developed  in  granules  from 
old  than  from  recent  lesions.  If  one  of  the  granules 
be  broken  up  on  a  cover  glass  and  suitably  stained 
there  will  be  seen  on  microscopical  examination, 
tion,  besides  long  filaments  which  branch,  short  rod- 
like or  bacillus-like  or  coccus-like  forms  (Fig.  30). 
These  forms  may  be  fragments  of  filaments  or  true 
bacilli  and  cocci  growing  in  intimate  association  with 
the  specific  microorganism  as  secondary  infecting 
elements.  Such  secondary  infection  of  the  lesions  by 
bacteria  is  quite  common. 

Microscopically,  the  lesions  consist  of  larger  or 
smaller  abscesses,  each  containing  one  or  two  of  the 
granules  or  colonies,  and  bounded  by  connective 
tissue,  in  all  grades  of  development  (Fig.  3(i).  In  the 
latter,  giant  cells  may  be  present.  A  granule  in  a 
section  stained  by  Gram's  method  appears  as  a  mass 


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AcromcKaly 


of  filaments  embedded  in  a  hyaline  material  and  .-.bow- 
ing at  tlic  margin  more  or  less  radially  arranged  fila- 
ments, or  the  ••clubs"  or  "  rays"  previously  described 
(Figs.  33  and  36).  The  hyaline  material  seems  to  be 
composed  in  many  instances  of  non-staining  degener- 
ated filaments.  In  other  instances  the  nature  of  this 
hyaline  material  is  not  clear,  but  it  is  very  probably 
the  result  of  degenerative  processes  in  the  colony. 
It  is  not  uncommon  to  see  bacillus-like  fragments  of 
the  organism  in  or  among  the  pus  cells  surrounding 
the  colony. 


jr. 

• 
f 

%    • 

* 

M 

-. 

^ 

§ 

^. 

• 

& 

m 

''fa** 

•> 

f'^             J*.H 

ft  .                           * 

Fig.  33. — A  <  rranule  or  Colony  of  Actinomyces,  in  a  section  about 
two micromilli meters  thick,  showing  the  "clubs"  with  central  fil- 
aments at  the  margin.  The  general  structure  of  the  colony  is 
shown  also.  From  an  abscess  in  the  heart  in  a  human  case. 
X750. 

The  pathological  significance  of  the  granules  in  the 
lesions  of  the  disease  was  first  clearly  shown  by 
Bollinger  in  1877,  although  their  presence  had  been 
noted  previously  by  several  observers  whose  work  was 
incomplete  and  did  not  receive  general  recognition. 
Bollinger  regarded  the  granules  as  growths  of  a  fungus 
and  as  the  essential  cause  of  the  disease.  Harz,  a  bota- 
nist, confirmed  Bollinger's  ideas  of  their  fungous  nature 
and  called  the  organism  ''Actinomyces  bovis,"  a 
name  that  has  clung  to  it  ever  since.  The  disease 
in  man  was  first  recognized  and  identified  as  due  to 
the  same  cause  as  that  found  in  the  disease  in  cattle 
by  Ponfick  a  short  time  after  Bollinger's  publication. 
The  granules,  however,  had  been  seen  in  a  suppura- 
tive process  in  the  neighborhood  of  the  vertebrae  in 
man  by  Langenbeck  in  1845,  and  had  been  described 
and  figured  by  Lebert  in  his  "  Atlas  of  Pathological 
Anatomy,"  published  in  1856. 

Many  untrustworthy  observations  have  been 
published  concerning  the  cultural  peculiarities  of 
Actinomyces  bovis.  It  is  commonly  stated  in  text- 
books that  culture  methods  have  shown  that  various 
pathogenic  species  of  this  parasite  are  known,  but 
the  writer  considers  that  the  observations  upon 
which  these  statements  are  based  are  open  to  serious 
question. 

It  is  the  writer's  opinion  based  upon  his  own  obser- 
vations and  those  of  others,  that  but  one  species  of 


Actinomyces  is  the  specific  infectious  agent  of  actinomy- 
cosis. This  microorganism  was  first  described  by  Woltf 
and  Israel  in  1891  and  has  been  isolated  from  many 
cases  of  the  disease  since  thai  time  l>y  various  workers 
[vide  V.  Harbitz  and  N  li.  Grondahl,  Am. ./.  Med.  Sci., 
September,  1911).  It  grows  on  certain  of  the  ordinary 
culture  media  in  the  form  of  masses  or  colonies  of 
closely  [lacked  branching  filaments  resembling  its 
colonies  in  the  tissues.  It  grows  best  al  body  tem- 
perature but  does  not  grow  at  all  at  ordinary  tem- 
peratures. The  characteristic  "clubs"  may  be  de 
veloped  in  colonies  placed  in  sterile  blood  serum,  as 
has  been  shown  by  the  writer. 

By  the  inoculation  of  guinea-pigs  and  rabbits  in 
the  peritoneal  cavity  with  cultures  of  the  micro- 
organism, nodular  lesions  may  be  produced  which 
have  the  characteristic  microscopical  appearances  of 
the  lesions  of  actinomycosis  and  the  inoculated  cul- 
ture material  forms  the  characteristic  "club-"  bearing 
colonies  or  granules.  It  is  not  known  whether  the 
disease  can  be  produced  experimentally  in  cattle  and 
other  animals. 

This  species  of  branching  microorganism  has  been 
confused  with  certain  other  similar  microorganisms 
which  are  widely  distributed  in  the  outer  world  and 
some  of  which  occasionally  have  been  found  in 
inflammatory  processes.  These  differ  from  it  so 
markedly  in  certain  ways  that  the  writer  thinks 
that  the}'  should  be  classed  in  a  separate  genus,  and 
that  cases  of  infection  by  them  should  not  be  called 
actinomycosis. 


Fig.  34. — A  Cover-glass  Preparation  Made  from  a  Granule. 
Some  rods  and  branching  filaments  in  association  with  pus 
cell  are  shown.    X  1,000. 

The  most  frequent  seat  of  primary  actinomycosis  in 
man  is  the  tissues  about  the  buccal  cavity  and  the 
neck.  Primary  actinomycosis  of  these  parts  forms 
more  than  half  of  all  the  recorded  cases.  Next_  in 
frequency  is  primary  actinomycosis  of  the  digestive 
tract  and  of  the  lungs.  Primary  actinomycosis  of  the 
outer  skin,  exclusive  of  the  skin  of  the  face  and  neck, 
is  less  frequent.  Various  cases  have  also  been  recorded 
of  actinomycosis  of  various  organs,  including  the  brain, 

105 


Acromegaly 


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without  any  demonstrable  primary  lesion  in  the  situa- 
tions above  mentioned. 

The  infecting  organism  is  probably  frequently 
carried  into  the  tissues  along  with  foreign  bodies, 
especially  such  as  occur  in  food  material  in  the  ease 
of  cattle.  The  not  infrequent  finding  of  such  foreign 
bodies  in  or  near  the  lesions  of  the  disease,  and  the 
observations  of  the  increase  of  the  disease  in  herds  of 
cattle  when  a  change  has  been  made  in  their  food,  as 
also  the  very  frequent  localization  in  the  neighbor- 


US 


.  ■'•< 


Fig.  35. — Section  of  a  Portion  of  an  Actinomycotic  Lesion  in 
the  Liver  of  the  Same  Case  as  That  Mentioned  in  Fig.  29.  The 
abscess,  containing  a  "colony"  or  "granule,"  and  the  surround- 
ing connective-tissue  growth  extending  into  the  liver  sub- 
stance, are  shown.  The  "colony"  appears  as  a  rounded,  dark 
mass  in  the  right  upper  quadrant  of  the  figure.  Low  magnifying 
power. 

hood  of  the  mouth,  pharynx,  etc.,  support  this  idea. 
The  facts  that  it  does  not  grow  at  the  ordinary  tem- 
perature of  the  air  but  best  at  body  temperature  and 
that  no  one  has  ever  satisfactorily  demonstrated  its 
occurrence  outside  of  the  body,  suggest  that  it  is  a 
natural  inhabitant  of  the  gastrointestinal  tract  as  are 
certain  of  the  pathogenic  bacteria  such  as  the  pneu- 
mococcus.  The  demonstration  by  F.  T.  Lord  of  the 
frequent  occurrence  in  carious  teeth  and  in  tonsillar 
crypts  of  microorganisms  very  closely  resembling  it, 
is  strongly  in  favor  of  this  view.  The  widely  accepted 
teaching  that  its  natural  habitat  is  on  grains  and 
grasses  is  based  on  faulty  knowledge  of  its  biological 
characters  and  is  erroneous.  There  is  no  satisfactory 
evidence  that  the  infection  may  be  transmitted  from 
animals  to  man  or  from  one  individual  to  another. 

Actinomycosis  in  man  is  distinguished  from  the 
disease  in  cattle  not  only  by  a  less  extensive  new 
formation  of  connective  tissue,  but  also  by  its  greater 
tendency  to  the  formation  of  fistula?  and  sinuses,  by 
which  the  disease  may  extend  widely  from  one  organ 
to  another.  Such  sinuses  may  extend  from  the  tissues 
about  the  mouth  or  pharyngeal  cavities  deeply  into 
the  thorax  and  along  the  spinal  column  (prevertebral 
phlegmon).      In   actinomycosis   of   the   lungs   fistula) 


may  perforate  the  chest  wall  or  go  through  the  dia- 
phragm into  the  abdominal  cavity.  In  actinomycosis 
of  the  intestines  fistulae  may  form  which  usually  perfo- 
rate the  anterior  abdominal  wall;  they  may,  however, 
extend  through  the  lumbar  region  or  into  the  rectum 
or  bladder.  The  disease  may  also  extend  metastat- 
ically  through  invasion  of  the  blood  stream  by  the 
organism,  and  in  this  way  various  organs  at  a  distance, 
such  as  the  heart,  brain,  kidneys,  etc.,  may  become 
the  seat  of  the  disease.  Only  rarely  does  it  spread  by 
the  way  of  the  lymphatics.  Secondary  infections 
with  pyogenetic  cocci  may  occur. 

The  clinical  course  and  prognosis  of  the  disease 
depend  upon  its  extent  and  localization,  and  upon  the 
occurrence  of  secondary  infections  with  the  pyogenic 
cocci.  The  last  mentioned  is  an  unfavorable  com- 
plication. In  extensive  involvement  of  internal 
organs  there  may  be  fever  and  marked  disturbance  of 
nutrition.  The  cases  in  which  it  is  localized  about  the 
buccal  cavity  or  neck  may  be  cured  by  surgical  treat- 
ment, but  recurrences  after  apparent  cures  are 
frequent.  The  bones  of  the  jaw  are  rarely  affected  in 
man.  The  occurrence,  in  the  soft  parts  of  the  neck 
or  cheek  near  the  jaw,  of  hard  swellings  which  have 
arisen  painlessly  and  present  a  fluctuating  or  suppu- 
rating focus,  should  excite  suspicion  of  actinomycosis. 

Actinomycosis  of  the  lungs  in  general  resembles 
chronic  pulmonary  tuberculosis.  The  affection  may 
last  for  months  or  years.     It  is  characterized  by  cough, 


■  ■  - 


^»"  V  y; 


■T&t-  ^£  jE»  -*  &$*?^£t»  ,•$&   '  , 


Fig.  36. — A  Colony  of  Actinomyces  in  a  Section  of  the  Same 
Lesion  as  in  Fig.  29.  This  is  a  colony  composed  of  filaments  and 
hyaline  substance.     There  are  no  "clubs."      X  500. 

by  much  sputum,  which  is  often  fetid  or  bloody,  and 
by  marked  pains  in  the  breast  and  back.  There  are 
also  irregular  fever  and  progressive  emaciation. 
Fistula?  perforating  the  chest  wall  and  involving  the 
sternum  or  ribs  are  not  infrequent.  In  this  the  disease 
differs  radically  from  tuberculosis  of  the  lungs.  The 
prognosis  is  generally  bad.  Remissions  with  appear- 
ances of  healing  occur.  The  process  may  be  localized 
in  any  part  of  the  lungs.  It  usually  appears  as  small 
abscesses  or  bronchopneumonia  patches,  from  which 


106 


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Active  Constituents  of  Plants 


cavities  may  be  formed  accompanied  by  new  growth 
of  connective  tissue. 

Actinomycosis  of  the  intestines  is  characterized  by 
extensive  induration  due  to  a  marked  development  of 
peritoneal  adhesions  and  to  the  extension  of  the  proc- 
ess to  the  abdominal  wall  and  neighboring  organs. 
\,  before  mentioned,  the  tendency  to  the  formation  of 
the  fistula'  is  marked.  Metastatic  involvement  of  the 
liver  is  not  unusual.  The  prognosis  must  be  regarded 
as  unfavorable  in  general. 

Actinomycosis  of  the  skin,  according  to  Leser 
(Archil*  f.  klin.  Chir.,  1899,  xxxix.),  may  appear  as  a 
circumscribed  ulcerated  lesion  or  as  a  nodular  forma- 
tion with  central  cicatrizations.  The  subcutaneous 
tissue  may  also  be  affected  and  a  chronic  phlegmonous 
condition  be  produced. 

I  ine  of  the  forms  of  the  disease  known  as  "Madura 
foot"  is  very  probably  actinomycosis  of  the  part. 
This  is  the  so-called  "white"  or  "ochroid"  variety,  in 
which  the  characteristic  granules  in  the  lesions  are  of 
this  color.  The  "black"  or  "melanoid"  variety  of 
"Madura  foot"  is  due  to  an  altogether  different 
vegetable  parasite,  which  is  a  hyphomycete  (Wright: 
Transactions  of  the  Association  of  American  Physi- 
cians, 1S9S,  Journal  of  Experimental  Medicine,  vol. 
Hi.,  1898). 

The  diagnosis  of  actinomycosis  is  made  by  finding 
the  characteristic  granules  or  colonies  of  the  organism 
in  the  lesions  or  in  the  discharges  from  the  same. 
These  in  some  instances  may  be  so  obscure  as  to  escape 
observation  with  the  naked  eye.  Microscopic  exami- 
nation is  necessary  to  distinguish  the  colonies  or 
granules  from  small  pieces  of  necrotic  tissue  and  masses 
of  pus  cells.  The  pus  or  suspected  material  should  be 
spread  on  a  piece  of  glass.  In  this  way  the  granules 
will  be  more  easily  seen.  In  actinomycosis  of  the 
lungs  the  organism  may  be  found  in  the  sputa  and  in 
the  discharges  from  fistulas  in  the  wall  of  the  thorax. 
In  the  sputum  the  parasite  is  to  be  distinguished  from 
the  common  leptothrix  of  the  mouth  by  the  fact  that 
the  filaments  of  the  latter  are  larger,  straighter,  and 
thicker  and  do  not  branch  as  do  the  filaments  of 
actinomycosis.  The  leptothrix  filaments  are  also 
frequently  adherent  to  epithelial  cells. 

The  treatment  of  actinomycosis  should  be  operative 
if  the  extent  of  the  disease  admits  of  it. 

In  internal  treatment  good  results  are  said  to  have 
been  obtained  from  the  use  of  potassium  iodide. 

The  photographs  which  accompany  this  article  were  made  by  Mr. 
L.  S.  Brown  and  the  writer,  in  the  Clinico-Pathological  Laboratory 
of  the  Massachusetts  General  Hospital. 

James  Homer  Wright. 


Actinomyxida. — An  order  of  protozoans  in  the 
class  Sporozoa.  These  animals  consist  of  a  double 
cellular  envelope,  three  polar  capsules,  and  eight 
spores  arranged  in  ternary  symmetry.  There  are 
four  genera,  mostly  parasitic  in  annelid  worms. 
See  Protozoa.  A.  S.  P. 


Active  Constituents  of  Plants. — If  this  term  were 
strictly  interpreted,  we  should  omit  from  consideration 
all  but  those  constituents  which  produce  positive 
physiological  effects,  other  than  nutritive,  upon  the 
animal  system.  As  this  treatment  would  exclude 
some  substances  having  important  medical  and  phar- 
maceutical relations,  especially  the  latter,  it  is  deemed 
better  to  consider  briefly  all  plant  constituents  which 
affect  the  properties  or  uses  of  drugs  or  medicines. 
_  Of  the  nutrients  proper,  the  albuminoids  may  be 
dismissed  as  of  neither  medicinal  nor  pharmaceutical 
importance  in  the  department  of  materia  medica. 
The  sugars,  inulin,  starch,  and  cellulose,  as  well  as  the 
more  important  plant  acids,  are  considered  in  their 
respective  alphabetical  order. 


The  other  principles  of  interest  to  us  may  be 
conveniently  divided  into  the  inorganic  and  the 
organic. 

The  inorganics  from  this  source  are  not  treated  as 
of  importance  in  tin-  modern  materia  medica.  The 
vegetable  compounds  of  iron,  being  readily  assimi- 
lated are  probably  worthy  of  much  more  study  and 
rational  employment  than  has  been  accorded  thorn 
heretofore.  Sea,  weeds  have  long  been  a  well-known 
source  of  iodine,  ami  some  vegetable  drugs  apparently 
owe  their  properties  largely  to  this  element.  For 
the  rest,  the  value  of  the  inorganics  in  drugs  depends 
chiefly  upon  the  presence,  especially  in  such  fruits  as 
prunes  and  tamarinds,  of  the  well-known  laxatives 
salts,  the  properties  of  which  do  not  differ  from 
those  of  inorganic  origin.  It  is  possible  to  obtain 
important  cutaneous  stimulant  effects  from  the  use 
of  many  vegetable  substances  rich  in  needles  of  cal- 
cium oxalate,  although  the  fact  has  never  been  duly 
appreciated. 

The  organic  constituents  which  here  require  atten- 
tion are  the  vegetable  acids,  gums,  fixed  oils,  resins, 
volatile  oils,  amaroids,  glucosides,  alkaloids,  and  en- 
zymes, together  with  such  mixtures  as  oleoresins, 
gum-resins,  and  balsams. 

Vegetable  Acids. — The  number  of  vegetable  acids 
which  have  been  extracted  from  plants  is  very  great, 
though  only  a  few  are  found  widely  distributed  among 
different  plants.  In  the  plant  they  serve  a  variety  of 
useful  purposes.  Some  of  them,  at  least,  act  as 
reserve  foods,  being  manufactured  during  darkness 
and  consumed  in  the  light,  while  the  reverse  is  true  of 
starch.  They  combine  with  organic  and  inorganic 
bases,  which  are  thus  rendered  soluble  and  trans- 
portable. They  render  many  fruits  more  palatable, 
thus  influencing  dissemination,  and,  on  the  other 
hand  and  in  other  cases,  by  their  irritating  or  anti- 
septic properties  they  protect  the  plant  against  its 
enemies.  Those  which  are  of  a  resinous  nature  are 
thus  particularly  useful  in  preventing  fermentation 
and  decay  (see  Resins).  Another  class  form  an 
essential  element  in  the  composition  of  fats  and  are 
known  as  fatty  acids  (see  Fixed  Oils).  Some  of  the 
vegetable  acids,  as  tannic,  citric,  benzoic,  and  hydro- 
cyanic, are  of  direct  use  as  medicinal  agents,  while 
others  are  of  pharmaceutical  interest,  as  influencing 
the  extraction  of  the  associated  .substances.  It  has 
been  claimed  in  numerous  instances  that  a  basic 
organic  substance  is  more  efficient  when  administered 
in  combination  with  its  iiatural  acid.  Many  of  the 
natural  compounds  of  these  acids  are  with  the 
inorganic  constituents,  and  it  is  these  salts  which 
chiefly  render  some  fruits  and  vegetables  laxative. 
The  antiseptic  properties  which  render  many  acids 
of  value  to  the  plant  are  made  to  render  a  similar 
service  to  man. 

The  acid  properties  of  the  vegetable  acids  are  much 
weaker  than  those  of  the  inorganic  acids,  so  that  they 
yield  up  their  bases  to  the  latter.  They  are  also  less 
corrosive  and  irritating  than  the  latter,  and  they  often 
cannot  perform  the  same  service  in  digestion.  Taken 
continuously  or  in  excess,  they  can  impair  digestion 
or  cause  gastritis,  and  they  are  supposed  to  favor  a 
rheumatic  diathesis.  Their  salts  are  commonly  more 
soluble  than  those  of  the  inorganic  acids.  Their  in- 
compatibilities are  in  general  the  same  as  those  of 
the  latter. 

Gums  are  supposed  to  exist  as  waste  substances  in 
the  plant.  They  usually  form  in  successive  layers 
upon  the  inside  of  the  cell  wall — the  process  known  to 
botanists  as  "mucilaginous  degeneration."  While 
these  statements  are  true  of  those  gums  which  are 
collected  as  such  for  medical  and  pharmaceutical 
uses,  another  class,  occurring  in  such  drugs  as 
althaea,  apparently  act  as  reserve  foods.  These  are  of 
interest  as  affecting  pharmaceutically  the  prepara- 
tions of  drugs.  The  gums  are  insipid,  insoluble  in 
alcohol   or   ether,   but   soluble   in   water   to   form   a 


107 


Active  Constituents  of  Plants 


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mucilage  or  an  adhesive  jelly.  They  differ  in  their 
precipitation  tests,  but  are  mostly  precipitated  by 
lead  acetate  and  by  alcohol.  Their  presence  in  an 
alkaloidal  solution  will  very  often  prevent  the  pre- 
cipitation of  the  latter  by  tannin  and  by  weak  solu- 
tions of  metallic  salts.  Chemically,  the  gums  are 
compounds  of  special  acids  with  potassium,  calcium, 
and  magnesium.  Medicinally  the  gums  are  inert,  but 
they  serve  to  form  a  protective  covering  in  many 
cases,  thus  guarding  against  irritation,  as  in  corrosive 
poisoning.  When  used  externally  for  this  purpose, 
some  antiseptic  substance  should  be  added.  Muci- 
laginous substances  are  highly  prized  in  the  making 
of  poultices,  because  of  their  marked  power  to  retain 
heat  and  moisture.  Here,  also,  it  is  desirable  to  add 
an  antiseptic. 

Peclosc,  the  mucilage-like  or  gelatinous  constituent 
of  such  fruits  as  apples  and  pears,  and  of  such  vege- 
tables as  turnips  and  beets,  acts  pharmaceutically 
like  mucilage,  being  soluble  in  aqueous  extracts,  but 
precipitated  upon  the  addition  of  alcohol. 

The  gelatinous  principle  of  sea  weeds  shares  the 
properties  of  gum  and  pectose,  and  exists  in  very  large 
percentage. 

Fixed  oils,  or  fats,  as  those  oils  are  called  which  are 
solid  at  ordinary  temperatures,  are  compounds  of 
special  acids,  known  as  fatty  acids,  with  glycerin. 
From  the  names  of  these  compounds  those  of  the 
acids  are  derived,  as  oleic  acid  from  "olein,"  stearic 
acid  from  "stearin,"  palmitic  acid  from  "palmilin." 
Many  fats  are  mixtures  of  such  compounds.  In  the 
plant,  fats  are  stored  in  parenchymatic  tissue  in  the 
cell  cavity.  As  they  are  reserve  foods,  of  special  use 
in  the  developing  embryo,  we  find  them  specially 
characteristic  of  seeds,  stored  in  both  endosperm  and 
embryo.  They  have  a  characteristically  smooth 
feeling  to  the  touch,  are  not  volatile  or  inflammable, 
but  combustible,  insoluble  in  water,  rarely  soluble  in 
alcohol,  and  then  but  partly  so  (see  Castor  and  Croton 
Oils),  but  are  soluble  in  volatile  oils,  ether,  and  chloro- 
form. Heated  with  or  kept  mixed  with  alkalies,  they 
are  decomposed  into  their  glycerin,  which  is  left  free, 
and  their  acid,  which  unites  with  the  alkali  to  form 
soap,  the  process  being  known  as  "saponification." 
On  exposure  to  the  atmosphere,  they  undergo  a 
peculiar  decomposition  known  as  rancidity,  giving 
them  a  very  disagreeable  odor  and  taste.  Physiolog- 
ically, they  are  important  nutrients,  of  exceptional 
value  because  of  their  ready  absorbability  through 
the  skin,  especially  when  rubbed  upon  it.  They  are 
not  dialyzable,  but  by  the  aid  of  an  albuminous 
substance  and  of  gum  they  are  resolved  into  an 
extremely  finely  divided  state  of  suspension  known  as 
an  "emulsion,"  and,  more  or  less  of  this  change  taking 
place  in  the  intestine,  they  can  then  become  absorbed. 
They  act  as  protectives,  and,  by  their  lubricating  and 
softening  power,  as  laxatives,  whether  taken  internally 
or  per  rectum.  It  has  been  suggested  that  if  taken 
in  large  quantities,  the  glycerin  set  free  by  their 
saponification  in  the  duodenum  acts  as  a  laxative 
also. 

They  readily  dissolve  a  great  number  of  substances, 
and  become  thus  of  the  greatest  use  pharmaceutically, 
as  vehicles.  This  use  is  the  more  important  because 
of  their  great  absorbability,  which  favors  the  absorp- 
tion of  many  dissolved  medicinal  substances  used 
externally  and  internally.  This  property  has  to  be 
considered  in  poisoning,  as  some  poisonous  substances 
not  naturally  absorbable  from  the  intestine  may  be 
so  under  their  influence.  Fats  are  naturally  destruc- 
tive to  insect  life,  apparently  by  clogging  up  their 
breathing  apparatus.  They  therefore  exert  an 
important  action  as  parasiticides  and  increase  the 
activity  of  other  agents  of  this  class.  For  similar 
reasons,  they  are  efficacious  in  destroying  ascarides. 
The  medicinal  effect  proper  of  fixed  oils  is  very 
slight,  if  we  except  a  few  like  castor  and  croton  oils, 
which  are  apparently  complex  substances  and  contain 

108 


an  irritating  element.  The  same  is  probably  true  of 
toxicodendrol,  the  poisonous  fat  of  poison  ivy  and 
its  relatives. 

Resins. — These  are  in  some  respects  like  the  fats, 
in  others  like  the  volatile  oils.  They  are  solid,  non- 
volatile and  non-inflammable,  but  fusible  and  com- 
bustible. They  are  insoluble  in  water,  but  most 
readily  soluble  in  volatile  oils;  frequently  also  in 
alcohol,  fixed  oils,  ether,  and  chloroform.  They  are 
acid  in  nature  and  are  saponified  by  alkalies,  giving 
us  a  series  of  resin  soaps.  Nitric  acid  converts  them 
into  a  peculiar  substance  resembling  tannin.  They 
are  apparently,  at  least  for  the  most  part,  waste 
substances  in  the  plant,  which  transports  them 
through  its  tissues  dissolved  in  volatile  oils,  as  liquid 
oleoresins,  in  which  form  they  are  stored  in  special 
lacuna1,  ducts,  or  tubes.  They  are  of  use  to  the  plant 
by  rendering  its  food  storage  parts  antiseptic  and 
disagreeable,  or  even  dangerous,  to  animals  eating 
them.  Pharmaceutically,  the  resins  are  very  trouble- 
some, as  they  are  dissolved  in  the  alcohol  in  the 
extraction  of  many  drugs,  and  are  then  most  easily 
precipitated  upon  the  addition  of  water,  and  often  of 
acid  substances.  As  to  their  medicinal  properties 
and  uses,  the  resins,  by  warming,  become  adhesive 
and  have  numerous  and  important  uses  depending 
upon  this  property.  Those  which  are  little  irritating 
can  be  used  as  protectives,  upon  the  evaporation  of 
their  solutions  painted  upon  the  surface.  They  are 
more  or  less  antiseptic;  less  so  than  volatile  oils. 
They  are  usually  more  or  less  irritant,  many  being 
thus  available  as  counter-irritants.  One  class  of 
them  exhibit  this  irritating  property  especially  in  the 
intestine,  and  become  purgative,  some  very  power- 
fully so.  Among  these  may  be  mentioned  those  of 
jalap,  scammony,  podophyllum,  leptandra,  iris,  and 
euonymus.  Preparations  of  such  drugs  should  be 
thoroughly  subdivided  through  an  excipient,  so  that 
no  large  particle  shall  lodge  in  a  pocket  of  intestine 
and  produce  undue  irritation. 

Gum-resins  are  merely  mixtures  of  gum  with  resin, 
which  adapts  them  very  well  to  being  used  in  the  form 
of  emulsions.  Not  only  do  the  relative  percentages 
of  gum  and  resin  vary  widely  in  different  gum-resin-, 
but  the  percentage  is  quite  variable  in  different  lots 
of  the  same.  The  activity  is,  of  course,  proportional 
to  the  percentage  of  resin.  Important  gum-resins 
are  myrrh,  asafetida,  ammoniac,  elemi,  galbanura, 
and  gamboge.  They  occur  also  in  many  drugs,  such 
as  sumbul,  angelica,  parsley,  and  lovage.  Volatile 
oil  is  a  very  common  constituent  of  gum-resins. 

Volatile  Oils. — For  the  sake  of  long  custom  and 
convenience,  these  are  treated  as  a  class  of  active 
constituents,  although  the  idea  is  not  a  scientific  one. 
They  are  in  reality  mixtures  which  are  very  indefinite 
in  kind,  as  well  as  in  degree.  The  name  may  without 
impropriety  be  extended  to  all  volatile  and  aromatic 
constituents  of  plants.  They  consist  mostly  of  one 
or  more  oxygenated  compounds  mixed  with  one  or 
more  hydrocarbons,  usually  terpenes.  Of  these,  the 
former  is  commonly  the  active  one.  Since  volatile 
oils  are  rather  irregular  in  the  relative  amounts  of  the 
active  and  the  inactive  portions,  and  also  highly 
subject  to  adulteration,  which  is  very  difficult  of 
detection,  the  use  of  {he  active  constituents,  the 
purity  of  which  is  readily  ascertained,  is  much  prefer- 
able to  that  of  the  oil.  Doubtless  such  use  will 
extend  as  these  facts  become  more  generally  appre- 
ciated, and  this  result  will  be  hastened  by  a  more 
common  custom  of  regarding  and  speaking  of  these 
oils  as  indefinite  and  irregular  mixtures,  a  custom 
which  is  carefully  followed  in  this  work.  Their 
chief  use  to  the  plant  is  perhaps  as  solvents  of  other 
constituents.  Their  nutritive  relations  are  not  well 
known,  and  if  they  were,  they  could  not  be  easily 
defined,  owing  to  their  variable  chemical  nature. 
Their  fragrant  properties  are  undoubtedly  of  value  in 
indirect    ways,    such    as    attracting    insects.     Their 


REFERENCE    HANDBOOK   OF   THE   MEDICAL   SCIENCES 


Active  Constituents  of  Plants 


antiseptic  properties  and  the  obnoxious  character  of 

many  of  them  to  some  animals  undoubtedly  serve  a 
protective  purpose.  They  may  be  found  in  any  part 
of  the  plant,  perhaps  most  frequently  in  the  seed. 
They  may  often  be  seen  in  the  leaf,  in  the  form  of 
pellucid  dots,  when  viewed  against  the  light.  Owing 
to  their  volatile  nature,  drugs  which  depend  upon 
their  presence  are  very  liable  to  deteriorate  on  being 
kept,  and  unusual  care  has  to  be  exercised  in  their 
preparation  and  preservation.  On  this  account  they 
are  usually  dried  in  the  shade. 

These  substances  leave  no  greasy  stain  on  paper. 
They  are  light,  volatile,  aromatic,  and  inflammable. 
They  dissolve  in  water  sufficiently  to  render  the  latter 
aromatic  and  somewhat  medicinal.  They  are  readily 
soluble  in  alcohol,  fixed  oils,  and  glycerin,  and  act  as 
solvents  of  resins,  fats,  and  many  medicinal  sub- 
stances. Aside  from  their  medicinal  properties,  they 
have  a  wide  use  within  as  well  as  outside  the  bounda- 
ries of  pharmacy,  in  odorizing  and  flavoring.  In  their 
physiological  and  medicinal  properties,  volatile  oils 
agree  in  some  characters  and  vary  greatly  in  others, 
so  that  they  fall  naturally  into  different  therapeutical 
classes.  Their  local  stimulant  properties  are  very 
general.  This  makes  them  counterirritant;  some 
of  them,  like  oil  of  turpentine,  very  powerfully  so, 
especially  when  confined  under  an  air-tight  covering. 
Others  which  are  strongly  counterirritant  are  those 
of  mustard,  amber,  erigeron,  cinnamon,  cloves,  and 
camphor.  The  irritating  effect  of  some  volatile  oils 
is  followed  by  a  local  anesthesia,  occasionally  quite 
strong,  as  in  the  case  of  menthol  and  oil  of  cloves.  In 
line  with  their  counterirritant  action  may  be  con- 
sidered their  stomachic  and  carminative  properties, 
which  are  perhaps  more  general  than  any  others. 
Here  again  certain  oils,  especially  those  of  the 
families  Umbelliferse  (anise,  fennel,  caraway,  etc.) 
and  LabiataB  (mint,  thyme,  pennyroyal,  etc.),  excel 
others.  As  to  their  gastric  effects,  it  is  to  be  noted 
that  their  presence  with  the  digesting  food  mass  tends 
to  inhibit  the  process.  This  action  also  is  greater  in 
the  ease  of  certain  oils,  and  is  said  to  be  quite  wanting 
in  that  of  oil  of  peppermint,  which  is  thus  an  excep- 
tionally valuable  carminative.  Aside  from  their 
intestinal  effects  in  stimulating  secretion  and  peris- 
talsis, they  exert  a  strong  action  in  stimulating  the 
sympathetic  nerves,  thus  overcoming  the  excessive 
relaxation  upon  which  various  forms  of  serous 
diarrhea  depend  in  whole  or  in  part.  This  action 
effects  a  final  result  similar  to  that  of  the  true  astrin- 
gents, and  makes  a  combination  of  volatile  oils  and 
astringents  highly  effective.  Their  carminative  prop- 
erties render  them  of  great  use  in  combining  with 
griping  purgatives.  Their  antiseptic  properties  are 
quite  general  and  strong,  though  they  vary  greatly 
in  degree  in  the  different  oils.  They  act  not  only  as 
direct  germicides,  but  they  stimulate  the  cells  them- 
selves in  their  fight  against  the  foreign  organisms. 
In  general,  the  oils  of  the  family  Jlyrtacese  and  many 
of  those  of  the  Lauraeeae  are  thus  antiseptic,  as  are 
those  of  birch,  wintergreen,  sandal,  copaiba,  and 
thyme.  Oil  of  cinnamon  is  probably  the  most  power- 
fully antiseptic  of  any,  eucalyptol,  if  pure,  perhaps 
standing  next.  Volatile  oils  agree  in  their  strongly 
diffusive  properties,  on  account  of  which  their 
systemic  effects  come  on  quickly.  If  the  vapor  is  con- 
fined, they  are  quickly  absorbed,  even  through  the 
skin,  as  they  are  by  inhalation.  They  then  become 
systemic  stimulants,  though  overdoses  may  act  as 
depressing  poisons.  This  stimulation  makes  them 
antispasmodic  in  many  cases.  Elimination  begins  as 
promptly  as  absorption,  and  their  local  effects  are 
again  seen  at  the  point  of  excretion.  They  vary  in 
their  selection  of  the  channel  of  excretion.  Some, 
like  eucalyptus,  copaiba,  and  cubebs,  have  a  tendency 
toward  the  respiratory  mucous  membrane  and  become 
important  stimulating  and  antiseptic  expectorants. 
Others,  like  sandal,  copaiba,  cubebs,  birch,  winter- 


green,   turpentine,   juniper,   savin,    tansy,   and    buchu, 

have  an  affinity  for  the  kidney,  and  become  stimulat- 
ing (to  irritating)  and  antiseptic  diuretics,  some 
important  antiblennorrhagics.  A  few,  like  oil  of 
chenopodium,  are  powerfully  anthelmintic.  Those 
especially  adapted  to  perfuming  and  flavoring  may 

be  named  as  orange,  lemon,  bergamot,  rose,  bay, 
bitter  almond,  citronella,  lavender,  nutmeg,  and 
cinnamon. 

Oleoresins,  being  resins  dissolved  in  volatile  oils, 
naturally  combine  their  properties.  They  very 
often,  however,  contain  a  third  substance  in  addition, 
and  this  may  give  to  them  specific  properties  distinct 
from  those  of  either  the  oil  or  the  resin,  and  in  some 
cases  exceedingly  powerful.  The  most  important 
oleoresins  in  use  are  those  of  the  male  fern,  capsicum, 
ginger,  copaiba,  black  pepper,  cubeb,  turpentine,  and 
hops.  Other  important  oleoresins  contained  in  drugs 
but  not  commonly  isolated  for  use  are  those  of 
calamus,  iris,  inula,  prickly  ash,  mezereum,  and 
stillingia. 

Balsams  are  liquid  or  solid  oleoresins  depending  in 
part  for  their  properties  upon  the  contained  benzoic 
or  cinnamic  acid,  or  both.  Their  properties  are 
readily  deduced  from  this  composition.  The  principal 
ones  are  benzoin,  dragons'-blood,  tolu,  and  peru. 
Copaiba,  though  commonly  so  called,  is  in  no  sense 
a  balsam. 

Amaroids  (their  Latin  names  ending  in  "inum," 
their  English  in  "in"). — This  term  has  been  proposed 
for  those  bitter  extractives  of  plants  which,  having  a 
definite  chemical  composition,  do  not  belong  to  any 
of  the  recognized  classes  of  proximate  principles. 
While  not  highly  scientific,  the  term  is  often  very 
convenient. 

Glucosides  (their  Latin  names  ending  in  "inum," 
their  English  in  "in"). — These  are  compounds  of 
glucose  with  some  other  substance,  the  latter  class 
covering  a  wide  range  and  occasionally  containing 
nitrogen.  They  are  especially  numerous  in  the 
Liliaeeae,  the  Apocynaceae,  and  some  other  families, 
but  are  very  widely  distributed  elsewhere.  They 
act  as  reserve  foods  to  the  plant,  and  are  therefore 
more  abundant  in  those  parts  which  act  as  storage 
reservoirs,  and  at  the  close  of  the  growing  period. 
The  bodies  associated  with  the  glucose  are  very  fre- 
quently poisonous  or  obnoxious,  subserving  thus  a 
protective  function,  while  the  glucoside  in  this  way 
also  acts  as  a  protective  of  other  parts  or  constituents. 
Owing  to  the  readiness  with  which  they  are  decom- 
posed (in  the  plant  by  special  enzymes),  their  nutri- 
tious portion  is  readily  available  and  at  once  assim- 
ilable. For  the  same  reason  they  constitute  very 
unstable  medicinal  agents  and,  like  drugs  contain 
ing  them,  require  to  be  treated  with  great  care  in 
pharmaceutical  operations.  They  are  mostly  soluble 
in  both  water  and  alcohol.  Some,  like  amygdalin, 
are  inactive  until  such  decomposition  occurs,  while 
others  may  be  thus  rendered  inactive.  Such  decom- 
position is  effected  by  the  action  of  dilute  acids, 
especially  if  heated,  by  hot  water,  and  by  the  pro- 
longed action  of  alkalies.  They  are  mostly  precipi- 
tated by  tannin  and  lead  acetate,  and  very  frequently 
by  mercuric  chloride.  They  are  usually  very  ener- 
getic physiological  agents,  but  their  actions  are  too 
diverse  for  generalization.  It  may  be  said,  however, 
that  they  are  as  a  class  more  disposed  to  act  upon  the 
circulation  than  in  any  other  one  direction.  Several 
of  the  glucosides  are  widely  distributed  among  differ- 
ent plants,  and,  exhibiting  variations  among  them- 
selves, may  be  regarded  as  forming  sub-classes.  Tannin 
or  tannic  acid  (elsewhere  considered)  is  technically  a, 
glucoside,  but  differs  so  much  from  the  others  that  it 
is  difficult  to  regard  it  as  such.  The  saponin  group  (see 
Saponin)  have  also  distinct  and  important  properties. 
The  chief  interest  in  glucosides  as  a  group  centers 
in  their  incompatibilities,  as  indicated  above.  The 
principal  glucosidal  drugs  are  as  follows: 

109 


Active  Constituents  of  Plants 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


Amygdalin. 


Emodin 
or  relatives. 


Saponin  or  a  similar 
body. 


Bitter  almonds, 

Peach  seeds, 

Wild  cherry. 

Cherry  laurel, 

Peach,  plum,  and  cherry  leaves,  etc., 

Buckthorn,  cascara  sagrada,  and  other 

species  of  Rhamnus, 
Aloes, 
Rhubarb, 
Srnna, 

Apocynum — apocynin  and  apocynein. 
Convallaria — convallamarin  and  couvalhirin 
Digitalis — digitalis  and  others. 
Dulcamara — dulcamarin. 
Phytolacca — phytolaccin. 
Piper — piperin. 

Soap  bark,  ^ 

Soap  root, 
Euonymus, 
Senega, 

Caulophyllum  and  others,  J 

Squill — scillin  and  others. 
Black  mustard — sinigrin. 
White  mustard — sinalbin. 
Strophanthus — strophanthiu  and  strophanthidin. 

Alkaloids  (their  English  names  ending  in  i/ic,  their 
Latin  in  ina,  although  it  is  now  proposed  to  abolish 
this  most  convenient  distinction  and  to  spell  them 
with  a  final  in,  a  practice  actually  now  in  use  to  a 
great  extent  in  Germany). — These  are  nitrogenized 
organic  bases,  occurring  in  plants  (also  in  animals) 
usually,  if  not  always,  as  waste  products,  and  in 
combination  with  acids.  Although  commonly  waste 
products  from  a  nutritive  standpoint,  they  perform 
the  most  useful  purposes  in  the  plant  economy. 
Usually  poisonous  and  intensely  bitter,  they  often 
serve  to  protect  those  parts  of  the  plant  which  are 
used  for  food  storage  from  consumption  by  animals. 
They  may  occur  in  any  part  of  the  plant,  but  are  most 
often  found  in  the  seeds,  leaves,  and  bark  of  both 
stem  and  root.  They  are  characteristically  common 
in  some  families,  like  the  Rubiacea?,  while  from  others, 
like  the  Compositae,  the  largest  of  all  families,  they 
are  nearly  or  quite  absent.  Alkaloids  are  usually 
crystallizable.  Many  were  formerly  known  only  in 
a  liquid  or  amorphous  state,  but  many  of  these,  when 
thoroughly  purified,  have  since  been  found  crystalliza- 
ble. Those  which  are  not  so,  yet  usually  yield  salts 
which  are.  Some  alkaloids  are  volatile.  Many 
alkaloids,  while  acting  as  proximate  principles  them- 
selves, readily  separate,  either  in  the  plant  by  natural 
processes  or  under  laboratory  treatment,  into  other 
alkaloids  and  some  associated  substance,  so  that 
series  of  them  are  formed.  These  are  necessarily  of 
unstable  chemical  composition.  In  some  cases,  an 
alkaloid  will  result  from  the  decomposition  of  a 
glucoside,  as  solanidine  from  solanin.  Alkaloids 
differ  greatly  in  solubility,  but  the  strong  tendency  is 
toward  solubility  in  alcohol  and  insolubility  in  water, 
while  of  their  salts  the  reverse  is  true.  A  few  which 
vary  markedly  from  this  rule  are  enumerated  below. 
These  bodies  show  their  basic  nature  by  turning  red 
litmus  paper  blue,  but  more  especially  by  uniting 
with  acids  to  form  salts.  They  do  this  without  dis- 
placing the  hydrogen  of  the  acid,  as  metals  do.  They 
vary  greatly  in  the  intensity  of  this  affinity  for  acids, 
some,  like  caffeine,  being  very  feebly  basic.  In  some 
cases  we  are  even  uncertain  whether  they  can  properly 
be  classed  as  alkaloids.  Alkaloids  are  as  a  class  prob- 
ably the  most  active  physiological  constituents  of 
plants.  Their  actions  are  so  dissimilar  that  they  can- 
not be  at  all  generalized,  except  to  say  that  by  their 
almost  invariably  bitter  taste  they  act,  in  the  absence 
of  other  antagonistic  properties,  as  bitter  stomachics 
and  tonics.  In  many  cases  two  alkaloids,  the  one  a 
derivative  of  the  other,  occur  in  the  same  plant,  with 
antagonistic  properties.  Alkaloids  converted  into 
methyl  compounds  are  thus  usually  antagonistic  to 
those  so  yielding  them. 

It  is  of  the  utmost  importance  that  the  prescriber 


should  keep  in  mind  the  incompatibilities  of  alkaloids. 
Some  of  these  incompatibilities  are  innocent,  or  can 
even  be  utilized  in  important  ways.  Thus  the  addi- 
tion of  acids  converts  alkaloids  into  salts,  which  may 
then  be  dissolved  in  water,  the  physiological  prop- 
erties being  usually  unaltered.  These  salts  differ 
greatly  in  solubility.  In  most  cases  acetates  are  the 
most  soluble,  hydrochlorides  next,  and  sulphates  the 
least.  In  other  eases,  a  physical  incompatibility 
exists,  so  that  the  alkaloid  is  precipitated.  Owing 
to  their  energetic  action  such  a  result  is  exceedingly 
dangerous,  the  first  portions  of  the  medicine  being 
ineffective,  the  last  portions  poisonous.  In  this 
connection  it  may  be  stated  that  all  salts  which  will 
turn  red  litmus  paper  blue  will  precipitate  aqueous 
or  weak  alcoholic  solutions  of  alkaloidal  salts.  Svich 
solutions  are  almost  always  precipitated  by  alkali 
hydrates,  soluble  salicylates,  benzoates,  iodides,  and 
bromides,  tannic  acid,  chlorides  of  mercury  and  of 
gold.  The  presence  of.  mucilage  or  hydrated  starch 
will  sometimes  prevent  this  precipitation,  especially 
th.it  by  tannic  acid.  In  other  cases  incompatibility 
involves  the  destruction  of  the  alkaloid.  Oxidizing 
agents  will  usually  accomplish  this  result,  except  when 
they  enter  into  a  saline  combination.  This  fact  is 
utilized  in  some  cases  of  antidotal  treatment,  as  of 
morphine  by  potassium  permanganate.  Chloral 
hydrate  is  incompatible  with  many  alkaloids,  forming 
a  soft  or  liquid  mass.  The  solanaceous  alkaloids, 
of  which  atropine  is  the  type,  as  well  as  aconitine  and 
confine,  are  decomposed  by  alkalies.  The  strength 
of  many  drugs  can  be  readily  standardized  by  de- 
termining the  average  percentage  of  alkaloid  con- 
tained. 

The  principal  drugs  which  depend  upon  alkaloids 
for  their  activity  are  the  following: 

Aconite  (aconitine). 

Aspidosperma  (aspidospermine,  a  mixture  of  six). 

Belladonna  (atropine). 

Berberis  (berberine). 

Coffee  (caffeine). 

Cannabis  indica  (?). 

Chelidonium  (chelerythrine  and  chelidonine). 

Cinchona  (quinine,  cinchonine,  and  cinchonidine, 
chiefly). 

Coca  (cocaine). 

Colchicum  (colchicine). 

Conium  (confine). 

Ergot  (?). 

Gelsemium  (gelsemine  and  gelseminine). 

Granatum  (pelletierine). 

Guarana  (caffeine). 

Humulus  (trimethylamine,  partly). 

Hydrastis  (berberine,  hydrastine,  and  [artificial] 
hydras  tinine). 

Hyoscyamus  (hyoscyamine  and  hyoscine). 

Ipecac  (emetine  and  cephaeline). 

Lobelia  (lobeline). 

Menispermum  (berberine  and  menispine). 

Nux  vomica  (strychnine  and  brucine). 

Opium  (many,  the  principal  being  morphine, 
codeine,  narcotine,  narceine,  and  the  artificial  deriva- 
tives apomorphine,    apocodcine,    and   heroine). 

Physostigma  (physostigmine  or  eserine). 

Pilocarpus  (pilocarpine  and  pilocarpidine). 

Piper  (piperidine,  partly). 

Sanguinaria  (sanguinarine,  chiefly). 

Seoparius  (sparteine,  partly). 

Spigelia  (spigeline). 

Staphisagria  (four  alkaloids,  the  properties  not 
wrell  differentiated). 

Stramonium  (daturine,  a  mixture). 

Tobacco  (nicotine). 

Veratrum  (veratrine,  a  mixture). 

Important  alkaloids  which  are  soluble  in  water 
are  confine,  codeine,  caffeine,  nicotine,  atropine 
(nearly  four  grains  to  the  ounce),  pelletierine,  lobeline 
(considerably). 


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Acupuncture 


Alkaloids  which,  with  their  salts,  are  little  solu- 
ble in  ordinary  alkaloklal  solvents  arc  morphine, 
trigonelline,  etc. 

Enzymes,  'rinse  are  vegetable  ferments,  acting 
like  the  animal  ferments,  pepsin,  trypsin,  etc.,  in  de- 
composing or  digesting  nutrients  for  the  use  of  the 
plant.  There  are  different  classes  of  them,  each  act- 
ing upon  a  certain  class  of  nutrients.  The  diastases 
acting  on  starch  have  become  extensively  utilized  in 
medicine,  but  most  enzymes  have  not.  One  class  has 
for  its  function  the  decomposition  of  glucosides, 
another  the  digestion  of  amaroids,  another  acts 
upon  certain  gums.  Like  pepsin  and  others  of  its 
Class,  the  vegetable  enzymes  cannot  be  extracted 
in  a  pure  condition  nor  can  their  composition  be 
determined.  II.  II.  Rusby. 


Actuarius,  John. — Very  little  is  known  about  the 
life  of  Actuarius  beyond  the  following  few  facts: 
He  practised  medicine  during  the  thirteenth  or 
fourteenth  century,  and  was  attached  to  the  Court 
at  Constantinople.  He  wrote  treatises  on  the  princi- 
ples of  therapeutics,  on  the  composition  of  various 
remedial  agents,  and  on  the  urine  as  an  aid  to  diagno- 
sis. He  is  systematic  in  his  manner  of  treating  these 
subjects  and  his  style  of  writing  is  clear.  Among 
Greek  medical  authors  he  is  the  first  to  mention  the 
milder  purgatives  like  cassia,  manna,  senna,  etc. 
Editions  of  his  treatise  on  urine  were  published  in 
Venice  (1519),  Basle  (1520),  Paris  (1522),  and 
Utrecht  (1(170);  and  a  collection  of  his  entire  works, 
in  two  volumes,  was  issued  in  Paris  in  1556. 

A.  H.  B. 


Acupressure. — A  procedure  devised  by  Sir  J.  Y. 
Simpson,  of  Edinburgh,  in  1859,  for  arresting  hemor- 
rhage from  a  vessel  by  means  of  pressure  made  bjr  a 
needle  transfixed  through  the  neighboring  tissues. 
The  flow  of  blood  through  an  artery  may  be  arrested 
in  any  one  of  three  ways.  The  vessel  may  be  simply 
compressed  between  the  needle  and  some  firm  tissue, 

as  a  bone  or  the  in- 
tegument, as  repre- 
sented in  Figs.  37  and 
38.  When  the  artery 
lies  embedded  in  a 
soft  tissue,  as  in  a 
divided  muscle,  its 
occlusion  may  be  ac- 
complished by  tor- 
sion. This  is  done  by- 
introducing  the  nee- 
dle on  one  side  of  the 
vessel,  and,  when  it 
has  passed  through  a  portion  of  the  tissue,  twisting 
it  around  the  artery,  and  fixing  its  point  in  the  tissue 
in  a  direction  opposite  to  that  in  which  it  was  first 
entered;  or  the  artery  need  not  be  included  in  the 
bight  of  the  needle,  but  the  latter  may  be  turned 
before  reaching  the  vessel,  the  latter  then  being  com- 
pressed by  the  elastic  force  of  the  twisted  tissues 
acting  upon  the  needle. 
A  third  method,  applica- 
ble also  in  cases  in  which 
the  vessel  lies  in  a  yield- 
ing tissue,  consists  in 
pressure  between  the 
needle  and  a  slip-knot. 
The  needle  is  passed 
beneath  the  artery,  and 
a  loop  of  fine  wire  is  slipped  over  its  point,  the 
ends  of  the  loop  passing  over  the  artery,  and  being 
fastened  by  two  or  three  turns  over  the  shaft  of  the 
needle  (see  Fig.  39).  In  the  case  of  small  vessels,  the 
needles  may  be  withdrawn  at  the  expiration  of 
twenty-four  hours;   but   when   large   arterial   trunks 


are  occluded,  the  pressure  should  be  maintained  for 
forty-eight   hours  at   least. 

The  advantages  claimed  for  this  method  are:  the 
ease  and  rapidity  with  which  the  needles  may  be 
applied,  no  delay  being  caused  in  the  operation;  the 

absence  of  danger  from  Suppuration  of  the  ends  of  the 
divided  vessels;  and  non-interlerenee  with  rapid  clo- 
sure of  the  wound,  no  inflammation  being  excited  by 
the  presence  of  the  needles  in  the  tissues  for  so  short 


Fiq.  39. 

a  period  of  time.  These  advantages,  however,  are 
less  manifest  at  the  present  time,  since  the  intro- 
duction and  general  employment  of  antiseptic  liga- 
tures, and  it  is  not  likely  that  the  procedure  will  ever 
again  enjoy  the  popularity  which  it  at  one  time 
possessed.  T.  L.  S. 


Acupuncture. — An  operation  which  consists  in  the 
introduction  of  needles  into  the  body,  either  as  a 
means  of  giving  exit  to  the  fluid  in  edematous  tissues 
or  for  the  relief  of  pain  in  neuralgia  and  muscular 
rheumatism.  It  is  a  method  in  great  vogue  in  China, 
and  is  used  by  the  physicians  of  that  country  not  only 
to  assuage  pain,  but  to  promote  reparative  action  in 
ulcers  and  in  the  treatment  of  various  other  affections. 
It  is  said  to  have  been  introduced  into  Europe  from 
China  by  the  missionaries  in  the  seventeenth  century. 
The  instrument  employed  is  a  round  polished  needle, 
having  a  cylindrical  handle  of  sufficient  size  to  permit 
of  its  being  readily  manipulated  by  the  fingers.  It  is 
introduced  into  the  tissues  by  a  quick  rotatory 
movement,  and  is  then  left  in  situ  for  a  number  of 
minutes,  or  even  for  an  hour.  Sometimes  the  inser- 
tion of  a  single  needle  is  sufficient  to  relieve  the  pain, 
but  ordinarily  half  a  dozen  or  more  are  employed. 
This  little  procedure  may  be  practised  almost  pain- 
lessly, and  is  sometimes  wonderfully  effective  in  con- 
trolling neuralgic  and  rheumatic  muscular  pains.  It 
often  fails,  indeed,  and  it  seems  impossible  to  deter- 
mine beforehand  in  what  cases  it  will  prove  service- 
able, but  certainly  no  case  of  lumbago  or  sciatica 
should  be  abandoned  until  acupuncture,  as  well  as 
the  more  ordinary  remedies,  has  been  tried.  In 
anasarca,  when  the  scrotum  and  lower  extremities 
are  distended  with  fluid,  the  patient  may  experience 
comfort  from  a  few  punctures  with  a  three-cornered 
surgical  needle.  The  operation  should  be  practised 
with  caution,  however,  as  it  is  apt  to  excite  an  ery- 
sipelatous inflammation  of  the  integument.  In  the 
treatment  of  paralysis  insulated  needles  are  some- 
times used  as  a  means  of  introducing  the  electric 
current  into  the  deeper  tissues.  This  procedure  has 
received  the  name  of  electropuncture. 

There  is  another  form  of  acupuncture,  called  Baun- 
scheidtismus,  which  at  one  time  enjoyed  a  great 
popular  reputation,  and  which  even  now  is  not  very 
infrequently  employed.  It  was  devised  by  Carl  Baun- 
scheidt,  a  German  mechanic,  who  is  said  to  have  con- 
ceived the  idea  from  observing  that  the  irritation 
caused  by  the  bites  of  insects  afforded  him  consider- 
able relief  from  the  pain  of  an  articular  affection  from 
which  he  was  suffering.  The  instrument  employed 
consists  of  a  cylinder  enclosing  a  button  into  which 
are  inserted  from  twenty  to  thirty  short  needles. 
The  open  end  of  the  cylinder  is  placed  on  the  integu- 
ment, and  then  by  means  of  a  handle  the  button  with 
needles  attached  is  drawn  up  into  the  cylinder  com- . 
pressing  a  spiral  spring:  when  the  handle  is  released 
the  force  of  the  spring  impels  the  needles  suddenly 


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and  sharply  into  the  skin.  The  operation  may  rest 
here  or  an  irritating  fluid,  such  as  mustard  water  or 
cajeput  oil,  may  be  applied  to  the  punctures.  This 
is  employed  for  the  relief  of  neuralgia  and  musculai 
pains,  and  often  proves  of  very  great  service. 

There  is  still  another  form  of  acupuncture,  if  such 


There  is  <» 
it  can  be  called,  though  it  is  more  nearly  related  to 
hypodermic  medication.  It  consists  in  the  hypo- 
dermic injection  of  pure  water,  and  has  received  the 
name  of  aquapuncture.  Many  superficial  pains,  even 
though  quite  severe,  may  be  relieved  by  this  simple 
procedure.  That  the  relief  thus  obtained  is  not 
merely  the  effect  of  imagination,  is  evidenced  by  the 
fact  that  neuralgias  of  distant  parts  are  not  benefited 
by  aqueous  injections,  but  in  order  to  be  effectual  the 
operation  must  be  practised  at  a  point  as  near  as 
possible  to  the  seat  of  pain.  The  Schlerich  method  of 
local  anesthesia  is  a  form  of  aquapuncture,  the  strength 

of  the  cocaine  solution  commonly  employed  being  in- 
sufficient to  account  for  the  complete  anesthesia  pro- 
duced. Aquapuncture  has  been  employed  in  various 
forms  of  neuralgia,  in  lumbago,  and  in  painful  func- 
tional affections  of  the  abdominal  viscera.  Bartholow 
claimed  to  have  obtained  excellent  results  from  the 
injection  of  water  into  the  substance  of  paralyzed  and 
atrophied  muscles.  From  2  to  4  c.c.  (4  to  1  dram) 
of  fluid  may  be  used  for  each  injection,  and  the  opera- 
tion may  be  repeated  if  no  relief  is  experienced  at 
the   expiration   of  two  or  three  minutes.     (See   also 


Anesthesia,  local.) 


T.  L.  S. 


Acystina. — A  group  established  by  Sambon  to 
include  those  protozoans  in  Hartmann's  tribe  Bmu- 
cleata  in  which  "the  ookinete  remains  free  and 
does  not  become  encysted."  It  includes  two  families: 
HcemoproteidcB    and    Leucocytozoidce.     See    Protozoa. 

A.  to.  x. 


Adamantinoma.— This  is  a  variety  of  neoplasm 
rather  frequently  found  in  the  lower  jaw,  and  more 
rarely  in  the  upper.  It  develops  from  the  remains 
of  the  enamel-organs,  hence  its  name,  adaman- 
tinoma, or  adenoma  adamaiitiiuim  as  it  is  sometimes 
wrongly  called,  since  it  has  nothing  to  do  with  glands. 
It  consists  of  cords  and  masses  of  epithelial  cells 
resembling  in  structure  the  fetal  epithelial  buds  that 
form  the  teeth.  The  stellate  cells  in  the  central 
portion  of  these  epithelial  masses  may  form  true 
enamel,  but  they  often  degenerate  and  undergo 
liquefaction,  thus  giving  rise  to  the  formation  of 
multiple  cysts.  When  the  cysts  are  large  and 
numerous  the  growth  often  assumes  the  character  of 
a  multilocular  cystoma.  The  tumor  is  essentially 
benign  and  closely  related  to  the  odontoma  with  which 
it  may  be  associated.  The  most  common  site  for 
both  of  these  neoplasms  is  at  the  angle  of  the  lower 
jaw  in  the  neighborhood  of  the  molar  teeth.  It  is 
probable  that  these  neoplasms  are  both  the  result  of 
disturbance  of  development  of  the  teeth.  The  writer 
has  seen  a  similar  tumor  replacing  the  hypophysis  in 
a  case  of  dystrophia  adiposogenitalis.  In  this  loca- 
tion the  adamantinoma  must  be  regarded  as  a  teratoid 
tumor  arising  from  remains  of  the  craniopharyngeal 
duct.  Aldred  Scott  Warthix. 

Adams  County  Mineral  Springs. — Adams  County, 
Ohio. 

Post-office. —  Mineral  Springs,  Ohio. 

Access. —  Via  Cincinnati,  Portsmouth  and  Vir- 
ginia Railroad  to  Mineral  Springs  station,  thence  four 
miles  by  carriage  to  Spring  hotel  and  cottages.  Con- 
veyances can  also  be  had  at  Rome  (on  the  Ohio  River) 
for  the  Springs. 

These  springs,  the  medicinal  properties  of  which 
were  recognized  by  the  Indians,  are  two  in  number 


and  flow  about  sixty  gallons  of  water  hourly,  having 
a  temperature  of  56°  F.  They  issue  from  the  base 
of  a  high  hill  and  are  surrounded  by  picturesque  and 
charming  scenery.  According  to  a  partial  analysis 
by  Prof.  E.  S.  Wayne,  the  water  of  Spring  No.  1  is 
highly  charged  with  gas  and  contains  205.35  grains 
of  sol'id  matter  per  United  States  gallon,  composed  as 
follows:  Magnesium  chloride,  calcium  chloride,  cal- 
cium sulphate,  calcium  carbonate,  sodium  chloride, 
iron  oxide,  and  iodine.  The  water  may  be  classified 
as  a  saline  calcic  with  ferruginous  properties. 

Spring  No.2.     In-  1.000,000  Parts  there  are: 

Magnesium  sulphate 10S  ■  U 

Sodium  sulphate 65.41 

Calcium  sulphate 56.00 

Sodium  chloride 16.  *9 

Potassium  chloride 3  .  69 

Ferrous  carbonate trace. 

Total  mineral  matter 250.00 

Free  acid  as  sulphuric 19.60 

The  accommodations  for  visitors  are  now  very  sat- 
isfactory, the  hotel  having  been  enlarged  and  a  num- 
ber of  cottages  added.  The  location  affords  a  pleasant 
retreat  for  those  who  seek  respite  from  the  cares  of 
business  or  need  the  refreshing  influences  of  rural 
scenery  and  air.  The  water  has  long  been  used 
by  persons  suffering  from  affections  involving  the 
stomach,  bowels,  kidneys,  and  liver. 

Emma.  E.  TA  alker. 


Adams,  William. — Born  in  London,  England,  on 
February,  1,  1820.  He  studied  at  Kings  College,  and 
afterward  held  successively  the  following  positions: 
Pathological  Prosector  in  St.  Thomas'  Hospital,  in 
1S42-  Assistant  Surgeon  (in  1851)  and,  later  (in  1857), 
Surgeon  in  the  Royal  Orthopedic  Hospital;  Instruc- 
tor in  Surgery  in  tlie  Grosvenor  Place  Medical  School, 
in  1854;  Surgeon  in  the  Great  Northern  Hospital,  in 
1S55-  and  Surgeon  in  the  National  Hospital  for 
Paralytics  and  Epileptics,  in  1874.  His  death 
occurred  February  3,  1900. 

Adams  was  a  prolific  contributor  to  medical  liter- 
ature The  following  are  the  titles  of  some  of  the  more 
important  of  his  writings:  "  A  Course  of  Lectures  on 
Orthopedic  Surgery,"  1S.55— 1858;  "On  the  Repara- 
tive Process  in  Human  Tendons  after  Division,  1.S60; 
"On  the  Pathology  and  Treatment  of  Club-foot 
(awarded  the  Jackson  Prize  by  the  Royal  College 
of  Surgeons  in  1866);  and  "On  the  Treatment  of 
Dupuytren's  Contraction  of  the  Fingers,  and  on  the 
Obliteration  of  Depressed  Cicatrices  by  Subcutaneous 
Operations,"  1879.  A-  H-  B- 

Adams,  Sir  William.— Born  in  Cornwall,  England, 
in  1700  He  began  the  study  of  medicine  under  a 
practitioner  in  Barnstaple  and  at  the  age  of  seventeen 
went  to  London  where  he  became  a  pupil  of  Sam 
at  the  Moorfields  Eye  Hospital.  After  practising  for 
a  time  as  an  oculist  he  suddenly  acquired  fame  by 
the  publication  of  a  work  on  Egyptian  ophthalmia, 
which  was  then  endemic  in  the  British  army  in  which 
he  advised  treatment  contrary  to  that  followed  by 
Saunders  and  others  connected  with  the  London  i.ye 
Infirmary.  This  led  to  a  polemic  in  which  he  accused 
his  opponents  of  attempting  to  prevent  the  rational 
treatment  of  that  disease.  The  quarrel  made  con- 
siderable noise,  but  he  triumphed  and  won  the  favor 
of  the  Court,  being  appointed  oculist  to  the  prince 
Regent,  afterward  George  IV  and  to  the  latter  a 
brother  the  Duke  of  Sussex.  He  was  later  knighted 
and  the  position  of  ophthalmologist  to  the  Greenwi  1 
Hospital  for  invalided  soldiers  and  sailors  was  created 
for  him      The  members  of  the  regular  medical  stan 


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Adaptation 


were    however,   incensed   at    this  appointment  and 

.soon  procured  the  abolition  of  the  office.  Adams 
receiving  a  grant  of  £4,000  as  compensation  for  his 
discharge.  Thereafter  his  life  was  uneventful  and 
was  passed  in  the  enjoyment  of  a  large  and  lucrative 
practice.  A  few  years  before  his  death,  in  order  to 
,,,,.,. i  the  conditions  of  a  large  legacy,  he  took  the 
name  of  his  wife,  Rawson.  He  died  at  Albemarle 
In  I  ebruary,  1829.  ,      .    ,       .  .  _       t. 

In  addition  to  his  polemical  writings  on  Egyptian 
ophthalmia,  the  most  important  of  Adams'  contri- 
butions to  medical  literature  are:  "Practical  Obser- 
vations on  Ectropion  or  Eversion  of  the  Eyelids, 
with  the  Description  of  a  New  Operation  for  the 
(in,,  of  that  Disease"  (since  known  as  Adams' 
operation),  1*1-';  "A  Practical  Inquiry  into  the 
Cause  of  the  Frequent  Failure  of  the  Operation  for 
Depression,"  etc.,  1817;  "A  Treatise  on  Artificial 
Pupil,"  etc.,  1819.  T.  L.  S. 

Adaptation. — If  we  think  of  life,  as  most  of  us  do, 
herently  a  process  of  adjustment  of  relations  to 
r  relations,  clearly  adaptation  is  the  most  univer- 
sal of  vital  events.  A  complete  denotation  of  the 
term  for  Medicine  would  comprise  much  of  the  chem- 
istry, anatomy,  and  physiology  underlying  the  whole 
profession.  Still,  one  thinks  of  adaptation  more  nat- 
urally as  an  adjustment  of  structure  to  function  or 
to  other  structure  than  in  the  opposite  phase  of  adap- 
tation of  function  to  structure.  In  other  words,  pur- 
pose is  the  ultimate  meaning  of  organism,  the  ever- 
changing  purpose  expressed  only  in  properly  adapted 
structure  and  for  which  indeed  the  structure  exists. 
Any  other  view  seems  to  involve  the  thinker  at  once 
or  else  ultimately,  sooner  or  later,  in  a  dilemma  which 
convicts  the  human  mind,  inherently  and  character- 
istically rational,  of  irrationality.  Function,  then, 
purposiveness,  is  properly  considered  primary  to 
structure,  and  adaptation  becomes  a  series  of  changes 
in  protoplasm;  and  it  is  thus  that  the  term  is  com- 
monly understood. 

The  ulterior  causes  of  organic  adaptations  we  may 
find  set  forth  at  any  length  almost  in  the  discussions 
of  the  determinants  of  evolution  by  the  old-time  Dar- 
winians (selectionists)  on  the  one  hand  and  by  the 
mutationists  (disciples  of  DeVries  and  Mendel)  on 
the  other.  Adaptations  are  at  once  the  causes  and 
the  results  of  this  principle  of  unrollment  or  progress 
which  we  designate  as  evolution.  Many  other  re- 
searchers than  these  of  course  have  elaborated  our 
knowledge  of  the  influences  exerted  on  an  organism 
by  environment,  notably  Buffon,  Lamarck,  Geoffrey, 
while  DeVarigny  in  his  book  called  "Experimental 
Evolution"  has  collected  a  large  number  of  examples 
of  variation  or  adaptation.  C.  B.  Davenport's  "  Ex- 
perimental Morphology"  discusses  many  of  the  char- 
acteristic adaptative  reactions  of  animals  and  plants, 
while  T.  H.  Morgan's  "Evolution  and  Adaptation" 
has  an  illuminating  account  of  the  most  broadly  bio- 
logical relations  of  the  theory  of  the  subject  we  are 
discussing.  From  the  last-mentioned  book  we  may 
quote  two  of  many  useful  paragraphs: 

"In  regard  to  the  perpetuation  of  the  advantages 
gained  by  means  of  this  power  of  adaptation" (for 
medical  science,  one  of  the  most  salient  aspects  of  the 
subject),  "it  is  clear  in  those  cases  in  which  the  young 
arc  nourished  during  the  embryonic  life  by  the  mother, 
that,  in  this  way,  the  young  may  be  rendered  im- 
mune to  a  certain  extent,  and  there  are  instances  of 
this  sort  recorded,  especially  in  the  case  of  some  bac- 
terial diseases.  Whether  this  power  can  also  be 
transmitted  through  the  egg,  in  those  instances  in 
which  the  egg  itself  is  set  free  and  development  takes 
place  outside  the  body,  has  not  been  shown.  In  any 
case,  the  effect  appears  not  to  be  a  permanent  one 
and  will  wear  off  when  the  particular  poison  no  longer 
acts.  It  is  improbable,  therefore,  that  any  permanent 
contribution  to  the  race  could  be  gained  in  this  way. 

Vol.  I.— S 


Adaptations  of  this  sort,  while  of  the  highest  im- 
portance to  the  individual,  can  have  produced  little 
direct  effect  on  the  evolution  of  new  forms,  all  hough 
il  may  have  been  often  of  paramount  importance  to 
the  individuals  to  be  able  to  adapt  themselves,  or 
rather  to  become  able  to  resist  the  effect  of  injurious 
substances.  The  important  fact  in  this  connection 
i-  the  wonderful  latent  power  possessed  by  all  animals. 

So  many,  and  of  Mich  different  kind-,  are  the  sub- 
stances to  which  they  may  become  immune,  that  it 
is  inconceivable  that  this  property  of  the  organism 
could  ever  have  been  acquired  through  experience, 
no  matter  how  probable  it  may  be  made  to  appear 

that  this  might  have  occurred  in  certain  cases  of  fatal 
bacterial  diseases.  And,  if  not.  in  so  many  other  cases, 
why  prevent  a  special  explanation  for  the  lew  case 
How  far-reaching  and  complex  at  once  the  relations 
of  adaptation  appear  to  be,  as  we  have  already  said, 
far  beyond  all  present  explanation,  is  suggested  in 
the  following  sentences  also  from  Morgans  treatise, 
it  being  noteworthy  that  they  seem  to  express  this 
authority's  opinion  on  this  matter  as  well  as  that  of 
the  writer  whom  he  quotes:  "Niigeli's  wide  experi- 
ence with  living  plants"  (protoplasm  is  one  appar- 
ently in  alga  and  in  man)  "convinced  him  that  there 
is  something  in  the  organism  over  and  beyond  the 
influence  of  the  external  world  that  causes  organisms 
to  change;  and  we  cannot  afford,  I  think,  to  despise 
his  judgment  on  this  point,  although  we  need  not 
follow-  him  to  the  length  of  supposing  that  this  inter- 
nal influence  is  a  'force'  driving  the  organism  forward 
in  the  direction  of  ever  greater  complexity.  A  more 
moderate  estimate  would  be  that  the  organism  often 
changes  through  influences  that  appear  to  us  to  be 
internal,  and  while  some  of  the  changes  are  merely 
fluctuating  or  chance  variations,  there  are  others 
that  appear  to  be  more  limited  in  number,  but  perfectly 
definite  and  permanent  in  character.  It  is  the  latter, 
which,  I  believe,  we  can  safely  accredit  to  internal 
factors,  and  which  may  be  compared  to  Nageli's  'in- 
ternal causes,'  but  this  is  far  from  assuming  that  these 
changes  are  in  the  direction  of  greater  completeness 
or  perfection,  or  that  evolution  would  take  place  in- 
dependently of  the  action  of  external  agencies." 
From  this  point  of  view  adaptations  with  which  the 
medical  man  is  most  apt  to  be  concerned  (and  when 
is  he  not  concerned  with  some  or  other  adaptations!) 
must  be  deemed  as  much  determined  from  within, 
perhaps  in  the  inherent  metabolism  of  the  organism, 
as  from  without  in  the  immensely  complicated  physio- 
chemimental  environment.  In  other  words,  the 
changes  of  an  adaptive  kind  that  occur  in  human 
beings  appear  to  be  alan  gebraic  balance  of  energies 
or  at  least  tendencies  without  and  within  the  person- 
ality— forces  acting  upon  but  never  wholly  controlling 
the  bodily  nature  of  man,  in  a  broad  sense. 

Among  the  varieties  of  adaptation  discussed  by 
Morgan  (loc.  cit.)  are  sex,  instincts,  form,  symmetry, 
degeneration,  protective  coloring,  length  of  life, 
secondary  sexual  organs,  individual  adjustments, 
growth,  atrophy,  reactions  to  poisons,  and  regenera- 
tion. In  the  broad  range  of  practical  medicine  many 
other  phases  of  adaptation  will  doubtless  occur  to  the 
reader,  most  of  them,  but  by  no  means  all,  useful  to 
the  individual.  Many  of  these  adjustments  to  con- 
ditions outside  of  the  organism  w:ould  more  naturally 
be  thought  of  perhaps  as  the  "effects"  of  certain 
"causes,"  yet  at  the  same  time  obviously  they  are 
steps  taken  by  the  self-protective  living  protoplasm 
toward  meeting  new  conditions.  Thus,  for  example, 
the  undersize  of  underfed  children,  while  properly  a 
result  of  too  little  food  (and  especially,  perhaps,  of  too 
little  protein)  results  in  fact  in  an  adaptation  to  the 
lack  of  sufficient  food,  a  small,  thin,  weak  inactive 
individual  requiring  somewhat  less  nutriment  than 
one  of  the  opposite  characters  of  structure  and  habits. 
This  illustration  has  its  chief  interest,  however,  in 
calling  attention  to  the  fact  that  adaptations  are  in 

113 


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reality  effects  whose  causes  in  the  total  coordination 
of  the  living  world  often  are  far  too  complex  to  be 
detailed  or  in  any  degree  described  in  this  present 
early  stage  of  human  knowledge. 

One  conspicuous  aspect  of  adaptation  for  our 
immediate  purpose,  as  elsewhere,  is  the  advantagous- 
ness  to  the  individual  of  wide  and  ample  powers  of 
adaptation  to  new  conditions  both  useful  and  the 
reverse.  By  having  this  efficiency  in  a  high  degree 
the  individual  on  the  one  hand  can  profit  by  favorable 
conditions  in  the  physio-chemi-mental  environment 
and,  on  the  other  hand,  fail  to  suffer  from  or  to 
succumb  to  those  effects  that  are  unfavorable.  Peo- 
ple differ  not  a  little  in  this  respect,  as  is  readily  seen 
in  the  various  and  varying  immunity  of  some  persons 
and  the  susceptibility  of  others  to  infections.  About 
the  precise  adaptations  of  the  organism  to  these 
multivarious  conditions  we  are  of  course  just  begin- 
ning to  learn  a  little  something — but  so  far  that  little 
certainly  is  not  much.        George  V.  N.  Dearborn. 

Addison,  Thomas. — Born  at  Newcastle-on-Tyne, 
England,  in  April,  1793.  He  received  the  degree  of 
Doctor  of  Medicine  from  the  University  of  Edinburgh 
in  1S15.  Shortly  afterward  he  was  given  the  appoint- 
ment of  House  Physician  at  Lock  Hospital.  About 
1820  he  was  received  as  a  pupil  at  Guy's  Hospital, 
London,  and  for  thirty-seven  years  he  retained  a  con- 
nection with  this  institution  in  one  capacity  or  an- 
other, first  (1824)  as  Assistant  Physician;  then  next 
(1827)  as  Instructor  in  Materia  Medica;  and  finallv 

(1S37)  as  full  Physi- 
cian and  as  a  co- 
lecturer  with  Bright 
on  the  Practice  of 
Medicine.  His  dis- 
covery of  the  disease 
which  bears  his 
name  ("  Addison's 
disease")  brought 
him  a  world-wide  ce- 
lebrity. A  master- 
ful description  of 
this  disease  was  pub- 
lishcd  by  him  in 
1855,  under  the 
title:  "On  the  Con- 
stitutional and 
Local  Effects  of  Dis- 
ease of  the  Suprare- 
nal Capsules,"  with 
plates.  Almost 
equally  meritorious  are  the  papers  on  pneumonia,  on 
pneumonic  phthisis  and  on  phthisis,  which  he  pub- 
lished from  time  to  time,  in  the  Guy's  Hospital  Re- 
ports. His  death  occurred  at  Brighton  on  June  29, 
I860.  A.  H.  B. 

Addison  Mineral  Springs. — Washington  County, 
Maine. 

Post-office. — Addison,  Maine. 

Access. — Via  steamer  from  Portland.  The  spring 
is  two  and  a  half  miles  distant  from  the  railroad 
station,  Columbia  Falls  or  Columbia  Station  on  the 
Washington  County  Railroad.  There  is  a  good  road 
to  the  spring.  Hotel  and  private  families  accommo- 
date visitors. 

This  spring  is  located  in  a  charming  hilly  section 
within  one-quarter  of  a  mile  from  an  inlet  of  the 
Atlantic  and  about  one  hundred  feet  above  the  ocean 
level.  The  ocean  is  nine  miles  distant.  The  beauti- 
ful Pleasant  River  is  near  by.  The  scenery  in  the 
neighborhood  is  charming.  The  spring  which  is 
boiling,  is  about  five  feet  in  diameter  and  four  feet  in 
depth,  and  has  a  steady,  voluminous,  and  rapid  flow. 
Tin'  following  analysis  was  made  by  Professor  Hayes, 
State  Assayer  and  Chemist,   Boston,  Massachusetts. 


vwi»W  -• 


Fig.  40. — Thomas  Addison. 


One  United  States  Gallon  Contains: 

Potassium  sulphate 0 .  60  grain. 

Sodium  sulphate 0 .  27  grain. 

Calcium  sulphate 0 .  52  grain. 

Sodium  chloride 0.S9  grain. 

Sodium  bicarbonate 0 .  44  grain. 

Calcium  bicarbonate 2.65  grains. 

Magnesium  bicarbonate 1.12  grains. 

Iron  bicarbonate 1 .65  grains. 

Silica  and  alumina traces. 

Total 8. 14  grains. 

The  gases  present  are  principally  nitrogen,   oxygen, 
and  carbonic,  acid  with  a  little  sulphureted  hydrogen. 

According  to  the  classification  adopted  by  Dr.  James 
K.  Crook,  this  water  is  properly  termed  a  light  alkaline 
chalybeate.  It  has  been  used  with  apparent  benefit 
in  acid  dyspepsia,  renal  congestion,  skin  affections, 
and  other  conditions  in  which  a  mild  antacid  diuretic 
is  required.  Emma  E.  Walker. 

Addison's  Anemia. — See  Anemia,  Pernicious. 

Addison's  Disease. — Synonyms.  Bronzed  Skin 
Disease;  Melasma  Suprarenale.  Of  the  above  terms 
the  one  adopted  as  the  title  is  to  be  preferred,  for 
while  the  peculiar  discoloration  of  the  skin  is  not  an 
invariable  characteristic  of  the  affection,  the  credit 
of  Addison  to  the  discovery  of  the  disease  called 
by  his  name  has  never  been  called  in  question. 

Definition. — A  disease  characterized  by  progres- 
sive asthenia,  digestive  disorders,  pain  and  tenderness 
chiefly  seated  in  the  epigastric,  hypochondriac,  and 
lumbar  regions;  and  an  abnormal  pigmentation  of  the 
skin  and  mucous  membranes. 

Historical  Notice. — The  first  case  of  Addison's 
disease  on  record  is  to  be  found  in  Lobstein's  treatise, 
"  De  nervi  sympathici  humani  fabrica  et  morbis," 
Paris,  1823,  from  the  English  translation  of  which,  by 
the  late  Prof.  Joseph  Pancoast,  I  take  the  following 
extract:  "I  have  myself  observed  the  nerves  forming 
the  suprarenal  plexus  much  thicker  in  disease,  where 
the  capsular  renales,  which  were  more  than  twice  aa 
large  as  usual,  had  degenerated  into  tuberculous  sub- 
stance." The  patient  was  an  unmarried  woman, 
twenty-five  years  of  age,  who  died  in  "  convulsive 
spasms  analogous  to  the  epileptic.  *****  Noth- 
ing unusual  was  discovered  in  the  body  of  this  woman 
but  the  aforesaid  change  in  the  suprarenal  glands,  and 
the  enlargement  of  the  nerves." 

Notwithstanding  the  fact  that  there  is  no  record  of 
any  darkening  of  the  complexion,  the  above  was 
undoubtedly  a  typical  case  of  Addison's  disease,  in 
which,  moreover,  death  by  convulsions  is  not  uncom- 
mon. The  observation  regarding  the  thickening  of 
the  nerves  in  this,  the  first  recorded  instance  of  the 
disease,  is  of  remarkable  interest.  The  second  case 
was  recorded  in  the  "Halle  Hospital  Reports"  by 
Schotte,  in  October,  1823,  and  republished  in  vol.  vii. 
of  the  Deutsches  Archiv  fur  klin.  Med.,  by  Risel,  in  the 
course  of  his  article  "Zur  Pathologie  des  Morbus 
Addisonii."  The  third  case  came  under  the  observa- 
tion of  Richard  Bright,  at  Guy's  Hospital,  in  July, 
1829.  It  is  contained  in  Bright's  classical  "Reports 
of  Medical  Cases,"  and  also  figures  as  Case  V.  in  Addi- 
son's original  memoir.  The  lesions  of  the  capsules 
were  characteristic;  there  was  no  other  affection  of 
any  consequence,  and  for  the  first  time  in  the  history 
of  this  disease  it  was  noted  that  the  "complexion  w:is 
very  dark."  A  few  other  cases  were  reported  before 
the  year  1S55,  when  Addison  published  his  work  "  ( )n 
the  Constitutional  and  Local  Effects  of  Disease  of  the 
Suprarenal  Capsules,"  but  it  was  reserved  for  his 
sagacity  to  detect  the  relation  between  the  well- 
marked  constitutional  symptoms  of  the  affection,  the 
peculiar  pigmentation  of  the  skin,  and  the  structural 
changes  in  the  suprarenal  capsules. 


114 


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Addison's  Disease 


It  is  no  disparagement  to  the  memory  of  Addison  to 
say  that  the  general  acknowledgment  of  his  discovery 
was  retarded  by  his  including  in  his  treatise  cases 
which,  at  the  present  day,  would  be  rejected  from  the 

,  egory  of  Addison's  disease.  Of  his  eleven  eases 
there  are  but  lour  uncomplicated  with  other  affec- 
tions, two  complicated;  while  of  the  remaining  five, 
one  was  a  case  of  softening  of  the  lira  in  with  advanced 
kidney  disease  ami  tuberculous  deposits  in  various 
organs,  among  others  in  one  suprarenal  capsule,  and 
tin'  oilier  four  were  eases  of  widespread  carcinomat- 
deposit,  the  suprarenal  capsules  being  more  or 
less  involved  in  each.  Addison  was  evidently  under 
impression  that  the  symptoms  of  the  disease  were 
I ,.  t  he  suppression  of  the  unknown  function  of  the 
adrenals,  ami  ih.it,  therefore,  any  destructive  lesion 
of  the-.-  bodies  was  capable  of  causing  them.  This 
view  of  the  pathogenesis  of  the  affection  has  been 
called  in  question  by  distinguished  pathologists,  who 
insisted  on  restricting  the  term  Addison's  disease 
to  a  tuberculous  inflammation  of  the  adrenals.  The 
inal  view  of  Addison,  however,  is  resuming  its 
sway  and  bids  fair  ere  long  to  be  generally  adopted. 
A  n  ill  be  seen  later  on,  the  most  reasonable  theory  of 
the  pathogenesis  of  the  disease  is  that  of  adrenal 
inadequacy. 

Etiology. — Age,  sex,  and  occupation  are  promi- 
nent factors  in  the  etiology  of  this  disease.  The  lesion 
of  the  adrenals  being,  in  the  great  majority  of  cases, 
tuberculous,  it  follows  that  the  affection  is  most  com- 
mon during  those  decades  in  which  tuberculous  proc- 
es  prevail — i.e.  between  twenty  and  forty  years  <  f 
age.  Exceptionally,  the  disease  may  manifest  itself 
both  in  adolescence  and  in  old  age,  and  it  may  even  be 
Congenital.  For  example,  Belyayeff  has  reported  the 
of  an  infant  born  with  a  dingy  yellowish-gray 
skin  who  died  at  the  age  of  eight  weeks.  At  the 
autopsy  both  adrenals  were  found  in  a  state  of  cystic 
degeneration.  The  disease  is  much  more  prevalent 
in  males  than  in  females,  and  especially  so  among  the 
laboring  classes.  Of  1S3  undoubted  cases  tabulated 
by  <  ireenhow,  119  were  males  and  sixty-four  females, 
and  more  than  nine-tenths  of  the  whole  number  were 
engaged  in  laborious  manual  work.  Several  cases 
have  been  associated  with  psoas  or  lumbar  abscess, 
t'n.'  adrenals  becoming  involved  by  extension  of  the 
inflammatory  process.  In  others  devoid  of  such 
spinal  complication,  the  origin  of  the  disease  has  been 
attributed  by  the  patient  to  overexertion  of  the  spinal 
muscles.  Such  was  the  fact  in  one  of  my  own  cases, 
the  patient's  first  symptoms  having  been  weakness  and 
pain  in  the  back  immediately  following  the  occupation 
of  weeding  her  garden.  In  cases  like  those  last 
referred  to,  it  is  probable  that  the  lesion  was  well 
advanced  at  the  time  of  the  overexertion  or  trauma- 
tism, the  latter  merely  serving  to  awaken  dormant 
symptoms. 

Symptomatology. — To  quote  the  words  of  Addison: 
"  The  leading  and  characteristic  features  of  the  morbid 
state  to  which  I  would  direct  attention  are — anemia, 
general  languor  and  debility,  remarkable  feebleness  of 
the  heart's  action,  irritability  of  the  stomach,  and  a 
peculiar  change  of  color  in  the  skin,  occurring  in  con- 
nection with  a  diseased  condition  of  the  suprarenal 
capsules." 

Taking  these  in  order,  the  anemia  first  claims  atten- 
tion. As  is  well  known,  it  was  while  studying  the 
disease  which  he  termed  idiopathic  anemia,  now  more 
generally  known  as  pernicious  anemia,  that  Addison, 
as  he  expressed  it,  "stumbled  upon"  the  discovery 
of  the  disease  which  bears  his  name.  With  his  mind 
intent  upon  the  disease  which  presents  the  profound- 
est  grade  of  anemia,  it  was  natural  that  Addison  should 
attribute  the  languor  and  debility  of  the  bronzed  skin 
disease  to  a  similar  state  of  the  blood.  The  anemia 
of  that  affection  is,  however,  more  apparent  than  real. 
In  one  of  the  most  typical  cases  on  record,  described 
and  pictured  by  Byrom  Bramwell  in  his  atlas  of  clin- 


ical medicine,  theredcorpu  cles  numbered  3,250,000, 

while  the  hemoglobin  was  present  "in  at  least  the 
norma]  amount."     In  another  case  of  dis- 

tinguished clinician  the  red  corpuscles  numbered 
3,500,000  per  cubic  millimeter,  i.e.  seventy  Jier  cent,  of 
the  normal.  These  figures  certainly  do  Dot  repn 
a  high  gi  ideoi  anemia.  As  to  the  leucocytes,  the  only 
change  worthy  of  remark  is  a  relative  lymphocytosis. 
According  to  Dr.  Wilkes,  to  whose  vigorous  and  loyal 
efforts  tin-  general  recognition  of  Addison's  disease  is 
perhaps  chiefly  due  |  Etolle  ton),  anemia  is  not  a  fea- 
ture of  the  disease.     Under  the  microscope  the  red 

corpuscles  are  seen  to  be  of  normal  size  and  shape,  and 
to  form  rouleaux  as  in  health,  while  the  white  cells 
may  or  may  not  be  slightly  in  excess.  In  one  or  two 
cases  free  pigment  granules  are  -aid  tn  have  been 
present,  but  the  observation  stand-  in  urgent  need  of 
confirmation.  Anemia  not  being  present  in  sufficient 
degree  to  account  for  the  profound  asthenia  of  Addi- 
son's disease,  to  what  then  is  it  due?  As  will  be  seen 
under  the  head  of  pathogenesis,  it  is  most  reasonably 
to  be  attributed  to  an  irregular  distribution  of  the 
blood,  to  its  accumulation  in  the  enormous  district 
of  the  abdominal  vessels. 

The  languor  and  debility  or,  in  one  word,  the 
asthenia  which,  according  to  Addison  ami  all  subse- 
quent observers,  is  a  cardinal  symptom  of  the  disease, 
is  also  one  of  the  earliest.  In  all  histories  of  the 
disease  the  patient  has  been  compelled  to  abandon 
his  usual  occupation  by  reason  of  muscular  weakness, 
and  when  there  is  no  complication  with  other  wasting 
disease  this  prostration  is  unattended,  at  least  in  the 
early  stage,  with  any  marked  diminution  in  the  vol- 
ume of  the  muscular  and  adipose  tissues.  The 
power  of  resistance  to  depressing  agents  is  greatly 
reduced.  Mental  and  bodily  exertion  which  would 
be  regarded  by  the  healthy  as  trivial,  is  followed  by 
exhaustion,  and  the  use  of  purgatives  is  positively 
dangerous.  As  remarked  by  Bramwell,  in  more 
than  one  of  the  recorded  eases  death  has  resulted 
from  an  ordinary  dose  of  a  purgative  drug. 

With  this  asthenia  there  is  enfeebled  action  of  the 
heart,  of  which  the  apex  beat  is  faint  or  imperceptible 
and  the  sounds  weak  and  distant.  Anemic  murmurs 
are  rare  and  the  same  is  true  of  valvular  defects, 
dilatation  and  hypertrophy.  Edema  is  seldom 
observed.  The  pulse  presents  varying  features,  but 
is  always  weak  and  compressible.  It  may  be  frequent 
or  infrequent,  full  or  small.  Patients  are  liable  to 
attacks  of  collapse  induced  by  vomiting,  purgation, 
or  other  depressing  cause,  or  without  apparent  cause, 
which  may  be  so  severe  as  to  resemble  the  collapse  of 
cholera.  Contrary  to  the  usual  frequency  of  the 
pulse  in  collapse,  a  remarkable  diminution  in  the 
number  of  the  heart  beats  has  been  observed  in  several 
cases  (Risel  mentions  seven),  and  this  without  any 
disease  of  the  brain  or  important  cardiac  disease.  In 
a  ease  reported  by  Cholmeley  (Medical  Times  and 
Gazette,  1S09,  vol.  ii.,  p.  219)  in  which  death  was 
preceded  by  profound  collapse,  dyspnea,  and  con- 
vulsions, the  pulse  fell  to  thirty-six  per  minute.  In 
advanced  cases,  the  blood  pressure  is  almost  invaria- 
bly low  and  is  not  raised  by  coincident  nephritis  or 
arteriosclerosis.  Pressures  as  low  as  seventy-five  are 
recorded. 

Symptoms  referable  to  disordered  digestion  are 
always  more  or  less  prominent  and  are  of  early 
appearance.  Among  them  are  marked  anorexia, 
nausea  and  vomiting,  constipation  alternating  with 
diarrhea,  and  epigastric  tenderness.  Sometimes  the 
nausea  and  vomiting  occur  in  paroxysms  without  any 
apparent  exciting  cause,  and  on  this  account,  as  well 
as  because  of  their  severity,  they  have  been  compared 
to  the  gastric  crises  of  locomotor  ataxia.  Epigastric 
tenderness  was  a  prominent  feature  of  two  cases  that 
came  under  my  care  at  the  Episcopal  Hospital  of 
Philadelphia.  In  the  report  of  the  first  I  noted  that 
"at    times    there    was   great    tenderness    about    the 


115 


Addison's  Disease 


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umbilical  region,  and  on  one  occasion,  after  palpating 
the  abdomen,  the  patient  uttered  loud  cries  for  ten 
or  fifteen  minutes  and  seemed  in  great  agony" 
(Trans.  Path.  Sue.  Phila.,  vol.  v.).  In  the  other  case, 
"the  pain  was  latterly  most  severely  felt  in  the  left 
lumbar  region,  in  which  situation  there  was  also  a 
great  degree  of  tenderness  on  pressure"  (Trans. 
Path.  Soc.  Phila.,  vol.  x.).  In  the  first  of  these  cases 
nothing  was  found  at  the  necropsy  to  account  for 
this  remarkable  tenderness;  in  the  second,  it  might 
have  been  due  to  the  great  tumefaction  of  the  lumbar 
glands. 

The  date  of  the  appearance  of  the  pathognomonic 
discoloration  of  the  skin,  from  which  the  disease  derives 
one  of  its  names,  is  very  variable.  It  may  either 
precede  or  follow  the  constitutional  symptoms,  or  the 
disease  may  terminate  fatally  without  its  manifesta- 
tion. Greenhow  has  collected  a  number  of  cases 
illustrating  the  erratic  appearance  of  this,  the  only 
pathognomonic  feature  of  Addison's  disease.  In  one 
of  his  cases  the  pigmentation  of  the  skin  is  said  to 
have  been  the  sole  symptom  for  eight  years,  at  the 
end  of  which  period  the  pigmentation  deepened  and 
the  other  well-known  symptoms  of  Addison's  disease 
were  superadded.  This  case  is  the  most  remarkable 
on  record  in  so  far  as  the  early  appearance  of  bronzing 
is  concerned,  but  it  has  been  criticised  by  Brain  well, 
who  has  shown  that  the  original  pigmentation, 
limited  to  the  forehead  and  parts  adjacent,  was 
probably  due  to  <a  chronic  peritonitis,  of  which  the 
signs  were  found  at  the  autopsy,  and  that  the  genuine 
melasma  suprarenale  dated  from  the  period  when  the 
pigmentation  was  observed  to  deepen  and  become 
more  general,  and  the  constitutional  symptoms  to 
develop. 

In  connection  with  the  statement  above  made, 
that  the  disease  may  terminate  without  cutaneous 
change,  it  is  important  to  observe  that  the  pigmenta- 
tion may  be  very  limited  in  area,  and  so  situated  as 
to  escape  observation  unless  the  entire  surface  of  the 
body  is  minutely  inspected.  The  most  remarkable 
illustration  of  this  important  point  is  furnished  by 
Bramwell.  He  had  exhibited  at  his  clinique  in  the 
Edinburgh  Royal  Infirmary,  a  patient  whose  chief 
symptoms  were  moderate  anemia  (3,500,000  red 
corpuscles  per  cubic  millimeter),  emaciation  and 
extreme  prostration,  and  had  confessed  his  inability 
to  make  a  positive  diagnosis.  As  the  patient  was 
walking  away  to  put  on  his  clothes,  "and  when  a  good 
light  fell  full  on  his  back,  I  noticed,"  says  Bramwell, 
"  two  or  three  brown  discolorations  over  the  spines  of 
some  of  the  dorsal  vertebra.  It  immediately  flashed 
across  my  mind  that  the  case  was  one  of  Addison's 
disease.  I  at  once  called  the  patient  back  and  care- 
fully examined  the  mucous  membrane  of  the  mouth. 
A  small  brown  discoloration  was  seen  to  be  present 
on  the  inner  side  of  the  left  cheek,  just  opposite  the 
angle  of  the  mouth.  The  discoloration  was  quite 
characteristic,  and  I  immediately  committed  myself  to 
a  positive  opinion  that  the  case  was  one  of  Addison's 
disease." 

The  abnormal  surface  pigmentation  has  its  seat  in 
the  skin  and  in  the  mucous  membrane  of  the  buccal 
cavity,  including  that  of  the  tongue;  it  has  been  said 
also  to  occur  in  the  vagina  and  the  conjunctiva.  The 
pigment  is  deposited  in  the  youngest  layers  of  the 
rete  Malpighii,  in  contact  with  the  papilla1.  It 
appears  both  as  a  diffuse  coloration  of  the  cells  and 
also  in  the  form  of  distinct  granules  in  the  cells,  or 
free;  in  the  latter  case  it  is  supposed  to  be  left  after 
the  dissolution  of  the  cells.  It  rarely  appears  in  the 
corium,  although  sometimes  branched  pigmented 
connective-tissue  cells  are  found.  The  parts  of  the 
external  surface  most  deeply  pigmented  are  those 
which,  under  normal  circumstances,  are  the  seat  of 
oft-recurring  hyperemia,  either  from  atmospheric 
influences  or  friction,  such  as  the  cheeks,  neck,  and 
backs  of  the  hands.     There  is  also  a  special  tendency 


to  the  deposit  of  pigment  in  those  parts  where  it  is 
found  normally  in  greater  amount  than  elsewhere, 
such  as  the  nipples,  genital  organs,  and  axilla;.  In 
well-marked  cases,  it  pervades  the  entire  cutaneous 
surface,  being  deeper  in  the  parts  above  mentioned, 
and  may  be  deposited  in  the  lunula?  of  the  nails  and 
even  in  the  teeth.  The  hair  and  the  iris  have  been 
observed  to  grow  darker  with  the  progress  of  the 
disease,  and  the  eyeground  is  sometimes  abnormally 
dark.  The  tint  of  the  discoloration  varies  in  different 
cases,  depending  to  some  extent  upon  the  normal 
complexion  of  the  patient.  It  is  most  striking, 
because  of  its  incongruity,  when  the  patient  is 
naturally  fair,  with  light  hair  and  blue  eyes.  The 
color  of  the  most  typical  cases  of  the  disease  may  be 
best  imitated  by  staining  the  healthy  skin  with 
walnut  juice.  In  chronic  cases,  the  complexion  may 
come  to  resemble  that  of  a  mulatto,  as  in  the  portrait 
illustrating  Bramwell's  classical  monograph  ("Atlas 
of  Clinical  Medicine,"  vol.  i.)  which  has  been  copied 
far  and  wide.  When  the  pigmentation  is  partial,  as 
it  is  apt  to  be  in  its  early  stage,  its  outline  is  not 
sharply  circumscribed,  as  in  other  pigmentary  affec- 
tions, but  gradually  fades  into  the  surrounding  integu- 
ment. Upon  the  darker  patches  also  are  frequently 
seen  black  specks  resembling  moles  or  freckles.  As 
above  stated,  the  pigmentation  is  most  pronounced 
in  parts  that  have  been  subjected  to  any  species  of 
irritation,  such  as  that  of  a  blister,  or  that  produced 
by  the  pressure  of  garters,  waist-bands,  or  suspenders. 
A  well-known  illustration  of  this  effect  of  cutaneous 
irritation  is  afforded  by  the  case  of  a  baker's  boy 
whose  shoulders  were  marked  with  dark  stripes 
corresponding  to  the  lines  of  pressure  of  straps  from 
which  his  basket  was  suspended. 

Pigmentation  of  the  mucous  membranes  is  at  least 
equal  in  diagnostic  value  to  that  of  the  skin,  although 
it  is  believed  by  most  authorities  to  be  rarer  and  to 
occur  at  a  more  advanced  stage  of  the  disease.  It  is 
most  frequently  observed  in  the  line  of  closure  of  the 
lip,  and  upon  the  tongue,  cheeks,  and  gums,  and  is 
accentuated  by  any  cause  of  irritation,  such  as  that  of  a 
carious,  jagged  tooth.  When  seated  in  the  gums  the 
discoloration  has  been  mistaken  for  that  of  lead- 
poisoning.  It  may  be  of  a  dingy  brown  hue  or 
darker,  as  if  caused  by  ink  stains.  It  has  also  been 
compared  to  the  stains  produced  by  whortleberries 
and  blackberries.  In  one  of  Bramwell's  cases  the 
pigment  was  accumulated  in  round,  ball-like  masses 
on  the  under  surface  of  the  tongue  parallel  with  and 
apparently  adherent  to  the  lingual  arteries. 

The  urine  presents  no  characteristic  changes.  The 
most  careful  study  of  the  urine  in  any  single  case  was 
made  by  Dr.  Tliudicum,  for  sixty-five  consecutive 
days,  in  a  patient  of  Dr.  Bunion  Sanderson.  Without 
complicating  fever  or  diarrhea,  there  was  a  great  dimi- 
nution in  the  daily  amount  of  urine,  it  being  reduced 
more  than  one-half;  the  specific  gravity  was  1.020  and 
upward,  and  the  reaction  acid.  The  most  important 
result  of  these  researches  was  the  determination  of  the 
fait  thai  the  urinary  pigments  were  much  diminished. 
Thudicum's  analyses,  so  far  as  the  estimate  of  the 
urinary  pigments  is  concerned,  have  been  since  con- 
firmed by  Drs.  A.  E.  Garrod  and  Dixon  Mann. 
Thudicum  was  apparently  of  the  opinion  that  the 
diminution  in  the  amount  of  urinary  pigments  might 
bear  a  relation  to  the  excess  of  pigment  in  the  skin; 
but  it  is  more  reasonable  to  suppose  that  if  the  disease 
of  the  adrenals  caused  an  accumulation  of  soluble 
pigments  in  the  blood,  the  coloring  matters  of  (he 
urine,  supposing  the  kidneys  to  be  healthy,  would  be 
present  in  excess. 

The  remaining  symptoms  of  Addison's  disease  are 
either  inconstant  or  negative,  and,  therefore,  of  sec- 
ondary importance.  Most  of  them  are  referable  to 
the  nervous  system  and  are  dependent  upon  a  defective 
or  irregular  supply  of  blood.  Among  them  may  be 
mentioned  insomnia  and  somnolence,  headache,  ver- 


116 


EXPLANATION  OF 
PLATE  VI. 


EXPLANATION  OF  PLATE  VI. 

Fig.  1. — Shows  the  Discoloration  of  the  Tongue  in  a  Case  of  Addison's  Disease,  a,  Dark 
ink-like  stains  near  the  free  border  of  the  tongue;  6,  fungiform  papillae  on  the  dorsum  of 
the  tongue,  discolored  by  deposit  of  pigment;  the  papillie  circumvallatas  remaining 
uncolored. 

Fig.  2. — Section  of  Pigmented  Patches  on  the  Tongue,  Viewed  with  a  One-Inch  Objective. 
The  lower,  plumper  cells  clothing  the  papilke  are  seen  loaded  with  pigment;  the  sub- 
epithelial connective  tissue  remaining  quite  uncolored. 

Fig.  3. — Section  of  Bronzed  Skin.  a.  Rough  scarf  skin  free  from  pigment;  6,  plumper  cells 
of  the  rete  mucosum,  the  deepest  layer  loaded  with  pigment;  c,  subepithelial  connective 
tissue  free  from  pigment. 

Fig.  4. — Section  of  Discolored  Patch  of  Skin,  Site  of  a  Recent  Blister,  a,  Brown  pigment 
deposited  in  the  deeper  layers  of  the  epidermis;  b,  scattered  masses  of  pigment  situated 
in  the  cutis  vera. 


Reference  Handbook 

or  THE 

Medical    Sciences. 


PLATE  VI. 


V 


i 


A  MJ&  ft  * 


i .. 


■  • 


■x  a20 


'«•;* 


PIGMENTATION  OF  THE  SKIN  AND  OF  THE  MUCOUS  MEMBRANE  OF  THE  TONGUE  OBSERVED  IN 
ADDISON'S   DISEASE.— (Copied  from  the  Treatise  of  Edward  H.  Qreenhoui,  M.D.,  F.R.S.) 


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Ailill-nn's   IHsia-i- 


tigo,  tinnitus  aurium,  neuralgic  pains  which  may  be 
seated  in  the  joints,  muscular  Switchings,  and  epi- 
leptiform  convulsions.  The  latter,  associated  with 
delirium  and  coma,  may  be  the  immediate  precursors 
of  death.  The  mental  faculties,  especially  the 
memory,  are  often  impaired  and  the  patient  may  be 
lacrymose  and  melancholic.  The  coma  which  so 
often  precedes  death  sometimes  resembles  that  of 
diabetes,  at  others,  that  of  uremia.  Bittorf  has 
demonstrated  an  increase  in  the  pressure  of  the 
cerebrospinal  fluid  up  to  3G0  millimeters  in  a  comatose 
patient.  The  reflexes,  skin,  tendon,  and  pupillary, 
are  not  materially  affected. 

Disturbances  of  sensibility,  both  subjective  and 
objective,  are  frequent.  Among  them  are  pains  in 
tin'  back,  joints,  and  muscles  without  demonstrable 
arthritis  or  myositis,  and  tenderness  on  pressure  over 
the  epigastrium  and  lumbar  region.  They  may  be 
explained  by  spinal  lesions  which  have  been  found  in 
certain  cases,  such  as  sclerosis  of  the  posterior  columns 
and  posterior  nerve  roots. 

The  temperature  throughout  the  disease  presents 
nothing  characteristic,  being,  in  the  absence  of  com- 
plications, normal  or  subnormal.  Just  before  death, 
fever  is  the  rule.  The  nutrition  in  the  earlier  stages 
may  be  well  maintained,  and  in  uncomplicated  cases 
there  may  be  little  loss  of  fat  throughout  the  entire 
course  of  the  disease.  When  associated  with  phthisis, 
however,  or  other  w-asting  disease,  and  even  some- 
times without  such  association,  emaciation  may 
become  extreme. 

Pathogenesis. — There  are  two  principal  theories 
of  the  pathogenesis  or  "pathological  physiology"  of 
Addison's  disease:  1,  The  nervous  theory;  2,  the 
theory  of  adrenal  inadequacy. 

1.  Nervous  Theory. — According  to  this  theory,  "the 
symptoms  of  Addison's  disease  are  not  directly  due  to 
the  destruction  of  the  suprarenal  bodies,  but  result 
from  the  derangements  in  the  abdominal  sympathetic 
(and  perhaps  other  nervous  structures)  which  the  lesion 
of  the  suprarenal  capsules  produces."  This  theory 
has,  to  support  it,  facts  derived  both  from  anatomy 
and  from  physiology.  In  the  great  majority  of  cases 
the  nerves  and  ganglia  of  the  abdominal  sympathetic 
are  extensively  involved  in  the  tuberculous  inflam- 
mation which  destroys  the  adrenals,  and  it  is  only 
reasonable  to  suppose  that  such  involvement  must 
give  rise  to  serious  symptoms.  In  addition,  it  has 
been  demonstrated  by  Alezais  and  Arnaud  that  upon, 
and  in  the  substance  of,  the  capsule  of  the  adrenals 
there  are  numerous  sympathetic  ganglia.  These  they 
term  the  pericapsular  nervous  ganglia,  and  they  hold 
that  the  peculiar  and  special  lesion  of  Addison's  dis- 
ease "is  their  degeneration."  They  explain  the  well- 
known  absence  of  symptoms  of  Addison's  disease  in 
many  cases  of  cancerous  disease  of  the  adrenals  by  the 
fact  that  the  malignant  growth  advances  from  within 
outward  and  is  limited  by  the  fibrous  covering  of  the 
glands,  whereas  tubercles  invade  both  gland  and 
fibrous  covering  alike.  Semmola  of  Naples  pushes  the 
nervous  theory  to  the  extreme  of  holding  that  the 
abdominal  nerves  and  ganglia  are  primarily  involved, 
and  that  the  lesion  of  the  adrenals  is  a  trophic  result 
of  their  functional  disturbance. 

Granting,  as  every  one  does,  the  common  involve- 
ment of  the  abdominal  nerves  and  ganglia,  and 
especially  that  of  the  pericapsular  ganglia,  it  remains 
to  be  considered  whether  the  results  of  experiments 
upon  the  abdominal  sympathetic  threw  any  light  upon 
the  pathogenesis  of  Addison's  disease. 

Irritation  of  a  sensory  nerve  produces  vasomotor 
paralysis  in  the  irritated  region,  and  the  well-known 
experiments  of  Goltz  (" Klop/verstich")  have  shown 
that  irritation  of  the  intestines  produces  complete 
vasomotor  paralysis  of  their  blood-vessels,  causing 
thereby  so  great  an  accumulation  of  blood  that  the 
animal  shows  symptoms  of  syncope,  the  same  as  if  it 
had  been  bled  copiously. 


The  irritation  of  the  numerous  nerves  and  ganglia 
of  the  adrenals  produced  by  inflammation  with  new 
formation  <  *i  I  issue  and  subsequent  softening,  such  as 
exists  in  Addison's  disease,  is  transmitted  to  the  semi- 
lunar ganglion  and  solar  plexu    from  tie-  beginning  of 

the  deposit  in  the  adrenals,  and,  later,  bj   extension  of 

the  inflammatory  proci      i"  the  e  nerve  centers.     By 

this  means  a  vasomotor  paralysis  of  the  intestinal 
vessels  is  produced,  as  in  the  experiments  of  Goltz, 
except  that,  unlike  in  the  latter  case  it  is  constant. 
This  continual  hyperemia  of  i  he  intestinal  vessels  leads 
to  enlargement  of   the  solitary   glands  and  Peyer's 

patches,  so  constantly  found  in  Addison's  disease,  ;i  i , .  I 

occasionally  to  catarrh  and  ulceration  of  the  stomach 
and  intestinal  mucous  membrane.  It  accounts  for  the 
dark  color  of  the  liver,  spleen,  pancreas,  and  kidneys  so 
often  observed,  as  well  as  for  the  brownish  hue  of  the 
peritoneum  noticed  in  a  few  instances.  Indirectly, 
it  explains  the  anemic  and  dry  condition  of  other  parts 
of  the  body,  and  directly  accounts  for  the  great  muscu- 
lar weakness,  syncope,  gastrointestinal  disturbance, 
dyspnea  on  slight  exertion,  and  small  radial  pulse. 
These  symptoms  have  been  attributed  to  a  high  grade 
of  anemia,  such  as  exists  in  pernicious  anemia;  and 
this  is  due  to  the  fact  that  many  of  the  symptoms  in 
the  two  affections  are  identical.  Repeated  examina- 
tions of  the  blood  have,  however,  demonstrated  that 
the  reduction  in  the  number  of  the  red  corpuscles  in 
Addison's  disease  is  trivial  compared  with  that  found 
in  pernicious  anemia.  The  symptoms  resembling 
those  of  pernicious  anemia — such  as  dyspnea  on 
slight  exertion,  syncope  on  assuming  the  upright 
posture,  rapid,  small,  and  feeble  pulse — are  attri- 
butable to  an  insufficient  supply  of  blood,  albeit 
of  fair  quality,  to  the  supradiaphragmatic  portion  of 
the  trunk. 

From  the  foregoing,  it  is  manifest  that  there  are 
well-established  facts,  both  anatomical  and  physio- 
logical, in  support  of  the  nervous  theory  of  Addison's 
disease.  This  is  the  theory  adopted  by  Bramwell, 
although  he  qualifies  his  adherence  to  it  by  the  state- 
ment that  it  is  "perhaps  possible  that  some  of  the 
symptoms  of  Addison's  disease  may  be  the  direct 
result  of  abolition  of  the  [glandular]  function  of  the 
suprarenal  capsules." 

Rolleston  (British  Medical  Journal,  April  6,  1S95) 
discards  the  nervous  theory  rather  summarily,  and 
chiefly,  as  it  seems  to  the  writer,  on  the  ground  that 
the  "sympathetic  in  the  neighborhood  of  the  supra- 
renal bodies  is  not  constantly  altered."  It  must  be 
recalled,  however,  that  Alezais  and  Arnaud  discuss 
this  contingency,  and  claim  that  Addison's  disease 
may  be  "accompanied  with  alterations  in  the  peri- 
capsular sympathetic  nervous  system  and  with  com- 
plete integrity  of  the  rest  of  the  solar  plexus  and  its 
ganglia." 

2.  Theory  of  Adrenal  Inadequacy. — The  arguments 
in  support  of  this  theory  are  derived  from  analogy, 
anatomy,  therapeutics,  and  experimental  pathology. 

The  structure  of  the  adrenals  is  distinctly  glandular. 
In  the  vast  majority  of  cases,  the  symptoms  of  Addi- 
son's disease  are  associated  with  destruction  of  these 
glands.  In  the  rare  cases  in  which  they  are  destroyed 
by  disease  without  concomitant  symptoms  of  morbus 
Addisonii,  the  absence  of  the  latter  may  be  due  to 
accessory  suprarenal  bodies  or  to  suprarenal  "rests." 
The  former,  according  to  Rolleston,  are  "very  com- 
monly present  in  the  connective  tissue  in  the  immedi- 
ate neighborhood  of  the  two  organs";  the  latter,  the 
so-called  "suprarenal  rests,"  are  found  "embedded  in 
the  kidney  or  liver."  The  analogy  with  myxedema  is 
thus  seeti  to  be  very  close,  and,  to  make  it  complete, 
it  need  only  be  added  that  the  life  of  an  animal 
whose  adrenals  have  been  removed  may  be  pro- 
longed by  embedding  beneath  its  skin  a  healthy 
adrenal  or  administering  subcutaneously  an  adrenal 
extract. 

The  experiments  upon  the  function  of  the  adrenals 


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which  seem  to  the  writer  to  be  the  most  free  from  criti- 
cism are  those  of  Abelous  and  Langlois  (Archives  de 
physiologie,  tome  iv.,  1892).  These  observers  found: 
(1)  that  the  total  destruction  of  both  adrenals  in  frogs 
was  invariably  followed,  sooner  or  later,  by  death,  the 
time  of  which  depended  upon  various  factors.  Frogs 
in  a  state  of  hibernation  survived  the  operation  for 
twelve  or  thirteen  days,  while  in  the  summer  the  ani- 
mals never  lived  longer  than  forty-eight  hours.  If  the 
animal  was  irritated  so  as  to  excite  active  muscular 
movements,  it  perished  sooner  than  if  it  were  allowed 
to  remain  quiescent.  In  other  words,  the  more  active 
the  nutritive  changes,  the  sooner  the  animal  died — a 
fact  in  accordance  with  the  longer  survival  of  hiber- 
nating animals  as  compared  with  those  operated  on 
during  the  summer. 

(2)  The  destruction  of  one  adrenal  did  not  cause 
death  or  any  abnormal  manifestation  (six  animals 
operated  on). 

(3)  If  one  adrenal  is  destroyed  and  a  large  portion 
of  the  other,  the  animal  may  or  may  not  die.  A  con- 
siderable portion  {tin  fragment  notable)  of  one  adrenal 
must  be  left  in  order  to  insure  the  survival  of  the 
animal. 

(4)  The  insertion  beneath  the  skin  (in  the  dorsal 
lymph  sac)  of  the  adrenals  taken  from  a  sound  frog 
prolongs  the  life  of  a  frog  from  which  both  adrenals 
have  been  removed. 

(5)  The  injection  (subcutaneous)  of  adrenal  extract 
into  frogs  from  which  the  adrenals  have  been  removed 
prolongs  their  lives  but  a  short  time — not  more  than 
twenty-four  hours. 

(6)  The  injection  (intravenous  or  subcutaneous)  of 
blood  from  a  frog  about  to  die  from  the  effects  of  loss 
of  adrenals  into  a  frog  from  which  the  adrenals  have 
just  been  removed,  causes  rapid  paralysis  and  death. 
The  same  injection  "into  a  normal  frog  produces  very 
slight  and  transitory  disturbances. 

In  none  of  their  experiments  did  Abelous  and  Lang- 
lois observe  any  anomalous  pigmentation. 

They  conclude  from  their  experiments,  of  which  the 
above  is  but  an  abstract:  (a)  that  the  death  of  frogs 
after  removal  of  their  adrenals  is  due  to  the  accumu- 
lation in  the  blood  of  one  or  more  toxic  substances; 
(6)  that  this  substance,  or  these  substances,  produces 
an  effect  resembling  that  of  curare,  acting  chiefly  upon 
the  terminations  of  the  motor  nerves  and  slightly  also 
upon  the  muscles.  The  role  of  the  adrenals,  in  their 
opinion,  is  to  destroy  this  poison  by  an  internal  secre- 
tion which  they  elaborate. 

So  much  for  the  theory  of  adrenal  inadequacy, 
which  is  the  one  adopted  by  Rolleston,  who  concludes 
his  elaborate  and  masterly  discussion  of  the  patho- 
genesis of  Addison's  disease  (Goulstonian  lectures, 
British  Medical  Journal,  1895)  with  the  statement 
that  the  affection  "is  due  to  an  inadequate  supply  of 
suprarenal  secretion.  Whether  the  deficiency  in  this 
internal  secretion  leads  to  a  toxic  condition  of  the 
blood,  or  to  a  general  atony  and  apathy,  is  a  question 
which  must  remain  open."  The  discovery  of  the 
vasoconstrictor  action  of  suprarenal  extract  by  Oliver 
and  Schaefer  and  Cybulski  affords  the  best  possible 
explanation  of  the  low  blood  pressure  (in  itself 
accountable  for  a  train  of  symptoms)  which  is 
invariably  observed  in  destructive  lesions  of  the 
adrenals. 

More  careful  observation  is  needed  to  determine 
whether  the  symptoms  of  those  cases  of  Addison's 
disease  in  which  the  sympathetic  nerves  and  ganglia 
are  implicated,  are  different  from  those  in  which  they 
are  not.  Judging  from  the  well-known  results  of 
physiological  experiment,  it  would  seem  reasonable 
to  expect  a  greater  degree  of  asthenia  and  a  greater 
tendency  to  syncope  in  cases  of  sympathetic  involve- 
ment, and,  on  the  other  hand,  to  expect  a  predomi- 
nance of  more  purely  toxic  symptoms  in  those  cases 
(the  type  of  which  is  simple  atrophy  of  the  adrenals) 
in  which  the  lesion  is  limited  to  the  capsules.     The 


supreme  judge  of  this  question,  as  of  all  questions 
of  pathogenesis,  is  the  clinician,  and  with  greater 
opportunities  for  observation,  the  expectation  of 
its  solution  is  not  unreasonable. 

Diagnosis. — When  the  disease  is  primary,  the  con- 
stitutional symptoms  well  marked,  and  the  discolora- 
tion of  skin  and  mucous  membranes  present,  the  diag- 
nosis presents  little  or  no  difficulty  to  one  who  has 
previously  studied  a  single  case  of  the  disease.  ( >n 
the  other  hand,  when  the  constitutional  symptoms 
are  well  pronounced  in  a  primary  case,  and  the  bronz- 
ing of  skin  is  not  yet  developed,  the  diagnosis  is  to  be 
made  only,  if  at  all,  by  the  exclusion  of  other  wasting 
diseases,  especially  cancer  of  abdominal  organs  and 
progressive  pernicious  anemia.  Many  years  ago  there 
came  under  my  care  at  the  Episcopal  Hospital  of 
Philadelphia  a  case  of  lumbar  abscess  with  several 
open  sinuses  leading  to  carious  vertebrae.  The  gen- 
eral surface  of  the  body  was  of  a  dark  dingy  hue,  and 
the  orifice  of  each  sinus  was  surrounded  by  a  broad, 
deeply  pigmented  ring.  The  patient  had  been  pre- 
viously at  another  institution,  where  secondary  dis- 
ease of  the  adrenals  had  been  suspected.  The  autopsy 
showed  these  bodies  to  be  perfectly  healthy  and  the 
kidneys  to  be  involved  in  extensive  amyloid  degenera- 
tion. A  dingy  discoloration  of  the  skin  is  not  uncom- 
mon in  amyloid  disease  of  the  kidney,  as  first  pointed 
out  by  Grainger  Stewart. 

The  discoloration  of  skin,  although  not  the  most 
essential  characteristic  of  the  disease,  is  justly  re- 
garded as  its  most  important  diagnostic  feature.  It 
is  to  be  distinguished  from  melasma  gravidarum,  pity- 
riasis versicolor,  lichen,  and  pigmentary  syphilides, 
and  this  is  readily  done  by  any  one  familiar  with 
these  affections.  The  melanoderma  of  phthisical  pa- 
tients presents  more  serious  difficulty.  Although  the 
latter  is  often  confined  to  the  face  and  does  not  invade 
the  mucous  membrane  of  the  buccal  cavity,  the  ditfi- 
culty  is  a  real  one,  and  is  augmented  by  the  fact  that 
pulmonary  tuberculosis  is  the  most  frequent  compli- 
cation of  Addison's  disease.  The  seat  of  the  melasma 
suprarenale,  or  its  greater  intensity,  upon  the  face  and 
neck,  the  dorsum  of  the  hands,  areola  of  the  nipple 
and  about  the  umbilicus,  in  the  axilla,  groin,  and  upon 
the  genitals,  is  characteristic.  Other  diagnostic  fea- 
tures of  the  pigmentation  have  been  described  above 
under  the  head  of  Symptoms.  A  discoloration  of  the 
skin  liable  to  be  confounded  by  the  inexperienced  with 
that  of  Addison's  disease  is  sometimes  seen  in  badly 
nourished  paupers  of  dirty  habits,  whose  skin  is  the 
abode  of  vermin  (vagabonds'  disease).  This  pigmen- 
tation shows  itself  in  the  form  of  patches  separated 
by  healthy  skin;  the  epidermis  is  often  roughened, 
and  the  discoloration  more  marked  upon  the  trunk 
than  on  the  face  and  hands.  The  skin  is  also  often 
marked  with  scratches,  the  result  of  the  intense  itch- 
ing. Under  the  microscope,  the  particles  of  pigment 
in  this  affection  are  found  in  all  the  layers  of  the 
epidermis,  instead  of  being  limited,  as  in  Addison's 
disease,  to  the  deeper  layers  of  the  rete  Malpighii. 
The  pigmentation  of  chronic  malarial  poisoning  i- 
distinguished  from  that  of  Addison's  disease  not 
only  by  its  distribution,  but  by  the  history  of  the 
case  and  the  frequent  presence  of  splenic  enlarge- 
ment; chronic  icterus,  with  which  Addison's  disease 
was  formerly  confounded,  is  distinguished  by  the 
presence  of  pigment  in  the  ocular  conjunctiva  and  in 
the  urine. 

Other  discolorations  of  the  skin  simulating  closely 
the  pigmentation  of  Addison's  disease  are  mentioned 
by  systematic  writers,  but  are  so  rare  as  to  be  in  them- 
selves pathological  curiosities.  Among  them  may  be 
mentioned  a  diffuse  pigmentation  associated  with 
chronic  scurvy  (Bramwell),  and  a  few  other  cases  of 
melasma  occurring  without  obvious  cause.  Accord- 
ing to  the  author  just  cited,  there  are  certain  forms  of 
pigmentation  of  the  skin  associated  with  chronic  peri- 
tonitis, or  malignant  disease  of  the  abdomen  or  pel- 


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Adenoma 


vis  which  it  is  impossible  to  distinguish  from  Addi- 
son's disease.  This  fact,  though  discomfiting  to  the 
clinician,  is  of  great  interest  to  the  pathologist,  as 
tending  to  prove  that  the  most  characteristic  symptom 
of  the  affection,  the  melasma  suprarenale,  is  to  be 
attributed  rather  to  the  implication  of  the  abdominal 
sympathetic  than  to  that  of  the  adrenals. 

Prognosis. — The  prognosis  is  in  the  highest  degree 
unfavorable,  although  recoveries  of  cases  presenting 
every  sign  and  symptom  of  the  affection  have  been 
reported  by  the  most  competent  observers.  Among 
these  may  be  mentioned  Sir  William  Gull  and  Dr 
Finney.  In  making  predictions  as  to  the  duration  of 
life,  the  remittent  character  of  the  disease  should  be 
liiune  in  mind.  A  case  seen  during  a  period  of  exacer- 
I,  1 1  em  may  lead  to  the  prognosis  of  a  speedily  fatal 
result,  but  the  worst  symptoms  may  disappear  and  be 
followed  by  a  prolonged  period  of  remission.  The 
average  duration  of  the  life  of  hospital  patients  who, 
i  rule,  do  not  apply  for  treatment  until  forced  to 
;ekiio\vledge  the  fact  of  their  illness,  has  been  es- 
timated at  two  years.  Sudden  death  without  pre- 
ceding exacerbation  is  sometimes  observed,  the  fatal 
result  being  apparently  due  to  syncope. 

Treatment. — At  the  present  time,  there  may  be 
said  to  be  a  specific  treatment  of  Addison's  disease — 
that  with  adrenal  extract.  This  fact,  however,  in  no 
way  diminishes  the  importance  of  general  therapeutic 
measures,  of  which  the  most  important  are  the  fol- 
lowing: Cessation  of  work  is  the  first  thing  to  be 
insisted  upon  in  the  way  of  treatment,  and  during  the 
exacerbations  strict  confinement  to  bed.  An  im- 
mediate mitigation  of  the  symptoms  has  often  fol- 
lowed the  admission  to  hospital  of  a  patient  who,  up 
to  that  time,  had  been  endeavoring  to  resist  the 
gradually  increasing  asthenia.  A  moderate  amount 
of  stimulants  is  generally  well  borne,  but.  cod-liver  oil, 
which  might  seem  appropriate  on  account  of  the 
tuberculous  nature  of  most  cases  of  the  disease,  is,  as 
a  rule,  not  tolerated.  Remedies  to  allay  irritability  of 
the  stomach  are  frequently  indicated,  such  as  ice, 
lime  water,  carbonic  acid  water  with  brandy,  bismuth, 
creosote,  hydrocyanic  acid,  and  small  doses  of  opium. 
Massage  and  faradization  are  well  worthy  of  a  trial 
in  order  to  drive  the  blood  from  the  abdominal 
vessels.  Iron  and  arsenic  should  be  employed  ten- 
tatively and  will  be  generally  found  useful,  and 
the  same  is  true  of  mix  vomica  and  its  derivatives. 
Cathartics  are  to  be  avoided,  as  profound  depression 
has  often  followed  their  employment  in  this  disease. 
When  constipation  is  troublesome  it  should  be  relieved 
by  enemata  and  suppositories.  The  diet  should  be 
simple  but  nourishing,  consisting  of  soups,  milk,  eggs, 
meat  jellies,  koumyss,  and  the  like. 

Treatment  with  Adrenal  Extract. — The  success  that 
has  attended  the  use  of  adrenal  extract  is  such  as  to 
make  it  imperative  in  all  cases  of  Addison's  disease. 
This  is  not  a  mere  obiter  dictum,  but  is  the  result  of  a 
careful  study  of  many  of  the  reports  upon  the  subject. 
A  few  examples  will  suffice  to  show  the  kind  of  evi- 
dence on  which  the  administration  of  the  adrenal 
extract  is  based. 

<  isler  (International  Medical  Magazine,  February, 
1890)  reports  a  case  in  which  there  was  marked  im- 
provement under  the  use  of  the  extract,  attended 
with  considerable  gain  in  weight  and  restoration  of 
general  vigor.  The  pigmentation,  however,  which 
was  of  advanced  grade,  had  not  diminished  except 
on  the  palate.  A  case  is  reported  by  Suckling 
(British  Medical  Journal,  May  28,  1S9S)  in  which  the 
symptoms  and  signs  were  well  pronounced  except 
pigmentation  of  mucous  membranes,  of  which  there 
is  no  mention.  Tablets  of  suprarenal  extract  (aa  gr.  v.) 
were  given  to  the  extent  of  from  twenty  to  thirty- 
five  daily.  In  the  course  of  a  year  recovery  was 
complete  with  disappearance  of  melanodermic  and 
leucodermic  patches.  Kinnicutt  tabulated  forty- 
«ight  cases  (American  J ournal  of  the  Medical  Sciences, 


July,  1897)  treated  with  adrenal  preparations.  "Six 
patients  are  reported  as  cured  or  practically  well, 
twenty-two  improved,  eighteen  unimproved,  and  in 
two  instances  an  aggravation  of  the  symptoms  is 
tiled  to  have  occurred  during  treatment.  In  the 
second  class  of  eases,  those  in  which  improvement 
took  place,  the  improvement  was  but  temporary; 
but  this  was  as  much  as  could  be  expected,  since  in 
many  the  disease  of  the  adrenals  was  associated 
with  grave  tuberculous  lesions  in  other  parts  of  the 
body. 

A  scries  of  120  cases,  including  ninety-seven 
previously  collected  by  E.  \V.  Adams  ( J'ractitioner, 
lxxii.,  473,  1903)  was  analyzed  by  Sajous  with  ref- 
ference  to  the  effect  of  adrenal  preparations.  In 
fifty-one  the  benefit  was  slight  or  nil,  in  thirty-six 
there  was  marked  improvement  and  in  twenty-five 
there  was  permanent  benefit.  The  adrenal  extrac- 
tives should  not  be  administered  in  a  haphazard 
manner.  In  one  of  the  cases  in  which  permanent 
benefit  was  the  result  of  their  administration,  the  dose 
was  one-twelfth  of  a  grain;  in  another,  the  initial  dose 
of  the  extract  was  ten  grains  thrice  daily  and  was 
gradually  increased  until  175  grains  were  administered 
per  diem.  The  adrenal  preparations  should  be  given 
to  meet  certain  indications  of  wdiich  the  most  promi- 
nent are  diminished  blood  pressure  and  hypothermia. 
When  the  temperature  and  the  blood  pressure  are 
raised  to  the  normal  standard,  the  full  effect  of  the 
remedy  has  been  secured  and  is  only  to  be  maintained 
by  a  careful  observation  of  the  case  and,  perhaps,  by 
occasional  suspension  or  increase  of  the  dose  employed. 
As  Sajous  remarks  with  reference  to  the  cases  in  which 
there  was  permanent  benefit:  "Although  the  remedy 
was  used  empirically  it  so  happened,  in  all  prob- 
ability, that  the  doses  employed  coincided  with  the  needs 
of  the  organism."  The  most  satisfactory  preparation 
has  been  found  to  be  the  desiccated  gland — glandulae 
suprarenales  sicca?,  U.  S.  P.,  the  dose  of  which  must 
be  ascertained  by  tentative  use  with  the  aid  of  the 
thermometer  and  the  blood  pressure  tests.  The 
subcutaneous  injection  of  adrenal  fluid  extracts  is 
exceedingly  painful  and  the  active  principles  which 
they  contain  are  rapidly  oxidized  and,  it  is  believed, 
rendered  inert  during  their  absorption. 

On  the  theory  that  Addison's  disease  is  chiefly  due 
to  suppressed  function  of  the  adrenals,  the  use  of 
adrenal  extract  would  find  its  most  successful  employ- 
ment in  those  cases  in  which  the  lesion  consists  of 
simple  atrophy  or  fibroid  degeneration. 

Frederick  P.   Henry. 


Adenitis. — See  Lymphatic  Glands,  Diseases  of. 


Adenoid  Vegetation. — See  Tonsils,  Pharyngeal. 

Adenoma. — Adenoma  (from  aS-n",  gland,  and  -oiua 
noting  in  pathology  a  swelling  or  tumor)  is  the  term 
applied  to  a  new  growth  originating  in  glandular 
epithelium  and  corresponding  in  histological  structure 
with  the  general  type  of  gland  tissue. 

Every  new  formation  of  glandular  tissue,  every 
glandular  hyperplasia,  cannot  be  regarded  as  an 
adenoma,  and  sometimes  it  is  impossible  to  say 
whether  an  apparent  growth  is  a  simple  hyperplasia 
or  a  tumor.  A  gland  which  is  increased  in  size  in 
consequence  of  excessive  nutrition  and  function  can- 
not be  called  an  adenoma,  but  must  be  considered  a 
hyperplasia. 

In  the  same  way  must  be  considered  those  forma- 
tions in  mucous  membranes  which  frequently  develop 
in  consequence  of  chronic  inflammation  and  take  the 
form  of  tumors.  These  are  local  new  formations  which 
project  above  the  surface  in  the  form  of  polypi  or 
papillary  masses.     The  new  growth  commences  in  the 


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connective  tissue,  and  the  epithelium  also  takes  part, 
in  that,  by  the  increase  of  the  surface,  the  covering 
epithelium  also  must  increase.  If  there  are  glands 
present  their  ducts  are  usually  obstructed,  and  cysts 
are  formed  with  papillary  projections  within  them. 
This  must  be  considered  simply  as  a  growth  due  to 
chronic  irritation,  and  as  entirely  distinct  from  the 
true  glandular  polyp  of  the  mucous  membranes  in 
which  a  formation  of  new  glands  actually  occurs. 
Clinically,  these  can  usually  be  distinguished  for  the 
simple  polyp  disappears  when  its  cause,  chronic 
irritation,  disappears. 

Etiology. — The  causation  of  adenomata  is  ob- 
scure though  probably  no  more  so  than  that  of  new 
growths  in  general. 

In  some  forms  congenital  misplacement  of  tissue  ele- 
ments appears  to  play  an  important  part.  Thus  in  the 
kidney,  adenomata  sometimes  are  found  which  cor- 
respond in  structure  to  the  adrenal.  These,  as 
pointed  out  by  Grawitz,  develop  from  aberrant 
remnants  of  the  adrenal  embedded  in  the  kidney 
substance.  This  is  also  true  of  adenomata  correspond- 
ing to  the  structure  of  the  mamma  occasionally  seen 
in  the  axilla,  and  of  the  rather  unusual  substernal 
tumors  in  which  a  tissue  similar  to  that  of  the  thyroid 
body  is  found.  Here  it  is  probable  that  the  theory 
of  embryonic  remains  of  Cohnheim  gives  the  true 
explanation:  the  tumor  in  each  of  these  instances 
develops  from  embryonic  fragments  which  become 
separated  from  the  gland  in  its  development.  Although 
in  certain  locations,  as  the  stomach  and  rectum,  the 
adenomata  appear  to  bear  out  Virchow's  irritation 
theory,  in  other  locations  they  offer  it  no  support 
at  all. 

The  parasitic  theory  receives  absolutely  no  support 
from  the  adenomata,  for  it  is  impossible  to  conceive 
of  a  vegetable  or  an  animal  parasite  causing  the  re- 
production of  definite  gland  tubules. 

Varieties  and  Structure. — The  appearance  of 
adenomata  varies  greatly  with  their  location.  Natu- 
rally any  particular  cell  or  arrangement  of  cells  cannot 
be  described  as  peculiar  to  this  tumor,  any  more  than 
any  type  of  cell  can  be  regarded  as  characteristic  of  all 
physiological  glandular  structures.  The  adenomata 
differ  from  one  another  in  structure  as  much  as  the 
structure  of  the  liver  differs  from  that  of  the  lacry- 
mal  gland. 

In  the  stomach,  intestine,  and  uterus,  in  a  general 
way,  the  epithelial  cells  are  arranged  as  tubular  acini 
with  a  central  lumen,  the  cells  generally  occurring  in 
one  layer,  though  there  may  be  more.  The  acini  are 
separated  from  one  another  by  connective  tissue  in 
which  the  blood-vessels  and  lymphatics  are  borne. 
Why  the  cells  in  their  growth  should  grow  as  tubules 
instead  of  breaking  through  the  basement  membrane 
and  forming  atypical  groups  of  epithelial  cells,  as  is 
seen  in  the  form  known  as  adenocarcinoma,  is  diffi- 
cult of  explanation.  It  is  probable  that  the  inherent 
tendency  thus  to  develop  is  not  early  influenced  by 
their  altered  environment.  That  they  do  not  break 
through  and  grow  as  carcinoma  is  frequently  seen 
in  some  large  and  rapidly  growing  adenomata. 
The  cells  lining  the  tubules  may  be  columnar  or 
cuboidal,  according  to  the  gland  from  which  the 
tumor  develops. 

In  addition  to  the  tubular  form  there  is  an  un- 
common variety,  the  racemose  adenomata,  in  which 
the  appearance  is  that  of  a  complicated  gland  struc- 
ture with  closely  aggregated  acini  of  circular  out- 
line containing  columnar,  cuboidal,  or  polyhedral 
cells. 

Then,  again,  in  the  liver,  kidney,  and  adrenal  occur 
adenomata  resembling  more  or  less  closely  the  normal 
structure  of  those  organs. 

As  in  any  other  epithelial  tumor,  the  relation  be- 
tween  the  epithelial  cells  and  the  connective  tissue 
varies.  When  the  development  of  the  connective 
tissue  is  excessive,   far  beyond   that  of  the  normal 


gland,  it  must  receive  some  recognition  in  naming  the 
tumor,  for  it  is  as  truly  new  formed  as  is  the  epithelial 
portion:  in  such  cases  it  is  called  an  adenofibroma. 
When  this  connective  tissue  is  especially  abundant  in 
cells  and  represents  an  embryonic  tissue,  the  term 
adenosarcoma  is  used.  In  the  ovary  occurs  an 
adenoma  in  which  the  acini  line  cyst  cavities.  This  is 
termed  an  adenocystoma. 

Adenomata,  as  far  as  known,  do  not  contribute  to 
the  body  metabolism.  That  there  is  a  partial  preser- 
vation of  function  is  occasionally  seen.  In  the 
adenoma  of  the  liver  sometimes  a  biliary  pigmentation 
occurs;  in  the  adenoma  of  the  breast  there  may  be  a 
secretion  of  milk-like  fluid;  in  the  adenoma  of  the 
intestine  the  tubules  may  contain  mucus;  in  the  ade- 
noma of  the  thyroid  colloid  material  may  collect. 
But  these  substances  remain  in  the  tubules  in 
which  they  are  formed,  and  take  no  part  in  the  general 
metabolism. 

Secondary  Changes. — All  forms  of  degeneration 
are  common  in  adenomata.  Hyaline  transformation 
may  give  the  tumor  an  appearance  justifying  the  term 
"cylindroma."  This,  however,  is  rare.  Myxomatous 
and  calcareous  degenerations  occasionally  occur. 
Cystic  change  may  result  from  gradual  dilatation  of 
the  glandular  acini.  Hemorrhages  are  common,  and 
on  free  surfaces  ulceration  is  frequent. 

The  most  important  change,  however,  is  a  carcino- 
matous transformation.  This  is  especially  common  in 
the  stomach,  intestine,  and  uterus.  The  proliferation 
of  the  epithelial  cells  becomes  excessive;  the  acini  be- 
come more  abundant  and  irregular;  the  cells  depart 
from  their  tubular  arrangement  and  grow  as  solid 
epithelial  masses  outside  the  acini,  forming  an  adeno- 
carcinoma, or,  as  Ziegler  named  it,  adenoma  destruens. 
The  growth  may  eventually  become  purely  carcino- 
matous, but  it  usually  retains  more  or  less  its  adeno- 
matous type. 

General  Character. — The  rapidity  of  growth 
of  an  adenoma  differs  in  various  parts  of  the  body  in 
which  it  has  its  seat,  and  the  same  holds  true  for  its 
malignancy.  There  are  few  which  can  be  considered 
as  strictly  benign  tumors.  The  pure  adenoma  seen 
in  the  liver  may  form  metastases  in  the  spleen  and 
less  frequently  elsewhere.  Fatal  metastases  from 
adenomata  of  the  thyroid  have  been  reported.  In  the 
sweat,  sebaceous,  and  lacrymal  glands  the  tumor 
usually  grows  slowly,  remains  local,  and  may  be  con- 
sidered benign.  In  some  locations,  although  adeno- 
mata never  produce  metastases,  they  may  endanger 
life  by  their  size,  as  in  the  ovary;  or  may  obstruct  im- 
portant canals,  as  in  the  intestine;  or  may  cause  great 
disfigurement,  as  displacement  of  the  eye  in  adenoma 
of  the  lacrymal  gland.  The  general  health  may  also 
be  influenced  by  interference  with  the  normal  function 
of  the  organ  in  which  they  are  located,  or  in  conse- 
quence of  ulceration  and  hemorrhage.  There  are 
few  tumors  more  malignant  than  the  adenomata  of 
the  intestinal  tract.  They  extend  rapidly,  infiltrating 
all  coats  of  the  intestine,  and  frequently  produce 
metastases  in  the  liver.  Their  malignancy  does  not 
always  depend  on  carcinomatous  transformation,  for 
some  of  the  most  destructive  tumors  of  this  canal  are 
pure  adenomata. 

As  regards  the  terms  Malignant  Adenoma  and 
Adenocarcinoma,  it  seems  best  to  use  the  former  in 
designating  those  growths  in  which,  although  there  is 
extensive  infiltration  of  surrounding  tissue  and  eyen 
the  formation  of  metastases,  the  tumor  still  retains 
its  glandular  type;  and  to  use  the  term  Adenocarci- 
noma for  those  forms  in  which  the  cells  depart  from  the 
tubular  arrangement  with  the  formation  of  distinct 
cancerous   areas. 

The  principal  locations  in  which  adenomata  may 
occur  and  brief  descriptions  of  their  characteristics 
dependent   on  location  and  origin  are  given  below: 

Skin. — Adenomata  of  the  skin  are  rare.  They  may 
develop  from  the  sebaceous  or  from  the  coil  glands. 


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They  crow  slowly  and  are  practically  always  benign. 
Adenomata  of  sweat  glands  are  found  in  various  parts 
of  the  body,  bu1  principally  on  the  face,  where  they  are 
of  a  dirty  grayish-white  color  with  nodular  surface. 

Histologically,    coils   of   dilated    duels   arc   seen,    from 

which  degenerated  epithelium  can  be  squeezed.  Cam- 
piniri  (1895)  describes  cystic  and  carcinomatous 
changes  in  such  tumors.     Adenomata  of  sebaceous 


Fig.  41. — Benign  Adenoma  of  the  Small  Intestine. 
X  10  diameters. 


glands  appear  principally  on  the  face  and  are  usually 
of  congenital  origin.  They  appear  as  small,  roundish, 
convex  papules,  of  bright  color,  and  in  old  people  are 
often  associated  with  fibromata. 

Whitnej'  has  described  an  adenoma  of  sebaceous- 
gland  origin  which  was  the  size  of  an  orange  and  con- 
led  large  cavities  filled  with  a  material  resembling 
butter  in  "its  color,  consistence,  and  general  appear- 
ance. (Consult  also  the  special  article  on  Adenoma 
of  the  Skin.) 

Mucous  Membranes. — Mouth. — Adenoma  of  the 
mucous  glands  of  the  mouth  is  very  rare.  It  occurs 
a-  isolated  nodes  and  in  some  cases  gives  rise  to  macro- 
cheilia.  Adenomata  of  the  salivary  glands  have  been 
reported. 

Larynx  and  Bronchi. — A  few  cases  have  been 
reported  of  benign  adenomata  arising  from  the  mucous 
glands  of  these  organs.  Eber  (1.S96)  has  reported 
several  cases  in  the  bronchi  of  sheep.  They  occur 
as  irregular  nodular  growths. 

Stomach  and  Intestine. — Small,  apparently  benign 
adenomata  are  sometimes  seen.  The  malignant 
adenomata  and  the  adenocarcinomata  are  the  most 
important  forms.  They  start  as  soft  nodular  growths 
which  break  down  readily  and  ulcerate.  They  infil- 
trate all  coats  and  may  cause  perforation.  Metas- 
tases in  the  liver  may  occur,  and  there  is  sometimes 
a  direct  extension  to  adjacent  organs,  as  from  stomach 
to  pancreas.  In  the  large  intestine,  of  all  forms  of 
new  growth,  this  tumor  is  the  most  common  cause  of 
chronic  intestinal  obstruction.  Histologically,  they 
may  be  made  up  of  dilated,  irregularly  branching 
tubules  presenting  a  single  layer  of  cylindrical  epithe- 
lium— in  the  stomach  originating  from   the  gastric 


tubules,  in  the  intestine  from  the  glands  of  Licberkuhn; 
or  in  addition  to  this  structure  there  may  I"-  irregular 
solid  masses  of  epithelium,  the  result  of  great  pro- 
liferation of  epithelial  cells  and  destruction  of  the 
basement  membrane. 

In    the    large    intestine    the    locations,    in    order    of 

frequency,  are  the  rectum,  the  sigmoid,  splenic  and 

hepatic  liexures  of  tl Ion,  and  the  cecum. 

In  the  small  intestine  adenoma  i-  occasionally 
found  in  the  duodenum  at  the  papilla  marking  the 
orifice  of  the  bile  duct. 

Vulva. —  Benign      adenomata      arising      from      the 
glands   of    Bartholin]    have    been    reported.     Kelly 
describes  an  adenocarcinoma,  as  large  as  an  oral 
of  the  vulvovaginal  glands. 

/  rinary  Bladder. — Adenomata  of  this  organ  are 
rare.  They  may  be  sessile  or  pedunculated,  smooth 
or  lobular,  benign  or  malignant.  It  is  not  easy  to 
explain  their  origin. 

tJterus. — Adenoma  originates  generally  in  the  body 
of  the  uterus,  but  occasionally  in  the  cervix.  It  may 
rapidly  infiltrate  the  myometrium  and  may  produce 
nodules  on  the  peritonea]  surface.  It  has  the  usual 
glandular  structure  and  a  small  amount  of  fibrous 
stroma.      Carcinomatous  areas  may  develop. 

Occasionally  a  benign  polypoid  adenoma  may  be 
seen,  but  it  is  often  difficult  to  distinguish  this  from  a 
hyperplastic  glandular  endometritis. 


Fig.  42.—  M 


X  le-  diameters. 


Diffuse  benign  adenomyomata  of  the  uterus  have 
been  carefully  described  by  von  Recklinghausen  and 
Cullen. 

Adenoma  in  Solid  Viscera. — Liver. — Adenomata 
of  this  organ  are  rare.  They  may  occur  in  the  normal 
or  in  the  cirrhotic  liver,  and  appear  as  small,  grayish- 
white,  reddish,  or  brown  miliary  solitary  or  multiple 
areas.  They  are  made  up  of  tortuous,  branching, 
gland-like  tubules  of  newly  formed  trabecular  of  liver 
cells,  not  arranged  as  typical  liver  lobules.     The  cells 

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are  large,  pale,  and  finely  granular.  They  arise  from 
proliferation  either  of  liver  cells  or  of  the  cells  of 
the  bile  capillaries.  The  larger  ones  have  a  distinct 
capsule.  Some  writers  believe  that  they  may  become 
carcinomatous. 

Another  and  rare  form  is  the  adenocystoma,  which 
is  made  up  of  cysts  containing  a  colorless  fluid,  the 
walls  of  the  cysts  being  covered  by  glandular  epi- 
thelium. This  form  probably  originates  from  the 
bile  ducts. 


Fig.  42,  a. — Malignant  Adenoma  of  the  Rectum.  Greatly  magni- 
fied in  order  to  show  character  and  arrangement  of  the  newly 
formed  glands. 

Kidney. — Congenital  adenoma,  struma  aberrata 
suprarenalis. — As  shown  by  Grawitz,  this  tumor 
develops  from  fragments  of  the  adrenal  body  which 
in  the  development  of  the  kidney  become  incorporated 
in  its  substance.  The  tumor  is  small,  grayish,  and 
generally  just  beneath  the  capsule.  Histologically, 
it  consists  of  large  pale  epithelial  cells  arranged  in 
tubules  similar  to  those  of  the  cortical  portion  of  the 
adrenal.  The  cells  are  filled  with  fat  granules. 
Active  proliferation  may  occur  with  tendency  to 
malignancy.  The  observations  of  Askanazy  and 
Lubarsh  indicate  that  malignant  tumors  resembling 
carcinomata  may  develop  from  these  growths. 

Adenomata  arising  from  renal  tubules  are  rare. 
They  originate  in  the  convoluted  tubules,  and  appear 
as  very  small  nodular  masses,  though  they  sometimes 
may  reach  a  diameter  of  three  to  four  centimeters. 
They  are  distinctly  encapsulated.  The  cells  may  be 
cuboidal  or  may  become  cylindrical,  and  are  arranged 
in  the  form  of  single  tubules;  the  glomeruli  and  different 
types  of  tubules  are  never  reproduced. 

A  papuliferous  cystic  adenoma,  a  small  tumor 
with  fibrous  capsule  in  which  the  lining  epithelium  is 
elevated  in  a  papillomatous  manner,  is  occasionally 
seen. 

Adrenal. — Adenoma  of  adrenal,  or  struma  lipomatosa 
suprarenalis  of  Virchow,  generally  develops  from  the 
cortex  as  an  irregular  nodular  growth,  yellowish  or 
pale  brown  in  color.  It  may  remain  small  or  may 
completely  destroy  the  organ,  sometimes  attaining  a 
very  large  size.  The  cells  resemble  those  of  the 
normal  gland  in  structure,  but  are  large,  pale,  and 
granular,  as  though  filled  with  fine  fat  granules. 

Breast. — Many  tumors  of  the  breast  combined  with 
the  formation  of  cysts  have  been  described  under  the 
name  of  adenoma.     In  such  cases  the  tumor  is  gen- 


erally a  fibroma  or  a  sarcoma,  and  has  grown  into 
the  ducts  of  the  gland  as  papillary  projections.  These 
are  covered  by  the  lining  epithelium,  which  they 
push  ahead  of  them  in  their  growth,  and  which  in- 
creases in  consequence;  but  this  is  only  secondary,  and 
these  tumors  should  be  considered  as  connective- 
tissue  formations. 

A  diffuse  enlargement  of  the  breast  due  to  uniform 
increase  in  the  glandular  elements  has  occasionally 
been  described  under  the  name  of  diffuse  adenoma. 
This  condition  is  bilateral,  usually  occurs  about  the 
time  of  puberty,  and,  strictly  speaking,  is  a  hyper- 
plasia and  not  a  new  growth. 

The  true  adeno?na  is  unilateral,  definitely  circum- 
scribed, and  encapsulated.  It  usually  occurs  in  young 
women,  starting  as  small  nodes  in  the  upper  or  outer 
quadrant  of  the  gland.  It  becomes  round  or  oval  in 
shape  and  sometimes  grows  to  considerable  size, 
though  usually  small.  On  section  it  is  uniformly 
smooth,  grayish-white,  and  quite  firm,  though  occa- 
sionally  it  is  soft  and  slightly  nodular. 

Histologically,  it  may  be  composed  of  acini  or  of 
ducts  lined  by  cylindrical  epithelium.  The  stroma 
is  fibrous  and  varies  greatly  in  character  and  amount, 
but  is  looser  and  more  cellular  than  that  of  the  normal 
gland.  According  to  the  character  of  the  inter- 
glandular  tissue,  it  may  be  an  adenofibroma,  adeno- 
myxoma,  adenosarcoma,  etc. 

Adenocarcinoma  is  generally  considered  to  be  an 
unusual  form  of  breast  tumor.  Halsted  (1898),  how- 
ever, reports  five  occurring  in  a  series  of  150  breast 
cancers.  According  to  Halsted's  observations,  these 
growths  differ  from  ordinary  cancer  of  the  breast  in  that 
they  are  softer,  more  pedunculated,  and  discharge  a 
peculiar  serous  fluid  when  ulcerated.  Histologically, 
they  are  composed  of  very  large  tubes  lined  by  epithe- 
lium many  layers  deep.  In  three  of  Halsted's  cases  the 
growth  was  pure  adenoma  (malignant  adenoma) ;  in 


Fig.  43. — Fibroadenoma  of  the  Mammary  Glands. 

the  others  carcinomatous  areas  were  present.  Metas- 
tases in  the  axillary  lymph  nodes  were  found  in  none. 
Ovary. — The  multilocular  cystadenoma  is  the  com- 
monest tumor  of  the  ovary,  and  the  one  usually 
attaining  the  greatest  size.  It  may  be  small  or  it  may 
weigh  a  hundred  pounds  or  more.  It  is  a  benign 
tumor  and  never  produces  metastases.  The  surface 
may  have  no  epithelium,  or  it  may  have  a  single  layer 
of  flat  epithelial  cells.  The  numerous  cysts  of  vary- 
ing size  which  make  up  the  mass  are  lined  on  their 
inner  surface   by  a  single   layer  of   cylindrical  cells, 


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often  ciliated.  The  nuclei  are  oval  and  placed  aeai 
the  basement  membrane.  Some  of  the  cells  may  be 
swollen  and  filled  with  clear  contents,  giving  them  the 
appearance  of  goblet  cells.  The  contained  fluid  is 
thick,  viscid,  sometimes  jelly-like,  and  may  be  color- 
less or,  if  there  has  been  hemorrhage,  yellowish  or  red- 
dish-brown. This  fluid  is  formed  by  secretion  from 
tli,.  epithelial  cells,  by  the  transudation  of  serum  from 
the  blood-vessels,  and  by  the  degeneration  of  the 
epithelial  cells.     The  most  important  chemical  sub- 


Fig.  44. 


-Papillary  Adenocystoma  of  the  Ovary. 
X  10  diameters. 


stance  in  the  fluid  is  pseudomucin,  a  true  secretion  of 
the  newly  formed  epithelial  cells.  It  does  not  occur 
in  the  normal  ovary,  in  dropsical  Graafian  follicles, 
or  in  the  parovarium. 

Calcification  or  necrosis  of  the  cyst  wall  may  occur  as 
secondary  changes.      Both  are  unusual. 

The  papuliferous  adenocystoma  is  characterized  by 
an  ingrowth  into  the  cyst  of  a  papuliferous  connective 
tissue  covered  with  epithelium.  On  cross-section  the 
appearance  is  that  of  gland  tubules.  The  papillary 
growths  may  be  prominent,  or  they  may  appear 
simply  as  fiat  excrescences  on  the  surface  of  the  cysts. 
The  epithelium  is  similar  in  character  to  that  in  the 
multilocular  adenocystomata.  This  tumor  is  not 
malignant  in  the  ordinary  sense;  but  after  rupture  of 
the  cysts  a  local  growth  on  the  neighboring  perito- 
neum may  occur. 

These  growths  are  supposed  to  originate  from  the 
epithelium  of  mature  or  residual  embryonic  follicles  or 
from  the  germinal  epithelium  of  the  ovary.  Pfliiger 
has  pointed  out  the  glandular  structure  of  the  ovary, 
and  Spiegelberg  and  Langhans  have  shown  in  the 
ovary,  even  after  birth,  residues  of  its  embryonic 
glandular  structure.     Doran,  as  a  result  of  his  inves- 


tigations, believed  that  the  tumor  might  originate  in 
childhood  or  even  in  the  intrauterine  period.  Williams 
states  that  the  papillary  adenocystomata  originate 
from  the  epithelium  on  the  surface  of  the  ovary  or 
from  that  of  the  Graafian  follicles,  or  from  both. 

Adenocarcinoma  of  the  ovary  may  originate  in  the 
ovary,  may  develop  in  a  papuliferous  adenocystoma, 
or  may  be  secondary  to  a  similar  growth  in  the  uterus. 

Thyroid. — Aside  from  the  hyperplastic  changes 
associated  with  the  condition  known  as  goiter,  circum- 
scribed adenomatous  tumors  of  the  thyroid  occur. 
These  appear  as  soft  nodular  growths  composed  of 
glandular  tubules  lined  by  tall  cylindrical  epithelium. 
Within  these  tubules  papillary  growths  sometimes 
appear  (adenoma  papilliferum).  Within  the  tubules 
is  seen  the  colloid  material  characteristic  of  the  normal 
thyroid.  Although  this  tumor  is  one  of  the  purest 
types  of  adenoma,  it  may  produce  metastases.  It 
may  also  by  direct  extension  invade  the  structure  of 
the  larynx. 

Testicle. — The  form  of  tumor  as  it  occurs  in  the 
testicle  is  generally  known  as  cystadenoma.  It  may 
occur  in  the  child  or  in  the  adult.  It  is  attributed  by 
some  writers  to  error  in  development.  Two  forms  are 
recognized.  In  one  the  tubules  are  lined  by  cylin- 
drical cells  which  sometimes  have  cilia,  their  contents 
being  a  clear  or  blood- tinged  slimy  fluid;  in  the  other 
the  epithelium  is  stratified  and  the  contents  a  greasy 
substance    with    many    fatty    epithelial    cells.     The 


Fig.  45. — Papillary  Adenocystoma  of  the  Ovary;  more  strongly 
magnified  than  Fig.  44,  in  order  to  show  the  cyst  wall,  the  papil- 
lary ingrowths  of  connective  tissue,  and  the  epithelium  lining  the 
papillary  projections.  As  seen  in  cross  section  this  epithelial 
structure  gives  the  appearance  of  a  glandular  growth. 

growth  usually  starts  in  the  testicle  and  may  attain  a 
large  size.  Instances  of  carcinomatous  changes  have 
been  reported. 

Prostate. — The  tumor  usually  occurs  in  this  organ  as 
an  adenocarcinoma  and  is  rare.  It  appears  as  soft, 
nodular  masses  which  project  into  the  urethra  or  neck 
of  the  bladder  and  invade  surrounding  tissues.  Ulcera- 
tion is  frequent,  and  when  it  occurs  is  accompanied 
by  copious  hemorrhage. 

Pituitary  Body. — Adenomata  of  this  structure  are 
rare,  but  are  occasionally  reported  in  connection  with 
cases  of  acromegaly.     They  may  be  as  large  as  a 

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pigeon's  or  hen's  egg;  may  protrude  from  the  sella 
turcica,  press  on  the  brain,  and  extend  even  into 
the  ventricles.  Histologically,  they  are  made  up  of 
large,  tortuous,  sometimes  branching  tubes  lined  by 
epithelial  cells. 

Pancreas. — Adenomata  of  this  gland  are  not  com- 
mon. They  are  generally  of  the  racemose  type. 
Cesaris-Demel  (1895)  reports  a  distinctly  encapsulated 
adenoma  the  size  of  a  dove's  egg  in  an  atrophied  pan- 
creas. The  cells  were  irregular  and  primitive, 
occurring  in  one  and  sometimes  in  several  layers, 
generally  arranged  in  alveoli. 

Lacrymal  Gland. — Adenomata  of  this  gland  are  not 
very  common.  They  generally  occur  in  persons  of 
advanced  age.  By  pressure  they  may  interfere 
seriously  with  the  movements  of  the  eye.  They  do 
not  tend  to  become  malignant  and  are  only  trouble- 
some on  account  of  their  size.  Adenocarcinoma  has 
been  reported,  but  is  very  rare. 

Pineal  Gland. — The  occurrence  of  adenomata  of 
this  body  is  occasionally  referred  to  in  the  literature. 
Richard  Mills  Pbarce. 


Adenoma  of  the  Skin. — Adenomatous  proliferation 
of  the  cutaneous  glands  is  an  extremely  rare  occur- 
rence, and  it  is  only  within  a  comparatively  recent 
period  that  the  condition  has  been  recognized. 
Hypertrophy  of  the  skin  glands,  on  the  other  hand,  is 
a  concomitant  of  many  chronic  local  disturbances  of 
nutrition,  and  doubtless  in  some  of  the  cases  recorded 
as  adenoma  there  has  been  confusion  between  this 
condition  and  hypertrophy.  The  considerations 
involved  in  the  differentiation  of  hypertrophy  and 
adenoma  have  been  discussed  in  the  preceding 
article. 

It  must  be  noted,  however,  that  all  these  growths 
are  probably  of  congenital  origin,  and  should  be 
classed  with  the  nrevi.  The  terms  na?vus  sebaceus 
and  nsevus  sudoriparus  respectively  are  to  be  pre- 
ferred to  the  designation  of  adenoma. 

Adenomata  of  the  skin  naturally  fall  into  two 
classes:  adenoma  of  the  sebaceous  glands  (adenoma 
sebaceum),  and  adenoma  of  the  sudoriparous  glands 
(adenoma  sudoriparum). 

Adenoma  Sebaceum. — Synonyms:  Na?vus  seba- 
ceus; Vegetation  vasculaire  (Rayer);  Naevi  vasculaires 
et  papillaires  (Vidal);  Adenoma  of  the  sebaceous 
glands;  Steatadenonia;  German,  Talgdrusenadenom; 
French,  Adenome  s£bac6. 

The  earliest  recorded  cases  of  the  disease  are  found  in 
the  writings  of  Rayer  and  of  Addison  and  Gull,  who, 
however,  failed  to  interpret  correctly  the  anatomical 
condition,  which  Balzer  was  the  first  to  recognize, 
though  Balzer's  case,  curiously  enough,  has  been 
shown  by  later  investigators  to  be  one  of  acanthoma 
adenoides  cysticum.  Cases  have  since  been  described 
by  Hallopcau  and  Vidal  in  France,  Mackenzie, 
Pringle,  Jamieson,  and  Crocker  in  England,  and 
Caspary  and  Boeck  in  Germany.  The  first  case 
recorded  in  America  was  described  by  the  present 
writer  in  1S93,  and  many  cases  have  been  observed 
since  that  time 

The  disease  manifests  itself  in  the  form  of  small  mul- 
tiple benign  tumors,  which  may  be  distributed  gener- 
ally on  the  face,  but  occur  most  frequently  at  the  sides 
of  the  nose.  Their  distribution  is  usually  fairly  sym- 
metrical, but  in  Jamieson's  and  one  of  Crocker's  cases 
they  were  limited  to  one  side  of  the  face,  and  in  my 
own  case  the  lesion  was  in  the  form  of  a  linear  patch 
on  the  forehead.  The  lesions  in  some  cases  were 
present  at  birth  or  appeared  in  infancy;  but  a  more 
active  growth,  as  to  number  and  size  of  the  tumors,  has 
been  noted  at  the  time  of  puberty.  In  Caspary's 
case  and  in  my  own  they  did  not  appear  until  the 
seventeenth  and  the  nineteenth  year  respectively. 
The  individual  growths  seldom  undergo  any  change 
after  they  have  attained  their  development,  though 


involution  of  a  few  of  the  nodules  with  resulting  faint 
cicatrices  has  been  noted. 

The  little  tumors  vary  in  size  from  one  to  five  milli- 
meters, are  usually  round  and  convex  in  shape,  and 
the  epidermis  over  them  may  be  smooth  or  have  a 
rough  and  somewhat  warty  appearance.  Their  color 
may  be  that  of  the  normal  skin,  or  they  may  have  a 
brownish  or  even  bright  red  hue.  The  color  depends 
greatly  on  the  presence  or  absence  of  telangiectases, 
which  often  appear  as  fine  lines  ramifying  over  their 
surface,  and  in  some  cases  may  form  so  striking  a  part 
of  the  tumor  as  to  give  the  whole  the  appearance  of  a 
vascular  nevus.  In  Vidal's  case  and  in  mine  there 
was  cystic  degeneration  of  a  part  of  the  tumors,  giving 
the  appearance  of  small  yellow  nodules  from  which 
on  incision  a  drop  of  inspissated  sebaceous  matter 
could  be  squeezed.  Some  importance  has  been  at- 
tached to  the  fact  that  in  many  of  the  cases  there 
were  other  striking  abnormalities  of  the  skin:  warts, 
pigmented  and  hairy  nevi,  and  small  pendulous  fibro- 
mata indicating  a  congenital  tendency  to  malforma- 
tions of  the  skin.  It  is  probably  only  a  coincidence 
that  many  of  the  cases  have  occurred  in  persons  of 
deficient  intelligence,  some  of  them  epileptics. 

Anatomy. — Under  the  microscope  the  entire  tumor 
is  seen  to  be  composed  of  larger  and  smaller  masses, 
which  bear  the  closest  resemblance  to  the  acini  of  nor- 
mal sebaceous  glands.  It  is  indeed  only  in  the  great 
number,  extent,  and  complex  arrangement  of  the  lob- 
ules that  an  abnormal  condition  becomes  apparent. 
In  some  cases  solid  epithelial  buds  are  given  off  from 
existing  sebaceous  gland  acini,  and  the  cells  of  these 
buds  later  undergo  the  peculiar  fatty  changes  indica- 
tive of  the  glands  from  which  they  take  their  origin. 
Unna,  who  draws  a  very  sharp  distinction  between 
hypertrophy  and  adenoma  of  the  sebaceous  glands,  re- 
gards most  of  the  published  cases  as  examples  of 
hypertrophy. 

The  treatment  of  the  condition  is  indicated  only 
for  cosmetic  purposes.  When  the  lesions  are  few  in 
number  they  may  be  removed  by  excision,  by 
scarification,  or  by  electrolysis.  When  they  are 
very  numerous,  any  form  of  operative  interference 
is  inadvisable. 

Adenoma  Sudoriparum. — Synonyms:  Naevus  su- 
doriparus; Adenoma  of  the  sweat  glands;  Spirade- 
noma;  Syringadenoma;  German,  Schweissdrusen- 
adenom;   French,  Adenome  sudoripare. 

The  disease  which  has  been  described  under  the 
various  names  of  hydradenomes  eruptifs,  syringo- 
cystadenoma, epithelioma  or  acanthoma  adenoides 
cysticum,  etc.,  and  which  was  formerly  regarded 
as  an  adenoma  of  the  sweat  glands,  is  now  known 
to  have  no  connection  with  these  structures.  The 
reader  is  referred  to  the  article  on  Epithelioma  of  the 
Skin  for  an  account  of  this  condition. 

In  view  of  the  fact  that  the  sweat  gland  is  an  ap- 
proximately uniform  cylindrical  tube,  the  distinction 
between  hypertrophy  and  adenoma  of  these  glanda 
can  readily  be  made.  Any  deviation  from  the  typical 
structure  in  the  form  of  lateral  budding  or  outgrowth 
suffices  to  constitute  adenoma,  provided,  of  course, 
that  the  new  formation  does  not  break  through  the 
membrana  propria  of  the  gland.  From  this  point  of 
view  adenoma  of  the  sweat  glands  is  by  no  means  a 
rare  occurrence.  It  is  frequently  found  in  connection 
with  other  diseases  of  the  skin,  especially  in  associa- 
tion with  tumors  and  malformations  of  the  blood- 
vessels of  the  cutis  and  hypoderm,  and  with  cancers  of 
the  skin.  Under  these  circumstances,  however,  the 
adenoma  constitutes  merely  an  interesting  micro- 
scopical condition  without  giving  rise  to  any  clinical 
symptoms.  In  these  cases  the  adenomatous  forma- 
tion affects  only  the  coiled  portion  of  the  gland,  and 
it  is  a  noteworthy  fact  that  in  all  the  observations 
hitherto  recorded  there  has  been  a  sharp  distinction 
between  adenoma  of  the  coil  and  adenoma  of  the  duct. 
This  distinction  has  given  rise  to  the  terms  spirade- 


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Adladorlioklnrsla 


noma  and  syringadenoma.     Adenomata  of  the  sweat 

glands  occurring  independently  are  of  extremely  rare 
occurrence. 

(Jnna  in  his  "  Histopathology  "  was  able  to  cull  only 
ises  of  spiradenoma  from  the  literature,  to  which 
he  added  a  seventh.  The  tumors  varied  in  size  in  the 
different  cases  from  a  small  chestnut  to  a  hen's  egg; 
were  found  on  the  head,  neck,  or  extremities  in  mid- 
dle-aged .11  elderly  people  lone  case  in  a  child);  and 
presented  no  characteristic  clinical  features.  The 
diagnosis  ran  be  made  only  with  the  microscope. 
The  proliferation  occurs  in  the  form  of  solid  epithelial 
buils.  which  usually  show  a  tendency  to  grow  in 
curved  lines  as  they  increase  in  length,  and  to  become 
canal  led  like  the  structures  from  which  they  took 
their  origin. 

Of  the  syringadenomata  there  is  but  a  single  un- 
doubted ease  on  record,  that  of  Petersen.  It  was  in 
the  form  of  a  papillary  ncevus  unius  lateris  on  the  neck, 
trunk,  and  thigh  of  a  girl  of  twenty.  The  adenomat- 
ous proliferation  was  confined  strictly  to  the  ducts 
of  the  glands,  which  appeared  considerably  widened 
shortly  above  the  coil,  the  cubical  epithelium  became 
cylindrical,  and  outgrowths  developed  which  were 
sometimes  solid  and  sometimes  canalled.  These  out- 
grow tin  divided  repeatedly  like  the  branches  of  a  tree, 
and  produced  thus  the  semispherical  or  mushroom 
form  of  the  tumors.  The  new-formed  tubes  were 
lined  with  a  distinct  membrane  and  showed  no  signs 
of  colloid  degeneration.  Sigmund  Pollitzer. 


Adeps. — Lard.  "The  prepared  internal  fat  of  the 
abdomen  of  the  hog  (Sms  scrofa,  var.  domestica  Gray), 
purified  by  washing  with  water,  melting  and  strain- 
ing"  (U.  S.  P.). 

The  tissue  from  which  lard  is  obtained,  lying  at 
each  side  of  the  backbone  and  enclosing  the  kidneys, 
and  which  goes  by  the  name  of  "  leaf  lard,"  is  washed, 
chopped,  cleaned  from  connective  bands  and  tra- 
becule, and  then,  with  a  little  water,  exposed  to  a 
boiling  temperature  until  the  connective  tissue  is 
softened  and  the  fat  has  run  out;  it  is  then  strained, 
and  the  heat  continued  until  the  water  is  nearly 
removed  and  the  melted  fat  is  clear  and  homogeneous, 
when  it  is  poured  out  and  cooled.  If  a  very  fine 
product  is  desired,  it  should  be  filtered  in  a  hot  filter- 
ing apparatus. 

Lard  should  be  of  a  soft  solid  consistency,  white, 
unctuous,  with  a  faint  but  not  at  all  rancid  odor,  and  a 
bland  taste.  Its  specific  gravity  is  about  0.917  at 
25°  C.  (77°  F.)  and  it  melts  at  3S°  to  40°  C.  (100.4°  to 
104°  F.).  It  is  insoluble  in  water  and  very  little 
soluble  in  alcohol. 

Olein,  palmitin,  and  stearin  are  the  principal  con- 
stituents of  lard,  their  relative  proportions  (upon 
which  its  consistency  depends)  varying  considerably. 

Commercial  lard  is  so  apt  to  be  impure,  either 
being  mixed  with  water  or  salt,  or  having  a  portion  of 
its  liquid  oil  removed,  that  it  is  in  general  unfit  for 
medicinal  use,  and  the  apothecary  will  do  well  always 
to  prepare  his  own. 

Ordinary  lard  rather  rapidly  becomes  rancid  and 
irritating,  but  if  perfectly  pure  and  free  from  water  it 
will  keep,  in  a  cool  place,  for  a  very  long  time.  When 
it  is  to  be  used  during  warm  weather,  five  per  cent,  of 
it,  or  more  if  necessary,  should  be  replaced  with  white 
wax.  For  pharmaceutical  purposes  it  is  scented,  as 
well  as  preserved,  with  benzoin,  a  little  of  the  balsam 
being  tied  in  a  bag  and  suspended  in  the  melted  lard 
for  two  hours.  Thus  treated,  it  is  almost  entirely 
permanent,  besides  having  an  agreeable  odor. 

Lard  is  an  article  of  food,  and  is  emulsified,  like 
other  fats,  when  taken  into  the  intestines,  without  any 
particular  physiological  action.  As  an  external 
dressing,  it  is  protective  and  bland  in  a  high  degree, 
qualities  which  have  given  it  its  popularity  as  a  basis 
of    ointments    and   cerates.     Those   of    the    L'nited 


States  Pharmacopoeia  follow:  A.  benzoinatus,  just 
mentioned.  (  era)  uin,  Ceratum  cantharidis,  Ceratum 
extract!  cantharidis,  ('.  resins,  Unguentum,  I'ng. 
bydrargyri,  l"ng.  mezerei,  Ung.  iodi,  etc 

II    H.  Rusby. 


Adeps  Lanjc  Hydrosus. — Lanolin.  Hydrous  Wool- 
fat.  "The  purified  fat  of  the  wool  of  sheep  0 
arks  Linne)  mixed  with  not  more  than  thirty  per 
cent,  of  water"  I  I'.  S.  P.).  Freed  from  water,  this  sub- 
stance is  the  Adeps  I. awe  or  WooL-fai  of  the  Phar- 
macopoeia, but  it  is  chiefly  used  fn  its  hydrous  form. 
Under  the  title  of  lanolin.  Oscar  Liebreich  propo  ed, 
to  serve  as  a  basis  for  ointments,  the  peculiar  body 
that  results  from  the  mixture  of  a  cholesterin  fat  with 
water.  The  cholesterin  fats  are  peculiar,  in  com- 
parison with  ordinary  glycerin  fats,  in  not  decompos- 
ing, in  •'  taking  up"  and  holding  in  intimate  blending 
an  equal  quantity  of  water,  in  mixing  also  with  gly- 
cerin, and  in  possessing  a  high  diffusion  power.  By 
reason  of  the  latter  power,  lanolin  used  as  an  inunction 
ointment  is  supposed  rapidly  to  impress  the  system 
with  any  absorbable  active  drug  substance  that  may 
be  incorporated  with  it.  This  wool-fat,  or  lanolin, 
as  it  is  still  commonly  called,  is  a  yellowish-white 
material  of  ointment-like  quality  and  a  faint  char- 
acteristic odor.  It  is  insoluble  in  water,  but  yet  will 
mix  with  twice  its  weight  of  water  and  still  retain 
its  unctuous  quality.  It  melts  at  about  40°  C. 
(104°  F.),  separating  into  an  upper  oily  and  a  lower 
aqueous  layer.  It  is  somewhat  sticky,  but  this 
quality  can  be  removed  by  the  addition  of  from 
twenty  to  twenty-five  per  cent,  of  some  ordinary 
oil,  such  as  castor  oil,  cr  of  vaseline. 

Clinical  experience  with  lanolin  does  not  seem  fully 
to  realize  the  expectation  of  unusual  power  on  the  part 
of  the  substance  to  penetrate  the  skin,  on  inunction. 
Nevertheless,  lanolin  makes  a  very  serviceable 
material  for  inunction  purposes,  either  by  itself  or 
medicated.  H.  H.  Rusby. 


Adiadochokinesia. — This  term  (also  within  adiado- 
chokinesia)  was  proposed  bj*  Babinski  of  Paris,  to 
designate  a  peculiar  difficulty  observed  in  certain 
patients  suffering  from  cerebellar  disorder.  It  consists 
in  an  inability  to  perform  rapid  alternating  move- 
ments, such  as  opening  and  closing  the  hands;  rapid 
supination  and  pronation;  finger  play,  such  as  piano 
playing;  extension  and  flexion  of  the  forearm  on  the 
arm.  It  has  been  found,  further,  that  the  symptom 
ha-  a  slightly  wider  significance  than  that  originally 
attributed  to  it,  and  "is  of  considerable  diagnostic 
importance.  The  defect,  in  order  to  be  called  adia- 
dochokinesia, should  not  be  complicated  by  the  pres- 
ence of  any  loss  of  muscular  power,  or  of  disturbance 
of  sensibility.  It  is  well  recognized  that  clumsiness 
in  performing  rapid  alternating  movements  exists  in 
ordinary  hemiplegia,  in  a  number  of  ataxic  states, 
due  to  impaired  sensibility,  but  the  significant 
feature  of  adiadochokinesia  is  that  it  should  be  found 
without  the  presence  of  muscle  palsies  or  of  sensi- 
bility disturbances.  It  is  one  of  a  series  of  closely 
related  motor  disturbances  due  to  interference  in 
certain  of  the  cerebellar  paths,  and  one  which,  taken 
in  conjunction  with  other  disturbances  of  cerebellar 
mechanism,  is  extremely  useful  in  the  differentiation 
of  cerebellar  disorders.  Essentially,  according  to 
Babinski,  it  consists  of  a  lack  of  proportion,  a  lack 
of  timing,  as  it  were,  between  the  successive  move- 
ments. In  other  words,  on  the  affected  side  there 
is  a  time  loss,  or  a  delay  in  the  motor  impulse.  This 
time  loss,  which  produces  the  disproportion  between 
the  series  of  movements  on  the  sound  and  on  the 
affected  side,  is  largely  due  to  the  disturbance  in  the 
automatic  tonic  mechanism,  the  most  important 
paths  for  the  maintenance  of  which  lie  in  the  cerebel- 

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Adiadochokinesia 


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lum,   I  lie  superior  cerebellar  peduncles,  and  the  red 
nucleus. 

When  this  symptom  is  present  in  its  pure  form,  a 
lesion  of  the  cerebellum,  or  of  the  superior  cerebellar 
peduncle  almost  invariably  has  been  found,  yet,  at 
the  same  time,  a  few  cases  have  been  recorded  in 
which  the  lesion  has  been  extra-cerebellar,  but  not 
non-cerebellar,  by  which  is  meant  that  although  the 
cerebellum  itself  has  proved  to  be  involved,  yet 
nevertheless  cerebellar  tracts  have  always  been 
implicated.  Thus,  a  few  patients  showing  this 
symptom  have  been  known  to  have  frontal  tumor. 
Here  the  cerebcllo-thalamoeortical  paths  have  been 
implicated.  Clinically,  the  majority  of  the  patients 
have  shown  tumors  of  the  cerebellum.  Some  mid- 
brain tumors,  or  midbrain  hemorrhages  with  impli- 
cation of  the  superior  cerebellar  peduncles  have  also 
shown  this  symptom.  Smith  Ely  Jelliffe. 

Adipocere. — (French,  adipocere,  gras  des  cadai'res; 
German,  Fettwachs.)  As  the  name  suggests,  adipo- 
cere, from  Latin  adeps,  lard,  and  ecru,  wax,  is  a 
material  resembling  in  its  gross  appearances  fat  and 
wax.  It  is  a  semitranslucent,  white,  or  slightly 
yellowish  substance  of  about  the  consistency  of 
cheese  at  ordinary  temperatures;  has  a  greasy  feel, 
and  yields  slightly  when  pressed  between  the  fingers. 
If  a  piece  be  rolled  between  the  fingers  for  a  few 
minutes  it  becomes  much  softer.  When  rubbed  with 
water  it  forms  a  lather.  Its  composition  is  that  of  a 
soap,  being  made  up  of  the  calcium  soaps  of  palmitic 
and  stearic  acids  and  also  of  acid  ammonium  soaps. 
Examined  under  the  microscope  it  shows,  occasion- 
ally, very  numerous  scales  having  a  crystalline  form; 
more  commonly  nothing  but  fat  globules  is  to  be 
seen.  If  it  be  melted  and  again  allowed  to  cool,  it 
is  found,  often,  to  have  crystallized  in  round  masses 
made  up  of  needle-shaped  crystals,  radially  arranged; 
hence  like  stearin. 

Most  of  the  specimens  of  adipocere  with  which  one 
is  familiar  come  from  the  macerating  troughs  of 
anatomical  departments  and  from  museum  jars 
which  have  long  contained  specimens  immersed 
in  dilute  alcohol.  It  thus  represents  the  results  of 
a  metamorphosis  of  dead  animal  tissues  placed  under 
peculiar  circumstances. 

The  only  special  point  of  interest  in  connection 
with  adipocere  lies  in  the  fact  that  it  is  occasionally 
found  in  dead  bodies  which  have  been  buried  a  con- 
siderable time.  In  fact,  nearly  all  the  structures  of 
the  body,  except  the  bones,  have  been  found  con- 
verted into  this  material.  For  centuries  its  presence 
had  been  noted  in  disinterred  corpses,  but  no  oppor- 
tunity was  afforded  for  studying  it  on  a  large  scale 
until  1876,  when,  upon  the  removal  of  the  bodies 
from  one  of  the  cemeteries  in  Paris,  a  considerable 
proportion  of  those  buried  in  the  common  grave  were 
found  by  Foucroy  to  have  been  converted,  to  a 
greater  or  less  degree,  into  this  peculiar,  fatty,  wax- 
like material,  and  to  it  he  gave  the  name  by  which 
it  has  since  been  known. 

The  conditions  favoring  its  formation  in  buried 
corpses  are  still  unknown.  Doubtless  moisture  is 
always  necessary;  but  why,  of  six  or  eight  bodies 
buried  in  close  proximity,  and  hence  presumably 
under  like  conditions  of  soil  and  moisture,  one  should 
undergo  almost  complete  change  into  adipocere, 
while  the  others  undergo  ordinary  putrefaction,  as  has 
been  observed,  is  at  present  inexplicable. 

At  one  time  it  was  thought  that  adipocere  might  be 
of  medicolegal  importance  in  helping  to  determine  the 
length  of  time  a  corpse  had  been  buried.  Foucroy  be- 
lieved that  thirty  years  was  required  for  its  formation. 
Later,  this  was  reduced  to  one  year;  and  Caspar 
mentions  finding  adipocere  in  the  body  of  a  new-born 
child  which  had  lain  for  three  months  in  a  house 
cesspool.     It  is  therefore  impossible  to  establish  an 


idea,  from  the  presence  of  adipocere  in  a  corpse,  as 
to  the  length  of  time  it  has  been  buried. 

Artificially,  adipocere  can  readily  be  produced, 
either  by  soaking  muscle  in  dilute  nitric  acid  for  two 
or  three  days  and  then  washing  it  thoroughly  in 
warm  water,  or  by  allowing  the  muscle  to  soak  for 
months  in  a  trough  supplied  with  running  water. 

Adipocere  is  probably  closely  allied  to  cholesterin. 

W.   W.  Gannett. 


Adiposis  Dolorosa. — At  a  meeting  of  the  American 
Neurological  Association,  held  in  New  York  in  June, 
1892,  the  writer  presented  the  histories  and  photo- 
graphs of  three  cases  of  an  affection  which  up  to  that 
time  had  not  been  recognized.  Four  years  previously 
the  writer  had  described  the  symptoms  which  con- 
stitute this  affection  in  reporting  a  case  under  the 
title  of  a  subcutaneous  connective-tissue  dystrophy. 
Subsequently  he  grouped  this  case,  a  second  described 
by  Dr.  F.  P.  Henry  and  a  third  rase  discovered  in  the 
wards  of  the  Philadelphia  Hospital  under  the  name  of 
adiposis  dolorosa  by  which  the  affection  has  since 
been  generally  known.  The  two  principal  features, 
fat  and  pain,  are  implied  by  the  name.  German 
writers  in  reporting  cases  of  this  disease  use  the  terra 
"adipositas  which  is  etymologically  correct,  while 
the  word  adiposis  is  of  mixed  origin,  being  made  up 
of  a  Latin  root  and  a  Greek  termination.  It  has, 
however,  been  used  for  generations,  more  especially 
by  English  medical  writers  and  is  paralleled  by  other 
mongrel  words,  long  approved  by  custom,  such  as 
'  tierminology."  Again  "adipositas"  is  itself  a 
'coned  word;  it  is  not  found  in  any  Latin  writing,  the 
real  Latin  word  being  "obesitas,"  which  if  we  insist 
upon  being  correct,  we  should  use. 

Subsequent  to  the  descriptions  published  by  the 
writer,  cases  were  reported  by  Collins,  Peterson, 
Ewald,  Eshner,  Spiller,  F6re  and  others  and  in  1901, 
Louis  Vitaut1  published  a  thesis  upon  the  subject. 
His  description  was  full  and  accurate,  so  much  so 
indeed  that  subsequent  observation  necessitates  but 
little  modification  of  it.  Up  to  the  present  time  a 
large  number  of  cases,  possibly  a  hundred,  have 
been  placed  on  record. 

Among  the  more  important  recent  publications 
were  those  by  Frankenheimer,2  Price,3  and  Poirier.4 

The  three  cases  which  the  writer  grouped  together 
in  his  original  paper  are  presented  in  brief  abstract 
herewith: 

Case  I. — M.  G.,  age  fifty-one,  female,  native  of 
Ireland,  domestic,  widow.  Family  and  early  history 
without  significance.  In  November,  1886,  she  was 
admitted  to  the  surgical  wards  of  the  Philadelphia 
Hospital  for  the  rupture  of  a  varicose  vein  of  the  leg. 
In  the  following  February  she  was  transferred  to  the 
medical  wards  for  a  severe  attack  of  bronchitis. 
Later  she  had  an  attack  of  severe  pain  and  swelling 
in  the  right  knee,  attended  by  chill  and  fever.  She 
was  treated  for  rheumatism  and  obtained  prompt 
relief.  Two  weeks  after  this  she  complained  of  a 
sharp  darting  pain  in  the  right  arm.  It  began  on  the 
outer  aspect  above  the  elbow  and  gradually  increased 
in  severity  and  extent,  spreading  upward  to  the 
shoulder  and  neck,  and  downward  to  the  forearm 
and  hand.  It  was  shooting  and  burning  in  character. 
She  felt  at  times  as  though  hot  water  were  being 
poured  upon  the  arm,  and  again  as  though  the  hands 
and  fingers  were  being  torn  apart.  No  rise  in  tem- 
perature was  noted.  The  pain  was  often  paroxysmal, 
but  it  was  never  absent.  On  June  4,  18S7,  she  was 
transferred  to  the  nervous  wards  of  the  hospital  and 
came  under  the  care  of  the  writer. 

Her  appearance  at  this  time  was  striking.  She 
was  a  tall,  large-framed  woman  who  looked  as  though 
she  had  at  one  time  presented  a  fine  physical  develop- 
ment, but  she  seemed  unnaturally  broad  across  the 
back  and  shoulders.     On  removing  the  clothing,  an 


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Adiposis  Dolorosa 


enormous  enlargement  of  these  parts  was  disclosed. 

The  enlargement  affected  both  shoulders,  the  arms, 
the  back  and  the  sides  of  the  chest.  It  was  most 
marked  in  the  upper  arms  and  bark,  forming  here 
huge    and    somewhat    pendulous    masses.      It     was 


■ 


neSS  about  the  knees,  followed  by  .--welling,  which 
gradually  increased.  At  first  she  thought  that  the 
swelling  was  due  to  her  growing  fat,  but  later  she 
was  astoni  hed  to  sec  that  then-  was  a  localized  mass 
on  the  inner  aspect  of  each  knee.      At  the  time  there 

was  dull  aching  pain  in  the  affected  p 
_^aBK^pa    Later,  the  right  arm  became  involved,  a 
mass  making  its  appearance  on  the  outer 
aspect.      Her   body,   as  she   then  observed, 
had   also  become  larger,   as  her  stays  wen- 

too  small  for  her.  During  this  time,  while 
-till  in  California,  inability  to  perspire 
freely,  except  at  the  Turkish  bath,  was 
marked,  and  was  part   of  her  reason    for 

^H|  coming  East.  Since  she  has  been  in  I'liila- 
I  delphia  the  lack  of  perspiration  has  not 
bi  en  as  marked  as  before.  Various  plans 
of  treatment  were  tried,  but  did  not  influ- 
ence the  progress  of  the  disease,  i.e.  the 
growth  of  the  swelling.  Five  or  six  years 
ago,  injections  of  chloroform  were  made 
into  the  swellings  on  the  inner  sides  of  the 
knees,  but  no  good  was  accomplished. 
Painful  ulcerations  were  the  result,  and 
scars  of  considerable  size  mark  their  loca- 


tion. 


Jrat  onbaek: 


elastic  and  yet  comparatively  firm  to  the  touch,  and 
it  was  impossible  to  produce  pitting.  In  some 
situations  it  felt  as  though  finely  lobulated  and  in 
others,  especially  on  the  insides  of  the  arms,  as  though 
the  flesh  were  filled  with  bundles  of  worms.  The 
skin  was  not  thickened;  it  did  not  take  part  in  the 
swelling,  and  it  was  not  adherent  to  the  subjacent 
tissues.  In  addition  the  swelling  was  very  painful  to 
pressure.  Pronounced  pressure  appeared  to  be 
absolutely  unbearable.  The  nerve  trunks  also  were 
exquisitely  sensitive,  but  this  painful  condition  was 
not  by  any  means  limited  to  them,  but  permeated 
the  swollen  tissue  as  a  whole. 


ad  Upper  Arm.  About  five  years  ago  a  slight  swelling 
appeared  in  the  epigastrium.  This  gradu- 
ally increased  in  size  until  it  resembled  the  breasts  in 
shape,  and  afterward  spread  so  as  to  involve  nearly 
the  whole  abdomen.  From  the  knees  the  process 
extended  to  the  thighs,  and  gave  rise  to  large  masses 
on  their  outer  side  and  about  the  hips.  At  various 
times  she  had  suffered  with  pains  apparently  situated 
in  the  enlarged  tissues,  or  running  down  the  limbs. 
Sometimes  these  attacks  were  fairly  well  localized  in 
one  limb,  in  one  side,  or  about  a  joint. 

Case  III. — M.  M.,  age  sixty,  widow,  a  tailoress  by 
occupation,  and  a  native  of  Germany.  Family  and 
early  personal  history  likewise  without  significance. 
On  examination  the  patient  was  found  to  be  excessively 


Fig.  47. — Another  View  of  Author's  First  Case. 


Case  II. — E.  W.,  female,  age  sixty-four,  married, 
native  of  England.  Family  and  early  personal 
history  without  significance.  Present  malady  began 
about  fifteen  years  ago,  when  she  was  forty-nine 
years  old.  At  that  time  she  was  living  in  California. 
The  first  thing  noticed  was  a  constant  feeling  of  cold- 


feeble.  For  some  two  weeks  she  had  been  unable 
to  walk.  She  lay,  for  the  most  part,  in  a  quiet, 
apathetic  state,  though  when  aroused,  she  answered 
questions  slowly,  but  intelligently.  She  was  also 
somewhat  deaf. 

Examination  further  revealed  soft,  fat-like  masses 


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Fig.  48. — Author's  Second  Case. 

or  swellings  in  various  situations.  Thus,  a  large,  soft 
mass  was  found  over  either  biceps,  and  others,  some- 
what smaller,  over  the  outer  and  posterior  aspect  of 
either  upper  arm.  Two  large  masses  were  found 
over  the  belly,  separated  above  the  umbilicus  by  a 
deep,  transverse  crease.  Another  gave  excessive 
prominence  to  the  mons  Veneris.  From  the  back  of 
the  neck,  at.  its  lower  part,  sprang  a  big  mass  like  a 
hump,  while  a  diffuse  swelling  gave  a  cushion-like 
coating  to  either  half  of  the  back,  and  extensive 
deposits  gave  unnatural 
prominence  to  either  hip. 
In  marked  contrast,  the 
deposit  was  absent  from 
the  forearms  and  hands, 
from  the  face,  from  the 
thighs  and  legs,  and  from 
the  buttocks.  The  glu- 
teal regions,  in  fact, 
seemed  flattened  and 
sloping. 

The  deposit  over  the 
bark  seemed  tolerably 
firm  and  resistant;  over 
other  portions  it  was 
quite  soft,  though  elastic, 
and  exhibited  the  same 
nodular  feel  noted  in  the 
previous  cases.  Further, 
it  was  discovered  at  once 
that  these  masses  were 
painful  to  the  touch,  the 
patient  complaining  very 
much  when  only  moder- 
ate pressure  was  exer- 
cised] This  was  espe- 
cially true  of  the  deposits 


over  the  arms  and  back  of  the  neck.  In  addition 
the  patient  complained  of  stabbing  pains  in  the 
deposits,  more  marked  in  the  regions  just  men- 
tioned. There  was  no  tenderness  over  the  nerve 
trunks.     She  complained  also  of  headache. 

These  cases  presented  in  brief  fatty  deposits,  ac- 
companied by  pains,  shooting,  burning,  or  stabbing 
in  character.  Sometimes  the  pain  occurred  in 
paroxysms  and  at  such  times  there  was  present  an 
increase  or  induration  of  the  swellings.  Sometimes 
new  deposits  were  formed  during  such  crisrs. 

Since  these  cases  were  published,  enough  has 
been  learned  about  the  affection  to  enable  the 
following  systematic  description  of  the  disease  to 
be  presented. 

Etiology. — In  a  proportion  of  the  cases,  neuro- 
pathic elements  are  noted  in  the  heredity;  occa- 
sionally also  in  collateral  relatives.  Again,  it  is  now 
and  then  noted  that  other  members  of  the  family 
are  obese  as  was  noted  by  Eshner,  in  one  of  whose 
cases  the  mother  of  the  patient  was  very  stout  and 
in  another  of  the  writer's  cases  in  which  the  father 
was  excessively  stout.  Occasionally  it  has  hap- 
pened that  several  instances  of  adiposis  dolorosa 
were  noted  in  members  of  the  same  family.  Chee- 
vers  has  placed  on  record  the  case  of  a  man  whose 
father  and  sister  had  the  same  disease  as  the 
patient;  Hammond  reports  two  cases  occurring 
among  sisters.  The  affection  appears  to  predomi- 
nate especially  in  the  female  sex,  the  proportion 
being  about  six  to  one. 

It  is  difficult  to  make  definite  statements  as  to 
the  age  at  which  the  disease  appears.     The  young- 
est case  reported  is  that  of  Hale  White  in  which 
the  disease  began  at  twelve  years  of  age,  while  the 
oldest  patient  thus  far  recorded  was  seventy-eight 
years  of  age.     According  to  Frankenheimer,  the 
majority  of  cases  in  men  occur  between  thirty  and 
forty  years  of  age  and  in  women  between  thirty  and 
fifty  years  of  age.     Now  and  then  there  is  an  an- 
tecedent history  of  alcoholism  or  of  syphilis.     The 
significance  of  these  facts,  however,  is  open  to  ques- 
tion, but  as  has  been  pointed  out  by  Price  and  has 
been    emphasized   by    Lorand,  both  alcoholism  and 
syphilis  not  infrequently  cause  degenerative  changes 
in  the  ductless  glands,  structures  which  are  probably 
at  fault  in  the  production  of  adiposis  dolorosa.     In  a 
case  described  by  E.  W.  Taylor,  the  disease  developed 
while   the  patient  was   convalescing   from   an  acute 
alcoholic  neuritis.       In  quite  a  number  of  cases  ex. 
cessive  menstrual  flow  and  even  uterine  hemorrhages 


■ 

EHk'^           Is 

m                              ~ 

\                                                         /  1 

x                          / 

--*fWj, 

Fig.  49. — Rear  View  of  Author's  Second  Case. 


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Adiposis  Dolorosa 


have  been  aoted.  In  one  ease,  that  of  Spiller;  the 
adiposis  dolorosa  followed  pregnancy,  while  in  another, 
thai  of  Schlesinger,  it  followed  an  abortion.  Quite 
:i  number  of  cases  finally  have  developed  after  the 
menopause. 


Fig.  50. — Author's  Third  Case. 

Among  other  facts,  trauma  has  been  noted  in  the 
ory;  attention  has  been  called  to  this  especially 
by  Guidiceandrea.  In  one  case  of  the  writer  and  in 
One  of  Eshner,  trauma  appeared  to  play  a  role  of 
exciting  cause.  Emotional  shock  has  also  preceded 
the  onset  as  in  the  case  of  Achard  and  Laubry.  In 
Vitaut's  case  there  appeared  to  be  a  mild  infection 
of  the  digestive  tract;  in  other  cases  exposure  to  cold 
and  dampness,  rheumatism,  appeared  to  play  a  role. 

sionally  also  some  other  neurosis  exists  side  by 

side  with  the  affection,  as  in  the  woman  reported  by 
Henry  and  in  a  man  reported  by  the  writer,  both  of 
whom  suffered  from 
epilepsy.  In  othercases 
again,  undoubted  men- 
tal disease  has  been 
noted,  and  even  com- 
mitment to  an  asylum 
for  the  insane  has  been 
resorted  to  in  such 
cases. 

Symptomatology . — 
The  symptoms  as  a 
rule  appear  very  gradu- 
ally. Most  frequently, 
as  stated  above,  the 
patient  is  a  woman. 
Up  to  the  period  of  the 
onset  of  her  symptoms, 
she  has  been  apparently 
well  and  perhaps  en- 
gaged with  the  usual 
household  duties  or 
other  occupation.  She 
has  occasion  at  one 
time  to  notice  a  slight 
pain  or  tenderness  in 
some  portion  of  her  body.  These  early  symptoms  of 
pain  are  very  variable  in  character  and  in  intensity. 
Most  often  it  is  a  sensation  of  smarting  or  stinging 
more  or  less  annoying  because  of  its  persistence. 
Sometimes  the  pain,  even  in  the  beginning  is  severe, 
though  this  is  unusual.  At  other  times  the  onset  of 
symptoms  is  preceded  by  a  sensation  of  cold  in  re- 
gions in  which  pain  subsequently  makes  its  appear- 
ance.  As  a  rule  the  pains  at  first  are  not  very  pro- 
nounced and   the   patient   is    for   some  time  able  to 

Vol.  I.— 9 


follow  her  ordinary  occupation.  Furthermore,  the 
pains  arc  not  pei  i  tenl  bul  recur  al  intervals,  the 
patient  being  comfortable  for  hour  i  and  ometimes 
for  days  al  a  tunc.  Little  by  little  the  pain  become 
mure  pronounced;  they  increase  in  intensity  and 
t  hen  also  accompa  nied  bj  di 
tinol  local  changes.  The  pa- 
tient nal  urally  examine:  I  lie 
pari  which  is  painful  and  may 

note     these     changes     herself. 

Sometimes    there   is  a   little 
flushing  of  the  skin  and  sooner 

or  later  a  swelling  is  noted. 
At  first  it  is  hardly  apprecia- 
ble but  gradually  becomes 
mi. re  pronounced.  The  swell- 
ing may  give  a  sensation  to 
the  linger  of  a,  rather  firm 
localized  edema.  As  a  rule  it 
is  in  the  beginning  a  small 
nodule — smaller  than  a  wal- 
nut, rarely  larger.  Some- 
times a  number  of  such  swell- 
ings are  noted  at  the  same 
time.  The  affection  contin- 
ues to  evolve,  usually  slowly; 
the  pains  become  more  in- 
tense and  more  frequent  and 
gradually  the  tumefactions 
change  their  character  and 
finally  become  veritable  tumors  or  great  tumor 
masses.  In  rare  cases  the  fatty  deposit  appears  to 
make  its  appearance  without  either  previous  or  con- 
comitant pain,  the  pain  making  its  appearance  only 
after  the  enlargements  or  swellings  have  for  some 
time  existed.  This,  as  already  stated,  is  unusual,  the 
most  common  history  by  far  being  that  just  outlined. 
The  pain  is  quite  commonly  paroxysmal,  though  in 
long  established  cases  it  may  be  continuous.  In  the 
intervals  the  tumefactions  are  usually  tender  or  pain- 
ful to  pressure. 

Vitaut  recognized  four  cardinal  symptoms,  namely, 


Fig.  51. — Rear  View  of  Author's  Third  <';tsr. 


swelling,  pain  or  tenderness,  asthenia,  and  psychic 
symptoms.  The  swellings  may  present  themselves 
under  three  different  aspects.  Sometimes  they  are 
small,  of  variable  dimensions,  distinct  from  one 
another  and  readily  isolated.  Under  these  circum- 
stances they  present  what  Vitaut  has  termed  the 
nodular  form  of  the  disease.  Sometimes  they  form 
extensive  masses  invading  an  entire  limb  or  the  seg- 
ment of  a  limb.  To  this  condition  Vitaut  has  given 
the  name  of  the  localized  diffuse  form.     Finally  a 

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tumor  properly  speaking  may  not  be  present,  but  the 
entire  body  may  be  augmented  in  volume  in  conse- 
quence of  a  hyperplasia  of  the  fatty  subcutaneous 
connective  tissue.  This  condition  Vitaut  has  called 
the  generalized  diffuse  form. 

When  the  affection  presents  itself  in  the  nodular 
form,  we  notice  at  first  pains  variable  in  character, 
for  example,  stinging,  itching,  smarting,  shooting, 
which  is  soon  followed  by  a  slight  redness  of  the  skin 
and  a  slight  induration  scarcely  appreciable  by  the 
finger.  If  we  examine  the  painful  area,  we  feel  a 
tumefaction  usually  of  small  size,  at  first  yielding 
and  later  a  little  more  resistant.  The  sensation  is 
that  of  a  firm  edema  which  is  not  well  differentiated 
from  the  surrounding  tissue.  The  tumefaction 
appears  to  develop  slowly  in  keeping  with  successive 
attacks  or  crises  of  pain.  Gradually  it  becomes 
somewhat  better  defined,  its  volume  increases  and 
its  consistence  changes  so  that  it  no  longer  has  the 
appearance  of  a  simple  tumefaction,  but  that  of  an 
actual  tumor.  Each  increase  of  swelling  is  pre- 
ceded or  attended  by  characteristic  pains.  The 
latter  are  sometimes  so  sudden  in  their  onset  and  so 
severe  as  to  cause  the  patient  to  cry  out.  During 
the  height  of  the  paroxysm,  the  tumor  may  resemble 
very  closely,  in  the  sensation  which  it  gives  to  the 
fingers,  a  "caking  breast."  The  painful  crisis  having 
passed,  it  is  found  that  the  dimensions  of  the  swelling 
have  distinctly  increased.  It  has  become  perma- 
nently larger  as  well  as  more  resistant  and  better 
defined.  After  repeated  paroxysms,  the  swelling 
resembles  a  distinct  tumor  more  and  more  closely. 
In  certain  portions  the  mass  may  appear  finely 
lobulated,  while  in  other  parts  it  gives  to  the  fingers 
the  sensation  of  a  bag  of  worms  beneath  the  skin. 
Each  painful  crisis  leaves  behind  it  very  appreciable 
changes.  In  an  area  where  nothing  existed  pre- 
viously, we  find  after  a  crisis  a  diffuse  edematous 
tumefaction;  if  the  tumefaction  has  existed  previous 
to  the  crisis,  we  find  it  transformed  into  a  lobulated 
tumor  more  or  less  well  encapsulated.  Sometimes 
after  a  crisis  we  discover  around  the  tumor  a  well- 
defined  edematous  zone  which  in  subsequent  crises 
undergoes  a  transformation  such  as  the  original  mass 
itself  had  undergone.  In  this  way  the  mass  may 
eventually  attain  great  size.  The  various  stages  of 
the  evolution  of  these  masses  can  be  followed  very 
closely  by  palpation.  One  and  the  same  patient, 
besides,  usually  presents  in  various  regions  tumors 
in  various  stages  of  development.  Painful  crises 
supervene  usually  without  appreciable  cause;  at 
times  they  are  provoked  by  trauma  and  at  others 
they  ensue  upon  unusual  exertion.  The  patient  is 
frequently  very  positive  in  stating  that  slight  con- 
tusions of  the  surface  or  that  excessive  fatigue  provokes 
the  painful  crises. 

The  swellings  vary  considerably  in  size.  Some  of 
the  very  smallest  may  be  no  larger  than  a  pea, 
though  so  small  a  mass  is  the  exception.  More 
frequently  the  mass  is  of  the  size  of  a  walnut  or  a 
small  orange.  .Much  larger  sizes  are  met  with.  The 
larger  masses  are,  of  course,  evident  to  ordinary  visual 
inspection,  the  smallest  ones  require  to  be  sought 
for  by  palpation.  If  we  examine  the  patient  atten- 
tively in  a  good  light,  we  are  struck  by  the  changes  in 
the  skin  in  certain  areas.  In  places  indeed  it  presents 
a  bluish  tint  due  to  a  slight  superficial  veining  and  if 
we  examine  such  a  region  by  the  feel,  we  frequently 
discover  a  small  subjacent  tumor.  Small  as  the  tumor 
may  be,  it  may  betray  its  existence  by  this  bluish  tint 
in  the  skin  which  covers  it.  It  happens  sometimes 
that  these  small  tumors  become  confluent  and  finally 
form  a  single  large  mass.  Such  a  mass  gives  rise  to  a 
sensation  like  that  of  a  varicocele  or  of  a  bag  of  worms. 
This  sensation  of  a  bag  of  worms  is  noted  with  especial 
frequency  in  the  fatty  masses  which  are  loose  and 
pendent. 

Swellings  may  occur  in  almost  any  situation  except 


in  the  face,  hands  and  feet.  These  are  rarely,  if  ever, 
involved.  Sometimes  the  swellings  are  symmetrical, 
especially  in  the  beginning  of  the  disease,  but  soon 
they  group  themselves  about  without  any  apparent 
order.  They  develop  by  preference  over  the  limbs 
or  in  the  segments  of  a  limb.  In  some  patients  they 
are  limited  to  the  arms  and  thighs,  or  forearms  and  legs 
in  others.  Sometimes  we  find  them  on  the  thorax, 
abdomen,  and  lumbosacral  region.  In  the  stage  of 
edematous  swelling,  the  tumor  masses  pass  without 
exact  limitation  into  the  surrounding  tissue.  As  a 
rule  the  skin  is  but  slightly  movable  over  them. 
Later,  however,  distinct  tumor  masses,  more  or  less 
encapsulated,  are  formed.  They  are  mobile  in  all 
directions.  They  are  slightly  adherent  to  the  skin 
so  that  if  one  tries  to  displace  the  overlying  skin, 
motion  is  transmitted  to  the  swelling.  At  times, 
however,  the  skin  can  be  gathered  in  a  fold  above 
the  tumor.  These  masses  again,  it  must  be  borne  in 
mind,  are  painful  not  only  during  the  crises,  but  are 
tender  to  pressure;  this  tenderness  as  already  stated, 
may  persist  in  the  intervals  between  the  paroxysms. 

When  the  painful  swellings  are  localized,  though 
diffuse,  they  may  begin  primarily  as  diffuse  wide- 
spread enlargements  or  a  number  of  nodules  may 
become  confluent  and  in  this  way  present  a  diffuse 
mass.  However,  the  more  frequent  manner  is  the 
gradual  appearance  of  a  diffuse  mass  without  the 
previous  formation  of  nodules.  In  such  a  case  the 
pains  are  felt  over  a  correspondingly  extensive  region. 
At  first  the  entire  region  presents  an  edematous 
swelling  easily  observable  by  the  eye.  Subsequently 
the  evolution  of  the  mass  is  substantially  the  same  as 
in  the  nodular  form.  Painful  crises  are  here  again 
present  and  the  swelling  increases  in  size  with  each 
successive  attack.  Finally  a  mass  is  formed  which  is 
resistant  and  painful  to  pressure.  It  may  be  quite 
smooth  or  it  may  be  finely  lobulated,  or  separate; 
apparently  encapsulated  tumors  may  be  found  im- 
bedded in  the  general  lipomatous  mass.  It  is  difficult 
to  make  out  the  limitations  of  the  latter  as  clearly  as 
in  the  nodular  form.  These  diffuse  masses  are  found 
more  frequently  upon  the  thighs,  the  buttocks,  the 
back,  the  abdomen,  and  the  upper  arms.  The  swell- 
ings are  usually  very  painful  and  during  a  "crisis" 
may  be  much  nodulated  and  may  present  the  sensation 
to  the  fingers  of  a  breast  distended  by  milk,  i.e.  a 
sensation  of  a  caked  breast. 

When  the  affection  presents  itself  in  the  generalized 
form,  the  appearance  may  be  less  distinctive  but  the 
origin  and  course  are  the  same.  The  swelling  may 
appear  rapidly,  even  suddenly  and  involve  the  greater 
part  of  the  surface  of  the  body  and  limbs,  exclusive 
of  the  face,  hands,  and  feet.  It  steadily  increases  and 
results  in  a  general  lipomatosis.  Most  commonly, 
however,  like  the  localized  diffuse  form,  it  begins  in 
a  certain  part,  for  instance  the  abdomen,  sometimes 
upon  one  side  and  then  begins  to  diffuse  itself  gradu- 
ally over  the  neighboring  portions  of  the  trunk  and 
limbs.  In  other  portions  of  the  body  similar  swell- 
ings may  make  their  appearance,  perhaps  at  the 
same  time,  perhaps  a  little  later  and  these  becoming 
confluent  with  the  original  mass  and  with  each  other, 
a  diffuse  lipomatosis  again  results.  The  parts 
affected  are  ordinarily  the  thighs,  hips,  buttocks, 
abdomen,  chest,  upper  arms,  and  forearms.  In 
exceedingly  advanced  cases,  small  masses  of  fatty 
tissues  may  be  observed  over  the  thenar  and  hypo- 
thenar  eminences  and  even  on  the  soles  of  the  feet; 
in  one  case  the  writer  observed  even  a  slight  invasion 
of  the  face.  Even  in  excessively  diffuse  forms,  with 
enormous  increase  of  the  body  weight,  the  writer 
has  never  observed  an  invasion  of  the  backs  of  the 
hands  or  the  dorsum  of  the  feet. 

The  swelling  of  the  generalized  diffuse  form  is 
much  less  resistant  than  the  nodular  or  localized 
diffuse  forms.  The  entire  fatty  mass  is  spontaneously 
painful  and  tender  to  pressure,  though  the  pain  is  not 


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Adiposis  Dolorosa 


equally  diffused  but  more  pronounced  al  certain 
times  and  in  certain  areas  than  others.  Local  II net  na- 
tions of  induration  also  are  noted.  Sometimes  the 
Buffering,  owing  to  the  universal  pain  and  tendernes 

is  exceedingly  great;  it  may  be  so  pri inced  as  to 

prevent  any  motion  on  the  part  of  the  patient  and  to 
immobilize  him  in  bed.  The  nodular  form  is  the 
most  common. 

A  word  remains  to  be  said  regarding  the  character  of 
the  pain.  This  occurs  either  spontaneously  or  is  readily 
elicited  by  pressure.  Most  frequently  the  pain 
precedes  the  appearance  of  the  edematous  swellings. 
Sometimes  it  comes  on  at  the  same  time  as  the  swelling; 
more  rarely  it  is  not  noted  until  after  the  swelling 
has  made  its  appearance.  Slightly  marked  and 
intermittent  at  first,  the  pain  becomes  more  violent 
after  the  disease  has  been  established.  It  is  described 
by  the  patient  as  stinging,  burning,  pinching,  darting, 
or  even  lancinating.  Most  frequently  it  darts  and 
radiates  or  is  diffused  in  and  about  the  nodules.  It 
does  not  follow  the  large  nerve  trunks  or  indeed  any 
nerves.  The  patient  describes  the  pain  as  though  it 
was  situated  in  the  thickness  of  the  masses.  One 
characteristic  is  presented  by  all  cases,  namely  the 
paroxysmal  exacerbations  of  pain  already  described. 
Suddenly  and  without  cause  or  following  an  effort  or 
trauma  the  patient  again  feels  active  pain.  At  the 
same  time  the  new  formations  increase  in  volume. 

In  addition  to  the  fatty  masses  and  the  pain  there 
an1  present  the  asthenia  and  the  psychic  symptoms. 
All  or  almost  all  of  the  patients  present  the  symptoms 
of  a  general  asthenia.  The  patient  is  very  readily 
exhausted.  Even  in  cases  in  which  the  muscular 
development  is  good  this  fact  is  early  noted  and  in 
cases  which  are  advanced,  the  asthenia  is  very  pro- 
nounced. Indeed  the  patient  may  become  bedridden 
by  reason  of  this  weakness  as  well  as  because  of  the 
pain  which  is  usually  made  worse  by  exertion,  espe- 
cially in  advanced  cases. 

Psychic  symptoms  are  also  very  frequently  present. 
A  cerebral  asthenia  or  cerebral  exhaustion  is  rarely 
absent.  There  is  present  in  addition  usually  great 
irritability.  This  is  at  times  so  marked  as  to  be  at- 
tended by  a  change  in  character  and  in  disposition. 
The  patient  frequently  quarrels  with  his  neighbors  in 
the  wards  and  to  such  an  extent  that  isolation  may 
become  imperative.  Sometimes  the  patient  thinks 
that  the  other  patients  or  the  nurses  "  are  against 
her."  Systematized  persecutory  ideas  are,  however, 
not  present.  The  sleep  may  be  broken  and  there 
may  be  distressing  dreams  and  nightmares.  One  of 
Eshner's  patients  had  to  be  committed  to  an  asylum 
because  of  the  pronounced  character  of  the  mental 
disturbance.  Hale  White's  patient  had  two  attacks  of 
mental  disturbance  and  Guidiceandrea  has  noted 
delusions  of  persecution  and  a  true  dementia.  Other 
symptoms  are  also  occasionally  noted.  Thus  there 
may  be  present  lessened  sensibility,  to  touch,  pain,  and 
temperature  or  paresthesias  may  be  complained  of, 
such  as  velvety  sensations  in  the  finger  tips  and  in  the 
soles  of  the  feet.  Patients  have  also  complained  of 
sudden  sensations  of  cold  or  of  heat,  of  formication,  or 
of  cramps  in  various  parts  of  the  body. 

Symptoms  may  also  be  presented  by  the  special 
senses.  Thus  narrowing  of  the  visual  fields  has  been 
noted.  In  others,  subjective  sensations,  such  as 
phosphenes  and  muscae  volitantes.  In  one  case 
amaurosis  was  observed;  this  disappeared  under 
thyroid  treatment.  In  a  case  of  the  writer  there  was 
noted  a  circinate  retinitis — a  mass  of  partly  fibrinous 
and  hemorrhagic  exudate  in  the  center  of  the  retina, 
surrounded  by  crescents  of  fatty  degeneration  in 
Mueller's  fibers. 

The  auditory  perception  has  been  observed  to  be 
diminished  in  a  number  of  cases.  Occasionally  tin- 
nitus aurium  has  been  recorded  and  finally  in  one  of 
the  writer's  cases,  smell  and  taste  were  distinctly 
impaired. 


Vasomotor   phenomena   are   quite   often    present. 

The  skin  over  a  nodule  may  present  no  changes  what- 
ever. On  the  oilier  hand,  it  may  be  no  ed  that  it  is 
somewhat  injected  during  a  crisis  of  pain  or  much 
veined  and  slightly  bluish.  Sometimes  the  face  is 
much  flushed,  especially  over  the  malar  regions  and 
the  forehead  or  it  may  be  tin-  nnk.  \o  induration 
or  swelling  accompanies  these  changes  in  color.  Cya- 
nosis of  the  extremity  and  transitory  edema  have 
also  been  observed.  A  very  common  symptom 
noticed  is  that  the  flesh  bruises  very  readily  and  quite 
commonly  small  ecchymoses  on  various  portions  of 
the  limb  and  trunk  are  revealed  at  the  time  that  the 
patient  is  examined.  These  ecchymoses  or  subcu- 
taneous bleedings  make  their  appearance  sponta- 
neously and  independently  of  trauma.  In  keeping 
with  this  fact  are  probably  the  metrorrhagia,  excessive 
menstruation,  epistaxis,  hematemesis  variously  ob- 
served. Trophic  changes  in  the  form  of  ulcerations, 
blebs,  and  bulla  have  been  noted.  It  is  important  to 
add  that,  there  is  quite  commonly  a  marked  dryness 
of  the  skin.  In  women  there  is  frequently  present 
a  history  of  relatively  early  cessation  of  the  men- 
strual function. 

Among  unusual  complications,  noted  in  adiposis 
dolorosa  are  changes  in  the  joints.  Cases  showing 
such  changes  have  been  noted  by  Renon  and  Heitz 
and  by  the  writer.  It  appears  that  the  changes  are 
in  part  due  to  the  fatty  infiltration  and  that  this  fat 
is  painful  to  pressure.  In  other  cases  it  is  probable 
that  an  actual  synovitis  is  present  and  in  one  of  the 
writer's  cases,  distinct  changes  were  revealed  in  the 
cartilage  and  bones  by  the  z-ray.  Price  has  also 
noted  changes  in  the  joints  confirming  these  findings. 
Price  together  with  Hudson  also  noted  changes  in  the 
bones — in  the  dorsal  vertebrae  and  in  the  ribs — the 
changes  being  evidently  trophic  in  character.  Their 
existence  was  confirmed  by  the  skiagraph.  Price 
and  Hudson  called  attention  to  the  possible  signif- 
icance of  these  findings  in  view  of  the  frequency  of 
pituitary  changes  in  adiposis  dolorosa. 

The  course  of  adiposis  dolorosa  is  essentially  chronic. 
The  progress  is  slow,  the  patient  being  better  or  worse 
by  turns  according  to  the  occurrence  of  paroxysms  of 
pain.  In  well-established  cases,  the  suffering  is  con- 
tinuous, subject  always  to  more  or  less  marked 
exacerbations.  In  the  majority  of  cases  the  patient 
becomes  exceedingly  obese,  the  weight  often  running 
from  two  hundred  to  three  hundred  pounds.  In  the 
nodular  form,  the  weight  may  undergo  very  slight 
if  any  increase. 

The  tendon  reflexes  may  be  normal  or  increased. 
Most  frequently  they  are  diminished  and  sometimes 
absent.  Occasionally  the  skin  reflexes  are  lost. 
Coincident  gross  nervous  or  other  disease  has,  as 
may  be  expected,  been  noted  a  number  of  times. 
Thus  hemiplegia  and  aphasia  coexisted  in  one 
case;  in  another  sclerosis  of  the  columns  of  Goll 
and  in  another  still  involvement  of  the  lateral 
tracts. 

Pathology. — Up  to  the  time  of  writing,  eight  autop- 
sies have  been  held.  These  indicate  that  in  adiposis 
dolorosa  there  is  some  disturbance  of  the  internal 
secretions,  excessive  formation  of  fatty  tissue  and 
an  interstitial  neuritis  of  the  nerve  fibers  contained 
in  the  deposits. 

Price  has  summarized  the  results  of  the  various 
autopsies  as  follows: 

Cases  I  and  II. — Dercum:  Macroscopic  disease  of 
the  thyroid,  the  glands  being  enlarged  and  the  seat 
of  calcareous  infiltration. 

Case  III. — Dercum:  Irregular  atrophy  of  the 
thyroid,  extensive  interstitial  neuritis  of  peripheral 
nerves  in  fatty  deposits,  degeneration  in  the  columns 
of  Goll. 

Case  IV. — Burr:  Glioma  of  the  pituitary  body; 
colloid  degeneration  with  atrophy  and  absence  of 
secreting  cells  in  many  acini  of  the  thyroid  gland; 

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Adiposis  Dolorosa 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


interstitial    neuritis   of    terminal    filaments;   sclerotic 
ovaries. 

Case  V. — Dercum  and  McCarthy:  Adenocarcinoma 
of  pituitary  body,  thyroid  normal,  right  suprarenal 
gland  hypertrophied,  hemolymph  glands,  interstitial 
neuritis,  undeveloped  testicles. 

Case  VI. — Guillain  and  Alquier:  Hypophysis 
doubled  in  size  with  marked  increase  of  connective 
tissue  in  the  glandular  portion  and  changes  suggesting 
an  alveolar  carcinoma;  thyroid  hypertrophied  with 
increase  in  connective-tissue  stroma. 

Case  VII. — Price:  Inflammatory  changes  in  thyroid, 
with  marked  increase  in  the  interstitial  connective 
tissue,  one  whole  lobe  being  especially  infiltrated, 
the  other  showing  compensatory  hypertrophy.  In- 
flammatory changes  in  hypophysis,  with  presence  of 
a  condition  suggesting  alveolar  or  glandular  carcinoma, 
interstitial  and  parenchymatous  neuritis,  sclerotic 
ovaries. 

Case  VIII. — Price:  Marked  increase  in  the  con- 
nective  tissue  of  the  thyroid  gland,  dilatation  of  the 
acini,  with  infoldings  of  the  cuboidal  epithelial  lining. 
The  same  changes  in  the  hypophysis  as  were  found 
in  Cases  VI  and  VII,  but  less  marked.  No  abnor- 
malities   of  the  adipose  tissue. 

Delecq  thinks  that  disease  of  the  thyroid,  testicle, 
ovary,  and  pituitary  body  may  be  causes  of  adiposis 
dolorosa.  Von  Schroeter  concludes  that  adiposis 
dolorosa  is  due  to  a  dysthyroidismus.  Pineles  regards 
the  disease  as  a  result  of  the  disturbance  of  function 
in  numerous  blood  glands  and  that  there  are  present 
hypothyroidism,  genital  atrophy,  and  changes  in  the 
hypophysis. 

The  thyroid  gland,  it  will  be  noted,  showed  unmis- 
takable changes  in  seven  of  the  eight  autopsies. 
These  changes  are  very  interesting  and  are  well 
illustrated  by  the  findings  in  the  third  autopsy  of 
the  writer  in  which  the  gland  was  submitted  to 
microscopic  examination.  The  changes  observed 
were  indicative  in  part  of  the  hypertrophy  and  in 
part  of  atrophy.  In  certain  portions  of  the  gland, 
numerous  small  acini  appeared  to  be  in  process  of 
development.  Exceedingly  large  acini  distended  by 
deeply  staining  colloid  material  were  also  present, 
while  plications  and  papillary  outgrowths  of  the 
walls  of  he  acini  seemed  to  be  an  attempt  to  increase 
the  secreting  surface.  Other  portions  of  the  gland 
were  distinctly  atrophic.  It  is  not  impossible  that 
there  was  present  a  compensatory  hypertrophy 
accompanying  degenerative  changes  in  other  portions 
of  the  gland.  The  findings  resembled  those  obtained 
by  Halstead  in  the  thyroid  of  a  dog  after  partial 
extirpation. 

It  is  not  improbable  that  qualitative  changes  of 
function  of  the  thyroid  gland  play  a  role.  Substances, 
the  result  of  deranged  thyroid  action,  may  be  formed 
which  may,  on  the  one  hand,  prevent  the  proper 
oxidation  of  the  hydrocarbons  of  the  foods  and  tissues 
and  on  the  other  may  act  as  a  cause  of  neuritis  and 
nerve  degeneration.  Whatever  the  explanation,  it  is 
interesting  to  recall  the  diminished  sweating  and  the 
occasional  slowness  of  speech  and  mental  irritability. 
The  interpretation  is  of  course  difficult;  the  obesity 
and  the  dryness  of  the  skin  suggest  thyroid  deficienev, 
while  the  flushing  of  the  face,  the  occasional  tachy- 
cardia and  the  psychic  symptoms  would  point  rather 
to  thyroid  excess,  and  it  is  safer  perhaps  with  Pineles 
to  regard  the  condition  as  one  of  dysthyroidismus. 

Among  the  most  significant  findings,  however,  are 
the  changes  noted  in  the  pituitary  bod}'.  In  five  of 
the  six  cases  in  which  the  pituitary  was  examined,  it 
was  found  diseased.  Thus  Burr  described  a  glioma 
of  the  pituitary,  Dercum  and  McCarthy  adeno- 
carcinoma, Guillain  and  Alquier  changes  suggesting 
an  alveolar  carcinoma,  and  Price  changes  likewise 
suggesting  alveolar  or  glandular  carcinoma  in  two 
cases. 

In  considering  the  possible  role  of  the  pituitary 


body,  we  must  bear  in  mind  the  recent  interesting 
researches  of  Harvey  Cushing  with  regard  to  the 
carbohydrate  function  of  this  organ.  It  apparently 
stands  in  the  most  intimate  relation  with  the  assimi- 
lation of  the  carbohydrates  so  that  if  its  anterior 
lobe  is  destroyed  in  animals,  carbohydrate  tolerance 
and  assimilation  are  greatly  diminished  or  lost.  The 
pituitary  body  is  thus  brought  into  relation,  though 
perhaps  indirectly  with  a  fat  producing  or  fat  destroy- 
ing function.  In  the  light  of  other  observations,  this 
subject  assumes  a  new  importance.  Froelich  has 
shown  that  instead  of  the  symptom-complex  termed 
acromegaly,  lesions  of  the  hypophysis  may  be  asso- 
ciated with  an  adipositas  universalis  and  genital 
atrophy.  In  other  words,  hypopituitarism  may  lead 
to  adipositas.  Further,  curious  and  remarkable  inter- 
relations of  function — seemingly  antithetical — appear 
to  exist  between  the  pituitary  and  the  pineal  gland, 
the  pineal  gland  appearing  to  have  a  fat  producing 
and  a  fat  destroying  function  inversely  to  the  pitui- 
tary. For  a  detailed  presentation  of  the  subject, 
which  here  would  lead  us  too  far  afield,  the  reader  i< 
referred  to  Otto  Marburg's  interesting  paper  on 
"  Adiposis  Cerebralis,  a  contribution  to  our  knowledge 
of  the  pathology  of  the  pineal  gland."5 

If  the  pituitary  is  diseased  in  adiposis  dolorosa,  it  is 
not  surprising  that  changes  should  also  be  found  in 
the  thyroid;  it  is  unnecessary  to  point  out  that  these 
two  glands  are  closely  interrelated  as  regards  their 
function.  Experimental  extirpation  of  the  thyroid 
in  animals  has  been  found  to  be  followed  by  pituitary 
enlargement;  it  would  seem  that  disease  of  one  gland 
would  mean  sooner  or  later  disease  of  the  other. 

An  examination  of  the  fatty  deposits  reveals  not 
only  the  structure  of  fatty  tissue,  but  also  the  signs 
of  great  nutritional  activity.  Fragments  removed 
during  life  by  the  Duchenne  trocar  in  the  writer's 
first  case  and  submitted  to  microscopical  examina- 
tion presented  the  appearance  of  a  connective-tissue 
embryonal  in  type.  The  cells  were  voluminous,  fusi- 
form, and  containing  large  nuclei  while  the  inter- 
cellular spaces  were  filled  by  a  transparent  substance 
apparently  without  structure.  On  the  whole  the 
appearance  was  that  of  a  lymphoid  tissue.  In  some 
fragments  fat  cells  were  numerous  and  among  these 
were  cells  which  evidently  had  not  undergone  com- 
plete fatty  transformation.  In  the  autopsy  recorded 
by  Dercum  and  McCarthy,  the  fatty  nodules  were 
submitted  to  microscopical  examination. 

The  capsule  was  composed  of  several  layers  of  well- 
developed  connective  tissue.  Within  this  capsule  a 
looser  areolar  tissue  was  met.  This  tissue  was  highly 
vascular,  and  between  the  vessels  was  a  reticular 
tissue,  denser  in  some  areas  than  others  and  inclosing 
a  large  number  of  mononuclear  cells,  a  few  pi 
nuclear  cells,  and  large  numbers  of  cells  stained  a 
tawny  color  by  the  Van  Gieson  stain.  Scattered 
through  the  granular,  tawny  masses,  many  of  the 
mononuclear  type  of  cells  could  be  found.  In  other 
areas,  granules  of  blood  pigment  in  clumps  could  be 
seen.  Wherever  the  connective-tissue  trabecule 
penetrated  into  the  congested  fat  nodule,  this  same 
fine,  reticular  structure,  holding  in  its  meshes  rich 
plexuses  of  blood-vessels,  and  between  these  a  fine 
reticulum  of  connective  tissue  filled  with  a  light 
yellow  granular  material,  with  nucleated  yellow  cells, 
small  mononuclear  cells,  polynuclear  cells,  and  num- 
bers of  degenerating  red  blood  cells,  could  be  seen. 
Some  of  these  cells  reacted  to  many  of  the  staining 
reagents  as  do  nucleated  red  blood-corpuscles,  but 
to  the  Biondi-Ehrlich  triple  stain  they  appeared 
more  as  mononuclear  leucocytes. 

Diagnosis. — The  diagnosis  of  adiposis  dolorosa  is 
exceedingly  simple.  It  is  based  upon  the  presence 
of  pain — spontaneous,  paroxysmal  or  elicited  by  ma- 
nipulation— in  fatty  masses  having  the  physical  pecu- 
liarities described  above.  The  affection  is  readily 
differentiated   from   myxedema  because  of  the  non- 


132 


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Adirondacks 


juvoh  cmenl  of  Ilii"  face  .-iml  hands  and  because  u!  I  he 

absence  of  pain  in  myxedema.  When  the  tumor 
masses  arc  numerous  and  quite  small,  they  may 
suggest  von  Recklinghausen's  disease,  i.e.  neurofibro- 
matosis, but  the  fact  that  the  nodules  arc  found  to  be 
tabulated  under  palpation,  that  they  are  spontane 
ously  painful  and  almost  never  occur  on  the  face  or 
hands  serves  to  make  the  differentiation;  again  in 
neurofibromatosis,  the  tumor  masses  are  only  later- 
ally mobile;  they  are  small,  very  hard,  and  often 
grouped  along  the  course  of  the  nerve  trunks  like  a 
string  of  beads.  In  adiposis  dolorosa,  the  tumors 
are  mobile  in  all  directions  and  are  irregularly 
distributed. 

The  differentiation  between  adiposis  dolorosa,  and 
simple  obesity  lies  in  the  fact  that  in  the  latter  affec- 
the  fat  is  distributed  throughout  all  the  tissues 
does  not  heap  itself  up  in  separate  lipomatous 
ma  ises  such  as  is  the  case  in  adiposis  dolorosa,  oven 
in  the  so-called  diffuse  form.  Besides  there  is  an 
absence  both  of  pain  and  of  crises  of  any  kind. 
( Ordinary  obesity  is  painless  ami  is  a  matter  of  gradual 
development,  while  the  peculiar  paroxysmal  charac- 
ter presented  by  both  the  pain  and  the  swellings  of 
adiposis  dolorosa  is  unmistakable. 

Prognosis. — The  affection  is  essentially  chronic.  It 
lasts  as  a  rule  for  many  years.  Eventually,  however, 
a  bedridden  period  sets  in,  general  exhaustion  super- 
penes,  degeneration  and  failure  of  the  heart  muscle, 
pulmonary  congestion,  or  disease  of  the  kidneys  may 
terminate  the  picture.  It  must  be  borne  in  mind 
also  that  these  patients  present  a  greatly  diminished 
resistance  to  infection. 

When  the  affection  is  in  the  early  stage,  the  out- 
look is  much  less  gloomy;  indeed  at  times  the  prog- 
nosis is  distinctly  favorable.  Early  cases  are  dis- 
tinctly amenable  to  improvement  and  indeed  an 
arrest  of  symptoms  or  relative  cure  may  sometimes 
be  brought  about.  Cases  far  advanced,  with  ex- 
tensive deposits  and  presenting  marked  asthenia  and 
especially  when  complicated  with  a  tendency  to 
Subcutaneous  hemorrhages  and  hemorrhages  from  the 
mucous  membranes  are  very  unpromising;  indeed,  in 
such  cases  treatment  proves  to  be  of  little  avail. 

Treatment. — In  cases  in  which  the  disease  is  not 
too  far  advanced,  the  writer  has  had  marked  success 
by  employing  the  following  measures.  First  he  places 
the  patient  in  bed,  secondly  he  withdraws  as  far  as 

Eossible  the  carbohydrates  from  the  diet,  and  thirdly 
e  administers  cautiously  but  in  increasing  doses, 
thyroid  extract;  beginning  usually  with  one  grain, 
three  times  daily,  and  increasing  to  three  grains,  three 
times  daily — rarely  five  grains.  In  order  to  control  the 
pains,  he  has  made  liberal  use  of  aspirin  or  novaspirin. 
At  times  he  has  fallen  back  upon  sodium  salicylate 
with  sodium  bromide  in  full  doses,  especially  during 
paroxysms  of  pain.  As  a  rule  these  measures,  if 
persisted  in  for  several  weeks  or  better  still  for  a 
number  of  months,  are  followed  by  a  marked  loss  of 
weight  and  a  marked  subsidence  of  pain.  In  three 
of  the  writer's  cases  the  improvement  was  both 
marked  and  persistent;  in  two  a  permanent  arrest  of 
symptoms  ensued. 

The  rest  should  be  absolute  and  should  extend  over 
several  months.  The  patient  should  be  weighed 
when  treatment  is  begun,  and  at  intervals  thereafter. 
Jt  should  be  remembered  that  a  diet,  no  matter  how 
rigid,  will  of  itself  make  no  impression  in  adiposis 
dolorosa;  it  will  fail  absolutely.  It  is  of  course  wise 
to  institute  a  careful  diet,  but  patients  do  better 
when  the  diet  is  not  too  strict.  Inasmuch  as  the 
affection  is  attended  by  a  marked  asthenia,  the  diet 
should  be  nutritious  It  should  consist  of  the  red 
meats  in  moderation,  the  white  meats  freely,  the 
succulent  vegetables,  eggs,  and  skimmed  milk.  The 
latter  can  be  used  between  meals  and  if  necessary 
also  at  meal  times. 

As  soon  as  the  tenderness  permits,  gentle  massage 


should  be  instituted;  sometimes  this  can  never  be 
employed,  in  other  eases  it  can  be  instituted  com- 
paratively early  and  there  can  be  no  doubt  thai  in  a 
measure  it  favors  the  diminution  of  the  swellings, 
especially  if  the  patient  can  bear  deep  kneading. 
Bathing  between  blankets  as  in  ordinarj  m  i  treat- 
ment should  also  be  carried  out,  but  of  themselves 

baths  accomplish  nothing  in  adiposis  dolorosa;  in- 
deed the  physical  exertion  and  manipulation  attend- 
ant upon  the  application  of  ordina  ry  hydrotherapeutio 

measures  in  these  cases  exhaust    the  patient. 

The  treatment  should  extend  over  a  period  of 
many  months  and    the  patient    should   be   kept    under 

observation  for  several  years.  F.  X.  Derci  m, 

I:  i   FEUENCES. 

1.  Vitaut:     Maladie  de  Dcrcum.     Thesede  Lyon,  [901. 

2.  Frankenheimer:     .tour.  Amer.  Med.  Asso.,  1908,  i..  p.  1012. 

3.  Price:     Amer.  Jour.  Med    Sciences,  May,  1909, 

4.  Leon  Poirier:      La  Maladie  deDercum.MontpelHer,    1910. 

5.  Marburg:  Deutsche  Zeitschrift  fur  Nervenheilkunde,  1908. 
Bd.  xxxvi  p.  111. 

Adiposity. — See  Obesity. 

Adirondacks. — This  extensive  forest  and  lake 
region  is  a  plateau  studded  with  mountains  and  lakes 

:d  situated  in  Northern  New  York,  between  lat.  42° 
30'  and  I  1  30',  long.  74°  to  7.5°  30'  W.,  being,  roughly 
e  timated,  1  25  miles  square. 

The  average  elevation  is  1,000  feet,  the  mountain 
peaks  varying  from  2,000  to  5,000  feet,  trending  in 
general  toward  the  southwest  in  several  irregular 
ranges.  The  northern  and  southern  boundaries  are 
gradual  slopes  to  the  St.  Lawrence  and  Mohawk  valleys 
respectively,  while  the  eastern  is  more  abrupt  to  Lakes 
George  and  Champlain,  and  the  western  less  so  to 
Lal^e  (  intario. 

Geologically,  this  region  is  related  to  the  Archean  or 
earliest  formation,  with  glacial  drift  and  moraines 
much  in  evidence.  The  soil  is  chiefly  light  sand, 
which  forms  a  feature  of  importance  in  determining 
the  climate  and  character  of  the  forest  growth. 

The  lake  shores,  lowlands,  and  valleys  are  wooded 
chiefly  with  fir,  pine,  white  cedar,  tamarack,  red 
spruce,  and  balsam.  The  lesser  elevations  and  foot- 
hills have  deciduous  trees  in  greater  proportion,  such 
as  sugar  maple,  birch,  beech,  poplar,  mingled  with 
a  few  evergreens,  while  the  majority  of  the  peaks  are 
wooded  to  the  top  with  firs  and  spruces. 

The  combination  of  dark-green-clad  mountains  and 
numerous  island-dotted  lakes  gives  at  all  seasons  a 
landscape  of  great  beauty. 

Large  tracts  of  forest  are  owned  by  the  State  and 
individuals  for  permanent  preserves,  insuring  pro- 
tection for  fish  and  game  and  conserving  the  water 
supply.  Temporary  camps  are  permitted  on  Stale 
land,  and  during  the  trout  and  deer  seasons  great 
numbers  of  sportsmen  find  delight  in  these  haunts. 
Modern  camp  life  for  the  invalid  or  convalescent  in 
the  Adirondacks  is  a  pleasure  hardly  surpassed,  when 
all  the  luxuries  are  available. 

The  climate  has  long  been  noted  for  its  invigorating 
qualities.  The  winters  are  usually  cold  and  dry,  the 
summers  cool  but  moist,  though  relatively  dryer  than 
coast  climates  or  lowlands. 

The  porous  soil,  elevation,  and  coolness  render  the 
moisture  less  apparent,  though  the  rains  are  very  fre- 
quent in  summer.  Meteorological  data  for  a  number 
of  years  are  now  available  for  the  comparison  of 
different  sections  of  the  plateau.  The  mean  annual 
temperature  for  the  whole  region  is  42. s°  F. ;  average 
total  precipitation,  forty-two  inches. 

The  prevailing  winds  are  west  and  southwest,  being 
much  varied  and  retarded  by  the  mountains  and  im- 
mense areas  of  forest.  The  coast  winds  do  not  reach 
inland  far  enough  to  affect  the  climate,  but  Lake 
( intario  modifies  the  western  slope,  while  the  northern 
part  is  influenced  more  by  the  St.   Lawrence  valley 

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winds,  which,  especially  in  winter,  sweep  across  the 
level  plains  of  Canada  from  the  west. 

The  precipitation  is  greater  on  the  southern  and 
western  slopes  than  in  the  interior  and  northern 
portion  of  the  Adirondack  plateau,  though  local  con- 
ditions appear  to  influence  the  amount  greatly.  Thus 
at  Saranac  Lake,  in  the  northern  center,  the  average 
annual  precipitation  is  thirty-four  inches,  yet  in  the 
foii'st,  within  a  few  miles,  it  is  manifestly  much 
greater.  At  the  same  place  the  annual  mean  tem- 
peral  lire  was  41.7°  F.,  and  for  the  four  winter  months 
19.5°  F.,  with  an  average  of  ten  rainy  days  for  the 
winter.     The  mean  summer  temperature  was  62°  F. 

Quoting  from  the  Annual  Report  of  the  New  York 
Weather  Bureau,  1896:  "The  Adirondack  plateau  is 
subject  mainly  to  the  same  influences  which  deter- 
mine the  climate  of  the  St.  Lawrence  valley,  excepting 
that  the  central  and  eastern  portions  of  the  highlands 
are  not  reached  by  the  lake  winds.  A  very  broken 
and  heavily  timbered  surface  offers  great  obstructions 
to  the  circulation  of  air  currents,  and  hence  the 
summer  temperature,  although  the-  lowest  in  the 
State,  is  somewhat  higher  than  would  otherwise  be, 
due  to  the  elevation  of  the  region.  ***** 

"  So  far,  then,  as  present  records  show,  the  whole  of 
Northern  New  York  has  substantially  the  same 
average  winter  temperature,  except  as  certain  deep 
valleys  are  subject  to  a  local  cooling  through  an  accu- 
mulation of  the  colder  and  denser  air.  In  summer  the 
warmth  of  the  highlands  decreases  at  about  0.3  degree 
per  hundred  feet  of  elevation  above  sea  level,  and 
the  average  temperature  of  the  Adirondack  region  at 
that  season  is  thus  reduced  to  nearly  the  same  level 
as  that  which  prevails  on  the  seacoast  of  Northern 
Maine;  the  days,  however,  being  wanner  and  the 
nights  cooler  than  in  the  coast  region." 

There  is  an  excess  of  cloudy  weather  in  November, 
December,  April,  May,  and  frequently  at  other 
seasons;  the  virtues  of  the  climate  being  attributable 
to  coolness,  altitude,  aseptic  atmosphere,  and  freedom 
from  dust,  rather  than  to  the  amount  of  sunshine. 

The  suitability  of  the  climate  for  the  cure  of  early 
tuberculosis  has  been  amply  demonstrated,  and  arrest 
or  amelioration  of  advanced  cases  is  secured  by  a 
prolonged  residence,  when  the  powers  of  resistance  can 
be  stimulated.  It  has  been  found  beneficial,  particu- 
larly in  summer,  for  chronic  bronchitis  and  asthma 
dependent  upon  it,  also  for  hay  fever.  The  winter 
is  equally  good,  if  not  better,  for  early  tuberculosis. 
It  is  unsuited  for  rheumatics,  renal  cases,  and  patients 
beyond  middle  life. 

The  principal  resort,  Saranac  Lake,  is  generally 
known  because  of  the  Adirondack  Cottage  Sanitarium, 
founded  by  Dr.  E.  L.  Trudeau,  for  tuberculous 
patients  of  moderate  means.  This  establishment  has 
one  hundred  rooms,  and  was  the  first  people's  sana- 
torium of  its  kind  in  America.  Twenty-five  per  cent 
of  all  cases  and  from  sixty  to  seventy-five  per  cent, 
of  the  incipient  class  are  discharged  apparently  cured. 

A  list  of  the  various  resorts  in  the  Adirondack 
region  with  their  respective  elevations,  is  appended. 
Further  information  can  be  found  in  Solly's  "  Medical 
Climatology,"  in  Knopf's  "Pulmonary  Tuberculosis," 
in  nuicis  book  ,  etc. 


Resort.  Elevation. 

Mini,-  Lake 1,535  feet. 

Lake  Placi.l 1,863  feet. 

Tupper  Lake 1,546  feet. 

Keene 1,000  feet. 

I  llizahethtown 759  feet. 

Old  Forge  1,684  Fei  t 

full,  in  Chain 1,700  feet. 

Paul  Smith's 1,623  feet, 

Saranac  Inn 1,560  feel. 

North  Elba                 1,68  i 

Chazy  Lake  1,500  feet. 

Blue  Mountain  Lake 1.S00  feet. 

Schroon  Lake 806  feet. 


During  the  past  ten  years  numerous  public  and 
private  institutions  have  been  established  in  and 
about  Saranac  Lake.  The  most  important  are  the 
New  York  State  Hospital  for  Incipient  Tuberculosis 
situated  at  Raybrook,  two  miles  east  of  Saranac 
Lake;  capacity,  350;  free  to  residents  of  New  York 
State.  Stony  Wold  Sanatorium,  Lake  Kushaqua, 
N.  Y. ;  women  and  children;  capacity,  100;  semi- 
charitable.  Sanitarium  Gabriels,  Gabriels,  N.  Y.; 
capacity,  sixty;  semicharitable. 

E.  R.  Baldwin. 


Adolescence. — The  term  adolescence  denotes  that 
portion  of  an  individual's  life,  vegetal  or  animal, 
during  which  it  is  becoming  adult  or  mature.  The 
Latin  term  adolescere  seems  to  have  been  allied  to 
alere,  to  nourish,  and  this  idea  still  enters  the  general 
notion  of  adolescence  as  the  period  of  growth  and  full 
development.  For  the  majority  of  English-speaking 
people,  at  least,  this  term  covers  the  period  between 
the  ages  of  fourteen  and  twenty-five  in  males,  and  in 
females  twelve  and  twenty-one.  It  includes  therefore 
puberty  and  years  following  puberty  until  the  menial 
and  physical  aspects  of  the  adult  may  reasonably  be 
said  to  have  become  complete. 

Individual  differences  are,  however,  here  as  uni- 
versally elsewhere,  conspicuous,  and  the  practitioner 
is  bound  to  keep  in  mind  the  well-known  fact  that  any 
particular  patient  may  be  either  precocious  or  re- 
tarded. These  differences  appear  on  the  surface  of  the 
literature  to  be  more  common  in  girls  than  in  boys, 
for  many  instances  of  sexual  maturity,  as  indicated  at 
bast  by  menstruation,  fully  developed  breasts  and 
other  sexual  organs,  etc.,  have  been  reported  in  indi- 
viduals only  a  few  years  or  even  a  few  months  of  age. 
Retarded  adolescence  is  probably  still  more  common 
but  with  far  less  disastrous  results  usually  to  the 
future  happiness  of  the  woman.  The  physical  signs 
of  puberty  and  later  adolescence  are  generally  so 
conspicuous  that  little  chance  of  harmful  error  in  any 
bodily  direction  normally  exists.  In  those  rarer 
eases,  however,  in  which  the  mental  efficiency  ami 
capabilities  are  uncorrelated  to  the  physical  evolu- 
tion, mistakes  with  unfortunate  consequences  are 
liable  to  be  made  by  teachers  and  by  parents.  This 
diseorrelation  is  a  subject  that  needs  scientific 
study. 

As  writers  have  pointed  out  repeatedly,  this  pre- 
eminently important  whole  period  of  life,  likewise, 
has  as  yet  received  but  a  small  part  of  the  study  and 
research  it  deserves;  but  there  are  indications  that 
physiologists,  psychologists,  and  hygienists  are  at 
last  awakening  to  their  dutiful  privilege  in  this  respect. 
President  G.  Stanley  Hall  is  the  one  conspicuous 
exception  to  this  generality,  so  much  so  indeed  that 
his  treatise  ("Adolescence,"  1907)  is  likely  to  remain 
for  some  years  yet  the  magnum  opus  in  this  particular 
scientific  field,  much  as  is  Havelock  Ellis's  "Psy- 
chology of  Sex,"  in  that  somewhat  closely  allied  sub- 
ject. The  present  writing  is  much  indebted  to  both 
of  these  compendiums,  especially  to  the  former,  ami 
to  them  the  reader  is  respectfully  referred  for  greater 
wealth  of  detail  and  statistics.  If  one  search  the 
medical  libraries  for  adequate  information  on  the 
physiology  and  pathology  of  adolescence,  one  will  he 
properly  surprised  at  the  contrast  between  the  abun- 
dance of  publications  on  childhood  and  their  paucity  in 
relation  to  the  no  less  important  developmental  con- 
ditions of  adolescence.  One  of  the  pressing  needs  in 
medical  literature  is  a  really  adequate  exposition 
of  this  subject  detailed  with  special  reference  to 
every  phase  of  the  professional  theory  and  practice; 
this  would  afford  one  more  set  of  adaptations  of 
the  general  principles  of  Medicine  to  particular  con- 
ditions. 

Somatology. — It   is   customary   in   discussions  of 


134 


REFERENCE    HANDBOOK   OF   THE    MEDICAL    SCIENI  I  3 


Adolescence 


puberty  to  devote  considerable  care  and  space  to  the 
tabulation  of  statistics  on  growth,  growth  of  tissues, 
of  organs,  and  of  Individuals,  sel  forth  in  about  every 
useful  way  both  in  absolute  numbers  and  in  percental 
relationships.  So  frequently  of  late  have  summaries 
of  these  averages  been  published  in  many  kinds  of 
books  that  it  seems  unnecessary  to  reproduce  them 
at  length.  Stanley  Hall  speaks  of  about  sixty  such 
iv  valuable  memoirs  and  tabulations"  of  growth. 
for  a  summary,  F.  Burk:  American  Journal  of 

hology.  April,  1898,  pp.  253-326.)  As  respects 
stature,  the  table  made  out  by  Prof.  Franz  Boas  of 
Columbia  from  his  own  measurements  and  those  i 
Bowditch,  Porter,  Peckham,  and  West,  of  45,151 
boys  and  43,298  girls  resident  in  Boston,  St.Louis, 
Milwaukee,  Worcester,  Toronto,  and  Oakland,  is  of 
fundamental    value    and    is,    therefore,    here    repre- 

d  as  the  American  standard  at  the  ages  repre- 
sented: 


Growth 


Number  at 
each  age 

Height 

Weight 

Vgi 

Actual, 

. 

ental 

in  nun 

■ 

in  kilns 

hut' 

16 

30 

37 .  23 

2    15 

8.01 

1  I..-.1 

17 

I  ;i 

2  )  76 

1.15 

18 

211 

0.70 

1 .  56 

7.  11 

19 

153 

7  99 

0 

3.18 

5.49 

20 

73 

7.69 

0.50 

5.29 

21 

•1!) 

6    in 

0.34 

2  s7 

5.60 

22 

27 

5.22 

,      , 

23 

12 

1.92            0.26 

3 .  1 5 

21 

13 

0.16 

1 .  92 

3.02 

25 

i 

1.28            2.42 

6.18 

12.76 

.71) 

1.19 

8    l-'i 

Boys. 

lirls. 

Approxi- 

mate 
average 

Number  of 

Average  height 

Absolute  an- 

Percental 

Number  of 

'■•  height 

Absolute    an- 

Percental 

observations 

for  each  year, 

nual  increase, 

annual 

observations 

ch  year, 

nual  increase. 

annual 

• 

inches. 

inches. 

increase. 

inches. 

inche 

increase. 

.". . ') 

1 ,535 

41.7 

2    . 

5.3 

1,260 

41.3 

2.0 

4.8 

6.5 

3,975 

43.9 

2.1 

l.s 

3.61S 

43.3 

2.4 

5.5 

i  ..> 

5.379 

46.0 

_'    s 

6.1 

4.913 

45.7 

2.0 

4.4 

8 . 5 

5,633 

IS     S 

1.2 

2.5 

5.2S9 

47.7 

2.0 

4.2 

9.5 

5,531 

50.0 

1.9 

3.8 

5,132 

49.7 

2.0 

4.0 

5,151 

51 . 9 

1.7 

3.3 

1,827 

51.7 

2.1 

4.1 

ll..r) 

1,759 

53.6 

l.S 

3.4 

1,507 

53.8 

2.3 

4.3 

12.5 

I.-'  15 

55.4 

2.1 

3.8 

4,187 

56.1 

2.4 

4.3 

13.5 

3,57)  1 

..» i  . . » 

2.5 

4.3 

3.411 

58.5 

1.9 

3.2 

14.5 

2,518 

60.0 

2.9 

4.8 

2,537 

60.4 

1.2 

2.0 

15.5 

1.481 

62.9 

2.0 

3.2 

1 ,656 

61.6 

0.6 

1.0 

16  5 

753 

64.9 

1.6 

2.5 

1.171 

i.J   J 

0.5 

O.S 

17.5 

129 

66.5 

0.9 

1.4 

790 

62 . 7 

229 

67.  t 

As  concerns  weight,  Burk's  table,  made  from  the 
weighing  of  69,000  children  in  Boston,  St.  Louis, 
and  Milwaukee  by*  the  same  observer-,  is  as  follows: 


The  relative  sizes  and  activities  of  the  various 
tissues  and  organs  characteristic  of  adolescence, 
although  of  importance  to  the  physician  very  often 


Boys. 


Girls 


Age 

Average  for  each 

\  1  isi  ilute  annual 

Percental  annual 

Average  for  each 

Al  isolute  annual 

Percental  annual 

age,  pounds. 

increase,  pounds. 

increase. 

age,  pounds. 

increase,  pounds. 

increase. 

6.5 

45.2 

43.4 

7.5 

49.5 

4.3 

9.5 

47.7 

4.3 

9.9 

8.5 

54.5 

5.0 

10.1 

52.5 

4.8 

10.0 

9.5 

59.6 

5.1 

9.3 

57.4 

4.9 

9.3 

10.5 

65.4 

5.8 

9.7 

62.9 

5.5 

9.6 

11.5 

70.7 

5.3 

8.1 

69.5 

6.6 

10.5 

12.5 

76.9 

6.2 

S.7 

78.7 

9.2 

13.2 

13.5 

84.8 

7.9 

10.3 

■s.S.7 

10.0 

12.7 

14.5 

93.2 

10.4 

12.3 

9S.3 

9.6 

11.9 

15.5 

107.4 

12.2 

12.8 

106.7 

S.4 

S.5 

16.5 

121.0 

13.6 

12.7 

112.3 

5.6 

5.2 

17.5 

115.4 

3.1 

2.8 

18.5 

114.9 

The  late  Professor  Edward  Hitchcock  of  Amherst 
College,  the  American  pioneer  in  this  work  and  in 
other  work  relating  to  physical  education,  measured 
T4J  different  students  (males),  at  that  institution, 
belonging  to  the  classes  between  1885  and  1901  and 
summarized  the  results  as  in  the  following  table.  This 
obviously  is  complementary  to  the  preceding  tables, 
for  it  takes  the  development  to  the  full  limits  of  the 
time  of  average  adolescence 


for  purposes  of  accurate  diagnosis  and  the  general 
understanding  of  conditions,  is  too  long  and  compli- 
cated a  matter  for  insertion  here,  consisting  as  it  does 
of  very  numerous  facts  and  statistics  from  which  it 
would  be  difficult  to  choose.  Stanley  Hall's  monograph 
already  referred  to  contains  the  most  complete  exposi- 
tion of  the  subject  known  to  the  present  collaborator, 
occupying  seventy-eight  pages  of  the  first  volume  of 
the  work;  to  this  compilation  the  reader  is  referred. 

135 


Adolescence 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Psychology. — The   mental   characteristics   of   the 

adolescent  receive  everywhere  extensive  description, 
of  course,  incidentally  in  fiction,  and  have  been  dis- 
cussed more  intensively  but  unsystematically  by  many 
competent  scientists,  and  of  late  still  more  technically 
through  knowledge  gained  by  the  new  method  of 
psychoanalysis.  None  of  the  scientific  accounts  is 
truer  to  the  life  than  that  of  G.  Stanley  Hall  and 
therefore  we  shall  not  hesitate  to  quote  from  him, 
first  reminding  the  reader  that  many  of  these  psy- 
chological considerations,  some  of  them  general  and 
hard  to  analyze  as  they  are,  are  of  preeminent  impor- 
tance in  medical  affairs  of  many  kinds,  somatic  as  well 
as  those  more  psychical  in  classification.  In  adoles- 
cence, fully  as  much  as  elsewhere  in  the  life  time, 
bodily  and  mental  relations  are  interdependent  and 
inseparable,  neither  being  fully  understandable  with- 
out knowledge  of  the  other,  for  each  is  part  and  par- 
cel of  one  indivisible  personality.  It  is  high  time  the 
medical  profession  put  this  basal  fact,  so  fully  realized 
as  true  by  every  observant  and  educated  student  of 
humanity,  into  practice  and  used  it  habitually  as  a 
principle  of  diagnosis  and  of  treatment,  as  already 
indeed  do  the  most  broadly  educated  of  our  physicians, 
more  and  more.  Nowhere  more  than  in  adolescence 
i-  this  interdependence  of  dependent  variables  con- 
spicuous and  important,  both  mind  and  body  being 
then  eminently  plastic  and  impressionable  to  stimuli 
within  and  without. 

"Psychic  adolescence,"  says  Stanley  Hall,  "is 
heralded  by  all-sided  mobilization.  The  child  from 
nine  to  twelve  is  well  adjusted  to  his  environment  and 
proportionately  developed;  he  represents  probably  an 
old  and  relatively  perfected  stage  of  race  maturity, 
still,  in  some  sense  and  degree  feasible  in  warm  cli- 
mates, which,  as  we  have  previously  urged,  stands  for 
a  long  continued  one,  a  terminal  stage  of  human  devel- 
opment at  some  post-simian  point.  At  dawning 
adolescence  this  old  unity  and  harmony  with  nature 
is  broken  up;  the  child  is  driven  from  his  paradise  mil 
must  enter  upon  a  long  viaticum  of  ascent,  must  con- 
quer a  higher  kingdom  of  man  for  himself,  break  out  a 
new  sphere,  and  evolve  a  more  modern  story  to  his 
psychophysical  nature.  Because  his  environment  is 
to  be  far  more  complex,  the  combinations  are  less 
stable,  the  ascent  less  easy  and  secure;  there  is  more 
danger  that  the  youth  in  his  upward  progress,  under 
the  influence  of  this  excelsior  motive  will  backslide  in 
one  or  several  of  the  many  ways  possible.  New 
dangers  threaten  on  all  sides.  It  is  the  most  critical 
stage  of  life,  because  failure  to  mount  almost  always 

means  retrogression,   degeneracy,  or  fall 

Youth  loves  intense  states  of  mind  and  is  passionately 
fond  of  excitement.  Tranquil,  mild  enjoyments  are 
not  its  forte.  The  heart  and  arteries  are,  as  we  have 
seen,  rapidly  increasing  in  size,  and  perhaps  heightened 
blood  pressure  is  necessary  to  cause  the  expansion 
normal  at  this  stage.  Nutritive  activities  are  greatly 
increased;  the  temperature  of  the  body  is  probably  a 
trifle  higher.  After  its  period  of  most  rapid  growth, 
the  heart  walls  are  a  little  weak,  and  peripheral  circu- 
lation is  liable  to  slight  stagnation,  so  that  in  the 
interests  of  proper  irrigation  of  the  tissues  after  the 
vascular  growth  has  begun,  tension  seems  necessary. 
Although  we  do  not  know  precisely  the  relation  be- 
tween blood  pressure  and  the  strong  instinct  to  tingle 
and  glow,  some  correlation  may  safely  be  postulated. 
Ii  is  the  age  of  erectile  diathesis,  and  the  erethism 
that  is  now  so  increased  in  the  sexual  parts  is  probably 
more  or  less  so  in  nearly  every  organ  and  ti-  lie 
The  whole  psychophysic  organism  is  expanding, 
stretching  out,  and  proper  elasticity  that  relaxes  and 
contracts  and  gives  vasomotor  range  is  coordinated 
with  the  instinct  for  calenture  or  warming  up,  which 
is  shown  in  phenomena  of  second  breath  in  both  phys- 
ical and  mental  activity.  In  savage  life  this  period 
is  marked  by  epochs  of  orgasm  and  carousal,  which  is 
perhaps  one  expression  of  nature's  effort  to  secure  a 

136 


proper  and  ready  reflex  range  of  elasticity  in  the  cir- 
culatory apparatus.  The  "teens"  are  emotionally 
unstable  and  pathic.  It  is  the  age  of  natural  inebria- 
tion without  the  need  of  intoxicants,  which  made 
Plato  define  youth  as  spiritual  drunkenness.  It  is  a 
natural  impulse  to  experience  hot  ami  perfervid 
psychic  states,  and  is  characterized  by  emotionalism. 

We  here  see  the  instabity  and  fluctuation 

now  so  characteristic.  The  emotions  develop  by 
contrast  and  reaction  into  the  opposite.  We  will 
specify  a  few  of  its  antithetic  impulses  now  so  marked. 
1.  There  are  hours,  days,  weeks,  and  perhaps  months 
of  overenergetic  action 2.  Closely  con- 
nected with  this  are  the  oscillations  between  pleasure 
and  pain — the  two  poles  of  life,  its  sovereign  masters. 
The  fluctuations  of  mood  in  children  are  rapid  and 

incessant 3.  Self-feeling     is     increased, 

and  we  have  all  degrees  of  egoism  and  all  form-  of 
self-affirmation.  .....  4.  Another  clearly  re- 
lated   alternation  is    that    between    selfishness    and 

altruism 5.  Closely  connected  with  the 

above  are  the  alternations  of  good  and  bad  conduct 

generally 6.  The   same   is    true    of    (he 

great  group  of  social  instincts,  some  of  which  resl 
upon  the  preceding.     Youth  is  often  bashful,  retiring. 

in    love    with    solitude 7.  Closely    akin 

to  this  are  the  changes  from  exquisite  sensitiveness 
to  imperturbability  and  even  apathy,  hard-hearted- 

ness,   and  perhaps  cruelty .s.   Curiosity 

and  interest  are  generally  the  first  outcrop  of  intel- 
lectual ability.  Youth  is  normally  greedy  for  knowl- 
edge, and  that  not  in  one  but  in  many  directions. 
9.  Another  vacillation  is  between  know- 
ing and  doing.  Now  the  life  of  the  study  chant  -. 
and  the  ambition  is  to  be  learned,  bookish,  or  there 
is  a  passion  to  read.     He  would  achieve  rather  than 

learn 10.  Less  often  we  see  one  or  more 

alternations    between    dominance    by    conservative 

and    by    radical    instincts 11.   We    find 

many  cases  of  signal  interest  in  which  there  is  a 
distinct  reciprocity  between  sense  and  intellect,  as  if 

each  had  its  nascent  period 12.  Closely 

connected  with  this  is  the  juxtaposition  of  wisdom 

and  folly We  have  already  seen  that  the 

body  growth  is  not  symmetrical,  but  to  some  extent 
the  parts,  functions,  and  organs  grow  in  succession, 
so  that  the  exact  normal  proportions  of  the  body  are 
temporarily  lost,  to  be  regained  later  on  a  new  plan. 
The  mind  now  grows  in  like  manner.  It  is  as  if  the 
various  qualities  of  soul  were  developed  successively; 
as  if  the  energy  of  growth  now  stretched  out  to  new 
boundaries,  now  in  this  and  now  in  that  direction." 

This  quotation  from  a  master  of  the  subject  is 
justified  in  the  extreme  importance  of  this  aspect  of 
the  adolescent  individual — preeminent  over  the  body, 
often  in  directions  to  which  the  physician  desires  to 
turn  his  attention  more  and  more  each  year  as  he 
gradually  learns  better  how  indivisible  is  the  psycho- 
physical nature  of  mankind.  Nowhere  else,  certainly, 
than  in  adolescence  has  the  mind,  its  feelings  and  its 
thoughts,  stronger  dominance  over  the  somatic 
phases  of  the  evolving  life — over  nutrition,  circula- 
tion, reproduction,  movement,  secretion,  the  bodily 
half  of  us  all.  Later  in  life,  body,  as  it  hardens,  tends 
more  to  dominate  mind,  but  in  adolescence  ii  i< 
eminently  impressionable  to  every  mental  influence. 
We  have  repeated  it  for  emphasis,  for  it  constitutes 
the  keynote  of  all  real  understanding  of  adolescei 

Another  inherent  factor  that  must  be  noted  con- 
cerning this  period  of  life  is  somewhat  related  to  this 
one — we  refer  to  the  rapid  growth  and  evolution  and 
activity  of  the  two-phased  individual.  This  vivacity 
of  the  whole  being,  both  as  protoplasm  and  as  com- 
plete animal,  both  as  body  and  as  mind,  makes  the 
youth  or  maiden,  as  compared  with  the  child  or  the 
adult,  much  more  apt  to  go  astray  off  the  beaten  I  nek 
of  the  average,  of  the  so-called  "  normal."  In  a  some- 
what metaphorical  sense,  it  is  a  irmtter  of  momentum. 


i;i:i  i;i:i:\ci:  ha.xuhook  of  Tin:  mfdicai.  sciences 


Adonis 


Just  as  a  rapidly  moving  oar  meets  usually  with  worse 
disaster  when  il  leaves  the  rails  than  does  one  moving 
slowly,  so  many  adolescent  conditions,  verging  at 
[ea  i  on  the  aberrant,  become  conspicuous  and 
often  distinctly  pathological,  because  of  the  rapid 
changes  going  on  in  the  living  tissues  and  in  the 
mental  action  oi  the  adolescent.  Perhaps  the  most 
conspicuous  illustration  of  this  tendency  is  to  be  seen 
in  the  distortions  of  the  skeleton  (mentioned  below). 

l'.v  iiiot.oov.  —  We  have  already  noted  the  paucity 
dual  descriptions  and  discussions  of  the  diseases, 
mental  and  bodily,  of  adolescence.  One  reason  for 
tins  has  been  the  obvious  fact,  borne  out  alike  by 
general  medical  observation  and  by  elaborate  sta- 
tistics, that  while  the  morbidity  of  adolescence  is 
large,  larger  than  thai  of  any  other  parts  of  life 
early  infancy  and  senescence,  the  mortality  of 
this  period  is  low,  in  fact  the  lowest  of  the  whole  life, 
especially  between  eleven  and  fifteen  (Hartwell). 
Another  important  reason  of  this  widespread  medical 
defect  in  the  study  of  adolescence  has  been  stated  by 
Hall  concisely  in  these  terms:  "The  general  reason 
for  this  neglect  is  that  medicine  has  been  chiefly 
concerned  with  the  study  and  practical  treatment  of 
pronounced  diseases,  and  has  not  yet  come  to  rest  on 
the  broad  basis  of  biology,  which  is  its  natural  and 
scientific  foundation.  Practitioners,  too,  have  been 
occupied,  both  at  home  and  in  hospitals,  with  grave 
cases  and  have  had  little  time  and  less  motive  to 
CorTsider  preventive  medicine  or  the  more  general 
problems  of  regimen  and  hygiene,  personal,  domestic, 
or  public.  Perhaps  occupation  with  flagrant  symp- 
toms tends  to  give  diminished  interest,  if  not  distaste, 
for  the  milder  and  incipient  manifestations  of  disease 
which  require  sharper  diagnosis  and  a  higher  quality 
of  mind  to  detect."  This  is  wisdom  of  the  highest 
practical  and  theoretic  importance,  but  these  con- 
ditions of  defect  mentioned  are  now  certainly  in 
process  of  elimination  from  all  adequate  medical 
education,  for  biology  is  rapidly  becoming  the  mother- 
science  of  scientific  medicine.  (See  for  example  the 
writer's  recent  pioneer  "Laboratory  Course  in  Phys- 
iology based  on  Daphnia  and  Other  Animalcules," 
in  the  Biologische  Zentralblatt,  Bd.  xxxii,  Nr.  o.  S. 
285  291,  May  20,  1912). 

One  large  part  of  the  pathological  conditions  of 
adolescence  is  commonly  thought  and  discussed  as 
"functional"  defects,  those  especially  that  depend 
ultimately  on  maladjustment  to  the  rapid  evolution 
of  mind  and  body  and  which  more  immediately  are 
obviously  conditions  only  a  little  beyond  fatigue 
coming  from  overuse.  Examples  of  this  that  will 
occur  to  every  reader  are  chlorosis,  eyestrains,  and 
kyphosis  (roundback). 

t  If  the  diseases  which  are  most  common  during 
adolescence  many  are  chronic  conditions  that  reach 
their  worst  later  on  in  adult  years.  Others  are  com- 
mon to  childhood  and  adolescence — holdovers,  as  it 
were,  from  their  more  proper  and  earlier  epochs  when 
the  susceptibility'  or  liability  to  them  is  greater. 

No  classification  of  the  diseases  of  adolescence  is 
adequate  owing  to  the  perfect  unification  of  the 
psychophysical  nature  of  man,  but  it  might  be  con- 
venient, none  the  less,  to  divide  them  into  classes 
more  or  less  corresponding  to  the  physiological  sys- 
tems of  the  individual.  We  should  then  have  groups 
of  infectious  fevers;  of  blood  and  circulatory  diseases; 
of  joint  and  skeletal  diseases;  of  digestive  and  meta- 
bolic diseases;  of  nervous  diseases;  of  skin  diseases; 
and  of  genital  diseases. 

The  infectious  fevers  most  often  seen  in  adoles- 
cence, perhaps,  are  pulmonary  tuberculosis  in  the 
acute  form,  rheumatic  fever,  typhoid  fever,  acute 
anterior  poliomyelitis,  rotheln  (German  measles), 
diphtheria,  mumps,  and  meningitis  in  all  its  forms. 
Of  these  typhoid  fever  is  at  its  worst  in  adolescence, 
and  the  life-ravages  of  acute  rheumatism  on  the  heart- 
valves  are  beyond  computation  in  many  parts  of  the 


world.    It  should  be  noted  that  poliomyelitis,  although 

most  unfortunately  railed  infantile  paralysis,  in  the 
recent  widespread  epidemics  has  frequently  attacked 
adolescents,  their  susceptibility  being  probably  under- 
estimated by  the  profession  as  well  as  by  the  laity, 
in  part  perhaps  owing  to  its  old-time  name. 

The  bl 1  and  circulatory  diseases,  perhaps  d 

conspicuous  between  the  ages  of  tweh  e  and  twenty- 
three,  are  simple  anemia,  chlorosis,  albuminuria, 
acute  myocarditis,  endocarditis,  tachycardia,  arrhyth- 
mia, brachycardia,  palpitation,  pharyngomyeosis, 
lymphadenitis,  epistaxis,  and  edema  "I  the  larynx 
Of  these  the  anemias  are  the  most  characteristic  of 
adolescence. 

Among  the  numerous  conditions  of  joint  at  id  bone 
disease  seen  most  frequently  at  the  age  which  we  are 
discussing,    are    scoliosis,     kyphosis,    genu    valgum, 

genu  varum,  pes  planum, acroiliac  disea  e, 

tuberculosis  ossium,  chondr a,  acromegaly,   giga 

tism,    infantilism,    and    the    rickets  of  adole  cence. 

Metabolic  diseases  proper  I  the  class  is  a  very  indefi- 
nite one  by  its  nature)  peculiar  to  adolescence  do  not 
exist,  but  among  those  most  commonly  met  with 
perhaps,  in  addition  to  those  already  noted,  are  myx- 
edema, goiter,  exophthalmic  goiter,  diabetes  insipi- 
dus, and  Addison'.-  disease.  Abnormal  conditions 
related  to  the  digestive  apparatus  more  or  less 
directly,  seen  in  adolescents,  are  dyspepsia,  gastric 
dilatation,  enteroptosis,  gastralgia,  floating  kidney, 
gastric  ulcer,  appendicitis. 

The  nervous  diseases  are  numerous  and  important, 
as  might  be  expected  from  the  unbalancing  effects  of 
the  strains  and  stresses  incident  to  the  rapid  changes 
and  violent  emotions  of  this  period  of  life.  Neuras- 
thenia, cephalalgia,  epilepsy,  catalepsy,  hysteria, 
chorea,  spasmodic  asthma,  "psychic  infantilism," 
acute  dementia,  early  stages  of  syringomyelia,  demen- 
tia precox,  cerebral  embolism,  spinal  apoplexy, 
Friedreich's  disease,  cerebellar  ataxia,  spasmodic 
spinal    paralysis,    are    among    the    most,    important. 

The  skin  diseases  of  adolescence  are  of  no  little 
practical  importance,  being  very  common,  some  of 
them,  indeed.  Acne  in  various  forms,  eczema, 
urticaria,  psoriasis,  keratosis,  lupus,  furunculosis, 
verruca  vulgaris,  seborrhea  are  among  the  most 
conspicuous  of  these. 

Gonorrhea  and  syphilis  are,  of  course,  the  most 
important  of  the  genital  diseases  of  adolescence,  with 
import  for  the  human  race  scarcely  yet  appreciated, 
even  by  our  profession. 

In  closing  this  brief  outline  of  this  significant  period 
of  life,  one  of  the  most  interesting  from  every  point  of 
view,  the  extreme  importance  of  the  new  awakening  in 
sexual  common  knowledge  of  all  kinds,  and  in  eugen- 
ics as  its  outcome,  cannot  be  too  strongly  urged.  In 
this  direction  lies  apparently  one  of  the  physician's 
most  splendid  opportunities,  for  the  very  root  of 
adolescence  is  the  sexual  evolution  and  sexual 
maturity.  George   V.  N.  Deaeborn. 

Adonidin. — Adonin.  A  glucoside  obtained  from 
several  species  of  Adonis,  chiefly  from  the  root  of  A. 
vernalis  L.  It  is  a  light-yellow  powder,  without  odor, 
but  intensely  bitter,  very  hygroscopic,  soluble  in  both 
water  and  alcohol.  Moisture  must  be  carefully  ex- 
cluded from  the  containers.  As  it  exists  in  commerce, 
it  is  a  mixture  of  variable  degree  of  purity.  Its  action 
is  described  under  Adonis.  The  dose  is  0.004  to  0.016 
gram  (grain  TV  to  \). 

Picradonidin  is  merely  the  very  pure  form  of 
adonidin.  H.   H.   Rusby. 

Adonis. — False  Hellebore  (family  Ranunculaeecc). 
The  carefully  dried  and  preserved  herb  of  Adonis 
vernalis  L.,  one  of  some  sixteen  species  in  the  genus. 

It   is   a   small    plant,    growing    wild    in    Southern 

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Europe,  and  somewhat  cultivated  as  an  ornamental 
flower.  Owing  to  the  instability  of  its  active  con- 
stituent, adonidin,  it  should  be  carefully  preserved  in 
a  cool  and  dry  place  and  should  not  be  kept  on  hand 
too  long.     The  plant  is  poisonous. 

Besides  the  active  constituent  described  above,  it 
contains  aconitic  acid  to  the  extent  of  ten  per  cent. 
The  action  of  adonis  is  apparently  due  altogether  to 
the  adonidin,  which  exists  to  the  extent  of  0.02  of 
one  per  cent.  Its  effects  are  for  the  most  part 
exerted  upon  the  circulation.  Its  first  and  chief 
action  is  to  stimulate  the  vasomotor  centers  and  thus 
greatly  increase  blood  pressure.  Next  it  stimulates 
the  heart  directly,  increasing  both  its  rate  and  force, 
and  thus  still  further  increases  the  blood  pressure. 
This  pressure  then  reacts  against  the  heart  and  may 
slow  it.  If  the  dose  is  larger,  the  inhibitory  centers 
are  stimulated,  and  this  markedly  slows  the  heart. 
The  same  causes  render  it  a  powerful  indirect  diuretic. 
The  vasomotor  stimulation  is  not  long  continued,  and 
is  succeeded  by  depression,  as  is  to  a  less  extent  the 
direct  cardiac  stimulation,  the  two  together  causing 
a  sudden  fall  in  blood  pressure.  If  the  dose  is  a 
poisonous  one,  death  will  occur  with  the  heart  in 
diastole.  Large  poisonous  doses  cause  vomiting  and 
purging.  The  treatment  of  poisoning  is  entirely 
physiological  and  symptomatic  and  is  practically  the 
same  as  in  digitalis  poisoning,  except  that  the  stage  of 
reaction  may  be  expected  much  more  quickly. 

Adonis  is  used  in  exactly  the  same  way  as  digitalis, 
as  a  cardiac  and  arterial  stimulant,  and  is  liable  to 
the  same  contraindications.  The  greatest  difference 
of  opinion  exists  as  to  which  is  preferable,  but  it 
appears  established  that  adonis,  at  least  in  the  form 
of  adonidin,  acts  more  quickly,  though  the  action  is 
not  so  prolonged,  and  is  more  apt  to  be  followed  by 
reaction.  No  attempts  have  been  made  to  ascertain 
whether  the  tissue  of  the  heart  muscle  is  permanently 
changed  in  quality  or  quantity  by  adonis,  as  appears 
to  be  the  case  with  digitalis. 

Adonis  is  best  given  in  the  form  of  tincture  or  fluid 
extract,  which  are  miscible  with  water,  or  :is  adonidin. 
The  dose  of  adonis  should  represent  0.05  to  0.25 
gram  (grain  i.  to  iv.).  It  is  best  to  begin  with  a 
small  dose  and  increase  gradually. 

H.  H.   Rushy. 

Adrenal  Glands. — See  Suprarenal  Glands. 

Adrenalin. — Trade  name  of  a  substance  derived 
by  Aldrieh  and  Takamine  in  1901  from  the  suprarenal 
glands  of  the  ox,  and  containing  the  active  principle 
of  the  internal  secretion  of  these  glands.  It  has  the 
empirical  formula  C10H15NO3  (Takamine)  or  C9H13- 
NO,  (Aldrieh),  and  occurs  as  a  grayish  or  light  brown 
finely  crystalline  powder,  of  a  somewhat  bitter  ami 
benumbing  taste,  slightly  soluble  in  w-ater,  insoluble 
in  alcohol,  ether,  and  chloroform.  The  form  in 
which  it  is  commonly  used  is  the  solution  of  adrena- 
lin chloride,  which  is  a  1-1  000  solution  of  adrena- 
lin chloride  in  physiological  salt  solution,  with  the 
addition  of  0.5  per  cent,  of  chloreton.  For  a  de- 
scription of  the  physiological  action  and  therapeutic 
uses  of  this  and  other  adrenal  gland  extracts  see 
Epinephrin  and  Suprarenal  glands. 

Aedinae. — A  family  of  mosquitos,  Culicidce,  in  which 
there  is  a  straight  proboscis,  short  palpi  in  both  sexes, 
plumose  antenna?  in  the  male  and  pilose  in  the  female. 
The  mosquitos  of  the  genera  in  this  family  are  usually 
found  in  jungles,  and  they  are  suspected  of  being  hosts 
of  the  malarial  germ  and  also  carriers  of  Filaria  es- 
pecially F.  perstans.     See  Insects,  poisonous. 

A.  S.  P. 

Aegidius  Corboliensis,  Petrus. — Pierre  Gilles  de 
Corbeil,  as  he  was  known  in  France,  was  born  in  the 


twelfth  century.  He  studied  medicine  at  Salernum, 
in  Italy,  was  the  regular  medical  attendant  of  Philip 
Augustus,  and  was  a  professor  in  the  Medical  Faculty 
of  Paris.  His  writings  on  various  medical  topics  (on 
the  urine,  on  the  arterial  pulse,  on  compound  drugs, 
and  on  the  signs  or  indications  of  disease)  were  gener- 
ally accepted,  for  a  long  period  of  years,  as  of  the  highest 
authority.  Printed  editions  were  issued  at  Padua 
Mist),  at  Venice  (1494),  at  Lyons  (1505,  1515, 
1526),  and  at  Basle  (1529).  Some  idea  of  the  import- 
ance attached  to  the  writings  of  Aegidius  may  lie 
formed  from  the  fact  that  an  entirely  new  edition  of 
the  first  three  works  mentioned  above  was  printed  at 
Leipzig  as  recently  as  in  1S26.  A.  H.  B. 


Aerophagy. — Aerophagia,  from  ii/p,  air,  +4>iyw, 
1  eat.  This  term  has  come  into  general  use  quite 
recently,  not  being  mentioned  in  Gould's  Dietianary 
of  1904,  though  frequently  encountered  in  periodicals 
early  in  the  present  century.  It  is,  however,  practi- 
cally identical  with  the  habit  of  cribbing  in  horses, 
long  and  well  known,  and  under  various  designations 
has  been  described  in  human  beings  for  many  years. 
For  the  most  part,  however,  it  has  been  confused  with 
ordinary  belching  of  gas  formed  in  the  stomach. 

The  inclusion  of  some  air  in  food,  drink,  and  secre- 
tions swallowed  is  inevitable,  especially  during  hasty 
eating  and  drinking  and  in  continued,  forcible 
attempts  to  clear  the  throat  of  mucus.  The  amount 
included  seems  to  depend  upon  the  conformation  of 
the  fauces  and  pharynx.  The  subsequent  belching 
of  at  least  part  of  the  air  thus  swallowed  is  a  normal, 
conservative  process. 

True  aerophagia  is  a  habit  neurosis  of  two  quite 
distinct  types:  (1)  The  literal  swallowing  of  air  and 
its  subsequent  eructation;  (2)  an  inspiratory  spasm 
with  closure  of  the  glottis — hiccough  or  singultus— 
with  the  added  feature  that  for  some  unexplained 
reason,  the  esophagus  becomes  patulous  and  dis- 
tended  under  the  thoracic  suction  due  to  the  action 
of  the  diaphragm  and  extrinsic  muscles. 

The  inclusion  of  the  second  type  is  justified,  partly 
because  the  essential  pathological  element  is  the  habit 
and  the  symptoms  are  similar;  still  more  because  of 
the  gradual  transition  from  the  former  to  the  latter 
type  through  (a)  the  combined  (obviously  not  syn- 
chronous) occurrence  of  swallowing  and  sighing;  \l>) 
the  interruption  of  the  sigh  by  a  closure  of  the  glottis; 
(c)  the  suction  of  air  into  the  esophagus  almost 
without  deglutitional  movements. 

Normal  aerophagia  implies  the  entry  of  air  into  the 
stomach.  Whether  air  enters  the  stomach  or  not  in 
the  first  type  of  pathological  aerophagia,  depends  on 
the  distensibility  or  actual  dilatation  of  the  esophagus 
(the  last  a  rare  complication),  and  the  length  of  the 
deglutition  stage.  The  patient,  almost  always — and 
the  physician  often — is  unaware  of  this  stage  and 
hence  regards  the  condition  as  an  eructation  of  gases 
developing  in  the  stomach  itself.  Cases  in  which  only 
one  or  two  swallows  are  taken,  followed  by  the 
eructation  of  a  mouthful  (approximately  fifty  cubic 
centimeters)  of  air,  do  not  usually  furnish  deglutition 
sounds  at  the  cardia  and  probably  no  air  reaches  the 
stomach.  When  the  two  stages  are  both  prolonged 
auscultation  usually  shows  that  air  enters  the  stomach 
and,  even  if  this  sign  is  absent,  a  large  quantity  of  air 
must  have  been  thus  stored,  unless  the  esophagu-  is 
considerably  dilated.  The  more  closely  cases  approach 
the  second,  singultic,  type,  the  less  likelihood  is  there 
of  penetration  of  air  into  the  stomach.  The  question 
must,  therefore,  be  determined  for  each  case  and  it 
must  not  be  forgotten  that  as  there  is  always  con- 
siderable gas  developed  in  the  intestine  and  not  very 
rarely  in  the  stomach,  the  aspiration  and  expulsive 
efforts  of  both  types  of  aerophagia  are  apt  to  be 
complicated  by  true  belching. 

The  diagnosis,  which  is  mainly  a  matter  of  differ- 


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Aerothempeutlcii 


entiation  from  ordinary  belching  in  the  first  type 
:unl  from  hiccough  withoul  esophageal  distention  in 
the  second,  rests  on  the  following  points:  (1)  Careful 
observation  of  the  muscular  action,  elevation  of  the 
thyroid,  etc.;  ('-')  Estimation  of  the  amount  of  gas 
eructated  as  by  merely  noting  the  duration  of  an 
attack,  by  collection  in  some  simple  form  of  trap,  as 
a  glass  inverted  over  a  basin  of  water,  etc.;  (3) 
auscultation  over  the  pharynx,  esophagus,  anil 
stomach;  (4)  inhibition  of  the  phenomenon  by  closure 
of  the  month  or  nares  or  both. 

ASrophagia  is  probably  always  essentially  hyster- 
ical, though  not  necessarily  to  the  extent  of  involving 
moral  perversion  or  manifestations  in  other  more 
eral  ways.  The  exciting  cause  may  be  almost 
any  emotional  or  physical  disturbance;  or,  as 
usually  in  cribbing  horses,  the  phenomenon  occurs 
in  periods  of  quiet  and  is  interrupted  by  any  form 
of  activity  or  by  the  same  causes  that,  in  other  in- 
stances, act  as  excitants.  To  some  degree,  a  great 
variety  of  organic  or  functional  disturbances  may  ad, 
at  times  as  predisposing,  at  others  as  exciting  causes. 
Nasal  polypi,  any  throat  lesion  of  an  irritating  nature, 
chronic  colitis,  pelvic  disease,  gallstones,  movable 
kidney  are  mentioned  with  special  frequency. 
fermentative  dyspepsia  and  hyperchlorhydria  with 
its  irritation,  usually  falsely  ascribed  to  the  pressure 
of  gas  in  the  stomach,  sometimes  genuinely  accom- 
panied with  gas  due  to  the  interaction  of  gastric  and 
upper  intestinal  contents  (carbon  dioxide)  logically 
lead  to  esophageal  reflexes  and  hence  occasionally  to 

rophagia.     From    the    nature    of    the    underlying 

exciting    and    predisposing    causes,    it    is    scarcely 

essary  to  state  that  women  are  more  often  affected. 

Treatment. — Removal  of  these  various  causes  and 
antispasmodic  and  general  hygienic  treatment  are 
indicated,  but  often  fail.  It  is  important  that  the 
patient  understand  the  mechanical,  if  not  the  neurotic 
ors  involved.  Drinking  water,  a  light  luncheon, 
gargling  the  throat,  shutting  the  lips  tightly,  and  if 
— ary  the  nostrils,  interrupt  the  actual  aerophagia, 
but  do  not  necessarily  either  terminate  the  attack  or 
produce  a  cure.  The  result  obviously  depends  on 
personal  factors,  notably  the  duration  and  fixity  of 
tla'  habit  and  the  degree  of  self  control,  spirit  of 
cooperation,  or  contrariness  of  the  patient.  The 
passage  of  the  stomach  tube  or  esophageal  bougie 
almost  always  accomplishes  a  cure,  if  persisted  in, 
partly  by  the  effect  of  massage  in  diminishing  spasm, 
partly  from  dread  of  reintroduction  of  the  tube.  Local 
analgesics  to  the  throat,  applied  on  the  esophageal 
sound  or  injected  through  the  stomach  tube  into 
the  esophagus,  thermic  and  various  electric  forms  of 
treatment  are  also  of  value,  probably  more  by  increas- 
ing the  force  of  suggestion  than  by  direct  therapeutic 
effect.  A.  L.   Benedict. 


Aerotherapeutics. — The  term  "aerotherapeutics" 
is  employed  with  varying  significance  by  different 
writers:  thus,  for  example,  Williams'  uses  the  term 
as  the  application  of  climate  in  the  treatment  of  lung 
disease;  others  apply  it  to  the  use  of  air  artificially 
attenuated  or  compressed  by  various  mechanical 
devices,  such  as  the  pneumatic  cabinet.  (See  Pneu- 
matotherapy).  Here,  however,  the  term  will  be  used 
in  the  more  simple  sense,  as  the  application  of  plain 
outdoor  air  in  the  treatment  of  disease. 

Since  the  open-air  treatment  of  pulmonary  tuber- 
culosis has  become  so  universal  and  the  results  there- 
from have  been  so  striking,  the  attention  of  the 
physician  and  surgeon  have  been  directed  to  its  use 
in  the  treatment  and  hygienic  management  of  other 
forms  of  tuberculosis,  notably  surgical,  as  well  as  in 
ether  non-tuberculous  diseases.  Not  only  in  diseased 
conditions  but  in  health  as  well  the  cult  of  the  outdoor 
life,  if  it  may  be  so  denominated,  has  become  popular, 
and  the  sleeping  porch  and  outdoor  living  room  are 


often  in  evidence;  ami  it  i.^  generally  acknowledged 
by  those  who  have  accustomed  themselves  t<>  open- 
air  conditions,   whatever  the   Season  of  the  year,   that, 

the  genera]  health  is  thereby  maintained  at  a  higher 

standard,    sleep    is    more    refreshing    and    colds    and 

other  infections  tire  less  frequent. 

The  literature  upon  the  subject  of  fresh  air  and  its 
application  has  grown  apace,  and  lie-  attention  of 
h"  pita]  and  school  authorities,  health  boards, 
factory  inspectors,  architects,  as  well  as  physicians 
and  sanitarians  have  been  increasingly  directed  to 
its  importance.  "If  fresh  air,"  they  say,  "is  SO 
valuable  for  the  sick,  it  must  be  equally  valuable  in 
keeping  a  man  well."  There  is  hardly  a  disease  or 
abnormal  condition  which  is  not  benefited  by  the 
open-air  treat  m«nt;  preeminently  so  are  the  various 
forms  of  tuberculosis,  pneumonia,  anemia,  and  var- 
ious conditions  of  depressed  vitality,  which,  unless 
they  receive  timely  remedy,  may  result  in  active 
tuberculosis. 

It  is  to  be  understood,  and  this  must  be  emphasized, 
that  the  open-air  treatment  means  out  of  doors,  or 
as  near  an  approximation  to  it  as  can  be  obtained, 
and  in  speaking  of  fresh  or  pure  air,  out  of  door  air 
is  meant.  Of  course,  no  air  practically  obtainable 
is  absolutely  pure.  Generally,  out-of-door  air  must 
be  that  supplied  in  the  place  or  locality  where  the 
patient  is  or  has  to  be.  If,  for  example,  he  is  ill  with 
pneumonia  in  a  city,  he  can  only  have  as  good  outdoor 
air  as  the  city  affords.  We  can,  as  we  do  in  many 
instances,  send  patients  to  various  health  resorts — in 
the  mountains,  on  the  sea-shore  or  to  other  climatic- 
ally favorable  localities  for  the  purpose  of  obtaining 
purer  air  than  can  be  found  at  home;  or  for  obtaining 
a  peculiar  variety  of  air,  like  the  rarified  air  of  the 
mountains  or  the  salt-impregnated  air  of  the  ocean; 
or  for  other  especial  climatic  characteristics  desired; 
or,  again,  because  outdoor  air  can  be  had  under 
more  agreeable  conditions,  as,  for  example,  in  the 
warmer  latitudes  during  the  colder  months  of  the 
year.  Nevertheless,  open-air  comparatively  fresh 
and  active,  or  at  least  that  which  will  serve  our 
purpose,  can  be  obtained,  fortunately,  almost  every- 
where, for  the  majority  of  invalids  cannot  go  far 
afield  to  seek  it.  The  roof  of  a  city  house,  the  piazza 
of  an  apartment,  a  shack  or  tent  in  the  yard,  a 
window  tent,  and  many  other  devices  will  furnish 
it;  or  we  can  approximate  to  open-air  conditions 
in  large  rooms,  with  windows  on  two  or  more  sides 
and  an  open  fireplace.  It  must  also  be  borne  in  mind 
that  the  therapeutic  application  of  the  open-air  treat- 
ment must  be  directed  in  the  same  careful  and  pains- 
taking way  as  with  other  therapeutic  measures,  and 
hence  be  under  the  direction  and  supervision  of  the 
physician. 

In  this  article  the  open-air  treatment  will  be  con- 
sidered in  its  application  to: 

(a)  Pulmonary  tuberculosis. 

(b)  Surgical  and  other  forms  of  tuberculosis. 

(c)  Pneumonia  and  other  infectious  and  respiratory 
diseases. 

(d)  Various  conditions  of  malnutrition,  anemia,  and 
other  dyscrasias. 

(e)  Organic  diseases. 

Pulmonary  Tuberculosis. — The  so-called  "open- 
air"  treatment  of  pulmonary  tuberculosis  is  the 
established  treatment  of  this  disease  at  the  present 
day.  In  a  word,  it  consists  in  affording  the  patient 
pure  outdoor  air  to  breathe  continuously,  both  night 
and  day,  keeping  him  out  of  doors  by  day  and  having 
his  bedroom  windows  open  by  night,  or  better  having 
him  sleep  also  out  of  doors.  It  is  hardly  necessary 
to  add  that  at  the  same  time  due  attention  should 
be  paid  to  diet,  rest,  hydrotherapy,  and  to  all  that 
pertains  to  the  hygienic  well-being  of  the  patient; 
hence  this  method  is  also,  and  perhapsmore  correctly, 
termed  the  "hygienic-dietetic"  treatment.  This 
treatment   has   been   brought   to   such   a   degree   of 

139 


Aero  therapeutics 


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perfection  that  it  may  almost  be  said  to  be  independ- 
ent of  climate;  that  is,  it  can  be  successfully  carried 
out  wherever  there  are  pure  air  free  from  dust, 
protection  from  wind,  and  a  moderate  amount  of 
SUnshin< — climatic  conditions  which  are  obtainable 
almost  everywhere  outside  of  large  centers  of  popula- 
tion and  even  there  it  can  successfully  be  carried  out, 
as  is  constantly  exemplified  in  tuberculosis  classes 
and  otherwise.  It  seems  a  very  simple  matter  to 
conduct  such  a  treatment,  but  experience  has  shown 
that  constant  supervision  is  necessary,  aided  by  the 
example  of  others,  in  order  to  keep  the  patient  up, 
day  after  day,  summer  and  winter,  to  this  treatment 
in  all  its  strenuousness;  hence  the  great  value  of 
sanatoria  and  their  constant  and  rapid  increase  in 
number.  Even  though  this  treatment  is  in  a  measure 
independent  of  climate,  it  is  not  to  be  asserted  that 
all  climates  are  equally  valuable,  for  it  is  obvious 
that  the  greater  the  number  of  favoring  climatic 
elements,  the  more  perfectly  the  treatment  can  be 
conducted,  and  the  more  successful  it  will  be.  Hence 
such  resorts  as  Davos,  Colorado  Springs,  California, 
Asheville,  the  Adirondacks  and  many  others  of 
superior  climatic  excellence  are  especially  favorable 
for  this  mode  of  treatment,  provided  the  other 
essential  factors,  such  as  diet,  etc.,  are  at  hand.  It 
may  be  thought  that  this  treatment  can  be  accom- 
plished by  simply  instructing  the  patient  to  keep  out 
of  doors;  nothing  could  be  more  fallacious  than  this. 
In  the  first  place,  the  patient,  in  many  cases,  will 
not  keep  out  of  doors  all  day  of  his  own  volition. 
If  he  is  out  for  a  few  hours  each  day,  he  is  prone  to 
think  that  he  is  fulfilling  his  instructions.  Further, 
he  is  too  often  left  to  himself  to  determine  whether  he 
shall  remain  at  rest  or  take  exercise  while  in  the  open; 
generally  he  does  the  latter,  sometimes  from  ignor- 
ance, sometimes  for  the  want  of  any  proper  place 
where  he  can  remain  at  rest.  Here,  again,  comes  in 
the  value  of  the  sanatorium  where  all  these  details 
are  carefully  looked  after. 

The  theory  of  the  outdoor  treatment  in  this  disease 
is,  of  course,  evident;  the  object  is  so  to  improve  the 
nutrition  of  the  pulmonary  tissue  and  general  system, 
and  so  to  harden  the  patient  and  thereby  increase 
his  resisting  power  that  he  will  no  longer  present  a 
favorable  soil  for  the  tubercle  bacillus.  It  is  also 
claimed  for  this  treatment  that  it  will  increase  tissue 
metabolism,  so  that  fibroid  transformation  of  tuber- 
culous tissue  may  be  hastened,  or  the  encapsulation 
of  caseous  areas  effected. 

Are  all  cases  of  pulmonary  tuberculosis  suitable  for 
the  open-air  treatment?  Obviously  not,  for  all  cases 
are  not  susceptible  of  an  arrest  or  improvement;  and 
the  object  of  this  treatment  is  to  cure.  Although 
it  is  difficult,  if  not  impossible,  in  many  cases  and  in 
the  various  stages  of  the  disease,  to  form  a  probable 
prognosis,  still  in  general  it  may  be  said  that  advanced 
cases  with  mixed  infection  and  septic  symptoms — 
cases  of  very  extensive  disease,  those  in  which  the 
tuberculous  process  is  accompanied  by  acute  symp- 
toms and  other  complications,  or  those  in  which  the 
recuperative  power  seems  to  be  lacking,  and  the  whole 
system  appears  to  have  collapsed — are  unfavorable 
cases  and  unlit  ted  for  the  severe  regime  of  the  continu- 
ous open-air  treatment.  Fresh  air,  of  course,  should 
be  afforded  all  cases,  as  to  everybody  else,  sick  or 
well;  but  this  can  often  be  best  done  in  a  well-venti- 
lated room,  where  the  patient  is  made  comfortable 
and  kept  at  rest.  If  some  of  these  apparently  hope- 
less cases  later  exhibit  more  favorable  symptoms  and 
develop  greater  recuperative  power,  they  then  can 
more  properly  be  subjected  to  the  complete  open-air 
treatment. 

I, est  there  may  be  some  misunderstanding,  it  is 
well  again  to  state  what  may  seem  self-evident,  viz., 
that  the  open-air  treatment  in  all  its  rigorousness 
means  practically  a  continuous  outdoor  existence. 
Day  after  day  in  all  kinds  of  weather  one  must  be 


exposed  to  the  open  air,  and  the  windows  of  his  sleep- 
ing-room must  be  kept  open  day  and  night,  summer 
and  winter,  or  better,  as  is  now  so  generally  the  custom, 
sleeping  outdoors.  This  does  not  mean  that  one 
shall  sit  out  in  a  rain  or  snow  storm,  but  on  a  veranda 
for  example,  which  affords  shelter  from  the  storm  and 
wind  and  yet  is  open  to  the  air.  The  writer,  for  ex- 
ample, had  a  patient  at  Rutland,  Mass.,  who,  during 
a  New  England  winter,  spent  eight  hours  daily  out  of 
doors,  always  slept  in  a  cool  room,  with  open  window .-. 
and  bathed  his  chest  every  morning  with  cold  water. 

As  has  been  said  above,  a  well-equipped  sanatorium 
affords  the  best  opportunity  for  taking  the  open-air 
treatment,  and  medical  supervision  is  always  at  ham', 
to  insist  upon  it;  at  the  same  time  it  is  practicable,  b 
very  many  cases,  to  devise  at  the  home  of  the  patient 
an  arrangement  lor  this  treatment.  A  properly  pro- 
tected veranda,  preferably  facing  the  south;  a  tent 
with  a  wooden  floor  and  properly  ventilated;  a  shed 
or  wooden  chalet  simply  and  cheaply  constructed, 
serving  also  as  a  sleeping-room  by  night — all  of  these 
afford  opportunities  for  the  "treatment."  If  the 
physician  is  at  all  ingenious  he  will  readily  invent 
some  way  by  which  this  can  be  accomplished,  for 
there  is  almost  always  something  in  or  about  tin 
patient's  house  that  can  be  utilized  for  this  purpose, 
and  the  devices  for  securing  open-air  life  are  innumer- 
able; vide  "Some  Plans  and  Suggestions  for  Housing 
Consumptives";  "Fresh  Air  and  How  to  Use  It" 
(Carrington),  published  by  the  National  Association 
for  the  Study  and  Prevention  of  Tuberculosis. 

It  is  hardly  necessary  to  say  that  a  patient  used  to 
an  indoor  life,  as  the  great  majority  of  them  are,  must 
be  somewhat  gradually  accustomed  to  a  constant 
open-air  exposure,  but  it  is  marvellous  how  perfectly 
they  establish  the  habit,  and  how  complete  is  the 
endurance  which  they  attain.  Knopf2  quotes  Andvoid 
of  Tonsaasen,  Norway,  as  saying  that  he  leaves  hi 
patients  on  their  chairs,  wrapped  in  furs,  for  from 
live  to  nine  hours  a  day  at  a  temperature  of-25°  ('. 
(-13°F.). 

The  number  of  hours  during  which  the  patient  re- 
mains out  of  doors  depends  largely  upon  the  location 
and  latitude  of  the  locality  where  he  is.  At  Davos, 
for  example,  the  sun  rises  late  and  sets  early,  on  account 
of  the  surrounding  mountains,  so  that  a  winter's  day 
is  only  about  four  or  five  hours  long.  In  Falkenstein 
the  patients  remain  out  of  doors  for  from  seven  to  ten 
hours  a  day  all  the  year  through;  at  Rutland,  Mass., 
for  about  eight  hours;  at  Colorado  Springs  for  from 
seven  to  eight. 

The  effects  upon  the  patient  of  this  prolonged  stay  in 
the  open  air  are  striking.  Appetite  and  weigh!  in- 
crease; cough  and  expectoration  diminish;  and  if  there 
is  any  rise  of  temperature  at  any  part  of  the  day,  this 
is  likely  soon  to  disappear.  The  patient  also  experi- 
ences a  sense  of  well-being  and  invigoration,  together 
with  mental  exhilaration.  After  a  course  of  open- 
air  treatment  one  is  no  longer  content  to  live  indoors 
or  sleep  with  closed  windows. 

It  may  be  pertinently  asked  if  patients  do  not  catch 
cold  under  this  constant  open-air  exposure.  On  the 
contrary,  experience  has  proved  that  they  are  less 
likely  to  do  so  than  when  they  live  under  constanl 
protection  with  the  consequent  unavoidable  exposure 
to  impure  air.  The  constant  exposure  to  pure  germ 
less  air,  however  cold,  when  one  is  properly  clad,  does 
not  render  one  susceptible  to  catching  cold,  as  Nansen 
so  strikingly  proved  on  his  Arctic  expedition. 

In  concluding  this  portion  of  the  subject,  it  is  well 
to  reiterate  that  the  open-air  treatment  is  not  the 
whole  treatment  of  pulmonary  tuberculosis.  In 
addition,  there  must  be  an  abundance  of  nutril 
and  properly  prepared  food;  rest;  a  most  careful 
avoidance  of  over-exertion  either  mental  or  physical; 
moderate  exercise  under  careful  supervision,  and  in 
suitable  cases;  and  due  attention  to  the  skin  by  the  use 
of  various  hydrotherapeutic  measures.     In  brief,  all 


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Ar-in  therapeutics 


tlic  hygienic  measures  conducive  to  increasing  the 
resistance  of  the  individual  to  the  infection,  must  be 
adopted. 

Surgical  and  Other  Forms-  of  Tuberculosis. — Insti- 
gated by  the  success  obtained  in  the  open-air  treat- 
ment of  pulmonary  tuberculosis,  general  and  the 
orthopedic  surgeons  have  been  led  to  apply  the  same 
methods  in  the  treatmenl  of  surgical  tuberculosis, 
particularly  that  of  the  bones,  joints,  and  glands  in 
children  and  young  persons,  sometimes  in  conjunction 
with  operative  measures  and  sometimes  without  them, 
and  the  results  have  been  as  striking  as  with  pulmon- 
ary tuberculosis.  Prof.  Halsted  of  the  Johns 
Hopkins  University  go<  s  so  far  as  to  say  that  most 
of  surgical  tuberculosis  will  recover  without 
ration  if  they  are  given  a  fair  opportunity  in  the 
open  air,3  and  lie  further  emphasizes  the  importance  of 
d  cures  by  the  intensive  employment  of  the  out-of- 
door  treatment  by  making  it  continuous,  night  and 
day,  this  being  especially  important  with  children 
affected  with  joint  tuberculosis. 

It  is  a  question  whether  seaside  or  country  air  is 

I     favorable    for   such    cases.     Seaside    sanatoria 

existed  for  a  long  time  on  the  coast  of  France 
and  England  and  other  countries  in  Europe,  and  more 
recently  a  few  have  been  established  in  this  country, 
njotably  "Sea-Breeze"  at  Coney  Island;  and  excellent 
rtsults    have    been    obtained.     Likewise    apparently 

gbod  results  have  1 n   secured  in  the  Adirondack^ 

and  elsewhere  inland.  Probably  it  does  not  make 
very  much  difference  provided  the  air  is  fresh  and 
pure  and  a  rigorous  application  of  the  open-air  regime 
is  enforced,  i.e.  the  child  being  exposed  continuously 
to  the  open  air. 

At  Leysin,  Switzerland,  which  is  some  4,000  feet 
above  sea-level,  the  writer  recently  saw  children  in 
Rollier's  Sanatorium  suffering  from  various  forms  of 
surgical  t  uberculosis,  especially  of  the  bones  and  joints, 
treated  by  exposure  of  the  naked  body  to  the  sun  and 
open  air;  the  deep  color  of  their  bodies,  bronzed  by 
the  intense  rays  of  the  sun  in  the  attenuated  air  of 
that  altitude,  made  them  look  like  North  American 
Indians.  The  excellent  general  condition  of  these 
children,  as  evidenced  by  their  well-nourished  appear- 
ance, healthy  complexion  and  exuberant  spirits, 
and  the  rapid  improvement  of  the  local  conditions, 
testified  to  the  success  and  value  of  the  treatment. 
Rollier  attributes  much  of  his  success  to  the  influence 
of  the  sun  baths,  but  one  must  remember  that  the  open 
air  includes  sunshine  to  a  greater  or  lesser  degree. 

The  technique  of  the  open-air  treatment  in  surgical 
tuberculosis  is  essentially  the  same  as  that  in  the  pul- 
monary form.  It  must,  however,  be  absolute  and 
continuous,  for,  as  Halsted  says,  a  rapidly  growing 
boy,  with  tuberculosis  of  the  knee  joint,  for  example. 
might  lose  a  great  deal  in  the  length  of  the  affected 
limb  unless  the  cure  were  rapidly  effected. 

Tuberculous  peritonitis  is  another  form  of  the  dis- 
ease peculiarly  amenable  to  the  open-air  treatment,  as 
are  also  tuberculous  glands;  and  many  cases  recover 
under  this  treatment  without  surgical  interference — 
indeed,  in  all  cases  of  internal  tuberculosis  other  than 
pulmonary,  the  open-air  conditions  of  living  are  of 
great  value  even  if  they  are  not  the  determining 
factor  in  the  cure  or  arrest.  It  is  all  important  thai 
such  accommodations  shall  be  provided  as  will 
enable  the  patient  to  obtain  fresh  air  continuously,  be 
it  again  repeated,  and  this  means  sleeping  out  of  doors 
at  night  as  well  as  living  out  of  doors  during  the  day. 

Pneumonia  and  Other  Infectious  and  Respiratory 
Diseases. — The  provision  of  open-air  conditions  is  now 
quite  generally  accepted  by  the  profession  as  an  essen- 
tial part  of  the  hygienic  care  of  pneumonia,  and  the 
more  favorable  results  obtained  attest  the  value  of 
such  procedure,  as  heroic  as  it  at  first  seemed.  Even 
with  infants  and  young  children  the  open-air  treat- 
ment is  fearlessly  employed,  and  its  value  has  been 
abundantly  proved  by  Northrup,  the  pioneer  in  the 


use  of  outdoor  air  with  children  suffering  from  pneu- 
monia, and  by  many  others.  The  patient  i  either 
placed   directly   on!  of  dooi     i'l   aii    open    porch    or 

loggia,  or  in  a  lame  room  with  wide  open  windows, 
i  he    bed    being    placed   eith  i    bet    een    •.  indov,      or 

close  to  them,  no  mailer  what    the  season  of  the  year 

may  1"-.  The  e  ential  thing  is  to  allow  the  pain  at 
an  unlimited  supply  of  "free,  fresh,  (lowing  i 
and  the  physician  must  determine  in  each  individual 
case  how  this  can  be  I  be  accomplished.  Instead  of 
the  application  of  oxygen  as  a  last  resort  the  patient 
under  the  open-air  treatment  is  obtaining  a  goodly 
supply  of  ii  continuously  and  from  the  beginning. 
In  winter  the  patient  should,  of  course,  be  prop* 

protected,  and  when  this  is  .lone,  he  will  suffei    BO  di    - 

comfort,  whatever  the  temperature  of  the  air,  al- 
though the  nurse  will  have  to  be  clothed  with  thick 

winter  garments.  The  effect  of  such  constant  ex- 
posure to  outdoor  air  is  better  and  more  restful 
sleep,  easier  respiration,    less    cyanosis,    and    fe    i 

nervous  phenomena. 

In  other  acute  infectious  diseases  an  essential  part 
of  the  hygienic  management  should  always  be  a 
bountiful  supply  of  pure,  fresh,  outdoor  air,  either  in 
a  large,  well- vent  dated  room,  in  a  well- vent  dated  tent , 
or  an  open  porch.  That  was  a  wise  old  school  physi- 
cian who  said  that  if  he  had  typhoid  fever  he  wanted 
to  be  put  under  a  tree  with  a  jug  of  milk  beside  him. 

In  acute  bronchitis,  especially  in  children,  it  is 
quite  as  important  to  supply  an  abundance  of  fresh 
air  as  in  pneumonia,  and  essentially  the  same  plan 
should  be  pursued  in  doing  so  as  in  the  latter  disea  e. 
"Outdoor  treatment  (in  acute  bronchitis)  should  be 
a  routine  practice"  says  Musser. 

In  chronic  bronchitis  and  asthmatic  conditions  the 
open-air  treatment  can  most  comfortably  be  carried 
out  in  the  warmer  latitudes,  such  as  in  Southern 
California,  the  West  Indies,  Florida,  the  various  re- 
sorts of  the  Southern  Pine  Belt,  or  on  the  Mediterran- 
ean coast  of  Italy,  France,  or  Northern  Africa.  In 
many  cases  the  open-air  life  can  be  properly  insti- 
tuted for  such  conditions,  occurring  so  frequently  in 
the  feeble  and  aged,  only  in  climates  milder  and  more 
equable  than  the  cold  and  changeable  one  of  the  North 
in  winter.  Some  cases  of  chronic  bronchitis  do  best 
in  a  dry,  warm  climate  and  others  in  a  warm,  moist 
one.  When  for  any  reason  the  patient  cannot  change 
his  climate  in  winter,  he  can  often  arrange  an  arti- 
ficial mild  climate  in  his  own  house  by  confining  him- 
self to  a  large  room  with  a  Southern  exposure,  pro- 
viding for  free  ventilation  and  a  sufficient  amount 
of  moisture  in  the  air.  Thus  he  will  obtain  compara- 
tively fresh,  warm,  moist  air,  and  a  reasonable  amount 
of  sunshine. 

In  the  various  chronic  diseases  of  the  upper  respira- 
tory tract,  such  as  pharyngitis,  laryngitis,  and  rhinitis, 
the  open-air  treatment  is  again  applicable;  and  often  a 
change  of  climate  where  outdoor  life  is  more  easily 
obtained  is  desirable;  and  in  choosing  a  resort  the 
climatic  characteristics  must  be  taken  into  considera- 
tion in  conjunction  with  the  individual  needs  and 
local  conditions. 

Convalescents  from  pleurisy  with  effusion  will 
obtain  a  more  rapid  expansion  of  the  compressed 
lung  by  the  open-air  treatment  in  high  altitudes, 
provided  the  heart  has  recovered  its  former  integrity 
and  there  are  no  extensive  or  firm  adhesions.  At  all 
events,  whether  in  a  high  or  low  altitude,  pure,  fresh 
air  is  most  important  in  the  after-treatment  of 
pleurisy. 

Various  Conditions  of  Malnutritions,  Anemia,  and 
Other  Dyscrasias. — A  residence  in  the  mountains  or 
at  the  sea-shore  has  long  been  recognized  as  perhaps 
the  most  important  element  in  the  successful  treat- 
ment of  malnutrition  and  anemia,  particularly  in 
children  and  young  women.  Although,  probably, 
either  the  mountain  or  sea.  air  will  produce  more 
rapid  results,  yet  any  locality  where  pure,  fresh  air 

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is  obtainable  will  avail.  Care  must  be  taken,  however, 
thai  a  really  outdoor  life  is  followed.  "It  is  little 
use,"  says  Trudeau,  "merely  to  tell  people  to  live 
out  of  doors,  they  must  be  made  to  do  it,  and  suita- 
ble accommodations  must  be  provided  so  they  can 
do  it." 

Depressed  vitality,  from  whatever  cause,  conva- 
lescence from  acute  diseases  and  surgical  operations, 
generally  respond  rapidly  to  the  outdoor  life  in  the 
country,  mountains,  or  sea-shore. 

The  beneficent  effect  of  mountain  air  upon  condi- 
tions of  debility,  anemia,  and  malnutrition  are 
strikingly  illustrated  by  a  modest  institution  at  Ste. 
Agathe,  Canada,  in  the  Laurentian  Mountains,  called 
"  Brehmer  Rest"  or  "Preventorium,"  where  young 
women  suffering  from  the  conditions  noted  above,  in- 
cident to  life  in  the  city,  in  shop  or  factory,  conditions 
which  are  so  often  the  forerunner  of  tuberculosis,  are 
subjected  to  the  open-air  treatment  for  weeks  or 
months,  until  the  normal  standard  of  health  is  re- 
st ured.  Undoubtedly  many  cases  of  tuberculosis  are 
thus  prevented,  and  how  much  more  satisfactory  is 
this  than  a  longer  period  in  a  sanatorium  after  the 
active  disease  has  developed.  Such  an  institution  is 
rightly  named  a  "Preventorium." 

The  open-air  school  and  the  open-air  school  room 
have  rapidly  come  into  favor  for  anemic,  illy-nour- 
ished school  children,  as  well  as  those  with  latent 
tuberculosis.  In  such  schools  the  children  are  practi- 
cally out  of  doors  or  in  rooms  with  the  windows  wide 
open,  throughout  the  year,  well  protected,  of  course, 
during  the  colder  months.  Instruction  alternates 
with  periods  of  rest,  which  is  taken  in  the  recumbent 
position.  Nourishing  food  is  also  provided.  Thus 
education  goes  on  coincidentally  with  the  open-air 
and  hygienic  treatment  which  is  restoring  the  health 
to  its  normal  standard. 

Organic  Diseases. — In  organic  cardiac,  vascular, 
or  renal  disease  life  is  often  prolonged  and  a  more 
comfortable  existence  afforded  by  residence  in  such 
a  climate  as  will  permit  of  an  outdoor  life.  A 
moderately  warm,  equable,  sunny  climate  would 
appear  to  be  that  of  choice.  In  renal  disease  sudden 
changes  of  temperature  and  wind  are  to  be  avoided. 
The  debility  and  degenerative  changes  of  old  age  are 
mitigated  and  produce  less  discomfort  if  one  can 
live  easily  out  of  doors  in  an  equable  climate  which 
makes  the  least  possible  demand  upon  the  limited 
vitality.  Such  a  climate  as  that  of  Southern  Cali- 
fornia is  ideal  for  the  aged. 

In  various  functional  nervous  disorders,  such  as 
neurasthenia,  insomnia,  and  neuralgia,  much  benefit 
is  derived  from  exposure  to  pure,  fresh,  open  air. 
Sometimes  mountain  air  and  sometimes  that  of  the 
sea-shore  will  prove  most  beneficial.  Each  case 
must  be  judged  by  itself  and  that  climate  selected 
which  seems  best  to  satisfy  the  individual  condi- 
tions. 

Thus  it  is  seen  that  there  is  hardly  any  abnormal 
condition  or  disease  that  will  not  derive  benefit  from 
the  open-air  treatment,  and  in  many  diseases  it  will 
be  the  determining  factor  in  the  recovery.  The 
supreme  importance  of  fresh  air  breathed  in  the 
open  is  so  obvious  that  it  seems  strange  that  it  is  so 
often  ignored  even  by  the  physician.  Modern 
civilization  has  so  accustomed  man  to  an  indoor 
existence  that  outdoor  life  almost  seems  unnatural 
to  him,  and  when  he  is  ill,  to  be  placed  under  open-air 
conditions  appears  to  him  and  his  friends  as  a  danger- 
ous expedient.  It  often  requires  much  reasoning  and 
persuasion  on  the  part  of  the  physician  to  be  allowed 
to  institute  the  open-air  treatment.  The  reader  is 
referred  to  "Fresh  Air  and  How  to  Use  It,"  by  Car- 
rington,  published  by  the  National  Association  for 
the  Study  and  Prevention  of  Tuberculosis  for  an 
excellent  detailed  description  of  the  various  methods 
of  applying  the  open-air  treatment. 

Edward  O.  Otis. 


References. 

1.  Williams,  C.  Theodore:  Aerotherapeutics,  London,  1S94. 

2.  Knopf,  S.  A.:  Prophylaxis  and  Treatment  of  Pulmonary 
Tuberculosis. 

:;.  Transaction  of  the  National  Association  for  the  Study  and 
Prevention  of  Tuberculosis,  1906,  p.  I'M. 

4.  Northrup,  W.  P.:  Cold  Fresh  Air  in  the  Treatment  of  Pneu- 
monia in  Infants  and  Children,  Medical  Record,  Feb.  IS,  1905. 


yEsculapius. — The  Latinized  name  of  'AitkXtjiros  the 
legendary  Greek  god  of  medicine,  the  son  of  Apollo 
and  the  nymph  Coronis.  Homer  mentions  him  as  a 
skilful  physician,  whose  sons,  Machaon  and  Podalirius. 
characterized  by  the  poet  as  "blameless  physicians," 
were  sergeons  "in  the  Greek  camp  before  Troy.    To 


Fit;.  52. — Statue  of  ^Esculapius  in  the  I'ffizi  Gallery  in  Florence; 
ii  is  said  to  be  a  copy  of  a  statue  by  Myron,  of  the  later  Greek 
period. 

Homer  ^Esculapius  was  still  onlv  a  hero,  a  "cunning 
leech,"  but  later  he  was  deified  by  Greek  tradition,  lus 
worship  being  well  established  by  the  fifth  century, 
B.C.,  at  Athens.  He  carried  his  art  to  such  a  degree  ol 
perfection  as  to  be  able  even  to  raise  the  dead:  thus 
Zeus,  fearing  he  might  abolish  death  altogether  and 
depopulate  Hades,  slew  him  with  a  thunderbolt. 

The  temples  dedicated  to  ^Esculapius  were  always 
located  in  some  conspicuously  salubrious  spot,  out- 
side the  limits  of  the  town  or  city,  as  on  the  summit 


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of  a  mountain  or  in  the  midst  of  a  sacred  grove. 
Nobody  was  permitted  to  die  on  the  consecrated  land 
surrounding  the  temple,  nor  could  any   woman  give 

birth  in  a  child  within  these  limits.     Further] •<•, 

repeated  purifications  were  required  of  all  those  who 
desired  to  approach  the  temple  for  the  purpose  of 
consulting  the  god.  All  who  were  healed  offered 
sacrifice  and  hung  up  votive  tablets,  on  which  were 
recorded  their  names,  their  diseases  ami  the  manner 
in  which  they  had  been  cured.  As  these  tablets  were 
carefully  preserved,  the  priests — the  custodians  of  the 
temples  —came,  in  the  course  of  time,  to  have  at  hand 
a  veritable  library  of  reference,  in  which  all  the  medical 
knowledge  of  that  period  was  carefully  stored,  ready  to 
be  consulted  on  any  convenient  occasion.      A.H.B. 

1  villus — Buckeye;  Horsechestnut  (fam.  Hippo- 
caatanacece).  A  genus  of  about  a  dozen  species,  of 
America  and  Asia,  growing  mostly  north  of  the 
Equator.  The  bark  and  seeds  of  JE.  hippocastanum 
1...  native  of  Asia,  but  largely  cultivated  for  ornament 
in  all  temperate  countries,  have  been  much  used  in 
domestic  practice  in  the  treatment  of  malaria  and 
rheumatism.  Both  contain  considerable  tannin,  but 
the  activity  appears  to  reside  in  the  bitter  glucoside 
lin  (0,,H,„O9  +1.5PLO)  which  is  crystalline, 
white,  soluble  in  water  and  alcohol,  and  antiperiodic 
in  fifteen-grain  doses. 

The  seeds  of  the  red  buckeye,  M.  pavia  L.,  of  the 
southern  United  States,  are  reported  to  have  caused 
fatal  cases  of  poisoning  in  children,  the  sj'mptoms 
being  those  of  poisoning  by  saponin.  It  is  even  said 
that  the  former  species  has  acted  similarly. 

H.  H.  Rusbt. 

.'Ether.— See  Ether. 

Aetius. — A  Christian  physician,  born  in  Amida  in 
Mesopotamia,  who  flourished  in  the  early  part  of  the 
sixth  century.  He  studied  at  Alexandria  and  became 
?ourt  physician  at  Byzantium.  He  belonged  to  the 
sect  of  the  methodists,  yet  inclined  at  times  toward 
the  practice  of  the  empiricists.  He  wrote  in  Greek  a 
treatise  on  medicine  in  sixteen  books,  for  the  most 
>art,  and  the  most  valuable  part,  a  compilation  from 
carious  authors,  chiefly  Oribasius  and  Galen.  His 
jwn  contributions  were  those  of  a  superficial  observer 
ind  obscure  writer.  The  treatise,  however,  is  on  the 
ivhole  a  valuable  commentary  on  the  works  of  the 
Dlder  writers,  such  as  Galen,  and  furnishes  a  rich 
naterial  for  the  history  of  the  medical  science  of 
tntiquity.  Eight  books  of  the  Greek  original,  edited 
Dy  Comarus  (q.v.)  were  printed  at  Venice  in  1534, 
tnd  a  complete  Latin  translation,  also  by  Comarus, 
>vas  published  at  Basle  in  1542.  A.  H.  B. 

.•Etna  Springs. — Napa  County,  California. 

Location. — At  the  upper  end  of  Pape  Valley, 
sixteen  miles  northeast  of  St.  Helena. 

Access. — By  rail  via  Southern  Pacific  Company's 
trains  via  Oakland  and  Vallejo  Junction;  or  via  the 
Napa  Valley  Route,  steamer  and  electric  cars  to  St. 
Helena,  and  thence  by  stage  or  automobile  over  a 
.veil-graded,  picturesque  road.  There  is  no  hotel 
tmilding,  but  a  number  of  attractive  cottages  are 
provided  for  guests. 

Gardens,  orchards,  and  vineyards  supply  fresh 
vegetables  and  fruits  for  the  table.  In  the  fall  a 
season  is  given  to  the  "  Grape  Cure."  There  is  also 
i  dairy. 

This  resort,  known  as  the  "American  Ems, "is 
delightfully  situated  at  an  elevation  of  1,000  feet 
above  the  Pacific,  in  the  midst  of  wild  mountain  sur- 
roundings. The  mountains  are  well  stocked  with 
game,  and  the  streams  afford  good  fishing.  Many 
forms  of  exercise  and  amusement  are  provided. 
There  are  a  number  of  excellent  springs  in  the  neigh- 


borhood,  those  u  ed  for  drinking  purposes  having  a 
temperature  ol  98  I  :  those  employed  for  bathing 
show  a  temperature  of  106°  F.  The  following  analy- 
sis of  .Etna  Spring  was  made  by  Professor  \\ .  T. 
Wenzell: 

Chains   in    ic.i      (J.    S.    Wink    GALLON,   231    CUBIC    I 

Chloride  of  i                              ;;n  no 

Nitrate  <>t  potassium..  u  titm 

Silica f  potassium                                                 .  0.780 

Borosilicate  "i  pota  -  ium                                      .  0,  150 

I'.,  irate  of  sodium 19 

Carl ate  ol  sodium 21.870 

Chloride  of  sodium . .  is. 550 

Sulphate  of  sodium                                             ...  0.020 

< '  i  rl  lonate  <>f  calcium                                         . . .  0. 750 

Sulphate  of  calcium.                                             - .  0.290 

Carbonate  of  magnesi   m,                            0 .  550 

Carbonate  of  iron..                           - 0.210 

Oxide  of  iroD .  0.100 

Amnion  i:i 0  .  006 

Organic  matter 0    140 

Alumina 2.130 

Total  grains 96.760 

Temperature.  72°  F. 

Specific  gravity  (at  69°F.),  1.00317. 

Carbonic  acid  gas,  313  cubic  inches. 

The  following  analysis  of  American  Ems  was  made 
by  Professor  J.  A.  Bauer,  chemist: 

Grains  in  One  Wine  Gallon  of  231   Cubic  Inches. 

I  -rains. 

Bicarbonate  of  magnesium 13.85 

Bicarbonate  of  sodium 75  .  22 

Bicarbonate  of  calcium 10.45 

Sulphate  of  sodium 7 .  73 

Chloride  of  sodium 28 .  65 

Silica 0.65 

Total  erains 136.55 

Temperature,  9S°  F. 

Caroonic  acid  gas,  58  cubic  inches. 

The  water  is  sparkling  and  invigorating,  with  a 
noticeable  electrical  element,  and  possesses  a  decided 
tonic  influence  as  well  as  slight  aperient  properties. 
It  is  a  good  type  of  alkaline-saline-carbonate  water 
and,  as  will  be  observed,  resembles  the  waters  of 
Ems  to  quite  a  marked  extent.  This  water  is  in- 
creasing in  favor  on  the  Coast,  and  has  already 
acquired  considerable  reputation  in  renal  diseases. 
Good  results  have  also  been  reported  in  cases  of 
rheumatism,  diabetes,  and  neuralgia  as  well  as  in 
those  of  dyspepsia,  torpidity  of  the  bowels,  hepatic 
disorders,  skin  affections,  and  uterine  disease. 

Several  other  springs  are  found  close  by.  Besides 
those  above  mentioned  are  the  Iron  Spring,  much 
resorted  to  for  anemia  and  wasting  affections,  the 
Bath  House  or  Artesian  Spring,  the  Soda  Spring,  and 
the  Iadora  Spring  containing  soda,  magnesia,  and  iron. 

Emma  E.  Walker. 


Agamofilaria. — A  name  given  to  certain  immature 
parasitic  nematode  worms,  the  adult  stages  of  which 
are  unknown,  bvit  which  belong  to  the  family  Filari- 
idoe.     See  Nematoda.  A.  S.  P. 

Agamodistomum. — A  name  given  to  certain  imma- 
ture distomes  which  are  sometimes  parasitic  in  the 
human  eye.     See  Trematoda.  A.  S.  P. 

Agar=agar. — Vegetable  gelatin.  The  name  of  a 
large  number  of  East  Indian  sea  weeds  which  are  used 
in  the  manufacture  of  "vegetable  gelatin";  also  the 
name  of  this  gelatin.  The  general  nature  of  these 
substances  is  similar  to  that  of  chondrus,  or  Irish  moss. 
It  is  one  of  these  species  which  yields  the  material  for 
the  Chinese    "bird's-nest    pudding."     Agar-agar    is 


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manufactured  chiefly  in  China,  the  sea  weeds  being 
sent  there  from  other  conn!  ries  for  this  purpose.  It  is, 
however,  more  or  less  manufactured  in  other  count  ries 
also,  especially  in  Japan,  and  it  is  the  latter  variety 
which  is  chiefly  used  for  bacterial  cultures.  In  the 
country  of  its  production,  agar-agar  is  very  largely 
used  for  food,  both  alone  and  as  an  ingredient  of 
jellies.  It  is  also  very  largely  employed  as  a  sizing 
in  silk  manufacturing.  It  occurs  in  thin,  transparent, 
colorless  sheets,  a  great  many  bound  together,  or  as 
bundles  of  long  shreds,  or  in  the  form  of  irregularly 
square  sticks,  nearly  a  foot  long.  The  latter  form  is 
that  generally  used  in  bacterial  work.  It  is  less 
transparent  than  either  of  the  others,  and  is  not  so 
white. 

Agar-agar  consists  almost  wholly  of  gelose,  a  sub- 
stance the  solution  of  which  cools  to  a  jelly,  which  is 
much  more  stable  than  that  of  gelatin,  requiring  a 
higher  temperature  for  melting.  It  is  said  that  a 
solution  of  1:500  of  water  will  yield  a  stiff  jelly. 
Gelose  is  precipitated  by  alcohol,  but  not  by  tannin. 

Gelasine  is  merely  a  variety  of  agar-agar. 

Agar-agar  has  no  medicinal  properties,  its  uses  being 
wholly  nutritive  and  mechanical.  Its  paste  is  some- 
times used  as  an  ointment  base.  Recently  it  lias  been 
employed  in  the  treatment  of  constipation.  It  is  ad- 
ministered for  this  purpose  in  dry  form  in  the  food;  ab- 
sorbing water  in  the  intestine  it  forms  a  jelly  mass 
which  increases  the  bulk  of  the  feces.  This  mechanical 
action  is  sometimes  supplemented  by  the  addition  of 
a  laxative,  as  e.g.  cascara  sagrada  in  the  preparation 
known  as  regulin.  H.  H.  Rusby. 


Agaric,  Purging. — While  agaric;  Touchwood;  Spunk; 

Timler.  The  decorticated  hymenium  of  Polyporus 
officinalis  Fries  (Boletus  laricis  Linn.;  order,  Basidio- 
mycetes,  Hymenomycetes).  This  is  a  large  fungus 
growing  upon  the  stems  of  the  European  larch  and  of 
one  or  two  other  conifers.  It  forms  large  hoof- 
shaped  masses  upon  the  sides  of  the  trunks,  and  pene- 
trates with  its  mycelium  deep  into  the  wood.  When 
young,  these  bodies  are  soft  and  juicy,  but  when  fully 
grown,  hard  and  of  a  consistence  between  spongy  and 
corky.  Agaric  is  collected  in  Europe,  Asia  Minor, 
etc.,  and  usually  prepared  by  drying  and  peeling.  It 
is  in  yellowish-white,  friable,  light,  and  spongy 
irregular  balls  and  lumps,  from  the  size  of  an  orange 
to  that  of  a  coconut  and  larger.  It  has  evidently 
been  peeled,  and  the  surface  is  finely  rough  and  dusty 
with  minute  separated  particles.  The  texture  is 
rather  firm,  but  soft;  it  can  easily  be  reduced  to  a 
coarsish  powder  by  friction  or  by  rubbing  on  a 
sieve,  but  is  difficult  to  pulverize  finely;  its  microscopic 
structure — a  tissue  made  up  of  interlacing,  thread- 
like cells — explains  its  peculiar  consistence. 

Agaric  has  a  heavy  fungous  odor,  and  a  slowly  de- 
veloping, bitter,  nauseous  taste,  which  is  at  first 
sweetish.  Its  powder  is  very  irritating  to  the  eyes  and 
nose,  and  produces  violent  sneezing.  As  it  is  also 
light  and  dusty,  persons  employed  in  beating  it  in 
mortars  are  obliged  to  resort  to  devices  to  prevent  its 
rising. 

It  contains  nearly  one-third  of  its  weight  of  resinous 
matters,  extractible  by  strong  alcohol,  and  these  can 
be  separated  further  into  three  or  four  simple  resins. 
The  active  principle  is  agaric  or  agaricic  acid.  Com- 
mercial agaricin  is  a  concentrated  extract  of  agaric, 
and  constitutes  an  impure  and  indefinite  mixture  of 
the  resins,  but  the  Agaricin  of  the  German  Phar- 
macopoeia is  agaric  acid. 

Agaric,  as  its  name  indicates,  was  originally  used 
chiefly  as  a  cathartic,  but  such  use  is  rare  at  present. 
1 1  i-.  now  rather  considered  that  purgation  is  indicative 
of  over-dosing.  It  is,  in  fact,  but  little  employed  in  its 
own  form,  while  agaricin  and  agaricic  acid  are  growing 
in  favor  as  remedies  for  the  control  of  sweating, 
especially  in  phthisis.     The  dose  of  agaric  is  0.02  to 


0.06  gram  (grain  iij.  to  x.).     More  than  this  acts  as  a 
purgative.      (See  also  Agaricic  Acid.) 

H.  H.  Rusby. 


Agaricic  (or  Agaricinic)  Acid. — (CV.H^Os  +  H.,0.) 
The  active  constituent  of  agaricin.  It  occurs  as  a 
white,  almost  tasteless  powder,  soluble  in  alcohol  and 
with  some  difficulty  in   water,  and   may  be  given  in 

doses  of  0.02-0.03  gram  (grain  £  to  A),  for  the  s: • 

purposes  as  those  for  which  agaricin  is  used.     (See 
Agaric.)  H.  H.  Rusby. 


Agathin. — Cosmin-salicyl-alpha-methyl-phenyl-hjr. 
drazone,  C6HsCH3N,.CH.CH4OH.  This  compound 
results  from  the  reaction  between  the  basic  alpha- 
methyl-phenylhydrazin  and  salicylic  aldehyde.  It 
occurs  in  colorless  crystals,  or  in  greenish-white 
crystalline  flakes;  is  odorless,  tasteless,  insoluble  in 
water,  and  soluble  in  alcohol  and  ether.  It  was 
introduced  by  Roos  as  a  remedy  for  rheumatism, 
and  has  been  found  effective  in  this  disease  and  in 
neuralgia.  It  has  been  known  at  times  to  produce 
headache,  but  the  claim  is  made  that  it  neither 
depresses  the  heart,  nor  gives  the  general  symptoms 
of  salicylism.  Dose:  gr.  iij.  to  x.  (0.2-0.6)  from  three 
to  six  times  a  day.  W.  A.  Bastedo. 


Age. — (Lat.  cetas).  The  age  of  a  person  is  usually 
reckoned  as  the  period  which  has  elapsed  since  his 
birth.  This  method,  although  the  most  convenient, 
does  not  represent  the  true  length  of  life.  The  new 
organism  is  formed  by  the  union  of  an  ovum  and  a 
spermatozoon,  and  the  individual  life  really  begins 
at    the    time    of    that    union.      (See    Impregnation.) 

Practically,  it  is  best  to  divide  the  span  of  life  into 
two  main  epochs:  (1)  antenatal,  and  (2)  postnatal, 
Age  during  the  first  epoch  is  reckoned  from  the  time  of 
fertilization  (conception),  and,  during  the  second, 
from  the  date  of  birth. 

There  are  three  principal  ways  of  expressing  age. 
The  usual  method  is  in  terms  of  time  (chronological 
age).  Age  may  also  be  expressed  in  terms  of  develop- 
ment (anatomical  age),  or  in  terms  of  functional 
activity  (physiological  age). 

Variability  is  a  fundamental  property  of  lhing 
things,  and  is  manifested  at  all  times  of  life.  This  is 
as  true  for  the  rates  of  developments  as  for  other 
characteristics,  and,  for  this  reason,  the  chronological 
age  does  not  correspond  exactly  to  the  anatomical  or 
to  the  physiological  age.  Ages  expressed  in  these 
three  ways  are  correlated,  but  the  correlation  is  not 
so   close   as  is   usually   supposed.     (See    Variation.) 

The  antenatal  epoch  may  be  divided  into  two 
periods:  first,  the  embryonic  period;  second,  the  fetal 
period.  The  first  lasts  from  fertilization  until  the 
organs  are  clearly  formed,  about  sixty  days;  the  second, 
or  time  of  intrauterine  growth,  from  the  end  of  the 
embryonic  stage  until  birth  at  about  the  two  hundred 
and  seventy-first  day. 

The  postnatal  epoch  is  divided  in  various  ways 
by  different  authorities  (Chamberlain,  1900).  The 
scheme  given  below  is  modified  from  the  scheme  of 
Tigerstedt  (1906),  and  has  eight  periods.  (1)  The 
new-born  baby,  tilt  the  falling  of  the  umbilical  cord  on 
the  fourth  or  fifth  day.  (2)  Early  infancy,  to  the 
seventh  or  ninth  month  when  the  first  teeth  erupt. 

(3)  Later  infancy,  lasting  to  the  appearance  of  the 
first    permanent    teeth    at    about    the    seventh    year. 

(4)  Childhood,  from  permanent  dentition  to  the  onsel 
of  puberty  at  about  the  thirteenth  or  fourteenth  year. 

(5)  Adolescence,   till   the  full  stature  is  attained  al 
about  the  twenty-first  year.      (6)  Maturity,  the  period 
of  complete  functional  activity,  ending  at  about  the 
forty-fifth  year  with  the  decline  of  the  sexual  function 
(7)  Middle  Life,  extending  to  the  waning  of  the  phys- 


144 


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Akp 


ica]  and  mental  functions  thai  indicates  the  gradual 
ition   to   old   age.     (8)    Senescence,    marked    by 
,uii,  1  degenerative  changes  which  finally  end  in 
death. 

Estimation  of  the  Age  of  Fetuses.-  The  duration  of 

pregnancy  is  reckoned  usually  fr the  first  day  of  the 

menstrual  period,  but  in  order  to  determine  the 
irobablc  age  of  the  fetus,  it  is  necessary  to  make 
certain  deductions.  These  will  depend  on  which  part 
if  the  menstrual  cycle  furnishes  the  most  favorable 
:onditions  for  fertilization. 

The   menstrual    cycle   normally  occupies   twenty- 
it   days,  and  is  divided  into  four  periods.     These 
ire — (1).  the  intermenstrual   time,  a  period  of  about 
fourteen    days,    during    which    there    is    very    little 
hange    in    tin-    mucous    membrane    of    the    uterus; 
he  premenstrual  period  of  six  or  seven  days,  a 
lime  of  proliferation  and   thickening  of  the  mucous 
membrane;    i:l)    the   menstrual   period,   three  to  five 
lavs,    with    extensive    degeneration    of    the    mucous 
membrane   resulting  in  a  decrease  of  thickness;  and 
ue  postmenstrual  period,  during  which  time  the 
mucous  membrane  is  regenerated. 

( >v  ulation,  apparently,  may  occur  at  an}-  time  during 
this  cycle,  but,  according  to  the  Reichert-His  theory, 
the  generally  accepted  theory,  the  most  fre- 
quent time  of  ovulation  is  toward  the  close  of  the 
premenstrual  period,  and  if  fertilization  takes  place 
immediately  the  menstrual  period  which  would 
v  is  inhibited.  Therefore,  the  probable  age  of 
the  fetus  is  obtained  by  subtracting  twenty-eight 
lays  from  the  time  since  the  beginning  of  the  last 
menstrual  period.  Mall  (1910),  on  the  other  hand. 
concludes,  from  data  collected  by  Leuchart,  that,  when 
copulation  occurs  late  in  the  menstrual  cycle,  the 
spermatozoa  may  reach  the  surface  of  the  ovary,  and 
there  await  the  appearance  of  the  ovum,  and  that,  if 
fertilization  follows  in  the  premenstrual  period,  it  does 
inhibit  menstruation.  If  copulation  occurs  after 
istruation,  the  spermatozoa  may  meet  the  ovum 
and  fertilize  it  on  its  way  down  the  tube.  He  regards 
the  latter  as  the  most  probab  e  event,  because  in 
1,200  cases,  it  was  found  that  the  duration  of  preg- 
nancy was  ten  days  longer  on  the  average  when 
reckoned  from  the  first  day  of  the  last  period,  than 
■  hen  reckoned  from  the  fruitful  copulation.  Most 
pregnancies  begin  during  the  first  week  after  menstru- 
ation. If  the  fruitful  copulation  has  occurred  late  in 
the  menstrual  cycle,  the  apparent  duration  of  preg- 
nancy, as  calculated  from  the  last  menstrual  period, 
is  longer  than  when  copulation  has  taken  place  earlier 
in  the  cycle.  From  a  large  number  of  records  of 
duration  of  pregnancy,  reckoned  from  the  beginning 
of  the  last  menstrual  period,  Mall  concludes  that  the 
mean  age  of  a  child  at  birth  is  271  days.  Its  average 
length   is   fifty   centimeters. 

Thus,  when  the  menstrual  history  is  known,  the 
age  of  the  fetus  can  be  estimated  by  taking  the  time 
elapsed  since  the  beginning  of  the  last  menstrual 
period,  and  correcting  this  for  the  probable  time  of 
conception. 

When,  however,  the  menstrual  history-  is  unknown, 
recourse  must  be  had  to  tables  showing  the  rate  of 
growth  of  the  fetus.  Three  standard  measurements 
are  used  to  express  the  size  of  a  fetus.  These  are  the 
crown-rump,  or  sitting  height,  the  crown-heel,  or 
standing  height,  and  third,  the  neck-breech,  ehiefly 
useful  for  embryos  from  four  to  seven  weeks  old. 
This  last  measurement  has  been  made  in  various  ways. 
Mall  i  1910)  recommends  that  the  upper  point  of  this 
line  be  taken  where  a  line  drawn  through  the  middle  of 
the  lens  and  the  auditory  meatus,  the  oculoauricular 
line,  intersects  the  dorsal  surface  in  the  median  plane 
of  the  body.  Graphic  tables  (Mall,  1910,  Figs.  115 
and  146)  appear  to  show-  a  close  correlation  between 
the  crown-rump  height  and  the  crown-heel  and 
neck-breech  measurements  respectively.  Just  how 
•  the  relation  is,  however,  it  is  not  possible  to  say, 

Vol.  I.— 10 


for  the  coefficients  of  correlation  have  not  been  cal- 
culated and  ii  i  ei  afe  to  rely  on  graphic  method 
alone  lor  statistical  deductions.  (See  Variai 
While  these  three  measurements  would  appear 
io  be  practically  interchangeable,  Mall  regards  the 
crown-rump  measurement  a-  the  best  standard  for 
the  present,  and  next  to  it  the  crown-heel.  Having 
obtained   an  exact    measurement    of   the   fetus,    the 

age    can    be    estimated    by    comparison    with    a    table 

made  from  data  concerning  embryos  and  fetuses  of 
known  menstrual  history,  showing  the  relation 
between  size  and  age.  Mall  (1910,  p.  199  and  I  ig 
1  17  and  1  Is)  gives  such  a  table.  It  is  assumed  that 
fertilization  most  frequently  occurs  ten  days  after 
the  beginning  of  the  last  menstrual  period.  With 
this  assumption,  the  table  gives,  for  each  week  of 
antenatal  life,  tin-  mean  menstrual  age,  the  mean 
crown-heel  and  the-  mean  crown-rump  measurements 
in  millimeters,  as  well  as  other  data  useful  for  esti- 
mating age.     This  is  reproduced  in  part  in  Table  1. 

Table  I. — For  Estimating:  Act.  of  Ff.tcses. 
Mull,  1910). 


Probable 

age  in 
days. 

Mean 
menstrual 

age. 

Mean  length 

of  the  embryo, 

crown-heel. 

mm. 

Mean  length 

of  the  embryo, 

crow  n-rump. 

mm. 

7 

1 1 

21 

31 

.5 

.5 

28 

37 

2.5 

2.5 

35 

43 

5.5 

5.5 

42 

:i 

11 

11 

49 

59 

19 

17 

56 

65 

30 

25 

63 

72 

41 

32 

70 

79 

57 

43 

77 

S6 

76 

53 

si 

94 

98 

68 

91 

100 

117 

81 

98 

108 

115 

100 

1115 

111 

161 

111 

112 

121 

180 

121 

119 

128 

198 

134 

126 

136 

215 

145 

133 

113 

233 

157 

110 

150 

250 

167 

117 

157 

268 

180 

154 

165 

2S6 

192 

161 

171 

302 

202 

16S 

177 

315 

210 

175 

185 

331 

220 

182 

192 

345 

230 

189 

199 

358 

237 

196 

205 

371 

245 

203 

212 

384 

252 

210 

219 

400 

265 

217 

228 

115 

276 

224 

234 

125 

2S4 

231 

241 

436 

293 

238 

24S 

44S 

301 

215 

256 

460 

310 

252 

262 

470 

316 

259 

271 

4S4 

325 

266 

276 

494 

332 

270 

2S0 

500 

336 

The  New-born  Baby. — This  critical  period  of  life 
lasts  from  birth  until  the  umbilical  cord  shrivels  and 
falls  off,  usually  about  four  or  five  days. 

At  the  beginning  of  the  period  there  is  a  sudden 
change  in  the  methods  of  respiration  and  nutrition. 
The  supply  of  oxygen  and  food  from  the  maternal 
blood  is  cut  off,  the  first  air  is  inhaled  into  the  lungs, 
and  the  first  food  taken  into  the  stomach.  The 
accumulation  of  carbon  dioxide  stimulates  the  res- 
piratory centers  to  their  first  effort,  and,  when  once 
begun,"  respiration  is  rapid,  about  35  per  minute. 
The  filling  of  the  lungs  causes  a  profound  change  in 
the  circulation.  Blood,  which  before  that  event  had 
passed  from  the  pulmonary  artery  directly  through 

145 


Age 


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the  ductus  arteriosus  into  the  aorta,  is  now  directed 
into  the  right  and  left  branches  leading  to  the  lungs, 
and  returned  to  the  left  side  of  the  heart  through  the 
pulmonary  veins.  The  ductus  arteriosus  begins  to 
contract  immediately  upon  the  establishment  of 
pulmonary  respiration;  and  partly  by  this  means, 
and  partly  by  a  thickening  of  its  walls,  becomes 
closed  by  the  sixth  or  seventh  day.  The  changes  in 
the  fetal  circulation  do  not  take  place  all  at  the  same 
time.  The  first  to  be  completed  is  the  closure  of 
the  distal  ends  of  the  allantoic,  or  umbilical,  arteries; 
and  the  last  is  the  closure  of  the  foramen  ovale  of 
the  heart,  which  may  remain  incomplete  for  months. 
The  movements  of  the  child  during  this  period  are 
largely  of  the  random  type.  There  are  few  estab- 
lished reflexes  during  the  first  week,  but  Darwin 
found  that  sneezing,  hiccoughing,  yawning,  stretching, 
sucking,  and  screaming  were  well  performed  during 
the  first  seven  days.  (Hobhouse,  1901,  p.  40.)  The 
sucking  movements  are  reflex  rather  than  instinc- 
tive, and,  at  first,  are  often  made  at  random,  the  baby 
frequently  sucking  at  the  wrong  place  (Hobhouse,  p. 
42).  The  senses  at  this  time  appear  to  be  defective. 
The  new-born  child  is  said  to  be  wanting  in  a  true 
olfactory  sense,  and  its  eyes  are  oversensitive  to 
light,  and  probably  do  not  form  clear  images  (Cham- 
berlain, pp.  77-79) 

That  the  changes  in  mode  of  existence  incidental 
to  birth  produce  a  crisis  in  the  life  of  the  child,  and 
present  new  conditions  to  which  the  child  adapts 
itself  with  difficulty,  is  shown  by  the  loss  of  weight 
which  normally  occurs  during  the  first  few  days, 
and  by  the  high  rate  of  mortality.  Earliest  infancy, 
as  well  as  other  periods  of  human  life,  has  its  charac- 
teristic diseases,  but,  'unfortunately,  statistics  of 
morbidity  are  lacking,  and  the  relative  frequency 
of  diseases  can  only  be  judged  by  means  of  the  statis- 
tics of  death.  The  Mortality  Statistics,  1910,  pub- 
lished by  the  U.  S.  Bureau  of  the  Census  ( Bulletin  109) , 
show  for  the  first  time  in  the  United  States  the  mor- 
tality due  to  each  of  the  principal  causes  of  death 
during  each  of  the  first  six  days  of  postnatal  life. 
For  the  year  1910  there  were  reported  36,351  deaths 
of  infants  less  than  a  week  old.  Of  these  16,197 
died  as  a  result  of  premature  birth,  and  more  than 
half  of  these  deaths  occurred  on  the  first  day.  The 
next  most  important  cause  of  death  was  congenital 
debility,  of  which  5,943  cases  occurred  in  the  first 
week,  and  2,007  during  the  first  day.  Malformation 
comes  next,  with  1,437  deaths  during  the  first  day, 
and  a  total  for  the  first  week  of  4,380.  Convul- 
sions and  syphilis  complete  the  list  of  important 
causes  of  death  of  the  new-born.  Here  we  see 
natural  selection  rigorously  at  work  weeding  out  the 
unfit  as  soon  as  they  leave  the  protection  of  the 
mother's  womb. 

Early  Infancy. — Having  survived  the  dangers  of 
birth,  the  infant  resumes  its  growth,  and  during  the 
next  few  months  undergoes  a  growth  more  rapid  in 
proportion  to  size  than  at  any  other  period  of  post- 
natal life.  In  fact,  after  this  early  maximum,  the 
relative  rate  of  growth  gradually  diminishes,  except 
for  a  considerable  rise  at  the  time  of  puberty,  until 
the  complete  stature  is  attained  in  about  the  twen- 
tieth year  (see  Growth).  The  skeletion  is  still  carti- 
laginous to  a  considerable  extent.  Recent  studies 
on  the  development  of  the  wrist  bones  by  Pryor 
(1906,  190S)  and  by  Rotch  (1909)  have  shown  that 
the  epiphyses  are  usually  wholly  cartilaginous,  and 
the  carpal  bones  do  not  exhibit  any  centers  of  ossi- 
fication in  the  early  part  of  this  period.  The  move- 
ments now  change  from  random  and  reflex  to  more 
adaptive  and  complicated  instinctive  actions.  Bo- 
manes  (1892)  has  pointed  out  that  some  of  these  are 
remarkably  simian  in  character;  for  example,  the 
position  of  the  feet  and  great  toe,  and  the  grasping 
iniivement  coupled  with  extraordinary  development 
of  strength  in  the  hands.     The  child  has  a  marked 


tendency  to  grasp  any  object,  especially  hair,  which 
comes  into  contact  with  the  hands,  and,  at  three 
weeks  of  age,  can,  by  holding  on  to  a  horizontal  bar, 
support  its  own  weight  for  a  half  to  more  than  two 
minutes.  The  sense  organs  soon  become  completely 
functional,  and  the  eyes  show  the  maximum  power 
of  accommodation.  The  face  changes  from  stupid 
passivity  to  an  animated  expression,  and  the  cries 
change  from  disordered  sounds  to  expressions  of  emo- 
tion and  desires  intermingled  with  laughter  and  tears. 

Although  this  development  of  the  baby  brings  with 
it  a  rapid  decrease  in  the  chances  of  death,  this  period 
of  early  infancy  has  its  grave  dangers.  During  the 
first  month,  congenital  debility  and  premature  birth 
are  still  important  causes  of  death.  Cases  of  diarrhea 
and  enteritis  and  of  bronchopneumonia  appear  with 
rapidly  increasing  frequency,  and,  during  the  greater 
part  of  the  period,  become  the  most  important  causes 
of  death.  The  maximum  number  of  deaths  from 
bronchopneumonia  and  pneumonia  occur  during  the 
second  half  of  the  first  month.  Diarrhea  becomes 
the  most  dangerous  disease  in  the  second  month, 
and  continues  as  such  until  the  end  of  the  period, 
reaching  its  maximum  in  the  fourth  month. 

Later  Infancy. — This  period  begins  with  the 
eruption  of  the  first  tooth  and  ends  at  the  first  appear- 
ance of  the  permanent  dentition  with  the  eruption 
of  the  first  true  molar.  It  extends  from  the  sixth 
month  to  the  sixth  year. 

The  usual  ages  at  which  the  teeth  of  the  temporary 
dentition  appear,  according  to  Legros  and  Magitot, 
are  as  follows  (Hill,  1909,  p.  138): 

First  inferior  incisors Sixth  month. 

First  superior  incisors Tenth  month. 

Second  inferior  incisors Sixteenth  month. 

Second  superior  incisors Twentieth  month. 

First  inferior  premolars Twenty-fourth  month. 

First  superior  premolars Twenty-sixth  month. 

Second  inferior  premolars Twenty-eighth  month. 

Second  superior  premolars Thirtieth  month. 

Canines Thirtieth  to  thirty-second  month 

The  replacement  of  the  cartilaginous  skeleton  by 
bone  is  incomplete  at  birth,  and  makes  important 
advance  during  the  period  of  later  infancy.  Pryot 
has  studied  the  development  of  the  bones  of  the  hand 
and  wrist  by  the  or-ray  method.  Rotch  (1909),  using 
the  same  method,  has  confirmed  Pryor's  results  con- 
cerning  the  wrist  bones,  and  proposes  to  use  the 
stages  in  their  development  as  indices  of  anatomical 
age.  From  a  study  of  289  children,  Pryor  (190S) 
has  constructed  the  following  table  showing  the  varia- 
tions in  the  order  of  appearance  of  the  carpal  boms, 
doubtful  cases  being  omitted. 

Table  II. — Order    of    Ossification    of    Carpal    Boxes. 


o 

a 

c 
to 

S3 

PS 

a 

u 

,C 

a 
P 

g 

'S 
a 

3 

O 

ci 

a 

1 
m 

'o 
-c 
a 

ej 
a 
CO 

-6 
'o 

N 

ft) 

a 
S 

a 

,3 

'5 
o 
Q. 

i 

'5 

1 

23S 

5 



9 

5 

236 

219 

12 

i 

10 

176 

3 

8 

7 

- 

8 

SO 

36 

30 

6 

2 

27 

59 

31 

- 

6 

l'.l 

21 

51 

8 

Totals 

243 

2-11 

229 

204 

129 

12  1 

119 

i  u; 


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Arc 


Rotch  (1909)  finds  that  the  Lower  epiphysis  of  the 

adius  begins  to  ossify  soon  after  the  unciform,  and  the 
ower  epiphysis  of  the  ulna  appears  after  all  the 
ither  carpal'  bones  except  the  pisiform.  Counting 
hese  two  epiphyses  in  with  the  eight  carpal  ossifi- 
cations, we  may  modify  a  table  given  by  Rotch 
J.  c,  p.  IS)  as  follows. 

Tadle  III. — Staoes  of  Anatomical  Age  as  Indicated  by 
the  Ossifications  in  the  Wrists. 


Stage. 

Number  of 
centers. 

Approximate  age  in 
years. 

A 

2 

&— 1 

B 

3 

(?— 2 

C 

4 

6*— 31 

D 

5 

9— 3i 
d1— 41 

E 

6 

9  —  11 
0^-51 

F 

7 

1 
d1— 53 

G 

8 

9 — 51 
61— 63 

H-J 

9 

9— 62 

c*— 71    to 

K-.U 

10 

9—101- 
d"—  12J- 

The  data  in  regard  to  six  and  chronological  age 
in  this  table  are  taken  by  Rotch  from  observations 
made  by  Pryor. 

Rotch  (1909)  gives  the  record  of  his  own  observa- 
tion on  133  children  showing  sex,  weight,  height,  num- 
of  teeth,  development  of  the  wrist,  mental  con- 
dition, and  approximate  age  in  years.  These  children 
were  selected  as  being  normally  developed.  Besides 
being  of  an  average  height  and  weight  and  healthy 
looking,  they  were  known  to  have  had  no  disease 
that  could  cause  an  enlargement  of  the  carpal  bones 
and  epiphyses,  and  they  had  not  shown  any  con- 
dition that  would  tend  to  retard  the  normal  devel- 
opment. From  his  results  Table  IV  has  been  com- 
piled. This  shows  the  relation  between  chrono- 
logical age,  sex,  number  of  teeth,  and  number  of  ossi- 
fications in  the  wrist.  The  columns  in  this  table  are 
divided  into  squares,  each  square  is  subdivided  into 
two  sections,  and  a  diagonal  line  crosses  each  section. 
The  "argument"  is  the  chronological  age,  and  the 
tabular  entries  are  the  numbers  of  individuals  having 
the  numbers  of  teeth  or  wrist  bones  indicated  at  the 
heads  of  the  columns.  The  numbers  in  the  upper 
section  of  each  square  refer  to  teeth,  in  the  lower 
section,  to  wrist  bones.  In  each  section,  the  number 
on  the  left  of  the  diagonal  indicates  males;  on  the 
right,  females. 

These  observations,  although  too  few  for  statis- 
tical analysis,  indicate  that  the  development  of  the 
temporary  dentition  is  relatively  rapid,  being  com- 
pleted by  the  end  of  the  second  year  with  little  show 
of  variation.  The  development  of  the  wrist  bones 
is  a  more  gradual  process,  and  is  very  variable  in 
respect  to  chronological  age.  But  by  the  time  the 
first  molars  of  the  permanent  dentition  have  erupted, 
the  majority  of  children  show  at  least  eight  ossi- 
fications in  the  wrist,  the  complete  number  except 
for   the  epiphysis  of   the  ulna  and   the  pisiform.     In 


some  cases  the  epiphysis,  too,  has  appeared.  As 
Crampton    (1908    0)   has  said,   the  question  of  the 

value  of  Rotch's  criterion  of  anatomical  age  can  be 
settled  only  by  establishing  a  correlation  between  the 
stages  of  development  of  tile  wrist  and  the  progress 
of  other  organs  or  functions.  The  material  for  such 
a  correlation  is,  however,  not  yet  available. 

Two  events  that  especially  distinguish  man  from 
the  lower  animals  occur  during  this  period.  These 
are  the  acquirement  of  speech,  and  the  assumption 
of  the  upright  position.  The  change  from  inarticulate 
cries  to  the  formation  of  words  is  a  gradual  one.  At 
the  beginning  of  this  period,  the  infant  lias  learned 
to  make  dental  articulations,  and  its  babbling  takes 
the  form  of  syllables  such  as  da,  I",  "'".  and  toward 
the  end  of  the  first  year,  or  at  the  beginning  of  the 
second,  the  first  words  are  spoken,  mamma,  /'»/'«, 
to  which  some  more  or  less  vague  meaning  is  attached. 
This  is  tin'  commencement  of  the  imitative  period, 
when  the  child  attends  to  the  words  it  hears,  and 
tries  to  reproduce  them.  The  preparation  for  walking 
is  largely  concerned  with  the  growing  strength 
in  the  legs  and  arms  of  the  child.  Attention  lias 
already  been  called  to  the  relatively  great  strength 
of  hands  and  arms  of  a  new-born  baby.  _  With  the 
rapid  accumulation  of  fat,  however,  the  infant  soon 
becomes, too  heavy  to  support  its  own  weight,  and 
can  only  wave  its  arms  and  legs.  As  the  muscles 
become  stronger  and  larger,  the  ability  to  support 
the  weight  gradually  returns.  The  child  can  sit  up, 
then  it  can  creep,  and  soon  it  learns  to  pull  itself  to  a 
standing  position  beside  a  chair.  Then  it  takes  the 
first  tottering  steps,  and  finally,  in  the  third  or  fourth 
year,  it  begins  to  walk  easily. 

At  the  beginning  of  this  period,  there  is  a  gradual 
diminution  in  the  mortality  from  the  infections  of  the 
endodermal  organs — the  digestive  tract  and  the  re- 
spiratory aparatus.  Whether  this  is  due  to  natural 
selection  or  to  a  gradual  acquirement  of  immunity, 
it  is  impossible  to  say.  Diarrhea,  while  diminishing 
considerably,  still  remains  the  chief  cause  of  death 
to  the  end  of  the  second  year.  It  has  active  com- 
petitors in  diphtheria  and  croup  which,  grouped 
together,  reach  their  maximum  frequency  in  the 
second  year,  and,  with  scarlet  fever  as  a  second,  are 
left  the  chief  causes  of  death  in  the  fourth  and  fifth 
years. 

Childhood. — This  period  starts  when  the  eruption 
of  the  first  true  molars  has  taken  place  and  ends  with 
the  onset  of  puberty.  Permanent  dentition,  with  the 
exception  of  the  third  molars  or  "wisdom"  teeth, 
which  come  later,  is  established  during  these  years. 
The  times  at  which  these  permanent  teeth  appear  as 
determined  by  Legros  and  Magitot  are  given  in  the 
second  column  of  Table  V.  The  columns  to  the 
right  give  the  sex.  age,  and  variability  as  tabulated 
by  Crampton  chiefly  from  data  collected  by  Boas. 
At  the  beginning  of  this  period,  the  wrist  bones  are 
in  Rotch's  stages,  G  or  H;  at  the  close  of  the  period, 
they  have  probably  reached  stage  M.  At  stage  K 
the  first  appearance  of  the  pisiform  is  noted.  The 
other  stages  after  H  still  need  more  exact  definition 
to    make    them    available   for   statistical  treatment. 

Hall  (190-1,  p.  9)  says  of  this  age:  "The  years  from 
about  eight  to  twelve  constitute  a  unique  period  of 
human  life.  The  acute  stage  of  teething  is  passing,  the 
brain  has  acquired  nearly  its  adult  size  and  weight, 
health  is  almost  at  its  best,  activity  is  greater  and  more 
varied  than  ever  before  or  than  it  ever  will  be  again, 
and  there  is  peculiar  endurance,  vitality.and  resistance 
to  fatigue.  The  child  develops  a  life  of  its  own  outside 
the  home  circle  and  its  natural  interests  are  never 
so  independent  of  adult  influences.  Perception  is 
very  acute,  and  there  is  a  great  immunity  to  expo- 
sure, danger,  accident,  as  well  as  to  temptation. 
Reason,  true  morality,  religion,  sympathy,  love,  and 
esthetic  enjoyment  are  but  very  slightly  developed. 
Everything,  in  short,  suggests  the  culmination  of  one 


147 


Age 


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Table  IV. — Number  of  Teeth  and  Wrist  Bones  in  Relation  to  Age  and  Sex. 


Teeth. 
Wrist. 

0 

1-2 
A- 2. 

3-4 
B  =  3. 

5-b 
C-4. 

7-8 
D=5. 

9-12 
E  =  6. 

13 -IS 
F=7. 

17-20 
G=8. 

24 
H-J 

=  9 

25 
K-M 

=  10 

►.& 

1— G  months 

5  ^*^ 
J>^     1 

5         ,'' 

7-11  months- 

3      .^ 

1     ^^ 

^-^     1 

1          -^ 

1     i^^ 
^-^    1 

1-2  years 

2     ^*^ 

^^   1 

1       ,^ 

_^^ 

1  ^^^ 

*^^ 

3       ,''' 

,-'     1 

,'''     1 

1 

,-''     1 

2-3  years. 

4      ^-^^ 
^-^    4 

>> 

,-*'     1 

3       ,-' 
,-''      1 

1 

,'''     2 

C 
e3 

c 

_ 

3-4  years. 

":f —---.' 

^'^"     2 

,-'"'  1 

1        "'' 
„,-''      1 

.,-"'     1 

4        -^ 

_______?, 

,-'''  1 

J 

4-5  years 

5    ^-^ 

^-^     5 

,-'''  1 

1      ,--' 
,-'       3 

2          -^ 
,.--"'  1 

1        ,-' 

1       ^,'- 

5-6  years. 

________ 

,--'      1 

______ 

.______. 

,""''     2 

,-''     2 

,-''      1 

6 -7  years 

1        ,-'' 
,-''     1 

^^  3 

^^4 

-'""'  3 

>--''  S 

7—8  years. 

1    ^-^ 

7     ^^ 
s^    2 

o 

2       ,-' 

4       ,--' 

8-9  years. 

4    ^^ 
4       ,--'"" 

9  -10  years. 

>-^ 

5      ^^ 

o 
2 

5        ^""' 
--''      3 

1       .-'l 
-''      1 

10  -11  years. 

/^  Z 

5 

5       --'' 
.--'        1 

,-''      2 

11— 12  years. 

4  ^^ 
^"^      5 

1 

>"\ 

12-13  years. 

4         -^"'' 

^^     4 

s'        1 

4      ,--'' 
--'''      5 

Table    V. — Age  of  Eruption  op  Permanent  Teeth. 


Teeth. 


Age. 


Sex. 


Mean 
age. 


o-6    years 

6-7    years 

8 J  years 

0-10  years 

10-11  years 
11—12  years 
12-13  years 
1 8-25  years 

Second  incisors 

First  premolars 

Second  premolars  .... 

[% 

it? 

7.0 
7.5 
8.9 
9.5 
9.0 
9.8 

1 .6  years 
1 . 4  years 
2.  1  years 
2 . 1  years 
2.  S years 
1 . 6  years 

1  6 
it? 

(_, 
I  t? 

5 

1  t? 

11.2 
11.3 
12.8 
13.2 
19.3 
22.0 

1 .4  years 

Second  molars    ...... 

Third  molars     

1 .0  years 
1 . 6  years 

2 . 0  years 

2 . 1  years 
1 . 8  years 

The  Greek  letter  aigma  (")  js  the  symbol  for  the  standard  devia- 
tions, a  measure  of  variability  (see  Variation), 

1  IS 


stage  of  life.  As  if  this  represented  what  was  once 
and  for  a  very  protracted  and  relatively  stationary 
period,  the  age  of  maturity  in  some  remote,  perhaps 
pigmoid,  stage  of  human  evolution,  when,  in  a  warm 
climate,  the  young  of  our  species  once  shifted  for 
themselves  independently   of  further  parental  aid." 

The  relative  immunity  from  disease  at  this  age  is 
shown  by  the  mortality  statistics.  Of  805,412 
deaths  reported  in  1910  (IT.  S.  Census  Bulletin  109), 
17,943  were  of  children  aged  five  to  nine  years,  and 
only  11,736  at  the  ages  of  ten  to  fourteen.  During 
the  first  five  years,  the  most  frequent  cause  of  deatn 
wns  diphtheria  (2,938);  scarlet  fever  was  second 
(1,731);  tuberculosis  of  all  kinds,  third  (1,422);  and 
pneumonia,  fourth  (1,138).  In  the  second  five 
years,  tuberculosis  becomes  the  chief  cause  of  death 
(all  kinds,  1,634);  typhoid  fever,  second  (8 
appendicitis,  third  (718);  and  diphtheria,  fourth  (709). 

Adolescence. — The  period  from  the  onset  of  puberty 


EEFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


A  ci- 


lo  the  attainment  of  maturity  is  called  adolescence, 
.1M,I  the  corresponding  age  in  years  is  generally  con- 
sidered to  be  from  twelve  to  twenty-one  for  girls 
and  from  fourteen  to  twenty-five  for  boys.  (Cramp- 
ton  (190S  6)  defines  puberty  as  the  moment  when  the 
sexual  life  begins.  In  girls,  this  time  is  plainly 
indicated  bv  the  first  menstruation;  in  boys  it  is  not 
so  easily  determined,  but  i.s  indicated  by  the  appear- 
of'the  secondary  sexual  characters.  These  are: 
first,  the  growth  and  pigmentation  of  the  hair  upon 


.- 

MO 

.... 

' 

,0.1 

HO 



no 

ii 

3'.' 

347 

»i« 

II 

100 

irj 

102 

/ 

ft] 

I? 

1 

1 

i  nrvo  of  Frequency  of  3,500  Cases  of  First  Menstruation 
(observed  by  Heinricius  in  Finland) . 

the  pubic  eminence  and  in  the  axilla?  in  both  sexes; 
id,    the  development   of  the  beard  and  change 

-ire  in  boys;  and,  third,  the  development  of  the 
ts  in  girl's,  and  the  deposition  of  subcutaneous 

giving  the  pleasing  rounded  contours  so  charac- 
teristic  of  young  womanhood. 

The  chronological  age  of  the  first  menstruation 
differs  in  various  countries  and  in  the  individuals  of 
each  country.  From  the  numerous  collections  of 
statistics  quoted  by  Hall  (1904,  p.  474-8),  it  would 
appear  that  the  average  age  in  southern  Asia  is  be- 
tween twelve  and  thirteen;  in  southern  Europe. 
thirteen  and  a  half  to  fourteen  and  a  half;  central 
Europe,  fourteen  to  fifteen;  and  northern  Europe, 
between  sixteen  and  seventeen.  In  the  United 
Mates,  a  number  of  investigators  have  found  an 
average  age  of  about  13.6;  others  place  the  age 
a i  1  1.5.  While  the  average  age  does  not  necessarily 
coincide  with  the  age  of  greatest  frequency,  they  may 
lie  Dearly  the  same.  This  is  shown  by  3,500  recorded 
cases  collected  by  Heinricius  (1SS3)  in  Finland.  His 
results  are  given  in  Table  VI. 

Table   VI. 


Age,  years. 


v.   ol  cases. 


11  1J     13    14;   15    16    17    18    10    20  212:2 
933  135  440  765  S46  560  347  198  102  11  12 

L 


2:;  2:,  21; 


4     1 


The  average  age  is  15.82,  and  the  tabular  age  of 
atest  frequency  i.s  sixteen,  and  when  the  curve  of 
variation  is  plotted  (Fig.  53),  it  is  seen  to  be  a  slightly 
^kew  curve.  (See  Variation.)  A  similar  curve  is  given 
bv  the  statistics  of  3,000  Prussian  girls,  collected  by 
bullies  (1886)  and  quoted  by  Hall  (1904,  p.  475). 
Marro  (1901)  has  collected  the  statistics  of  the  signs 
of  puberty  in  girls,  including  not  only  menstruation, 
but  also  the  appearance  of  pubic  hairs,  of  axillary 
hairs,  and  the  development  of  the  breasts.  These 
results  have  been  presented  by  Crampton  (190S  6) 
in  a  table  reproduced  below,  which,  for  each  year 
between  the  ages  of  nine  and  a  half  and  eighteen  and 


a  half  shows  the  percentage  of  girls  that  exhibit  each 

of  thesefour  signs  of  puberty.  The  lineal  the  IhiII.hu 
of  the  table  has  been  added  to  show  the  relative  fre- 
quency of  first  menstruation  at  each  ■<■ ! 

AGE 


9.5 

10.5 

11.5 

12.5 

13.5 

14.5 

15.5 

KS.5 

i  i  .5 

18.5 

/fy  ' 

-^-* 

^-** 

00 

ty 

// 

/// 

/ 

-// 

o00 
< 

1- 

2  50 

0 
en 
w  in 

I 

i 

i 

h 

f 

fi 

(4 

0 

J^' 

AXILLA MENST.- 


■  BREASTS^- K- 


Fio.  54. — Integral  Curves  showing  the  Percentage  of  Italian 
(Jirls  who  at  Each  Age  had  Attained  Each  of  the  Four  Signs  of 
Puberty.     (From  statistics  by  Marro.) 


Table  VII. — Percenta 

IE    OF 

Italian' 
Puberty. 

jIRLP 

Showing 

St   ;\-.   OF 

Age  in  years. .  . 

9.5 

10.5 

11.5 

12.5 

13.5 

14.5 

1  ', .  5 

16.5 

17.5 

IS. 5 

Pubes,  '. 

0 

3 

3 

9 

35 

57 

76 

S9 

100 

Axilla,  %    ... 

0 

3 

3 

6 

16 

12 

64 

74 

90 

or, 

Menstr'ation  % 

0 

3 

3 

3 

15 

55 

67 

77 

96 

100 

Breasts,  f"; 

0 

3 

3 

7 

13 

to 

71 

82 

96 

96 

First  .Menses.  .  . 

0 

3 

0 

0 

12 

10 

12 

10 

19           4 

The  curves  plotted  in  Fig.  54  show  the  same  facts 
in  graphic  form.  From  examination  of  the  table 
and  curves,  it  will  be  seen  that  half  of  the  girls  had 
menstruated  before  the  end  of  the  first  half  of  the 
fifteenth  year.  The  pubic  pubescence  appeared 
somewhat  earlier,  while  the  axillary  pubescence 
and  the  breasts  developed  at  about  the  time  of  the 
first  menstruation,  sometimes  a  little  earlier,  some- 
times a  little  later. 

A  similar  table  from  the  same  sources  and  the 
curves  (Fig.  55)  plotted  from  it,  show  that  in  a  group 
of  Italian  boys  studied  by  Marro,  pubic  pubescence 
had  appeared  in  fifty  per  cent,  by  the  end  of  the 
first  half  of  the  sixteenth  year.  The  axillary  pubes- 
cence becomes  evident  nearly  two  years  later,  and  a 
year  later  still  the  mustache  begins  to  grow. 

Table  VIII. — Percentage    of    Italian    Bots    Pi-bescent    at 
Various  Ages. 


12.5 

13.5 

14.5 

15.  i 5. 

16.5 

17.5 

18.5 

0 

14 

29 

59 

77 

100 

100 

0 

0 

11 

9 

33 

57 

88 

0 

0 

1 

0 

29 

43 

60 

149 


Age 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Crampton  lays  great  stress  on  the  pubic  pubescence 
as  an  indication  of  physiological  age.  He  defines 
pubescence  as  the  process  of  becoming  covered  with 
hairs,  especially  the  pubic  pubescence.  A  pubes- 
cent is  an  individual  undergoing  this  process,  which 
presents  three  phases.  The  first  is  the  appearance 
of  an  evident  and  rapid  growth  of  fine  hairs  upon  the 


[00 


o 


BO 

80 

70 

60 

£50 
o 

UL 
Ld 

a.  40 

30 

20 

10 

0 


12.5 

13.5 

14.5 

AGE 
15.5     16.5 

17.5 

18.5 

19.5 

/ 

/ 
/ 

j 

/ 

/ 

1 
1 
1 

1 

1 
1 
1 

/ 

i 

1     / 

I 

i 
i 
i 
■ 

1 

1 

;  / 

/ 

/ 

/ 

S 

^ 

AXILLA 


Fig.    55. — Plotted    from    data    given    in    Table     VIII.      (After 
Cramptou.) 

pubic  eminence,  the  second  is  the  pigmentation  of 
this  hair,  and  the  third  is  the  acquirement  of  its 
characteristic  twist  or  kink.  A  prepubescent  is  an 
individual  in  whom  this  process  has  not  become 
evident;  a  postpubescent  is  one  who  by  reaching  the 
third  phase,  has  completed  the  process.  From  an 
examination  of  3,835  high  school  boys  in  New  York 
City,  Crampton  obtained  the  data  presented  in 
Table  IX. 


ossification  of  the  epiphyses  which  is  completed  with 
the  cessation  of  growth  at  the  end  of  this  period. 

In  regard  to  the  mental  condition  of  the  adolescent 
Hall  says:  "Adolescence  is  a  new  birth,  for  the 
higher  and  more  completely  human  traits  are  now 

born The     functions    of    every    sense 

undergo  reconstruction;  and  their  relations  to  other 

psychic     functions     change The     voice 

changes,  vascular  irritability,  blushing,  and  flushing, 


,„                                                                                                ^"     1         /"' 

-^     ~3? 

-o                         ,Z         Z    . 

/                     / 

/                   / 

A             / 

/             / 

/              I 

/                j 

™          /                1 

~7^r        ' 

,/         jf" 

s 

'"  12.25  12.75  13.20  13.75  11.25  11.75  15.25  15.76  16.25  1G.75 17.25  17.75 
AGE;  HALF  YEAR  MEAN 

Fig.  56. — Integral  Curves  showing  at  each  age  the  percentage 
of  New  York  High  School  Boys  in  each  of  the  three  phases  of 
Pubescence.     Plotted  from  Table  IX. 

are  increased.  Sex  asserts  its  mastery  in  field  after 
field.  There  are  new  repulsions  felt  toward  home 
and  school,  and  truancy  and  runaways  abound.  The 
social  instincts  undergo  sudden  unfoldment,  and  a 
new  life  of  love  awakens.  It  is  the  age  of  sentiment 
and  of  religion,  of  rapid  fluctuation  of  mood,  and 
the  world  seems  strange  and  new.  Interest  in 
adult  life  and  in  vocations  develops.  Youth  awakes 
to  a  new  world,  and  understands  neither  it  nor 
himself." 

The  death  rate  during  adolescence  is  still  low,  but 
considerably  greater  than  during  childhood.  Of  a 
total  of  805,412  deaths  reported  in  the  registration 
area  of  the  United  States  during  1910,  19,772  occur- 
red between  the  ages  of  fifteen  and  nineteen  years. 


Table  IX. — Age  of  Pubescence  in  High  School  Boys  of  New  York  City  (3,835  Cases). 


Age,  half-year 
mean. 

12.25 

12.75 

13.25 

13.75 

14.25 

14.75 

15.25 

15.75 

16.25 

16.75 

17.25 

17.75 

Prepubescent 

(81)* 

69 

55 

11 

26 

16 

9 

5 

2 

1 

0 

0 

(16)* 

25 

26 

2S 

28 

24 

20 

10 

4 

4 

2 

0 

(21* 

6 

IS 

31 

46 

60 

70 

So 

93 

95 

98 

100 

*  Calculated. 


This  table,  represented  graphically  in  Fig.  4,  shows 
that,  in  this  group  of  boys,  fifty  per  cent,  have  entered 
the  first  phase  of  pubescence  by  the  middle  of  the 
fourteenth  year  and  have  completed  the  process 
before  the  middle  of  the  fifteenth. 

The  rate  of  growth,  which  has  been  gradually 
decreasing  during  childhood,  increases  during  pubes- 
cence, and,  according  to  Crampton,  reaches  a  climax 
at  or  immediately  after  the  change  to  postpubescence. 
(See  Groivth.)  There  is  an  acceleration  in  weight 
and  strength  at  the  same  time.  Among  changes  in 
the  internal  organs  in  puberty  may  be  noted  an  in- 
crease in  the  size  of  the  heart  and  in  lung  capacity, 
a  loss  of  fat  in  boys,  and  a  temporary  loss  in  girls, 
a  lengthening  of  the  jaw,  and  an  acceleration  of  I  Ik- 
ISO 


Tuberculosis  of  the  lungs  was  the  chief  cause  with 
5,166  cases.  In  the  next  five  years,  the  number 
nearly  doubled;  9,622  cases.  Typhoid  fever  was 
next  in  importance,  and  was  likewise  increasing, 
there  being  1,681  cases  in  the  years  fifteen  to  i 
teen  and  2,067  in  the  years  twenty  to  twenty-five. 
Organic  disease  of  the  heart,  and  pneumonia,  about 
equally  important,  and  both  increasing,  occupy  the 
third  place. 

Maturity. — No  sharp  line  can  be  drawn  between 
adolescence  and  maturity.  Between  the  twentieth 
and  the  twenty-fifth  year  the  fully  adult  stature  is 
attained  and  growth  ceases.  The  change  is  so  grad- 
ual as  to  be  hardly  perceptible.  Now  both  psy- 
chic and  physical  functions  have  reached  their  max- 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Agenesis 


iiiHiia  development  and  power.  According  to  Osier 
(1905),  "The  effective,  moving,  vitalizing  work  of 
the  world  is  done  between  the  ages  of  twenty-live 
and  forty."  . 

The  ten  years  from  twenty  to  thirty  is  the  chief 
reproductive  period,  and  therefore  at  this  age  most 
of  the  accidents  of  childbirth  occur,  t  If  all  the  ileal  lis 
due  to  the  puerperal  slate  in  1910,  15.5  per  cent. 
were  during  this  decade.  The  death  rates  from 
typhoid  fever  and  from  tuberculosis  both  reach  their 
maximum  at  this  time,  but  the  latter  is  by  far  the 
most  important,  causing,  in  1910,  35  per  cent,  of  all 
the  death-  in   this  age. 

Middle  Age. —  The    boundary  between    the  age    of 

maturity  and  middle  age  is  distinctly  marked  in 
women  by  the  climacteric,  or  menopause.      This  i>  the 

ation  of  menstruation  and  oilier  sexual  functions, 
which  usually  occur  rather  suddenly  between  the 
of  forty-five  and  fifty.  In  men,  sexual  activity 
diminishes  al  about  tlie  same  age,  but  so  gradually 
that  many  men  have  been  able  to  beget  children 
at  a  much  later  period  of  life. 

These  changes  are  accompanied  by  other  evidences 

of  the  approach  of  senility.     The  most   noticeable  of 

i  is  the  turning  gray  of  the  hair.     The  dynamic 

ficient  of  the  skeletal  muscles  begins  to  diminish 

thirty  or  forty  years  of  life,  and  the  plain  muscles 

suffer  a  similar  change,  as  is  shown  by  the  diminished 

t  of  the  heart,  intestines,  bladder,  and  other 
organs.  The  lessened  power  of  accommodation  in 
the  eyes  is  not  so  characteristic  of  this  period  as  is 
generally  supposed.  According  to  Donders  (1858), 
the  power  of  accommodation  is  at  its  maximum 
in  young  children,  when  the  lens  is  soft  throughout. 
It  soon  begins  to  harden  at  the  center,  and  as  the 
Sclerosis  gradually  spreads  toward  the  periphery 
there  is  a  parallel  loss  of  accommodation.  The  in- 
verse correlation  between  accommodation  and  age 
when  plotted  is  represented  by  a  straight  line.  The 
range  of  accommodation,  measured  in  diopters,  as 
given  by  Donders  is 


At  ten  years 14 

At  twenty  years 10 

At  thirty  years 7 

At  forty  years 4.5 


After  forty,  1  D  less  every  five  years.  When  the 
power  of  accommodation  becomes  so  limited  that  it 
IS  no  longer  possible  to  focus  the  eyes  upon  a  small 
object  near  enough  for  clear  vision,  we  have  the 
condition  known  as  presbyopia,  which  is  characteristic 
of  middle  and  old  age.  (See  the  articles  on  Accom- 
vwdalinn  and  Refraction  and  Eye,  Dioptrics  of.) 

The  fatal  diseases  characteristic  of  middle  age  are 
heart  disease,  nephritis,  and  cancer.  In  1910,  they 
caused,  in  persons  between  fifty  and  fifty-nine  years 
of  age,  13.4,  11.7,  and  12.1  per  cent,  of  registered 
deaths  respectively,  and  in  persons  between 
sixty  and  sixty-nine  18.2,  12.1,  and  11.1  per  cent, 
respectively. 

Senescence. — There  is  no  sharp  boundary  between 
middle  life  and  old  age,  but  an  individual  may  be 
said  to  have  become  senescent  when,  by  reason  of 
age,  the  decline  of  any  of  his  bodily  or  mental  func- 
tions has  reached  a  point  that  renders  him  in- 
capable of  continuing  his  previous  occupation.  This 
is  apt  to  occur  at  about  the  seventieth  year.  The 
theories  as  to  the  cause  of  senility  will  be  discussed 
in  another  article.  (See  Senility.)  During  this  last 
period  of  life,  heart  disease  reaches  its  maximum  as 
a  cause  of  death,  and  is  the  principal  cause  of  that 
calamity.  The  next  most  important  cause  is  cerebral 
hemorrhage,  resulting  from  arteriosclerosis,  the  charac- 
teristic malady  of  old  age. 

Robert  Payne  Bigelow. 


Rj  it   i:i   NCES. 

Cameron,  W.,  1908,     Children'    Growth  in  Weight  and  Height. 

Pfaundler  and    Schlossmann,    l'i  e I    Children,    vol    i  .    pp. 

urn    124. 

Chamberlain,  A.  F..  1900.  The  i  Ihild  as  a  Study  in  the  evolution 
•  it  Man.     N.  V.;  Scribners. 

Crampton,  ('.  \\\,  1908  6.  [ical    V.gi  ,  b  I  und intal 

Principle.  Am.  Phys.  Educ.  Review,  voL  xiii.,  pp.  1  n  L54,  21  1- 
227,  268  283,  34S    161 

Donders,F  C,  1864,     Onthi  Iccom dation  and 

,i,.ii  ,,t  the  I  ye.  E1]  in  bj  w  D.  Moore,  London:  New 
Sydenham  Soc. 

Forsyth,    D.,  1909.     Children  in  Health  and    I  Phila.: 

Blakiston. 

i,    ter.  Sir  M.,  1891.     Textbook  of  Phj   i  Ed    6,  Pt.  4, 

London:  Macmiilan. 

II    II.  i ;.  s  .  1904.      Wole  ■  i'm.-.     N.  Y  :  Appleton. 

Heinricius,  ('..,  1883.  Ueber  das  Alter  binn  Eintritl  der 
Menstruation  bei  3500  Weibern  in  Finnland.  Centralblatl  fur 
Gynakologie,  voL  vii.,  pp.     72  73. 

Hill,  C,  1909.      Manual  of  Normal  Histology.     Phila.:  Saunders. 

Ilobhousc,  L.  T.,  1901.  -Mind  in  Evolution.  London:  Mac- 
miilan. 

Mall,  F.  P.,  1910.  Determination  of  the  Age  of  Human  I  Imbryoa 
and  Foetuses.  Keibel  and  Mall.  Manual  of  Human  Embry- 
ology,  vol.  i.,  pp.  1S0-201. 

Marro,  A.,  1901.  La  puberte  chez  l'homme  et  choz  la  femme. 
Paris:     Schleicher 

Osier,  W.,  1905.  Commemoration  Address.  .Johns  Hopkins 
Univ.  Bulletin. 

Pryor,  J.  W.,  1005.  Development  of  the  Bones  "f  tin-  Hand  as 
shown  by  the  X-ray  Method.  Bull.  Stale  College  of  Kentucky. 
Sec.  2,  No.  .5. 

Pryor,  J.  W.,  1906.  Ossification  of  the  Epiphyses  of  the  Hand. 
Bull.  State  College  of  Ky.,  See.  a.  No    1. 

Pryor,  J.  W.,  1908.  Chronology  and  t  irder  of  Ossification  of  the 
Bones  of  the  Human  Carpus.  Bull.  State  University  of  Kentucky, 
New  Sec.  1,  No.  2. 

Romanes,  J.  G.,  1892.  Darwin  and  after  Darwin.  Chi<  ago: 
Open  Court  Pub.  Co. 

Rotch,  T.  M.,  1909.  Development  of  the  Bones  in  Early  Life 
Studied  by  the  Roentgen  Method.  Trans.  Assoc.  Am.  Physicians, 
1909. 

Tigerstedt,  R.,  1906.  Text-book  of  Human  Physiology,  Ed.  3, 
Trans,  by  J.  R.  Murlin.      N.  Y.:  Appleton. 

U.  S.  Census  Bureau.  Twelfth  Census,  1900:  Special  Reports, 
Supplementary  Analysis  and  Derivative  Tables,  1906. 

U.  S.  Census  Bureau.  Bulletin  109.  Mortality  Statistics,  1910, 
1912. 


Agenesis. — (Agenesia,  from  a,  priv.  +7e>«is,  origin.) 
AVithout  generation;  without  formation;  without 
parents;  unborn;  undeveloped;  failure  of  anlage; 
possessing  no  sex.  From  the  latter  meaning  arose  the 
conception  of  sterility  or  impotence,  and  the  early 
use  of  the  term  in  medicine  was  restricted  to  this 
meaning.  Later,  the  idea  of  lack  of  sexual  appetite 
became  included  in  this,  and  the  word  was  used 
by  French  writers  especially  with  the  meaning  of 
anaphrodisia  rather  than  with  that  of  impotence. 
The  word  has  now  entirely  lost  its  early  significance 
and  has  acquired  the  technical  meaning  of  total 
failure  of  development. 

A  partial  or  imperfect  development  of  parts  whose 
embryonic  foundations  have  been  laid  is  not  to  be  in- 
cluded in  the  significance  of  this  term,  but  should  be 
expressed  by  the  words  aplasia,  hypoplasia,  and 
hypogenesis.     (See  also  Ateleiosis.) 

There  is,  nevertheless,  much  diversity  of  use  among 
writers  as  to  the  exact  significance  given  to  each  one  of 
these  terms.  Aplasia  in  its  original  sense  means  a 
failure  of  restoration  or  rebuilding,  but  is  now  used 
with  two  meanings:  that  of  a  numerical  atrophy,  and 
that  of  a  partial  failure  of  development.  By  some 
writers  the  three  words  are  used  synonymously  with 
the  meaning  of  either  partial  or  entire  failure  of  devel- 
opment. A  few  authors  also  use  these  terms  with 
the  significance  of  atrophy.  The  present  tendency  is 
strongly  in  the  direction  of  giving  to  each  word  a 
distinct  place  in  technical  terminology:  to  atrophy, 
that  of  diminution  in  size  after  development;  to 
aplasia  and  hypoplasia,  that  of  imperfect  develop- 
ment; to  agenesia,  that  of  total  failure  of  growth  of  the 

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anlage  or  destruction  of  the  part  after  it  has  begun 
to  develop.  Hypoplasia  appears  to  have  acquired  the 
significance  of  a  slight  defect  of  growth;  aplasia  is 
used  to  indicate  more  important  deficiencies.  The 
term  hypogenesia  is  now  used  by  many  embryologists 
to  cover  all  forms  of  imperfect  and  arrested  develop- 
ment, but  particularly  with  reference  to  arrested  de- 
velopment of  primary  and  secondary  growing  points 
in  the  developing  embryo. 


Fig.  57. — Partial  Agenesia  of  the  Bones  of  the  Cranium  in 
Aneneephalia.  a,  defect;  /<,  occipital  portion;  c,  parietal  bone; 
d,  frontal  bone.     Reduced  1/5.     (Ziegler.) 

The  causes  leading  to  imperfect  development  may 
operate  at  such  an  early  period  in  fetal  life  that 
organs  or  parts  may  entirely  fail  of  development 
(agenesia),  or  later,  before  the  completion  of  growth, 
so  that  the  affected  parts  are  not  of  normal  size 
(aplasia,  hypoplasia).  Fetal  agenesias  and  aplasias 
play  the  chief  role  in  the  formation  of  monsters. 
The  extrauterine  aplasias  affecting  the  develop- 
ment after  birth  may  lead  to  a  reduction  of  size  of 
the  entire  body  or  extremities,  and  to  an  imperfect 
development  of  the  sexual  apparatus. 

Aplasia  may  affect  the  entire  skeleton  so  that  abnor- 
mally short  individuals  result  (dwarfs),  or  the  bones 
maybe  unsymmetrically  developed  (partial  dwarfism). 
The  bones  of  the  head  are  very  frequently  affected, 
giving  rise  to  the  conditions  known  as  microcephalus 
and  micrencephalus.  The  central  nervous  system 
may  show  defective  development,  with  or  without 
changes  in  its  bony  covering;  one  of  the  hemispheres 
may  be  abnormally  small  or  the  entire  brain  may  show 
a  retarded  growth.  Next  to  those  of  the  nervous 
system,  aplasias  of  the  genito-urinary  tract  are 
most  common  in  occurrence.  The  uterus  or  the 
entire  set  of  female  generative  organs,  external  and 
internal,  may  remain  in  an  undeveloped  state  at 
puberty.  The  external  organs  of  the  male  are  also 
not  rarely  abnormally  small,  and  in  non-descent  of 
the  testicle  aplasia  of  the  organ  usually  takes  place. 
Parts  of  the  intestine  may  be  so  imperfectly  formed  as 
to  consist  of  a  narrow  canal  or  a  small  fibrous  cord; 
and  in  the  development  of  the  lungs  the  alveoli  of 
portions  of  one  or  more  lobes  may  be  imperfectly 
developed.  The  kidney  and  liver  may  also  suffer  a 
greater  or  less  imperfection  of  growth.  Hypoplasias 
of  the  heart  and  vascular  system  have  been  thought 
to  play  an  important  part  in  the  pathology  of  chlorosis 
and  lymphatic  struma. 

Agenesia  for  the  greater  part  leads  to  the  production 
of  monsters  or  to  the  development  of  malformations 
which  may  be  of  so  serious  a  nature  as  to  preclude  the 
possibility  of  extrauterine  life.  There  may  be 
absence  of  the  cranium  (acrania)  (Fig.  57),  or  of  the 
brain  (anencephalus),  or  of  the  spinal  cord  (amyelia). 
A  complete  failure  of  development  of  any  part  of  the 
skeleton  may  take  place,  or  of  any  part  of  the  nervous 
system.     Agenesia  may  also  result  from  the  failure  of 


developing  centers  to  unite  or  of  clefts  to  close;  in  the 
hitter  class  are  to  be  placed  a  great  variety  of  mal- 
formations (cleft  palate,  hare  lip,  exstrophy  of  the 
bladder,  spina  bifida,  cleft  sternum,  omphalocele, 
etc.).  Agenesia  of  a  single  organ  may  also  arise  from 
the  imperfect  separation  of  two  organs  which  develop 
from  a  single  focus  (cyclopia),  or  from  the  secondary 
union  of  two  divided  organs.  Atresia  of  the  mouth, 
nose,  ear,  anus,  vagina,  or  urethra  may  also  result  from 
agenetic  development  of  portions  of  these  structures. 
Agenesia  of  the  bones  of  the  extremities,  of  single 
muscles  or  groups  of  muscles,  of  the  auricular  septum, 
etc.,  are  among  the  more  common  malformations 
which  permit  of  extrauterine  life. 

The  tissues  composing  aplastic  organs  may  be 
normal  in  structure,  but  there  is  very  frequently 
assi  iciated  with  abnormal  smallness  of  the  entire  organ 
a  deficient  development  of  its  elements  or  a  complete 
absence  of  the  more  highly  specialized  ones.  In  aplasia 
of  the  central  nervous  system  there  may  be  agenesia 
of  the  ganglia  cells  and  nerve  fibers;  portions  of  the 
brain  may  be  represented  by  fibrous  or  membranous 
masses.  The  hypoplastic  ovary  may  show  complete 
agenesia  of  its  ova;  and  in  the  lung  there  may  be  entire 
failure  of  development  of  the  alveoli  (Fig.  58).  Like- 
wise in  the  liver  and  kidney,  portions  of  the  secreting 
structures  may  fail  entirely. 

The  causes  of  aplasia  and  agenesia  may  be  either  in- 
trinsic or  extrinsic. 

As  intrinsic  causes  may  be  considered  all  of  those 
that  arise  in  the  germ  either  through  inheritance  or 
pathological  germ  variation,  or  through  disturbances 
of  the  copulation  of  the  sexual  nuclei.  The  inherit- 
ance of  agenetic  malformations  may  be  direct, 
atavistic,  or  collateral.  Certain  types  of  faulty  de- 
velopment, notably  those  of  the  nervous  system 
and  genito-urinary  tract,  occur  with  a  certain  fre- 
quency in  degenerative  inheritance  (harelip,  hypo- 
spadias, single  kidney,  monorehidism,  syndactylism, 
deficient  extremities,  etc.).  The  pathological  germ 
variation  may  be  the  result  of  the  union  of  two 
nuclei,  one  or  both  of  which  are  abnormal,  or  of  the 
union  of  two  normal  nuclei  which  are  not  suited  to 
each  other.  Premature  exhaustion  of  the  growing 
point  or  arrested  growth  of  the  same  may  be  due  to 
a  reversionary  degeneration  with  defective  constitu- 
tion of  the  biophores,  or  to  an  intrinsic  quantitative 
defect  in  matricial  cells  that  should  normally  develop 
into  certain  organs  or  tissues.  Chemical  and  physical 
influences  may  act  upon  the  ovum  or  sperm  before 


Fig.  5S. — Agenesis  of  the  Respiratory  Parenchyma  of  the  Left 
Lung.  The  lung  consists  of  dense  connective  tissue  in  the  midal 
of  which  dilated  bronchi  are  found.  (Horizontal  section  through 
the  apex  of  the  upper  lobe;  natural  size.      (Ziegler.) 

fertilization  as  well  as  immediately  after  fertilization, 
and  we  know  that  agenesis  and  hypogenesis  can  be 
produced  experimentally  in  this  way  (Roentgen  ray, 
action  of  various  chemicals,  etc.). 

But  by  far  the  chief  causes  of  agenesia  are  extrinsic. 
Of  these,  pressure,  jarrings,  disturbances  in  the  supply 
of  oxgyen  and  nutrition,  contaminations  of  the  mater- 
nal blood  from  intoxications  and  infections,  fetal 
inflammations,  abnormal   conditions  of  the  amnion, 


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Aggresslns 


play  the  most  important  part.  There  is  very  strong 
evidence  that  a  large  proportion  of  agenetic  malfor- 
mations arise  from  abnormal  adhesions  between  the 
embryo  and  the  amnion,  or  from  abnormal  pre 
exerted  by  the  amnion  upon  the  developing  germ. 
The  head  and  extremities  suffer  most  frequently  from 
these  causes.  Aplasia  of  the  bones  is  sometimes 
associated  with  thyroid  disease.  Agenesis  and  hypo- 
genesis  are  undoubtedly  produced  by  many  different 
causes;  and  in  any  given  case  of  defective  development 
ji  uiay  be  impossible  to  determine  the  particular 
etiological  factors. 

The  agenesias  of  the  more  important  structures  of 
the  body  lead  as  a  rule  to  the  production  of  a  non- 
viable   fetus.      Only    those    failures    of    development 
cting  the  body  in  such  a  degree  that  life  processes 
arc  not  seriously  interfered  with  admit  of  living  after 
birth.     Dwarfism,  agenesia  of  the  bones  or  muscle-  of 
the   extremities    many   of   the   cleft   malformations, 
esia  of  the  sexual  organs,  etc.,  permit  of  life  and 
rauterine  growth.     Some  of  these  may  be  corn- 
sated  for  by  hypertrophy  of  other  organs  or  parts 
of  tin-  same  organ,  while  others  may  be  improved  by 
rical  treatment.  Aldked  Scott   Warthin. 


Ageusia. — (From  tv-privative  and  yev<ns  taste 
\  condition  in  which  the  sense  of  taste  is  lost,  tin- 
perception  of  sweet,  sour,  salt,  and  bitter  being  absent. 
It  occurs  sometimes  temporarily  in  catarrhal  affection 
of  i  he  nose  and  tongue,  and  is  present  in  lesions  of  the 
glossopharyngeal  and  trigeminal  nerves.  In  greater 
or  lesser  degree  it  is  one  of  the  stigmata  of  degeneracy, 
eness  of  taste  being  often  absent  in  paranoids  and 
other  defectives.     See  Tantc. 


Agglutination. — If  a  suspension  of  bacteria  is  mixed 
\  it  b  serum  from  an  animal  which  has  been  inoculated 
with  bacteria  of  the  same  species,  the  organisms, 
after  a  time,  may  be  seen  to  adhere  together  in  clumps 
or  agglutinate.  This  process  is  called  agglutination 
and  its  occurrence  is  due  to  the  presence  in  the  serum 
of  bodies  called  agglutinins.  Agglutinins  are  anti- 
bodies of  Ehrlich's  second  order  and  possess  two 
groups,  a  haptophore  group  whereby  the  substance 
nes  attached  to  the  bacterial  cells,  an  J  a  function 
group  or  agglutinophore  group.  The  ferment  group 
may  be  destroyed  by  heating  at  65°  C.  but  the  hapto- 
phore group  remains  uninjured  at  this  temperature. 
An  immune  serum,  therefore,  which  has  been  heated 
to  65°  C.  for  an  hour  will  no  longer  agglutinate  bacteria 
upon  being  mixed  with  them.  However,  organism- 
which  have  been  in  contact  with  such  a  serum  are 
not  agglutinable  by  any  serum  because  they  are 
united  with  the  changed  agglutinins  and  have  no 
unsatisfied  receptors  for  the  fresh  agglutinins  in  the 
new  serum. 

Agglutinins  are  of  three  kinds,  normal,  group,  and 
specific.  Normal  agglutinins  are  those  which  are 
normally  present  in  the  blood  serum,  they  are  few 
in  number  and  will  act  only  upon  certain  organisms. 
Group  agglutinins  are  developed  in  the  serum  as  the 
result  of  inoculation  and  act  upon  organisms  bio- 
logically and  chemically  related  to  the  one  used  for 
inoculation.  They  may  be  removed  from  a  serum 
by  the  absorption  process.  For  example,  if  an  animal 
is  inoculated  with  the  typhoid  bacillus,  its  serum 
will  agglutinate  more  or  less  strongly  many  of  the 
organisms  of  the  typhoid-coli  group.  If  now  the 
serum  is  mixed  with  a  suspension  of  the  colon  bacillus 
and  allowed  to  stand  for  a  time  and  then  eentrifugated 
to  remove  the  bacteria,  it  will  be  found  no  longer 
able  to  agglutinate  the  colon  bacillus,  but  its  action 
upon  the  typhoid  bacillus  will  be  nearly  as  strong  as 
before.  Specific  agglutinins  also  develop  as  the  result 
of  inoculation  but  will  act  only  upon  that  organism 
which  has  been  used  for  the  purpose.     As  a  rule  they 


are  very  highly  specific,  that  is,  they  -how  little  (ii- 
no    tendency    to    agglutinate    any    other    bacteria. 

Following  an  infection  whether  experimental  or 
accidental,  all  three  kinds  of  agglutinins  may  be 
found  in  the  serum  but  ii-ualU  the  specific  are  present 
in  much  greater  numbers  than  the  other  two. 

The  practical  uses  of  the  phenomena  of  agglutina- 
tion are  two,  in  the  diagnosis  of  infection  di  ea  - 
anil  in  identifying  unknown  bacteria.  'I  lie  I.,  i 
known  example  of  their  diagnostic  use  is  the  Oiuber- 
Widal  reaction  for  the  detection  of  typhoid  fever. 
In    this    reaction    several    dilutions    of    the    patient's 

serum  are  mixed  with  equal  quantities  of  a  suspension 

of  typhoid  bacilli.  If  agglutination  takes  place 
within  one  hour  using  the  serum  dilution  of  1-100 
the  test  is  considered  positive.  If  only  the  lower 
dilutions  show  agglutination  the  reaction  may  be 
due  to  normal  or  group  agglutinins  ami  the  serum 
should  lie  tested  against  other  strains  of  organisms 
or  subjected  to  absorption  tests  in  order  to  determine 
whether  specific  agglutinins  are  present.  The  reac- 
tion is  usually  positive  1  y  the  end  of  the  tir-t  week  of 
the  disease  and  remains  so  for  a  variable  time  after 
convalescence. 

For  the  identification  of  bacteria  an  immune  serum 
is  necessary.  This  is  obtained  by  injecting  an 
emulsion  of  killed  organisms  into  an  animal.  The 
serum  then  will  contain  specific  agglutinins  for  that 
organism.  If  now  a  suspension  of  the  unknown 
bacteria  is  agglutinated  by  high  dilutions  of  the 
serum,  the  identity  of  the  two  bacteria  is  established. 

The  agglutinins  are  protein-like  bodies  though  not 
proteins.  They  exhibit  but  little  resistance  to 
external  influence  such  as  light,  heat,  etc.,  and  are 
precipitated  from  a  serum  by  ammonium  sulphate 
along  with  the  globulins.  Of  the  nature  of  agglutina- 
tion but  little  is  known.  A  positive  reaction  is 
accompanied  by  a  certain  change  in  the  surface 
tension  of  the  mixture  as  shown  in  the  meiostag- 
min  reaction.  It  is  also  thought  that,  in  the  case  of 
the  motile  bacteria,  the  cilia  become  swollen  and  ad- 
here to  one  another.  This,  however,  has  not  been 
established. 

Ardiagglutinins  may  be  produced  by  the  injection 
of  an  immune  serum  into  an  animal  and  their 
presence  will  prevent  the  development  of  the  re- 
action. If  bacteria  are  grown  in  an  immune  serum 
they  will  gradually  develop  a  resistance  to  the  action 
of  agglutinins,  possibly  as  a  result  of  the  production 
of  antiagglutinins  within  themselves.  It  is  to  be 
noted  that  agglutination  does  not  kill  or  injure  the 
organisms.  For  a  discussion  of  the  relation  of 
agglutinins  to  other  antibodies  see  the  article  on 
Immunity.  Ralph  G.  Stillman. 


Aggressins. — If  an  animal  is  inoculated  with  the 
cholera  vibrio  in  sufficient  dosage  it  becomes  sick  and 
dies.  During  its  illness  it  develops  a  peritonitic 
exudate.  Now  if  this  exudate  is  sterilized  by  filtra- 
tion through  a  porcelain  filter  and  injected,  together 
with  cholera  vibrios  in  too  small  numbers  to  cause 
death,  into  another  animal,  this  animal  will  also  die. 
The  exudate  therefore  contains  some  substance  which 
is  able  to  convert  a  non-fatal  dose  of  the  organisms 
into  a  fatal  dose.  It  is  this  substance  which  has  been 
called  aggressin.  The  exudate  alone  has  but  little 
effect  and  there  is  no  definite  relation  between  its 
toxicity  and  its  ability  to  increase  the  virulence  of  an 
infection.  For  this  reason  it  is  hardly  probable  that 
the  aggressin  is  identical  with  the  endotoxin.  These 
bodies  may  be  obtained  by  treating  cultures  with 
normal  animal  serum  or  distilled  water  and  sterilizing 
the  extract  by  filtration.  The  artificial  aggressin 
so  obtained  is  apparently  identical  with  the  natural 
substance.  The  ability  to  produce  aggressin  has  led 
to  one  classification  of  bacteria  by  Bail.  He  claims 
that    saprophytic    organisms    are    unable    to    form 


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aggressins,  that  half-parasites  produce  them  only  in 
sniall  numbers,  while  full  parasites  produce  them  in 
very  large  quantities. 

The  injection  of  aggressins  will  result  in  the  pro- 
duction of  a  passive  immunity  against  infection  with 
living  bacteria.  This  fact  is  of  advantage  when  it  is 
desired  to  protect  an  animal  against  a  pure  parasite 
when  it  is  impossible  to  obtain  a  non-fatal  dose  of 
the  living  organisms  and  injection  of  the  dead  bacteria 
fails  to  produce  any  immunity.  The  injection  of 
aggressins  results  also  in  the  development  of  anti- 
aggressins  which  are  able  to  neutralize  that  property 
of  aggressins  whereby  they  increase  virulence.  For  a 
discussion  of  the  relation  of  the  aggressins  to  the 
other  phenomena  of  immunity  see  the  article  on 
Immunity.  Ralph  G.  Stillmax. 


Agnew,  Cornelius  Rea. — Born  in  New  York  City, 
August  8,  1830.  He  received  the  degree  of  Doctor 
of  Medicine  from  the  College  of  Physicians  and  Sur- 
geons in  that  city  in  1852.  After  an  interval  of  three 
years,  spent  partly  in  service  at  the  New  York 
Hospital  and  partly  in  special  studies  at  Dublin, 
London,  and  Paris,  he  settled  in  his  native  city  as  a 
general  practitioner.  Before  visiting  Europe  he  had 
received  the  appointment  of  Surgeon  to  the  New  York 
Eye  and  Ear  Infirmary.  In  1S5S  he  was  appointed 
Surgeon-General  of  the  State  of  New  York.  In  1864 
he  was  made  a  member  of  the  United  States  Sanitary 
Commission.  Charles  J.  Stille,  in  his  History  of  the 
United  States  Sanitary  Commission,  refers  to  Dr. 
Agnew's  efficient  services  in  the  following  terms: 
"  Dr.  Agnew  brought  to  the  service  of  the  commission 
the  valuable  experience  he  had  gained  while  per- 
forming the  duties  of  a  medical  director  of  the  troops 
then  being  raised  in  New  York.  He  soon  exhibited  a 
practical  skill,  executive  ability,  and  at  all  times  a 
perfect    generosity   of   personal    toil   and   trouble   in 

carrying   on    the    commission's  work It 

is  not  too  much  to  say  that  the  life-saving  work  of  the 


Fir;.  50. — Cornelius  Rea  Agnew. 

commission  at  Antietam,  the  relief  which  it  afforded 
on  so  vast  a  scale  after  the  battles  of  the  Wilder- 
ness,     owed    much    of    its    efficiency    and 

success  to  plans  arranged  by  Dr.  Agnew,  and  carried 
out  at  personal  risk  and  inconvenience  under  his 
immediate  superintendence."  During  the  later  period 
of  his  life  Dr.  Agnew  devoted  himself  particularly  to 
the  treatment  of  eye  and  ear  diseases.  In  1866  he 
established,  in  the  College  of  Physicians  and  Surgeon  . 
an    ophthalmic    clinic,   and   in    1S69  he  was  elected 

154 


Clinical  Professor  of  Diseases  of  the  Eye  and  Ear.  In 
1  868  he  founded  the  Brooklyn  Eye  and  Ear  Hospital, 
and  in  1S69  the  Manhattan  Eye  and  Ear  Hospital' 
New  York  City.    He  died  April'  IS,  1S88.    A.  H.  B.   ' 


Agnew,  David  Hayes. — Born  November  24,  1818, 
in  Lancaster  County,  Pennsylvania.  He  studied 
medicine  at  the  University  of  Pennsylvania,  in 
Philadelphia,  and  took  his  degree  of  Doctor  of  Medi- 
cine in  1S38.  After  practising  for  a  short  time  in 
Lancaster  County  he  settled  in  Philadelphia,  and 
soon  afterward  began  lecturing  at  the  famous  Phila- 
delphia School  of  Anatomy.  His  work  in  this  field 
was  so  successful  that,  at  the  outbreak  of  the  (  nil 
War.  his  class  numbered  265  students — at  that  time 
the  largest  number  of  medical  pupils  studying  under 


Fig.  60. — David  Hayes  Agnew. 


one  teacher  in  the  country.  In  1S54  he  was  chosen 
one  of  the  surgeons  of  the  Philadelphia  Hospital,  and 
in  1863  he  was  given  the  position  of  Demonstrator  of 
Anatomy  and  Assistant  Lecturer  on  Clinical  Surgery 
in  the  Medical  Department  of  the  University  of 
Pennsylvania.  In  1S70,  in  recognition  of  the  great 
value  of  his  services  as  a  teacher,  the  trustees  of  this 
institution,  at  the  request  of  the  Medical  Faculty, 
conferred  upon  Dr.  Agnew  the  title  of  Professor  of 
Clinical  and  Operative  Surgery;  and  one  year  later, 
upon  the  resignation  of  Prof.  Henry  H.  Smith,  who 
occupied  the  chair  of  Principles  and  Practice  of 
Surgery,  he  was  also  assigned  to  this  chair.  His 
death  occurred  March  22,  1892. 

Dr.  Agnew  was  distinguished  in  several  ways:  he, 
like  the  great  surgeons  of  the  sixteenth  and  seven- 
teenth centuries,  devoted  a  large  part  of  his  time,  in 
the  earlier  years  of  his  career,  to  the  study  of  anatomy 
on  the  dissecting  table;  as  a  result  of  the  great  knowl- 
edge of  human  anatomy  which  he  thus  gained  he  was 
able  to  operate  rapidly  and  safely  upon  the  living 
human  subject;  and  finally,  through  his  careful  and 
unremitting  observation  of  the  progress  of  events  in 
each  one  of  his  numerous  cases,  he  acquired  an  ex- 
traordinarily large  experience — an  experience  upon 
which  he  could  safely  base  an  opinion  as  to  the  prob- 
able behavior  of  the  body  under  a  great  variety  of 
pathological  conditions.  When  to  this  large  store  of 
anatomical  and  surgical  knowledge  is  added  the  fact 
that  he  possessed  the  qualities  of  a  true  man  in  his 
dealings  with  his  fellowmen,  one  can  readily  appre- 
ciate the  justice  of  the  claim  that  Dr.  Agnew  deserves 
to  rank  high  in  the  esteem  of  the  medical  profession. 

As  a  writer  Agnew's  fame  will  rest  chiefly  em  his 
"  Treatise  on  tlie  Principles  and  Practice  of  Surgery," 
three  volumes,  Philadelphia,  1878-Sa  A.  H.  B. 


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Aiki'n 


Agoraphobia. — This  term  (from  dyopi,  market- 
place, and  <p6pos,  fear)  signifies  a  peculiar  emotional 
state,  occurring  in  psychasthenia,  in  which  one  has 
an  unconquerable  dread  of  being  alone  in.  or  of  even 

i ing  an  open  space.     The  subject  of  this  impera- 
tive idea  lias  a  perfect  consciousness  that   the   fear 
is  groundless  ami  even  absurd,  yet   suffers  from  an 
absolute   inability   to  overcome   it.     As   one   of   the 
psychic  stigmata,  this  state  of  neurasthenic  obsession 
[s  perhaps  among  the  most  frequent  and  most  typical 
of    the    numberless    morbid    fears    or    phobias.     The 
sufferer  may  be  able  to  walk  without  distress  in  the 
,  row  city  streets,  but  in  coming  to  an  open  square 
or  a  «  ill''  space  where  several  si  reets  converge  he  dare 
ittempt  to  cross  it  and  will  go  far  out  of  his  way 
through   side   streets    to   get    past    the   non-existent 
acle.     The   opposite   condition,    in   which    terror 
aused  by  being  in  an  enclosed  space,  such  as  a 
public   hall,    church,    or    theater,    is    known   as   claus- 
hobia  i  Latin  claustrum,  an  inclosed  space).     The 
only  condition  likely  to  be  mistaken  for  agoraphobia 
is  basophobia,  in  which  one  is  seized  with  the  impera- 
tive  idea   that  it   is   impossible   to   stand.     The   legs 
grow   weak    and   give   way,    the   .sufferer   seeking    the 
nearest    doorstep    or    any    convenient    place    to    sit. 
The  attacks  are  not  necessarily  excited  on  approach- 
ing an  open,  space  but  may  occur  anywhere  on  the 
street  or  even  in  a  room.     See  Fears,  morbid. 

T.  L.  S. 

Agrimonia. — Agrimony.  A  genus  of  about  a  dozen 
species  (fam.  Rosacece),  widely  distributed  through  the 
Northern  hemisphere.  The  species  which  has  been 
chiefly  used  in  medicine  is  A.  eupatoria  L.,  common  in 
Imth  Europe  and  America.  Its  use  is  merely  of 
historical  interest,  as  the  small  amounts  of  volatile 
oil,  tannin,  and  bitter  substance  impart  but  feeble 
aromatic  and  astringent  properties,  and  it  is  now 
scarcely  used.  H.  H.  Rusby. 


Aguas  Calientes. — See  Warner  Hot  Springs. 


Ague. — A  term  derived  from  the  French  aigu 
(from  Latin  acutus,  acute,  sharp,  severe),  popularly 
applied  to  various  conditions  marked  by  severe  or 
violent  symptoms.  The  malarial  paroxysm,  with 
its  chill,  fever,  and  sweating,  was  called  the  ague,  and, 
from  this  any  chill  attended  with  shivering  and 
chattering  of  the  teeth  came  to  be  so  designated. 
On  the  other  hand,  dumb  ague  was  applied  to  a  sub- 
acute form  of  malaria  in  which  the  chill  is  absent, 
and  the  term  ague  was  also  used  to  denote  various 
conditions  of  intermittent  character  attended  or  not 
with  fever;  such  as  brass-foiuiders'  ague,  an  inter- 
mittent fever,  not  malarial,  attacking  workers  in 
brass,  copper,  and  bronze  moulding;  and  brow  ague, 
an  intermittent  form  of  supraorbital  neuralgia.  The 
association  of  neuralgic  pain  in  this  latter  affection 
led  probably  to  the  use  of  the  term  face  ague  for 
simple  facial  neuralgia.  Urinary  fever,  or  "catheter 
fever,"  also,  either  through  a  misconception  of  its 
true  nature  or  because  of  the  character  of  its  symp- 
toms resembling  an  acute  malarial  paroxysm,  was 
also  called  ague.  It  will  be  seen  from  the  above 
that  the  word  has  no  definite  meaning,  and  in  the 
interest  of  a  precise  nomenclature  it  deserves  to  be 
dropped,  as  it  has  been  for  the  most  part,  from  the 
language  of  scientific  medicine.  T.  L.  S. 

AigIe=Les=Bains. — This  resort  is  situated  in  the 
Canton  of  Vaud,  Switzerland,  sixty-three  miles  from 
Geneva,  and  five  from  Bex.  It  is  a  pleasantly  located 
town  of  about  3,500  inhabitants,  and  of  an  eleva- 
tion of  1,375  feet  above  sea-level.  The  climate  is 
mild,  although  there  is  wind  in  the  valley.  The 
"season"  is   from   April    15  to  October  31,  and  the 


mean    average    temperature    during    this    period  is 
practically  that  of  Bex   near  by.  which  is  as  follows 
expres:  eil    in   degree     I  ahrenheit  I : 

April 

May 


51.2 

59 . 7 


June 83  5 

Julj  66  9 

August 02.9 


September. .  -   59  9 
October 69  -' 


Aigle-Les-Bains  has  a  mineral  spring,  which, 
according  to  Hi  choir's  analy  is,  i tains  a  pre- 
ponderance of  carbonate  ami  sulphate  of  calcium, 
carbonate  of  magnesium,  bicarbonate  of  sodium    ami 

potassium,  chloride  of  sodium  and  silica,  and  a  little 

free  carbonic  acid.  Saline  waters  are  also  Used,  the 
'•mother  water"  or  brine  being  brought  from  Bex. 
There  are  also  electric  bath  .  and  a  milk  and  whey 
cure.  The  arrangements  for  hydrotherapeutic  treat- 
ment  are  good. 

The  diseases  and  conditions  for  which  the  baths 
and  waters  are  employed  are:  catarrhal  affections 
of  the  stomach,  affections  of  the  bladder  and  liver, 
certain  uterine  diseases,  glandular  and  bone  tuber- 
culosis, rheumatism,  various  nervous  conditions  and 
neurasthenia. 

There  is  a  large  Kurhaus  and  hotel,  situated  on  a 
hill  above  the  village,  surrounded  by  a  fine  park. 
There  are  also  smaller  hotels  and  pensions,  and  then- 
is  an  English  church. 

Aigle  is  recommended  as  a  quiet,  restful  resort  for  a 
prolonged  stay  in  summer  where  one  can  find  en- 
joyable  walks  and  excursions,  far  from  the  "madding 
crowd."  Edward  O.  Otis. 


Aiken. — This  winter  resort  is  situated  in  the  west- 
ern portion  of  the  State  of  South  Carolina,  seventeen 
miles  from  the  Georgia  line,  between  the  Savannah 
and  Edisto  rivers,  but  at  a  considerable  distance  from 
either;  it  stands  upon  the  elevated  tableland  or  plateau 
forming  the  common  water-shed  of  both.  From  the 
Atlantic  Ocean,  Aiken  is  distant  a  little  more  than  a 
hundred  miles  in  a  "bee  line."  The  elevation  of  the 
town  above  sea  level  is  560  feet.  The  soil  is  very 
sandy,  consisting,  indeed,  of  little  else  than  such 
absolutely  pure  and  unmixed  sand  as  is  usually  found 
only  upon  the  immediate  borders  of  the  sea.  Grass 
grows  but  scantily,  and  the  vegetation  of  the  sur- 
rounding country  is  such  as  characterizes  a  region 
possessing  a  dry,  porous  soil,  and,  in  consequence,  a 
dry  atmosphere.  The  yellow  pine  of  the  South  finds 
here  its  congenital  habitat.  Several  varieties  of  oak 
are  also  to  be  found  in  the  woods  about  Aiken,  and 
many  varieties  of  flowering  vines  and  shrubs;  but 
the  pine  is  the  characteristic  growth  of  the  country. 

The  chief  factors  in  producing  the  healthfulness  of 
this  now  celebrated  resort  are  the  mildness  and  general 
equability  of  its  winter  climate;  the  preponderance  of 
bright  sunny  days,  which  enable  the  invalid  to  pass 
much  of  his  time  in  the  open  air;  and  last,  but  by  no 
means  the  least  important,  the  remarkable  dryness  of 
the  air,  already  alluded  to,  depending  upon  the 
peculiar  character  of  the  soil  and  the  distance  from 
any  large  body  of  water.  With  the  exception  of 
certain  stations  lying  in  close  proximity  to,  or  west 
of,  the  Rocky  Mountains,  there  is  no  place  in  the 
United  States  which  possesses  a  drier  air  than  that 
which  exists  at  Aiken. 

To  demonstrate  the  small  amount  of  variability  in 
the  temperature  possessed  by  the  climate  of  Aiken, 
the  following  figures  are  appended;  they  are  deduced 
from  observations  taken  by  Dr.  C.  F.  McGahan,  and 
embrace  a  period  of  seven  years. 


Month. 

Nov. 

Dec. 

Jan. 

1      :     1 

March. 

April. 

Daily  variation...  . 

13.14 

14.57 

10.39 

12.43 

10.25 

18.52 

155 


Aiken 


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Aiken  being  only  a  winter  resort.  Dr.  McGahan's 
observations  have  been  confined  to  that  season  which 
extends  from  October  to  May,  and  therefore  the 
following  figures,  quoted  from  "Smithsonian  Contri- 
butions to  Knowledge,"  No.  277,  are  here  inserted. 
They  show  the  mean  temperature  at  Aiken  for  each 
of  the  twelve  months,  for  each  of  the  four  seasons,  and 
for  the  year.  The  observations  upon  which  these 
figures  are  based  were  taken  at  7  a.  m.,  2  p.  m.,  and 
9  p.  M.  (by  .Messrs.  H.  W.  Ravenel,  J.  H.  Cornish,  and 
Newton),  and  extended  over  a  period  of  seventeen 
years,  from  January,  1S53,  to  December,  1S69. 


January 44   15° 

February....  47   83° 

March 

April 61    49° 

May 69    25 

June 76.08° 


July 7S.S0° 

August 77.19° 

September. .  72.23° 

October 61.80° 

November.  .   .".1    84° 
December...  45.4S0 


Spring 61.32° 

Summer 77.36° 

Autumn 61.96° 

Winter 45   82  ' 

Year 61   61° 


The  mean  relative  humidity  from  November  to 
April  inclusive,  taken  from  the  accompanying  table, 
i-  58.73  per  cent.  The  prevailing  winds  are  from  the 
west  and  southwest,  and  the  number  of  clear  day^  is 
unusually  large. 


markable  for  its  absence.  During  a  practice  of  fifteen 
years,  I  have  never  known  a  case  to  originate  here." 
The  absence  of  moisture  and  standing  water  leaves 
no  opportunity  for  the  breeding  of  the  malarial 
mosquito. 

The  water  supply  is  derived  from  an  artesian  well 
which  is  7S0  feet  deep,  the  last  200  feet  being  through 
a  solid  bed  of  granite.  Its  purity  is  attested  by  an 
analysis  which  was  made  in  1S9S  by  Prof.  Charles  F. 
Chandler,  of  Columbia.  University,  New  York. 

The  system  of  sewerage  is  the  one  that  has  been 
tested  thoroughly  for  the  past  twelve  years  by  the  Si  ;ite 
Board  of  Health  of  Massachusetts  for  its  inland  towns, 
and  is  considered  by  sanitary  engineers  the  best  for 
such  places. 

Amusements. — On  account  of  the  sandy  roads,  this 
is  the  ideal  country  for  horseback  riding;  then  there 
are  fox  hunts  for  those  who  an-  more  venturesome. 
A  mile  race  track  is  one  of  the  features  of  the  place, 
and  some  of  the  best  race  horses  in  the  East  winter 
here.  The  Palmetto  Golf  Club  has  the  finest  links 
in  the  South.  At  the  race  track  is  a  fine  polo  field, 
and  exciting  team  matches  are  played  frequently 
during  the  winter  and  spring  month-. 


Meteorological   Record  of  Aiken  S.  C. — Latitude,  33°  32';  Longitude,  81c 

Period  of  Observation,  1907-1911. 


34';  Altitude,  565  Feet; 


Temperature. 

Precipitation 

(inches). 

Sky. 

Prevailing 
wind. 

Mean 

relative 

humidity. 

Months. 

Mean. 

Highest. 

Lowest. 

Greatest 
daily 
range. 

Clear 
days. 

Partly 

i  ]  i  iih 
days 

Cloudy 

il.i\  -. 

55. S 

78.3 

29  2 

.:.:    I 

1.6 

18.2 

3.3 

4.2 

W. 

.59 . 65 

1 1  '■  imber     

46.3 

70   2 

1'.'  3 

34  ■; 

2.9 

IS. 3 

9.1 

3.0 

W. 

58.58 

i                         

49.3 

7:;   1 

20    1 

it  i) 

2.9 

19   2 

4   3 

6.2 

W. 

19  8 

76.3          23    1 

31    2 

4.3 

16.3 

4.0 

7    _> 

W. 

60.31 

March 

58.9 

si;  7         31.1 

35.3 

3.3 

23   2 

3.2 

4.0 

w. 

57.90 

April 

65  2 

89  3          36.3 

34.1 

2.4 

19.3 

6.2 

3   3 

S.E. 

52. 7S 

M:   in 

54  2 

7S.8 

26  6 

35.3 

2.9 

19.0 

5. 

4   5 

58  7; 

\Ve  possess,  then,  in  this  climate  all  of  the  attributes 
of  a  health  resort  favorable  for  the  relief  of  pulmonary 
tuberculosis,  except  altitude  and  its  accompaniments 
— viz.,  pure  dry  air  at  a  moderate  temperature,  a  dry 
and  well-drained  soil,  an  absence  of  high  winds  with  an 
occasional  exception,  and  an  abundance  of  sunshine. 
Experience  through  a  long  series  of  years  m  the  treat- 
ment of  pulmonary  tuberculosis  at  this  place  verifies 
this  conclusion.  In  the  writer's  opinion,  the  high- 
altitude  climates  are  superior,  as  proved  so  far  by 
results,  to  those  without  altitude;  but  it  must  never- 
theless be  borne  in  mind  that  not  all  cases  of  pulmo- 
nary tuberculosis  are  suitable  for  the  high  altitudes, 
and  in  such  a  climate  as  Aiken  we  have  a  most  valu- 
able resource  for  such  cases  as,  from  limited  vitality 
or  other  unfavorable  conditions,  are  unsuitable,  at 
least  fcir  a  while,  for  the  high  altitudes.  Here  we  can 
surely  carry  out  to  perfection  the  modern  open-air 
treatment,  which  after  all  is  the  essential  part  of  the 
climatic  treatment  of  pulmonary  tuberculosis. 

Moreover,  the  climate  of  Aiken  is  suitable  for 
patients  who  are  suffering  from  other  diseases,  such 
as  rheumatism  and  albuminuria;  for  convalescents 
from  acute  diseases  or  injuries;  and  for  large  numbers 
of  individuals  who,  for  one  reason  or  another,  possess 
little  physical  vigor.  Here  they  can  exist  in  comfort 
with  a  minimum  expenditure  of  vital  force. 

•Malaria,"    says    the   late  Dr.   Geddings,   "is  re- 


The  Highland  Park  Hotel,  which  was  destroyed  by 
fire  in  190S,  has  been  replaced  on  another  site  by  tin- 
Hotel  Park-in-the-Pines,  which  compares  favorably 
with  the  highest  class  metropolitan  hostelries  and  is 
equipped  as  are  few  modern  resort  hotels.  The  special 
feature  of  the  place  is  the  cottage  life,  and  cottage-  of 
all  sizes  can  be  rented,  from  the  simple  three-room 
cabin  to  the  pretentious  villa  provided  with  all 
the  modern  improvements.  There  are  four  family 
hotels  in  the  town,  and  also  numerous  boarding- 
houses. 

Any  account  of  Aiken  would  be  incomplete  without 
mention  of  the  small  but  excellent  Aiken  Cottage 
Sanatorium  founded,  in  1S96,  for  the  treatment  of 
cases  of  incipient  phthisis.  It  is  a  charity,  and  is 
modelled  after  the  institution  of  Dr.  Trudeau's  al 
Saranac  Lake.  The  cottages  at  present  are  arranged 
to  accommodate  sixteen  patients.  The  treatment 
consists  mainly  in  providing  good  nourishment  and 
keeping  the  patients  in  the  open  air  from  seven 
to  nine  hours  a  day. 

The  educationaf advantages  of  Aiken  are  very  good, 
there  being  several  excellent  junior  schools,  and  a  high 
school  which  fits  its  pupils  for  college.  Churches  of  all 
denominations  are  to  be  found  here. 

In  conclusion  it  may  be  added  that  Aiken  is  situated 
upon  the  Southern  Railroad,  with  three  daily  trains 
from  New  York,     For  much  of  the  above  account  the 


156 


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Airiliiini 


writer  is  indebted  to  the  late  Dr.  Mc<  iahan,  one  of  the 
founders  of  the  Aiken  Cottage  Sanatorium. 

Edwabd  < ».  Otis. 


Allanthus. — A  genus  of  some  seven  species,  in  the 

family  Simarubacece,  natives  of  Eastern  Asia  and  the 

East  Indies,  the  A.  glandulosa  Desf.  common  in  the 

Eastern    United   States.     It   is  in   this  species  thai 

Ileal  interest  chiefly  centers. 

It  has  been  observed  that  the  tree  is  odious  to  flies, 
which,  it  is  said,  will  not  approach  even  decayed  meat 
when  placed  among  its  leaves.  Mild  poisoning  has 
been  recorded  from  the  habitual  drinking  of  water 
into  which  the  roots  of  the  tree  had  penetrated,  and 
i\  hidi  its  leaves  had  fallen.  The  symptoms  were 
those  of  simple  gastric  irritation,  similar  to  what 
would  be  caused  by  the  amaroids  contained  in  quassia 
and  similar  drugs.  The  bark  and  leaves  have  been 
I  medicinally,  and  are  purgative  and  anthelmintic. 

I  b.<  constituents  of  the  plant  are  known  only  in  the 
mosl  general  way.  An  amaroid,  a  volatile  oil,  and 
i  resin  are  active.  The  pure  resin  has  been  found 
purgative,  but  not  anthelmintic,  while  the  oleoresin 
is  an  efficient  teniacide.  The  teniacidal  property  is 
therefore  assumed  to  reside  in  the  dark-green  volatile 
oil.  This  oil,  taken  by  inhalation,  is  a  powerful 
depressant  poison,  producing  vomiting,  dizziness,  and 
cold  perspiration.  Taken  by  the  stomach  these 
effects  have  not  been  observed,  though  due  pre- 
cautions in  regard  to  dosage  should  be  observed. 

The  dose  of  the  powdered  leaves,  as  a  teniacide,  is 
0.5-2.0  grams  (grain  viij.  to  xxx.),  of  the  oleoresin 
0.2  to  0.6  gram  (grain  iij.  to  x.). 

In  India,  the  juice  of  the  leaves  and  bark  of  .1. 
exeelsa  Roxb.  have  been  used  from  ancient  times  as 
a  tonic,  especially  in  convalescence  after  parturition. 
The  bark  of  this  and  of  A.  malaharica  D.  C,  is  also 
used  as  a  vegetable  bitter,  in  forms  of  dyspepsia. 

II.    II.    RUSBY. 


Ainhum. — (Synonyms:  Ainhun;  dactylolysis  spon- 
tanea; Absiigen  [German];  Daetiliolisia  [Spanish].) 
The  etymology  of  the  word  is  usually  attributed  to 
Africa,  and  is  derived  from  a  word  meaning  to  "saw 
off."  Matas  states  that  the  word  ainhum  is  from 
the  negro  patois  of  Brazil,  ainhoum,  meaning  a 
"fissure." 

Definition. — Ainhum  is  a  disease  of  tropical 
countries,  and  is  characterized  by  the  gradual  painless 
amputation  of  one  or  more  joints  of  one  or  more 
toes  by  a  trophic  process  of  mixed  atrophy  and 
hypertrophy. 

History. — While  the  first  accurate  description  of 
the  disease  was  made  by  da  Silva  Lima,  of  Bahia, 
Brazil,  in  1S67,  as  much  earlier  as  1860  Dr.  Clark 
called  attention  to  ainhum  in  the  Gold  Coast  natives. 
Since  1S67,  a  number  of  observers  have  reported 
upon  the  disease,  notably  Duhring  and  Wile,  and 
Matas  in  this  country.  Zambaco  Pacha,  in  the 
Transactions  of  the  1897  Lepra  Conference  in  Berlin, 
writes  at  length  upon  the  condition  in  its  relation  to 
leprosy. 

Etiology. — The  cause  of  the  disease  is  not  known. 
It  has  been  found  in  the  negro  races  in  most  of  the 
-  reported;  it  usually  occurs  in  adults,  though 
de  Brun  reports  a  ease  at  six  years  of  age,  and  is 
essentially  a  tropical  disease,  exotic  cases  occurring 
occasionally  elsewhere.  The  parasitic  nature  of  the 
disease  is  maintained  by  some,  but  it  has  not  been 
proven.  Zambaco  Pacha  maintains  the  identity  of 
ainhum  and  trophic  leprosy  of  the  mutilating  type. 

Hanson  suggests  that  the  lesion  is  due  to  irritation 
from  injuries  received  in  walking  barefooted,  resulting 
in  the  peculiar  scarring,  like  keloid,  to  which  the 
negro  race  is  especially  prone. 

Symptoms. — Prodromes    are    absent.     There    may 


be  some  itching,  but  usually  the  disease  is  evidenced 
by  a  slightly  constricting  band,  a  furrow,  at  the 
digitoplantar  fold  of  the  fifth  toe.  At  times  other 
toes  may  be  affected.  For  example,  I  have  seen  the 
great  toe  involved,  at  the  New  Orleans  Charity 
Hospital.  The  furrow  gradually  becomes  more 
pronounced,  harder  in  consistency,  and  more  and 
more  constricting,  the  confined  portion  of  the  digit 
increasing  in  size  SO  as  to  lose  the  shape  and  form  of  a 
toe.  There  is  absence  of  inflammation  and  of  sub- 
jective   symptoms,     excepting    occasional     pain.      As 


Fig.  61. — Ainhum,  End  of  Small  Toe  after  Amputation.     (Enlarged 
about  2  1/2  times.) 

the  constricting  band  narrows,  the  toe  becomes  more 
and  more  tumefied,  until  finally  only  a  small  pedicle 
remains.  From  this  the  tumor  either  sloughs  off, 
is  torn  or  knocked  off,  or  is  intentionally  removed. 
When  ulceration  takes  place,  there  is  a  distinct  odor, 
of  a  nauseous  character,  resembling  that  of  the 
neurotic  ulcer.  The  pedicle,  or  base,  heals  kindly. 
The  process  lasts  months — even  years  in  some 
instances. 

Pathology. — Unna  believes  the  condition  to  be 
"a  ring-formed  scleroderma  with  callous  formation 
of  the  epidermis,  leading  to  secondary  total  stagnating 
necrosis,  resembling  artificial  snaring  of  tumors. 
There  is  a  primary  inflammation  with  marked  hyper- 
trophy of  the  epidermis,  the  papilla?  being  narrowed 
and  elongated.  In  the  papillary  body  there  is 
cellular  infiltration;  the  vessels  are  dilated.  The 
tumefaction  of  the  toe  indicates  a  stagnation  of 
lymph  and  fat,  whicli  gradually  causes  degeneration 
of  all  of  the  constituents  of  the  cutis,  a  rarefaction  of 
the  bones,  and  the  disappearance  of  the  phalanges. 
In  this  most  observers  agree. 

Differential  diagnosis  must  be  made  especially 
from  Raynaud's  disease,  from  paronychia,  from  the 
neurotic  ulcer,  and  from  leprosy. 

Raynaud's  disease  is  nearly  always  painful,  occurs 
seldom  on  the  lower  extremities,  is  quite  common  on 
the  upper  extremities,  and  the  trophic  change  is 
evidenced  most  often  by  the  occurrence  of  preliminary 
lesions,  e.g.  vesicles  or  bulla?. 

Paronychia  is  inflammatory  throughout  and  occurs 
on  the  ungual  phalanx  always. 

The  neurotic  ulcer  begins  as  a  callosity,  is  circum- 
scribed and  deep  seated,  occurs  usually  on  the  plantar 
surface  of  the  heel  or  great  toe,  and  is  never  located 
just  at  the  digitoplantar  fold  of  the  fifth  toe.     It  is 


157 


Ainhiim 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


characterized  almost  from  the  start  by  the  loss  of  the 
central  tissue  and  by  a  persistent  slough,  exulcerating 
and  discharging  freely. 

Leprosy  of  the  mutilating  type  has  points  of  resem- 
blance to  ainhum,  especially  when  the  latter  disease 
is  well  advanced.  Leprosy,  however,  has  no  prefer- 
ence for  the  negro,  and  it  is  not  a  tropical  disease. 
The  trophic  lesions  of  leprosy  are  found  on  any  toe 
or  any  finger,  usually  on  the  dorsal  side.  These  are 
almost  invariably  associated  with  other  present  or 
past  manifestations.  The  initial  evidence  of  muti- 
lating leprosy  is  a  macule,  excoriation,  or  bulla  on 
the  site  of  the  destruction.  The  initial  evidence  of 
ainhum  is  a  callous  furrow,  without  inflammatory 
redness. 

Treatment. — All  observers  agree  that  perpen- 
dicular and  free  incision  of  the  circular  bands  may 
arrest  the  process,  but  that  usually  the  course  of 
spontaneous  amputation  is  completed,  unless  arti- 
ficially or  surgically  produced. 

Isadore  Dyer. 

Bibliography. 

Clark:  Trans.  Epidemiolog.  Soc.,  I860,  London. 

Da  Silva  Lima:  Ainhum.  Amer.  Archiv.  of  Dermat.,  1SS0,  p. 
367. 

Duhring  and  Wile:  Ainhum.  Amer  Jour.  Med  Sciences.  January, 
1S81. 

Eyles:    Lancet,  1886.  ii,  p.  576. 

Walter  Pyle:  Medical  News,  Jan.  26,  1S95  (with  full  bibliog- 
raphy). 

DeBrun:    Annales  de  Dermatologie,  vol.  x  (1S99),  p.  325. 

X.  D.  Brayton:  Journal  of  the  American  Medical  Association, 
July  8.  1905. 


Air. — To  appreciate  the  various  sanitary  relations 
of  the  atmosphere,  the  subject  must  be  studied  from 
the  physical  as  well  as  from  the  chemical  stand- 
point. In  considering  the  physical  aspects  of  air, 
attention  must  be  given  to  the  subjects  of  atmos- 
pheric  pressure,  light,  heat,  humidity,  and  electrical 
condition. 

Physical  Properties.  1.  Atmospheric  Pressure. — 
The  air  is  an  invisible  gaseous  ocean.  In  it,  as  in  all 
gases,  there  is  no  cohesion  between  the  molecules. 
They  are  apart  from  one  another,  and  their  tendency 
to  spring  farther  apart  and  occupy  more  space  is  so 
great  that  a  restraining  force  is  needful  to  prevent 
expansion  and  attenuation.  Air  at  the  sea  level, 
the  bottom  of  the  aerial  ocean,  is  compressed  b}-  the 
weight  of  the  superincumbent  air.  This  weight  ex- 
presses the  influence  of  gravity  on  the  air  as  a  whole, 
or  the  influence  which  the  earth  exerts  on  the  mole- 
cules of  its  atmosphere  to  keep  them  from  escaping 
into  limitless  space  or  from  being  whirled  away  by 
the  centrifugal  force  of  the  diurnal  rotation.  The  pres- 
sure of  the  atmosphere  at  the  sea  level  balances  a 
column  of  water  thirty-four  feet  high.  It  forces 
water  up  the  cylinder  of  a  pump  in  proportion  as 
the  air  pressure  within  the  cylinder  is  lessened  by  the 
working  of  the  piston,  but  the  raising  power  of  the 
pump  is  limited  by  the  height  mentioned.  Similarly 
at  the  sea  level  the  atmospheric  pressure  balances  a 
column  of  mercury  29.92  inches,  or  760  millimeters,  in 
height  (at  45°  N.  latitude),  and  as  this  number  of 
cubic  inches  of  the  liquid  metal  weighs  14.75  pounds, 
or  1  kilogram,  to  the  square  centimeter,  the  air 
pressure  on  every  measure  of  surface  becomes  known. 
Generally,  however,  air  pressure  is  expressed  in  inches 
of  mercury  as  being  more  convenient  than  a  state- 
ment of  the  actual  weight  on  a  given  area.  The  pres- 
sure on  a  surface  of  one  square  foot  amounts  to  nearly 
a  ton.  The  average  man  has  a  surface  of  about  fifteen 
square  feet,  but  the  fifteen  tons  of  air  pressure  under 
which  he  moves  are  unfelt  because  of  the  fluidity  of 
the  atmosphere.  The  freedom  of  movement  possessed 
by  its  molecules  transmits  their  pressure  in  all 
directions.     Air   permeates   all    porous   bodies,    and 


the  internal  pressure  in  bodies  so  permeated  counter- 
acts the  external  pressure.  Noticeable  effects  of  air 
pressure  are  seen  or  felt  only  when  there  are  local 
disturbances,  as  when  the  tissues  are  pressed  by  the 
weight  of  the  atmosphere  into  the  rarefied  air  of  a 
cupping  glass. 

The  higher  we  ascend  into  the  atmosphere  the  less  is 
the  pressure,  because  there  is  less  overlying  air  to 
affect  us  by  its  weight.  Heights  are  measured  by  the 
decreased  pressure,  and  balloonists  calculate  their 
distance  from  the  earth  by  the  fall  of  the  mercurial 
column  in  their  barometers.  At  the  sea  level,  under 
a  pressure  equivalent  to  that  of  29.92  inches  of  mer- 
cury, a  cubic  foot  of  air  weighs  536  grains.  Air  is 
increased  in  bulk  as  pressure  is  diminished.  At  the 
height  of  one  mile,  the  barometric  column  falls  to 
24.5  inches,  equivalent  to  a  pressure  of  12.04  pounds 
to  the  square  inch.  Under  this  lessened  pressure,  a 
cubic  foot  of  sea-level  air  would  expand,  other  things 
being  equal,  to  29.92-^24.5,  or  1.22  cubic  feet,  and 
one  cubic  foot  of  this  rarefied  air  would  weigh  only 
439  grains.  The  pressure  at  two  miles  being  equiva- 
lent to  only  twenty  inches  of  mercury,  one  cubic  foot  of 
sea-level  air  would  expand  to  29.92-^20,  or  1.49  cubic 
feet,  and  the  weight  of  a  cubic  foot  of  this  expanded 
air  would  be  360  grains.  With  increased  height  there 
is  diminished  density,  but  as  the  elastic  force  which 
separates  the  molecules  becomes  lessened  by  their  sepa- 
ration, there  may  be  a  certain  condition  of  tenuity  in 
which  this  force  is  unable  to  overcome  those  which 
operate  in  restraint.  The  depth  of  the  atmospheric 
ocean  has  been  estimated  variously  at  from  45  to  350 
miles  or  more. 

2.  Light. — Light  from  the  sun  or  other  sources 
passes  through  the  air  without  illuminating  it.  Were 
it  otherwise  we  should  be  able  to  see  the  air.  We  see 
things  by  the  light  which  they  emit  or  reflect,  but 
the  air  merely  transmits.  We  speak  of  atmospheric 
glows  and  beams  of  light,  of  the  blue  of  the  firma- 
ment and  the  radiance  of  morn,  but  these  pin 
relate  to  the  visibility  of  substances  in  the  air.  Light 
is  transmitted  in  straight  lines,  with  the  exception  of 
some  refraction  in  the  denser  strata  near  the  earth's 
surface;  but  as  more  or  less  of  the  light  is  refused  a 
lodgment  by  every  substance  on  which  it  falls,  and 
is  reflected  from  one  object  to  another  at  all  angles 
and  hence  in  every  direction,  the  whole  of  the  air  is 
filled  with  rays  which  illuminate  objects  that  are  not 
exposed  directly  to  the  source  of  the  illumination. 
Molecules  of  watery  vapor  and  minute  particles  of  dust 
suspended  in  the  air  give  rise  to  the  apparent  diffusion 
of  light  in  the  atmosphere.  These  account  for  the 
dawning  light  of  morn,  and  the  twilight  after  sundown. 

3.  Heat. — Associated  with  solar  light  are  actinic  and 
heat  rays.  The  latter  are  of  the  highest  interest,  as 
being  the  cause  of  the  tides,  currents,  and  local  move- 
ments in  the  atmosphere.  Heat  rays  pass  through 
the  atmosphere  without  warming  it.  The  air  of  high 
mountain  regions  is  cold,  although  the  same  rays  pass 
through  it  which  may  give  a  tropical  warmth  to  the 
plains  below.  It  is  usually  said  that  the  temperature 
falls  1°  F.  for  every  300  feet  of  altitude,  or  about  134 
meters  for  1°  C.  This,  although  not  accurate,  is 
useful.  If  the  temperature,  average  or  actual,  of  a 
given  locality  be  stated,  an  approximation  to  the 
corresponding  temperature  of  a  neighboring  plateau 
may  be  calculated.  Glaisher,  during  his  balloon 
ascents,  found  the  temperature  on  a  cloudy  day 
lowered  4°  F.  for  every  inch  of  a  barometric  fall  of 
eleven  inches;  and  the  further  ascent  was  marked  by 
a  more  rapid  refrigeration.  As  eleven  inchc-  oi 
mercury  indicate  an  elevation  of  12,000  feet,  the 
average  ascent  for  the  Fahrenheit  degree  was  a  I 
270  feet.  On  a  clear  day  the  thermometer  fell  5° 
for  each  of  the  first  four  inches  of  barometric  fall, 
4°  for  each  of  the  next  nine  inches,  and  13.5°  for  the 
last  three  inches  of  his  ascent.  The  cold  is  propor- 
tioned to  the  lessened  pressure,  4°  F.  for  each  inch; 


1  ,-,s 


REFER  EXIT.    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Air 


but  as  the  height  to  bi>  ascended  fur  each  inch  of 
f;lll  increases  with  the  ascent,  the  height  for  each 
degree  of  temperature  increases  correspondingly. 

Air,  in  expanding  under  lessened  pressure,  lias  its 
expansion  restricted  in  some  measure  by  the  loss  of 
heat  attending  the  expansion,  for  the  volume  of  a 
gas  is  contracted  by  cold.  Air  expands  TJ,T  of  its 
volume  at  0°  F.  for  each  degree  of  increased  tempera- 
ture Os+j  in  the  case  of  Centigrade).  Hence  460  cubic 
inches  or  feet  or,  in  general  terms,  volumes,  at  0°  F. 
expand  at  60°  to  520  volumes,  and  conversely  by  a 
reduction  of  temperature  from  60°  F.  to  6°  520 
olumes  contract  to  460.  On  these  data  is  based  that 
which  in  dealing  with  air  and  gases  is  called  the 
"correction  for  temperature."  The  molecules  of  a 
.  ubic  foot  of  dry  air  weigh,  at  the  sea  level,  536  grains. 
Under  the  diminished  pressure,  at  16,000  feet,  these 
molecules  would  occupy  a  space  of  two  cubic  feet, 
each  foot  containing  26*  grains;  but  the  coincident 
reduction  of  temperature  would  so  modify  this  that 
the  cubic  foot  of  air  would  weigh  303  grains.  The 
rarefaction  of  the  atmosphere  in  mountain  regions 
is  thus  seen  to  be  somewhat  less  than  we  should  be 
led  to  expect  by  a  consideration  merely  of  the 
barometric  pressure. 

Heat,  like  light,  is  absorbed  in  varying  proportions 
by  everything  on  the  surface  of  the  earth,  and  that 
which  is  not  absorbed  is  reflected  at  various  angles, 
so  that  the  air  in  its  lower  strata  is  filled  with  reflected 
rays  which  become  manifest  only  when  they  arc 
absorbed  and  increase  the  temperature  of  the  ab- 
sorbing substance.  Absorbed  heat  is  radiated  to 
cooler  bodies  in  the  neighborhood,  for  the  tendency 
in  nature  is  to  an  equable  distribution.  Hence, 
besides  reflected  rays,  the  air  may  be  filled  with  rays 
of  radiant  heat,  but  in  all  this  there  is  merely  trans- 
mission, with  no  appreciable  influence  on  the  air 
itself.  When,  however,  absorbed  heat  is  distributed 
by  convection  the  air  assumes  an  active  part  in  the 
process.  A  warm  substance  communicates  part 
of  its  heat  to  the  air  molecules  in  immediate  contact 
with  it.  The  air  thus  heated  expands  and  is  floated 
upward  by  the  inflow  of  colder  and  heavier  air 
beneath  it;  and  it  is  thus  raised  until  by  admixture 
with  the  general  mass  of  the  air  its  rarefaction  is  lost, 
or  until  under  unusual  conditions  of  placidity  it 
reaches  a  stratum  of  equal  rarefaction.  The  cold  air 
that  replaced  it  in  contact  with  the  heated  substance 
becomes  similarly  warmed  and  borne  upward;  and 
this  continued  in  an  uninterrupted  sequence  gives  rise 
to  an  upward  current  of  warm  air  with  inflowing 
currents  of  colder,  heavier  air  on  all  sides.  We 
sometimes  seem  to  see  this  upward  current  by  the 
side  of  a  heated  stove,  when  its  varying  density  dis- 
turbs the  passage  of  the  rays  of  light  from  objects 
seen  through  it,  and  gives  a  quivering  movement  to 
their  outlines.  In  the  sandy  districts  of  southern 
Arizona  and  New  Mexico,  trees  and  other  objects  at 
a  little  distance  from  the  observer  are  often  tremu- 
lously distorted  to  his  sight  by  the  upward  currents 
from  the  sun-heated  surface. 

Objects  that  absorb  much  radiate  much,  and  those 
warmed  rapidly  by  absorption  cool  quickly  by  radia- 
tion. Color  has  an  influence  on  these  movements,  for 
black  surfaces  absorb  and  radiate  better  than  white. 
Radiation  and  reflection  are  therefore  different  pro- 
cesses, for  white  is  the  better  reflector.  The  radiant 
powers  of  different  substances  vary  much,  but  it  is 
unnecessary  here  to  do  more  than  indicate  in  general 
terms  the  differences  presented  by  land  and  water  in 
this  regard. 

As  compared  with  water,  land  heats  quickly  and 
cools  quickly.  The  heat  does  not  penetrate  but  ac- 
cumulates in  and  immediately  beneath  the  surface 
Children  know  how  cool  is  the  underlying  sand  turned 
up  on  the  seashore  in  their  holiday  play.  The  surface 
is  hot  by  day  and  cool  by  night,  but  at  a  depth  of  three 
feet  there  is  no  diurnal  increase  of  temperature,  and 


even  the  heat  of  a  prolonged  summer  penetrates  only 
about  seventy  feet,  for  well   water  at    this  depth   has 

the  same  temperature  summer  and  winter. 

.Masses  of  water,  on  the  other  hand,  heat  slowly  and 
cool  slowly;  the  rays  penetrate  to  the  depths.  The 
temperature  of  the  surface  waters  of  the  ocean  is  never 
over  80°  F.  (26.6°  C.)  in  the  tropics,  and  its  diurnal 
range  is  small.  In  higher  latitudes  the  temperature 
is  lower,  bul  the  mass  of  the  waters  of  the  ocean,  in 
both  high  and  low  latitudes,  is  never  below  39°  I'. 
(3.9°  O).  Thus  the  air  is  warmed  intermittently  by 
the  land  and  continuously  by  the  ocean,  and  its 
molecules  are  kept  in  motion  by  the  convection  which 
is  in  progress. 

The  solar  rays  are  the  only  source  from  which  the 
air  derives  its  warmth,  for,  although  animal  life  and 
the  combustion  of  fuel  develop  heat,  the  heat  thus 
developed  is  merely  the  liberation  of  energy  derived 
originally  from  the  sun.  Again,  although  the  earth 
has  an  internal  heat,  this  heat  is  not  transmitted 
through  the  crust,  for  the  superficial  strata  to  a 
depth  of  seventy  feet  are  affected  by  the  seasonal 
warmth  of  the  sun,  and  not  by  the  interior  heat. 

4.  Humidity. — The  effects  of  heat  on  the  atmos- 
phere are  multiplied  and  varied  by  the  phenomena 
attending  its  action  on  water.  Vapor,  invisible  as 
the  atmosphere  itself,  rises  from  water  at  all  tempera- 
tures. The  higher  the  temperature  the  more  rapid 
the  evaporation.  Thus  vapor  is  absorbed  into  the 
atmosphere,  and  the  amount  that  can  be  absorbed 
increases  with  increase  of  temperature.  A  cubic 
foot  of  air  at  32°  F.  is  saturated  with  moisture  when 
it  contains  10  cubic  inches  or  about  two  grains  of 
vapor  of  water;  but  at  100°  F.  (37.8°  C.)  the  cubic  foot 
of  air  can  absorb  about  100  cubic  inches,  or  nearly  20 
grains.  The  molecules  of  the  vapor  find  place  for 
themselves  in  the  intermolecular  spaces  of  the  air,  but 
not  without  crowding  aside  the  air  molecules  to  such 
an  extent  that  saturated  air  is  lighter  than  dry  air. 
Air  is  known  to  be  saturated  when  the  slightest 
lowering  of  its  temperature  causes  a  deposition  of 
moisture.  We  call  such  a  deposition  cloud  when  in 
the  air  above  us,  fog  or  mist  when  in  the  air  around 
us.  and  dew  when  deposited  at  night  on  vegetation 
and  other  highly  radiating  surfaces.  The  dew  point 
may  be  found  by  noting  the  temperature  at  which 
moisture  appears  on  the  outside  of  a  test  tube,  cooled 
by  the  evaporation  of  ether  in  its  interior.  Usually 
an  approximation  to  it  is  obtained  by  the  wet  bulb 
thermometer,  from  which  the  actual  dew  point  may 
be  calculated  or  gathered  from  Glaisher's  tables. 
Moisture  in  the  air  is  expressed  as  relative  humidity 
on  a  scale  of  which  100  is  the  point  of  saturation. 
Absolute  figures  give  no  satisfaction.  With  two 
grains  of  moisture  in  a  cubic  foot  of  air  the  air,  as  we 
have  seen,  may  be  very  moist  or  very  dry.  If  the 
temperature  is  32°  F.,  the  air  is  saturated;  if  it  is  100° 
F.,  the  air  is  so  dry  that  it  is  ready  to  take  up  eighteen 
grains   more  before  it  becomes  saturated. 

Evaporation  aids  radiation  and  convection  in  cool- 
ing a  warm,  moist  surface.  The  soldier  in  a  summer 
camp  moistens  the  outside  of  his  canteen  and  hangs  it 
on  a  branch  that  the  passing  breeze  may  cool  its  con- 
tained water.  Even  the  surface  of  the  water  of  the 
tropical  oceans  is  cooled  slightly  at  night.  It  is,  how- 
ever, not  so  much  by  the  production  of  a  local  coolness 
as  by  the  transference  of  heat  from  one  place  to  an- 
other that  the  chief  influence  of  evaporation  is  ex- 
ercised. From  the  surface  of  the  ocean,  particularly 
in  the  warmer  latitudes,  evaporation  is  going  on  at  all 
times.  An  upward  movement  of  moist,  warm  air  is 
continuously  in  progress.  Partial  condensation  occurs 
by  the  time  this  air  reaches  a  stratum  of  its  own 
density,  but  the  clouds  there  formed  are  usually 
hurried  by  air  currents  to  other  and  colder  regions  of 
the  globe  before  the  particles  of  condensed  vapor 
become  aggregated  and  fall  as  rain.  The  heat 
gathered  from  the  tropics  is  thus  distributed  to  other 


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pari-  of  the  earth,  the  air  of  which  is  warmed  by  con- 
densation above  as  well  as  by  convection  from  below. 
Moreover,  the  clouds  absorb  heat  radiated  from  the 
surface  of  the  earth,  thus  preventing  its  dissipation 
into  the  ether  beyond.  Every  object  on  the  surface 
is  thus  kept  warmer  than  it  otherwise  would  be. 
Clouds  act  as  a  blanket  to  keep  the  air  and  the  earth 
under  them  warm.  Any  roof,  however  flimsy,  even 
the  spreading  branches  of  a  tree  in  foliage,  is  a  pro- 
tection against  the  cold  of  radiation  into  space.  The 
great  heat  of  the  direct  rays  of  the  sun  at  high  alti- 
tudes, where  the  surrounding  air  is  intensely  cold,  is 
attributed  to  the  freedom  of  the  air  from  intercepting 
moisture. 

5.  Electrical  Condition. — Electricity  pervades  the 
atmosphere.  It  is  generated  by  the  evaporation  of 
water,  the  friction  of  the  wind  on  the  surface,  and  of 
the  molecular  constituents  of  the  air  each  on  the 
other;  but  its  relations  to  these  constituents  are  not 
clearly  understood.  It  is  greatest  in  cold,  dry  weather, 
but  the  greatest  electrical  disturbances  are  associated 
with  condensation  and  rainfall. 

( )ur  knowledge  of  the  effects  of  heat  and  moisture 
enables  us  with  but.  little  effort  to  recognize  the  causes 
of  many  meteorologic  phenomena  that  have  important 
bearings  on  the  well-being  and  comfort  of  the  human 
race.  Meteorology  is  probably  the  oldest  of  the 
sciences,  for  man,  even  in  the  earliest  days  of  his 
racial  existence,  found  it  necessary  to  study  the 
probabilities;  and  the  weather  wisdom  of  every  nation 
is  embodied  in  proverbial  expressions.  The  co- 
operative work  of  modern  times,  made  possible  by 
the  use  of  the  telegraph,  has  enlarged  our  knowledge 
and  broadened  our  views  of  these  phenomena,  so  that 
we  now  have  a  useful  understanding  of  the  general  as 
well  as  the  local  movements  of  the  atmosphere. 

Air  Currents. — Extending  for  a  few  degrees  on  each 
side  of  the  equator  is  a  region  of  calm  and  light  varia- 
ble winds,  known  to  sailors  as  the  doldrums.  Here  the 
uprising  of  the  moist,  warm  air  leads  to  condensation 
in  the  higher  strata.  Heavy  rains  fall,  and  the  heat 
liberated  during  the  condensation  rarefies  the  relative- 
ly dry  air  of  the  upper  regions  and  develops  a  swell  on 
the  surface  of  the  atmospheric  ocean  which  divides  or 
flows  over,  one-half  to  the  north,  the  other  to  the 
south,  while  an  inflow  in  the  lower  strata  restores  the 
aerial  equilibrium.  The  inflowing  currents  do  not 
come  from  the  poles;  they  reach  only  from  the  thirtieth 
parallels,  and  their  motion  is  more  or  less  obliquely 
from  the  east  on  account  of  the  diurnal  revolution  of 
the  earth.  A  belt  of  variable  winds  is  found  about 
the  thirtieth  parallels.  Here  the  upper  current  from 
the  tropics  impinges  (in  the  northern  hemisphere)  on 
a  northeast  upper  current  from  the  Arctic  circle,  and 
the  swell  of  their  meeting  occasions  an  increased 
pressure  at  this  point.  Escape  for  the  accumulated 
air  is  found  below,  southward  constituting  the  trade 
winds  and  northward  constituting  the  regular  south- 
west winds  of  the  north  temperate  zone.  At  the 
Arctic  circle  is  another  doldrum  belt  into  which  flows 
the  wind  last  mentioned  and  a  surface  current  from 
the  northeast.  These,  warm  and  cold  intermingling, 
produce  condensation  and  rainfall  and  an  expansion  or 
swell  which  overflows  into  a  northeast  upper  current 
over  the  temperate  zone,  and  a  southwest  upper 
current  toward  the  pole.  The  surface  currents  affect 
the  air  to  a  height  of  10,000  feet,  involving  about 
one-half  of  the  weight  of  the  atmosphere,  and  their 
velocity  averages  about  fifteen  miles  an  hour.  This 
constitutes  the  general  circulation  of  the  atmospheric 
ocean,  but  there  arc  many  secondary  currents,  as  that 
between  land  and  sea.  In  fact  innumerable  causes  of 
greater  heating  at  one  place  than  at  another  give  rise 
to  local  currents. 

The  resultant  of  all  the  meteorological  conditions 
constitute  climate;  but  temperature,  as  being  the 
most  notable  condition,  is  usually  adopted  to  give 
formal    expression    to    the    character   of   a    climate. 


Temperature  depends  on  latitude,  altitude,  and  the 
presence  of  large  bodies  of  water  to  reduce  the  daily 
and  seasonal  ranges.  One  of  the  first  discoveries  by 
those  who  collated  the  meteorological  observations  of 
the  medical  officers  of  the  United  States  Army  was 
the  climatic  importance  of  the  great  lakes.  In  New 
England  the  influence  of  the  ocean  was  found  to 
modify  the  mean  temperature.  In  the  interior  of  New 
York,  the  daily  range  increased  and  the  seasons  were 
strongly  contrasted.  Farther  west,  near  the  great 
lakes,  a  climate  similar  to  that  of  the  seaboard  was 
again  found,  but  in  the  interior  beyond  them,  ex- 
treme changes  again  became  the  rule.  Water  tempers 
the  winds  which  blow  over  it  and  loads  them  with 
vapor  for  subsequent  condensation  and  warmth.  The 
regular  southwest  winds  of  the  temperate  zone 
reaching  Europe  from  the  Atlantic  and  California 
from  the  Pacific  Ocean  give  these  shores  a  climate 
markedly  different  from  that  of  the  Eastern  coast  or 
interior  of  the  United  States.  The  air  of  continental 
interiors  is  dry  and  the  solar  rays  beat  with  full  in- 
tensity on  the  surface,  while  at  night  there  is  no  pro- 
tection against  radiation  into  the  cloudless  skies. 

That  climate  has  a  powerful  influence  on  the  welfare 
of  man  is  manifest  when  we  compare  the  weakness 
and  indolence  of  tropical  races  with  the  strength  and 
energy,  mental  as  well  as  physical,  of  those  of  the 
temperate  zones.  Since  the  earliest  ages  it  has  been  a 
favorite  theory  that  diseases  come  upon  mankind 
through  the  air.  But  although  the  tendency  of 
modern  research  is  to  absolve  the  air  from  any  special 
complicity  in  the  propagation  of  epidemic  diseases, 
the  charge  of  influencing  the  human  system  unfavor- 
ably still  holds  good  in  certain  other  respects.  Altera- 
tions of  atmospheric  pressure  have  been  regarded  by 
some  medical  observers  as  causing  pulmonary  con- 
gestions, and  both  compressed  and  rarefied  airs  have 
been  used  in  the  treatment  of  diseased  conditions  of 
these  organs.  In  hospitals  for  consumption,  how- 
ever, where  any  general  influence  causing  congestion 
of  the  lungs  would  be  manifested  by  an  increase  in  the 
number  of  cases  of  hemoptysis,  careful  observation 
has  shown  that  there  is  no  such  increase  during  the 
passage  of  the  storm  center.  The  exacerbations  of 
neuralgic  and  rheumatic  pains  coincident  with 
alterations  of  atmospheric  pressure  have  established  a 
popular  belief  in  their  relations  as  effect  and  cause, 
which  has  received  some  support  from  a  consideration 
of  "caisson  disease." 

The  caisson  for  the  Brooklyn  tower  of  the  East  River 
Bridge  measured  168  X  102  feet,  its  interior  or  working 
chambers  being  fourteen  feet  in  height.  It  was,  in  fact, 
a  huge  box  sunk  mouth  downward  by  laying  courses 
of  concrete  on  its  upper  surface.  Compressed  air 
forced  into  the  chambers  displaced  the  water;  and 
relays  of  men  excavated  the  bottom  of  the  river  bed 
beneath  it  until  a  rock  foundation  was  reached. 
The  upper  end  of  each  shaft  leading  to  the  chambers 
was  guarded  by  an  air-lock  to  prevent  injury  to  the 
men  by  a  sudden  change  of  pressure  on  entering  or 
leaving.  Before  descending,  compressed  air  from 
below  was  admitted  gradually  into  the  lock  chamber, 
and  only  when  the  density  was  equal  to  that  in  the 
caisson  was  the  descent  made.  Correspondingly, 
before  leaving,  a  gradual  transition  from  compressed 
to  ordinary  air  was  effected.  On  exposure  to  air 
under  a  pressure  of  three  or  four  atmospheres,  the 
skin  became  pale  and  shrivelled  and  the  countenance 
shrunken,  as  the  blood  was  forced  from  the  superficial 
vessels  to  those  of  the  bones  and  the  cavity  of  the 
skull.  The  heart's  action  increased  in  rapidity  to  oxer- 
come  the  impediment  to  the  circulation;  but  after  a 
time  the  system  accommodated  itself  to  the  altered 
conditions,  and  generally  no  bad  effect  was  manifested 
until  the  men  returned  to  the  colder  and  relatively 
rarefied  air  of  the  surface,  when  many  suffered  from 
pains  in  the  bones,  giddiness,  faintness,  numbni 
and  even  paralysis.     A  longer  time  in  the  lock  chani- 


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Air 


ber    td  permit    of  accommodation   to  lessening  air 
,  .  would  have  prevented  these  injurious  effect  - 
Phe  diminished  pressure  at  high  altitudes  is  described 
by  travellers  as  causing  soroche,  or  mountain  sickness, 
which  is  characterized  by  restlessness,  sleeplessness, 
ping  respiration,  anxiety,  vomiting,  and  fainting, 
ft  is  experienced  al  a  height  of  ten  or  twelve  thousand 
when   the   individual    is  expending   energy    by 
climbing,  but  in  balloon  ascents  the  effects  of  dimin- 
ished pressure  are  not  felt  until  twice  this  distance  has 
been  reached. 

Heat    relaxes   the   tissues  and   depresses  the   vital 
energies.     Cold  stimulates  these  energies  to  make  good 
loss  of  animal  heat;  but  if  excessive  it  benumbs 
and  paralyzes  and  ultimately  destroys  by  freezing. 
When  local  in  its  application  it  disturbs  the  cireula- 
uf  the  blood,  causing  a  congestion  of  some  internal 
in  when  the  surface  of  the  body  is  chilled  and  its 
els  are  contracted. 
Air  at  50°  F.  (10°  C.)  saturated  with  moisture  is 
colder  to  the  feel  than  dry  air  at  the  same  temperature; 
it  chills  by  contact.     Above  50°,  however,  it  is  warmer, 
prevents  evaporation  from  the  body.     At  high 
tospheric  temperatures  it  is  oppressive  and  induces 
exhaustion    or    sunstroke.     As    evaporation    is 
stopped,  the  system  is  unable  to  keep  down  its  heat  to 
normal  of  9S.6°  F.  (37°  C),  and  when  the  blood 
becomes  heated  higher  than  this,  dangerous  symptoms 
leveloped. 
i  in  mical   Constitution. — Formerly   air   was   re- 
garded as  one  of  the  elements.     It  is  now  known  to  be 
a  composite  substance;  the  properties  of  its  constitu- 
ents have  been  determined,  their  relations  to  animal 
and  vegetable  life  have  been  discovered,  and  traces  of 
idental  impurities  swept  up  by  its  currents  from  the 
face  of  the  earth  have  been  detected  and  studied  in 
their  bearing   on   sanitary   conditions.     The   atmos- 
phere, according  to  the  chemist,  consists  of  a  mixture 
of  two  gases,  oxygen  and  nitrogen.     The  former  is 
active  in  its  properties,  combining  with  many  suscept- 
ible elements,    and   especially    with    the  carbon  and 
hydrogen  of  devitalized  organic  matter,  constituting, 
ording  to  the  rapidity  of  the  process,  either  oxida- 
tion or  combustion,  and,  with  the  same  elements  in 
the  living  tissues  of  animals,  constituting  one  of  the 
itials  for  the  continuance  of  life.     A  certain  small 
percentage  of  the  oxygen  of  the  air  exists  in  the  form 
of  ozone,  but   the  quantity  present  cannot  be  deter- 
mined, and  even  its  existence  is  at  times  indicated 
with  doubt  by  the  iodized  starch  papers,  which  have 
been  largely  used  for  its  detection,  as  they  are  affected 
by  other  matters,  as  nitrous  acid  and  peroxide  of 
hydrogen,    occasionally   present   in   the   atmosphere. 
Iodized  litmus  papers  have  been  shown  by  Dr.  Fox 
to  be  of  value  as  a  qualitative  test,  and  as  indicating 
comparative  quantities  when  known  volumes  of  the 
air  are  aspirated  over  them.     It  is  certain,  however, 
ozone  has  stronger  affinities  than  ordinary  oxy- 
gen, and  that  oxidation  goes  on  more  rapidly  in  its 
presence  than  in  its  absence.     It  undoubtedly  de- 
stroys the  volatile  substances  which  are  evolved  dur- 
ing   the   putrefactive   process.     When   foul    organic 
odors  are  present,  ozone  is  absent.    Hence,  when  the 
presence  of  ozone  is  indicated  by  the  test  papers,  the 
air  is  regarded  as  free  from  organic  contaminations 
susceptible  of  oxidation.     Animals  exposed  to  ozone 
artificially  produced  suffer  from  irritation  of  the  lungs. 
The  n  ilrogen  is  regarded  as  negative,  or  passive,  serv- 
ing merely  to  moderate  the  activities  of  the  oxygen  by 
dilution.     Mention,  however,  should  be  made  of  the 
discovery  of  the  element  argon  by  Lord  Rayleigh  and 
Professor  Ramsey.     Argon  has  characters  similar  to 
those  of  nitrogen;  but  as  its  uses  in  the  economy  of 
nature  have  not  as  yet  been  determined,  it  must  be 
left  for  the  present  with  the  nitrogen,  with  which  it  has 
so  long  been  associated. 

In  the  atmosphere  the  chemist  recognizes  also  the 
presence  of  small  but  varying  quantities  of  other  mat- 


ters such  as  carbon  dioxide,  ammonia,  and  watery 
vapor.  The  percentage  composition  of  dry  air  i-.  by 
volume,  79  of  nitrogen,  20.96  of  oxygen,  and  0.04  oi 
carbon  dioxide;  by  weight  the  relative  proportions  of 
nitrogen  and  oxygen,  are  76.99  and  23.01.   Nitrogen  is 

the  lightest,  carbon  dioxide  is  the  heaviest;  yet,  on 
account  of  the  const  ant  I  not  ion  of  the  atmosphere  and 

the  tendency  of  gases  to  diffuse,  there  is  no  separation 

into  st  rat. a  richer  in  nitrogen  above  and  carbon  dioxide 
below.  This  power  of  diffusion  possessed  by  gases  is 
such  that,  in  places  where  t  here  is  a  continuous  genera- 
tion of  carbon  dioxide,  it  does  not  accumulate  un- 
less it  is  confined  as  in  a  room,  and  even  t  hen  it  is  dif- 
fused through  the  whole  air  of  the  room  and  not  col- 
lected by  its  weight  near  the  floor.  The  intermingling 
of  gases  by  diffusion  is  shown  by  I'ettcnkofer's  exami- 
nation of  the  air  over  certain  effervescing  springs. 
Samples  from  the  water  level  contained  70  per  cent,  of 
carbon  dioxide;  from  40  inches  above  the  water  level, 
2  percent.,  and  from  5.5  inches  only  0.5  percent.  Hence 
little  difference  is  found  in  the  percentage  composition 
of  the  free  air,  whether  samples  be  taken  from  over 
the  land  or  the  ocean,  from  the  sea  level  or  from  a 
high  altitude. 

The  oxygen  of  the  air  varies  but  little  from  its 
average  percentage,  but  the  quantity  of  it  taken  into 
the  lungs  varies  with  the  temperature  and  pressure. 
Much  of  the  depressing  effects  of  atmospheric  heat  is 
probably  due  to  a  want  of  oxygen  in  the  expanded  air. 
A  cubic  foot  of  sea-level  air  at  32°  F.  contains  132 
grains  of  oxygen;  at  100°  F.  it  contains  116  grains,  a 
reduction  of  12  per  cent.  Again,  the  distress  felt  by 
mountain  climbers  and  usually  ascribed  to  lessened 
pressure,  is  probably  due  in  great  part  to  the  lessened 
amount  of  oxygen  inhaled.  A  cubic  foot  of  air,  at  60° 
F.  and  30  inches  of  pressure,  contains  124.6  grains  of 
oxygen.  The  expansion  under  a  barometric  pressure 
of  20  inches,  corresponding  to  a  height  of  two  miles, 
with  the  coincident  contraction  by  a  fall  of  tempera- 
ture to  20°  F.,  would  reduce  the  oxygen  in  a  cubic 
foot  to  90  grains,  a  reduction  of  2.8  per  cent. 

The  carbon  dioxide,  C02,  familiarly  (but  incorrectly) 
known  as  carbonic  acid,  is  produced  by  the  oxidation 
of  carbon  in  dead  and  living  tissues,  and  its  percentage 
in  air  varies  with  the  local  causes  which  determine 
its  production.  Thus  it  is  greater  in  the  alleys  and 
streets  of  a  city  than  in  the  open  country,  and  as  this 
gas  is  soluble  to  some  extent  in  water,  its  proportion 
varies  with  the  hygrometric  and  other  conditions, 
being  greater  in  a  damp  atmosphere  before  rain  has 
fallen  than  in  the  air  of  the  same  locality  after  the 
aqueous  vapor  has  been  precipitated.  The  air  cur- 
rents and  the  diffusive  power  tend  to  equalize  the 
percentage,  but  as  production  is  constant  in  some 
localities,  the  air  of  these  must  always  show  a  rela- 
tively larger  quantity  of  this  gas  than  that  of  others 
remote  from  such  sources.  The  proportion  in  the 
external  air  seldom  exceeds  4  volumes  in  10,000.  De 
Saussure  made  many  series  of  observations  to  deter- 
mine the  percentage  under  various  conditions.  In 
an  investigation  of  the  ventilation  of  soldiers'  quar- 
ters, at  Fort  Bridger,  Wyoming,  in  1S74,  there  was 
found  in  the  external  air  a  gradual  decrease,  day  by 
day,  from  4.5  to  2.6  volumes  per  10,000  as  the  season 
advanced,  and  the  surface  of  the  earth  became  covered 
with  luxuriant  vegetation. 

Carbon  dioxide  is  a  product  of  combustion;  it  will 
therefore  not  support  combustion.  It  is  a  product 
of  respiration,  therefore  it  will  not  support  respiration. 
In  mines,  life  is  in  danger  when  a  candle  will  not  burn. 
Because  workmen  in  soda-water  factories  suffer  no 
inconvenience  in  breathing  an  atmosphere  containing 
as  much  as  two  per  cent,  of  carbon  dioxide,  many  have 
supposed  that  this  gas  is  not  poisonous,  but  that,  like 
water,  it  drowns  fire  and  life  alike  by  preventing  the 
access  of  oxygen.  Nevertheless  experiments  have 
shown  it  to  be  actively  harmful.  Animals  breathing 
it  along  with  as  much  oxygen  as  is  present  in  the 


Vol.  I.— 11 


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REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


atmospheric  air  have  the  heart's  action  weakened  even 
to  fainting,  and  when  man  is  the  subject  of  the  experi- 
ment, dulness  of  mind  culminates  in  unconsciousness 
or  stupor.  This,  however,  is  not  of  much  practical 
importance,  for  the  sources  which  furnish  carbon 
dioxide  to  the  atmosphere  generally  yield  with  it 
other  and  more  dangerous  substances. 

Ammonia  is  diffused  from  putrefactive  processes  in 
progress  on  the  surface  of  the  earth.  It  is  also  pro- 
duced, in  traces,  from  the  nitrogen  of  the  atmosphere 
by  electric  agency.  Its  quantity  is  variable,  but 
0.1  milligram  in  a  cubic  meter  of  air  is  a  not  unusual 
amount.  This  corresponds  to  a  grain  in  about  23,000 
cubic  feet.  Rain  washes  the  ammonia  from  the  air  to 
the  surface  of  the  earth  in  amounts  varying  from  0.2 
to  0.5  part  per  million  of  the  rain  water.     The  im- 

Erovement  in  fields  which  are  permitted  to  lie  fallow 
as  been  attributed  to  ammonia  in  the  rainfall,  but 
this  ammonia  is  manifestly  inadequate  to  account 
for  the  masses  of  vegetation  which  annually  find 
nourishment  in  the  soil.  The  ammonia  originating 
on  or  in  the  soil  during  the  decomposition  of  its 
organic  matters  is  the  source  of  the  nitrogen  which 
feeds  the  living  plants.  A  trace  only  of  this  ammonia 
escapes  into  the  air  and  is  afterward  washed  down 
with  the  rain.  Prior  to  its  use  by  the  vegetation 
which  covers  the  surface  of  the  earth,  it  is  nitrified  by 
bacteria  which  are  everywhere  present  in  the  upper 
layers  of  the  soil.  Some  of  the  lower  forms  of  vege- 
table life,  such  as  certain  alga?  and  bacteria,  absorb 
nitrogen  directly  from  the  atmosphere.  Some  legu- 
minous plants  also  fix  atmospheric  nitrogen  in  their 
tissues,  but  this  is  accomplished  indirectly  through 
the  medium  of  parasitic  bacteria  found  in  nodules  on 
their  roots. 

The  ammonia  of  the  air  is  condensed  on  exposed 
surfaces,  and  R.  A.  Smith  has  suggested  that  the 
quantity  of  ammonia  deposited  on  a  given  surface 
in  a  given  time  may  be  taken  as  an  exponent  of  the 
sanitary  condition  of  the  atmosphere.  A  glass  or 
other  surface  which  has  been  exposed  for  some  time 
in  an  unventilated  bedroom,  when  washed  with  pure 
water  will  show  in  the  washings  the  presence  of  a 
readily  determinable  quantity  of  ammonia;  but  the 
attempt  to  demonstrate  the  relative  purity  of  atmos- 
pheres by  the  quantity  deposited  on  equal  and  similar 
surfaces  in  equal  periods  of  exposure  meets  with 
failure  unless  the  temperature,  the  hygrometric  con- 
dition, and  the  air  movement  are  the  same  in  both 
instances.  This  concurrence  of  similar  conditions 
is  difficult,  if  not  impossible,  to  obtain  in  practice. 
The  air  constituents  which  have  been  mentioned 
must  be  regarded,  from  the  scientific  and  sanitary 
point  of  view,  as  individually  essential  to  the  consti- 
tution of  the  atmosphere.  The  oxygen  is  vital  to 
animals,  its  quantity  being  preserved  by  the  evolution 
from  vegetation  and  the  equilibrium  established 
between  these  two  kingdoms  of  nature.  The  carbon 
dioxide  is  vital  to  vegetation,  being  the  source  of  the 
carbon  solidified  in  its  tissues;  its  quantity  is  preserved 
by  the  evolution  from  animals  and  the  retrogressive 
metamorphosis  of  the  organic  carbon  of  devitalized 
tissues. 

For  our  present  purpose  organic  substances  may  be 
considered  as  those  developed  by  the  forces  of  life. 
They  include  all  living  bodies  and  those  that  have 
ceased  to  live,  with  many  products  of  the  life  of  the 
one  and  of  the  decay  or  decomposition  of  the  other. 
With  the  infinite  variety  of  animal  and  vegetable  life 
constantly  before  us,  it  is  needless  to  suggest  the  com- 
plex character  of  organic  matters,  but,  notwithstand- 
ing this  complexity  little  more  than  the  elements 
contained  in  air  and  water  enter  into  their  composition. 
Animal  life  depends  on  vegetable  life  for  its  suste- 
nance  directly,  or  in  the  case  of  carnivorous  animals  in- 
directly. Animals  cannot  combine  the  elementary 
bodies,  but  these  are  taken  by  plants  and  formed  into 
organic  substances,  which  animals  are  capable  of  util- 

162 


izing  as  food.  So  complex  are  all  vitalized  substances 
that  but  for  the  preservative  influence  of  their  vitality, 
their  molecules  would  speedily  break  up  into  simpler 
forms,  and,  indeed,  when  life  ceases  to  protect  them 
their  putrefactive  decomposition  begins  immediately 
and  ends  in  their  resolution  into  the  very  substances 
from  which  they  were  originally  constructed.  Nature 
moves  in  cycles.  Day  follows  day  and  season  season. 
The  seed  germinates  and  the  grown  plant  matures  its 
seed.  Every  generation  is  a  cycle,  and,  in  the 
instance  before  us,  the  elements  from  which  life 
elaborated  the  highest  organic  structures  revert  to  the 
inorganic  condition  of  carbon  dioxide,  ammonia  or 
nitrates,  and  water  for  use  in  some  succeeding  cycle. 

Even  in  the  living  organism  similar  changes  take 
place.  No  machine  works  without  wear.  The 
tissues  of  the  animal  body  are  worn  by  exercise.  The 
nitrogen  of  the  worn-out  tissues  is  removed  by  the 
kidneys  as  urea,  which  speedily  becomes  converted 
into  ammonia,  while  the  carbon  is  oxidized  and  the 
resulting  carbon  dioxide  is  carried  to  the  lungs  to 
be  expelled. 

During  quiet  breathing  twenty-seven  cubic  inches  of 
air  enter  the  lungs  at  each  inspiration,  and  if  the  air  be 
pure  nearly  six  of  these  cubic  inches  are  oxygen  and 
only  one  one-hundredth  part  of  a  cubic  inch  carbon 
dioxide.  The  air  expired  has  less  oxygen,  more 
watery  vapor,  a  taint  of  organic  matter,  and  some- 
what more  than  a  cubic  inch  of  carbon  dioxide. 
Breathed  air,  therefore,  contains  a  hundred  times 
more  carbon  dioxide  than  is  contained  in  an  equal 
volume  of  the  free  atmosphere.  The  frequency  and 
depth  of  the  respiratory  acts  vary  in  the  individual 
with  his  condition  as  to  health,  exercise,  or  repose; 
and  as  might  be  expected,  they  vary  also  in  different 
individuals  under  the  same  or  similar  conditions. 
The  average  excretion  of  carbon  dioxide  by  the  human 
lungs  can  therefore  be  stated  only  approximu1 
Giving  due  consideration  to  the  experimental  results 
obtained  by  various  qualified  investigators,  its  amount 
may  be  stated  to  be  at  least  0.01  cubic  foot  per  min- 
ute, 0.6  per  hour,  or  14.4  in  the  twenty-four  hours. 
The  energy  of  the  vital  actions  concerned  in  respira- 
tion, may  be  appreciated  when  we  realize  that  in  14.4 
cubic  feet  of  this  invisible  gas  we  have  nearly  half  a 
pound  of  solid  carbon. 

Although  the  inflow  into  the  lungs  is  interrupted  by 
expiration  at  comparatively  regular  intervals,  the 
absorption  of  oxygen  and  evolution  of  carbon  dioxide 
are  continuously  in  progress.  The  inspiratory  inflow 
of  twenty-seven  cubic  inches  mixes  with  the  air 
already  in  the  lungs  and  freshens  it  for  the  use  of  the 
system.  Deep  breathing  washes  out  the  lungs  and 
permeates  them  with  an  air  rich  in  oxygen  and  com- 
paratively free  from  carbon  dioxide.  No  ma  Iter 
how  pure  the  surrounding  air  may  be,  an  individual 
may  suffer  from  impure  air  in  his  lungs  if  by  seden- 
tary habits,  or  other  cause,  his  breathing  becomes 
shallow  and  insufficient. 

Allowing  sixteen  as  the  average  number  of  respira- 
tions per  minute,  with  an  air  movement  of  twenty- 
seven  cubic  inches  into  and  out  of  the  lungs,  the  air 
respired  in  an  hour  would  measure  fifteen  cubic  fi  et 
and  in  twenty-four  hours  360  cubic  feet,  and  with  an 
output  of  0.01  cubic  foot  of  carbon  dioxide  per  min- 
ute the  respired  air  would  contain  four  per.  cent,  of 
this  gas.  From  these  data  may  be  calculated  the 
amount  of  dilution  needful  to  bring  respired  air  back 
to  a  condition  of  purity  approximating  that  of  the 
free  atmosphere.  If  fifteen  cubic  feet  of  breathed 
air  containing  0.6  of  a  cubic  foot,  or  four  per  ce 
of  carbon  dioxide,  be  uniformly  mixed  with  ninety- 
nine  times  its  bulk  of  air  containing  no  carbon  diox- 
ide, the  0.6  cubic  foot  of  this  gas  present  would 
constitute  0.04  per  cent,  of  the  mixture;  but  is 
using  atmospheric  air  for  the  dilution  the  pereem 
of  carbon  dioxide  in  the  resulting  1,500  cubic  feet 
would  be  nearly  0.08,  inasmuch  as  each  cubic  foot  of 


REFERENCE    HANDBOOK    OF    THE    MI'.HK  AT,    SCIENCES 


Air 


the  diluting  air  brings  with  it  the  0.04  per  cent,  of  this 
gas  which  ii  naturally  contains.  Bui  as  the  organic 
Taint  in  respired  air  which  lias  been  diluted  to  this 
extent  is  perceptible  by  its  odor  to  one  entering  from 
the  fresh  air.  it  is  evident  that  this  dilution  is  insuf- 
ficient Even  when  the  carbon  dioxide  is  diluted  to  0.07 
cent.,  sensitive  nostrils  can  detect  the  presence  of 
the  associated  organic  matter;  but  if  the  1,500  cubic 
feel  containing 0.08  per  cent,  be  further  diluted  with  an 
equal  volume  of  fresh  air  containing  0.04  per  cent,  of 
carbonic  oxide,  the  mixture  is  reduced  to  O.Oti  or  six 

umes  in  10,000  volumes  of  the  air,  and  with  this 
dilution  of  3,000  cubic  feet  per  hour  per  person, 
sanitarians  are  satisfied,  except  in  the  ease  of  certain 
hospitals. 

It  is  easier  to  pass  3,000  cubic  feet  of  air  without 
creating  coldness  or  draughts  through  a  large  cubic 
space  per  man  than  through  a  small  one.  If  a  room 
only  300  cubic  feet  per  man,  its  air  has  to  be 
changed  ten  times  in  an  hour  to  supply  the  3,000 
cubic  feet  of  ventilation.  If  it  give  1,000  cubic  feet 
per  man,  the  air  has  to  be  changed  only  three  times. 
A  linear  inflow  of  less  than  two  feet  per  second  is 

lerceptible.  With  two  feet  of  current  air  the 
area  of  the  inflow  to  deliver  the  3,000  cubic  feet  would 

Ixty  square  inches. 
The  amount  of  carbon  dioxide  in  a  sample  of  air 

.  termined  by  adding  a  known  quantity  of  lime  or 
baryta  water  to  the  air  in  a  large  glass  bottle  or  jar, 
and'  there  after  finding  how  much  of  the  hydroxide  has 

i  converted  into  carbonate.  The  practical  details 
1 3  follows: 
Make  an  oxalic  acid  solution,  lc.c.  of  which  is  equiva- 
lent to  one  milligram  C02.  Make  also  a  caustic  baryta  or 
lime  solution  of  equivalent  strength.  Transfer  the  al- 
kaline solution  for  storage  until  required  for  use  to  small 
bot  ties  each  holdingabout  GO  c.c.(  two-ounce  vials),  each 
of  which  is  corked  securely  and  weighed,  and  the  total 

ight  of  the  bottle  and  its  contents  marked  upon  the 

1.  The  air  to  be  examined  is  collected  in  a  clean 
perfectly  dry  glass  bottle  or  narrow-mouthed  jar, 
of  known  capacity.  Ten  liter  bottles  are  large  enough 
to  give  accurate  results.  A  small  bellows  with  a 
rubber  tube  on  its  nozzle  is  conveniently  used  in 
tilling  the  jar  with  the  air  to  be  examined,  but 
care  must  be  taken  that  the  air  entering  by  the  valve 
of  the  bellows  is  not  contaminated  by  any  direct 
respiratory  streams  from  individuals  present.  As 
soon  as  the  change  of  air  has  been  effected,  one  of  the 
prepared  baryta  vials  is  uncorked  and  its  contents 
poured  into  the  jar,  which  is  then  closed  by  an  ac- 
curately ground  stopper,  or  preferably  by  a  tightly 
fitting  rubber  cork.  The  baryta  solution  is  then  shaken 
in  the  jar,  and  made  to  flow  all  over  its  interior  to 
promote  its  contact  with  the  contained  air;  but  to  in- 
sure thorough  absorption  of  the  carbon  dioxide  the  jar 
is  usually  permitted  to  stand  until  the  following  day 
before  determining  the  loss  of  alkalinity.  Meanwhile 
the  volume  of  the  air  operated  on  is  ascertained  from 
observations  made  at  the  time  the  air  was  collected. 
The  height  of  the  barometer  and  of  the  dry  and  wet 
bulb  thermometers  or  the  dew  point  must  be 
known,  as  well  as  the  quantity  of  baryta  solution  in- 
troduced into  the  jar.  The  last  is  obtained  by  weighing 
the  now  empty  vial  in  which  it  was  stored  and  deduct- 
ing this  weight  from  the  gross  weight  marked  on 
the  label.  The  quantity  in  grams  of  the  baryta 
solution  employed  must  be  deducted  as  cubic  centime- 
ters from  the  known  capacity  of  the  jar.  But  in 
order  that  the  experimental  results  may  be  suscepti- 
ble of  comparison,  it  is  necessary  to  express  the  air 
volume  in  the  space  which  it  would  occupy  when  dry 
at  0°  Centigrade  and  under  a  pressure  of  760  millimeters 
of  mercury.  Increased  pressure  diminishes  the  volume 
of  air,  increased  temperature  expands  it;  and  the  pres- 
sure of  the  watery  vapor  present  must  also  be  taken 
into  account.  The  temperature  observations  furnish 
the  dew  point,  and  through  it,  from  the  observations 


of  Regnault,  the  pressure  or  tension  of  the  aqueous 
vapor  may  be  obtained.  If  \>  repre  ents  this  pressure, 
/,  the  temperature  in  Centigrade  degrees,  b  the  baro- 
metric height  in  millimeters,  and  V  the  capacity  of  the 
jar,  minus  the  number  of  cubic  centimeters  of  baryta 
solution  introduced,  the  corrected  volume  will  be 
equal  to 

\    '--/>)  273 

(273  I  '(760 

If   the   observations   have   been    made   on    Fahren- 
heit's scale  and  in  barometric  inches  the  formula  is: 

V(6-p)491 


!».).!).'    I1U    .  dt) 

in  which  dt  is  the  number  of  degrees  between  32°  F. 
and  the  observed  temperature. 

When  baryta  solution  is  used  to  absorb  the  carbon 
dioxide,  the  action  may  be  considered  completed 
in  half  an  hour;  but  with  lime  water  it  is  better  to 
suspend  further  proceedings  until  next  day.  Then 
take,  say,  20  c.c.  from  the  jar,  add  phenolphthalein, 
and  drop  in  the  oxalic  solution  from  a  burette  until 
the  color  is  discharged.  The  loss  of  alkalinity  in 
cubic  centimeters  =  milligrams  of  CO.,  in  the  20  c.c.  of 
the  solution  tested,  from  which  the  *C02  absorbed  by 
the  whole  of  the  baryta  solution  may  be  calculated  = 
milligrams  of  CO,  in  the  air  collected.  Convert 
weight  of  C02  into  volume  by  multiplying  by  0.573, 
and  for  purposes  of  comparison  calculate  it  into 
volumes  per  10,000  of  the  corrected  air.  It  must  be 
mentioned,  however,  that  the  volume  of  carbon 
dioxide  found  by  this  experiment  is  not  all  carbonic 
impurity,  but  includes  that  which  is  naturally  present 
in  the  atmosphere.  When  the  result  of  a  contem- 
poraneous experiment  on  the  external  air  has  been 
deducted  from  it,  the  remainder  will  indicate  the 
carbonic  impurity  or  the  carbon  dioxide  due  to 
imperfect  ventilation. 

An  easily  applied  method  of  ascertaining  whether  a 
given  air  contains  more  than  a  certain  number  of 
volumes  of  carbon  dioxide  per  10,000  is  based  on  the 
turbidity  caused  in  lime  water  by  the  precipitated 
carbonate.  If  a  half  ounce  of  this  liquid  is  shaken 
up  in  an  eight-ounce  vial  filled  with  the  air  to  be 
examined,  the  appearance  of  turbidity  indicates  the 
presence  of  eight  or  more  volumes  of  carbon  dioxide 
in  10,000  volumes  of  the  air,  and  that  the  arrange- 
ments for  ventilation  in  the  apartments  which  fur- 
nished the  air  are  not  as  satisfactory  as  could  be 
wished.  Bottles  of  various  sizes  are  used  by  the 
operator  conducting  this,  the  household  method  of 
sanitary  air  analysis,  and  from  the  capacity  of  the 
bottle  in  which  a  just  visible  turbidity  is  produced  the 
volumes  of  carbon  dioxide  per  10,000  become  known. 

In  another  method,  the  minimetric,  air  is  introduced 
in  small  quantity  into  a  vial  containing  lime  or  baryta 
solution,  which  is  well  shaken,  with  gradual  additions 
of  the  air,  until  the  liquid  shows  a  certain  loss  of 
transparency,  when  the  carbon  dipxide  is  calculated 
from  the  quantity  of  air  needful  to  the  production 
of  this  result. 

These,  although  pretty  experiments,  and  described 
in  full  by  most  sanitary  writers,  have  not  come  into 
general  use,  because  they  are  not  required.  As  they 
yield  results  which  are  only  approximate,  they  can- 
not take  the  place  of  the  accurate  determination  need- 
ful in  a  scientific  inquiry,  while,  as  rough-and-ready 
methods,  their  results  convey  no  more  information  of 
practical  value  than  may  be  gathered  unpretentiously 
by  the  sense  of  smell.  A  well-ventilated  room  should 
not  have  more  than  one  or  two  volumes  per  10,000 
in  excess  of  the  external  air,  equalling  a  total  of  five 
or  six  volumes.  When  the  carbon  dioxide  amounts 
to  seven  volumes,  a  want  of  freshness  is  recognized 
on  entering.  When  nine,  ten,  or  more  volumes  are 
present,  the  organic  odor  becomes  manifest. 

Although  the  carbon  dioxide,  as  has  been  stated,  is 


163 


Atr 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


generally  accepted  as  a  measure  of  the  respiratory 

impurity,  it  is  not  an  accurate  one,  for  it  is  more 
readily  diffused  and  carried  off  by  ventilating  currents 
than  the  organic  exhalations  which  accompany  it 
from  the  human  system.  Whence  it  comes  that  the 
continued  occupancy  of  an  apartment  may  give  rise 
to  organic  odors  in  its  atmosphere,  although  carbon 
dioxide  may  not  be  present  in  large  quantity.  The 
exhalation  appears  to  adhere  to  walls  and  other 
surfaces,  and  textures,  and  to  require  time  for  its 
dissipation. 

But,  while  the  carbon  dioxide  is  not  an  accurate 
measure  of  the  organic  contamination  in  the  air  of 
occupied  buildings,  its  estimation  affords  the  best 
means  of  testing  the  efficiency  of  the  ventilation. 
Sanitary  inspectors  do  not  recognize  this  fact.  Sani- 
tary chemists  have  not  brought  it  prominently  into 
notice.  When  questions  of  ventilation  are  to  be 
settled,  Casella's  air  meter  is  used,  and  the  air  move- 
ment is  calculated  from  its  indications  and  the  areas 
of  inflow  and  exit.  The  inspector  shows  that  so 
much  air  has  entered  or  that  so  much  has  escaped,  to 
be  replaced  of  necessity  by  a  corresponding  volume 
of  fresh  air  through  the  inflow  ducts.  But  this  is  not 
enough.  It  must  be  shown  that  the  air  introduced 
has  effected  the  purpose  for  which  it  was  introduced. 
This  may  be  done  by  a  calculation  based  on  the 
amount  of  carbonic  impurity  found  by  experiment. 
The  capacity  of  the  room  must  be  ascertained,  and 
in  exact  calculations  deduction  should  be  made  for 
the  body  bulk  of  the  occupants  and  for  the  furni- 
ture. The  time  during  which  the  deterioration  has 
been  going  on  is  another  factor  entering  into  the 
calculation. 

The  carbonic  evolution,  0.01  cubic  foot  per  minute 
or  0.6  per  hour  per  person,  multiplied  by  the  number 
of  minutes  or  hours,  gives  the  amount  of  the  carbonic 
impurity  expired.  When  this  is  divided  by  the 
carbonic  impurity  found  by  experiment  in  10,000 
volumes  of  the  air,  the  quotient  multiplied  by  10,000 
will  express,  in  cubic  feet,  the  volume  of  the  air  with 
which  the  respiratory  products  have  been  diluted. 
But,  as  the  air  volume  in  the  room  has  contributed 
to  the  dilution,  its  capacity  has  to  be  deducted  from 
the  total  to  obtain  the  amount  of  the  inflow.  Thus  if 
the  data  consist  of  twenty  persons,  three  hours  in  a 
room  having  a  capacity  of  10,000  cubic  feet,  the 
air  on  analysis  showing  14.5  volumes  or  a  respiratory 
impurity  of  eleven  volumes,  as  a  parallel  experiment 
on  the  external  air  indicates  the  presence  of  3.5 
volumes. 

0.6  X20  X3  =36  cubic  feet  of  carbon  dioxide  expired, 
11  :  10,000  ::  36  :  32,727  cubic  feet  of  air  concerned 

in  the  dilution. 
32,727-10,000  in  room  =22,727  inflow. 
22, .  27  -j-3  =7,576  cubic  feet  inflow  per  hour. 
75,76  -=-20  =379  cubic  feet  per  hour  per  person. 

In  practice  it  is  often  found  that  the  inflow,  as 
determined  by  the  anemometer,  is  much  greater  than 
that  obtained  from  the  chemical  results.  That  the 
air  enters  is  certain,  and  that  it  fails  to  be  utilized  in 
diluting  the  expired  air  is  equally  so.  In  one  of  the 
schools  of  Washington,  D.  C,  800  cubic  feet  per  min- 
ute entered  the  room,  while  but  324  cubic  feet  con- 
tributed to  the  ventilation.  The  cause  in  this 
instance  was  manifest.  The  temperature  of  the 
inflow  was  so  great  that  the  air  rose  immediately  to 
the  ceiling,  whence  it  was  drawn  off  by  the  lowered 
windows  and  foul-air  flues. 

Impurities  in  Air. — Carbon  dioxide  in  air,  while 
essential  to  vegetable  life,  must  be  regarded  as  an 
accidental  impurity  in  its  relations  to  animal  life 
when  present  in  any  locality  in  excess  of  that  found 
in  the  free  atmosphere.  The  sources  from  which  the 
carbon  dioxide  is  derived  often  yield  with  it  other  and 
more  dangerous  substances.  These  sources  are,  first, 
combustion  for  artificial  warmth  and  lighting; 
second,  the  resolution  or  dissipation  of  dead  organic 


matter,  and,  third,  the  resolution  or  dissipation  of 
the  tissues  of  living  animals  by  the  respiratory  process. 

Products  of  imperfect  oxidation  are  associated  with 
the  carbon  dioxide  from  the  combustion  of  fuel.  A 
lamp  or  fire  smokes  and  smells  when  its  oxygen  or 
air  supply  is  insufficient.  The  smoke  is  unoxidized 
carbon  and  the  smell  an  emanation  from  transition 
products.  The  dangerous  product  in  the  combustion 
of  fuel  is  carbon  monoxide  (CO).  This  colorless  and 
inodorous  gas  is  highly  poisonous,  entering  the  blood 
and  rendering  the  red  corpuscles  incapable  of  per- 
forming their  functions  even  though  pure  air  be 
afterward  supplied.  Death  is  the  result  of  asphyxia. 
In  rooms  heated  by  stoves  the  headache,  languor, 
and  oppression  occasionally  produced  are  due  to 
the  escape  of  this  with  other  gaseous  products 
through  the  open  stove  doors,  leaky  joints,  and 
turned  dampers.  Some  experiments  of  St.  Claire 
Deville  and  Troost  indicated  that  the  carbon  mon- 
oxide might  even  pass  through  the  pores  of  cast 
iron  when  the  metal  became  strongly  heated.  The 
French  Academy,  therefore,  caused  an  investigation 
to  be  made  of  this  subject,  and  the  conclusion  was 
reached  that  this  dangerous  gas  does  pass  through  the 
metal  when  its  temperature  reaches  a  dark  red  heat. 
Since  these  experiments,  air  heated  by  furnaces  or 
cast-iron  stoves  has  been  regarded  as  injurious.  But 
doubt  has  been  thrown  upon  the  results  of  the 
French  chemists  by  several  later  experimenters,  and 
particularly  by  Professor  Remsen,  who  has  shown 
some  possible  sources  of  error,  and  who,  having 
guarded  against  these,  has  concluded  that,  while 
carbon  monoxide  may  be  present  in  the  air  of  furnace- 
heated  rooms,  it  must  exist  in  quantities  so  minute 
that  it  is  questionable  if  it  can  act  injuriously  on  the 
health  of  those  who  breathe  it. 

The  deadly  nature  of  water  gas  as  compared  with 
coal  gas  is  due  to  its  larger  proportion  of  carbon 
monoxide.  Coal  gas  contains  less  than  ten  per  cent., 
while  water  gas  contains  thirty  to  forty  per  cent. 
Water  gas  is  manufactured  by  playing  steam  on  glow- 
ing coke  or  charcoal,  the  products  being  carbon 
dioxide,  carbon  monoxide,  and  hydrogen.  The  num- 
ber of  deaths  from  leakage  of  gas  has  been  greatlj 
increased  since  the  introduction  of  water  gas.  Where 
one  death  was  formerly  reported  in  a  given  time  and 
population,  there  are  now  twenty-five  to  thirty  deaths. 
Must  of  these  deaths,  however,  are  attributable  to 
suicide  rather  than  to  accidental  poisoning. 

In  connection  with  local  accumulations  of  these 
gases  it  should  be  remembered  that  they  are  explosive 
when  mixed  with  air.  It  is  therefore  dangerous  to 
strike  a  light  in  the  room  of  a  gas  suicide  or  to  look  for 
a  gas  leak  in  a  cellar  or  basement  until  after  sonic 
ventilation  has  been  effected.  A  mixture  of  one  part 
gas  to  eight  parts  air  is  most  violent  in  its  explosion. 
With  one  to  four  there  is  not  enough  air  for  explosion, 
and  with  one  to  twelve  there  is  not  enough  gas. 

The  evolution  of  carbon  dioxide  into  the  air  of  a 
room  during  the  combustion  of  illuminating  gas  or  oil 
is  generally  underestimated  in  considering  the  carbonic 
impurity  of  occupied  rooms.  Parkes  states  that  one 
cubic  foot  of  gas  consumed  in  an  hour  produces  as 
much  as  the  respiration  of  one  person.  One  oil  burner 
consuming  four  ounces  of  illuminating  oil  per  hour 
was  allowed  in  United  States  barracks  for  every  ten 
soldiers.  The  oil  consumed  pervaded  the  barrack 
room  with  somewhat  more  carbon  dioxide  than  was 
expired  by  the  ten  men.  The  necessity  for  increased 
ventilation  must  be  considered  with  the  presence  of 
each  lamp  or  gas  jet. 

Associated  with  the  carbon  dioxide  derived  from 
the  oxidation  of  the  carbon  of  dead  and  decomposing 
organic  matters  on  the  surface  of  the  earth,  some- 
times aggregated  locally  into  manure  piles,  cesspools, 
vaults,  drains,  and  sewers,  are  certain  compounds 
intermediate  in  composition  between  the  complex  or- 
ganic matter  in  process  of  putrefaction  and  the  simply 


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REFERKNCK    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


Air 


constituted  organic  substances  which  arc  the  re  ull 
of  the  completed  oxidation.  The  sulphur  present  in 
certain  tissues  becomes  converted  into  hydrogen  or 
ammonium  sulphide,  while  among  the  nitrogenous 
products  are  many  foul-smelling  and  harmful  gases 
.  apors  of  an  ammoniacal  character;  hydrocarbons 
also  are  formed.  Formerly  the  reversion  of  organic 
matter  to  the  inorganic  condition  was  supposed  to  be 
due  to  I  he  purely  chemical  process  of  oxidation  by  I  he 
oxygen  of  the  air.  Decomposition  was  regarded  as  a 
slow  oxidation  at  a  low  temperature,  as  combustion 
was  a  rapid  oxidation  at  a  high  temperature;  but  when 
Pasteur  showed  that  meat  could  be  preserved  from 
putrefaction  when  exposed  to  the  air,  provided  the  air 
was  first  filtered  through  cotton  wool,  this  chemical 
theory  of  decomposition  had  to  be  abandoned. 
Ultimately  the  saprophytic  bacteria  were  discovered, 
:oid  now  these  are  recognized  as  so  universally  present 
and  so  essential  to  the  disposal  of  organic  matter  that 
cannot  be  regarded  as  an  impurity  in  the  air. 
They  arc  the  means  to  an  end,  one  of  the  great  links 
in  the  endless  chain  of  life,  and  as  important  in  the 
wonderful  scheme  of  creation  as  the  carbon  dioxide 
which  they  prepare  for  the  future  growth  of  vegetation. 

The  action  of  the  sulphur  gases  on  the  animal  system 
has  been  demonstrated  experimentally  by  Barker  on 
dogs  and  other  small  animals.  Hydrogen  sulphide 
produces  vomiting  and  diarrhea,  prostration  and 
coma,  which,  like  the  effects  of  carbon  monoxide, 
persist  after  removal  from  the  contaminated  atmos- 
phere. The  exhaustion  and  coma  continue,  and  death 
results  if  the  impression  fixed  on  the  blood  is  suffi- 
ciently powerful.  But,  while  this  occurred  in  the 
subjects  of  Dr.  Barker's  experiments,  it  is  well  known 
that  men  may  breathe  with  impunity  for  a  time  a 
sulphureted  atmosphere  many  times  stronger  than 
those  employed  by  him.  Ammonium  sulphide, 
irding  to  this  experimenter,  caused  vomiting  and 
febrile  action,  quickly  followed  by  the  development  of 
a  typhoid  condition. 

Chronic  poisoning  by  hydrogen  sulphide  manifests 
itself,  according  to  some  observations,  by  gradual 
prostration,  emaciation,  and  anemia,  with  headache, 
foul  tongue,  anorexia,  and  the  occasional  eruption  of 
boils,  but  it  is  not  certain  that  these  symptoms  are 
due  to  this  gas  and  not  to  organic  vapors  which 
accompany  it. 

The  action  of  the  more  complex  organic  vapors  given 
off  during  decomposition  has  not  been  determined. 
The  dogs  subjected  by  Dr.  Barker  to  cesspool  air  were 
all  more  or  less  affected,  the  symptoms  being  those  of 
intestinal  derangement  with  prostration,  heat  of 
surface,  distaste  for  food,  and  those  general  signs  which 
mark  the  milder  forms  of  continued  fever  common  to 
"  the  dirty  and  ill-ventilated  homes  of  the  lower  classes 
of  the  community."  But  the  sulphur  compounds 
already  mentioned  contributed  to  these  results. 

Even  the  constitution  of  these  organic  vapors  is  not 
known  with  certainty.  Dr.  Odling  distilled  half  a 
gallon  of  the  liquid  contents  of  a  cesspool  until  all 
volatile  matters  had  come  over.  He  treated  the  fetid 
ammoniacal  distillate  with  hydrochloric  acid,  and 
afterward  precipitated  with  platinum.  The  platino- 
chlorides  of  the  organic  alkalies  were  found  to  crystal- 
lize in  well-defined,  flattened,  orange-colored  tablets, 
evidently  not  the  platinochloride  of  ammonium. 
Incineration  of  this  platinum  salt  yielded  41.30  per 
cent,  of  the  metal,  while  the  platinoehlorides  of 
ammonium,  methylamine,  and  ethylamine  gave 
respectively,  44.36,  41.04,  and  39.40  per  cent,  of 
platinum.  The  salt  formed  from  the  carboammoniacal 
vapors  was  analogous  in  composition  to  that  formed 
with  methylamine.  But  inasmuch  as  the  crystals 
were  more  like  those  of  the  ethyl  salt,  and  as  a  mixture 
of  the  ethylamine  and  ammonium  salts  would  corre- 
spond in  percentage  composition  to  that  obtained  from 
the  distillate,  he  supposed  that  the  sewage  emana- 
tions were  ammoniacal  and  ethylic. 


A  sei'ies  of  experiments  made  by  Smart  showed 
that  the  volatile  matters  evolved  during  the  fer- 
ment a  1 1  \  o  changes  in  organic  substances  are  of  two 
different  characters,  the  one  vaporous  ami  ethylic, 
but  not  containing  nitrogen  if  separated  from  the 
ammonia  with  which  if  is  volatilized  anil  condensed, 
and  the  other  volatile,  carbonaceous,  and  solid,  con- 
creting on  distillation  into  white,  soft,  and  grea  v 
particles.  The  former  has  a  dull,  mawkish,  not 
positively  unpleasant  odor,  the  latter  a  strong  and 
intensely  disagreeable  smell. 

Marsh  gas  (Vllt),  a  colorless,  inodorous,  and,  fortun- 
ately, non-poisonous  gas,  is  largely  formed  as  a  tran- 
sition product  in  the  decomposition  of  vegetable 
mat  ter.  It  is  evolved  in  the  gradual  transformation  of 
wood  into  coal,  constituting  in  mines  the  "fire  damp" 
which  is  the  occasion  of  so  many  disastrous  explosions. 
It  explodes,  in  the  presence  of  flame,  when  forming 
only  one-eighteenth  of  the  air  of  the  mine.  The  re- 
sulting gases,  carbon  dioxide,  nitrogen,  and  vapor  of 
water,  constitute  the  "after  damp"  or  "  choke  damp" 
which  suffocates  those  imners  who  have  not  been  killed 
outright  by  the  explosion. 

Associated  with  the  carbon  dioxide  of  respiration 
are  certain  organic  exhalations  which  differ  in  con- 
stitution, according  to  the  efficiency  or  imperfection 
of  the  oxidation  in  the  tissues.  In  diseased  condi- 
tions of  the  body  these  exhalations  are  thrown  out  in 
greater  quantity  than  in  health  and  the  infection  of 
clisease  in  some  instances  accompanies  them.  They 
are  exhaled  not  only  from  the  lungs,  but  also  along 
with  the  perspiration  from  the  pores  of  the  skin.  The 
quantity  of  organic  matter  thus  eliminated  has  not 
been  determined,  but  is  known  to  be  small.  It  does 
not  diffuse  like  a  gas  into  the  atmosphere,  but  floats, 
when  there  are  no  currents  to  disturb  it,  like  an 
odorous  but  invisible  cloud.  If  evolved  into  the  air 
of  a  close  room  its  amount  is  proportioned  to  that  of 
the  carbon  dioxide  exhaled  by  the  occupants,  in  the 
absence,  of  course,  of  any  other  output  of  this  gas. 
As  vapor  of  water  is  deposited  from  a  saturated  air, 
so  these  organic  clouds  become  similarly  condensed  on 
walls,  furniture,  hangings,  bedding,  clothing,  and 
other  exposed  articles.  In  a  room  saturated  with 
organic  exhalations  the  mere  renewal  of  the  air  does 
not  dissipate  the  taint,  for  the  renewed  air  becomes 
immediately  affected  by  the  volatilization  of  the  or- 
ganic deposits.  The  necessity  for  a  thorough  aeration 
is  obvious. 

The  evil  effects  of  breathing  respired  air  are  at- 
tributed to  these  organic  matters.  Many  experiments 
have  been  made  on  this  subject,  the  most  striking  of 
which  are  those  by  Brown-Sequard  and  d'Arsonval, 
reported  in  1SS9.  They  connected  a  series  of  four 
air-tight  cages  by  means  of  rubber  tubing  and  as- 
pirated a  steady  current  of  air  through  them.  In 
each  cage  was  a  rabbit.  The  animal  in  the  last  cage 
of  the  series  breathed  the  air  which  contained  the 
respiratory  products  of  the  animals  in  the  other  cages, 
while  the  animal  in  the  first  cage  was  supplied  with 
pure  air.  After  a  time  the  animal  in  the  last  cage 
died  as  a  result  of  its  confinement  in  the  impure  air, 
and  a  few  hours  later  that  in  the  cage  next  to  the  last 
also  succumbed.  The  inmates  of  the  first  and  sec- 
ond cages  survived.  On  placing  an  absorption  tube 
between  the  third  and  fourth  cages,  the  animal  in  the 
last  cage  survived  the  experiment,  while  that  in  the 
third  cage  died.  This  seemed  to  indicate  that  the 
toxic  substance  in  the  air  was  destroyed  by  the  sul- 
phuric acid  and  was  therefore  probably  organic  mat- 
ter. These  experiments  were  repeated,  with  the  same 
results,  by  Merkel  in  1892.  In  a  Smithsonian  con- 
tribution, however,  by  Drs.  Billings  and  .S.  W.  Mitch- 
ell, published  in  1895,  it  is  contended  from  some 
experiments  made  under  their  direction  that  in  the 
air  expired  by  healthy  mice,  rabbits,  etc.,  there  is  no 
peculiar  organic  matter  which  is  poisonous  to  the 
animals   mentioned,    or   which   tends   to   produce   in 


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them  any  special  form  of  disease,  and  that  it  is  very 
improbable  that  the  minute  quantity  of  organic  mat- 
ter contained  in  the  air  expired  from  human  lungs 
has  any  deleterious  influence  upon  persons  who  inhale 
it  in  ordinary  rooms.  They  concluded  also  that  the 
discomfort  produced  by  crowded,  ill-ventilated  rooms 
in  persons  not  accustomed  to  them  is  not  due  to  ex- 
cess of  carbon  doxide,  nor  to  bacteria,  nor  in  most  cases 
to  dusts  of  any  kind,  the  two  great  causes  of  such  dis- 
comfort being  excessive  temperature  and  unpleasant 
odors.  These  odors,  it  is  said,  may  in  part  be  due  to 
volatile  products  of  decomposition  contained  in  the 
expired  air  of  persons  having  decayed  teeth,  foul 
mouths,  or  certain  disorders  of  the  digestive  appa- 
ratus, and  they  are  due  in  part  to  volatile  fatty  acids 
given  off  with,  or  produced  from,  the  excretions  of 
the  skin,  and  from  clothing  soiled  with  such  excre- 
tions. They  may  produce  nausea  and  other  disagree- 
able sensations  in  specially  susceptible  persons,  but 
most  men  soon  become  accustomed  to  them  and  cease 
to  notice  them,  as  they  will  do  with  regard  to  the  odor 
of  a  smoking  car  or  of  a  soap  factory  after  they  have 
been  for  some  time  in  the  place. 

There  are  no  microorganisms  in  the  air  in  the  lungs. 
They  are  filtered  out  of  the  inspired  air,  or  captured 
in  mucus  and  ciliated  out  before  they  can  reach  the 
pulmonary  cells.  We  know  this  to  be  the  case  be- 
cause when  there  is  no  break  in  the  skin  in  an  injury 
to  the  lung  from  a  fractured  rib,  we  may  have  em- 
physema and  pneumothorax  with  hemorrhage,  but 
no  pleurisy.  Besides  this,  Tyndall  showed  by  the 
electric  beam  the  freedom  of  the  expired  air  from  par- 
ticulate matter. 

But  that  evil  consequences  do  follow  overcrowding 
and  its  necessarily  vitiated  air  is  well  known.  Every 
schoolboy  knows  the  history  of  the  Black  Hole  of  Cal- 
cutta. Evil  consequences  of  a  lighter  grade  are  also 
recognized  as  the  legitimate  offspring  of  vitiated  air. 
The  breathing  of  air  that  has  already  been  breathed 
gives  rise  in  succession  to  feelings  of  languor  and 
heaviness,  headache,  dulness  of  mind,  drowsiness, 
dizziness  and  faintness,  sometimes  nausea  and,  if 
continued,  feverishness.  These  symptoms  indicate  a 
poisoning  of  the  blood  by  organic  matters  which  would 
not  be  present  in  it  with  free  supplies  of  air  to  wash 
them  away.  The  brain  is  the  first  of  the  organs  to 
feel  the  effects  of  the  tainted  blood.  The  mental  in- 
aptitude of  children  after  two  or  three  hours  in  a 
close  schoolroom  is  easily  understood.  The  waste  or- 
ganic matters  retained  in  the  blood  are  not  necessarily 
absorbed  from  the  contaminated  air.  They  may  be 
due  in  great  part  to  a  suppression  of  the  regular 
exhalations  and  a  consequent  retention  of  matters 
which  ought  to  have  been  exhaled.  As  with  moisture 
in  air,  so  with  these  organic  exhalations.  The  air 
when  saturated  refuses  to  take  up  more.  Again, 
their  retention  in  the  blood  interferes  with  the  oxida- 
tion which  should  go  on  in  the  tissues;  and  the  transi- 
tion products  that  are  formed,  being  also  retained,  add 
seriously  to  the  disordered  condition.  The  individual 
becomes  poisoned  by  products  of  his  own  living 
processes. 

The  human  system,  however,  appears  to  accommo- 
date itself  to  a  certain  degree  of  impurity  in  the  air, 
so  that,  after  a  time,  the  breathing  of  such  air  ceases 
to  occasion  the  feelings  of  acute  discomfort  that  have 
been  mentioned.  But  in  their  stead  a  depressed  con- 
dition of  the  system  is  developed,  manifested  by  pal- 
lor of  countenance  and  loss  of  appetite,  strength,  and 
spirits.  The  vitality  of  the  individual  is  lessened. 
Every  draught  becomes  dangerous  to  him,  and 
even  the  chill  from  a  wall  or  closed  window  may  cause 
serious  sickness.  He  becomes  a  ready  victim  to  con- 
sumption if  the  germ  of  that  disease  is  present,  as  is 
so  frequently  the  case  in  the  crowded  dwellings  of  the 
poor  in  our  large  cities.  Health,  in  fact,  becomes 
broken  and  the  nervous  system  prostrated,  a  condi- 
tion in  which  a  resort  to  alcoholic  stimulants  often 


gives  temporary  relief  at  the  expense  of  a  more  rapidly 
fatal  issue. 

Besides  the  gases  and  vapors  already  mentioned 
there  are  many  particulate  bodies,  living  and  dead 
organic  and  mineral,  floating  in  the  atmosphere.  All 
are  accidental  and  therefore  impurities.  More  than 
thirty  years  ago,  Professor  Tyndall  made  use  of  an 
electric  beam  as  a  searchlight  for  floating  particles. 
In  pure  air,  made  so  by  specially  filtering  it,  the  track 
of  the  ray  is  invisible,  but  in  the  free  atmosphere  it  is 
defined  with  more  or  less  brightness  by  reflection  from 
particles  ordinarily  invisible.  If  the  electric  bean 
were  passed  through  the  air  of  many  of  our  rooms,  we 
would  hesitate  to  inhale  the  aerial  turbidity  which  it 
would  reveal.  The  lower  strata  of  the  air  are  tilled 
with  such  impurities,  but  air  at  a  height  of  600  feet 
is  comparatively  pure  in  this  respect.  The  smoke 
clouds,  consisting  of  particles  of  unburned  carbon 
which  hover  over  manufacturing  cities,  seldom  rise 
higher  than  this. 

It  is  impossible  to  do  more  than  outline  these  float- 
ing particles  in  the  most  general  way,  because  every- 
thing on  the  face  of  the  earth  is  susceptible  of  being 
ground  into  dust  and  of  being  swept  up  by  atmos- 
pheric currents.  Matters,  indeed,  of  an  extraterres- 
trial origin  are  present  in  the  form  of  dust  derived 
from  the  destruction  of  meteors  in  their  passage 
through  the  atmosphere.  The  inorganic  dust  con- 
sists chiefly  of  carbon  particles,  amorphous  silicates, 
irregular  fragments  of  hard  mineral  substances,  and 
salts  of  calcium,  potassium,  sodium,  and  ammonium. 
The  organic  dust  includes  the  detritus  of  decaying 
vegetation,  starch  cells,  epidermal  hairs,  filaments 
from  the  pappus  of  the  Composite,  pollen  grains,  and 
disintegrated  woody  tissue.  The  animal  kingdom  al- 
so is  represented  in  the  dust  by  fibers  of  wool,  plume- 
lets of  feathers,  butterfly  scales,  and  other  debris  of 
insect  life,  together  with  occasionally  epidermal  and 
epithelial  scales.  Saprophytic  bacteria  are  present, 
and  in  certain  localities  pathogenic  bacteria  as 
well.  Locality  and  season  influence  the  quantity  and 
character  of  these  impurities.  Naturally  air  which 
blows  over  a  long  stretch  of  land  contains  more  than 
sea  air.  Cotton  is  found  in  nearly  every  sample  of 
autumnal  air  in  the  Southern  States.  Pollen  grains, 
on  many  occasions,  have  given  a  yellow  color  to  the 
rainfall.  Autumnal  catarrh,  sometimes  called  hay 
fever,  which  affects  so  many  people  at  a  certain  period 
of  the  year,  is  attributed  by  many  to  this  impurity. 
Crystals  of  sodium  chloride  are  notably  present  in  the 
air  of  the  seacoast,  while  in  that  of  cities  we  find  car- 
bon particles  and  crystals  of  ammonium  sulphate 
from  the  combustion  of  coal.  The  air  of  houses 
contains  fragments  of  the  fibers  of  clothing  and 
epidermal  scales,  while  that  of  hospitals,  workshops, 
factories  and  mines,  etc.,  is  charged  with  particles 
varying  in  character  with  the  occupancy  and  work. 

Sometimes  the  inorganic  matters  pervade  the  at- 
mosphere of  localities  in  the  form  of  vapor,  as  in  fac- 
tories where  phosphorus  or  mercury  is  in  constant  use. 

The  earliest  observations  on  the  impurities  of  air 
were  made  on  condensations  gathered  from  the  outside 
of  a  vessel  containing  ice.  Subsequently  experiments 
were  made  on  water  which  had  been  shaken  with  suc- 
cessive volumes  of  air.  In  both  cases  a  liquid  was 
obtained  which  putrefied  readily  and  in  which  the 
presence  of  living  organisms  could  be  identified.  R. 
A.  Smith  was  perhaps  the  first  to  use  the  latter 
method.  He  put  150  drops  of  pure  water  in  a 
small  vial  containing  air  from  a  cow  stable.  He 
shook  the  bottle  that  the  water  might  entangle  and 
wash  out  all  particles  of  solid  matter  from  the  air. 
He  renewed  the  air;  and  this  he  did  500  times. 
When  he  examined  the  water  under  the  microscope, 
he  was  astonished  at  the  immense  number  of  spores 
which  were  visible,  along  with  many  other  matins 
organic  and  mineral:  ami  afterward  many  animalcules 
of  various  kinds  were  developed  in  it. 


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Air 


At  the  present  time  aerial  organic  matter  is  investi- 
i,.,]   microscopically,  biologically,  and  chemically. 
■Jolid  particles  for  microscopic  study  arc  caught  on  a 
r|ass  slide  lightly  coated  with  glycerin.     The  general 
ractcrs  of  atmospheric  impurities  may  be  ascer- 
tained by  an  examination  of  I  lie  rain  or  snow,  for  all 
e  impurities  that  arc  not  dissolved  or  absorbed  by 
lie  rain  are  washed  down  by  it.     But  for  evaporation, 
lensation,   and   rainfall,   the  inhabitants  of   the 
h  would  speedily  be  stifled  in  the  dust  swept  up 
mi'  atmospheric  currents.     Distant  objects,  hazy 
,ud  indistinct   in  a  dry  summer  air,  become  sharply 
lUtlined   in   a    purified   rain-washed   atmosphere.      In 
water  suspended  impurities  may  be  seen  with  the 
laked  eye,  and  in  the  gradual  melting  of  a  pure  white 
nantle  of  snow  the  stain  made  by  its  entangled  im- 
mrities  will  appear  before  it  has  shrunk  to  half  its 
iriginal  thickness. 

The  biological  examination  resolves  itself  into  a 
letermination  of  the  number  of  bacterial  colonies  and 
ither  microorganisms  in  a  given  volume  of  the  air. 
\ith  culture  experiments  for  the  study  of  species. 
Official  observations  at  the  Montsouris  Observatory 
tear  Paris.  Trance,  have  shown  that  there  are  few 
lacteria  in  the  air  in  winter,  and  that  the  numbers 
acrease  through  spring  and  summer  to  over  100 
cubic  meter  in  the  autumn.  The  air  of  city 
I  -  is  densely  charged  with  bacteria.  The  atmos- 
phere is  purer  in  this  respect  in  its  upper  strata: 
tir  collected  at  over  6.000  feet  is  practically  free 
rom  bacteria  and  moulds. 

Chemistry  has  done  but  little  to  perfect  the  organic 
inalysis  of  air.  With  known  methods  of  analysis  the 
I  s  obtained  by  the  expenditure  of  much  time  and 
■are  are  of  small  value.  If  an  air  specimen  contains 
tit  unusual  amount  of  the  organic  elements,  it  may  be 
orrectly  considered  as  impure,  but  the  nature  of  the 
mpurity  is  not  denned.  The  carbon  estimated  may 
■  been  a  harmless  particle  of  soot,  or  in  part  it  may 
lave  been  essential  to  the  spread  of  a  deadly  disease. 
Nevertheless,  analyses  are  made  as  a  matter  of  official 
routine  by  sanitary  officers  in  England  and  France. 
The  organic  substances  are  absorbed  by  aspirating 
arge  volumes  of  the  air  through  a  small  volume  of 
listilled  water,  and  the  liquid  menstruum  is  then  inves- 
tigated by  the  processes  of  water  analysis.  Professor 
Remsen  endeavored  to  improve  on  this  process  by 
Altering  the  air  through  powdered  and  moistened 
pumice  before  passing  it  in  fine  bubbles  through  the 
distilled  water.  He  thus  showed  that,  so  far  as  could 
be  determined  by  chemical  means,  all  nitrogenous 
aiatter  was  retained  by  the  filter.  But,  as  germs  or 
microscopic  organisms  might  have  passed  through 
without  thus  showing  their  presence  in  the  absorbing 
liquid,  owing  to  the  necessarily  minute  trace  of  nitro- 
gen in  them,  Smart  carried  out  a  series  of  experiments 
which  determined,  first,  that  the  nitrogenous  matter 
of  air,  excluding  ammonia  from  consideration,  is 
particulate;  second,  that  it  consists  in  large  part  of 
microorganisms;  and  third,  that  filtration  through 
Austrian  glass  wool  effects  their  removal  from  the 
passing  air.  The  experiments  were  conducted  in  a 
sterilized  apparatus.  The  air  was  drawn  through  a 
short  glass  tube  one  centimeter  in  diameter,  lightly 
packed  for  two  or  three  inches  of  its  length  with  the 
glass  wool.  From  this  it  was  passed  in  fine  division 
through  distilled  water.  After  this  it  was  mixed  with 
steam  generated  from  a  dilute  solution  of  alkaline  po- 
tassium permanganate,  the  mixture  immediately  enter- 
ing the  tube  of  a  Liebig's  condenser,  where  the  steam 
was  deposited,  carrying  down  with  it,  after  nature's 
process  of  air  purification  by  the  rainfall,  any  micro- 
organisms which  might  have  escaped  removal  by 
lilt  ration  or  absorption.  The  difficulties  in  the  way  of 
sterilizing  the  various  parts  of  this  apparatus  were 
such  that  the  first  experiments,  which  gave  speedy 
developments  in  culture  liquids  tainted  by  the  filter, 
the  absorbing  liquid,  and   the   condensate,   were   re- 


garded only  as  the  practical  expression  of  these  diffi- 
culties. The  experiments  we;  I  with  precau- 
tions.suggested  as  necessary  by  the  previous  experience, 
and  ultimately  success  attended  them. 

One  of  the  processes  of  water  analysis  to  which  these 
matters  were  subjected  involved  the  distillation  of  the 

ammonia,   which    was    present    in     the    liquid,    and    its 

estimation  by  the  calorimetric  method  with  Nessler's 

solution.  Ammonia  gives,  with  this  test  solution,  a 
faint  straw-yellow  color,  which  deepens,  in  proportion 
to  the  amount  of  ammonia  present,  to  a  dark  sherry 
brown,  or  to  a  dark  haziness  or  distinct  precipitate. 
But  it  not  infrequently  happened  that  in  testing  for 
ammonia  in  the  distillate  from  the  pure  water  in  which 

the  glass  wool  containing  the  organic  matter  of  the  air 
was  suspended,  as  well  as  in  that  from  the  absorbing 
liquid  which  contained  most  of  the  ammonia,  and  in 
that  from  the  condensate  which  contained  but  a  trace, 
a  citron-green  color  was  produced  which  masked  the 
ammonia  reaction  and  rendered  its  estimation 
impossible.  Dr.  Kidder,  of  the  navy,  observed  this 
interference  with  the  ammonia  coloration,  and  attrib- 
uted it  to  the  presence  of  substances  evolved  in  the 
putrefaction  of  organic  matter.  He  concluded  from 
the  few  experiments  he  made  that  the  amines  are  not 
necessarily  concerned  in  its  production,  as  he  found 
that  butyric  acid  gave  a  somewhat  similar  interference 
to  that  met  with  in  the  experiments  on  air  washings. 
But  the  haziness  with  which  the  presence  of  butyric 
acid  masks  the  true  ammonia  color  is  not  the  citron- 
green  coloration  which  so  frequently  occurs  in  the 
analysis  of  foul  airs.  This  is  due  to  the  presence  of  an 
ethyl  compound  which  is  given  off  from  the  carbo- 
hydrates while  undergoing  change.  It  may  be  ob- 
tained free  from  the  ammonia  which  ordinarily  accom- 
panies it  and  obscures  its  reaction  by  submitting  the 
liquid  containing  both  to  the  process  of  nitrification. 
It  may  also  be  obtained  from  ammonia  and  free  glu- 
cose, and  from  starch,  cane  sugar,  tannin,  salicin,  etc., 
after  treatment  with  heat  and  acids. 

In  some  of  the  experiments  referred  to,  an  air 
volume  of  100  liters  was  passed  through  the  interior  of 
a  glass  globe  which  contained  liquid  sewage  and  silt, 
garbage,  or  other  foul  and  decomposing  materials,  and 
then  through  the  glass-wool  filter,  absorber,  and 
condenser  to  remove  the  matters  with  which  it  had 
become  contaminated.  Culture  experiments  showed 
the  satisfactory  removal  by  the  filter  of  all  germs  and 
nitrogenous  matters,  ammonia  excepted,  and  chem- 
ical tests  determined  approximately  the  quantity  of 
organic  matter  thus  removed.  In  some  instances  a 
second  air  volume  of  100  liters  was  drawn  over  the 
organic  matter  in  the  globe,  and  the  results  obtained 
from  the  filter  through  which  it  was  afterward  passed 
did  not  differ  from  those  of  the  first  experiment  on 
the  same  organic  matter.  From  these  experiments  the 
conclusion  appears  admissible  that  the  volume  of  air 
which  is  contaminated  by  a  certain  decomposing 
organic  mass  is  the  volume  which  comes  in  contact 
with  it.  If  no  air  is  drawn  through  the  foul  globe, 
only  that  which  is  contained  in  it  is  rendered  impure. 
This  air  has  its  oxygen  in  time  replaced  by  the  foul- 
smelling  gases  of  decomposition.  Evaporation  takes 
place  from  the  contained  liquid  until  the  stagnant  and 
enclosed  air  becomes  saturated.  The  ascensional 
force  of  evaporation  carries  from  the  smeared  and 
half-dried  sides  of  the  globe,  and  from  the  unsub- 
merged  solids  within  it,  some  of  the  innumerable  mi- 
croorganisms with  which  they  are  pervaded,  and  the 
air  becomes  charged  with  organic  particles  to  an  ex- 
tent proportioned  to  its  temperature  and  hygrometric 
condition.  If  a  volume  of  air  is  drawn  through  the 
globe,  it  will  be  contaminated  by  organic  matters 
carried  away  by  its  own  movement  and  by  the  in- 
creased activity  of  evaporation  produced  by  it.  If 
a  second  volume  is  drawn  through,  it  will  be  con- 
taminated in  like  manner,  and  to  the  same  extent,  if 
the  volume,   rapidity   of   passage,  temperature,  and 


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hygrometric  condition  are  the  same  in  both  instances; 
and  so  for  a  third,  a  fourth,  or  more  volumes,  until 
the  decomposing  mass  has  become  changed  by  their 
agency.  This  is  recognized  practically  in  sanitary 
work.  The  dead  are  buried  that  their  decomposition 
may  not  contaminate  the  atmosphere.  For  the  same 
reason  garbage  is  collected  and  removed.  A  recep- 
tacle for  foul-smelling  and  fermenting  matter  is  less  of 
a  nuisance  and  less  dangerous  to  health  when  fitted 
with  an  air-tight  cover  than  when  freely  exposed  to 
the  air,  for  in  the  latter  case  every  volume  of  air  which 
comes  in  contact  with  it  is  a  volume  of  air  polluted. 
Sanitary  officials  in  growing  cities  protest  against  the 
continued  existence  of  small  surface  streams  which  of 
necessity  pass  into  the  condition  of  open  sewers,  taint- 
ing every  volume  of  air  which  comes  in  contact  with 
their  foulness.  These  are  bricked  over  and  the  air  is 
preserved  from  the  impure  contact.  But  in  the  con- 
struction of  regular  systems  of  sewerage  provision  is 
made  for  this  contact  under  the  name  of  ventilation. 
The  sewers  are  tapped  at  regular  intervals  along  the 
streets  for  the  exit  of  the  contaminated  air.  From 
the  present  point  of  view  this  ventilation  of  the  sewers 
is  of  questionable  benefit.  The  volume  of  air  rendered 
impure,  and  possibly  dangerous,  is  proportioned  to  the 
thoroughness  of  the  ventilation.  Sulphureted  gases 
may  be  diluted,  and  the  outflowing  air  be  free  from 
disagreeable  odors,  but  the  very  air  movement  which 
effects  this  may  raise  invisible  clouds  of  fermentative 
and  morbific  agencies  from  the  foul  interior.  Ex- 
periments on  this  point  would  be  of  value.  Those 
mentioned  above  indicate  that  the  communication 
with  the  outer  air  should  be  only  such  as  is  needful 
to  relieve  tension  and  prevent  the  forcing  of  seals, 
and  that  these  air  holes  should  be  guarded  by  some 
filtering  material.  But  since  the  volume  of  air  which 
becomes  contaminated  is  that  which  comes  in  contact 
with  the  fermenting  material,  it  may  be  reduced  as 
well  by  diminishing  the  extent  of  the  impure  surface 
as  by  cutting  off  the  ventilation.  Hence  sewers  of 
small  size,  as  in  what  is  known  as  the  separate  system, 
are  to  be  preferred,  on  sanitary  grounds,  to  the  large 
ramifying  tunnels  of  the  combined  system.  The  foul 
airs  which  arise  from  sewer  apertures  are  matters  of 
every-day  observation.  If  well  diluted  with  air  they 
may  not  affect  the  sense  of  smell,  but  they  rise,  never- 
theless, from  the  grated  covers  on  our  streets,  and 
may  be  seen,  by  the  vapor  precipitated  from  them,  as 
an  uprising  column  in  weather  which  clouds  the  air  of 
respiration  thrown  out  from  the  lungs.  With  open 
streets  and  lively  breezes  it  is  probable  that  these 
exhalations  are  dissipated,  or  rather  diluted,  to 
harmlessness,  but  in  enclosed  spaces  and  stagnant 
atmospheres  the  sewer  air,  which  is  so  carefully  ex- 
cluded from  living  rooms  by  intelligent  plumbing, 
may  enter  as  fresh  air  through  open  windows  and 
apertures  specially   devised   for  its  admission.  _ 

Sewer  air  is  atmospheric  air  with  its  oxygen  dimin- 
ished and  its  carbon  dioxide  increased  to  from  ten  to 
fifty  volumes  per  10,000,  and  with  taints  or  not- 
able amounts  of  marsh  gas,  hydrogen  sulphide,  am- 
monium sulphide,  and  amines  or  compound  am- 
monias in  which  one  or  more  atoms  of  hydrogen  are 
replaced  by  a  positive  radicle,  methyl,  ethyl,  amyl, 
etc.  Cesspool  air  has  an  excess  of  these  foul-smelling 
constituents,  for  the  contents  of  a  cesspool  continue 
to  putrefy,  while  the  sewage  in  a  well-constructed 
system  of  sewerage  should  be  carried  away  before 
putrefaction  sets  in.  Each  of  the  impurities  in 
sewer  air  is  harmful  when  breathed  in  strength,  but 
not  specially  dangerous  when  diluted  with  atmos- 
pheric air,  for  it  is  well  known  that  men  whose  occu- 
pations bring  them  into  contact  with  this  contaminated 
air  do  not  suffer  specially  from  disease.  But  sewer  air 
may  be  a  cause  of  diarrhea  or  other  gastrointestinal 
disturbance;  also,  general  depression  or  ill  health,  and 
anemia  may  be  due  to  the  same  cause.  It  is  believed 
by  some  that  other  infectious  diseases    may  be  ac- 


quired from  exposure  to  sewer  air,  provided  always 
that  the  necessary  causative  bacteria  are  present 
therein. 

The  air  of  dwellings  is  sometimes  contaminated 
with  ground  or  cellar  air  drawn  up  through  a  porous 
soil  by  the  greater  warmth  of  the  living  rooms. 
Ground  air  contains  more  carbon  dioxide  in  summer 
than  in  winter  on  account  of  the  influence  of  heat  in 
promoting  decomposition  of  organic  matters  in  the 
soil.  In  general  terms  it  contains  in  summer  more 
and  in  winter  less  than  one  per  cent,  of  this  gas,  or 
100  volumes  in  10,000  of  the  air;  it  may  also  be 
contaminated  by  other  products  of  decomposition. 
Hence  may  be  inferred  the  inadvisability  of  furnish- 
ing cellar  air  or  air  introduced  by  tunnels  into  a  build- 
ing for  purposes  of  ventilation.  This  applies  in  par- 
ticular to  buildings  erected  on  made  ground.  In  fact, 
cellars,  in  default  of  an  impermeable  lining,  should 
have  a  free  circulation  of  air  separate  from  the  venti- 
lation system  of  the  superimposed  building. 

Charles  Smart. 
R.  J.  E.  Scott. 

Air  Embolism. — See  Embolism. 

Airol. — Airoform,  bismuth  iodosubgallate,  bis- 
muth oxyiodosubgallate,  C0H2(OH),CO2Bi(OH)I.  It 
is  prepared  by  heating  equivalent  amounts  of  bis- 
muth subgallate  and  hydriodic  acid,  or  of  freshly 
precipitated  bismuth  oxyiodide  and  gallic  acid,  in 
water.  It  is  a  graj'ish  or  greenish,  light,  odorless  and 
tasteless  powder,  insoluble  in  water  or  alcohol,  but 
soluble  in  mineral  acids  and  weak  alkaline  solutions. 
When  exposed  to  the  air  it  gradually  takes  on  a  red 
color.  It  is  employed  as  a  substitute  for  iodoform 
in  the  treatment  of  wounds,  ulcers,  burns,  etc.,  in 
powder,  in  ten-per-cent.  ointment,  or  in  ten-per-cent. 
suspension  in  glycerin  and  water.  The  best  oint- 
ment base  for  airol  is  a  mixture  of  seven  parts  of 
anhydrous  adeps  lanse  and  two  parts  of  petrolatum. 


Air  Passages,  Foreign  Bodies  in  the. — Nose. — The 
presence  of  foreign  bodies  in  the  nose  is  of  common 
occurrence.  The  list  of  them  comprises  extraneous 
substances  introduced  either  through  accident  or,  in 
the  case  of  infants  or  of  insane  adults,  by  design; 
sequestra  of  diseased  bone;  and  parasites.  They  may 
also  enter  the  nasal  cavities  from  behind,  during  the 
act  of  vomiting  or  of  choking,  or  in  paralysis  of  the 
soft  palate.  Rarely,  as  in  gunshot  wound,  they  may 
pass  through  the  walls  of  the  nasal  cavity  from  with- 
out; an  erratic  tooth  may  enter  the  cavity  from  below. 
The  history  of  those  of  the  first  variety  is  usually 
as  follows:  A  child  of  about  two,  old  enough  to  creep 
but  not  sufficiently  intelligent  to  know  better,  thrusts 
some  small,  rounded  object,  such  as  a  bean  or  a  shoe- 
button,  which  it  has  found  upon  the  floor,  into  its 
nostril.  If  the  child  be  not  caught  in  the  act  the 
body  may  escape  immediate  detection.  Soon  symp- 
toms of  chronic  inflammation  are  established.  These 
are  confined  to  the  nostril  in  which  the  body  is,  and 
continue  until  it  is  removed,  the  irritation  often 
being  severe  and  the  discharge  exceedingly  fetid. 
The  mucous  membrane  adjacent  to  the  foreign  bod; 
is  in  a  condition  of  superficial  erosion.  The  body, 
if  too  firmly  impacted  to  be  dislodged  by  simply 
blowing  the  nose,  remains  fixed,  usually  in  the  in- 
ferior meatus,  until  removed  by  the  surgeon. 

Removal  should  be  attempted  by  means  of  a  hooked 
probe  or  fine  forceps,  the  sensitiveness  of  the  nasal 
cavity  being  borne  in  mind,  and  the  removal  of  the  body 
carefully  effected  after  thorough  cleansing  of  the 
cavity  "has  been  effected  and  local  anesthesia  has 
been  obtained,  either  by  cocaine  or  by  suprarenal 
extract.  In  the  case  of  nervous  children  general  anes- 
thesia is  desirable.  Copious  hemorrhage,  lasting  two 
or  three  minutes,  often  follows,  but  is  generally  of  little 


168 


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Air  Passacps,  Foreign 
bodies  In 


moment.  The  nostril  should  be  washed  several  limes 
a  day  with  a  weak  disinfectant.  In  four  or  five 
days  the  membrane  will  often  have  healed  so  com- 
pletely that  no  trace  of  the  trouble  can  be  seen;  the 

discharge   ceases   entirely,    and    the   cure    is   complete. 

The  possibility  of  the  presence  of  a  foreign  body  in 
all  cases  of  fetid  discharge  confined  to  one  nostril  should 

always  he  remembered,  and,   tin1  nostril  having  I n 

cleansed  with  a  warm  douche,  careful  examination 
should  be  made  with  speculum  and  probe.  If  l  lie 
object  be  lodged  far  backward,  care  should  be  taken 
in  removing  it  not  to  allow  it  to  fall  into  the  larynx 


Fig.  62. — Lead  Collar-button  in  the  Right  Bronchus  of  a  Lad 
of  Eighteen  Years;  removed  by  upper  bronchoscopy  by  Dr. 
Chevalier  Jackson. 

The  writer  has  seen  a  case  in  which  a  button  intro- 
duced during  infancy  remained  undiscovered  in  the 
nose   for   thirty-two   years. 

Rhinoliths  are  merely  calculi  formed  by  an  accu- 
mulation of  the  earthy  salts  of  the  nasal  secretions 
around  some  foreign  body  or  inspissated  mucus.  Their 
presence  has  given  rise  to  such  irritation  that  they 
have  been  mistaken  for  cancer.  Careful  examination 
and  the  history  of  the  case  will  easily  establish  the 
diagnosis.  If  the  concretion  be  too  large  to  be  readily 
removed  it  should  first  be  crushed.  Foreign  bodies 
of  this  nature  are  rarely  met  with,  although  one  is 
reported  which  weighed  720  grains.  Sequestra  of 
bone,  particularly  in  tertiary  syphilis,  sometimes  re- 
main in  the  nasal  cavity  after  their  separation,  tints 
acting  as  foreign  bodies.  They  must  be  thoroughly 
removed  preliminary  to  further  local  treatment. 

Parasites. — In  tropical  countries,  seldom  elsewhere, 
various  kinds  of  flies,  of  the  order  Muscidoe,  may 
enter  the  nasal  cavity,  preferably  of  a  patient  suf- 
fering from  catarrh,  and  there  deposit  eggs.  These 
are  quickly  hatched,  causing  in  succession  irrita- 
bility, tickling,  and  sneezing;  later,  formication,  bloody 
discharges  and  epistaxis,  with  edema  of  the  face, 
eyelids,  and  palate;  excruciating  pain,  generally 
frontal;  insomnia,  and  if  the  condition  be  unrelieved, 
convulsions,  coma,  and  death.  Sometimes  the  larva? 
are  sneezed  out,  or  may  be  seen  on  examination  of 
the  parts.  This  will,  of  course,  establish  the  diag- 
nosis. Destruction  caused  by  the  larvae  may  extend 
to  the  mucous  membrane,  the  cartilages,  and  even 
the  bones  of  the  head,  the  ethmoid,  sphenoid,  and 
palate  bones  having  been  found  carious. 

Where  the  maggots  have  entered  the  frontal  sinus 


or  the  antrum  of  Highmore,  injections  of  tobacco  or 

alum,   or  insufflations  of  calomel,   formerly   used,  will 

be  of  little  avail.  Chloroform  or  ether,  preferably  the 
former,  either  inhaled  or  driven  into  the  nasal  recesses 

in  I  he  form  of  spray,  is  the  sovereign  remedy,  as  under 
it  the  larva'  are  not  killed,  to  remain  in  situ  and  thus 
cause  further  trouble,  but  escape  with  all  haste  to  tin; 
outer  air.  Meanwhile,  anodynes  should  be  given 
to  allay  pain,  and  the  patient's  strength  should  be 
carefully  sustained.  Such  measures,  however,  are 
serviceable  only  when  tin'   ease   i,^  seen   early   and   the 

Larvae  are  si  ill  upon  the  surface  of  the  mucous  mem- 
brane. When  they  have  attained  their  full  develop- 
ment they  burrow  into  the  soft  tissues,  whence  it 
seems  impossible  lo  extract  them  except  by  Seizing 
them  bodily  and  dragging  them  out.  If  the  desper- 
ate character  of  the  situation  in  severe  cases  of  this 
kind,  and  the  impossibility  of  reaching  the  seat  of 
irritation  through  the  natural  passages  are  taken  into 
consideration,  no  surgical  procedure  which  promises 
relief  can  be  thought  too  severe.  It  is  therefore  jus- 
tifiable to  open  into  the  antrum  or  the  frontal  sinuses 
from  without,  to  perform  Rouge's  operation,  in  order 
to  gain  access  to  the  upper  part  of  the  nasal  cavities, 
or  to  open  freely  into  the  ethmoid  cells.  Several 
cases  in  which  the  patient's  life  has  thus  been  saved 
have  been  related  to  the  writer  in  recent  years. 

Leeches,  ascarides,  earwigs,  and  centipedes  have 
been  found  in  the  nose,  causing  insomnia,  frontal 
pain,  sanious  discharge  from  the  nose,  lacrymation, 
vomiting,  and,  in  some  cases,  great  cerebral  excite- 
ment. Sternutatories  are  generally  sufficient  for 
their  expulsion. 

Tonsils. — Three  general  varieties  of  foreign  bodies 
may  be  found  in  the  tonsil:  (1)  Foreign  bodies 
proper,  or  substances  which  have  become  lodged  in 
the  tonsil  during  deglutition;  (2)  tonsillary  concretions 
or  calculi;  (3)  parasites.  The  last  two  conditions  are 
not  common;  the  first  will  be  described  under  Foreign 
Bodies  in  the  Pharynx. 

Tonsillary  calculi  are  formed  in  the  lacunae  of  a 
chronically  inflamed  tonsil  by  a  perverted  condition 
of  the  natural  secretions  and  their  retention  in  the 
recess  through  closure  of  its  outlet.  They  vary  in 
size,  seldom  attaining  a  greater  diameter  than  three- 
fourths  of  an  inch,  and  consist  of  phosphate  and  car- 
bonate of  lime,  some  iron,  soda,  and  potassa,  with 
varying  proportions  of  mucus  and  water.  Hence 
they  are  not  necessarily  of  gouty  origin. 

The  symptoms,  generally  not  prominent,  may  be 
slight  pricking  of  the  throat  with,  occasionally, 
dysphagia.  The  presence  of  the  calculus  is  sometimes 
directly  irritating,  and  may  give  rise  to  quinsy, 
ulceration  of  the  cavity,  and  abscess.  Frequently, 
however,  the  symptoms  are  reflex  in  character.  This 
is  especially  true  with  relation  to  the  ear,  in  which 
organ  the  existence  of  a  tonsillary  calculus  may  be 
associated  with  various  forms  of  otic  congestion  and 
with  tinnitus. 

Diagnosis,  by  ocular  examination  or  by  the  use  of 
the  probe,  is  usually  easy,  and  so  also  is  the  removal 
of  the  calculus  by  means  of  a  forceps.  Sometimes, 
however,  the  mass  is  so  completely  covered  that  it 
is  only  seen  after  careful  exploration  with  the  probe 
or  even  after  the  actual  removal  of  the  tonsil.  In 
most  cases  the  latter  operation  will  afford  the  most 
certain  cure.  Very  rarely,  hydatids  and  trichoceph- 
ali  have  been  found  in  the  tonsil. 

Pharynx. — Foreign  bodies  are  often  arrested  in 
the  pharynx,  and  the  variety  of  these  bodies  is  great. 
Certain  individuals  seem  especially  liable  to  this 
accident,  either  from  carelessness  in  eating,  from 
insensibility  of  the  parts,  or  from  some  unusual  irregu- 
larity in  the  pharyngeal  walls.  Foreign  bodies  of  large 
size  generally  lodge  in  the  lower  part  of  the  cavity, 
where  the  cricoid  and  arytenoid  cartilages  project 
backward,  or  between  the  base  of  the  tongue  and  the 
epiglottis.     Small    and    sharp-pointed    bodies    may 

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become  fixed  at  any  part  of  the  pharynx,  particu- 
larly in  the  tonsils,  on  account  of  their  exposed  posi- 
tion and  the  irregularity  of  their  surface.  They 
may  also  be  entangled  in  the  pillars  of  the  velum, 
or  in  the  lateral  folds  of  the  cavity.  A  large  body 
may  be  found  stretching  across  the  whole  width  of 
the  pharynx. 

Symptoms. — These  are  local  pain,  dysphagia,  and 
more  or  less  inflammation,  with  occasionally  ulcera- 
ion  or  abscess  of  the  pharynx;  but  generally  there  is 
simply  localized  inflammation  and  irritation.  If  an 
abscess  be  formed,  the  foreign  body  may  escape 
through  a  fistulous  opening  in  the  neck,  or  it  may 
perforate  some  important  blood-vessel,  or  may  even 
penetrate  the  intervertebral  substance  and  cause 
caries  of  the  vertebral  bodies. 


Fig.  63. — Outer  Tube  of  a  Tracheal  Cannula,  inhaled  and  lodged 
in  the  left  bronchus  in  a  man  of  thirty-five  years,  upon  whom 
tracheotomy  for  larryngeal  carcinoma  had  been  performed;  tube 
removed  by  bronchoscopy  through  the  tracheal  wound  by  Dr. 
Thomas  R.  French. 


Inflammation  of  the  pharynx  may  give  rise  to  dysp- 
nea, while  a  large  foreign  body  may  cause  suffoca- 
tion by  obstructing  the  entrance  to  the  larynx. 

The  diagnosis  can  generally  be  established  by  the 
history  of  the  case  and  by  inspection  of  the  pharynx. 
In  cases  presenting  unusual  difficulty  the  diagnosis 
may  be  established  by  the  use  of  radiography. 
Nervous  patients  often  insist  upon  the  presence  of  a 
foreign  body  in  the  throat  despite  all  assurances  to  the 
contrary,  particularly  if  the  pharynx  be  sensitive, 
or  if  at  a  certain  point  there  is  an  inflamed  lymph 
gland,  or  if,  as  often  happens,  a  hard  substance  may 
have  caused  a  slight  laceration  of  the  mucous  mem- 
brane while  being  swallowed. 

Treatment. — The  patient's  tongue  should  be  well 
depressed,  and  the  upper  parts  of  the  pharynx  carefully 
examined  in  a  strong  light.  If  the  foreign  body 
does  not  then  appear,  search  should  be  made  fin-  it 
with  the  aid  of  the  laryngoscope  in  the  region  of 
th  ■  base  of  the  tongue,  the  glossoepiglottic  and  pyra-* 


form  sinuses,  and  the  upper  portion  of  the  larynx.  If 
present,  it  will  generally  be  found  without  much  diffi- 
culty, and  should  be  removed  by  the  finger  or  by  a 
suitable  forceps  or  probang.  Local  anesthetization 
of  the  pharynx  will  greatly  assist  in  the  diagnosis  and 
treatment  of  these  cases.  If  dyspnea  be  urgent, 
immediate  surgical  interference,  of  a  nature  suited 
to  the  special  features  of  the  case — either  tracheot- 
omy, thyrotomy,  or,  possibly,  some  form  of  sub- 
hyoidean  pharyngotomy — may  be  required.  The 
sensations  of  the  patient  are  often  unreliable,  and 
the  feeling  of  irritation  caused  by  the  presence  of  the 
body  may  continue  for  a  long  while  after  its  removal. 
This  may  be  relieved  by  swallowing  small  lumps  of 
ice,  and  later,  if  necessary,  by  the  application  of  as- 
tringents and,  in  some  cases,  by  galvanism. 

Larynx. — By  reason  of  the  danger  to  life  which 
attends  the  lodgment  of  a  foreign  body  in  the  larynx, 
this  condition  becomes  one  of  the  most  important  in 
surgery.  The  variety  of  objects  found  is  infinite, 
and  may  be  thus  divided:  Alimentary  matters, 
introduced  during  mastication  in  the  act  of  laughing 
or  talking,  in  deglutition,  or  in  inspiration  during 
vomiting;  metallic  bodies,  such  as  coins,  buttons, 
puff-darts,  etc.;  teeth,  artificial  or  natural;  necrosed 
bone  from  neighboring  regions,  as  from  the  nose  in 
tertiary  syphilis;  and  fragments  of  the  laryngeal 
cartilages  themselves,  as  thrown  off  in  the  Tate 
stages  of  syphilis,  tuberculosis,  and  cancer  of  the 
larynx.  Foreign  bodies  in  the  trachea  may  pass 
upward  and  become  impacted  in  the  larynx;  and, 
rarely,  they  may  gain  access  to  the  larynx  directly 
from  without,  by  forcible  penetration  of  its  walls, 
as  in  the  case  of  bullets.  Again,  the  epiglottis  may 
become  incarcerated  in  the  larynx,  or  occlusion  may 
take  place  from  the  so-called  swallowing  of  the  tongue. 

The  symptoms  vary  with  the  size  and  position  of 
the  object.  Thus  a  large  body  fixed  in  the  rinia 
glottidis  may,  unless  dislodged,  cause  almost  instant 
death.  Again,  small  bodies  lodged  in  out-of-the-way 
corners  may  remain  indefinitely,  causing  nothing 
more  than  cough  and  discomfort.  Dyspnea  may 
occur  days  after  the  entrance  of  a  foreign  body,  from 
inflammation  and  tumefaction  of  the  soft  parts  of 
the  larynx,  and  danger  from  the  presence  of  a  foreign 
body  may  suddenly  become  imminent  from  alteration 
in  its  position.  Great  peril  sometimes  arises  from 
violent  spasm  of  the  glottis,  due  to  irritation  caused 
by  the  foreign  body.  Mental  anxiety  and  localized 
pain  are  prominent  symptoms  in  cases  in  which  the 
accident  does  not  immediately  threaten  life,  but  is 
followed  by  inflammation  which  rapidly  becomes 
active. 

The  diagnosis  is  established  by  the  history  of  the 
case,  verified  or  otherwise  by  laryngoscopic  exami- 
nation or  by  radiography.  The  greatest  difficulties 
arise  with  children  too  young  to  express  themselves, 
in  whom  pain  in  the  throat  and  symptoms  resem- 
bling croup  will  often  be  the  only  indications  ob- 
tainable. Here  the  use  of  the  laryn-gosope,  or 
direct  inspection  of  the  larynx  as  practised  by  Kirstein 
and  his  later  followers,  or  radiograph}',  will  be  in- 
dispensable. A  cautious  prognosis  must  be  given, 
even  after  removal  of  the  body,  as  long  as  there  are 
any  symptoms  of  local  inflammation. 

Treatment. — The  offending  body  should,  of  course, 
be  at  once  removed;  if  possible,  through  the  natural 
passages  and  by  means  of  the  laryngeal  forceps, 
aided  by  the  laryngoscope,  in  case  the  symptoms  are 
not  urgent.  Removal  may  be  facilitated  by  placing 
the  patient  on  his  back  upon  a  table,  with  the  head 
hanging  over  the  edge  of  the  table,  in  which  position 
breathing  is  easier  and  the  law  of  gravitation  becomes 
directly  helpful.  If  asphyxia  threaten,  tracheotomy 
should  be  done  at  once  and  the  foreign  body  after- 
ward extracted  as  described  above.  Bodies  which 
at  first  are  immovable  may  sometimes  bo  loosened  by 
reducing  the  local  inflammation.     In  rare  cases,  when 


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Bodies  In 


the  object  has  become  firmly   impacted,  thyrotomy 
become  necessary.      A  case  is  recorded  in  which 
:,  oeedle,  transfixed  in  the  larynx,  was  pushed  through 
the  anterior  laryngeal  wall,  and  thus  removed. 

Trachea  and  Bronchi. — Any  object  which  can 
pass  through  the  rima  glottidis  may,  of  course,  find 
[ts  way  into  the  trachea,  in  the  same  manner  as  was 
ribed  in  the  paragraph  relating  to  foreign  bodies 
in  the  larynx.  Sharp  objects  lodged  in  the  esophagus, 
and  even  diseased  bronchial  glands,  may  work  their 
way  through  the  walls  of  the  trachea,  and  into  its 
cavity.  It  sometimes  has  happened,  through  careless- 
Mi'  by  accident,  that  parts  of  instruments  used  in 


Fig.  61. — Glass-headed  Pin  in   the   Left   Bronchus  of  a  Child 
[Vo-and-a-half  Years;  removed  by  upper  bronchoscopy  by 
Dr.  Chevalier  Jackson. 

intralaryngeal  operations,  tracheal  cannula?,  laryngeal 
brushes,  and  even  bits  of  solid  nitrate  of  silver, 
have  dropped  into  the  trachea.  If  too  large  to  enter 
either  main  bronchus  the  body  will  probably  remain 
at  the  bifurcation.  Otherwise  it  will  pass  into  one 
bronchus  or  the  other,  preferably  the  right,  on  account 
of  its  anatomical  position,  in  the  proportion  of  five 
to  three,  and  thence  travel  indefinitely  into  one  of  the 
more  remote  bronchial  divisions.  Asphyxia  may 
also  be  caused  by  the  entrance  of  water  into  the 
trachea,  of  blood  during  a  surgical  operation,  of  pus 
from  the  bursting  of  an  abscess,  of  vomited  matter, 
or  of  liquid  food. 

The  symptoms  will  depend  upon  the  nature  of  the 
body  and  its  exact  location  in  the  lung.  Small 
objects  have  remained  encapsulated  for  years  withoul 
causing  discomfort  or  serious  results.  Smooth,  rounded 
bodies  irritate  less  than  irregular  ones.  Inflamma- 
tion of  the  lungs  from  a  foreign  body  may  occur,  and 
at  the  same  time  the  presence  of  such  a  body  may  be 
entirely   unknown.     Large   objects   and   fluids   may 


eau  e  death   by   instanf    suffocation,  or  death   may 

re   nil    in   the  eour-e  of  a  few  minutes,   the  symptoms 

pre  'Midi  being  urgent  <h  pica,  and  cyanosis  from 
asphyxia.  The  patient  under  these  circumstances 
makes  frantic  efforts  to  obtain   relief.     He   thrusts 

his  lingers  down  his  throat,  rushes  to  the  window- 
to  gel  fresh  air.  and  makes  strong  inspiratory  efforts; 
and  if  aid  l>e  not  speedily  afforded,  death,  with  all  the 

signs  of  asphyxia,  soon  follows.  Severe  dyspnea,  fol- 
lowed by  relief  without  extrusion  of  the  foreign  body, 
indicates  thai  the  body  has  probably  dropped  from 
the  larynx  into  the  trachea.  Dyspnea  is.  of  course, 
more  urgent  when  the  trachea  i-  occluded  than  when 
the  foreign  body  stops  only  one  bronchus.  Physical 
signs  due  to  the  presence  of  a  foreign  body  in  the 
lung  may  be  altogether  wanting,  but  they  are  gener- 
ally more  or  less  distinct.  They  are  the  following:  whis- 
tling or  flapping  sounds  at  the  point  of  lodgment, 
decreased  fremitus,  and  absence  of  respiratory  murmur 
in  the  lung  beyond.  The  body  may  change  its  posi- 
tion, passing  from  one  bronchus  to  that  of  the  opposite 
side.  A  body,  small  when  swallowed,  may  become 
more  dangerous  through  increase  in  size,  either  by 
imbibition  of  water  or  by  forming  the  nucleus  of  a 
concretion.  If,  however,  a  hollow,  cylindrical  body, 
such  as  one  of  the  parts  of  a  tracheotomy  tube  has 
found  lodgment  in  the  bronchus,  little  resistance 
may  be  offered  to  the  passage  of  the  air,  no  advent  it  ions 
sounds  created,  and  no  obstruction  caused  in  the 
lung  area  beyond.  In  such  a  case  diagnosis  by 
ordinary  means  might  be  impossible.  At  or  about  the 
bifurcation  the  body  may  be  seen  with  the  laryn- 
goscope. While  the  laryngoscope  may  fail  to  reveal 
the  presence  of  the  foreign  body  in  the  trachea, 
it  can  at  least  furnish  satisfactory  evidence  that 
the  object  in  question  is  not  located  in  the  larynx. 
The  lodgment  of  a  foreign  body  in  the  lung  may 
result  in  pneumonia,  tuberculosis,  abscess,  or 
gangrene.  Or  it  may  become  encapsulated  and 
do  no  apparent  harm.  Rarely  a  body,  in  several 
recorded  cases  an  ear  of  barley  or  other  grain,  having 
formed  an  abscess  of  the  lung,  has  been  discharged 
through  the  wall  of  the  thorax,  with  complete  recovery. 

Diagnosis. — The  fact  that  some  foreign  body  has 
been  inhaled  should  be  established,  if  possible,  and 
the  site  of  the  body  determined.  In  children  and 
incompetents,  and  in  cases  in  which  the  dyspnea  is 
urgent,  this  may  not  be  easy. 

In  addition  to  the  diagnostic  aids  already  mentioned 
there  are  two  which,  in  comparatively  recent  years, 
have  revolutionized  this  whole  subject,  turning  dark- 
ness into  light  and  affording  almost  certain  relief, 
when  formerly  the  life  of  the  patient  was  generally 
sacrificed.  The  first  of  these  is  radiography,  the 
efficiency  of  which  in  cases  of  a  foreign  body  in  the 
bronchus  has  proved  it  one  of  the  most  valuable 
contributions  to  science  of  modern  times.  By  means 
of  this  admirable  method  it  is  possible  to  determine 
with  almost  mathematical  certainty  the  precise 
location  in  the  lung  of  the  object  inhaled,  as  well  as 
its  shape,  its  size,  and  its  special  characteristics. 
These  details  of  information  become  invaluable  when 
the  extraction  of  the  object  is  attempted,  as  they  en- 
able the  operator  to  determine  what  particular 
methods  and  what  special  instruments  may  best  be 
suited  to  the  case.  Thus,  for  example,  the  procedure 
for  the  extraction  of  a  closed  safety  pin  of  small  size 
would  be  far  more  simple  than  the  measures  called 
for  in  the  removal  of  a  safety  pin  of  large  size,  open, 
and  lodged  in  the  bronchus  point  uppermost. 

The  prognosis  is  serious;  it  depends  upon  the  nature 
of  the  foreign  body,  the  amount  of  dyspnea,  and  the 
organic  lesions  which  may  result.  The  danger  is 
greatest  at  the  first,  and  although  it  diminishes  in 
varying  degree  as  time  passes,  it  is  never  entirely 
absent.  Even  after  expulsion  of  the  foreign  body 
death  may  occur  from  the  organic  disease  set  up.  The 
expulsion  of    one  object  does    not,    especially    with 

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children,  preclude  the  possibility  of  others  remaining 
in  the  lung. 

Treatment. — The  treatment  of  foreign  bodies  in  the 
trachea  must  be  determined  by  the  circumstances  of 
the  case  and  by  the  nature  of  the  foreign  body. 
When  the  trachea  and  bronchi  are  filled  with  fluid 
the  patient  should  be  placed  upon  his  back,  the  head 
and  shoulders  as  low  as  possible,  the  mouth  should  be 
forced  open,  the  tongue  drawn  far  forward,  and  the 
walls  of  the  chest  compressed.  Artificial  respiration 
should  be  instituted  the  moment  the  trachea  is  suf- 
ficiently free  to  allow  of  the  ingress  of  air. 

The  treatment  of  solid  bodies  which  have  gained 
access  to  the  trachea  or  bronchi  has  been  until  re- 
cently one  of  the  most  difficult  problems  of  surgery. 


Fig.  65. — Brass  Paper-fastener  in  the  Right  Bronchus  of  a 
Woman,  Twenty-three  Years  old;  removed  by  upper  bronchoscopy 
by  Dr.  Chevalier  Jackson. 

With  the  advent  of  bronchoscopy  many  of  the  dan- 
g3rs  attending  it  have  been  overcome  and  many 
lives  saved.  Thus  far,  however,  the  technical  diffi- 
culties in  the  application  of  the  bronchoscope  have 
caused  its  use  to  be  confined  to  a  comparatively 
few  experts.  Occasion  may  arise,  therefore,  when  its 
aid  may  not  be  attainable.  In  view  of  this,  it  may  be 
well  to  rehearse  the  measures  hitherto  employed.  In 
general  two  plans  have  been  pursued.  One,  an  ex- 
pectant treatment  in  which  spontaneous  expulsion  of 
the  foreign  body  has  been  hoped  for.  Failing  in  this, 
surgical  measures  have  been  resorted  to.  Of  the  lat  ter 
the  most  common  has  been  the  performance  of  a  low 
tracheotomy. 

Analysis  of  large  numbers  of  cases  treated  by  the 
older  methods  shows  that  if  the  object  inhaled  has 
been  small  in  size,  regular  in  contour,  and  of  a  smooth 
surface,  better  results  have  been  obtained  by  waiting 
for  spontaneous  expulsion  than  through  operation. 
Thus  Roe,  of  Rochester,  N.  Y.,  in  a  notable  contri- 
bution to  the  subject,  in  which  more  than  500  cases 
of  all  kinds  were  studied,  reported  that  in  cases  oper- 
ated upon  seventy-eight  per  cent,  recovered.  Of  all 
not  operated  upon,  including  the  cases  in  which  death 
from  suffocation  followed  the  inhalation  of  the  object 

t |uickly  for  any  operative  aid  to  have  been  offered, 

seventy-three  per  cent,  recovered.  Operations  by 
which  the  chest  wall  was  nsected  and  entrance  made 
into  the  substance  of  the  lung  have  almost  invariably 
proved  fatal. 

It  will  thus  be  seen  that  surgery  in  these  cases  has 
met  with  little  success.     The  most  practical  method 


has  been  the  performance  of  a  low  tracheotomy. 
Through  the  opening  thus  obtained  it  was  hoped  that 
the  foreign  body  might  be  expelled  by  the  act  of 
coughing.  Failing  in  this,  attempts  were  made  to 
recover  it  by  the  aid  of  suitably  constructed  forceps. 
In  cases  where  this  could  not  be  accomplished  it 
was  recommended  that  the  edges  of  the  wound  in 
the  trachea  be  kept  apart,  if  necessary,  for  several 
days,  in  order  to  facilitate  the  expulsion  of  the  foreign 
body  should  it  become  dislodged  and  coughed  up- 
ward toward  the  surface  of  the  body.  Where  such 
measures  are  pursued  it  is  important  that  the  pi 
tion  of  the  patient  should  be  considered.  If  possible, 
he  should  be  caused  to  lie  with  the  head  and  shoulders 
lower  than  the  rest  of  the  body.  Thus  the  pid  of 
gravitation  may  be  secured  and  the  tendency  of  the 
body  to  fall  backward,  after  efforts  at  coughing 
which  have  driven  it  upward,  will  be  overcome. 

Mild  sedatives  may  also  be  indicated.  The  admin- 
istration of  belladonna  to  lessen  the  bronchial  secre- 
tions, as  long  ago  recommended  by  the  writer  in 
general  operations  in  the  region  of  the  larynx  and 
trachea,  is  useful.  Morphin  may  also  be  used.  Swain 
suggests  the  hydrobromate  of  hyoscine  as  an  adjuvant 
to  morphin. 

The  conditions  demanding  speedy  operation  are:  1. 
Urgent  and  dangerous  symptoms,  as  progressive 
dyspnea,  or  frequently  occurring  attacks  of  dysp- 
nea or  laryngeal  spasm,  when  laryngoscopic  exami- 
nation fails  to  reveal  the  object  or  shows  that 
its  speedy  removal  by  the  natural  passages  is  impos- 
sible. 2.  When  a  sharp  and  irregular  body  is  im- 
pacted, as  shown  by  the  laryngoscope,  in  such  a  way 
that  immediate  extraction  is  impossible,  and  when 
acute  inflammation,  and  especially  edema,  are  rap- 
idly developing,  as  evinced  by  increasing  dj'spnea. 
3.  In  the  case  of  a  foreign  body  of  any  nature  which 
lies  loosely  in  the  trachea,  and  the  movements  of 
which  excite  laryngeal  spasm  or  coughing  of  dan- 
gerous violence.  4.  In  the  case  of  a  foreign  body 
which  is  impacted  in  either  of  the  primary  bronchi, 
as  ascertained  by  the  rational  and  physical  signs, 
particularly  by  auscultation.  In  this  latter  condition 
low  tracheotomy  and  immediate  direct  attempts  at 
extraction  are  often  successful.  Direct  examination 
of  the  site,  and  demonstration  of  the  foreign  body  in 
or  at  the  mouth  of  a  bronchus,  by  means  of  the  fin- 
ger introduced  quickly  into  the  trachea,  are  possible, 
and  this  knowledge  renders  the  subsequent  instru- 
mental removal  of  the  body  more  easy.  The  entrance 
of  a  foreign  body  into  a  bronchus  to  such  a  distance 
as  to  place  it  beyond  reach  through  the  natural  pas- 
sages, is  an  accident  of  the  gravest  danger.  A  num- 
ber of  cases  have  occurred  of  late  years  in  which  sur- 
gical operation  has  been  attempted  by  entering  the 
bronchus  through  the  chest  wall  from  without.  All 
have  proved  fatal.  5.  Sharp-pointed,  hard,  and 
irregular  bodies  within  the  air  passages  will,  as  a  rule, 
demand  bronchotomy,  provided  they  are  not  so 
located  that  they  may  be  reached  and  removed  by 
the  natural  passages  at  an  early  moment.  The  plan 
of  treatment  by  inversion  of  the  patient  has  of  late 
years  fallen  into  disrepute,  and  should  seldom  be 
practised,  unless  tracheotomy  can  be  done  at  once  if 
required.  In  employing  it,  it  should  be  remembered 
that  the  supine  position  will  favor  exit  of  the  body, 
particularly  if  the  glottis  be  in  the  condition  of  deep 
inspiration.  In  all  cases  the  diagnostic  importance 
of  a  thorough  laryngoscopic  examination  cannot  be 
too  strongly  insisted  upon. 

The  development  of  the  method  known  as  bronchos- 
copy has  effected  a  revolution  in  this  department, 
as  to  diagnosis,  prognosis,  and  treatment.  To  the 
genius  of  the  late  Joseph  O'Dwyer  of  New  York  is 
due  the  first  suggestion  bearing  upon  the  subject. 
Among  other  modifications  of  his  intubation  tubes 
O'Dwyer  devised  one  especially  intended  for  the 
expulsion  of  foreign  bodies  from  the  trachea.     This 


172 


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Aix-la-Chapelle 


•  ibe  was  of  the  largesl  possible  inner  caliber,  with 
hii  walls,  almost  straight  in  its  long  diameter  and 
lung  enough  to  extend  well  into  tlie  trachea.  Through 
ii  loose  bodies  of  relatively  small  size  may  be  coughed 
out.  This  tube  is  especially  adapted  for  small 
children. 

UgernOll    Coolidge    of     Boston    demonstrated     the 

cticability  of  passing  a  long  tube  through  the 
cervical  wound  and  down  the  trachea  in  a  tra- 
oheotomized   patient,    and    of    then  illuminating  by 

means   of   a   head    mirror   the   parts   of    the    trachea 
below     the    distal    end    of    the    tube.       By    this    means 

ign    bodies   could   be   searched   for   in   the   more 

ote  parts  of  the  bronchial   tract.     Later.  Kirstein 
lit   the  method  of  direct  laryngoscopy.     Finally, 

bining   the   suggestion  of   O'Dwyer    that  a    long 

could   1"'  passed  into  the  trachea  through   the 

larynx,  with  the  suggestion  of  Coolidge  that  by  means 

strong  light   the  deeper  bronchial  tract   could  be 

ifactorily  illuminated,  Killian  of  Freiburg  modified 
the  instrument  of  Kirstein  in  such  a  manner  as  to 
produce    the    bronchoscope,    an    instrument    which, 

nidified  by  Chevalier  Jackson    of  Pittsburg  Pa., 

ns  to  have  reached  a  stage  of  perfect  adaptation 

tie  uses  for  which  it  is  designed.     (See  Bronckns- 
i     Mosher  of  Boston,  Ingals  of  Chicago  and  other 
American  experts  have  also  contributed  to  the  elabora- 
tion of  the  method.     By  Jackson's  method  a  strong 

trie  light  is  carried  at  the  distal  end  of  the  tube. 
Be  has  also  devised  many  special  types  of  forceps 
and  other  appliances,  has  developed  a  very  succi  — 
fill  technique  and  has  written  most  instructively  upon 

whole  subject  of  bronchoscopy,  esophagoscopy, 
and  gastroscopy.  Tha  art  of  bronchoscopy  is  one 
which    seems  to  require  special  experience  and  skill. 

side  ring  its  extraordinary  value  in  the  saving  of 
life,  it  is  only  fair  to  expect  that  every  general  hos- 
pital be  prepared  to  employ  it  and  that  at  various 
centers  throughout  the  country  there  may  be  found 
practitioners  qualified  to  extend  its  aid. 

D.  Brysox  Delavan. 


Johnson:    Lancet,  October  12,  1S78. 

Learning:  Growths  and  Foreign  Bodies  in  Air  Passages,  Diagnosis 
and  Surgical  Treatment.     Medical  Record,  1879,  xv.,  20S. 
Wagner:    Ziemssen's  Cyclopaedia. 
Holmes'  System  of  Surgery. 

Mnrell  -Mackenzie:    Diseases  of  Throat  and  Xose,  London,  1SS0. 
Elsberg:    Archives  of  Laryngology,  vol.  iii.,  p.  275. 
Wcist:      Transactions  American   Surgical   Association,   vol.   i., 

Vbltotini:  The  Operative  Removal  of  Foreign  Bodies  and  X.-w 
Growths  frrom  the  Air  Passages.  Transactions  Eighth  Inter- 
national Med.  Congres-. 

Lefferts:   Transactions  Eighth  International  Med.  Congress. 


Aiv=Ia=ChapelIe  {Aachen),  renowned  for  its  hot 
sulphur  springs,  is  an  ancient  Prussian  town  of  100,000 
inhabitants,  easily  reached  from  Paris,  Brussels,  or 
Cologne,  being  only  forty-four  miles  distant  from 
the  latter  city.  In  its  ancient  and  renowned  cathedral 
"are  the  famous  relics  of  Charles  the  Great,  who  has 
been  honored  as  the  discoverer  of  the  springs  and 
founder  of  the  town;  but  thermal  waters  at  Aachen 
were  certainly  known  to  the  Romans,"  whose  pre- 
dilection for  baths  and  hot  springs  is  well  known,  as 
their  elaborate  remains  at  Bath,  England,  and  else- 
where testify.  The  springs  of  Aachen  were  also 
visited  in  a.d.  756  by  King  Pepin  the  Short.  The 
town  is  at  an  elevation  of  about  565  feet  above  sea 
level,  is  built  on  sandy  soil,  and  is  fairly  sheltered  by 
hills.  Although  the  town  itself  has  become  entirely 
modern,  its  surroundings  are  very  attractive.  The 
climate  is  moderately  moist.  The  average  tempera- 
ture is  54°  F.;  the  mean  temperature  for  the  three 
summer  months  is  61.9°  F.  and  for  the  three  winter 
months  37°  F.,  and  the  number  of  rainy  days  110. 


The  entire  city  is  underlaid  with  hot  springs,  and 
within  a  distance  of  1,316  meters  the  water  issues 
from  ten  springs.  The  principal  ones  are  the  Kai  i  i 
quelle  (the  strongest),  with  a  temperature  of  131°  F.; 
tli«>  QuirinusquelTe,  122°  I'.:  the  Rosenquelle,  117..".' 
I.;  and  the  Corneliusquelle,  ill  I  .  The  waters  of 
the  various  springs  are  very  similar  in  mineral  con- 
stituents, differing  in  temperature  and  the  amount  of 
sulphur  thej  contain.  The  Elisenbrunnen,  the  one 
most  used  for  drinking  purposes,  derives  its  waterfront 
the  Kaiserquelle. 

At  the  larger  bath  establishments,  which  are 
elegantly  fitted  up  and  arranged,  there  are  vapor 
baths,  inhalation  chambers  for  bronchial  and  laryn- 
geal affections,  and  other  rooms  set  apart  for  the 
various  hydrotherapeutic  processes.  "The  great 
advantage  of  Aix-la-Chapelle,"  says  Baruch,  "is  the 
fact  that  nearly  all  the  baths  are  situated  in  five 
hotels,  and  there  is  no  necessity,  as  at  Aix-les- Bains, 
for  the  patients  to  be  carried  in  sedan  chairs  from  the 
springs  to  the  hotels."  In  the  town  is  a  Zander 
Institute,  with  medico-mechanical  appliances  for 
Swedish  gymnastics.  Although  one  can  be  treated 
at  Aachen  at  all  times,  the  two  seasons  are  the 
summer,  from  April  15  to  October  15.  and  the  winter, 
from  November  to  April.  The  accommodations  are 
very  good,  and  one  can  live  in  the  bath  establish- 
ments themselves,  as  has  been  said. 

In  10.000  parts  of  water,  the  Kaiserquelle,  accord- 
ing to  the  analysis  of  J.  von  Liebig,  contains: 

Sodium  chloride 26. 161 

Sodium  bromide 0.036 

Sodium  iodide 0 .  005 

Sodium  sulphide 0.095 

Sodium  sulphate 2.S36 

Potassium  sulphate 1 .527 

Sodium  carbonate 6.449 

Lithium    carbonate 0.029 

Magnesium  carbonate 0.506 

Calcium  carbonate 1 .  579 

Strontium  carbonate 0.002 

Ferrous  carbonate 0 .  095 

Silica  hydrate 0.661 

Organic  matter 0 .  769 

Total 40.750 

Carbonic  oxide  (free  and  partially  free) 5  000 

Traces  of  fluorine,  boron,  and  arsenic.  There  is  probably  an 
organic  sulphide  (allyl)  present  in  minute  quantity. 

The  action  of  the  Aachen  thermal  waters,  as  indeed 
of  all  thermal  waters,  is  to  increase  tissue  meta- 
morphosis and  thus  to  promote  absorption  of  chronic 
inflammatory  products,  as  in  chronic  rheumatism 
and  gout;  but,  as  Weber  wisely  remarks,  "hot  baths 
and  hot-water  drinking  are  likewise  beneficial  in  these 
conditions,  and  it  is  not  certain  that  the  presence  of 
small  quantities  of  sulphur  adds  much  to  the  effect  of 
hot  water";  "  the  same,"  he  adds,  "may  be  said  with 
regard  to  some  chronic  skin  diseases."  In  another 
place  the  same  writer  remarks  that  in  other  cases 
besides  those  of  syphilis  the  reputation  of  the  Spa  is 
due  not  so  much  to  the  water  as  to  the  energetic 
hydrotherapeutic  measures,  special  exercises,  massage, 
etc.,  which  are  employed  there. 

On  account  of  the  chloride  of  sodium  which  they 
contain  the  waters  are  used  in  catarrhal  conditions 
of  the  stomach  and  alimentary  canal  and  of  the 
bronchi.  There  are  inhalation  chambers,  as  has 
been  stated  above,  for  bronchial  and  laryngeal 
affections.  The  waters  are  also  used  in  various 
affections  of  the  abdominal  viscera:  in  sluggish  action 
of  the  bowels  and  stagnation  in  branches  of  the  portal 
vein,  with  the  resulting  dyspeptic  troubles;  in  con- 
gestion of  the  pelvic  organs  and  hemorrhoidal  vessels; 
and  in  enlargement  of  the  liver.  Chronic  skin  diseases, 
such  as  eczema  and  psoriasis,  are  treated  at  Aachen 
with  more  or  less  success,  "the  results  obtained, "  as  one 
author  remarks,   "being  doubtless  partly  due  to  the 

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Aix-la-Chapelle 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


medicinal  treatment."  Besides  chronic  skin  diseases, 
the  following  affections  constitute  the  major  part  of 
those  treated  at  Aachen:  chronic  rheumatism,  gout, 
and  the  stiffness  of  joints  resulting  from  these 
affections;  metallic  poisoning;  and  syphilis.  Cases  of 
the  latter  disease  by  far  outnumber  all  the  rest,  for 
out  of  the  20,000  annual  visitors  at  the  Spa,  14,000 
are  said  to  come  there  for  syphilitic  treatment. 
"The  value  of  these  baths  in  this  disease,"  says 
Baruch,  "has  produced  such  an  afflux  of  syphilitics 
that  the  town  has  obtained  quite  an  unenviable 
reputation,  which  prevents,  it  is  said,  purely  gouty, 
rheumatic,  and  other  patients  from  frequenting  it." 
Weber  thinks  that  the  reputation  of  Aix-la-Chapelle 
in  syphilis  has  been  due  in  great  part  to  the  ordinary 
medicinal  treatment  employed  there  and  to  the 
attention  paid  to  the  subject  by  the  local  doctors. 
Be  this  as  it  may,  the  success  of  the  Aix  method  of 
treating  syphilis  is  undoubted. 

In  this  country  the  Hot  Springs  of  Arkansas  is 
perhaps  the  most  renowned  place  for  the  treatment 
of  syphilis,  and  so  far  as  the  waters  are  concerned,  it 
offers  essentially  the  same  advantages  as  Aachen. 
Sulphur  waters  similar  to  those  at  Aix  are  found  in 
New  York,  Virginia,  West  Virginia,  Alabama, 
Michigan,  California,  and  Ontario,  Canada. 

Edward  O.  Otis. 


Aix=Ies=Bains. — This  is  a  town  of  about  5,000  in- 
habitants, picturesquely  situated  in  a  beautiful  valley 
on  the  east  shore  of  the  Lake  of  Bourget,  and  sur- 
rounded by  high  mountains  (the  Savoy  Alps).  It  is 
about  twenty  hours  from  London  via  Paris  and  Macon, 
eight  hours  from  Turin,  four  from  Lyons,  and  three 
from  Geneva.  Its  elevation  above  the  sea  level  is 
8.50  feet,  and  100  feet  above  Lake  Bourget.  The 
climate  is  soft  and  mild,  the  average  temperature 
being  55°  F.  during  the  year,  and  the  mean  summer 
temperature  70°  F.,  though  it  is  sometimes  hot  in 
summer.  June  and  September  are  delightful  months. 
"  Owing  to  its  excellent  atmosphere,"  says  Linn, 
"people  rest  well  here." 

The  thermal  sulphurous  waters,  known  to  the  Ro- 
mans, for  which  about  35,000  people  visit  the  town 
annually,  are  derived  from  two  copious  springs  which 
have  a  temperature  of  from  107°  to  112°  F.,  and  which 
are  called  "  St.  Paul's"  and  the  "Alum."  They  yield 
about  one  million  gallons  of  water  daily.  They  are 
nearly  devoid  of  solid  constituents  and  contain  suffi- 
cient sulphureted  hydrogen  to  give  them  the  charac- 
teristic odor.  "  The  waters  of  the  two  springs  are 
chiefly  used  for  baths,  but  the  'Alum,'  spring  is  like- 
wise used  for  drinking.  For  internal  use,  however, 
t he  stronger  cold  waters  of  Challes,  near  Chambery, 
and  of  Marlioz  are  chiefly  employed. 

"  The  waters  and  the  various  methods  of  treatment 
employed  at  Aix  are  of  service  in  cases  in  which  indif- 
ferent thermal  (or  sulphur)  waters  are  of  use";  the 
methods  of  treatment  are  probably  the  most  effica- 
cious in  producing  the  results.  "The  diseases  which 
receive  especial  benefit  from  the  Aix  treatment  are 
chronic  gouty  and  rheumatic  affections,  muscular 
rheumatism,  sciatica,  neuralgia,  neurasthenic  condi- 
tions in  arthritic  subjects,  chronic  cutaneous  erup- 
tions, and  chronic  catarrhal  affections  of  the  mucous 
membranes."  "In  rheumatic  arthritis,"  says  A.  B. 
Garrod,  "  the  value  of  the  Aix  course  far  exceeds,  ac- 
cording to  my  experience,  that  of  any  other  known 
spa."  Excellent  results  are  also  obtained  in  the  stiff- 
ness of  joints  arising  from  former  injuries  and  from 
gouty  and  rheumatic  affections. 

The  large  bathing  establishment  is  the  property  of 
the  state,  and  is  one  of  the  most  efficient  of  these  in- 
stitutions known.  There  are  swimming  baths  (pis- 
cines), fifty  douche  rooms  with  conveniences  for  ad- 
ministering massage;  six  vapor  rooms  (bouillons); 
five  hot  dry-air  rooms  (etuves) ;    two  general  vapor 

174 


baths  (caisses);    and  four  apparatuses  (Berthollet's) 
for  applying  vapor  locally. 

There  is  a  special  piscina  for  the  treatment  of 
chronic  skin  affections  by  prolonged  baths,  after  the 
method  of  Loeehe-les- Bains.  Poor  people  are  cared  for 
well  as  the  rich.  The  especial  feature  at  Aix,  for  which 
it  is  so  famous,  is  the  "  douche  massage,"  consisting  of 
the  methodical  application,  by  two  skilled  attendants, 
of  massage  combined  with  douches.  This  procedure, 
which  may  be  used  for  the  whole  body  or  espei  i- 
ally  applied  to  the  desired  part,  is  carried  out  in  the 
following  manner:  Ihe  patient  is  seated  upon  a 
wooden  stool,  and  two  attendants,  male  or  female  as  the 
case  may  be,  pour  the  water  upon  the  body  from  a 
hose,  while  at  the  same  time  they  shampoo,  knead, 
and  rub  according  to  the  directions  given  by  the  physi- 
cian, who  accompanies  the  patient  to  the  douche  the 
first  time,  to  give  instructions  as  to  temperature,  force, 
duration,  and  pressure  on  particular  parts.  The 
masseurs  have  each  a  hose  under  the  arm  from  which 
they  direct  the  water  over  the  bather.  The  "douche 
massage"  may  be  combined  with  passive  movements 
of  special  joints,  to  be  followed  or  preceded  by  a  vapor 
bath  in  the  adjoining  bouillon.  In  many  cases  pa- 
tients, after  walking  to  the  bathing  establishment, 
send  back  to  their  hotel  their  clothes,  and,  at  the 
close  of  the  bath  (which  lasts  about  ten  or  fifteen 
minutes),  they  are  rubbed  dry,  wrapped  in  a  blanket, 
and  carried  in  bath  chairs  by  porters  back  to  their 
hotel  and  put  to  bed.  "  The  men  and  women  who 
perform  the  douche  massage  have  had  their  art 
handed  down  to  them  for  many  years,  as  their  fathers 
and  mothers  were  masseurs  and  masseuses  before 
them."  The  Aix  waters  have  an  unctuous  quality 
which  makes  them  particularly  adapted  to  rubbing  and 
kneading  the  musular  structures,  a  quality  that  is  not 
found  in  other  waters.  While  using  the  waters  the 
patient's  diet  is  carefully  regulated  by  the  physician. 
For  a  more  detailed  description  of  the  "Aix  douche" 
the  reader  is  referred  to  that  of  Dr.  Jean  Dardel  of 
Aix-les-Bains  given  in  Hinsdale's  "Hydrotherap\ ." 
1910. 

Some  two  thousand  douches  and  one  thousand 
baths  are  often  given  daily  during  the  season. 

The  sanitation  of  Aix  is  excellent  and  the  accom- 
modations are  ample  and  satisfactory.  The  season 
extends  from  May  to  October,  though  the  baths  are 
open  the  entire  year.  July  and  August  are  the  most 
frequented  months.  In  this  country  the  Hot  Springs 
of  Virginia,  and  the  springs  of  Richfield  and  Sharon  in 
New  York  State,  correspond  to  the  waters  of  Aix  a~ 
to  the  class  of  diseases  treated,  and  the  bathing  estab- 
lishments at  these  places  are  modelled  after  those  of 
the  European  spas. 

For  much  of  the  above  description  of  Aix-les-Bains 
the  writer  is  indebted  to  Weber's  "Spas  and  Mineral 
Waters  of  Europe,"  1896;  to  Linn's  "Health  Res 
of  Europe";  and  to  the  article  in  the  first  edition  of 
the  Handbook.  Edward  O.  Otis. 


Ajaccio. — The  principal  town  of  the  island  of  Cor- 
sica, with  a  population  of  20,000.  It  is  situated  in 
the  center  of  a  beautiful  and  well-protected  bay  open- 
ing to  the  southwest.  "Fifteen  to  twenty  miles  in 
the  rear  of  Ajaccio  is  a  semicircular  mountain  chain 
of  granitic  formation  sloping  down  to  undulating 
foothills,  and  presenting  a  glowing  panorama  at  sun- 
down. During  the  winter  season  the  distant  peak! 
of  Monte  Onto,  Rotondo,  and  d'Oro  are  capped  with 
snow,  and  the  chilly  northeast  wind  over  the  gulf  of 
Genoa  is  dried  and  broken  in  force  before  it  reai 
the  western  shore,  where  it  is  again  arrested  near 
Ajaccio  by  the  sheltering  hills  surrounding  the  town" 
(A.  Tucker  Wise:  Transactions  of  the  American  Cli- 
1 1 iat ological  Association,  1890).  The  visitors' quarter 
is  along  the  Course  Grandival  in  the  northwestern  por- 
tion of  the  town,  "which  is  the  section  most  protected 


REFEREXCK    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Alaska 


and  best  sheltered  from  the  winds."  "The  .soil  at 
Ajaccio  is  disintegrated  granite,  and  allows  a  rapid 
disappearance  of  the  heavy  .showers  which  fall  during 
the  autumn.  But,  unlike  the  Riviera,  this  locality 
lias  only  a  small  rainfall  in  March." 

The  water  supply  is  of  a  pure  quality,  and  is  brought 
I,,  I  he  town  from  Carazzi,  twelve  miles  distant.  "  'I  lie 
drainage  of  Ajaccio  is  certainly  not  perfect,"  says 
Wise,  "but  zymotic  diseases  are  very  uncommon." 

The  vegetation  is  most  luxuriant,  and  all  the  prin- 
cipal streets  are  bordered  with  avenues  of  acacia, 
orange,  or  citron  trees.  Bananas,  oranges,  lemons,  a 
variety  of  cactus,  the  castor-oil  plant,  prickly  pear, 
alec.  6g,  and  olive  flourish. 

••  1.  at  any  rate,"  writes  D.   W.  Freshfield  in  the 

Alpine  Club  Journal,   quoted  by  Ball,  "know   of  no 

such  combination  of  sea  and  mountains,  ot  the  sylvan 

beauty  of  the  North  with  the  rich  colors  of  the  South; 

no  region  where  within  so  small  a  space  Nature  takes 

so  many  sublime  and  exquisite  aspects  as  she  does  in 

Corsica.     Orange  groves,  olives,  vines,  and  chestnuts, 

most  picturesque  beach  forests,  the  noblest  pine 

Is  in   Europe,  granite  peaks,  snows,  and  frozen 

lakes — all  these  are  brought  into  the  compass  of  a 

journey." 

The  accommodations  now  appear  to  be  ample  and 
satisfactory,  both  from  the  standpoint  of  health  and 
from  that  of  convenience,  whether  one  desires  hotel, 
pension,  or  villa. 

As  to  the  meteorology  of  Ajaccio,  the  mean  tem- 
perature during  the  -winter  is  about  55°  F.  with  a 
small  daily  variation  of  not  more  than  10°  F. ;  this 
is  two  or  three  degrees  higher  than  the  mean  tempera- 
ture  of  the  Riviera. 

•'  During  the  season  (November  to  April)  the  ther- 
mometer rarely  rises  above  59°,  or  falls  below  50°" 
(Hall).  The  relative  humidity  is  given  by  Wise  as  SO 
per  cent.,  and  by  another  authority  as  varying  be- 
n  70  and  78  per  cent.  The  average  number  of 
rainy  days  for  the  season  is  stated  by  Wise  to  be  30, 
and  by  the  writer  on  Ajaccio  in  Eulenburg's  "  Real- 
Eneyclopadie,"  for  the  months  from  October  to  April 
inclusive,  40  to  45.  During  the  three  rainy  months, 
ember,  January,  and  February,  the  average 
number  is  not  more  than  14,  according  to  Ball.  The 
prevailing  wind  is  the  southwest,  which  is  "a  tem- 
perate and  soft  wind,  with  genial  bright  weather,  and 
prevails  as  a  high  current  throughout  the  greater  part 
of  the  winter,  and  in  spring  its  continuance  for  a  pro- 
longed period  is  almost  a  certainty"  (Wise).  The 
southeast  wind  ("sirocco")  is  a  very  depressing  one, 
producing  loss  of  appetite  and  sleeplessness.  "From 
my  own  personal  point  of  view"  says  Wise,  "I  regard 
Ajaccio  as  the  most  comfortable  climate  I  have  ever 
visited,  with  the  exception  of  the  winters  in  the 
Bermudas,  and,  in  comparison  with  Madeira,  it  is 
certainly  more  bracing  and  agreeable  to  the  able- 
bodied."  The  climate  can  be  characterized  as  a 
moderately  moist,  mild,  marine  climate,  with  a  com- 
paratively large  number  of  sunny  days,  ranking 
between  Madeira  and  the  Italian  Riviera,  but  warmer 
and  more  equable  than  the  latter.  On  account  of 
the  hard  granite  soil  there  is  no  dust,  and  high  winds 
are  infrequent,  a  contrast  to  the  Riviera.  "  People  who 
find  the  Riviera  too  exciting,"  says  Huggard,  "com- 
monly do  well  at  Ajaccio.  For  young  and  vigor- 
ous subjects    the   climate   usually   proves  relaxing." 

"It  has  always  been  a  matter  of  surprise  to  me," 
says  Williams  '("Aero-Therapeutics,"  1S94),  "that 
Ajaccio  has  not  been  more  utilized  as  an  alternative 
climate  by  the  Riviera  medical  men,  when  their  own 
has  proved  too  stimulating  or  too  marked  by  radiation 
extremes,  for  this  mild,  moist  atmosphere,  with  its 
freedom  from  all  but  sea  breezes,  and  its  good  hotels 
and  quiet  surroundings,  seems  to  supply  the  requisite 
and  beneficial   change." 

The  phthisical  patients  for  whom  this  climate  is 
especially  well  adapted  are  those  who  can  afford  but 


little    physical    effort     in     order     to     exist — cases     of 

"phthisis  of  advanced  life,  with  cardiac  feeblei 

where  t  he  powers  ot  resistance  In  eold  are  at  a  low  ebb, 

or  there  is  much  emphysema  with  cold,  livid  extremi- 
ties" (Wise),  it  is  also  beneficial  for  those  in  whom 
"the  breathing  powers  an-  greatly  diminished  or 
when  a  stubborn  cough  is  a  prominent  symptom." 
Those  suffering  from  a  dry,  irritable,  bronchial  or 
laryngeal  catarrh  are  said  to  do  well  here.  Certain 
cases  of  incipient  phthisis  which  are  unsuited  to  the 
altitude  treatment  do  well  in  Ajaccio;  and  the  same 
remark  applies  to  those  affected  with  nervous  irrita- 
bility who  require  a  soothing  climate. 

Ajaccio  is  reached  by  .steamer  from  Nice  and  from 
Marseilles  in  twelve  and  a  half  and  eighteen  hours, 
respectively.  Edwahd  O.  Otis. 


Ajowan. — Ajava;  Bishop's  Weed;  IVeed-seed.  The 
fruit  of  Ptychotis  coptica,   D.   C.   ifam.    Umbelliferce), 

This  plant  is  supposed  to  be  indigenous  to  India, 
where  it  has  always  supplied  an  important  cultivated 
crop.  The  fruit — one  of  the  cremocarps  commonly 
called  "seeds" — is  prized  for  table  use,  an  equivalent 
of  thyme,  as  well  as  for  its  medicinal  properties.  It 
is  employed  in  all  cases  requiring  a  carminative,  and 
its  action  is  powerful.  It  has  also  been  much  used  in 
cholera,  combined  with  camphor,  on  account  of  its 
powerful  stimulation  of  the  abdominal  nerves,  and 
for  its  antiseptic  effect.  These  uses  are  fully  ex- 
plained when  it  is  known  that  the  plant  contains 
four  per  cent,  of  a  volatile  oil  rich  in  thymol,  and  that  it 
is  largely  used  as  a  source  of  that  substance.  Its 
properties  and  uses  are  therefore  those  of  that  drug. 
The  dose  is  one  to  two  grams  (gr.  xv.-xxx.). 

H.  H.  Rusby. 

Akinesia  Algera. — See  Acinesia  Algcra. 

Alaska. — This  vast  northwestern  possession  of  the 
United  States,  extending  over  16  degrees  of  latitude 
and  35  degrees  of  longitude,  and  embracing  590,884 
square  miles  of  territory,  equal  to  nearly  one-sixth 
of  the  area  of  the  United  States,  exhibits  a  variety  of 


from  Greenwich 


Fig.  66. — Map  of  Alaska. 

climatic  conditions  and  contrasts  dependent  not  only 
upon  latitude,  but  upon  the  topography  of  the  country 
and  the  influence  of  the  surrounding  waters  and 
currents.  Two  great  climatic  divisions  can  be  made: 
southern  or  temperate  Alaska,  which  can  be  sub- 
divided into  the  Sitka,  Kodiak,  and  Aleutian  divi- 
sions,  and   northern  Alaska   or  the    Yukon  district, 


175 


Alaska 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


embracing  the  vast  region  to  the  north  and  west  of 
the  Alaskan  Mountains. 

The  climate  of  temperate  Alaska  is  characterized  by 
two  striking  peculiarities:  comparative  warmth  and 
great  moisture,  formerly  supposed  to  be  caused  by  the 
Kuro  Siwo,  the  "  gulf  stream  "  of  the  Pacific,  but  "now 
held  to  be  the  general  eastward  drift  of  the  waters  of 
the  North  Pacific  in  the  direction  of  the  prevalent 
winds."  As  a  result  of  this  condition,  the  tempera- 
ture is  greatly  modified  from  what  the  latitude  alone 
would  lead  one  to  expect,  exactly  as  the  climate  of 
Great  Britain,  for  example,  is  modified  by  the  gulf 
stream.  The  isotherm  of  40°  mean  annual  tempera- 
ture, that  of  the  lower  St.  Lawrence  valley,  is  the 
mean  annual  isotherm  of  the  Southern  Alaskan  coast 
region.  Sitka,  with  a  latitude  of  57.03°,  which  is  the 
same  as  the  latitude  of  Labrador  on  the  Atlantic  coa.-t, 
has  a  mean  annual  temperature  of  43.9°  F.,  which  is 
only  2.6°  lower  than  that  of  Portland,  Me.,  and  a 
mean  winter  temperature  of  32.5°,  which  is  6.9° 
higher  than  that  of  Portland,  and  only  a  little  less 
than  that  of  Washington,  D.  C.  "  The  coldest  month 
of  Sitka,  31.4°,  closely  agrees  with  the  coldest  month 
of  St.  Louis."  (Greely.)  The  extreme  range  of  tem- 
perature is  from  a  point  a  trifle  below  zero  to  90° 
above.  Similarly,  Juneau,  in  the  Sitka  district, 
northeast  from  Sitka,  has  a  mean  annual  temperature 
of  40.9°  F.  The  annexed  chart  of  the  maximum, 
minimum,  and  mean  temperatures  of  Juneau  and 
Sitka  for  the  year  indicate  still  further  the  moderate 
temperature  of  the  region. 

The  second  peculiarity  of  temperate  Alaska  is 
moisture  in  the  form  of  rain  or  fog,  and  in  the  Sitka 

Average  Monthly  Maxim™.  Minimum,  and  Mean  Temperatures  (Degrees  Fahrenheit)  of  Juneau  and 

Sitka  for  the  Four  Years  1899-1902  Inclusive. 


which  results  in  this  enormous  rainfall,  nowhere  else 
equalled  in  the  United  States,  the  annual  rainfall  at 
Sitka  being  more  than  double  that  on  the  Atlantic 
coast.  At  Sitka  the  rainfall  for  the  three  winter 
months  is  about  thirty  inches,  and  for  the  three 
summer  months  sixteen  inches. 

The  Sitka  region  is  the  scenic  portion  of  Alaska, 
visited  by  tourists,  and  here  are  found  immense 
glaciers  descending  into  the  ocean. 

The  country  is  heavily  wooded  with  spruce,  hem- 
lock, and  cedar,  and  the  vegetation  is  dense.  On 
account  of  the  sparse  sunshine  agriculture  is  difficult, 
but  many  garden  vegetables  are  successfully  grown. 

In  the  Kodiak  district,  which  comprises  Cook's 
Inlet,  the  peninsula  of  Alaska,  and  the  Kodiak  Islands, 
the  climate  is  similar  to  that  of  the  Sitka  region,  but 
there  is  more  sunshine  and  less  rain,  and  the  seasonal 
extremes  of  temperature  are  greater.  At  Kodiak  the 
annual  mean  temperature  is  40.6°  F.,  and  the  number 
of  days  of  rain  or  snow  for  ten  months  of  the  year 
1899  was  133,  and  the  number  of  cloudy  days  124, 
making  2."i7  cloudy  and  rainy  days  out  of  304.  The 
monthly  mean  temperature  at  Kodiak  for  eight  year3 
is  as  follows: 

Kodiak— Lat.  57°  48';  Long.  152°  19'.     Monthly  Mean  Tem- 
perature (Degrees  Fahrenheit)  for  Eight  Years. 

August 55.2 

September 50.0 

October 42.3 

November 34.7 

December 30.5 

Year 40.6 


Januarv 30 . 0 

February 28 .  2 

March 32.6 

April 36.3 

May 4:i  2 

June 49.5 

July 54.7 


Jan. 

Feb. 

.Mar. 

Apr. 

May. 

June. 

July. 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

Juneau — 

41    7° 

0.5 

29.7 

.51.0 
23.3 
35.7 

43.0° 

12.0 

29.1 

47.3 
16.3 
34.3 

50.7° 

6.0 
32 . 8 

53.6 

7.6 

35.8 

57   2° 

29.5 

40.6 

58.0 
2S.3 
42.0 

66.2° 

33.2 

46.6 

64.7 
31.2 

44.6 

73 . 2° 
39  2 
56.6 

67.7 
34.7 
50.6 

78.5° 
44  0 
57.5 

7S.5 
40.0 
55.5 

67.7° 

41.7 

54.2 

65  2 
39.7 
54   4 

63.7° 

35.7 

49.8 

65.0 

37.7 
50.9 

58  7° 

27.0 

43.0 

60.0 
30.5 

45   2 

49.6° 

19.3 

35.9 

54 . 0 
23  3 
3S.0 

47.6° 

11.0 

32.6 

Sitka— 

49.7 

21  .3 

Daily  mean 

34.3 

division,  which  extends  from  Dixon  Entrance  to 
William's  Sound,  the  yearly  rainfall  is  from  eighty  to 
one  hundred  and  three  inches,  and  there  are  on  an 
average  but  sixty-six  clear  days  in  the  year.  "  'When 
the  sun  shines,  "the  atmosphere  is  remarkably  clear, 
the  scenic  effects  are  magnificent,  all  nature  seems 
to  be  in  holiday  attire.  But  the  scene  may  change 
very  quickly;  the  sky  becomes  overcast;  the  winds 
increase  in  force;  rain  begins  to  fall;  the  evergreens 
sigh  ominously,  and  utter  desolation  and  loneliness 
prevail."  Fogs  are  exceedingly  frequent  on  this  coast 
and  occur  whenever  the  wind  blows  from  the  sea. 
(United  States  Department  of  Agriculture,  Weather 
Bureau.)  The  Sitka  district  is  very  mountainous, 
and  the  coast  bold  and  steep  with  few  beaches.  On 
account  of  the  fringe  of  islands  lying  off  this  coast  and 
separated  by  narrow  and  deep  channels  called 
"sounds,"  there  is  afforded  an  almost  unbroken 
protected  waterway  for  ocean  steamers  from  Puget 
Sound  to  Cross  Sound,  one  hundred  miles  or  more 
above  Sitka,  with  many  excellent  harbors.  The 
mountain  sides  are  densely  wooded,  and  the  snow 
line  begins  at  an  elevation  of  from  three  thousand 
to  five  thousand  feet.  The  prevailing  winds  being 
westerly  and  off  the  ocean,  bring  the  moisture  to  the 
.snowy  mountains,  which  condense  it.  Hence  it  is  the 
combination  of  the  mountains,  the  prevailing  moist 
winds  from  the  sea,  and  the  warm  ocean  currents, 

176 


In  the  Aleutian  district,  comprising  the  range  of 
Aleutian  Islands,  the  range  of  temperature  is  much  the 
same,  as  the  following  chart  of  Unalaska  indicates: 

Unalaska — Lat.    53°   54';    Long.    166°    24'.     Monthly    Mean 
Temperature  (Degrees  Fahrenheit)   for  Six  Years. 

January 30.0     August -"'1  9 

February 31 .9     September 45.5 

March...  .30.4     October 37.6 

November 33.6 

December 30.1 

Year 38.7 


April 35.6 

May 40.9 

June 46.3 

July 50.6 

According  to  Harriman  (Alaskan  expedition),  there 
were  at  Unalaska  only  eight  days  in  the  year,  during 
several  years'  record,  which  were  entirely  clear,  the 
remaining  312  being  cloudy  and  271  of  these  were 
rainy  or  snowy. 

The  Yukon  district,  or  Northern  Alaska,  comprises 
that  vast  region  of  the  Yukon  Valley  which  extends 
from  the  Alaskan  Mountains  to  the  Arctic  Ocean  on 
the  north  and  Behring  Sea  and  Strait  in  the  west. 
"  If  there  is  a  region  more  infested  with  fogs  than  the 
Pacific  coast  of  Alaska,"  says  Harriman,*  "it  is 
Bering  Sea."  "  Here  fog  is  the  normal  condition, 
and  clear,  bright  weather  the  rare  exception.  It  is 
no  uncommon  experience  for  vessels  bound  for  the 

*  Alaska  Expedition,  vol.  ii.,  1901. 


referexce   h\ni>ro<>k  of  the  medical  sciences 


Alnjlra 


I'ribilofs  to  miss  the  islands  in  the  fog.  and  to  spend 
days  searching  for  them,  as  for  needles  in  a  haystack." 
In  the  interior  of  this  region  the  climate  becomes 
colder  and  drier — extremely  rigorous  during  the  long 
winter  and  relatively  hot  in  the  short  summer.  As 
one  continues  north  arctic  conditions  of  climate  begin'. 
On  the  Behring  Sea  coast,  north  of  the  Aleutian 
Islands,  the  winter  climate  is  much  more  severe  than 
of  temperate  Alaska  on  the  Pacific  coast,  hut  in 
summer  the  difference  is  less  marked.  At  St. 
Michaels,  on  the  south  side  of  Norton  Sound,  the 
mean  summer  temperature  is  50°  F.,  which  is  but  4° 
below  that  of  Sitka:  and  at  Point  Barrow,  on  the 
\rctic  Ocean,  the  most  northerly  point  in  the  United 

:  s,  the  mean  summer  temperature  is  36.8°  F. 
Furthermore,  the  winter  on  the  Behring  Sea  coa-t 
about  the  mouth  of  the  Yukon  River  and  the  Seaward 
Peninsula  is  somewhat  less  protracted  and  severe 
than  in  the  interior,  although  it  is  still  long,  and  from 

iber  to  May  the  temperature  rarely  rises  above  the 
freezing-point. 

St.    Mr 


covered    there.       It      is   reached   either  overland—  the 

common  passenger  route  from  Skagway  by  rail  for 
about  one1  hundred  mill.-  by  the  White  Pass  and 
Yukon  Railroad,  and  thence  by  steamer  on  the  upper 
Yukon  to  Dawson  -or  by  the  longer  all-water  route, 
which  is  principally  used  for  freight,  by  way  of  the 
lower  Yukon.  I  he  distance  from  Skagway  to  Daw- 
son, the  principal  city  of  the  Klondike  (in  Canadian 
Territory),    is    five  hundred  and  eighty  miles. 

The  general  characteristics  of  the  Klondike  climate 
are  similar  to  those  of  Nome — long,  extremely  cold 
winters,  with  much  snow  and  "brief  hut  relatively 
hot  summers."  "In  midwinter  the  sun  rises  from 
9:30  to  10  a.m.,  and  sets  from  2  to  3  cm.,  the  total 
length  of  daylight  being  about  four  hours."  (United 
States  Weather  Bureau  report.)  In  June  the  sun 
rises  about  1:30  in  the  morning  and  sets  at  10:30  p.m., 
"giving  about  twenty  hours  of  daylight,  and  diffuse 
twilight  the  remainder  of  the  time."  "During  the 
warmer  days  of  summer  the  heat  feels  almost  tropical ; 
the  winter  cold  is,  on  the  other  hand,  of  almost  the 


Jan. 

Feb. 

Mar. 

Apr. 

May. 

June. 

July. 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

Year. 

Mean  maximum 

33.5° 

38.0° 

32  0° 

40 . 5° 

48.5° 

62  5° 

77.0° 

65  0° 

56.0° 

47.5° 

37  0° 

34  0° 

M*  tn  minimum.  .  .  . 

—34.0 

—20.0 

—  17   1) 

—20.5 

—7.0 

27.0 

40  0 

37.0 

25.0 

6.5 

— i.O 

—24.0 

Mean  monthlv.  .  . 

—7.4 

—2.3 

8.9 

19.9 

33.1 

46.3 

53.6 

51  .9 

43.9 

30 . 5 

15   6 

4.8 

26.1° 

Kxtreme  maximum 

44.0 

41.0 

43.0 

46.0 

57.0 

7.3  0 

7.5  0 

69.0 

69.0 

54.0 

42   0 

45  0 

75.0 

Extreme  minimum. 

-47.0 

—41.0 

—39.0 

—27.0 

—2.0 

22.0 

33.0 

32.0 

18.0 

3  0 

—24.0 

—43.0 

—47   0 

Mean     number     of 

rainv  and  snowy 

7 

4 

6 

S 

9 

9 

12 

14 

14 

11 

9 

o 

108 

Extreme  cold,  however,  as  one  knows  from  the 
experience  of  Arctic  explorers,  is  not  detrimental  to 
health,  and  at  Nome,  the  most  populous  mining  town 
in  Alaska,  the  winter  is  said  to  be  the  most  agreeable 
season  of  the  year,  in  spite  of  the  fact  that  in  mid- 
winter there  are  but  few  hours  of  daylight,  the 
shortest  days  giving  but  about  three  and  a  half  hours 
of  dusky  light.  "  With  hands  and  feet  warmly 
protected,  and  winter  underwear  and  windproof 
miter  clothes  and  exercise,  one  can  comfortably 
weather  a  degree  of  cold  which,  in  lower  latitudes, 
would  immediately  transform  him  to  an  icicle.  This 
is  due  to  the  dryness  of  the  cold."  ("The  Land  of 
Xome,"  by  Laurie  McKee,  New-  York,  1902.) 

The  accompanying  table,  compiled  from  observa- 
tions of  the  U/nited  States  Weather  Bureau,  gives  the 
annual  and  months  mean  temperatures  and  the 
extremes  for  St.  Michaels,  which  is  on  the  southern 
of  Xorton  Sound;  it  also  may  be  utilized  for  as- 
lining  approximately  the  yearly  temperature  of 
Cape  Xome,  which  is  one  hundred  and  fifty  miles 
listant  on  the  northern  shore  of  X'orton  Sound,  at  its 
junction  with  Behring  Sea.  In  the  same  table  will 
be  found  a  statement  of  the  mean  number  of  rainy 
and  snowy  days.  As  will  be  seen,  the  rainfall  is 
light,  and  is  about  fourteen  inches  annuallv.  a 
striking  contrast  to  that  of  Southern  Alaska. 

One  cannot  be  sure  of  reaching  Xome  by  sea  much 
before  the  middle  of  June  on  account  of  the  ice  in 
Behring  Sea,  or  of  getting  away  from  there  after  the 
latter_  part  of  September  or  1st  of  October.  The 
prevailing  winds  are  from  the  north,  and  severe 
blizzards  with  strong  northeast  gales  are  frequent  in 
winter.  In  comparing  the  climate  of  Xome  with 
"f  the  Klondike  region  to  be  spoken  of  directly. 
it  may  be  said  that  in  general  the  climate  of  the  latter 
i-  rather  more  favorable  than  that  of  the  former.  The 
most  trying  climatic  element  is  the  continual  wind. 

The   Klondike. — Fifteen    hundred  miles   in  the  in- 

r,    to   the   east    of    Xome  City,  is  the  Klondike 

region,  also  famed  and   frequented  for  the  gold  dis- 

Vol.  I.— 12 


extreme  Siberian  region."  "Yet  a  beautiful  vegeta- 
tion smiles  not  only  over  the  valleys,  but  on  the  hill- 
tops, the  birds  gambol  in  the  thickets,  and  the  tiny 
mosquito  pipes  out  its  daily  sustenance  to  the  wrath 
of  man."     (Heilprin,  "Alaska  and  the  Klondike.") 

The  following  observations  of  mean  and  extreme 
temperatures  of  the  United  States  Weather  Bureau 
made  at  the  Yukon  River  at  the  international 
boundary,  about  eighty  miles  north  of  Dawson,  from 
September,  1889,  to  June,  1891,  will  indicate  approxi- 
mately the  temperature  conditions  of  the  Klondike. 

From  observations  made  on  the  Yukon,  not  far 
from  the  site  of  the  gold  discoveries,  by  the  l'nited 
States  Coast  and  Geodetic  Survey  for  a  series  of  six 
months,  the  following  temperatures  are  noted: 
From  October,  1889,  to  April,  1890,  the  mean  tem- 
perature was  as  follows:  October,  33°  (above  zero); 
November,  8°  (above  zero):  December.  11°  (below- 
zero)  ;  January,  17°  (below  zero) ;  February,  15°  (below- 
zero);  March,  6°  (above  zero);  April,  20°  (above  zero). 
"The  daily  mean  temperature  fell  and  remained 
below  the  freezing  point  (32°  F.)  from  November  4. 
18S9,  to  April  21,  1890,  thus  giving  16S  days  as  the 
length  of  the  closed  season.  The  lowest  temperatures 
registered  during  the  winter  were:  32°  below  zero  in 
X'ovember:  47°  below  zero  in  December;  59°  below- 
zero  in  January:  55°  below  zero  in  February:  45° 
below  zero  in  March;  26°  below-  zero  in  April.  "The 
greatest  continued  cold  occurred  in  February,  1890, 
when  the  daily  mean  for  five  consecutive  days  was 
47°  below  zero.  The  weather  moderated  slight  ly 
about  the  1st  of  March,  but  the  temperature  still 
remained  below  the  freezing-point.  Generally  cloudy 
weather  prevailed,  there  being  but  three  consecutive 
days,  in  any  month,  with  clear  w-eather,  during  the 
whole  winter.  Snow  fell  upon  one-third  of  the  days 
in  winter,  and  a  less  number  in  the  early  spring  and 
late  fall  months.  The  change  of  temperature  from 
winter  to  summer  is  rapid,  owing  to  the  great  increase 
in  the  length  of  the  day."  (Bulletin  of  the  United 
States  Weather  Bureau,"  July  29,  1S97.) 

177 


Alaska 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Yukon  River  at   International  Boundary.  Lat.  6o°,  Long.   141°. 


Jan. 


Feb. 


Mar. 


Apr. 


-May. 


June.  |  July. 


Aug. 


Sept. 

Oct. 

Nov. 

39.0° 

31.0° 

3  0° 

66  0 

52. 0 

39.0 

14.0 

4.0 

—35.0 

Dec. 


Year. 


2:)  0° 

87  (I 

-60.0 


.Mean     temperature 

(degs.  Fahr.  i 
Extreme  maximum. 
■  rue  minimum 


-17.0°    —10.0° 

25  0  37.0 

-60 . 0      —.35 . 0 


7.0° 
3S.0 

-45  II 


24.0° 
56.0 
-26.0 


45 . 0° 

74  0 

8.0 


57.0° 
S4.0 
30.0 


60.0°  52  0° 
87.0  74  0 
35.0       31.0 


-16.0° 
17.0 
19  n 


Harriman  (Alaska  expedition)  says  that  the  mean 
temperature  of  the  warmest  month  on  the  Yukon,  in 
latitude  64°  41',  was  4°  higher  than  at  Sitka  over  five 
hundred  miles  farther  south;  but  while  at  Sitka  the 
extreme  range  of  temperature  is  90°,  it  will  be  seen 
from  the  above  table  that  on  the  Yukon  it  is  147°. 

"  With  a  claim  to  have  seen  many  distant  lands," 
says  Professor  Heilprin,  "I  can  truthfully  say  that 
never  before  had  it  been  my  fortune  to  experience 
such  a  succession  of  wonderful  summer  days  as  during 
my  stay  in  t he  region  about  Dawson.  From  August 
6  to  September  21),  barring  three  days  of  partial  rain, 
and  perhaps  a  fourth  of  cloudiness  and  mist,  the 
weather  was  simply  perfection — a  genial,  steady, 
mild  summer,  with  a  temperature  rising  at  its  highest 
to  about  80°  or  82°  F.  in  the  shade." 

The  average  annual  rainfall  is  given  as  from  ten  to 
twenty-five  inches,  and,  according  to  the  authority 
just  quoted,  the  weather  is  bright  and  sunny,  and  there 
is  practically  no  fog.  "There  is  more  sunshine,"  saj  - 
Harriman,  "in  a  month  (in  the  interior)  than  at  Sitka 
in  a  year." 

Such  a  climate,  although  severe,  is  said  to  be  a 
healthy  and  invigorating  one  to  most  people,  for  the 
cold  is  uniform  and  dry,  and  there  is  very  little  wind. 
a  contrast,  in  this  respect,  to  Nome.  In  a  report  by 
Capt.  W.  P.  Richardson,  Eighth  Infantry,  U.  S.  A., 
tin'  fact  is  stated  that  when  the  thermometer  rises  to 
zero,  as  it  sometimes  does  in  midwinter,  it  is  too 
warm  for  comfortable  travel.  The  best  temperature, 
he  states,  is  from  10°  to  25°  or  30°  below  zero.  "  With 
this  temperature  the  sleds  run  easily,  dogs  work  with 
spirit,  and  one  can  exercise  with  the  warm  clothing 
necessary  at  all  times  in  Alaska  without  discomfort." 
The  ground  is  frozen  deeply,  and  in  the  wannest 
season  only  thaws  to  the  depth  of  a  foot  or  two. 

The  vegetation  in  the  Klondike  region  is,  compara- 
tively speaking,  far  more  luxuriant  than  at  Nome, 
where  it  is  of  arctic  character,  chiefly  mosses  and 
lichens,  and  the  tundra  or  thick  peat  moss,  or  grass 
which  renders  foot  travelling  wearisome  and  slow. 
In  the  Klondike  region  the  country  is  well  wooded, 
principally  with  the  spruce,  although  the  aspen,  birch, 
balsam,  and  poplar  are  found,  and  this  region  of  forest 
extends  with  breaks  several  hundred  miles  northward 
of  Dawson.  In  the  summer  the  country  is  green  and 
variegated,  with  a  rich  flora.  Grass  grows  abun- 
dantly, and  all  the  hardy  vegetables  are  said  to  grow 
without  trouble.  Grain,  vegetables,  and  fruit  have  been 
raised  in  small  quantities.  The  native  strawberry  is 
found  in  many  parts  of  the  Yukon  valley,  and  so  also 
are  various  native  berries,  especially  the  blueberry. 
In  the  Yukon  valley,  near  Dawson,  celery,  lettuce, 
potatoes,  turnips,  etc.,  have  been  successfully  grown, 
as  well  as  oats  and  wheat,  and  this  in  a  latitude  which 
runs  through  Greenland  and  Iceland!  Of  course 
such  results  would  be  impossible  were  it  not  for  the 
fait  that  the  summer  days,  though  few,  are  very  hot 
and  the  sun  is  almost  continually  above  the  horizon. 

Fish,  furs,  and  gold  are  the  principal  industries 
of  Alaska.  The  discovery  of  gold  has  naturally 
attracted  the  most  attention,  but  the  fisheries  form 
one  of  the  most  important  industries,  and  next  in 
importance  to  the  fur  trade  is  the  salmon  industry. 
Large  bodies  of  coal  have  also  been  discovered  in 
S  mi  hern  Alaska,  but  from  lack  of  transportation  and 
the  formulation  of  a  definite  plan  of  development  by 


the  TJ.  S.  Government,  whose  property  they  are.  they 
have  not  yet  been  worked.  There  are  also  extensive 
petroleum  fields  and  copper  mines.  The  population 
was  64,356  at  the  census  of  1910,  about  equally  divided 
as  between  whites  and  natives. 

Nome  City  is  the  largest  town,  with  a  population  of 
over  12,000,  and  next  comes  Skagway,  with  a  little 
over  3,000.  Dawson,  the  principal  town  of  the  Klon- 
dike region,  in  Canadian  Territory,  had  in  1899  16,000 
inhabitants. 

The  testimony  is  somewhat  conflicting  regarding  the 
mosquitos,  but  they  are  apparently  pretty  abundant, 
and  at  certain  times  and  places  constitute  a  veritable 
scourge.     The  gnats  are  also  ven*  annoying. 

The  accommodations,  especially  in  the  mining 
towns,  are  naturally  not  of  the  best,  and  are  expensn  i 
still,  any  one  possessed  of  robust  health  need  mil  be 
deterred  either  by  the  climate  or  by  the  poor  accom- 
modations from  a  journey  to,  or  a  permanent  abode 
in,  Alaska.  The  steamer  accommodations  from 
San  Francisco,  Seattle,  or  Vancouver  are  by  some  lines 
quite  satisfactory.  A  summer  excursion  to  the  south- 
eastern coast  of  Alaska — the  iceberg  region — is  a 
favorite  one,  and  is  in  calm  waters  on  account  of  the 
protection  of  the  outlying  islands. 

References. —  Various  government  reports  from  the 
Interior  Department;  Department  of  Commerce  and 
Labor;  Department  of  Agriculture,  and  the  Weather 
Bureau;  yearly  reports  of  the  governor  of  Alaska: 
Harriman,  "Alaska  Expedition";  Heilprin's  "Alaska 
and  the  Klondike";  "The  Land  of  Nome,"  by  Laurie 
McKee;  "The  Pacific  Coast  Pilot,"  Maj.  Gen.Greely's 
"  Handbook  of  Alaska"  and  "  Alaska  Almanac,"  1908, 
and  many  other  special  works.      Edward  O.  Otis. 


Alassio. — A  winter  health  resort  on  the  Italian 
Riviera,  fifty-seven  miles  from  Genoa,  and  about  the 
same  distance  from  Nice.  It  is  a  small  town  of  about 
4,200  inhabitants,  attractively  situated  at  the  head  of 
a  curving  bay  about  five  miles  in  width.  To  the  rear 
is  a  circle  of  hills,  the  greatest  elevation  of  which  is  on 
the  North  (1,963  feet).  Thus  the  town  is  protected 
from  the  winds  of  the  north,  west,  and  southwest, 
The  Mistral  (north  wind),  that  bane  of  the  Riviera, 
is  rarely  felt  here.  From  the  east,  however,  a  strong 
wind  is  not  infrequent,  which,  in  mid-winter,  may  !"■ 
exceedingly  uncomfortable. 

Besides  the  town  proper,  there  are  suburbs  at  the 
two  promontories  at  each  end  of  the  bajr,  in  each  of 
which  there  is  a  hotel  facing  the  sea.     There  are 
hotels  and  villas  on  the  beach,  and  on  the  hill 
above  the  town  are  villas  of  the  English  residi 
and  one  or  more  hotels.     One  can,  therefore,  obtain 
comfortable  accommodations  at  a  somewhat  cheaper 
rate  than  at  many  other  Riviera  resorts. 

No  accurate  information  can  be  obtained  as  to  the 
sanitary  condition  of  the  town,  but  from  its  location  tin1 
natural  drainage  ought  to  be  efficient.  Sparks  ("The 
Riviera,"  London,  1879)  declared  that,  the  drinking 
water  was  good. 

The  scenery  is  very  attractive,  with  a  luxurious 
vegetation  and  the  picturesque  olive  groves.  "It 
would  be  difficult  to  imagine,"  said  Dean  AJford 
(Ball's  "Mediterranean  Winter  Resorts"),  "any  place 
more  lovely  in  spring  than  Alassio.  The  somber  hoe 
of   the  olive   is  broken   by   patches  of  bright  green 


178 


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Albinism 


here  oak  and  acacia  and  chestnut  lives  are  bursting 
!,,  leaf.     Hoses  everywhere  with  the  lavish  wealth 

1  [taly  a  cascade  of  ruses  over  terrace,  walls,  balus- 
ii, ilcs,  and  trees  one  glorious  mass  of  bloom.  Below, 
[retching  away  to  the  horizon,  is  the  bluest  of  seas 
;  hing  and  gleaming  in  the  sunlight." 
The  following  table  gives  the  mean  temperatures 
in  degrees  Fahrenheit  |  for  the  months  indicated, 
uring  a  period  of  six  years: 

lotober    i;1  '■'      January 47.3      April 56.4 

...r....   54.3       February. ...   48.2       .May 64. 3 

!,  r   .  ,  .    40.7       March 52.3 

:iu  temperature  of  the  three  winter  months  is, 

hen,   IS.  t°  1'. 

The   average    rainfall   for   the   above    period    was 

ighty  inches,  and   the  average  number  of  days  per 

nontfl  on  which  rain  fell  was  6.6.      The  mean  relative 

imidity   was  57.6,  and  of  the  three  winter  months 

i  1.7.      ''  Fog  has  been  recorded  on  fourteen  days 

[g  the  six  winters." 

It  will  be  seen  from  the  above  that  Alassio  possesses 

dry,  bracing   temperate  climate;  almost  complete 

of  fog,  and  an  abundance  of  sunshine;  and, 

ition,  the  characteristics  peculiar  to  a  seaside 

I  he  cases  for  which  such  a  climate  is  suitable  are: 
children    suffering    from    malnutrition    and   sur- 
real tuberculosis,  particularly  glanduar  tuberculosis; 
2)  sufferers  from  various  nervous  diseases  and  ner- 

ireakdowns,  provided  they  sleep  well;  (3)  cases 
if  heart  diseases;  (4)  cases  of  gout  and  chronic  rheu- 

i    are   said   to  do  well  here;  (5)  convalescents 

i  nte  disease;  (6)  in  general,  the  valetudinarian 
rom  whatever  cause,  who  desires  a  mild,  sunny 
ilimate  where  existence  is  easy,  and  outdoor  life  is 
,  issible  under  attractive  surroundings.     Patients  suf- 

imin  hysteria  and  melancholia  should  not  be 
.at  here,  as  the  climate  is  said  to  aggravate  those 
■omplaints. 

I  d  conclusion,  the  writer  may  be  allowed  to  quote  a 
portion  of  a  letter  received  from  an  intelligent 
gentleman  who  resided  at  Alassio  for  some  months: 
The  climate  in  December  and  January,"  he  says, 
"  is  somewhat  severe  indoors  in  the  Italian  houses, 
but  one  can  be  perfectly  warm  and  comfortable  in  the 
hotels  on  the  sea  beach  and  in  those  villas  which 
have  been  rebuilt  or  remodelled  by  the  English.  But 
the  climate  out  of  doors  is  delightful  even  in  these 
two  months,  when  it  does  not  rain,  that  is,  for  more 
than  half  the  time.  Early  in  February  acres  of 
riolets  for  the  Paris  and  even  the  St.  Petersburg 
market  perfume  the  open  air,  where  they  grow  quite 
unprotected,  and  we  had  an  endless  supply  of  open 
air  roses  all  through  the  winter." 

Edward  O.   Otis. 


Albargin. — Gelatose  silver,,  prepared  by  evaporat- 
ing or  precipitating  a  mixture  of  nitrate  of  silver 
and  aqueous  solution  of  gelatose.  It  contains  about 
fifteen  per  cent,  of  silver.  It  occurs  in  the  form  of  a 
ciiarse,  yellow,  light  crystalline  pow'der,  readily 
soluble  in  water.  It  should  be  kept  in  the  dark. 
Ubargin  is  an  astringent  and  antiseptic,  employed 
an  intestinal  antiseptic,  and  as  a  substitute  for 
silver  nitrate  as  an  injection  in  gonorrhea.  For  the 
latter  purpose  solutions  of  0.1  to  1  per  cent,  strength 
are  employed,  the  stronger  solution  only  in  inveterate 

T.  L.  S. 

Albarran,  Joaquin. — Born  in  Sagua  la  Grande, 
Cuba,  on  August  22,  1S60.  His  preparatory  medical 
studies  were  carried  on  partly  in  Havana  and  partly  in 
Barcelona,  Spain.  In  1S77  he  removed  to  Paris  and 
devoted  himself  to  the  study  of  urology  under  Prof . 
Guyon  in  the  Necker  Hospital;  in  1S84  he  was  ap- 
pointed an  interne  in  this  hospital;  in  18S9  he  was 


awarded  the  faculty  prize  (a  gold  medal)  for  his 
graduating  thesis  on  " Les  reins  ih-^  urinaires"; 
in  1890  he  was  made  Chiei  of  the  Clinic  for  Diseases 
of  the  Uropoietic  System  and  in  1892  he  was  appointed 
"Professeur  agregeV'  From  1901  to  1906  he  was  Chief 
of  Service  in  another  hospital;  and  in  l'.x  iti  he  was  called 
to  succeed  Prof.  Guyon.  It  was  not  long,  however, 
before  he  began  to  show  signs  of  breaking  down 
under  the  heavy  strain  to  which  he  was  subjected. 
He  died  in  France  on  January  L8,  1912,  after  a  linger- 
ing illness  (t ubereulosis) . 

Of  his  contributions  to  medical  literature  the  follow- 
ing two  deserve  special  mention:  "Anatomic  et 
physiologic  pathologique  de  la  retention  de  l'urine" 
(in  association  with  Prof.  Guyon),  1890;  and  "Traits 
des  maladies  ehirurgicales  de  la  verge."   1896. 

A.  II.  B. 


Albert!,  Solomon. —  Born  in  Nuremberg,  Germany, 
in  1540;  studied  medicine  at  Wittenberg;  and  in  1575 
was  appointed  professor  of  physics.  Two  years  later 
the  chairs  of  physics  and  medicine  were  combined, 
and  Albert!  filled  the  position  acceptably  for  over 
twenty  years.  Having  been  chosen  by  the  Elector 
of  Saxony  as  his  chief  physician,  he  transferred  his 
residence  to  Dresden,  and  died  in  that  city  on  March 
29,  1600.  His  chief  distinction  rests  upon  the  fact 
that  he  was  honorably  esteemed  as  an  anatomist. 
According  to  Haller  he  was  the  first  to  publish  an 
actual  picture  of  the  valve  of  the  colon;  he  had 
drawings  made  of  some  venous  valves;  and  he  also 
furnished  more  complete  descriptions  of  the  anatomy 
of  the  tear  duets.  Portal  is  authority  for  the  state- 
ment that  Alberti  described  very  accurately  the  little 
bones  of  the  cranium,  the  discovery  of  which  some 
authors," insufficiently  informed,"  have  attributed 
to  Olaus  Worm.  Alberti  also  published  interesting 
researches  in  relation  to  the  brain,  the  sinuses  of  the 
dura  mater,  etc.;  and  he  described  the  anatomy  of 
the  ear  in  great  detail.  A.  H.  B. 

Albinism. — Synonyms:  Albinismus,  congenital 
achroma,  leucasmus,  leucoderma,  leueopathia,  leucism, 
leucosis,  leucynosis,  kakerlakism. 

The  term  albinism  (Latin,  albus,  white),  or  con- 
genital leueopathia  (Greek,  Xewcos,  white,  and  TzdOos, 
affection),  is  used  to  designate  the  peculiar  condition 
characterized  by  congenital  absence  of  pigment  in  the 
skin,  hair,  choroid,  and  iris,  and  which  is  classed  under 
the  atrophies.  Although  albinism  has  been  noted 
from  the  earliest  historical  period,  the  Portuguese 
are  the  first  on  record  to  have  named  this  lusus  naturce, 
which  they  met  now  and  then  among  the  negroes  on 
the  western  coast  of  Africa.  These  abnormal  indi- 
viduals they  called  albinoes.  In  some  of  the  African 
courts,  especially  in  Congo,  they  are  venerated  and 
are  known  as  "  dondos."  The  term  "leuca?thiopes", 
i.e.  white  negroes,  has  been  applied  to  them. 

Extensive  investigations  have  been  made  in  regard 
to  the  origin  of  pigment  in  the  skin.  Various  workers 
have  reached  the  conclusion  "that  the  pigment  in  the 
epithelial  cells  is  carried  there  by  special  connective 
tissue  cells  (chromatophores)  which  wander  up  to  or 
actually  in  between  the  epithelial  cells  to  supply  the 
pigment."  However,  still  later  work  gives  strong 
evidence  "  that  pigment  can  be  produced  without 
the  transfer  by  aid  of  chromatophores." 

Concerning  the  etiology  of  albinism  there  have  been 
numerous  theories  many  of  which  have  been  thor- 
oughly unscientific. 

Some  investigators  have  attempted  to  attribute  to 
albinism  a  pathological  origin.  Indeed,  in  early 
times,  albinoes  were  considered  a  sort  of  leper,  and 
consequently  were  avoided  and  shunned  in  life, 
while  after  death  the  bodies  were  throw-n  on  a 
dunghill  unburied.  On  account  of  their  faulty 
vision  by  day,  and  their  custom  of  appearing  most 

179 


Albinism 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


frequently  at  twilight,  since  their  sight  is  most  per- 
fect at  this  time,  they  were  contemptuously  called 
"  cockroaches." 

Consanguinity  in  marriage  has  been  considered  an 
etiological  factor,  an  example  being  noted  by  Darwin, 
in  which  "  two  brothers  married  two  sisters,  their 
first  cousins,  none  of  the  four  nor  any  relation  being 
an  albino;  but  the  seven  children  produced  from  this 
double  marriage  were  all  perfect  albinoes." 

A  theory  has  been  advanced  connecting  inactivity 
of  the  suprarenal  bodies  with  deficiency  in  pigment 
and  so  with  albinism. 

Also  excessive  function  of  the  carbon-eliminating 
organs  has  been  suggested  as  a  causative  factor,  as 
well  as  constitutional  insufficiency  of  iron. 

Albinism  has  been  ascribed  to  certain  disturbances 
of  the  nervous  system. 

The  affection  has  been  said  to  be  endemic  in  some 
tropical  countries. 

Maternal  impression  has  also  been  suggested  as  the 
cause. 

Another  theory  considers  that  the  formation  of 
pigment  may  be  due  to  the  action  of  a  ferment.  Con- 
sequently albinism  would  result  from  the  absence  of 
this  ferment. 

The  theory  of  arrested  development  must  be  true 
in  a  certain  sense  but  nevertheless  it  does  not  account 
for  anything.  "  If  the  distinction  between  the  nor- 
mal and  the  albinotic  be  assumed  to  be  an  absence  of 
pigment,  and  if  pigmentation  normally  begins  to 
appear  during  fetal  life,  then  albinism  is  distinctly 
an  arrest  of  development."  This  theory  merely  asserts 
"  that  albinism  is  a  pre-natal  defect,  not  excess,  of 
development.  It  is  quite  consistent  with  any  modern 
theory  which  asserts  that  albinism  is  due  to  the 
absence  of  one  or  more  development  controlling 
determinants  in  either  one  or  both  parents.  It  is 
little  more  than  the  statement  of  an  obvious  fact,  as 
far  as  concerns  pigmentation." 

Heredity,  as  the  chief  etiological  factor  in  albinism, 
has  been  as  vigorously  upheld  as  it  has  been  sharply 
attacked.  There  are  instances  on  record  of  families 
of  albinoes.  These  are  very  rare,  however,  and  have 
been  said  to  be  observed  only  in  the  tropics.  It  is 
well  known  that  the  offspring  of  an  albino  and  a  black 
is  generally  the  pure  type — either  universal  albino  or 
black;  though  some  cases  of  partial  albinoes  have 
been  reported.  However,  the  children  of  a  normally 
pigmented  individual  and  an  albino  are  usually  not 
lacking  in  pigment.  Also  healthy,  normal  parents 
have  had  albino  offspring.  In  several  instances 
families  have  been  observed  in  which  universally 
pigmented  children  have  alternated  in  birth  with 
albinoes. 

A  very  recent  hy-pothcsis  advanced  is  "  that  albin- 
ism is  an  hereditary  defect  of  structure,  and  possibly 
only  of  superficial  tissue  structure,  which  interferes 
with  the  normal  metabolic  process  by  which  pigment 
is  produced  and  stored.  The  absence  of  pigment  is 
a  secondary  result  of  the  albinotic  structure,  and  not 
the  primary  source  of  the  albinotic  constitution. 
The  delicacy  and  thinness  of  the  albinotic  tissues, 
their  resulting  increased  vulnerability,  and  diminished 
resistance  to  thermal,  luminous,  and  mechanical  in- 
fluences are  not  solely  due  to  the  absence  of  pigment; 
it  is  suggested  that  they  mark  a  differentiated  tissue 
structure  on  which  the  absence  of  pigment  itself 
depends.  There  are  many  ways  by  which  this 
hypothesis  can  be  tested,  and  such  tests  will  be 
fruitful  even  if  the  hypothesis  has  to  be  dis- 
carded." (Draper's  Company  Research  Memoirs, 
Biometric  Series  vi.) 

Casting  aside  first  the  theory  that  albinism  is  a 
disease  ami  secondly  the  theory  of  arrest  of  develop- 
ment, and  accepting  as  the  only  or  at  least  the  chief 
source  of  albinism  "the  inheritance  of  an  abnormal 
tissue1  structure,"  we  are  then  in  a  position  to  put 
albinism  in   the  category  of  "other  forms  of  inheri- 


tance of  abnormal  structure."  In  addition,  we  shall 
be  able  to  put  the  hypothesis  to  proof  "  by  ascertaining 
whether  its  inheritance  follows  the  same  laws' 
All  facts  being  considered,  we  may  conclude  that  "  the 
essential  pathological  characteristic  of  albinism"  j~ 
not  the  mere  absence  of  pigment  but  the  condition 
of  the  tissues  lacking  pigment — in  other  words,  tin- 
texture  of  these  structures. 

As  to  the  sex  in  which  albinism  most  frequently 
occurs,  both  male  and  female  seem  to  be  equally  repre- 
sented, different  authors  inclining  toward  one  or  the 
other  according  to  their  individual  observations. 

Albinoes  have  been  known  in  all  climates  and  among 
all  races.  Albinism  is  more  common  in  colored  than 
in  white  races. 

Albinism  may  be  universal  or  partial.  In  univer- 
sal albinism  the  appearance  of  the  individual  is  very 
striking.  The  skin  is  absolutely  lacking  in  pigment, 
though  there  is  sometimes  a  slight  reddish  tinge  from 
the  circulating  blood  underneath  the  translucent  sur- 
face, the  characteristic  complexion  having  a  dull 
waxen  pallor.  The  skin  is  often  roughened,  scaly,  or 
scurfy,  a  condition  which  is  easily-  explained  by  it. 
extreme  delicacy  of  structure  and  the  consequent 
effects  of  its  exposure.  It  is  often  covered  with  a 
soft  white  down,  though  sometimes  it  is  perfectly 
smooth. 

The  whole  hairy  system  is  colorless.  This  may  he 
due  to  the  absence  of  iron  in  its  composition,  as  in 
the  chemical  analyses  of  hair  of  various  colors,  made 
by  the  French  chemist  Vauquelin,  black  hair  has  been 
proved  to  contain  iron,  while  white  hair  lacks  this 
element.  The  texture  is  peculiarly  fine,  glossy,  and 
silky.  Although  the  hair  is  colorless,  its  appearance 
is  not  that  of  hair  whitened  by  age,  but  rather  that  of 
flax  or  corn  silk.  There  is  one  case  on  record  of  an 
albino  having  red  hair  (Folker).  In  the  albinoes  of  the 
black  race,  the  hair,  though  white,  is  as  woolly  and 
the  features  as  characteristic  as  those  of  their  black 
brothers. 

Although  the  appearance  of  the  eye  in  this  condi- 
tion differs  so  widely  from  the  normal,  "the  patho- 
logical significance  of  albinism  lies  solely  in  the  fart 
that  the  iris  or  diaphragm  of  the  ocular  camera  is 
transparent,  or  so  nearly  so  that  it  does  not  act  as  a 
true  photographic  or  physiological  diaphragm'' 
(Gould).  This  deficiency^  of  ocular  pigment  brings  in 
its  train  much  pain  and  discomfort.  The  usual  color- 
ing matter  of  the  eye  being  absent,  the  pupil  looks 
bright  red  from  the  rich  background  of  blood-vessel-, 
and  the  iris  light  pink  or  a  very  delicate  blue,  tin 
variations  in  tint  depending  upon  the  angle  of  observa- 
tion and  the  nature  of  the  illumination.  Photople 
is  present  in  the  highest  degree,  the  characteristic 
position  of  the  albino  in  daylight  showing  him  with 
one  arm  held  up  as  a  shield  for  the  eyes.  There  is 
perpetual  nictitation — rapid  and  repeated  motion  of 
the  transparent  eyelids,  which  open  and  shut  con- 
tinually in  the  double  effort  to  see,  and  at  the  same 
time  to  exclude  the  overpowering  amount  of  light 
which  has  free  access  to  the  inner  parts  of  the  eye 
The  iris  is  constantly  expanding  and  contracting. 
Nystagmus,  or  oscillation  of  the  eyeballs,  which  is 
present,  is  due  to  the  effort  to  obtain  a  clearer  vv« 
of  the  objects  of  vision.  Amblyopia  is  a  serious  fea- 
ture in  albinism,  various  causes  cooperating  to  pro- 
duce it — viz.,  ametropia,  which  increases  with  the  age 
of  the  albino,  and  which  is  due  to  pressure  on  the  i 
ball  in  the  effort  to  exclude  light,  retinal  exhaust  i 
and  nystagmus.     Myopia  is  also  common. 

It  has  been  generally  supposed  that  albinoes  are 
weak  both  in  bocty  and.  in  mind,  but  this  is  by  no 
means  always  true.  Often  the  albino  member  of  :i 
family  has  been  intellectually  the  strongest,  many  el 
these  unfortunates  being  particularly  shrewd. 

Partial  albinism,  more  common  in  negroes  than  in 
white  people,  is  observed  as  one  or  more  patches, 
colorless  or  pinkish,  generally  circumscribed  and  ir- 


I.SII 


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Albuminuria 


regular,  of  any  size  or  form.     Instances  have  been 
noted,  however,  in  which  these  patches  were  sym- 

trically  disposed,  corresponding  to  the  course  of 

peripheral  nerves,  as  similarly  happens  in  the  case 
of  certain  pigmentary  and  verrucose  nsevL      They  may 
be  in  any  pari  of  the  body,  being  most  c< non,  how- 
ever on  the  scalp,  face,  dorsal  surface  of  the  hands, 
pies,  and  genital  region.      The  hair  on  these  spots 
,  nerally    while.      The    eyes   are    usually    normal, 
bowing   the   ordinary   amount    of   pigment,    though 
I   may  be  bluish  or  pinkish.     Negroes  having  this 
affection  are  called  pied  or  piebald.      The  hair  is  flaxen 
,,l.     These  patches  generally  remain  permanent 
iugh  life,  or  they  may  gradually  extend  (ill  they 
include  a  large  surface;    they  have  been   known   to 
change  to  a  normal  appearance  through  a  redepdsi- 
tion  of  pigment,  although  this  is  rare. 

Work  by  the  most  recent  investigators  calls  atten- 

iii  "the  relative  rareness  of  complete  albinism, 

ie  spotted  or  splashed  condition,  and  of  xanthisin, 

and  their  relatively  frequent  coincidence  in  the  same 

L."     Such  conditions  would  seem  to  point  to  the 

that   these  abnormalities   of  pigment  conditions 

arc   not    entirely   independent.      It   may  be  accepted 

reasonable  working  hypothesis  that  these  various 

conditions  complete,   partial,   and  incomplete  albin- 

and  xanthism,  "all  static  forms  of  leucosis,  are 

phases  of  tin'  same  process  and  are  probably  linked 

«  ith  leucoderma  and  possibly  other  forms  of  dynamic 

losis In    albinism    as  in   many   other 

defects,  we  find  equivalence  or  interchangeability  of 
dity."    These  workers  look  forward  to  still  further 
-ligation  of  this  subject  from  the  various  stand- 
>f  pathology,  physiology,  and  genetics. 
Albinism  has  been  noted  not  only  in  man,  but  also 
in  the  lower  animals,  and  among  plants,  a  very  com- 
mon example   among   animals   being   the   pink-eyed 
white  rabbit.     It  is  seen  in  elephants,  otters,  horses, 
cows,  hogs,  dogs,  cats,  squirrels,  rats,  mice,  raccoons, 
ferrets,  hooting  owls,  leather-wing  bats,  doves,  chick- 
ens, pigeons,   parrots,    blackbirds,    robins,    martins, 
swallows,  sparrows,    and  the  silver   variety  of  gold- 
fish.   Some  animals  become  white  physiologically  in 
winter.     This  is  not  an  example  of  true  albinism. 

It  lias  been  suggested  that  the  etiolation  of  plants 
kept  in  the  dark  may  belong  in  the  same  category, 
but  this  differs  from  persistent  lack  of  pigment,  since 
color  returns  on  exposure  to  light. 

As  to  the  therapeutics  of  albinism — there  is  abso- 
lutely no  remedy  for  the  affection. 

Emma  E.   Walker. 


Albinus,  Bernard  Siegfried. — Born  at  Frankfort-on 
-the-Oder,  Germany,  February  24,  1697.  The  fam- 
ily name  was  Weiss,  but  at  some  period  of  the  six- 
teenth century  it  was  latinized  into  Albinus.  The 
father  of  Bernard  Siegfried  and  his  two  brothers 
(Christian  Bernard  and  Jakob)  were  all  of  them 
physicians  of  considerable  distinction.  Bernard 
Siegfried  studied  medicine  at  the  University  of  Leyden, 
Holland.  From  the  very  beginning  he  showed  a 
strong  predilection  for  anatomy  and  botany,  branches 
of  medical  science  which  were  then  being  taught  at 
Leyden  by  Boerhaave  and  Rail.  In  October,  1719, 
he  was  chosen  Instructor  in  Anatomy  by  the  Faculty, 
the  degree  of  Doctor  of  Medicine  having  been  given 
to  him  only  a  short  time  previously.  Two  years 
later  he  was  made  Professor  of  Anatomy  and  Surgery 
in  the  same  university.  In  1726  he  published  his 
treatise  on  osteology,  and  he  was  engaged,  at  about 
the  same  period,  in  assisting  Boerhaave  in  the  prep- 
aration of  an  edition  of  the  works  of  Vesalius.  In 
1734  he  published  his  History  of  the  Muscles  of  the 
Human  Body,  a  work  which  was  remarkable  in  at 
least  two  respects:  it  was  most  beautifully  illustrated, 
and  the  individual  figures  were  drawn  with  great 
delicacy   and   with   almost   perfect   correctness.     In 


L736  and  1 7: ;7  he  published  two  other  works  of 
importance — a   treatise   on    the    veins   and   arteries 

of    the    intestines,    and    one    on    the    seal    of    the    color 

of  the  skin  in  negroes  and  other  dark-skinned  raci 

and  on  the  causes  of  this  coloration.  In  17".s  lii- 
was  chosen  Boerhaave's  successor  as  President  of 
the  College  of  Surg is  al    Leyden,  and    he  was  also 

(for  the  second  time)  made  Rector  of  i  he  University. 
In  addition  to  all  his  other  work  Albinus,  during 
this  very  busy  period  of  his  life,  never  lost  sight  o£ 
the  two  undertakings  which  he  considered  of  the 
greatest  importance — viz.,  the  preparation  and 
publication  of  a  commentary  on  the  anatomical 
plates  of  Eustachius,  and  the  construction  of  his 
ow  n  large  plates. 

As  the  health  of  Albums  was  beginning  to  be 
affected  injuriously  by  his  spending  such  a  large 
proportion  of  his  time  in  the  atmosphere  of  the  dis- 
secting-room, the  curators  of  the  university  made 
him  Professor  of  Medicine  in  174").  His  younger 
brother  was  appointed  his  successor  in  the  Chair  of 
Anatomy.  Bernard  Siegfried  Albinus  died  Septem- 
ber 9,  1770. 

Of  his  fairly  numerous  contributions  to  medical 
literature  the  following  deserve  to  receive  special 
mention:"  De  ossibus  corporis  humani  ad  auditores 
suos  libellus,"  Leyden,  1726  (reprinted  in  1762); 
"  Historia  musculorum  corporis  humani,"  Leyden, 
1734  (Frankfort,  1784);  "Dissertatio  de  arteriis  et 
venis  intestinorum  hominis,"  Leyden,  1736  and  173S; 
"Dissertatio  secunda  de  sede  et  causa  coloris  jEthi- 
opum  et  ca?terorum  hominum,"  Leyden,  1737; 
"  Icones  ossium  foetus  humani:  aecedit  osteogenic 
brevis  historia,"  Leyden,  1737;  " Explicatio  tabularum 
anatomicarum  Barthol.  Eustachii,"  Leyden,  1744 
and  1761;  "Tabuke  sceleti  et  musculorum  corporis 
humani,"  Leyden,  1747;  "Tabulae  ossium  humah- 
orum,"  Leyden,  1753;  and  "  Academicarum  annota- 
tionum  libri  VIII,"  Leyden,  1754-1768. 

A.  H.   B. 

Albucasis    (Abul-Casem-Khalaf-Ebn-Abbas.) — The 

last  one  of  the  Arabian  physicians  whose  writings  have 
been  preserved  up  to  the  present  time  in  the  form  of 
Latin  translations.  He  was  born  in  Zahara,  near 
Cordova,  Spain,  reached  the  period  of  his  greatest 
celebrity  at  the  beginning  of  the  twelfth  century,  and 
died  in  1122.  According  to  the  opinion  of  Schenck, 
stated  in  his  "  Biblia  iatrica,"  Albucasis  and  Alsa- 
haravius  were  one  and  the  same  person.  The  great 
treatise  on  the  theory  and  practice  of  medicine  (en- 
titled "al  Tasrif"),  which  is  commonly  accredited  to 
Alsaharavius,  is  therefore  the  work  of  Albucasis. 
While  parts  of  the  book  have  gone  through  numerous 
editions  (1471-1602),  the  work  as  a  whole  has  been 
printed  only  three  times.  Albucasis  was  the  first  to 
describe  the  affection  popularly  termed  "milk*tetter" 
(crusta  lactea),  the  symptom  known  as  dysphagia, 
and  mercurial  salivation;  and  he  was  also  familiar 
with  tetanus,  smallpox,  the  aphthous  affections  of 
childhood,  and  a  variety  of  mental  disorders.  "  But 
his  three  books  on  surgery  constitute  one  of  the  most 
precious  monuments  of  the  twelfth  century."  (Dic- 
tionnaire  historique  de  la  medecine,  etc.)       A.H.B. 

Albuminuria. — Albumin  is  a  normal  constituent  of 
human  urine  in  the  same  sense  as  is  glucose,  that  is, 
neither  can  be  demonstrated  in  the  renal  secretion 
by  ordinary  clinical  tests  but  both  are  found  in  traces 
when  the  urine  is  subjected  to  refined  methods  of 
examination.  This  normal  albuminuria,  clinically 
of  no  interest  whatsoever,  is  not  analogous  to  that 
which  Senator,  for  instance,  understands  by  "physi- 
ological albuminuria"  when  he  declares  that_  the 
increase  of  urinary  albumin  ensuing  after  consider- 
able bodily  exercise,  a  diet  rich  in  proteins,  cold 
baths,   and   during   menstruation  is  a  physiological 

181 


Albuminuria 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


phenomenon.  Senator  evidently  does  not  consider 
the  facts  that  physiological  circumstances  may  give 
rise  to  pathological  effects,  and  that  the  frequency  of  a 
pathological  occurrence  is  not  a  criterion  by  which 
its  physiological  character  can  be  determined.  En- 
demic goiter  for  instance,  so  frequent  in  certain  moun- 
tainous districts  and  of  probably  pure  physiological 
causation,  is  nevertheless  a  disease,  and  it  occurs  to 
nobody  to  describe  it  as  a  physiological  manifestation. 

The  conception  of  Senator  is  shared  by  other 
authors  who  assign  to  physiological  albuminuria  a 
wider  scope  than  can  be  conceded  by  him  who  rea- 
sons by  analogy.  If,  for  instance,  the  output  of 
glucose  by  the  urine  be  ever  so  small  in  a  clinical 
sense,  the  trained  observer  will  never  designate  it 
as  a  physiological  occurrence.  He  may  accept  a 
normal  glycosuria  in  the  same  sense  as  I  admit  the 
possibility  of  a  normal  albuminuria,  for  glucose  will 
invariably  be  detected  in  large  amounts  of  artifi- 
cially concentrated  urine,  but  he  will  never  speak 
of  a  physiological  glycosuria  if  he  discovers  sugar 
in  the  native  urine  by  his  every-day  reagents. 

Withal,  no  evidence  has  as  yet  been  brought  forth 
that  the  protein  substance,  excreted  in  tangible 
amounts  after  bodily  or  psychical  exertion,  is  iden- 
tical with  the  protein  which  is  present  in  every  urine. 
The  true  character  of  the  latter  is  not  only  unknown, 
but  there  is  also  sufficient  proof  that  we  do  not  always 
have  to  deal  with  the  same  albumin  body,  and  that 
there  may  occur  diverse  kinds  of  protein,  succes- 
sively or  together,  in  the  manifold  forms  of  so-called 
physiological  albuminuria. 

Normal  albuminuria  is  a  fact,  but  it  is  and  re- 
mains an  academic  issue  as  far  as  the  practitioner  is 
concerned.  Whenever  albumin  can  be  demon- 
strated in  the  native  urine  by  the  ordinary  clinical 
methods,  we  are  confronted  with  an  abnormal  con- 
dition. Normal  albuminuria  is  the  only  feasible 
physiological  albuminuria,  and  every  albuminuria 
recognized  by  routine  examination,  and  be  it  ever  so 
slight  or  evanescent,  is  an  abnormal  albuminuria. 

Clinical  Albuminuria. — Clinical  albuminuria  is 
always  a  tangible  fact.  It  is  due  to  the  appearance 
in  the  urine  of  one  or  more  proteins,  in  the  vast  ma- 
jority of  instances  of  dissolved  serum  albumin  together 
with  serum  globulin  (paraglobulin).  The  native 
serum  proteins  do  not  always  occur  in  the  urine  in  the 
relative  amounts  in  which  they  exist  in  the  blood 
serum  wherein  they  are  found  on  the  average  in  the 
proportion  of  two  parts  of  globulin  to  three  parts  of 
albumin.  As  a  rule  the  serum  albumin  preponder- 
ates in  the  general  run  of  chronic  cases  of  albumi- 
nuria, but  a  genuine  serinuria  (the  excretion  of  serum 
albumin  alone)  is  an  exceedingly  rare  occurrence. 
In  maivy  instances  of  acute  nephritides,  on  the  other 
hand,  globulin  seems  to  be  the  prevailing  urinary 
protein.  As  a  matter  of  course,  we  treat  now  and  in 
the  following  pages  of  genuine  albuminuria  only, 
and  not  of  the  spurious  variety  which  is  the  result 
of  the  admixture  of  adventitious  protein  substances 
like  pus,  lymph,  blood,  prostatic  secretion,  etc., 
with  a  urine  that  was  free  from  protein  material 
when  it  had  just   traversed   the  renal  parenchyma. 

While  clinical  albuminuria  in  itself  is  an  abnormal 
incident,  it  is  no!  of  necessity  the  result  of  a  demon- 
strable pathological  state.  True  enough,  at  its  foun- 
dation, especially  if  it  be  of  a  chronic  nature,  stands 
very  frequently  a  permanent  structural  lesion,  but 
then  it  is  invariably  associated  with  a  chain  of  more 
or  less  pronounced  pathological  features  which  have 
a  definite  significance  in  the  majority  of  the  cases. 
However,  when  the  albuminuria  is  the  most  prominent 
or  even  the  only  abnormal  phenomenon,  the  true 
state  of  affairs  underlying  it,  for  the  reason  that  it  is 
often  of  a  functional  and  not  an  anatomical  charac- 
ter, is  disclosed  in  a  comparatively  small  number 
of  instances  only.  Albuminuria  without  ascertain- 
able cause  may  be  transitory,  as  is  frequently   the 

182 


case;  it  may,  however,  tend  to  recurrence  or  may 
be  persistent.  Albuminurics  of  this  class  may  enjoy 
the  best  of  health,  and  their  metabolic  equilibrium 
is  often  perfectly  maintained  for  long  periods  They 
may  attain  a  good  old  age,  and  they  generally  die 
from  other  than  renal  diseases.  The  albuminuria, 
and  may  it  be  ever  so  evanescent,  is  nevertheless  an 
abnormal  occurrence,  and  even  if  its  cause  be  not 
determinable  by  the  clinical  means  at  our  disposal 
a  cause  there  must  be. 

Medical  writers  generally  differentiate  between 
"functional"  and  "pathological"  albuminurias.  How- 
ever, the  clinical  albuminurias  are  of  necessity  abnor- 
mal circumstances,  for  were  it  not  so,  why  does  not 
every  urine  exhibit  ascertainable  amounts  of  albu- 
min? All  "functional  albuminurias,"  the  scope  of 
which  has  heretofore  been  too  narrowly  drawn,  are 
albuminurias  of  pathological  function;  they  are  just 
as  pathological  as  the  "pathological  albuminurias" 
of  former  writers.  The  only  difference  between  tin 
albumin  output  of  these  two  arbitrary  forms  of  albu- 
minuria is  possibly  that  of  degree;  this,  however,  is 
not  invariably  the  fact. 

The  greater  part  of  this  encyclopedic  statement 
is  devoted  to  a  discourse  of  the  group  of  albumi- 
nurias at  the  foundation  of  which  there  apparently 
stands  one  or  the  other  perverted  physiological 
function.  Albuminuria  symptomatic  of  structural 
disease,  sufficiently  understood  by  the  practitioner 
even  if  only  on  account  of  the  accompanying  clinical 
features,  is  dealt  with  in  a  casual  manner  only. 
Renal  affections,  as  such,  are  not  dwelt  upon  at  ail, 
neither  are  the  other  diseases  during  the  course  or  in 
the  wake  of  which  albuminuria  may  supervene. 

Albuminuria  Due  to  Patholoqical  Function. — By 
albuminuria  due  to  pathological  function  is  under- 
stood the  occurrence  in  the  urine  of  clinically  deter- 
minable amounts  of  serum  albumin  and  serum  glob- 
ulin in  the  absence  of  any  demonstrable  anatomical 
disease  of  the  kidneys.  This  group  includes,  however, 
albuminurias  which  are  the  result  of  malposition  of, 
and  undue  traction  or  pressure  upon  an  otherwise 
normal  kidney.  In  the  latter  instance  the  albumin- 
ous urine  is  not  infrequently  excreted  by  one  kidney 
only.  Besides  the  albumin,  the  urine  of  this  group 
of  albuminurias  generally  exhibits  no  abnormal 
features.  The  diurnal  amount  of  the  excreted 
albumin  varies  greatly  and  may  be  considerable, 
but  does  not  exceed  one  or  two  grams  in  the  majority 
of  cases.  In  the  presence  of  a  definite  renal  lesion,  on 
the  other  hand,  the  twenty-four  hours' urinary  albumin 
output  usually  amounts  to  from  five  to  ten  grains  and 
may  exceptionally  attain  a  much  higher  figure. 

A  transient  albuminuria  may  obtain  in  a  healthy 
individual  without  any  recognizable  cause.  E 
such  cases  must  be  considered  as  the  result  of  a  patlio- 
logical  function  inasmuch  as  there  is  no  physiological 
albuminuria  which  is  clinically  demonstrable.  No 
matter  how  insignificant  and  fleeting  the  exciting 
cause  it  must  have  been  of  sufficient  impetus  to  give 
rise  to  a  disturbance  of  function  somewhere  in  the 
organism.  A  long-continued  functional  disturbanci 
may  develop  into  a  state  of  pathological  physiology  in 
which  the  abnormal  phenomenon — in  this  instance  the 
albuminuria — bears  less  a  frankly  pathological  than  a 
compensatory  character.  Many  functional  albumi- 
nurias are  compensatory  manifestations  of  some  non- 
renal deficiency  or  disturbance.  The  "compensatory 
albuminurias,"  as  the  writer1  has  termed  them, 
although  not  pointing  to  a  kidney  affection  are,  no 
theless,  of  a  decidedly  clinical  nature. 

Compensatory  Albuminuria. — The  various  transi- 
tory types  of  albuminuria  have  been  considered  by 
some  to  reflect  a  specific  or  latent  form  of  nephritis 
while  others  have  viewed  it  as  an  expression  of  a  tem- 
porary disturbance  of  renal  function.  Langstein's 
autopsy  findings  have  finally  done  away  with  the  first 
assumption,  at  least  so  far  as  the  orthotic  type  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Albuminuria 


dbuminuria  is  concerned;  the  latter  supposition 
nerely  substitutes  a  derangement  of  renal  activity 
or  aii  anatomical  renal  lesion — a  conjecture  which 
loes  not   bring   us   one  step   nearer   the   solution    of 

ted  question. 

\n   albuminuria   cannot    ensue   if   the   cells   of    the 
cidney  are  impermeable  for  the  large  albumin  molecule. 
We  know,  however,  that  the  structurally  sound  renal 
nembranes  permit  under  certain  circumstances  the 
lassage  of  albumin  from  the  blood  current   into  the 
Is  this  transudation  of  the  large  albumin  mole- 
through  the  normal  kidney  membranes  referable  to 
oerted  function  or  to  a  compensatory  response  of  the 
i.e.  is  the  o Hi ii  miliaria  due  to  deficiency  or  efficiency 

,  rial  action;  to  a  renal,  exclusively  local,  functional 
\\  eoiii/n  li  neij  or  to  anterenal  pathological  influences  .' 

The  kidneys  regulate  the  composition  of  the  blood. 
When  their  work  is  not  interfered  with  the  amount  of 

-  arii his  urinary  constituents  ordinarily  reflects  the 

omparative  quantity  in  which  the  same  substances 

have  existed  in  the  blood.     However,  when  the  renal 

activity  is  lowered,  be  it  on  account  of  functional  or 

rphological  circumstances,  there  will  be  retention 

ol    the  urine-making  substances  in  the  blood  and  a 

lortional  deficiency  of  them  in  the  renal  secretion. 

lertony  of  the  blood  plasma  in  the  presence  of 

idly  functionating  kidneys  can  be  only  a  transi- 
tory occurrence,  and  if  there  be  a  hypotony  of  the 

ma   tin'  regulatory  function  of  the  kidneys  will 

ion  correct  it.     Thus,  the  kidneys  tend  to  maintain 

a  rather  definite  concentration  and  osmotic  tension  of 

the  blood  for  every  period  of  life.     Substances  which 

contained  in  excess  or  are  foreign  to  the  blood 
invariably  reach  the  kidneys  whence  they  are  elimi- 
ited.     (While  water  and  the  normal  catabolic  prod- 
ucts do  not  alter  the  constitution   of   the    sensitive 
renal  membranes,  blood-foreign  material  is  liable  to 

t  the  function  of  the  renal  cells  and  may  cause 
their  structural  damage  if  large  amounts  of  it  are 
continuously  brought  in  contact  with  them  through 
the  medium  of  the  circulation).  This  fact  again 
demonstrates  the  blood-regulative  ability  of  the 
kidneys,  and  also  evinces  that  the  appearance  in  the 
urine  of  certain  so-called  pathological  substances  is 
not  of  necessity  due  to  diseased  excretory  organs,  but 
that  it  may  be,  on  the  contrary,  a  manifestation  of 
their  healthy  and  vigorous  condition. 

The  occurrence  of  albumin  in  the  urine  in  the  pres- 
of  structurally  sound  and  functionally  efficient 
kidneys  must  be  designated  as  a  regulatory  act  of  the 
litter.  By  their  regulatory  capability  the  renal 
organs  tend  to  compensate  for  the  insufficiency  of 
those  organs  which  have  permitted  entrance  into  the 
circulation  of  blood-foreign  albumin,  or  to  the  incom- 
petency of  which  is  due  a  peculiar  physicochemical 
blood  composition,  demonstrating  itself  in  the  defi- 
cient power  i'f  attaching  the  absorbed  protein  material. 
In  a  limited  sense,  that  is  as  far  as  the  interchange 
between  blood  and  urine  is  concerned,  we  may  speak 
nf  regulatory  albuminuria;  in  so  far,  however,  as  the 
blood-foreign  protein  or  the  abnormal  blood  compo- 
sition  is  the  outcome  of  perverse  metabolic  processes, 
we  are  justified  in  describing  the  resulting  albumi- 
nuria  as  compensatory    in    character.      While,    as   a 

ter  of  course,  a  non-nephritic  albuminuria  cannot 
ensue  without  renal  regulatory  activity,  the  causative 
factors  of  compensatory  albuminuria  are  anterenal 
in  time  as  well  as  location,  and  are  entirely  independ- 
ent of  the  kidneys.     The  designation  "compensatory 

inintiria"  is  therefore  much  more  comprehensive 
mid  expressive  than  either  the  terms  "regulatory 
albuminuria,"  chosen  by  Rosenbach,  or  "hematogenic 
albuminuria,"  propounded  by  Bamberger.  Although 
regulatory  albuminuria  corresponds  in  many  respects 
with  compensatory  albuminuria,  its  most  distinctive 
factor  is  deemed  to  be  the  regulatory  function  of  the 
kidneys,  while  the  conception  of  compensatory  albumi- 
nuria sees  in  the  regulatory  activity  of  the  kidneys 


not  a  selective-voluntary,  but,  more  properly,  a  com- 

pulsatory  operation.  On  the  other  hand,  the  rather 
indefinite  so-called  hematogenic  albuminuria  (</  <  I, 
which  does  not  go  beyond  an  altered  condition  of  the 
blond    as    the    prime    factor   in    the    production   of   the 

albuminuric  phenomenon,  conforms  but  in  few  points 
to  (he  definite  and  comprehensive  scope  of  compensa- 
tory albuminuria. 

An  albuminuria  may  be  designated  to  be  of  a  com- 
pensatory nature  when  the  quantitatively  and  quali- 
tatively entirely  normal  urine  contains  albumin  with- 
out the  presence  of  renal  inflammatory  products,  oil 
globules,  connective-tissue  shreds,  casts,  and  particu- 
larly of  more  than  a  few  isolated  renal  epithelia.  The 
urine  in  compensator}'  albuminuria  exhibits  a  normal 
density  and  the  aggregate  of  solids  eliminated  by  it  is 
proportional  to  the  intake,  if  the  end-products,  which 
would  have  been  yielded  had  the  albumin  not  been 
excreted,  be  taken  into  due  account.  It  is  evident 
that  the  kidneys  while  responding  to  corrective 
demands  exert  increased  activity,  and  it  is  also  evi- 
dent that  only  healthy  and  strong  excretory  organs  can 
undertake  and  perform  the  task  of  eliminating  incom- 
pletely or  perversely  converted  protein  or  such 
albuminous  material  which  is  not  sufficiently  fastened 
to  the  blood.  However,  if  the  additional  burden 
becomes  too  heavy  or  if  the  supplementary  activity  is 
continued  over  a  protracted  period,  the  kidneys  may  be 
rendered  functionally  insufficient  after  a  time  and  in 
some  instances  may  even  become  structurally  affected. 
The  primary  changes  accruing  in  the  kidneys  after 
excessive  renal  activity  are  of  a  reactive  nature,  that 
is,  they  are  due  to  a  more  or  less  marked  exhaustion 
of  the  secreting  apparatus,  or,  in  other  words,  to 
trophic  disturbances.  The  excretory  work  of  a  set  of 
functionally  exhausted  kidneys  is,  of  course,  propor- 
tionally less  than  that  of  competent  organs.  The 
total  urinary  solids  are  diminished  to  a  greater  or 
lesser  degree,  and  this  may  be  also  the  case  with  the 
urinary  water.  The  general  relaxation  of  the  secern- 
ing renal  cells  permits  the  transudation  of  albumin 
from  the  plasma  into  the  urine,  an  occurrence  which 
prior  to  kidney  exhaustion  was  accompanied  by  en- 
forced renal  activity. 

There  may  be  a  period  during  the  enfeebled  renal 
state  when  the  relative  and  absolute  amounts  of 
excreted  albumin  are  actually  reduced.  This  dimin- 
ution of  urinary  protein  is  generally  looked  upon  as 
an  improvement  of  the  renal  condition;  in  reality, 
however,  it  may  denote  precisely  the  opposite,  i.e. 
renal  deterioration.  At  a  later  period,  when  the 
structural  alteration  of  the  kidneys  has  progressed 
to  a  certain  degree,  the  albumin  output  is  again 
increased,  becoming  in  all  likelihood  larger  than  ever 
before.  Still,  it  is  a  question  whether  the  structural 
renal  changes  following  long-continued  or  excessive 
excretion  of  albumin  attain  the  nature  of  a  genuine 
nephritic  process.  The  inflammatory  stage,  or  what 
may  be  considered  such,  runs  very  often  a  mild  and 
rapid  course,  and  the  patients  may  actually  feel 
better  while  it  supervenes  than  during  the  period  of 
functional  renal  insufficiency  without  organic  alter- 
ation. It  is  even  plausible  that  an  eventual  inflam- 
matory stage  after  renal  exhaustion — a  temporary 
occurrence  in  many  instances — is  itself  a  compensa- 
tory process  enabling  the  kidney  to  resume  some  of 
its  regulatory  activity  after  the  inflammation  has 
run  its  course. 

Alterations  in  the  exchanging  membranes  in  the 
kidneys  may  be  the  mediate  result  of  a  protracted 
compensatory  albuminuria,  but  there  is  no  renal 
lesion  which  stands  at  the  foundation  of  the  com- 
pensatory albuminuria.  The  primary  cause  of  the 
latter  is  seemingly  always  of  a  functional  nature  and 
is  situated  in  the  organs  concerned  in  the  general 
metabolism,  and  more  especially  in  those  partici- 
pating in  the  process  of  blood-making.  The  immedi- 
ate cause  of  the  albuminuria  is  either  a  surplus  of 


183 


Albuminuria 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


circulating  albumin  or  the  inability  of  the  blood  to 
attach  to  itself  certain  albuminous  material  which 
has  entered  the  circulation.  If  the  binding  qualities 
of  the  blood  for  albumin  are  of  a  normal  degree,  and 
if  the  albumin  is  not  admitted  to  the  blood-current 
in  too  great  amounts,  it  will  be  brought  to  the 
various  tissues  whence,  after  successive  stages  of 
oxidation,  it  will  again  be  taken  up  by  the  blood  in 
the  form  of  urea,  the  normal  end-product  of  intra- 
systemic  albumin  disintegration.  In  the  majority 
of  instances,  therefore,  an  overabundance  of  cir- 
culating albumin  will  hardly  give  occasion  to  com- 
pensatory albuminuria.  A  peculiar  chemicophysical 
slate  of  the  blood,  on  the  other  hand,  seems  to  be 
nearly  always  the  direct  cause  of  the  compensatory 
albuminuric  phenomenon.  Rosenbach  has  already 
drawn  attention  to  this  point.  Normal  blood  is 
unable  to  bind  certain  blood-foreign  proteins,  as  egg 
albumin,  casein,  albumoses,  etc.;  they  are  eliminated 
by  the  normal  kidneys,  some  quite  rapidly,  others, 
like  the  albumoses,  after  having  accumulated  to  some 
degree  in  the  blood.  Blood  possessing  only  limited 
combining  qualities  for  blood-assimilable  albumin 
will  lose  a  portion  of  it  in  its  native  state  by  way  of 
the  kidneys.  Such  blood  cannot  transport  to  the 
tissues  all  the  albumin  which  had  been  admitted  to 
the  circulation,  although  its  amount  may  have  been 
perfectly  normal.  The  natural  result  of  this  inability 
of  the  blood  will  be  the  excretion  of  a  diminished 
amount  of  urea,  and  the  urea  deficit  will  be  found 
to  stand  in  close  proximity  to  the  amount  of  urea 
which  would  have  been  yielded  by  the  albumin  that 
transuded  through  the  kidneys  in  its  native  state. 

Compensatory  albuminurias  are,  as  a  rule,  easily 
recognized  and  readily  differentiated  from  nephri- 
tides.  One  has  to  recall  that  in  compensatory 
albuminuria  the  excretion  of  albumin  is  frequently 
the  only  clinical  phenomenon,  that  there  are  no  other 
exceptional  urinary  features,  and  that  the  physical 
signs,  symptoms,  and  disturbances  usually  met  with 
in  one  or  the  other  form  of  renal  disease,  are  not 
present.  Again,  the  amount  of  urinary  albumin  is 
not  very  large;  the  daily  output  not  exceeding  a  few 
grams  never  reaches  that  noted  in  the  average  case 
of  chronic  parenchymatous  nephritis. 

The  compensatory  phenomenon  is  of  a  more  or  less 
temporary  nature,  persisting  ordinarily  not  longer 
than  its  underlying  causes;  it  may,  however,  assume 
an  intermittent  or  recidivating  character,  especially 
in  its  milder  forms,  but  then  by  the  spell-like  suc- 
cession of  limited  outputs  of  albumin  an  apparent 
chronicity  is  imparted  to  it.  In  nephritic  conditions 
the  functional  work  of  the  kidneys  is  more  or  less 
interfered  with;  the  renal  activity,  on  the  other  hand, 
is  not  only  not  lessened  in  compensator}-  albuminuria, 
but  may  even  be  increased.  While  the  hypodermatic 
introduction  of  0.01  gram  phloridzin  yields  a  mini- 
mum of  about  1.6  gram  glucose  within  three  and  a 
half  and  four  and  a  half  hours  in  the  presence  of 
normally  functionating  kidneys,  the  amount  of 
glucose  will  be  diminished  or  none  at  all  will  be  pro- 
duced, if  the  renal  organs  are  structurally  damaged. 
In  individuals  with  compensatory  albuminuria 
phloridzin  glycosuria  can  always  be  induced,  and  the 
quantity  of  glucose  often  surpasses  the  minimum 
amount  to  a  considerable  degree.  Kidneys  rendered 
less  efficient,  or  exhausted  functionally  by  overwork — 
a  condition  liable  to  supervene  in  protracted  instances 
of  compensatory  albuminuria — always  respond  to 
the  phloridzin,  but  ordinarily  yield  slightly  less 
glucose  and  produce  it  less  quickly  than  do  the  normal 
and  competent  organs.  The  most  potent  means  of 
differentiating  between  a  set  of  functionally  deficient 
kidneys  resulting  from  overwork  and  one  which  is 
structurally  affected  are  the  absence  from  the  urine 
of  any  specific  nephritic  elements  and  the  occurrence 
of  a  slightly,  but  very  slightly,  lowered  phloridzin 
glycosuria  in  from  five  to  seven  hours. 

184 


Many  of  the  functional  albuminurias  of  the  older 
writers,  hiding  their  identity  under  more  or  less 
inappropriate  names,  bear  in  reality  a' compensatory 
character.  In  the  following  the  various  clinical 
albuminurias  occurring  without  structural  renal 
lesions  are  given  some  detailed  consideration. 

Albuminuria  of  the  New-born. —  Virchow3  was  the 
first  to  draw  attention  to  the  occurrence  of  albumin 
in  the  urine  of  the  new-born.  Some  later  observers 
maintain  that  albumin  is  quite  regularly  present  in 
the  urine  during  the  first  eight  or  ten  days  of  life. 
Albuminuria  in  the  new-born  does  not  give  rise  In, 
or  is  not  associated  with  any  special  clinical  mani- 
festations. Albumin  can  also  frequently  be  demon- 
strated in  the  urine  obtained  from  the  bladders  of 
still-born  children. 

In  the  majority  of  these  cases  the  protein  substance 
is  not  true  serum  albumin  but  consists  of  mucin  and 
the  various  "nucleoalbumins."  It  is  possible  that 
mucinuria  or  microalbuminuria  may  be  produced 
by  irritation  from  the  urates  which  often  occur  in 
large  amounts  in  the  kidneys  of  the  new-born. 
When,  on  the  other  hand,  true  serum  albumin  appears 
in  the  urine  of  the  new-born  it  is  very  likely  the  result 
of  the  altered  osmotic  and  metabolic  conditions.  In 
the  very  beginning  of  extrauterine  life  the  renal  blood 
pressure  becomes  considerably  augmented  which  fact 
alone  may  account  for  the  transudation  of  the  serum 
albumin  into  the  urinary  fluid.  The  change  of 
nutriment  and  the  early  insufficiency  of  hepatic 
function  may,  moreover,  be  contributing  to  the 
albuminurias  of  the  first  few  days  of  life. 

Intermittent  Albuminuria. — Under  intermittent  al- 
buminuria the  writer  groups  all  albuminurias  of 
pathological  function  which  have  been  variously 
designated  as  "transient,"  "remittent,"  "intermit- 
tent," "cyclic,  ""periodic,  ""postural, ""orthostatic," 
"orthotic,"  "lordotic,"  or  as  "albuminuria  of  adoles- 
cents." Excepting  perhaps  a  genuine  transitory 
form  in  which  the  albumin  appears  in  the  urine  during 
one  brief  period  only  (an  academic  contention  lacking 
satisfactory  clinical  proof),  intermittency,  i.e.  tem- 
porary cessation  of  albumin  excretion,  is  a  character- 
istic common  to  all  the  types  of  this  group.  Inter- 
mittent albuminuria  is  not  inevitably  a  short-lived 
phenomenon  as  which  it  is  regarded  by  some  authors, 
for  its  phases  of  alternate  increment  and  cessation  may 
continue  for  protracted  periods.  One  meets  with 
instances  in  which  the  albuminuria  prevails  for 
months  without  intermission,  and  on  the  other  hand, 
there  are  cases  with  prolonged  intermission. 

There  are  two  forms  of  intermittent  albuminuria, 
(a)  the  regularly  intermittent,  (b)  the  irregularly 
intermittent.  Regularly  intermittent  albuminuria 
always  manifests  itself  during  the  period  of  twenty- 
four  hours;  irregularly  intermittent  or  recidivating 
albuminuria  disappears  and  returns  at  irregular 
intervals.  Between  the  two  main  forms  of  inter- 
mittent albuminuria  there  occurs  a  transitional  type 
in  which  the  albumin  may  be  entirely  absent  during 
twenty-four  hours  and  reappear  in  a  regularly  inter- 
mittent fashion  on  the  following  days. 

The  characteristic  feature  of  regularly  intermittent 
(cyclic,  periodic,  orthostatic,  adolescent,  etc.)  albu- 
minuria is  its  definite  course,  i.e.  during  the  twenty- 
four  hours'  period  the  albumin  is  constantly  found  in 
certain  mictions,  while  it  is  ordinarily  absent  in  others. 
These  absolutely  intermittent  cases  are  those  must 
frequently  encountered  and,  accordingly,  most 
thoroughly  studied.  But  there  are  cases  designated 
as  relatively  intermittent,  in  which  there  ensues  no 
albumin-free  interval  at  all,  but  in  which  certain 
urinations  regularly  exhibit  a  more  intense  albumin- 
uria than  others. 

Regularly  intermittent  albuminuria  preeminently 
obtains  in  the  youthful  organism,  but  it  is  not  an 
extraordinary  circumstance  in  adult  life.  The  out- 
put of  albumin  in  all  forms  of  intermittent  albumi- 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Albuminuria 


nuria  is  usually  small,  not  exceeding  0.0  to  0.7.")  per 
mille,  as  a  rule.  However,  when  dealing  with  a  case 
of  intermittenl  albuminuria  it  is  not  the  twenty-four 
hours' excretion  of  the  protein  bul  the  latter's  amount 
in  each  albuminous  micturition  during  this  period 
which  should  be  determined.  In  this  manner  only 
may  the  intensity  of  the  albuminuric  process  and  the 
degree  of  the  underlying  fund  ional  disturbance  be 
properly  adjudged.  The  pathological  function  of 
which  the  albuminuria  is  a  manifestation,  is  modified 
or  reduced   when   the   meta-  and   catabolie   processes 

it  t  heir  mini mu in,  when,  in  other  words,  the  organ- 
IB  's  tit  rest.     Furthermore,  the  greater  the  retarda- 
tion of   the   general    biological   activity,    the   smaller, 
ordinarily,  is  the  quantity  of  protein  in  intermittent 

iiniiiuria.      After     administration     of     medicinal 

-   of   morphine,   for  instance,   when   the  physio- 
ical    and    with    these    the    pathologico-physiolog- 
ieal  processes  are  slackened,  the  intensity  of  the  al- 
bumin  excretion    in    intermittent   albuminuria   may 
become   more  or  less  diminished.     It  seems,   there- 
that  it  is  primarily  the  alterations  in  the  physio- 
logical energy  which  cause   the   albumin   to   appear, 
er  to  disappear,  in  the  absolutely  intermittent  cases. 
To  the  extent  only  that  factors  like  posture,  muscu- 
lar exertion,   exposure  to   cold,   physical  exhaustion, 
etc.,    increase   pathologico-physiological   activity  can 
j   be  brought  in  any  connection  with  an  ensuing 
albuminuria. 
The  type  of  albuminuria  designated  by  Pavy4  as 

r  exhibits  a  regularly  intermittent  character. 
In  this  form  of  albuminuria  the  urine  voided  during 
the  night  or  during  rest  in  the  recumbent  posture  is 
usually  free  from  protein,  while  the  mictions  during 
the  day,  that  is,  after  the  individual  has  assumed  the 

■  position,  display  rather  definite  quantities  of 
albuminous  material.  Accordingly,  the  erect  pos- 
ture has  been  brought  into  causative  relationship 
with    the    reappearance    of    the    urinary    protein;  it 

is,  therefore,  that  terms  like  postural,  orthotic, 
or  orthostatic  are  very  well  adapted  to  denote  this 
form  of  albuminuria.  Edel5  found  in  his  cases  of 
orthostatic  albuminuria  that  the  protein  output  was 
greatest  in  the  morning  after  rising  and  after  a  scanty 
breakfast.  Moderate  exercise  was  followed  by 
augmentation,  sitting  by  diminution,  and  lying 
down  by  cessation  of  the  albuminuric  phenomenon. 
Shortly  after  the  midday  meal  the  urine  contained 
no  protein,  as  a  rule.  A  change  in  the  meal  hour 
effected  a  corresponding  change  in  the  protein-free 
period,  while  protein  was  continuously  excreted 
when  the  dinner  was  entirely  omitted.  When  the 
urinary  flow  was  abundant  the  protein  excretion  was 
diminished;  the  urine  was  secreted  in  larger  amounts 
when  the  individual  was  sitting  or  reclining  than 
when  standing.  Diuretics  like  potassium  acetate 
called  forth  an  increased  flow  of  urine  free  from  pro- 
He  further  observed  that  when  the  pulse  was 
strong  and  full  a  large  amount  of  albumin-free  urine, 
when  it  was  weak  and  small  a  scanty  amount  of 
urine  exhibiting  albumin  was  voided.  Subsequently 
the  same  author0  furnished  experimental  evidence 
that  the  form  of  albuminuria  under  consideration  is 
associated  with  a  depressed  state  of  the  circulation 
and  a  lowered  arterial  tension.  The  last  observa- 
tions were  confirmed  by  a  number  of  investigators, 
among  others  by  Erlanger  and  Hooker  who  found  that 
orthostatic  albuminuria  is  caused  by  a  diminution 
pi  the  pulse  pressure  invariably  ensuing  when  the 
individual  changes  from  the  reclining  to  the  erect 
posture.  Jacobsohn7  states  that  orthostatic  albumi- 
nuria occurs  persistently  after  rising  and  that  it 
also  supervenes  in  the  wake  of  fatiguing  exercise  or 
upon  standing  unassociated  with  special  physical 
exertion.  The  albuminuria  invariably  disappears 
when  resting  in  bed,  and  frequently  vanishes  after 
exercise  that  is  stimulating  and  not  exhausting.  A 
number   of   authors   maintain    that    there    must   be 


some  nerve  influence  at  the  Foundation  of  ortho- 
static albuminuria.  According  to  Jacobsohn  the 
ancestry  of  albuminurics  of  the  cyclic  type  is  often 

affected    with    nervous    disease,    and    one    would    be 

justified  to  consider  orthostatic  albuminuria  as  a 
manifestation  of  pronounced  defeneration.  The 
nervous  origin  of  this  form  of  albuminuria  is  declared 
by  Sutherland8  and  also  by    Heck"  who  points  out 

that  there  exist  in  all  I  he  eases  certain  vasomotor 
disturbances  as  cyanosis  of  the  extremities  and  hay 
fever,  and  that  the  albuminuric  process  i-  due  to  a 

vasomotor  irregularity  of  the  renal  circulation  pro- 
ducing a.  fluctuating  congestion  of  (be  kidney. 

Jehle10  demonstrated  that  changes  in  the  position 
of  the  lumbar  spine  are  apt  to  cause  cyclic  albuminuria. 
If  the  spine  is  lordotic  albumin  is  found;  the  latter 
disappears  from  the  urine  when  the  lordosis  has 
been  corrected.  Nothmann"  also  furnished  proof 
that  lordosis  influences  the  albumin  excretion,  but 
found  that  the  condition  must  be  pronounced  in 
order  to  produce  albuminuria  when  both  kidneys 
are  healthy.  Hamburger1-  accepts  a  possible  lordotic 
origin  of  albuminuria  but  maintains  that  there  must 
be  additional  causative  factors  at  the  bottom  of  the 
protein  excretion  as  the  same  individual,  remaining 
under  unchanged  external  influences,  exhibits  at 
one  time  a  pronounced  and  at  another  a  slight 
albuminuria  or  none  at  all.  He  ascribes  the  fluctuat- 
ing intensity  of  the  protein  output  to  vasomotor 
influences. 

That  the  production  of  lordotic  albuminuria  depends 
upon  an  abnormal  mobility  of  the  kidneys  is  the  con- 
tention of  a  number  of  recent  investigators.  Lury," 
for  instance,  demonstrated  that  by  fixation  of  the 
kidneys  (pressure  with  the  hands  of  the  examiner 
upon  the  loins  of  the  patient  in  lordotic  incline),  the 
albumin  excretion  may  be  partially  or  entirely  sub- 
dued. 

The  few  foregoing  excerpts  from  the  literature 
show  that  there  is  no  consensus  of  opinion  as  regards 
the  mode  of  production  of  regularly  intermit- 
tent albuminuria,  of  which  there  are  at  least 
two  distinct  types,  i.e.  the  orthostatic  and  the 
lordotic.  Orthostatic  albuminuria  may  certainly 
occur  without  the  presence  of  lordosis.  While  the 
mechanical  factors  admittedly  play  an  etiological 
role  in  the  production  of  both  types,  orthostatic 
albuminuria  in  the  main  is  a  vasomotor  phenomenon 
with  probably  compensatory  tendencies  for  anterenal 
disturbances. 

Intermittent  albuminuria,  as  we  have  seen,  is 
preeminently  a  condition  of  the  growing  organism. 
In  adolescent  life  all  processes  of  metabolism  are 
enhanced.  This  is  especially  the  case  just  before 
and  at  the  period  of  puberty.  If  augmentation  of 
the  various  processes  of  life  does  not  ensue  in  a 
uniform  manner  all  the  time,  temporary  disturbances 
of  the  metabolic  equilibrium  may  supervene.  If  it  be 
true  that  glycosuria  is  sometimes  the  direct  result 
of  such  a  disturbance,  then  it  ought  to  be  equally 
true  that  the  albuminuria  of  adolescents  (or  other 
types  of  intermittent  albuminuria)  may  be  an  ex- 
pression of  altered,  but  not  entirely  proportionate, 
metabolic  processes.  Lassitude,  feeble  cardiac  and 
vascular  impulse,  mental  sluggishness,  extreme 
leanness,  headache,  and  other  symptoms  so  frequent 
at  the  age  of  puberty,  are  the  result  of  the  changing 
metabolic  conditions  in  the  individual.  These  symp- 
toms are  concomitants  of  an  eventual  intermittent 
albuminuria  and  are  not  the  consequence  of  the 
latter;  they  have  sprung  from  the  same  or  a  similar 
source  which  occasioned  the  albuminuria.  In  other 
words,  the  enfeebled  state  of  the  organism  is  not  due 
to  the  loss  of  one  or  two  grams  of  serum  albumin, 
but  to  a  temporarily  disturbed  or  rather  an  as  yet 
not  uniformly  altered  metabolism. 

Many  cases  looked  upon  as  purely  intermittent 
in  character  are  in  many  instances  pathognomonic 


1S5 


Albuminuria 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


of  an  organic  renal  lesion,  though  the  latter  may  be 
undeterminable  for  the  time  being.  When  there  is 
a  history  of  an  antecedent  kidney  involvement,  the 
irregular  intermittent  albumin  excretion  may  be 
due  to  a  renal  affection  even  if  the  latter  is  not 
clinically  manifest.  The  renal  element  of  the  albu- 
minurias of  this  class  will  sooner  or  later  be  re- 
vealed in  the  great  majority  of  the  cases.  On  the 
other  hand,  there  is  sufficient  evidence  that  a  certain 
proportion  of  kidney  lesions  will  heal,  in  which  case 
the  albuminuric  symptom  may  permanently  cease. 

Diagnostically  it  should  be  remembered  that  only 
such  albuminurias  may  be  designated  as  purely 
orthostatic  or  lordotic  in  which  anatomical  elements 
of  renal  origin  have  never  been  demonstrated.  In 
orthotic  children  who  have  acquired  nephritis  the 
orthostatic  or  lordotic  albuminuria  is  overshadowed 
by  one  which  is  distinctly  nephritic  in  character.  The 
regularly  intermittent  type  of  albuminuria  should 
be  differentiated  from  nephritic  albuminuria  by  the 
normal  amount,  composition,  and  specific  gravit}'  of 
th''  urine;  its  freedom  from  pathological  renal  elements, 
such  as  casts  and  oil  globules,  or  from  abnormal 
numbers  of  normal  kidney  elements,  such  as  leucocytes 
and  specific  renal  epithelia;  the  absence  of  the  protein 
from  the  night-urine,  its  presence  in  the  mictions 
when  the  patient  has  been  standing  for  a  long  time; 
the  small  amount  of  the  diurnal  protein  excretion  and 
the  absence  of  the  constitutional  manifestations  of 
frank  nephritis.  The  subjective  symptoms  are 
usually  slight:  the  one  most  constant  and  pronounced 
being  a  feeling  of  general  lassitude  which  is  often 
entirely  out  of  proportion  to  the  insignificant 
albuminuric  process.  Headache  and  afternoon  fever- 
ishness  are  rarer  accompaniments  of  the  condition. 
Among  the  objective  symptoms  anemia  and  pallor 
are  the  most  frequent.  In  adults  vasomotor  dis- 
turbances and  that  which  is  usually  called  neurasthenia 
are  the  rule.  In  nearly  one-third  of  all  the  cases  a 
more  or  less  movable  kidney  can  be  demonstrated. 
The  subjective  and  objective  phenomena  usually 
abate  and  are  revived  with  the  fall  and  rise  of  the 
albuminuria.  Determination  of  the  blood  pressure 
and  examination  of  the  fundus  of  the  eye  are  imper- 
ative in  a  positive  diagnosis.  Uncomplicated  cases  of 
this  form  of  albuminuria  are  not  accompanied  by 
increase  of  blood  pressure,  hypertrophy  of  the  left 
ventricle,  or  accentuation  of  the  second  aortic  sound. 

The  prognosis  of  the  uncomplicated  intermittent 
forms  of  albuminuria  is  absolutely  favorable.  No 
applicant  for  life  insurance  with  an  uncomplicated 
orthostatic  albuminuria  should  be  rejected  as  long 
as  there  are  no  other  factors  against  him.  The 
albuminuria  is  a  harmless  occurrence  when  the 
observation  of  the  case,  continued  over  an  entire 
year,  has  demonstrated  that  the  night-urine  is  always 
devoid  of  protein;  that  there  ensue  fluctuations  in 
the  protein  excretion  during  the  day  time  (the  absolute 
aim mnt  of  excreted  protein  is  of  little  significance); 
and  that  the  greater  portion  of  the  protein  is  precipi 
table  by  acetic  acid  in  the  cold.* 

Treatment  should  never  be  directed  toward  the 
suppression  of  the  albuminuria  per  se.  The  endeavor 
will  hardly  ever  be  crowned  with  success,  as  the  albu- 
minuria is  but  a  manifestation  of  a  functional  dis- 
turbance and  not  a  disease  in  itself.  In  some 
instances  the  underlying  cause  can  be  reached  and 
treated;  the  subjective  and  objective  manifestations — 
exclusive  of  the  albuminuria — frequently  call  for 
symptomatic  interference.  Children  affected  with 
any  of  the  forms  of  intermittent  albuminuria  should 

*  This  protein  test  is  performed  in  the  following  manner:  Equal 
amounts  of  urine  are  placed  in  two  test-tubes  and  a  few  drops  of 
moderately  diluted  acetic  acid  are  added  to  each  tube.  To  the 
contents  in  one  tube  a  few  drops  of  a  weak  solution  of  potassium 
fernicyunide  an-  added.  The  Miedler  the  difference  in  the  turbid- 
ity of  the  two  mixtures  the  greater  is  the  probability  of  the 
exist  enee  of  an  uncomplicated  cyclo-intermittent  albuminuria. 


be  guarded  against  untoward  influences  and  exer- 
tions. Abundant  food,  open-air  life,  systematic 
exercises  not  sufficient  to  cause  fatigue  and  followed 
by  rest  in  the  reclining  posture,  not  less  than  ten 
hours  in  bed  at  night,  orthopedic  correction  of  spinal 
deformities,  wearing  of  a  well-fitting  abdominal  sup- 
porter with  kidney  pads,  regulation  of  the  bowels, 
etc.,  will  frequently  raise  the  general  health  of  the 
individual  and  incidentally  check  the  albuminuria. 

Recidivating  Albuminuria — By  recidivating  albu- 
minuria I  understand  an  irregular  intermittent  excre- 
tion of  urinary  protein  caused  by  and  associated 
with  tangible  anterenai  disturbances.  Kidney  dis- 
ease stands  not  at  the  foundation  of  recidivating 
albuminuria,  but,  on  the  contrary,  may  be  its  med- 
iate result.  This  type  of  albuminuria  is  of  a  com- 
pensatory nature  and  its  fluctuations  reflect  the  in- 
tensity degree  of  its  causative  factors.  The  even- 
tual cessation  of  the  albuminuria  depends  upon  the 
correction  of  the  etiological  functional  disturbances. 
Kidney  debility  and  disease  only  ensue  in  the  wake 
of  the  albuminuria  when  the  latter's  causative  far- 
tors  have  endured  for  protracted  periods.  This 
form  of  albuminuria  is  invariably  expressive  of  a 
disturbance  which  is  benign  though  possibly  tending 
to  progressiveness.  In  the  absence  of  more  than 
normal  numbers  of  renal  epithelia,  the  occurrence 
of  an  occasional  hyaline  cast  in  the  albumin-carrying 
urine  does  not  per  se  point  to  the  existence  of  a  kid- 
ney lesion.  This  form  of  albuminuria  prevails  be- 
tween the  middle  of  the  third  and  the  end  of  the 
fourth  decennary  of  life.  It  may,  however,  ensue 
much  earlier.  In  later  life  when  degenerative, 
especially  angiosclerotic  processes  are  more  pro- 
nounced, an  eventual  recidivating  albuminuria  cannot 
any  longer  be  definitely  differentiated  from  the 
slight  albuminuria  of  chronic  interstitial  nephritis. 
As  a  matter  of  fact,  there  may  then  exist  a  diploal- 
buminuria,  i  e.  the  concurrence  of  non-nephritic  and 
nephritic  albuminuria. 

Alimentary  Albuminuria. — This  type  of  albu- 
minuria has  frequently  been  assigned  to  the  cyclic- 
intermittent  group  but  it  is  in  reality  a  recidivating 
albuminuria.  It  results  from  the  ingestion  of  large 
amounts  of  proteins  like  meat,  cheese,  milk,  gelatin, 
and  especially  raw  eggs.  Little  is  known  of  the 
albuminurias  occurring  after  excessive  ingestion  of 
cheese  and  beef;  it  seems  that  in  these  albuminurias 
only  serins  and  no  blood-foreign  proteins  are  ex- 
creted. This  and  the  additional  fact  that  an  existing 
renal  albuminuria  may  be  aggravated  by  overin- 
dulgence in  certain  proteins  tend  to  prove  that 
there  must  be  in  all  these  instances  a  larvate  or  frank 
nephritis  to  which  is  due  the  albuminuric  phe- 
nomenon. This  is  not  the  case  in  ovialbuminuria 
which  may  occur  without  an  accompanying  serinnal- 
buminuria.  Native  egg  albumin  when  injected  into  a 
vein  of  a  healthy  individual  will  pass  into  the  urine 
within  a  comparatively  short  time;  if,  on  the  other 
hand,  the  egg  albumin  has  undergone  partial  diges- 
tion it  may  be  retained  in  the  blood.  In  individuals 
with  perfectly  normal  kidneys  the  ingestion  of  the 
whites  of  three  or  four  eggs  may  be  followed  by  the 
excretion  of  egg  albumin.  Uhlenhuth,1*  Inouye  " 
Croftan,10  and  others  who  have  studied  alimentary 
albuminuria,  i.e.  ovialbuminuria,  by  means  of  sennit 
reactions  could  demonstrate  ovialbumin  in  the 
blood  and  urine.  Ascoli  "  employing  the  same  test 
showed  that  when  egg  albumin  is  subcutaneouslj 
injected  serum  albumin  as  w-ell  as  egg  albumin  will 
appear  in  the  urine.  Wells18  who  has  made  obser- 
vations on  alimentary  albuminuria  by  means  of  the 
anaphylaxis  reaction  obtained  therewith  quite  dif- 
ferent results.  He  demonstrated  that  sensitized 
guinea-pigs  reacted  typically  and  markedly  to  human 
protein  and  not  at  all  to  egg  albumin,  and  he  dou 
whether  any  of  the  unaltered  food  protein  ever 
reaches  the  urine. 


I  Mi 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Vllniliilii.ii  i  .1 


The  contradictory  results  obtained  by  the  pre- 
cipitin and  anaphylaxis  reactions  do  not  prevent  us 
from  accepting  the  results  of  the  former  method  as 

j  are  in  entire  accord  with  the  clinical  findings. 
li  appears  that  the  presence  "I'  ovialbumin  in  the 
blood  is  solely  due  to  a  perversion  in  the  digestive 
organs.  Croftnn'"  has  encountered  alimentary  albu- 
minuria, (1)  in  motor  insufficiency  of  the  stomach 
of  advanced  degree,  due  to  either  pyloric  obstruc- 
i,  gastric  atony  or  dilatation,  especially  when 
i  01  iated  with  hypochlorhydria  and  hypochylia; 
[2)  in  certain  forms  of  intestinal  indigestion  (dys- 
trypsia)  with  the  appearance  of  abnormally  large 
quantities   of    undigested   food   constituents   in    the 

oes  and  very  frequently  associated   with  diarrhea; 

as  a  part  phenomenon  of  the  symptom-complex 

of   pronounced    hepatic    insulliciency;    (1)    very   eom- 

ily   after  rectal   feeding   with  raw  egg,  peptones, 

J    albumoses),  or  milk;  (5)  after  ingestion  of  large 

tnts  of  albuminous  food. 

Crof tan's  method  of  performing  the  precipitin 
reaction  is  simple  and  the  reaction  sufficiently  scn- 
i  to  serve  for  the  identification  of  egg  albumin 
in  the  urine.  In  gastric,  intestinal,  or  hepatic  albu- 
minuria there  occur  besides  the  albuminuric  phe- 
ii  anil  as  a  rule  no  other  symptoms  than  those 
pointing  to  a  disturbed  function  of  the  stomach,  in- 
testines, or  liver.  .Malaise,  lack  of  energy,  and  bodily 
decline  concurring  with  alimentary  albuminuria  are  not 
the  consequence  of  the  latter  but  of  the  underlying 
alimentary  disorder.  The  treatment  of  the  alimen- 
tary forms  of  albuminuria  resolves  itself  into  the 
treatment  of  the  respective  gastric,  intestinal,  or 
hepatic  perversion,  and  the  exclusion  or  reduction 
of  the  protein  food,  in  part  reappearing  in  the  urine, 
in  order  to  avert  definite  pathological  lesions  in  the 
kidneys  which  may  ensue  when  the  excretion  of  a 
blood-foreign  protein  is  continued  for  a  long  time. 

The  prognosis  as  to  the  cessation  of  the  albu- 
minuria is  favorable  provided  the  alimentary  disturb- 
ance and  the  protein  intake  be  regulated.* 

i  diovascular  Albuminuria. — There  is  a  form  of 
recidivating  aluminuria  which  is  due  to  circulatory 
disturbances.  It  is  not  associated  with  a  frank  renal 
disease,  but  some  hyaline  casts  may  occasionally  be 
demonstrated  when  the  albuminuria  has  endured 
for  a  long  time.  Interstitial  or  parenchymatous 
changes  in  the  kidneys  may  ensue  in  later  life;  there 
is  no  proof,  however,  that  this  form  of  early  cardio- 
vascular albuminuria  is  associated  with  renal  disease, 
much  less  that  it  is  caused  by  it.  Heart  and  blood- 
Is  in  recidivating  cardiovascular  albuminuria 
are  not,  as  a  rule,  structurally  affected,  the  disturbances 
being  in  the  main  of  an  angioneurotic  nature.  This 
type  of  albuminuria  must  not  be  confounded  with 
nephritic  albuminuria  concurring  with  or  supervening 
in  the  wake  of  organic  heart  and  blood-vessel  disease. 
The  amount  of  excreted  protein  hardly  ever  exceeds 
0.2  per  cent,  in  recidivating  cardiovascular  albumin- 
uria. The  protein-free  intervals  are  dependent  upon 
cardiovascular  ease  and  tranquility.  The  duration 
of  the  albuminuric  periods  is  decidedly  erratic;  they 
may  persist  for  days  or  months. 

It  is  this  type  of  cases  offering  few  or  no  clinical 
symptoms  of  cardiovascular  disturbance  which  is  so 
frequently  rejected  by  the  ignorant  life  insurance 
examiner  and  his  timid  medical  director  on  ac- 
count of  "a  trace  of  albumin  and  a  hyaline  cast." 
There  is,  however,  no  evidence  that  the  usual  applicant 
for  life  insurance  thus  stigmatized  and  deprived  from 
the  benefits  of  life  assurance  will  not  attain  the 
average    age.     While    the    insurance    policy    in   not 

*  Albumosuria  of  alimentary  origin  may  supervene  after  inges- 

>l  food  products  rich  in  albumoses.     Artificial  preparations 

g  :i^  albumin  substitutes  often  exhibit  a  large  proportion  of 

albumoses.     Such  artificial  products  are  frequently  prescribed  in 

gastrointestinal  affections  and  during  convalescence  from  acute 


forth ing,  the  blow  received  by  the  unsuspecting 

former   proposer   lor   life   insurance   is   in    realitj    a 

great  boon  to  him,  for  now  he  knows  I  hat  a  change  in 
his  mode  of  life,  con fnrin ing  to  I  he  decreased  demands 

and  functional  activity  of  bis  organism,  i^  imperative. 
Febrile  Albuminuria.     In  many  of  the  acute  diseases 

there  may  ensue  an  albuminuria  which  endures  with 
or  without  intermissions  during  the  febrile  stage. 
An  albuminuria  developing  in  l  he  course  or  in  t  he  wake 
of  a  febrile  disease  may,  of  course,  be  a  manifestation  of 
a  nephritic  process;  in  the  preponderating  majority 
of  instances,  however,  there  exists  no  .structural 
disease  of  the  kidney.  The  albuminuria  usually 
vanishes  with    the   decline  of   the   fever,   and   appears 

never  to  be  associated  with  any  permanent  disturb- 
ance of  the  renal  function.  The  amount  of  excreted 
protein  varies  and  depends  entirely  upon  the  intensity 
of  the  toxic  process.  In  rare  instances  the  protein 
output  may  be  so  abundant  that  it  may  be  impossible 
to  differentiate  between  this  type  of  albuminuria  and 
an  actual  nephritis.  The  temperature  elevation  as 
such  does  not  influence  the  protein  output.  The 
albuminuria  may  be  due  to  several  factors  working 
synchronously  or  successively.  At  the  onset  of  the 
affection  it  may  be  deficient  renal  blood  supply 
(ischemia)  and  at  a  later  stage,  especially  in  grave 
cases,  renal  hyperemia  to  which  the  advent  of  the 
albuminuria  can  be  attributed.  In  either  eventuality 
the  albuminuria  may  be  a  compensatory  phenomenon. 
The  albuminuria  in  typhoid  fever  complicated  by 
meningism  is  probably  not  alone  dependent  upon 
the  bacterial  toxin  circulating  in  the  blood  but  also, 
in  some  degree  at  least,  to  an  irritation  of  a  portion 
of  the  central  nervous  system.  In  influenza  there 
may  ensue  an  active  renal  hyperemia  characterized  by 
an  insignificant  serumalbuminuria  and  globulinuria. 
The  moment  the  influenza  poison  is  eliminated  or 
neutralized,  the  albuminuria  ceases  and  the  renal 
incident  of  influenza  closes  there  and  then.19  In 
other  infectious  diseases,  particularly  in  scarlet 
fever  and  diphtheria,  the  bacterial  poisons  may 
directly  and  permanently  injure  the  renal  parenchyma. 
It  is  also  possible  that  the  excreted  protein  in  some 
of  the  minor  febrile  albuminurias  is  neither  serum 
albumin  nor  globulin  but  toxalbumin  due  to  bacterial 
activity.     This,   at  least,  is   Krehl's  suggestion  who 

n mmends     differential     testing    for     the     urinary 

proteins.. 

The  albuminurias  of  this  class  are  erroneously 
termed  febrile  as  it  is  not  the  thermic  but  bacterio- 
toxic  influences  to  which  their  origin  must  be  assigned. 
A  more  appropriate  designation  would  therefore  be 
"  bacteriotoxic  albuminuria." 

Toxic  Albuminuria. — Besides  febrile  albuminuria 
which  is  in  some  respects  a  toxic  albuminuria  there 
occur  albuminurias  as  the  consequence  of  poisoning 
with  certain  chemical  substances.  While  there  can 
be  no  doubt  that  the  ingestion  of  agents  like  oil  of 
turpentine,  cantharides,  mustard,  and  mineral  acids, 
when  undiluted  or  insufficiently  diluted,  is  liable  to 
be  followed  by  renal  irritation  or  even  structural 
disease,  it  is  also  true  that  the  specific  toxic  albumin- 
uria may  arise  in  the  absence  of  a  kidney  lesion.  This 
is  particularly  the  case  when  an  albuminuria 
ensues  after  the  introduction  of  chemicals  like  arsenic, 
phosphorus,  phenol,  mercury,  iodine,  salicylic  acid, 
and  potassium  chlorate  and  nitrate.  Such  toxic 
albuminurias  are  due  to  disturbances  in  the  general 
and  renal  circulation  and  to  an  altered  blood  com- 
position. Here  again  the  protein  excretion  is  refer- 
able to  an  effort  on  the  part  of  the  kidneys  to  com- 
pensate for  anterenal  difficulties.  The  heretofore 
sound  kidneys  remain  sound  if  the  toxic  process 
called  forth  by  these  agents  declines  within  a  short 
time.  Even  the  presence  in  the  urine  of  hyaline 
casts  and  some  fresh  blood  after  the  introduction  of 
such  chemicals  does  not  indicate  nephritis.  In  the 
average    case    soon  after   the   toxicosis  has  ceased, 


1S7 


Albuminuria 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


there  is  no  longer  any  albuminuria,  nor  can  casts  or 
blood  be  demonstrated. 

Hematogenous  Albuminuria. — There  is  no  con- 
sensus of  opinion  as  regards  the  nature  of  hematog- 
enous albuminuria.  This  type  of  albuminuria 
accompanies  affections  like  pernicious  anemia,  leu- 
cemia,  scurvy,  diabetes,  etc.  Many  clinicians  believe 
that  the  renal  structures  participating  in  urine  pro- 
duction have  become  deteriorated  and  pathologic- 
ally altered  in  the  course  of  these  systemic  diseases, 
so  as  to  be  rendered  permeable  for  the  albumin  mole- 
cule. Though  there  can  be  little  doubt  that  the 
kidneys  may  in  time  become  involved  in  the  general 
process  of  bodily  decline,  there  is  no  evidence  that 
there  commonly  exists  renal  deterioration  in  the  early 
stages  of  these  affections.  The  characteristic  hema- 
togenous albuminuria  which  prevails  before  neph- 
ritic changes  have  taken  place  is  virtually  a  toxic 
albuminuria  and  is  almost  entirely  due  to  qualitative 
and  quantitative  changes  in  the  circulating  protein. 
The  abnormal  excretory  work  of  the  kidneys  in  these  in- 
stances must  be  regarded  in  the  light  of  a  regula- 
tory or  compensatory  process.  (See  Compensatory 
Albuminuria.) 

Postepileptic  Albuminuria. — By  the  term  postepi- 
leptic albuminuria  is  understood  the  occurrence  of 
urinary  protein  after  an  epileptic  attack.  While 
some  observers  have  found  the  protein  in  the  wake 
of  every  seizure,  others  assert  that  it  appears  only 
occasionally,  and  a  few  others  have  failed  altogether 
to  detect  it  after  the  attacks.  The  truth  of  the  mat- 
ter seems  to  be  that  the  urinary  protein  appears 
quite  irregularly;  in  the  same  individual  even  it 
may  occur  after  one  seizure  and  may  be  absent 
after  another.  Postepileptic  albuminuria  may  be 
due  to  a  latent  nephritis  temporarily  activated  by  an 
epileptic  paroxysm;  to  circulatory  renal  disturbances 
concurring  with  the  seizure  and  manifesting  them- 
selves mostly  as  passive  congestion;  or  to  toxins  in 
the  circulation  prior  to  and  during  the  attack.  The 
first  eventuality  assumes  an  out  and  out  nephritic 
hcaracter  of  postepileptic  albuminuria  which,  however, 
is  displayed  in  only  a  certain  proportion  of  the  cases. 
We  possess  sufficient  proof  that  eventual  chronic 
kidney  changes  may  be  of  an  entirely  secondary 
nature,  and  that  the  majority  of  instances  of  post- 
epileptic albuminuria  arise  on  a  non-nephritic  basis. 
There  is  little  doubt  that  circulating  toxins,  and 
especially  disturbances  in  the  blood  supply  of  the 
kidneys  stand  at  the  foundation  of  this  type  of 
albuminuria.  The  one  eventuality  would  stamp  it  a 
toxic,  the  other  a  recidivating  albuminuria.  Mun- 
son20  who  has  examined  .'543  epileptics,  197  men  and 
146  women,  for  the  albuminuria  following  epileptic 
seizures,  summarizes  his  observations,  thus:  (1) 
postepileptic  albuminuria  is  found  in  about  twenty  per 
cent,  of  epileptics;  men  are  much  more  frequently 
affected  than  women,  and  severe  seizures  are  more 
likely  to  cause  the  condition  than  are  mild  attacks; 
(2)  the  condition  is  not  constant  in  the  same  individ- 
ual; (3)  the  presence  of  albumin  is  almost  invariably 
associated  with  the  finding  of  casts,  sometimes  in 
great  numbers  and  variety;  they  persist  longer  than 
the  albumin,  but  may  also  be  found  in  the  inter- 
paroxysmal  period  in  the  absence  of  albumin;  (4) 
the  first  appearance  of  albumin  may  be  at  any  time 
within  the  first  two  hours  after  the  attack  and  it 
may  not  disappear  till  the  fourth  day;  (5)  physical 
examinations  are  not  fruitful  of  diagnostic  results, 
except  that  a  few  slight  heart  findings  are  noted;  the 
blood  pressure  is  elevated  in  some  of  the  cases;  (6) 
in  a  series  of  cases  of  death  in  or  shortly  after  seizures, 
congestion  of  the  kidneys  is  almost  constantly 
found,  with  albumin  in  the  lumen  of  the  tubules; 
there  is  also  a  good  deal  of  chronic  change  which,  it 
may  be  assumed,  is  due  to  the  congestion,  so  often 
repeated. 

Postepileptic  albuminuria  is  not  the  only  so-called 


neurotic  albuminuria,  for  a  transient  excretion  of 
urinary  protein  has  been  observed  in  hyperthy- 
roidism, apoplexy,  progressive  paralysis,  brain  tumor 
delirium  tremens,  etc.  The  cause  of  neurotic  albu- 
minuria has  been  ascribed  to  the  stimulation  of  the 
albuminuriogenic  center  of  Bernard  situated  in  the 
floor  of  the  fourth  ventricle;  however,  it  appears  fco 
be  due  to  exactly  the  same  factors  which  may  occa- 
sion the  postepileptic  albuminuria,  i.e.  circulatory 
disturbances  in  the  kidneys  or  a  toxic  state  of  the 
blood.  Thus  the  albuminuria  of  Graves'  disease  is 
undoubtedly  of  hyperthyrotoxic  origin. 

Heinrich  Stern. 

1.  Heinrich   Stern:    Compensatory  Albuminuria,  a  Contribu- 
tion to  the  Study  of  the  Clinical  Albuminurias,  -Medical   1;, 
June  26,  1909. 

2.  Langstein:  Die  AJbuminurien  alterer  Kinder,  Leipzig.  1907. 

3.  Virchow:  Verhandlungen  d.  Gesellsch.  f .  Geburtsnilfe,  1846. 

4.  Pavy:  The  Lancet,  18S5. 

5.  Edel:  Munchener  med.  Wochenschr.,  Nov.  19,  1901. 

6.  Edel:  Deutsche  med.  Wochenschr.,  Sept.  3,  1903. 

7.  Jacobsohn:  Berliner  klin.  Wochenschr.,  Oct..  5,  1903. 

8.  Sutherland:  Am.  Jour.  Med.  Sciences,  Aug.,  1903. 

9.  Beck:  Am.  Jour.  Med.  Sciences,  Sept.,  1903. 

10.  Jehle:  Munchener  med.  Wochenschr.,  Jan.  7,  1908. 

11.  Nothmann:  Archiv  f.  Kinderheilkunde,  Vol.  XLIX,  Nos.  3 
and  4. 

12.  Hamburger:  Wiener  klin.  Wochenschr.,  1912,  No.  25. 

13.  Lury:  Jahrbuch  f.  Kinderheilkunde,  1910,  p.  705. 

It.  Uhlenhuth:   Deutsche  med.  Wochenschr.,  1900,  p.  734. 

15.  Inouye:  Deutsches  Archiv  f.  klin.  Med.,  March,  1903. 

16.  Oroftan:  Archives  of  Diagnosis,  Oct.,  1908. 

17.  Ascoli:  Zeitschr.  f.  physiolog.  Chemie,  1903,  p.  2S3. 
IS.  Wells:  Jour.  A.  M.  A.,  Sept.  11,  1909. 

19.  Heinrich  Stern:   Renal  Complications  and  Sequela?  of  Influ- 
enza.    Medical  Record,  Jan.  11,  1908. 

20.  Munson:  N.  Y.  Med.  Jour.,  Nov.  27,  1909. 


Alburgh  Springs. — Grand  Isle  County,  Vermont. 

Post-office. — Alburgh  Springs. 

Access. — The  Canada  Atlantic  Railroad  runs 
through  the  village.  The  Central  Vermont  Railroad 
is  within  a  mile  of  the  village;  thence  one  mile  to 
Springs  hotels. 

This  is  an  old-time  New  England  resort,  which  has 
been  in  use  since  the  year  1816.  The  springs  are 
located  on  the  shores  of  Missisquoi  Bay,  and  are  sur- 
rounded by  picturesque  lake  and  mountain  scenery. 
The  situation  is  thirty  feet  above  the  level  of  Lake 
Champlain  and  about  eighty  rods  from  the  water's 
edge.  There  are  two  springs,  one  of  which  was 
analyzed  by  Dr.  C.  T.  Jackson,  in  1868,  with  the 
following  results: 

One  United  States  Gallon  Contains: 

Solids.  Grains. 

Sodium  sulphate 7   11 

Potassium  sulphate  with  potassium  sulphide 9.50 

Sodium  chloride 8  T ' . 

Magnesium  chloride 5.02 

Calcium  chloride  with  calcium  sulphate 4.81 

Insoluble  matter 0  Ml 

Organic  matter,  acid,  and  loss 2.00 

Total 38.00 

The  water  gives  off  a  large  quantity  of  sulphureted1 
hydrogen,  and  may  be  placed  in  the  saline  sulphureted 
class  of  mineral  waters.  We  are  informed  that  an 
analysis  by  Professor  Chandler,  of  New  York,  shows 
also  the  bicarbonates  of  lithium  and  strontium.  The 
other  spring  in  the  neighborhood  is  of  a  ferruginous 
character.  Emma  E.  Walker. 

Alcaptonuria. — A  rare  condition,  first  described 
by  Bodeker  in  1857,  in  which  the  urine,  clear  and  of 
normal  color  when  passed,  becomes  of  a  dark  brown 
and  finally  black  color  on  exposure  to  the  air.  This 
change  in  color  is  produced  immediately  upon  the 
addition  of  an  alkali,  such  as  a  solution  of  caustic 


188 


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Alcohol 


soda      The  addition  of  a  few  drops  of  ferric  chloride 

,,luti,PM  "i\r.,  «  ''I'"'  l'"1'"'  which  soon  fades,      me 
urine  reduces  Fehling's  solution,  a  fact  which  might 
cause  a  suspicion  of  diabetes,  but  the  specific  gravity 
is  normal,  the  fermentation  test  fails,  and  the  plane 
of  polarization  is  not  deviated.     Trine  presenting  this 
peculiarity  always  contains  homogentisic,  or  hydro- 
quinone-acetic,  acid  CsH80„  which,  though  not  itself 
nitrogenous,   is  derived  from   the  splitting  up  of  the 
aromatic   nucleus  of  albumin,  more  especially   from 
tyrosine  and  phenylalanine.     The  cause  of  this  con- 
dition is  unknown",  but  it  is  doubtless  due  to  some 
ormality    of    protein    metabolism,    analogous    to 
and   diabetes.     It    is  seen  more  frequently   in 
lis  and  may  be  intermittent  or  permanent  in  its 
irrence.      In  some  cases  it  appears  to  be  a  familial 
affection,  Osier  having  observed  it  in  four  members  of 
family.     It  is  said  to  be  observed  more  frequently 
in  cases  of  consanguinity  of  the  parents. 

AJcaptonuria  is.  so  far  as  at  present  known,  a  con- 

in  of  no  pathological  significance,  being  accom- 

ied  by  no  other  symptoms  of  functional  or  organic 

ise.     It    may.    indeed,    be    present    in    cases    of 

ochronosis,  but   is   not   a   necessary   accompaniment 

of    this     affection.     Gouget     (La     Prcsse     Olediccdi  . 

July  20,  1912)  has  found  a  number  of  references  in 

the" literature  of  the  past,  to  cases  of  melanuria  which 

.   probablv  instances  of  alcaptonuria.     Thus  Scri- 

ius  (1584),  Zacutus,  and  Lusitanus  (1649)  describe 

-  of  young  children  in  apparent  health  who  passed 

black  urine,  and  Schenck  (1609)  reports  the  case  of  a 

monk  who  presented  the  same  urinary  anomaly  during 

his  whole  life.  T.  L.  S. 

Alchemy  was  the  immature  chemistry  of  the 
Middle  Ages,  characterized  by  the  pursuit  of  the 
transmutation  of  base  metals  into  gold,  and  the 
ch  for  the  alkahest  and  the  panacea.  Adam, 
states  a  medieval  legend,  was  the  first  alchemist; 
one  cannot  say  absolutely  that  the  last  has  not  yet 
heen  born,  but  certain  it  is  that  the  alchemist  still 
lives,  and  thrives,  indeed,  in  this  twentieth  century. 
This  pseudoscience  existed  in  Egypt  and  India;  the 
Us  handed  it  on  to  Rome  and  Constantinople. 
The  rise  of  the  Christian  Church,  and  the  fall  of 
paganism,  contributed  a  belief  in  the  warring  spirits 
of  right  and  wrong,  and  in  the  constant  presence  of 
unseen  powers.  What  was  true  of  humanity  was  to 
the  medieval  thinker  true  also  of  non-sentient  matter. 
There  was  human  demonology;  and  the  half-under- 
Stood  chemical  phenomena  were  considered  demon- 
iaoal  struggles.  Thus  was  alchemy  part  and  parcel 
with  necromancy,  witchcraft,  and  the  black  arts. 
Many  of  the  alchemists  of  the  Middle  Ages  were  also 
true  mystics  and  followers  of  the  esoteric  teachings 
of  ancient  Egypt  and  Greece.  Alchemy  should 
have  died  when  Lavoisier  in  the  eighteenth  century 
discovered  oxygen  and  the  laws  of  the  conservation 
of  mass.  Instead  alchemy  simply  slipped  out  of 
scientific  society.  And  yet  even  to-day  chemists 
are  not  at  all  sure  regarding  the  number  of  elements 
in  matter,  or  whether  there  are  elements  at  all;  nor 
are  they  sure  of  the  impossibility  of  changing  one 
kind  of  matter  into  another.  It  has  oftentimes 
happened  that  out  of  charlatanry  comes  good;  cer- 
tain it  is  that  out  of  alchemy  was  born  the  modern 
ile  science  of  chemistry,  by  which  medical  science 
has  in  turn  so  greatly  benefited.     Johx  B.  Huber. 

Alcohol. — Ethyl  Alcohol;  Ethyl  hydrate;  Ethanol; 
Methyl  carbanol,  Spiritus  Vini.  The  term  alcohol 
formerly  restricted  to  grain  or  ethyl  alcohol,  but 
is  now  used  as  a  generic  name  for  a  definite  class  of 
bodies.  Other  alcohols  resemble  ethyl  alcohol  in 
their  properties;  that  is,  they  contain  hydroxy!  (OH) 
in  combination  with  a  hydrocarbon  radical.  The 
general  formula  for  an  alcohol  can  be  expressed  by 


"ROH,"   where  "R"  is  any  aliphatic  hydrocarbon 

radical.  When,  however,  "R"  is  an  aromatic  radi- 
cal,   the   resulting  compound   closely   resembles   the 

alcohols    in    its    properties,    but    possess    a    I e    acid 

character,  and  is  classified  under  the  phenols,  the 
type  member  of  \\  hich  is  carbolic  acid. 

The  alcohols,  while  not  alkaline  in  character, 
resemble   the   inorganic   bases  in  forming  salts  with 

acids.      The    compounds   so   formed   are   called  esters. 

Under  the  influence  of  dehydrating  agents,  two  mole- 
cules of  alcohol  lose  ft  molecule  of  water  and  an  ether 

IS  formed.  The  hydrogen  atom  of  the  alcoholic  hy- 
droxy! reacts  with  some  metals,  as  sodium,  and  forms 
alkoxides  or  alcoholates.  With  the  fixed  alkali'  , 
no  salts  are  formed,  while  the  phenols,  on  the  other 
hand,  form  definite  compounds.  Ordinary  alcohol, 
grain  or  ethyl  alcohol,  is  produced  by  (1)  the  fermen- 
tation of  a  saccharine  body;  (2)  synthesis  in  the 
laboratory. 

Preparation. — Alcohol  is  produced  by  a  particular 
ferment  (Torula  cerevi&ice)  acting  upon  saccharine  sub- 
stances, causing  them  to  split  up  into  alcohol  and 
carbon  dioxide,  e.g.: 

Glucose  =  Alcohol  +  Carbon  dioxide. 

C5H12Oa       =     2C,H,HO     +  2CO, 

Its  preparation  depends  on  the  property  of  glucose 
(dextrose)  to  decompose  into  carbon  dioxide  and  alco- 
hol in  the  presence  of  yeast.  On  account  of  the  pro- 
hibitive cost  of  dextrose,  substances  rich  in  starch, 
as  potatoes,  grain,  etc.,  are  used.  After  the  proper 
treatment,  by  which  the  starting  material  is  converted 
into  a  fine  pulp,  the  starch  is  converted  into  sugar  by 
an  enzyme  or  acid.  The  saccharine  solution  is  then 
fermented  by  the  aid  of  yeast.  The  resulting  liquid, 
containing  the  alcohol,  contains  also  carbonic  acid 
gas,  and  is  known  as  a  fermented  liquor.  It  may  be 
used  in  this,  the  carbonated  or  "sparkling"  condition, 
all  t he  effects  of  the  alcohol  exhibiting  themselves,  or 
it  may  be  left  until  the  CO,  has  escaped;  or  the  alcohol 
may  be  distilled  off  in  a  more  or  less  impure  condition, 
giving  us  a  distilled  alcoholic  liquor  or  spirit. 

Cane-sugar  and  milk-sugar  undergo  a  conversion 
first  into  glucose  and  then  into  alcohol.  Minute  quan- 
tities of  acetic  and  succinic  acids,  also  traces  of  alde- 
hyde, fusel  oil  (amyl  alcohol),  and  glycerin  are 
produced  at  the  same  time.  It  is  an  interesting  and 
important  fact  that  the  fermentation  gradually  ceases 
as  the  alcohol  produced  nears  eighteen  per  cent, 
strength,  and  when  the  latter  is  reached  further  action 
ceases.  This  is  due  to  the  action,  on  the  ferment,  of 
the  alcohol  itself;  the  strength  named  above  being  just 
able  to  precipitate  it.  In  the  grape  juice,  when  this 
strength  is  reached,  if  there  still  be  unfermented  sugar, 
a  "sweet"  wine  results;  if  none,  a  "dry"  wine. 

When  any  of  the  fermented  liquors  are  distilled,  al- 
cohol mixed  with  water  passes  over  into  the  receiver. 
Repeated  distillations  free  it  from  the  greater  portion 
of  higher  alcohols  and  water.  Its  degree  of  concentra- 
tion can  then  be  determined  by  taking  its  specific 
gravity  and  comparing  the  result  with  a  fixed  and 
official  table  in  which  the  strength  for  each  specific 
gravity  is  worked  out.  The  last  amounts  of  water  can 
be  gotten  rid  of  only  with  the  greatest  difficulty;  as, 
for  example,  by  distillation  over  quicklime  out  of 
contact  with  air  (from  which  it  rapidly  abstracts 
moisture). 

In  a  diluted  condition,  under  the  influence  of 
another  ferment,  alcohol  is  changed  to  acetic  acid  by  a 
process  of  oxidation;  thus,  e.g.  white  wine  vinegar 
is  produced. 


Alcohol 
C,.H,HO     + 


O, 


=     Acetic  acid 

=     CILO, 


+      Water. 

-f-     H,0. 


Alcohol  occurs  in  commerce  and  pharmacy  in  vary- 
ing degrees  of  concentration.  When  absolute  alcohol 
is  required,  it  should  be  freshly  prepared,  that  of  the 
shops    being    often    only   of   98   per  cent,   strength. 

IS!) 


Alcohol 


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Absolutely  pure  alcohol  is  a  colorless,  limpid,  pleas- 
antly smelling  liquid  having  a  sharp,  burning  taste; 
boiling  at  7S.5°  C.  (173.3°  F.),  and,  at  20°  C,  having  a 
specific  gravity  of  0.7895.  Its  affinity  for  water  is 
intense,  even  abstracting  it  from  the  air  when  the 
bottle  is  not  securely  corked.  If  it  be  mixed  directly 
with  water,  heat  will  be  produced,  the  volume  of  the 
mixture  being  less  than  the  sum  of  the  volumes  of 
the  components,  thus  showing  that  combination  has 
resulted.  It  is  a  solvent  of  great  power,  advantage 
of  which  is  taken  both  in  the  arts  and  in  medicine, 
e.g.  in  the  solutions  of  the  fixed  active  principles  of 
drugs,  called  tinctures,  or  the  solutions  of  the  volatile 
active  principles,  called  spirits.  It  dissolves  the  alka- 
loids, essential  oils,  many  resins,  some  fats,  and  C02 
freely. 

Its  distinguishing  chemical  properties  are:  (1)  its 
affinity  for  water,  (2)  its  coagulating  power  on  albu- 
minoids, and  (3)  its  antifermentative  power  when 
stronger  than  eighteen  per  cent.  Advantage  is  taken 
of  the  first,  in  the  mounting  of  microscopical  sections, 
to  abstract  all  the  water  before  immersing  them_  in 
the  oils  and  balsams;  of  the  second,  in  the  hardening 
of  the  tissues  for  study  and  section;  of  the  last,  in  the 
preservation  in  bulk  of  anatomical  specimens,  and 
those  medicinal  agents  which  undergo  change  in  other 
media. 

Alcohol,  U.  S.  P.,  is  defined  as  "a  liquid  composed 
of  about  91  per  cent.,  by  weight,  or  94  per  cent,  by 
volume,  of  ethyl  alcohol,  and  about  9  per  cent.,  by 
weight,  of  water."  It  has  a  specific  gravity  of  0.820 
at  60°  F.  and  boils  at  7S°  C.  (172.4°  F.). 

Alcohol  Absoluhim ,  U.  S.  P.,  is  "ethyl  alcohol,  con- 
taining not  more  than  1  per  cent.,  by  weight,  of  water." 
Its  specific  gravity  and  boiling-point  are  stated  above. 

Alcohol  Dilutum,  U.  S.  P.,  is  "a  liquid  composed  of 
about  41  per  cent,  by  weight,  or  about  48.6  per  cent. 
by  volume,  of  absolute  ethyl  alcohol,  and  about  59 
per  cent,  by  weight,  of  water."  It  has  a  specific 
gravity  of  0.938  at  60°  F. 

Alcohol  Deodoratum,  U.  S.  P.,  is  "a  liquid  composed 
of  about  92.5  per  cent,  by  weight,  or  95.1  per  cent,  by 
volume,  of  ethyl  alcohol,  and  about  7.5  per  cent.,  by 
■weight,  of  water."  It  has  a  specific  gravity  of  0.S16 
at  60°  F. 

Physiological  Action. — The  extraneous  effects  of 
alcohol  are  of  high  importance.  By  the  creation  of  a 
partial  vacuum  upon  the  cooling  of  an  enclosed  space 
previously  heated  by  burning  it,  glasses  are  affixed  in 
cupping.  It  is  a  powerful  disinfectant,  especially 
antizymotic,  being  thus  one  of  the  best  and  most 
generally  used  preservatives. 

Its  local  effects  are  even  more  important.  Exter- 
nally, it  is  cooling  by  its  evaporation,  although,  if  the 
solutions  have  a  strength  of  fifty  per  cent,  or  more,  it 
becomes  a  rubefacient,  especially  if  rubbed  into  the 
surface,  or  if  its  vapor  be  confined.  It  is  slightly 
locally  anesthetic,  especially  in  relieving  itching,  and, 
through  the  contraction  of  the  vessels  by  its  cooling 
effect,  may  locally  check  perspiration.  Its  solvent, 
combined  with  its  disinfectant  and  stimulant  proper- 
ties, render  it  a  useful  lotion  for  cleansing  diseased 
surfaces.  If,  however,  the  solution  be  strong,  it  acts 
rather  as  an  irritant,  and,  by  the  abstraction  of  water, 
and  the  partial  and  temporary  coagulation  of  the 
albumen,  as  an  astringent.  It  acts  very  promptly 
upon  mucous  surfaces,  being,  as  upon  denuded  tissues, 
stimulant  to  irritant  and  more  or  less  astringent.  Its 
presence  in  the  mouth  stimulates  the  secretions,  not 
only  of  the  mouth,  but  of  the  stomach.  Even  a  few 
drops  applied  at  the  base  of  the  tongue  have  been 
seen  to  produce  an  almost  immediate  flow  of  gastric 
juice.  The  intellectual  functions  are  thus  reflexly 
stimulated  also,  though  later,  by  direct  contact  with 
the  cells,  the  opposite  effect  is  produced,  upon  both 
the  salivary  glands  and  the  brain.  If  held  in  the 
mouth,  it  produces  a  numbing  effect. 

Small  quantities  of  alcohol,  properly  diluted,  taken 


into  the  stomach,  produce  an  agreeable  sensation  of 
warmth.  A  turgescence  of  the  capillary  plexus  of 
the  mucous  membrane  occurs,  which  is  speedily 
followed  by  a  free  secretion  from  the  gastric  follicles 
due,  in  all  probability,  to  (a)  the  increased  supply  of 
blood,  and  (,3)  the  stimulation  of  their  glandular 
orifices.  The  movements  of  the  stomach,  as  well  as 
its  secretions,  are  increased,  and  absorption  of  the 
products  of  digestion  is  greatly  hastened.  It  is 
therefore  one  of  our  most  powerful  stomachics  and 
digestive  stimulants.  These  effects  are  not  lost  upon 
the  absorption  of  the  alcohol,  but  appear,  upon  the 
contrary,  to  be  still  further  increased  by  its  presence 
in  the  circulation.  Its  presence,  however,  in  any 
considerable  quantity  in  the  food  mass  inhibits  pro- 
teolysis, while  in  concentrated  form  it  acts  rather  as 
an  irritant,  and  its  favorable  action  upon  digestion  is 
wanting.  The  direct  irritation  may  result  even  in 
vomiting.  Continued  concentrated  doses  tend  to 
produce  chronic  gastritis  and  gastric  catarrh.  More- 
over, the  continued  recourse  to  this  artificial  aid  to 
digestion  tends  to  necessitate  it,  and  in  increasing 
degree.  Larger  and  larger  amounts  are  apt  to  be 
required,  and  the  natural  powers  of  digestion  be- 
come permanently  and  seriously  impaired,  and  at 
length  may  be  almost  completely  lost.  Aside  from 
the  effects  upon  digestion  already  described,  the 
action  of  alcohol  in  the  stomach  is  one  of  reflex  stimu- 
lation of  the  heart  and  of  the  respiration,  provided 
t hat  the  drug  is  not  too  much  diluted.  In  the  intes- 
tine, peristalsis  is  directly  stimulated,  and  an  astrin- 
gent effect  produced. 

Alcohol  is  very  promptly  absorbed,  and  circulates 
as  alcohol,  in  which  form  it  comes  into  contact  with 
the  tissues  and  exerts  its  peculiar  activities. 

The  liver,  being  the  first  to  receive  the  blood  freshly 
charged  with  alcohol,  in  a  more  concentrated  con- 
dition than  after  dilution  by  the  general  circulation, 
is  the  first  to  feel  its  stimulating  effect,  and  the  first  to 
undergo  pathological  changes.  The  liver  cells  are 
stimulated,  and  as  a  result  we  have  an  increased  flow 
ofbile.  Later,  the  cellsenlarge  and  become  infiltrated 
with  fat  globules.  The  stronger  drinks,  particularly 
if  taken  undiluted,  and  if  the  practice  be  persisted  in 
for  any  considerable  period,  cause  an  irritation  of  the 
connective-tissue  cells  in  the  liver  surrounding  the 
portal  radicles.  A  proliferation  of  the  same  occurs, 
and,  as  a  final  effect,  contraction  of  this  newly  formed 
tissue — as  is  the  case  with  all  newly  formed  connective 
tissues— ensues,  producing  the  so-called  cirrhotic  or 
hob-nailed  liver.  With  the  primary  new  formation 
there  is  naturally  an  increase  in  the  size  of  the  organ, 
while  the  secondary  contraction  causes  an  atrophy  of 
the  liver  cells,  (a)  by  direct  pressure,  and  (,.))  by 
diminishing  their  normal  blood  supply.  In  I 
countries  where  the  more  dilute  alcoholic  drinks 
(wines  and  beers)  are  the  national  beverage,  cases  of 
cirrhosis  are  unusual;  while  the  contrary  is  true  whi  n 
the  more  concentrated  drinks  (brandy,  whiskey,  gin, 
or  rum)  are  largel}r  consumed.  Finally,  the  portal 
radicles  become  so  narrowed  by  the  contraction  of  tlie 
connective  tissue  in  which  they  lie  that  the  portal 
circulation  is  interfered  with,  thus  producing  a 
mechanical  congestion  of  the  intestinal,  peritoneal, 
and  gastric  capillaries,  with  ascites  and  watery  stools. 

Kidneys. — The  alcohol  being  in  a  much  less  concen- 
trated condition  on  reaching  the  kidneys  than  is  the 
ease  with  the  liver,  the  effects,  both  physiological  and 
pathological,  are  less  marked.  The  watery  portion  of 
the  urine  is  increased;  the  solid,  at  least  so  far  as  urea 
is  concerned,  is  diminished.  The  increased  amount 
of  water  excreted  is  a  natural  result  of  the  increi 
blood  pressure;  the  diminution  of  urea  is  due  to  the 
lessening  of  oxidation  of  the  nitrogenous  tissues.  In 
these  organs,  although,  the  irritating  results  manifest 
themselves  more  slowly  than  in  the  liver,  they  occur 
in  an  exactly  similar  manner.  Bright's  disease  is 
thus  frequently  induced. 


190 


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Ah  nliiil 


I  ]„■  effect  of  alcohol  upon  the  skin  is  moderately  to 
ncrease  perspiration.  'I  his  is  a  natural  result  of  the 
•utaneous  turgescence,  but  it  is  not  known  whether 
here  is  also  a  direct  stimulation  of  secretion. 

I  he  temperature  of  the  skin  is  temporarily  raised  I  v 
his   turgescence,   and    the   nerve  endings  are   thus 
vanned.     There  is  thus  a  false  impression  of  warmth 
created,    the    general    temperature    actually    falling 
liiiekly,  and  the  individual  being  especially  exposed 
o  the  evils  of  cold,     tn  chronic  alcoholism  there  is  apt 
,  be  interstitial  thickening  of  the  integument. 
Systemic  Effects. — In  spite  of  the  great  amount  of 
i  which  has  been  concentrated  upon  the  investi- 
gation  of    the  systemic  effects  of  alcohol,  our  con- 
clusions arc  doubtful  to  a  greater  extent  than  in  the 
ol  almost  any  other  drug.     There  seems  to  be 
room  for  question  as  to  the  ultimate  net  results, 
ml  a  great  deal  of  it  as  to  the  modus  operandi.     The 
ndications  are  those  of  a  drug  which  for  a  very  brief 
id   stimulates,    then   depresses    the  tissues  upon 
ii  it  acts.     As  to  the  depression,  there  is  nowhere 
question,  but  it  is  claimed  by  high  authority  that, 
nit  for  the  reflex  stimulation  already  noticed,  its  effects 
ipon  the  nervous  system  are  wholly  depressing,  the 
irent  stimulation  resulting  from  depression  of  the 
bitory   and    controlling  functions.      Undoubtedly 
his   weakening   of    will    power,    and    of    the    higher 
unctions  of  coordination,  plays  a  very  important  part 
:   i  lie  apparent   manifestations  of  stimulation,   and 
nuts  for  the  great  lack  of  uniformity  in  them  in 
lifferent  individuals;  yet  it  does  not  seem  possible  to 
nit  so  well  in  any  other  way  for  the  symptoms 
i^  by  assuming  the  existence  of  a  primary  stimulation. 
practical  study  like  the  present,  it  seems  more 
irofitable  to  discuss  the  conspicuous  net  results,  and 
■  id  extended  discussion  of  the  mechanism. 
Thi>   peculiar    interaction   between    the   effects   of 
deohol    upon    the    circulation    and    those    upon    the 
ous  system  renders  it  difficult  to  consider  either 
without  having  first  taken  up  the  other. 

As  a  result  of  the  systemic  effect  of  alcohol,  the  rate, 

md  to  a  greater  extent  the  force,  of  the  heart,  are 

eased,  and  this  sufficiently  to  increase  the  blood 

-lire,   in   spite  of  the  fact  that  there  is  marked 

ial  dilatation.     This  period  is  followed  by  one  of 

lepression,  and  the  first  stage  is  shorter,  even  almost 

altogether    wanting,    in    proportion    as    the    dose   is 

increased.      How  far  this  result  is  due  to  depression 

of   inhibition    is   one   of    the   questions   of   greatest 

dissension  among  physiologists. 

The  same  observation  of  an  increase  in  respiration, 
and  the  same  dispute  as  to  its  cause,  are  to  be  re- 
corded. In  any  case,  it  seems  clear  that  the  result  is 
nut  due  to  any  direct  central  stimulation. 

The  chief  nervous  effects  of  alcohol  are  upon  the 
brain,  especially  upon  the  cerebrum.  Its  action  is 
delirifacient,  there  being  a  preliminary  period  of 
stimulation  running  into  excitement.  Even  this 
stimulation  is  a  narcotic  one,  being  unequal,  and 
resulting  from  the  first  in  an  interference  with 
equilibrium.  It  is  because  this  increased  activity  is 
due  largely  to  inhibition  of  the  powers  of  self-control 
and  restraint  that  the  claim  has  been  advanced  that 
this  is  the  sole  cause,  and  that  alcohol  does  not 
directly  stimulate  at  all.  It  is  quite  evident,  however, 
that  such  a  result  would  necessarily  follow  the 
increased  cerebral  circulation  due  to  general  circula- 
stimulation,  even  if  there  were  not,  as  there 
appears  to  be,  a  direct  primary  stimulation  of  the 
rebral  cells.  Only  at  the  very  beginning  are  the 
mental  processes  quickened,  but  after  they  have 
become  slowed  and  blunted,  the  individual  still  be- 
lieves them  to  be  greatly  improved.  Despondency 
and  mental  pain  are  thus  decreased,  but  the  subject 
loses  his  judgment  and  becomes  talkative  and  other- 
wise demonstrative  and  self-asserting.  Intellectual, 
followed  by  sensory  and  motor  paralysis  then  comes 
on,  and    the   coma   stage   follows   that   of  delirium. 


Paralysis  of  respiration  and  particularly  of  circulation 
may  become  complete,  resulting  in  death.  During 
the  stage  of  depression,  vomiting  of  central  origin 
usually  appears. 

Alcohol  is  itself  Oxidized  as  a  food,  but  decreases 
tissue  oxidation.      This   may   to  some  extent    account 

for  the  reduced  temperature,  though  this  is  chiefly 

due    to    the    increased    heat    radiation    resulting    from 

engorgement  of  the  superficial  vessels.  It  is  more 
rapidly    oxidized    under    the    influence   of   exercise, 

exposure  to  cold,  and  in  fever,  'this  is  regarded  as 
the  normal  method  of  its  elimination,  only  five  or 
ten  per  cent,  ot  it  being  excreted  by  the  kidneys  and 
lungs  as  alcohol,  it  is  believed  that  this  nutrient 
function  does  not  at  all  relieve  the  demand  for 
nitrogenous  nutriment,  but  may  to  a  great  extent 
supply  that  for  carbonaceous.  The  latter  fact 
explains  the  accumulation  of  fat  in  alcoholic  subjei 
though  their  obesity  is  also  favored  by  the  decreased 
elimination  of  water  which  finally  takes  place. 

The  remote  effects  of  alcohol  may  be  good,  but  are 
far  more  likely  to  be  harmful,  due  to  excessive  use, 
or  to  use  continued  beyond  the  period  required.  The 
general  rule  should  be  to  use  alcohol  only  temporarily. 
If  used  only  to  the  extent  of  stimulating  the  digestion, 
it  can  result  in  great  improvement  of  nutrition.  But 
it  may  result  in  the  complete  destruction  of  digestion. 
If  properly  proportioned  as  to  dosage,  it  is  an  excellent 
food  in  fever,  but  it  may  be  used  so  as  to  exhaust  the; 
system.  It  can  be  used  to  benefit  the  excretory 
processes  of  skin  and  kidneys,  but  it  may  destroy 
cither  or  both,  resulting  in  cutaneous  hypertrophies, 
or  in  nephritis.  It  is  very  apt  to  induce  obesity, 
partly  by  interfering  with  the  elimination  of  water, 
ami  partly  by  checking  the  oxidation  of  fat.  It  has 
a  tendency  to  destroy  fine  cell  structure  everywhere. 
This  is  specially  seen  in  the  destruction  of  the  finer 
moral  and  intellectual  functions,  in  sensory  and  motor 
paralysis,  and  in  reducing  the  parenchymatous  liver 
tissue,  with  an  increase  of  its  fibrous  portions.  A 
peculiar  kind  of  mania  is  induced  by  it,  known  as 
delirium  tremens,  chiefly  characterized  by  hallucina- 
tions and  delusions  of  snakes,  demons,  and  other 
terrifying  subjects.  This  appears  to  be  connected 
with  some  peculiar  form  of  malnutrition,  as  it  never 
appears  until  after  the  loss  of  appetite  has  become 
pronounced.  The  ability  of  the  system  to  withstand 
exposure,  fatigue,  or  disease  is  slowly  but  most  surely 
destroyed  by  alcoholism.  This  is  especially  noticed 
in  pneumonia,  which  is  almost  certainly  fatal  to 
drunkards,  although  alcohol  is  one  of  the  surest 
reliances  in  supporting  pneumonic  patients  who  have 
not  been  addicted  to  its  use.  Fatal  acute  poisoning 
by  alcohol  is  not  unknown,  the  effects  pertaining  espe- 
cially to  respiration  in  some  cases,  to  circulation  in 
others. 

Various  accidents  are  frequently  mistaken  for 
intoxication,  especially  apoplexy,  coma  from  blows 
upon  the  head,  and  opium  poisoning,  and  many 
scandals  have  originated  from  wrong  diagnoses.  The 
greatest  care  should  be  taken  in  the  differential 
diagnosis  of  these  cases. 

Therapeutic  Uses. — The  therapeutic  local  uses  of 
alcohol  are  sufficiently  indicated  by  our  account  of  its 
local  effects.  Its  uses  as  a  digestant  are  undoubtedly 
its  most  important  ones,  if  we  regard  the  frequency  of 
employment.  Here  the  method  of  administration  is  of 
the  utmost  importance.  It  should  not  be  used  when 
any  inflammation  or  irritation  of  the  stomach  exists. 
The  smallest,  possible  dose  consistent  with  effectiveness 
should  be  employed.  A  teaspoonful  to  a  tablespoon- 
ful  of  brandy  or  whiskey  should  suffice.  The  strength 
as  imbibed  should  not  be  greater  than  five  to  fifteen 
per  cent.  It  should  be  taken  quickly  just  at  the 
beginning  or  during  the  early  part  of  the  meal.  If 
taken  too  soon,  the  effect  is  lost,  and  the  liver  may 
suffer.  If  taken  too  late,  it  interferes  with  digestion. 
Diluted  alcohol  is  preferable  to  liquors,  if  one  regards 


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the  danger  of  forming  a  habit.  The  administration 
should  be  carefully  watched  and  skilfully  controlled, 
and  an  effort  made  to  decrease  the  dose  almost  from 
the  beginning,  and  abandon  it  just  as  soon  as  possible. 
This  is  not  only  to  avoid  the  formation  of  drinking 
habits,  but  to  avoid  inducing  the  stomach  to  depend 
upon  the  artificial  stimulus. 

Its  next  most  important  use  is  as  a  food.  This  may 
be  at  such  times  as  ordinary  food  is  not  desired  or  not 
borne,  but  when  food  is  imperatively  required.  It 
may  then  be  taken  by  the  stomach  or  the  rectum. 
It  will  often  aid  in  the  digestion  and  assimilation  of 
milk,  besides  contributing  its  own  portion  of  nutri- 
ment. Therefore  a  milk  punch  is  one  of  its  most  use- 
ful forms,  but  one  of  the  most  dangerous  as  to  habit. 
In  fever,  it  is  useful  in  one,  injurious  in  another  class 
of  cases.  In  a  typical  case,  it  should  not  only 
nourish  the  patient,  but  calm  him,  and  reduce  the 
fever.  If  the  opposite  effects  are  induced,  it  should 
not  be  used.  Alcohol  is  a  fairly  good  carminative, 
and  brandy  is  astringent  in  many  cases  of  diarrhea; 
it  is  very  difficult  to  say  why.  Insomnia  may  be 
relieved  by  alcohol,  though  there  is  a  tendency  to 
require  its  continued  and  increasing  use,  and  this 
should  under  no  circumstances  be  permitted.  Gin  is 
an  excellent  diuretic,  but  the  alcohol  plays  probably 
a  subordinate  part. 

Alcohol,  if  taken  in  full  dose  and  very  early,  espe- 
cially with  an  abundance  of  water,  is  most  valuable 
in  breaking  up  an  impending  cold.  It  is  readily 
conceivable  that  the  most  disastrous  results  may  be 
thus  avoided,  when  we  consider  the  consequent  trans- 
fer of  blood  from  the  viscera  to  the  skin.  The  effect 
of  the  alcohol  must  in  such  cases  be  promptly  sup- 
plemented by  warm  external  applications,  or  at 
least  protective  coverings. 

Alcoholic  Liquors. — The  various  forms  of  alcohol 
can  profitably  be  here  considered,  rather  than  to  take 
them  up  in  their  regular  alphabetical  order  in  the 
different  parts  of  this  work.  The  alcoholic  liquids  of 
the  different  classes  are  as  follows: 

Kumyss  is  the  weakest  of  all  in  alcohol.  It  is 
simply  fermented  milk.  Mare's  milk  was  originally 
used,  but  it  is  now  very  often  substituted  by  cow's 
milk  variously  modified.  It  was  originally  fermented 
by  the  action  of  a  special  ferment,  but  yeast  is  now 
generally  employed.  It  should  be  used  while  fresh, 
never  more  than  four  or  five  days  old.  It  should  con- 
tain about  one  and  a  half  or  two  per  cent,  of  alcohol, 
and  be  strongly  carbonated.  There  are  also  traces  of 
unknown  ethers  developed  in  the  fermentation.  It  is 
estimated  to  contain  about  twelve  per  cent,  of  solid 
nutriment.  It  is  soothing  to  the  stomach,  without 
in  any  degree  retarding  digestion.  Its  primary 
stimulating  effect  is  followed  by  a  slight  soporific 
tendency. 

Beer,  Stout,  Ale,  and  Porter  are  made  from  barley, 
the  starch  being  first  converted  into  sugar  by  the 
action  of  the  diastase,  under  the  influence  of  heat 
and  moisture.  In  this  condition  it  is  Malt.  The 
malt  is  subjected  to  a  vinous  fermentation.  In 
making  beer,  this  is  done  slowly  at  a  low  temperature'. 
in  the  others  more  quickly,  at  a  high  temperature. 
The  darker-colored  stout  and  porter  are  made  so  by 
a  partial  burning  of  the  materials.  The  percentage 
of  alcohol  ranges  from  two  to  nine,  ordinarily  about 
four  or  five.  These  liquors  are  abundantly  carbon- 
ated and  they  contain  more  or  less  digestible  nutri- 
ment. They  appear  also  to  exercise  a  small  amount 
of  digestive  effect  upon  some  foods.  Hops  or  lupulin 
are  added  to  genuine  beer,  but  a  great  variety  of 
bitter  substances  are  in  use,  many  of  them  selected 
without  the  slightest  regard  to  their  injurious  effects 
upon  the  system,  so  that  beer,  if  prescribed,  should 
be  always  of  a  brand  of  known  composition. 

Various  other  seeds,  especially  rice  and  peanuts,  are 
similarly  used,  as  well  as  many  other  starchy  sub- 
stances.    Some  savage  tribes  are  ahead  of  us,  in  that 


they  use  substances  which  contain  distinct  medici- 
nal constituents,  together  with  the  alcohol-yielding 
portion. 

Wine,  Cider,  Pulque. — These  are  fermented  vege- 
table juices,  wine  from  the  grape,  cider  from  the 
apple,  and  pulque  from  the  century  plant.  If  used 
while  still  in  the  carbonated  state,  they  are  called 
"sweet"  or  sparkling,  otherwise  they  are  "hard"  or 
"  dry."  In  addition  to  the  carbonic  acid  and  alcohol, 
there  are  considerable  amounts  of  sugar.  When 
this  amount  is  large,  they  are  specially  called  "sweet." 
There  are  also  considerable  amounts  of  tartaric  and 
acetic  acids.  When  this  is  the  case  the  wines  are 
called  "sour."  A  variable  amount  of  tannin  is 
present  in  red  wines.  Wines  which  have  had  the 
percentage  of  alcohol  artificiallj-  increased,  as  port  and 
sherry,  are  called  "heavy"  or  "fortified  ". 

Vinum  Rubrum,  or  Red  Wine,  U.  S.  P.,  is  made 
from  the  entire  grapes. 

Vinum  Album,  or  White  Wine,  U.  S.  P.,  is  made 
from  grapes  from  which  the  skins,  seeds,  and  stems 
have  been  removed.  Each  contains  from  ten  to 
fourteen  per  cent,  of  alcohol. 

A  very  large  number  of  sugary  fruits  are  utilized  in 
the  manufacture  of  special  wines. 

Distilled  Spirituous  Liquors. — Any  fermented  alco- 
holic liquor  may  have  its  alcohol  distilled  off.  In 
this  process  various  other  substances  are  certain  to 
come  away  with  the  alcohol,  and  their  complete  re- 
moval is  very  difficult,  so  that  each  kind  of  spirit 
will  possess  its  characteristic  color,  odor,  and  taste. 
For  the  most  part,  however,  these  associated  matters 
have  not  a  high  degree  of  physiological  importance. 
Medicinally,  the  liquors  are  used  chiefly  for  their  alco- 
hol, and  there  is  little  choice  among  them.  The  physi- 
cian's responsibility  in  prescribing  brandy,  whiskey, 
and  other  pleasant  forms  of  alcohol,  and  thus  tending 
to  promote  alcoholic  habits,  is  very  great.  In  most 
cases,  dilute  alcohol  or  diluted  deodorized  alcohol, 
variously  admixed  so  as  to  obscure  its  character  or  to 
make  it  less  palatable,  can  frequently  be  employed 
with  equal  advantage.  Because  this  is  now  so  gen- 
erally done  by  the  more  cautious  class  of  physicians, 
and  as  there  is  so  little  genuine  prescription  demand 
for  brandy  and  whiskey,  it  is  seriously  proposed  to 
drop  them  from  the  Pharmacopoeia. 

Spiritus  Yini  Gallici,  or  Brandy,  is  distilled  from 
wine,  and  contains  thirty-nine  to  forty-seven  percent., 
by  weight,  of  alcohol.  There  must  be  no  admixture 
or  modification  of  any  kind,  and  it  must  be  at  least 
four  years  old.  With  the  ordinary  properties  of  its 
alcohol,  it  combines  a  distinctly  astringent  effect  upon 
the  bowels. 

Spiritus  Frumenti,  or  Whiskey,  U.  S.  P.,  is  similarly 
distilled  from  the  fermented  product,  "mash,"  of 
grain,  either  rye  or  corn  (the  latter  "  Bourbon  Whis- 
key"), or  mixtures  of  them.  It  should  be  at  least 
two  years  old  and  contain  from  forty-four  to  fifty 
per  cent,  of  alcohol. 

Gin  is  the  equivalent  of  the  compound  spirit  of 
juniper,  elsewhere  considered. 

Upon  keeping  spirituous  liquors,  various  ethers  de- 
velop in  them,  which  tend  to  make  them  pleasanter 
to  the  taste,  but  which  do  not  materially  modify  the 
action  of  the  alcohol. 

The  principal  impurity  of  alcohol,  especially 
of  whiskey,  is  fusel  oil,  or  Amylic  Alcohol,  next 
considered. 

Amylic  Alcohol. — Fusel  Oil;  Grain  Oil;  Potato 
Spirit  Oil.     (C,H„HO.) 

In  speaking  of  the  alcoholic  liquors,  reference  v  i 
made  to  fusel  oil  as  one  of  the  commonest  of  impu- 
rities. It  can  be  obtained  from  all  crude  alcoholic 
liquids,  and  is  removed  from  them  in  purification. 
It  is  chiefly  obtained  during  the  later  portions  of  their 
distillation,  and  is  much  more  abundant  in  spirits 
obtained  from  some  sources  than  from  others,  notably 
from  potato  spirit.     It  is  considerably  heavier  than 


192 


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Alcoholic  and  Drue 
Intoxication 


pure  ethyl  alcohol  (specific  gravity  0.818)  and  its 
boiling-point  (128  130  C.)  is  very  much  higher.  It 
has  an  oily  consistency,  is  colorless,  has  :i  powerful 
odor  and  a  burning,  acrid  taste,  the  inhalation  caus- 
ing headache.  Although  amylic  alcohol  has  very 
powerful   physiological   properties,   it    has   never  been 

b  utilized  in  medicine,  and  it  is  used  chiefly 
solvent   in   manufacturing  operations.      It   is  a   very 

, -rf ul  poison,  the  symptoms  being  those  of  great 

iression. 

Mi:tiiylic    Alcohol. — Methyl   Alcohol;    Wood   Al- 
Spirit;  Wood  Naphtha;  Columbian  Spirit; 
Pyroiylic  Spin!.     ( (II  .<  > II.) 

In  the  crude  pyroligneous  acid  distilled  from  wood 
'.c  Acid)  there  is  about  one  per  cent,  of  methyl 

ihol,  which  is  obtained  by  light  distillation,  after 
iddition  of  lime,  and  is  then  purified.     It  comes 
first  in  the  series  of  alcohols,  that  is,  it  is  the  simplest 
of  them.     It  has  been  found  somewhat  sedative,  es- 
pecially  to   the   cough   of   consumptive   patients,   in 

s  of  1  to  3  c.c.  (15  to  -15  minims),  yet  it  can 
t-lv  be  regarded  as  a  medicinal  substance.  As  it 
cannot"  be  used  as  a  beverage,  ten  per  cent,  of  it  is 
added  to  alcohol  in  England,  to  allow  of  the  use  of 
the  latter  in  the  arts  without  danger  of  defrauding 
the  customs  laws  relating  to  spirituous  beverages. 
This  mixture  is  known  as  Methylated  Spirit.  Methyl 
alcohol  is  excellent  for  burning  purposes,  owing  to  its 
large  percentage  of  carbon,  and  isrelatively  very 
cheap. 

Denatured  Alcohol. — In  190f>,  a  Federal  law  was  en- 
acted, providing  that  domestic  alcohol  may  be  with- 
drawn from  bond  without  the  payment  of  the  internal 
revenue  tax.  for  use  in  the  arts  and.industries,  and 
for  fuel,  light,  and  power,  provided  it  shall  have  been 
mixed  in  the  presence  and  under  the  direction  of  an 
authorized  Government  officer,  with  methyl  alcohol  or 
other  denaturing  material  which  is  destructive  of  its 
character  as  a  beverage  and  which  renders  it  unfit 
for  liquid  medicinal  purposes.  By  a  subsequent 
amendment,  it  was  specified  that  such  alcohol  can  be 
used  in  the  manufacture  of  definite  chemical  sub- 

ices,  when  the  alcohol  is  changed  into  some  other 

mical  substance  and  does  not  appear  as  alcohol 
in  the  finished  product. 

The  denaturing  material  employed  may  be  either 
ten  parts  of  methyl  alcohol  and  one-half  part  of  ben- 
zene to  one  hundred  parts  of  alcohol,  or  two  parts  of 
methyl  alcohol  and  one-half  of  pyridine  basis.  The 
characters  of  the  methyl  alcohol  and  pyridine  basis 
to  be  employed  are  specified,  as  are  all  other  condi- 
tions and  regulations,  in  a  pamphlet  of  169  pages  issued 
by  the  Internal  Revenue  Department. 

Toxicology. — The  internal  use  of  wood  alcohol  is 
most  dangerous  and  even  its  application  externally 
should  be  discouraged.     So  small  an  amount  as  a 

poonful  has  produced  serious  results,  as  has  ab- 
sorption through  the  skin,  notwithstanding  that  it  is 
often  applied  in  this  way  with  impunity.  Serious 
results  nave  also  followed  its  free  inhalation.  The 
poisonous  effects  are  much  like  those  of  formaldehyde. 
There  is  great  irritation  of  the  mucous  surface,  fre- 
quently with  severe  vomiting.  There  is  headache, 
mostly  frontal,  with  a  sense  of  pressure,  pain  and 
soreness  of  the  eyeballs;  later,  usually  from  the  second 
to  the  fourth  day,  there  are  disorders  and  then  loss 
of  vision.  Sometimes  this  first  failure  will  be  followed 
by  apparent  recovery,  but  total  blindness  almost 
certainly  supervenes.  Very  large  doses  may  result  in 
prompt  and  fatal  depression  following  an  initial 
period  of  irritation.  Most  cases  of  poisoning  by 
wood  alcohol  have  resulted  from  its  fraudulent  use 
in  liquors,  medicinal  preparations  and  flavoring  ex- 
tracts, and  most  of  the  States  now  have  stringent 
laws  against  its  use.  Very  little  can  be  done  in  the 
way  of  antidotal  treatment,  though  the  early  use  of 
pilocarpine  has  sometimes  resulted  favorably. 

Henry  H.  Rusby. 

Vol.  I.— 13 


Alcoholic  and  Drug  Intoxication  and  Habituation.— 

I  he  role  that  alcohol  plays  in  the  production  of 
psychoses,  while  admittedly  an  important  one,  is 
not  at  all  well  understood.  Recent  statistics,  con- 
servatively  interpreted,   would  indicate   that    about 

twelve  per  cent,  of  the  insane  confined  in  public 
institutions  in  the  United  States  are  there  because 
of  its  influence,  direct  or  indirect.    When,  however, 

the  multitudinous  ways  in  which  alcohol  may  enter 
as  a  factor  in  the  production  of  mental  disease  and 
the  far-reaching  effects  it  produces  are  considered, 
it  is  readily  seen  that  do  statistical  study  can  begin 
to  fathom  the  problem. 

While  the  psychoses  considered  under  this  heading 

clo.-ely  associated  with  alcohol  and  in  the 

main  present  fairly  constant  and  characteristic 
pictures,  it  must  not  be  forgotten  that  alcohol  may 
enter  as  an  etiological  factor  in  the  production  of 
symptoms  ordinarily  considered  to  be  quite  distinct 
from  the  alcoholic  psychoses  properly  so  called,  such 
as  the  manic-depressive  and  dementia  precox  psy- 
choses, while  it  is  considered  by  some  to  be  a  very 
important  causative  agent  in  paresis.  When  attacks 
of  these  psychoses  are  brought  about  by  alcoholic 
indulgence  it  is  probable  that  they  are  considerably 
modified  and  as  a  result  present  a  somewhat  atypical 
picture. 

That  the  psychoses  produced  as  the  result  of 
abuse  of  alcohol  are  dependent,  in  the  last  analysis, 
upon  something  besides  the  alcohol,  namely,  upon 
some  peculiarity  of  make-up  of  the  individual,  is  well 
shown  by  the  fact  that  while  a  history  of  abuse  of 
alcohol  is  frequent  in  cases  admitted  to  hospitals  for 
the  insane,  it  is  rare  to  find  at  autopsy  what  in 
general  hospitals  is  considered  so  typical  of  alcoholism, 
namely,  cirrhosis  of  the  liver.  This  means  that  the 
locus  minoris  resistentiae  in  these  cases  is  the  brain 
and  that  mental  disease  supervenes  before  the  liver 
becomes  involved. 

Psychology. — Alcohol  has  long  been  supposed  to 
be  a  stimulant.  Such  supposition,  however,  was 
based  largely  upon  false  interpretations  of  subjective 
experiences.  For  example,  one  feels  rested  from 
fatigue  by  a  small  dose  of  alcohol.  The  rested 
feeling  was  supposed  to  be  due  to  stimulation.  On 
the  contrary,  it  is  due  to  inhibition  in  the  sensory 
channels  conveying  the  sense  impressions  that  make 
up  the  feeling  of  fatigue. 

It  has  also  long  been  supposed  that  small  doses  of 
alcohol  produced  an  increase  in  the  power  of  muscular 
work  and  an  increase  in  efficiency  in  the  performing 
of  simple  mental  tasks.  This  stimulation  was  sup- 
posed to  continue  for  twenty  minutes  to  one-half  hour. 
The  recent  work  of  Rivers  and  Webber  indicates  that 
such  small  doses  produce  no  effect  whatever.  If  they 
are  correct  alcohol  then  remains  a  depressant  and 
paralyzant  from  the  first  without  any  effects  of 
stimulation  whatever. 

The  types  of  persons  who  drink  and  the  reasons  for 
drinking  are  many  and  varied.  While  there  are 
certain  social  factors  involved,  the  more  important  of 
the  conditions  lie  in  the  make-up  of  the  individual. 

First,  we  have  the  cases  in  which  the  drinking  is  the 
expression  of  a  psychosis  and  in  no  wise  its  cause. 
Here  we  find  especially  the  early  cases  of  paresis  and 
the  mild  cases  of  manic-depressive  psychosis.  The 
alcoholic  symptoms  may  completely  cloud  the  picture 
for  some  time. 

Second,  there  is  a  considerable  group,  to  which 
belong  those  who  drink  "to  drown  their  troubles," 
who  attempt  to  escape  from  reality  by  introducing  a 
veil  between  it  and  them,  by  making  themselves  less 
accessible  to  the  world  of  reality  by  dulling  their 
sensorium.  This  class  is  composed  of  hysterics  and 
members  of  that  large  group  of  psychasthenics.  It 
should  be  remembered  that  the  expressions  of  their 
difficulties  are  often  periodic  and  that  it  is  generally 
upon  such  a  groundwork  that  dipsomania  is  founded. 

193 


Alcoholic  and  Drug 
Intoxication 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Third,  there  is  a  considerable  group  who  are 
especially  susceptible  to  alcohol  and  although  not 
consuming  large  quantities  manifest  an  exaggerated 
reaction  to  small  doses.  Here  we  have  especially  the 
post-traumatic  constitution — cases  following  head  in- 
jury and  sunstroke — and  arteriosclerotic  and  senile 
cases.  These  are  the  unresistive  types  and  alcohol, 
like  fever,  proves  to  be  a  measure  of  their  resistance 
and  stability. 

Fourth,  we  have  alcoholism  entering  into,  compli- 
cating, and  modifying  the  picture  of  other  psychoses, 
particularly  dementia  pracox.  Not  infrequently 
praecox  cases  are  supposed  to  be  alcoholic  in  their 
early  stages  because  of  the  prominence  of  the  alcoholic 
features. 

Finally,  there  appears  to  be  a  certain  number  of 
purely  alcoholic  psychoses — that  is,  psychoses  de- 
pendent upon  alcohol  per  se.  Of  these  psychoses 
those  clearly  dependent  upon  the  effects  of  alcohol  are 
the  states  of  acute  intoxication,  including  patholog- 
ical drunkenness,  while  delirium  tremens,  alcoholic 
hallucinosis,  Korsakoff's  psychosis,  and  the  chronic 
alcoholic  psychoses  are  dependent  upon  long  indul- 
gence, and  whether  they  are  directly  thefurt  her  ex- 
pression of  chronic  alcoholism  or  are  in  some  way 
dependent  upon  the  secondary  elaboration  of  toxins 
the  result  of  disordered  nutrition,  they  certainly 
need  something  besides  the  simple  ingestion  of  a  toxic 
dose  of  alcohol.  Kraepelin  proposes  to  call  them, 
after  the  manner  of  the  psychoses  due  to  syphilis,  the 
meta-alcoholic  psychoses. 

Drunkenness. — The  phenomena  of  drunkenness 
are,  from  the  first,  phenomena  of  paralysis.  In  the 
early  stages  it  is  only  the  higher  psychic  functions, 
which  are  largely  inhibitive,  that  are  affected,  so  we 
get  apparent  stimulation  in  the  excitement  produced 
with  flight  of  ideas,  pressure  of  activity,  loss  of  the 
sense  of  propriety,  degradation  of  the  moral  tone,  and 
loss  of  power  of  voluntary  attention.  The  lower 
centers  then  become  paralyzed  and  then  appears 
muscular  incoordination,  manifesting  itself  first  in  the 
hands  and  facial  muscles  and  the  muscles  controlling 
articulation,  the  speech  becomes  thick  and  the  gait 
unsteady.  Sensory  disturbances  appear,  such  as  diplo- 
pia, tinnitus  aurium,  and  the  senses  of  touch  and 
pain  are  blunted.  If  the  paralyzing  action  of  the 
alcohol  continues,  coma  results  which  may  be  fatal. 
The  mood  during  intoxication  may  be  a  pleasant  one, 
and  frequently  is  one  of  boisterous  exaltation,  consti- 
tuting the  exalted  type;  on  the  other  hand,  a  sad, 
depressive,  lacrymose  mood  may  prevail,  constituting 
the  depressed  type. 

Pathological  Drunkenness. — Among  certain  predis- 
posed individuals  alcohol  produces  unusual  and  much 
more  severe  symptoms.  In  this  condition  we  may  find 
hallucinations  and  delusions  dominating  the  field  of 
consciousness,  the  delusions  being  usually  of  a  per- 
secutory character.  In  other  cases  the  excitement 
may  issue  in  a  wild,  maniacal  frenzy  or  the  depres-ion 
may  be  so  profound  as  to  result  in  attempts  at  suicide, 
In  some  persons  the  paralyzing  effects  of  alcohol  are 
unusually  pronounced  and  coma  appears  early  on  the 
scene.  Those  who  have  latent  hysterical  tendencies 
may  have  hysterical  attacks  during  intoxication, 
while  alcohol  frequently  produces  convulsions  in 
epileptics.  Aside  from  this  latter  action,  however, 
the  convulsive  properties  of  alcohol  alone  are  capable 
of  producing  convulsions  in  persons  who  have  long  in- 
dulged and  are  profoundly  degenerated,  though  this  is 
disputed  by  others  who  claim  that  such  individuals 
must  have  been  of  epileptogenic  make-up. 

In  these  cases  of  pathological  drunkenness  in  which 
the  reaction  to  alcohol  is  so  pronounced,  it  is  quite 
common  to  find  amnesia  for  periods  of  profound 
intoxication. 

Delirium  Tremens. — This  disorder  usually  occurs 
as  the  result  of  a  prolonged  drunken  debauch  in  a 
chronic  alcoholic,  during  which  the  patient  has  had 


insufficient  food  and  rest.  According  to  some  authors 
it  may  result  directly  from  the  withdrawal  of  alcohol'. 
It  may,  however,  appear  in  the  moderate  but  continu- 
ous drinker  as  the  result  of  a  single  excess,  following  a 
traumatism,  or  as  the  initial  symptom  of  an  acute 
illness. 

The  whole  question  of  the  occurrence  of  an  absti- 
nence delirium  is  a  mooted  one.  The  recent  researches 
of  Holitscher  on  this  point  are  illuminating.  The 
conclusion  appears  to  indicate  that  abstinence 
delirium  if  it  occurs  at  all  is  extremely  rare.  Care 
must  be  taken  in  reaching  a  conclusion  to  eliminate 
as  possible  causes,  wounds,  infectious  diseases,  psychic 
shocks,  operations,  etc.  We  must  remember  also 
that  in  many  cases  the  delirium  has  had  a  prodromal 
period  of  a  number  of  days,  and  that  one  of  the  symp- 
toms of  this  period  is  a  disgust  for  liquor.  The 
delirium,  therefore,  occurs  in  spite  of,  not  because  of 
abstinence.  The  disease  may  appear  suddenly,  but 
there  is  generally  a  prodromal  period  during  which 
the  patient  is  nervous,  with  coated  tongue,  suffering 
from  anorexia,  restlessness,  tremulousness,  disturbed 
sleep  and  insomnia.  This  condition  rapidly  advances 
with  the  onset  of  the  attack,  the  characteristic 
symptoms  of  which  are  rapidly  developed.  They  are 
tremor,  delirium,  and  albuminuria. 

The  tremor  involves  more  particularly  the  small 
muscles  of  the  hand,  face,  and  tongue,  but  may  also 
affect  the  entire  musculature.  It  is  increased  by 
muscular  tension,  such  as  forcibly  spreading  the 
fingers  apart. 

The  delirium  is  an  acute  hallucinatory  confusion. 
Disorientation  is  often  quite  complete,  the  patient, 
although  perhaps  fastened  in  bed,  believing  himself  in 
his  office  or  home,  surrounded  by  familiar  faces.  The 
predominating  hallucinations  are  visual  and  charac- 
teristically take  on  the  form  of  animals.  The  patient 
sees  all  sorts  of  horrible  creatures,  snakes,  rats,  mice, 
alligators,  etc.,  which  are  uniformly  in  motion. 
Surrounded  by  the  loathsome  creatures  and  by  hor- 
ribly grimacing  faces,  terrified  by  screams  and  shrieks 
(auditory  hallucinations),  he  presents  a  picture  of 
abject  terror.  In  addition  to  these  symptoms,  the 
patient  may  complain  that  insects  or  worms  are  crawl- 
ing under  his  skin  (paresthesia)  and  mistake  spots 
upon  the  bed  or  walls  for  bugs,  mice,  etc.  (illusions). 
At  the  height  of  his  excitement  the  patient  is  in  con- 
stant motion,  picking  insects  from  his  night-die--, 
repelling  the  approach  of  terrible  animals;  in  the 
extreme  frenzy  of  his  fright,  he  may  make  murderous 
assaults  on  those  about  him,  believing  them  to  be  his 
enemies,  or  perhaps  attempt  his  own  life  to  escape 
from  his  horrible  surroundings.  During  all  this  time 
the  patient  is  constantly  talking,  shrieking  in  fear  at  I 
times,  at  others  carrying  on  an  incoherent  discourse 
with  imaginary  persons,  fragments  of  which  often 
relate  to  his  former  occupation  and  friends. 

The  character  of  the  delirious  experiences  varies 
greatly.  One  patient  left  the  house  in  his  m 
clothes  and  went  a  distance  of  several  miles  attired 
thus  to  the  house  of  his  sister.  On  reaching  there  lie 
told  them  that  his  father  and  some  Chinamen  \ 
going  to  kill  him.  Another  patient  came  to  the 
hospital  with  the  history  that  he  suddenly  became 
disturbed  one  night  and  told  his  wife  that  he  saw  a 
troop  of  darkies  dancing  in  his  bedroom;  they  appeared 
to  be  rehearsing  a  play;  he  saw  a  strange  man  of  giant 
stature  jump  off  his  bookcase  into  his  wife's  bed.  He 
tried  to  chase  these  strangers  from  the  room,  and  as 
they  vanished  he  could  see  the  skirts  of  the  women 
and  the  heels  of  the  men  flitting  past  the  doors;  they 
would   invariably   return;    their   faces   mocked   him. 

Some  patients  do  not  present  this  picture  of  ex- 
treme restlessness  and  the  pressure  of  activity  is  not 
communicated  to  such  a  degree  to  the  function  of 
speech.  Such  patients  may  present  an  alert  appear- 
ance, be  fairly  calm,  and  can  often  be  taken  in  the 
lecture  room  before  the  class. 


194 


iiKi  i:i:i:\n:   handiwidk   01    tiik   medical  sciences 


Alcoholic  and  l>niu 
Intoxication 


The  mood,  ton.  may  be  quite  different ;  instead  of  be- 
ing in  a  condition  of  constant  apprehension  and  tear  of 
an  overwhelming  and   terrifying  environment,  they 
may  be  calm,  interested,  and  amused  by  their  delirious 
experiences.     The  patient  quoted  above  on  his  second 
day  i"  the  hospital  was  highly  entertained  by  the 
iearance  in  the  ward  of  a  man  with  a  monkey's 
\   walking  aliing  the  floor  in  a  barrel,  the  bottom 
hich  had  been  knocked  out.     Then  there  was  the 
"human   ironing   board."     This   was   a   man's   head 
I    to  an  ironing  board  on  wheels;  the  man  spit 
icco  juice  a fiout  the  floor  and  water  squirted  from 
eyes.     The  patient   was  much  amused  by  these 
riences  ami  told  the  doctor  how  he  loved  to  lie 
ed  anil  watch  it  come  and  go.     He  thought  these 
two  monstrosities  the  property   of   the  government 
that  they  were  intended  for  the  amusement  of  the 
nts. 

Another  patient  saw  flocks  of  partridges  about  his 

D  ami  a  turkey  an  inch  high  on  his  window  sill. 

spiders  and  thousand-legged  bugs  came  crawling  on 

bed.     These  hallucinations  produced  no  surprise 

lisgust.     He    merely    cited    them   as   of   passing 

■rest    while    talking.      His   aunt's   face    was   lying 

•  to  him  on  the  bed,  and  he  tried  to  kiss  it.     An- 

er  patient  in  the  hospital  saw  about  him  numerous 

of    Lilliputian    dimensions    anil    displayed    the 

liveliest  interest  in  these  strange  little  people. 

Often  dreamy  hallucinations  and  delusions  relate 
igether  to  his  occupation  and  the  patient  busies 
himself  with  his  usual  pursuits — occupation  delirium. 
Physically  he  is  in  a  condition  of  acute  exhaustion. 
The  pulse  is  rapid  and  of  low  tension,  the  temperature 
normal  or  only  slightly  elevated  (occasionally  high, 
the  febrile  delirium  tremens  of  Magnan),  the  body 
id  in  a  profuse  perspiration  and  constantly 
agitated  by  muscular  shocks  and  tremors.  Occa- 
ally  one  sees  cases  ushered  in  by  all  the  typical 
prodromal  symptoms,  sweating,  atonic  dyspepsia, 
restlessness,  tremor,  precordial  distress,  anxiety,  and 
disturbed  sleep,  which  do  not  proceed  to  the  typical 
lition  of  mental  confusion  with  multiform  halluci- 
nations. This  is  the  so-called  abortive  type,  the 
:  in  sine  delirio  of  Dollken. 

During  the  course  of  the  disease  almost  any  cxperi- 

ee  the  patient  may  have,  any  impression  made  upon 
his  sensorium  is  woven  into  the  warp  and  woof  of  his 
d  ilirious  experiences — sensory  flight  of  ideas.  Hallu- 
cinations seem  to  arise  spontaneously  or  are  easily 
produced  by  pressure  on  the  eyeball  or  merely  by 
Lr  ning  the  patient  to  look  at  a  blank  piece  of  paper. 
Paraphasia    and    paralexia    are    commonly    present. 

Albuminuria  is  found  in  a  considerable  proportion 
uf  cases,  probably  considerably  over  fifty  per  cent., 
.luring  the  early  stages.  At  the  height  of  the  delir- 
ium leucocytosis  has  been  found.  It  must  not  be  for- 
gotten, too,  that  here,  as  in  acute  toxic  states  gener- 
ally, a  sluggish  reaction  of  the  pupil  to  light  and  even 
complete  Argyll-Robertson  pupil  may  be  found. 
This  sign  disappears,  however,  on  recovery.  This  is 
an  important  fact  to  be  borne  in  mind  in  the  matter 
of  diagnosis. 

Acute  cardiac  dilatation  may  develop  at  the  height 
of  the  disease. 

Course  and  Duration. — The  psychosis  runs  an 
acute  course  of  about  three  days  and  terminates  in 
recovery  in  the  majority  of  cases.*  The  delirium 
usually  ends  in  a  long  sleep.  About  ten  to  fifteen 
per  cent.  die. 

Potliology. — Degenerative  conditions  are  found  in 
the  central  nervous  system — acute  degenerations  of 
the  ganglion  cells,  and  recent  hemorrhages.  The 
ganglion  cells  are  found  shrunken  and  there  is  increase 
in  the  glia  and  some  vascular  proliferation  with  slight 
round-celled  infiltration.  There  may  be  a  chronic 
leptomeningitis  and  some  narrowing  of  the  cell  layers 
of  the  convolutions.  Changes  are  also  found  in  the 
cerebellum.     The   alterations   in    the   Purkinje   cells 


are  supposed  to  be  correllated  with  the  motor  symp- 
tom— tremor  and  ataxia  (Kraepelin,  Allers). 

Wassermeyer  is  of  the  opinion  that  the  pathology 
indicates  that  the  delirium  results  from  an  increase  in 

the  chronic  alcohol  poisoning  rather  than   a   metabo- 
lism poison. 

Chronic  Alcoholism. — The  effects  of  chronic 
alcohol  poisoning  arc  exhibited  in  every  organ  of  the 
body)  mure  particularly  the  central  nervous  organs, 
stomach,  pancreas,  liver,  kidneys,  and  blond-vessels, 
and  give  rise  to  characteristic  symptoms  as  a  result, 
the  most  prominent  of  which  are  tremor,  gastric 
catarrh,  arteriosclerosis,  albuminuria,  and  progres- 
sive   mental    cnfeebleinent. 

The  effects  on  the  nervous  system  are  shown  in 
disturbances  of  sensation,  motion,  and  the  intellect. 
The  sensory  disturbances  arc  paresthesia  (prickling, 
tingling,  formication),  hyperesthesia,  and  hyperal- 
gesia. The  sensory  disorders  of  the  special  senses 
involve  principally  the  eye  and  ear,  producing  illu- 
sions and  hallucinations,  muscie  volitantes,  photopsia, 
amblyopia  and  amaurosis,  diminution  of  the  acute- 
ness  of  hearing  with  the  production  of  subjective 
noises  (hissing,  ringing,  roaring,  etc.),  due  to 
middle   or  internal  ear  disease. 

The  motor  disturbances  are  tremor,  spasms  and 
cramps,  epileptiform  attacks,  and  general  motor  en- 
feeblement. 

The  mental  changes  are  gradual  and  progressive, 
the  intellect  is  obtunded,  the  judgment  overthrown,  the 
moral  sense  blunted,  and  mendacity  appears  in  its 
most  bizarre  forms;  delusions  may  develop,  the  most 
characteristic  of  which  is  of  marital  infidelity  and  jeal- 
ousy, and  the  patient  sinks  gradually  into  a  condition 
of  permanent  mental  enfeeblement. 

Diagnosis. — Alcoholic  dementia  is  to  be  differen- 
tiated from  other  dementias  largely  by  the  history. 
Alcoholic  dementia  will  have  a  history  of  progressive 
mental  enfeeblement  closely  associated  with  alcoholic 
indulgence. 

Graeter  has  recently  called  particular  attention  to 
the  association  of  alcoholism  and  dementia  precox. 
Many  of  the  cases  of  mental  deterioration  associated 
with  over-indulgence  in  alcohol  will  be  found  to  be 
true  cases  of  precox  in  which  the  alcohol  is  only  an 
incidental  and  associated  feature. 

Alcoholic  Psbudoparesis. — On  a  groundwork  of 
mental  enfeeblement  the  alcoholic  may  develop  a  true 
expansive  delirium  which,  combined  with  the  signs 
of  alcoholism  (ataxia,  speech  defects,  tremor,  pupil- 
lary anomalies,  and  muscular  weakness),  may  make 
the  distinction  from  paresis  difficult — alcoholic  pseu- 
doparesis.  This  similarity  to  paresis  is  noticeable 
even  when  the  expansive  delirium  is  absent  in  cases 
in  which  the  mental  reduction  is  marked,  but  be- 
comes greatest  when  the  symptom  complex  above 
outlined  is  ushered  in  by  epileptiform  attacks. 

Diagnosis. — The  distinction  from  true  paresis  can 
usually  be  made.  Pupillary  inequality  is  more  com- 
mon and  the  permanent  results  of  apoplectic  insults 
(hemiplegia,  aphasia)  are  more  often  found  in  the  alco- 
holic form  than  in  the  true.  The  results  of  polyneu- 
ritis should  be  looked  for  and  if  found  suggest  alcohol- 
ism. The  most  reliable  differential  sign  is  found  in 
the  course  of  the  two  maladies.  True  paresis  is  pro- 
gressive, tending  toward  ever-increasing  degradation, 
while  in  the  alcoholic  form  removal  of  the  poison  re- 
sults very  shortly  in  a  remission  of  all  the  symptoms, 
even,  in  some  cases,  amounting  to  a  recovery.  The 
symptoms,  however,  reappear  subsequently  if  drink- 
ing habits  are  returned  to. 

It  must  not  be  forgotten  that  an  Argyll-Robertson 
pupil  may  be  transiently  present.  It  is  an  open 
question  whether  both  this  sign  and  the  whole  pseudo- 
paresis  picture  may  not  be  dependent  upon  the  pres- 
ence of  syphilis. 

Alcoholic  Epilepsy. — As  a  result  of  chronic  alco- 
holic toxemia,  the  symptoms  of  which  are  marked 


195 


Alcoholic  and  Drug 
Intoxication 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


throughout  by  their  explosive  character,  it  is  not 
strange  that  actual  convulsions,  alcoholic  epilepsy, 
should  complicate  the  morbid  picture.  These  con- 
vulsions, so  far  as  their  individual  characteristics  are 
concerned,  are  indistinguishable  from  true  epilepsy. 
Occurring,  however,  in  a  person  beyond  the  period  of 
adolescence  who  is  addicted  to  the  immoderate  use 
of  alcohol,  their  origin  should  be  suspected.  The 
diagnosis  is  made  clear  if  they  cease  upon  the  with- 
drawal of  alcohol.  As  this  sometimes  does  not  occur 
the  diagnosis  can  be  made  only  by  excluding  the 
causes  both  of  true  and  of  symptomatic  epilepsy  other 
than  from  alcohol. 

Alcoholic  Hallucinosis. — This  psychosis  may 
come  on  suddenly  in  a  chronic  alcoholic,  as  the  result 
of  an  unusual  excess,  or  it  may  be  of  gradual  evolution. 
It  is  sometimes  preceded  by  one  or  more  attacks  of  de- 
lirium tremens.  It  is  characterized  by  hallucina- 
tions, auditory  predominating,  thus  contrasting 
strongly  with  the  predominance  of  the  visual  hallu- 
cinations in  delirium  tremens. 

The  delusions  are  of  a  persecutory  nature,  in  which 
the  sexual  element  is  frequently  prominent,  and  show 
a  tendency  to  systematization.  The  system,  how- 
ever, is  of  rapid  growth  and  loosely  organized. 

Whether  of  sudden  or  gradual  onset,  the  first  symp- 
toms are  hallucinations,  with  which  persecutory 
delusions  are  intimately  bound  up.  The  patient 
hears  voices  making  all  sorts  of  inimical  remarks,  tell- 
ing him  that  his  children  are  not  his  own,  calling  him 
an  onanist,  reviling  or  threatening  him.  In  every 
way  his  persecutors  annoy  him  by  their  malign  com- 
ments. Visual  hallucinations  are  rare.  Hallucina- 
tions of  smell  and  taste  are  not  infrequent.  The  au- 
ditory hallucinations,  quite  characteristically,  tend  to 
fall  into  rhythm  with  outside  sounds,  as,  for  example, 
in  one  of  my  cases,  the  humming  of  a  dynamo. 

The  delusions  of  this  state  harmonize  well  with  the 
hallucinations.  The  patient  is  persecuted  by  invisible 
enemies  who  inject  noxious  vapors  in  his  room  at 
night,  poison  his  food,  draw  off  his  semen,  and  pro- 
duce nocturnal  pollutions. 

One  patient  heard  voices  of  enemies  whispering 
at  the  windows;  they  were  going  to  kill  him,  called 
him  a  variety  of  unpleasant  names  and  accused  him 
of  all  sorts  of  crimes.  The  patient  attempted  suicide. 
He  gave  a  history  of  being  troubled  with  noises  in  his 
cars  for  a  considerable  time,  resembling  the  click  of  a 
telegraph  machine.  When  he  was  drinking  these  noises 
became  voices.  Another  patient  thought  he  heard 
different  people  talking  about  him,  cursing  him,  and 
calling  him  vile  names.  Then  later  he  thought  he 
heard  his  thoughts  repeated.  While  on  a  drinking 
bout  he  wandered  about  aimlessly,  felt  that  he  was 
being  pursued,  and  heard  threats  made  against  him. 
He  bought  a  knife  and  walked  into  the  water.  In  the 
hospital  he  heard  his  old  friends  accusing  him  of 
sexual  perversions,  pederasty,  etc.  He  told  of  having 
heard  his  associates  say,  "  He  is  no  good;  we  will  get 
him  out  of  the  army,"  and  "  He  is  a  sucker  for  fixing 
a  horse  instead  of  allowing  the  veterinary  to  do  it," 
etc.  Another  patient,  a  sailor,  had  been  drinking 
heavily  while  on  shore.  When  three  days  out  at  sea 
he  began  to  hear  threats  against  him.  He  heard  the 
men  say  that  they  would  kill  him,  they  would  cut 
his  heart  out,  and  cut  him  into  50,000  pieces.  On 
the  evening  of  the  third  day  he  could  stand  it  no 
longer  and  thinking  that  he  saw  land  ahead  he  jumped 
overboard. 

Grandiose  delusions  do,  however,  occasionally  occur 
though  they  are  not  sufficiently  controlling  to  modify 
the  picture  in  any  essential  way.  A  case  cited  by 
Mitchell  shows  how  they  usually  manifest  themselves. 
In  this  ease,  in  the  midst  of  an  active  hallucinosis, 
during  which  the  patient  was  constantly  hearing 
voices  coming  from  the  air  and  out  of  the  floor,  and 
the  passing  trains  were  whist  ling  his  name,  and  while  he 
saw  faces  staring  at  him  from  the  walls,  he  had  an 


episode  during  which  he  assumed  chaTge  of  affairs 
gave  orders,  and  threatened  with  death  the  doctors 
who  refused  to  obey.  Bonhoeffer  reports  only  one 
case  with  grandiose  ideas,  which,  however,  were  only 
of  temporary  duration,  during  the  course  of  an  hallu- 
cinosis with  auditory  hallucinations  of  a  distinctly 
threatening  character,  and  one  case  in  which  the 
patient  heard  music,  but  otherwise  had  disagreeable 
hallucinations. 

In  this  state  the  patient  is  depressed,  apprehensive, 
often  fearful  of  impending  danger,  may  have  anxious 
and  angry  states,  and  often  reacts  by  attacking  his 
supposed  persecutors.  Throughout  this  condition  the 
patient  is  well  oriented  and  consciousness  is  clear. 

Some  of  these  cases  run  a  long  course  and  become 
chronic. 

Diagnosis. — The  diagnosis  from  delirium  tremens 
is  made  by  the  absence  of  disorientation  and  by  the 
marked  prevalence  of  auditory  hallucinations  in  the 
form  of  threatening  voices.  It  must  not  be  forgotten 
that  there  exist  cases  that  are  intermediate  in  their 
symptomatology  between  delirium  tremens  and  acute 
hallucinosis.  From  paranoia  the  distinction  is  made 
by  the  very  rapid  systematization  of  the  delusional 
system,  as  opposed  to  the  slow  evolution  in  that 
disease. 

Alcoholic  Psetjdoparanoia. — In  some  cases  of 
chronic  alcoholism  a  paranoid  state  is  developed,  in 
which  psychosensory  disturbances  (hallucinations) 
may  be  of  secondary  importance  or  not  present  at 
all.  The  characteristic  delusion  in  these  cases  is  that 
of  marital  infidelity. 

While  some  of  these  cases  develop  primarily  upon 
a  background  of  chronic  alcoholism,  others  may  fol- 
low directly  upon  an  attack  of  hallucinosis  or  de- 
lirium tremens. 

These  cases  have  a  long  course,  a  poor  prognosis, 
and  may  terminate  in  considerable  impairment. 

Diagnosis. — This  delusion  of  marital  infidelity  and 
jealousy  may  not  be  accompanied  by  any  noticeable 
degree  of  impairment  of  judgment  or  mental  cti- 
feeblement,  and  in  these  cases  it  may  be  extremely 
difficult  to  make  a  differential  diagnosis  between  this 
form  of  alcoholic  psychosis  and  true  paranoia. 
Particularly  is  it  difficult  to  recognize  paranoia  with 
subsequent  or  coincident  alcoholic  indulgence. 

Certain  other  paranoid  conditions,  especially  of 
the  involution  period,  may  present  this  picture  with 
the  characteristic  delusions  of  jealousy. 

Differentiation  is  made  by  excluding  alcohol  in  the 
anamnesis. 

Korsakoff's  Psychosis. — The  mental  state  of  this 
psychosis  accompanies  polyneuritis  and  is  usually  of 
alcoholic  origin,  but  may  be  caused  by  other  poi 
as  those  of  typhus,  tuberculosis,  influenza,  diabetes, 
the  metallic  poisons,  etc.,  and  the  Korsakoff  syn- 
drome is  seen  not  infrequently  in  general  paresis  and 
in  senility.  The  signs  of  polyneuritis  may  be  very 
slight. 

Symptoms. — The  patient  is  usually  a  chro 
alcoholic  and  may  enter  the  hospital  suffering  from 
delirium  tremens.  The  delirium  instead  of  clearing 
completely,  as  is  usual,  merges  into  Korsakoff's 
psychosis,  which  has  often  been  called  chronic  alcoholic 
delirium  in  contradistinction  from  delirium  tremens, 
which  is  an  acute  alcoholic  delirium. 

The  mental  symptoms  are  the  result  of  a  charac- 
teristic combination  of  disorders  of  attention  and 
memory,  together  with  a  serious  defect  in  the  sense  of 
time.  The  result  is  a  peculiar  type  of  amnesia 
There  is  a  defect  in  the  recording  of  present  evi 
resulting  in  an  anterograde  amnesia.  In  more  severe 
cases  this  amnesia  may  reach  back  a  considerable 
distance — retrograde  amnesia — but  the  events  of 
early  life  and  long  distant  occurrences  are  well 
remembered. 

This  defect  of  memory  is  associated  with  a  com- 
posed   bearing    and    apparent    lucidity    on    casual 


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Alcoholic  and  Drug 
Intoxication 


questioning.  A  more  careful  examination,  however, 
will  show  not  only  this  memory  defect,  but  probably 
also  that  the  patient  is  disoriented  as  to  time  and 
place. 

The  characteristic  symptom  is  associated  with  the 

,   i;l    and   consists  of  a   peculiar  falsification  of 

nory.     The  gaps  in  memory  are  filled  by  all  sorts 

of  fabrications  which  are  narrated  in  great  detail  and 

with    a    perfeel     appearance    of    lucidity — opportune 

ibulation. 

A  patient  who  had  been  confined  to  his  bed  for  days 

ith  font- and  wrist-drop  told  inc.  when  asked  where 
he  was  the  day  before,  about  having  gone  to  the  races 
and  detailed  his  conversation  with  different  person-, 
described  the  events,  told  what  horses  won,  and  the 
like. 

One  such  patient  says  to  the  physician  on  approach- 
ing the  bed:  "I  am  pretty  sleepy.  I  have  just  had  a 
over  home  and  I  came  over  here  to  lie  down 
in."     Asked  if  his  wife  had  been  to  see  him  lately 

0    had  'idled  the  day  before),  said  that  he  saw  her 

two  days  ago  and  added:  "  I  was  just  out  there  at  the 

front  window  a  few  moments  ago  to  see  if  she  was 

ing."      Being  questioned  as  to  what  he  had  for 

dinner  yesterday  (he  was  on  a  milk  diet),  said  he  had 

ie   delicious  New  York  plums,  the  usual  vege- 

and  cocoa." 

Often  delirious  experiences  seem  to  be  related  to 
the  neuritic  pain.  This  same  patient  told  once  how  a 
big,  black,  burly,  ugly  negro  grabbed  his  sore  legs 
lays  before  and  how  it  made  him  angry. 

Another  patient  tells  how  two  years  ago  he  was 
chloroformed  by  unknown  parties.  He  awoke  just 
hey  had  escaped  from  the  room  and  saw  a  machine 
.in  his  right  foot.  (He  suffers  from  pain  and  weak- 
ness in  this  foot  and  ankle.)  This  was  crushing  the 
tendons  of  the  instep.  He  immediately  dropped  off 
leep  again.  When  he  awoke  the  next  morning 
the  instrument  of  torture  had  been  removed,  but  he 
suffered  from  pain  and  weakness  in  that  right  foot 
and  also  to  some  extent  in  the  left  foot. 

In  many  cases  the  fabrications  can  be  suggested  by 
leading  questions  and  the  patient  may  be  led  to  make 
almost  any  statements,  no  matter  how  contradictory 
gestion  confabulation. 

One  patient,  confined  to  bed,  -when  asked  what  he  did 
the  day  before,  replied:  "I  took  the  horse  and  buggy 
out  and  took  a  drive,  my  father  being  in  Baltimore; 
I  don't  know  whereabouts  I  had  him  fed;  I  went 
down  Pennsylvania  Ave.  and  Fourteenth  Street." 

Another  patient,  when  asked  what  she  had  for 
breakfast,  proceeded  to  give  a  bill  of  fare,  none  of  the 
articles  of  which  she  really  had  had. 

These  pseudo-remin  iscences  are  usually  unstable  and 
fleeting,  or  at  least  seldom  told  twice  alike.  Such  for 
instance  is  the  following:  "  A  few  weeks  ago  I  was  out 
walking  on  the  Washington  Heights,  you  know,  just 
beyond  the  Treasury,  with  a  friend.  It  was  during 
lunch  hour  at  the  office.  We  saw  some  cattle  grazing 
on  the  hillside  and  we  thought  we  would  have  a  little 
shooting  match.  I  went  down  to  the  man  and  he 
gave  me  a  gun  and  I  fired  away  and  hit  a  steer  right 
behind  the  ear.  It,  of  course,  killed  him.  They  all 
laughed  and  considered  me  a  crack  shot.  They  sent 
me  a  check  for  it  the  next  day.  It  was  for  a  pretty 
large  amount,  but  I  do  not  remember  just  how  much. 
I  suppose  by  looking  up  the  records  I  could  find  just 
uuch  they  did  give  me." 

Sometimes,  however,  some  of  them  become  fixed. 
It  is  fairly  common,  for  example,  for  women  to 
ive  and  act  as  though  they  had  a  baby  in  bed 
with  them. 

With  this  state  of  mind  the  patient  is  usually  very 
poorly  oriented  if  not  completely  disoriented.  His 
time  sense  i<  particularly  affected. 

Physically  the  patient  typically  has  all  the  signs  of 
a  polyneuritis,  which  of  course  differs  in  its  distribution 
according  to  the  etiological  factor.     In  the  alcoholic 


type,  which  is  the  mo  t  common,  wrist-drop  and 
foot-drop  are  characteristic  symptoms.  Of  com  e 
various  unusual  and  anomalous  involvements  may 

occur,  for  example,  of  the  cranial  nerves.  Bulbar 
and  vagUS  involvement   are  naturally  most   serious. 

Inasmuch  as  the  pathology  of  the  disease  shows  that 

it    is    not    confined    to    the    peripheral    nerves    but    is 

general,  involving  the  whole  of  the  nervous  system, 

cord,    basal  ganglia,  and  cortex,  and  inasmuch  also  as 

there  seems  to  be  some  tendency  to  the  localization 
of  the  pathological  process,  we  might  expect  to  find, 
and  as  a  matter  of  fact  do  find  in  certain  cases,  focal 

symptoms.     These  an-  the  various  types  of  aphasia, 

apraxia,  reading  and  writing  disturbances,  homonym- 
ous hemianopsia,  etc. 

Pupillary  disturbances  are  not  infrequent.  In- 
equality of  the  pupils,  sluggishness  to  lighl  and 
accommodation  reflexes,  and  transitory  Argyll- 
Robertson  pupil  may  be  present.  .More  rarely 
various  kinds  of  ocular  palsies  or  muscular  weaknesses 
occur. 

Clinical  Forms. — Various  clinical  types  of  the 
disease  have  been  described  according  to  the  promi- 
nence of  special  symptoms.  Thus  Dupre  describes 
five  as  follows:  (1)  amnesic,  (2)  confusional,  (3) 
delusional,  (4)  anxious,  and  (5)  demented.  Knapp 
describes  eleven  forms:  (1)  delirious,  (2)  stuporous, 
(3)  demented,  (4)  hallucinatory  without  systematiza- 
tion  of  false  ideas,  (5)  hallucinatory  with  systematiza- 
tion  of  false  ideas,  (6)  paranoic!,  (7)  anxious,  (8) 
expansive,  (9)  manic  and  melancholic,  (10)  poly- 
neuritic motility  psychosis  (of  Wernicke),  and  (11) 
anomalous.  Of  course  it  will  be  understood  that  this 
separation  of  forms  of  the  disease  is  nothing  more  than 
giving  the  name  of  the  most  prominent  symptom. 
Thus  in  the  stuporous  type  stupor  is  especially  in 
evidence,  etc. 

Diagnosis. — The  association  of  the  peculiar  falsi- 
fication of  memory,  with  confabulation  and  usually 
disorientation,  with  foot-  and  wrist-drop  is  charac- 
teristic. Paresis  is  to  be  distinguished  by  the  absence 
of  evidences  of  polyneuritis. 

Dream  States. — Less  common  and  more  unusual 
effects  of  alcohol  are  the  conditions  of  so-called  trance, 
automatism,  double  consciousness,  spontaneous  som- 
nambulism, which  are  followed  by  amnesia.  In  these 
conditions  the  subject  of  alcoholism  may  do  almost 
anything  imaginable,  make  contracts,  transfer  prop- 
erty, commit  criminal  acts,  take  long  journeys,  enter 
into  complicated  business  or  professional  transac- 
tions, and  later  have  absolutely  no  knowledge  of  what 
he  has  done.  During  a  protracted  debauch  the  sub- 
ject may  suddenly  start  off  on  a  journey  and  travel 
under  an  assumed  name,  meanwhile  conducting  him- 
self in  such  a  manner  as  not  to  lead  to  any  comment 
on  the  part  of  those  whom  he  meets.  Suddenly, 
without  warning  or  after  a  night's  sleep,  he  "wakes 
up''  to  a  realization  of  his  true  situation  with  abso- 
lutely no  memory  of  how  he  got  where  he  is  or  what 
he  has  been  doing  since  he  started  away  from  home. 
As  the  name  indicates,  this  condition  has  been  de- 
scribed as  one  of  automatism,  but  a  moment's  con- 
sideration will  serve  to  show  that  acts  of  such  a  com- 
plex character  cannot  be  automatic  acts.  The  fact 
that  no  recollection  remains  of  what  was  done  has 
been  used  to  argue  unconsciousness,  but  that  is 
equally  inconceivable.  Hundreds  of  miles  could  not 
be  travelled  by  an  unconscious  man  without  attract- 
ing attention.  The  mere  fact  that  the  patient  has 
forgotten  what  occurred  is  no  reason  why  he  must 
necessarily  have  been  unconscious.  I  have  been 
fully  able  to  demonstrate  that  consciousness  actually 
did  exist  in  certain  cases  that  I  have  studied  which 
were  followed  by  amnesia,  and  as  a  result  I  am  con- 
vinced that  the  same  condition  might  be  found  to 
exist  in  others.  Some  persons  are  especially  liable 
to  this  form  of  mental  disturbance,  and  it  may  re- 
peat itself  on  the  occasion  of  renewed  intoxication. 

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Its  psychopathological  basis  is  probably  a  dissocia- 
tion of  consciousness. 

Course. — Chronic  alcoholism,  whether  interrupted 
or  not  by  any  of  the  forms  of  mental  disturbance  de- 
scribed in  this  chapter,  tends  to  an  ever-increasing 
dementia,  alcoholic  dementia.  Mental  enfeeblement 
is  a  symptom  from  the  outset  and  is  noticeable  at 
first  in  the  esthetic  and  moral  sphere.  The  previously 
proud,  well-dressed  man  becomes  slovenly  in  his 
habits  and  unkempt  in  his  appearance.  Incapable 
of  the  close  and  continuous  mental  application  of 
former  years  it  becomes  impossible  for  him  to  meet 
the  requirements  of  his  business  or  professional  life 
and  lying  is  resorted  to  in  finding  excuses.  This  is 
followed  by  moral  obliquities  of  a  more  serious  nature 
in  which  the  sexual  element  is  apt  to  predominate 
and  result  in  medicolegal  complications.  Memory 
is  early  and  noticeably  affected.  The  every-day 
affairs  of  life  are  forgotten,  so  that  the  subject  of  alco- 
holism neglects  to  keep  appointments,  forgets  impor- 
tant business  engagements,  etc.  Judgment  and  the 
reasoning  faculties  are  similarly  enfeebled,  until  finally 
the  most  profound  degree  of  dementia  is  reached, 
hastened  perhaps  by  apoplectic  insults  which  are  not 
uncommon. 

Pathology. — The  gross  pathology  of  alcoholism  has 
already  been  indicated.  Cirrhotic  liver,  chronic  ne- 
phritis, fatty  heart,  chronic  gastritis,  arteriocapil- 
lary  fibrosis,  cerebral  arteriosclerosis,  and  cerebral 
hemorrhage. 

The  principal  lesions  found  in  the  brain  are  pachy- 
meningitis, edema,  congestion,  thickening  and  opacity 
of  the  piarachnoid,  atrophy  of  the  convolutions, 
sclerosis  of  the  vessels,  degeneration  of  the  cells,  and 
increase  of  neuroglia. 

Treatment. — The  treatment  of  delirium  tremens 
and  the  other  acute  alcoholic  psychoses  should  be  sup- 
porting; liquid  concentrated  food,  predigested  if 
necessary.  The  bowels  should  be  kept  free  and  the 
kidneys  kept  flushed  by  a  goodly  supply  of  fluid. 
Heart  stimulants  are  often  necessary,  digitalis, 
caffeine,  strychnine,  to  combat  cardiac  failure,  and 
hypnotics  to  induce  sleep  and  give  rest.  The  latter 
should  be  carefully  selected  with  reference  to  the  pa- 
tient's condition,  depressing  agents,  such  as  chlo- 
ral, giving  place  to  safer  ones  as  trional  if  there  is 
much  heart  embarrassment.  The  after-treatment  con- 
sists of  abstinence  from  alcohol,  tonics,  nourishing 
food,  and  regulation  of  the  emunctories. 

For  the  excitement  especially  hydrotherapy  in  the 
form  of  the  continuous  bath  is  valuable.  The  thing 
to  be  kept  constantly  in  mind  in  these  eases  is  the 
matter  of  nourishment.  If  the  patient  does  not  take 
sufficient  food,  tube  feeding  should  be  begun  at  once 
without  any  delay  in  temporizing.  Food  alone  will 
often  ameliorate  in  a  remarkable  manner  the  excite- 
ment and  the  insomnia. 

The  medicinal  treatment  of  chronic  alcoholism 
should  be  tonic  and  supporting.  Strychnine  for  a 
general  nervous  and  cardiac  stimulant,  ergot  if  there 
be  symptoms  of  "wet  brain,"  capsicum  and  bitter 
tonics  for  the  gastric  condition  and  anorexia;  atten- 
tion to  the  emunctories,  moderate  exercise,  baths, 
massage  and  electricity  for  their  general  tonic  effects; 
sedatives  and  hypnotics  with  caution;  a  modified 
"rest  treatment"  if  there  is  marked  neurasthenia, 
and  later  a  sufficient  amount  of  mental  and  bodily 
exercise  to  keep  the  patient  healthfully  occupied. 

The  matter  of  isolation  is  an  important  one.  I 
feel  convinced  that  in  all  cases  in  which  the  habit  is 
firmly  fixed  isolation  is  highly  desirable,  if  not  im- 
perative, as  in  these  cases  the  patient  is  unable  to 
resist  temptation  and,  as  soon  as  opportunity  presents 
itself,  will  lapse.  After  confinement  for  a  few  months, 
during  which  the  patient  is  restored  as  far  as  possible 
to  physical  health,  he  is  in  condition  to  abstain  if  he 
wants  to  and  is  able;  if  he  does  not  wish  to  or  if  he 
suffers  from  too  great  weakness  of  will,  he  will  return 


to  his  old  practices  and  his  case  is  hopeless.  If  he 
does  wish  to  stop  drinking,  however,  he  has  been  given 
the  best  possible  opportunity,  an  opportunity  which 
should  be  early  extended  in  all  cases  and  not  offered 
when  by  long-continued  indulgence  the  case  is  of 
necessity  hopeless. 

Opiumism. — Causes. — As  in  other  varieties  of  nar- 
comania the  most  important  cause  is  the  neuropathic 
diathesis.  In  this  class  of  patients  the  habit  is  often 
initiated  by  the  use  of  morphine  to  relieve  the  periodic 
pains  of  neuralgia,  tabes,  dysmenorrhea,  rheumatism 
etc.,  or  the  mental  depression  incident  to  worry,  loss 
of  position,  grief,  and  the  like.  A  great  many  ca 
are  unfortunately  traced  to  the  carelessness  of  p) 
cians  in  prescribing  the  drug,  and  as  if  in  retribution 
medical  men  furnish  the  largest  quota  of  sufferers  (fif- 
teen per  cent.). 

Symptoms  and  Diagnosis. — The  symptoms  of  a  sin- 
gle dose  are  at  first  those  of  mild  stimulation  of  the 
mental  faculties,  followed  by  a  period  of  quiet,  half- 
waking,  half-sleeping,  interrupted  by  multiform  pleas- 
ant hallucinations  (predominantly  visual)  which  show 
no  tendency  to  delusive  elaboration  in  the  waking 
slate.  This  condition  is  followed  by  malaise, head- 
ache, dry  mouth,  constipation,  and  nausea. 

The  physical  symptoms  of  prolonged  use  of  opium 
in  any  of  its  forms  are  anorexia,  irregular  action  of 
bowels,  constipation  alternating  with  diarrhea,  car- 
diac weakness,  general  muscular  weakness  and  tremor, 
miosis  and  sluggish  pupils,  impotence,  amenori 
diminished  sensibility,  paresthesias,  sensation  of 
coldness. 

Mentally  there  is  a  gradual  degradation.  The 
memory  and  power  of  attention  become  impaired 
and  the  capacity  for  initiation  is  lost.  Then 
marked  impairment  in  the  ethical  feelings  and  pre- 
viously honest  persons  will  begin  by  lying  out  "f 
business  engagements  and  about  the  taking  of  the 
drug  and  end  by  associating  with  the  most  degraded 
persons  and  resorting  to  any  means  whatever,  even 
criminal,   to  obtain    the  drug. 

Some  persons  who  have  taken  opium  in  some  form 
for  a  considerable  time  and  in  large  doses  develop  an 
hallucinated  state  that  may  be  of  paranoid  coloring  or 
may  be  distinctly  delirioid.  Thus  one  patient  (laud- 
anum and  whiskey)  on  admission  to  the  hospital  said 
that  her  food  was  poisoned.  Another  patient  (mor- 
phine) is  restless  and  excited,  has  hallucinations  of 
hearing,  and  carries  on  conversation  with  imaginary 
persons.  Sometimes  her  language  is  violent  and 
abusive,  she  threatens  her  imaginary  persecu 
and  will  jump  out  of  bed  and  run  through  the 
hall-way  looking  for  the  people  she  thinks  are 
after   her. 

The  diagnosis  can  often  not  be  made  without  the 
anamnestic  data.  The  patients  frequently  deny  their 
habit — mendacity  is  a  prominent  symptom,  and  they 
are  often  cute  enough  to  find  means  of  indulgence 
even  though  carefully  watched.  The  moral  deg- 
radation is  pronounced  and  they  will  go  any  length 
to  obtain  their  drug.  Symptoms  which  should  ex- 
cite suspicion  are  periods  of  torpor  and  languor  in 
marked  contrast  to  the  activity  of  alcoholism,  amount- 
ing at  times  to  an  inability  even  to  sit  up,  occasio 
signs  of  stimulation,  small  pin-point  pupils,  yellowish- 
brown  cachectic  complexion,  and,  above  all,  the  numer- 
ous scars  of  hypodermic  injections.  In  conditions  in 
which  a  diagnosis  is  necessary  it  is  to  be  remembered 
that  morphine  can  be  recovered  from  the  urine  and 
stomach. 

The  least  serious  method  of  taking  the  drug  is  by 
smoking,  the  next  more  serious  by  mouth,  and  the 
most  serious  method  is  the  hypodermic.  Morphine 
is  distinctly  more  dangerous,  more  dominating  after 
habituation,  than  the  other  forms.  It  is,  too,  more 
serious    in    its    effects    upon    the    general    health. 

Prognosis. — The  prognosis  is  not  good  and  except 
in  such  cases  as  are  not  complicated  by  neurotic  or 


I '.IS 


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Alcoholic  anil  Drue 
Intox  Icatlon 


psychopathic  taint  or  disorders  relieved  by  opium, 
recovery  is  hardly  to  be  expected. 

>logy.     Opium    has  less   tendency  to   produce 
[issue  degeneration  than  alcohol  and  many  persons 

continue    for  years   to    take   small   doses   With    no   ap- 
parent  harm. 

Trent i',:  "i.     The  treatment  of  morphinism  has  to  do 
with  the  removal  of  the  drug  and  the  symptoms  of 
abstinence.     Isolation    is   more    necessary   than    in 
alcoholism,  as   these  patients  make   more  effort  to 
tin  their  accustomed  stimulant  surreptitiously.     It 
II,  in  accordance  with  Dercum's  suggestion,  not  to 
n  stopping  the  drug  until  thepatienthasbeenunder 
itment  fur  a  time,  confidence  being  established,  and 
t he  general  health  raised  to  the  best  standard.     The 
luxe  can  then  be  rapidly  withdrawn,  in  ac- 
vrith   the   method   of   Erlenmeyer,   leaving 
patient  on  about  0.15  to  0.20  gram  morphine  per 
i,  below  which  amount  serious  symptoms  are  apt 
present    themselves.     From    this    point    on    tfie 
withdrawal   should   be   gradual.     Symptoms   of   ab- 
if  they  appear,  are  referable  to  the  heart, 
aach,  bowels,  and  nervous  system:  the}'  are  circu- 
latory    failure,     respiratory     disturbance,     pyrosis, 
vomiting,    diarrhea,    tremor,    general    debility,    and 
hallucinatory     delirium     and     sometimes     profound 
ipse.      Ball   has  called  attention  to  pollutions  and 
erotomania  which  may  result  from  abstinence.      For 
the  cardiac  weakness  digitalis  or  sparteine  hypoder- 
illy  should  be  used;  for  the  pyrosis,  bicarbonate  of 
nin;  vomiting  and  diarrhea  should  be  treated  in 
ce   with  general  principles   (bismuth,   etc 
opium  being  avoided.     If  the  mental  and  physical 
symptoms  become  grave  morphine  should  be  given 
and   will   usually    relieve    them.     The   evening   dose 
should  be  omitted  last,  to  combat  any  tendency  to  in- 
somnia, and  full  feeding,  massage,  and  hydrotherapj' 
aluable  adjuncts. 
Meconarceine  (Duquesnel's  solution)  has  been  used 
Jennings  a-  a  substitute  for  morphine  for  a  few  days 
after  entire  discontinuance.     It  is  necessary  to 
■  ■all  attention  to  the  danger  of  cocaine  for  this  purp<  ise. 
ine  has  also  sunk  into  disuse  and  the  synthetized 
derivatives  of  morphine,  heroin,  dionin,  and  peronin, 
aot  be  said  to  be  any  better.     Their  use  is  founded 
on  a  wrong  theory  and  is  fraught  witli  danger.     Cases 
i  ious  addiction  to  codeine  and  heroin  have  been 
reported. 

unism. — Causes. — Addiction  to  this  drug  has  in 
a  great   many  cases  come  about  by  attempting   to 
substitute  it  for  morphine,  and  as  a  result  pure  cases 
of  cocainism  were  formerly  more  rare  than  at  present, 
line  has  been  used  so  much  of  late  in  dentistry, 
minor  surgery,  and  especially  nose  and  throat  work, 
that  a  knowledge  of  it  has  become  more  or  less  general. 
The  victims  are  often  those  who  have  commenced 
its  use   for   its  analgesic  effects  and  are  frequently 
<  ians. 
ptoms. — The  symptoms  resulting  from  the  use 
of  cocaine  are  those  of  marked  stimulation.     The  pulse 
is  increased,   pupils  are   dilated.     The   patients  are 
active  and  extremely   talkative,  often  repeating  re- 
marks a  number  of  times;  they  are  constantly  busy. 
~ome  of  them  writing  endless  letters,  and  their  whole 
tearance  indicates  an  acute  intoxication.    The  ef- 
-  are, however,  very  fleeting  and  the  dose  has  to  be 
frequently    renewed.     Chronic    addictions    result    in 
marked     emaciation,     cachectic    anemia,    insomnia, 
times  epileptiform  attacks  and  various  paresthe- 
tic most  marked  of  which  is  a  sensation  of  crawl- 
inder  the  skin  ("cocaine  bug")-     In  the  psychic 
re    occur     incapacity     for     mental     application, 
aed    moral    sense,    mendacity,    irritability,    im- 
paired   judgment,    and    sometimes    the    delusion    of 
marital  infidelity.     These  symptoms  may  be  followed 
by   mental   confusion   with   hallucinations,    or   by   a 
paranoid  state.     From  true  paranoia  this  is  differen- 
■'1  by  the  greater  variety  of  delusions,  those  of 


paranoia  being  less  Variable,  rather  noticeable  for 
their  QOtony.  In  the  paranoid  -tale  of  alcohol- 
ism, on  tin-  o'tner  hand,  the  hallucinations  are  more 

stereotyped. 

The  absl inence  symptoms  are  ncit  so  severe  as  with 
morphine  and  may  not  appear  for  several  days. 
Erlenmeyer  has  called  attention  to  a  profoundly 
depressed,    lacrymose,    demoralized    condition,    with 

moaning  and  sighing,  which  may  supervene.  The 
persecutory  delirium  may  persist  for  a  long  time  and 
constitute  the  patient  a  dangerous  individual. 

Morphine  and  cocaine  addictions  may  also  bring 
out  a  neuropsychopathic  state,  with  symptoms  of 
psychasthenia — morbid  impulses,  insistent  ideas,  etc. 
line  such  r:i-i  sutleied  fn.ni  a  convulsive  tic  with 
mental  depression  and  suicidal  impulse.  Recovery 
followed  prolonged  abstinence. 

Treatment. —  Isolation  should  be  insisted  upon. 
The  drug  may  be  withdrawn  rapidly  a-  the  symptoms 
of  abstinence  are  not  as  marked  as  in  morphine.  The 
prognosis  of  deprivation  is  good,  but  relapses  are 
pretty  a] it  to  occur. 

Miscellaneous  Intoxicants. —  V a r i o us  other 
drugs  may  produce  marked  mental  disturbances  as  a 
result  of  acute  or  chronic  poisoning  or  habituation. 
Ihe  limits  of  this  article  permit  only  of  their  mention. 
They  are  chloral,  cannabis  indica,  somnal,  sulfonal, 
paraldehyde,  ether,  chloroform,  aspirin,  antipyrine, 
phenacetin,  trional,  chloralamid,  iodoform,  belladonna, 
hyoscyamus,  salicylic  acid,  quinine,  the  preparations 
of  lead,  arsenic,  and  mercury,  and  the  bromides. 

It  should  be  realized  that  many  of  these  drugs  are 
drugs  in  common  use  and  that  unless  the  possibilities 
of  their  producing  a  psychosis  are  borne  in  mind  such 
an  accident  may  arise  as  the  result  of  large  doses  or 
even  of  moderate  doses  in  especially  susceptible 
persons.  It  is  just  such  cases  as  these  together  with  the 
■  ases  that  arise  as  the  result  of  taking  several  drugs, 
analgesics  and  hypnotics,  that  one  meets  and  finds 
that  no  suspicion  has  arisen  as  to  the  true  cause  of  the 
trouble.  Attention  has  recently  been  called  to  the 
frequency  of  bromide  delirium  (O'Malley  and  Franz, 
I  asamajor).  Casamajor  has  called  particular  at- 
tention to  the  frequency  with  which  bromide  de- 
lirium  is  produced   in   the   treatment  of  alcoholism. 

The  character  of  the  delirium  in  these  cases  may  1  it- 
described  as  dream-like.  The  content  of  the  delirious 
experiences  reminds  one  of  delirium  tremens,  while  the 
tendency  to  confabulation  reminds  one  of  Korsakoff's 
ps3'chosis.  The  patients  are  not  usually  apprehen- 
sive and  restless  as  in  delirium  tremens,  but  more 
composed  and  may  be  dull  and  stupid,  though  there 
are  not  infrequently  outbreaks  of  violence  dependent 
upon  paranoid  experiences.  The  following  extracts 
from  cases  will  illustrate  these  points: 

The  patient,  a  woman,  fft.  thirty-six,  had  been  tak- 
ing morphine  hypodcrmically  and  bromides,  chloral, 
anil  hyoscine  hydrobromate.  On  admission  she  sees 
men  in  rubber  garb  who  stay  in  the  water  and  look 
at  her  constantly.  She  also  sees  the  king  and  queen, 
bugs  and  snakes,  and  bull-dogs  with  huge  open 
mouths.  Says  the  king  and  queen  congratulated 
her  when  she  picked  up  the  broken  glass  at  F — 's 
on  Ninth  Street.  She  hears  bull-dogs  scream  and 
answers  imaginary  voices.  Electricity  is  played  on 
her  by  Dr.  B —  and  she  feels  snakes  which  crawl  about 
her  neck.  Says  there  are  men  who  throw  green  pow- 
der about  the  room. 

Another  patient,  woman,  a?t.  thirty-eight,  had  been 
taking  antirheumatic  treatment  with  aspirin  to 
relieve  pain  and  later  morphine  and  hyoscin.  She 
related  the  following  delirious  experience  that  oc- 
curred just  before  admission: 

"  I  believed  that  a  party  of  us  were  going  down  in 
the  country  on  a  picnic  and  that  a  cavalry  regiment 
had  been  ordered  out.  When  we  got  started,  we 
found  that  a  whole  regiment  of  Indians  and  negroes 
were  following  us.     We  went  to  the  place  in  the  coun- 


109 


Alcoholic  and  Drug 
Intoxication 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


try  where  I  was  born  and  brought  up,  and  there  we 
found  a  hospital  which  was  to  be  used  for  earing  for 
us  until  the  negroes  and  Indians  were  allowed  to  kill 
us.  The  patients  in  the  hospital  were  all  in  little 
beds  just  like  at  Providence,  but  were  all  sitting  up. 
The  doors  were  looked  so  that  we  could  not  get  out, 
but  I  could  hear  the  negroes  and  Indians  talking 
about  killing  us.  They  decided  to  divide  the  party 
up  and  take  us  to  their  different  camps.  They  also 
talked  of  blowing  the  hospital  up  with  dynamite. 
They  talked  of  setting  fire  to  a  haystack  that  was 
situated  near  my  mother's  home.  I  heard  them  pre- 
paring fuse  which  was  to  be  used  in  exploding  the 
dynamite.  I  was  dreadfully  afraid  all  the  time  I 
was  at  Providence  Hospital  and  felt  that  I  was  among 
enemies.  I  thought  the  nurses  were  trying  to  do  the 
best  they  could  for  me,  but  that  they  were  in  the 
employ  of  the  Indians  and  negroes." 

Another  patient,  female,  let.  thirty-seven,  took 
"bromo-quinine"  for  two  weeks  when  she  developed 
a  delirium.  The  following  is  the  substance  of  a 
letter  she  wrote  while  suffering  from  the  delirioid 
experiences.  "Just  go  there,  I  cannot  talk,  I  am 
under  a  terrible  spell,  I  do  not  know  what  it  is,  but  it 
is  the  most  wonderful  experience  I  ever  had.  I  am 
hypo,  I  am  hypnotized.  I  ma}'  be  in  a  trance  for 
three  months.  Do  not  for  God's  sake,  bury  me  alive 
— Molly.  Keep  me  out  of  the  grave  four  or  five 
months.  It  will  be  all  right.  You  will  hear  some 
things  that  will  surprise  you.  Ben,  go  in  that  room 
for  God's  sake,  there  is  a  man  in  there,  he  scares 
everybody  dumb,  I  cannot  talk,  but  for  God's  sake, 
break  down  that  door.  Take  Jack,  he  has  got  a  good 
strong  arm,  break  that  door  down.  That  poor  man 
is  suffering,  I  saw  him  do  something  terrible,  and  it 
awed  me  so  I  am  half  paralyzed.  For  God's  sake, 
break  that  door  down,  hurry  up." 

In  a  case  of  bromide  delirium  (reported  by  O'Malley 
and  Franz)  the  patient  had  taken  on  an  average 
300  grains  of  bromide  daily  for  fifteen  days.  Her 
case  illustrates  well  the  dream-like  character  of  the 
hallucinatory  and  delusional  experiences.  She  was 
disoriented  on  admission.  Three  days  later  said  she 
had  spent  the  night  in  the  city,  was  with  a  large  crowd 
of  men  and  women,  that  her  husband  was  dead  and 
that  she  had  seen  his  body  buried.  The  next  day, 
asked  where  she  had  been  the  night  before,  said,  "I 
was  over  to  the  gipsy  camp;  I  went  over  in  northeast 
Washington  and  saw  them  kill  my  husband — smash 
his  head;  his  brother,  who  is  a  sculptor,  made  a  form 
of  his  head;  I  saw  it;  he  will  be  buried  to-morrow." 
A  few  minutes  later  her  husband  visited  her.  She 
told  him  she  thought  he  was  dead,  took  him  to  task 
severely  for  putting  her  in  the  hospital  and  being 
unkind  to  her,  but  throughout  the  visit  insisted  that 
he  had  been  killed.  Six  days  after  admission  she 
still  had  visual  hallucinations — saw  cats  and  rabbits; 
thought  some  of  the  women  patients  were  men, 
thought  she  had  to  walk  on  cats'  heads  when  she 
left  her  bed  and  that  the  physicians  were  watching 
her  from  the  register  plate  in  her  room.  Later  she 
complained  that  she  was  "spirited  away  every  night 
by  some  influence." 

In  the  treatment  of  these  cases  the  principal  thing  is, 
of  course,  the  removal  of  the  drug,  though  often  the 
underlying  condition,  for  which  the  drug  was  taken — 
pain,  insomnia,  must  then  be  treated.  It  must  lie 
borne  in  mind  that  it  may  take  several  weeks  for  the 
patient  to  clear  up  after  all  drugs  are  discontinued. 

William  A.  White. 


Aldehyde. — The  aldehydes  form  a  class  of  chem- 
ical compounds.  Of  this  class,  acetic  aldehyde  is 
the  commonest  example,  and  accordingly  the"  word 
aldehyde,  when  used  singly,  is  understood  always 
to  mean  that  substance.  '  Acetic  aldehyde,  CTL.- 
COH,  is,  from  the  point  of  view  of  chemical  com- 


position, the  first  outcome  of  the  oxidation  of  com- 
mon— ethylic — alcohol.  It  resembles  alcohol  very 
closely  in  physical  and  physiological  properties, 
being  a  thin,  colorless  fluid  of  pungent  smell  and 
taste;  inflammable,  miscible  in  all  proportions  with 
water,  alcohol,  and  ether;  antiseptic,  irritant,  and 
narcotic.     It  is  not  used  in  medicine. 

R.  J.  E.  Scott. 


Alder. — Abuts;  Brook  or  Tag  alder.  Alnus  Tournef. 
is  a  genus  of  a  dozen  or  more  species  in  the  family 
Betulaccw,  distributed  through  the  north  temperate 
zone,  and  extending  along  the  mountains  into  the 
tropics.  The  bark  and  leaves  are  rich  in  tannin,  and 
therefore  strong  astringents,  without  special  char- 
acter. They  are  used  in  tanning,  and  have  numerous 
domestic  medicinal  uses,  all  depending  upon  the 
action  of  the  tannin.  Finely  powdered,  they  have 
been  found  very  useful  by  travellers  for  applying  to 
chafed  surfaces.  The  wood,  deprived  of  the  bark, 
makes  a  favorite  charcoal  for  powder  manufacture. 

H.  H.  Rusby. 


Alder,  Black. — Prinos;  Wititerberry.  The  bark  of 
Ilex  verticillata  Gray  (fam.  Aquifoliacece).  (For  the 
properties  of  other  species  of  this  large  and  interesting 
genus,  the  reader  should  consult  Mate,  Holly,  and 
Cassine.)  The  plant  under  consideration  is  a  lars;r. 
shrub,  growing  in  hedges  and  borders  of  forests  in  the 
Northeastern  United  States,  and  displaying  in  fall  and 
early  winter  slender  branches  densely  covered  with 
shining,  scarlet  berries. 

The  bark  is  smooth,  grayish  or  whitish  ash-colored, 
and  when  dried  for  medicinal  use  is  in  "  thin,  slender 
fragments,  about  one  millimeter  (■,'-  inch)  thick, 
fragile,  the  outer  surface  brownish  ash-colored,  with 
whitish  patches,  and  blackish  dots  and  lines,  the  corky 
layer  easily  separating  from  the  green  tissue;  inner 
surface  pale  greenish  or  yellowish;  fracture  short, 
tangentially  striate;  nearly  inodorous,  bitter,  slightly 
astringent." 

It  contains  tannin,  resin,  and  an  amaroid.  No 
special  physiological  properties  are  known,  but  it 
has  been  used  as  a  tonic  and  mild  astringent.  The 
dose  is  two  to  four  grams    (5  ss.  to  i.). 

H.  H.  Rusbt. 


Alectrobius. — A  genus  of  ticks  which  contains  some 
species  that  are  parasitic  on  man.     See  Arachnida. 

Aleppo  Evil. — See  Oriental  Sore. 

Aletris. —  I'nieorn  root;  Star  grass;  Mealy  starwort; 
Colic  root.  Sometimes  erroneously  called  Blazing- 
star.  The  rhizome  of  Aletris  farinosa  L.  (fain. 
Liliaceai).  This  plant  is  a  low,  slender,  erect,  per- 
ennial herb,  common  in  swamps  and  low  land-  cast  of 
the  Mississippi  River.  It  has  been  much  used  in 
domestic  practice  as  an  abdominal  stimulant.  It 
contains  an  unknown  bitter  principle,  soluble  in 
alcohol  and  somewhat  in  water.  The  use  of  !li» 
drug  is  purely  empirical — in  colic  and  rheumatism. 
The  fluid  extract  is  the  best  form  of  administration, 
and  is  given  in  doses  of  0.5  to  1  c.c.  (ni  viij.-xv.). 

Seven  other  species  of  Aletris  are  known,  one  in  tin' 
Southern  States  and  six  in  Fastern  Asia,  but  their 
properties  have  not  been  investigated. 

H.  H.  Rt/sby. 


Aleurobius. — A  genus  of  the  cheese    mites.    Tiirn- 
glyphince,    which    is    found    in    flour,  fruit,  tobacco, 

cl se,  and  other  organic  materials.     A.  farina  has 

been  observed  to  be  the  cause  of  a  cutaneous  eruption 
on  men  unloading  wheat.     See  Arachnida.     A.  S.  !'■ 


200 


REFERENCE    HANDBOOK    OF    THE    .MEDICAL    SCIENCES 


AlKlers 


Alexander  of  Tralles. — Alexander  was  born  in 
fralles,  a  small  city  (if  Lydia,  during  the  reign  of  the 
■mperor  Justinian,  about  the  middle  of  the  sixth 
entury.  After  travelling  for  some  time  in  Italy. 
Spain,  and  Egypt,  he  finally  settled  in  Rome,  in 
\  hich  city  he  published  several  treatises  I  hat  summed 
m  i  lie  results  of  his  long  experience  in  the  observation 
mil  treatment  of  disease.  Here  are  the  titles  of 
iome  of  these  works,  several  editions  of  which  (both 

•k    and    Latin)     were    printed    during    the    period 
,,  1498  to  1772:  "Libellus  de  febribus,"  "De  arte 
lica,"  "De  corporis  partium  segritudinibus,"  "  De 
mbricis,"  and  "Problematum  medicorum  et   nat- 
tralium  libri  duo."     These  books  display  an  extra- 
ordinary degree  of  independent  thinking  on  the  pari 
if  the  author,   for  it    must   be  remembered   that   he 
1  at  a  time  when  the  science  of  medicine  had  sunk 
lo  a  very  low  level;  indeed,  they  are  worthy  in  many 
ects  of  being  read  by  physicians  of  the  present 
time.  A.  H.  B. 

Alexin. — This  is  the  term  originally  used  by 
Buchner  to  designate  that  substance  in  immune 
scrum     which     caused     bacteriolysis.      It     was     later 

overed  that  this  substance  really  consisted  of 
two  bodies,  one  specific,  the  amboceptor,  the  other 

-essiug  little  or  no  specificity  now  called  the 
complement  or  alexin.  The  alexin,  also  called  end- 
body  or  cytase,  probably  consists  largely  of  a  pro- 

ftic  ferment  which  acts  upon  cells  causing  1yds. 
It  is  present  in  all  sera  to  a  greater  or  lesser  extent 
and  is  unable  to  attack  cells  unless  joined  to  them 
by  means  of  the  amboceptor.  Alexin  is  destroyed  by 
heating  to  56°  C.  for  half  an  hour  and  gradually 
becomes  inert  on  standing  even  though  in  the  cold. 
\  scrum  thus  "inactivated,"  that  is  robbed  of  its 
alexin,  may  be  reactivated  by  the  addition  of  fresh 
scrum  from  the  same  or  some  other  animal.  As 
alexin  from  one  animal  can  be  used  to  activate  the 
scrum  of  another  or  to  cause  lysis  of  a  number  of 
different  cells  it  evidently  has  but  little  specificity. 
[he  complement  does  differ  to  a  certain  extent  for 
different  cells  but  this  difference  is  slight  and  may 
usually  be  disregarded.  The  phagocytes  are  believed 
chiefly  to  be  concerned  in  its  production  but  it  is 
probable  that  there  are  other  sources  for  it.  For  a 
.1  tailed  discussion  of  this  subject  and  the  place 
which  the  alexin  holds  in  immunity  reactions  see  the 
article  on  Immu nity.  Ralph  G.  Stillman. 

Algiers.— Algiers  (latitude  36°,  37'  N.;  longitude 
3°,  2'  E.)  is  the  capital  and  seaport  of  the  French 
Colony  of  Algeria.  It  is  almost  directly  south  from 
Marseilles,  upon  the  Mediterranean  coast  of  Africa, 
and  has  a  population  of  154,000,  composed  of  a 
variety  of  races.  The  town  has  a  most  attractive 
situation  on  the  slope  of  a  hill  facing  the  east,  and  as 
seen  from  the  sea,  it  is  exceedingly  picturesque  and 
striking,  its  white  houses  rising  in  a  succession  of 
terraces  from  the  water's  edge  to  the  hills  in  the  rear. 
The  luxuriant  vegetation  also  adds  to  the  beauty  of 
the  scene. 

The  city  consists  of  the  modern  French  town  near 
the  seashore,  composed  of  public  buildings,  residences, 
■i  handsome  boulevard,  and  a  well-built  quay;  and 
the  old  city  of  the  Turkish  period  on  the  slope  of  the 
hill  back  of  the  French  quarter,  culminating  in  the 
Kasba,  or  former  palace  of  the  deys,  about  500  feet 
above  the  level  of  the  sea.  This  old  city  is  compose.  1 
of  a  crowded  "mass  of  low,  flat-roofed,  whitewashed 
houses  intersected  by  the  narrow,  crooked,  dark,  and 
dirty  streets  characteristic  of  an  Oriental  town." 

<  * 1 1  the  slope  of  the  hills  above  the  lower  town, 
facing  the  east,  is  the  picturesque  suburb  of  Mustapha 
Superieur,  about  two  miles  from  the  center  of  the  city. 
This  is  the  resort  of  choice  for  invalids  and  others  who 
spend  the  winter  in  Algiers.  Here  are  excellent 
hotels  and  villas  with  fine  gardens,  and  the  summer 


palace  of  the  Governor  General.     Many  English  and 

Americans  reside  here;  there  are  :m  English  club, 
English  physicians,  English  churches,  golf  links,  and 
all  the  attractions  and  luxuries  of  a  first-class   winter 

health  resort.  It  is  well  supplied  with  water,  and 
the  sanitary  condition  is  good.  The  hills  about  are 
covered  with  vegetation  and  flowers,  and  there  are 
very  attractive  walks  and  drives. 

The  winter  climate  of  Algiers  is  characterized  by 
mildness,    moderate  humidity,   and  an  abundance  of 

sunshine.  With  the  exception  of  the  humidity,  it 
resembles  that  of  Egypt  and  the  Riviera.  In  summer 
it  is  hot  and  dry.  In  many  respects  it  resembles  the 
climate  of  those  portions  of  Southern  California  near 
the  coast. 

The  mean  annual  rainfall  is  about  thirty-six  inches, 
the  most  of  which  falls  in  the  winter.  The  rain  comes 
in  heavy  downpours  and  suddenly  ceases.  It  is 
quickly  absorbed  by  the  sandy  soil. 

The  following  tables,  given  by  Dr.  Bennet,  indi- 
cate the  distribution  of  the  rainfall  and  the  number 
of  rainy  days. 

Mean  Rainfall  at  Algiers.  1839-1845. 

5  inches.      May 1 J  inches. 


November 

December S  inches. 

January 6  inches. 

February 5  inches. 

March 3  inches. 

A]  iri]    4  inches. 


June    . .  .      $  inch. 

July 0    inch. 

August i  inch. 

September 1     inch 

October 21  inches. 

Number  of  Days  and  Nights  int  1S43  on  Which  Rain  Fell. 


Days.       Nights. 


November 10 

December 5 

January 10 

February 9 

March 9 

April 1 

Total 44 


10 


34 


Days 

May 3 

June 2 

July 0 

August 0 

September 2 

October 3 

Total 10 


Nichts 
1 
0 
0 
0 
0 

1 


The  relative  humidity  is  fairly  high,  as  shown  by 
the  following  table  from  Hann: 

Nov.     Dec.      Jan.      Feb.     Mar.      Winter  Mean,  Dec. -Feb. 
68  %    73  % 


Jan. 
73% 


Feb. 
72% 


Mar. 
69% 


Winter  Mean, 
73^ 


The  average  number  of  fair  days  in  the  course  of  the 
year  is  233.  The  mean  winter  temperature  from 
December  to  February  is  54.38°  F.,  and  the  mean 
annual  temperature  is  67.22°  F. 

The  duration  of  the  season  for  invalids,  according 
to  Weber,  is  from  November  to  the  end  of  April,  and 
for  this  period  the  average  temperature  is  50.99°  F. 

There  are  not  infrequent  sudden  falls  of  tempera- 
ture during  the  days,  such  changes  occurring  most 
commonly  between  four  and  five  in  the  afternoon. 
The  daily  variations  of  temperature,  according  to 
Weber,  are  from  10.8°  F.  to  14.4°  F.;  while  the  differ- 
ence between  the  day  and  the  night  temperature  is 
given  by  Rochard  as  from  5.4°  to  9°  F. 

The  prevailing  wind  for  the  year  is  the  northwest 
from  the  Mediterranean,  which  often  blows  with 
great  violence.  The  west  wind  brings  rain,  and  is  the 
one  which  is  most  frequent  in  the  winter  season.  The 
Sirocco,  which  blows  from  the  desert,  is  a  dry,  dusty, 
hot  wind,  and  is  most  prevalent  in  the  summer, 
although  it  occurs  also  during  the  winter  season.  It 
i~  always  oppressive  and  exceedingly  disagreeable  on 
account  of  the  clouds  of  dust  which  it  brings  with  it 
from  the  Great  Desert.  Dust  is  one  of  the  very  annoy- 
ing features  of  the  climate  of  Algiers.  The  wind  is 
not  regular,  and,  although  its  prevalent  direction  is 
from  the  northwest,  it  also  comes  from  the  north  and 
east  during  the  winter  months,  and  the  sudden 
alterations  of  temperature  mentioned  above  are  said 
by  Huggard  (Handbook  of  Climatic  Treatment, 
London,  1906)  to  be  due  to  this  irregularity.  The 
north  and  northeast  winds  blow  most  frequently 
during  the  spring  and  summer  months. 

The  rate  of  mortality  is  said  by  Huggard  to  be 


201 


Algiers 


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high,    probably  due   to   the   unhygienic  mode  of  life 
of  the  native  inhabitants. 

Such  a  resort  as  Algiers  is  favorable  for  those  per- 
sons who  thrive  best  in  a  warm,  sunny  winter  climate 
where  the}-  can  spend  a  greater  part  of  the  day  com- 
fortably out  of  doors  with  attractive  surroundings, 
such  as  the  aged  and  delicate  and  those  convali  - 
from  acute  diseases.  Cases  of  emphysema  and  chronic 
bronchitis  are  said  to  derive  benefit  from  this  cli- 
mate, although  opinions  differ  with  regard  to  this. 
For  instance,  Huggard  (loc.  cit.)  says  that  Algiers  "  is 
hardly  the  place  of  resort  for  those  who  catch  cold 
easily.  Such  persons,"  he  says,  "are  very  apt  to  be 
troubled  with  rheumatic  affections  or  with  recurrent 
bronchial  troubles,"  and  one  would  readily  think  this 
might  be  true  when  he  remembers  the  sudden  changes 
of  temperature  and  the  dust.  For  tuberculosis,  for 
which  this  resort  formerly  had  a  reputation,  one  would 
now  hardly  recommend  it.  A  moderately  moist, 
warm  marine  climate,  with  frequent  high  winds  and 
dust  and  sudden  variations  of  temperature,  is  far 
from  the  best  one  for  this  disease,  although  certain 
cases  may  do  well  there  when  for  any  reason  the  high 
altitudes  are  not  applicable  or  the  dry  inland  resorts 
are  badly  borne.  However,  Dr.  Charles  Theodore 
Williams  (Aero-Therapeutics,  1894)  speaks  thus 
favorably  from  his  own  personal  experience: 

"  Of  the  dozen  consumptive  patients  of  whom  I 
have  notes  who  have  wintered  once  or  oftener  at 
Algiers  the  large  majority  improved  greatly  and  num- 
ber at  least  two  cases  of  arrest;  but  I  note  that  the 
greatest  improvement  took  place  where  patients  re- 
sided in  villas  with  gardens  and  not  in  hotels.  In 
one  case  where  a  young  lady,  a  member  of  a  very 
consumptive  family,  developed  the  disease  and  a  very 
considerable  cavity  had  formed  in  one  lung,  complete 
contraction  of  the  cavity  took  place  with  arrest  of 
the  disease  in  two  winters,  and  the  lady  has  since 
married  and  has  resided  for  the  last  nineteen  years 
in  England  without  any  signs  or  symptoms  of  relapse. 
Another  lady,  with  well  marked  tuberculosis  of  one 
lung,  spent  two  winters  in  a  villa  at  Mustapha  Su- 
perieur  with  the  result  that  the  disease  became  ar- 
rested, and  since  that  date  she  has  been  able  to  pass 
twelve  winters  in  Scotland  with  impunity." 

Two  arrested  cases  out  of  twelve,  or  sixteen  per 
cent.,  would  be  considered  a  very  poor  result  in  the 
light  of  present  experience,  and  from  this  showing. 
Algiers  could  not  be  recommended  as  a  favorable 
resort  for  the  successful   treatment   of  tuberculosis. 

Edward  0.   Otis. 

Alhambra  Springs. — Jefferson  County,  Montana. 

Post-office. — Alhambra. 

Access. — Via  Northern  Pacific  or  Great  Northern 
Railroad.  The  hotel  is  within  600  feet  of  the  Great 
Northern  Depot,  and  is  equipped  with  every  modern 
convenience. 

These  springs  are  located  seventeen  miles  from 
Helena,  at  a  level  of  4,200  feet  above  the  sea,  the  sur- 
rounding country  being  broken  and  mountainous.  A 
dry  and  salubrious  climate,  with  varied  and  pictur- 
esque scenery,  characterizes  this  region.  The  hills 
and  mountains  are  covered  by  different  varieties  of 
pine,  fir,  and  cypress,  while  the  bottoms  are  dotted 
with  groves  of  alder,  willow,  mountain  ash,  poplar, 
and  other  trees.  Many  varieties  of  plants  have  been 
found  in  the  neighborhood,  which,  it  is  said,  have 
never  yet  been  classified.  The  ideal  location  has 
earned  for  Alhambra  its  title  of  "The  Garden  Spot 
of  Montana."  In  the  Government  Forest  Reserve 
four  miles  back  of  the  hotel,  game  is  still  abundant, 
consisting  of  grouse,  pheasant,  deer,  elk.  mountain 
sheep,  and  numerous  other  varieties.  The  springs 
are  situated  in  an  angle  formed  by  the  junction  of 
two  creeks,  in  which  mountain  trout  abound.  They 
are  twenty-two  in  number,  and  vary  in  temperature 
from  90°  to  129°  F.      The    water   has    1 n    analyzed 

202 


by  the  chemist,  Emil  Starz,  Ph.  G.,  Helena,  Montana 
who  has  given  the  following  report : 

Solids..  Parts  per  Gallon-. 

Calcium  bicarbonate 10.06 

Magnesium  bicarbonate 4  40 

Potassium  carbonate 4.16 

Potassium  chloride 6  .00 

Calcium  sulphate 1 .75 

Alumina 272 

Sodium  sulphate 24  76 

Silica 6  46 

Toul 60.31 

"The  Thermal  Springs,  located  at  Alhambra,  Mon- 
tana, possess  great  medicinal  virtues  and  rank  among 
the  best  medicinal  thermal  waters  in  the  United  States. 
They  are  eminently  effective  in  all  cases  of  rheumat- 
ism, especially  in  chronic  rheumatism,  renal  calculus, 
kidney,  liver,  and  bladder  diseases.  Their  curative 
properties  are  due  not  only  to  the  temperature  of  the 
water,  129°  F.,  but  also  to  the  mineral  constituents 
contained  in  it.  The  drinking  of  this  water  is  in- 
dicated and  most  beneficial  in  all  kinds  of  stomach 
troubles,  especially  when  such  are  due  to  a  hyper- 
acidity of  the  stomach.  At  least  one  or  two  quarts 
should  be  drunk  during  the  day  and  one  or  two  baths 
a  day  used." 

Abundant  facilities  for  hot  and  cold  bathing,  with 
a  plunge  and  swimming  bath,  vapor  and  mud  baths, 
are  provided.  Hospital  accommodations  are  fur- 
nished for  invalids.  Emma  E.  Walker. 

Alicante. — This  Spanish  city  of  30,000  inhabitants 
lies  upon  the  shore  of  the  bay  bearing  the  same  name, 
on  the  eastern  or  Mediterranean  coast  of  Spain,  and 
about  fortv  miles  south  of  the  middle  point  of  that 
coast  (lat.  38°  20'  N..  long.  0°  30'  W.).  Extending 
in  the  form  of  a  crescent  along  the  northern  shore  or 
head  of  the  bay,  and  dominated  by  a  rocky  hill, 
some  400  feet  high,  the  town  is  tolerably  well 
sheltered  from  the  north  and  northwest  winds,  the 
bay  being  open  only  to  the  westerly  winds.  "  The 
landward  environs  are  dreary,"  says  Baedeker;  "but 
the  distant  mountains,  the  castle,  the  harbor,  and 
the  sea  combine  to  form  a  memorable  picture.'' 
'The  view  from  the  east  mole  of  the  harbor,"  con- 
tinues the  same  authority.  "  with  its  white,  flat-roofed 
houses,  its  palms,  and  the  bare  and  tawny  cliffs  of 
the  castle  hill,  has  probably  no  parallel  in  Europe." 

The  climate  is  a  mild  and  dry  one,  drier  than  the 
Riviera,  the  annual  rainfall  being  only  16.93  inches,  of 
which  (according  to  Lorenz  and  Rothe,  quoted  by 
Dr.  Weber,  in  Ziemssen's  "  Handbook  of  General 
Therapeutics")  20.7  per  cent.,  or  the  extremely 
small  quantity  of  3.5  inches,  falls  during  the  winter 
months.  The  percentage  of  clouds  prevailing  in  the 
sky  of  that  portion  of  Spain  in  which  Alicante  is  situ- 
ated is  much  lower  than  is  found  in  any  other  part 
of  Europe,  Italy  and  Greece  included.  The  relative 
humidity  of  Alicante  the  writer  has  not  been  able  to 
ascertain;  but  at  Valencia,  some  eighty-five  miles 
north  of  Alicante,  the  mean  yearly  relative  humidity 
is  66  per  cent.,  and  it  is  probably  somewhat  les-  at 
Alicante.  The  mean  annual  temperature  is  64.4°  F.; 
that  of  winter  being  53.5°  F.  Another  authority  B 
the  mean  winter  temperature  as  60°  F.  There  is  no 
mistral  or  dust. 

The  present  condition  of  the  water  supply  is  not 
known  to  the  writer;  it  is  probably  the  same  as  when 
Dr.  Bennet  wrote  of  it  in  1S75,  which  consisted  then 
of  a  large  spring  and  rain  water  tank.  The  accom- 
modations are  said  by  Dr.  Weber  to  be  good.  The 
wine  of  Alicante  is  famous,  and.  besides  a  large  com- 
merce, the  town  possesses  an  extensive  tobacco  fac- 
tors', which  employs  400  Spanish  girls. 

When  a  mild,  dry,  and  sunny  climate  is  con 
desirable  for  various  conditions   of   debility,    anemia, 
convalescence  from  acute  diseases,  and  the  like,  Ali- 


REFERENCE    HANDBOOK    OF   TDK    MEDICAL   SCIENCES 


Mini,  lit 


ante  would  seem  admirably  to  fulfil  these  conditions 
ases  of  latent   scrofula,  asthma,  bronchorrhea,  albu- 
ninuria,  and  rheumatism  are  also  said  to  do  well  here. 

Edwaud  O.  Otis. 

Aliment. — Food  or  aliment  is  matter  which,  in  con- 
unction  with  the  air,  supplies  the  elements  necessary 
(ir  the  maintenance,  growth,  and  development  of  the 
irganism,  and  is  thus  the  source  of  the  power  on  which 
vitality  of  the  organism  is  dependent — i.e.  the 
-mine  of  the  heat,  mechanical  work,  and  other  forms 
if  energy  liberated  in  the  body.  Hence,  in  the 
tdest    sense,    true  aliment  is  a  mixture  of  food- 

-  and  water,  together  with  the  air,  from  which 

-  the  uxyni'ii  necessary  for  the  oxidation  of  the 
ormer   and   by    which   energy   is   liberated.     Again, 

siologically    considered,    true   aliment,    especially 

in  the  animal  kingdom,  is  to  be  distinguished  fromso- 

d  "food"  as  being  only  that  portion  of  the  food 

which  is  either  directly  available  for  absorption,  or 

convertible  by  the  digestive  juices  of  the  body  into 

ible  and  more  or  less   diffusible  products,  appro- 

ite   for   absorption   by   the   blood   and   lymph. 

The  food  of  vegetable  organisms  is  quite  different 
from  that  of  animal  organisms.  Moreover,  the  nature 
of  the  processes  involved  is  likewise  quite  different, 
vegetable  organism,  by  a  synthetical  process — a 
building  up  of  more  complex  bodies  from  simpler  ones 
— derives  its  nourishment  from  the  inorganic  world; 
ells  appropriate  such  of  the  inorganic  principle-  as 
are  needed  for  its  growth,  and  convert  them  under 
the  influence  of  the  sun's  rays  into  organic  compounds 
which  enter  into  its  own  structure. 

The  animal  organism,  on  the  other  hand,  does  not 
possess  this  power  to  a  great  extent  and  thus  we  look 
to  the  creative  power  of  the  vegetable  kingdom  as  the 
source,  either  directly  or  indirectly,  of  the  aliment  of 
animals.  Moreover,  the  vegetable  matter  which 
thus  serves  as  food  not  only  furnishes  the  material 
necessary  for  the  growth  and  life  of  the  organism,  but 
it  contains,  in  addition,  stored  up  within  its  molecules, 
a  certain  amount  of  latent  force  derived  from  the 
solar    energy    originally    used    in    its    construction. 

Animal  organisms,  by  a  process  of  transformation 
quite  the  reverse  of  synthetical,  convert  the  pre- 
formed animal  or  vegetable  organic  matter  into  allied 
or  simpler  forms,  which  are  absorbed  into  their  own 
tissues.  Animal  food  possesses  stimulating  proper- 
tics,  due,  without  doubt,  to  the  crystalline  nitrogenous 
bodies  contained  in  it.  Organic  matter  once  entered 
as  a  part  of  an  animal  organism  and  applied  to  the 
purposes  of  life  is  decomposed  or  broken  apart,  and 
its  decomposition  products  are  ultimately  reconverted 
into  inorganic  principles.  There  is  thus  a  comple- 
mental  relationship  between  vegetable  and  animal 
life  and  the  inorganic  world.  The  plant,  by  a  se- 
lective action,  appropriates  as  an  element  of  nutrition 
certain  kinds  of  mineral  matter,  together  with  nitrogen 
in  the  form  of  ammonia  and  nitrates,  from  the  soil  in 
which  it  grows,  at  the  same  time  drawing  from  the  air 
carbon  in  the  shape  of  carbonic  acid,  while  hydrogen 
and  oxygen  are  supplied  to  an  unlimited  extent  in  the 
form  of  water.  The  vegetable  products  thus  formed 
serve  in  turn  as  the  food  of  animals,  while  the  latter 
at  every  breath  pour  forth  carbonic  acid  and  water, 
which  utimately  find  their  way  again,  more  or  less 
modified,  into  the  tissues  of  plants.  These,  together 
with  the  nitrogenous  excreta,  products  of  the  meta- 
bolism of  life,  and  the  postmortem  decompositions 
which  follow,  continually  serve  in  their  variously 
modified  forms  as  agents  by  which  the  conservation 
and  transference  of  energy  are  accomplished. 

Now,  since  food  is  the  source  from  which  the 
various  elements  of  the  body  are  supplied,  it  is  evident 
that  to  fulfil  its  purposes  food  must  contain  all  of  the 
elements  present  in  the  body.  These  are,  of  course' 
not  free,  but  in  a  state  of  organic  combination,  for  it  is 
only  in  the  latter  case  that  they  are  of  service  as  food. 


Aside  from  the  elements  which  appear  as  inorganic 
sails,  there  are  in  the  body  at  the  mo  I  bul  seven 
elements,  three  of  which  are  present  only  in  small 
quantity.  These  seven  elements  are  en  lion,  hydro- 
gen, nitrogen,  oxygen,  sulphur,  phosphorus,  and  iron. 
Any  substance  which  as  food  is  to  satisfy  the  re- 
quirements of  life,  should  contain  all  of  these  ele- 
.  in  addition  to  inorganic  salts  and  water. 
Food  as  it  OCCUI     in  nature:  -d  of  mixtures 

of   chemically    distinct    substances    which    may    be 

eparated    into    four   great    divisions,    termed    food 

stuffs.    Food    stuffs   are    classified    as  (a)    proteins, 

(6)    carbohydrates,   (c)    fats,   and  (d)  inorganic  salts 

and    water.     .Many   of   the   comp i     included   in 

these  groups  are  to  be  found  in  both  the  animal  and 
vegetable  kingdoms,  as  for  example,  the  fat.- and  pro- 
teins, although  minor  points  of  difference  in  chemical 
composition  and  structure  may  be  observed.  On  the 
other  hand,  certain  of  these  substances  are  present 
only  in  the  vegetable  kingdom,  for  example,  starch, 
and  others  such  as  the  gelatin-forming  substances  are 
characteristic  of  the  animal  kingdom  only. 

Viewed  from  the  standpoint  of  origin  food-stuffs 
may  be  classified  under  two  heads,  viz.,  organic  and 
inorganic.  In  the  first  division  may  be  placed  those 
compounds  which  have  been  produced  by  the  agency 
of  living  cells;  bodies  which  contain  carbon  and  are 
capable  of  combustion  and  of  furnishing  energy. 
Ihe  second  group  contains  substances  belonging  to 
the  mineral  kingdom  that  have  become  mixed  with 
the  organic  materials.  Proteins,  carbohydrates,  and 
fats  are  organic  compounds.  Various  salines  and 
water  make  up  the  division  termed  inorganic.  Fur- 
thermore, the  organic  food-stuffs  are  divisible  into 
two  groups,  dependent  upon  whether  the  element 
nitrogen  is  present  in  their  structure.  Fats  and 
carbohydrates  are  non-nitrogenous  whereas  proteins 
contain  nitrogen.     Following  is  a  partial  classification 


of  foods: 

Organic. 


Nitrogenous 

Non-nit  rogenous. . 


T  f  Water. 

Inorganic ^  g^ 


[   Proteins. 

1 
I  Carbohydrates. 


Proteivs  may  be  defined  as  complex  compounds  of 
high  molecular  weight  made  up  of  carbon,  hydrogen, 
oxygen,  nitrogen,  sulphur,  and  sometimes  containing 
phosphorus  and  iron.  The  distinctive  feature  which 
differentiates  protein  from  the  other  food  stuffs  is 
that  nitrogen  is  present  and  is  contained  in  the  molecule 
in  a  form  that  is  available  for  the  physiological  needs 
of  the  organism.  The  term  protein  is  derived  from 
-pcurevui  (I  am  the  first)  and  refers  to  the  fact  that  it 
forms  the  chief  mass  of  the  organic  constituents  of 
animal  tissues.  The  average  composition  of  the 
best  known  proteins  is,  approximately,  carbon,  fifty- 
three  per  cent.;  hydrogen,  seven  per  cent.;  nitrogen, 
sixteen  per  cent.;  oxygen,  twenty-three  per  cent.; 
sulphur,  one  per  cent.  Considered  from  the  stand- 
point of  chemical  structure  our  knowledge  concerning 
the  proteins  is  very  incomplete  although  as  a  result  of 
the  recent  investigations  of  Emil  Fischer1  proteins 
may  be  regarded  as  essentially  complex  anhydrides 
of  amino  acids.  Glycocoll,  or  glycine,  chemically 
known  as  amino-acetic  acid,  may  be  taken  as  an  ex- 
ample of  a  simple  amino  acid.  The  structure  of  this 
substance  is  CH,.NH2.COOH.  If  two  molecules  of 
glycocoll  are  combined  in  such  a  manner  that  one 
molecule  of  water  is  eliminated,  a  new  compound  re- 
sults.    Thus: 

CH,.NH,.CO 


CH„.    NH,.  CO  OH 


CH, 


|H! 
N.COOH 


CH2.NH.COOH 

Glycyl-glycine 


203 


Aliment 


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Glycyl-glycine  is  the  simplest  of  an  enormous  group 
of  anhydrides  of  amino  acids,  and  these  compounds 
are  called  "peptids."  A  combination  of  more 
than  two  amino  acids  is  designated  "polypeptid." 
Through  synthetic  processes  Fischer  has  succeeded 
in  fastening  together  various  of  these  amino  acids 
until  products  have  been  obtained  finally  which 
would  respond  to  some  of  the  chemical  reactions 
most  characteristic  of  the  proteins.  Previous  to 
this  type  of  investigation  our  knowledge  of  the  struc- 
ture of  protein  was  derived  mainly  from  studies 
of  the  products  resulting  from  the  hydrolytic  cleavage 
of  these  substances.  The  products  of  protein 
hydrolysis  include  a  long  series  of  amino  acids  of 
varying  chemical  complexity  and  significance.2 
It  is  the  presence  or  absence  of  one  or  more  of  these 
amino  acids  or  the  quantitative  variation  in  the 
content  of  their  antecedents  that  undoubtedly 
is  t lie  reason  why  some  protein  substances  are  not  as 
well  adapted  to  serve  the  nitrogenous  needs  of  the 
body  as  others.  The  most  striking  examples  illustra- 
tive of  this  point  are  found  in  gelatin  and  zein,  the 
latter  a  protein  contained  in  corn.  A  clearer  con- 
ception  of  the  varied  composition  of  the  proteins  may 
!»■  gained  perhaps  from  the  following  table3  in  which 
tin1  content  of  amino  acids  of  several  proteins  is 
given. 

Table  I 


Glycocoll 

Alanine 

Ammo-valeric  acid 

Leucine 

a  Proline. 

Phenylalanine 

Glutamic  acid 

Aspartic  acid 

Serine 

Tyrosine 

Tryptophane 

Lysine 

Arginine 

Histidine 

Cystine 

Ammonia 


( rliadin 
from 

wheat 
flour. 


0.9 
2.7 
0.33 
6.0 
2.4 
2.6 
43.0 
1.3 
0.12 
2  4 
1.0 
0 

3.4 
1.7 


5.1 


Albu- 
min 

from 
egg. 


7.1 
2  2.3 
4.4 
8.0 
1.5 


1    1 
l'rrs.-nl 


0.2 
1.6 


Casein 
from 
cow's 
milk. 


0 

0.9 

1.0 
10.5 

3.1 

3.2 
16.0 

1  2 
0.23 
4.5 
1.5 
5.S 
-I    M 

2  59 
(I  085 
1.9 


Zein 
from 
corn. 


0.5 
Present 

11.2 
1.5 
7.0 

26.0 
1.0 


10.1 
0 


0 

1.82 
0.S1 
3.6 


Gela 

tin. 


0 


4 

II  ss 
0.56 
0.4 
0 
0 

2.75 
7.62 
0.4 


These  variations  in  amino  acid  content  are  obvi- 
ously responsible  for  differences  of  chemical  structure 
and  may  account  in  large  measure  for  the  varying 
physical  properties  upon  which  our  present  classifica- 
tion is  based. 

Until  very  recently  the  classification  of  proteins 
was  in  a  state  of  confusion  owing  to  the  fact  that 
several  classifications  were  recognized  by  various 
groups  of  English-speaking  scientists.  At  present  in 
the  English-speaking  world  the  British  and  American 
classifications  only  are  of  value.  These  are  quite 
similar  in  a  general  way,  the  points  of  difference  being 
a  question  of  nomenclature  and  of  minor  importance. 
The  following  is  the  outline  of  the  American  classifica- 
tion and  it  will  be  noted  that  the  term  "protein"  has 
been  substituted  for  the  older  designation  "  proteid." 

I.  Simple  Proteins. 
(a  I  Albumins 
ib)  Globulins 

(c)  Glutelins 

(d)  Alcohol-soluble  proteins 

(e)  Albuminoids 

(fl      Histories 

(g)    Protamines 

204 


II.  Conjugated  Proteins. 

(a)  Nucleoproteins 

(b)  Glycoproteins 

(c)  Phosphoproteins 

(d)  Hemoglobins 

(e)  Lecithoproteins 

III.  Derived  Proteins. 

A.  Primary  protein  derivatives. 

(a)  Proteans 

(b)  Metaproteins 

(c)  Coagulated  proteins 

B.  Secondary  protein  derivatives. 

(a)  Proteoses 

(b)  Peptones 

(c)  Peptids 

Simple  proteins  are  protein  substances  which  yield 
only  a  amino  acids  or  their  derivatives  on  hydrolysis. 
The  albumins  are  simple  proteins  that  are  soluble  in 
pure  water  and  are  coagulable  by  heat.  The  globu- 
lins, on  the  other  hand,  are  insoluble  in  pure  water 
but  are  soluble  in  neutral  solutions  of  salts  of  strong 
bases  with  strong  acids,  for  example,  sodium  chloride. 
Albumins  and  globulins  are  very  often  associated,  as 
for  example,  in  blood  serum,  and  in  the  substance  <>f 
cells.  In  a  general  way  albumins  are  more  abundant 
in  animal  fluids  (blood,  etc.),  while  globulins  pre- 
dominate in  animal  tissues  and  in  plants.  Glutelins 
are  simple  proteins  insoluble  in  all  neutral  solvents 
but  readily  soluble  in  very  dilute  acids  and  alkalies. 
Alcohol-soluble  proteins  are  simple  proteins  soluble 
in  relatively  strong  alcohol  (seventy  to  eighty  per 
cent.)  but  are  insoluble  in  water,  absolute  alcohol,  and 
other  neutral  solvents.  These  last  two  mentioned 
groups,  the  glutelins  and  the  alcohol-soluble  proteins, 
occur  as  constituents  of  the  cereal  grains.  The  best 
known  examples  of  these  two  groups  are  glutinin  and 
gliadin  respectively.  They  make  up  what  is  known 
as  the  gluten  of  flour.  The  elasticity  and  strength  of 
the  gluten  and  therefore  the  baking  qualities  of  the 
flour  are  influenced  by  the  proportions  of  glutinin 
and  gliadin,  about  twice  as  much  gliadin  as  glutinin 
being  usually  considered  desirable  in  bread  flour. 
Albuminoids  may  be  defined  as  simple  proteins  which 
possess  essentially  the  same  chemical  structure  as  the 
other  proteins,  but  are  characterized  by  great  in- 
solubility in  all  neutral  solvents.  Examples  of  this 
group  may  be  found  as  the  organic  basis  of  bone 
(ossein),  of  tendon  (collagen  and  its  hydration  pro- 
duct gelatin),  of  ligament  (elastin),  and  of  nails,  hair, 
horns,  hoofs,  feathers  (keratins).  The  histones  arc 
soluble  in  water  and  insoluble  in  ammonia.  They 
are  precipitated  by  other  proteins  and  yield  a  coas;u- 
lum  on  heating  which  is  readily  soluble  in  very 
dilute  acids.  Histones  may  be  regarded  as  basic 
proteins  which  stand  between  protamines  and  true 
proteins.  Histones  have  been  isolated  from  varied 
sources,  as  globin  from  hemoglobin,  scombron  from 
spermatozoa  of  the  mackerel,  gaduhiston  from  the 
codfish  and  arbacin  from  the  sea-urchin.  The 
protamines  are  relatively  simple  polypeptids.  They 
are  the  simplest  natural  proteins.  On  decomposition 
l  lev  yield  comparatively  few  amino  acids  among 
which  the  basic  ones  predominate.  Thus  far  they 
have  been  isolated  only  from  fish  spermatozoa,  and 
according  to  origin  have  been  designated  salmine, 
st urine,  clupeine,  etc. 

The  conjugated  proteins  are  substances  which 
contain  the  protein  molecule  united  to  some  other 
molecule  or  molecules  otherwise  than  as  a  salt. 
Nucleoproteins  are  compounds  of  one  or  more  protein 
molecules  with  nucleic  acid.  These  substances  are 
the  characteristic  proteins  of  the  nuclei  and  hence 
are  found  in  largest  quantity  wherever  cells  are  most 
abundant,  for  example,  in  the  glandular  organs  and 
tissues.  By  artificial  means  or  during  digestion  a 
nucleoprotein  is  first  decomposed  into  protein  and  a 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


\  linn  til 


substance  called  nuclein;  the  latter  on  further  decom- 
position yields  more  protein  ami  nucleic  arid. 
1    Nucleic  acid,  of  which  then-  may  be  several  types, 
,,,;IV  be  resolved  into  a  series  of  peculiar  compounds, 
purine  bases  (xanthine,  hypoxanthine,   adenine, 
,,„!  quanine),  the  pyrimidine  bases  (uracil,  cytosine, 
and  thymine),  a  carbohydrate  group  (pentose),  and 
phosphoric  acid.     Glycoproteins  are   compounds  < >f 
protein  molecule  with  a  substance  <>r  substances 
aining  a  carbohydrate  group  other  than  a  nucleic 
,i.l      The    mucus-yielding    portions    of    tissues    are 
particularly  rich  in  the  glycoproteins  which  serve  as 
ibstance  to  hold  together  the  fibers  in  tendon 
ligament,  etc.     Glucosamine  has  been  isolated 
,  some  nf  the  glycoproteins  and  is  recognized  as 
carbohydrate  constituent.     Phosphoproteins  are 
compounds  of  the  protein  molecule^  with  some,  as 
undefined,    phosphorus-containing     substances 
i   than  a  nucleic  acid  or  lecithin.     Milk,  with  its 

and    tl gg,   with    vitellin  of   the   yolk 

arc   conspicuous    foods   containing   phosphoproteins. 
compounds  yield  a  trace  of  iron  on  analysis 

I  although  this  has  been  regarded  as  an  impurity  it 
is  not  at  all  improbable  that  it  actually  exists  in  the 

ein  in  combination.  Hemoglobins  are  corn- 
els of  the  protein  molecule  with  hematin  or 
ome   similar  substance.     Hematin    is    the    coloring 

matter  of  the  blood  which  acts  as  oxygen  carrier  for 
tissues  and  is  characterized  by  containing  iron  in 

an    organic    combination.     The    protein    portion    of 

II  glob  in  consists   of  globin,   a   histone.      Leeitho- 

firoteins  are  compounds  of  the  protein  molecule  with 
bins.  Lecithins  are  complex  substances  charac- 
terized by  containing  nitrogen  and  phosphorus 
together  with  fatty  acid  radicles  and  choline.  They 
■are  found  in  nearly  all  plant  and  animal  cells,  but  are 
especially  abundant  in  the  nervous  tissues.  They 
are  essential  cell  constituents. 

As  their  name  implies  the  derived  proteins  are  sub- 
stances that  have  been  formed  from  the  naturally  oc- 
curring proteins.  Of  these  compounds  the  proteoses 
and  peptones  and  the  metaproteins  are  of  particular 
importance  since  they  represent  stages  of  protein  diges- 
tion. With  a  few  exceptions  proteoses  and  peptones 
are  not  found  preformed  in  nature.  These  two  groups 
of  derived  proteins  are  characterized  by  their  great 
solubility.  The  peptones  are  sometimes  looked 
upon  as  simple  mixtures  of  rather  complex  poly- 
peptids. 

Carbohydrates1  are  especially  abundant  in  the 
plant  kingdom  forming  the  chief  mass  of  the  dry 
tance  of  the  plant  structure.  In  the  animal 
tissues  they  are  found  only  in  small  quantities  either 
in  a  free  condition  or  in  combination  with  proteins 
forming  conjugated  proteins.  The  carbohydrates 
serve  as  food  for  both  man  and  animals  and  hence  are 
of  great  importance  from  the  standpoint  of  aliment. 
They  contain  the  elements  carbon,  hydrogen,  and 
oxygen,  and  the  last  two  elements  are  usually  in  the 
same  proportion  that  occurs  in  a  molecule  of  water, 
namely  2  : 1,  hence  the  term  carbohydrates.  All 
carbohydrates,  however,  do  not  have  the  hydrogen 
ami  oxygen  in  this  proportion,  for  a  sugar,  rhamnose, 
C,H1205,  has  these  elements  in  a  different  relation. 
Moreover,  various  organic  acids  have  the  elements 
hydrogen  and  oxygen  in  the  proportion  of  2  : 1  and  yet 
are  not  carbohydrates.  It  is  exceedingly  difficult  to 
give  an  exact  definition  of  carbohydrates  since  they  do 
not  differ  from  main-  other  substances  in  many  respects. 

Chemically  the  carbohydrates  may  be  defined  as 
aldehyde  or  ketone  derivatives  of  polyhydric  alcohols. 
The  simplest  carbohydrates  are  aldehyde  or  ketone 
derivatives  of  such  alcohols,  and  the  more  complex 
members  of  this  group  of  compounds  may  be  regarded 
as  anhydrides  of  the  simple  carbohydrates.  The 
carbohydrates  are  generally  divided  into  three  chief 
groups  namely,  monosaccharides,  disaccharides,  and 
polysaccharides.     Viewed   from   another  standpoint 


they  may  be  classified  into  sugars,  starches,  dextrins, 

gums  and  vegetable  mucilages,  and  celluloses.     The 

sugars  are  mono-  and  disaccharides  and  t  he  remaining 

groups  belong  under  the  division  <>f  polysaccharides. 

The  mono-  and  di-nccharides  are  fairly  soluble  sub- 
stances possessing  varying  degrees  of  sweetness.  In 
general  the  polysaccharides  are  more  or  less  insoluble 
in  the  ordinary  solvents.  Mono-  and  disaccharides 
are  given  the  ending  "use"  in  accordance  with  the 
number  of  carbon  atoms  contained  in  the  molecule. 
Thus,  one  speaks  of  a  pentose,  <  . 1 1 , , , <  > , ,  of  a  hexose, 
( ',, 1 1 ,_,( >„,    or   of    a    heXobin   i  ,    (        II  ._,»_>,,. 

(if  tlie  monosaccharides  only  the  pentoses  and 
hex oses  are  of  practical  significance  in  their  relation  to 
the  food  of  man.  The  pentoses  do  not  occur  as  such 
in  nature  but  are  formed  by  the  cleavage  of  more 
complex  molecules,  the  pentosanes,  which  are  of  a 
gum-like  nature.  The  pentosanes  are  widely  dis- 
tributed in  the  plant  kingdom  and  are  of  great  impor- 
tance as  food  for  the  herbivora.  In  man  pentoses  are 
absorbed  and  partially  utilized  but  even  when  ingested 
in  small  quantities  traces  promptly  reappear  in  the 
urine.  The  pentoses  are  of  significance  in  human 
metabolism  since  they  were  first  discovered  in  the 
animal  kingdom  by  Salkowski  and  Jastrowitz  in  the 
urine  of  a  morphine  habitue\  They  may  also  occur 
in  traces  in  normal  urine  and  in  the  urine  of  diabetics. 
A  pentose  is  furthermore  an  integral  part  of  certain  of 
the  nucleoproteins,  and,  therefore,  may  be  isolated 
from  organs  rich  in  nuclear  material,  as  for  example, 
the  pancreas,  thymus,  thyroid,  spleen,  and  liver. 
This  pentose  is  xylose  and  is  the  only  one  thus  far 
separated  from  animal  tissues.  It  is  identical  with 
the  xylose  obtained  by  boiling  wood  gum  with  dilute 
acids.  Arabinose  is  a  pentose  that  has  been  isolated 
from  human  urine  by  Neuberg. 

The  hexoses  are  sugars  and  most  of  them  occur  in 
nature.  They  readily  undergo  fermentation  with 
yeast,  leading  to  the  production  of  alcohol.  They  are 
either  aldehydes  or  ketones  and  hence  are  termed 
aldoses  or  ketoses.  Dextrose,  an  aldose,  and  levulose, 
a  ketose,  are  found  either  free  in  nature  or  else  may 
be  formed  by  the  hydrolytic  cleavage  of  more  com- 
plex carbohydrates  or  of  glucosides.  Such  hexoses 
as  mannose  and  galactose  result  only  from  hydrolysis 
of  naturally  occurring  products  Ca),  for  example, 
galactose  is  formed  by  the  hydrolytic  splitting  of 
lactose,  or  milk  sugar,  or  from  hydrolysis  of  certain 
glucoside-like  complexes,  the  cerebrosides,  found 
in  nervous  tissue.  Of  the  hexoses,  dextrose  and  levu- 
lose are  the  most  important.  Dextrose  ( =  grape  sugar 
=  glucose)  is  found  particularly  abundant  in  the  grape 
and  also  in  company  with  levulose  in  various  fruits, 
seeds,  roots,  honey,  etc. 

Perhaps  the  most  interesting  feature  in  connection 
with  dextrose  from  the  standpoint  of  metabolism  is 
that  it  is  the  sugar  of  the  blood  and  lymph.  It  is 
present  in  minute  traces  in  normal  urine  but  may  be 
found  in  large  quantities  in  that  voided  by  diabetics. 
Dextrose,  and  levulose,  are  capable  of  ready  assimi- 
lation by  the  body  without  previous  alimentary 
treatment,  a  statement  wdiich  in  general  does  not 
apply  to  most  of  the  other  carbohydrates.  Levulose 
(  =  fruit  sugar  =  fructose)  is  found  especially  distrib- 
uted in  fruits  and  honey.  It  may  be  formed  also  in 
the  hydrolysis  of  cane  sugar  and  other  more  complex 
carbohydrates.  In  certain  types  of  diabetes  mellitus 
levulose  may  be  eliminated  in  the  urine.  Dextrose 
and  levulose  have  been  so  designated  because  of  their 
influence  upon  the  plane  of  polarized  light,  dextrose 
solutions  causing  a  rotation  to  the  right,  levulose  to 
the  left.  Glucosamine  (chitosamine)  is  an  amino 
derivative  of  dextrose.  It  was  first  prepared  by  Led- 
derhose  from  chitin  by  the  action  of  strong  hydro- 
chloric acid.  It  is  also  a  cleavage  product  of  several 
mucin  substances  and  of  proteins  and  may  be  re- 
garded as  the  connecting  link  between  the  proteins 
and  the  carbohydrates.     All  of  the  hexoses,  because 


205 


Aliment 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


of  their  aldehyde  or  ketone  structure,  possess  the 
property  of  reducing  metallic  oxides,  of  copper,  bis- 
muth, etc.  This  behavior  of  the  hexoses  has  been 
made  use  of  for  the  identification  and  quantitative 
estimation  of  these  substances. 

The  disaccharides  are  divisible  into  two  groups, 
those  occurring  preformed  in  nature,  saccharose  (= cane 
sugar  =  sucrose)  and  lactose  (  =  milk  sugar),  and  those 
produced  by  hydrolysis  of  more  complicated  carbo- 
hydrates, maltose  and  isomaltose.  The  disaccharides 
are  to  be  regarded  as  anhydrides,  formed  from  two 
monosaccharides  by  the  expulsion  of  one  molecule  of 
water.  By  the  addition  of  one  molecule  of  water, 
that  is  by  hydrolysis,  the  disaccharides  may  be  re- 
solved into  two  molecules  of  hexoses,  thus: 

C12H220Il+H20=C6H1206-rC,)H12Oe 
Since  the  disaccharides  all  possess  the  same  elemen- 
tary composition,  Cl2H22Ou,  and  the  hexoses  have  the 
composition  C„Hi:,Or,  in  common,  the  above  reaction 
will  apply  to  the  hydrolysis  of  all  the  disaccharides. 
The  hexoses  yielded  by  the  various  disaccharides  may 
vary,  however,  as  may  be  seen  from  the  following 
scheme.     On  hydrolysis 

Saccharose  yields  dextrose  plus  levulose. 

Maltose  yields  dextrose  plus  dextrose. 

Lactose  yields  dextrose  plus  galactose. 
This  process  of  hydrolysis  takes  place  along  the  en- 
teric tract  so  that  all  disaccharides  ingested  as  food 
eventually  are  absorbed  in  the  blood  stream  as  mono- 
saccharides. Unlike  the  hexoses,  saccharose  does  not 
reduce  metallic  oxides,  whereas  maltose,  isomaltose, 
and  lactose  possess  this  power.  All  of  the  disaccharides 
exert  a  specific  influence  upon  the  plane  of  polarized 
light  in  common  with  the  hexoses.  Saccharose  or  cane 
sugar  occurs  widely  distributed  in  the  vegetable  king- 
dom. It  is  found  in  the  stalk  of  the  sugar  cane,  in 
the  roots  of  the  sugar  beet,  in  carrots  and  other  vege- 
tables, etc.  It  is  of  exceedingly  great  importance  as  a 
food  since  the  ordinary  table  sugar  is  pure  saccharose. 
The  mixture  of  dextrose  and  levulose  produced  by 
hydrolysis  of  cane  sugar  is  termed  "invert  sugar"and 
the'  process  is  called  "inversion."  Cane  sugar  is  not 
directly  fermentable  by  yeast.  Ordinary  yeast,  how- 
ever, contains  an  inverting  enzyme  which  transforms 
the  saccharose  into  invert  sugar.  This  readily  under- 
goes fermentation  resulting  in  the  formation  of  alco- 
hol. Lactose  is  found  only  in  milk  where  it  occurs  to 
the  extent  of  three  to  eight  per  cent.,  varying  with  the 
type  of  animal.  In  the  pregnant  woman  and  animals 
lactose  is  sometimes  found  in  the  urine.  It  may  also 
be  eliminated  through  the  kidneys  during  a  stagnation 
of  milk.  Milk  sugar  is  not  fermentable  with  ordinary 
yeast  but  may  undergo  fermentation  resulting  in  the 
formation  of  alcohol  by  the  action  of  certain  schizo- 
mycetes  and  the  production  of  "kumyss"  from  mare's 
milk,  or  "kephir"  from  cow's  milk.  Maltose  is  ob- 
tained by  the  hydrolysis  of  starch  induced  by  the 
action  of  diastase,  saliva,  or  pancreatic  juice,  or  from 
glycogen  under  certain  conditions.  It  forms  the  fer- 
mentable sugar  of  the  potato  or  grain  mash,  and  also 
of  the  beer  wort.  In  general,  isomaltose  occurs  when- 
ever maltose  is  formed. 

Unlike  the  mono-  and  disaccharides  the  polysac- 
charides as  a  class  are  not  possessed  of  a  sweet  taste. 
While  a  few  are  soluble  in  water  most  of  them  are 
not,  although  the  latter  may  swell  in  hot  water  with- 
out visible  change.  The  polysaccharides  are  all  con- 
vertible into  monosaccharides  by  hydrolytic  cleavage. 
The  chief  groups  of  the  polysaccharides  are  the  starch 
group,  gum  and  vegetable  mucilage  group,  and  the 
cellulose  group.  The  polysaccharides  all  have  the 
formula  (C6H10Os)a;.  Starch  occurs  as  a  white  taste- 
less powder  stored  in  various  portions  of  the  plant 
structure  as  reserve  food.  It  is  found  chiefly  in  seeds, 
roots,  tubers,  and  trunks.  Starch  may  be  quanti- 
tatively transformed  into  dextrose  by  hydrolysis  with 
acids.     Under  the  influence  of  amylolytic  enzymes 

206 


starch  yields  a  variety  of  dextrins,  maltose,  and  a 
small  quantity  of  dextrose.  The  various  types  of 
starch  vary  considerably  in  the  character,  that  is,  the 
shape  and  size,  of  the  starch  granules.  Starch  is 
incapable  of  utilization  by  the  human  organism  unless 
it  has  been  boiled.  The  starch  grains  are  enclosed  in 
a  cellulose  covering  which  is  not  dissolved  by  the 
enzymes  of  the  alimentary  canal.  When  starch  is 
boiled  with  water,  however,  this  cellulose  membrane  is 
ruptured  and  the  starch  grains  are  transformed  into 
a  paste  which  is  readily  attacked  by  the  enteric  en- 
zymes. Upon  these  facts  as  a  basis  rests  the  ordinary 
procedure  of  cooking  vegetables  containing  consider- 
able quantities  of  starch.  The  herbivora,  however, 
possess  cellulose-dissolving  ferments,  hence  raw  starch 
can  be  well  utilized  by  this  class  of  animals.  Inulin 
is  a  polysaccharide,  in  many  respects  similar  to  starch, 
which  is  found  in  many  underground  parts  of  plants, 
especially  in  roots  and  tubers.  Enzymes  have  little 
or  no  action  upon  inulin,  but  levulose  may  be  pro- 
duced from  it  by  the  influence  of  acids.  Glycogen 
stands  in  a  position  between  starch  and  dextrose  and 
is  an  essential  constituent  of  all  animal  cells,  the 
largest  quantities  being  found  in  the  liver  and  mus- 
cles. The  former  organ  is  looked  upon  as  the  prin- 
cipal store-house  for  this  material.  The  quantity  of 
glycogen  in  the  body  at  any  time  depends  upon  the 
food  and  the  amount  of  muscular  work  performed. 
While  it  is  conceded  that  protein  and  various  other 
types  of  compounds  may  lead  to  a  storage  of  glycogen 
it  is  well  established  that  glycogen  is  most  readily 
stored  in  the  liver  after  large  intakes  of  carbohydra 
The  amount  thus  stored  may  reach  twelve  to  sixteen 
per  cent,  of  the  weight  of  the  liver.  The  degree  of  ac- 
tivity of  the  body  also  bears  a  direct  relation  to  glyco- 
gen storage,  since  by  hard  muscular  work,  or  by  the  en- 
ergy expended  in  shivering,5  glycogen  in  the  liver  may 
be  reduced  to  a  minimum  in  a  few  hours.  Starvation 
may  bring  about  a  similar  result  although  less  rapidly. 
LTpon  hydrolysis  with  acid,  glycogen  yields  dextrose, 
and  maltose  or  dextrose  may  result  from  the  action 
of  diastatic  enzymes  in  accordance  with  the  type  of 
enzyme  employed.  The  dextrins  stand  in  a  close 
relationship  to  the  starches  and  are  formed  as  inter- 
mediate products  from  the  latter  in  their  transforma- 
tion into  sugar  by  the  influence  of  acids  and  enzymes. 
On  the  other  hand  the  gums  and  mucilages  occur  ;ts 
natural  products  in  the  vegetable  kingdom.  The  cel- 
lulose group  comprises  the  mixture  of  carbohydrates 
constituting  the  cell  wall  of  plants.  The  celluloses  are 
characterized  by  their  great  insolubility  in  all  ordinary 
solvents.  It  is  probable  that  these  substances  are 
utilized  by  man  to  only  an  exceedingly  limited  extent. 

The  fats0  constitute  the  third  group  of  the  organic 
food-stuffs.  These  substances  are  widely  distributed 
in  both  the  animal  and  vegetable  kingdoms.  In  the 
latter  the  fats  occur  in  the  seeds,  fruits,  and  in  certain 
instances,  in  the  roots.  All  animal  tissues  and  organs 
contain  fat,  although  the  quantity  present  in  th( 
different  structures  may  vary  greatly.  There  are 
three  principal  deposits  of  fat  in  the  animal  body. 
namely,  in  the  intermuscular  connective  tissue,  tie 
fatty  tissue  in  the  abdominal  cavity,  and  the  sub- 
cutaneous connective  tissues. 

Chemically  the  so-called  neutral  fats  are  esters  of 
fatty  acids  and  an  alcohol,  usually  glycerol.  Those 
esters  are  triglycerides,  that  is,  the  hydrogen  atoms  of 
the  three  hydroxyl  groups  of  glycerol  are  replaced  by 
the  fatty  acid  radicles.  The  chief  animal  fats  are 
mixtures  of  the  esters  of  stearic,  palmitic,  and  oleic 
acids.  In  addition  glycerides  of  such  fatty  acids  as 
butyric,  caproic,  caprylic,  and  capric  acids  occur  in 
considerable  amounts  in  the  fat  contained  in  milk. 
Less  well  known  are  the  esters  of  lauric,  myristic,  and 
arachidic  acids  which  are  usually  present  in  small 
quantities  in  animal  fats.  The  triglycerides  of 
lauric,  myristie,  linoleic,  erucic  acids,  etc.,  sometimes 
are  found  in  great  abundance  in  the  plant  kingdom. 


REFERENCE    HANDBOOK   OF   TIIK    MEDICAL   SCIENCES 


Allmrnt 


i,.  three  most  common  animal  fats  present  varying 
erees  of  hardness,  tristearin  being  the  hardest, 
olein  a  liquid  at  ordinary  temperatures,  and  tri- 
Imitin  occupying  a  position  between  the  two.  The 
riable  hardness  of  animal  fats  depends  upon  the 
iantitative  relationships  of  these  three  triglycerides. 
impaled  with  the  carbohydrates  fats  are  poor  in 
;ygen.  The  fats  are  soluble  in  ether,  carbon  bisul- 
ilde,  chloroform,  benzene,  etc.,  but  are  insoluble  in 
1 1  ei ■.  The  color,  taste,  and  odor  of  fal  from  different 
iinvs  are  due  to  contaminating  substances,  since 
ire  fats  are  colorless,  tasteless,  and  odorless.  The 
ts  give  a  temporary  emulsion  when  shaken  with 
iter,  but  when  shaken  with  an  alkali  or  a  soap  the 
nulsion  is  permanent.  The  fats  may  be  split  into 
,-ir  component  parts,  glycerol  and  fatty  acids,  by 
e  addition  of  the  components  of  water  in  accordance 
ith  the  following  reaction,  where  R  represents  any 
i  iv  acid  radicle: 

C3Hs(OR)3  +  3H:0=C3H5(OH)3  +  3HOR 

'lis  process  is  called  saponification  and  may  be 
i  niially  induced  by  pancreatic  lipase  and  other 
uiilar  enzymes  of  the  plant  and  animal  kingdoms. 
may  also  be  brought  about  by  the  action  of  steam 
iilcr  pressure;  by  long  continued  contact  with  air 
id  lignt;  and  finally  by  treatment  with  an  alkali, 
i  the  last  instance  soaps  result  and  this  reaction  is 
ie  underlying  principle  in  soap  making  on  a  com- 
ercial  scale. 

In  addition  to  the  naturally  occurring  fats  advan- 
ige  has  been  taken  of  the  varying  melting-points  of 
ie  principal  fats  to  make  artificial  mixtures  on  a 
immercial  scale  as  substitutes  for  butter.  Thus 
eomargarine  is  the  name  given  by  law  to  these 
liter  substitutes  in  the  United  States.  By  heating 
ief  suet  to  its  melting-point,  cooling  slowly  and 
tbjecting  the  warm  mass  to  pressure  in  a  filter  press, 
ie  softer  portions  consisting  mainly  of  triolein  and 
ipalmitin,  may  be  separated.  The  soft  portion  is 
nown  as  oleo  oil,  the  hard  part  as  beef  stearin.  The 
loo  oil  is  the  material  most  often  employed  under  the 
;itne  oleomargarine.  A  similar  mixture  is  made  by 
imbining  cotton  seed  oil  with  beef  stearin.  Some- 
mes  the  fats  are  churned  with  a  certain  amount  of 
al  butter  to  furnish  a  product  with  a  flavor  sugges- 
ve  of  butter.  The  name  butterine  is  given  to  such 
lixtures  and  from  the  standpoint  of  food  they  are 
illy  as  wholesome  and  nutritious  as  butter.7 
Closely  related  to  the  fats  stands  a  group  of  sub- 
lances  known  as  lipoids.  They  are  similar  to  the 
.is  in  physical  properties,  but  differ  from  them  in 
lictnical  structure.  Cholesterol,  a  monatomic  aleo- 
•  il,  C26H.5OH,  is  undoubtedly,  of  importance  in  the 
utritional  rhythm,  although  its  exact  significance  is 
ot  definitely  known.  Its  wide  distribution  in 
nimal  fluids  and  tissues  and  the  occurrence  of  closely 
lied  compounds,  the  phytosteroles,  in  the  plant 
ingdom  is  indicative  of  the  significance  of  this  group 
l  substances  in  life  processes.  Of  special  importance 
-  another  group  of  compounds  included  under  the 
<Tin  lipoids,  namely,  the  phosphatids.  Of  these  the 
•cithins  are  peculiarly  worthy  of  mention.  They 
omprise  a  group  of  esters  containing  nitrogen,  phos- 
ihoric  acid,  and  fatty  acid  radicles  and  a  case, 
iioline,  containing  nitrogen. 

CH2 — O — fatty  acid  radicle 

CH — O — fatty  acid  radicle 

CH.,— 0\ 

"HO->P  =  0 

CH-O/ 


I 


N 


'CH, 

"CH. 

CH, 


I  mm  the  st  rue  t  urn  I  1 01  inula  given  abo\  e  it  is  evident 

that  there  may  be  various  types  of  lecithins  in 
correspondence  with  the  fatty  acid  radicle  or  radicles 
contained  in  the  molecule.  '|  he  phosphatides  are 
widely  distributed,  being  especially  abundant  in  the 
brain  and  other  nervous  structures,  in  the  yolk  of  the 
egg,  and  in  the  muscles.  The  phosphatids,  and 
especially  the  lecithins,  are  of  the  greatest  importance 
in  the  development  and  growth  of  living  organisms 
for  they  serve  to  build  up  the  complex  pnosphorized 
nuclein  substances  of  the  cell  and  cell  nucleus. 

Wood,  as  eaten  by  man  and  animals,  is  a  natural 
mixture  of  the  various  food  stuffs  described.  Seldom 
are  the  isolated  principles  eaten  by  themselves,  other 
than  in  the  case  of  sugar  and  salt,  or  pure  fat.  It 
is  the  function  of  digestion  to  separate  the  individual 
principles  from  this  natural  mixture,  by  which  means 
they  are  separately  absorbed.  The  behavior  of 
animal  and  vegetable'  food  is  quite  different  in  the 
alimentary  canal,  which  difference  is  dependent  more 
upon  the  quality  of  dry  substance  contained  in  the 
latter  food  than  upon  its  quantity.  Vegetable  food 
yields  a  much  larger  percentage  of  indigestible  residue, 
and  is  in  itself  much  less  easily  digestible,  owing  to  the 
fact  that  it  is  more  or  less  enclosed  in  the  difficultly 
soluble  cellulose,  while  animal  food  is  free.  More- 
over, vegetable  food,  as  a  rule,  is  less  easily  absorbed, 
and,  as  it  contains  usually  a  less  percentage  of 
nitrogen,  a  much  larger  quantity  is  needed  to  furnish 
a  certain  amount  of  this  element  than  in  the  case  of 
animal  food.  Again,  the  large  quantities  of  starch 
contained  in  a  vegetable  diet  tend  to  produce  an  acid 
fermentation  in  the  small  intestines,  with  formation 
of  butyric  acid,  together  with  marsh  gas  and  hydro- 
gen, which  causes  the  frequent  intestinal  excretions 
of  herbivorous  animals. 

Nearly  all  foods  contain  appreciable  amounts  of 
water  and  inorganic  salts.  That  these  are  essential 
to  the  well  being  of  the  organism  has  been  demon- 
si  rated  repeatedly.  For  the  present  it  will  be  suffi- 
cient to  note  that  the  chief  mineral  substances  needed 
by  the  organism  are  the  four  elements  calcium,  so- 
dium, potassium,  and  magnesium,  which  exist  in  com- 
bination with  four  acids,  namely,  phosphoric,  hydro- 
chloric, sulphuric,  and  carbonic.  The  different  nu- 
trients are  found  in  nature  in  a  variety  of  combina- 
tions or  admixtures.  Milk  contains  all  the  types  of 
food  stuffs,  whereas  in  lean  beef  the  carbohydrates  and 
fats  may  be  present  only  in  small  quantity,  although 
the  protein  content  is  large.  On  the  other  hand,  cer- 
tain types  of  vegetables,  as  the  potato,  contain  only 
small  amounts  of  protein  and  little  or  no  fat,  but  the 
carbohydrates  are  present  in  large  quantity.  In  gen- 
eral, foods  of  animal  origin  are  particularly  rich  in 
protein  and  fat.  Usually  carbohydrates  are  abun- 
dant in  vegetable  foods. 

In  the  Table  II.,  p.  208,  is  given  the  relative  distribu- 
tion of  the  various  food  stuffs  as  they  occur  in  the 
edible  portion  of  the  natural  products. 

In  a  determination  of  the  food  value  of  a  given  food 
stuff,  or  of  a  given  diet  composed  of  a  mixture  of  food 
stuffs,  it  is  necessary  to  ascertain  its  chemical  compo- 
sition with  special  reference  to  the  content  of  protein, 
fat,  carbohydrate,  and  inorganic  salts;  its  caloric  or 
heat  value;  and  lastly  its  digestibility  or  availability. 
In  an  ordinary  mixed  diet,  protein  matter  is  usually 
present  in  the  proportion  of  one  part  to  about  five 
parts  of  non-protein  matter — i.e.  fats  and  carbohy- 
drates. The  proportion  of  fat  to  carbohydrate  is 
usually  exceedingly  variable,  ranging  anywhere  from 
one  part  of  fat  to  from  five  to  twelve  parts  of  carbo- 
hydrate. While  these  statements  are  to  be  accepted 
as  a  general  expression  of  the  ordinary  proportion  of 
the  three  primary  varieties  of  food  stuffs  contained 
in  an  average  diet,  it  is  to  be  remembered  that  the 
element  of  cost  or  the  ease  of  procuring  frequently 
determines  the  relative  amount  of  the  three  classes  of 
food  stuffs  in  the  daily  diet.     Thus,  in  countries  where 


207 


Ailment 


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meat  is  plentiful,  as  in  South  America,  protein  food 
is  consumed  in  much  larger  proportion  than  above, 
whereas,  in  some  Asiatic  countries,  the  prevalence  of 
rice,  cereals,  and  fruits  leads  to  a  daily  diet  in  which 
non-protein  foods  are  especially  conspicuous,  and  the 
proportion  of  protein  is  reduced  to  the  minimum  nec- 
essary for  life.  Further,  for  similar  reasons,  the  ratio 
of  fat  to  carbohydrate  undergoes  wide  variation  among 
different  races  or  in  different  countries.  Thus,  in  the 
far  north,  fat  (animal)  constitutes  the  greater  pro- 
portion of  the  non-protein  part  of  the  diet,  while 
in  countries  where  cereals  abound,  carbohydrates, 
mainly  in  the  form  of  starch,  make  up  the  greater 
portion  of  the  non-nitrogenous  food. 

Regarded  from  a  broad  viewpoint  the  human  body 
needs  food  for  three  purposes,  namely,  for  growth 
and  development,  to  replace  wornout  cellular  mate- 
rial, and  finally  to  furnish  energy  for  vital  activities. 
Nitrogen  is  particularly  necessary  for  the  purpose  of 
cell  repair,  and  food  should  be  of  such  a  nature  that 
it  will  readily  yield  its  potential  energy.  Proteins 
are  the  only  food  stuffs  capable  of  supplying  the  nitrog- 
enous need,  whereas  all  types  of  food  stuffs  will  yield 
energy  in  varying  degree.  The  older  view  that  the 
proteins  were  to  be  regarded  as  tissue  formers  and 
the  carbohydrates  and  fats  as  energy  yielders  has 
been  discarded.  The  prevalent  view  at  present  is  that 
the  body  is  not  restricted  to  the  use  of  any  one  food 
stuff  for  a  particular  purpose,  but  it  may  make  use 
of  all  types  in  order  to  employ  the  energy  of  all  nu- 
trients in  an  economical  manner.  "Thus,  the  carbo- 
hydrates, fats,  and  proteins  stand  in  such  close  mutual 
relations  in  their  service  to  the  body  that  for  many 
purposes  we  may  properly  consider  the  food  as  a  whole 
with  reference  to  the  total  nutritive  requirements, 
provided  a  common  measure  of  values  and  require- 
ments can  be  found.  Since  the  most  conspicuous 
nutritive  requirement  is  that  of  energy  for  work  of  the 
body,  and  since  these  organic  nutrients  all  serve  as 
fuel  to  yield  this  energy,  the  best  basis  of  comparison 
is  that  of  fuel  value."9  Energy  may  be  measured 
in  terms  either  of  heat  or  of  mechanical  work.  The 
energy  available  in  the  food  stuffs  is  expressed  by  its 
heat  or  fuel  value,  that  is,  in  units  of  heat,  or  calories. 
In  accordance  with  this  unit  it  has  been  demonstrated 
that  one  gram  of  protein  has  a  heat  value  of  4.1 
large  calories;  one  gram  of  fat  will  yield  9.3  large  calor- 


ies, and  the  heat,  or  fuel  value  of  one  gram  of  carbohy- 
drate amounts  to  4.1  large  calories.  The  total  fu'ei 
value  of  a  few  of  the  common  food  stuffs  is  given  in 
Table  II. 

The  conditions  which  most  obviously  influence  the 
food  requirement  with  respect  to  fuel  value  are  age 
size  of  body,  and  muscular  activity.  'When  a  man 
is  at  rest,  that  is,  with  all  external  muscular  work 
excluded,  it  has  been  estimated  that  approximately 
2.UU0  calories  per  day  are  necessary  for  proper  nutri- 
tional rhythm.  Such  an  energy  requirement  lias 
been  called  the  maintenance  requirement.  Of  this 
about  eight  to  twelve  per  cent,  is  expended  upon  the 
work  of  digestion  and  assimilation,  five  to  ten  per 
cent,  upon  the  circulation,  ten  to  twenty  per  cent, 
upon  the  respiration  and  thirty  to  fifty  percent,  upon 
the  maintenance  of  muscular  tension  or  "tone." 
Muscular  work  is  the  most  important  factor  in  raising 
the  energy  requirement  above  the  maintenance  Deed. 
Thus  a  man  who  works  at  manual  labor  may  inn 
his  metabolism  by  1,000  to  2,000  calories  per  day 
above  what  is  needed  for  maintenance  at  rest,  making 
his  total  food  requirement  3,000  to  4,000  calories  per 
day,  although  with  severe  labor  this  may  rise  to  6,000 
calories  or  even  higher.  Voit  estimated  the  food  re- 
quirement of  a  moderate  worker  at  3,050  calories,  and 
Atwater  in  the  United  States  believed  that  the 
American  needs  3,400  to  3,500  calories  per  day.  By 
moderate  worker  was  meant  a  man  engaged  in  manual 
labor  for  nine  to  ten  hours  a  day,  such  as  a  carpenter 
or  a  mason.  It  is  well  recognized  that  the  calorific 
need  varies  directly  with  the  severity  of  the  muscular 
exercise,  and  in  accordance  with  this  idea  Tigerstedl 
has  estimated  the  energy  requirements  sufficient  for 
individuals  engaged  in  a  variety  of  occupations. 
Thus, 

2,001  to  2,400  calories  suffice  for  a  shoemaker. 
2,401  to  2,700  calorics  suffice  for  a  weaver. 
2,701  to  3,200  calories  suffice  for  a  carpenter  or  mason. 
3,201  to  4,100  calories  suffice  for  a  farm  laborer. 
4,101  to  5,000  calories  suffice  for  an  excavator. 
Over  5,000  calories  suffice  for  a  lumberman. 

In  a  general  way  the  total  food  requirement  varies 
with  the  body  weight.  This  is  not  strictly  true,  for  the 
food  requirement  though  greater  in  absolute  amount 
in  the  larger  individual  is  less  per  unit  of  body  weight 


Table  II. 

Composition  of  Edible  Portion-  of  Some  Common  Food  Materials.8 


Food  materials. 

Water. 

Protein. 

Carbohydrate. 

Fat. 

Mineral 
matter. 

Fui  1  value 
per  pound. 

Per  cent. 
73  8 
54.6 
67.1 
S3 . 6 
74.8 
55.5 
SS.3 
73   7 
11.0 
79  2 
53 , 5 
58.5 

Per  cent. 
22.  1 
15  8 
19.4 
15  3 
2 1  . 5 
21.1 

6.0 
13   4 

1.0 
17  6 
25    I 
11.1 

Per  rent. 

Per  cent. 

2.9 

28.5 

12.7 

26.2 

22  9 

1  .3 
10.5 
S5.0 

1.8 

0  3 

0  2 
100  0 

4.0 
33.7 

Per  cent. 
1  .2 
0.9 
0.8 
4.9 
1.1 
1.0 
1.1 
1.0 
3.0 
1.7 
24   7 
0.8 

i  'alories. 
;30 

1 495 

91)11 

1395 

505 

Turkey 

Fresh  oysters,  s  ilid 

1360 

3  .; 

0 
720 

Butter 

360.5 

■in:, 

411) 

215 

Milk 

87  l) 
34.2 

3.3 

25 . 9 

5.0 

2  4 

100.0 

56  7 

73    1 
22  0 
65 . 9 
19  7 
16  9 
IS   4 
17.3 
6.9 

(1   7 
3.S 

325 

1950 

29  _' 

5.9 

68.5 

10    I 

75    1 

74.6 

78.3 

4.S 

6.4 

8.9 

9.8 

7    1 

18   1 

3    1 

7.7 

2.2 

21.0 

33.9 

4.1 
9.1 

0  7 
1.5 

1  1 
0.5 
0.1 

54.9 
49.4 

1  1 

2  1 
1    7 
4.1 
0.7 
1.0 
1.0 
2.0 
3.4 

1925 

Fresh  lima  beans 

:,7I) 
1625 

-179 

165 

385 

3030 

2845 

208 


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Ailment 


than  in  the  smaller.  The  energy  metabolism  increases 
in  proportion  to  the  surface  rather  than  with  the 
weight.  However,  in  the  human  species  the  variation 
in  size  is  relatively  not  very  great  and  for  all  practical 
purposes  the  statement  is  essentially  correct  that  the 
greater  the  weight  the  greater  is  the  energy  require- 
ment, cither    tilings  being  equal.      Fur   the   young  the 

,1   requirement    is   relatively   greater   than   in    the 

adult  even  when  calculated  according  to  the  unit 
surface  of  body.  It  is  probable  that  the  period  of 
growth  has  a  distinct  influence  on  the  extent  of 
metabolism  and  for  this  reason  the  food  of  children 
should  furnish  ample  fuel  value  to  compensate  for  the 
more  active  general  metabolism.  In  old  age  metab- 
olism is  much  reduced,  being  lower  than  in  an  in- 
dividual of  medium  age,  hence  the  food  requirement 
is  correspondingly  diminished.  The  question  as  to 
what  extent  sex  especially  influences  the  food  require- 
ment cannot  be  said  to  be  definitely  established. 
During  life  cellular  material  is  constantly  undergoing 
disintegration  as  a  result  of  life  processes,  thereby 
creating  a   constant   demand  for  the  elements   that 

titute  the  cellular  structures.  In  a  large  measure 
the  underlying  basis  of  these  structures  is  nitrogenous 

rial,  or  protein.  Hence,  the  need  for  food  pro- 
tein is  in  direct  proportion  to  the  destruction  of  the 
nitrogenous  structural  elements  of  the  organism. 
Under  ordinary  conditions  of  life,  work  is  not  done  at 
tin1  expense  of  the  nitrogenous  constituents.  Ex- 
pressed in  other  words,  muscular  activity  is  not  per- 
formed as  a  result  of  the  combustion  of  protein  ma- 
terial composing  the  muscles.  Work  is  done  by  the 
organism  preferably  by  the  energy  liberated  during 
the  combustion  of  the  non-nitrogenous  substances, 
the  fats  and  carbohydrates.  In  the  absence  of  a 
sufficient  supply  of  the  last-mentioned  compounds 
protein  material,  for  example,  that  of  muscle,  may 
e  as  the  source  of  energy  and,  therefore,  under 
these  circumstances  work  may  be  done  as  a  result  of 
protein  disintegration.  There  are  only  a  few  condi- 
tions under  which  a  storage  of  protein  occurs  in  the 
body,    and    even    under    these  circumstances  storage 

be  merely  transitory.  Nitrogen  may  be  stored 
(a)    in   the   growing  body    (or  in    pregnancy)    where 

tissue  is  being  constructed;   (/<)   in  cases  where 

ased  muscular  exercise  calls  for  enlargement  of 
muscles;  (r)  in  cases  where,  owing  to  insufficient  food 
intake,  or  to  wasting  disease,  the  protein  content  of 
the  body  has  been  more  or  less  diminished  and  conse- 
quently any  surplus  available  is  utilized  to  make  good 
the  loss.  It  follows  from  these  facts,  therefore,  that 
any  huge  excess  of  protein  over  the  actual  daily  need 
for  tissue  reconstruction  is  probably  uneconomical 
physiologically.  Although  protein  may  furnish  gram 
for  gram  as  much  energy  as  carbohydrates  its 
utilization  as  a  source  of  energy  is  attended  by  a  great 

more  difficulty  than  is  true  for  the  carbohydrates. 
The  latter  are  usually  easily  digested  and  are  entirely 
assimilated  whereas  protein  disintegration,  which 
isential  in  order  to  make  available  potential 
energy  contained  therein,  is  a  much  more  protracted 
process,  finally  resulting  in  the  necessity  for  increased 
activity  on  the  part  of  the  kidneys  so  that  the  non- 
available  nitrogenous  products  may  be  eliminated. 
The  exact  amount  of  nitrogenous  food  necessary 
for  man  per  day  is  difficult  of  determination  and  is 
a  matter  upon  which  has  been  based  a  great  deal  of 
i  Dntroversy10.  An  idea  of  the  normal  dietary  need  is 
probably  best  obtained  by  an  experimental  determina- 
tion of  how  much  protein  must  be  contained  in  the 

food  in  order  to  keep  the  body  in  protein  or 
nitrogenous  equilibrium.  This  is  done  by  striking  a 
balance  between  the  nitrogen  of  the  food  ingested 
and  the  nitrogen  eliminated  in  the  excreta.  A  plus 
balance  indicates  a  storage  of  nitrogen  in  the  body;  a 
minus  balance  shows  a  loss  of  body  protein.  When 
the  balance  is  approximately  zero  the  body  is  said  to 
be  in  protein  or  nitrogenous  equilibrium.  From  a 
Vol.  I.— 14 


long  series  of  investigations  it  has  been  concluded 
that  the  body  may  so  adjust  itself  in  a  short  period 
of  time  that  nitrogenous  equilibrium  may  be  estab- 
li  bed  on  widely  varying  quantities  of  protein. 
Thus   the   same    individual   may   exhibit    nitrogenous 

equilibrium  on  -even  grams  of  nitrogen  in  the  form  of 
protein  or  on  thirty  grams  or  even  more.  The  fuel 
value  of  the  food  lias  a  great  influence  upon  the-  ex- 
tent of  protein  metabolism  by  determining  whether 
the  body  must  draw'  upon  its  own  tissues  for  fuel. 
Under  these  circumstances  it  is  readily  conceivable 
that  non-nitrogenous  food  -luffs  play  an  important 
role  in  the  establishment  of  nitrogenous  equilibrium. 
other  things  being  equal  it  is  much  easier  to  get  an 
individual  into  a  condition  of  nitrogen  equilibrium 
when  the  fuel  value  of  the  food  is  ample  than  when 
the  energy  yield  is  small.  That  tissue  protein 
catabolism  may  be  greatly  diminished  by  intake  of 

carbohydrates  and  fats  has  long  been  known  and  this 

action  has  been  designated  as  their  "protein  sparing'' 
effect.  Thus  the  loss  of  protein  from  the  tissues 
which  occurs  with  an  insufficient  diet  may  be  de- 
creased or  even  entirely  stopped  by  adding  carbo- 
hydrates and  fats  to  the  food.  If  these  substances  are 
added  to  the  diet  of  an  individual  in  nitrogen  equili- 
brium a  temporary  storage  of  protein  may  occur.  Up 
to  a  certain  point  the  fats  and  carbohydrates  are  inter- 
changeable m  isody  nan  lie  quantities,  that  is,  one  gram 
of  fat  is  isodynamic  with  2.2  grams  of  carbohydrate, 
beyond  this  point,  which  may  show  marked  variation 
for  different  individuals,  fat  is  not  well  utilized. 
Carbohydrates  tin-  easily  utilizable,  fats  with  more 
difficulty.  The  gastroenteric  tract  rebels  at  large 
quantities  of  fat.  This  statement  is  especially  true 
for  most  civilized  peoples  though  exceptions  may  be 
found,  as  in  the  Esquimaux  and  certain  savage 
tribes. 

On  the  assumption  that  energy  is  supplied  suffi- 
cient to  meet  all  the  ordinary  demands,  how  much  pro- 
tein or  nitrogen  must  the  daily  food  contain  in  order 
to  maintain  the  organism  in  nitrogenous  equilibrium 
and  in  a  general  condition  of  well  being?  Among 
other  investigators  Siven  has  attempted  to  answer 
this  query.  Siven  with  a  body  weight  of  sixty  kilos 
experimenting  upon  himself  found  that  with  sufficient 
fuel  value  he  was  able  to  maintain  nitrogen  equilib- 
rium upon  thirty-nine  grains  of  protein  per  day. 
The  most  extended  and  thorough  series  of  investiga- 
tions upon  this  point  were  those  carried  through  by 
Chittenden.11  Professional  men,  athletes,  and  soldiers 
of  the  United  States  Army  acted  as  subjects.  In  the 
following  table  are  given  a  few  examples  of  the  results 
obtained. 

Table  III. 

TmtalFcel  Valce,  Protein-  Intake  and  N'itrogex 
Balance  per  Day. 


Subject. 

Body 

weight. 

Fuel 
value. 

Protein. 

Nitrogen 
balance. 

C 

Kilos. 

.",7 
70 
01 
61 
04 
64 
60 
02 
7."» 

Calories.           Grams. 
1,613              40  n 

Gram. 
+  0  165 

VI.  . 

2,448 

2.00.S 
2,152 
2,509 
2.S40 
2.S40 
2.4.-.0 
2,809 

53  2 
55  2 
63.1 
59  4 
53.9 
54 . 2 
55  2 
71    7 

4-0  38 

u 

4-0  158 

Bo... 

+  0  34 

O(I) 

0(11) 

Br 

+  0 . S09 
-0   2' 12 
+  0   1  5  ! 

P 

4-0.089 

S 

4  0  339 

It  is  apparent  from  these  data  that  nitrogenous 
equilibrium  may  be  established  and  maintained  by 
men  weighing  between  fifty-seven  and  seventy-five 
kilos  upon  an  ingestion  of  protein  per  day  varying 

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from  forty  to  seventy-two  grains  without  appreciably 
increasing  the  fuel  value  of  the  food  ingested.  The 
figures,  however,  probably  represent  the  minimum 
quantity  of  protein  compatible  with  nutritional 
rhythm    and    continued    vigor,. 

On  the  other  hand,  custom  and  habit  have  played  a 
role  in  the  establishment  of  so-called  dietary  stand- 
ards.11'! Thus  Voit  in  Germany,  by  estimation  of 
the  food  eaten  by  the  ordinary  individual,  set  up  a 
standard  whereby  the  organic  food  requirement 
should  approximate: 

IIS  grams  protein. 
5G  grams  fat. 
500  grams  carbohydrates. 
These    quantities  of  food-stuffs  would  furnish  about 
3,000  calories. 

Playfair  in  England  promulgated  the  following 
standard: 

119  grams  protein. 

51  grains  fat. 
531  grains  carbohydrates, 
which    would    yield   a   fuel    value   of   3,000   calories. 
In  France  Gautier  proposed  a  standard  for  men 
with  little  muscular  work  as  follows: 
107  grams  protein. 
65  grams  fat. 
407  grains  carbohydrates. 
The  fuel  value  of  this  dietary  would  furnish  2,630 
calories. 

Langworthy  has  collected  the  data  of  large  numbers 
of  dietaries  of  families  under  diverse  conditions  both 
in  the  United  States  and  abroad,  and  stating  them  in 
terms  of  protein  and  calories  per  man  per  day  has 
compiled  the  following  table. 

Table  IV. 

Langworthy's  Compilation  of  Results  of  Dietary 
Studies.12 


Food  per  man 

Occupation  of  head  of  family. 

per 

day. 

Protein 

Fuel  value 

grams. 

cal<  tries. 

United  States: 

Man    at    very    hard    work    (average    19 

177 

6,000 

studies). 

Farmers,  mechanics,   etc.   (average   162 

100 

3,425 

studies). 

Business   men,    students,    etc.  (average 

106 

3,285 

51  studies). 

Inmates  of  institutions,  little  or  no  mus- 

S6 

2,600 

cular  work  (:iv<-ruge  of  49  studies). 

Very  poor  people,  usually  out  of  work 

69 

2,100 

(average  15  studies). 

Canada:  Factory      hands      (average      13 

10S 

3,480 

studies). 

89 

2,685 

108 

3  228 

9S 

3,107 

German  v: 

134 

3,061 

Professional  men 

111 

2,511 

110 

2,750 

Japan: 

118 
S7 

4,415 

2,190 

At 

3,-100 

112 

2,825 

108 

2,812 

In  addition  to  the  foregoing  functions  of  the  non- 
nitrogenous  food  stuffs  these  substances  may  be  of 
service  to  the  body  in  other  ways.  Thus  although 
fats  are  especially  important  for  the  fuel  value  they 


furnish,  they  form  the  basis  of  adipose  tissue  and  are 
essential  for  tissue  development  generally.  The 
great  importance  of  fat  in  food  and  of  that  deposited 
in  the  body  is  to  be  found  in  the  aid  which  it  furnishes 
to  the  hungry  organism  in  developing  its  wasted 
tissue.  A  purely  protein  diet  for  a  person  poor  in 
fat  necessitates  a  large  amount  of  the  former  to 
sustain  the  weight  of  the  body,  indeed  more  than  the 
intestines  are  capable  of  absorbing.  But  a  mixture 
of  fat  and  protein  diminishes  protein  metabolism. 
It  is  not  possible  to  convert  a  poor  body  into  a  body 
rich  in  fat  and  protein  material  by  an  exclusive 
protein  diet;  fats  or  carbohydrates  are  needed, 
admixture  of  which  diminishes  the  work  of  the 
organism.  Carbohydrates,  without  doubt  are  in  a 
large  measure  the  source  of  fat  in  the  body.  Sugar 
or  starch  is  always  present  in  fattening  foods  and 
although  there  is  little  evidence  of  a  positive  nature 
that  fat  is  formed  directly  from  carbohydrate  there 
is  a  close  relationship  between  carbohydrate  intake 
and  fat  deposition  in  the  organism.  It  has  been 
suggested  that  carbohydrate  functions  by  protecting 
the  fat  already  deposited.  It  does  this  by  under- 
going combustion  instead  of  the  fat. 

Collagenous  tissue,  comprising  the  gelatinous 
principles  (organic  basis  of  bone,  cartilage,  tendons, 
and  connective  tissue),  cannot  supply  the  place  of 
the  true  proteins;  still,  Voit  has  found  that  nitrogen- 
ous equilibrium  is  established  at  a  lower  level  of 
protein  food  when  gelatin  is  added.  The  value  of 
gelatin  has  been  found  by  Murlin13  to  be  dependent 
to  a  high  degree  upon  the  protein  condition  of  the 
body,  on  the  calorific  value  of  the  food  and  the  quan- 
tity of  carbohydrates  in  the  latter.  When  two-thirds 
of  t  lie  total  calories  partaken  of  were  in  the  form  of 
carbohydrates,  gelatin  could  supply  sixty-three  per 
cent,  of  the  total  nitrogen.  Gelatin  may  also  some- 
what decrease  the  consumption  of  fat,  although  it  is 
of  less  value  in  this  respect  than  the  carbohydrates, 

Water  is  of  exceeding  great  importance  for  the  well 
being  of  the  organism.  According  to  Voit,  the  body 
of  a  fully  developed  man  contains  sixty-three  per 
cent,  of  water,  while  the  body  of  a  growing  child 
contains  nearly  66.5  per  cent.  Any  great  alteration 
in  the  content  of  water  in  the  animal  body  is  always 
attended  with  disastrous  results;  thus,  in  diarrhea, 
cholera,  etc.,  such  large  quantities  of  water  are  lost 
as  tn  render  the  blood  quite  thick,  and  even  the 
muscles  may  lose  as  much  as  six  per  cent,  of  water. 
Such  loss,  if  long  continued,  soon  results  in  loss  of 
vitality  and  consequent  death.  It  is  noticeable, 
moreover,  that  a  certain  proportion  of  the  water 
contained  in  the  tissues  of  the  body  can  be  removed 
without  difficulty,  while  a  smaller,  residual  portion, 
apparently  more  closely  united  to  the  organic  matter, 
can  be  separated  only  with  great  difficulty;  this  is 
well  illustrated  in  the  simple  drying  of  dead  muscle 
tissue.  Removal  of  the  water  from  low  forms  of 
animal  life,  by  drying  them  at  the  ordinary  tempera- 
ture, or  at  a  temperature  below  the  coagulating 
point  of  their  body  protoplasm,  causes  them  to  lose 
all  appearance  of  life;  but  in  such  condition  they  will 
again  absorb  the  water  lost,  and  return  to  their 
former  appearance  and  vitality.  Increase  of  water 
in  the  organism  beyond  the  normal  amount  is  usually 
associated  with  an  unhealthy  condition  of  the  body. 
Various  investigators  have  likewise  demonstrated 
t  hat  there  is  a  close  connection  between  the  percen 
of  water  in  the  body  and  the  diet,  irrespective  of  tin' 
water  taken  as  drink.  Thus  Voit  has  shown  that  a 
bread  diet,  continued  for  some  time,  renders  the  body 
more  watery  than  normal.  In  one  experiment  with 
a  cat,  the  amount  of  water  in  the  brain  and  muscles 
was  increased  three  to  four  per  cent.  Increase  of 
fat  in  the  body  is  usually  attended  with  a  diminished 
percentage  of  water.  A  vigorous,  well-nourished 
man  possesses  organs  much  poorer  in  water  than  a 
badly  fed  person.     Forster14  nas  figured  that  under 


210 


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Aliment 


normal  conditions  a  person  living  on  an  average  diet 
alces  daily  from  2,215  to  3, 538  grams  (about  6.5  pounds 
ivoirdupois)  of  water.     It   is  easy  to  see,  however, 

i   a  great   variety  of  circumstances,  as  variations 

,i    diet,    exercise,    temperature,    etc.    may    have    a 

modifying  influence  on  the  amount  of  water  taken 

i  to  the  system  during  the  twenty-four  hours.     The 

just  given  do  not,  however,  represent  all  of 

the  water,  since  a  variable  amount   is  formed  within 

[he  body  by  oxidation  of  tin-  hydrogen  contained  in 

organic  food -stuffs.     Tims,  according  to  Voit  in 

case  of  a  hungry  man.  thirty-two  grams  of  hydro- 

in  the  form  of  organic  matter  were  oxidized  to  288 

us  of  water  during  twenty-four  hours. 

It   is  thus  plainly  evident  from   tin'  Ion  going  that 

er  is  a  necessary  constituent  of  the  body,  and  as 

.     of   the   food-stuffs  is  a   decidedly    important    one; 

are  need  to  understand  its  true  significance.     It 

-  not  itself  undergo  any  chemical  change,  and  is 

it   source   of   energy,    though    it    aids    chemical 

ige    in    supplying   by   its   presence   a   condition 

Mutely    necessary    for    its    occurrence    in    other 

bodies. 

The   mineral  matters  are  more  closely  concerned  in 
the  structure  of  the  organism  than  in  the  liberation 
of  energy,  and  this  is  true  both  of  animal  and  vege- 
table organisms.     Further,  inorganic  salts  appear  to 
.  >   an  important  part  in  regulating  and  controlling 
line  measure  the  various  metabolic  processes  oi 
the  body  although  they  themselves  contain  little  or 
no  potential  energy.     They  maintain  a  normal  com- 
ii. m    and    osmotic    pressure    in    the   liquids   and 
ues  of  the  body,  and  by  virtue  of  their  osmotic 
~ure  they  play  an  important  part  in  controlling 
low  of  water  to  and  from  the  tissues.      Moreover, 
•  salts  constitute  an  essential  part  of  the  com- 
position  of  living  matter.     They  are  bound  up  in  the 
re  of  the  molecule  in  an  intimate  manner  and 
are  necessary  to  its  normal  irritability.     The  proteins 
of  the  body  fluids  contain  definite  amounts  of  ash 
if  this  is  removed  the  properties  of  these  sub- 
ire  greatly  changed.     They  are  particularly 
ssary  in  the  developing  animal  body.     Mineral 
ter  is  needed  not  only  for  the  growth  and  nutrition 
of  the  skeletal  port  ions  of  the  body,  but  it  is  also  needed 
in  the  structure   of  the  softer   tissues,   as  well  as  in 
formation   of  secretions;   thus,   the  acid  of   the 
lie  juice  has  its  origin  in  the  chlorine  of  sodium 
i!e,    or    common   salt,    while    the    alkalinity    of 
the  pancreatic  secretion,  as  well  as  that  of  some  of  the 
er  fluids  of  the  body,  is  due  mainly  to  inorganic 
salts,  as  the  alkali  phosphates  and  perhaps  bicarbon- 
ates.     In  many  juices  of  the  body,  inorganic  elements 
arc  held  not  only  in  solution,  but  quite  firmly  united 
i  the  more  characteristic  matter,  as  in  the  sodium 
salts  of  the  bile  acids,  and  in  some  instances  they  can 
be  removed  only  by  decomposition  of  the  compound. 
The  excess  of  salts  taken  into  the  body,  by  the  food 
or  other  means,   and   that   which   becomes  free  by 
imposition  within   the  body,   is  easily  removed 
througn  the  urine  and  feces. 

There  is  still  other  evidence  that  the  various 
inorganic  salts  of  food  serve  definite  purposes  in  the 
body."  The  two  alkalies,  potash  and  soda,  so  widely 
distributed  (for  distribution  of  sodium  and  potassium 
in  some  common  foods  see  Table  V.)  and  so  closely 
allied  in  their  chemical  properties,  cannot  be  made 
to  replace  each  other  in  the  living  organism,  while 
the  same  is  likewise  true,  to  a  certain  extent,  of  the 
alkali  earths,  lime  and  magnesium.  Thus  a  qualita- 
tive, and  also  a  quantitative,  selection  of  inorganic 
matter  is  noticeable  in  the  body,  particularly  in  the 
blood,  where  the  corpuscles  contain  the  greater  por- 
tion of  the  potassium  salts  and  phosphates,  while  in 
the  serum,  sodium  salts  and  chlorides  are  in  excess. 
Again,  it  is  quite  noticeable  that  potassium  salts 
predominate  in  the  formed  tissues  of  the  body,  while 
sodium  salts  are  characteristic  of  the  fluids. 


I  orster's  experiments  on  pigeons  with  food  poor  in 
salts,  and  on  dogs  ujth  powdered  meat  from  which 
the  greater  portion  of  inorganic  matter  had  been 
ii  moved  by  extraction  with  hot  water,  fat  and  carbo- 
hydrates being  afterward  added,  showed  that  these 
animals  could  not  bear  the  loss  longer  than  four  to 
live  weeks  without  great  suffering,  and,  finally,  death. 
In  fact,  it  is  evident,  from  physiological  experiment, 
that  an  organism  supplied  with  all  organic  food  -tell 
and  water  can  live  only  for  a  limited  time  without 
mineral  matter.  For  a  time  the  body  draws  upon 
tin'  inorganic  matter  stored  up  in  it-  own  tissue:  but 
this  failing,  and  that  naturally  present  in  the  organic 

f Is  being  removed,  death  soon  results  from  lack  of 

inorganic  aliment.  In  the  ordinary  diet  of  men  and 
animals,  sufficient  salts  are  generally  contained  in  the 
non-nitrogenous  and  proteid  foods  to  furnish  the 
required  amount  of  mineral  matter.  As  to  the 
actual  quantity  of  inorganic  mat  ter  needed  to  counter- 
balance that  withdrawn  from  the  hotly  in  twenty- 
four  hours,  we  can  hardly  say. 

The  eight  elements,  iron,  calcium,  magnesium,  po- 
tassium,  sodium,  chlorine,  sulphur,  and  phosphorus, 
constitute  the  so-called  ash  of  our  foods,  in  other 
words,  the  inorganic  food-stuffs. 

Iron  may  be  looked  upon  as  the  link  connecting  the 
organic  and  inorganic  food  stuffs  to  the  body  com- 
pounds. This  element  is  an  integral  part  of  hemo- 
globin and  other  compounds  associated  with  the  proc- 
esses involved  in  oxidation,  secretion,  reproduction, 
and  development.  The  iron  contained  in  these  sub- 
stances is  in  a  firm  organic  combination  with  proteins. 
These  organic  compounds  of  iron  are  probably  in 
turn  constructed  from  somewhat  similar  iron-con- 
taining groupings  in  the  food-stuffs.  Numerous  in- 
vestigations have  been  carried  through  to  determine 
the  influence  of  various  preparations  of  iron  upon 
the  storage  of  this  element  within  the  organism,  with 
the  general  conclusion  that  the  iron  of  naturally 
occurring  food-stuffs  best  serves  the  purpose  of  recon- 
struction of  hemoglobin  within  the  body.  It  has 
been  estimated  that  approximately  ten  to  fifteen 
milligrams  of  food  iron  are  sufficient  to  maintain  an 
average  man  under  normal  conditions  in  iron  equilib- 
rium. In  the  typical  food-materials  iron  exists  in 
varying  quantities  (see  Table V.).  In  meat  iron  occurs 
largely  in  hemoglobin  retained  in  the  muscle  tissue. 
The  iron  present  in  milk,  eggs  and  the  vegetable 
foods  is  perhaps  better  absorbed  and  assimilated  to 
greater  advantage  than  the  iron  of  meat.  In  the 
grains  a  great  portion  of  the  iron  exists  in  the  germ 
and  outer  layers.  Hence,  in  the  process  of  milling 
this  iron  is  rejected  so  that  fine  flours  are  less  rich 
in  this  element  than  the  natural  cereals.  Vegetables 
and  fruits  contain  appreciable  quantities  of  iron  which 
man  undoubtedly  utilizes  to  the  best  possible  advan- 
tage. Foods  containing  little  iron  are  fat  pork,  bacon, 
lard,  butter,  salad  oils,  sugars,  starches,  and  confec- 
tionery. Iron  is  eliminated  from  the  body  chiefly 
through  the  intestine. 

Of  the  calcium  salts  ingested  only  about  one-tenth 
is  excreted  through  the  kidney.  Like  iron  this  ele- 
ment is  eliminated  from  the  body  through  the  intes- 
tinal wall  and  so  passes  out  with  the  feces.  If  ani- 
mals are  kept  for  long  periods  of  time  upon  diets  poor 
in  calcium,  marked  wasting  of  lime  salts  from  the 
bones  may  occur.  This  is  especially  true  for  the 
young  growing  individual  in  whom  the  symptoms  of 
an  inadequate  supply  of  calcium  salts  are  chiefly  mani- 
fested by  abnormal  weakness  and  flexibility  of  the 
bones.  Herter10  ascribes  to  insufficient  assimilation 
of  calcium  in  the  food  many  cases  of  arrested  develop- 
ment in  infancy.  The  calcium  requirement  has  not 
been  definitely  established,  although  it  is  probable 
that  the  ordinary  healthy  man  needs  about  0.7  gram 
calcium  oxide  per  day  to  maintain  calcium  equilibrium. 
Calcium  occurs  chiefly  in  the  skeleton  as  calcium  phos- 
phate  and    carbonate.     It   is   these  salts   that   give 


211 


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rigidity  to  the  bones.  Of  the  calcium  in  the  body 
about  ninty-nine  per  cent,  is  found  in  the  bones  and 
the  remainder  is  distributed,  partly  in  organic  com- 
bination with  the  proteins,  and  partly  in  solution  in 
the  blood  and  other  body  fluids.  Calcium  salts  are 
especially  necessary  for  the  coagulation  of  the  blood 
and  are  of  prime  significance  for  the  normal  action 
of  the  heart  muscle.  Moreover,  calcium  plays  an 
important  role  in  regulating  disturbances  in  inorganic 
equilibrium.  "Calcium  is  capable  of  correcting  the 
disturbances  of  the  inorganic  equilibrium  in  the  animal 
body,  whatever  the  directions  of  the  deviations  from 
the  normal  may  be.  An  abnormal  effect  which 
sodium,  potassium,  or  magnesium  may  produce, 
whether  abnormality  be  in  the  direction  of  increased 
irritability  or  of  decreased  irritability,  calcium  is 
capable  of  reestablishing  the  normal  equilibrium."17 
The  occurrence  of  calcium  in  some  of  the  common 
foods  may  be  seen  from  an  inspection  of  Table  V.  It 
will  be  noted  that  milk  is  particularly  rich  in  this 
element.  Beef  and  flour  are  much  poorer  in  calcium. 
Other  cereals  which  have  undergone  the  milling 
process  contain   less  calcium  than  the  whole  grain-. 


ample,  phenol,  cresol,  indol,  skatol,  in  a  form  which 
is  known  as  an  "ethereal  or  conjugated  sulphate." 
Table  V.  shows  the  distribution  of  sulphur  in  a  few 
common  foods. 

Phosphorus  is  an  essential  cell  constituent  and  as 
such  is  found  distributed  throughout  every  tissue  and 
fluid  of  the  body.  Phosphorus  occurs  in  foods  chiefly, 
in  four  forms;  (a)  in  the  proteins,  as  nucleoprotein  of 
cell  nuclei,  lecithoproteins,  and  phosphoproteins  as 
exemplified  by  casein  and  vitellin;  (b)  in  the  phos- 
phatides, as  the  lecithins;  (c)  as  organic  derivatives 
of  phosphoric  acid  (inosite  phosphoric  acid  ester)  of 
which  the  salts  occurring  naturally  in  wheat  are  called 
"phytin";  and  (d)  inorganic  phosphates  which  are 
found  in  abundance  in  most  foods.  Phosphorus  is 
absolutely  necessary  for  normal  nutritional  processes 
and  to  maintain  phosphorus  equilibrium  approx- 
imately one  gram  of  phosphorus  is  required  per  day. 
For  the  reconstruction  of  nuclear  material  of  cells 
phosphorus  is  essential,  and  the  problem  has  ari-cn 
whether  for  this  purpose  organic  or  inorganic  phos- 
phorus is  demanded.  It  is  probable  from  recent  ex- 
periments'9 that  the  organic  phosphorus  constituents 


Table   V. 
Ash  Constituents  of  Foods  in  Percentage  op  the  Edible  Portion. ls 


Food. 


CaO. 


MgO. 


K-O. 


Najtl. 


r  ii 


ci. 


Fe. 


Almonds 

Apples 

Asparagus 

Bananas 

Lima  beans,  fresh . . 

Beets 

Cab]  >age 

Carrots 

Celery 

Corn,  fresh 

Eggs 

Codfish 

Lean  beef 

Milk 

Oatmeal 

Wheat  flour 

Peas,  fresh 

Potatoes 

Rice 

Squash 

Turnips 

Walnuts 

Wheat,  entire  grain 


30 

.35 

014 

.014 

04 

.02 

01 

.04 

04 

.11 

03 

.033 

068 

.026 

077 

.034 

10 

.04 

nils 

ii.-,.', 

09S 

.01.-) 

(II.-) 

.03 

nil 

.04 

16S 

.019 

13 

.212 

025 

.1127 

04 

.07 

016 

.036 

012 

.045 

02 

.01 

089 

.028 

108 

.  237 

061 

.213 

20 

.03 

15 

.02 

20 

.01 

50 

.02 

70 

.12 

45 

.10 

45 

.05 

35 

.13 

37 

.11 

137 

.05 

165 

.20 

40 

.13 

12 

.09 

171 

.038 

158 

.109 

146 

.04 

30 

.04 

53 

.025 

084 

.028 

05 

.05 

40 

.08 

44 

.03 

519 

.mis 

.87 
.03 
.09 

1 1.-,;, 
.27 
.09 
.09 
.10 
.10 

22 
.37 
.40 
.50 
.215 
.872 
.20 
.26 
.140 
.  203 
.OS 
.117 

.902 


005 

.135 

.002 

004 

.005 

.0003 

04 

.04 

.0010 

20 

.013 

.0006 

009 

.06 

.0025 

04 

.015 

.0006 

03 

.07 

0011 

036 

(122 

.0008 

17 

1125 

;> 

014 

.044 

.0008 

10 

.19 

.003 

24 

0004 

05 

.20 

0038 

12 

.033 

. 00024 

035 

.215 

.0036 

07 

.17 

.01115 

01 

.06 

.0016 

03 

.03 

.0013 

05 

.105 

.0009 

01 

.026 

in  ins 

04 

.07 

.  000.5 

01 

.195 

.0021 

OS 

.17 

.0053 

In  general  fruits  and  vegetables  contain  fairly  large 
amounts  of  this  element.  This  is  particularly  true 
of  the  fresh  vegetables.  It  is  apparent,  however, 
that  in  order  to  insure  to  the  body  an  abundance  of 
available  calcium  the  dietary  should  include  an  ample 
supply  of  milk. 

Our  knowledge  concerning  the  functions  of  mag- 
nesium in  the  body  is  vague.  Beyond  the  fact  that 
this  element  is  a  constituent  of  practically  all  the  tis- 
sue-; and  fluids  of  the  body,  especially  of  the  bones 
and  muscles,  and  that  in  general  calcium  and  mag- 
nesium appear  to  be  antagonistic  little  is  definitely 
known.  For  the  distribution  of  magnesium  in  a  few 
foods  see  Table  V. 

Sulphur  occurs  chiefly  in  the  body  in  combination 
with  proteins  and  as  such  it  gains  entrance  to  the 
organism,  although  some  sulphur  in  the  form  of  sul- 
phates may  also  be  ingested  with  the  food.  In  the 
disintegration  of  the  protein  materials  incidental  to 
their  assimilation,  sulphur  is  oxidized  to  sulphuric 
acid  which  is  neutralized  as  rapidly  as  it  is  formed  by 
one  of  the  basic  elements  and  in  this  form  is  elimi- 
nated by  the  kidneys.  A  smaller  portion  of  the  sul- 
phuric acid  formed  is  combined  with  an  organic 
radicle,  usually  but  not  necessarily  derived  from 
putrefactive  processes  in  the  large  intestine,  for  ex- 

212 


of  the  cells  may  be  satisfactorily  constructed  from 
the  ingestion  of  inorganic  phosphates,  although  it  is 
also  undoubtedly  true  that  the  organism  has  a  prefer- 
ence for  phosphorus  in  organic  combination.     Table 

V.  gives  the  content  of  phosphorus  in  a  few  f Is. 

These  figures  do  not  indicate  the  nature  of  the  phos- 
phorus compound  present  and  it  is  possible  that  the 
four  types  of  phosphorus  compounds  mentioned  above 
are  not  equally  available  for  the  restoration  of  body 
phosphorus.  Phosphoproteins  and  phosphatides  arc 
particularly  abundant  in  eggs.  In  milk  both  phos- 
phoprotein  and  inorganic  phosphates  are  found, 
Meats  and  fish  contain  phosphorus  chiefly  in  the  form 
of  inorganic  phosphates.  The  salts  of  phytic  acid, 
collectively  designated  "  phytin  "  are  present  in  largest 
quantity  in  both  the  inner  and  outer  portions  of  the 
various  grains. 

Condiments. — Under  the  general  term  of  accessory 
articles  of  diet  are  classed  the  condiments,  flavors,  and 
stimulants.  These  substances  are  included  in  the  diet 
to  increase  the  attractiveness  of  our  food  and  although 
in  general  they  may  impart  a  certain  amount  of  energy 
to  the  organism  by  their  oxidation  they  are  of  nutri- 
tional importance  for  entirely  different  reasons.  The 
condiments  and  flavors  function  by  giving  to  the  food 
a  sufficient  degree  of  palatability  which  in  turn  by  the 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Alimi'iit 


so-called  psychical  stimulation  facilitates  gastric  se- 
cretion. Some  of  these  substances  may  have  an 
additional  value  in  that  they  increase  the  rapidity  of 
absorption  from  the  stomach.  Gautier20  has  divided 
the  condiments  into  the  following  classes:    (1)   Aro- 

matics,  comprising  vanilla,  anise,  cinnai i,  nutmeg, 

and  other  similar  essential  oils;    (2)  peppers;   (3)  the 

alliaceous  condiments,  garlic,  mustard,  etc.;    (4)  the 

acid  condiments,  vinegar,  citron,  pickles,  etc. ;     (5)  the 

condiments,  such  as  table  salt :  (6)  the  sugar  condi- 

I  rider  the  head  of  stimulants  are  included 

hoi,  tea,  coffee,  cocoa,  chocolate,  and  meat  extracts. 

ol. — The  alcoholic,  drinks  contain  from  forty 

to  sixty  per  cent,  of  alcohol,  as  in  rum,  brandy,  and 

whisky,  to  from  two  to  ten  per  cent.,  as  in  beer  and 

wines.     Malt  liquors  contain,  perhaps,  the  largest 

iber    of   constituents,   among  others  there  being 

ii-,   dextrin,  gluten,  and  various  substances  from 
hops.     The   exact   value   of  alcohol-'1  as  a  food, 
broadly  considered,  is  uncertain.     Experiments,  care- 
fully made  on  man,  however,  clearly  show  that  when 
rale  amounts  of  alcohol  are  ingested,  the  alcohol 
is  burned  up  in  the  bodj- — i.e.  oxidized  like  any  non- 

ogenous  food.     The  potential  energy  of  the  alcohol 
is  transformed   into  kinetic  energy,  and  consequently 

hoi  h  to  be  considered  as  having  some  food  value. 
it  may,  therefore,  be  classified  with  the  non-nitrogen- 
ous foods.  Further,  as  a  non-nitrogenous  food,  alcohol 
replace  an  isodynamic  amount  of  fat  or  carbohy- 
drate in  the  diet  without  change  in  the  balance  of  income 
and  outgo.  Alcohol  serves  to  protect  body  protein 
and  fat  from  oxidation;  i.e.  like  a  typical  non-pro- 
tein food  it  diminishes  the  oxidation  of  tissue  protein 
by  being  itself  oxidized.  These  facts,  however,  do 
not  imply  that  alcohol  is  necessarily  a  desirable  food 
or  that  it  is  physiologically  economical.  It  is  to  be 
remembered  that,  prior  to  its  oxidation  in  the  body, 
alcohol  may  produce  deleterious  effects  of  various 
kinds,  more  than  counterbalancing  any  gain  which 
may  result  from  its  oxidation.  It  may  likewise  give 
rise  to  changes,  either  directly  or  indirectly,  in  the 
various  metabolic  processes  of  the  body,  which  must 
of  necessity  influence  more  or  less  its  value  as  a  food. 
Moreover,  the  danger  entailed  when  the  dose  is  too 
large  prevents  its  ready  acceptance  as  a  practical 
food-stuff.  On  account  of  its  easy  absorption  it  has 
f't  d  suggested,  however,  as  a  useful  substitute  for 
the  solid,  non-nitrogenous  food-stuffs  in  sickness. 
There  are  many  reports  of  cases  where  alcohol  has 
served  as  the  principal  nutriment  during  the  critical 
periods  of  fevers  and  in  other  conditions  which  would 
tend  to  lend  support  to  the  above  suggestion.  There 
are  also  results  upon  diabetic  patients  which  indicate 
that  in  this  condition  alcohol  used  as  a  food  dimin- 
ishes the  production  of  acetone  bodies  and  protects 
the  protein.  Alcohol  has  a  direct  and  an  indirect 
influence  upon  the  secretion  of  gastric  juice.  In  this 
direction  it  acts  as  a  stimulant.  It  likewise  stimu- 
lates the  secretion  of  saliva. 

Tea  and  coffee  owe  their  well-known  stimulating 
action  to  the  presence  of  the  alkaloid  caffeine,  or 
trimethyl  xanthine.  This  substance  has  a  diu- 
retic action  upon  the  kidney  and  raises  blood  pressure. 
This  influence  upon  blood  pressure  is  probably  the 
reason  that  sleepiness  may  be  prevented  by  partaking 
of  tea  or  coffee.  Muscular  energy  is  augmented  and 
the  sense  of  fatigue  dissipated  by  nie  use  of  these 
stimulants. 

Cocoa,  or  the  chocolate  made  from  it  by  the  addi- 
tion of  sugar,  has  considerable  nutriment  due  to 
the  presence  of  proteins,  fats,  and  carbohydrates. 
Its  stimulating  action,  however,  is  caused  in  large 
measure  at  least  by  theobromine  or  dimethylxanthine. 
Meat  extracts  in  themselves  have  very  little  food 
value.  They  contain  a  trace  of  protein  and  gelatin, 
but  the  peculiar  value  of  meat  extracts  lies  in  the 
presence  of  the  so-called  nitrogenous  extractives, 
namely :  creatine,  xanthine,  hypoxanthine,  etc.    These 


substances  are  likewise  stimulants.  They  also 
call  forth  a  copious  secretion  ol  gastric  juice  and 
for  this  reason  have  been  called  secretogogues.  They 
are  undoubtedly  of  great  importance  in  thi~  respect. 
The  experiments  of  FolinM  would  seem  to  indicate 
that  creatine  may  serve  as  a  real  food-stuff  when  the 
diet  is  deficient  in  protein. 

The  significance  of  some  hitherto  unrecognized  com- 
ponents Of  the  food  is  gradually  being  evolved.  An 
example  may  be  cited  in  the  disease  beriberi  preva- 
lent among  the  Japanese.  This  condition  of  abnor- 
mal nutrition  has  long  been  assumed  to  bear  an  indefi- 
nite relation  to  the  large  quantity  of  rice  consumed 
by  this  nation.  <  inly  recently,  however,  has  it  been 
demonstrated  that  beriberi  is  caused  presumably  by 
polished  rice.  Experimentally,  it  has  been  shown 
that  a  pathological  condition  of  the  nature  of  poly- 
neuritis may  be  induced  in  bints  by  feeding  rice  that 
has  been  polished  and  hence  deprived  of  the  cortical 
layers.  Both  beriberi  in  man23  and  polyneuritis 
provoked  in  birds  may  be  cured  by  feeding  the  cortical 
layers  df  rice.  The  chemical  nature21  of  the  curative 
substance  has  not  yet  been  exactly  determined  for  the 
reason  that  it  is  present  only  in  minute  amount, 
probably  not  more  than  0.1  gram  per  kilo  of  rice.  It 
is  probable  that  other  equally  striking  relationships 
bet  ween  certain  at  present  unappreciated  constituents 
of  the  food  and  disorders  of  nutrition  will  be  made 
clear  as  detailed  knowledge  of  the  foods  is  increased. 

Frank  P.  Underbill. 

References. 

1  Fischer:  Untersuchungen  ueber  Aminosauren,  Polypeptide,  und 
Proteine,  1906. 

2  Protein  literature  may  be  found  as  follows:  Schryver,  The 
General  Characters  of  the  Proteins,  1909:  Plimmer,  The  Chemical 
Constitution  of  the  Proteins,  190S;  Osborne,  The  Vegetable 
Proteins,  1909. 

3  Compiled  from  Abderhalden:  Text-book  of  Physiological 
Chemistry,  190S,  and  Osborne:  The  Proteins  of  the  Wheat  Kernel, 
1907. 

4  For  literature  on  carbohydrates  consult  Armstrong:  The 
Simple  Carbohydrates  and  the  Glucosides,  1910. 

4a  cf.  Schwartz:  Nutrition  Investigations  on  the  Carbohydrates 
of  Lichens,  Alga?,  and  Related  Substances:  Transactions  Con- 
necticut Academy  of  Arts  and  Sciences,  1911,  16,  p,  247. 

5  Lusk :  American  Journal  of  Physiology,   1910-11,  p.  27,  xxii, 

6  Literature  relative  to  fats  may  be  found  in  Leathes:  The 
Fats,  1910. 

7  Long:  Text-book  of  Physiological  Chemistry,  1905. 

8  Atwater  and  Bryant :  Bulletin  2S  (Revised  edition)  U.  S. 
Dept.  of  Agriculture. 

9  Sherman:  Chemistry  of  Food  and  Nutrition,  1911,  p.  118. 

10  cf.  Sherman:  loc.  cit.  p.  221,  for  brief  review. 

11  Chittenden:  Physiological  Economy  in  Nutrition,  1904. 
Chittenden:  The  Nutrition  of  Man,  1907. 

11a  cf.  Mendel:  Theorien  des  Eiweissstoffweehsels  nebst  einigen 
praktischen  Konsequenzen  derselben.  Ergebnisse  der  Physiologie, 
xi.,  Jahrgang. 

12  Taken  from  Sherman:  loc.  cit. 

13  Murlin:  American  Journal  of  Physiology,  1907,  19,  p.  285. 

14  Hammarsten:  Text-book  of  Physiological  Chemistry,  1911, 
p.  S61 ,  for  literature. 

15  Albu  and  Neuberg:  Physiologie  und  Pathologie  des  Mineral- 
stoffn-echsels,  1906. 

16  Herter:  On  Infantilism  from  Chronic  Intestinal  Infection, 
190S,  cf.  also  Albu  and  Neuberg,  toe. cit. 

17  Meltzer:  Transactions  of  Association  of  American  Physicians, 
190S. 

IS  Compiled  from  Sherman,  loc.  cit. 

19  McCollum:  Research  Bulletin.  No.  8  Wisconsin  Agricultural 
Experiment  Station  and  Fingerling:  Bichemische  Zeitschrift, 
1912,  38,  p.  448. 

20  Quoted  from  Howell:  Text-book  of  Physiology,  1911. 

21  Atwater  and  Benedict:  Bulletin  69,  IT.  S.  Dept.  Agriculture; 
Chittenden,  Mendel  and  Jackson:  American  Journal  of  Physology, 
1898,1,  p.  47;  Rosemann :  Alcohol  in  Handbuch  der  Biochemie,  1911, 
iv,  1,  p,  413. 

22  Folin  :  Hammarsten's  Festchrift,  1906. 

23  Eykman:  Virchow's  Archiv.,  1S92,  14S,  p.  523;  Ibid.,  1897, 
149,  p.  187;  Archiv.  fiir  Hygiene,  1906,  58,  p.  150.  Gryns  quoted 
by  Schaumann  :  Archiv.  fiir  Schiffs-Tropenhygiene,  1910.  Fraser 
and  Stanton:  Studies  from  the  Institute  for  Medical  Research. 
Federated  Malay  States,  No.  12.     The  Etiology  of  Beriberi,  1911 

24  Funk:  Journal  of  Physiology,  191] ,  43,  p.  395. 

213 


Alimentary  Tract 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


Alimentary  Tract. — See  Digestive  Tract. 

Alimentation,  Duodenal. — Every  clinician  knows 
how  unsatisfactory  rectal  feeding  is.  The  food  is 
utilized  only  in  a  small  degree,  and,  besides,  the 
rectum  often  becomes  irritable,  so  that  the  enemata 
'  must  be  stopped.  It  is,  therefore,  desirable  to  have 
some  other  way  of  feeding  to  the  exclusion  of  the 
stomach. 

The  duodenal  pump,1  which  usually  serves  the  pur- 
pose of  obtaining  the  duodenal  contents,  can  also  be 
used  for  the  introduction  of  food  into  the  duodenum. 
This  kind  of  feeding  the  writer  has  designated, 
"  duodenal  alimentation".2, 3, 4 

The  method  consists  simply  in  introducing  the 
duodenal  pump  (Fig.  68)  into  the  digestive  tract,  and 
feeding  is  begun  as  soon  as  its  end  is  in  the  duodenum. 
The  apparatus  is  left  in  the  digestive  system  for  from 
ten  to  fourteen  days.  The  thin  rubber  tube  does  not 
inconvenience  the  patient,  and  thus  every  thing  is 
ready  for  the  feeding.  This  is  best  done  at  intervals 
of  two  hours.  After  the  feeding,  water  is  forced 
through  the  tube,  and  finally  air  blown  through  and 
t  In-  stop-cock  is  closed.  We  can  introduce  at  one  feed- 
ins;  between  240  to  300  c.c.  of  food  slowly.  All  fluids 
must,  of  course,  be  used  at  body  temperature. 

The  injection  of  the  food  is  facilitated  by  the  use  of 
a  specially  constructed  support  for  the  duodenal 
feeding  apparatus.     (See  Fig.  2.) 

Usually  the  following  nutritive  material  is  used 
every  two  hours,  from  seven  in  the  morning  until 
nine  in  the  evening.  Milk,  240  c.c;  one  raw  egg; 
sugar  of  milk,  fifteen  to  thirty  grams.  The  mixture 
is  well  beaten  up,  strained,  and  injected  at  blood  tem- 
perature. At  times  I  have  added  cream  in  order  to 
increase  the  nutritive  value;  sometimes  have  omitted 
the  milk  sugar  when  there  was  a  tendency  to  loose 
bowels.     In  one  case,  I  had  to  discard  the  milk  en- 


Fig.   67. — Patient  Being  Fed  through  the  Duodenum. 

tirely,  since  the  patient  had  a  marked  idiosyncrasy  for 
this  substance,  even  when  passed  directly  into  the 
duodenum.  Severe  abdominal  pains  resulted  as 
well  as  diarrhea.  In  this  case  I  used  the  following 
scheme  of  nutrition:  7:30  a.m.,  oatmeal  gruel,  ISO  c.c, 
one  egg,  butter,  15  c.c,  lactose,  15  c.c;  9.30  a.m., 
pea  soup,  180  c.c,  one  egg,  butter,  15  c.c,  lactose, 
15  c.c;  11.30  a.m.,  the  same  as  at  9.30  a.m.;  1 .30  p.m. 
bouillon,  ISO  c.c,  and  one  egg;  3.30  p.m.,  oatmeal 
gruel,  ISO  c.c,  butter,  15  c.c,  one  egg,  lactose,  15  c.c; 
5.30  p.m.,  pea  soup,  180  c.c,  butter,  15  c.c,  one  egg, 
lactose,  15  c.c;  7.30  p.m.,  the  same  as  at  5.30  p.m.: 
9.30  p.m.  bouillon,  ISO  c.c,  and  one  egg.  Total  daily 
quantity  oatmeal  gruel,  360  c.c;  pea  soup,  720  c.c; 

214 


eggs,  8 ;  lactose,  90  c.c. ;  bouillon,  360  c.c. ;  butter,  90  c.c. 
The  pea  soup  .was  made  from  Knorr's  pea  flour,  one 
tablespoonful  to  250  c.c.  of  water  which  was  boiled 
down  for  from  one  and  a  half  to  two  hours  to  180  c.c. 
It  is  self-evident  that  many  more  substances  might 
be  utilized  for  duodenal  alimentation.  Tin-  main 
point  to  be  observed  is  that  the  mixture  must  be  a 
very  fine  fluid  emulsion,  without  any  coarser  particles, 
so  as  not  to  clog  the  narrow  duodenal  tube.  I;  i, 
therefore  best  to  filter  the  mixture  first  through  a  fine 
sieve  or  through  gauze.  If  these  rules  are  observed 
there  will  rarely  be  any  difficulty. 


Fig.  6S. — The  Duodenal  Feeding  Apparatus,  with  Table  Support. 
A,  Tube  leading  to  syringe;  B,  tube  leading  to  duodenal  | 
C,  crank;  D,  tube  leading  to  fluid;  F,  fluid;  G,  glass;  T,  t;  I 
or  shorter  support.      When  crank  C  is  turned  parallel  to  A.  fluid 
can  be  aspirated  from   the  glass   into   the  syringe.     When   C  is 
moved  parallel  to  B,  the  fluid  from  the  syringe  can  be  em] 
into  the  duodenum. 

The  patients  may  be  given,  besides,  a  quart  of 
physiological  salt  solution  by  rectum,  according  to 
the  Murphy  drop  method,  or  the  water  may  be  injected 
directly  into  the  duodenum,  but  very  slowly,  drop  by 
drop. 

The  advantages  of  duodenal  over  rectal  feeding 
are  at  once  apparent;  for  while  the  rectum  and  colon 
are  simply  organs  for  the  expulsion  of  feces  and  for 
the  absorption  of  possibly  remaining  liquids,  we  have 
to  deal  in  the  duodenum  with  an  organ  where  the  most 
important  digestive  juices  are  secreted.  In  the  colon 
we  have  to  do  with  the  last  part  of  the  digestive  tract, 
in  the  duodenum,  however,  with  the  principal  part  of 
the  digestive  apparatus,  so  that  everything  is  here 
utilized.  Max  Eixhorx. 

References. 

1  Medical  Record,  January  15,  1910. 

2  Medical  Record,  July  16,  1910. 

3  Interstate  Medical  Journal,  vol.  xvii.,  No.  10,  1910. 

4  Medical  Record,  March  9,  1910. 


Alimentation,     Rectal. —  Rectal     alimentation     is 
employed  whenever  nutrition  in  the  ordinary  way  (by 
the  mouth)  is  either  impossible  or  not  desirable.      I 
method  of  alimentation  was  already  used  in  the  Mid- 
dle Ages  and  in  ancient  times.     Aetius  occasionally 
mentions  such  method  of  feeding.     The  value  of  tliis 
way  of  nourishing  a  patient,  however,  was  belii 
to  be  very  slight,   until  extensive  experimental  re- 
searches with  reference  to  absorption  of  food  from 
the  large  bowel   had   been   made.     These  defini 
showed  that  digestion  to  a  great  extent  can  pn" 
in  the  colon  if  the  ingested  food  is  suitably  prepared. 
Among  the  earliest  investigators  in  this  direct  ion  were 
Hood  and  Steinhauser.     Hood  observed  that  a  piece 
of  mutton  introduced  into  the  rectum  and  retail' 
after  some  time  showed  evident  signs  of  digestion. 
Steinhauser  experimented  on  a  patient  with  a  fistula 
of  the  ascending  colon,  and  found  that  pieces  of  al- 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Alimentation,  Rectal 


mmen  introduced  into  the  fistula  could  not  be  disco  v- 
,v,l  in  the  feces.  Pieces  of  smoked  beef  and  apples, 
,,,  (fir  oilier  hand,  were  found  either  slightly  altered 
>r  entirely  unchanged  in  the  stool. 

Eichhorst  stated  in  l.Si  1  that  absorption  of  album in- 
ites  from  the  bowel  is  facilitated,  if  not  made  possi- 
ile,  by  the  addition  of  common  table  salt.  He  ex- 
lerimented  principally  with  egg  albumen  mixed  with 

he  yolk  and    with   milk.     S e   years   later,   Ewald 

ibserved  the  very  interesting  fact  thai  raw  eggs  were 

iiuch  better  absorbed  from  the  large  intestine  than 

artificially  peptonized  foods  (Kemmerich's  peptone). 

Filippi  experimented   on   animals  by  resecting  por- 

ions  of  the  intestinal  canal.     He  found  that  after 

xtirpation  of  seven-eighths  of  the  small  intestine  in  a 

there  was  no  appreciable  decrease  in  the  absorp- 

.  i  of  food-;  consisting  of  albuminates  and  carbohy- 

-.   while  nineteen  per  cent,  of  the  ingested  fat 

eturned  with  the  feces.     This  clearly  shows  that  the 

ilon  can  vicariously  do  the  work  of  the  small  intestine. 

[I   further  demonstrates  that  albuminates  can  be  ab- 

ied  from  the  large  intestine  and  enter  the lacteals 

..ithoiit    previous  peptonization.     These   remarkable 

meats   have    been   confirmed   by   Aldor.      This 

er    experimented    principally    with    milk,    and 

il  «i  I  t  he  coagulat  ion  of  t  he  milk  in  the  large  bowel 

action  of  bacteria,  not  to  enzymes.      He  found 

after  the  injection  of  from  ten  to  fifteen  ounces  of 

uilk    into    the    bowel,    intestinal    lavage,   performed 

to  one  and  a  half  hours  later,  showed  only  minute 

particles  of  milk.     The  spontaneous  evacuation  re- 

ulting  thereafter  likewise  contained  but  very  small 

it  tions  of  coagulated  milk. 

Aldor,  in  his  paper,  arrived  at  the  following 
conclusions: 

1.  A  quart  of  milk,  injected  by  means  of  a  fountain 
syringe  into  the  bowel,  produces  no  pains  either 
luring  the  injection  or  afterward.  No  irritation  of 
the  intestine  follows,  and  milk  is  most  suitable  for  a 
nutritive  enema. 

2.  The  coagulation  of  the  milk,  which  is  due  to  the 
action  of  the  bacterium  coli  commune,  is  rather  detri- 
mental to  absorption.  This  coagulation  can  be  pre- 
vented, (a)  by  thorough  lavage  of  the  bowel  before 
giving  the  nutritive  enema,  (b)  by  adding  1  to  1.5 
grams  (gr.  xvi.-xxiv.)  of  sodium  carbonate  to  one 
quart  of  milk. 

3.  No  digestion   takes  place   in   the  large  bowel. 

4.  Carbohydrates  are  absorbed  in  an  excellent 
manner,  albuminates  in  a  great  measure,  and  fats  but 
poorly. 

5.  After  an  injection  of  a  quart  of  milk  into  the 
bowel,  there  was  never  found  either  albumin  or  sugar 
in  the  urine. 

In  America  the  attention  of  the  medical  profession 
was  first  directed  to  rectal  alimentation  by  Austin 
Flint,  who  read  an  extensive  and  important  paper  on 
this  subject  before  the  New  York  Academy  of  Medi- 
cine in  December,  1877.  Flint  mentioned  a  case  in 
which  a  woman  was  almost  wholly   nourished   per 

■turn  for  five  years.  After  emphasizing  the  impor- 
tance of  rectal  alimentation  in  instances  in  which  the 
usual  mode  of  nutrition  fails  or  is  impossible,  he  gave 
directions  as  to  the  mode  of  employment  of  the  nutri- 
tive^ enemata.  From  three  to  six  ounces  of  fluid  or 
semi-fluid  foods  may  be  injected  at  intervals  of 
from  three  to  six  hours.  He  did  not  deem  it  neces- 
sary to  wash  out  the  rectum  prior  to  each  administra- 
tion of  the  nutritive  enema.  Flint,  as  well  as  Peasley, 
lordyce  Barker,  A.  H.  Smith,  and  G.  M.  Smith, 
who  took  part  in  the  discussion  of  the  above  paper, 
had  all  practised  this  method  of  feeding  with  best 
results.  A.  H.  Smith  mentioned  several  instances  of 
gastric  ulcer  in  which  nutrition  had  been  successfully 
maintained  by  rectal  alimentation  for  from  eleven 
to  sixteen  and  twenty-one  days.  He  was  the  first 
who  suggested  the  use  of  defibrinated  blood  for  this 
purpose. 


Very  shortly  afterward  W.  Bodenhamer  published 

an  instructive  monograph  on  rectal  medication,  in 
which  he  also  laid  stress  upon  t lte  practical  value  of 
rectal  alimentation  as  deserving  much  more  frequent 
application  than  heretofore. 

Stillman,  in  his  paper  on  rectal  alimentation,  says: 

"The  clinical  fact  remains  th.it  certain  foods,  digested 
or  undigested,  are  taken  into  the  system  when  thrown 
into  the  rectum;  that  the  power  of  absorption  there 
may  be  good  when  the  stomach  is  weak  and  rebellious; 

that  it  is  assimilated,  for  the  body  gains  in  flesh  and 
power,  and  that  there  may  be  merely  the  customary 
evacuation  as  an  excretory  resultant.  As  far  as  1 
am  aware,  no  danger  attends  feeding  by  the  rectum, 
when  conducted  with  ordinary  care  and  intelligence 
on  the  part  of  nurses  or  attendants."  In  this  paper 
Stillman  calls  attention  to  the  use  of  supplementary 
rectal  feeding,  i.e.  to  the  use  of  nutrient  enemata 
while  the  stomach  is  yet  performing  its  functions  to 
quite  a  considerable  extent,  as,  for  instance,  in  chronic 
gastritis,  gastralgia,  nausea,  etc.  He  used  principally 
enemata  of  milk  according  to  the  following  formula: 
five  grains  of  pancreatic  extract  and  fifteen  grains  of 
bicarbonate  of  sodium  to  a  pint  of  milk. 

The  writer  has  had  extensive  experience  with  rectal 
alimentation  and  is  fully  convinced  of  its  great  prac- 
tical value,  notwithstanding  the  impossibility  of 
keeping  thereby  the  body  weight  in  balance.  The 
indications  for  this  mode  of  alimentation  may  be 
summarized  as  follows: 

1.  In  conditions  in  which  the  passage  of  food  from 
the  mouth  to  the  stomach  or  to  the  small  intestine  is 
impeded  or  made  impossible  (strictures,  benign  or 
malignant,  of  a  high  degree,  of  the  esophagus  or  cardia, 
spasmodic  or  paralytic  conditions  of  the  esophagus, 
pyloric  or  duodenal  stenosis). 

2.  In  ulcer  of  the  stomach  accompanied  by  consider- 
able  hemorrhage,   or  when   the   usual    methods   of 
treatment  have  failed. 

3.  Incessant  vomiting,  no  matter  to  what  cause  it 
be  due. 

4.  In  all  conditions  in  which  absolute  rest  for  the 
stomach  seems  to  be  imperative  (intense  pains  soon 
after  ingestion  of  food;  persistent  hyperchlorhydria  of 
a  high  degree;  intense  chronic  continuous  gastro- 
succorrhea;  pronounced  ischochymia). 

5.  In  typhoid  fever  and  other  severe  lesions  of  the 
small  intestine  necessitating  a  complete  rest  of  this 
portion  of  the  bowel. 

For  how  long  a  period  rectal  alimentation  should  be 
administered  depends  upon  the  condition  necessitat- 
ing it.  In  ulcers  and  irritating  affections  of  the 
stomach,  rectal  alimentation  should  be  administered 
alone,  without  any  additional  nourishment  through 
the  mouth,  for  a  period  varying  from  one  to  two  weeks, 
when  the  natural  mode  of  nutrition  may  be  cautiously 
resumed.  In  cases  in  which  there  is  an  organic 
obstacle  within  the  esophagus  or  at  the  pylorus 
preventing  the  passage  of  food  into  the  intestine, 
rectal  feeding  must  be  carried  on  as  long  as  the 
impediment  exists  (in  operative  cases  until  a  few  days 
after  the  operation  has  been  performed;  in  inoperable 
cases,  indefinitely).  Here,  whenever  possible,  besides 
the  enemata,  small  quantities  of  liquid  foods  may 
also  be  given  by  way  of  the  mouth. 

Shortly  after  operations  on  the  esophagus,  stomach, 
and  small  intestine,  rectal  alimentation  must  be 
administered  for  a  period  varying  from  four  days  to 
a  week  or  ten  days. 

Mode  of  Administration. — Before  administering 
the  feeding  enema,  a  cleansing  injection  (consisting 
of  a  quart  of  water  and  a  teaspoonful  of  salt)  should 
be  given  early  in  the  morning,  in  order  thoroughly  to 
evacuate  the  bowel.  One  hour  later  the  first  rectal 
alimentation  may  be  administered.  The  feeding 
enema  is  best  injected  by  means  of  a  fountain  syringe 
or  a  Davidson  syringe,  or  a  plain  hard-rubber  piston 
syringe,  and  a  soft-rubber  rectal  tube,  which  is  intro- 


215 


Alimentation,  Rectal 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


duced  into  the  anus  for  a  distance  of  about  five  to 
seven  inches.  The  injection  should  be  administered 
slowly  and  without  much  force.  After  the  with- 
drawal of  the  tube  from  the  rectum,  the  patient  is 
told  to  lie  quietly  and  to  endeavor  to  retain  the  enema. 
The  quantity  of  the  feeding  enema  may  be  from  five 
to  ten  ounces.  From  three  to  five  such  enemata  may 
be  given  daily. 

The  following  substances  may  be  used  as  feeding 
enemata: 

(a)  The  different  kinds  of  peptones  and  propeptones 
in  the  market  (Rudisch's  or  Kemmerich's  peptone, 
somatose,  sanose,  sanatogen),  of  which  about  one  to 
two  ounces  dissolved  in  from  six  to  eight  ounces  of  water 
are  to  be  injected.  The  different  beef  juices  i  Valen- 
tine's beef  juice,  bovinine,  Mosquera's  beef  jelly,  etc.) 
may  also.be  dissolved  in  water  and  injected  in  corre- 
sponding quantities. 

(6)  The  milk  and  egg  enemata;  these  are  the  most 
commonly  used.  Their  composition  is  as  follows: 
six  to  seven  ounces  of  milk,  one  or  two  raw  eggs  well 
beaten  up  in  it,  one  teaspoonful  of  powdered  sugar, 
and  one-third  of  a  teaspoonful  of  common  table 
salt.  Pancreatin  (one  tube  of  Fairchild's  pancreatin) 
may  be  added  to  such  an  enema,  to  facilitate  its 
assimilation. 

(c)  Meat  pancreas  enema.  Leube  employs  ene- 
mata consisting  of  well-chopped  meat  (five  ounces), 
fresh  pancreas  (two  ounces),  one  ounce  of  fat  (butter) 
— all  these  ingredients  being  thoroughly  mixed  with 
about  six  ounces  of  water. 

(d)  Grape  sugar  enema.  One  ounce  of  grape  sugar 
in  ten  ounces  of  water  or  physiological  saline  solution. 

Instead  of  always  using  one  and  the  same  nourish- 
ing enema,  the  above  combinations  may  be  alternately 
administered. 

In  conjunction  with  these  food  enemata,  injections 
of  water  into  the  bowel  are  made  in  order  to  increase 
the  amount  of  fluid  in  the  system.  These  injections 
of  water  for  absorption  are  of  great  importance. 
They  are  retained  much  better  if  injected  very  slowly 
by  the  so-called  "Murphy  Drop  Method."  Usually 
saline  solutions  are  employed,  in  quantities  varying 
from  a  pint  to  a  quart,  which  may  be  given  twice  a 
day.  Max  Einhorn. 


Alkalies,  Antacids. — (See  also  under  title  of  each 
drug.)  Medicines  which  are  administered  for  the 
purpose  of  correcting  acidity.  The  terms  are  almost 
synonymous,  but  it  will  be  found  that  the  drugs 
arrange  themselves  into  two  groups,  according  ot 
their  solubility,  which  in  a  great  measure  determines 
their  therapeutic  uses.  In  one  we  have  potash,  soda, 
and  lithia;  in  the  other  lime,  magnesia,  cerium.  The 
former  are  generally  employed  as  alkalies,  the  latter 
as  antacids.  Ammonia  is  intermediate;  its  character 
would  place  it  in  the  first  group,  but  its  therapeutic 
use  makes  it  belong  rather  to  the  second. 

Alkalies  are  all  powerful  depressors.  Potash  and 
lithia  are  the  most  injurious,  and  soda  is  the  least. 
They  reduce  the  blood  corpuscles  and  the  proto- 
plasmic tissue.  In  large  doses  they  are  cardiac  poi- 
sons, and  their  prolonged  use  in  moderate  doses 
causes  anemia,  loss  of  body  weight,  and  loss  of  mus- 
cular power. 

Potash,  soda,  and  lithia  salts  are  very  soluble,  and 
are  readily  absorbed  and  as  readily  excreted;  they 
pass  from  the  system  in  a  very  short  time.  They  are 
normal  constituents  of  the  blood,  and  their  presence 
in  increased  amount  tends  to  render  the  plasma 
more  alkaline. 

Those  of  the  second  group,  comprising  lime,  mag- 
nesia, and  cerium,  are  much  less  soluble,  and  even  their 
more  soluble  salts  (as  the  sulphate  of  magnesium, 
etc.)  are  but  slowly  absorbed.  In  consequence  their 
action  is  almost  entirely  limited  to  the  digestive  tract. 
Many  of  their  soluble  salts,  as  the  chlorides,  phos- 


phates, and  hypophosphites,  are  only  mildly  alka- 
line, and  are  of  value  more  for  the  acids  in  combina- 
tion than  for  the  alkaline  base. 

The  action  of  alkalies  upon  the  secretions  of  the 
stomach,  as  formulated  by  Ringer,  has  been  confirmed 
by  subsequent  experience.  His  view  is  that  the  con- 
tact of  weak  alkaline  solutions  with  glands  secreting 
an  alkaline  fluid  causes  a  lessening  of  the  secretion 
while  on  acid-secreting  glands  the  effect  is  to  cause 
an  increase  of  the  acid  secretion.  Advantage  has 
been  taken  of  this  in  gastric  disturbances,  when  there 
is  a  deficiency  of  acid  during  digestion.  The  admin- 
istration of  alkalies  just  before  meals  has  proved 
most  serviceable  in  relieving  this  defect.  They  rnusl 
be  given  well  diluted  and  in  moderate  doses.  The  bi- 
carbonate of  sodium  or  the  bicarbonate  of  potassium  is 
generally  selected;  it  is  to  be  given  in  five-grain  doses. 
Ammonia,  in  the  form  of  the  aromatic  spirits,  is 
often  combined  with  some  stomachic,  as  tincture 
of  rhubarb,  tincture  of  cardamom,  capsicum,  gin- 
ger, or  peppermint,  and  in  addition  a  vegetable  bitter. 
This  combination  has  been  found  to  be  valuable. 
In  addition  to  the  local  effect  thus  produced  upon 
gastric  digestion,  a  further  benefit  is  derived  by  the 
action  of  alkalies  after  absorption.  They  rapidly  pass 
into  and  improve  the  blood,  and  during  excretion 
they  cause  a  general  stimulation  of  all  secreting  organs. 
As  alkalizers  of  the  blood,  they  are  used  in  gouty  and 
rheumatic  conditions,  in  lithiasis,  and  in  many  dis- 
orders of  the  skin  in  which  there  is  supposed  to  be  an 
excess  of  uric  acid  or  allied  acids  in  the  blood.  Their 
purpose  is  to  keep  these  morbid  products  in  solution 
until  they  are  carried  out  of  the  system.  The  potas- 
sium salts  are  preferred,  as  their  rapid  absorption 
renders  the  blood  more  quickly  alkaline,  while  their 
equally  rapid  excretion  prevents  any  accumulation. 
For  immediate  action  the  bicarbonate  salt  is  selected; 
but  when  a  prolonged  use  is  required,  the  citrate, 
acetate,  or  tartrate  is  preferred.  Sodium  salts  are 
more  slowly  absorbed  and  are  less  powerful  alkalies. 
The  normal  alkaline  state  of  the  blood  is  due  chiefly 
to  sodium  salts,  and  as  they  are  less  depressing  than 
potassium  salts,  they  offer  many  advantages  when  a 
prolonged  course  of  treatment  is  necessary.  In 
treating  rheumatism  with  the  alkalies,  they  require 
to  be  given  freely  until  the  urine  becomes  alkaline, 
and  then  they  should  be  reduced,  enough  being  given 
simply  to  maintain  this  reaction.  There  may  be  given 
a  dram  and  a  half  of  bicarbonate  of  sodium  and 
half  a  dram  of  the  acetate  of  potassium  every  three 
or  four  hours,  well  diluted,  for  four  or  five  doses;  fol- 
lowing this,  fifteen  or  twenty  grains  will  usually  be 
sufficient.  Lithia  is  very  similar  to  potash  in  the 
rapidity  of  its  absorption  and  excretion. 

The  alkalies  are  excreted  rapidly  by  all  the  secreting 
organs.  Their  effect  is  most  evident  on  the  kidneys, 
and  during  excretion  they  render  the  urine  alkaline. 
At  the  same  time  they  augment  the  watery  flow 
through  an  increased  activity  of  the  renal  cells.  The 
secretion  of  all  organs  is  increased,  as  is  also  the  se- 
cretion of  the  mucous  surfaces. 

The  alkalies  are  also  of  benefit  when  applied  to  the 
surface  of  the  body.  In  rheumatism  a  hot  lotion  of 
carbonate  of  sodium  with  opium  often  affords  relief  to 
the  painful  joint.  In  all  forms  of  cutaneous  disease 
accompanied  by  a  troublesome  itching,  an  alkaline 
wash  of  carbonate  of  sodium  or  potassium,  half  a  dram 
to  the  pint,  is  of  service,  and  in  eczema  during  the 
early  stage,  with  an  alkaline  watery  discharge,  the 
same  solution  is  curative.  Burns  and  scalds  may 
be  treated  in  the  same  way,  the  solution  being  con- 
stantly applied.  The  alkali  removes  the  heat  and 
pain  and  allays  inflammatory  action.  The  bites  and 
stings  of  insects  and  the  urticaria  produced  by 
poisonous  plants  are  also  benefited. 

The  oxides  and  carbonates  of  calcium  and  magne- 
sium are  the  most  serviceable  salts  as  antacids,  on  ac- 
count of  their  insolubility.     If  these  drugs  are  given 


216 


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Allantois 


n  small  quantities  their  action  maybe  Limited  to  the 
tomach;   when   they  are  freely  administered,   their 
ction  is  continued  into  the  intestines.     They  neu- 
ralize  all  acids  with  which  they  come  in  contact,  and 
iv  contact  with  the  mucous  surface  they  exercise  a 
oothing  and  sedative  effect.     In  addition  to   neu- 
ralizing  the  local  acids,  they  arc  of  value  as  antidote  i 
,,  poisoning  by  acids,  and  also  in  poisoning  by  vege- 
tble  poisons,  the  alkali  precipitating   the   poisonous 
Jkaloids   and    retarding    their   absorption.      In    the 
ie   the  antacid   action   is   continued,   but    the 
iltimate  effects  of  lime  and  magnesia  differ;  the  for- 
ts as  a  mild  astringent,  while  the  latter  be- 
omes  converted  into  the  bicarbonate  and  acts  as  a 
axative. 

The  soluble  alkalies  are  not  so  useful  as  antacids, 
oid  are  of  lit  i  Ie  service  when  an  effect  in  the  intest  ines 
required.     Sodium  bicarbonate,  however,  is  a  well- 
cnown  antacid.      Its  disadvantages  are  that  it  tends 
o   generate   a   large   amount    of   carbonic   acid   gas, 
is  stimulating  instead  of  soothing  to  the  mucous 
•urface.     The  aromatic    spirit   of    ammonia  is  simi- 
ar  in   its  action  and    more  rapid.      Cerium   oxalate 
ind  bismuth   are   both   useful   antacids,    their   chief 
value  being  due  to  the  local  soothing  action  which 
I  hey   exert    upon   the   mucous   membrane.     The   ce- 
rium salt  has  probably  a  sedative  action  on  the  ter- 
minals of  the  nerves.  Beaumont  Small. 

Alkaloids. — See  Active  Constituents  of  Plants. 

Alkanet. — Orcannettc.  The  fleshy  root  of  Alhanna 
."■in  (L.)  Tausch.  (fam.  Boraginacem),  a  small 
perennial  herb  of  Europe  and  Asia  Minor,  largely 
illltivated  for  its  coloring  matter.  The  dried  root, 
a  foot  or  more  in  length  and  about  a  half  inch  in 
thickness,  its  bark  purple-red  without,  deep  red 
within,  its  wood  pinkish-white,  is  sometimes  marketed 
entire,  but  more  frequently  as  a  stringy,  shredded, 
tough  mass.  Its  only  value  is  for  coloring  purposes, 
the  coloring  matter  being  alkannin  or  alkanna  red. 

Alkannin  is  a  dark,  brownish-red,  resinous  mass, 
insoluble  in  water,  but  soluble  in  alcohol  and  ether. 
Acids  intensify  the  red  color,  alkalies  convert  it  to  a 
bluish-green,  in  which  respect  it  acts  like  hematoxylin. 

H.  H.  RusBY. 

Alkaptonuria. — See  Alcaptonuria. 

Allantiasis. — See  Food  Poisoning. 

Allantoin. — This  is  a  colorless  crystalline  substance, 
glyoxyl  diureide,  C1HllN103,  very  slightly  soluble  in 
cold  water  and  cold  alcohol,  but  readily  soluble  in 
boiling  water  and  warm  alcohol.  It  may  be  obtained 
by  the  alkaline  oxidation  of  uric  acid  in  the  cold. 
In  some  of  the  mammalia,  in  which  it  occurs  in  the 
urine,  it  is  probably  an  end-product  of  metabolism, 
but  is  not  so  in  man,  the  minute  quantities  some- 
times found  in  healthy  human  urine  being  derived 
from  the  food  and  excreted  unchanged  by  the  kidneys. 
It  is  found  in  the  allantoic  fluid  (whence  the  name), 
in  the  amniotic  fluid,  in  the  urine  of  the  new-born  and 
of  pregnant  women,  in  the  urine  of  the  dog,  cat,  and 
certain  other  mammals,  usually  in  minute  quantity 
in  the  urine  of  healthy  persons,  and  in  milk.  It  is 
also  found  in  the  growing  parts  (buds,  the  bark  of 
twigs,  etc.)  of  various  plants,  and  especially  in  the 
root  of  comfrey,  Symphytum  officinale. 

Macalister1  of  Liverpool,  investigating  the  healing, 
or  cell-proliferating,  properties  of  this  plant,  a  popular 
vulnerary  in  domestic  practice,  found  that  they  were 
due  to  the  presence  of  a  crystalline  substance,  identical 
in  its  empirical  formula  and  chemical  reactions  with 
allantoin.  A  number  of  experiments  in  the  way  of 
the  application  of  this  substance  to  old  ulcers,  fistulre, 
and  other  sores,  made  by  Macalister,  BramwelF,  and 
others3  seemed  to  show  that  it  is  a  cell-proliferant  of 


< siderable  power.     Ulcers  which  had  long  resisted 

treatment  healed  readily  when  treated  with  allantoin 
or  with  an  extract  of  the  root  of  comfrey.  Sinuses  of 
long  standing  also  closed  promptly  after  the  insertion 
of  wicks  of  gauze  impregnated  with  a  solution  of 

allantoin.  T    I,.  S. 

References. 

1 .  Macalister,  Charles  J      Liverpool  Medico-ChirurgicalJoumal, 
January,  1912;  British  Medical  Journal,  January  6,  1912. 

2.  Bramwell,    William:     British    Medical  Journal,   January6, 
L912 

3.  Murray,  R.  W.:    British  Medical  Journal,  January  13,  1912. 


Allantois. — (From    N.  T..,   allantoides;    Creek,  dXXSs 
(dXXovr-),  a   sausage,  and  (l~io$.  form:   sausage-shaped 

The  allantois  is  one  of  the  fetal  membranes  peculiar 
to  I  he  group  of  higher  vetebrates  in  which  the  embryo 

is  enveloped  in  an  amnion,  the  Amninta.  These  are 
reptiles,  birds,  and  mammals.  The  reptiles  and  birds 
are  often  grouped  together  on  account  of  certain 
anatomical  similarities  under  the  name,  Sauropsida. 


am 


Fig.  69. — Median  Longitudinal  Section  through  a  Chick 
Embryo  at  the  End  of  the  Third  Day  of  Incubation.  X20.  all, 
Allantois;  am,  amnion;  ho,  hind  gut;  n,  neural  canal;  rv,  right 
ventricle  of  the  heart;  up,  splanchnopleure;  t,  tail.      (After  Marshall. 

There  is  no  allantois  in  the  fishes  and  Amphibia, 
but  the  Amphibia  have  a  highly  vascular  urinary 
bladder  that  is  usually  regarded  as  homologous  with 
the  allantois. 

In  the  Amniota  the  embryo  is  formed  from  a  com- 
paratively small  part  of  the  blastoderm  (see  Area 
Embryonalis).  At  an  early  stage  of  development 
the  mesoderm  becomes  divided  into  two  layers  of 
cells,  with  a  cavity  between  known  as  the  caelom,  a 
part  of  which  becomes  the  body  cavity.  The  outer 
layer  unites  with  the  ectoderm  to  form  the  somato- 
pleure,  which  gives  rise  to  the  body  wall,  the  amnion 
(see  Amnion)  and  the  chorion;  while  the  inner  layer 
unites  with  the  endoderm,  or  hypoblast,  to  form  the 
splanchnopleure,  which  gives  rise  to  the  wall  of  the 
digestive  tract  and  its  appendages  and  to  the  wall  of 
the  yolk-sac  (see  Fetus). 

The  allantois  is  a  diverticulum  of  the  posterior 
end  of  the  embryonic  digestive  tract  and  is  composed 

217 


Allantois 


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of  two  layers  of  cells,  endoderm  and  splanchnic  meso- 
derm. It  grows  out  usually  as  a  thin-walled  sac 
between  the  amnion  and  the  yolk-sac,  and  blood- 
vessels develop  in  its  mesodermal  tissue.  In  most 
placental  mammals  the  distal  portion  of  the  allantois 
fuses  with  the  chorion  and  forms  the  essential  part 
of  the  fetal  portion  of  the  placenta  (see  Placenta), 
while  the  proximal  part  becomes  dilated  to  form  the 
urinary  bladder,  and  a  part  of  the  middle  portion 
finally  loses  its  lumen  and  persists  as  the  urachus, 
connecting  the  bladder  with  the  umbilicus. 

In  regard  to  the  details  of  its  origin,  its  structure, 
and  its  relations  to  adjacent  parts,  the  allantois 
varies  greatly  in  different  groups  of  animals. 


Fig.  70. — Diagram  of  Fetal  -Membranes  in  a  Hen's  Egg.  .1, 
Remnant  of  the  albumen:  All,  allantois;  Am,  amnion;  C,  chorion; 
S,  shell  membrane;  Y,  yolk.     (After  H.  Virchow,  from  Strahl.) 

With  respect  to  the  allantois  the  Amniota  may  be 
divided  into  two  groups,  first,  those  with  a  free 
allantois,  including  the  Sauropsida,  the  Monotremes, 
the  Marsupials,  and  most  of  the  placental  mammals, 
such  as  the  Insectivora,  the  Ungulates,  the  Lemurs, 
etc.;  second,  those  in  which  the  allantois  is  more  or 
less  enclosed  in  a  connective  stalk  by  which  the  em- 
bryo is  attached  to  the  chorion  from  a  very  early 
period  in  its  development.  This  group  includes 
some  Rodents,  Tarsius,  the  Monkeys,  and  Man. 

We  may  take  the  common  hen  as  a  type  of  the 
Sauropsida.  At  about  the  thirty-sixth  hour  of 
incubation  the  rudiment  of  the  allantois  first  appears 
as  a  shallow  pocket  in  the  endoderm,  at  the  extreme 
posterior  end  of  the  embryo.  As  the  formation  of 
the  tail  fold  progresses,  this  comes  to  lie  on  the  ven- 
tral side  of  the  hind  gut  (Fig.  69).  By  the  end  of  the 
fifth  day  it  has  grown  out  into  the  ccelomic  space 
(exoccelom)  between  the  yolk-sac  and  the  amnion,  as 
a  vesicle  of  considerable  size.  It  then  grows  rapidly 
until,  uniting  with  the  chorion,  it  spreads  out  as  a 
large,  thin-walled,  highly  vascular  sac,  and  com- 
pletely surrounds  the  amnion  and  yolk-sac.  It 
serves  as  the  organ  of  respiration  for  the  embryo. 
Finally  a  part  of  it  nearly  surrounds  the  remnant  of 
the  albumen  and  probably  assists  in  its  absorption 
(Fig.  70).  A  short  time  before  hatching,  its  vessels 
are  cut  off  by  the  closure  of  the  umbilicus,  it  dries 
up,  and  is  left  behind  when  the  chick  emerges  from 
the  shell. 

The  allantois  has  essentially  the  same  history  in 
most  reptiles.  In  a  lizard  (Lacerta),  according  to 
Strahl,  confirmed  by  Corning  and  Janosik,  it  arises 
in  a  peculiar  way  independently  of  the  gut  and  comes 
into  connection  with  it  secondarily.  And  Giacomini 
found  that  in  another  lizard,  which  brings  forth  its 
young  alive,  Seps  chalcidt ■*,  it  probably  has  a  nutri- 
tive as  well  as  a  respiratory  function.  In  this  species 
both  the  allantois  and  the  yolk-sac  fuse  with  the 
chorion,  forming  an  allanto-chorion  and  an  omphalo- 
chorion.    The  egg  is  very  small,  without  envelopes, 


and  the  allanto-chorion  becomes  folded  into  a  series 
of  ridges  and  hollows  which  fit  into  corresponding 
inequalities  in  the  wall  of  the  viaduct,  forming  a  kind 
of  placenta.  A  similar  but  less  perfect  connection  is 
formed  by  the  omphalo-chorion. 

In  the  most  primitive  of  living  mammals,  the 
Monotremes,  which  lay  eggs,  the  relation  of  the' fetal 
membranes  is  essentially  similar  to  what  obtains  in 
the  Sauropsida. 

The  Marsupials  are  born  in  a  very  imperfect  con- 
pit  ion  and  a  true  placenta  is  rarely  formed  (Hill,  1897), 
In  this  group  the  allantois  remains  comparatively 
small,  and  in  the  opossum,  according  to  Selenka,  it 
does  not  even  touch  the  chorion;  and  it  begins  to 
degenerate  before  birth.  The  yolk-sac,  on  the  other 
hand,  is  large,  filling  most  of  the  space  between  the 
embryo  and  the  chorion.  It  fuses  with  the  latter,  I  e- 
comes  highly  vascular,  and  serves  during  fetal  life 
both  as  an  organ  of  nutrition  and  as  one  of  respiration. 
These  conditions  are  usually  regarded  as  primitive; 
for  the  Marsupials  are  generally  supposed  to  have  been 
derived  from  monotreme  ancestors  and  to  have  given 
rise  in  turn  to  the  placental  mammals. 

Among  the  mammals  with  a  free  allantois  the  most 
diagrammatic  arrangement  is  to  be  found  in  the 
mole,  one  of  the  Insectivora,  a  group  that  shi 
many  primitive  characters.  According  to  Strahl,  in 
a  cross-section  of  a  gravid  uterus  of  the  mole,  Talpa 
i  uropea  (Fig.  71),  one  may  see  the  embryo  surrounded 
by  the  amnion,  except  on  the  ventral  side,  where 
the  yolk-sac  and  the  allantois  are  attached.  The 
allantois  has  a  large  lumen,  which  occupies  the 
greater  part  of  the  space  between  the  embryo  and 
the  chorion.  Its  outer  wall  fuses  with  the  chorion, 
and  the  greater  part  of  it  gives  rise  to  the  thickened 
placenta.  On  the  opposite  side  the  smaller  yolk-sac 
spreads  out  in  a  similar  way  and  likewise  fuses  with 
the  chorion,  but  its  outer  surface  does  not  become 
vascular  like  that  of  the  allantois.  Except  for  the 
increase  in  the  size  of  the  embryo  and  the  correspond- 
ing reduction  in  the  lumina  of  the  allantois  and  yolk- 
sac,  these  relations  persist  until  the  end  of  gestation. 

We  may  take  the  sheep  as  representing  the  type 
of  allantois  common  to  the  Ungulates. 


Fig.  71. — Fetal  Membranes  of  the  Mole      e.  Embryo;  am.  amnion; 
all,  allantois;  p,  placenta;  y,  yolk-sac.     (After  Strahl.) 

According  to  Bonnet,  the  rudiment  of  the  allantois 
appears  in  the  sheep  at  about  the  end  of  the  fifteenth 
day  after  copulation.  The  tail  fold  has  not  yet 
formed,  and  the  allantois  appears  as  a  sac-like  pos- 
terior prolongation  in  the  axis  of  the  gut,  which  is  then 
being  folded  off  from  the  general  endoderm.  With 
the  development  of  the  tail  fold  the  allantoic  stalk 
gradually  assumes  its  normal  position  as  an  appen- 
dage of  the  hind  gut.  Very  soon  the  young  allantois 
begins  to  spread  laterally,  so  that  by  the  end  of  the 
sixteenth  day  it  has  become  a  half-moon-shaped 
appendage  nearly  half  as  large  as  the  embryo.     From 


•J  IS 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Allanlol-, 


72. — Diagrams  Showing  the  Developmenl  of  the  Fetal  Membranes  of  the  Sheep. 

e    ec i  "ii  the  twelfth  day  after  copulation;  />',  thirteenth  -lay;  C,  about 

e;  I),  longitudinal  section  about  the  same  age;  K,  transverse  section  of  an 
mbryo;  F,  diagram  of  the  fetal  membranes   at    the   end  of   the  first   month;    'ill, 
;    nil   ch,   allanto-chorion;  ach,  amniogen  chorion;  am,  amnion;  ams,  amnion 
stalk;    ro,  cotyledon;    eel,  ectoderm;    end,  entoderm;    ?;,  cavity  of   yolk-sac.     (After     persistent  lumem 


Bonnet.) 

this  time  on,  its  growth  is  rapid  until  it  extends  the 
whole  length  of  the  chorion.  As  it  becomes  dis- 
tended with  liquid  its  mesodermal  layer  is  pressed 
closely  against  that  of  the  chorion,  and  the  two  fuse 
and  form  the  important  placental  structures.  At  the 
twenty-first  day,  when  the  embryo  is  about  a  third 
of  an  inch  in  length,  the  allantois  is  a  large  sausage- 


shaped  bag  measuring  more  than  a 
fool  from  tip  in  tip.  The  embryo  en- 
veloped in  its  relatively  small  amnion 
lii is  in  a  depression  .-it  the  center  of  the 
allantois,  ami  the  yolk-sac  has  dwin- 
dled to  a  hollow,  thread-like  structure 
lying  in  a  groove  in  one  side  of  the 
allantois  and  extending  in  both  direc- 
tions lo  1 1 10  ends  of  the  chorion  (fig. 
72,  /•'). 

The  Carnivora  have  likewise  an 
allantois  with  a  large  lumen.  The 
allantois  tit  first  bends  dorsally  and 
enlarges  into  a  mushroom-shaped  sac. 
lis  outer  wall  unites  with  the  chorion 
and  forms  at  first  a  discoidal  placenta. 
But  the  allantois  continues  to  enlarge 
until  it  has  fused  with  the  whole  im  i  r 
surface  of  the  chorion.  Ii  completely 
surrounds  the  amnion,  containing  the 
embryo,  and  finally  encloses  also  the 
yolk-sac.  \l  lie'  time  lime  (lie  |i!:i- 
centa  extends  around  the  equator  of 
the  egg  as  a  broad  band,  and  finally 
acquires  its  characl  erisl  ic  zonary  form. 

In  (he  Rodentia  (he  allantois  unites 
with  only  a  pari  of  the  chorion  mi  (he 
dor  ,il  side  of  (he  embryo,  the  res)  of 
(In-  chorion  being  fused  with  the  large 
cup-shaped  yolk-sac,  Keibel  (1906). 
In  this  group  there  are  two  types  of 
allantois.  One  of  these  is  represented 
by  the  rabbit  (Fig.  73),  and  has  a  large 
In  the  other  type, 


am 
coel 


Fro.  73. — Transverse  Section  through  the  Gravid  Uterus  of  a 
Rabbit  at  the  End  of  the  Nineteenth  Hay  of  Gestation.  X  1  3/4. 
fi'\  Allantoic  artery;  all,  allantois;  am,  amnion;  cod,  exoccelom; 
nun.  mesometrium;  p,  placenta;  y,  cavity  of  yolk-sac,  which  is 
continuous  with  the  uterine  cavity  owing  to  the  absorption  of  the 
lew  er  wall  of  the  yolk  sac  represented  by  the  dotted  line  yl.  (After 
Marshall.) 


represented  by  the  rat  and  the  guinea- 
pig,  the  lumen  is  very  small  or  may 
disappear  altogether.  According  to  Fleischmann,  the 
squirrel  presents  a  form  of  allantois  intermediate  be- 
tween  these  two  types.  Aside  from  these  differences 
in  the  allantois,  the  rodents  are  generally  alike  in 
having  a  large  omphalo-chorion,  a  smaller  discoidal 
placenta,  a  small  amnion,  and  a  large  ccelomic  cavity 
filled  with  fluid,  separating  the  allantois  from  the 
yolk-sac  (Fig.  73). 

The  second  type  of  allantois  is  found  in  the  Pri- 
mates; that  is  Tarsius,  the  monkeys,  and  man.     In 


Fig.  74. — Diagram  of  a  Blastocyst  of  Tarsius  in  Sagittal  Section. 
all,  Allantois;  am,  Amnion;  va,  and  ha,  anterior  and  posterior 
amniotic  folds;  c,  exoccelom;  n,  yolk-sac;  nc,  neurenteric  canal;  j>, 
placenta.     (From  Hubrecht.) 

the  earliest  known  embryos  of  both  the  monkeys  and 
man  the  fetal  membranes  are  already  more  or  less 
established,  and  the  earliest  stages  of  their  develop- 
ment are  therefore  unknown.  But  there  is  no 
reason  to  doubt  that  Hubrecht  (1908)  is  correct  in 
his  inference  that  the  earlier  stages  in  the  higher 
Primates  are  similar  to  what  he  found  in  an  extraor- 


219 


Allantois 


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dinarily  complete  series  of  embryos  of  Tarsius.  This 
interesting  animal  is  a  small  arboreal  mammal  found 
in  the  forests  of  Borneo,  Sumatra,  Java,  Banka  and 
the  Philippine  Islands.  It  is  usually  classified  with 
the  Lemurs.  But  while  all  true  Lemurs  that  have 
been  examined  exhibit  a  free  allantois,  Tarsius 
closely  resembles  the  true  Primates  in  the  corre- 
sponding stages  of  development  (Fig.  7-1). 


Emb      Am 


Fig.  75. — Embryo  of  the  gibbon,  Hylobales  concolor.  All, 
Allantois;  am.  amnion;  b.s..  connective  stalk;  emb,  embryonic 
shield;  veu,  neurenteric  canal;  yk,  yolk-sac;  Ye,  blood-vessels. 
(After  Selenka  from  Minot.) 

In  Tarsius  the  embryonic  shield  (area  embryo- 
nalis)  is  developed  on  the  surface  of  the  blastocyst, 
and  is  subsequently  covered  by  the  folds  of  the 
amnion  The  development  of  the  allantois  begins 
by  a  proliferation  of  mesodermal  cells  which  extends 
backward  from  the  primitive  streak,  and  forms  a 
ridge  on  the  inner  side  of  the  somatopleure.  This 
ridge  is  the  "  connective  stalk,"  which  is  continuous 
from  the  first  with  the  chorion. 

At  the  point  in  the  median  line  where  the  somatic 
and  splanchnic  mesodermal  layers  join,  a  tubular 
projection  of  the  endoderm  grows  into  the  connective 
stalk  from  the  yolk-sac  and  forms  the  lumen  of  the 


^fl&las 


Fig.  ,6—  Human  Embryo  "von  HerfT."  Internal  Diameter  of 
Blastocysts  about  4  mm.  Side  view  after  removal  of  part  of 
chorion  a.  Amnion;  6,  blood-islands  (much  more  prominent  in 
original);  c,  chorion;  «,  connective  stalk;  ec,  ectoderm  of  chorion- 

HaudbuchT1  "'  *  y0lt"SaC-     (AftCT  SpCe  fr°m  Hert»'^ 


allantois.  Even  before  the  appearance  of  the  area 
vasculosa  in  the  yolk-sac,  there  begin  to  develop  in 
the  connective  stalk  blood-vessels  that  are  destined 
lSQoT"  Placental  circulatory  system  (Hubrecht, 

When  Tarsius  has  reached  this  stage,  it  corresponds 
to  the  youngest  embryo  of  the  gibbon,  Hylobates, 

220 


described  by  Selenka  (1900,  Figs.  75),  and  to  the 
youngest  human  embryo  described  by  Count  von 
Spree,  the  von  Herff  embryo  (Keibel,  1906  FiVs  -  ■ 
and  86).  The  gibbon  and  man  appear  to  dim', 
however  from  Tarsius  in  that  the  blood-vessels 
develop  first   in   the  area  vasculosa  of  the   yolk  sai 


i  ■?'  /.7-"-Human  Embryo,  same  as  Fie.  76.  Diagram  of  « 
longitudinal  section.  „,  Amnion;  all,  allantois;  c,  chorion  r, 
connective  stalk;  e,  area  embryonalis;  ec,  ectoderm  of  chorion-  „",' 
mesoderm;  y,  yolk-sac.      (After  Spee,  from  Hertwig's  Handbuch.) 

and  subsequently  grow  out  into  the  connective  stalk 
and  thence  into  the  chorion  to  form  the  fetal  vessels 
of  the  placenta. 

In  a  human  embryo  2.15  mm.  in  length  (Fig.  78) 
the  allantois  is  a  long  narrow  tube  extending  from 
the  hind  gut  into  the  connective  stalk  parallel  with 
the  allantoic  vessels  as  far  as  the  chorion,  where  it 
ends  blindly. 

By  the  continued  infolding  of  the  somatopleure 
the  body  wall  is  completed  except  at  the  umbilicus 
where  the  extraembryonic  part  of  the  somatopleure 
forms  a  tube  enclosing  the  stalk  of  the  yolk-sac  and 


exclusive 8-T"™^.Embryo  "Gle."     Dimensions  of    blastocyst, 
TsA   i  m       P      '  8:5 X  10X6.5  mm.;  length  of  area  embryo 
amnion     ;>,r?°d    SiIPt,al    SeCtim-     -4"'    Allantois;    „„,. 
amnion,  6.s.,   connective  stalk;  cho,   chorion;  ec,    ectoderm'  .  „l 

from&r- mesoderm:  *■ vUU:  vk-  yoi-sac- (A,ur 

the  connective  stalk  with  their  vessels;  the  whole  being 
he  umbilical  cord,  of  which  the  connective  stalk  m 
the  center.  According  to  Lowy  (Grosser,  1910)  the 
allantois  remains  hollow  throughout  its  entire 
length  m  human  embryos  of  S  mm.  maximum  length. 
In  older  embryos  its  lumen  soon  begins  to  be  obliter- 
ated at  the  distal  end,  but  even  in  the  fourth  month 


ki:i  i:ki:\(  k  handbook  of  the  medical  sciences 


Alleghany  Springs 


remains  of  the  duct  lined  by  cubical  epithelium  may 
be  found  in  the  cord  near  the  embryo. 

The  allantoic  fluid  of  the  cow  lias  been  shown  by 
Doderlein  to  differ  from  the  amniotic  fluid  in  being 

rer  in  salts  of  sodium  and  richer  in  nitrogen.     The 

latter  increases  with  the  age  of  the  fetus,  indicating 
that  it  is  an  excretory  product;  and  according  to 
Foster  and  Balfour  urates  are  abundant  in  the  allan- 
toic fluid  of  the  chick  by  the  sixteenth  day. 

The  circulation  in  the  allantois  takes  place  pri- 
marily through  two  pairs  of  blood-vessels,  the  allan- 
toic or  umbilical  arteries,  and  the  allantoic  veins 
:,|  their  branches.  The  allantoic  arteries  arise  as 
lireel  prolongations  of  the  primitive  forks  of  the 
iorta.  When  the  hind  limbs  bud  out,  the  external 
iliac  arteries  arise  as  branches  of  the  allantoic  arteries. 
In  the  chick  the  right  allantoic  artery  does  not  grow 

so  fast  as  the  left, 
and  it  finally  dwin- 
dles and  disap- 
pears altogether. 
In  man  the  two 
arteries  persist. 
They  may  be 
traced  from  the 
posterior  end  of 
the  aorta  through 
the  umbilical  cord 
(see  U m  bil  i c a  I 
Cord)  to  the  pla- 
centa, where  they 
branch  freely. 

The  two  allan- 
toic veins  in  the 
chick  are  formed 
during  the  fourth 
day.  They  unite 
in  the  body  of  the 
embryo,  becoming 
there  a  single  allan- 
toic vein,  which 
passes  forward  on 
the  left  side  and 
joins  the  left  vitel- 
line vein.  In  man 
and  other  mam- 
mals the  two  allan- 
toic veins  at  first 
open  into  the  sinus 
venosus,  one  on 
each  side,  in  com- 
pany with  the  corresponding  Cuvierian  and  vitelline 
veins.  Later,  while  the  allantoic  veins  remain  dis- 
tinct within  the  embryo,  in  the  allantoic  stalk  they 
fuse  to  form  a  single  vessel.  During  the  fourth  week 
in  man  the  allantoic  veins  become  separated  from  the 
duus  venosus.  The  smaller,  right  one  soon  after  dis- 
ears,  while  the  left  one  unites  with  the  portal 
vein  (formed  by  the  union  of  the  vitelline  veins)  and 
increases  in  size. 

Creighton  has  described  (1S99)  a  series  of  lym- 
phatic cylinders  and  capsules  surrounding  certain 
allantoic  vessels  in  the  chick.  They  are  found  upon 
the  vessels  where  the  allantois  and  amnion  come 
into  contact,  and  are  supposed  to  aid  in  the  absorp- 
tion of  the  yolk  and  albumen.  (For  a  description 
of  the  circulation  in  the  placental  portion  of  the 
allantois,  see  Placenta.) 

The  principal  adult  structure  developed  from  the 
allantois  is  the  urinary  bladder.  Of  that  part  of  the 
allantois  which  lies  within  the  body  of  the  embryo, 
the  proximal  portion  begins  to  enlarge  during  the 
second  month  to  form  the  bladder,  while  the  tapering 
distal  portion  finally  loses  its  lumen  and  becomes  the 
urachus,  or  ligamentum  vesica?  medium,  connecting 
the  bladder  with  the  umbilicus.  The  portions  of  the 
allantoic  arteries  within  the  embryo  are  called  the 
hypogastric   arteries,   and   are  more  or  less  homol- 


Ftc.  79. — Human  Embryo  of  2.15  mm., 

Reconstructed  from  Sections.   All,  Allan- 
is;    Ao,   aorta;   Ht,   endothelial  heart; 

/.  ,  liver;  Om,  omphalo-mesenteric  vein; 

b  .  allantoic  vein;  IV:,  yolk-sac.     (From 

Minot,  after  His.) 


OgOUS  with  arteries  of  the  same  name  in  lower  verte- 
brates.     At    birth   the  dislal   part    of  the  hypogastric 

on  each  side  loses  its  I -n  and  become-  a  -olid  cord 

enclosed    in    the    superior    ligament     of    the    bladder, 

while  the  proximal  part  persists  as  the  common  iliac, 

internal  iliac  ia^  far  as  the  bifurcation),  and  superior 
vesical  arteries.  The  remaining  allantoic  or  um- 
bilical vein  loses  its  cavity  at  birth  and  becomes  the 
ligamentum  teres,  or  round  ligament,  connecting 
the  liver  with  the  umbilicus  I  see  Ft  Ins). 

Robert  Payne  Bigelow. 

References. 

Bonnet,  R.:  18S3.  Ueber  die  Bih&ute  der  Wiederkiiuer.  Sits.- 
Ber.  Morph.  Phys.,  Mum-hen,  Bd.  ii. 

Creighton:  1S99.  A  system  of  perivascular  cylinders  and  cap- 
sules in  the  united  amnion-allantois  of  the  chick.  Jour.  Anat. 
Phys.  Vol  xxxiii  p,  ">_'7  545. 

Grosser,  O.:  1910.  Development  of  the  egg  membranes  and  the 
placenta.  Keibel  and  Mall's  Manual  of  Human  Kmbrvologv,  p 
91-179. 

Herzog,  M.:  1909.  Contribution  to  our  knowledge  of  the 
earliest  known  stages  of  placentation  and  embryonic  development 
in   man.     Amer.  Jour.  Anat.   Vol  9  p.  361— tOO. 

Hill,  J.  P.:  1S97.  The  Placentation  of  Perameles.  Q.  J.  Mic. 
Sci.,  vol.  xl. 

Hubrecht,  A.  A.  W.:  1896.  Hie  Keimblase  von  Tarsius. 
Festschrift  fur  Gegenbaur,  Kd.  ii.,  p.  147-17S, 

Hubrecht,  A.  A.  W.:  1897.  Descent  of  the  Primates,  New 
York,  Scribner's. 

Hubrecht,  A.  A.  W.:  1902.  Furchung  und  Keimblattbildung 
bei  Tarsius  Spectrum.  Verh.  K.  Akad.  v.  Weten.  Amsterdam, 
Sect.  2,  vol.  viii..  No.  6. 

Hubrecht,  A.  A.  \\\:  1908.  Early  Ontogenetic  Phenomena  in 
Mammals  and  their  bearing  on  our  Interpretation  of  the  Phylo- 
geny  of  the  Vertebrates.  Quart.  Jour.  Mic.  Sci.,  vol.  liii.,  p. 
1-181. 

Hubrecht,  A.  A.  W.:  1912.  Feetal  Membranes  of  the  Verte- 
brates    Proc.  Seventh  Internat.  Zodl.  Cong.,  1907,  426. 

Keibel,  F. :  1902.  Die  Entwiehelung  der  ausseren  Korperform 
der  Werbeltierembryonen.  Hertweg's  Handbuch,  Bd.  i.,  Teil  2, 
1-176. 

Minot,  C.  S-:  1903.  Laboratory  Text-book  of  Embryology. 
Phila.,  Blakiston. 

Schauinsland,  H.:  1902.  Die  Entwickelung  der  Eihiiute  der 
Reptilien  und  der  Vogel.  Hertwig's  Handbuch,  Bd.  i.,  Teil  2, 
p.  177-334. 

Selenka,  E.:  1900.  Studien  iiber  Entwickelungsgeschichte  der 
Tiere,  Heft  7  and  8,  Entwickelung  des  Gibbon.  Wiesbaden; 
Kreidel. 

Spee,  F.  Graf  von:  1S96.  Ueber  friihe  Entwickelungsstufen 
des  mensehlichen  Eies.     Arch.  f.  Anat.,  p.  1-30. 

StrahL  H.:  1891.  Eihiiute  und  Placenta  des  Sauropsiden. 
Ergeb.     Anat.  u.  Entwick. ,   Bd.  i. 

Strahl,  H.:  1902.  Die  Embryonalhullen  der  Sauger  und  die 
Placenta.     Hertwig's  Handbuch,  Bd.  i.,  Teil  2,  p.  23.3-270. 


Alleghany  Springs. — Montgomery  County,  Virginia. 

Post-office. — Allegheny  Springs. 

Access. —  Ma  Norfolk  and  Western  Railroad  to 
Shawsville  station,  thence  by  carriage  or  omnibus 
three  and  a  half  miles  to  springs.      Hotel  and  cottages. 

This  well-known  resort  is  located  on  the  eastern 
slope  of  the  Alleghanies,  on  the  head  waters  of  the 
Roanoke  River.  The  hotel  and  principal  range  of 
cottages  occupy  smooth  and  undulating  hills,  gently 
sloping  to  a  broad,  grass-covered  lawn  of  forty  acres, 
extending  to  the  banks  of  the  river.  The  accommoda- 
tions here  are  first  class,  affording  every  convenience 
and  comfort  to  the  pleasure  seeker  as  well  as  to  the 
invalid.  The  hotel  is  large  and  spacious,  and  is 
supplied  with  all  requisite  improvements.  Contigu- 
ous to  the  hotel  are  150  double  cabins,  arranged  with 
a  view  to  the  comfort  and  good  health  of  the  guests. 
The  scenery  in  the  vicinity  is  not  excelled  for  pictur- 
esque loveliness  and  variety  at  any  watering  place  in 
the  Old  Dominion.  Only  one  spring,  which  flows 
about  thirty  gallons  per  hour,  is  in  use  at  the  present 
time.  The  water  is  limpid,  and  has  a  temperature 
of  56°  F.  The  following  is  the  latest  analysis  of  this 
water: 


221 


Alleghany  Springs 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


One  Gallon,  70.000  Chains,  Contains: 

Grains, 

Magnesium  sulphate 50 .  S8 

Calcium  sulphate llo.29 

Sodium  sulphate 1.72 

Potassium  sulphate 3.70 

Copper  carbonate trace. 

Lead  carbonate trace. 

Zinc  carbonate trace. 

Iron  carbonate 0. 16 

Manganese  carbonate 0.06 

Calcium  carbonate 3  .61 

Magnesium  carbonate 0.36 

S1  fntium  carbonate 0.06 

Barium  carbonate 0 .  02 

Lithium  carbonate trace. 

Magnesium  nitrate 3 .  22 

Ammonium  nitrate O.o6 

Aluminum  phosphate 0.03 

Aluminum  silicate 0 .  20 

Calcium  fluoride -  •  -  -  ■        0 .  02 

Sodium  chloride 0.2Ti 

Silicic  acid °-88 

Crenic  acid trace. 

Aprocrenic  acid trace. 

Other  organic  matter trace. 

Cobalt  carbonate trace. 

Antimony  teroxide trace. 

182.95 

Solid  ingredients  by  direct  evaporation  gave 184.07 

Half  combined  carbonic  acid 1.89 

Free  carbonic  acid* o  46 

Hydrosulphuric  aeidf trace. 

Total  amount  of  ingredients 191  -42 

This  water  is  distinguished  for  the  great  variety  of 
its  mineral  constituents.  When  taken  in  large  doses 
it  is  actively  diuretic  and  cathartic,  operating  with 
special  activity  on  the  mucous  membrane  of  the  lower 
intestines.  In  smaller  doses  its  action  may  be  de- 
scribed as  tonic,  alterative,  and  detergent.  The 
water  has  been  found  particularly  beneficial  in  the 
treatment  of  dyspepsia,  for  which  it  has  a  wide  repu- 
tation. Excellent  effects  are  also  observed  in  nervous 
affections,  in  diseases  of  the  liver  and  kidneys,  in 
catarrh  of  the  stomach  and  intestines,  diarrhea,  and 
dysentery,  gout,  rheumatism  and  troubles  arising 
from  a  faulty  venous  circulation,  such  as  headache, 
dizziness,  and  hemorrhoids.  It  is  recommended  in 
small  doses  by  many  physicians  in  the  treatment  of 
anemia  and  chlorosis,  general  debility,  and  other  con- 
ditions in  which  tonic  and  reconstructive  effects  are 
sought.     The  water  is  used  commercially. 

Emma  E.  Walker. 

*  S. 455726  grains  of  carbonic  acid  is  equal  to  11.544067  cubic 
inches. 

t  0.000139  grain  of  hydrosulphuric  acid  is  equal  to  0.000369 
cubic  inches. 

Allen,  Harrison  A. — Born  in  Philadelphia,  Pa.,  on 
April  17,  1841.  He  received  the  degree  of  Doctor  of 
Medicine  in  1861,  and  held  the  position  of  Resident 
Physician  in  the  Pennsylvania  Hospital  up  to  1862, 
when  he  entered  the  Confederate  Army.  Upon  his 
return  to  Philadelphia  in  1865  he  was  appointed 
Instructor  in  Comparative  Anatomy  and  Medical 
Zoology  in  the  University  of  Pennsylvania.  In  186i 
he  was  made  Professor  of  Anatomy  and  Surgery  in  the 
Philadelphia  Dental  College,  and  in  1870  he  was 
appointed  a  Surgeon  in  the  Philadelphia  Hospital. 
From  1875  to  1885  he  held  the  Chair  of  Physiology  in 
the  University  of  Pennsylvania,  and  in  1S94  he 
became  the  first  Director  of  the  newly  founded 
Wistar  Institute  of  Anatomy.  His  death  occurred 
in  November,  1S97. 

Allen  acquired  considerable  reputation  both  as  an 
authority  in  comparative  anatomy  and  as  a  skilful 
specialist  in  the  treatment  of  laryngeal  and  nasal 
affections.     Among  his  published  writings  the  follow- 


ing deserve  to  receive  special  mention  here:"  Outlines 
of  Comparative  Anatomy  and  Medical  Zoology," 
1869;  "Conformation  of  the  Bones  of  the  Orbit.'' 
1S70;  "On  Localization  of  Diseased  Action  in  the 
(Esophagus,"  1877;  and  "On  the  Mechanism  of 
Joints,"  1876;  "A  System  of  Human  Anatomy.'' 
two  volumes,  Philadelphia,  1SS2-1884.        A.  H.  B. 

All-Healing  Spring. — Livingston  County,  New 
York. 

Post  Office. — Dansville. 

Access. — Via  Delaware,  Lackawanna,  and  West- 
ern Railroad. 

This  spring  is  charmingly  located  among  the  hills 
of  the  picturesque  Genesee  Valley  country  of  western 
New  York.  The  region  is  exempt  from  malaria. 
The  climate  is  equable  and  genial  for  its  latitude. 
The  air  is  pure  and  dry.  Nights  throughout  the 
summer  are  cool,  while  the  winters  are  unusually  mild 
with  little  snow.  The  soil  is  dry  and  porous.  The 
following  is  the  most  recent  analysis  of  the  water: 

One  United  States  Gallon  Contains: 
Solids.  Grains. 

Sodium  sulphate 0.7a0 

Calcium  sulphate 0  432 

Calcium  carbonate 5.246 

Potassium  chloride 0  1 1  < 

Magnesium  chloride 0  -'44 

Silica " 

Alumina  and  iron (t 

Volatile  and  organic  matter 0.641 

Total  solids ^1S0 

This  water  is  of  marked  value  in  rheumatism,  gout, 
gravel,   neuralgia,   and  neurasthenia  of  toxic  origii.. 
The  water  of  the  spring  comes  from  rocky  hen 
far    above    any    possible    source    of    contamination. 

Excellent  accommodation  for  visitors  to  the 
Springs  may  be  found  at  the  Jackson  Health  Resort, 
a  sanatorium  located  on  the  hillside  at  an  elevation  of 
800  feet  above  sea-level.  Emma  E.  Walker. 

Alligator  Pear. — Avocado;  Abogate;  Aguacate;  Pal- 
ta;   Midshipman's  Butter. 

The  above  are  the  names  of  the  fruit  of  Per$(  a  gra- 
tissima  Gaertn.,  a  large  tree  of  the  Lauracew,  and 
they  are  also  applied  to  the  seeds,  which  have  distinct 
medicinal  properties.  The  genus  is  related  to  that 
yielding  cinnamon.  It  contains  about  a  dozen  spe- 
cies, which  grow  in  the  tropics  of  both  contine 
but  the  one  under  discussion  alone  possesses  the  prop- 
erites  here  described.  It  is  native  in  many  parts  .if 
the  American  tropics,  and  is  largely  cultivated  in  all 
tropical  countries  for  its  fruit,  which  is  common  in 
northern  markets.  This  is  inequilaterally  elongated- 
pyriform,  sometimes  spheroidal  or  ovoid,  and  as  large 
as  the  very  largest  pears.  The  skin  has  a  leathery, 
rusty-green  appearance,  or  deep  purple  in  some  var- 
ieties. The  solitary  ovoid  seed  fills  half  of  the  inte- 
rior, the  remaining  space  being  occupied  by  a  ere 
white  pulp,  penetrated  by  numerous  gray  or  greenish 
veins,  of  the  finest  and  smoothest  fatty  texture,  highly 
nutritious  and  of  peculiar  flavor.  On  first  trial,  it  is 
disgusting  to  some  persons,  but  they  usually  become 
extravagantly  fond  of  it  on  continuing  to  use  it. 
The  juice  of  the  seeds  makes  indelible  stains  on  linen, 
and  is  used  for  this  purpose.  The  seeds  are  larg 
used  in  the  tropics  as  a  local  application  in  rheumatism 
and  neuralgia,  am'  some  physicians  have  thus  found 
the  fluid  extract  of  service."  They  are  also  credited 
with  anthelmintic  properties,  and  doses  of  fl.  o  '■  of 
the  fluid  extract  have  been  used  to  expel  tenia. 

H.   H.  Rushy. 

Allomorphism.— A  term  used  by  Orth  to  cover  the 
conditions  of  pseudometaplasia  or  histological  accomr 


•_'!"_» 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


\ltM- 


odation  (change  of  cylindrical  cells  to  flat  cells  in 

is  a  result  of  pressure,  change  of  flat  endothelial 

■IN.  Bat  serosa  cells,  and  pulmonary  epithelium  into 

ibo'idal  or  columnar  cells,  etc.)  and  prosopla    a  oi 

ive  metaplasia  (change  of  colls  of  the  salivary 

:,  i.  into  secreting  cells,  the  cells  of  bile-ducts  into 

T-cells,  etc.).     Dysmorphism    has  also  been   used 

-  a  synonym.  Aldrbd  Scott  Wakthin. 


Vloplasia. — A  term  suggested  by  Orth  to  designate 

ie  condition  in  which   the  cell-forms   normally  pre- 
iminating  in  a   given  organ  or  tissue  are  replaced 

cell-forms     normally    latent,    so    that     the    latter 

:is    an    apparent    metaplasia    or    heterotopia 

iasia      of     Schridde).      Such     conditions     as 

;,.  presence   of   squamous   epithelium   in    the   pros- 

,i,-,  bladder,    urethra,  uterus,  trachea  and  bronchi, 

of    uterine    mucosa   in    the   mucosa   of     the 

■rvi\'    and    on    the    inner    surface    of     the   hymen, 

inds  of    gastric   mucosa   in    the   esophagus,  intes- 

aal    glands   in   the    stomach,   pancreatic     tissue    in 

ie  stomach  and  intestine,  bone  in  the  intermuscular 

etc.,  are  grouped  under  this  head.     Since  these 

isias  as  a  rule  always  represent  tissue  of  an 

•ordering  directly  upon  the  one  affected,  they 

ie  regarded  as  disturbances  in  the  course  of  the 

letic  differentiation,  and  not  as  changes  occur- 

ter  differentiation  lias  taken  place — hence,  not 

rue  metaplasias.     Schridde  classes   these  congenital 

momalies  as  heteroplasias;     Orth  proposed  the 

rin  alloplasia  or  dysplasia. 

Aldred  Scott  Warthtx. 


Allouez    Mineral    Springs. — Brown    County,    Wis- 
onsin. 

Post-office. — Green  Bay.     Hotels  in  Green  Bay. 

The  Allouez   Springs  are  beautifully  located   near 

he  base  of  an  elevation,  Astor  Hills,  in  the  Valley  of 

in  the  southern  part  of  the  city  of  Green  Bay. 

inning  city,  which  lies  at  the  head  of  the  bay 

f  the  same  name,  is  one  of  the  oldest  settlements  of 

Northwest.     In    the  year    166S    Father   Allouez 

-tablished  a  missionary  station  here,  and  from  that 

leriod  dates  the  first   settlement  of  the  citj-.     The 

are  located  but  a  short  distance  from  the  site 

old  mission,  and  are  named  in  honor  of  its  in- 

repid  and  worth}'  founder.     The  water  bubbles  out 

rmn  the  hillside  at  a  uniform  rate  all  the  year.      It 

emperature  of  46°  F.     A  pretty  park  surrounds' 

nd  an  ornamental  pavilion  covers  the  spring,  which 

lushes  up  through  an  octagonal  marble  basin.      An 

nt   in   charge  supplies  water  to  the  visitors. 

i  i-  believed  that  the  Menominee  Indians  used  the 

ipring  for  medicinal  purposes.     The  following  analysis 

ras   made   by   the    Bureau   of  Chemistry,    IT.   S.   A., 

inent  of  Agriculture,  Washington,  D.  C,  June, 

.'JUT: 

On~e  TJ.  S.  Gallon-  OnxTAiva  grains 

Magnesium  chloride 0.99 

Magnesium  sulphate.  ...  .4.27 

Magnesium  bicarbonate. . .  s    11 

Calcium  bicarbonate is  43 

Calcium  phosphate Trace. 

Calcium  silicate 1  ..50 

Sodium  chloride 1 .60 

Sodium  nitrate 2.11 

i-sium  chloride 0   17 

Ammonium  chloride Trace. 

Liihium  chloride Trace. 

Ferric  oxide  and  alumina 0.07 

Silica 0.45 

ToUil  grains  per  United  States  gallon 3S.09 

An  alkaline-magnesic-saline-calcic  water  of  rare  light- 
ness and  softness,  possessing  marked  diuretic  and  al- 
terative qualities. 


In  his  work  on  the  mineral  waters  of  the  United 
States  the  writer,  Dr.  .lames  K.  (rook,  classified  this 
asau  alkaline-saline-calcic  mineral  water.  It  contains 
a  very  fortunate  combination  of  mineral  ingredi- 
ents. The  bicarbonate  of  magnesium  gives  it  valuable 
antacid  and  laxative  properties.  Authorities  are 
agreed  that  the  carbonate  oi  magnesium  is  an  ex- 
cellent  antilithic  in  those  cases  in  which  uric  acid  is 
too  abundant.  The  chloride  of  sodium  anil  bicar- 
bonate of  magnesium  contribute  to  render  the  water 
diuretic.     In  diseased  states  ii  -  best  effects  have  been 

observed  in  diabetes,  Bright's  disease,  disorders  of 
the  stomach  and  liver,  and  in  gout,  rheumatism,  and 
vesical  calculi.  The  water  is  soft  and  sparkling,  anil, 
as  it  contains  no  trace  of  organic  or  vegetable  matter, 
is  well  adapted  for  general  table  use.  It  has  also 
tonic  effects. 

The  spring  is  isolated  and  is  protected  from  surface 
water  by  circular  stone  walls,  well  cemented.  This 
wall  development  extends  to  the  gravel  strata,  and 
is  capped  by  a  marble  slab,  sealed  except  at  center  or 
point  of  overflow  into  the  marble  basin. 

< liven  Bay  offers  numerous  advantages  as  a  health 
resort.  Its  elevated  location  renders  the  air  cool  and 
refreshing  during  the  summer  months,  and  malaria 
is  unknown.  The  magnificent  Fox  River,  which 
Hows  into  the  bay  at  this  point,  is  spanned  by  five 
bridges.  The  streets  are  embowered  with  avenues  of 
maud  old  trees,  and  there  are  excellent  drives  in  all 
directions  for  miles  around.  Small  steam,  motor,  and 
sailing  yachts,  with  their  burdens  of  pleasure  seekers, 
ply  the  placid  waters  of  the  bay,  forming,  during  the 
spring  and  summer  months,  a  picture  of  serene  and 
restful  beauty.  Emma  E.  Walker. 

Allspice. — See  Pimento. 

Ally!  Tribromide. — Tribromhydrin,  tribrompro- 
phenyl,  CJIIir,,  is  obtained  by  the  action  of  bromine 
on  oil  of  garlic  (allyl  sulphide).  It  is  a  heavy,  color- 
less, or  faintly  yellowish  liquid,  which  is  insoluble  in 
water  and  soluble  in  alcohol,  ether,  and.  volatile 
fixed  oils.  Liquid  at  ordinary  temperature,  it  solidi- 
fies at  10°  C.  (.50°  F.).  This  remedy,  containing  as 
it  does  eighty-five  per  cent,  of  bromine,  may  well 
replace  the  alkaline  bromides  as  sedative  and  anti- 
spasmodic. In  asthma,  pertussis,  laryngismus  stridu- 
lus nervous  irritability,  and  especially  in  epilepsy  it 
has  had  a  marked  effect.  In  hysteria  on  the  other 
hand,  it  has  been  of  no  value.  Its  dose  is  two  to 
ten  minims  (0.13-0.6),  given  in  capsule  or  on  sugar, 
two  or  three  times  a  day;  or  it  may  be  given  hypo- 
dermically  dissolved  in  ten  or  twenty  minims  of 
ether  or   oil.  W.  A.  Bastedo. 

Almonds. — See  Amygdala. 

Aloe. — Aloes.  The  inspissated  juice  of  the  leaves 
of  various  species  of  Aloe,  a  genus  of  nearly  a  hundred 
species,  in  the  family  I/Macece,  widely  distributed 
through  tropical  Africa,  on  the  continent  and  islands, 
and  at  least  two  species  extending,  through  introduc- 
tion, into  Asia,  and  one  into  Southern  Europe  and  the 
West  Indies. 

They  are  plants  of  desert  or  arid  regions  and 
strongly  succulent,  as  is  common  among  plants  of 
such  localities.  They  have  large,  fleshy,  bayonet-like 
leaves,  densely  arranged  in  a  distichous  or  tristichous 
manner,  and  tall  spikes  of  fleshy  flowers,  often 
similarly  arranged.  All  method  i  of  producing  aloes 
from  them  are  based  upon  the  fact  that  the}'  contain 
two  distinct  juices,  the  one  thin  and  flowing  at  once 
when  the  leaves  are  cut,  the  other  thicker  and  not 
readily  flowing  except  under  pressure.  It  is  the 
former  of  these  juices  which  yields  the  drug,  and 
which  is  therefore  allowed  to  flow  from  the  cut  leaves 
without  pressure. 

This  juice  is  then  inspissated,  either  spontaneously 

223 


Aloe 


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or  by  boiling,  and  yields  a  yellow,  yellow  brown,  gray- 
brown,  green  brown,  or  nearly  black  mass,  which  may 
be  hard  and  brittle  or  of  a  soft,  tarry  consistency,  or 
of  any  intermediate  degree.  It  may  be  dull,  waxy, 
or  glassy,  and  opaque  or  translucent,  and  its  odor 
varies  greatly.  It  is  thus  seen  to  be  unfitted  for  any 
general  description. 

The  places  of  manufacture  give  the  names  to  the 
different  commercial  sorts.  It  is  one  of  the  oldest  of 
medicines;  valued — according  to  tradition — long 
before  the  Christian  era.  Certainly  it  was  known  to 
the  Greeks  and  Romans  of  the  first  century,  and  to 
the  rest  of  Europe  during  the  Middle  Ages.  It  has 
always  been  extensively  used  and  highly  prized,  as 
the  fanciful  names  given  to  many  of  the  older  aloes 
compounds  testify.  The  variety  earliest  known, 
socotrine  aloes,  is,  singularly  too,  the  same  which  is 
still  considered  the  best  in  England  and  America,  and 
is  nominally  obtained  from  the  same  little,  obscure, 
out-of-the-way  island  that  Alexander  is  reported  to 
have  peopled  with  Greeks,  in  order  to  protect  and 
improve  its  production.  Of  all  the  known  commercial 
varieties  of  aloes,  the  U.  S.  P.  recognizes  the  following: 
Aloe  Socotrina  or  Socotrine  Aloes,  from  A.  Pcrryi 
Baker;  Aloe  Curussarira  or  Barbndensis,  the  Curacao 
or  Barbados  Aloes,  from  .4..  vera  (L.)  Webb  and 
Aloe  Capensis  or  Cape  Aloes,  from  A.ferox  Miller. 

Barbados  aloes,  which  used  to  come  in  gourds,  is 
no  longer  produced,  although  the  Curacao  product, 
usually  packed  in  boxes,  is  now  sometimes  sent  in 
gourds,  to  imitate  the  other.  They  are  identical  in 
character.  This  plant  is  the  most  widely  distributed 
of  the  genus,  growing  through  Northern  Africa, 
Southern  Europe,  and  the  East  Indies,  as  well  as  in 
the  West  Indies,  where  it  is  cultivated  for  the  pro- 
duction of  aloes.  It  grows  to  a  height  of  nearly  two 
feet,  with  a  thick  head  of  bluish-green,  blotched 
leaves,  and  a  dense  spike  of  greenish-yellow  flowers, 
each  a  little  more  than  an  inch  in  length,  and  of  an 
elongated,  contracted-campanulate  form.  From  the 
Pharmacographia  the  following  account  of  the  prep- 
aration of  Barbados  aloes  is  quoted: 

"  The  cutting  takes  place  in  March  and  April,  and  is 
performed  in  the  heat  of  the  day.  The  leaves  are  cut 
off  close  to  the  plant,  and  placed  very  quickly,  the  cut 
end  downward,  in  a  V-shaped  wooden  trough,  about 
four  feet  long  and  twelve  to  eighteen  inches  deep. 
This  is  set  on  a  sharp  incline,  so  that  the  juice  which 
trickles  from  the  leaves  very  rapidly  flows  down  its 
sides,  and  finally  escapes  by  a  hole  in  its  lower  end 
into  a  vessel  placed  beneath.  No  pressure  of  any 
sort  is  applied  to  the  leaves.  It  takes  about  a  quarter 
of  an  hour  to  cut  leaves  enough  to  fill  a  trough.  The 
troughs  are  so  distributed  as  to  be  easily  accessible 
to  the  cutters.  Their  number  is  generally  five,  and 
by  the  time  the  fifth  is  filled,  the  cutters  return  to  the 
first,  and  throw  out  the  leaves,  which  they  regard  as 
exhausted.  The  leaves  are  neither  infused  nor  boiled, 
nor  is  any  use  afterward  made  of  them,  except  for 
manure. 

"  When  the  vessels  receiving  the  juice  become  filled, 
the  latter  is  removed  to  a  cask  and  reserved  for  evap- 
oration. This  may  be  done  at  once,  or  it  may  be  de- 
layed for  weeks,  or  even  months,  the  juice,  it  is  said, 
not  fermenting  or  spoiling.  The  evaporation  is  gen- 
erally conducted  in  a  copper  vessel:  ai  the  bottom  of 
this  is  a  large  ladle,  into  which  the  impurities  sink,  and 
are  from  time  to  time  removed  as  the  boiling  goes  on. 
As  soon  as  the  inspissation  has  reached  the  proper 
point  (which  is  determined  solely  by  the  experienced 
eye  of  the  workman),  the  thickened  juice  is  poured 
into  large  gourds,  or  into  boxes,  and  allowed  to 
harden.  " 

This  product  varies  from  an  orange  brown  to  a 
chocolate  brown.  The  latter  when  broken  up  ex- 
hibits the  orange  brown  color  also.  It  is  commonly 
of  a  waxy  luster,  dry  and  brittle  or  friable,  but  is 
occasionally  harder  and  of  a  glassy  luster.     Its  pecu- 


liar odor  constitutes  its  most  characteristic  feature. 
About  sixty-five  per  cent,  of  it  is  soluble  in  cold  water' 
the  solution  assuming  a  purplish-red  color.  It  is  the 
chief  source  of  Aloin,  and  is  regarded  as  a  very  good 
article,  though  cheaper  and  less  desired  than  the  next 
A  large  amount  of  it  is,  however,  sold  under  the  title 
of  the  next. 

Socotrine  Aloes  comes  from  the  Island  of  Socotre 
although  the  mainland  yields  an  almost  identical 
article.  The  drug  was  formerly  brought  into  Europe 
via  the  Red  Sea  and  Alexandria.  After  the  dis- 
covery of  the  route  around  the  Cape  of  Good  Hope, 
it  followed  the  course  of  commerce  in  that  direction' 
at  present,  Socotrine  aloes  is  apt  to  go  to  India,  and 
from  there  to  England,  with  the  enormous  mass  of 
Indian  products. 

The  preparation  of  Socotrine  aloes  is  said  to  differ 
from  that  of  Barbados,  in  that  the  heat  of  the  sun  is 
relied  upon  for  its  evaporation.  Although  sometimes 
imported  in  large  barrels,  it  is  usually  in  small  kegs 
or  small  skins.  The  latter  is  a  cheaper  grade,  dry  and 
brittle,  the  former  a  soft-solid,  at  least  at  the  center 
where  it  is  frequently  very  soft,  so  as  to  flow.  Si 
trine  aloes  is  typically  of  a  brownish-yellow  or  yellow 
brown,  rather  than  an  orange  brown  like  the  last,  but 
it  is  occasionally  darker,  nearly  of  a  brown  black. 
There  should  never  be  any  hint  of  green  in  its  color.  If 
exposed  to  the  atmosphere,  it  at  length  becomes  hard, 
through  evaporation.  Its  odor  is  much  finer  than 
that  of  Barbados.  Although  not,  strictly  speaking, 
less  strong,  it  is  less  rank  and  heavy.  It  is  its  odor 
which  is  relied  upon  for  identification,  as  well  as  fur 
an  indication  of  its  quality.  At  least  sixty  per  cent, 
of  it  is  soluble  in  cold  water,  the  solution  assuming  a 
yellow  color. 

Exported  from  India  is  an  article  known  variously 
as  Moken  (or  Mochen),  East  Indian,  or  Fetid  Aim:-, 
which,  although  totally  unlike  the  Socotrine  variety, 
has  been  very  largely  imported,  sold,  and  used  for  it,  in 
the  United  States.  It  is  a  disgusting  substai 
black,  semi-liquid  and  of  a  stinking  odor,  like  putrid 
animal  matter.  It  contains  much  albuminoid 
matter.     Its   use   is   wholly   indefensible. 

Cape  Aloes  is  commonly  hard,  brittle,  more  or  less 
glassy  and  translucent.  It  turns  to  green  black,  red 
black,  or  even  bluish-black.  Not  less  than  seventy- 
five  per  cent,  of  it  is  soluble  in  cold  wrater,  the  solution 
being  pale  yellow. 

All  official  varieties  agree  in  the  following  characters. 
They  have  a  saffron-like  odor.  They  should  yield 
not  more  than  1.5  per  cent,  of  ash  and  should  contain 
not  more  than  ten  per  cent,  of  water.  A  nearly  clear 
solution  should  result  from  mixing  one  gram  with 
50  c.c.  of  alcohol,  gently  heating  and  then  cooling. 
If  one  gram  be  mixed  with  10  c.c.  of  hot  water,  and 
1  c.c.  of  this  mixture  be  diluted  with  100  c.c.  of 
water,  a  green  fluorescence  should  be  produced 
upon  the  addition  of  a  five  per  cent,  solution  of 
sodium  borate;  or,  if  1  c.c.  of  such  dilution  be 
shaken  with  10  c.c.  of  benzol,  upon  separating  the 
benzol  solution,  and  adding  50  c.c.  of  ammonia 
water,  a  permanent  deep  rose  color  will  be  produced 
in  the  lower  layer. 

All,  on  being  dissolved  in  water  or  alcohol,  yield  a 
crystalline  sediment  of  aloin.  All  consist  chiefly  of  a 
resin-like  substance  which  is  soluble  in  alcohol  and 
hot  water,  but  precipitated  from  the  latter  solution 
by  boiling.  A  small  amount  of  volatile  oil  is  found 
in  all. 

Aloe  Purificata,  U.  S.  P.,  is  Socotrine  aloes  which 
has  been  heated,  dissolved  in  alcohol,  strained  through 
a  No.  60  sieve,  evaporated,  cooled,  and  broken  up. 

Aloe  Natalensis,  or  Natal  aloes,  has  a  dull  surface 
and  a  grayish-yellow  brown  color.  It  is  crystalline 
and  contains  aloin,  but  is  weak  in  odor  and   taste. 

Hi  putie  aloes  is  a  name  which  has  come  to  be  applied 
to    any    form    having   a    distinct    liver-brown    color. 

Considering  its  immense  importance  as  a  drug,  the 


224 


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Alopecia 


action  of  aloes  is  a  remarkably  simple  one.  Aside 
from  iis  action  in  the  mouth  and  stomach  as  a  simple 
hitter,  its  operation  is  almost  entirely  confined  to  the 
lower  part  of  the  large  intestine,  where,  by  its  irritant 

properties,    it     powerfully    stimulates    peristalsis    ami 

moderately  stimulates  secretion.  It  is  therefore  a 
•.ery  dilatory,  but  quite  active  cathartic.  Its  action 
is  quite  apt' to  be  griping  and  painful,  especially  to 
those  affected  with  hemorrhoids.  Although  it  has  been 
claimed  that  this  condition  can  be  relieved  by  the 
skilful,  continued  Use  of  aloes,  this  is  doubtful;  while 

it  is  certainly  true  that  the  condition  is  thus  frequently 
ravated  in  a  serious  degree.  A  diuretic  effect  fre- 
quently ac ipanies  the  purgation,  and  is  probably 

hief  part  due  to  a  mere  extension  of  the  irritation. 
The  same  is  to  be  said  of  its  emmenagogue  effect,  and 
to  he  remembered  that  this  may  lead  to  abortion. 
I'll.'  intensity  of  the  action  of  aloes  is  quite  variable, 
only  in  different  individuals,  but  in  the  same 
individual  at  different  times,  and  this  is  especially 
true  when  aloin  is  used  alone.  This  is  believed  to  be 
to  variations  in  the  solution  of  the  aloin.  The 
I. ilc  is  its  natural  solvent.  Glycerin  acts  similarly, 
and  either  of  these  solvents,  injected  into  the  rectum 
with  aloes,  will  cause  it  to  take  effect.  Taken  inter- 
nally, alkalies  increase  its  activity,  as  does  iron.  Aloes 
can  be  absorbed  by  the  subcutaneous  tissue,  excreted 
into  the  bowel,  and  become  active.  Because  of  its 
slowness,  and  its  limited  field  of  action,  it  is  usually 
preferred  to  combine  it  with  some  differently  acting 
cathartic.  Its  peculiar  mode  of  action  indicates  that 
aloes  is  especially  useful  in  those  cases  of  constipation 
which  result  from  torpidity  of  the  intestinal  muscles. 

The  dose  of  aloes  is  exceedingly  variable,  according 
to  the  patient  and  the  effect  desired,  being  from  0.03 
to  0.6  gram  (gr.  ss.-x.). 

The  Pharmacopoeia  provides  a  large  number  of 
preparations,    as   follows: 

Liquids. — Tinctura  Aloes,  containing  ten  per  cent. 
of  aloes  and  twenty  per  cent,  of  licorice  root,  made 
with  dilute  alcohol,  dose  1  to  4  c.c.  (fl.  5.  i~i-);  Tinc- 
tura Aloes  et  Myrrhas,  containing  ten  per  cent,  each 
of  aloes,  myrrh,  and  licorice  root,  made  with  alcohol; 
dose  the  same  as  of  the  last. 

Solids. — Extractum  Aloes  (aqueous),  dose  0.03  to 
0.2  gram  (gr.  ss.-iij.);  Extractum  Colocynthidis 
Compositum,  containing  purified  aloes  50  per  cent., 
extract  of  colocynth  16  per  cent.,  resin  of  scammony 
and  soap,  each  14  per  cent.,  cardamom  6  per  cent., 
dose  0.06  to  1.0  gram  (gr.  i.-xv.);  Piluke  Aloes,  each 
containing  0.13  gram  (gr.  ij.),  each  of  aloes  and  soap; 
Pilulse  Aloes  et  Ferri,  each  containing  0.07  gram 
(about  gr.  i.)  each  of  aloes,  dried  sulphate  of  iron,  and 
aromatic  powder,  with  a  little  confection  of  rose; 
Piluke  Aloes  et  Mastiches,  each  containing  0.13  gram 
(gr.  ij.)  of  aloes,  0.04  gram  (gr.  §)  mastic,  and  0.03 
gram  (gr.  ss.)  of  red  rose;  Pipulas  Aloes  et  Myrrhae, 
each  containing  0.13  gram  (gr.  ij.)  aloes,  0.06  gram 
(gr.  i.)  myrrh,  and  0.04  gram  (gr.  f)  of  aromatic 
powder;  Pilulas  Rhei  Composita?,  each  containing 
0.13  gram  (gr.  ij.)  rhubarb,  0.1  gram  (gr.  iss.)  aloes, 
0.06  gram  (gr.  i.)  myrrh,  and  a  little  oil  of  peppermint. 

H.  H.  Rusby. 


Aloinum. — Aloin.  "A  neutral  principle  obtained 
from  aloes,  varying  more  or  less  in  chemical  com- 
position and  physical  properties  according  to  the 
source  from  which  it  is  obtained.  Chiefly  prepared 
from  Curasao  aloes."     (U.  S.  P.) 

Aloin  is  a  minutely  crystalline  powder,  lemon 
yellow  to  dark  yellow,  having  a  slight  odor  of  aloes, 
intensely  bitter,  slightly  hygroscopic  and  soluble  in 
water  and  alcohol.  It  exhibits  slight  differences  as  de- 
rived from  the  different  varieties  of  aloes,  and  the 
Pharmacopoeia  describes  only  that  from  Curasao 
aloes  (barbaloin). 

Aloin  is  the  principal  active  constituent  of  aloes, 


Vol.  I.—U 


and    its    action    and    uses    are    essentially    the     same. 
The  dose  is  about  one-fourth   that   of  purilied  aloe  . 

II.    II.     ROSBY. 


Alopecia.  —  Alopecia  is  a  partial  or  general  loss  of 
hair,  from  any  cause  whatever,  and  that  in  sufficient 
quantity  to  be  noticeable  to  the  naked  eye. 

The  word  "alopecia"  is  derived  from  the  Creek 
d\u>7T7)S,  meaning  fox.  Why  this  word  has  been 
used  to  express  baldness,  it  is  difficult  to  say.  tine 
explanation  might  be  that  the  fox  is  said  to  have, 
normally,  twai  bald  spots  over  his  eyes,  and  another, 

that  he  is  especially  liable  to  i  he  di  i.i  e. 

The  term  as  it.  is  used  to-day  covers  a  broader 
field  than  it  did  formerly.  It  includes  not,  only  all 
varieties  and  degrees  of  dystrophies  and  atrophies 
of  the  hair  of  the  scalp  causing  baldness,  but  also 
similar  conditions  of  the  hair  upon  any  other  part  of 
the  body. 

In  text-books  the  alopecias  are  usually  divided  into 
two  main  classes,  congenital  and  acquired.  In  the 
present  article  this  classification  is  not  followed,  but 
we  will  attempt  to  give  a  more  scientific  one  instead. 

Alopecia  may  be  due  to  a  local  disease  of  some 
hairy  part  of  the  body,  and  in  this  case  it  would  be 
limited  throughout  its  whole  course  to  the  part  in 
which  it  commenced,  or  it  may  be  the  result  of  disease 
elsewhere,  and  then  the  consequent  baldness  is  only 
incidental  to  the  other  affection. 

This  line  of  thought  also  evolves  two  principal 
classes:  (1)  Alopecke  essentiales,  idiopathicoe  sive 
primaries;  (2)  Alopecias  symptomatica^  sive  secund- 
arke.  The  first  class  includes  the  congenital  and 
senile  forms,  and  those  primary  affections  of  the 
hair  that  are  premature,  comprising  alopecia  presen- 
ilis, alopecia  pityrodes,  alopecia  areata,  folliculitis 
dccalvans,  and  dermatitis  papillaris  capillitii. 

(We  are  well  aware  of  the  fact  that  strict  logic 
would  really  not  permit  alopecia  pityrodes  to  be 
placed  in  this  class,  but  it  stands  out  so  prominently 
among  those  diseases  causing  baldness  that  for  prac- 
tical purposes  it  may  be  classed  among  the  essential 
alopecias.  Similar  objections  could  be  made  against 
the  placing  of  alopecia  areata  among  the  "idiopathic 
premature  alopecias,"  and  yet  we  find  it  there  by  the 
consent  of  many  good  authorities.) 

The  second  class  contains  first,  alopecia  toxica, 
which  includes  those  instances  of  alopecia  caused  by 
the  use  of  drugs  like  mercury  and  acetate  of  thallium 
and  also  those  caused  by  the  toxins  of  systemic 
infections  such  as  syphilis,  typhoid  fever,  etc.;  second, 
alopecia  dynamica  sive  destructiva,  in  which  loss  of 
hair  is  principally  due  to  atrophy  caused  by  mechanical 
force,  such  as  pressure  atrophy  (lupus  erythematosus), 
or  to  the  destruction  of  tissue  the  result  of  suppura- 
tion (gummata,  epitheliomata,  sycosis,  etc.),  or  to 
severe  local  inflammation  (acute  eczema,  erysipelas, 
etc.);  and  finally,  alopecia  neurotica,  which  follows 
traumatic  or  functional  nerve  injuries. 

The  following  represents  a  brief  schedule  of  this 
classification: 
I.   Alopecia:  Essentiales,  Idiopathicce  sive  Primariai. 

1.  Congenita. 

2.  Senilis. 

3.  Prematura. 

II.  Alopecia  Symptomatica;  sive  Secundaria;. 

1.  Toxica. 

2.  Dynamica  sive  destructiva. 

3.  Neurotica. 

Alopeci.e  Essentiales. — Alopecia  Congenita. 
(Depilatio  Congenita,  Atrichia,  Oligotrichia). — Con- 
genital alopecia  is  a  rare  affection.  It  may  be  com- 
plete, the  new-born  babe  being  wholly  devoid  of  hair, 
even  of  lanugo.  After  some  time  has  elapsed,  from 
a  few  months  to  a  few  years,  let  us  say,  lanugo  hairs 
may  begin  to  form,  and  later  on,  full-sized  normal 
hairs  may  make  their  appearance.     It  may,  however, 

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be  the  case  that  growth  of  hair  never  takes  place. 
This  has  been  frequently  found  to  be  true  where  there 
was  only  a  partial  alopecia  at  birth.  In  an  instance 
like  this  the  individual  bald  patches  may  multiply 
in  number  until  they  spread  over  the  entire  scalp,  and 
they  often  show  a  tendency  to  increase  in  size. 

In  connection  with  this  malady,  anomalies  of  the 
teeth  and  nails  are  often  observed.  Crocker  reports 
the  case  of  an  individual  who  had  only  four  molar 
teeth,  and  was  never  known  to  have  perspired  or 
shed  tears. 

Alopecia  congenita  represents  one  of  the  evidences 
of  arrested  development ;  there  is  a  marked  hereditary 
tendency,  and  more  than  one  member  of  the  same 
household  may  suffer  from  it. 

Schede1  is  apparently  the  only  one  who  ever  pub- 
lished the  results  of  a  complete  microscopical  exami- 
nation of  this  disease.  He  found  the  sebaceous  glands 
well  developed,  in  many  places  sending  their  open 
ducts  through  the  somewhat  atrophic  epidermis;  in 
some  of  these  rudimentary  hairs  could  be  observed, 
in  others  the  papilUe  were  merely  indicated.  The 
cutis  surrounding  this  region  was  changed  into  a 
coarse  areolar  tissue  interspersed  with  granules  and 
fat  cells. 

The  prognosis  in  the  universal  congenital  alopecia 
is  said  to  be  not  as  bad  as  in  the  partial  affection. 

Treatment  can  only  be  hygienic,  and  is  limited  to 
aiding  the  general  nutrition  processes. 

Alopecia  Senilis  (Calvities  Senilis)  — With  the 
advent  of  old  age,  a  loss  of  hair  not  only  of  the  scalp, 
but  also  of  the  eyebrows,  the  genital  and  the  bearded 
region  is  observed.  Women  are  not  as  extensively 
affected  as  men.  While  it  is  true  that  at  the  decline 
of  human  life  an  increase  in  the  growth  of  hair  is  often 
seen,  it  is  equally  true  that  this  growth  never  takes 
place  upon  the  scalp. 

As  a  rule  the  hair  becomes  gray  before  there  is  any 
sign  of  senile  baldness,  which  begins  upon  the  top  of 
the  vertex,  at  its  junction  with  the  occiput.  The 
coarse  hairs  begin  to  fall  out,  at  first  from  a  small 
circular  area  only;  this  loss  of  hair  spreads  at  the 
periphery,  presenting  a  picture  like  the  full  moon 
shining  through  the  clouds,  and  later  on  assuming 
the  form  of  the  tonsure  of  a  friar.  The  disease 
spreads  forward  along  the  vertex,  and  descends 
laterally  upon  the  temples  and  the  region  above  the 
ears,  and  finally  also  invades  the  occiput.  As  a  rule, 
it  leaves  a  small  rim  of  normal  hair  encircling  the 
lower  lateral  and  posterior  parts  of  the  scalp.  The 
coarse  hairs  are  replaced  by  lanugo  hairs,  but  these 
also  finally  drop  out.  The  scalp  is  then  left  as  a 
smooth,  shining  surface,  thinner  and  tenser  than 
before,  but  still  freely  movable  over  the  cranium. 
The  mouths  of  the  follicles  may  still  be  seen  for  some 
time,  but  they  too  shortly  disappear. 

The  whole  process  is  incidental  to  the  retrogressive 
nutrition  changes  of  senility.  The  prime  factor  is  an 
obliterating  endarteritis,  which  here  means  occlusion, 
lack  of  blood  supply,  atrophy,  and  death  of  these 
structures. 

From  the  pathology  of  this  condition  it  is  plain 
that  treatment  is  of  no  avail  in  averting  the  loss  of 
hair. 

Alopecia  Prematura;.  Alopecia  Presenilis. — When 
the  symptoms  of  the  last-described  malady  appear 
in  younger  persons  who  do  not  show  any  other  evi- 
dences of  the  degeneration  of  old  age,  it  is  called 
"alopecia  presenilis."  Its  course  and  pathology  are 
the  same  as  in  the  senile  form,  and  therapeutic  efforts 
are  as  useless.  The  wearing  of  stiff  headgear,  such 
as  derbys  and  silk  hats,  is  considered  by  some  as  a 
cause  of  this  affection.  They  argue  not  only  that  the 
hard  brims  impede  the  circulation,  by  pressure  upon 
the  blood-vessels  encircling  the  scalp,  but  that  on 
account  of  their  tight  fit  the  air  from  expiration 
becomes  so  deteriorated  as  to  be  obnoxious.  This 
factor   may   be   remembered   when   a   case  presents 


itself.  Invigorating  treatment,  and  the  avoidance 
of  injurious  diet  and  habits,  may  in  some  degree 
retard  the  progress  of  the  disease.  Active  cell  metab- 
olism should  be  encouraged. 

Alopecia  Piti/rodes  sice  Alopecia  Furfuracea  Capil- 
lilii. — Our  reasons  for  placing  this  affection  among 
the  essential  premature  diseases  of  the  hair  causing 
baldness  have  already  been  given.  Its  true  nature 
is  by  no  means  definitely  settled,  as  shown  by  the 
various  designations  given  to  it,  e.g.  seborrheal  eczema 
inflammatory  seborrhea,  seborrheal  dermatitis,  besides 
those  that  are  now  obsolete,  as,  seborrhea  sicca,  seborr- 
liea  oleosa  capitis,  acne  oleosa,  and  others.  It  is  one  of 
the  most  frequent  causes  of  baldness.  It  is  not  con- 
fined toany  particular  age,  but  still  is  oftenest  seen  in 
persons  who  are  at  the  end  of  the  second,  or  at  the 
beginning  of  the  third  decade  of  life.  Women  suffer 
from  it  more  frequently  than  men.  Elliot  gives  the 
relative  frequency  of  the  disease  in  the  two  sexes  to 
be  as  five  women  to  four  males.  Michelson  states 
that  women  are  not  as  often  attacked  as  men. 

Symptomatology. — One  of  the  first  conditions  no- 
tire,  1  by  a  patient  is  an  increased  scaliness  of  the  scalp 
commonly  known  as  dandruff.  Associated  with  this  is 
an  obstinate  itching,  and  a  sensation  of  burning  heat. 
The  pityriasis  increases  as  the  years  go  on,  when  the 
sufferer  complains  that  more  hairs  than  usual  fall  out 
when  combing.  A  woman  will  soon  notice  that  her 
braids  grow  thinner  at  the  ends,  and  that  hairs  com- 
mence to  project  from  them.  This  phenomenon  is 
due  to  the  fact  that  the  life  duration  of  the  individual 
hairs  (a  duration  which,  normally,  is  about  four 
years)  has  become  less  than  normal;  therefore  they 
do  not  attain  the  usual  length. 

The  hairs  taking  the  place  of  the  shorter-lived  ones 
grow,  in  the  course  of  time,  not  only  smaller,  but  also 
thinner.  They  lose  their  luster  and  natural  curliness, 
and  finally  are  replaced  only  by  lanugo  hairs.  An 
associated  senile  alopecia  may  hasten  their  disap- 
pearance. During  all  this  time  the  dandruff  increasea 
in  quantity,  but  at  the  appearance  of  the  lanugo  con- 
dition it  stops  suddenly,  as  if  the  disease  had  spent 
its  energy.  The  pityriasis  consists  of  whitish  scales 
made  up  of  epithelium,  sebaceous  matter,  and  dirt. 
According  to  the  proportion  of  sebum  in  them,  they 
may  feel  greasy  or  comparatively  dry.  The  amount 
of  dandruff  is  a  good  indication  of  the  severity  of  the 
disease. 

In  addition  to  the  itching,  heat,  and  headache, 
there  is  now  experienced  a  feeling  of  tension  all  over 
the  scalp.  Michelson  has  observed  increased  pers- 
piration in  some  cases  at  this  period. 

Although,  strictly  speaking,  the  loss  of  hair  begins 
simultaneously  over  the  whole  scalp  (Pincus,  Michel- 
son), there  are  certain  areas  that  are  more  rapidly 
and  more  intensely  invaded  than  others.  As  a  rule, 
there  are  two  principal  centers  of  development,  and 
both  lie  in  the  median  line  of  the  top  of  the  head;  the 
anterior  one  begins  about  one-half  inch  behind  the 
border  of  the  hair,  and  runs  backward;  the  other  one 
starts  from  the  junction  of  the  vertex  and  occiput, 
ami  progresses  forward,  so  that  there  remains  a 
bridge  of  hair  between,  which  connects  both  parietal 
region,  and  still  remain  even  when  the  disease  is  far 
advanced;  but  it  also  finally  breaks  down.  The 
occiput  and  lateral  portions  of  the  hairy  scalp  are 
not  seriously  attacked.  The  small  bunch  of  hair  in 
front  of  the  anterior  bald  spot  is  also  quite  persistent. 
The  anterior  temporal  regions,  "the  corners  of  the 
hair,"  may  form  two  additional  starting-points. 

Pathological  Anatomy. — According  to  the  descrip- 
tion given  by  Pincus  the  epidermis  is  not  thickened 
but  made  rather  thinner  than  normal.  Elliot  found 
processes  of  vacuolation  in  the  epidermic  cells,  and 
infiltration  with  wandering  cells.  The  granular  layer 
is  seen  to  be  slightly  increased.  The  subcutis  is 
the  seat  of  marked  inflammatory  changes,  as  shown 
in  the  dense,  small,  round-cell  infiltration  which  is 


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Alopecia 


arranged  especially  around  the  blood-vessels,  partic- 
ularly around  those  supplying  the  hair  follicles  and 
their  papillae.  The  hairs  in  themselves  show  nothing 
characteristic.  They  differ  in  no  way  from  those 
that  have  undergone  the  process  of  physiological  death, 

pt that  in  some  instances  the  roots  are  smaller, 
atrophied,  and  have  pointed  ends,  instead  of  showing 
the  nollowed-ouf  knob  of  the  healthy  hair.  Increased 
brittleness  may  also  be  observed;  but  this  probably 
occurs  only  in  bad  cases,  and  then  only  in  the  ad- 
vanced stages  of  the  disease.  Later  on,  as  evidences 
of  a  chronic  inflammation  make  their  appearance, 
the  small  round-cell  infiltration  is  replaced  by  a 
dense  net  work  of  fibrous  tissue,  which  gives  the  feeling 
of  tightness  to  the  scalp,  and  prevents  its  being  lifted 
up  between  the  fingers.  The  subcutaneous  fat  is 
greatly  increased  in  quantity. 

Ft  iology. — Some  diseases,  such  as  syphilis,  diabetes, 
typhoid  fever,  etc.,  are  predisposing  factors.  French 
writers  consider  "arthritisme"  as  an  important  cause. 
Heredity  also  plays  quite  a  role  here.  Any  condition 
or  malady  that  leaves  the  system  in  a  weakened 
must  naturally  be  looked  upon  as  furnishing  a 
favorable  chance  for  the  invasion  of  the  disease.  Lad 
hygienic  surroundings,  defective  cell  metabolism, 
neglect  of  proper  care  of  the  scalp,  general  malnutri- 
tion, increased  ingestion  of  sugars,  loss  of  sleep — 
all  of  these  have  to  be  looked  upon  as  probable  pre- 
disposing factors.  How  really  sensitive  the  hairs  of 
the  scalp  are  is  shown  by  the  loss  of  their  healthy 
luster  and  oiliness  after  a  single  protracted  dissipation, 
with  its  attendant  loss  of  sleep  and  subsequent 
general  depression. 

Numerous  are  the  organisms  described  by  those 
who  have  attempted  to  verify  the  parasitic  nature 
of  the  disease.  Malassez  considered  his  flask-shaped 
bacillus  (called  by  Sabouraud  Bacillus  asciformis)  as 
the  cause  of  alopecia  pityrodes.  Unna  holds  that 
alopecia  pityrodes  is  identical  with  his  eczema  seb- 
orrhoicum,  and  is  caused  by  the  morrococcus  or 
mulberry  coccus.  Merrill,  in  connection  with  Elliot, 
found  a  diploeoccus  with  sufficient  frequency  to  be 
able  to  attach  to  it  some  etiological  importance. 
Sabouraud,  after  some  painstaking  experiments, 
believed  that  he  had  established  the  identity  of  some 
follicular  affections  hitherto  regarded  as  separate 
diseases — i.e.  comedones,  acne,  seborrhea,  alopecia 
pityrodes,  alopecia  senilis,  and  alopecia  areata.  He 
describes  a  punctiform  bacillus  almost  resembling  a 
coccus,  lft  in  length  and  0.5/i  in  diameter.  It  has 
the  power  of  penetrating  deeply  into  the  hair  follicles 
and  into  the  sebaceous  glands,  while,  according  to 
him,  the  flask-shaped  bacillus  of  Malassez  is  confined 
to  the  funnel-shaped  enlargement  of  the  mouths  of 
the  diseased  follicles.  He  sums  up  his  explanation 
of  the  pathogenesis  of  alopecia  pityrodes  by  stating 
that  the  presence  of  the  microorganism  described  by 
him  first  causes  an  irritation,  and  thus  a  hypersecre- 
tion of  the  sebaceous  glands;  then  there  follows  an 
hypertrophy,  and  by  further  invasion,  a  progressive 
papillary  atrophy,  with  malnutrition  and  atrophy 
of  the  hair  producing  cells,  hence  death  of  the  hairs 
that  are  formed,  and  cessation  of  the  growth  of  new 

one-;. 

Right  here  it  would  seem  appropriate  to  mention 
the  fact  that  the  parasitic  theory  of  alopecia  pity- 
rodes was  first  advanced  by  Lassar  and  Bishop2  after 
some  experiments  in  which  alopecia  followed  the  in- 
unction of  a  mixture  of  vaseline  and  finely  cut  hairs, 
taken  from  a  tyr  cal  case  of  this  disease.  In  the 
case  just  mentioned  alopecia  appeared  in  the  third 
week,  and  could  be  transmitted  from  the  first  series 
of  animals  to  others.  Michelson  remarks  that  he  was 
able  to  produce  the  same  effects  with  rancid  olive  oil. 

Saalfeld,3  repeated  the  experiments  of  Lassar  and 
the  bacteriological  studies  of  Unna  and  Sabouraud. 
He  was  able,  like  Lassar,  to  produce  a  loss  of  hair, 
but  not  a  typical  alopecia  pityrodes.     He  also  suc- 


ceeded in  producing  the  same  conditions  with  simple 
non-rancid  oil,  and  even  with  the  somewhat  vigorous 
strokes  of  a  brush.  Using  rancid  oil,  he  obtained 
the  same  effects  as  Michelson.  Ee  has  found  micro- 
organisms which  may  be  considered  identical  with 
tho  e  of  Unna  and  Sabouraud,  but  he  looks  upon 
them  as  incidental.  He  was  unsuccessful  in  proving 
that  they  produced  alopecia  pityrodi 


Fig.  SO. — Alopecia  Areata.     (From  a  photograph  of  one  of  the 
author's  cases.) 

The  direct  exciting  cause  is  probably  a  local  exogen- 
ous toxemia  from  organisms  situated  in  the  skin;  and 
the  predisposing  cause  and  the  more  important  one, 
an  endogenous  or  metabolic  toxemia  or  an  exogenous 
toxemia  from  the  digestive  tract,  making  the  soil 
favorable  for  the  organisms  directly  concerned  in 
causing  the  inflammatory  process. 

Diagnosis. — The  disease  may  be  readily  recognized 
by  its  occupying  usually  the  median  portion  of  the 
scalp,  the  lateral  and  posterior  parts  being  compara- 
tively free  from  the  furfuraceous  scales  always  pres- 
ent in  greater  or  less  quantities,  and  from  the  sensa- 
tions of  itching  and  heat. 

It  is  distinguished  from  senile,  and  more  espe- 
cially from  presenile  alopecia,  in  that  these  two  forms 
begin  upon  the  vertex  of  the  head,  wdiile  the  anterior 
portions  are  invaded  much  later.  There  is  no  pity- 
riasis in  these  diseases,  and  the  loss  of  hair  is  more 
rapid.  Psoriasis  does  not  attack  the  scalp  as  a  whole. 
Its  lesions  are  usually  isolated  and  sharply  limited ; 
its  scales  are  silvery  and  dry  and  comes  off  in  lam- 
ellae; and  it  never  attacks  the  scalp  alone. 

Eczema  seborrhoicum  is  especially  noticeable  by 
the  margin  along  the  front  of  the  hairs;  this  margin 
is  more  or  less  continuous  and  covered  with  yellowish 
greasy  scales.  As  a  rule,  the  chest  and  the  back  are 
affected  at  the  same  time.  The  diagnosis  is  some- 
times impossible. 

Alopecia  syphilitica,  while  it  may  be  seen  all  over 
the  scalp,   is,   however,  generally  situated  upon    the 

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sides  and  the  occiput;  often  the  external  halves  of 
the  eyebrows  and  the  eyelashes  fall  out. 

Alopecia  areata  can  hardly  be  confounded  with 
alopecia  pityrodes.  Like  the  preceding  it  completely 
lacks  the  furfuraceous  desquamation. 

Pincus  has  called  attention  to  the  disproportion  of 
the  sharply  pointed  hairs,  those  that  are  so  small 
that  in  cutting  the  hair  they  escape  the  shears  or 
the  barber;  and  those  which,  on  account  of  their 
length  are  clipped,  and  therefore  present  to  view  a  dull- 
pointed  end.  If  the  proportion  is  as  1:8  of  hairs  of 
thirteen  centimeters  length,  and  as  1 :10  in  those  hav- 
ing a  length  of  from  five  to  eight  centimeters,  the  shed- 
ding is  abnormal;  and  this  circumstance,  in  connection 
with  the  other  symptoms  described,  gives  the  diagnosis 
of  alopecia  pityrodes.  The  way  in  which  it  is  recog- 
nized in  women  has  already  been  alluded  to  under  the 
heading  of  Symptomatology. 

Prognosis. — The  disease  is  curable,  but  can  be  com- 
bated only  by  energetic  and  long-continued  treatment 
which  may  last  weeks,  months,  or  even  years.  As  it 
it  not  in  human  nature  to  spend  the  time  and  energy 
necessary  for  the  cure  of  an  affection  where  the  dam- 
age done  is  simply  an  offence  to  the  esthetic,  the 
disease  as  a  rule,  is  permitted  to  run  its  regular  course 
to  the  end,  which  is  perhaps  put  off  for  a  few  years  by 
intermittent  attempts  at  treatment.  Heredity,  and 
the  appearance  of  this  form  of  alopecia  in  the  earlier 
years  of  life,  render  the  prognosis  less  favorable. 

Treatment. — We  will  not  enumerate  all  the  reme- 
dies advised  for  the  cure  of  alopecia  pityrodes,  but 
simply  lay  down  the  principles  for  its  treatment,  and 
cite  one  or  two  examples.  Any  other  plans  and 
methods  advocated  can  then  be  readily  appreciated 
by  the  reader.  The  first  step  must  be  to  remove  the 
pityriasis.  This  procedure  removes  at  the  same  time 
a  good  many  organisms,  and  by  the  mechanical  force 
applied,  massages  the  scalp,  and  hence  helps  to  re- 
move some  of  the  inflammatory  exudates.  The 
next  step  is  to  apply  some  antiseptic  medicament 
which  should  not  only  cover  the  scalp,  but  should 
also  penetrate,  if  possible,  into  the  hair  follicles,  so  as 
to  reach  organisms  situated  there.  Through  the 
washings,  and  the  applications  of  antiseptics  which 
are  usually  dissolved  in  alcohol,  the  natural  oil  of 
the  scalj)  will  be  removed.  This  must  be  replaced,  and 
this  replacing  constitutes  the  third  and  last  step  of  the 
treatment.  An  ointment  having  as  a  basis  vaseline 
or  lanolin  is  rubbed  into  the  scalp.  It  is  a  good  plan 
to  add  to  this  some  antiseptic,  so  as  to  have  the  dis- 
eased parts  in  constant  contact  with  a  germ-de- 
stroying agent. 

This  treatment  has  to  be  repeated  daily  for  from 
one  to  six  weeks;  then  once  every  other  day  for  a 
similar  period  of  time;  then  three  times  a  week;  after 
that  once  a  week,  and  this  latter  must  be  continued 
for  a  period  of  years  for,  as  stated  above,  if  the  scalp 
is  not  treated  energetically  and  persistently  the  dis- 
ease is  certain  to  recur.  No  method,  however,  can 
resuscitate  the  atrophied  hair-producing  structures; 
but  the  simply  diseased  ones  may  be  restored  to 
health,  if  treated  before  the  changes  are  too  far 
advanced. 

Twenty  or  more  years  ago  Unna  recommended  a 
simple  remedy,  which,  according  to  him,  is  attended 
with  good  results.  It  consists  simply  of  an  oint- 
ment of  ten  per  cent,  precipitated  sulphur  in  unguen- 
tum  pomadini.  The  hair  is  parted  first  in  a  sagittal, 
then  in  a  coronal  direction,  the  parts  being  a  distance 
of  about  one  centimeter  away  from  each  other,  and  tin- 
salve  is  lightly  spread  along  the  furrows.  This  is 
done  every  night.  The  scalp  is  washed  every  three 
or  four  days  to  cleanse  it  from  the  scales  and  the  salve. 
In  the  second  week,  or  later,  according  to  circum- 
stances, the  intervals  between  the  applications  be- 
come longer  and  longer,  until  finally  treatment  is 
stopped  altogether  after  a  cure  is  thought  to  have  been 
obtained. 


The  method  laid  down  by  Lassar  meets  all  the  indi- 
cations for  treatment.  The  scalp  is  washed  daily 
with  a  good  tar  soap  for  at  least  ten  minutes,  warm 
water  being  used  at  first,  and  the  lather  then  rinsed 
off  with  cool,  and  finally  with  cold  water.  After 
this  the  hair  and  scalp  are  thoroughly  dried — this  is 
very  important.  Now  a  solution  of  one-half  per  ci 
corrosive  sublimate  in  equal  parts  of  glycerin  and  ; 
water  is  used,  being  applied  to  the  scalp  with  some 
friction.  This  is  followed  by  the  use  of  a  solution  of 
one-half  per  cent,  of  ^-naphthol  in  absolute  alcohol. 
As  the  parts  are  now  completely  dehydrated  and  poor 
in  fat,  the  latter  has  to  be  replaced  and  now  any  fur- 
ther antiseptic  added  is  taken  up  very  eagerlv  on 
account  of  the  dehydration.  Lassar  recommends  the 
following:  fy  Acidi  salicylici,  10;  Tincture  benzoini, 
3;  Olei  bubuli,  100.  In  severe  cases  the  corrosive 
sublimate  solution  may  be  used  several  times  dur- 
ing the  day.  If  there  be  a  tendency  to  great  greasi- 
ness  of  the  scalp,  resorcin  of  from  three  to  five  per 
cent,  strength  is  suggested,  instead  of  the  /3-naphthnl 
or  salicylic  acid  in  the  ointment;  or,  it  may  be  added 
to  the  same,  the  percentage  of  the  latter  being  then 
of  course  reduced  accordingly.  The  combination 
of  resorcin  and  salicylic  acid  is,  besides,  very  appro- 
priate from  a  pharmaceutical  standpoint,  for  resorcin 
has  the  tendency,  when  used  alone,  and  especially 
when  combined  with  alkaline  media,  to  turn  red  in 
color;  a  change  which  does  not  take  place  when  in 
union  with  acids. 

When  the  hair  is  very  dry  sulphur  acts  better  than 
resorcin.  Of  course,  when  sulphur  is  used,  the  wash- 
ing with  corrosive  sublimate  is  omitted.  The  sul- 
phur in  that  case  is  incorporated  into  the  pomade  in 
combination  with  salicylic  acid  and  also  with  resorcin, 
if  we  choose.  As  the  greasy  ointments  are  often 
objectionable  to  women,  we  may  add  the  ingredients 
to  a  basis  of  a  lower  melting-point  than  lard  or  vase- 
line; as,  for  instance,   benzoinol  or  liquid  albolene. 

This  treatment  of  the  scalp  must  be  repeated  daily 
for  at  least  one  week,  and,  in  more  marked  cases,  for 
as  long  as  six  weeks;  after  this  once  every  other  day; 
then  three  times  a  week;  and  finally  once  a  week 
will  be  sufficient,  but  this  must  be  continued  for 
months  if  necessary. 

Corrosive  sublimate  1  to  1000  in  bay  rum  is  a 
cleanly  preparation  and  usually  gives  satisfactory 
results.  It  is  to  be  used  as  a  daily  dressing  of  the 
hair. 

Alopecia  Pityrodes  Universalis. — Under  this  name 
Michelson'  described  a  variety  of  the  former  disease 
affecting  all  the  hairy  regions  of  the  body.  Kaposi 
had  observed  a  similar  condition  in  connection  with 
seborrhea.  The  disease  may  begin  like  a  simple 
alopecia  pityrodes  affecting  the  top  of  the  head,  hut 
si  urn  the  whole  scalp  becomes  involved,  and  si- 
multaneously, or  a  little  later,  all  the  hairs  of  the  body 
begin  to  fall  out;  at  the  same  time  there  is  an  abun- 
dant production  of  pityriasis  in  the  parts  affected. 
Lanugo  hairs  take  the  place  of  those  that  have  dis- 
appeared, and  in  places  the  stumps  of  hairs  I 
have  been  broken  off  may  still  be  seen.  This  affec- 
tion somewhat  resembles  a  universal  alopecia, 
areata,  but  differs  from  it  in  the  pityriasis  present. 
and  in  the  fact  that  the  scalp  is  tense  and  tightly 
stretched  over  the  cranium,  while  in  alopecia  areata 
it  is  thin  and  readily  movable.  A  greatly  debilitated 
system  seems  to  lie  at  the  bottom  of  this  malady. 

The  prognosis  is  not  unfavorable;  the  new  hairs 
that  grow  in  may  be  different  in  color  from  the  old 
ones.  The  diagnosis  is  readily  made,  if  it  be  remem- 
bered in  what  points  it  differs  from  alopecia  areata. 
The  pathology  is  essentially  the  same  as  that  ol 
alopecia  pityrodes  localis. 

Michelson  has  noticed  a  peculiar  brush-like  deform- 
ity of  the  ends  of  the  diseased  hairs,  a  deformity 
which  he  attributes  to  the  affected  papillae  being 
unable  to  furnish  enough  cement  substance  to  li"M 


228 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Alopecia 


the  individual  cells   together.     The  lower   parts  of 
the  hairs  show  an  increa  ;e  in  nuclei  and  pigment. 
Besides    the    local    treatment,    which    consists   of 

in\  igorating  l>aths,  as  ft)!1  instance  these  of  salt  water, 
and  that  special  treatment  described  under  the  local 
form  of  this  alFection,  particular  attention  is  to  be 
directed  to  the  general  nutrition,  which  must  be 
improved. 

Alopecia  Simplex. — Pineus  described  instances  in 
which  there  is  a  general  loss  of  hair  of  the  scalp;  the 
crop  of  hair  becomes  thinner  and  thinner,  just  as  it 
does  in  alopecia  pityrodes,  but  there  is  no  pityriasis  in 
nection  with  the  loss  of  hair.  This  latter  fact 
made  it  seem  proper  to  give  this  special  form  of  the 
disease  a  separate  name.  The  treatment  is  similar 
to   that   in   alopecia   pityrodes,   only   the  shampooing 

-  remove  dandruff  may  be  omitted  as  unnecessary. 

Alopecia    Areata    (Area   celsi,    area   circumscripta, 

i    accidentalis,    tinea    decalvans,    teigne    pelade, 

pelade). — The  term  "alopecia  areata,"  as  it  is  used 

to-day,    is    rather    vague    and    ill    defined.     Several 

diseases  are  probably  included  under  it. 

The  affection  is  a  disease  of  the  hairy  parts  of  the 
body,  producing  a  loss  of  hair  in  circumscribed  areas, 
which  commence  as  small  spots  and  gradually  in- 
crease at  the  periphery,  the  underlying  skin  being 
apparently  little  or  not  at  all  affected.  The  regions 
most  frequently  attacked  are  the  scalp,  the  beard, 
and  the  eyebrows.  The  disease  may  occur  on  any 
part  of  the  body  where  hair  is  found.  The  loss  of 
hair  may  be  partial  or  complete.  The  mild  cases  are 
usually  limited  to  the  head,  beard,  and  eyebrows. 

Crocker,  in  order  to  substantiate  his  belief  in  a 
connection  between  alopecia  areata  and  ringworm, 
has  pointed  out  that  it  is  more  frequent  in  those 
countries  where  the  latter  prevails  (France  and 
England),  while  both  affections  are  far  less  frequent 
in  Germany  and  America.  Men  are  more  often 
attacked  than  women,  persons  between  the  ages  of 
tin  and  twenty-one  more  frequently  than  others; 
dark-haired  persons  suffer  more  from  the  affection 
than  blondes. 

Symptomatology. — Constitutional  or  local  prodro- 
mal symptoms  are  absent  as  a  rule;  there  may  be 
some  malaise,  loss  of  appetite,  headache,  slight  itch- 
ing, and  other  paresthesia?.  H.  Schultze,5  who  ob- 
served the  disease  on  himself,  made  note  in  his  case 
of  a  unilateral  headache  upon  that  side,  which,  later 
on,  became  invaded  by  alopecia  areata. 

The  parts  of  the  scalp  most  generally  affected  are 
those  surrounding  the  junction  of  the  occiput  and  the 
parietal  bones.  There  is  no  symmetry  in  the  lesions 
as  a  rule.  The  formation  of  the  individual  patches 
is  about  as  follows:  A  person  may  notice  that  in  a 
certain  spot  his  hair  conies  out  very  freely.  He 
observes  a  bald  space.  He  attempts  to  pull  out 
some  hairs,  and  finds  that  they  can  be  removed  very 
easily  and  wholly  without  pain.  Afterward  the 
hairs  may  fall  out  spontaneously  along  the  periphery 
of  the  small  patch  first  seen.  The  patch  grows  larger, 
rapidly  or  slowdy,  and  in  all  directions.  The  increase 
in  size  may  progress  more  rapidly  in  one  direction 
than  in  another,  thus  creating  oval  or  irregular  patches. 
There  may  be  only  one  patch,  or  there  may  be  several, 
beginning  at  the  same  time,  or,  as  is  usually  the  case, 
there  may  be  successive  crops  of  bald  spots. 

The  areas  of  baldness  are  from  one-half  to  two 
inches  in  size,  but  by  the  coalescence  of  several  areas 
very  large  patches  are  sometimes  formed.  Individual 
areas  are  not  always  very  sharply  defined  from  the 
surrounding  healthy  structures  in  the  first  stages  of 
the  malady.  The  periphery  is  surrounded  for  a  short 
distance  by  a  thinner  crop  of  hair.  There  may  be 
some  few  healthy  hairs  left  even  in  the  center  of  the 
bald  areas,  hairs  which  cling  to  their  papilla;.  Some 
broken-off  hairs  projecting  from  their  follicles  are 
often  noticed  upon  close  inspection.  The  skin  at  the 
seat  of  the  affection  is  smooth,  shiny,  thin,  and  can 


readily  be  lifted  up  between  the  fingers.  It  looks 
paler  than  the  normal  skin,  and  on  being  pricked  with 
a    needle    blood    oozes    less    readily.      There    are    no 

vesicles,  crusts,  or  scales,  no  efflorescences  of  any 
kind.     In  some  feu-  cases  I  have  observed  a  slight 

caling,  redness,  and  some  edema  at  the  beginning 
Of  the  disease.  The  level  of  the  affected  skin  is  felt 
to  be  below  that  of  the  neighboring  normal  skin. 
This  is  duo  to  the  fact  thai  tie  skin  has  sunken  in, 
on  account  of  I  lie  ab  ence  of  so  many  hairs  in  the 
now  collapsed  hair  follicles,  and  not,  as  some  believe, 
to  an  atrophy  of  the  cutis.  The  nervous  impressions 
are  not  impaired.  The  tactile,  temperature,  and 
pressure  senses  may  be  slightly  increased  (  Michelson). 
Neumann,  however,  has  observed  anesthesia.  \\  hen 
the  disease  at  a  given  patch  has  come  to  a  standstill, 
the  hairs  at  the  periphery  become  more  normal  in 
number  and  cannot  be  as  easily  plucked  out  as  before; 
the  affected  area  is  now  sharply  defined.  The  period 
of  baldness  of  such  a  patch  is,  as  a  rule,  of  several 
weeks' duration,  and  if  at  the  expiration  of  this  time 
there  are  no  signs  of  regeneration,  it  is  difficult  to 
determine  when  the  hairs  will  make  their  reappear- 
ance. The  malady  may  go  on  for  years  and  years. 
Recovery  has  been  observed  after  a  period  of  from 
ten  to  fourteen  years,  and  even  after  a  much  longer 
time;  it  may,  however,  never  take  place. 

Reproduction  of  healthy  hair  begins  almost  always 
at  the  periphery  and  progresses  from  without  inward. 
First,  small  lanugo  hairs  begin  to  appear.  These, 
after  a  short  struggle  for  existence,  may  fall  out  again, 
to  be  replaced  by  stronger  and  longer  hairs.  This 
replacement  of  the  new  hairs  by  others  may  repeat 
itself  several  times  before  the  normal  hairs  finally 
make  their  appearance,  and  these  latter  may  even 
then  lack  color  for  a  long  time.  The  affected  area 
may  long  after  be  recognized  as  the  site  of  a  previous 
alopecia  areata. 

A  seborrheal  eczema  condition  sometimes  precedes 
the  alopecia  area  but  in  my  experience  it  occurs  only 
in  a  small  percentage  of  the  cases. 

Alopecia  areata  of  the  other  hairy  regions  presents 
analogous  phenomena.  The  beard,  eyebrows,  axil- 
lary and  pubic  hairs  may  fall  out.  All  the  hairs  of 
the  body  may  disappear,  thus  constituting  the  al- 
opecia maligna  of  Michelson. 

Pathology. — Nothing  characteristic  of  this  affec- 
tion can  be  obtained  from  an  examination  of  the 
hairs.  They  show  the  same  simple  atrophy  as  seen 
in  the  hairs  shed  in  the  physiological  way.  In  some 
the  roots  are  not  bulb-shaped,  but  pointed,  a  fact  to 
which  we  have  already  called  attention,  in  connec- 
tion with  the  pathology  of  alopecia  pityrodes. 

My  observations  of  the  microscopical  changes  of 
the  skin  were  reported  to  the  Ninth  International 
Medical  Congress  at  Washington  (1887).  Many  pieces 
of  skin  were  taken  from  seven  different  patients. 
In  spite  of  the  clinical  appearance  of  the  dis- 
ease, the  presence  of  an  inflammatory  process  in 
every  case  could  be  observed.  S.  Giovannini  and 
Sabouraud  have  also  found  perivascular  small  round- 
cell  infiltration,  consisting  of  mast  cells  and  mono- 
nuclear leucocytes.  This,  according  to  Sabouraud, 
goes  to  show  fhe  presence  of  an  agent  with  decided 
chemotactic  influences  upon  these  cells,  an  agent 
probably  emanating  from  a  microorganism.  In  my 
sections,  the  subcutaneous  tissue  was  normal,  the 
lymphatics  were  somewhat  dilated  and  contained 
micrococci.  Whether  they  have  any  etiological 
relationship  to  the  pathological  phenomena,  I  have 
so  far  been  unable  to  demonstrate. 

Some  hair  follicles  showed  replacement  of  the  normal 
hair  by  lanugo.  The  hairs  in  some  were  broken,  or 
stubbed  and  split.  The  lower  parts  of  the  follicles 
were  devoid  of  pigment,  this  explaining  the  loss  of 
color  of  the  returning  hairs  during  convalescence. 
In  cases  of  permanent  alopecia  of  long  standing,  hair 
follicles  and  sebaceous  glands  had  been  destroyed. 


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Alopecia 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


The  blood-vessels  showed  a  thickening  of  their  walls. 

Etiology. — There  is  in  dermatology  hardly  a  single 
disease  whose  nature  is  so  much  disputed  as  that  of 
alopecia  areata.  Three  views  are  held  in  regard  to 
it:  first,  that  it  is  a  trophoneurosis;  second,  that  it  is 
of  parasitic  origin;  third,  that  what  we  understand 
under  alopecia  areata  to-day  is  not  a  clinical  entity 
at  all,  but  that  under  this  name  are  grouped  several 
diseases,  some  of  which  are  neurotic,  while  others  are 
parasitic. 

In  my  opinion  every  case  of  alopecia  that  com- 
mences as  a  small  spot  and  gradually  increases  in 
area  by  extension  at  the  periphery  and  shows  the 
clinical  characters  I  have  described,  is  due  to  the 
local  action  of  an  organism. 

In  support  of  the  first  view  are  cited  the  nervous 
prodromal  symptoms,  such  as  neuralgia,  headache, 
and  the  various  paresthesia?,  and  the  fact  that  loss 
of  hair  in  patches  often  follows  nerve  injuries.  Kap- 
osi enumerates  many  instances  of  this  kind.  Best 
known  are  the  experiments  of  Joseph  and  Mibelli, 
who  observed  alopecia  following  the  excision  of  the 
second  cervical  ganglion.  Moskalenko  and  Ter- 
Gregoryanitz  {Vrach,  1899)  have  produced  typical 
alopecia  areata  in  dogs,  cats,  and  rabbits  by  per- 
forming the  same. operation,  and  also  by  cutting  the 
nerve  roots.  Injury  to  the  peripheral  nerves  pro- 
duced no  typical  alopecia  areata,  as  the  patches  that 
showed  themselves  were  not  round.  If  the  disease 
were  always  due  to  nerve  injuries,  the  triangular 
form,  corresponding  to  the  area  of  supply  of  a  given 
nerve,  should  be  more  frequent.  Besides,  there  arc 
undoubted  cases  in  which  the  lesions  spread  without 
regard  to  blood-vessel  or  nerve  supply. 

According  to  my  view  of  the  subject,  the  cases  of 
circumscribed  loss  of  hair  following  nerve  injuries 
are  not  instances  of  alopecia  areata,  if  we  understand 
this  term  to  mean  an  affection  in  which  the  hair  falls 
out  in  round  patches  which  spread  at  the  periphery, 
and  only  such  cases  should  be  called  cases  of  alopecia 
areata. 

The  fact  that  regeneration  progresses  from  without 
inward  has  been  brought  forward  as  an  argument 
against  the  theory;  if  justly  so,  remains  to  be  seen. 
Another  argument  against  it  is  the  absence  of  all 
inflammatory  symptoms  usually  seen  upon  the  sur- 
face— i.e.  vesicles,  scales,  crusts,  etc.;  but  as  already 
mentioned,  an  inflammatory  process  is  always  present. 

Numerous  organisms  have  been  found.  As  early 
as  1843,  Gruby  had  described  his  Microsporon  au- 
douini,  but  it  was  found  that  it  represented  one  of 
the  forms  of  the  ringworm  fungus.  Others  who 
called  attention  to  parasites  are  Malassez  (1875), 
Thin  (1881,  bacterium  decalvans),  von  Sehlen 
(18S4,  areacoccus),  mvself  (1SS7),  and  Vaillard. 
Vincent,  Nimier  (18S9),  etc.  In  1S9G  Sabouraud6 
brought  to  notice  an  organism  which  he  named 
"  microbacillus  alopecia?  areata?,"  and  not  being 
certain  as  to  its  etiological  importance,  "le  micro- 
bacille  de  l'utricle  peladique."  He  admits  that  it 
may  be  identical  with  Unna's  and  Hodam's  organism 
found  in  comedones,  and  in  acne.  In  the  following 
year  (1897)  he  stated  that  in  his  opinion  comedones, 
acne,  seborrhea,  alopecia  pityrodes,  and  alopecia 
areata  are  all  caused  by  the  same  organism,  varying 
only  in  intensity  and  location. 

As  reported  to  the  American  Dermatological 
Association,  I  have  experimentally  produced  small 
areas  of  alopecia  with  all  the  objective  characters  of 
alopecia  areata  by  the  subepidermal  injections  of 
Staphylococcus  epidemicus  albtis.  The  patches  did 
not  extend  beyond  the  area  injected. 

In  support  of  the  parasitic  theory,  frequent  refer- 
ence is  made  to  the  instance  of  contagion  as  cited  by 
Crocker,  many  French  authorities,  and  by  Bowen 
and  Putnam7  of  this  country,  and  again  by  Bowen.8 
In  France  the  disease  lias  been  observed  especially  in 
(lie  army,  and  is  believed  to  have  been  due  to  the  same 


hair-clipping  machines  having  been  used,  or  to  the  same 
caps  and  helmets  having  been  worn.  .Sabouraud  has 
observed  that  many  patients  applying  for  treatment  at 
the  Hopital  St.  Louis  came  from  the  same  section 
of  the  town,  and  that  some  had  employed  the  same 
hairdresser.  The  epidemic  in  an  asylum,  described 
by  Putnam,  is  remarkable.  Sixty-three  out  of  sixty- 
nine  girls  were  infected,  and  there  was  no  trace  of 
ringworm.  A  girl,  who  was  believed  to  have  spread 
the  disease,  left  the  institution,  and  went  home 
where  in  a  short  time  her  stepfather  became  infeel 
In  the  mean  time  the  epidemic  at  the  asylum  had 
come  to  a  standstill.  A'few  years  after,  this  Ban 
girl  was  again  received  at  the  institution,  and  in  a 
very  short  time  twenty-six  out  of  forty-five  children 
showed  evidences  of  the  disease.  Hutchinson  and 
Crocker  think  that  there  is  some  relationship  between 
ringworm  and  alopecia  areata. 

I  have  seen  several  examples  of  an  almost  simul- 
taneous appearance  of  the  disease  in  two  or  more  of 
the  same  family. 

Diagnosis. — A  typical  case  can  be  readily  recog- 
nized by  the  lesions  being  round  and  spreading  at 
the  periphery.  The  thin,  smooth,  shiny  skin,  sunken 
beneath  the  niveau  of  the  surrounding  health}-  skin, 
and  showing  no  signs  of  an  inflammatory  process 
makes  the  diagnosis  easy.  Alopecia  areata  has  to 
be  differentiated  from  ringworm,  favus,  syco 
syphilis,  folliculitis  decalvans,  and  the  loss  of  hair 
after  traumatism.  Alopecia  maligna  must  be  dis- 
tinguished from  alopecia  pityrodes  universalis  (vide 
above). 

In  ringworm  we  find  dermatitis,  broken-off  hairs, 
and  the  ringworm  fungus  under  the  microscope;  in 
favus,  also,  the  organism  producing  it,  as  well  as  the 
yellow  cups,  scar  tissue,  and  a  grayish  discoloration 
of  the  atrophied  hairs.  Folliculitis  decalvans  pre- 
sents evidences  of  follicular  inflammation  and  sear- 
tissue  formation.  Alopecia  syphilitica  shows  irreg- 
ular patches,  not  depressed,  especially  affecting  the 
outer  portions  of  the  scalp  and  the  eyebrows;  besides 
these,  there  are  concomitant  symptoms  of  the 
disease. 

Cases  of  the  falling  out  of  hair  in  patches,  in  con- 
sequence of  nerve  injuries,  have  been  observed,  and 
the  characteristics  of  the  resulting  bald  spots  were 
similar  to  those  of  the  ordinary  cases  of  alopecia 
areata.  The  clinical  history  of  the  manner  of  forma- 
tion of  the  patch  is,  however,  different.  I  consider 
those  cases  only  to  be  true  examples  of  alopecia 
areata  in  which  the  patches  grow  by  extension  at  the 
periphery. 

Prognosis. — As  alopecia  areata  tends  to  a  spon- 
taneous recovery  in  the  majority  of  cases  the  prog- 
nosis is  favorable.  Even  if  regeneration  does  net 
show  itself  for  years,  hope  should  not  be  entirely 
abandoned,  for  regeneration  may  ultimately  take 
place.  This  was  true  in  several  instances,  where 
new  hairs  grew  even  after  a  decade  or  more  from  the 
beginning  of  the  malady.  It  is  my  experience,  how- 
ever, that  if  a  patch  remains  quite  free  from  lanugo 
hairs  for  several  months,  it  shows  that  the  follicles 
are  probably  destroyed  and  that  there  will  be  a  per- 
manent alopecia.  The  older  the  patient,  and  (he 
longer  the  area  has  been  affected,  the  graver  becomes 
the  outlook  as  to  recovery.  The  possibility  of 
relapses  must  not  be  forgotten. 

Treatment. — On  account  of  the  fact  that  recovery 
is  often  spontaneous,  it  is  exceedingly  difficult  to 
appreciate  the  value  of  any  therapeutic  agent  other- 
wise than  by  means  of  a  long  series  of  observations. 
A  host  of  remedies  has  been  recommended.  Inter- 
nally, arsenic,  cod-liver  oil,  tonics,  and  jaborandi  may 
be  tried  in  connection  with  dieting,  physical  and 
mental  hygiene.  While  such  a  therapy  may  not 
have  any  direct  effect  upon  the  cause  of  the  lesions, 
it  may  help  to  render  the  system  more  resistant  to 
the  disease.     Tincture  of  jaborandi  is  administered  to 


230 


Kill  KKKXCK    HANDBOOK    ( >!•'    TIIK    MKDICAL    SCIK.WKS 


Alopecia 


produce  a  local  hyperemia  of  the  pale  patches  who  e 
blood-vessels  are  abnormally  contracted. 

The  older  methods  <>f  I  oral  treatment  wore  addressed 
to  stimulate   the   nutritive   processes  of    the    part; 

lav,  when  the  parasitic  theory  prevails,  para- 
siticides   are    used.     Chrysarobin,    in    my    opinion, 

ds  out  far  above  any  other  remedy.      It   is  must 

ctual  when  incorporated  in  vaseline  or  lanolin; 
much    more    so    than    when    combined    with    liquor 

ta  percha  or  traumaticin.  As  a  rule,  a  six-  to 
ten-per-cent.  preparation  is  applied  daily  for  one  or 
two   weeks,    and    then   stopped    for   a   short    time    to 

erve  if   the   disease   has   been   cured.     If   lanugo 

■a  do  not  appear  soon,  or  if  the  hairs  at  the  pe- 
riphery continue  to  fall  out  or  can  be  easily  pulled  out, 
the  treatment  is  continued.  Care  should  be  taken 
that  the  application  does   not  reach  the  eyes,  as  a, 

re  conjunctivitis  might  follow.      Because  of  this 

ible  danger  it  cannot  be  used  upon  the  eyebrows. 
it"  recommends  for  these  that  carbolic  acid  be 

ned  biweekly.     The  slight  mahogany  discoloration 

rved  around  the  neck  and  in  the  face  after  the 

of  chrysarobin  is  the  first  danger  signal  of  an 
approaching  dermatitis.  The  remedy  should  now 
either  be  stopped  at  once,  or  the  strength  of  the  oint- 

|   be  reduced.     The  hairs  around  the  periphery 

Id  be  removed  as  soon  as  they  become  loose. 

1  believe  the  great  majority  of  the  cases  can  be  cured 

within  two  or  three  weeks  by  this  treatment  if  seen  at 

an  early  stage.     Croton  oil,  which  is  a  pure  irritant, 

be  of  benefit  in  chronic  cases.     It  should  be 

I  with  olive  oil,  equal  parts,  and  applied  every 
day  until  a  dermatitis  is  produced. 

Balzer  and  Storianowitch  have  obtained  good  re- 
sults with  a  fifty-per-cent.  solution  of  lactic  acid  in 
water  or  alcohol.  The  affected  parts  are  first  freed 
from  oil  with  alcohol  and  ether,  and  the  remedy  is 
then  applied  with  a  swab  of  cotton  until  slight  redness 
appears.     Besides  this  the  scalp  is  washed  with  a  one- 

cent.  bichloride  solution.  After  the  stimulation 
has  become  well  marked,  the  applications  of  lactic 
acid   are    interrupted    for    a    few    days.      Boric  acid 

line  is  spread  upon  the  surface  in  the  intervals. 
The  alcoholic  solution  is  said  to  be  the  less  painful. 
Recovery  was  obtained  fifteen  times  out  of  nineteen 

is,  in  from  two  to  three  and  a  half  months.  Lan- 
ugo hairs  made  their  appearance  at  the  end  of   the 

md  week,  at  the  earliest.  McGowan  recom- 
mends tricresol  used  pure  upon  the  scalp,  and  upon 
the  face  in  a  fifty-per-cent.  solution.  He  was  led  to 
use  this  remedy  from  his  experience  with  pure  car- 
bolic acid. 
Scarification    with    subsequent    application    of    a 

•ion  of  corrosive  sublimate  1:2,000,  as  in  erysipe- 
as,  seems  to  be  a  rational  mode  of  treatment,  but 
•till  there  is  some  danger  here  of  infection  with  pus 
irganisms.  Injections  of  bichloride  1:40,  made  at 
ii'.fcrent  points,  are  recommended  by  Moty  of  Paris. 
Finsen  of  Copenhagen,  who  obtained  such  brilliant 
'csults,  especially  in  lupus  vulgaris,  with  the  applica- 
tion of  concentrated  violet  light  rays  was  successful 
n  treating  alopecia  areata  by  the  same  method. 
lesfld  who  followed  Finsen  in  his  treatment,  states 
;hat  it  cures  alopecia  areata  in  two  months,  instead 
jf  the  three  to  six  months  necessary  by  the  use  of 
older  methods. 

Brisquet  uses  oil  of  cinnamon  (Chinese)  and  sul- 
phurous ether  1:3.  He  avoids  washing  the  scalp 
!o  exclude  humidity  (after  the  hairs  have  ceased  to 
ill).  The  sulphur  preparations  are  often  of  prompt 
ind  decided  value;  e.g.  an  ointment  of  one  to  two 
hams  of  precipitated  sulphur  to  an  ounce  of  vaseline, 
rubbed  well  into  the  scalp  daily,  after  a  thorough 
washing  of  the  whole  scalp  with  soap  and  water. 

In  my  opinion,  as  already  stated,  cures  can  be 
obtained  more  quickly,  and  with  greater  certainty, 
rom  the  use  of  chrysarobin  than  by  any  other  method. 
After  the  hairs  have  ceased  to  fall  out,  some  stimulat- 


ing and  antiparasitic  application  should  be  applied 
for  a  few  months. 

Relying  upon  internal  medicine  and  hygienic 
measures  alone  I  believe  to  be  a  serious  mistake 
and  accountable  for  many  cases  of  permanent  alo- 
pecia. Such  measures  if  employed  should  invari- 
ably be  accompanied  by  a  vigorous  local  antipari  n  ic 
i  real  merit. 

Folliculitis  Decalvans. — Within  the  last  decade 
French  authors  especially  have  called  attention  to  the 

hair  follicles  being  attacked  by  some  affection  whose 
nature  still  remains  obscure.  Each  authority  in  turn 
has  considered  the  individual  disease  before  him  as  a 
new  one,  and  has  stamped  it  with  a  new  name,  so  that 
in  wading  through  their  literature,  we  meet  with  a 
formidable  array  of  names,  "the  sum  of  which  has 
brought  despair  to  every  humble  reader."10  Some 
of  these  affections  are  identical,  some  represent  only 
novel  aspects  of  well-known  diseases. 

The  following  are  a  few  of  the  titles  given:  "Follicu- 
lites et  perifolliculites  agminees  destructives  du 
follicle  pileux"  (Brocq);  "folliculite  epilante"  (Quin- 
quaud);  "folliculites  et  perifolliculites  decalvantes 
agminees  (Brocq);  "alope'cie  cicatricielle  innomineV 
(Besnier);  "acn6  decalvante"  (Besnier,  Lailler,  Rob- 
ert); "lupoid  sycosis"  (Milton,  Brocq);  "ulerythma 
sycosiforme"  (Unna). 

A  description  of  a  few  of  these  types  may  suffice. 

"  Pscudo-Pelade,"  Simple  Folliculitis  Decalvans. — 
This  affection  somewhat  resembles  alopecia  areata, 
but  on  close  inspection  a  mild  folliculitis  and  peri- 
folliculitis may  be  noticed.  There  are  rose-colored, 
inflammatory  tumefactions,  soft  to  the  touch;  the 
hairs  fall  out,  and  are  easily  plucked  out;  they  are  not 
broken;  there  is  a  marked  atrophy  in  the  older  spots; 
these  are  depressed,  shiny,  and,  unlike  those  of  alo- 
pecia areata,  hard  and  irregular,  and,  as  a  ride, 
smaller.     The  disease  spreads  in  an  irregular  manner. 

"Folliculite  Epilante"  of  Quinquaud. — This  form 
corresponds  to  the  acne  decalvante  of  Lailler  and 
Robert.  It  resembles  the  former  with  the  addition 
of  suppuration  in  the  follicles.  Besides  the  scalp,  the 
beard,  axilla;,  and  pubic  regions  may  be  involved. 
Permanent  alopecia  appears  also,  caused  by  the 
cicatricial  destruction  of  the  hair-producing  areas. 
The  bald  spots  are  round  or  irregular;  along  "their 
periphery  or  in  islands  of  healthy  hair  within  them, 
small  pustules,  perforated  with  a  hair,  are  usually 
to  be  seen."  Quinquaud  found  micrococci,  but  was 
unable  to  establish  their  causative  effect. 

"Alope'cie  cicatricielle  innominee"  of  Besnier  is 
almost  identical  with  Quinquaud's  disease.  It  is 
slightly  more  superficial,  more  chronic,  and  more 
obstinate;  the  cicatricial  changes  are  greater;  the 
margins  are  not  sharply  defined;  the  disease  spreads 
by  continuity.  Besnier  himself  considered  both 
diseases  the  same,  but  Quinquaud  stated  that  they 
are  not  identical. 

"Dermatitis  Papillaris  Capillitii." — Under  this 
name  Kaposi  has  described  a  follicular  disease  appear- 
ing at  the  junction  of  the  nape  of  the  neck  and  the 
-alp,  invading  the  latter  often  as  far  as  the  vertex. 
It  is  doubtful  whether  this  affection  is  a  clinical 
entity,  or  simply  a  variety  of  some  other  disease. 
According  to  Kaposi  it  commences  in  the  form  of  an 
isolated  papule  of  the  size  of  a  pin's  head.  These 
papules  later  on  aggregate  to  form  elevated  red 
plaques,  which  are  quite  hard  and  from  which  the 
hairs  project  in  brush-like  bunches.  The  hairs  are 
not  readily  removed;  they  break  and  are  atrophied; 
pustules  may  be  noted  in  places.  After  the  disease 
has  invaded  the  scalp  and  lasted  a  long  time,  papil- 
lomatous vegetations  are  formed,  two  to  three  centi- 
meters in  diameter,  covered  with  crusts  from  which 
oozes  a  foul-smelling  secretion.  Abscesses  may  de- 
velop also. 

Microscopical  examination  shows  an  extremely 
vascular  papillary  outgrowth,  very  much  resembling 


231 


Alopecia 


REFERENCE   HANDBOOK    OF   THE    MEDICAL   SCIENCES 


granulation  tissue.  The  disease  finally  progresses  to 
the  formation  of  connective  tissue  and  scar  tissue, 
with  the  subsequent  death  of  the  invaded  hair  fol- 
licles. Nothing  is  known  positively  as  to  its  etiology. 
It  occurs  at  all  ages  and  in  both  sexes.  It  is  undoubt- 
edly a  local  parasitic  affection. 

Diagnosis. — The  disease  would  have  to  be  differen- 
tiated from  a  papular  syphilide.  Coccogenic  sycosis 
and  eczema  do  not  show  such  a  firm  induration,  and 
their  clinical  history  is  different. 

Prognosis. — The  disease  has  no  tendency  to  spon. 
taneous  recovery,  but  it  is  usually  slow  in  its  progress- 
The  general  health  remains  unaffected.  The  lesions 
may  return  after  excision  of  the  affected  area. 

Treatment. — Mechanical  removal  of  the  growth  is 
the  only  means  of  treatment  so  far  as  we  know. 
Curetting,  excision,  and  cauterization  with  chemi- 
cal, electric,  or  actual  cautery  must  destroy  the  base 
of  the  disease  or  there  will  be  recurrences.  A*-ray 
treatment  has  given  good  results  in  my  hands. 

Ai.opeci.e  Symptomatica. — Alopecia  Toxica. — 
In  the  course  of  some  infectious  diseases  there  are 
noticed  grave  disturbances  of  nutrition  from  the 
toxins  in  the  system,  disturbances  which  also  affect 
the  growth  of  hair.  It  seems  as  if  the  toxins  them- 
selves can  produce  baldness,  when  it  occurs  during 
the  attack  of  the  infectious  disease,  as  in  alopecia 
syphilitica.  The  loss  of  hair  may  be  subsequent  to 
the  general  grave  nutrition  disturbances,  as  when  it 
appears  during  convalescence  after  typhoid  fever. 
This  form  of  alopecia  is  also  seen  in  the  cachexia; 
that  occur  with  malignant  disease,  chlorosis,  etc. 
Some  drugs  may  produce  it,  as  mercury  and  acetate 
of  thallium.  S.  Giovannini  and  others  have  observed 
general  loss  of  hair  following  the  administration  of 
doses  of  0.1  of  this  latter  remedy  given  for  the  sup- 
pression of  tuberculous  night  sweats. 

Alopecia  sypliilitica  is  perhaps  of  sufficient  interest 
to  warrant  a  short  description,  on  account  of  its  com- 
parative frequency,  its  often  very  typical  course,  and 
the  importance  of  making  a  correct  differential  diag- 
nosis. We  refer  here  only  to  that  variety  that  is 
noticed  at  the  beginning  of  the  secondary  period.  It 
may  be  complete,  all  the  hairs  of  the  scalp,  the  pubic 
region,  and  the  axilla;  disappearing,  or  the  hair  may 
fall  out  in  larger  or  smaller  patches  which  arc  usually 
symmetrical.  It  is  highly  characteristic  of  this  affec- 
tion that  it  invades  especially  the  outer  border  of  the 
scalp,  the  temporal,  parietal,  and  occipital  regions, 
and,  unlike  alopecia  pityrodes,  avoids  the  top  and 
front  of  the  head.  What  is  stated  by  Fournier  to 
be  almost  typical  of  syphilitic  alopecia  is  the  falling 
out  of  the  outer  halves  of  the  eyebrows  on  both  sides. 
Any  concomitant,  syphilitic  lesions  will  aid  in  dis- 
tinguishing it  from  alopecia  areata,  which  it  often 
resembles. 

Its  prognosis  is  good,  even  the  complete  alopecia 
yielding  to  proper  antisyphilitic  treatment.  Alo- 
pecia pityrodes,  however,  often  follows  in  its  wake. 
It  is  obvious  that  attention  must  be  paid,  to  this 
according  to  the  rules  prescribed  for  this  disease. 
The  prognosis  in  all  the  alopecia;  due  to  toxins  is 
very  favorable.  Cessante  causa,  cessat  effectus.  The 
underlying  cause  should  therefore  be  removed,  if 
possible. 

Alopecia  Dynamica  sive  Destructiva. — Loss  of 
hair  may  be  caused  by  toxins  in  connection  with 
local  destructive  processes.  It  is  then  purely  mechan- 
ical, due  to  the  loss  of  tissue  or  to  pressure  atrophy. 
This  may  occur  in  severe  or  deep  local  inflammations, 
as  in  long-continued  sycosis,  aggravated  forms  of 
acute  eczema,  erysipelas,  impetigo  contagiosa,  or  in 
inflammations  accompanied  by  ulceration  spreading 
over  the  surface,  as  in  pustular,  tubercular,  and  gum- 
matous syphilides,  lupus  vulgaris,  lepra,  the  kerion 
of  tinea  trichophytina,  and  ulcerating  neoplasmata, 
most  frequently  epithelioma.  Finally,  the  hair  fol- 
licles may  be  choked  to  death,  so  to  speak,  by  some 


chronic  inflammatory  processes  which  do  not  sup- 
purate, but  have  a  tendency  to  scar-tissue  formation 
causing  atrophy,  due  to  the  mechanical  cutting  off  of 
the  blood  supply.  Lupus  erythematosus,  sclero- 
derma, lichen  planus,  and  the  keratosis  follicularis  of 
Brocq  belong  in  this  class. 

The  prognosis  depends  upon  the  severity  of  the 
local  primary  disease.  In  most  of  them  the  "resulting 
alopecia  is  permanent.  The  treatment  is  that  of  the 
underlying  affection. 

Alopecia  Neurotica. — Traumatism  to  an  individ- 
ual nerve,  or  to  the  central  nervous  system,  as  a 
fractured  skull,  concussion  of  the  braiii,  shock,  or 
their  combinations,  may  cause  loss  of  hair — a  'loss 
which  may  be  complete,  as  in  the  three  case::  cited 
by  Michelson,  one  of  which  showed  not  even  a  single 
lanugo  hair;  this  occurred  after  a  fall,  followed  by  a 
period  of  unconsciousness  lasting  for  a  year.  It.  may 
Ik-  unilateral,  or  partially  limited  to  the  area  of  dis- 
tribution of  a  single  nerve;  in  the  latter  case  the 
resulting  bald  spot  is,  as  a  rule,  triangular. 

Fisher  observed  complete  alopecia  of  the  extremi- 
ties following  gunshot  wounds.  These  cases  wen- 
remarkable  from  the  fact  that  they  were  preceded  by  a 
decided  increase  in  hair  growth. 

The  so-called  functional  psychoses  and  neuroses. 
such  as  melancholia,  migraine  of  long  standing, 
hemiatrophy  of  the  face,  produce  discoloration 
and  falling  out  of  the  hair.  Persistent  neuralgias  di 
the  same,  but  here  the  alopecia  is  never  complete. 
There  always  remain  lanugo  hairs  in  the  affected  are 
Some  cases  that  are  looked  upon  as  examples  of  alope- 
cia areata    undoubtedly  belong  in  this  category. 

A.  R.  Robinson 

References. 

1.  Schede:   Archiv  fur  klinische  Chirurgie,  Bd.  xiv 

2.  Lassar:    Monatshefte  fur  praktische  Dennatologie,  1882,  i 

3.  Saalfeld:    Virchow's  Archiv,  vol.  clvii. 

4.  Michelson:    Zeimssen's  Handbuch  der  Hautkranken. 

5.  Schultze:    Virchow's  Archiv,  vol.  lxxx. 

6.  Sabouraud:  Annales  de  Dermatologie  et  de  Syphiligraphie, 
1S96,  i. 

7.  Bowen  and  Putnam:  Journal  of  Cutaneous  ami  Ge&ito* 
urinary  Diseases,  1S97. 

8.  Bowen:    Journal  of  Cutaneous  and  Genito-urinary   I 
1899. 

0    Jessner:    Monatshefte  fur  praktische  Dermatologie,  1900. 
10.   Robinson:      Morrow's  System  of  Genito-urinary   I 
Syphilis,  and  Dermatology. 


Alphozone. — Succinvl  peroxide,  succinic  dioxide, 
(COOH.CH2.CH,.CO),b2,  similar  in  structure  to 
hydrogen  dioxide,  the  hydrogen  atoms  being  i 
by  succinic  acid  radicles.  It  occurs  in  the  form  of  a 
white,  fluffy,  odorless,  crystalline  powder,  soluble  in 
thirty  parts  of  water.  It  is  a  powerful  oxidizing 
agent,  and  consequently  an  antiseptic  and  deodorant, 
but  does  not  effervesce  in  the  presence  of  organic 
matter.  It  is  employed  as  an  intestinal  antiseptic 
in  typhoid  fever  and  dysentery,  and  as  an  external 
application  in  the  treatment  of  ulcers  and  inflamma- 
tions of  the  mucous  membranes  of  the  nose  aid 
throat.  For  the  latter  purpose  a  solution  of  1  3,000 
to  1-1,000  is  emploved  in  the  form  of  sprav. 

T.  L.S. 

Alps. — The  extensive  and  lofty  group  of  mountains 
occupying  the  central  region  of  Europe,  in  S 
land.  Savoy,  Southern  Bavaria,  and  Western  Am  tria 
and  separating  Italy  from  the  colder  countries     h 
he  to  the  north  of  it,  presents  to  the  invalid  a 
variety  of  places  of  resort,   some  chiefly  serviceable 
during  the  summer  months,  some  during  the  winter 
season,  and  some  of  them  available  as  sanatoria  aj  all 
times  of  the  year.     The  climatic  and  other  pcculiariti 
of  this  region  are  discussed  in  the  articles  treating  of 
the    several    Alpine    resorts,    such   as   Arosa, 
Engadine.  Meran    Vevey,  etc. 


232 


RE    ERENCE    IIW'DHOOK    OF    Till:    MEDICAL   SCIENCES 


\  I in  ii  hi 


\lston,   Charles.  —  Born    in    1683    in    the    west    of 

otland.     Studied    medicine   in    Leyden,    Eolland, 

,1,-r  the   teaching  of    the    celebrated     Boerhaave. 

lring  his  stay  of  three  years  in  that  city  he  formed 

strong    friendship    with     Alexander    Monro;  and 

,  two  Mien,  upon  their  return  to  Scotland,  formed 

,.  project  of  greatly  strengthening  the  College   of 

Unburg  as  a  center  of  medical  education.     With  this 

n  view  they  secured  the  cooperation  of  Ruther- 

il,  Sinclair,  and  Plummer.     It  is  undoubtedly  true 

it    tilt'  ureal    celebrity  which  the  Edinburgh  Sell, .el 

Medicine  subsequently  attained  should  !»■  attribu- 

I  in  large  measure  to  the  efforts  made  by  these  five 

>n  and  to  the  wise  and  skilful  manner  in  which  they 

,1    the    business.      Alston    filled    t In-    chair   of 

m\     and    materia     mediea    in     the     reorganized 

and  performed  this  duty  acceptably  up  to  the 

no    of    his    death,     November,    22,     17(1(1;   but   the 

ititude  of  posterity  is  due  to  him,  not  so  much  for 

contributions  to  this  department  of  medicine,   as 

r  the  reorganization  work   to  which  reference  has 

been  made.  A.  H.  B. 


\ltcratives. — Formerly     this      term    was     applied 

a  group  of  remedies  supposed  to  exert  a  very  de- 
led action  in  removing  morbid  conditions  of  the  sys- 
tnand  promoting  the  patient's  general  well-being.  It 
,~  understood  to  mean  "remedies  which  would  rees- 
hlish  the  healthy  functions  of  the  animal  economy 
thout  producing  any  sensible  evacuation."  With 
e  advance  in  physiology  and  therapeutics  and  the 
cognition  of  the  importance  of  excretion  as  a  factor 

promoting  health,  a  new  conception  of  the  term 

and  alteratives  were  defined  as  "agents  which 

ter   the   course   of   morbid   conditions   and   modify 

le    nutritive    processes    while    promoting    waste." 

v   most  modern   therapeutists   the   term    has  been 

cted  as  meaningless,  or  at  least  too  indefinite 
i  be  tolerated  in  any  scientific  classification  of 
•UgS,  and  at  best  alteratives  may  be  defined  as 
remedies,  such  as  arsenic,  iodine,  and  mercury, 
Inch  act  in  a  way  to  correct  disordered  metabolism 
id  promote  repair."  In  addition  to  the  drugs  just 
entioned,  this  class  included  sulphur,  antimony, 
)ld,  guaiacum,  colchicum,  calcium  chloride,  and 
ater,  to  which,  were  the  class  still  recognized,  would 
■  added  thyroid  extract  and  other  organothera- 
mtic  agents.  T.  L.  S. 


Althaus,  Julius.  —  Born  in  Lippe-Detmold,  Ger- 
i  my,  on  March  31,  1833.      He  pursued  his  medical 

tidies    in    Bonn,    Goettingen,    Heidelberg,     Berlin, 

ienna,  Prague,  and  Paris,  and  finally  settled  in 
ondon  in  1857.  In  1866  he  established,  in  the 
eighborhood  of  Regent's  Park,  a  "  Hospital  for 
Ipilepsy  and  Paralysis."  His  death  occured  on  June 
I.  1900. 

Of  his  published  writings  the  following  deserve  to 
e  mentioned:  "A  Treatise  on  Medical  Electricity," 
lird  edition  in  1873;  "  Diseases  of  the  Nervous  Sys- 
•m,"  1X7!);  "On  Failure  of  Brain  Power,"  fifth  edi- 
inn  in  1S9S,  and  "The  Value  of  Electrical  Treatment," 
hird  edition  in  1S99.  A.  H.  B. 


Althasa. — Marshmallow.  "The  root  of  Althma  offi- 
inalis  L.  (fain.  Malvaceae)"  deprived  of  the  brown 
orkey  layer  and  small  roots,  and  carefully  dried  " 
l'.  S.  P.)  The  Marshmallow  is  a  tall,  perennial 
alt-marsh  herb  of  temperate  European  sea  coasts, 
t  is  also  largely  cultivated,  sometimes  for  ornament, 
nit  chiefly  for  its  root,  in  Southern  Europe.  The 
oot  of  commerce  is  from  six  inches  to  nearly  a  foot 
ong,  usually  about  half  an  inch  in  greatest  thickness, 
simple  and  regularly  tapering.  It  is  nearly  white, 
rom  the  removal   of   the  outer  bark,   and  marked 


with    several  broad    grooves    ami    numerous    small, 

brown,    slightly    elevated    spots.      It    is    more   or    less 

fuzzy  with  loan,  hair-like,  partly  detached  ba  I 
fibers.  Ii  snaps  readily,  owing  in  ii-  large  amount  of 
starchy  parenchyma,  bul  the  parts  still  cling  together 

by  their  tOUgh  bat  liber.-,.  It  ha-  a  sweetish  and 
Strongly    mucilaginous    taste.       It    i.-,    about    one-third 

gum  and  another  third  starch,  with  about  ten  per  cent. 

of  peel  in,  eight   pea'  cent .  of  SUgar,  and  one  pel-  cent,  of 

asparagin.     In  properties  are  wholly   nutritive  ami 

demulcent.      There  IS  no  pleasanter  ad.ju\  a  at  than  the 

official    Syrupus    Althoece   of   five-per-cent.    strength. 

The  leaves  and  flowers  are  also  rich  in  gum,  and 
both  are  much  used  in  domestic  practice  in  Europe 
for  poultices  and  demulcent  drinks. 

IIesry  II.   Rusby. 

Altitudes,  High. — See  Climate  and  Climatology. 

Altmann's  Granules. — These  are  granules  of  an 
acid-protein  nature  present  in  the  cells  of  nearly  all 
normal  tissues,  the  chief  exceptions  bring  the  cells  of 
unstriped  muscular  tissue,  squamous  epithelium, 
ami  the  cells  of  the  pyramidal  portion  of  the  kid- 
ney. The  granules  are  demonstrated  by  fixing  in  for- 
mol-Muller  fluid  (formalin,  2,  in  Midler's  fluid,  98)  for 
one  week,  then  staining  skin  sections  (5/<)  in  aniline 
acid  fuchsin  for  three  minutes  at  60°C,  and  differ- 
entiating with  picric  acid  alcohol  (two  minutes)  or 
ammonia  (half  a  minute).  According  to  Henry 
Beckton1,  the  absence  of  Altmann's  granules  from 
a  new-growth,  originating  in  cells  normally  con- 
taining them,  is  an  indication  of  malignancy.  On  the 
other  hand,  "  the  presence  of  Altmann's  granules  in  all 
or  nearly  all  the  essential  cells  of  a  new-growth  is 
usually  associated  with  non-malignancy  or  only  with 
malignancy  of  a  special  kind  or  limited  degree."  In 
a  tumor  the  diagnosis  of  which  lies  between  inflam- 
mation and  sarcoma  the  presence  of  Altmann's  gran- 
ules indicates  the  former,  the  absence  of  them  points 
to  sarcoma. 

1.  Eighth,  ninth,  and  tenth  reports  of  the  Cancer  Research 
Laboratories  of  Middlesex  Hospital,  1909-1911. 

Aluminum. — Aluminum  is  a  metallic  chemical 
clement,  with  symbol  Al,  and  atomic  weight  27.  It 
is  not  found  free,  but  in  contamination  (chiefly  as 
silicates).  It  is  white,  has  a  valence  of  three,  melts 
at  about  626°  C,  somewhat  resembles  tin  in  colors 
and  is  a  constituent  of  several  useful  alloys. 

General  Medicinal  Properties  of  the  Com- 
pounds of  Aluminum. — As  compared  with  the  ma- 
jority of  the  heavy  metals,  aluminum  exerts  but  an 
insignificant  constitutional  action — one  useless  in  med- 
icine, and  not  certainly  recognizable  even  in  poisoning 
by  aluminum  compounds.  All  the  evidence  there  is 
of  constitutional  action  by  this  metal  is  that,  in  toxic 
doses  of  alum,  there  have  been  observed  along  with 
the  symptoms  of  local  irritation,  tremors,  spasms, 
fainting  fits,  and,  in  severe  cases,  death,  with  dispro- 
portionately slight  local  lesions.  Locally,  aluminum 
compounds  are  astringent — the  freely  soluble,  such 
as  alum,  highly  so,  but  yet  with  less  conjoint  irritation 
than  is  usual  with  astringent  metallic  salts.  The 
main  therapeutic  use  of  aluminum  preparations  is 
for  a  local  astringent  effect,  for  which  purpose  these 
compounds  combine  potency  with  freedom  from  bad 
taste,  undue  irritation,  or  power  to  stain. 

The  Compounds  of  Aluminum  Used  in  Medi- 
cine. — These  are  the  hydroxide,  sulphate,  and  the 
aluminum  and  potassium  sulphate  (potassium  alum). 

Aluminum  Hydroxide. — Aluminum  hydroxide,  Al2 
(OH)0,  is  official  in  the  U.  S.  P.  as  Alumini  Hydrox- 
iihim.  It  is  prepared  by  precipitation,  a  boiling  hot 
aqueous  solution  of  alum  being  poured  into  a  similarly 
hot  solution  of  sodium  carbonate.  The  precipitate 
of  the  hydroxide  is  then  washed  with  hot  distilled 


233 


Aluminum 


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water,  drained,  dried,  and  pulverized.  The  product 
is  a  "  a  white,  light,  amorphous  powder,  odorless  and 
tasteless,  and  permanent  in  dry  air.  Insoluble  in 
water  or  alcohol,  but  completely  soluble  in  hydrochloric 
or  sulphuric  acid,  and  also  in  potassium  or  sodium 
hydroxide.  When  heated  to  redness  it  loses  about 
thirty-four  per  cent,  of  its  weight."  (U.  S.  P.)  This 
preparation,  from  its  insolubility,  can  exert  active  prop- 
erties only  through  chemical  conversion.  Locally 
applied,  it  operates  as  an  absorbent  powder,  develop- 
ing, possibly,  a  faint  astringency.  Its  employment 
is  almost  exclusively  German,  and  consists  in  its 
application  to  the  skin  in  inflammatory  affections. 

Aluminum  Sulphate.— The  salt,  A1,(S04)3 +  16H20. 
is  official  in  the  U.  S.  P.  asAlumini  Sulphas.  It  occurs 
as  "a  white,  crystalline  powder,  or  shining  plates,  or 
crystalline  fragments,  without  odor,  having  a  sweetish 
and  afterward  an  astringent  taste,  and  permanent 
in  the  air.  Soluble  in  1  part  of  water  at  25°  C.  (77° 
F.),  and  much  more  freely  in  boiling  water,  but  in- 
soluble in  alcohol.  When  gradually  heated  to  about 
200°  C.  (392°  F.),  it  loses  its  water  of  crystallization 
(4.3.7  per  cent,  of  its  weight).  The  aqueous  solution 
of  the  salt  has  an  acid  reaction  upon  litmus  paper." 
(U.  S.  P.)  Aluminum  sulphate  is  powerfully  astrin- 
gent, and  also  antiseptic.  Its  use  is  local  only,  as  a 
conjoint  astringent  and  detergent,  or,  in  saturated 
solution,  as  even  a  mild  caustic  in  simple  hyperplasias. 

Aluminum  and  Potassium  Sulphate. — This  double 
salt,  A1K(S0,)2  +  12H,0,  is  official  in  the  U.  S.  P 
as  Alumen,  Alum.  Alum  is  in  "large,  colorless, 
octahedral  crystals  sometimes  modified  by  cubes, 
or  in  crystalline  fragments,  without  odor,  but  having 
a  sweetish  and  strongly  astringent  taste.  Soluble 
in  nine  parts  of  water  at  25°  C.  (77°  F.),  and  in  0.3  part 
of  boiling  water;  it  is  also  freely  soluble  in  warm 
glycerin,  but  is  insoluble  in  alcohol.  When  gradually 
heated,  it  loses  water;  at  92°  C.  (197.  6°  F.)  it  fuses, 
and  if  the  heat  be  gradually  increased  to  200°  C.  (392° 
F.)  it  loses  all  its  water  of  crystallization  (4.5.5.5  per 
cent,  of  its  weight),  leaving  a  voluminous,  white 
residue.  An  aqueous  solution  of  alum  has  an  acid 
reaction  upon  litmus  paper."  (U.  S.  P.)  Alum  is 
decomposed  by  the  alkalies  and  their  carbonates, 
lime,  magnesia  and  magnesium  carbonate,  potassium 
tartrate,  and  lead  acetate.  The  salt  is  highly  astrin- 
gent, and,  internally,  in  dose  of  from  oi-ij.  (4.0-S.O) 
or  more,  is  promptly  and  efficiently  emetic,  with  little 
nausea  or  depression.  In  large  concentrated  dosage 
it  is  an  irritant  poison,  but  death  is  rare.  Alum  is 
principally  employed  locally  as  an  astringent.  For 
limited  application  to  an  accessible  part  a  smooth 
crystal  may  be  swept  over  the  surface,  but  more  com- 
monly aqueous  solutions  are  used,  ranging  in  strength 
from  one-half  of  one  per  cent,  to  three  or  four  per 
cent.,  according  to  the  sensitiveness  of  the  part.  A 
domestic  but  serviceable  form  of  application  is  alum 
curd,  made  by  boiling  alum  in  milk,  one  part  to  sixty, 
until  coagulation  ensues,  then  straining  and  applying 
the  curds  like  a  poultice,  between  layers  of  fine  linen. 
Or  the  curd  may  be  obtained  by  mixing  30  grains 
(2.0)  of  powdered  alum  with  the  white  of  an  egg. 
Alum  may  be  used  almost  universally  for  astringent 
purposes,  except  that  as  a  gargle  it  is  objectionable 
because  of  an  injurious  action  upon  the  teeth,  and  as 
a  collyrium  because  of  its  attacking  and  softening  the 
tissue  of  the  cornea  wherever  the  protective  influence 
of  the  epithelium  may  be  wanting,  as  in  case  of  abra- 
sion or  ulcer.  Internally  alum  may  be  used  as  an 
emetic  in  the  doses  stated  above,  and  has  been  held 
for  a  century — off  and  on — to  be  of  peculiar  avail 
in  lead  colic,  abating  all  the  symptoms,  even  to  break- 
ing the  tendency  to  constipation.  For  internal  as- 
tringent medication  alum  is  nowadays  comparatively 
seldom  used,  other  astringents  being  preferred.  The 
<\<y<r  of  alum  is  about  8  grains  (0.5)  in  powder,  with 
sugar  and  an  aromatic,  or  in  mixture  with  honey  or 
molasses.     Or  alum  whey  may  be  given — simply  the 

234 


whey  left  after  straining  out  the  curds  in  the  pre- 
paration described  above.  Such  whey  may  be  given 
by  the  wineglassful.  These  various  dosings  may  be 
repeated  three  or  four  times  a  day,  or,  in  lead  colic 
given  even  hourly. 

Burnt    Alum. — As   has   been  already  said  in  the 
quoted  description  of  alum,  the  salt  parts  with  water 
of  crystallization  when  heated  to  about  200°  C.     Such 
heating  of  effloresced  alum,  continued  till  the  alum 
has  been  reduced  to  a  standard  weight,  is  ordered  by 
the  U.  S.  P.,  and  the  product,  pulverized,  is  entitled 
Alumen  Exsiccatum,  Exsiccated  or  Dried  Alum,  m 
commonly  called  burnt  alum.     Dried  alum  is  "a  white 
granular  powder,  without  odor,  possessing  a  sweetish, 
astringent  taste,  and  attracting  moisture  on  exposure 
to  the  air.     It  is  very  slowly  but  completely  soluble 
in   seventeen  parts  of  water  at  25°  C.  (77°  F.),  and 
quickly  soluble  in  1.4  parts  of  boiling  water"  (U.  S.  P.). 
Dried  alum  dissolves  more  slowly  in  water  than  I 
crystalline    salt,    but   is    physiologically   much   in 
active,  for  it  is  powerfully  astringent  even  to  can 
ity,   and   its  use  is,  applied  dry,  to  cauterize  exuber 
ant  granulations  or  to  repress  hemorrhage. 

Poisoning  by  Alum. — Cases  of  poisoning  by  this 
drug  are  rare.  The  symptoms  appear  very  soon 
after  the  poison  has  been  swallowed.  There  is  severe 
pain  in  the  esophagus  and  stomach,  followed  by 
vomiting,  often  of  blood;  sanguineous  discharges  from 
the  bowels,  and  all  the  symptoms  of  a  violent  gastro- 
enteritis. The  pulse  is  small  and  frequent;  there  is 
muscular  tremor  with  great  weakness;  thirst  is  some- 
times excessive,  and  swallowing  is  difficult  and  painful; 
the  body  temperature  is  lowered.  Death  may  occur 
in  syncope.  Alkalies  and  their  carbonates  and  cal- 
cined magnesia  are  the  antidotes  for  alum.  After 
the  immediate  danger  has  passed  away,  the  gastro- 
enteric inflammation  remains  to  be  treated  on  general 
principles.  Chronic  alum  poisoning  is  manifested  by 
gastric  disturbance  and  constipation.  It  is  to  he 
treated  by  first  removing  the  cause,  and  then  com- 
bating the  effects  by  means  of  laxatives  and 
stomachics.  Edward  Cfrtis. 

R.  J.  E.  Scott. 


Alumnol. — Beta-naphtholdisulphonate  of  alum- 
inum— aluminum  naphthol  sulphonate,  Ale.  (,11- 
OH.(S03),)j.  This  is  a  white  powder  obtained 
the  action  of  sulphate  of  aluminum  on  beta-naphthol 
barium  disulphonate.  It  is  freely  soluble  in  waler 
and  glycerin,  the  solutions  having  a  bluish  flu<> 
cence  and  becoming  dark  on  exposure  to  light  ami 
air;  it  is  also  slightly  soluble  in  alcohol,  and  it  pre- 
cipitates albumin  and  gelatin,  the  precipitate  being 
soluble  in  excess  of  either.  Alkalies  cause  the  for- 
mation of  a  flocculent  precipitate  of  aluminum 
hydroxide. 

Alumnol  combines  the  astringency  of  alum  with  the 
antiseptic  power  of  naphthol.  Externally  it  may  lie 
applied  to  ulcers  and  wounds,  having  a  strong  tend- 
ency to  check  exuberant  granulations  and  to  stim- 
ulate healing.  Although  it  coagulates  albumin,  it 
does  not  form  a  slough  in  the  wound  if  spread  thinly, 
because  the  precipitate  formed  is  soluble  in  excess  of 
albumin.  For  such  local  application  it  may  be  em- 
ployed in  from  two  to  ten  per  cent,  strength,  diluted 
with  starch  or  talc.  For  abscesses  a  ten-per-cent.  solu- 
tion has  been  used  as  a  dressing.  Applied  in  one-half  to 
two-per-cent.  solution  as  a  spray  it  is  very  efficacious 
in  ordinary  catarrhal  conditions  of  the  nasal  and 
pharyngeal  mucous  membranes,  lessening  the  ci in- 
gestion and  the  edema  and  relaxation  of  the  soft 
palate  and  uvula.  For  insufflation  in  chronic  rhi- 
nitis or  laryngitis,  a  ten  to  twenty  per-cent.  snuff  with 
camphor  and  starch  may  be  used. 

In  gonorrhea'  a  solution  of  from  one-half  to  four  per- 
cent, strength  may  be  injected  into  the  urethra,  after 
the  acute  symptoms   have  subsided.     Alumnol  has 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Amar.yllldaieie 


I  n  suggested  as  an  intestinal  astringent,  but  data 

rning  its  internal  use  are  wanting. 

\V.    \.    Babtedo. 


ilum   Rock   Springs. — Santa   Clara   County,    Cali- 
I  da. 

ICCESS.      From  San  Jose  by  electric  railway  seven 

,  northeast.     San  Jose  is  a  terminal  point   and 

center  to  all  parts  of  the  Easl   and   Pacific 

i  ,st.     San  .lose  is  called  the  Garden  City  of  Cali- 

u'a. 

springs  are  located  on  the  western  slope  of  the 

si   range  in  a  romantic  canon  called   Alum  Rock 

.  M>n  Park,  the  pride  of  San  .lose.      This  is  a  canon 

r  yground    of     1,000    acres,    a    city    reservation   six 

,  t  of  the  town  in  the  Coast  .Mountains.     Here 

sixteen    mineral    springs   already    developed    and 

id   free   to   the   public.     The   nearness  of   the 

to  San  Jose1   and   the  excellent  accommoda- 

fered   at   the  hotels,   with   the  many   natural 

iges  of  climate  and  scenery,  make  the  Alum 

l    k  Springs  a  favorite  resort  for  tourists,  summer 

itors,   and   invalids.      The   summer   temperature   is 

above  90°  F.,  and  in  the  winter  it  is  never  too 

I  .■  for  comfort.     Trout  and  mountain  quail  abound, 

irding  good  sport  for  rod  and  gun. 

The  analyses  of  four  of  the  springs  are  given  below: 


Alvelos. — The  milky,  resinous  juice  of  Eupho 
heterodoxa  Miiller  (fain.  Ewphorlnaceae).  This  Bra- 
zilian product  is  employed  in  its  own  home  as  an  heroic 
application  to  "cancerous"  tumors,  which  are  there, 
for  the  most  pail,  syphilitic  ulcers.  The  drug  i-  a 
powerful  irritant,  and  sets  up  inflammatory  suppura- 
tion. Many  years  ago  an  attempt  was  made  to  intro- 
duce it  to  scientific  medicine,  but  the  allempt  was 
abandoned.  If.    II.   Rusby. 

Alypin. — Trade  name  of  the  monohydrochloride  of 
benzoyl  -  tetramethyldiamino  -ethylisopropyl  alcohol, 

(„  II  „".o..\,.llci   =  iriu.vi  ii.rr.ii  , :  ,'c,  iu  :<  K  I) 

,1   II   XiCH  ,).,11CI.      It    occurs   as   a    white    crystalline 
powder,  of  bitter  tasie,  melting  at  109°  C.  (336°+F.). 

It  is  highly  hygroscopic  and  consequently  very  freely 
soluble  in  water  and  alcohol.  Aqueous  solutions  are 
neutral  and  do  not  become  turbid  on  the  addition  of  a 
small  quantity  of  sodium  bicarbonate.  Solutions 
may  be  sterilized  by  boiling  for  a  brief  period;  if  heat 
is  continued,  however,  the  alypin  is  decomposed.  It 
has  a  strong  bitter  taste.  Because  of  its  hygroscopic 
nature,  alypin  should  be  kept  in  securely  stoppered 
vials  to  exclude  the  air.  From  2  to  4  per  cent. 
s.ilut  ions  are  stable;  weaker  ones  soon  become  mouldy. 
Alypin  is  one  of  the  many  local  anesthetics  which 
have  appeared  as  surrogates  for  cocaine.  It  is  claimed 
to  equal  cocaine  in  intensity  and  duration  of  anesthe- 


Soda  Spring. 
Grs.  per  gal. 


Blue  Sulphur 

Spring. 
Grs.  per  gal. 


White  Sulphur 

Spring. 

Grs.  per  gal. 


'  .~;i!i  Condiment.' 
Grs.  per  gal. 


a 1.21 

m  sulphate .S3 

ni  bicarbonate 10.57 

;  Hum  chloride 126.94 

:  lium  bicarbonate 267 .  12 

I  lium  sulphate 

hia  (with  spectroscope) slight  trace 

en  chloride .50 

nil  sulphate 

gnesium  carbonate 7.45 

I  ;cium  carbonate 20.82 

I  lium  .sulphate .18 

ii mi  phosphate 3.04 

n  and  alumina  (carbonates  and  phosphates) ....  .35 

acid  (with  spectroscope) well  marked  trace 

Totals !  4:i!l  ill 

ionic  arid  gas,  cubic  inches  per  gallon                          215.62 
-*■  hydrogen  sulphide  gas,  cubic  inches  per  gallon 


1.19 
3.27 


1.30 
3.03 


7.;  68 
159.45 

13.68 
slight  trace 


39 

5.00 

19.52 

.20 

1.17 

.49 

well  marked  trace 


3S.S9 
115  44 

13.77 
very  slight  trace 


.31 

7.81 

12  as 

1.03 

.97 

.29 

well  marked  trace 


3.52 
5.88 


146  67 
25    11 

116.51 
trace 


24  .  30 
1 5  45 
19.91 
-,r,  ,;'i 

.32 

.58 
,vell  marked  trace 


278.04 

174.03 

5.60 


195  S7 
98  50 
10  31 


414.64 


At  Alum  Rock  there  are  two  thermal  sulphur 
rings  which  have  a  temperature  of  S5°  F.  They 
e  used  for  bathing  purposes.  Sulphur  plunge  baths 
all  sorts  are  to  be  provided. 

The  waters  at  this  resort  have  gained  considerable 
natation  in  the  treatment  of  rheumatism,  anemia, 
ilorosis,  chronic  malaria,  nervous  prostration,  and 
•bility.  They  ought,  furthermore,  to  be  useful  in 
e  hemorrhagic  diathesis,  to  menorrhagia,  etc.,  on 
count  of  the  iron,  alum,  and  acids  which  the  waters 
mtain.  Emma  E.  Walker. 


Alum  Root. — Heuchera.  Under  this  name  the 
lizome  of  Heuchera  Americana  L.  (fam.  Saxifragacece) 

used  as  a  simple  astringent,  by  reason  of  the  four- 
•cn  per  cent,  of  tannin  which  it  contains.  It  is  a 
ooked,  tuberculate  rhizome,  five  or  six  inches  long 
id  half  an  inch  thick,  of  a  purplish  or  reddish  color, 
itbin  and  without.  The  plant  grows  abundantly  in 
le  Eastern  United  States  and  is  represented  through 
te  West  by  other  species  of  the  genus,  with  similar 
imposition  and  properties.  The  dose  is  from  one  to 
air  grams  fgr.  xv.-lx.).  Either  water  or  alcohol  will 
xtraet  its  tannin.  H.  H.  Rusby. 


sia;  that  its  use  does  not  affect  the  accommodation, 
produce  mydriasis  or  intraocular  pressure,  and  that  it 
is  less  toxic  than  cocaine.  Injections  are  followed  by 
a  transient  hyperemia. 

In  intralaryngeal  and  urethral  intervention  alypin 
seems  to  be  an  ideal  substitute  for  cocaine.  It  is  used 
externally  to  the  unbroken  skin  or  mucous  membrane, 
as  well  as  hypodermically  and  subcutaneously,  and  also 
to  induce  spinal  anesthesia.  Indications  for  its  use 
are  the  same  as  for  cocaine.  Solutions  should  be 
freshly  prepared  and  may  be  combined  with  any  one 
of  the  suprarenal  preparations.  Locally  alypin  is 
used  in  10  per  cent,  solutions;  hypodermically,  1  to 
4  per  cent.;  instillations  into  the  eye,  1  to  2  per  cent. 

Alypin  nitrate  may  be  combined  with  silver  nitrate 
when  treating  urethritis  or  cystitis  and  to  anesthetize 
the  urethra  before  the  introduction  of  instruments. 

T.  L.  S. 

Amaroids. — See  Active  Constituents  of  Plants. 

Amaryllidaceae. — The  Amaryllis  family.  A  family 
of  some  seventy  genera,  growing  chiefly  in  tropical  or 
warm  countries,  and  very  largely  cultivated  for  floral 
decoration.     Many  species,  especially  of  the  Narcis- 

235 


Amaryllidaceie 


REFERENCE    HANDBOOK    OF    THE   MEDICAL    SCIENCES 


sus  group,  are  known  to  be  poisonous.  They  are 
almost  unknown  to  medical  literature,  but  the  agave 
or  century  plant  is  an  important  source  of  fermented 
and  distilled  liquor  in  Mexico.  The  family  may  be 
expected  to  yield  important  additions  to  the  materia 
medica.  H.  H.   Rusby. 

Amaurosis. — See  Blindness. 

Amber. — Succinum.  Arribra  flava.  A  fossil  resin 
produced  by  Pinites  succinifer  Goeppert  (JPityoxylon 
sucdniferum  Kr.),  and  other  tertiary  and  long  extinct 
Coniferm.  Amber  has  been  found  from  Alaska 
westward  to  Greenland,  and  southward  in  New  Jersey 
and  Maryland,  but  our  supplies  come  chiefly  from  the 
shores  of  the  Baltic.  It  is  east  up  by  the  waves, 
fished  from  the  bottom,  and  mined  upon  the  shore 
and  under  the  edges  of  the  sea.  The  grades  that  are 
unfit  for  ornamental  purposes,  and  the  trimmings, 
are  used  medicinally. 

Amber  is  found  in  hard,  brittle  tears  and  lumps  of 
more  or  less  rounded  but  often  irregular  shape.  They 
are  usually  small,  rarel}'  exceed  a  few  grams  in  weight, 
and  vary  very  much  in  clearness  and  transparency. 
They  often  contain  coarse  impurities,  vegetable 
remains,  and  dirt.  Occasionally  entire  insects  are 
beautifully  preserved  in  them.  The  color  of  amber 
is  generally  yellow  or  brownish,  but  varies  from 
almost  white  to  nearly  black;  it  is  rarely  greenish. 
The  external  or  natural  surface  is  usually  rough  or 
irregular,  the  interior  often  beautifully  transparent. 
It  is  harder  than  most  resins,  has  no  odor  or  taste, 
breaks  with  a  conchoidal  fracture,  and  is  capable  of 
receiving  a  high  polish. 

It  is  insoluble  in  water  and  cold  alcohol,  but  may 
be  dissolved  in  boiling  alcohol,  benzol,  etc.  It  softens 
at  a  moderately  high  temperature,  but  does  not  melt 
until  29°  C,  when  it  begins  also  to  decompose. 

The  use  of  amber  itself  in  medicine  is  long  past.  It 
is  sometimes  an  ingredient  of  fumigating  powders  or 
pastilles;  directions  also  for  making  an  ethereal 
tincture  are  in  pharmaceutical  works.  The  oil  of 
amber  {Oleum  Succini)  is  an  empyreumatic  liquid, 
obtained  by  dry  distillation  and  purified  by  distilla- 
tion from  water.  The  crude  oil  is  a  thick,  dark  red, 
offensive-smelling  liquid.  The  redistilled  oil  is  a 
colorless  or  pale  yellow,  thin  liquid,  becoming  darker 
and  thicker  by  age  and  exposure  to  air;  having  an 
empyreumatic  balsamic  odor,  a  warm,  acrid  taste, 
and  a  neutral  or  faintly  acid  reaction.  Specific 
gravity  about  0.91.5.  It  is  readily  soluble  in  alcohol. 
It  is  extensively  adulterated.  Internal  dose,  0.2  to 
0.5  gram.-(ni  iij.  viij.=gtt.  v.-xv.) — it  is  said  to  be 
stimulant  and  antispasmodic.  Externally  it  is  rube- 
facient, and  is  occasionally  used  as  an  ingredient  of 
liniments.  The  residual  pitch,  "amber  resin,"  left 
after  the  distillation  of  the  oil,  is  dissolved  to  make 
a  slowly  drying,  but  very  hard  and  durable  var- 
nish. Succinic  acid  is  also  one  of  the  products  of  the 
disintegration  of  amber.  H.  H.  Rusby. 


Ambergris. — Ambrn  grisea  (gray  amber).  A  pe- 
culiar fatty  material,  found  in  lumps,  generally  on 
the  surface  of  tropical  seas,  occasionally  in  the  intes- 
tines of  the  sperm-whale,  Physeter  macrocephalus 
Shaw,  where  it  is  supposed  to  be  a  pathological 
formation.  The  balls  are  often  of  concentric  struc- 
ture, and  in  appearance  and  position  are  analogous 
to  concretions  found  in  other  animals.  Pieces  vary 
in  size  from  small  fragments  to  great  masses  of  fifty 
kilograms  or  more  in  weight.  It  is  a  waxy,  tasteless 
sulwtance,  crumbling,  but  also  softening  in  the  hand, 
having  about  the  consistency  of  some  gallstones,  its 
color  usually  grayish  or  brownish,  streaked  or  spotted 
wiih  whit-.  Odor  slight,  peculiar,  not  nauseous. 
At  the  temperature  of  boiling  water  it  melts,  and  at 
a  higher  one  is  dissipated,  leaving  but  little  residue. 


Soluble  in  alcohol,  ether,  fixed  and  essential  oils,  etc 
Ambergris  consists  to  the  extent  of  about  eighty- 
five  per  cent,  of  a  peculiar  non-saponifiable,  crystalliz- 
ahle  fat,  ambrein,  besides  small  amounts  of  extractive 
benzoic  acid,  etc. 

Ambergris  is  almost  wholly  used  in  perfumery,  but 
has  been  employed  as  an  antispasmodic  of  the 
type,  though  it  is  probably  weaker    than  that.     Its 
medical  use  is  nowadays  not  worth  serious  i  i 
In  perfumery,  like  musk,  it  has  the  property  of  holdiiic 
and  developing  the  vegetable  odors. 

The  dose  may  be  accepted  as  from  0.2.)  to  I 
gram  (gr.  iv.-xvi.).  A  tincture  would  be  a  suitabl 
preparation.  H.  H.  Risby. 


Ambidexterity. — This  is  to  be  equally  and  indif- 
ferently efficient  with  either  hand.  From  time  to 
time  ambidexterity  has  been  extolled  as  universally 
desirable;  and  some  educators  consider  that  the 
development  of  the  left  hand,  along  with  that  of 
right,  should  be  begun  with  the  entrance  of  little 
children  into  our  schools.  It  is  therefore  worthy 
discussion  in  what  manner  right-handedness  has 
become  habitual  among  ninety-six  per  cent,  of  human- 
kind; and  whether  ambidexterity  is  a  really  de- 
sirable human  qualification. 

The  lower  animals,  at  least  those  which  have  not 
been    taught    tricks,  use    their   forepaws   indiscrimi- 
nately; the  cat  strikes  at  a  fly  indifferently  with  either 
paw;  the  squirrel  manipulates  its  nuts  quite  as  indif- 
ferently.    Even  in  monkeys  and  gorillas,  which  mosl 
of  all  animals  use  the  forepaws  as  hands,  there  is  no 
preferential  use  of,  or  superior  expertness  in,  the  left 
or  the  right  hand.     But  animals  can  be  tutored  to 
one  or  the  other  paw.     The  dog  is  taught  to  shake 
hands   with    the   right   paw;    the    monkey    to   si 
manwisc,  with  the  musket  butt  at  the  right  shoulder. 
Among    microcephalic    idiots,    in    whom    the    small 
headedness    is    due    to    arrested    development,    lclt- 
handedness  or  ambidexterity  has  been  found  to  reach 
a  proportion   of  fifty  per   cent.      But   as  we  rise  in 
the   evolutionary  scale   of   normal   creatures,  and 
we  exclude  disease,  ambidexterity  progressively  gives 
way  to  single-handedness,  generally  right-handedn 
Sir'  James    Crighton-Browne    holds    that    "by 
superior   skill    of   his   right    hand    man    hath   gol 
himself  the  victory."  To  try  to  undo  his  dextral  , 
eminence  were  to  make  for  devolution. 

Glimpses  of  right-handedness  in  man  are,  it 
manifest  in  the  bronze  and  paleolithic  age-.     It  is 
evident  in  the  arts  of    the  ancients — Assyrian,  Gre- 
cian,   Egyptian.     Historic   investigation   shows   that 
all  peoples,  however  savage,  have  uniformly  used  by 
preference  not  only  one  but  the  same  hand — the  n 
It  is  said   that  some  races  to-day   manifest   either- 
handed  ness;  but  this  is  very  doubtful.     It  has  I 
said   that   the  Japanese  are  by  practice  and  bj 
ambidextrous;  but  Baron  Komura  has  given  positive 
assurance  to  the  contrar}'.     Crighton-Browne  abi 
quoted  believes  it  doubtful  whether,  "strictly  spi 
ing,  complete  ambidextry  exists  in  any  fully  di 
oped  and  civilized  human  beings,  though  so 
very  close  approximations  to  it  occur."     Most  hui 
beings,    then,    are    right-handed;    though   of    COU 
there  are  those  of  great   intellectuality   who  are  in 
more  or  less  degree  ambidextrous,   having  educated 
themselves  to  this  end.     But  these  latter  are  exc 
tional  and  by  reason  of  the  peculiar  and  special  train 
ing  they  have  subjected  themselves  to. 

The  origin  of  right-handedness  lies  much  d 
than  the  individual's  voluntary  selection  as  to  v\  hit  her 
he  will  use  his  right  hand  or  his  left,  or  whether  he  will 
be  ambidextrous.  The  reason  is  to  be  found  largely 
in  human  anatomy,  in  the  position  of  the  heart, 
and  in  the  cerebral  structure  and  organization, 
which  all  voluntary  movements  are  directed  and 
controlled.     The   heart   and    the   great   arteries  are 


236 


REFERENCE    HANDBOOK    OF    TIIF.    MEDICAL   SCIENCES 


Ambulances 


,,1,  though  in  the  primordial  organism  from 

,,.|,   thr  ran-  has  evoluted   there   was,   it   serins,  no 

.  Ii  asymmetry.     The  savage,  from  time  iminemo- 

',1   has  protected  his  heart  with  his  left,  his  shield 

/■liit  his  aggressive  motions  have  been  made  with 

,t,  his  spear  arm.  The  modern  savage,  too, 
:  iugn  he  bears  no  shield — which  would  be  useless 

modern  weapons — fires  his  musket  uniformly 

mble  sense)  from  the  right  shoulder,  sighting 
>  h  his  right  eye;  the  sword  also  is  wielded  in  the 
(hi  hand.     Such  things  are  now.  as  they  have  been 

oul   history,  absolutely  fixed  in  our  military 

.  torn. 

Hie    sec. md    important    fact    is    that    in    human 

I  ttomy  all  voluntary  movements  are  directed  and 

,   trolled  in  the  cerebral  structure  and  organization. 

I    the  brain's  two  hemispheres,  the  right    presides, 

as  of   the  decussating  nerve  fibers,  over   the 

of  the  body;  while   the    left    brain  presides 

,    r  the  right    side.      And   functional   differences   in 

sides  are  connected  with  and  contingent  upon 

ces   in   the  two  hemispheres.     The  left  brain. 

,  all  right-handed  people,  is  more  highly  developed 

ie    right   brain.     It    is   said   that    this  greater 

i   elopmenl  of  the  left  brain  in  the  right-handed  is  due 

t  the  fact  that  the  heart,  being  on  the  left  side  of  the 

nds  its  blood  with  greater  force  and  directness 

i  tii.'  left  brain;  this  is  a  fact  worthy  of  consideration 

i  .ugh  not  very  weighty,  because  the  (low  of  blood 

ise  of  the  brain  is  pretty  well  equalized  in  the 

if  Willis. 

An   important  anatomical  point   is  that  in  right- 

)  tided    people    the    speech    center    is    situated    in 

oca's  convolution,  in  the  cortex  of  the  left  frontal 

be;  while   in   left-handed  people  the  speech  center 

in  the  same  position,  but  in  the  right  frontal  lobe. 

!>W,  it  has  been  found  that  damage  to  Broca's  con- 

lution    in    the   left   hemisphere    has   deprived    the 

ht-handed  man  of  speech,  which  is  unimpaired  in 

■  left-handed  man  in  the  same  circumstances:  the 

t-handed  man  would  suffer  contrariwise,  were  the 

in  the  right  side.    The  hand  and  arm  centers 

the  brain  are  intimately  linked  in  the  cortex  witli 

e  speech  centers.     Crigliton- Browne's  inference    is 

at  the  preferential  use  of  the  right  hand  and  arm 

voluntary  movements  is  due  to  the  leading  part 

ken  by  the  left  brain.     "  We  could  not  get  rid  of 

r  right-handedness,  try  how  we  might — it  is  woven 

the  brain." 

Of  course  there  are  professions  and  trades  in  which 

ertain  amount  of  ambidexterity  is  essential.     The 

mist,  in  playing  the  fugues  of  Bach,  must  strike 

down  on  the  key  board)  almost  the  same  notes 

th  the  fingers  of  the  left  hand  as  he  does  with  those 

the  right;  and  he  has  to  hit  harder  too,  for  the  base 

il   the  piano  are  more  heavily-  wired  than  those 

the  treble.     A  certain   amount  of  ambidexterity 

tial  also  in  the  surgeon;  yet  this  gift  has  its 

-advantages   withal,    as    when   a   colleague   skilled 

this  way   admitted   that  before  doing  a  thing  he 

-i.d   appreciable  time  wondering   which  hand  to 

iploy. 

It  may  be  objected,  in  favor  of  general  training  in 
obidexterity,  that  when  a  clerk,  for  example,  lost 
3  writing  hand,  he  would  then  not  be  debarred  from 
rning  his  living.  On  those  rare  occasions  of  right- 
ind  mutilation,  however,  there  will  in  good  time 
How,  through  education  and  practice,  an  adequate 
tvelopment  of  the  right  brain,  with  a  very  fair  skill 
the  use  of  the  left  hand.  John  B.  Hubeb. 

Amblyomma. — A  genus  of  eyeless  ticks,  family 
I .  which  is  common  on  cattle,  particularly 
warm  countries.  .1.  americanum  occurs  from 
aborador  to  Florida.  It  burrows  into  the  skin 
id  mayT  cause  tumors.  Ticks  of  this  genus  are 
so  known  to  carry  germs  of  certain  infections 
iseases.     See  Arachn'ida.  A.  S.  P. 


Amboceptor. — Amboceptors  or  immune  bodies  are 
antibodies  of  I'.hrlieh's  third  order.  They  are  .!.■  .  I- 
opi'd  in  the  serum  as  one  of  the  re    till     nt  the  inject  ion 

oi  cells  of  various  kinds.    The  amboceptor  i-  belie  ed 

t..  consist  of  t  v.  o  elements,  the  ci  implement! iphilr  group 
which  combines  with  the  alexin  or  complement ,  and 
the  cytophile  group  whereby  the  immune  body  be- 
comes  attached    to    the    cell.      Amboceptors   are    al-o 

called  cytolysitis.  for  it  is  by  means  of  these  substances 
that  the  complement  is  joined  to  the  cell  body  and 
thus  permitted  to  exercise  its  lytic  effect.  It  is  evi- 
dent therefore  that  lysis  is  impossible  except  in  the 
presence  of  both  tin  mces.      The  amboceptor 

is  thermostabile.  that  is,  it  is  nol  destroyed  by  heating 
at  55°  C.  for  on.-  hour,  and  it  may  be  kept  with  but 
little  deterioration  for  long  periods  of  time.  Ambo- 
ceptor differs  from  complement  in  being  very  highly 
specific.  An  immune  body  developed  by  the  injection 
of  the  red  cells  of  a  rabbit,  for  instance,  will  not  unite 
with  the  red  cells  of  any  other  animal.  The  comple- 
ment of  normal  serum,  on  the  other  hand,  will  activate 
many  different  amboceptors.  These  antibodies  appear 
in  the  serum  usually  within  from  five  to  ten  days  after 
experimental  or  accidental  infection,  and  form  one  of 
the  strongest  defences  that  the  body  is  able  to  present 
against  an  infection.  Almost  all  animal  cells  are  able 
to  stimulate  the  body  to  the  production  of  ambocep- 
tors. In  some  instances  experimenters  have  been  able, 
by  the  injection  of  amboceptor,  to  stimulate  the  pro- 
duction of  antiamboceptor,  but  the  results  have  not 
been  constant  and  there  is  still  some  doubt  as  to  the 
accuracy  of  this  explanation  of  the  results  obtained. 

The  chief  importance  of  the  immune  bodies  is  the 
part  they  play  in  the  recovery  of  an  animal  from  an 
infection,  but  they  can  also  be  employed  in  the  diagno- 
sis of  disease  and  in  the  identification  of  unknown 
organisms.  An  immune  serum  should  cause  lysis  of 
the  bacteria  which  have  acted  the  part  of  antigen  if 
sufficient  complement  is  present.  Therefore  if  either 
the  bacterium  or  the  serum  is  known,  the  other  can 
be  identified.  For  a  discussion  of  the  relation  of  the 
amboceptor  to  the  general  subject  of  immunity  the 
reader  is  referred  to  the  article  on  Immunity. 

Ralph  G.   Stillmax. 


Ambulances. — An  ambulance  is  a  vehicle  specially 
designed  for  the  transportation  of  sick  or  wounded. 
It  owes  its  origin  and  general  characteristics  to  the 
needs  of  civilized  warfare.  The  growth  of  humane 
practices  in  the  wars  of  the  eighteenth  century  pro- 
duced an  increasing  demand  for  some  method  of  carry- 
ing wounded  both  effective  and  merciful,  and  the 
French  wars  following  the  Revolution  of  17;S9  brought 
the  ambulance  service  along  with  all  their  other 
military  innovations. 

An  organized  system  for  the  transportation  of 
wounded  was  first  introduced  by  Baron  Larrey,  the 
French  military  surgeon,  in  the  Army  of  the  Rhine 
in  1792.  Only  slight  improvement  upon  his  system 
was  made  during  the  wars  of  the  first  half  of  the  nine- 
teenth century,  and  it  was  not  until  the  latter  part 
of  the  Civil  War  that  the  ambulance  obtained  proper 
recognition  and  development  in  the  introduction  of  a 
uniform  system  by  act  of  Congress  in  March.  iv.  1. 

The  need  for  civil  ambulances,  though  increasingly 
felt,  was,  of  course,  in  these  earlier  day-  less  urgent, 
but  shortly  after  the  close  of  the  war  a  modified  sys- 
tem adapted  for  use  in  cities  was  recognized  to  be  an 
important  requirement  of  a  well-organized  hospital 
system;  its  adoption  was  repeatedly  discussed  in 
several  of  the  hospitals  of  New  York  City,  and  in 
December,  1S69,  the  first  service  was  established  by 
the  Commissioners  of  Charities  and  Corrections  in 
Bellevue  Hospital.  Though  crude  and  limited  at 
first,  the  Bellevue  service  was  rapidly  improved  and 
extended,  and  was  soon  copied  by  the  other  hospitals 
of  New  York. 


237 


Ambulances 


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Important  modifications  in  the  army  type  were,  of 
course,  required  in  the  adaptation  of  the  ambulance  to 
civil  hospital  work.  The  necessary  changes  were  ap- 
parent and  were  quickly  made;  the  civil  could  be 
lighter,  and  therefore  faster,  than  the  army  vehicle 
on  account  of  better  thoroughfares;  it  would  not  be 
required  to  carry  so  many  people,  but  for  use  in  nar- 
row and  crowded  streets  it  must  be  able  to  turn  in 
the  arc  of  a  small  circle.  Since  the  differentiation 
in  the  types  of  the  two  wagons  in  the  more  funda- 
mental particulars  referred  to,  the  evolution  of  the 
civil  ambulance  has  been  along  lines  chiefly  of  mechan- 
ical construction,  and  the  very  great  substitution 
of  mechanical  for  horse  power  since  the  introduction 
of  motor  vehicles.  The  type  of  horse  drawn  vehicle 
has  remained  essentially  the  same,  but  the  restric- 


service  is  the  most  elaborate  and  enterprising,  and  will 
probably  remain  as  the  standard  for  this  country. 

The  eagerness  of  foreign  medical  authorities  to 
accept  American  innovations  effecting  improved  con- 
ditions of  service,  especially  of  a  mechanical  character 
has  never  been  marked,  and,  in  the  case  of  the  am- 
bulance system,  has  amounted  almost  to  disin- 
clination. For  one  thing,  the  foreigner  does  not  feel 
the  constantly  expressed  desire  of  the  American  for 
rapidity  of  transit  of  all  kinds.  The  hurry  call  f„r 
fire  and  for  accident  relief  does  not  seem  to  him  bo 
urgent,  and  the  ambulance  is  not  to  be  found  in  his 
medical  traditions.  On  the  continent,  ambulances 
fur  the  transportation  of  the  injured  have  i„ 
until  very  recently  an  unknown  quantity.  Tl. 
of  caring  for  the  injured  was  and  is  in  many  cities 


Fig.  SI. — Horse  Ambulance. 


tions  on  weight  being  largely  removed,  the  motor 
ambulances  are,  as  a  rule,  much  larger,  more  comfor- 
table and  better  protected  from  the  weather. 

The  advantages  of  an  ambulance  system  com- 
mended themselves  to  the  hospital  authorities  of 
every  city  of  consequence  in  the  United  States,  and 
ambulances  were  introduced  as  fast  as  means  per- 
mitted or  the  conditions  of  each  case  required.  The 
New  York  system  has  remained  the  most  extensive  and 
elaborate.  In  many  of  the  smaller  American  cities 
where  the  number  of  hospitals  is  small,  ambulances 
are  few  and  are  used  chiefly  for  sick  cases;  their 
emergency  use  is  restricted  to  a  small  area  surround- 
ing the  hospital.  Accident  cases  in  other  parts  of  the 
city  are  attended  to  by  the  police  patrol,  which 
still  performs  in  a  rudimentary  way  the  functions  of 
an  ambulance  service  proper.  It  is  not  so  easy  to 
understand  why  this  use  of  patrols  should  survive, 
as  it  does,  in  many  large  cities,  although  there  are 
unquestionably  abuses  of  the  ambulance  system 
(hereafter  touched  upon)  which  are  avoided  when 
the  duty  is  performed  by  the  police.     The  New  York 

238 


carried  on  by  voluntary  societies  established  for  the 
purpose  which  maintained  small  stations  in  dif- 
ferent parts  of  a  city  where  stretchers,  splints,  an'1. 
paraphernalia  for  first  aid  to  the  injured  could  be 
found.  Delivery  wagons  requisitioned  for  the  exigency 
and  police  patrol  wagons  were  used  to  convej  thi 
injured  to  hospitals.  The  ambulances,  and  they  were 
often  of  a  very  primitive  kind,  were  used  only  for  the 
transportation  of  the  sick.  Within  recent  yea 
ever,  there  has  been  a  marked  change  of  attitude  ail 
ambulances  are  now  to  be  found  in  almost  all  *>f  the 
large  cities  of  Europe.  They  are  still  chiefly  for  the 
transportation  of  the  sick,  but  are  being  used  more 
and  more  for  accident  cases.  They  are  admirably 
constructed  and  equipped.  A  trained  attendant,  nol 
a  medical  man,  is  carried.  The  conception  of  the 
duty  of  the  hospital  differs  in  Europe  and  America 
The  European  hospital  considers  it  sufficient  to  pi 
vide  proper  transportation,  the  American  hi 
considers  it  necessary  to  provide  skilled  treatment  as 

Automobile    ambulances    here    and    abroad   have 


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Vliililll.ini   <     . 


ijgely  taken  the  place  of  horse  drawn  ambulances, 

It  have  not  entirely  displaced  them.     Automobiles 

I  vc  not  yet  reached  such  a  state  of  perfection  that 

i  v  are  absolutely  reliable,  especially  during  inclem- 

i     winter   weather   with   streets    blocked    with    ice 

:  I   snow.      The    number   of   horse   ambulances   Still 

',  ployed  is,  therefore,  large. 

liicyele  ambulances  have  been  tried  in  some  places 

i   li  but  little  success. 

\ll  horse  ambulanees  are  so  nearly  alike  that  one 

,  description  will  coverall  their  salient  features. 

;  ,.  enclosed   body   of   the   vehicle  is  from   eight  to 

ie  feet   long  and  from  three  to  three  and  one-half 

I  I  wide.      As  lightness  is  an  important  element,  it  is 

!  ill  of  as  light  material  as  is  compatible  with  thorough 

ength.      The  roof  is  supported  by  uprights,  a  hood 

i.  ding  over  the  driver's  seat,  and  only  a  short 

i.incc  is  boarded  in  on  the  sides,  the  front  and  rear 

ug  open.     In  cold  or  stormy  weather  all  but  the 


circumstances  or  the  conditions  of  the  streets  require. 

The  average  weight,  of  such  a  vehicle  is  from  twelve 
hundred    to    fourteen    hundred    pounds.      The    wheels 

are  made  with  solid  rubber  I  ires,  which  are  as  satis- 
factory and  far  more  durable  than  the  pneumatic 
tires  that  were  in  vogue  for  a  short  time.  A  large 
foot  gong  in  front  of  the  dashboard,  or  under  it,  can 
be  operated  by  the  driver. 

The  most  satisfactory  situation  for  the  stable  is 
within  the  limits  of  the  hospital,  but  in  a  separate 
building.  By  this  adjustment  the  inevitable  noise 
and  odor  are  minimized,  and  the  ambulance  is  still 
within  close  call.  The  interior  arrangement  of  I  he 
stable  need  not  differ  from  that,  of  any  private  one. 
There  should  be  one  more  horse  than  the  number  of 
ambulances  in  service,  in  case  of  accident  or  disease 
and  to  meet  any  emergency.  One  stall  is  kept  for 
the  horse  on  call,  where  he  stands  with  his  bridle  in 
place,    only    the   bit   requiring   to   be   inserted.     The 


Fig.  S2. — Ambulance  Showing  Movable  Bed. 


ar  can  be  closed  in  by  leather  or  rubber  curtains, 
ie  patient  lies  on  a  movable  bed  covered  with  leather, 
id  this  runs  on  a  track,  and  is  so  held  by  inverted 
imps  that  it  will  still  remain  horizontal  when  drawn 
it  to  its  full  length.  A  stretcher  lies  on  this  bed. 
lie  surgeon  sits  at  the  rear  on  a  transverse  seat, 
-a  over  the  tail-piece,  so  arranged  that  it  can  by 
ised  perpendicularly  and  clasped  out  of  the  way 
lien  the  tail-piece  is  let  down  for  the  entrance  or 
cit  of  the  patient.  A  step  behind  assists  the  sur- 
-on  to  his  seat,  and  there  are  straps  to  which  he 
ay-hold.  Under  the  driver's  seat,  in  front,  is  room 
ir  splints  and  other  appliances,  and  the  longer 
ilints  are  suspended  by  straps  from  the  roof.  A 
ntern  is  clamped  inside,  and  two  red  lights  on  the 
de  indicate  to  other  drivers  the  ambulance's  right 

way.  The  fore  wheels  can  be  cramped  under  the 
ire  part  of  the  vehicle,  which  can  thus  turn  in  the 
lortest  possible  space.     Usually  drawn  by  one  horse, 

may  of  course  be  changed  to  a  double  rig  whenever 


harness  is  patterned  after  that  used  by  fire  depart- 
ments, and  hangs  suspended  over  the  shafts  ready  to 
be  lowered;  then  the  collar  is  clasped,  one  or  two 
straps  are  buckled,  and  in  a  moment  or  two  the 
trained  horse  is  under  way.  Calls  are  sent  to  the 
stable  from  the  office  by  telephone  or  gong.  There 
must  be  one  more  ambulance  than  the  number  run- 
ning, in  order  that  repairs  required  by  accidents  and 
wear  and  tear  may  be  made  without  a  disabling  of 
the  service.  So,  also,  an  extra  man  is  needed  to  take 
care  of  the  stable,  horses,  and  ambulances,  and  to  act 
as  a  relief  driver  and  stable  watchman.  His  extra 
time  may  be  employed  in  the  doing  of  other  necessary 
work  around  the  institution. 

A  conventional  assortment  of  medical  and  surgical 
instruments,  appliances,  and  supplies  is  always  kept 
in  each  ambulance,  and  others  are  carried  by  the 
surgeon  in  a  hand  satchel.  Among  the  former  are 
the  long  thigh  and  body  splints  that  are  suspended 
under  the  roof,  and  the  shorter  splints  that  are  kept 

239 


Ambulances 


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under  the  driver's  seat,  together  with  one  or  two 
pairs  of  handcuffs.  In  an  iron  rack,  in  the  enclosed 
part,  just  back  of  the  driver's  seat,  is  kept  an  assort- 
ment of  bandages  and  cotton,  and  in  other  racks 
variously  situated  are  found  stomach  pump,  antidotes 
for  poisons,  bottles  of  carron  oil,  etc.  In  the  satchel 
the  surgeon  carries  sterilized  dressings  and  band- 
ages, the  ordinary  instruments  of  a  pocket  surgical 
set,  catheters,  hypodermic  syringes  and  needles, 
cardiac  stimulants,  tourniquets,  and  chloroform. 
This  enumeration  includes  the  standard  articles 
carried,  and  hospitals  differ  as  to  the  selection  only 
in  minor  details. 

The  cost  of  a  horse  ambulance  complete  with 
rubber  tires,  etc.,  varies  between  $550  and  $700.  The 
cost  of  equipping  an  entire  service  must  include  the 
stable  with  its  furnishings,  horses,  harness,   and  am- 


and  gasoline  ones  are  now  in  active  operation  ir 
all  of  the  cities  of  this  country.  As  indicated  abov< 
they  are  larger  and  of  more  solid  construction  thai 
the  horse  ambulances.  The  sides  are  of  wood  01 
wood  and  glass  and  they  frequently  are  closed  behint 
by  a  door.  The}'  are  generally  lighted  by  electricity 
Their  increased  size,  sufficient  to  accommodate  twi 
patients  in  an  emergency,  allows  of  many  minoi 
conveniences  and  greater  comfort,  although  thi 
tial  features  are  the  same  as  those  of  the  horsi 
lance.  Electric  ambulances  have  the  advantage  tha 
solid  rubber  tires  may  be  used  and  the  unpleasant  dela-\ 
incident  to  a  punctured  tire  is  avoided.  On  theothei 
hand,  the  speed  of  these  is  much  less  and  tin  v  la, 
the  power  to  drive  them  through  snow  which  wouli 
not  prevent  the  passage  of  a  gasoline  ambulance 
But  no  hospital,  until   motor  vehicles  have  reachei 


Fig.  83. — Electric  Automobile  Ambulance. 


bulance,  and  demands  a  large  initial  outlay.  The 
expense  of  maintenance,  however,  is  less  than  would 
appear  at  first  glance,  and  becomes  proportionately 
cheaper  as  the  number  of  ambulances  is  increased. 
Items  to  be  considered  are:  Running  repairs  on 
ambulances  (annually  about  $50  to  $100  each),  feed 
and  shoeing  of  horses,  wages  of  men  and  their  board 
and  incidentals,  cost  of  medical  and  surgical  equip- 
ment, etc.  In  New  York  the  annual  expense,  com- 
Euted  from  the  figures  of  a  number  of  different 
ospitals,  of  running  an  ambulance  service  on  the 
basis  of  two  ambulances  constantly  in  use  and  one 
for  extreme  emergencies,  is  between  $2, 100  and  $3,000. 
In  other  localities  the  cost  varies  with  price  of  feed 
and  of  wages. 

The  first  automobile  ambulance  was  put  in  opera- 
tion in  New  York  in  1900.  It  was  at  once  so  success- 
ful that  others  were  rapidly  introduced.    Both  electric 

240 


a  greater  state  of  perfection,  could  be  sure  of  maintain- 
ing  an   uninterrupted   service   throughout   the  yeai 
without  a  horse  ambulance  for  use  in  an  emergency, 
especially   in   the   north    where   winters   are   seven-. 
Besides  its   speed  and   size   the  advantages  of  the 
motor  ambulance  are  that  it  requires  less  room,  it 
does  away  with  the  noise  and  odors  of  a  I 
stable,  it  is  always  ready,  no  harnessing  is  nee 
and  it  is  less  expensive   when  in  actual   operation. 
The  disadvantages  are  the  great  initial  cost   and  the 
expensive   repairs,    that   more  skilled  and   thi 
more   expensive  labor  is   required,    and  that   meter 
vehicles  alone  cannot  entirely  be  relied  upon.     Motor 
ambulances  cost   between  $3,000  and  $5,000.      I 
cost  for  repairs  and  for  tires  cannot  with  any  accuracy 
be  predicted. 

Before  the  general  introduction  of  telephone 
were  usually  sent  to  hospitals  in  New  York  City  bj 


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Ambulances 


■  tinging  of  a  gong,  as  is  now  done  by  the  Fire 
partment.     It    was  also  customary  at    one  time 

;  an  ambulance  to  go  to  every  fire  call.  Since 
ephones  have  become  so  universal  tliey  alone  are 
ierally  used.     The  ambulance  work  is  under  the 

'  iervision  of  the  Police  Department,  and  every  call 

[theoretically  supposed  to  be  sent  by  an  officer, 
ictically,  however,  every  reasonable  <  ■;  1 1 1  suit  by 

;  civilian  is  answered.  The  Fire  Department 
iomes  an  element  in  falling  ambulances  only  when 
re  is  a  large  fire  with  much  loss  of  life.  In  .such 
e    following   the  alarm   of  fire   which   is  rung   in 

:  niisl  all  hospitals  having  an  ambulance  service, 
all  of  three  fours  is  rung  to  summon  all  available 
ibulances  in  the  city;   immediate  response  is  made 

i  the  call 


service';  the  police  system  is  undoubtedly  more 
economical.  In  some-  cities  public  hospitals  do  all 
i  Ih>  accident  work,  the  private  hospitals  running  am- 
bulances only  for  sick  cases.  Sometimes  then-  are 
ambulance  stables  distributed  about  t  hi'  city  \\  il  In  nit 
trained  surgical  attendants;  these  carry  patients 
directly  to  the  nearest  public  hospital;  in  other  cases 
all  calls  are  sent  in  to  the  hospital.  The  value  of 
prompt  transportation  without  skilful  assistance  on 
the  one  hand  offsets  the  intelligent  skill  coupled  with 
delay  on  t  he  Ot  her. 

The  most  perfect   but   most   extravagant  method  is 

the  establishment  of  an  ambulance  service  in  private  as 

well  as  in  public  hospitals,  and  the  assignment  to  each 
hospital  of  a  limited  area  so  that,  all  parts  of  a  city 
can  be  rapidly  covered  by  intelligent  workers.     This 


■aiiiaiias^ 


■af^ 


Fig.  S-t. — Automobile  Ambulance. 


Cities  differ  considerably  in  the  way  in  which  their 
cidenl  service  is  done.  Sick  cases  are  everywhere 
nulled  in  much  the  same  way;  patients  who  are  too 
or  too  poor  to  be  taken  in  carriages  are  conveyed 
'  ambulances.  The  accident  work  in  certain  cities 
done  entirely  by  po'ice  patrols.  This  system  has 
me  peculiar  advantages;  it  is  not  imposed  on 
norantly  by  civilians,  or  wilfully  abused  by  the 
■lice  themselves;  slight  scalp  wounds  received  by 
Irunk  and  disorderly"  unfortunates  do  not  so  often 
fiipy  the  time  of  a  hospital  staff,  and  cases  of  pre- 
nded  illness  are  more  carefully  investigated,  to  the 
lief  of  the  temper  of  the  hospital  authorities,  while 
ills  in  outlying  sections  far  from  a  hospital  can  be 
iswered  more  readily  and  promptly.  On  the  other 
ind,  the  patients  are  not  handled  so  carefully  or  so 
.ilfuhy,  and  ignorance  does  in  exceptional  cases  pro- 
loe  very  serious  consequences.  On  the  balance  of 
lvantage,   the  individual  benefits  by   the  hospital 

Vol.  I.— 16 


entails  much  expense  on  private  institutions,  which 
may  even  be  laboring  under  financial  difficulties,  but  is 
another  refinement  in  the  method  in  which  many  of 
our  cities  look  after  the  welfare  of  their  inhabitants. 
This  is  the  case  in  the  city  of  New  York,  where  the 
Board  of  Charities  divides  the  city  into  districts  and 
allots  to  each  district  a  certain  number  of  police 
precincts.  The  districts  are  so  divided  as  each  to  con- 
tain a  hospital  maintaining  an  ambulance  service, 
and  the  jurisdiction  of  each  hospital  within  the 
limits  of  its  own  district  is  complete. 

In  all  cities  cases  of  contagious  disease  are  trans- 
ferred to  reception  and  contagious  hospitals;  this  is 
generally  done  by  special  vehicles,  old  city  ambu- 
lances  altered   into    closed   vehicles. 

There  are  in  many  of  the  cities  ambulances  operated 
by  private  individuals  for  the  purpose  of  transferring 
patients  in  as  inconspicuous  a  way  as  possible;  these 
are  built  to  represent  an  ordinary  vehicle  externally, 

241 


Ambulances 


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with  a  stretcher  arrangement  within  like  that  of  the 
usual  ambulance.  The  varieties  are  numerous,  and 
that  one  is  best  which  least  attracts  attention. 

That  ambulance  services  are  imposed  upon  there 
can  be  no  doubt;  unfortunately  there  seems  to  be  no 
remedy  for  the  evil.  The  imposition  is  sometimes 
effected  through  ignorance,  sometimes  through  design. 
The  convenient  and  efficient  practice  of  calling  ambu- 
lances by  telephone  increases  the  opportunity  for 
mischief.  To  the  hysterical  layman  every  attack  of 
syncope  means  apoplexy,  and  every  abrasion  of  the 
scalp  a  fractured  skull.  When  these  or  kindred 
things  come  to  his  attention,  he  immediately  sends 
in  a  "hurry  call"  by  the  nearest   telephone,   often 


Fig.  So. — Interior  of  an  Automobile  Ambulance,  with  bed  drawn 
out  to  receive  a  patient. 

without  the  knowledge  or  desire  of  the  patient; 
when  it  is  answered  with  all  possible  speed,  the 
surgeon  finds  that  the  patient  has  gone  home  or 
refuses  treatment.  By  ambulances,  also,  ready 
means  is  afforded  to  the  policeman  to  dispose  of  his 
obstreperous  and  slightly  battered  alcoholic  charges, 
and  when  no  evidence  of  injury  is  apparent  the  sur- 
geon is  solemnly  told  that  the  patient  was  comatose 
when  the  call  was  sent.  A  hospital  that  does  not 
leave  anything  to  the  discretion  of  the  surgeon,  but 
insists  on  all  cases  being  brought  in,  unless  the  pa- 
tient refuses,  of  course  suffers  most  in  this  way.  No 
remedy  that  will  throw  out  all  improper  calls  and 
answer  all  the  worthy  ones  can  be  devised,  and,  as  in 
the  fire  service,  much  time  and  money  are  sacrificed 
in  order  that  no  single  case  requiring  attention  shall 
be  neglected. 

The  position  of  ambulance  surgeon  is  usually  filled 
by  internes  or  by  physicians  specially  appointed  for 
the  purpose,  or  by  students  nearing  the  completion 
of  their  medical  school  course.  There  can  be  no 
doubt  of  the  inadvisability  of  allowing  medical  stu- 
dents to  occupy  so  important  a  position.  Most  cases 
require  simple  treatment,  but  exceptional  circum- 
stances arise,  and  one  untrained  to  meet  them  is 
little   better   than   a   layman.     Such    training   as   a 


service  requires  can  be  readily  and  thoroughly 
acquired  in  an  emergency  ward,  under  competent 
supervision,  and  as  either  of  the  first  two  methods 
brings  every  benefit  to  the  patient,  the  choice  must 
fall  upon  the  one  which  better  meets  the  requirements 
of  the  service  without  affecting  the  administration  of 
the  hospital  as  a  whole.  A  very  active  ambulance 
service  is  too  much  of  a  drain  upon  the  strength  of  a 
man  busy  with  additional  work;  on  the  other  hand 
such  a  service  is  but  a  slight  inducement  to  a  capable 
man,  unless,  as  is  seldom  the  case,  it  offers  chance  of 
future  advancement.  The  question  is  open,  and  is 
decided  in  each  case  by  existing  conditions. 

John  Howland. 

Ameba. — See  Amoeba. 


Amelie=les=Bains. — These  baths,  situated  in  the 
extreme  southwestern  part  of  France,  in  the  district 
of  the  Pyrenees,  are  said  to  be  "  the  best  baths  in 
Europe  where  rheumatism  can  be  safely  treated  in 
winter."  _  The  village  of  Am^lie-les-Bains,  situated 
in  the  midst  of  pine  trees,  has  a  population  of  a!- 
1.200,  and  is  twenty-three  hours  by  rail  from 
Paris. 

The  winter  climate  is  dry,  clear,  and  mild,  and 
possesses  some  of  the  characteristics  of  a  mount 
atmosphere.  The  average  number  of  sunny  d 
during  the  three  winter  months  is  sixty-two;  cloudy, 
seventeen;  and  rainy,  eleven.  (C.  B.  Black.  "South 
of  France,"  1905.)  The  mean  temperature  of  Jan- 
uary is  45°  F. ;  of  February,  47°  F.;  and  of  March, 
53°  F.  "  During  the  day,  in  the  sun,  the  temperature 
rises  considerably  above  these  figures,  but  during  the 
night  and  morning,  especially  in  January,  it  falls  con- 
siderably below  them. 

Amelie  is  sheltered  for  the  most  part  from  the  ci 
northwest  wind  which  sweeps  over  the  plain  of 
Roussillon.  The  summer  is  hot,  but  the  autumn  i 
cool,  and  the  air  possesses  the  tonic  quality  of  thai 
of  the  mountains  and  is  not  so  relaxing  as  that  atPau. 
The  scenery  is  very  attractive  and  there  are  many 
pleasant  walks  with  fine  views.  The  river  Tech  runs 
through  the  town,  on  the  left  side  of  which  is  the 
sunny  and  sheltered  promenade  called  the  "Petite 
Provence,"  a  favorite  winter  walk. 

The  springs  are  of  the  class  of  the  hot  sulphuron- 
waters  similar  to  those  of  Aix-les-Bains;  they  contain 
the  carbonate,  sulphate,  chloride,  and  silicate  of 
sodium  with  a  trace  of  carbonate  of  iron  and  calcium 
and  free  nitrogen.  The  temperature  is  from  90°  to 
148°  F. 

As  with  other  warm  sulphur  springs,  these  wat>  -• 
are  of  value  in  chronic  rheumatism  in  its  various 
forms;  chronic  catarrhal  affections  of  the  respiratory 
organs;  glandular  tuberculosis;  neuralgia;  chronic 
skin  diseases,  such  as  eczema,  prurigo;  syphilis; 
uterine  diseases,  and  certain  bladder  and  kidney 
affections.  As  has  been  before  noted,  AmeUie  is 
said  to  be  the  best  station  in  Europe  with  hot  sulphur 
springs,  which,  on  account  of  its  mild  climate,  can 
be  utilized  in  winter. 

In  the  higher  part  of  the  village  near  the  springs 
are  the  two  hotels  with  baths:  the  hotel  Them 
Romains,  which  is  warmed  by  the  hot  water  of  the 
springs;  and  the  hotel  Thermes-Pujade,  a  part  of 
which  is  warmed  by  the  vapor  of  the  springs  over 
which  it  is  located.  In  each  case  one  does  not  have 
to  go  out  of  the  hotel  for  the  baths.  Both  hotels  are 
in  grounds  of  their  own,  and  have  sheltered  walks. 
Various  kinds  of  baths  are  given  similar  to  those  at 
other  spas.     The  water  is  also  used  for  drinking. 

Not   far   from  Am6lie-les-  Bains  are  various  othi  r 
thermal  sulphur  water  spas:  Preste-les- Bains;  \  ernet- 
les-Balns;  Ax-les-Thermes,  which  is  said  to  K 
largest    supply    of    thermal    sulphurous    waters   in 
Europe;  and  others.  Edward  0.  Otis. 


242 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Amenorrhea 


\menorrhea.  By  amenorrhea  ia  meant  a  sus- 
osion  or  cessation  of  the  menstrual  function  in  a 
, I, ,an  who  is  not  pregnant  and  who  has  not  reached 
e  "change  of  life,    or  the  period  at  which  menstrua- 

■  n  naturally  erases.  The  term  should  not  be  em- 
,ved    to    include    eases   in   which    menstrual    blood 

slides    from    the    uterine    mucous    membrane 
r  from  that   of  the  oviducts,  since  we  accept   the 
ictrine   that   the  Fallopian   tubes   take   part   in   the 
i.-t  ion),  but  is  prevented  from  making  its  appearance 
illy   by   some   malformation,   such   as   an   im- 
rforate  hymen.     It  should  be  borne  in  mind  that 
i  hea  is  not  in  itself  a  disease,  but  simply  a  re- 
It  of  some   morbid   condition   affecting  either   the 
at  large  or  some  part  of  the  genital  apparatus. 
igical  amenorrhea  is  that  which  exists  prior  to 
iberty,  during  a  normal   period  of  gestation,   and 
equent  to  the  establishment  of  the  menopause. 
Causes. — There  is  scarcely  any  derangement  of  the 
neral  health,  especially  if  of  a  serious  nature  and 
in  its  course,  that  is  not  prone  to  prove  at 
ist  the  predisposing  cause  of  amenorrhea.      Usually, 
T,   these  deviations  from  health    affect  either 
e  function  of  hematosis,  the  general  nutrition  of  the 

■  iy,  or  the  normal  action  of  the  nervous  system,  and 

o,  or  all  three,  of  these  disturbances  may  be 
unbined.  Moreover,  it  may  be  said  that  defective 
■ -mitosis  is  itself  a  nutritive  disorder,  and  that  all 
regularities  of  nutrition  may  take  their  origin  in 
I  nervous  action.  All  this  is  true,  but  the 
actical  utility  of  these  distinctions  remains  doubtful, 

rertheless.  Of  the  particular  diseases  that  give 
se  to  amenorrhea,  the  most  noticeable  are  pulmonary 
iberculosis  and  chlorosis.  In  both  instances,  the 
ispension  of  menstruation  seems  to  be  a  conserva- 
ve  effort  on  the  part  of  nature  to  spare  the  system 
cry  unnecessary  tax,  and  this  consideration  alone 
ight  to  be  enough  to  teach  us  that  it  is  not  the 

istablishment  of  the  menstrual  flow  that  we  should 
m  at,  but  rather  the  restoration  of  the  general 
lalth. 

It  has  been  doubted  by  good  observers  whether  it  is 
'^ible  for  a  woman  in  perfect  health  to  suffer  from 
aenorrhea,  and  there  is  much  to  sustain  this  position; 
H  it  is  certain,  nevertheless,  that  in  many  cases  the 
ipairment  of  the  general  health  goes  on  for  a  long 
^riod  without  producing  amenorrhea,  until,  finally, 
une  additional  factor  comes  into  play,  and  may 
uly  be  looked  upon  as  the  exciting  cause  of  the 
isorder.  Among  these  exciting  causes  we  may 
•ckon  almost  all  pelvic  diseases,  the  functional 
■rturbation  consequent  on  exposure  to  cold  during  a 
icnstrual  period,  emotional  shocks,  and  traumatic 
ijuries. 

Amenorrhea  may  be  an  indication  of  imperfect 
evelopment  of  the  internal  generative  organs.     This 

not  infrequently  the  cause  of  late  appearance  of 
liberty,  at  eighteen  to  twenty  years  of  age,  the 
terus  being  a  small  infantile  organ.  Of  course, 
ingenital  absence  of  the  organs  of  generation  will  be 
ccompanied  by  complete  amenorrhea  and  even  by 
n  absence  of  the  menstrual  molimina.  A  curious 
irm  of  temporary  amenorrhea,  undoubtedly  hemat- 
genous  in  nature,  is  that  noted  in  young  immigrants 
ito  a  country.  For  from  six  months  to  a  year  or  more 
'iere  may  frequently  be  noted  in  these  young  girls  a 
>>tal  suppression  of  menstruation,  without  any  of 
lie  symptoms  of  anemia  or  chlorosis.  Certain  mental 
iseases,  especially  those  of  the  melancholic  type, 
■  ill  be  attended  by  varying  periods  of  menstrual 
impression;  and  certain  of  the  neuroses  (chorea 
aajor,  epilepsy)  show  the  same  peculiarity.  A 
arge  uterine  tumor  (fibroma  or  myoma),  while 
;enerally  causing  menstrual  anomalies  in  the  form  of 
lysmenorrhea,  monorrhagia,  and  metrorrhagia,  may 
iccasionally  cause  complete  amenorrhea,  and  in 
uch  cases  the  diagnosis  from  pregnancy  becomes 
xceedingly   difficult  or  even  impossible  until  after 


the  normal  duration  of  gestation  has  passed.  Ovar- 
ian cystomata,  on  the  contrary,  an-  not  infrequently 
accompanied  by  absence  of  menstruation  probably 
because  of  the  anemia  which  is  present  in  these  eases 
in  their  advanced  stage. 

Doubt    has   been   east    upon    the   doctrine    that   the 

menstrual  function  is  dominated  by  the  ovaries,  but 

it  cannot  be  said  that  the  doctrine  lias  been  over- 
thrown, and  we  have,  therefore,  to  distinguish,  for 
purposes  both  of  diagnosis  and  of  prognosis,  between 
amenorrhea  which  is  and  thai  which  is  not  due  to 
failure  on  the  part  of  the  ovaries.  In  other  word  . 
concerning  ourselves  only  with  the  mechanism,  and 
leaving  ultimate  causes  out  of  account  for  the  t  inn- 
being,  we  have  to  distinguish  between  uterine  and 
ovarian  amenorrhea.  Practically,  the  only  guide  we 
have  to  a  failure  of  that  ovarian  action  which  should 
serve  to  stimulate  the  menstrual  flow,  is  the  absence 
of  the  menstrual  molimen — the  ensemble  of  symp- 
toms usually  attendant  upon  the  flow,  including  a 
sense  of  weight  and  pain  in  the  pelvis,  and  in  some 
eases  pain,  tenderness,  and  swelling  of  the  breasts, 
with  or  without  the  various  reflex  disturbances  that 
sometimes  attend  the  menstrual  effort. 

The  uterine  variety  is  to  be  recognized  by  the  state 
of  the  uterus,  which  will  commonly  be  found  to  be 
one  of  atrophy  (including  the  so-called  " superinvolu- 
tion")  or  of  impeded  circulation  due  to  the  contraction 
of  old  inflammatory  exudates. 

Diagnosis. — Amenorrhea,  as  it  is  here  defined, 
requires  to  be  diagnosed  only  from  retention  of  the 
menses  and  from  the  physiological  suspension  due 
to  pregnancy.  The  diagnosis  will  necessarily  rest 
upon  a  physical  examination,  and  for  the  details  the 
reader  is  referred  to  the  articles  on  Pregnancy  and  on 
Menses,  Retention  of. 

Prognosis. — The  question  of  our  ability  to  restore 
the  menstrual  function  is  to  be  answered  wholly  in  the 
light  of  the  causes  on  which  its  suspension  is  found  to 
depend.  Grave  constitutional  diseases,  such  as  pul- 
monary tuberculosis,  render  the  treatment  in  that 
direction  not  very  promising,  while  the  cure  of  any  less 
serious  fundamental  disorder  may^  on  the  other  hand, 
be  reasonably  expected  to  be  followed  by  the  re- 
establishment  of  menstruation.  As  regards  the 
local  conditions,  atrophy  of  the  uterus  and  functional 
inactivity  of  the  ovaries  must  give  rise  to  an  un- 
favorable prognosis,  although  temporary  benefit 
may  be  produced  by  treatment  in  some  instances. 
The  prospect  is  better  in  the  case  of  old  inflammatory 
disease  within  the  pelvis,  for  such  affections  are  often 
amenable  to  treatment.  In  general,  the  causes  will 
be  found  to  be  remediable,  and,  therefore,  the 
prognosis  favorable. 

Treatment. — The  patient  should  be  made  to 
understand,  at  the  outset,  that  her  courses  will  come 
on  when  her  health  has  been  reestablished,  provided 
no  obvious  anatomical  defect  exists,  which  can  be 
determined  only  by  a  careful  physical  exploration. 

Another  caution  needs  to  be  given.  Women  who 
know  or  suspect  themselves  to  be  pregnant,  fre- 
quently consult  a  physician  in  the  hope  that,  in  the 
attempt  to  bring  on  menstruation,  he  will  really 
succeed  in  causing  abortion.  Whoever,  under  such 
circumstances,  prescribes  any  measure,  no  matter 
how  innocent,  with  the  understood  purpose  of  in- 
ducing the  menstrual  flow,  is  liable  to  have  un- 
pleasant charges  brought  against  him  in  case  abortion 
actually  does  take  place,  even  as  the  result  of  some 
interference  with  which  he  had  no  connection. 
When  called  upon  to  undertake  the  treatment  of  a 
case  of  suppressed  menstruation,  it  is  prudent, 
therefore,  for  the  physician  to  satisfy  himself  that 
pregnancy  does  not  exist,  and,  in  case  of  doubt,  to 
decline  the  management  of  the  case  unless  he  can 
protect  himself  in  some  way,  as  by  insisting  that 
some  trustworthy  person  be  made  acquainted  with 
the  facts  at  the  start. 


243 


Amenorrhea 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


Having  undertaken  the  management  of  a  case  in 
which  treatment  is  sought  for  on  account  of  amenor- 
rhea, the  physician  should  make  a  systematic  in- 
quiry into  the  patient's  state  of  health,  and  whatever 
deviation  from  the  normal  standard  is  found  should 
be  made  the  subject  of  treatment.  For  the  details  of 
such  treatment,  the  reader  is  referred  to  the  articles 
devoted  to  the  various  diseases  that  may  be  found. 
But,  while  insisting  upon  the  general  futility  of 
measures  addressed  to  the  organs  concerned  in  the 
menstrual  function,  without  first  attending  to  the 
general  health,  it  must  be  admitted,  nevertheless, 
that  in  a  very  limited  number  of  cases  stimulation  of 
those  organs  may  be  resorted  to  with  some  chance  of 
success  when  no  other  indication  can  be  made  out; 
and.  moreover,  that,  in  cases  in  which  there  are  other 
indications  at  first,  there  often  comes  a  time  when  the 
result  aimed  at  may  be  hastened  by  measures  that 
operate  directly  upon  the  pelvic  organs. 

There  are  but  few  therapeutic  procedures  that 
have  a  direct  and  unequivocal  influence  upon  the 
function  of  menstruation,  and,  in  so  far  as  they  tend 
to  relieve  amenorrhea,  those  few  act  as  local  stimu- 
lants. The  so-called  emmenagogues  are  not  much  to 
be  depended  upon,  although  we  may  admit  that 
aloetics  and  chalybeates  tend  to  produce  a  pelvic 
congestion  favorable  to  heightened  functional  ac- 
tivity of  the  sexual  organs.  Tins  is  also  true  of  sink 
remedies  as  apiolin  and  oxalic  acid,  which  in  suitable 
cases  and  in  suitable  doses  will  cause  sufficient 
pelvic  congestion  to  establish  the  menstrual  flow. 
Their  use,  however,  in  the  absence  of  other  indications 
than  the  mere  failure  of  the  menstrual  flow,  is  not  to  be 
recommended,  although,  if  employed  in  conformity 
with  such  indications,  they  undoubtedly  exert  a 
certain  influence. 

The  preparations  of  manganese  have  been  recom- 
mended by  Ringer  and  Murrell.  One-grain  pills  of 
potassium  permanganate  may  be  administered,  be- 
ginning with  one  pill  three  times  a  clay,  and  increasing 
to  two  four  times  a  clay.  The  use  of  the  drug  should 
be  begun  three  or  four  days  before,  the  time  at  which  a 
menstruation  should  take  place,  and  be  continued,  if 
the  flow  does  not  come  on,  until  the  time  for  the  next 
period.  It  should  be  kept  up  also  during  the  flow. 
Both  sodium  manganate  and  manganese  binoxide  are 
said  to  be  equally  effective,  and  it  is  stated  that 
manganese  acts  as  well  with  the  plethoric  as  with  the 
anemic.  The  manganese  treatment  has  not,  on  the 
whole,  justified  the  expectations  with  which  its  em- 
ployment was  begun.  Oxalic  acid  in  doses  of  one- 
eighth  to  one-quarter  of  a  grain  three  times  daily,  com- 
bined with  lemon  juice  or  citric  acid,  may  be  tried 
advantageously  in  certain  cases. 

There  are  several  other  drugs  that  have  more  or  less 
repute  in  the  treatment  of  amenorrhea.  Among 
them  is  apiol  or  apiolin,  which  is  said  to  act  best  in 
cases  in  which  whatever  flow  there  may  be  is  ill- 
smelling.  From  eight  to  ten  minims  should  be 
given  daily  during  the  week  preceding  the  day  for 
menstruation  to  begin,  and  fifteen  minims  on  the 
morning  of  that  day.  Cimicifuga  has  been  thought 
serviceable  in  cases  of  delayed  or  arrested  menstrua- 
tion. Senecio  vulgaris  has  been  recommended  in 
cases  unaccompanied  by  pelvic  lesions.  In  the  ovar- 
ian variety  of  amenorrhea,  a  preparation  made  from 
the  expressed  juice  of  the  fresh  ovaries  of  healthy 
young  animals,  has  been  used  with  success.  Aloes 
undoubtedly  aids  the  action  of  the  other  so-called 
emmenagogues,  and  should  be  employed  if  there  is 
constipation. 

Electricity  was  formerly  used  more  frequently  as  a 
provocative  of  menstruation  than  any  other  agent. 
Good  effects  were  thought  to  have  been  produced  by 
either  the  galvanic  or  the  induced  current.  The  use 
of  electricity  for  this  purpose  has,  however,  largely 
fallen  into  disfavor.  If  used  at  all,  galvanism  is  more 
to  be  relied  on  for  increasing  the  blood-supply  of  the 

244 


uterus,  while  faradization  may  be  useful  to  intensify 
and  precipitate  the  hemorrhagic  effort.  To  ac- 
complish the  latter  purpose,  the  application  ou^ht  to 
be  made  at  a  time  when  the  degenerative  changes  in 
the  endometrium  have  advanced  to  such  a  degree 
that  heightened  blood-pressure,  aided  by  muscular 
action,  may  operate  at  the  greatest  advantage 
producing  rupture  of  tin'  capillaries.  This  condition 
can  be  judged  to  be  present  only  when  there  are 
symptoms  of  ovulation,  or  when  the  amenorrhea  is  ,,f 
such  recent  date  that  the  time  for  a  menstrual  Bom 
to  fall  due  is  accurately  known.  In  the 
galvanism,  it  will  generally  be  prudent  to  place  both 
electrodes  on  the  external  surface,  unless  the  current 
is  quite  weak  and  the  sitting  a  short  one;  aiming 
however,  to  pass  the  current  directly  through  the 
uterus.  When  the  faradic  current  is' employed,  or 
the  other  hand,  one  electrode  should  be  applied 
within  the  vagina,  or  even  within  the  canal  of  the 
cervix. 

Milder  measures  than  the  use  of  electricity  will 
often  succeed,  especially  when  there  is  not"  com- 
plete absence  of  the  flow,  but  scantiness  and  lack  of 
color  of  the  discharge.  Among  these  measures, 
refrigeration  of  that  portion  of  the  spinal  region  cor- 
responding to  the  motor  center  of  the  uterus  is  of  greal 
value.  The  skin  over  the  junction  of  the  dorsal  with 
the  lumbar  vertebras  may  be  sprayed  with  ether 
but  not  frozen,  three  or  four  times  a  day,  for  five 
minutes  at  a  time,  or  ice-water  compresses  may  be 
applied.  These  means  are  supposed  to  exert  their 
effect  by  depressing  the  activity  of  the  vasomotor 
nerves.  They  are  to  be  used  only  at  the  time  when  a 
menstrual  flow  is  due.  In  the  interim,  an  auxiliary 
measure  of  some  value  consists  in  the  use  of  a  very 
brief  cold  hip-bath  every  night. 

W.  A.  Newman  Dokla.nd. 


American  Medical  Association. — The  American 
Medical  Association  owes  its  existence  largely  to  a 
widespread  demand  which  had  prevailed  in  the  British 
Colonies  of  North  America  long  before  the  Revolution- 
ary War  for  a  uniform  and  withal  a  more  thorough 
education,  for  those  intending  to  practise   medii 

The    first    clinical    lecturer    on    medicine    in    this 
country  seems  to  have  been  Dr.  Thomas  Bond,  who 
gave  instruction  to    medical    students    in  the   first 
permanent    hospital  in  North    America,  which 
opened  in  Philadelphia  in   1752.     This   led    to   the 
establishment  of  the  Medical  Department  of  the  Uni- 
versity of  Pennsylvania  which   opened   its   doors   to 
students  in  1765.     Seventeen  years  later  thi 
medical  school  in  the  United  States  was  establisl 
in  connection  with  Harvard  University.     These  v. 
the  only  permanent  medical  schools   in   this  country 
that    were   in    operation    prior    to    1800.     This   was 
nearly  200  years  after  the  settlement  of  the  country. 
When,  however,  the  great  distances,  the  limited  re- 
sources of   the   people,    the  sparse  settlements,  and 
the   difficulties  of   transportation  in  America  before 
the  Revolution  are  considered,  there  is  little  wonder 
perhaps  at,  the  slow  development  of  American  medical 
schools. 

In  1760,  the  General  Assembly  of  New  York,  and 
in  1772,  the  governing  body  of  the  Colony  of  .V. 
Jersey,  had  "passed  measures  for  restricting  medical 
practice  by  requiring  an  examination  in  'physick 
surgery."'  In  1S27,  the  Medical  Society  of 'the  State 
of  Vermont  issued  an  invitation  to  the  medical  socie- 
ties and  ''Institutions,"  of  the  States  of  Maine,  \< 
Hampshire,  Vermont,  Massachusetts,  Rhode  Island, 
Connecticut,  and  New  York,  to  a  conference  which 
was  held  at  Northampton,  Mass.,  June  21,  1827. 
The  object  of  the  convention  was  solely  the  improve- 
ment and  standardization  of  medical  education  in  the 
United  States.  A  set  of  regulations  was  adopted, 
requiring  a  four  years'  course  of  study  for  the  degree 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


American  Medical 

Association 


doctor  of  medicine,  as  well  as  a  good  preliminary 

nation,  evidence  of  good  moral  character  and  the 
tainmenl  of  the  age  of  twenty-one  years  by  the 
iplicanl  for  the  degree. 

[,,  the  following  year  (1828)  the  Medical  Society  of 

e  stai<'  of  New  York,  recommended  "  the  calling  of 

National  Convention  to  consist  of  a  delegate  from 

tlir   regular  medical   colleges  ami   the   State 

societies    to   meet     in    Philadelphia    for    tin' 

of    suggesting    a   more   uniform   system    of 

■ilical  education  than  now  prevails." 

movements  seem  to  have  accomplished  little, 
cept    to    direct    attention    to    the    unsatisfactory 
itus  of  medical  education  in  America  in  the  early 
rt  of  the  nineteenth  century.     The  United  States 
■re   growing    fast    in    wealth    and    population    and 
1830  and  1S45,  the  number  of  medical  colleges 
lan  doubled.     These  institutions  wore  without 
y  supervision  and  had  full  power  to  confer  the  de- 
doctor  of  medicine,   and  inasmuch  as  many 
,  had  been  started  with  insufficient  equipment 
d  with  little  or  no  endowment,   the  eagerness   to 
indents  was  extreme,   and   the   tendency   to 
lie   courses  of  study   leading  to  the   doctor's 
<-  short   and  easy  as  possible,  seemed  to  be 
lie.     The  annual  courses  of  lectures  had  been 
ly   shortened  to  sixteen  weeks  and  in  some 
,s,  to  thirteen.     Two  of  these  courses,  without  any 
or  laboratory  advantages,  and  a  year  or  two 
more  or  less  nominal  study  with  a  preceptor,  were 
teemed  sufficient  to  qualify  a  student  to  receive  the 
•  degree  and  to  practise  medicine  anywhere  in 
United  States. 
In  1835,  the  .Medical  College  of  Georgia  proposed 
call  a  convention  of  delegates  from  all  the  medical 
lieges  of  the   Union   to   take   these   matters  under 
ration.     In   1S39,   the  Medical  Society  of  the 
ate  of  New  York   took  the   matter  up  again  at   its 
mual  meeting.     After  a  full  discussion  of  the  question 
medical  education  in  the  United  States,  a  resolu- 

-  passed  by  a  large  majority  of  those  present, 
daring  that  "the  business  of  teaching  should  be 
parated  as  far  as  possible,  from  the  privilege  of 
anting  diplomas."  An  invitation  was  sent  to  all 
e  medical  societies  and  medical  colleges  in  the 
untry  to  send  delegates  to  a  convention  to  be  held 

Philadelphia  in  1S40.  This  movement,  however, 
d  not  elicit  enough  enthusiasm  to  bring  about  the 
■sired  result,  and  the  matter  was  dropped  temporar- 
-.  But  the  subject  would  not  down,  and  was  again 
ought  up  in  the  medical  society  of  the  State  of 
r\v  York  in  1S44,  and  was  vigorously  pushed  by 
athan  Smith  Davis,  a  young  practitioner  and  a  new 
to  the  State  Society  from  Broome  County, 

-  made  chairman  of  a  committee  to  investigate 
e  entire  question  and  report  upon  it  at  the  next  an- 
uil  meeting.  This  committee  having  communicated 
ith  practically  every  county  medical  society  in  the 
ate  of  New  York,  had  aroused  much  interest  in  the 

i  of  medical  education  by  the  time  of  the  next 
inual  meeting  of  the  Society,  when,  after  an  arduous 

bate,  it  was  determined  to  call  a  national  conven- 

iq  in  New  York  City  in  May,  1846.  The  medical 
'ess  quite   generally   lent   its   aid   in   pushing    this 

oject  and  Dr.  Ticknor,  the  President  of  the  Medical 
iciety  of  the  State  of  Connecticut,  proposed  that 
te  convention  should  organize  itself  into  a  National 
1  dical  Society.  The  idea  of  a  permanent  national 
■  ii-ty  was  enthusiastically  embraced  by  Dr.  Davis, 
ho  exploited  it  freely  in  the  medical  press. 

The  delegates  met  in  the  hall  of  the  Medical  De- 

I  of  the  University  of  New  York  on  May  5, 

^16.     Of    119   delegates   appointed  by    the   various 

icieties  and   medical  schools   throughout    the 

nion,  about  100  were  present,  and  took  part  in  the 

liberations.  They  represented  sixteen  of  the 
tales  of  the  Union,  an  especially  large  delegation 
-'ing  present  from  the  societies  and  medical  schools 


"i  Philadelphia.     The  following  propositions  wen-  laid 
before  the  convention: 

"  1.    That   it   is  expedient   for  the  medical  profession 

of  the  United  States  to  institute  a  National  Medical 
Association. 

"2.  That  it  is  desirable  that  a  uniform  and  elevated 
standard  of  requirements  for  the  degree  of  Doctor  of 
Medicine  should  be  adopted  by  all  the  medical  schools 
in  the  United  States. 

"3.  That  it  is  desirable  that  young  men,  before 
being  received  as  students  of  medicine,  should  have 
acquired  a  suitable  preliminary  education. 

"  1.  That  it  is  expedient  that  the  medical  profession 
in  the  United  States  should  be  governed  by  the  same 
code  "f  ethics." 

Each  of  these  propositions  was  referred  to  a  com- 
mittee of  seven,  with  instructions  to  report  at  a  con- 
vention to  be  held  in  the  City  of  Philadelphia  in  May, 
1847.  A  committee  was  appointed  to  invite  every 
regularly  organized  medical  society  and  chartered 
medical  school  in  the  United  States  "to  send  delegates 
to  the  Philadelphia  meeting.  A  resolution  was 
adopted  setting  forth  that  "  the  union  of  the  business 
of  teaching  and  licensing  in  the  same  hands  is  wrong 
in  principle,  and  liable  to  great  abuse  in  practice";  and 
recommending  that  "all  licenses  to  practise  medicine 
should  be  conferred  by  a  single  board  of  medical 
examiners  in  each  State."  This  also  was  referred  to  a 
committee  to  be  reported  upon  at  the  meeting  in 
Philadelphia.  Committees  were  also  appointed  to 
report  at  the  same  time  and  place,  upon  the  best 
method  of  securing  registration  of  births,  marriages, 
and  deaths  throughout  the  United  States,  and  upon 
the  adoption  of  a  proper  and  uniform  nomenclature 
of  diseases  and  causes  of  death. 

In  Ma}',  1S47,  the  convention  met  in  Philadelphia. 
There  were  present  about  250  delegates,  representing 
not  less  than  forty  medical  societies  and  twenty- 
eight  medical  colleges,  which  were  the  organized  medi- 
cal institutions  of  twenty-two  of  the  twenty-six 
States  of  the  American  Union.  The  reports  of  the 
various  committees  appointed  at  the  previous  meet- 
ing were  read  and  after  careful  consideration,  were,  in 
the  main,  adopted.  The  convention  resolved  itself 
into  the  American  Medical  Association,  adopted  a 
constitution  and  by-laws  and  a  code  of  ethics,  and 
adjourned  to  meet  in  Baltimore  the  following  year. 
The  large  share  which  the  Medical  Society  of  the  State 
of  New  York  took  in  initiating  and  carrying  out  the 
work  that  had  resulted  in  the  formation  of  this 
Association  shows  that  the  Empire  State  was  the  cradle 
of  the  movement. 

Membership. — The  plan  of  organization  provided 
that  "members  of  the  American  Medical  Association, 
should  be  either  delegates  from  local  institutions 
i  State,  or  county,  or  town  medical  societies,  medical 
colleges  and  hospitals,  lunatic  asylums,  and  other 
permanently  organized  medical  institutions,  in  good 
standing"),  or  members  by  invitation,  or  permanent 
members.  Thus  there  were  created  three  classes  of 
members,  of  which  the  delegates  constituted  the  bulk, 
and  the  most  important  part. 

Each  delegate  was  appointed  for  one  year.  The 
basis  of  representation  was  one  delegate  for  every  ten 
regular  resident  members  of  every  regularly  organized 
medical  society.  Two  delegates  for  even-  regularly 
constituted  and  chartered  school  of  medicine,  two  for 
every  hospital  containing  100  beds  or  more,  and  one 
for  all  permanently  organized  medical  institutions  of 
good  standing,  not  included  in  the  above  summary. 
In  order  to  admit  of  representations  from  portions  of 
the  United  States  not  otherwise  represented,  provision 
was  made  for  members  by  invitation.  If  a  physician 
from  a  section  of  the  country  in  which  no  medical 
institution  of  any  sort  existed,  attended  an  annual 
session,  the  association  could  elect  him  a  member  by 
invitation  for  that  session  only.  He  thus  became  an 
unofficial  delegate  for  a  section  of  the  country  that 


245 


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Association 


REFERENCE    HANDBOOK    OF   THE   MEDICAL   SCIENCES 


would  otherwise  have  been  without  representation. 
Any  member  belonging  to  one  of  these  two  classes,  after 
his  appointed  service,  and  such  other  persons  as  the 
association  might  select  by  unanimous  vote,  might 
be  made  permanent  members.  These  were  entitled 
to  attend  the  meetings  and  to  participate  in  the  busi- 
ness of  the   association,  but  had  no  right  to    vote. 

In  1850,  at  the  third  annual  session  of  the  associa- 
tion, a  resolution  was  offered  that  members  by  invi- 
tation should  become  such  only  after  a  committee  had 
passed  upon  their  eligibility.  In  the  following  year 
(1S51)  a  minority  report  from  the  committee  on 
amendments  to  the  constitution,  allowing  the  per- 
manent members  to  vote,  was  defeated  by  a  large 
majority. 

Thus  it  can  be  seen  that  from  its  earliest  history, 
the  association  established  the  principle  which  has 
been  adhered  to  up  to  the  present  time,  that  it  is 
essentially  a  representative  body  exercising  powers 
delegated  to  it  by  State  and  county  medical  socii  i  ies 
and  medical  institutions  distributed  over  the  entire 
country. 

No  further  change  of  any  importance  was  made  in 
the  matter  of  membership  in  the  American  Medical 
Association,  until  the  session  of  1S69  at  New  Orleans, 
at  which  an  amendment  was  adopted  that  a  continu- 
ous membership  in  a  county  or  State  society,  where 
one  existed,  was  essential  for  membership  in  the 
National  Association;  and  that  without  a  continuous 
membership  in  such  local  or  State  society,  no  one 
could  retain  his  membership  in  the  American  Medical 
Association.     This  applied  to  all  classes  of  members. 

In  1874,  at  the  twenty-fifth  annual  session  at 
Detroit,  a  provision  was  adopted  limiting  the  dele- 
gates to  those  selected  from  the  members  of  per- 
manently organized  State  societies,  and  such  county 
and  district  medical  societies  as  were  duly  represented 
in  their  State  societies,  and  from  the  medical  de- 
partments of  the  Army  and  Navy  of  the  United 
States.  The  United  States  Marine-Hospital  Service 
was  subsequently  admitted  to  the  same  representation 
as  that  of  the  Army  and  Navy. 

In  1881,  a  fourth  class  of  members  was  provided 
for,  viz.,  "members  by  application."  It  was  voted 
that  members  of  State  or  county  societies,  certified  to 
be  in  good  standing  by  the  president  and  secretary  of 
such  a  society,  might  become  members  of  the  Ameri- 
can Medical  Association  "by  application."  They 
were  entitled  to  attend  the  annual  sessions,  and  to 
receive  the  journal  of  the  association,  but  had  no 
right  to  vote.  These  provisions  regarding  member- 
ship remained  in  force  until  the  reorganization  in 
1901,  when  the  only  societies  recognized  as  having 
the  right  to  send  delegates  (i.e.  to  be  represented  in 
the  newly  formed  House  of  Delegates)  were  the  State 
societies. 

Primarily  only  delegates  could  become  members, 
and  up  to  the  time  of  the  proposed  establishment  of 
the  Journal  (1881)  the  only  means  of  becoming  a 
member  was  to  attend  an  annual  session  of  the  Ameri- 
can Medical  Association,  either  as  a  delegate,  or  a 
member  by  invitation. 

Membership  by  application  was  devised  to  allow 
members  of  county  and  State  societies  to  become 
members  of  the  American  Medical  Association  (and 
to  receive  the  Journal)  without  attendance  upon  an 
annual  session  of  the  Association,  and  without 
having  been  elected  delegates  to  such  a  session. 

The  basis  of  representation  was  changed  from  one 
delegate  to  ten  members  of  a  constituent  society,  to 
one  delegate  to  every  500  members  of  a  State  society. 
At  the  former  rate  there  would  have  been  6,000 
delegates  at  the  annual  meeting  in  1901;  since  the 
constituent  State  societies  contained  an  aggregate 
of  60,000  members,  or  about  half  of  the  entire  num- 
ber of  physicians  in  the  country  at   that   time. 

The  House  of  Delegates  is  now  limited  by  the 
titution    to    150    members,    of   which    seventeen 


represent  the  sections  of  the  Association  and  the 
public  services.  When  the  membership  in  the  State 
societies  shall  have  increased  so  that  the  aggregate  of 
delegates  shall  exceed  150,  on  the  present  basis  of  rep- 
resentation, this  will  be  raised,  so  that  the  total  num- 
ber of  delegates  shall  not  at  any  time  exceed  the 
present  total. 

At  the  second  meeting  of  the  Association  in  Balti- 
more in  1848,  the  registration  was  266,  representing 
societies  and  medical  institutions  in  twenty-one 
States  and  the  District  of  Columbia.  The  Presidi 
Dr.  Nathaniel  Chapman  of  Pennsylvania,  decline 
election  and  advocated  the  plan  of  rotation  in  office, 
a  rule  which  so  far  as  the  office  of  president  and  th.i-i- 
of  the  vice-presidents  are  concerned,  has  been  rigidly 
adhered  to  ever  since. 

The  scientific  and  literary  work  of  the  Association 
was  presented  in  the  form  of  reports  of  the  com- 
mittees which  had  been  appointed  for  this  purpose  at 
the  original  meeting.  To  the  report  of  the  conim 
on  surgery  were  appended  three  papers  on  anest 
agents  in  surgical  practice.  These  papers  led  to  an 
interesting  discussion  in  which  Dr.  J.  C.  Warren  of 
Boston,  Professor  of  Surgery  in  the  Harvard  Univer- 
sity Medical  School,  who  had  but  recently  performed 
the  first  major  surgical  operation  in  the  world  upon  a 
patient  who  had  been  rendered  insensible  by  the  in- 
halation of  ether,  took  an  active  part.  Dr.  Olivet 
Wendell  Holmes,  Professor  of  Anatomy  in  the  Harvard 
Medical  School,  presented  the  report  on  Medical 
Literature,  and  Dr.  Alexander  H.  Stevens  of  Ne 
York,  the  newly  elected  President,  and  also  at  that 
time  President  of  the  College  of  Physicians  and 
Surgeons  of  New  York,  presented  the  report  on 
Medical  Education. 

Dr.  Holmes  criticized  with  severity  the  rather  un- 
satisfactory character  of  the  current  medical  litera- 
ture and  exhorted  the  members  of  the  Association 
to  produce  original  medical  brochures  and  text-books, 
instead  of  contenting  themselves  with  editing  thos 
foreign  authorship. 

A  communication  was  received  from  the  medical 
department  of  the  National  Institute  in  referent 
the  sanitary  condition  of  the  United  States,  stating 
that  they  had  appointed  a  committee  to  take 
matter  up  and  urging  the  cooperation  of  the  Associa- 
tion. This  request  was  acceded  to  and  a  cooperating 
committee  appointed.  Dr.  T.  O.  Edwards,  then  a 
member  of  Congress  from  Ohio,  presented  a  memorial 
to  the  Association  relating  to  the  adulteration  of 
imported  drugs,  and  urging  Congress  to  take  action  to 
prevent  this,  and  to  require  an  inspection  of  all  im- 
ported drugs  and  medicines.  Another  report  was 
presented  demanding  a  careful  study  and  report  upon 
the  medicinal  properties  of  all  the  indigenous  plants  in 
the  United  State*.  Committees  were  appointed  to 
visit  the  British  and  Provincial  Medical  and  Surgical 
Associations. 

Considering  all  that  had  been  accomplished  in  the 
first  year  of  its  existence,  the  remarks  of  its  president 
on  taking  the  chair,  do  not  seem  extravagant.  II 
expressed  the  hope  that  the  Association  might  "ex- 
hibit in  a  new  form  to  our  brethren  in  Europe,  the 
easy  adaptation  of  our  institutions  to  the  great  eni 
promoting  the  happiness  of  mankind." 

The  State  Societies  and  the  Medical  Colleges. — During 
the  period  intervening  between  the  sitting  of  the  con- 
vention in  Philadelphia  and  the  next  annual  meeting 
in    Baltimore    (1846-47),   new   State    societies    ' 
organized  in  South  Carolina,  Alabama,  and  Pennsyl- 
vania  and     the   already   existing    State   societie 
Georgia,  Mississippi,  Tennessee,  Ohio,  and   Wisconsin 
were  aroused  to  renewed  vigor  and  efficiency.     In  all 
of  these  societies  and  in  others  in  the  New 
and  Middle  States,  resolutions  were  adopted  appro' 
the    proceedings  of   the    National    Convention,  es 
cially   those  relating  to  medical  education, 
ommendation  that  the  course  of  study  in  the  medical 


246 


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American  Medical 
A  SSOI  hi  t  litu 


ioo|s  I"'  increased  to  six  months  in  each  year,  met 

I,  general  approval,  except  that  the  delegates  from 

the  medical  schools  objected,  fearing  that  the 

i  ,uls  in   which    they   were   interested   would   lose 

However,    the    University    of   Pennsylvania 

end  its  course-;  of  lectures  to  six  months,  and 

■  College  of  Physicians  and  Surgeons  in  New  York, 

■  oldest  and  most  influential  of  the  medical  schools 
i  the  metropolis,  extended  its  lecture  period  to  five 

While  most   of  the  other  medical    schools 

■d  themselves  with  adding  to  their  curricula 

o    to    four    weeks    of    optional    preliminary 

ion, 

\i    the  annual  meeting  in   1N53,   thirty  States  and 

(ritories  were   represented   by  delegates,   as  well  as 

Hi  of  Columbia,  the  Army  and  Navy  of  the 

lited    States,    the    American    Medical    Society    of 

id  one  member  was  present  by  invitation  "from 

and     one     from     Canada     West.      The     whole 

■nber  of  members  in  attendance  was  573,  and  the 

umber  of  institutions  and  societies  represented 

Previous  to  the  organization  of  the  National  Associa- 

'     ii'  medical  societies  had  been  formed  in  about 

jlf  of  the  States  of  the  Union.      But  a  large  proportion 

had  practically  ceased  an  active  existence. 

en  State  societies  and  eleven  local  ones  were 

tited  in  the  National  Convention  held  in  1846. 

Philadephia,  in  the  following  year  sixteen  State 

were  represented,  all  that  were  known  to  be 

active  existence  in  the  United  States  at  that  time. 

ght  years  after  the  organization  of  the  Association, 

enty-six    State    societies    were    represented    in    its 

;nual   meeting,    together   with   delegates   from    the 

ietv    of    Minnesota     Territory    and    that    of    the 

1  erokee  Nation,  and  from  more  than  100  county, 

,-trict,  and  town  societies. 

The  Code  of  Ethics. — It  is  a  noteworthy  fact  that 

■  're  has  been  only  one  schism  or  split  of  any  con- 

llerable  consequence  in  the  ranks  of  the  American 

lical  Association   since   its  foundation,  and  that 

1  'urred  in  the  State  of  New  York;  which,  as  already 

iitcd  out,  is  the  State  in  which   the  Association 

illy  had  its  origin. 

The  quarrel  was  over  the  so-called  code  of  ethics, 
lich  like  the  theological  tenets  of  former  ages,  led 
many  prolonged  and  bitter  controversies.  It  is 
ble  in  a  limited  space  properly  to  consider  the 
de  of  ethics  in  all  its  bearings.  Suffice  it  to  say 
at  one  section  of  this  document,  which  all  members 
the  Association  were  obliged  to  subscribe  to,  for- 
ile  consultation  with  any  practitioner  whose  prac- 
e  was  based  upon  "an  exclusive  dogma."  The 
dical  society  of  the  State  of  New  York  had  long 
afed  under  a  too  strict  interpretation  of  this  pro- 
lition.  and  many  of  its  members  maintained  that  it 
is  unjust  and  improper  to  refuse  to  consult  with  le- 
lly  qualified  practitioners,  no  matter  whether  they 
•re  bound  by  an  exclusive  dogma,  or  not.  Steps  were 
ken  to  induce  the  National  Association  to  modify 
code  of  ethics  which  had  been  preserved  intact 
ice  its  original  adoption  in  1S47,  but  without  avail, 
nally,  at  the  annual  meeting  in  February,  1882,  the 
Ural  Society  of  the  State  of  New  York  adopted  a 
le  of  ethics,  or  rather  statement  of  principles, 
the  effect  that  "the  only  ethical  offenses  for  which 
'■y  [the  medical  profession  of  the  State  of  New  York] 
um  and  promise  to  exercise  the  right  of  discipline 
"  those  comprehended  under  the  commission  of  acts 
■  worthy  a, physician  and  a  gentleman."  At  the  meet- 
g  of  the  National  Association  following  this  action, 
e  Judicial  Council  ruled  that  the  New  York  Society, 
iving  adopted  a  revised  code  several  provisions  of 
iich  were  in  conflict  with  the  code  of  ethics  of  the 
ssociation.was  not  entitled  to  representation  by  dele- 
tes in  the  American  Medical  Association.  There- 
ter  for  over  twenty  years  the  Medical  Society  of 
State  of  New  York  was  not  represented  in  the 


councils  or  scientific  work  of  the  .National   Associa 
tion. 

The  State,  however,  was  not  long  without  represen- 
tation, for  in   1884  a  number  of  physicians  in  New 

York,  .who   were   willing   to  subscribe    to    the   code   of 

ethics  of  the  American  Medical  Association  and  who 
wished  to  retain  the  right  of  membership  in  the  Asso- 
ciation, established  a  new  society  entitled  the  New 
York  State  Medical  Association.  There  were  then 
three  classes  of  pracl  itioners  in  Now   York  State :  those 

who  believed  in  the  old  code,  those  win,  had  adopted 
the  new  code,  and  those  who  regarded  all  codes  as 
unnecessary. 

When  the  American  Medical  Association  was  re- 
organized in  1901,  it  was  hoped  that  some  modifica- 
tion would  be  adopted  in  1  lie  cod,-  of  et  hies,  or  in  its 
enforcement,  so  that  a  union  might  lie  brought  about 
between  the  two  medical  societies  in  the  State  of  New- 
York,  and  all  their  members  might  be  eligible  to 
membership  in  the  National  Association.  The  last 
named  body,  however,  declined  at  that  time  to  modify 
its  code  of  ethics,  and  the  union  was  postponed. 
However,  the  leading  men  in  all  three  of  these  socie- 
ties were  by  this  time  striving  for  harmony,  and 
finally  in  1903,  the  National  Association  abrogated 
the  compulsory  clause  in  its  code  of  ethics  which  had 
made  all  the  trouble,  and  adopted  in  place  of  the  old 
code  certain"principles  of  medical  ethics'  which  it  pro- 
mulgated as  "a  suggestive  and  advisory  document." 
There  was  then  no  longer  any  cause  for  dissension, 
and  on  January  1,  190(3,  one  hundred  years  after  the 
establishment  of  the  Medical  Society  of  the  State  of 
New  York,  this  society  and  the  Medical  Association 
of  the  State  of  New  York,  having  overcome  certain 
legal  difficulties  in  their  way,  were  amalgamated,  and 
with  much  satisfaction  and  general  good  feeling,  laid 
to  rest  forever  the  objectionable  feature  of  the  code 
of  ethics. 

The  Journal. — The  history  of  the  progress  of  the 
Association  for  the  first  thirty  years  of  its  existence, 
is  not  especially  noteworthy.  Gradual  progress  was 
made  along  the  lines  laid  down  by  its  founders. 
Two  or  three  sessions  were  missed  during  the  troub- 
lous times  of  the  civil  war.  With  these  exceptions, 
however,  not  a  year  has  passed  in  the  sixty-seven 
years  of  the  existence  of  the  Association  in  which  a 
meeting  has  not  been  held  and  more  or  less  good 
scientific  work  done,  as  well  as  some  effort  made  to 
bring  about  improvements  in  medical  education  for 
the  enactment  of  better  health  and  quarantine  laws 
and  the  furtherance  of  many  good  objects  which  the 
founders  of  the  Association  had  in  mind. 

Still  the  Association  lacked  coherence,  and  it 
lacked  funds.  Its  loose  organization  precluded 
almost  any  sustained  and  effective  scientific  or  legis- 
lative work.  Its  means  of  communicating  with  its 
members  were  inadequate,  and  it  was  without  power 
to  discipline  either  its  own  members,  or  the  profession 
at  large.  It  was  obvious  that  one  potent  means  of 
accomplishing  a  stronger  organization  would  be  the 
establishment  of  a  journal.  Hence,  as  early  as  1S52, 
it  was  proposed  to  start  a  journal.  Again  in  1870, 
Dr.  Samuel  D.  Gross  of  Philadelphia  offered  a  resolu- 
tion that  the  transactions  be  periodically  published  in 
a  journal.  This  resolution  was  passed  and  then 
rescinded.  In  18S0,  Dr.  Louis  A.  Say  re  of  New  York 
made  a  similar  proposition  to  the  society  which  was 
referred  to  a  committee  who  after  a  careful  investiga- 
tion, recommended  that  another  committee  be 
appointed  to  report  in  detail  a  plan  for  journalizing 
the  transactions  of  the  Association.  Again  the  inde- 
fatigable N.  S.  Davis  came  to  the  fore  and  by  his 
industry  and  perseverance  secured  pledges  from  2,100 
physicians  to  sustain  the  Journal.  Dr.  Davis  became 
its  editor  and  the  first  issue  appeared  in  1SS3.  At 
that  time  the  membership  of  the  Association  was 
about  2.000.  The  annual  dues  were  .S3. 00  which 
were    in    many    cases    uncollectable.     The    financial 

247 


American  Medical 
Association 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


outgo  was  between  five  and  seven  thousand  dollars, 
the  greater  portion  of  which  was  spent  in  printing, 
binding,  and  distributing  the  annual  volume  of 
transactions. 

With  the  publication  of  the  Journal,  a  new  era  in 
the  life  of  the  Association  was  begun.  In  fifteen 
years  the  edition  of  the  Journal  of  the  American 
Medical  Association  had  risen,  under  the  editorship 
first  of  Dr.  Davis,  then  of  Dr.  John  B.  Hamilton, 
from  3,800  to  11,270.  In  1S9S  the  present  editor, 
Dr.  George  H.  Simmons,  took  charge.  The  member- 
ship of  the  Association  has  now  reached  over  34,000 
(about  a  quarter  of  all  the  physicians  in  the  United 
States),  forming  a  body  about  one-half  as  large  again 
as  that  of  the  British  Medical  Association,  which  was 
started  in  1S32,  but  which  did  not  complete  its  present 
organization  as  the  National  Association  of  Great 
Britain  until  1S56,  about  ten  years  subsequent  to  the 
establishment  of  the  American  Association.  The  cir- 
culation of  the  Journal  has  increased  to  nearly  54,000, 
including  the  membership  list,  and  the  assets  of  the 
Association  have  increased  since  18S3,  from  a  deficit  on 
the  Treasurer's  books  to  over  one-half  a  million  dollars, 
of  which,  $100,000  represents  interest-bearing  invest- 
ments and  over  $350,000  represents  real  property,  ma- 
chinery, furniture,  and  supplies.  The  gross  revenue 
amounted  last  year  in  round  numbers  to  over  $459,000 
and  after  all  expenses  covering  insurance,  deprecial  inn 
of  plant  and  machinery,  etc.,  had  been  deducted,  over 
$53,000  was  added  to  the  assets  of  the  Association. 

Organization. — By  the  reorganization  in  1901,  as 
already  stated,  the  American  Medical  Association  was 
divided  into  a  scientific  and  legislative  body.  The 
latter  has  already  been  described  as  the  House  of 
Delegates  which  does  all  the  business  of  the  Associa- 
tion including  the  election  of  the  officers.  The 
scientific  work  is  done  in  fourteen  sections  covering 
every  branch  of  medicine  and  surgery.  From  3,000 
to  6,000  members  attend  the  annual  meetings  of  the 
Association. 

The  finances  of  the  Association  and  the  business 
management  of  the  Journal  and  of  the  investments 
and  the  care  of  all  the  property,  are  in  the  power  of  the 
Board  of  Trustees.  This  consists  of  nine  members, 
three  going  out  of  office  yearly  and  being  succeeded 
by   new   men,   elected   by   the    House   of   Delegates. 

The  judicial  council  consists  of  five  members  (one 
elected  each  year)  and  the  secretary  of  the  Associa- 
tion. They  look  after  and  regulate  all  matters  need- 
ing adjudication  between  members  and  between  the 
American  Medical  Association  and  other  medical 
societies,  and  harmonize  the  action  of  the  diverse 
interests  over  which  the  Association  lias  supervision. 
There  are  besides,  three  permanent  councils: 

1.  That  on  Health  and  Public  Instruction,  consisting 
of  five  members  and  the  secretary  of  the  Association. 

2.  That  on  Medical  Education,  consisting  of  five 
members  and  a  secretary. 

3.  That  on  Pharmacy  and  Chemistry,  consisting  of 
fifteen  members  and  a  secretary. 

A  brief  review  of  the  work  of  these  councils  will 
serve  to  outline  some  of  the  major  activities  of  the 
Association  since  its  reorganization  in  1901. 

The  council  on  Health  and  Public  Instruction  has 
conducted  a  Publicity  Bureau  and  has  sent  informa- 
tion on  matters  affecting  public  and  personal  health 
to  5,000  newspapers  and  periodicals  in  the  past  year 
only  six  of  which  have  declined  to  receive  and  make 
some  use  of  the  information.  This  is  sent  out  in 
weekly  bulletins,  and  covers  practically  the  entire 
range  of  hygiene  and  preventive  medicine.  A  sub- 
committee of  this  council  has  waged  war  against 
preventable  blindness,  with  great  success.  The 
council  also  maintains  a  corps  of  healfh  lecturers,  at 
present  consisting  of  100  speakers,  who  will  go  any- 
where in  the  United  States  upon  request,  and  address 
lay  and  professional  audiences  on  matters  of  State  and 
personal  sanitation. 

248 


The  council  on  Medical  Education  has  finished  its 
third  complete  report  upon  every  medical  teaching 
institution  in  the  country.  In  the  past  five  years 
fifty-six  medical  schools  in  the  United  States  have 
closed  their  doors  or  merged  themselves  into  other 
schools,  evidently  as  a  result  of  the  publicity  to  which 
they  have  been  exposed.  All  the  medical  schools  in 
the  United  States  are  carefully  classified  in  the 
Council's  report,  as  good,  fair,  and  poor.  Of  the  14:: 
schools  now  active  in  this  country,  nearly  one-half 
are  reported  to  be  inadequately  equipped,  or  defective 
in  some  important  particulars.  Fortunately,  a 
college  diploma  no  longer  confers  the  right  to  practise 
medicine,  inasmuch  as  the  appointment  of  a  81 
medical  examining  board  has  been  secured  in  every 
State  in  the  Union.  Efforts  are  now  being  mad''  to 
equalize  the  requirements  for  license  to  prai 
throughout  the  country,  and  to  elevate  and  improve 
the  personnel  of  the  State  examining  boards.  Further- 
more, an  effort  is  also  being  made  to  require  at  lea  I 
one  year's  internship  in  a  recognized  hospital  before 
a  physician  shall  be  licensed  to  practise. 

The  work  of  the  Council  on  Pharmacy  and  Chem- 
istry is  almost  too  well  known  to  require  comment. 
They  will  examine  and  report  upon  any  remedy, 
new  or  old,  that  is  advertised  to  be  useful  in  the 
treatment  of  disease.  The  amount  of  work  that 
they  have  done  in  bringing  to  light  frauds  : 
deceptions  in  the  drug  and  medicine  business 
almost  incredible.  It  is  to  be  hoped  that  their  efforts 
to  establish  standards  of  purity  and  reliability  in  the 
entire  drug  business,  and  even  in  that  of  handling  and 
preparing  food  of  all  sorts,  will  be  abundantly 
successful. 

Besides  the  Journal  of  the  American  Medical 
Association,  the  Board  of  Trustees  have  authorized 
the  publication  of  two  other  periodicals,  "The 
Archives  of  Internal  Medicine"  and  the  "American 
Journal  of  the  Diseases  of  Children."  The  Associa- 
tion has  also  compiled  and  published  a  register  of 
every  physician  in  the  United  States  and  Canada, 
which  is  claimed  to  be  complete  and  authoritative. 

It  should  not  be  forgotten  that  for  over  fifty  years, 
the  American  Medical  Association  has  struggled  for  a 
National  Department  of  Public  Health  and  is  still 
bending  its  energies  toward  the  establishment  of  that 
great  boon  to  our  common  country. 

Of  the  great  objects  with  which  the  founders  of  the 
Association  charged  themselves,  all  have  bet 
accomplished,  or  are  in  fair  way  to  be  accomplish 
Like  the  statesmen  who  founded  our  government, 
and  gave  us  our  national  constitution,  the  wise  men 
who  founded  the  American  Medical  Association 
"builded  better  than  they  knew." 

Richard  Cole  Newton. 


Ammoniacum. — Ammoniac.     Gum   Ammoniac.     \ 
gum   resin   obtained  from  Dorema  ammoniacum  Don 
i  lam.  Umbellifera:).     The  ammoniac  plant  abounds  in 
the  deserts  of  Persia  and  Beloochistan.     It  is  a  stunt 
perennial  herb  two  meters  or  more  in  height  with  a 
few  coarse  leaves  at  the  base  and  a  large  terminal 
panicle  of  flowers.     It  grows  from  a  large  turnip-like 
root,  which  has  a  domestic  use  under  the  name  "  lJ">in- 
bay  Sumbul."     The  milky  juice  exudes  from  punc- 
tures made  by  beetles,  and  concretes  upon  the 
often  falling  to  the  ground  in  irregularly  rounded  01 
ellipsoidal   nodules  or  "tears"  often  nearly  an  inch  in 
diameter,   which  constitute  the    drug   of   commerci 
In  the  best  grades,  these  tears  are  dry  and  separate, 
but  are  sometimes  soft  and  agglutinated.     Tiny  a 
brownish  cream-colored  externally,  darkening 
namon  brown  with  age,  creamy  white,  or  pure  white 
within.     They  break  with  a  conchoidal  fracture,  dis- 
closing a   waxy,   but  shining  surface.     The  odor  is 
peculiar,  rather  disagreeable,  but  faint,  excepting  u 
masses  or  upon  warming.     The  taste  is  bitter  and 


REFERENCE    IIWIMtiioK    OF   THE    MEDICAL   SCIENCES 


Ammonia  and  Ammonium 
Sails 


i  her  acrid.     It  is  a  difficult  drug  to  powder,  unle 
,  v  cold  or  very  dry.     When  heated  it  softens,  but 

,  ,s  I,,, i  melt.  Alcohol  dissolves  about  three-fourths 
,  i.  Water  disintegrates  it,  and  forma  with  it  a  milky 
,  ulsion. 

Ammoniac  consists  of  about  seventy  per  cent,  of 
■  in,  fifteen  to  eighteen  per  cent,  of  .soluble  gum,  anil 
Ki   rest  of  insoluble  gum,   water,   and    from   one-half 

i  four  per  cent,  of  volatile  oil.  The  latter  does  no! 
nil  sulphur,  and,  therefore,  is  not  similar  to  the 

of  asafetida,  which  drug  is  much  adulterated  with 

moniac. 

Vminoniac  is  stimulant,  expectorant,  and  antispas- 
IjidiC,  but  is  scarcely  used  now  internally.      The  dose 

,., id  to  be  0.5  to  2  grams  (gr.  viij.-xxx.)  thre ■ 

mes  a  day.      An  emulsion  would  be  an  eligible 

i    although  a  tincture  would  probably  contain  all 

i    is  active   in   it.     The   principal   preparation   is 

uiac   Plaster  (Emplastrum   Ammoniaci),  made 

softening  the  ammoniac  in  diluted  acetic  acid,  and 

iporating  to  a  suitable  extent.     It  is  a  stimulating 

:  1    rubefacient,    sometimes    blistering    application, 

i  ful  as  a  mild  counterirritant. 

One  other   species   of    Dorema,   according   to   the 

i  icographia,"     yields     ammoniac.      Bentham 

I    Hooker  include  only  two  species  in  the  genus. 

e  ammoniac  of  Dioscorides  and  Pliny,  and  other 

i,  nt  writers,  was  obtained  in  Africa,  and  is  a  dif- 

lent  article,   namely,   a  gum   resin   obtained   from 

ingitana  Linn.     It  is  rarely  found  in  European 

i  irkets. 

II.    II.    RUSBY. 


\mmonia  and  Ammonium  Salts. — General  Med- 

sai.  Properties  op  Ammonium  Compounds. — 
umonium    compounds,    as    a    class,    are    irritant, 

ally,  to  a  degree  greater  than  that  shown  by  the 
.'■responding  compounds  of  sodium,  but  less  than 
:  the  case  of  compounds  of  potassium.     They  tend 

be  of  high  diffusion  power,  and  are  therefore, 
len  swallowed,  quickly  absorbed,  and  hence  are 
c  from  the  purgative  tendency  of  the  low  diffusion 
Its  of  potassium,  sodium,  and  magnesium.  C'on- 
tutionally    they    tend    to   increase    the   force   and 

[uency  of  the  heart's  action  and  to  determine  a 
e  of  arterial  tension;  to  excite  the  respiratory 
nter  in  the  medulla  oblongata,  causing  fuller  and 
ire  frequent  respirations,  and  to  enhance  reflex 
itability  of  the  motor  tract  of  the  spinal  cord — an 
limn  i  incut  leading  in  poisonous  dosage  in  animals 

tetanoid  convulsions.  General  nutrition  is  not 
riously  affected  by  therapeutic  doses.  In  long- 
atinued  excessive  dosage  the  heart  becomes 
feebled  and  the  quality  of  the  blood  deteriorates, 
th  marked  impairment  of  the  power  of  the  hemo- 
ibin  to  fix  oxygen.  An  important  difference  be- 
een  the  alkaline  ammonium  compounds  and  the 
[•responding  potassium,  sodium,  and  lithium 
eparations  is  that,  whereas  the  latter  carry  their 
kalinity  through  the  system  generally  and  into  the 
■ine,  no  such  effect  follows  the  ingestion  of  the 
mnonium  compounds.  On  the  contrary,  the 
idity  of  the  urine  tends  rather  to  be  enhanced  under 
umonium  medication.  The  explanation  of  this 
•culiarity  among  ammonium  compounds  is  an 
sinned  oxidation  of  the  elements  of  the  ammonium 
dicle,  leading  to  the  formation  of  nitric  acid  as  one  of 
ie  products.  By  virtue  of  the  properties  described, 
umonium  compounds  furnish  important  medicines 
i  restoring  or  sustaining  flagging  heart  or  lung 
tiou;  for  relieving  dyspnea,  and  for  opposing  the 
tion  of  motor-paralyzing  poisons. 
The  Ammonium  Compounds  Used  in  Medicine. 
-These  are  ammonia,  and  the  following  ammonium 
ilts:  salicylate,  carbonate,  acetate,  chloride,  bromide, 
dide,  benzoate,  and  valerate.  In  the  present 
"tide  will  be  discussed  the  first  three  only;  for  the 


others  see  respectively  Chlnriilcs,  Bromides,  Iodides, 
Benzoic  Arid,  Salicylic  Aral.   I  aleric  Acid. 

Ammonia. —  Ammonia,  NIL,,  is  used  in  medicine 
only  in  aqueous  or  alcoholic  solution,  as  afforded  by 
the  following  official  preparations  of  the  U.  S.  P.: 
Aqua  Ammonia   Fortior,  Stronger  Ammonia  Water. 

This  is  an  aqueous  solution  of  ammonia,  containing 
twenty-eight  per  cent.,  by  weight,  of  the  gas.  It 
presents  itself  as  a  "colorless,  transparent  liquid, 
having  an  excessively  pungent  odor,  a  very  acrid  ami 
alkaline  taste,  and  a  strongly  alkaline  reaction. 
Specific  gravity,  0.897  a!  25°  C.  (77°F.)."  (U.  S.   P.) 

It  is  completely  volatilized  by  the  heat  of  a  water 
bath.  On  bringing  a  glass  rod,  dipped  into  hydro- 
chloric acid,  near  the  liquid,  dense  white  fumes  are 
evolved.  From  the  volatility  of  its  contained  am- 
monia this  preparation  is  directed  to  be  kept  in 
"partially  filled  strong  glass-stoppered  bottles,  in  a 
cool    place." 

Aqua  Ammonias,  Ammonia  Water.  "An  aqueous 
solution  of  ammonia,  containing  ten  per  cent.,  by 
weight,  of  gaseous  ammonia."  This  weaker  solution 
has  the  properties  of  the  stronger,  only  not  to  so 
intense  a  degree.  Its  specific  gravity  is  0.958  at  25° 
C.  (77°  F.).  It  also  should  be  kept  cool,  in  glass- 
stoppered  bottles,  but  the  precaution  to  avoid  filling 
the  bottles  completely  is  not  here  necessary.  Dose, 
about  itstxv.  (1.0). 

Spirit  us  Ammonia;,  Spirit  of  Ammonia.  "  An  alco- 
holic solution  of  ammonia,  containing  ten  percent., 
by  weight,  of  the  gas."  This  solution  is  prepared 
by  subjecting  stronger  water  of  ammonia,  in  a  still, 
to  a  gentle  heat,  and  conducting  the  ammonia  gas 
thereby  volatilized  to  a  receiver  containing  freshly 
distilled  alcohol.  The  product  is  assayed  and  brought 
to  standard  strength  by  the  addition  of  alcohol. 
Spirit  of  ammonia  is  a  "colorless  liquid,  having  a 
strong  odor  of  ammonia,  and  a  specific  gravity  of 
about  0.S0S  at  25°  C.  (77°  F.)."  (U.  S.  P.)  It  should 
be  kept  in  glass-stoppered  bottles,  in  a  cool  place. 
Dose,  about  njixv.  (1.0). 

Spiritus  Ammonia:  Aromaticus,  Aromatic  Spirit  of 
Ammonia.  This  is  a  composite  preparation,  contain- 
ing, in  1,000  c.c.,  ammonium  carbonate,  34  grams; 
ammonia  water,  90  c.c;  oil  lemon,  10  c.c;  oil  of 
lavender  flowers  and  oil  of  nutmeg,  each,  1  c.c; 
alcohol,  700  c.c;  and  the  rest  distilled  water.  It  is  a 
"nearly  colorless  liquid  when  freshly  prepared,  but 
gradually  acquiring  a  somewhat  darker  tint.  It  has 
a  pungent  ammoniacal  odor  and  taste.  Specific 
gravity,  about  0.900  at  25°  C.  (77°  F.)."  (U.  S.  P.) 
Dose,  about  mrxxx  (2.0).  This  spirit,  like  the  other 
ammonia  solutions,  should  be  kept  glass-stoppered, 
in  a  cool  place.  But  in  spite  of  this  precaution,  the 
fact  obtains  generally  with  ammoniacal  solutions  that 
they  lose  strength  upon  keeping,  so  that  a  sample  a 
year  or  more  old  may  be  almost  wholly  without 
ammoniacal  odor.  Ammoniacal  solutions  are  incom- 
patible with  acids,  acidulous  salts,  and  many  salts  of 
the  metals  and  earths;  ammonia,  however,  does  not 
decompose  calcium  salts,  nor,  except  partially,  those 
of  magnesium. 

Ammonia  is  a  powerful  alkali,  and  in  gaseous  form 
is  intolerably  pungent,  its  fumes,  if  strong,  exciting 
vigorous  spasm  of  the  larynx.  In  strong  solution, 
it  is  intensely  irritant.  Either  of  the  official  ammonia 
waters  or  the  simple  spirit  will,  if  of  standard  strength, 
excite  severe  irritation  upon  incautious  inhalation  of 
the  fumes,  and  if  applied  to  the  skin  upon  cloths  so 
covered  as  to  prevent  evaporation,  will  very  speedily 
cause  burning  pain  and  redness,  and,  after  a  few 
minutes,  blistering.  Prolonged  application  may  lead 
to  ulcerative  inflammation  or  gangrene.  Internally, 
in  proper  dilution,  ammoniacal  solutions  are  locally 
alkaline  so  far  as  the  contents  of  the  stomach  and 
bowels  are  concerned.  Also,  because  of  the  pun- 
gency and  volatility  of  ammonia,  they  tend  to  allay 
nausea   and    to   expel   flatus.     Ammonia,    being    of 


249 


Ammonia  and  Ammonium 
Salts 


REFERENCE    HANDBOOK    OF   THE   MEDICAL   SCIENCES 


high  diffusion  power,  is  readily  absorbed,  whether 
taken  by  swallowing  or  by  inhalation,  and  then 
quickly  but  evanescently  exerts  the  peculiar  effects  of 
the  ammonium  compounds  upon  the  heart,  respira- 
tion, and  motor  tract  of  the  cord,  as  already  set 
forth.  Undiluted,  the  three  first-named  pharmaco- 
pu'ial  ~ .  1 1 1 1 1  i < . 1 1 ^  i.f  ammonia  arc  so  irritant  as  prac- 
tically to  be  corrosive  to  the  mucous  membrane  of  the 
stomach  and  bowels.  Large  doses  are,  therefore, 
violently  poisonous,  capable  of  causing  speedy  death, 
with  all  the  usual  symptoms  of  corrosive  irritation. 
In  some  cases  death  results  in  so  short  a  time  as  a  very 
few  minutes,  probably  from  suffocation  through 
rapidly  developed  edema  of  the  glottis.  So  small  a 
quantity  as  about  a  teaspoonful  and  a  half  of  a  strong 
solution  of  ammonia,  swallowed  undiluted,  has  killed. 
Dangerous,  and  even  fatal,  poisoning  has  also  resulted 
from  inhalation  of  strong  ammoniacal  fumes. 

The  therapeutic  uses  of  ammoniacal  solutions  are 
local  and  general.  Locally,  according  to  strength  of 
application,  ammonia  may  be  made  to  serve  as  a 
vesicant  or  rubefacient.  To  blister,  a  pledget  of  lint, 
steeped  in  a  strong  solution,  is  covered  with  a  watch- 
glass  or  wooden  pill  box  to  prevent  evaporation,  and 
then  directly  applied.  In  such  way  the  stronger 
water  of  the  Pharmacopoeia  has  been  used,  but  this 
solution  is  unnecessarily  and,  unless  very  carefully 
manipulated,  dangerously  strong.  If  employed,  the 
application  should  be  held  in  contact  with  the  skin 
for  only  three  or  four  minutes,  or  until  the  part  is  well 
reddened,  and  should  then  be  removed  and  a  hot 
poultice  applied  until  the  blister  rises.  It  is  safer  to 
dilute  the  stronger  water  with  one-half  its  volume  of 
additional  water.  Ammonia  is  rarely  selected  as  a 
blistering  agent,  unless  the  need  for  the  blister  is 
urgent,  when  the  quickness  with  which  ammonia  acts 
makes  it  preferable  to  cantharides.  For  rubefacient 
purposes  a  clash  of  the  stronger  water  is  a  very  com- 
mon addition  to  composite  liniments,  and  there  is 
official  in  the  U.  S.  P.  Linimentum  Ammonia,  Ammo- 
nia Liniment,  or,  as  it  is  sometimes  called,  volatile 
liniment.  This  preparation  is  made  by  mixing  350 
c.c.  of  ammonia  water  (not  the  stronger  water)  with 
50  c.c.  of  alcohol,  570  c.c.  of  cotton-seed  oil,  and  30 
c.c.  of  oleic  acid.  An  ammonia  soap  results,  which 
partly  dissolves  and  partly  remains  emulsified  in  the 
fluid,  forming  a  white  viscid  mixture.  The  prepara- 
tion is  saponaceous,  yet  possesses  mildly  the  irritant 
qualities  of  ammonia,  and  makes  a  capital  liniment 
for  rubef action.  Still  a  third  local  purpose  of  ammonia 
is  to  relieve  the  pain  or  itching  of  bites  of  insects.  For 
this  purpose  a  drop  or  two  of  the  weaker  water,  clear 
or  diluted,  may  be  applied  to  the  part.  Internally, 
ammonia  may  be  used,  first,  to  correct  the  gastric 
malaise  that  attends  a  fit  of  acid  indigestion,  or  to 
allay  nausea  from  any  cause.  For  such  purpose  the 
aromatic  spirit  is  specially  devised,  to  be  given  in 
doses  of  from  one-half  to  one  teaspoonful,  diluted  with 
three  or  four  volumes  of  water.  Secondly,  ammonia 
may  be  given  for  the  constitutional  effects  of  reviving 
the  heart  in  faintness,  of  supporting  it  in  chronic  con- 
ditions threatening  heart  failure,  of  stimulating 
flagging  respiration,  as  in  dyspnea  from  lung  disease, 
or  in  respiratory  failure  in  poisoning  by  paralyzing 
agents,  of  allaying  mild  spasmodic  seizures,  and  of 
opposing  generally  the  action  of  narcotics  and  para- 
lyzers.  For  all  internal  medication  the  stronger  water 
is  entirely  too  strong,  and  the  weaker  water  or.  the 
spirit  is  to  be  preferred.  Of  the  water  or  of  the 
simple  spirit  from  ten  to  thirty  drops  may  be  admin- 
istered at  a  dose,  largely  diluted.  If  swallowing  be 
impossible,  as  in  case  of  unconsciousness  from  a  faint, 
the  effects  of  ammonia  may  be  obtained  by  inhalation, 
but  great  caution  is  necessary  lest  dangerous  or  even 
fatal  irritation  of  the  air  passages  be  set  up  by  too 
strong  inhalation  during  complete  or  partial  uncon- 
sciousness. None  of  the  pharmacopoeial  ammoniacal 
solutions   should    be   applied    close    to   the   nostrils. 

250 


Ammonium  Carbonate. — Upon  subliming  a  mixtun 
of  chalk  and  ammonium  chloride  or  sulphate,  doubli 
decomposition  ensues,  and  a  sublimate  is  obtained 
which  consists  of  acid  ammonium  carbonate  and 
ammonium  carbamate,  represented  bv  the  svmhol 
NILHCO3,  NH4NH,C02.  This  composite  salt  is  oil,. 
cial  under  the  title  Ammonii  Carbonas,  Ammonium 
Carbonate.  It  occurs  as  "white,  hard,  translucent 
striated  masses,  having  a  strongly  ammoniacal  odor 
without  empyreuma,  and  a  sharp,  saline  taste.  On 
exposure  to  the  air,  the  salt  loses  both  ammi 
and  carbon  dioxide,  becoming  opaque,  and  is  finally 
converted  into  friable,  porous  lumps,  or  a  white 
powder.  Slowly  but  completely  soluble  in  about  four 
parts  of  water  at  25°  C.  (77°  F.);  decomposed  by  hoi 
water  with  the  elimination  of  carbon  dioxide  and 
ammonia.  By  prolonged  boiling  with  water  the 
is  completely  volatilized.  Alcohol  dissolves  the  car- 
bamate [NH4NH2C02],  and  leaves  the  acid  carbonate 
(ammonium  bicarbonate).  When  heated,  ammonium 
carbonate  is  completely  volatilized,  without  charring 
The  aqueous  solution  possesses  an  alkaline  reaction 
and  effervesces  with  acids."  (U.  S.  P.)  This  salt 
must  be  kept  in  well-stoppered  bottles  in  a  cool  place. 
Ammonium  carbonate  behaves,  physiologically . 
like  ammonia  itself,  but  is  a  little  less  rapid  and 
evanescent  in  operation.  In  concentrated  solution  it 
is  locally  irritant,  and  taken  internally,  dangero 
poisonous.  The  salt  is  used  for  the  constitutional 
stimulant  and  sustaining  effects  of  ammonia,  and 
often  for  such  purpose  preferred  to  solutions  ,,t 
ammonia  because  of  the  slightly  longer  duration  of  the 
action.  It  is  given  internally  in  frequently  repeated 
doses  of  gr.  iv.  (0.25)  in  aqueous  solution,  with  the 
acrimony  disguised  by  gum  arabic  or  sugar,  or  si 
agreeably  flavored  aromatic  addition.  Large  s: 
doses  should  be  avoided,  since  they  easily  overirritate 
the  stomach  and  may  excite  vomiting.  Ammonium 
carbonate  is  also  much  used  to  get  an  ammonia 
effect  by  inhalation.  For  this  purpose  it  is  coarsely 
bruised,  treated  with  half  its  bulk  of  strong  water  of 
ammonia,  and  flavored  with  a  little  oil  of  lavender  or 
bergamot,  such  mixture  constituting  what  is  knov 
smelling  salts. 

Ammonium  Acetate.— -This  salt,  CH3.COONH„  is 
used  only  in  the  aqueous  solution  in  which  it  results 
from  the  procedure  of  neutralizing  wit  h  ammonium  car- 
bonate the  diluted  acetic  acid  of  the  Pharmacopoeia. 
Such  solution,  commonly  called  spirit  of  Minderi 
is  official  as  Liquor  Ammonii  Acetatis,  Solution  of 
Ammonium  Acetate.  It  is  "a  clear,  colorless  liq 
free  from  empyreuma,  of  a  mildly  saline,  acidulous 
taste,  and  an  acid  reaction."  (U.  S.  P.)  The  solution 
contains  five  per  cent,  of  the  salt.  It  should  be  made 
freshly  for  use,  since  like  other  solutions  of  alkaline 
salts  of  the  common  organic  acids  it  tends  to  sponta- 
neous decomposition  on  keeping.  Ammonium  acetate 
is  a  bland,  mawkish  salt,  which  upon  absorption  may 
prove  feebly  diaphoretic  or  diuretic,  according  to 
circumstances,  and  may  to  a  slight  degree  exert  the 
characteristic  effects  of  the  ammonium  compounds 
generally.  It  is  used  to  allay  headache,  especially  the 
headache  of  pyrexia,  to  quiet  an  uneasy  stomach,  or 
to  promote  gentle  diaphoresis  or  diuresis  in  fevr; 
but  it  is  at  best  a  feeble  medicine.  One  or  two 
tablespoonfuls  may  be  given  at  a  dose,  clear  or  diluted, 
sweetened  and  aromatized.  The  pharmacopceial  dt 
is  oss.  (16. C).  If  diluted,  carbonic  acid  water  mal 
an  excellent  addition. 

Toxicology  of  Ammonia. — Ammonia  is  met  with 
in  commerce  in  a  number  of  forms. 

First,  as  anhydrous  ammonia  condensed  in  large 
steel  cylinders  for  use  in  ice  machines.  In  these  the 
ammonia  is  under  a  pressure  of  several  hundred  pounds 
and  is  in  a  liquid  condition.  When  the  pressun 
removed,  the  liquid  assumes  a  gaseous  form  and 
issues  from  the  opening  as  a  colorless,  irrespirable  gas 
intensely  corrosive  to  organic   tissues. 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Ammonia  and  Ammonium 
Salts 


V  number  of  fatal  accidents  have  happened  from 

action  of  this  gas,  either  through  the  bursting  of 

.   cylinder    when    it    has    been    highly    heated,    ur 

h  imperfect  connection  with  the  refrigerating 

n'hine. 

Vxt,  as  the  Aqua  Ammonia  Fortior  and  the  Aqua 
of    the    pharmacist.     Both    of    these  are 
ied  above. 

a  solution  of  varying  strength  containing 
number   of    impurities,    sold    under    the    name  of 

hold    Vmmonia. 

Poisoning   from   gaseous   ammonia   is   always    the 

,|  accident,  and  such  cases  occur  only  in  plants 

ie  gas  is  stored  or  where  it  is  used  in  quantity 

refrigerating  purposes.     Poisoning  by  inhalation 

the  gas  arising  from   its   water  solution  has  also 

own  as  the  result  of  accident. 
When  the  gas  is  inhaled  there  is  generally  a  sense  of 
ion  and  giddiness,  followed  at  times  by  vomit- 
i.    The  face  is  pale,  and  the  pulse  is  faint  and  accel- 
In   some  instances  the  mucous  membrane  of 
e  mouth  becomes  detached   in  the  form  of  white 
ds,  leaving  the  surface  beneath  intensely  reddened 
v   sure.     The  sense  of  taste  is  seriously  im- 
ired  for  some  time  and  the  contact  of  solids  with 
ch    eroded     surfaces     is     intensely     painful.     The 
effects  of  the  inhalation  of  the  gas  are  said  to 
inflammation  of  the  eyes  and  a  diseased  condition 
-kin.     There  is  also  a  general  lowering  of  the 
f    the    system    with    pronounced    anemia. 
\\  hen  applied  to  the  surface  of  the  skin,  a  strong 
lution    of    ammonia    causes    an    intense    smarting 
-at  ion  and  the  skin  may  become  rough  and  ex- 
I  through  the  corrosive  action  of  the  solution. 
When   a  solution   of   ammonia   is   swallowed,    the 
tnptoms  depend  largely  on  the  degree  of  concen- 
ution  of  the  solution.     When  it  is  concentrated. there 
itly  a  strong  smarting  pain  in  the  mouth  and 
mat,  which  extends  very  soon  to  the  stomach  and 
".vels.     The  abdomen  becomes  distended,  and  the 
ightest  touch  increases  the  pain.     There  is  vomiting 
stringy  matter  having  the  odor  of  ammonia  and 
metimes   containing  blood.     The   face  is  pale,  the 
ion    anxious,     the     inspiration     hurried     and 
linful.     The  pulse  is  feeble  and  rapid.     The  body 
covered    with   a   cold   perspiration.     The   interior 
the  mouth  is  white  or  bright   red,   more  or  less 
>vered  with  shreds  of  mucous  membrane,  and  the 
irte  are  greatly  swollen.     There  is  loss  of  voice  and 
icre  is  also  difficulty  in  swallowing.     The  thirst  is 
tense  and  the  mouth  feels  dry  and  parched.     The 
>\v  of  saliva  is  greatly  increased,  in  one  case  reaching 
ie  amount  of  three  liters  in  twenty-four  hours.     The 
rine  is  scanty,  slightly  acid  or  even  alkaline  in  rear- 
on,  and  it  may  contain  albumin  and  casts.     The 
owels  are  sometimes  constipated  and  sometimes  the 
■verse,  the  liquid  dejecta  at  times  containing  much 
lood.     If  the  patient  dies  from  the  immediate  action 
f  the  poison,  it  is  usually  from  suffocation  on  account 
f  the  swelling  of  the  glottis.     Some  have  died  in  a 
ondition  of  coma  and  some  in  convulsions.     In  a  few 
:i<es  in  which  recovery  has  taken  place  from  the  im- 
tediate  effect  of  the  poison,  death  has  ensued  after 
■  me  weeks  or  months  from  starvation,  owing  to  the 
■struction  of  a  considerable  portion  of  the  glands  of 
nach  or  to  constriction  of  either  its  cardiac  or 
s  pyloric  opening  or  of  the  esophagus. 
The   treatment    consists   in   the   administration   of 
'lutions  of  weak  acids  like  vinegar  or  lemon  juice 
o  neutralize  the  action  of  the  alkali,  and  in  the  use 
f  mucilaginous  or  oily  drinks  to  cover  the  corroded 
'fares.     Often  the  inflammation  of  the  respiratory 
assages    is    successfully   combated   by    keeping   the 
Kitient   in  an  atmosphere  saturated  with   moisture. 
f  there  is  impending  suffocation,  tracheotomy  must  be 
sorted  to,  if  the  condition  of  the  patient  will  allow  it. 
'reparations  of  opium  may  also  be  made  use  of  to 
ontrol  the  intense  pain. 


The  amount  of  thi-  poison  which  will  cause  death 
varies  greatly.  Umn  i-ry  has  taken  place  from  so  great 
a  dose  as  an  ounce  of  the  concentrated  liquid,  and 

death    has    ensued    from    as    little    as    four    drams. 

Death  sometimes  takes  plan'  within  a  few  mint 
but  generally  it   is  di  layed  for  from  eight   to  forty- 
eighl  hours.     Death  from  the  secondary  effects  of  the 
corrosive  has  resulted  after  many  months. 

In  cases  in  which  death  has  resulted  within  a  short 
time,  the  postmortem  examination  shows  a  con- 
dition of  intense  inflammation,  which  extend-  from 

the  lips  to  the  stomach,  but  seldom  beyond.  The 
interior  of  the  mouth  is  white  or  red  and  the  epithelial 

layer  largely  loosened  or  detached.     The  tongue  is 

swollen  and  the  epiglottis  much  enlarged.  The 
bronchial  tubes  are  reddened,  and  their  minute 
ramifications  show  the  effect  oT  the  corrosive.  Some- 
times a  diphtheritic  condition  exists  or  the  tubules  are 
filled  with  a  tenacious  mucus.  The  heart  is  partly 
empty,  the  blood  bright  red,  and.  for  the  most  part, 
fluid.  The  esophagus  is  blanched  or  intensely  red. 
The  stomach  is  either  white  or  bright  red,  its  lining 
membrane  loosened  and  in  shreds.  The  stomach  con- 
tents are  more  or  less  bloody.  If  the  patient  recovers 
from  the  immediate  effects,  and  death  ensues  a  con- 
siderable time  after  the  corrosive  was  taken,  the 
esophagus  and  stomach  show  scars  of  greater  or  lesser 
extent,  and  there  may  be  more  or  less  constriction  of 
the  esophagus  and  of  the  cardiac  or  pyloric  openings  of 
the  stomach. 

If  life  has  been  prolonged  for  some  time,  or  if  de- 
composition has  begun,  it  is  useless  to  attempt  to 
detect  the  ammonia  that  may  have  caused  the  death, 
for  either  it  has  been  eliminated  during  life,  or  its 
presence,  after  putrefaction  sets  in,  may  be  accounted 
for  by  the  decomposition  of  nitrogenous  compounds  of 
the  body. 

When  death  follows  soon  after  the  ingestion  of  the 
corrosive,  the  materials  vomited,  or  the  stomach  con- 
tents, or  the  stomach  itself  may  be  found  to  contain 
sufficient  ammonia  to  respond  to  characteristic  tests. 
For  this  purpose  the  material  is  distilled  first  alone 
and  afterward  with  the  addition  of  an  alkali  like 
lime  or  magnesia,  and  the  distillates  are  then  separ- 
ately collected  and  are  subjected  to  the  several  tests 
for  ammonia. 

These  tests  are  as  follows: 

If  a  portion  of  the  distillate  be  added  to  a  small 
amount  of  Xessler's  solution  (prepared  by  adding  to  a 
solution  of  corrosive  sublimate,  containing  40  grams 
to  300  c.c.  of  water,  a  strong  solution  of  potassium 
iodide  until  a  permanent  precipitate  begins  to  form, 
and  then  adding  to  this  solution  GOO  c.c.  of  a  solu- 
tion containing  160  grams  of  potassium  hydrate),  a 
yellow  or  brown  color  or  a  brown  precipitate  is 
produced. 

A  portion  of  the  distillate  added  to  a  few  drops 
of  a  solution  of  mercuric  chloride  gives  a  white  pre- 
cipitate. 

A  portion  of  the  distillate  added  to  a  few  drops  of  a 
mercurous  nitrate  solution  gives  a  black  precipitate. 

To  a  portion  of  the  distillate,  made  neutral  by  the 
addition  of  dilute  hydrochloric  acid  if  alkaline,  add  a 
little  alcoholic  solution  of  picric  acid.  In  the  pres- 
ence of  ammonia  compounds  yellow  crystals  of  am- 
monium picrate  are  formed  on  standing. 

To  a  portion  of  the  distillate  acidified  with  hydro- 
chloric acid  add  platinic  chloride  solution  and  evap- 
orate to  small  bulk  at  a  gentle  heat.  When  am- 
monium compounds  are  present,  yellow  crystals  of 
ammonioplatinic  chloride  are  formed,  insoluble  in 
alcohol  and  but  slightly  soluble  in  dilute  mineral  acids 
and  free  alkalies. 

In  the  form  of  ammonioplatinic  chloride  the 
quantity  of  ammonia  present  may  be  weighed  and 
calculated.  To  this  end  the  precipitated  double 
chloride  is  filtered  on  to  a  tared  filter  and  washed 
with  strong  alcohol  until  free  from  acid.     After  this 


251 


Ammonia  and  Ammonium 
Salts 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


the  filter  with  its  precipitate  is  dried  at  100°  C.  and 
weighed.  The  ammonium  salt  contains  7.62  per  cent, 
of  its  weight  of  ammonia  as  Nil,. 

Edward  Curtis. 

R.  J.  E.  Scott. 

Amnion. — The  amnion  (Greek  a^vlov)  is  one  of 
the  fetal  appendages,  being  a  thin  membrane  which 
forms  the  innermost  of  the  envelopes  surrounding 
the  fetus.  It  occurs  only  in  mammalia,  birds,  and 
reptiles  (the  Amniota).  Among  the  invertebrates  a 
somewhat  similar  structure,  also  called  amnion,  is 
developed  by  the  embryos  of  many  insects  but  this  is 
not  at  all  homologous  with  the  amnion  of  vertebrates. 

The  amnion  (am.  Fig.  86)  isathin,  delicate  membrane, 
or  sac,  which  is  situated  next  to  the  embryo;  outside 
the  amnion  are  the  chorion  and  allantois,  and  outside 
these  (in  mammals)  the  uterine  walls.  In  the  fully 
developed  human  afterbirth  the  amnion  is  a  well- 
marked,  thin,  pellucid  membrane  lining  the  inner 
surface  of  the  placenta  and  fetal  membranes,  from 
which  it  can  be  easily  stripped  off.  At  the  insertion 
of  the  umbilical  cord  into  the  placenta  the  amnion 
merges  into  the  integument  of  the  cord,  which  differs 
somewhat  in  character  from  the  remainder  of  the 
amnion.  At  the  junction  of  the  cord  with  the  ab- 
dominal wall,  the  superficial  layers  of  the  cord  be- 
come continuous  with  the  skin  of  the  fetus.  Hence 
the  amnion  is  a  structure  continuous  (through  the 
integument  of  the  cord)  with  the  skin,  and  in  the 
main  it  is  genetically  as  well  as  structurally  homolo- 
gous to  the  skin.  The  amnion  possesses  tun  layers: 
the  superficial  layer  (that  directed  toward  the  fetus) 
is  of  ectodermal  origin  and  epithelial  nature,  and  is  the 


Fig.  86. — Fetal  Envelopes  of  a  Rabbit;  Embryo  of  Eleven 
Days.  (From  Minot,  after  Van  Beneden  and  Julin.)  .4.  pi.,  area 
placentitis;  PL,  placenta;  AL,  allantois;  Ch.,  chorion;  a.m.,  amnion; 
a.m.',  portion  of  the  amnion  united  with  the  walls  of  the  allantois; 
Av.,  Av.' ,  area  vasculosa;  T,  sinus  terminalis;  Coe,  ccelom,  or  body 
cavity.  Coe.',  Coe.",  extra-embryonic  portion  of  the  body  ca\  ity; 
En,  endodermin  canal  of  the  embryo;  Ent.' ,  endoderm  of  the  blasto- 
dermic vesicle;  J",  cavity  of  the  blastodermic  vesicle;  Ec,  ectoderm; 
pro- A.,  proamnion. 

precise  homologue  of  the  epidermis;  the  deeper  layer 
is  a  connective-tissue  stratum  of  mesodermal  (somat- 
opleural) origin,  and  corresponds  in  the  main  to  the 
cutis  vera.  Within  the  amnion  is  a  cavity,  the 
amniotic  cavity,  which  is  filled  with  a  fluid,  the 
amniotic  fluid,  in  which  the  fetus  is  immersed. 

A  distinction  litis  been  made  between  the  true  am- 
nion and  the  false  amnion.  The  true  amnion  is  the 
amnion  proper,  the  innermost  of  the  fetal  envelopes. 
The  term  ''false  amnion"  is  now  obsolete.  It  was 
applied  by  English  embryologists  to  what  is  now 
called  membrana  serosa,  or  chorion. 


p. a 


Development  of  the  Amnion. — The  ontogenetit 
development  of  the  amnion  in  all  reptiles  and  bird 
(which  together  are  often  called  the  sauropsida)  ap 
pears  to  take  place  by  substantially  the  same  process 
In  the  mammalia,  however,  there  are  several  impor- 
tant differences  and  variations  in  the  mode  of  amnior 

formation,      tnougl 
in  many  of  the  man 
mals  the  proces 
similar  to  that  in  thi 
sauropsida. 

Amnion     Forma- 
tion  in   i/'.   Sa 
sida. — In  the  d 
opment  of   its   am- 
nion, the  chick  may 
lie    taken  as  repre 
sentative      of     the 
Sauropsida.    A: 
about  the  twenl 
hour   of   incuba 
the  embryonic  area 
(see    Area   i  mbi  .. 
tilix)  of  the  hen 
is    still     continuou 
with      the      get 
blastoderm    tna 
spread  out  flat  over 


Fir..  87.— Embryo  of  the  Albatross     tie  yolk.     Soonaftei 
with    the   Head   partly  Covered  by     this,  the  first  indica- 
the  Amnion,     a,  amnion ;  a.p.,  audi-     tion  of  the  outline  of 
torypit;  m,  mesodermal  wing;  p.a.,      the  embryo  appears 
proamnion.     (After  Sehauinsland.)       as     a     crescontic 
groove  which  sinks  into  the  yolk  and  marks  the  an- 
terior boundary  of  the  head,  the  head  fold.     This  fold 
and  the  blastoderm  in  front  of  it  consist  of  two  girn,- 
layers,  ectoderm  and  endoderm.      The  lateral  wings 
of  mesoderm  grow  forward  on  each  side  and  unite 
some  distance  in  front  of  the  head  fold  enclosing  a 
space  that  is  free  from  mesoderm.     To  this  area  of 
the  blastoderm,  Van 
Beneden    gave    the 
name        proamnion. 
(Pa.  Fig.  87.) 

In  t h e  1  a t e r a  1 
wings  of  mesoderm 
on  each  side  of  the 
head  the  body-cav- 
ity, or  ccelom,  begins 
to  form  between  the 
somatic  and  the 
splanchnic  layers  of 
mesoderm,  and  soon 
becomes  inflated 
into  a  pair  of  large 
cavities  known  as 
the  amniocardiac 
vesicles  (c.  Fig.  90) 
which  eventually  tie- 
come  continuous 
with  one  another  in 
the  median  line  be- 
neath the  fore-gut 
and  extend  laterally 
and  posteriorly  into 
the  extraembryonic 
ccelom.  The  head, 
as  it  enlarges,  grows 
for  ward  over  the 
proamnion  and 
sinks  into  a  cup- 
shaped  depression  of 
which  the  sides  are  walls  of  the  amniocardiac  vesi 
and  the  floor  is  the  proamnion. 

When  the  embryo  has  reached  the  stage  witl 
or  nine  somites  the  development  of  the  amnion  1" 
with  a  thickening  of  the  ectoderm  in  a  narrow  trans- 
verse band  near  the  anterior  boundary  of  the  proam- 


Fig.    88.-     1  mbryo    of    \ 
older    than    Fig.    87.     The  hi 
completely  covered  by  the  amnion, 
in    which    the    mesodermal    winga 
nearly  meet,     a,  amnion;  >".  I 
dermal    «  ing;      ma,    me 
amnion;  p.o..  region  free  from  n 
derm;  p. s.,  primitive  streak.     (Aftet 
Sehauinsland.) 


252 


REFERENCE    IIAXDHOOK    of    THE    MEDICAL    SCIENCES 


,ui.    This   band,  known    as    the  ectamnion,   bends 

iliquely  backward  on  each  side  of  the  head,  extending 

■i  point  aboul  opposite  the  middle  of  tin-  heart. 

the  stage  with  twelve  it  thirteen  somites,  the  head 

to  the  ectamnion,  anil,  bending  downward, 

iks  into  the  proamnion  beneath  it.     At  the  same 

\d  fold  of  the  amnion,  with  tin'  ectamnion 

rest,  begins  to  grow  backward  over  the  head. 

1  tir-t  this   is  a   fold  of   the  proamnion,  but  by  tin' 

ae  it  lias  reached  the  midbrain,  it    is  invaded   by 


pc    h  ph  pc 


I.  — Transverse  Section  of  the  Albatross  Embryo  shown  in 
ss,  interior  to  the  Liue  ma.     a,  amnion;  ao,  aorta;  apt  audi- 
v  pit;  />,  brain;  h,  heart;  m,  mesoderm;  nc,  notochord;  ,. 
-dium;  ph.  pharynx;  5,  serosa;  va,  anterior  vitelline  vein.     (After 
aauinsland.) 

Ida  of  somatic  mesoderm  from  the  amniocardiac 
.  and  the  endodermal  layer  is  withdrawn, 
bile  the  embryo  is  sinking  gradually  into  the  sub- 
rminal  space  and  the  amnion  is  growing  over  the 
ad,  the  ectamnion  is  extending  backward  along  the 
-  ;,-  the  crests  of  two  lateral  folds  of  the  amnion 
igs.  91  and  92)  which  are  continually  being  drawn  in 
tween  the  embryo  and  the  vitelline  membrane  and 
oieh  fuse  along  the  median  line  from  in  front 
ickward,  beginning  at  the  edge  of  the  head  fold  of  the 
anion. 


ac'.  pc 
ph 

Fig.  00. — Seetion  through  the  Line  ma  of  Fig.  88.  a.  amnion; 
.  amniotic  cavity;  c,  ccelom;  ea,  ectamnion;  ec,  ectoderm:  in, 
loderm;  >■>,  somatic,  and  sp,  splanchnic  mesoderm;  other  let- 
ring  as  in  Fig.  89. 

When  the  anterior  half  of  the  embryo  lias  been 
ivered  by  the  amnion,  the  outlines  of  the  body  are 

mpleted  by  tin'  appearance  of  the  tail  fold  of  the 
pleure.      Where  the  posterior  limb  of  this  fold 

ins  the  general  surface  of  the  blastoderm,  the  tail 
Id  of  the  amnion  arises.  This  grows  forward  over 
ic  embrvo  and,  at  the  sides,  becomes  continuous 
ith  the  lateral  folds. 

The  amnion  of  the  chick  is  thus  formed  by  folds  of 
ie    somatopleure    which    meet    and    fuse  over  the 


median  lineol  the  embryo  (ae,  Fig.  90).     At  the  line  of 
fu  urn  t  lie  ectoderm  of  each  fold  separates  ami  unites 
with   its  fellow  of  the  opposite  side.      Tin'   sami 
inn'  of  tin-  mesoderm.     In  this  way  tin-  exoccelom  on 

each  side  of  the  embryo  beCO S  confluent,  separating 

the   two   membrane         I iei    one   i  "■■  ei  ing  the 

embryo  is  the  ami  ion;  the  outer  one  lining  thevitel- 
line  membrane  is  the  chorion,  or  membrana  serosa 
ig.  90).  This  process  of  amnion  formation  in  the 
chick  continues  to  aboul  the  stage  with  thirty-one 
somites,  when  the  embryo  is  completely  covered  ex- 
cepl    for  a   very   small   opening  called   the  arm 


Fig.  91. — Section  of  Fig.  88  behind  the  Head-fold  of  the 
Ainiu.m.  a,  amnion;  ca,  ectamnion;  If,  lateral  fold;  other  letter- 
ing as  in  Fig.  89. 

umbilicus.  This  soon  closes,  but  at  this  point  the 
amnion  and  the  chorion  remain  united,  funning  the 
\tic  connection,  which  later  becomes  per- 
forated allowing  communication  between  the  amni- 
otic cavity  and  the  albumen-sac. 

Among  the  other  Sauropsida  the  development 
differs  (1)  in  the  relative  time  of  beginning;  (2)  in 
regard  to  the  importance  of  the  proamnion;  and  (3) 
in  the  comparative  size  and  form  of  the  several  folds. 

The  amnion,  in  time  of  appearance,  is  earlier  in 
reptiles  and  later  in  birds.  It  is  earliest  in  the 
chameleon  and  latest  in  the  hen.  The  chameleon  is 
peculiar  in  that  the  amnion  arises  as  a  continuous 
elliptical  fold  surrounding  the  area  embryonalis  when 
the  latter  consists  of  but  two  germ  layer-. 


h    ac  pc  nc 

Fig.  92. — Longitudinal  Section  of  an  Embryo  a  little  older 
than  Fig.  87.  a,  proamnion;  hf,  head  fold  of  amnion;  mc,  medul- 
lary canal;  other  lettering  as  in  Figs.  S8  to  91.     After Schaninsland.) 

In  general,  according  to  Schauinsland  (1902)  the 
earlier  the  amnion  appears,  the  greater  the  impor- 
tance and  the  longer  the  duration  of  the  proamnion. 
In  Sphenodon,  a  remarkable,  primitive  reptile  of 
New  Zealand,  in  which  the  amnion  appears  earlier 
than  in  any  other  reptile  except  the  chameleon,  the 
entire  anterior  part  of  the  embryo  is  enclosed  in  the 
proamnion  for  a  great  part  of  the  fetal  life.  The 
embryo  is  bent  nearly'  at  right  angles  into  the  yolk 
and  all  of  the  amnion  from  the  fore-limbs  forward 
is  free  from  mesoderm. 


253 


Amnion 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


In  Sphenodon,  the  turtles,  and  some  birds  where 
the  tail  fold  is  wanting  or  poorly  developed,  the 
amniotic  umbilicus  is  prolonged  as  a  tube,  the  amni- 
otic duct,  which  extends  backward  over  the  blasto- 
derm and  finally  opens  on  the  surface  of  the  chorion. 

For  the  nourishment  of  the  amnion,  blood-vessels 
grow  into  it  from  the  ventral  wall  of  the  embryo, 
about  the  eleventh  day  of  the  chick  embryo.  Some 
of  the  mesodermal  cells  of  the  amnion  become  differ- 


IV:.  93. — Section  of  the  Blastocyst  of  a  Hedgehog  at  the  Stage 
when  the  Amniotic  Cavity  is  a  Cleft  Between  the  Trophoblast  and 
Formative  Ectoderm,  a,  amniotic  cavity;  ec,  ectoderm;  en.endo- 
derin;  trt  trophoblast.      (After  Hubrecht.) 

entiated  into  muscle  fibers  (beginning  about  the 
sixth  day  in  the  chick)  and  these,  by  their  rhythmic 
contractions,  are  capable  of  rocking  the  infant  bird  at 
about  the  rate  of  sixteen  oscillations  per  minute. 

Amnion  Formation  in  Mammalia. — The  Mam- 
malia are  divided  into  three  main  groups:  Mono- 
tremes,  or  Prototheria;  Marsupials,  or  Metatheria; 
and  placental  mammals,  or  Eutheria.  These  groups 
differ  in  the  character  of  their  eggs  and  in  their  ontog- 
eny as  much  as  they  do  in  their  adult  structure. 


Fig,  94. — Section  of  the  Blastocyst  of  a  Hedgehog  in  which  the 
Amnion  is  Complete,  a,  amniotic  cavity;  Co,  ccelom;  en,  endo- 
derm;  tr,  trophoblast.     (After  Hubrecht..) 

In  the  Monotremes,  which  are  oviparous  with  rel- 
atively large  eggs  (3.5-4  mm.)  enclosed  in  a  shell, 
the  formation  of  the  amnion  probably  is  similar  to 
what  has  been  observed  in  the  Sauropsida,  but  the 
steps  in  this  process  are  at  present  unknown.  Semon 
(ls'.M),  however,  has  described  the  fully  formed 
amnion  of  Echidna.  An  extensive  proamnion  is 
present,  and  a  persistent  seroamniotic  connection 
extends  the  whole  length  of  the  fetus. 


The  early  stages  in  the  development  of  the  amnior 
of  Marsupials  is  also  unknown,  but  the  fully  formed 
fetal  membranes  of  a  number  of  species  have  beet 
described.  Semon  (1894)  divides  them  into  twi 
groups.  In  the  one  of  which  the  opossum  is  a  typi 
there  is  a  remarkable  development  of  the  proamnion 
which  envelopes  all  but  the  posterior  extrerjQ 
of  tin'  embryo.  Later,  this  is  converted  into 
amnion    by    the    ingrowth    of    mesoderm    from    tin 


Fig.  95. — Human  Embryo.  Diagram  of  a  Longitudinal  Section 
a,  Amnion;  all,  allantois;  c,  chorion;  cs,  connective  stalk;  c,  area 
embryonalis;  ec,  ectoderm  of  chorion;  m,  mesoderm;  //,  yolk  Bac. 
(After  Spee,  from  Hertwig's  Handbuch.) 

sides  and  behind  between  the  two  primary  germ 
layers  of  the  proamnion.  In  the  other  group  the 
amnion  shows  no  remarkable  characteristics. 

The  development  of  the  amnion  of  the  Eutheria  i 
complicated  by  the  entypy  of  the  embryonic  area, 
which  in  the  new  formed  blastocyst  is  surrounded 
by  an  extra  embryonic  membrane,  tin'  trophobla  I 
of  Hubrecht.  (See  articles  Area  embryonalis  and 
Blaaimlt  nn.j 


Fig.  96. — Human  Embryo  "Gle."  Dimension  of  blastocyat, 
exclusion  of  villi,  S. 5X10X6. 5  mm.;  length  of  area embi 

1.54    i.     Reconstructed  sagittal  section.     All,   allantois;   Am, 

amnion;  b.8,  connective  stalk;  cho,  chorion;  Ec,  ectoderm 
endoderm;  mes,  mesoderm;  Vi,  villi;  Yk,  yolk-sac.  (Aftei 
from  Minot.) 

According  to  Hubrecht  (1912)  the  most  primitive 
method  of  amnion-formation  is  that  found  in  the 
hedgehog.  This  begins  with  a  cleft  that  separates 
the  trophoblast  from  the  formative  ectoderm  of  the 
area  embryonalis.  Later,  this  is  roofed  over  by  :> 
sheet  of  the  extraembryonic  ectoderm  which,  carry- 
ing a  fold  of  mesoderm  with  it,  grows  up  on  all  sides 
finally  enclosing  the  cavity,  which  thus  becomes  the 


254 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Amnion 


amniotic  cavity.  The  double  layer  of  ectoderm  and 
mesoderm  which  now  forms  its  roof,  is,  of  course, 
the  amnion.  The  outer  limb  of  the  mesodermal 
[old  unites  with  the  trophoblastic  ectoderm  to  form 
the  diplotrophoblast,  or  chorion.  (Figs.  93  and  94.) 
In  a  number  of  mammals  is  found  a  very  simple 
type  of  amnion  formation  that  Hubrecht  regards 
as  an  example  of  accelerated  development.  In 
the  ectodermal  central  cell-mass  simply  be- 
hollow.  The  floor  of  this  cavity  is  the  em- 
bryonal area,  its  roof  is  the  amniotic  ectoderm, 
which  subsequently  receives  a  mesodermal  covering. 
!  in-  amnion  is  found  in  this  way  in  the  guinea-pig, 
i in-  hats,  some  insectivores,  edentates,  and  probably 
in  most  primates. 

In  the  earliest,  known  human  embryos,  the  Teacher- 
Bryce  and  the  Peters  embryos,  the  amnion  and  the 
yolk-sac  are  already  formed.  In  both,  the  amnion 
is  a  simple  globular  cavity  lined  by  a  layer  of  ecto- 
dermal cells  and  surrounded  by 
a  solid  mass  of  mesoderm. 
Spee's  von  Herff  embryo  (Fig. 
95),  which  is  somewhat  ad- 
vanced in  its  other  structures, 
has  the  amnion  still  in  the  ear- 
liest known  condition.  Then- 
is  no  evidence  of  any  amniotic 
folds.  The  amnion  is  probably 
formed  by  the  expansion  of  a 
split  in  the  ectoderm  of  the 
inner  cell-mass,  as  in  the 
guinea-pig  and  frugivorous 
bats. 

In  mice,  the  central  cell 
mass  is  elongated,  and  he- 
comes  tubular  with  the  lumen 
closed  at  both  ends;  at  the 
outer  end  by  the  trophoblast, 
at  the  inner  end  by  the  em- 
bryonic area.  The  amnion  is 
formed  by  folds  (a,  Fig.  97) 
which  constrict  this  cavity  near 
the  middle. 

In  the  majority  of  mammals 
the  embryonic  shield  becomes 
spread  out  upon  the  surface  of 
the  blastocyst.  This  may  fol- 
low a  rupture  of  the  tropho- 
blast over  this  area,  as  in  Tar- 
sius,  in  some  insectivores,  and 
in  the  ungulates;  or  may  be 
accompanied  by  a  stretching 
of  the  trophoblast,  as  in  the  rabbit,  where  the  tropho- 
blast  over  the  embryonal  area  becomes  very  thin  and 
finally  disappears.  In  all  of  these  mammals  the 
amnion  is  formed  by  a  folding  of  the  somatopleure, 
very  much  as  it  is  in  the  Sauropsida.  The  main  differ- 
ence is  that  in  the  mammals  the  tail  fold  is  generally 
more  prominent,  with  the  result  that  the  point  where 
the  amnion  finally  closes  is  farther  forward. 

In  the  cat,  however,  the  head  fold  of  the  amnion 
is  the  first  to  appear,  while  in  the  dog  amnion  forma- 
tion begins  with  the  tail  fold  (R.  Bonnet,  1901). 
In  both  the  dog  and  the  cat,  the  mesoderm  at  first  is 
continuous  in  front  of  the  head  region.  But  as  the 
head  develops,  the  mesoderm  disappears  from 
beneath  it.  In  these  animals,  the  proamnion  is  not 
a  primary  structure  as  in  the  chick,  but  is  formed 
econdarily,  and  finally  covers  a  considerable  part  of 
the  embryo  as  it  does  in  the  rabbit  (Fig.  99). 
Later,  the  mesoderm  returns  to  the  proamnion  which 
thus  becomes  uniform  in  structure  with  the  rest  of 
the  amnion. 

Tin  Phylogeny  of  the  Amnion. — The  origin  of  the 
amnion  and  the  history  of  its  development  in  t lie 
course  of  phylogeny  of  the  vertebrates  is  unknown. 
Paleontology  furnishes  no  evidence,  and  we  can  only 
Speculate  as  to  the  probable  history  of  the  amnion 


Flo.  97. — Early  Embryo 
of  Mus  Sylvaticus.  En, 
lerm;  c,  cavity  of 
umbilical  vesicle;  ol,  tro- 
ist ;  TV,  proliferating 
trophoblast;  Ec,  embry- 
onal ectoderm;  a,  ecto- 
dermal cavity,  the  lower 
portion  of  which  is  after- 
rard  cut  off  to  form  the 
amniotic  cavity.  (From 
Minot,  after  Selenka.) 


from  such  facts  as  may  he  gathered  from  embryology 
and  comparative  anal omy. 

First  of  all,  I  he  writers  on  the  history  of  the  amnion 
may  In'  divided  into  t«o  classes:  i  1 )  those  who  regard 
the  amnion  as  formed  independently  of  the  chorion, 

and  (2)  those  who  regard  the  amnion  and  the  chorion 
as  being  due  to  the  same  process.  (If  the  first  group 
Hubrecht  is  almost  the  sole  representative.  lie 
regards  the  trophoblast  which  form-  the  outer  layer 
of  the  chorion  as  a  larval  envelope  similar  to  what  is 
found    in    the  echinoderms   and    -nine    marine   worms, 

where  the  body  of  i  he  first  larval  stage  forms  an  envel- 
ope within  which  a  small  part  of  the  body  gives  rise 
to  the  definitive  embryo  that  developsinto  the  adult 
worm.  Just  as  in  certain  groups  of  worm-,  some 
species  undergo  such  a  metamorphosis,  while  in  others 
the  development  is  direct;  so  Hubrecht  thinks  that 
I  he  ancestral  group  that  gave  rise  to  the  vertebrates 
early  separated  into  two  divisions.  One  of  these 
lost  its  larval  envelope  and  gave  rise  to  Amphioxus, 
the  cyclostomes  and  elasmobranchs,  in  which  no 
trace  of  trophoblast  has  been  found;  the  other  divi- 
sion retained  its  larval  envelope  and  its  descendants 
include  the  ganoids,  dipnoi,  teleosts,  Sauropsida,  and 
Mammals,  in  all  of  which  groups  Hubrecht  finds  the 
trophoblast  to  be  more  or  less  developed. 

He  regards  the  type  of  amnion  as  found  in  the 
hedgehog  as  the  most  primative  and  as  having 
arisen  in  the  holoblastic  eggs  (see  Segmentation  of  the 
ovum)  of  the  viviparous  quadruped  (Prototetrapoda) 
which  first  forsook  aquatic  life  for  the  land  and  gave 
rise  to  the  terrestial  vertebrates.  The  oviparous 
habit,  large  yolk,  and  folded  amnion  of  the  Sauropsida, 
are,  according  to  Hubrecht,  secondary  acquisitions. 

Although  brilliantly  expounded  and  supported  by 
a  wealth  of  facts,  Hubrecht's  argument  is  not  con- 
vincing to  the  majority  of  zoologists,  for  several 
reasons. 

In  t he  first  place,  Hubrecht's  hypothesis  involves 
the  theory  of  the  amphibian  origin  of  mammals, 
which  is  by  no  means  universally  accepted,  although 
supported  by  certain  morphological  comparisons; 
as  in  the  development  of  the  heart,  and  ear  bones, 
and  the  anatomy  of  the  epiglottis  and  the  intestinal 
arteries. 

In  the  second  place,  if  we  accept  Hubrecht's  views, 
we  must  believe  that  the  Sauropsida  have  abandoned 
the  viviparous  habit  for  the  oviparous  one  and  that 
the  yolk  of  these  forms  is  not  a  gradual  development 
from  the  conditions  found  in  the  present  representa- 
tives of  the  amphibia,  but  has  been  acquired  anew. 
This  seems  highly  improbable,  because  it  would 
seem  to  involve  a  loss  of  productive  efficiency,  and, 
moreover,  the  other  groups  of  the  animal  kingdom 
present  no  analogy  for  such  a  course  of  evolution. 

Those  who  believe  that  the  Sauropsida  and  Mam- 
malia have  evolved  independently  from  amphibian 
ancestors,  must  believe  in  the  independent  origin  of 
the  amnion  in  the  two  groups.  This  seems  very 
improbable  on  general  biological  principles,  and 
needs  very  strong  support  on  morphological  grounds, 
especially  in  view  of  the  important  results  recently 
announced  by  Hill  (1910).  Without  going  into 
details,  (for  which  see  articles  Ovum  and  Blastoderm) 
it  may  be  said  that  Hill  finds  in  the  eggs  of  the  Mono- 
tremes  and  Marsupials  progressive  stages  connecting 
the  Sauropsidian  type  of  egg  with  that  found  in  the 
higher  mammals  (Eutheria). 

Whatever  views  may  be  held  regarding  the  morpho- 
logical history  of  the  amnion,  from  the  physiological 
point  of  view  it  must  be  regarded  as  an  adaptation  to 
a  terrestrial  mode  of  life.  In  the  Ichthiopsida 
(fishes  and  amphibia),  life  is  either  wholly  aquatic  or 
else  generally  so  in  the  larval  stage,  and  either  the 
whole  egg  is  developed  into  the  embryo,  or  else  the 
embryo  is  folded  off  from  the  general  blastoderm, 
which  grows  over  the  yolk  forming  a  double  layered 
yolk  sac,  that  is  eventually  absorbed.     In  this  case 


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the  embryo  projects  from  the  upper  surface  of  the 
volk-sac,  as  is  well  seen  in  the  catfish.  (Jlinot,  1903, 
Fig.  97.) 

The  embryos  of  the  Amniota,  on  the  other  hand, 
never  project  above  the  general  surface  of  the  blasto- 
derm, but  sink  into  it,  or  else  are  developed  from  the 
first  in  a  depressed  area.  In  either  case,  the  embryo 
is  soon  enclosed  in  the  amnion,  which  is  filled  with 
a  fluid.  Thus,  although  on  land,  the  young  replilc, 
bird,  or  mammal  really  leads  an  aquatic 
life  from  conception  until  birth. 

Several  authors  have  sought  mechan- 
ical explanations  of  the  origin  of  the 
amnion.  Balfour  tried  to  explain  the 
amnion  and  chorion  as  formed  by  a 
folding  of  the  somatopleure  which  results 
from  the  development  of  the  allantois. 
It  has  been  objected  that,  the  amnion 
may  be  fully  formed  before  there  is  any 
trace  of  the  allantois.  This  disproves 
any  direct  mechanical  effect;  but,  never- 
theless, the  two  organs  may  be  geneti- 
cally related  in  tin'  history  of  the  race. 
We  have  many  examples  of  the  develop- 
ment of  organs  in  ontogeny  in  anticipa- 
tion of  their  use.  A  woman  develops 
breasts  long  before  she  has  a  child  to 
suckle,  yet  we  must  believe  the  evolu- 
tion of  mammas  to  have  been  genetically  related  to 
the  production  of  offspring. 

Van  Beneden  and  Julin  sought  for  an  explanation 
of  the  amnion  in  the  effect  of  gravity,  causing  the 
embryo  to  sink  into  the  fluid  yolk.  But  Semon 
(1894)  has  shown  that  the  embryo  at  first  has  less 
specific  gravity  than  the  yolk. 

Selenka  regards  the  amnion  as  the  direct  mechan- 
ical effect  of  the  development  of  the  allantois  and  its 
distention  with  embryonic  urine,  combined  with  a 
bending  of  the  embryo  into  the  yolk  that  results  from 
the  cephalic  and  cervical  flexures. 

Semon,  on  the  other  hand,  has  pointed  out  that 
the  amnion  is  a  protective  organ  that  has  been  d<\  el- 
oped by  natural  selection  in  the  course  of  evolution, 
and  that  it  is  not  to  be  regarded  as  purely  the  result 
of  the  developmental  processes  of  neighboring  organs. 

In  order  that  an  animal  may  bring  forth  young  on 
land,  either  the  young  must  develop  in  the  oviduct 
until  viable  in  air,  or  the  egg  must  be  provided  with  a 
shell.  The  former  is  the  primary  condition  according 
to  Hubrecht,  the  latter,  acording  to  Hill  (1910),  who 
makes  the  important  suggestion  that,  "The  acqui- 
sition of  a  shell  by  the  Proamniota  conditioned  I  In' 
appearance  of  the  amnion.  The  loss  of  the  shell  in 
the  Eutheria  conditioned  the  occurrence  in  their 
ontogeny  of  entypy."  Little  reflection  is  needed  to 
make  il  appear  that  Hill  is  probably  correct.  Deane 
has  described  the  relation  of  the  shell  te  the  embryo 
in  the  chimeras,  but  it  would  be  interesting  in  view 
of  Hill's  hypothesis  to  know  what  influence  the  shell 
has  upon  ontogeny  in  other  fishes  that  have  egg  shells, 
as  the  skates,  ami  in  what  way  the  embryo  is  modified 
in  the  terrestrial  amphibia  that  do  not  lay  eggs  in 
water  but  deposit  in  moist  places  eggs  covered  with  a 
leathery  shell. 

Anatomy  and  Histology  of  the  Human  Amnion. 
— The  amnion  in  the  fully  developed  afterbirth  is  a 
thin,  smooth,  translucent  membrane  lining  the  inner 
or  fetal  surface  of  the  placenta  and  membranes. 
It  rests  upon  the  chorion,  to  which  it  is  loosely  at- 
tached— so  loosely  that  it  has  some  play  on  the  chorion 
and  can  be  easily  stripped  off.  At  the  placental 
insertion  of  the  umbilical  cord  the  amnion  merges 
into  the  integumentary  covering  of  the  cord,  which, 
while  corresponding  to  the  amnion,  differs  from  the 
latter  in  some  important  particulars. 

The  amnion  is  made  up  of  two  layers:  (1)  a  super- 
ficial ectodermal  epithelial  layer,  and  (2)  a  deeper 
mesodermal  connective-tissue  layer. 


1.  The  inner  free  surface  of  the  amnion,  that  di 
rected  toward  the  fetus,  is  lined  by  a  single  layer  o 
epithelial  cells  of  ectodermal  origin.  These  cells  a 
an  early  period  are  thin,  but  later  become  thicker 
low  columnar  or  cuboidal  in  form.  At  times,  however 
in  the  mature  state  they  appear  thin  and  squamous 
The  measurements  of  the  dimensions  of  these  cell; 
(diameters  or  diagonals)  given  by  various  obsen  en 
vary  from  0.008  to  0.012  mm.  (Dohrn),  0.011  to  0.01! 


Fig.  9S. — Epithelial  Cells  Lining  Inner  Surface  of  the  Amnion.     Surface  view. 
Silver  nitrate  and  hematoxylin.      X  1,000. 

mm.  (Kolliker),  0.011  to  0.014  mm.  (Lang.),  0.011 
to  0.033  mm.  (Nichols).  The  varying  sizes  of  these 
cells,  as  stated  by  different  observers,  probably 
depend,  partly  at  least,  upon  the  degree  to  which 
the  membrane  is  stretched  in  the  process  of  prep- 
aration for  microscopical  examination.  When  hard- 
ened by  the  usual  reagents  without  taking  any  pre- 
cautions, the  membrane  is  apt  to  contract  or  shrink 
in  superficial  extent  and  at  the  same  time  to  become 

*  MM, 


Fig.    99. — Surface  View  of    Eoithelium  of  Amnion  from   1  It- 
Day  Embryo,  Showing  Intercellular  Bridges  or   1' esses  (pr) 

pi,  Protoplasm  (cytoplasm):  nu,  nuclei.      XI, 225.     (Miuot.) 

thicker,  thus  giving  these  cells  an  appearance  of 
greater  thickness  and  less  superficial  area:  while 
when  stretched  on  a  cork  and  so  hardened,  the  cells 
may  be  unduly  stretched  and  thinned. 

Viewed  from  the  surface,  as  after  treatment  by  the 
silver-nitrate  method  to  bring  out  the  cell  boundaries, 
these  cells  present  the  appearance  of  pavement 
epithelium,  uniting  in  a  single  layer  edge  to  edge, 
with  often  slightly  wavy  margins,  and  being  in  shape 
polygonal    (often  pentagonal   and  hexagonal),  elon- 


256 


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Amnion 


gated,  or  irregular  (Fin-  98).     Some  observers  have 
seen  intercellular  bridges  uniting  these  cells  (Fig.  99). 

Viewed  in  vertical  sections,  the  amniotic  epithe- 
lial colls  appear  as  low  columnar,  cuboidal,  or  thinner 

;  the  nuclei  arc  often  situated   near  the  free  ends 
0f  the  cells,  leaving  a  clearer  protoplasmic  none  in  the 
per  portions  (Figs.  100,  L03,  104). 
Che  nuclei  of  these  cells  are  rounded  or  spherical, 
about  0.004  mm.  diameter.     Most  of  the  cells  contain 
g  single  nucleus  each,  hut   cells  containing  two,  three, 
or  four  nuclei  are  common;  these  multinucleated  cells 
of  larger  size  than  the  uninucleated.      In  the  latter 
part   of  pregnancy   the  epithelial  cells  sometimes  un- 
dergo a  certain  degree  of  degeneration.     Among  these 


■*;■-, 
v  Mes 

-  Msth 

Fir,.    100. — Section   of  Placental  Portion    of   Amnion   of  Two- 
months'   Embryo.     Ec,  epithelial  layer;  Afcs,  mesenchymal  con- 
ive-tissue     layer;    Msth,    mesothelial     or     endothelial    layer. 
250.     (Minot.) 

cells  are  occasionally  observed  round  clear  spaces 
or  objects,  which  have  been  variously  interpreted 
as  stomata,  vesicles,  or  cells  that  have  undergone 
mucinous  degeneration  and  burst. 

2  Beneath  the  superficial  epithelial  layer  is  a  con- 
nective-tissue stratum  of  mesodermal  origin.  This 
stratum  can  be  divided  into  two  layers:  (a)  a  thick 
connective-tissue  layer  (mesenchymatous),  and  (b) 
in  endothelioid  (mesothelial)  layer  lining,  par- 
tially at  least,  the  outer  surface  of  the  amnion,  that 
directed  toward  the  chorion 

(n)  The  connective-tissue  layer  of  the  amnion, 
underlying  the  epithelial  layer,  makes  up  the  larger 
part  of  the  thickness  of  the  membrane,  and  corresponds 


Fig.  101. — .Surface  View  of  Nuclei  of  Cells  of  Amnion  from  Five- 
Months' Fetus.      X  1,225.     (Minot.) 


to  that  portion  of  the  mesoderm  which  has  been 
termed  the  mesenchyma.  This  layer  is  somewhat  em- 
bryonic in  character,  and  consists  of  connective- 
li-Mie  cells  embedded  in  an  abundant  matrix.  The 
cells  for  the  most  part  occupy  the  deepest  plane  of  the 
amnion,  often  leaving  in  the  upper  portion  of  this 
connective-tissue  layer,  immediately  beneath  the 
epithelial  layer,  a  zone  that  is  free  from  cells  (Fig. 
103).  The  nuclei  of  these  cells  are  at  first  rounded 
and  oval,  but  later  become  irregular  in  form  and 
size.  The  cells  are  flat  and  thin,  arranged  parallel  with 
the  surface.  The  shapes  of  these  cells,  especially  in  the 
ire  amnion,  have  not  been  well  made  out;  one 
specimen  from  a  mature  afterbirth  in  which  the 
amnion   had   remained    permanently   separate   from 


the  chorion,  presenting  unusually  favorable  condi- 
tions for  observal  ion,  (Fig.  102)  has  been  examined  by 
the  writer  (Nichols).  In  this  instance  the  connect  i ve- 
t  issue  cells  were  mostly  huge  flat  cells,  very  irregular  in 
form,  giving  off  irregular  processes  and  branches, 
some  broad,  some  fine  and  filamentary.  The  proc- 
esses of  neighboring  cells  were  often  directly  con- 
tinuous with  one  another.     The  general  outlines  of 

the  smaller  of  these  cells  were  often  roughly  rounded; 
of  the  larger,  polygonal  or  altogether  irregular. 
These  cells  ranged  in  size  from  0.025  to  0.100  nun. 
in    extreme  dimensions,    measuring    between   the   e.x- 


Fig.   102. — Connective-Tissue  Colls  from  Mesenchymatous  Layer 
of  the  Amnion.     Silver  nitrate  and  hematoxylin.      X500. 


tremities  of  the  processes  (perhaps  the  specimen  in 
which  these  measurements  were  made  was  somewhat, 
overstretched).  Mingled  with  these  larger  cells  were 
smaller  rounded  or  oval  cells,  not  so  well  provided 
with  processes  and  ranging  in  size  from  about  0.008 
to  0.016  mm. 

The  intercellular  matrix  in  which  the  connective- 
tissue  cells  of  this  layer  are  embedded  is  a  homo- 
geneous ground  substance  said  to  be  of  gelatinous 
or  mucinous  character.  At  times,  however,  toward 
the  close  of  pregnancy,  the  deeper  portion  of  the 
layer  (where  the  cells  are  mostly  situated)  becomes 


Fig.  103. — Section  of  Placental  Amnion  from  Eight-Months* 
Embryo,  ect,  epithelial  layer;  mes,  connective-tissue  layer,  show- 
ing non-cellular  subepithelial  stratum  and  deeper  fibrous  stratum. 
X340.     (Minot.) 

markedly  fibrous  in  character  (Fig.  103),  the  outer 
subepithelial  non-cellular  stratum  still  retaining  its 
homogeneous  mucinous  nature.  The  amnion  of  man 
is  a  non-vascular  structure  and  contains  no  blood- 
vessels; the  presence  of  an  extensive  system  of  lymph 
channels  has  not  been  definitely  demonstrated,  though 
such  vessels  may  be  present.  The  amnion  of  the 
chick  is  contractile,  and  is  said  to  contain  muscle 
cells. 

(b)  The  outermost  surface  of  the  amnion,  that  di- 
rected toward  the  chorion,  is  lined,  partially  at  least, 
by  a  single  layer  of  thin,  flat  endothelioid  cells  (Figs. 


Vol.  I.— 17 


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100,  101).  These  are  descendants  and  representatives 
of  the  mesotheliai  cells  which  line  the  coelom  and 
from  which  the  endothelial  cells  of  the  pleura  and 
peritoneum  are  also  derived.  These  cells  are  nat- 
urally well  marked  in  the  early  period  of  pregnancy, 
while  the  amnion  is  still  unattached  to  the  chorion 
and  presents  a  free  (.niter  surface.  A  similar  layer 
of  cells  probably  lines  the  innermost  surface  of  the 
chorion.  After  the  amnion  becomes  united  with  the 
chorion,  these  cells  would  probably  be  suppressed 
at  the  points  of  union  of  the  two  membranes,  though 
even  at  full  term  such  cells  have  been  seen  at  a  plane 
corresponding  to  the  deepest  part  of  the  amnion  or 
innermost  part  of  the  chorion,  perhaps  lining  spaces 
left  between  the  membranes  similar  to  lympn  spaces 
in  the  bodv  lined  with  endothelium. 


mes 


Fig.  104. — Section  of  Placental  Amnion,  at  Term,  cct ,  Epithelial 
layer;  mes,  mesenchyznatous  connective-tissue  layer;  a,  meso- 
theliai endothelioid  layer.      X  340.      (Minot.) 

In  the  specimen  of  afterbirth  above  referred  to,  in 
which  the  amnion  remained  permanently  separate 
from  the  chorion  and  presented  a  free  outer  surface, 
this  layer  of  cells  was  nicely  demonstrated  by  the 
silver-nitrate  method  (Fig.  105).  On  surface  view 
these  cells  were  mostly  of  hexagonal  shape  (some 
pentagonal  and  heptagonal),  quite  uniform  and 
regular  in  shape  and  size,  with  slightly  rounded  angles. 
They  were  united  to  one  another  by  their  edges, 
which  were  straight,  not  sinuous.  Their  size  was 
small,  measuring  0.0055  to  0.007  mm.  in  diameter. 
They  did  not  form  a  complete  lining  over  the  entire 
outer  surface  of  the  amnion,  or  at  least  they  appeared 
only  in  patches;  perhaps  many  of  them  were  lost 
from  degeneration.  No  nuclei  were  visible  in  them 
■ — possibly  another  degenerative  sign;  if  present,  they 
did   not  take  the  nuclear  stains  employed.    Patches 

of  precisely  similar  cells 
were  also  obsen  ed  on 
the  inner  surface  of  the 
chorion  in  this  case. 

The  covering  of  the 
umbilical  cord,  which  is 
continuous  at  the  pla- 
cental end  with  the 
amnion  and  at  the  fetal 
end  with  the  skin, 
differs  in  some  marked 
characters  from  the 
amnion  elsewhere. 
This  covering  consists  of  a  superficial  layer  of  epithe- 
lium, which  rests  directly  upon  the  mucoflbrous  tissue 
composing  the  chief  part  of  the  cord.  The  integu- 
ment of  the  cord  is  therefore  intimately  adherent 
to,  or  an  integral  part  of,  the  cord,  and  cannot  be 
stripped  off  as  can  the  amnion  elsewhere.  The  epi- 
thelial covering  is  composed  at  first  of  a  single  layer 
of  cells,  but  later  becomes  stratified  squamous  in 
character,  consisting  of  two  to  four  layers  of  len- 
ticular cells. 

Union  of  Amnion  and  Chorion. — In  its  origin  and 
early  period  the  amnion  is  distinct  from  the  chorion 
and  separated  from  it  by  a  space,  which  is  the  extra- 
embryonic part  of  the  ccelom,  and  is  homologous 
and  at  first  continuous  with  the  pleural  and  peritoneal 
cavities.  After  about  the  third  month  of  pregnancy, 
in   man,    the   amnion   comes   into   contact  with   the 


Fig.  105. — Endothelioid  Cells  of 
Outer  Surface  of  Amnion  (and 
Inner  Surface  of  Chorion).  Silver 
nitrate.      X  1,000. 


chorion,  and  the  two  membranes  grow  loosely  together. 
The  precise  character  of  the  histological  connection 
between  the  amnion  and  chorion  has  not  been  well 
made  out. 

Abxormalities  of  the  Amnion. — Very  rarely  is 
the  amnion  the  seat  of  abnormal  or  pathological 
conditions.  Such  abnormalities  may  arise  in  two 
ways:  from  anomalies  of  development,  or  from 
pathological  processes. 

Among  conceivable  anomalies  of  developmeni 
the  amnion  might  be:  complete  absence  of  the  amnion; 
incomplete  development  of  the  amnion  from  failure 
of  one  of  the  amnion  folds  to  grow;  failure  of  tin 
edges  of  the  amnion  folds  to  unite,  leaving  a  hi 
in   the   amnion  and   chorion;   persistence  of  a  coYd 
or    connection    of    tissue   between   the   amnion   and 
chorion    (the    "amniotic    cord"),    such   as   normally 
occurs  in  ruminants:  incomplete  expansion  of  ami 
after    closure,    compressing    the    fetus.     Some   such 
anomalies   of   development   have   been   occasion; 
observed   in   some   animals,   but   in   man   they   are 
exceedingly  rare. 

A  couple  of  human  cases  are  recorded  (Hamard) 
in  which  there  was  a  separate  small  amniotic  pouch 
around  the  abdominal  insertion  of  the  umbilical  co 
The  reporter  of  one  of  these  cases  attributed  the  con- 
dition to  a  rupture  of  the  amnion  (the  chorion  re- 
maining intact)  with  retraction  of  the  amniotic  mem- 
brane. Hamard,  who  reported  tin-  other  case,  con- 
sidered the  condition  to  be  due  in  both  cases  to  an 
early  anomaly  in  the  development  of  the  amnion. 

It  happens,  rarely,  that  the  primitive  separation  of 
the  amnion  and  chorion  persists,  in  man,  throughout 
pregnancy,  so  that  the  fetus  to  the  time  of  birth  is 
enveloped  in  two  separate  sacs,  the  amnion  internally 
and  the  chorion  (united  to  the  decidua)  externally. 
This  constitutes  a  rare  anomaly  of  the  human  after- 
birth, of  which  the  writer  has  reported  one  case  and 
cited  seven  other  cases  found  recorded. 

Small  nodules  or  caruncles  have  been  observed  in 
the  human  amnion,  scattered  about  in  considers 
numbers,  some  flat  and  sessile,  some  more  or  less 
pedunculated,  and  ranging  in  size  from  (hat  of  a  pin- 
head  to  that  of  a  pea.  Structurally,  these  are  of  two 
kinds,  one  composed  of  epithelium,  the  other  of  con- 
nective tissue.  The  epithelial  nodules  are  commoner 
and  have  little  or  no  pathological  significance;  thy 
are  small  aggregations  of  epithelial  cells.  The  con- 
nective-tissue nodules  are  composed  of  tissue  like 
that  of  the  mesodermal  portion  of  the  amnion;  they 
are  very  rare,  and  have  been  observed  in  connection 
with  early  fetal  death. 

Adhesions  of  the  amnion  to  various  parts  of  the 
fetus,  with   resulting  deformities  of   the  latter,  I 
been   observed.     These    adhesions   have   apparently 
been  due  to  inflammatory  action. 

Deficiency  and  excess  in  the  quantity  of  the  amniotic 
fluid,  with  the  resulting  pathological  consequences, 
are  considered  in  other  articles. 

Amniotic  Fluid. — The  amniotic  sac  is  filled  with  a 
serous  fluid,  the  amniotic  fluid  or  liquor  amnii,  in 
which  the  fetus  is  immersed. 

In  quantity  the  amniotic  fluid  at  full  term  in  the  hu- 
man female  may  vary  greatly,  but  ordinarily  ranges 
from  about  500  to  1,000  c.c,  averaging  from  600  to 
800  c.c.  Abnormally  there  may  be  a  deficiency  (oligo- 
hydramnios) or  an  excess  (polyhydramnios)  of 
amniotic  fluid,  both  conditions  giving  rise  to  certain 
pathological  conditions  and  dangers.  The  differences 
in  quantity  at  different  periods  of  pregnancy  are  not 
well  determined;  it  is  quite  possible  that  the  fluid 
increases  in  amount  during  the  earlier  portion  of 
pregnancy,  and  diminishes  in  the  later  portion. 

The  liquor  amnii  is  a  serous  or  watery  fluid,  con- 
taining in  solution  a  small  proportion  of  protein, 
organic,  and  mineral  substances.  It  is  normally 
clear,  limpid,  and  transparent,  colorless,  alkaline  in 
reaction,  and  has  a  specific  gravity  of  about  1.007  or 


25S 


REFER  KM  IE    HANDBOOK    OK   THE    MEDICAL    SCIENCES 


Amnion,  Pathology 


1.008.  It  contains  from  one  to  two  per  cent,  of  dry 
solids,  besides  a  small  amount  of  adventitious  epithe- 
ligj  cells,  haii's,  vernix  caseosa,  and  occasionally 
leucocytes.  Proteins  (albumin,  globulin,  mucin, 
eto.)  are  present  in  the  early  part  of  pregnancy  in 
large  amount  (10.77  per  cent,  at  four  months,  7.67 
per  cent,  at  fix  e  months,  (i.ti7  per  cent,  at  six  mont  h  !, 
l, hi  undergo  a  great  decrease  toward  the  end  of  preg- 

cy,  when  there  is  only  a  small  proportion  present 
(0.82  per  cent.).  The  inorganic  sails  present  are 
those  usually  found  in  serous  fluids,  chiefly  salts  of 

i,  potassium,  ammonium,  and  calcium.      Urea 

is  present  in  slight  proportion;  t  he  aim  unit  is  less  early 

in  pregnancy  and  gradually  increases,  0.03  or  0.045 

per  cent,  being  present  at  the  ninth  and  tenth  months. 

(larked  abnormalities  in  the  physical  and  chemical 

racteristics  of  the  amniotic  fluid  have  been  rarely 
encountered. 

\-  io  the  source  from  which  the  amniotic  fluid 
originates,  there  have  been  two  opposing  views:  one 
that  it  is  derived  (in  mammals  at  least)  from  the 
maternal  tissues  by  transudation  from  the  decidua 
through  the  chorion  and  amnion;  the  other  that  it  is 
derived  from  the  fetus,  being  the  excretory  products 
of  the  urinary  or  sweat  glands  of  the  latter.  The 
view  that  the  liquor  amnii  is  of  fetal  origin  has  long 
been  held;  but  in  opposition  thereto  and  in  support 
of  its  maternal  origin  it  has  been  urged  by  Minot  that 
the  fluid  in  its  composition  does  not  resemble  urine, 
but  is  more  of  the  nature  of  a  serous  fluid  transuded 
from  the  blood-vessels:  that  the  fluid  appears  before 
the  urinary  or  other  excretory  glands  of  the  embryo 
are  developed  and  while  the  urethral  outlet  of  the 
male  is  still  imperforate;  and  that  substances  experi- 
mentally administered  to  the  mother  have  afterward 

i  found  in  the  liquor  amnii  but  not  in  the  fetal 
tissues.  On  the  contrary,  the  fluid  occurs  in  saurop- 
sidan  embryos  which  have  lost  their  connection  with 
the  maternal  tissues;  and  as  to  the  finding  of  dines 
administered  to  the  mother  in  the  liquor  amnii  but 
not  in  the  fetus,  it  is  possible  that  the  substances 
may  have  been  entirely  excreted  and  eliminated 
from  the  fetus  and  discharged  into  the  amniotic 
fluid.  Possibly  in  mammals  the  fluid  is  derived  from 
both  the  fetus  and  the  mother — from  the  mother  at 
first  and  later  from  the  urine  of  the  fetus,  but  in 
man,  according  to  Grosser,  the  latter  source  is  not 
important. 

The  function  of  the  amniotic  fluid  is  largely  to 
ai end  protection  to  the  fetus  in  utero,  by  equalizing 
the  pressure  on  all  parts  of  the  fetal  body  and  pre- 
venting undue  direct  pressure  of  the  uterine  walls  on 
particular  parts  of  the  fetus.  By  maintaining  a 
symmetrical  shape  of  the  uterus,  and  protecting  the 
umbilical  cord  and  uterine  walls  from  excessive  and 
unequal  local  pressure,  it  obviates  interference  with 
the  umbilical,  placental,  and  uterine  circulation.  The 
amniotic  fluid  also  permits  the  movement  of  the 
fetus  in  the  uterus,  and  prevents  adhesions  of  the 
fetus  to  the  amnion  or  of  parts  of  the  fetus  with  one 
another  from  taking  place.  The  symmetrical  dis- 
tention of  the  womb  by  it  facilitates  and  assists  in 
the  dilatation  of  the  os  uteri  during  labor.  It  has 
been  also  asserted  that  the  amniotic  fluid  serves  as  a 
source  of  water  for  the  fetus;  as  the  fluid  contains  only 
a  small  proportion  of  solids,  it  could  have  little  nutri- 
tive value  except  as  supplying  water.  It  is  well 
settled  that  both  mammalian  and  bird  embryos 
swallow  amniotic  fluid;  but  whether  this  is  done  as  a 
reflex  act  or  for  nutritive  purposes,  or  whether  the 
placental  circulation  is  incapable  of  furnishing  suffi- 
cient water  to  the  fetus,  is  not  known. 

J.  B.  Nichols. 
Revised  by  R.  P.  Bigelow. 

Referexces. 
Bonnet,  R.  (1901).     Beitriige  zur  Embryologie  des  Hundes.      1. 
Fortsetzung.     Anat.  Hefte,  51  (Bd.  16,  Heft  2),  p.  232-413. 

Hill,  J.  P.  (1910).     The  early  development  of  the  Marsupialia, 


with     pecial   ace   bo   the   native  cal     I '     i  iru     rivin 

Q   .1    Mir   Sci.,  vol.  hi.,  i>.  I    I  ;  i 

Hubrechti  A.    V.  W.  (18  ESarly  ontogenetic  phei lena  in 

mammals  and  their  bearing  on  ou pretal i  '  I"   phyli 

"i  the  vertebrates.     Quart.  Jour.  Mic   Sci  .  '■"!   liii  .  pp.  I    181. 

Hubrecht,    V     \.   w       191  !        I  ruhe   I  ntwicklungsstadien  des 
[gels  und  ihre  Bedeutung  fur  die  Vorgeschichte    Phylogi 
Amnions.     Zool.  Jahi  b.    Suppl    15     I  estrchr 

;       ,    19     771. 

Keibel,  I  .  1 1910  a),  "i  oung  human  ova  .'en  I  embryos  up  to  the 
formation  ol  the  first  primitive  segment.  Keibel  and  Mall's 
Manual  of  human  embryology,  vi   i  .  p   2]    !_' 

Keibel,  F.  (1910  6).  The  formation  ol  the  germ  layei  md  the 
i. >n  pri >l ilera.     f.c,  p    13 

Lillie,  !•'.  It.  il'.ins).     The developmei thechick.     Nen  York: 

Hell. 

Minot,    C.    S.    (1903).     Laboratory    texl  "logy. 

Phila    Blakiston. 

Schauinsland,  If.  (1902).  Die  I  atwickelung  der  Eihaute  der 
Reptilien  und  der  VogeL  Hertwig's  Handbuch,  Bd.  1.  Teil.  2, 
p.  177-234. 

Semen,  Richard  (1894).  Die  EmbryonalhtUlen  der  Monotre- 
rnen  mid  Marsupialier.  Zool.  Forsch.  im  Australien,  Bd.  2,  J.fg. 
1.      (l)enk.  .Med    nat.  Gessel.  Jena),  p.  17—74. 

Si  relit,  II,  (1902).  Die  EmbryonalhUllen  der  Siiuger  und  die 
Placenta.     Hertwig's  Handbuch.     Bd.  1,  Teil  2,  p.  235-270. 


Amnion,  Pathology. — The  amnion  is  the  inner- 
most of  the  membranes  inclosing  the  fetus.  It  is 
continuous  with  the  fetal  epidermis  at  the  umbilicus 
and  forms  a  sheath  about  the  umbilical  cord.  The 
exact  manner  of  the  development  of  the  human  am- 
nion is  as  yet  unknown,  for  in  the  earliest  embryos 
examined  it  forms  a  complete  sac  about  the  embryo. 
It  probably  arises  through  the  vacuolization  of  a  por- 
tion of  the  inner  cell-mass,  and  is,  therefore,  a  closed 
cavity  from  the  beginning.  Morphologically,  it  is  a 
part  of  the  body  wall.  It  consists  of  two  layers:  an 
epithelial  one  continuous  with  the  ectoderm,  and  a 
layer  of  embryonic  connective  tissue  continuous  with 
the  somatic  mesoderm.  The  epithelial  layer  is  on  the 
inside  of  the  membrane,  toward  the  fetus;  the  con- 
nective-tissue layer  on  the  outside,  next  to  the  chorion 
and  uterus  wall. 

The  membrane  is  thin  and  translucent,  containing 
no  blood-vessels,  but  is  rich  in  large  lymph  spaces, 
forming  lacunae  in  which  the  mesodermic  cells  lie. 
These  spaces  are  connected  by  a  system  of  very  fine 
lymphatics.  In  the  earliest  stage  the  tissue  of  the 
.-minion  consists  of  but  two  layers  of  cells  (ectodermal 
and  mesodermal),  between  which  lies  a  distinct  space. 
By  the  second  month  these  layers  have  become  united, 
and  the  mesodermal  portion  has  increased  greatly  in 
thickness  so  that  it  is  capable  of  being  divided  into 
two  parts,  a  thin  mesothelial  layer  covering  the  cho- 
rionic surface  of  the  membrane,  and  the  mesenchyma, 
which  makes  up  the  greater  part  of  the  fully  devel- 
oped amnion.  The  tissues  of  the  amnion  do  not 
normally  develop  beyond  an  early  embryonic  stage; 
the  ectoderm  preserves  its  one-layered  structure,  and 
the  mesodermal  tissue  remains  embryonic  in  char- 
acter. No  blood-vessels  or  nerves  have  been  found 
in  the  human  amnion.  In  the  later  months  of 
pregnancy,  physiological  degenerative  changes  occur 
in  both  mesodermal  and  ectodermal  nuclei. 

The  amniotic  fluid  (liquor  amnii)  is  most  probably, 
for  the  greater  part,  a  secretion  of  the  amnion,  but 
the  manner  of  this  secretion  or  the  source  of  supply 
to  the  amnion  is  still  unknown.  In  the  later  months 
of  pregnancy  some  portion  of  the  fluid  is  undoubtedly 
derived  from  the  fetus.  It  is  probable  that  the  fluid 
is  secreted  by  the  capillaries  of  the  chorionic  villi  next 
to  the  amnion,  and  is  passed  on  through  the  amnion 
by  means  of  the  activity  of  its  cells.  The  fluid  serves 
as  a  source  of  water  supply  to  the  fetus;  and,  as  a 
mechanical  protection  against  blows,  shocks,  pressure, 
etc.,  it  assists  in  maintaining  a  uniform  temperature, 
allows  room  for  fetal  movements,  and  aids  in  delivery. 
The  amniotic  fluid  has  a  specific  gravity  of  about 
1.003,  and  contains  about  one  per  cent,  of  solids,  chiefly 


259 


Amnion,  Pathology 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


albumin,  urea,  and  grape  sugar.  It  occurs  in  greatest 
amount  (J  to  %  liter)  at  the  beginning  of  the  last 
month  of  "pregnancy,  but  diminishes  to  about  half 
that  amount  at  birth. 

During  the  first  two  months  there  is  a  definite 
space  between  the  amnion  and  chorion,  but  in  the 
third  month  the  amnion  is  gradually  pressed  against 
the  chorion,  until  an  agglutination  takes  place  be- 
tween the  two  membranes  through  the  formation  of 
a  homogeneous  fluid  or  gelatinous  matrix  containing 
few  cells.  This  union  is  always  very  slight,  as  the 
amnion  in  all  normal  cases  can  be  readily  stripped 
from  the  chorion.  In  the  first  three  weeks  the  mem- 
brane is  somewhat  removed  from  the  embryo;  in 
the  fourth  week  the  rapid  growth  of  the  latter  almost 
entirely  fills  the  amniotic  cavity.  During  the  second 
month  the  membrane  enlarges  more  rapidly,  forming 
a  larger  space  for  the  amniotic  fluid,  but  after  the 
fourth  month  it  fits  more  closely  about  the  fetus,  from 
which  it  is  kept  separated  by  the  fluid. 

The  structure  of  the  amnion  is  analogous  to  that 
of  the  serous  membranes,  and  there  is  consequently 
a  close  analogy  between  the  general  pathology  of  the 
fetal  membrane  and  that  of  the  latter.  The  tendency 
toward  plastic  exudations  with  the  formation  of  more 
or  less  extensive  adhesions,  changes  in  the  amount 
and  character  of  the  secretion,  etc.,  occur  here  as 
upon  other  serous  surfaces.  The  peculiar  function  of 
the  amnion  and  its  close  relations  to  the  embryo  lead, 
however,  to  pathological  processes  peculiar  to  itself. 

Hematoma. — An  effusion  of  blood  between  the 
chorion  and  the  amnion  may  occur  as  the  result  of 
accidental  or  voluntary  trauma,  or  of  diseased  con- 
ditions of  the  chorionic  villi.  Rupture  of  the  umbili- 
cal vessels  may  lead  to  the  formation  of  a  very  large 
blood  clot  between  the  two  membranes.  The  small 
extravasations  from  the  capillaries  of  the  chorionic  villi 
are  relatively  frequent  and  have  little  significance,  but 
large  ones  may  strip  the  amnion  from  the  chorion 
over  a  large  area,  producing  abnormal  pressure  upon 
the  embryo  and  alterations  in  the  amniotic  secretion. 
Death  of  the  embryo  and  abortion  may  result  from 
these  causes,  or  the  pressure  upon  the  amnion  may 
produce  adhesions  between  it  and  the  fetus,  leading 
to  disturbances  of  development.  The  small  clots  are 
absorbed  and  replaced  by  new  chorionic  villi  or  fibrous 
connective    tissue,    or    they    may    become    calcified. 

Retrograde  Changes.  —  The  placenta  and  fetal 
membranes  at  term  must  be  regarded  as  senile  struc- 
tures, and  certain  retrograde  changes  must  be 
recognized  as  a  part  of  their  physiological  decay. 
These  signs  of  age  in  the  amnion  begin  as  early  as  the 
fourth  month,  and  manifest  themselves  chiefly  by 
degenerative  changes  in  the  mesodermal  nuclei,  as 
shown  by  diffusion  of  chromatin,  hydropic  and  fatty 
degeneration.  Marked  alterations  in  the  shape  of  these 
cells  occur  in  the  later  months,  but  these  changes 
are  probably  dependent  upon  the  tension  of  the 
membrane. 

Fatty  Degeneration. — Minute  fat  droplets  are  very 
frequently  found  in  the  mesodermal  cells  of  the  mature 
amnion,  and  are  to  be  regarded  as  physiological.  In 
retention  of  the  membranes  after  abortion  this  change 
may  reach  a  pathological  degree. 

Hydropic  Degeneration. — This  may  occur  to  a 
limited  extent  in  the  mature  amnion.  In  the  rare 
cases  of  edema  of  the  chorion  the  cells  of  the  amnion 
become  hydropic;  and  frequently,  after  death  of  the 
fetus,  both  the  cells  and  intercellular  substance  of  the 
mesenehyma  undergo  liquefaction. 

Myxomatous  Degeneration. — A  myxomatous  degen- 
eration of  tin'  amnion  may  be  associated  with  a  similar 
change  in  the  chorion.  The  mesodermal  cells  be- 
en     branched,    the    intercellular    substance    more 

gelatinous  in  character,  and  small  mucin-containing 
cysts  may  be  formed  in  tin'  mesenehyma.  A  hyper- 
plasia of  the  mesodermal  cells  may  precede  this 
change,    and  the   amnion   may   be   greatly  thickened 


throughout,  or  villous-like  projections  into  the  am- 
niotic cavity  may  be  formed.  In  very  rare  cases 
these  may  acquire  such  size  that  they  may  be  classed 
as  myxomata.  These  changes  are  of  most  frequent 
occurrence  in  the  earlier  months  of  pregnancy  and 
usually  follow  the  death  of  the  fetus. 

Colloid-like  Change. — The  mesoderm  of  the  am- 
nion not  infrequently  becomes  homogenous  and 
hyaline,  loses  its  cells  and  slight  fibrillation,  and 
stains  as  colloid.  The  exact  nature  of  this  change  is 
not  known.  It  occurs  rather  frequently  after  the 
death  of  the  fetus. 

Hyaline  Change. — Portions  of  the  amnion  may 
undergo  a  proliferation  of  the  connective-tissue  cells, 
leading  to  the  formation  of  a  more  mature  connective 
tissue  in  which  fibers  are  formed.  The  intercellular 
substance  acquires  a  true  hyaline  character  and  stains 
rose  red  with  Van  Gieson's  stain.  This  sclerosis  in  a 
limited  degree  may  be  considered  as  a  senile  change, 
but  in  the  normal  amnion  it  is  never  extensive,  and 
the  membrane  for  the  greater  part  preserves  its 
embryonic  character.  Any  extensive  hyaline  change 
must  be  regarded  as  pathological.  The  causes  and 
conditions  of  occurrence  of  this  change  are  not  known, 
but  it  may  occur  after  the  death  of  the  fetus  or  in 
connection  with  syphilitic  changes  in  the  chorionic 
villi. 

Calcification. — Small  plaques  of  calcification  are  not 
infrequently  found  at  full  term  upon  the  inner  side  of 
the  amnion,  most  frequently  in  the  placental  amnion. 
These  most  probably  are  calcified  masses  of  fibrinous 
exudate  or  blood-clots.  After  the  death  of  the  fetus 
lime  salts  may  be  deposited  in  the  amniotic  meso- 
derm. This  deposit  may  be  preceded  or  accompanied 
by  fatty,  myxomatous,  or  hyaline  change.  The 
pathological  significance  of  calcification,  either  of  the 
chorion  or  of  the  amnion,  is  probably  very  slight,  and 
the  deposits  of  lime  salts  found  in  these  structures 
at  delivery,  unless  very  extensive,  are  to  be  regarded 
as  senile  phenomena. 

H ypcrplasia.— After  the  death  of  the  fetus  the  amnion 
may  become  much  thickened  from  a  hyperplasia  of  the 
mesodermal  cells.  The  new  tissue  formed  usually  un- 
dergoes hyaline  or  myxomatous  change  or  calcification. 
Localized  hyperplasias  may  appear  as  new  growths. 
The  processes  underlying  these  changes  are  practically 
unknown,  but  hyperplasia  of  the  amnion  is  associated, 
at  least  in  some  cases,  with  syphilitic  hyperplasia  of 
the  chorionic  villi. 

Amniotitis. — Since  the  amnion  contains  no  blood- 
vessels, a  primary  inflammation  in  the  ordinary 
acceptance  of  the  term  cannot  occur  in  the  membrane. 
But  the  tissues  of  theamnion  may  become  involved  in 
changes  which  are  so  analogous  in  character  and 
sequelae  to  inflammatory  processes  that  the  use  of  the 
term  amniotitis  may  be  accepted  for  practical  reasons. 
Edema  and  liquefaction  of  the  intercellular  substance 
of  the  mesenehyma  may  occur;  fibrinous  exudates 
may  take  place,  leading  to  the  formation  of  extensive 
deposits  of  fibrin  on  the  epithelial  surface  of  the 
membrane,  and  to  the  presence  of  strings  and  bands 
of  fibrin  in  the  lymph  spaces  of  the  mesenehyma. 
The  gelatinous  tissue  connecting  the  amnion  and 
chorion  may  wholly  or  partially  liquefy,  its  number  of 
wandering  cells  may  be  increased,  and  in  very  rare 
cases  pus  may  be  formed  between  the  two  structures. 
In  these  cases  there  is  also  present  a  small-celled  in- 
filtration of  the  chorionic  villi.  The  umbilical  cord 
may  show  a  similar  infiltration.  Purulent  placentitis 
is  apparently  very  rare,  and  no  well-studied  ca  es 
have  been  reported.  I  have  seen  two  cases  of  pla- 
cental abscess  resulting  from  infection  of  the  placi 
through  attempted  abortion.  In  these  the  space 
b  tween  the  chorion  and  amnion  contained  masses  of 
fibrin  and  collections  of  leucocytes;  the  amnion  "as 
swollen  and  colloid-like,  containing  fibrin  strings  and 
large  numbers  of  leucocytes. 

In  both  of  these  cases  the  amnion  was  involved  oy 


260 


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Amnion,  Pathology 


extension  from  the  chorion ;  and  il  is  probable  thai  the 
fibrinous  exudates,  which  are  rather  frequently  found 
i,,  ;, n, i  upon  the  amnion,  are  the  result  of  primarj 
pathological  changes  in  the  chorion  or  decidua.  The 
existence  of  a  primary  amniotitis  is  yet  to  be  proved. 
Ii  has  been  stated  that  in  cases  in  which  the  am- 
,n  itic  fluid  is  absent  or  greatly  reduced  in  quantity, 
the  friction  of  the  fetus  upon  the  membrane  Leads  to  the 
formation  of  plastic  exudates  and  adhesions.  It  yel 
remains  to  be  proved  that  such  exudates  are  the 
direct  result  of  changes  in    the  amniotic  cells. 

Iliai    fibrinous  exudates  do  occur  has  been  con- 
firmed by  numerous  observers,  but  we  are  as  yet  at  a 
to  explain  either  their  etiology  or  the  manner  of 
occurrence.     Through     the     organization     of 
fibrinous  adhesions  between  the  fetus  and  the  amnion, 
•  us  bands  may  be  formed  which  may  lead  to  the 
production   of   marked   abnormalities    in    the    fetus. 
These  adhesions   may   also   be   formed   between   the 
of  the  umbilical  cord  or  between  it  and  the  body 
of  the  let  us.     Amniotitis  is  also  regarded  as  one  of  the 
causes    of    hydramnion,    the   overproduction   of    the 
amniotic    fluid    being    explained    as    of    the    nature 
ni    acute    serous    inflammation.     The    proof    of 
this  remains  to  be  established,  but  the  fact  that   hy- 
dramnion  and   the  formation  of  adhesions  between 
fetus  and  amnion  have  followed  traumatic  injuries  to 
mother  may  be  taken  as  support  of  this  theory. 

The  amnion  is  not  a  perfect  protection  in  so  far  as 
the  entrance  of  bacteria  is  concerned.  A  number  of 
■  il  amniotic  infection  have  been  reported.  The 
pyogenic  cocci,  the  tubercle  bacillus,  and  other  organ- 
isms are  reported  as  having  gained  entrance  through 
this  membrane.  The  amnion  must  be  regarded, 
therefore,  as  a  possible  portal  of  entrance  for  patho- 
genic microorganisms. 

In  the  later  months  of  pregnancy  the  epithelium  of 
the  fetal  surface  of  the  amnion  may  be  torn  away  in 
snips.  According  to  Ahlfeld,  this  is  the  result  of 
fetal  movements,  the  epithelium  being  scratched  by 
the  finger  and  toe  nails  of  the  fetus.  The  amnion 
may  burst  in  the  last  months  of  pregnancy,  the 
ovum  being  preserved  by  the  chorion.  Through  the 
movements  of  the  fetus,  the  torn  membrane  may  be 
mlled  up  into  bands,  which  may  become  entangled  with 
the  umbilical  cord  and  constrict  it  even  to  the  extent 
of  shutting  off  the  fetal  blood  supply.  Inflamma- 
tory changes  have  not  been  shown  to  follow  these 
conditions. 

Amniotic  Bands  and  Adhesions. — During  the  early 
stages  of  development  of  the  membrane  there  may 
occur  total  or  partial  union  of  the  amnion  with  the 
developing  skin  of  the  embryo.  This  union  may  be 
the  result  of  an  imperfect  development  of  the  mem- 
brane, in  that  it  does  not  become  differentiated  from 
the  ectoderm,  or  fits  too  closely  about  the  embryo, 
BO  that  the  amount  of  secretion  is  not  sufficient  to 
separate  the  amnion  from  the  surface  of  the  embryo. 
At  the  points  of  contact,  union  through  direct  fusion 
or  intergrowth  may  take  place;  or  a  plastic  exudate 
may  be  thrown  out  which  unites  the  surfaces  and 
later  becomes  organized  after  the  manner  of  plastic 
exudates  on  any  serous  surface.  It  is  still  an  unsettled 
Question  as  to  how  far  these  adhesions  between 
the  amnion  and  the  fetus  are  to  be  referred  to  a  pri- 
mary failure  of  separation  and  fusion,  or  to  inflamma- 
t  iry  processes;  but  it  is  probable  that  in  the  majority 
of  cases  they  are  primary  defects  of  development. 
Amniotic  bands  may  also  be  produced  by  the  rupture 
of  the  membrane,  and  the  rolling  up  of  the  torn 
portions  into  bands  or  strings.  In  a  case  reported  by 
Tetzer  a  rupture  of  the  amnion  had  evidently  occurred 
at  an  early  month,  with  the  rolling  up  of  one  portion 
into  a  fold,  while  from  the  other  portion  complete 
regeneration  of  the  membrane  occurred. 

rhese  adhesions  play  a  great  part  in  the  formation 
of  monsters  and  malformations,  and  their  teratologi- 
cs! inportance  can  hardly  be  overestimated.     Bam  Is 


and  strings  of  union  uol  infrequently  per  i  t  at  full 
term,  and  their  connection  with  the  mi  shapen  por- 
tion of  the  child  leaves  no  doubt  thai  they  bear  a 
direct  causal  relation  to  the  malformation.  The 
structure  of  these  hands  ii  uallj  resembles  that  of  the 
amnion,  containing  no  blood-vessels;  and  they  may 

be  covered  with  epithelium.     In  other  eases  they  

in  be  regarded  as  prolongations  and  outgrowths  of 
the  fetal  dermis,  and  con  lain  blood- vessels  which  arise 
from  those  in  the  fetal  skin.  Very  frequently  the  only 
remnants  of  these  bands  al  birth  are  short  tags  in  the 
skin  of  the  child.  These  have  a  tructure  similar  to 
thai  of  normal  skin.  Stretching  of  the  adhesions 
through  increase  of  the  amniotic  fluid  may  lead  to 
their  atrophy  or  to  the  formation  of  fibrous  bands, 
which  contain  few  cells  and  no  blood-vessels  and 
po    i    -  no  epithelial  covering. 

A  total  adhesion  of  the  membrane  to  the  embryo 
causes  marked  disturbances  of  development  of  the 
head  and  extremities.  Partial  adhesions  occur  most 
frequently  al  the  extremities  of  the  embryo.  An 
abnormal  tightness  of  the  cephalic  cap  may  lead  to 
marked  malformations  of  the  cranium,  brain,  Or  face 
(acrania,  anencephalia,  exencephalia,  cephalocele, 
cyclopia,  arrhinencephalia,  etc.) ;  while  abnormal  tight- 
ness of  the  caudal  cap  produces  a  deficient  develop- 
ment of  the  lower  ext  remities  (amelia,  phocomelia,  etc). 
Clefts  of  the  thoracic  and  abdominal  walls,  failures 
of  closure  of  the  dorsal  and  genital  furrows,  etc.,  are 
aNo  associated  with  deficient  growth  of  the  amnion. 
Jt  is  impossible  to  say  to  what  extent  this  association 
is  one  of  cause  and  effect  or  merely  a  coincidence. 

If  the  amniotic  fluid  increases  greatly  in  amount  at 
an  early  period,  portions  of  the  adhesions  may  be 
separated  and  torn  loose,  floating  in  the  fluid:  or 
remaining  attached  at  the  ends,  they  may  become 
stretched  into  fine  threads  and  bands.  These  may 
entangle  the  extremities  of  the  fetus  and  affect,  their 
development  through  pressure  and  disturbance  of 
blood-supply,  or  even  cause  intrauterine  amputations. 
The  variety  of  malformations  produced  in  this  way  is 
very  great.  Larger  bands  of  adhesions  may  divide 
the  amniotic  cavity  into  several  chambers,  and  an 
over-accumulation  of  fluid  in  one  or  several  of  these 
cavities  may  result  in  the  production  of  pressure 
malformations  (club-foot,  flat-foot,  etc.). 

Hydramnion. — The  pathology  of  an  abnormal 
increase  of  the  amniotic  fluid  remains  unsettled. 
No  constant  pathological  changes  have  been  found 
in  the  membrane  in  hydramnion.  It  is  evident  that 
a  number  of  factors  may  underlie  this  condition.  It 
may  be  acute  or  chronic.  The  latter  may  be  due  to 
pathological  changes  in  the  mother  (edema  and 
dropsy  from  nephritis,  cardiac  disease,  etc.),  hyper- 
trophy of  placenta  and  decidua,  placental  tumors,  per- 
sistence of  chorionic  vessels  which  normally  undergo 
obliteration,  abnormalities  of  the  umbilical  vessels; 
or  to  pathological  changes  in  the  fetus  (increased 
blood  pressure,  cardiac  hypertrophy,  obstruction  of 
the  ductus  Botalli,  syphilitic  cirrhosis,  fetal  tumors, 
oversecretion  of  urine,  as  in  the  case  of  unioval  twins, 
especially  when  one  is  an  acardius  and  the  other  a 
maerocardius,  ichthyosis  and  lymphangiomatous  con- 
ditions of  the  fetal  skin,  etc.).  Deficient  absorption 
of  the  fluid  may  also  lead  to  an  overproduction  of  the 
fluid.  In  some  instances,  as  in  syphilis,  disease  of 
both  the  mother  and  child  may  contribute  to  an  exces- 
sive formation  of  the  fluid.  Chronic  amniotitis  is  a 
hypothetical  cause.  Acute  cases  following  trauma  to 
the  mother  have  been  ascribed  to  the  occurrence  of  an 
acute  serous  amniotitis.  Other  cases  of  acute  hy- 
dramnion arise  without  apparent  cause.  These  cases 
are  most  common  during  the  fourth  and  sixth  months 
of   pregnancy. 

OKgohydramnion. — A  deficient  formation  of  the 
amniotic  fluid  may  occur,  but  the  pathology  of  the 
condition  is  as  obscure  as  that  of  hydramnion.  It  is 
commonly  found  in  cases  in  which  extensive  adhesions 


261 


Amnion.  Pathology 


REFERENCE    HANDBOOK   OF    THE    MEDICAL    SCIENCES 


exist  between  the  fetus  and  the  amnion,  and  in  the  case 
of  twins  in  which  one  sac  may  present  a  deficiency  of 
the  fluid,  the  other  an  excess.  Imperfect  develop] unit 
of  the  urinary  apparatus  (cystic  kidney,  imperforate 
urethra,  etc)  has  been  regarded  as  a  probable  cause. 

Abnormalities. — A  large  number  of  varieties  of 
abnormal  development  of  the  amnion  have  been 
described.  The  most  important  of  these,  the  bands 
and  adhesions,  have  been  mentioned  above.  Defects 
of  the  membrane,  total  or  partial  reduplication,  for- 
mation of  multiple  cavities,  etc.,  may  occur.  The 
etiology  and  the  manner  of  production  of  these  are 
unknown.  A  very  rare  anomaly  is  monoamniotic 
twin  pregnancy.  It  is  usually  associated  with  acute 
hydramnion. 

Tuberculosis. — Primary  tuberculosis  of  the  amnion 
has  not  yit  been  reported.  In  one  case  of  placenta] 
tuberculosis  which  I  have  seen,  miliary  tubercles 
found  in  the  chorion  just  beneath  the  amnion, 
which  was  thickened  and  adherent,  showing  small- 
celled  infiltration  and  signs  of  connective-tis  ne 
proliferation.  Tubercle  bacilli  have  been  demon- 
strated in  the  armniotic  fluid  and  on  the  surface  of  the 
amnion.  The  rupture  of  chorionic  tubercles  through 
tin-  amnion  has  been  reported  by  Schmorl. 

Syphilis.  —  In  syphilis  of  the  fetus  and  fetal  placenta 
a  hyperplasia  of  the  amnion  similar  to  that  of  the 
chorion  may  take  place.  This  may  lead  to  a  general 
or  localized  thickening  of  the  membrane,  and  i-  asso- 
ciated with  various  degenerative  processes  (fatty, 
colloid-like,  hyaline). 

New  Growths. — Cysts  of  the  amnion  have  been 
described.  These  were  small  and  without  clinical 
significance.  They  were  most  probably  due  to  a 
myxomatous  degeneration  of  the  mesenchyma.  Der- 
moid  cysts  of  the  amnion  have  also  been  described. 
They  may  be  single  or  multiple  and  may  contain 
daughter  cysts.  They  are  most  probablj-  the  result 
of  errors  of  development  and  not  to  be  regarded  as 
true  neoplasms.  Small  myxomatous  projections  into 
the  amniotic  cavity  occur  rarely.  They  are  either 
localized  hyperplasias  or  remains  of  adhesions  which 
have  undergone  a  myxomatous  change.  The  exist- 
ence of  true  amniotic    neoplasms  is  as  yet  doubtful. 

Extrauterine  Pregnancy. — In  extrauterine  pregnan- 
cies, either  before  or  after  the  death  of  the  embi  yo, 
the  tissue  of  the  amnion  may  undergo  extensive  hyper- 
plasia, ami  become  greatly  thickened.  It  may  con- 
tain new  blood-vessels,  which  penetrate  it  from  the 
external  cyst  wall.  After  the  death  of  the  fetus  the 
entire  amnion  may  become  calcified,  forming  a  cal- 
careous cyst  wall,  from  which  the  mummified  fetus 
may  be  easily  shelled  out  (lithokelyphos) ;  or  if 
adhesions  exisi  between  the  fetus  and  the  membrane, 
these  may  also  become  calcified,  while  the  remaining 
portion  of  the  fetus  undergoes  mummification 
(lithokelyphopedion).  Aldred  Scott  YVarthix. 

Amoeba. — Ameba.  A  genus  of  simple  protozoans 
of  the  class  Rhizopoda,  order  Gymnamaebida,  which 
have  blunt  or  lobose  pseudopodia  and  are  without  a 
shell  or  test.  Tlii-  genus  i<  non-pathogenic,  but  some 
nearly  related  forms  like  Entamoeba,  Paramoeba,  etc., 
are  more  or  less  important  in  connection  witli  cer- 
tain intestinal  and  other  diseases.     See  Protozoa. 

A.  S.  P. 

Amok. — A  Malay  word  meaning  "an  impulse  to 
murder.*'  .More  commonly  spelled  annul..  Thi  i 
pression  "running  amuck"  is  used  to  describe  the 
action  of  a  .Malay  who  suddenly  and  apparently  with- 
out reason  rushes  into  the  street  armed  with  a  kris, 
bolo,  or  other  cutting  weapon  and  slashes  or  kills  the 
f i i  —  t  person  he  meets  and  as  many  more  as  possible 
until  he  is  killed  himself  or  put  under  restraint. 
The  motive  for  this  performance  and  the  mental  stati 
of   the   performer  are    QOl    always   clear   to   the   white 


man  in  the  East.     The  cases  seem  to  fall  into  several 
categories. 

1.  In  many  cases  it  appears  to  be  a  genuine  psycho- 
sis, a  form  of  epileptoid  seizure,  or  of  manic-depres- 
insanity,  the  murderous  outbreak  being  preceded  and 
followed  by  marked  emotional   depression. 

2.  In  other  cases  the  action  appears  to  be  a  form  of 
religious  frenzy  carried  out  in  pursuance  of  a  vow. 

3.  In  some  instances  it  appears  to  be  merely  ar, 
of  desperation  resolved  upon  by  the  native  in  i 
sequence   of  domestic  jealousy,   gambling   losses,   or 
other  misfortune  or  disgrace.     In  this  form  it  is  said 
to  be  an  intentional  mode  of  committing  suicide, 
indirect  mode  taking  the  place  among  the  Malays  thai 
hara  kiri  has  among  the  Japanese. 

Each  case  must  be  dealt  with  on  its  merits. 
W.  \Y.  Skeat  says,  "The  act  of  running  amuck  is 
probably  due  to  causes  over  which  the  culprit 
3ome  amount  of  control,  as  the  custom  has  now  died 
out  in  the  British  possessions  in  the  Peninsula,  the 
offenders  probably  objecting  to  being  caught  and 
tried  in  cold  blood."  J.  F.  Leys. 

Amphistomum. — A    synonym    for    Gastrodiscua,  a 

genus  of  flukes  belonging  to  the  order  Malacoi 
family  Amphistomidos.     G.  hominis  has  been  four 
the   colon  and   cecum   of  cholera  victims.     It   i-  an 
occasional  parasite  in  man.     See  Trematoda. 

A.  S.  P. 

Amputation. — Amputation    (Latin,    nmputare.    to 
cut   away)  is  a  term  generally  used  to  designate  tin- 
removal   by   surgical   operation   of  a   portion   or   the 
whole  of  an  extremity.      In  a  wider  application  tin- 
word   is   still   used   with   reference   to   separations  of 
other  prominent  or  projecting  portions  of  the  body, 
-u«h  as  the  mamma,  penis,  and  cervix  uteri.     In  this 
article  amputations  of  the  extremities  alone  will  be 
considered.     Older  writers,  and  many  of  the  pn 
time   in   Germany   and   France,   still   further   res 
tin-  term  amputation  to  the  operative  removal  of  a 
limb  in  its  continuity,  as  in  amputation  through 
forearm  or  thigh,  while  they  designate  a-  "disarticu- 
lations,"  "enucleations,"  the   removal  of  a  member 
in  its  contiguity  {i.  e.  through  the  joint), 
tinction  is  properly  ignored  by  English  and  Amei 
writer-,  since  many  operations  present  combinations 
of  the  two  procedures  (Syme,  Pirogoff). 

Historical  Sketch. — The  helplessness  of  sui 
of  ancient  times  to  cope  with  profuse  hemo 

ally  accepted  as  the  sole  admissible  explanation 
of  the  fact  that,  for  nearly  two  thousand  years,  from 
the  time  of  Hippocrates  to  that  of  Pan'-,  amputal 
were   practically   limited   to  the  removal   by   cutting 
through  the  dead  tissues  of  gangrenous  extremities. 
The  only  reference  to  amputations  in  the  Hippocratic 
writings  is  as  follows:  "In  case  of  fractun 
bones,  when  strangulation  and  blackening  of  the  parts 
lake   place,   at  first   the  separation  of  the  d 
living  parts  quickly  occurs,   and   the  parts  speedily 
drop  off,  as  the  bones  have  already  given  way ; 
when  the  blackening  (mortification)  takes  place  . 
the  bones  are  entire,  the  fleshy  parts  in  this  can 
quickly  die,  but  the  bones  are  slow  in  separating  ai 
the  boundary  of  the  blackening  and  where  the  b< 
are    laid    bare.     Those   parts   of   the   body  which   arc 
below   the  boundaries  of   the   blackening   ate   to  be 
removed  at  the  joint  as  soon  as  they  are  fairly  d 
and  have  lost   their  sensibility,  care  being  taken  not 
to  wound  any  living   part:  for   if   the   part  which  i- 
cut  off  give  pain,  and  if  it  should  prove   to  lie 
quite   dead,   there  is    gnat   danger  lest    the    pal 
swoon  away  from  the  pain,  and  such  swoonings  are 
often  immediatelv  fatal/'1 

The  anatomical  labors  of  the  Alexandrian  school 
could  not  have  been  without  influence  on  the  status 
of  surgery.     This  we  see  illustrated  in  the  surgical 


262 


REFERENCE    BANDBOOK    OF   THE    MEDICAL   SCIENCES 


Amputation 


writings  of  Celsus,  who  unquestionably  was  the  first 
to  suggest  amputations  in  the  living  tissues  above  the 
line  thai  separates  them  from  the  sphacelus.  While 
lie  admits  that  patients  frequently  succumb  during 
the   operation    from    hemorrhage,    there   can    be    no 

ition    I .ut    that    Celsus   was   acquainted   with   the 

■  usefulness  of  the  ligature.  In  Ids  chapter 
on  wound-,  he  advises  that  "if  these  [plugging  the 
wound,  compression,  and  mild  caustics]  do  not  pre- 
vail against  the  hemorrhage,  the  vessels  which  dis- 
charge the  blood  arc  to  he  taken  hold  <>f  and  tied  in 

places, aboul   the  wounded  part,  and  cut  through, 
they  may  both  unite  together  and  neverthele 
have  their  orifices  closed." 

1 1  seems  scarcely  possible  that  the  theory,  if  not  the 
practice,    of   surgery    could   have    developed    to    the 

ion  designated,  unless  a  less  difficult  procedure 
for  the  ligation  of  a  bleeding  vessel  in  an  open  wound 
had  been  likewise  perfected,  particularly  in  view  of 
the  facts  that  Archigenes  had  introduced  the  tourni- 
quet, that  every  writer  of  the  Greek  and  Arabian 
schools  makes  repeated  reference  to  the  use  of  the 
ligature  for  the  relief  of  hemorrhage,  and  that  torsion 
of  bleeding  vessels  was  advised  under  certain  circum- 
jtances  by  Galen,  Rhazes,  and  Paulus  ^Egineta.  It 
is  quite  certain,  therefore,  that  the  proper  mam 
incnt  of  hemorrhage  was  not  entirely  lost  sight  of 
in  the  darkest  period  of  the.  history  of  medicine. 
Indeed,  the  indications  for  amputation  seem  to  have 
a  more  elucidated  fcr  a  time  after  the  labors  of 

is.  Thus  Archigenes  enumerates,  among  the 
circumstances  which  require  amputation,  "the 
presence  of  intractable  disease,  such  as  gangrene, 
necrosis,  putrefaction,  cancer,  certain  callous  tumor-, 
and  sometimes  wounds  inflicted  by  'weapon-." 
Nevertheless,  the  advanced  position  occupied  by  this 
writer  was  soon  receded  from.  For  a  thousand 
years  from   the   time  of  the  latter  authority   retro- 

sion  was  the  fate  of  amputations  as  of  surgery 
in  general.  Where  recourse  to  amputations  was 
unavoidable,     the    most    barbarous    methods    wi  i 

i  ted  to.  The  Arabians  operated  with  red-hot 
knives.     Throughout  the  dark  ages  the  actual  cautery 

applied  to  the  bleeding  stump,  or  this  was  covered 
with  boiling  oil,  or  molten  pitch,  or  sulphur.  More 
cruel  than  any  other  was  the  practice  of  Guy  de 
Chauliac,  who  in  the  fourteenth  century  bound  a 
cord  with  sufficient  force  around  a  limb  to  insure  its 

ival  by  gangrene.  While  amputations  were 
dreaded,  until  within  the  last  three  centuries, 
alike  by  surgeons  and  patients,  it  is  certain  that  this 
operation  was  not  called  for  so  frequently  as  it  is 
now.  Lacerations  as  terrible  as  those  produced  by 
machinery  and  firearms,  which  for  the  most  part 
e  the  amputating  knife  into  the  surgeon's  hands. 
could  hardly  have  been  often  encountered  prior  to 
the  discovery  of  gunpowder  and  steam. 

While  Gersdorff  of  Strasburg  probably  had  used 
the  ligature  in  amputation  wounds  for  some  year-,  it 
remained  for  the  genius  of  Pare  to  give  to  amputations 
a  comparatively  firm  position  among  surgical  opera- 
tions. After  nearly  thirty  years  of  experimentation 
and  practical  test  of  the  ligature,  he  published  results 
which  should  at  onfee  have  revolutionized  the  surgical 
practice  of  the  time.  With  the  retraction  of  the  skin 
and  soft  parts  above  the  site  of  operation,  to  insure 
sufficient   tissue  to  cover  the  divided  bone,  and  the 

of  a  constricting  band,  Pare  had  adopted  all  the 
preliminary  means  which  are  deemed  necessary 
to-day  by  many  for  making  a  circular  amputation. 
Grasping  the  open  mouths  of  the  arteries  with  curved 
forceps,  he  closed  them  with  a  double  thread,  and  the 
wound  with  three  or  four  sutures.  Likewise  was 
Pare  the  first  who  clearly  taught  the  value  of  the 
ligature  en  masse  in  refractory  hemorrhages.  "In- 
1  by  God  with  this  good  work,"  it  would  seem 
that  Pare  should  have  speedily  moulded  the  prac 
of  his  contemporaries.     That  this  was  not  the  case 


is  evident  from  the  great  opposition  encountered 
by  him,  and  that  it  required  nearly  two  centuries  for 
the  ligature  to  supplant  the  actual  cautery  as  a  hemo- 
static measure.  Although  Fabricius  Hildanu 
Germany,  Dionys  in  France,  and  Richard  Wiseman 
in  England  (last  half  of  seventeenth  century)  make 
mention  of  the  ligature,  they  in  nowise  recommend 
it.  It  is  not  remarkable,  therefore,  thai  in  the  seven- 
teenth century,  Botal  did  not  hesitate  to  perf 
amputation  by  means  of  two  hatchet-,  one  placed 
immediately  below  the  member  and  the  othi  r  loaded 
with  leads  let  fall  upon  it  ( \  elpeau),  and  that  even  as 
late  as  1 70 1  W.  Sharp  saw  cause  for  complaint  at  the 
restricted    practice    of    ligaturing    blei  -el-. 

Indeed,  it  is  questionable  whether  the  ligature  of 
Is  in  amputation  wounds  could  even  then  have 
obtained  a  firm  foothold  without  the  assistance  given 
to  it  by  the  tourniquet.  The  origin  of  the  latter  is 
enshrouded  in  mystery.  There  can  be  no  doubt 
that  II.  \iiii  <  lersdorff  made  use  of  constricting  bands. 
It  appears  that  the  idea  of  provisional  compression 
of  the  artery,  as  now  practised,  was  introduced  inde- 
pendently by  two  surgeons  of  diffi  i  o  mtries  at 
about  the  same  time.  Morel,  in  France,  and  Young, 
in  England,  each  devised  a  tourniquet  for  the  arrest 
of  the  circulation.  It  remained,  however,  for  the 
great  J.  L.  Petit  (1718)  to  elaborate  the  principles  of 
arterial  compression  and  to  construct  an  instrument 
from  which  those  now  in  use  differ  but  little.  Finally, 
with  the  introduction  of  digital  compression  and  the 
use  of  the  Esmarch  bandage,  the  appliances  for  the 
control  of  hemorrhage  appear  as  perfect  as  human 
ingenuity  can  make  them. 

The  most  dangerous  feature  of  an  amputation  being 
controlled,  attention  could  be  directed  toward  the 
securing  of  a  more  rapid  cure  and  a  useful  stump. 
When,  in  ancient  and  medieval  times,  an  amputation 
terminated  well,  a  year  elapsed  before  the  wound  had 
healed,  and  a  conical  stump  usually  resulted.  In 
1678  a  friend  of  Thomas  Young  expressed  his  great 
surprise  that  larger  extremities  could  be  removed 
in  such  a  manner  that  the  wound  was  firmly  cica- 
trized by  first  intention  in  three  weeks.  The  circular 
incision  for  amputations  being  the  one  most  quickly 
implished  and  intuitively  resorted  to  by  the 
earlier  operators,  was  the  one  generally  adopted. 
Although  Celsus  clearly  indicates  the  necessity  of 
completely  covering  the  ends  of  the  bone  with  the 
soft  parts  by  dividing  it  upon  a  higher  level,  yet  it 
was  but  rarely  accomplished.  This  will  not  appear 
remarkable  when  we  consider  how  the  operation 
was  described  a-  late  a-  the  -ixteenth  century  by  Hans 
von  Gersdorff,  the  meat  barber-surgeon  of  Strasburg: 
"And  when  you  will  cut  him,  order  some  one  to  draw 
the  -kin  hard  up,  and  then  bind  the  skin  with  your 
bleeding  tape  tight.  Next  tie  a  simple  tape  in  front 
of  the  other  tape  in  such  a  way  that  a  space  is  left 
between  the  two  tapes  of  one  finger's  breadth,  so 
that  you  may  cut  with  the  razor  between  them.  In 
this  way  the  cut  is  quite  reliable,  goes  easily,  and 
makes  a  perfect  stump.  Now-  when  you  have  done 
the  cut,  take  a  saw  and  separate  the  bone,  and  after 
that  undo  again  the  bleeding  tape  and  order  your 
assistant  to  draw  the  skin  over  the  bone  and  the 
flesh,  and  to  hold  it  hard  in  front.  You  should  have 
a  bandage  ready  of  two  fingers'  breadth;  it  should  be 
moistened  beforehand,  so  as  to  be  wet  through,  then 
bind  the  thigh  from  above  downward  to  the  cut.  that 
the  flesh  may  protrude  in  front  of  the  bone,  and  then 
bandage  this  too."  Amputation  by  a  single  circular 
incision  down  to  the  bone  has  since  been  revived  by 
Louis  and  Brunninghausen  in  the  beginning  of  our 
century,  and  has  been  advised  by  Esmarch  recently 
in  emaciated  and  exhausted  subjects. 

Early  in  the  last  century  J.  L.  Petit  originated  the 
first  decided  improvement  upon  the  ancient  method 
of   practising   the   circular   incision.      With    the    I 
circular  incision  he  divided  the  skin  and  subcutane- 


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ous  cellular  tissue  alone,  and  after  reflecting  them 
divided  the  muscles  upon  a  higher  level  by  a  second 
circular  sweep  of  his  concave  knife.  Cheselden  and 
Sharp  in  England,  and  Heister  in  German}-,  independ- 
ently devised  and  became  adherents  of  this  improved 
operation,  by  which  the  end  of  the  bone  could  be 
completely  covered.  To  still  further  improve  the 
stump  Edward  Alanson,  after  the  customary  circu- 
lar incision  through  the  skin,  sought  to  give  the  wound 
a  funnel  shape  by  applying  the  knife  obliquely  and 
dividing  the  muscles  in  the  form  of  a  hollow  cone. 
Subsequent  operators  finding,  however,  that  the 
wound  thus  made  was  not  conical,  but  spiral,  and 
that  it  entailed  conditions  unfavorable  to  primary 
union,  this  modification  failed  to  get  a  permanent 
foothold  among  recognized  operations.  A  better  and 
simpler  means  to  produce  a  conical  wound  was  pro- 
duced by  Desault,  who,  after  division  of  the  skin, 
divided  the  superficial  and  deep  muscles  on  different 
levels  by  two  separate  sweeps  of  the  knife. 

Meanwhile  flap  operations  had  been  devised.  Al- 
though, according  to  Yelpeau  anil  Lacauchie,  Helio- 
dorus  had  described  amputation  of  superfluous  fingers 
by  the  double  flap  operation,  the  knowledge  of  this 
method  was  entirely  forgotten.  R.  Lowdham  of 
Exeter  in  1(579,  introduced  the  flap  operation  for 
amputation  of  the  leg  by  making  a  lateral  flap  on  one 
side,  a  semicircular  incision  on  the  opposite  side  com- 
pleting the  operation.  The  incision  was  made  from 
without,  and  included  the  skin  and  muscles  of  the 
calf  of  the  leg.  Although,  as  already  indicated, 
Young  (currus  triumphalis)  most  highly  lauded  the 
results  achieved  by  the  new  method,  it  was  ignored 
until  Peter  A.  Verduyn  of  Amsterdam  (1696), 
practised  a  similar  amputation,  transfixing  the  soft 
parts  with  a  double-edged  knife.  Sabourin  and  Gar- 
engeot  adopted  the  method  by  transfixion.  Other 
modifications  rapidly  followed  the  first  steps  of  the 
new  method.  H.  Ravaton  (1750)  and  Vermale  (1767), 
surgeons  of  the  Palatinate,  recommended  the  for- 
mation of  double  flaps,  while  Charles  Bell  (1807)  and 
the  elder  Langenbeck  (Gottingen)  again  practically 
returned  to  the  older  operation  of  Lowdham.  ( )n 
the  other  hand,  Sedillot,  in  1841,  and  Teale,  in  1858, 
greatly  improved  the  double-flap  operation.  Sedillot 
formed  two  musculocutaneous  flaps,  in  which  only 
a  small  part  of  the  flesh  was  included,  and  divided 
the  remaining  soft  parts  by  a  circular  incision.  A 
number  of  operators  advised  that  the  flaps  be  of 
unequal  size,  lest  the  cicatrix  become  adherent  to 
the  divided  end  of  the  bone.  Finally,  Thomas 
Teale  of  Leeds  (185S),  devised  the  anteroposterior 
rectangular  musculocutaneous  flaps.  Scoutetten 
of  Metz  in  1827,  combined  into  what  is  termed  the 
oval  method  a  number  of  operations  which  had  been 
previously  employed  by  the  elder  Langenbeck, 
Larrey,  Guthrie,  and  others.  According  to  Scoutet- 
ten, this  method,  which  is  best  adapted  to  disarticu- 
lations, is  supposed  to  possess  the  advantages  of  both 
flap  and  circular  operations.  While,  on  the  Conti- 
nent, this  operation  has  found  a  small  band  of  fol- 
lowers, it  has  never  met  with  general  favor. 

Indications. — Amputation  has  been  termed  the 
"last  resource"  and  the  "opprobrium"  of  the  sur- 
geon. Recourse  to  this  radical  measure  signifies  the 
surgeon's  unbelief  in  his  efforts  to  restore  to  useful- 
ness an  injured  limb;  it  is  his  confession  that,  in  the 
combat  with  disease,  he  has  been  conquered,  or  that 
his  ability  to  rectify  a  congenital  deformity  is  limited. 
To  recognize  the  limits  of  his  powers  to  save  a  part 
requires  the  keenest  judgment  of  the  surgeon,  and 
it  is  remarkable  how,  in  the  history  of  amputations, 
this  has  swayed  between  the  extremes  of  radicalism 
and  conservatism.  It  is,  of  course,  not  remarkable 
that,  prior  to  the  introduction  of  the  ligature,  ampu- 
tations were,  for  the  most  part,  confined  to  the  re- 
moval of  pails  which  were  all  but  removed  by  an 
accident  itself,  or  were  already  the  seat  of  gangrene. 


On  the  other  hand,  the  multiplication  of  methods 
of  amputation,  during  the  eighteenth  and  the  early 
part  of  the  nineteenth  century,  went  hand-in-hand 
with  the  most  reckless  condemnation  of  limbs.  The 
voices  of  Gervaise  and  Boucher,  which  were  raised 
in  defence  of  conservatism,  were  unheard,  and  even 
the  remarkable  reports  of  Bilguer  were  unable  to 
stay  the  useless  sacrifice  of  limbs.  Bilguer,  the  fal 
of  conservative  surgery,  and  surgeon  to  Frederick 
the  Great,  could  report,  in  1763,  169  compound 
fractures  successfully  treated  by  conservative  meth- 
ods. Among  these  were  nine  of  the  femur,  forty- 
two  of  the  leg,  nineteen  of  the  ankle,  nine  of  the  head 
of  the  humerus,  sixteen  of  its  shaft,  twenty-two  of 
the  elbow,  nine  of  the  forearm,  three  of  the  wrist, 
and  three  of  the  hand.  The  distinction  which  these 
statistics  brought  to  Bilguer  was  materially  dimmed 
by  the  fact  that  he  published  his  successes  alone,  and 
that  for  a  while  he  denied  amputations  a  place  among 
justifiable  operations.  The  incredulity  of  surgeons 
in  these  results  and  extreme  views  was  one  of  the 
causes  which  prevented  them  for  many  decades  from 
resl  ricting  the  indications  for  an  amputation.  Faulty 
methods  of  treating  wounds  and  an  insufficient 
appreciation  of  the  dangers  attending  major  amputa- 
tions were  likewise  potent  factors  in  so  frequently 
forcing  the  amputating  knife  into  the  hand  of  the 
surgeon.  The  introduction  of  immovable  dress- 
ings, the  startling  statistics  of  Malgaigne,  published 
in  1842  and  1848,  the  favor  with  which  excisions 
were  received,  and,  above  all,  the  advantage  of  anti- 
septic and  later  of  aseptic  wound  treatment  in  the 
widest  sense,  were  the  chief  causes  in  finally  deter- 
mining the  indications  for  amputations  as  they  are 
now  generally  accepted. 

In  general  terms,  it  is  proper  to  resort  to  amputa- 
tion when  the  sacrifice  of  a  part,  which  is  hope! 
diseased,  is  necessary  to  the  preservation  of  life  or  the 
enjoyment  of  its  various  functions  and  duties.  It 
is  well  to  remember  that  "  the  vast  majority  of  people 
would  prefer  living  with  three  extremities  to  being 
buried  with  four."  While  in  each  individual  case 
the  danger  and  advantages  of  an  operation  are  to  be 
carefully  balanced,  conditions  may  arise  which  may 
make  an  operation  imperative  which  but  a  few  clay- 
before  seemed  uncalled  for. 

Contraindications  to  amputation,  either  tempo- 
rary or  permanent,  should  also  be  clearly  recognized. 
Among  the  former,  particularly  as  to  amputations 
for  injury,  should  be  considered  extreme  shock  and 
exhaustion  from  excessive  hemorrhage.  As  perma- 
nent contraindications,  such  conditions  should  be 
recognized  as  will  preclude  the  possibility  of  attain- 
ing the  object  of  all  operative  procedure,  viz.,  the 
restoration  of  the  patient  to  health.  Such  indica- 
tions are,  first,  so  extensive  an  involvement,  by 
disease,  of  a  limb  and  contiguous  parts  that  ampu 
tation  will  not  suffice  for  its  complete  removal 
and,  second,  complications  on  the  part  of  important 
internal  organs  from  injury  or  disease,  under 
which  circumstances  an  amputation  would  not  on!. 
be  useless,  but  would  probably  curtail  life. 

While  it  is  an  axiom  that  amputation  should  be  re- 
sorted to  only  under  circumstance's  in  which  no  other 
means  will  avail,  there  is  no  little  difficulty  in  deter- 
mining the  conditions  that  call  for  this  extreme 
measure.  They  may  be  most  readily  investigated  by 
considering  them  under  the  three  general  headings  of 
injuries,  non-traumatic  lesions,  and  deformities. 

Injuries. — (a)  When,  from  accident  of  any  kind,  B 
limb  is  entirely  severed  from  its  connection,  or  the 
soft  parts  are  so  mutilated  that  it  is  attached  by  skin 
alone,  or  by  it  and  pulpified  flesh,  an  amputation  is 
absolutely  indicated.  Wounds  from  circular  sai 
railroad    accidents,    extensive    gunshot     lacerati 

afford  numerous  instances  in  which  the  amputal 

consists  in  nothing  more  than  trimming  off  the 
ged  edges  of  the  wound,  leveling  the  inequalities  of 


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Amputation 


the  protruding  fleshy  masses,  and  placing  the  stump 
in   tin'   best    condition    for   speedy   repair.     To    thi^ 
class  of  injuries  belong  those  cases,  caused  by  rail- 
iad    trains,    heavily    loaded    wagons,    entanglement 
in  machinery,  etc.,  in  which  the  soft  parts  are  exten- 
sively torn  from  the  bone,  the  muscles  being  pulpi- 
fied,  the   blood-vessels   and   nerves   lacerated.     It    is 
remarkable   that  in   instances  of  this   character   the 
skin  itself   may   remain   unbroken,   while  all    that    it 
ers    has    been    practically    crushed.     The    shock 
i  ading  the  tearing  off  of  a  leg  or  an  arm  is  usually 
:  scessive  thai  a  formal  operation  with  attendant 

of  blood  must  be  dispensed  with, 
i  In  the  other  hand,  it  is  a  well-established  fact  that 
fingers,  portions  of  the  nose  and  ear  which  had  been 
almost  completely  and  even  totally  separated  by  an 
incised  wound  uncomplicated  by  contusion,  have 
been  permanently  replaced  by  the  careful  use  of 
sutures.  In  amputating  crushed  parts  of  the  hand 
ervatism  is  particularly  desirable.  Every  part, 
e\  en  of  a  finger,  that  can  be  sewed  may  be  sen  iceable. 
When  a  doubt  exists  as  to  the  viability  of  a  crushed 
part  of  a  hand,  an  effort  to  save  it  should  be  made. 
In  the  event  of  death  or  uselessness  of  the  part  if  saved 
a  secondary  amputation  can  be  made.  For  this 
reason  amputations  for  crushed  wounds  of  the  fingers 
and  hand  should  in  most  cases  be  atypical. 

(b)  Extensive  hums  and  circumferential  lacerations 
of  only  the  skin  and  subcutaneous  cellular  layers 
may,  in  rare  cases,  require  the  sacrifice  of  a  limb. 
When,  from  the  depth  of  a  burn,  it  becomes  evident 
that  the  reparative  process  must  be  suppurative  in 
character,  and  continue  for  many  months,  and  when 
finally  ended  leave  a  disfigured  and  practically  use- 
less member,  it  is  usually  better  at  once  to  amputate 
than  to  expose  the  life  of  the  sufferer  to  the  dangers 
of  septic  infection  or  exhaustion.  Extensive  strip- 
ping of  the  integument  from  a  member  may  likewise 
impel  the  surgeon  to  operative  interference.  A  most 
interesting  case  of  this  character  is  recorded  by  M. 
Schede,3  in  which  an  entire  arm  was  caught  in  a  cog- 
wheel and  stripped  of  its  integument,  the  muscles 
of  the  arm  and  forearm  being  laid  bare  as  in  a  care- 
ful dissection.  Although  amputation  at  the  shoulder 
was  successfully  resorted  to  and  the  acromion  re- 
moved, the  integument  was  insufficient  for  the  closure 
of  the  wound. 

(c)  The  simultaneous  injury  of  the  main  artery  and  vi  in 
of  an  extremity  has  usually  been  considered  an  indi- 
cation for  amputation,  since  it  almost  invariably 
results  in  its  mortification  if  conservatism  is  practised. 
This  has  applied  particularly  to  wounds  of  the  femoral 
artery  and  vein.  The  advisability  of  an  operation  in 
all  such  cases  must,  however,  be  seriously  questioned, 
since  instances  are  multiplying  in  which  with  neo- 
plasms, several  inches  of  the  main  vessels  of  the  limb 
nave  been  removed  without  resulting  in  its  death. 
When  the  vein  alone  is  slightly  injured,  it  is  far  pref- 
erable to  trust  to  a  properly  applied  lateral  ligature, 
or  if  it  is  completely  divided,  an  attempt  to  save  the 
limb  should  be  made  by  ligation  of  the  accompanying 
artery.  Quite  recently  a  case  has  been  recorded  by 
Pilcher  in  which  an  incised  wound  of  both  femoral 
artery  and  vein  was  successfully  treated  by  double  liga- 
tion of  both  vessels.  On  the  other  hand,  amputation 
may  be  required  for  the  relief  of  traumatic  aneurysms 
or  those  of  spontaneous  origin  which  have  become 
diffused.  Particularly  may  ablation  of  the  thigh 
be  preferable  to  other  plans  of  treatment  of  aneurysm 
of  the  popliteal  and  of  the  deep  arteries  of  the  leg  in 
persons  of  advanced  years.  In  cases  of  subclavian 
aneurysm  exartieulation  at  the  shoulder  has  likewise 
been  successfully  performed  as  a  modified  distal  liga- 
tion. Finally,  secondary  hemorrhage  after  injuries 
from  whatever  cause,  when  other  measures  have 
failed,  can  be  relieved  alone  by  the  sacrifice  of  the 
limb.  Since,  after  ligation  in  continuity  of  an  artery, 
the    secondary   hemorrhage   most   frequently    comes 


from   the  distal  end  of  the  vessel,  it    is  apparent    why 
amputation    is   often    successfully   practised.       Rei 
advances  in  the  surgery  of  the  blood-vessels  has  made 

mi  ervatism  in  these  injuries  practicable.  Arterior- 
rhaphy    and    aneurysmonhaphy   have  in   many  ca 

done  away  with  the  necessity  for  primary  amputation 

for  injury  Of  eil  her  artery,  vein,  or  both. 

(</)  Compound fractw  i  s  and  dislocations  are  the  con- 
ditions which  most  frequently  call  for  amputation  in 
all  communities  where  manufacturing  interests  are 
largely  developed  and  where  railroads  furnish  employ- 
ment to  large  numbers.  Not  very  long  ago,  the 
presence  of  a  compound  comminuted  fracture  was 
deemed  sufficient  cause  for  an  amputation,  even  if 
unattended  by  extensive  laceration  of  the  soft  parts. 
In  no  field  of  surgery  have  greater  triumphs  been 
recorded  than  in  the  conservative  treatment  of  these 

compound   fractures.      There  can  be   no  question  but 

that  to-day  all  surgeons  of  twenty  years'  experience 
save  limbs  which  in  their  earlier  experiences  they 
would  have  doomed,  for  these  results  we  are  in 
the  main  indebted  to  the  principles  of  antiseptic 
treatment,  which,  although  first  promulgated  in 
1S65  in  Glasgow  by  -Mr.  Lister,  were  first  extensively 
practised  on  the  Continent,  especially  in  Germany, 
by  Bardeleben,  Volkmann,  and  Nussbaum. 

It  is  immaterial  for  our  purpose  which  of  the  numer- 
ous antiseptic  agents  be  preferred,  or  whether  the 
open  method  of  wound  treatment  with  thorough 
drainage  be  employed.  Such  remarkable  results 
have  been  achieved  in  the  conservative  treatment 
of  compound  fractures  that  ordinary  cases  may  be 
said  to  present  no  indications  for  amputation.  Nearly 
a  year  ago  a  lad  of  eighteen  had  his  left  arm  caught 
in  the  belt  of  a  wheel  in  a  machine  shop.  When 
brought  to  the  Good  Samaritan  Hospital,  in  Cincin- 
nati, an  hour  after  the  accident,  there  was  detected 
a  double  fracture  of  the  humerus,  one  of  which  was 
compound,  a  simple  dislocation  backward  of  the 
elbow,  a  compound  fracture  in  the  middle  third  of  the 
radius  with  two  inches  of  fragment  protruding,  and  a 
compound  dislocation  of  the  ulna  at  the  wrist.  An 
amputation  was  strenuously  advised,  but,  fortunately, 
it  was  rejected  by  the  parents.  The  boy,  after  con- 
finement for  nine  months,  recovered  after  two  inches 
of  the  radius  and  six  inches  of  the  ulna  had  been 
removed.  The  hand  and  forearm  are  almost  useless, 
but  this  condition  is  infinitely  preferable  to  that  of 
being  obliged  to  wear  an  artificial  limb,  no  matter 
how  perfect  it  may  be.  In  his  service  at  the  Cincin- 
nati Hospital  the  writer  recently  saw  a  negro  with  a 
cog-wheel  crush  of  the  ulnar  half  of  the  wrist  and 
metacarpal  bones,  and  of  the  upper  third  of  the  hu- 
merus, and  pulpifying  of  the  overlying  deltoid.  The 
removal  of  the  upper  third  of  the  humerus,  including 
its  head,  and  of  the  crushed  bones  of  the  carpus  and 
hand,  and  the  establishment  of  ample  facilities  for 
drainage,  left  the  man  with  good  use  of  forearm  and 
three  fingers.  Particularly  in  injuries  of  the  upper 
extremity  is  conservatism  commendable. 

Statistics  of  the  advantages  of  conservatism  in  the 
treatment  of  these  accidents  are  rapidly  accumulating. 
Thus,  Volkmann  was  enabled  to  report  seventy-five 
compound  fractures  of  the  larger  long  bones  without 
a  single  death,  although  in  eight  cases  he  was  com- 
pelled to  resort  to  secondary  amputation.  Sir 
Joseph  Lister,  with  rigid  adherence  to  the  antiseptic 
method,  lost  two  out  of  ninety-seven  cases.  In  the 
treatise  of  Billroth  and  Luecke  is  a  most  exhaustive 
compilation  of  254  cases  which  were  treated  by  the 
Listerian  method.  Of  224  of  these  cases  which  were 
treated  conservatively  only  fourteen  died.  But  it 
remained  for  our  own  countryman,  Dr.  Fred.  S. 
Dennis,  to  record  the  most  brilliant  and,  indeed, 
unique  successes  ever  obtained  in  this  field.  Of 
144  cases  of  compound  fracture  treated  in  Bellevue 
Hospital,  New  York  City,  not  one  died  from  septic 
infection,  and  100  cases  were  treated  without  a  death 


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from  any  cause.  Similar  results  are  now  obtained  in 
all  well  regulated  hospitals  and  in  military  practice. 
The  principles  of  asepsis  have  become  the  property 
of  every  physician  so  that  even  in  private  practice 
equally  good  results  are  obtainable.  Bone  wiring 
and  bone  plating,  with  bone  grafting  at  a  Inter  period 
have  helped  to  make  amputations  less  frequent  than 
formerly.  Extensive  splintering  of  bone  and  lacera- 
tion of  soft  parts  can,  therefore,  no  longer  be  con- 
sidered an  excuse  for  the  sacrifice  of  the  limb.  If 
amputations  still  form  a  considerable  percentage  of 
the  operations  performed  in  large  hospitals,  it  is 
because  of  the  more  extensive  employment  of  heavy 
machinery,  and  the  great  extent,  of  railway  travel. 
Most  of  the  primary  amputations  thus  practised  are 
indicated  by  the  conditions  above  detailed  (sub  a). 

(e)  Compound  Dislocations. — Closely  allied  to  com- 
pound fractures  in  their  relation  to  amputations  are 
compound  dislocations.  Since  the  more  general 
appreciation  of  the  value  of  primary  excision  of  joints, 
amputations  for  these  injuries  are  now  less  frequently 
resorted  to  than  formerly.  Indeed,  all  formal  opera- 
tions for  compound  dislocations  should  be  greatly 
restricted.  Cooper  and  Nelaton  already  leaned 
toward  conservatism.  The  latter  advised  reduction 
of  the  dislocation,  closure  of  the  external  wound. 
and  antiphlogistic  measures.  What  has  been  accom- 
plished in  this  way  in  recent  years,  and  particularly 
by  immobilization,  could  be  demonstrated  by  a 
stately  array  of  cases  of  compound  dislocations  of 
large  joints  in  which  the  limb  was  saved,  and  often 
with  perfect  motion.  Compound  dislocations  of 
shoulder,  wrist,  hand,  and  elbow,  unless  the  damage 
of  the  soft  parts  is  such  as  per  se  to  call  for  amputa- 
tion, should  always  be  treated  without  operation,  or 
by  excisions.  A  compound  dislocation  of  the  elbow, 
with  laceration  of  the  brachial  artery,  was  success- 
fully treated  without  operation  by  McCarthy,  and 
Davis  reports  another  such  dislocation  of  the  knee, 
in  which  all  the  functions  of  the  joint  were  retained. 

On  the  other  hand,  amputations  for  compound 
dislocations  of  the  foot  and  ankle  are  more  frequently 
indicated,  since  excision  and  conservative  measures 
often  leave  the  parts  useless,  if  not  positively  a 
burden,  and  the  dangers  of  primary  amputations  are 
at  least  no  greater  than  those  which  attend  milder 
methods  of  treatment  of  these  eases. 

(/)  Gunshot  Wounds. — These  are  of  sufficient  fre- 
quence in  civil  practice  often  to  call  for  amputation. 
Here,  on  account  of  suitable  accommodations  and 
facilities  for  proper  treatment,  conservative  means 
may  be  adopted,  whereas  in  the  field  a  part  must  be 
sacrificed  for  the  benefit  of  the  whole.  Revolver 
wounds  of  the  large  vascular  and  nerve  trunks,  with 
shattering  of  the  bones,  may  necessitate  amputation. 
Shotgun  wounds,  from  the  greater  laceration  inflicted, 
particularly  in  the  neighborhood  of  the  larger  joints, 
may  require  the  sacrifice  of  a  limb.  Nevertheless, 
with  our  better  methods  of  wound  treatment,  the 
surgeon  should  even  here  lean  toward  conservatism. 
The  writer  has  recently  saved  a  lower  and  an  upper 
extremity  by  a  typical  resection  of  the  knee  and 
shoulder  in  cases  of  gunshot  wounds  sustained  at 
close  range. 

Before  the  introduction  of  small-caliber  projectiles 
Connor  enunciated  the  conditions  calling  for  amputa- 
tion as  follows:  1.  When  there  has  been  great  de- 
struction of  soft  and  hard  parts,  as  in  a  crush  by  large 
shot,  or  when  the  limb  has  been  almost  completely 
or  altogether  carried  away.  2.  When  the  fracture 
is  associated  with  laceration  of  the  main  vessels  or 
nerves  of  the  part.  3.  When  acute,  infective  osteo- 
myelitis has  been  developed.  In  the  chronic  form  of 
this  disease,  when  the  entire  length  of  the  bone  has 
become  affected,  it  may  or  may  not  be  nece  sary  to 
amputate,  according  to  the  general  condition  of  the 
patient  and  the  particular  bone  that  is  disea  ed. 
4.    When  there  is  severe  secondary  hemorrhage  from 


an    eroded    vessel,    or    from    a    ruptured     traumatic 
aneurysm,     5.   When  gangrene  has  supervened. 

The  small  caliber  of  the  modern  rifle  ball  has  so 
modified  wounds  sustained  in  action  that  amputations 
are  but  rarely  demanded.  Furthermore,  the  thor- 
ough curetting  of  the  medullary  canal  in  acute  osteo- 
myelitis when  it  has  developed,  tends  still  further  to 
limit  the  scope  for  amputation.  Secondary  hemor- 
rhage from  an  eroded  vessel  or  the  rupture  of  a 
traumatic  aneurysm  should,  in  the  light  of  our  better 
methods  of  the  treatment  of  wounds  of  vessels,  not  be 
considered  an  indication  for  amputation  until  search 
for  the  wound  and  ligation  or  suture  have  been  tried 
without  success.  In  modern  warfare,  amputations 
are  becoming  less  and  less  frequent.  In  the  second 
report  by  Totsuka,  director  of  the  Sasebo  Hospital, 
we  note  that  of  the  wounded  persons  admitted  those 
who  finally  lost  a  part  of  the  upper  or  lower  limbs 
(excepting  fingers  or  toes)  were  thirty-two  in  all.  Of 
these  twenty  were  operated  on  before  admission  to 
the  hospital.  There  were  seven  amputations  of  the 
thigh,  three  at  the  knee,  nine  of  the  leg,  one  at  the 
ankle,  eight  of  the  arm,  two  at  the  shoulder,  one  at 
the  elbow  and  one  of  the  forearm.  In  many  instate 
the  wounded  limbs  were  already  mutilated  or  carried 
away  at  the  time  of  the  injury,  so  that  the  operation 
performed  was  nothing  more  than  a  trimming  of  the 
wound.     Onlj'  one  death  resulted. 

In  the  report  of  the  Surgeon  General  (1900,  p.  2'.iv, 
there  were  seventeen  fractures  of  the  upper  third  of 
the  femur  recorded  with  three  deaths,  but  there  were 
no  amputations.  Of  seventeen  fractures  of  the 
middle  third  of  the  femur,  only  one  was  amputated. 
And  of  nine  fractures  of  the  lower  third  of  the  femur, 
none  was  fatal  and  none  was  amputated. 

(g)  Gangrene. — The  presence  of  gangrene,  as  a 
sequel  of  trauma  or  of  the  application  of  the  extremes 
of  heat  and  cold,  offers  an  unmistakable  indication 
for  the  ablation  of  a  part  as  soon  as  the  evidences  of 
the  limitation  of  the  gangrene  are  made  manifest. 
Nor  is  it  always  advisable  to  wait  for  this  in  the  i 
of  traumatic  gangrene,  which  often  extends  with 
such  rapidity  that  a  few  hours  will  rob  the  sufferer 
of  his  onl}-  chance.  The  mortification  which  follows 
tin1  ligation  of  an  artery  or  upon  an  embolism,  is  a 
condition  calling  for  operative  interference.  In 
senile  and  diabetic  gangrene  amputation  is  often 
demanded.  Amputation  should  be  performed  far 
from  the  gangrenous  area.  In  the  first-named  form 
of  gangrene,  as  of  the  foot  or  part  of  it,  the  amputa- 
tion must  be  made  at  or,  better,  above  the  knee.  In 
both  forms  of  gangrene  amputation,  to  be  successful, 
must  be  performed  before  secondary  and  general 
infection  has  taken  place  from  about  the  gangrenous 
field.  In  a  few  instances  favorable  results  have  been 
obtained  in  gangrene  by  arteriovenous  anastomosis. 
In  most  instances,  however,  where  this  has  been 
practised  it  has  failed. 

In  determining  the  proper  place  to  amputate  in 
senile  gangrene,  the  hyperemia  test  suggested  by 
Mozkowicz  is  very  serviceable.  To  apply  it,  the 
affected  limb  is  elevated  long  enough  to  obtain  a 
marked  pallor  of  the  skin,  then  a  circular  broad 
elastic  bandage  is  applied  around  the  thigh  as  high 
up  as  possible,  and  the  constrictor  is  allowed  to 
remain  in  place  five  minutes.  When  the  constrictor 
is  removed,  the  usual  hyperemic  blush  spreads  over 
the  limb,  even  though  marked  sclerosis  be  present. 
The  hyperemic  blush,  however,  is  much  less  active 
as  the  ischemic  areas  of  the  foot  or  leg  are  approached. 
The  red  color  spreads  downward  hesitatingly,  almost 
imperceptibly,  especially  at  the  toes.  Individual 
anemic  patches  persist  for  a  long  time,  and  the  con- 
trast between  the  red  and  the  pale  areas  becomes 
marked  in  proportion  with  the  extent  of  the  arterial 
obstruction.  It  is  evident  that  any  operation  within 
the  pale  zone  will  end  in  sloughing  of  tin'  flaps. 
Vloschcowitz,  who  has  made  numerous  experimental 


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Amputation 


and  clinical  tests  with  this  method,  shows  very 
satisfactorily  thai  the  viability  of  the  deep  parts  cor- 
responds very  closely  with  the  living  red  skin  areas, 
and  that  the  surgeon  may  amputate  with  safety  any- 
where within  the  line  of  the  pink  or  livpereiuic  skin. 

In  this  u:iv  conservative  operations  are  favored,  and 
there  is  less  guesswork  or  accident  in  determining 
the  proper  level  of  amputation  (Matas).     ' 

Non-th  \r\i.\Tic  Affections,  (a)  Inflammation. — 
Severe  and  extensive  inflammations  of  the  skin,  sub- 
cutaneous cellular  layer,  and  intermuscular  layer, 
as  they  are  frequently  encountered  in  phlegmonous 
erysipelas  from  injuries  which  in  themselves  are  most 
trivial,  and  which  from  septic  infection  or  protracted 

Suppuration  would  lead  to  death,  are  conditions  thai 
may    necessitate    an    amputation.      While    with    free 

ions,  the  permanent-water  dressing,  and  irrigation, 
many  limbs  thus  affected  may  be  saved,  amputation 
must  always  lie  resorted  to  in  a  certain  small  propor- 
tion of  especially  aggravated  eases.  The  presence  of 
Beptioemia  and  pyemia  should  not  lie  deemed  a 
contraindication,  unless  the  want  of  vitality  of  the 
patient,  will   preclude  the  possibility  of  surviving  the 

I;  resulting  therefrom.  Billroth,  Volkmann, 
Fayrer,  Weinliichner,  Luecke,  and  numerous  other 
surgeons  cite  cases  in  which  amputation  was  success- 
fully practised  after  a  varying  number  of  rigors  had 
placed    the    presence    of    the    gravest    constitutional 

lion  beyond  doubt.  By  removing  the  primary 
seal  of  the  septic  changes,  the  general  manifestations 
of  pyemia  may  frequently  be  caused  to  disappear. 

(/>)  Inflammatory  conditions  of  the  bones  and 
joints  which  cannot  be  relieved  by  less  radical  meas- 
ures may  rarely  make  an  amputation  imperative. 
Acute  osteomyelitis,  when  unrelieved  by  trephining, 

when  affecting  only  a  single  bone,  must  be  con- 
sidered a  condition  requiring  this  radical  interference. 
Necrosis  which  involves  the  entire  thickness  of  the 
shaft  of  the  bone,  as  for  example  a  part  of  the 
humerus,  or  the  femur,  and  especially  when  repeated 
necrotomies  have  proved  to  be  unavailing,  occasionally 
requires  the  sacrifice  of  a  limb.  In  extensive  tuber- 
culosis of  the  articular  ends  of  the  long  bones,  or  of  the 
carpus  and  tarsus,  when  from  the  depraved  condition 
of  the  patient  excision  is  unfeasible,  amputation  is 
compulsory.  The  improved  methods  of  dealing  with 
suppurative  and  destructive  affections  of  joints  by 
immobilization,  by  the  injection  of  formalin  or,  if 
need  be,  by  resection,  have  happily  reduced  the 
number  of  cases  calling  for  amputation  from  these 
causes  to  a  minimum. 

(c)  Extensive  circumferential  ulcerations  of  the 
leg,  which  sap  the  strength  of  the  patient  through 
hemorrhage  or  profuse  suppuration,  or  which  unfit 
him  for  the  vocations  of  life,  not  unfrequently  render 
amputation  advisable.  This  also  applies  to  cases  of 
true  and  spurious  elephantiasis,  in  which  milder 
measures  have  proven  of  no  avail. 

(d)  Tumors  of  benign  and  malignant  character, 
when  from  their  size  they  destroy  the  usefulness  of  a 
limb  or  endanger  life,  are  well-recognized  indications 
for  amputation.  The  neoplasms  most  frequently 
demanding  the  latter  are  carcinomatous  degenerations 
of  chronic  ulcers  or  epitheliomata  developing  around 
a  sequestrum,  or  an  osteosarcoma  of  the  articular 
ends  of  the  long  bones.  Under  all  these  conditions 
amputation  offers  a  better  chance  for  permanent 
recovery  than  does  excision.  For  the  central  giant- 
celled  sarcomata,  curett  ng  or  excision  should  be 
tried  repeatedly  before  amputation  is  resorted  to. 

The  rule  which  applies  to  the  management  of  neo- 
plasms generally,  that  an  operation  must  lie  refrained 
from  unless  all  of  the  diseased  tissue  can  be  removed, 
is  particularly  to  be  remembered  before  an  amputa- 
tion is  determined  upon  for  the  relief  of  a  tumor  of  an 
extremity.  The  bearing  of  amputation  upon  certain 
traumatic  affections  of  the  blood-vessels  and  upon 
special    spontaneous    aneurysms    has  already    been 


referred  to.     Congenital  telangiectases  likewi  e  exacl 

amputation    when    rapidity    of   growth   endangers    life 

or  when  other  plans  of  treatment  have  been  unsuc- 
cessful. 

Deformities. — (a)  Supernumerary  fingers  and  toes 

are  proper  cases  for  removal,  and   the  operation   may 

be  safely  practised  six  months  after  birth.  This 
early  removal  assures  a  better  form  of  hand  or  foot 
and  a  diminutive  scar.  Cases  of  club-foot  which 
have  been  altogether  neglected  or  badly  managed, 
and   which,   from   extensive    ulceration   or   infli id 

bursa-,  entail  great  suffering  upon  the  patient,  not 
infrequently  can  be  relieved  by  amputation  only. 
But  in  early  life  no  case  of  talipes  is  of  sufficient 
severity  to  warrant  the  removal  of  the  foot. 

(6)  Cicatricial  contractions  of  tin-  joints,  associated 
with  great  wasting  of  the  muscles,  from  extensive 
burns;  great  deformity  and  uselessness  of  a  limb 
from  neglected  dislocation  (foot  or  ankle),  may  call 
for  an  amputation.  For  these  and  similar  ca  <  . 
amputations  of  expediency  may  occasionally  be 
required,  but  the  surgeon  should  carefully  weigh  all 
factors  in  the  case  before  subjecting  his  patient  to 
the  risks  of  an  operation  for  the  relief  of  a  condition 
which  in  itself  is  only  a  burden  and  not  a  source  of 
danger.  To  this  category  belong  limbs  useless 
In  low  the  knee  from  infantile  paralysis.  Such  legs 
are  often  burdensome  from  one  cause  or  another 
(sensation  of  cold,  proneness  to  superficial  ulceration, 
etc.)  and,  since  they  are  useless,  it  is  probably  better 
to  amputate  them  and  substitute  an  artificial  Hint). 
The  paralysis  alone  is  not  an  indication  for  amputa- 
tion, since  marvelous  results  may  lie  obtained  from 
tendon  grafting  and  its  various  modifications. 

Time  fob  Amputation. — When,  in  consequence  of 
an  injury,  an  amputation  is  indicated,  the  proper 
time  for  performing  it  must  be  considered.  While 
the  patient  is  still  suffering  from  collapse,  or  even 
exhaustion  from  excessive  hemorrhage,  it  would  be 
sealing  his  fate  to  resort  to  an  operation.  At  least 
moderate  reaction  may  ordinarily  be  awaited,  and 
hastened  by  the  use  of  morphine,  transfusion  of  salt 
solution  with  adrenalin,  and  possibly  the  strapping 
of  the  abdomen  to  raise  the  blood  pressure.  A 
moderate  degree  of  shock  is  no  contraindication  to 
immediate  amputation.  Indeed,  this  may  put  an 
end  to  the  shock  by  removing  the  afferent  painful 
impulses  from  the  dragging  of  the  mangled  limb,  the 
added  pain  of  the  tourniquet,  and  the  oozing. 
Wil  h  ether,  or  preferably  gas-oxygen  anesthesia  com- 
bined witli  cocainization  of  the  larger  nerve  trunks, 
the  amputation  does  not  increase  the  shock  but  tends 
to  end  it.  For  from  twelve  to  seventy-two  hours, 
rarely  more,  an  injured  part  may  appear  to  remain 
unchanged,  after  which  the  evidences  of  infection 
or  of  tissue  necrosis  (gangrene)  may  become  manifest. 

Primary. — All  amputations  practised  prior  to  the 
advent  of  these  changes  are  designated  primary. 
Since  the  time  when  these  changes  supervene  varies 
from  one  to  three  or  four  days,  according  to  a  multi- 
tude of  circumstances,  foremost  of  wTiich  is  the 
character  of  the  wound  and  the  extent  to  which  it 
can  be  maintained  aseptic,  no  absolute  limit  can  be 
fixed  to  the  time  when  an  amputation  should  no 
longer  be  classed  among  the  primary  amputations. 
With  very  few  exceptions,  surgeons  of  the  present 
day  recognize  the  necessity  for  immediate  amputation 
in  every  instance  in  which  conservatism  cannot  be 
practised.  The  diversity  of  opinion  which  has  pre- 
vailed on  this  subject  has  been  great.  Among  the 
advocates  of  primary  amputation  may  be  enumer- 
ated Du  Chesne,  Wiseman,  Pott,  Percy,  J.  Bell, 
Larrey,  and  Guthrie;  among  its  opponents,  Faure, 
Hunter,  and,  in  the  last  quarter  of  the  last  century, 
.1.  NeudOrffer.  Paul,  and  Cross.  The  extensive  ex- 
periences of  Guthrie  and  Larrey  have  finally  con- 
vinced surgeons  of  the  advantages  of  early,  as  com- 
pared    with     late,     amputations.      Of    291     primary 


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amputations,  107  recovered,  twenty-four  died,  and 
160  remained  under  observation.  Of  551  secondary 
operations,  170  recovered,  265  died,  while  116  re- 
mained under  treatment  (Guthrie).  The  accumu- 
lated experiences  of  the  Crimean  and  Franco-Prussian 
wars,  and  the  vast  statistics  of  our  Civil  War,  indorse 
the  prevailing  practice  of  resorting  to  early  ampu- 
tations. In  the  statistics  of  Otis,  there  were  in 
3,259  primary  amputations  of  the  arm,  602  deaths, 
IS. 4  per  cent,  mortality;  in  902  intermediary  ampu- 
tations of  the  arm,  302  deaths,  33.4  per  cent,  mor- 
tality; in  411  secondary  amputations  of  the  arm, 
114  deaths,  27.7  per  cent",  mortality;  in  1,914  primary 
amputations  of  the  lower  third  of  the  thigh,  927 
deaths,  48.7  percent,  mortality;  in  676  intermediary 
amputations  of  the  lower  third  of  the  thigh,  459 
deaths,  67.9  per  cent,  mortality;  in  207  secondary 
amputations  of  the  lower  third  of  the  thigh,  100 
deaths,  48.3  per  cent,  mortality.  The  obvious  rea- 
sons for  tin'  better  results  which  follow  early  opera- 
tions are  that  they  are  made  at  a  time  when  the  con- 
stitution has  not  yet  been  exhausted  by  protracted 
suppuration  and  high  temperatures,  and  that  they 
leave  wounds  which  can  be  kept  free  from  septic 
infection. 

Intermediary. — The  second  date  at  which  an  amputa- 
tion might  be  forced  upon  the  surgeon  is  that  during 
which  the  severest  local  and  general  signs  of  inflam- 
mation are  present.  The  damaged  limb  has  become 
red,  edematous,  and  painful.  From  the  wound  there 
issues  a  sanious,  malodorous  fluid,  and  a  more  or  less 
extensive  sloughing  of  the  tissues  adjacent  to  the 
wound  ensues.  Associated  with  these  local  conditions 
are  an  acceleration  of  the  pulse,  elevation  of  the 
temperature,  often  to  a  dangerous  degree,  headache, 
dry  tongue,  scanty  urine,  and  muttering  delirium. 
Unless  the  patient  succumbs  to  the  paralyzing  influ- 
ences of  excessive  temperatures,  his  condition  be- 
comes gradually  ameliorated  in  from  five  to  fifteen 
days.  As  the  discharge  of  scanty  serum  is  followed 
by  a  free  secretion  of  pus,  the  gangrenous  parts  are 
exfoliated,  and  the  swelling  largely  subsides;  the 
fever  and  acceleration  of  pulse  are  reduced;  the 
tongue  regains  its  normal  moisture  and  color,  and  a 
comparative  degree  of  comfort  is  enjoyed.  Ampu- 
tations practised  during  this  stormy  period  of  the 
clinical  history  of  an  accident  have,  after  the  desig- 
nations of  Boucher  and  Alcock,  been  called  inter- 
mediary. Since  they  are  made  at  a  time  when  the 
damaged  part  and  the  system  at  large  are  in  the  very 
worst  condition  for  operations,  it  is  not  remarkable 
that  such  amputations  offer  the  worst  prospects  for 
recovery.  Although  the  mortality  following  such 
amputations  must,  therefore,  be  very  much  greater 
than  that  following  primary  or  late  amputations, 
cases  will  arise  in  which  the  very  gravity  of  the  local 
and  general  phenomena,  such  as  recurrent  hemor- 
rhage, impending  gangrene,  or  septicemia,  will  neces- 
sitate the  speedy  removal  of  the  limb,  as  the  last  hope 
of  deliverance.  With  improved  methods  of  avoiding 
wound  infection,  in  patients  who  are  already  septic, 
the  terrors  of  so-called  intermediary  operations 
have  been  largely  laid,  although  no  statistics  are 
available  in  proof.  As  an  illustration  may  be  cited 
the  frequency  with  which  success  attends  high  ampu- 
tations for  rapidly  spreading  diabetic  gangrene  and 
that  in  the  presence  of  a  high  degree  of  acidosis. 

Secondary. — With  the  subsidence  of  the  grave  con- 
stitutional symptoms  and  the  advent  of  profuse  sup- 
puration begins  that  period  when,  if  amputations  are 
performed,  they  are  termed  secondary.  It  has  already 
been  seen  that  the  prospects  for  recovery  after  amputa- 
tions in  this  period  are  less  promising  than  after  those 
of  an  earlier  period.  An  equally  strong  objection  to 
waiting  for  this  period  is  that  more  of  a  limb  must 
generally  be  sacrificed  than  by  an  early  operation. 
Thus  Guthrie  observes  that  "  When  an  amputation  is 
delayed  from  any  cause  to  the  secondary  period,  a 


joint  is  most  frequently  lost:  for  instance,  if  a  leg  be 
shattered  four  inches  below  the  knee,  it  can  fre- 
quently be  taken  off  on  the  field  of  battle  and  the 
joint  saved.  Three  or  four  weeks  after,  the  joint  will  in 
all  probability  be  so  much  concerned  in  the  disease 
that  the  operation  must  be  performed  in  the  thigh; 
the  same  in  regard  to  the  forearm  and  hand,  and  the 
upper  part  of  the  arm  with  the  shoulder."  Notwith- 
standing the  drawbacks  attending  secondary  ampu- 
tations, certain  circumstances  frequently  make  them 
imperative.  Continued  fever,  impending  exhaustion 
from  excessive  and  protracted  suppuration,  and 
evident  uselessness  of  the  limb,  even  if  saved,  may 
force  the  knife  into  the  hand  of  the  surgeon,  after 
much  valuable  time  has  been  lost  through  an  error  of 
judgmenl  on  his  part,  or  a  procrastination  on  the 
part  of  friends. 

Anesthesia. — Many  minor  amputations  of  the 
fingers,  of  the  toes,  and  parts  of  the  hand  and  foot 
can  very  easily  be  performed  under  local  anesthesia 
with  cocaine,  tropococaine,  or  novocain.  In  the 
same  way  by  nerve  blocking  with  cocaine,  a  badly 
lacerated  limb  can  be  removed  by  trimming  the  parts 
without  resorting  to  an  immediate  formal  amputa- 
tion. In  almost  all  major  amputations,  however,  a 
general  anesthesia  must  be  induced,  and  the  choice  is 
an  important  one.  Chloroform  should  practically 
never  be  given,  ether  being  preferable  because  it  is 
a  cardiac  stimulant.  In  cases  of  severe  shock,  which 
so  often  attends  the  mutilations  of  the  extremities 
caused  by  machinery,  the  anesthetic  should  be  of 
gas-oxygen.  Unfortunately  it  is  a  method  that 
cannot  be   used   outside   of   well 

A  equipped  hospitals  and  is  a  dan- 
gerous one,  except  in  the  hands 
of  an  expert  anesthetist. 

Preparations. —  Before  begin- 
ning an  amputation  it  is  essential 
to  make  such  preparations  for  it 
as  are  required  for  every  major 
operation.  If  possible,  the  ampu- 
tation should  be  made  in  the  early 
part  of  the  day,  in  order  that  if 
there  be  much  hemorrhage  subse- 
quent to  the  operation  its  source 
may  be  looked  for  without  artifi- 
cial illumination.  It  can  be  most 
satisfactorily  performed  on  any 
operating  table,  or,  in  the  absence 
of  this,  on  two  kitchen  tables 
placed  end  to  end.  The  instru- 
ments necessary  for  major  ampu- 
tations are:  1.  An  Esmarch  elastic 
bandage  and  strap  for  the  produc- 
tion of  anemia  of  the  part  to  be 
removed.  2.  A  suitable  tourni- 
quet. 3.  Amputating  knives  of 
various  lengths  and  widths,  with 
at  least  one  double-edged  blade 
(catlin)  (Fig.  106).  4.  One  large 
and  one  metacarpal  amputating 
saw.  5.  From  six  to  twelve  hemo- 
static forceps.  6.  A  bone-cutting 
forceps,  and  a  lion-jawed  forceps. 
7.  Ligature  and  sewing  materials, 
drainage  tubes,  needles,  and  an 
abundance  of  hot  water. 
Fig.  106. — Catlins.  The  preparations  which  are  to 

be  made  for  the  after-treatment, 
although  they  are  necessarily  a  preliminary  to  the 
operation  itself,  will  vary  according  to  the  plan  to 
be  adopted,  and  will  be  considered  at  some  length 
hereafter. 

While  a  finger  or  toe  can  be  removed  by  a  surgeon 
with  only  such  aid  as  a  layman  can  give,  at  least 
three  assistants  are  required  for  every  larger  amputa- 
tion. The  duties  of  these  should  be  first  clearly 
defined  by  the  operator,   lest   valuable   time  be  lost 


•jes 


REFERENCE    HANDBOOK    OF    Till-:    MEDICAL    SCIENCES 


Amputation 


during  the  operation.  The  undivided  attention  of 
one  must  be  given  to  inducing  and  maintaining  anes- 
thesia. The  second  is  to  support  the  part  to  In- 
removed,  after  which  he  can  be  entrusted  with  the 
ligation  of  the  vessels.  The  duly  of  the  third  should 
be  confined  to  controlling  the  circulation  of  the  limb 
above  the  seat  of  operation,  and  eventually  to  retract 
the  flaps.  These  details  arranged,  the  patient  is 
anesthetized  and  brought  into  such  a  position  that 
the  limb  to  be  removed  is  everywhere  accessible.  Tin- 
part  to  be  removed  must  now  be  carefully  wrapped 
in  towels,  the  entire  limb  thoroughly  cleansed  with 
soap  and  brush,  and  the  hair  removed  from  the  part 
wln-re  the  incision  is  to  be  made.  The  skin  is  then 
sterilized  with  tincture  of  iodine  or  a  ten  per  cent, 
solution  of  iodine  in  benzine.  The  surgeon  is  then 
ready  to  take  the  final  and  most  important  prelimi- 
nary measure  for  the  amputation,  that  by  which  he 
intends  to  control  the  circulation  of  the  limb  and 
reduce  the  loss  of  blood  to  a  minimum. 

Prevention  of  Hemorrhage. — There  are  various 
methods  by  which  the  circulation  may  be  more  or 
less  controlled  during  an  amputation,  and  they  are 
of  sufficient  importance  to 
justify  a  detailed  considera- 
tion. To  prevent  hemorrhage 
the  surgeon  can  choose  be- 
tween tourniquets,  digital 
compression,  and  the  Es- 
march  elastic  bandage,  or 
combine  the  latter  with  one 
of  the  other  two. 

T  ourniquet.— From  the  time 
of  Morel  the  ingenuity  of  sur- 
geons has  been  taxed  to  devise 
an  instrument  which  will 
safely  compress  the  main 
artery  of  a  limb  above  the 
point  where  an  amputation  is 
to  be  practised.  Of  the  many 
instruments  introduced,  only 
a  few  have  been  able  to  gain 
general  recognition.  The 
oldest  of  these  is  the  Spanish 
windlass  or  garrote  of  Morele, 
which  consists  of  nothing 
Fig.107.— Morel's  Tourniquet.  more  than  a  wide  band  (Fig_ 

107,  g)  of  an  unyielding  ma- 
terial (muslin  or  linen),  firmly  drawn  around  the 
limb  and  tied.  Over  the  main  artery  and  at  a  point 
diametrically  opposite,  there  are  inserted  under- 
neath it  compresses  of  linen,  a  piece  either  of 
thick  leather  or  of  pasteboard  (p).  At  a  point 
opposite  the  artery  a  firm  rod  (s,  s)  is  introduced 
underneath  the  encircling  band  and  is  then  turned  in 
such  a  manner  as  to  shorten  the  latter,  and  thus  the 
compression  of  the  main  artery  is  effected.  Owing  to 
the  simplicity  of  its  construction,  the  garrote  of  Morel 
stands  without  a  peer  in  cases  of  emergency  in  civil 
as  well  as  military  practice.  It  has,  however,  one 
very  objectionable  feature  which  renders  its  use  a 
matter  of  necessity  rather  than  of  choice.  Not- 
withstanding the  use  of  the  pads  of  linen  or  leather 
already  referred  to,  veins,  arteries,  and  soft  parts  are 
compressed  to  an  almost  uniform  degree;  hence  exten- 
sive venous  hemorrhage  and  insufficient  retraction 
of  the  muscles  follow.  A  great  improvement  on  the 
windlass  is  the  tourniquet  of  Petit  which  was  in  gen- 
eral use  until  the  Esmarch  strap  was  introduced.  It 
consists  of  two  metal  plates,  the  distance  between 
which  can  be  regulated  by  a  screw,  and  which  are  con- 
nected by  a  strong  linen  band  supplied  with  a  buckle, 
by  which  the  limb  is  encircled  (Fig.  108).  To  apply 
it  properly,  the  limb  should  be  surrounded  by  a  few- 
turns  of  a  roller,  while  the  body  of  the  bandage  (p) 
is  placed  over  the  artery  (a).  Over  this  bandage 
the  lower  metallic  plate  is  then  placed,  and  the  band 
and  buckle  are  fastened,  when,  by  turning  the  screw7, 


compression  of  the  main  vessel  can  be  regulated  at 
pleasure.  The  objection  has  been  raised  to  the 
tourniquet  of  Petit  that  it  compresses  not  only  the 
artery,  but  also  its  accompanying  vein,  and  thus 
induces  venous  stasis,  and  enhances  the  dangers  of 
thrombosis.  While  this  is  doubtless  true,  it  is  an 
insurmountable  defect  com- 
mon to  all  tourniquets,  and 
based  more  on  theoretical 
t  nan  on  clinical  data.  \\  hen 
properly  applied  the  tourni- 
quet  of  Petit  is  not  apt  to 
slip  or  yield,  and  its  safety 
i<  such  that  in  case  of  emer- 
gency the  management  of 
the  screw  might  be  en- 
trusted even  to  a  layman. 
In  order  to  limit  the  com- 
pression  to  the  main  vessel 
alone,  complete  or  incom- 
plete metallic  rings  have 
been  devised  which,  while 
they  surround  the  limb 
more  or  less  completely, 
make  compression  at  only 
two  points,  i.e.  over  the  Fig.  108.— Petit 's  Tourniquet, 
artery  and  at  a  point  dia- 
metrically opposite.  The  best  known  tourniquets  con- 
structed on  this  principle  are  the  horseshoe  tourniquet 
of  Signorini  and  Dupuytren,  the  arterial  compressor  of 
the  late  Professor  Gross,  and  the  abdominal  tourniquet 
of  Pancoast  and  Lister  (Fig.  109).  While  with  these 
the  compression  can  be  limited  to  the  main  vessels 
of  the  limb,  and  the  circumferential  constriction  of 
the  latter  is  thus  avoided,  they  are  more  liable  to  slip 
than  the  tourniquet  of  Petit,  and  are  far  less  reliable 
than  digital  compression.  For  certain  amputations, 
however  (of  the  hip  and  shoulder),  the  instrument 
of  Petit  is  inapplicable;  it  is  then  that  one  or  other 
of  the  horse-shoe  tourniquets  or  digital  compression 
will  be  found  indispensable.  The  tourniquets  above 
described  have  for  the  most  part  only  an  historical 
value,  they  having  been  almost  altogether  supple- 
mented by  the  Esmarch  apparatus. 

Digital  compression,  when  made  by  trustworthy 
hands,  is  admirably  suited  to  control  temporarily 
the  circulation.  If  compression  of  the  artery  alone 
is  anatomically  possible,  it  can  be  best  accomplished 
by  the  finger.  To  be  practicable,  the  vessel  must  be 
contiguous  to  a  bone  against  which  it  can  be  pressed, 
as  the  femoral  upon  the  os  innominatum,  the  brachial 
upon  the  humerus,  the  subclavian  against  the  first 
rib,  or  the  abdominal  aorta 
against  the  vertebra.  Since 
only  a  few  minutes  are  re- 
quired for  the  amputation 
of  a  limb  and  the  ligation 
of  the  larger  arteries,  the 
endurance  of  the  assistant 
entrusted  with  the  duty  is 
not  severely  taxed.  In 
digital  compression  asso- 
ciated w-ith  the  use  of  the 
elastic  bandage  we  have  a 
combination  by  which  the 
circulation  of  a  limb  can  be 
completely  controlled,  and 
by  which  certain  parts,  the 
compression  of  which  would 
be  useless  or  even  harmful,  are  protected.  Notwith- 
standing the  advantages  of  this  method,  the  surgeon 
should  never  resort  to  it  unless  he  can  absolutely  rely 
upon  the  ability  and  skill  of  Iris  assistant.  For  ampu- 
tations' at  the  hip  or  shoulder  direct  compression  of 
the  common  iliac  through  a  laparotomy  wound,  or  of 
the  subclavian  through  an  incision  above  the  clavicle 
is  justifiable.  With  unreliable  assistance  temporary 
ligation  of  these  vessels  would  be  an  absolute   safe- 

269 


Fig.  109. 


-Horseshoe  Tourni- 
quet. 


Amputation 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Fig.    110. — Esmarch's  Apparatus. 
(Bandage  not  shown  in  cut.) 


guard  against  excessive  bleeding.  Digital  compres- 
n  >n  is  especially  indicated  in  amputations  for  senile 
gangrene  when  the  diseased  condition  of  the  main 
artery  is  likely  to  be  made  worse  by  the  prolonged 
pressure  of  a  tourniquet. 

Elastic  Compression. — Notwithstanding  the  pre- 
cautions against  hemorrhage  after  amputations,  these 
were  invariably  associated  with  very  great  loss  of 
blood  until  twenty  years  ago.  The  blood  thus  lost 
was  venous  in  character  and  came  from  the  veins 
of  the  amputated  member.     Through  the    practices 

of  Grandesso  Silvestri, 
an  Italian  surgeon, 
and  particularly  of 
1  }smarch  of  Kiel,  the 
blood  contained  in 
the  part  to  be  re- 
moved is  saved,  and 
that  this  is  not  an  in- 
considerable quantity 
has  been  demon- 
strated by  experi- 
ment. The  apparatus 
of  Esmarch  consists 
of  an  elastic  bandage 
and  an  elastic  tube  or 
flat  band  with  chain 
or  clasp  attachment. 
Commencing  at  the 
fingers  or  toes,  the 
bandage  is  applied  by 
spiral  turns  until  the 
limb  is  covered  to  a 
line  at  least  four 
inches  above  the  point 
u  here  the  bone  is  to 
be  divided.  Above 
the  last  turn  of  the 
bandage,  the  elastic  band  or  tube  is  rather  firmly 
and  repeatedly  wound  around  the  limb,  and  secured 
by  clasp  or  hook  and  chain  (Fig.  110).  When  the 
bandage  is  then  removed,  a  condition  of  ischemia 
is  observed  in  the  limb,  which  will  permit  its  ampu- 
tation without  a  more  than  appreciable  loss  of 
blood  during  the  operation  proper.  In  recent  years 
the  elastic  bandage  is  used  less  and  less,  because  of 
the  danger  of  disseminating  the  infective  or  malig- 
nant process  for  which  the  amputation  is  to  be 
done.  By  elevating  the  limb  for  five  minutes  be- 
fore applying  the  strap,  complete  ischemia  can 
always  be  induced.  When  the  elastic  strap  is  re- 
moved, the  integument  of  the  stump  rapidly  assumes 
a  bright-red  color,  and  in  the  wound  there  appears 
free,  persistent,  and  often  embarrassing,  capillary 
oozing.  It  is  generally  accepted  now  that  the  source 
of  this  hemorrhage  is  from  the  dilated  capillaries, 
the  walls  of  which  have  been  paralyzed  in  conse- 
quence of  the  pressure  exerted  by  the  strap  on 
the  vasomotor  nerves.  When  in  from  twenty  to 
thirty  minutes  the  vessel  walls  regain  their  tonicity, 
the  hemorrhage  ceases.  To  check  this  capillary 
oozing,  a  number  of  remedies  have  been  suggested. 
That  of  Riedinger,  to  apply  the  faradic  current, 
while  very  serviceable,  is  not  always  practicable.  Es- 
march relies  upon  closure  of  the  wound  and  elevation 
of  the  stump  before  the  strap  is  entirely  removed. 
Hot  water  (150°  to  180°  F.),  applied  with  sponges, 
often  acts  admirably  in  these  cases.  Since  compres- 
sion of  the  vasomotor  nerves  caused  by  the  bandage 
is  the  cause  of  this  parenchymatous  hemorrhage, 
this  can  best  be  obviated  by  completely  substitut- 
ing digital  compression  for  the  elastic  strap,  or,  if 
the  latter  be  used,  by  preventing  the  ingress  of  blood 
by  the  use  of  a  tourniquet  until  the  vessels  have  re- 
gained their  natural  tone.  The  latter  plan,  as  practised 
bj  Ashhurst,  is  "to  place  a  tourniquet  in  position, 
but  not  screwed  down  over  the  main  artery  of  the 
limb,   and   then  to  apply   the   Esmarch   tube  a  few 


inches  above  the  point  at  which  it  is  intended  to  am- 
putate. As  soon  as  the  principal  vessels  have  been 
secured,  the  tourniquet  plate  is  screwed  down  and 
the  tube  removed.  No  bleeding  follows,  and  by  the 
time  that  the  remaining  arteries  requiring  ligatures 
have  been  tied,  the  vessels  will  have  regained  their 
tone,  and  the  tourniquet  can  be  removed  without 
any  risk  of  bleeding  following."  In  amputations 
near  the  trunk  the  elastic  strap  or  tube  should  not 
be  used  in  the  ordinary  manner  (see  Special  Amputa- 
tions). In  an  amputation  of  the  shoulder,  and  in 
another  of  the  hip,  I  have  seen  it  loosen  or  slip  over 
the  stump  immediately  after  the  disarticulation 
effected,  and  in  both  instances  (lie  hemorrhage  was 
most  alarming.  In  amputation  at  the  shoulder, 
when,  by  the  use  of  the  bandage,  the  blood  in  the 
extremity  has  been  returned  to  the  economv,  it  is 
better  to  rely  upon  compression  of  the  main  artery 
against  the  first  rib  with  the  finger  or  a  padded  key. 
In  amputations  of  the  hip,  the  main  artery  cat 
compressed  against  the  pubic  bone,  or  even  the  cir- 
culation in  the  aorta  can  be  controlled  by  one  of  the 
many  compressors  already  referred  to.  In  consider- 
ing amputations  of  the  shoulder,  of  the  hip,  or  of  I  he 
ilium  special  methods  of  controlling  hemorrha 
applicable  to  them  will  be  discussed. 

Methods    of    Amputation. — Every    amputation 
consists  of  three  steps:  (1)   Division  of  the  soft  pa 
(2)  division  of  the  bone,  or  disarticulation;  (3)  1 
tion  of  t  lie  vessels  and  closure  of  the  wound. 

According  to  the  method  adopted  for  the  division 
of  the  soft  parts,  amputations  are  classified  as  cir- 
cular or  flap  operations,  and  in  the  choice  of  tin- 
method  the  surgeon  must  be  guided  by  the  condition 
of  the  soft  parts  about  the  bone,  the  ease  with  which 
the  joint  can  be  opened  in  a  disarticulation,  the  prob- 
able position  of  the  cicatrix  and  form  of  the  slump, 
and,  above  all,  the  desire  to  save  as  much  of  the  limb 
as  possible.  Of  the  circular  and  flap  operations,  all 
methods  of  amputation  may  be  said  to  be  but  modifi- 
cations. By  the  circular  method  it  is  attempted 
to  give  to  the  stump  the  form  of  an  inverted  cone  or 
funnel,  the  apex  of  which  is  occupied  by  the  divided 
end  of  the  bone,  the  base  or  margin  of  which  is  rep- 
resented by  the  cutaneous  margin  of  the  wound.  In 
the  flap  operation  the  soft  parts  are  so  divided  as  to 
make  one  or  more  flaps,  the  bases  of  which  are  on  a 
level  with  the  divided  bone,  and  the  free  margins  of 


FlQ.    Ill 

which  are  so  adapted  to  each  other  as  completely  to 
cover  the  bone  and  admit  of  the  ready  closure  of  the 
wound.  Whatever  plan  of  operation  is  adopted,  the 
surgeon  should  stand  in  such  a  position  that  he 
grasps  the  stump  with  his  left  hand,  so  that  the 
amputated  part  falls  toward  his  right  side. 

Circular  Method. — All  modifications  of  the  circu- 
lar method  call  for  a  similar  incision  through  the  skin 
and  subcutaneous  cellular  layer,  this  incision  being 
made  around  the  entire  circumference  of  the  limb  ami 
at  a  right  angle  to  its  axis.  According  to  the  depth 
to  which  the  incision  is  carried,  the  method  is  sub- 


270 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SI  1ENCES 


Amputation 


divided  into  that  by  single  incision  and  that  by  double 
incision.  . 

Single  Incision.— This,  as  already  remarked  (see 
History),  is  the  oldest  method  of  amputation,  and  is 
generally  known  as  the  Celsian  operation.  Alter 
tction  of  the  soft  pari-,  a  long  amputating  knife 
is  -wept  around  the  limb,  and  all  of  the  soft  parts  are 
divided  down  to  the  In. no.  This  is  then  divided  on  a 
slightly  higher  level  by  the  retraction  of  the  soft  parts. 
Wnile'this  operation  yields  the  smallest  wound,  and 
i<  the  most  rapid  in  it's  execution,  its  manifest  disad- 
vantage is  in  the  insufficient  covering  which  it  affords 


for  the  bone.  It  is 
admissible  only  in 
greatly  emaciated 
subjects.  Brunning- 
hausen,  in  the  begin- 
ning of  the  century, 
reintroduced  this 
method,  but,  after 
Fia.  112.  the  amputation  of  the 

limb  was  completed, 
made  a  second  section  of  the  bone  several  inches 
above  the  point  at  which  it  was  first  divided. 

Double  Incision. — This  operation  of  which  those  of 
Petit,  Cheselden,  B.  Bell,  Desault,  and  Alanson  are 
but  unimportant  modifications,  has  received  its  name 
from  the  fact  that  the  skin,  underlying  fascia,  and 
muscles  are  divided  upon  different  levels,  and  there- 
fore by  at  least  two  circular  incisions.  It  i<  made  as 
follows:  The  surgeon,  securely  holding  the  limb  with 
the  left  hand,  carries  his  right  hand,  in  which  he 
firmly  holds  a  large  amputating  knife,  underneath 
and  around   the  limb   until  the  heel  of  the  cutting 


Fig.   113. 

edge  is  over  the  uppermost  part  of  the  line  of  the 
proposed  incision.  Giving  the  knife  this  position 
forces  the  operator  into  a  more  or  less  stooping  pos- 
ture, from  which  he  raises  himself  as  the  incision  is 
completed.  This  is  commenced  with  the  heel  of  the 
knife,  winch,  by  a  single  sweep  is  carried  around  the 
entire  circumference  of  the  limb,  severing  the  skin 
and  adipose  layer  down  to  the  deep  fascia  (Fig.  111). 
Two  incisions,  the  ends  of  which  meet,  will  answer  as 
well  as  the  division  by  a  single  sweep  of  the  knife. 
As  soon  as  the  integument  is  divided  the  wound  gapes. 
The  upper  margin  is  raised  by  the  thumb  and  finger 
of  the  left  hand,  and  gradually  detached  from  the 
fascia  by  repeated  long  incisions  carried  perpen- 
dicularly to  the  axis  of  the  limb.  This  operation  of 
detachment  is  continued  until  the  skin  and  adipose 


Fig.  11 1. 


layer  can  be  reflected  like  a  cuff,  the  length  of  which 
should  be  equal  to  half  the  diameter  of  the  limb  (Fig. 
112).  When  the  latter  rapidly  increa  e  in  circum- 
ference, or  there  is  a  thick  subcutaneous  layer,  oi  this 
has  been  infiltrated,  the  reflection  of  a  cuff  is  often 

impract  icable.  'I  ben 
two  longitudinal  inci- 
sions, diametrically  op- 
posite each  other  will 
materially        facilitate 

this  part  of  the  opera- 
tion,   although   by    this 

means  the  amputation 
is  in  a  manner  con- 
verted into  a  Hap  oper- 
al  ion.  The  integument 
having  been  reflected 
to  the  required  extent, 
the  muscles  are  next 
divided  close  to  the  line  of  reflection  by  one  steady 
circular  sweep  of  the  knife,  which  should  cut  through 
everything  down  to  the  bone  (Fig.  113)  or  rather  to  the 
periosteum.  Before  using  the  saw,  the  bone  should 
be  stripped  of  its  muscle  and  a  periosteal  cuff  made, 
which  after  the  division  of  the  bone  falls  natur- 
ally over  its  raw  surface,  and  applies  itself  to  the  open 
medullary  canal.  Where  there  is  no  oozing  it  may 
even  be  sewed  in  place  advantageously  with  catgut 
sutures.  In  dividing  the  muscles  it  is  often  desirable 
to  do  so  on  different  levels  whereby 
the  wound  naturally  assumes  a 
cone-shape  and  is  more  easily 
closed. 

Where  there  is  but  one  bone  to 
be   divided,    the  surgeon   is   now 
prepared  to  use  the  saw.     Where 
there  are  two  bones,  the  interos- 
seous   tissues     re- 
main to  be  divided. 
Whereas    this   can 
be      accomplished 
with   an    ordinary 
amputating  knife, 
it  is  safer  to  use  a 
double-edged      in- 
strument    (catlin) 
for    this    purpose. 
By  using  it  in  the  fig.  us. 

manner    indicated 

in  Fig.  114,  there  is  no  danger  of  cutting  the  blood- 
vessels twice,  and  thus  one  danger  of  troublesome 
hemorrhage  is  avoided.  To  protect  the  soft  parts 
from  injury  by  the  saw  they  must  be  well  retracted 
by  the  hands  of  an  assistant,  or  by  the  use  of  a  band 
of  muslin  (retractor)  divided  into  two  or  three  slips 
according  to  the  absence  or  presence  of  an  interosse- 
ous space  (Fig.  115). 

The  movements  of  the  saw  can  be  greatly  facilitated 
by  guiding  them  with  the  nail  of  the  left  thumb 
(Fig.   116).     The  to-and-fro  movements  of   the  saw 


Fig.  116. 

should  be  slow,  lest  the  heat  developed  by  its  too 
rapid  use  endanger  the  vitality  of  the  bone.  Where 
there  are  two  bones  of  the  same  diameter  (forearm), 
they  should  be  divided  simultaneously.     In  the  leg, 

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Fig.  117. 


the  tibia  is  to  be  almost  entirely  divided  before  the 
section  of  the  fibula  is  commenced.  Unless  this 
precaution  is  adopted,  splintering  of  the  bone  is  not 
easily  avoided.  For  the  same  reason,  the  assistant  in 
charge  of  the  part  to  be  amputated  should  hold  it 
horizontally, 

allowing   it  xaW 

neither     to  ,  J-Jft 

drag     by     its  L*J       MWmi 

weight  nor  to 
be  raised  in  a 
manner  to  in- 
terfere with 
the  move- 
ments of  the 
saw.  Should 
splintering  of 
t  h  e  bone 
neve  rtheless 
occur,  the 
splinters  and 
sharp  margin 
of  the  latter 
must  be  re- 
moved with 
the  cutting 
bone  forceps. 
Oval  Method. 
— Holding  an 
i  n  t  ermediate 
position  be- 
tween the  cir- 
cular and  flap 
operations  is 
the  oval  method,  which,  although  practised  by  the 
older  Langenbeck  and  others,  was  first  generalized 
by  Scoutetten  (1827).  The  essential  feature  of  this 
amputation  in  the  continuity  of  the  limb  is  that  the 
incision,  instead  of  being  made  perpendicnlar  to  its 
long  axis,  is  carried  at  an  angle  of  forty-five  degrees, 
and  in  such  a  way  that  the  soft  parts  in  front  of  the 
bone  are  divided  upon  a  higher  level  than  those  on  its 
posterior  aspect.  At  the  same  time  the  upper  portion 
of  the  wound  is  converted  into  an  acute  angle,  whereas 
its  lower  portion  is  given  an  oval  outline.  The  upper 
extremity  of  the  wound  is  placed  at  the  point  where 
the  bone  is  to  be  divided.  The  operation  is  com- 
menced by  two  incisions    in  the  form  of  an  inverted 

V,  the  lower 
ends  of  which 
are  united  by 
a  transverse 
cut  on  the 
posterior  sur- 
face of  the 
limb(Blasius). 
Here,  as  in  the 
circular  am- 
putation, by 
a  single  inci- 
sion all  the 
soft  parts  are 
divided  at 
once  on  each 
side  of  the 
bone,  and 
then  those  on 
its  posterior 
aspect.  This 
operation  has 
been  generally 
discarded  for 
amputations  in  the  continuity,  although  for  disarticu- 
lations at  certain  joints  it  presents  advantages  which 
an1  worthy  of  consideration  (see  Fig.  117). 

Flap  Method. — As  already  indicated,  this  consists 
in  the  formation  of  one  or  more  flaps,  comprising 
integument  and  muscular  tissue,  or  integument  alone, 


and  designed  in  a  manner  completely  to  cover  the 
divided  extremity  of  the  bone  or  its  exposed  articular 
surface.  According  to  the  anatomical  components 
of  the  flaps,  they  can  therefore  be  called  tegumentary 
and  musculotegumentary. 

Tegumentary  Flaps. — This  operation  is  generally 
practised  by  making  two  semilunar  incisions,  the 
ends  of  which  meet  on  opposite  sides  of  the  part, 
down  to  the  deep  fascia,  and  dissecting  up  the  skin 
and  subcutaneous  cellular  layer  to  an  extent  sufficient 


Fig.  119. 

to  cover  the  stump  (Fig.  118).  When  it  is  practicable, 
the  flap  should  be  taken  from  the  anterior  and  pos- 
terior aspects  of  the  limb  in  the  forearm,  thigh,  and 
leg,  and  they  should  not  be  of  equal  lengths,  the 
anterior  flap  usually  being  made  longer,  to  fall  like  a 
curtain  over  the  divided  end  of  the  bone,  where  it 
comes  in  contact  with  the  posterior  (shorter)  flap. 
In  recent  years  the  tegumentary  method,  with  only 
one  cutaneous  flap,  made  from  the  anterior  surface 
of  the  limb,  has  been  most  highly  advocated  (Garden, 
Bruns).  When,  from  choice  or  necessity,  a  single 
tegumentary  flap  is  to  be  made,  the  incision  should 
be  commenced  on  a  level  with  the  point  where  the 
division  of  the  bone  is  contemplated,  and  carried  for 
a  varying  distance  down  one  aspect  of  the  limb, 
parallel  to  its  axis,  and  then  by  a  wide  curve  on  the 
opposite  side  to  a  point  on  a  level  with  its  commence- 
ment (see  Fig.  118).     In  this  manner  the  base  of  the 


Fig.  120. 

cutaneous  flap  extends  over  half  the  circumference 
of  the  limb,  while  its  length  should  be  greater  than 
its  anteroposterior  diameter  at  the  level  of  the 
amputation.  After  separation  of  this  flap  from  the 
deep  fascia  (it  may  be  made  to  include  this)  it  is 
reflected  and  the  ends  of  the  incision  are  united  by 
a  posterior  incision  carried  perpendicularly  to  the 
axis  of  the  limb  as  in  the  circular  operation  (Fig.  119). 
Whether  one  or  more  cutaneous  flaps  be  made,  the 
division  of  the  remaining  soft  parts  is  practised  by  a 
single  sweep  of  the  knife,  carried  perpendicularly 
around  the  limb  at  the  base  of  the  flap,  as  in  the 
circular  operation.     Owing   to   this  division  of  the 


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Amputation 


muscles,  amputations  by  the  tegumentary  flap 
method  are  not  infrequently  called  "modified  circular 
operal  ions." 

Musculotegumentary  Flaps. —  Here,  as  in  the  tegu- 
mentary method,  one  or  more  Haps  may  be  made  to 
rever  the  stump.  They  may  be  formed  by  transfixion 
of  the  limb  and  cutting  from  within  outward,  or  by 
cutting  from  without  inward,  or  by  making  one  flap 
by  the  former  and  the  other  by  the  latter  mentioned 
method.  Where  there  is  but  a  single  bone  (thigh, 
arm),  it  was  the  custom  of  the  older  surgeons  to  make 
at  least  one  flap  by  transfixion.  The  integument 
being  well  retracted,  and  the  soft  parts  raised  from 
the  bone  with  the  left  hand,  a  sharp-pointed  and 
large  amputating  knife  is  passed  through  the  limb 
from  side  to  side,  the  knife  being  made  to  graze  the 
surface  of  the  bone  (Fig.  120).  By  a  sawing  move- 
ment the  instrument  is  gradually  carried  downward 
and  forward,  and  then  obliquely  outward,  thus  form- 
ing a  wide  flap  with  convex  margin.  The  danger  of 
making  a  flap  too  narrow  is  best  avoided  by  not 
cutting  outward  too  soon.  The  knife  is  then  entered 
at  the  angle  of  the  wound  on  one  side,  passed  around 
the  bone  on  the  side  where  the  soft  parts  are  still 
adherent,  and  out  at  the  opposite  end  of  the  wound. 
The  second  flap  is  then  made  by  cutting  outward  as 
before.  The  flaps  being  now  retracted,  the  knife  is 
rapidly  carried  around  the  bone,  as  high  as  possible, 
to  divide  the  muscular  tissue  still  adhering  to  it. 
The  application  of  the  saw  then  follows.  In  order 
to  make  sufficient  allowance  for  shrinkage,  the  flaps 
should  have  a  length  at  least  equal  to  three-fourths 
the  diameter  of  the  limb.  Redundance  of  the  flap 
is  always  preferable  to  insufficiency,  since  the  excess 
of  muscular  tissue  can  easily  be  removed  with  a  few 
strokes  of  the  knife.  In  flap  operations,  owing  to 
unequal  retraction  of  the  soft  parts,  tendons  and 
nerves  are  particularly  apt  to  protrude  above  the 
surface  of  the  wound,  thus  giving  it  an  irregular 
appearance,  and  interfering  with  its  ready  union. 
After  ligation  of  the  blood-vessels,  these  protruding 
masses  are  to  be  carefully  removed  with  the  scissors. 
The  protrusion  of  the  muscular  tissue  of  the  flap 
and  the  irregularity  of  the  latter 
can  be  totally  avoided  by  cut- 
ting from  without  inward.  This 
plan,  generally  known  as  that  of 
Langenbeck  (Fig.  121),  insures 
perfect   symmetry  of  the  flaps, 


Fig.  121. 

and  permits  the  ligation  of  the  vessels  as  they  are 
exposed  or  divided.  It  is  also  practicable  to  cut 
through  the  skin  and  subcutaneous  tissue  from  with- 
out inward,  and  complete  the  operation  by  transfixion. 
Although  already  practised  by  Dupuytren,  this  plan 
was  advocated  later  by  Agnew.*  Most  surgeons  who 
prefer  accuracy  to  speed  will  fashion  their  flaps  by 
cm  ting  them  from  without. 

Rectangular  Flap. — In  1S55  Mr.  Teale  of  Leeds 
practised  the  formation  of  one  long  and  one  short 
rectangular  flap,  each  of  which  comprised  one-half 
the  circumference  of  the  limb  and  all  the  tissues 
down  to  the  bone.  The  operation  is  made  as  follows: 
A  rectangular  anterior  flap  (posterior  in  the  forearm), 
equal  in  length  and  breadth  to  half  the  circumference 
of  the  limb  at  the  base  of  the  flap,  is  marked  out  by 
one  transverse  and  two  parallel  longitudinal  incisions, 
the  latter  involving  only  the  skin  and  superficial 
fascia,  and  the  former  being  carried  down  to  the  bone. 

Vol.  I.— IS 


Fig.  122. 


The  longitudinal  incisions  should  be  so  placed  that 
the  posterior  obtains  one-fourth  the  length  of  the 
anterior   Hap.     The   two   flaps   are    then    turned    up 

from  the  bone  from  below  upward,  and  the  saw  is 
applied.  To  insure  equal  width  of  the  Haps  at  their 
bases  and  their  extremities  it  is  besl  to  map  out  the 
Haps  by  actual  measurement  before  tin-  incisions  are 
made.      In  closing  the  wound,  the  long  Hap  is  doubled 

upon  itself  so  that  the  square  ends  of  the  two  flaps 
are  brought  into  apposition,  where  they  are  retained 
by  a  number  of  sutures  (Fig.  122). 

Comparison  of  Methods. — The  surgeon  who 
would  obtain  the1  best  results  after  amputul  ions  should 
be  familiar  with  all  the  different  methods  without 
becoming  too  partial  to  any,  since  the  condition  of  the 
part  to  be  ampu- 
tated, the  thick- 
ness and  vitality 
of  the  subcutane- 
ous cellular  tissue, 
the  position  of  the 
wound,  and  many 
other  circum- 
stances should 
guide  him  in  the 
selection  of  a 
m e  t  h  od  ra  t  her 
than  individual 
preference.  To 

save  as  much  of  a 
limb  as  possible 
must  be  the  first 
aim  of  the  opera- 
tor, and  this  can 
be  accomplished 
only  by  resorting 
to  various  methods 
according  to  the  exigencies  of  individual  cases.  If 
one  method  of  operating  deserves  a  preference,  it  is 
that  by  tegumentary  flaps  with  circular  division  of 
the  remaining  soft  parts.  By  this  method  the  posi- 
tion of  the  angles  of  the  wound  for  favorable  drainage 
and  that  of  the  cicatrix  can  be  readily  determined, 
and  when  two  oval  cutaneous  flaps  are  made  no 
anxiety  for  their  vitality  need  ordinarily  be  enter- 
tained. When  the  subcutaneous  cellular  layer  is  very 
thin,  there  is  a  manifest  advantage  in  dissecting  up 
with  the  integument  some  of  the  superficial  muscular 
fibers.  The  marked  advantage  of  the  tegumentary 
flap  over  the  circular  method  lies  in  the  fact  that  by  it, 
when  the  disease  extends  higher  on  one  side  of  the 
limb  than  on  the  other,  it  often  enables  us  to  ampu- 
tate several  inches  lower  than  we  could  by  the  circular 
method.  While  during  the  early  part  of  this  century 
the  musculocutaneous  method  by  transfixion  was 
very  extensively  practised,  on  account  of  the  rapidity 
with  which  it  could  be  executed  and  the  muscularity 
of  the  stump  which  it  left,  it  is  gradually  being  dis- 
carded for  two  reasons  chiefly.  In  the  first  place,  the 
general  use  of  anesthetics  has  removed  the  necessity 
for  unusual  haste,  and  in  the  second  place,  the  muscu- 
lar tissue  left  in  the  stump  generally  undergoes 
atrophic  changes  from  disuse  during  the  first  year. 
A  most  decided  disadvantage  of  the  musculotegumen- 
tary flaps  exists  in  the  oblique  division  of  the  blood- 
vessels, on  account  of  which  they  are  often  difficult 
to  find  and  to  ligate.  It  is  for  this  reason  that  sec- 
ondary hemorrhages  are  more  prone  to  follow  ampu- 
tations made  by  this  method,  although  by  proper  care 
in  the  act  of  ligation  and  with  sufficient  compression 
of  the  stump  with  the  dressing  this  can  usually  be 
avoided.  The  circular  operation  commends  itself, 
owing  to  the  facility  with  which  it  can  be  executed, 
even  by  a  novice  in  the  operative  art,  and  by  its 
special  applicability  for  amputations  in  certain  parts, 
as  in  the  forearm  and  lower  part  of  the  leg.  Where 
the  operator  can  choose  his  method,  amputations 
may  be  made  with  good  results  as  follows:  In  the 

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arm  and  forearm,  by  circular  method  or  rectangular 
flaps;  in  the  upper  part  of  the  leg,  by  tegumentary 
and  rectangular  flaps  (lateral  or  anteroposterior) ; 
in  the  lower  part  of  the  thigh,  by  anteroposterior 
muscular  flaps;  in  the  middle  of  the  thigh,  by  one 
tegumentary  flap  raised  from  the  anterior  surface  of 
the  limb.  The  oval  method  will  be  found  particularly 
applicable  to  amputations  at  certain  articulations, 
while  the  method  of  Teale,  which  has  not  been  exten- 
sively practised  in  this  country,  will  give  good  results 
in  amputations  of  the  leg  and  forearm  where  the 
injury  or  disease  has  invaded  a  limb  more  extensively 
on  one  side  than  on  the  other. 

Ligation  of  Vessels. — When  the  amputation 
proper  is  completed,  the  entire  attention  of  the 
operator  must  at  once  be  directed  toward  permanently 
controlling  the  hemorrhage.  For  this  purpose  it  is 
best  to  grasp  the  divided  blood-vessels,  one  after 
another,  as  they  are  seen,  with  hemostatic  forceps, 
which  are  allowed  to  remain  in  the  wound  until  all 
the  vessels  are  thus  held.  This  accomplished,  the 
vessels  are  separately  tied  with  catgut.  The  ligatures 
are  then  cut  short.  Veins  should  be  tied  to  avert  the 
development  of  a  general  infection  out  of  a  possible 
local  infection.  As  a  rule,  not  more  than  from  four 
to  six  arteries  will  require  ligation  in  all  amputations, 
except  those  of  the  hip  and  shoulder,  although  long- 
standing disease  (large  neoplasms  or  preexisting 
occlusion  of  the  main  artery)  may  have  multiplied 
the  number  of  vessels  requiring  ligation.  Here,  as  in 
ordinary  wounds,  at  least  the  larger  arteries  should  be 
carefully  exposed  before  the  ligature  is  applied.  In 
the  smaller  vessels,  where  their  exposure  would  entail 
an  unnecessary  loss  of  time,  portions  of  the  tissues  in 
which  they  are  embedded  may  safely  be  included  in 
the  ligature  by  passing  this  with  a  needle  behind  the 
bleeding  vessel.  The  question  has  for  a  long  time 
been  discussed  as  to  whether  the  veins  should  be  tied. 
There  can  be  no  question  but  that  the  ligature  of  the 
divided  veins  removes  a  common  source  of  secondary 
hemorrhage,  and  materially  reduces  that  immediately 
following  the  removal  of  the  Esmarch  bandage.  The 
opposition  to  the  ligation  of  veins  in  amputations  has 
been  mainly  based  upon  the  fear  of  exciting  an  as- 
cending phlebitis  and  of  giving  rise  to  embolic  proc- 
esses. That  these  fears  are  utterly  groundless  has 
been  conclusively  demonstrated.  "  Of  forty  cases  of 
ligation  of  the  internal  jugular  vein,  death  was  fairly 
ascribable  to  the  ligature  in  only  four,  all  due  to 
secondary  hemorrhage  coming  on  about  the  time  of 
the  separation  of  the  thread.  In  not  a  single  instance 
was  diffused  phlebitis  excited.  In  twenty  cases  of 
ligation  of  the  external  jugular  vein,  and  fifteen  of  the 
axillary,  additional  evidence  of  the  safety  of  ligation 
of  veins  is  recorded."  The  most  troublesome  hemor- 
rhage is  the  parenchymatous  oozing  which  supervenes 
when  the  Esmarch  bandage  is  removed.  How-  to 
contend  against  this  has  already  been  discussed 
(see  above).  It  is  proper  to  add,  however,  that  in 
every  case  the  application  of  an  abundance  of  hot 
water  is  of  unquestionable  value.  When  the  oozing 
from  the  divided  end  of  the  bone  is  not  checked  by 
this,  the  medullary  canal  may  be  temporarily  plugged 
with  clean  white  wax,  or  with  sterile  gauze.  The 
accurate  closure  of  the  wound  and  pressure  upon  it  by 
a  well-applied  bandage  are  among  the  best  means  of 
checking  the  capillary  hemorrhage.  When  it  is 
necessary  to  resort  to  this  means,  a  large  gauze  pad 
is  firmly  pressed  against  the  wound  and  retained  until 
the  sutures  are  passed.  As  the  sutures  are  tightened 
the  pad  is  gradually  withdrawn  while  an  assistant 
tightly  presses  the  wound  surfaces  against  each  other. 
In  large  amputation  wounds,  the  size  can  be  greatly 
reduced  by  buried  continuous  catgut  sutures  which 
bring  the  divided  muscles  close  together.  Sutures 
thus  applied  in  purse-string  fashion  or  in  tiers  help 
to  cover  the  bone  and  to  prevent  the  formation  of 
dead  intermuscular  spares. 


After-Treatment. — It  is  beyond  the  scope  of  this 
article  to  enter  into  an  extended  discussion  of  the 
various  methods  of  treatment  of  wounds,  although  in 
hardly  any  other  class  of  wounds  are  the  good  or  evil 
results  so  clearly  attributable  to  the  manner  of  treat- 
ment adopted.  The  question  at  once  presents  itself 
whether  the  surgeon  will  pursue  a  course  which  will 
reasonably  assure  a  total,  or  at  least  partial  primary 
agglutination  of  the  wound,  or  whether  he  will  avoid 
the  dangers  of  retention  and  decomposition  of  the 
secretion  of  the  wound  by  treating  this  openly,  thus 
expecting  its  closure  by  the  slower  process  of  granula- 
tion. The  latter  plan,  which  is  now  known  as  the 
"open  method,"  was  first  enunciated  by  Vezin. 
Bartscher,  and  Burow5  in  Germany  and  disseminated 
in  this  country  by  the  late  Dr.  James  R.  Wood. 
When  this  method  of  treatment  is  adopted,  sutures 
adhesive  straps,  etc.,  are  entirely  dispensed  with,  the 
stump  being  comfortably  placed  on  a  pillow  or  pad, 
and  the  wound  freely  exposed  to  the  air.  A  mass  of 
absorbent  cotton  is  placed  underneath  the  stump  to 
catch  the  discharges  from  it.  Twice  daily  the  wound 
is  irrigated  with  an  antiseptic  solution,  usually  of 
carbolic  acid,  until  at  the  termination  of  the  first 
week,  when  the  process  of  granulation  has  been  thor- 
oughly established,  the  edges  of  the  wound  are  ap- 
proximated by  adhesive  strips,  care  being  taken  that 
retention  does  not  occur.  The  manifest  advantage  of 
the  "open  method"  of  treating  amputation  wounds 
is  in  the  ready  outlet  which  is  given  to  the  secretions. 
Their  decomposition  in  the  wound  is  thoroughly 
prevented,  and  the  chief  factor  of  septic  absorption 
is  thus  avoided.  However  admirable  the  results 
which  have  been  obtained  from  it,  the  length  of  time 
required  for  the  closure  of  the  wound  (six  to  twelve 
weeks)  militates  against  its  general  adoption.  While 
incomparably  better  than  the  older  methods  of 
tightly  closing  the  wound  regardless  of  proper  drain- 
age, the  open  treatment  of  wounds  has  subserved  its 
purpose,  and  has  yielded  to  the  superior  advantages 
of  the  aseptic  method,  which  strives  to  obtain  the 
ideal  of  the  surgeon  in  the  treatment  of  wounds,  viz., 
primary  union.  The  open  treatment  of  amputation 
wounds  has  been  therefore  properly  relegated  to  those 
cases  in  which  the  surgeon  is  convinced  that,  from  the 
condition  of  the  parts  in  which  the  operation  has 
been  made,  or  from  the  general  condition  of  the 
patient,  primary  union  cannot,  take  place. 

When  a  doubt  exists  as  to  the  certainty  of  primary 
union,  sutures  should  be  passed  both  deeply  and 
superficially  and  left  untied.  The  wound  itself  is 
packed  lightly  with  sterile  gauze.  If,  at  the  end  of 
forty-eight  or  seventy-two  hours,  there  is  no  evidence 
of  septic  infection,  the  gauze  may  be  removed  and 
the  sutures  closed  with  prospect  of  securing  union 
without  suppuration.  When,  on  the  other  hand, 
primary  union  is  aimed  for,  all  drainage  is  to  be 
dispensed  with  unless  there  is  considerable  oozing. 
The  rubber  drainage  tube  formerly  extensively  used 
is  gradually  being  replaced  by  a  narrow  wick  of 
sterile  gauze  drain  in  rubber  tissue,  or  a  strand  of 
silkworm  gut  passed  through  the  angle  of  the  wound 
from  the  immediate  vicinity  of  the  divided  bone. 
This  can  be  removed  on  the  third  or  fourth  day,  or,  if 
there  is  no  evidence  of  infection,  may  be  allowed  to 
remain  until  the  first  dressing  is  changed,  after  a  week 
or  ten  days.  When,  as  in  the  case  of  amputation  of  I  he 
heel  (Syme),  there  is  danger  of  the  formation  of  a 
dead  space,  one  of  the  flaps  can  be  perforated  in  such 
a  manner  as  to  prevent  pocketing  of  wound  secret  ion. 
Although  an  advocate  of  limiting  drainage  as  far  OS 
possible,  the  writer  believes  it  should  be  resorted  to 
in  every  case  in  which  oozing  has  not  been  entirely 
stopped  by  the  time  the  sutures  are  read}'  to  be  tied. 
Primary  union  is  often  prevented  by  the  accummula- 
tion  of  bloody  serum,  which  mechanically  separates 
surfaces    which    ought    to    be    held    in    apposition. 

An  amputation  wound  is  to  be  closed  by  three  or 


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Amputation 


four  deep  sutures,  which  should  include  the  entire 
thickness  of  the  muscles  on  each  side  of  the  divided 
bone,  they  should  be  of  fine  cupper  wire  or  silk- 
worm put.  The  superficial  sutures  or  skin  clamps 
should  he  placed  al  distances  of  about  one-third  of  an 
inch  from  one  another. 

The  dressing  of  the  wound  follows.  The  amount 
of  material  used  should  be  ample  and  it  should  be  so 
applied  that  pressure  will  tend  to  keep  the  wound  sur- 
s  in  apposition.  Unless  a  moist  dressing  is 
ued  advisable  because  a  doubt  as  to  the  asepsis 
-.  a  dry  dressing  should  always  be  used  with 
pulous  attention  to  surgical  cleanliness.  Even 
amputation  wounds,  as  those  of  the  thigh,  hip, 
or  shoulder,  will  generally  heal  under  one  or  two 
dressings.  As  in  other  operations,  the  dressing  should 
kllowed  to  remain  for  at  least  a  week  or  ten  days. 
Should  there  be  a  slight  oozing,  a  change  of  dressing 
i~  imperative.  The  stump  should  always  be  main- 
tained in  an  easy  position  on  a  pillow  or  a  well-padded 
posterior  splint.  It  is  usually  advisable  to  elevate 
this  to  a  degree  sufficient  to  faciliate  the  return  of 
blood  through  the  veins.  Postoperative  oozing  can 
thereby  be  best  prevented. 

After  amputations  in  which  the  asepsis  has  been  suc- 
cessfully carried  out,  even  the  largest  wounds  will 
heal  entirely  by  first  intention.  The  dissimilarity  of 
tissues  which  are  often  brought  in  contact  with 
one  another  in  an  amputation  wound,  and  which 
were  formerly  supposed  to  preclude  the  possi- 
bility of  immediate  union,  is  no  obstacle  to  the 
achievement  of  this  result.  Of  greater  importance 
are  the  novel  relations  of  the  blood-vessels  to  one 
another.  The  circulation  in  the  veins  of  the  stump 
has  lost  the  vis  a  tergo  so  essential  to  the  proper  per- 
formance of  their  function,  while  the  smaller  arteries 
are  distended  with  blood  in  consequence  of  the  in- 
terrupted circulation  in  the  main  vessel.  It  is  for 
this  reason  that  a  marked  edema  and  congestion  will 
often  manifest  themselves  in  the  stump.  Unless 
infection  has  occurred,  these  manifestations  will 
disappear  in  three  or  four  days. 

In  whatever  manner  the  wound  heals,  certain 
marked  changes  will  occur  in  the  stump.  The 
muscular  tissue  undergoes  atrophic  changes,  its 
fibrous  elements  becoming  firmly  adherent  to  the 
end  of  the  bone.  This  itself  gradually  decreases  in 
size,  the  end  becoming  rounded  off  and  often  covered 
by  a  rounded  osteophyte  formed  from  the  periosteum 
or  from  the  granulations  springing  from  the  medullary 
canal.  Where  two  bones  are  present,  an  irregular 
osseous  bridge  not  infrequently  unites  them  (Gueter- 
bock6).  As  a  rule,  the  end  of  the  bone  is  intimately 
united  to  the  soft  parts  covering  it,  although  at  times 
a  bursa  is  developed  between  them.  The  ligated  vessels 
are  converted  into  firm  fibrous  cords  for  a  varying  dis- 
tance and  are  reduced  in  size,  not  only  in  the  stump  but 
also  in  the  entire  limb.  Thus,  in  amputations  of  the 
leg,  the  artery  and  vein  are  reduced  over  one-half  in 
size  as  high  as  the  inferior  vena  cava  and  the  bifurcation 
of  the  aorta.  The  divided  nerves  lose  their  nervous 
elements  by  atrophy,  while  their  connective-tissue 
components  increase  in  number  until  their  extremities 
"ften  expanded  and  bulbous,  thus  forming  false 
neuromata. 

Complications. — Pain  and  muscular  spasm  maybe 
said  to  be  present  to  a  greater  or  less  degree  after  every 
major  amputation.  They  usually  supervene  soon 
after  the  patient  regains  consciousness,  and  may 
develop  to  a  distressing  severity,  particularly  in 
persons  of  a  nervous  and  irritable  disposition.  For 
the  relief  of  these  symptoms  hypodermatic  injections 
of  morphine  act  most  promptly.  The  jactitations  of 
the  -tump  are  most  successfully  overcome  by  lightly 
fastening  the  stump  with  a  few  turns  of  a  bandage  to 
a  well-padded  posterior  splint. 

A  very  slight  reaction  may  be  said  to  be  necessary 
to  the  process  of  repair.     When  infection  has  taken 


place,  the  evidences  air  speedily  seen  in  the  wound. 
It  may  lead  to  more  or  less  extensive  suppuration, 
to  a  limited  sloughing,  or  to  gangrene  of  the  -lump. 
When  such  severe  inflammation  attacks  the  wound, 
the  stump  becomes  exquisitely  sensitive  and  hot,  and 
i  Lines  a  dusky  red  and  glistening  appearance. 
The  discharges  from  the  wound  arc  scant  and  offen- 
sive, while  the  elevated  temperature  aid  hard  and 
rapid  pulse  sufficiently  indicate  'lie  constitutional 
dist  urbancc.  When  the  inflammatory  proci 
along  the  intermuscular  spaces  the  limb  becomes 
sensitive  to  the  touch,  and  swollen  for  a  considerable 
distance  above  the  seat  of  operation.  When  suppu- 
ration ensues  all  may  yet  be  well,  (in  the  other 
hand,  the  exudation  into  the  tissues  may  develop  in 
proportions  incompatible  with  the  vitality  of  the 
parts,  when  extensive  sloughing,  and  even  gangrene 
..t  i he  entire  stump,  may  result. 

The  treatment  of  these  conditions  must  be  con- 
ducted upon  established  principles.  Locally  nothing 
answers  so  excellent  a  purpose  as  measures  which 
relieve  the  tension.  Stitches,  when  too  tight,  mii-i 
be  removed,  and  as  soon  as  a  suspicion  of  purulent 
accumulation  is  aroused,  free  incisions  are  to  be  made. 
When  such  extensive  suppuration  has  supervened 
it  is  advisable  to  remove  all  constricting  dressing, 
and  to  treat  the  wound  by  the  open  method,  removing 
sloughs  as  fast  as  they  are  formed.  Frequent  irri- 
gations with  sublimate  solutions  and  hydrogen  di- 
oxide are  now  indicated.  As  a  dressing  the  balsam 
of  Peru  (ten  per  cent.)  in  castor  oil  applied  on  strips 
of  gauze  will  do  away  with  the  necessity  of  drainage. 
As  an  especially  dangerous  seat  of  inflammation  the 
medullary  canal  of  the  bone  must  be  referred  to. 
Periostitis  and  osteomyelitis  are  particularly  prone 
to  follow  amputations  made  for  gunshot  injuries. 
It  usually  manifests  itself  during  the  first  week  after 
the  operation  by  a  brownish  or  greenish  appearance 
of  the  medulla,  the  bone  appearing  dull  and  devi- 
talized, while  the  periosteum  is  detached  from  its 
surface.  The  pain  is  usually  very  severe,  and 
associated  with  it  are  the  well-known  symptoms  of 
systemic  infection,  i.e.  rigors  elevated  and  irregular 
temperatures,  diminished  secretion  of  the  kidneys, 
and  a  dry  and  thickly  coated  tongue.  Not  only  does 
this  condition  lead  to  extensive  necrosis  when 
recovery  ensues,  but  death  may  result  from  general- 
ized sepsis.  The  only  measures  that  offer  any  hope 
for  this  condition  are  to  scoop  out  the  bone  cavity 
with  a  sharp  spoon,  and  if  this  prove  unavailing,  to 
resort  to  a  second  amputation  at  the  nearest  joint. 
However  desperate  this  procedure  may  be,  a  very- 
large  number  of  cases  have  been  reported  in  which 
lives  have  been  saved  which,  without  it,  would  have 
been  inevitably  lost. 

As  a  sequel  of  moderate  inflammation  of  bone, 
necrosis  of  its  extremity  is  not  infrequently  encoun- 
tered. This  may  result  from  devitalizing  of  the  bone 
from  excessive  heat  generated  by  the  improper  use 
of  the  saw.  If  the  necrosis  be  limited  to  the  divided 
end,  this  condition  does  not  interfere  with  the  primary 
union  of  the  greater  part  of  the  wound.  The  exis- 
tence of  such  a  superficial  sequestrum  can  be  deemed 
probable  when,  after  the  permanent  closure  of  the 
wound,  a  fistulous  tract  continues  to  discharge.  Its 
actual  presence  can  always  be  recognized  by  the 
cautious  use  of  a  probe  or  by  the  x-ray.  When  the 
sequestrum  is  of  larger  proportions,  numerous  fistu- 
lous openings  will  usually  be  found  in  the  soft  parts, 
which  are  then  more  or  less  adherent  everywhere  to 
the  bone.  The  treatment  of  this  condition  must  In- 
palliative  until  nature  has  completely  separated  the 
sequestrum,  when  it  can  ordinarily  be  removed  with 
little  difficulty  by  laying  the  fistulse  freely  open. 
When  the  sequestrum  is  large,  it  occasionally  becomes 
necessary  to  resort  to  a  formal  sequestrotomy  for  its 
removal.  In  a  very  small  proportion  of  cases  the  irri- 
tation consequent  upon  the  long-standing  discharges 

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Amputation 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


from  the  necrosis  of  the  bone  gives  rise  to  epithelioma 
for  the  relief  of  which  a  second  amputation  is  usually 
necessary. 

One  of  the  most  dreaded  complications  of  an  ampu- 
tation is  hemorrhage.  It  may  supervene  within  a  few 
hours  after  the  completion  of  the  dressing,  or  as  late  as 
the  third  or  fourth  week.  The  sources  of  early  and 
late  hemorrhages  after  amputations  differ  materially. 
The  former  arise  from  small  arteries  or  veins  that 
have  escaped  ligation,  from  arteries  divided  above  the 
ligature,  or  from  the  divided  capillaries  of  the  muscles. 
This  condition  is  readily  recognized  by  the  staining  of 
the  dressing,  the  distended  appearance  of  the  stump, 
and  the  flowing  of  blood  from  a  number  of  places 
where  the  edges  of  the  wound  have  been  separated. 
The  rapid  distention  of  the  stump  and  the  bright 
hue  of  the  blood  which  is  discharged  at  once  indicate 
the  arterial  source  of  the  hemorrhage.  The  darker 
appearance  of  the  blood  and  its  appearance  in  a 
sluggish  stream  sufficiently  indicate  its  venous  origin. 
Blood  oozing  from  a  hematoma  is  always  dark. 
When  the  hemorrhage  is  slight,  and  particularly  if 
it  can  be  recognized  as  venous,  elevation  of  the  limb 
and  the  application  of  ice  may  suffice  for  its  control. 
When  it  becomes  evident  that  such  simple  measures 
are  futile,  the  wound  must  be  reopened,  the  coagula 
removed,  and  the  bleeding  vessel  found  and  ligated. 
\\  hen  it  is  found  that  the  hemorrhage  has  come  from 
the  medullary  canal,  this  must  be  treated  in  the 
manner  already  described.  The  hemorrhages  which 
supervene  during  the  second  week,  or  even  later, 
usually  result  from  the  erosion  of  a  vessel  wall  weak 
from  sclerotic  changes  at  the  time  of  operation,  or 
from  wound  infection  and  softening  of  the  thrombus. 
By  cutting  short  both  ends  of  the  ligature  the  neces- 
sity for  the  "cutting  through"  of  the  latter  is  done 
away  with,  and  at  least  one  important  factor  in  the 
causation  of  late  hemorrhages  is  thus  removed.  For 
the  relief  of  late  hemorrhages,  compression  of  the 
artery  by  a  compress  and  firm  bandage  should  first 
be  tried.  When  this  proves  unsuccessful,  pressure 
should  be  made  at  different  points  of  the  main  artery 
to  determine  the  point  nearest  the  stump  where  the 
hemorrhage  can  be  controlled.  Here  the  artery  is 
to  be  exposed  and  ligated,  or,  what  seems  to  be 
preferred  by  most  recent  writers,  it  may  be  included 
in  the  pressure  of  an  acupressure  needle.  Reopening 
of  the  wound  and  direct  treatment  of  the  bleeding 
vessel  is  usually  successful  although  in  rare  cases  it 
may  become  necessary  to  resort  to  reamputation. 

A  peculiar  and  very  rare  condition  of  the  stump  is 
the  development  in  it  of  a  dilatation  of  the  blood- 
vessels, commonly  in  the  form  of  an  aneurysmal  varix. 
Cases  of  this  nature  have  been  recorded  by  Cadge  of 
Norwich,  England,  by  Gross,  and  by  Agnew.  Whereas, 
in  some  cases  of  this  kind,  operative  treatment 
would  not  be  called  for,  in  others  it  may  become 
directly  indicated.  Thus,  in  the  case  of  Gross,7 
ligation  of  the  femoral  was  deemed  necessary.  The 
operation  resulted  fatally,  from  secondary  hemor- 
rhage, on  the  sixth  day. 

The  form  of  the  stump  very  frequently  gives  rise  to 
considerable  annoyance  and  suffering.  A  healthy 
stump  should  present  a  nicely  rounded  outline,  with 
tin-  bones  hidden  beneath  and  away  from  the  cicatrix. 
From  a  variety  of  causes  this  normal  appearance  of 
the  stump  may  give  place  to  prominence  of  the  bone, 
retraction  and  ulceration  of  the  soft  parts  covering  it, 
and  uselessness  of  the  part  for  locomotion.  Such  an 
abnormal  condition  is  commonly  known  as  the 
"conical"  or  "sugar-loaf"  stump.  It  may  result 
from  an  insufficiency  of  flap,  from  inordinate  retrac- 
tion of  the  soft  parte,  or  from  gangrene  of  the  integu- 
ment alone.  It  is  a  condition  which  is  more  likely 
to  follow  the  circular  and  tegumentary  flap  ampu- 
tations, although  with  ordinary  precautions  it  would 
seem  that  amputations  in  healthy  tissues  should  not 
result  in  a  badly  formed  stump.      When  this  condition 

276 


does  result,  nevertheless,  its  treatment  must  vary 
according  to  the  extent  of  the  deformity.  When 
from  an  insufficiency  of  flap  or  excessive  retraction  of 
the  soft  parts,  the  end  of  the  bone  assumes  a  too 
prominent  position,  the  flaps  can  be  drawn  down  by 
appropriate  bandaging,  from  above  downward;  or, 
by  the  aid  of  adhesive  straps  and  weights,  extension 
may  be  made  in  such  a  way  as  to  cover  the  end  of  the 
prominent  bone  with  integument  (Fig.  123).  When, 
notwithstanding  these  measures,  the  proper  relation 
between  bone  and  soft  parts  cannot  be  brought 
about,  nothing  remains  but  to  enlarge  the  wound, 
remove  the  periosteum  from  the  bone,  and  divide 
this  several  inches  above  the  level  of  the  first  section. 
It  is  unnecessary  to  defer  this  until  the  first  wound 
has  cicatrized.  In  extreme  cases  of  conical  stump 
reamputation  will  be  indicated.  It  can  be  more 
highly  recommended  since  reamputation  is  not  often 
followed  by  bad  results.  Mr.  Bryant  refers  to  a  very 
interesting  condition  of  amputation  stumps  in 
children,  in  whom  the  development  of  conical  stumps 


Fig.  123. 

may  be  in  a  measure  expected,  since,  in  the  process 
of  growth,  the  bone  appears  to  develop  more  rapidly. 
In  the  case  of  a  boy  whose  leg  was  amputated,  he 
found  it  necessary  on  two  occasions,  at  intervals  of 
three  years,  to  remove  two  pieces  of  bone  at  least  an 
inch  long. 

Neuroses  of  the  stump  are  among  the  most  intract- 
able of  its  diseases.  They  may  appear  in  the  form  of 
severe  neuralgias,  or  in  the  form  of  spasmodic  muscu- 
lar contractions.  The  former  condition  usually 
depends  upon  an  adherence  of  the  divided  nerves  to 
the  bone  or  the  cicatrix,  while  in  exceptional  cases  it 
results  from  the  bulbous  enlargement  of  the  extrem- 
ities of  the  nerve.  For  the  relief  of  the  former 
condition,  subcutaneous  division  of  the  adherent 
cicatrix  must  be  practised.  Where  neuromata  can 
be  felt,  these  are  to  be  removed;  when,  from  the 
number  of  these  enlargements  or  from  their  deep 
positions,  this  procedure  is  impracticable,  nothing 
short  of  a  reamputation  will  give  relief.  Continuous 
jactitations,  or  "chorea"  of  the  stump,  as  it  might 
be  termed  (Gross),  is  very  rarely  encountered.  It 
is  more  prone  to  develop  in  the  thigh  than  elsewhere. 
The  stump,  when  thus  affected,  is  the  seat  of  a 
constant  tremor,  often  sufficiently  active  to  be 
noticed  when  the  limb  is  covered.  In  a  case  of  this 
character  which  I  saw  two  years  ago,  and  which 
involved  the  thigh  in  an  otherwise  healthy  subject, 
the  spasms  continued,  notwithstanding  all  efforts  to 
allay  them.  The  most  efficient  measure  was  the 
deep  injection  of  ether,  which  would  relieve  the 
spasm  for  about  two  weeks  at  a  time,  when  the 
injection  had  to  be  repeated. 

Prognosis  and  Mortality. — In  estimating  the 
inherent  dangers  of  the  operation,  we  must  take  into 
consideration  only  those  cases  in  which  the  individuals 
operated  on  were — aside  from  the  lesion  which  neces- 
sitated the  operation — in  the  enjoyment  of  compara- 
tively good  health.  As  it  is  incorrect  to  attribute 
the  immense  mortality  of  tracheotomy  for  diphther- 
itic croup  to  an  operation  which,  if  performed  for  the 
removal  of  foreign  bodies,  is  almost  alwaj's  successful, 
so  it  is  manifestly  improper  to  attribute  most  deaths 
after  amputation  to  the  operation  itself.     A  compila- 


reference  handbook  of  the  medical  sciences 


Amputation 


tioii  of  the  amputations  of  "expediency,"  made  in 
Guy's   Hospital,   indicates  a  mortality   of  26.8   per 

criii.  If  we  remember,  however,  thai  these  statistics 
of  Bryant  and  Golding  Bird  include  amputations 
made  for  neoplasms,  and  that  the  most  valuable 
methods  of  after-treatment  were  at  that  time  not 
employed  in  the  hospital  in  question,  tliis  percentage 
must  be  misleading  as  to  the  inherent  dangers  of 
amputations.  That  the  mortality  of  the  operation 
under  favorable  circumstances  can  be  greatly  reduced 
front  the  percen  age  aBovo  given  can  be  easily 
demonstrated.  Thus,  of  716  late  and  pathological 
amputations  collected  by  Sir  James  V.  Simpson  from 
smaller  hospitals  and  private  practitioners  of  Scotland 
and  England,  only  seventy-four,  or  10.3  per  cent., 
died.  Of  100  amputations  (including  thirty-nine  of 
the  thigh)  made  by  Brims,  only  twelve  terminated 
fatally.  According  to  the  latest  statistics  of  Bruns, 
of  204  major  amputations  two  per  cent,  only  died. 
Finally,  of  187  amputations  made  by  Volkmann  for 
onlj  seven  succumbed  (three  per  cent.). 
This  number  includes  seventy-four  amputations  of 
the  thigh  with  only  two  deaths. 

statistics  can  hardly  be  improved  upon, 
although  we  are  in  need  of  carefully  compiled  data  of 
amputations  performed  with  modern  aseptic  pre- 
■ion.  Except  for  the  amputations  near  or  at 
tin-  hip,  or  of  a  limb  and  part  of  the  shoulder  girdle 
or  ilium,  the  mortality  uf  amputations  is  practically 
nil.  One  must  exclude,  of  course,  such  cases  as 
diabetic  gangrene  or  acute  septic  invasions. 

Unhappily  these  statistics  are  largely  at  variance 
with  those  gathered  either  from  large  hospital-  or 
from  the  battlefield.  Thus,  of  500  larger  amputations 
for  all  causes  collected  by  Malgaigne  in  the  hospitals 
of  Paris,  299  ended  fatally,  the  mortality  being  fifty- 
three  per  cent.  The  fatality  attending  amputations 
by  English  surgeons  in  the  Crimean  campaign  is 
represented  by  420  operations,  with  169  deaths 
(39.6  per  cent.),  while  the  figures  of  the  French 
surgeons  during  that  war  are  4,390  amputations, 
with  3,218  deaths,  giving  the  appalling  mortality  of 
seventy-three  per  cent.  Compared  with  such  results 
those  obtained  during  the  War  of  the  Rebellion  show 
a  most  decided  improvement.  Of  29,980  ampu- 
>  is,  the  result  was  determined  in  28,261;  of  these, 
20,802  recovered.  There  were  7,4.59  deaths,  tints 
yielding  a  mortality  of  26.3  per  cent.  The  most 
complete  recent  statistics  of  amputations  for  gunshot 
injur}'  show  only  a  moderate  improvement  over 
those  obtained  by  the  older  methods.  Thus  the 
irt  of  Surgeon  General  Stevenson  on  the  South 
African  War  shows  that  of  134  major  amputations, 
only  seventy  per  cent,  recovered.  This  was  largely- 
due  to  the  fact  that  at  the  time  of  the  operation,  the 
patients  were  already  septic. 

John  F.  Erdmann,8  in  1S9.5,  tabulated  the  statistics 
of  amputation  performed  in  the  leading  hospitals  in 
York,  done  during  the  decade  preceding.  Of 
709  major  amputations  109,  or  fifteen  per  cent.,  died. 
Page,*  in  1S95,  collected  712  major  amputations  from 
the  infirmary,  Newcastle-upon-Tyne,  of  which  sixty- 
one  died,  giving  a  mortality  of  8.5  per  cent.  In 
thirty  of  the  fatal  cases  death  resulted  from  shock 
and  loss  of  blood.  Forty  years  before,  Fenwick  had 
tabulated  225  amputations  done  in  the  same  infirmary 
with  a  mortality  of  fifty-four,  or  twenty-four  per  cent. 
Of  163  amputations  done  in  the  Cincinnati  Hospital 
during  the  decade  preceding  January  1,  1000,  nineteen 
terminated  fatally.  The  gross  mortality  of  the 
series  was  12.7  per  cent.  From  the  clinic  of  Bruns10 
comes  the  remarkable  record  of  eighty-one  ampu- 
tations of  the  leg  without  a  death.  An  examination 
of  all  statistics  will  show  that  the  mortality  of  major 
amputations  is  gradually  being  reduced.  If  the 
cases  are  subtracted  in  which  death  resulted  from 
shock  and  the  loss  of  blood,  the  mortality  of  all 
major  amputations  will  be   reduced   to  about  four 


per  eeni.,  as  has  been  the  case  with  the  statistics 
published  By  Estes. 

It  is  not  the  least  important  achievement  of  Mal- 
gaigne to  have  directed  the  attention  of  -urge. ins  to 
the  chief  causes  which  modify  the;  prognosis  in  indi- 
vidual cases  of  amputation,  and  how,  therefore, 
statistics  must  vary  according  to  certain  now  well- 
known  conditions  under  which  they  are  collated. 
In  a  somewhat  similar  direction  were  the  investiga- 
tions of  Simpson.  The  conditions  which  influence  the 
prognosis  of  amputations  will  now  be  considered  in 
the  order  of  their  importance. 

Age. — The  mortalitj  of  amputations  is  determined 
more  By  age  than  By  any  other  one  factor,  since  they 

betterborne  in  childhood   and    adolescence   than 

later  in  life.  Malgaigne  was  the  first  to  point  this  out 
By  the  tabulation  of  560  i :a  es  in  which  the  mortality 
steadily  increased  with  the  age  of  the  patients. 
Amputations  between  the  ages  of  five  and  fifteen 
years  yielded  a  mortality  of  thirty-three  per  cent., 
those  Between  fifty  and  sixty-five  one  of  ,  1.1  per  nut. 
Similar  investigations  have  Been  made  By  Callender, 
Holmes,  Bryant,  and  Golding  Bird  in  England,  and 
By  Morton  and  Ashhursf  in  this  country.  The  last- 
mentioned  author  combined  the  statistics  from  various 
sources,  and,  after  the  manner  of  Mr.  Holmes,  he 
divided  life  into  three  periods  of  twenty  years  each. 
The  total  number  of  cases  thus  tabulated  is  sum- 
marized as  follows: 

Table  I. — Percentage  of  Mortality  at  Different  Ages. 


Whole 
number  of 


Mortality 

below  20 

years. 


Mortality 
between  20 

and  40. 


Mortality 
over  40 

years. 


General 

death 

rate. 


2,619               16.7                 30.1 

43.4 

29.4 

Table  II. — Percentage  of  Mortalitt  Before  and  After 
Thirty  Years  of  Age. 

Whole  number 
of  ca-ts. 

Mortality              Mortality         General  death 
below  30  years,    above  30  years.              rate. 

1,805 

19.2                        37.4 

26.7 

The  comparatively  excellent  results  after  amputa- 
tions in  children  must  Be  attributed  to  the  rapidity 
with  which  even  large  wounds  unite  in  them,  to  the 
resistance  which  their  ordinarily  unvitiated  constitu- 
tions offer  to  septic  processes,  and  to  their  freedom 
from  visceral  complications.  The  ease  with  which 
even  large  amputations  are  supported  in  childhood 
was  particularly  impressed  on  the  mind  of  the  writer 
By  the  case  of  a  lad  of  seven,  in  whom  he  had  ampu- 
tated Below  the  shoulder  for  railway  injury.  Because 
he  was  not  given  the  freedom  of  the  ward,  the  boy 
escaped  from  the  hospital  (Good  Samaritan,  in 
Cincinnati)  on  the  eighth  day  after  the  operation. 
The  wound  had  healed   per  primam. 

The  very  unfavorable  results  which  follow  amputa- 
tions in  advanced  life  are  readily-  accounted  for  by  the 
reduced  vitality  of  the  system  at  large.  By  the  imper- 
fect nutrition  of  the  stump  from  impaired  integrity 
of  the  blood-vessels,  and  By  the  rapidity  with  which 
these  patients  succumb  to  septic  infection,  or  post- 
operative pneumonia.  It  is  extremely  probable  that 
if  the  latter  could  be  prevented  the  marked  influence 
of  advanced  life  on  the  results  of  amputations  would 
be  materially  lessened.  Thus  of  sixty-one  uncompli- 
cated amputations  made  by  Volkmann.  in  persons 
over  fifty,  only  4.S  per  cent.  died.  Among  these  was 
a  successful  amputation  of  the  thigh  for  injury  in  a 
man  eighty-four  years  of  age. 

277 


Amputation 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Seat  of  Operation. — The  danger  of  an  amputation 
always  increases  with  the  size  of  the  wound  and  its 
proximity  to  the  trunk — amputations  of  the  lower 
extremity  yielding  a  greater  mortality  than  those  of 
the  upper.  Since  about  thirty-two  per  cent,  of  the 
deaths  following  amputations  are  directly  attributable 
to  the  combined  shock  and  hemorrhage  consequent 
upon  the  injury  and  the  operation,  it  is  easily  under- 
stood why  the  mortality  varies  in  the  manner  indi- 
cated. The  dangers  of  septic  infection  also  increase 
with  the  size  of  the  wound,  and  when  amputation 
wounds  fail  to  unite  by  primary  union,  death  often 
results  from  the  exhaustion  consequent  upon  pro- 
tracted suppuration.  The  situation  at  which  the  bone 
is  divided  also  materially  influences  the  result. 
The  opening  of  the  medullary  cavity  of  a  large  bone 
like  the  femur  or  tibia  is  more  apt  to  be  followed  by 
osteomyelitis  and  its  consequences  than  is  the  division 
of  the  bone  through  its  articular  end.  This  is  well 
shown  by  a  comparison  of  the  results  of  amputation 
through  the  lower  third  of  the  thigh  and  through  the 
femoral  condyles,  the  former  operation  yielding  a 
mortality  of  thirty-nine  per  cent,  against  twenty-nine 
per  cent,  of  the  latter. 

The  ratio  of  deaths  following  amputations  for 
injury  and  disease  in  different  parts  of  the  body  is 
well  illustrated  in  a  subjoined  table  which  is  based 
upon  large  hospital  reports  issued  from  1S64  to  Ins  I. 
For  exceptional  operations  (hip-joint  and  elbow) 
reports  of  cases  from  private  practice  were  included. 
This  doubtless  explains  the  apparently  greater  mor- 
tality of  amputation  of  the  thigh  than  of  the  hip, 
since  relatively  more  successful  than  unsuccessful 
cases  are  thus  recorded. 

Nature  of  Lesions. — Very  potent  in  its  influence  on 
the  results  of  amputations  are  the  causes  for  which 
they  are  made.  When  the  operation  is  resorted  to  in 
an  individual  who,  while  in  perfect  health,  has  received 
a  severe  injury  from  which  he  has  probably  lost  a 
considerable  amount  of  blood,  the  prognosis  is  much 
less  favorable  than  when  it  is  made  for  disease. 
This  applies  particularly  to  amputations  after  railway 
injuries  and  traumata  inflicted  by  heavy  machinery. 
The  shock  and  hemorrhage  are  very  often  so  severe 


Table  III.   (From  Max  Schede). 


Amputations  for 

Amputations  for 

lnjury. 

disease. 

o 

0 

:•>  j 

o 

=■>.! 

— .  t.    . 

$  2  S 

z    -    r. 

H  go 

S  j= 

3  -O 

1  i 

o  S 

B2  % 
Si  3  2 

3-B 

£    05 

Z 

z 

Z 

z 

Amputation — 

55 

39 

70.9 

153 

65 

42.6 

of    thigh,    upper 

73 

57 

78.0 

42 

15 

35.7 

third. 

of   thigh,    middle 

67 

50 

74.6 

137 

55 

10.1 

third. 

of     thigh,     lower 

149 

71 

50.0 

205 

64 

31.0 

third. 

of  thigh,  through 

136 

44 

32.3 

79 

20 

25.4 

condyles. 

of  thigh,  locality 

1.3S4 

664 

48.0 

2,494 

S17 

32.7 

not  specified. 

314 

130 

103 
54 

32.8, 
41.5 

123 
17S 

30 

44 

24.4 

of  leg,  upper  and 

24.7 

middle  third. 

of  leg,  lower  third. 

33 

3 

9.1 

128 

19 

14.0 

of  leg,  locality  not 

1,956 

785 

40.0 

1,695 

215 

12.7 

specified. 

of  foot,  partial.. . 

223 

45 

20.2 

562 

70 

12.4 

at  shoulder- joint. 

271 

116 

42.3 

IIS 

33 

28  0 

1,167 
23 

364 
6 

31.2 
26.0 

441 

8 

SI 

1 

18.4 

at  elbow-joint. . .  . 

12.5 

1,316 

143 

10.8 

506 

62 

12.2 

199 

337 

5 

6 

L> .  5 

1.8 

27 
329 

of     fingers     and 

6 

1.8 

toes. 

It  will  be  seen  from  the  table  given  below  that  the 
statistics  indicate  with  remarkable  uniformity  the 
greater  mortality  of  amputations  when  made  for 
injury  than  when  made  for  disease.  The  explanation 
generally  offered  for  this  feature  of  the  prognosis  of 
amputations  is  that  patients  who  have  for  a  long  time 
been   subjected   to   suppurative   processes    (necrosis, 


TABLE  IV. 


Amputations  for 

injury. 

Amputations  for  disease. 

Total  Amputations. 

Authority. 

Number 
of  cases. 

Number  of 
deaths. 

Mortality, 
per  cent. 

Number 
of  cases. 

Number  of 
deaths. 

Mortality, 
per  cent. 

Number 
of  cases. 

Number  of 
deaths. 

Mortality, 
per  cent. 

1S2 
4  17 
846 
106 
1  1  1 

28 
130 

72 
1S6 
388 
355 
159 
115 

117 

201 
202 

57 
58 
21 
24 
24 
77 
126 
84 
72 
33 

64 
45 
24 
54 
40 
75 
19 
33 
41 
32 
2  1 
46 
29 

378 

679 

524 

58 

94 

52 

1S7 

2S 

371 

338 

305 

409 

424 

1S2 

147 

102 

IS 

32 

25 

7 

4 

73 

40 

48 

99 

55 

48 
2° 
19 
31 
33 
4S 
3 
14 
19 
12 
16 
24 
13 

560 

1.126 

1,370 

164 

238 

SO 

317 

100 

557 

726 

660 

568 

539 

299 

34S 

304 

75 

90 

46 

31 

28 

150 

166 

132 

171 

88 

53 

31 

22 

Billroth  (1860-67) .  . 

46 

38 

57 

9  + 

28 

27 

23 

20 

30 

16 

Total.. .    

3.158 

1,096 

34.7 

3,847 

832 

21.6 

7,005 

1,928 

27.5 

that  death  results  within  a  few  hours  after  the  opera- 
tion. The  prejudicial  effect  of  a  trauma  on  the 
results  "f  amputations  is  still  further  enhanced  if  the 
subject  is  addicted  to  intemperate  habits.  This  was 
well  illustrated  in  the  Cincinnati  riots  in  1SS4.  Those 
injured  were  for  the  timst  part  more  or  less  under  the 
influence  id'  alcohol  when  wounded,  and  four-fifths  of 
those  on  whom  amputations  were  made  succumbed. 


caries,  etc.),  are  so  inured  to  suffering  that  they  bear 
the  shock  of  an  operation  comparatively  well,  and 
that  they  are  less  prone  to  septic  infections  which  are 
so  often  the  immediate  cause  of  death  titter  amputa- 
tions for  trauma.  The  correctness  of  this  view  is 
substantiated  by  the  fact  that  about  seventy-five 
per  cent,  of  so-called  pathological  amputations  are 
made  for  chronic  inflammatory  conditions  of  either 


278 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Amputation 


bones  or  joints,  and  that  under  these  circumstances 
tin'  soft  parts  are  usually  more  or  less  atrophied,  and 
yel  at  the  same  time  densely  infiltrated  with  a  connec- 
tive-tissue growth  which,  when  divided  in  an  opera- 
tion, presents  a  barrier  to  the  absorption  of  deleterious 
elements.  It  is  noteworthy,  as  Mr.  Bryant  has  pointed 
out,  that  this  infiltration  of  the  soft  parts  does  not 
necessarily  interfere  with  the  ready  union  of  the 
wound.  While  amputations  for  chronic  affections  of 
the  nature  indicated  terminate  fatally  in  only  four- 
teen per  cent,  of  the  cases,  those  made  for  deformity 
and  neoplasms  present  a  mortality  of  26. S  per  cent, 
and  forty-six  per  cent,  respectively  (Golding  Bird  and 
S  pence). 

Tables  V.  and  VI.,  while  they  show  the  great 
reduction  in  the  mortality  of  amputations  in  general, 
Mill  demonstrate  the  greater  mortality  of  operations 
done  for  trauma.  That  the  difference  is  not  so  marked 
in  my  own  table  (V.)  is  due  to  the  fact  that  many 
of  the  pathological  amputations  were  made  for  senile 
gangrene. 

Tadle  V. — Major  Amputations  Done  at  the  Cincinnati  Hos- 
pital from  January   1,   1890,  to  January   1,   1900. 


Injury. 

Disease. 

•6 

u 

o 
> 
o 
a 

-3 

3 

O 

H 

c 

Hi 

o 
u 

a 

•6 

> 

0 

a 

Ci 

~6 
0) 

s 

o 

o 
o 

Leg 

54 

4 
11 

3 
5 

57 

4 

16 

5.2 
31.3 

22 
2 

17 
1 

2 
1 
3 

24 

3 

20 

1 

8.3 

3.3 

nigh 

Hip 

1.5 

Wrist 

2 
11 

1 

2 
12 

Elbow 

S.3 

3 

*3 

11 
2 

4 

11 
6 

3 

1 

3 
1 

Total 

95 

13 

108 

13.7 

19 

6 

55 

10.9 

*  One  multiple  injury. 

Table  VI. — Amputations  Done  During  Twelve  Years  Prior 
to  1895,  Newcastle-on-Tyne.      (Page.) 


ta 

3 

> 

o 

s 

u 

1) 

s 

3 

> 

o 

5 

fc 

Ph 

55 

0) 

Ph 

13 

7 

6 

46 

tation, 

Hip-joint 

6 

3 

3 

50 

23 

14 

9 

3.9 

Thigh 

52 

39 

13 

25 

1.31 

141 

10 

6.4 

7 
76 

7 
69 

2 
70 

2 
67 

7 

9.2 

3 

4.2 

26 

2.". 

1 

3.8 

[22 

120 

2 

1.6 

Shoulder 

17 

16 

1 

5.8 

15 

14 

1 

6.6 

37 

31 

3 

8.1 

IS 

17 

1 

5.5 

36 

7 

35 

7 

1 

2.S 

31 

31 

Total 

277 

212 

35 

12.6 

435 

109 

26. 

5.9 

Multiple  Amputations. — While  it  is  comparatively 
rare  that  disease  or  injury  affects  more  than  one 
extremity  in  a  degree  sufficient  to  warrant  double 
amputations,  these  are  nevertheless  occasionally  re- 
quired. It  is  self-evident  that  they  are  of  the  gravest 
importance  and  present  a  most  unfavorable  prognosis, 
on  account  of  the  shock  associated  with  the  injury. 
Of  twenty-eight  double  amputations  made  in  the  West- 
ern Pennsylvania  Hospital,  twenty-seven  were  for  rail- 


road accidents  and  fifteen  of  the  patients  died.  The 
fact  that  eleven  of  the  deaths  occurred  in  the  first  forty- 
eight  hours  shows  that  they  were  due  rather  to  the  in- 
juries than  to  the  amputations.  Of  thirteen  multiple 
amputations  done  for  injury  at  the  .Newcastle 
Infirmary  six,  or  forty-six  per  cent.,  died.  When 
multiple  amputations  are  made  for  disease,  which  is 
in  about  ten  per  cent,  of  all  cases,  they  are  usually  for 
frost-bite. 


Table  VII. — Multiple  Amputations  in 

Military  Practice. 

"5 

|  i 

EJ 

> 

o 

~.  8 

*D  .5 

2j 

si 

3  " 

a 

U  ~ 

*  2 

„°  a 

Ph 

Both    amputations    in    the 

17 

31 

16 

34 

upper  extremity. 

One  amputation   in   upper, 

43 

21 

21 

1 

50 

one  in  lower  extremity. 

Both  amputations  in  lower 

S2 

31 

50 

1 

61.7 

extremity. 

Total 

172 

83 

87 

2 

50.5 

Tarle  VIII. — Multiple  Amputations  in  Civil  Practice. 


Number 
of 

.■uses. 

Recovered. 

Died. 

.Mortality, 
per  cent. 

Thighs 

18 

21 

5 

7 

42 

11 

12 

9 

15 

3 

9 
2 
4 

20 
6 

10 
6 

11 

15 
12 
3 
3 
22 
5 
2 
3 
4 

83 

Thigh  and  forearm..  .  . 

57 
60 
43 
52 

45 

Foot  and  foot 

Forearm  and  forearm. 

16 
33 

27 

Total 

140 

71 

69 

49 

The  mortality  attending  multiple  amputations,  it 
will  be  seen  from  the  preceding  tables,  is  about  fifty 
per  cent.,  amputations  through  the  lower  extremities 
presenting  a  greater  fatality  than  those  of  the  upper. 
The  first  table  illustrates  the  mortality  of  these  am- 
putations in  military  practice.  The  second  table, 
made  up  from  German,  English,  and  American  re- 
ports, shows  the  relative  frequency  and  fatality  of 
multiple  amputations  as  they  are  made  in  different 
parts  of  the  body. 

When  the  necessity  for  multiple  amputations  arises, 
the  question  must  be  considered  whether  they  shall  be 
made  at  the  same  time,  when  they  are  called  syn- 
chronous amputations,  or  whether  a  longer  or  shorter 
interval  shall  intervene  between  them.  In  these 
cases,  as  in  amputations  generally,  no  definite  rules 
can  be  formulated.  In  cases  of  trauma  it  is  generally 
advisable  to  make  both  amputations  at  the  same 
time,  removing  the  larger  member  first,  but  deferring 
the  closure  of  the  wound  until  both  amputations  are 
completed.  If,  after  the  first  operation,  the  condition 
of  the  patient  is  such  as  to  preclude  the  possibility  of 
recovery  if  the  second  is  performed  at  once,  the  less 
injured  member  must  bo  treated  as  if  the  injury 
sustained  by  it  were  of  a  less  degree  of  severity  and 
justified  an  attempt  at  conservatism.  In  cases  of 
disease  affecting  several  extremities  (frost-bite,  white 
swelling,  etc.),  it  is  generally  better  to  observe  a, 
sufficient  interval  between  the  operations  to  permit 
the  constitution  to  rally  from  the  first  before  the 
second  amputation  is  made.  In  these  cases  the 
danger  of  septic  infection  from  the  limb  that  is  spared 
is  not  as  great  as  in  cases  of  traumatic  origin. 


279 


Amputation 


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Even  triple  and  quadruple  amputations  are 
occasionally  performed  with  success.  In  a  case  of 
railway  accident,  Dr.  G.  Koehler,  of  Schuylkill  Haven, 
Pa.,  in  1S67,  removed  simultaneously  both  legs  and 
one  arm  from  a  lad  thirteen  years  of  age,  recovery 
taking  place.  Professor  Stone,  of  New  Orleans,  had  a 
similar  case  in  a  man  of  thirty,  the  subject  of  a  railway 
accident.  According  to  Professor  Agnew,  successful 
triple  amputations  were  made  in  York,  Pa.,  in  1868, 
and  Rochard  reported  to  the  Academy  the  case  of 
DeLeseleuc  of  Brest,  who  had  successfully  amputated 
a  thigh,  leg,  and  arm  in  a  man  the  subject  of  trauma. 
Quadruple  amputations,  usually  made  for  frost-bite, 
have  been  successful  in  the  cases  of  Muller,  of  the 
United  States  army,  Begg,  of  Dundee,  and  Cham- 
penois,  of  the  French  army.  Other  cases  are  referred 
to  by  Morand,  Longmore,  and  Southam.  Larrey 
mentions  two  cases,  one  of  which,  the  case  of  a  soldier 
who  had  all  his  extremities  removed  by  heavy  ord- 
nance, he  had  seen  in  the  "Invalides."  The  other 
case,  which  he  had  seen  in  Algiers,  was  that  of  an  Arab 
twelve  j'ears  of  age  who  had  intentionally  placed 
himself  on  the  track  in  such  a  position  that  a  passing 
train  mangled  both  hands  and  both  feet.  Still  another 
successful  quadruple  amputation  for  frost-bite  has 
recently  been  recorded  by  Tremaine. 


Individual  Amputations. 

Amputation  op  the  Fingers. — When  the  pha- 
langes of  the  fingers  or  thumbs  are  the  seat  of  incur- 
able disease  or  of  severe  injury,  amputation  often 
becomes  necessary.  It  is  well  to  remember  that  if 
the  bone  of  the  distal  phalanx  alone  is  affected,  its 
natural  exfoliation  should  be  awaited,  when  the  soft 
parts  can  often  be  preserved,  to  the  great  advantage 
of  the  patient.  Particularly  in  the  thumb  and  index 
finger  is  it  necessary  to  save  as  much  as  possible. 
In  the  third  and  fourth  fingers  amputation  should 
not  be  practised  at  the  second  joint,  since  the  pres- 
ervation  of  the  proximal  phalanx  leaves  a  part  that 
is  ungainly  and  does  not  add  to  the  usefulness  of  the 
hand.  When  a  portion  of  a  finger  requires  removal 
the  operation  may  be  practised  either  at  a  joint  or  in 
the  continuity  of  a  phalanx.  In  both  cases  it  is 
important  to  remember  that  when  the  finger  is  flexed 
the  articulations  are  below  the  prominences  made  by 
the  knuckles,  the  distal,  middle,  and  proximal  articu- 
lations being  respectively  one-sixth,  one-fourth,  and 
one-third  of  an  inch  below  the  most  prominent  lines 
of  the  joints.  It  must  also  be  borne  in  mind  that 
strong  lateral  ligaments  prevent,  until  they  are 
divided,  the  complete  exposure  of  articular  surfaces 
(Fig.  124).  When  the  amputation  is  to  be  made  at 
the  joint,  it  can  be  most  ex- 
peditiously executed  in  the 
following  manner:  The 
hand  being  held  in  the  prone 
position,  the  tip  of  the  finger 
encased  in  a  piece  of  gauze 
is  firmly  seized  by  the  oper- 
ator and  flexed.  With  a 
long  and  narrow  knife  an 
incision  is  made  from  side 
to  side  over  the  dorsal  sur- 
face. By  this  the  joint  is 
at  once  opened.  With  two  rapid  strokes  of  the 
point  of  the  knife  the  lateral  ligaments  are  next 
severed.  The  blade  of  the  knife,  with  edge  directed 
downward,  is  then  placed  behind  the  flexor  surface  of 
the  phalanx  to  be  removed,  from  the  soft  parts  of 
which  a  well-rounded  flap,  is  to  be  cut  from  within 
outward  by  a  sawing  movement.  The  wound  pre- 
sents the  appearance  shown  in  Fig.  125.  Only  when 
there  is  an  insufficiency  of  flap  is  it  proper  to  remove 
the  head  of  the  proximal  bone.  The  disarticulation 
of  a  phalanx  can  also  be  effected  by  transfixion:  the 


Fig.  124. 


hand  being  held  in  a  supine  position  and  the  finger 
extended,  the  latter  is  transfixed  on  the  palmar  side 
of  the  bone,  just  below  the  fold  of  the  joint;  a  palmar 
flap  of  sufficient  length  is  then  made.  The  flap  being 
held  out  of  the  way,  the  joint  is  made  prominent  by 
hyperextension  and  opened.  The  soft  parts  on  the 
dorsal  surface  of  the  joint  are  then  divided  by  a 
single  sweep  of  the  knife.  In  amputations  of  the 
fingers,  the  soft  parts  of  the  palmar  aspect  are  always 
preferable  for  a  flap,  since  the  cicatrix  is  then  pro- 
tected from  pressure. 
Where  they  cannot  be 
utilized,  a  dorsal  flap 
can  be  made,  either 
by  transfixion  or, 
what  is  preferable,  by 
cutting  from  without. 
Lateral  flaps,  single 
or  double,  can  like- 
wise be  utilized  in  this 
amputation.  In  amputations  in  the  continuity  of  a 
phalanx  the  flap  may  be  cut  from  the  palmar  aspect 
by  a  transfixion,  the  dorsal  surface  being  divided  by  a 
transverse  incision,  or  a  second  flap  may  be  formed. 
The  circular  operation,  with  longitudinal  lateral  cuts, 
may  likewise  be  successfully  practised  in  this  position. 
After  the  division  of  the  soft  parts,  the  bone  must  be 
divided  with  a  metacarpal  saw  or  the  cutting  forceps. 
In  all  amputations  of  the  fingers  two  digital  arteries 
usually  "spirt."  Their  ligation  is  unnecessary; 
the  approximation  of  the  wound  surfaces  generally 
suffices  for  their  closure. 

Amputation  of  an  entire  finger  at  the  metacarpo- 
phalangeal joint  can  be  readily  accomplished  as 
follows:  The  adjacent  fingers  being  held  aside  by  an 
assistant,  the  operator  with  his  back  to  the  patient 
grasps  the  finger  to  be  removed  with  the  left  hand  and 
extends  it  sufficiently  to  see  its  palmar  surface.  A 
narrow  knife  being  introduced  from  the  right  side 
divides  the  soft  parts  on  the  palmar  surface  on  a  level 
with  the  extended  interdigital  web.  The  incision  is 
then  carried  around  the  right  side  of  the  finger  (Fig. 
120,  Esmarch)  in  a  slight  curve  into  the  dorsal  surface 


Fig.  126. 

of  the  head  of  the  metacarpal  bone.  The  knife  is  then 
carried  around  the  left  side  of  the  finger  in  the  same 
manner,  the  ends  of  the  first  incision  being  thus 
joined.  The  tendons,  lateral  ligaments,  and  capsule 
being  successively  divided,  the  disarticulation  ia 
completed  and  a  heart-shaped  wound  left.  The 
margins  of  this  wound  come  accurately  into  contact, 
when  the  remaining  fingers  are  approximated  to  one 
another.  When  comeliness  of  the  hand  is  valued 
more  than  strength,  it  is  best  to  remove  the  head  of 
the  metacarpal  bone  with  cutting  forceps  (Fig.  127), 
since  its  preservation  usually  leaves  an  unsightly 
prominence.     In  persons  who   do   manual   labor  its 


280 


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Amputation 


removal  should  be  avoided,  since  it  would  materially 
lessen  the  strength  of  the  hand. 

The  incisions  for  disarticulations  of  the  thumb, 
index  and  little  fingers  may  often  l>e  advantageously 
modified  in  such  a  manner  as  to  make  two  lateral 
llaps,  the  longer  of  which  is  on  the  free  side  of  the 
tiger,  the  shorter  being  made  on  the  side  of  the 
tnterdigital  web.     To  preserve  the  symmetry  of  the 

hand,  t  he  heads  of  the  Second 
and  fifth  metacarpal  bones 
should  always  be  removed  by 

an  oblique  section  when  the 
index    and    little    fingers    are 

amputated.     \\  hen  I  no  or  more 

fingers  are   to  be  removed,  it 

can   easily  be  done  by  making 

two    convex    flaps,    one   on    the 

dorsal    and    the   other    on    the 

palmar    aspect     of    the    hand, 

the    latter    being    given     the 

greater    length.      A   flap   may 

likewise  be  taken 

from   the  side  of 

one  finger,   or 

reel  angular  flaps 

from  the  opposite 

surfaces  of  the 
fingers  that  are 
farthest  from 
each  other.  In 
amputations  of  a 
number  of  finger- 
it  is  generally 
best  to  remove 
Fia.  127.  each  finger  sepa- 

rately, since  un- 
issary  sacrifices  for  thesakeof  brilliancy  will  thereby 
be  avoided  and  a  better  result  be  obtained.  When, 
in  consequence  of  accident  or  disease,  the  metacarpal 
bone  must  be  removed  with  the  finger,  the  incisions 
are  like  those  for  the  removal  of  an  entire  finger,  only 
that  the  dorsal  cut  must  be  continued  upward  toward 
the  wrist  for  a  varying  distance,  and  that  the  incision 
around  the  root  of  a  finger  is  to  be  made  above  the 
interdigital  web.  The  extensor  tendons  being  divided 
as  high  as  possible,  and  the  bone  separated  from  its 
muscular  attachments,  this  is  divided  with  cutting 
forceps  near  its  articular  extremity  or  entirely  enucle- 
ated. When  the  surgeon  has  the  option,  the  former 
practice  should  be  preferred,  to  avoid 
opening  the  articulations  of  the  wrist. 
Exceptions  can  be  made  in  the  first 
and  fifth  metacarpal  bones,  which, 
having  individual  synovial  sacs,  may 
be  removed  without  the  danger  of 
producing  extensive  inflammation  of 
the  wrist.  Amputation  of  the  entire 
thumb  should  rarely  be  practised,  for 
every  portion  of  it  that  can  be  saved 
is  of  value  for  opposition  to  the  fin- 
gers. When  it  becomes  necessary 
to  remove  the  thumb  with  its  meta- 
carpal bone,  it  is  best  accomplished 
by  the  oval  method.  The  point  of  a 
knife  should  be  entered  above  its 
articulation  with  the  carpus,  and  a 
triangular  incision  (Fig.  12S)  made 
along  its  radial  aspect,  the  sides  of 
the  triangle  diverging  from  each 
other  as  they  approach  the  head  of  Fig.  128 

the  metacarpal  bone  and  becoming 
continuous  with  each  other  in  the  web  and  index 
finger.  The  muscles  being  detached  and  the  extensor 
tendons  divided,  disarticulation  is  readily  effected 
by  forcibly'  extending  the  thumb  toward  the  radial 
side  and  severing  the  ligaments.  In  disarticulating, 
the  edge  of  the  knife  should  be  kept  close  to  the  base 
of  the  bone,  lest  the  joint  between  the  second  meta- 


carpal and  trapezium,  and  through  it  the  remaining 

Carpal    joints,    be    opened.       After    this    operation     a 

linear  cicatrix  remains.  The  most  expeditious 
method  <>i  amputating  the  thumb  yet  devised  is  that 
of  Walther,  and  is  admirably  suited  to  cases  in  which 
an  a  nes  i  he  tie  is  not  used.     The  thumb  being  abducted, 

the  knife  is  made  to  cut   its  way  between  the  lir-1   and 

econd  metacarpal  bones  until  the  base  of  the  former 

is  reached   (Fig.   11".)).      The  thumb  being  greatly  ab- 


Fia.  129. 

ducted,  the  joint  between  its  metacarpal  bone  and 
trapezium  is  opened  and  traversed.  The  knife  is 
then  carried  downward  upon  the  radial  side  of  the 
bone,  where,  by  cutting  outward  to  the  level  of  the 
interdigital  web,  a  radial  flap  is  made.  Amputations 
of  the  little  finger  with  its  metacarpal  bone  can  be 
made  in  the  same  manner,  either  by  the  oval  or  by  the 
flap  method. 

Injuries  of  the  palm  of  the  hand  are  generally  of 
such  a  nature  that  by  a  little  ingenuity  on  the  part 
of  the  surgeon  part  of  it  can  be  preserved.  "\\  hen  in 
rare  cases  disarticulation  of  the  last  four  metacarpal 
bones  becomes  necessary,  the  thumb  being  left,  it 
may  be  done  as  follows:  The  hand  being  grasped 
and  held  in  supine  position,  a  long,  narrow  blade  is 
passed  through  the  palm  from  the  base  of  the  fifth 
metacarpal  bone  to  the  web  of  the  thumb.  By  cut- 
ting outward,  a  broad  semilunar  flap  is  made  (Fig. 
130).  An  incision  is  next  made  on  the  back  of  the 
hand,  beginning  at  the  web  of  the  thumb  and  carried 
obliquely  upward  to  the  upper  third  of  the  second 
metacarpal  bone, 
whence  it  is  continued 
transversely  over  the 
three  last  metacarpal 
bones  until  it  meets  the 
palmar  flap  at  the  ul- 
nar border  of  the  hand. 
Both  flaps  are  thus  re- 
flected to  the  carpo- 
metacarpal joints,  and 
disarticulation  is  ef- 
fected from  the  ulnar 
side,  the  hand  being 
forcibly  abducted. 

Amputation  at  the 
Wrist. — In  amputa- 
tions at  the  wrist  the 
surgeon  has  the  choice  of  the  circular  and  the  tegu- 
mentary  flap  methods,  both  of  which  leave  an  excel- 
lent stump. 

Circular  Method. — Retracting  the  skin  of  the  fore- 
arm with  his  left  hand,  the  operator  carries  the  knife 
in  a  circular  sweep  around  the  hand  one  inch  below 
the  styloid  processes.  The  skin  and  subcutaneous 
layers,  being  liberated  by  incisions  perpendicular 
to  the  axis  of  the  limb  as  far  as  the  styloid  processes, 
should  be  reflected  like  a  cuff.  The  hand  being  then 
pronated  and  forcibly  flexed,  the  tendons  are  divided 
and  the  joint  opened  by  an  incision  over  the  dorsum 
from  one  styloid  process  to  the  other.     In  making  this 


Fig.  130. 


2S1 


Amputation 


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incision  the  convexity  of  the  upper  surface  of  the 
carpus  must  be  remembered.  The  lateral  ligaments 
being  next  severed,  the  anterior  part  of  the  capsule 
and  all  the  flexor  tendons  are  cut  through  with  one 
stroke  of  the  knife  (Fig.  131). 


Fig.  131. 

Anteroposterior  Flap. — The  operator  seizes  the 
lower  part  of  the  pronated  hand,  and  after  flexing  it 
makes  a  semilunar  incision  over  the  middle  of  the 
back  of  the  hand  from  one  styloid  process  to  the  other 
(Fig.  132).  After  reflection  of  the  flap  the  joint  is 
opened  as  in  the  circular  operation,  and  the  operation 
is  completed  by  cutting  a  short  palmar  flap  from 
within  outward  (Fig.  133).  The  projection  of  the 
pisiform  bone  often  renders  this  part  of  the  operation 
embarrassing. 

Method  of  Dubreuil. — A  very  excellent  result  can  be 
obtained  by  making  a  single  lateral  flap,  either  from 

the  radial  sur- 
face of  the 
thumb  or  from 
the  soft  parts 
covering  the 
fifth  metacar- 
pal bone,  the 
former  being 
preferable.  As 
will  be  seen 
from  Fig.  134, 
the  operation 
c  onsis  ts  in 
making  a  semi- 
lunar flap  with 
broad  base, 
from  the  integ- 
ument which 
covers  the  first 
me  tacarpa  1 
bone,  the  point 
of  the  flap 
reaching  the 
base  of  the 
first  phalanx.  A  transverse  incision  around  the  wrist 
is  then  made  and  disarticulation  is  completed  as  in 
the  other  operations. 

Amputation  of  the  Forearm  maybe  practised 
by  the  circular,  tegumentary,  or  musculotegu- 
mentary  flap  method.  The  lower  third  of  the 
forearm,  containing  a  large  number  of  tendons,  is 
ill  suited  for  the  latter  method,  the  circular  oper- 
ation being  preferable  (Fig.  135).  When  the  in- 
tegument is  greatly  infiltrated  and  the  reflection 
of  a  cuff  is  thereby  rendered  impracticable,  tegument- 
ary flaps  can  be  made,  the  tendons  being  divided  by 
a  circular  incision  (Fig.  130).  The  presence  of  a  large 
number  of  synovial  sheaths,  and  the  danger  of  inflam- 

282 


Fig.  133. 


mation  in  them  when  they  are  opened  should  not 
militate  against  the  value  of  operations  in  the  lower 
third  of  the  forearm,  since,  by  operating  below  the 
insertion  of  the  pronator  radii  teres,  movements  of 
pronation  and  supination  will  be  preserved. 

A  number  of  surgeons  prefer  the  flap  operation  in 
all  amputations  of  the  forearm,  making  both  flaps  by 
transfixion  in  fleshy  subjects.  Under  opposite  cir- 
cumstances the  anterior  flap  can  be  made  in  this 
manner,  and  the  posterior  by  cutting  from  within 
outward.  When 
this  method  is 
resorted  to,  the 
bones  must  be 
divided  as  high 
up  as  possible, 
to  overcome 
their  tendency 
to  protrude  at 
the  angles  of 
the  wound. 
Muse  ulotegu- 
mentary  flaps 
should  be  used 
only  in  the 
fleshy  part  of 
the  forearm. 
In  all  amputa- 
tions in  this 
part  the  catlin 
is  to  be  used,  in 
t  lie  man  n  er 
al  ready  de- 
scribed. The  divided  tendons  and  nerves  must 
be  drawn  from  the  wound  and  cut  as  short  as 
possible.  The  arteries  requiring  ligation  are  the 
radial,  ulnar,  and  interosseous.  It  is  particularly 
essential  that  the  latter  should  be  divided  but  once, 
and  carefully  secured.  When  secondary  hemorrhage 
occurs  after  amputation  of  the  forearm,  it  is  almost 
always  the  result  of  faulty  ligation  of  this  vessel. 

Amputation    at   the    Elbow. — The    removal    of 
the  forearm  at  its  articulation  with  the  humerus  is 

generally  acknowl- 
edged to  have  been 
first  performed  by 
Ambrose  Pare,  in 
1536,  in  the  case  of  a 
soldier  who  had  re- 
ceived a  gunshot 
wound  of  the  fore- 
arm, which  was  fol- 
lowed by  gangrene. 
The  operation  did  not 
meet  with  much  favor 
by  surgeons  generally,  until  it  wras  again  advised  and 
practised  in  the  second  quarter  of  this  century  by 
Textor  of  Wtirzburg,  by  Dupuytren,  and  by  Liston. 
With  the  exception  of  Chenu's  statistics,  the  results 
of  amputation  at  the  elbow  have  been  very  favorable, 
the  death  rate  not  exceeding  fourteen  per  cent. 
(Agnew).  The  last-named  writer,  however,  gives  a 
mortality  of  sixty-five  per  cent,  as  that  which  attended 
disarticulations  of  the  forearm  during  the  Crimea. 
On  the  other  hand,  of  thirty-nine  amputations  at  the 
elbow,  made  during  the  War  of  the  Rebellion,  in  which 


Fig.  134. 


Fig.  135. 


the  result  was  determined,  only  three  succumbed;  the 
mortality  being  less  than  eight  per  cent. 

The  operations  generally  resorted  to  in  amputations 
at  the  elbow  are  the  circular  and  musculotegumentary 


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Amputation 


flap  methods.  When  the  former  is  practised,  a  circu- 
lar incision  should  divide  the  skin  and  subcutaneous 
cellular  layer  of  the  forearm  ui  least  two  inches  below 
the  humeral  condyles.  When  a  cuff  of  sufficient 
length  has  been  reflected,  the  anterior  surface  of  the 
joint  is  made  prominent  by  hyperextension,  and 
divided  by  a  transverse  cut  with  the  end  of  the  knife. 
When  the  lateral  ligaments  are  next  divided,  the 
joint  surfaces  are  sufficiently  separated  from  each 
other  to  permit  the  knife  to  be  passed  behind  the 
ranon,  where  the  tendon  of  the  triceps  is  to  he 
divided.  The  latter  step  of  the  operation  is  some- 
times attended  with  such  difficulty  that  many  sur- 
preserve  the  olecranon  process  by  sawing  the 
transversely  after  disarticulation  of  the  radius 
has  been  effected.  The  advantages  which  are  to  he 
nned  by  it.--  preservation,  on  account  of  the  in- 
fluence which  the  triceps  will  have  over  the  artificial 
limb,  are  more  than  balanced  by  the  increased 
dangers  of  retention  of  secretion  in  the  wound  and 
i  >>is. 
Excellent  results  can  also  be  obtained  by  tegumen- 
tary  flaps.  As  represented  in  Fig.  148  (Esmarch),  a 
curved  incision  is  made  over  the  flexor  surface  of  the 
forearm,  beginning  and  ending  about  one  inch  below 
the  condyles.  The  large  semilunar  flap  thus  made  is 
reflected  to  its  base.  A  second,  but  shorter  convex 
flap  is  made  posteriorly,  which,  when  reflected, 
exposes  the  olecranon.  The  operation  is  then  com- 
pleted by  disarticulation,  as  in  that  by  the  circular 
method.  The  most  brilliant  operation,  and  at  the 
same  time  a  very  satisfactory  one,  is  that  by  which  a 

long  anterior  flap  is  made 
by  transfixion.  The 
knife,  being  introduced 
a  little  less  than  an  inch 
below  the  external  con- 
dyle (for  the  right  arm) 
of  the  humerus,  is  pushed 
directly  across  the  front 
of  the  articulation  to  a 
point  on  the  same  level 
on  the  opposite  side. 
The  arm  being  held  in  a 
supine  position,  a  broad, 
almost  rectangular  flap, 
from  four  to  five  inches 
in  length,  is  made  by 
cutting  outward.  The 
ends  of  the  wound  should  then  be  united  by  a  slightly 
convex  incision  carried  across  the  posterior  aspect  of 
the  joint.  Disarticulation  is  then  effected  as  in  the 
previous  operations. 

When  the  soft  parts  of  the  anterior  portion  of  the 
forearm  cannot  be  utilized,  the  integument  of  the 
posterior  surface  can  be  shaped  into  an  admirable 
covering  for  the  end  of  the  bone.  Ashhurst  thus 
describes  the  elliptical  incision  by  which  this  is  ac- 
complished: "  The  arm  being  semiflexed,  the  point  of 
the  knife  is  entered  nearly  an  inch  below  the  internal 
condyle  of  the  humerus,  curved  upward  over  the 
front  of  the  forearm  nearly  to  the  line  of  the  joint,  and 
downward  again  to  a  point  an  inch  and  a  half  below 
the  external  condyle;  the  arm  being  then  forcibly 
flexed,  the  ellipse  is  completed  on  the  back  of  the 
forearm  by  a  curved  incision  passing  nearly  three 
inches  below  the  tip  of  the  olecranon.  The  cuff  thus 
marked  out  is  rapidly  dissected  upward  as  far  as 
necessary,  when  the  muscles  of  the  front  of  the  forearm 
are  cut  about  half  an  inch  below,  and  the  ulnar  nerve 
as  far  above  the  joint,  and  disarticulation  is  effected 
from  the  outer  side.  The  wound  is  closed  transversely, 
forming  a  small  curved  cicatrix  in  front  of  the  bone!" 
It  is  probably  always  advisable,  except  in  eases  of 
disease,  to  preserve  the  articular  surface  of  the  hu- 
merus intact,  although  Sir  William  Ferguson  believed 
that  a  section  above  the  condyles  leaves  a  preferable 
stump,  and  one  more  likely-  to  heal  promptly.     In  all 


\    %w  ~ T~ ~~^— — 


Fig.  136. 


amputations  at    the  elbow,   the   radial,    ulnar,   and 

interosseous  arteries  require  ligation.  When  the  in- 
ci~i. ui  through  the  soft  parts  anteriorly  is  made  on  a 
higher  level  than  is  ordinarily  necessary,  the  brachial 
may  be  divided  and  require  ligation. 

Amputation  of  the  Asm. —  This  may  be  perform- 
ed at  any  point  below  the  axillary-  folds,  and  all  the 
methods  of  amputation  may  he  used  with  advam 
in  different  cases,  since  the  choice  of  methods  often 

permits  the  operator  to  save  a  considerable  portion  of 


Fig.  137. 


the  arm.  On  account  of  the  central  position  of  the 
humerus,  the  arm  is  properly  considered  the  typical 
position  for  the  double  musculotegumentary  flap 
operation  by  transfixion,  and  many  surgeons  prefer 
this  method  in  this  situation.  The  objection  to  be 
urged  against  it  is  the  unequal  retraction  of  the  in- 
tegument and  underlying  muscles,  the  latter  gener- 
ally protruding  a  varying  distance  over  the  cutaneous 
margins  of  the  wound.  Agnew  properly  advises  that. 
to  overcome  this  unequal  retraction,  anteroposterior 
oval  skin  flaps  should  be  raised  of  sufficient  length  to 
compensate  for  the  difference  in  muscular  and  cutane- 
ous retraction;  after  these  are  made,  the  muscular 
flaps  are  formed  either  by  transfixion  or  by  cutting 
from  within  outward.  The  latter  plan  of  operating, 
although  less  brilliant  than  that  by  transfixion,  should 
always  be  preferred  in  amputations  of   the  arm  in 


Fig.  138. 

very  fleshy  subjects.  In  making  the  flaps,  the 
posterior  should  always  be  made  first,  the  anterior, 
containing  the  important  vessels  and  nerves,  being 
made  last.  According  to  the  dimensions  of  the  limb, 
the  flaps  should  be  made  from  two  to  three  inches  in 
length. 

In  slender  subjects,  the  circular  operation  answers 
admirably.  In  exceptionally  thin  arms,  the  integu- 
ment can  be  retracted  sufficiently  to  make  the  opera- 
tion by  a  single  circular  incision.     As  a  rule,  however, 

283 


Amputation 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


it  is  best  formally  to  reflect  a  cuff  (Fig.  137),  or  to 
make  rectangular  cutaneous  flaps  by  slitting  the 
cuff  on  each  side.  In  dividing  the  muscles  by  a 
circular  incision,  the  biceps  generally  retracts  more 
than  the  remaining  muscles.  The  wound  is  often 
so  irregular  in  consequence  that  a  second  division  of 
the  muscles  becomes  necessary  (Fig.  138).  In  cases 
of  injury  attended  with  great  destruction  of  the  soft 
parts  on  the  dorsal  aspect  of  the  arm,  the  Teale 
method,  by  rectangular  flaps,  offers  particular  advan- 
tages. The  incisions  for  making  the  long  anterior 
flap  must  be  made  in  such  a  manner  that  the  inner 
one  shall  be  without  the  brachial  artery,  which  should 
be  contained  in  the  short  posterior  flap. 

In  amputations  through  the  middle  and  lower 
thirds  of  the  arm,  the  circulation  can  be  controlled  in 
the  ordinary  manner  by  the  Esmarch  tube  or  tourni- 
quet. In  amputations  higher  up,  where  the  tourni- 
quet would  be  in  the  way  of  the  operator,  and  liable 
to  slip,  the  main  artery  can  be  compressed  against 
the  head  of  the  bone  by  an  assistant,  or  against  the 
first  rib  above  the  clavicle.  When  a  tourniquet  is 
used  in  amputations  in  the  upper  part  of  the  arm,  it 
should  be  so  applied  that  a  roller  covers  the  axillary 
artery  in  the  arm-pit,  while  the  plate  of  the  tourni- 
quet can  be  fixed  against  the  acromial  process  of  the 
scapula.  The  arteries  requiring  ligation  after  ampu- 
tation of  the  arm  are  the  brachial,  superior  or  in- 
ferior profunda,  occasionally  the  anastomotica,  and 
four  or  five  muscular  branches.  It  should  be  remem- 
bered, likewise,  that  in  every  fifth  subject,  according 
to  Quain,  there  is  a  high  division  of  the  brachial  into 
radial  and  ulnar. 

In  5,273  cases  of  amputation  of  the  arm  for  gunshot 
injury,  1,246,  or  23.6  per  cent.,  terminated  fatally. 
The  gravity  of  amputation  of  the  arm  does  not 
increa-e  with  the  extent  of  the  limb  removed,  am- 
putations through  the  lower  third  presenting  a 
mortality  of  thirty-five  per  cent,  against  nineteen 
per  cent,  for  amputations  in  the  middle  and  twenty- 
two  per  cent,  for  those  of  the  upper  third.  In  the 
statistics  of  Gorman,  derived  from  civil  practice,  this 
remarkable  feature  in  the  prognosis  of  amputations 
of  the  arm  is  even  more  pronounced,  the  mortality 
following  amputations  in  the  upper,  middle  and 
lower  thirds  being  twenty-three  per  cent,  twenty-one 
per  cent,  and  forty-four  per  cent,  respectively.  Of 
fourteen  amputations  of  the  arm  in  the  Cincinnati 
Hospital  all  recovered.  Of  157  amputations  of  the 
arm  collected  from  the  recent  statistics  of  Erdmann. 
Page,  and  my  own,  twenty,  or  12. S  per  cent.,  died. 
Fur  the  comparative  mortality  after  amputations  of 
the  arm  for  injury  and  for  disease  the  reader  is  re- 
ferred to  Tables  III.,  IV.,  and  V. 


Amputation-  at  the  Shoulder. — Although  this 
operation  was  referred  to  by  ancient  writers  on 
medicine,  it  was  not  performed  as  a  formal  operation 
till  1710,  when  the  elder  Morand  performed  it  with  a 
fatal  result  in  a  case  of  caries.  The  case  was  not 
recorded  until  some  years  later,  by  the  younger 
Morand.     The  second  operation,  which  was  success- 

284 


ful,  was  made  in  1715  by  the  elder  Le  Dran,  likewise 
for  caries.  That  the  arm  had  previously  been  re- 
moved at  the  shoulder  in  a  case  of  gangrene  appears 
in  the  Jour,  de  Med.  de  M.  Dc  la  Roque,  1686.  "The 
surgeon  took  a  small  saw  to  remove  the  bone  of  the 
arm,  but  perceiving  that  it  was  loose  in  the  joint,  he 
gave  it  several  slight  'jerks',  when  the  bone  was 
readily  drawn  from  the  socket."  Ravaton,  La  Faye, 
Heister,  and  Bromfield  repeated  the  operation  from 
time  to  time  on  the  Continent  and  in  England,  but  it 
remained  for  the  distinguished  Larrey  to  give  it  a 


Fig.  140. — Showing  Wyeth's  Pins  and  the  Rubber  Tubing  in 
Place.     A  piece  of  black   court  plaster  indicates   the  tip  of  the 
acromion.     (Taken,  by  permission,  from  Keen's  article  on  shoul- 
der amputations,  in  the  Transactions  of  the  American  Su: 
Association  for  1S94.) 

firm  footing  among  surgical  procedures.  Of  111 
amputations  made  by  him  at  this  part,  ninety-seven 
recovered. 

In  all  amputations  of  the  shoulder,  the  circulation 
in  the  axillary  artery  must  be  controlled.  This  can 
be  accomplished  by  the  use  of  the  rubber  tube  of  the 
Esmarch  bandage  firmly  wound  around  the  axilla 
and  shoulder,  and  held  by  an  assistant  or  cL 
toward  the  neck  of  the  patient  (Fig.  139).  To  prevent 
the  slipping  of  the  strap,  which  is  likely  to  occur  \\  hen 
the  head  of  the  humerus  leaves  the  socket,  two  long 
transfixion  pins  may  be  used,  the  one  in  front  of  and 
the  other  behind  the  acromion.  The  anterior  pin  is 
introduced  through  the  middle  of  the  anterior  axillary 
fold  near  the  trunk  line.  It  is  made  to  emerge  an 
inch  above  the  shoulder,  one  inch  to  the  inner  side  of 
the  acromial  tip.  The  second  pin  transfixes  the 
posterior  axillary  fold  in  the  same  manner,  emerging 
behind  the  acromion  (Fig.  140).  In  all  amputations 
of  the  shoulder  the  joint 
should  be  approached 
from  the  outer  side,  so 
that  the  artery  shall  not 
be  divided  until  disartic- 
ulation has  been  effected. 
In  this  manner  an  assis- 
tant can,  if  necessary, 
pass  his  thumb  into  the 
wound  above  the  knife 
(Fig.  141)  and  compress 
I  he  vessel  before  it  is  cut. 
Two  pairs  of  pedicle 
clamp  forceps  with 
blades  three  inches  long 
applied  above  the  line 
of  division  of  the  inner 
flap,  the  one  from  in  front 
and  the  other  from  be- 
hind, will  perfectly  con- 
trol the  artery  while  the  operation  is  being  completed. 
Thereby  skilled  assistance,  and  even  the  Esmarch 
strap,  can  be  dispensed  with.  The  hemorrhage  is 
from  the  smaller  vessels  only  and  is  slight.  When 
the    axilla    is   invaded    so    high  that  this   plan   of 


Fig.  141. 


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Amputation 


hemostasis  is  impracticable,  the  axillary  shouUl  In- 
tied  by  dividing  the  pectoral  muscle  as  suggested  by 
Delpech,  or  the  subclavian  should  be  tied  in  its  third 
part,  as  a  preliminary  step  to  the  amputation.  When 
such  precautions  as  have  been  described  can  be  taken, 
it  is  not  necessary  to  make  a  preliminary  ligation  of 
the  artery  in  the  axilla.  Amputations  at  the  shoulder 
joint  can  be  made  by  the  oval  or  flap  method,  and 
likewise  by  a  circular  operation  with  external  longi- 
tudinal incision. 

Oval  Method. — This  operation,  generally  designated 
rey's  operation  (as  shown  in  Fig.  139),  is  per- 
formed as  follows:  The  patient  being  placed  in  a 
semi  recumbent  position,  with  the  part  to  be  amputated 
projecting  over  the  edge  of  the  operating  table,  the 
point  of  the  knife  is  introduced  just  beneath  the  point 
of  the  acromion  process,  and  carried  down  over  the 
external  surface  for  a  distance  of  from  two  and  one- 
half  to  four  inches,  according  to  the  dimensions  of  the 
part.  This  incision  should  divide  all  the  tissues  down 
to  the  bone.  From  the  center  of  this  incision  an  oval 
cut  is  carried  around  the  arm,  passing  a  little  below 
the  axillary  folds,  but  involving  only  the  skin  and 
superficial  fascia.  The  flaps  thus  outlined  are 
carefully  liberated  from  the  bone.  The  capsule  is 
then  freely  opened  by  a  transverse  cut  over  the  head 
of  the  humerus,  and  the  arm  is  rotated  inward  and 
outward  to  facilitate  the  diyision  of  the  tendons  of 
the  articular  muscles;  in  this  part  of  the  operation, 
the  edge  of  the  knife  must  be  kept  in  close  contact 
with  the  bone.  The  operation  is  completed  by 
dividing  the  soft  parts  on  the  internal  surface  of  the 
arm  on  a  level  with  the  cutaneous  incision  already 
made.  "While  it  is  not  essential,  in  this  operation,  to 
cany  the  oval  incision  completely-  around  the  arm 
before  beginning  the  dissection  of  the  flaps,  it  is 
preferable,  since,  without  it,  the  lower  part  of  the 
oval  wound  is  very  apt  to  be  ragged  and  uneven.     The 

wound  following  this 
operation  is  united 
so  as  to  leave  a  linear 
cicatrix  parallel 
to  the  axis  of  the 
body  (Fig.  142,  from  a 
photograph  of  one  of 
Ashhurst's  patients). 
Circular  Method. — 
In  cases  in  which  the 
humerus  is  shattered 
to  such  a  degree  that 
it  cannot  easily  be 
used  in  the  manipula- 
tions necessary  for 
effecting  disarticula- 
tion, the  following 
modification  of  the 
circular  incision  will 
answer  admirably: 
The  arm  being  ab- 
ducted, a  circular  in- 
cision at  the  lower 
border  of,  or  through, 
the  deltoid  divides  all 
the  soft  parts  down  to 
the  bone.  This,  if  necessary,  is  divided  on  the  same 
level,  and  all  the  gaping  vessels  are  Iigated.  When 
the  amputation  of  the  arm  is  thus  completed,  a  long 
incision,  dividing  all  the  soft  parts,  is  made  from  the 
tip  of  the  acromion  over  the  external  surface  of  the 
shoulder  to  the  circular  wound.  The  remaining stumd 
of  the  humerus  is  then  seized  with  a  strong  pair  of 
forceps,  and  liberated  from  its  muscular  attachments 
and  from  the  joint  by  short  incisions  directed  well 
against  the  bone  (Esmarch). 

Flap  Method. — Amputation  at  the  shoulder  by  the 
flap  method  can  be  made  either  by  transfixion  or  by 
cutting  from  without  inward.  The  latter  method, 
while   less  brilliant,   is  preferable  in  every  way.     It 


Fig.   14_\ 


Fiq.  143. 


should  be  performed  in  the  following  maimer:  In 
amputation  of  the  left  arm  the  operator  begin-  his 
incision  at  the  coracoid  process,  and  carries  it  down 
over  the  anterior  surface  of  the  shoulder  to  the  level 
of  the  insertion  of  the  deltoid,  across  which  it  i~  carried 
in  a  wide  curve;  it  is  then  prolonged  upward  on  the 
posterior  surface  of  the  shoulder  to  the  junction  of 
the  acromion  with  the  spine  of  the  scapula  1 1  it:.  143). 
This  broad  flap,  including  a  great  part  of  the  deltoid, 
is  then  raised  by  rapid  strokes  of  the  knife  and  reflected 
over  the  acromion  in  order  that  the  joint  may  be 
exposed.  This  is  made  prominent  by  pushing  the 
head  of  the  humerus 
upward,    and    is   to  be 

i ipened  by  a  trans- 

cut  upon  the  latter. 
The  head  of  the  bone  is 
now  easily  dislocated. 
The  knife  is  then  car- 
ried behind  the  hu- 
merus (as  shown  in 
Fig.  141)  and  down  its 
inner  surface  to  a  point 
one  or  two  inches  below 
the  axillary  fold,  when, 
by  rapidly  cutting  out- 
ward, all  the  soft  parts 
on  the  inner  side  are 
divided. 

In  making  this  oper- 
ation by  transfixion 
(Dupuytren's  method) 
the  arm  must  be  held 
at  a  right  angle  with 
the  body,  while  the 
surgeon  grasps  and  raises  the  fleshy  part  of  the 
shoulder  with  the  left  hand.  The  knife  is  entered  one 
or  two  inches  behind  the  acromion  and  pushed  directly 
across  the  front  of  the  joint,  emerging  just  outside  the 
coracoid  process  of  the  scapula.  Transfixion  being 
effected,  a  broad  flap  is  cut  from  within  outward. 
The  further  steps  of  the  operation  are  similar  to  those 
above  detailed. 

Both  of  the  operations  described  leave  a  wound 
that,  from  its  position,  is  more  readily  drained  than 
that  which  is  left  by  the  oval  method.  The  cica- 
trix which  remains  is  transverse  in  direction  and 
curvilinear. 

A  wound  closely  resembling  that  left  by  Larrey's 
oval  operation  remains  after  the  formation  of  postero- 
external and  antero-internal  flaps  by  Lisfranc's 
method.  In  practising  this  method,  when  the  left 
arm  is  to  be  removed,  a  long  and  narrow  amputating 
knife  is  introduced  at  the  margin  of  the  posterior 
axillary  fold.  The  blade  is  then  pushed  along  the 
posterior  surface  of  the  humerus  until  the  head  of  the 
bone  has  been  cleared,  when  the  counter-puncture  can 
readily  be  made  an  inch  beneath  the  clavicle  and  on 
the  outer  side  of  the  coracoid  process.  A  broad 
postero-external  flap  must  then  be  shaped  by  cutting 
from  within  outward.  The  capsule  is  then  opened  as 
in  other  operations,  and  an  antero-internal  flap  cut 
likewise  from  within  outward.  In  operations  on  the 
right  side  the  posterior  flap  is  also  made  first;  the 
surgeon,  standing  behind  the  patient,  inserts  the 
point  of  the  knife  from  above  and  lets  it  emerge  from 
the  posterior  axillary  fold. 

Professor  Spence  of  Edinburgh  introduced  a  method 
of  amputating  which  is  but  a  modification  of  the  ova] 
operation,  in  which  the  perpendicular  incision  is  made 
upon  the  head  of  the  humerus,  nearer  to  its 
inner  than  its  outer  surface.  This  incision  is  com- 
menced just  beneath  and  outside  of  the  coracoid  pro- 
cess and  carried  through  the  clavicular  fillers  of  the 
pectoralis  major  and  deltoid  muscles  until  the  hu- 
meral attachment  of  the  former  is  reached.  From  the 
lower  end  of  this  incision  the  external  and  internal 
curvilinear  incisions  are  almost  the  same  as  those  of 


285 


Amputation 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


the  oval  operation  as  generally  practised.  The  ad- 
vantages claimed  by  Professor  Spence  for  this  modi- 
fication are  the  facility  with  which  the  disarticulation 
can  be  effected,  the  avoidance  of  injury  to  the  main 
trunk  of  the  posterior  circumflex  artery,  and  the  better 
shape  of  the  stump. 

The  prognosis  of  amputation  of  the  shoulder  has 
been  very  greatly  improved.  For  example,  from 
Estes's  statistics  from  the  South  Bethlehem,  Pa., 
Hospital,  of  twenty-two  amputations  at  the  shoulder 
joint  done  during  twenty  years  only  one  died.  This 
is  in  contrast  to  the  amputations  done  on  the  battle 
field  or  in  military  hospitals.  Of  seven  cases  re- 
ported by  Col.  Stevenson,  two  or  twenty-eight  per 
cent.  died.  Most  of  these  cases  were  septic  when 
operated  on. 

IxTEKSCAPULO-THORACTC       AMPUTATION. In        the 

first  edition  of  this  work  fourteen  cases  of  avulsion 
of  the  entire  upper  extremity  were  referred  to,  which 
ended  favorably.  In  Ashhurst's  "Surgery,"  seven- 
teen cases  are  recorded  of  such  avulsion  which  ended 
favorably.  Here  also  are  recorded  eighty-nine  cases, 
in   which  the  entire  upper  extremity  including   the 


Fig.    144. — Interscapulo-Thoracic   Amputation.     (After    Treves.) 

scapula  and  part  of  the  clavicle  was  removed  by 
operation,  with  sixty-seven  recoveries  and  twenty- 
two  deaths.  Bergmann  has  put  on  record  fourteen 
amputations  of  the  entire  upper  extremity,  with  only 
one  death.  Favorable  cases  have  likewise  been 
recorded  by  Chavasse,  Ochsner,  Keen,  Doll,  and 
Heddaens.  Barling"  collected  nineteen  cases  operated 
on  within  five  years  without  a  death.  Jeanbrau 
Riche  collected  188  observations  from  sixty  surgeons. 
The  mortality  was  11.1  per  cent.  But,  while  the 
operations  performed  before  1S87  or  when  the  tech- 
nique was  imperfectly  developed,  showed  a  mortality  of 
29. 16  per  cent. ;  those  performed  after  1887  showed  one 
of  only  7.84  per  cent.  If  cases  in  which  intervention 
was  contraindicated  are  left  out,  the  figures  could 
be  reduced  to  5.2  per  cent.  Of  125  cases  in  which 
the  nature  of  the  new  growth  had  been  determined 
by  a  microscopic  examination,  recovery  followed  in 
105.  Of  the  twenty  others,  ten  died  from  operation, 
and  reports  about  another  ten  could  not  be  obtained 
(Rodman).  The  operation  is  indicated  in  cases  of 
severe  crush  of  the  upper  extremity  when  exarticula- 
tion  at  the  shoulder  would  not  suffice,  and  in  neo- 
plasms of  the  upper  extremity  when  it  is  essential  to 
get  as  far  as  possible  from  the  disease.  The  first  opera- 
tion was  done  by  Gumming,  in  1808,  for  gunshot 
injury;  the  second,  in  1830,  by  Gaetaui  for  a  severe 
trauma  from  an  explosion.  In  1887  Paul  Berger 
tabulated  all  of  the  cases  recorded  up  to  that  time,  and 
submitted  the  most  comprehensive  monograph  upon 
tin-  subject. 

As  in  amputations  at  the  shoulder  joint,  the  control 
of  hemorrhage  is  the  essential  point  of  the  operation. 


It  is  now  the  consensus  of  opinion  that  the  first  step 
of  the  operation  should  be  the  resection  of  the  middle 
third  of  the  clavicle  as  a  preliminary  step  to  the 
tying  of  the  subclavian  artery  and  vein.  It  is 
essential  to  tie  the  latter  as  well  as  the  artery,  in  order 
to  prevent  the  ingress  of  air.  According  to  the 
publication  by  Nasse  of  Bergmann's  cases,  the  Berlin 
surgeon  begins  his  operation  with  the  typical  ligation 
of  the  subclavian  artery  to  the  outer  side  of  the  ante- 
rior scalenus  muscle.  This  is  followed  by  division  of 
the  clavicle.  The  arm  is  then  elevated  and  the  sub- 
clavian vein  tied.  The  brachial  plexus  is  at  once 
divided.  Ochsner  has  called  attention  to  the  fact 
that  this  plexus  ought  to  be  divided  with  a  sharp 
knife  rather  than  with  scissors,  since  the  shock  is 
thereby  greatly  lessened.  Le  Conte  has  wisely 
suggested  the  complete  excision  of  the  clavicle  in 
place  of  resection  of  its  outer  portion.  In  malignant 
disease  it  is  preferable,  and  when  once  accomplished 
simplifies  the  control  of  the  vessels.  The  cutaneous 
incision  must  vary  somewhat  according  to  the  degree 
to  which  the  soft  parts  about  the  shoulder  are  in- 
volved. Bergmann  makes  an  anterior  incision, 
through  the  skin  only,  from  the  incision  made  for  the 
division  of  the  clavicle  straight  through  the  axilla  to 
the  lower  angle  of  the  scapula.  The  posterior  in- 
cision is  made  over  the  dorsal  aspect  of  the  scapula 
from  the  resection  line  of  the  clavicle  to  the  end  of  the 
anterior  incision.  The  illustration  will  indicate  the 
lines  of  incisions  recommended  by  Treves.  That  for 
the  antero-inferior  flap  extends  outward  from  the 
incision  made  for  the  division  of  the  clavicle  to  the 
outer  and  lower  border  of  the  axilla,  which  it  crosses 
directly  from  before  backward,  whence  it  passes 
downward  to  the  lower  tip  of  the  scapula  posteriorly. 
The  posterior  incision  extends  across  the  upper  sur- 
face of  the  shoulder,  from  which  it  inclines  over  the 
scapula  to  its  lower  angle,  as  seen  in  the  illustration. 
After  the  lifting  of  the  cutaneous  flaps,  the  muscles 
are  divided  and  the  small  vessels  tied  as  they  are 
encountered.  In  one  of  Kern's  cases,  owing  to  the 
involvement  of  the  parts  about  the  acromion,  an  oval 
incision  was  made  beginning  three  inches  above  the 
acromion,  each  limb  passing  in  front  of  and  behind 
the  shoulder  respectively,  and  meeting  in  front  of  the 
inferior  angle  of  the  scapula.  In  the  cases  of  recovery, 
the  wounds  heal  within  the  course  of  ten  days  or  two 
weeks.  In  operations  for  malignant  disease,  the  prog- 
nosis is  far  more  favorable  when  it  is  done  for  myeloid 
sarcoma  than  for  periosteal  sarcoma.  The  prognosis 
is  more  favorable  in  those  cases  in  which  the  soft  parts 
about  the  shoulder  are  not  involved.  Thus  in  all  the 
cases  of  Heddaens  recurrence  rapidly  took  place. 
Amputation  of  the  Toes. — It  is  occasionally 
necessary  to  remove  the  toes  in  consequence  of 
accident,  disease,  or  deformity.  While  in  cases  of 
accident,  it  may  occasionally  be  well  to  save  a  part  of 
one  of  the  smaller  phalanges,  it  is  generally  best  that 
the  amputation  be  made  at  the  metatarso-phalangeal 
joint.  In  amputations  of  the  phalanges,  a  flap 
operation,  like  that  for  the  fingers,  must  be  made, 
care  being  taken,  as  in  all  amputations  of  the  foot, 
that  the  cicatrix  is  placed  on  the  dorsal  aspect  of  the 
stump.  In  amputations  of  an  entire  toe,  the  in- 
cision should  be  commenced  on  the  dorsal  surface  of 
the  metatarsal  bone,  a  little  above  the  joint,  but 
considerably  above  the  web,  and  carried  directly 
down  an  inch  or  more.  It  is  then  carried  obliquely 
around  the  web  on  each  side,  in  such  a  manner  as  to 
preserve  as  much  of  the  soft  parts  as  possible.  This 
preservation  of  tissue  is  necessary  for  a  sufficient 
covering  for  the  large  head  of  the  metatarsal  bone. 
When  the  operation  is  performed  in  this  manner,  the 
cicatrix  is  linear  and  entirely  removed  from  pressure. 
No  part  of  the  metatarsal  bone  should  be  removed, 
lest  the  strength  of  the  foot  be  deteriorated.  Dis- 
articulation of  the  great  toe  may  be  effected  by  the 
oval  method  just  described,  or  by  the  formation  of 


286 


REFERENCE    HANDBOOK   OF   THE   MEDICAL   SCIENCES 


Amputation 


an  internal  flap.  In  1  ho  latter  case,  an  incision  is 
begun  on  the  outer  side  of  the  extensor  tendon,  just 
below  the  joint,  and  carried  longitudinally  to  the  head 
,,i  the  first  phalanx,  from  its  lower  end  an  incision 
j-  carried  transversely  around  the  inner  side,  to  the 
flexor  tendon,  along  the  outer  side  of  which  it  is 
continued  backward  to  the  plantar  fold,  whence  it  is 
again  given  a  transverse  direction  around  the  outer 
siTle  of  the  toe  until  it  meets  the  first  incision  near  its 
center  (Stimson).  The  rectangular  flap  thus  marked 
out. is   dissected  up,    the  tendons    are    divided,    and 

disarticulation  is  effected.     Although  it  is  s times 

ommended,  the  head  of  the  lirst.  metatarsal  bone 

should  never  be  re ved  unless  it  is  implicated  in  the 

lesion,  since  it  tonus  one  of  t ho  most  important  points 
of  support  in  the  foot. 

Amputation  of  all  the  toes  at  the  metatarso- 
phalangeal joints  may  be  made  by  carrying  a  curved 
incision  along  the  groove  between  the  base  of  the  toes 
and  sole  of  the  foot  from  one  margin  of  the  latter  to  the 
other.  The  toes  being  forcibly  flexed,  a  similar 
incision  is  made  along  the  dorsum,  which  joins  the 
ends  of  the  plantar  wound.  The  semilunar  flaps 
thus  formed  are  dissected  back  as  far  as  the  meta- 
tarso-phalangeal  joints,  when  disarticulation  of  the 
individual  toes  can  be  made.  It  certainly  _  cannot 
be  often  that  a  formal  operation  of  this  nature  is  called 
into  requisition. 

Amputation  through  the  Metatarsus. — In 
consequence  of  injury  or  disease  it  not  unfrequently 
becomes  necessary  to  remove  a  part  or  all  of  the 
metatarsal  bones.  In  amputations  through  individ- 
ual bones  of  the  metatarsus,  conservatism  must  be 
particularly  insisted  upon,  since,  except  in  that  of  the 
great  toe,  the  complete  removal  of  a  metatarsal 
Bone  cannot  be  accomplished  without  opening  the 
large  synovial  sac  which  separates  it  from  the  first 
row  of  the  tarsus.  For  amputations  through  the 
second,  third,  and  fourth  metatarsal  bones,  the 
longitudinal  incision  necessary  for  disarticulation  at 
the  metatarso-phalangeal  joint  must  be  carried 
upward  for  a  distance  varying  according  to  the 
extent  of  bone  to  be  removed.  A  short  transverse 
incision  is  then  made  to  facilitate  the  separation  of  the 
soft  parts  and  the  use  of  either  chain-saw  or  bone- 
cutting  forceps.  When  the  bone  has  been  divided. 
its  distal  end  is  drawn  from  the  wound  with  a  pair  of 


stout  forceps,  and  the  operation  is  completed  by 
severing  the  soft  parts  on  the  plantar  surface  of  the  foot 
with  short  strokes  of  the  scalpel.  The  removal  of  the 
first  and  fifth  metatarsal  bones  can  be  accomplished 
by  the  oval  method  or  by  internal  and  external  flaps 
respectively.  The  oval  method,  where  it  is  practi- 
cable, is  doubtless  preferable,  since  it  yields  a  smaller 
wound  and  a  cicatrix  protected  from  pressure.  The 
incisions  for  the  oval  amputations  of  the  great  toe 
with  its  metatarsal  bone  are  well  shown  in  Fig.  145. 
( in  account  of  the  great  width  of  the  base  of  the  latter 
bone,  a  short  transverse  incision  facilitates  the  libera- 
tion of  the  flaps.  In  disarticulations  of  the  fifth 
metatarsal  bone  the  oblique  line  of  its  articulation 
with  the  cuboid  bone  should  be  borne  in  mind. 
When  the  first  or  fifth  metatarsal  bone  is  amputated 
in  its  continuity,  the  section  should  be  made  obliquely 
to  avoid  undue  prominence  of  the  stump. 


Amputation  in  the  continuity  of  all  the  metatarsal 
bones  is  not  very  infrequently  called  for,  in  consequence 

Of  injury  or  gangrene  following  frost-bile.      \\  hen  it  can 

be  resorted  to,  it  is  preferable  to  amputation  through 

ihe    tarsometatarsal    articulation.      The   operation    is 

commenced  with  a  curved  incision  carried  along  the 

anterior  furrow  of  the  Bole  of 
the  foot ,  from  bonier  to  border, 
and  the  semilunar  flap  thus 
outlined  is  reflected  to  the  line 

where   section   of   the  bones  is 

to  be  made.     A  smaller  semi- 
lunar flap  is  then  shaped  from 
the  dorsal  surface  of  the  foot. 
The  interosseous  soft  parts  are 
then  divided  transversely  with 
a     narrow     knife, 
and    retracted    by 
means    of    narrow 
strips  of  linen,  when  the  bones 
are  sufficiently  exposed  for  the 
application    of    the  saw   (Fig. 
140).     The  appearance  of  the 
wound  resulting  from  t  his  oper- 
ation is  well  shown  in  Fig.  1  IT. 
In  this  age  of  conservatism 
Fia.  146.  in  surgery,  in  which  "the  least 

sacrifice  of  parts"  is  the  lead- 
ing tenet  of  surgical  creed  and  practice,  every  half-inch 
of  the  foot  that  can  be  saved  to  the  economy  is  properly 
considered  of  incalculable  value.  It  is  for  this  reason 
that,  whereas  before  the  times  of  Hey,  Chopart,  and 
Lisfranc,  amputations  of  the  foot  above  the  ankle 
were  made  comparatively  often,  they  have  of  late 
been  largely  replaced  by  partial 
amputations  through  the  differ- 
ent articulations  which  it  con- 
tains. The  partial  amputations 
which  will  be  considered  are  the 
tarsometatarsal,  the  mediotarsal, 
the  subastragaloid,  and  their 
modifications. 

Tarsometatarsal  Amputa- 
tion.— A  glance  at  Fig.  149 
shows  the  difficulty  which  the 
surgeon  must  contend  with  in 
this  amputation  of  the  foot.  It 
is  the  firm  impaction  of  the  base 
of  the  second  metatarsal  bone 
between    the    internal    and  ex-  Fig.  147. 

ternal     cuneiform     bones.        In 

1797,  Mr.  Hey,  of  Leeds,  overcame  this  difficulty  by 
disarticulating  the  outer  metatarsal  bones,  and  divid- 
ing the  prominent  internal  cuneiform  with  a  saw. 
.Surgeons  after  him  have  generally  adopted  the  plan  of 
separating  the  outer  three  and  the  internal  metatarsal 


Fig.  148. 

bones  at  their  articulations,  and  dividing  the  base  of 
the  second  metatarsal  below  its  articulation  with  the 
middle  cuneiform.  When  disarticulation  of  all  the 
metatarsal  bones  is  effected  the  operation  is  known  as 
Lisfranc's  (1815). 

2S7 


Amputation 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Lisfranc's  amputation  of  the  foot  is  made  as  follows: 
The  joint  between  the  cuboid  and  prominent  base  of 
the  fifth  metatarsal  bone  having  been  marked  on  the 
outer  side  of  the  foot,  and  that 
between  the  first  metatarsal  and 
internal  cuneiform  (about  one  inch 
and  a  half  below  the  tuberosity  of 
the  scaphoid)  on  the  inner  side,  a 
large  semilunar  incision  is  made 
between  them  on  the  sole  of  the 
foot,  the  convexity  of  which  should 
pass  over  the  heads  of  the  metatarsal 
bones.  The  plantar  flap  thus  out- 
lined may  then  be  dissected  up  to 
its  base.  The  foot  being  then  for- 
cibly extended,  a  slightly  convex 
dorsal  incision  is  carried  between 
the  ends  of  the  plantar  flap  (Fig. 
149).  The  flaps  being  retracted  and 
the  foot  forcibly  extended,  the 
operator  opens  the  joint  from  the 
outer  or  inner  side,  according  to 
whether  the  right  or  the  left  foot 
be  the  seat  of  the  operation  (Fig. 
150).  The  articulation  of  the  second  metatarsal 
bone,  which  is  less  than  half  an  inch  above  the 
general  level  of  the  joints,  must  then  be  opened  by  a 
transverse  cut,  the  lateral  attachments  of  the  bone 


Fig.  149. 


Fig.  150. 

to  the  cuneiform  being  severed  with  the  point  of  the 
knife  by  longitudinal  incision  (Fig.  148).  When  all 
the  joints  are  widely  opened  by  this  process,  the  re- 
maining ligaments  at  the  side  and  sole  of  the  foot,  and 
the  soft  parts  still  undivided,  are 
severed.  As  the  operation  is  gen- 
erally performed,  the  plantar  flap 
is  merely  outlined  by  an  incision 
through  the  skin  in  the  first  step 
of  the  operation,  the  flap  being 
cut  from  within  outward  after  dis- 
articulation has  been  effected. 
The  vessels  usually  requiring  liga- 
tion are  the  dorsal  artery  of  the 
great  toe,  the  metatarsal  branches, 
and  the  plantar  arteries.  When 
the  parts  are  brought  together 
by  suture,  the  stump  should  be 
placed  in  a  posterior  splint,  to 
overcome  the  contraction  of  the 
powerful  muscles  of  the  calf  of 
the  leg.  In  Hey's  amputation, 
the  external  incisions  are  identical 
with  those  necessary  for  the  Lis- 
franc  operation.  The  cicatrix 
resulting  from  either  of  these  procedures  is  far  re- 
moved from  pressure,  and  the  stump,  on  account  of 
it-  length,  is  one  admirably  fitted  for  use. 

288 


Fig.  151. 


Mediotausal  Amputation. — Although  Garengeot 
and  Heister  mentioned  the  practicability  of  ampu- 
tation between  the  rows  of  the  tarsal  bones,  the 
operation  was  first  performed  by  "Du  Vivier  of 
Rochefort  in  1781.  In  1701  Chopart  repeated  the 
operation    a    number    of    times.    anc]    published    his 


Fig.  15U. 


Fig.  152. 

experience  with  it.  It  has  since  been  known  as 
"  Chopart 's  amputation,"  and  the  joint  between  the 
rows  of  the  tarsus  is  not  infrequently  designated  by 
his  name.  Although  it  was  opposed  by  Larrey,  who 
preferred  to  amputate  in  the  lower  part  of  the  leg, 
the  operation  was  popularized  by  Roux  and  Walt  her 
on  the  Continent,  and  by  Mr. 
James  of  Exeter  and  by  Syme,  in 
Great  Britain. 

The  articulation  between  the 
scaphoid  and  the  head  of  the 
astragalus,  and  that  between  the 
cuboid  and  os  calcis  are  respec- 
tively placed  one-half  inch  above 
the  tuberosity  of  the  scaphoid  on 
the  inner  border,  and  one  inch  or 
more  above  the  prominence  of  the 
fifth  metatarsal  bone  upon  the 
outer  border  of  the  foot.  These 
two  points  being  fixed,  a  curved 
incision,  extending  to  within  an 
inch  or  less  of  the  heads  of  the 
metatarsal  bones,  is  carried  across 
the  sole  of  the  foot,  and  connects 
them.  The  foot  being  then  forci- 
bly extended,  a  curvilinear  inci- 
sion, with  convexity  below,  is  carried  between  the 
same  points  across  the  dorsal  surface.  The  small 
dorsal  cutaneous  flap  thus  outlined  is  retracted,  and 
by  one  stroke  of  the  knife  the  tendons  are  divided 
and  the  joint  widely  opened.  The  point  of  the  knife 
then  divides  the  la.e.al  and  plantar  ligaments,  which 
are  put  on  the 
si  ret  eh  by  forcible 
extension  until  the 
articular  surfaces 
of  the  scaphoid 
and  cuboid  bones 
are  completely 
liberated.  By  in- 
serting the  knife 
behind  these 
bones,  the  plantar 
flap  is  completed 
by  cutting  from 
within        outward 

(Fig.  152).  The  vessels  requiring  ligation  are  tin- 
dorsal  and  two  plantar  arteries,  and  occasionally  a 
few  muscular  twigs.  The  appearance  of  the  stump 
after  the  completion  of  Chopart 's  amputation  is  well 
shown  in  Fig.  153,  from  Esmarch. 

The  only  difficulty  at  times  encountered  in  this 
operation  is  in  the  opening  of  the  joint  in  front  of 
instead  of  behind  tlie  scaphoid  bone.  The  error  is 
readily    recognized    through    the    presence    of    three 


Fig.  154. 


REFERENCE    HANDBOOK    <>F   Till'.    MEDICAL    SCIENCES 


Amputation 


articular  facets  cm  the  anterior  surface  of  the  scaphoid 
DOne>  and  ran  easily  be  corrected  if  it  be  desired,  or 
:!,,  operation  may  be  completed  by  dividing  the 
cuboia  bone  with  a  saw  on  a  line  with  the  anterior 
, ,.  of  the  scaphoid.  In  this  ma  unci'  the  operator 
would  be  practising  Forbes'  modifi- 
cation  of  the  mediotarsal  amputa- 
t  ion,  a  mm  lificai  inn  also  menl  ioned 
by  Mr.  Hancock  and  Professor 
Agnew. 

After  Chopart's  amputation,  the 
gastrocnemius  and  soleus  having 
exclusive  control  of  the  stump, 
there  is  a  marked  tendency  toward 
iis  hyperextension.  This  may  as- 
sume such  a  decree  (lull  I  lie  cical  rix 
itself  will  he  pressed  upon  in  loco- 
motion. This  objection  to  the 
operation  is  best  overcome  by 
bandaging  the  leg  from  above  down- 
ward, and  keeping  (he  limb  flexed. 
In  extreme  cases  the  difficulty  is 
easily  remedied  by  division  of  the 
tendo  Achillis,  and  forced  flexion 
of  the  stump. 
SuBAsruAOAi.oiD  Amputation. — 
Although,  according  to  Velpeau,  this  operation  was 
I  by  De  Lignerolles  and  by  Textor,  it  was  first 
given  prominence  by  Malgaigne,  in  1846.  In  this 
amputation  all  the  bones  of  the  foot,  except  the 
astragalus,  are  removed.  The  operation  is  com- 
menced by  an  incision,  which,  beginning  behind  and 
i  m  me  tl  iat  ely 
abov  ■  the  great 
tuberosity  of 
the  os  calcis,  at 
once  divides  the 
tendo  Achillis. 
The  incision  is 
then  carried  in 
a  wide  curve  on 
the  outer  sur- 
of  the  os 
below  the 
external  malle- 
olus  (Fig.    154, 

Malgaigne).  Thence  it  is  continued  over  the  middle  of 
l  lie  cuboid  and  anterior  margin  of  the  scaphoid,  across 
the  dorsum  of  the  foot  (Fig.  155),  and  over  its  inter- 
nal border  to  the  center  of  the  sole  (Figs.  150  and  157). 
From  this  point  the  incision  is  turned  at  a  right 
angle  and  continued  directly  back  till  it  meets  the 
beginning  of  the  incision  at  the  inner 
border  of  the  tendo  Achillis  (Es- 
march).  The  short  internal  and  long 
internoplantar  flaps  thus  formed  arc 
dissected  up  until  the  lateral  surfaces 
of  the  os  calcis  are  exposed,  when  dis- 
articulation of  the  anterior  part  of 
the  foot  is  effected  in  the  mediotarsal 
joint.  The  anterior  end  of  the  os 
calcis  being  then  seized  with  a  lion- 
jawed  forceps,  and  rotated  from  side 
to  side,  the  operation  is  completed 
by  dividing  the  external  lateral  and 
interosseous  ligaments.  The  appear- 
ance of  the  stump  after  this  opera!  inn 
is  shown  in  Fig.  158  (Esmareh).  The 
marked  irregularities  of  the  inferior 
surface  of  the  astragalus  do  not  inter- 
fere with  its  usefulness  in  locomotion. 
In  a  case  of  gangrene  in  a  deformed 
limb,  Linhart  performed  the  sub- 
astragaloid  amputation,  and  was  enabled  two  years 
later  to  examine  the  stump.  The  astragalus,  which  had 
maintained  a  perpendicular  position  before,  and  even 
at  the  time  of  amputation,  had  been  forced  into  its 
normal  horizontal  position  by  the  act  of  walking. 

Vol.  I.— 19 


Fia.  156. 


Fig.   157. 


Fig.  158. 


A  number  of  modifications  of  the  subastragaloid 
amputations,  both  in  the  direction  of  the  inci  ions 
and  in  the  preservation  of  parts  of  'in-  c,    calcis,  have 

been   devised.      In    the   operation   of   Mr.    Hancock,   a. 

large  plantar  flap  i.-;  reflected  a  fai  back  a  i  he  i  uber- 
osities  of  the  calcaneum,  and  a  short  dorsal  flap  is 
formed  by  a  transverse  incision  across  the  fool  on  a 

le\  el  u  ii  h  i  he  anterior  margin  of  the 
astragalus.       By  (he  use  of  a  saw,  the 

plantar  flap  being  ret  racted,  a  per- 
pendicular section  of  the  os  calo    is 

then  made  in  front  of  the  tuberosities. 

Disarticulation  of  the  foot,  with  the 
anterior  port  ion  of  tin  rj  calci  .in  (lie 
mediotarsal  joint  is  next  effected,  and 
the  operation  completed  by  making 
a  transverse  section  of  i  he  astragalus. 
When  the  flaps  are  approximated  the 

divided  surfaces  of  the  latter  bone 
and  os  calcis  are  broughl  into  appo- 
sition. The  operation  of  Mr.  Han- 
cock, although  as  ingenious  as  that  of 
1'irogolf,  is  much  more  difficult  of  ex- 
ecution, and  lime  will  probably  show 
that  the  results  obtained  from  it  are 
far  less  valuable.  In  Tripier's  opera- 
tion the  incision  is  made  in  the  form 
of  an  oval,  the  apex  of  which  is  on  the  outer  side  of  the 
foot,  just  beneath  the  external  malleolus,  while  the 
Miles  pass  forward  and  inward  over  the  back  and  sole 
of  the  foot,  and  meet  at  its  inner  border.  After 
disarticulation  in  the  mediotarsal  joint,  a  transverse 
section  of  the  os  calcis  completes  the  operation. 

Partial  amputations  of  the  foot,  at  least  in  civil 
practice,  are  not  attended  with  great  mortality.  Of 
152  cases  of  Chopart's  amputation  examined  by 
Hancock,  only  eleven  terminated  fatally,  seven  per 
cent.;  the  fatality  following  this  operation  in  France 
has  been  much  greater,  fourteen  out  of  thirty-eight 
cases  recorded  by  Larger  (3G.8  per  cent.)  having  died 
(Ashhurst).  Of  twenty-two  cases  of  the  subastrag- 
aloid  amputation,  twenty  recovered. 

Of  123  partial  amputations  of  the  foot,  made  during 
the  Civil  War,  in  which  the  result  was  determined, 
eighteen  were  unsuccessful,  the  mortality  being 
fifteen  per  cent.  Of  these  partial  amputations  there 
were  eighty-three  of  the  mediotarsals,  with  eleven 
deaths;  twenty-three  Lisfranc  operations  with  one 
death,  and  seventeen  Hey's  amputations  with  six 
deaths.  Of  sixteen  amputations  of  the  foot  at  the 
Cincinnati  Hospital,  one  died.  The  mortality  accor- 
ding to  Erdmann's  tables  is  7.8  per  cent.  According 
to  Page's  tables  the  mortality  is  3.8  per  cent,  for 
traumatic  and  1.6  per  cent,  for  pathological  cases. 
In  making  a  partial  amputation,  it  must  be  remem- 
bered that  the 
value  of  the  stump 
for  locomotion  is 
proportionate  to 
the  length  of  foot 
maintained.  Man- 
ufacturers of  arti- 
ficial limbs  main- 
tain that  conserva- 
tism is  out  of  place 
here,  ami  that  am- 
putation several 
inches    above    the  Fig.  159. 

ankle     should     be 

given  preference  over  partial  amputations  m  front  of 
or  at  the  ankle. 

Amputation  at  the  Ankle. — Historically  associ- 
ated with  this  operation  is  the  name  of  Synie  of 
Edinburgh  who,  in  1842,  devised  and  practised  a 
method  by  which  a  shapely  and  useful  stump  could 
be  obtained  after  removal  of  the  entire  foot.  Dis- 
articulation at  the  ankle  had  been  performed  during 
the  last  and  early  part  of  this  century.     It  was  pcr- 

289 


Amputation 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


formed  by  S6dillier,  Rossi,  and  Baudens,  and  recom- 
mended by  Brasdor  and  Sabaticr.  But  the  circular 
ration  of  the  latter  and  the  dorsal  flap  method  of 
Baudens  yielded  alike  unsatisfactory  results,  and  the 
operation  was,  therefore,  discarded  for  amputation 
in  the  lower  part  of  the  leg.  Lateral  flaps  taken  from 
below  the  malleoli,  as  suggested  by  Velpeau,  also 
failed  to  form  a  sufficient  cushion  for  the  end  of  the 
tibia.  This  great  desideratum  in  amputation  at  the 
ankle  is  squarely  met  by  the  operation  of  Syme, 
since  its  principal  feature  is  the  retention  of  the  integ- 
ument of  the  heel,  which  is  accustomed  to  pressure,  to 
form  the  end  of  the  stump.  The  operation  is  made 
in  the  following  manner:  The  foot  being  held  at  a 
right  angle  to  the  body,  the  malleoli  are  fixed  by  the 
thumb  and  fingers  of  the  left  hand,  the  heel  resting 
between  them.  A  perpendicular  incision  touching 
the  bone  is  then  made  across  the  sole  of  the  foot  from 
the  tip  of  one  malleolus  to  that  of  the  other,  the 
incision  on  the  inner  side,  however,  ending  at  least 
one-half  inch  below  the  malleolus  (Fig.  159).  The 
posterior  lip  of  the  wound  is  then  seized  with  the  left 
hand,  and  the  soft  parts  covering  the  calcaneum  are 
separated  from  it  by  short  strokes  of  the  knife,  which 
must  be  kept  close  against  the  bone  to  prevent 
perforation  of  the  integument  and  damage  to  tin- 
plantar  vessels.  When,  by  this  process  of  dissection, 
the  tuberosities  of  the  os  calcis  nave  been  fairly  ex- 
posed, a  transverse  incision  joining  the  two  extrem- 
ities of  the  first  is  carried  across  the  instep  (Fig.  159). 
The  ankle-joint  being  thus  opened  from  in  front,  the 
knife  is  carried  down  on  each  side  of  the  astragalus 
until  the  lateral  ligaments  are  divided,  when  complete 
disarticulation  is  effected.  By  forcibly  depressing 
the  foot  the  tendo  Achillis  should  then  be  divided 
from  before  backward,  when  by  a  few  strokes  of  the 
knife  the  foot  can  be  removed  (Fig.  160,  Esmarch). 


Fig.  160. 

Lastly,  the  knife  is  drawn  around  the  extremities  of 
the  tibia  and  fibula,  so  as  to  expose  them  sufficiently 
for  being  grasped  in  the  hand  and  removed  by  the 
saw.  "After  the  vessels  have  been  tied  and  before 
the  climes  (.1  the  wound  are  stitched  together  an  open- 
ing should  be  made  through  the  posterior  part  of  the 
flap  where  it  is  thinnest,  to  afford  a  dependent  drain 
for  the  matter." 

The  appearance  of  the  wound  after  Syme's  amputa- 
tion is  well  shown  in  Fig.  161.  It  will  be  seen  thai 
the  heel  flap  presents  the  form  of  a  cup,  which  must 
be  flattened  by  pressure  against  the  bones  of  the  leg. 
While  there  is  danger,  therefore,  of  making  the  flap 
too  short,  there  is  likewise  a  danger  in  making  it  too 
long,  since  a  pouch  would  be  formed  for  the  retention 
of  inflammatory  products. 


Moschcowitz12  modified  the  Syme  operation  by 
making  osteoplastic  flaps,  whereby  no  exposed  bone 
is  left  in  the  wound.  From  the  external  malleolus 
he  chisels  a  triangular  wedge  and  from  the  internal 
malleolus  a  rectangular  wedge.  When  the  exposed 
bone  surfaces  are  brought  in  contact  only  bone 
covered  by  periosteum  and  the  cartilaginous  lower 
end  of  the  tibia  come  in  contact  with  the  wound. 
The  favorable  results  which  follow  Syme's  amputa- 
tion  in  civil  practice  are  shown  by  the  statistics  of 
Hancock  and  Spence,  who,  among  316  operations, 
found  only  25  deaths  (7  per 
cent.).  In  military  practice 
the  results  are  far  less  favor- 
able. Of  159  amputations 
made  at  the  ankle  during  the 
Civil  War,  and  in  which  the 
result  was  determined,  40 
terminated  fatally  (25.1  per 
cent.). 

Pirogoff's  Amputation. — 
On  the  principle  that  by 
preserving  the  posterior  por- 
tion of  the  calcaneum  the 
natural  length  of  the  limb 
could  almost  be  preserved, 
Pirogoff,  during  the  Crimean 
war,  devised  the  osteoplastic 
operation  that  bears  his  name. 
It  differs  from  the  operation 
of  Syme  in  preserving  a  por- 
tion of  the  os  calcis,  in  the 
expectation  that  it  will  unite 
firmly  to  the  divided  end  of 
the  tibia.  The  incisions  for 
this  amputation  are  identical  with  those  made  in 
Syme's  operation.  After  opening  the  joint  from  in 
front,  the  foot  is  depressed  until  the  posterior  ex- 
tremity of  the  astragalus  is  exposed,  when  a  saw  is 
introduced  behind  this,  and  the  os  calcis  divided  ex- 
actly on  a  level  with  the  incision  in  the  sole  of  the 
foot  (Figs.  162  and  163,  Esmarch).  Both  malleoli 
and  a  thin  section  of  the  tibia  are  removed,  as  i,i 
Syme's  operation.  It  is  generally  advisable  to  divide 
the  tendo  Achillis  and  at  the  same  time  to  perforate 
the  skin  for  the  passage  of  a  drainage   tube.     The 


Fig.  161. 


appearance  of  the  stump  after  a  successful  Pirogoff 
amputation  is  well  shown  in  Fig.  164,  taken  from  a 
man  who  died  three  years  after  the  operation  was 
made  by  Linhart. 

A  number  of  modifications  of  Pirogoff's  amputa- 
tion have  been  devised.  Ferguson  and  Agnew  have 
wedged  the  end  of  the  os  calcis  into  the  interval 
between  the  malleoli,  and  have  obtained  good  re- 
sults. Different  methods  of  dividing  the  bone  have 
been  devised  by  Sedillot,  Gunther,  Le  Fort,  and 
Bruns,  to  remove  the  pressure  from  the  thin  part  of 


290 


REFERENCE    HANDBOOK    OF    TIIK    MKDH'AI.    SCll'.xri'.S 


Amputation 


ili,'  integument  on  the  back  of  the  heel,  which  mil  I 
bear  it  after  the  Pirogoff  amputation,  and  to  keep  the 
retained  part  of  the  os  calcis  in  its  natural  position. 
Sgdillot  and  i  Silnthei .  therefore,  ad- 
vised t  liat  an  oblique  sect  en    1 1 

abi  i\  e  dowm*  ard  and   forw  ard  I   oi 
the  calcaneum,  tii>ia.  and  fibula  be 
made.     Le  Fort  (  Fig.   163  i  advised 
a  Iran-  verse    ection  of  t  he  bone,  by 
imp  obtains  a  very 
broad    base. 
Bruns      has 
modified  t  he 
operation  of 
Le  Fort   by 
sawing     the 
os   calcis   in 
such  a  man- 
ner    as     to 
make        the 
upper      sur- 
face of  the  retained  part  concave,  the  concavity  thus 
formed  receiving  the  convex  section  of  the  tibia  and 
fibula. 

A  further  modification  of  Syme's  amputation  is 
that  of  Guyon.  It  is  an  amputation  above  the  mal- 
leoli.    The  operation  is  begun  with  an  elliptical  in- 


Fig.  163. 


Fig.  164. 

cision  beginning  one  inch  above  the  lower  edge  of  the 

tibia  in  front,  which,  passing  obliquely  in  front  of  the 

ankle,  crosses  the  heel  below  the  attachment  of  the 

tendo  Achillis.     The  posterior  portion  of  the  flap  is 

dissected  from  the  heel  and  the  tendon  divided  close 

to  its  insertion.     The  anterior  extensor  tendons  are 

divided  transversely 

as   high  as  possible. 

After  the  malleoli  are 

exposed    the    fibula 

and     the    tibia    are 

divided    just    above 

them.     The  heel  end 

of   the   flap   is   then 

brought   forward   to 

cover    them.       The 

suture    line    is    safe 

from  pressure. 

A    comparison    of 

the  merits  of  Syme's 

amputation   and    its 

osteoplastic    modification    shows  that  a  cure  follows 

more  rapidly  after  the  latter  than  after  the  former, 

although    the    mortality    of    Pirogoff's    amputation 

against  21.4 
147  cases  of 


in   military   practice  is 


Fig.  165. 


per   cent. 


per  cent,  following  that  of  Syme.     Of 


Pirogoff's  amputation   collected   bj    li 

"hl\  foui ' '  ived   fatal,  and  Volk- 

mann  has  performed  the  operation  thirty-fo 
without  a  death.     Considering  the  number  of  reampu 
tations  after  S\  me'    and  Pirogofi     operation      l 
ter  would  seem  to  1  ii  ul.     <  >f  eighty- 

t  In- -i-es  cif  Syme's  amputation,  i  v  enty,  or  twenty- 
four  per  cent.,  submit  ted  to  reamputation ;  ol  fo 
nine   Pirogoff's  operation  .  eight,  or    L6.3   per  rent., 
were  subjected  to  reamputat  ion. 

In  cases  of  caries  involving  all  the  bone-  of  the  tar- 
sus, preference  should  be  given  to  the  Syme  opera- 
tion, since  disease  is  not  unlikely  to  develop  in  the 
retained   segment    of   the   calcaneum.     In   traumatic 
the  greater  ease  with  which  it  is  made  and  the 

length  of  limb  which  follows  it  should  incline  the 
operator  to  choose  the  operation  of  Pirogoff.  That 
necrosis  often  follows  the  latter  operation  is  emphatic- 
ally denied  by  its  originator,  who  had  never  witne  ''I 
it  in  over  sixty  cases  in  which  he  had  performed  it. 
Amputation  op  the  Leg. — An  amputation  may 
be  performed  in  any  part  of  the  leg.  according  to  the 
nature  and  seat  of  disease  or  injury.  When  the  sur- 
geon can  select  the  seat  of  operation,  the  amputation 
should  be  made  two  or  three  inches  above  the  mal- 
leoli, on  account  of  the  greater  safety  of  the  opera- 
tion in  this  locality  and  the  greater  power  to  be 
exerted  over  an  artificial  limb.  In  all  amputations 
of  the  leg,  the  fibula  should  be  divided  from  half  an 
inch  to  an  inch  above  the  saw  line  of  the  tibia,  to 
prevent  pressure  against  the  outer  wound  margin. 
The  operations  which  have  hitherto  been  most  fre- 
quently performed  in  amputations  above  the  malleoli 
are  the  circular  and  that  by  lateral  flaps.  Unhappily, 
the  anatomical  construction  of  the  part  is  such  that 
after  these  operations  the  cicatrices  are  central  and 
not  infrequently  adherent,  and  therefore  unable  to 
bear  pressure.  In  this  situation  M.  Guyon  practises 
the  elliptical  method.  According  to  Stimson,  this 
operation  promises  well.  "  The  incision  is  made  in 
the  form  of  an  ellipse,  whose  lower  end  crosses  the 
heel  below  the  insertion  of  the  tendo  Achillis,  and 
whose  upper  end  is  about  an  inch  above  the  anterior 
articular  edge  of  the  tibia.  Beginning  at  the  lower 
end  and  dividing  the  tendo  Achillis  at  its  insertion, 
and  hugging  the  bone  all  the  way,  the  operator  dis- 
sects up  the  flap  posteriorly  as  high  as  the  upper  end 
of  the  ellipse.  The  anterior  muscles  are  then  divided 
by  transfixion,  the  bones  sawn  through,  and  the  pos- 
terior tibial  nerve  resected.  In  this  operation  the 
sheath  of  the  tendo  Achillis  is  not  opened,  and  the 
tendon  itself  serves  afterward  as  a  covering  for  the 
ends  of  the  bones." 


Fig.  166. 

In  amputations  in  the  lower  third  of  the  leg  in 
fleshy  subjects,  a  long  anterior  flap  containing  the 
interosseous  muscles  may  sometimes  be  used  with 
advantage  (Bell). 

The  rectangular  operation  of  Teale  may  likewise  be 
practised  in  this  region,  the  long  anterior  flap  being 
made  from  the  soft  part  of  its  anterior  aspect  (Fig. 
134  see  above,  Methods  of  Amputation).  By  this 
method  the  cicatrix,  being  placed  posteriorly,  is  out 
of  the  way  of  pressure. 


291 


Amputation 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


In  the  middle  and  upper  thirds  of  the  leg  very 
many  operators  amputate  by  means  of  anteropus- 
terior  flaps,  after  the  following  manner  (for  the  left 
limb):  The  point  of  the  knife  being  entered  at  the 
posterior  edge  of  the  tibia,  an  incision  is  carried  down- 
ward along  this  for  a  distance  of  an  inch  and  a  half 
or  two  inches;  then  by  a  wide  curve  across  the  ante- 
rior surface  of  the  leg  it  is  continued  to  the  posterior 
border  of  the  fibula,  up  which  it  is  carried  until 
the  level  of  its  commencement  on  the  opposite  side 
is  reached.     The  broad  flap  thus  outlined  is  rapidly 


operation  the  knife  is  entered  a  little  external  to 
the  crest  of  the  tibia,  and  while  the  soft  parts  are 
drawn  to  the  outer  side  with  the  left  hand,  it  is  made 
to  graze  the  surface  of  the  fibula  and  to  perforate  the 
posterior  surface  of  the  limb  as  far  to  the  inner  side 
of  the  fibula  as  possible.  By  cutting  downward 
close  to  the  bones  a  broad  rounded  flap  three  to 
four  inches  long  is  formed.  The  extremities  of  this 
flap  are  then  united  by  a  slightly  convex  incision 
across  the  anterointernal  aspect  of  the  limb.  '[  he 
remaining  soft  parts  being 
then  divided  by  circular  in- 
cision, the  operation  is  com- 
pleted in  the  ordinary  way. 
In  Langenbeck's  operation, 
the  internal  incision  is  semi- 
circular, and  the  external  flap 
being  cut  from  without  pre- 


Fio.  167.  Fig.  16S.  Fig.  169.  Fig.  170. 

Figs.  167  to  170. — Osteoplastic  Amputation,  after  the  -Method  of  Bier.     (Langenbeck's  Arch.  f.  Chir.,  vol.  xlvi.) 


dissected  up,  the  interosseous  muscles  being  care- 
fully severed  from  the  underlying  membrane.  The 
posterior  flap  is  then  made  by  transfixion  and  cutting 
from  within  outward,  and  should  be  about  three 
inches  long  (Fig.  166,  Erichsen).  The  flaps  being 
held  out  of  the  way,  the  catlin  is  to  be  used  for  com- 
pleting  the  division  of  the  interosseous  soft  parts, 
care  being  taken  that  the  arteries  be  divided  trans- 
versely and  only  once.  After  division  of  the  bones 
with  a  saw,  the  sharp  anterior  edge  of  the  tibia  should 
be  removed  with  the  saw  or  bone-cutting  forceps. 
For  the  upper  portions  of  the  leg  the  long  poste- 
rior rectangular  flap  amputation  advised  b3r  Henry 
Lee  gives  an  excellent  result.  Tin'  incisions,  similar 
to  those  of  the  Teale  operation,  involve  only  the  skin, 
the  long  flap  being  made  from  the  posterior,  the  short 
one  from  the  anterior  surface  of  the  limb.  With 
the  long  posterior  flap  only  the  superficial  muscles 
of  the  calf  are  reflected,  the  remaining  soft  parts 
being  divided  by  a  circular  incision.  A  good  covering 
is  likewise  obtained  in  this  region  by  an  external  flap, 
made  either  by  transfixion  (Sedillot),  or  by  cutting 
from  without  inward  (Langenbeek).     In  the  former 

292 


sents  a  smoother  surface  and  a  more  perfect  outline. 
The  arteries  requiring  ligation  after  amputation  of  the 
leg  are  the  tibials,  peroneal,  and  a  varying  number  of 
muscular-branches. 

,S iili/n  rinst,  nl  Amputation. — When  amputations  of 
the  leg  are  unsatisfactory,  it  is  chiefly  because  of  two 
things,  namely,  gangrene  of  the  flaps,  and  the  ten- 
dency of  the  stump  to  become  conical,  or.  at  any  rate, 
to  be  unable  to  bear  pressure.  It  is  for  this  reason 
that  Bruns  devised  his  subperiosteal  amputation,  of 
which  he  reported  seventeen  cases  in  1S93.  Accord- 
ing to  a  report  by  Hahn13  this  operation  was  per- 
formed in  eighty-four  cases  without  a  death.  In  only 
three  cases  was  there  gangrene  of  the  flaps  and  in  only 
two  cases  was  a  second  amputation  necessary.  The 
operation  is  performed  as  follows:  The  skin  being 
well  retracted  by  an  assistant,  a  circular  incision 
involving  all  the  soft  parts  is  carried  down  to  the 
bone.  The  two  perpendicular  incisions,  from  two  to 
three  inches  in  length,  are  then  made,  one  along  the 
inner  border  of  the  tibia,  the  other  between  the  mus- 
cles over  the  fibula.  Both  incisions  are  carried  to  the 
bone  through  the  periosteum.     Through  these  inci- 


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Amputation 


aiona  all  the  sofl  parts,  including  the  periosteum, 
are  raised  from  the  bone.  After  the  soft  pari-  are 
well  retracted  the  bones  arc  divided  in  the  usual  way. 
\i;i.r  the  amputation  has  been  completed,  there 
remain  an  anterior  and  a  posterior  Hap  of  periosteum, 
muscles,  and  skin.  The  mu  cles  are  united  sepa- 
rated by  buried  suture.  When  the  amputation  is 
in  the  upper  portion  of  the  leg,  tne  circular 
incision  through  the  skin  is  made  as  a  higher  level 
than  thai  through  the  muscles. 

Osteoplastic  AmptUations  of  the  Leg.— la  1892, 
Bier'  firs!  described  a  method  of  securing  a  weight- 
bearing  stump,  which,  in  patients  who  are  unable  to 
purchase  an  artificial  limb,  secures  for  them  a  stump 
which  will  bear  the  body  weight.  The  operation  con- 
sists of  the  usual  circular  amputation.  Thereupon 
follows,  through  an  oval  window  cut  into  the  sofl 
parts,  a  cuneiform  excision  of  part  of  the  Sbula. 
a  the  resection  surfaces  of  the  tibia  are  brought 
apposition  a  kind  of  artificial  foot  project  -  ante- 
riorly. The  posterior  surface  of  the  tibia  covered 
by  the  -oft  parts  of  the  calf  bear  pressure.  Bier  has 
ned  iii  many  cases  with  uniformly  good  results. 
Some  German  surgeons  think  that  this  should  l>e 
the  normal  procedure.  A  number  of  minor  modifi- 
cations  of  the  original  method  have  been  made. 
When  there  is  any  possibility  that  the  patient  can 
scrim-  an  artificial  limb,  the  operation  has  nothing 
to  commend  it.  Figures  167  to  170  will  illustrate 
the  method  of  amputation  and  the  result. 

Since  good  results  follow  all  the  different  methods 
of  operation  in  the  middle  and  upper  portions  of  the 
leg,  the  surgeon  should  be  guided  in  his  choice  solely 
by  the  desire  to  sacrifice  as  little  of  the  limb  as  pos- 
sible.  An  exception  should  probably  be  made  in  the 
upper  portion  of  the  upper  third,  where  it  is  better 
to  amputate  at  the  knee  than  to  save  only  the  por- 
tion of  the  tibia  above  its  tubercle. 

The  mortality  following  amputation  of  the  leg,  as 
ha-  already  been  seen,  is  largely  determined  by  the 
conditions  necessitating  it.  According  to  Chadwick, 
the  mortality-  of  pathological  amputations  is  sixteen 
per  cent.;  that  of  amputations  for  trauma  nearly 
thirty-seven  per  cent.  The  general  mortality  of  the 
operation  at  Guy's  Hospital  for  a  period  of  thirty 
years  was  thirty-five  per  cent.;  that  for  traumatic 
amputations  being  fifty-five  per  cent.,  against  fifteen 
per  cent,  following  those  for  disease.  Volkmann  who 
employs  a  long  anterior  and  short  posterior  flap  per- 
formed the  operation  in  fifty-four  cases  with  only 
four  deaths  (seven  per  cent.),  of  which  there  were 
fourteen  traumatic  cases  with  only  two  deaths 
(fourteen  per  cent.).  Of  forty-six  amputations  in  the 
lei;  made  by  Brums,  seven  succumbed  (sixteen  per 
lent.).  The  fatality  following  amputations  of  the 
leg  in  military'  practice  is  well  shown  by  the  stat  is- 
le- of  Otis.  Of  5,314  amputations  in  which  the 
result  was  determined,  1,753  terminated  fatally,  the 
mortality  being  32.9  per  cent.  From  statistics  ob- 
tained during  the  late  War  of  the  Rebellion,  it  appears 
that  amputation  of  the  leg  is  attended  with  least 
danger  when  performed  in  the  middle  third".  The 
fatality  of  operations  in  the  upper  third  was  twenty- 
en  per  cent.,  in  the  middle  third,  20.6  per  cent.. 
and  in  the  lower  third,  27.6  per  cent.  The  mortality 
of  amputations  of  the  leg  has  been  greatly  reduced. 
Of  eighty-one  amputation-  of  the  leg  five,  or  6.2  per 
cent.,  died.  In  the  New  York  hospitals  the  mor- 
tality is  twelve  per  cent.  In  the  Newcastle-on-Tyne 
Infirmary  it  is  nearly  seven  per  cent. 

Amputation  at  the  Knee. — According  to  Sab- 
atier,  this  operation  was  first  performed  by  Fabricius 
Hildanus  in  1581,  in  a  case  of  gunshot  injury.  Al- 
though advocated  by  Guillemeau  (1612)  in  prefer- 
ence to  higher  amputation,  there  is  no  record  of  a 
repetition  of  the  operation  until  1764.  when  it  was 
successfully  performed  by  Hoin  of  Dijon  for  trau- 
matic gangrene.     Brasdo'r  and   J.    L.   Petit  advised 


the  operation,  the  latter  having  twice  witnessed  it. 
In   L830,   Velpeau  attempted  with  success  firmi-    to 
establish  the  operation  by  citing  a  number  of  sua 
iHi  cases.     The  operation  was  first  performed  in  thi 

country  by  Nathan  Smith,  of  New  Haven,  in  1824, 
since  which  time  it  has  gradually  grown  in  popularity. 

Fergusson  and  Legouesl  for  a  long  ii [uestioned 

the  advisability  of  the  operation,  preferring  amputa- 
tion in  the  lower  portion  of  ilc  thigh.     Tne  rea  o 
which   prevailed   to   give   this  operation    recognition 

are    the    greater   length    of   the   slump   and    it>.   ability 

to  bear  pressure,  tin-  smaller  probability  of  pyemia, 

lie-  medullary  canal  remaining  unopened,  ami, 
most  important  of  all,  the  smaller  mortality  which 
follows  thi-  operation,  at  least  in  civil  practice,  as 
compared  with  amputations  of  the  thigh. 


Fig.  171. 

Amputation  at  the  knee  may  be  practised  by  either 
the  circular,  the  flap,  or  the  oval  method.  In  all 
methods  of  amputation  it  is  best,  if  possible,  to  pre- 
serve the  semilunar  cartilages.  Thereby  the  fascial 
attachments  are  maintained  intact  and  the  tendency 
to  retraction  of  the  flaps  is  greatly  reduced.  The 
circular  operation  recommended  by  Velpeau,  San- 
son, and  Malgaigne,  made  by  an  incision  two  or  three 
inches  below  the  patella  and  the  reflection  of  a  cuff, 
is  difficult  of  execution,  and  should  be  resorted  to 
only  when  an  insufficiency  of  tissue  prevents  the  adop- 
tion of  one  of  the  other  methods.  The  oval  method 
has  been  practised  by  Baudens  and  Sedillot,  the  for- 
mer preferring  the  integument  from  the  anterior 
portion  of  the  leg,  the  latter  that  from  the  posterior 
portion,  as  a  covering  for  the  end  of  the  femur.  The 
operation  of  Baudens  is  performed  as  follows:  An 
oval  incision  is  carried  around  the  leg,  crossing  its 
anterior  surface  five  finger-breadths  below   the   end 


Fig.  172. 

of  the  patella,  and  its  posterior  surface  three  finger- 
breadths  higher  than  in  front.  The  anterior  and 
lateral  portions  of  the  oval  are  then  reflected  until 
the  ligamentum  patellae  is  fairly  exposed.  This  is  then 
divided  transversely,  the  capsule  is  fairly  opened,  and 
the  lateral  and  crucial  ligaments  are  divided.  In  this 
as  in  all  amputations  of  the  knee,  the  latter  structures 
should  be  divided  with  the  point  of  the  knife,  and 


293 


Amputation 


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$m^'m 


Fig.  173. 


from  behind  forward,  to  prevent  injury  of  the  pop- 
liteal vessels.  When  disarticulation  has  been  effected, 
the  soft  parts  on  the  posterior  aspect  of  the  limb 
are  divided  with  one  sweep  of  the  knife.  This  opera- 
tion is,  doubtless,  preferable  to  Sedillot's  method, 
according  to  which  the 
lower  part  of  the  oval  is 
placed  behind. 

In  amputating  at  the 
knee,  a  long  flap  may  be 
taken  from  the  anterior  or 
posterior  surface  of  the 
leg.  The  latter  method, 
that  of  Hoin  (Fig.  171), 
can  be  most  readily  exe- 
cuted, but  is  objectionable 
on  account  of  the  excess 
of  muscular  tissue  in  the 
flap,  and  the  difficulty  of 
establishing  thorough 
drainage.  Lateral  flaps 
have  been  advised  by 
Rossi  and  Stephen  Smith. 
The  operation  which  is 
generally  performed,  how- 
ever, is  that  by  one  long 
anterior  and  one  short 
posterior  flap.  It  is 
readily  performed,  and 
leaves  a  wound  that  is 
easily  drained,  and  a 
stump  in  which  the  cica- 
trix is  protected  from 
pressure. 
Operation. — The  leg  being  raised,  a  semilunar  flap, 
three  to  four  inches  long,  is  outlined  from  the  calf,  the 
incision  beginning  a  little  below  the  middle  of  the 
lateral  border  of  the  condyles.  This  flap  is  dissected 
up  as  far  as  its  base.  The  leg  being  then  flexed  an 
anterior  flap  four  to  five  inches  long  is  outlined  on 
the  anterior  surface  of  the  leg  from  the  ends  of  the 
posterior  incision  (Fig.  172, 
Esmarch).  The  anterior 
flap  is  then  raised  from  its 
attachments  until  the  liga- 
mentum  patellae  is  en- 
countered and  trans- 
versely divided.  The  cap- 
sule is  then  extensively 
incised  laterally  and  the 
anterior  flap  including  the 
patella,  reflected  (Fig. 
173).  Disarticulation  and 
division  of  the  soft  parts 
on  the  posterior  aspect  of 
the  limb  are  then  effected 
in  the  manner  already  de- 
scribed. This  operation  is 
preferable  to  forming  the 
posterior  flap  without  the 
guidance  of  a  cutaneous 
incision.  The  vessels  re- 
quiring ligation  are  the 
popliteal  artery  and  vein, 
which  should  be  carefully 
separated  and  tied  indi- 
vidually. A  number  of 
smaller  arteries,  sural  and 
muscular,  will  also  require 
ligation  in  the  posterior 
portion  of  the  wound. 

A  number  of  operators 
f  Billroth  among  them)  ad- 
vise the  removal  of  the  patella,  lest  inflammatory 
products  accumulate  in  the  pouch  above  it.  This 
prpcedgire  is  generally  held  to  be  superfluous,  since 
tin'  upper  part  of  the  wound  can  readily  be  drained 
without  it,  and  the  removal  of  the  patella  endangers 

294 


the  vitality  of  the  long  flap.  It  is  always  advisable, 
to  insure  drainage,  to  divide  the  lateral  attachments 
of  the  synovial  membrane  to  the  femoral  condyles, 
by  which  means  the  retention  of  inflammatory  prod- 
ucts in  the  pouch  alluded  to  can  be  avoided. 

In  1870  Stephen  Smith15  described  an  amputation 
by  "lateral  hooded  flap."  It  leaves  an  admirable 
stump,  the  cicatrix  being  placed  behind  and  between 
the  condyles.  The  writer  gives  it  the  preference  over 
other  amputations  through  or  immediately  above 
the  knee. 

Fig.  174  illustrates  the  incisions  of  this  amputa- 
tion and  the  method  of  forming  the  flaps.  The  inci- 
sion begins  an  inch  below  the  tuberosity  of  the  tibia 
and  passes  over  the  outer  side  of  the  leg  and  is  carried 
in  a  gentle  curve  to  the  middle  of  the  posterior  sur- 
face. Here  it  ends  opposite  to  tin'  interarticular  line. 
A  similar  but  longer  flap  is  outlined  on  the  inner 
side.  The  flaps  are  then  dissected  up  and  are  made  to 
include  everything  down  to  the  bone.  While  the 
flaps  are  being  formed  the  limb  must  be  maintained 
in  extension.  The  disarticulation  completes  the  oper- 
ation, the  semilunar  cartilages  being  retained  in  the 
stump. 

In  the  last  forty  years  a  number  of  modifications  of 
the  operations  just  described  have  been  introduce,  1. 
They  all  have  the  feature  in  common  that  a  portion 
of,  or  the  entire  condyles  of  the  femur  are  to  be  re- 
moved. In  1845  Syme  advised  amputation  through 
the  condjdes,  making  a  large  posterior  musculo- 
tegumentary  flap.  In  1S46  Mr.  Carden  first  per- 
formed the  operation  which  has  since  borne  his  name, 
and  has  become  deservedly  popular.  The  operation 
consists  in  the  formation  of  a  long  anterior  flap, 
which,  like  a  hood,  falls  easily  over  the  divided  end 
of  the  bone.  The  incision,  similar  to  that  made  for 
amputation  at  the  knee,  extends  no  farther  down  than 
the  tubercle  of  the  tibia.  The  anterior  flap  being  re- 
flected, the  joint  is  opened  aboi'c  the  patella,  which 
is  not  included  in  the  flap.  After  disarticulation  has 
been  effected,  the  soft  parts  of  the  posterior  aspect 
of  the  limb  are  severed  by  a  single  stroke  of  the  knife, 
and  the  saw  is  applied  through  the  bases  of  the  con- 
dyles. For  the  better  coaptation  of  the  cutaneous 
margins  of  the  wound  Lister  has  advised  the  forma- 
tion of  a  short  posterior  tegumentary  flap.  Mr. 
Carden  has  recorded  thirty  operations,  with  only 
five  deaths  from  this  method.  Of  twent3'-six  Car- 
den amputations  made  by  Volkmann,  three  termi- 
nated fatally. 

In  1857  Gritti  of  Milan  devised  an  osteoplastic 
operation  by  which  the  articular  surface  of  the  pa- 
tella is  removed  and  placed  in  apposition  with  the 
divided  ends  of  the  femoral  condyles.  The  opera- 
tion was  first  practised  by  Sawostytzki  in  1862.  In 
this  operation  long  anterior  and  short  posterior 
rectangular  flaps  are  formed.  Paikrt  and  Linhart 
after  raising  the  anterior  flap  amputate  without 
first  disarticulating.  In  1870  Dr.  William  Stokes 
still  further  modified  Gritti's  operation  by  making 
an  oval  flap  and  dividing  the  femur  at  least  half  an 
inch  'above  the  anterosuperior  margin  of  the  con- 
dyloid cartilage.  Hence  this  amputation  is  gener- 
ally known  as  the  supracondyloid  amputation,  that 
of  Carden  being  known  as  the  transcondyloid  operation. 
A  further  modification  of  the  Gritti  osteoplastic  am- 
putation is  that  of  Ssabanajeff.  An  anterior  and  a 
posterior  flap  are  fashioned  in  the  usual  manner  bul 
the  knee  is  opened  from  behind.  After  this  has  been 
done  the  leg  is  hyperextended  so  that  the  anterior  sur- 
face of  the  leg  and  thigh  are  in  contact.  The  lower 
end  of  the  femur  is  then  divided  transversely  through 
the  thickness  of  the  condyles.  Finally  a  bone  flap 
is  made  over  the  upper  and  anterior  part  of  the 
tibia  to  which  the  attachment  of  the  fibular  ligament: 
is  left  undistrubed.  The  sawed  surfaces  of  the  tibial 
bone  flap  and  of  the  femur  an'  then  brought  in  con- 
tact and  retained  by  a  suture.     The  attachmenf   of 


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Amputation 


the  patella  is  ool  disturbed.     The  relative  merits  o) 

these  various  methods  of  amputation  at  the  knee  have 

extensively  investigated  by  American,  English, 

.,,„!  German  writers.     Edmund  Andrews  oi  Chicago 

j  thai  disarticulation  al  the  knee  and  transcondy- 
loid amputation  present  alike  mortality  (twentj  eight 
uejcent).  Of  <  rritti's  operation  and  Stokes'  modifica- 
tion Dr.  R.  F.  Weir  has  collected  seventy-six  cases 
with  twenty-two  deaths.  In  the  reports  of  the 
Munich  Surgical  Clinic,  1895-1907,  Paul  Weiden- 
uesch"  found  there  were  twenty-three  Gritti  opera- 
tions without   any  deaths,  although  primary   union 

Ited  in  only  fourteen  of  the  cases.  While  time 
may  show  that   the  last-mentioned  procedures  maj 

,i    service   in  amputations  for  disease,  sufficient 
lence   has    been   adduced    by   Zeiss,    Beck,   and 

man,  that,  so  far  as  military  practice  is  con- 
cerned, the  operation  ought  to  be  abandoned.  From 
the  mure  recent  statistics  ([noted  above  for  other  am- 
putations, the  mortality  of  amputations  at   the  knee 

h  il  practice  is  11  per  cent.,  there  being  seven 
deaths  for  sixty-two  operations. 

The  mortality  of  amputations  at  the  knee  in  civil 

tice  appears  from  an  examination  of  Table  III. 

above).      Of  1S7  amputations  made  for  gunshot 
injury,  in  which  the  result  was  determined,  10(3  suc- 
cumbed, the  mortality  being  56.6  per  cent.,  and  ex- 
ling  by  2.8  per  cent,  the  fatality  of  amputations 
in  the  lower  part  of  the  femur. 

Amputation  of  the  Thigh. — This  operation  may 

died  for  in  any  part  of  the  thigh.  The  central 
position  of   the   femur    and   its  extensive    muscular 

ring  -auction  the  application  of  any  of  the  va- 
rious methods  of  amputation  in  this  part.  The 
choice  from  among  the  different  operations  permits 

um i  at  all  times  to  save  as  much  of  the  femur 

as  possible.  Until  twenty  years  ago  amputation 
of  the  thigh  was  generally  performed  by  the  trans- 
fixion method,  by  which  an  anterior  and  a  posterior 
flap  were  formed.  The  rapidity  and  ease  with  which 
it  could  be  performed  were  its  chief  commendation-. 
The  manner  in  which  it  is  generally  performed  i-  the 
following:  Grasping  and  raising  the  soft  parts  on 
the  anterior  aspect  of  the  limb  with  his  left  hand, 
the  operator  introduces  the  knife  at  the  side  of  the 
limb,  at  a  point  an  inch  or  more  below  the  level  of  the 


Fig.  175. 

proposed  section  of  the  femur,  and,  carrying  it  across 
the  anterior  surface  of  the  femur,  transfixes  and  cuts 
out  a  broad  flap  equal  in  length  to  half  the  diameter 
of  the  limb  (Fig.  175,  Fergusson).  The  flap  thus 
formed  being  retracted,  the  knife  is  again  introduced 
into  the  wound  behind  the  femur,  and  a  posterior 
:lap  formed  by  cutting  from  within  outward  and 
downward  through  the  soft  parts.  The  flap  thus 
made  should  be  quite  as  long  as  the  anterior,  since 
the  greater  retraction  of  the  posterior  muscles  would 
otherwise  reduce  it  to  a  size  that  would  prevent  the 
accurate  coaptation  of  the  cutaneous  margins  of  the 
wound.     In  very  fleshy  subjects,  all  of  the  muscular 


Fig.  176. 


1 1    ue    hould  "<<t  be  included  in  t  he  hap-  thu    c 
When  the  flaps   have  been  made  they  are  retracted 

by  an  assistant,  the  I •  i    cleared  of  the  -nil  adl 

cut  soft  parts  by  a  circular  weep  of  the  knife  at 
the  level  where  the  em  i  to  be  applied.  In  amputat- 
ing by  musculotegumentary  flaps  below  the  mid- 
dle of  the  thigh,  the  anterior  flap  should  bi'  formed 
first;  in  amputations  higher  up  it   must  be  made  last, 

in  order  that  the  femoral  ve  el  maj  qoI  be  divided 
until  the  operation  ha-  been  nearly  completed.  'I  he 
vessels  requiring  ligation  in  amputations  below  the 
middle  of  the  thigh  are  the  femoral,  anastomotic, 
and    five   or   six   muscular   branches.     To   insure   a 

smooth  margin  to  the  flaps,  it  is  well  first  to  outline 
them  by  an  incision  extending  through  the  skin 
alone. 

Amputation  of  the  thigh  by  lateral  museulotcgu- 
nieiitarv  flap-,  as  recommended  by  Vermale,  should 
not  be  resorted  to. 
since,  owing  to  the 
weight  of  the  soft 
part-,  the  flaps  are 
easily  displaced,  .and 

1 1 ad  of  the  bone  is 

liable  to  protrude 
from  the  upper  angle 
of  the  wound. 

In  the  middle  and 
upper  portions  of  the 
thigh  tlie  very  best 
results  are  unques- 
tionably to  be  ob- 
tained by  the  modi- 
fied circular  method, 
the  cutaneous  flaps 
being   made  in  front 

and  behind,  and  the  muscles  divided  by  a  circular 
incision.  The  admirable  results  which  Volkmann 
and  Bruns  achieved  from  amputations  of  the  thigh 
are  largely  attributable  to  their  preference  for  this 
method.  With  a  longer  anterior  and  shorter  posterior 
cutaneous  flap,  the  wound  obtains  an  excellent  posi- 
tion for  drainage  (Fig.  176,  Ilueter),  and  the  stump 
which  is  left  is  well  suited  for  the  application  of  an 
artificial  limb.  In  the  lower  third  of  the  thigh  the 
operation  may  be  made  with  only  a  single  long  anterior 
flap,  which  should  extend  as  low  as  the  upper  margin 
of  the  patella,  the  integument  on  the  posterior  aspect 
of  the  limb  being  divided  by  a  semicircular  incision. 
The  latter  should  be  made  at  least  half  an  inch  below 
the  margins  of  the  anterior  flap,  to  allow  for  the  greater 
retraction  of  the  posterior  lip  of  the  wound  (Fig. 
177).  In  amputations  near  the  hip  or  through  the 
trochanters,  no  other  operation  than  that  by  long 
anterior  and  short  posteriorjflaps  leaves  a  wound  that 
is  easily  drained.  When  there  is  any  question  as  to 
the  vitality  of  the  long  anterior  flap,  it  is  an  easy 
matter  to  "include  with  it  a  varying  thickness  of  the 
muscular  tissue. 

When  an  amputation  of  the  thigh  is  demanded  for 
senile  or  diabetic  gangrene,  it  is  essential  that  the 
flaps  shall  be  short.  The  circular  amputation,  with 
short  liberating  lateral  incisions  and  circular  division 
of  the  muscles  in  different  planes,  without  question 
gives  the  best  results. 

A  study  of  Table  III.  shows  that  amputations  of 
the  thigh  are  associated  with  a  mortality  that  is 
largely  responsible  for  the  high  death  rate  attending 
major  amputations  in  general.  The  fatality  of  this 
operation  in  civil  practice  increases  as  the  trunk 
is  approached. 

According  to  Macleod  and  Legouest,  this  applies 
equally  to  amputations  for  gunshot  injury. 

According  to  the  statistics  of  Otis,  this  view,  which 
is  generally  entertained,  must  be  modified.  Of  76S 
amputations  for  gunshot  injury,  made  in  the  upper 
third  of  the  thigh,  53. S  per  cent.  died.  Of  the  1,866 
amputations  made  in  the  middle  third,  44.5  per  cent. 


295 


Amputation 


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died.      Of  2,901  operations  in  the  lower  third,   53.6 
per  cent,  succumbed. 

The  general  mortality  attending  the  operation  is 
represented  by  6,229  cases,  with  3,310  deaths,  the 
mortality  being  53.8  per  cent. 

By  modern  methods  the  mortality  of  amputa- 
tions has  been  greatly  reduced.  From  the  sources 
above  quoted,  of  46.5  amputa- 
tions of  the  thigh,  seventy- 
nine,  or  seventeen  per  cent., 
were  fatal.  Of  15-1  amputa- 
tions for  disease  done  at  the 
Newcastle  Infirmary,  ten 
patients  died.  Of  twenty  done 
at  l  he  Cincinnati  Hospital, 
only  three  died. 

Amputation  at  the  Hip. — 
The  first  idea  of  this  operation, 
the  most  formidable  of  justifi- 
able surgical  procedures,  ap- 
pears to  have  originated  with 
Morand  and  two  of  his  pupils. 
Volker  and  Puthod,  practised 
it  on  the  cadaver  in  173S.  A 
year  later,  Le  Dran  taught  the 
operation  in  his  practical 
courses,  and  presented  a  report 
on  its  feasibility  to  the  French 
Academy.  In  1740  Ravaton 
proposed  to  amputate  at  the 
hip  joint  on  a  patient,  but  was 
dissuaded  therefrom  by  other 
surgeons  in  consultation.  In 
1756  and  1759  the  Paris  Aca- 
demy offered  a  prize  for  the 
best  treatise  on  the  justifiabil- 
Fig.  177.  ity  of   the  operation  and    the 

best  method  of  performing  it. 
Of  forty-four  contestants,  thirty-four  supported  "the 
operation,  the  prize  being  awarded  to  Barbette,  who 
concisely  mentioned  the  indications  that  made  it 
necessary.  That  life  could  continue  after  loss  of  the 
lower  extremities  had  been  shown  by  the  following 
case:  "In  174S,  there  came  to  the  hospital  of  Orleans, 
a  lad  fourteen  years  of  age,  who  was  the  subject  of 
ergotism.  Gangrene  of  both  lower  extremities  had 
supervened,  extending  on  the  right  side  to  the  hip 
.1  <  > i  1 1 1 ,  and  on  the  left  to  the  trochanter.  The  sup- 
puration which  was  established  almost  separated  the 
right  thigh,  the  round  ligament  and  great  sciatic  nerve 
alone  holding  it  to  the  trunk.  Lacroix,  surgeon  to  the 
hospital,  completed  the  separation  of  the  member. 
This  operation  succeeded  so  well  that  four  days  later 
he  also  amputated  the  left  thigh.  There  was  "neither 
hemorrhage  nor  pain,  and  the  patient  progressed  well 
till  the  tenth  day,  when  fever  supervened,  and  death 
followed  fifteen  days  after  the  first  operation."  In 
1773  Perault  removed  the  entire  thigh  in  a  case  of 
traumatic  gangrene  "of  several  months'  duration," 
in  which  a  complete  recovery  ensued  in  eighteen 
months. 

Although  in  1774  and  1778  Kerr  and  Thomson 
made  the  first  amputations  at  the  hip  through  living 
tissues  in  cases  of  coxalgia,  both  operations  termi- 
nated fatally,  and  the  procedure  was  not  again  resort- 
ed to  till  the  last  decade  of  the  past  century.  Ampu- 
tation at  thr  hip  in  reality  owes  its  existence  to  the 
wars  of  the  French  Revolution.  In  1794  the  elder 
Blandin  performed  it  thrice,  with  one  recovery.  Dur- 
ing his  different  campaigns,  Larrey  repeated  the 
operation  seven  times  and  gave  it  a  standing  among 
surgical  procedures,  although  it  is  doubtful  whether 
any  of  his  cases  recovered.  In  1812  and  1815, 
Brownrigg  and  Guthrie,  after  repeated  failures,  were 
enabled  to  report  successful  amputations  at  the  hip 
for  gunshot  injury.  The  first  operation  in  this  coun- 
try was  made  in  Kentucky  in  1S06,  by  Brashear,  for 
compound  fracture,  and  ended  in  recovery. 

296 


The  most  comprehensive  statistics  of  the  operation 
in  question  have  been  collected  by  Otis,  Liming,  and 
Ashhurst.  Over  three-fourths  of  all  the  operations 
have  been  made  since  the  introduction  of  anesthe- 
sia, and  fully  two-thirds  of  the  entire  number  were 
performed  later  than  1860.  Up  to  1875  Liining  was 
enabled  to  collect  but  497  well-authenticated  cases 
while  in  1881  Ashhurst  tabulated  633  operations' 
since  which  time  over  100  cases  have  been  added  to 
the  list. 

The  question  of  supreme  moment  in  amputation 
at  the  hip  joint  is  that  which  pertains  to  a  complete 
anil  yet  safe  method  of  controlling  the  circulation 
during  the  operation.  Its  importance  becomes  mani- 
fest from  the  fact  that  five  per  cent,  of  the  patients 
operated  on  do  not  survive  the  operation,  and  that 
seventy  per  cent,  of  the  deaths  occur  during  the  fir-t 
five  days  (Liining).  To  overcome  this  great  and  im- 
mediate danger  of  amputation  at  the  hip,  progress 
has  been  made  in  the  direction  of  preserving  the  blood 
contained  in  the  condemned  part  and  by  temporarily 
or  permanently  occluding  the  sources  of  its  blood 
supply.  By  the  use  of  the  elastic  bandage  from  the 
toes  to  the  groin,  and  by  keeping  it  in  place  during 
the  operation  (Erskine  Mason),  or,  in  cases  of  exten- 
sive suppuration  of  the  extremity,  by  maintaining  the 
lat  ter  in  a  vertical  position  for  some  minutes  before  the 
operation,  a  not  inconsiderable  amount  of  blood  can 
be   saved  to  the  economy. 

In    I860    Pancoast    first    called    attention    to    the 
practicability  of  compressing  the  aorta  against  the 
vertebral  column  by  means  of  an  abdominal  tourni- 
quet.    A   number   of   instruments   have   since   been 
devised  similar  to  that  of  Pancoast,  by  Lister,  Skey, 
and  Esmarch,  and  it  is  to  one  of  these  contrivances 
that  most  surgeons  have  recourse  before  proceeding 
to  the  operation  proper.     In  the  tourniquet  of  Es- 
march,  the  aortic  pad  exerts  its  compression  by  mi 
of  an  elastic  band  which  is  passed  through  its  handle. 
In  the  absence  of  a  tourniquet,  a  pad  can  be  impro- 
vised by  firmly  winding  a  long  roller  bandage  around 
the  middle  of  a  stick,  which  should  be  about  a  foot 
long  and  of  the  thickness  of  the  thumb.     The  pad 
thus  formed  being  placed  in  position,  is  retained  by 
five  or  six  turns  of  an  elastic  bandage  around  the  ab- 
domen (Esmarch).     Spence  resorts  to  a  similar  pro- 
cedure.    Whatever  tourniquet  be  used,  it  should  be 
applied  while  the  patient  is  lying  on  the  right  side,  the 
pad  being  placed  a  little  to  the  left  of  the  umbilicus 
(Fig.   178,   Esmarch).     The  operation  should  not  be 
commenced     until 
the    operator    has 
satisfied       himself 
that    the    circula- 
tion  in   the   lower 
extremities  is  com- 
pletely controlled. 
It    having   been 
held,   but  without 
sufficient     clinical 
evidence,  that  pro- 
longed      compres- 
sion of  the  abdom- 
inal aorta  is  injuri- 
ous  from  damage 
to  the  branches  of 
the    solar    plexus, 
and  by  interfering 
with      respiration, 
compression  of  the  common  iliac  artery  through  the 
rectum    has   been    advised    and    practised.       A\ - 
bury    of     Philadelphia    and     Van     Buren    of     New- 
York  proposed  that  this  be  accomplished  by  the  hand 
of  an  assistant,  while  R.  Davy  of  London  devised  for 
the  same  purpose  a  polished  rod  twenty  inches  long, 
and  from  one-half  to  three-fourths  of  an  inch  thick, 
surmounted  at  its  extremity  by  an  ivory  enlargement, 
with  which  the  artery  is  to  be  compressed  against  the 


Fig.   178. 


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Amputation 


brim  of  tin'  pelvis.  1"  one  case  in  which  Davy  used 
the  lever  on  the  right  iliac  artery,  deal  h  followed  from 
B  rent  in  the  rectum.  In  seventeen  other  cases  in  which 
ho  had  resorted  to  its  use  an  accident  resulted. 
\,  cording  to  the  originator  of  the  "lever,"  this  instru- 
ment has  been  used  in  forty  cases,  in  an  ulnu >-t  equal 
proportion  of  amputations  of  the  right  and  left  side, 
and  sixty-five  per  cent,  of  the 
,..(.,.<  recovered.  Davy11  has  re- 
ported ten  cases  with  right  re- 
coveries. 

[n  thin  or  emaciated 
Bubjects,  the  circular 
(ion  can  be  controlli 


Fig.   179. 

by  digital  compression  of  the  aorta  or  external  iliac 
artery,  or  both  may  be  employed  (Gross).  It  may 
likewise  be  effected  by  the  use  of  a  wide  roller 
bandage  placed  over  the  external  iliac  and  held  in 
position  by  an  elastic  bandage.  The  latter  should  be 
about  two  yards  in  length,  its  center  being  placed 
between  the  anus  and  tuberosity  of  the  ischium;  the 
anterior  part  of  the  bandage  is  brought  above  the 
crest  of  the  ilium,  the  posterior  portion  crossing  the 
sacrosciatic  notch  and  meeting  the  anterior  above 
the  iliac  crest;  both  are  firmly  held  in  position  by  an 
assistant.  This  method  of  preventing  hemorrhage 
from  both  anterior  and  posterior  flaps  has  been 
resorted  to  in  four  cases  by  Jordan  Lloyd  of 
Birmingham;  three  of  the  patients  recovered. 

With  the  introduction  of  better  methods 
against  hemorrhage,  the  use  of  the  abdominal 
tourniquet,  of  Davy's  lever,  and  of  digital 
compression  can  no  longer  be  advised. 

In-  1S76  Trendelenburg  of  Rostock  devised 
a  steel  rod  fifteen  inches  long,  one-fourth  of  an 
inch  wide,  and  one-eighth  of  an  inch  thick, 
with  a  movable  point  attachment  which  is  to 
be  pushed  through  the  soft  parts  in  front  of 
the  joint,  an  inch  above  the  level  where  trans- 
fixion is  to  be  made  with  the  knife.  "The 
rod  having  been  pushed  through  the  soft  parts, 
the  point  is  removed  and  a  rubber  tube  wound 
around  the  protruding  ends  of  the  rod  in 
figure-of-S  turns.  In  this  manner  compression 
of  all  the  soft  parts  in  front  of  the  joint  is  effected, 
and  the  flap  can  be  made  without  loss  of  blood.  After 
the  vessels  divided  in  the  anterior  flap  have  been 
ligated,  the  rod  is  introduced  through  the  soft  parts 
behind  the  joint  in  a  similar  manner  before  the 
posterior  flap  is  made."  Although  tedious  in  its 
performance,  this  method  of  controlling  hemorrhage 
is  thoroughly  practicable  and  promises  good  results. 
It  has  been  successfully  resorted  to  by  Varrick  in 
a  case  of  traumatic  amputation  in  a  subject  very 
anemic  from  hemorrhage. 


In  1890,  Wyeth"  described  a  bl Hess  amputa- 
tion at  the  hip,  which,  while  it  appears  to  be  an 
amplification  ot  Trendelenburg's  method,  is  exceed- 
ingly simple,  and  can  be  highly  recommended  for 
all  amputations  at  the  nip,  save  those  rare  ca 
which  the  di  ea  e  involves  the  trochanter.  In  these 
cases  the  transperitoneal  ligation  of  the  external,  or, 
better  still,  of  the  i mon,  iliac  is  to  be  pre- 
ferred to  the  pins  and  constriction  used  by 
Trendelenburg  and  Wyeth.  The  accompanying 
diagrams  (Figs.  17U  and  180),  inserted  with  Dr. 
Wyeth's  permission,    illu  trate   the  method  of 

the  introduction  of  the  pins. 

The  patient    is   placed    with    the  hip   well  over 

the  end  of  the  table,  and  an  Esmarch  bandai 
is  applied.     With  the  bandage  still  in  position, 

Wyeth's  needles  are  inserted  as  follows:     "Two 

steel    mattress    n lie-,  t h i eo-sixteenths  of  an 

inch  iii  diameter  and  a  foot  long,  are  used. 
The  point  of  one  is  inserted  an  inch  and  a  half 
below  the  anterior  superior  .-pine  of  the  ilium 
^  and  slightly  to  the  inner  side  of  this  prominence, 
and  is  made  to  traverse  the  muscles  and  deep 
fascia,  passing  about  half  way  between  tic  great 
trochanter  and  the  iliac  spine,  external  to  the 
neck  of  the  femur  and  through  the  substance 
of  the  tensor  vagina'  femoris,  coining  out  just 
back  of  the  trochanter.  About  four  inches  "f 
the  needle  should  be  concealed  by  the  tissues. 
The  point  of  the  second  needle  is  entered  an 
inch  below  the  level  of  the  crotch,  internally  to 
the  saphenous  opening,  and,  passing  through 
the  adductors,  comes  out  about  an  inch  and  a 
half  in  front  of  the  tuber  ischii.  No  vessels  are 
endangered  by  these  needles.  The  points  are 
protected  by  corks  to  prevent  injuries  to  the 
operator's  hands.  A  piece  of  strong  white  rub- 
ber tube,  half  an  inch  in  diameter,  and  long  enough 
when  tightened  in  position  to  go  five  or  six  times 
around  the  thigh,  is  now  wound  very  tightly  around 
and  above  the  fixation  needles  and  tied."  The 
Esmarch  bandage  is  then  removed,  and  if  the  oper- 
ation is  to  be  completed  according  to  Wyeth's  plan, 
a  circular  incision  is  made,  the  skin  flap  is  turned  up, 
the  muscles  are  divided  at  the  lesser  trochanter,  and 
the  bone  is  sawed 
through.  All  vessels 
are  then  tied.  The 
remaining  portion  of 


Fig.  ISO. 

the  femur  is  then  removed  by  division  of  the  attach- 
ments of  the  muscles. 

The  methods  of  hemostasis  above  described  will 
probably  be  supplanted  by  the  constriction  of  the 
abdominal  aorta  by  an  ordinary  rubber  tourniquet 
as  devised  by  Momberg  in  190S.  It  is  a  method 
applicable  to  amputations  of  the  thigh,  of  the  hip,  and 
of  the  os  innominatum.  I  have  used  it  in  high  am- 
putations of  the  thigh  and  in  controlling  the  bleed- 
ing during  an  aneurysmorrhaphy.  It  is  applied  as 
follows: 

297 


Amputation 


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The  patient  is  placed  in  the  Trendelenburg  position. 
The  end  of  a  piece  of  soft  rubber  tubing,  having  the 
thickness  of  the  index  finger  and  the  length  of  about 
four  feet,  is  passed  through  under  the  back  of  the 
patient  to  be  grasped  by  the  hand  of  an  assistant  who 
stand-;  at  the  opposite  side  of  the  operating  table. 
This  tube  is  then  stretched  to  the  utmost,  and  thus 
stretched,  is  passed  by  the  surgeon  midway  between 
the  border  of  the  ribs  and  the  "iliac  crests  across  the 
abdomen  to  the  other  hand  of  the  assistant,  whose 
duty  it  is  to  maintain  tension.  The  free  end  of  the 
tube  is  now  led  back  under  the  patient  by  the  sur- 
geon and  is  again  put  on  the  stretch,  the  assistant 
in  the  meanwhile  gradually  releasing  the  bite  of  the 
stretched  tubing  which  now  firmly  encircles  the  waist. 
\\  liile  this  is  being  done  another  assistant  places  a 
finger  on  the  femoral  artery  to  ascertain  the  moment 
of  the  cessation  of  the  pulse.  Observing  the  same 
steps,_two,  three,  or  more  turns  of  tubing  are  exactly 
superimposed  until  the  femoral  pulse  disappear-. 
In  slim  individuals  two  turns  will  suffice;  in  fat  or 
muscular  ones,  as  many  as  six  may  be  necessary. 
As  soon  as  the  femoral  pulse  is  suppressed  the  ends 
of  the  tube  are  crossed  and  secured  by  forceps  or 
ligature.  After  this  is  done  constrictors  are  applied 
to  the  thighs  below  Poupart's  ligaments,  and  to  the  legs 
below  the  popliteal  spaces.  As  soon  as  the  operation 
is  finished  and  all  the  vessels  have  been  secured  by 
ligatures,  the  rubber  band  encircling  the  waist  is  re- 
moved. Directly  after  this  the  other  rubber  liga- 
tures embracing  the  thighs  and  legs  are  untied  one  by 
one.  The  object  of  this  is  the  gradual  extension  of 
the  scope  of  the  circulation  and  the  avoidance  of  a 
too  sudden  demand  upon  the  efficienc}-  of  the  heart 
muscle.  By  this  switching  on  of  one  segment  of  the 
circulatory  system  after  another,  the  readaptation  of 
the  heart  to  the  changed  conditions  is  gradually 
effected. 

Two  dangers  would  seem  to  attend  the  tubular  con- 
striction of  the  aorta;  namely,  the  sudden  lowering 
of  blood  pressure  on  removal  of  the  tourniquet  and 
injury  to  the  intestines.  How  to  avoid  the  former 
has  already  been  shown.  The  second  is  averted  by 
having  the  bowels  thoroughly  emptied  and  by  placing 
them  out  of  reach  of  the  tourniquet,  by  using  the 
Trendelenburg  position.  Mayer18  has  recorded  nearly 
200  cases  in  which  it  was  used,  and  in  only  two  was 
there  damage  to  the  intestines.  Matas*20  experi- 
mented on  eight  healthy  students  without  any  ill 
effects. 


Fig.  181. 

Methods. — Although  a  large  number  of  methods  of 
amputation  at  the  hip  have  been  devised  (according 
to  Ashhurst  there  are  forty-five),  only  a  few  of  them 
are  of  practical  value,  and  are,  therefore,  commonly 
employed.  The  methods  which  will  be  considered 
are,  that  by  musculotegumentary  flaps,  that  by 
cutaneous  flaps  and  circular  division  of  the  remaining 
soft  parts,  and  that  by  a  high  circular  amputation 
with  subsequent  excision. 

298 


Musculotegumentary  Flaps. — Amputation  at  the 
hip  can  be  most  quickly  accomplished  by  means  of 
anteroposterior  muscular  flaps,  of  which  the  anterior 
is  made  by  transfixion,  and  the  posterior  by  cutting 
from  within  outward.  With  able  assistance  the 
operation  can  easily  be  performed  in  less  than  twenty 
seconds.  At  least  three  assistants  are  required  in 
this,  as  in  all  amputations  of  the  hip.  One  of  these  is 
entrusted  with  the  control  of  the  circulation  in  the 
limb,  the  second  follows  the  knife  to  grasp  the  flap 
before  the  artery  is  divided  (Fig.  181,  Hueter)  and 
then  to  retract  it,  and  the  third  takes  charge  of  the 
condemned  limb. 


Fig.  182. 

The  patient's  body  having  been  brought  to  the  foot 
of  the  table,  the  nates  are  made  to  project  over  its 
edge,  and  the  scrotum  and  sound  thigh  are  held  out 
of  the  way.  While  the  condemned  limb  is  slightly 
flexed,  the  operator,  standing  on  the  left  side,  enters 
the  point  of  an  amputating  knife,  the  blade  of  which 
is  at  least  a  foot  long,  midway  between  the  anterior 
superior  spinous  process  of  the  ilium  and  the  trochan- 
ter major.  It  is  carried  deeply  into  the  limb  in  a 
direction  parallel  to  Poupart's  ligament,  across  the 
anterior  surface  of  the  joint,  which  is  thus  opened, 
and  made  to  issue  on  the  inner  surface  of  the  thigh 
close  to  the  perineum  and  just  in  front  of  the  tuberos- 
ity of  the  ischium.  Transfixion  accomplished,  a 
broad  rounded  flap,  five  to  seven  inches  in  length, 
is  made  by  carrying  the  knife  downward  in  front  of  the 
bone  and  cutting  outward.  This  flap  is  at  once 
reflected  and  held  out  of  the  way.  By  a  transverse 
incision  on  the  head  of  the  bone  the  capsule  is  then 
widely  opened,  while  the  limb  is  forcibly  abducted 
and  everted.  Hyperextension  then  causes  the  head 
of  the  bone  to  start  from  its  socket  with  a  "  popping'' 
noise  when  the  ligamentum  teres  is  cut.  The  knife 
being  then  introduced  behind  the  head  of  the  femur, 
the  posterior  portion  of  the  capsule  is  divided  and  a 
posterior  flap  four  inches  in  length  is  cut  from  within 
outward  (Piston).  When  the  operation  is  made  on 
the  right  side,  the  knife  is  entered  from  the  inner  side 
just  above  the  ischial  tuberosity.  When  the  poster- 
ior flap  is  cut  from  within  outward  the  cutaneous 
margin  of  the  wound  is  generally  irregular  and  not 
well_  suited  for  close  coaptation  with  the  anterior  flap. 
It  is  advisable,  therefore,  particularly  in  robust 
limbs,  .either  to  outline  this  flap  by  an  incision  through 
the  skin,  or  to  cut  it  altogether  from  without  inward 
(Fig.  182,  F.smarch)  (Manec).  Indeed,  both  flaps 
may  advantageously  be  cut  in  this  manner  (Guthrie). 
The  great  advantage  of  the  operation  just  described 
is  in  the  rapidity  with  which  it  can  be  executed.  Its 
disadvantages  are  in  the  excessively  large  wound 
which  it  leaves,  the  tendency  to  the  retention  of  pus 


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A  mputatlon 


in  the  intermuscular  spaces,  and  the  great  probability 
3ive  hemorrhage  from  the  posterior  flap. 

\  Wound  better  suited  for  drainage  is  thai  made  by 
lateral  flaps  In  this  form  of  operation  a  semicircular 
incision  is  made,  beginning  at  the  tuberosity  ofthe 
:  chium  and  terminating  on  the  outer  side  oi  the 
femoral  vessels  in  the  center  of  the  groin.  The 
incision  crosses  the  outer  surface  oi  the  thigh  four  or 
five  inches  below  the  trochanter.  The  flap  thus 
outlined  is  then  reflected  over  the  latter  and  the  joint 
tied.  The  inner  flap  is  then  made  by  cutting 
from   within  outward.  ,     .     ,  , 

gumentary   Flap   Method. — Tins  is  an  admirable 
method    to    overcome    the   superfluity   of    muscular 
tissue  in  the  wound  and  the  consequent  tendencj   to 
purulent  infection,  and  it  is  therefore  preferred  by  a 
number  of  operators,  among  whom  are  Agnew  and 
Volkmann.     The  operation  is  described  by   Agnew 
Hows:  "The  surgeon  makes  a  semilunar  incision 
in  front  of  the  limb    with  its  convexity   downward 
commencing  midway  between  the  anterior  sup- 
erior   spinous    process    and    the    trochanter    on    the 
outside,    descending    the    thigh    in    a    longitudinal 
urn    for    five    inches,    then    passing    across    the 
front  of  the  limb  in  an  oval  course,  adding  thereby 
an  inch  to  the  length  of  the  flap,  and,  lastly,  ascending 
the  inner  border  of  the  thigh,  and  terminating  one 
inch  below  the  ramus  of  the  pubes.      The  integument 
,v  rapidly  dissected  up  from  the  deep  fascia  and 
isted  to  the  lingers  of  an  assistant." 

The  next  step  is  to  isolate  the  femoral  vessels  above 
th,  origin  of  the  profunda  and  to  apply  separately  to 
the  artery  and  vein  a  strong  ligature.  Volkmann 
divides  the  vessels  between  two  ligatures.  By  dis- 
placing the  pectineus  muscle  the  obturator  artery  can 
be  readily  found  and  ligated  below  the  obturator 
membrane. 

The  limb  being  now  raised,  the  surgeon  proceeds 
to  cut  a  semilunar  tegumentary  flap  from  the  back  of 
the  thigh,  one  inch  shorter  than  the  anterior.  With 
amputating  knife  the  muscles  are  then  severed 
circularly  in  front  of  the  joint,  "when  after  liberation 
of  the  head  of  the  bone,  as  in  other  methods,  the 
operation  is  completed  by  dividing  through  the  soft 
parts  posteriorly.  According  to  Agnew,  this  opera- 
tion can  be  completed  in  forty  seconds. 

Circular  Amputation. — In  order  to  make  a  smaller 
wound,  and  to  divide  the  vessels  where  they  are 
.smaller,  a  circular  amputation  of  the  thigh  at  the 
lower  part  of  the  upper  third  is  made.  This  may  be 
accomplished  by  a  single  incision  in  thin  subjects, 
while  in  robust  extremities  it  is  preferable  to  resort 
to  a  double  incision.  When  the  amputation  in  this 
part  is  effected,  all  the  blood-vessels  that  can  be 
recognized  must  be  ligated.  An  incision  is  then 
made  along  the  outer  side  of  the  stump  from  a  point 
two  inches  above  the  trochanter  to  the  circular 
wound,  and  dividing  everything  down  to  the  bone 
(Dieffenbach).  The  operator  then  seizes  the  stump 
of  the  femur  with  a  lion-jawed  forceps,  and  while  the 
edges  of  the  vertical  incision  are  separated  by  an 
assistant,  the  soft  parts,  including  the  periosteum, 
are  stripped  from  the  bone,  and  the  capsule  is  opened 
and  disarticulation  effected  as  in  other  procedures. 
Fig.  179  from  Wyeth  shows  the  circular  amputation 
Wound  with  pins  in  situ  and  before  the  head  of  the 
bone  has  been  removed.  In  1S80  Mr.  Furneaux 
Jordan  of  Birmingham  published  a  method  of 
amputating  at  the  hip  which  docs  not  differ  essentially 
from  the  method  just  described.  In  his  operation 
the  outer  incision  is  first  made,  disarticulation  is 
effected,  and  the  circular  incision  forms  the  last  step 
of  the  operation. 

finally,  mention  must  be  made  of  the  methods  of 
Verneuil  and  Ed.  Rose,  and  of  Senn,21  who  in  ampu- 
tating at  the  hip  treat  the  lower  extremity  as  they 
Would  a  neoplasm  that  is  to  be  removed,  cutting  from 
Wi!  hout  inward   and  tying  each  vessel  as  it  is  encoun- 


tered. A  shorter  internal  and  longer  external  inci- 
sion   is   made    through    the    skin    wnen    the    femoral 

artery     and     vein     are     to    lie     divided     between     two 

ligatures.     The  incisions  are  then  gradually  carried 

through  the  muscles  in  front  and  on  the  outer  side 
until  the  articulation  is  reached,  when,  after  dis- 
articulation has  been   effected,    the  addueted   muscles 

are  divided  last  of  all. 

Amputations  at  I  he  hip  of  nece  it  y  pre  ent  a 
deplorable  mortality.  Of  633  ca  e  tabulated  by 
Dr.    1'.   C.   Sheppard   for   Ashhurst,   393   terminated 

fatally,  and  in  twenty  the  result  was  undetermined. 
The  general  mortality  of  the  operation  is,  therefore, 
sixty-four  per  cent.  The  most  unfavorable  results 
obtained  are  those  from  military  practice.  Of  249 
cases  of  this  character  in  which  the  result  was  ascer- 
tained, including  sixty-six  operations  performed 
during  the  War  of  the  Rebellion,  only  twenty-seven 
patients  recovered,  the  mortality  being  89.1  per  cent.; 
twenty-five  of  the  sixty-six  cases  referred  to  were 
primary  amputations,  of  which  three  recovered; 
twenty-three  of  the  operations  were  secondary,  and 
all  terminated  fatally.  Of  nine  secondary  operations, 
two  survived,  and  of  nine  reamputations,  six  recov- 
ered. Of  seventy-one  cases  of  hip-joint  amputation 
for  injury  in  civil  practice,  forty-seven  died,  the 
mortality  being  60.1  per  cent.  Of  270  cases  of  hip- 
joint  amputation  for  disease,  of  which  fifteen  were 
undetermined,  105  terminated  fatally,  the  mortality 
being  40.2  per  cent. 

Owing  to  the  improved  methods  of  preventing 
hemorrhage,  and  particularly  through  the  use  of 
Wyeth 's  method,  the  mortality  of  amputations  at 
the  hip  has  been  very  greatly  reduced.  Wyeth-2 
collected  sixty-nine  cases  with  only  eleven  deaths. 
Of  the  fatal  cases,  five  had  severe  injuries.  I  have 
collected  138  cases  of  amputations  at  the  hip,  pub- 
lished between  1889  and  1900,  including  the  sixty- 
nine  cases  collected  by  Wyeth.  The  total  mortality 
of  the  139  cases  was  twenty-seven,  giving  a  mor- 
tality of  a  little  over  nineteen  per  cent.  Of  the 
amputations  there  were  121  for  disease  with  twenty- 
one  deaths — in  this  estimate  I  include  three  cases  of 
my  own,  one  of  which  was  fatal — or  a  mortality  of 
seventeen  per  cent.  I  find  that  six  amputations 
were  done  for  injury,  with  only  one  recovery — the 
cases  reported  by  McBurney.  In  fifteen  cases  the 
cause  for  the  amputations  was  not  stated;  of  these 
one  died. 

Interilio-abdominal  Amputations. — The  indi- 
cations for  interilio-abdominal  amputations  have 
thus  far  been  neoplasms  of  the  upper  end  of  the 
femur  and  of  the  pelvis  and  intractable  tuberculous 
coxitis  involving  the  acetabulum  and  the  iliac  pan. 
The  first  operation  was  performed  in  1891  by  Billroth 
and  ended  fatally  in  a  few  hours.  Extensive  con- 
sideration of  the  operation  was  given  after  the  report 
of  three  operations  by  Jaboulay.  The  original 
operation  of  Jaboulay  consisted  of  making  one  large 
posterior  flap.  The  first  incision  was  made  from 
the  symphysis  parallel  to  and  over  Poupart's  ligament 
and  the  entire  length  of  the  iliac  crest.  By  retracting 
the  upper  wound  margins  the  soft  parts  are  lifted 
from  the  iliac  fossa,  and  the  vessels  easily  reached 
for  tying.  A  circular  incision  is  next  made  at  the 
upper  third  of  the  thigh,  through  the  center  of  which, 
on  the  anterior  surface,  the  two  incisions  diverge 
toward  the  pubes  and  the  iliac  crest.  Thus  a  very 
large  posterior  flap  is  left  which  completely  and 
easily  covers  the  wound. 

Girard  operated  in  three  cases  by  making  internal 
and  posterior  flaps,  Bardenhauer  formed  external 
and  internal  flaps,  and  Salistcheff  in  his  successful 
case  operated  by  the  racquet  method.  His  incision 
begins  below  the  twelfth  rib  and  passes  over  the 
anterior  superior  spine  of  the  ilium  to  Poupart's 
ligament,  which  it  follows  to  the  pubes.  Through 
this  incision  the  vessels  are  secured.     The  wide  end 

299 


Amputation 


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of  the  racquet  incision  sweeps  over  the  buttock  to  the 
point  of  starting.  The  simplest  method,  from  an 
operative  standpoint,  is  that  of  the  long  internal  flap 
the  method  of  Savariaud  slightly  modified  by  Keen 
and  adopted  by  me.  It  has  the  signal  disadvantage 
Of  having  to  be  exceedingly  long  to  cover  the  wound, 
ihe  risks  of  gangrene  I  believe  to  be  larger  after  this 
operation  than  after  any  other.  Where  it  is  feasible 
it  appears  to  me  that  the  incision  of  Salistcheff  has 
superior  advantages. 

Interilio-abdominal  amputation  must  always  re- 
main a  desperate  operation.  It  should  not  be  re- 
sorted to  where  a  less  mutilating  procedure  is  possible 
artial  resection  of  the  os  innominatum  for  tumors  of 
the  iliac  pan  ought  to  be  performed  in  preference  to 
the  mterilio-abdominal  amputation.  Strange  as  it 
may  seem  the  three  complete  hemipelvic  resections 
performed  by  Kocher  (2)  and  Roux  (1)  all  recovered. 
Whereas  according  to  Croisier,  of  the  partial  resection 
there  were  eight  deaths  and  seven  operative  recoveries. 
It  is  need  ess  to  add  that  these  conservative  operations 
have  a  place  only  for  limited  neoplasms.  So  far  as 
the  usefulness  of  the  ilium  is  concerned  in  hemiresec- 
tion  of  the  pelvis,  there  has  been  less  impairment  of 
stability  and  usefulness  than  one  might  imagine 
in  the  cases  of  interiliac  amputation  that  have  sur- 
vived, there  has  been  no  tendency  toward  eventra- 
tion, a  condition  which  one  would  judge  to  be  a  cer- 
tainty after  removing  so  much  of  the  bony  support  of 
the  abdominal  viscera. 

Table  I.— Operations   in   One   Stage   for  Sarcoma. 
'.    Bi"roth  (1891).      Death  in  a  few  hours.      Verbal  communi- 

call.Mi.  .-.nvari.-iud.   It, -v.  dc  Chir.,  vul      xxvi      p    ,T,0 

i»oiJab^ay  (1S94)-     Deathin  thirty-six   hours!     Lyon  Med 

ioLr-i,  p.  o07. 

,,;,  J;'':,'ull,y    (1,S?5)-     Death    in  twenty-four  hours.     Province 

4.  Jaboulay  (1895).     Death  in  five  days.     Girard,  verbal  com- 
munication (Pnrigle). 

5.  Cacciopoli     (1894).     Death    in    three    hours.     Centralbl     f 
Chir.  (quoted),  1S94,  p.  988. 

6.  Gayet  (1S95).     Death   in    one    hour.     Province  Me,  1      1894 
J\o.  XXXV.  ' 

7.  Girard  (1895).     Recovery.     Congres  Chirurg.,  1898 

8.  *aure  (1S99).     Operation  abandoned.     Savariaud,  Rev    do 
Chir.,  vol.  xxvi.,  p.  365. 

9  Freeman  (1S99).     Recovery.     Annals  of  Surg.,  vol.  xxxiii., 

10  Nann    (1900).     Recovered    from    operation.     Gangrene    of 
other  leg.     Congres.  Intermit.  Paris,  1900 

_    11.  SaUstcheff    (1900).     Recovery.     Arohiv.  f.  klin    Chir     vol 
ix.,  p.  57.  '         ' 

12.  Savariaud    (1901).     Death  in  two  hours.      Rev    de  Chir 
vol.  xxvi.,  p.  360. 

13.  Gallat  (1901).     Death  in  one  hour.     Annal.de  Chir  .Beige) 
vol.  ix.,  p.  569.  " 

nJ*'  Jir"",    (19°2)-     Dea,h   in    nine  h"ur«-     A»*-  Gen.    de 
Chir.,  1903,  vol.  cxii  .  p.  1665 

15.  DeRuyter  (1902).     Death  in  an  hour.     Henri  Myer,  Inang 
Thesis.,  Leipzig,  1902. 

,    J6'   ^e™,.and   DaC°Sta    (1903).      Death   in   thirty-three  hours 
internal.  Clinics,  vol.  lv.,  Series  13. 

Chir"   no'''1'''   I™''      Death    °nBeCOnd   day"      Jahresbericht  f. 

Chir'  190°'ler  003°3>'     De''lth  °"  SeC°nd  day-     Jahresberi<*t  f- 
19.   Lastaria   (1907).     Died  „,,  table.     Reiforma  Med    Nanoli 
vol.  v.,  p.  457. 

Chir'   ?902W      IK)!''      I''VOd    thir'y"five    days-     Jahresbericht    f. 
,n™    BitC    (190S)-     R«=overy.     Momburg.,    Centblt.    f.    Chir 

22.  Ransohoff  (1909)  Recovery.  Lived  thirty-eight  days. 
Anuals  of  Surg.,  Nov.,  1909 

It  will  be  seen  from  Table  No.  1  that  the  post- 
operative mortality  of  this  amputation  "the  mosl 
extensivfe  operation  in  all  the  realm  of  surgery  "  is 
sixty-eight  per  cent.,  counting  the  cases  of  death'  after 

*  In  a  personal  communication  Prof.  Bier  informs  me  thai  his 
patient  died  two  months  after  operation,  of  recurrence  in  the 
abdominal  wall. 


twenty  days  with  the  operative  recoveries 
I    have   followed    the   lead   of   Keen.     In 'the  ca,^ 
where   the  resection  of  the  pelvis  was  preceded  bv 
amputation  at  the  hip,  no  deaths  followed  the  tlnd 
operation.     From    this    it    might    be    inferred   iu 
tins  course  is  preferable  as  a  routine  procedure      r„ 
fortunately    in    tumors  of   the   pelvis    the   two-staaa 
operation  is  not  feasible   and  in  those  for  tuberculosis 
none  other  is  ordinarily  applicable.     In  the  c! 
corded  by  Freeman,  the  amputation  at 1 .  | •' 
^mediately   followed    by    resection    of    the    pelvb 
Ihe  ex  en    of  the  disease  was  evidently  not  apparent' 
until   the  hip-ioint  amputation  had  been  done      In 
the  cases  of  Girard  and  Pringle  the  second  operations 
at'tlunhip  recurrent  di*ase  ^ter  disarticulat^ 

Doleful   as  are  the  immediate  results  of  interilio- 
abdominal    amputation,    the    end    results    have   been 
even  more  unpromising      The  cases  of  Girard  classed 
with  recoveries,  died  within  six  months  of  recurrent 
Pringle  s  case  died  in  five  months  with  metastases! 
Salistcheff's    case    was    reported    well    within    four 
months  of  the  operation.     The  end  result   I  do  not 
know.     I  he  record  case  is  probably  I  hat  of  Freeman 
Although  he  left  the  anterior  third  of  the  acetabulum 
and  of  the  ilium,  the  case  belongs  in  the  category  o 
intenho-abdominal  amputations.     Freeman's  patient 
was  well  at  the  end  of  sixteen  months,  when  reported 
but  died   twenty  months  after  operation   from  recur- 
rence in  the  abdominal   wall    (personal   communica- 
tion).    Of  the  end  results  of  the  operation  for  tuber- 
culosis,  the   data  are   extremely  meager.     The   case 
of   Bardenheuer  gained  in  health  and  strength  four 
months  after  the  operation,  and  it  is  presumed  was  a 
permanent  recovery.     The  case  of  Pringle  was  with- 
out recurrence  seven  years  after  the  operation. 

Table  II.— Operation  in  two  Stages  for  Sarcoma. 
1.  Girard    (1S95).     Amputation    at    hip.     Some   months    later 
resection  of  pelvis.     Recovery.     Rev.  de  Chir.,  vol.  xxvi     ,,    :6S 
.f^"™;1    llfS):     Amputation    at    hip.      Death    six    months 
alter  reaecUon  of  os  innominatum.     Lancet,  Feb.  20,  1909. 

In  the  face  of  these  unpromising  results,  it  may  be 
questioned  whether  the  operation  is  justified  'Tic 
same  question  has  been  put  for  every  major  operation 
in  surgery,  and  has  in  the  course  of  time  with  un- 
varying uniformity  been  answered  affirmatively 
By  limiting  the  operation  to  suitable  cases  and  per- 

orming  it  at  a  time  when  there  is  at  least  a  probability 
that  the  patient  can  bear  the  shock  connected  there- 
with, it  is  almost  certain  that  the  prognosis  will 
improve  as  it  has  so  markedly  for  amputation  at  the 

up.  _  Disseminating  the  knowledge  that  the  opera- 
tion is  feasible  will,  by  bringing  the  eases  earlier  to  the 
surgeon,  contribute  much  toward  this  desirable  end 
\\  ith  two  exceptions,  I  know  of  no  text-book  in  which 
the  operation  is  even  mentioned. 

Table  III. — Amputations  for  Tuberculosis.* 

1.  Girard  (1S95).      I  lied  in  fifty  minutes.     Rev.  de  Chir     1S98 
p.  1111. 

2.  Bardenheuer  (1897).     Recovery.     Gesellsch.  d.  Chir.,  xxvi 
I,  p.  130. 

3.  Gallet  (1900).     Died  in  six  hours.     Gesellsch.  d.  Chir    xxvi 
I,  p.  130. 

4    Ribera    (Madrid)    (1902).     Died,    collapse.     Luis   y   Simon 
Siglo  Med.,  1903,  vol.  v, 

5.  Ribera  (1902).  Died  eighth  day.  Luis  y  Simon,  Siglo  Med., 
1903,  vol.  v. 

6.  Ribera  (1902).      Died,  collapse.      Luis  y  Simon,  Siglo  Med 
1903,  vol.  v. 

7.  H.  Vermeuil  (1905).  Died  in  two  hours.  Jour  de  Chir 
(Beige).,  vol.  v.,  p.  406. 


The  operations  for  tuberculosis  were  practically  all  done  in 
two  stages,   the  first   being  either  a  hip  resection  or  amputa 
I  he  extent  ol  the  resection  of  the  pelvic  bone  varies  much.       I  have, 
however,  excluded  all  cases  in  which  the  resection  did  not  involve 
the  major  part  of  the  ilium. 


300 


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Amygdala 


8    Morestin    (1908).     Recovery.     Bull.    Soe.    de    Chir.,    Paris, 

vol   n\iv  i  P    ""'" 

.,    pringlo    1908)       R very.     Lancet,  Feb.  20,  1909. 

1908).      I  ><  iii'  on    in   i    day,      Lanoet,    Feb.    20, 

M     r.   Fiaschi.     Recovery.     Australian    Med.   .lour.,   Deo.   23, 

1911. 

In  an   operation   of  such    magnitude,    the   initial 
mortality  is  largely  due  to  hemorrhage  and  to  shock. 
i  if  all  the  cases  thai  arc  not  included  under  postopera- 
tive recoveries,  only  two  survived   the  fourth  day. 
The  prevention  of  hemorrhage  has  in  mosl  rases  been 
;.i    ii\    preliminary   tying  of  the  common   iliac, 
internal  iliac,  or  the  external  iliac.     Many  believe 
the    tying   of   the    corresponding   veins   ought 
always  to  be  practised.     Kocher  and  Kadjan  encoun- 
i    severe  venous    bleeding.     Tying  of    the    thin- 
walled  large  veins  doubtless  would  increase  the  diffi- 
culties  of    the    operation.     Fame,    after    a,    median 
my,  applied  a  temporary  ligature  to  tin-  aorta 
below  the  common  iliac.     Nevertheless,  a  severe 
venous  hemorrhage  from  subcutaneous  and  subperi- 
toneal veins  necessitated  abandonment  of  the  opera- 
tion.    Xanu,    Jaboulay,    Cacciopoli,    and    Salistcheff 
also    ligated    the    common   iliac.      Bardenheuer    tied 
h  i  he  external  and  the  internal  iliac  vessels.     Free- 
man lied  the  external  iliac  and,  later  in  the  operation, 
common  iliac.      Keen  tied  the  internal  iliac  artery. 
by   the   tying  of  the  common  iliac  artery  pre- 
ventive' hemostasis   can   be  accomplished,  has  been 
amply  demonstrated  in  the  case  reported,  and  it  was 
satisfactory.     Unfortunately     where     a    long 
nal  Hap  is,  as  in  our  case,  a  matter  of  necessity, 
there  is  great  danger  of  gangrene.     This  had  already 
commenced    in    Keen's    case,    although    the    patient 
lived  only  thirty-three  hours.     The  gangrene  strangely 
loped  in  the  superior  flap  and  not  in  the  margin 
ot   the  long  internal.     In  my  ease  the  gangrene  in- 
volved the  long  flap  only.      Were  a  similar  case  to 
e  under  my  observation,  I  would  tie  the  external 
iliac  and  the  posterior  trunk  of  the  internal.      In  that 
manner  the  obturator  artery  would  be  left  intact  for 
tin-  nutrition  of  the  long  internal  flap. 

Joseph  Ransohoff. 

Bibliography. 

1.  Hippocrates:     Sydenham  Society  edition,  vol.  ii.,  p.  639. 

2.  Paulus  Aeginetus:     Sydenham  Society  edition,   vol.  ii.,  p. 
110. 

3.  Billroth    nnd    Pitha:     Handbuch    der    Chirurgie,    vol.    ii., 

!,  Abth.  2,  p.  19. 
1    Agnew:     System  of  Surgery,  vol.  ii.,  p.  305. 
."..    Burow:     Deutsche  Klinik,  18.36. 

6.  Gueterbock,  P.:  Archiv  fur  klinische  Chirurgie,  Bd.  x\\,  and 
stvii. 

7    Gross:     System  of  Surgery,  voL  i.,  p.  530. 

3    I  rdmann,  .1.  F.:     Annals  of  Surgery,  vol.  xxii.,  p.  358. 

0.  Paget:     Lancet,  1S95,  i.,  p.  023. 

10.  Bruns:     Beitrage  z.  klin.  Chirurgie,  vol.  xxii.,  p.  2. 

11.  Barling:     Clinical  Society  Transactions,  xxxi.,  p.  1S2. 

12.  Moschcowitz:     Annals  of  Surgery,  vol.  xxxix,  p.  794. 

13.  Ilalm:     Beitrage  zur  klinischen  Chirurgie,  vol.  xxii.,  part  2. 

I I.  Bier:  Deutsche  Zeitschrift  fur  Chirurgie,  vol.  xxxiv.,  p.  436. 
15.  Smith,  Stephen:  Am.  Journal  of  the  Med.    Sciences,   vol. 

Kix,  ii   :;;,  1S70. 

III.  Weidenpesch, Paul:  Dissertation,  Munich,  190S. 
17.  Davy:     Lancet,  1892,  ii.,  p.  570. 

is.  Wyeth:     New  York  MedicalJournal,  1890,  ii.,  p.  528. 

19.  Mayer:      Journal  de  Chirurgie,  1910,  p.  121. 

20,  Matas:     Transactions  of  the  Am.  Surgical  Association,  vol. 
xxviii.,  1910,  p.  622. 

-'1     Senn:     Chicago  Clinical  Review,  1S92,  p.  343. 
22.  Wyeth:     Annals  of  Surgery,  vol.  xxv.,  p.  129. 


Amussat,  Jean  Zulema. — Born  at  St.  Maixent, 
France,  November  21,  1706.  He  studied  the  rudi- 
ments of  medicine  under  his  father,  a  physician,  com- 
pleting his  education  at  Paris.  His  earlier  medical 
life  was  devoted  chiefly  to  anatomy  which  he  taught 
to  artists   as   well   as   to   medical   students.     While 


FIG.1S3. — Jean  Zulema  Amussat. 


preparing  for  a  concours  in  competition  for  appoint- 
ment to  a  professorship  he  acquired  an  infection 
which  nearly  ended  his  life  and  left  him  invalided  for 
so    long    thai     he    was    forced    lo    give    up    the    public 

teaching  of  anal y.     On  recovering  his    health  hi? 

turned  his  attention  lo  surgery  in  which  he  -nun 
acquired  fame,     lie  was  an  indefatigable  worker,  a 

skilful  Operator,  an  orig- 
inal thinker,  and  in- 
genious  in   devising   new 

operations    and    in    the 

i  n  ve  n  t  io  n  of  instru- 
ments. While  an  in- 
terne at  the  Salpetriere 
he  invented  a  rachitome 
for    exposing    the    spinal 

cord.     He  developed  tin; 

operation  of  lithotrity, 
.Ii  >  ising  a  probe,  which 
st  ill    bears   his    name,  for 

i  e  in  locating  and 
steadying  the  stone  in 
thai  procedure.  He  ga\  e 
his  name  also  to  theoper- 
aiion  for  lumbar  colos- 
tomy in  the  ascending 
colon.  He  was  the  recip- 
ient of  several  grants,  aggregating  1,500  francs,  from 
medical  and  scientific  bodies  in  recognition  of  his 
labors  in  advancing  the  science  and  art  of  surgery. 
He  died  .May  13,  1856. 

Amussat  was  a  most  prolific  writer  of  monographs 
and  journal  articles  on  a  great  variety  of  gynecological 
and  surgical  subjects,  his  most  extensive  work  being  a 
treatise  on  "Torsion  des  Arteres,"  published  in  1829. 
Other  minor  works  were  on  the  Entrance  of  Air  into 
the  Veins,  and  on  his  special  operations  of  Lithotrity 
and  Lumbar  Colostomy.  T.  L.  S. 


Amygdala. — Almond.  A.  dtjlcis.  Street  almond. 
The  ripe  seed  of  Prunus  amygdalus  dulcis  D.  C. 
(Fam.  Rosacea:).  (U.  S.  P.).  A.  aiiaha.  Bitter 
almond.  The  ripe  seed  of  Prunus  amygdalus 
arnara  D.  C.     (Fam.     Rosacea). 

The  almond  tree  is  a  native  of  the  east  Mediterra- 
nean region  and  is  now  cultivated  in  all  warm- 
temperate  regions,  especially  in  California.  The  tree, 
with  its  leaves  and  flowers  closely  resembles  the 
peach.  The  fruit  differs  in  being  dry  instead  of 
fleshy,  and  in  splitting  to  discharge  the  stone,  which, 
with  its  contained  seed,  is  the  unshelled  almond  of 
commerce.  The  shelled  almond  is  the  article  here 
considered.  The  bitter  almond  is  probably  the 
original  wild  form,  from  which -the  sweet  has  been 
derived  by  selection,  breeding,  and  cultivation.  There 
are  so  many  forms  of  both  the  sweet  and  bitter  varieties 
that  it  is  useless  to  attempt  any  differential  description 
of  the  two,  except  as  to  order,  tests,  and  constituents. 
Those  used  as  drugs  are  about  an  inch  in  length,  ovoid, 
with  strongly  rounded  base  and  obtusely  pointed 
apex,  flattened  so  as  to  be  three  times  as  broad  as 
thick,  and  about  one-half  longer  than  broad.  The 
surface  is  of  some  shade  of  brown,  more  or  less 
wrinkled,  scurfy,  with  a  dense  covering  of  short, 
thick,  microscopical  hairs,  and  with  numerous  lines 
radiating  from  the  base.  The  kernel  consists  entirely 
of  two  oily  cotyledons  of  the  same  form  as  the  seed,  in 
contact  by  their  flat  faces,  and  of  a  nearly  white  color. 

The  bitter  almond  has  a  characteristically  bitter 
taste,  the  sweet  ones  being  entirely  bland,  sweet,  oily, 
and  nutty. 

Of  sweet  almonds,  the  important  constituent  is 
fifty  per  cent,  or  more  of  a  fixed  oil  (see  Oleum 
Amygdala-  Expressum),  which  occurs  with  about  three 
per  cent,  of  gum  and  six  per  cent,  of  sugar,  and  a 
large  amount  of  albuminoid  matter.  There  is  a  very 
small   amount   of   tannin   in   the   seed   coat.     Their 


301 


Amygdala 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Eroperties  are  purely  demulcent  and  nutritive.      We 
ave  an  official  emulsion  and  a  syrup,  which  are  used 
as  vehicles. 

In  composition,  bitter  almonds  have  about  one- 
sixth  less  of  the  same  fixed  oil,  and  contain  from 
one  to  three  per  cent,  of  a  peculiar  glucoside  (see 
Amygdalin  and  Emulsln)  which  yields  hydrocyanic 
acid  and  benzaldehyde,  as  described  under  Hydrocy- 
1. ■id.  The  yield  of  oil  of  bitter  almond  is  about 
one  per  cent.,  that  of  prussic  acid  about  .00  to  .18 
of  one  per  cent.,  of  the  weight  of  the  seeds. 

It  is  evident  that  the  bitter  almond  combines  the 
properties  of  sweet  almonds  and  prussic  acid,  and 
that  an  ounce  of  the  drug  is  equivalent  to  almost  one 
grain  of  the  latter.  It  does  not  follow  that  the  effect 
would  be  the  same  as  that  dose,  inasmuch  as  the 
development  of  the  acid  would  be  neither  so  sudden 
nor  so  complete.  Nevertheless,  bitter  almonds  must 
be  regarded  as  poisonous.  Even  a  small  number  of 
them,  if  eaten,  are  apt  to  produce  a  slight  gastric 
irritation  as  an  after  effect.  Their  chief  use  is  a 
flavoring  agent,  though  small  doses  are  used  for  their 
sedative  effect. 

Peach  seeds  are  often  used  to  adulterate  bitter 
almond,  and  their  composition  is  very  similar.  Sweet 
almonds  are  also  used  as  an  adulterant. 

H.   H.   Rusby. 


Amygdalin. — The  source,  occurrence,  and  general 
nature  of  amygdalin  will  be  been  stated  in  discussing 
hydrocyanic  acid.  It  is  not  official  and  is  scarcely 
used  in  its  own  form,  although  occurring  in  com- 
merce. Boiling  alcohol  is  used  to  extract  it  from 
almond  oil  cake,  after  which  it  is  precipitated  by  ether. 
It  occurs  in  crystals  or  scales  which  are  soluble  in 
twelve  parts  of  water.  It  is  odorless,  but  very  bitter. 
If  entirely  free  from  emulsin,  it  does  not  yield  prussic 
acid  and  is  not  poisonous. 

H.   H.   Rusby. 


Amvlene  Chloral. — Dormiol,  chloral-dimethvl- 
ethyl-carbinol,  C(CH,)2CsH5OH.CCLCOH,  is  a  coin- 
pound  of  one  molecule  of  amvlene  hydrate  and  one 
molecule  of  chloral.  It  is  a  colorless,  oily-looking  liquid, 
with  an  aromatic  odor  and  a  pungent,  followed  1>\ 
cooling,  taste.  It  is  practically  insoluble  in  water, 
and  is  freely  miscible  with  alcohol,  ether,  acetone, 
and  volatile  and  fixed  oils.  It  goes  under  the  trade 
name  of  dormiol,  and  is  claimed  to  be  a  certain 
hypnotic  without  depressing  effect  on  the  heart  or 
respiration.  Its  dose  is  njf.  viii.-xxx.  (0.5-2.0),  given 
in  syrup,  or  in  emulsion  with  a  small  amount  of  olive 
or  almond  oil,  and  flavored  with  lemon  or  cinnamon. 

R.  J.  E.  Scott. 


Amvlene  Hvdrate. — Tertiary  amyl  alcohol,  di- 
methyl-ethyl-carbinol,  (CH3)2C,H-.COH.  This  is  a 
clear,  colorless,  thin,  neutral  liquid,  with  a  burning 
taste  and  an  aromatic  odor  somewhat  resembling 
camphor.  It  is  soluble  in  eight  parts  of  water  and 
in  alcohol,  ether,  glycerin,  and  oils;  specific  gravity. 
0.812  at  53.6°  F.  It  has  been  recommended  for  its 
soporific  properties.  Its  advantage  over  chloral  is, 
that  it  has  no  depressing  effect  on  the  heart.  Its 
smaller  dose  and  less  disagreeable  odor  make  it 
preferable  to  paraldehyde  in  many  cases.  It  is  a 
rather  mild  hypnotic,  producing  a  calm,  refreshing 
sleep,  which  lasts  for  six  or  eight  hours,  from  which 
the  patient  awakens  without  any  bad  symptoms. 
It  has  not  proved  of  use  when  the  sleeplessness  is  due 
to  pain.  In  very  large  doses  it  produces  coma,  a 
lowered  temperature,  shallow7  respiration,  feeble  and 
iregular  pulse,  loss  of  reflexes,  and  paralysis  of  the 
extremities,  its  poisonous  symptoms  resembling 
those  of  alcohol  and  ether.     Its  taste  and  odor  often 


prove  objectionable,  but  may  be  disguised  by  extract 
of  licorice,  syrup  of  lemon,  lemonade,  or  some  aro- 
matic. Occasionally  it  is  administered  by  rectum  in 
solution  in  water.  Its  dose  is  tin xxx.-xlv. (2.0-3.0) 
but  administered  in  capsules. 

A  case  of  poisoning  has  been  reported.  The  patient 
who  had  taken  27  grams  (about  4oo  grains),  « L,< 
stimulated  with  mustard  plasters  and  inject  inns  ,,f 
ether,  and  recovered.  R.  J.  E.  Scoi  i. 

Amylene. — Valerine,  C5Hl0.  Amylene  is  a  volatile 
and  inflammable  ethereal  fluid  of  an  unpleasant  odor 
resembling  that  of  cabbage.  It  was  experimented 
with  by  Snow  in  1856,  as  an  anesthetic,  and  prove  I 
itself  powerful,  after  the  manner  of  chloroform;  but 
proving  itself  also  capable  of  killing,  it  never  came  into 
accepted  service.  R.  J.  E.  Scott. 


Amyl  Iodide. — Iodamyl.  C\,H„I,  is  an  oily  liquid 
obtained  by  distilling  together  iodine,  isoamyl  alcohol, 
and  red  phosphorus.  It  is  purified  by  washing  with 
water  and  redistilling.  This  liquid  is  about  as  heavy 
as  chloroform,  boils  at  148°  C,  is  freely  soluble  in 
alcohol,  and  insoluble  in  water.  It  is  used  for  the 
same  purpose  as  amyl  nitrite  in  asthma  and  angina 
pectoris,  but  has  distinctly  less  effect  in  relaxing 
the  arterial  muscle.  Dose,  r^  ii.-v.  (0.13-0.3)  by 
inhalation.  W.  A.  Bastedo. 


Amyl  Nitrite. — Amylis  nitris,  a  liquid  containing 
about  eighty  per  cent,  of  amyl  (chiefly  isoamyl) 
nitrite  (U.  S.  P.).  It  is  a  yellowish,  ethereal,  very 
volatile  liquid,  of  a  not  disagreeable  fruit-like  odor 
and  pungent  taste,  insoluble  in  water  but  soluble  in 
alcohol  and  ether;  it  is  neutral  in  reaction,  but  becomes 
acid  on  exposure  to  air,  and  should  be  kept  in  well- 
stoppered  containers  away  from  the  light.  When 
inhaled  or  administered  by  the  mouth  or  hypoder- 
mically,  it  causes  rapid  heart  action  and  flushing 
of  the  surface,  dilating  the  vessels  and  reducing  blood- 
pressure,  and  induces  general  muscular  relaxation. 
1 1  is  employed  by  inhalation  in  asthma,  dysmenorrhea, 
muscular  spasm,  and  especially  in  angina  pectoris. 
For  the  latter  purpose  pearls  of  very  thin  glass,  con- 
taining three  minims  (0.2),  are  prepared;  thesi 
be  crushed  in  the  handkerchief  and  the  fumes  inhaled 
to  cut  short  an  attack.  The  dose  for  inhalation  is 
usually  from  two  to  five  minims  (0.13-0.3).  Fi 
fuller  discussion  of  the  physiological  action  and 
therapeutic  uses,  see  Nitrites. 

Amyl  Valerate. — Amyl  valerianate,  apple  oil,  apple 
essence,  C5H11C5H902,  is  obtained  by  the  action  of 
valeric  acid  on  isoamyl  alcohol,  in  the  presence  of 
sulphuric  acid.  It  is  a  clear,  colorless  liquid,  lighter 
than  water,  having  an  odor  like  that  of  apples  and  a 
sharp  ethereal  taste.  It  is  insoluble  in  water,  soluble 
in  alcohol  and  ether,  and  it  boils  at  18S°-190°  C. 

Amyl  valerate  is  used  in  place  of  valerian  in  func- 
tional nervous  disorders,  especially  hysteria.  As  il 
is  a  solvent  for  cholesterin,  it  was  thought  to  have 
the  power  to  diminish  the  size  of  gallstones,  but  il  ia 
hardly  probable  that  this  solvent  action  could  take 
place  in  the  system.  In  fact,  alcohol  and  other 
cholesterin  solvents  taken  in  large  quantities  ha\ 
effect  whatever  on  the  size  of  the  stone.  Amyl 
valerate  is  administered  in  dose  of  n\  ii.-v.  (0.13  I 
in  capsules,  or  in  five-per-cent.  alcoholic  solution 
with  an  equivalent  quantity  of  amyl  acetate. 

W.  A.  Bastedo. 


Amyloid. — From  i/ivKov,  starch,  and  efSos,  resem- 
blance, so  called  from  the  fact  that  the  amyloid  sub- 
stance gives  with  iodine  and  sulphuric  acid  a  reaction 


302 


REFERENC]     EANDBOOK   OP   THE    MEDICAL   SCIENCES 


i 1. .1.1 


similar  to  that  of  starch.      Uso  called  chondroid,  ■ 
lardaceou      or    albuminous    degeneration.     French, 
p  iloide;  German,   Amyloidentartung, 

ii.  mg. 

lii,-  term  amyloid  degeneration  is  applied  to  the 

appearance,  in  the  body,  of  a  clear,  colorless,  shining, 

homogeneous,    highly    refractive,     and     translucent 

body,  greatly   resembling  wax,  firm  in  consistency, 

and  possessing   but    little  elasticity.     Winn  treated 

with  iodine  solution,  it   takes  on  a  mahogany  color, 

which  in  marked  cases  may  become  bluish  or  green 

Plate    VII.).     If   the  specimen   thus  treated  is 

further  subjected  to  the  action  of  dilute  sulphuric  acid, 

zinc  or  calcium  chloride,  the  mahogany  color  may  be 

ed,  or  a  play  of  colors — red,  violet,  blue,  or 

i     may   be   produced.     This  reaction,  however, 

docs  not  always  occur. 

iuse  of  this  characteristic  reaction  with  iodine, 

nalogous  to  that  of  starch,  Virchow  was  led  to 
believe    that    the    newly    discovered    substance    was 

oid  of  nitrogen  and  closely  allied  to  cellulose  or 
starch,  and  for  this  reason  gave  it  the  name  amyloid. 
It  was  further  designated  as  "animal  cellulose." 
On  the  other  hand,  Meckel  believed  it  to  be  closely 
related  to  cholesterin.  Several  years  after,  the  chem- 
ical    investigations    of   Friedrich,    Kekule,    Schmidt, 

.-new,  and  Kuhne  proved  conclusively  that  the 
so-called  amyloid  was  in  reality  a  nitrogenous  body 

u  albuminous  nature.  According  to  Tscher- 
niak,  it  is  a  coagulated,  albuminous  substance,  and 
i-  possibly  an  intermediate  product  between  the  pro- 
tein- on  one  side  and  fat  and  cholesterin  on  the  other. 
The  exact  chemical  nature  of  amyloid  is  not  yet 
known.  It  is  very  probable  that  its  chemical  con- 
stitution is  not  the  same  in  all  organs,  and  that  it 
represents  different  phases  of  a  progressive  metamor- 

is  of  albumin.  The  great  variation  shown  in 
the  different  staining  reactions  of  amyloid  speaks  is 
favor  of  such  a  view.  In  the  amyloid  isolated  by 
means  of  digestion  of  amyloid  organs,  there  is 
always  found  a  certain  amount  of  ehondroitin-sul- 
phuric  acid,  and  recent  writers  have,  therefore,  re- 
garded amy  I.  .id  as  a  compound  of  a  basic  albuminous 
body  and  this  acid.     The  latest  researches  by  Haus- 

1908)  do  not  favor  this  view;  according  to  his  in- 
vestigations the  amyloid  isolated  mechanically  from 
sago-spleens  contains  no  chondroitin-sulphuric  acid. 
Bo  that  this  substance  cannot  be  regarded  as  an 
essential  component  of  amyloid.  Nevertheless  the 
in  ijority  of  amyloid  tissues  show  an  increased  con- 
tent of  chondroitin-sulphuric  acid.  Lipoids  soluble 
in  alcohol  are  also  usually  obtainable  from  amyloid. 

A irding  to  Krakow  there  occur  normally  in  the  wall 

of  the  aorta  of  the  horse,  in  the  ligamentum  nuchas  of 
cattle,  and  in  the  spleen  and  stomach-wall  of  calves, 
combinations  of  chrondroitin-sulphuric  acid  closely 
related  to  amyloid.  The  writers  who  accept  Krakow's 
view  that  amyloid  is  a  combination  of  a  protein  and 
chondroitin-sulphuric  acid  would,  therefore,  class  amy- 
loid as  a  glycoprotein  allied  to  cartilage  and  yellow 
elastic  tissue.  Experimental  feeding  of  chondroitin- 
sulphuric  acid  salts  does  not  give  rise  to  the  formation 
of  amyloid. 

Amyloid  bears  also  a  very  close  chemical  relation  to 
the  hyaline  deposits  found  in  blood-vessels  and  eon- 
nective  tissue,  as  is  shown  by  the  fact  that  amyloid 
organs  sometimes  contain  hyaline  masses  in  no  way 
distinguishable  from  the  neighboring  amyloid  ex- 
cept by  the  application  of  specific  staining  methods. 
In  some  cases  the  periphery  of  large  masses  of 
amyloid  gives  the  reactions  for  hyalin  and  not  for 
amyloid.  Litten  found  that  pieces  of  amyloid  tissue 
lost  their  characteristic  reactions  and  became  changed 
to  hyalin  when  introduced  into  the  abdominal  cavity 
of  animals.  The  strong  general  resemblances  be- 
i  ween  the  two  bodies,  their  similarity  of  location,  and 
the  frequent  coincidence  of  occurrence  make  it  very 
probable  that  the  two  substances  are  so  very  closely 


ed  thai    they   1 1 1 :  i  \    cha  uge  from  Oni  it  her. 

ie  writers  regard  the  coincidence  of  hyalin  and 
amyloid  as  accidental  and  reject  the  view  thai  the 
formation  of  hyalin  may  be  a  preliminary  step  to  the 
de\  elopment  of  amyloid. 

Amyloid  differs  from  other  albuminous  bodies  in  its 
characteristic  .staining  reactions,  in  its  resistance  to 
tin-  action  of  pepsin,  and  in  its  very  slight  tendency  to 
putrefaction.  When  exposed  for  a  long  time  t,i  the 
action  of  gastric  juice  ii  slowly  dissolves,  so  that  it  is 
po  ible  that  its  resistance  to  pepsin  and  agents  of 
putrefaction  is  due  to  its  great  den  ity,  which  hinders 
the  penetration  of  fluids.  It  is  likewise  resistant  to 
acids  and  alkalies,  and  is  not   altered   by  alcohol  and 

chromic  acid.  Through  the  prolonged  action  of  di- 
lute sulphuric  acid  tyrosin  and  leucin  may  be  obtained 
from  amyloid,  its  end  products  thus  harmonizing  with 
its  albuminous  nature. 

Hut  little  is  known  with  certainty  regarding  the 
causes  and  nature  of  amyloid  formation.  It  is  one  of 
I  lie  most  common  pal  holoL'i eal  conditions  of  the  body, 
and  may  exist  as  a  local  change,  or  be  widely  distri- 
buted through  many  organs  and  tissues.  It  usually 
occurs  as  a  slowly  progressive  disease  in  association 
with  various  cachectic  conditions.  In  these  eases  of 
widespread  formation  it  must  be  the  result  of  some 
general  disturbance  of  metabolism.  The  amyloid 
substance  does  not  exist  in  the  blood  as  such,  but  the 
material  from  which  it  is  formed  may  be  derived  from 
the  blood,  or  some  ferment  circulating  in  the  blood 
may  cause  a  fermentative  coagulation  of  albuminous 
substances  outside  of  the  vessels.  Though  called 
amyloid  degeneration,  the  process  is  not  to  be  classed 
with  the  true  degenerations  of  cell  protoplasm,  but  is 
rather  to  be  regarded  as  a  pathological  deposit,  in  the 
tissues,  of  a  substance  derived  from  the  circulation. 
It  has  been  conclusively  shown  that  the  cells  of  the 
affected  tissue  take  no  active  part  in  the  formation  of 
amyloid.  The  location  of  the  deposit  is  practically 
always  in  the  walls  of  the  blood-vessels  or  in  the  inter- 
stices  of  the  tissues  immediately  around  the  vessel-, 
and  the  organs  which  show  the  greatest  degree  of  the 
change  are  those  abundantly  supplied  with  blood,  as 
the  liver,  spleen,  and  kidneys.  It  is  possible  that  the 
amyloid  substance  is  the  result  of  the  union  of  some 
albuminous  material  derived  from  the  blood  with 
some  constituent  of  the  tissues,  and  that  the  lowered 
vitality  of  the  tissues  resulting  from  general  or  local 
disturbances  of  nutrition  favors  its  formation;  or,  as 
the  result  of  impaired  nutrition,  a  peculiarly  modified 
albuminous  body  may  be  separated  from  the  blood 
through  the  activity  of  the  secretory  cells  of  the  blood- 
vessel  walls.  As  the  chief  seat  of  the  amyloid  deposit 
is  always  just  outside  the  endothelium  of  the  blood- 
vessels, it  becomes  highly  probable  that  it  is  a  product 
of  endothelial  cell  activity,  and  is  deposited  in  the 
tissues  outside  the  endothelium  in  a  manner  analogous 
to  the  deposit  of  hyalin,  lime  salts,  or  silver  pigment. 
This  pathological  secretion  may  be  the  result  of 
general  changes  in  the  circulation  whereby  the  secre- 
tory function  of  the  cells  of  the  vessels  is  changed,  or 
the  changes  may  be  primary  in  the  cells  themselves. 
The  fact  that  local  deposits  of  amyloid  occur  without 
apparent  general  changes  of  nutrition  favors  this  view. 
Another  probability  is  that  the  formation  of  amydoid 
outside  of  the  blood-vessels  depends  upon  the  action 
of  a  ferment  derived  from  the  blood,  this  ferment 
causing  a  coagulation  and  precipitation  in  the  damaged 
tissues  of  some  decomposition  product  of  albumin. 
Of  the  origin  of  this  ferment  nothing  is  known. 
According  to  Davidsohn  it  is  probably  formed  in  the 
spleen,  since  experimental  amyloidosis  cannot  be 
produced  in  splenectomized  white  mice.  In  the 
widespread  deposit  of  amyloid  in  cachectic  conditions 
the  pathological  condition  of  the  cells  may  be  pro- 
duced by  the  altered  state  of  the  blood  or  by  toxins; 
in  the  local  deposits  it  may  be  due  to  local  changes  in 
the  vessels,  caused  by  local  inflammatory  processes. 


303 


Amyloid 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


In  the  majority  of  cases  the  deposit  of  amyloid 
appears  as  a  secondary  phenomenon  in  various 
cachectic  states,  being  most  commonly  associated  with 
chronic  tuberculosis  of  the  lungs  and  bones,  chronic 
staphylococcus  osteomyelitis,  chronic  suppurative 
processes,  syphilis  both  congenital  and  acquired, 
chronic  dysentery,  and  leucemia.  In  these  diseases 
the  most  extensive  deposits  may  be  found.  It  rarely 
occurs  in  the  cachexia  of  carcinoma,  and  usually  only 
when  there  is  ulceration  of  the  growth.  Amyloidosis 
has  also  been  observed  in  cases  of  hypernephroma. 
1 1  is  also  found,  though  less  frequently,  in  association 
with  pseudoleucemia,  chronic  arthritis,  nephritis, 
chronic  diarrhea,  typhoid  fever,  prolonged  malaria, 
chronic  gonorrhea,  chronic  empyema,  chronic  bron- 
chitis, bronchiectasis,  pyelitis,  gout,  lead  poisoning, 
beriberi,  actinomycosis,  hypertrophic  cirrhosis,  and 
after  severe  forms  of  rachitis.  Occasionally  there  may 
occur  in  children  a  widespread  deposit  of  amyloid 
without  any  discoverable  cause. 

According  to  Cohnheim,  amyloid  deposits  may 
become  well  developed  in  from  two  to  three  months. 
Czerny  and  Krawkow  claim  to  have  produced  it  in 
animals  in  from  three  to  sixty  days  through  the  estab- 
lishment of  suppurative  processes,  caused  by  inject- 
ions of  turpentine  and  of  staphylococci.  Experi- 
ments made  in  Ziegler's  laboratory  throw  doubt  upon 
these  investigations  although  they  are  generally 
accepted.  The  administration  of  the  sodium  salt  of 
chondroitin-sulphuric  acid  to  animals  does  not  pro- 
duce amyloid  change  (Oddi,  Kettner,  Wells).  There 
is  also  no  evidence  that  amyloid  is  formed  from  dis- 
integrating red  blood-cells.  Experimental  amyloidi  isis 
has  also  been  produced  by  injections  of  gonococci  and 
other  bacteria,  various  bacterial  products  and  many 
chemical  substances.  Amyloidosis  is  not-uncommon 
in  white  mice  affected  with  carcinoma  or  sarcoma,  but 
will  not  develop  in  such  mice  after  extirpation  of  the 
spleen.  Amyloidosis  is  also  said  to  occur  in  horses 
used  for  the  production  of  antidiphthcritic  serum 
(Pearce  and  Pease).  As  a  rule,  the  formation  of 
amyloid  takes  place  very  slowly.  It  occurs  most 
frequently  between  the  tenth  and  thirtieth  years,  but 
may  be  found  in  new-born  infants  (congenital  syphilis) , 
and  also  in  extreme  old  age. 

Occurrence. — Amyloid  occurs  most  frequently  as 
a  widespread  deposit  in  one  or  several  organs,  especi- 
ally affecting  the  spleen,  liver,  kidneys,  and  lymph 
glands.  Next  to  these  the  mucosa  of  the  endocar- 
dium, stomach  and  intestine,  the  adrenals,  and  the 
omentum  may  show  a  marked  degree  of  the  change. 
In  all  of  the  organs  it  may  occur  to  such  an  extent 
that  it  affects  greatly  the  gross  appearance.  It  is 
less  frequently  found  in  the  intima  of  the  great  vessels, 
mucosa  of  the  respiratory  and  urinary  passages,  thy- 
roid, lungs,  ovaries,  testicles,  prostate,  bone  marrow, 
salivary  glands,  and  muscle.  In  these  its  occurrence 
is  usually  so  limited  that  its  presence  can  be  made  out 
only  by  means  of  the  microscope. 

The  degree  of  the  change  varies  very  much  in 
different  cases.  The  kidneys  may  show  a  marked 
deposit  while  the  other  organs  may  contain  but  little 
amyloid;  in  other  cases  the  liver  or  spleen  may  be  the 
chief  seat  of  the  change.  The  primary  seat  of  the 
deposit  and  the  order  in  which  the  different  organs  a  re 
affected  vary  with  the  individual  case,  and  bear  no 
definite  relation  to  the  associated  pathological 
condition. 

Local  deposits  of  amyloid  occur  rarely  in  single  lymph 
glands  following  inflammatory  processes  (mesenteric 
glands  after  typhoid),  in  scars,  local  inflammations, 
hyperplastic  growths,  tumors  (osteofibroma  of  tongue, 
chondroma  of  lung),  in  the  tongue,  tonsils,  larynx, 
trachea,  and  bronchi,  following  syphilitic  processes 
in  the  wall  of  the  urinary  bladder,  and  in  the  scars  of 
liver  gum  ma  ta.  Klebs  obtained  the  amyloid  reactions 
in   a   hard  chancre.     Numerous  authors  have  found 


amyloid  in  pathological  conditions  of  the  cornea  and 
conjunctiva  (trachoma,  staphyloma,  etc.).  It  has 
also  been  found  in  old  blood  clots  and  thrombi,  and 
frequently  in  the  cartilages  of  old  individuals  who 
have  presented  none  of  the  pathological  conditions 
with  which  amyloid  is  usually  associated.  Localized 
amyloid  is  sometimes  found  in  tumors,  usually  in 
endotheliomata.  These  local  deposits  of  amyloid 
sometimes  form  tumor-like  masses  under  conditions 
in  which  it  is  impossible  to  establish  any  relationship 
between  them  and  any  other  pathological  process. 
The  causes  and  manner  of  formation  of  localized 
amyloid  are  unknown.  There  appears  to  be  some 
relationship  between  cartilage  and  elastic  tissue  and 
these  localized  amyloid  masses.  In  the  local  forma- 
tions the  amyloid  is  found  chiefly  around  the  lymph- 
vessels,  but  also  in  the  vessel-walls  and  tissue-spaces. 
On  the  whole  these  local  amyloid  deposits  must  be 
very  rare;  and  it  is  probable  that  hyaline  formations 
have  sometimes  been  mistaken  for  amyloid.  In  a 
wide  and  varied  pathological  experience  I  have  never 
seen  any  localized  deposits  of  true  amyloid.  The 
corpora  amylacea  found  in  the  prostate,  nervous 
-\  stem,  lung,  etc.,  sometimes  give  a  reaction  resembl- 
ing that  of  amyloid  (see  Corpora  Amylacea). 

Macroscopical  Appearances. — When  the  de- 
posit of  amyloid  is  at  all  extensive,  it  is  readily  rec- 
ognizable by  the  naked  eye;  but  the  degree  and 
nature  of  the  deposit  and  of  the  associated  degenera- 
tive conditions  vary  so  much  that  no  general  descrip- 
tion can  be  given  which  will  apply  to  all  cases.  The 
organ  is  usually  swollen  and  plumper  that  normal,  its 
edges  are  more  rounded  and  its  fissures  deepened. 
Its  volume  and  weight  are  increased,  the  latter 
sometimes  four-  to  fivefold.  The  consistency  is 
greatly  increased;  in  severe  cases  the  organ  may 
have  a  wooden  hardness.  There  is  also  a  great  loss 
of  elasticity,  so  that  pressure  indentations  made  upon 
the  surface  of  the  organ  remain  for  a  long  time.  The 
blood-content  of  the" affected  organ  is  usually  greatly 
diminished,  so  that  its  color  becomes  grayish  or  yellow 
if  much  fatty  change  is  present.  Very  characteristic  is 
the  shining,  translucent,  waxy  appearance  of  the  cut 
surface,  resembling  that  of  bacon  (lardaceous).  The 
differences  in  histological  structure  of  the  various 
organs  lead  to  individual  appearances  when  amyloid 
is  present,  and  these  will  be  described  separately. 

The  iodine  test  is  best  applied  to  fresh  tissue.  A 
moderately  strong  LugoPs  solution  should  be  used 
after  washing  out  the  blood  with  dilute  acetic  acid, 
as  the  color  resulting  from  the  combination  of  the 
red  hemoglobin  and  yellowish-brown  iodine  very 
closely  resembles  the  mahogany  red  of  the  amyloid. 
The  iodine  solution  is  poured  over  the  freshly  cut 
surface,  allowed  to  stand  for  a  minute  or  so,  and  then 
washed  off.  The  amyloid  areas  are  reddish-brown, 
the  non-amyloid  ones  yellow.  If  dilute  sulphuric 
acid  is  now  applied,  the  amyloid  portion  may  become 
dark  green  to  black,  or  dark  violet,  while  the  unaffected 
tissue  is  of  a  clear  gray  color.  This  gross  reaction 
is  plainly  seen,  as  a  rule,  only  when  the  amyloid 
deposit  is  marked;  but  sometimes,  as  in  the  intima 
of  the  large  arteries,  it  may  be  brought  out  very 
distinctly  when  no  other  appearances  point  to  the  pres- 
ence of  amyloid  (see  Plate  VII.). 

Microscopical  Appearances.  —  Microscopically, 
amyloid  appears  as  a  homogeneous,  hyaline  substance, 
of  "rather  high  refraction,  which  is  deposited  al- 
most exclusively  in  the  walls  of  the  capillaries  and 
smaller  arterioles  and  veins.  In  its  earliest  stages  it 
appears  as  a  homogeneous  layer  outside  the  endothel- 
ium, but  in  more  advanced  cases,  owing  to  the 
atrophv  of  the  intervening  tissue,  the  masses  of  amy- 
loid increase  greatly  in  size  and  may  finally  become  con- 
fluent, so  that  the  entire  tissue,  or  a  large  part  of  it, 
may  be  replaced  by  amyloid.  The  amyloid  in  the 
tissue-spaces    probably  lies  around    the    small    lym- 


304 


REFERENCE    HANDBOOK 

OF  THE 

MEDICAL    SCIENCES 


PLATE    VI 


~»*. 


^ 


Fig.  3. 


Fig.  1. 


H 


Fig.  2. 


AMYLOID   DEGENERATION    IN    DIFFERENT  ORGANS 


FIG.  1.  Section  i if  an  Amyloid  Liver,  Showing  the  Effects  of  stain- 
ing  it  Willi  aSolutionof  Iodine,  re.  Normal  liver  tissue;  '>.  tissue  tliat 
has  undergone  amyloid  degeneration;  c,  Glisson's  capsule  magnified 
35  diameters.    (Ziegler.) 

Fig.  2.— Amyloid  Kidney,  stained  with  Aniline  Violet.  The  amy- 
loid is  stained  red.  The  deposit  is  most  marked  in  the  capillaries  of 
the  glomeruli  and  in  the  small  arteries,  and  is  seen  also  as  a  tine 
hyaline  ring  surrounding  the  membrana  propria  of  the  tubules.  Mag- 
nified 400  diameters,    i  Ribbert.) 


Fig.  3.— Section  of  an  Amyloid  Liver  After  being  Treated  with 
Methyl  violet  and  Acetic  Acid,  a.  Elongated  masses  of  liver  cells ;  6, 
amyloid  substance:  i\  endothelium  of  the  capillaries;  e,  colorless 
blood  corpuscles.    Magnified  150  diameters.    (Ziegler.) 

Fig.  4. — Amyloid  Degeneration  of  the  Follicles  and  Pulp  of  the 
Spleen.  (Alcohol;  methyl  violet;  hydrochloric  acid.)  «.  Follicular 
tissue  in  a  marked  state  of  amyloid  degeneration;  o.  pulp  tissue  in 
which  the  degeneration  has  begun.  Magnified  300  diameters. 
(Ziegler.) 


i: i ; i  1 : i :  1  x <  i :   handbook   ok  tiii:   medical  SCIENCES 


Amyloid 


phatics.  In  severe  grades  of  amyloid  formation  the 
fibers  of  the  connective-tissue  reticulum  and  the  base- 
menl  membranes  of  the  glands  may  give  an  amyloid 
reaction  so  that  the  entire  organ  or  tissue  may  appear 
tn  have  undergone  an  amyloid  transformation. 
In  this  way  large  nodules  or  tumor-like  masses  are 
formed.  I'  must  be  emphasized,  however,  that  inits 
earliest   stages   the   first    appearance  of  amyloid   is 

rys  next   to  endothelium. 
[t  is   never   deposited    in   living   cells.      The   tissue 
Cells  proper  take  no    active  put     in  the  process,   and 

the  cnanges  found  in  these  cells  are  to  be  regarded  as 

secondary.     The    lumen    of    the    affected    vessel    is 

,,.„   narrowed  by  the  increasing  deposit,  and   the 

ilting  disturbance  of  blood  supply  leads  to  degen- 

ve   changes    (atrophy    and    fatty    degeneration) 

of  the  cells  of  the  affected    region.      Pressure-atrophy 

is  commonly  found  in  the  amyloid  liver,  while  el lv 

swelling  anil  fatty  degeneration  arc  more  common   in 

unyloid  kidney.  The  deposit  of  amyloid  between 
ami  around  the  cells  near  the  blood-vessels  leads  to 
similar    changes.     The     individual    vessels     are    not. 

illy  affected  throughout,  and  different  vessels 
of  the  same  organ  may  show  the  change  in  very 
different    degrees. 

The  microscopical  appearance  of  amyloid  in  sec- 
tions stained  with  hematoxylin  and  eosin  is  so  similar 
to  that  of  hyalin  that  a  differential  diagnosis  be- 
tween the  two  deposits  can  be  made  only  by  means  of 

e  specific  staining  reaction.  Of  these  the  be  I 
and  most  practical  is  the  Van  Gieson  method.  The 
sections  are  overstained  in  hematoxylin  and  then 
stained  for  one-half  to  one  minute  in  a  concentrated 
water  solution  of  picric  acid  to  which  enough  of  a 
concentrated  water  solution  of  acid  fuchsin  has 
been  added  to  give  it  a  distinctly  red  color.  By  this 
met  hod  amyloid  is  stained  a  pinkish-brown  or  yellow, 
while  hyalin  takes  a  deep  red  color. 

The  iodine  reaction  does  not  show  so  well  in  hard- 
ened material,  so  is  best  applied  to  fresh  tissue.  The 
specific  reactions  of  amyloid  with  various  aniline 
dyes  are  classic  in  the  history  of  microchemistry,  and 
it  is  largely  to  the  wonderful  amount  of  interest  be- 
stowed upon  these  that  this  branch  of  pathological 
technique  owes  a  very  great  part  of  its  development. 
The  aniline  stains  most  commonly  used  are  methyl  and 
gentian  violet,  methyl  green,  thionin,  toluidin-blue, 
kresyl-echt-violett,  and  iodine  green.  The  amyloid 
tissue  is  best  hardened  in  alcohol  or  formol  and  cut 
without  embedding  or  upon  the  freezing  microtome 
after  washing  out  the  alcohol.  The  sections  are 
then  stained  for  five  to  ten  minutes  in  a  two  to  five 
per  cent,  solution  of  the  stain,  differentiated  with 
dilute  acetic  acid,  and  mounted  in  glycerin  or  syrup. 
With  all  of  these  stains  amyloid  exhibits  a  metachro- 
masia.  Methyl  and  gentian  violet,  kresyl-echt-violett, 
ami  iodine  green  stain  the  amyloid  portion  ruby  red, 
while  the  non-amyloid  is  stained  blue.  Methyl  green 
stains  the  amyloid  a  sky-blue,  the  non-amyloid  tissue 
a  bright  green.  Thionin,  toluidin-blue,  polychrome- 
methylene  blue  and  other  metachromatic  dyes  are 
used  to  give  similar  reactions  with  amyloid,  but  are 
not  as  satisfactory,  as  kresyl-echt-violett  which  is 
best  used  in  a  five  per  cent,  carbolic  acid  solution. 
The  best  metachromatic  stains  are  secured  by  fixing 
in    formol    for   twenty-four   hours,   sectioning    on   a 

ing  microtome,  staining,  and  examining  in  water. 
The  metachromatic  reactions  are  not  satisfactory 
with  celloidin  sections  but  good  results  can  be  ob- 
tained, with  paraffin  sections.  Amyloid  may  also  be 
stained  with   scharlach    R  and    Sudan    III,   but  the 

Its  are  not  satisfactory.  The  reactions  with 
the  fat-dyes  are  due  to  the  presence  of  lipoids  in  the 
amyloid  tissue.  None  of  the  metachromatic  reac- 
tions is  permanent;  the  sections  so  treated  gradually 
fade.  On  the  whole,  the  Van  Gieson  method, 
which  can  be  applied  to  either  paraffin  or  celloidin 
sections,  is  the  most  convenient  and  practical  stain  for 

Vol.  I.— 20 


the  differentiation   of   amyloid,  since  it    differentiates 

connective-tissue    hyalin    by   staining   it    deep    red; 

and  epithelial  hyalin  which  stains  like  amyloid 
with  this  stain  is  differentiated  by  its  different  tissue- 
relations.      The    variability    in    staining    of    amyloid 

may  be  dependent  upon  differences  of  composition  as 

well  as  of  density.  The  met  hyl-violet  reaction 
appears  to  depend  upon  the  albuminous  constituents, 
while  the  iodine  reaction  depends  upon  unknown 
substances  that  can  in  various  ways  be  removed  from 
the  amyloid. 

Liecr. — This  organ  is  very  frequently  I  he  seat  of 
amyloid  deposit.     Outside   the  endothelium   oi    the 

liver  capillaries,  between  it  and  the  liver  cells,  t  here  is 
deposited  a  layer  of  amyloid,  which,  as  it  increases  in 
thickness,  presses  upon  the  liver  cells  and  separates 
them  from  their  normal  relations  with  the  blood,  SO 
that  (hey  undergo  atrophy  and  degeneration,  and 
finally  may  entirely  disappear.  The  amyloid  masses 
thus  become  confluent,  the  capillary  walls  are  pressed 

together,  and  the  only  cells  left  in  the  area  are  the 
endothelial  cells,  which  may  persist  for  a  long  time. 
The  intermediate  zone  of  the  lobule  is  almost  always 
affected  to  a  greater  extent  than  either  the  central 
or  the  peripheral  one.  The  walls  of  the  larger  blood- 
vessels may  also  show  the  deposit.  In  more  advanced 
cases  the  entire  lobule  may  be  replaced  by  amyloid. 
This  marked  change  is  usually  confined  to  single 
scattered  lobules,  so  that  these  appear  to  the  naked 
eye  as  grains  of  boiled  sago  (sago-liver).  More  rarely 
the  greater  part  of  the  liver  may  be  replaced  by  con- 
fluent masses  of  amyloid,  whereby  the  organ  acquires 
a  wooden  hardness  and  on  section  resembles  the 
translucent  portions  of  bacon  (S  peck-leber) . 

Spleen. — In  the  spleen  the  amyloid  deposit  takes 
place  in  the  fine  reticulum  of  the  pulp  beneath  the 
endothelium  of  the  blood  spaces.  The  follicles  may 
alone  be  affected,  appearing  enlarged  and  translucent 
like  boiled  sago  (sago  spleen);  or  the  chief  deposit 
may  be  throughout  the  pulp,  or  may  involve  both 
pulp  and  follicles  (Speckmilz,  Schinkenmilz,  lardace- 
ous  spleen).  The  arterioles  of  the  follicles  are  often 
the  only  portions  of  the  organ  which  show  the  deposit, 
and  it  is  in  these  that  the  earliest  appearance  of 
amyloid  in  the  body  as  a  rule  occurs.  The  lymphoid 
cells  disappear,  and  the  spleen  may  ultimately  con- 
sist only  of  an  amyloid  network  between  and  around 
the  blood  spaces,  the  endothelium  of  which  may  be 
preserved. 

Kidney. — The  afferent  arterioles  of  the  glomeruli 
are  usually  first  affected,  then  the  glomerular  capil- 
laries and  efferent  vessels,  and  finally  the  smaller 
vessels  throughout  the  entire  organ.  The  change  is 
never  so  marked  in  the  medullary  pyramids  as  in  the 
cortex,  but  it  may  appear  early  in  the  straight  vessels 
of  the  former.  As  the  disease  advances  the  deposit 
extends  from  the  intertubular  capillaries  to  the 
basement  membrane  of  the  tubules,  which  may  ap- 
pear as  if  surrounded  by  a  hyaline  ring.  The  intinia 
of  the  larger  branches  of  the  renal  artery  may  show 
small  and  irregularly  scattered  deposits.  Since  the 
glomeruli  are  the  chief  seat  of  the  deposit,  they 
appear  on  the  freshly  cut  surface  of  the  organ  as  small, 
firm,  translucent  dots  usually  about  the  size  of  pin- 
heads.  Marked  fatty  degeneration  and  cloudy 
swelling  of  the  renal  epithelium  are  always  present, 
and  the  kidney  presents  the  microscopic  picture  of  a 
chronic  parenchymatous  nephritis,  more  rarely  that 
of  a  chronic  interstitial  process. 

Lymph  Glands. —  Extensive  amyloid  deposit  is  not 
common  in  the  lymph  glands,  but  scattered  masses 
are  very  frequently  found  in  them;  and  the  walls  of 
their  small  arterioles  usually  show  a.  moderate  degree 
of  change  in  all  cases  in  which  the  liver,  spleen,  and 
kidneys  are  extensively  affected.  Local  inflamma- 
tory changes,  both  of  the  lymph  glands  and  the  tonsils, 
are  frequently  accompanied  by  the  formation  of 
small  masses  of  amyloid  in  connection  with  hyaline 

305 


Amyloid 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


deposit,  and  the  close  relation  of  these  substances  is 
nowhere  else  so  well  shown  as  in  these  organs.  In 
advanced  cases  the  deposit  may  extend  from  the 
neighborhood  of  the  capillaries  into  the  reticulum, 
causing  atrophy  of  the  lymphadenoid  cells. 

Muscle,  Fat  Tissue,  etc. — In  striated  muscle  amy- 
loid deposit  is  rarely  found.  It  has  been  found  in  the 
tongue  and  in  the  muscles  of  the  larynx  in  the  shape 
of  nodular  masses.  The  deposit  takes  place  first  in 
the  walls  of  the  capillaries  of  the  endomysium,  and  as 
it  increases  in  size  the  sarcolemma  comes  to  be  sur- 
rounded by  a  clear,  hyaline  mass.  As  the  muscle 
fiber  is  thus  separated  from  its  blood-supply  it  under- 
goes atrophy  and  degeneration,  finally  disappearing,  so 
that  the  deposits  of  amyloid  become  confluent  into 
nodular  masses.  A  similar  process  may  take  place 
in  heart  muscle  and  in  unstriped  muscle,  but 
is  of  rare  occurrence.  The  amyloid  deposits  in  striped 
muscle  occur  very  frequently  in  the  scars  of  gum- 
mata,  but  occasionally  no  evidences  of  preceding 
pathological  changes  can  be  made  out.  Adipose  tissue 
is  often  extensively  affected  by  amyloid  disease, 
the  deposit  taking  place  in  the  walls  of  the  larger 
blood-vessels  and  of  the  intercellular  capillaries,  so 
that  the  fat  cells  come  to  be  surrounded  by  a  thin 
hyaline  layer. 

Heart. — Amyloid  degeneration  of  the  endocardium, 
particularly  in  the  right  auricle,  is  not  rare.  I  If 
rarer  occurrence  is  the  formation  of  amyloid  in  the 
myocardium. 

Adrenals. — In  this  organ  the  cortex  is  usually  the 
seat  of  amyloid  change.  As  the  amyloid  is  formed 
between  the  capillary  wall  and  the  epithelial  cords 
the  latter  undergo  atrophy  and  may  in  part 
disappear. 

Mucous  Membranes. — The  mucous  membranes  of 
the  respiratory  tract  are  very  rarely  affected.  Scat- 
tered deposits  may  occur  in  the  mucosa  of  the 
stomach  and  intestine,  producing  more  or  less  ex- 
tensive thickenings  of  the  mucosa,  which  show  the 
characteristic  homogeneous,  glassy  appearance  of 
amyloid.  Large  elevations  may  undergo  ulceration, 
and  at  the  bottom  of  the  ulcer  remains  of  the  amyloid 
may  be  preserved.  The  large  intestine  is  more 
frequently  affected  than  the  small.  The  deposit  is  in 
the  walls  of  the  capillaries  of  the  mucosa  and  sub- 
mucosa,  particularly  in  those  of  the  villi;  amyloid 
deposits  also  occur  in  the  intestinal  muscularis. 
Only  in  very  rare  cases  is  amyloid  found  in  the  mucosa 
of  the  genito-urinary  tract. 

General  Nature  op  Amyloid  Disease. — As 
stated  above,  the  formation  of  amyloid  is  almost 
always  secondary  to  other  processes  which  are 
ulcerative  or  inflammatory  in  character,  and  of  in- 
fective nature.  While  not  in  itself  a  true  degenera- 
tion of  ceil  protoplasm,  the  process  is  essentially 
degenerative  in  character,  in  that  it  leads  to  marked 
disturbances  of  nutrition.  The  deposit  in  the  walls 
of  the  blood-vessels  leads  to  partial  or  complete  ob- 
literation of  their  lumina,  thus  producing  permanent 
interference  with  the  circulation.  As  a  result  of  this 
disturbance  of  nutrition,  atrophy,  fatty  degeneration, 
or  necrosis  of  the  tissue  cells  takes  place.  The  pres- 
sure of  the  amyloid  deposits  between  the  cells  leads  to 
similar  results.  Fatty  degeneration  and  infiltration 
are  almost  always  present  to  a  greater  or  less  degree 
in  amyloid  disease,  and  to  a  certain  extent  must  be 
regarded  as  coincident  processes  produced,  perhaps,  by 
the  same  general  disturbances  of  metabolism  which 
give  rise  to  amyloid.  Severe  anaemia  is  usually 
associated  with  the  condition,  and  death  takes  place  as 
a  rule  from  a  gradually  increasing  marasmus.  The 
presence  of  the  amyloid  in  the  tissues  does  not 
usually  set  up  any  local  reactive  process.  Only 
rarely  (usually  in  local  amyloid  formations)  does 
the  amyloid  act  as  a  foreign  body  and  give  rise  to  the 
formation  of  foreign-body  giant  cells  that  may  exert 


a  phagocytic  action  upon  fragments  of  amyloid. 
The  formation  of  such  phagocytic  foreign-body 
giant  cells  has  been  observed  in  the  experimental 
amyloidosis  of  rabbits. 

Symptoms. — The  marked  alterations  in  the  struc- 
ture of  the  affected  organs  and  tissues  lead  to  func- 
tional disturbances,  which,  however,  may  be  very 
slight  when  compared  to  the  extent  of  the  deposit. 
The  general  clinical  picture  of  the  condition  will  vary, 
of  course,  with  the  organ  affected  and  with  the  extent 
of  the  disease,  so  that  a  comprehensive  description 
is  not  possible.  Moreover,  from  the  nature  of  the  case, 
it  is  manifestly  difficult  or  impossible  to  separate  the 
symptoms  of  amyloid  deposit  from  those  of  the  dis- 
ease leading  to  or  associated  with  it.  The  nature 
of  the  primary  process  will  modify  very  much  the 
clinical  appearances  dependent  upon  the  amyloid 
change.  Frequently  the  beginning  of  the  condition  is 
shown  by  a  rapid  increase  in  the  marasmus  already  exis- 
ting, and  by  the  enlargement  of  liver  and  spleen.  These 
phenomena  are  always  more  marked  in  syphilis  and 
in  chronic  ulcerative  processes  than  in  pulmonary 
tuberculosis.  In  such  conditions  as  chronic  varicose 
ulcers  of  several  years'  standing  a  rapid  increase  of  the 
cachexia  is  usually  pathognomonic  of  amyloid  disea 

Associated  with  enlargement  of  the  liver  certain 
disturbances  of  digestion  go  hand-in-hand:  absence 
of  bile-pigment  in  the  feces,  fecal  decomposition, 
meteorism,  etc.  Icterus  is  rarely  present,  and  ascites 
only  as  associated  with  a  general  hydremic  or  cachectic- 
anemia.  Marked  amyloid  deposit  in  the  kidneys  is 
not  always  known  by  disturbances  of  its  function. 
The  urine  may  show  no  changes;  but  as  a  rule  al- 
bumin is  present,  the  amount  is  increased,  and  the 
sediment  contains  hyaline  casts,  though  usually  not 
in  great  numbers.  The  latter  never  give  the  amyloid 
reaction,  in  spite  of  the  repeated  statements  that 
they  do.  As  amyloid  deposit  in  the  kidneys  is,  in  the 
majority  of  cases,  associated  with  chronic  inflamma- 
tory changes,  the  character  of  the  urine  may  vary 
greatly.  Usually  the  picture  is  that  of  a  chronic 
parenchymatous  nephritis.  Marked  amyloid  dis- 
ease of  the  intestine  is  usually  accompanied  by  foul 
diarrhea. 

Diagnosis. — The  nature  of  the  primary  affection 
must  first  be  considered.  If  in  patients  affected 
with  any  one  of  the  chronic  diseases  known  to  be 
associated  with  amyloid  (chronic  tuberculosis,  syphi- 
lis, chronic  suppurative  processes),  painless  swellings 
of  the  liver  and  spleen  arise,  in  association  with  albu- 
minuria and  extreme  paleness  of  the  skin  and  mucous 
membranes,  the  diagnosis  of  amyloid  is  made  very 
probable,  but  in  early  stages  of  the  disease  the 
diagnosis  is  difficult. 

Duration. — The  earliest  stages  of  amyloid  change 
cannot  be  ascertained  clinically.  It  is  probable  that 
in  many  cases  the  process  develops  through  several,  or 
even  many  years,  with  alternate  periods  of  improve- 
ment and  exacerbation.  It  may,  however,  develop 
within  shorter  periods,  as  in  a  case  observed  by 
Cohnheim,  in  which  suppuration  of  bone  after  a  frac- 
ture led  to  well-developed  amyloid  disease  within  a 
few  months.  The  duration  of  well-marked  cases  de- 
pends upon  the  organ  chiefly  affected.  Extensive 
changes  in  the  kidney  are  much  more  serious  than 
those  of  the  liver  or  spleen,  as  they  may  lead  to 
.death  within  a  few  weeks  or  months. 

Prognosis. — This  is  in  general  unfavorable.  It  is 
probable  that  amyloid,  when  once  formed,  is  not 
removed  from  the  site  of  deposit.  In  all  cases  in 
which  the  condition  is  so  marked  that  the  diagnosis  is 
certain,  death  usually  occurs  within  short  periods. 
Temporary  improvement  may  take  place;  and  in  some 
cases,  especially  after  operation  for  chronic  purulent 
conditions  of  bone,  the  disease  apparently  comes  to  a 
standstill,  marked  general  improvement  takes  place, 


306 


REFERENCE    EANDBOOK    OF    THE    MEDICAL   SCIENCES 


Amylum 


the  liver  swelling  decreases,  and  the  albuminuria  dis- 
appears It  is,  of  course,  impossible  to  say  to  what 
extent  these  symptoms  were  due  to  the  amyloid 

A  similar  improvement  has  been  -  the 

jl  ,,,'  a  prolonged  inunction  cure  in  a  case  of  amy- 
loid associated  with  syphilis  so  that  the  |  is  in 
syphilitic  amyloid  is  usually  regarded  as  more  favor- 
able. Corneal  tumors  may  slowly  disappear  under 
the  influence  of   local   irritation   and   inflammation. 

Treatment. — For  the  well-established  condition 
it  is  hardly  probable  that  treatment  will  avail,  though 
iodine,  ammonium  chloride,  potassium  iodide,  dilute 
nitric  acid,  etc.,  have  been  recommended.  When 
syphilis  is  present  tin-  treatment  should  be  anti- 
syphilitic.  The  improvement  of  the  local  or  general 
primary  condition  is,  of  course,  the  most  important 
therapeutic  line  to  be  followed:  and  in  connection  with 
this  the  general  improvement  of  nutrition.  Of  far 
,  r  importance  are  prophylactic  measures,  even 
to  the  extent  of  such  radical  procedures  as  amputation 
in  cases  of  chronic  varicose  ulcerations,  chronic 
suppuration  of  bone-,  etc.,  in  which  persistent  opera- 
tive and  therapeutic  measures  have  been  without 
result.  General  amyloid  disease  is  much  less  common 
than  it  was  fifteen  years  ago,  and  this  change  is  to  be 
ascribed  to  the  greater  tendency  to  surgical  operations, 
and  the  greater  success  attending  the  preventive  treat- 
ment of  suppurative  processes.  Even  in  the  case  of 
inic  pulmonary  tuberculosis  modern  methods  of 
treatment  seem  to  have  lessened  the  occurrence  of 
amyloid.  Aldeed  Scott  \Yarthin-. 

Amvlopsin. — See  Pancreas.  Anatomy  and  Physiology 
of  the.' 

Amylum. — Starch.      Corn       starch.     The       starch 

grains*  separated  from  the  fruit  of  Zea  mays  Linn£ 

u.  Graminea),  i  V .  S.  P.).     There  appears  to  be  no 

ial  reason  why   the  Pharmacopoeia  should  thus 

restrict  its  requirements  to  corn-starch,  except  that 

this  variety  is  cheap  and  abundant  and  readil3r  defined 


Fig.  1S4. — Section  of  Seed  of  Vetch.  Vicia  salira  Linn,  showing 
rounded  granules  of  starch  in  ceils  otherwise  filled  with  granular 
nitrogenous  substance.      X  190. 


and  described.  Our  account  of  starch,  therefore, 
will  apply  to  the  entire  class,  and  will  be  followed  by 
the  differential  characters  of  the  more  important 
varieties. 

Starch  is  the  ordinary  form  of  reserve  carbohydrate 
nutriment  in  plants,  at  least  in  most  of  those  of  the 
higher  classes,  and  in  many  of  those  of  the  lower 
classes.  It  may  be  reserved  for  but  a  brief  period,  at 
the  point  where  it  is  produced,  or  it  may,  after  pro- 
duction, be  changed  into  diffusible  forms  and  trans- 
ported to  special  storage  reservoirs,  where  it  is  again 
transformed  into  starch,  and  may  remain  for  months 
or  even  for  years.     For  example,  being  produced  only 


under  the  influence  of  light,  it  may  be  consumed  dur- 
ing the  succeeding  hours  of  darkness,  or,  upon  the 
;  hand,  it  may  l>e  transported  to  the  bulb  or  tuber 
of  a  desert  plant,  which  may  exist  dormant  ii 
sand  for  several  years,  consuming  this  starch  supply 
upon  the  recurrence  of  a  period  of  activity.  In  the 
most  highly  developed  and  largest  family  of  plants, 
.  and  in  some  others,  inulin,  a  rel  '  I 
compound,  altogether  replaces  starch  as  a  reserve 
food.     Th  of  starch  present   in  vegetable 

tissues  is  often  very  great,  being  about   seventy  per 


JSi 


Fig.  185. — Wheal  Starch. 


Fie.    1S6. — Maize  Starch. 


cent,  in  dried  potato,  and  about  the  same  in  corn  meal 
and  wheat  flour.  With  the  exception  of  some  rare 
cases  in  which  special  forms  are  found,  starch  occurs 
in  peculiar  grains,  which  are  free  in  the  cell  cavity. 
It  originates  in  a  small  colorless  body  known  as  the 
amylogenic  body,  upon  which  the  starch  gathers 
in  layers,  the  central  body  becoming  the  nucleus,  and 
being  located  in  the  grain  at  the  hilum.  The  numer- 
ous layers  of  the  grain  are  discernible  under  the  micro- 
scope by  their  different  degrees  of  refraction,  due 
apparently  to  different  amounts  of  water,  as  they 
disappear  under  the  effect  of  drying  heat.  The  grains 
may  exist  singly,  or  coherent  in  masses  containing  a 
variable  number.  The  limits  of  this  numerical  varia- 
tion are  often  fairly  constant  in  a  given  plant,  and 


Fig.  1S7. — Potato  Starch. 

may  thus  be  utilized  as  a  characteristic.  This  cohe- 
sion often  produces  peculiar  forms  of  the  grains, 
which  forms  also  become  characteristic.  Even  if 
this  is  not  the  case,  the  form  of  the  grains  in  a  given 
plant  is  usually  characteristic,  as  is  the  position  of  the 
hilum.  The  larger  grains  usually  become  ruptured 
or  fissured  at  the  hilum.  This  fissure  may  be  simple 
or  in  various  ways  compound,  and  the  forms  so  result- 
ing are  also  characteristic.  In  all  starches  in  the 
living  plant  there  must  be  small  grains  of  various 
sizes  in  process  of  formation,  but  the  largest  of  them 
usually  fall  fairly  well  within  certain  limits,  so  that 
the  extreme  limits  of  a  given  variety  are  of  diagnostic 
value.  Although  single  starch  grains  are  colorless 
and  semitransparent.  masses  of  them  are  pure  white. 
Starch  powder  is  very  fine  and  smooth,  but  the  ulti- 
mate grains  are  hard  and  gritty.  They  are  very 
hygroscopic. 

307 


Am.\  linn 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Fig.  188.— A  Granule 
of  Potato  Starch  Swollen 
by  Boiling. 


Starch  has  no  odor,  but  a  peculiar,  though  slight, 
farinaceous  taste.  The  grain  consists  of  two  sub- 
stances, granulose,  which  is  colored  blue  by  iodine, 
and  another  substance  very  similar  to  cellulose, 
colored  pale  yellow  by  iodine.  Starch  is  insoluble  in 
water  and  alcohol.  Several  substances  are  often 
spoken  of  as  solvents  of  starch,  but  they  all  apparently 
change  it  into  some  other  com- 
pound before  the  solution  takes 
place.  Water,  under  the  influ- 
ence of  heat,  converts  it  into 
hydrated  starch,  a  transparent, 
jelly-like  mass,  which  is  then 
soluble  in  water.  Alkali  hy- 
drates of  a  strength  of  more 
than  five  per  cent,  similarly 
dissolve  it.  Both  these  solu- 
tions are  then  precipitated  by 
lime  water,  lead  acetate,  tan- 
nin, and  some  other  reagents. 
Diastase,  the  principal  enzyme 
which  naturally  exists  with 
starch,  is  the  agent  which  in 
the  plant  converts  it  into  sugar,  suitable  for  imme- 
diate use  as  food.  The  same  agent  can  be  made  to 
perform  this  office  artificially,  as  can  dilute  acids  under 
the  influence  of  heat,  and  as  is  done  by  the  natural 
processes  of  digestion  within  the  animal  body.  From 
the  above-mentioned  characters  of  starch,  it  is  seen 
that  it  can  readily  be  obtained  by  grinding  finely  any 
cellular  structure 
which  contains  it, 
washing  out  with  cold 
water  and  filtering  or 
allowing  to  settle.  It 
is  also  seen  that,  be- 
sides the  interest 
which  centers  in 
starch  for  its  own 
value,  the  character- 
istics of  the  starches 
contained  in  different 
plants,  and  more 
especially  in  drugs, 
may  be  utilized  in  the 
identification  of  the 
latter,  in  powdered  form,  as  well  as  in  the  detection 
of  adulterations. 


Fig.   189. — Arrowroot  Starch. 


Varieties. — The  only  certain  means  of  determining 
from  what  source  a  given  specimen  of  starch  has  been 
derived  is  to  examine  it  microscopically,  when  the  size, 
shape,  markings,  and  other  visible  peculiarities  of  the 

granules  will  generally 
suffice  to  make  it  cer- 
tain. The  accompany- 
ing illustrations  of  the 
commoner  kinds  are 
magnified  uniformly 
350  diameters. 

1.  Wheat  Starch,  from 
various  species  and 
varieties  of  Triticum 
L.  (fam.  Graminea  ) 
(Fig.  185).  In  irreg- 
ular, angular  masses, 
which  are  easily  re- 
duced to  powder;  under 
the  microscope  appear- 
ing as  granules,  mostly  very  minute,  more  or  less 
lenticular  in  form,  and  indistinctly  concentrically 
striated.  The  granules  average  about  0.050  milli- 
meter in  diameter. 

2.  Maize,  or  Corn  Starch  (defined  above,  Fig. 
186),  i-  smaller  than  the  preceding,  about  0.030 
millimeter  in  diameter,  of  polyhedral  form,  with 
central   hilum. 

3.  Rice   Starch,  from  Oryza  saliva  L.  (fam.  Gram- 

308 


Fig.  190.  -SaKo. 


ineee)    resembles    maize    starch,    but    is    very    much 
smaller. 

4.  Potato  Starch,  from  Solanum  tuberosum  L. 
(fam.  Solanacecr),  (Fig.  1S7)  consists  of  two  classes 
of  granules  mingled  together — fine  spherical  ours, 
from  0.01  to  0.03  millimeter  in  diameter,  and  large 
ovoid  ones  with  very  eccentric  hilums  and  very 
distinct  ruga-,  recalling  oyster  or  clam  shells,  from 
0.14   to  0.18  millimeter  long. 

5.  Arrow-root,  from  Maranta  arundinacea  L.  (fam. 
Marautacew)  (Fig.  1S9)  is  finer  than  potato  starch, 
which  it  somewhat  resembles;  the  granules  are  more 
spherical,  with  blunter,  thicker  ends,  very  distinct 
eccentric    fissures,    and    less    distinct    ruga.     Canna 


Fig.  192.— Oat  Starch. 


starchy  a  variety  of  arrow-root,  has  enormous  granules, 
nearly  twice  as  large  as  those  of  potato.  Neither  of 
these  varieties  has  the  small  forms  of  that  from 
potato. 

6.  Sago,  chiefly  from  several  species  of  Metroxylon 
Rottb.  (fam.  Sabalacea?)  (Fig.  190)  has  medium-sized 
(0.04-0.07  mm.),  oblong,  rather  irregular,  often 
faceted,  sometimes  shoe-shaped  granules,  with  eccen- 
tric hilum  and  fairly  distinct  ruga.  The  sago  of  com- 
merce is  often  half-cooked,  with  many  of  the  granules 
destroyed,  and  is  still  more  often  merely  tapioca. 

7.  Tapioca  (Fig.  191)  has  spherical,  medium-sized 
granules,  with  large  facets;  commercial  tapioca  is  also 
partly  cooked.      (See  also  separate  article  on  Tapioca). 

Besides  the  above  are  the  starches  of  numerous 
familiar  grains  and  roots,  which  are  not  separated  for 
sale  or  use,  but  which  are  of  interest  in  detecting 
adulterations,  mixtures,  etc.,  or  in  identifying  the 
powders  of  drugs.  The  accompanying  cuts  of  oat 
and  turmeric  starches  will  serve  as  illustrations  of 
this  large  class. 


Fig.  193.— Turmeric  Starch. 


Medical  and  Surgical,  Uses  of  Starch. — This  sub- 
stance can  in  no  sense  be  called  a  medicine,  :i  -  it  is  abso- 
lutely without  physiological  action.  It  is  the  type  of 
crude  carbonaceous  or  non-nitrogenous  food,  and  its 
conversion  into  sugar  in  the  mouth,  stomach,  and  intes- 
tine is  one  of  the  elementary  facts  of  digestive  physi- 
ology. Asa  toilet  powder  the  finer  varieties — rice  and 
corn  starches — are  in  universal  use,  and  one  or  other 
of  these  is  the  foundation  of  most  of  the  proprietary 
powders. 

Boiled  starch,  and  especially  the  flours  of  starchy 
substances,  are  frequently  used  as  poultices,  but  they 


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Anuphrurilslacs 


arc  mil  so  convenient  and  suitable  as  the  mucilaginous 
of  linseed  and  slippery  elm. 
Starch  mucilage  is  occasionally  used  for  immovable 
bandages,  but  it  is  less  adhesive  and  less  suitable  for 
ibis  purpose  than  flour  paste,  glue,  dextrin,  silicate  of 
potash,  or  plaster  of  Paris.  One  part  dissolved  glue, 
as  prepared  for  cabinet-makers'  use,  and  two  or  three 
parts  starch  mucilage,  a  little  thinner  than  the  laun- 
dress uses  it,  mixed  and  applied  hot,  make  a  most 

,  Unit  ( ibination  for  such  bandages — light,  very 

and  agreeable  in  color. 
The  only  official  preparation  of  starch  is  the  Glycer- 
Glyceritum  Amyli,  ten  parts  of  starch  dissolved  in 
■i  v  of  hoi  glycerin).     This  is  a  permanent  trans- 
lucent  jelly,    useful    in   moistening    pill    masses,   for 
emulsions     and     similar     purposes.       Iodized      Starch 
i/kiii  I  odd  I  ii  in),  formerly  official,  is  rather  a  prepa- 
ration of  iodine.     It  is  made  by  triturating  five  parts 
of  iodine  with  ninety-five  of  starch,  with  the  aid  of  a  lit- 
tle water.     It  is  a  blue-black  powder,  and  a  suitable 
preparation  to  administer  for  free  iodine  if  it  is  desired 
to  give  that  drug  internally. 

Henry  II.  Rusby. 


Amyotonia  Congenita. — This  disorder  was  first 
described  by  Oppenheim  in  1900,  under  the  term 
\1\  iinnia  Congenita.  It  was  later  called  Amyotonia 
i  ongenita  by  Collier  and  Wilson,  since  the  name 
myotonia  congenita,  or  Thompson's  disease  could 
so  readily  be  confused  with  myatonia  congenita  or 
i  tppenheim's  disease.  It  has  been  termed  congenital 
muscular  atony  by  French  writers.  It  is  a  condition 
illy  found  in  children,  in  which  there  is  extreme 
flaccidity  of  the  muscles  associated  with  the  entire 
loss  of  the  deep  reflexes,  most  marked  as  a  rule  at 
birth,  and  tending  to  slow  but  gradual  amelioration. 
The  muscles  are  weak,  but  are  apparently  not  para- 
lyzed. In  a  paper  which  appeared  in  1904,  Oppenheim 
published  more  in  detail  concerning  the  condition, 
lie  says  that  he  had  observed  for  some  years  children 
of  from  several  months  to  two  years  whose  muscles, 
chiefly  those  of  the  lower  extremities  are  immobile 
and  flaccid.  Objectively  there  is  marked  hypotonus, 
almost  atony,  with  loss  of  the  reflexes.  The  flaccidity 
is  so  marked  at  times  that  the  limbs  can  be  placed 
in  almost  any  position.  The  motility  is  always 
diminished,  varying  considerably  according  to  the 
patient.  In  severe  grades  the  motility  is  almost  nil. 
In  the  milder  cases  certain  groups  of  muscles  may 
ontracted,  but  feebly.  In  very  light  involvement 
the  hypotonus  is  marked,  and  the  patients  lack 
force  in  their  muscular  movements.  In  the  majority 
of  instances  the  lower  extremities  are  involved,  but  in 
a  few,  other  muscles  are  involved.  Thus  far,  the 
eyes,  tongue,  pharynx,  and  diaphragm  seem  to  be 
spared.  The  intercostals  have  been  known  to  be 
affected.  On  palpation,  the  muscles  are  soft  and 
flabby,  are  thin,  but  not  apparently  atrophied. 
Electrical  excitability  is  usually  markedly  diminished, 
at  times  lost,  again  only  slightly  involved.  The 
intelligence  is  apparently  uninvolved,  as  is  also  the 
sensibility.  It  is  apparently  a  congenital  affair. 
There  is  a  tendency  to  progressive  amelioration.  The 
disorder  simulates  infantile  poliomyelitis,  but  has 
nothing  in  common  with  it.  It  is  a  disease  of  the 
muscles. 

This  was  Oppenheim's  disease  as  he  left  it  in  190-1. 
Batten,  Collier  and  Wilson,  Spiller,  Orbison,  Skoog, 
Comby,  Haberman,  and  Maserey  have  written  upon 
it,  and  Chene  published  a  small  thesis  upon  the 
disease  in  1910,  reporting  forty-three  cases.  Marburg 
gave  a  small  study  in  1911.  Spiller  was  the  first  to 
report  upon  the  pathology  in  1905. 

The  general  tendency  has  been  to  regard  the  dis- 
order in  the  light  of  a  dystrophy;  most  of  the  authors 
have  said  that  poliomyelitis  could  be  excluded. 
Marburg,  on  the  other  hand,  claims,  and  with  con- 


siderable    evidence,     that     amyotonia     congenita     of 

Oppenheim  is  a  fetal  poliomyelitis. 

Smith  Eli  Jelliffe. 

Anabolism.— See   V,  tula  lism. 

Anacarcliacea.\ —  Terebinthinaeea  .  (The<  'ashew fam- 
ily.) A  remarkable  and  important  family  of  some 
fifty-nine  genera,  chiefly  tropical  or  subtropical,  ex- 
ceedingly vaired  in  the  nature  of  its  products.    The 

mango,  the  cashew,  and  the  spondias  or  hog-plum, 
are  important  fruits;  those  of  Pistacia  furnish  a  well- 
known  flavoring  agent,  while  the  bark  of  another 
species  yields  the  commercial  resin  mastic;  the  milk 

juice    of    several    Japanese    species   of    Rhus  furnishes 

Japanese  lacquer,  and  the  leaves  and  fruits  of  other 

species  Of  this  genus  yield  tanning  agents.  The  oil 
which  abounds  in  several  species  Of  Rhus  I  more  prop- 
erly called  Toxicodendron),  and  in  some  other  genera, 
acts  as  a  powerful  cutaneous  poison.  (See  Poisonous 
PI, nils.)  II.  II.  RtJSBY. 

Anaemia. — See  Anemia. 

Anaesthesia. — See  Anesthesia. 

Anaesthol. — This  is  an  anesthetic  introduced  by 
Willy  Meyer  of  New  York  to  replace  the  A.C.E. 
mixture.  He  mixes  chloroform  and  ether  in  molecu- 
lar proportions,  i.e.  43.25  per  cent,  of  chloroform  and 
56.75  per  cent,  of  ether  by  volume,  and  calls  the 
mixture  "M.  S."  Of  this  he  takes  eighty-three 
volumes,  and  adds  seventeen  volumes  of  ethyl 
chloride.  The  mixture  has  a  boiling  point  of  40°  C. 
{ 104°  F.),  and  would  seem  to  be  open  to  the  objection 
urged  against  the  A.C.E.  mixture,  that  constituents 
of  different  volatilities  do  not  volatilize  equally. 
We  might  expect  the  ethyl  chloride  to  vaporize 
more  rapidly  than  the  ether,  and  this  more  rapidly 
than  the  chloroform.  The  experience  of  anesthetists 
is  that  the  action  of  the  mixture  is  little  if  any  differ- 
ent from  that  of  pure  chloroform,  and  that  the 
amount  required  is  about  twice  that  of  chloroform. 
In  other  words,  the  quantities  of  ether  and  ethyl 
chloride  are  too  small  to  have  much  effect.  The 
dangers  are  those  of  chloroform. 

W.  A.   Bastedo. 


Analeptics. — This  term  was  formerly  used  to  include 
several  classes  of  agents  which  were  employed  to  re- 
store the  body  to  health,  after  a  period  of  sickness. 
They  were  also  called  restoratives,  and  included  hy- 
giene, rest,  food,  warmth,  stimulants,  and  tonics. 

R.  J.  E.  S. 


Analgesics. — See  Anodynes. 

Anaphrodisiacs. — These  are  agents  which  are  used 
to  lessen  an  immoderate  or  morbid  sexual  desire. 
In  the  usual  and  narrow  acceptation  of  the  term  it 
includes  only  the  medicinal  and  physical  remedies, 
but  "in  a  wider  sense  it  embraces  as  well  all  the 
moral,  dietetic,  hygienic,  and  surgical  measures  hav- 
ing this  end  in  view.  The  causes  of  aphrodisia  are 
many,  and  not  the  least  important  is  reflex  irritation 
of  the  genitalia,  resulting  from  physical  peculiarities  or 
deformities,  phimosis,  stricture  of  the  urethra,  dis- 
ease  of  the  prostate,  chronic  constipation,  hemor- 
rhoids, eczema  or  fissures  of  the  anus,  highly  concen- 
trated urine,  etc.  In  other  cases  the  reflex  irritation 
may  be  caused  by  the  presence  of  worms  in  the  rectum, 
or  in  the  vagina  in  the  case  of  female  children,  and  by 
friction  of  the  thighs  produced  by  horseback  riding, 
bicycling,  running  the  sewing-machine,  etc.  These 
conditions  will  each  call  for  its  own  special  treatment 
in  addition  to  the  general  measures  which  should  be 

309 


Anaphrodisiacs 


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adopted;  for  the  detection  and  relief  of  the  exciting 
cause  are  difficult  problems  and  far  more  important 
than  the  exhibition  of  drugs.  For  another  class  of 
patients,  those  suffering  from  diseases  of  the  nervous 
system  or  those  with  psychical  perversion,  psycho- 
therapeutic measures  are  of  special  value. 

The  principal  anaphrodisiac  drugs  are  the  bromides, 
camphor,  hops,  salicin,  potassium  iodide,  coniuni. 
and  chloral  and  other  hypnotics.  When  there  is 
excessive  acidity  of  the  urine,  potassium  acetate  may 
be  of  service  indirectly  in  removing  this  source  of 
irritation. 

In  general,  for  the  treatment  of  habitual  sexual 
erethism  nothing  will  be  found  better  than  physical 
and  particularly  mental  work  to  the  point  of  fatigue. 
The  latter  accomplishes  its  results  in  two  ways:  first, 
by  exhausting  the  brain  where  the  sexual  impulse 
(if  not  reflex)  has  its  origin;  and  secondly,  by  so 
absorbing  the  patient's  interest  as  to  preclude  the 
occupation  of  his  mind  by  lascivious  thoughts. 

In  the  general  management  of  a  case  the  physician 
should  advise  a  non-sedentary  life,  as  much  as  possible 
in  the  open  air,  light  diet,  with  an  absence  of  meats, 
coffee,  highly  seasoned  foods,  and  alcoholic  stimulants; 
the  kidneys  should  be  kept  well  flushed,  the  bowels 
well  open,  and  the  patient  should  sleep  on  a  hair 
mattress,  with  light  covering,  in  a  cool,  well-ventilated 
room.  As  a  full  bladder  is  frequently  a  cause  of 
irritation,  U  should  be  emptied  upon  going  to  bed  and 
the  first  thing  in  the  morning.  The  patient  should 
arise  early  and  take  a  cold  douche  or  sponge  bath. 
Charles  Adams  Holder. 


Anaphylaxis. — The  term  anaphylaxis  (from  &m. 
up,  away,  and  <t>v\ai,  guard,  or  0i/Xa|«,  protection! 
also  called  hypersusceptibility,  supersensitiveness, 
allergy,  is  a  condition  of  unusual  or  exaggerated  sen- 
sitiveness of  an  organism  to  foreign  proteins;  in  other 
words,  an  altered  power  of  reaction  toward  such  pro- 
teins. Anaphylaxis  may  be  congenital  or  acquired, 
local  or  general;  it  is  specific  in  nature.  Hypersus- 
ceptibility to  any  strange  protein  in  itself  quite  non- 
poisonous  may  be  readily  induced  in  certain  animals 
by  the  introduction  of  a  minute  quantity  of  that  par- 
ticular protein  into  the  body. 

The  word  anaphylaxis  was  coined  by  Richet  in 
1902  to  suggest  the  opposite  condition  to  prophylaxis, 
or  protection,  since  it  appeared  that  in  certain  cases 
the  second  injection  of  a  poisonous  substance  instead 
of  reinforcing  the  immunity  induced  by  the  first, 
iter  susceptibility,  so  that  less  than  a 
minimal  lethal  dose  of  it  caused  death.  But  more 
recent  investigations  have  shown  that  the  contradic- 
tion between  immunity  and  anaphylaxis  is  only 
apparent,  that  they  have  to  do  with  the  same  general 
mechanism  of  the  animal  body  and  that  in  fact  the 
former  may  be  dependent  on  the  latter.  For  this 
reason  von  Pirquet  has  suggested  the  word  '"allergy 
(fi/./os,  different,  and  ep)-sta,  reactivity)  to  indicate 
an  altered  power  of  reaction  of  the  body  toward  a 
foreign  substance,  thus  combining  in  the  same  term  a 
conception  of  acquired  immunity  and  the  related 
state  of  acquired  hypersusceptibility. 

Historical. — The  first  to  note  and  record  accurately 
his  observation  on  this  altered  power  of  reaction  of 
the  human  body  was  probably  Jenner,  who  at  the 
end  of  the  eighteenth  century  in  England  began  to 
study  the  modification  of  the  form  of  smallpox  by 
previous  vaccination,  and  noted  particularly  the 
immediate  reaction  to  variolous  matter  by  the  skin 
of  persons  who  had  had  either  smallpox  or  cowpox. 
This  we  now  recognize  as  an  anaphylactic  phenome- 
non of  great  importance,  as  we  shall  show  later. 

Early  in  the  last  century  (1839)  Magendie  found 
that  rabbits  which  had  tolerated  two  intravenous 
injections  of  egg  albumin  without  any  ill  effects 
immediately  succumbed  to  a  further  injection  made 


after  a  number  of  days.  Later,  workers  attempting 
to  obtain  precipitins  frequently  found  that  some  of 
their  animals  died  suddenly  during  the  course  of  treat- 
ment from  no  apparent  cause,  though  we  now  know 
they  were  in  a  state  of  anaphylaxis  to  the  foreign 
protein.  Other  analogous  instances  may  be  found 
scattered  throughout  the  literature,  the  true  import 
of  which  was  not  realized  until  1905. 

Von  Behring  and  Kitashima  (1901)  reported  an 
increasing  sensitiveness  on  the  part  of  guinea-pigs 
to  successive  small  doses  of  diphtheria  and  tetanus 
toxins.  This  they  called  the  paradoxical  phenomenon 
or  "hypersusceptibility''  (the  first  use  of  this  term  in 
a  specific  sense).  This  hypersensitiveness  to  toxil  - 
is  not  true  anaphylaxis,  which  is  produced  by  prot 
which  are  non-poisonous  in  themselves  and,  as 
Hektoen  has  recently  pointed  out,  the  animal  dies 
with  the  symptoms  of  the  disease  in  question  and  nut 
those  of  anaphylaxis,  which  are  constant  for  the  same 
species  of  animal.  Furthermore,  the  "hypersuscepti- 
bility" described  by  von  Behring  seems  incapable  of 
passive  transmission  to  normal  animals,  though 
anaphylactic  hypersensitiveness  is  thus  transferable. 

Portier  and  Richet  (1902)  found  that  if  dogs  were 
given  a  small  dose  of  a  glycerin  extract  from  the 
tentacles  of  actinia,  and  then  in  fifteen  or  twenty  days 
given  a  second  small  dose,  the  animals  quickly 
succumbed.  The  dose  given  was  so  small  as  to  cause 
no  symptoms  in  a  normal  animal.  They  were  the 
first  to  use  the  word  "anaphylaxis"  to  indi 
hypersensitiveness  to  a  poison,  which  they  interpreted 
as  the  opposite  of  prophylaxis. 

Arthus  (1903)  was  the  first  to  experiment  with  a 
non-poisonous  substance,  and  at  the  instigation  of 
Richet,  studied  the  effect  of  repeated  subcutaneous 
injections  of  sterile  normal  horse  serum  in  rabbits. 
These  caused  a  local  reaction,  even  a  necrosis,  about 
the  site  of  injection  which  is  called  the  "Arthua 
phenomenon,"  and  is  now  interpreted  as  a  local 
anaphylaxis. 

At  about  this  time  Theobald  Smith  began  to  be 
puzzled  at  the  sudden  and  unexplained  death  of 
guinea-pigs  used  in  the  standardizing  and  subsequent 
testing  of  diphtheria  antitoxin,  while  von  Pirquet, 
approaching  the  same  subject  from  an  entirely 
different  angle,  was  noting  clinically  the  peculiar 
reactions  of  the  human  bod}-  to  serum  therapy  in 
diphtheria.  The  fact  that  guinea-pigs  which  had 
been  used  for  the  testing  of  diphtheria  antitoxin 
frequently  died  when  later  given  an  injection  of 
serum  had  been  noticed  in  several  laboratories  soon 
after  the  discovery  of  diphtheria  antitoxin,  but  no 
one  seems  to  have  perceived  any  connection  between 
the  two  injections  until  this  time.  Most  of  the 
workers  with  serum  regarded  it  as  an  accident  pure 
and  simple  or  that  the  animal's  vital  resistance  had 
been  lowered  by  the  first  treatment;  some  even 
thought  that  it  was  the  effect  of  cold,  as  the  serums 
were  usually  kept  in  the  ice  chest  and  were  injected 
at  once  after  removal  from  the  ice  box.  During 
Ehrlich's  visit  to  America,  however,  in  1904,  1 
bald  Smith  told  him  the  fact  that  guinea-pigs  often 
died  suddenly  when  used  a  second  time  as  described 
above,  and  upon  Ehrlich's  return  he  gave  the  problem 
to  Otto,  at  that  time  his  assistant.  Otto  began  to 
publish  the  results  of  his  work  the  next  year,  describ- 
ing acute  anaphylactic  shock  under  the  name  of 
"Theobald  Smith's  phenomenon." 

Meanwhile,  the  clinical  studies  of  von  Pirquet  and 
Schick  bore  fruit  in  their  classic  monograph  on  "  the 
serum  disease"  (1905).  which  described  in  detail  the 
syndrome  that  often  follows  injections  of  horse  serum 
in  man.  They  noted  an  "altered  reaction"  of  the 
human  body  to  repeated  injections  of  serum,  pointing 
out  its  profound  bearing  on  the  meaning  of  the  in- 
cubation period  of  disease;  they  drew  original  and 
far-reaching  conclusions  concerning  the  relation  of 
these    clinical    observations    to    hypersusceptibility, 


310    • 


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Anaphylaxis 


and  they  called  al  tention  to  the  tuberculin  rea< 
an  analogous  instance  <>f  anaphylactic  sensitivi 

In  moo  and  liiini.   ll.i-i-nau  and  Anderson  simul- 
eously  with  Otto  took  up  a  systematic  study  of 
anaphylaxis.     They  bad   also  encountered  the  phe- 
nomenon described  by  Theobald  Smith  to  Ehrlich,  and 
it  occurred  to  them  thai  there  might  be  some  relation 
between    it    and    certain    exceptional    instances    of 
;  iath  following  the  injection  of  horse  serum  in 
man.      Otto,     whose   "paper    appeared     first     (1905 
described   the  typical  anaphylactic  reaction  of   the 
.  ig  to  a  second  injection  of  horse  serum;  be 
onstrated    that   the   diphtheria    poisons    play  no 
part  in  the  reaction,  and  later  worked  out  many  of  the 
ntial   features  of  the   phenomenon,   notably   the 
"refractory"  period  and  the  passive  transference  of 
the  anaphylactic  state  to  normal  animals  by  means  of 
the  serum  of  sensitized  animals  (19i)7).      Kosenau  and 
lerson,  working  also  mainly  with  horse  serum  and 
ea-pigs,  established  in  a  series  of  researches  ex- 
ling  over  several  years  (1905—1909)  many  of  the 
facts     of     experimental     anaphylaxis,     notably     the 
itieity  of  the  reaction  and  the  nature  of  anaphylac- 
tic substances,  the  maternal  transmission,  the  relation 
to  endotoxins,  and  immunity,  etc. 

Noteworthy  contributions  to  the  study  of  this 
interesting  subject  have  been  made  in  ever  increasing 
volume  in  recent  years.  The  chemistry  of  the 
itizing  substances  has  been  investigated  by 
Vaughan  and  Wheeler,  and  Wells;  the  physiology 
and  pathology  of  the  anaphylactic  state  by7  Gay, 
Southard,  Besredka,  Auer  and  Lewis,  and  Schultz 
and  Jordan.  The  important  subject  of  anaphylaxis 
in  relation  to  bacterial  proteins  is  still  in  the  con- 
troversial stage,  and  active  researches  have  been 
carried  out  by  Friedberger  and  his  assistants,  Doerr, 
lemann,  Rosenow,  Cole,  and  others,  and  finally 
the  important  bearing  of  anaphylaxis  upon  clinical 
and  forensic  medicine  has  been  demonstrated  by  von 
Pirquet,  Uhlenhuth,  Thomsen,  Pfeiffer,  and  others. 

Serum  Anaphylaxis. — Horse  serum,  either  normal 
or  antitoxic,  when  injected  into  normal  guinea-pigs, 
causes  no  symptoms.  By  "normal"  guinea-pigs  is 
meant  animals  that  have  not  previously  received 
treatment  of  any  kind  and  were  born  of  untreated 
mothers.  As  much  as  20  c.c.  may  be  injected  into 
the  peritoneal  cavity  of  a  guinea-pig  without  causing 
any  apparent  inconvenience  to  the  animal.  When 
injected  subcutaneously  there  may  be  a  slight 
traumatic  local  reaction,  which  disappears  in  a  few 
hours.  Small  amounts  of  horse  serum,  such  as  0.25 
c.c.  may  be  injected  directly  into  the  brain  without 
causing  any  untoward  symptoms. 

Very  characteristic  symptoms,  however,  are  pro- 
duced by  horse  serum  when  injected  into  a  susceptible 
guinea-pig,  i.e.  one  that  has  received  a  prior  injection 
of  horse  serum.  The  symptoms  are  apparently7  the 
"  whether  the  injection  is  made  subcutaneously 
or  into  the  peritoneal  cavity,  or  whether  normal  or 
antitoxic  horse  serum  is  used.  In  five  or  ten  minutes 
after  injection  the  pig  manifests  indications  of  respi- 
ratory embarrassment  by  scratching  at  the  mouth, 
coughing,  and  sometimes  by  spasmodic,  rapid,  or 
irregular  breathing;  the  pig  becomes  restless  and 
agitated;  there  is  a  discharge  of  urine  and  feces. 
This  stage  of  exhilaration  is  soon  followed  by  one  of 
paresis  or  complete  paralysis  with  arrest  of  breathing. 
The  pig  is  unable  to  stand  or,  if  it  attempts  to  move, 
falls  upon  its  side;  when  taken  up  it  is  limp.  Spas- 
modic, jerky7,  and  convulsive  movements  now  super- 
vene. This  chain  of  sy7mptoms  is  very  character- 
istic, although  not  always  following  in  the  order 
given.  Pigs  in  the  stage  of  complete  paralysis  may 
fully  recover,  but  usually  convulsions  appear,  and 
are  almost  invariably  a  forerunner  of  death.  Symp- 
toms appear  about  ten  minutes  after  the  injection 
has  been  given;  occasionally  in  pigs  not  very  sus- 
ceptible they  are  delayed  thirty  to  forty-five  minutes. 


Only  in  one  or  two  instances  of  tic-  many  bund 

observed  by  Rosenau  and  Anderson  bave  the 
symptoms  developed  after  on.-  hour.  Piga  developing 
symptoms  as  late  as  this  are  not  very  susceptible 
ami  do  not  die.  Death  usually  occurs  within  an  hour 
and  frequently  in  less  than  thirty  minutes.  If  the 
second  injection  be  made  directly  into  the  brain  or 
circulation,  the  symptoms  are  manifested  with  explo- 

the    animal    frequently    dying    within 

two  or  three  minute  . 
A  tall  in  temperature  occurs  which  in  fatal  cases 

may  be  as  great   as   13°  C.   (Pfeiffer).      Owing   to 

apparent  relation  betv a  the  depression  in  ten 

ature  ami  the  severity  of  the  symptoms,  the  extent 
duration  of  the  fall  have  beet 

degree    of    anaphylaxis.      Very    minute    reinjeetions 

of  antigen,   however,   have  1 n   known   to  raise   the 

temperature.  The  blood  during  anaphylactic  shock 
shows  a  leucopenia,  and  a  diminution  in  complement. 
Immediate  autopsy  shows  a  striking  condition  of  the 
lungs  described  by  Gay  and  Southard,  also  by  Auer 
and  Lewis.  When  the  chest  is  opened  the  lungs  do 
not  collapse  but  remain  fully  and  permanently  dis- 
tended, forming  a  cast  of  the  pleural  cavities.  The 
heart  continues  to  beat  strongly  for  some  time. 
Asphyxia,  due  to  inspiratory  immobilization  of  tic- 
lungs,  is  therefore  probably  the  immediate  cause  of 
death. 

The  essential  features,  then,  of  experimental 
anaphydaxis  are:  (1)  the  first  injection,  consisting  of  a 
bland  alien  protein,  non-poisonous  in  itself,  which 
sensitizes  the  animal;  (2)  an  interval  of  about  eight 
to  fourteen  days;  (3)  the  second  injection  of  the  same 
protein  which  produces  a  reaction  known  as  acute 
anaphylactic  shock. 

Judged  by  the  severity  of  the  symptoms  of  the 
acute  anaphylactic  reaction  the  guinea-pig  is  appa- 
rently the  most  susceptible  of  animals  (being  400 
times  more  sensitive  than  the  rabbit,  according  to 
Doerr),  but  probably  all  animals  may  be  sensitized 
to  a  greater  or  lesser  degree,  although  our  methods  of 
observation  are  still  too  crude  to  admit  of  any  accu- 
rately graded  comparison.  White  mice  were  long 
thought  to  be  incapable  of  anaphylaxis,  probably 
because  of  the  absence  of  sudden  death  from  as- 
phyxia, so  constant  and  striking  in  the  guinea-pig;  but 
Schultz  and  Jordan  have  shown  that  white  mice  do 
react  toward  horse  serum  with  restlessness,  marked 
irritability7  of  the  skin,  passage  of  urine  and  feces,  and 
temperature  and  blood-pressure  changes. 

In  dogs  (according  to  Richet,  who  worked  with 
them  almost  exclusively7)  the  principal  symptoms 
are  gastrointestinal.  Tiiere  is  immediate  vomiting, 
followed  by  tenesmus  and  bloody  discharges  from 
the  intestines.  Death  is  infrequent,  but  there  may 
develop  a  condition  of  hemorrhagic  inflammation 
in  both  the  large  and  the  small  intestine  which  is 
called  by  Richet  "chronic  anaphylaxis.''  and  by 
Schittenhelm  and  Weichardt,  enteritis  anaphy- 
lactic*."  Another  important  sign  is  the  rapid  fall 
in  blood  pressure,  sometimes  80  to  100  millimeters; 
coagulation  of  the  blood  is  delayed.  Dyspnea  is  not 
marked,  but  as  in  other  animals,  there  are  initial  rest- 
lessness  and  skin  irritability7;  there  may  be  paralysis 
and  death. 

Rabbits  are  apt  to  react  to  a  reinjection  of  horse 
serum  by  edema  and  even  necrosis  at  the  site  of 
injection — the  "Arthus  phenomenon"  or  local 
anaphydaxis.  Arthus  also  described,  in  non-fatal 
cases  in  rabbits,  respiratory7  disturbance,  general 
prostration,  fall  in  blood  pressure,  and  increased 
peristalsis.  In  cases  of  acute  lethal  anaphylaxis 
produced  in  rabbits  highly7  sensitized  by  repeated 
minute  injections,  Auer  describes  the  slow7  respiration, 
the  sudden  falling  of  the  animal  on  its  side  witli  a 
short  clonic  convulsion,  stoppage  of  the  respiration, 
weak  heart  beat,  and  death  within  a  few  minutes. 
Auer  believes,  from  observations  made  at  immediate 


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autopsy  and  by  actual  inspection  of  the  chest  contents 
during  shock,  that  acute  anaphylactic  death  in  rab- 
bits is  due  primarily  to  a  failure  of  the  heart  muscle  to 
perform  its  work,  and  not  to  a  condition  in  the  lungs 
causing  asphyxia,  as  in  guinea-pigs.  The  lungs 
collapse  well,  "though  not  fully;  but  the  right  heart 
remains  dilated,  and  its  muscle  is  seen  to  be  changed 
anatomically  and  functionally,  as  though  in  chemical 
rigor. 

Altered  reaction  to  a  second  injection  of  serum  has 
been  observed,  though  not  studied  so  carefully,  in 
numerous  other  animals,  e.g.  in  cows,  horses,  goats, 
sheep,  and  cats,  in  hens  and  pigeons,  and  in  certain 
cold-blooded  animals,  with  symptoms  varying  accord- 
ing to  the  species. 

It  is  evident  that  no  one  symptom,  or  group  of 
symptoms  can  be  taken  as  an  adequate  criterion  of 
anaphylaxis  in  all  cases.  For  while  the  symptoms 
of  anaphylactic  shock  are  characteristic  and  practi- 
cally constant  in  the  same  species  of  animal,  a  differ- 
ent species  will  give  a  widely  differing  picture  with 
the  same  protein  agent,  because  the  same  organs  are 
not  involved  to  the  same  degree.  An  explanation  of 
these  differences  from  the  physiological  point  of  view 
has  been  given  by  Schultz.  He  has  shown  that 
serum  anaphylaxis  is  essentially  a  matter  of  hypersen- 
sitization  of  smooth  muscle  in  general.  He  concludes, 
as  a  result  of  his  experiments  that  during  anaphy- 
lactic shock,  all  smooth  muscle  contracts.  This  is 
fatal  to  the  guinea-pig  owing  to  the  peculiar  though 
normal  anatomical  condition  of  its  bronchial  tree; 
the  mucosal  layer  of  the  secondary  bronchi  is  relatively 
thick  in  comparison  with  the  lumen,  and  the  contrac- 
tion of  the  smooth  muscle  throws  it  into  folds  which 
completely  occlude  the  bronchi  (Schultz  and  Jordan). 
The  guinea-pig  dies  of  asphyxia  the  cause  of  which  is 
purely  local  and  not  in  the  central  nervous  system,  as 
the  first  investigators  believed.  Auer  and  Lewis  had 
previously  shown  the  same  thing  by  producing 
immobilization  of  the  lungs  with  a  toxic  dose  of  pro- 
tein in  sensitized  animals  whose  cord  and  medulla 
were  destroyed.  The  bronchi  of  mice,  dogs,  and 
rabbits,  however,  are  relatively  poor  in  mucous 
membrane,  which  accounts  for  the  almost  complete 
absence  of  death  from  asphyxia  in  the  animals  during 
anaphylaxic  shock.  In  the  dog  the  contraction  of 
smooth  muscle  sets  up  a  vigorous  intestinal  peristalsis 
and  a  forced  emptying  of  the  urinary  bladder;  the 
characteristic  initial  rise  in  blood  pressure  may  be  due 
to  constriction  of  the  pulmonary,  coronary,  and 
systemic  arteries,  and  according  to  Auer  the  sub- 
sequent marked  fall  to  direct  action  on  the  heart 
muscle  itself,  particularly  of  the  right  side,  causing  a 
venous  accumulation  of  blood,  an  effect  typified  most 
strikingly  in  the  rabbit.  This  provides  also  an  ade- 
quate pharmacological  explanation  of  the  action  of 
atropine  and  the  anesthetics  in  alleviating  the  symp- 
toms of  acute  anaphylaxis. 

Serum  anaphylaxis  in  man  is  met  with  most  fre- 
quently following  the  use  of  antitoxic  sera  and  has 
been  carefully  described  by  von  Pirquet  and  Schick 
(1005).  After  an  injection  of  scrum  (usually  in  from 
eight  to  twelve  days)  there  is  apt  to  be  a  febrile 
reaction,  now  generally  known  as  "serum-sickness." 
The  common  symptoms  are  local  redness,  itching,  and 
pain  at  the  point  of  injection,  swelling  of  the  lymph 
nodes,  fever,  and  a  general  urticaria  lasting  from  two 
to  six  days.  In  more  severe  cases  there  are  general 
malaise,  albuminuria,  pronounced  joint  pains  and 
even  effusions,  swelling  of  the  mucous  membranes, 
hoarseness  and  cough,  nausea  and  vomiting,  vertigo, 
and  remarkable  skin  manifestations  varying  from 
hyperemias  and  erythemas  to  efflorescences  resem- 
bling measles  or  scarlatina. 

Rarely  there  may  be  subnormal  temperature,  a 
weak  and  rapid  pulse,  a  catarrhal  or  hemorrhagic 
enteritis  and  extreme  weakness  approaching  collapse. 
These  results  are  independent  of  the  antitoxic  quali- 


ties of  the  serum,  for  Johannessen  obtained  the  same 
symptoms  by  introducing  normal  horse  serum  into 
the  bodies  of  perfectly  healthy  human  beings.  Indeed 
the  very  earliest  animal  experiments  were  particu- 
larly concerned  in  determining  whether  the  antitoxin 
played  any  part  in  the  phenomenon  and  it  was  soon 
conclusively  eliminated  as  a  factor. 

Both  the  incidence  and  the  severity  of  serum 
sickness  are  proportional  to  the  amount  injected  up 
to.  a  certain  point,  but  the  acute  (sometimes  fatal) 
reaction  in  man  is  more  dependent  upon  the  hyper- 
susceptibility  of  the  individual  than  upon  the  amount 
of  serum  injected.  If  the  serum  is  "concentrated" 
(i.e.  serum-globulin)  the  reactions  are  correspondingly 
lessened  because  smaller  quantities  of  the  foreign 
protein  are  injected,  and  the  albumins  and  certain 
other  proteins  have  been  eliminated.  If  the  serum 
be  properly  aged  (a  year  or  two  old)  the  incidence  of 
serum-sickness  is  believed  to  be  decreased.  The 
peculiarity  of  serum  sickness  in  man  is  that  it  may 
follow  the  first  injection  of  a  foreign  serum,  though 
only  after  a  definite  incubation  period  corresponding 
to  the  time  required  to  sensitize  an  experimental 
animal.  It  has  been  suggested  that  enough  serum 
remains  unchanged  or  incompletely  changed  near  the 
point  of  injection  to  cause  a  sharp  reaction  when  the 
body  becomes  sensitized.  There  is  no  proof  more- 
over that  other  animals  do  not  develop  a  reaction  to 
the  first  dose  which  never  rises  to  the  threshold  of 
clinical  observation.  In  fact  Ehrlich,  Francione,  and 
others  have  observed  a  temporary  diminution  of 
complement  in  the  blood  of  guinea-pigs  ten  to  twelve 
days  after  the  first  injection. 

A  second  injection  of  serum  after  some  days  finds 
the  human  organism  in  a  sensitive  condition  and  if  a 
clinical  reaction  is  produced,  it  is,  as  we  might  expect, 
immediate  and  often  severe,  but  of  shorter  duration 
than  the  first.  Von  Pirquet  noticed  that  if  many 
months  or  years  elapsed  between  the  two  injections, 
the  reaction  was  no  longer  "immediate"  but  only 
"accelerated,"  coming  between  the  sixth  and  eighth 
days  instead  of  between  the  eighth  and  twelfth  days 
which  is  the  normal  incubation  period  for  serum  sick- 
ness. He  concluded  that  sensitiveness  may  disap- 
pear in  course  of  time,  but  is  more  quickly  regenerated 
on  a  second  occasion. 

Besides  the  typical  serum  sickness,  there  have  been 
reported  since  the  introduction  of  serum  therapy  a 
certain  small  number  of  unforeseen  and  fatal  catas- 
trophes attending  the  injection  of  serum  into  human 
beings.  The  following  case  published  by  H.  F. 
Gillette  will  serve  to  illustrate  them  all: 

"  The  patient  was  a  man  of  fifty-two,  a  subject  of 
asthma.  He  asked  me  to  administer  diphtheria 
antitoxin  to  him  hoping  it  might  cure  his  asthma. 
I  administered  2,00(3  units  under  the  left  scapula 
with  the  usual  precautions.  He  had  about  com- 
pleted dressing  when  he  said  he  had  a  pricking 
sensation  in  the  neck  and  chest;  soon  he  sat  down  and 
said  he  could  not  breathe,  nor  did  he  breathe  again. 

His  pulse  at  the  wrist  remained  regular 

and  full  for  some  time  after  respiration  ceased.  He 
had  a  mild  degree  of  cyanosis  and  edema  of  the  face. 
He  died  in  tonic  spasm  ten  minutes  after  injection. 
Autopsy  revealed  no  palpable  cause  of  death." 

The  same  author  collected  twenty-eight  cases  of 
collapse  or  death  after  serum  injection,  of  which  fifteen 
ended  fatally.  There  was  a  common  history  of  previous 
asthmatic  trouble  in  all  but  five  of  the  twenty-eight, 
and  all,  after  injection,  showed  common  symptoms  of 
sudden  intense  dyspnea,  a  sense  of  overwhelming 
anxiety,  edema  and  cyanosis  of  the  face,  a  sudden 
massive  urticaria,  tonic  muscular  spasms,  and  con- 
tinued beating  of  the  heart  long  after  the  ceasing  of 
respiration.  Rosenau  and  Anderson  collected  nine- 
teen cases  and  were  able  to  examine  the  serum  used 
in  two  of  them.  It  was  found  to  be  no  more  toxic  to 
sensitized  guinea-pigs  than  other  horse  serum.     These 


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Anaphylaxis 


rases  of  severe  systemic  shock  seem  susceptible  of  no 
other  explanation  than  that  the  unfortunate  individ- 
uals had  been  in  some  manner  at  a  previous  time 
sensitized  to  horse  protein.     They  present  a  picture 
which  is  almost  the  counterpart  of  typical  anaphylactic 
shock   in  guinea-pigs,  and   the   most    striking   thing 
n   them  is  that  practically  all  give  a  history  of 
piratory    trouble    in    the    past,    especially    horse- 
,1,1a.      Schultz    and    .Ionian     suggest     that    these 
occasional  cases  of  sudden  death  in  man  may  perhaps 
be  due  to  an  abnormal  development   or  condition  of 
mucous   membrane   and   smooth    muscle   of    the 
bronchi    (as   in   asthmatics),   and   that   the   smooth 
muscle,    being    hypersensitive,    produces   asphyxia 
by   sudden    contraction.     One   thing   is   clear,    that 

(hese  immediate  and  sometimes  fatal  reactions  are 
not  dependent  upon  any  peculiar  property  in  the 
in.  bul  to  an  altered  powered  of  reaction  of  the 
individual  to  the  foreign  protein  injected.*  The 
anaphylactic  reactions  following  the  injection  of 
serum  in  man  may  l>e  summed  up  briefly  as  follows: 
Reactions  following  first  injection: 

'Serum  sickness,"  incubation  eight  to  twelve 

days. 

Vcute   anaphylactic   shock,    with    collapse    or 

death  i rarely). 

Reactions  following  second  injection: 

interval  between  injections  less  than  eight  days, 
iction. 
b  |  interval  twelve  to  forty  days,  immediate  reaction. 
c)    interval    fifteen    days    to    six    months,    either 
immediate  or  accelerated  reaction,  or  both. 

,/  interval  over  six  months,  accelerated  reaction. 
The  above  table  represents  the  usual  course  of  events, 
but  exceptions  may  occur,  and  the  time  intervals  are 
only  approximate.  Sometimes  the  reactions  in  man 
do  not  appear  until  the  third,  fourth,  or  some  subse- 
quent injection. 

Two  precautions  are  suggested  in  serum  therapy: 

1.  Except  in  urgent  cases,  avoid  injecting  horse 
serum  into  individuals  known  to  be  asthmatic,  or  to 
have  symptoms  when  around  horses. 

2,  If  hypersensitiveness  is  suspected,  give  at  first 
a  very  small  portion  of  the  dose,  following  it  in  an 
hour  or  so  with  the  rest,  injecting  it  exceedingly 
slowly  and  avoiding  a  direct  injection  into  the 
circulation. 

Experimental  Anaphylaxis. — 1.  The  Anaphy- 
lactic Agents,  or  Allergens. — A  great  variety  of  pro- 
teins,  animal,  vegetable,  and  bacterial,  can  induce 
hypersensitiveness.  Such  substances  also  give 
rise  to  antibodies,  and  are  therefore  true  antigens; 
toxins  which  are  also  antigens  are  not  able  to  produce 
a  -late  of  true  anaphylaxis.     Gelatin,  a  protein  of  a 

Eeculiar  sort,  is  not  an  allergenic  substance.  This 
as  led  to  the  supposition  that  sensitizing  power  has 
some  connection  with  the  aromatic  radicle  of  the  pro- 
tein molecule,  which  is  not  found  in  gelatin. 

The  stability  of  anaphylactic  antigens  is  remarkable. 
Chemicals  can  destroy  the  sensitizing  power  only  by 
breaking  down  the  protein  molecule  into  cleavage 
products  as  low  as  peptones.  The  antigens  are  ther- 
mostable to  a  high  degree.  Eel  serum,  naturally  a  very 
toxic  substance,  is  rendered  quite  non-toxic  at  60°, 
but  its  sensitizing  power  is  unaffected.  When  ths 
physical  state  of  a  substance  is  altered  by  heat,  as  in 
coagulation,  its  allergenic  properties  disappear,  but 
if  coagulable  substances  such  as  egg-white,  horse 
serum  and  milk  are  first  carefully  dried,  thev  may  then 
be  heated  to  130°  C.  for  two  hours,  or  to  170°  C.  for 
ten    minutes    without    appreciably    affecting    their 

♦Rosenau  and  Amoss  have  recently  indicated  a  possible 
explanation  of  the  way  in  which  such  persons  may  become  sensi- 
tized. They  have  proved  that  a  protein  material  is  given  off  in 
the  expired  breath  of  human  beings.  There  is  thus  some  reason 
to  suppose  that  an  interchange  of  protein  may  take  place  between 
two  individuals  of  different  species  by  way  of  the  lungs. 


anaphylactic     powers     i  Rosenau     and     Anderson). 
\:e  also  is  proved  to  have  no  appreciable  effect,  Bince 

I'lilenhuth  has  sensitized  animals  with  the  flesh  of 
mummies. 

An  incredibly  small  amount  of  ant  igen  is  sufficient 
to  induce  hypersuseept  ibilii  v.  Uoseiiau  and  Ander- 
son used  on   an  average  0.004  CC.  of  serum   in   their 

experi ntS,    and    once   sensitized    a    guinea-pig    with 

one  one-millionth  of  a  cubic,  centimeter.  Well; 
sensitized  a  guinea-pig  with  such  a  minute  amount  as 
one  twenty-millionth  of  a  gram  of  purified  egg-albu- 
min. 

The  first  injection  or  sensitizing  dose  may  be  given 

subcutaneously,  intraperitoneally  or  directly  into  the 
circulation.  In  fact,  susceptible  animals  may  be 
sensitized  by  intrpducing  the  alien  protein  into  the 
body  by  any  route  through  which  it  may  be  absorbed. 
For  example,  guinea-pigs  have  been  sensitized  by  the 

inhalation  of  a  fine  spray  of  serum,  and  even  by  tier 
ingestion  of  horse  serum  or  horse  meat  over  a  period 
of  two  or  three  weeks  (Rosenau  ami  Anderson).  As 
an  interesting  parallel  to  the  latter  fact  Uhlenhuth 
has  shown  that  precipitins  are  formed  in  the  blood 
after  the  prolonged  ingestion  of  meat  and  Carrol  has 
induced  the  production  of  specific  agglutinins  by  the 
ingestion  of  dead  typhoid  bacilli.  The  second  injec- 
tion or  reacting  dose  must  be  relatively  larger  than 
the  sensitizing  dose,  but  the  actual  quantity  required 
to  produce  poisonous  symptoms  is  nevertheless  very 
small.  One-tenth  of  a  cubic  centimeter  of  horse 
serum  injected  into  the  peritoneal  cavity  is  sometimes 
sufficient  to  cause  death  in  a  sensitized  guinea-pig; 
0.1  c.e.  subcutaneously  may  cause  symptoms,  while 
much  smaller  amounts  given  into  the  brain  or  directly 
into  the  circulation  may  be  fatal.  Proteins  vary  in 
this  respect;  for  example,  egg-white  is  effective  in 
even  smaller  quantities  than  horse  serum  at  the  second 
injection,  whereas  a  larger  amount  of  milk  is  necessary 
to  produce  an  equivalent  reaction. 

The  anaphylactic  reaction  is  specific.  Thus  a 
guinea-pig  sensitized  with  horse  serum  does  not 
react  to  a  subsequent  injection  of  egg-white,  vege- 
table protein  or  milk.  The  specificity  extends  even 
further  than  this:  in  order  to  give  rise  to  anaphylactic 
symptoms,  the  protein  material  given  at  the  first  and 
second  injections  must  be  from  the  same  species  or 
from  some  closely  related  species.  Thus  a  guinea-pig 
sensitized  with  cow's  milk  will  not  react  to  a  subse- 
quent injection  of  woman's  milk.  Guinea-pigs 
sensitized  with  the  albumin  of  hen's  eggs  will  not 
react  to  a  subsequent  injection  of  the  albumin  of  the 
eggs  of  pigeons,  but  do  react  mildly  to  duck  egg-white 
(Rosenau  and  Anderson).  This  specificity  according 
to  species  is  therefore  of  the  same  degree  as  that  of 
certain  immune  reactions,  notably  the  precipitins. 
That  is,  there  is  a  group  reaction  in  the  proteins  of 
allied  species,  but  no  reaction  between  the  proteins  of 
widely  different  species  or  between  proteins  of 
widely  different  origin.  The  maximum  effect  at 
second  injection  is  obtained  by  the  use  of  the  identical 
protein  used  for  sensitization.  Certain  sera  which 
react  interchangeably  to  precipitins,  as,  for  example, 
human  and  ape,  horse  and  ass,  sheep  and  goat,  rat 
and  mouse,  remain  indistinguishable  also  by  the 
anaphylactic  reaction.  The  same  specificity  holds 
with  respect  to  bacterial  proteins:  an  animal  sensitized 
with  typhoid  bacilli  will  react  strongly  toward  paraty- 
phoid, and  somewhat  toward  colon  bacilli,  but  not  at 
all  to  unrelated  species. 

One  of  the  remarkable  facts  in  relation  to  the 
specificity  of  anaphylaxis  is  that  guinea-pigs  may  be 
in  a  condition  of  anaphylaxis  to  three  protein  sub- 
stances at  the  same  time.  For  instance,  a  guinea- 
pig  may  be  sensitized  with  egg-white,  milk  and  horse 
serum,  and  subsequently  react  separately  to  a 
second  injection  of  each  one  of  these  substances.  The 
guinea-pig  may  be  sensitized  by  giving  these  strange 
proteins  either  at  the  same  time  or  at  different  times, 


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in  the  same  place  or  in  different  places,  or  by  in- 
jecting them  separately  or  mixed.  The  guinea-pig 
differentiates  each  anaphylactogenic  protein  in  a 
perfectly  distinct  and  separate  manner.  The  animal 
is  susceptible  to  the  second  injection  of  each  one  of 
the  three  substances  in  the  same  sense  that  it  is 
susceptible  to  three  separate  infectious  diseases 
(Rosenau  and  Anderson). 

That  there  may  be  exceptions  to  the  rule  of  species- 
specificity  is  shown  in  the  case  of  the  crystalline  lens. 
A  guinea-pig  sensitized  to  the  lens-extract  of  one 
species  of  animal  will  react  to  the  lens-extracts  of 
widely  different  species,  or  even  of  its  own  species  but 
not  to  other  tissues  (Andrejew).  Here  too  there  is  an 
exact  parallel  in  the  precipitin  reaction  which  fails  to 
distinguish  the  lens  of  one  species  from  that  of 
another  (Uhlenhuth).  This  is  an  example  of  organ- 
specificity.  It  is  said,  but  without  definite  confirma- 
tion, that  the  tissue  of  the  uveal  tract,  and  of  neo- 
plasms also  contain  organ-specific  proteins.  In  the 
vegetable  world,  Osborne  has  shown  that  whereas 
preparations  of  globulins  from  hemp,  flax,  and 
squash  do  not  react  with  each  other,  gliadin  from 
rye  reacts  strongly  with  gliadin  from  wheat,  a  result 
in  accord  with  the  fact  that  by  chemical  and  physical 
means,  no  differences  have  been  detected  which  were 
sufficient  to  indicate  that  these  gliadins  were  different 
substances. 

It  is  probable  that  only  proteins  which  have  a 
complete  or  partial  chemical  identity  of  structure  will 
react  with  each  other.  Differences  too  small  to  be 
detected  by  analytic  means  at  our  disposal,  may  yet 
prevent  any  tendency  toward  interaction,  and  the 
anaphylactic  phenomenon  may  thus  be  used  to  deter- 
mine the  finer  relationships  of  proteins.  It  is  evident 
from  these  facts,  as  Osborne  concludes,  that  struc- 
tural differences  exist  between  very  similar  proteins 
of  different  origin,  and  that  chemically  identical 
proteins  apparently  do  not  occur  in  animals  and  plants 
of  different  species  unless  they  are  biologically  very 
closely  related. 

The  identity  of  the  sensitizing  with  the  intoxicating 
substance  has  been  frequently  brought  into  question 
in  the  past.  Besredka,  Vaughan,  and  others  report 
results  which  led  them  to  the  conclusion  that  anaphy- 
lactic antigens  contain  two  separable  substances,  one 
of  which  acts  as  sensitizer,  the  other  as  the  reacting 
agent.  The  impossibility  of  obtaining,  at  present,  a 
chemically  pure  protein  to  work  with,  renders  it 
difficult  to  establish  this  point.  Wells,  however,  has 
shown  that  the  purer  the  protein,  the  smaller  is  the 
amount  necessary  both  to  sensitize  and  to  intoxicate, 
a  fact  pointing  to  the  identity  of  the  two  substances. 
Rosenau  and  Anderson  as  well  as  Doerr  and  Russ 
have  shown  that  both  qualities  of  a  foreign  serum 
are  affected  equally  by  age,  heat,  and  other  modifying 
influences,  indicating  that  both  phases  of  the  anaphy- 
lactic phenomenon  have  to  do  with  one  and  the  same 
sul  i-tance. 

2.  Incubation  Period. — Sensitization  in  an  animal 
appears  only  after  a  period  of  from  eight  to  twelve 
days  after  the  first  injection.  This  corresponds  to 
the  incubation  period  of  a  large  group  of  the  infectious 
diseases,  and  to  that  of  serum-sickness  in  man. 
That  infection  and  sensitization  are  in  some  way 
correlated  phenomena  has  long  been  believed.  Von 
Pirquet's  explanation  of  the  incubation  period  of 
both  in  common  terms  of  "allergy"  with  be  discussed 
later.  A  second  injection,  given  within  the  incuba- 
tion period,  produces  no  symptoms  of  reaction,  and 
indeed  postpones  or  prevents  the  appearance  of 
sensitization.  Similarly  it  has  been  said  that  a 
large  initial  dose  prolongs  the  incubation  period. 
However,  once  the  condition  of  hypersensitiveness  is 
established,  it  lasts  (with  perhaps  a  slight  but  gradual 
waning  of  intensity)  for  an  indefinite  period.  The 
exact  limit  is  not  known,  but  Rosenau  and  Anderson 
have  found  a  guinea-pig  highly  sensitive  1,096  days 


after   the  first  injection,  and   they  believe  that  the 
condition  is  persistent  throughout  life. 

3.  The  Refractory  Slate  (antianaphylaxis,  anergy 
immunity). — If  a  sensitized  animal  recovers  from 
acute  anaphylactic  shock,  or  is  given  a  second 
comparatively  large  dose  of  protein  within  the 
incubation  period,  it  immediately  enters  a  so-called 
refractory  state  or  antianaphylaxis  (Nicolle),  in  which 
it  is  "immune"  to  further  injections  of  that  particular 
protein  and  acts  like  an  animal  that  has  never  been 
sensitized. 

The  state  of  antianaphylaxis  is  not  believed  to  be 
a  true  "immunity"  in  a  serological  sense,  becau.-e  it 
appears  at  once,  without  any  incubation  period; 
it  disappears  in  the  course  of  a  few  weeks  leaving  the 
animal  again  sensitive;  and  the  serum  of  refractory 
animals  is  not  protective  against  anaphylaxis  when 
introduced  into  other  animals,  but  on  the  contrary 
actually  confers  a  condition  of  hypersensitiveness. 
No  adequate  explanation  of  this  state  has  been 
advanced;  it  is  commonly  attributed  either  to  dis- 
appearance of  complement,  which  is  apparently  a 
necessary  factor  in  anaphylactic  shock,  or  to  neutral- 
ization (saturation)  of  the  antibodies  upon  which 
the  state  of  hypersensitiveness  seems  to  depend 
(Friedberger).  A  pseudo-refractory '  state  may  be 
induced  by  certain  drugs,  notably  the  anesthetics 
which  merely  mask  the  symptoms  of  shock  by 
paralyzing  the  central  nervous  system;  or  by  large 
intravenous  injections  of  physiological  salt  solution, 
which  seem  to  prevent  shock  by  temporary  deviation 
of  complement.  A  correct  conception  of  this  interest- 
ing phenomenon  of  antianaphylaxis  is  not  possible 
until  we  have  mastered  the  fundamental  principles 
underlying  anaphylaxis. 

4.  Passive  Hypersusceptibility  (passive  anaphy- 
laxis).— Otto  was  the  first  to  describe  the  passive 
sensitization  of  guinea-pigs.  He  noted  that  if  serum 
from  a  sensitized  animal  be  transferred  directly  to  a 
normal  animal,  the  recipient  becomes  hypersuscep- 
tible  without  the  intervention  of  the  usual  incubation 
period  and  remains  hypersusceptible  for  one  or  two 
weeks.  Otto,  Gay,  and  Southard,  and  others  found 
that  a  latent  period  of  about  twenty-four  hours  must 
elapse  after  the  transference  of  serum  before  a  reaction 
could  be  elicited.  It  has  recenth'  been  stated  (Doerr 
and  Russ)  that  under  proper  conditions,  an  immediate 
passive  hypersusceptibility  can  be  obtained.  This 
would  make  the  condition  analogous  to  passive 
immunity  and  it  is  generally  known  therefore  as 
"passive  anaphylaxis."  At  the  same  time,  as 
Hektoen  points  out,  the  period  of  latency  observed 
in  so  many  of  the  experiments  in  passive  anaphylaxis 
has  not  been  explained  altogether  satisfactorily. 
Furthermore,  it  has  not  been  conclusively  proved 
that  sensitiveness  is  capable  of  heterogenous  trans- 
mission, i.e.  from  one  species  to  another,  as  in  the 
case  of  passive  antitoxic  immunity.  Hypersuscepti- 
bility is  transmitted  by  the  mother  guinea-pig 
to  her  young,  which  may  remain  sensitive  for  as  much 
as  a  year  after  birth.  This  fact  (as  first  pointed  out 
by  Rosenau  and  Anderson)  may  throw  some  light  on 
the  transmission  of  a  tendency  to  a  disease  from 
generation  to  generation. 

5.  Local  Anaphylaxis. — The  fact  that  a  second 
subcutaneous  injection  of  alien  protein  in  a  rabbit 
may  cause  local  edema  and  necrosis  instead  of  acute 
systemic  shock  has  been  referred  to  as  an  example 
of  local  anaphylaxis.  The  ocular  instillation  of 
tuberculin  may  lead  to  a  sensitization  which  is  local 
to  a  certain  extent,  and  w-hieh  renders  a  subsequent 
application  liable  to  misinterpretation.  In  experi- 
ments by  Rosenau  and  Anderson,  out  of  twelve  men 
who  gave  an  absolutely  negative  test  to  the  first 
conjunctival  application  of  tuberculin,  ten  reacted 
typically  to  a  second  application  of  the  same  material 
after  an  interval  of  fifty-one  days.  Bloch  infected 
himself   with  a  new   species  of  ringworm  which  he 


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Anaphylaxis 


,■ .,  Isolating,  and  two  years  later  found  thai  he  still 
gave  a  vigorous  cutaneous  reaction  to  an  extract  of 
the  fungus,  prepared  like  tuberculin.  He  now  skin- 
grafted  a  patient  from  himself,  and  discovered  thai 
these  graft  3  continued  to  give  a  cuti-reaction  toward 
the  same  extract,  although  the  patient's  own  skin 
failed  to  react.  This  bespeaks  a  local  effecl  upon  the 
in  addition  to  changes  in  the  blood  during 
certain  forms  of  sensitization—  in  other  word-;  ana- 
phylaxis is  probably  a  cellular  as  well  as  a  humoral 
omenon. 

Practical  Relation  of  Anaphylaxis  to  Medi- 
,  im  .  -One  effecf  of  serum  therapy  (viz.  serum-sick- 
i:i-  been  noted  above,  but  ol  her  forms  of  treat- 
ment in  which  protein  matter  is  injected  are  liable  to 
be  followed  by  anaphylactic  manifestations.  In  the 
Pasteur  prophylactic  treatment  for  rallies  for  example, 
there  is  apl  to  be  a  sudden  and  simultaneous  Baring 
up  of  previous  points  of  inoculation  sometime  during 
the  second  week.  Vaughan  reports  a  case  receiving 
the  Pasteur  treatment  for  the  bite  of  a  rabid  dog  in 
January,  1906.  In  March,  19U7,  the  patient  was 
bitten  by  a  rabid  cat  and  received  a  second  course  of 
treatment.  Each  injection  produced  almost  at  once 
a  local  area  of  aseptic  inflammation  three  inches  in 
diameter  which  disappeared  in  forty-eight  hours. 
The  patient  's  sister  who  received  the  same  emulsion 
I  no  reaction. 

Hay  fever  and  asthma  form  a  group  of  diseases 
which  are  undoubtedly  anaphylactic  in  origin.  The 
different  types  of  hay  fever  are  characterized  by 
uniform  symptoms  at  definite  seasons,  namely,  redden- 
ing and  swelling  of  mucous  membranes  and  watering 
of  the  eves,  sneezing,  asthma,  and  a  soreness  in  the 
throat  and  larynx.  Elliotson  in  1831  showed  the 
cause  to  be  pollen.  The  disease  can  be  produced  at 
will,  even  in  winter,  by  exposing  sensitive  individuals 
to  pollen;  normal  persons  do  not  react.  Appreci- 
ation of  this  reaction  as  a  phenomenon  of  hyper- 
sensitiveness  is  due  to  Wolff-Eisner  from  whose 
monograph  the  following  data  are  taken.  The 
pollen  test  consists  in  suspending  one  centigram  of 
pollen  in  5  c.c.  of  salt  solution,  and  instilling  two  drops 
into  the  eye.  Normal  persons  feel  a  slight  itching, 
but  sensitive  individuals  react  with  typical  symptoms: 
the  conjunctivae  become  injected  and  rapidly  che- 
motic;  the  nasal  mucous  membrane  swells  and  there  are 
sneezing  and  asthma.  The  analogy  to  serum  disease 
and  to  hypersensitiveness  to  tuberculin  is  strength- 
ened by  the  fact  that  the  same  symptom-complex 
may  be  obtained  by  subcutaneous  injection  of  the 
pollen  suspension,  in  which  case  an  urticaria  develops 
about  the  point  of  inoculation  as  well.  Asthmatics 
of  the  various  types  presumably  are  sensitized  to 
different  protein  substances  found  in  their  environ- 
ment. Tims  certain  individuals  may  have  symp- 
toms of  hay  fever  (including  asthma)  in  the  presence 
of  horses,  rabbits,  guinea-pigs  and  other  animals. 
Many  substances,  which  as  far  as  can  be  discovered, 
possess  no  inherent  toxic  properties  of  their  own, 
and  to  which  the  vast  majority  of  human  beings  are 
utterly  insensible,  cause  in  certain  people  intense 
inflammatory  reactions  when  they  are  brought  into 
contact  with  their  bodies,  either  directly  upon  the 
skin  or  in  the  alimentary  tract.  Of  the  external 
irritants  cases  have  been  reported  of  severe  general 
urticaria  following  contact  with  satinwood,  prim- 
roses, and  many  other  substances.  Idiosyncrasies 
with  regard  to  articles  of  diet  belong  to  the  same 

■ gory.     Apparently     almost     every     variety     of 

protein  food  has  at  some  time  or  other  been  reported 
as  intolerable  to  certain  individuals.  Buck  had  a 
patient  who  was  sensitized  to  pork  and  suffered 
urticaria  whenever  he  ingested  it  in  any  form  or  any 
quantity.  Ten  cubic  centimeters  of  the  patient's 
serum  were  put  into  a  guinea-pig,  which  twenty-four 
hours   later   reacted   with   acute   fatal   anaphylactic 


shock  to  5  c.c.  of  pig  serum,  evidently  an  example  of 
passive  anaphylaxis.  Egg-albumin  not  infrequently 
produces  the  most  severe  gastrointestinal  disturb- 
ances, with  vomiting  ami  watery  diarrhea,  as  well  as 
a  generalized  urticaria  ami  asthmatic  crises  even 
when  disguised  in  minute  quantities  in  other  funds. 
Egg-white  as  well  a-,  any  other  protein  substance  to 
which   the   individual   has   bet le   sensitized,    may 

produce;  a  local  reaction  when  rubbed  into  the  skin. 
This  is  analogous  to  the  von  Pirquet  reaction  with 

tuberculin,   which  will  be  discussed  later.      All   forms 

of  sea-f 1  (oysters,  lobsters,  fish,  etc.)  an'  notorious 

intoxicating  agents  in  some  people,  and  among  the 
vegetables,   buckwheat,   tomatoes,   and  strawberries 

may  cause  the  same  unpleasant  effects.  In  such 
cases,  it  is  unknown  how  the  sensitization  is  originally 
'Heeled,    but    both    the    alimentary    and    respiratory 

t  ract  s  have  been  suspected. 

Besides  serum-sickness,  hay-fever,  as  well  as  most 
of  t  he  asthmas  and  urticarias,  w  hich  are  now  generally 
accepted  as  anaphylacl  ic  in  nature,  there  are  a  number 
of  other  phenomena  which  are  now  being  explained  in 
terms  of  anaphylaxis.  Light  is  thrown  on  puerperal 
t  clampsia  by  the  fact  that  a  pregnant  guinea-pig  can 
be  sensitized  to  her  own  placental  extracts  (Rosenau 
and  Anderson)  and  probably  to  her  own  amniotic 
fluid  and  the  serum  of  her  young.  This  sensitive- 
ness has  also  been  passively  transferred  (Gozony  and 
Wiesinger).  Hektoen  points  out  the  fact  that 
sympathetic  ophthalmia  may  be  an  allergic  phenome- 
non, since  it  has  been  shown  that  the  lens  protein  and 
possibly  also  uveal  tract  protein  may  cause  antibodies 
in  the  same  animal  from  which  they  are  obtained. 
The  tuberculous  diathesis  (as  well  as  other  diatheses) 
is  explained  in  part  as  an  hereditary  transmission  of 
hypersusceptibility.  And  anaphylaxis  has  been  sug- 
gested now  and  again  as  a  factor  in  the  onset  of  labor, 
the  crisis  in  pneumonia,  the  spasmophilic  diathesis, 
the  symptoms  attendant  on  the  rupture  of  the  cysts 
in  echinococcus  disease,  and  the  effect  of  quinine  in 
suddenly  liberating  hemoglobin  in  black-water  fever. 

Anaphylaxis  in  Diagnosis. — The  most  important  of 
the  special  anaphylactic  phenomena  are  the  tuberculin 
and  mallein  reactions. 

The  hypodermic  injection  of  tuberculin  was  intro- 
duced by  Koch  in  1S90,  but  its  diagnostic  as  well  as 
its  therapeutic  use  was  abandoned  for  a  long  while, 
when  its  dangers  were  discovered.  The  reaction  was 
determined  by  the  rise  in  temperature.  In  a  tubercu- 
lous individual,  the  temperature  rises  in  six  to  twelve 
hours,  is  at  its  height  from  twelve  to  twenty-four 
hours,  and  declines  to  normal  in  twenty-four  to  thirty- 
six  hours.  The  patients  compare  their  symptoms  to 
those  of  grippe;  headache,  prostration,  pains  in  the 
joints  and  limbs.  In  1907  von  Pirquet  introduced 
the  cutaneous  tuberculin  test,  in  which  a  drop  of 
"old"  tuberculin  is  placed  upon  a  scarified  point 
on  the  skin.  The  specific  reaction  appears  within 
twenty-four  hours  as  a  red  papule  at  least  five  milli- 
meters in  diameter.  The  reaction  reaches  its  maxi- 
mum in  forty-eight  hours  and  fades  out  slowly,  ulti- 
mately leaving  no  trace.  Simple  contact  of  the  outer 
skin  with  "old"  tuberculin  is  sufficient  for  the  specific 
reaction  where  there  is  a  high  degree  of  sensitiveness 
of  the  skin  (Lautier).  Upon  intense  rubbing  with  a 
fifty  per  cent,  tuberculin  ointment  (Moro's  percu- 
taneous test)  the  reaction  is  nearly  as  delicate  as  the 
cutaneous.  The  mucous  membranes  are  even  more 
sensitive  than  the  skin,  e.g.  the  conjunctiva,  nose, 
urethra,  rectum,  and  vagina.  In  all  tests  a  non-sen- 
sitized person  will  give  no  reaction.  The  explanation 
of  this  advanced  by  Koch  was  that  the  small 
addition  of  the  injected  tuberculin  to  the  antigen 
already  in  the  body  is  sufficient  to  cause  general  symp- 
toms. Marmorek  thought  the  dose  stimulated  old 
foci  to  renewed  activity.  It  is  now  generally  accepted 
as  an  anaphylactic  reaction.  Indeed  it  is  analogous 
to    the    "accelerated    reaction"    in    serum    disease. 


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Tuberculin  is  believed  to  be  a  suspension  of  ultra- 
microscopic  particles  of  the  protein  material  contained 
in  the  bodies  of  tubercle  bacilli.  The  old  tuberculous 
focus  plays  no  part  except  as  the  sensitizing  agent; 
the  tuberculin  injection  or  cutaneous  application  acts 
as  the  reacting  dose.  It  is  the  rapid  destruction  of 
the  protein  material  by  the  prepared  organism  which 
liberates  poisonous  products  and  gives  rise  to  symp- 
toms of  local  inflammation,  or  of  systemic  reaction. 

Both  the  prevention  and  cure  of  tuberculosis  may 
be  explained  on  the  basis  of  anaphylaxis.  The  power 
of  defense  against  the  tubercle  bacillus  is  directly  pro- 
portional to  the  power  of  the  body  to  react  and  thus 
prevent  the  invasion,  growth,  and  multiplication  of 
the  parasites.  If  a  tubercle  bacillus  lodges  in  a  sen- 
sitized organ  or  tissue,  a  vigorous  reaction  takes  place 
at  once.  The  bacillus  is  attacked  by  the  cells  and 
fluids  which  are  concentrated  upon  the  point  where 
they  are  most  needed.  If  the  organ  or  tissue  is  not 
sensitized,  no  reaction  occurs  and  the  natural  defences 
of  the  body  are  not  brought  into  operation;  little  or 
no  obstacle  is  presented  to  the  development  of  a 
tuberculous  focus. 

The  cure  of  tuberculosis  also  depends  upon  the 
power  of  the  tissues  to  react  in  the  anaphylactic 
sense.  Thus,  the  tissues  immediately  surrounding  a 
tuberculous  focus  become  sensitized  by  the  autolytic 
products  of  the  tubercle  bacillus.  The  power  of  such 
tissues  to  react  may  be  seen  with  the  naked  eye  as  a 
red  zone  of  congestion  when  tuberculin  is  injected  into 
such  an  animal.  The  cure  of  tuberculosis  depends 
upon  the  ability  of  the  surrounding  tissues  to  react 
promptly  and  vigorously  enough  to  wall  off  and  thus 
neutralize  or  destroy  the  tuberculous  focus.  In  case 
the  power  of  reaction  fails,  the  primary  focus  spreads 
and  the  disease  advances  to  a  fatal  termination. 

If  instead  of  the  minute  quantity  of  tuberculous 
material  which  gains  entrance  into  the  animal  body 
by  natural  or  artificial  inoculation,  we  inject  large 
amounts  of  tubercle  bacilli  into  infected  animals, 
we  get  very  intense  and  usually  fatal  anaphylactic 
symptoms,  which  are  elicited  equally  by  living  or 
dead  bacteria,  or  by  bacterial  extracts. 

Von  Pirquet  points  out  that  the  tuberculin  test 
fails  under  the  following  conditions: 

1.  Very  early  in  life,  i.e.  in  nurslings.  Schlossman 
and  Moll  found  that  serum  disease  also  is  very  rare  in 
nurslings.  This  led  them  to  experiment  on  rabbits, 
and  they  showed  that  no  demonstrable  antibodies 
(such  as  precipitins  and  agglutinins)  are  formed  before 
the  eighth  week,  and  that  injections  of  albumin  pro- 
duce no  anaphylaxis  during  this  period. 

2.  In  advanced  stages,  in  chronic  or  cachectic  forms, 
in  miliary  tuberculosis,  and  in  tuberculous  meningitis, 
tuberculin  tests  fail.  This  is  probably  due  (according 
to  von  Pirquet)  to  saturation  of  the  antibodies  owing 
to    preponderance     of    antigen     (antianaphylaxis?). 

3.  Continued  treatment  with  tuberculin  will  destroy 
the  reaction  for  the  same  reason. 

4.  A  long  interval  following  a  healed  infection  will 
allow  the  antibodies  to  disappear. 

The  mallein  and  leprolin  tests  in  the  diagnosis  of 
glanders  and  leprosy  are  precisely  similar  in  theory 
and  practice  to  that  of  tuberculin.  A  similar  test 
has  been  put  to  use  in  actinomycosis.  The  recent 
preparation  of  syphilitic  virus  in  the  form  of  "  luet  in" 
by  Xoguchi,  may  perhaps  offer  a  similar  opportunity 
to  diagnose  syphilis  by  a  cutaneous  test.  Individuals 
with  many  other  bacterial  infections  will  respond  to 
the  cutaneous  or  conjunctival  application  of  the 
corresponding  bacterial  extract,  and  the  test  has  been 
proposed  in  typhoid  fever,  gonorrhea,  pneumonia,  and 
other  diseases. 

Passive  anaphylaxis  has  been  tried,  but  rather  un- 
successfully as  an  aid  to  diagnosis  of  tuberculosis  and 
cancer.  Yamanouchi  (1908)  claimed  to  have  sensi- 
tized rabbits  passively  with  serum  from  tuberculous  pa- 
tients  or   cadavers,  and  Capelle  has  recently  (1911) 


transferred  sensitiveness  to  tuberculin  from  one 
animal  to  another.  These  results  have  not  been 
rigidly  confirmed,  nor  applied  in  any  practical  manner 
toward  the  diagnosis  of  the  disease.  According  to 
Pfeiffer  the  serum  of  cancer  patients  renders  guinea- 
pigs  passively  sensitive  to  cancer  proteins.  The 
assumption  is  that  the  cancer  protein  is  specifically 
different  from  that  of  the  host.  This,  if  confirmed, 
would  aid  not  only  in  the  diagnosis  of  malignant  dis- 
ease, but  in  its  treatment. 

The  anaphylactic  reaction  has  forensic  value  in  the 
identification  of  blood  stains.  Thomsen  at  the  State 
Serum  Institution  in  Copenhagen  easily  rendered 
guinea-pigs  anaphylactic  to  homologous  serum  by 
means  of  an  aqueous  extract  of  the  blood  spot  in 
question.  The  specificity  of  the  reaction  has  made  it 
valuable  in  the  detection  of  protein  adulterants  in 
food,  such  as  horse  meat  in  sausages,  etc. 

Anaphylaxis  as  a  Scientific  Instrument. — In 
the  detection  of  minute  quantities  of  protein,  and  in  the 
study  of  the  relationships  of  different  proteins,  the 
anaphylactic  reaction  is  invaluable.  Rosenau  and 
Amoss  have  determined  that  the  expired  breath  of 
human  beings  contains  protein  material  enough  to 
sensitize  guinea-pigs,  a  fact  which  may  have  a  bearing 
on  the  cause  of  symptoms  in  crowded,  ill-ventilated 
places,  and  also  offers  an  explanation  of  the  way  in 
which  individuals  may  become  sensitive  to  horse 
serum  and  some  other  foreign  proteins.  In  cases  of 
alimentary  albuminuria,  "Wells  has  found  by  this 
reaction  that  the  albumin  excreted  is  not  chemically 
identical  with  that  ingested.  Doerr  has  suggested 
using  anaphylaxis  in  the  differentiation  and  grouping 
of  bacteria.  The  potentialities  of  the  anaphylactic 
reaction  are  therefore  rather  broad  in  the  domain  of 
scientific  research.  A  limitation  in  the  practical 
application  of  anaphylaxis  is  that  the  only  method  of 
observing  the  reaction  is  in  the  production  of  acute 
symptoms  in  experimental  animals,  a  test  at  present 
less  capable  of  accurate,  quantitative  determination 
than  hemolysis  or  precipitatii  in  in  a  test-tube,  and  of  no 
greater  specificity.  On  the  other  hand,  the  minute 
quantity  required  for  sensitization  gives  anaphylaxis 
a  certain  advantage  over  other  specific  tests. 

Theory  of  Anaphylaxis. — The  literature  on  this 
subject  is  already  immense;  the  basic  facts  upon  which 
it  is  founded  are  few  and  somewhat  contradictory. 
In  general,  the  theories  may  be  divided  into  those 
which  assume  the  formation  of  specific  antibodies  as 
necessary  to  the  anaphylactic  state,  and  those  which 
dispense  with  antibodies  altogether  as  a  factor  in  the 
phenomenon.  Examples  of  the  latter  group  are  Gay 
and  Southard's  " anaphylactin "  theory  and  Vaughan's 
"proteolytic  enzyme"  theory,  neither  of  which  can  be 
discussed  here  for  want  of  space. 

The  prevailing  view  is  that  sensitization  depends 
in  some  way  upon  antibody  formation,  and  that  the 
anaphylactic  reaction  is  essentially  an  antibody 
reaction.  This  theory  finds  support  in  the  facts 
already  noted  above,  namely,  (1)  all  anaphylactic 
agents  are  true  antigens;  (2)  the  incubation  period 
agrees  precisely  with  that  necessary  to  the  production 
of  antibodies;  (3)  complement  is  a  necessary  factor 
in  the  anaphylactic  reaction;  (4)  hypersusceptibility 
is  capable  of  passive  transference  in  serum;  (5)  in 
point  of  specificity  it  bears  the  closest  relation  to  the 
immune  reactions  of  the  second  order  (Ehrlich), 
particularly  the  precipitin  reaction.  In  its  simplest 
terms,  the  present  conception  is  that  the  sensitizing 
dose  of  anaphylactic  antigen  gives  rise  after  the 
usual  period,  to  substances  of  the  general  nature  of 
amboceptors.  These  combine  with  the  reacting  dose 
of  antigen  and  form  with  the  aid  of  complement, 
poisonous  products  which  cause  the  anaphylactic 
symptoms  and  lesions.  These  toxic  substances 
according  to  Vaughan  are  protein  cleavage  products 
formed  during  the  sudden  destruction  of  the  antigen 


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Anaphylaxis 


in  the  body  of  the  sensitized  animal.  He  has  pro- 
duced  from  ege-albumin,  by  chemical  means,  cleavage 
products  which  are  exceedingly  poisonous  and  cause 
death  in  guinea-pigs  resembling  that  of  acute  lethal 
anaphylaxis.  Friedberger  has  mixed  together  an- 
tigen, complement,  and  serum  containing  the  supposed 
antibodies  in  a  test-tube  and  has  obtained  a  poisonous 
product  (anaphylatoxin)  of  which  a  single  injection 
in  a  guinea-pig  causes  symptoms  like  those  of  acute 
anaphylactic  shock.  This  is  the  so-called  "ana- 
phylaxis in  vitro."  He  concludes  that  the  antigen 
is  first  precipitated  and  then  destroyed  by  specific 
antibodies  which  have  all  the  characteristics  of  pre- 
cipitins. Opposed  to  this  theory  Is  the  very  minute 
amount  of  antigen  required  to  produce  a  high  degree  of 
itization,  and  the  further  fact  that  although  the 
ipitin  reaction  is  very  clear  in  the  rabbit,  the 
anaphylactic  reaction  is  much  less  intense  than  in  the 
guinea-pig  in  w  hich  there  is  a  very  small  production  of 
antibodies  of  any  sort.  Many  other  theories  have 
:  proposed,  but  as  yet  none  is  regarded  as  entirely 
satisfactory,  for  it  seems  plain  that  the  cells  as  well 
as  the  blood  and  allergenic  substance  play  a  role  in 

tin-  phenomenon. 

Rklation  op  Anaphylaxis  to  Infection  and  Im- 
munity.— The  experiments  of  Vaughan  with  egg-white 
and  those  of  Friedberger  with  bacterial  proteins  have 
led  them  to  the  conclusion  that  infection  and  anaphyl- 
axis are  different  expressions  of  the  same  proce 
Vaughan  finds  that  cleavage  products  of  egg-white 
and  other  harmless  proteins  are  quite  as  toxic  as  the 
cleavage  products  obtained  from  the  bodies  of  patho- 
■  bacteria.  We  might  suppose  that  if  egg-white 
Id  grow  and  multiply  in  the  animal  body,  it 
would  as  a  result  of  such  growth  and  subsequent 
age  by  proteolytic  antibodies  be  just  as  deadly 
as  the  bacilli  of  the  infectious  diseases.  In  fact,  in 
the  invasion  of  the  body  by  bacteria,  the  incubation 
period  necessary  for  the  education  of  the  tissues  to 
produce  antibodies,  the  destruction  of  the  bacteria 
with  the  simultaneous  appearance  of  symptoms  and 
lesions,and  the  storing  of  the  surplus  antibodies,  we 
have  an  exact  if  theoretical  analogy  to  our  conception 
of  the  processes  leading  to  "serum-sickness."  In 
other  words,  the  question  is  whether  in  bacterial 
diseases  we  have  to  do  with  preformed  endotoxins  or 
with  the  poisonous  cleavage-products  of  a  protein 
substance  endowed  with  the  powers  of  growth  and 
reproduction.  Rosenau  and  Anderson,  Friedberger, 
and  many  others  have  shown  that  bacterial  protein  acts 
like  any  other  antigen  in  producing  acute  anaphylactic 
-hock,  if  injected  a  second  time  in  sufficient  quantity. 
Rosenow,  after  much  patient  work  with  the  pneumo- 
coccus  has  shown  that  autolytic  products  of  disinte- 
grated cocci  will  cause  anaphylactic  symptoms  in  a 
tea-pig  at  the  first  injection.  These  facts  have  led 
I  i  iedberger  to  hazard  the  conclusion  that  anaphylaxis 
is  only  an  extreme  and  acute  form  of  infection,  and 
infection  a  mild,  protracted  form  of  anaphylaxis. 
It  cannot  be  said  that  this  view  is  as  yet  justified, 
but  it  is  at  least  an  interesting  and  suggestive 
theory. 

The  exact  relation  between  anaphylaxis  and 
immunity  is  not  yet  clearly  understood,  although  all 
workers  in  the  field  have  recognized  that  there  must 
be  a  close  connection  between  the  two,  on  account  of 
the  many  striking  analogies,  already  recounted  under 
the  heading  -'Theory  of  Anaphylaxis"  and  elsewhere 
in  this  article.  The  clearest  elucidation  of  the  two 
processes  as  part  and  parcel  of  the  same  general 
phenomenon  has  been  furnished  by  von  Pirquet. 
In  his  own  words,  "an  immune  person  does  not 
become  insensible  to  inoculation,  but  the  time, 
quality,  ami  quantity  of  his  reaction  are  changed." 
He  would  combine  therefore  the  conceptions  ,of 
immunity  and  hypersensitiveness  in  the  one  work 
"allergy" — or  the  changed  reactivity  of  an  organism 


to  a  second  invasion  of  a  foreign  antigen.  Of  all  the 
infectious  diseases  conferring  immunity,  the  one  best 
luted  lor  experimental  and  clinical  study  in  man  is 
COWpoX,  or  vaccinia.  When  we  vaccinate  for  I  lie 
first  time,  we  note  a  fairly  constant  symptom-com- 
plex, tin  the  third  or  fourth  day  a  small  red  papule 
appear-    which    is    the    specific    la-    distinct    from    the 

traumatic)  reaction.     From  the  fourth  to  the  sixth  day 

the   middle  of   the   papule   bee !     elevated    into    the 

papilla,  and  is  surrounded  by  a  flat,  peripheral  "areola" 
or  zone  of   inflammation.     From    the  eighth    to   the 

eleventh  day  we  see  firs!  a  vesile,  then  a  pustule  which 

is  attended  by  fever  and  leucopenia.     from  tin-  time 

the  reaction  subsides,  leaving  the  well-known  vaccina- 
tion scar.  If  we  revaccinate  daily  for  a  fortnight,  the 
papillae  appear  in  order  uninfluenced  by  each  other; 
but  the  "areola"  appears  on  all  the  vaccination 
points  simultaneously,  i.e.  at  the  time  when  its 
development  is  due  on  the  first  vaccination.  From 
this  time  on,  no  papillse  develop;  we  get  another  type 
of  reaction — the  "early  reaction" — in  which  the 
papule  is  at  its  maximum  in  twenty-four  hours,  then 
disappears.  This  occurs  whenever  vaccination  is 
repeated.  Some  years  later,  we  get  a  "torpid  early 
reaction,"  or  accelerated  reaction,  in  which  the 
maximum  comes  on  the  third  or  fourth  day.  Just 
as  in  serum  sickness,  the  altered  reaction  (allergy), 
which  follows  reinoculation  with  the  antigen,  ex- 
presses itself  temporally  in  a  shortened  incubation 
period,  quantitatively  in  a  heightened  intensity  of 
reaction  which  is,  however,  of  short  duration,  and 
qualitatively  in  the  kind  of  lesions  produced. 

It  is  interesting  at  this  point  to  refer  to  Jenner's 
own  observation  of  this  phenomenon,  recorded  in 
1  798.  He  says,  "  It  is  remarkable  that  variolous  mat- 
ter, when  the  system  is  disposed  to  reject  it,  should 
excite  inflammation  on  the  part  to  which  it  is  applied 
more  speedily  than  when  it  produces  the  smallpox. 
Indeed,  it  becomes  almost  a  criterion  by  which  we 
can  determine  whether  the  infection  will  be  received 
or  not.  It  seems  as  if  a  change,  which  endures  through 
life,  had  been  produced  in  the  action,  or  disposition  to 
action,  in  the  vessels  of  the  skin:  and  it  is  remarkable, 
too,  that  whether  this  change  has  been  effected  by 
the  smallpox  or  the  cowpox,  the  disposition  to 
sudden  cuticular  inflammation  is  the  same  on  the 
application  of  variolous  matter."  This  remarkably 
clear  statement  (quoted  by  Hektoen)  probably 
records  the  first  observation  of  allergy  in  an  infectious 
disease. 

The  actual  processes  underlying  these  different 
types  of  reaction  are  described  by  von  Pirquet  as 
follows:  We  implant  a  colony  of  microorganisms  on 
the  skin.  They  grow  day  by  day,  and  on  the  eighth 
i lay  there  are  an  enormous  number  of  them.  The 
contents  of  the  blister  will  start  new  colonies  on 
thousands  of  other  arms.  But  now  the  antibody 
appears  and  the  colony  is  attacked  and  digested,  and 
a  toxic  body  formed.  This  is  diffused  in  the  neighbor- 
hood and  we  get  an  intense  local  inflammation  called 
the  areola.  Some  of  the  toxic  bodies  enter  into  the 
circulation  and  cause  fever.  But  the  microorganisms 
are  killed  and  we  can  no  longer  vaccinate  with  the 
contents  of  the  now  yellow  pustule.  After  two  or 
three  days,  the  struggle  is  over,  but  the  antibodies 
remain  a  long  time.  Let  us  now-  revaccinate.  The 
microorganisms  are  immediately  attacked  and  di- 
gested— they  are  given  no  chance  to  multiply  and 
little  toxin  is  binned.  This  is  the  immediate  reaction. 
After  a  few  years,  antibodies  are  no  longer  present, 
but  can  be  formed  more  quickly  than  the  first  time. 
This  causes  the  accelerated  reaction.  A  smallpox 
germ  deposited  in  the  throat  of  an  unvaccinated 
individual,  multiplies  without  opposition  throughout 
the  incubation  period,  and  the  individual  goes  through 
the  whole  course  of  the  disease.  In  the  throat  of  a 
vaccinated  person,  it  is  overwhelmed  by  the  early 
reaction    in    the    first    twrenty-four    hours;    a    slight 


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redness  appears  about  its  disintegrating  body,  and 
that  is  all. 

According  to  this  attractive  theory,  then,  infection 
produces  sensitization,  like  the  preliminary  injection 
of  horse  serum  or  egg-white.  A  second  inoculation 
of  the  same  antigen,  whether  it  be  living  pathogenic 
bacteria,  or  a  tenth  of  a  cubic  centimeter  uf  foreign 
serum,  produces  an  allergic  reaction,  differing  from 
the  first  in  time,  quantity,  and  quality.  The  antigen 
is  broken  down  with  fulminating  rapidity,  and  if  the 
amount  is  minute,  the  reaction  is  correspondingly 
trifling.  But  if  the  amount  of  antigen  is  large  (as 
in  the  guinea-pig  experiment)  poisonous  cleavage 
products  are  liberated  en  masse,  which  overwhelm  the 
organism    and    produce    acute    anaphylactic    shock. 

New  light  is  thrown  on  that  mysterious  factor  in 
infectious  disease,  the  incubation  period.  According 
to  the  usual  theory,  microorganisms  have  to  reach  a 
certain  development  before  toxins  enough  are  produced 
to  cause  symptoms.  If  this  were  true,  one  would 
suppose  that  in  a  body  rendered  somewhat  immune 
by  previous  infection,  microorganisms  would  grow 
more  slowly  and  the  incubation  period  would  be  pro- 
longed. But  vaccinia  (and  serum-sickness)  exhibits 
just  the  opposite  condition.  Von  Pirquet  concludes 
that  in  most  diseases,  the  clinical  reaction  is  not  an 
immediate  consequence  of  infection,  but  a  phenom- 
enon of  a  more  complicated  nature,  not  explicable 
simply  by  the  action  of  microorganisms  and  other 
foreign  substances  on  the  tissues,  but  involving  the 
existence  of  a  third  factor  which  appeal's  only  some 
time  after  the  first  infection.  Thus  far  antibodies 
have  been  numbered  among  the  protective  substances. 
Now  it  is  conceived  that  disease  may  be  due  to  the  ac- 
tion of  some  antibodies  and  immunity  is  based,  not 
on  an  acquired  insensibility  to  virus,  but  on  an  altered 
power  of  reaction  toward  it. 

There  are,  then,  three  general  theories  of  immunity 
in  vogue  today:  Ehrlich's  side-chain  theory,  Metchni- 
koff's  phagocytosis  theory,  and  the  theory  of  the  ana- 
phylactic or  allergic  reaction.  Curiously  enough 
each  one  of  these  apparently  divergent  theories  is 
based  upon  the  metabolism  of  the  cell.  In  the  side- 
chain  theory,  it  is  the  hungry  receptors  seeking  a 
chemical  union  with  protein  food  molecules;  in 
phagocytosis,  it  is  the  hungry  ameboid  cell  engulfing 
protein  food  particles;  and  finally  anaphylaxis  is  an 
adjustment  to  alein  food  proteins  in  the  sense  of  a 
defence.  All  three  theories  are  intimately  concerned 
with  protein  metabolism.  No  one  theory  fully 
explains  the  mechanism  of  immunity  to  all  diseases. 
Each  has  distinctive  features,  although  all  overlap 
more  or  less.  The  only  satisfactory  explanation  of 
the  immunity  to  a  certain  large  and  important  group 
of  diseases  finds  its  solution  in  terms  of  anaphylaxis. 
Lewis   Wendell   Hackett. 


Anaplasia. — This  word  (from  dm,  again,  and  irk&ais 
a  moulding)  is  used  by  some  writers  synonymously 
with  anaplasty,  having  the  meaning  of  a  repair  of  in- 
jured parts  by  means  of  plastic  operation.  In  1893 
its  use  in  an  entirely  different  sense  was  introduced  by 
von  Hansemann,  who  wished  to  designate  by  some 
specific  term  the  morphological  and  physiological 
differences  which  exist  between  the  cells  of  malignant 
tumors  and  those  of  the  normal  parent  tissue. 

The  type  and  character  of  the  parent  cells  are 
usually  preserved  to  some  extent  in  the  tumor  cells 
which  arise  from  them;  as,  for  example,  the  cells  of  a 
squamous-cell  carcinoma  of  the  skin  may  undergo 
a  horny  change;  those  of  an  adenocarcinoma  arising 
from  cylindrical  cells  are  more  or  less  cylindrical  in 
shape;  the  cells  of  an  adenocarcinoma  of  the  thyroid 
m  iv  produce  a  colloid-like  substance;  metastases  of 
an  adenocarcinoma  of  the  liver  may  secrete  a  bile- 
like fluid;  and  the  sarcomata  arising  from  the 
chromatophores  of  the  skin  produce  melanin.     These 


resemblances  uf  tumor  cells  to  their  parent  cells  are 
not  so  marked  as  the  differences  which  exist  between 
them,  both  in  morphological  and  physiological 
characteristics.  The  latter  are  shown  by  striking 
variations  in  size  and  form;  by  changes  in  the  finer 
structure  of  the  nucleus  and  cell  body  as  shown  by 
staining  reactions  (hyperchromatosis,  hypochro- 
matosis,  etc.);  by  abnormal  cell-division  forms;  by 
the  changed  chemical  character  or  total  absence  iif 
cell  function;  by  increased  vegetative  activity(habit 
of  growth);  and  by  the  tendency  to  undergo  degen- 
eration. To  all  of  these  alterations  in  cell  character 
which  constitute  malignancy  von  Hansemann  would 
apply  the  term  anaplasia,  as  opposed  to  heteroplasia 
and  metaplasia.  According  to  his  view,  the  signifi- 
cance of  these  changes  must  be  that  the  cells  of  ma- 
lignant tumors  have  lost  in  differentiation  (Entdiffer- 
enzierung)  and  so  have  acquired  the  powerof  individual 
existence.  The  manner  in  which  the  cells  have 
undergone  this  change  or  the  etiology  of  malignant 
tumors  is  not  included  in  the  meaning  of  the  term. 
There  can  be  no  doubt  that  the  use  of  the  term 
anaplasia  in  this  application  is  of  great  service,  and 
though  von  Hansemann's  views  have  "met  with 
much  opposition,  it  has  gained  a  wide  acceptance  in 
modern  pathology.  As  used  now  anaplasia  em- 
braces all  these  qualities  of  tumor  cells  as  shown 
in  their  lessened  differentiation  and  increased  poirer 
of  independent  existence.  Various  other  expressions 
are  also  in  use  to  indicate  the  same  peculiarities  of 
tumor  cells,  such  as  kataplasia  (Beneke),  "new  cell- 
races"  (Hauser),  "reversion  from  organotypical 
to  cytotypical  growth"  (R.  Hertwig).  For  a  fuller 
discussion  of  the  problems  of  malignancy  included 
under  anaplasia  see  the  article  on  Neoplasms. 

Aldred  Scott  Warthin. 

Bibliography. 
Von   Hansemann:   Studien    iiber   Specificitat,    Altruismus   und 
Anaplasia  der  Zellen,  Berlin,  1S93.     Die  mikroscopische  Diagnose 
der  bosartigen  Geschwulste,  Berlin,  1S97. 


Anatomical  Nomenclature,  the  Basle. — The  expres- 
sion BNA  is  an  abbreviated  title  for  the  Basle  Nomina 
Anatomica,  or  anatomical  nomenclature,  adopted  by 
the  Anatomische  Gesellschaft  of  Germany,  during 
their  ninth  session  at  Basle,  1895.  The  list  comprises 
some  4,500  terms,  regarded  as  the  most  fitting  de-d- 
ilations for  the  various  structures  of  human  macro- 
scopic anatomy.  The  terms  were  selected  by  a 
Commission  of  Anatomists,  appointed  six  years  pre- 
viously, by  the  Gesellschaft,  at  the  instigation  of  the 
late  Professor  Wilhelm  His,  for  the  purpose  of  revising 
anatomical  terminology. 

The  official  list  is  constructed  in  Latin  under  the 
various  headings  of  Osteology,  Myology,  S3'ndesmology 
Splanchnology,  Angiology,  and  Neurology.  A  large 
proportion  of  the  terms  embodied  in  the  list  were 
culled  from  the  many  synonyms  already  in  use  in  the 
standard  text-books  of  gross  anatomy,  or  in  anatom- 
ical monographs,  preference  in  each  case  being  given 
to  the  shortest  and  most  suitable  name  for  the  part. 
A  few  of  the  terms  are  new,  such  being  introduced 
only  in  those  cases  where  a  search  of  the  literature 
failed  to  reveal  a  designation  deemed  proper  for  the 
part  under  consideration.  Only  one  name  was  given 
to  a  part,  and  while  the  list  may  in  no  way  be  styled 
a  new  nomenclature,  it  has  served  to  simplify  anatom- 
ical terminology  by  greatly  reducing  the  number  of 
anatomical  terms  in  current  use. 

The  reasons  for  undertaking  a  revision  of  anatomical 
nomenclature  at  the  time  Professor  His  brought  the 
matter  before  the  Anatomische  Gesellschaft, 
most  urgent.  Hitherto,  there  had  been  no  authentic 
principles  governing  the  formation  and  usage  of  ana- 
tomical terms.  With  the  rapid  progress  of  the  science 
of    anatomy    and    the    stimulation    of    research,  in 


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Anatnmir.il  Nomenclature) 
the  Basle 


ope  and  America,  the  reduplication  of  anatomical 
rune-  had  grow  a  excessive.  The  naming  of  a  sti 
ure  was  left  to  tin-  choice  of  the  individual  investi- 
'ator,  who  was  not  infrequently  ignorant  of  the  work 
lone  by  his  fellows  in  the  same  field.  As  a  resull 
>ach  teacher,  each  school,  and  each  country  acquired 
i  peculiar  group  of  anatomical  names.     These  multiple 

is  gradually  found  their  way  into  tin-  anatomical 

ext-books,    each    author    adopting,    or    discarding 

whatever  names  he  chose.     One  of  the  larger  standard 

ol   tin-  era  contained  as  many  as   10,000 

lames,  over  one-half  of  which  were  synonyms,  while 

,       ,  of  the  various  synonyms  employed  in 

i  number  of  standard  works  revealed  a  list  of  -ohm 

mii  names.     Indeed,  for  the  approximately   500 

>.  a  structures  of  the  brain  alone,  Professor  Wilder 

able  to  collect  from  the  literature  a  list  of  no  less 

■  i  mi  names. 

This  cumbersome   multiplication  of  terms   was   a 

jriovous  burden   to  both   teacher  and    student,    and 

rise    to  much   ambiguity   and    confusion.     The 

of  double  names  for  each  pari  in  the  schools  was 

isl  the  rule.  Such  multiple  synonyms  as  Valvula 
coli,    vel    ileocoecalis,   vel    Bauhini,    vel    Tulpi,    vel 

ipii,    wen'    not    infrequent.     Anatomical    termi- 

■,  was   necessarily  wholly  lacking  in  uniformity 

and  in   any   plan   of   construction.     To   usage   alone 

left  the  final  justification  of  a  new  term  in  the 
science.  Important  structures  were  differently  named 
in  the  various  countries,  the    Corpuscula    lamellosa 

g  known  as  the  corpuscles  of  Vater  in  Germany 
and  the  corpuscles  of  Pacini  in  Italy.     Xor,  indeed, 

i  his  species  of  anatomical  patois  alone  national 
in  extent,  but  was  characteristic  of  the  various 
universities.     Each    great    medical    school    had,     in 

asure,  its  own  anatomical  language,  and  a 
student    migrating   from   one   university    to  another 

often  forced  to  acquire  a  new  set  of  anatom  ical 
terms. 

I  Ine  of  the  first  anatomists  to  revolt  againstethe 
tyranny  of  multiple  anatomical  terms  was  J.  Honle, 
who.  in  writing  his  well-known  treatise  on  anatgmy, 
only  one  name  for  each  part,  relegatinfe  all 
synonyms  to  the  footnote.  To  his  example  Provissor 
His  attributed  his  conception  of  an  official  reacsion 
of  anatomical  nomenclature.  Henle  further  attacked 
the  use  of  personal  names  in  terminology  and  re- 
placed them  by  objective  terms,  on  the  ground  hat- 
the  use  of  such  names  frequently  gave  rise  to  this 
torical  injustice.  His  efforts  to  simplify  anatomical 
terminology,  strangely,  only  tended  to  create  still 
greater  confusion,  due  to  the  fact  that  he  himself 
introduced  many  new  terms,  and  while  his  terminology 
found  favor  with  many  anatomists,  others  refused  to 

pt  it,  and  a  third  group  became  eclectic,  reserving 
the  right  to  retain  the  use  of  personal  names. 

Individual  endeavor,  such  as  that  of  Henle,  could 
not  hope  to  effect  a  speedy  reform  in  anatomical 
nomenclature,  yet  the  efforts  of  a  few  pioneers  paved 
the  way  for  a  concerted  action  on  the  part  of  the 
anatomical  societies.  Early  in  the  nineteenth  cen- 
tury John  Barclay,  Owen,  and  Pye-Smith  began  a 
crusade  of  reform  in  England,  while  later  in  America 
(1861)  Dr.  Leidy,  the  first  president  of  the  American 
Association  of  Anatomists,  published  a  work  on 
Human  Anatomy,  in  which  he  eliminated  all  synonyms 
from  the  text,  retaining  only  such  terms,  one  for  each 
Mire,  as  seemed  most  suitable.  Numerous  foot- 
notes supplied  a  list  of  synonyms.  The  use  of  proper 
names  was  also  much  restricted.  Unfortunately  his 
attempt  to  simplify  American  anatomical  terminology 
met  with  little  encouragement.  A  decade  later 
Professor  Wilder  began  to  advocate  a  simplification 
of  anatomical  language  and  called  attention  to  the 
special  need  of  a  revision  of  neurological  nomencla- 
ture. Largely  owing  to  his  efforts,  Committees  on 
Anatomical  Nomenclature  had  been  appointed  by 
the   American   Association  for   the  Advancement   of 


Science,  the  American  Neurological  Society,  ami  the 
American  \  o  ol  Anatomists,  prior  to  the 
adoption  of  the  report  of  the  German  Commission. 
When  the  AnatOD  chafl  was  founded 
at  Leipzig,  in  1887,  one  of  the  firsl  matters  discussed 
was  the  need  of  establishing  a  uniform  nomenclal 
\  resolution  was  passed  instructing  the  officers  of 
the  Society  to  undertake  a  revision  of  anatomical 
terms.  However,  a-  soon  as  the  task  was  begun. 
numerous  unforeseen  difficulties  presented  themselves 
and  it  at  once  became  apparent  that  an  undertaking 
involving  so  much  detail  would  require  the  coopera- 
tion of  many  anat ists,  and  a  period  of  se\  oral  years, 

for  its  execution.  At  Berlin  in  1889  His  brought 
these  difficulties  before  the  ( lesellschafl  and  advocated 
the  formation  ol  a  permanent  Commission  on  Nomen- 
clature with  the  appointment  of  an  editor-in-chief,  who 

might  devote  his  time  a! st  exclusively  for  several 

year-  to  the  work  of  revision.     Hi-  suggestions  were 

adopted    and    the    Commission    was    appointed    with 

Professor  v.  Kolliker  a-  chairman  and  Professors  0. 
Hertwig,  His.  Kollmann,  Merkel,  Bardeleben,  Toldt, 
Waldeyer,  and  Schwalbe  as  members. 

The  two  remaining  need-  of  the  Commission,  viz., 
the  securing  of  an  editor-in-chief  and  the  assurance 
of  financial  aid  for  carrying  on  the  work, were  quickly 
Professor  W.  Krause  of  Berlin  accepted  the 
post  of  editor.  The  expenses  of  the  undertaking 
amounted  to  some  11,000  Marks,  slightly  in  excess 
of  the  original  modest  estimate  of  10,000  Marks.  To 
defray  this  sum,  the  Anatomische  Gesellschaft  voted 
3.S00  Marks,  the  balance  being  secured  by  grants  from 
the  scientific  academies  of  Munich,  Berlin,  Leipzig, 
Vienna,  and  Budape-t. 

Before  beginning  their  task  the  Commission  wisely 
realized  the  necessity  of  limiting  the  scope  of  their 
undertaking.  It  was  obvious  that  any  attempt  to 
establish  a  rigid  terminology7  for  structures  still  the 
subject  of  dispute,  could  only  end  in  failure.  Accord- 
ingly the  Commission  decided  to  confine  its  work  to 
the  descriptive  anatomy7  of  structures  visible  to  the 
naked  eye,  or  at  least  with  the  aid  of  a  hand  lens. 
The  designating  of  the  finer  structures  of  microscopic 
anatomy  was  sedulously  avoided.  While  the  terms 
of  the  list  were  to  be  constructed  in  Latin,  the  Com- 
mission made  it  clear  that  anatomists,  who  might 
accept  the  terminology,  should  be  left  free  to  translate 
these  terms  into  their  native  tongue. 

A  further  preliminary  question  of  a  delicate  nature 
for  the  Commission  to  decide,  was  to  what  extent  the 
nomenclature  might  assume  an  international  charac- 
ter. The  Commission  attempted  to  establish  clearly 
its  position  on  this  point.  It  was  granted  that  the 
list  was  to  be  a  product  of  the  Anatomische  Gesell- 
schaft, but  as  Professor  His  has  stated,  this  Society, 
while  founded  in  Berlin,  from  the  first  day  of  its 
origin,  assumed  a  character  broader  than  German. 
At  the  time  of  its  organization  a  small  majority7  of  its 
members  were  Germans  (145),  while  the  remaining 
members  (129)  came  from  Belgium,  Denmark,  Eng- 
land, Sweden.  Russia,  Austria,  and  France.  The 
Commission  reasoned  that  the  composition  of  the 
Gesellschaft  was  sufficient  cause  for  establishing  an  in- 
ternational standard  of  nomenclature.  With  this  end 
in  view,  anatomical  terms  used  in  the  standard  text- 
books of  anatomy7  of  countries  other  than  Germany 
were  considered  in  compiling  the  lists.  Opportunely 
a  meeting  of  the  Anatomische  Gesellschaft  conjoint  ly 
with  the  section  of  anatomy  of  the  International 
Medical  Congress  at  Berlin  afforded  the  Commission  a 
means  of  enlisting  the  services  of  such  foreign  anato- 
mists as  Sir  William  Turner,  Cunningham,  Romiti. 
and  Leboucq.  At  a  later  time  Professor  Thane  of 
London  was  also  included  in  the  Commission.  Amer- 
ica, it  is  true,  was  not  represented  on  the  Commission, 
nor  were  the  representatives  of  France  and  England 
present  at  the  signing  of  the  report  in  1895.  Recogni- 
tion of  the  desirability7  of  imparting  an  international 


319 


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character  to  the  -work  of  the  Commission  was  acknowl- 
edged by  the  action  of  the  Anatomical  Society  of 
Great  Britain  and  Ireland  in  the  appointment  of  a 
Committee  in  1S93  to  consider  adapting  the  sugges- 
tions of  the  Commission  to  English  needs,  while  from 
America,  Professor  Wilder  had  forwarded  to  the 
Commission  a  series  of  reports  of  Committees  on 
Anatomical  Nomenclature  of  the  various  scientific 
societies. 

In  order  to  secure  uniformity  in  the  character  of 
the  revised  nomenclature,  the  Commission  formulated 
certain  general  rules,  which  they  followed  in  the 
selection  of  anatomical  terms.  These  fixed  principles, 
as  stated  by  the  Editor,  were: 

1.  Each  part  of  the  body  shall  have  one  Latin 
name;  there  shall  be  no  synonyms  separated  by 
"  sive"  or  "seu."  Each  nation  using  the  Latin  name 
may  translate  it  in  the  way  that  seems  best. 

2.  The  name  shall  be  as  short  and  simple  as  pos- 
sible, and  should  recall  some  point  of  description,  or 
distinctive  character. 

3.  No  part  of  the  body  shall  have  an  unnecessarily 
long  Latin  name. 

4.  No  two  parts  of  the  body  shall  have  the  same 
name  unless  they  are  truly  homologous  structures. 

5.  The  names  shall  be  consistent  with  Latin  gram- 
mar and  orthography. 

6.  Personal  names  shall,  as  far  as  possible,  be  re- 
moved from  anatomical  terms,  except  where  they 
actually  mark  historical  observation. 

7.  In  the  whole  work  the  Commission  shall  endeavor 
to  be  as  conservative  as  possible. 

8.  The  same  names  shall  be  used  for  arteries,  veins, 
and  nerves,  where  they  run  together;  e.g.  A.  fem- 
oralis, V.  femoralis,  N.  femoralis. 

9.  The  same  names  shall  be  given  to  foramina  and 
to  the  vessels  and  other  structures  which  pass  through 
them. 

10.  Adjectives  shall,  as  far  as  possible,  be  used  as 
opposites;  e.g.  profundus  and  superficialis. 

11.  Ligaments  shall  be  named  according  to  their 
attachments,  the  final  part  of  the  name  indicating  the 
proximal  attachment;  e.g.  sacroiliac,  not,  iliosacral. 

12.  There  shall  be  no  hybrid  names. 

While  the  Commission  followed  these  guiding  prin- 
ciples as  closely  as  possible,  in  certain  instances,  a 
deviation  from  the  rules  in  the  selection  of  a  term 
seemed  advisable.  Thus,  while  such  cumbersome 
terms  as  M.  petrosalpingostaphylinus  could  read- 
ily be  discarded,  no  good  substitute  could  be  found 
for  so  commonly  a  used  term  as  M.  sternocleido- 
mastoideus.  In  a  few  instances  dual  terms  were 
retained,  as  in  the  case  of  Valvula  bicuspidalis  ve] 
mitralis,  the  latter  term  being  retained  out  of  eon- 
cession  to  the  clinicians.  Nor  did  it  seem  wise  in 
every  case  to  affix  similar  terms  to  neighborhood 
structures,  such  a  term  as  Foramen  spinosum  being 
retained  as  being  preferable  to  styling  it  Foramen 
meningeum  medium  by  virtue  of  its  penetration  by 
the  A.  meningea  media. 

A  systematic  plan  for  the  execution  of  the  work  to 
which  the  Commission  adhered  during  the  early  years 
of  the  work,  was  elaborated  by  the  Editor  and  sanc- 
tioned by  the  Commission.  He  suggested  a  compila- 
tion of  the  lisl  of  anatomical  terms  used  in  a  stand- 
ard text-book  of  Anatomy  (Gegenbauer's  "Lehrbueh 
der  Anatomie  des  Menschen"  being  so  employed). 
These  terms  were  arranged  in  vertical  columns, 
while  parallel  to  them,  in  other  columns,  were  placed 
the  various  synonyms  from  a  number  of  other  widely 
used  text-books  of  anatomy.  A  copy  of  this  list 
compiled  by  the  Editor  was  sent  to  each  member  of 
the  Commission,  with  a  request  that  he  indicate  the 
term  of  his  choice  for  the  part,  from  one  of  the  syno- 
nyms submitted,  or  in  case  none  of  the  terms  seemed 
suitable  for  the  part,  that  he  propose  a  new  name. 
The  lists,  along  with  comments  upon  the  terms,  were 
then  returned  to  the  Editor. 


Following  this  plan,  the  terms  of  Myology  were  first 
subjected  to  the  ballot.  The  result  of  the  first  vote  was 
most  gratifying  to  the  Commissioners,  since  eighty-five 
per  cent,  of  the  terms  considered  received  a  majority 
vote,  and  of  this  number,  more  than  forty  percent, 
received  an  almost  unanimous  approval.  A  second 
revised  list  was  issued,  containing  the  selected  terras 
and  those  still  in  dispute,  together  with  the  new- 
names  proposed  by  the  members  and  comments 
thereon.  Whatever  terms  the  second  written  bal- 
lot left  undecided,  were  finally  adjusted  in  personal 
meetings  of  the  Commission.  The  fact  that  such 
meetings  of  the  Nomenclature  Commission  were 
held  during  the  annual  session  of  the  Anatomische 
Gesellschaft  afforded  the  Commission  an  opportunity 
of  seeking  the  advice  of  the  distinguished  members 
of  that  bod}T.  In  such  manner  the  terminologv  of 
Myology  was  completed  at  Munich  in  1S91  with  a 
list  of  300  accepted  terms.  At  a  later  session  in 
Vienna  the  terms  for  Osteology  and  Angiology  were 
similarly  brought  to  completion. 

As  the  process  of  balloting  by  correspondence  for 
the  proper  terms  of  the  list  progressed,  it  became 
evident  that  a  repeated  voting  over  terms  in  dispute 
gave  no  more  satisfactory  results  than  a  single  ballot. 
Frequently  it  happened  that  newly  proposed  names, 
representing  the  fruit  of  much  thought  and  special 
knowledge,  received  too  scanty  consideration,  and 
were  rejected  without  sufficient  testing.  In  order 
to  obviate  this  fault,  the  Commission,  somewhat 
hastily,  decided  that  all  new  terms  and  comments 
should  be  considered  in  verbal  discussion.  This 
scheme,  however,  proved  to  be  wholly  impracticable, 
owing  to  the  tedious  discussions  provoked.  As  a 
wise  alternative  it  was  resolved  to  allot  the  work 
under  certain  headings,  in  charge  of  special  commit- 
tees. At  Vienna  a  committee,  consisting  of  Profess- 
ors Merkel,  Thane,  and  Toldt,  was  appointed  to 
take  charge  of  Angiology.  At  a  later  time  Profess- 
ors Rudinger,  Toldt,  and  Merkel  were  assigned  to 
regional  Anatom}',  and  Professor  Toldt  was  appointed 
a  committee  of  one  in  charge  of  Syndesmology. 

The  need  of  correlation  of  the  work  of  these  special 
committees  next  forced  itself  upon  the  Commission. 
Since  the  balloting  for  the  terms  had  taken  place  at 
different  times,  and  frequently  at  long  intervals,  a 
certain  element  of  dissimilarity,  and  in  a  few  instances, 
contradictory  expressions,  had  crept  into  the  lists. 
In  order  to  adjust  these  difficulties  and  to  impart 
uniformity  and  logical  sequence  to  the  nomencla- 
ture, a  general  editing  Committee  composed  of  Pro- 
fessors Hi-.  Krause,  and  Waldeyer  was  appointed. 
This  Committee  soon  found  its  task  of  smoothing 
out  inequalities  and  correcting  contradictions  a 
most  arduous  one,  working  continuously  for  three 
years  partly  by  correspondence,  and  partly  by  per- 
sonal interviews.  Frequently  authorities  were  con- 
sulted in  order  to  arrive  at  clearness  and  unity  in 
regard  to  disputed  and  difficult  points  in  terminol- 
ogy. The  most  perplexing  sections  of  the  work 
proved  to  be  Neurology  and  Splanchnology.  With 
the  appointment  of  a  general  editing  Committee  its 
original  plan  of  execution  was  somewhat  altered,  and 
the  work  much  facilitated.  The  individual  mem- 
bers of  the  Commission  were  invited  to  forward  their 
various  suggestions  and  comments  for  the  terms  of 
the  sections  under  discussion,  prior  to  the  first  ('al- 
lot, in  order  that  such  suggestions  might  receive  due 
consideration  before  the  voting.  After  the  vote  was 
taken,  the  lists  were  rearranged  by  the  editor  and  sub- 
mitted to  the  general  editing  Committee.  In  this 
way  the  value  and  precise  meaning  of  each  express  ion 
was  subjected  to  critical  examination.  In  many 
instances  the  bibliography  was  consulted  and  dissec- 
tions undertaken,  to  verify  the  fitness  of  the  decli- 
nations for  structures  in  question.  The  lists,  thus 
revised,  were  again  submitted  to  the  members  of  the 
Commission  for  approbation,   or  further  comments, 


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which  in  turn  received  the  consideration  of  the  edit- 
ing Committee.     The  final    revision  of    the  various 

chapters  was  sent  to  the  members  of  the  Commission 
in  July,  1894.  This  revised  list  was  again  critically 
studied  and  tested  by  the  members.  After  a  care- 
ful consideration  of  the  comments  and  suggestions 
arising  from   this  examination  the  definitive  lis!   of 

anatomical  terms  was  presented   to  the  Anatomische 
Cesellschaft   as   a   whole,   for  adoption,   during    the 
jion  at  Basle,  1895. 

The  task  of  sweeping  out  of  anatomical  terminology 
tic  great  ma"  of  synonyms,  which  usage  had  well 
established,  was  one  that  presented  many  difficul- 
ties. One  of  the  greatest  of  these  was  in  respect 
to  the  use  of  personal  names  as  designations  for 
structures.  The  question  of  eliminating  these  from 
the  nomenclature  was  very  carefully  weighed  by  the 
Commission.  Many  convincing  reasons  were  urged 
by  Professor  His  against  their  retention.  It  was 
stated  that  the  use  of  personal  names  frequently 
rise  to  historical  injustice,  the  name  applied  to 
a  structure  not  being  that  of  the  real  discoverer, 
hut  of  some  later  observer.  Personal  names  of  dif- 
it  anatomists  in  two  or  more  countries  were 
frequently  chosen  for  the  same  structures,  the  glands 
of  bieberkuhn  in  Germany  being  those  of  Galeati  in 
Italy.  Moreover,  no  system  had  been  followed  in 
I  he  choice  of  names  of  the  old  anatomists.  The 
names  of  such  famous  anatomists  as  Harvey  and 
Vesalius  were  wanting  in  anatomical  literature, 
while  the  names  of  Malpighius  and  Eustachius  had 
been  duplicated. 

A  more  cogent  reason  for  dropping  personal  names 
was  found  in  the  fact  that  a  great  mass  of  proper 
names  had  accumulated  in  modern  anatomical 
writings,  especially  in  the  literature  of  the  specialties, 
where  frequently  names  of  very  questionable  scien- 
tific importance  were  encountered. 

On  the  other  hand,  in  favor  of  the  retention  of 
personal  names  in  the  lists,  Professor  His  pointed 
out  that  the  use  of  such  names  may  at  times  furnish 
good  mnemotechnic  material.  It  was  believed  that 
the  use  of  such  terms  as  Poupart's,  Gimbernat's  and 
is's  ligaments  might  incite  a  student  to  acquire 
the  meaning  of  such  expressions,  whereas  his  interest 
in  a  Ligamentum  inguinale,  L.  lacunare,  or  L.  ingui- 
nale rcflexum,  was  apt  to  be  less  certain.  Again  the 
members  of  the  Commission  were  dominated  by  a  cer- 
tain feeling  of  piety,  which  inhibited  them  from  drop- 
ping personal  names.  It  was  a  question  in  their 
minds  whether  names  of  the  immortals,  which  for 
centuries  had  served  a  good  and  useful  purpose  in 
anatomical  literature,  should  be  sacrificed  for  a  prin- 
ciple. Moreover,  it  was  doubtless  advantageous  for 
the  student  in  his  first  semester  to  encounter  such 
names  as  Fallopius,  Eustachius,  and  Malpighius,  for 
thereby  a  _  certain  historical  interest  was  aroused 
which  is  stimulating. 

As  a  solution  of  this  perplexing  question,  the 
Commission,  very  wisely  it  seems,  effected  a  com- 
promise in  place  of  arbitrarily  banishing  all  personal 
names  from  the  lists.  For  each  structure  a  material 
objective  designation  was  given,  and  the  better  known 
personal  names  were  added  in  brackets.  Following 
the  precedent  of  the  Zoological  Nomenclature  Com- 
mission, such  names  were  put  in  the  genitive  case. 
Further,  the  use  of  personal  names  was  much  cur- 
tailed, being  retained  only  where  these  were  common 
to  a  majority  of  the  national  anatomical  terminol- 
ogies. This  mode  of  treatment,  while  less  simple 
than  the  use  of  material  terms  alone,  offered  the 
advantage  of  leaving  to  time  the  final  decision  as  to 
which  of  the  two  terms  would  survive. 

Another  problem  which  confronted  the  Commis- 
sion was  the  need  of  incorporating  the  terminology 
of  the  medical  specialties  into  their  list.  The  many- 
specialists,  who  had  carried  on  investigations  in  their 
own  special   fields,   notably  in  Neurology,   Otology, 

Vol.  I.— 21 


Ophthalmology,    and    Laryngology    had    introduced 

itito  the  literature  an  anatomical  nomenclature  whirl, 
deviated  greatly  from  the  terms  used  in  tin'  stand- 
ard text-books.     A  danger  had  arisen  of  a  veritable 

terminological    crevice.       The    question    arose    should 

the  ( lommission  adhere  to  the  old  plan,  or  should  eon- 
cessions  be  made  to  tin' specialists.'  Careful  consid- 
eration of  the  matter  convinced  the  members  of  the 
Commission   that  the   nomenclature   of   the  special- 

i-t  -  had  arisen  through  a  real  need  of  the  same, 
the  terms  of  the  text-books  being  no  longer  adequate. 

It  was  clearly  the  duty  of  the  Commission  i"  aco  pt 
the  terms  of  the  specialists,  or  to  supply  better  ones. 
A  conference  was  held  with  a  number  of  the  lead- 
ing specialists,  active  as  investigators,  and  a  mutual 
adjustment  was  effected  w  hereby  a  full  list  of  the 
names  of  macroscopic  structures  in  these  special 
regions  was  to  be  included  in  the  nomenclature.  In 
return  the  Commission  was  assured  that  the  nomen- 
clature of  the  Anatomische  Gesellschaft  would  be 
accepteil  as  soon  as  it  covered  the  requirements  of 
the  specialties. 

In  the  course  of  selecting  the  list  of  terms  from 
the  text-books,  the  Commission  encountered  many 
antiquated  and  obscure  names,  some  of  which  \ 
used  by  one  author  in  a  sense  different  from  that  of 
another,  owing,  in  certain  cases  at  least,  to  obscure 
or  inexact  views.  The  fact  was  revealed  in  the  dis- 
cussions that  the  members  of  the  Commission  them- 
selves were  frequently  at  variance  regarding  the  pre- 
cise meaning  of  an  expression.  In  the  case  of  such 
ambiguous  terms  there  arose  the  need  of  searching 
the  bibliography,  making  dissections,  and  in  a  few 
instances  undertaking  research,  over  a  given  term. 
Such  investigations  led  to  the  introduction  of  a  num- 
ber of  new  terms  into  the  lists,  where  these  were 
demanded  for  the  sake  of  clarity  and  accuracy.  Pro- 
fessor His  and  his  colleagues  have  written  explanatory 
notes  indicating  the  sense  in  which  these  new  terms 
were  employed,  such  notes  being  inserted  at  the  end 
of  the  list  of  terms  in  the  official  publication  of  the 
BNA. 

With  the  completion  of  the  work  of  the  Commission, 
representing  six  consecutive  years  of  arduous  appli- 
cation to  their  task,  the  final  report  was  officially 
presented  to  the  Anatomische  Gesellschaft  by  Pro- 
fessor His  at  Basle,  1895.  The  report  was  unani- 
mously adopted  by  the  Gesellschaft.  In  presenting 
their  report  the  Commissioners  emphasized  the  fact 
that  they  regarded  their  list  as  only  provisional, 
and  by  no  means  complete.  There  remained  an 
undoubted  need  of  a  revision  of  certain  gaps  in  the 
lists.  Their  aim  had  been  to  prepare  a  common 
teaching  nomenclature,  and  at  the  same  time  to 
create  a  uniform  standard,  which  might  serve  for 
use  in  anatomical  literature,  especially  that  of  an 
international  character.  Professor  Waldeyer,  in  his 
presidential  address  at  the  following  meeting  of  the 
Gesellschaft,  invited  his  colleagues  to  point  out 
errors  and  defects  in  the  lists  along  with  suggestions 
for  improvement  and  referred  to  the  advisability  of 
having  separate  sections  of  the  nomenclature  taken 
up  by  the  Commission  for  revision. 

The  BNA  nomenclature  may  now  be  justly  re- 
garded as  the  standard  of  anatomical  terminology  in 
the  leading  anatomical  laboratories  of  the  world.  The 
official  list  was  published  not  only  in  the  anatomical 
journals,  but  also  separately  by  Professors  Krause 
and  His,  in  the  form  of  hand-books  containing  the 
list  of  terms  with  explanatory  notes.  The  appear- 
ance of  such  widely  used  atlases  as  those  of  Spalte- 
holz,  Toldt,  and  Sobotta  couched  in  the  BNA  terms, 
shortly  following  the  report  of  the  Commission, 
ensured  at  once  its  use  in  the  leading  German  uni- 
versities. Nor  was  its  recognition  in  foreign  coun- 
tries long  deferred.  The  Anatomical  Society  of 
Great  Britain  and  Ireland  appointed  a  Committee  in 
1893  to  consider  the  adaptation  of  this  nomenclature 

321 


Anatomical  Nomenclature, 
the  Basle 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


to  the  needs  <>f  English  anatomists.  Professor  Cun- 
ningham introduced  the  BNA  terms  in  the  first 
edition  of  his  text-book,  published  in  1902,  adding 
separately  a  glossary  of  the  terms.  In  America  in 
1898  the  Committee  on  Anatomical  Nomenclature  of 
the  American  Association  of  Anatomists  gave  an 
official  recognition  of  the  BNA  terminology  by  a 
recommendation  of  the  use  of  many  of  its  terms,  the 
Committee,  however,  in  respect  of  many  terms,  pre- 
ferring mononyms,  as  suggested  by  Professor  Wilder, 
in  place  of  the  less  simple  dionyms  of  the  BNA  list. 
At  a  later  time  Professor  Barker  in  his  translation  of 
Spalteholz's  Atlas,  rendered  the  complete  list  of  the 
BNA  available  for  students  and  teachers,  while  in 
a  monograph  on  Anatomical  Terminology  with 
special  reference  to  the  BNA,  published  in  1907,  he 
made  a  strong  plea  for  the  adoption  of  the  nomen- 
clature in  its  entirety  in  America.  Gradually  a  ma- 
jority of  the  authors  of  the  leading  American  anatom- 
ical text-books  have  come  to  employ  the  BNA 
terminology,  either  exclusively  or  in  part,  some  of  the 
authors  preferring  the  anglicized  forms,  while  others 
append  the  Latin  terms  in  brackets. 

The  Commission  has  rendered  an  invaluable  serv- 
ice to  medical  science  in  establishing  an  international 
code  of  anatomical  terminology  and  in  abolishing  a 
mass  of  needless  terms.  The  use  of  the  nomenclature 
in  anatomical  journals  has  greatly  facilitated  the 
reading  of  articles  published  in  a  foreign  country. 
It  was  acknowledged  by  the  Commission  that  the 
terms  of  research  lay  wholly  beyond  their  province, 
and  the  right  of  the  investigator  to  apply  special 
names  to  parts  which  have  no  designations  was 
fully  recognized.  Their  aim  had  been  to  prepare  a 
common  school  speech,  free  from  ambiguous  expres- 
sions, realizing  that  research  requires  a  terminology 
of  its  own,  which  lias  no  pretension  of  coming  into 
school  usage.  As  a  result  of  their  efforts  the  work 
of  the  student  has  been  reduced  by  at  least  one-half 
with  a  sparing  of  the  memorizing  of  over  5,000  names 
during  his  anatomical  studies.  A  further  result,  of 
great  importance,  achieved  through  the  labors  of 
the  Commission,  was  the  establishment  of  certain 
principles  regarding  the  formation  and  use  of  anatom- 
ical terms,  which  will  tend  to  impart  uniformity 
and  simplicity  to  anatomical  terminology,  and  which 
may  serve  as  a  basis  for  future  revisions  of  the  same. 

Although  the  advantages  to  be  gained  by  the  adop- 
tion of  a  uniform  standard  of  terminology  were  read- 
ily conceded,  it  was  nevertheless  to  be  expected  that 
for  a  time  a  certain  strife  must  exist  between  the  use 
of  the  older  terminologies  and  the  BNA  list.  The 
Commission  was  fully  aware  of  the  impossibility 
of  forcing  any  fixed  nomenclature,  however  superior, 
either  on  teacher  or  pupil,  believing  that  its  adoption 
must  be  a  matter  of  gradual  growth  dependent  on 
its  intrinsic  merits.  Indeed,  among  the  Commis- 
sioners themselves,  it  was  questioned  whether  a 
rigid  terminology  might  not  act  as  a  stumbling  block 
and  retard  the  progress  of  research.  In  order  to 
enlist  the  good  will  and  cooperation  of  anatomists 
generally  in  accepting  the  list,  they  carefully  re- 
frained from  giving  names  to  structures  still  under 
investigation.  Despite  the  care  exercised  by  the 
Commission  there  has  crept  into  the  lists  a  number  of 
defects  and  errors,  which  have  evoked  lively  criticism, 
and  have  given  rise,  in  certain  quarters,  to  objections, 
which  have  served  to  retard  in  some  measure  a  uni- 
versal acceptance  of  the  nomenclature.  Some  of  the 
objections  urged  have  arisen  through  a  misconception 
of  the  intention  of  the  Commission.  The  fact  that  it 
has  been  erroneously  styled  a  new  terminology,  has  im- 
peded its  adoption  on  the  part  of  clinicians  who  have 
acquired  their  anatomical  terms  from  the  older  text- 
books. Yet,  as  a  matter  of  fact  over  ninety  per  cent,  of 
the  terms  are  already  familiar  to  English-speaking 
anatomists,  and  in  the  few  instances  where  new  terms 
have  been  introduced  these  are,  in  much  the  greater  ma- 


jority of  cases,  preferable  to  the  older  terms.  Another 
misapprehension,  which  has  deterred  many  from 
using  the  BNA  list,  is  the  false  impression  that  the 
Latin  names,  as  constructed  in  the  lists,  were  to  be 
used  as  such  in  every  day  speech.  This  was  clearly 
not  the  purpose  of  the  Commission,  it  being  intended 
that  the  anatomists  of  the  various  countries,  would 
in  spoken  language,  translate  the  terms  into  their 
native  tongue.  The  fact  that  the  BNA  terms  more 
closely  resemble  the  corresponding  English  names 
than  those  of  any  other  language,  should  render  them 
readily  acceptable  to  English-speaking  anatomists. 

It  has  been  urged  with  some  degree  of  justice  that 
the  BNA  terms  do  not  always  afford  the  simplest 
form  possible.  In  numerous  instances  dionyms  have, 
been  used  where  mononyms  would  seem  to  suffice. 
The  use  of  polynyms  had  already  grown  burdensome 
to  both  student  and  clinician  and  the  tendency,  in 
daily  speech,  had  been  to  discard  the  use  of  such  in 
favor  of  mononyms.  Thus  one  commonly  hears 
cecum  in  place  of  the  official  Caput  ccecum  coli,  and 
cortex  rather  than  Substantia  corticalis,  while  the 
popular  term  appendix  would  seem  preferable  to  the 
more  authentic  Processus  vermiformis.  The  nomen- 
clature Committee  of  the  American  Association  of 
Anatomists  have  recommended  the  use  of  mononyms, 
in  many  instances,  as  substitutes  for  the  more  cumber- 
some dionyms  of  the  BNA  list.  In  defense  of  the 
attitude  of  the  Commission  on  this  point,  it  may  be 
said  that  a  desire  to  avoid  ambiguity  restrained  them 
from  selecting  the  simplest  term  in  many  cases. 
Moreover,  it  was  shown  that  the  free  use  of  mononj'ms 
would  require  the  coining  of  many  new  terms,  and 
the  creation  of  etymological  barbarisms. 

Following  the  critical  examination  to  which  the 
nomenclature  has  been  subjected  since  its  publication, 
it  is  not  surprising  that  a  few  inconsistencies,  and 
inappropriate  expressions,  have  been  demonstrated. 
The  Commission  has  been  accused  of  deviating  from 
the  principles  laid  down  in  the  selection  of  terms, 
in  the  introduction  of  new,  or  comparatively  unfamilar 
names  for  structures,  where  the  older  terms  would 
seem  preferable,  notably  in  the  case  of  the  names 
given  to  several  of  the  carpal  bones.  It  was  obviously 
inconsistent  that,  while  the  term  maxilla  was  applied 
to  the  upper  jaw  and  mandibula  to  the  lower,  the  name 
Glandula  submaxillaris  should  be  retained.  The,  term 
Bursa  mucosa  has  been  pointed  out  as  a  misnomer, 
since  the  secretion  of  a  bursa  is  not  mucus,  and  Bursa 
synovialis  or  serosa  lias  been  proposed  as  more  ap- 
propriate. Again  the  Commission  has  been  charged 
with  violating  the  rules  that  "each  term  in  Latin  shall 
be  philologically  correct."  Triepel  and  others  have 
pointed  out  numerous  etymological  defects  in  the 
terminology,  and  a  proposed  etymological  reform  of 
the  entire  list,  employing  only  classical  Latin  and 
latinized  Greek  expressions,  has  been  instituted  by 
Triepel.  The  introduction  of  many  hybrid  names 
into  the  lists  has  been  criticized,  although  it  is  admitted 
by  the  critics  that  there  is  a  certain  justification  for 
the  use  of  such  hybrid  terms  as  urethralis  in  place  of 
the  more  correct  urethricus  on  the  ground  of  euphony. 
Again  it  may  be  grammatically  proper,  but  whether 
preferable  or  not,  seems  doubtful,  to  use  carpiaeus, 
or  carpicus,  for  carpeus,  and  coccygicus  for  coccygcus. 
It  has  been  stated  with  respect  to  certain  adjectives 
in  the  list  ending  in  -icalis  that  there  is  correctly  no 
such  termination  and  that  such  terms  as  A.  umbilicalis 
and  M.  lumbricalis  should  be  A.  umbilicaris  and  M. 
lumbricosus.  Another  defect  is  the  undifferentiated 
use  of  the  ending  -ideus.  A  number  of  anatomists 
hold  the  opinion  that  the  ending  -ides  for  the  Greek 
ending  -sidris  should  remain  in  anatomical  ter- 
minology, the  term  Os  hyoides  being  preferable  to 
the  BNA  term  Os  hyoideum.  Some  would  prefer 
the  writing  of  anulus  in  place  of  the  less  correct 
annulus,  while  the  term  antibrachium  should  be 
more  properly  written  antebrachium. 


322 


Kl I IMM.XCK    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Anatomy,  History  of 


It  [a  admitted  that  the  UNA  nomenclature  does 
,,,,t  tneel  the  need  of  comparative  anatomy.  Most 
of  the  expressions,  especially  those  for  muscles 
been  constructed  in  application  to  human  anatomy 
and  hence  are  misleading  for  vertebrate  anatomy. 
Thus  the  use  of  the  terms  M.  pectoralis  major  a 
minor  would  be  erroneous  if  applied  to  the  relative 
proportions  of  those  muscles  in  the  vertebrates, 
in,  from  the  view  point  of  morphology,  the  BNA 
grouping  is  at  times  quite  artificial.  As  pointed  out 
Professor  McMurrich  certain  of  the  facial  muscle: 
have  been  grouped  as  a  M.  quadrants  labii  superioris 
credited  with  three  heads  of  origin,  which  have 
elsewhere  been  more  properly  regarded  as  distinct 
muscles.  A  revision  of  the  BNA  list  to  render  it 
applicable  to  vertebrate  anatomy  is  highly  desirable. 
The  appointment  of  an  International  Commission  on 
logical  Nomenclature  has  already  proven  a  rec- 
ognition of  this  need. 

There  has  been,  it  is  stated,  a  certain  reluctance 
on  the  part  of  some  American  ami  English  anatomists 
ept  the  BNA  nomenclature,  for  the  reason 
that  it  is  the  product  of  a  German  organization,  and 
uch  is  not  adapted  to  the  needs  of  English- 
ting  anatomists.  However,  as  has  already  been 
pointed  out,  the  Anatomische  Gesellschaft  might 
fairly  claim  to  be  international  in  its  composition  and 
the  Nomenclature  Commission  embraced  representa- 
tives from  several  countries.  America  was  not 
represented  on  the  Commission,  doubtless  due  to  the 
that  anatomical  laboratories  had  not  yet  attained 
a  high  degree  of  organization,  and  but  few  American 
anatomists  attended  the  meetings  of  the  Gesellschaft 
at  the  time  of  the  formation  of  the  Commission.  In 
the  various  international  nomenclature  committees 
which  have  been  formed  since  then,  American  anat- 
omists have  obtained  full  representation.  Moreover, 
in  defense  of  the  initiative  taken  by  Germany  in  under- 
taking a  revision  of  terminology  of  an  international 
character,  it  would  seem  probable  that  at  the  time  the 
reform  was  instituted,  no  other  country  could  have 
provided  so  distinguished  a  group  of  anatomists, 
who  might  devote  so  much  of  their  time  for  so  long 
a  period  to  the  undertaking.  The  scientific  world. 
which  recognizes  no  national  boundaries  is  under 
great  obligation  to  the  Anatomische  Gesellschaft 
for  initiating  terminological  reform,  and  even  should 
the  nomenclature  established  by  it  not  prove  the  ideal 
one,  the  obvious  benefits  gained  for  anatomical 
science  through  the  general  adoption  of  it  as  the 
international  terminology,  would  seem  to  offset  any 
sacrifices  attendant  upon  the  relinquishing  of  a  few- 
national  colloquialisms. 

The  ultimate  result  of  the  efforts  of  the  Anatomische 
llschaft  toward  terminological  reform  has  been 
broader  in  extent  than  the  mere  production  of  the 
BNA  nomenclature.  The  BNA  list  of  terms  has 
been  welcomed  by  anatomists  as  providing  the  best 
common  anatomical  terminology  yet  presented. 
Further  than  this  the  work  of  the  Commission  estab- 
lished a  basis  for  future  and  more  comprehensive 
revisions  of  anatomical  terms.  Since  the  presenta- 
tion of  the  Basle  report  a  number  of  Nomenclature 
Committees  of  truly  international  character  have 
been  formed.  Some  years  ago  an  International  Com- 
mittee was  appointed  to  revise  Myological  Nomencla- 
ture, with  a  view  of  coordinating,  if  possible,  the 
comparative  and  human  anatomical  terminologies. 
Professors  McMurrich  and  Harrison  were  made  the 
American  representatives.  As  yet  no  report  of  the 
Committee  has  appeared.  At  the  third  meeting  of 
the  Commissionfor  Brain  Investigation,  appointed  by 
the  International  Association  of  Academies,  at  Vienna. 
1906,  a  committee  for  the  revision  of  neurological 
nomenclature  was  formed,  with  Professor  Waldeyer 
as  chairman.  During  the  second  International 
Congress  of  Anatomists  at  Brussels,  1910,  Professor 
Minot,   on  behalf   of   the    American   Association   of 


Anatomists,    presented    a    recommendation    for    the 
formation  of  an    International  Committee  to  revise 

embryological     nomenclature    and    prepare    a    li-t     of 

standard   terms.     Pi M  chairman)   and 

Mall  represented  America  on  the  I  ommittee.  With 
the  cooperation  of  these  various  nomenclature  com- 
mittees, revising  and  elaborating  the  work  of  the  B 
Commission  as  they  will,  the  establishment  of  a 
uniform  international  standard  of  terminology  for 
tin'    various   anatomical  would    seem    ftdly 

assured.  Benson  Amhkose  Cohoe. 

BlBLIOGRAPHT. 

Annahme  der  Nomenklatur  durch  dii  '-haft. 

Anat.  Ariz.,  Bd.  X..  Erganz.,  S.   L61,  1895 

v.  Bardeleben,  K.:  Einige  Vorschlage  zur  Nomenklatur.  Anat. 
Am.,  D.I.  xxiv.,  S.  301-304,  L904 

Barker,  L.  F.:  Anatomical  Terminology  with  Special  Reference 
t..  the  UNA.     Blakiston,  Phila.,  L907. 

Chaine,  J.:  Reforme  de  la  nomenclature  myologique.  Anat. 
Any,  ,  Bd,  xxvii.,  Erganz..  S.  38-39,  ton.-,. 

genbauer,    C.:     Bemerkungcn    zur    anatomiechen    Nomen- 
klatur.    Morphol.  Jarhbuch,  Bd.  XV.,  S.  151,  1S98. 

Bis,  W.:  Die  anatomische  Nomenklatur.  Nomina  anatomica. 
(Reprinted  from  the  Arch,  f.  Anat.  u.  Physiol.,  Anat.  Abth., 
Leipzig,  1895.     Supplement-Band.) 

Krause,  \V.:  -Die  anatomische  Nomenklatur.  Internat.  Mo- 
natsschr.  f.  Anat.  u.  Physiol.,  Bd.  jr.,  S.  313,  1893. 

Spitzka,  E.  A  :  Review  of  Dr.  Barker's  Book.  Bulletin  of  the 
Johns  Hopkins  Hospital,  Vol.  xviii..  No.  195,  1907. 

Triepel,    H.:     Die    anatomischen    Nanien,    ihre    Ableitung    u. 
iche.  2  aufl.  Wiesbaden.  190S. 

Triepel,  H.:  Die  anatomische  Nomenklatur.  Ergebn.  d.  Anat. 
u.  Entwickl.,  Bd.  xvii.,  S.  531-554,  1909. 

Triepel,  H.:  Nomina  anatomica  mit  Unterstutzung  von  Fach- 
philologen  bearbeitet.  Wiesbaden,  1910. 

Triepel,  H. :  Merkblatter  zur  anatomischen  Nomenklatur.  Anat., 
Anz.,  Bd.  xxxviii.,  S.  161-165,  1911. 

Yiorordt,  H. :  Bemerkungen  zu  BNA.  Anat.  Anz.,  Bd.  xiii., 
S.  1S1-1S3,  1S97. 

Waldeyer,  W.:  Eroffungsrede,  11  Vers.  d.  Anat.  Gesell.,  Anat. 
Anz.,  Bd.  xiii.,  S.  2-3.  1S97. 

Wilder,  B.  G.:  The  Fundamental  Principles  of  Anatomical 
Terminology.     Med.  News,  Phila.,  Dec.  19,  1S91. 

Wilder,  B.  G.:  Some  Misapprehensions  as  to  the  Simplified 
Nomenclature  of  Anatomy.  Proc.  of  the  Amer.  Assoc,  of  Anat., 
X.  Y  .  1895,  pp.  35-39. 

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clature. Proc.  of  the  Amer.  Assoc,  of  Anat.,  11th  session,  N.  Y., 
1S9S. 


Anatomy,  History  of. — Considering  the  necessity 
of  the  anatomical  sciences  as  a  basis  for  the  proper 
study  of  the  healing  art,  and  the  high  position  assigned 
them  in  modern  times,  it  may  seem  strange  that  their 
early  development  was  slow,  and  the  knowledge  of  the 
ancients  concerning  the  structure  of  the  human  body 
crude  and  superficial.  The  principal  cause  of  this 
was  the  prevalence  of  animistic  ideas,  it  being  thought 
that  extraneous  spirits  inhabited  or  controlled  the  body 
in  some  mysterious  way.  Involuntary  movements, 
such  as  the  pulsation  of  the  heart  and  arteries,  the 
twitching  of  muscles,  the  phenomena  of  respiration 
and  bodily  heat,  were  all  considered  indubitable  signs 
of  the  presence  of  such  spirits,  to  which  were  ascribed 
most  cases  of  disease  and  disordered  action. 

After  leaving  the  body  the  psychical  entity  that  ani- 
mated it  was  thought  to  maintain  some  occult  relation 
to  it;  hence  the  corporeal  remains  were  either  preserved 
with  pious  care,  or  burned  or  entombed  to  prevent  their 
suffering  insult  or  injury  that  might  affect  the  career  of 
the  spirit  in  the  other  world.  Mingled  with  these 
superstitious  ideas  were  others  derived  from  horror  of 
death  and  repulsion  from  corrupting  flesh.  Contact 
with  a  dead  body  was  usually  held  to  be  a  defilement 
requiring  long  purification,  and  to  attempt  to  in- 
spect its  internal  structure  was  a  sacrilege  meriting 
the  severest  punishment.  Dissection  was,  under 
such  circumstances,  practically  impossible.  It  is 
certain  that  but  few  writers  of  antiquity  were  able  to 
avail  themselves  of  this  method  of  research. 

The  sources  of  information  were  therefore  indirect. 


323 


Anatomy,  History  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Animals  killed  either  for  food  or  sacrifice,  the  occasional 
examination  of  persons  severely  wounded  or  suffering 
from  eroding  diseases,  the  noting  of  the  effects  of  putre- 
faction which  displayed  the  deeper  structures,  es- 
pecially the  bones,  were  the  usual  means  employed 
for  the  investigation  of  the  human  body.  In  Egypt, 
it  is  true,  bodies  were  eviscerated  for  the  purpose  of 
preserving  them  as  mummies;  but  this  appears  to 
have  been  done  by  a  low  class  of  servants  under 
the  direction  of  priests  who  regarded  the  interests  of 
the  spirit  in  the  other  world  as  the  only  essential,  and 
who  therefore  gave  no  thought  to  exact  anatomical 
knowledge. 

Yet  among  the  ancient  Egyptians  are  found  some 
of  the  earliest  attempts  at  recording  anatomical 
data.  They  were  acquainted  with  the  heart,  the 
lymphatic  glands  and  the  crystalline  lens.  The 
Ebers  papyrus,  of  about  1550  B.C.,  and  said  to  be  the 
oldest  complete  book  extant,  relates  to  the  healing 
art  and  contains  incidental  allusion  to  the  structure 
of  the  body.  Vessels  and  nerves  are  together  des- 
ignated as  "metu";  of  which  four  are  distributed 
to  the  nostrils,  four  to  the  temples,  four. to  the  head, 
two  in  each  hand  and  foot,  etc.  The  heart  is  regarded 
as  the  center  of  the  vascular  system,  and  vessels  con- 
taining blood,  air,  water  and  other  fluids  pass  from 
it  to  all  parts  of  the  body.  Vital  spirits  are  said  to 
enter  one  nostril  and  penetrate  to  the  heart;  an  idea 
which  was  to  have  a  great  effect  upon  anatomy  and 
physiology  as  far  down  as  the  seventeenth  century. 
Similar  determinations,  of  no  greater  value,  are  found 
in  papyri  of  a  somewhat  later  date. 

Contemporary  with  the  Egyptian  culture,  or 
possibly  anterior  to  it,  was  that  of  Chaldaea  and 
Assyria  from  which  the  Phoenicians  and  Hebrews 
derived  much.  One  of  the  contributors  to  the 
Ebers  papyrus  is  stated  to  be  from  Byblus,  a  town  of 
Phoenicia.  Certain  cuneiform  inscriptions  indicate 
that  the  situation  of  the  vessels  of  the  neck  was  known, 
as  they  describe  the  compression  of  these  structures 
to  relieve  the  pains  of  circumcision.  These  inscrip- 
tions refer  to  the  heart  as  the  seat  of  the  mind,  the 
liver  as  the  central  organ  for  the  blood. 

The  anatomy  of  the  Hebrews  was  probably  derived 
mainly  from  Chaldean,  Assyrian,  and  Egyptian 
sources.  The  principle  of  life  was  by  them  believed  to 
reside  in  the  blood  (Gen.  ix.  4;  Lev.  xvii.  11),  which 
was  accordingly  forbidden  as  food  and  used  as  a  pro- 
pitiatory offering.  The  heart  was  supposed  to  be  the 
seat  of  the  understanding,  courage,  and  love;  to  dilate 
with  joy,  contract  with  sadness,  harden  or  soften  with 
the  passions.  These  expressions,  which  have  become 
wholly  figurative  in  modern  times,  were  formerly 
believed  to  be  literally  true.  The  later  Talmudists 
had  some  anatomical  knowledge  of  the  female  geni- 
talia, the  oesophagus,  the  lungs,  the  kidneys,  the  spinal 
cord,  and  the  cauda  equina.  One  of  the  rabbis,  at 
the  close  of  the  first  century,  is  said  to  have  boiled  a 
body  for  the  purpose  of  obtaining  the  skeleton.  A 
fabulous  bone,  "luz,"  was  thought  to  become  the 
seed  of  the  body  from  which  it  is  to  be  renewed  at 
the  resurrection. 

The  early  writings  of  India  contain  no  anatomical 
knowledge  except  names  of  a  few  parts  of  the  body. 
Somewhat  later  (900-200  b.c.)  there  are  rude  attempts 
at  the  enumeration  of  structures.  To  what  extent 
these  enumerations  are  based  upon  actual  examina- 
tion and  misinterpretation  of  anatomical  facts  it  is 
impossible  to  say.  In  them  the  primitive  elements 
of  the  body  are  air,  bile,  and  phlegm,  air  having  its 
seat  below  the  navel,  the  bile  between  the  navel  and 
the  heart,  the  phlegm  above  the  heart.  Seven 
organic  products  were  believed  to  be  formed  from 
these  primitive  elements:  watery  chyle  which  in  the 
liver  and  spleen  forms  blood,  from  which  arises  flesh 
which  forms  cellular  tissue,  from  whence  comes  bone 
which  generates  marrow,  which  gives  origin  to  semen 
and    menstrual    blood.     The    ancient    Hindoos    are 

324 


said  to  have  practised  dissection,  it  being  held  lawful 
to  pursue  such  investigations  for  scientific  purposes 
though  under  many  limitations  and  restrictions;  but 
the  sculptures  of  the  rock-cut  temples  of  Elephanta 
and  Ellora  show  ignorance  of  the  anatomy  of  muscles. 
Later  authors  appear  to  have  had  a  vague  idea  of  the 
circulation  of  the  blood,  as  they  state  that  the  watery 
chyle  circulates  through  the  vessels  and  irrigates  the 
system  as  water  does  a  field. 

The  Chinese  have  not,  even  at  the  present  day,  any 
exact  anatomical  knowledge.  The  tracing  of  their 
crude  notions  back  to  the  mists  of  the  past  is  of  purely 
archeologic  interest,  and  it  is  difficult  to  say  whether 
the  alleged  great  antiquity  of  some  of  their  medical 
writings  is  based  upon  authentic  facts.  They 
considered  the  elements  of  the  body  to  be  air,  water, 
"metal,"  and  "wood";  the  liver  to  be  the  seat  of  the 
intelligence,  the  seat  of  life  to  be  in  the  middle  of  the 
breast.  Arteries  and  veins  were  not  separately 
distinguished,  but  some  notion  of  a  circulation  or 
translation  of  the  blood  appears  to  have  been  ad- 
vanced, as  it  is  stated  that  it  completes  a  course 
throughout  the  body  fifty  times  in  twenty-four  hours. 
In  rare  instances  only  was  dissection  allowed.  It  is 
alleged  that  in  the  fourth  century  a.d.  forty  corpses 
of  decapitated  persons  were  turned  over  to  phy- 
sicians for  dissection,  and  that  in  the  eighteenth 
century  the  emperor  Khang-hi,  inspired  by  the  Jesuit 
fathers,  had  the  anatomical  works  of  Dionis  and 
ThomasBartholin  translated  into  Chinese. 

The  Japanese  in  matters  of  anatomy  copied  from 
the  Chinese.  Their  older  writings  are  curious  mixtures 
of  fact  and  error.  They  teach  that  the  heart  contains 
blood,  rules  all  the  other  viscera,  and  is  connected 
with  the  liver,  lungs,  spleen,  and  kidneys;  that  blood 
is  prepared  in  three  "combustion  organs"  of  rather 
mythical  character,  perhaps  the  thoracic  duct,  the 
pancreas,  and  the  lacteals.  They  assert  the  structure 
of  the  lungs  to  be  like  that  of  a  honeycomb,  and  state 
that  they  contain  a  nourishing  gas  which  penetrate 
the  whole  body  outside  the  vessels  that  carry  the 
blood.  The  brain,  the  spinal  cord,  and  the  marrow 
are  said  to  be  of  one  nature,  the  brain  having  the 
highest  rank.  The  seat  of  the  soul  is  stated  by  most 
authors  to  be  the  heart,  as  it  has  been  seen  in  some 
animals  to  beat  after  the  severing  of  the  head  from 
the  body.  Others  place  it  in  the  brain,  the  spleen, 
the  lungs,  the  kidneys,  or  the  liver.  The  nerves  are 
often  confounded  with  the  tendons,  often  described 
as  tubular  canals.  In  the  middle  of  the  eighteenth 
century,  a  physician  named  Yamawaki  obtained  per- 
mission from  his  prince  to  dissect  a  body,  an  illegal 
act  that  could  be  done  only  under  powerful  protection. 
He  published  his  observations  and  declared  that  the 
older  teaching  should  no  longer  be  thoughtlessly 
followed.  Dissection  was  thereafter  surreptitiously 
practised,  and  very  accurate  wooden  models  of  the 
skeleton  were  made.  About  1775  the  Dutch  edition 
of  an  anatomical  work  by  Kulmus,  Professor  at 
Dantzig,  was  translated  into  Japanese. 

It  is  among  the  Greeks  that  we  first  meet  with  a 
knowledge  of  anatomy  that  can  be  called  scientific. 
With  keen  and  active  intelligence  they  examined  and 
speculated  upon  all  things  in  the  world  around  them. 
Prepossessed  with  the  anthropocentric  theory  of  the 
universe,  they  attained  only  a  partial  and  distorted 
view  of  natural  phenomena,  but  often  showed  aston- 
ishing powers  of  generalization  in  speculative  theories. 
Among  them  arose  the  group  of  so-called  "natural 
philosophers,"  at  the  head  of  whom  we  find  Pytha- 
goras (584-504  B.C.).  He  attempted  to  explain 
natural  phenomena  by  means  of  harmonic  numbers 
which  he  considered  as  actual  entities  having  myste- 
rious powers,  the  elements  of  the  body  being  comprised 
in  the  number  10,  each  single  number  (1+2+3+4) 
having  therein  a  counterpart.  He  was  the  first  to 
deny  the  spontaneous  generation  of  animals,  holding 
that  all  life  must  spring  from  germs  preexisting  in  the 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Anatomy!  History  of 


semen  which,  formed  from  the  brain  of  the  male, 
combines  with  moisture  from  the  brain  of  the  female, 

Ml|  is  t  In'  perfected  foam  of  (he  blood.      This  idea  is 

perhaps  connected  with  thai  of  the  origin  of  the  god- 
dess  of  generation,  Aphrodite  (a<pph,  foam),  from  the 
foam  of  the  sea.     To  the  successors  of  Pythagoras  are 
igned  by  later  writers  some  anatomical  investiga- 
tions   ami     discoveries.     Thus     Empedocles     (about 
.".no  B.C.)  discovered  the  labyrinth  of  tin  ■car,  Alcmseon, 
his  contemporary,  the  Eustachian  tube  and  (he  optic 
c,  Diogenes  of  Apollonia  (,l",(l  b.c.)  described  the 
it   vessels,    all    after    the    dissection    of   animals. 
Tie  is  said  to  have  been  the  first  to  undertake  system- 
anatomical  dissections.     It  is  to  him  we  owe  the 
names  of  the  amnion  and  the  chorion,  membranous 
lopes  of  thi'   fetus.      Empedocles  is  said   to   have 
advanced  some  crude  ideas  of  the  modern  doctrine  of 
:ii  \  ivalof  fit  and  adapted  animal  forms.      Democ- 
.  (about  450  B.C.)  studied  and  compared  the  or- 
of  man  with  those  of  lower  animals  and  observed 
that     they    become    adapted    to    certain    purposes 
As  in  many  primitive  nations,  the  physicians  of  the 
Greeks   became   segregated  into  a  guild.     This   was 
known  as  the  Asclepiadse,  after  the  god  Asclepias  or 
.Esculapius,  from  whom  they  claimed  descent.     With 
the  advance  of  culture,  the  need  of  a  more  careful 
investigation  of  the  human  body  became  evident,  and 
about  hid  b.c.  a  group  of  physicians  of  this  guild  arose 
who  pursued  a  more  rational  method.     The  principal 
of  these  was  the  celebrated  Hippocrates,  often  called 
the  "father  of  medicine."     A  large  body  of  writings 
formerly  ascribed  to  him  has  been  shown  by  modern 
research  to  be  the  product  of  his  school  rather  than 
his    individual    work.     The    anatomical    data   found 
therein    are    evidently    obtained    mainly    from    the 
dissection  of  animals,  although  the  osteology  is  that 
of  man.     The  statements  concerning  the  bones  and 
sutures  of  the  skull  are  fairly  accurate,  as  are  also 
those  concerning  the  larger  bones  and  joints.     The 
heart   (apparently   described   from   that  of  man)   is 
recognized  as  forcing  the  blood  and  pneuma  or  vital 
spirits  of  the  air  through  the  vessels,  and  the  brain  is 
in  some  writings  distinguished  as  the  organ  of  thought 
and  conscious  sensation.     Tolerably  accurate  though 
these  facts  may  be,  the  conceptions  of  the  elementary 
constitution  of  the  body  were  erroneous  in  the,  extreme, 
being    similar    to    the    speculations    of    the    natural 

Ehilosophers.  It  was  believed  that  the  bodies  of 
ving  things  were  composed  of  four  elements — earth, 
water,  air,  and  fire — proper  mixtures  of  which  pro- 
duced the  so-called  elementary  fluids:  blood,  mucus, 
black  and  yellow  bile;  that  yellow  bile  was  formed  in 
the  liver,  black  bile  in  the  spleen;  that  the  different 
organs  were  produced  by  the  action  of  "innate  heat" 
upon  the  elemental  fluids,  the  food  stuffs,  and  the 
aqueous  and  earthy  bases  of  the  body.  Muscles  were 
not  usually  recognized  as  distinct  from  the  general 
mass  of  the  flesh.  Arteries  were  not  distinguished 
from  veins,  both  being  described  under  the  common 
name  of  0Xe/3<?s.  Under  the  term  vevpa,  nerves  were 
likewise  confounded  with  tendons  or  even  sometimes 
with  vessels.  The  brain  is  described  in  some  passages 
as  an  organ  for  the  absorption  of  superfluous  mucus 
which  it  again  gives  out,  and  for  the  secretion  of  semen 
which  is  conveyed  to  the  testes  by  the  spinal  cord. 
The  lungs  are  said  to  take  up  cold  air  and  pass  it 
through  tubes  (aprqplai)  to  the  heart  for  the  purpose 
of  cooling  that  organ.  These  characterizations  show 
that  the  ideas  then  prevalent  as  to  the  structure  of  the 
body  were  largely  imaginary,  the  necessity  of  con- 
trolling hypotheses  by  exact  observation  not  yet  being 
fully  realized. 

The  conceptions  of  Plato  as  to  the  constitution  of 
the  body  and  its  union  with  a  mortal  and  an  immortal 
essence  were  founded  upon  the  Hippocratic  anatomy. 
He  imagined  the  seat  of  the  immortal  soul  to  be  in  the 
head,  that  of  the  higher  passions  in  the  upper  thorax, 
and  the  heart  to  be  "  the  center  or  knot  of  the  blood- 


vessels, the  spring  or  fountain  of  the  blood  which  is 
carried  impel  uously  around";  and  I  hal  it  is  cooled  by 
the  soft,  spongy,  and  bloodless  lung  .  I  In  lower 
passions  hi'  supposed  to  lie  placed  in  the  Ihorax  below 
the  diaphragm,  "in  the  same  house"  with  the  liver, 
which  is  "solid  and  smooth  and  bright  and  sweet,  and 
also  bitter,  in  order  thai   the  power  of  thought   which 

originates  in  the  mind  may  be  reflected  as  in  a  mirror." 
The  uterus  he  considered  a  wandering  organ,  that, 
like  a  wild  beast,  seeks  satisfaction  for  its  inordinate 
desires.  Death  he  thought  to  be  caused  by  the 
separation  of  the  soul  from  the  marrow,  of  which  the 
brain  is  the  most  perfect  part,  and  whose  basis  is 
"triangles"—  a  Pythagorean  concept  ion. 

In  these  remarkable  speculations  we  discern  an 
attempt  to  ascertain  by  imagination  alone,  without 
any  careful  examination,  the  purpose  or  end  for  u  Inch 
structures  are  formed.  This  teleological  error,  the 
belief  that  the  mind  can  discern  the  "final  causes" 
of  structure,  tinctured  all  the  anatomical  investiga- 
tions of  the  ancients. 

Aristotle  (384-323  B.C.),  a  pupil  of  Plato,  opposed 
the  idealism  of  his  master,  insisting  that  the  proper 
method  of  advancing  science  is  first  to  collect  all  the 
facts  or  particulars  and  afterward  to  deduce  from  them 
causes  and  principles.  His  extraordinary  industry 
and  activity  and  his  penetrating  intelligence  had  a 
great  influence  not  only  upon  his  own  time,  but  upon 
I  he  scientific  thought  of  all  subsequent  ages.  He  may 
be  said  to  have  originated  the  sciences  of  comparative 
anatomy  and  morphology,  and  was  the  first  to  con- 
ceive the  animal  kingdom  as  a  connected  genetic 
chain.  By  the  aid  of  Alexander  the  Great  he  was  able 
to  collect  vast  stores  of  material,  which  he  utilized  as 
far  as  the  limited  resources  of  that  age  would  permit. 
He  dissected  numerous  animals  and  gave  a  fairly 
accurate  idea  of  their  constitution.  A  great  deal  of 
his  classificatory  work  holds  good  to  the  present  day. 
He  distinguished  arteries  from  veins  by  their  struc- 
ture, but  grouped  them  together  as  0Xe/3A,  correctly 
describing  many  of  their  principal  branches.  He  con- 
sidered, however,  that  some  of  the  arteries  carried  only 
"pneuma."  Certain  of  the  nerves  he  distinguished 
from  tendons,  supposing  them  to  be  hollow  tubes 
(irbpoi.)  a  name  which  he  also  applied  to  the  ureters. 
Vessels  and  nerves  he  believed  to  arise  from  the  heart, 
which  he  therefore  considered  as  the  seat  of  movement 
and  of  the  soul.  Different  from  the  usual  four  ele- 
ments is  his  principle  of  life,  a  fifth  element  (quinta 
essentia  of  after  writers)  which  produces  heat  and  cold. 
He  appears  to  have  considered  this,  however,  as  a 
function  of  the  organized  body.  He  seems  to  have 
been  aware  of  the  lacteals  and  to  have  supposed  them 
to  empty  into  the  inferior  vena  cava  and  the  aorta. 
His  division  of  the  body  into  structures  and  products 
composed  of  parts  similar  to  each  other  and  to  the  whole 
which  they  compose  (homceomeria)  and  of  others 
formed  of  dissimilar  parts  is  an  adumbration  of  the 
modern  conception  of  tissues  and  organs.  In  the 
domain  of  purely  human  anatomy  he  depends  upon 
other  authors,  and  expressly  says  "the  internal  parts 
of  the  human  body  are  unknown  or  are  supposed  to  be 
the  same  as  the  similar  or  analogous  parts  of  animals." 
He  studied  the  development  of  the  chick  in  the  egg, 
and  held  that  it  was  an  advance  from  a  simple  to  a 
more  complicated  form.  Observations  of  putrefying 
matter  and  of  many  cases  in  which  germinal  develop- 
ment is  obscured  led  him  to  the  view  that  animals  may 
be  generated  spontaneously — "  Corruptio  unius  est 
generalio  altcrius."  These  views  were  destined  to  have 
a  powerful  influence  upon  subsequent  speculation. 

A  contemporary  of  Aristotle,  Praxagoras  (about 
335  b.c),  appears  to  have  been  the  first  clearly  to 
distinguish  arteries  from  veins  by  both  structure  and 
function.  He  held  that  arteries  normally  contain 
air  during  life,  but  when  wounded,  blood  is  drawn 
into  them  from  the  surrounding  parts.  The  brain 
he  supposed  to  be  an  appendage  to  the  spinal  cord. 


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Anatomy,  History  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Under  the  patronage  of  the  Ptolemies  the  natural 
sciences  flourished  greatly  in  Egypt  during  the  third 
century  before  Christ.  At  Alexandria  the  "  Museum" 
was  founded,  an  institution  very  like  a  modern 
university,  provided  with  a  large  body  of  teachers 
and  having  students  from  the  entire  civilized  world. 
Here  dissection  was  publicly  practised  for  the  first 
time;  the  Egyptian  custom  of  embalming  the  dead 
probably  aiding  to  break  down  the  prejudice  against 
it.  A  large  number  of  anatomical  specimens  were 
made  and  a  vast  library  collected.  The  advances 
were  considerable.  Herophilus  (335-280  B.C.),  called 
by  Fallopius  "  the  evangelist  of  anatomists,"  especially 
investigated  the  brain,  which  he  believed  to  be  the 
organ  of  thought  and  motion.  He  named  the  calamus 
scriptorius,  surmising  it  to  be  tile  seat  of  the  soul, 
discovered  the  sinuses  of  the  dura  mater,  the  con- 
fluence of  the  sinuses,  which  still  bears  his  name 
(torcular  Herophili),  the  retina,  the  uvea,  and  ciliary 
processes  of  the  eye,  the  hyoid  bone,  the  lacteals  and 
lymphatics.  He  gave  the  duodenum  its  present 
designation  (da5cKa5dKTv\ov  =  duodenum),  described 
the  liver,  pancreas,  uterus,  ovaries  and  oviducts; 
distinguished  the  arteries  from  the  veins,  and  ad- 
mitted that  both  contained  blood.  It  is  said  that 
he  even  vivisected  criminals  to  obtain  a  knowledge 
of  the  soul. 

His  contemporary  and  rival,  Erasistratus,  was  no 
less  famous.  He  also  saw  the  lacteals,  and  dis- 
tinguished nerves  of  sensation  from  those  of  motion. 
He  held  that  the  vital  spirits  received  from  the  air 
were  changed  to  animal  spirits  in  the  brain,  described 
well  the  heart  and  its  valves,  assumed  a  virtual 
connection  between  the  arteries  and  the  veins,  holding 
that  they  discharge  opposite  each  other.  The 
arteries  he  supposed  to  carry  air,  blood  being  drawn 
into  them  when  wounded.  Had  it  not  been  for  this 
error  he  would  probably  have  anticipated  Harvey 
in  the  discovery  of  the  circulation  of  the  blood.  The 
substance  of  glandular  organs  he  named  the  paren- 
chyma (wap£yxvlxa,  poured  in  beside),  holding  that  it 
is  formed  from  altered  blood  effused  from  the  blood- 
vessels. The  name  still  remains.  He  held  that  the 
development  of  the  fetus  is  by  epigenesis  or  new 
formation,  instead  of  bjr  preformation.  He  remarked 
the  induration  of  the  liver  in  dropsy,  and  may  thus 
be  said  to  have  been  the  first  to  make  observations 
in  pathological  anatomy. 

The  school  of  Alexandria  gradually  declined  and 
made  no  further  progress  in  anatomy,  it  even  being 
held  by  certain  of  its  teachers  that  a  knowledge  of 
that  science  was  unnecessary  for  the  healing  art. 
The  influence  of  the  anatomical  teaching  of  Herophilus 
and  Erasistratus  was,  however,  widely  extended. 

Asclepiades  (128-56  b.  c.)  revived  the  atomic 
theory  of  Leucippus,  Democritus,  and  Epicurus, 
applying  it  to  the  structure  of  the  body,  which  he 
conceived  as  composed  of  innumerable  minute 
particles,  the  "leptomeres,"  cognizable  by  the 
understanding  though  not  by  the  senses,  between 
whose  interstices  the  fluids  of  the  body  move.  This 
appears  to  be  the  first  hint  of  the  modern  cell  theory. 

The  rise  of  the  Roman  empire  transferred  the  center 
of  civic  activity  from  the  Eastern  cities  to  Rome. 
Among  the  earlier  Roman  writers  on  medical  subjects 
we  find  Celsus,  who  lived  under  Tiberius  and  Claudius 
(about  50  b.c.  to  7  a.d.).  Such  of  his  works  as  have 
survived  are  interesting  as  showing  the  value  placed 
upon  anatomical  studies  at  this  period.  He  speaks 
decidedly  as  to  dissection:  "The  examination  of 
dead  subjects  is  imperatively  necessary  for  students, 
as  they  ought  to  know  the  position  and  order  of  the 
parts."  Of  osteology  and  the  larger  viscera  he  shows 
some  accurate  knowledge  marred  by  numerous  errors. 

Marinus  (under  Nero)  is  known  to  us  only  through 
the  writings  of  Galen,  who  praises  his  anatomical 
knowledge.  He  is  said  to  have  given  excellent 
tie  criptions   of    the    muscles   and   glands.     He    dis- 


tinguished seven  pairs  of  cranial  nerves,  apparently 
those  mentioned  by  Galen,  as  follows:  I.  Optic; 
II.  oculomotor  and  patheticus;  III.  ophthalmic 
branch  of  the  trigeminus;  IV.  superior  and  inferior 
maxillary  branches  of  the  trigeminus;  V.  facial  and 
auditory;  VI.  glossopharyngeal,  vagus,  spinal  ac- 
cessory, sympathetic,  and  hypoglossal;  VII.  first 
cervical. 

Rufus  of  Ephesus  (under  Trajan)  had  considerable 
reputation  as  an  anatomist.  He  discovered  the 
oviducts  (in  the  sheep),  the  optic  chiasm,  and  the 
capsule  of  the  crystalline  lens.  He  wrote  a  work 
intended  for  students'  use,  giving  the  names  of  part, 
of  the  body,  but  only  fragments  of  this  remain. 

Soranus  of  Ephesus  (under  Trajan  and  Hadrian, 
some  twenty  years  before  Galen)  described  witli  con- 
siderable accuracy  the  internal  genital  organs  of  the 
female,  and  it  seems  clear  that  he  must  have  dissected 
sufficiently  to  inspect  them.  He  distinguished  the 
vagina  from  the  uterus,  stated  that  the  latter  has 
the  form  of  a  cupping  glass,  and  is  conected  witli 
contiguous  parts  by  means  of  membranes,  so  that 
it  is  impossible  that  it  should  be  endowed  with  indi  - 
pendent  movement.  His  statements  concerning 
the  ovaries  and  oviducts  are,  however,  obscure. 

Far  surpassing  these,  and  indeed  excelling  all  other 
writers  of  antiquity  in  anatomical  exactitude,  was 
Claudius  Galen  of  Pergamus,  a  physician  at  Rome 
under  the  Antonines  (a.d.  131-201).  He  studied 
at  Alexandria,  and  esteemed  himself  especially 
fortunate  in  having  there  seen  a  complete  human 
skeleton.  He  was  an  arduous  investigator,  dissecting 
many  animals  and  even  vivisecting  some  in  ordei  to 
ascertain  the  functions  of  nerves.  He  may  indeed 
be  said  to  have  been  the  first  physiological  anatomist. 
Numerous  errors  of  description  make.it  certain  that 
he  never  dissected  the  human  body,  but  it  is  evident. 
that  he  investigated  that  of  the  monkey,  probably 
Macacus  ecaudatus  (Geoffr.)  of  the  north  coast  of 
Africa.  Many  of  his  descriptions  hold  good  to-day, 
and  all  were  of  such  value  that  his  authority  in  anatomy 
was  dominant  for  more  than  thirteen  hundred  years. 
He  was  strongly  prepossessed  with  teleological  ideas, 
and  assumed  false  physiological  notions  (usually 
derived  from  his  predecessors)  as  a  basis  for  the 
interpretation  of  structure.  He  was  greatly  im- 
pressed with  the  dignity  and  importance  of  his  wink. 
calling  it  "a  religious  hymn  in  honor  of  the  Creator. 

He  held  that  the  food  undergoes  "coction"  in  the 
stomach,  from  whence  it  passes  to  the  liver,  where, 
by  the  influence  of  "natural  spirits,"  it  is  converted 
into  blood  which  enters  the  vena  cava,  part  of  it 
proceeding  peripherally  to  give  alimentation  to  the 
limbs,  part  to.  the  left  side  of  the  heart  where  the 
"innate  heat"  removes  from  it  the  part  unsuitable 
for  the  nutrition  of  the  more  delicate  organs  of  the 
body  (smoke,  fuliginous  matter)  which  is  expelled 
by  the  lungs.  He  supposed  the  greater  part  of  the 
blood  to  be  distributed  by  a  to-and-fro  oscillation  in 
the  veins  throughout  the  body,  while  a  portion  passes 
through  minute  holes  in  the  interventricular  septum 
into  the  left  ventricle,  where  it  mingles  with  pneuma 
received  from  the  lungs  with  the  blood  in  the  pul- 
monary veins  forming  "vital  spirits"  (Hippocrates); 
the  mingled  blood  and  vital  spirits  then  pass  into  the 
aorta  and  the  arteries,  in  which  they  oscillate  to  and 
fro,  giving  life  to  the  body.  He  adopted  the  view 
of  Erasistratus,  that  pore-like  openings  at  the  termina- 
tion of  the  arteries  communicate  with  the  veins. 
He  taught  that  there  are,  therefore,  two  kinds  of 
blood;  one,  contained  within  the  veins,  suitable  for 
nutrition  and  growth;  the  other,  in  the  arteries, 
suitable  for  the  maintenance  of  life.  The  blood  that 
goes  to  the  brain  undergoes  there  a  further  changi  ■: 
by  the  choroid  plexuses  of  the  ventricles  its  vital 
spirits  are  further  refined  to  "animal  spirits"  suitable 
for  producing  motion  and  activity  (Erasistratus);  (he 
unused    residue    is   expelled   through  the   cribriform 


326 


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Anatomy,  History  of 


plate  of  tlic  ethmoid  bone;  the  animal  spirits  being 
distributed  I"  various  parts  (if  the  body  by  means  01 
il„  tubular  nerves  (Aristotle).  The  brain  he  deemed 
an  organ  for  the  secretion  of  mucus  and  at  the  same 
time  the  seat  of  the  soul,  of  which  the  natural  spirits, 
the  vital  spirits,  and  the  animal  spirits  are  all 
modalities. 

Notwithstanding  these  faulty  assumptions,  which 
greatly  retarded  the  development  of  correct  ideas 
cerning  the  actual  functions  of  the  body,  the 
ices  that  Galen  rendered  to  anatomy  were  real 
important.  His  descriptions  are  clear,  exact, 
and.  barring  some  errors  derived  from  his  precon- 
ceptions or  the  material  he  used,  fairly  accurate. 

In  osteology  and  arthrology  ho  is  at  his  best,  and 
many  of  his  designations  of  bones  and  joints  are 
still  in  use.  In  the  muscular  system  he  described 
for  the  first  time  the  muscles  of  the  face,  larynx,  and 
tongue.  The  muscles  of  the  limbs  he  separated 
ly  as  is  now  done.  He  omitted  the  opponens 
polhcis  (not  found  in  apes),  while  in  his  description 
of  the  muscles  of  the  foot  he  included  some  ape-like 
characters.  His  descriptions  of  the  vascular  system 
are  marred  by  his  preconceptions.  He  made  the 
veins  arise  from  the  liver,  the  arteries  from  the  heart, 
which  he  did  not  consider  to  be  muscular  although 
composed  of  fibers.  He  considered  the  spinal  cord 
to  be  an  appendage  to  the  brain  and  developed  from 
it,  that  nerves  of  sensation  arise  from  the  brain, 
those  of  motion  from  the  spinal  cord,  and  mixed 
nerves  from  the  medulla  oblongata.  He  noted  that 
the  sensory  nerves  are  soft,  the  motor  harder.  The 
olfactory  bulb  and  tract  he  correctly  considered  as 
an  extension  of  the  brain,  and  hence  excluded  it  from 
his  enumeration  of  the  cranial  nerves  (Marinus?). 
He  knew  the  ventricles  of  the  brain,  the  fornix,  the 
corpora  quadrigemina,  the  terms  nates  and  testes 
applied  to  the  latter  being  his  own.  He  was  ac- 
quainted with  the  membranes  of  the  brain,  with  the 
pleura,  the  pericardium,  and  the  peritoneum.  The 
divisions  of  the  alimentary  canal  he  accurately 
described.  The  genital  organs  of  the  male  and 
female  he  considered  essentially  the  same,  the  ovaries 
corresponding  to  the  testes  and  secreting  a  seminal 
fluid  that  is  conveyed  to  the  uterus  by  the  oviducts. 

The  decline  of  the  Roman  empire  caused  a  gradual 
decay  of  intellectual  culture  and  a  total  neglect  of  all 
tices  of  investigation.  It  is  only  occasionally 
that  we  find  in  the  writings  of  some  compiler  like 
Oribasius  (a.d.  326-403)  an  indication  of  a  new 
discovery.  He  is  said  to  have  been  the  first  to  de- 
scribe the  membrana  tympani  and  the  salivary 
glands.  The  cultivation  of  literature  gradually 
declined  and  but  few,  even  of  the  clergy,  could  read 
or  write.  Superstition  and  vague  tradition  usurped 
the  place  of  science.  No  one  thought  it  necessary 
to  ascertain  the  structure  of  the  human  body  when 
it  was  universally  held  that  it  was  controlled  by 
spiritual  influences  wholly  independent  of  physical 
or  natural  laws.  Anatomy  was  forgotten  and  the 
treatises  of  its  founders  either  destroyed  or  suffered  to 
remain  in  almost  complete  oblivion.  Almost,  not 
quite,  for  the  torch  of  science,  laid  down  by  the  rude 
hands  of  the  West,  was  taken  up  and  relighted  by 
the  scholars  of  the  East. 

The  Arabians  now  began  to  take  an  active  part  in 
intellectual  culture.  In  imitation  of  the  school  of 
Alexandria  they  founded  great  universities  at  Bag- 
dad, Bassorah,  Damascus,  Alexandria,  Cordova,  and 
Granada.  Forbidden  by  the  Koran  to  dissect  the 
human  body,  or  even  to  make  any  representation  of 
it,  the  physicians  of  these  schools  had  recourse  to 
Greek  authors,  particularly  to  Hippocrates,  Aristotle, 
and  Galen.  On  these  they  made  long  commentaries, 
their  remarks  often  showing  perspicacity  and  judg- 
ment. Some  of  them  must  have  examined  human 
bones,  as  they  corrected  Galen's  error  of  ascribing 
tu  o    parts    to    the    human    mandible      The    most 


important  authors  of  the  Arabian  school  who  treated 
of  anatomy  are  Rhazes  (Abu-Bekr-Al-Razi,  850  923 
v.ii.i,    Ali    Abbas    i  \U    ben   el-Abbas,    Haly    Abl 
930-994),  and     Avicenna   (Abu-Ali-Ibn     Sina,    980 
L037).      Their  direct    contributions   to  anal \    were 

not   great,  but   their  nomenclature  was  for  a  time 

adopted    by     I  lure  ipea  n    v.  riter  .      \    t  ran  lat  ion    of 
\ii    \lil>as'  work  into  Latin,  by  Constantinus  Afer,  a 
Benedictine  monk  {circa   1080),  is  probably  the 
work  on  anatomy  in  that  Language  (Hyrtl). 

The  leavening  influence  of  the  crusades  now  began 
to  be  felt.  The  uniting  of  the  scattered  peoples  of 
Western  Europe  into  vast  armies  that  made  long 
journeys  by  land  and  sea,  and  came  in  contact  with 
nations    of    totally    different    culture    and    habits    of 

thought,    had    great    effect     in    c billing    the    small, 

warring,  feudal  factions  into  larger  social  units  more 
susceptible  of  advancement,  in  opening  new  avenues 

of  com rce,  in  diffusing  a  knowledge  of  t  he  learning 

of  the  East,  and  in  bringing  about  a  revival  of  intel- 
lectual activity.  New  universities  were  founded 
throughout  Europe;  at  Bologna  in  11 10,  at  Padua  in 
1228,  at  Salamanca  in  123'.),  at  the  Sorbonne  in  1253. 
Others  whose  foundations  dated  back  to  the  Roman 
period  received  new  accessions.  Among  the  latter 
were  Salerno  and  Montpellier,  at  each  of  which  an 
active  medical  school  was  established.  At  Salerno 
was  seen  the  first  symptom  of  a  revival  of  practical 
anatomy,  for  the  Emperor  Frederick  II.  (1212-12.">(l) 
made  a  law  in  1240  that  no  one  should  practise 
surgery  without  having  been  previously  examined  in 
anatomy,  and  provided  that  a  dissection  of  the 
human  body  should  be  made  at  Salerno  once  every 
five  years,  inviting  physicians  and  surgeons  from  all 
parts  of  the  empire  to  witness  it.  It  has  been 
erroneously  stated  that  the  bull,  dc  sepulturis,  of  Pope 
Boniface,  issued  in  1300,  was  an  interdict  against 
dissection;  but  it  was  really  intended  to  prevent  the 
gruesome  practice  of  dismembering  and  boiling  dead 
crusaders,  "more  teutonico,"  for  the  purpose  of  more 
easily  transporting  their  bones  to  their  native  land. 
The  bodies  of  the  Emperor  Barbarossa,  of  Saint 
Louis  (King  Louis  XL  of  France),  and  of  many 
nobles  were  treated  in  this  manner.  The  Senate  of 
Venice,  in  1308,  decreed  that  a  human  body  should 
be  dissected  annually.  It  is  uncertain  to  what 
extent  these  dissections  were  carried,  but  it  is  prob- 
able that  only  the  larger  viscera  were  examined. 

Among  the  products  of  the  school  of  Salerno  that 
have  survived  are  the  "Anatome  Porci"  of  Copho, 
and  the  anonymous  "Demonstratio  Anatomica." 
These  are  both  based  wholly  upon  dissection  of 
animals. 

There  is  evidence  that  at  this  period  autopsies  were 
occasionally  held  to  determine  the  cause  of  death, 
whether  by  poisoning  or  otherwise.  It  is  also  said 
that  the  bodies  of  those  who  had  been  hanged  were, 
in  Italy,  not  infrequently  given  over  to  physicians 
for  dissection.  Occasionally  bodies  were  stolen  for 
anatomical  purposes. 

It  is  at  about  this  time  that  occurred  the  first 
attempts  at  pictorial  representations  of  bodily 
structure.  These  are  found  in  a  translation  of  Galen 
made  by  Nicholas  Regio  and  published  at  Dresden 
in  the  fourteenth  century.  Two  manuscripts  on 
anatomy  by  Mondeville  and  Magister  Ricardus  that 
have  survived  from  the  school  of  Montpellier  also 
contain  rude  drawings  of  structures. 

The  credit  of  first  establishing  systematic  public 
demonstrations  of  anatomy  belongs  undoubtedly  to 
Mundinus  (Raimondo  de  Luzzi,  Mondino,  1275-1326), 
who  taught  at  Bologna.  Not  content  with  expound- 
ing Galen,  Abbas,  and  Avicenna,  he  brought  the 
science  back  to  the  correct  path  of  ocular  investiga- 
tion. At  least  three  bodies  of  women  were  publicly 
dissected  by  him,  and  there  is  reason  to  believe  that 
the  number  was  considerably  greater.  He  is  the 
author  of  a  small  work  known  as  the  "Anathomia 


327 


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REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Mundini,"  that  was  circulated  extensively  in  manu- 
script before  the  invention  of  printing,  and  afterward 
ran  through  at  least  twenty-three  editions.  Although 
very  incomplete  and  containing  numerous  errors,  it 
was  used  as  a  text-book  for  two  hundred  years.  It 
is  very  difficult  to  read,  as  much  of  the  nomenclature 
is  borrowed  directly  from  Arabian  authors.  The 
abdomen  appears  as  the  "myrach,"  the  peritoneum 
the  "cyphach,"  the  omentum  the  "zirbus,"  the 
sternum  "the  shield  of  the  mouth  of  the  stomach." 
Some  of  his  appellations  are  still  used:  as  "nucha" 
for  the  nape  of  the  neck,  "saphena"  for  the  great 
superficial  vein  of  the  thigh.  His  anatomy  is  crude 
and  incomplete  rather  than  positively  erroneous. 
He  held  that  the  body  has  three  cavities  (ventres): 
the  head,  containing  animal  members;  the  thorax, 
spiritual  members;  the  abdomen,  natural  members. 
His  anatomy  of  the  heart  and  of  the  pulmonary 
circulation  is  fairly  accurate  as  he  follows  Galen. 

In  view  of  the  imperfect  and  incomplete  character 
of  this  treatise  of  Mundinus,  it  is  difficult  to  under- 
stand its  great  influence  upon  the  anatomical  instruc- 
tion of  that  age.  It  was,  however,  the  first  work 
since  Galen  avowedly  based  upon  personal  inspection 
of  the  human  body,  and  it  appealed  to  the  medieval 
spirit  of  curiosity  that  now  began  to  manifest  itself. 
The  same  impulses  that  led  Marco  Polo  to  the  terri- 
tories of  the  Great  Khan  and  impelled  the  alchemists 
to  new  discoveries  in  their  search  for  the  transmuta- 
tion of  metals,  animated  many  physicians  of  that 
time  in  their  examination  of  the  body  of  man.  A 
zeal  for  anatomical  studies  arose,  first  in  the  Italian, 
afterward  in  the  French  and  German  universities. 
At  Mundinus'  own  university  of  Bologna  definite 
rules  for  dissection  were  established.  At  Venice 
(1308),  Florence_(13S8),  Padua  (1429),  also  at  Ferrara 
and  Pisa  dissection  was  either  required  or  allowed  as 
an  aid  to  medical  instruction.  Pope  Clement  VII 
(1523-24)  granted  it  at  Rome.  At  Montpellier  in 
1376  or  1377  the  medical  faculty  obtained  from  the 
Duke  of  Anjou  a  regular  license  to  dissect  the  cadavers 
of  criminals,  which  was  successivelv  continued  by  the 
kings  of  France  (Charles  VI.,  1396;  Charles  VIII., 
1496).  In  Prague  dissection  was  practised  from  the 
very  foundation  of  the  university  in  134S,  and  a 
building  was  given  for  that  special  purpose  in  1460. 
At  Vienna  dissection  was  practised  as  early  as  1404, 
and  made  a  definite  part  of  the  medical  curriculum 
in  1433.  Pope  Sixtus  IV.  granted  special  authority 
for  dissections  at  Wittenberg  in  14.82  and  it  was 
practised  at  Tubingen  in  1485.  The  first  anatomy 
act  in  England  was  passed  in  1540,  allowing  the 
company  of  barbers  and  surgeons  of  London  four 
bodies  annually  for  dissection.  In  Paris  we  hear  of 
it  as  early  as  1478  and  Moreau  says  it  was  customary 
to  make  four  dissections  annually.  In  1483  the 
Paris  Faculty  decreed  that  graduates  in  medicine 
should  be  required  to  have  anatomical  knowledge. 
No  doubt  the  actual  number  of  dissections  was 
greater  than  is  shown  by  these  scattered  records. 
Yet  this  was  nowhere  carried  on  with  the  care  and 
precision  that  characterize  work  in  modern  schools. 
The  freeing  of  muscles,  vessels,  and  nerves  from  the 
tissues  that  envelop  them  seems  not  to  have  been 
understood.  Usually  the  great  cavities  of  the  body 
were  opened  and  the  principal  viscera  therein  con- 
tained were  displayed  and  demonstrated.  Slices 
were  removed  from  the  cadaver  by  a  razor  in  the 
hands  of  an  attendant.  The  modern  methods  of 
injection  and  preservation  were,  of  course,  unknown; 
and  a  cadaver  was  soon  a  mass  of  disgusting  and 
noxious  putrescence.  There  was  as  yet  no  approach 
to  exact  and  complete  anatomical  investigation. 

That  anatomy  was  but  of  slight  assistance  to  either 
medicine  or  surgery  is  amply  shown  by  the  records  of 
the  time.  Indeed,  it  fell  into  such  disrepute  that 
Paracelsus  (Theophrastus  Bombastus  von  Hohenheim, 
1  193-1541)   declared  it   to   be  useless  to  know   the 


internal  structure  of  the  body,  that  a  knowledge  of 
the  shape  or  situation  of  the  lungs,  heart,  or  stomach 
was  of  no  value  in  the  diagnosis  or  treatment  of  dis- 
ease. In  1525  he  burned  the  works  of  Galen  and 
Avicenna  before  his  pupils  at  Basle,  denouncing 
these  teachers  as  blind  guides.  This  was  at  the  close 
of  an  address  in  which  he  denounced  scholasticism 
which  he  felt  was  retarding  the  progress  of  true 
science.  He  said  "I  would  admonish  you  to  put 
aside  for  awhile  the  mere  dreams  and  opinions  of 
others  who  think  by  rote  and  not  by  experience.  Of 
what  use  is  the  rain  that  fell  a  thousand  years  ago? 
We  are  more  interested  in  that  which  falls  to-day." 
Some  of  the  doctrines  of  Paracelsus  reappear  at  later 
periods.  He  considered  the  body  to  be  a  microcosm 
representing  the  entire  external  universe,  formed 
from  preexisting  and  indestructible  germs  (Weis- 
mann's  germ  plasm),  and  governed  by  astrological 
influences,  the  sun  affecting  the  heart,  the  moon  the 
brain,  Mercury  the  liver,  etc.,  etc.  The  functions 
of  the  body  he  supposed  to  be  carried  on  by  the 
archcens,  a  sort  of  dcus  in  machina,  that  resided  in 
the  belly.  He  made  many  other  fantastic  specula- 
tions, especially  in  therapeutics  and  appears  to  be 
the  original  author  of  the  homeopathic  doctrine  of 
"  like  cures  like." 

Among  those  who  carried  on  the  work  started  by 
Mundinus  and  somewhat  extended  the  domain  of 
anatomy  are: 

Gabriele  de  Zerbi  (1468-1505),  professor  at  Padua, 
Bologna,  and  Rome,  who  first  separated  the  organs 
into  systems,  described  the  musculature  of  the 
stomach,  and  the  puncta  lachrymalia.  He  knew 
that  the  tunica  vaginalis  testis  is  derived  from  the 
peritoneum. 

Achillinus  (Alessandro  Achillini,  1463-1512),  pro- 
fessor at  Bologna  and  Padua,  author  of  a  commentary 
on  Mundinus,  who  discovered  the  malleus  and  the 
incus,  the  labyrinth  of  the  ear,  the  patheticus  nerve, 
the  ileocecal  valve,  and  the  entrance  of  the  bile  duct 
into  the  duodenum. 

Alessandro  Benedetti  (1460-1525),  professor  at 
Padua  in  1490,  afterward  at  Venice,  built  the  first 
anatomical  amphitheater.  His  demonstrations  were 
public  and  he  complains  of  the  "numerous  populace" 
that  crowded  to  them.  He  wrote  a  work  on  anatomy 
that  is  one  of  the  very  best  of  the  period. 

Berengarius  Carpensis  (Jacopo  Berengario  Carpi, 
1470-1530),  professor  at  Pavia  and  Bologna,  author 
of  a  commentary  on  Mundinus.  He  showed  the 
mythical  character  of  the  rete  mirabile  which  Galen 
had  described  as  existing  on  the  internal  carotid 
arteries  (as  in  the  herbivora),  and  was  the  first  to 
deny  that  orifices  existed  in  the  interventricular 
septum.  He  stated  that  he  had  dissected  more  than 
a  hundred  cadavers,  but  does  not  say  that  these  were 
all  human. 

Marcus  Antonius  (Marc  Antonio  della  Torre,  14S1- 
1512),  professor  at  Padua  and  Pavia,  the  pupil  of 
Lionardo  da  Vinci  who  is  said  to  have  designed  plates 
for  his  work.  Lionardo  was  himself  an  anatomist 
fully  equal  to  any  of  the  pre-Vesalian  epoch.  He 
made  many  dissections  and  carefully  reproduced 
them  in  drawings  that  show  a  great  deal  of  anatomical 
knowledge.  William  Hunter  says:  "  I  expected  to 
find  in  the  drawings  of  Lionardo  da  Vinci  at  most 
only  the  anatomical  indications  indispensable  for  a 
painter  in  practising  his  art;  but  to  my  great  astonish- 
ment I  discovered  that  Lionardo  had  studied  anatomy 
as  a  whole  and  that  very  profoundly.  When  I 
consider  the  care  with  which  he  studied  every  part 
of  the  human  body,  I  am  persuaded  that  he  ought  to 
be  considered  the  best  and  greatest  anatomist  of  his 
epoch."  He  seems  to  have  come  nearer  to  the 
circulation  of  the  blood  than  any  of  his  contempora- 
ries. "The  heart,"  he  says  "is  a  muscle  of  great 
strength,  much  stronger  than  the  other  muscles. 
The  blood  that  returns  when  the  heart  opens  again 


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Anatomy,  History  of 


j,  not  the  same  as  that  which  closes  tin1  valves."  It 
should  I"'  remembered  thai  Raphael,  Michael  Angelo, 
Bandinelli,  Pollajuolo,  Verocchio,  and  Donatello  all 
studied  anatiitiiy  and  left  anatomical  drawings, 
Concerning  Michael  Angelo,  the  slanderous  story  was 
circulated  that  he  had  practised  vivisection  of  a 
criminal  in  order  to  gel  the  expression  that  ho  desired 
to  portray  in  a  picture  of  the  crucifixion. 

Vidus  Vidius  (Guido  Guidi,  1545-1569),  physician 
to  Francis  [.,  and  professor  at  Talis  and  Pisa,  whose 
name  is  retained  in  the  Vidian  canal  and  t ho  Vidian 
nerve;  Guintherus  Andernacensis  (Gtinther  von 
lernach,  1487-1574),  professor  at  I.ouvain  and 
Paris;  and  Jacobus  Sylvius  (Jacques  Dubois,  1478- 
1555),  professor  at  Paris,  are  all  chiefly  famous  as 
being  the  instructors  of  Vesalius.  Gunther  had  both 
\  esaiius  and  Servetus  as  prosectors  in  his  laboratory 
at  the  same  time.  His  description  of  the  valves  of 
the  heart  is  good,  and  he  appears  to  have  been  the 
first  to  discover  that  both  air  and  blood  undergo 
changes  in  passing  through  the  lungs.  Sylvius 
fly  improved  nomenclature,  assigning  designa- 
tion- to  muscles  and  vessels,  distinguishing  voluntary 
from  involuntary  muscles,  and  demonstrating  more 
by  personal  dissection  than  was  done  in  other  schools. 
In  his  little  "Introduction  to  Anatomy"  he  says: 
■■  1  would  have  you  look  carefully  and  recognize  by 
eye  when  you  are  attending  dissections  or  when  you 
see  anyone  else  who  may  be  better  supplied  with 
instruments  than  yourself.  For  my  judgment  is 
that  it  is  much  better  that  you  should  learn  the 
manner  of  cutting  by  eye  and  touch  than  by  reading 
and  listening.  For  reading  alone  never  taught  any- 
how to  sail  a  ship,  to  lead  an  army,  nor  to  com- 
pound a  medicine,  which  is  done  rather  by  the  use  of 
one's  own  sight  and  the  training  of  one's  own  hands." 
fie  discovered  valves  in  some  of  the  veins,  but  appears 
to  have  had  no  idea  of  their  function. 

The  time  was  now  ripe  for  a  new  advance.  The 
invention  of  printing  and  consequent  general  dif- 
fusion of  ancient  literature,  the  discovery  of  new 
countries  and  continents,  the  progress  of  invention 
and  the  flourishing  condition  of  pictorial  and  plastic 
art,  created  an  intellectual  activity  that  would  no 
longer  brook  the  restraints  of  schools  and  the  un- 
supported dicta  of  the  ancients.  The  power  of 
tradition,  which  had  weighed  like  an  incubus  upon 
anatomical  teaching  for  over  thirteen  hundred  year-, 
was  now  to  be  rudely  shaken.  There  arose  a  group 
of  anatomists  who  were  to  pursue  their  work  again 
in  the  proper  spirit  of  free  inquiry  and  to  institute  for 
the  first  time  in  the  history  of  the  science  of  careful 
examination  of  the  human  body  made  with  thorough- 
ness and  skill.  The  chief  of  these  was  Andrew 
Wesel,  more  commonly  known  by  his  Latin  ap- 
pellative of  Andreas  Vesalius,  who  was  born  at 
Brussels,  December  31,  1514.  He  was  the  son,  grand- 
son, and  great-grandson  of  distinguished  physicians, 
a  fact  of  which  he  was  justly  proud.  He  showed  a 
taste  for  anatomical  investigations  at  an  early  age, 
and  after  an  excellent  training  in  Latin,  Greek, 
and  perhaps  in  Arabic,  at  the  university  of  Louvain,  he 
went  to  Paris  to  work  in  the  laboratory  conducted 
by  Vidius  and  afterward  by  Sylvius  at  the  school 
founded  in  1.330  by  Francis  I.  His  description  of  the 
way  in  which  anatomy  was  pursued  there  shows  the 
state  of  teaching  at  that  time.  The  demonstrations 
were  mostly  upon  animals,  and  upon  those  rare 
occasions  when  the  human  body  was  examined 
it  was  hurried  over  in  three  lessons,  the  teacher 
merely  opening  the  great  cavities  and  so  hastening 
over  the  demonstration  that  "more  anatomy  might 
be  learned  in  the  shop  of  a  butcher  than  in  such  a 
dissecting  room."  Except  the  eight  muscles  of  the 
abdomen  which  were  badly  mangled  and  improperly 
prepared,  not  a  muscle  was  demonstrated,  nor  were 
any  bones  shown,  much  less  were  nerves,  veins,  and 
arteries  properly  dissected  and  displayed. 


At  odd  times    Ve  aim     haunt'-,!   tin-  city  Cemeti  ii' 
to  procure  chance  hour-  turned  up  by  t  he  spade  of  the 
Sexton.       He  early   noted  errors  in  the  description     "I 

Galen  and  Mundinus.  Returning  to  Louvain  he  con- 
ducted anatomical   demonstrations   there,   and  pos- 

Sessed  himself,  it  is  said,  of  an  entire  human  skeleton 
by  remaining  all  night  beyond  the  city  gates  and 
robbing  the  gibbet    of  a   bnd\     partially   destroyed    by 

birds.  Jle  afterward  went  to  Italy,  and  received,  in 
1537,  at  twenty-three  years  of  age,  the  appointment 

of  professor  of  anatomy  at  Padua,  already  famous 
for  its  anatomical  instruction.  II.  n-  he  at  once 
achieved  a  striking  success.  His  demonstrations 
were  crowded;  the  clergy,  the  laity,  even  women 
thronging  to  hear  him.  He  remained  in  Italy  seven 
years,  delivering  courses  in  I'isa  and  Bologna  as  well 
as  at  Padua,  a  proceeding  rendered  possible  by  the 
short  duration  of  each  course,  viz.,  seven  weeks. 
While  not  employed  in  teaching  he  gave  his  time  to 
the  composition  of  his  great  work,  "  De  Huniani 
Corporis  Fabrica,  Libri  VII.,"  the  first  attempt  at  a 
complete  exposition  of  the  structure  of  the  human 
body. 

In  this  we  find  the  result  of  his  own  personal  re- 
searches, a  careful  and  generally  accurate  description 
of  the  anatomical  features  of  man  made  for  the  first 
time  from  actual  inspection.  As  Vesalius  himself 
says,  it  is  an  attempt  to  demonstrate  the  structure  of 
man  upon  himself.  Galen's  many  errors,  caused  by 
his  almost  exclusive  study  of  inferior  animals,  were 
unsparingly  noted.  Excellent  plates  made  from 
drawings  of  preparations  illustrated  the  work.  These 
were  so  good  that  they  were  often  ascribed  to  Titian, 
but  they  were  probably  the  work  of  Stephen  von 
Calcar,  one  of  Titian's  pupils,  with  perhaps  some 
aid  and  advice  from  the  master  and  an  occasional 
drawing  from  Vesalius  himself,  who  was  skilful  with 
the  pencil. 

From  this  epoch-making  work  modern  anatomy 
may  be  said  to  have  its  birth.  It  is,  however,  by  no 
means  free  from  errors,  both  those  due  to  hasty 
preparation,  and  those  arising  from  the  preconcep- 
tions then  current.  Vesalius  still  supposed  that 
mucus  passed  through  the  holes  in  the  cribriform 
plate,  that  the  tubular  nerves  distributed  animal 
spirits,  etc.  Many  of  his  errors  were  pointed  out  by 
his  contemporaries 

This  new  departure  should  be  considered  as  belong- 
ing to  the  movement  of  the  age.  As  has  been  already 
noted,  the  world  was  becoming  impatient  of  tradi- 
tionary authority  and  seeking  for  facts  by  personal 
observation  and  research.  Vesalius'  great  work 
appeared  in  1543,  in  the  same  year  that  Copernicus 
published  his  treatise  "On  the  Motions  of  the  Heav- 
enly Bodies";  it  was  in  1521  that  Luther  made  his 
memorable  appeal  before  the  Diet  of  Worms,  and  in 
1534  that  he  completed  his  translation  of  the  Bible. 

The  adherents  of  ancient  tradition  did  not  yield 
without  a  struggle.  Vesalius  was  denounced  by 
many,  his  former  teacher  Sylvius  calling  him  an 
impious  madman  whose  breath  poisoned  Europe. 
The  errors  of  Galen  which  Vesalius  had  pointed  out 
were  explained  in  the  most  grotesque  manner,  either 
by  supposing  a  corruption  of  Galen's  text,  or  by  the 
hypothesis  that  the  human  body  had  changed  since 
Galen's  time.  The  seven  pieces  of  the  sternum  which 
Galen  had  described  (from  apes)  were  supposed  to 
indicate  how  much  larger  and  more  developed  the 
thorax  was  in  Galen's  time;  the  curvature  of  the  thigh 
bones,  not  seen  in  modern  man,  was  said  to  be  their 
natural  free  condition  before  they  were  straightened 
by  the  wearing  of  tight  breeches.  More  important 
were  criticisms  directed  toward  Vesalius'  own  demon- 
strations by  Eustachius,  who  pointed  out  a  number  of 
errors,  and  thoroughly  disapproved  of  the  conduct  of 
Sylvius.  Vesalius  seems  to  have  taken  this  opposition 
very  much  to  heart.  He  had  previously  resigned  his 
chair,  and  now  he  went  to  Madrid,  where,  in  the  gloomy 


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Anatomy,  History  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


court  of  Philip  II.,  he  found  a  most  uncongenial 
atmosphere.  He  was  surrounded  by  enemies  who 
attempted  to  stop  his  work  by  the  power  of  the  In- 
quisition. Philip  asked  from  the  University  of 
Salamanca  an  opinion  as  to  the  permissibility  of 
dissection,  and  the  reply  of  the  learned  doctors  was 
that  since  it  is  useful  to  man  it  may  be  allowed  (1556). 
Restless  and  ill  at  ease,  Vesalius  wished  to  return  to 
his  chair  in  Italy,  now  vacant  by  the  death  of  Fal- 
lopius.  He  was  destined  never  to  do  this.  Making 
a  voyage  to  Palestine  in  the  fulfilment  of  some  vow,* 
recalled  while  there  by  the  Senate  of  Venice  to  re- 
sume his  chair,  he  was  shipwrecked  on  the  island  of 
Zante,  and  suffered  so  much  from  exposure  that  he 
died  there,  October  15,  1564.  He  was  one  of  the  great 
pioneers  and  pathmakers  of  science,  worthy  to  rank 
with  Copernicus  and  Columbus.  Anatomy  has  never 
lost  the  impulsion  due  to  his  arduous  efforts.  He 
found  it  a  mass  of  crude  speculations  based  on 
ancient  authority,  he  left  it  a  recognized  science  hav- 
ing for  its  basis  actual  observation  of  structure. 
■  Vesalius  was  by  no  means  alone.  Two  other  great 
figures  stand  out  at  this  epoch,  Eustachius  (Barto- 
lommeo  Eustacchi,  1520-1574),  professor  of  an- 
atomy at  Rome,  and  Fallopius  (Gabriele  Fallopio, 
1523-1562),  professor  at  Ferrara,  Pisa,  and  Padua. 
It  is  to  Eustachius  that  we  owe  the  first  idea  of  in- 
vestigating the  tissues,  also  the  conception  that  to 
understand  adult  structures  we  should  examine  the 
fetal  ones.  To  correct  the  current  errors  in  Vesalius 
and  others,  he  prepared  a  great  illustrated  work 
on  the  controversies  of  anatomists,  but  it  was  never 
published,  and  the  plates  that  he  had  made  for  it  at 
great  expense  were  long  supposed  to  be  lost,  but  were 
finally  discovered  in  the  Vatican  library  and  presented 
by  Pope  Clement  XI.  to  Lancisi,  who  published  them 
in  1714.  They  were  the  first  copper  plates  used  for 
anatomical  illustrations,  and  show  that  their  author 
had  anticipated  many  of  the  discoveries  of  his 
successors.  The  Gasserian  ganglion  and  the  pan- 
creatic duct  are  clearly  shown,  and  the  ciliary  muscle 
not  only  figured  but  given  its  modern  designation. 
The  name  of  Eustachius  is  preserved  in  the  Eustachian 
tube,  said  to  have  been  first  discovered  by  Alcmreon, 
and  the  Eustachian  valve  of  the  fetal  heart  mentioned 
previously  by  Jacobus  Sylvius.  He  first  described 
the  membranous  cochlea  and  the  tensor  tympani 
muscle,  the  origin  of  the  optic  nerve,  the  suprarenal 
capsules,  and  the  ventricles  of  the  larynx. 

Fallopius  was  especially  renowned  for  his  exact 
description  of  the  organs  of  hearing.  He  discovered 
the  facial  canal  and  its  hiatus,  the  communication  of 
the  mastoid  cells  with  the  middle  ear,  the  fenestra 
ovalis,  the  chorda  tympani,  the  aqueductus  vestibuli, 
and  the  lamina  spiralis.  He  gave  the  membrana 
tympani  its  present  name  and  named  the  oviducts 
(previously  discovered  by  Herophilus)  the  tuba' 
seminales.  The  inguinal  ligament  (Poupart's)  was 
first  described  by  him,  as  also  the  hymen,  the  clitoris, 
the  seminal  vesicles,  and  the  uriniferous  tubules.  He 
also  described  the  ileocecal  valve,  which  was,  however, 
probably  known  to  Achillinus.  He  discussed  the 
development  of  bones  and  teeth,  and  knew  the  ganglia 
of  the  spinal  nerves. 

In  their  zeal  for  knowledge  the  anatomists  of  that 
age  are  reputed  to  have  not  infrequently  overstepped 
the  bounds  of  common  humanity.  Vesalius,  following 
the  example  of  Herophilus,  is  said  to  have  vivisected 
criminals,  and  the  records  found  in  the  criminal 
archives  of  Florence  (1545-1570)  show  beyond  dis- 
pute that  it  was  by  no  means  uncommon  to  send 
living  persons  to  Pisa  "to  be  made  an  anatomy." 
While    this   language   seems   to   indicate    that    such 

*  The  report  that  he  was  condemned  to  death  by  the  Inquisition 
for  opening  by  accidenl  the  body  of  a  living  man,  and  that  his 
sentence  was  by  Philip  commuted  t<>  a  pilgrimage,  appears  to  be 
wholly  without  foundation,  unsupported  by  the  records  of  the 
Inquisition  or  of  1  he  royal  archives. 


subjects  were  dissected  alive,  there  is,  on  the  other 
hand,  some  evidence  to  show  that  they  were  first 
executed  by  smothering  or  otherwise. 

Many  other  almost  equally  famous  men  contrib- 
uted to  the  anatomical  knowledge  of  the  period. 
Among  these  are  the  following: 

Servetus  (Miguel  Serveto,  1509-1553),  a  Spaniard 
from  Villanova,  in  Arragon,  burned  at  the  stake  by 
Calvin,  at  Geneva,  for  heretical  opinions.  He  was  the 
first  clearly  to  describe  the  pulmonary  circulation  and 
the  change  from  venous  to  arterial  blood  that  occurs 
in  the  lung.  This  description  occurs  in  the  rare  work 
" Christianismi  Restitutio,"  published  by  him  at 
Vienne  in  1553.  In  this  he  clearly  states  that  air 
mixed  with  blood  passes  from  the  lungs  to  the  heart. 
"A  pulmonibus  ad  cor  non  simplex  aer  sed  mixtia 
sanguine  mittitur  per  arteriam  venosam."  He  had, 
however,  no  idea  of  the  greater  or  general  circulation. 

Columbus  (Matteo  Realdo  Colombo,  1494-1559), 
a  bitter  opponent  of  Vesalius,  and  who  immediately 
succeeded  him  at  Padua  and  afterward  taught  at 
Pisa  and  Rome,  dissected  with  great  assiduity, 
completing  at  least  fourteen  bodies  in  a  year.  He 
also  ransacked  old  charnel  houses  for  bones  and  is 
said  to  have  compared  about  half  a  million  of  skulls. 
He  was  an  ardent  investigator,  demonstrated  ex- 
perimentally the  lesser  circulation,  perhaps  with 
knowledge  of  the  prior  work  of  Servetus,  and  had 
an  accurate  idea  of  the  functions  of  the  valves  of 
the  heart. 

Ingrassias  (Giovanni  Filipo  Ingrassia,  1510-15S0), 
professor  at  Naples,  of  high  rank  as  an  osteologist, 
who  discovered  the  stapes  and  studied  the  sphenoid 
and  ethmoid  bones. 

Cananus  (Giambattista  C'anano,  1515-1579),  one 
of  the  earliest  to  mention  the  valves  of  the  veins 
(1547). 

Coesalpinus  (Andreas  Cfesalpini,  1519-1603),  the 
first  to  use  the  term  circulatio  in  speaking  of  the  move- 
ment of  the  blood.  He  seems  to  have  anticipated 
Harvey  in  holding  that  the  blood  returns  from  the 
general  tissues  to  the  heart  by  the  veins  alone.  He 
lacked,  however,  the  precise  demonstration  which 
characterizes  Harvey's  work. 

Arantius  (Giulio  Cesare  Aranzio,  1530-1589), 
professor  at  Bologna,  who  discovered  the  ductus 
arteriosus,  the  corpora  Arantii,  named  the  hippo- 
campus major,  carefully  described  the  gravid  uterus, 
which  he  considered  a  muscular  organ,  and  first  spoke 
of   a   separation   of   the   maternal   and    fetal    blood. 

Coiterus(VolcherKoyter,  1534-1600),  of  Groningen, 
who  investigated  the  osteology  of  the  fetus  and  the  de- 
velopment of  the  bones. 

Varolius  (Constanzo  Varolio,  1543-1575),  pro- 
fessor at  Rome,  who  made  special  researches  into  the 
brain  and  nervous  system,  describing  the  base  of  the 
brain  and  the  apparent  origin  of  the  cranial  nerves. 
His  name  is  preserved  in  the  pons  Varolii. 

Bauhinus  (Caspar  Bauhin,  1560-1624),  professaj 
at  Basle,  who  made  improvements  in  terminology, 
(The  discovery  of  the  ileocecal  valve,  ascribed  to  him, 
is  apparently  due  to  Achillinus.) 

Spigelius  (Adrian  van  den  Spieghel,  1578-1625),  of 
Brussels,  who  made  a  special  study  of  the  liver,  one  of 
whose  lobes  still  bears  his  name. 

Fabricius  ab  Aquapendente  (Girolamo  Fabrizio, 
1537-1613,  so  called  to  distinguish  him  from  Fabriciua 
Hildanus,  a  celebrated  surgeon  of  the  period),  who  was 
the  successor  of  Fallopius  at  Padua,  and  worthily 
maintained  the  reputation  of  that  celebrated  school. 
He  erected  at  his  own  expense  an  anatomical  amphi- 
theater which  still  remains.  It  is  a  small  dark  pit 
with  seats  risintr  almost  perpendicularly  about  it, 
excluding  the  light  so  that  all  dissections  must  have 
been  by  candle  light!  It  was  here  that  Harvey 
learned  anatomy  ami  obtained  from  Fabricius  the 
germs  of  the  knowledge  which  was  to  result  in  the 
discovery  of  the  circulation  of  the  blood.     Fabricius 


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Anatomy,  History  »t 


was  the  first  to  demonstrate  in  a  complete  manner 
the  valves  of  the  veins. ,  The  first  mention  of  these  i~ 
by  Stephanus  (Charles  Etienne)  of  Paris  in  1545,  who 
,  to  them  as  "apophyses  membranarum,"  in- 
tended to  prevent  the  regurgitation  of  the  blood. 
Sylvius  i  1555)  noted  them  in  several  veins,  Eustachius 
in  the  coronary  vein  (1563).  Vesalius  seems  not  to 
have  realized  their  importance,  but  figures  them  in  the 
hepatic  veins.  Fabricius,  however,  wrote  a  cum; 
treatise  upon  them  ("De  Venarum  Ostiolis,"  1603 
and  .stated  that  they  prevent  the  overdistention  of 
Is  when  blood  passes  from  the  larger  to  the  small- 
er veins.  He  also  .studied  the  development  of  the 
human  fetus  and  of  the  embryo  chick,  tho  muscular 
of  the  bladder,  tho  esophagus,  stomach,  and  intes- 
tines, particularly  the  appendix  vermiformis.  He  was 
leeded  at  Padua  by  C'asserius  (Giulio  Casserio, 
1561-1616),  who  paid  especial  attention  to  the  organs 
of  voice  and  hearing  and  discovered  the  stapedius 
muscle.  The  musculo-cutaneous  nerve  of  the  arm  is 
sometimes    called    the    nervus    perforans    Casserii. 

The  zeal  for  investigation  instituted  by  Vesalius  and 
carried  on  by  his  contemporaries  and  immediate 
was  undoubtedly  a  great  advance  over  the 
ignorant  apathy  that  preceded  it,  but  it  was  not  so 
ij  a  new  movement  as  a  revival  of  an  old  one. 
The  anatomy  of  that  time  was,  after  all,  the  anatomy 
of  the  Greeks,  carried  to  a  greater  degree  of  detail,  it  is 
true,  but  marred  by  the  same  teleological  errors.  The 
spiritualistic  theories  of  Hippocrates,  Aristotle,  and 
Qalen  still  prevailed  and  blinded  the  eyes  of  anato- 
mists to  the  true  significance  of  structure.  The 
doctrine  of  the  tissues,  hinted  at  by  Aristotle,  and 
dimly  groped  after  by  Eustachius  and  Fallopius,  had 
borne  as  yet  no  fruit.  The  development  of  the  embryo 
had  been  but  little  studied  and  its  details  were  im- 
perfectly known.  In  osteology  and  arthrology  the 
advances  were  greatest,  the  general  features  of  the 
■s,  joints,  and  ligaments  being  well  described;  but 
their  nomenclature  was  as  yet  undeveloped,  they  being 
mated  in  each  region  by  numbers.  In  the 
vascular  system  the  veins  were  considered  the  most 
important  vessels,  it  being  supposed  that  the  blood  in 
them  had  an  oscillatory  movement  which  the  valves 
modified  without  absolutely  controlling  its  direction. 
The  heart  had  been  fairly  well  described,  but  as  no  one 
had  shown  experimentally  the  impossibility  of  regur- 
gitation of  blood  into  it  from  the  aorta  and  the  pulmon- 
ary artery,  it  was  still  supposed  to  be  a  sort  of  mixing 
reservoir  for  the  blood  and  animal  spirits.  The 
permeability  of  the  interventricular  septum  was  still 
in  dispute,  it  being  held  necessary  for  the  mixing  of 
the  blood.  The  powerful  muscular  character  of  the 
heart  was  still  unrecognized,  and  though  the  lesser  or 
pulmonary  circulation  had  been  mentioned  by 
Bervetus  and  Columbus,  it  was  not  generally  ac- 
cepted. The  lymphatics,  although  seen  and  vaguely 
mentioned  by  several  ancient  authors,  were 
not  understood. 

The  macroscopic  anatomy  of  the  brain  was  not  yet 
well  known;  the  ventricles  were  supposed  to  be  the 
reservoirs  of  the  vital  spirits,  and  the  nerves  to  be 
tubular  in  character.  The  distribution  of  the  cranial 
nerves  was  not  clearly  made  out. 

In  splanchnology  vague  ideas  prevailed.  The  liver 
and  spleen  were  thought  to  be  potent  organs  for  the 
elaboration  of  blood,  which  was  made  in  them  as  fast 
as  it  was  distributed  by  the  heart  through  the  veins 
and  arteries  to  be  poured  out  into  the  substance  of 
the  organs.  The  pancreas,  although  discovered  by 
Herophilus,  was  overlooked,  as  it  is  evident  that 
\  esalius  mistook  for  that  organ  the  collective  mesen- 
teric glands.  The  ovaries  were  believed  to  produce  a 
female  semen. 

Anatomical  instruction  was  still  carried  on  mainly 
by  demonstrations  by  the  professor.  The  prosectors 
usually  made  dissections  in  sight  of  the  pupils,  the 
professor   sitting   opposite   and   with,  a   little   wand 


pointing  oui  the  part  described.     The  muscles 
dissected  in  one  day,  the  contents  of  the  head,  chi    t, 

and  abdomen  in  a  second,  the  bones  and  ligaments  in 
a  third.     It  was  not  usually  practicable  to  extend  this 

lime  on  account  of  the  rapid  decay  oi  tie-  body.      As, 
however,  the  whole  day  was  occupied  by  each  demon- 
tration,  the  work  was  nut  as  superficial  as  might  at 
first  appear. 

Another  great  advance  was  now  made  in  a  domain 
which,  although  physiological  in  its  scope,  yet  reacted 

powerfully  upon  anatomy  by  affecting  conceptions  of 

bodily  structure.  This  was  the  careful  inductive 
demonstration  (commonly  called  discovery)  of  the 
circulation  of  the  blood  made  by  the  renowned 
William  Harvey  who  was  born  April  1,  l~>7s.  He 
studied  at  Cambridge  and  Padua,  graduating  from 
both  universities  in  lfi()2.  In  Italy  he  became  ac- 
quainted with  the  views  of  Fabricius  whose  pupil  he 
was,  as  to  the  wide  distribution  of  the  valves  of  the 
veins,  and  those  of  Columbus  regarding  the  pulmonary 
circulation.  It  was  not,  however,  until  lie  had  made 
many  vivisections  and  studied  the  movements  of  the 
heart  in  many  living  animals,  under  varying  conditions, 
that  he  attained  to  a  correct  idea  of  the  double  circuit 
made  by  the  blood. 

Harvey  began  to  teach  the  new  doctrine  in  his 
lectures  at  the  Royal  College  of  Physicians  as  early 
as  1615,  but  did  not  publish  them  until  1028,  when 
appeared,  at  Frankfort,  his  "Exercitatio  Anatomica 
de  Motu  Cordis  et  Sanguinis  in  Animalibus"  (An 
anatomical  treatise  on  the  movements  of  the  heart 
and  the  blood  in  animals).  In  this  he  frankly  breaks 
with  traditional  teaching:  "  I  profess  to  learn  and 
teach  anatomy  not  from  books,  but  from  dissections; 
not  from  the  suppositions  of  philosophers,  but  from 
the  fabric  of  nature."*  Showing  that  the  anatomical 
arrangement  of  the  valves  of  the  veins  and  of  the 
heart  necessarily  implies  a  movement  of  the  blood 
from  the  veins  toward  the  heart  and  from  the  heart 
into  the  arteries,  he  demonstrated  such  movement  by 
a  compression  of  veins  and  arteries  and  by  various 
other  experiments  in  living  animals,  making  an  ear- 
nest plea  for  comparative  anatomy:  "Had  anatomi-ts 
only  been  as  conversant  with  the  dissection  of  the  lower 
animals  as  they  are  with  that  of  the  human  body,  the 
matters  that  have  hitherto  kept  them  in  a  perplexity 
of  doubt  would,  in  my  opinion,  have  met  them  freed 
from  every  kind  of  difficulty."  For  the  first  time  we 
see  doubt  cast  upon  the  doctrine  of  "spirits."  Says 
Harvey:  "We  are  too  much  in  the  habit  of  worship- 
ping names  to  the  neglect  of  things.  The  word  blood 
has  nothing  of  grandiloquence,  about  it,  for  it  signifies 
a  substance  which  we  have  before  our  eyes  and  can 
touch;  but  before  such  titles  as  spirit  and  innate  heat 
we  stand  agape." 

The  new  doctrine  was  at  first  universally  rejected, 
especially  in  Italy  where  most  of  the  preliminary 
discoveries  had  been  made  that  led  to  Harvey's  con- 
elusions.  As  in  the  case  of  Vesalius,  the  innovator 
was  greeted  with  abuse  and  detraction  instead  of 
demonstration  and  legitimate  argument.  Harvey 
received  this,  however,  with  a  singularly  calm  and 
judicial  spirit.  He  says:  "To  return  evil  speaking 
with  evil  speaking  I  hold  to  be  unworthy  in  a  philoso- 
pher and  searcher  after  truth.  I  believe  that  I  shall 
do  better  and  more  advisedly'  if  I  meet  so  many  indica- 
tions  of  ill-breeding  with  the  light  of  faithful  and  con- 
clusive observation."  The  only  opponent  he  deigned 
to  answer  was  Jean  Riolan  (Riolanus,  Jr.,  1.577-1657), 
professor  at  Paris,  so  renowned  for  his  acerbity  in  con- 
troversy that  it  was  said  of  him  that  he  would  rather 
give   up  a  friend  than  yield  an  opinion.     Harvey's 

*  In  the  possession  of  the  Royal  College  of  Physicians  of  London 
are  preparations  of  tin-  blood-vessels,  mounted  on  boards  and  show- 
ing the  aortic  valves,  that  are  said  to  have  been  prepared  by  Har- 
viv  when  a  student  in  Italy  and  used  for  demonstration  to  his 
classes.  Hyrtl  believes  them  to  be  the  oldest  anatomical  prepara- 
tions extant. 


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reply  was  judicial  and  complete,  but  failed  to  con- 
vince Riolan,  who  obtained  a  decree  from  the  Faculty 
at  Paris  forbidding  the  teaching  of  the  new  doctrine, 
and  opposed  it  up  to  the  time  of  his  death.  Harvey 
lived  to  see  his  views  almost  universally  accepted, 
dying  in  1657,  a  few  years  before  Malpighi  discovered 
the  capillaries  and  thus  placed  the  anatomical  basis  of 
the  circulation  beyond  cavil  (1661). 

Harvey's  work  called  more  attention  to  the  heart, 
and  many  points  in  its  gross  anatomy  were  now  estab- 
lished. Among  those  who  worked  to  this  end  may  be 
mentioned  Richard  Lower  of  London  (1631-1691, 
tuberculum  Loweri),  Raymond  Vieussens(1641-1715 
or  16,  fossa  ovalis),  professor  at  Montpellier,  Nils 
Stensen  (Nicholas  Stenonis,  1638-16S6),  professor  at 
Copenhagen,  who  worked  at  the  musculature  and 
looped  fibers,  and  Adam  Christian  Thebesius  (1686- 
1732),  who  discovered  the  foramina  Thebesii. 

As  a  consequence  of  the  doctrine  of  the  circulation, 
the  distribution  of  blood-vessels  was  more  accurately 
studied.  A  passage  in  Sylvius  is  sometimes  cited  to 
show  that  he  suggested  injections,  but  it  is  clear  that 
he  could  not  have  made  any  effective  use  of  them. 
The  first  to  do  this  was  Stephen  Blancaard,  of  Middle- 
burg,  Holland  (1650-1702),  who,  in  1675,  succeeded 
in  injecting  the  blood-vessels.  Others  obtained  great 
success  with  this  method,  especially  Frederick  Ruysch 
(1638—1731),  professor  at  Amsterdam,  whose  prepara- 
tions were  justly  famous.  It  is  to  him  we  owe  the  dem- 
onstration of  the  vascular  distribution  in  the  choroid 
of  the  eye  (tunica  Ruyschiana  =choriocapillaris). 
Using  fine  injections  he  found  vessels  in  every  part 
of  the  body  in  such  numbers  that  he  inclined  to  the 
belief  that  the  body  was  mainly  composed  of  them, 
"totum  corpus  ex  vasculis." 

Closely  associated  with  the  anatomy  of  the  blood- 
vascular  system  is  that  of  the  lymphatics.  These 
structures  were  probably  seen  in  goats  by  Aristotle 
and  Herophilus,  but  as  their  course  and  termination 
were  not  determined,  the  remarks  of  those  authors 
concerning  them  were  overlooked  or  misunderstood. 
Eustachius  saw  and  described  the  thoracic  duct  in  the 
horse,  supposing  it  to  be  a  vein  for  the  nourishment  of 
the  thorax.  The  chyliferous  lymphatics  were  first  ob- 
served in  1622  by  Gaspare  Aselli  (1581-1626),  professor 
at  Pa  via,  in  the  mesentery  of  a  dog  lately  fed.  Misled 
by  the  prevalent  conceptions  as  to  blood  formation,  he 
thought  they  could  be  traced  to  the  liver.  His  dis- 
covery was  not  published  until  1627,  and  the  next 
year  such  vessels  were  demonstrated  in  the  mesentery 
of  a  criminal  two  hours  after  death  by  Fabrice  de 
Peiresc,  a  senator  of  Aix,  to  whom  Gassendi  had  com- 
municated Asellius'  discovery.  In  1647,  Jean  Pecquet 
(1622-1674),  a  student  at  Montpellier,  accidentally 
discovered  the  thoracic  duct  in  a  dog  and  traced  it 
through  the  diaphragm  to  the  receptaculum  chyli 
(reservoir  of  Pecquet).  It  was  still  considered  a  vein, 
though  further  research  showed  its  connection  with 
the  mesenteric  glands.  The  distinction  between  the 
lymphatics  and  the  mesenteric  veins  was  first  made 
by  Nathanael  Highmore  (1613-16S4),  of  Shaftesbury. 
Jan  Van  Home  (1621-1670),  professor  at  Leyden  was 
the  first  to  observe  the  thoracic  duct  in  man,  though 
Olaus  Rudbeck  (1630-1702),  professor  at  Upsala, 
noted  it  about  the  same  time.  The  latter  also  dis- 
covered the  general  lymphatics,  distinguishing  them 
as  vasa  serosa  in  1651,  their  present  name  being  given 
by  Thomas  Bartholin  (1616-1680),  professorat  Copen- 
hagen, who  greatly  extended  the  knowledge  of  them. 
Finally  Anton  Nuck  (1650-1692),  professorat  Leyden, 
invented  the  method  of  injecting  these  vessels  with 
mercury  and  traced  them  to  nearly  all  parts  of  the 
body. 

It  was  at  about  this  period  that  anatomical  science 
obtained  great  assistance  by  the  invention  of  the 
microscope.  As  an  instrument  of  research  the  simple 
microscope  was  not  used  until  the  seventeenth 
century,   although    the   magnifying   power   of  lenses 


seems  to  have  been  known  in  remote  antiquity.  The 
greater  power  of  the  compound  microscope  invented 
about  1608  by  Hans  and  Zacharias  Janssen,  of 
Middelburg,  Holland,  still  further  stimulated  inves- 
tigation and  led  to  the  discoveries  of  Malpighi, 
Leeuwenhoek,  Redi,  and  others.  The  imperfection 
of  the  instrument  so  greatly  affected  its  utility  that 
many  anatomists  distrusted  the  results  obtained 
from  its  use.  After  many  attempts  and  partial 
successes  by  others,  Chevalier  of  Paris  (1824)  and 
Amiei  of  Modena  (1827)  finally  succeeded  in  correcting 
chromatic  and  spherical  aberration,  thus  producing 
an  instrument  by  which  minute  structure  can  be 
accurately  investigated. 

The  immediate  result  of  microscopical  investigation 
was,  on  the  one  hand,  greatly  to  extend  the  knowledge 
of  structure,  and,  on  the  other,  to  introduce  novel 
ideas  regarding  generation  and  the  diffusion  of  animal 
life.  Marcello  Malpighi  (1628-1694),  professor  at 
Bologna,  Pisa,  and  Messina,  a  man  of  great  scientific 
force,  laid  the  foundations  of  modern  botany,  of 
histological  anatomy,  and  of  embryology.  His 
discovery  of  the  capillaries  in  the  lung  of  the  frog 
has  already  been  mentioned.  Molyneux  (1683)  and 
Leeuwenhoek  (1688)  almost  immediately  extended 
this  by  finding  them  in  the  extremities  of  lizards  and 
tadpoles.  Malpighi  discovered  the  red  corpuscles 
of  the  blood  in  1665  and  thought  them  to  be  fatty 
globules.  He  was,  however,  anticipated  in  this  by 
Johannes  Swammerdam  (1637-1680)  who  not  only 
saw  them  but  correctly  described  them  in  1658. 
Malpighi  published  the  first  accurate  account  of  the 
consecutive  development  of  the  chick,  carrying  his 
investigations  as  far  as  the  imperfect  instruments 
and  methods  of  his  time  would  permit.  He  greatly 
advanced  the  knowledge  of  glands,  showing  the 
structure  of  acini  and  ducts,  demonstrated  the  glomer- 
uli of  the  kidney  and  the  splenic  corpuscles  which 
still  bear  his  name,  and  by  inflating  the  air  vesicles 
showed  the  glandular  structure  of  the  lungs  and  the 
impossibility  of  air  passing  into  the  vessels  by 
mechanical  means.  Misled  by  his  imperfect  instru- 
ments and  crude  methods  of  preparation  he  endeav- 
ored to  show  that  the  brain  also  has  a  glandular 
character.  Having  cooked  the  organ  he  thought 
that  the  gray  matter  appeared  on  examination  to  be 
composed  of  minute  spherules  connected  with  the 
fibrous  central  portion.  He  assumed  that  these 
spherules  secreted  the  nervous  fluid  which  was  dis- 
tributed by  the  nerves.  This  accorded  with  the 
prevalent  ideas  and  greatly  retarded  a  true  apprecia- 
tion of  the  structure  of  the  brain. 

Many  other  anatomists  added  to  our  knowledge  of 
glands:  Francis  Glisson  (1597-1677),  professor  at 
Cambridge,  gave  a  description  of  the  liver  that  is  the 
basis  of  our  knowledge  at  the  present  day;  Johann 
Georg  Wirsung,  professor  at  Padua  in  1642,  discovered 
in  man  the  pancreatic  duct,  alleged  to  have  been 
previously  found  in  the  fowl  by  his  pupil  Moritz 
Hofmann  (1621-1698),  afterward  professor  at  Altorf; 
a  discovery  that  retarded  rather  than  advanced 
anatomical  science,  for  the  pancreas  was  supposed 
to  be  a  lymphatic  gland  and  the  duct  a  lymphatic 
leading  from  the  intestine  to  the  liver,  and  thus  were 
confirmed  erroneous  views  of  lymphatic  distribution; 
Thomas  Wharton  of  London  (1610-1673)  wrote  of 
the  nature  and  classification  of  glands,  and  discovered 
the  duct  of  the  submaxillary  gland  that  bears  his 
name. 

At  Paris  a  remarkable  advance  was  made  by  the 
establishment  by  Jean  Riolan,  Jr.,  of  the  Jardin  du 
Roi,  afterward  the  Jardin  des  Plantes,  which  was, 
in  effect,  a  biological  laboratory  where  various  prob- 
lems of  human  and  comparative  anatomy  could  be 
studied.  Jean  Guichard  Duverney  (1648-1730)  was 
an  able  demonstrator  there,  so  popular  that  noblemen 
flocked  to  hear  him.  He  discovered  the  vulvovaginal 
glands   (in   the   cow),    to   which   Caspar    Bartholin's 


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Anatomy,  History  of 


name  was  afterward  attached.     H>'  also  confirmed 
the    existence    of    the    bulbourethral    glands,    first 
discovered   by    Mery   (1645-1722)   and  named   after 
nglish  anatomist  Cowper. 

\1, ixis    I.ittrc    i  Hi.")S-17'_'(i)   described    the   urethral 
elands    that    bear    bis    name,    and    Martin    Naboth 
(1675-1721)   the  glands  of  the  neck   of   the   uterus 
and  the  closed  follicles  of  the  same  region.     Lorenzo 
Bellini    (1643-1704),    professor    at    Pisa,    examined 
,  -  fully  the  structure  of  the  kidney  (uriniferous 
tubules).     Thomas  Bartholin  (1616-1680),  professor 
at  Copenhagen,  one  of  the  most  distinguished  anatom- 
ists ef  the  seventeenth  century,  discovered  the  duct 
of  the  sublingual  gland  which  joins  Wharton's  duct, 
while  the  ducts  of  that  gland  that  open  separately 
into  the  mouth  were  found  by  August  Quiriu  Bach- 
i    (Rivinus,    1652-1723),   professor    at     Leipsic. 
The  duet  of  the  parotid  gland,  seen  and  described  as 
I  iment  by  C'asserius,  was  first  recognized  as  a  duct 
by    Walter    Needham,    of    London,    in    1655.     Nils 
sen    i  Nicholas    Stenonis,    1638-1(386),    professor 
ipenhagen,  mentioned  it  in  his  inaugural  thesis  in 
,    and   its   discovery   is  often   assigned   to   him. 
Stensen  was  one  of  the  most  able  thinkers  of  his  time. 
He  held  that  in  order  to  understand  the  function  of 
organs  we  must  first  determine  their  structure,  and 
that  no  accurate  knowledge  of  the  brain  can  be  had 
until     we     understand     its    conducting     tracts.      He 
declared,    contrary   to   the   prevailing   opinion,    that 
petrifactions  are  not  mere  erratic  freaks  of  nature, 
but  the  remains  of  plants  and  animals  that  formerly 
lived.     The    glands    of    the    intestinal    tract     were 
investigated  by  Johann  Conrad  Brunner  (1653-1727) 
and  Johann  Conrad  Peyer  (1653-1712);  those  of  the 
eye-lids  by  Heinrich  Meibom  (1638-1700),  professor 
at  Helmstadt;  while  Conrad  Victor  Schneider  (1614- 
1680),   professor  at    Wittenberg,   demonstrated    the 
true    nature   of   the   lining   membrane   of   the   nasal 
fosse,  and  thus  overthrew  the  ancient  doctrine  of  the 
tion  of  mucus  (pituita)  by  the  brain  and  of  the 
cerebral     origin     of     catarrhal     disorders.     Antonio 
Pacchioni(1665-1726),  professor  at  Rome,  discovered 
the   bodies   that   bear   his   name,    situated    near    the 
superior  longitudinal  sinus;  and  the  synovial  fringes 
and    so-called    synovial    glands    were    described    by 
Clopton  Havers  (1692). 

The  Pythagorean  and  Galenical  doctrine  that  the 
embryo  is  formed  from  two  kinds  of  semen,  generated 
respectively  by  the  male  and  female,  was  generally 
held.  Harvey,  following  in  the  footsteps  of  his 
master  Fabricius,  investigated  the  course  of  develop- 
ment not  only  in  fowls  but  in  mammals,  and  published 
(1651)  a  treatise  on  development  in  which  he  formu- 
lated the  famous  proposition  that  the  egg  is  the 
primary  stage  of  development  for  all  animals.  The 
original  phrase  is,  "Ovum  esse  primordium  commune 
omnibus  animalibus,"  afterward  currently  abbreviated 
as,  "Omne  vivum  ex  ovo."  According  to  this  view 
the  ovum  is  the  essential  element  in  the  generative 
process.  This  belief  was  shaken  by  the  discovery, 
in  1(>77,  by  Johann  Ham,  a  pupil  of  Leeuwenhoek,  at 
Leyden,  of  the  spermatozoa,  which  were  at  once 
accepted  by  many  as  the  true  generative  elements, 
and  were  even  considered  to  be  minute  but  completely 
formed  creatures,  possessing  in  miniature  all  the 
organs  of  the  adult.  There  thus  arose  two  schools, 
the  Animalculists  and  the  Ovists,  that  respectively 
maintained  the  efficacy  of  the  male  and  female 
products.  Nathanael  Highmore  (1613-1684),  a  phy- 
sician of  Shaftesbury,  England,  investigated  the 
testicle,  the  seminal  ducts,  and  the  epididymis. 
His  name  is  preserved  in  the  corpus  Highmorianum 
(mediastinum  testis)  and  the  antrum  of  Highmore 
(maxillary  sinus).  Wharton  described  the  round 
ligament  of  the  uterus  as  the  excretory  duct  for  the 
female  semen,  but  the  question  of  this  hypothetical 
product  was  finally  settled  by  Caspar  Bartholin,  who 
correctly    described    the    functions    of    the    vulvo- 


vaginal   glands.     The     mammalian     ovum     eluded 
research   for  a   long    time.     The    ovisacs    (Graafian 
follicles)  were  described  by  Etegnier  de  Graaf  (1641 
1673),  who  says  that  they  were  known  and  mentioned 

by  Vesalius  and  others.  He  supposed  them  at  first 
to  be  ova,  though  he  ei  m  later  to  have  had  a  correct 
idea  of  their  nature.  When  Naboth  discovered  the 
closed    follicles    of    the    luck    of    the    uterus,    he    too 

supposed  that  he  had  found  the  ova  (nvula  Nabothi). 
It  is  said  that  Van  Borne  I  1621-1670),  professor 
at  Leyden,  saw  the  ovum  in  Kills,  but  it  was  not 
definitely  and  unquestionably  recognized  until  von 
Baer  demonstrated  it  in  L827.  Nicolas  Andry  do 
Boisregard  (1658-1742)  was  the  first  to  note  the 
entrance  of  a  spermatozoon  into  an  ovum,  and 
believed  that  it  did  this  in  order  to  feed.  Antonio 
Vallisneri  (1661-1730),  professor  at  Padua,  held,  on 

the  contrary,  that  the  ovum  was  necessary  for 
generation,  and  supposed  the  spermatozoon  to  be 
unessential.  Needham  first  showed  that  the  fetus 
was  nourished  by  maternal  blood. 

In  the  nervous  system  considerable  advances  were 
made  during  this  period.  Although  Harvey  stated 
that  he  was  unable  to  discover  the  animal  spirits, 
yet  he  does  not  seem  to  have  been  able  wholly  to  free 
himself  from  the  influence  of  the  prevailing  doctrine. 
Ren£  Descartes  (Cartesius,  1596-16.50,)  the  eminent 
mathematician,  held  that  although  the  soul  was  im- 
manent throughout  the  whole  body,  it  must  be 
specially  centralized  in  the  pineal  gland,  that  being 
the  only  unpaired  organ  of  the  brain  and  situated  so 
as  effectually  to  control  the  animal  spirits  contained 
in  the  ventricles.  He  held  that  the  brain  is  the 
seat  of  sensation,  motion,  and  thought,  sensation 
being  due  to  impulses  transmitted  to  that  organ  by 
nerves,  motion  to  the  contraction  of  muscles  induced 
by  impulses  also  transmitted  by  the  nerves.  He  seems 
to  have  been  aware  of  reflex  action,  noting  that  sen- 
sation may  cause  motion  independently  of  the  will. 
He  thus  anticipated  discoveries  made  nearly  two 
hundred  years  later,  and  was  the  first  to  attempt  to 
explain  the  phenomena  of  life  by  purely  physical 
causes.  He  was  a  warm  adherent  of  Harvey's 
doctrine  of  the  circulation,  though  he  would  not 
admit  that  the  blood  was  impelled  by  the  action  of  the 
heart.  Johann  Jacob  Wepffer  (1620-1695)  was  the 
first  distinctly  to  deny  that  spirits  were  generated  in 
the  cavities  of  the  brain.  Pacchioni  considered  the 
dura  mater  as  an  organ  for  effecting  the  circulation  of 
the  spirits,  and  provided  it  with  three  muscles  and  four 
tendons. 

Francois  de  le  Boe  (Franciscus  Sylvius,  1614- 
1672),  professor  at  Leyden,  carefully  studied  the 
brain  and  gave  true  ideas  of  its  interior  spaces.  His 
name  is  preserved  in  the  aqueduct,  fissure,  fossa,  and 
artery  of  Sylvius.  The  fifth  ventricle  which  he 
discovered  is  sometimes  called  the  Sylvian  ventricle. 
Raymond  Vieussens  (1641-1715),  of  Montpellier, 
also  investigated  the  brain.  He  was  the  first  to 
describe  the  anterior  pyramids  of  the  medulla  oblon- 
gata, the  olive,  and  the  centrum  ovale.  His  name 
remains  in  the  valve  of  Vieussens  or  anterior  medullary 
velum.  Duverney  described  the  decussation  of  the 
pyramids  and  the  connection  of  the  jugular  sinuses 
with  the  jugular  vein;  while  Humphrey  Ridley 
(1653—1708)  described  the  restiform  body  and  the 
circular  sinus.  Malpighi  recognized  the  functional 
importance  of  the  gray  matter  of  the  brain,  and 
Burrhus  (1616-1695)  showed  that  one-fourth  of  the 
cerebral  substance  was  a  spermaceti-like  fat.  Much 
advance  was  made  by  the  investigations  of  Thomas 
Willis  (1622-1675),  professor  at  Oxford,  who  showed 
that  the  brain  gradually  increases  in  complexity  as  we 
ascend  the  animal  series,  and  considered  that  only 
by  comparative  studies  could  its  anatomy  be  prop- 
erly understood.  He  renamed  and  rearranged  the 
cranial  nerves,  separating  the  nervus  intercostalis  or 
sympathetic  from  the  vagus.     In  his  enumeration  he 


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made  ten  pairs,  including  the  first  cervical  nerve,  and 
classing  as  single  pairs  the  auditory  and  facial,  and  the 
glossopharyngeal,  vagus,  and  spinal  accessory.  He 
described  the  optic  thalamus  and  the  corpus  striatum. 

Osteology  continued  to  be  assiduously  cultivated. 
It  is  from  Ole  Worm  (158S-1054),  professor  at  Copen- 
hagen, that  the  Wormian  or  sutural  bones  are  named; 
and  Clopton  Havers  (1692),  an  English  physician, 
demonstrated  the  structure  of  bone  (Haversian  canals 
and  systems).  The  structure  and  action  of  muscles 
were  specially  investigated  by  Stensen,  by  Borelli 
(1608-1679),  the  celebrated  mathematician,  and  by 
Hooke.  (1635-1703),  who  was  the  first  to  recognize 
the  primitive  fibrillar. 

Knowledge  of  the  viscera  was  essentially  advanced 
by  John  Mayow  (1643-1679),  of  Oxford,  who  was  the 
first  to  recognize  the  true  function  of  the  lungs;  by 
Theodor  Kerckring  of  Amsterdam  (1640-1693),  who 
described  the  valvuke  conniventes  (plicae  circulares 
BNA)  of  the  intestine;  by  Jacques  Benigne1  Winslow 
(1669-1760)  of  Paris  (foramen  of  Winslow,  posterior 
ligament  of  knee  joint),  and  by  James  Douglas  (1675- 
1742)  of  London  (Douglas'  pouch  of  peritoneum, 
semilunar  fold,  etc.). 

The  eye  was  specially  examined  by  several  investi- 
gators, who  considered  it  because  of  its  interest  as  an 
optical  instrument.  Among  these  we  may  mention 
Johann  Kepler  (1571-1630)  the  astronomer,  who 
demonstrated  the  optical  properties  of  the  crystalline 
lens  and  showed  that  it  is  not  the  seat  of  vision,  as  was 
held  by  Hippocrates;  Christoph  Scheiner  (1575- 
1650),  who  demonstrated  the  image  on  the  retina  and 
studied  the  movements  of  the  pupil  and  the  mechanism 
of  accommodation;  Descartes,  who  compared  the 
eye  to  a  camera  obscura  and  suggested  that  accom- 
modation for  near  vision  was  effected  by  changing  the 
figure  of  the  lens;  and  Edme.  Mariotte  (1620-16S4), 
who  discovered  the  "blind  spot"  of  the  retina. 

Another  great  result  of  the  introduction  of  the  mi- 
croscope was  a  vast  increase  in  the  knowledge  of 
living  things.  The  source  of  life  and  the  "vital 
principle"  had  been  favorite  subjects  for  speculation 
among  the  philosophers  and  poets  of  antiquity,  and 
the  generation  of  living  from  non-living  matter  was 
held  to  be  demonstrated  by  many  ordinary  phe- 
nomena, such  as  the  appearance  of  maggots  in  putrefy- 
ing meat  and  of  other  insect  larva?  in  stagnant  water. 
Aristotle  even  held  that  tadpoles  and  snakes  were 
generated  from  the  mud  of  the  Nile.  As  the  laws  of 
development  were  more  carefully  studied  this 
"generatio  oequivoca"  was  controverted,  especially, 
in  the  case  of  the  chick,  by  Harvey  and  Fabricius. 
Francesco  Redi  (1626-1694),  professor  at  Pisa,  by  a 
scries  of  well-conducted  experiments,  showed  that 
meat  did  not  produce  maggots  when  protected  from 
flies  by  means  of  gauze.  The  doctrine,  discarded 
for  the  higher  forms  of  life,  was,  however,  revived  by 
the  discoveries  of  the  microscope.  Antony  van 
Leeuwenhoek  of  Delft  (1632-1723)  discovered  that 
stagnant  water  and  infusions  containing  animal  or 
vegetable  matter  swarmed  in  a  few  days  with  minute 
forms  of  life,  the  "infusoria."  Nicolaas  Hartsoeker 
(1656-1725)  extended  these  researches  and  held  that 
the  air  was  filled  with  animalculce  that  settled  upon 
plants  and  from  them  passed  into  infusions.  This 
view,  afterward  conclusively  demonstrated  by  Spal- 
lanzani,  became  known  as  "panspermatism"  and  is 
the  forerunner  of  the  modern  "germ  theory." 

The  eighteenth  century  was  distinguished  rather 
for  its  work  in  elaborating  and  defining  what  had 
previously  been  discovered  than  by  any  great  ad- 
vances in  anatomical  science.  A  few  remarkable 
men  appeared  who  advanced  generalizations  that 
were  afterward  to  bear  fruit,  but  they  were  in  advance 
of  their  time  and  had  but  little  influence  upon  their 
contemporaries.  The  microscope  was  still  very 
defective  and  felt  to  be  a  wholly  untrustworthy 
instrument     when    used    with     the    higher    powers. 


Speculation  was  rife,  and  in  the  absence  of  direct 
observation  philosophers  held  the  field.  Of  these 
should  be  mentioned  Leibnitz  (1646-1716),  who 
shares  with  Newton  the  renown  of  inventing  calculus. 
He  supposed  the  universe  to  be  composed  of  monads, 
minute,  invisible,  intelligent  constituents  of  all 
bodies  and  beings,  that  in  the  human  body  are  gov- 
erned by  a  central  monad,  the  soul;  as  the  universe 
is  governed  by  a  central  monad,  God.  He  was  a  firm 
believer  in  the  uniformity  of  action  of  natural  causes 
and  the  author  of  the  celebrated  aphorism,  "  Natura 
mm  facit  saltum."  Like  Paracelsus,  Georg  Ernst 
Stahl  (1660-1734)  scorned  anatomy  and  physiology, 
holding  the  soul,  which  eludes  investigation,  to  be 
the  supreme  principle.  This  doctrine  was  termed 
"animism."  Friedrich  Hoffmann  (1600-1742),  pro- 
fessor  at  Halle,  taught  that  the  medulla  oblongata  is 
the  chief  reservoir  of  collier,  an  extremely  volatile 
principle  circulating  through  the  vessels  and  nerves. 
David  Hartley  (1705-1757)  considered  the  white 
medullary  substance  of  the  brain  as  an  organ  for  the 
secretion  of  thought,  and  explained  mental  processes 
as  caused  by  minute  vibrations  (vibratiuncles)  of 
particles  in  the  nerves.  Cabanis  (1757-1808)  had  a 
similar  idea,  which  he  expressed  rather  grossly,  com- 
paring the  brain  to  the  stomach,  sense  impressions 
to  food,  thought  to  excrement,  etc.  Theophile  de 
Bordeu  (1722-1776)  considered  the  stomach,  heart, 
and  brain  as  the  "tripod  of  life,"  regulating  the  other 
organs.  Finally,  there  should  be  mentioned  among 
these  speculative  philosophers  Lorenzo  Oken  (1779- 
1851),  who  held  that  the  entire  organic  world  origi- 
nated from  sea  slime  formed  of  microscopically 
minute  vesicles.  This  is  apparently  an  adumbration 
of  Bathybius  and  the  cellular  theory,  but  appears  to 
be  only  a  chance  hit  not  derived  from  observation. 
Oken  also  independently  worked  out  a  theory  of  the 
veretebral  character  of  the  skull,  but  many  of  his 
speculations  were  wild  and  absurd. 

It  is  in  this  century  that  we  first  see  the  influence 
of  speculative  ideas  concerning  the  relation  of  the 
structure  of  man  to  that  of  other  organisms — ideas 
which  have  had  a  powerful  effect  upon  modern  ana- 
tomical science.  The  collection  of  materials  in  the 
field  of  biology  had  become  so  vast  that  some  system 
of  classification  became  necessary.  Steps  toward  this 
were  first  taken  in  the  realm  of  plants  by  John  Ray 
(1628-1705),  who  revived  the  Aristotelian  idea  of 
genera  and  species  and  established,  as  criteria  for 
species,  immutability  of  form  and  non-fertility  with 
other  species.  Tournefort  (1656-1708)  gave  a  clear 
definition  of  a  species  as  individuals  having  some  dis- 
tinct characteristic,  and  of  a  genus  as  a  collection  of 
species  resembling  each  other  in  structure.  It  was, 
however,  Karl  von  Linne1  (Linnaeus,  1707-177S),  of 
Rashult  in  Smaland,  Sweden,  professor  at  Upsala, 
who,  by  inventing  the  binomial  nomenclature  and 
applying  it  widely  to  all  known  species  of  animals 
and  plants,  finally  established  firmly  the  idea  of 
the  immutability  of  species.  He  even  extended 
his  system  of  classification  to  diseases,  of  which  he 
described  three  hundred  and  twenty-five  genera. 
His  earlier  view  was  that  all  the  species  of  plants 
and  animals  were  immutably  created  at  the  be- 
ginning of  the  world,  but  in  his  later  works  he  ap- 
pears to  admit  a  certain  amount  of  variation.  In  the 
classification  of  Linne  man  was  placed  at  the  head  of 
the  order  Primates,  comprising  also  apes,  lemurs,  and 
bats.  The  recently  discovered  orang  was  classified 
in  the  same  genus  with  man  as  "Homo  silvestris," 
and  the  great  naturalist  declares  himself  unable  to 
discern  any  character  by  which  the  great  apes  can  be 
made  genericallv  distinct  from  man.  The  race  of  man 
himself,  Homo  sapiens,  he  subdivided  into  six  groups: 
H.  fcrus  (savage);  H.  americanus;  H.  europceus;  H. 
asiaticus;  H.  asser(negroes) ;  H.  monstrosus  (abnormal). 

The  great  rival  and  contemporary  of  Linne1  was 
George  Louis  Leclerc  de  Buffon  (1 707-1 7S8),  director 


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\  li:itom>  '.    Illstnry  of 


if  the  Jardin  du  Roi  at  Paris,  and  a  very  prolific 
.vriter  in  all  domains  of  natural  history.  At  Brsl 
Buffon  agreed  with  Linne-  a-  to  the  immutability  of 
species,  but  in  his  studies  of  comparative  anatomy 
met  with  many  difficulties,  and  soon  admitted  thai 
uany  variations  may  arise  through  changes  of  climate, 
uod,  etc.;  that  t he  least  perfected  species  disappear: 
finally  he  even  hinted  at  the  possibility  that  all 

ies  of  animals  were  derived  fr a  common  stock. 

While  he  by  no  means  clearly  worked  out  these  ideas, 
contain  the  germs  of  the  doctrine  of  adaptation 
the  survival  of  t  he  tit  test,  and  it  is  evident  that  he 
realized  that  genera  and  species  are  merely  human 
ons   made   for   convenience   in    classification. 
In  like  manner  we  may  discern  in  Maupertuis  (1698- 
.   president   of  the  Berlin  Academy  and  a  cele- 
d  mathematician  and  astronomer,  an  approach 
ome  modern  theories  of  heredity  and  variation. 
Il<'  held  that  all  matter  has  psychic  qualities,  that  the 
particles  of  the  embryo  retain  and  transmit  impressions 
derived  from  their  parents,  chance  combinations  pro- 
ducing differences  which  accumulate  and  thus  form 
new    species.     It   was   Charles    Bonnet    (1720-1793) 
who   lirst   advanced    the   view   that   animals   can   be 
arranged  in  a  graded  series  with  man  at   the  head. 
His  conception  of  the  series  was  that  it  was  necessarily 
linear.     Erasmus    Darwin    (1731-1S02),    the    grand- 
father of  the  great  naturalist,  anticipated  some  of  the 
-    that    afterward   made   his   grandson   famous. 
He  showed  that  the  structure  of  animals  changes  be- 
se  of  their  exertions,  that  many  of  these  changes 
are  transmitted  to  posterityl  transmission  of  acquired 
characters),   and   that  many  anatomical  features  of 
man  indicate  that  his  primitive  attitude  was  quadru- 
pedal.    Reasoning  from  such  data,  he  maintained  that 
all  warm-blooded  animals  may   have  arisen  from  a 
single  living  filament  which  improved  and  transmitted 
its  improvements  to  posterity. 

The  poet  Goethe  (1749-1S32)  was  also  famous  for 
his  morphological  researches.  Besides  the  remark- 
able contribution  to  botany  in  which  he  advanced  the 
thesis  of  the  metamorphosis  of  leaves  into  parts 
of  the  flower  and  fruit,  he  also  suggested  that  the 
skull  of  vertebrates  is  composed  of  modified  vertebrae. 
He  recognized  the  importance  and  significance  of 
vestigia]  structures  and  predicted  that  a  premaxillary 
bone  would  be  found  in  the  human  fetus. 

Widely  different  from  these  philosophers  who  sought 
to  explain  the  complicated  structure  of  man  by  the 
at  ions  of  natural  forces,  were  the  views  of  the 
eminent  philosopher  and  metaphysician  Emmanuel 
Kant  (1724-1804),  who  held  that  a  great  gap  neces- 
sarily exists  between  organic  and  inorganic  matter, 
and  that  while  in  the  latter  natural  causes  prevail,  the 
former  is  the  product  of  preordained  intention,  be- 
yond the  power  of  man  to  comprehend. 

Closely  allied  with  these  theories  of  the  relation  of 
the  structure  of  man  to  that  of  other  animals  are 
others  regarding  his  individual  deve'opment.  The 
imperfections  of  the  microscope  and  of  technical 
methods  prevented  an  accurate  determination  of  the 
earlier  embryonic  stages,  and  it  was  imagined  that  all 
details  of  the  completed  structures  are  prefigured  in 
the  impregnated  ovum.  This  necessarily  involved 
the  conclusion  that  the  successive  generations  of 
offspring  must  also  be  prefigured  in  the  same  manner. 
Burden  accordingly  declared  that  the  semen  of  Adam 
must  have  contained  the  archetype  of  all  mankind. 
The  whole  of  the  past  and  present  organic  life  of  the 
globe  was  held  to  have  been  contained  in  miniature  in 
the  first  created  beings,  the  successive  individuals 
merely  developing  by  growth  from  these  preformed 
and  structurally  complete  miniatures.  This  is  the 
celebrated  theory  of  preformation  or  encasement  (cm- 
boitcment)  which  has  profoundly  interested  biologists 
for  the  past  one  hundred  and  fifty  years.  It  was  to 
this  unfolding  that  Bonnet  applied  the  term  evolution, 
a  meaning  widely  different  from  that  now  in  common 


use.    Tin'  great  weigh)  of  authority  at  lirst  favored 

this  view,  ami   the  celebrated   Albrechl    von   Haller 

1708— 1777),  professor  al  Berne  and  Gottingen,  a  most 

learned  and  acute  observer,  whose  reputation   v.  a 
greal     that     he    practically     controlled     the    scientific 

thought  of  the  latter  half  of  the  eighteenth  century, 
i  alculated  the  number  of  i      a  ed  in  the 

ovary  of  Eve,  the  mother  of  mankind,  placing  it  at. 
about  200,000,000,000. 

In  opposition  to  this  is  the  theory  of  post -format  ion 
01  i  pigenesis  advanced  by  Hippocrates  and  Aristotle, 
according  to  which  the  human  body  develops  from  a 
structureless  blastema  by  successive  stages  not  qi 

sarily  resembling  the  adult  individual.  This  view 
was  revived  by  Caspar  Friedrich  Wolff  (1733-1794), 
who  published,  in  17.V.I,  his  now  celebrated  thesis, 
"Theoria  Generationis,"  which  contained  an  account 
of  accurate  observations  showing  that  the  organs 
of  the  body  are  not  preformed  in  the  fetus,  but  devel- 
oped from  membranous  sheets  (the  blastodermic 
membranes  of  later  embryologists)  which  are  them- 
selves composed  of  globules  or  vesicles  (cells).  These 
ideas  were  not  accepted  by  the  anatomists  of  his  day. 
Opposed  to  them  was  the  great  authority  of  Haller, 
who  declared,  "Nulla  est  epigenesis,"  and  they  were 
quite  forgotten  until  fifty  years  later  when  Meckel 
called  attention  to  them.  Wolff's  name  remains  to 
us  in  the  Wolffian  bodies  or  primordial  kidneys. 

It  was  from  Haller  that  the  doctrine  of  the  vital  and 
animal  spirits  finally7  received  its  coup  de  grace.  By  a 
series  of  most  carefully  conducted  experiments  he 
showed  that  there  exists  in  living  tissues  a  property 
of  motility  independent  of  the  nervous  or  vascular 
systems.  This  he  termed  irritability.  Haller  is  often 
justly  termed  the  father  of  physiology,  which  he  him- 
self loved  to  call  living  anatomy.  His  works  abound 
in  most  excellent  anatomical  observations.  He  was 
an  indefatigable  worker,  dissecting  as  manyr  as  four 
hundred  bodies  in  the  space  of  seventeen  years.  He 
classified  structures  according  to  their  properties  and 
thus  paved  the  way  for  Bichat.  Many  structures 
have  been  at  one  time  or  another  named  after  him. 
He   was   the  first  to   describe   the  pes  hippocampi. 

The  doctrine  of  spontaneous  generation  continued 
to  be  discussed.  Antonio  Maria  Valsalva  (1666-1723) 
professor  at  Bologna,  a  pupil  of  Malpighi  and  a  teacher 
of  Morgagni,  finding  that  living  forms  still  appeared  in 
liquids  that  he  had  heated  and  then  enclosed  in  vessels, 
concluded  that  they  must  have  originated  from  the 
liquids  themselves;  but  this  was  overthrown  by  the 
experiments  of  Lazzaro  Spallanzani  (1729-1799), 
professor  at  Reggio,  Modena,  and  Pavia,  who  repeated 
the  experiments  with  careful  precautions  and  failed 
to  produce  life.  It  was  to  this  observer  that  we  owe 
the  demonstration  that  the  spermatozoa  are  the  con- 
stituents of  semen  essential  to  fertilization.  He 
showed  that  the  fluid  obtained  by  filtering  semen  has 
no  effect,  also  that  no  exhalations  from  semen  can 
cause  impregnation.  Thus  were  overthrown  some 
of  the  more  fanciful  hypotheses  of  generation. 

Throughout  the  eighteenth  century  we  find  isolated 
attempts  at  generalizing  the  complicated  structures 
of  the  body  under  a  few  categories.  Almost  equally 
famous  with  Haller  for  his  erudition  was  Hermann 
Boerhaave  (1668-1738),  professor  at  Leyden,  a 
skilful  anatomist  who  discovered  the  sudoriparous 
glands  of  the  skin,  and  held  that  the  elementary 
structures  composing  the  body  are  vessels  and  fibers. 
In  Andreas  Bonn  (173S-181S),  professor  at  Amster- 
dam, we  discern  a  decided  advance.  He  endeavored 
to  show  that  ail  structures  can  finally  be  reduced  to 
membranes.  Of  these  he  made  four  classes:  (1)  the 
tectorial — skin,  mucous  membrane,  etc.;  (2)  fibrous — 
fascia  and  aponeuroses;  (3)  synovial,  and  (4)  serous. 

The  real  founder  of  the  science  of  general  anatomy 
was,  however,  Marie  Francois  Xavier  Bichat  (1771- 
1S02)  who,  by  his  philosophical  insight  and  great 
energy  in  research,  demonstrated  the  existence  of  the 


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REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


tissues  of  the  body  in  a  complete  and  definite  manner. 
Distrusting  the  microscope,  he  made  his  distinctions 
by  the  chemical,  physical,  or  vital  properties  of  each 
tissue — i.e.  by  its  behavior  with  various  reagents; 
by  its  color,  density,  etc.;  or  by  its  alterations  in 
health  and  dN^ase.  Of  these  tissues  or  tissue  systems 
he  made  twenty-one,  such  as  the  cellular,  the  osseous, 
the  fibrous,  the  arterial,  etc.  As  these  tissues  are 
everywhere  the  same,  their  diseases  must  be  identical, 
hence  this  separation  is  a  proper  foundation  for 
pathological  anatomy.  He  considered  life  to  be  the 
composite  effect  of  the  separate  interaction  of  the 
forces  resident  in  these  tissues.  He  died  at  the  early 
age  of  thirty-one,  from  overwork  and  disease  con- 
tracted in  the  putrid  dissecting  rooms  of  his  day, 
having  effected  the  greatest  advance  in  anatomical 
knowledge  made  since  the  time  of  Vesalius. 

The  anatomy  of  diseased  organs  was,  prior  to 
Bichat,  specially  investigated  by  the  illustrious 
Giovanni  Battista  Morgagni  (1682-1771),  who  may 
be  said  to  be  the  founder  of  pathological  anatomy. 
He  was  likewise  an  ardent  investigator  in  the  normal 
field,  as  will  appear  from  the  large  number  of  struc- 
tures that  bear  his  name;  as  the  caruncula  Morgagni 
(middle  lobe  of  prostate),  frenum  Morgagni  (near 
ileocecal  valve),  fossa  Morgagni  (navicular  fossa  of 
urethra),  hydatids  of  Morgagni  (on  fimbria  of 
Fallopian  tube),  columns  of  Morgagni  (in  the  rectum), 
etc.,  etc. 

Closely  allied  to  pathological  anatomy  is  surgical 
anatomy,  which  made  many  important  advances. 
John  Hunter  ( 172S— lTO^),  an  indefatigable  investi- 
gator, is  said  to  have  dissected  some  thousands  of 
bodies.  It  is  to  him  that  we  owe  a  demonstration 
of  the  ease  with  which  collateral  circulation  is  estab- 
lished after  ligation  of  vessels,  and  the  reparative 
significance  of  inflammation.  He  also  appears  to 
have  been  aware  of  the  law  of  recapitulation  in  em- 
bryology, by  which  the  fetus  of  an  animal  successively 
passes  through  forms  resembling  creatures  below  it 
in  the  animal  scale.  During  thirty  years  he  worked 
at  collecting  a  museum  illustrative  of  comparative 
and  human  anatomy  and  pathology,  which  finally 
comprised  some  fourteen  thousand  specimens.  It  is 
still  considered  one  of  the  best  extant.  It  is  from 
him  that  is  named  the  canal  traversed  by  the  femoral 
artery  under  the  adductor  magnus. 

Other  workers  in  surgical  anatomy  were  Antonio 
Scarpa  (1752-1832),  professor  at  Modena  (Scarpa's 
triangle,  fascia,  nerve,  ganglion,  etc.);  Franz  Caspar 
Hesselbach  (1759-1816),  professor  at  Wiirzburg 
(Hesselbach's  triangle);  Antonio  de  Gimbernat 
(latter  part  of  18th  century),  professor  at  Barcelona 
(Gimbernat's  ligament-ligamentum  lacunare  BNA). 

Certain  beginnings  were  now  made  in  the  study  of 
the  comparative  anatomy  of  the  races  of  man.  Pieter 
Camper  (1722-1789),  professor  at  Amsterdam, 
Franeker,  and  Groningen,  was  a  widely  learned  man; 
at  once  an  anatomist,  a  zoologist,  a  geologist,  and  an 
artist,  he  published  in  almost  every  branch  of  natural 
history  essays  remarkable  for  their  originality  and 
research.  He  was  the  first  to  show  that  the  hollow 
bones  of  birds  are  connected  wdth  their  respiratory 
apparatus,  and  wrote  an  important  memoir  on  the 
anatomy  of  the  orang,  showing  that  that  animal 
could  not  be  considered  as  degenerated  from  man,  as 
had  been  supposed  by  some.  Noticing  that  painters 
took  no  pains  to  depict  the  special  physiognomy  of 
the  races  of  mankind,  he  began  to  study  racial  types 
and  invented  the  celebrated  "facial  angle,"  formed 
by  a  plane  tangent  to  the  most  prominent  points  of 
the  forehead  and  face  and  another  drawn  through  the 
auditory  openings  and  the  ate  of  the  nose.  He  found 
that  this  angle  gradually  decreases  as  we  descend 
througli  the  animal  kingdom,  and  concluded  that  the 
different  races  of  mankind  might  be  distinguished  by 
it.  A  wider  examination  has  shown  that  this  view 
is  incorrect,  but  the  method  instituted  by  him  of 

336 


measuring  portions  of  the  skull  by  means  of  angles 
has  been  extensively  used  in  other  directions. 

Another  famous  angular  measurement  was  that  of 
the  occipital  angle  of  L.  J.  M.  Daubenton  (1716-1799) 
the  curator  and  almost  the  creator  of  the  splendid 
museum  of  the  Jardin  des  Plantes.  This  was  intended 
to  measure  the  inclination  of  the  foramen  magnum 
which  also  varies  very  much  in  the  animal  scale,  and 
has  relation  to  the  erect  position  of  the  body. 

The  comparison  of  crania  was  systematically  pur- 
sued by  Johann  Friedrich  Blumenbach  (1752-1840) 
professor  at  Gottingen,  who  prescribed  for  the  exam- 
ination of  skulls  certain  positions  that  are  still  in  use. 
He  possessed  a  very  large  collection  of  crania,  and  made 
important  generalizations  regarding  the  races  of  men. 
While  considering  these  as  very  numerous,  he  grouped 
them  in  five  principal  divisions,  to  which  he  applied 
designations  that  held  for  more  than  a  century.  Three 
of  these  he  considered  primary:  the  Caucasian,  Mon- 
golian, and  Ethiopian;  two  secondary  or  intermediate: 
the  American  and  Malayan. 

Logically  connected  with  this,  although  not  devel- 
oped until  early  in  the  nineteenth  century,  was  the 
curious  doctrine  widely  known  as  "phrenology," 
though  its  founder,  Franz  Joseph  Gall,  of  Baden 
(1758-1828),  called  it  "organology."  Gall  was  by 
no  means  ignorant  of  the  gross  anatomy  of  the  brain, 
but  he  knew  nothing  of  its  histology  and  supposed 
the  white  substance  to  be  equally  active  with  the 
gray  in  intellectual  processes.  Noticing  the  conver- 
gent fibers  of  the  corona  radiata,  he  conceived  the  idea 
that  the  brain  was  a  series  of  pyramidal  "organs'' 
whose  bases  were  superficial  and  whose  apices  were 
deeply  buried  in  the  medulla  oblongata.  These 
organs  correspond  to  supposed  functions  of  the  mind, 
concerning  which  he  appears  not  to  have  had  any  well- 
digested  philosophical  ideas.  He  believed  that  he 
had  demonstrated  that  the  organs  varied  in  size 
and  external  prominence  in  different  individuals  to 
such  an  extent  that  character  and  mental  aptitudes 
could  be  told  by  palpation  of  the  protuberances  of 
the  cranium,  due  allowance  being  made  for  the  natu- 
ral bony  prominences  common  to  all  skulls.  Gall 
described  twenty-seven  organs,  his  pupil  Spurzheim 
added  ten  more,  and  his  followers  in  this  country 
increased  these  by  six,  making  a  total  of  forty-three. 
When  the  nerve  cells  were  discovered  and  it  was 
seen  that  the  gray  matter  was  the  effective  working 
element  of  the  brain,  and  that  the  surface  projecting 
externally  was  only  a  small  portion  of  the  cortical 
area,  phrenology  had  no  longer  a  satisfactory  reason 
for  existence  as  a  doctrine.  However,  it  retained  a 
considerable  vogue  for  a  time,  being  especially  diffused 
by  peripatetic  lecturers  whose  influence  in  spreading 
among  the  people  a  knowledge  of  the  physical  basis 
of  mind  was  often  considerable. 

A  correct  appreciation  of  some  parts  of  the  body  was 
now  greatly  aided  by  the  advancement  of  chemistry. 
Oxygen  was  discovered  by  Priestley  in  1774.  Its 
true  significance  was  not,  however,  understood  until 
the  demonstrations  of  Lavoisier  (1743-1794),  who 
showed  its  importance  in  combustion  and  respiration. 
Antoine  Francois  de  Fourcroy  (1755-1809)  was  the 
first  to  investigate  the  composition  of  organic  prod- 
ucts, and  William  C.  Cruikshank  (1745-1800)  dis- 
covered urea. 

The  delimitation  of  the  organs  of  the  body  in  the 
living,  which  may  be  said  to  be  an  anatomical  art, 
was  now  much  advanced  by  the  invention  of  per- 
cussion by  Joseph  Leopold  Auenbrugger  (1722-1S09), 
a  physician  of  Vienna. 

The  advances  made  in  the  knowledge  of  the  grosser 
structures  were  rather  refinements  upon  what  was 
already  roughly  sketched  out  than  incursions  into 
new  fields.  Josias  Weitbrecht  (1702-1747)  was  the 
author  of  a  celebrated  treatise  upon  syndesmology 
that  contains  the  elements  of  our  knowledge  of 
ligaments    to-day.     Exupere   Joseph    Bertin    (1712- 


REFEKKNCK    HANDBOOK    OF    THE    MEDICAL    SCIKNCES 


Anatomy,  History  of 


1781),  an  academician  of  Paris,  described  the  ilio- 
femoral ligament,  the  sphenoidal  turbinated  bones, 
and   the  septa  of  the   kidney.     Bernhard   Siegfried 
Ubinus   (Weiss,    10{.)7-177(>),    professor   at    Leyden, 
itly    improved    myology    by    the    publication   of 
ni'licvni    plates    showing    the    muscular    system 
lm,st  carefully  delineated.     He  was  also  the  first  to 
demonstrate  by  injections  the  relation  between  the 
[at    ystems  of  the  mother  and  the  fetus. 
In  the  vascular  system  considerable  advances  were 
made.     Gilbert    Breschet   (1784-1845)  described  the 
veins    and    canals    of    the    diploS;    William     Hunter 
(1718-1783).  brother  of  John  and  lecturer  at  Middle- 
go  pital,  demonstrated  the  arrangement  of  the 
lymphatics  and  showed  them  to  be  absorbents.     He 
llso  the  author  of  a  paper  on  the  anatomy  of  the 
id  uterus  which  is  the  basis  of  all  subsequent 
descriptions.     It  particularly  notes  the  changes  in  the 
cavity  and  the  formation  of  the  decidua.     He  care- 
fully described  the  descent  of  the  testes,  and  his  name 
is  often  coupled  with  the  round  ligament  of  the  uterus 
ami     the    gubernaculum     testis.     William     Hewson 
(1739-1774)   also   contributed   to   knowledge   of   the 
ils    and     lymphatics,     tracing    them    in    birds, 
3,    and    reptiles.     Paolo    Mascagni    (1752—1815) 
fessor   at    Siena,    Pisa,    and    Florence,    published 
studies  of  the  lymphatics  which  were  after- 
ward continued  by  Vincenz  Frohmann  (1794-1837), 
professor  at   Heidelberg  and  Louvain. 

In  the  realm  of  the  nervous  system  considerable 
lines  were  made.  Giovanni  Maria  Lancisi 
1654-1720),  the  teacher  of  Morgagni  and  physician 
to  I  he  Pope,  described  more  carefully  than  had  been 
■  before  some  features  of  the  brain  (nerves  of 
Lancisi  =  longitudinal  striae  of  corpus  callosum). 
Alexander  Monro  I.  (1097-1767),  one  of  Boerhaave's 
favorite  pupils,  professor  at  Edinburgh,  gave  an 
excellent  description  of  the  bones  and  nerves;  but 
his  fame  was  eclipsed  by  that  of  his  son,  Alexander 
Monro  II.  (1733-1817),  also  professor  at  Edinburgh, 
who  was  especially  noted  for  his  work  in  the  anatomy 
> >f  the  brain  (foramen  of  Monro  =  foramen  inter- 
ventriculare,  sulcus  of  Monro  =  sulcus  hypothal- 
amicus).  He  was  the  first  to  attempt  a  description 
of  all  the  bursa?  mucosae  of  the  body.  Felix  Vicq 
d'.Vzyr  (174X-1794),  an  academician  of  Paris,  demon- 
strator at  the  Jardin  du  Roi,  and  excellently  versed 
in  comparative  and  veterinary  anatomy,  also  studied 
the  brain  and  added  to  our  knowledge  of  the  minute 
structure  of  the  white  and  gray  matter  (line  and 
bundle  of  Vicq  d'Azyr).  Johann  Christian  Reil 
1 1759-1813)  first  described  the  insula  or  island  of  Reil. 
Luigi  Rolando  (1773-1831),  professor  at  Turin, 
distinguished  himself  by  careful  researches  in  both 
the  brain  and  spinal  cord  (fissure,  gelatinous  sub- 
stance, and  tubercle  of  Rolando). 

The  cranial  nerves  received  renewed  attention. 
It  was  Johann  Jacob  Huber  (1707-1778),  professor 
al  Gottingen  and  Cassel,  who  clearly  pointed  out  the 
error  of  Willis  in  placing  the  suboccipital  nerve 
among  the  cranial  nerves,  though  Haller  also  com- 
mented upon  this.  Carl  Samuel  Andersch  (1732- 
1777)  distinguished  from  each  other  for  the  first  time 
the  ninth,  tenth,  and  eleventh  nerves,  and  discovered 
the  petrous  ganglion.  Samuel  Thomas  Sommering 
(1755-1830)  is  credited  with  being  the  first  to  sepa- 
rate the  facial  and  the  auditory  nerves,  thus  estab- 
lishing the  twelve  cranial  nerves  as  we  now  enumerate 
them.  This  enumeration,  however,  was  really  first 
definitely  proposed,  in  1794,  by  Johann  Christoph 
Mayer  (1747-1801).  The  little  intermediary  nerve 
that  makes  the  tale  of  the  cranial  nerves  absolutely 
complete  was  first  described  by  Heinrich  August 
Wrisberg  (1739-1808),  professor  in  Gottingen,  who 
also  made  other  discoveries,  his  name  remaining  in  the 
medial  cutaneous  nerve  of  the  arm,  in  the  cuneiform 
cartilages  of  the  larynx,  and  in  a  small  ganglion  in  the 
substance  of  the  heart. 

Vol.  I.— 22 


Johann  Friedrieh  Meckel  (1721-1771),  the  In  I 
in   a   succession   of   famous   anatomists   of    the  name, 

professor  at  Berlin,  gave  especial  attention  to  the 
trigeminus  and  facial  nerves  and  was  the  first  to 
describe  the  sphenopalatine  and  submaxillary 
ganglia  and  the  space  in  the  dura  mater  that  con- 
tains the  semilunar  ganglion  of  the  trigeminus.  The 
latter  struct  ure  appears  to  have  been  firsl  recognized 
as  a  ganglion  by  .1.  Lorenz  Gasser,  of  Vienna,  about 
17"i(l.  Meckel  had  previously  described  it  as  a 
tenia  nervosa,  and  Vieussens  as  a  plexus  ganglioni- 
formis,  and  Eustachius  had  figured  it  in  his  cele- 
brated plates.  It  was  named  by  Hirsch  as  the  gang- 
lion Gasserianum,  in  honor  of  his  illustrious  master. 

The  tympanic  nerve  and  the  superior  ganglion  of 
the  glosso-pharyngeal  nerve  were  first  described  by 
Johann  Ehrenritter  (about  1775),  professor  at  Vienna, 
although  from  the  exact  researches  of  L.  L.  Jacobson 
(1783-1843),  professor  at  Copenhagen,  the  nerve 
usually  bears  his  name.  To  the  latter  author  is 
also  ascribed  the  discovery  of  the  vomeronasal 
organ  in  the  nasal  fossa-  of  the  sheep  and  of  its 
vestiges  in  man. 

A  physiological  discovery  of  much  importance  in  the 
elucidation  of  the  anatomy  of  the  nervous  system  was 
that  of  the  distinction  between  the  motor  and  the 
sensory  roots  of  the  spinal  nerves  made  by  Georg  Pro- 
chaska,  (1749-1S20),  professor  at  Prague.  This  was 
afterward  clearly  established  by  Magendie  (1783- 
1855)  and  by  the  Edinburgh  anatomist,  Sir  Charles 
Bell  (1774-1S42),  who  also  showed  conclusively 
the  motor  function  of  the  facial  nerve.  The  long 
thoracic  nerve  is  often  called  the  external  respira- 
tory nerve  of  Bell. 

In  the  anatomy  of  the  viscera  there  should  be  men- 
tioned the  investigations  of  Lorenz  Heister  (1083- 
1758),  professor  at  Altorf  and  Helmstadt,  who  dis- 
covered the  spiral  valve  in  the  neck  of  the  gall-bladder; 
Antoine  Ferrein  (1693-1709),  professor  at  Paris, 
who  investigated  the  kidney  and  the  organs  of  voice; 
Joseph  Lieutaud  (1703-1780),  who  described  anew 
the  bladder,  mentioning  for  the  first  time  the  trigone. 
He  was  famous  in  pathological  anatomy,  publishing 
a  work  based  on  the  examination  of  twelve  hundred 
bodies.  Johann  Nathanael  Lieberkiihn  (1711-1765) 
was  famous  for  injected  preparations  and  made 
some  excellent  observations  on  the  minute  anatomy 
of  the  intestinal  mucous  membrane,  including  the 
villi  and  glands.  Johann  Christian  Rosenmiiller 
(1771-1820),  professor  at  Leipsic,  investigated  the 
nasal  fossce  and  the  annexes  of  the  uterus.  The 
anatomy  of  the  vocal  organs  was  also  investigated 
by  Denis  Dodart  (1634-1707),  who  held  that  the 
voice  was  caused  by  a  vibration  of  the  air  in  the  larynx, 
while  Ferrein  held  that  it  was  due  to  a  vibration  of 
the  vocal  chords.  Giovanni  Domenico  Santorini 
(1081-1737)  also  paid  especial  attention  to  the 
organs  of  voice,  to  the  emissary  veins  of  the  cranium, 
and  to  the  muscles  of  the  face  (corniculate  cartilage 
of  the  larynx,  emissaria  Santorini,  musculus  riso- 
rius  Santorini  of  the  face). 

The  anatomy  of  the  eye  was  especially  enriched  by 
important  discoveries  during  this  period.  Francois 
Pourfour  du  Petit  (1604-1741)  paid  especial  attention 
to  the  lens  and  described  the  zonular  spaces  in  the 
suspensory  ligament,  often  called  the  canal  of  Petit. 
Jacob  Hovius,  a  Dutch  anatomist  (about  1702), 
appears  to  have  discovered  the  choriocapillary  layer 
of  the  chorioid,  afterward  accredited  to  Ruysch 
(tunica  Ruyschiana).  He  also  described  the  vena? 
vorticosas.  Eberhard  Jacob  von  Wachendorff  dis- 
covered the  pupillary  membrane  in  1740,  though  it 
is  possible  that  it  may  have  been  previously  known 
to  Albinos.  Jacques  Rene1  Tenon  (1724-1816),  an 
academician  at  Paris,  described  the  fascial  attach- 
ments of  the  eyeball  more  accurately  than  had  been 
heretofore  done  (capsule  of  Tenon  =  fascia  bulbi, 
space  of  Tenon  =  interfaseial  space).     In  some  cases 

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controversies  arose  as  to  priority  of  discovery:  the 
separable  posterior  elastic  layer  of  the  cornea,  which 
was  apparently  seen  and  described  by  Benedict 
Duddell,  an  oculist  of  London  in  1729,  was  rediscovered 
by  Jean  Descemet,  professor  at  Paris  (1732-1810), 
and  at  about  the  same  time  by  Pierre  Demours 
(1702-1795),  demonstrator  at  the  Jardin  du  Roi. 
The  most  important  treatise  on  the  anatomy  of  the  eye 
that  appeared  during  the  18th  century,  and  the  basis 
of  all  that  has  since  been  published,  is  that  of  Johann 
Ciottfried  Zinn  (1727-1759),  professor  at  Gottingen 
(zonule  of  Zinn  =  ciliary  zonule,  ligament  of  Zinn  = 
common  tendinous  ring  of  ocular  muscles).  Felice 
Font  ana  (1730-1805),  professor  at  Pisa,  described 
the  attachment  of  the  iris  and  the  trabecular  tissue 
since  known  as  the  spaces  of  Fontana  (spaces  of  the 
angle  of  the  iris  BNA).  Johann  Gottfried  Berger 
(1059-1736)  was  probably  the  first  to  indicate  the 
existence  of  the  orbicular  fibers  of  the  iris. 

The  profound  and  exact  researches  in  the  anatomy 
of  the  internal  ear  made  by  Domenico  Cotugno  (Cotun- 
nius,  1736-1822),  professor  at  Naples,  were  probably 
the  most  significant  of  any  made  in  this  region  during 
the  century.  He  also  investigated  the  pathological 
anatomy  of  the  skin,  and  was  the  first  to  demonstrate 
by  boiling  the  existence  of  albumin  in  urine.  His 
name  remains  in  the  liquor  of  Cotunnius  or  perilymph, 
the  aqueduct  of  Cotunnius  (aqueductus  vestibuli), 
and  the  nerve  of  Cotunnius  (nasopalatine  nerve). 

The  great  advance  in  the  anatomical  sciences  during 
the  nineteenth  century  has  been  primarily  due  to 
what  may  be  termed  their  secularization,  that  is  to 
say,  to  the  extension  of  research  by  placing  it  in  the 
hands  of  all  students  inclined  to  pursue  it.  At  the 
beginning  of  the  century  the  old  method  of  teaching 
by  means  of  demonstration  was  still  almost  every- 
where pursued.  Students  were  rarely  able  to  dis- 
sect, and  the  procuring  of  bodies  for  anatomical 
purposes  was  beset  with  difficulties.  In  1S27  the 
University  of  Edinburgh,  with  nine  hundred  students, 
made  dissection  compulsory,  and  this  excellent 
example  was  immediately  followed  by  London,  Liver- 
pool, and  Dublin. 

In  consequence  of  this  the  demand  for  human 
cadavers  was  greatly  increased  and  the  price  so  en- 
hanced that  unscrupulous  persons  were  tempted 
to  procure  them  by  surreptitious  means.  Grave- 
robbing,  hitherto  exceptional,  now  became  common, 
and  in  every  large  city  where  medical  schools  flourished 
there  became  established  a  set  of  ruffians  who 
made  it  their  business  to  supply  dissecting  tables 
with  bodies  ruthlessly  torn  from  the  graves  to  which 
they  had  been  consigned  by  sorrowing  friends.  The 
large  iron  cages  built  over  many  graves  and  the  for- 
midable enclosures  of  cemeteries  of  this  period  in 
England  and  Scotland  testify  to  a  widespread  fear, 
and  a  glance  at  the  literature  of  the  early  part  of 
this  century  will  show  what  an  effect  this  ghastly 
practice  had  upon  the  popular  mind.  It  would  be 
easy  to  give  many  authentic  examples  which  were 
not  confined  to  disreputable  law-breakers;  for,  led  by  a 
youthful  love  for  adventure  or  perhaps  in  some  cases 
by  a  real  zeal  for  knowledge,  bands  of  students  and 
even  of  professional  men  broke  into  cemeteries  and 
violated  graves.  The  law  required  of  medical  practi- 
tioners a  competent  knowledge  of  anatomy,  and  yet 
denied  them  the  means  necessary  for  attaining  it. 

The  absurdity  of  such  a  position  was  not  realized 
until  the  shocking  disclosures  of  the  trial  of  Burke 
and  Hare  at  Edinburgh  in  December,  1828.  It 
was  shown  that  these  scoundrels  had  murdered  at 
least  sixteen  persons  for  the  purpose  of  selling  their 
bodies.  Similar  cases  were  those  of  Bishop  and 
Williams,  executed  in  London  in  1831.  Bishop  had 
followed  his  nefarious  trade  for  twelve  years,  and  had 
sold  to  the  colleges  at  least  five  hundred  bodies,  some 
of  which  were  doubtless  those  of  murdered  victims. 
The  excitement  occasioned  by  these  trials  led  to  a 


parliamentary  inquiry  and  the  passage  of  the  War- 
burton  anatomy  act,  August  1,  1832,  which  legalized 
dissection  under  certain  restrictions  and  provided 
for  turning  over  to  the  medical  schools  the  bodies  of 
unclaimed  paupers.  Upon  the  continent  of  Europe 
similar  regulations  had  already  been  for  some  time 
established. 

The  cooperation  of  a  large  number  of  additional 
workers  led  to  greater  precision  in  all  anatomical 
work,  to  the  accumulation  of  a  vast  body  of  additional 
facts,  and  finally  to  a  more  comprehensive  and  satis- 
factory generalization  of  the  principles  that  underlie 
and  affect  anatomical  structure.  The  idea  of  the 
filiation  and  progressive  development  of  all  organic 
beings — considered  a  wild  and  unsubstantial  hypothe- 
sis_  during  the  eighteenth  century — has  constantly 
gained  in  weight  and  force  by  increasing  knowledge 
of  existing  forms — comparative  anatomy;  of  extinct 
forms — paleontology;  and  of  individual  development 
— embryology.  This  increase  in  knowledge  has  been 
greatly  aided  by  improvement  in  the  microscope, 
which  has  become  an  efficient  and  reliable  instrument 
of  research,  and  by  the  application  of  chemical 
and  mechanical  methods  to  the  preparation  of  (is- 
sues for  microscopical  examination,  which  met  I: 
are  grouped  together  under  the  term  of  microscopical 
technology. 

Fragments  from  the  writings  of  some  of  the  ancient 
philosophers,  notably  Empedocles  and  Democritus, 
show  that  ideas  of  adaptation  and  mutability  of 
forms  had  occurred  to  them.  So,  too,  we  find  traces 
of  such  speculations  in  the  writers  of  the  last  century: 
Buffon,  Erasmus  Darwin,  and  Goethe.  These  ideas 
were  developed  into  a  coherent  system  by  Jean 
Lamarck  (1774-1829),  professor  of  natural  history 
at  the  Jardin  des  Plantes  and  one  of  the  most  acute 
minds  of  his  age.  His  force  as  a  naturalist  will  be 
appreciated  when  we  recall  that  we  owe  to  him  the 
division  of  animals  into  vertebrates  and  invertebrates, 
and  also  the  separation  of  the  groups  Crustacea, 
arachnida,  and  annelida.  He  invented  the  term 
biology  for  the  sciences  of  life,  though  Treviranus 
suggested  it  during  the  same  year  (1802).  In  his 
"  Philosophie  zoologique"  is  first  scientifically  stated 
and  systematically  supported  the  mutability  of  species 
and  their  origin  by  adaptation.  Lamarck  thought 
that  such  changes  were  caused  mainly  by  the  needs 
of  the  animal  and  the  use  and  disuse  of  organs,  be- 
coming cumulative  in  the  race  by  the  transmission 
of  acquired  characters.  For  these  changes  three 
factors — space,  time,  and  matter — are  requisite; 
and  these  are  produced  by  nature  in  unlimited 
quantities,  hence  the  multiplicity  of  organic  forms. 
He  was  the  first  to  conceive  the  ancestral  record  of 
man  as  a  branching  tree  instead  of  a  series  of  ascend- 
ing steps.  The  formation  of  the  lowest  animal 
from  mucilaginous  matter  was  suggested  by  him, 
prior  to  Oken's  sea-slime  theory. 

The  views  of  Lamarck,  although  widely  accepted  in 
a  modified  form  by  the  naturalists  of  to-day,  were 
very  coldly  received  at  that  time.  This  was  largely 
due  to  the  powerful  opposition  of  Georges  Cuvier 
(1769-1832),  professor  at  the  Musee  d'Histoire  Nat- 
urelle  at  Paris,  and  the  foremost  naturalist  of  his  time. 
He  greatly  advanced  knowledge  of  both  living  and 
extinct  forms  of  animal  life  and  has  been  called  (he 
founder  of  comparative  anatomy  and  of  paleontology. 
From  a  modern  point  of  view  his  work  is  most  con- 
tradictory. While  he  founded  a  true  natural  system 
in  zoology,  showing  that  the  forms  of  the  animal 
world  may  be  reduced  to  a  few  distinct  types,  he  yet 
upheld  the  absolute  fixity  of  species.  While  investi- 
gating fossil  remains  with  an  ardor  and  success 
never  before  equalled,  he  advanced  the  theory  that 
all  organic  living  forms  had  been  repeatedly  wiped 
out  of  existence  by  unexplained  cosmic  catastrophes. 
In  opposition  to  the  epigenetic  views  of  Wolff  and 
others,  he  also  upheld  the  evolution  of  the  embryo 


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Anatomy,  History  nf 


•om  a  preformed  miniature.     Throwing  the  weight 

f  his  great  influence  against  the  development  theory, 

e  was  able,  owing  to  the  lack  of  data,  to  discredit 
almost   wholly,  and  to  control  the  trend  of  biolog- 

■al  thought,  until  after  the  middle  of  the  century. 
A  growing  revolt  against  this  domination  was,  how- 

ver,  caused  by  the  advances  of  knowledge.     Gott- 

["reviranus  of  Bremen  t,177<i— ls;;7j  was  among 

hose   who   protested   against   making   the   biological 

noes  a  mere  catalogue  of  names,  as  was  don.    I  n 

.inne  and  Cuvier,  holding  that  it  is  possible  to  dis- 

over   a    philosophy   of    nature.     He   suggested    the 

heory  of  compensatory  development,  deficiency  in 

me  part    being   made   up  b\'  excess  in  another,   and 

gnized    that    the   environment   reacts   upon    the 

udividual.     The    wider    and     more'  complex     the 

•nvironment  the  higher  must  be   the  grade  of  the 

irganism. 

Eiienne  Geoffroy  St.  Hilaire  (1772-1S44),  professor 

it  /oology  at  t lie  Jardin  des  Plantes,  and  the  author  of 

ukable  treatises  on  teratology  and  philosphical 

inatomy,   was  also  an  opponent  of  Cuvier's  views. 

lie  held  that  the  principal  factor  in  the  transformation 

vies  i-i  changing  environment,  acting  particularly 

mgh  its  effect  upon  respiration.     His  teratological 

lies  led  him  to  conclude  that  the  course  of  develop- 

inent  of  organic  forms  is  not  necessarily  gradual,  but 

that  sudden   and   considerable   changes  may   occur, 

thus  opposing  the  Leibnitzian  doctrine  in  favor  of  so- 

I  "saltatory "  evolution. 

A   collateral   influence   in   favor   of  uniformity   of 

action  was  afforded  by  Sir  Charles  Lyell  (1797-1875), 

who  by  a  cogent   marshalling  of  ascertained   facts 

inally  overthrew   (1S30)   the  Cuvierian  doctrine  of 

catastrophes  in  geology.     He  also  published  in  1S63 

an   important   treatise  on  the  "Antiquity  of  Man," 

in  which  he  showed  that  human  remains  are  found  in 

the  strata  of  quarternary  or  perhaps  earlier  times, 

I  hat  they  in  general  indicate  a  lower  organization 

than  that  of  modern  Europeans. 

Advances  in  knowledge  of  embryological  develop- 
ment continued  and  afforded  support  to  the  new 
hypotheses.  Johann  Friedrich  Meckel  (17S1-1S31), 
professor  in  Halle,  grandson  of  the  previous  anato- 
mist of  the  same  name,  called  to  notice  the  forgotten 
writings  of  Wolff,  and  himself  made  important  observ- 
ations. To  him  is  due  the  discovery  of  Meckel's 
cartilage  in  the  embryonic  lower  jaw,  and  of  Meckel's 
diverticulum,  the  vestigial  stem  of  the  omphalomes- 
enteric duct.  He  seems  to  have  been  the  first  clearly 
to  formulate  what  is^now  known  as  the  law  of  recapitu- 
lation, stating  that  the  original  form  of  all  organ- 
isms is  the  same,  and  that  in  process  of  development 
the  higher  assume  as  transitory  stages  the  perma- 
nent forms  of  the  lower.  This  was  even  more  defi- 
nitely stated  by  Serres  (1842)  in  his  "  Precis  d'anat- 
oniie  transcendente,"  who  declared  comparative 
anatomy  to  be  an  arrested  embryology,  and  embryol- 
ogy a  transitory  comparative  anatomy.  Haeckel 
calls  this  the  "fundamental  biogenetic  law,"  and 
states  it  thus:  "Ontogeny  is  a  short  and  quick 
repetition  or  recapitulation  of  phylogeny,  determined 
by  the  laws  of  inheritance  and  adaptation." 

Under  the  influence  of  Ignatz  Dollinger,  of  Wiirz- 
burg,  who  was  an  ardent  embryologist,  and  who 
revived  the  use  of  the  microscope,  arose  Christ. 
Pander  (1794-1865),  who  studied  the  development 
of  the  chick  and  confirmed  Wolff's  theory  of  the  ger- 
minal layers,  and  Carl  Ernst  von  Baer  (1792-1876), 
professor  in  Dorpat,  St.  Petersburg,  and  Konigs- 
berg,  who  discovered  the  mammalian  ovum  and  the 
chorda  dorsalis.  He  pointed  out  that  the  develop- 
ment of  the  individual  is  an  advance  from  a  gener- 
alized to  a  more  specialized  form,  and  brought  the 
theory  of  the  blastodermic  layers  to  nearly  its  pres- 
ent condition. 

The  correction  of  chromatic  and  spherical  aberra- 
tion in  the  microscope  was  finally  practically  effected 


about     1824,    and    the    instrument     wag    BOOD    Used    in 

research  with  more  certain  results  than  had  In:: 
been  possible.  This  led  to  a  reinvestigation  oi  the 
tissues  of  the  body  and  the  formulation  of  the  impor- 
tant doctrine  known  as  the  cell  theory.  That  organic 
forms  had  for  their  basis  minute  elementary  units 
had  been  suspected  by  many  observers,  especially 
in    the    domain    of    vegetal    anatomy,    the    cellular 

structure  of  plaids  being  more  apparent  than  that 
of  animals.  The  speculations  of  the  Greek  philo  ci- 
phers in  this  field  were  wholly  metaphysical,  and  it 
was  not   until  alter  the   invention  of  the   microscope 

(1665)  that  Robert  Hooke  first  saw  and  figured  tne 
structure  of  cork  as  a  series  of  minute  honeycomb- 
like cavities,  to  which  lie  applied  the  name  of  cells. 
In  11171,  Crew  and  Malpighi  separately  presented  to 
the  Royal  Society  of  London  papers  advancing  the 
view  that  plants  are  composed  of  vesicles  with  fluid 
contents  and  rigid  walls,  and  of  vessels  or  tubes. 
Wold'  (1759)  supposed  the  primitive  elements  of 
plants  to  be  gelatinous  globules  or  droplets;  Molden- 
hawer  (1812)  showed  that  each  plant  cell  has  its 
own  distinct  wall;  Turpin  (1S26)  held  that  each  has 
an  individuality  of  its  own;  Leeuwenhoek,  Eontana, 
and  others  appear  to  have  seen  the  cell  nucleus, 
while  Robert  Brown  (ls:;i)  was  the  first  to  recog- 
nize it  as  a  constant  normal  constituent.  Schleiden 
(1838)  considered  the  nucleus  to  be  the  generator 
of  the  cell,  calling  it  the  cytoblast,  and  also  showed 
that  all  parts  of  plants  are  composed  of  cells  or  their 
derivatives.  Dutrochet,  as  early  as  1824,  advanced 
the  idea  that  animals  and  plants  are  composed  of 
cells,  but  it  was  reserved  for  Theodor  Schwann  (1810- 
1882),  professor  at  Louvain,  to  demonstrate  this  in  a 
satisfactory  manner  in  1838-39.  At  this  time  a  cell 
was  supposed  to  be  a  hollow  vesicle  having  a  wall 
and  a  cavity  containing  fluid. 

The  constitution  of  the  cell  now  received  attention. 
The  name  sarcode  was  applied  by  Dujardin  (1S35)  to 
the  gelatinous  matter  composing  the  body  of  rhizo- 
pods,  while  a  similar  substance  in  plants  was  called 
by  Mirbel  cambium,  by  Schleiden  mucilage,  and 
finally  by  Hugo  von  Mohl  protoplasm,  a  term  pre- 
viously used  by  Purkinje  for  the  formative  tissue  of 
young  embryos.  The  practical  identity  of  these 
substances  was  shown  by  Max  Schultze  and  De  Bary, 
and  the  name  protoplasm  was  henceforth  used  for  the 
active  living  matter  of  both  plant  and  animal  cells. 

Further  observation  of  young  cells  now  showed  not 
only  that  they  had  no  permanent  cavity,  but  that  the 
cell  wall,  supposed  by  earlier  observers  to  be  essen- 
tial, was  often  absent.  Reduced  to  its  simplest 
expression  the  definition  of  a  cell  was  then  formulated 
by  Leydig  (1856)  as  "a  mass  of  protoplasm  provided 
with  a  nucleus." 

Schwann  and  the  earlier  observers  believed  that 
cells  originate  in  a  structureless  blastema  as  crystals 
form  in  a  mother  liquor.  Cellular  division  was  first 
observed  by  Mohl  in  alga?  (1835),  in  other  plants 
and  in  animals  by  Nageli,  Kolliker,  and  Bischoff, 
and  others,  and  finally,  in  1855,  Virchow  was  able  to 
formulate  his  famous  maxim,  "  Omnia  ccllula  c  ccllula," 
which  had  been,  however,  anticipated  by  Goodsir, 
who  declared  in  1845,  "No  cells  without  preexisting 
cells." 

The  phenomena  of  embryology  were  now  brought 
under  the  category  of  cell  division.  The  ovum  was 
recognized  as  a  cell  by  the  immediate  followers  of 
Schwann,  with  the  "germinal  vesicle"  of  Purkinje 
(1825)  as  its  nucleus.  The  segmentation  of  the  ovum, 
first  definitely  described  (in  frog's  eggs)  byPrevost 
and  Dumas  (1824),  was  now  seen  to  be  a  case  of  cell 
division.  Ova  were  already  known  to  develop  from 
the  body  of  the  mother — a  similar  development  was 
shown  for  the  spermatozoa  by  Kolliker  ( 1 S4 1).  The 
structure  of  the  body  was  thus  shown  to  depend  upon 
cells  derived  from  the  parents. 

The  resemblance  of  infusoria  to  cells  was  first  noted 


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Anatomy,  History  of 


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by  Meyer  in  1S39,  and  in  1845  Siebold  classed  them  as 
unicellular  beings,  naming  them  protozoa. 

The  cell  theory  as  formulated  by  Schwann  and  his 
immediate  successors  may  then  be  formulated  as 
follows: 

1.  All  organized  beings,  including  man,  are  com- 
posed of  minute  microscopical  units  that  have  inde- 
pendent life  and  multiply  by  division. 

2.  The  primitive  form  of  each  individual,  as  well  as 
the  permanent  form  of  the  lowest  creatures,  is  a  single 
cell. 

The  influence  of  this  doctrine  upon  all  departments 
of  anatomy  was  very  great.  The  human  body  was 
wholly  reexamined  to  ascertain  the  arrangement  and 
relations  of  its  elements.  Thus  the  department  of 
histology  became  elevated  to  a  high  rank,  affording 
scope  for  thousands  of  investigators.  In  patholog- 
ical anatomy  also  great  advances  were  made,  and 
the  investigation  of  disease  was  placed  upon  a  sound 
scientific  basis.  In  this  field  Rudolph  Virchow,  by 
the  publication  of  his  classical  treatise  "Cellular 
Pathology,"  performed  most  valuable  service. 

Hand-in-hand  with  the  investigation  of  the  anatom- 
ical constitution  and  the  relations  of  cells  proceeded 
the  development  of  technical  methods  and  the  dis- 
covery of  the  behavior  of  cells  toward  various  re- 
agents. These  have  greatly  aided  microscopical 
research,  and  account  in  a  very  large  measure  for  the 
immense  progress  in  this  field  as  compared  with  any 
previous  period  of  equal  extent.  In  1842  Stilling 
invented  the  cutting  of  thin  serial  sections  which 
can  be  examined  by  transmitted  light.  By  this 
means  it  became  possible  to  reconstruct  the  interior 
fabric  of  the  most  delicate  organs.  By  the  improved 
instruments  of  recent  times  there  can  now  be  cut 
sections  as  thin  as  from  5  ft  to  1  fi  ( rtfW  t°  2iffonx  of  an 
inch).  The  clearing  and  mounting  of  sections  was 
invented  by  Lockhart  Clarke  in  1851,  hardening  by 
dehydration  with  absolute  alcohol  by  H.  Miiller  in 
1856.  These  at  once  greatly  facilitated  manipulation 
and  a  wider  study  of  microscopical  preparations. 
The  immediate  result  was  the  discovery,  by  Remak 
and  Deiters,  of  the  processes  of  nerve  cells.  Carmine 
staining  was  invented  by  Gerlach  in  1858,  and  led  to 
knowledge  of  nuclear  structure  and  the  discovery 
of  nuclei  where  none  had  been  hitherto  suspected. 
Silver  staining  in  solution  appears  to  have  been  first 
invented  by  von  Recklinghausen  in  I860,  although 
staining  by  the  solid  stick  had  been  previously  used 
by  His  and  others;  it  led  to  a  clearer  knowledge  of 
cell  boundaries  and  contents.  The  staining  by  aniline 
dyes  and  the  method  of  double  staining  were  first  ap- 
plied by  Waldeyer  in  1S63,  and  led  to  important  ad- 
vances in  knowledge  of  cell  structure  and  cell  divi- 
sion. Max  Schultze,  in  1S65,  first  devised  staining 
by  perosmic  acid,  which  resulted  in  clear  concep- 
tions of  the  medullary  sheath  of  nerve  fibers.  Other 
means  of  differentiating  nervous  tissue  were  found  in 
the  gold  stain  of  Cohnheim  (1S66),  the  palladium 
stain  of  F.  E.  Schultze  (1S67),  and  the  remarkable 
bichromate  of  silver  stain  of  Golgi  (1873).  These 
have  made  it  possible  to  trace  the  processes  of  nerve 
cells  to  their  finest  ramifications  and  have  given  to 
neurology  the  remarkable  precision  possessed  by  it 
to-day,  a  precision  never  dreamed  of  by  the  anato- 
mists of  the  18th  century.  Embedding  in  eelloidin 
was  invented  by  Schicfferdecker  in  1SS2,  the  hema- 
toxylin mordant  method,  which  has  given  such  excel- 
lent results  in  tracing  nerve  tracts,  by  Weigert  (1SS4) 
and  Pal  (1887).  The  methylene  blue  method  of 
Ehrlich,  to  which  are  due  some  of  the  most  impor- 
tant of  the  recent  discoveries,  was  invented  in  1886. 
Finally  should  be  mentioned  the  improvements  in  the 
instrument  itself  by  the  invention,  in  1887,  by  Abbe 
of  Jena,  of  apochromatic  lenses  of  wide  aperture  and 
homogeneous  immersion,  by  which  clearer  definition 
is  obtained  together  with  more  accurate  correction 
of     chromatic    aberration.     The    magnifying    power 

340 


with  good  definition,  which  was,  in  the  earlier  half 
of  the  century,  limited  to  less  than  500  diameters 
is  now  from  1,000  to  1,500  diameters. 

Besides  the  microscope,  other  optical  inventions 
and  discoveries  have  greatly  aided  the  extension  of 
anatomical  knowledge.  Among  these  should  be 
mentioned  the  ophthalmoscope,  invented  in  1851  by 
Hermann  von  Helmholtz  (1821-1894),  professor  at 
Berlin;  the  laryngoscope,  invented  in  1S58  by 
Johann  Nepomuk  Czermak  (1828-1873),  professor 
at  Prague  and  Leipsic;  and  the  astounding  discovery, 
made  in  1S95  by  Wilhelm  Konrad  Roentgen  (born 
1845),  professor  at  Wiirzburg,  of  the  so-called  j- 
rays,  by  which  actinic  shadows  of  the  more  solid  parts 
of  the  living  human  body  can  be  cast  upon  a  photo- 
graphic plate. 

The  question  of  the  spontaneous  generation  of  the 
cells  of  the  body  and  of  unicellular  forms  of  life  was 
naturally  considered  in  connection  with  theories  of 
development  and  structure.  The  experiments  of 
Spallanzani  and  Needham  on  the  generation  of  in- 
fusoria were  found  to  be  not  always  conclusive  wh«n 
repeated  by  others,  and  it  was  generally  held  that 
cells  might  generate  de  novo  in  the  bodily  fluids. 
This  had  great  bearing  upon  questions  in  patholog- 
ical anatomy. 

A  new  light  was  thrown  on  this  by  the  discovery,  in 
1836,  by  Cagniard  de  la  Tour  and  by  Schwann,  of  the 
yeast  plant,  which  by  its  rapid  multiplication  spreads 
from  a  small  quantity  of  leaven  throughout  a  large 
mass.  F.  E.  Schultze  had  previously  shown  that 
exclusion  of  air  prevented  fermentation.  This  led 
to  the  theory  of  chemical  ferments  (Liebig),  which 
was  in  1857  overthrown  by  Louis  Pasteur  (1822- 
189.5),  who  showed  that  fermentation  and  putre- 
faction are  due  to  the  presence  of  minute  living  spores. 
The  parasitic  character  of  many  disorders  was  shown, 
and  it  was  also  proved  that  the  supposed  formation 
of  pus  cells  in  the  tissues  of  the  body  was  due  to  the 
multiplication  of  living  corpuscles  already  existing 
there  or  the  transmigration  of  others  from  the  blood- 
vessels (diapedesis,  Cohnheim,  1S67).  The  experi- 
ments of  Pasteur,  Tyndall,  and  others  served  to  show 
that  ordinary  air  is  crowded  with  living  particles 
that  reproduce  their  kind  when  placed  in  suitable 
conditions.  Hence  arose  the  so-called  "germ  the- 
ory" of  the  origin  of  many  diseases,  which  has  had  an 
important  influence  upon  the  development  of  patho- 
logical anatomy. 

As  an  offset  to  the  all-pervading  germs  came,  in 
1S84,  the  discovery  by  Metchnikoff,  at  that  time  pro- 
fessor in  Odessa,  that  white  blood  corpuscles  and 
cells  of  lymphoid  organs  have  the  property  of  de- 
stroying foreign  organisms  that  may  be  introduced 
into  the  body  (phagocytosis). 

The  most  significant  event  in  the  history  of  anat- 
omy, as  in  that  of  other  biological  sciences  during 
the  nineteenth  century,  was  doubtless  the  publica- 
tion, in  1859,  of  the  "Origin  of  Species"  by  Charles 
Darwin  (1S09-1SS2).  As  early  as  1S37  Darwin 
began  to  collect  data  with  reference  to  the  variation 
of  structure  in  animals  and  plants,  and  with  a  reti- 
cence as  unusual  as  rare  withheld  his  speculations 
until  they  were  ripened  by  mature  thought  and  cor- 
roborated by  numerous  experiments.  The  great  ad- 
vance that  he  made  upon  the  theory  of  Lamarck  was 
in  recognizing  the  "struggle  for  existence"  as  the 
potent  factor  in  producing  change  by  inducing  the 
"survival  of  the  fittest"  forms  to  reproduce  their 
kind.  Similar  views  were  produced  at  about  the 
same  time  by  Alfred  Russell  Wallace,  the  distin- 
guished naturalist.  Darwin  applied  his  principles  to 
the  structure  of  man  in  his  work  "The  Descent  of 
Man,"  published  in  1871. 

The  careful  and  cautious  character  of  Darwin's 
work,  fortified  as  it  was  by  the  most  exhaustive  and 
minute  investigations,  caused  it  to  be  received  far 
differently  from  that  of  his  predecessors.     The  human 


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Anatomy,  History  nf 


organism  evolved  throughout  countless  ages  was 
hou  seen  to  be  a  cosmic  phenomenon  of  vast  impor- 
tance and  significance,  not  an  isolated  and  special 
matter  dependent   on  the  action  of  some  unknown 

.,„',!  in nprehensible  power.     The  influen xerted 

upon   all  departments  of  anatomy   was  very  great, 
mger  could  the  structure  of  man  1»-  considered 
by   itself,  it   must   be  illustrated  and  interpreted  by 
that    of   all    other   creatures.      The    binned    and    for- 
gotten  pages  of  the  book  of  life  on  the  globe  must   be 
phered  to  give  man  a  clew  to  the  meaning  of  his 
bodily   form.     Comparative  anatomy  and  pale- 
ontology thus  became  powerful  coadjutor-  to  human 
mi      and    the    study    of    development,    under 
Meckel's   law  of  recapitulation,  became  more  essen- 
tial  than  ever. 

The  study  of  the  variet  ies  of  man  assumed  a  new  im- 
portance.    The    groundwork    of    a    rational    anthro- 
pology    had    already    been    laid    by     Andreas    Adolf 
ius    (1796-1860),    professor   at    Stockholm,    who 
iied   the  cephalic  index  and  introduced  the  prin- 
of   indi  xes  for   the   classification   of   measure- 
fcs.     Other  workers  in  this  field  were  the  Amer- 
icans:   Samuel    G.    Morton,    J.    Aitken    Meigs,    Nott 
Gliddon,    and    Jeffries     Wyman;    the     British: 
Pritchard,    Lawrence,    Barclay,    Flower,    and    Tylor; 
the  Germans:  Spix,  Lucae,  Welcker,  Ranke,  Ihering, 
Schmidt;  and  in  France:  Dumoutier,  Jacquart, 
ttrefages,  and  especially  Paul  Broca  (1S24-18S0), 
founded     the    Paris    Societe     d'    Anthropologic 
i9),  and  by  his  great  intellectual  activity  reduced 
3  stem   the  somewhat  irregular   methods   in   use 
before    his    time.     Similar  societies  were  formed   at 
most     scientific     centers:     London — 1863,     Berlin — 
1869,   Vienna— 1871,  Washington— 1SS0. 

A  more  careful  search  disclosed  the  remains  of  man 
rata  of  geologic  epochs  far  more  distant  than  had 
erto  been  imagined.  Thus,  in  the  grotto  of 
is,  near  Liege,  they  were  found  (1835)  in  conjunc- 
tion witli  the  bones  of  the  mammoth  and  the  cave 
:  in  the  valley  of  the  Somme,  Boucher  de  Perthes 
discovered  (1846)  implements  of  human  manufacture 
in  strata  of  unquestionable  quaternary  origin;  in 
the  Neanderthal,  near  Diisseldorf,  there  was  found 
i  v>7)  a  remarkable  ape-like  skull  associated  with 
bones  of  the  cave  bear;  at  La  Naulette,  in  Belgium, 
near  Dinant,  a  fragment  of  a  human  jaw  of  very  low 
type,  together  with  bones  of  the  mammoth  and 
woolly  rhinoceros;  and  in  1886,  in  the  grotto  of  Spy, 
bank  of  the  Orneau  River,  in  Belgium,  were  un- 
earthed two  skeletons  associated  with  similar  bones 
of  extinct  animals.  Other  discoveries  of  like  nature 
were  made  in  Kent,  England,  near  Prague,  in  Mor- 
avia, in  the  Balkan  peninsula,  in  Bohemia,  at  many 
places  in  France,  in  the  pampas  of  South  America 
and  in  Patagonia,  the  latter  being  associated  with 
the  huge  carapaces  of  the  glyptodon.  The  most 
remarkable  find  of  all  was,  however,  that  of  Dr. 
Eugene  Dubois,  who  during  explorations  in  Java 
(1890-1S95)  discovered  a  fossil  skull  cap,  a  femur,  and 
two  molar  teeth  embedded  in  rock  and  associated 
with  the  remains  of  extinct  animals  belonging  to  the 
Pliocene  epoch.  These  remains  appear  to  be  transi- 
tion forms  between  those  of  the  higher  apes  and  the 
lowest  existing  men. 

At  the  time  of  Darwin  the  intimate  structure  of  the 
cell  was  little  understood  or  considered,  but  the  re- 
searches of  Oscar  Hertwig,  van  Beneden,  Flemming, 
and  man}'  others  have  shown  the  great  importance 
of  this  branch  of  anatomical  inquiry,  and  it  is  about 
the  problems  here  found  that  the  principal  discus- 
sions of  more  recent  times  have  been  raised. 

In  1S66  the  lowest  form  of  a  cell  was  considered  to 
be  simply  a  mass  of  structureless  protoplasm  endowed 
with  vital  properties,  the  cell  membrane  and  the 
nucleus  having  been  successively  dismissed  as  non- 
essential elements.  Protoplasm  was  considered  as  a 
homogeneous,  semi-fluid  substance,  with  little  or  no 


trace  of  organization,   whose  chemical   constitution 

was  only  approximately  known,  but  was  believed 
to  I"-  highly  complex.     S •  daring  spirits  ventun  d 

to  surmise  that    it    might    be  possible   to  produce  pro- 

topla  in  iii  i he  chemical  laboral ory. 

The  elaborate  investigations  of  recent  jreai  have 
shown  the  futility  of  such  a  pretension,  indicating 
that  protoplasm  has  an  almost  inconceivable  insta- 
bility, that  it  differs  in  composition  in  different  o 
in  different  parts  of  the  body,  and  under  different 
stimuli.  The  substance  of  which  it  is  composed  are 
among  the  most  complicated  known  to  chemistry, 
and  there  is  reason  t<>  suppose  that  in  the  living  body 

it  is  much  more  unstable  than  in  tlie  cadaver.      There 

appears  to  be  a  wide  distinction  to  be  made  between 
those  organic  bodies  thai  an-  products  of  secretion 
and  excretion  such  as  sugar,  starch,  and  urea,  and 
the  organi  ed  bodies  such  as  the  different  proto- 
plasms that  are  produced  by  the  slow  and  peculiar 

processes  of  biotlC  growth. 

The  morphological  character  of  protoplasm  has 
also  been  found  to  be  much  more  complicated  than 
had  been  supposed.  First  granules  were  observed, 
then  striations,  then  vacuolizations.  The  appear- 
ances  being  often  contradictory  and  varying  much 
with  varying  conditions,  it  is  not  surprising  that  they 
have  led  to  diverse  views  as  to  its  structure.  These 
are  by  no  means  settled  as  yet,  but  they  may  be 
succinctly  grouped  as  follows: 

1.  The  reticular  theory,  first  brought  clearly  for- 
ward by  Karl  Heitzmann  (1830-1896)  in  1873,  and 
still  maintained,  under  various  modifications,  by  a 
great  number  of  cytologists.  According  to  this  all 
protoplasm  is  composed  of  two  substances:  a  more 
solid  network — the  cytoreticulum  or  spongioplasm, 
and  a  more  fluid  interstitial  substance — the  cyto- 
lymph,  hyaloplasma,  or  enchylema.  The  granules 
observed  in  cells,  when  not  foreign  inclusions  or 
masses  of  dead  protoplasm,  are  the  intersections  of 
this  network.  There  is  no  doubt  but  that  the  great 
majority  of  cells,  when  fixed  by  the  usual  methods 
and  treated  with  staining  reagents,  show  some  traces 
of  such  a  reticulum. 

2.  The  filar  theory,  advocated  by  Flemming  (1887), 
who  by  studying  cells  unaffected  by  reagents  concludes 
that  they  are  structurally  composed  of  free  thread-, 
the  cytomitom,  not  combined  into  a  reticulum  but 
often  containing  numerous  nodosities. 

3.  The  granular  theory,  first  brought  forward  by 
Arndt,  and  afterward  advocated  by  Altmann  (1S87). 
This  supposes  protoplasm  to  be  formed  of  granula- 
tions embedded  in  a  homogeneous  basis  substance. 
These  granules,  Altmann's  bioblasts,  are  held  to  be 
themselves  morphological  units  of  a  still  lower  order 
than  the  cells.  Special  means  of  preparation  are 
required  to  demonstrate  them. 

4.  The  alveolar  theory  of  Biitschli  (professor  at 
Heidelberg,  1S89)  and  his  school,  who  hold  that  the 
structure  of  protoplasm  is  like  that  of  a  fine  viscous 
froth  or  foam,  that  is  to  say,  composed  of  alveoli 
with  extremely  thin  walls.  This  structure  is  be- 
lieved to  be  a  physical  consequence  of  the  peculiar 
conditions  of  tension  and  surface  flow  possessed  by 
the  substance,  and  may  be  imitated  by  emulsions  of 
thickened  oil  and  various  salts.  This  view  attempts 
to  explain  the  appearances  of  the  other  theories 
either  by  the  optical  conditions  under  which  the 
alveoli  are  viewed  or  by  the  reaction  of  the  reagents 
employed.  To  demonstrate  the  alveoli  in  perfection 
the  protoplasm  must  be  living  and  the  best  attain- 
able optical  conditions  secured.  Under  such  cir- 
cumstances they  are  seen  actively  to  change  their 
forms  and  relations  to  each  other,  these  phenomena 
being  so  swiftly  evanescent  that  it  is  impossible 
accurately  to  represent  them  in  a  camera  drawing — ■ 
while  the  hand  is  tracing  one  part  another  is  rapidly 
changing. 

Attempts  have  been  made  to  reconcile  these  con- 


341 


Anatamy,  History  of 


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flirting  views.  Kolliker  considered  that  the  different 
appearances  are  due  to  different  states  of  develop- 
ment of  the  protoplasm.  In  young  eells  he  supposes 
it  to  be  homogeneous  and  without  strueture,  formed 
of  a  mixture  of  various  substanres  possessing  different 
degrees  of  contractility  and  solubility  in  acids.  In 
such  a  medium  vacuoles  will  sooner  or  later  appear. 
If  these  are  numerous  and  small  the  structure  of  the 
protoplasm  will  be  alveolar;  if  the  walls  of  the  alveoli 
break  it  becomes  reticular;  if  the  threads  of  the  retic- 
ulum break  it  beromes  filar.  Doubtless  this  view 
may  assist  us  in  certain  interpretations,  yet  it  must 
be  said  that  recent  observations  tend  to  show  that 
even  the  earliest  ovum  does  not  possess  a  homogene- 
ous structure. 

Among  the  differentations  of  the  protoplasmic 
mass  of  the  cell  the  nucleus  has  been  the  most  sueces- 
fully  investigated.  Flemming  was  the  first  to  show 
that  it  contains  several  substances,  one  of  which, 
from  its  affinity  for  coloring  matters,  he  named  chro- 
matin. The  phenomena  of  indirect  cell  division 
(mitosis,  karyokinesis)  were  first  connectedly  observed 
by  •  Anton  Schneider  in  1873,  although  Balbiani 
and  others  had  previously  noted  separate  stages. 
The  nuclear  reticulum  which  plays  so  important  a 
part  in  this  process  was  first  noticed  by  Frommann  in 
1865.  The  fragmentation  of  this  into  separate  sec- 
tions or  chromosomes  was  shown  by  Balbiani  and 
Carnoy.  These  again  are  separable  into  granular 
bodies,  to  which  the  name  of  chromomeres  has  been 
given  by  Fol  (1891).  Other  investigators  who  have 
greatly  advanced  the  knowledge  of  this  process  are 
Strasburger,  Boveri,  Oscar  and  Richard  Hertwig,  van 
Beneden,  and  Rabl. 

The  great  advance  made  in  theoretical  chemistry  by 
the  atomic  theory  of  Dalton  (180S)  is  well  known. 
Although  atoms  and  molecules  have  never  been  seen, 
the  hypothetical  constitution  of  bodies  supposed  to 
be  formed  by  them  is  now  definitely  stated  and  pre- 
dirted.  The  signal  success  of  this  theory  has  led  to 
similar  speculations  regarding  the  constitution  of  pro- 
toplasm. The  first  of  these  was  that  of  Niigeli,  who 
in  18S4  propounded  his  micellar  hypothesis.  Accord- 
ing to  this,  protoplasm  is  composed  of  an  immense 
number  of  "micellae,"  elementary  units  of  a  crystal- 
line character,  far  beyond  the  limits  of  microscopic 
vision.  As  molecules  are  formed  of  atoms,  so  micellae, 
units  of  a  next  higher  order,  are  formed  of  molecules. 
The  peculiar  physical  properties  of  protoplasm,  its 
imbibition  of  water,  etc.,  are  explained  by  the  arrange- 
ment and  affinities  of  the  micellae. 

The  hypothesis  of  Nageli  has  led  the  way  to  a  num- 
ber of  others  of  a  similar  character  by  De  Vries, 
Wiesner,  Haeckel,  Hertwig,  Roux,  and  Weismann. 
These  have  generally  been  directed  toward  explaining 
by  this  means  the  phenomena  of  heredity.  By  a 
series  of  beautiful  experiments  (1884)  Oscar  Hertwig 
has  apparently  succeeded  in  showing  that  the  phys- 
ical substance  upon  which  this  transmission  of 
characters  depends  is  the  chromatin  found  in  the  cell 
nucleus. 

Starting  with  this  for  a  basis  Weismann,  in  various 
publications  from  1875  to  1894,  has  propounded  an 
elaborate  theory  by  which  he  attempts  to  explain 
the  phenomena  of  hereditary  resemblance.  Accord- 
ing to  this,  the  chromatin  is  a  structure  of  almost 
inconceivable  architectural  complexity.  In  his  sys- 
tem Weismann,  following  Nageli,  names  it  "idio- 
plasm," and  supposes  it  to  be  composed  of  groups 
called  "ids,"  corresponding  to  the  chromomeres  seen 
under  the  microscope.  During  the  segmentation 
of  the  ovum  or  any  other  cell  division,  these  ids  also 
divide,  so  that  they  are  distributed  to  each  cell 
throughout  the  body.  The  ids  are  themselves  com- 
posed of  lesser  units  called  "determinants,"  because 
they  determine  the  histological  character  of  the  cells 
within  which  they  dwell.  There  are  as  many  kinds 
of  determinants  as  there  are  parts  of  the  body  cap- 

342 


able  of  being  different.  Determinants  are  themselves 
compound,  being  composed  of  "biophores,"  or  ulti- 
mate units  that  control  the  vital  activities  of  the  cell. 

In  the  segmentation  of  the  ovum  certain  of  the  cells 
divide  so  that  each  division  retains  exactly  similar 
determinants  and  thus  remains  equal  in  capacity  to 
the  original  ovum.  Such  duplicative  division  pro- 
duces the  tissue  denominated  "germ  plasm"  found 
in  the  nuclei  of  the  germinal  cells  of  the  ovary  and 
testis.  Other  of  the  cells  divide  by  a  differer, 
division  by  which  determinants  of  different  kinds 
are  sorted  out,  grouped  together,  and  relegated  to 
different  cells.  These  are  the  somatic  or  body  o 
from  which  the  general  tissues  of  the  body  are  formed. 
Since  the  germ  cells  and  body  cells  separate  at  the 
earliest  stage,  no  modification  of  the  latter  can  affect 
the  germ  plasm,  hence  it  is  denied  that  characters  ac- 
quired by  the  body  cells  can  be  transmitted  to  the  off- 
spring. 

The  arrangement  of  the  determinants  by  which 
bodily  characters  are  affected  is  caused  by  architect- 
ural peculiarities  inherent  in  the  original  ovum  and 
spermatozoon.  There  is  contained  within  each  fecun- 
dated ovum  an  entirely  closed  system  of  interrelated 
units  that  can  develop  only  in  a  predetermined 
manner.  We  have  here  a  reappearance,  under  a  new 
form,  of  the  theory  of  preformation  sustained  by 
Haller  and  combated  by  Wolff. 

Closely  connected  with  this  is  His's  theory  of  ger- 
minal foci  (1S74),  which  supposes  that  within  the 
protoplasm  of  the  egg  the  different  parts  of  the 
adult  body  are  prelocalized  and  distinct,  although 
not  yet  formed.  To  this  view  many  eminent  anato- 
mists and  embryologists  have  adhered,  but  recent 
experiments  of  Hertwig,  which  show  that  when  the 
segments  of  a  dividing  ovum  are  shaken  apart  each 
may  develop  into  a  complete  individual,  appear  to 
have  dissipated  these  ingeniously  devised  theories 
as  a  puff  of  wind  lays  prostrate  a  house  of  cards. 

Among  the  most  ardent  and  indefatigable  investi- 
gators in  the  domain  of  general  anatomy  during  the 
nineteenth  century  should  be  mentioned  Jacob  Henle 
(1809-1S85),  professor  at  Zurich,  Heidelberg,  and 
finally  at  Gottingen.  He  was  among  the  first  to 
realize  the  importance  of  the  cell  theory  and  did  much 
toward  its  establishment.  He  also  advanced  what 
may  be  called  the  modern  theory  of  pathological 
processes,  holding  that  they  are  merely  modifications 
of  those  of  health. 

Albert  von  Kolliker  (1817-1905),  professor  at  Zurich 
and  Wiirzburg,  also  had  great  influence  upon  research 
in  both  general  anatomy  and  embryology. 

In  comparative  anatomy  should  be  mentioned 
Richard  Owen  (1S04-1892),  the  author  of  a  curious  i 
theory  of  the  vertebral  origin  of  the  skeleton,  Thomas 
H.  Huxley  (1S25-1S95),  who  by  his  writings  and 
researches  greatly  furthered  the  doctrine  of  devel- 
opment  by  descent,  and  Carl  Gegenbaur  (1826-1908), 
at  Heidelberg,  whose  researches  upon  the  morphology 
of  the  head  and  limbs  are  justly  famous.  In  tie 
paleontological  field  great  advances  were  made  by 
the  discovery  in  America  of  fossil  deposits  of  large 
extent,  and  of  importance  far  surpassing  anything 
hitherto  known.  These  were  especially  investigated 
by  Joseph  Leidy  (1S23-1891),  professor  in  the 
University  of  Pennsylvania;  by  O.  C.  Marsh  (18 
1899),  professor  in  Yale  University;  Edward  D.  Cope 
(1840-1S97),  professor  in  the  University  of  Penn- 
sylvania; Henry  F.  Osborn  (born  1S57),  professor  in 
Columbia  University;  and  G.  Baur,  professor  in  the 
University  of  Chicago.  They  have  thrown  great 
light  upon  human  anatomy  by  confirming  in  a 
striking  degree  the  theories  of  development  and  the 
morphological  laws  controlling  the  formation  of  the 
human  body.  The  anatomy  of  the  head,  of  the  teeth, 
and  of  the  vertebral  column  have  been  especially 
elucidated. 

The  advancement  of  embryology  has  been  greatly 


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Anatomy,  History  of 


.icicd  by  the  anatomists  whose   names  have   been 
ilready  given,  and  also  by  Johannes  MUller  (1801- 
S58),  professor  at  Bonn  and  Berlin,  one  of  the  most 
earned   men   of  his  day,   who  especially   studied    the 
levelopment  of  the  genital  organs,   the  glands  and 
he  peritoneum;  and  by  Francis  M.   Balfour  (1851- 
1882),  professor  at   Cambridge,    whose   tragic  death 
,n  the  Aiguille  Blanche  of  the  Alps  was  a  great   loss 
,i  science.     An  important  advance  in  the  establish- 
nent  of  the  phyletic  history  of  man  and  other  ani- 
mals was  made  in  187-1  by  Ernst  Ilaeckel  (born  Is::  I), 
ifessor  at  Jena,  who  attempted   to  show   that   all 
mimals  possessing  a  food  sac  or  intestinal   cavity 
descended  from  a  common  ancestor  (as  yet  hypo- 
thetical),   the  Gastrcea,  and   that  this  is  represented 
mbryological  development  by  a  stage  which  may 
rmed  the  gastrula,  formed  by  the  invagination 
il    the  blastodermic   vesicle  or  blastula.     This,   the 
elebrated   gastrwa    theory,    aroused    violent     opposi- 
tion from  the  opponents  of  the  development  hypoth- 
n  is  now  quite  generally  accepted. 
The  details  of  the  intracellular  phenomena  of  the 
fecundation  of  the  ovum  were  first  observed  by  Oscar 
Hertwig  in  1N75,  in  the  transparent  eggs  of  the  sea 
urchin. 

In  osteology  during  the  century  there  should  be 
noted  the  work  of  John  Goodsir  (1S14-1S67)  on  the 
structure  and  development  of  bone,  the  discovery  of 
the  lacuna?  and  canaliculi  by  Purkinje,  and  that 
of  the  osteoblasts  by  Gegenbaur  (1864).  William 
Sharpey  (1S02-18S0)  did  much  to  increase  the  knowl- 
edge of  the  structure  and  development  of  bone,  as 
also  did  Oilier  and  Robin  in  France  and  H.  Muller, 
Gegenbaur,  and  Kolliker  in  Germany.  The  archi- 
tecture of  the  spongy  tissue  of  bones  received  especial 
attention  from  Jeffries  Wyman  of  Harvard  University 
and  from  H.  von  Meyer  of  Zurich.  The  develop- 
ment of  limbs  in  vertebrates  has  been  studied  by  R. 
Wiedersheim  of  Freiburg,  the  form  of  the  skull  by 
R.  Virchow  of  Berlin,  and  Welcker  of  Halle,  the 
general  morphology  of  the  skull  by  Gotte  of  Stras- 
burg,  and  Gegenbaur  (1SS7).  The  vertebral  column 
has  been  investigated  by  Cunningham  of  Dublin  and 
Edinburgh,  by  Merkel  and  Henke. 

Arthrology  has  made  important  advances  in  pre- 
cision and  knowledge  of  the  mechanism  of  joints. 
Especially  worthy  of  mention  are  the  works  of  Meyer 
of  Zurich,  Braune  of  Leipsic,  Morris  of  London, 
Heiberg  of  Christiania,  and  Bigelow  and  Dwight  of 
Boston.  Bland  Sutton,  of  London,  has  investi- 
gated the  nature  of  ligaments,  Bernays,  of  St.  Louis, 
the  development  of  joints. 

In  myology  the  minute  anatomy  of  muscle  has 
received  particular  attention,  but  cannot  yet  be  said 
to  be  settled,  as  a  knowledge  of  the  intimate  structure 
of  protoplasm  is  as  yet  imperfect.  Bowman,  in 
1M0,  was  the  first  to  throw  any  clear  light  on  the 
subject.  He  was  followed  by  Leydig  and  Cohn- 
heim.  Afterward  Krause  (1S6S)  brought  forward 
his  theory  of  "muscle  caskets,"  Hensen  showed  new 
details,  and  Merkel,  Engelmann,  Rollett,  and  Ranvier 
respectively  advanced  their  views.  The  general 
morphology  of  the  muscular  system  has  been  ad- 
vanced by  the  researches  of  Huxley,  Humphry  of 
Cambridge,  and  Gegenbaur:  the  study  of  muscular 
anomalies  has  been  pursued  by  Wenzel  Gruber, 
Theile,  Wood,  Macalister,  Struthers,  Chudzinsky, 
Testut,  and  Ledouble.  Special  groups  of  muscles 
have  also  received  attention,  Fiirbringer  studying 
those  of  the  larynx  and  of  the  shoulder,  von  Bardele- 
ben  and  Cunningham  those  of  the  hand  and  foot, 
Ruge  those  of  the  face. 

In  the  earlier  part  of  the  century  the  structure  of  the 
capillaries  was  not  understood,  it  being  believed  that 
they  were  interstitial  lacunae  without  walls.  The 
demonstration  of  their  independence  and  continuity 
was  first  made  by  Treviranus  in  1836.  The  endothe- 
lium of  the  blood-vessels  was  first  demonstrated  by 


llenle  in  18158.  Johannes  Muller  made  important 
discoveries  in  the  vascular  system,  especially  that 
of    the    helicine   arteries   of   erectile    tissue,    in    1835. 

The  study  of  the  formed  elements  of  the  blood  has 
greatly  advanced,  but  still  leaves  much  to  be  desired. 
The  blood  platelets  (hematoblasts  or  third  corpus- 
cles) were  first  discovered  by  Max  Schultze  in  1865, 
and  were  afterward  studied  by  Bizzozero,  Hayem, 
and  Pouchet.  Ehrlich  (1891)  carefully  studied  the 
white  corpuscles  and  separated  them  into  varieties 
that  appear  to  be  of  great  value  in  pathological  anat- 
omy. Neumann  and  Malassez  have  investigated 
the  origin  and  formation  of  the  red  blood  corpuscles. 

Other  angiological  studies  of  note  are  those  of  His 
and  Bernays  on  the  development  of  the  heart,  of 
Braune  on  the  venous  system,  and  of  Bardoleben, 
Thoma,  and  Bonnet  on  the  variations  in  the  struct- 
ure of  the  vascular  walls.  Heubner  (1872)  greatly 
elucidated  the  vascular  distribution  in  the  brain. 
A  profound  study  of  vascular  anomalies  has  been 
made  by  W.  Krause. 

The  lymphatics,  formerly  believed  to  originate  from 
the  interstitial  spaces  of  connective  tissue  (Ludwig, 
Brtickc),  were  shown  by  Recklinghausen,  Kolliker, 
and  Ranvier  to  form  a  closed  system.  The  true  nature 
of  the  lymphatic  glands  has  been  elucidated  by  the 
labors  of  His,  Klein,  Ranvier,  and  others.  Impor- 
tant investigations  into  the  origin  of  the  lymphatics 
have  been  made  by  P.  C.  Sappey  (1810-1896), 
professor  at  Paris,  and  by  Ranvier;  in  this  country 
by  Sabin  and  Huntington.  The  connection  of  the 
serous  cavities  of  the  body  with  the  lymphatic  system 
has  been  studied  by  Schweigger-Seidel,  Klein,  Tour- 
neux,  and  Kolossow.  The  lymphatic  tissue  of  the 
throat  (pharyngeal  tonsil,  etc.)  has  been  the  object 
of  research  by  Killian,  Stohr,  Flesch,  and  others;  and 
von  Davidoff  and  Klatsch  have  shown  that  the  lym- 
phoid tissue  of  the  intestine,  the  mesenteric  glands  and 
the  spleen  are  all  developed  from  the  intestinal  epithe- 
lium, a  conception  which  Stieda  has  extended  to 
the  thymus  gland.  Finally  Heidenhain  has  demon- 
strated the  wandering  of  leucocytes  throughout 
glandular  tissues. 

The  convolutions  of  the  brain  were  thought  by  the 
earlier  anatomists  to  be  arranged  without  definite 
order,  being  compared  to  the  irregularities  of  the  coils 
of  the  small  intestine.  In  1855  Gratiolet  (1815- 
1865),  by  a  careful  comparative  study  of  the  brains  of 
man  and  animals,  showed  that  the  apparently  con- 
fused complexity  can  be  reduced  to  a  comparatively 
simple  plan.  This  was  further  developed  by  Pozzi, 
Leuret,  Ecker,  Giacomini,  and  others. 

Closely  connected  with  this  is  the  discovery,  first 
made  by  Broca,  that  certain  motor  and  sensory 
activities  can  be  located  in  definite  areas  of  the  cere- 
bral cortex.  He  noted  that  the  loss  of  articulate 
speech  known  as  aphasia  is  usually  associated  with  a 
lesion  of  the  left  third  frontal  convolution  (Broca's 
convolution).  This  doctrine  has  been  greatly  ex- 
panded by  the  experiments  of  Fritsch  and  Hitzig, 
Ferrier,  Charcot,  Horsley,  and  many  others,  and 
has  become  of  great  diagnostic  value.  It  will  be  per- 
ceived that  it  only  superficially  resembles  the  older 
doctrine  of  Gall  and  Spurzheim. 

The  nerve  cells  in  the  brain  and  spinal  cord  were 
probably  first  mentioned  in  1S33  by  Christian  Gott- 
fried Ehrenberg  (1795-1876),  professor  at  Berlin. 
They  were  better  described,  however,  in  1836,  both 
by  Gabriel  Gustav  Valentin  (1810-1883),  professor  at 
Berne  and  Johannes  Evangelista  Purkinje  (17S7- 
1869),  professor  at  Breslau  and  Prague,  from  whom 
are  named  the  cells  or  corpuscles  of  Purkinje  in  the 
cerebellum.  They  were  for  some  time  misunderstood, 
Magendie,  in  1839,  describing  them  as  infusoria. 
Their  nervous  character  was  established  in  1844  by 
Robert  Remak  (1S15-1865),  professor  at  Berlin, 
who  at  the  same  time  suggested  their  connection  with 
nerve  fibers. 


343 


Anatomy,  History  of 


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The  first  to  note  the  axis  cylinder  process  or  axone 
of  nerve  cells  appears  to  have  been  Rudolph  Wagner 
(1805-1864),  professor  at  Gottingen,  but  its  true 
nature  was  first  shown  by  Otto  F.  K.  Deiters  (1S34- 
1863),  professor  at  Bonn,  in  1S65.  Although  unable 
to  demonstrate  its  actual  continuity  with  the  axis 
cylinder  of  a  nerve  fiber,  he  gave  to  the  process  the 
name  by  which  it  is  generally  known  and  also  named 
the  protoplasmic  processes  or  dendrites.  The  con- 
nection of  nerve  cells  with  nerve  fibers  remained  for 
some  time  obscure.  Counting  experiments  instituted 
by  Benedict  Stilling  (1S10-1S79),  of  Kassel,  showed 
that  at  the  level  of  the  second  cervical  nerve  there  are 
found  not  more  than  half  the  number  of  fibers  that 
reach  the  cord  by  the  posterior  nerve  roots. 

Since  the  direct  methods  of  anatomical  research 
failed  to  resolve  the  complex  architecture  of  the 
nervous  system,  recourse  was  had  to  the  indirect 
methods  of  physiological  experimentation,  patholog- 
ical lesions,  and  embrvological  development.  In 
1S33  Marshall  Hall,  of  London  (1790-1857),  first 
clearly  demonstrated  reflex  movements  and  the  in- 
dependent action  of  the  spinal  cord  and  the  medulla 
oblongata  already  surmised  by  Descartes.  As  early 
as  1839  Nasse  snowed  that  wdien  a  nerve  is  cut  its 
peripheral  end  degenerates,  and  in  1S50  this  was  more 
carefully  studied  by  Augustus  Waller  (1S16-1S70), 
who  showed  that  it  is  always  the  end  that  is  detached 
from  the  nerve  cell  that  perishes,  and  that  when  the 
posterior  root  of  a  spinal  nerve  is  severed  between  its 
ganglion  and  the  cord,  an  area  of  ascending  degenera- 
tion will  ascend  to  the  cord.  In  1852  Ludwig  Tiirck, 
of  Vienna  (1810-187S),  showed  that  a  descending 
degeneration  might  occur  from  a  lesion  of  the  cord. 
Following  these  were  similar  experiments  by  Burdach, 
Goll,  Charcot,  Vulpian,  Kahler  and  Pick,  Gowers,  and 
many  others,  showing  the  results  of  lesions  of  the 
brain  or  cord  in  producing  degenerations. 

Connected  with  these  are  the  experiments  instituted 
by  Bernhard  von  Chidden  (1824-1886),  professor  at 
Munich,  which  showed  that  when,  in  a  young  animal, 
a  nerve  root  or  nerve  tract  is  torn  away  or  injured, 
the  group  of  cells  with  which  it  is  centrally  connected 
suffers  atrophy.  Among  the  experimenters  in  this 
line  of  work  there  may  be  mentioned  Hay  em,  Forel, 
and  von  Monakow. 

Many  investigators  had  noticed  in  sections  of  the 
brain  and  cord  a  difference  in  coloration  between 
fetal  and  adult  structures  which  varied  with  advanc- 
ing growth.  It  was  Paul  Flechsig,  of  Leipsic,  who 
first  showed  that  this  was  due  to  the  fact  that  different 
groups  of  fibers  develop  their  myeline  sheath  at 
different  epochs,  and  that  by  this  means  certain 
fiber  systems  can  be  made  out  that  correspond  in 
general  to  the  results  obtained  by  degenerations. 
Improvements  in  technical  methods  have  made  this 
means  of  research  comparatively  easy,  and  such  in- 
vestigations of  the  nervous  system  have  been  carried 
on  by  Bechterew,  Edinger,  Darkschewitch,  and 
others. 

Observations  in  the  comparative  anatomy  of  the 
nervous  system  have  also  led  to  important  results. 
In  this  field  should  be  mentioned  the  names  of 
Theodor  Meynert  (1S33-1S92),  professor  at  Vienna; 
Mathias  Duval,  professor  at  Paris;  and  E.  C.  Spitzka, 
professor  at  New  York. 

By  a  combination  of  these  methods  there  was 
gradually  evolved  a  general  idea  of  the  architecture  of 
the  central  nervous  system.  This  was,  however, 
necessarily  somewhat  vague  and  indefinite  as  long  as 
the  minute  anatomical  relations  could  not  be  actually 
demonstrated.  Power  to  do  this  was  at  last  obtained 
by  the  improvement  in  technical  methods  which 
made  it  possible  to  demonstrate  the  finest  ramifi- 
cations of  the  nerve  cells.  Hence  arose  the  neurone 
theory  as  advanced  by  Ramon  y  Cajal,  van  Gehuchten, 
LenhossiSk,  and  supported  by  Kolliker  and  Waldeyer. 
According  to  Joseph  von  Gerlach  (1820-1896),   the 


protoplasmic  processes  of  cells  unite  in  a  fine  anasto- 
motic network  upon  which  all  sensory  impressions 
are  discharged  and  from  which,  in  some  mysterious 
manner,  all  motor  impulses  originate.  This  doctrine 
was  opposed  by  His  (1886)  on  embryological  grounds, 
by  Forel  (1887)  on  pathological  grounds.  The  new 
methods  of  staining  showed  that  nerve  fibers  are 
merely  elongated  processes  of  nerve  cells.  This  led 
to  the  conception  that  the  nervous  system  is  composed 
of  histological  units  (termed  neurones  by  Waldeyer) 
which  may  comprise  a  cell  body  with  its  extensions, 
the  protoplasmic  processes,  the  axis-cylinder  proc- 
esses, the  nerve  fibers,  and  end  organs.  These  units 
are  held  to  be  substantially  independent  of  each 
other,  never  uniting  to  form  a  plexus.  This  view, 
which  has  been  used  with  great  success  to  explain  the 
architecture  of  the  nervous  system,  is  now  accepted 
by  most  histologists.  It  should  be  noted,  however, 
that  the  recent  investigations  of  Apathy  (1S97)  on 
the  earthworm  and  leech  seem  to  show  that  it  may 
require  some  modification. 

The  internal  structure  of  the  body  of  the  nerve  o  I! 
has  also  received  much  attention  and  is  still  under 
discussion.  Remak  and  Max  Schultze  considered  it 
fibrillary  with  interstitial  granules.  Franz  Nissl,  by 
peculiar  methods  of  staining,  thinks  that  he  has 
shown  that  the  structure  is  not  fibrillary,  but  that 
two  substances  exist,  one  being  masses  of  stainablc 
granular  substance  (Nissl  bodies,  tigroid  substance), 
the  other  unstainable.  He  considers  that  different 
types  of  cells  exist  distinguishable  by  the  arrangement 
of  these  substances. 

The  finer  anatomy  of  the  organs  of  special  sense  is 
almost  wholly  the  work  of  the  nineteenth  century. 
The  development  of  the  eye  has  been  most  carefully 
investigated  by  Hatschek,  Ayers  (of  Cincinnati),  and 
Kupffer,  and  the  curious  discovery  was  made  by 
Ahlborn  (18S6),  Rabl-Ruckhard,  and  Spencer  that 
the  pineal  body  is  a  vestige  of  an  eye  that  occurs  in 
some  reptiles.  The  anterior  limiting  layer  of  the 
cornea  was  discovered  by  Sir  William  Bowman  (1816- 
1892),  professor  at  London;  the  scleral  sinus  (canal  of 
Schlemm)  was  first  described  by  Schlemm  (1830),  but 
was  previously  known  to  Albinus,  as  appears  from  a 
catalogue  of  his  preparations.  The  ciliary  muscle 
was  first  demonstrated  as  such  (in  the  sheep)  by 
William  Clay  Wallace,  of  New  York  (1835).  Bruckc 
(1S46)  and  Bowman  (1847)  afterward  described  it. 
Even  the  deep  circular  fibers  whose  discovery  is 
usually  ascribed  to  H.  Miiller  appear  to  have  been 
seen  by  Wallace.  The  action  of  the  muscle  was  first 
correctly  described  by  Helmholtz  (1851).  A  contro- 
versy of  long  standing  regarding  the  existence  of  a 
dilator  muscle  of  the  iris  appears  to  have  been 
settled  affirmatively  by  the  researches  of  Kolliker, 
Retzius,  and  Juler.  The  structure  of  the  lids,  the 
lacrymal  apparatus,  and  the  retina  was  specially 
studied  by  H.  Miiller  (Midler's  muscle,  Mailer's 
fibers).  The  layer  of  rods  and  cones  (Jacob's  mem- 
brane) was  discovered  by  A.  Jacob,  of  Dublin,  in 
1S19,  the  visual  purple  by  Boll  in  1876.  Recently 
important  comparative  studies  of  the  retina  have 
been  made  by  W.  Krause  and  Ramon  y  Cajal. 

The  complicated  anatomy  of  the  ear  has  been  the 
object  of  research  by  a  great  number  of  observers, 
only  a  few  of  whom  can  be  mentioned  here.  The 
membrana  tvmpani  has  been  carefully  investigated 
by  O.  Shrapnell  (1832),  Jos.  Toynbee  (1851),  Rudingei 
(1S67),  and  Prussak  (1868);  the  anatomy  of  the 
auditory  ossicles  and  the  mechanism  of  their  move- 
ments has  been  elucidated  by  Helmholtz  (1868);  the 
Eustachian  tube  has  been  specially  studied  by 
Rudinger,  Huschke,  and  Kolliker;  the  membranous 
labyrinth  by  Botteher,  Henle,  and  Hyrtl.  The  organ 
of  Corti  was  discovered  by  the  Marchese  di  Corti  in 
1851.  Additional  details  of  its  structure  were  estab- 
lished by  E.  Reissner  (1854),  M.  Claudius  (1856). 
O.    Deiters    (1S60),    and    Hensen     (1863).     Special 


344 


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Anderson  Mineral  Springs 


memoirs  on  the  anatomy  of  the  car  have  been  written 
l,v  Ku.liiiH'T,  Wharton  Jones,  Ayers,  and  Retzius. 
'  \.  in  ihc  organ  of  smell,  the  olfactory  cells  were 
described  by  Max  Schultze  in  1862,  although 
they  were  probably  seen  previously  by  Ecker  and 
Eckhardt.  The  tracing  of  the  olfactory  fibers  has 
been  effected  by  the  labors  of  Kelliker,  van  Gehuch- 
ten  and  Ram6n  v  Cajal.  The  general  anatomy  oi 
the  passages  of  the  nose  has  been  carefully  studied  by 
Zuckerkandl. 

The  taste  buds  of  the  tongue  were  discovered  by 
Schwalbe,  of  Strasburg.  in  isii7,  and  at  aliont  the 
same  time  by  Loveh,  of  Christiania. 

The  tactile  corpuscles  of  the  skin  were  first  seen  by 
Meissner  and  Wagner  in  1852,  the  end  bulbs  by  W. 
Krause  and  Kolliker  1 1850-  1858).  Pacini  discovered 
the  corpuscle's  that  bear  his  name  in  1836,  and  they 
described  by  Vater  somewhat  later  (1841). 
Other  nerve  endings  recently  described  are  those  of 
Golgi  in  tendons  (1878),  those  of  Ruffini  in  the  fingers 
(1893),  and  the  "muscle  spindles"  of  Kiihne  and 
others  found  in  the  substance  of  muscle. 

Most    of   our   accurate   knowledge   of    the    minute 

iv   of   the  viscera  was  developed  during   the 

nineteenth  century.  Space  does  not  permit  a 
detailed  account  of  the  discoveries,  but  mention 
lid  be  made  of  the  work  of  Neumann,  Lent,  and 
Rose  upon  the  teeth,  and  the  attempts  of  Ryder, 
iorn,  Cope,  and  others  to  obtain  from  paleonto- 
logical  and  other  evidence  a  connected  account  of 
the  mechanics  of  their  development;  of  the  work  of 
Flemming,  of  Kiel,  upon  the  principles  of  gland  con- 
struction; and  that  of  Heidenhain  of  Breslau  upon  the 
anatomy  of  the  pancreas,  the  salivary  and  peptic 
glands."  Investigations  of  the  development  of  the 
peritoneum  by  Toldt,  His,  Treves,  Brosike,  and 
others  have  greatly  aided  our  comprehension  of  that 
plicated  structure.  The  liver  has  been  specially 
investigated  by  Kiernan,  Hering,  Heidenhain,  and 
Kanvier,  and  in  the  anatomy  of  the  kidney  great 
advances  have  been  made.  Henle  described  the 
loops  of  the  uriniferous  tubules  that  bear  his  name 
in  1862,  Ludwig  and  Heidenhain  have  done  much  in 
elucidating  the  structure  of  the  tubules,  and  Disse 
has  studied  the  changes  of  the  epithelia  during 
tion. 

In  the  generative  organs  of  the  male  researches  in 
spermatogenesis  have  been  carried  on  by  La  Valette 
St.  George,  Nussbaum,  Flemming,  Hermann,  and 
Minot.  In  the  female  organs  Pfliiger  and  Waldeyer 
have  investigated  the  structure  of  the  ovary  and  the 
development  of  ovules,  and  Nagel  has  given  the  first 
exact  description  of  the  human  ovum.  The  situation 
of  the  pelvic  organs  has  been  carefully  determined  by 
B.  Schultze  and  Waldeyer,  and  an  exhaustive  exami- 
nation of  the  human  placenta  has  been  made  by 
Minot.  Frank   Baker. 


Anderson  Mineral  Springs. — Lake  County,  Cali- 
fornia. 

Location. — Twenty-one  miles  from  Calistoga, 
five  miles  from  Middletown,  and  ten  miles  from  the 
Great  Geysers. 

Access. — By  stage  from  Calistoga  and  Clovendale. 

The  worshipper  at  nature's  shrine,  the  lover 
of  grand  and  varied  scenery,  will  find  all  that 
can  be  desired  at  the  Anderson  Mineral  Springs. 
The  mountain  stage  ride  is  one  of  the  most  picturesque 
in  the  State.  The  ever-changing  picture  of  hill  and 
dale,  of  forest  and  shrubbery,  and  of  brooks  with 
ferns  and  mosses  forms  one  of  those  pleasing  pano- 
ramas which  the  spectator  loves  to  recall  in  after  days. 
The  springs  with  the  hotel  and  cottages  are  located  in 
a  cosy  nook  in  a  large  canon  surrounded  by  forests 
abounding  in  picturesque  waterfalls.  The  cool, 
leafy  dells  and  the  profound  silence  and  solitude  of  the 


dense  forests  form  an  ideal  combination  to  at  I  ract  the 
early  morning  rambler.  The  atmosphere  hen'  is 
balmy  and  exhilarating  and  free  from  humidity. 
Fish   and   game  abound   all    the  year   round.     The 

accomi lations  offered    to  guests  are  excellent,   and 

\  isitors  come  by  the  thousand  to  enjoy  the  numerous 

advantages  of  the  spot.  There  are  nine  important 
springs.  The  principal  drinking-spring,  known  as  the 
Cold   Sulphur,   is  located  about  250  yards  from   the 

hotel.     It  »;e  .-.nil..   I'd    ic     1 1;     n  ,:    :.. 

and   found  by  him  to  have  the  following  composition: 


One  United  States  Gallon  Contains: 

Solids.  Grains. 

Sodium  chloride. 1  -09 

Sodium  carbonate.  .        ''  -'' 

Sodium  sulphate 6. 18 

Potassium  salts Traces. 

Magnesium  carbonate 11 .73 

Magnesium  Bulphate 16.95 

I   1 1,  i inn  carbonate 20.40 

Calcium  sulphate 9.10 

Ferrous  carbonate 0.46 

Arsenious  salts Traces. 

Silica 2.45 

Organic  matter Traces. 

Total 77  .  03 

Cub.  in, 

P    ,      f  Carbonic  acid  gas 243  50 

aseS  I  Sulphurated  hydrogen 4-20 


This  may  be  characterized  as  a  saline  sulpho- 
carbonated  water.  It  has  been  found  very  beneficial 
in  chronic  skin  diseases  of  strumous  and  syphilitic 
origin.  In  liver,  stomach,  kidney,  and  bowel  troubles, 
in  uterine  and  ovarian  engorgement,  and  in  glandular 
congestions,  the  water  has  also  proved  to  be  of  much 
value.  It  is  aperient,  diuretic,  and  alterative  in  its 
action. 

The  "Sour  Spring"  is  one  of  the  few  California 
mineral  springs  containing  free  sulphuric  acid.  Its 
sour  taste  was  formerly  supposed  to  be  due  to  alum, 
but  the  following  analysis  by  Mr.  George  E.  Colby,  of 
the  California  State  University  (1889),  shows  that  no 
alum  is  present: 


One  United  States  Gallon  Contains: 

Solids.  Grains. 

Sodium  chloride 0 .  08 

Sodium  sulphate 0 .  49 

Potassium  sulphate ®'„ 

Magnesium  sulphate 4.76 

Calcium  sulphate 2.07 

Ferric  sulphate 0 .  63 

Aluminum  sulphate* 7.11 

Boric  acid  (with  spectroscope) Strong    test. 

Lithium  (with  spectroscope) Well-marked  test. 

Ammonia  (manganous  sulphate) 0 .  33 

Silica 3-94 

Organic  matter Traces. 

Total 20.28 


A  considerable  quantity  of  free  sulphuric  acid  was 
also  revealed  by  the  analysis.  The  temperature  of 
the  water  is  64.3°  F.  It  possesses  tonic,  astringent, 
and  gently  laxative  properties,  and  has  proved  bene- 
ficial in  hemorrhages  from  the  lungs,  menorrhagia, 
and  dyspepsia.  . 

Another  valuable  water  is  the  "  Iron  Spring.  1  he 
following    is    Mr.    Colby's   analysis,    made    in   1S99: 

*  A  microscopic  examination  of  the  residue  obtained  by  slow 
evaporation  fails  to  show  characteristic  crystals  of  alum. 


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One  United  States  Gallon  Contains: 

Solids.  Grains. 

Sodium  chloride 0.18 

Sodium  bicarbonate 0. 19 

Sodium  sulphate 3.42 

Potassium  sulphate 1 .  17 

Maunesium  sulphate 7.36 

Calcium  sulphate 10.88 

Calcium  phosphate 0.15 

Ferrous  carbonate 1.18 

Alumina 0.93 

Boric  acid  (with  spectroscope) Strong  test. 

Lithium  (with  spectroscope) Well-marked  test. 

Manganous  carbonate 177 

Silica 4 .  22 

Organic  matter Small  quantity. 

Total 31.45 

Free  carbonic  acid  gas,  25. SO  cubic  inches. 
Temperature  of  water,  124°  F. 

This  is  a  mild  calcic-chalybeate  water.  It  possesses 
tonic  and  slightly  laxative  properties,  and  is  useful  in 
anemia  and  chlorosis  and  in  conditions  requiring 
restorative  agents. 

Among  other  valuable  springs  in  this  group  may  be 
mentioned  the  "Cosmopolitan,"  an  excellent  drinking 
water,  but  possessing  slightly  laxative  properties;  the 
"Bellmer"  Spring,  a  light  saline-sulphur  water;  the 
"Magnesia  Spring"  (known  also  as  "Father  Joseph's 
Spring"),  a  rich  saline  water  having  valuable  laxative 
properties;  and  the  "Hot  Sulphur  and  Iron"  or  bath- 
ing spring.  These  last  waters  have  a  temperature  of 
14.5.5°  F.,  and  have  been  found  very  beneficial  in  rheu- 
matism, chronic  joint  swellings,  constipation,  and  skin 
diseases.  It  is  claimed  that  the  inhalation  of  the  hot 
sulphurous  steam  of- this  water  is  highly  useful  in  cases 
of  chronic  bronchitis,  incipient  phthisis,  and  catarrhal 
affections  of  the  nose  and  throat.  There  are  good  facili- 
ties for  bathing.  The  incrustations  formed  by  the  hot 
sulphurous  vapors  on  the  surrounding  rocks  are 
gathered  and  powdered  and  used  in  cases  of  chronic 
nasal  catarrh,  as  well  as  for  acute  coryza  and  phar- 
yngitis. This  powder  represents  all  of  the  solid 
mineral  ingredients  found  in  the  water. 

The  pine  forests,  elevation,  and  climate  are  of 
undoubted  value  in  many  subacute  and  chronic 
diseases.  Emma  E.  Walker. 


Andral,  Gabriel. — Born  in  Paris,  France,  on  Novem- 
ber C,  1797.  He  took  his  medical  degree  in  1821. 
In  1830  he  was  made  Professor  of  Internal  Pathology 
at  the  Faculty  de  M<§decine;  and  in  1839  he  accepted, 
as  the  successor  of  Broussais,  the  Chair  of  General 
Pathology  and  Therapeutics.  He  performed  the 
duties  of  the  latter  professorship,  during  a  period  of 
twenty-seven  years,  with  such  distinction  that  he  was 
spoken  of  on  all  sides  as  one  of  the  celebrities  of 
French  medicine.  He  was  also  one  of  the  attending 
physicians  of  La  Charity  Hospital.  In  1S66  An- 
dral retired  from  practice  and  from  his  professorial 
duties.     He  died  on  February  13,  1S76. 

Andral 's  lectures  were  characterized  by  the  ex- 
traordinary clearness  with  which  he  described  all  the 
phenomena  of  disease;  and  this  same  characteristic 
will  be  found  to  exist  in  his  published  writings. 
Of  these  the  two  most  celebrated  are:  "Clinique 
Medieale,"  Paris,  1823-1S27,  five  volumes;  and 
"Traite  d'Anatomie  Pathologique,"  Paris,  1X29, 
three  volumes.  A.  H.  B. 


Andre,  Nicholas. — Born  in  Dijon,  France,  October 
15,  1704.  He  practised  for  years  in  Paris  and 
vicinity,  serving  as  surgeon  to  the  Maison  royale 
de  Saint-Cyr  and  as  charity  surgeon  to  the  parish  of 
Versailles.  His  chief  claim  for  recognition  rests  upon 
the  fact  that  he   invented   urethral   bougies.     Trea- 

346 


Uses  published:  "Dissertation  sur  les  maladies  de 
l'uretre  qui  ont  besoin  de  bougies";  "Observations 
pratiques  sur  les  maladies  de  l'uretre,  et  sur  plusieurs 
faits  convulsifs,  et  la  gudrison  de  plusieurs  maladies 
chirurgieales,  avec  la  composition  d'un  remede  propre 
a  r<?primer  la  dissolution  gangrSneuse  et  cancereuse 
et  a  la  reparer;  avec  des  principes  qui  pourront 
servir  a,  employer  les  differens  caustiques, "  Paris 
1756.  Among  modern  writers  Andr6  seems  to  have 
been  the  first  to  study  and  carefully  describe  tic  doul- 
oureux of  the  face.  A.  H.  B. 

Anei,  Dominic. — Very  little  is  known  about 
Anel's  life.  He  practised  medicine  in  Turin,  Italy, 
in  the  early  part  of  the  eighteenth  century.  His 
reputation  rests  upon  two  facts:  that  he  planned  a 
new  method  of  treating  lacrymal  fistula,  and — of  still 
greater  importance — that  he  was  the  first  to  operate 
upon  aneurysms  according  to  the  method  which  is 
erroneously  ascribed  to  Hunter.  His  more  im- 
portant publications  are:  "Nouvelle  m<5thode  de  guerir 
les  fistules  lacrymales, "  Turin,  1713;  "  Relation 
d'une  enorme  tumeur  occupant  toute  l'etendue  du 
ventre  d'un  homme  cru  hydropique,  et  remplie 
de  plus  de  7,000  corps  strangers,"  Paris,  1722. 

A.  H.  B. 

Anelectrotonus. — See  Eleclrotonus. 

Anemia,  Pernicious  (Addisonian). — Definition. — 
A  chronic  and  usually  fatal  malady,  of  unknown  etiol- 
ogy, whose  chief  features  are  (clinically)  a  reduction, 
at  times  profound,  in  the  number,  and  paroxysmal 
variations  in  the  character,  of  the  red  blood  cells, 
and  (postmortem)  specific  changes  in  the  marrow  of 
the  long  bones. 

History  and  Terminology. — This  disease,  which 
was  first  clearly  described  by  Addison1  in  his  account 
of  that  other  condition,  now  known  as  Addison's 
disease,  has  received  many  names.  It  would  be 
unnecessary  to  record  even  a  few  of  these. except 
that  in  so  doing  one  learns  that  the  clinical  course  of 
the  malady  is  very  varied.  One  case  may  present  a 
rapidly  "pernicious"  (Biermer2)  character,  another 
may  drag  on  for  years,  through  several  relapses  mani- 
festing throughout  a  downward  "progressive" 
(Biermer3)  tendency.  Others  apparently  recover, 
making  both  "pernicious"  and  "progressive"  misno- 
mers (Hunter3). 

Again,  searching  for  a  cause  and  failing,  writers 
have  attempted  to  embody  in  a  term  this  fact  by 
such  names  as  "idiopathic"  (Addison1),  "essential" 
(Immermann3),  "cryptogenic,"  etc.  Another  ob- 
server finds  changes  in  the  alimentary  tract  which  he 
attributes  to  an  undiscovered  toxic  agent,  and  though 
he  considers  this  the  primary  factor  in  the  whole 
disease,  rather  than  employ  any  limiting  adjective 
he  recommends  the  non-committal  term  "Addisonian" 
anemia  (Hunter3).  Following  Ehrlich's  demon- 
stration of  the  blood  changes  in  this  disease,  some 
observers  suggested  the  term  "  normoblastic"  anemia, 
but  closer  investigation  revealing  the  fact  that  in 
the  course  of  the  disease  long  periods  occur  in  which 
there  are  no  nucleated  cells  in  the  peripheral  blood, 
the  term  has  become  one  of  that  long  list  of  names 
descriptive  of  inconstant  symptoms  or  signs  and  in 
consequence  has  never  been  adopted. 

As  stated  above  the  review  of  these  attempts  to 
name  the  disease  presents  its  features  far  more  vividly 
than  could  any  word  or  group  of  words  by  which  to 
term  it.  If  we  were  to  give  a  complete  list  of  these 
names  ("essential,"  "malignant,"  "essential  febrile," 
etc.)  and  add  a  few  definitions  ("producing  usually 
in  elderly  men  paroxysms  of  intense  anemia  and 
usually  degenerations  of  the  cord")  it  would  be  found 
that  many  constant  and  transient  or  accidental 
features  of  the  disease  as  well  as  the  theories  regarding 
its  origin  had  received  notice  in  some  term  or  defini- 
tion.    To-day  the  term  "pernicious  anemia"  is  that 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


\  Mi-nil. i.  Pernicious 


mosl   employed  and  aa  a  label  merely  it  will  serve 

quite  as  well "us  more  descriptive  titles.  The  addition 
of  Addison's  name  is  not  unsuitable.  Pernicious 
(Addisonian)  Anemia  then,  in  our  present  stale  of 
knowledge    regarding   the   disease,    seems   the    most 

appropriate. 

Etiology. — The  etiology  is  unknown.  Much  that 
has  been  written  regarding  supposed  factors  has  been 
proven  to  be  merely  records  of  associated  or  inter- 
current diseases  which  were  probably  induced  by, 
.  i.-.l  as,  aggravating  factors  in  an  already  destruc- 
process.     Thus  in  the  Zurich  cases  reported  bj 

I  erow  shortly  after  Biermer's  original  paper  (also 
:  ruses  observed  in  Zurich)  the  condition  was  re- 
corded in  five  pregnant  women.  Hemorrhage,  the 
menopause,  nervous  strain  or  shock,  malaria  (Ewing), 
inanition,  syphilis  have  appeared  too  inconstantly, 
in  the  many  hundreds  of  cases  now  on  record,  to 
warrant  accepting  them  as  real  agents  in  so  fatal  a 
disease.  Two  conditions,  however,  deserve  consid- 
eration here:  A  disease  identical  with  pernicious 
anemia  occurs  from  the  action  of  the  intestinal  para- 
sites, Dibothriocephalus  latus  (fishworm)  (Schaumann) 
and  an  almost  identical  anemia  in  that  caused  by 
the  Uncinaria  (hookworm).  The  removal  of  these 
causes  early  enough  is  followed  by  immediate  im- 
provement and  rapid  recovery.  These  deserve 
mention  in  a  discussion  on  etiology  because  of  the 
blood  destruction  which  is  identical  or  almost  iden- 
tical with  that  due  to  the  undemonstrable  factor  in 
the  disease  now  under  consideration.  While  the 
hookworm  may,  and  probably  in  the  majority  of 
inst  tnces  does,  gain  entrance  to  the  system  through 
the  skin,  its  seat  of  chief  activity  is  in  the  intestine. 
There  is  something  suggestive  in  this  location  of  a 
proven  factor  and  in  Hunter's  claim  of  an  oral,  gastric, 
and  intestinal  sepsis  as  one  of  the  factors  in  pernicious 
anemia.  Hunter  recognizes  two  factors  in  perni- 
cious anemia:  (1)  a  blood  destruction  (hemolysis)  and 
(■J)  a  chronic  septic  infection  in  which  there  usually 
occurs  a  specific  glossitis,  and  oral,  gastric,  and 
intestinal  sepsis.  While  the  parasites  above  men- 
tioned are  capable  of  producing  the  counterpart  of 
pernicious  anemia,  such  anemia  should  not  be  classified 
under  primary  pernicious  anemia.  In  a  discussion 
upon  the  etiology  of  pernicious  anemia,  however,  they 
have  an  important  bearing. 

Although  unsupported  conclusively  by  experi- 
mental or  clinical  evidence,  such  evidence  (Bunting, 
Schumann,  Hunter)  as  we  do  possess  justifies  us  in 
considering,  theoretically,  that  a  toxie  agent,  acting 
over  a  considerable  period  is  the  hemolytic  factor; 
that  the  blood-forming  apparatus  strives  to  replace 
the  blood  loss,  but  ultimately  itself  is  unable  ade- 
quately to  meet  the  enormous  demand  for  new  cells. 
That  the  products  of  sepsis  are  highly  hemolytic  is 
well  known,  that  a  small  undetectable  focus  of  pus 
may  be  a  fertile  source  of  toxemia,  and  that  such  a 
focus  may  be  active  over  long  periods  without  mani- 
festing any  marked  clinical  symptoms  or  signs — all 
these  are  well-known  facts. 

While  no  definite  conclusions  can  be  drawn  from 
any  of  these  facts  it  is  well  to  rehearse  them  in  order 
that  the  physician  may  be  vigilant  in  detecting  small 
smouldering  areas  of  septic  infection.  It  is  possible 
that  pernicious  anemia,  as  we  see  it  clinically-,  is  the 
last  and  hopeless  stage  of  a  long  standing  toxemia 
which,  were  it  detected  before  the  blood-making 
apparatus  has  been  "worked  to  death,"  could  be 
checked.  Much  of  this  theoretical  reasoning  is 
supported  by  the  widespread  pathological  changes 
observed  in  the  body  after  death — which  we  shall 
now  consider. 

Pathology. — The  postmortem  findings  in  perni- 
cious anemia  show:  (1)  That  there  has  been  an 
agent,   powerfully   destructive  (toxic)  at  work  upon 


many  of  the  body  tissues  for  a  comparatively  long 
period  of  time;  (2)  That  hemolysis  is  a  prominent 
result  of  this  toxemia;  (3)  That  the  blood,  being 
Called  Upon  not  only  to  defend  and  repair  its  own 
Constituents  but  also  tO  supply  defensive  and  re- 
parative material  to  the  body  as  a  whole,  suffers 
most  prominently;  (  1)  That  the  effort  at  repair  is 
carried  to  its  utmost  limit  by  the  erythrogenetic 
tissues  in  the  bone  marrow. 

The  body  as  a  whole  presents  no  emaciation  and  at 
times  an  excess  of  adipose.  This  may  appear  in 
small  aggregations  of  fat  about  the  chest,  abdomen, 
arms,  and  thighs.  The  skeletal  muscles  are  bright 
red;  all  the  organs  are  extremely  pale.  There  fre- 
quently occur  hemorrhages  upon  t  he  serous  surfaces 
and  effusions  into  the  various  cavities.  Fat  again 
appears  as  a  degeneration  of  the  heart,  of  the  liver, 
and  of  the  kidneys. 

In  the  heart,  the  fat,  which  occurs  especially  in 
the  papillary  muscles,  gives  to  it  a  speckled  appear- 
ance (faded  leaf;  tiger  lily)  due  to  the  numerous  small 
yellowish-white  areas  of  fat  replacing  the  muscle  fiber. 
There  may  be  small  hemorrhages  upon  the  endo- 
cardium and  the  heart  may  be  slightly  enlarged,  but 
beyond  a  moderate  widening  of  the  mitral  ring  there 
is  usually  no  endocardial  or  valvular  disease. 

The  liver  is  slightly  enlarged  and  yellow.  In  this 
organ  we  find  the  evidences  of  hemorrhage  in  the 
presence  of  an  iron  deposit.  This  iron-bearing  pig- 
ment occurs  in  the  kidneys,  especially  in  the  cortex, 
the  lymph  glands,  and  the  spleen  as  well  as  in  the 
liver. 

The  spleen  is  usually  small,  showing  atrophy  with 
great  cellular  poverty.  This  organ  is  in  direct  con- 
trast to  the  marrow  in  that,  while  regeneration  is  the 
feature  of  the  marrow,  destruction  is  the  chief  change 
in  the  spleen.  The  lymph  glands  like  the  spleen 
show  destructive  (hemolysis)  rather  than  reconstruc- 
tive changes.  It  is  as  yet  impossible  to  say  where 
the  blood  destruction  takes  place,  but  that  blood 
destruction,  rather  than  failure  at  blood  production, 
is  primarily  the  cause  of  the  anemia  seems  well  sup- 
ported by  this  (iron-bearing  pigment)  evidence  of 
hemolysis. 

The  stomach  and  intestinal  tract  have  been  the  sub- 
ject of  much  discussion  owing  to  the  evidences  of 
atrophy  of  the  mucosa  which  many  (not  all)  cases 
show.  If  a  toxin  is  attacking  the  tissues  of  the  body 
it  is  quite  possible  that  some  of  these  would  resist 
longer  than  others  and  that  we  should  have  one 
system,  the  spinal  cord  for  example,  more  prominently 
affected  in  one  case,  the  gastrointestinal  tract  in 
another,  etc.  That  the  toxin  has  its  origin  in  the 
intestinal  tract  is  an  attractive  theory,  but  it  has  not 
as  yet  been  supported  by  evidence.  It  has  even  been 
suggested  that  these  gastrointestinal  changes  may 
be  postmortem  phenomena  (Cabot),  but  one  cannot 
dismiss  all  the  extensive  destruction,  macroscopic  and 
microscopic,  which  is  to  be  seen  in  the  gastrointes- 
tinal mucosa,  with  this  explanation.  In  Nothnagel's 
Encyclopedia  will  be  found  a  complete  discussion  of 
this  subject. 

The  Bone  Marrow. — The  normal  marrow  of  the  long 
bones  is  semisolid  and  yellow  in  color.  Microscopic- 
ally it  shows  large  roundish  nucleated  cells  (myelo- 
cytes, marrow  cells)  and  fat  globules.  It  is  with  diffi- 
culty that  the  beginner  detects  the  cellular  elements 
of  the  normal  yellow  marrow.  In  marked  contrast, 
however,  is  the  marrow  in  a  person  dying  from  perni- 
cious anemia.  Instead  of  being  yellow  it  is  red  and 
the  semisolid  has  changed  to  a  more  liquid  consistency. 
Microscopically  this  marrow,  even  to  a  beginner,  can 
be  seen  to  be  made  up  of  many  varieties  of  cells. 
There  are  few  fat  cells,  but  the  nucleated  cells  (ery- 
throblasts),  both  large  (megaloblasts)  and  small 
(normoblasts),  are  distinctly  seen.  This  presence  of 
nucleated  cells,  in  a  situation  normally  occupied  by 
yellow   marrow,   means  a  greatly  increased   activity 


347 


Anemia,  Pernicious 


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of  the  blood-forming  tissues  (erythrogenetic  tissues). 
There  is  no  ground  for  assuming  that  the  active  agi'iit 
in  the  disease  (toxin)  has  a  selective  action  on  the 
erythrogenetic  centers.  It  would  seem  rather  that  the 
extreme  hemolysis  affects  the  whole  blood-forming 
process,  causing  leucoblastic  as  well  as  erythroblastic 
activity.  The  former  is  manifested  by  an  increase  in 
mononuclear  lymphocytes  and  by  the  presence  of 
myelocytes.  These  observations  bring  the  blood  dis- 
eases (anemia,  leucemia,  etc.)  into  much  closer  relation 
than  was  formerly  believed. 

If  instead  of  blood  destruction  (hemolysis)  anemia 
is  produced  by  fatal  hemorrhage  (in  an  animal),  or  if 
there  is  stasis  from  pressure  or  cardiac  disease,  or 
if  hemolysis  takes  place  rapidly  from  an  active  toxic 
agent  introduced  into  the  body,  such  marrow  shows 
numerous  normal  red  cells  with  a  varying  number  of 
small  nucleated  red  cells  (normoblasts)  and  no 
megaloblasts  and  no  hyperplasia  of  the  red  cell-forming 
portions  of  the  marrow.  This  is  taken  to  mean  that 
if  mechanical  or  hemolytic  agencies  act  for  short 
periods  of  time  the  destructive  effects  will  be  different 
from  those  (especially  if  it  be  a  hemolytic  toxic  agent) 
working  over  a  long  period  of  time.  That  such  a 
destructive  agent  is  probably  still  at  work  up  to  the 
time  of  death  in  pernicious  anemia  is  suggested  by 
the  fact  that  when,  even  in  extreme  anemia,  the 
cause  is  removed,  as  is  possible  in  dibothriocephalus 
and  uncinaria  disease,  the  blood  promptly  returns  to 
normal. 

This  megaloblastic  degeneration  then  is  the  chief 
feature  of  the  long  bone  marrow  of  pernicious  anemia. 

In  the  embryo  and  for  some  time  after  birth  the 
marrow  of  the  long  bones  contains  little  fat,  being 
similar  in  many  respects  to  that  seen  in  pernicious 
anemia.  That  is  to  say,  the  long-bone  marrow  in 
advanced  pernicious  anemia  takes  on  or  reverts  to  the 
fetal,  embryonic,  or  infantile  type.  This  reversion 
to  a  primitive  characteristic  is  taken  to  mean  a 
desperate  effort  of  the  blood-forming  apparatus  to 
use  every  resource,  even  an  outgrown  one,  as  it  were, 
in  order  to  meet  the  overwhelming  demand  for  new 
blood.  This  red  marrow  with  the  cellular  con- 
stituents, above  described,  is  found  normally  in  the 
cancellous  portion  (diploe)  of  the  cranial  bones, 
vertebra,  ribs,  sternum,  and  articular  ends  of  the 
long  bones. 

To  sum  up  then: 

I.  The  yellow  marrow  in  the  normal  adult  is  situ- 
ated in  the  cavities  (medullary  portion)  of  the  long 
bones.  It  consists  of:  (1)  Net-work  of  fibrous  tissue; 
(2)  blood-vessels,  numerous;  (3)  fat  islands  and 
globules  in  quantity;  (4)  marrow  cells  (myelocytes), 
large  nucleated  ameboid  cells,  few  in  number. 

II.  The  red  marrow  in  the  normal  adult  is  situated 
in  the  marrow  spaces  (diploe)  of  the  cranial  bones 
and  in  the  same  spaces  (cancellous  tissue)  of  the  verte- 
bra?, ribs,  and  sternum.  It  consists  of:  (1)  Capillary 
net-work,  dense;  (2)  fat  islands  and  globules  (few 
in  number),  and  between  these  are  (3)  germinal 
areas:  (a)  erythroblastic  germinal  centers,  and  (b) 
leucoblastic  germinal  areas.  From  these  the  follow- 
ing cells  arise:  (4)  Cytoblast — large  and  nucleated, 
the  mother  megaloblast;*  (5)  megaloblast — later 
generation  than  No.  4;  (6)  normobast — small  nucle- 
ated, immediate  forerunner  of  the  red  blood  cell;  (7) 
non-nucleated  red  blood  cell;  (8)  mononuclear  neutro- 
phile  (myelocyte)  and  its  derivative  the  polynuclear 
neutrophile;  (9)  mononuclear  eosinophile  (myelocyte) 
and  its  derivative  the  polynuclear  eosinophile;  (10) 
mononuclear  basophile  and  its  derivative  the  (Roman- 
owsky  staining)  mast  cell;  (11)  giant  cell  or  macro- 
phage (15  to  50  /k).  Mono-  or  polynuclear — in- 
tensely staining,  non-granular;  (12)  megacaryocyte — 
smaller  than  No.  11,  irregularly  shaped,  pale  staining, 

*  This  cell  differs  in  the  intensity  of  its  basophilic  nuclear  stain- 
ing from  later  generations  of  megaloblasts  and  is  thought  to  be 
the  common  ancestor  of  both  red  and  white  cells. 

348 


eccentrically  placed  nucleus;  non-granular.     Nos.   11 
and   12   are  the  chief  phagocytes  of  the  blood. 

In  the  embryo,  in  early  infancy,  and  in  pernicious 
anemia,  either  from  unknown  etiology  or  from  un- 
cinaria or  dibothriocephalus,  the  red  marrow 
with  all  its  cellular  characteristics  will  be  found  in 
the  shaft  of  the  long-bone  marrow.  This  process 
which  in  pernicious  anemia  is  known  as  hyperplasia 
of  the  marrow  or  reversion  to  the  fetal  type  (hyper- 
plasia of  the  erythrogenetic  areas  or  centers,  megalo- 
blastic   metamorphosis    or    degeneration,    medullary 


Fig.  194. — The  Spinal  Cord  from  a  Case  of  Pernicious  Anemia, 
Showing  Destruction  and  Cavity  Formation  in  the  Gray  Matter 
of  the  Left  Side.  (This  and  the  following  illustration  are  repro- 
duced, by  permission,  from  the  Am.  Journal  of  Vie  Med.  Sciences.) 

hyperplasia),  is  not  found  in  ordinary  secondary 
anemia  and  so  constitutes  a  most  important  differen- 
tial feature. 

It  is  well  to  add  that  the  whole  marrow  process, 
right  up  to  the  time  of  death,  is  one  of  active  regen- 
eration, having  no  suggestion  of  atrophy  or  cessation 
of  formative  activity,  and  it  is  this  which  strongly 
suggests  that  the  widespread  toxemia  has  been  the 
cause  of  death  and  not  either  the  anemia  or  a  failure 
on  the  part  of  the  blood-making  apparatus  which 
may  be  said  to  die  fighting. 


Fig.  195. — The  Spinal  Cord  from  a  Case  of  Pernicious  Anemia. 
Showing  Extensive  Destruction  of  the  Gray  Matter  of  the  Left 
Side. 

The  Spinal  Cord. — The  changes  found  in  the  cord 
are  taken  as  another  evidence  of  a  toxemia  as  the 
primary  factor  in  the  disease.  In  support  of  this  is 
the  fact  that  clinical  manifestations  of  cord  damage 
sometimes  antedate  the  anemia.  At  the  same  time  a 
small  percentage  of  pernicious  anemia  cases  (under 
twenty  per  cent.)  show  no  involvement  of  the  cord  post- 
mortem. Of  the  combined  sclerosis  cases  ten  per 
cent,  have  been  shown  to  be  associated  with  pernici- 
ous anemia.  This  would,  however,  be  in  favor  of 
a  toxic  agent  rather  than  anemia,  because  anemia 
produces  uniform  changes,  whereas  it  is  well  known 
that  the  lesions  of  toxins  are  quite  irregular  in  dis- 


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\in  mi.i.  Pernicious 


trfbution  and  degree.     For  example  endocarditis,  arth- 
ritis meningitis,  pneumonia  are  not  constant  associates 
eptic  infection.     Combined  trad  degeneration  and  of 
at  least  degenerative  changes  in  the  posterior  columns 
have  been  noted  with  identical  appearance  in  some 
twenty  varieties  of  chronic  toxic,  cachectic,  or  anemic 
litions.    The  large  percentage  of  cases  of  perni- 
3  anemia  presenting  spinal  cord  lesions  lias  led 
ie  authors  to  incorporate  the  latter  as  a  definite 
feature  of   the  disease.      it    would   seem   more  correct 

to  consider  it  an  additional  evidence  of  the  action  of  a 


196. — The  Spinal  Cord  from  a  Case  of  Pernicious  Anemia, 
Showing  Swelling  of  the  Cray  -Matter  of  the  Left  Side  from 
Edematous  Separation  of  the  Tissues. 


toxin  in  common  with  the  other  lesions  attributable  to 
toxins,  but  not  constant  in  occurrence  or  degree. 
There  are,  as  a  rule,  no  gross  changes  in  the  cord. 
There  may,  however,  be  distinct  areas  of  swelling 
which  will  indicate  the  position  of  an  underlying 
destruction  of  gray  matter  which  destruction  may 
extend  almost  to  the  surface  of  the  cord. 

The  cervical  region  is  that  most  commonly  in- 
volved, but  the  destruction  may  affect  any  portion 
of  the  cord.  The  severity  of  the  destructive  process 
will  usually  be  found  to  become  less  from  above 
downward.  Microscopically  there  may  be  patchy 
degeneration  especially  of  the  posterior  and  lateral 
columns. 


Fig.  197. — The  Spinal  Curd  from  a  (  ase  of  Pernicious  Anemia, 
Showing  Patchy  Degeneration  of  the  Posterior  Columns. 

The  destruction  may  amount  to  a  well-defined 
cavity  formation  in  the  gray  matter  without  any 
inflammatory  reaction  or  sclerosis  surrounding  it. 
The  illustrations  here  given  are  more  expressive  than 
text  description.  The  reader  is,  therefore,  referred  to 
them  for  more  detailed  histological  features  of  these 
changes. 

No  pathological  changes  are  found  in  the  brain 
except  minute  scattered  hemorrhages  in  the  brain 
substance. 


Clinical  Course.  Of  cither  symptoms  or  -inns 
in  the  early  stage  of  this  disea  •■  practically  nothing  is 
know  n.     Undoubtedly    were   the   milder   complaints 

which  are  seen  in  i he  dispensary  studied  by  trained 

Clinicians    aided     by    laboratory    experts    and      their 

oil  ervations  properly  recorded,  a  consecutive 
of  the  disease  from  its  incipiency  could  be  bad.  Per- 
nicious anemia  is  accidentally  discovered  in  mo  I 
instances.  There  are  asthenia,  heart  palpitation, 
shortness  of  breath  or  slight  edema,  and  the  individ- 
ual seeks  medical  aid.     other  symptoms  are  referable 

to  the  gastrointestinal  tract — diarrhea,  loss  of  appetite, 
vomiting.     Jaundice    and    epistaxis    are    bul     rarely 

met  with. 


q£>    ^:--:  •  ->  ■,*-♦■ 
•!Wt--'.  i>  •• 

m 


Fig.  198. — The  Spinal  Cord  from  a  Case  of  Pernicious  Anemia, 
Showing  the  Microscopic  Appearances  of  the  Gray  Mutter  in  the 
Section  Shown  in  Fig.  197.  The  small  veins  are  surrounded  by 
distended  perivascular  spaces  and  one  of  them  is  filled  by  a 
recent  thrombus. 

The  word  "febrile"  it  will  be  remembered  was  in- 
corporated into  one  of  the  many  descriptive  names 
given  this  disease.  It  is  well  to  remember  that  fever 
is  not  an  uncommon  associate  of  the  more  advanced 
stages  of  pernicious  anemia.  It  is  impossible  to  state 
any  symptom-complex,  even  in  the  fairly  well  ad- 
vanced stage  of  the  disease.  The  important  point, 
here,  then,  is  that  many  other  conditions  are  suspected 
before  pernicious  anemia  is  thought  of.  This  can- 
not be  emphasized  too  strongly — a  heart  lesion  or 
nephritis  or  both,  in  the  majority  of  cases,  are  thought 
to  be  the  real  malady.  Perhaps  there  are  two  reasons 
for  this — first,  because  of  the  signs  pointing  to  both  the 
heart  and  the  kidneys,  and  second,  because  it  is 
hard  for  the  physician  to  believe  that  one  can  walk 
about  with  a  blood  count  of  two  and  one-half  million 


349 


Anemia,  Pernicious 


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cells.  The  asthenia  is  usually  taken  to  mean  cardiac 
incompetency  but  it  is  often  the  only  symptom  of  a 
profound  toxemia  with  a  red  cell  count  of  a  little  over 
2,000,000  and  the  physician  is  thrown  off  the  right 
track  by  the  fact  that  the  patient  "walked  in." 
This  feature  of  the  disease  is  probably  due  to  the 
fact  that  the  destructive  process  has  worked  grad- 
ually. A  healthy  individual  whose  blood  is  re- 
duced suddenly  by  hemorrhage  to  2,000,000  is  pros- 
trated. Here  is  another  evidence  that  the  disease  is 
of  long  standing  before  symptoms  develop.  It  per- 
haps also  shows  that  the  reserve  power  of  the  blood, 
like  that  of  many  other  organs,  is  considerable. 
Though  there  are  symptoms  in  the  advanced  cases 
pointing  to  the  heart  (palpitation,  dyspnea),  these  are 
not  as  marked  as  in  primary  cardiac  disease,  because 
the  patient  with  pernicious  anemia  rarely  attempts 
violent  physical  effort.  .Some  patients  become  very 
irritable  and  being  unwilling  to  seek  medical  aid  as 
they  "feel  perfectly  well,"  it  is  through  a  member  of 
the  family  that  the  report  of  this  irritability  reaches 


Fig.  199. — The  Spinal  Cord  from  a  Case  of  Pernicious  Anemia, 
Showing  Combined  Degeneration  of  the  Posterior  and  Lateral 
Tracts.  The  direct  pyramidal  tracts  are  also  considerably  degene- 
rated. 

the  physician.  This  indefinite  group  then  com- 
pletes the  symptoms  of  the  early  and  advanced  stage. 
Vertigo,  headache,  numbness  and  tingling  of  the 
extremities  may  be  complained  of,  and  in  the  late 
stage  of  the  disease  symptoms  referable  to  the  lo- 
comotor apparatus  may  be  present.  The  patient 
may  stagger  slightly,  the  Romberg  symptom  being 
present  in  some  cases,  so  that  tabes  and  multiple  sclero- 
sis are  diagnosed  without  the  blood  condition  being 
suspected.  Such  cases  have  had  the  diagnosis  of 
pernicious  anemia  made  at  autopsy  only.  Hemor- 
rhage from  the  nose  and  other  mucous  membranes  is 
not  common.  Even  at  the  late  stage  asthenia  stands 
out  as  the  distinctive  feature  but  this,  like  many  of  the 
associated  symptoms,  is  quite  compatible  with  other 
suspected  pathological  conditions,  especially  cardiac 
and  renal  disease.  Perhaps  a  distinctive  feature  is  to 
be  found  in  the  fact  that  these  people  even  after  or 
during  a  second  or  third  paroxysm  of  profound 
anemia  often  insist  upon  continuing  at  work  or 
business  and  declare  they  "feel  quite  well."  This 
is  unlike  the  cardiac  or  renal  case.  There  are  then 
no  symptoms  peculiar  to  pernicious  anemia. 

Physical  Signs.  Early  Stage. — As  with  symptoms 
we  know  practically  nothing  definitely  of  the  early 
signs  of  pernicious  anemia. 

Advanced  Stage. — When,  however,  the  patient 
begins  to  fail  he  seeks  medical  aid.  This  may  be 
during  one  of  the  paroxysms  of  profound  blood  defici- 
ency, at  which  period  a  positive  diagnosis  can  be 
made  by  the  blood  picture.     If,  however,  the  patient 


is  seen  between  such  paroxysms  he  may  present  fea- 
tures of  a  secondary  anemia,  such  as  occurs  from  any 
of  the  common  causes — neoplasm,  nephritis,  cardiac 
disease,  etc.  The  retention  or  excess  of  fat  will  be  an 
important  sign.  The  patient  looks  ill — very  ill — yet  he 
is  fat;  the  fat  can  often  be  picked  up  from  the  abdomen 
in  thick  folds.  The  shoulders,  the  thighs,  and  the  hips 
are  well  rounded  out  with  fat.  There  may  be  small 
aggregations  of  fat  in  the  abdominal  wall  and  about 
the  back  and  neck,  which  might  be  mistaken  for 
metastases  from  a  malignant  growth.  A  wasting 
disease  (especially  portal  cirrhosis)  in  those  who  have 
been  obese  but  who  are  beginning  to  lose  flesh,  will 
sometimes  present  this  appearance  of  fatness,  but 
such  cases  usually  show  the  lineae  atrophica?  in  the 
skin  of  the  hips  and  shoulders  and  axilke,  due  to  the 
loss  of  the  underlying  fat.  Pernicious  anemia  patients 
are  well  rounded  out  with  fat  even  at  death.  This 
point  has  not  been  sufficiently  emphasized  in  the 
clinical  description  of  this  disease.  In  marked  con- 
trast with  this  plump  body  is  the  yellow  white  color, 
which  gives  at  once  the  impression  that  the  individual 
is  ill;  the  yellow  tinge  may  be  detected  in  the  con- 
junetme  and  by  pressing  a  glass  slide  upon  the  lips. 
The  appearance  is  not,  as  a  rule,  that  of  jaundice;  one 
must  look  closely  for  the  yellow  color,  compare  it  with 
a  normal  skin,  and  so  convince  himself  that  it  is  not 
the  dough  white  of  chronic  Bright's,  the  brown  white 
of  cachexia,  or  the  light  yellow  of  hepatic  disease. 
The  blue  veins  stand  out  markedly  in  the  yellow 
white  skin;  the  conjunctiva?  as  mentioned  above  show 
a  light  yellow  tinge,  this  differing  from  the  blue 
white  sclera  of  chlorosis  which  resembles  the  white  of  a 
hard-boiled  egg.  The  conjunctiva;  in  chronic  Bright's 
have  a  pearly  whiteness  and  do  not  show  any  yellow 
tinge.  A  fairly  plump  but  ill-looking  individual  with 
a  yellow  white  skin,  slightly  yellow  tinged  conjunctiva, 
complaining  of  an  undefined  sense  of  weakness,  but 
who  is  able  to  walk  about  and  insists  on  continuing 
with  his  business  (provided  this  does  not  involve 
more  than  ordinary  physical  effort)  is  one  in  whom 
pernicious  anemia  should  be  strongly  suspected.  It 
is  between  paroxysms,  when  the  blood  picture  is  not 
typical,  that  these  clinical  features  are  of  great  value 
in  detecting  pernicious  anemia. 

The  heart  examination  reveals  very  little  or  no 
displacement  of  the  impulse  or  enlargement  of  the 
heart,  but  the  systolic  thrust  may  be  rather  widely 
distributed  and  fairly  forcible.  The  blood  pressure 
is  exceptionally  low.  At  times  there  may  be  an 
acceleration  and  slight  irregularity  of  the  heart.  The 
systolic  impulse  may  be  quite  marked  at  the  base  of 
the  heart  and  in  the  arteries  of  the  neck.  The  jugu- 
lar pulsations  are  visible  but  are  not  systolic  in  time 
(negative  pulsation).  This  combination  of  pulsa- 
tions requires  careful  analysis — at  times  with  the 
sphygmograph — in  order  that  very  misleading  con- 
clusions be  not  accepted.  Their  explanation  has  been 
set  forth  by  many  observers,  but  neither  experimental 
nor  postmortem  findings  have  placed  these  explana- 
tions beyond  the  realm  of  theory. 

To  one  not  familiar  with  the  blood  in  this  disease  it 
might  be  inferred  that  a  blood  examination  would  at 
once  settle  the  diagnosis.  The  whole  blood  picture 
will  be  discussed  later,  but  it  is  well  to  state  here  that 
all  the  foregoing  symptoms  and  signs  may  be  present 
and  yet  the  blood  present  a  reduction  only  in  the 
hemoglobin  and  red  cells,  an  irregularity  in  size  and 
shape  and  a  high  color  index  and  possibly  an  increase 
in  the  small  mononuclear  cells.  In  other  words,  the 
blood,  if  seen  between  the  paroxysms  of  profound 
anemia,  is  by  no  means  distinctive.  The  high  color 
index  and  the  increased  small  mononuclear  percentage 
would  be  in  favor  of  the  diagnosis  of  pernicious  anemia, 
and  should  prompt  the  physician  to  keep  the  patient 
under  close  observation.  The  paroxysmal  character  of 
the  blood  changes  in  this  disease  is  frequently  over- 
looked and  cannot  be  too  emphatically  insisted  upon. 


350 


REFERENCE   HAXDBOOK   OF   THE    MEDICAL   SCIENCES 


Anemia,  Pernicious 


\  systolic  murmur  is  usually  hoard  along  the  .sternum, 
,i  the  apex  or  above  the  clavicU — often  at  all  these 
es  with  equal  intensity.  Diastolic  murmurs  are 
r,l,.,l,  but  their  cause  is  a  matter  of  surmise  a  no 
ms  postmortem  have  been  found  to  account 
o.  Extreme  dilatation  is  rare  and  tricuspid 
insufficiency  is  uncommon. 

It  will  be  seen  that  the  physician  could  very  res  son 
ably  take  the  dyspnea  and  asthenia  to  mean  a  failing 
compensation  in  a  heart  too  damaged  to  produce  e\  i- 

dence  of  valve  lesion.      Cases  of  pernicious  anemia  are 

frequently  sent  to  the  hospital  with  this  diagno 

lungs  with  the  exception  of  an  occasional  pleural 
effusion  are  negative.     The  liver  may  be  just  palpable, 
spleen  is  usually  not  palpable.     The  urine   is 
usually  pale,  normal  in  quantity,  varying  in  specific 
gravity,  and  shows  serum  albumin,  distinct    trace, 
with  finely  granular  and  hyaline  casts.     Examination 
of   the   eye-grounds   may    reveal    large   hemorrhagic 
3  (flame  spots)  though  personally  I  have  not  seen 
these  except  in  the  far  advanced  cases.      In  fact  hem- 
orrhages (petechias,  epistaxis,  etc.)  are  not  common 
until  very  late  in  the  disease,  then  they  may  be  exten- 
sive and  occur  on  any  of  the  serous  or  mucous  sur- 
3,     This,  together  with  slight  edema  of  the  extrem- 
(usually  legs,  but  sometimes  hands,  very  rarely 
face)  and  occasionally  the  serous  effusions  above 
referred  to  and  the  signs  in  the  heart  almost  uniformly 
to  ih"  overlooking  of  the  blood  condition.      If 
pallor  of  the  skin  has  been  noted  by  the  physician 
he  is  apt  to  dismiss  this  with  the  statement  "second- 
ary anemia."    It  is  well  to  emphasize  this,  for  scarcely 
a  year  passes  in  a  hospital  service  without  the  cardial'. 
renal,  or,  as  will  be  seen  presently,  the  nervous  signs 
and    symptoms    masking    the    blood    condition    and 
deferring  the  diagnosis  to  a  week  or  more  after  the 
patient's  admission  and  even  till  his  autopsy,  as  not 
Infrequently    occurs,    when    the    nervous   symptoms 
have  been  those  most  evident. 

In  the  gastrointestinal  tract  the  absence  of  hydro- 
chloric acid  (achvlia)  in  the  gastric  contents  is  an 
early  and  fairly  constant  finding.  This  occurs  with- 
out'reference  to  the  symptoms  and  its  significance 
i<  by  no  means  understood.  One  is  tempted  into 
theoretical  explanations  which  are  without  foundation 
in  clinical,  experimental,  or  postmortem  evidence 
\s  a  clinical  sign,  in  pernicious  anemia,  it  is  very  con- 
i.  but  with  regard  to  the  stage  or  severity  of  the 
disease  it  vields  us  no  information. 

The  changes  in  the  nervous  system  (spinal  cord) 
have  been  so  constant  that  some  writers  have  incor- 
porated these  into  a  definition  of  the  disease.  In  the 
ion  on  pathology  in  this  article  will  be  found 
photographs  of  sections  of  the  cord  illustrating  the 
histological  changes  which  occur.  At  what  stage  in 
the  disease  these  changes  occur  is  difficult  to  deter- 
mine. Clinical  manifestations  are  very  variable. 
The  tingling  and  numbness  observed  early  have  been 
attributed  to  the  action  of  toxins  upon  the  cord. 
There  may  be  paresthesias  and  spastic  paraplegia  and 
signs  of  multiple  sclerosis  and  of  tabes,  the  two  latter 
diagnoses  being  made  at  times  without  pernicious 
niia  being  discovered  till  autopsy.  There  may 
aNo  lie  practically  no  neurological  features  clinically, 
vet  extensive  cord  destruction  be  found  at  autopsy. 
That  these  cord  lesions  cannot  be  produced  by 
ischemia  alone  seems  proven.  It  is  therefore  reason- 
able to  conclude  that  the  destruction  is  rather  the 
result  of  a  toxemia  than  of  an  anemia,  and  that  the 
cord,  like  the  blood  and  other  tissues,  is  a  victim  in 
the  general  destruction. 

In  the  late  stage  of  the  disease  these  neurological 
features  may  eclipse  all  others  and  the  case  may  go 
to  autopsy  as  exclusively  a  tabes,  a  multiple  or 
lateral  sclerosis,  etc.  Neurological  features  being 
present  or  absent  and  the  diagnosis  of  pernicious 
anemia  having  been  made,  there  may  develop  slight 
delirium  but  the  asthenia  is  now  so  profound  that  this 


i>  never  active.  The  patient  usually  sinks  into  coma, 
in  which  he  may  remain  for  two  or  three  days  when 
death  takes  place. 

There   are   no  complications  of  this  di  \ny 

feature  such  as  hemorrhage,  eord  lesions,  etc.,  which 
might  lie  considered  a-  a  complication  is  attributed 
to  the  hemolytic  and  toxic  action  of  the  undiscovi 

poison  assumed  to  be  the  active  agent  in  the  di  • 

Relapses  and  Duration. — A  most  important 
feature  of  the  disease  is  «  tendency  t"  improvement 
with  subsequent  relapses.     The  number  of  relapse     i 

patient  may  go  through  would  appear  to  be  limited 
in  the  majority  of  eases  to  three.      After  two 
ysms   of  profound  anemia,   one  has  grave  doubts  re- 
garding  the   outcome   of   the   third.     These   may  be 
spread   over  one  year  or  five,   seven,  or  ten  years.     I 

have  seen  no  case  last  beyond  five  years.  When  a 
patient  dies,  apparently  in  the  first  paroxysm,  it  is 
difficult  to  say  whether  he  has  not  "worked  through" 
former  attack's  without  consulting  a  physician.  The 
blood  changes  during  and  between  these  attacks  will 
be  now  considered. 

The  Peripheral  Blood. — (For  a  study  of  the  bone 
marrow  see  "The  Bone  Marrow"  under  "Pathology" 
in  this  Article,  p.  347.)  An  individual  presenting  some 
or  all  of  the  above  symptoms  and  signs  may  be  in  one 
of  several  degrees  of  blood  destruction  when  the  physi- 
cian sees  him.  The  most  distinctive  of  these  are 
the  following: 

I.   /  ,ind  Interparoxysmal  Stage. — Moderate 

reduction  of  hemoglobin  (oligochromemia)  and  red 
blood  cells  (oligocythemia)  (3,500,000).  Color  index 
high.  Variations  in  size  and  shape  (anisocytosis)  of 
the  red  blood  cells.  Variations  in  the  intensity  of  the 
staining  of  the  red  blood  cells  (polychromatophilia). 
Increase  in  the  percentage  of  small  mononuclears 
i  lymphocytosis). 


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H^MOGl-OBllC RED  CORPUSCLES: 

WHITE  COHPUSCLES- 

Fig.  200. — The  Blood  Chart  of  a  Case  of  Pernicious  Anemia  as 
Observed  in  1904.  The  highest  lymphocyte  count  (October  3 
1904)  was  37  per  cent.,  with  a  polynuclear  neutrophile  count, 
on  the  same  date,  of  55.6  per  cent,  '  Normoblasts  were  usually 
present;  and  reached  34  in  a  slide  on  October  10,  1904.  At  this 
time  9  meftaloblasts  were  also  found,  but  thereafter  nucleated 
red  cells  were  not  seen.     See  subsequent  findings  on  Fig.  201. 

II.  Anteparoxysmal  and  Postparoxysmal  Stage 
(shortly  before  "and  shortly  after  a  paroxysm). — Oli- 
gocythemia and  oligochromemia  marked  (2,500,000). 
Red  cells  appear  deeply  stained.  High  color  index. 
Anisocytosis.  Lymphocytosis.  Polychromatophilia. 
i  Iccasional  nucleated  red  cells  (normoblasts). 

III.  Paroxysmal  Stage. — Oligocythemia  and  oligo- 
chromemia profound  (1,500,000).  Color  index  high. 
Anisocytosis.  Ervthroblasts  numerous.  Normoblasts 
and  large  nucleated  red  cells  (megaloblasts)  present. 
Karyokinetic  figures  may  be  seen. 

IV.  Profound  Degree  of  Paroxysmal  Stage.  Such 
as   usually   precedes   a   fatal     termination. — Oligocy- 

351 


Anemia,  Pernicious 


REFERENCE    HANDBOOK    OF    THE    MEDCAL    SCIENCES 


themia  profound  (1,000,000  or  less).  Oligochromemia; 
hemoglobin  may  be  too  low  to  estimate.  High  color 
index.  Anisocytosis  marked,  stippling.  Polychro- 
matophilia.  Erythroblasts  often  entirely  absent. 
Megaloblasts  may  be  present.  Free  nuclei  may  be 
present.     Lymphocytosis. 

If  a  case,   presenting  either   I  or  II,  be  carefully 


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H/CMOGLOEIN: RED  CORPUSCLES; 


Fig  201  — The  Blood  Chart  in  same  Case  (as  shown  in  Fig.  200)  in  1909.  The  highest  lympho- 
cyte count  was  43  per  cent.  (July  25,  1909) ;  the  polynuclear  neutrophile  count,  at  the  same 
time,  was  38  per  cent.     Nucleated  red  cells  were  a  constant  feature,  megaloblasts  preponderating. 

followed,  sooner  or  later  a  paroxysm  will  occur  and  III 
will  be  observed.  Figures  200  and  201  show  the  blood 
course  of  a  case  over  a  period  of  five  years.  The 
clinical  error  is  in  failing  to  follow  carefully  the  case 
which  presents  the  apparently  unimportant  anemia 
seen  in  I.  In  I,  the  high  color  index,  the  anisocyto- 
sis and  the  lymphocytosis  should  arouse  suspicion  of 
pernicious  anemia.  Myelocytes  may  occur  at  any 
stage,  but  there  is  nothing  significant  in  their  presence. 
The  blood  plates  are  said  to  be  increased, 
but  this  is  not  a  constant  finding. 

From  what  has  been  said  and  from  these 
charts  it  will  be  seen  that  the  diagnosis  is 
not  to  be  made  upon  the  presence  of 
nucleated  red  cells  alone.  This  must  be 
emphasized,  for  cases  of  pernicious  anemia 
are  frequently  overlooked  during  the  in- 
tervals between  paroxysms  because  the 
physician  considers  the  erythroblast  an 
essential  feature  of  the  blood  of  pernicious 
anemia. 

Under  what  circumstances  then  are 
nucleated  red  cells  present  or  absent  in 
pernicious  anemia?  Nucleated  cells  may 
be  entirely  absent  in:  (1)  The  interparox- 
ysmal  period.  (2)  The  latter  part  of  a 
parox3'siii,  when  the  blood  has  increased 
one  to  two  million  cells.  (3)  The  early  or 
mild  paroxysms.  (4)  The  graver  stages 
of  the  disease  and  in  the  later  paroxysms; 
in  these  stages  the  erythrogenetic  centers 
would  seem  to  have  been  overwhelmed. 

It  is  well  to  warn  against  a  poor  nuclear 
stain  which  fails  to  bring  out  the  nuclei, 
thus  giving  the  impression  of  no  nucleated 
red   cells.     The  nuclei   of   the  white  cells 
will  show  whether  or  not  such  a  stain  has 
been   used.     Lymphocytes   may   be   mis- 
taken   for    erythroblasts.     (See    also    below.)      Nu- 
cleated   red    cells    are    usually    present:    (1)   During 
the    gravity    of    the    paroxysm;    in    the    profound 
stages    the    megaloblast    preponderates;    as   the    red 
blood    count   begins    to   rise   the  normoblast  usually 
preponderates.      (2)  At  the  beginning  of  the  parox- 
ysm. 

352 


It  will   therefore   be  seen   that  the  characteristic 
features  of  the  blood  in  pernicious  anemia  are: 

1.  Red  cell  reduction  (oligocythemia)  constant. 

2.  Hemoglobin  reduction  (oligochromemia)  constant. 

3.  High  color  index  constant.  • 

4.  Nucleated  red  cells  (erythroblasts),  gigantoblasts, 
megaloblasts,  normoblasts,  microblasts  inconstant. 

5.  Anisocytosis,  giganto- 
cytes,  mcgalocytes,  normo- 
cytes, microcytes,  poikilocytee 
constant. 

6.  Polychromatophilia  in- 
constant. 

7.  Normal    or    low    white 

count  constant. 

8.  Deep  staining  inconstant. 

9.  Stippling  inconstant. 
The   nucleated  red    cell,   if 

present,  may  be  an  expression 
of  the  stage  and  severity  of 
the  disease  but  never  an  essi  «- 
Hal  feature  on  which  to  base 
the  diagnosis.  One  may  go 
further  and  say  that  though 
the  nucleated  red  cells  may  be 
present,  unless  the  other  char- 
acteristics above  enumerated 

white  corpuscles ..     are  also  present  the  diagnosis, 

pernicious  anemia,  cannot  be 
made.      Nucleated   red   cells, 
then,  are  distinctive  of  a  grave 
anemia  only.      To  determine 
the  type  of  the  anemia  in  which  such  cells  are  found 
the  other  clinical  and  blood  features  of  the  case  must 
be  taken  into  account.     The  small  lymphocytes  may 
be  mistaken  for  a  nucleated   red  cell.      It  is  some- 
times  quite   difficult   to  determine,  certainly,  which 
cell  one  is  dealing  with,  but  it  is  safer  to  decide  iu 
favor  of  the  leucocyte.     The  karyokinetic  figures  seen 
n  the  red  cell  nuclei  are  of  more  interest  at  present  to 


the  hematologist  and  the  biologist  than  to  the  clinician. 


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RED  CORPUSCLES  - 


-  WHITE  CQREUSCLES — 


Fig.  202. — The  Blood  Chart  of  a  Case  of  Pernicious  Anemia.  The  microscopic 
examination  was  typical  of  pernicious  anemia.  The  highest  lymphocyte  count 
was  58  per  cent.  (July  18) ;  the  polynuclear  neutrophile  count  on  the  same  date 
was  25  per  cent.  A  strking  feature  was*  the  absence,  for  the  most  part,  of 
megaloblasts.  Normoblasts  were  constantly  observed,  although  not  in  great 
numbers.  In  September,  1909,  this  case  developed  marked  neurological  symp- 
toms and  was  treated  exclusively  in  his  final  illness  for  these.  Pernicious  anemia 
was  detected  at  autopsy  and  his  early  record  (given  here)  in  an  other  hospital 
was  looked  up.      He  died  December,  1909,  in  his  third  paroxysm  (probably). 


This  is  true  also  of  the  extruding  and  free  nuclei.  I 
have  never  found  free  nuclei  without  nucleated  red 
cells  as  well.  The  stippling,  polychromatophilia,  and 
deep  staining  of  the  red  cells  are  important  but  not 
constant  features. 

The  blood  crisis  occasionally  occurs  in  this  disease. 
Within  a  few  hours  there  may  be  a  shower  of  nucleated 


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Anemia,  Pernicious 


red    cells,    mostly    normoblasts.     The   striking   point 

aboul    this  crisis  is  the  sudden  appearance  and  dis- 

earance  of  these   cells  in  the  periphereal  blood. 

es,  as  described  by  \  on  Noorden  in  1891 ,  are 

,,  n  also  after  profound  hemorrhage  from  traumatic 

other  causes.     There  are  many  theories  regarding 

the  phenomenon,   but   as  yet  none  of  these  is  sup- 

ported  by  substantial  evidence. 

It  is  important  to  remember  thai : 

1.  Pernicious  anemia  may  occur  without  nucleated 
ills. 

2.  Nucleated  red  cells  occur  more  commonly  in 
this  than  in  any  other  anemia. 

,:.  Nucleated  cells  occur  in  other  diseases  than 
pernicious  anemia. 

I.    rhe  normoblast  is  the  commoner  of  the  nucleated 

red  cells  and  its  presence  either  in  excess  of  or  to 
the  exclusion  of  megaloblasts  warrants  a  better 
osis. 

5.  The  presence  of  many  gigantoblasts  and  me- 
galoblasts is  of  grave  significance. 

ii.  Nucleated  red  cells  occur  in  showers,  which  may 
appear  and  disappear  suddenly.* 

7.  The  presence  of  megaloblasts  is  strong  evidence 
of  pernicious  anemia,  but  must  be  taken  together 
with  other  blood  features. 

s.  Small  mononuclears  may  be  mistaken  by  ex- 
perienced observers  for  nucleated  red  cells. 

Diagnosis. — The  diagnosis  has  been  considered 
to   a    large   extent    in    describing    the    blood    picture. 

ere  are  a  few  conditions,  however,  which  should  be 
cially  mentioned  here,  namely:  (1)  Secondary 
anemia,  especially  in  the  profound  stages:  (2)  Unci- 
naria  anemia  (uncinariasis,  hookworm  disease,  anky- 
lostomiasis);   (3)    dibothriocephalus  anemia. 

1.  Secondary  Anemia. — One  should  remember 
that  it  is  generally  admitted  that  a  toxin  is  the  factor 
in  the  causation  of  all  anemias,  barring  only  that  due 
to  traumatic  hemorrhage,  which  might  be  considered 
in  a  class  by  itself.  So  far  as  we  know  the  most 
destructive  of  such  toxins  is  that  associated  with 
pernicious  anemia.  It  therefore  is  a  matter  largely 
of  degree  of  destruction,  when  comparing  the  anemias, 
as  is  the  case  when  considering  purpura.  Occasion- 
ally an  anemia  due  to  the  toxin  of  a  known  disease, 
nephritis,  carcinoma,  portal  cirrhosis,  tuberculosis, 
etc.,  will  reach  a  stage  when  the  erythrogenetic  areas 
would  seem  to  fail  to  respond  to  the  demand  for  new 
cells  and  the  blood  features  of  pernicious  anemia  will 
begin  to  appear.  Rarely,  however,  is  the  picture 
identical  and  certainly  never  is  this  so  in  the  early 
stage.  The  ravages  of  the  primary  disease  will 
usually  have  manifested  themselves  by  the  time  the 
blood  takes  on  the  features  of  pernicious  anemia. 
Oligocythemia  and  oligochromemia  are  rarely  as  pro- 
found and  the  color  index  is  rarely  above  O.S  and 
usually  about  0.5.  Polynuclear  leucocytosis  is  com- 
mon and  there  is  a  greater  tendency  to  poikilocytosis 
than  to  variation  in  size.  That  is,  megalocytes  and 
macrocytes  are  uncommon.  It  must  be  remembered 
that  nucleated  red  cells  may  be  found  in  the  severer 
M;iges  of  secondary  anemia  and  that  the  cell  most 
commonly  found  is  the  normoblast.  Perhaps  the 
most  important  differential  feature  is  the  absence,  in 
secondary  anemia,  of  a  paroxysmal  tendency.  The 
anemia  may  be  profound,  but- is  more  apt  to  have 
become  so  after  long  periods  of  stationary  character- 
istics in  which  there  has  been  no  disposition  to  im- 
provement.    The  person    presenting  the  emaciation 

*  Export  hematologists  may  observe  a  blood  and  report  no  nu- 
cleated red  cells  in  a  specimen  in  which  a  house  officer  will  find 
many  such  cells.  Each  may  be  quite  correct  owing  to  the  "show- 
ering" tendency  of  the  normoblasts.  It  is  well,  however,  to 
uric  such  a  blood  as  soon  as  possible  after  such  an  erythro- 
blastic finding  is  reported,  in  order  to  determine  whether  lympho- 
have  been  mistaken  for  red  cells.  "As  soon  as  possible" 
beca  i  nil  "showers"  may  soon  "clear  up"  and  the  finding 
remain  in  permanent  doubt. 

Vol.  I.— 23 


and  cachexia  of  Secondary  anemia  appeal      ii)    marked 

contrast    to  the  one  with    pernicious  anemia   who  is 

plump  and   well   rounded  out    with   fat    even    to   death. 

When  the  blood  shows  characteristics  Buggestive  of 
pernicious  anemia  and  no  primary  factor  is  evident 
these  features  should  be  carefully  considered  and  a 
thorough  search  made  for  .in  obscure  parasitic  or 
septic  agent.     It  all  the  clinical  features  be  carefully 

Considered  it  will  be  rare  to  find  that  secondary  or 
symptomatic  anemia  presents  characteristics  identical 

with  those  of  pernicious  i  \ddi  onian)  anemia. 
Exceptions    to    this    statement    are    the    following: 

2.  Uncinariasis  (Hookworm,   I '  urimirin  il,m,/, ,,,,!,. , 

Ankylostoma  duodenale).^M\  that  has  been  said  re- 
garding pernicious  anemia  is  applicable  to  the  ad- 
vanced  stage   of   the   anemia    associated    with    this 

parasitl — the  only  difference  being  the  presence  of 
ova  in  the  feces,  .-i  low  color  index,  and  a  tendency 
toward  an  eosinophilic  leucocytosis.  For  further  in- 
formation on  this  important  subject  the  reader  is 
referred  to  the  article  with  this  title  in  the  Reference 
Handbook  and  1'..  K.  Ashford's  excellent  monograph 
published  by  the  I".  S.  Government. 

3.  Bothriocephalus  lotus. — Except  in  the  early 
stage  of  the  anemia,  (chlorotic  stage)  caused  by  this 
worm,  the  blood  is  identical  with  that  seen  in  perni- 
cious anemia.  The  finding  of  ova  in  the  stools  there- 
fore constitutes  the  differential  feature. 

The  blood  of  children  up  to  six  or  eight  years  of  age 
presents  many  variations  and  one  must  make  careful 
clinical  observation  upon  a  child  whose  blood  shows 
oligocythemia,  oligochromemia,  or  a  leucocytosis,  for 
such  variations  may  be  compatible  with  a  temporary 
reaction  to  some  slight  physiological  disturbance. 
Megalocytes,  erythroblasts,  and  myelocytes  may 
appear  in  children  with  moderate  anemia.  Well 
authenticated  cases  of  pernicious  anemia  are  unknown 
in  infancy,  extremely  rare  in  childhood,  and  uncommon 
before  the  age  of  thirty  and  after  the  age  of   fifty. 

Prognosis. — Among  the  1,200  cases  collected  from 
literature,  including  his  own  case  reports,  Cabot  finds 
but  six  recoveries,  taking  "  six  years  free  from  trouble" 
as  the  criterion  upon  which  to  base  an  assumption 
of  cure.  While  these  statements  indicate  a  great 
mortality  they  show  also  that,  as  Hunter  strongly 
maintains,  the  disease  is  not  invariably  fatal.  See 
section  on  Relapse  and  Duration  for  further  con- 
sideration of  the  prognosis. 

Treatment. — Although  the  physician  is  helpless 
before  this  destructive  condition  there  are  one  or  two 
warnings  which  can  with  great  advantage  be  given. 

During  the  intervals  between  paroxysms,  even 
though  the  patient  feels  energetic  and  is  impatient  to 
be  at  work,  every  effort  should  be  made  to  conserve 
the  energies.  Journeys,  sight  seeing,  long  hours  at 
business,  exacting  work  should  at  these  times  be 
emphatically  forbidden.  Travel  is  not  infrequently 
prescribed  to  the  business  man  who  is  in  the  stage  of 
remission  of  a  pernicious  anemia,  and  subsequent 
events  will  lay  the  physician  open  to  severe  and  just 
criticism  for  giving  such  advice.  It  must  be  remem- 
bered that  these  people,  as  though  impelled  by  some 
stimulant  in  the  system,  are  difficult  to  restrain,  not 
from  hard  labor,  but  from  considerable  activity. 
Hunter's  teaching  that  oral  and  gastrointestinal 
sepsis  is  largely  responsible  for  the  toxemia  has  sug- 
gested intestinal  irrigations  in  an  effort  to  reduce 
absorption  of  any  possible  toxin  from  this  source. 
The  condition  of  the  teeth  should  be  repeatedly  and 
thoroughly  looked  into.  A  minimum  of  protein  in 
the  diet  has  been  recommended,  but  it  is  not  clear 
that  this  has  any  importance  one  way   or  another. 

The  only  drug  employed  is  arsenic  and  no  one 
preparation  seems  superior  to  another,  and  adminis- 
tration by  mouth  seems  quite  as  efficacious  as  by 
hypodermic  injection.  It  is  most  commonly  given 
as  Fowler's  solution  or  in  pill  form,  the  dose  of  the 

353 


Anemia,  Pernicious 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


former  being  gradually  increased  from  two  to  three 
minims  thrice  daily  to  fifteen  or  twenty  thrice  daily. 
Physiological  effects  should  be  carefully  looked  for 
and    the  dose  reduced  accordingly. 

ManjT  other  measures  might  be  mentioned  but  so 
far  experience  offers  nothing  in  their  support. 

C.   N.  B.  Camac. 

References. 
1.  "On  the  Constitutional  and  Local  Effects  of  Disease  of  the 

renal  Capsules,"  by  Thomas  Addison,  1855. 
_'.  "Correspondenzblatt  f.  Schweizer  Aerzte,  Biermer,  1872. 
3.  Lack  of  space  admits  of  no  more  references  being  given.  In 
Vol.  v.  of  Allbutt  and  Rolieston's  System  of  Medicine  (1009)  will 
be  found  a  full  bibliography.  Addison's  (1855)  and  Riermer's 
(1872)  Monographs,  to  which  reference  is  given  above,  mark  the 
beginning  of  a  clinical  recognition  of  this  important  disease. 

Anemia,  Secondary. — Anemia  might  literally  be 
assumed  to  refer  to  diminution  of  the  amount  of  blood, 
but  actual^  it  is  made  to  refer  to  diminution  or 
deterioration  in  the  erythrocytes,  or  hemoglobin,  or 
both. 

The  greater  the  accuracy  of  medical  diagnosis,  the 
fewer  will  be  the  conditions  to  be  labelled  Anemia." 
As  "inflammation,"  ''fever,"  "indigestion,"  have 
gradually  marched  out  of  the  column  of  diseases  into 
the  field  of  symptoms,  so  must  also  anemia.  And  as 
chlorosis  has  lost  many  of  its  class  to  tuberculosis, 
and  pernicious  anemia  to  malignant  disease  and  to 
the  animal  parasites,  even  more  must  secondary 
anemia  divide  itself  up  and  become  a  symptom  only, 
and  that  of  the  most  varied  disorders. 

But,  for  the  present,  there  must  continue,  for 
descriptive  purposes  at  least,  the  symptom  group, 
which  may  be  called  anemia.  This  group-name  will 
include  visible  pallor,  alterations  in  the  physical  and 
chemical  characters  of  the  blood;  circulatory  dis- 
turbances, such  as  palpitation  of  the  heart  and 
dyspnea,  and  a  tendency  to  edema;  various  muscular 
and  nervous  disturbances,  or  as  has  been  stated,  any 
alteration  in  the  respiratory  function  of  the  blood. 

The  particular  phase  of  the  symptom  group  which 
is  most  in  evidence  will  vary  with  the  cause  of  the 
anemia,  and  here  one  must  be  cautious  in  drawing 
conclusions,  as  in  many  instances,  not  the  anemia 
itself,  but  the  primary  cause  of  the  anemia,  may  be 
responsible  for  the  symptoms.  For  example  in  the 
anemia  of  tuberculosis  the  pallor  is  a  marked  feature, 
while  the  diminished  quantity  of  blood  renders  the 
blood  count  often  but  little  removed  from  the 
normal.  Again,  in  beriberi  edema  may  be  as 
prominent  a  feature  as  pallor,  while  in  malignant 
disease  the  pallor  as  such  gives  way  to  the  well- 
known  cachectic  hue. 

The  blood  characteristics  of  secondary  anemia  are 
a  diminution  of  red  cells  and  hemoglobin,  but  with  low 
color  index,  but  though  this  is  typical,  there  are  also 
secondary  anemias  such  as  that  due  to  Ankylosto- 
mum  and  Bothriocephalus,  where  the  blood  picture 
runs  closely  parallel  with  the  primary  Addisonian,  or 
pernicious  form. 

The  pathological  anatomy  of  secondary  anemia  is, 
of  course,  the  anatomy  of  the  process  which  has 
given  rise  to  the  anemia,  but  there  are  certain  con- 
ditions more  or  less  directly  referable  to  the  anemia 
itself,  such  as  pallor  of  the  organs  and  fatty  de- 
generation, particularly  noticeable  in  the  heart  and 
in  the  liver,  in  the  capillary  blood-vessels;  and 
changes  in  the  bone-marrow,  which  may,  however, 
vary  according  to  the  excitant  of  the  anemia. 

Broadly  speaking,  the  secondary  anemias  may  be 
divided  into  the  Acute  and  Chronic. 

Acute  Anemia. — The  one  great  cause  of  this 
condition  is  hemorrhage,  either  externally,  or  into 
one  of  the  body  cavities.  This  may  be  due  to 
trauma  or  surgical  operation;  uterine  hemorrhage 
occurring  either  during  an  abortion,  or  after  delivery, 

354 


pulmonary  or  gastric  or  intestinal  solutions  of  con- 
tinuity may  give  rise  to  external  bleeding,  while  a 
rupture  of  the  liver,  spleen,  or  kidney  may  be  a 
cause  of  internal  bleeding. 

Symptoms. — Anemia  from  any  of  the  above  causes 
shows  itself  by  certain  well  defined  signs: 

(a)  Pallor. 

(b)  Actual  shrinking  of  the  body;  this  is  brought 
about  by  the  flow  of  the  body  fluids  toward  the  blood- 
vessels to  make  up  for  blood   lost.     The  shrinking 
shows   itself   in    the   drawn    face,    sunken  eyes,    s 
cadaveric  expression. 

(c)  Nervous  Symptoms.  These  are  dependent 
upon  cerebral  anemia,  and  manifest  themselves 
through  the  reaction  of  the  medullary  centers;  of 
these,  the  respiratory  center  gives  the  earliest  and  t  In- 
most obvious  warning,  such  as  sighing,  disturbed 
respiratory  rhythm,  rapid  respiration,  or  in  a  later 
stage  actual  air  hunger. 

(d)  Psychical  manifestations,  as  restlessness,  mild 
forms  of  delirium,  failure  to  appreciate  one's 
surroundings. 

(f)  Amblyopias  which  may  terminate  in  optic 
atrophy  are  also  to  be  found. 

(f)  'the  Blood  Picture.  Crile's  observations  upon 
the  donors  in  transfusions  showed  a  fall  in  both 
hemoglobin  and  red  cells,  beginning  immediately 
after  the  bleeding  or  up  to  several  hours  after.  The 
white  cells  in  nearly  all  cases  showed  a  sudden  sharp 
rise  in  number,  and  this  rise  was  maintained  above 
the  previous  level  for  four  or  five  days.  In  a  small 
series  of  experiments  made  to  compare  the  blood  pic- 
ture of  hemorrhage  and  shock,  Crile  found  that  the 
diminution  of  red  cells  and  hemoglobindid  not  occur  in 
shock,  and  the  rise  of  white  cells  was  not  observed. 

(g)  Cardiovascular  Symptoms.  A  rapid  pulse, 
becoming  more  rapid  with  increasing  hemorrhage,  is 
an  almost  invariable  sign  in  acute  anemia.  The 
blood  pressure  falls  and  the  heart  sounds  become 
weak,  due  not  only  to  the  diminished  total  volume  of 
blood,  but  to  the  diminished  flow  through  the  coro- 
nary vessels  and  consequent  impairment  of  the 
heart  muscle. 

The  diagnosis  between  shock  and  acute  anemia 
from  hemorrhage  is  naturally  difficult  in  the  ab- 
sence of  external  bleeding,  or  of  evidence  of  free 
blood  in  a  body  cavity,  since  most  of  the  symptoms 
of  the  two  are  identical.  However,  a  preliminary 
stage  of  restlessness,  an  increasing  pulse  rate  and  the 
early  appearance  of  diminished  hemoglobin  and  red 
cells  with  increase  of  leucocytes,  speaks  strongly  for 
anemia  from  hemorrhage. 

Subacute  Anemia. — As  opposed  to  the  sudden 
onset  of  the  anemic  syndrome,  we  have  to  deal  with 
one  having  a  rapid  onset  in  which  the  condition  may 
develop  in  days  or  hours  instead  of  minutes.  Such 
a  condition  has  been  reported  in  acute  septicemias. 

Chronic  Anemia. — Among  the  chronic  anemias, 
though  their  cause  is  legion,  the  following  groups 
may  be  cited: 

1.  Anemia  from  continued  losses  of  blood,  e.g. 
hemorrhoids. 

2.  Anemia  from  infectious  diseases,  e.g.  tuberculo- 
sis,    rheumatism,     typhoid     fever,     syphilis,     sepsis. 

3.  Anemia  from  parasites,  malaria,  uncinariasis, 
bothriocephaliasis. 

4.  Anemia  from  malignant  disease. 

5.  Anemia  from  intoxications  by  lead,  arsenic, 
cocaine,  morphine,  carbon  monoxide,  carbon  dioxide, 
and  in  nephritis  and  pregnancy. 

1.  Continued  Small  Hemorrhages. — This  cause  may 
give  rise  to  a  most  profound  degree  of  anemia  which 
may,  in  some  instances,  show  a  blood  picture  very 
similar  to  that  of  pernicious  anemia.  The  common 
causes  are  uterine  hemorrhage  in  fibroids  and  chronic 
metritis  and  carcinoma,  hemorrhoids,  purpura,  and 
hemophilia. 


i;i  i  EREN<  i:    II  WiU'.ooK    OF    THE    Ml  DICAL   S<  [] 


VncMii.i.  Secondary 


These  are  cases  which  show  an  extreme  degri f 

pallor,  and  also  acquire  t lie  drawn,  haggard  look  oi 
chronic  ill  health;  as  a  rule  there  is  also  associated  a 
iderable  degree  of  loss  <>f  weight,  but   it   is  rare 
them   to  manifest   any  appearand  lexia. 

Tlic  patient  may  be  quite  unconscious  of  the  cause  of 
his  steady  decline  in  health,  since  many  of  the  ca 

rhage  are  painless,  ii  is  not  uncommon  for 
such  a  patient  to  be  dosed  over  long  periods  with 
inm  and  tonics,  while  the  actual  can-.'  is  unsuspected. 
In  this  form  ol  anemia  there  is  usually  a  considerable 

diminution,  even   to    1,500, r  2,000,000  ii 

number  of  red  blood  cells  with  a  color  index  still  more 
diminished,  and  as  a  nil'',  a  slight  or  moderate  leuco- 
cytosis.  An  extreme  grade  of  poikilocytosis  may  be 
present  ami  normoblasts  may  be  found  in  i 
at  sometimes.  Megaloblasts  may  also  be  found,  but 
iiim-h  less  commonly,  and  never  in  a  majority  of  the 
nucleated  red  cells  (( 'abot). 

cases  may  be  difficult  to  distinguish  by.  the 
blood  picture  alone  from  primary  anemia. 

2,  Infectious  Diseases.— Tuberculosis,  perhaps,  of 
all  diseases  shows  the  greatest  discrepancy  be- 
tween the  apparent  anemia,  as  judged  by  pallor, 
and  the  diminution  of  the  blood  content  as  shown 
by  examination. 

Red  Cells. — In  patients  undergoing  treatment 
counts  of  Li. 00(1.(1(10  or  over  are  not  uncommon,  and 
the  number  rarely  falls  below  3,000,000.  A  slight 
diminution  from  the  normal  number  is  the  usual 
condition  found.  After  hemoptysis  there  isasudden 
slight  reduction  of  hemoglobin.  Commonly,  even 
with  marked  pallor  and  loss  of  weight,  the  hemo- 
globin estimation  gives  a  high  figure,  but  the  typical 
finding  is  one  of  less  than  normal  and  a  color  index 
which  is  reduced.  It  is  claimed  that  in  tuberculosis 
the  red  cells  resist  hemolysis  to  a  greater  extent  than 
normal  cells. 

The  most  satisfactory  explanation  of  the  relatively 
high  red  cell  and  hemoglobin  estimation  is  that  there 
is  an  actual  diminution  in  the  total  blood  mass,  due 
to  loss  of  body  fluid  by  the  skin,  and  through  bronchial 
lion.  In  the  treated  cases  also,  hyperalimenta- 
tion, together  with  sun  and  fresh  air,  stimulate  blood 
production. 

Leucocytes. — In  many  cases  these  are  diminished 
and  in  non-progressive  cases  a  count  in  the  neighbor- 
hood of  5,000  is  the  rule.  In  cavity  formation  a 
cytosis  is  the  rule  and  advancement  of  the 
disease  is  usually  marked  by  an  increase  in  the  number 
of  white  cells,  this  increase  being  chiefly  in  the  poly- 
morphonuclears. A  lymphocytic  increase  has  been 
shown  to  correspond  with  periods  of  improvement. 

Arneth  has  pointed  out  that  the  number  of  nuclei 
in  a  polymorphonuclear  cell  has  a  bearing  upon 
prognosis.  The  greater  the  number  of  leucocytes 
with  one  or  two  nuclei,  the  graver  the  outlook,  while 
an  increase  in  cells  having  three  to  five  nuclei  is  an 
indication  of  favorable  import.  Minor  and  Ringer 
confirm  this  work. 

The  pallor  of  tuberculosis  is  notorious  and,  set  off 
against  the  red  lips  and  flushed  cheeks,  tells  its  own 
story;  often,  however,  one  sees  the  bluish-white,  or 
skim-milk  complexion,  with  a  pale  palate  and  con- 
junctiva?, while  in  the  later  cases  a  cachectic  appearance 
not  unlike  malignant  disease  may  make  its  appearance, 
especially  in  the  poor  and  ill-cared  for. 

Si  pticemia. — Here  is  found  a  quality  of  anemia 
which  in  acuteness  nearest  approaches  that  due  to 
hemorrhage.  The  red  cells  may  diminish  at  the  rate 
of  1,000,000  a  week,  and  extremely  low  counts  have 
been  recorded.  Hayem's  case  of  puerperal  sepsis 
showed  only  1,450.(100  with  twenty  per  cent,  of 
hemoglobin.  The  hemolysis  is  so  marked  and  so 
rapid  in  severe  cases,  that  the  hemoglobinemia  causes 
staining  of  the  organs,  and  to  this  is  due  the  sallow 
icteroid    tint   of  acute   sepsis. 

Leucocytosis. — Polymorphonuclear   leucocytosis   is 


the    rule,  except    in    some    fulmii  es    where 

there  may  be  actual  leucopenia.     With  leucocyti 
or  in  the  al  leucocytosis,  the  presence  of  red- 

!i  granules  in  i  he  polj  nucleai  ile  leuco- 

cytes when  I  real  i 'd  by  iodine,  either  in  vapor  or  solu- 
tion, is  said   to  be  distinctive  of  a   septic  or  toxic 

Methe elobinemia   has  been   recorded  following 

sept  icemia  t  rom  Ba<  llv 

The  anemia  of  rheumatic  fever  lias  many  of  the 
characters  of  that  found  in  sepsis  and  shows  itself 
early  in  the  disease  by  a  diminution  of  red  cells, 
with  a  greater  diminution  of  hemoglobin,  but   rarely 

to     the    same    degree    as    in    Sepsis.      Li  i-     is 

usually  present. 

:!.  Parasites. — CJm  which  has  of  late  yi 

been  recognized  as  a  cause  of  the  endemic  anemia 
in  many  districts,  may  give  rise  to  an  acute  illness  or 
may  run  over  years.  Besides  the  blood  changes 
there   are   symptoms    referred    to   the   digestive   tract. 

Abdominal  pain  relieved  by  f 1,  perverted  appetite, 

dyspepsia,  constipation  followed  by  irregular  diar- 
rhea, and  with  blood  frequently  found  in  the  mo- 
tions. Adults,  the  subjects  of  chronic  infection, 
may  show  the  vocal,  bodily,  and  sexual  characters  of 
infantilism. 

The  blood  picture  shows  a  red  blood  corpuscle 
count  which  may  range  from  800,000  to  1,200,000  with 
a  low  color  index.  The  cells  may  be  altered  in  size, 
shape,  and  coloring.  Normoblasts  are  frequent  and 
megaloblasts  are  often  found  but  not  as  a  majority 
of  the  nucleated  cells. 

Eosinophilia  is  characteristic  and  is  most  marked 
before  the  anemia  is  pronounced.  A  rise  in  the  eo- 
sinophilia is  of  favorable  import.  The  number  of 
these  cells  has  been  found  as  high  as  sixty-six  per 
cent,  with  an  average  of  eighteen  per  cent. 

The  diagnosis  is  suggested  from  the  symptoms  in  an 
infected  locality,  especially  when  there  is  a  history  of 
boils  or  a  papular  skin  eruption.  The  finding  of  ova 
in  the  stools  is  diagnostic. 

Thymol  in  fifteen  to  thirty  grain  doses  repeated 
for  three  or  four  times  at  short  intervals  (one  to  one 
and  one-half  hours)  followed  by  a  purge,  is  the  treat 
nient  of  choice;  but  toxic  symptoms  from  the  drug 
such  as  vertigo,  delirium  and  brown  colored  urine, 
must  be  kept  in  mind.  After  one  week  the  stools 
should  be  examined  and  if  ova  are  still  found  the 
treatment  should  be  repeated. 

Malaria. — The  chief  characteristic  is  the  rapidit}' 
of  its  onset;  a  drop  of  from  five  to  ten  per  cent,  in  red 
cells  may  occur  with  each  paroxysm.  Grawitz 
records  a  fall  of  400,000  in  six  days.  The  hemoglobin 
content  falls  in  proportion.  Manson  sugge.-ts  that 
the  rapidity  of  the  fall  in  the  number  of  red  cells  is 
due  to  the  liberation  of  lytic  substances  into  the 
plasma  which  continue  the  corpuscular  destruction. 

Mary  Rowley  Lawson  suggests  that  the  cause  of 
the  rapid  blood  destruction  is  the  migration  of 
parasites  from  corpuscle  to  corpuscle,  destroying 
one  after  the  other.  The  blood  volume  in  malaria 
is  also  diminished.  After  recovery  from  the  infection 
in  the  tertian  and  quartan  forms,  the  blood  recovery 
is  fairly  rapid,  but  in  estivoautumnal  fevers  the 
anemia  is  liable  to  continue. 

In  some  pernicious  forms  the  blood  destruction 
may  be  extraordinarily  severe,  the  red  count  falling 
as  low  as  500,000,  with  the  absence  of  any  nucleated 
red  cells,  indicating  an  absence  of  marrow  reaction. 
In  other  cases  a  blood  picture  closely  resembling 
that  of  primary  anemia  may  be  seen. 

.Malarial  cachexia  follows  usually  a  chronic  estivo- 
autumnal infection.  Here  the  red  cells  may  drop  to 
less  than  half  the  normal,  while  the  hemoglobin  shows 
a  corresponding  diminution.  The  mononuclear 
leucocytes  are  increased  in  number,  while  pallor  with 
sallowness,  dyspnea,  edema,  and  weakness  are 
usually    prominent.     A     much    enlarged    spleen    is 


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characteristic  of  the  condition.     Plasmodia  may  be 
with  difficulty  discovered  in  the  blood. 

4.  Malignant  disease  is  cue  of  the  most  constant 
causes  of  severe  grades  of  secondary  anemia.  It  is 
rare  to  find  a  malignant  growth  at  all  advanced 
which  has  not  given  rise  to  some  blood  deterioration. 
The  typical  finding  is  a  greater  or  lesser  decrease  in 
the  number  of  red  cells,  with  a  greater  diminution 
of  hemoglobin,  and  a  moderate  degree  of  leucocytosis. 

In  cancer  of  the  stomach  of  typical  form,  the 
average  red  blood  corpuscle  count  will  be  about  three 
to  four  millions,  though  in  rare  instances  the  count  has 
gone  above  five  millions,  and  less  rarely  as  low  as  one 
and  a  half  million.  Poikilocytosis  and  polychromato- 
philia  are  not  uncommon.  Basophilic  granules 
and  iodophilia  have  also  been  noted.  Jez  reports  the 
finding  of  nucleated  red  cells — normoblasts — with 
frequency,  and  even  in  cases  where  the  red  count 
was  4,000,000. 

The  hemoglobin  value  is  practically  always  dimin- 
ished, and  in  150  cases  collected  by  Osier  and  McCrae 
averaged  fifty  per  cent.  The  hemoglobin  content 
falls  before  the  red  cells  and  the  color  index  ranges 
usually  between  0.4  and  O.S. 

The  white  cells  are  nearly  always  at  or  above  the 
normal,  rarely  below;  a  white  cell  count  of  10,000 
will  be  an  average  for  any  large  number  of  cases.  A 
differential  count  shows  a  polynuclear  estimation  of 
seventy-five  per  cent.  A  digestive  leucocytosis  is 
a^  a  rule  absent.  The  resistance  of  the  red  cells  is 
increased. 

Besides  these  typical  cases  of  gastric  cancer, 
Marcorelles  points  out  a  group  of  cases  in  which  the 
anemia  is  the  outstanding  feature.  Here  we  find, 
(a)  Clinical  signs  of  cancer  of  the  stomach,  with 
intense  anemia  {forme  avec  anemie).  (b)  Very 
intense  anemia  without  obvious  signs  of  cancer 
(forme  animique).  (c)  The  form  with  metastases 
in  the  bone  marrow. 

The  appearance  of  the  first  two  groups  is  one  of 
excessive  pallor  without  the  characteristic  yellowish 
tint  of  the  ordinary  case  of  cancer.  The  patient 
appears  exsanguinated,  and  though  usually  ema- 
ciated, sometimes  shows  retention  of  adipose;  edema 
is  common  and  asthenia  is  profound,  palpitation 
and  ringing  in  the  ears  are  frequent.  The  digestive 
disturbances  are  those  found  in  other  grave  anemias. 

The  red  cells  range  from  three-quarters  of  a  million 
to  three  millions.  The  hemoglobin  index,  though 
usually  below  0.5,  may  rise  to  1  or  over.  Poikilocyto- 
sis is  the  rule  and  nucleated  red  cells  are  numerous. 
The  leucocytes  usually  range  above  the  normal  and 
the  formula  is  various,  a  polymorphonuclear  increase 
being  the  rule,  but  a  mononuclear  increase  is  not 
uncommon.  Eosinophils  are  increased  and  myelo- 
cytes are  sometimes  found  in  considerable  numbers. 

It  will  be  seen  that  in  almost  every  particular  the 
blood  picture  here  may  simulate  that  in  primary 
pernicious  anemia. 

Cases  with  Involvement  of  Bone  Marrow. — Clin- 
ically, these  are  accompanied  by  tenderness  over  the 
bones,  by  splenic  enlargement  and  by  hemorrhage  in 
retina,  gums,  and  skin.  The  blood  picture  differs 
from  that  of  the  previous  form  in  the  more  frequent 
elevation  of  the  hemoglobin  index  and  in  the  greater 
number  of  nucleated  cells,  particularly  megaloblasts. 

5.  Chemical  Poisons. — The  type  of  this  group  is 
saturnism,  which  gives  rise  to  most  intense  forms  of 
blood  deterioration.  The  pallor  is  usually  marked 
and  is  frequently  the  most  noticeable  feature.  It  is 
quite  frequently  associated  with  a  tinge  of  sallowness. 
The  blood  picture  shows  a  lessened  number,  often  a; 
low  as  3,000,000,  of  red  cells,  a  hemoglobin  percentage 
relatively  lower,  and  a  leucocyte  count  not  differing 
much  from  the  normal  in  number  or  in  variety. 
Two  features  of  the  red  cells  are  almost  constant, 
basophilic  granulation  and  polychromatophilia.  Baso- 
philia is  more  common  than  in  any  other  disease  in  a 


case  where  the  anemia  is  not  extreme.  A  lead  line 
will  usually  give  the  clue  to  the  cause  of  the  anemia 
if  looked  for,  but  many  cases  occur  where  the  infection 
is  accidental  rather  than  industrial,  and  for  this  reason 
the  cause  of  the  anemia  may  remain  unsuspected. 

The  anemia  of  nephritis  may,  in  the  present  state 
of  knowledge,  be  also  classed  among  the  toxic 
anemias,  admitting,  however,  that  it  would  probably 
be  more  correct  to  attribute  the  anemia  and  the 
nephritis  to  a  common  cause,  rather  than  the  anemia 
to  the  nephritis. 

Though  practically  all  forms  of  nephritis  show  a 
certain  grade  of  anemia,  it  is  most  marked  in  that 
group  classed  as  "  chronic  parenchymatous,"  where 
pallor  and  edema  are  the  classical  symptoms — "large 
white  legs,  large  white  kidneys." 

The  blood  picture  is  a  diminished  red  count  and  a 
greater  diminution  of  hemoglobin  with  often  a 
lowered  specific  gravity  due  to  the  hydremia.  The 
freezing  point,  though  usually  low,  may  rise  to  normal 
from  the  same  cause. 

The  anemias  of  infancy  are  even  yet  an  ill- 
assorted  lot,  the  condition  known  as  von  Jaksch's 
disease  being  the  central  figure.  The  clinical  features 
of  anemia,  splenic  enlargement,  glandular  enlarge- 
ment, and  enlargement  of  the  liver,  may  exist  with 
marked  diversity  of  the  blood  picture,  and,  on  the 
other  hand,  there  are  seen  in  rickets,  syphilis,  and 
tuberculosis,  cases  with  similar  clinical  characters. 
The  blood  picture  in  infancy  is  extremely  unstable, 
variations  in  the  characters  and  proportions  of  the 
cellular  elements  occurring  with  the  greatest  readiness. 
For  this  reason,  in  infancy  any  diagnosis  founded 
upon  the  blood  examination  alone  is  open  to  almost 
certain  error. 

Setting  aside  forms  of  anemia  common  to  adults, 
there  remain  the  anemias  due  to  malnutrition,  faulty 
feeding,  bad  hygiene,  enteric  diseases,  marasmus,  etc. 

The  Anemias  of  Old  Age. — "A  moist  eye,  a  dry 
hand,  a  yellow  cheek,  a  white  beard,"  are  commonly 
the  things  which  "accompany  old  age,"  and  many 
troubles  incidental  to  senility  are  also  causes  of 
anemia.  Hypertrophy  of  the  prostate,  with  its 
accompanying  cystitis  in  men  and  a  senile  endometri- 
tis in  women;  arteriosclerosis  and  contracted  kidney; 
infections  of  the  mouth,  as  pyorrhea;  neoplasms  in 
various  situations;  and  by  no  means  least,  the  senile 
forms  of  tuberculosis,  may  all  be  reasons  for  the 
anemia  of  the  aged.  AYhether  infections  of  the 
intestinal  tract  shall  be  proved  to  be  as  Metchnikoff 
considers  them,  the  foundation  of  old  age,  as  well  as 
of  some  of  its  anemias,  remains  to  be  seen. 

Diagnosis. — In  acute  anemias,  the  distinction  be- 
tween shock  and  hemorrhage  has  been  already 
mentioned.  It  is  of  service  to  remember  that  in  rare 
instances  an  acute  anemia  may  occur  from  the  action 
of  an  actively  hemolytic  agent  as  in  some  acute 
infections,  and  in  poisoning  by  ricin,  potassium 
chlorate,  or  nitrobenzol. 

Chronic  Anemias. — The  diagnosis  here  is  from 
chlorosis  and  from  primary  pernicious  anemia.  This 
must  be  made  by  exclusion  on  the  one  hand,  and 
recognition  on  the  other.  In  young  women  tubercu- 
losis, Graves' disease,  nephritis,  lead  poisoning,  and 
gastric  ulcer  must  be  eliminated  before  chlorosis  is 
diagnosed. 

A  conscientious  use  of  the  thermometer,  and  if 
necessary,  of  tuberculin,  will  often  clear  up  doubt  in 
the  case  of  tuberculosis,  and  in  the  other  cases  the 
recollection  of  the  causes  suggests  the  avenue  by  which 
the  distinction  may  be  made. 

Pernicious  anemia,  as  a  rule,  offers  a  definite  blood 
picture,  but  it  must  be  remembered  that  there  is  no 
single  pathognomonic  sign.  Under  forty,  a  diagnosis 
of  pernicious  anemia  should  be  viewed  with  suspicion. 

At  the  age   when  this   disease  is  in   question,  ma- 


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AnestheBla  and  Analgesia 


lignancy  insome  portion  of  the  digestive  tract  must 
be  always  before  the  mind.     Repeated  hemorrhages, 
unknown   to   the  patient,  and  animal  parasites  arc 
other  causes  of  anemia  in  which  pernicious  anemia 
may  be  simulated.     The  examination  of  the  rectum 
and  of  the  stools  may  give  the    clue   to  the  cause. 
To  summarize— the    diagnosis  of  the   cause   ol    a 
ndary  anemia  i-  made  with  certainty  only  after 
mtine  examination  of  the  whole  body,  and  only 
when  no  cause  for  blood  deterioration  can  be  made  out 
is  a  primary   anemia   to  I"'  considered.     If  then  a 
sponding  blood   picture  be  found,  that  opinion 
infirmed. 
Aplastic    anemia   is    a    disease    of   young    person-. 
chiefly  women.     The  color  index  is  low  and  lympho- 
cytes form   the  great    proportion  of  the  white  cells. 
Milar  leucocytes  are  few  and  nucleated  red  cells 
practically    absent.     The    disease    runs    a    progres- 
sively downward  course. 

After  the  elimination  of  the  so-called  primary 
anemia-,  the  further  apportioning  of  the  direct  cause 
of  the  anemia  is  done  by  the  associated  symptoms. 

Treatment. — In  the  face  of  so  varied  an  etiology, 
it  would  appear  useless  to  suggest  any  one  form  of 
treatment. 

The  diagnosis  is  everything.  This  may  indicate  a 
transfusion  for  acute  hemorrhage,  an  excision  of 
hemorrhoids  for  recurring  hemorrhage,  a  change  of 
diet  for  scurvy,  an  antituberculous  regime,  or 
antisyphilitic  medication;  a  change  of  occupation 
for  plumbism,  or  a  change  of  climate  for  nephritis; 
a  laparotomy  for  cancer,  or  an  anthelmintic  for 
parasites. 

In  addition  to  these  obvious  procedures,  the  direct 
i  upon  blood  production  of  sunlight  and  in- 
creased elevations  should  not  be  overlooked.  The 
diminished  respiratory  function  of  the  blood  in 
anemia  calls  for  free  flowing  fresh  air,  and  the  per- 
verted metabolism  for  extra  assimilable  nutrition. 
Of  drugs,  we  may  say  there  are  but  two — iron,  which  has 
not  the  specific  action  it  shows  in  chlorosis,  but  which 
i-  generally  useful,  and  arsenic  which  clinically,  at  any 
rale,  does  improve  the  blood  production. 

Were  the  writer  to  be  limited  to  three  preparations 
of  iron,  these  would  be  Blaud's  pill,  the  tincture  of 
chloride  of  iron  in  an  acid  mixture  as  dilute  phos- 
phoric acid,  and  syrup  of  the  iodide  of  iron. 

Ma-sage  and  certain  hydrotherapeutic  douches 
may  be  of  definite  value;  and  last,  but  not  least,  rest 
in  bed,  which,  after  the  correction  of  the  primary 
cause,  may  alone  work  wonders.       A.  H.  Gordon. 

Anemia,  Splenic. — See  Splenic  Anemia. 
Anencephalus. — See  Teratclogy. 

Anesthesia  and  Analgesia. — Definition  of  Terms. — 
Anesthesia,  accurately  speaking,  denotes  the  loss  of 
e  of  touch.  The  term  is  often  used  to  indicate 
the  loss  of  all  forms  of  sensibility,  as  pain,  tempera- 
ture, muscular  location,  etc.  In  this  article,  when 
the  word  is  used  without  qualification,  it  shall  mean 
the  loss  of  tactile  sense.  Tactile  sensibility  is  sub- 
served by  structures  that  take  cognizance  of  change 
of  contact,  and  are  stimulated  by  motion  of  an  ex- 
ternal object  in  contact  with  the  surface. 

Analgesia  is  a  term  employed  to  denote  the  loss 
of  sensibility  to  painful  impressions. 

Thermoanesthesia  is  a  loss  of  temperature  sense. 

Present  day  clinical  neurology  has  been  compelled 
in  large  part  to  abandon  these  general  terms  since  the 
more  extended  observations  of  Head  and  those  fol- 
lowing him  have  shown  that  the  sensations,  hereto- 
fore thought  of  as  simple,  are  in  reality  very  complex, 
and  that  it  is  far  better  to  express  one's  clinical 
findings  in  terms  of  the  test  used,  than  by  the  em- 
ployment of  general  terms.     Thus  one  discriminates 


between    touch   sensibility    to   cotton    wool,   and    pri     - 

sure  sensibility  to  the  finger  touch.     Lo  ia) 

ol  one  does  not  imply  loss  of  the  other.  A  patient 
may  lose  the  ability  to  distinguish  between  extremes 
of  neat  and  cold  and  yet  retain  the  ability  to  dis- 
criminate between  very  minute  variations  in  warmth 
or  coolness. 

Mi  iioiii-  01  Testing  Sensibility. — The  determi- 
nation of  the  varying  degrees  of  anesthesia  and  anal- 
gesia is  made  difficult  by  the  fact  that  the  physii 
must  depend  upon  the  statement  of  the  patient  for 
his  information.  The  intelligence,  attention,  and 
sincere  cooperation  of  the  patient  are  necessary  to 
secure  reliable  responses.  Furthermore,  individuals 
vary,  within  the  limits  of  what  is  normal,  quite 
appreciably  in  their  sensibility  to  external  irritation. 
finally,  in  patients  suffering  from  lesions  which  cause 
either  a  slighter,  or  perhaps  a  greater  degree  <>f  hiss 
of  consciousness,  sensibility  is  more  or  less  diminished 
up  lo  entire  loss  of  sensation,  even  though  the  lesion 
may  cause  no  anesthesia  directly. 

In  testing  sensibility,  the  patient  should  be  blind- 
folded  or  in  some  other  way  prevented  from  seeing 
what  is  being  done,  in  order  that  simulation  or  self- 
deception  may  be  avoided.  It  is  remarkable  how 
vividly  one  can  feel  the  prick  of  a  pin  or  touch  of 
a  feather  through  the  medium  of  sight.  When  the 
lesion  is  unilateral,  a  comparison  of  the  two  sides  is 
very  desirable.  Various  instruments  of  precision 
have  been  devised  by  neurologists  for  testing  sensi- 
bility (see  Esthesiometer).  Some  are  indispen- 
sable, others  of  value  only  in  carrying  out  systematic 
and  controlled  observations.  A  systematic  sensory 
examination  is  recognized  to  be  of  extreme  impor- 
tance, and  of  recent  years  has  become  successively 
more  extended  and  precise.  The  following  scheme 
or  schedule  laid  down  by  Head  and  Holmes  con- 
tains the  usual  present  day  necessities  for  a  complete 
sensory  examination. 

A.  Spontaneous  Sensations:  Pain,  numbness, 
tingling,  position  of  the  limb,  idea  of  the  limb,  hallu- 
cinations or  illusions. 

B.  Loss  of  Sensation: 

1.  Touch: 

a.  Light   touch,   cotton  wool    on  hairless  and 

hair  clad  parts;  threshold  with  von  Trey's 
hairs. 

b.  Pressure  touch,  threshold  with  pressure  es- 

thesiometer. 

2.  Localization: 

Naming  the  part  touched; 

Henri's  or  Head's  method,  target,  etc. 

3.  Roughness,  threshold   with   Graham-Brown's 

esthesiometer: 
Sandpaper  tests,   discrimination  of  relative 
roughness. 

4.  Tickling  and  scraping: 

Tickling  on  soles  and  palms; 

Cotton    wool   rubbed  over  hair-clad    parts; 

Light  scraping  with  finger  nails. 

5.  Vibration,  tuning  fork: 

Loss  or  diminution  of  sensibility, 
Alteration  in  the  character  of  the  sensation 
evoked. 

6.  Compass  points: 

Points  simultaneously  applied. 
Points  successively  employed. 

7.  Pain: 

a.  Superficial  pain:     pinprick;  threshold  with 

algesimeter;    reaction   to   measured    pain- 
ful stimuli. 

b.  Pressure     pain:     threshold    with   the   algo- 

meter;  reaction  to  painful  pressure. 

8.  Temperature: 

Thresholds  for  heat  and  cold: 
Effect  of  adaptation  on  threshold; 

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Discrimination  of  different  degress  of  heat  and 

cold; 
Affective    reactions  (a)   to    extreme    degrees, 
(6)   to  warmth. 
9.  Position: 

By    imitating    with    the    sound    limb    the 

position  of  the  affected  limb; 
By  pointing  with  the  sound  limb: 
Measurement  of  defect  by  Horsley's  method. 

10.  Passive   Movement: 

Appreciation  of  movement; 

Recognition  of  the  directions  of  movement: 

Measurement  of  the   angle  of  the  smallest 

movement  which  can  be  appreciated; 
Falling    away    of     the     unsupported    limb 

when  the  eyes  are  closed. 

11.  Active  Movement: 

Imitation  of  movement  by  the  sound  limb; 
Ability  to  touch  a  known  spot; 
Measurement    of    the    defect    by    Horsley's 
method. 

12.  Weight: 

a.  With  hand  supported, 
Recognition  of  differences  in  weights  applied 

successively  to  one  hand; 
Appreciation    of    increase    or    decrease     of 

weight; 
Comparison  of  two  weights  placed  one  in 

each  hand. 
6.   With  hand  unsupported, 
Comparison  of  two   weights  placed  one  in 

each  hand; 
Recognition  of  differences  in  weights  applied 

successively  to  one  hand. 

13.  Size: 

I  Hfference— threshold. 

Distinction  of  the  head  from  the  point  of 
the  pin. 

14.  Shape  (two  dimensional). 

15.  Form    (three    dimensional):     Recognition   of 

common  objects  by  their  form. 

16.  Textures: 

17.  Dominoes:     Ability  to  count  points  by  touch. 

18.  Consistence: 

19.  Testicular  sensibility: 

o.   Light  pressure; 
6.  Painful  pressure. 

20.  Sensibility  of  glans  penis  to  measured  prick. 

Such  a  detailed  examination  is  demanded  by  the 
present  day  knowledge  of  the  sensory  nervous  sys- 
tem. This  knowledge  is  the  accumulation  from  a 
number  of  research  workers.  The  most  important 
researches  have  come  notably  from  English  physiolo- 
gists and  clinicians.  A  brief  summary  of  this  work 
as  outlined  by  Head  and  Holmes  in  a  recent  (1912) 
monographic  presentation  will  be  found  useful. 

They  write  that  it  is  a  matter  of  universal  belief 
that  man  has  evolved  from  the  lower  animals,  and 
yet  when  we  deal  with  sensation  and  sensory  processes, 
we  speak  as  if  he  were  created  with  peripheral  end 
organs  capable  of  reacting  to  one  of  the  sensory 
qualities  of  human  experience.  The  impulses  start- 
ins:  in  these  end-organs  are  supposed  to  pass  unal- 
tered to  the  brain,  there  to  set  up  that  peculiar  and 
unknown  change  which  underlies  a  specific  sensation. 

Spots  were  found  on  the  skin  sensitive  to  touch,  to 
pain,  to  heat,  or  to  cold  only.  With  the  discovery 
of  these  highly  developed  end  organs,  the  doctrine 
of  specific  nerve  energy  seemed  to  be  proved  in  the 
strictest  manner.  All  other  forms  of  sensory  appre- 
ciation were  supposed  to  be  produced  by  the  psychical 
transformation  of  these  primitive  sensory  elements, 
in  association  with  an  ill-defined  faculty  called  the 
"muscle  .sense."  Recognition  of  the  locality  of  a 
stimulus,  and  the  posture  of  the  limbs  were  attrib- 
ute 1  to  judgment  and  association. 

But  alongside  the  systematic  investigation  of  von 

358 


1  rev,  and  others,  of  the  capabilities  of  these  specific 
areas  in  the  skin  the  clinicians  were  discovering  the 
importance  of  "muscular  sensibility."  Sherrington's 
demonstration  of  afferent  fibers  in  muscles  and  ten- 
dons placed  the  existence  of  the  "muscle  sense'' 
beyond  a  doubt,  and  the  use  he  made  of  these  afferent 
impulses  from  deep  structures,  in  his  theory  of  the 
proprioceptive  system,  necessitated  a  complete  explo- 
ration of  the  nature  of  deep  sensibility. 
■■  By  their  experiment  directed  to  this  end,  Rivers 
and  Head  showed  that  beneath  the  skin,  indi 
of  all  "touch"  and  "pain  spots,"  lies  an  afferent 
system  capable  of  a  wide  range  of  functions.  Pres- 
sure, that  in  ordinary  life  would  be  called  a  touch, 
can  be  appreciated  and  localized  with  considerable 
accuracy.  Increase  of  pressure,  especially  on  bones 
and  tendons,  will  cause  pain.  Moreover,  it  is  from 
the  impulses  of  this  deep  afferent  system  that  we 
gain  our  knowledge  of  the  posture  of  the  limbs  and 
the  power  of  recognizing  passive  movements. 

Evidently,  therefore,  the  peripheral  mechanism 
of  sensation  is  less  simple  than  was  at  first  supposed. 
For  there  are  two  sets  of  end  organs,  that  can  respond 
to  tactile  stimuli,  and  two  independent  mechanisms 
for  the  initiation  of  pain.  Further  analysis  showed 
that  the  peripheral  apparatus  in  the  skin,  by  which 
we  become  conscious  of  the  nature  of  external  stimuli, 
is  highly  complex.  No  one  sensory  quality  is  sub- 
served by  a  single  set  of  end  organs,  but  every  specific 
sensation  is  the  result  of  the  combined  activity  of 
more  than  one  group.  This  is  exactly  the  result 
that  might  have  been  expected,  when  we  bear  in 
mind  that  the  structure  of  man  is  the  product  of  a 
long  evolution. 

But  it  is  equally  obvious,  from  an  evolutionary 
standpoint,  that  these  diverse  impulses  could  not  pass 
uncombined  to  the  highest  physiological  level.  Within 
the  spinal  cord,  the  opportunist  grouping  of  the 
periphery  gives  place  to  an  arrangement  according  to 
quality  (Head  and  Thompson).  All  impulses  capable 
of  generating  pain  become  grouped  together  in  the 
same  path,  and  can  be  disturbed  simultaneously  by 
an  appropriate  lesion  of  the  spinal  cord. 

The  most  remarkable  condition  revealed  by  an 
intramedullary  lesion  is  the  complete  separation  of 
the  impulses  underlying  the  appreciation  of  posture, 
the  discrimination  of  two  points,  and  their  corre- 
lated faculties  from  those  of  other  sensory  groups. 
All  painful  and  thermal  impulses  coming  from  the 
periphery  undergo  regrouping  after  entering  the 
spinal  cord,  and,  whether  they  arise  in  the  skin  or  in 
deeper  structures,  become  arranged  according  to 
functional  similarity.  Then,  after  a  longer  or  shorter 
course,  they  pass  away  to  the  opposite  side  of  the 
spinal  cord. 

This  process  of  filtration  leaves  all  the  impulses 
associated  with  postural  and  spacial  recognition  to 
continue  their  course  unaltered  in  the  posterior 
columns;  they  are  the  survivors  of  peripheral  groups 
broken  up  by  the  passing  away  of  certain  compo- 
nents into  secondary  afferent  systems.  At  any  point 
in  the  spinal  cord  these  columns  transmit  not  only 
impulses  from  the  periphery  which  are  on  their  way, 
after  a  shorter  or  longer  passage,  to  regrouping  and 
transformation,  but  at  the  same  time  they  form  the 
path  for  impulses,  arising  both  in  the  cutaneous  and 
deep  afferent  systems,  which  undergo  no  regrouping 
until  they  reach  tlie  nuclei  of  the  medulla  oblongata. 

Thus,  a  lesion  confined  to  one-half  of  the  spinal 
cord,  even  at  its  highest  segment,  may  interfere  with 
the  passage  of  sensory  impulses,  some  of  which  are 
traveling  in  secondary  paths,  while  others  are  still 
within  the  primary  level  of  the  nervous  system.  All 
impulses  concerned  with  painful  and  thermal  sensa- 
tions from  distant  parts,  disturbed  by  such  a  lesion, 
will  be  traveling  in  secondary  paths  and  will  have 
come  from  the  opposite  half  of  the  body:  for.  after 
regrouping,  they  have  passed  across  the  spinal  cord. 


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Anesthesia  and  Analgesia 


But  those  impulses  underlying  the  appreciation  of 
posture,  the  compass  test,  size,  shape,  form,  weight, 
consistence,  vibration,  will  be  affected  on  the  same 
half  cf  the  body  as  the  Lesion.  They  still  remain  in 
paths  of  the  peripheral  level  and  have  undergone 
n.i  regrouping. 

In  such  a  case  the  parts  on  the  side  opposed  to  the 
lesion  may  l"'  insensitive  to  pain,  heal  and  cold;  but 
all  the  postural  and  spacial  aspects  of  sensation  will 
ba  perfectly   maintained.     Yet,   all  power  of  recog 
owing  position,  of  estimating  size,  shape,  form  and 
weight,  or  of  discriminating  the  two  compass  points, 
will  lie  lost  in  the  limbs  which  lie  on  the  side  of  the 
in,   although   tactile   sensibility   and   localization 
the  spot  stimulated  maj   be  perfectly  preserved. 
This     remarkable     arrangement     enables     one     to 
analyze  the  nature  of  the  peripheral  impulses  upon 
which    depend    our    power    of    postural    and    spacial 
recognition.     Obviously,  even  at  the  periphery,  they 
must   be  independent  of  touch  and   pressure.     The 
r   to  distinguish   two  points  applied   simultane- 
ously and  to  recognize  such  size  and  shape,  requires 
as  a  preliminary  the  existence  of  sensations  of  touch; 
the  patient  may  be  deprived  of  all  such  powers 
of  spacial  recognition  without  any  discoverable  loss 
of  tactile  sensibility.      In  the  same  way,  our  power 
to  appreciate  the  position  of  a  limb,  or  to  estimate 
the  weight  of  an  object,  is  based  upon  impulses  which, 
even  at  the  periphery,  exist  apart  from  those  of  touch 
and  pressure  called  into  simultaneous  being  by  the 
same  external  stimulus. 

This  long  delay  of  the  postural  and  spacial  ele- 
ments in  reaching  secondary  paths  enables  them  to 
give  off  afferent  impulses  into  the  spinal  and  cere- 
bellar coordinating  mechanisms,  which  lie  in  the 
same  half  of  the  spinal  cord.  The  impulses  which 
pass  away  in  this  direction  are  never  destined  to 
r  consciousness  directly.  They  influence  co- 
ordination, unconscious  posture  and  muscular  tone, 
and,  although  arising  from  the  same  afferent  end 
organs,  they  never  become  the  basis  of  a  sensation. 

finally,  the  last  survivors  of  these  impulses  from 
the  periphery  become  regrouped  in  the  nuclei  of  the 
posterior  columns  and  cross  to  the  opposite  half  of 
the  medulla  oblongata  in  paths  of  the  secondary 
level.  So  they  pass  to  the  optic  thalamus  and 
thence  to  the  cortex,  to  underlie  those  sensations 
upon  which  are  based  the  recognition  of  posture  and 
spacial  discrimination. 

Groups  op  Sensory  Disturbances. — In  clinical 
neurology  and  psychiatry  it  is  important  to  realize 
then  that  it  is  possible  closely  to  localize  and  delimit 
sensory  disturbances  into  the  following  groups: 

1.  Sensory  disturbances  of  the  peripheral  neurons: 
Neuralgia,  neuritis,  etc. 

2.  Sensory  disturbances  within  the  cord. 

3.  Sensory  disturbances  of  the  brain  stem. 

I.  Sensory  disturbances  of  the  optic  thalamus. 

5.  Sensory  disturbances  of  the  cortex:  (a)  Due 
to  altered  fiber  tracts  (so-called  organic);  (6)  Due 
to  altered  ideation  (psychical  alterations  as  seen  in 
psychoneuroses  and  psychoses). 

1.  Sensory  Disturbance  in  the  Peripheral  Neurones. 
—  No  attempt  will  be  made  here  to  give  the  specific 
anatomical  disturbances  such  as  underlie  the  various 
neuralgias  and  neuritides.  The  laying  down  of 
general  principles  which  enable  one  to  determine 
that  the  lesion  is  one  of  the  peripheral  neurone  is 
alone  attempted.  Thus  the  various  sensory  dis- 
turbances occurring  in  diseases  of  the  cranial  nerves, 
the  branches  of  the  cervical,  or  brachial  plexus,  the 
thoracic  nerves  or  the  lumbar  and  sacral  plexuses, 
will  be  found  under  their  appropriate  headings: 
trigeminal  neuritis,  brachial  neuritis,  median  nerve, 
intercostal  neuralgia,  sciatica,  etc.,  etc. 

Attention  will  be  directed  here  solely  to  certain 
general  facts  which  the  work  of  Head,  Rivers  and 
Sherren    have    bought    out  relative  to  the  peripheral 


sensory  system.  They  first  show  thai  the  ordinary 
method  of  testing  for  sensibility,  i.e.  by  touching  with 
the  linger  is  worthless.  It  fails  to  show,  in  per- 
ipheral  lesions,   such   as  sections  of  the  median  oi  ol 

the  ulnar  nerve,  that  grave  def  cl  oi  en  ibility  may 
i"  present,  for  the  pressure  touch  of  the  fingers  is 
after  all  a  type  of  test  for  deep  sensibility,  and  that 

i  he  tibers  for  deep  sensibility  pass  nil  in  t  he  tendons, 
muscles  or  deep  motor  nerves.  Thus  in  a  wound, 
say  of  the  wrist,  severing  median  or  ulnar  or  both, 
pre  ure  touch  would  not  be  involved  at  all,  unless 
the  tendons  were  also  divided,  but  that  tests  by 
cotton  wool  and  by  pin  prick  would  show  marked 
epicritic  and  protopathic  loss  respectively  are  ac- 
curately locahzable.  Their  researches  sh.ev  that. 
e  types  of  sensibility,  subserved  by  distinct  sets 

of  libers,  must  be  distinguished  in  the  eutan. 
system.  These  are  the  protopathic,  the  epicritic  and 
deep  sensibility  fibers.  Protopathic  sensibility  is  the 
more  elementary  and  original  type  of  sensibility,  It, 
is  that  which  serves  as  a  general  protection  of  the 
animal  body  from  harm.  It  distinguishes  pain,  as 
from  pin  prick,  it  distinguishes  between  extreme  ot 
heat  and  cold,  but  not  between  warm  and  cool. 
Epicritic  sensibility  on  the  other  hand  is  a  specialized 
discriminative  type  of  sensibility.  It  distinguishes 
light  touch  as  by  cotton  wool,  determines  minute 
variations  in  temperature,  localizes  compass  points 
which  are  close  together.  Deep  sensibility  finally 
is  concerned  with  postural  sense,  and  deep  pressure 
sense  tested  by  an  algesimeter  (Carttell)  the  epi- 
critic and  protopathic  sensibilities  travel  in  the 
cutaneous  system,  that  of  deep  sensibility  in  the  ten- 
dons and  muscles  and  motor  nerves.  Attention  has 
been  called  to  the  fact  that  in  severe  nerve  injuries 
deep  sensibility  is  lost  only  when  tendon  or  muscle 
or  motor  nerve  is  implicated.  Again,  as  in  median  or 
ulnar  nerve  injury  it  is  observed  that  if  the  periphery 
is  involved  the  area  of  insensibility  to  cotton  wool  is 
usually  larger  than  that  of  pin  prick.  Immediately 
following  the  injury  they  may  be  coterminous  but 
soon  the  condition  of  wider  extension  of  epicritic 
touch  loss  becomes  apparent.  When  the  lesions 
reach  the  main  branches  of  the  plexuses  however  it 
is  noted  that  the  epicritic  and  protopathic  loss  is 
about  equal  and  enduringly  so  until  recovery  takes 
place,  whereas,  and  this  is  an  interesting  point 
brought  out  by  Head,  when  the  injury  involves  the 
sensory  roots,  there  is  a  peculiar  reversal  of  the 
reaction  and  here  the  loss  to  pin  prick  is  wider  and 
more  extensive  than  the  loss  to  cotton  wool. 

In  recovery  the  practical  point  to  bear  in  mind  is 
that  if  the  area  to  cotton  wool  loss  rapidly  recedes,  i.e. 
within  five  or  six  weeks,  it  is  probable  that  the  nerve 
affected  has  been  partially  cut  across  only.  Cotton 
wool  loss  usually  persists  about  100  days  in  a  totally 
divided  nerve  before  recovery  commences  to  set  in. 
If  after  that  time  the  area  to  cotton  wool  loss  does 
not  recede,  operation  is  indicated.  Testing  then  by 
cotton  wool,  by  pin  prick  and  for  deep  sensibility  are 
absolute  necessities  in  determining  lesions  of  the  per- 
ipheral nervous  system.  For  research  purposes  the 
use  of  compasses,  of  von  Frey's  hairs,  of  measured 
thermal  and  pressure  stimuli,  are  necessary.  In 
practical  work  they  are  valuable  but  under  certain 
circumstances  may  be  dispensed  with. 

2.  Disturbances  of  Sensibility  in  Spinal  Cord  Affec- 
tions.— Similarly  no  detailed  description  of  the 
diseases  of  the  spinal  cord  will  be  attempted.  It  is 
well-known  that  one  disease  process  will  give  rise  to  a 
number  of  clinical  pictures.  Thus  a  plaque  of  mul- 
tiple sclerosis  may  give  rise  to  the  picture  of  a  tales, 
amyotrophic  lateral  sclerosis,  a  poliomyelitis,  a 
spastic  paraplegia,  or  a  complete  transverse  myelitis. 
This  section  will  deal  only  with  those  diagnostic 
criteria  which  from  the  analysis  of  the  sensory  symp- 
toms alone  indicate  that  the  sensory  paths  are  inter- 
rupted in  their  spinal  course. 


359 


Anesthesia  and  Analgesia 


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In  the  previous  section  it  has  been  shown  that  the 
epicritic,  protopathic  and  deep  sensibility  fibers  are 
capable  of  being  stimulated  separably  and  that  these 
three  systems  remain  distinctly  isolated  as  systems. 
Not  so  in  the  spinal  cord.  Here  an  entirely  new  dis- 
tribution takes  place  and  we  find  that  functional 
pathways  make  way  for  quality  paths:  Heat  as  heat, 
cold  as  cold,  pain,  pass  up  separately,  and  there  is 
no  longer  any  distinction  between  epicritic  and  pro- 
topathic heat,  epicritic  or  protopathic  pressure, 
etc  .  such  as  is  found  in  the  cutaneous  system  in  the 
arms  or  legs. 

In  the  spinal  cord  one  finds  the  pain  and  thermal 
fibers  usually  crossing  the  cord — traveling  up  in  the 
spino-thelamic  paths  in  the  anterolateral  portion  of 
the  cord.  Deep  sensibility  fibers,  subserving  postural 
sense,  pass  up  in  the  posterior  columns  of  the  same 
side,  while  pressure  touch  usually  passes  up  both  sides 
of  the  cord.  The  work  of  Head  and  Thompson  has 
given  the  main  clue  to  the  study  of  the  different 
forms  of  sensibility  in  their  pathological  alterations 
in  lesions  of  the  spinal  cord. 

3.  Disturbances  of  Sensibility  in  Lesio?is  of  the 
Brain  Stem. — Disease  of  the  brain  stem  offers  special 
problems  of  diagnosis  of  extreme  difficulty,  so  far  as 
the  analysis  of  the  sensory  disturbances  is  concerned. 
So  long  as  the  sensory  paths  were  in  their  spinal 
route  they  were  capable  of  a  certain  amount  of  isola- 
tion either  as  they  entered  the  cord  and  made  their 
first  synapses,  or  as  they  continued  up  the  cord  in 
primary  or  secondary  paths.  But  as  these  paths 
converge  to  enter  the  brain  stem  they  become  closer 
anatomically,  disease  processes  are  apt  to  overrun 
many  paths,  and  thus  the  analysis  becomes  increas- 
ingly difficult  up  to  the  entering  of  these  paths  into 
the  optic  thalamus. 

Head  and  Holmes  hold  that  the  impulses  under- 
lying sensations  of  pain,  heat,  and  cold  seem  alone 
to  run  unaltered,  either  directly  or  by  intercalated 
fibers  associated  with  the  ganglion  cells  of  the  forma- 
tio  reticularis,  between  the  upper  end  of  the  spinal 
cord  and  the  optic  thalamus.  Here  are  received 
the  regrouped  secondary  impulses  from  the  face 
which  cross  and  join  the  specific  paths  for  pain,  for 
heat  or  for  cold.  These  paths  are  so  situated  that 
they  can  be  interrupted  without  disturbance  of  any 
other  form  of  sensation  on  the  body,  and  the  anal- 
gesia and  thermoanesthesia  so  produced  resemble  in 
quality  the  loss  of  sensation  to  pain,  heat  and  cold 
caused  by  a  lesion  in  the  spinal  cord. 

Thus  when  a  lesion  of  the  bulb  interferes  with 
sensation  of  pain,  not  only  may  the  skin  be  insensitive 
to  prick,  but  the  readings  of  the  pressure  algometer 
may  be  raised  on  the  analgesic  side.  In  the  same 
way  the  affected  area  of  the  body  may  be  insensitive 
to  all  degrees  of  heat,  and  to  all  stimuli  capable  of 
evoking  normally  a  sensation  of  cold.  Here,  how- 
ever, in  the  bulb,  in  distinction  to  lesions  of  the  cord, 
the  grosser  form  of  pain  and  discomfort  may  traverse 
other  paths  if  the  usual  ones  are  closed — whereas  in 
the  cord  all  painful  impulses  are  blocked  by  an 
equivocal  lesion. 

In  the  bulb  moreover  all  three  forms  of  sensibility 
may  be  affected  together  or  any  one  may  escape  or 
be  alone  involved. 

These  impulses  of  pain,  heat  and  cold  all  run  up  in 
the  neighborhood  of  the  fifth  nerve  nucleus,  and  in 
cases  of  occlusion  of  the  posterior  cerebellar  artery 
the  paths  are  usually  implicated.  This  same  accident 
may  occasion  a  dissociation  of  the  impulses  underlying 
the  appreciation  of  posture  and  passive  movement 
from  those  concerned  with  spatial  discrimination. 

A  summary  of  the  findings  which  may  occur  in  the 
lesions  which  cut  off  the  sensory  pathways  between 
the  nuclei  of  the  posterior  columns  and  the  optic 
thalamus  has  been  stated  by  Head  and  Holmes  as 
follows: 

1.   The  impulses  for  pain,  heat  and  cold  continue 

360 


to  run  up  in  separate  secondary  paths  on  the  opposite 
side  of  the  nervous  system  to  that  by  which  they 
entered.  They  receive  accessions  from  the  regrouped 
afferent  impulses  from  the  nerves  of  the  head  and 
upper  part  of  the  neck. 

Although  these  paths  are  frequently  affected 
together,  they  are  independent  of  one  another,  and 
any  of  the  three  qualities  of  sensation  may  be  disso- 
ciated from  the  others  by  disease. 

2.  Lesions  of  the  spinal  cord  tend  to  diminish 
simultaneously  all  forms  of  painful  sensibility,  but 
with  disease  of  the  brain  stem  the  gross  forms  of  pain 
and  discomfort  may  pass  to  consciousness,  although 
the  skin  is  analgesic.  This  applies  not  only  to  painful 
pressure  but  to  the  discomfort  produced  by  excessive 
heat. 

3.  The  impulses  concerned  with  postural  recogni- 
tion part  company  with  those  for  spacial  discrimina- 
tion at  the  posterior  column  nuclei.  Up  to  this 
point,  they  have  traveled  together  in  the  same 
column  of  the  spinal  cord,  but  as  soon  as  they  reach 
their  first  synaptic  junction  they  separate.  Above 
the  point  where  they  enter  secondary  paths,  the 
power  of  recognizing  posture  and  passive  movements 
can  be  affected  independently  of  the  discrimination 
of  two  points  and  the  appreciation  of  size,  shape  and 
form  in  three  dimensions. 

4.  It  would  seem  as  if  those  elements  which  under- 
lie the  power  of  localizing  the  spot  touched  or  pricked 
become  separated  off  from  their  associated  tactile 
impulses  before  they  have  actually  come  to  an  end 
in  the  optic  thalamus.  The  long  connection  of  local- 
ization with  the  integrity  of  tactile  sensibility  is  here 
broken  for  the  first  time. 

All  these  changes  are  preparatory  to  the  great 
regrouping  which  takes  place  in  the  optic  thalamus. 

4.  The  Thalamic  Syndrome  and  Se?isory  Changes 
in  Disorders  of  the  Thalamus. — Practically  the  entire 
mass  of  sensory  fibers  carrying  impulses  of  all  kinds — 
the  tests  for  most  of  which  have  already  been  outlined 
— have  synaptic  junctions  within  the  optic  thalamus. 
No  note  has  been  made  here  of  the  numerous  fibers 
coming  from  the  chemical  receptors  of  the  respiratory, 
gastrointestinal,  or  genitourinary  tract,  nor  those 
from  the  organs  of  internal  secretion,  nor  even  of  the 
sympathetic — all  of  these  make  up  an  enormous 
terra  incognita  for  the  future  explorer. 

Lesions  in  and  about  the  thalamus  cause  sensory 
symptoms,  as  well  as  motor  ones,  of  a  very  char- 
acteristic nature — so  much  so  that  one  can  speak  of 
a  special  thalamic  syndrome.  Such  a  syndrome  was 
first  described  by  Dejerine  and  his  pupils,  particu- 
larly by  Roussy,  who  devoted  a  monograph  to  the 
subject. 

Here  one  observes  the  following  notable  features: 

1.  A  persistent  loss  of  superficial  sensation  of  one- 
half  of  the  body  and  face.  This  loss  to  touch,  pain, 
and  to  temperature,  is  more  or  less  definite,  subject 
to  considerable  variation  and  to  partial  recovery, 
but  the  loss  of  deep  sensibility,  deep  pressure,  pos- 
tural  sense,  etc.,  is  much  more  pronounced,  and  is 
more  apt  to  persist.  This  latter  is  usually  more 
marked  distally  and  in  many  instances  diminishes 
as  one  approaches  the  trunk. 

2.  There  is  slight  hemiataxia  and  more  or  less  com- 
plete astereognosis. 

3.  There  are  in  the  complete  syndrome  acute  pains 
on  the  affected  side  which  are  very  persistent,  coming 
on  in  paroxysms.  They  are  frequently  extremely 
severe  and  rarely  respond  to  the  ordinary  analgesics. 
These  pains  may  involve  a  single  member,  may  he 
limited  to  the  side  of  the  face,  simulating  a  trigeminal 
neuralgia,  or  they  may  involve  one  whole  side  of  the 
body. 

4.  There  is  usually  a  more  or  less  distinct  though 
slight  hemiplegia,  which  in  the  unmixed  syndromes 
rapidly  clears  up.  Contractures  rarely  develop  in 
the  pure  syndrome.     In  the  mixed  syndrome — with 


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extension  of  the  lesion  to  the  external  capsule — con- 
tracl  ures  may  be  pres  ;n1 . 

5,  Choreic,  athetoid,  or  paralysis  agitans-like 
movements    may    be   present    on   the   affected   side. 

rhese  are  the  symptoms  which  permit  one  to  diag- 
nose a  lesion  of  the  optic  thalamus  and  its  surrounding 
pruts,  but  in  addition  to  these  Head  ami  Holmes  have 
pointed  out  an  extremely  suggestive  series  of  affect- 
ive reactions  which  arc  due  to  lesions  in  the  optic 
thalamus.  They  have  opened  up  an  attack  upon 
the  analysis  of  the  sensory  content  of  emotional 
reactions.  They  show  that  in  thalamic  lesions  there 
ia  a  tendency  to  react  excessively  to  unpleasant 
luli.  The  prick  of  a  pin,  painful  pressure,  exces- 
sive heat  or  cold,  all  produce  more  distress  than  on 
the  normal  half  of  the  body.  Thus,  in  one  of  Head 
and  Holmes'  patients,  if  a,  pin  is  dragged  lightly 
-  the  face  or  trunk  from  the  sound  to  the 
affected  side,  there  is  felt  an  excessive  discomfort 
passes  the  middle  line.  She  not  only  complained 
that  it  hurt  her,  but  the  face  was  contorted  with 
pain,  and  all  this  notwithstanding  the  fact  that  she 
was  less  able  to  distinguish  head  from  point,  yet 
the  prick  hurt  her  more.  This  very  anomalous  state 
of  affairs  is  a  purely  thalamic  reaction. 

This  excessive  reactivity  is  seen  not  only  to  pin 
prick,  hut  also  to  deep  pressure,  to  extremes  of  heat 
and  cold,  to  visceral  stimulation,  to  scraping,  rough- 
ness, vibration,  tickling,  to  pleasureable  stimuli, 
and  to  ideational  emotional  states.  Not  all  patients 
show  all  of  these  reactions,  but  in  practically  ninety  per 
cent,  of  the  thalamic  cases  examined  by  Head  and 
Holmes  excessive  affective  response  to  one  or  more 
measured  stimuli  were  found.  For  head  and  cold,  and 
other  forms  of  sensibility  as  well  as  for  pain  the  exces- 
response  may  be  present,  and  yet  the  patients  are 
unable  to  detect — i.e.  are  anesthetic  to — trie  stimulus 
itself.  So  far  as  the  ideational  affective  reaction 
is  concerned  these  patients  express  themselves  as 
follows:  On  hearing  affecting  music  "a  horrid  feel- 
ing came  on  in  the  affected  side,  and  the  leg  screwed 
up  and  started  to  shake."  The  singing  of  a  comic 
song  left  one  patient  absolutely  cold,  but  a  tragic 
2,  produced  a  very  distinct  unpleasant  effect. 
One  patient  said  "my  right  hand  seems  to  crave 
sympathy,  my  right  side  seems  more  artistic."  In 
practically  all  of  the  cases  the  increased  affective 
reaction    was   accompanied   by   actual   sensory   loss. 

\  more  detailed  study-  of  the  loss  of  sensibility  in 
thalamic  disorders  made  by  Head  and  Holmes  re- 
vealed the  following:  Xo  sensory^  functions  are  so 
frequently  affected  as  the  appreciation  of  posture 
and  the  recognition  of  passive  movement.  The 
amount  of  this  loss  varies  greatly  from  a  scarcely 
mensurable  defect  to  complete  want  of  recognition 
of  the  posture  of  the  limbs  of  the  abnormal  naif  of 
tic  body. 

Tactile  sensibility  is  frequently  diminished;  but, 
excepting  in  a  few  cases  where  all  appreciation  of 
contact  was  destroyed,  a  threshold  could  be  obtained. 
It  was  always  possible  to  show  that  increasing  the 
Strength  of  the  stimulus  improved  the  proportion  of 
right  answers  unless  the  observations  were  confused 
by  the  disagreeable  tingling  or  other  accessory 
sensations. 

Localization  of  the  spot  touched  was  defective  in 
half  the  cases  where  sensation  was  sufficiently  pre- 
served to  carry  out  accurate  tests.  This  inability 
to  recognize  the  site  of  simulation  was  equally  great, 
whether  the  patient  was  pricked  or  touched.  In 
cases  where  localization  was  gravely  affected,  the 
disagreeable  sensation,  so  easily  evoked,  tended  to 
spread  widely  on  the  abnormal  half  of  the  body. 
A  prick  on  the  hand  may  cause  an  extremely  painful 
ation  in  the  cheek  or  side,  and  sometimes  the 
patient  simplv  recognized  the  stimulus  as  a  change 
within  himself,  and  did  not  refer  the  discomfort  from 
which  he  suffered  to  the  action  of  any  external  agent. 


Sensibility   to  heat    and  cold   may  show    all   degl 
of  change  from   total  loss  to  a  slight   increase  of  the 
neutral   zone.     Beat    and   cold   are   not    dissociated; 
and  if  one  form  of  sensation  is  lost,  the  other  will  be 

ely   disturbed.     The   apparent    exceptio 
from  a  misinterpretation  of  the  sensatio  ed  by 

high  or  low  temperatures  on  the  affected  half  of  the 
body. 

\oi  infrequent  l\  I  lie  compa     tesl  cannot  be  carried 

out  because  of  the  gro     sation  and  inability 

to  recognize  contact;  but   whenever  this  method  can 
be  applied  a  threshold  can  be  worked  out,  and  wii 
ing  the  distance  between   the  points  increases  the 
accuracy  of  the  answers. 

The  power  of  estimating  the  relation  between 
two  weights  is  frequently  disturbed  on  the  abnormal 
half  of  the  body.  If  the  appreciation  of  posture  and 
movement  is  affected,  the  patient  can  no  longer 
recognize  the  identity  or  the  differi  vo  weights 

placed    in    the    unsupported    hands.       Hut    so    long    as 

tactile  sensibility  is  not  diminished,  he  can  still 
estimate   the   relation   between   weights   applied   one 

after  tl ther  to  the  same  spot,   and  can  recognize 

the  increase  or  diminution  in  weight  of  in  object 
already  resting  on  tin-  hand. 

The  appreciation  of  relative  size  is  often  disturbed 
in  tin  but  with  care  it  is  usually  easy  to  dem- 

onstrate a  difference-threshold.  Shape  and  form  in 
three  dimensions  are  frequently  not  recognizable  on 
the  affected  hand.  But.  if  tactile  sensibility  is  not 
grossly  affected,  the  patient  usually  retains  an  idea 
that  the  object  possesses  a  form,  and  may  obtain  a 
considerable  percentage  of  right  answers. 

Vibration  of  the  tuning  fork  is  recognized  by  all 
but  three  of  our  patients.  In  almost  every  case, 
however,  the  length  of  time  during  which  it  was 
appreciated  was  shorter,  and  sometimes  the  rate  of 
vibration  was  thought  to  be  slower  on  the  affected 
half  of  the  body. 

Roughness,  as  tested  with  Graham  Brown's  esthe- 
siometer.  was  always  recognized,  except  in  three 
cases  where  the  loss  of  all  forms  of  sensation  was 
unusually  severe.  Usually  the  threshold  was  the 
same  on  the  two  sides,  but  it  was  occasionally  raised 
on  the  affected  hand, 

5.  Sensory  Disturbances  due  to  Cerebral  Lesions. — 
The  sensory  paths  from  the  thalamus  to  the  cortex 
undergo  a  new  distribution,  thus  making  at  least 
five  distinct  regroupings  of  the  sensory  phenomena 
in  the  entire  course  of  the  sensory  neuron.  The 
analysis  of  the  phenomenon  introduces  more  com- 
plex factors,  and  the  necessity  for  abandoning 
all  generalizations,  even  those  more  refined,  that 
anesthesia,  analgesia,  as,  for  instance,  light  touch, 
cutaneous  sensations,  etc.,  become  more  apparent. 
Newer  valid  terms  may  be  coined,  but  one  is  here 
forced  to  state  the  results  in  terms  of  the  tests 
emploved. 

1.  Using  graduated  tactile  stimuli  such  as  von 
Frey's  hairs,  and  the  pressure  esthesiometer,  Head 
and  Holmes  have  found  as  follows: 

A  cortical  lesion  may  reduce  the  accuracy  of 
response  from  the  affected  part  to  graduated  tactile 
stimuli. 

The  form  assumed  by  this  defective  sensibility 
differs  from  that  produced  by  lesions  at  other  levels 
of  the  nervous  system.  Here  the  affected  part  may 
respond  to  the  same  graduated  hair  as  the  normal 
hand;  but  this  response  is  irregular  and  uncertain. 
Increasing  the  stimulus  may  lead  to  no  corresponding 
improvement,  and  even  the  strongest  tactile  hair  may 
occasionally  evoke  less  certain  answers  than  a  hair 
of  much  smaller  bending  strain.  Moreover,  a  touch 
with  the  unweighted  esthesiometer  may  be  as  effec- 
tive at  one  moment  as  the  same  instrument  weighted 
with  30  grm.  at  another.  In  such  cases  no  tactile 
threshold  can  be  any  longer  obtained. 

2.  This  irregularity  of  response  is  associated  with 


361 


Anesthesia  and  Analgesia 


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persistence  of  the  tactile  sensation  and  a  tendency 
to  hallucinations  of  touch. 

Where  the  sensory  defect  is  not  sufficiently  gross 
to  abolish  the  threshold,  persistence,  irregularity  of 
response  and  a  tendency  to  hallucinate  may  still 
disturb  the  records. 

3.  In  all  cases  where  tactile  sensibility  is  affected, 
whether  a  threshold  can  be  obtained  or  not,  fatigue 
is  induced  with  unusual  facility.  Although  the 
patient  may  cease  to  respond  to  tactile  stimuli  over 
the  affeeted  part  in  consequence  of  fatigue,  his  an- 
swers may  remain  as  good  as  before  from  the  normal 
parts.     The  fatigue  is  local  and  not  general. 

4.  With  stationery  cortical  lesions,  uncomplicated 
by  states  of  shock  or  by  "diaschisis,"  sensibility  to 
touches  with  cotton  wool  is  never  lost  over  hair-clad 
parts.  Over  hairless  parts,  stimulation  with  cotton 
wool  may  produce  a  sensation  which  seems  "less 
plain"  to  the  patient,  and  his  answers  may  show  the 
same  inconstancy  so  evident  when  he  is  tested  with 
graduated  tactile  stimuli. 

For  measured  painful  stimuli  they  found  that  a 
pure  cortical  lesion  leads  to  no  change  in  the  threshold 
to  measureable  painful  or  uncomfortable  stimuli. 
Nor  does  the  patient  express  greater  dislike  to  these 
stimuli  on  one  side  than  on  the  other.  A  prick 
may  be  said  to  be  "plainer"  or  "sharper"  on  the 
normal  than  on  the  affected  side;  but  this  is  due  to  a 
defective  appreciation  of  the  pointed  nature  of  the 
stimulus  and  bears  no  direct  relation  to  the  pain- 
fulness  of  the  sensation  evoked. 

The  temperature  tests  they  found  as  follows: 

1.  The  neutral  zone,  within  which  the  stimulus  was 
said  to  be  neither  hot  nor  cold,  was  considerably  en- 
larged in  comparison  with  that  observed  on  similar 
normal  parts  of  the  same  patient. 

2.  The  patient  complained  that  although  he 
recognized  correctly  the  nature  of  the  stimulus,  it 
seemed  "less  plain"  than  over  normal  parts.  His 
answers  were  less  constant  and  less  certain;  a  tem- 
perature recognized  without  difficulty  at  one  time 
seemed  doubtful  at  another. 

3.  The  power  of  discriminating  the  relative  cool- 
ness of  two  stimuli,  or  the  relative  warmth  of  two 
hot  tubes  may  be  diminished.  Thus  20°  C.  may  be 
said  to  be  the  same  as  ice,  although  both  are  uniformly 
called  cold,  and  40°  C.  may  seem  as  warm  as,  or  even 
warmer  than  48°  C.  The  faculty  of  appreciating 
the  relation  to  one  another  of  two  temperatures  on 
the  same  side  of  the  scale  is  disturbed. 

For  recognition  of  posture  and  for  passive  move- 
ments they  found  that: 

1.  Cortical  lesions  most  frequently  disturb  the 
recognition  of  posture  and  of  passive  movements. 
Whenever  sensation  is  in  any  way  affected  in  conse- 
quence of  a  cortical  lesion  these  two  functions  suffer. 

2.  In  all  their  cases  the  distubrance  in  the  faculty 
of  recognizing  posture  and  passive  movements  was 
greater  toward  the  peripheral  parts  of  the  affected  limb. 

3.  When  a  patient  with  unilateral  disturbance  of 
these  faculties  attempts  to  point  to  some  part  of  his 
body,  defective  knowledge  of  its  position  causes 
greater  error  than  want  of  recognition  of  posture 
and   movement   in   the   hand  with  which  he  points. 

4.  When  testing  the  patient's  power  of  appreciat- 
ing passive  movement,  the  answers  are  frequently 
uncertain  and  hallucinations  of  movement  may  occur. 
And  yet  the  patient  may  be  remarkably  consistent 
and  accurate  when  normal  parts  are  tested. 

5.  Localization  tests  showed: 

(a)  The  power  of  localizing  the  stimulated  spot  is 
not  infrequently  preserved,  although  sensation  may 
!»■  otherwise  disturbed  as  a  consequence  of  cortical 
lesions. 

(b)  This  faculty  is  independent  of  the  power  of 
recognizing  the  position  of  the  affected  limb;  appre- 
ciation of  posture  may  be  lost,  although  localization 
is  not   in  any  way  diminished. 

362 


(c)  If  the  power  of  localization  is  lost,  the  patient 
will  be  unable  to  recognize  not  only  the  position  of  a 
spot  touched  but  also  the  position  of  a  prick. 

(d)  When  localization  is  defective  in  consequence 
of  cerebral  lesions,  the  patient  docs  not  habitually 
localize  in  any  particular  direction,  but  ceases  to  be 
certain  where  he  has  been  touched  or  pricked. 

6.   The  compass  test  revealed  that: 

(a)  A  cortical  lesion  may  destroy  the  power  of 
discriminating  two  compass  points,  both  when  applied 
simultaneously  and  collectively. 

If  this  is  the  case,  no  threshold  can  be  obtained  for 
either  form  of  the  test;  increasing  the  distance  be- 
tween the  points  does  not  constantly  improve  the 
accuracy  of  the  answers. 

(b)  This  disturbance  is  not  caused  by  changes  in 
tactile  appreciation;  for  it  can  be  demonstrated 
equally  well  with  two  painful  as  with  two  tactile 
stimuli. 

(c)  The  condition  of  tactile  sensibility  and  the 
accuracy  of  the  simultaneous  compass-test  are  cloi  elj 
associated;  a  disturbance  of  the  tactile  threshold  is 
usually  accompanied  by  a  raised  threshold  for  the 
appreciation  of  two  points  applied  simultaneously. 

(d)  Should  the  power  be  preserved  of  recognizing 
two  points  when  the  compasses  are  applied  consecu- 
tively, localization  will  be  found  to  be  intact.  The 
patient's  appreciation  of  the  two  points  when  they 
are  separated  by  an  interval  of  time  is  due  to  the 
recognition  of  the  separate  locality  of  the  two  spots 
touched. 

7.  Appreciation  of  weights  showed  that: 

(a)  The  power  of  estimating  the  relative  of  two 
objects  of  the  same  size  and  shape  is  readily  disturbed 
by  cortical  lesions. 

(6)  Though  the  patient  may  retain  sensations 
of  contact  when  the  weight  is  placed  in  his  hand,  all 
power  of  recognizing  the  relative  heaviness  of  the 
object  has  disappeared. 

(c)  This  faculty  is  equally  disturbed  in  most  cases 
whether  the  weights  are  placed  on  the  supported 
or  the  unsupported  hand. 

From  these  and  related  studies,  it  would  appear 
that  sensory  impulses  pass  from  the  thalamus  to  the 
cortex  is  five  groups: 

1.  Those  concerned  with  the  recognition  of  posture 
and  passive  movement.  If  these  impulses  are 
affected  the  power  of  discriminating  weights  on  the 
unsupported  hand  may  be  also  diminished. 

2.  Certain  tactile  elements;  integrity  of  this  group 
is  necessary  for  the  discrimination  of  weights  placed 
on  the  fully  supported  hand. 

3.  Those  impulses  which  underlie  the  appreciation 
of  two  points  applied  simultaneously  (the  compass 
test);  on  this  group  also  depends  the  recognition  of 
size  and  shape. 

4.  Those  which  underlie  the  power  of  localizing 
the  situation  of  a  stimulated  spot.  Recognition  of 
the  double  nature  of  two  points  applied  consecutively 
also  depends  on  this  group  of  impulses. 

5.  All  thermal  impulses  are  grouped  together  to 
underlie  a  scale  of  sensations  with  neat  at  the  one 
end  and  cold  at  the  other.  At  the  level  with  which 
we  are  now  dealing  these  impulses  have  already  ex- 
cited the  affective  center  and  are  passing  away  to  the 
cortex. 

Head  and  Holmes  believe  that  the  functional 
integrity  of  the  cortex  enables  attention  to  be  con- 
centrated   upon    those    changes   which  are  produ 1 

by  the  arrival  of  afferent  impulses.  When  this  is 
disturbed,  some  impulses  evoke  a  sensation,  but  others 
from  lack  of  attention,  do  not  affect  consciousness. 
Attention  no  longer  moves  freely  over  the  sensory 
field  to  be  focussed  successively  on  fresh  groups  of 
sensory  impressions.  Sensations,  once  evoked,  are 
not  cut  short  by  the  moving  away  of  the  focus  of 
attention  as  when  cortical  activity  is  perfect.  Hence 
arise  persistent  sensations  and  hallucinations  which 


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are  so    prominent    a    feature    after    lesions    of    the 
cortex. 

They  believe  that    the  cerebral   cortex   is  tin-  organ 

1  ,y  which  we  are  able  to  foi         i       ition  upon 
changes  evoked  by  sensory  impulses.     A  pure  cortical 
lesion,  which  is    not  advancing  or   causing  periodic 
discharges,  will  change  the  sensibility  of  the  affected 

-  in  such  a  way  that  t  he  patient 's  answers  appear 
to  be  untrustworthy.  Such  diminished  power 
makes  the  estimation  of  a  threshold  in  many  cases 
impossible.  Uncertainty  of  response  destroys  all 
power  of  comparing  one  set  of  impressions  with 
another  and  so  prevents  discrimination. 

;.:  addition  to  its  function  as  an  organ  of  local 
attention  the  sensory  cortex  is  also  the  storehouse  of 
past  impressions.  These  may  rise  into  consciousness 
as  images,  but  more  often,  as  in  the  case  of  spacial 
impressions,  remain  outside  central  consciousness. 
Here  they  form  organized  models  of  ourselves  which 
may  be  termed  "schemata."  Such  schemata  modify 
the  impressions  produced  by  incoming  sensory  im- 
pulses in  such  a  way  that  the  final  sensations  of 
position,  or  of  locality,  rise  into  consciousness  cha 
with  a  relation  to  something  that  has  happ 
before.  Destruction  of  such  "schemata"  by  a  lesion 
of  the  cortex  renders  impossible  all  recognition  of 
posture  or  of  the  locality  of  a  stimulated  spot  in  the 
affected  part  of  the  body. 

In  daily  life  all  stimuli  excite  more  or  less  both 
thalamic  and  cortical  centers,  for  most  unselected 
itions  contain  both  affective  and  discriminative 
elements.  But,  among  the  tests  employed  in  sen- 
sory analysis,  some  appeal  almost  entirely  to  the  one 
or  the  other  center.  The  test  for  recognition  of 
posture,  as  carried  out  by  Head  and  Holmes,  is 
purely  discriminative;  while  the  pain  produced  by 
dug  the  testicle,  or  to  a  less  degree  by  the 
pressure  algometer,  appeals  almost  exclusively  to 
the  more  affective  center. 

-  nsory  impulses  arriving  at  the  optic  thalamus 
are  regrouped  in  such  a  way  that  they  can  act  upon 
both  its  essential  center  and  the  sensor}-  cortex.  The 
itial  organ  of  the  thalamus  is  excited  to  affective 
activity  by  certain  impulses,  and  refuses  to  react  to 
those  which  underlie  the  purely  discriminative  aspects 
of  sensation.  These  pass  on  to  influence  the  cor- 
tical centers  where  they  are  readily  accepted.  In  a 
similar  way.  the  primary  centers  of  the  cortex  cannot 
receive  those  components  which  underlie  feeling 
tone:  in  this  direction  they  are  completely  blocked. 

It  has  long  been  recognized  that  sensations  are 
endowed  with  feeling  tone  to  different  degrees.  In 
those  which  underlie  postural  appreciation  this 
quality  is  entirely  absent,  while  visceral  sensations 
are,  in  some  instances,  little  more  than  a  change 
in  a  general  feeling  tone,  one  set  of  impulses  appeals 
almost  exclusively  to  the  cortical  center,  the  other 
to  that  of  the  optic  thalamus.  All  thermal  stimuli, 
however,  make  a  double  appeal.  Every  sensation 
of  heat  or  cold  is  either  comfortable  or  uncomfortable; 
the  only  entirely  indifferent  temperature  is  one  that 
is  neither  hot  nor  cold. 

In  the  same  way.  some  unselected  tactile  stimuli 
appeal  both  to  the  sensory  cortex  and  to  the  optic 
thalamus.  For  not  only  is  a  touch  always  related  to, 
and  distinguished  from,  something  that  has  gone 
before  it,  but  we  have  shown  that  contact,  especially 
of  an  object  moving  over  hair-clad  parts,  is  capable 
of  exciting  thalamic  activity.  Vibrations  of  the 
tuning  fork  also  make  a  double  appeal,  for  when  the 
cortical  paths  are  cut  the  amplitude  of  the  vibration 
must  be  greater  in  order  that  it  may  be  appreci- 
ated; on  the  other  hand,  the  vibratory  effect  may  be 
stronger  on  the  abnormal  side  in  those  thalamic 
cases  where  the  affective  response  is  excessive. 

But  these  two  centers  of  consciousness  are  not  co- 
equal  and  independent.  Under  normal  conditions 
the  activity  of  the  thalamic  center,  though  of  a  dif- 


ferent nature,  is  dominated   by  that  of   the  cortex. 
When  we  examine  ttion  normally  prod 

by  a  prick,    we   rei  ■    ,  lops 

slowly  and  lasts  a  considerable  time  after  the  stimu- 
lus has  ceased.  Moreover,  the  same  intensity  of 
stimulation  will  produce  a  different  effect  01 
same  spot  on  different  occa  ions.  A  long,  latent 
and  want  of  uniformity,  are  char- 
acteristic of  all  painful  Si  This  is  seen  in  an 
exaggi  rat  d  form  in  cases  "her.-  the  thalamic  center 
has  been  freed  from  control.  The  to  prick 
is  slow,  but  persists  long  after  the  stimulus  has  ceased. 
Moreover,  the  reaction  when  it  occurs,  tends  to  be 
explosive;  it  is  as  if  a  spark  had  fired  a  magazine 
and  the  consequences  were  not  commensurate  with 
the  cause. 

On  the  contrary,  the  sensations  normally  prodt 
by  moderate  tactile  stimuli  are  characterized  by  a 
short  latent  period,  and  disappear  almost  immediately 
on  the  cessation  of  the  stimulus!  A  lesion  of  tic 
sory  cortex  disturbs  both  these  characteristics. 
Tactile  sensations  become  uncertain  and  incalcu'able, 
and  no  threshold  can  be  obtained;  persistence  and 
hallucinations    mar    the    uniformity    of    the    records. 

Now  we  have  shown  that  the  sensory  cortex  is  the 
organ  by  which  attention  can  be  concentrated  on 
any  part  of  the  body  that  is  stimulated.  The  focus 
of  attention  is  arrested  by  the  changes  produced  by 
cortical  activity  at  any  one  spot.  These  are  sotted 
out  and  brought  into  relation  with  other  sensory 
processes,  past  or  present.  Then  the  focus  of  atten- 
tion sweeps  on,  attracted  b}7  some  other  object. 

All  stimuli  which  appeal  to  the  thalamic  center 
have  a  high  threshold.  They  must  reach  a  high 
intensity  before  they  can  enter  consciousness,  but 
once  they  have  risen  above  the  threshold  they  tend 
to  produce  a  change  of  excessive  amount  and"  dura- 
tion, and  this  it  is  the  business  of  the  cortical  mechan- 
ism to  control.  The  low  intensity  of  the  stimuli 
that  can  arouse  the  sensory  cortex,  and  its  quick 
reaction  period,  enable  it  to  control  the  activity  of 
the  cumbersome  mechanism  of  the  thalamic  center. 

The  view  of  the  sensory  mechanism  put  forward  in 
their  paper  explains  many  of  the  facts  already  recog- 
nized by  both  psychologists  and  clinicians.  It 
enables  us  to  understand  how  integrations  can  occur 
at  all  afferent  levels  of  the  nervous  system,  and  makes 
development  possible  even  in  the  individual.  The 
aim  of  human  evolution  is  the  domination  of  feel- 
ing and  instinct  by  discriminative  mental  activities. 
This  struggle  on  the  highest  plane  of  mental  life  is 
begun  as  the  lowest  afferent  level,  and  the  issue 
becomes  more  clearly  defined  the  nearer  sensory 
impulses  approach  the  field  of  consciousness. 

Smith  Ely  Jelliff!:. 


Anesthesia,  General  Surgical. — Anesthesia  (apaur- 
thpla)  may  be  defined  as  loss  of  feeling  or  sensation, 
and  general  surgical  anesthesia,  with  which  this  arti- 
cle deals,  as  loss  of  feeling  or  sensation  in  the  entire 
organism  during  any  surgical  procedure,  caused  by 
introduction  into  the  blood  of  an  anesthetizing  agent. 

It  is  impossible  to  say  at  what  time  in  human  his- 
tory attempts  were  first  made  to  relieve  pain  and  suf- 
fering. Certain  it  is,  however,  that  the  Assyrians 
and  the  Egyptians  were  familiar  with  substances  cap- 
able of  producing  soporific  and  anodyne  effects. 
Homer,  Herodotus,  Dioscorides,  Pliny,  and  many 
other  ancient  writers  frequently  referred  to  such  sub- 
stances. Shakespeare  also  frequently  mentioned  an- 
esthetizing draughts,  but  the  production  of  surgical 
anesthesia,  as  we  now  understand  it,  is  a  matter  of 
quite  modern  development. 

During  the  early  part  of  the  nineteenth  century 
considerable  attention  was  given  to  the  anesthetic 
properties  of  nitrous  oxide  and  ether  by  different 
observers,  but  no  satisfactory  and  practical  applica- 


363 


Anesthesia,  General  Surgical 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


tion  was  made  in  the  induction  of  general  surgical  an- 
esthesia till  December,  1S44,  when  Horace  Wells,  a 
dentist  of  Hartford,  Connecticut,  demonstrated  the 
anesthetic  properties  of  nitrous  oxide  by  having  one 
of  his  own  teeth  extracted  while  he  was  insensible 
through  the  inhalation  of  this  gas.  Further  experi- 
ence with  the  use  of  this  anesthetic  convinced  Wells 
that  painless  tooth  extraction  was  both  possible  and 
practical,  but  after  an  unfortunate  failure  in  a  dem- 
onstration at  the  Harvard  Medical  School  this  use 
of  nitrous  oxide  was  generally,  but  undeservedly, 
discredited  for  several  vears. 

On  September  30,  1846,  \V.  G.  Morton,  a  dentist  of 
Boston,  employed  ether  vapor  in  anesthetizing  a 
patient  for  tooth  extraction,  and  thereafter  admin- 
istered it  for  surgical  operations  with  complete  suc- 
cess. The  use  of  this  agent  rapidly  spread  and  it  was 
soon  quite  extensively  employed  in  America,  Great 
Britain,  and  on  the  Continent. 

On  November  10,  1847,  Sir  James  Simpson  an- 
nounced the  discovery  of  the  anesthetic  properties  of 
chloroform  and,  on  account  of  Simpson's  influence 
and  of  the  more  rapid  action  and  less  irritating  and 
disagreeable  vapor  of  the  drug,  chloroform  began  rap- 
idly to  supplant  ether  in  general  surgery.  However, 
in  a  few  weeks  after  its  first  use  a  fatality  was  reported, 
and  from  time  to  time  similar  casualties  occurred, 
until  finally  it  became  quite  apparent  that  whatever 
advantages  the  new  agent  seemed  to  possess  its  anes- 
thetic use  was  not  without  considerable  danger  to  life. 

In  1847  Heyfelder  first  administered  ethyl  chlor- 
ide for  a  surgical  operation,  and  successfully  demon- 
strated its  anesthetic  properties;  but  it  did  not  pax 
into  general  use  until  about  fifty  years  later.  It  will 
thus  be  seen  that  surgical  anesthesia  and  the  anes- 
thetic properties  of  nitrous  oxide,  ether,  chloroform, 
and  ethyl  chloride  all  were  discovered  within  a  short 
period  of  three  years;  and  in  the  three-quarters  of 
a  century  that  has  since  elapsed,  although  replete 
with  research,  experimentation,  and  synthetic  produc- 
tion, no  widely  used  inhalation  anesthetic  has  been 
discovered  or  evolved,  so  that  the  four  agents  above 
mentioned,  used  either  singly,  in  sequence,  or  in  com- 
bination, hold  practically  undisputed  sway  in  this 
great  and  important  field  of  modern  medicine. 

The  Physiology  of  General  Anesthesia. — Gen- 
eral anesthetics  affect  all  the  various  systems  of  the 
organism  in  a  more  or  less  characteristic  manner. 
There  is  a  distinct  difference,  however,  in  the  effect 
produced  by  each  of  the  general  anesthetics  in  the 
same  organism,  no  matter  by  what  means  or  manner 
the  anesthetic  may  be  introduced.  Furthermore,  the 
same  subject  displays  different  phenomena  under  the 
influence  of  the  same  anesthetic  with  only  a  difference 
in  the  method  of  administration.  Finally,  subjecl  . 
seemingly  essentially  similar,  display  markedly  differ- 
ent phenomena  under  the  same  anesthetic  and  iden- 
tical system  of  administration.  It  will  be  readily  in- 
ferred from  a  consideration  of  these  facts  that  the 
selection  of  the  anesthetic  and  the  practical  applica- 
tion of  a  method  of  administration  that  will  secure 
the  desirable  phenomena  and  avoid  the  undesirable, 
in  any  individual  subject,  are  matters  that  present 
no  small  amount  of  difficulty. 

Nitrous  Oxide. — As  nitrous  oxide  when  inhaled  pure 
readily  combines  with  hemoglobin,  producing  a  dark 
colored  blood  on  account  of  the  cells  being  deprived  of 
oxyhemoglobin,  it  rapidly  causes  cyanosis  as  well  as 
loss  of  consciousness  and  sensation.  Inasmuch  as 
the  cyanosis  and  anesthesia  are  intimately  associated 
when  only  nitrous  oxide  is  inhaled,  it  was  formerly 
thought  that  the  anesthesia  was  due  to  the  cyanosis 
or  asphyxiation.  However,  Edmund  Andrews  of 
Chicago,  in  1868,  conclusively  proved,  by  the  sim- 
ultaneous administration  of  pure  oxygen,  that 
nitrous  oxide  possessed  distinct  anesthetic  properties 
separate   and  apart  from  its  asphyxial  phenomena, 

36  1 


and  that  anesthesia  might  be  secured  with  it  when 
mixed  with  sufficient  oxygen  to  maintain  a  normal 
color. 

The  initial  sensations  of  nitrous  oxide  are  of  an 
agreeable  and  stimulating  character,  as  is  the  case 
with  the  other  general  anesthetics,  and,  with  oxygen 
excluded,  anesthesia  and  cyanosis  rapidly  follow,  to- 
gether with  jactitation,  stertor,  respiratory  depres- 
sion, muscular  spasm,  and  finally  respirator}'  failure 
all  usually  in  the  order  mentioned. 

Under  nitrous  oxide  anesthesia  the  amount  of  car- 
bonic acid  in  the  blood  is  less  than  during  anesthesia 
produced  by  the  other  general  anesthetics,  but  accord- 
ing to  investigations  thus  far  reported  it  produces 
no  permanent  effect  upon  the  cells  or  other  constitu- 
ents of  the  blood.  Arterial  tension,  however,  is 
slightly  raised  by  the  action  of  this  anesthetic.  As 
nitrous  oxide  is  unirritating  it  causes  no  pathological 
change  in  the  cells  of  the  tract  of  its  administration 
and  elimination,  or  degenerating  effect  upon  the  cells 
of  the  liver,  kidneys,  or  brain.  Its  toxicity,  therefore, 
is  very  low  indeed. 

Ether.— One  of  the  leading  characteristics  of  ether  is 
that  it  is  a  very  energetic  stimulant  to  the  respira- 
tory, circulatory,  nervous,  and  glandular  systems. 
Its  vapor  is  irritating  to  the  respiratory  passages, 
often  causing  the  secretion  of  considerable  mucus  and 
saliva.  As  is  the  case  with  nitrous  oxide,  its  effects 
are  greatly  increased  by  the  limitation  of  oxygen.  In 
ether  toxemia  respiratory  failure  precedes  that  of  the 
circulation.  The  effect  upon  blood  pressure  is  prob- 
ably nil,  as  some  observers  claim  that  it  increases 
it,  while  others  claim  it  produces  a  slight  fall  in 
arterial  tension. 

The  blood  changes  under  ether  anesthesia  are  quite 
important  and  far  reaching,  affecting  detrimentally, 
both  the  quantity  and  quality  of  the  blood  constitu- 
ents. The  volume  index  shows  an  immediate  loss 
which  is  not  regained  till  after  the  seventh  day.  The 
color  index  shows  an  almost  constant  drop  beginning 
during  or  immediately  after  anesthesia  and  continu- 
ing till  the  fifth  or  sixth  day.  The  most  important 
blood  effect,  however,  is  upon  the  leucocytes,  for  while 
it  produces  a  leucocytosis  it  decreases  the  functional 
activity  of  the  phagocytes,  and  in  this  manner  very 
materially  lowers  the  patient's  resisting  power  against 
infection. 

In  addition  to  its  degenerative  effect  upon  the 
cells  of  the  blood  ether  likewise  causes  a  pathological 
change  in  the  cells  of  the  brain,  liver,  and  kidneys. 
and  decreases  the  secretion  of  urine  as  to  both  its 
watery  and  nitrogenous  elements.  The  pathological 
change  in  the  brain  cells  induced  by  ether  is  undoubt- 
edly one  of  the  leading  factors  in  the  depression  and 
shock  that  follow  every  ether  anesthesia  of  any  con- 
siderable  duration  or  depth. 

Chloroform. — In  common  with  the  other  general 
anesthetics  chloroform  at  first  stimulates  respiration, 
but  as  narcosis  becomes  established  the  breathing  is 
quiet  and  shallow,  and  under  full  effect  respiratory 
paralysis  follows.  It  is  a  mistake  to  believe  that  chlo- 
roform always  produces  fatality  by  primary  cardiac 
failure,  for  in  true  chloroform  toxemia  the  heart  may 
continue  to  beat  after  respiration  has  ceased,  although 
one  of  the  leading  causes  of  such  respiratory  failure  is 
a  circulatory  effect,   viz.,  a  fall   in  arterial   tension. 

Chloroform  produces  a  dilatation  of  the  whole  car- 
diovascular system.  Circulatory  paralysis,  or  sud- 
den heart  failure,  however,  is  due  to  the  use  of  a  loo 
concentrated  vapor,  for  if  precaution  is  taken  to  avoid 
this  the  heart  continues  to  beat  after  respiration 
ceases.  What  really  constitutes  a  too  concentrated 
vapor,  or  overdosage,  is  a  matter  that  varies  consider- 
ably, but  depends  more  upon  the  depth  of  res- 
piration than  upon  any  other  factor  other  than  the 
percentage  of  vapor.  Most  of  the  fatalities  with  chlo- 
roform have  occurred  during  the  induction  of  anes- 
thesia, and  often  by  the  patient  simply  making  a 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Anesthesia!  Genera]  Surgical 


deep  inspiration  of  a  vapor,  which,  with  an  ordinary 

inspiration,  would  doI   have  been  too  concentrated, 

and,  therefore,  would  not  have  been  an  overdosage, 

Chloroform  product's  more  destructive  changes  in 

the  cells  of  (he  blood  and  liver,  and  less  in  the  e 
oreting  cells  of  the  kidneys,  than  does  ether.  The 
degenerative  visceral  effects  of  chloroform  are  very 
pronounced,  especially  upon  the  liver,  and  when  taken 
in  connection  with  the  immediate  fatalities  the  com- 
plete mortality  is  very  high  indeed. 

Ethyl  Chloride. —  In  physiological  action  ethyl  chlo- 
ride more  nearly  resembles  nitrous  oxide  than  any 
other  general  anesthetic.  It  first  stimulates  respira- 
tion and  rapidly  causes  loss  of  consciousness,  muscular 
spasm,  stertor,  and  cardiac  paralysis.  It  affects  the 
cardiovascular  system  in  very  much  the  same  manner 
as  chloroform,  by  causing  a  fall  in  blood  pressure,  and 
death  occurs  either  directly  or  indirectly  through  its 
effect  upon  the  circulatory  system.  Its  effects  upon 
the  blood,  brain,  and  viscera  have  not  as  yet 
investigated. 

SELECTION    OF    THE    ANESTHETIC    AND    METHOD    OF 

Administration. — The   anesthetist    of    the    present 

day  has  at  his  disposal  the  four  primary  inhalation 
anesthetics,  a  number  of  mixtures  and  combinations 
of  these  agents,  a  number  of  sequences,  and  a  large 
variety  of  methods  of  administration,  and  each  has 
its  special  advantages. 

In  the  selection  of  the  anesthetic,  as  well  as  in  the 
determination  of  the  method  of  administration,  the 
primary   consideration  should   be   the   safety    of  the 

Satient,  but  unfortunately  this  is  not  always  the  case. 
[ere  convenience  or  a  slight  difference  in  cost  should 
not  for  a  single  moment  be  weighed  against  the 
patient's  safety  while  on  the  operating  table  or 
welfare  during  the  period  that  should  be  one  of 
convalescence.  Selecting  a  particular  anesthetic 
and  method  of  administration  on  the  basis  that  it  is 
safe  in  the  hands  of  the  unskilled,  as  is  so  often  the 
case,  is  unscientific  and  belongs  to  a  bygone  age 
The  surgeon  never  recommends  a  particular  method  of 
operation  because,  perchance,  it  is  safe  in  the  hands 
of  the  unskilled!  Why  then,  the  question  may  well 
be  asked,  is  the  literature  of  to-day  so  replete  with 
the  advocacy  by  surgeons  themselves  of  a  particular 
method  of  administering  ether  because  it  is  safe  in 
the  hands  of  the  unskilled?  Such  practice  is  a 
stigma  upon  the  whole  profession.  If  any  other 
method  or  any  other  anesthetic  is  safer  and  better 
for  the  patient,  the  necessary  skill  for  its  proper 
administration  will  be  forthcoming  just  as  soon  as 
the  surgeon  makes  a  real  demand  for  it.  It  is  not  a 
valid  or  scientific  criticism  or  objection  against  any 
anesthetic  or  method  that  its  use  requires  skill. 

It  is  a  very  difficult,  if  not  impossible,  matter 
to  determine  the  real  mortality  of  the  different  anes- 
thetics. The  personal  factor  of  the  anesthetist  is 
more  important  than  the  anesthetic  or  method,  so 
even  if  individual  statistics  were  accurate,  which  is 
usually  not  the  case,  they  would  be  very  misleading. 
Besides,  as  a  rule,  statistics  cover  only  the  immediate 
mortality,  while  the  remote  effect  and  its  accom- 
panying mortality,  which  with  some  of  the  anes- 
thetics is  high,  is  disregarded. 

Practically  all  authorities  agree  that  nitrous  oxide 
is  the  safest  anesthetic  known  for  the  induction  of 
anesthesia,  and  the  mortality  for  this  particular  form 
of  administration  is  very  low  indeed,  being  given  by 
\Yood  at  1  in  1,000,000.  For  prolonged  administra- 
tion oxygen  must  be  combined  with  nitrous  oxide, 
and  while  this  combination  is  safer  than  nitrons 
oxide  alone,  the  mortality  during  prolonged  use  is 
much  higher  than  in  brief  administrations,  though 
it  is  very  generally  considered  to  be  less  than  that  of 
ether.  Certain  it  is  that  when  the  innocuous  effect 
of  nitrous  oxide-oxygen  is  considered,  the  entire 
absence  of  any  irritation  of  the  respiratory  and  genito- 


urinary tracts  and  of  degeneration  of  the  cells  of 
tli.1  blood,  brain,  liver,  and  kidneys,  together  with  its 
shock-preventing  and  immunity-preserving  quali- 
ties, show  that  its  real  or  total  mortality  is  decidedly 
less  than  (hat  of  el  her. 

It  is  quite  certain  that  ether  ranks  second  a  to 
safety.  Its  mortality  is  usually  given  a-  I  in  16,000. 
Such  statistics,  however,  cover  only  the  immediate 
mortality,   and,   when   in   connection   with    this   the 

remote  mortality  is  considered,  tin'  real  or  total 
mortality  is  much  higher  than  the  figure  just  given. 

The  mortality  of  chloroform  is  usually  given  as 
1  in  4,000,  leit  tic  real  or  total  mortality,  a-  i-  the 

case    with   ether,    is    much    higher    than    the    stati   tics 

thai  cover  only  the  immediate  mortality  indicate. 
The  mortality  of  ethyl  chloride  is  generally  placed 

between   that    of  ether  and  chloroform,  or  about    I    in 

in. null.  As  ethyl  chloride  is  used  chiefly  to  induce 
anesthesia,  and  it  is  for  this  form  of  administration 
upon  which  this  rate  of  mortality  is  based,  it  is  evident 
that  for  such  use  it  is  many  times  more  dangerous 
than  nitrous  oxide. 

As  the  majority  of  deaths  that  are  given  in  statis- 
tics occur  in  the  induction  stage,  it  is  quite  evident 
that  the  patient's  safety  demands  that  nitrous  oxide 
be  used  as  the  preliminary  anesthetic;  also  that 
for  this  purpose  ethyl  chloride  is  much  safer  than 
chloroform. 

Difficulties  and  Dangers  of  General  Anes- 
thesia.— The  immediate  danger  to  the  life  of  the 
patient  inhaling  an  anesthetic  is  connected  with  the 
respiratory  and  circulatory  systems.  Either  system 
may  be  the  one  primarily  affected,  but  the  other 
one  soon  becomes  involved,  so  that  it  is  usually  a 
complex  state  when  the  patient's  condition  is  serious. 

Respiratory  failure  may  be  classified  under  two 
general  heads:  (1)  Obstructive,  (2)  central. 

The  obstruction  to  respiration  may  arise:  In  the 
mouth  by  the  lips  being  drawn  together  during 
inspiration;  in  the  nose  by  polypi,  spurs,  malforma- 
tion, tumors,  etc.,  and  if  the  mouth  and  lips  are 
tightly  closed  there  may  be  complete  obstruction 
to  the  respiratory  movement.  At  the  beginning  of 
the  administration  the  obstruction  may  be  only 
partial,  but  on  account  of  the  attending  congestion 
and  swelling  of  the  mucous  membrane,  it  may  later 
on  become  complete. 

The  tongue,  increased  in  size  on  account  of  conges- 
tion, may  cause  obstruction  simply  on  account  of  its 
abnormal  size,  or,  as  is  more  often  the  case,  it  falls 
backward,  thereby  causing  more  or  less  complete 
obstruction.  Morbid  growths  of  the  tongue,  palate, 
tonsils,  pharynx,  and  epiglottis  and  foreign  bodies 
also  offer  more  or  less  obstruction  to  the  respiratory 
movement.  Excessive  secretion  of  mucus  may 
produce  considerable  obstruction.  Spasm  of  muscles 
about  the  neck,  jaw,  and  of  the  glottis  may  produce 
complete  and  sudden  arrest  of  respiration.  Keflex 
stimulation  by  operative  procedure,  distention  of  the 
abdomen  producing  upward  pressure  on  the  dia- 
phragm, or  position  of  the  patient  on  the  operating 
table  producing  the  same  effect,  and  distention  of 
the  pleural  cavities  with  fluid  alter  or  obstruct  normal 
respiration. 

Respiratory  failure  from  central  cause  may  be  due 
to  an  overdose  of  the  anesthetic,  loss  of  blood,  or 
shock.  This  form  of  failure  usually  develops  insidi- 
ously, and  is  more  difficult  to  treat. 

The  most  common  form  of  sudden  and  temporary 
respiratory  arrest  occurs  with  the  act  of  vomiting, 
and  this  in  itself  is  not  serious.  However,  if  the  vom- 
it ns  is  not  immediately  and  completely  wiped  away, 
it  may,  during  inspiration,  be  aspirated  into  the 
trachea  and  thus  cause  complete  respiratory  obstruc- 
tion, or,  by  the  conveyance  of  infection,  be  the  direct 
cause  of  a  subsequent  pneumonia. 

In  the  treatment  of  respiratory  obstruction,  arrest, 

365 


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or  failure  the  cardinal  principle,  of  course,  is  to  re- 
move the  cause,  and  this  usually  is  not  a  difficult 
matter  if  the  cause  is  only  recognized.  The  anesthe- 
tist must  be  ever  alert  to  detect  the  indications  of  the 
various  cause,-,  of  respiratory  embarrassment. 

In  the  induction  stage,  or  during  incomplete 
anesthesia,  too  great  concentration  of  the  vapor  is  the 
most  frequent  cause  of  holding  the  breath  and  of 
spasm  of  various  muscles  concerned  in  respiration.  If 
the  spasm  is  not  severe,  the  temporary  withdrawal 
of  the  anesthetic  is  usually  sufficient;  but  if  this  does 
nut  relieve  the  condition  the  jaws  should  be  widely 


Fig.  203.— Hard  Rubber  Oral  Screw. 

opened  with  a  wedge,  a  gag  inserted,  the  tongue 
grasped  with  a  pair  of  forceps,  and  traction  used,  at 
the  same  time  intermittent  compression  being  made 
upon  the  chest,  or  actual  artificial  respiration  being 
resorted  to;  unless  the  spasm  is  unusually  severe  these 
means  will  quickly  restore  nor- 
mal breathing.  Tracheotomy 
will  always  afford  the  desired 
relief,  unless  its  use  is  too  long 
deferred,  and  if  the  spasm  is 
very  severe,  and  jaws  closed 
and  rigid,  it  is  practically  the 
only  available  effective  treat- 
ment. 

If  the  tongue  falls  back 
against  the  posterior  wall  of 
the  pharynx,  the  patient's  head 
should  be  turned  to  one  side  and 
the  angle  of  the  jaw  pressed  for- 
ward. In  case  it  is  necessary  to 
keep  the  jaw  thus  pressed  for- 
ward, or  whenever  such  a  position  does  not  completely 
relieve  this  source  of  obstruction,  a  Coburn  "breathing 
tube"  (Fig.  204)  should  be  quickly  placed  in  position. 
This  tube  is  specially  moulded  with  a  curve  adapting 
it  to  be  slipped  over  the  base  of  the  tongue,  and  car- 


dioxide  in  the  blood.  Accordingly  whenever  respira- 
tion needs  stimulation  no  more  effective  or  practical 
respiratory  stimulant  can  be  used  than  carbon  dioxide. 
This  may  be  administered  from  two  sources,  allowing 
the  patient  to  rebreathe  his  own  exhalations,  or  add- 
ing pure  carbon  dioxide  direct;  am!  with  the  carbon 
dioxide  utilized  from  either  source  pure  oxygen  should 
be  added.  A  very  practical  method,  other  than  the 
rebreathtng,  is  to  administer  from  a  cylinder  a  mix- 
ture of  ten  per  cent,  carbon  dioxide  and  ninety  per 
cent,  oxygen.  Hypodermics  of  atropine  and  a  heart 
stimulant,  preferably  adrenalin,  with  either  caff,  ine 
camphor,  or  alcohol,  may  also  be  used.  If  these 
means  fail  pharyngeal  or  intratracheal  insufflation 
of  air  or  oxygen  is  the  last  resort.  If  there  is  a  sudden 
respiratory  arrest,  artificial  respiration  by  Silvester'a 
method  must  be  maintained  until  the  patient  inspires 
sufficient  carbon  dioxide  to  stimulate  the  respiratory 
center,  but  if  the  patient  does  not  respond  to  tins 
treatment  properly  the  insufflation  should  not  be  too 
long  delayed,  or  else  circulatory  failure  may  supervene 
as  well. 

It  is  important  always  to  bear  in  mind  that  mere 
movement  of  the  chest  does  not  necessarily  indicate 
actual  respiration,  and  in  all  doubtful  cases  the 
anesthetist  must  immediately  make  absolutely  sure 
whether  there  is  a  true  respiration  or  not.     In  some 


1'  ig.  204. — Coburn 's  Breathing  Tube. 

ries  a  metal  fitting  at  its  outer  end  which  fits  between 
the  teeth,  holding  it  in  position  and  preventing  it  from 
being  closed  during  incomplete  relaxation  of  the 
jaws.  The  curve  facilitates  its  introduction  and 
keeps  it  patulous.  The  tube  is  ample  in  size  for 
full  and  free  respiratory  movement,  and  presents 
no  interference  with  the  application  of  any  face 
mask. 

When  respiratory  failure  is  due  to  central  cause  the 
treatment  is  radically  different.  Henderson,  with  his 
revolutionizing  theory  of  carbon  dioxide,  has  shown 
that  the  great  controller  of  respiration  is  the  carbon 

366 


Fig.  205. — Pozzi's  Tongue  Forceps. 

methods  of  administration  this  matter  is  difficult  to 
ascertain.  The  Coburn  apparatus  has  an  automatic 
indicator  which  always  shows  whether  the  patient  is 
actually  breathing,  no  matter  what  anesthetic  is  used 
or  what  method  is  employed. 

Circulatory  failure  may  be  either  gradual  or 
sudden.  In  gradual  failure  of  circulation  there  is 
usually  ample  warning.  The  patient  becomes  pale, 
eyelids  separate,  pupils  dilate,  lips  and  finger-tips 
become  slightly  cyanotic,  pulse  is  fast  and  feeble,  nose 
is  "pinched,"  cold  sweat  comes  out  on  the  forehead, 
and  the  pulse  finally  becomes  imperceptible  at  the 
wrist  or  about  the  head. 

Whenever  there  is  marked  weakening  of  the  pulse 
appropriate  treatment  is  imperative.  Before  insti- 
tuting treatment,  however,  the  anesthetist  should 
quickly  make  sure  of  the  exact  condition  of  the  pa- 
tient. If  the  corneal  reflex  is  abolished  the  anesthetic 
should  be  withheld  for  a  short  time  at  least.  If  the 
anesthesia  is  light  and  there  is  any  tendency  toward 
vomiting  the  anesthesia  should  be  deepened.  An 
absolutely  free  air-way  should  be  immediately  secured 
ami  good  oxygenation  maintained.  A  change  in  anes- 
thetic or  method  may  be  desirable.  The  patient's 
head  should  be  kept  low.  Hypodermics  of  ergotol 
(large  amounts)  and  of  camphor  or  caffeine  may  be 
administered.  A  very  effective  treatment  is  a  saline 
infusion  of  1,000  c.c.  to  which  has  been  added  about 
forty  minims  of  adrenalin  solution,  even  though  there 
has  been  no  considerable  loss  of  blood.  The  admin- 
isl  ration  of  carbon  dioxide  and  oxygen  stimulates  res- 
piration and  vascular  tonus  and  thereby  indirectly 
greatly  improves  the  circulation  and  is  the  most 
effective  single  treatment  for  this  condition,  unless 
the  anesthetic  itself  is  exerting  a  direct  inhibitory 


REFERENCE    HANDBOOK    OP    THE    MEDICAL    SCIENCES        Amnesia,  General  Surgical 


action  upon  the  heart,  when,  of  course,  a  change  in  the 
anesthetic  is  imperal  ive. 

In  sudden  circulatory  failure  the  anesthetic 
be  discontinued  and  the  patient  immediately  inverted 

nearly   as    possible,    and    carbon   dioxide-ox 
administered,  using  :ui ili<ia!  respiration  if  necessary, 


Fig.  206. — Bfeyer-Denhaxdt  Mouth  Gag. 

ami  simultaneously  making  direct  cardiac  massage. 
Should  these  means  prove  ineffective  no  time  should 
be  lost  in  making  an  abdominal  incision,  if  the  ab- 
domen is  not  already  open,  so  as  to  make  rhythmic 
compression  of  the  heart  by  pressing  upon  the  dia- 
phragm; for  after  the  circulation  has  ceased  for 
seven  minutes  the  brain  cells  lose  their  vitality. 
However,  efforts  at  resuscitation  should  be  con- 
tinued longer  than  for  this  period,  for  it  is  difficult 
to  say  just  when  the  circulation  actually  ceases  in 
such  cases.  Besides,  a  form  of  circulation  is  prob- 
ably maintained  by  rhythmic  compression  of  the 
heart  though  there  is  little  or  no  spontaneous  con- 
traction. 

The  remote  dangers  of  anesthetics  are  quite  as 
important  as  the  immediate,  though  it  is  only  of 
recent  years,  during  which  the  administration  of 
anesthetics  has  really  reached  a  scientific  basis,  that 
tliis;  view  has  been  advanced.  The  physiologist, 
the  pathologist,  and  the  critical  clinical  observer 
have  united  in  forcing  this  view 
into  prominent  consideration. 
Formerly  it  was  considered 
that  the  anesthesia  was  a  suc- 
cess if  the  surgeon  was  unper- 
turbed and  the  patient  sur- 
vived his  removal  from  the 
operating  table  a  reasonable 
time.  To-day  science  demands 
that  the  anesthesia  shall  not 
only  be  satisfactory  to  the 
surgeon  but  at  the  same  time 
that  it  shall  conserve  the  pa- 
tient's vitality  and  maintain 
his  physiological  agencies  at 
this  critical  time  at  the  highest 
possible  degree  of  efficiency,  so 
that  nature  may  continue  the 
struggle  for  the  preservation 
of  life,  the  highest  and  most 
fundamental  of  all  natural  law, 
without  a  needless  handicap. 

The  most  universal  detri- 
mental effect  of  general  anes- 
thesia is  depression  or  shock. 
In  many  cases  this  may  seem 
to  be  a  matter  of  immaterial 
consequence,  but  it  is  always 
an  effect  of  much  more  importance  than  is  at  first 
apparent.  It  has  long  been  observed  that  the  fright 
and  fear  preceding  'general  anesthesia  causes  shock, 
often  quite  severe,  and  Crile  has  shown  that  it  pro- 
duces a  demonstrable  pathological  lesion  of  the  brain 
cells,  thus  placing  the  observation  on  a  scientific 
basis.     Means  to  assuage  the   patient's  fear  should, 


Fir,.    207. — Meli-lk-ister's 
Mouth    Gag. 


therefore,  be  used,  and  its  most  efficient  preventative 
is  morphine  li\  podermically  administered. 

All  observers  pracl  ically  agree  that  more  depre    ion 

and    shock    follow    ether    and    chloroform    am     thi 

than  thai  by  nitrous  oxide,  and  thai  in  this  re  peri  the 

effect  of  chloroform  i  i  e  i unced  than  that  of 

ether,     ('rile  shows  that  ether  causes  f  our  times  thi 

lion  of  brain  cell  .  as  evidenced  by  nun,,  copical 
demon  1 1  >  nit  rou    oxide.     <  >r  in  other 

words  ether  prod  id  four  times  as  much  shock  as 
nitrous  oxide  a  very  important  scientific  matter,  as 
,  hock  is  a  feature  of  every  surgical  operation. 

Practically  all  critical  observers  agree  thai  in 
infection  the  toxemia  is  decidedly  more  pronounced 
after  ether  or  chloroform  anesthesia  than  after  that 

of    nitrons    oxide.      Graham     Shows    that     chloroform 

and  ether  markedly  impair  phagocytosis,  and  thereby 
demonstrates  the  scientific  basis  of  the  previously 
observed  clinical  facl . 

Pneumonia  and  bronchitis  are  sequels  of  general 
anesthesia,  most  frequently  Observed  after  ether  and 
least  frequently  after  nitrous  oxide.  The  explana- 
tion of  this  difference  is  to  be  found  in  the  irritant 
qualities  of  ether  vapor,  and  in  the  fact  that  the 
resulting  anesthesia  markedly  lowers  the  patient's 
resistance  against  infection. 


lEMflfJNSCC.N  V 

Fig.  208. — Mussey's  Mouth  Gag. 

The  irritant  action  of  ether  upon  the  kidneys  and 
genitourinary  tract  and  the  degenerating  effect  of 
chloroform  upon  the  liver  contraindicate  these  agents 
whenever  these  organs  are  involved.  It  has  recently 
been  shown  that  ether  also  produces  a  degenerating 
effect  upon  the  liver,  and  that  chloroform  likewise 
affects  the  kidneys. 

In  diabetes  nitrous  oxide  is  always  strongly  indi- 
cated as  the  anesthetic,  as  coma  much  more  frequently 
follows  the  administration  of  ether  and  chloroform 
in  this  condition. 


Role  of  Carbon  Dioxide.- — Dr.  Yandell  Hender- 
son, of  the  Yale  Medical  School,  in  his  remarkable 


Fig.  209. — Cusco's  Tongue  Forceps. 


work  on  carbon  dioxide,  has  startled  the  entire 
scientific  world  with  his  demonstrations  of  the  vast 
role  that  carbon  dioxide,  heretofore  considered  practi- 
cally an  insignificant  waste-product,  plays  as  a  regu- 
lator of  so  many  of  the  vital  functions  of  the  human 
body.  His  work  is  reported  mainly  in  a  series  of 
papers  published  in  the  American  Journal  of  Physi- 
ology,   and    I    can   here  make  only  a  brief  summary 


367 


Anesthesia,  General  Surgical 


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ami  quotation  of  the  more  important  features  that 
pertain  to  anesthesia. 

Respiration. — The  great  regulator  of  respiration  is 
nut  an  automaticity  of  the  respiratory  center  similar 
to  that  of  the  heart,  or  afferent  nerve  influences,  or 
need  of  oxygen,  but  the  amount  of  CO,  in  the  blood. 
The  respiratory  center  requires  a  continuously  acting 
stimulant  to  force  it  into  constant  activity.  The 
afferent  impulses,  under  ordinary  conditions,  affect 
only  the  rate  or  depth  of  respiration  and  not  the 
amount  of  pulmonary  ventilation.  Whenever  pul- 
monary ventilation  is  increased,  the  amount  of  CO, 
in  the  arterial  blood  is  thereby  decreased,  i.e.  acapnia 
results.  "Perhaps  there  is  no  idea  more  firmly  fixed 
in  the  medical  mind,  or  which  it  will  be  harder  to 
root  out,  than  that  the  respiratory  center  is  sensitive 
to  alterations  in  its  oxygen  supply.  Yet  during  the 
past  few  years  it  lias  been  ((inclusively  demonstrated 
that  within  wide  limits  the  respiratory  center  is 
indifferent  both  to  excess  and  to  lack  of  oxygen. 
It  should  be  added,  however,  that  this  statement 
needs  modification,  so  as  to  admit  that  conditions 
which  result  from  anoxhemia  do  irritate  the  center. 
These  conditions,  however,  are  produced  slowly  and 
in  the  tissues,  not  primarily  in  the  center.  Even 
to  a  total  lack  of  oxygen  the  respiratory  center 
makes  no  immediate  response,  although  it  may  be 
killed  thereby. 

"  The  crucial  experiment  in  this  field  is  that  of 
voluntary  forced  breathing.  The  experiment  is  so 
simple  and  easily  performed,  at  any  time,  by  any 
one,  that  it  ought  to  become  universally  familiar. 
It   is   only   necessary   to  breathe  as   rapidly  and   as 

deeply  as  you  can  (for  several  minutes) 

Thereby  you  will  induce  in  yourself  a  moderate  degree 
of  acapnia.  When  you  cease  the  voluntary  effort 
you  may  find  that  your  hands  are  temporarily 
paralyzed.  Your  legs  and  arms  may  be  asleep. 
You  may  shiver  as  in  a  chill.     You  will  feel  strangely 

lightheaded If   your   efforts   have   been 

sufficiently  energetic  and  a  considerable  degree  of 
acapnia  has  been  induced,  when  you  stop  forcing 
yourself  to  breathe  you  will  stop  breathing  alto- 
gether. In  this  respect  the  respiratory  center  is 
automatic.  If  you  nave  previously  reduced  your 
store  of  CO„  sufficiently,  you  will  remain  breathless 
and  without  any  desire  to  breathe,  until  you  turn  blue 
in  the  face,"  thereby  demonstrating  that  it  is  not  the 
lack  of  oxygen  but  the  amount  of  CO,  in  the  blood 
that  is  the  essential  factor  in  respiratory  control. 

Circulation. — The  carbon  dioxide  content  of  the 
blood  exerts  far-reaching  effects  upon  the  circula- 
tion by  its  control  over  venous  pressure.  A  decrease 
from  normal  of  the  CO,  in  the  blood  causes  loss  of 
venous  tonus,  and  thereby  lowers  venous  pressure — 
an  essential  phenomenon  in  shock.  "Both  Crile  and 
llnmberg  and  Passler  concluded  (correctly,  I  believe) 
that  in  shock  the  circulation  fails  in  the  same  manner 
as  after  hemorrhage,  and  that  the  heart  fails  because 
too  little  blood  is  supplied  to  it  through  the  veins. 
Both  found  that  intravenous  infusion  restored  for  a 
time  normal  arterial  pressure  and  heart  action. 
Unfortunately  both  labelled  this  true  picture  with 
the  misleading  formula — the  only  formula  for  it 
offered  by  current  physiology — vasomotor  failure. 
Present  knowledge  regarding  the  vasomotor  nervous 
system  indicates  that  its  control  is  exercised — mainly 
at   least — upon    the   finer   branches   of    the    arterial 

system Now    the    failure    of    vascular 

tonus  in  traumatic  and  toxemic  shock  is  almost 
wholly  in  the  venous  system.  Both  Crile  and  Rom- 
berg and  Passler  saw  and  emphasized  this  fact.  It 
seems  not  to  have  occurred  to  them  that  they  were 
dealing  with  the  failure  of  a  mechanism  as  yet  un- 
recognized in  physiology.  In  this;  they  were  in  it 
alone.  For  half  a  century  physiologists  have  been 
so  dazzled  by  Claude  Bernard's  discovery  of  the  vaso- 
motor nervous  system  that  they  have  neglected  to 

368 


emphasize  the  fact  that  the  circulation  must  involve 
a  third  factor  in  addition  to  the  heart  and  the  per- 
ipheral resistance  of  the  arterial  system.  Otherwise 
it  would  be  as  unstable  as  a  stool  balanced  only  on 
two  legs.  It  must  include  a  mechanism,  or  mechan- 
isms,  regulating  the  volume  of  the  blood,  and  deter- 
mining the  venous  supply  to  the  right  heart.  It  is 
1 1 1 i  — ;  venopressor  mechanism,  I  believe,  and  neither 
the  heart  nor  vasomotor  nervous  system,  which  is 
the  essential  element  in  the  failure  of  the  circulation 
in  shock. 

"  It  is  so  easy  to  record  arterial  pressure  and  so 
difficult  to  measure  the  minute  volume  of  the  arterial 
blood  stream  that  one  is  inclined  to  forget  that  the 
pressure  in  the  arteries  is  really  a  phenomenon  of  only 
secondary  importance The  primary  func- 
tion of  the  circulation  is  the  volume  of  blood  pumped 

onward  by  the  heart  in  unit  time The 

heart  can  discharge  during  systole  only  so  much 
blood  as  distends  its  chambers  during  diastole.  The 
diastolic  filling  of  the  right  heart  depends  upon  the 
volume  of  the  stream  flowing  to  it  through  the  veins 
and  upon  the  distending  pressure  which  this  stream 
affords.  Venous  pressure,  is,  so  to  speak,  the  fulcrum 
of  the  circulation. 

"  The  respiratory  center,  by  regulating  the  CO, 
content  of  the  arterial  blood  within  narrow  limits  of 
variation,  exerts  an  indirect  but  powerful  control 
of  the  venopressor  mechanism.  Any  considerable 
accumulation  of  CO,  above  normal  augments  the 
venous  pressure.  Excessive  pulmonary  ventilation 
tends  to  lower  it.  Acute  acapnia  diminishes  the 
volume  of  the  blood  as  effectually  as  does  an  extensive 
hemorrhage." 

Henderson  was  able  to  produce  all  grades  of  severity 
of  shock  in  animals  by  excessive  artificial  respiration, 
the  increased  pulmonary  ventilation  causing  acapnia. 

"  Voluntary  forced  breathing  in  man,  so  far  as 
the  experiment  can  be  carried,  induces  symptoms 
similar  to  those  of  shock.  Death  from  failure  of 
respiration  would  probably  result  from  vigorous 
voluntary  hyperpnea  for  fifteen  to  twenty  minutes. 
Pain,  ether  excitement,  sorrow,  fear,  and  other  con- 
ditions inducing  shock,  involve  excessive  respiration. 

"  Excessive  artificial  respiration,  applied  to  dogs 
for  twenty-five  to  thirty  minutes,  is  followed  by 
apnea  so  prolonged  that  the  heart  fails,  after  seven 
to  eight  minutes,  for  lack  of  oxygen.  The  inactivity 
of  the  respiratory  center  is  solely  due  to  the  depletion 
of  the  body's  store  of  C02 Administra- 
tion of  CO,  gas  during  apnea  induces  an  immediate 
return  to  natural  breathing.  Administration  of 
oxygen  by  the  Volhord  method  affords  ideal  condi- 
tions for  recovery  from  acapnia,  and  prevention  of 
asphyxial  acidosis." 

The  dangers  of  anesthesia  that  are  concerned  in 
the  acapnial  theory  are  thus  summarized  by 
I  tenderson: 

"  1 .  Anesthetics  tend  to  prevent  shock  because  they 
diminish  pain-hyperpnea,  and  thus  obviate  the  de- 
velopment of  acapnia. 

"2.  Respiratory  excitement  during  the  initial 
stages  of  anesthesia  diminishes  the  C02  content  of 
the  blood,  and  thus  tends  to  induce  a  subsequent 
failure  of  respiration. 

"  3.  Morphine  raises  the  threshold  for  CO,  more 
than  it  does  the  afferent  threshold  of  the  respiratory 
center.  Chloroform  elevates  the  latter  threshold  more 
than  the  former.  Ether  in  quantities  short  of  pro- 
found anesthesia  exerts  a  respiratory  stimulant  in- 
fluence which  lowers  the  threshold  for  C02,  and  thus 
tends  to  induce  acapnia. 

"4.  Apnea  in  anesthesia  depends,  in  the  same 
manner  as  in  normal  life,  upon  the  relation  of  the 
level  of  the  threshold  of  the  respiratory  center 
for  CO,  to  the  quantity  of  CO,  in  the  blood  and  tis- 
sues. Whenever  the  former  is  above  the  latter, 
spontaneous  breathing  ceases. 


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Anesthesia)  General  Surgical 


"5,  Under  anesthesia  the  threshold  for  Co..  may 
be  elevated  fifty  per  cent,  above  normal,  or  depressed 
fifty  per  cent,  below  normal.  Such  a  depression 
of  the  threshold  causes  vigorous  hyperpnea.  If 
Inns,'  continued,  it  results  in  intense  acapnia. 

■•~ii.  Chloroform  apnea  may  be  regarded  as 
merely  a  form  of  apnea  vera. 

"7.'  Experiments  show  thai  ether-hyperpnea  is  quite 
fective  as  pain-hyperpnea  as  u  means  of  inducing 
a  suoscqui  nt  fatal  apn>  a  r,  ra. 

Kg,  in  normal  subjects  under  chloroform  respi- 
ration always  fails  before  the  heart.  Subjects  which 
passed  through  a  period  of  sickness  and  suffering, 
or  tin  ir  experimental  equivalent,  are  hyper-susceptibli 
to  the  toxic  influences  of  chloroform.*  In  uchca  es  the 
circulation  failsfirst,  or  simultaneously  with  respiration. 
i.  Hypercapnia  during  anesthesia  may  be  the 
factor  which  determines  the  development  of  chlor- 
oform necrosis. 

"10.  Skilful  anesthesia  consists  in  maintaining 
the  threshold  of  the  respiratory  center  for  COs  al  a 
\  normal  level,  and  in  avoiding  the  developmenl 
either  of  acapnia  or  of  hypercapnia." 

The    Signs    and    Stages    of    Anesthesia. — For 
enience  of  description  the  phenomena  of  anes- 
thesia are  usually  divided  into  four  stages: 

1.  The  first  stage  extends  from  the  beginning  of 
the  administration  to  complete  loss  of  conscious- 
ness. The  phenomena  observed  in  this  stage  arc 
dependent  largely  upon  the  manner  of  administration 
and  the  character  of  respiration.  If  the  anesthetic 
is  cautiously  and  skilfully  administered,  and  the 
patient  breathes  fully  and  regularly,  the  induction  is 
doI  disagreeable,  but  if  the  anesthetist  is  unskil- 
ful the  first  stage  is  distinctly  unpleasant,  especially 
if  the  patient  is  nervous  or  becomes  excited,  and 
ether  or  chloroform  is  the  anesthetic.  With  such 
quickly  acting  anesthetics  as  nitrous  oxide  and 
ethyl  chloride  this  stage  is  very  short  and  the  pa- 
tient usually  experiences  no  unpleasant  sensations. 
During  this  period  the  room  should  be  kept  as  quiet 
as  possible,  conversation  being  especially  prohibited. 
During  this  stage  there  is  increased  cardiac  action 
with  a  rise  in  blood  pressure,  and  respiration  is  in- 

ised  in  frequency  and  depth  unless  modified  by 
emotional  disturbances  or  irritant  action  of  the 
anesthetic  vapor;  the  pupils  are  dilated. 

2.  The  second  stage  extends  from  the  loss  of 
consciousness  to  the  loss  of  the  corneal  reflex,  and 
is  otherwise  known  as  the  stage  of  "struggling," 
for  during  this  period  many  patients,  especially 
those  addicted  to  alcohol  or  to  smoking,  struggle 
more  or  less  violently.  While  assistants  should 
be  at  hand  to  prevent  self-injury  if  the  patient  strug- 
gles, yet  the  patient  should  never  be  forcibly  re- 
strained as  that  increases  the  tendency  to  struggle. 
The  limbs  are  often  rigidly  extended,  respiration 
is  temporarily  suspended  "through  contraction  of 
t ho  muscles  controlling  respiratory  movement,  and 
the  jaws  are  at  the  same  time  firmly  clenched.  The 
respirations  become  deeper  and  more  frequent  unless 
impeded  by  muscular  spasm,  deglutition,  etc.  Heart 
action  is  still  further  increased,  much  depending, 
however,  upon  respiration.  It  is  in  this  stage,  espe- 
cially if  there  be  struggling  and  holding  of  the  breath, 
that  chloroform  becomes  so  dangerous,  for  when  there 
has  been  no  breathing  for  several  seconds  and  a  deep 
inspiration  is  taken,  as  is  often  the  case,  sufficient 
chloroform  for  a  fatal  overdose  may  be  inhaled  and  ab- 
sorbed even  though  the  strength  of  vapor  would  have 
been  tolerable  under  normal  respiration.  With  ether 
the  patient's  skin  will  be  flushed,  and  the  secretion 
of  mucus  and  saliva  increased.  The  pupils  are 
smaller  than  in  the  first  stage. 

3.  The  third  stage,  otherwise  known  as  the  stage 
of  surgical  anesthesia,  begins  with  the  loss  of  the 
*  The  italics  are  mine. 

Vol.  I.— 24 


corneal  reflex.  The  muscular  rigidity  of  the  second 
stage  disappears  in  the  third  stage,  but  more  quickly 
under  chloroform  than  under  ether  or  nitrous  oxide. 
Under  ether  the  patient  is  more  florid,  if  there  is 
ufficienl  oxygenation,  the  secretion  of  mucus  and 
saliva  is  still  further  increa  ed,  and  the  circulation 
still  further  stimulated.  If  chloroform  is  being  ad- 
ministered it  is  of  the  Him"  I  importance  thai  there 
should  be  good  oxygenation  of  the  blood,  so  evidences 
of  pallor  or  of  cyanosis,  especially  about  the  lips 
and  cars,  should  be  closely  watched,  as  even  mild 
asphyxia  greatly  increa  e  the  depre  ing  effect  of 
this  anesthetic.  Accordingly  it  is  of  the  utmost  im- 
portance that  the  air-way  be  open  and  respiration 
free  and  not  obstructed  in  any  way  whatever  when- 
ever chloroform  is  being  administered.  The  color  of 
the  face,  more  especially  of  the  lips  and  ears,  is  a 
reliable  index  of  oxygenation. 

The  character  of  the  respiration  is  perhaps  the 
most  important  single  guide  in  the  maintenance 
of  the  proper  degree  or  depth  of  anesthesia.     The 

rhythm  in  this  stage  is  regular  under  all  anesthet- 
ics, increased  in  frequency  and  depth  under  nitrous 
oxide  and  ether,  and  somewhat  decreased  in  these 
respects  under  chloroform.  At  the  time  of  mak- 
ing the  initial  incision  the  anesthetist  should  notice 
if  this  procedure  alters  the  respiratory  movement 
in  any  way,  and  if  it  does,  the  anesthesia  should  be 
immediately  deepened.  A  careful  watch  should  be 
at  all  times  kept  of  the  respiration,  as  slight  changes 
in  it  will  forewarn  the  experienced  administrator 
of  impending  danger.  The  anesthetisl  musl  not  only 
know  that  air  is  passing  into  and  out  of  the  lungs, 
mere  movements  of  the  muscles  of  respiration  not 
being  sufficient,  but  he  must  also  know  about  what 
the  volume  is.  If  the  breathing  in  this  stage  becomes 
quiet  and  shallow  it  is  because  the  anesthesia  is 
cither  too  light  or  too  deep.  If  the  former,  the  lid  and 
corneal  reflexes  will  be  present  and  more  of  the 
anesthetic  should  be  administered;  if  the  latter,  the 
pupil  will  be  widely  dilated  and  the  lid  and  corneal 
reflexes  abolished,  and  the  administration  should  be 
held  in  abeyance  temporarily. 

The  pulse  in  the  third  stage  also  settles  down  to  a 
regular  rhythm  and  volume,  increased  in  both  re- 
spects under  nitrous  oxide  and  ether,  and  slightly 
decreased  under  chloroform.  The  pulse  should  be 
taken  at  frequent  intervals,  as  sudden  changes  may 
take  place  at  any  time  in  both  heart  action  and  blood 
pressure.  As  the  operation  proceeds  the  tendency 
is  for  the  pulse  to  increase  slightly  in  frequency  and 
decrease  in  volume,  but  any  considerable  change  in 
these  respects  demands  attention,  as  shock  may  be 
developing. 

The  pupil  is  of  value  in  determining  the  depth 
of  anesthesia  ordinarily  only  when  there  has  been 
no  preliminary  hypodermic  medication  that  affects 
its  size.  As  the  tendency  to  the  use  of  such  medi- 
cation is  increasing,  and  rightly  so,  less  and  less 
attention  is  being  given  to  the  size  of  the  pupil; 
although  it  is  a  very  delicate  indicator  when  no  such 
medication  has  been  used,  yet  it  is  not  at  all  essential. 
In  the  surgical  stage  the  average  size  of  the  pupil 
under  ether  is  about  4  mm.  in  diameter,  and  about 
2.5  mm.  under  chloroform.  A  contracted  pupil 
indicates  a  light  anesthesia,  while  a  dilated  pupil 
indicates  cither  a  light  or  a  deep  anesthesia.  When 
it  is  dilated  under  a  light  anesthesia,  the  lid  and  cor- 
neal reflexes  are  present  and  the  dilatation  is  due  to 
reflex  stimulation  by  the  operative  procedure,  and 
of  course  indicates  that  more  of  the  anesthetic  should 
be  given  if  a  deeper  anesthesia  is  desirable.  If  the 
pupil  is  dilated  and  the  corneal  or  lid  reflex  is  absent 
the  anesthesia  is  deep,  and  the  further  adminis- 
tration of  the  anesthetic  must  be  carefully  watched, 
for  the  danger  line  has  been  reached.  Even  with 
these  conditions  present  it  is  sometimes  necessary  in 
the  administration  of  ether  to  increase  further  the 

369 


Anesthesia,  General  Surgical 


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depth  of  anesthesia  by  adding  more  of  the  anesthetic 
in  order  to  obtain  complete  relaxation,  but  in  such 
instances  the  anesthetist  must  be  thoroughly  alert 
and  watch  the  pulse,  respiration,  and  color  most 
assiduously.  When  the  upper  lid  is  raised  quickly 
the  pupil  responds  to  the  stimulation  of  light  by 
contracting  during  a  light  or  moderate  depth  of 
sthesia,  but  in  deep  anesthesia  it  remains  dilated. 

Muscular  movements  in  the  surgical  stage  are 
usually  in  complete  abeyance,  but  it  is  not  necessary 
or  even  desirable  that  this  depth  of  anesthesia  should 
always  be  maintained.  It  is  well  to  bear  in  mind 
that  coughing,  vomiting,  etc..  with,  of  course,  special 
exceptions,  occur  during  light  anesthesia,  and  that 
anesthesia  should  be  maintained  at  such  a  depth 
that  these  phenomena  are  suppressed  whenever 
their  occurrence  would  interfere  with  the  work  of 
the  surgeon.  The  invariable  rule  should  be  that  the 
patient  receive  as  little  of  the  anesthetic  as  is  neces- 
sary to  procure  the  depth  of  anesthesia  desired  for 
the  particular  procedure.  For  some  operations  the 
anesthesia  may  be  very  light,  while  for  certain  others 
it  must  be  profound.  In  a  general  way  it  may  be 
said  that  abdominal  operations  and  those  upon 
the  genitourinary  organs  require  a  deep  anesthesia. 
but  even  this  is  subject  to  exceptions.  Some  pan 
particularly  alcoholics,  require  a  large  amount  of  the 
anesthetic  to  produce  the  desired  state  of  anesthesia, 
while  others,  particularly  the  debilitated  and  elderly 
subjects,  and  more  especially  women  than  men, 
require  only  a  small  amount  to  produce  the  same 
effect. 

The  aim  should  be  not  only  to  administer  the  min- 
imum amount  of  the  anesthetic,  but  also  that  the 
rate  of  administration  be  continuous  and  as  even  as 
practical,  so  as  to  maintain  a  smooth  anesthesia. 

i.  The  fourth  or  toxic  stage  is  not  separated  from 
the  third  or  surgical  stage  by  a  clear  line  of  demar- 
cation. However,  the  general  condition  of  a  patient 
suffering  from  an  overdose  of  the  anesthetic  is  so 
different  from  that  of  one  properly  anesthetized  that 
even  the  onset  of  the  fourth  stage  is  readily  recog- 
nized by  the  experienced  observer.  The  respiration 
is  shallow,  usually  increased  in  frequency  under 
ether,  and  decreased  under  chloroform.  The  pulse 
is  very  feeble  and  rapid,  though  it  may  be  slow  under 
chloroform.  The  eyelids  separate.  The  face  is 
"deathly  pale"  under  chloroform,  and  cyanotic 
under  ether.  The  nose  is  cold  and  cold  sweat  appears 
upon  the  forehead.  There  is  a  peculiar  expression 
of  the  face.  The  pupils  are  widely  dilated  and  fixed, 
and  the  lid  and  corneal  reflexes  are  entirely  absent. 

In  case  ether  is  the  anesthetic  the  patient  is  not 
in  so  much  imminent  danger,  as  when  chloroform 
is  used  to  a  toxic  degree,  for  in  the  former  instance 
the  patient  usually  recovers  if  the  condition  is  recog- 
nized, the  administration  stopped,  and  appropriate 
treatment  instituted.  With  chloroform,  however, 
this  stage  is  much  more  serious,  as  irreparable  dam- 
age may  have  been  done  before  the  serious  condition 
of  the  patient  is  recognized. 

The  IxDrcnox  of  Anesthesia.  Preparation 
of  the  Patient. — In  all  but  emergency  cases  the  patient 
should  undergo  a  preparation  before  being  anes- 
thetized. Whenever  possible  the  diet  should  be 
supervised  and  regulated,  the  bowels  kept  open, 
and  tobacco  and  alcohol  avoided  for  twenty-four  to 
forty-eight  hours  immediately  preceding  a  major 
surgical  anesthesia;  for  a  minor  anesthesia  a  less 
rigid  regime  should  be  followed,  as  far  as  circum- 
ill  allow.  Whenever  possible  the  patient 
should  undergo  a  rigid  physical  examination  prefer- 
ably a  day  or  more  prior  to  the  anesthetization, 
special  attention  being  given  to  the  condition  of  the 
heart,  lungs,  kidneys,  blood,  and  to  the  state  of  the 
bowels.  Oftentimes  an  appropriate  course  of  med- 
ical  treatment  will  improve  the  patient's  condition 


and  fortify  it  against  the  shock  and  depression  of  the 
anesthetic  and  operative  procedure.  The  attending 
physician  will  often  furnish  valuable  information 
o  the  patient's  peculiarities  and  idiosyncrasies. 
The  ingestion  of  food  and  fluids  should  be  regulated 
so  that  the  stomach  is  empty  at  the  time  of  anes- 
thetization. The  bowels  should  be  emptied,  but  not 
by  drastic  means,  shortly  before  the  administration, 
unless  there  is  some  special  contraindication,  while 
the  bladder  should  be  emptied  immediately  prior  to 
the  anesthetization.  Children  especially  are  liable 
to  micturition  under  nitrous  oxide  unless  the  bladder 
is  thus  emptied. 

The  mouth  should  be  examined  in  all  cases  to  in- 
sure the  removal  of  all  artificial  teeth  that  are  not 
firmly  fixed.  Notice  should  also  be  made  of  loose 
teeth  which  ruay  become  dislodged  by  spasm  of  the 
muscles  of  the  jaw,  or  during  the  introduction  of  a 
mouth  wedge  or  gag. 

All  examinations  of  the  patient  just  prior  to  the 
administration  of  the  anesthetic  should  be  very  brief 
and  tactful,  as  the  patient,  at  this  particular  time, 
is  highly  susceptible  to  nervous  impressions,  and 
consequently  much  more  damage  than  benefit  rnav 
follow  an  extended  examination  at  this  time. 

Apparatus,  Appliances,  and  Remedies. — The  anes- 
thetist should,  if  practical,  have  his  apparatv.- 
perfect  working  order  before  the  entrance  of  the 
patient,  or  if  the  anesthesia  is  to  be  induced  or  main- 
tained in  the  patient's  room  the  apparatus  should  be 
inspected  and  placed  in  order  beforehand. 

The  anesthetist  should  always  have  conveniently 
at  hand,  in  addition  to  the  apparatus  or  applia' 
for  administering  the  anesthetic,  the  necessary  instru- 
ments and  remedies  for  the  prompt 
treatment  of  any  accident  or  compli- 
cation that  may  arise  at  any  time 
during  the  administration.  This  in- 
cludes a  mouth  wedge,  a  gag.  tongue 
forceps,  mouth  prop,  a  hypodermic 
syringe,  and  solutions  of  adrenalin, 
or  its  equivalent,  atropine,  digitalin, 
morphine,  caffeine,  camphor  in  oil, 
ergotol,  whiskey,  a  "'breathing  tube,"  oxygen  and 
carbon  dioxide  in  cylinders,  and  means  for  perform- 
ing tracheotomy  and  pharyngeal  or  intratracheal 
insufflation. 

In  using  a  tongue  forceps  of  the  pressure-contact 
form  care  must  be  exercised  not  to  make  too  much 
pressure  or  allow  it  to  be  applied  too  long,  as  it  may 
cause  serious  injury  to  the  tongue,  consequently 
a  puncturing  tongue  forceps  (Fig.  205)  is  very  useful. 
Mouth  props  are  used  in  practically  all  dental  cases. 
and  in  all  other  surgical  cases  where  it  is  desirable  to 
keep  the  mouth  open  for  a  considerable  period  of 
time,  or  where  the  gag  interferes  with  the  applica- 
tion of  the  face  mask,  especially  when  nitrous  oxide 
is  being  used. 

The  '"'breathing  tube"  is  very  useful  whenever 
there  is  respiratory  obstruction  at  the  base  of  the 
tongue  as  often  occurs  under  nitrous  oxide  and  less 
frequently  under  ether.  In  suspension  of  respiration 
it  is  also  highly  useful,  as  this  part  of  the  respir- 
atory tract  can  thereby  be  kept  open  and  a  mask 
applied  tightly  to  the  face,  and  oxygen,  or  preferably 
oxygen  and  carbon  dioxide,  forced  into  the  lungs, 
while  artificial  respiration  is  simultaneously  main- 
tained. 

The  use  of  the  hypodermic  solutions  alone  should 
never  be  depended  upon  in  any  serious  case,  and  in 
emergencies  they  are  of  little  or  no  value,  but  when 
possible  they  should  be  conveniently  at  hand  so  as 
not  to  delay  their  prompt  administration,  when 
wanted.  The  hypodermic  injection  during  the 
administration  should  be  given  b}-  an  assistant,  and 
not  by  the  anesthetist. 

The  apparatus  for  the  administration  of  anesthetics 
should  be  simple  in  design,  construction,  and  opera- 


Fta   _10. — Clover's 
Mouth  Prop. 


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Anesthesia,  General  Surgical 


ii,,n,  ->i  as  to  be  easily  manipulated  under  the  varying 
conditions  in  which  it  has  to  be  used.  No  matter 
how  apparently  efficient  ii  may  be,  a  large,  cumber- 
some, and  i iplicated  apparatus  is  open  to  criticism. 

Ml  apparatus  and  appliances  should  be  kepi  thor- 
oughly cleansed  and  sterilized,  and  no  apparatus 
deserves  a  second  consideration  thai  cannol  be  easily 
and  thoroughly  sterilized.  Since  the  recent  intro- 
duction of  rebreathing  in  the  administration  of  nitrous 
oxide  most   of  the  designers  and   manufacturers  of 

uratus  for  such  use  have  lost  sight  of  the  fact  that 

rebreathing  should  cause  a  change  in  construc- 
tion, so  that  all  parts  contaminated  by  the  rebreathing 
be  sterilized.  Regardless  of  this  fact  hundreds 
of  apparatuses  for  administering  nitrous  oxide 
by  rebreathing  through  an  integral  part  of  a  large 
and  cumbersome  stand,  not  capable  of  practical 
sterilization,  are  being  used  in  this  country.  Such 
practice  is  to  be  strongly  condemned.  It  is  little 
short  of  criminal  to  compel  a  patient  to  breathe 
hark  and  forth  through  an  apparatus  contaminated 
by  the  expirations  of  a  previous  patient  suffering 
from  tuberculosis  or  other  infection.  Complete 
sterilization  is  indispensible  in  the  rebreathing 
method. 

Morphine  before  Anesthesia. — The  use  of  mor- 
phine hypodermically  as  preliminary  medication  to 

general  anesthetic  has  been  growing  in  favor,  and 
is  now  recognized  as  a  good  procedure.  It  has  long 
been  noticed  that  pal  ients  who  suffer  from  fright  and 
fear  preceding  the  anesthesia  or  during  its  induction, 
suffer  greatly  from  shock,  and  that  out  of  all  pro- 
portion to  the  extent  of  the  operative  procedure. 
That,  such  fright  and  fear  produce  distinct  patho- 
logical lesions  of  the  brain  cells  has  been  clearly  and 

lusively  demonstrated  by  C'rile.  A  hypodermic 
injection  of  morphine  one-half  to  one  hour  preceding 
the  anesthesia  quiets  the  patient's  nerves,  induces  a 
tranquil  state  of  the  higher  centers  of  the  brain, 
dispels  fear,  and  creates  a  pleasant  state  of  mind, 
thereby  preventing  or  minimizing  the  shock  that 
usually  follows  the  preanesthetic  state.  Besides, 
after  this  preliminary  medication  the  induction  of 
anesthesia  is  smoother,  quieter,  and  more  rapid, 
relaxation  is  more  complete,  and  a  lesser  amount  of 
the  anesthetic  is  required  throughout  the  entire 
administration.  While  this  medication  alters  the 
size  of  the  pupil,  yet  there  are  so  many  other  and 
more  reliable  signs  in  determining  the  depth  of 
anesthesia  that  this  objection  to  the  use  of  mor- 
phine may  be  disregarded,  for  its  benefits  far  out- 
weigh its  disadvantages.  In  prolonged  anesthesia 
under  nitrous  oxide  the  use  of  morphine,  combined 
with  either  atropine  or  hyoscine  (scopolamine),  is 
practically  imperative,  as  morphine  aids  materially 
in  securing  muscular  relaxation,  and  prevents  the 
inhibitory  action  of  nitrous  oxide  upon  the  heart. 
Moreover,  morphine  alone  should  never  be  used  in 
nitrous  oxide  anesthesia  on  account  of  its  depressing 
effect  upon  respiration. 

Administration  and  Subsequent  Treatment. — It  is 
preferable  to  anesthetize  some  patients  in  their  own 
room,  others  in  the  regular  anesthetizing  room,  while 
with  nitrous  oxide  it  is  often  advisable  to  anesthetize 
on  the  table  in  the  operating  room,  with  the  patient 
previously  prepared  and  in  proper  position.  Wher- 
ever the  patient  is  anesthetized,  and  whatever  anes- 
thetic is  used,  the  aim  should  always  be  to  subject  the 
patient  to  the  shortest  possible  influence  of  the 
anesthetic,  consequently  the  administration  should 
never  be  begun  until  all  the  other  preparations  con- 
nected with  the  operative  procedure  are  either  com- 
pleted or  will  certainly  be  completed  at  such  a  time 
as  not  to  delay  the  continuous  and  expedituous  work 
of  the  surgeon  just  as  soon  as  the  patient  is  brought 
into  the  proper  degree  of  anesthesia.  Any  consider- 
able handling  and  moving  of  a  patient  in  the  state  of 
surgical  anesthesia  is  to  be  condemned.     Except  in 


the  case  of  nitrous  oxide  or  ethyl  chloride  the  induc- 
tion should  alwaj  -  be  made  w  ith  the  patient  lying  on 
his  back  with  the  head  in  the  body  plam  and  prefer- 
ably   turned   a    little   to  one   side,    the    head    thereafter 

being  kept  iii  thai  plane  if  pos  ible.  With  few  excep- 
tions it  is  dangerous  to  ke.-p  the  head  of  a  fully 
anesthetized  patient  above  the  body  level. 

During    the    administration    of    an    anesthetic    it 

is  quite  important  that  the  clothing  about  the 
patient's  chest  and  neck  should  be  light  and  loo  i  ly 
lilting,    the    room    warm,    and     the    patient's    limbs 

especially  protected  with  blankets.  The  anesthe- 
tist should  see  that  the  patient's  chest  is  not  encum- 
bered with  heavy  instruments,  and  that  none  of  the 
assistants  should  lean  i  hereon.    Also  t  hat  the  patient's 

entire  body  be  kept  properly  covered,  and  as  warm 
and  dry  as  is  compatible  w  ith  the  operative  procedure 
at  hand,  and  thai  this  same  care  in  this  respect  be 
exercised    until    the    patient    is    afterward    placed 

in  bed,  for  undoubtedly  much  of  the  unnecessary 
exposure  which  one  sees  in  many  Operating  rooms  ami 
in  the  handling  and  transference  of  anesthetized  pa- 
tients through  cold  and  draughty  halls,  is  a  very  great 
factor  in  the  subsequent  complications  and  sequela 
that  occur,  and  for  which  the  anesthetist  or  the 
anesthetic  is  often  held  responsible. 

After  the  operation  is  finished  and  the  dressings 
are  applied,  the  patient's  wet  clothing  should  bore- 
placed  by  dry,  and  the  patient  carefully  lifted  onto 
the  stretcher  or  carried  to  his  bed,  care  being  used 
not  to  elevate  the  head.  The  bed  should  have  been 
previously  warmed  by  hot-water  bottles  or  by  ironing 
the  sheets.  The  room  should  be  of  a  temperature  of 
about  06°  F.,  and  well  ventilated,  but  with  abso- 
lutely no  draughts,  and  the  patient  should  be  kept 
warm  by  proper  clothing  and  artificial  heat  when 
indicated.  The  anesthetist  should  see  that  the  pulse, 
respiration,  and  color  are  satisfactory,  and  that 
the  reflexes  are  returning,  and  when  these  con- 
ditions are  met  his  responsibility  in  the  case  ordi- 
narily ceases.  The  patient's  head  should  be  only 
moderately  elevated,  unless  there  are  special  indica- 
tions for  deviating  from  this  rule.  When  the  cir- 
culation is  poor  the  foot  of  the  bed  should  be  elevated. 
The  patient  should  be  kept  quiet  and  moved  as 
little  as  possible,  as  otherwise  vomiting  and  syncope 
are  more  likely  to  occur.  The  room  should  be 
darkened,  and  kept  quiet  and  the  patient  should 
be  encouraged  to  sleep.  All  anesthetized  patients 
should  be  carelully  watched  until  complete  conscious- 
ness returns. 

The  time  when  water  and  food  may  be  allowed 
varies  w-ith  different  anesthetics  and  with  the  gas- 
tric condition  of  the  patient.  In  general  it  may  be 
said  that  they  may  properly  be  allowed  much  sooner 
after  nitrous  oxide  than  after  chloroform  or  ether. 
If  postanesthetic  vomiting  occurs  there  should  be 
abstinence  from  food  and  water  for  several  hours, 
excepting  that  small  amounts  of  very  hot  water  at 
frequent  intervals  may  be  administered  to  allay 
nausea  and  vomiting.  A  rectal  injection  of  1,000  to 
1,500  c.c  of  saline  solution  at  the  completion  of  the 
operation  has  a  tendency  to  relieve  thirst  and  improve 
the  circulation,  and  is  a  good  routine  procedure  after 
major  operations. 

The  Practical  Administration  op  Anesthet- 
ics.— Nitrous  oxide,  N,(),  is  a  colorless  and  prac- 
tically  tasteless  gas,  and  is  known  either  under  its 
chemical  name  or  as  "gas,"  or  "laughing  gas,"  on 
account  of  its  specially  pleasant  effect  upon  the  emo- 
tions. Under  a  low  "temperature  and  high  pressure 
it  becomes  a  liquid,  and  the  nitrous  oxide  of  commerce 
is  in  this  form,  stored  in  steel  cylinders,  varying 
in  capacity  from  twenty-five  gallons  to  several  thou- 
sand gallons.  As  heat  expands  liquid  nitrous  oxide 
the  cylinders  containing  it  should  not  be  exposed  to 
any  high  temperatures,  as  an  explosion  may  result, 


371 


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although  interstate  commerce  cylinders  must  be 
provided  with  an  appropriate  safety  device  which  per- 
mits the  gas  to  escape,  before  the  pressure  becomes 
dangerously  high.  The  gas  weighs  one  ounce  to  each 
four  gallons,  and  by  knowing  the  net  weight  of  the 
cylinder,  which  is  always  marked  thereon,  the  amount 
of  gas  in  each  cylinder  can  be  determined  quite 
accurately.  This  is  a  very  important  matter  when 
nitrous  oxide  is  to  be  used  in  major  anesthesia  outside 
of  hospitals  where  there  is  no  reserve  supply  at  hand. 
Institutions  using  large  amounts  of  nitrous  oxide 
find  it  practical  to  manufacture  their  own  gas  in  a 
private    plant,     usually    located    in    the    basement, 

store  it  in  gaseous 
form  in  a  large  tank, 
and  pipe  it  to  the 
operating  rooms,  ils 
cost  being  thereby 
greatly  reduced. 

Nitrous    oxide    is 
administered  i  n 

several  ways,  and 
as  the  technique  of 
each  is  slightly  dif- 
ferent the  several 
methods  will  be  de- 
scribed in  more  or 
less  detail.  These 
different  methods  of 
administering  ni- 
trous oxide  are:  (1 ) 
Nitrous  oxide 
alone;  (2)  nitrous 
oxide  with  air;  (3) 
nitrous  oxide  with 
oxygen;  (4)  nitrous 
oxide-oxygen,  with 
ether  as  an  adju- 
vant; (5)  nitrous 
oxide  as  a  prelimi- 
nary to  ether;  (C) 
nitrous  oxide-oxy- 
gen by  the  intra- 
tracheal method, 
and  For  brief  adminis- 
trations nitrous 
oxide  is  remarkably 
free  from  danger,  being  for  this  purpose  much 
the  safest  anesthetic  known.  It  also  possesses  the 
great  advantages  of  being  practically  tasteless  and 
odorless,  rapid  in  action,  and  quickly  eliminated, 
the  patient  losing  and  regaining  consciousness  in 
very  short  periods  of  time  with  comparative  freedom 
from  unpleasant  after-effects.  While  for  this  form 
of  use  it  is  not  essential  that  there  be  t lie  usual  pre- 
liminary preparation  of  the  patient  it  is  desirable 
that  the  stomach  be  at  least  comparatively  empty, 
and  in  children  and  nervous  folk  the  bladder  should 
be  empty.  Usually  t he  patient  is  able  to  arise  and 
walk  in  a  very  few  minutes  after  such  adminisl  rat  ions. 
For  the  prolonged  administration  of  nitrous  oxide 
there  should  he  the  same  preliminary  preparations 
of  the  patient  as  with  the  other  anesthetics,  and 
while  consciousness  returns  very  quickly  after  this 
anesthetic  is  withdrawn  yet  the  patient  should  not 
be  permitted  to  make  any  undue  exertion  for  the  first 
hour  after  a  major  anesthesia. 

The  Apparatus. — The  apparatus  for  administering 
nitrous  oxide  is  of  necessity  more  complicated  than 
that  for  the  other  anesthetics.  However,  experience 
has  shown  that  the  large,  heavy,  and  cumbersome 
apparatus  is  not  only  not  necessary,  but  a  distinct 
disadvantage,  for  in  the  light  of  present  day  science 
the  principles  underlying  the  administration  of  the 
different  anesthetics  are  so  similar  that  one  apparatus 
may  advantageously  be  used  for  all  anesthetics  and 
for  all  methods  except  those  highly  specialized. 
The    Coburn   apparatus,    devised  by   the   author, 


Fig.  211. 


—Hewitt's  Nitrous  <  >\i.k' 
Oxygen  Inhaler. 


and  herewith  illustrated,  is  based  primarily  upon 
the  principle  of  simplicity.  While  for  administering 
nitrous  oxide  a  special  stand  is  not  necessary  for 
holding  the  cylinder  or  cylinders,  such  a  stand  is 
however,  highly  desirable,  convenient,  and  useful' 
The  stand  should  furnish  means  for  holding  at  least 
two  cylinders,  so  that  when  one  cylinder  is  exhausted 
a  fresh  supply  is  at  hand  and  ready  for  instant  use 
without  delay.  The  stand  should  also  provide  means 
for  holding  two  cylinders  of  oxygen.  Instead  of  one 
of  the  other  cylinders  mentioned  a  cj'linder  of  CO, 
gas  or  of  a  mixture  of  CO.,  gas  and  oxygen  may  be 
attached.  Certainly  such  C3rlinders  should  always 
be  in  the  operating  room  at  least,  ready  for  immediate 
use  at  any  time. 

The  hospital  stand  (Fig.  212)  carries  four  cylinders, 
and  is  constructed  so  that  means  may  be  added  for 
holding  two  additional  cylinders.  It  matters  not  in 
what  order  or  position  the  different  cylinders  are 
attached  .-is  they  all.  both  singly  and  conjointly, 
communicate  with  the  tubing  that  leads  to  the  rubber 
bag.  The  stand  is  strong,  and  will  support  the 
medium  sized  cylinders.     It  is  mounted  upon  wheels 


Fig.  212. — Coburn  Apparatus  Complete,  with  Hospital  Stand, 
for  Adniinistei  itijr  ami  Warming  Nitrous  <  >xide-oxygen  aud  Ether 
by  the  Rebreathing  Method. 


and  may  readily  be  moved  about  the  operating  room 
or  from  one  room  to  another  with  the  cylinders 
attached.  In  the  center  it  carries  two  shelves  on 
which  may  be  kept  all  the  paraphernalia  of  the  anes- 
thetist and  the  inhaler  when  not  in  use.  It  serves, 
therefore,  as  a  combined  anesthetist  and  cylinder 
stand. 

The  portable  stand  (Fig.  213)  is  of  light  construction 
and  so  arranged  that  it  may  be  very  easily  and  quickly 
assembled  or  taken  apart  and  folded  into  a  small 
space,  thus  rendering  it  readily  portable.  It  is 
mounted    on    castors    and    supports    four    cylinders, 


372 


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Aiirsthc^i.i,  General  Surgical 


which  either  singly  or  in  combination  communicate 
with  the  rubber  tubing  that  leads  to  the  rubber  stop- 
cock attached  to  the  rebreathing  bag 


Fig.  213.- 


Apparatua  w 


nil  Folding,  Portable  Stand. 


The  neck  of  the  bag  is  attached  to  a  metal  fitting 
which    carries    a    shut-off    and     air-vent     operated 
together;  when  the  ether  attachment  is  not  used  this 
fitting    is    attached    directly    to    the    inhaler.     The 
inhaler    carries    an    inner    tube    in    which    are 
located  two  light  and  delicately  acting  valves, 
so  arranged  that  one  prevents  breathing  back 
into  the  bag  when  the  exhalations  are  to  escape, 
while   the  other  prevents    air   being    inspired 
through   the   expiratory  orifice  during  inspira- 
tion.    When    there    is    to   be    rebreathing   the 
valves  are  both  thrown  out  of  action  and  the 
expiratory  orifice  is  closed  by  turning  the  little 
knob  (rebreathing  control)  through  an  angle  of 
90°.     To   the  inhaler  is  attached  a  face  mask 
(made    either   of    transparent    celluloid    or    of 
metal)  which  carries  an  inflatable  rubber  hood. 

The  ether  attachment  consists  of  a  chamber 
for  holding  the  gauze  and  a  cup  for  holding  the 
ether,  the  bag  carrier  fitting  into  one  end  of  the 
chamber  and  the  inhaler  into  the  other.     The 
opening  at  the  end  of  the  chamber  into  which 
the  bag  carrier  slips  is  quite  large,  and  through 
this  opening  the  necessary  gauze  is  easily  and 
quickly  placed   within   the  chamber.       As   the 
chamber  is  ample  in  size  it  is  never  packed,  but 
just  loosely  filled  with  coarse  gauze.     The  cup 
is  attached  to  the  chamber  and  may  always  be 
maintained  in  an  upright  position  by  turning 
the  chamber  on  its  connection  with  the  inhaler. 
At  the  top  of  the  cup  is  a  needle-point  valve 
for  controlling  the  flow  of  the  ether  upon  the  gauze 
in  t  he  chamber.     As  the  ether   drops   from  the  cup 
upon  this  gauze  it  can  be  plainly  seen,  and  the  rate 
of  administration  can  thus  be  accurately  regulated  at 
all  times. 


The  rubber  bag  and    the  ether  attachment    extend 

either  back  over  the  patient's  head  or  down  over  the 

chest. 

A  small  and  light  electric  heater  (]  ig,  215),  which 
may  lie  connected   to  any  lamp  socket,   either  diri     I 

or  alternating  current,  i-  attached  to  the  chamber 
by  spring  clamps  whenever  it  is  desired  to  warm 
the  vapor.     A  small  rheostat   i-  provided  to  control 

the  radiation.  This  heater  may  l>e  attached  or 
detached  at  any  time  without  interrupting  the 
administration  of  the  anesthetic,  and  it   thoroughly 

warms  all  the  vapor  to  body  temperature  at  the 
time  it  is  inhale,  I, 

Systems  of  Administering  Nitrous  Oxide.— 'There 
are  two  systems  of  administering  nitrous  oxide:  (1) 
Without  rebreathing;  (2)  with  rebreathing. 

1.  In    the    first    system    the   exhalations   all    pass 

out  into  the  air,  and  the  patient  continuously  in- 
spires fresh  nitrous  oxide  either  with  or  without 
other  additions  (air,  oxygen,  or  ether);  this  is  its 
nei-i  e  .p.  nsive  I  or  ui  of  admin  ist  rat  ton,  as  the  patient's 
respiratory  movement,  under  nitrous  oxide  averages 
"Joll  gallons  per  hour. 

_'.  In  tin-  system  of  rebreathing  there  are  two 
fundamentally  different  principles: 

(a)  When  the  supply  of  nitrous  oxide  is  a  con- 
tinuous flow  only  a  part  of  each  expiration  passes 
back  into  the  bag  and  is  reinhaled,  the  other  part 
escapes  from  the  inhaler  into  the  air.  .Most  of 
the  apparatuses  for  this  form  of  administration  re- 
quire the  patient  to  rebreathe  through  a  long  tube. 
This  tube  presents  a  two-fold  disadvantage:  (1)  it 
requires  energy  to  breathe  back  and  forth  for  a  length 
of  time  through  a  long  tube;  at  the  same  time  _') 
it  causes  an  unnecessarily  high  retention  of  carbon 
dioxide,  inasmuch  as  one  expiration  does  not  reach 
the  bag  before  the  next  inspiration  takes  place,  and 
this  inspiration,  therefore,  consists  almost  entirely 
of  a  mixture  of  the  previous  expiration  and  the  con- 
tent s  of  the  face  mask  and  tube  only;  consequently 
the  patient  continually  inspires  a  higher  percentage  of 
carbon  dioxide  than  would  be  the  ease  were  the  bag 
placed  close  to  the  patient's  face.  This  method  of  con- 
tinuous supply  and  rebreathing  through  a  long  tube 
requires  about  125  gallons  of  nitrous  oxide  per  hour. 

(6)  When  the  supply  of  nitrous  oxide  is  inter- 
mittent,   the   patient    breathes  back  and  forth  into 


"EE-DLE     y*l.VE 


f  ■  ■  n  r 


Respcath^ 


Inhaler 
\ 

RcarTEATHtNa 
CONTROL 


\ 


Fig.  214. — Coburn  Apparatus  for  Administering  Ether  and  Ethyl  Chloride 
by  the  Rebreathing  method,  Stand  Disconnected. 


the  bag  from  one  to  eight  minutes,  by  which  time 
the  bag  is  emptied,  usually  by  the  exhalations  escap- 
ing from  the  inhaler  instead  of  passing  back  into  the 
bag.  The  bag  is  then  refilled  and  the  patient  again 
rebreathes  the  bag  of  gas  the  desired  length  of  time. 

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Anesthesia,  General  Surgical 


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The  method  of  intermittent  supply  and  rebreathing 
requires  an  average  of  about  thirty  gallons  of  nitrous 
oxide  per  hour,  and  is  therefore  much  the  most  econom- 
ical method  of  administration.  Besides  it  is  the  more 
scientific,  as  the  stimulant  action  of  carbon  dioxide  on 
respiration  is  needed  to  counter-balance  the  depressing 
respiratory  action  of  nitrous  oxide,  as  well  as  to  pre- 
vent shock.  And  in  the  method  of  intermittent  supply 
of  nitrous  oxide  the  amount  of  rebreathing,  and  conse- 
quently the  carbon  dioxide  retention  as  well,  is  under 
much  better  and  more  positive  control. 


Fig.  215. — Coburn  Apparatus  for  Administering  and  Warming  all 
Liquid  Anesthetics  by  the  Open  Drop  Method. 

Rebreathing  nitrous  oxide  undoubtedly  renders 
its  administration,  whether  short  or  prolonged,  much 
safer,  and  at  the  same  time  the  resulting  anesthesia 
is  deeper,  smoother,  and  better  in  every  particular. 

Pure  Nitrous  Oxide  and  Nitrous  Oxide  with 
Air. — In  addition  to  the  apparatus  and  gas  the 
anesthetist  should  also  be  provided  with  at  least  a 
mouth  wedge,  props,  tongue  forceps,  a  gag,  and,  if 
possible,  the  other  accessories  previously  mentioned. 
In  dental  work  the  mouth  prop  should  be  placed  in 
position  before  the  administration  begins.  All  such 
props  should  have  a  ligature  attached  so  that  they 
may  not  be  swallowed  should  they  become  displaced. 
For  short  anesthesias — the  only  form  of  administra- 
tion for  which  nitrous  oxide  alone,  or  combined  with 
air  is  adapted — the  patient  may  be  placed  in  any  posi- 
tion required  by  the  operator,  except  in  grave  car- 
diac cases,  but  usually  a  semirecumbent  posture  gives 
sufficient  elevation  of  the  head.  It  is  important 
that  the  respiratory  movements  and  the  air-passages 
be  unobstructed  at  all  times. 

The  rubber  cushion  should  be  well  inflated,  the 
bag  nearly  filled  with  gas,  with  the  air-vent  open 
and  shut-off  closed.  With  the  expiratory  orifice 
open  the  inhaler  is  next  placed  over  the  patient's 
face,  care  being  exercised  to  see  that  the  mask  and 
inflated  cushion  form  an  air-tight  fitting  with  the 
patient's  face.  The  patient  is  allowed  to  make  a 
few  respirations  in  order  to  get  accustomed  to  the 
apparatus  and  to  learn  that  it  need  cause  no  appre- 
hension. Air  is  being  inspired  through  the  air-vent, 
and  the  expirations  escape  at  the  expiratory  orifice. 
After  thus  breathing  a  few  times,  the  air-vent  is 
closed.  The  patient  now  inspires  nitrous  oxide  from 
the  bag  and  all  the  exhalations  escape  at  the  expi- 


ratory orifice.  After  making  four  or  five  such  exhala- 
tions, so  that  the  air  in  the  apparatus  and  respira- 
tory tract  may  be  replaced  with  nitrous  oxide,  the 
expiratory  orifice  is  closed,  and  the  patient  now  re- 
breathes  nitrous  oxide  back  and  forth  from  and  into 
the  rubber  bag.  During  all  this  procedure  the  room 
should  be  kept  quiet. 

The  induction  of  anesthesia  with  nitrous  oxide  is 
usually  so  rapid  that  it  is  impossible  to  divide  it  into 
all  the  different  stages.  The  first  effect  usually  dis- 
cernible is  a  change  in  the  patient's  color;  at  first 
it  is  a  little  dusky,  grows  darker,  and  finally  becomes 
markedly  cyanotic,  the  breathing  becomes  loud  and 
stertorous,  and  jactitations  or  irregular  muscular 
contractions  rapidly  follow,  unless  the  administra- 
tion is  stopped  or  air  (or  its  equivalent)  admitted. 
The  administration  should  not  be  pushed  to  the  point 
of  causing  jactitation,  so  whenever  there  is  marked 
cyanosis  or  stertor  the  anesthetic  should  be  discon- 
tinued, or  the  air-vent  opened  for  one  or  two  inha- 
lations of  air  (the  shut-off  operated  simultaneously 
automatically  prevents  the  waste  of  the  nitrous  oxide). 
The  administration  may  be  continued  by  allowing 
the  patient  to  inspire  a  breath  of  air  about  e 
five  respirations.  A  bag  full  of  nitrous  oxide  may 
thus  be  rebreathed  for  from  three  to  five  minutes. 

The  time  required  to  produce  anesthesia  varies 
from  a  few  seconds  to  a  few  minutes,  the  average 
being  a  little  less  than  one  minute. 

The  administration  of  nitrous  oxide  pure  and  com- 
bined with  air  should  be  confined  to  dental  and 
other  very  brief  operations  when  a  complete  anes- 
thesia is  not  required. 

In  some  cases,  especially  for  dental  work,  it  is 
desirable  to  administer  nitrous  oxide  so  that  at  the 
same  time  the  oral  cavity  may  be  open  and  unob- 
structed for  operations  therein.  For  this  purpose 
a  nasal  inhaler  is  used  and  the  gas  is  forced  into  the 
nasal  passages  under  pressure.  It  is  absolutely 
essential  that  such  an  inhaler  make  an  air-tight  fitting 
over  the  patient's  nose,  and  that  a  net  be  placed  over 
the  rubber  bag  to  prevent  its  excessive  expansion 
under  the  pressure  necessary  to  force  nitrous  oxide 
through  the  patient's  nasal  passages.  If  a  Macintosh 
bag  is  used  the  net  is  not  needed. 

The  patient  is  anesthetized  in  the  same  manner 
as  with  the  face  inhaler  except  there  is  no  rebreathing 
and  the  mouth  is  kept  covered  with  a  small  sheet  of 
rubber.  "When  the  patient  is  anesthetized  the  ex- 
piratory orifice  is  closed,  and  nitrous  oxide  is  forced 
through  the  nasal  passages,  while  the  mouth  is  open 
during  the  performance  of  the  operation.  Although 
the  patient  necessarily  inspires  considerable  air 
through  the  mouth,  it  is  advisable  to  administer 
simultaneously  a  small  amount  of  oxygen  when  in- 
dicated by  the  patient's  color. 

The  state  of  analgesia  in  which  there  is  loss  of  setts 
sation  of  pain  but  not  loss  of  consciousness,  and  which 
is  now  very  much  used  in  dentistry,  is  secured  by 
administering  a  somewhat  smaller  amount  of  the 
anesthetic  than  is  necessary  for  anesthesia.  In  this 
form  of  administration  for  dental  purposes  the  nasal 
inhaler  is  used,  and  as  the  mouth  is  open,  more  or 
less  air  is  inspired  through  it,  consequently  very  little 
additional  oxygen  is  required  in  prolonged  adminis- 
trations. Analgesia  might  be  termed  "anesthetic 
intoxication." 

Nitrous  Oxide  with  Oxygen. — The  administration 
is  begun  the  same  as  that  of  nitrous  oxide  pure,  but 
at  soon  as  the  patient  shows  the  first  tinge  of  cyano- 
sis, pure  oxygen,  in  a  small  amount,  is  added  from  a 
cylinder  to  the  rebreathing  bag.  The  anesthetist  soon 
learns  to  gauge  the  amount  of  oxygen  needed,  being 
cautious  not  to  add  too  much,  as  more  can  be  added 
at  any  time  if  the  color  indicates  that  the  oxygena- 
tion is  deficient.  It  is  entirely  unnecessary  to  know 
the  percentage  of  oxygen  used;  sufficient  oxygen 
should  be  added  to  maintain  a  normal  oxygenation, 


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Anesthesia,  General  Surgical 


and  as  the  patient's  color  is  the  most,  delicate  indi- 
ator  no  other  guide  is  needed. 

After  the  patient  has  rebreathed  a  bag  of  gas  from 
two  to  eighl  minutes  the  expiratory  orifice  is  opened, 

and  the  bag  is  automatically  emptied  by  the  exhala- 
tions passing  out  into  the  air.  Just  before  the  bag  is 
mletely  empty  the  expiratory  orifice  is  closed, 
the  bag  is  nearly  refilled  with  nitrous  oxide,  and  the 
indicated  amount  of  oxygen  added,  or,  if  the  patient 
lightly  cyanotic,  the  oxygen  maybe  added  Brst. 
thus  rebreathing  a  bag  of  gas  and  oxygen  for  a  few 

s,  emptying  and  refilling  in  turn,  as  outlined, 

this  form  of  anesthesia  may  be  maintained  as  long  as 
desired.  Care  and  skill,  however,  must  be  exercised  to 
maintain,  as  nearly  as  possible,  a  normal  color  of  I  he  pa- 
1  s  cutaneous  circulation,  for  a  continued  cyanosis 
throws  considerable  extra  strain  upon  the  heart. 
On  the  other  hand,  too  much  oxygen  should  not  be 
i,  as  it  lightens  the  anesthesia.  It  requires  a 
little  aptitude  and  experience  to  administer  this 
anesthetic  throughout  a  prolonged  operation  and 
io  pilot  the  patient  successfully  through  the  narrow 

mnel  that  lies  between  a  too  light  and  a  too  deep 
anesthesia.  The  best  guide  in  maintaining  the 
proper  depth  of  anesthesia  is  the  respiration  and  the 
respiratory  sounds. 

The  amount  of  rebreathing  is  to  be  governed  by 
depth  of  anesthesia  and  the  effects  of  the  retained 
carbon  dioxide.  As  a  considerable  amount  of 
the  nitrous  oxide  is  absorbed  by  the  blood  the 
anesthesia  may  become  too  light  on  account  of  the 
diminished  strength  of  the  gas  in  the  bag,  so  that  it 
is  not  advisable  to  rebreathe  the  maximum  period. 

The  effects  of  the  retained  carbon  dioxide  upon 
respiration  are  very  noticeable.  As  has  been  shown 
by  Henderson,  the  respiratory  center  is  controlled 
by  the  amount  of  carbon  dioxide  in  the  blood.  When 
the  carbon  dioxide  is  increased  (the  threshold  of  the 
respiratory  center  remaining  the  same)  pulmonary 
ventilation  is  increased,  i.e.  respiration  is  stimulated 
in  frequency,  or  depth,  or  both.  When  the  carbon 
dioxide  in  the  blood  is  low,  respiration  is  depressed 
and  the  venous  system  loses  its  tonicity.  When  the 
veins  dilate  less  blood  reaches  the  heart,  and  there- 
fore less  blood  is  pumped  on  through  the  circulatory 
system,  consequently  shock  supervenes. 

As  nitrous  oxide  primarily  stimulates,  and  finally 
depresses  respiration,  there  is  a  special  indication  for 
its  administration  by  rebreathing,  so  as  to  secure  the 
direct  stimulant  action  of  carbon  dioxide  upon  the 
respiratory  center.  Besides,  the  increased  rate  and 
depth  of  respiration  permit  of  the  absorption  of  a 
larger  amount  of  nitrous  oxide,  and  rebreathing 
therefore  deepens  the  anesthesia. 

Under  ordinary  conditions  an  eight-liter  bag  of 
gas  can  be  rebreathed  for  an  average  of  about  three 
minutes.  A  condition  of  excessive  carbon  dioxide 
retention  is  shown  chiefly  by  deep  and  labored  res- 
piration. Increased  blood  pressure  and  decreased 
frequency  of  cardiac  action  also  indicate  too  high  a 
retention  of  carbon  dioxide. 

Pulmonary  ventilation,  however,  is  not  the  only 
source  of  excessive  loss  of  carbon  dioxide,  for,  being 
a  diffusible  gas,  it  readily  transpires  through  the  thin 
capillary  walls  whenever  there  is  a  considerable 
exposure  of  these  vessels.  In  abdominal  operations, 
with  the  viscera  exposed,  there  is  such  a  pronounced 
loss  of  carbon  dioxide  from  this  source  that  a  patient 
will  tolerate  to  good  advantage  double  the  amount 
of  rebreathing  that  the  same  patient  will  tolerate 
in  the  same  anesthesia  when  the  abdomen  is  closed, 
or  in  an  operation  where  there  is  little  exposure  of  the 
capillaries.  Accordingly,  in  abdominal  operations, 
and  kindred  conditions,  a  patient  can  advantageously 
rebreathe  an  eight-liter  bag  of  gas  from  four  to  eight 
minutes. 

As  nitrous  oxide  causes  more  or  less  swelling  of  the 
tongue,   there  is  considerable   trouble  in   this  anes- 


thesia  from  the  tongue  obstructing  respiration.  Aa 
one  hand  is  required  to  hold  the  mask  tightly  against 
the  patient's  face,  and  the  other  is  occupied  with 
supplying  the  requisite  ease  .  etc.,  there  is  little 
opportunity  for  holding  the  .jaw  forward.  To  meet 
this  situation  I  devised  the  breathing  tube''  iiig. 
204)  previously  described.  It  can  be  inserted 
the   mask    reapplied    so    quickly,    that    the    patient 

makes    no    n very    during    its    introduction,    from 

even  this  evanescent,  anesthetic. 

The  advantages  of  nitrous  oxide-oxygen  anes- 
thesia are:  It  is  pleasant  for  the  patient,  causes 
little  or  no  depression  (or  shock),  and  is  followed  by 
little  or  no  depression  or  vomiting;  it  causes  no 
irritation  of  the  respiratory  or  genitourinary  tract 
and  does  not  impair  the-  patient's  resistance  against 
infect  ion. 

[ts  disadvantages  are:  The  anesthesia  and  relaxa- 
tion are  not  always  complete;  it  requires  a  special 
apparatus  and  rather  burdensome  supplies  for  its 
administration,  and  the  cost,  of  the  nitrous  oxide  is 
more  than  that  of  the  other  anesthetics  (about  SI. 00 
per  hour  with  the  method  just  described,  or  sixty-five 
cents    with    hospital  discounts). 

Nitrous  Oxide-oxygen  with  Bther  as  an  Adjuvant. — 
This  administration  is  conducted  the  same  as  that 
of  nitrous  oxide-oxygen  (just  described)  except  that 
when  the  anesthesia  is  too  light  or  the  relaxation 
incomplete  a  small  amount  of  ether  vapor  is  added 
to  the  nitrous  oxide  by  slightly  turning  the  needle- 
point valve  on  top  of  the  anesthetic  cup,  and  the 
ether  drops  slowly  upon  the  gauze  in  the  chamber, 
and  is  immediately  vaporized.  And  with  the 
respirations  deep  and  rapid  under  the  stimulating 
influence  of  the  carbon  dioxide  in  the  rebreathing 
method  it  only  requires  a  small  amount  of  the  addi- 
tional ether  vapor  to  obtain  a  deep  anesthesia  with 
relaxation  in  all  cases.  In  order  that  the  ether  may 
drop  regularly  it  is  necessary  that  the  bag  never  be 
distended,  for  otherwise  the  pressure  prevents  the 
ether  from  dropping  upon  the  gauze.  It  is  also 
necessary  that  the  cap  does  not  completely  close  the 
opening  on  the  top  of  the  cup,  for  without  a  little 
air-supply  a  vacuum  is  created  in  the  cup,  and  this 
prevents  the  ether  from  dropping  into  the  chamber. 
Inasmuch  as  the  ether  may  be  added  continuously, 
or  pure  ether  administered  by  either  the  open  or 
closed  methods  until  the  desired  depth  of  anesthesia 
and  degree  of  relaxation  are  secured,  this  method  of 
administration  is  dependable  and  is  adapted  equally 
well  for  major  as  for  minor  surgery. 

The  aim  in  this  form  of  administration  should  be 
to  use  the  minimum  amount  of  ether,  and  have  the 
major  part  of  the  anesthesia  produced  by  nitrous 
oxide,  so  as  to  avoid,  as  far  as  possible,  the  depress- 
ing, nauseating,  irritating,  degenerating,  shock- 
producing,  and  immunity-destroying  effects  of  the 
former  anesthetic.  And  the  fact,  which  is  not  usually 
recognized,  is  to  be  strongly  emphasized  that  the 
ether  thus  used  does  not  produce  the  same  propor- 
tion of  its  toxic  effects  that  this  amount  bears  to  the 
amount  necessary  to  maintain  anesthesia  with  straight 
ether.  It  is  the  last  third,  and  not  the  first  two- 
thirds,  of  straight  ether  that  produces  almost  all  of 
its  toxic  effects.  In  other  words,  after  a  certain 
effect  is  produced  by  the  administration  of  straight 
ether  the  additional  amount  necessary  produces 
toxic  effect  out  of  all  proportion  that  this  additional 
amount  bears  to  the  total  amount  used,  and  it  is  this 
fact  that  explains  the  comparative  absence  of  the 
toxic  effects  of  the  ether  used  as  an  adjuvant  to  the 
nitrous  oxide,  as  outlined. 

When  hyoscine  (scopolamine)  has  been  combined 
in  the  preliminary  hypodermic  injection  with  mor- 
phine, considerably  less  ether  will  be  needed  as  an 
adjuvant,  and  in  a  smaller  percentage  of  cases,  than 
when  atropine  has  been  combined  with  the  morphine. 
Whenever  hyoscine  is  used  it  is  necessary  to  keep  the 


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REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


blood  extra  well  oxygenated,  especially  until  the 
stimulant  action  of  carbon  dioxide  upon  respiration 
is  secured. 

Nitrous  Oxide  as  a  Preliminary  to  Ether. — This 
administration  is  begun  the  same  as  that  of  nitrous 
oxide  alone  (q.r.).  The  average  patient,  after  re- 
breathing  the  nitrous  oxide  for  twenty  to  forty 
seconds,  shows  the  signs  of  anesthesia,  and  at  this 
time,  but  not  until  there  are  signs  of  anesthesia 
observable,  the  valve  on  top  of  the  cup  is  slightly 

turned,  and  ether 
thus  slowly 
dropped  upon  the 
gauze.  The  ether 
should  be  gradu- 
ally increased  but 
not  more  rapidly 
than  the  patient's 
tolerance  of  the 
irritating  vapor 
will  permit  with- 
out disturbance. 
Marked  cyanosis 
should  be  pre- 
vented by  opening 
the  air-vent  and 
allowing  the  pa- 
tient to  inspire  one 
or  two  breaths  of 
air  every  five  or  six 
inspirations,  or  by 
leaving  tlie  air- 
vent  slightly  open 
during  the  re- 
mainder of  the  in- 
duction  period. 
(A  much  better 
method  is  to  add 
pure  oxygen  direct 
to  the  rebreathing 
bag  and  thereby 
prevent  all  cyano- 
sis.) It  is  impor- 
tant that,  the  drop- 
ping of  the  ether  should  not  be  begun  until  the  patient 
is  unconscious  from  the  nitrous  oxide,  and  that  it 
should  be  added  very  slowly  at  first,  for  if  the  vapor 
is  too  strong  the  patient  will  either  hold  his  breath  or 
cough.  But  if  no  coughing  occurs  and  the  patient 
breathes  deeply  and  regularly  the  ether  may  be  in- 
creased quite  rapidly.  Smokers  are  quite  liable  to 
cough  with  even  a  mild  vapor,  so  with  this  class  it  is 
necessary  to  proceed  with  the  ether  administration 
very  slowly.  Alcoholics  are  very  susceptible  to  the 
oxygen  deprivation  of  nitrous  oxide  and  so  require  a 
large  amount  of  air  (or  of  pure  oxygen). 

Only  a  few  patients  will  require  more  than  one 
bagful  of  nitrous  oxide.  The  rebreathing  bag  should 
be  used  until  the  patient  is  relaxed,  when  it  may  be 
removed,  and  the  administration  of  ether  continued 
by  the  open  method,  if  desired. 

"  Nitrous  oxide  should  not  be  administered  imme- 
diately before  the  administration  of  chloroform,  but 
if  chloroform  is  to  be  the  anesthetic,  and  there  is  no 
respiratory  irritation,  the  induction  may  be  made 
with  nitrous  oxide-ether  as  above  outlined  and  the 
change  made  to  chloroform  just  as  soon  as  the  pa- 
tient is  anesthetized  witli  the  ether  sequence. 

Ethyl  Chloride. — While  ethyl  chloride  was  em- 
ployed about  sixty  years  ago  to  produce  general  anes- 
thesia it  was  not  until  within  the  last  decade  that  its 
use  has  met  with  any  general  public  favor.  Many  of 
the  fatalities  following  its  use  have  been  attributed  to 
impurities  which,  to-day,  are  not  found  in  the  product 
intended  for  inhalation  use.  It  is  supplied  in  con- 
tainers of  60  to  100  c.e.  capacity  and  in  glass  ampoules 
of  3  and  5  c.c.  The  latter  are  to  be  broken  and  used 
at  once,  while  the  former  has  a  valve  which  controls  its 


Fig.  216.— Hewitt's  ( 
with  Clover's  Etl 


as-ether  Inhaler 
er  Chamber. 


administration,  which  is  usually  in  the  form  of  a  spray. 
Ethyl  chloride  for  inhalation  differs  from  that  intended 
for  local  anesthesia  as  marketed  by  some  manufac- 
turers, so  one  should  always  be  sure  that  the  prepara- 
tion for  general  anesthesia  is  used.  Pure  ethyl  chlo- 
ride is  the  only  form  that  is  adapted  for  inhalation. 

Ethyl  chloride  may  be  administered  by  either  the 
open  or  closed  systems,  and,  as  is  the  case  with  ether, 
the  skilled  and  qualified  anesthetist  usually  prefers 
the  closed  method.  Like  nitrous  oxide  it  is  rapid  in 
action,  and  the  anesthesia 
is  likewise  evanescent.  If 
the  administration  is  for  a 
dental  operation  a  prop 
should  always  be  previ- 
ously inserted,  and  the 
patient  may  be  in  a  semi- 
recumbent  position. 

In  the  open  method  any 
suitable  mask  such  as  the 
Schimmelbusch  or  Yank- 
auer's  may  be  covered  with 
ten  or  twelve  layers  of 
gauze  and  used.  The  Co- 
burn  apparatus,  with  the 
bag  removed,  offers  dis- 
tinct advantages  in    this 


Fig.  217. — Schimnielbusch's 
Folding  Mask. 


form  of  administration,  inasmuch  as  the  gauze  in  it  is 
several  inches  distant  from  the  patient's  face,  and  conse- 
quently the  vapor  is  always  well  diluted  with  air  before 
being  inhaled.  And,  besides,  the  exhalations  do 
not  pass  over  the  gauze  and  needlessly  waste  about  half 
of  the  anesthetic.  Whatever  apparatus  or  mask  is  used 
the  ethyl  chloride  is  slowly  sprayed  upon  the  gauze, 
but  if  the  usual  open  mask  is  used  care  must  be 
exercised  not  to  spray  the  anesthetic  suddenly,  or  in  a 
large  amount,  or  with  much  force.  Respiration  is 
stimulated  in  frequency  and  increased  in  volume,  and 
the  patient's  color  should  be  quite  florid.  Anesthesia 
is  induced  so  quickly  that  the  different  stages  are 
u -i  tally  not  distinguishable,  as  it  ordinarily  requires 
only  about  a  minute  for  the  induction  period,  and  a 
few  c.c.  of  the  anesthetic.  If  a  prolonged  anesthesia 
is  desired,  the  anesthetic  is  sprayed  in  small  quanti- 
ties at  frequent  intervals  upon  the  gauze,  extremely 
diligent  care  being  exercised  in  watching  the  eye 
reflexes,  the  pulse,  blood  pressure,  and,  of  course, 
the  breathing,  for  signs  of  overdosage. 

As  ethyl  chloride  produces  a  fall  in  blood-pressure 
it  is  not  well  adapted  for  prolonged  administration, 
and  its  after-effects  are  more  unpleasant  than  those 
of  nitrous  oxide. 

In  the  closed  method  of  administering  ethyl 
chloride  a  special  apparatus  is  necessary  and  for 
this  purpose  numerous  ones  have  been  devised.     The 


kauer's  Mask. 


Coburn  apparatus,  with  the  bag  attached,  is  well 
adapted  for  this  purpose.  The  bag  is  partly  filled 
with  the  patient's  expirations  and  the  anesthetic 
sprayed  in  small  quantities  at  frequent  intervals 
into  the  bag  through  a  slight  opening  of  the  air  vent. 
It  only  requires  about  forty  or  fifty  seconds  of  time 
and  from  3  to  5  c.c.  of  ethyl  chloride  to  induce  anes- 
thesia by  this  method.    The  anesthesia  is  recognized  by 


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Anesthesia,  General  Burglcal 


its  usual  signs  but  more  especially  by  the  snoring  char- 
acter of  respiration.  Many  anesthetists  -pray  from 
;;  to  5  c.c.  of  ethyl  chloride  into  the  bag  at  once,  but 
I  believe  it  to  be  dangerous  practice  to  introduce 
such  large  amounts  at  one  time.  Prolonged  anes- 
thesia is  maintained  by  spraying  the  anesthetic 
into  the  bag  al  frequent  intervals,  extreme  care  be- 
ing taken  to  watch  for  the  signs  of  overdosage. 

When  ethyl  chloride  i-  used  as  a  preliminary  to 
ether  tin-  Coburn  apparatus  can  be  very  advanta- 

f;-lv  used  in  either  the  open  or  closed  methods. 
administration  is  begun  a  mtlined,  es 

that  the  cup  should  be  previously  filled  with  ether 
.lust  as  soon  as  the  palie.it  exhibits  signs  of  at 
thesis  the  valve  on  the  cup  is  slightly  turned,  and  thi 
ether  is  slowly  dropped  upon  the  gauze,  the  rate  oi 
the  ether  administration  being  cautiously  and  gradu- 
ally increased  by  turning  the  needle-point  valve. 
In  the  open  method  it  i>  advisable  to  spray  a  little 
ptlivl  chloride  upon  the  gauze  after  the  admini 
tion  of  ether  is  begun  so  as  to  prevent  any  recovery, 
but  in  the  closed  method  this  will  rarely  be  necessary. 

Ethyl  chloride  possesses  no  particular  advantages 
over  nitrous  oxide  except  that  of  convenience;  it  is 
inctly  more  dangi  rous  and  its  use  is  followed  by 
more  disagreeable  after-effects,  .such  as  headache. 
vomiting,  dizziness,  etc  In  general,  it  may  be  said 
that  ethyl  chloride  is  better  adapted  for  administra- 
tion to  i  hildren  than  to  adults. 

Ethyl  bromide  is  administered  in  practically  the 
manner  and  amounts  as  ethyl  chloride  except 
that  it  is  dropped  upon  the  gauze  or  poured  into  the 
bag  or  inhaler  instead  of  being  sprayed.  In  the 
trn  apparatus  -4  to  S  c.e.  are  poured  into  the  cup 
and  it  is  then  dropped  upon  the  gauze  by  turning 
the  needle  valve.  If  there  is  to  be  an  ether  sequence, 
just  as  soon  as  the  patient  is  anesthetized  ether  is 
poured  into  the  cup  and  the  administration  of  this 
anesthetic  begun,  so  there  is  no  recovery  from  the 
preliminary  agent. 

Ethyl  bromide  seems  to  possess  no  special  advan- 
over  ethyl  chloride,  and  is  much  more  liable  to 
decomposition. 

Ether. — Ether  is  administered  by  one  of  four 
general  systems:  (1)  The  open;  (2)  the  closed;  (3) 
rectal  etherization;  (4)  intravenous  etherization; 
and  various  modifications  of  these  systems,  including 
the  intratracheal  method,  in  conjunction  with  pure 
oxygen,  warmed  vapor,  etc. 

Hewitt  makes  a  different  classification,  including 
the  semi-open  system,  which  he  defines  as  '•limiting 
to  some  extent  the  access  of  atmospheric  air  without 
in  any  way  retaining  the  expiratory  products  for 
rebreathing."  This  definition,  however,  describes 
an  impossible  condition,  for  the  air  supply  cannot 
possibly  be  limited  unless  the  expiration  is  rebreathed. 
Limiting  the  air  supply,  in  the  administration  of 
ether,  does  not  decrease  the  respiratory  volume, 
hence,  in  a  general  way,  there  must  always  be  re- 
breathing  in  the  proportion  that  the  air  supply  is 
restricted  (excepting,  of  course,  where  there  is  an 
artificial  supply  of  some  gas,  such  as  nitrous  oxide  or 
oxygen,  that  is  simultaneously  respired,  and  whose 
volume  is  equal  to  that  of  the  restricted  air).  The 
semi-open  system,  or  as  it  is  sometimes  called,  the 
semi-closed  system,  then,  is  simply  a  modification 
of  the  closed  system. 

The  intratracheal  method,  on  the  other  hand, 
appears  to  be  simply  a  modification  of  the  open 
system,  inasmuch  as  there  is  no  rebreathing  and  the 
air  supply  is  abundant. 

The  induction  of  anesthesia  with  ether  requires 
several  minutes,  and  is  more  or  less  disagreeable  to 
the  patient,  inasmuch  as  the  odor  of  the  vapor  is 
unpleasant  and  produces  more  or  less  of  a  choking 
sensation.  Besides,  there  is  a  very  general  fear  and 
dread  of  undergoing  the  ordeal  of  a  general  anesthesia, 
hence   at   the   time   of   administration   the   patient's 


nerves  are  in  a  state  of  exa  ed  excitation  which 

causes  a   prolongation  of  the  induction   period  and 

ised  resistance  ami  struggling.     Tin-  fright 
fear,  and  the  struggling,  especially  with  ether  by  the 

method,  all  tend  to  produce  rapid  breathing, 
which  in  turn  causes  shock.  The  acapnia  thus 
produced   by  etherization   may   In  i     to 

primary  heart  failure,  even  in  normal  subjects, 
according  to  Henderson.      1"  Cril    ha      down 

thai    tear  and   fright    produce   distinct    pathological 
lesii >ns  of  t he  brain  cells.      Mi.',    two   tnvi 
have  demonstrated  the  scientific  basis  fur  the  a 

lute   need   of  a   rapid  and   pleasant   induction  of  ane  — 

the  ia  and  the  elimination  "i  preanesthetic  fear. 
Anesthesia  cannot  be  in. lined  rapidly,  as  that  term 
is  here  intended,  with  straight  ether,  and  such  an 
induction  is  usually  distinctly  unpleasant,  hi 
there  is  a  scientific,  as  well  as  esthetic  basis,  for  the 
plea-ant  induction  of  anesthesia  with  rapidly  act- 
ing anesthetizing  a^'-uts  such  a-  nitro  ■  ■  and 
ethyl  chloride,  followed  by  an  ether  sequence  when- 
ever the  latter  anesthetic  is  t.i  be  administered,  the 
methods  having  already  been  described.  The  pre- 
anestl  c  is  best  prevented  by  the  administra- 

tion of  morphine,  as  outlined  by  (.file.  Besides, 
when  morphine  is  used  less  of  the  inhalation  anes- 
thetic is  required,  and  morphine  in  proper  dosage  is 
less  toxic  than  ether. 

Ether  vapor  is  highly  inflammable  and  therefore  it 
should  never  be  administered  near  an  open  flame.  In 
the  use  of  the  Paquelin  cautery  this  physical  property 
must  always  be  borne  in  mind  by  the  anesthetist,  as 
well  as  by  the  surgeon. 

The  open  system  of  administering  ether  requires 
only  a  very  simple  inhaler,  preferably  a  Yankauer's 
mask,  but  any  chloroform  mask  will  answer  very  well. 
In  the  selection  of  face  masks  preference  should  be 
given  to  those  that  fit  the  contour  of  the  face  so  that 
ail  the  air  that  the  patient  breathes  is  inspired 
through  the  gauze.  Accordingly,  the  masks  that 
have  a  pliable  rim  that  can  be  formed  to  fit  the  con- 
tour of  individual  faces  are  useful.  The  mask  should 
be  made  of  metal  and  simple  in  design  and  construc- 
tion so  as  to  be  easily  sterilized  by  boiling.  Such  a 
mask  should  be  covered  with  ten  or  twelve  layer-  of 
gauze. 

The  perfection  of  the  open  system  is  attained  in 
the  open  drop  method,  and  it  is  this  method  that 
will  be  outlined.  If  the  anesthesia  is  to  be  induced 
with  ether  the  gauze-covered  mask  is  placed  gently 
over  the  patient's  face  in  proper  position  and  the 
patient  permitted  to  breathe  for  a  few  seconds  through 
the  mask  and  learn  that  it  offers  no  obstruction  to 
respiration.  The  highly  esthetic  anesthetist  next 
adds  a  few  drops  of  some  pleasant  perfume.  The 
administration  of  the  ether  is  begun  by  dropping 
the  ether  very  slowly  a  single  drop  at  a  time  upon  the 
gauze,  and  very  gradually  increasing  the  rate  of 
administration  as  the  patient  becomes  accustomed 
to  the  vapor.  The  frequency  of  the  drops  and  the  rate 
of  increase  will  depend  largely  upon  the  regularity 
of  respiration  and  laryngeal  irritation.  If  the  patient 
holds  his  breath  or  coughs,  the  vapor  is  too  strong 
and  the  ether  must  be  dropped  more  slowly.  Mus- 
cular subjects,  and  more  especially  alcoholics,  will 
sometimes  struggle  violently,  but  forcible  restraint 
should  be  used  only  when  necessary.  The  mistake 
is  much  more  frequently  made  of  administering  the 
ether  too  rapidly  during  the  induction  rather  than 
too  deliberately.  It  is  not  the  amount  of  ether  that 
is  dropped  upon  the  mask  that  produces  or  maintains 
anesthesia,  but  the  amount  that  the  patient  inhales 
and  absorbs,  consequently  the  rhythm  and  depth  of 
respiration  are  important  guides  in  determining  the 
rate  of  administration  in  the  induction  as  well  as  in 
the  maintenance  of  anesthesia.  The  idea  cannot 
be  too  strongly  emphasized  that  in  the  open  drop 
method  the  ether  should  be  dropped  regularly   and 


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REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Fig.  219. — Allis'  Ether  Inhaler. 


continuously,    and    not    poured    upon    the   gauze   in 
quantities  at  intervals,  as  is  so  often  done. 

Muscular  subjects,  and  more  especially  alcoholics, 
are  often  quite  difficult  to  relax  under  ether  by  this 
method,  so  that  it  becomes  necessary  to  use  some 
rebreathing.  This  may  be  secured  by  covering  the 
gauze  with  a  small  sheet  of  rubber  in  the  center  of 
which  is  a  hole  about  five-eighths  of  an  inch  in  diameter 
and  through  this  hole  the  ether  is  still  dropped  upon 
the  gauze.  If  an  impervious  covering  is  not  available 
several  more  sheets  of  gauze  or  a  towel  may  be  placed 
on  the  mask  so  as  to  limit  the  air  supply  and  thereby 
cause  rebreathing.      After  the  patient  is  relaxed  only 

the  original  gauze  need 
cover  the  mask.  Surgical 
anesthesia  is  recognized  by 
the  absence  of  the  lid  re- 
flex, moderate  dilatation 
of  the  pupil,  and  muscular 
relaxation. 

Whether  surgical  anes- 
thesia is  induced  with 
straight  ether,  or  by  a 
preliminary  anesthetic 
with  an  ether  sequence, 
the  anesthesia  is  further 
maintained  by  a  regular 
and  constant  dropping  of 
l  he  ether  upon  the  gauze. 
<  hi  account  of  the  diffi- 
culty of  continuously  hold- 
ing the  ether  can  in  the 
hand  and  continuing  a  reg- 
ular and  constant  drop- 
ping of  the  anesthetic,  especially  throughout  a  pro- 
longed operation,  the  Coburn  apparatus  is  very  useful 
for  this  form  of  administration,  inasmuch  as  the  ether 
is  added  by  a  mechanical  drop  method,  and  therefore 
the  drops  are  mechanically  regular  and  constant. 
Since  the  air  supply  in  this  apparatus,  when  the  bag 
is  removed,  is  free  and  no  rebreathing  takes  place  it 
completely  fulfils  the  requirements  of  the  open  drop 
method.  Besides,  in  this  apparatus  the  expirations 
do  not  pass  over  the  gauze  and  thus  waste  the 
anesthetic  and  thereby  saturate  the  operating  room 
with  ether  vapor. 

As  ether  stimulates  respiration,  its  administration 
by  the  open  method  causes  more  or  less  acapnia,  and 
consequently  more  or  less  shock  supervenes.  Periods 
of  apnea  from  a  few  to  many  seconds  in  duration  are 
frequently  seen  during  this  form  of  administration, 
and  these  are  undoubtedly  due  to  the  acapnia  which 
the  open  method  of  administration  tends  to  produce. 
It  has  long  been  recognized  by  skilled  anesthetists 
that  less  shock  follows  the  administration  of  ether 
by  the  closed  method  than  by  the  open  method,  and 
the  work  of  Henderson  gives  scientific  vertification  of 
this  clinical  observation. 

The  acapnia  of  the  open  method  may  be  overcome 
by  the  simultaneous  administration  of  carbon  dioxide 
gas,  either  pure  or  mixed  with  oxygen,  for  when  there 
is  a  pronounced  indication  for  carbon  dioxide  admin- 
istration oxygen  is  usually  indicated  also.  A  mixture 
of  ten  per  cent,  carbon  dioxide  and  ninety  per 
cent,  oxygen  is  a  very  good  proportion  to  use  and 
either  such  a  mixture,  or  the  carbon  dioxide  and 
oxygen  in  separate  tanks,  should  be  convenient  at 
hand  in  every  well-appointed  operating  room,  for 
use  not  only  in  emergencies,  but  also  when  shock  is 
either  probable  or  developing.  The  old  adage  that 
"an  ounce  <>f  prevention  is  worth  a  pound  of  cure" 
is  strikingly  verified  in  all  general  anesthesia  work, 
and  as  this  science  is  developed  it  becomes  more  and 
more  apparent  that  the  anesthetist  must  be  a  person 
keen  in  perception,  discriminating  in  judgment,  and 
most  attentive  to  detail.  For  years  there  has  been 
such  ceaseless  agitation  regarding  the  desirability  of 
administering  ether  drop  by  drop  in  the  open  method 


that  sight  has  been  lost  of  the  other  and  even  more 
important  duties  of  the  anesthetist.  Almost  any  one 
can  be  taught  to  drop  ether;  it  is  easy  to  take  the 
pulse,  and  to  count  the  respiration,  and  it  requires 
little  instruction  to  record  the  blood  pressure  accu- 
rately. But  these  are  not  all  that  must  be  observed, 
for  as  Henderson  well  shows  it  is  the  volume  of  the 
blood  actually  pumped  onward,  that,  in  the  proper 
protection  of  the  patient's  vital  interests,  surpasses 
all  else  in  importance,  for  in  the  development  of  shock 
the  arterial  blood  pressure  is  high  and  the  pulse  and 
respiration  are  good. 

The  evaporation  of  ether  upon  the  gauze  in  the 
open  method  produces  quite  a  cold  vapor,  on  account 
of  the  large  quantity  of  ether  used.  In  a  series  of 
observations  I  found  that  in  a  moderate  anesthesia 
the  temperature  of  the  inspired  vapor  was  45°  F.,  in  a 
deep  anesthesia  3.5°  F.,  and  in  a  profound  anesthesia 
32°  F.,  the  operating  room  temperature  being  75°  F.; 
and  in  these  temperature  observations  I  have  been 
corroborated  by  Joss,  who  conducted  a  perfectly 
independent  investigation  of  this  phase  of  the 
matter. 

Vapors,  as  a  rule,  are  more  irritating  cold  than 
warm,  and  this  is  especially  true  of  ether,  conse- 
quently it  has  long  been  held  that  the  cold  vapor  of 
ether  was,  per  se,  a  factor  in  the  production  of  post- 
operative lung  complications.  This  general  belief  is 
probably  correct,  although  it  is  conceded  that  in  pass- 
ing through  the  upper  respiratory  tract  it  is  probably 
warmed  to  body  temperature  by  the  time  it  reaches 
the  lungs.  It  is  also  certain  that  the  heat  necessary 
to  warm  this  cold  vapor  to  body  temperature  is  ab- 
stracted directly  from  the  patient's  vitality.  In 
prolonged  anesthesia  with  ether  by  the  open  method, 
the  energy  thus  abstracted  from  the  patient  is  not 
infinitesimal  in  amount  by  any  manner  of  means,  and 
in  a  number  of  such  cases,  it  must  be  borne  in  mind, 
there  is  urgent  need  for  the  utmost  possible  conserva- 
tion of  vitality,  so  the  needless  loss  from  this  source 
should  not  be  longer  disregarded. 

Davis  says:  "The  effect  of  warming  ether  vapor 
before  inhalation  is  very  marked.  In  twenty-six 
patients  anesthetized  by  this  method  the  loss  of 
temperature  averaged  0.29°  F.,  against  a  loss  of  1.02° 
F.  in  140  cases  under  similar  operating-room  condi- 
tions by  the  open  drop  method."  This  shows  a 
difference  of  0.73°  F.  in  loss  of  body  temperature  in 
favor  of  the  warm  ether  vapor  over  that  of  the 
cold. 

This  double  loss  of  heat,  however,  is  not  the  only 
detrimental  effect  of  cold  ether  vapor,  for  as  Joss 
well  says,  the  cooler  air  chills  the  air  passages,  undoubt- 
edly lowering  their  resisting  powers  and  checking  the 
movements  of  the  cilia  of  the  epithelium  lining  them. 
The  ciliary  movement  is  affected  by  variation  of  tem- 
perature and  is  entirely  arrested  at  the  freezing-point. 
Infectious  material  is  thus  liable  to  find  its  way  more 
readily  into  the  finer  air  passages  as  salivation  becomes 
increased  under  the  influence  of  the  anesthetic. 

In  order  to  avoid  the  effects  of  the  cold  vapor, 
when  either  is  administered  by  the  open  method, 
I  devised  the  electric  heater  previously  described, 
and  when  this  is  attached  to  the  chamber  it  warms 
the  vapor  to  body  temperature  at  the  time  it  is  in- 
haled. And  as  I  have  elsewhere  stated  that  "while 
it  would  require  very  extended  clinical  experience  to 
establish  any  reliable  statistics  on  the  difference  in 
postoperative  complications  it  can  be  said  with  a 
certainty  that  when  the  warm  vapor  is  used  the 
respirations  are  quieter  and  smoother,  and  the  secre- 
tion of  mucus  less — facts  strongly  indicative  of  less 
trauma  to  the  respiratory  passages.  And  this  is  all 
the  more  significant  when  it  is  recalled  that  pneumo- 
cocci  and  other  pathogenic  organisms  are  practically 
ever  present  in  the  respiratory  tract,  and  that  ether, 
through  its  action  on  the  phagocytes,  materially 
weakens   the   patient's   natural   defenses  against  in- 


378 


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feotion  in  general,  as  well  as  thai  against   pneumo- 
cocci  in  part  icular." 

/ ■/.,.     [dm  n     ration  of  Ether  by  the  Closed  S 

H  is  doubtful  who  firs)  discovered  theadvantai 

Limiting  the  air  supply  in  the  administrat  ion  of  ether. 
Clover,  in  1876,  described  "An  Apparatus  for  Ad- 
ministering Nitrous  Oxide  Gas  and  Ether  Singly  or 
Combined.  And  a  few  months  later  he  described 
ys  "Portable  Regulating  Ether  Inhaler."  In  L877 
Ormsby  brought  his  inhaler  to  the  attention  of  the 
profession.  While  neither  of  these  inhalers  is  in  use 
iv  extent  in  the  United  States  modifications  of 
the  two  types  of  inhalers  are  used,  so  a  brief  descrip- 
of  them  and  more  particularly  of  their  differences, 
will  here  be  given. 

the  Clover  and  the  Ormsby  inhaler  have  a 
fare  mask  and  a  rubber  rebreathing  bag,  and  be- 
tween the  lias;  and  mask  is  the  ether  supply  for  vapori- 
zation. The  original  Clover  inhaler  has  no  special 
provisions    for    air    supply    while    such   provision  is 


B/..2& 
FlG.  220. — Clover's  Self-regulating  Kther  Inhaler  and  Case. 

made  in  the  Ormsby  inhaler.  The  difference  in 
supplying  the  ether  vapor  is  quite  radical,  and  it  is 
to  this  difference  that  special  attention  will  here  be 
given.  In  the  Clover  inhaler  a  part  of  the  patient's 
inspirations  and  expirations  pass  back  and  forth 
over  liquid  ether,  thus  producing  a  vapor  practically 
uniform  in  strength,  while  in  the  Ormsby  inhaler  the 
ether  is  poured  on  a  sponge  in  quantities  at  intervals. 
producing  at  one  time  a  strong  vapor  and  at  another 
time  a  weak  vapor.  Practically  all  of  the  inhalers  in 
the  United  States  that  are  specially  designed  for  the 
administration  of  ether  by  the  closed  method  embody 
the  Ormsby  method  of  supplying  the  ether  after  the 
patient  has  been  anesthetized. 

To  the  author  it  seems  a  significant  fact  that  in 
England,  where  the  Clover  principle  of  supplying  a 
uniform  vapor  predominates,  the  closed  method  is  in 
very  extensive  use,  while  in  the  United  States,  where, 
after  the  patient  is  anesthetized,  the  Ormsby  prin- 
ciple of  supplying  a  vapor  varying  greatly  in  strength 
at  different  intervals,  has  been  practically  the  only 
closed  method  used,  the  closed  method  is  not  so 
popular.  Besides,  it  is  this  feature  of  the  intermittent 
and  irregular  supply  of  ether  by  the  closed  method 
that  has  been  assailed  by  so  many  writers  on  the 
subject,  including  the  Anesthesia  Commission  of  the 
American  Medical  Association.  The  concentrated 
vapor  that  occurs  at  intervals  produces  pronounced 
and  unnecessary  irritation  of  the  respiratory  passages 
as  evidenced  by  the  increased  secretion  of  mucus  and 
injury  to  the  epithelial  cells.  Inasmuch  as  less  ether 
is  required  by  the  closed  method  than  by  the  open 
method,  there  should  be  less  irritation,  and  this  is 
the  ease  when  the  vapor  of  the  closed  method  is 
constant  and  regular.  Besides,  the  vapor  is  warmer, 
since  the  warmth  of  the  expirations  elevates  its 
temperature. 

The  other  chief  objection  to  the  closed  method  is 
the  retention  of  carbon  dioxide,  but,  as  Henderson 


has  so  clearly  and  conclusively  shown,  the 

carbon    dioxide,    properly    regulated,    is   a    distinct 

benefit  and  not   a  detriment. 

An  inexpi  n   tve   inhaler  is  always  available,  a-   i 
can  be  made  from  a   paper-COne  and  a  folded  tov.el  or 

gauze,  ami  while  this  is  crude  it  is  quite  efficient. 

[n  inducing  anesthesia  with  such  an  inhaler,  three  or 
four  drams  of  ether  are  pom,-. I  upon  the  absorbent 
material,  which  should  be  of  coarse  composition,  and 
the  cone  slowly  placed  In  position  over  the  patient's 
face,  allowing  the  patient's  respirator}  pa  ages  to  get 
accustomed  to  and  anesthetized  bj  the  vapor  before 
placing  the  cone  tightly  over  the  face.  Holding  the 
breath,  coughing,  or  laryngeal  or  other  spasm  indicates 
that  the- vapor  is  too  strong,  o  the  inhaler  should  be 
removed,  the  patient  allowed  a  little  air,  and  the 
inhaler  then  held  SO  that  a  more  attenuated  vapor  is 
inspired  until  the  anesthesia  deepen-,  when  a  stronger 
will  be  tolerated.  More  ether  is  added  in  small 
quantities  as  indicated. 

In  inducing  anesthesia  with  ether  by  the  clo 

method  with  the  author's  apparatus,  the  bag  is  first. 
partly  distended  with  the  patient's  expirations,  and 
then  the  administration  of  ether  is  begun  very  slowly 
by  slightly  turning  the  valve  on  the  cup,  and  as  tin; 
ei  her  drops  upon  the  gauze  it  can  be  plainly  seen  and 
the  rate  of  administration  can  be  very  accurately 
gauged.  As  the  patient's  air-passages  become  accus- 
1  to  the  vapor  the  drops  are  to  be  increased  in 
frequency.  Holding  the  breath,  coughing,  or  spasm 
of  any  of  the  respiratory  muscles  indicates  that  the 
vapor  is  too  strong,  and  the  valve  should  be  turned 
back  a  little  so  the  drops  will  be  slower;  then,  as  the 
patient's  breathing  becomes  regular,  the  rate  of  the 
drop  is  gradually  increased  by  slightly  turning  the 
needle-point  valve.  When  signs  of  cyanosis  appear 
the  air  vent  should  be  slightly  opened,  so  that  a 
little  air  is  inspired  with  each  inspiration,  or  a  little 
pure  oxygen  may  be  added  to  the  rebreathing  bag. 
If  the  latter  method  is  used  for  furnishing  the  requisite 
oxygen  there  is  a  retention  of  a  larger  amount  of 
earl 'on  dioxide,  and  respiration  is  quickened  and 
deepened,  which  causes  the  absorption  of  a  larger 
amount  of  the  anesthetic,  and  therefore  the  patient  is 
brought  into  the  state  of  surgical  anesthesia  quicker; 
at  the  same  time,  this  procedure  is  safer,  inasmuch  as 
the  carbon  dioxide  by  stimulating  respiration,  tends 
to  prevent  spasm  of  the  respiratory  muscles — the 
chief  source  of  danger  in  the  induction  period. 

After  the  stage  of  surgical  anesthesia  has  been 
reached  the  rate  of  administration  should  be  decreased, 
but  regulated  at  all  times  by  the  patient's  condition 
and  the  depth  of  anesthesia  required.  It  is  to  be 
particularly  noticed  that  from  the  beginning  till  the 
close  of  the  administration,  the  ether  is  added  drop 
by  drop  and  therefore  the  vapor  is  never  concentrated, 
and  after  the  induction  it  is  practically  uniform  in 
both  strength  and  temperature.  Unnecessary  irrita- 
tion and  injury  to  the  respiratory  passage^  are  con- 
sequently prevented. 

The  prevention  of  shock,  so  far  as  acapnia  is  con- 
cerned, lies  in  maintaining  a  normal  amount  of 
carbon  dioxide  in  the  blood.  Such  anesthetics  as 
ether  that  stimulate  respiration  produce  acapnia  by 
overventilation  of  the  lungs,  consequently  there  is 
a  special  indication  for  the  rebreathing  of  ether  so  as 
to  maintain  the  carbon  dioxide  at  a  normal  level.  In 
nearly  all  of  the  specially  designed  apparatuses  used 
in  this  country  for  the  administration  of  ether  by  the 
closed  method,  the  amount  of  rebreathing  is  governed 
by  the  air  supply  or  oxygenation.  In  other  words, 
the  rebreathing  cannot  be  increased  beyond  the  point 
where  the  air  supply  barely  furnishes  sufficient 
oxygen,  for  to  increase  the  rebreathing  is  to  decrease 
the  air  supply.  Since  with  ether  it  is  necessary  to 
have  rebreathing  to  prevent  acapnia,  for  ordinary 
conditions  there  is  usually  a  sufficient  amount  of 
rebreathing  when  the  air  supply  is  restricted  as  much 

379 


Anesthesia,  General  Surgical 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


as  proper  oxygenation  will  allow,  but,  as  carbon 
dioxide  readily  transpires  through  the  thin  walls  of 
the  capillaries  whenever  there  is  a  considerable 
exposure  of  these  vessels,  in  abdominal  operations 
with  the  viscera  much  exposed,  there  is  such  a  marked 
and  direct  loss  of  carbon  dioxide  from  this  source  that 
the   rcbreathing   must    be    markedly    increased   over 


S3078 


Fig.  221. — Pynchon  Apparatus. 

that  necessary  in  ordinary  conditions  in  order  still  to 
maintain  the  carbon  dioxide  at  a  normal  level.  To 
meet  this  condition,  either  the  air  supply  should  be 
further  restricted,  thereby  increasing  the  rebreathing, 
pure  oxygen  being  added  to  the  rebreathing  bag,  or 
with  the  air  supply  sufficient  for  oxygenation  carbon 
dioxide  gas  should  be  added  to  the  bag.  Accordingly 
in  the  apparatus  which  the  author  uses  there  is 
provision  for  a  cylinder  of  nitrous  oxide  for  the 
induction  of  anesthesia,  and  a  cylinder  each  of 
oxygen  and  carbon  dioxide  for  instantaneous  use 
whenever  indicated,  either  in  routine  or  emergency 
work.  A  mixture  of  carbon  dioxide  and  oxygen 
is  also  very  useful,  and  can  be  attached  to  the 
same  stand.  Each  of  the  four  different  cylinders 
is  in  direct  connection  with  the  rebreathing  bag, 
and  all  are  easily  wheeled  about  the  room  and 
kept  entirely  out  of  the  way  of  the  surgeon  and 
assistant-  at  all  times. 

The  Insufflation  Method. — In  some  operations, 
especially  about  the  face,  it  is  impossible  to  use  a 
mask,  and  then  it  becomes  either  desirable  or  Fig 
necessary  to  force  the  vapor  through  a  flexible 
tube,  placed  either  in  the  mouth  or  nares.  With 
such  a  method  of  administration  the  mouth,  nares, 
and  throatare  perfectly  accessible  throughout  a  pro- 
longed anesthesia,  and  the  anesthetist  is  at  quite  a 
distance  from  the  patient's  face  so  as  to  be  completely 
out  of  the  way  of  the  surgeon  and  his  assistants. 

The  Pynchon  inhaler  (Fig.  221)  is  very  simple  and 
compact  and  well  exemplifies  the  essentials  of  this 


Fig.  222. — Paine's  Nasal  Catheter. 

form  of  apparatus.  It  consists  of  two  large-mouthed 
bottles  (about  eight  ounces)  connected  together  with 
a  screw-cap  metal  fitting;  one  bottle  contains  ether, 
and  the  other  acts  as  a  mixing  or  safety  chamber, 
and  has  located  within  it  also  a  small  bottle  for 
chloroform.  Connected  with  the  ether  bottle  is  a 
ten  ounce  Politzer  foot-bulb  for  forcing  an  air  current 

380 


through  the  ether,  and  for  carrying  the  vapor  onward 
to  the  patient's  respiratory  passages.  The  bag  carries 
an  air-inlet  valve,  and  in  the  tubing  between  the  bag 
and  ether  bottle  is  another  valve  to  prevent  suction 
of  ether  or  vapor  back  into  the  bag  when  the  latter 
is  expanding  after  being  compressed.  To  the  other 
or  safety  bottle,  is  attached  a  small  rubber  tube  which 
leads  to  the  patient's  respiratory  passages.  This 
tubing  may  be  terminated  in  one  of  several  different 
methods,  depending  chiefly  upon  the  requirementa 
of  the  individual  case.  The  illustration  (Fig.  221) 
shows  it.  terminating  in  two  nasal  tips  which,  when  of 
the  proper  size,  fit  tightly  into  the  nares.  Instead 
of  the  nasal  tips,  nasal  catheters  (Fig.  222)  may  be 
attached  to  the  tubing  by  means  of  a  Y-fitting,  and 
often  only  one  such  catheter  is  needed.  Instead  of 
these  nasal  fittings  the  tubing  may  be  attached  to  a 
special  gag  such  as  a  Ferguson,  with  anesthetic 
tubes  added,  which  distributes  the  vapor  well  within 
the  mouth  as  well  as  acting  as  a  gag.  The  tubing 
may  also  be  connected  with  a  mouth  tube,  or  the 
regular  tracheotomy  tube,  and  in  certain  instances 
become  most  useful  in  the  maintenance  of  anesthesia. 
Many  other  end  attachments  for  the  efferent  tubing 
will  be  found  serviceable. 

Within  the  safety  bottle,  which  is  large  enough  to 
prevent  any  ether  being  pumped  through  the  tubing 
which  leads  to  the  patient's  respiratory  passages  in 
case  a  large  volume  of  air  is  suddenly  forced  into  the 
ether  bottle,  is  placed  a  small  bottle  for  chloroform. 
The  chloroform  is  forced  out  of  this  bottle  by  a  small 
hand  bulb  and  made  to  drop  into  the  larger  bottle  in 
the  original  apparatus.  Kilmer's  suggestion  is  good, 
that  a  little  gauze  be  placed  just  beneath  the  metal 
tube  that  leads  from  the  chloroform  bottle,  and  as 
the  hand  bulb  is  compressed  the  chloroform  drops 
upon  this  gauze,  and  is  rapidly  vaporized  by  the  air,  or 
etherized  air  current  that  passes  into  the  mixing  bottle. 
At  all  other  times  the  ether  vapor  passes  through  this 
mixing  bottle  without  t  he  absorption  of  any  chloroform. 


223. — Coburn  Apparatus  for  Administering  all  Liquid  Anesthetics 
by  the  Insufflation  Method. 

The  apparatus  is  light  and  may  be  conveniently 
hooked  or  pinned  to  the  anesthetist's  coat  or  gown. 
The  Coburn  apparatus  is  also  well  adapted  for  this 
form  of  administration,  the  mask,  chamber,  cup,  and 
heater  being  used  (Fig.  223).     The  mask  and  heater 
maintain  the  cup  in  an  upright  position.     Into  the 
opening  of  the  chamber  is  inserted  a  stopper  to  which 
is    connected    the    tubing   that   leads   to   the 
Politzer  bag.     In  the  opening  within  the  mask 
is  inserted  another  stopper  to  which  tubing  is 
attached  that  leads  to  a  small  "safety  bottle." 
and    connected    with   this  bottle   is   also   the 
tubing    that    leads    to    the   patient's  respira- 
tory passages.     The  administration  of  ether  is  con- 
trolled by  the  needle  valve,  and  any  desired  strength 
of  vapor  or  rate  of  administration  may  be  attained  in 
this,   as  in  all  other  methods.     Chloroform   may  be 
added  to  the  "safety  bottle,"'  if  the  addition  of  this 
anesthetic  is  desired  at  any  time. 

In  most  of  the  cases  in  which  this  method  is  well 


REFERENCE    IIAXDIK  ><  >K    OF    THE    MEDICAL    SCIENCES 


Anesthesia,  General  Surgical 


suited   there   is  considerable   advantage   in   using  a 

I,,  bulb  to  force  the  air  current  through  the  appara- 
tus   for  the  compressions  of  tin'  bulb  can  be  timed 

with  the  patient's  inspirations  and  little  or  ither 

wasted  or  blown  into  the  surgeon's  face.  When 
two  bulbs  are  used  the  vapor  current  is  continuous, 
an.l  much  of  it  is  wasted  by  the  patient's  expirations 
ami  blown  out  into  the  surgeon's  face. 

Ordinarily  the  patient  i.--  anesthetized  in  the1  usual 
manner,  preferably  by  gas-ether  sequence,  and  the 
anesthesia  continued  with  some  special  apparatus. 
However,  the  patient  may  be  primarily  anesthetized 
with  an   insufflation   apparatus   by   connecting   the 

of  the  efferent  tubing  with  a  face  mask  covered 
with  rubber,  and  the  vapor  then  pumped  into  this 
mask.  If  the  operation  is  to  be  in  the  throat,  after 
the  patient  is  anesthetized  either  the  nasal  tips  or 
catheters  are  fitted  into  the  nares,  and  the  vapor  thus 
pumped  through  the  nasal  passages,  or  the  end  of  the 
afferent  lulling  is  connected  to  a  modified  Ferguson 
gag  or  metal  mouth  tube  and  the  vapor  thus  forced 
into  the  oral  cavity. 

This  method  of  procedure  is  to  be  much  preferred 
to     that     of     an     intermittent     anesthetization     for 

ations  within  the  mouth  or  throat,  where  the 
original  anesthesia  does  not  last  till  the  completion  of 
the  operation.  Henderson  lias  clearly  shown  that  in- 
termittent anesthetization  is  highly  conducive  to 
shock,  and  may  even  cause  primary  heart  failure  in 
normal  subjects;  consequently  the  method  of  anes- 
thetizing deeply  with  ether  in  tonsillectomies  ami 
similar  work,  then  removing  the  mask  and  reapplying 
it  when  the  patient  begins  to  recover,  deeply  anes- 
thetizing again,  and  again  removing  the  mask,  is  to  be 
severely  criticised.  Furthermore,  in  tonsillectomies 
chloroform  should  not  be  used  even  in  conjunction 
with  ether  vapor,  although  the  apparatus  is  well 
adapted  for  such  a  combination,  for  in  this  class  of 
operations  chloroform  has  been  found  to  be  extremely 
dangerous. 


Fig.  22i. — The  Jauway  Apparatus;  front  veiw. 

The  method  just  described  has  been  called  the 
"Vapor  Method,"  but  this  is  a  misnomer,  for  all  in- 
halation anesthetics  are  administered  as  a  vapor, 
ami  consequently  they  are  all  vapor  methods. 

Intratracheal  Insufflation. — To  Meltzer  and  Auer 
the  profession  is  indebted  for  the  developing  and 
perfecting  of  the  intratracheal  insufflation  method  of 
anesthesia.  The  essentials  of  this  method  consist  in 
the  introduction  deep  into  the  trachea  of  a  flexible 
tube,  the  diameter  of  which  is  considerably  less  than 
that  of  the  lumen  of  the  trachea  and  the  forcing 
through  this  tube  of  the  anesthesic  vapor,  the  excess  i  if 
air  and  vapor  and  the  products  of  respiration  passing 
out  through  the  space  between  the  tube  and  the  walls 
of  the  trachea.  The  essentials  as  thus  outlined,  are 
very    few,    and    quite    easily    attained.     Apparatus, 


however,  for  this  method  of  administration  is  usually 

quite     elaborate    and     complicated,     not     because     of 

absolute  necessity,  but  rat  her  to  render  the  method  of 

administration  as  nearly  automatic  as  possible,  and 
to    guard    against    dangers    which    are    more    or 

1 1 etical. 

The  .laneway  apparatus  (figs.  224  and  225)  is  com- 
pact portable,  and  will  be  briefly  described.  It  con- 
sists of  an  electrically  driven  fan  for  forcing  a  st< 

air  stream  through  I  he  apparatus  and  finally  into  i  in- 
patient's trachea.  A  valve  deviate-  any  de  ired 
portion  of  this  air  stream  so  that  il  pa  se  over 
liquid  ether,  thereby  furnishing  the  anesthetic  vapor. 

The   ether   vapor   and    air    then    pass   over   water  kept 

hot  by  an  electric  heater;  from  this  warming-moisten- 
ing  bottle  the  etherized  air  passes  into  a  small  con- 


1  rrr^ 


1 1  imiL^ 


Fig.  225. — The  Janeway  Apparatus;  back  view. 

denser,  removing  the  excess  moisture,  and  then  it 
passes  through  a  small  rubber  tube  several  feet  in 
length  to  the  catheter  introduced  into  the  patient's 
trachea.  The  hot  water  heats  and  moistens  the 
ether  vapor  and  air.  Connecting  with  the  tubing 
which  leads  to  the  trachea  is  a  mercury  manometer 
which  registers  the  intratubular  pressure.  The  in- 
tratracheal pressure  is  usually  one-fourth  of  the  in- 
tratubular pressure.  It  is  very  important  that  the 
pressure  be  neither  too  high  nor  too  low.  If  the 
intratracheal  pressure  is  too  high  death  may  easily 
be  caused  by  rupture  of  the  lungs  and  if  this  pressure 
is  too  low  an  insufficient  amount  of  air  will  be  supplied 
to  the  lungs  and  consequently  oxygenation  will  be 
low.  Usually  a  pressure  of  twenty  millimeters 
fulfils  all  requirements.  Increasing  the  pressure 
decreases  the  muscular  respiratory  movement. 
Accordingly,  if  the  respiratory  movement  impedes  the 
work  of  the  surgeon,  the  pressure  may  be  increased 
up  to  thirty  millimeters,  but  it  is  dangerous  to  in- 
crease it  much  beyond  this  amount. 

On  account  of  the  danger  connected  with  an  ex- 
cessive  intratracheal  pressure,  especially  if  sudden, 
it  is  advisable  to  use  a  "safety  valve."  This  is  con- 
nected with  the  etherized  air  current  and  the  height  of 
the  mercury  column  is  such  that  the  mercury  blows 
out  when  the  pressure  exceeds  a  certain  point.  The 
safety  valve  may  be  set  at  any  desired  pressure, 
usually  forty  millimeters,  and  unless  the  air  current  is 
absolutely  constant  and  reliable  it  adds  a  great  ele- 
ment of  safety  to  this  method  of  anesthesia. 

An  interrupter  is  operated  by  the  electrically 
driven  motor  so  as  to  interrupt  the  air-ether  current 
every  few  seconds.  The  frequent  interruption  of  the 
current  entering  the  lungs  is  an  element  of  safety  in 
the  method.     There  is  also  an  air  filter  near  the  fan. 

Instead  of  the  electrically  operated  fan  a  foot 
bellows  may  be  used,  and  even  if  the  former  is  used 
a  bellows  should  alway-s  be  conveniently  at  hand 
ready  for  use  in  case  of  an  accident  in  the  electric 
service  or  mechanism. 


3S1 


Anesthesia,  General  Surgical 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


An  extremely  simple  and  portable  apparatus  for 
the  intratracheal  method  of  administration  is  the 
Coburn  apparatus  as  shown  in  Fig.  223,  with  the 
following  changes:  A  foot  bellows  is  substituted  for 
the  Politzer  bag;  a  pressure  dropping  cup  is  sub- 
stituted for  the  regular  cup;  and  a  manometer  and  a 
"safety  valve"  are  connected  with  the  efferent  tubing. 

.Much  of  the  success  and  safety  of  the  anesthesia 
depend  upon  the  size  of  the  catheter  introduced  into 
the  trachea,  as  well  as  upon  the  method  of  its  intro- 
duction. If  the  catheter  is  too  small  the  return 
current  is  so  rapid  that  too  small  an  amount  of  the 
.•mi  -i  lutic  is  absorbed,  and  therefore  the  anesthesia  is 
too  light.  If  the  catheter  is  too  large  it  offers  too 
much  obstruction  to  the  return  current,  and  the 
intratracheal  pressure  becomes  too  high,  approaching 
that  of  the  tube  registered  by  the  manometer.  The 
end  of  the  catheter  should  be  introduced  to  a  point 
about  three  centimeters  above  the  bifurcation  of  the 
trachea.  If  the  catheter  is  introduced  too  far  it  pro- 
duces overdistention  of  a  lung,  and  if  it  is  not 
introduced  far  enough  not  a  sufficient  amount  of  the 
anesthetic  and  air  reaches  the  alveoli  of  the  lungs, 
and  consequently  the  anesthesia  is  too  light  and 
oxygenation  incomplete.  Finally,  the  catheter  is 
sometimes  passed  into  the  esophagus  instead  of  the 
trachea,  and  the  stomach  is  thereby  inflated. 

Just  prior  to  use  the  apparatus  should  be  connected 
up  and  tested  in  order  to  insure  that  it  is  in  good 
working  order.  The  size  of  the  catheter  should  be 
selected  according  to  the  size  of  the  glottis.  The 
proper  size  for  adults  is  usually  22  French, 
and  in  order  to  facilitate  its  introduction  it  should  be 
a  silk  woven  catheter,  the  plain  rubber  being  too 
pliable.  While  the  catheter  must,  of  course,  be 
flexible,  it  must  not  be  too  pliable,  for  in  its  introduc- 
tion the  fingers  or  holder  are  several  centimeters 
distant  from  the  glottis,  and  in  passing  it  through 
the  glottis  down  into  the  trachea,  there  is  sonic 
little  resistance.  If  the  catheter  is  too  pliable  it 
will  curl  upon  itself  instead  of  passing  on  down  into 
the  trachea,  and  if  it  is  too  rigid  it  will  not  adapt 
its  shape  to  the  necessary  curves.  The  silk  woven 
variety  has  been  found  to  answer  all  the  various 
requirements.  The  point  to  which  the  catheter  should 
be  introduced  is,  in  the  adult,  about  twenty-six 
centimeters  from  the  teeth,  so  an  indelible  ring  should 
be  marked  on  the  catheter  twenty-six  centimeters 
from  the  internal  end.  As  the  glottis  is  about  thir- 
teen centimeters  from  the  teeth  it  is  well  to  have 
another  such  a  ring  thirteen  centimeters  from  the 
end  to  be  introduced.  The  catheter  should,  of  course, 
be  sterile  and  lubricated. 

While  not  absolutely  necessary  it  is  advisable  to 
have  the  patient  deeply  anesthetized,  preferably 
with  ether,  just  prior  to  the  introduction  of  the 
catheter  so  the  muscles  about  the  head  and  neck  will 
be  relaxed,  and  so  that  the  patient's  reflexes  will  not 
recover  and  displace  the  catheter  by  coughing  before 
the  intratracheal  insufflation  of  the  anesthetic  can  be 
started.  After  the  mask  has  been  removed  the  patient 
is  quickly  moved  on  the  table  so  the  head  and  neck  are 
clear  of  the  edge,  and  a  mouth  gag  is  inserted.  An 
assistant  then  places  one  hand  at  the  back  of  the 
patient's  neck  and  presses  upward,  and  grasps  the 
forehead  with  the  other  hand  and  presses  downward 
The  tongue  is  then  pulled  forward  and  a  Jackson 
laryngoscope  passed  over  its  base,  the  epiglottis 
is  identified  and  the  laryngoscope  passed  over  it  also, 
and  as  the  larynx  is  completely  exposed,  the  catheter 
is  passed  between  the  vocal  cords  down  to  the  indi- 
cated mark.  While  it  requires  a  little  experience  to 
make  the  introduction  deftly  the  necessary  skill  is 
usually  acquired  readily.  Special  introducers  have 
been    designed    lo   facilitate    the   introduction   of   the 

cat  liefer,  but  1  he  I  hod  and  means  here  outlined  are 

practical,    convenient,   and   efficient,   and   are   quite 
generally  employed. 


As  soon  as  the  catheter  .has  been  introduced  the 
proper  distance  a  special  examination  should  be 
made  to  determine  whether  it  was  actually  introduced 
into  the  trachea,  as  intended,  or  into  the  esophagus, 
as  has  frequently  been  the  case.  If  air  passes  in  and 
out  of  the  catheter  with  the  patient's  respirations,  of 
course  it  has  been  introduced  into  the  trachea.  Tin- 
respiratory  movements  can  be  heard  or  felt  at  the 
external  end  of  the  catheter.  A  very  positive  way 
to  determine  this  matter  is  to  place  the  end  of  the 
catheter  near  the  top  surface  of  some  water  in  a 
small  vessel,  and  if  the  catheter  is  in  the  trachea  the 
expiratory  current  will  make  a  distinct  depres 
and  disturbance  on  the  surface  of  the  water.  ( if 
course,  if  the  catheter  is  found  by  any  of  these 
means  to  be  in  the  esophagus,  it  should  be  immedi- 
ately withdrawn  and  properly  introduced  into  the 
trachea. 

After  one  is  assured  that  the  catheter  is  in  proper 
position,  a  metal  protector  is  slipped  over  the  catheter 
to  prevent  its  being  closed  at  any  time  by  the  patient's 
teeth,  the  gag  is  removed,  the  patient  is  moved  down 
on  the  table,  and  the  catheter  is  connected  with  the 
tubing  that  leads  from  the  apparatus.  When  the 
etherized  air  stream  is  forced  into  the  trachea  it  is 
advisable  to  take  the  precaution  to  anchor  the  cathe- 
ter with  a  strip  of  adhesive  plaster  to  prevent  its 
displacement  should  the  patient  cough. 

As  soon  as  the  air  current  is  started  through  the 
intratracheal  catheter  the  patient  should  be  watched 
carefully  for  the  first  minute  or  two  for  evidence  of 
faulty'  introduction  of  the  catheter,  for  herein  lies 
much  of  the  clanger  connected  with  this  method  of  an- 
esthesia. If  it  has  been  introduced  into  the  esophagus 
instead  of  the  trachea  the  stomach  will  be  rapidly  and 
dangerously  inflated.  Should  this  accident  occur  the 
tubing  must  be  immediately  disconnected  from  the 
catheter,  the  stomach  emptied,  the  catheter  with- 
drawn and  then  properly  introduced. 

If  the  catheter  has  been  passed  too  far  into  the 
trachea  the  end  may  reach  one  of  the  bronchi  (usually 
the  right),  and  through  hyperdistention  of  the  lung 
rapidly  cause  pneumothorax.  Should  there  be  evi- 
dence of  too  low  an  introduction  the  catheter  must 
be  immediately  withdrawn  a  few  centimeters  so  that 
the  end  rests  about  three  centimeters  above  the  right 
bronchus. 

By  the  time  the  catheter  is  properly  introduced  and 
connected  with  the  apparatus  the  patient  may  begin 
to  show  signs  of  recovery,  so  for  the  first  few  minutes 
it  is  usually  necessary  to  use  quite  a  strong  vapor, 
but  the  strength  of  the  vapor,  as  in  all  other  methods 
of  administration,  must  be  regulated  according  to  the 
individual  requirements  and  the  indications  of  the 
particular  case  at  hand.  The  strength  of  the  vapor 
is  easily  regulated  by  turning  the  valve  on  the 
Janeway  apparatus  which  controls  the  amount  of  the 
air  current  that  passes  over  the  liquid  ether,  and  this 
valve  may  be  set  so  that  it  may  run  for  many  minutes 
without  any  change  or  manipulation  of  any  other 
part  of  the  apparatus.  As  the  air  current  passes 
over  the  ether,  and  not  through  it,  the  maxi- 
mum amount  of  ether  that  may  thus  be  administered 
to  the  patient  is  limited,  but  for  most  patients  it  is 
sufficient  to  secure  complete  anesthesia  with  relaxa- 
tion. In  the  Coburn  apparatus  the  administration 
of  ether  is  controlled  by  the  needle  valve,  just  as  it  is 
with  all  other  methods.  The  amount  of  ether  used 
slightly  exceeds  that  of  other  methods,  but  the  patient 
does  not  absorb  as  much,  as  the  return  current  quickly 
carries  the  excess  out  of  the  lungs. 

Nitrous  oxide  and  oxygen  may  also  be  used  as  the 
anesthetic,  the  general  principle  involved  being  the 
-: as  that  for  ether,  except  no  fan  or  bellows  is  re- 
quired, since  both  gases  are  under  pressure,  and  when 
expanded  furnish  sufficient  power  to  force  the  an- 
esthetic stream  automatically  through  the  tubing  and 
catheter. 


:',s-2 


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Anesthesia!  General  Surgical 


The  advantages  of  this  method  oi  anesthesia  are 
many  and  distinct,  especially  in  the  field  for  which 
it  Is  particularly  well  adapted,  and  its  pronounced 
benefits  are  not  limited  to  thoracic  surgery  for  which 
ii  was  originally  intended.  Willi  this  method  of  anes- 
thesia the  che  I  cavity  may  be  opened  with  impunity. 
It  ^  also  highly  useful  in  operations  within  the  mouth 
or  upon  the  tongue  or  upper  respiratory  tract  as  1 1 n- 
mums  outward  flowing  stream  of  air  prevents 
|,  infectious  and  other  material  from  reaching 
lower  respiratory  tract  or  interfering  in  any  way 
with  respiration,  it  is  also  useful  in  operations 
;  the  face,  head,  and  neck  when  the  usual  face 
mask  cannot  lie  used  or  when  it  is  desirable  to  have  t  he 
anesthetist  away  from  the  field  of  operation.  Finally, 
it  is  useful  in  operations  where  the  usual  respiratory 
movement  interferes  with  the  work  of  the  surgeon  and 
where  there  is  continuous  vomiting,  as  in  intestinal 
obstruction. 

Diffi  rential  Pressure. — The  work  of  Sauerbruck 
and  Brauer  first  made  possible  and  feasible  the  open- 
ing of  the  chest  cavity  for  surgical  purposes,  the  one 
using  positive,  and  the  other  negative  pressure. 
Connected  with  each  form  of  apparatus,  however, 
were  many  deficiencies  and  difficulties.  Willy  .\le\  er 
bined  the  two  methods  into  one  apparatus,  over- 
most  of  the  difficulties,  added  original  improve- 
it  5,  and  perfected  a  system  of  differential  pressure 
thai  completely  fulfils  all  of  the  requirements  for 
thoracic  surgery.  The  Meyer  differential  pressure 
apparatus  consists  of  a  positive  chamber  within  a 
negative  chamber,  and  the  necessary  means  for  ven- 
tilating and  controlling  the  pressure  in  both  cham- 
bers. The  positive  chamber  is  of  sufficient  size  so 
that  the  anesthetist  may  have  plenty  of  room  for 
himself  and  supplies.  The  patient's  head  is  placed 
jusl  within  the  positive  chamber,  and  the  body  lies 
on  the  table  in  the  outer  or  negative  chamber.  A 
sheet  of  rubber  is  drawn  snugly  around  the  patient's 
neck  to  make  the  inner  or  positive  chamber  air-tight 
when  the  door  leading  into  the  same  is  closed.  The 
negative  chamber  is  sufficiently  large  for  the 
table,  the  surgeon,  his  assistants,  and  necessary 
paraphernalia. 

With  this  apparatus  any  desired  negative  or  posi- 
tive pressure  may  be  secured  or  any  desired  combina- 
tion of  negative  and  positive  pressure,  or  a  change 
from  either  pressure  to  the  other,  and  artificial 
respiration  may  be  had  at  any  time. 

The  different  anesthetics  are  administered  in  the 
usual  manner  when  using  the  Meyer  differential  pres- 
sure apparatus. 

Nitrous  oxide  and  oxygen  may  be  administered 
under  sufficient  positive  pressure  for  thoracic  surgery 
without  any  special  apparatus.  The  supply  of  gases 
must  be  continuous,  the  mask  very  accurately  fitted 
to  the  face,  and  the  exhaling  valve  closed  by  a  coiled 
spring  set  at  the  desired  pressure.  The  gas  bags  must 
be  kept  distended  sufficiently  to  open  the  expiratory 
valve  slightly  during  expiration.  Otherwise  the  ad- 
ministration is  the  same  as  at  normal  pressure. 

The  Administration  of  Anesthetics  in  Conjunction 
with  Pure  Oxygen. — The  intimate  physiology  of 
anesthesia  is  closely  associated  with  the  oxidation  of 
the  brain  cells.  In  the  prolonged  administration  of 
nitrous  oxide  the  amount  of  oxygen  required  approxi- 
mates that  required  under  ordinary  circumstances. 
and  the  same  may  be  said  regarding  all  administra- 
tions of  chloroform.  With  ether  and  ethyl  chloride, 
however,  there  are  some  advantages  in  limiting  the 
Oxvgen  supply  in  normal  or  robust  subjects.  In  the 
delicate  and  debilitated  subject,  on  the  other  hand, 
there  is  an  advantage  in  increasing  the  normal  oxygen 
supply. 

The  administration  of  pure  oxygen  in  conjunction 
with  nitrous  oxide  and  ether  in  the  closed  method  has 
already  been  described.  If  the  condition  of  the 
patient  is  such  that  there  is  need  of  increasing  the 


normal  supply  "i  oxygen  in  the  administration  of 
ethyl  chloride  (with  exceptional  cases  in  thi  <' 
in,  .  1 ....  1 1  i  In  ane  I  het  ic  i  ab  olutelj  cont  i  aindicated. 
I  I....'  remains  ft  .1  con  ii  lera  1  ii  in  here,  t  hen.  1  he 
administration  of  chloroform,  anesthol,  and  ether  by 
the  open  method,  and  for  this  purpose  no  special 
apparatus  is  required.     T) xygen    is  allowed   to 

bubble  through  the   water  slowly,  and  the  end  of  the 

efferent  i  u  I  h  •  i-  pi,-..-,, |  beneath  the  patient's  nare  , 
the  tube  extending  through  or  beneath  the  ma  1. 
With  the  Coburn  apparatus  the  end  of  the  tube  is 

extended  into  the  chamber,  and  is  held  in  position  by 

the  gauze.  Will,  the  Pynchon  and  Junker  inhalers 
the  efferent  tube  is  attached  to  the  apparatus  so  thai 
the  oxygen  passes  through  the  liquid  anesthetic, 
\  apprizing  it,  instead  of  air. 

The  advantages  of  administering  oxygen  in  con- 
junction with  ether,  chloroform,  and  anesthol 
are    that,    in   debilitated  subjects,   it    conserves   the 

patient's  vitality  and  t  he  post  narcotic  ell  eels  are  less 
pronounced. 

Rectal  Etherization. — Very  soon  after  the  anesthetic 
properties  of  ether  were  demonstrated  bj  pulmonary 
administration  Etoux,  in  1M7,  suggested  its  admin- 
istration per  rectum.  Pirogoff,  during  the  same 
year,  so  administered  it  upon  the  human  subject,  using 
liquid  ether  mixed  with  water,  the  chief  object  in 
view  being  to  facilitate  the  performance  of  operations 
within  and  about  the  moiilh,  nose,  and  pharynx. 
The  method  was  tried  by  a  few  others,  and  it  was 
soon  learned  that  t he  administration  of  the  vapor 
was  followed  by  better  results  than  that  of  the  liquid 
ether,  either  pure  or  diluted  with  water.  Little 
attention,  however,  was  given  to  this  method  of 
administration  for  several  decades,  when  Molliere, 
in  1884,  after  quite  an  extensive  trial,  reported  favor- 
ably concerning  it.  Weir,  the  same  year,  reported 
t he  death  of  an  eight  months  child  from  rectal 
etherization,  the  operation  being  for  harelip.  Death 
occurred  from  melena  within  twenty-four  hours 
after  the  operation.  Bull,  the  same  year,  reported 
seventeen  cases  of  rectal  etherization,  but  the  results 
were  unsatisfactory,  for  not  only  did  melena  and 
diarrhea  supervene  in  some  of  the  cases,  but  others 
had  prolonged  and  profound  stupor,  and  asphyxia! 
symptoms.  Buxton  has  used  this  method  and  finds 
it  to  answer  admirably  for  operations  about  the 
mouth,  nose,  postbuccal  cavities,  and  larynx,  and  for 
operations  for  the  relief  of  empyema.  Cunningham 
in  1S9S  reported  forty-one  cases,  there  being  no 
deaths,  diarrhea,  or  bloody  stools.  Leggett,  in  1907, 
had  a  series  of  thirty-one  cases,  with  anesthesia 
incomplete  in  three  cases,  and  with  bloody  stools  in 
one  case,  but  no  deaths. 

In  this  form  of  administration  it  is  absolutely 
essential  that  the  bowels  be  empty,  for  the  feces  will 
not  only  prevent  the  absorption  of  the  anesthetic  but 
will  also  plug  the  rectal  tube. 

The  Pynchon  apparatus  previously  described 
(Fig.  221),  is  admirably  suited  for  this  method  of 
administration.  The  Coburn  apparatus  with  the 
insufflation  attachments  (Fig.  223),  may  likewise  be 
used  if  a  pressure  dropping  cup  is  substituted  for  the 
regular  cup.  An  efficient  apparatus  is  easily  im- 
provised by  using  an  ordinary  graduated  flask,  having 
a  rubber  cork  with  two  holes.  Into  one  of  the  holes 
insert  a  rod  nearly  to  the  bottom  of  the  flask,  and 
into  the  other  hole  insert  a  short  rod  that  extends 
just  through  the  cork.  Connect  the  long  rod  to  a 
Politzer  bag  and  the  short  rod  to  a  small  rubber  tube 
one  meter  long.  Fill  the  flask  one-third  full  of  ether. 
A  double  current  rectal  tube  is  used,  the  ether  vapor 
entering  through  one  tube  and  the  excess  vapor 
and  gases  escaping  through  the  other  tube,  the  end 
of  which  tubing  is  immersed  in  alcohol  to  the  depth 
of  three  or  four  centimeters.  When  wanning  de- 
vices are  used  they  should  be  placed  as  close  to  the 
I  patient  as  possible  so  that  the  vapor  may  not  be  cooled 

383 


Anesthesia,  General  Surgical 


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before  it  reaches  the  rectum,  as    warm   vapor    cools 
very  rapidly. 

After  inserting  the  tube  high  into  the  rectum  and 
connecting  it  to  the  efferent  tube  of  the  apparatus,  the 
vapor  is  slowly  pumped  into  the  rectum,  the  excess 
vapor  returning  through  the  escape  tube,  as  de- 
scribed. It  requires  longer  to  anesthetize  with  this 
method  than  with  the  pulmonary  methods,  but  the 
signs  of  anesthesia  are  the  same,  and  similar  care  must 
be  exercised  at  all  times  to  see  that  the  respiratory 
movement  is  free  ami  unobstructed. 

Advantages  and  Disadvantages  of  Rectal  Etheriza- 
tion.— Prior  to  the  perfection  of  the  insufflation 
methods,  and  of  nitrous  oxide-oxygen  anesthe  ia, 
rectal  etherization  had  some  practical  advantages, 
inasmuch  as  it  prevents,  to  a  very  great  extent,  the 
irritant  action  of  pulmonary  methods  of  administra- 
tion of  ether  upon  the  respiratory  tract,  displaces  the 
face  mask,  and  removes  the  anesthetist  away  from 
the  patient's  head.  However,  all  the  advantages 
of  rectal  etherization  can  be  better  secured  by  the 
methods  and  anesthetic  just  mentioned  without  the 
slow  induction,  uncertain  anesthesia,  rectal  irritation 
and  diarrhea  that  so  often  follow  the  rectal  method, 
Besides,  its  death  rate  has  been  the  highest  of  any 
method  described  in  this  resume. 

Intravenous  Etherization. — The  direct  introduction 
of  anesthetics  into  the  vascular  system  has  attracted 
considerable  attention  during  the  past  few  years,  and 
during  the  past  year  considerable  use,  both  practical 
and  experimental,  has  been  made  of  this  method  of 
administering  ether.  Five  per  cent,  of  ether  in 
normal  saline  solution  is  usually  employed.  At  first 
the  administration  was  conducted  with  an  intermit- 
tent introduction  of  the  dilute  ether  into  the  vein,  but 
the  interruption  of  the  stream  had  a  tendency  to 
cause  the  formation  of  thromboses  in  and  about  the 
cannula.  A  continuous,  but  slower  rate  of  adminis- 
tration, however,  overcame  this  objection  and  at  the 
same  time  the  resulting  anesthesia  was  more  satis- 
factory inasmuch  as  it  was  smooth  and  even. 

The  apparatus  used  successfully  by  Rood  is  simple, 
practical,  and  satisfactory.  The  ether,  diluted  with 
ninety-five  per  cent,  saline  solution,  is  held  in  a.  reser- 
voir placed  about  eight  feet  above  the  floor.  Rubber 
tubing  with  a  pipette  attached  leads  from  the  bottom 
of  the  reservoir  to  a  chamber,  the  pipette  being  within 
the  latter.  From  the  bottom  of  the  chamber  rubber 
tubing  leads  to  a  warming  bottle  and  thence  to  the 
cannula  into  the  vein.  There  is  a  shut-off  below 
tin1  chamber  to  control  the  rate  of  administration  and 
there  should  be  one  above  the  chamber  to  control  the 
rate  of  flow  into  it.  As  the  ether  solution  drops  from 
the  pipette  the  rate  of  flow  can  be  plainly  seen,  and 
regulated  according  to  the  special  requirements. 

It  is  preferable  to  give  the  preliminary  hypodermic 
of  morphine  and  atropine,  or  morphine  and  hyoscine 
The  arm  is  lightly  bandaged  to  a  splint  to  prevent 
flexion  at  the  elbow.  Eucaine  is  then  injected  locally, 
and  the  vein  exposed  by  a  one-third  inch  incision. 
The  cannula  is  properly  tied  in  the  vein,  and  the 
wound  packed  with  sterile  gauze,  strict  asepsis 
being  observed  through  the  procedure.  The  ether 
solution  is  allowed  to  flow  rapidly  until  the  patient  is 
anesthetized,  which  requires  about  ten  minutes  of 
time  and  eight  ounces  of  the  solution.  After  anes- 
thesia is  established  the  rate  of  administration  is  much 
slower,  about  sixteen  ounces  of  the  solution  per  hour 
being  ordinarily  sufficient. 

Rood  reports  one  case  of  three  and  one-half  hours 
administration,  in  which  four  and  one-half  ounces  of 
ether  and  four  and  one-half  pints  of  saline  solution 
were  used,  and  several  cases  of  over  two  hours  dura  l  ion. 

The  advantages  claimed  are:  (1)  The  anesthesia  is 
delicately  controlled;  (2)  early  return  of  conscious- 
ness; (3)  postanesthetic  vomiting  and  pulmonary 
irritation  are  rare;  (4)  saline  infusion  per  se  is  of 
benefit  sometimes. 


Chloroform. — In  the  administration  of  chloroform 
it  is  quite  essential  that  the  air  supply  be  unrestricted, 
consequently  it  is  always  administered  by  the  open 
system,  but  by  a  variety  of  methods.  The  open 
drop  method  is  the  most  popular  method  in  this 
country.  Any  open  mask  such  as  Esmarch's  or 
Schimmelbusch's  covered  with  a  single  layer  of  flan- 
nel, or  a  few  layers  of  gauze,  is  well  adapted  for  the 
open  administration.  On  account  of  the  local  irritant 
properties  of  chloroform  the  skin  beneath  the  mask 
should  be  protected  with  vaseline,  cold  cream,  or 
some  such  preparation. 

The  chief  source  of  immediate  danger  in  the  ad- 
ministration of  this  anesthetic  is  "overdosage." 
It  is  ordinarily  stated  that  the  percentage  of  the 
chloroform  vapor  is  too  high,  but  the  percentage  of 
the  vapor  that  the  patient  may  safely  inspire  de- 
pends upon  the  rate  and  depth  of  respiration,  and  is 
therefore  variable.  With  the  ordinary  rhythm  and 
volume  of  respiratory  movement  it  is  generally  con- 
sidered that  a  two  per  cent,  vapor  is  the  maximum 
amount  that  the  patient  may  safely  inspire,  but 
there  are  circumstances,  such  as  deep  and  rapid 
respiration  after  an  apnea  from  muscular  spasm, 
holding  the  breath,  and  other  respiratory  impedi- 
ments, when  this  percentage  might  be  excessive. 
Accordingly,  in  the  induction  of  this  form  of  anesthesia 
especially  the  anesthetist,  must  gauge  the  strength 
of  the  vapor  according  to  the  patient's  respiration, 
particularly  when  he  is  not  dealing  with  known 
percentages. 


Fig.  226. — Esmarch's  Mask  and  Dropper. 

When  chloroform  is  exposed  to  light  it  decomposes 
and  is  rendered  unfit  for  use.  Therefore,  it  should 
be  purchased  in  small,  strongly  colored,  and  well 
stoppered  bottles.  Chloroform  vapor  when  exposed 
to  an  open  flame  is  decomposed  into  irritating  gases, 
which  apparently  affect  the  other  occupants  of  the 
room  more  than  they  do  the  patient.  If  it  is  neces- 
sary to  have  an  open  light  in  the  room  it  should  be 
placed  as  high  as  possible,  as  the  anesthetic  vapor  is 
heavier  than  air,  and  therefore  tends  to  settle  down- 
ward. The  fumes  of  ammonia  are  said  to  combine 
with  the  chlorine  and  other  irritating  gases  liberated 
in  this  decomposition  of  chloroform,  and  render  them 
innocuous. 

In  order  to  reduce  the  size  of  the  drop  a  special 
dropper  such  as  the  Esmarch's  or  Filling's  should  be 
used,  as  the  rate  of  administration  is  much  easier 
controlled  if  the  drop  is  small.  The  Coburn  appara- 
tus also  has  such  a  special  dropper  for  the  open 
administration  of  chloroform.  The  dropping  of 
the  anesthetic  should  be  very  slow  at  first  and 
gradually  increased.     Coughing,  holding  the  breath, 


:;m 


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or  muscular  spasm  indicates  that  the  vapor  is  too 
strong,  and  whenever  such  symptoms  occur  the  rate 
of  administration  must  be  decreased,  or  withheld 
altogether  temporarily,  until  normal  respiration  is 
resumed.  Excitement,  struggling,  crying,  etc.,  in 
this  method  of  induction  arc  especially  dangerous, 
and  if  such  conditions  cannot  be  prevented,  the  anes- 
thetist must  be  very  careful  that  the  patient  does  not 
suddenly  make  a  deep  respiration  of  a  strong  vapor, 
for  just  a  single  inspiration  of  this  character  may  lie 
followed  by  fatal  results.  Under  no  circumstances, 
should  the  induction  be  unduly  hastened,  as  some- 


FlG.  227. — Junker's  Inhaler. 

times  it  requires  seven  or  eight  minutes  to  anesthetize 
completely  with  chloroform.  Junker's  Inhaler  (Fig. 
227)  or  one  of  its  various  modifications  is  very  useful 
in  administering  chloroform,  especially  in  operations 
within  or  about  the  mouth,  nose,  or  pharynx.  In 
inducing  the  anesthesia  a  face  mask  is  employed,  and 
the  vapor  is  slowly  pumped  through  the  tubing  by 
compressing  the  bulb  during  inspiration.  After  full 
anesthesia  is  secured,  if  the  operation  is  of  such  a 
character  that  the  face  mask  would  interfere  with 
the  work  of  the  surgeon  the  end  of  the  efferent  tube 
should  be  connected  with  a  curved  metal  tube  or  to 
a  gag  with  anesthetic  tubes  or  to  a  nasal  catheter 
(Fig.  222),  and  the  vapor  thus  forced  into  the  respira- 
tory passages. 

In  using  a  Junker  inhaler  care  must  be  exercised 
not  to  compress  the  bulb  too  rapidly  or  too  vigor- 
ously, for  liquid  chloroform  may  be  easily 
forced  into  the  patient's  respiratory  pas- 
sages. Several  deaths  from  this  accident 
have  been  reported. 

The  Trendelenburg  apparatus  (Fig.  228) 
is  sometimes  used  for  the  administration  of 
chloroform  when  a  tracheotomy  has  previ- 
ously been  performed.  The  anesthetic  is 
added  by  the  drop  method. 

The  Harcourt  inhaler  (Fig.  229)  is  quite 
extensively  used  in  England,  and  very  ac- 
curately regulates  the  percentage  of  chloro- 
form vapor,  it  being  practically  impossible 
to  exceed  the  maximum  limit  of  two  per 
cent.  Inasmuch  as  with  this  inhaler  air 
is  always  well  mixed  with  the  vapor,  and 
any  strength  of  vapor  up  to  two  per  cent. 
can  be  obtained,  it  affords  a  very  safe 
means  for  the  administration  of  chloroform  when  a 
face  mask  may  be  continuously  applied. 

Chloroform  mixtures,  such  as  A.  C.  E.  and  C.  E., 
and  chloroform  preparations,  such  as  anesthol,  should 
always  be  administered  by  the  open  system,  as  the 
chloroform  content  makes  it  unsafe  to  limit  in  any 
way  the  oxygen  supply,  and,  at  the  same  time,  renders 
it  imperative  that  the  strength  of  vapor  be  as  constant 
as  possible,  so  as  not  to  exceed  the  limit  of  safety. 
When  air  is  passed  through  any  of  these  mixtures  or 
preparations  to  vaporize  them  the  unequal  rates  of 
volatility  of  the  several  ingredients  cause  the  vapor  to 

Vol.  I.— 25 


vary  in  composition.  All  of  these  anesthetics  are 
administered  in  somewhat  larger  quantities  than 
chloroform,  but   is  lesser  quantities  than  ether. 

The  advantages  oi  the  chloroform  mixtures  and 
preparations  are  that  they  are  less  irritating  to  the 
respiratory  tract  than  ether,  and  less  depressing  than 
chloroform. 

The  s ial  advantages  claimed  forane  thol  (li   per 

cent,  ethyl  chloride,  35.89  per  cent,  chloroform,  and 
47.11  per  cent,  ether)  are:  Ashorl  induction  without 
excitement  or  struggling;  no  increase  in  saliva  or 
mucus;  early  recoverj  of  consciousness;  and  no 
irritation  of  limns  or  kidneys.  [ts  specific 
gravity  is   1045,  being  close  to   that    of    the 

blood;' and  its  boiling-point  is  104°  F.,  be- 
ing close  to  the  temperature  of  the  blood. 

Alkaloidal  Anesthesia. — For  many 
centuries  past  (see  the  introductory  para- 
graph) more  or  less  complete  analgesia  and 

anesthesia  were  secured  by  the  administra- 
tion of  various  preparations  of  different 
plains  and  herbs.  However,  throughalack 
of  knowledge,  either  in  preparation  or  ad- 
ministration, this  primitive  and  primal 
form  of  anesthesia  was  then  never  widely 
utilized  for  surgical  purposes,  and  for  many 
years  was  completely  superceded  by  the 
inhalation  anesthesia  already  outlined. 

The  advent  of  the  modern  laboratory 
means  of  investigation,  combined  with 
more  careful  clinical  observation  clearly  showing 
the  detrimental  and  far-reaching  remote  effects 
of  the  inhalation  anesthetics  usually  employed, 
has  led  to  a  partial  reversion,  at  least,  to  the  original 
method  of  attempted  anesthesia,  refined,  of  course, 
by  modern  means  of  preparation  and  methods  of  ad- 
ministration. To-day  it  is  the  physiologically  tested 
alkaloid  rather  than  uncertain  and  inert  substances; 
it  is  the  hypodermic  solution,  not  the  decoction. 

The  alkaloids  most  commonly  used  for  this  pur- 
pose are  morphine,  atropine,  hyoscine,  and  scopolam- 
ine. As  hyoscine  and  scopolamine  are  so  nearly,  if 
not  entirely  identical  in  both  composition  and  physio- 
logical action,  many  authorities  consider  them  identi- 
cal, and  that  view  is  here  followed. 

The  effect  of  hyoscine  alone  is  quite  uncertain,  but 
when    combined 'with   such   an   active   syngerist    as 


Fig.  228. — Trendelenburg's  Trachea  Tampon  and  Inhaler. 


morphine  the  anesthetic  action  is  positive,   though 
not  reliable  unless  excessive  amounts  are  given. 

For  complete  anesthesia  one-fourth  grain  of  mor- 
phine and  one  one-hundredth  grain  of  hyoscine  are 
given  hypodermically,  three  hours  before  the  time  set 
for  the  operation  and  repeated  at  the  end  of  two  hours 
in  the  original  or  decreased  dosage,  according  to  the 
patient's  condition.  Fifteen  minutes  before  the  opera- 
tion another  injection  is  given,  if  the  patient  is  not 
already  anesthetized.  While  quite  a  number  of 
successful  reports  have  been  made  by  a  number  of 
writers  of  such  use  of  these  anesthetics,  there  have 

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REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


likewise  been  quite  a  number  of  failures  and  fatalities 
reported.  Accordingly,  this  method  for  the  induction 
of  complete  surgical  anesthesia  is  quite  generally 
condemned.  But  while  the  dose  of  alkaloids  alone 
for  the  production  of  complete  surgical  anesthesia 
is  so  large  and  is  attended  with  so  much  danger 
that  their  use  for  this  purpose  has  been  practically 
abandoned,  the  toxicity  is  so  low  in  medium  dosage 
that  they  are  quite  generally  employed  for  analgesia, 
and  as  a  preliminary  to  the  inhalation  anesthetics. 
For  these  purposes  a  single,  medium-sized  dose 
is    given    hypodermically.     In    obstetrical    practice, 

in  which  the  com- 
bination of  mor- 
phine and  hyoscine 
has  been  so  widely 
lauded  by  enthu- 
siasts, both  the 
child  and  mother 
need  to  be  closely 
watched  for  several 
hours,  and  the  dose 
of  hyoscine  usually 
recommended  i  s 
too  large  to  be  safe. 
In  general  it  may 
be  said  that  the 
maximum  dose  for 
the  robust  adult 
male  is  one-fourth 
grain  morphine, 
and  one  one-hun- 
dredth grain  hyos- 
cine, and  for  the 
female  about  two- 
third  s  of  this 
amount,  and  lesser 
amounts,  of  course, 
where  the  individ- 
ual is  under-sized, 
or  where  the  phys- 
ical condition  is 
impaired,  or  the 
patient  is  above 
fifty  years  of  age; 
and  this  medica- 
tion should  not  be  repeated  for  at  least  several  hours. 
The  value  of  morphine  alone,  or  combined  with  some 
other  alkaloid,  as  a  preliminary  to  other  anesthetics,  has 
been  discussed  elsewhere  in  this  article.  It  may  be 
further  said  that  this  practice  is  approved  by  the 
leading  anesthetists  throughout  the  civilized  world. 
There  is,  therefore,  a  decided  and  growing  tendency  to 
combine  the  alkaloidal  and  inhalation  anesthetics  in 
the  most  approved  production  of  modern  anesthesia. 
Electric  Anesthesia. — Electric  anesthesia  is  in- 
duced by  a  direct  current  interrupted  a  great  number 
of  times  per  minute,  and  connected  to  the  body  by 
electrodes.  It  is  important  that  the  potential  of  the 
current  be  limited  to  a  little  more  than  that  required 
for  the  anesthesia,  for  otherwise  it  is  very  easy  to 
electrocute  instead  of  only  to  anesthetize  the  subject. 
The  number  of  interruptions  for  anesthesia  should  be 
6,000  to  7,000  per  minute,  and  the  period  of  the 
passage  of  the  current  one-tenth  of  the  entire  time. 
Storage  batteries  afford  the  best  form  of  direct  current. 
Apparatus. — The  special  paraphernalia  needed  are 
storage  batteries  and  connections,  a  rheostat,  two 
meters,  one  for  voltage,  and  the  other  for  amperage, 
a  make-and-break  switch,  electrodes,  and  a  Leduc  or 
Robinovitch  interrupter. 

Technique. — The  negative  pole  is  connected  to  the 
head  electrode  and  the  positive  pole  is  connected  to 
the  electrode  applied  at  the  lower  end  of  the  spine. 
It  is  quite  important  that  the  cathode  should  always 
be  applied  to  the  head,  for  if  the  anode  is  applied 
there  instead,  respiration  is  impeded,  and  death  is 
much   more   likely   to   follow,   even   with   the   same 


Fig.  229. — Harcourt's  Chloroform 
Inhaler. 


potential.  Before  applying  the  electrodes,  in  animal 
experimentation,  the  fur,  at  the  point  of  application 
is  first  cut  away  and  the  skin  shaved,  care  being  exer- 
cised not  to  cut  the  skin.  The  shaved  spots  are 
washed  with  alcohol,  and  then  covered  with  a  thin 
layer  of  cotton  wet  with  saline  solution.  The  elec- 
trodes are  then  applied  to  the  wet  cotton,  and  the 
circuit  is  closed  on  a  low  potential.  As  the  voltage  is 
increased,  there  is  slight  struggling  of  the  animal,  but 
loss  of  consciousness  soon  follows.  If  the  potential 
is  increased  too  much,  respiration  becomes  labored 
and  convulsions  follow,  and  this  state  can  be  relieved 
only  by  reducing  the  voltage.  The  respiration  is 
therefore  the  best  single  guide  in  the  proper  main- 
tenance of  electric  anesthesia,  just  as  it  is  with  the 
inhalation  anesthetics. 

Utility. — Thus  far  electric  anesthesia  for  surgical 
purposes  has  been  used  chiefly  for  experimental  work 
on  animals,  and  when  skilfully  handled  it  is  a  very 
safe  form  of  anesthesia.  The  postanesthetic  effects 
are  practically  nil.  Recovery  takes  place  as  soon  as 
the  current  is  opened.  Johnson  reports  one  case  in 
the  human  subject,  successfully  anesthetized  for 
forty-five  minutes  for  the  amputation  of  several  toes. 

Raymond  C.  Coburx. 

Anesthesia,  Local. — General  anesthesia  and  spinal 
anesthesia  (or  analgesia)  are  studied  elsewhere  in 
this  work  under  these  respective  headings.  Before 
discussing  local  anesthesia  it  may  be  as  well,  in  view 
of  the  increasing  tendency  toward  accurate  terminol- 
ogy, to  say  that  quite  frequently,  now,  analgesia  is 
employed  rather  than  anesthesia,  as  indicating, 
properly,  a  condition  of  absence  of  pain;  whereas 
anesthesia  really  means  only  absence  of  common 
sensation.  After  the  employment  of  both  spinal  and 
local  means  against  painful  operating  it  is  not  unusual 
for  a  measure  of  common  sensation  to  be  retained  in 
the  region  in  question,  whereas  pain  may  be  wholly 
absent  (analgesia). 

The  subject  of  local  as  distinguished  from  general 
anesthesia  is  one  of  increasing  importance,  year  by 
year.  Far  more  operations  are  done  by  such  help  (in- 
cluding spinal  analgesia)  at  present  than  was  the 
case  even  a  few  years  ago.  The  main  reason  for  this 
change  is  the  fear  so  general  among  all  mankind  of 
being  forced  into  unconsciousness;  and  this  is  as 
prevalent  among  physicians  as  laymen.  Argument, 
proving  the  almost  invariable  safety  of  ether,  chloro- 
form, etc.,  in  skilled  hands,  does  not  change  the  fact 
that  people  often  dread  the  oblivion  more  than  the 
knife.  In  the  earlier  years  of  the  local  use  of  cocaine 
and  a  few  other  drugs  in  surgery  there  were  enough 
mistakes  made  and  unsatisfactory  results  from  one  or 
another  cause  to  justify  the  limitation  of  "minor 
anesthesia"  to  minor  work;  but  latterly,  with  our 
present  knowledge  of  ways  and  means,  there  are  few 
fields  of  operative  endeavor  that  have  not  been 
successfully  invaded  by  the  surgeon,  his  patient 
feeling  no  pain,  although  entirely  conscious,  and  often 
chatting  interestedly  meantime.  It  follows  from  this, 
that  many  a  patient  needing  a  radical  cure  of  hernia, 
or  interval  appendicitis  operation — to  mention  one 
or  two  among  large  numbers — will  to-day  readily 
submit  to  being  operated  upon,  who  would  formerly 
have  hesitated  and  postponed,  chiefly  because  of  the 
major  anesthesia  dread,  until  operation  became  com- 
pulsory, and  very  possibly  until  too  late  for  safe  surgery. 

Of  course  there  are  exceptions,  both  in  kind  of 
operation  under  discussion  and  in  nature  of  patient 
in  question.  It  would  take  us  too  far  afield  to  go 
into  these.  There  will  always  remain  an  abundant 
field  for  major  anesthesia;  but  nevertheless  the  rapid 
development  of  local  analgesia  instead  of  that  demand- 
ing unconsciousness  is  a  noticeable  sign  of  the  times. 

To  discuss  our  topic  in  an  orderly  way  let  us  study 
it  as  follows:  Local  anesthesia  produced  by  aid  of 
cold,  of  light,  of  sinusoidal  electric  energy,  by  analgesic 


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REFERENCE    IIAXIHtook    (  >F    Till'    MEDICAL    SCIENCES 


Anesthesia,  Local 


tr 


chemicals  applied  to  skin  or  raucous  membrane,  or  con- 
veyed in  deeper  parts  by  aid  of  the  hypodermic  needle, 
i  ric  catapnoresis  and  by  intravenous  injection 
(,nii.— In  increasing  degree  of  intensity  we 

ibility  by  application  of  ice-water  or  ice, 
iray    of    benzine   or   rhigolene   or  gasoline,    by 
of  ethyl  chloride,  by  application  of  carbonic- 
snow,  or  by  liquid  air. 
Ihe   last    named   is  destructiv< — is  too   inter  elj 
cold  for  practical  purposes.     Even  C02  ice  turns  the 
^ k i r i  a  corpse-white  instantly,  ami  contact  with  it  for 
longer  than  a  few  seconds  will  not  only  freeze  but  will 
destiny   vitality  -and   it   is  an   ideal   agent    for   this 
purpose    in    attacking    superficial    growths.     Ethyl 
chloride  as  to  degree  of  cold,  may  be  said  to  represent 
a  mean  between  extremes,  ami  is  our  choice  for  local 
esia  by  chilling.     Applied  as  a  spray  ii    pro- 
duces the  corpse-white,  which   means  insensibility,  in 
econds,  but  if  cutting  deeply — as  to  the  bone  in 
felon — is  needed,  the  freezing  must  be  continued  some 
longer.     If,   however,    several     minutes,   of 
solidly   frozen  flesh  result   from  its  prolonged  use,  the 
tatient    may   complain   of   the   aching,   just    as  from 
rost-hite  or  chilblains  subsequently.     Where  benzine 
or  rhigolene  spray,  or   ice-application    must  be   de- 
pended upon  for  freezing  it  is  best  to  begin,  wherever 
Eossible,  by  cording  firmly;  for  example,  with  felon, 
y  snapping  an  elastic  band  several  times  about   the 
finger  at  its  palmar  juncture.     Thus  the  chilled  blood 
is  not   -wept  away  and  replaced  by  heated  for  some 
time'  before  freezing  occurs,  and  considerable  suffer- 
ing is  spared    the  patient    by  the  saving  in  time  of 
exposure  to  the  cold. 

Thi  method  of  local  anesthesia  under  discussion 
(i.e.  freezing  by  any  means)  should  be  employed,  in 
operating,  for  only  one  purpose,  namely,  to  make  one 
or  several  cuts  for  the  relief  of  pus  or  of  inflammatory 
tension.  It  is  not  a  desirable  choice  where  there 
needs  to  be  careful  dissection — the  flesh  being  frozen 
solid  as  deeply  as  the  knife  is  to  penetrate,  if  pain  is 
to  be  entirely  obviated. 


Analgesic  Drugs. — Water. — Under  this  second 
heading  water  should  first  be  mentioned,  because  for 
rations  it  has  been  recognized  as  having  analgesic 
qualities.  In  Bartholow's  Materia  Medica  (Third 
Edition,  1S79),  under  the  heading  of  Aquapuncture, 
for  example,  it  is  affirmed  that  some  physicians  in 
giving  a  hypodermic  injection  of  a  watery  solution  of 
morphine  attribute  the  subsequent  relief  from  pain 
more  to  the  water  than  to  the  morphine!  While  by 
no  means  going  so  far  as  this,  the  writer,  in  common 
with  many  practitioners  can  claim  often  to  have 
observed  in  severe  sciatica,  for  instance,  much  relief 
from  pure  water  injected  by  needle  either  into  or  in 
contact  with  the  sciatic  nerve. 

Balsted,  nearly  thirty  years  ago,  suggested  and 
employed  water  for  this  purpose,  injecting  it,  for  ex- 
ample, all  about  and  beneath  superficial  tumors, 
which  could  be  then  removed  painlessly.  In  the  arti- 
cle on  Subcutaneous  Emphysema  in  the  first  edition 
of  this  Handbook  the  present  writer  detailed  his  ex- 
periments upon  his  own  person  in  an  endeavor  to 
rtain  whether  mere  pressure  alone  upon  the 
"ry  nerve-endings  would  suffice  to  benumb,  or 
whether  water  has  an  analgesic  property  inherent  in 
itself;  and  reached  the  latter  conclusion. 

The  addition  of  even  a  very  small  proportion  of 
any  one  of  quite  a  number  of  other  drugs  greatly 
helps  to  render  more  effective  this  power  of  water. 

Before  studying  these  seriatim,  let  me  say  that 
it  is  well  for  the  general  practitioner,  occasionally 
called  upon  to  do  some  major  operation  in  emergency, 
to  remember  that  without  rendering  the  patient 
unconscious,  and  by  the  use  of  simple  means  readily 
at  hand,  a  very  fair  degree  of  success  in  blunting  pain 
may  be  attained.  The  writer  well  recollects  assisting 
Dr.  John  A.  Wyeth  twenty-five  years  ago,  in  ampu- 


tating  a   en;  ii,, I    arm   at     the   shoulder-joint.     The 
pat  ient .  a  middle-age<  l.m  inesl  hesia. 

Instead  he  drank  nearly  a  tumblerful  oi  .and 

received  by  needle  nearly  a  half  grain  of  morphine. 
lie   was  maudlin  and  cheerful  throughout;   hi 
showed   no   suffering— and    he   had    no   -hock    sub- 

equently,  making  a  good  recovery.  Ucohol  u  ed 
in   this  way  v,  a  eery 

of  major  ane  the  ia. 

I.oc.-d  applications  of  the  volatile  oih  are  among 
the  best  known  and  oldest  mean-  of  benumbii 
suffering  nerve.  Each  and  everj  volatile  oil  possi 
analgesic  qualities,  but  some  surpass  other-  in  this 
,1.  Oil  of  cloves,  for  example,  applied  within 
the  cavity  of  an  aching  tooth,  upon  a  bit  oi  cotton, 
usually  gives  prompt  relief,  'linger  for  intestinal 
colic — dependent  for  effect  upon  it-  oil  is  as  well- 
known  an  instance.  Menthol  in  say  ten  per  cent. 
solution    in    alcohol    gives    much     relief    in    tteur 

uffering,  alike  from  the  analgesic  power  of  its 
volatile  oil  and  because  of  vigorous  eounterirrita- 
tion.  Of  course  sundry  other  instances  of  this  gen- 
eral principle  could  be  adduced. 

Chief  in  importance  among  drugs  for  local  anesthesia 
is  cocaine,  usually  in  the  form  of  the  hydrochlorate. 
It  may  now  be  obtained  in  both  the  natural  and 
synthetic  forms.  It  is  soluble  in  0.4  parts  water  at 
77°  F.  Except  in  very  strong  watery  solution  it  has 
no  antiseptic  power,  and  in  any  strength  ordinarily 
used  it  quickly  develops  fungus,  rendering  it  irritant 
and  unfit  for  use.  Therefore,  it  is  best  to  make  a 
fresh  solution  each  time  it  is  to  be  employed,  al- 
though a  saturated  solution  of  boric  acid  in  water 
will  keep  it  quite  well  for  an  indefinite  period.  Boil- 
ing decomposes  it  into  ecgonine  and  other  alkaloids 
all  of  which  have  some  little  anesthetic  power,  1  nit 
much  less  than  the  undecomposed  cocaine.  A  simple 
and  reliable  plan  of  making  readily  one's  solutions  of 
it  afresh  is  as  follows:  Boil  in  a  test-tube  say  100 
minims  of  water;  remove  from  the  flame,  and  the 
instant  ebullition  ceases  the  temperature  will  be 
fractionally  lower  than  the  boiling-point.  Instantly 
drop  in  a  hypodermic  tablet  of  gr.  J,  if  a  half  per 
cent,  solution  be  required,  and  so  on.  These  tabids 
are  made  by  all  responsible  dealers  in  a  most  careful 
and  cleanly  way,  to  avoid  a  bad  reputation  for 
hypodermic  abscesses  from  their  goods,  and  the  heat 
is  still  enough  within  the  boiled  water,  if  used  instantly 
as  stated,  to  render  safely  sterile  such  tablets  in  this 
solution. 

Cocaine  is  unquestionably  the  most  anesthetic  of 
known  remedies  for  use  in  this  manner,  but  it  is 
likewise  the  most  dangerous;  first  from  acute  poisoning 
from  an  overdose,  and  second  because  of  the  great 
risk  of  inducing  a  habit  hard  to  be  overcome  and 
ruinous  to  the  health,  if  its  adminisaration  is  repeated 
more  than  a  few  times.  The  smallest  fatal  dose,  with 
sound  organs,  seems  to  be  about  one  grain,  in  the  adult, 
though  much  more  than  this  has  often  been  absorbed 
without  trouble,  particularly  when  injected  in  highly 
diluted  solution.  One  of  the  most  striking  character- 
istics of  cocaine  activity,  and  in  which  it  differs  from 
almost  all  the  other  anesthetic  remedies  intended  for 
hypodermic  usage,  is  its  power  to  cause  vigorous  con- 
traction of  blood-vessels.  For  instance,  given  an 
acute  coryza,  the  patient  being  wholly  unable  to 
breathe  through  the  nostrils  because  of  mechanical 
obstruction  of  the  nasal  air-passages  from  great 
congestion  of  the  mucous  membrane  and  turbinate 
bodies;  if  the  interior  of  a  nose  so  affected  be  sprayed 
with  a  cocaine  solution,  within  a  few  minutes  a  mu- 
cous pallor  will  have  replaced  the  angr}-  redness,  and 
the  breathing  through  the  nose  will  have  become 
quite  free.  And  yet  this  would  be  a  very  objec- 
tionable mode  of  treatment,  for  within  a  half  hour 
or  so  the  congestion  would  return — indeed,  worse 
than  ever,  because  of  the  violence  done  the  nerve- 
mechanism  of  the  vessels.     Also    perhaps   the  chief 


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way  in  which  the  cocaine  habit  has  been  started 
is  by  the  employment  of  weak  cocaine  snuffs  and  solu- 
tions intranasally  in  futile  attempts,  commonly  by 
advertising  quacks,  to  cure  catarrhal  conditions. 

There  are  a  few  instances,  however,  in  which  this 
contractile  power  of  cocaine  may  be  used  wisely  and 
with  advantage  to  the  patient.  Especially  is  this 
true  of  complete  urinary  retention  due  to  a  temporary 
congested  or  inflammatory  stricture  superadded  to 
a  more  or  less  tight-calibered  true  or  organic  one. 
Here  filiform  bougies  as  well  as  the  smallest  soft 
catheters  having  failed  to  gain  entrance  to  the  bladder, 
the  intraurethral  injection  of  a  one-  or  two-per-cent. 
cocaine  solution,  held  for  some  minutes  pressed 
backward  against  the  obstructed  region,  quite  regu- 
larly results  in  permitting,  for  a  few  minutes,  as  free 
emptying  of  the  bladder  as  before  the  congestive 
trouble  was  acquired;  and  a  small  catheter  or  fil- 
iforms  can  be  passed,  painlessly  too,  to  be  temporarily 
retained  after  the  congestion  returns. 

Injection  of  adrenalin  in  solution  would  do  the 
same  thing,  but  without  the  anesthetic  effect  also 
resultant  from  the  cocaine. 

We  have  dwelt  upon  this  power  of  cocaine  over 
blood-vessel  caliber  chiefly  to  emphasize  its  responsi- 
bility for  most  of  the  dangerous  symptoms  consequent 
upon  cocaine  poisoning  from  overdosage.  Contrac- 
tion of  the  blood-vessels  everywhere  in  the  brain 
doubtless  results,  but  the  danger  is  chiefly  because  of 
this  effect  upon  those  vessels  at  the  base  of  the  brain, 
and  hence  supplying  blood  to  the  respiratory  center. 
Death  occurs,  if  at  all,  from  failure  of  respiration — 
save  in  cases  where  the  heart  is  not  normal.  The 
patient  becomes  pale,  breaks  out  into  a  cold  per- 
spiration, often  is  nauseated,  complains  of  dizziness, 
is  seen  to  breathe  with  some  difficulty  and  irregularity, 
and  has  a  rapid — sometimes  a  slow — and  feeble 
pulse.  Convulsions  sometimes  precede  coma.  The 
treatment  consists  in  the  use  of  stimulants,  vasodi- 
lators, and  a  good  sized  hypodermic  injection  of 
morphine.  Why  the  latter  should  be  so  valuable — 
as  it  unquestionably  is — the  writer  does  not  know; 
for  morphine  is  not  a  vasodilator.  Trinitrin  by 
needle  and  amyl  nitrite  by  inhalation  are  of  value 
as  such  dilators,  also  atropine  as  a  direct  respiratory 
stimulant.  Artificial  respiration  is  of  course  indicated 
when  breathing  fails;  but  both  in  prevention  and 
in  treatment  one  may  safely  rely  largely  upon  the 
free  use  of  alcohol,  remembering  alike  its  stimulant 
effect  and  its  striking  power  in  full  doses  to  dilate 
blood-vessels,  especially  of  the  brain  and  face.  The 
writer  never  fails  to  give  a  drink  of  whiskey — unless 
there  is  some  moral  scruple — prior  to  using  cocaine 
in  surgery,  and  attributes  to  this  measure  of  pre- 
vention, as  well  as  caution  in  dosage,  his  never  having 
personally  had  to  deal  with  really  serious  symptoms 
from  this  drug. 

While  upon  this  phase  of  the  subject  it  is  well  to 
call  attention  to  the  seeming  contradiction  between 
the  weak  dosage  at  present  almost  always  used  in 
cocaine  hypodermic  injection,  and  the  concentration 
in  which  it  is  employed  by  nasal  specialists  prepara- 
tory to  cutting  or  sawing  work  within  the  nose. 
Twenty-per-cent.  strength  is  an  every-day  matter, 
and  some  such  operators  prefer  to  apply — as  being 
safer — cocaine  hydrochloride  in  powder  form,  undi- 
luted, to  the  mucous  membrane  about  to  be  operated 
upon.  The  explanation  is  found  in  this  extreme 
contractile  power  of  the  drug  over  vessels;  and  the 
greater  the  concentration  the  more  striking  and 
almost  instantaneous  is  this  effect,  the  blood-vessels 
being  reduced  to  the  merest  threads,  and  the  mucous 
parts  to  the  most  extreme  pallor.  In  consequence 
this  poison  cannot  be  absorbed  and  carried  into  the 
general  circulation. 

In  ordinary  local  analgesic  usage — in  preparation  for 
operation  elsewhere  than  within  the  nose — the  writer 
seldom  employs  a  strength  greater  than  one-half  per 


cent,  in  the  skin,  and  one-fourth  per  cent,  in  the  deeper 
tissues.  Indeed  it  is  often  used  far  more  dilute  even 
t  han  this.  One  part  in  a  thousand  of  water  or  of  nor- 
mal saline  solution  is  not  rare  when  we  wish  to  diffuse 
the  anesthetic  effect  over  a  large  area,  and  one  to  five 
or  even  ten  thousand  is  a  proportion  employed  by  some 
surgeons.  The  only  objection  to  such  a  large  bulk  of 
injected  fluid  is  the  distortion  of  normal  relationships, 
anatomically  speaking,  and  at  times  this  is  not  a  triv- 
ial objection. 

Schleich,  who  was  first  to  point  out  the  value  of 
cocaine  in  such  high  dilution,  has,  for  hypodermic 
injection,  prepared  after  considerable  experimenta- 
tion the  following  solutions,  known  respectively  as 
the  strong,  the  normal  (for  average  use)  and  the  weak: 


Sol.  I. 


Cocalni  hydrochlorici 0.2 

Morphinse  hydrochlorici 0.025 

Natr.  chloral,  sterilisat 0.2 

Aquas  destill.  sterilisat ]ad  100.0 

Addeacid.  carbol.  (5  per  cent.)    gtt.    2 


Sol.  II. 


0.1 
0.025 
0.2 
100.0 
Ktt.    2 


Sol.  III. 


0.01 
0.005 
0.2 
100.0 
gtt.   2 


It  must  be  noted  that  to  accomplish  a  painless 
cutting  of  the  skin  the  drug,  in  whatever  degree  of 
solution,    must    be     in- 


u 


%&p 


^%< 


pv. 


jected  into,  not  beneath, 
the  skin.  Beginners  in 
surgery  commonly  do 
not  do  this  in  such 
way  as  to  give  a  max 
mum  of  prompt  anesthe- 
sia with  a  minimum  of 
prior  annoyance. 

It  is  now  well  recog- 
nized that  Schleich  was 
in  error  in  adding  mor- 
phine to  his  solutions  for 
local  anesthesia.  So  far 
from  being  an  advantage, 
the  morphine  has  no  local 
anesthetic  properties 
whatever.  Indeed,  it  is 
to  a  very  slight  degree 
an  irritant,  and  has  a 
tendency  to  cause  a 
troublesome  after-edema 
of  the  tissues.  It  is  well, 
however,  to  dilute  the 
cocaine  solution  for  in- 
fill ration  work  with  a 
little  chloride  of  sodium. 
About  three-quarters  of 
one  per  cent,  of  it  makes 
a  satisfactorily  isotonic 
solution;  and,  particu- 
larly in  dealing  with  in- 
flamed or  highly  sensi- 
tive tissues,  this  is  dis- 
tinctly more  soothing 
than  dissolving  the  co- 
caine or  other  analgesic 
agent  in  plain  sterile 
water. 

As  in  inexperienced 
hands  the  method  by 
edematization  (infiltra- 
tion) is  apt  to  give  un- 
satisfactory results,  be- 
cause not  thoroughly 
done,  it  may  be  well 
to  give  Schleich's  own 
vivid  description:  "The 
infiltrated  area  must  project  high  over  the  normal 
level  of  the  surrounding  tissues,  taking  the  form  of 


&s0 


Fia.  230. — Showing  Injection 
Along  a  Line  of  Incision  in  Skin. 
X,  X1,  X2,  etc.,  first,  second,  third, 
etc.,  points  of  injection.  After  the 
first  puncture,  A,  the  needle  is 
always  inserted  in  the  edge  of  the 
area  last  anesthetized.  (From 
Schleich.) 


388 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Anesthesia,  Local 


si.  edematous,  broad-based  sessile  tumor.  On  in- 
cision the  tissues  should  have  a  glassy  or  jelly-like 
appearance,  the  tissue  fibrils  being  spread  out,  and 
ii„.  mi  surface  weeping  like  that  of  a  cucumber  or  an 
over-ripe  melon.  An  infiltrated  penis,  lip,  <>r  ear 
lobule  musl  appear  as  it  affected  with  elephantiasis, 
and  pendulous  tumors  such  as  hemorrhoids,  fibromas, 
sarcomas,  become  often  ten  times  their  former  size. 
The  >kia  over  such  tissues  becomes  like  silky  papi  r 
and  almost  transparent  like  glass.  The  tough, 
elastic  cutis  vera  naturally  opposes  considerable 
tance  to  this  distention,  but  even  with  it  a 
ienl  edema  is  much  more  intense  than  that 
i  in  any  pathological  conditions."  In  a  word, 
the  tissues  musl  be  distended  to  their  utmost  to 
produce  sal  isfactory  anesthesia  by  this,  the  in  lilt  rat  ion 
method. 

The  writer  prefers,  for  infiltration,  toanyoi  i  he  t hive 
Schleich  formula'  those  of  Struthers,. which  follow,  and 
particularly  No.  •"■. 

No.   1. 

Cocaine  hydrochloride 1  grain. 

Solution  of  adrenalin  chloride  '  1  in  loom    .  . .  12  drops. 

Solution  of  sodium  chloride  (0.75  percent.)..  2  ounces. 

No.  2. 

Eucaine  lactate 1  grain. 

Solution  of  adrenalin  chloride    I  in  1000)....     5  drops. 
Solution  of  sodium  chloride  (0.75  percent.)..    10  drams. 

No.  3. 

Cocaine  hydrochloride 1  grain. 

Eucaine  lactate 1  grain. 

Solution  of  adrenalin  chloride  (1  in  10001 ....  12  drops. 

Si  lution  of  sodium  chloride  10.75  per  cent.)..  3  ounces. 

The  syringe  and  needles,  as  also  the  glass  measure 
for  preparing  solutions,  must  be  sterilized  in  plain 
water  or  saline  solution,  but  not  in  soda  solution,  for 
soda  breaks  up  the  cocaine  or  eucaine  and  destroys 
their  analgesic  properties. 

The  needle — always  small  in  caliber  and  very  sharp — 
is  passed  into  the  skin  at  a  first  point  proximal  to  the 
region  inflamed,  or  to  any  region  requiring  cutting. 
The  injection  of  some  drops  into  the  skin,  ju.st 
beneath  the  cuticle,  almost  instantly  produces  a 
roundish  very  pallid  area  called  a  "wheal."  Into 
this  wheal  the  needle  may  now  be  advanced  without 
sensation  of  discomfort  resulting,  and  at  its  farther 
border  a  further  wheal  is  produced  in  the  same  way. 
Thus  continue  until  a  pallid  and  insensitive  area  is 
produced  as  far  as  the  knife  is  to  reach.     Beneath 


to  benumb  the  more  effectually  the  operative  area  sup- 
plied by  the  nerve  in  question  n  is  always  to  b  o 
injected  at  a  point  well  proximal  to  the  field  of  its 
operative  nerve  supply),  and    b)  b    a  means  of  trying 

to  prevent  shock,  received  through  the  sensory,  hence 

afferent,  fibers  of  the   nen nerves  in  question, 

about  to  be  divided  at  operation.  If  at  some  proximal 
level    nerve  blocking  can  l>e  accomplished,  then  the 

blow  of  a  major  operation    cannot   for    the  time   being 

be  conveyed  to  the  vasotonic  or  shock  center  in  the 
brain.  The  trouble  is  that  within  an  hour  Ol  0  pp  ' 
operationem   the  effects   of  cocaine    nerve   blocking 

pass  ofi  as  the  drug  is  taken  up  in  the  genera]  cir- 
culation and  the  shock  is  only  postponed  for  this 
brief    period.      An   agent  capable  of   maintaining  such 

nerve  blocking  for  a  day  or  longer  is  s -tiling  still 

to  be  searched  for.  Quinine  and  urea-hydrochlorate 
nen  e  blocking — to  be  discussed  later  on — gives  promise 
of  this. 


Fig.   231. — Showing  Injection  Below  Abscess  Near  Surface  of  the  Skin. 
X,  X,  points  of  injection.      (From  Schleich.) 

this  area  infiltration  may  be  used  as  desired.  Let  it 
be  noted,  however,  that  whenever  in  process  of  cut- 
ting any  blood-vessel  or  sensory  nerve  is  exposed, 
such  will  probably  require  a  special  additional 
injection  to  prevent  pain  before  section.  Blood- 
vessels are  unquestionably  more  sensitive  to  pain 
than  most  other  structures  except  sensory  nerves. 
"Nerve  blocking"  is  a  name  used  to  cover  the  em- 
ployment of  a  special  technique  for  either  of  two  pur- 
poses. It  implies  the  injection  directly  into  a  nerve 
containing  sensory  fibers  of  a  rather  stronger  cocaine 
solution  than  that  used  for  any  infiltration,  thereby  (a) 


Fig.  232. — Showing  Injection  Around  a  Tumor  (in  this  case  a 
ganglion)  with  Curved  Needle.  G,  (ianglion;  N.  skin;  T,  tendon 
and  sheath;  a,  6,  c,  etc.,  first,  second,  third,  etc.,  points  of  in- 
jection.    (From  Schleich.) 

It  is  worthy  of  careful  note  that  cocaine  anesthesia 
is  invariably  distal  from  the  point  of  nerve  blocking. 
For  example,  if  into  the  ulnar  nerve  behind  the  inner 
condyle  at  the  elbow  cocaine  is  injected  in  effective 
strength — a  few  drops  will  suffice — within  a  few  min- 
utes we  can  amputate  the  little  finger  painlessly. 
But  if  we  expose  this  nerve  at  any  level  even  in  the 
least  proximal  from  the  point  so 
blocked,  it  will  be  found  just  as 
sensitive  as  ever. 

This    explains     the    otherwise 

rather    surprising    ineffectiveness 

of    cocaine    solutions,    even    the 

strongest,       conveyed     into     the 

cavity    of    a   tooth,    to    attempt 

thereby  obtunding  pain  when  the 

dentist   resumes   his    excavating. 

Only    the    surfaces   of    the    tiny 

nerve   fibrils    within    the   dentine 

actually  exposed  are  in  the  least. 

affected.     The  first  few  strokes  of 

his  sharp  bone  cutting  implement 

remove     this    surface,    and   as   the   anesthesia    from 

cocaine  never  travels  backward  toward  the  brain,  but 

only  distally,  the  pain  is  presently  as  bad  as  before. 

The  writer  many  years  ago  before  the  New  York 
Institute  of  Stomatology  described,  as  a  result  of  his 
experiments,  methods  whereby,  during  extracting  or 
excavating,  cocaine  can  be  introduced  so  as  effectually 
to  block  the  pain-bearing  power  of  the  dental  nerves, 
both  upper  and  lower. 

For  the  four  upper  incisors,  take  a  thin  pad  of 
absorbent  cotton,  saturated  with  a  cocaine  solution 
varying  from  two  per  cent,  to  a  little  stronger,  and 


E,  Abscess; 


3S9 


Anesthesia,  Local 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


pack    this   with    the   little   finger   end,    or   a   narrow 
spatula,    upon   the   floor   of   the   nose,    at  the  front. 

Within  ten  minutes  as  a  rule  the  insensibility  is 
readily  observable  in  these  four  teeth. 

It  is  well  known  that  from  the  second  bicuspid  to 
the  last  molar  the  roots  of  the  teeth  are  close  in  con- 
tact with  the  floor  of  the  antrum  of  Highmore.  Now 
by  injecting  a  cocaine  solution  into  this  antrum 
through  its  natural  opening  in  the  outer  wall  of  the 
nose — middle  meatus — in  a  few  minutes  benumbing 
follows. 

Where  the  opening  is  not  readily  found,  with  a 
stout,  short  hypodermic  needle  a  passage  can,  by  a 
single  light  tap,  be  forced  through  the  extremely 
thin  bone  constituting  the  front  wall  of  the  sinus — just 
above  the  roots  of  the  first  molar  teeth,  by  choice — 
and  thus  injection  into  the  antrum  accomplished. 

As  to  the  teeth  in  the  lower  jaw,  all  those  behind 
the  mental  foramen  can  be  reached  by  obtunding  the 
inferior  dental  nerve  by  aid  of  a  very  long  hypoder- 
mic needle  passed  through  the  cheek  at  right  angles, 
through  the  sigmoid  notch  of  the  mandible  just 
below  the  zygomatic  arch.  Of  course  more  space 
for  the  ready  accomplishment  of  this  step  will  be 
gained  if  meanwhile  the  lower  jaw  be  held  apart  from 
its  fellow. 

As  to  the  front  teeth,  injection  directly  into  the 
mental  foramen,  to  be  found  directly  beneath  the 
second  bicuspid  tooth,  will  satisfactorily  prepare 
them  for  work. 

It  is  nowadays  quite  customary  for  dentists  to 
extract  painlessly,  and  in  dealing  with  certain  very 
sensitive  patients,  to  excavate  without  causing 
suffering,  by  use  of  cocaine  solutions — or  of  eucaine  /J 
or  of  novocain — combined,  for  the  longer  effect,  with 
a  little  adrenalin,  and  injecting  this  directly  into  or 
in  contact  with  the  nerves  about  to  enter  the  roots 
of  the  teeth,  by  aid  of  very  slender  hypodermic 
needles  of  platinum,  and  permitting  of  bending  to  any 
desired  curve  without  breaking. 

It  is  worth  mentioning  that  cocaine  is  undesirable 
for  use  as  a  means  of  relieving  inflammation  by 
its  application,  however  dilute.  Dr.  Carl  Koller,  who 
is  the  discoverer  of  the  anesthetic  power  of  this  drug, 
has  pointed  out  that  in  ophthalmia  for  instance,  the 
prolonged  use  of  such  solution  as  a  soothing  agent  for 
the  local  pain  may  result  in  superficial  ulcers  of 
the  cornea. 

To  Dr.  J.  Leonard  Corning  we  owe  the  first  demon- 
stration of  the  means  whereby  in  operating  upon  any 
extremity,  now,  we  are  enabled  to  hold  the  cocaine 
solution  in  place  until  we  can  at  our  leisure  complete 
the  operation,  instead  of,  as  formerly,  having  to 
inject  again  and  again,  the  circulation  sweeping 
away  our  anesthetic  agent  and  the  anesthesia  there- 
with. This  is  the  simple  device  of  cording  proxi- 
mally  to  the  operative  field. 

In  freezing,  be  it  remembered  that  if  we  cord  at  all 
we  do  it  first,  and  then  freeze.  The  reverse  should 
be  the  case  when  employing  any  drug  by  hypodermic 
means  preparatory  to  cutting;  for  here  we  inject  first 
and  immediately  afterward  cord.  During  the  fraction 
of  a  minute  intervening  between  the  injection  and  the 
cording  the  circulation  will  convey  our  chemical 
to  tissues  round  about  the  points  of  injection;  whereas 
had  we  first  corded,  then  injected,  the  solution  would 
lie  in  the  track  of  the  needle  or  thereabouts  and 
anesthesia  would  be  less  satisfactorily  accomplished. 

The  addition  of  a  certain  amount  of  adrenalin  to 
the  cocaine  solution,  or  indeed  to  any  of  the  other 
drugs  used  likewise  in  operation,  materially  helps 
us  in  regions  where  cording  is  impossible,  |,%-  producing 
a  strong  degree  of  local  anemia  not  obtainable  by  the 
weaker  proportions  of  cocaine  and  not  obtainable 
at  all  otherwise  by  almost  all  of  the  other  local 
anesthetics.  Indeed,  hi  one  sense  the  adrenalin  may 
be  said,  in  operations  upon  head,  neck,  and  trunk, 
to  take  the  place  of  cording  elsewhere,  in   that  it 


effectually  holds  the  analgesic  agent  in  place  where  it 
is  needed. 

It  may  here  be  noted  that  the  addition  of  a'ntipy- 
rine  to  a  cocaine  solution  prolongs  very  noticeably  its 
anesthetic  effects.  The  strength  of  the  antipyrine 
may  be  as  high  as  four  per  cent.,  but  in  this  proportion 
it  smarts  somewhat.  If  only  one  to  two  per  cent,  be 
employed  this  objection  is  not  observable  when 
it  is  combined  with  cocaine. 

Cocaine  is  freely  absorbed  from  a  mucous  surface 
but  not  from  the  skin.  This  explains  why  it  is  useless, 
in  whatever  concentration  of  solution,  when  intro- 
duced within  the  external  auditory  meatus  for  the 
relief  of  earache,  or  prior  to  cutting  the  ear  drum 
which  is  covered  with  skin,  not  with  mucous  membrane. 

Tropacocaine  Hydrochloride. — This  is  obtainable 
both  from  the  small-leaved  coca  plant  of  Java,  and 
by  synthesis.  It  is  quite  expensive,  compared  with 
cocaine,  and  is  relatively  much  weaker.  It  has  chiefly 
been  used  in  spinal  analgesia  up  to  the  present  time. 
The  writer  has  thus  employed  it  in  his  service  at  the 
City  Hospital  (New  York  City)  in  over  500  instances 
without  death  or  serious  symptoms  resulting.  He 
has  regularly  used  for  this  purpose  gr.  ij.  dissolved  in 
normal  saline  solution  5j.  and  finds  that  this  can 
usually  be  relied  upon  to  produce  within  ten  minutes 
or  less  a  perfectly  satisfactory  analgesia  lasting  upon 
the  average  one  hour.  And  this  is  devoid  also  of  the 
nausea  and  vomiting  so  frequently  attendant  upon 
the  early  stages  of  spinal  analgesia  produced  by  the 
use  of  cocaine  solutions.  The  only  drawback  is  the 
occasional  severe  headache  following  and  sometimes 
lasting  a  day  or  even  longer;  but  this  objection  seems  to 
attend  the  employment  of  other  spinal  analgesics, 
an  ideal  one  of  which  has  not  yet  in  this  single  respect 
been  found.  Very  large  doses  of  phenacetin,  repeated, 
are  perhaps  as  good  a  way  as  any  of  treating  such 
headaches. 

Tropacocaine  is  freely  soluble  in  water,  keeps  well 
in  solution,  and  is  not  decomposed  by  boiling. 

Novocain  is  soluble  in  one  part  of  water.  May  be 
boiled  without  decomposition,  and  its  solution  keeps 
well.  It  is  a  local  anesthetic  of  much  value,  and  far 
less  toxic  than  is  cocaine.  Its  effect  is  greatly  enhanced 
by  the  addition  of  adrenalin  to  the  solution;  and 
numerous  firms  now  prepare  tablets  combining  these 
agents  in  various  proportions.  Novocain  itself  1  as 
no  contractile  power  over  blood-vessels.  This  drug, 
in  the  combination  mentioned,  is  being  much  more 
used  of  late,  and  the  reports  are  uniformly  favorable. 
It  is  employed  in  from  one-half  or  two-per-cent. 
strength  usually,  but  has  been  used  even  in  twenty  per 
cent.  It  has  been  absorbed  up  to  gr.  vij.  or  viij.  with- 
out trouble,  so  feeble  is  its  toxicity.  Tablets  contain- 
ing gr.  J  novocain  and  gr.  ■*%■$  synthetic  supra- 
renin  are  obtainable  on  I  he  market  andareineverj  way 
satisfactory.  One  such  tablet  in  oj.  of  sterile  water 
makes  a  solution  of  slightly  more  than  0.5-per-cent. 
strength,  and  is  amply  sufficient  for  ordinary  opera- 
tions upon  skin  and  muscular  tissues.  Less  than  this 
strength  suffices  for  work  upon  mucous  membrane  and 
the  tissues  just  beneath  it. 

Eucaine  beta,  and  lactate  of  eucaine,  which  latter  is 
more  freely  soluble  in  water,  is  a  most  excellent  drug 
for  producing  anesthetic  solutions  for  local  use.  It 
is  practically  devoid  of  poisonous  properties.  Thirty 
grains  have  been  injected  and  absorbed  without  pro- 
ducing toxic  symptoms  (Kiessel).  It  is  somewhat 
less  anesthetic  in  power  than  is  cocaine,  weight  for 
weight,  but  this  objection  is  easily  overcome  by 
using  it  in  stronger  solutions  than  the  latter.  It  is 
slower  in  developing  its  analgesic  effect  than  is  cocaine. 
Two  per  cent,  is  perhaps  an  average  strength,  and  it 
stands  boiling  well,  and  keeps  well.  The  addition  of 
adrenalin  to  its  solution  is  of  distinct  advantage  in 
maintaining  and  prolonging  the  analgesic  effect. 
By  itself  eucaine  has  no  power  to  contract  blood- 
vessels, even  perhaps  somewhat  dilating  them,  rather. 


390 


REFERENi  E   HAXDHOOK   OF   TIIF.    MEDICAL    S<  II  Si  ES 


LnesthesUt!  Local 


Pennington  recommends  the  following 
R 


Boil. 


Beta-eucaine  lactate sr.  iij. 

Sodium  chloride.  .  gi 

Bolu    "i  Buprarenal  chloride,  full  strength,  tljx. 

ed  water o,.  s.  ad  ?,. 

Tor  hypodennio  use. 


In  as  great  strength  as  five  per  cent,  the  writer 
cannot    commend  eucaine   beta   for  local  anesl 
because  in  this  percentage  injected  beneath  the  fore- 
skin in  a  case  of  circumcision  it  caused  sloughing  of 
the  skin. 

and  Quinine  Hydrochloride. —  In  this  com- 
ition  we  have  a  very  old  and  reliable  means  of 
treating  ugly  types  of  malarial  infection  successfully, 
in  doses  of  gr.  xv  and  more  of  the  quinine  by  hypo- 
dermic. To  the  writer's  knowledge,  here  in  New 
York.  Dr.  \Y.  II.  Thomson  (who  is  believed  to  have 
originated  the  thought)  and  other  eminent  physicians 
more  than  thirty  years  ago  used  this  plan.  And  they 
recognized  and  spoke  of  the  striking  degree  of  local 
anesthesia  which  resulted.  It  will  ever  be  a  source  of 
wonderment  to  the  writer  that  nobody  "put  two  and 
two  together"  and  thought  of  making  use  of  this 
benumbing  as  a  means  of  avoiding  the  agony  of  tin- 
knife.  It  was  long  years  afterward  before  cocaine 
anesthesia  was  proclaimed  to  the  world,  and  in  the 
interval,  as  before  then,  we  used  to  put  our  pan 
of  necessity,  as  far  under  major  anesthetic  uncon- 
sciousness to  remove  a  sliver  or  cinder  from  the  cornea 
as  to  amputate  a  thigh. 

Only  within  the  past  very  few  years  has  analgesia 
from  this  source  been  recognized  as  of  practical 
surgical  value.  Tablets  of  various  strengths  arc 
now  upon  the  market.  These  are  freely  soluble  in 
water,  and  stand  boiling  well;  but,  as  with  cocaine. 
a  fungus  or  mould  forns  if  allowed  to  remain  long  in 
solution  after  exposure  to  the  air. 

An  ordinary  tablet  is  one  containing  urea  and 
quinine  hydrochloride  gr.  ss.  This  is  dissolved  in 
5i.  of  water,  and  though  often  used  stronger,  for  it  is 
not  poisonous  in  any  dosage,  it  is  somewhat  irritant  in 
increasing  strengths  of  solution.  Indeed,  because  of 
such  irritant  property  it  is  not  advised  usually 
for  local  anesthesia  where  one  hopes  and  expects  to 
obtain  healing  by  primary  union. 

The  surprising  thing  about  the  employment  of 
this  anesthetic,  wherein  chiefly  it  differs  from  any  and 
all  others  for  local  employment  by  hypodermic  is  the 
la<t  ing  quality  of  the  analgesia  produced.  It  is  nothing 
unusual  for  entire  absence  of  pain,  even  when  the 
part  so  treated  is  pricked  or  cut,  to  continue  from 
twenty-four  up  to  one  hundred  hours — sometimes 
even  for  considerably  longer. 

Dr.  Douglas  H.  Stewart  has  suggested  a  combina- 
tion which  in  his  hands  has  proven  so  highly  satis- 
factory as  to  make  it  seem  certain  that  it  is  coming 
into  general  use.     This  is  a  single  tablet  containing: 

B.     Urea  and  quinine  hydrochloride. 

N  ivocain aa  gr.  ss. 

Synthetic  adrenalin gr,  zbv 

Enough  for  5i  of  water.     Boil  before  using. 

In  these  proportions  the  irritant  quality  of  the  urea 
combination  is  not  noticed.  It  may  safely  be  em- 
ployed wherever  and  whenever  novocain  and  adrenalin 
solutions  would  be,  and  with  the  great  advantage 
of  preventing  all  postoperative  pain  or  discomfort; 
for  the  analgesia  usually  lasts  well  beyond  the  more 
acute  period  of  the  healing  process. 

In  injecting  it  do  not  distend  the  tissues  more 
than  is  necessary.  The  irritation  observable  from 
a  Wronger  dosage  of  the  urea  and  quinine  is  due 
largely  to  local  tension  in  excess.  Never  inject  more 
than  rriv.  of  Stewart's  combination  in  any  single 
spot;  but,  without  wholly  withdrawing  the  needle, 
make  a  series  of  such  spots  as  if  around  the  rim  of  a 
wheel,  the  point  of  needle  entrance  through  the  skin 


being  the  hub.  This  may  be  repeated  ad 
A  good  plan  is  to  block  the  main  nerve  trunk  or 
trunks  where  possible,  as  then  very  little  of  the 
■  hetic  «ill  be  required. 
Such  an  injection  followed  by  a  ten-minute  ex- 
posure  to  the  \  inlet  or  royal  purple  light,  which  con- 
siderably deepens  any  form  of  anesthesia  locally, 
will  give  some  seventy-two  hours  <>(  anesthesia;  but 
200  hours  is  not  surprising,  although  not  always 
obtainable. 

By  reference  tn  the  earlier  remarks  ("under  heading 
of  Cocaine)  upon  Nerve  Blocking  against  Shock,  it 
will  be  readily  seen  how  much  more  likely  is  so  la-ting 
an  effect  upon  the  afferent  nerve  fibers  to  prove 
essful  and  life  saving  than  any  anesthetic  the 
effects  of  which  are  gone  within  an  hour  or  a  very 
few  hours  at  longest. 

','  I  lie. — This    drug,    soluble    in    eight 

ami  one-half  pans  water,  is  sometimes  used  alone 
(without  the  combination  with  urea),  and  is  eff( 
in  two  per  cent,  solution.  Dr.  B.  1).  Sheedy  of  New 
York  uses  it  upon  adults  thus,  prior  to  tonsillectomy. 
In  five  per  cent,  strength  we  have  more  bleeding,  dis- 
tinctly, than  without  its  use,  and  also  post-operative 
inflammatory  reaction.  This  seems  evidence  of  its 
tendency  to  irritate,  and  a  greater  strength  of  solu- 
tion than  two  per  cent,  is  not  advocated.  It  is 
prompt  in  producing  its  analgesic  effect,  and  is  of 
course  practically  devoid  of  danger  of  systemic 
poisoning  in  any  desired  dosage. 

Stovaine  H ydrochlorate. — This  is  a  synthetic  prod- 
uct, freely  soluble  in  water.  Is  an  "effective  local 
anesthetic,  but  dilates  the  blood-vessels — the  more 
reason  for  combining  it  in  solution  with  adrenalin. 
It  rather  tends  to  stimulate  the  heart  action,  and  is 
only  from  one-third  to  one-half  as  toxic  as  cocaine. 
The  dosage  varies  from  three-quarters  of  one  per 
cent,  which  is  usual  for  hypodermic  use,  up  to  five  or 
ten  per  cent,  when  employed  upon  mucous  membranes 
chiefly. 

It  has  largely,  perhaps  mainly,  been  advocated  in 
spinal  analgesia,  and  Jonnesco  has  strongly  advocated 
its  employment  thus,  combined  with  a  small  per- 
centage of  strychnine,  which  he  claims  adds  to  its 
benumbing  power. 

Holocaine.  H ydrochlorate.— This  is  soluble  in  fifty 
parts  of  water.  It  has  an  even  quicker  anesthetic 
effect  than  cocaine,  and  its  solutions  in  water  keep  well, 
as  it  is  strongly  bactericidal.  It  is,  however,  more 
toxic  than  cocaine.  A  oue-per-cent.  solution  has  just 
about  the  same  analgesic  power  as  cocaine  (Wharton). 
Because  of  its  more  poisonous  properties  it  is  used 
chiefly  upon  mucous  membranes,  especially  the 
conjunctiva.  It  has  no  effect  upon  the  size  of  the 
pupil. 

Alypin. — This  occurs  in  a  white  crystalline  powder, 
extremely  soluble  in  water — even  hygroscopic.  Its 
solutions  may  be  sterilized  by  boiling  for  not  longer 
than  five  minutes.  Locally  applied  to  the  eye  it 
causes  congestion  of  the  blood-vessels,  but  no  myd- 
riasis nor  disturbance  of  the  accommodation.  It  is 
less  toxic  than  cocaine,  but  about  equal  to  it  in  local 
anesthetic  power.  Is  used  upon  the  mucous  mem- 
branes in  ten-per-cent.  solution.  For  hypodermic 
injection  a  one-  to  four-per-cent.  strength  may  be 
employed.  Not  more  than  gr.  ij.  should  be  absorbed 
at  one  time.  It  has  largely  been  employed  in  spinal 
analgesia,  chiefly  in  Germany. 

Orthoform  (new). — This  occurs  as  a  fine,  white,  taste- 
less and  odorless,  crystalline  powder,  moderately  solu- 
ble in  water.  Is  decomposed  by  boiling  water.  Is  a 
local  anesthetic  of  much  power  and  value  but  acts 
only  upon  mucous  or  broken  or  ulcerated  surfaces. 
It  is  somewhat  antiseptic,  and  is  practically  devoid 
of  poisonous  properties. 

It  is  used  as  an  antiseptic  and  to  relieve  the  pain 
of  burns,  wounds,  ulcers,  excoriations,  etc.  The 
writer  can  strongly  commend   it,   having  for  years 

391 


Anesthesia,  Local 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


applied  it  to  newly  operated  rectal  and  intranasal 
surfaces,  in  ten-  to  twenty-pcr-cent.  strength  rubbed 
on  with  vaseline,  also  as  a  dusting  powder  to  painful 
ulcerations.  Its  analgesic  power  is  longer  main- 
tained, as  compared  with  all  other  local  anesthetics, 
(except  quinine  and  urea  hydrochloride)  for  twenty- 
four  to  forty-eight  hours  after  operation,  for  example. 
The  only  difference  between  the  old  and  new  ortho- 
form  is  that  the  latter  is  more  readily  soluble  in 
water. 

Anesthesia. — This  occurs  as  a  white,  odorless,  taste- 
less, crystalline  powder,  almost  insoluble  in  cold  water. 
By  prolonged  boiling  is  decomposed.  Is  a  local 
anesthetic  similar  in  effect  to  cocaine,  but  without 
its  local  irritant  action  and  its  toxicity.  On  account 
of  its  insolubility  its  anesthetic  effect  is  only  super- 
ficial, but  is  more  prolonged  than  that  of  cocaine. 

Xcrrociilhic. — This  is  the  hydrochloride  of  an  alka- 
loid derived  from  gasu-basu,  an  Indian  plant.  It 
occurs  as  a  yellow  hygroscopic  powder,  readily 
soluble  in  water.  It  is  used  ehieflj'  in  dentistry  as  a 
local  anesthetic,  in  a  0.1-per-cent.  solution;  upon  the 
eye,  in  0.01-per-cent.  strength. 

Brenzcain  (guaiacol  benzyl  ester). — This  occurs  as 
white  crystals,  insoluble  in  water.  Is  said  to  possess 
the  advantages  of  guaiacol  without  its  irritant,  action, 
and  is  used  in  the  same  manner  as  the  other  guaiacol 
preparations.  Its  chief  value  is  in  producing  anesthe- 
sia locally  by  aid  of  cataphoresis. 

Phenol  (carbolic  acid). — A  deliquescent  white 
powder,  its  solutions  becoming  pink  and  subsequently 
dark  red  upon  prolonged  exposure  to  light.  Soluble  in 
water,  when  deliquesced,  to  the  extent  of  five  per  cent. 
Is  studied  under  the  present  heading  only  because  of 
its  quite  striking  benumbing  qualities.  In  watery 
solution  of  from  two  up  to  five  per  cent.,  it  soon 
obtunds  local  sensibility  of  skin  or  mucous  surfaces, 
but  is  too  poisonous  for  safe  usage  beneath  the  skin 
in  this  manner.  Application  of  alcohol,  if  promptly 
employed,  neutralizes  its  poisonous  effects.  Not 
more  than  gr.  j.-ij.  should  be  absorbed  at  one  time. 

Pantopon. — This  is  a  reddish  powder,  a  mixture  of 
all  the  active  principles  found  in  opium,  in  their 
several  relative  proportions.  Is  soluble  freely  in 
water,  and  supplied  to  the  market  in  ampoules  of  a 
clear  watery  solution,  of  an  average  dose  each;  or 
else  a  mixture  may  be  prepared  for  hypodermic 
usage  of  seventy-five  per  cent,  water  and  twenty-five 
per  cent,  glycerin,  as  to  the  menstruum.  Gr.  §  is  an 
ordinary  dose  of  the  powder;  corresponds  (about)  to 
gr.  J  morphine,  in  strength.  It,  however,  affects  tin' 
respiratory  center  much  less  than  does  morphine, 
and  has  not  the  unpleasant  after  effects  of  morphine. 

It  is  desirable — but  not  essential — to  combine  for 
hypodermic  use  with  each  gr.  $  of  pantopon  gr.  j-J^  of 
scopolamine.  The  result  is  very  satisfactory.  Biirgi 
has  pointed  out  that  whenever  two  narcotics  are 
injected  simultaneously,  the  effect  is  more  potent 
than  when  a  dose  of  one  alone,  equal  in  strength  to  t  he 
combination,  is  injected. 

Pantopon  is  not  alone  used  to  relieve  local  pain, 
but  is  a  very  desirable  means  of  preparing  the  pal  ient 
for  major  anesthesia,  injected  an  hour  beforehand. 

Acoin. — This  is  a  white,  very  bitter  powder,  soluble 
in  seventeen  parts  of  water.  Is  very  sensitive  to 
alkalies  and  to  light.  Is  a  local  anesthetic,  employed 
in  one-per-cent.  solution. 

Benzoyl  peroxide  (or  superoxide). — This  occurs  as 
permanent,  non-deliquescent,  white,  odorless  prisms, 
slightly  soluble  in  water.  Is  a  mild  Ipcal  anesthetic, 
but  a  strong  disinfectant.  Is  used  either  pure,  in 
ten-per-cent.  ointment,  or  in  a  saturated  solution  in 
olive  oil. 

Chloretone  (chlorbutanol,  acetone  chloroform)  oc- 
curs as  a  white,  crystalline,  volatile  compound, 
having  a  camphoraceous  odor  and  taste.  It  is  soluble 
in  water.  Is  a  weak  local  anesthetic,  an  antiseptic, 
and  a  hypnotic  similar  to  chloral.     Is  used  as  a  mild 

392 


local  anesthetic,  in  dentistry  chiefly;  also  inwardly  to 
soothe  gastric  irritability.     Dose,  gr.  v.-xx. 

Chloral-menthol  is  produced  by  triturating  equal 
parts  of  chloral  hydrate  and  menthol  in  a  mortar 
and  then  heating  in  a  water-bath  until  liquefied. 
It  occurs  as  a  colorless,  oily  liquid,  with  a  distinct 
mint-like  odor  and  warm  taste.  Is  used  as  a  local 
anesthetic  and  counterirritant,  chiefly  in  treating 
neuralgia. 

Cliloral-camphor. — This  is  a  thick,  almost  colorless 
liquid,  with  a  strong  camphoraceous  odor  and  biting 
taste.  Is  the  result  of  prolonged  trituration  of  cam- 
phor with  chloral  hydrate  in  equal  proportions.  It 
is  botli  locally  analgesic  and  counterirritant,  and  is 
rather  a  favorite  application  to  the  skin  in  cases  of 
obdurate  tic  douloureux.  We  can  strongly  commi  ,,,[ 
the  following  as  an  improvement  upon  chloral-cam- 
phor unmodified. 

H     Camphor 3   ij 

Chloral  hydrate 5   iv 

Olei   betula1 5  iij 

Ext.  fl.  cannabis  ind 5  ij 

Alcohol q.  s.  ad  5   iij 

M.  S.  "Pain  paint." 


Phenol-camphor. — The  curious  property  of  camphor 
wherebyit  prevents  phenol  from  causing  sloughing, 
even  in  equal  parts,  is  worthy  of  notice.  If  to  these 
we  add  glycerin  c.p.,  making  a  mixture  of  equal  parts 
each  of  camphor,  phenol,  and  glycerin,  we  have  a  most 
excellent  dressing  for  an  unclean  wound — acting  as  a 
powerful  antiseptic,  and  also  stopping  the  pain  and 
tenderness  which  is  one  of  the  most  striking  clinical 
features  distinguishing  the  course  of  an  infected 
wound  from  one,  however  large,  which  is  aseptic 
If  used  in  a  wound  of  the  latter  class  the  presence 
alike  of  carbolic  acid  and  of  glycerin  will  cause  the 
wound  to  discharge  serum  freely,  and  thus  necessitate 
drainage  at  first. 

Used  upon  the  skin  the  camphor-phenol-glycerin 
combination  constitutes  a  really  excellent  liniment 
against  the  pain  of  neuritis,  rheumatism,  etc.,  and 
is  one  of  the  best  antipruritics. 

Propepsin. — This  is  a  white,  tasteless  powder,  non- 
crystalline, almost  insoluble  in  water,  slightly  less 
poisonous  than  cocaine.  Because  of  its  relative 
insolubility  in  water,  propaesin  is  used,  like  orthoform, 
upon  mucous  membranes  and  on  raw  surfaces,  chiefly. 

Sodium  Bicarbonate. — Ordinary  baking  soda.  This 
chemical  is  soluble  in  water,  one  part  in  twelve.  It 
is  our  main  reliance  to  soothe  the  suffering  attendant 
upon  burns,  and  fortunately  is  at,  hand  where  burns 
are  oftenest  produced — the  kitchen.  Saturated  in 
cold  water  or  else  applied  supersaturated,  as  a  kind 
of  mud,  it  is  very  comforting  and  moderately  an- 
algesic and  is  to  a  slight  degree  antiseptic.  Most  bi- 
salts  are  acid,  but  this  is  exceptional,  being  slightly 
alkaline  in  reaction. 

As  another  and  striking  instance  of  its  employ- 
ment in  surgery  under  our  present  heading,  we  may 
mention  that  after  operating  upon  a  lacerated  cervix 
uteri,  or  its  amputation,  numerous  operators  adopt 
the  custom  of  packing  the  upper  portion  of  the  vagina 
with  sodium  bicarbonate  in  order  that  there  may 
be  no  after-pain  or  tenderness. 

By  whatever  drug  the  surgeon  decides  to  produce 
local  anesthesia,  the  following  sensible  statement 
(Struthers)  should  be  borne  in  mind.  It  is  well  not 
to  pinch  or  prick  the  skin  over  the  injection-area  and 
ask  the  patient  if  pain  is  felt.  A  certain  amount  of 
tactile  sensibility  is  nearly  always  retained;  and 
patients  are  apt,  when  nervous,  to  misinterpret  their 
sensations  and  in  reply  mislead  the  operator.  If  the 
injections  have  been  properly  made,  the  skin  will  be 
absolutely  analgesic,  though  not  anesthetic.  It  is  a 
good  rule  after  waiting  the  necessary  time,  to  cover 
the  patient's  face  with  a  handkerchief  or  towel  to  pre- 
vent a  view  of  the  operation,  and  to  proceed  with  the 


REFERENCE    HANDBOOK   OF   THE    MEDICAL  SCIENCES 


Anesthesia,  Local 


incision  at  once  without  asking  any  questions,  it  is 
:l  good  working  rule  to  ask  no  questions  as  to  pain 
during  operation,  in  order  to  avoid  any  suggestion 

tli-it  one  is  uncertain  of  the  power  of  the  drug  to  pre- 
vent pain.  Should  real  pain  be  felt,  the  patient  may 
safely  be  trusted  to  intimate  it  by  word  or  gesture, 
without  being  asked. 

Venous  Local  Anesthesia. — This  method,  an  ex- 
cellent and  successful  one,  was  first  advocated  publicly 
by  Bier  of  Berlin,  in  1908.     The  technique  follows, 

modified  by  reversing  the  order  of  pr tdure; 

it  seeming  to  the  writer  self-evident  that  the  exposure 
of  the  vein  should  first  be  done  while  full  of  blood, 
and  hence  easily  found;  and  that  thru  the  double 
constriction  of  the  limb  should  follow  this  step. 

Any  large  superficial  vein  is  to  be  exposed  by  dis- 
ion:  the  internal  saphenous,  not  far  from  the  level 
of  the  knee,  in  cases  where  excision  of  this  joint  is 
templated,  for  instance.  Next  apply  a  stout 
rubber  bandage  as  in  the  Esmarch  method  of  obtain- 
ing anemia,  carrying  this  to  a  point  well  above  the 
region  of  operation.  Undo  it  from  below,  leaving  it, 
shutting  off  all  blood  supply  at  the  highest  (most 
proximal)  level. 

By  a  second  rubber  bandage  we  constrict  the  limb 

tightly  at  a  level  away  from — distal  to — the  region 

operation.     We    now    have    an    entirely    anemic 

interval  of  limb  varying  from  a  few  inches  in  vertical 

ut    to   much    more,    according    to    cutting-room 

led.     In  the  middle  of  this  space  lies  the  exposed 

and  of  course  empty  vein  referred  to. 

This  is  next  cut,"  obliquely,  partly  across — enough 
to  receive  the  nozzle  of  an  ordinary  saline-infusion 
cannula;  and  this  is  tied  in  securely.  The  anesthetic 
in  somtion  (to  be  farther  mentioned  later  on)  is  now 
injected  by  aid  of  a  sterile  syringe. 

Bier  thinks  it  of  small  importance  whether  the 
fluid  lie  injected  proximally  or  distally;  if  anything, 
he  rather  inclines  to  prefer  the  latter;  which  of  course 
means  that  under  steady  and  firm  pressure  all  the 
veins  in  this  region  will  have  their  valves  overcome, 
so  that  within  a  few  minutes  all  the  interval  between 
the  two  bandages  will  have  become  analgesic. 

Bier  prefers  a  half  of  one  per  cent,  of  novocain 
dissolved  in  physiological  salt  solution.  For  exci- 
sion of  a  knee  he  injects  of  this  lin-SO  c.c;  for 
excision  of  an  elbow,  40-50  c.c. — and  so  on. 

The  cutting  being  completed,  before  suturing  he 
desires  to  get  rid  of  some  of  the  chemical  rather  than 
to  have  it  all  absorbed.  For  this  purpose  he  first 
entirely  removes  the  lower — distal — rubber  bandage, 
and  then  loosens  the  proximal  one  enough  to  permit 
general  congestion  of  the  limb  below,  and  some 
bleeding  from  the  arterioles;  removing  the  constric- 
tion entirely  when  he  judges  that  enough  novocain 
has  been  thus  washed  out.  However,  novocain  is 
certainly  among  the  safer  of  the  newer  anesthetics; 
it  is  far  less  poisonous  than  is  cocaine,  for  example. 

Light. — The  local  anesthetic  effect  of  light  is  one  of 
the  most  striking  of  those  produced  by  exposure  of 
the  body  to  the  actinic  end  of  the  spectrum — the 
violet  and  ultra-violet  rays,  chiefly,  being  responsible 
therefor.  This  is  best  accomplished  by  the  use  of  the 
Minin  light  (A.  W.  Minin,  at  present  Surgeon- 
General  of  the  Russian  Army).  This  lamp,  aided 
by  a  parabolic  reflector,  for  concentration,  conveys 
the  violet  rays  phis  those  just  beyond  and  faintly 
but  distinctly  visible  against  a  white  background. 
The  "step-off"  rays,  as  Douglas  H.  Stewart  ap- 
propriately terms  these  last;  and  he  names  the  color 
of  the  Minin  bulb  "royal  purple." 

.Minin  affirms  that  the  therapeutic  value  of  his  lamp 
is  perhaps  even  greater  in  treating  surgical  injuries 
and  conditions  than  in  handling  internal  diseases.  As 
to  the  former,  the  analgesic  power  is  strikingly 
manifested,  permitting  operation,  suturing,  etc.,  to  be 
performed   painlessly  after   some  ten  minutes   or   so 


of  exposure.     The  al ption  of  subcutaneous  and 

interstitial  hemorrhages  and  also  of  inflammatory 
exudates  is  quite  readily  accomplished. 

As  to  the  analgesic  relief  of  non-surgical  afflictic 

the  power  of  tin-  IilIiI  i-  also  remarkable;  for  ex- 
ample, nil  pains  from  pleuri  y,  from  articular  rheuma- 
tism, from  cutaneous  inflammation  and  that  of  the 
deeper  cellular  tissue  di  appear  entirely  after  a 
single  thorough  treatment,  or  reappeai  greatly  di- 
minished after  a  longer  or  shorter   interval  of  time. 

He  says  that  it  is  true  that  neuralgias  make  an  ex- 
ception to  this  claim  of  benefit,  and  that  pains  of  this 
nature  may  even  become  aggravated   following  the 

first  seance;  but  that  after  the  second  sitting  a  dis- 
tinct improvement  can  usually  be  noticed. 

The  writer,  in  neuralgia  due  to  neuritis  and  peri- 
neuritis— obstinate  sciatica  of  this  nature,  for  a 
striking  example — has  upon  tl ther  hand  repeat- 
edly observed  the  most   rapid  and  really  wonderful 

relief  from   tin'   u-e  of  the    Minin   light;  and    it    would 

seem   that    we   should   distinguish,   as   to  its  value, 

between  neuralgia  due  to  inflammatory  action  anil 
neuralgia  not  a  neuritis  but  most  commonly  die  to 
anemia — or  as  Romberg  phrased  it,  "  a  prayer  of 
the  nerves  for  more  red  blood" — and  hence  best  treated 
by  hematinics,  especially  chalybeates. 

Although  the  Minin  royal-purple  bulb  is  preferable, 
yet  it  is  well  worth  knowing  that  by  use  of  the  or- 
dinary sixteen  candle-power  Edison  incandescent 
bulb  of  colorless  glass  we  can  produce  a  fairly  good 
analgesia  locally  in  the  course  of  from  twenty  minutes 
to  a  half-hour's  exposure;  and  that  this  is  indeed  a 
better  degree  of  analgesia  than  is  obtainable  by  use 
of  any  blue-glass  bulb  upon  the  market.  These  latter 
crcen  out  the  violet,  the  ''step-off,"  and  ultra- 
violet rays — the  power  of  which  is  by  no  means 
lost  to  use  with  the  Edison  light,  which  contains  all 
the  ray- of  ordinary  sunlight  except  the  ultra-violet. 
The  glass  of  the  Edison  bulb  screens  these  out, 
unfortunately. 

There  is  one  striking  difference  readily  noticeable 
between  the  activit3r  of  the  royal  purple  lamp  and  the 
Edison,  namely,  that  the  former  contracts  blood- 
vessels  and  thus  depletes  a  granulating  surface  of  its 
blood,  whereas  the  white  light  congests  it. 

The  local  analgesic  effect  of  light,  as  just  discussed, 
is  not  in  any  way  due  to  its  accompanying  heat. 
Indeed,  it  acts  best  when  held  far  enough  away  to 
avoid  discomfort  from  the  increased  temperature. 
Furthermore,  under  analgesia  by  light,  healing  by 
primary  union  is  promoted  and  aided — a  thing  which 
cannot  be  said  of  infiltration  anesthesia  by  any  drug, 
though  some  of  them  do  no  harm. 

Electric  Phoresis. — This  term  is  applied  to  the 
passage  by  a  galvanic  current  of  crystalline  sub- 
stances in  solution  through  the  skin  and  indeed  even 
through  the  entire  thickness  of  a  limb  or  the  body. 
By  this  device  local  anesthesia  may  be  produced, 
although  it  is  of  more  value  as  a  means  of  relieving 
deep-seated  pain  than  as  a  practical  surgical  agent — 
both  because  of  the  expense  and  the  time  involved. 
Non-colloid  (i.e.  crystalline)  chemicals  may  be  divisible 
for  the  purpose  under  discussion  into  those  electro- 
positive and  those  electro-negative.  Cocaine  is 
electro-positive  for  example.  Cocaine  hydrochlride  is 
applied  in  concentrated  solution  (twenty-per-cent. 
strength  in  water,  for  instance)  to  the  positive  pole 
(anode).  The  current  being  turned  on,  and  the 
negative  pole  (cathode)  being  placed  upon  any  in- 
different spot — say  upon  the  opposite  side  of  the 
limb — and  the  acid  will  remain  at  the  positive  pole 
while  the  active  base  goes  to  the  negative  ditto.  This 
is  called  cataphoresis. 

If  upon  the  contrary  we  wish  to  administer  for 
some  different  purpose  an  electro-negative  remedy — ■ 
for  example,  arsenic  in  the  form  of  arsenite  of 
potassium — this,  in  concentrated  solution,  should  be 

393 


Anesthesia,  Local 


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placed  upon  the  negative  pole,  the  other  pole  being  as 
before  placed  at  any  indifferent  point,  and  with  the 
electric  action  the  arsenic  as  arsenous  acid  goes  to  the 
positive  pole,  while  the  potassium — the  base — re- 
mains at  the  negative  pole  (anaphoresis) . 

For  local  anesthesia  by  cataphoresis,  begin  by  re- 
moving the  natural  oil  from  the  skin  by  washing  with 
ether  or  benzene.  Then  apply  upon  an  electrode,  in 
solution,  as  just  described,  cocaine  muriate,  or  aconi- 
tine,  or  helleborin,  or  menthol.  An  alcoholic  solu- 
tion may  be  employed  where  the  drug  to  be  used 
is  more  freely  soluble  in  this  than  in  water.  Chloro- 
form dissolved  in  water  is  sometimes  used  where  both 
a  local  analgesic  and  a  counterirritant  action  are 
desired. 

Electrification. — Sinusoidal  alternating  electric 
currents  of  sufficiently  high  frequency,  and  in  which 
the  positive  and  negative  phases  are  nearly  equal, 
possess  the  power  of  producing  local  anesthesia. 
After  the  frequency  has  reached  5,000  complete 
alternations  per  second  the  muscular  contraction  so 
familiar  with  medical  batteries  and  other  alternating 
currents  decreases,  and  at  25,000  alternations  per 
second  a  current  passing  from  the  elbow  to  the  hand 
completely  deadens  that  portion  of  the  limb,  and 
needles  may  be  passed  through  the  flesh  without 
being  felt.  When  subjected  to  currents  of  such  high 
frequency  the  sensory  nerves  appear  to  lose  the  power 
of  transmitting  sensations. 

The  sinusoidal  current  is  often  anesthetic  when  all 
other  currents  are  not. 

Dourner  and  Oudin  believe  that  the  anesthesia 
described  by  d' Arson val  (a  sinusoidal  current),  and 
recommended  by  him  for  surgical  operations,  is  the 
first  stage  toward  cell-death  which  is  quite  analogous 
to  the  anesthesia  caused  by  freezing. 

Vibratory  Massage. — There  are  numerous  ma- 
chines upon  the  market,  mostly  driven  by  electricity, 
for  this  purpose.  It  is  used  for  a  number  of  other 
indications  to  discusss  which  would  take  us  afield; 
but  it  is  worth  remembering  that  vibratory  massage 
is  often  effectual,  and  quite  promptly  so  in  relief  of 
the  local  pain  and  tenderness  of  nerra'gia,  and  of  sub- 
acute and  chronic  rheumatism.  The  effective  dosage 
must  be  learned  by  individual  experience. 

Robert  H.  M.  Dawbaen. 


Anesthesia,  Spinal. — Spinal  anesthesia,  sometimes 
called  subarachnoid,  medullary,  or  lumbar  anesthesia, 
is  insensibility  to  pain  produced  by  the  injection  of 
an  analgesic  substance  into  the  arachnoid  cavity  of 
the  spinal  cord.  The  process  was  first  demonstrated 
by  Dr.  J.  Leonard  Corning,  of  New  York,  in  1885, 
and  since  that  date,  this  method  of  inducing  anes- 
thesia has  been  carefully  elaborated,  and  has  been 
practised  in  thousands  of  recorded  cases  by  numerous 
observers  both  in  America  and  in  Europe,  where  it  is 
much  more  popular  than  it  is  in  this  country. 

A  large  number  of  drugs,  capable  of  causing  loss  of 
sensation  by  contact  with  the  unsheathed  roots  of  the 
spinal  nerves,  have  been  used  for  this  purpose,  prin- 
cipally, cocaine,  stovaine,  tropacocaine,  novocaine, 
eucaine,  nirvanin,  alypin,  morphine,  antipyrine,  mag- 
nesium sulphate,  etc.  In  the  early  history  of  spinal 
anesthesia,  cocaine  was  almost  exclusively  employed, 
but,  on  account  of  its  admitted  dangers,  its  use  has 
been  practically  abandoned  and  it  has  been  super- 
seded by  other  substances  which  are  closely  allied 
to  it,  both  chemically  and  therapeutically,  but  which 
have  proven  far  less  toxic  and  consequently  less 
dangerous.  Of  these  preparations,  stovaine,  tropa- 
cocaine and  novocain,  especially  the  first  two  and, 
perhaps,  in  the  order  named,  are  used  much  more 
than  any  other  representatives  of  this  class.  Tin' 
usual  dose  of  cocaine  for  a  robust  adult — male  or 
female — is    0.02    to    0.03   (i   to  J  gr.)   dissolved  in 

394 


sterile  water  or  in  the  spinal  fluid  itself.  Smaller 
doses  are  recommended  for  j'oung,  very  old,  or  very 
feeble  persons.  A  two-per-cent.  solution  is  ordi- 
narily employed — a  smaller  quantity  of  a  stronger 
solution  being  generally  preferred  to  an  equivalent 
dose  of  a  weaker  solution. 

Stovaine  is  readily  soluble  in  water  and  the  so- 
lution, if  desired,  may  be  sterilized  by  boiling  with- 
out appreciable  injury,  although  some  doubt  has  been 
expressed  on  this  point.  It  is  a  vasodilator,  is 
slightly  irritating  to  the  tissues  and  has  very  decided 
effect  upon  the  motor  nerves — causing  paresis  more 
or  less  profound.  It  is  this  property  which  pro- 
vokes distrust  in  its  safety  for  high  anesthesia,  on 
account  of  the  danger  of  producing  paralysis  of  the 
respiratory  muscles.  The  usual  dose  for  an  adult, 
either  male  or  female,  is  0.03  to  0.06  or  0.1  (J  to  1 
or  14  gr.)  dissolved  in  1  c.c.  (10  minims)  of  water, 
of  physiological  salt  solution,  or  of  the  spinal  fluid. 
The  dose  for  a  child  under  five  years  of  age  is  about 
0.01  (J  gr.). 


Fig 


-Showing  the  Location  of  the  Spinous  Process  of  the 
Fourth  Luinbar  Vertebra. 


Tropacocaine,  like  stovaine.  is  very  soluble  and 
the  solution  may  be  sterilized  by  boiling,  probably 
without  injurious  effect.  It  is  a  vasodilator,  but 
it  is  not  irritating  to  the  tissues  and  it  does  not 
affect  the  motor  nerves.  The  adult  dose  is  0.03  to 
0.06  or  0.1  (J  to  1  or  li  gr.).  It  may  be  dissolved  in 
water,  in  physiological  salt  solution  or  in  the  spinal 
fluid. 

Novocain  is  also  soluble  in  water,  in  normal  salt 
solution  and  in  the  spinal  fluid.  It,  too,  may  be 
sterilized  by  boiling  the  aqueous  solutions,  probably 
without  material  injury.  The  motor  nerves  are  only 
slightly  affected  bv  it.  The  dose  is  0.05  to  0.1  or 
even  0.15  (}  to  H  or  2\  gr.). 

Magnesium  sulphate  exerts  a  remarkable  influence 
when  injected  into  the  subarachnoid  space.  Lim- 
ited  anesthesia  ensues  in  about  forty-five  minutes 
and  deep,  general  anesthesia,  with  paralysis  of  the 
lees  and  abolition  of  the  tendon  reflexes,  follows  after 
three  or  four  hours.  This  state  may  continue  for 
several  hours  and,  although  analgesia  may  be  com- 
plete, the  tactile  sense  sometimes  remains,  and  the 


REFEREM  I!    IIAXnmioK    OF    THE    MEDICAL    SCIEN( 


Anesthesia,  Spinal 


vital  reflexes  are  not  disturbed.  Under  its  influi 
abdominal  and  pelvic  operations  and  various  opera- 
tions upon  the  lower  extremities  have  been  success- 
fully performed;  ii  is,  moreover,  stated  that  with  a 
Li  ienl  « 1  < >—< - .  operations  upon  any  pari  of  the  body 
may  be  rendered  painless.  The  results  of  the  sub- 
dural injection  of  the  magnesium  salt  have  not  been 
uniform  but,  on  the  contrary,  have  proved  extremely 
variable  and  uncertain,  and  the  aftereffects  have 
occasionally  been  distressing.  .V  twenty-five-per- 
cent, thoroughly  sterile  aqueous  solution  of  a  chem- 
ically pure  salt  is  used.  The  dose  usually  recom- 
ded  is  0.02  to  0.03  (J  to  J  gr.)  for  every  two 
pounds  of  the  patient's  weight. 

Tlie  several  anesthetic  substances  which  arc  com- 
monly employed — stovaine,  troparocaine  and  QOVO- 
— are  all  freely  soluble  in  water,  in  normal  salt 
solution,  and  in  the  spinal  fluid  withdrawn  into  the 
Syringe  at  the  time  of  the  operation.  It  is  claimed 
that  attempts  to  sterilize  these  drugs  are  unneces- 
sary, as  they  themselves  are  antiseptic,  and  the 
exact  effect  upon  the  activity  of  the  drug  caused  by 
boiling  the  solution  is  regarded  by  some  as  an  open 
question,  but  the  water  used  as  a  solvent  and  the  con- 
tainers should  be  absolutely  sterile. 


Flo.  234. — Oblique  Insertion  of  the  Xeedle  for  Spinal  Anesthesia. 

Some  operators  believe  that  the  specific  gravity 
of  the  anesthetic  solution  should  be  greater  than 
that  of  the  spinal  fluid.  This  may  be  effected,  in 
part,  by  using  a  solution  not  too  dilute,  or  by  the 
addition  to  the  solution  of  five  per  cent,  of  glucose 
or  of  dextrine.  The  advantage  claimed  for  the 
heavier  solution  is,  that  it  is  not  so  diffusible  as  a 
lighter  solution,  and  that  it  will  not  ascend  to  the 
upper  portions  of  the  canal  unless  forced  up  under 
the  influence  of  gravity  by  elevating  the  hips  or  by- 
depressing  the  shoulders  of  the  patient.  The  heavier 
solution  tends  to  pool  at  the  most  dependent  part 
of  the  canal  and  in  this  manner  the  height  of  the 
anesthesia  may  be  regulated  by  posture.  The  addi- 
tion of  adrenalin  or  of  atropine  to  the  injection  is  ap- 
proved or  rejected  according  to  the  individual  views  of 
the  operator.  Strychnine  in  the  solution  or  the  hypo- 
dermic use  of  scopolamine  and  morphine,  preced- 
ing the  injection,  is  regarded  as  an  advantage  or 
as  indispensable  by  some  and  is  declined  by  others. 
All  agree,  however,  that  the  anesthetic  solutions 
should  be  freshly  made — preferably,  at  the  time  of 
the  operation. 

In  performing  the  puncture,  the  instruments,  the 
hands  of  the  operator  and  the  skin  over  the  back 
and  the  loins  of  the  patient  should  be  prepared  as 
carefully  as  for  a  major  operation.  Any  of  the  lum- 
bar interspaces  may  be  selected  for  the  puncture, 
but  the  third  or  fourth  is  usually  chosen.  It  has 
been  done  as  high  as  the  sixth  cervical  vertebra, 
but  puncture  in  the  cervical  region  or,  indeed,  in  the 
dorsal  region  is  considered  extra  hazardous,  and  it  is 
generally  admitted  that  under  ordinary  circumstances, 
puncture  in  the  lumbar  region,  even  when  high  anal- 
gesia is  desired,  is  equally  effective  and  is  safest  and 
best.  The  spinous  process  of  the  fourth  lumbar 
vertebra  may  be  located  by  drawing  a  transverse 


line  to  connect  the  inn  iliac  crests;  it  may  then  be 
accurately  defined  by  deep  palpation,  li"-  eat  of 
puncture  may  be  frozen  by  ethyl  chloride  or  some 
other  local  ane  thetic  n  he  ski 

the  only  sensitive  tissue  penetrated  with  the  point 
of  a  bistoury.      The  patient   should   -it    upon  the 

of  the  table  or,  by  preference,  lie  upon  either  side, 
with  the  body  well  curved  forward.      The  needle  may 

I Iltered    ]US(     beneath    the    spinOUS    prOCeSS    in    the 

median    line   and    pre!    ed    firmly    a   little    upward    and 

ard,  or  it   may   be  entered   half  an  inch   to   the 

right    or    to    the    left    of    the    median    line    and    passed 

obliquely  toward  the  spinal  canal  (]  ig.  234).   When  the 

point  of  the  needle  enter-,  the  space,  which  in  a  well 
developed  adult  i-  about  two  ami  a  half  inches  below 
the  surface,  a  sense  of  diminished  resistance  will  be 
noticed,  ami  the  spinal  fluid  will  How  from  the  outer 
end,  drop  by  drop,  or  in  a  steady  stream.  '1  he 
escape  of  the  fluid  is  the  only  conclusive  evidi 
that  the  cavity  has  been  reached,  and  if  the  fluid 
!  noi   appear  after  the  point  of  the  needle  is  sup- 

posed to  have  'ill.  i-'d  the  -pace,  the  solution  should 
nol  !"•  injected,  but  the  needle  may  be  rotated  or 
pushed  a  little  further,  a  stylet  may  be  passed,  tin; 
patient  may  cough  or  make  a  slight  straining  effort, 
or  gentle  aspiration  by  means  of  a  syringe  may  be 
employed.  When  the  fluid  begins  to  How  the 
finger  should  be  placed  over  the  end  of  the  needle 
and  the  syringe  containing  the  warm  solution,  or  the 
dry  anesthetic  substance  if  the  spinal  fluid  is  to  be 
used  as  the  solvent,  should  be  attached.  Operators 
of  experience  disagree  as  to  the  advisability  of  allow- 
ing a  few  drops  of  the  spinal  fluid  to  escape  before 
throwing  in  the  solution,  some  alleging  that  the  nor- 
mal quantity  of  the  fluid  in  the  cavity  should  not  be 
disturbed,  but  that  the  amount  withdrawn  should 
equal  or  slightly  exceed  the  volume  introduced,  while 
others  assert  that  severe  headaches  and  various  un- 
pleasant effects  are  infrequent  if  the  spinal  fluid  is 
not  wasted.  If  a  solution  is  used,  after  satisfactory 
assurance  as  to  the  position  of  the  needle,  the  piston 
should  be  slowly  depressed,  but  if  a  powder  or  a 
tablet  is  to  be  dissolved  in  the  spinal  fluid,  the  piston, 
already  closed,  should  first  be  withdrawn,  until  the 
barrel  containing  the  anesthetic,  with  a  capacity  of 
2  c.c.  (32  minims),  is  about  half  filled  with  the  fluid, 
which  readily  dissolves  the  anesthetic,  and  then  the 
solution  should  be  gradually  returned  into  the  space, 
the  needle  removed  and  the  puncture  sealed.  The 
patient  is  then  gently  laid  upon  his  back  with  the 
[dps  and  the  shoulders  at  such  relative  elevation  as 
may  be  appropriate  for  the  desired  extension  upward, 
or  for  the  limitation,  of  the  level  of  the  anesthetic 
zone. 

The  anesthetic  effect  of  a  lumbar  injection  is  gen- 
erally felt  in  the  lower  portions  of  the  body  in  three 
to  five  or  ten  minutes  and  gradually  extends  upward 
coincidently  with  the  upward  diffusion,  in  the  spinal 
fluid,  of  the  anesthetic  solution.  This  diffusion,  which 
is  a  determining  factor  in  the  level  of  the  anesthetic 
influence,  is  regulated  by  gravity,  and  is  controlled 
by  the  weight  of  the  anesthetic  solution  as  compared 
with  that  of  the  spinal  fluid,  and  by  the  posture  of  the 
patient.  Besides  the  question  of  gravity  and  of  the 
patient's  position,  the  height  of  the  anesthesia — the 
extent  to  which  it  rises — is  influenced  by  the  point 
of  insertion  and  by  the  quantity  of  t he  anesthetic 
substance  used.  The  high  injection,  however,  is  not 
necessary  to  high  anesthesia,  but  a  full  dose,  eleva- 
tion of  the  hips  and  a  little  more  time,  may  be  re- 
quired for  a  high  effect  when  the  puncture  is  made  in 
the  lumbar  region,  which  is,  by  all  means,  the  proper 
place  for  the  injection.  The  usual  duration  of  spinal 
anesthesia  is  from  thirty  minutes  to  two  hours,  and, 
in  some  instances,  even  longer.  In  testing  the  pa- 
tient to  ascertain  the  progress  of  the  anesthesia,  it  is 
important  to  remember  that  paralysis  of  the  muscles 
in  the  anesthetic  area  does  not  always  occur  and  that 


395 


Anesthesia,  Spinal 


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the  tactile  sense  may  remain  after  analgesia  has  been 
completely  developed. 

An  imperfect  anesthesia  may  follow  incomplete 
penetration  of  the  membranes  so  that  the  lumen  of 
the  needle  is  not  well  within  the  cavity,  thus  allowing 
a  portion  of  the  solution,  when  it  is  discharged,  to  be 
lost  in  the  tissues,  or  a  one-sided  anesthesia  may 
result  from  maintaining  the  lateral  position  of  the 
patient,  causing  the  nerve  roots  of  one  side  only 
to  be  bathed  in  the  anesthetic  solution.  A  total 
absence  of  anesthesia  following  an  injection  is 
usually  due  to  failure  to  enter  the  cavity.  It  may, 
however,  be  caused  by  inert  drugs,  by  an  insufficient 
dose,  or,  possibly  but  not  likely,  by  idiosyncrasy  of 
the  individual.  In  the  event  of  partial  or  of  imperfect 
anesthesia  succeeding  the  injection,  or  of  insufficient 
duration  of  the  anesthesia,  repetition  of  the  injection  or 
inhalation  anesthesia  in  the  discretion  of  the  operator, 
may  be  practised,  or  a  combination  of  the  two  methods, 
which  is  wholly  unobjectionable,  may  be  used. 

Consciousness  of  the  patient  under  anesthesia, 
frequently  urged  as  an  argument  in  favor  of  spinal 
analgesia  may,  very  rarely,  be  an  advantage,  but  in 
the  vast  majority  of  cases  it  is  a  positive  disadvantage. 
The  cooperation,  the  assent,  or  the  dissent  of  the 
patient  is  seldom  required  during  the  progress  of  an 
operation,  and  his  knowledge  of  what  is  transpiring 
may  result  in  unfortunate  embarrassment  to  the 
operator,  especially  in  the  presence  of  an  unexpected 
emergency.  The  field  of  the  operation  should  always 
be  screened  from  the  patient's  view  by  some  suitable 
device  attached  to  the  operating  table,  rather  than 
by  a  mask  or  by  a  bandage  placed  across  his  eyes. 

Some  enthusiastic  supporters  of  spinal  anesthesia 
attribute  to  it  the  power,  if  promptly  invoked,  to 
prevent,  to  limit,  or  to  arrest  surgical  shock  or  shock 
from  severe  injuries,  and  claim  for  it  moreover,  bene- 
fits beyond  the  range  of  strictly  surgical  procedures. 
It  has  been  used,  with  varying  success,  in  the  treat- 
ment of  tetanus,  and  it  has  been  employed  also,  in 
obstetric  practice  for  the  purpose  of  lessening  the 
pains  of  parturition.  The  injection  is  advised  dur- 
ing the  second  stage,  and  it  is  said  that  the  pain  is 
relieved,  while,  at  the  same  time,  the  force  of  the 
uterine  contractions  is  not  diminished,  but  that  vol- 
untary effort,  on  the  other  hand,  is  increased— the 
suffering  being  absent — so  that  the  duration  of  the 
labor  is  thereby  actually  decreased. 

The  after-effects  of  a  spinal  injection  are  sometimes 
more  or  less  severe  and  protracted,  and  they  may 
be  very  serious  and  really  alarming.  Among  these, 
are  headache,  dizziness,  mental  confusion,  inco- 
herence, fever,  delirium,  nausea,  vomiting,  coma,  par- 
esis, retarded  or  suspended  respiration,  rigidity  of 
the  cervical  muscles,  pallor,  tremor,  sweating,  incon- 
tinence of  feces,  retention  of  urine,  panting,  shock, 
restlessness,  cramps,  rigors,  cyanosis,  rapid  pulse, 
subnormal  temperature,  collapse,  etc.  Any  or  several 
of  these  symptoms  may  occur  during  or  after  anes- 
thesia without  warning  and  without  obvious  reason. 

The  work  of  Professor  Thomas  Jonnesco,  of  Bucha- 
rest, an  ardent  advocate  and  a  most  daring  exponent 
of  spinal  anesthesia,  lias  recently  attracted  wide 
attention.  The  novel  points  in  his  method  provide, 
first,  that  the  puncture  for  high  anesthesia — that  is, 
for  the  arms,  thorax,  neck,  and  head — should  be  made 
between  the  first  and  second  dorsal  vertebrae,  rather 
than  in  the  lumbar  region  and,  second,  that  in  I  lie 
production  of  spinal  anesthesia,  strychnine  should 
invariably  be  added  to  the  solution  of  either  stovaine, 
which  he  prefers,  or  of  tropacocaine  or  novocain, 
which  he  approves — claiming  that  this  precaution 
averts  the  danger  of  respiratory  paralysis  and  fully 
sustains  the  circulation.  For  low  anesthesia — that  is. 
below  i  he  diaphragm — the  site  selected  for  the  punct- 
ure is  the  dorsolumbar  interspace.  Injections  at  these 
two  sites  suffice  for  all  regions,  and  coverevery  portion 
of    the    body.     After   the    injection,    the   patient  is 


changed  from  a  sitting  to  a  dorsal  position,  with  the 
relative  height  of  the  hips  and  of  the  shoulders  regu- 
lated according  to  the  desired  level  of  the  anes- 
thesia. The  dose,  both  of  the  anesthetic  employed 
and  of  the  strychine,  should  be  smaller  by  one-half 
to  two-thirds  in  the  upper  dorsal  puncture  than  in 
the  dorsolumbar  puncture,  but  at  either  site,  whether 
high  or  low,  the  dose  should  always  be  adjusted  to 
the  age  and  the  general  physical  condition  of  the 
patient,  although  the  variation  on  this  account  in 
the  quantity  of  the  strychnine  is  not  relatively  great. 
His  usual  adult  dose,  in  dorsal  puncture,  is  stovaine, 
0.03  (i  gr.),  strychnine  0.0005  (^  gr.).  In  the 
dorsolumbar  puncture,  stovaine,  0.06  to  0.1  (1  to  1J 
gr.),  strychnine,  0.001  (Ti¥  gr.).  The  injection 
should  always  consist  of  1  c.  c.  (16  minims)  of  a  freshly 
made  solution  of  varying  strength,  within  certain 
limits,  in  the  discretion  of  the  operator. 

In  his  practice,  age  does  not  seem  to  bar  spinal 
anesthesia.  It  is  applicable  alike  to  the  infant  and 
to  the  octogenarian.  He  reports  many  successful 
cases  ranging  from  one  year  and  nine  months  to 
seventy-five  years. 

The  claim  that  the  presence  of  strychnine  in  the 
solution  injected  obviates  the  danger  of  respiratory 
paralysis  is  not  generally  accepted,  and  the  alleged 
safety  of  high  anesthesia — whether  induced  by  the 
dorsal  or  by  the  lumbar  puncture — is  stoutly  contested 
and  is  vigorously  denied.  Few  men  of  mature 
judgment  regard  spinal  anesthesia  as  applicable  to 
all  operative  cases,  but  it  is  generally  conceded  on 
the  part  of  surgeons  with  large  practical  experience 
that,  while  its  field  is  limited,  it  may  be  successfully 
employed  when  general  anesthesia  would  involve 
extraordinary  risks,  as  in  very  old  or  very  feeble 
persons,  in  alcoholics  or  diabetics,  or  in  the  subjects 
of  pulmonary,  cardiac,  renal,  or  hepatic  disease,  and 
that  in  certain  cases  and  under  certain  conditions, 
it  may  be  considered  an  available  substitute  for 
inhalation  anesthesia,  and  as  a  useful  and  reasonably 
safe  recourse  in  operations  below  the  diaphragm, 
although  it  has  not  proved  entirely  satisfactory  or 
uniformly  efficient  in  abdominal  section. 

Caution  should  be  observed  in  the  application  of 
spinal  anesthesia  to  cases  of  extreme  anemia,  asthenia, 
toxemia,  or  infection,  and  if  it  should  be  used  under 
these  unfavorable  circumstances,  the  ordinary  dose 
should  be  reduced.  James  B.  Baird. 

Anethol  (C,„H,.,0). — The  active  constituent  of  oil  of 
anise,  of  which  it  constitutes  about  ninety  per  cent., 
of  oil  of  star  anise,  which  contains  somewhat  less  of  it, 
and  of  oil  of  fennel,  which  contains  about  sixty  per 
cent,  of  it.  It  occurs  both  as  a  solid  and  as  a  liquid, 
the  former  in  colorless  crystalline  plates.  Its  specific 
gravity  at  25°  C.  is  0.985."  and  it  melts  at  21°  to  22°  C. 
It  is  freely  soluble  in  alcohol  and  slowly  in  water.  Its 
odor  and  taste  are  purely  those  of  anise,  and  it  may 
be  used  with  advantage  in  doses  of  one  to  ten  grains  as 
a  substitute  for  the  above-named  oils. 

H.  H.  Rusby. 

Aneurysm,  External. — An  aneurysm  of  an  artery  is 
a  circumscribed  tumor  composed  of  a  sac,  the  cavity 
of  which  communicates  with  the  lumen  of  the  artery 
and  contains  liquid  or  coagulated  blood.  The  sac  may 
be  formed  in  whole  or  in  part  of  the  distended  wall  of 
the  artery,  or  of  the  condensed  adjoining  tissues. 

Definitions  and  Classification. — The  terminol- 
ogy of  the  affection  has  been  much  confused  by  a  lack 
of  agreement  in  the  use  of  terms  and  in  the  meaning 
attached  to  them.  Most  of  these  terms  are  intended 
to  indicate  differences  in  the  composition  of  the  wall 
of  the  sac,  some  of  which  cannot  be  recognized  with 
certainty  on  direct  examination,  and  are  not  marked 
by  any  corresponding  clinical  differences. 

Internal    and    External. — Internal    aneurysms    are 


306 


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Aneurysm!  External 


those  situated  within  the  thoracic  or  abdominal 
oavity;  external  aneurysms  are  those  formed  at  the 
expense  of  arteries  lying  outside  these  cavities. 
I  \tedical  is  sometimes  used  as  a  synonym  of  internal; 
surgical,  of  external.) 

Spontaneous   and    Traumatic. — Spontaneous   aneu- 
rysms are  those  thai   have  arisen  in  consequence  ol 
rjisi  ase  <>r  gradual  change  in  the  wall  of  an  artery.     A 
italic  aneurj  sm  is  one  which  has  formed  in  CO 
[Ce  of  sudden  mechanical  ili\i.-i< m  or  injury  of  the 
wall  of  an  artery,  as  by  a  knife  or  splinter  of  bone. 

The  following  anatomical  classification,  adopted 
by  Holmes,  is  tlie  one  in  i mon  use.  The  distinc- 
tion made  between  "true"  and  "false"  aneurysms 
is  anatomically  justified,  but  the  terms  an-  likely  to 
mislead,  for  "true"  aneurysms,  in  the  narrow  sense 
of  the  term — i.e.  aneurysms  whose  walls  are  every- 
where composed  of  all  the  coats  of  the  artery-  arc  rare 
and  always  small.  The  common  form  of  aneurysm 
■  ugs  io  the  class  termed  "false,"  those  in  which 
on,'  of  the  coals  of  the  artery  takes  part  in  the 
formation  of  the  wall  of  the  sac. 

I.  Common  orencysted  aneurysm,  subdivided  into — 
(a)  Aneurysmal  dilatation,  or  fusiform  aneurysm. 

Iln  artery  is  dilated  for  some  distance,  and  the  wall 
of  the  dilated  portion  preserves  its  three  coats. 

(6)  True  aneurysm.  The  sac  is  formed  throughout 
by  all  the  coats  of  the  artery  dilated  at  only  one  point. 

(c)  False  aneurysm.  The  sac  is  formed  by  only 
one  or  two  of  the  coats  of  the  artery,  the  middle  one 
having  disappeared  or  being  unrecognizable  in  con- 
BBQuence  of  change. 

(</)  Consecutive  or  diffused  aneurysm.  The  wall 
of  the  sac  is  formed  of  the  condensed  adjoining 
tissues,  and  the  communication  of  its  cavity  with  the 
artery  is  therefore  through  an  actual  opening  in  the 
wall  of  the  latter.  A  traumatic  aneurysm  is  the 
type  of  this  class,  but  most,  if  not  all,  large  aneurysms 
would  be  included  under  the  definition,  rather  than 
in  class  (c),  because  of  the  substitution  of  condensed 
connective  tissue  in  the  wall  for  the  distended  external 
coat  of  the  artery.  The  presence  of  a  lining  coat 
similar  to  the  intima  of  the  artery  is  not  proof  of  the 
persistence  of  the  latter;  it  may  be  of  new  formation. 

II.  Arteriovenous  aneurysm  formed  by  abnormal 
communication  between  an  artery  and  a  vein;  sub- 
divided into — - 

(a)  Aneurysmal  varix,  in  which  there  is  no  sac 
intermediate  between  the  artery  and  the  vein;  and 

(6)  Varicose  aneurysm,  in  which  there  is  an  inter- 
mediate sac. 

III.  Cirsoid  aneurysm  (or  arterial  varix),  formed  by 
the  general  dilatation  of  an  artery  and  its  branches. 

I  V.  Dissecting  aneurysm,  formed  by  the  effusion 
of  blood  between  the  coats  of  an  artery  after  ulcera- 
tion of  the  intima. 

Common  Encysted  Aneurysm  (mainly-  Spon- 
taneous).— The  formation  of  a  spontaneous  aneurysm 
appears  to  be  preceded  by  a  degenerative  change  in 
the  wall  of  the  artery  by  which  both  its  elasticity 
and  its  power  to  resist  a  distending  strain  are  dimin- 
ished. This  change  is  in  the  nature  of  an  endarteritis 
and  mesarteritis,  and  consists  in  a  hyaline  degenera- 
tion of  the  intima  and  a  disintegration  of  the  clastic 
and  muscular  tissues  forming  the  middle  coat.  It 
may  begin  without  known  cause,  or  may  follow  the 
lodgment  of  an  embolus  or  some  mechanical  injury  to 
the  vessel,  as  the  overstretching  of  the  artery,  the 
application  of  a  ligature,*  or  even,  as  in  one  case,  pro- 
longed digital  pressure.     Under  the  influence  of  the 

*See  cases  quoted  by  Follin  ("Pathologie  Externe,"  vol.  ii.,  p. 
339),  in  one  of  which  three  aneurysms  formed  after  three  successive 
ligatures,  of  which  the  first  was  in  an  amputation  just  above  the 
elbow,  the  second  of  the  brachial,  to  cure  the  first:  the  third,  to 
cure  the  second;  a  fourth  ligature,  on  the  axillary  artery,  was  not 
followed  by  dilatation  The  case  was  Warner's,  in  the  first  half 
of  the  eighteenth  century,  and  the  aneurysm  was  laid  open  in 
each  operation. 


blood  pressure,  increa  ed  at  every  contraction  of  the 
heart,  the  degenerated  wall  yields,  and  becomes 
stretched;  if  tin-  degeneration  has  involved  the  entire 
circumference  and  a  considerable  length  of  the 
el,  tin'  dilatation  is  uniform  'in  iform  aneurysm) 
or  irregularly  pouched;  if  only  a  -mall  portion  of  the: 
wall  is  involved,  it  expand-  ami  forms  a  pouch  which 

communicate-,  eit  her  largely  or  by  a  narrow  opening, 
with  the  lumen  of  the  artery.  The  elongated  forms, 
or  dilatations,  are  common  in  the  aorta,  the  pouched 
forms  in  the  arteries  of  the  limbs.  In  -mall,  bud- 
like  aneurysms  the  persisting  three  coats  can  be 
identified;  in  t  he  larger  ones  they  cannot  be  1  raced  for 

more  than  a  very  short    distance  beyond  the  neck  of 

t  he  sac.  It  is  reported  thai  Haller  produced  aneu- 
rysms in  frogs  by  dissecting  away  the  outer  coat  of 
the  artery  (the  mesenteric),  but  similar  attempts 
made  by  Hunter  upon  the  carotid  and  femoral  of  the 
dog  were  unsuccessful,  although  the  dis.-ect  ion  was 
Carried  BO  far  that  tin'  color  of  the  blood  could  be 
-  ien  through  the  thin  remaining  portion  of  the  wall. 
The  effect  of  local  inflammatory  conditions  in 
producing  aneurysm  is  besl  -ecu  in  the  small  ones 
due  to  infected  emboli  coming  from  the  heart  in  endo- 
carditis,  and  in  those  due  to  the  extension  to  the 
\  essel  of  tuberculous  processes  on  the  outside;  in  these 
it  appears  that  dissociation  of  the  elastic  bundles  of 
the  media  is  a  necessary  preliminary. 

Examination  of  the  wall  of  a  sacculated  aneurysm 
of  considerable  size  (Fig.  235)  shows  that  it  is  composed 
of  condensed  connective  tissue,  with  a  lining  membrane 

in    its    inner  surface  that 

rti'    § — '"  resembles  the  intima  of  an 

|j     jj     a  artery  to  this  extent,  that 

•LoTl   l^*>*>*~  it  has  an  epithelial  surface 

■'  ■j^MMjS^itL  °f  tlat  cells  and  a  deeper 

!  isJ/wBP  ^^Sk  structure  of  flat  cells  sepa- 

He'^wM  ~^»  rated  by  a  fibrillary  sub- 

»~  stance.     A   similar   struc- 

ture is  found  also  upon  the 
surface  of  thrombi,  as  after 
the  ligature  of  an  artery, 
and  it  must,  therefore,  be 
deemed  not  simply  a  dis- 
tended intima,  but  rather 
a  layer  of  newly  formed 
tissue.  Traces  of  tlie  mid- 
dle coat  may  be  found  at 
different  parts  of  the 
aneurysmal  sac,  especially 
in  the  neighborhood  of  its 
neck,  where,  indeed,  they 
may  form  a  continuous 
layer  with  that  of  the 
artery;  but  in  the  more 
di-teiided  portions  of  the 
sac  they  are  entirely  ab- 
sent, and  it  appears  to  be 
well  established  that  there  is  no  hyperplasia  of  the 
muscular  and  elastic  tissues  which  compose  this  coat, 
but  that  their  elements  undergo  not  only  degeneration 
but  also  mechanical  separation,  and  they  have  practi- 
cally no  share  in  the  formation  of  the  wall. 

The  new  tissue  may  itself  either  undergo  fatty  degen- 
eration, or  become  atheromatous  or  calcified.  As  the 
sac  enlarges  it  may  become  thinned  at  some  point  and 
burst,  with  escape  of  its  contents  into  the  adjoining 
tissues  ("ruptured  aneurysm");  and  when,  in  its 
growth,  it  reaches  and  presses  upon  firm,  unyielding 
tissues  like  bone,  the  latter  undergo  absorption. 
Bone  disappears  under  this  pressure  by  rarefaction 
that  is,  a  general  rarefying  osteitis  is  set  up,  charac- 
terized by  the  enlargement  of  the  vascular  canals  of  the 
bone,  by  multiplication  of  the  cellular  elements,  and 
by  disappearance  of  the  earthy  salts,  but  without 
production  of  pus.  Other  tissues  may  become  in- 
flamed under  the  same  irritation,  and  the  inflamma- 
tion may  be  plastic,  with  production  of  adhesions, 

397 


Fig.  235. — Aneurysm  of  the 
Femoral  Artery.  The  walls  of 
the  sac  consist  only  of  the  adven- 
titia  (a)  and  intima  ib) ',  the  mus- 
cidaris  (c)  remains  only  at  the 
entrance  of  the  sac.     (Weber.) 


Aneurysm,  External 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


or  ulcerative.  Thus,  adjoining  serous  surfaces  unite 
(pleura,  pericardium,  peritoneum),  or  rupture  may 
take  place  through  ulceration  of  the  walls  of  the 
trachea  or  of  the  esophagus,  or  of  the  wall  of  any 
other  cavity  that  is  pressed  upon.  These  openings 
may  be  large  or  small,  and  may  give  rise  to  repeated 
small  hemorrhages,  or  may  cause  death  instantly  by 
a  free  one,  either  external  or  internal. 

The  growth  of  the  sac  takes  place  in  the  direction  of 
least  resistance,  but  this  direction  is  determined 
rather  by  the  distensibility  of  the  wall  itself  than  by 
the  resistance  of  the  surrounding  parts.  Thus,  the 
wall  may  be  comparatively  firm  on  the  side  adjoining 
a  cavity,  and  growth  may  be  slow  in  that  direction, 
while  at  another  point  where  it  rests  against  bone 
the  latter  may  be  rapidly  absorbed  and  even  perfo- 
rated, as  is  seen  in  the  sternum,  and  this  perforation 
will  be  followed  by  rapid  enlargement  of  the  aneu- 
rysm through  the  opening.  Aneurysms  of  the  limbs 
seldom  rupture  through  the  overlying  skin,  probably 
because  they  receive  treatment  before  their  growth 
has  reached  such  a  point;  but  those  of  the  thoracic 
aorta  and  innominate  not  infrequently  end  by  ulcera- 
tion of  the  skin  and  fatal  external  hemorrhage.  An 
aortic  aneurysm  reaches  the  surface  either  by  growth 
upward  into  the  neck  or  through  the  sternum,  or 
between  the  ribs  to  the  surface  of  the  chest.  The 
absorption  of  the  bodies  of  the  vertebra;  by  thoracic 
or  abdominal  aneurysms  gives  rise  to  some  of  the  most 
painful  symptoms  of  this  fatal  and  painful  affection. 
In  two  cases  quoted  by  Mr.  Holmes  from  Dr.  Gairdner 
tin-  spontaneous  opening  of  an  aneurysm  through  the 
skin  was  followed  by  the  healing  of  the  opening,  and 
in  one  of  them  apparently  by  the  cure  of  the  disease; 
but  such  a  result  is  so  entirely  exceptional  that  it 
deserves  mention  only  as  a  surgical  curiosity.  When 
an  aneurysm  has  ruptured  externally  or  internally, 
the  progress  in  the  immense  majority  of  cases  is  from 
bad  to  worse  if  the  hemorrhage  is  not  immediately 
fatal.  The  bleeding  may  be  arrested  by  syncope  or 
by  the  plugging  of  the  orifice  by  a  clot,  but  it  recurs 
again  and  again,  and  ultimately  proves  fatal,  unless 
the  recurrence  can  be  prevented  by  treatment. 

The  pressure  of  the  growing  tumor  not  only  leads  to 
the  condensation  and  absorption  of  the  tissues  pressed 
upon,  but  it  also  causes  much  pain,  either  by  stretching 
nerves  or  by  provoking  a  neuritis,  and  it  may  inter- 
fere with  the  circulation  of  a  part  or  limb  by  closing 
a  vein  or  even  an  artery,  and  thus  lead  to  gangrene. 

The  blood  contained  within  an  aneurysm  is  usually 
in  part  liquid  and  in  part  clotted,  and  "the  inner  sur- 
face of  the  wall  of  the  sac  is  lined  with  layers  of  gray- 
ish, opaque  fibrin  of  irregular  thickness  and  extent. 
These  layers  may  be  comparatively  thin,  or  they  may 
fill  the  greater  part  of  the  cavity.  They  are  produced 
by  gradual  deposit  of  the  fibrin  on  the  wall,  so  that 
those  layers  that  are  nearest  the  wall  are  the  oldest, 
and  also  the  shortest,  because  the  sac  has  usually 
increased  m  size  since  they  were  deposited.  They 
occasionally  undergo  degeneration  and  break  down 
into  a  granular  detritus,  forming  small  cavities  filled 
with  a  pulpy  mass.  Ordinarily  the  connection  be- 
tween the  wall  of  the  sac  and  the  adjoining  layers  of 
fibrin  is  one  merely  by  contact,  and  there  is  no 
growth  of  tissue  from  the  former  into  the  latter. 
This  condition  seems  to  be  true  at  least  of  all  grow- 
ing aneurysms,  but  in  those  that  have  undergone  spon- 
taneous  cure,  or  have  been  cured  by  treatment, 
the  development  of  new  tissue  is  observed.  This 
firm,  laminated  fibrin  is  called  the  "active  clot"; 
the  soft,  dark  clot,  or  "passive  clot,"  which  is  fre- 
quently found  loose  in  the  cavity  of  the  sac,  is  prob- 
ably a  postmortem  formation  in  most  cases. 

The  growth  of  an  aneurysm  may  be  stayed,  and  a 
practical  cure  obtained,  by  the  deposit  of  sufficient 
laminated  fibrin  either  to  fill  its  cavity  or  thoroughly 
to  protect  its  wall  from  the  distending  effect  of  the 
blood  pressure,  and  this  is  thought  to  be  the  mode 

398 


of  cure  by  most  methods  of  treatment.  It  seems 
extremely  improbable  that  this  laminated  fibrin  is  a 
later  stage  of  a  "passive"  clot;  there  is  every  reason 
to  believe  that  it  is  gradually  deposited  as  such  by 
the  blood  in  consequence  of  changes  or  peculiar  con- 
ditions in  the  lining  membrane  of  the  sac,  or  in  the 
rapidity  of  the  circulation.  Under  ordinary  condi- 
tions this  deposition  does  not  take  place  rapidly 
enough  to  effect  a  cure;  it  occurs  at  some  parts  of  the 
sac  and  not  at  others;  its  union  with  the  sac  is  slight, 
and  the  blood  can  readily  insinuate  itself  between 
the  two  at  the  edge  of  the  layers,  and  as  the  sac  en- 
larges fresh  portions  are  created  and  left  uncovered 
to  undergo  subsequent  distention.  If  the  conditions 
are  modified  by  operative  or  other  treatment  that 
diminishes  the  volume  and  force  of  the  stream  of 
blood,  time  may  be  given  to  the  tissues  of  the  sac  at 
the  edge  of  the  clot  to  become  more  intimately  adher- 
ent to  the  latter,  and  thus  to  make  the  clot  a  per- 
manent protection  against  further  increase.  This 
is  effected  by  granulations  from  the  lining  membrane, 
«  Inch  spread  into  the  clot  and  over  its  surface,  making 
it,  as  it  were,  a  part  of  the  wall  of  the  sac,  binding 
down  its  edges,  and  covering  it  with 
a  smooth  epithelial  layer.  The  union 
between  the  walls  and  the  layers  of 
fibrin  appears  to  be  very  slight,  and 
limited  to  those  layers  immediately 
adjoining  the  wall,  and  there  is  no 
evidence  that  new  vessels  extend 
from  the  wall  or  between  the  layers 
of  the  fibrinous  clot.  Some  aneu- 
rysms, after  a  long  period  of  rest  ami 
apparent  cure,  have  begun  again  to 
pulsate  and  to  enlarge,  and  this  fact 
can  be  explained  only  on  the  theory 
of  a  simple  mechanical  obstruction 
that  has  persisted  during  the  period 
of  quiescence,  and  has  then  yielded 
and  allowed  the  reentrance  of  blood, 
the  insinuation  of  blood  between  the 
layers  of  fibrin  and  the  wall. 

A  cure  may  also  follow  the  sudden 
formation  of  a  soft  "passive"  clot. 
This  fact  has  been  demonstrated  by 
examinations  made  after  the  rapid 
cure  of  aneurysms  by  the  use  of  the 
elastic  bandage.  The  first  case  is 
reported  by  Mr.  Wagstaffe  in  the 
Transactions  of  the  London  Patho- 
logical Society,  vol.  xxix.,  p.  72;  it 
was  a  case  of  popliteal  aneurysm 
cured  a  few  months  before  the  pa- 
At  the  autopsy  the  sac  was  found 
to  measure  two  inches  in  length  and  one  inch  in 
diameter,  and  to  contain  a  central  blood  clot 
measuring  one  by  one-half  inch,  and  surrounded  by 
fibrous  tissue  which  was  continuous  with  the  sac 
and  artery.  This  tissue  was  abundantly  supplied  with 
blood-vessels,  and  the  artery  was  permanently  closed 
above  and  below.     The  process  is  probably  as  follows: 

In  consequence  of  the  arrest  of  the  current  of  bl I, 

whether  by  a  distal  plug,  or  by  ligature,  or  by  com- 
pression, the  blood  within  the  sac  clots,  and  it  proba- 
bly does  so  more  promptly  than  within  normal  vessels 
because  of  the  character  of  the  inner  surface  of  the  wall 
of  the  sac.  This  clot  fills  the  sac,  and  probably  extends 
for  a  variable  distance  into  the  artery  above  and  below 
the  opening.  This  extension  prevents  the  reentrance 
of  blood  into  the  sac  even  if  the  obstruction  that  led 
to  the  formation  of  the  clot  is  afterward  removed, 
and  the  latter  then  undergoes  those  changes  with 
which  we  are  familiar  in  clots  formed  outside  the  body. 
It  divides  into  two  portions,  a  central,  shrunken,  firm 
clot,  composed  of  corpuscles  and  fibrin,  and  an  ex- 
ternal layer  of  serum.  The  latter  is  absorbed  b}'  the 
neighboring  tissues,  and  the  sac  correspondingly  re- 
tracts, and  its  wall  thickens  by  this  retraction  and 


Fig.  236.— Sec- 
tion of  an  Aneu- 
rysmal Sac  Con- 
taining a  Clot  Sur- 
rounded by  Organ- 
ized Fibrous  Tis- 
sue.    (Wagstaffe.) 

tie nt's   death. 


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Ani'iii}  sm,  External 


possibly   by  a   hyperplasia  of   its  cellular  element 
provoked  by  the  irritation  excited  by  the  clot, 
irritation    involves   also    the   adjoining    wall   of   the 
artery,  as  is  proved  by  the  changes  that  occur  even 
in  normal   vessels  into  which  clots    have  extended. 
The  intima  thickens  and  sends  oul  cellular  prolo 

.    which    perforate    I  hi'   clot    ami   spread   over    M - 
surface;  these  new  cells  soon  constitute  a  completely 

ned    and    resistant    plug  structurally   continuoi 
with   the   wall   of   the  artery,  and  provided   with  a 

00th    epithelial     surface.      The    artery     is     now     a- 
ipletel)    and    permanently   closed   on  each   side   of 

aneurysm  as  if  ligatures  had  been  placed  upon  it 

there,  and   the  clot    is  left    free  to  undergo  its   natural 

retrogressive   changes,  and  the  aneurysm  is  relieved 

distending   pressure  of   the  arterial   stream. 

Complete  absorption  of  the  serum  reduces  the  clot 
to  less  than  half  its  original  size,  and  this  reduction 
lowly  carried  further  by  molecular  disintegration 
rption  of  the  corpuscles  and  fibrin. 

This  conception  of  the  process  is  supported  by  our 
knowledge  of  the  changes  which  occnr  in  blood  that 
has  clot t i'd  within  the  body  under  ot  her  circumstances, 
by  certain  clinical  features  observed  in  aneurysms 
that  are  undergoing  or  have  undergone  cure,  and  by 
the  examination  of  specimens.  Thus,  in  a  case  of 
popliteal  aneurysm  cured  by  the  application  of  the 
rubber  bandage,  a  non-pulsating  area  of  fluctuation 
appeared  in  the  sac  a  day  or  two  after  the  operation, 
and  slowly  disappeared  as  the  tumor  diminished; 
there  can  be  but  little  doubt  that  it  was  due  to  the 
pressure  of  serum  exuded  from  the  clot  more  rapidly 
than  it  was  absorbed  by  the  surrounding  tissues. 
Again,  in  .Mr.  Wagstaffe's  case  above  referred  to,  there 
was  found  a  central  blood  clot  of  comparatively  small 
size,  closely  surrounded  by  the  thickened  sac,  and  the 
artery  was  permanently  occluded  by  fibrous  tissue 
continuous  with  its  wall  and  with  that  of  the  sac;  and 
in  Reid's  case  (Lancet,  August  5,  1876),  the  first  one 
cured  by  the  use  of  the  elastic  bandage,  a  similar 
condition  of  the  parts  was  found:  a  central  blood 
clot,  dark  in  color  and  of  cheesy  consistency;  a  con- 
tracted but  thin  sac  with  a  few  partly  adherent 
layers  of  laminated  fibrin;  and  the  artery  occluded  by 
fibrous  tissue  for  a  distance  of  two  and  one-half  inches 
above  the  sac. 

The  transformation  of  an  obliterated  aneurysm  into 
a  blood  cyst  after  many  years  has  been  observed  in  one 
case,  which  is  apparently  unique.  It  is  reported  by 
Reinhold  ("Ihaug.  Dissert.,"  Marburg,  1SS2;  abstract 
in  Ci  ntralblatt  fur  Chirurgie,  1SS2,  p.  571).  It  was  a 
traumatic  varicose  aneurysm  of  the  popliteal  artery 
and  vein  successfully  treated  by  ligature  of  the  fem- 
oral artery  and  by  compression  of  the  sac.  Nine 
years  afterward  a  large,  tense  cyst  formed,  containing 
crystals  of  cholesterin  and  hematin,  and  suppurated 
after  multiple  punctures;  it  was  then  laid  open,  and 
several  old  blood  clots  and  a  few  calcified  fragments 
were  turned  out. 

Causes. — Anything  which  reduces  the  power  of 
resistance  possessed  by  the  arterial  wall  below  what 
is  sufficient  effectively  to  oppose,  the  distending  force 
of  the  blood  may  be  an  immediate  or  a  predisposing 
cause  of  aneurysm.  A  sudden  increase  of  intravascu- 
lar pressure  may  combine  with  preexisting  weakness  of 
the  wall  to  produce  an  aneurysm,  but  in  the  great 
majority  of  cases  the  change  which  leads  to  this  pro- 
duction lies  in  the  wall  alone.  Mr.  Holmes  quotes  two 
cases  in  which  the  formation  of  an  abdominal  aneurysm 
appeared  to  have  been  the  direct  consequence  of  the 
emotion  experienced  by  a  criminal  on  receiving  a 
severe  sentence.  Weakness  of  the  wall  may  be  lim- 
ited to  a  single  large  or  small  area,  or  may  exist  at 
many  points,  with  the  production  of  a  corresponding 
number  of  aneurysms.  This  latter  condition  is  termed 
the  aneurysmal  diathesis,  and  although  the  affection 
is  usually  single,  as  many  as  sixty-three  aneurysms 
have  been  found  in  one  individual.     The  weakness 


of  the  wall  i    i ! ill  of  change  in  i  he  innei    and 

i ii  cially  the  middle,  coats  of  thi  I  this 

change  maj  be  either  the  hyaline  degeneration  above 
described,  or  the  one  known  an  atheroma.     Among 
the  predisposing  causes,  therefore,  mu  I   bi    con 
all  those  w  hich  lead  to  degi  aeral  ion  of  th 
wall.     The   statistics   collected   i>.\    Mr.    Crisp   show 
that  of  551  spontaneous  aneu  :  all  kinds,  only 

two  were  of  the  pulmonary  artery.   1  7."i  of  tic  tho 

aorta,  fifty-nine  of  the  abdominal  aorta,  137  of  the 
popliteal  artery,  sixty-six  of  the  femoral,  twenty- 
four  of  the  carotid,  twenty-three  of  the  subclavian, 

t  wenty  of  t  he  innominate,  ami  eighteen  of  t  he  axillary. 
The  disease  is  mosl  common  between  the  ages  of 
thirty  and  fifty  year-,  and  i-   verj    rare  in   childhood; 

have  I n  operated   upon   at   eight    and   nine 

years.  Broca  claimed  that  the  liability  to  aneurysm 
increased  with  advancing  years  in  the  arteries  above 
i  he  diaphragm,  and  diminished  in  those  below  it. 
Aneurysms  of  the  arteries  of  the  extremities  are  much 
less  frequent  in  women  than  in  men.  but  there  ap- 
pears to  be  no  such  difference  as  regards  internal 
aneurysms.  This  unequal  distribution  as  regards  the 
artery,  the  age,  and  the  sex,  indicates  some  of  the 
.  both  general  and  special.  Among  the  gen- 
eral causes  are  habits  of  life  and  peculiarities  of  con- 
stitution -which  increase  the  arterial  tension  or  diminish 
the  strength  of  the  arterial  walls;  the  special  ones  are 
anatomical  peculiarities  and  local  lesions,  changes, 
and  injuries. 

The  habits  of  life  which  act  as  predisposing  causes 
are  excess  in  the  use  of  alcoholic  drinks,  and  occupa- 
tions  which  call  for  the  exertion  of  much  muscular 
effort.  The  influence  of  syphilis  has  been  alleged. 
Modern  methods  of  diagnosis  of  syphilis  ought  to  give 
us  more  accurate  data;  in  the  same  way  the  more 
vigorous  action  of  salvarsan  may  give  better  results 
than  the  older  usually  inefficacious  mercurial  treat- 
ment. The  gouty  or  rheumatic  diathesis  predis- 
poses to  it.  The  influence  of  muscular  effort,  so 
far  at  least  as  regards  external  aneurysms,  is  shown 
by  the  greater  prevalence  among  males  than  among 
females,  and  the  greater  frequency  during  the  prime 
of  life,  notwithstanding  the  fact  that  degenerations 
of  the  arterial  walls  are  more  common  in  advanced 
life.  Follin  quotes  in  support  of  the  influence  of 
alcohol  a  remarkable  statement  made  to  him  by  the 
Dublin  surgeon,  Colics,  to  the  effect  that  while  the 
Father  Mathew  Temperance  Societies  flourished  in 
Ireland,  aneurysms  were  much  less  frequently  seen 
than  before  or  since  that  time. 

The  anatomical  peculiarities  which  influence  the 
occurrence  of  an  aneurysm  are  changes  in  the  direction 
of  an  artery  (as  the  arch  of  the  aorta),  normal  enlarge- 
ments of  its  caliber  (as  at  the  upper  end  of  the  car- 
otid), bifurcations,  and  the  neighborhood  of  joints 
which  are  habitually  and  violently  extended  and 
flexed  (as  the  knee  and  hip).  The  local  changes 
which  are  to  be  regarded  as  exciting  causes  are  the 
changes  already  described  as  occurring  in  the  arterial 
wall  and  other  changes  or  injuries  which  diminish  its 
power  of  resistance  or  break  its  continuity.  Thus  the 
sharp  edge  of  a  calcified  atheromatous  patch  may  cut 
through  the  intima  and  admit  the  blood  into  the  rent, 
with  the  subsequent  formation  of  a  real  aneurysm, 
or  of  the  variety  known  as  dissecting  aneurysm.  Or 
the  middle  coat  may  be  ruptured  by  being  over- 
stretched, and  the  part  thus  weakened  will  be  ex- 
panded to  form  an  aneurysm;  or  ulcerative  in- 
flammation outside  the  vessel  may  weaken,  or  even 
perforate  its  wall,  leading,  in  the  former  case,  to  the 
formation  of  a  typical  aneurysm,  and  in  the  latter, 
to  the  transformation  of  an  abscess  into  an  aneurysm. 
Or,  rarely,  the  process  set  up  by  a  ligature  upon  an 
artery  may  extend  beyond  what  is  needed  for  the 
sealing  of  the  vessel,  and  so  weaken  the  adjoining 
portion  by  modifying  its  middle  coat  that  it  yields 
under  the  pressure  of  the  blood  and  expands  into  an 


399 


Aneurysm,  External 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


aneurysm.  Or  an  embolus  may  lodge  in  an  artery 
and  lead  to  the  same  result  by  the  same  process;  this 
seems  to  be  especially  probable  when  the  embolus 
has  formed  during  ulcerative  endocarditis,  and  the 
explanation  is  to  be  found  in  the  septic  or  virulent 
qualities  then  possessed  by  the  embolus.  Four 
cases  of  this  kind  were  reported  by  Dr.  James  F. 
Goodhart,  in  the  Transactions  of  the  London  Patho- 
logical Society,  1S77,  vol.  xxviii.,  p.  98:  in  three  of 
them  the  aneurysm  occupied  the  middle  cerebral 
artery,  or  one  of  its  branches;  in  the  others,  the 
posterior  cerebral  artery. 

Symptoms  and  Progress. — When  an  aneurysm 
forms  suddenly  by  rupture  or  perforation  of  an  artery, 
or  in  consequence  of  a  violent  effort  or  emotion,  its 
formation  is  accompanied  by  sharp  pain  and  the 
more  or  less  prompt  appearance  of  a  tumor,  if  it  is  so 
situated  that  a  tumor  is  recognizable.  But  ordi- 
uarily  the  formation  is  slow,  and  the  patient's  attenl  ion 
is  first  attracted  by  the  presence  of  a  tumor.  This  is 
situated  in  the  line  of  an  artery,  is  not  adherent  to 
the  skin,  is  slightly  movable,  smooth  and  regular  in 
outline,  usually  globular  or  ovoid,  soft  and  compressi- 
ble, and  pulsates  synchronously  with  the  heart.  If 
steady  pressure  is  made  upon  it,  its  size  may  be  more 
or  less  diminished  while  the  pressure  is  made,  but  it 
immediately  regains  its  former  volume  when  the 
pressure  is  removed.  If  it  is  grasped  between  the 
thumb  and  fingers  or  between  the  two  hands,  the 
pulsation  is  found  to  be  expansile,  that  is.  the  fingers 
or  hands  are  pushed  apart  by  it,  not  simply  lifted  by 
it.  If  the  ear  is  placed  upon  it  a  sound  is  heard 
corresponding  to  the  pulsation;  this  is  the  aneurysmal 
bruit;  and  while  it  may  vary  somewhat  in  character 
in  different  cases,  it  is  usually  harsh  rather  than  soft 
or  blowing;  it  may  be  limited  to  the  time  occupied  by 
the  pulsation,  or  may  extend  over  the  entire  interval 
from  the  beginning  of  one  pulsation  to  that  of  the 
next.  If  pressure  is  made  upon  the  artery  above  the 
tumor,  the  latter  diminishes  somewhat  in  size,  and 
the  pulsation  and  bruit  cease.  The  pulsation  in  the 
distal  branches  of  the  artery  may  be  normal  or 
diminished;  and  if  the  tumor  presses  upon  the  corre- 
sponding vein,  the  limb  may  be  edematous  and 
swollen.  The  compressibility  and  softness  of  the 
tumor  are  modified  by  the  amount  of  laminated  fibrin 
within  the  sac. 

Pain  may  accompany  aneurysm  when  once  formed 
and  is  due  either  to  stretching  of  nerves  or  to  pressure 
upon,  and  inflammatory  processes  excited  in  them 
and  other  adjoining  tissues. 

The  tendency  of  an  aneurysm  is  to  increase  in  size; 
for  the  absence  from  the  wall  of  the  sac  of  a  muscular 
coat  the  most  efficient  agent  to  withstand  the  expand- 
ing blood  pressure,  leaves  the  wall  unprovided  with 
any  tissue  able  successfully  to  oppose  this  pressure. 
The  growth  may  be  rapid  or  slow,  according  to  cir- 
cumstances, chief  among  which  are  the  size  of  the 
opening  by  which  the  sac  communicates  with  the 
artery,  the  firmness  of  the  surrounding  tissues,  and 
the  readiness  with  which  the  blood  in  the  aneurysm 
clots  or  deposits  laminated  fibrin  upon  its  wall. 
The  enlargement  may  be  uniform,  or  more  marked 
at  some  points,  and  may  take  place  more  rapidly  at 
certain  times  than  at  others. 

The  natural  tendency  of  an  aneurysm  is  to  spread 
and  finally  to  rupture,  either  by  gradual  weakening 
of  its  wall  or  by  ulceration  into  a  natural  adjoining 
cavity  or  through  the  skin.  As  it  approaches  the 
surface  the  skin  becomes  tense,  adherent,  and 
inflamed,  and  may  ulcerate  or  become  gangrenous. 
The  subcutaneous  tissues  may  be  similarly  affected, 
and  thus  an  abscess  may  form  between  the  sac  and 
the  skin,  into  which  the  aneurysm  may  rupture 
either  before  or  after  the  abscess  has  opened  exter- 
nally. The  inflammatory  process  outside  the  sac  has 
been  thought  to  favor  coagulation  of  the  blood  within 
it,  and  thus  to  lead  to  a  temporary  or  even  a  perma- 


nent arrest  of  the  disease;  but  ordinarily  free  hemor- 
rhage follows  the  rupture  and  requires  extreme 
measures  for  its  arrest,  if  indeed  arrest   is  possible. 

The  most  favorable,  and  one  of  the  possible  termi- 
nations of  aneurysm,  is  its  spontaneous  cure  by  coagu- 
lation of  the  blood  within  it.  Some  of  the  conditions 
which  provoke  or  favor  this  occurrence  have  already 
been  referred  to.  They  may  all  be  classified  under 
three  heads:  (1)  Those  which  favor  clotting  in  the 
sac  by  retardation  or  arrest  of  the  current  through  it; 
(2)  those  which  increase  the  coagulability  of  (lie 
blood;  (3)  those  which  provoke  coagulation  through 
change  in  or  about  the  wall  of  the  sac. 

(1)  Retardation  or  arrest  of  the  current;  and  (2) 
Conditions  which  increase  the  coagulability  of  the  blood. 
It  has  been  abundantly  proved,  both  clinically  and 
by  the  study  of  specimens,  that  total  arrest  of  the 
current  in  the  sac  is  not  necessary  for  the  coagulation 
of  the  blood  contained  in  it,  but  that  a  partial  arrest 
or  slowing,  effected  by  influences  acting  upon  the 
general  circulation  or  only  upon  the  blood  occupying 
portions  of  the  sac,  may  either  begin  the  process  or 
promote  the  extension  of  the  process  after  it  has  been 
begun.  Most  aneurysms  of  any  size  contain  lami- 
nated fibrin  adherent  to  some  portion  of  the  wall, 
and  some  are  found  completely  filled  with  it,  or  so 
nearly  filled  as  to  leave  only  a  small  canal  through 
which  the  current  is  maintained.  When  these  clots 
are  small,  they  habitually  occupy  those  portions  of 
the  sac  in  which  the  circulation  was  apparently  the 
least  rapid,  and  it  has  been  observed  that  the  adoption 
of  measures  or  the  occurrence  of  changes  which  have 
diminished  the  rate  of  flow,  or  the  quantity  of  blood 
passed  through  the  vessel  upon  which  the  aneurysm 
is  situated,  has  been  followed  by  a  gradual  cure 
through  the  deposition  of  fibrin.  The  permanency 
of  such  a  cure  depends  upon  the  maintenance  of  the 
reduction  in  the  rate  or  volume  of  the  blood  current, 
or  upon  the  creation  of  such  relations  between  the 
clot  and  the  wall  of  the  sac  that  the  former  becomes 
a  permanent  part  of  the  latter  and  protects  all  por- 
tions of  it  from  the  action  of  the  expanding  force  of 
the  blood.  These  relations  consist  in  the  formation 
of  a  membrane  by  proliferation  of  the  cellular  ele- 
ments of  the  intima  of  the  artery,  and  the  spread  of 
this  membrane  over  the  edges  and  perhaps  over  the 
whole  of  the  exposed  surface  of  the  clot,  in  such  a  way 
as  to  prevent  the  insinuation  of  the  blood  between 
the  clot  and  the  wall,  and  to  give  a  smooth  epithelial 
surface  over  which  the  blood  passes  without  depos- 
iting additional  fibrin. 

The  causes  of  retardation  or  arrest  are  various. 
They  may  be  found  in  the  shape  of  the  sac,  in  the 
general  condition  or  habits  of  the  patient,  or  in  special 
modifications  of  the  flow  through  the  artery  itself. 

Pouched  sacs,  or  sacs  with  small  necks,  are  more 
favorable  to  the  occurrence  of  clotting  than  are 
fusiform  dilatations  or  sacs  with  large,  free  openings, 
because  the  blood  that  enters  does  not  immediately 
leave  them,  but  forms  a  sort  of  eddy  beside  the  general 
stream  in  which  the  current  is  slow  or  almost  nil. 

Of  the  causes  arising  in  the  general  condition  or 
habits  of  the  patient,  the  first  and  most  important  is 
continuous  rest  in  bed  for  Weeks  or  months,  combined 
with  a  light,  non-stimulating  diet.  Other  causes, 
which  may  also  act  by  increasing  the  coagulability  of 
the  blood,  are  bleeding,  either  large  or  small  and 
repeated,  and  the  internal  use  of  various  drugs,  such 
as  digitalis,  tartar  emetic,  veratrum  viride,  iodide  of 
potassium,  acetate  of  lead,  ergot,  and  the  chloride 
of  barium.  Cures  have  followed  the  use  of  each  of 
these  measures,  alone  or  in  combination,  but  it  is 
not  always  easy  to  determine  how  much  credit  is  to 
be  awarded  to  "the  treatment  in  any  one  case. 

Retardation  or  arrest  of  the  flow  may  also  be  caused 
by  obstruction  of  the  orifice  of  the  sac,  if  it  is  small,  or 
of  the  artery  above  or  below  the  aneurysm.  The 
most  common  agency  in  producing  this  change  is  the 


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Aneurysm,  External 


detachment  of  a  fragment  of  fibrin  from  the  wall  of 
the  sac  and  its  lodgment  in  the  neck  of  the  s:ir,  or 
in  the  artery  below.  The  latter  occurence  is  habitu- 
ally accompanied  by  severe  pain  in  the  limb,  and  is 
evidenced  by  arresl  of  pulsation  in  the  distal  branches 
(if  the  artery.  A  euro  by  this  mechanism  has  been 
observed  a  number  of  limes,  and  it  forms  the  basis 
of  a  method  of  treatment  suggested  by  Sir  William 

Ferguson,  in  which  the  forcible  detacl nt  of  a  clot 

from  the  wall  is  sought  to  be  effected.  If  the  de- 
tached 'lot  is  small,  it  may  lodge  on  the  spur  of  a 
bifurcation,  and  then  grow  in  size  by  additional  de- 
posits  of  fibrin  until  it  obstructs  one  or  both  of  the 
branches,  and  in  such  a  case  retardation  precedes 
complete  aires!. 

This  possibility  of  the  detachment  of  small  clots 
and  their  passage  into  the  distal  branches  of  the 
artery  involves  the  risk  of  other  changes  far  different 
from  the  cure  of  the  aneurysm.  The  arrest,  of  the 
circulation  may  lead  to  gangrene  of  the  lower  portion 
of  the  limb,  total  or  partial,  according  to  the  seat 
of  the  obliteration;  and  if  the  aneurysm  is  situated 
upon  the  arch  of  the  aorta  or  upon  one  of  the  vessels 
going  to  the  head,  the  emboli  may  lodge  in  the  vessels 
of  the  brain  and  cause  death  promptly. 

When  there  is  merely  retardation  of  the  current  the 
cine  takes  place  by  the  gradual  deposit  of  lamina  led 
fibrin:  and  when  there  is  total  arrest,  it  takes  place 
probably  by  coagulation  in  mass  of  all  the  blood 
within  the  sac,  and  the  subsequent  shrinking  of  the 
clot  and  sealing  of  the  vessel  by  the  production  of 
fibrous  tissue,  as  has  been  described  above. 

Another  alleged  cause  of  retardation  of  the  stream 
is  pressure  of  the  tumor  upon  the  proximal  portion 
of  th  '  artery,  but  no  cases  have  been  reported  in 
which  this  mechanism  has  been  demonstrated.  Its 
supposed  possibility  rests  upon  theoretical  grounds 
alone,  and  while  it  may  be  admitted  as  a  possibility, 
there  is  but  little  reason  to  believe  it  has  ever  taken 
place. 

(3)  Conditions  which  provoke  coagulation  through 
change  in  or  about  the  wall  of  the  sac.  Inflammation 
of  the  sac,  or  of  the  tissues  immediately  overlying 
it,  is  alleged  by  Broca  and  others  to  be  a  cause  of 
coagulation  within  it  and  of  consequent  cure.  Mr. 
Holmes  thinks  this  assertion  has  never  been  demon- 
strated, and  attributes  the  cure,  in  the  eases  that 
have  been  cited  in  support  of  the  theory,  to  impaction 
of  a  clot.  There  is  no  doubt  that  inflammation 
about  an  artery  or  vein  can  and  does  often  lead  to 
the  formation  of  a  thrombus  within  the  vessel,  but 
the  conditions  in  an  aneurysmal  sac  are  so  different 
that  it  is  perhaps  unjustifiable  to  argue  from  a  sup- 
posed analogy. 

The  sudden  formation  of  a  soft  elot  within  an 
aneurysm  may  excite  inflammation  and  suppuration 
of  the  sac  with  subsequent  rupture.  In  a  few  cases 
this  process  has  been  followed  by  a  cure;  but  the 
cure  must  be  attributed  to  the  obstruction  of  the 
vessel,  either  by  the  original  clot  previous  to  the 
rupture,  or  by  a  secondary  clot  after  the  hemorrhage 
that  has  followed  the  rupture. 

In  like  manner,  tardy  suppuration  may  follow  cure, 
and  after  an  aneurysm  has  remained  quiescent  and 
shrunken,  in  fact  cured,  for  months  or  even  years, 
such  suppuration  may  lead  to  the  casting  out  the  clot 
in  whole  or  in  part. 

Changes  in  laminated  fibrin  after  the  cure  of  an 
aneurysm  are  slight  and  gradual,  and  rarely  amount 
to  more  than  a  diminution  in  size  by  shrinking;  some- 
times the  fibrin  becomes  soft,  and  sometimes  lime 
salts  are  deposited  in  it.  A  unique  case  of  later  trans- 
formation into  a  blood  cyst  has  been  mentioned  above. 

Diagnosis. — The  typical  symptoms  of  aneurysm  are 
the  existence  of  a  more  or  less  well-defined  tumor 
that  pulsates  synchronously  with  the  beat  of  the  heart, 
has  a  distinct  intermittent  bruit,  and  diminishes  in 
size  while  pressure  is  made  upon  it  or  upon  the  proxi- 

Vol.  I.— 26 


mal  portion  of  the  artery  from  which  it  arises.      Hut 

these  signs  may  lie  variously  modified  or  abolished 
by  the  varying  conditions  that  have  been  described 
above,  or   may  be   undemonstrable  because  of   the 

position  of  the  tumor,  or  may  be  simulated  by  those 
of  other  affections.      An  additional  sign   is  Minn-limes 

found  in  a  difference  In  the  character  of  the  pulse  in 
the  distal  branches  of  the  artery  when  compared 
with  thai  in  the  branches  of  the  corresponding  artery 
of  the  outer  side,  a  difference  that  may  be  recognized 
by    the    linger,    but     much     more     certainly     by    the 

sphygmograph. 

The  symptoms  in  external  aneurysm  may  be 
modified  by  the  partial  or  complete  consolidation 
of  its  contents,  or  by  the  temporary  obstruction  of  its 

orifice,  either  of  which  occurrences  may  greatly 
diminish  Or  arrest,  the  pulsation  and  bruit. 

The  affections   with  which  an   aneurysm  is  most 

likely  to  be  Confounded  are  solid  or  liquid  tumors 
overlying  an  artery  and  very  vascular  tumors  lying 
in  or  near  the  course  of  a  large  artery.  In  all,  the 
common  signs  an'  a  pulsating  tumor  with  bruit,  and 
the  circumstance  that  the  pulsation  and  bruit  may  be 

arrested  by  pressure  on  the  artery.  The  pulsation  of 
an  aneurysm  is  expansive,  the  tumor  enlarging  later- 
ally at  each  pulsation;  that  of  an  overlying  tumor  is  a 
simple  lifting  of  the  entire  mass;  but  this  difference 
cannot  always  be  recognized  with  certainty,  or  if  the 
fingers  cannot  be  pressed  down  to  the  widest  part  of 
I  he  tumor,  the  simple  rising  of  the  sloping  sides  of  the 
globular  mass  between  them  forces  them  apart  and 
simulates  lateral  expansion.  A  bruit  may  be  caused 
in  an  artery  or  vein  by  pressure  upon  it.  In  a  vein 
such  a  bruit  is  harsh  and  continuous;  in  an  artery  it  is 
intermittent  and  more  "blowing"  in  character  than 
that  of  an  aneurysm. 

In  the  case  of  a  suspected  liquid  collection  simulat- 
ing aneurysm,  the  diagnosis  may  be  aided  by  aspira- 
tion with  a  fine  needle.  An  aneurysm  has  been 
mistaken  for  an  abscess  frequently  enough  to  make 
great  caution  necessary  in  the  diagnosis  and  treat- 
ment of  any  supposed  abscess  lying  in  the  course  of 
a  large  artery.  The  fingers  should  always  be  pressed 
deeply  into  the  swelling  in  search  of  pulsation,  and 
even  if  an  abscess  is  certainly  present,  it  should 
be  remembered  that  it  may  have  formed  over  an 
aneurysm. 

As  pulsation  and  bruit  have  their  origin  in  the  stream 
of  blood  brought  by  the  artery,  pressure  upon  the 
proximal  portion  of  the  vessel  will  arrest  them, 
whether  they  belong  to  an  aneurysm  or  are  simply 
communicated  through  a  tumor.  Vascular  tumors, 
especially  those  arising  from  bone,  often  have  well- 
marked  pulsation  and  bruit:  but  their  pulsation  is  less 
"heaving"  or  massive"  than  in  aneurysm,  and  the 
bruit  is  rarely  well  marked.  The  diagnosis  may  be 
extremely  difficult,  or  only  possible  by  the  aid  of 
exceptional  explorations.  In  a  case  of  large  pulsating 
tumor  of  the  gluteal  region,  under  the  care  of  Prof. 
Henry  B.  Sands,  in  the  Roosevelt  Hospital,  New 
York,  in  1880,  the  diagnosis  of  aneurysm  was  made  by 
passing  the  hand  into  the  rectum,  and  thus  learning 
that  the  internal  iliac  artery  was  enlarged,  the 
enlargement  increasing  from  above  downward  to  the 
sacrosciatic  notch.  The  frequent  presence,  in  vascular 
tumors,  of  large  collections  of  blood  contained  within 
sacs  formed  by  the  rupture  or  dilatation  of  capillaries 
or  small  vessels,  increases  the  resemblance  to  an 
aneurysm. 

An  aneurysm  which  has  just  ruptured  into  the 
adjoining  tissues  does  not  pulsate,  and  may  have  no 
bruit;  under  such  circumstances  the  diagnosis  must 
be  made  by  the  history  of  the  case,  the  preexistence 
of  a  pulsating  tumor,  and  the  cessation  of  the  pulsa- 
tion coincidently  with  a  marked  change  in  the  shape 
and  size  of  the  tumor.  In  like  manner,  where  an 
artery  has  just  been  ruptured  or  perforated  and  the 
blood   has   been   effused   into   the   adjoining  tissues, 

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pulsation  and  bruit  are  not  present  until  after  the 
effusion  has  become  circumscribed  by  a  distinct 
firm  wall  composed  of  the  condensed  tissues  ("trau- 
matic aneurysm"  or  "ruptured  artery"). 

For  the  differential  diagnosis  of  arteriovenous  aneu- 
rysm and  cirsoid  aneurysm  or  arterial  varix,  vide  infra. 

Prognosis. — The  gravity  of  the  prognosis  varies 
with  the  artery  involved,  and  the  size  and  character  of 
the  aneurysm.  In  internal  aneurysms  the  prognosis 
is  very  grave;  in  external  aneurysms  it  is  commonly 
much  less  so,  since  in  most  of  them  suitable  treatment 
offers  a  reasonable  hope  of  cure. 

Treatment.  Medical  treatment. — The  medical  treat- 
ment of  aneurysm,  especially  of  internal  aneurysms, 
consists  in  absolute  rest  in  the  recumbent  position, 
maintained  for  weeks  or  months,  combined  with  a 
restricted  diet,  and  aided,  perhaps,  by  the  use  of  vari- 
ous drugs.  The  absolute  rest  and  the  low  diet  are  un- 
questionably the  most  efficient  part  of  the  treatment, 
and  the  drugs,  even  those  for  which  most  has  been 
claimed,  are  only  adjuvants  of  uncertain  and  often 
very  doubtful  utility.  Systematic  treatment  of  this 
kind  dates  from  the  time  of  Valsalva,  and  even  in  his 
hands  the  rest  was  subordinate  to  repeated  venesec- 
tion, which  he  carried  to  such  an  extent  that  rest  in 
bed  was  a  matter  not  of  choice,  but  of  necessity. 
This  active  depletion  was  never  regarded  with  much 
favor,  and  as  it  was  long  deemed  an  essential  part  of 
treatment  by  rest,  the  latter  shared  in  the  disfavor  of 
its  associate,  and  patients  affected  with  internal 
aneurysms  were  habitually  looked  upon  as  beyond 
the  reach  of  art,  and  the  interference  of  the  physician 
was  restricted  to  relief  of  pain  and  the  occasional 
employment  of  drugs  from  which  it  was  thought  some 
benefit  might  possibly  accrue.  To  Mr.  Tufnell  of 
Dublin  belongs  the  credit  of  demonstrating  the  value 
of  absolute  rest  in  bed  and  restricted  diet  in  pro- 
moting a  cure  or  affording  great  relief.  He  insisted 
upon  the  absolute  maintenance  of  the  recumbent 
posture,  and  restricted  the  amount  of  food  to  about 
eight  ounces  of  solid  food  and  six  ounces  of  liquid 
daily,  the  solid  food  being  bread,  butter,  and  meat, 
the  liquid,  milk  and  a  little  claret  wine. 

Of  drugs,  the  iodide  of  potassium  has  been  most 
employed,  in  doses  of  from  half  an  ounce  to  one  ounce 
daily.  A  number  of  cases  of  aortic  aneurysm  appar- 
ently cured  or  greatly  relieved  by  its  use  have  been 
reported.     Salvarsan  might  be  useful  in  certain  cases. 

Digitalis,  veratrum  viride,  and  ergot  have  also  been 
used,  with  the  object  of  slowing  the  circulation; 
occasional  supposed  cures  or  temporary  arrests  by 
their  agency  have  been  reported,  but  they  are  not 
regarded  with  favor  by  the  authors  of  systematic 
treatises  on  the  subject.  Ergot  is  given  internally 
in  the  form  of  the  fluid  extract,  or  subcutaneously 
as  ergotine.  Mr.  Holmes  regards  the  acetate  of  lead  as 
offering  the  best  promise.  Dr.  F.  Flint  reported  a 
case  of  aneurysm  of  the  abdominal  aorta  apparently 
cured  by  the  use  of  the  chloride  of  barium  in  doses  of 
from  one-fifth  to  three-fifths  of  a  grain  three  times 
daily  for  about  five  months,  after  Tufnell 's  method 
had  entirely  failed.  The  most  rapid  improvement 
coincided  with  the  smallest  dose. 

Surgical  methods  of  treatment  may  be  grouped  in 
three  classes: 

1.  Radical  obliteration  of  the  sac  by  opening  it  and 
tying  the  artery  immediately  above  and  below  its 
point  of  communication  with  the  aneurysm.  This 
is  known  as  the  "old  method,"  or  the  "method  of 
Antyllus."  Under  the  same  head  may  be  included 
the  method  of  extirpation  of  the  sac.  with  ligature  of 
the  artery  above  and  below;  and  the  Matas  operations: 
(a)  Obliterative  endoaneurysmorrhaphy;  (6)  Recon- 
structive endoaneurysmorrhaphy.  (See  under  Ar- 
teries, Surgery  of  the.)  Suture  of  each  opening 
in  arteriovenous  aneurysm  or  excision  of  the 
injured  vessel  with  end-to-end  Union  of  the  two 
segments,  or  implantation  between  them  of  a  segment 


of    another    vessel     (vein).      See    Binnie,    Operative 
Surgery,  fifth  edition. 

2.  Permanent  or  temporary  arrest  of  the  afferent 
stream  at  a  point  on  the  proximal  side  somewhat 
removed  from  the  aneurysm,  (a)  Ligature  of  the 
artery  (Anel's  method,  or  the  Hunterian  method). 
tin  Compression  of  the  artery — direct,  indirect,  digi- 
tal, or  tentative  by  apparatus  whose  pressure  can 
be  regulated  or  by  apparatus  which  can  be  re- 
moved, (c)  Esmarch's  elastic  bandage,  (d)  Flexion 
of  the  limb. 

3.  Permanent  arrest  or  obstruction  of  the  stream 
on  the  distal  side,  (a)  Distal  ligature.  (6)  Manipula- 
tion to  produce  an  embolus  or  impacted  clot. 

4.  Rapid  coagulation  of  the  blood  in  the  sac  (with 
or  without  temporary  arrest  of  the  stream),  (a)  Co- 
agulating injections.  (6)  Introduction  of  solid  bodies, 
(c)  Galvanopuncture  and  the  introduction  of  a  wire 
plus  galvanism. 

5.  Promotion  of  the  formation  of  a  laminated  clot 
by  irritation  of  the  wall — "needling." 

1.  The  "old  method"  (or  the  method  of  Antyllus). 
The  aneurysms  with  which  the  ancient  surgeons  had 
mainly  to  deal,  or  at  least  those  to  which  operative  in- 
terference  was  mainly  limited,  were  traumatic  an- 
eurysms at  the  bend  of  the  elbow  following  venesec- 
tion. It  has  been  claimed  for  them  that  they  knew 
and  practised  the  method  of  cure  by  ligature  of  the 
artery  in  continuity  above  the  sac,  but  Hodgson's 
statement,  which  is  quoted  by  Holmes  in  support 
of  this  claim,  does  not  fully  and  accurately  present 
the  practice.  Ligature  of  the  brachial  artery  "three 
or  four  finger-breadths  below  the  axilla"  was  indeed 
recommended  by  Aetius  in  the  fifth  century,  but  only 
as  a  preliminary  to  the  opening  of  the  sac  at  the  elbow 
and  the  application  of  another  ligature  there,  and 
solely  with  the  object  of  preventing  hemorrhage 
during  the  operation  proper.  The  main  "object  of 
treatment  was  to  remove  the  clot,  which  was  thought 
to  be  a  source  of  danger,  and  to  prevent  subsequent 
hemorrhage  by  obliterating  the  artery  or  closing  the 
opening  by  which  it  communicated  with  the  sac. 
The  operation  appears  to  have  fallen  into  disuse  and 
not  to  have  been  revived  until  about  the  seventeenth 
century,  when  it  was  again  used  with  various  modifica- 
tions, but  at  first  only  in  traumatic  aneurysms  at  the 
elbow.  It  appears  to  have  been  first  used  in  popliteal 
aneurysm  by  Keyslere;  the  date  of  his  first  operation 
is  not  known;  his  second  and  third  were  done  in  1747 
and  174S  respectively.  His  first  three  cases  were 
successful;  the  fourth  ended  fatally. 

The  method  of  operation  as  practised  in  popliteal 
and  brachial  aneurysms  until  the  end  of  the  eight- 
eenth century,  was  to  control  the  artery  by  a  tourni- 
quet or  the  fingers,  divide  the  sac  by  a  longitudinal 
incision,  turn  out  the  clots,  find  the  point  of  communi- 
cation with  the  artery,  isolate  the  latter,  and  tic  it 
above  and  below  the  opening.  The  cavity  was  then 
packed  with  lint  and  allowed  to  fill  by  granulation. 
The    difficulties    and    the    dangers    were    great. 

The  frequency  of  secondarj'  hemorrhage  was 
thought  by  Hunter  to  be  due  to  the  diseased  condition 
of  the  arterial  wall  near  the  sac,  where  the  ligature  was 
applied,  and  this  has  always  been  deemed  one  of  the 
most  weighty  reasons  for  preferring  the  Hunterian 
method,  in  which  the  ligature  is  placed  upon  a  more 
distant  and  presumably  healthy  part  of  the  artery. 
It  must  be  remembered,  however,  that  secondary 
hemorrhage  was  much  more  common  in  former  days, 
after  all  operations  in  which  a  large  artery  was  tied, 
than  it  is  at  present,  when  it  has  become  very  rare 
after  ligature  with  catgut  or  aseptic  silk;  and  that 
arteries  so  degenerated,  or  even  calcified,  that  they 
broke  when  the  ligature  was  drawn  tightly,  1 
remained  securely  closed  by  slighter  pressure,  and 
the  wounds  have  healed  without  accident.  .Mere- 
over,  recent  experience  with  the  catgut  ligature  in  the 
"old"  operation  and  in  extirpation  of  the  sac  has 


402 


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\neiirysm.   External 


shown  that   the  chance  of  s ndary  hemorrhage  is 

!-.  The  objection  raised  against  the  old  method, 
the  condition  of  the  adjoining  arterial  wall  is 
altered,  cannot  properly  be  urged  in  the  case  of  a 
traumatic  aneurysm;  and  the  only  other  possible 
objections  are,  that  the  operation  is  more  difficult  and 
the  wound  larger. 

Syme's  method  of  operating  when  the  artery  could 
oot  be  controlled  on  the  proximal  side  of  the  sac  was 
to  make  an  incision  into  the  tumor  just  large  enough 
to  admit  his  finger,  with  which  he  then  felt  for  and 
compressed  the  opening  in  the  vessel.  If  he  could  not 
thus  find  the  opening,  he  enlarged  the  incision  and 
then  introduced  a  second  and  third  finger,  and.  in 
,  ,1M — so  says  Holmes — the  entire  hand.  When 
the  opening  was  found  and  commanded,  he  si  ill 
further  enlarged  the  incison,  turned  out  the  clots,  and 
denuded    and    tied    the    artery    above    and    below. 

Extirpation  of  the  sac  is  now  done  as  for  the  re- 
moval of  a  tumor.  The  mass  is  exposed  by  a  long 
incision,  the  artery  is  tied  above  and  then  below,  and 
the  >ae  is  dissected  out  with  great  can-  to  a\  oid  injury 
to  the  vein.  The  water  operation  is  described  in  the 
article  on    '  ry  of  the. 

2.  Permanent  or  temporary  arrest  of  the  afferent 
stream  at  a  point  on  the  proximal  side  somewhat  re- 
moved from  the  sac. 

Ligature  by  Anel's  method,  or  the  Hunterian 

The  question  of  priority  in  the  introduction 

of  the  method  of  ty-ing  the  artery  above  the  sac,  as 


Fig.  237. — Different  Forms  nf  Ligatures  for  Aneurysm,      a,  Ariel's; 
b,  Hunter's;  c,  Brasdor's;  d,  Warurop's;  e,  Antyllus's. 

now  practised,  has  given  rise  to  much  controversy, 
but  must  here  be  dealt  with  very  briefly.  It  is 
claimed  by  the  French  for  Anel,  a  French  surgeon 
itising  in  Rome  in  1710,  and  by  the  English  for 
John  Hunter  in  17S5.  The  reader  who  is  curious  in 
the  matter  is  referred  to  Broca  ("  Des  aneVrysmes, " 
Paris,  1856),  to  Holmes  ("A  System  of  Surgery "1, 
and  to  a  paper  by  the  writer  in  the  New  York  Medical 
Journal,  November  1,  1SS4.  The  facts,  in  brief,  are 
as  follows:  January  30,  1710,  Anel  treated  a  traumatic 
aneurysm  at  the  bend  of  the  elbow  by  tying  the  artery 
close  above  the  sac  without  opening  the  latter,  and 
thereby  effected  a  cure.  The  patient  was  a  priest. 
The  case  gave  rise  to  much  discussion,  the  account  of 
it  was  reprinted  in  several  books  and  journals,  and  the 
method  was  subsequently  used,  before  1785,  in  at 
least  three  other  eases,  in  one  of  which  the  ligature 
was  applied  about  two  inches  above  the  sac  (Broca.  p. 
446).  June  22,  1785,  Desault  (after  having  a  few 
months  previously  sought  to  cure  an  axillary  aneu- 
rysm by  compression  of  the  subclavian)  treated  a 
popliteal  aneurysm  by  tying  the  artery.  "  immediately 
below  the  ring  of  the  third  adductor,"  that  is,  at  th  ■ 
point  where  the  femoral  artery  ends  and  the  popliteal 
artery  begins;  the  aneurysm  was  cured,  and  the 
patient  died  eleven  months  later  of  disease  of  thelower 
end  of  the  tibia.  December  12,  1785,  John  Hunter 
treated  a  popliteal  aneurysm  by  tying  the  femoral 
artery   and    vein    "rather   below-    the   middle   of  the 


thigh."*     In    tl  ing    March,    1786,    Di 

Inning  knowledge  of   Huntei  operated   upon 

another  anil  tied  the  artery  at  a  -till  higher  point, 
dividing  the  sartori  i  e  it. 

Bunter  repeated  the  operation  four  times  within 
four  years  following  hi  ie  vein  as 

.    i  lie  artery,  except  in  the  last  I  wo;   I  >ei  aull 
shortly  after  his  owe  second  case. 

These  facts  are   riot    disputed;   the  controversy  lias 
arisen  over  the  principles  which  are  thought  to  I 
led,  in  the  minds  of  the  different   opi  \ne|, 

Desault,  and  Hunter),  to  the  adoption  of  the  method. 

It  is  claimed  by  the  English  (Guthrie,  Holmes)  that 
Anel  did  not  know  what  he  was  doing,  did  not 
appreciate  the  importance  of  the  method,  the  m 

by  which  it  affected  a  cure,  and  it-  applicability  to 
I  aneurysms  than  those  at  the  elbow,  and  that, 
as  he  used  it.  it  was  radically  defective  in  placing  the 
ligature  too  close  to  the  sac,  and  without  the  interven- 
tion between  I  he  tun  of  any  collateral  branch  given  off 
from  the  artery;  that,  in  short,  it  wa  a  mere  happy 
e,  stumbled  upon  without  reflection,  and  passed 
without  appreciation;  that  Desault's,  in  like  manner, 
was  a  mere  experiment,  but  that  Hunter's  was  the 
result  of  profound  reflection  and  reasoning  upon  the 
nature  of  the  disease  and  the  manner  in  which  coagu- 
lation of  the  blood  in  the  sac  is  effected,  and  especially 
of  his  knowledge  of  the  fact  thai  complete  shutting 
off  of  the  current  from  the  sac  was  not  necessary.  The 
original  reports,  on  examination,  do  not  appear  to 
justify  any  of  these  claims,  which  seem  to  have  no 
more  solid  basis  than  ignorance  of  what  Anel  and 
Desault  really  thought,  and  the  crediting  of  Hunter, 
before  his  operation,  with  knowledge  which  he  ob- 
tained at  a  later  period.  Hunter's  identification  with 
the  operation  was  in  large  part  the  result  of  his 
exceptional  authority  at  the  time,  the  publicity  which 
attended  or  was  given  to  the  act,  the  frequent 
repetitions,  and  the  generalization  which  promptly 
followed  it,  and  also  of  the  great  ability  with  which  he 
set  forth  the  principles  upon  which  it  rested.  These  in 
themselves  are  an  ample  title  to  recognition  and  re- 
spect, and  Hunter's  glory  may  well  be  left  to  rest  on 
them  without  robbing  others  of  their  just  due. 

Three  months  after  Desault's  first  operation,  and 
three  months  before  Hunter's  first  operation,  at  a 
consultation  held  in  London  on  a  ease  of  femoral 
aneurysm  as  large  as  an  orange,  in  which  Hunter 
took  part,  all  agreed  that  it  was  impossible  to  resort 
to  the  operation  ordinarily  practised  upon  aneurysms, 
and  recommended  pressure  on  the  artery  in  the  groin; 
the  attempt  was  made,  and  abandoned  because  of 
the  pain  it  caused.  It  is  apparent  that  at  this  time 
Hunter  had  not  developed  his  method.  The  argu- 
ments that  led  Hunter  to  tie  the  femoral  artery  for 
popliteal  aneurysm,  according  to  Home,  his  pupil, 
assistant,  and  reporter  (loc.  cit.,  p.  145),  were  "that 
the  disease  often  extends  along  the  artery  for  some 
way  from  the  sac;  and  that  the  cause  of  failure  in  the 
common  operation  arises  from  tying  a  diseased 
artery,  which  is  incapable  of  union  in  the  time  neces- 
sary   for   the  separating  of  the  ligature." 

If  the  artery  should  afterward  give  way  [if  tied  just 
above  the  sac]  there  will  not  be  a  sufficient  length  of 
vessel  remaining  to  allow  of  its  being  again  secured 
in  the  ham.  To  follow  the  artery  up  through  the 
insertion  of  the  triceps  muscle,  to  get  at  a  portion  of 
it  where  it  is  sound,  becomes  a  very  disagreeable  part 
of  the  operation;  and  to  make  an  incision  upon  the 
fore  part  of  the  thigh,  to  get  at  and  secure  the  femoral 
artery,  would  be  breaking  new  ground,  a  thing  to  be 
avoided,  if  possible,  in  all  operations.  Mr.  Hunter, 
from   having   made   these   observations,    was   led    to 

*  Everard  Home,  in  Transactions  of  a  Society  for  the  Improve- 
ment of  Medical  and  Surgical  Knowledge,  London,  1793,  p.  148. 
This  appears  to  be  the  first  official  publication  of  the  case;  the  paper 
is  not  dated,  but  it  is  printed  between  two  which  are  dated  Sep- 
tember, 17S9,  and  September,  1790,  respectively. 


403 


Aneurysm,  External 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


propose  that  in  this  operation  the  artery  should  be 
taken  up  in  the  anterior  part  of  the  thigh,  at  some 
distance  from  the  diseased  part,  so  as  to  diminish  the 
risk  of  hemorrhage  and  admit  of  the  artery  being 
more  readily  secured,  should  any  such  accident 
happen.  The  force  of  the  circulation  being  thus 
taken  off  from  the  aneurysmal  sac,  the  progress  of  the 
disease  would  be  stopped;  and  he  thought  it  probable 
that,  if  the  parts  were  left  to  themselves,  the  sac  with 
its  contents  might  be  absorbed  and  the  whole  of  the 
tumor  removed;  which  would  render  any  opening 
into  the  sac  unnecessary." 

It  is  plain,  from  this,  that  Hunter's  idea  in  seeking 
the  artery  at  a  higher  point  was  simply  to  avoid 
secondary  hemorrhage  and  to  make  its  treatment. 
if  it  should  occur,  easier;  and  the  extent  to  which 
this  idea  preoccupied  his  mind  is  shown  in  the  strange 
additional  precautions  he  took  in  the  matter  of  the 
ligature  itself.  He  tied  the  artery  with  four  ligature-;, 
"  but  so  slightly  as  only  to  compress  the  sides  together. 

The  reason  for  having  four  ligatures  was 

to  compress  such  a  length  of  artery  as  might  make  up 
for  the  want  of  tightness,  it  being  wished  to  avoid 
great  pressure  on  the  vessel  at  any  one  part." 

According  to  Holmes,  "the  great  merit  of  Hunter 
consists  in  his  having  seen,  first,  that  it  was  not 
necessary  to  turn  the  clots  out  of  the  aneurysmal 
tumor; and,  second,  that  it  was  not  neces- 
sary to  stop  the  circulation  through  it  absolutely,  but 
only,  as  he  said,  'to  take  off  the  force  of  the  circula- 
tion.' "  The  first  of  these  was  certainly  appreciated 
by  Anel  and  Desault,  for  they  saw  their  patients  get 
well;  the  second  is  difficult  to  explain  if  it  is  based 
upon  the  fact  that  the  ligatures  were  tied  loosely, 
for  they  certainly  were  intended  to,  and  did,  cut  out, 
and  therefore  occluded  the  artery  entirely;  and  in 
Hunter's  subsequent  operations  he  used  a  single 
ligature  and  tied  it  tightly,  so  that  if  this  was  his 
opinion  and  object  at  first,  he  subsequently  aban- 
doned it.  The  idea,  moreover,  is  expressed  by  Home 
(loc.  cit.,  p.  150)  as  a  conclusion  drawn  from  what 
was  found  at  the  autopsy  eleven  months  later:  "The 
conclusion  to  be  drawn  from  the  above  account 
appears  a  very  important  one,  viz.,  That  simply 
taking  off  the  force  of  the  circulation  from  the  aneu- 
rysmal artery  is  sufficient  to  effect  a  cure  of  the  dis- 
ease, or  at  least  to  put  a  stop  to  its  progress."  It 
seems  much  more  reasonable  to  infer  that  Hunter's 
object  in  tying  the  ligatures  loosely  was  to  give  the 
artery  more  time  to  become  sealed  before  the  ligature 
cut  through.  (See  the  first  quotation  from  Home 
given  above.) 

The  statement  has  been  generally  quoted  as  mean- 
ing that  Hunter  proposed  to  leave  one  or  more  col- 
lateral branches  between  the  ligature  and  the  sac, 
but  there  is  nothing  in  the  account  of  the  operation 
or  of  the  autopsy  to  justify  such  an  opinion.  "The 
femoral  artery  was  impervious  from  its  giving  off 
the  arteria  profunda  as  low  as  the  part  included  in 
the  ligature,  and  at  that  part  there  was  an  ossifica- 
tion for  about  an  inch  and  a  half  along  the  course  of 

the  artery Below  this  part  the  femoral 

artery    was   pervious   down   to   the  aneurysmal   sac, 
and   contained  blood,   but  did  not  communicate  with 
the  sac  itself,  having  become  impervious  just  at  the  en- 
trance [italics  ours].    ......     The  popliteal  artery, 

a  little  way  below  the  aneurysmal  sac,  was  joined 
by  a  small  branch,  very  much  contracted,  which 
must  have  arisen  from  the  profunda,  or  the  trunk  of 
the  femoral  artery."  This  is  the  only  collateral 
branch  mentioned,  and  one  cannot  see  how  the  conclu- 
sion is  to  be  avoided  that  even  if  the  phrase  "to  take 
off  the  force  of  the  circulation"  meant  any  more  than 
"to  arrest"  or  "cut  off"  the  circulation,  it  meant 
only  that  the  artery  was  left  containing  blood,  and 
that  this  blood  was  in  communication  with  that 
brought  to  the  lower  part  of  the  same  artery  by  col- 
laterals coming  from  above  the  ligature.     It  would  be 


interesting,  too,  to  know  by  what  "profound  reason- 
ing Hunter  excogitated  the  principle"  (Holmes)  of 
including  the  vein  in  the  ligature  with  the  artery. 

Even  if  Hunter  afterward  declared  the  presence  of 
a  collateral  branch  between  the  ligature  and  the  sac 
to  be  a  favorable  condition,  it  does  not  affect  the 
original  conception;  and  furthermore,  the  existence 
of  such  a  collateral  branch  is  not  essential  to  the 
method,  and  it  is  not  found  when  the  carotid  or 
femoral  is  tied,  or  in  some  cases  when  the  external 
iliac  or  subclavian  is.  In  short  the  method  as  now 
employed  is  to  place  the  ligature  at  the  nearest  con- 
venient point,  sufficiently  far  above  the  sac  to  find 
the  artery  probably  healthy;  and  the  claim  that  has 
been  made  that  complete  arrest  of  the  circulation 
is  more  dangerous  than  partial  arrest,  because  it 
leads  to  the  formation  of  a  passive  clot  which  is 
likely  to  provoke  suppuration  of  the  sac,  has  been 
proved,  especially  by  the  experience  with  the  Esmarch 
bandage,  to  be  incorrect,  or  at  least  the  danger  of 
exciting  suppuration  is  much  less  than  was  claimed. 

The  changes  within  the  sac  by  which  a  cure  is  effected 
after  ligature  are  similar  to  those  above  described  as 
effecting  a  spontaneous  cure.  The  closure  of  the 
artery  relieves  the  sac  from  all  expanding  pressure, 
except  the  slight  amount  which  may  be  exerted  by 
the  blood  that  comes  into  the  artery  below  the  sac  or 
between  it  and  the  ligature  through  collateral  branches. 
The  pressure  being  removed,  the  sac  shrinks,  the 
blood  within  it  either  coagulates  in  mass,  forming  a 
dark  passive  clot,  or  a  slight  movement  persists  in  it 
and  laminated  fibrin  is  deposited  on  the  wall.  Pulsa- 
tion in  the  sac  ceases  as  soon  as  the  ligature  is  tied, 
and  usually  remains  permanently  absent,  but  in 
si  ime  cases  it  returns  after  a  longer  or  shorter  interval 
and  lasts  for  a  few  hours  or  days.  This  return  is 
due  to  the  freedom  and  rapidity  with  which  the  col- 
lateral circulation  is  established.  The  blood  leaves 
the  artery  through  the  branches  given  off  above  the 
ligature,  which  dilate  to  accommodate  the  increased 
supply,  makes  its  way  through  the  minute  terminal 
branches  and  capillaries  into  the  terminals  of  the 
branches  given  off  from  the  main  artery  below  the 
ligature,  passes  through  them  in  the  retrograde 
direction,  and  thus  regains  the  main  artery  to  be 
distributed  as  before  through  its  terminal  branches. 
The  greater  the  length  of  artery  that  has  been 
obliterated  by  the  ligature  and  disease,  the  greater  the 
difficulty  of  the  reestablishment  of  the  circulation,  and 
thus  it  is  found  that  when  two  or  three  aneurysms  are 
situated  upon  a  single  artery,  or  when,  on  account  of 
secondary  hemorrhage,  a  second  ligature  has  been 
placed  upon  the  artery  at  a  higher  point,  the  proba- 
bility is  great  that  the  circulation  will  be  reestab- 
lished too  slowly  or  imperfectly  to  preserve  the  life  of 
the  tissues,  and  the  occurrence  of  gangrene  is  to  be 
feared. 

The  method  of  operation  is  to  expose  the  artery 
by  a  suitable  incision,  denude  it  just  sufficiently  to 
allow  an  aneurysm  needle  to  be  passed  under  it,  and 
to  tie  it  with  a  sterile  ligature.  Silk  may  be  used, 
but  most  surgeons  prefer  today  the  thoroughly 
reliable  catgut;  when  moderately  chromicised  this 
remains  unchanged  ten  days  or  more. 

The  chief  dangers  of  the  operation  are  secondary 
hemorrhage  and  gangrene.  Before  the  introduction 
of  the  antiseptic  method  these  dangers  were  so 
great  that  the  mortality,  after  ligature  of  the  fem- 
oral, for  example,  was  about  twenty-five  per  cent. 
They  are  now  very  much  less.  In  twenty-nine  eases  of 
ligature  of  the  principal  arteries  with  catgut,  by 
New  York  surgeons,  collected  by  Stimson  in  1880 
(.4m.  Jour,  of  the  Mid.  Sciences,  January,  1S81), 
there  was  no  secondary  hemorrhage,  and  only  one 
ease  of  gangrene;  the  latter  was  of  the  foot,  after 
ligature  of  the  common  iliac  artery,  and  was  followed 
by  recovery.  The  diminution  of  the  risk  of  secondary 
hemorrhage  is  plainly  due  to  the  avoidance  of  sup- 


404 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SI  II  NCES 


Aneurysm,  External 


Duration  about  the  ligature,  and  the  freedom  from 
gangrene  appears  to  be  the  result  of  the  same  rapidity 
and  ease  oi  healing,  through  diminution  of  the  inter- 
ference with  the  \Ou  by  the  inflammatory  process. 

The  attempt  has  been  several  times  made  to  dimin- 
ish i  hi'  chance  nf  I  lie  occurrence  of  gangrene  by  rep 
edly  compressing  the  artery  above  the  aneurysm  for 
several  days  before  tying  it,  in  the  hope  of  thereby 
lually  enlarging  the  collaterals,  and  belter  fitting 
them  for  carrying  on  the  circulation  when  if  is  finally 
thrown  entirely  upon  them.  The  result  lias  not 
liorne  out  the  expectation;  on  the  contrary,  gangrene 
has  followed  the  attempt  in  a  larger  proportion  of 
cases  than  when  the  artery  lias  been  tied  without 
preliminary  compression.  A  satisfactory  explanation 
lot  been  found. 

i  n her  ill  results  of  the  ligature  of  the  main  artery  of 

a  limb  may  be  permanent  deterioration  of  its  nutrition, 

of    nerve    and    muscular    power,    persistent    or 

recurrent   ulceration  of  the  skin,  and  suppuration  of 

the  sac. 

In  order  to  diminish  the  chances  of  the  occurrence 
of  gangrene,  the  limb  should  be  wrapped  in  cotton 
immediately  after  the  operation,  and  kept  thus  pro- 
tected  from  losing  heat  until  the  circulation  is  shown 
to  be  fully  reestablished.  If  its  temperature  is  found 
main  too  low,  external  heat  should  be  cautiously 
applied  in  the  form  of  hot  bottles,  bricks,  or  sand,  but 
care  must  be  taken  that  the  heat  thus  applied  is  not 
much  above  the  normal  body  heat,  lest  it  should 
cause  blisters.  Good  results  have  been  reported 
from  the  use  of  baking  by  suitable  apparatus.  The 
temperature  can  be  raised  to  300°,  provided  moisture 
is  excluded. 

Suppuration  of  the  sac  may  occur,  and  either  cause 
spontaneous  rupture  or  make  an  incision  necessary. 
The  opening  may  be  followed  by  dangerous  hemor- 
rhage, or  the  communication  between  the  sac  and  the 
patent  portion  of  the  artery  may  have  previously 
become  permanently  obliterated.  Sometimes  pres- 
sure is  sufficient  to  arrest  the  hemorrhage  and  lead  to  a 
final  cure  by  granulation:  in  other  cases,  the  clots  will 
have  to  be  turned  out  and  all  bleeding  points  secured, 
or  a  second  ligature  may  be  applied  between  the  first 
one  and  the  sac.  A  second  ligature  above  the  first 
greatly  exposes  to  gangrene. 

If  pulsation  returns  permanently  in  the  sac  and  the 
tumor  again  begins  to  grow,  several  courses  are  open 
to  the  surgeon.  If  the  aneurysm  is  at  the  knee, 
groin,  or  elbow,  flexion  should  first  be  tried,  and  this 
failing,  perhaps  galvanopuncture.  If  resort  to  opera- 
tion becomes  necessary,  the  artery  may  be  tied  again 
between  the  first  ligature  and  the  sac,  or  the  "old 
operation"  of  incision  into  the  sac  and  ligature  of  all 
vessels  entering  it  may  be  done.  Both  methods  have 
proved  successful. 

The  numerous  statistics  that  have  been  collected  of 
the  various  results  following  treatment  by  ligature  do 
not  furnish  a  fair  basis  for  estimating  the  chances 
after  ligature  with  antiseptic  catgut  or  with  silk,  and 
treatment  of  the  wound  by  modern  methods.  There 
is,  therefore,  good  reason  to  believe  that  the  operation 
has  become,  under  antiseptic  methods  of  treatment, 
much  less  serious  than  it  formerly  was. 

In  like  manner  the  aseptic  ligature  has  caused  the 
entire  abandonment  of  various  devices  (metallic 
ligature,  artery  constrictor)  designed  to  diminish  the 
chance  of  the  occurrence  of  secondary  hemorrhage, 
except  for  the  methods  of  Halsted  and  Matas  whereby 
compression  is  produced  by  metallic  bands  which 
can  be  removed  or  their  pressure  effects  modified. 

iM  Compression  of  the  artery,  direct,  indirect,  and 
digital.  Direct  compression  is  made  upon  the  artery 
by  acupressure  needles  or  wires,  threads,  or  forceps, 
after  incision  of  the  skin  and  exposure  of  the  vessel; 
indirect  compression  is  made  by  suitable  instruments 
or  weights  resting  on  the  surface  over  the  artery; 
digital  compression  is  made  by  the  fingers. 


Indirect  eompre  sion  is  an  older  method  even  than 
ligature  of  the  artery,  and  was  em  ployed,  alt  hough  un- 
successfully, by  Desault  in  the  treatment  ol  an  axillary 
aneurysm  a  few  month  before  he  first  treated  a 
popliteal  aneurysm  by  ligature,  as  mentioned  above. 
It  is  claimed  for  Hunter,  al  o,  that  he  was  the  real 
originator  of  the  treatment  bj  eompre  -inn,  because 
In-  showed  that  complete  arre  I  ol  the  circulation  was 
unnecessary,  and  that  the  compression  might  be 
partial  or  intermittent,  and  because  all  previous 
operators  sought  to  effect  a  cure  by  obliterating  the 
artery  .it  the  point  pressed  upon,  a  statement  which 

does  not  appear  to  be  bo]  in     m!  by  the  report-  ol  their 

However  that  may  be,  the  for r  theory  that 

a  passive  clot  was  a  source  of  danger,  and  that  persist- 
ent pressure  upon  the  artery  to  arrest  the  circulation 
for  several  hours  was,  therefore,  a  more  dangerous 

method     than     intermittent    or    inc plete    arrest, 

which  would  give  a  laminated  clot  of  slow  formation, 
is  now  abandoned,  and,  as  a  rule,  when  compression 
is  used,  it  is  with  t he  aid  of  anesthesia  or  morphine,  is 
forcible  enough  completely  to  arrest  pulsation  in  the 
-ae.  and  is  continued  until  the  contents  of  the  sac 
have  coagulated.  Intermittent,  incomplete  arrest 
is  occasionally  used  under  exceptional  circumstances. 
In  a  few  cases  in  which  pressure  above  the  sac  could 
not  be  made,  complete  arrest  of  the  circulation  below 
it,  usually  by  the  elastic  bandage,  has  effected  a  cure. 
See  Distal  Ligature,  below.) 

The  method  of  cure  by  this  means  varies  in  the 
different  cases;  in  some  it  is  by  the  deposit  of  laminated 
clot,  in  others  by  a  soft  passive  clot.  The  changes 
in  the  aneurysmal  sac  are  the  same  as  those  above 
described,  and  the  dangers  of  the  method  are  the  same 
as  after  ligature,  with  the  exception  of  secondary 
hemorrhage.  A  unique  consequence,  reported  by 
Pemberton,  was  the  formation  of  a  communication 
several  months  afterward  between  the  artery  and 
vein  at  the  point  where  pressure  had  been  made, 
resulting  in  an  arteriovenous  aneurysm  that  finally 
caused  the  patient's  death. 

The  operative  methods  include  the  use  of  weights 
or  of  special  instruments  having  the  general  character 
of  a  truss.  The  latter  are  numerous  and  varied,  but 
all  consist  essentially  of  a  branch  to  make  counter- 
pressure  without  circular  constriction  of  the  limb,  and 
of  a  pad  which  can  be  screwed  or  bound  down  upon 
the  artery  with  suitable  force.  For  weights,  bags  of 
-hot  are  used,  or  pieces  of  lead  moulded  to  fit  the 
parts.  They  may  be  allowed  to  rest  entirely  upon 
the  limb,  or  may  be  suspended  by  an  elastic  cord. 

Prolonged  complete  arrest  of  the  current  requires 
the  aid  of  anesthesia,  for  the  pressure  soon  becomes 
very  painful;  anesthesia  may  be  safely  prolonged  for 
many  hours.  It  is  well  to  aid  the  control  of  the  circu- 
lation above  by  pressure  also  below,  or  by  tightly 
bandaging  the  limb  below  the  aneurysm. 

Digital  pressure,  which  had  previously  been  em- 
ployed in  two  cases  as  an  aid  to  compression  by  instru- 
ments, was  first  used  as  the  sole  means  of  cure  by 
Jonathan  Knight,  of  New  Haven,  Conn.  The  case 
was  one  of  popliteal  aneurysm,  and  a  cure  was 
effected  in  about  two  days.  The  plan  has  since  been 
employed  in  a  large  number  of  cases,  and  with  a  large 
measure  of  success.  Fischer's  statistics,  quoted  by 
Holmes,  contain  ninety  cases,  with  seventy-six  com- 
plete cures,  and  eight  deaths;  six  of  these  deaths 
occurred  after  subsequent  ligature,  the  remaining 
two  after  amputation.  In  about  one-third  of  the 
successful  cases  the  cure  was  effected  within  twenty- 
four  hours. 

Digital  pressure  can  be  made  only  with  the  aid  of  a 
considerable  number  of  assistants,  and  it  is  usual  to 
employ  them  in  pairs,  one  making  pressure  while  the 
other  feels  for  pulsation  in  the  sac.  The  skin  should 
be  covered  with  French  chalk  at  the  point  where  the 
pressure  is  made,  and  the  assistants  should  be  carefully 
instructed  as  to  the  amount  of  pressure  needed  and 


405 


Aneurysm,  External 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


the  place  where,  and  direction  in  which,  it  should  be 
made.  When  the  change  is  made  from  one  assistant 
to  another,  the  latter  should  place  his  finger  or  thumb 
upon  the  artery  immediately  above  or  below  that  of 
the  one  whom  he  replaces,  and  this  one  should  not 
remove  his  finger  until  after  the  artery  is  duly  com- 
pressed by  the  other.  Ether  or  morphine  should  be 
used  u  hen  the  patient  begins  to  complain  of  the  pain. 

(c)  Compression  by  Esmarch's  elastic  bandage. 
This  method  was  first  employed  in  1S75  by  Walter 
Reid,  of  the  British  navy,  in  a  case  of  popliteal 
aneurysm.  The  bandage  was  applied  tightly  to  the 
leg,  loosely  over  the  tumor,  and  then  tightly  over  the 
lower  third  of  the  thigh;  then  the  cord  was  put  on  and 
the  bandage  removed.  At  the  expiration  of  fifty 
minutes  the  pain  had  become  so  great  that  the  cord 
was  removed,  two  Carte's  compressors  on  the  upper 
portion  of  the  femoral  artery  having  been  substituted. 
At  the  expiration  of  three  hours  from  the  commence- 
ment the  aneurysm  was  found  to  be  pulseless;  inter- 
mittent pressure  was  kept  up  for  two  days,  and  then 
the  patient  was  pronounced  cured.  The  condition 
of  the  parts  found  at  the  death  of  the  patient  a  few 
months  later,  and  the  method  by  which  this  treatment 
appears  to  effect  a  cure,  have  been  described  above. 
In  January,  1881,  Stimson  collected  sixty-two  cases 
treated  by  this  method,  which  may  be  grouped  in  three 
classes  according  to  differences  in  detail.  In  the  first 
class,  fifty-two  cases,  Reid's  method  was  followed  ex- 
actly or  very  closely;  in  the  second  class,  five  cases, 
the  rubber  tubing  or  the  elastic  bandage  was  used 
repeatedly  and  alternately  with  the  tourniquet  or 
digital  pressure  to  arrest  the  circulation  for  several 
hours;  in  the  third  class,  five  cases,  the  bandage  was 
used  for  a  short  time  daily  for  many  successive  days, 
without  any  compression  of  the  artery  in  the  intervals, 
or  with  a  tourniquet  loosely  applied.  In  the  first 
class  there  were  twenty-eight  cures,  twenty-two 
failures,  and  two  deaths;  and  of  the  cures  twenty- 
four  were  obtained  by  a  single  attempt  continued  for 
about  an  hour  on  the  average,  the  extremes  of  time 
being  fifty  minutes  and  three  and  one-half  hours,  and 
four  by  two  attempts  each,  separated  by  an  interval 
of  from  one  to  four  days.  After  the  removal  of  the 
bandage  the  artery  was  compressed  with  a  tourni- 
quet or  the  fingers,  usually  for  a  few  hours,  but  in  one 
case  for  only  one  hour,  and  in  another  for  five  days. 
In  two  or  three  cases  pulsation  returned  in  the  aneu- 
rysm on  the  following  day,  and  was  then  definitely 
arrested  by  compression  for  a  few  hours.  In  twelve 
of  the  twenty-two  failures  the  same  method  was  used 
in  nineteen  different  attempts;  in  the  remaining  ten 
with  eighteen  attempts,  no  pressure  seems  to  have 
been  made  after  the  removal  of  the  bandage.  In  at 
least  five  of  the  twelve  the  method  was  skilfully  em- 
ployed, with  every  detail  used  in  most  of  the  success- 
ful cases;  they  show,  therefore,  when  added  to  the 
twenty-eight  cases  treated  successfully  by  this 
method,  that  it  may  be  expected  to  fail  in  at  least 
fifteen  per  cent,  of  the  cases.  As  for  the  remaining 
failures,  there  is  some  reason  to  suppose  that  the 
method  was  not  carried  out  with  as  much  care  and 
attention  to  details  as  it  was  in  the  others. 

A  very  important  fact  is  that  the  method  appears 
not  to  involve-  any  serious  risk,  and  not  to  diminish 
the  chances  of  success  if  resort  is  subsequently  had 
to  the  ligature.  Of  the  two  fatal  cases,  in  one  the 
bandage  Was  applied  twice  with  an  interval  of  three 
days,  and  retained  in  the  last  trial  for  nearly  eight 
hours.  The  patient  died  twenty-seven  hours  after- 
ward with  symptoms  of  heart  failure  or  shock,  the 
dorsum  of  the  foot  remaining  cold.  In  the  other  the 
aneurysm  (of  the  anterior  tibial  artery)  had  ruptured 
externally,  and  amputation  was  strongly  urged,  but 
refused  by  the  patient;  gangrene  of  the  foot  and  lower 
part  of  the  leg  followed,  and  the  patient  died  dur- 
ing the  second  week.  The  circumstances  in  each 
i.i  i-  were    quite    exceptional.     Bryant   applied    the 


bandage  twice  for  three  hours  each  time,  with  an 
interval  of  four  days,  in  a  case  of  popliteal  aneurysm 
in  a  man  forty-five  years  old.  A  fortnight  after 
the  second  attempt  he  tied  the  femoral  artery  with 
catgut,  the  wound  healed  by  immediate  union,  but 
"anemic  gangrene"  followed  and  the  leg  was  ampu- 
tated. This  is  the  only  instance  of  gangrene  in  the 
sixteen  cases  in  which  the  ligature  was  resorted  to 
after  the  bandage  had  failed  to  produce  a  cure. 

The  conclusion  to  be  drawn  from  all  these  cases 
seems  to  be  that  we  have  in  the  elastic  bandage  an 
efficient  means  for  safely  shortening  the  duration  of 
the  treatment  by  compression  of  popliteal  and  some 
femoral  aneurysms.  The  greater  efficiency,  the 
more  speedy  action  of  the  method  is  apparently  due 
mainly,  if  not  entirely,  to  the  arrest  of  the  circulation 
through  the  collateral  channels  as  well  as  through 
the  main  artery,  thus  securing  absolute  stagnation  of 
the  contents  of  the  sac.  Consequently  the  rubber 
tubing,  which  is  drawn  tightly  twice  or  three  times 
about  the  limb  above  the  aneurysm,  is  to  be  deemed 
the  efficient  part;  and  the  principal,  perhaps  the  sole 
benefit  from  the  bandage  is  that  of  making  a  less 
severe  constriction  by  the  tubing  sufficient. 

The  method  of  carrying  out  this  procedure  is 
simple:  thus,  in  popliteal  aneurysm,  the  bandage 
should  be  applied  tightly  to  the  leg,  loosely  over  the 
aneurysm,  and  tightly  again  above  it,  and  the  bandage 
or  the  tubing  should  be  kept  in  place  for  one  or  two 
hours;  then  the  artery  should  be  compressed  by  a 
tourniquet  or  the  fingers  for  several  hours  afterward, 
the  compression  being  occasionally  intermitted  for  a 
moment  to  see  if  pulsation  returns  in  the  sac.  If 
pulsation  returns  within  a  few  hours,  the  artery 
must  be  again  compressed.  The  introduction  of 
needles  or  a  coagulating  injection  might  be  proper  in 
connection  with  a  second  trial  after  a  failure.  Matas 
{Annals  of  Surgery,  vol.  lii.,  p.  126)  describes  an 
elaboration  of  this  test. 

(d)  Compression  by  flexion  of  the  limb.  When  an 
aneurysm  is  situated  at  the  bend  of  a  joint,  pulsation 
in  it  may  sometimes  be  diminished  or  arrested  by 
flexion  of  the  joint,  and  this  fact  has  been  occasionally 
utilized,  either  as  the  principal  means  of  treatment  or 
as  an  adjuvant  thereto. 

The  method  appears  to  have  been  first  suggested  by 
Fleury,  a  French  surgeon,  in  a  paper  published  in  the 
Journal  de  Chirurgie,  in  1846,  as  an  inference  from  his 
success  in  curing  a  wound  of  the  brachial  artery  at  the 
elbow  by  flexion.  In  18.52  the  suggestion  was  put  into 
practice  by  Thierry  in  a  case  of  traumatic  aneurysm 
at  the  elbow,  and  in  1857  a  large  popliteal  aneurysm 
was  cured  by  flexion  of  the  knee  by  Maunoir  of 
Geneva.  He  tried  at  first  to  keep  the  leg  forcibly 
Hexed  upon  the  thigh,  but  the  patient  could  not 
endure  the  pain,  so  he  had  to  be  content  with  keeping 
it  partly  flexed  by  a  strap  crossing  the  shoulders, 
while  the  patient  went  about  on  crutches.  This 
was  kept  up  about  three  weeks,  at  the  end  of  which 
time  the  tumor  had  ceased  to  pulsate. 

Flexion  has  been  used  successfully  in  aneurysms  of 
the  popliteal  artery,  at  the  groin,  and  at  the  elbow. 
Of  forty-nine  cases  of  popliteal  aneurysm  treated  by 
flexion,  analyzed  by  Liegeois,  twenty-six  were  cured, 
in  eleven  of  which  flexion  alone  was  used,  in  eleven 
others  flexion  in  combination  with  other  means,  and 
in  four  flexion  after  other  means  had  failed.  It  \\:is 
first  used  at  the  groin  by  Gurdon  Buck  at  the  New 
York  Hospital  in  an  aneurysm  which  had  recurred 
sixteen  months  after  apparent  cure  by  compression. 
Pressure  on  the  external  iliac  did  not  arrest  the 
pulsation,  and  flexion  was  tried  as  the  only  alternative 
lor  treatment  by  laying  open  the  sac.  In  a  case  of 
inguinal  aneurysm  treated  by  Eldridge,  of  Yokohama, 
a  cure  was  obtained  by  keeping  the  thigh  flexed  upmi 
the  pelvis  for   twenty  days. 

In  making  use  of  the  method  it  seems  to  be  usually 
necessary  to  carry  the  flexion  to  a  point  at  which  it 


406 


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Aneurysm,  External 


markedly  diminishes  the  pulsation  in  the  tumor,  ami 
perhaps  arrests  ii  entirely,  and  then  to  keep  the  limb 
in  tins  position  for  a  long  time  by  suitable  bandage   oi 

apparatus.     It  is  well,  also,  in  popliteal  aneurysm,  to 

bandage  the  leg  up  to  the  knee  to  prevent  swelling. 
The  turrits  of  the  method  lie  in  the  facility  with  u  hich 
it  can  be  carried  out,  and  in  the  freedom  from  the 
chance  of  accidents  if  care  is  taken  not  to  make  too 
ible  pressure. 

:>.  Permanent  arrest  or  obstruction  of  the  stream  on 
the  distal  side. 

By  distal  ligature  (Brasdor's  and  Wardrop's 
methods).  Distal  ligature,  firsl  suggested  by  Brasdor 
and  Desanlt  toward  the  end  of  the  eighteenth  century, 
was  first  performed  by  Deschamps  in  1798;  the  femoral 
v  was  tied  in  the  middle  of  the  thigh  for  the  cure 
of  a  large  aneurysm,  the  upper  border  of  which  was 
less  than  a  finger's  breadth  below  Poupart's  ligament. 
As  rupture  of  the  sac  threatened  on  the  fourth  day, 
the  artery  was  compressed  on  the  pubis,  the  sac 
opened,  and  the  vessel  tied  above  and  below;  the 
patient  died  eight  hours  afterward.  The  operation 
was  next  performed  by  Sir  Astley  Cooper,  who  tied  the 
common  femoral  artery  below  the  epigastric  for  a 
large  aneurysm  of  the  external  iliac;  the  patient 
recovered  from  the  operation,  but  the  aneurysm 
continued  to  pulsate  and  soon  afterward  ruptured. 
In  1825  Wardrop  obtained  the  first  success,  tying  the 
<  ommon  carotid  on  the  distal  side  of  a  large  aneurysm 
in  a  woman  fifty-seven  years  old.  Wardrop's  efforts 
to  popularize  the  operation,  and  especially  his 
extension  of  it  to  aneurysms  of  the  innominate  artery, 
have  permanently  associated  his  name  with  it  as 
distinctive  of  that  form  in  which  the  current  is  not 
completely  arrested,  but  continues  only  through 
branches  given  off  from  the  artery  between  the 
ligature  and  the  sac;  while  the  name  of  Brasdor  is 
given  to  that  form  in  which  there  are  no  such  branches 
and  the  arrest  of  the  current  is  complete. 

The  operation  is  practically  limited  to  aneurysms  at 
the  root  of  the  neck,  those  of  the  common  carotid, 
subclavian,  and  innominate.  In  some  cases  in  which 
an  aneurysm  of  the  arch  of  the  aorta  has  been  mistaken 
for  an  innominate  aneurysm,  and  the  carotid  and  the 
subclavian  in  its  third  portion  have  been  tied,  marked 
relief  of  symptoms  has  followed,  and  in  two  or  three 
cases  the  left  carotid  has  been  tied  for  recognized 
aortic  aneurysm.  The  operation  benefits  by  arresting 
or  retarding  the  circulation  in  the  vessel  and  sac  and 
thus  favoring  the  formation  of  a  laminated  clot.  The 
anticipation  that  the  pressure  within  the  sac  would 
be  increased  by  the  distal  ligature  has  proved  un- 
founded, and  the  first  effect  of  the  operation  has 
often  been  an  immediate  decrease  in  the  size  of  the 
aneurysm  and  in  the  force  of  its  pulsation. 

The  proportion  of  successes  previous  to  the  introduc- 
tion of  the  antiseptic  ligature  was  very  small,  but  with 
the  introduction  of  this  form  of  ligature  the  operation 
entered  upon  a  new  career  of  usefulness  and  of  appli- 
cability to  cases  that  had  been  beyond  aid  by  surgical 
art.  In  eight  cases  of  ligature  of  the  carotid'  and  sub- 
clavian for  innominate  aneurysm  in  which  catgut  was 
used,  death  was  caused  by  the  operation  in  only  one, 
and  other  successes  have  been  since  reported.  Monod 
and  Yanverts  collected  seventy-nine  cases,  the  results 
being  operative  mortality  S.  5  per  cent.,  lasting  improve- 
ment 60. S  per  cent.,  failures  21.7  per  cent.  It  is,  of 
course,  less  certain  in  its  action  than  ligature  on  the 
proximal  side,  and  its  use  will  therefore  be  restricted 
to  cases  in  which  the  proximal  ligature  or  compression 
i*  impossible  or  too  dangerous — in  other  words,  to 
aneurysms  at  the  root  of  the  neck,  and  perhaps  of  the 
external  or  common  iliac.  It  is  to  be  judged  not 
by  comparison  of  its  proportion  of  successes  with  that 
of  other  methods,  but  rather  as  a  grave  alternative 
in  a  limited  class  of  cases  that  are  open  to  few  other 
means  of  treatment,  and  that  lead  inevitably,  if  left 
to  themselves,  to  prompt  and  certain  death. 


Manipulation  or  malaxation  of  the  aneur; 

This  method,  introduced  by  l  erguson  in   L852  and 

employed  twice  by  him,  rests  upon  the  same  print 
as    the    distal    ligature — arrest    or    diminution  of  the 
current   by  an  obstacle  placed  upon  the  distal  side  of 
ac.      In  this  method   thi  is  a  fragment 

of  old  clot  mechanically  displaced  from  the  wall  of  the 
and  lodged  within  the  artery.  This  displacement 
of  a  clot  is  thought  to  be  the  mechanism  by  which 
many  of  the  so-called  spontaneous  cures  have  been 
obtained.  The  conditions  essential  to  its  employ- 
ment are  the  presence  of  enough  laminated  clot  in  the 
sac  to  make  the  detachment  of  a  piece  of  sufficient 
size  possible  and  practicable  by  external  manipulation, 
and  the  impossibility  of  safely  resorting  to  other 
methods  of  treatment.  The  latter  condition  limits 
the  method  to  a  small  number  of  cases,  mainly  those 
situated  upon  the  subclavian  artery.  It  is  inapplicable 
to  those  situated  upon  the  carotid,  because  of  the 
certainty  that  small  fragments  will  pass  into  the  arter- 
ies of  the  brain  and  become  cerebral  emboli,  with 
consequent  paralysis. 

4.  Rapid  coagulation  of  the  blood  in  the  sac,  with 
or  without  temporary  arrest  of  the  stream. 

(a)  Coagulating  injections.  This  also  is  a  method 
of  very  limited  applicability,  and  is  only  mentioned 
for  the  sake  of  historical  record;  it  can  be  used  only 
as  an  adjuvant  to  other  methods,  or  in  exceptional 
cases,  as  of  recurrence  or  of  pouched  aneurysms. 

Hydrate  of  chloral  has  been  recently  recommended. 

(6)  Introduction  of  solid  bodies.  A  few  attempts 
have  been  made  to  induce  coagulation  of  the  blood 
in  an  aneurysm  by  permanently  or  temporarily 
introducing  foreign  bodies,  such  as  wire,  needles, 
horsehair,  catgut.  The  method  rests  upon  the  well- 
known  facts  that,  if  freshly  drawn  blood  is  whipped 
with  a  bundle  of  fine  rods,  the  fibrin  collects  upon 
them,  and  that  firm  clot  forms  upon  a  foreign  body 
introduced  into  an  artery  or  vein.  With  one  or  two 
exceptions  these  attempts  have  been  made  upon 
aneurysms  that  were  not  open  to  treatment  by  any 
of  the  methods  of  ligature  or  compression,  such  as 
aneurysms  of  the  aorta  and  subclavian.  The  first 
case  of  permanent  introduction  was  that  of  Mr.  Moore; 
the  first  of  temporary  introduction  of  needles,  those 
of  Rizzoli  and  Malago.  All  these  methods  are  obso- 
lete to-da37  and  have  been  replaced  by  the  Moore- 
Corradi  method  of  introducing  gold  wire  into  the 
aneurysm  and  performing  electrolysis.  Good  reports 
have  been  given  by  Lusk,Stuart,  and  Finney  (Annals 
of  Surgery,  May,  1912). 

(c)  Galvanopuncture.  In  this  method  the  con- 
stant galvanic  current  is  employed  to  produce  rapid 
coagulation  of  the  blood  in  the  sac.  The  details  of 
the  operation,  as  employed  in  different  cases,  vary 
greatly.  Most  operators  will  to-day  prefer  to  use 
the  wiring  method  already  referred  to. 

5.  Promotion  of  the  formation  of  a  laminated  clot 
by  irritation  of  the  wall,  "needling."  This,  recently 
introduced  by  Macewen,  has  led  in  a  number  of  cases 
to  marked  reduction  of  the  symptoms  and  even 
apparent  cure.  A  long,  stiff  needle  is  pushed  through 
the  sac  until  its  point  reaches  the  opposite  side  where 
it  is  moved  to  and  fro  so  as  to  scratch  the  surface. 
By  changing  its  direction  several  areas  may  be  thus 
irritated  without  withdrawal  and  reintroduction  of 
the  needle. 

Traumatic  Aneurysm,  and  Rupture  op  an-  Ar- 
tery.— A  traumatic  aneurysm  is  one  which  owes  its 
formation  to  a  wound  of  the  artery  that  has  divided 
all  its  coats,  or  to  an  injury  (stretching,  bruising)  that 
has  divided  one  or  more  of  them.  The  common  cause 
is  a  penetrating  or  punctured  wound;  less  common 
causes  are  overstretching  in  the  neighborhood  of  a 
joint  and  fracture.  The  continuity  of  the  artery  is 
usually  not  entirely  destroyed,  and  while  some  of  its 
blood  escapes  into  the  adjoining  tissues  the  remainder 


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continues  within  it  and  is  distributed  through  its 
branches.  The  effused  blood  is  in  part  absorbed, 
and  in  part  coagulates;  and  after  a  time  a  distinct 
sac  forms  about  it,  by  condensation  of  the  tissues, 
and  it  then  differs  in  no  essential  way  from  the  com- 
mon encysted  form  of  aneurysm.  Its  symptoms  and 
it-  subsequent  course  are  then  the  same,  but  during 
the  stage  of  formation  of  the  sac  the  condition  is 
associated  with  dangers  peculiar  to  itself.  There 
is  the  history  of  the  injury,  absence  or  diminution  of 
pulsation  in  distal  branches,  local  swelling  and 
ecchymosis,  and  sometimes  marked  lowering  of  the 
temperature  of  the  limb.  There  is  usually  a  bruit 
but  no  pulsation  in  the  swelling  at  first,  but,  after 
the  sac  has  formed,  the  expansive  pulsation  charac- 
teristic of  an  aneurysm  is  present. 

During  the  formative  stage  of  the  sac  the  injury  is 
peculiarly  amenable  to  treatment  by  direct  pressure 
at  the  seat  of  injury;  and  often  after  the  sac  has 
formed  a  cure  may  be  effected  by  the  same  means. 
This  is  the  one  important  practical  point  of  difference 
between  traumatic  and  spontaneous  aneurysms. 

When  the  injury  is  associated  with  fracture  of  a 
bone  the  immediate  treatment,  unless  the  symptoms 
are  very  alarming,  should  be  confined  to  securing  the 
repair  of  the  fracture  and  to  limiting  the  extravasa- 
tion of  blood  by  suitable  pressure,  and  the  treatment 
of  the  aneurysm  should  be  postponed,  if  possible, 
until  after  the  bone  has  united.  The  presence  of  the 
extravasated  blood  is  not  a  serious  obstacle  to  this 
repair,  while  the  conversion  of  the  fracture  into  a 
compound  one  by  an  incision  made  to  secure  the 
wounded  artery  may  have  very  serious  consequences. 

Exceptionally,  the  extravasation  may  be  so  free  as 
to  endanger  the  vitality  of  the  limb  by  its  interference 
with  the  circulation,  and  under  such  circumstances 
the  surgeon  may  be  compelled  to  turn  out  the  clots 
and  secure  the  vessel,  or  even  to  amputate.  This  is 
much  more  likely  to  be  the  case  in  complete  rupture 
of  the  artery,  when  none  of  the  blood  brought  by 
the  artery  is  carried  past  the  injury  into  its  distal 
branches,  but  all  is  poured  out  into  the  tissues,  and, 
being  bound  down  by  the  enveloping  fascia,  exerts  a 
pressure  which  checks  the  venous  flow  and  prevents 
the  establishment  of  collateral  circulation.  This  con- 
dition is  characterized  by  great  and  uniform  swelling, 
absence  of  pulse,  and  notable  loss  of  temperature  in 
the  limb. 

Arteriovenous  Aneurysm. — When  an  abnormal 
direct  communication  is  established  between  the 
trunk  of  an  artery  and  that  of  a  neighboring  vein, 
the  condition  is  known  as  an  arteriovenous  aneu- 
rysm. When  the  two  vessels  remain  in  close  con- 
tact,  and  the  blood  passes  directly  from  the  artery 

into  the  vein, 
the  variety  is 
known  as  aneu- 
rysmal  varix, 
the  prominent 
feature  being  a 
varicose  dilata- 
tion of  the  vein. 
When,  on  the 
other  hand,  an 
aneurysmal 
pouch  is  formed 
by  condensation  of  the  adjoining  tissues,  the  variety  is 
known  as  a  varicose  aneurysm,  or  as  an  arteriovenous 
aneurysm  in  the  narrow  sense.  In  the  great  majority 
of  cases  of  varicose  aneurysm  the  aneurysmal  sac  is 
intermediate  between  the  artery  and  the  vein,  and 
blood  passes  through  it  on  its  way  from  the  former  to 
the  latter.  Broca  describes  a  sub-variety,  in  which 
the  artery  and  vein  communicate  directly  with  each 
other  and  there  is  an  aneurysmal  pouch  lying  on  the 
opposite  side  df  the  artery.  Probably  tile  distinction 
could  not  be  made  during  life.     In  some  of  the  classi- 


Fig.  23S. — Arteriovenous  Aneurysm.  (Bell.) 


fications  any  case  that  presents  a  distinct  aneurysmal 
tumor,  whether  enclosed  by  a  sac  of  new  formation 
or  by  one  formed  by  circumscribed  dilatation  of  the 
vein,  is  called  a  varicose  aneurysm;  but  the  latter 
variety,  that  in  which  the  aneurysm  is  formed  by 
dilatation  of  the  vein,  seems  to  be  much  more  closely 
allied  in  every  way  to  aneurysmal  varix. 

The  common  cause  of  this  affection  is  a  wound 
involving  both  the  artery  and  the  vein;  but  in  some 
cases  the  communication  forms  by  ulceration  of  the 
wall  of  the  vein  where  it  is  pressed  upon  by  an  aneu- 
rysm, and  in  one  case  (reported  by  Pemberton  in 
Med.-Chirurg.  Trans.,  vol.  xliv.,  p.  189)  an  arterio- 
venous aneurysm  formed  at  the  groin  ten  months 
after  prolonged  instrumental  pressure  had  been 
made  at  that  point  to  cure  a  popliteal  aneurysm. 
The  most  frequent  cause  by  far,  in  the  past,  has  been 
the  wounding  of  the  artery  in  venesection  at  the 
elbow.  The  usual  cause  in  recent  times  is  a  gunshot 
or  stab  wound.  Another  occasional  cause  is  fracture 
of  the  base  of  the  skull,  by  which  the  carotid  artery 
is  torn  in  the  cavernous  sinus.  Spontaneous  forma- 
tion by  rupture  of  an  aneurysm  into  a  vein  i.s  rare,  and 
almost  confined  to  thoracic  and  abdominal  aneurysms. 

The  'pathological  changes  which  are  found  in  this 
class  of  aneurysms  vary  greatly  in  their  details, 
according  to  the  character  and  extent  of  the  primary 
injury  and  of  the  communication  between  the  vessels, 
and  to  the  distance  of  the  vessels  from  the  heart. 
The  principal  factor  in  the  production  of  these  changes 
is  the  extent  to  which  the  intraarterial  pressure  is 
transferred  to  and  exerted  upon  the  wall  of  the  vein 
and  the  aneurysmal  sac;  and  this  is  determined  by  the 
size  of  the  opening  in  the  artery  and  by  the  resistance 
offered  to  the  return  of  the  blood  through  the  vein  to 
the  heart.  Hence,  when  the  communication  is  be- 
tween an  artery  and  a  large  venous  trunk,  such  as  the 
internal  jugular,  which  can  readily  carry  away  the 
excess  of  blood  almost  as  rapidly  as  it  is  supplied,  the 
distending  force  is  not  much  exerted  and  the  obstruc- 
tive changes  in  the  vein  are  slight;  but  when  the 
communication  is  between  an  artery  and  a  vein  in  one 
of  the  extremities,  or  in  the  head,  an  immense  aneu- 
rysmal pouch  may  be  formed  or  the  veins  may  become 
greatly  dilated  and  varicose.  The  pouch  usually  has 
a  smooth  internal  surface  and  contains  little  or  no 
stratified  clot,  and  when  it  is  formed  in  great  part  by 
dilatation  of  the  vein,  the  orifices  of  other  veins  open- 
ing into  it  are  seen  at  various  points,  and  these  veins 
are  enlarged  and  their  walls  thickened. 

The  artery  below  the  point  of  communication  is 
smaller  than  normal,  and  if  it  has  been  entirely 
divided  by  the  original  injury,  the  lower  portion  may 
be  occluded  at  the  point  of  division;  the  end  of  the 
upper  portion  is  kept  open  by  the  stream  of  blood. 

The  symptoms  vary  somewhat  with  the  pathological 
changes;  there  may  be  a  well-defined  pulsating  tumor, 
presenting  the  usual  features  of  an  aneurysm  and  the 
special  ones  peculiar  to  this  variety,  or  there  may  be 
simply  a  diffused  swelling  of  the  region,  or  the  super- 
ficial adjoining  veins  may  be  markedly  varicose.  The 
special  features  are  the  bruit  and  the  thrill.  The 
bruit  is  continuous,  with  a  systolic  reinforcement:  it 
is  most  intense  immediately  over  the  point  of  commu- 
nication between  the  vessels,  and  becomes  less,  or 
may  be  changed  into  an  intermittent  murmur,  as  the 
distance  from  this  point  increases.  This  apparent 
intermittence  is  due  simply  to  the  fact  that  the  por- 
tion of  the  murmur  which  corresponds  in  time  to  the 
contraction  of  the  heart  is  louder  than  the  rest,  and  is 
heard  at,  a  distance  at  which  the  latter  has  become 
inaudible.  In  some  cases  the  murmur  could  be  heard 
at  a  great  distance  along  the  vessels;  thus  in  one 
quoted  by  Follin,  it  could  be  heard  from  the  elbow  to 
the  heart;  in  another  (of  the  femoral),  from  the  head 
to  the  feet.  The  thrill  is  a  peculiar  sensation  given  to 
the  hand  when  laid  upon  the  aneurysm,  a  vibration 
that  has  been  compared  to  the  purring  of  a  cat. 


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Ani-ur;  -in.  External 


The  interference  with  the  circulation  below  the 
point  of  communication  is  commonly  well  marked,  and 
i-  shown  by  swelling  of  the  limb  which  is  not  edema, 
but  which,  in  some  cases  at  least,  i-  an  actual  hyper- 
trophy, and  is  accompanied  by  a  permanent  elevation 
of  i  he  temperature  of  the  limb,  by  a  greater  growth  of 
hair  upon  it.  and  in  one  case  by  an  increase  of  an  inch 
in  lengl  h.  There  is  a  feeling  of  numbness  or  of  act  ual 
pain  in  the  limb,  increased  by  its  use,  and  there  may 
be  a  marked  loss  of  muscular  power,  and  sometimes 
persistent  ulcers  or  eczema. 

The  lesion  may  fail  to  become  apparent  until  some- 
time after  the  receipt  of  the  injury  (four  years  in  one 
case),  and  commonly  it  remains  stationary  after 
havin.s  reached  a  certain  development.  Thus,,  situ- 
ated upon  the  great  vessels,  the  carotid  and  internal 
jugular  for  example,  seldom  cause  any  inconvenience 
he  patient.  In  a  few  cases  the  opening  into  the 
vein  has  closed  spontaneously,  and  the  aneurysm  has 
been    thus    transformed   into   a   simple   arterial   one. 

Treatment. — In  recent  cases  carefully  graduated. 
direct  pressure  has  sometimes  availed  to  close  the 
opening,  and  this  may  be  aided  by  compression  of  the 
artery  above.  Operative  interference  in  the  past, 
which  has  included  a  variety  of  methods,  has  proved 
exceptionally  dangerous,  but  the  statistics  for  obvious 
reasons  have  lost  much  of  their  value  with  the  improve- 
ment in  operative  methods  and  in  the  treatment  of 
grounds.  The  operations  may  be  divided  into  two 
main  classes,  according  as  the  sac  is  or  is  not  opened, 
and  in  the  latter  class  they  will  further  vary  accord- 
ing to  the  number  of  the  ligatures  applied. 

The  question  of  interference  will  be  determined  by 
the  extent  of  the  disability  and  the  number  of  vessels 
involved  in  the  lesion.  In  the  forearm  or  on  the  scalp 
it  is  usually  practicable  to  tie  all  the  vessels,  arterial 
and  venous,  that  are  involved,  and  thus  effect  a 
radical  cure.  In  the  neck  (carotid  and  jugular)  the 
history  of  recorded  cases  shows  that  the  lesion  rarely 
causes  more  than  a  moderate  amount  of  inconvenience 
that  can  be  easily  borne  by  the  patient. 

Ligature  of  the  artery  alone  on  the  proximal  side, 
in  arteriovenous  aneurysm  of  the  lower  extremity,  has 
proved  remarkably  fatal  by  gangrene.  In  twelve 
cases  collected  by  Van  Buren,  the  external  iliac  was 
tied  in  five  and  the  common  femoral  in  two  and  gang- 
rene followed  in  all;  the  femoral  was  tied  in  five,  and 
;rene  occurred  in  two.  Monod  and  Vanverts 
cite  eighteen  cases  with  only  thirty-eight  per  cent,  of 
successes.  This  extraordinary  frequency  is  presum- 
ably due  to  the  easj'  return  to  the  heart,  through  the 
opening  into  the  vein,  of  the  blood  brought  to  the 
distal  segment  of  the  artery  by  the  collateral  branches; 
it  fails  to  pass  on  and  nourish  the  limb.  Consequently 
a  second  ligature  applied  to  the  artery  close  below  the 
opening,  diminishes  the  chance  of  gangrene.  Ligature 
of  all  the  veins,  as  well  as  of  the  artery,  suppresses  all 
subsequent  growth  of  the  sac  or  continuance  of  the 
disease,  but  it  adds  a  factor  that  is  most  important  in 
the  production  of  gangrene — obstruction  of  the 
venous  flow.  Moreover,  the  operative  difficulties  are 
extreme.  The  record  of  cases  in  which  the  sac  has 
been  opened  and  the  attempt  made  to  arrest  all  bleed- 
ing from  it,  is  such  as  to  discourage  any  one  from 
undertaking  it;  again  and  again  operators  have  had  to 
resort  to  ligatures  en  masse,  passed  by  means  of  curved 
needles,  and  more  or  less  blindly,  in  deep,  inaccessible 
corners  of  the  wound,  to  the  actual  cautery,  and  even 
to  styptics  and  pressure.  The  incision  has  always 
been  very  long,  and  the  tissues  have  been  bruised  and 
lacerated  by  the  prolonged  search  and  dissection.  The 
method  seems  to  violate  all  the  principles  that  govern 
modern  methods  of  making  and  treating  wounds,  and 
it  does  so,  in  the  effort  to  attain  an  end  that  is  not 
only  unnecessary,  but  introduces  an  element  of  great 
additional  danger.  Monod  and  Vanverts  found  that 
quadruple  ligation  of  the  vessels  resulted  in  gangrene 
three  times  out  of  fifteen,  while  incision  or  extirpation 


nf  the  sac  gave  such  a  result  in  only  two  out  of  one 
hundred  and  seventeen  cases. 

A    few   successes    have    been    obtained    by    galvano- 

puncture  and  by  the  inject  inn  oi  coagulating  solutions 
without  ligaturing  any  vessel,  and  quite  recently,  in 

a  few  cases  in  which  the  changes  were  not  very  ex- 
tensive, the  sac  has  been  successfully  extirpated. 
Cirsoid  \\i  i  rysw  (arterial  varix;  aneurysm  by 
anastomosis). — This  name  ha-  been  given  to  an 
affection  of  the  arteries,  sometimes  involving  also  the 
capillaries  ami  even  the  derived  veins,  which  differs 
materially  from  that  which  constitute-  the  common 
variety  of  aneurysm,  and  i-  characterized  by  a  uni- 
form or  irregular  dilatation  and  to  Ilgthening 
of  an  artery  and  its  branches.  The  affection  is  mo  I 
common   in    the   superficial   arteries  of   the   head — the 

temporal,  occipital,  and  auricular — but  it  is  also  found 
in  the  hand,  forearm,  leg,  and  even  involving  the  ex- 
ternal iliac  artery. 

The  change  consists  in  a  dilatation  and  lengthening 
of  the  artery,  with  atrophy  of  its  middle  coat  and 
consequent  thinning  of  the  wall,  or  possibly  with 
hypertrophy  by  thickening  of  the  middle  coat  in  the 
early  stages;  the  dilatation  may  make  the  caliber  of 
the  vessel  ten  time-  larger  than  normal,  and  may  Ik; 
uniform,  but  is  usually  accompanied  by  the  formation 
of  small  pouches.  In  consequence  of  the  lengthening 
the  artery  assumes  a  tortuous  form.  The  change  has  a 
marked  tendency  to  spread  in  both  directions,  in- 
volving the  arterial  branches  and  even  the  consecu- 
tive capillaries  and  veins,  and  in  the  latter  case  it  is 
known  as  aneurysm  by  anastomosis  or  racemose 
ant  urysm.  There  is  also  reason  to  think  that  in 
some  cases  the  change  has  originated  in  a  nevus  and 
has  spread  backward  to  the  arteries.  At  the  central 
portion  of  the  tumor,  where  the  tortuous  and  dilated 
vessels  are  most  numerous  and  closely  packed,  there 
may  exist,  as  Lefort  has  pointed  out,  a  sort  of  central 
lake,  as  in  cavernous  angioma,  or  a  real  aneurysm 
or  even  an  arteriovenous  aneurysm.  The  overlying 
skin  and  soft-  parts  may  be  thinned,  or  thickened  ami 
indurated,  and  the  underlying  bone  may  be  absorbed 
in  consequence  of  the  pressure. 

The  principal  causes  are  found  in  contusions  and 
preexisting  erectile  tumors  or  birth-marks,  and  the 
change  takes  place  most  frequently  at  the  time,  or 
shortly  after,  the  age  of  puberty  is  reached.  In  w  hat 
manner  or  through  what  agency  these  causes  act  is  not 
known,  nor  why  the  region  of  the  head  is  the  common 
-cat.  Blake  and  Auchencloss  in  a  study  of  the 
etiology  and  pathology  of  cirsoid  aneurysms  ascribe 
trauma  as  a  frequent  cause,  and  emphasize  the  fact 
that  they  tend  to  extend  centripeally,  i.e.  toward  the 
heart.  Some  of  the  microscopic  findings  show  ap- 
pearances somewhat  resembling  conditions  seen 
in  a  dissecting  aneurysm.  (Medical  Record,  June 
24,  1011.) 

The  symptoms  of  the  disease  are  a  soft,  ill-defined 
swelling  under  the  skin,  in  which  numerous  pulsating 
vessels  can  be  felt,  and  into  which  tortuous  arteries 
can  be  seen  to  pass.  The  overlying  skin  is  reddened 
or  livid,  either  by  implication  of  its  own  minute  ves- 
sels or  by  transmission  of  the  color  of  the  blood  below 
it;  the  tumor  communicates  a  sort  of  thrill  to  the 
hand,  and  a  continuous  murmur  to  the  ear.  In  a 
complete  typical  case  four  distinct  varieties  of  changes 
or  lesions  can  be  recognized:  First,  a  cutaneous 
erectile  tumor,  formed  by  dilatation  of  the  arterial 
capillaries  of  the  skin;  second  a  subcutaneous  arterial 
cir-oid  tumor,  formed  by  the  dilatation  of  the  finest 
arterioles  under  and  around  the  first ;  third,  dilatation 
and  tortuosity  of  the  main  arteries  leading  to  the 
tumor;  fourth,  dilatation  of  the  veins  coming  from  the 
tumor,  sometimes  with  pulsations  S3rnchronous  with 
those  of  the  heart. 

The  affection  is  a  serious  one,  because  of  its  tendency 
to  increase  and  the  danger  of  hemorrhage  through 
ulceration    of    the    skin   or   an    accidental    injury. 


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Treatment  has  generally  proved  not  only  difficult, 
bloody,  and  dangerous,  but  also  unsatisfactory  as  re- 
gards the  cure  of  the  disease.  It  comprises  ligature  of 
the  main  trunks  from  which  the  affected  arteries  arise, 
as  of  the  temporal,  or  the  external  or  common  carotid, 
in  cirsoid  aneurysm  of  the  scalp;  excision  or  incision  of 
the  tumor;  caustics;  galvanopuncture  and  coagulating 
injections,  or  extirpation  of  the  main  trunk  leading  to 
the  aneurysm,  this  latter  not  being  touched  at  all.  A 
suitable  case  is  an  aneurysm  of  the  temporal  region 
cured  by  excision  of  the  external  carotid  to  its  bifur- 
cation into  the  internal  maxillary  and  temporal  arteries 
(Blake  and  Auchencloss,  Medical  Record,  June  24, 
1911).  Lefort,  who  made  a  careful  study  of  eighty- 
three  cases,  says  that  whenever  treatment  has  been 
directed  only  to  the  afferent  arteries,  it  has  failed  or 
has  produced  only  an  incomplete  cure;  but  that,  on 
the  other  hand,  the  obliteration  of  the  vessels  forming 
the  central  portion  of  the  mass  has  been  followed  by 
the  return  of  the  afferent  vessels  to  their  normal  con- 
dition. He  claims,  therefore,  that  the  treatment  should 
always  be  directed  to  this  central  portion.  It  in- 
cludes three  methods:  removal  or  destruction  of  the 
mass  by  caustics  or  the  knife;  the  injection  of  coagulat- 
ing liquids;  galvanopuncture.  Removal  by  the 
knife  exposes  to  severe  hemorrhage,  but,  if  practised 
with  caution,  is  practicable  and  to  be  recommended 
when  the  central  mass  predominates.  Destruction 
by  caustics  (chloride  of  zinc)  seems  to  be  without 
much  danger  of  hemorrhage,  but  is  slow  and  tedious 
and  may  cause  superficial  necrosis  of  underlying  bone. 
Lefort  recommends  the  injection  of  a  solution  of  the 
perchloride  of  iron,  which  has  given  nine  successes  in 
ten  cases;  he  prefers  a  five-per-cent.  solution  to  the 
stronger  ones.  John  Duncan  refers  to  four  cases 
treated  by  electrolysis,  three  of  them  successfully. 
The  variety  known  as  aneurysm  by  anastomosis,  in 
which  the  capillaries  and  veins  are  also  involved,  is  less 
amenable  than  the  others  to  this  method  of  treatment. 

Dissecting  Aneurysm. — This  is  a  lesion  occas- 
ionally found  in  the  aorta,  which  has  only  a  patho- 
logical interest,  since  it  cannot  be  recognized  with 
certainty  during  life  and  is  not  open  to  treatment. 
It  consists  of  a  partial  rupture  of  the  wall  of  the 
vessel,  and  the  passage  of  the  blood  between  its  coats, 
usually  in  the  substance  of  the  middle  coat,  to  a 
second  opening  into  the  lumen  of  the  vessel  at  a 
lower  point,  or  backward  to  one  into  the  pericardial 
sac.  The  primary  opening  is  usually  in  the  arch  of  the 
aorta;  the  second  one  may  be  in  the  same  vessel,  or 
at  a  considerable  distance  in  one  of  its  branches — once 
in  the  subclavian,  once  even  in  the  popliteal.  When 
the  flow  is  backward  into  the  pericardium,  death 
promptly  follows;  in  other  cases  the  period  of  survival 
is  usually  short,  but  may  be  prolonged  for  years,  and 
under  such  circumstances  the  track  followed  by  the 
blood  develops  a  resisting  wall  lined  with  epithelium. 

Lewis  A.  Stimson. 
Charles  L.  Gibson. 

Aneurysm,  Internal. — Etiology  and  Pathology. — 
In  this  article  no  attempt  is  made  to  discuss  at 
length  the  etiology  and  pathology  of  aneurysm  in 
general.  It  is  intended  rather  to  present  in  as  con- 
densed a  form  as  possible  the  principal  points  bearing 
upon  the  diagnosis  and  treatment  of  the  internal 
form  of  the  disease. 

Age. — Aneurysm  may  occur  at  any  age  but  it  is 
most  frequently  found  in  the  decade  from  thirty  to 
forty  and  next  from  forty  to  fifty.  In  children  and 
adolescents  it  is  extremely  rare  and  usually  results 
from  an  infected  embolus,  or  in  some  instances  from 
inherited  syphilis.  Aneurysm  becomes  less  frequent 
with  advancing  years,  and  is  then  usually  associated 
with  atheroma. 

Sex. — Men  are  mi  ire  liable  to  the  disease  than  women. 
Peacock  states  that  from  two-thirds  to  four-fifths  of 


the  cases  of  circumscribed  aneurysm  occur  in  males 
while  Crisp's  extensive  figures  show  a  ratio  of  five  to 
one.  The  difference  is  no  doubt  to  be  accounted  for 
by  the  fact  that  men  are  much  exposed  to  the  efficient 
promoting  causes,  viz.,  strain,  laborious  occupation 
syphilis,  and  intemperance.  In  dissecting  aneurysm 
the  sexes  are  attacked  with  almost  equal  frequency. 

The  development  of  the  disease  is  favored  by  a 
high  blood  pressure,  but  weakening  of  the  arterial 
wall  plays  a  far  more  important  role  in  the  morbid 
process.  It  is  particularly  apt  to  develop  from 
inflammatory  processes  in  the  media,  resulting  in 
most  instances  from  syphilis,  but  occasionally  due  to 
rheumatism  or  other  infections. 

The  influence  of  syphilis  as  a  cause  of  aneurysm  is 
now  very  generally  admitted,  and  evidence  of  pre- 
vious luetic  infection  occasionally  gives  an  important 
clue  to  the  diagnosis  of  obscure  abdominal  or  thoracic 
aneurysms.  From  forty  to  eighty  per  cent,  of  cases 
are  usually  attributed  to  this  cause,  and  some  writers 
give  even  a  higher  percentage.  The  syphilitic  lesions 
are  usually  very  limited  in  extent,  consisting  in  patches 
of  mesarteritis,  of  an  inch  or  less  in  diameter,  with 
furrowing  and  scarring  of  the  intima,  occurring  most 
frequently  in  the  ascending  aorta.  Remnants  of  these 
patches  may  be  found  at  the  orifices  of  an  aneurysm 
and  their  specific  character  has  been  proved  by  the 
discovery  of  the  spirochete.  An  important  con- 
firmation of  the  influence  of  syphilis  is  found  in  the 
Wassermann  reaction.  The  figures  available  are 
still  somewhat  meager,  but  Steinmeier  has  been  able 
to  collect  sixty-five  cases  of  aneurysm,  of  which 
seventy-five  per  cent,  gave  a  positive  reaction,  while 
several  negative  cases  presented  indubitable  evidence 
of  the  disease. 

Other  infections  play  a  recognized  but  infrequent 
part  in  the  causation  of  aneurysm.  Acute  rheumatism 
typhoid  fever,  pneumonia,  influenza,  and  septic 
processes  frequently  lead  to  degeneration  of  the 
intima  and,  what  is  of  much  more  importance,  to 
patches  of  inflammation  with  subsequent  necrosis  in 
the  media;  these  areas  when  yielding  to  the  blood 
pressure  result  in  aneurysmal  dilatation. 

Embolomycotic  aneurysms,  found  chiefly  in  malig- 
nant endocarditis,  and  only  in  rare  instances  following 
immediately  on  other  infective  processes,  seldom 
attain  a  larger  size  than  a  walnut.  They  occur  most 
frequently  in  the  superior  mesenteric,  the  cerebral 
\  essels,  and  t he  aorta,  but  the  visceral  arteries,  as  well 
as  the  iliacs  and  peripheral  vessels  are  occasionally 
involved.  Often  occurring  at  an  earlier  age  than  the 
chronic  form  of  the  disease,  and  frequently  multiple, 
they  seldom  attain  a  size  larger  than  an  egg,  and 
usually  terminate  rapidly  by  rupture  and  hemorrhage. 
Lewis  and  Schrager  state  they  most  commonly  origi- 
nate in  the  intima  from  the  lodging  of  infected  em  In  >  1 1 
at  tlie  bifurcation  of  arteries,  and  less  seldom  in  the 
media  through  bacterial  invasion  by  the  vasa  vasorum. 
Mechanical  injury  of  the  arterial  coats  by  a  sharp 
pointed  embolon  is  now  regarded  as  unusual,  and  the 
infective  origin  as  much  the  more  usual  method  of 
production. 

Traumatism. — Since  blows  or  violent  straining 
efforts  especially  in  muscular  men  are  sometimes 
sufficient  to  tear  the  intima  and  a  portion  of  the 
media,  the  greater  frequency  of  aneurysm  in  the 
laboring  classes  is,  at  least  in  part,  to  be  attributed  to 
the  influence  of  strain  and  effort.  The  tear  commonly 
begins  over  atheromatous  plaques,  but  a  healthy  artery 
may  suffer  as  in  the  case  related  by  Busse  (Virchou's 
Areliiv,  1S3).  The  tear  may  lead  to  a  saccular 
aneurysm,  or  in  rare  instances  to  a  dissecting  aneu- 
rysm. Adami  has  pointed  out  the  frequency  with 
which  the  latter  form  is  associated  with  hyaline  athero- 
matous areas  in  the  aorta.  Severe,  sudden  pain  marks 
t  he  mi -el  of  the  tear  and  later  the  development  of  aneu- 
rysm or  a  rapidly  fatal  termination  from  hemorrhage 
may  occur. 


410 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Aneurysm,  Internal 


Atheroma   is   the  common   cause  of  aneurysm   in 

elderly  people,  and  is  less  seldom  responsible  in 
earlier  life.  There  is  no  apparent  relation  between 
the   extent    of    atheroma    and    the    development    of 

irysm  and  most  extensive  lesions  are  extremely 
common  without  the  slightest  tendency  to  aneurysm. 

ious  conditions  leading  to  atheromatous  dogenera 
t ion,   such   as   alcoholism,   lead   poisoning,   and   gout, 

Elay  some  part  in  the  production  of  aneurysm,  and  the 
igh  blood  pressure,  so  frequently  present,  also 
-  the  development  of  the  malady. 

Site. — The  most  frequent  site  is  on  the  ascending 
aorta.  In  Hare's  statistics  570  out  of  953  case  oi 
aortic  aneurysm  involved  this  portion  of  the  vessel, 
while  the  transverse  arch  was  affected  in  104  and  the 
descending  arch  in  110  instances.  The  abdominal 
aorta  suffers  much  less  frequently  than  the  thoracic, 
the  ratio  being  as  one  to  ten.  In  the  great  majority 
idominal  cases  the  aorta  is  involved  at  or  near  the 
celiac  axis  and  the  lower  portion  of  the  aorta  is  seldom 
attacked.  In  Nixon's  tables  (St.  Bartholomew's 
Hosp.  Hep.,  1911),  it  is  suprising  how  seldom  an- 
eurysm is  found  except  at  or  in  the  immediate  neigh- 
borhood of  the  celiac  axis. 

The  arteries  arising  from  the  aorta  often  share  in  the 
aneurysmal  process,  and  are  less  commonly  affected 
alone.  These  vessels,  however,  and  also  the  cerebral 
ics  are  involved  in  a  considerable  number  of 
cmbolomycotic  aneurysms  and  also  in  those  some- 
what rare  cases  from  acute  infections. 

Sacculated  aneurysm  is  by  far  the  most  common 
form.  In  Hare's  figures  there  were  544  instances  and 
only  twenty-six  fusiform  in  the  ascending  arch. 
Dissecting  aneurysm  is  a  rare  type.  Adami  has 
shown  that  it  occurs  in  almost  equal  number  in  the 
two  sexes,  and  that  it  is  frequently  found  associated 
with  gelatinous  hyalofibrinous  plaques;  the  blood 
passes  in  a  channel  between  the  coats  of  the  vessel  of 
which  the  inner  wall  is  formed  by  the  intima  and  part 
of  the  media.  This  channel  commonly  begins  in  the 
ascending  arch  and  may  extend  along  the  whole 
length  of  the  aorta  and  even  along  the  iliacs  as  in  a 
of  Field's.  The  lining  of  the  sac  is  often  smooth 
and  gives  at  first  sight  the  impression  of  a  double 
tube,  while  the  branches  may  spring  from  the  sac  or 
from  the  vessel  itself. 

The  onset  of  these  cases  may  be  marked  by  sudden 
violent  pain  which  gradually  subsides  as  the  stretching 
due  to  separation  of  the  arterial  wall  subsides.  The 
subsequent  course  is  variable;  rupture  followed  by 
hemorrhage  with  a  rapidly  fatal  termination  is 
frequently  found,  but  in  a  few  instances  the  process 
becomes  chronic  and  the  condition  may  last  for 
years. 

Thoracic  Aneurysm*. — Symptomatology. — The 
existence  of  a  dilatation  at  some  part  of  the 
aorta  is  not  necessarily  accompanied  by  manifestation 
of  disordered  function  or  local  distress,  that  is  to  say, 
by  symptoms.  Unless,  therefore,  it  mechanically  in- 
terferes with  neighboring  parts,  it  may  continue 
even  for  a  long  time  unsuspected.  The  occurrence, 
then,  of  symptoms  which  will  indicate  the  existence 
of  thoracic  aneurysm,  depends  more  upon  the  exact 
situation  of  the  tumor  than  upon  any  other  circum- 
stance. The  symptoms  also  will  present  wonderful 
variety  in  accordance  with  the  varying  locality  and 
direction  of  the  expansion  of  the  growth.  The 
clinical  history  of  these  patients  previous  to  the  de- 
velopment of  the  characteristic  symptoms  is  often  ex- 
tremely indefinite.  It  is  quite  common  to  find  a  man 
seeking  advice  for  a  loss  of  voice  or  a  harsh  cough,  or  a 
thoracic  pain,  found  to  be  due  to  an  aneurysm  of 
some  standing,  and  yet  he  will  give  an  account  of 
having   enjoyed    excellent   health    in   every   respect 

*  The  article  on  Thoracic  Aneurysm  by  the  late  Dr.  George 
Ross,  in  the  previous  edition  of  the  Reference  Handbook, 
remains  as  written,  with  but  few  alterations. — F.  G.  F. 


until  (perhaps  quite  recently)  these  symptoms 
attracted    his  attention.     Again,  sometimes  a  quick 

pain,    wit  1 1    palpil  at  n  in    and    breathle      tti  has    been 

observed  at  some  remote  period,  to  be  followed  later 

OD     by     other    symptoms    of     intrathoracic     disorder. 
Or,  some   laryngeal  or  bronchial  symptoms  may  ha    ■ 
b  i  a  coming  on  imperceptibly  for  a  long    time  pa 
In  many  cases,  belonging  to  one  of  the  above  types, 

of   men   about    middle  age,  whose   general    health   and 

nutrition  remain  unimpaired,  suspicion  of  aneurysm 
may  very  reasonably  be  entertained.  Deepseated 
aneurysms    may   be    entirely   latent,    presenting    no 

evidence    of    their    existence    by   either  .symptom     or 

physical  signs.  The  comparative  frequency  of  such 
cases  is  now  being  very  generally  recognized. 

The  symptoms  of  thoracic  aneurysm,  therefore,  are 
mainly  the  symptoms  of  intrathoracic  pressure,  and 
mostly  differ  in  no  respect    from  those  produced  by 

tumors ol  different  nature  in  the  sa sit  nation.     The 

symptoms  consist  of  the  manifestations  by  which  we 
■  •an  recognize  displacement  of  lung  substance,  con- 
pression  of  the  main  or  secondary  air  tubes,  irritation 
or  destruction  of  nerves,  obliteration  of  venous 
channels,  obstruction  of  the  esophageal  tube,  or 
erosion  of  some  of  the  bony  structures. 

The  principal  symptoms  of  intrathoracic  pressure 
may  be  thus  enumerated — pain,  dyspnea,  altered 
voice,  cough,  stridor,  headache,  and  disordered  vision, 
and  lastly,  paraplegia. 

The  pain  of  thoracic  aneurysm  is  a  most  frequent 
symptom,  but  very  variable  as  to  its  character,  degree, 
and  situation.  In  not  a  few  cases  pain  of  some  kind 
will  be  the  first  indication  of  existing  disorder.  Early 
pain  is  usually  of  a  somewhat  lancinating  nature,  and 
is  suggestive  of  neuralgia.  It  is  often  complained  of  as 
darting  across  some  region  of  the  chest  or  along 
certain  nerves  to  distant  parts.  When  the  aneurysm, 
for  example,  is  seated  in  or  near  the  innominate 
artery,  the  pain  is  often  referred  to  the  back  of  the 
neck  on  the  right  side  and  behind  the  right  ear; 
when  it  is  seated  in  the  transverse  arch,  the  pain  may 
be  across  the  top  of  the  chest  and  down  perhaps  the 
entire  length  of  one  arm.  Pains  of  this  kind  should 
always  prompt  a  search  for  internal  aneurysm. 
Later  on  in  the  complaint  the  pain  is  likely  to  be  of  a 
steady,  wearing  kind,  and  referred  to  some  fixed 
spot,  probably  deep  in  the  chest.  Aneurysms 
pressing  backward  against  the  vertebral  column  and 
the  spinal  nerves  emerging  therefrom  have  two  special 
forms  of  pain  connected  with  them:  either  a  persistent 
boring  pain  experienced  in  some  particular  part  of  the 
spinal  column,  or  a  definite  intercostal  neuralgia, 
having  a  distributive,  intermittent  character,  and 
tender  spots  often  unusually  well  marked.  There  is 
sometimes  pain  of  a  real  anginoid  character,  ac- 
companied by  a  sense  of  tightness  in  the  chest,  but 
it  is  very  seldom  that  attacks  of  true  angina,  with  the 
typical  features  of  this  complaint,  are  witnessed. 
Pressure  on  the  phrenic  nerve  has  been  found  some- 
times to  be  accompanied  by  a  painful  feeling  of  con- 
striction round  the  lower  part  of  the  thorax,  together 
with  dyspnea  and  singultus,  from  disturbed  inner- 
vation of  the  diaphragm. 

Dyspnea  is  a  very  frequent  symptom,  and  is  of  vary- 
ing character  and  degree  in  accordance  with  the  cause 
to  which  it  may  be  due.  It  may  arise  from  compression 
of  a  portion  of  the  pulmonary  structures,  from  pressure 
upon  the  trachea,  upon  a  main  bronchus,  or  upon  the 
pneumogastric  trunk  or  one  of  the  recurrent  nerves. 
An  aneurysm  must  have  attained  to  a  considerable  size 
before  it  can  shut  off  a  portion  of  a  lung  sufficient  to 
produce  decided  dyspnea.  .Shortness  of  breath, 
therefore,  will  not  be  much  complained  of  in  the  early 
stages,  unless  the  tumor  interferes  with  some  of  the 
other  stuctures  just  named.  Compression  of  the  tra- 
chea commonly  occurs  from  aneurysms  of  the  arch,  and 
the  dyspnea  will  be  observed  toexist  both  in  inspiration 
and  in  expiration.     It  is  accompanied   by  enfeeble- 


411 


Aneurysm,  Internal 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


menl  of  the  respiratory  murmur  in  both  lungs,  and  the 
laryngoscope  shows  the  mechanism  of  the  vocal  cords 
to  be  normal.      Under  favorable  conditions  a  skilled 

irver  can  detect  the  narrowed  lumen  of  the  trachea 
by  the  laryngoscopic  mirror,  and  in  some  instances 
can  even  observe  pulsation  transmitted  from  the 
aneurysm  at  the  point  of  pressure.  Standing  beside 
such  a  patient,  it  is  quite  usual  to  hear  a  rough, 
raucous  sound  of  peculiar  caliber  accompanying 
both  inspiration  and  expiration,  especially  when  these 
acts  are  performed  somewhat  forcibly.  The  dyspnea 
here,  as  in  the  last-mentioned  form,  is  very  markedly 
increased  by  even  slight  exertion,  the  chief  reason,  no 
doubt,  being  that  the  tumor,  being  expansile,  the  in- 
creased heart's  action  expands  it,  and  causes  it  to 
compress  the  elastic  tube  more  firmly.  In  exceptional 
cases  of  tracheal  compression,  paroxysms  of  intense 
dyspnea  may  be  occasionally  witnessed,  and  that 
without  direct  involvement  of  any  of  the  important 
nerves.  Attacks  of  this  character  are  apt  to  come  on 
from  exertion  or  emotional  disturbance,  and  are 
attributed  by  Bristowe  to  more  or  less  complete  ob- 
struction of  the  trachea  by  a  plug  of  mucus.  Position 
will  often  relieve  the  respiratory  distress  considerably, 
and  patients  very  frequently,  of  their  own  accord, 
rest  or  sleep,  leaning  the  chest  well  forward  to  take  off 
the  pressure  from  the  windpipe.  If  a  main  bronchus 
be  compressed  (and  it  is  more  often  the  left),  the 
dyspnea  is  not  likely  to  be  so  great,  and  enfeebled 
breathing  is  found  in  the  corresponding  lung.  It 
has  long  been  recognized  that  pressure  upon  the  impor- 
tant nerves  supplying  the  muscles  of  the  larynx  which 
pass  through  the  chest  will  cause  dyspnea  and  that, 
very  often,  of  the  most  intense  kind.  Here  the  striking 
feature  is  dyspnea  in  paroxysms.  There  may  be 
periods  of  comparative  calm,  during  which  there  is 
only  a  moderate  shortness  of  breath  on  making  some 
exertion,  but  suddenly,  with  or  without  any  exciting 
cause,  severe  suffocative  dyspnea  sets  in,  and  in  some 
cases  actually  proves  fatal.  This  result  may  be 
brought  about  by  either  the  compression  or  involve- 
ment of  a  pneumogastric  nerve  or  a  recurrent  laryngeal 
nerve.  Sometimes  nerves  of  both  sides  are  implicated. 
(  hving  to  its  situation  in  relation  to  the  aneurysm,  the 
nerve  of  the  left  side  is  more  often  affected  than  that  of 
the  right.  When  the  latter  is  involved,  it  is  generally 
from  its  being  disturbed  by  the  dragging  of  a  tumor 
upon  the  root  of  the  right  subclavian  artery.  It  is 
held  by  some  that  this  form  of  dyspnea  may  be 
brought  about  either  by  spasm  of  the  muscles  supplied 
by  the  recurrent  nerve  or  by  their  paralysis.  Pressure, 
it  is  said,  will  either  irritate  or  destroy  a  nerve. 
Irritation  will  cause  spasm,  destruction,  paralysis. 
There  does  not,  however,  seem  to  be  any  reliable 
evidence  of  the  occurrence  of  spasm  as  a  cause  of 
dyspnea;  while,  on  the  other  hand,  whenever  decided 
laryngeal  symptoms  are  observed  from  intrathoracic 
pressure,  the  laryngoscope  nearly  always  shows  the  ex- 
istence of  paralysis  in  a  greater  or  less  degree.  Uni- 
lateral paralysis  may  exist  for  a  long  time  without 
marked  dyspnea,  but,  if  the  opposite  muscles  become 
affected,  the  liability  to  paroxysmal  attacks  becomes 
developed,  the  flaccid  cords  are  sucked  together  by 
the  inspiratory  effort,  and  a  suffocative  condition  is 
induced.  Why  does  this  occur  in  paroxysms?  It 
may  be  that  a  rapid  temporary  enlargement  of  the 
tumor  occurs  (from  exertion,  etc.),  and  that  this 
causes  increased  pressure,  as  a  result  of  which  the 
paralysis  may  be  rendered  complete;  or  it  may  be  that, 
from  incomplete  coughing  efforts,  mucus  collects  in  the 
glottis,  and  forms  a  complete'  barrier  in  the  already 
partially  obstructed  glottic  opening.  A  rare  form  of 
dyspnea  in  aneurysmal  patients  consists  in  a  sim- 
ulation of  ordinary  asthma.  I  have  seen  one  such 
case  in  a  young  unman  in  which  the  picture  pre- 
sented was  exactly  that  of  a  common  attack  of 
spasmodic  asthma. 

All/rations   of  voice  are   observed   only   when   the 


tumor  presses  upon  one  of  the  recurrent  nerves,  or 
upon  a  pneumogastric  trunk.  The  changes  in  the 
voice  consist  mainly  in  diminution  of  its  power  and 
clearness  in  varying  degree,  together  with  hoarseness 
and  sometimes  a  squeaky  or  high-pitched  tone. 
The  loss  of  voice  may  come  on  quite  suddenly,  and 
ultimately  complete  aphonia  may  result.  These 
laryngeal  symptoms  may  be  among  the  very  first 
complained  of,  thus  simulating  catarrhal  laryngitis, 
for  which  this  condition  has  frequently  been  mis- 
taken. Laryngoscopic  examination  almost  invari- 
ably shows  deficient  abduction  of  a  vocal  cord  (more 
frequently  the  left).  If  the  paralysis  be  incomplete, 
the  affected  cord  is  seen,  on  phonation,  to  fail  to 
reach  the  median  line,  and  thus  an  open  space  is  left 
between  the  two.  If  it  be  complete,  the  paralyzed 
band  remains  almost,  if  not  quite,  stationary,  and  the 
healthy  cord  is  seen  to  move  rapidly  across  the 
median  line  until  it  approaches  its  fellow  of  the 
opposite  side. 

Stridor  is  specially  noticed  when  an  aneurysmal 
tumor  presses  upon  the  trachea  or  one  of  the  main 
bronchi.  It  differs  altogether  from  the  stridulous. 
respiratory  sounds  heard  in  cases  of  laryngeal  disease, 
and  is  distinguished  also  from  them  in  that  the 
ordinary  speaking  voice  remains  unimpaired.  The 
stridor  is  usually  a  rough,  low-pitched,  growling 
sound,  accompanying  both  inspiration  and  expiration, 
and  giving  the  impression  of  originating  deep  within 
the  chest.  It  is  markedly  increased  by  full  breathing. 
This  is  the  so-called  "stridor  from  below"  of  the 
older  authors. 

Cough  very  commonly  occurs  during  the  course  of 
a  thoracic  aneurysm.  It  is  produced  mainly  by  the 
irritation  from  pressure  of  the  pulmonary  and  laryn- 
geal nerves,  and  is  often  very  frequent  and  distressing. 
If  there  be  laryngeal  paralysis  the  cough  will  proba- 
bly be  husky,  and  even  suppressed.  When  tracheal 
pressure  with  stridor  exists,  the  cough  becomes  dry 
and  harsh.  A  peculiar  ringing,  brassy,  croupy, 
cough  is  very  suggestive  of  aneurysm.  The  expecto- 
ration at  first  is  very  small  in  quantity — in  fact  it 
may  be  so  throughout;  but  when  there  has  been 
much  pulmonary  irritation,  or  when  a  tracheo- 
bronchial catarrh  has  been  set  up,  large  quantities 
of  purulent  expectoration  may  be  got  rid  of.  Blood 
sometimes  appears  in  the  sputum,  and  must  always 
be  looked  upon  as  a  sign  of  impending  danger. 

Dysphagia  is  a  symptom  more  often  seen  in  con- 
nection with  other  forms  of  intrathoracic  tumor  than 
with  aneurysm.  It  has  also  been  clearly  proven 
that  an  aneurysm  may  have  exerted  considerable 
pressure  upon  the  esophagus  and  yet  no  resulting 
dysphagia  will  have  been  observed.  Certain  pecul- 
iarities in  esophageal  obstruction  due  to  aneurysm 
(as  compared  with  that  which  results  from  other 
tumors  or  from  organic  stricture)  are  these:  that  it  is 
variable — perhaps  at  one  time  of  day  nothing  can  be 
swallowed,  and  again,  later  on,  fluids  or  semi-solids 
pass  with  comparative  ease;  and,  secondly,  it  is 
altered  by  position — the  patient  may  be  able,  by 
removing  the  weight  of  the  tumor  on  leaning  well 
forward,  to  swallow  fairly  well,  while  the  same  thing 
is  impossible  in  the  recumbent  position. 

Engorgement  of  the  vena  cava  and  its  branches,  from 
pressure  of  the  sac  upon  this  great  trunk  or  upon  one 
of  the  innominate  veins,  occurs  pretty  frequently. 
It  is  indicated  in  the  lesser  degrees  by  undue  fulness 
of  certain  of  the  superficial  veins  of  the  neck,  shoulder, 
and  front  of  the  chest.  In  an  extreme  degree  the 
appearances  produced  are  very  striking.  The  face 
is  purple  and  congested,  the  eyes  are  suffused,  the 
superficial  veins  greatly  distended  with  blood  and 
mostly  tortuous.  The  tissues  at  the  root  of  the  neck 
become  infiltrated  and  present  a  soft,  swollen  appear- 
ance, obliterating  more  or  less  the  hollow  above  the 
clavicle.  The  congestion  of  the  internal  veins, 
which    must    simultaneously    occur,    causes    these 


412 


REFERENCE    HANDliOOK    OF   Till:    MEDICAL   SCIENCES 


Aneurysm,  Internal 


patients   to  suffer  from   headache  and   often    from 
great    drowsiness,   ami  death   may   take   place  in   a 
natose  condition.     Pressure  mi  the  brachial  veins 
will  cause  swelling  of  the  corresponding  arm. 

rence  in  the  Size  of  the  Pupils. — The  anterior 
roots  of  the  spinal  nerves  from  the  sixth  cervical  to 
the  sixth  dorsal  (according  to  Brown-Sequard  to  the 
ointh  or  tenth  dorsal)  supply  the  cervical  sympathetic 
filaments  which  pass  to  the  iris.  When  an  aneurysm 
presses  upon  these  nerves,  then  ocular  symptoms  arc 

i  veil,  more  or  less  marked  according  to  t  lie  degree 
of  the  pressure.  If  the  pressure  is  slight,  then  irrita- 
tion only  is  produced  and.  as  a   consequence,    there 

itationof  the  corresponding  pupil.  If  the  pressure 
i-  considerable,  then  paralysis  is  produced,  and  we 
find  permanent  cunt  raction  of  that  pupil,  occasionally 
associated  with  enophthalmos  and  slight  drooping  of 
the  lid.     With  reference  to  this  symptom,  it  must  be 

loped  to  a  decided  degree  before  any  reliance  can 
I  upon  it,  because  the  slighter  differences  in 

between   the   two  pupils   are   quite  commonly 

rved  in  healthy  persons.  Even  when  this  symp- 
tom is  clearly  made  out  its  importance  is  not  great 
from  a  diagnostic  point  of  view,  for  there  an-  generally 
then  present  many  more  reliable  indications  of  bhe 
disease.  But  it  can  be  used  as  one  means  to  assist 
in  enabling  us  to  locate  more  precisely  the  seat  of  the 
tumor.  The  Argyle-Robertson  pupil  is  occasionally 
noticed  and  is  to  be  regarded  as  a  post-syphilitic 
imenon. 

is  very  often  wanting,  and  persons  with 
large  tumors  may  remain  quite  well  nourished.  Con- 
siderable emaciation  is,  however,  often  seen  arising 
from  coincident  weakness  of  *  ho  digestion,  want  of 
exercise,  and  continued  suffering.  Marked  wasting 
of  the  tissues  has  in  rare  cases,  been  traced  to  pressure 
upon  the  thoracic  duct,  and  again,  although  it 
develops  less  rapidly,  to  pressure  upon  the  esophagus 
and  to  inanition. 

Such  are  the  chief  symptoms  of  thoracic  aneurysm, 
which  are  the  result  of  the  intrathoracic  pressure 
which  it  must  sooner  or  later  produce,  and  it  is  to 
them  we  must  generally  look  for  aid  in  establishing  a 
diagnosis.  But  there  are  others  which  must  be 
mentioned.     It  sometimes  happens  that  the  objective 

-  of  aneurysm  may  be  present  while  subjective 
symptoms  are  entirely  wanting.  But  the  contrary 
is  more  generally  true.  Various  complaints  will  be 
made  before  the  existence  of  their  cause  can  be  satis- 
factorily made  out.  .Much,  of  course,  will  depend 
Upon  the  situation  of  the  tumor.  Patients  often 
first  experience  pains  in  the  chest,  the  different  charac- 
ters of  which  have  been  already  alluded  to.  As  the 
tumor  increases  in  size  these  painful  sensations  may 
be  modified  in  various  ways  by  the  occurrence  of 
complicating  inflammations  of  surrounding  parts, 
and  especially  of  the  pleura.  There  may  also  be  a 
distinct  sensation  of  throbbing  or  pulsation  in  the 
chest  in  the  region  of  the  aneurysm.  Palpitation  of 
the  heart  and  tightness  in  the  chest  are  often  associ- 
al  1  with  these.  The  patients  themselves  may  also 
observe  that  alterations  of  position  have  an  effect  in 
increasing  or  diminishing  their  discomfort.  Then 
dyspnea  of  some  kind  is  likely  to  occur  and  to  be 
followed  by  dysphagia,  neuralgias,  pareses,  or  actual 
paralysis  (perhaps  only  formication  or  numbness), 
some  anemia,  diminution  of  strength,  and  sometimes 
edema.  An  aneurysm  of  the  chest  may  thus  cause 
death  by  a  gradual  process.  Less  commonly  we 
observe  continuous  increase  in  the  tumor  until  it 
finally  ruptures  and  death  ensues,  either  directly 
from  hemorrhage  or  indirectly  from  the  effects  of  the 
effusion  of  blood  upon  some  vital  organ.  Rupture 
is  generally  associated  with  enormous  hemorrhage, 
which  is  inevitably  fatal  in  a  few  minutes  or  seconds. 
It  does  happen,  however,  that  smaller  bleedings 
occasionally  make  their  appearance  for  some  time  n 
may  be  for  only  a  day  or  even  for  a  longer  time) 


previous  to  the  final  gush.  In  the  case  of  a  gentle- 
man, under  the  care  of  the  writer,  who  died  of  this 
disease  a  short  time  ago,  small  quantities  (a  few 
ounce-)  of  bright  arterial  blood  were  brought  up  for 

more  than  twenty-four  hour-  pi. -ceding  the  actually 
udden  end.  In  this  case  the  aneurysm  broke  into 
the  substance  of  the  lung,  and  evidently  had  leaked 
into  a  small  bronchus  during  the  time  mentioned. 
The  final  rupture  took  place  into  the  left  main 
bronchus,  and  was  accompanied  by  a  great  spirt  of 
fluid  blood,  and  followed  by  instant  death.  Hemop- 
tyses  sometimes  occur  at  long  interva 
aneurysms,  generally  from  associated  pulmonary 
conge  tions. 

When  rupture  take  place,  it  may  be  accompanied 
by  a  sense  of  tearing  within  the  chest,  and  if  the  blood 

does    not    appear  externally   With   cough   or  efforts   of 

vomiting  (through  the  trachea  or  through  the  esopha- 
gus), then  it  will  be  recognized  by  the  accompanying 

pallor  and  syncope,  with  failure  or  extinction  of  the 
pulse.  Internal  rupture  takes  place  most  frequently 
into  the  pericardium,  and  is  almost  always  immedi- 
ately fatal,  although  in  a  case  quoted  by  Kelynack  the 
patient  lived  for  four  hours.  Pepper  and  Griffith 
have  published  a  ease  of  rupture  into  the  superior 
vena  cava,  and  they  have  collected  twenty-seven 
other  instances,  while  Fr&nkel  has  recorded  two  such 
accidents  recognized  during  life.  The  symptoms  are 
dyspnea,  followed  by  slight  proptosis,  and  by  edema 
and  cyanosis  of  the  face,  neck,  upper  part  of  the 
thorax,  and  arms.  There  is  frequently  a  continuous 
murmur,  louder  during  systole  and  produced  by  the 
passage  of  blood  from  the  aorta  into  the  vena  cava. 
1  leath  in  such  cases  is  not  necessarily  immediate,  and 
has  been  postponed  for  several  weeks  or  months  after 
the  occurrence  of  the  rupture.  Escape  into  a  pleural 
cavity  is  common,  and  is  marked  by  severe  pain  and 
dyspnea,  and  by  the  presence  of  the  physical  signs  of 
effused  fluid.  I  have  seen  one  case  of  rupture  into 
the  pulmonary  artery  when  the  symptoms  consisted 
of  sudden  pain,  collapse,  want  of  pulse,  and  tumultu- 
ous action  of  the  heart  for  about  two  hours  before 
death.  External  rupture  is  comparatively  rare.  If 
such  a  rupture  is  impending,  the  fact  will  be  recog- 
nized by  the  commencing  lividity  and  finally  gangren- 
ous appearance  of  the  tensest  portion  of  the  projecting 
tumor.  This  accident  is  sometimes  induced  by 
straining  or  falling,  or  by  rough  handling. 

Physical  Signs. — The  foregoing  symptoms  (which 
are  mainly  those  of  excentric  pressure)  are  indicative 
of  intrathoracic  tumor  of  some  kind,  but  cannot  indi- 
cate aneurysm  specially.  On  observing  any  combina- 
tion of  them,  we  must  turn  to  the  physical  signs  to 
determine  the  character  of  the  tumor — they  are,  of 
the  two,  therefore,  the  more  important;  and  both 
together  will,  in  the  majority  of  cases,  enable  the  phy- 
sician to  arrive  at  a  positive  diagnosis.  These  phys- 
ical signs  are  derived  both  directly  from  the  tumor 
itself  and  indirectly  from  an  examination  of  the  neigh- 
boring organs  which  may  have  been  pressed  upon, 
displaced,  or  otherwise  interfered  with  by  the  encroach- 
ing tumor.  The  signs,  as  regards  the  aneurysm,  will 
evidently  depend  mainly  upon  its  size  and  its  exact 
position,  especially  as  regards  the  surface  of  the 
chest . 

Inspection  will  readily  demonstrate  the  existence  of 
any  distinct  bulging  of  the  parietes  of  the  chest.  This 
may  be  only  a  slight  or  ill-defined  elevation  of  a  cir- 
cumscribed area,  or  it  may  be  a  tumor  of  some  mag- 
nitude. The  elevated  part,  moreover,  is  seen  to  pul- 
sate (almost)  synchronously  with  the  apex  of  the 
heart.  The  situation  of  the  pulsating  prominence 
depends  upon  the  portion  of  the  aorta  involved,  and 
the  direction  in  which  it  has  been  tending.  Aneurysms 
of  the  ascending  arch  are  most  commonly  seen  in  the 
second  or  third  interspace  of  the  right  side.  Those 
of  the  descending  aorta  will  most  commonly'  reach  the 
surface  on  the  posterior  or  lateral  wall  of  the  chest. 


413 


Aneurysm,  Internal 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


The  skin  over  the  prominence  is  usually  healthy, 
epf  when  the  external  tumor  is  large,  when  it  may 
be  red  or  livid.  There  may  be  no  elevation  from  the 
general  surface,  the  eye  detecting  only  a  pulsating 
spot  similar  to  that  over  the  cardiac  apex.  In  the 
absence  of  these  more  characteristic  appearances,  if 
the  front  of  the  chest  be  carefully  examined,  while  the 
patient  stands  sideways  to  the  observer,  a  more  or 
less  distinct  systolic  heaving  of  the  chest  wall  can  be 
noticed,  especially  when  the  respiration  is  withheld. 
This  indicates  usually  an  aneurysm  of  considerable 
size  and  deeply  seated.  If  the  heart  be  displaced, 
this  fact  can  also  be  determined  by  the  altered  posi- 
tion of  the  apex  beat. 

Palpation  of  the  chest  is  of  service  only  when  the 
tumor  sufficiently  approaches  the  chest  walls.  Local 
fulness  or  bulging  can  be  appreciated,  pulsation  can 
be  located,  and  the  force  of  the  impulse  measured. 
Fremissement,  or  thrill,  systolic  in  rhythm,  can  also 
not  infrequently  be  felt,  perhaps  over  the  entire  area 
covering  the  tumor;  and  following  this,  sometimes  a 
diastolic  shock  may  be  recognized.  In  obscure  cases, 
in  which  a  deep-seated  aneurysm  may  be  suspected, 
the  bimanual  method  of  examination  may  prove 
of  great  service.  The  patient's  chest  is  firmly  grasped 
between  the  two  extended  hands  laid  flat  upon  the 
surface.  By  this  means  a  diffused  sense  of  expansion 
will  be  experienced  which  is  extremely  significant  and 
can  be  ascertained  only  in  this  way.  The  supra- 
sternal notch  should  also  be  explored.  The  patient's 
head  being  bent  forward  to  relax  the  sternomastoid 
muscles,  one  or  two  fingers  are  pressed  deeply  into 
the  fossa  and  beneath  the  manubrium  sterni,  when 
pulsation  or  thrill  communicated  from  the  transverse 
portion  of  the  arch  can  be  distinctly  perceived. 
Another  physical  sign  of  very  great  diagnostic  impor- 
tance, and  one  which  is  also  to  be  obtained  by  the  edu- 
cated sense  of  touch,  is  what  is  now  known  under 
the  term  "tracheal  tugging,"  or  Oliver's  sign.  To 
examine  for  this  sign  proceed  as  follows:  Let  the 
patient  be  seated  upright  and  with  the  head  well 
thrown  back,  in  order  to  put  the  windpipe  upon  the 
stretch.  Then  with  the  finger  and  thumb  of  the 
right  hand  grasp  the  cricoid  cartilage  or  the  lower 
border  of  the  thyroid,  and  make  steady  pressure 
upward.  If  a  deep-seated  aneurysm  be  present  which 
impinges  at  all  upon  the  trachea  or  one  of  its  principal 
divisions,  then  a  very  distinct  and  unmistakable 
tugging  downward  will  be  felt  with  each  systole  of  the 
heart.  When  the  heart  is  acting  strongly,  or  when 
aortic  incompetence  is  present,  considerable  rhyth- 
mical pulsation  may  be  communicated  to  the  fingers 
from  the  adjacent  carotids,  but  with  a  little  care  this 
cannot  be  mistaken  for  the  tugging  directly  downward 
above  described.  I  have  observed  a  considerable 
number  of  cases  of  thoracic  aneurysm,  cardiac  and 
other  thoracic  diseases  with  reference  to  this  sign,  and 
I  have  never  observed  it  produced  by  any  other  con- 
dition but  aneurysm.  In  one  case,  which  I  saw  in 
consultation,  there  seemed  clear  evidence  of  an 
aneurysm  of  the  transverse  arch,  and  the  presence  of 
stridor  and  paroxysmal  dyspnea  showed  its  interfer- 
ence with  the  trachea  and  nerves.  No  tugging  could 
be  felt.  The  autopsy,  however,  showed  that  the 
tumor  was  completely  filled  with  firm  laminated  fibrin, 
and  its  pulsatile  character  was  lost.  Except  in  cases 
of  this  kind  (which  must  be  of  pretty  long  standing) 
tracheal  tugging  may  always  be  looked  for  in  central 
aneurysms  of  the  chest.  This  sign  was  attributed  by 
MacDonnell  to  pulsation  transmitted  downward  to 
the  left  bronchus.  It  may,  however,  be  present  in  any 
instance  in  which  the  aneurysm  is  adherent  to  the 
trachea,  and  Fraenkel  has  seen  it  in  an  aneurysm  of 
tile  ascending  aorta  in  which  firm  adhesions  were 
present  between  it  and  the  trachea.  A  few  cases  are 
recorded  in  which  a  tumor  lying  between  the  aorta 
and  bronchus  lias  given  rise  to  this  sign.  Care  must 
]>r  taken  to  distinguish  a  slight  downward  pulsation, 


often  felt  in  healthy  necks,  from  true  tugging.  Hall 
has  described  a  diastolic  shock  following  the  systolic 
tracheal  tug. 

Percussion  elicits  a  flat  note  over  the  area  through- 
out which  the  aneurysm  is  in  contact  with  the  chest 
wall.  This  area,  of  course,  may  give  no  idea  of  the 
actual  size  of  the  aneurysm,  for  its  principal  bulk  may 
be  buried  beneath  healthy  lung  tissue.  A  modified 
dulness  may  sometimes  be  found  for  some  distance 
around  the  flat  region.  It  is  often  impossible  to 
separate  the  dulness  of  the  aneurysm  from  that  o 
solid  organs,  the  heart,  liver,  etc".  Of  course,  if  the 
tumor  be  entirely  deep-seated,  the  percussion  may  be 
everywhere  normal.  If  also  the  lungs  be  emphyse- 
matous, no  information  can  be  obtained  from 
percussion. 

Auscultation  over  an  aneurysm  of  the  aorta  reveals 
of  necessity  only  a  systolic  and  a  diastolic  sound,  such 
as  we  hear  over  the  vessel  itself.  The  systolic  sound, 
however,  may  be  modified,  and  is  sometimes  accom- 
panied by  murmur.  The  modification  consists  gen- 
erally in  loudness,  while,  at  the  same  time,  a  sense  of 
impulse  is  conveyed,  the  so-called  bruit  de  choc.  The 
diastolic  sound  is  communicated  from  the  aortic 
valves,  any  increase  in  their  tension  intensifying  the 
second  sound  over  the  aneurysm.  It  is  always  accen- 
tuated when  the  diastolic  shock  is  perceptible  on  pal- 
pation. Systolic  murmurs  are  of  tolerably  frequen 
occurrence.  They  are  probably  produced  in  one  of 
two  ways:  either  by  sudden  alteration  in  the  caliber  uf 
the  vessel  (causing  fluid  waves  or  eddies)  or  by  the 
vibrations  produced  by  contained  coagula  or  irregu- 
larities in  the  course  of  the  blood  current. 

The  systolic  murmur  of  an  aneurysm  is  generally 
blowing  in  character,  but  sometimes  possesses  a  de- 
cided musical  or  "  cooing"  quality.  Its  seat  of  maxi- 
mum intensity  is  likely  to  be  the  central  part  of  the 
tumor,  and  it  is  not  generally  diffused  to  any  very  con- 
siderable distance  from  this.  The  significance  of  the 
murmur  is  derived  from  its  seat  of  maximum  intensity 
being  away  from  that  usually  associated  wit  h  valvular 
lesions,  and  from  its  being  accompanied  by  a  mag- 
nified second  sound.  Heard  alone  (i.e.  without 
accentuation  of  the  second  sound)  a  systolic  murmur 
is  rather  indicative  of  some  other  condition  than 
aneurysm.  Indeed,  diastolic  accentuation,  if  con- 
fined to  some  circumscribed  dull  area  in  the  neighbor- 
hood of  the  aorta,  is  of  more  value  than  any  murmur. 
Any  murmurs  generated  at  the  aortic  valves  and 
orifice  are  likely  to  be  transmitted  through  an  aneu- 
rysmal tumor  as  well.  Often,  therefore,  double 
aortic  murmurs  are  to  be  heard  in  this  situation. 
Sometimes,  however,  similar  to-and-fro  sounds  are 
generated  within  the  sac  itself,  their  origin  being 
declared  by  their  being  much  louder  over  the  corre-  I 
sponding  area  than  elsewhere,  by  being  much  more 
restricted  to  this  region,  and  by  not  being  at  all  neces- 
sarily associated  with  dilated  hypertrophy  of  the  left 
ventricle.  A  diastolic  murmur  alone  may,  exception- 
ally, be  heard  arising  from  an  aneurysm,  and  Gerhardt 
states  that  a  diastolic  murmur  may  sometimes  be 
heard  in  the  left  supraspinous  area.  Over  the  tumor 
the  respiratory  murmur  is  absent,  but  on  passing 
just  beyond  the  edges  of  this,  the  breathing  sounds 
are  heard,  but  generally  of  a  somewhat  bronchial 
character.  In  the  same  areas  the  voice  will  have  a 
bronchial  resonance,  although  decided  bronchophony 
will  not  be  found  (or,  at  any  rate,  is  rare). 

The  pulse  in  internal  aneurysm  may,  or  may  not, 
afford  positive  information.  The  arteries  themselves 
are  frequently  in  a  diseased  condition,  fibroid  or 
sclerotic,  and  may  thus  affect  the  pulse.  The  slate 
of  the  heart  will  also  have  to  be  taken  into  account. 
If,  however,  the  blood  be  flowing  into  an  aneurysm  of 
considerable  size,  special  alterations  in  the  blond 
current  in  the  parts  on  the  distal  side  of  this  may  ho 
observed  and  delineated.  The  effect  of  the  diverticu- 
lum is  to  act  like  the  empty  rubber  ball  in  the  ordinary 


•II  I 


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Aneurysm,   Intern. tl 


syringe,  i.e.  to  make  the  current  more  e  eady 

anil  l|J"  spasmodic  and  jerky.      When,   therefore,   :i 

gphygmographic  tracing  is  taken,  the  curve  is  found 

ffer  from  the  normal  our  in  accordance  with  this 

hanism.  The  ascent  of  the  systole  is  less  abrupt, 
more  gradual,  and  the  descent  also  occurs  without  the 
game  sharpness.  The  necessary  result  of  this  i<  to 
render  the  apex  of  the  cur\  e  more  rounded,  less  acute 
than  that  of  the  natural  pulse.  The  larger  the  sac 
ami  the  more  distensible  the  walls,  the  better  this 
kind  of  tracing  i-  brought  out,  while  fibrillation  of  the 
contents  and  stiffening  of  the  walls  tend  to  obscure 
these  peculiarities  and  cause  the  tracing  to  resemble 

the  normal  curve.     The  value  of  the bservations 

is  greatest   when  we  examine  at   the  same  time  the 

esponding  artery  of  the  opposite  side,  or  else  the 
same  artery  m-  a  branch  of  it  i  above  the  region  of  the 
suspected  aneurysm.  It  is  not  uncommon  to  fuel 
such  a  degree  of  difference  between  the  pulses  of  the 
two  sides  a<  may  lie  clearly  recognized  by  the  finger. 
The  differences  consist  in  delay  of  the  pulse  and  in 
alteration  in  its  volume.  Delay  of  the  pulse  in  the 
radial  artery  is  a  diagnostic  sign  upon  which  too  much 
stress  must  not  be  laid,  and,  indeed  it  is  very  often 
absent,  or  difficult  to  appreciate  with  the  finger. 
Findley.  however,  has  shown  that  it  may  be  often 
detected  by  the  clinical  polygraph,  and  he  regi 
the  sign  as  due  to  the  blood  wave  passing  through  ah 
aneurysm,  and  consequently  of  some  value  in  local- 
izing the  site  of  the  aneurysm.     Diminution  in  the 

«r  of  the  radial  pulse  of  one  side  is  important  as 
an  additional  point  of  evidence  in  a  case  of  suspected 
thoracic  aneurysm.  Its  positive  value  is,  however, 
detracted  from  by  a  consideration  of  the  fact  that  the 
same  thing  is  often  seen  from  congenital  peeuliaritv 
or  from  irregular  distribution  of  the  blood-vessels  of 
that  arm.  The  latter  possibility  should  always  be 
sought  for,  and  a  comparison  made  between  the  bra- 
chials of  the  two  arms.  The  alteration  in  the  volume 
of  the  pulse  may  be  produced  by  twisting  or  distortion 
of  the  vessel,  by  dragging  upon  it  by  the  advancing 
growth,  or  by  partial  or  complete  obliteration  of  the 
lumen  by  the  entrance  into  it  of  detached  fragments 
of  fibrin.  The  only  special  distinguishing  mark  of 
embolism  is  the  suddenness  with  which  it  is  apt  to 
occur. 

Thoracic  aneurysm  is  very  frequently  associated 
with  changes  in  the  heart  and  in  the  circulation. 
Other  neighboring  organs  also  become  physically 
altered  by  reason  of  the  pressure,  or  other  interference, 
to  which  they  may  have  been  subjected.  These  con- 
ditions can  generally  be  recognized  by  physical  exami- 
nation. Enlargement  of  the  heart  does  not  arise 
from  aneurysm,  but  often  occurs  from  the  associated 
arteriosclerosis,  or  from  valvular  defects,  particularly 
aortic  incompetence.  Displacement  of  the  heart  is 
often  seen.  This  is  generally  a  downward  displace- 
ment only,  or  with  some  inclination  to  the  left.  When 
the  tumor  affects  the  descending  aorta,  the  heart  is 
displaced   forward.     If   incompetence   of   the   aortic 

•s  be  present,   as  often  occurs,  its  existence  is 

iinized  by  the  usual  physical  signs.  The  cause 
of  the  incompetence  may  be  either  atheroma,  as  above 
mentioned,  or  the  altered  caliber  of  the  root  of  the 
aorta  produced  by  the  tumor,  i.e.  relative  incompetence 
with  healthy  valves  near  to  which  the  expansion  has 
begun.  Tumors  near  the  origin  of  the  aorta  are  also 
liable  to  cause  pericarditis.  This  occurrence  has 
frequently    been    found    postmortem,    and    is   occa- 

illy  witnessed  during  life.  Byrom  Bramwell 
("  Diseases  of  the  Heart  and  Thoracic  Aorta."  p.  71  1 1 
says:  "In  any  case  of  non-rheumatic  pericarditis 
occurring  after  the  age  of  forty,  in  which  the  cause  of 
the  pericarditis  is  obscure,  I  strongly  suspect  the  pres- 
ence of  an  aneurysm."  The  same  author  suggests 
that  aneurysm  in  the  same  locality  may  account  for 
certain  eases  in  which  pericarditis  and  angina  pectoris 
have  been  observed  at  the  same  time.     Pleurisy  is  a 


common  complication,  and  musl  be  looked  for  either 
from  friction  sounds  or  from  the  signs  of  liquid  effusion, 

curs st  often  with  aneurysm  of  the  descending 

aorta.     The  existence  of  a  pleurisy  at    the    base  of 

one  lung,  followed  by  prolonged  pain  iii   the 
region,    otherwise  ted    for,    will    certainly 

sometimes  lead  us  aright    by  suggesting  aneurysm. 
If  a  main  bronchus  be  compressed,  the  correspond- 
ing lung  becomes  comparatively  airless,  it-  circuls 
is    impaired,    and    catarrhal    conditions    prevail.      In 

consequence  of  this  the  following  physical  signs  will 
be  found,  viz.,  moderate  dulness  on  percussion  and 
enfeebled  respiration,  with  or  without   moist    i 
In  a  few  of  these  cases  a  whistling  sound  can  be  made 

out  over  the  situation  of  the  I  'I  tube. 

Changes  in  the  lungs  are  not  uncommon  in  aneu- 
rysm.    Owing  to  the  frequency  with  which  the  left 

hus  is  compressed  these  changes  are  much  n 
frequent  in  the  left  than  in  the  right  lung.  Fibroid 
changes  with  retraction,  gangrene,  and  suppuration 
are  seen  and  may  even  mask  the  primary  disease. 
i  onstriction  of  the  left  bronchus  by  aneurysmal  pres- 
sure sometimes  sets  up  bronchiectatic  dilatation 
below  the  site  of  stricture.  Such  a  condition  is 
usually  not  recognized  during  life,  but  exception- 
ally symptoms  and  signs  of  bronchiectasis  can  be 
discovered. 

We  may  now  consider  more  particularly  the  chief 
symptoms  and  physical  signs  which  indicate  an- 
eurysm in   the  different  parts  of  the  thoracic  aorta. 

eurysms  of  the  Hoot  of  the  A<  a  (the  Sim 
Valsalva). — Those  aneurysms  which  spring  from  the 
very  commencement  of  the  aortic  tube  are  not  very 
uncommon.  They  are  frequently  entirely  latent,  but 
symptoms  of  pericarditis,  or  of  angina  pectoris,  may 
occur.  They  are  quite  liable  to  cause  aortic  incom- 
petence. Such  tumors  are  very  dangerous,  as,  before 
arriving  at  any  great  size,  they  are  liable  to  rupture, 
especially  into  the  pericardium.  Bramwell  figures 
(op.  cit..  p.  720)  a  remarkable  aneurysm  springing 
from  this  situation:  it  attained  an  enormous  size, 
perforated  the  sternum,  formed  a  large  external  pro- 
jection, and  finally  ruptured  through  the  integument. 

Aneurysms  of  the  Ascending  Portion  of  the  Arch. — In 
this  region  of  the  tube,  dilatations,  cylindrical  or 
spindle-shaped,  are  most  frequent,  but  saccular 
aneurysms  also  occur.  The  latter  are  then  generally 
situated  upon  the  right  side  of  the  aorta.  In  an 
early  stage  of  dilatation  we  shall  find  altered  pitch  of 
the  percussion  note  to  the  right  of  the  sternal  margin 
above  the  second  rib,  and  the  pulsation  of  the  aorta 
becomes  stronger  and  more  perceptible  above  the 
sternum.  As  it  increases,  we  get  more  decided  dulness 
extending  to  the  right  above  the  second  rib.  The 
first  sound  becomes  dull  and  the  second  more  forcible 
and  clanging.  A  systolic  murmur  may  then  become 
developed  in  the  same  area,  and  this,  by  its  seat  of 
origin  and  want  of  diffusion,  may  be  distinguished 
from  a  valvular  murmur.  Disease  of  the  aortic 
valve  frequently  coexists.  Aneurysm  in  the  ascending 
arch  has  a  tendency  to  reach  the  surface  of  the  chest, 
and  can  therefore  generally  be  made  out  with  ease  by 
the  physical  signs.  The  locality  where  pulsation  and 
bulging  are  most  apt  to  be  discovered  is  the  neighbor- 
hood of  the  second  costal  cartilage  of  the  right  side. 
The  edge  of  the  sternum  and  one  or  two  ribs  become 
eroded,  and  the  tumor,  which  may  be  of  considerable 
size,  projects.  The  pulse  in  the  vessels  on  the  right 
side  will  be  small  and  delayed  compared  to  that  in  the 
Is  on  the  left,  if  the  innominate  be  involved. 
Compression  of  the  superior  cava  or  right  innominate 
vein  may  happen,  with  resulting  dilatation  of  the  veins 
of  the  upper  half  of  the  body  or  right  arm.  The 
symptoms  commonly  complained  of  are  pain  and 
dyspnea,  perhaps  cough.  When  the  aneurysm  is  of 
considerable  size,  numbness  and  weakness  in  the 
right  arm  may  occur  from  pressure  on  the  brachial 
plexus.     The  right  bronchus  may  also  be  sometimes 


415 


Aneurysm,  Internal 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


compressed.  Rupture  of  an  aneurysm  in  this  situa- 
tion occurs  most  frequently  into  the  right  pleural  sac, 
the  pericardium,  the  lungs,  or  externally.  In  one  of 
my  own  cases,  already  mentioned,  rupture  took  place 
into  the  pulmonary  artery. 

Aneurysms  of  the  Transverse  Portion  of  the  Arch. — 
These  may  be  either  spindle-shaped  or,  more  com- 
monly, saccular.  As  they  occupy  that  portion  of  the 
arch  of  the  aorta  from  which  spring  the  great  brachial 
and  cephalic  branches,  the  latter  are  quite  frequently 
involved  in  the  aneurysmal  growth.  They  are  com- 
mon, but  somewhat  less  so  than  those  of  the  ascending 
portion.  Their  situation  is  such  that  they,  soon  after 
attaining  any  size,  necessarily  impinge  upon  some  of 
the  important  structures  in  the  center  of  the  thorax, 
giving  rise  in  consequence  to  decided  evidences  of 
intrathoracic  pressure.  The  presence  of  a  pulsating 
tumor  in  this  region  will  also  cause  easily  recognized 
changes  in  the  percussion  of  the  sternum  and  its  mar- 
gins, and  can  further  be  detected  by  the  sense  of 
touch  behind  the  manubrium.  Aneurysm  in  the 
transverse  arch  is  therefore,  as  a  rule,  readily  diag- 
nosed except  when  the  tumor  is  quite  small.  Some- 
times, even  before  any  other  signs  have  developed,  the 
aneurysm  may  be  discovered  by  means  of  the  finger 
pressed  well  down  behind  the  sternum  in  the  jugular 
fossa.  As  the  expansion  of  the  aorta  here  increases 
it  pushes  aside  the  edges  of  the  lungs,  and  dulness 
becomes  well  marked  over  the  first  piece  of  the  ster- 
num, and  to  a  variable  distance  on  either  side  of  this. 
Then  a  heaving  prominence  makes  its  appearance  in 
the  same  region,  and,  following  upon  the  absorption 
of  the  sternum  and  upper  ribs,  an  external  tumor 
becomes  developed  which  may  even  reach  a  large 
size.  The  radial  pulses  of  the  two  sides  quite  fre- 
quently differ  in  size  and  fail  to  beat  with  the  usual 
synchronism.  This  sign  is  more  often  met  with  in  an- 
eurysms of  the  arch,  because  here  the  innominate  and 
subclavian  arteries  are  so  apt  to  have  their  caliber 
interfered  with  by  pressure,  by  twisting  or  dilatation,  or 
by  the  entrance  of  eoagula.  The  parts  most  liable  to 
compression  in  these  cases  are  the  esophagus,  trachea, 
recurrent  laryngeal  nerve,  and  left  innominate  vein. 
If  the  concave  border  of  the  arch  be  also  involved,  the 
left  bronchus  is  liable  to  be  partially  or  wholly 
obliterated.  The  signs  by  which  these  various  con- 
ditions can  be  recognized  have  been  already  considered. 
Rupture  occurs  into  the  trachea,  the  esophagus,  or  the 
pleural  cavity,  or  more  rarely  into  the  mediastinum, 
the   pulmonary   artery,   or   one   of   the   large   veins. 

Aneurysms  of  the  innominate  artery  alone  are  rare, 
but  we  oftener  see  tumors  of  the  arch  associated  with 
more  or  less  considerable  dilatation  of  the  innominate 
trunk.  The  enlargement  will  be  found  beneath  the 
right  sternoclavicular  articulation  and  inner  part  of 
the  first  rib,  and  it  may  extend  into  the  neck  beneath 
the  sternomastoid  muscle.  In  these  situations  we 
must  look  for  the  usual  local  signs,  swelling,  pulsation, 
and  bruit.  The  latter  may  be  heard  up  the  carotid. 
The  effect  upon  the  distal  arteries  is  generally  well 
marked.  The  symptoms  are  chiefly  pain,  both  local 
and  more  especially  radiating  up  the  right  side  of 
the  neck  and  back  of  the  head,  sometimes  down  the 
right  arm,  with  numbness;  and  if  the  tumor  be  larger, 
there  will  be  signs  of  compression  of  the  trachea  or  the 
esophagus  or  an  innominate  vein.  Cases  sometimes 
arise  in  which  it  is  extremely  difficult  to  determine 
whether  the  disease  is  confined  to  the  innominate 
artery  or  occupies  as  well  a  portion  of  the  arch  at  the 
origin  of  this  vessel.  For  instance,  a  man  came  under 
observation  a  short  time  ago  at  the  Montreal  General 
Hospital,  with  a  strongly  pulsating  tumor  rising  out 
of  the  neck  above  the  right  sternoclavicular  articula- 
tion. Fenwick,  whose  patient  he  was,  believed  it 
to  be  purely  innominate.  Its  strict  limitation  to  the 
area  near  tiiis  vessel,  the  distinctness  with  which  the 
cylindrical  tumor  could  be  defined  by  the  examining 
finger,    t he   interference    with    the   pulsations  in    the 


radials,  and  the  absence  of  all  signs  of  swelling  of  the 
arch,  as  determined  by  most  careful  examination,  all 
seemed  to  favor  this  conclusion.  This  opinion  was 
confirmed  at  a  consultation  of  several  members  of  the 
staff,  and  it  was  decided  to  recommend  treatment  by 
distal  ligature.  This  the  patient  refused  to  submit  to 
and  was  discharged.  He  subsequently  died  suddenly', 
while  running,  from  rupture  into  the  pericardium  of  a 
small  aortic  dilatation  just  above  the  valves.  The 
aneurysm  in  question  was  found  at  the  autopsy  to  be 
entirely  aortic.  A  remarkably  elongated  saccular 
dilatation  sprang  from  the  arch  directly  behind  the 
innominate  artery  (somewhat  compressing  it)  and 
appeared  above  the  inner  edge  of  the  clavicle.  The 
innominate  was  completely  pervious  and  of  normal 
size.  The  deception  was  complete  and  would 
have  given  rise  to  a  grave  error  of  treatment 
had  the  patient  consented.  Although,  as  in  the  ease 
just  related,  mistakes  of  this  kind  are  sometimes 
quite  unavoidable,  yet,  in  the  majority  of  cases,  a 
thorough  investigation  of  all  the  symptoms  and 
physical   signs   will   suffice    to   make   a   diagnosis. 

Aneurysms  of  flic  descending  thoracic  aorta  are  less 
common  than  the  others.  They  also  may  be  cylin- 
drical or  saccular.  From  the  depth  at  which  they  are 
situated  in  the  chest,  and  from  the  thickness  of  the 
structures  everywhere  surrounding  them,  they  are 
difficult  of  detection,  and  as  the  symptoms  from  them 
may  be  only  slight  and  ill  defined,  they  may  con- 
tinue for  a  long  time  unsuspected.  Pain  is,  however, 
seldom  absent,  and  when  due  to  pressure  on  the 
nerve  roots  is  of  an  extremely  violent  and  intractable 
character.  It  may  be  accompanied  by  hyperesthesia 
or  anesthesia  of  the  skin,  and  MacDonnell  has  re- 
corded an  instance  in  which  there  was  sweating  in  the 
course  of  the  nerves.  This  point  has  been  already 
sufficiently  dwelt  upon.  The  earliest  physical  signs 
consist  in  localized  dulness  and  pulsation  to  the  left  of 
the  spine,  and  enfeebled  breathing  over  the  same  area. 
Later  on,  a  systolic  bruit  may  be  heard.  ( )ccasionally, 
retardation  of  the  left  femoral  pulse,  as  compared  with 
that  of  the  radial,  has  been  observed.  When  of  large 
size,  the  aneurysm  pushes  the  heart  forward,  and  the 
heaving  impulse  of  the  tumor  can  be  felt  anteriorly 
through  the  heart.  A  rare  symptom  is  dilatation  of  the 
veins  on  the  anterior  aspect  of  the  chest  from  pressure 
upon  the  azygos  and  intercostal  veins.  Lying  against 
the  vertebral  bodies,  these  aneurysms  very  commonly 
produce  erosion  of  those  structures;  and  if  this  be 
sufficiently  considerable,  bending  of  the  vertebral 
column  occurs,  with  posterior  curvature.  From  this 
cause,  or  from  opening  of  the  vertebral  canal,  pressure 
is  sometimes  brought  to  bear  upon  the  spinal  cord 
itself,  with  a  resulting  paraplegia.  The  esophagus 
is  sometimes  compressed  and  dysphagia  produced. 
Attacks  of  pleuritis  in  the  lower  part  of  the  left  side 
are  a  very  frequent  accompaniment.  These  usually 
result  in  plastic  effusion,  but,  at  times,  even  pretty 
considerable  quantities  of  serum  may  be  found. 
Some  years  ago  I  found  a  hospital  patient  com- 
plaining of  stitching  pain  in  the  left  side.  Aery 
moderate  effusion  was  determined  by  physical  ex- 
amination. There  had  been  slight  pain  in  the  back 
for  some  time  previously,  but  this  had  not  been  of 
sufficient  duration  or  intensity  to  lay  stress  upon. 
The  fluid  continued  to  collect,  and  was  removed  by  as- 
piration, with  relief.  A  few  days  afterward  he  died 
suddenly  from  rupture  of  an  aneurysm  of  the  descend- 
ing aorta  into  the  same  pleural  cavity. 

Wynter  records  cases  of  simulating  aneurysm  of 
the  descending  arch  associated  with  a  ringing  second 
sound,  tracheal  tugging,  paralysis  of  the  left  recurrent, 
nerve,  and  downward  displacement  of  the  heart  owing 
to  lengthening  of  the  aorta.  He  believes  these  signs 
are  due  to  atheroma  of  the  upper  portion  of  the  arch 
and  that  they  can  be  distinguished  from  aneurysms  of 
the  arch  only  by  x-ray  examination. 

Rupture  of  these  aneurysms  occurs  most  frequently 


416 


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Aneurysm,  Interna] 


Into  the  left  pleural  cavity,  sometimes  into  the  right, 
and  occasionally  into  the  esophagus.  Cases  are  known 
in  which  the  sac  opened  into  the  spinal  canal. 

Diagnosis.     The  recognition  of  thoracic  aneurysm 
i  t  as  easy  in  some  cases  as  it  is  difficult  in  ol  hers. 
During  the  i >:i-t  decade  ii  has  become  more  generally 
recognized  that  a  not  inconsiderable  number  of  cases  of 
trysm  arc  entirely  latent.      An  important  method 
in  the  recognition  of  such  eases  has  been  made  by  the 
application  of  the  x-rays.     Cases  otherwise  obscure 
ran  be  cleared  up  in  this  way,  and  when  aneurysm  is 
falsely  suspected  an  x-ray  examination  may  disprove 
its  existence.     Observations  are'   best    carried  out  by 
means  of  the  fluorescent  screen,  when  a  distinct  en- 
largement lying  in  the  course  of  the  aorta  is  detected. 
Pulsation  is  sometimes  observed,  and,  its  occurence 
ngthens    the    view    that   an  aneurysmal   tumor  is 
ent.     Williams  states  that    the  movements  of  the 
diaphragm   are  often  less  on  the  left  side,  due  prob- 
to  pressure   on    the   left  bronchus.     Care  must 
.crcised  not  to  mistake  enlarged  glands  or  other 
intrathoracic  tumor  for  aneurysm.     Such  an  error  is 
likely  to  occur  only  when  the  growth  lies  in  contact 
with  the  aorta. 

By  this  method  of  examination  the  diagnosis  often 
becomes  apparent  in  obscure  cases,  and  aneurysms  are 
limes   found  which  are  unrecognizable  by  other 
methods  of  physical  examination. 

Superficial,  strongly  pulsating  aneurysms  are 
readily  observed,  and  not  unfrequntly  the  throbbing 
will  have  been  noticed  by  the  patient  himself.  On 
the  contrary,  deep-seated  dilatations  may  give  no 
appreciable  physical  signs,  and  in  that  case  the 
diagnosis  may  be  obscure.  Furthermore,  if,  in  one  of 
these  obscure  cases,  the  aneurysm  causes  no  symptoms 
by  its  pressure,  then  the  diagnosis  becomes  impossible. 
Not  a  few  aneurysms  of  the  ascending  arch,  even  of 
considerable  size,  prove  the  cause  of  sudden  death  in 
persons  previously  believed  to  have  been  in  good  health. 
These,  having  caused  no  symptoms,  had  never  been 
looked  for,  but  could  undoubtedly  have  been  detected 
by  physical  examination.  The  combination  which 
gives  the  greatest  certainty  to  the  diagnosis  of  thoracic 
aneurysm  is  the  union  of  physical  signs  of  tumor  with 
pulsation  in  the  course  of  the  aortic  arch,  together 
with  some,  or  best,  several,  of  the  pressure  symptoms 
enumerated.  The  difficulties  in  the  diagnosis  of 
these  cases  arise  from  the  great  variability  which  is 
met  with  in  the  manner  in  which  these  different  in- 
dications may  be  grouped  together.  Thus  we  meet 
with  cases  in  which  some  of  the  physical  signs  of 
aneurysm  are  observed,  and  no  pressure  symptoms; 
others,  again,  in  which  there  are  evident  pressure 
symptoms,  with  perhaps  only  a  few  of  the  signs  of 
aneurysm.  In  not  a  small  number  of  cases  the  con- 
ditions lead  to  the  recognition  of  an  intrathoracic 
tumor,  and  the  difficulty  begins  only  when  we 
endeavor  to  differentiate  between  a  solid  tumor  and 
aneurysm.  The  resemblance  between  an  an- 
eurysm and  a  solid  tumor  placed  between  the  chest 
walU  and  the  aorta  maybe  very  close.  In  both  there 
may  be  dulness  on  percussion,  pulsation,  and  a 
recognizable  bruit,  and  pressure  symptoms  of  identical 
character  may  also  be  present.  The  chief  points  of 
distinction  ari'  the  following:  In  the  case  of  the  neo- 
plasm, the  dulness  is  likely  to  be  less  clearly  restricted 
to  the  aortic  region,  the  pulsation  will  not  be  at  all  so 
forcible,  and  the  systolic  bruit  will  probably  not  be 
followed  by  an  accent  uated  second  sound.  Bronchial 
respiration  is  commonly  heard  over  a  solid  tumor, 
while  enfeeblement  or  silence  is  the  rule  in  aneurysm. 
Again,  persons  with  aneurysm  are  not  likely  to  suffer 
severely  in  their  general  nutrition  and  appearance, 
while  the  contrary  holds  good  with  reference  to  nearly 
all  forms  of  intrathoracic  solid  growth.  Attention 
to  the  following  points  may  also  assist  the  investigator 
in  doubtful  eases.  Aneurysm  is  many  times  more 
frequent    than   solid    tumor.     It    occurs  much  more 


often  in  men  than  in  women.  It  i-  favored  by  a 
in  t.iry  of  syphilis,  rheumatism,  or  -train. 

Pulsating  empyema  is  i lition,  which  some- 
times simulates  aneurysm.  The  chief  physical  signs 
to  be  here  met  with  will  be  dulness  1,11  percussion  and 
local    pul  ation,    but    no    pic   -lire    symptoms    will    be 

present.     Examined  closely,  the  dulness  will  be  ob- 
served to  be  less  clearly  localized  in  the  aortic  region 
than  is  that   of  an  aneurysm.      Moreover,  other  sign 
of  arterial  disease  will   be-  wanting,  and.  on    I  he  other 

hand,  there  will  be  some  evidences  of  disease  in  the 
pleura  or  the  lung,  accompanied  by  a  certain  degree 
of  constitutional  disturbance.  These  differences  will 
usually  suffice  to  prevent  error.  Puncture  with  a 
tine  aspirator  needle  will,  in  any  case,  clear  up  the 
diagnosis. 

Violent  throbbing  pulsation  of  the  aorta  in  eases 
of  severe  aortic  regurgitation  often  leads  to  a  sus- 
picion, or  even  to  an  erroneous  diagnosis,  of  aneurysm. 
The  pulsation,  however,  ha-  not  the  heaving  charac- 
ter of  aneurysm,  and  there  is  an  absence  of  pressure 

J  nipt  ollis. 

Prognosis. — It  is  usually  a  matter  of  considerable 
difficulty  to  form  a  satisfactory  opinion  as  to  the 
prospects  of  life  of  a  person  suffering  from  thoracic 
aneurysm.  Undoubtedly  the  disease  generally  tends 
to  prove  fatal,  and  is  actually  the  immediate  en 
of  death  in  the  majority  of  eases;  and  yet,  in  a  certain 
number,  increase  in  the  tumor  is  arrested  and  moder- 
ate health  is  enjoyed  for  perhaps  a  period  of  several 
years,  even  (hen  the  fatal  event  being  brought  about 
by  some  affection  entirely  independent  of  the  aneu- 
rysm itself.  It  is  often  clearly  impossible  to  estimate 
at  all  accurately  the  size  of  a  deep-seated  tumor,  or 
the  degree  to  which  it  may  lie  against  important 
adjacent  organs;  and  hence  ruptures  in  various 
directions,  which  no  skill  could  possibly  foresee. 
Those  aneurysms  which  arise  from  the  root  of  the 
aorta  are  the  most  dangerous,  as  they  tend  most 
frequently  to  rupture  while  yet  small.  Those  of  the 
ascending  arch — if  they  grow  forward  and  to  the 
right — are  calculated  to  permit  of  the  longest  tenure 
of  life.  Those  of  the  transverse  arch  and  descending 
thoracic  aorta  are  probably,  on  the  whole,  more 
favorable  than  the  first  and  less  so  than  the  last; 
the  reason  for  this,  of  course,  being  their  greater 
proximity  to  numerous  important  structures,  which 
can  hardly  escape  from  injurious  pressure.  Our 
opinion,  therefore,  of  the  probability  of  the  pro- 
longation of  the  patient's  life  must  depend  upon  the 
situation  of  the  aneurysm,  the  fluidity  or  the  contrary 
of  its  contents,  and  the  presence  or  absence  of  symp- 
toms of  compression,  to  a  serious  extent,  of  the  sur- 
rounding parts.  If  this  be  well  marked  upon  the 
trachea  or  esophagus,  a  fatal  result  may  lie  anticipated 
before  many  weeks  or  months.  Other  conditions 
to  be  considered  are  the  following:  Mode  of  life;  if  a 
person  with  aneurysm  is  obliged  to  earn  his  living, 
and  especially  if  the  occupation  followed  is  at  all 
laborious,  his  chances  of  living  will  be  far  less  than 
those  of  his  more  favored  fellow  who  is  able  to  live  at 
ease  and  free  from  care.  Rest  is  so  important  in 
these  eases  that  if  this  cannot  be  secured  the  disease 
is  almost  sure  to  be  progressive,  and  perhaps  even  to 
advance  rapidly,  while,  on  the  other  hand,  it  seems 
sometimes  surprising  how  long  the  fatal  end  can  be 
averted,  even  in  advanced  cases,  by  the  observance 
of  great  precautions  in  this  respect.  This  remark 
will  also  necessarily  apply  to  the  cases  of  patients  who, 
from  irritability  of  temper  or  other  similar  causes, 
refuse  to  carry  out  this  essential  principle  of  their 
treatment.  The  temperament  of  the  patient  is  of 
importance,  for  anger,  excitement,  and,  indeed,  any 
violent  reaction  may  be  followed  by  the  most  serious 
results.  Indulgence  in  alcoholic  liquors  is  sure  to 
interfere  with  the  quiet  action  of  the  heart  which  is 
so  desirable;  intemperance  must,  therefore,  influence 
strongly  our  prognosis. 


Vol.  I. — 27 


417 


Aneurysm,  Internal 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Associated  Conditions. — In  estimating  what  is 
likely  to  be  the  future  of  any  given  case  of  thoracic 
aneurysm,  it  is  important  to  study  carefully  any 
pathological  conditions  which  may  be  associated 
with  it— such,  for  example,  as  affections  (especially 
valvular)  of  the  heart,  of  the  lungs,  of  the  larynx,  of 
the  bronchi,  etc. — and  to  assign  to  each  its  true 
value  as  a  factor  in  the  problem.  Finally,  the  general 
condition  with  reference  to  nutrition,  muscular 
development,  etc.,  must  also  take  its  place  in 
rendering  the  prognosis  either  more  or  less 
favorable. 

Treatment. — Aneurysm  within  the  chest  is  capable 
of  the  same  spontaneous  cure  which  occurs  occasion- 
ally elsewhere.  Complete  coagulation  and  hardening 
of  the  contents,  with  arrest  of  all  symptoms,  is,  how- 
ever, extremely  rare.  Still  it  is  always  obviously  a 
duty  to  endeavor  to  place  a  patient  who  is  the  subject 
of  this  formidable  disease  in  as  favorable  a  position  as 
possible  for  this  process  to  occur.  All  treatment, 
therefore,  which  is  not  merely  palliative  should  be 
directed  toward  insuring  conditions  likely  to  promote 
firm  coagulation  within  the  sac. 

In  the  large  majority  of  cases  of  intrathoracic 
aneurysm  we  are,  from  the  nature  of  things,  pre- 
cluded from  those  methods  of  treatment  which  are 
applied  directly  to  the  tumor  itself  or  its  immediate 
neighborhood,  and  are  frequently  distinctly  curative. 
We  are,  on  the  contrary,  compelled  to  treat  these 
cases  by  general  measures  and  by  such  indirect 
means — drugs — as  experience  has  proved  to  be  of 
value.  The  objects  in  view  may  be  briefly  stated 
to  be  to  reduce  the  tension  within  the  aneurysm,  to 
secure  regularity  of  the  heart's  action  without  fre- 
quency, to  maintain  the  blood  in  good  chemical  con- 
dition without  undue  bulk,  and  to  favor  thickening 
of  the  sac's  walls.  To  follow  out  these  indications 
it  is  necessary  to  secure  the  full  direction  of  the  case 
for,  perhaps,  several  months.  If  the  physician, 
therefore,  is  to  meet  with  any  success,  it  is  absolutely 
requisite  that  he  should  have  the  hearty  cooperation 
of  the  patient,  who,  if  sufficiently  intelligent,  must  be 
made  acquainted  with  the  nature  of  the  case  and  the 
urgent  need  of  his  assistance,  irksome  though  he  may 
find  it  to  be. 

The  recumbent  position,  for  a  length  of  time,  is 
always  to  be  recommended.  The  effects  of  this 
measure  alone,  are  often  sufficiently  striking.  When 
the  person's  circumstances  permit,  the  restriction 
to  a  lying  posture  should  be  absolute,  and  should  be 
persisted  in  for  several  months,  unless  the  general 
health  appear  to  be  suffering  materially  from  the 
close  confinement,  when,  with  due  precautions, 
sitting  up  and  slow  walking  may  be  permitted.  If, 
on  the  other  hand,  circumstances  prevent  absolute 
rest  from  being  carried  out,  then,  at  any  rate,  very 
stringent  rules  must  be  insisted  upon,  governing  the 
patient's  entire  mode  of  life,  with  the  view  of  insuring 
the  least  possible  muscular  exertion.  This  is  a  point 
on  which  too  much  stress  cannot  be  laid.  These 
patients  live  constantly  on  the  edge  of  a  precipice, 
yet,  when  immediate  suffering  is  relieved,  this  fact 
is  too  often  lost  sight  of,  with  disastrous  results.  A 
patient  whom  I  treated  during  a  year  not  long  ago, 
for  an  aneurysm  of  the  ascending  arch,  was  so  far 
benefited  that  he  took  a  situation  as  a  messenger. 
In  spite  of  all  warnings  to  the  contrary,  he  soon 
undertook  to  handle  heavy  baskets  and  other  pack- 
ages. One  day,  shortly  after,  he  experienced  sudden 
pain  in  the  chest,  followed  by  the  extraordinarily 
rapid  development  of  an  external  tumor.  This 
quickly  attained  the  size  of  a  child's  head,  and 
proved  fatal,  with  great  suffering.  Hardly  less 
important  than  physical  rest  is  mental  quietude. 
Habitual  worries  of  all  kinds  should  be  as  much  as 
possible  excluded,  while  actual  excitement  is  in  every 
respect  highly  dangerous.  A  fit  of  anger  or  other 
violent  emotion  may  prove  fatal,  either  by  actually 


causing  rupture  of  the  sac  or  (as  in  a  recent  case  of 
my  own)  from  syncope. 

The  diet  is  a  matter  of  importance.  A  very  old 
treatment  of  aortic  aneurysm  is  that  of  Valsalva,  in 
which  repeated  blood-lettings  were  practised, .  to- 
gether with  a  gradual  restriction  of  the  food  until 
the  amount  of  this  was  brought  within  the  lowest 
possible  limits  short  of  actual  starvation.  The 
fallacy  of  this  proceeding  has,  however,  been  long 
ago  demonstrated.  Blood-letting  has  but  little,  or 
but  a  temporary,  effect  upon  the  blood  pressure; 
and  the  withdrawal  of  food  causes  anemia  and  weak- 
ness, with  irritability  of  the  heart  and  impaired 
nutrition  of  the  arterial  walls,  which  conditions 
indirectly  aggravate  the  disorder.  The  result  of 
experience  shows  that  the  formation  of  a  coagulum 
which  is  likely  to  be  of  service  in  the  process,  will 
proceed  better  if  the  patient  be  not  too  much  reduced, 
Tufnell,  of  Dublin,  is  the  only  comparatively  recent 
writer  who  has  advocated  the  starvation  plan. 
Conformably  with  his  recommendation,  the  system 
has  been  extensively  tried,  but  few  are  found  who 
can  report  results  calculated  to  lend  support  to  its 
efficacy.  The  quantity  of  fluid  allowed  should  not 
exceed  forty  or  fifty  ounces  daily;  it  is  difficult  to 
get  patients  to  submit  to  smaller  quantities  for  a 
prolonged  period  of  time.  If  the  patient  be  plethoric 
and  show  evidences  of  congestive  tendencies,  then 
our  treatment  may  well  be  begun  by  the  adoption  of 
depletory  measures  for  a  time — a  low  diet  with  laxa- 
tives or  saline  purgatives. 

As  regards  medicines,  many  have  been  tried,  but 
few  have  proved  useful.  The  most  valuable  drug  is 
undoubtedly  iodide  of  potassium.  The  good  effects 
of  the  iodide  were  described  by  Chuckerbutty  in 
1862,  and  by  Roberts  in  1S63,  and  they  were  em- 
phasized and  enlarged  upon  by  George  Balfour  a 
few  years  later.  Since  that  time  it  has  been  exten- 
sively employed,  and  has«ontinued  to  grow  in  favor. 
The  two  former  writers  considered  that  it  acted  by 
inducing  increased  coagulability  of  the  blood,  but 
this  view  is  not  shared  by  Balfour.  He  considers 
that  the  iodide  has  "a  peculiar  action  on  the  fibrous 
tissue,  whereby  the  walls  of  the  sac  are  thickened  and 
contracted,  while  if  coagulation  should  take  place 
within  the  sac,  it  plays  but  a  very  secondary  and  unim- 
portant part,  depending  for  its  occurrence  solely  on 
the  remora  of  the  blood,  and  is  in  no  respect  due  to  the 
iodide  of  potassium."  This  corresponds  entirely  with 
the  results  of  my  own  observations,  for  in  one  case,  in 
which  the  relief  to  pain  and  the  general  improvement 
had  been  very  marked  for  a  long  time  under  this 
treatment,  the  autopsy  subsequently  showed  that  not 
a  particle  of  fibrin  had  been  deposited  on  the  walls  of 
the  sac.  The  symptoms  which  specially  indicate  the 
use  of  the  drug  are  pain  and  troublesome  cough.  The 
special  pains  of  thoracic  aneurysm  are  generally  very 
rapidly  alla3*ed,  and  are  often  for  a  great  length  of 
time  held  in  abeyance  by  this  agent;  and  the  same 
may  be  stated  with  reference  to  tin?  troublesome 
attacks  of  irritating  cough  which  the  tumor  may 
excite  from  time  to  time.  Independently,  however, 
of  its  employment  for  the  relief  of  these  urgent  symp- 
toms, it  is  to  be  administered  steadily  for  such  a  I 
as  may  be  thought  necessary  to  influence,  as  al" 
the  disease  itself.  The  dose  usually  given  varies  from 
gr.  x.  to  gr.  xxx.  thrice  daily.  Balfour,  who  formerly 
inclined  to  the  larger  dose,  thinks  now  that  fully  as 
good  effects  can  be  obtained  from  smaller  ones.  His 
rule  is  to  employ  such  a  quantity  as  will  lower  the 
blood  pressure  without  increasing  the  frequency  of 
the  cardiac  contractions.  Beginning  with  ten-grain 
doses,  ascertain  the  pulse  rate  (the  patient  h< 
recumbent),  and  increase  to  fifteen;  if  no  increase  in 
the  pulse  be  observed,  this  is  to  be  continued;  but  if 
the  pulse  gets  quicker,-  then  return  to  ten.  It  is  rare 
that  more  than  fifteen  grains  can  be  borne  within  the 
limits  of  this  test.     The  treatment  must  be  persevered 


4  IS 


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Aneurysm,  Internal 


in,  mi  the  least,  for  several  months,  and,  to  give  it  a 
f:iir  trial,  probably  for  a  whole  year,  or  even  longer. 
If  troublesome  erupt  inns  are  produced  by  the  potash, 
an  intermission  must  be  allowed  till  these  are  recovered 
from.  II  is  also  well  to  remember  that  some  persons 
who  are  thoroughly  intolerant  of  iodide  of  potassium 
,  J,,  takciodide  of  odium  without  any  outward  effects. 
Balfour  speaks  truly  when  he  says  the  results  (from 
iodide  treatment)  "are  extremely  encouraging;  and 
when  we  reflect  upon  the  entire  absence  of  any  risk 
to  tlic  patient  from  the  treatment,  and  the  almost 
certainty  of  relief  to  his  sufferings  and  prolongation  of 
his  life  being  at  least  attained,  I  think  I  am  warranted 
in  saying  that  no  treatment  for  internal  aneurysm 
hitherto  devised  holds  out  anything  like  an  equal 
prospect  of  relief,  if  not  of  cure,  with  that  by  the 
i if  potassium." 

Tlic  hypodermic  injection  of  a  one-per-cent.  solu- 
tion of  gelatin  in  normal  saline  solution  has  been 
gly  recommended  by  Lancereaux,  with  the  view 
of  causing  coagulation  in  the  sue.  From  50  to  100 
o.c.  may  be  injected  beneath  the  skin  of  the  buttock, 
or  thrown  deeply  into  the  muscles.  There  is  some- 
times considerable  local  pain  and  even  general  febrile 
reaction  after  this  procedure.  Although  successful 
have  been  reported,  the  method  is  by  no  means 
free  from  danger.  Serious  and  even  fatal  results 
have  followed  the  injections,  owing  to  the  detach- 
ment of  large  emboli.  This  method  has  not  stood  the 
of  experience  and  is  now  seldom  used. 

Christopher  Heath  and  a  few  others  have  sug- 
gested and  practised  ligature  of  one  or  more  of  the 
great  branches  of  the  aortic  arch,  the  object,  of 
course,  being  to  retard  still  further  the  blood  current 
and  thus  promote  coagulation.  Some  support  is 
given  to  this  procedure  from  the  benefit  that  has  been 
observed  in  certain  cases  of  aortic  aneurysm  in  which 
the  carotid  and  subclavian  of  the  right  side  had  been 
ligatured,  under  the  impression  that  the  disease  was 
confined  to  the  innominate  artery.  At  most  it  would 
be  applicable  only  to  cases  in  which  the  tumor  was 
sacculated  and  either  involved  the  root  or  was  situ- 
ated close  to  the  origin  of  some  of  the  great  vessels. 
Evidence  of  extensive  atheromatous  disease  would 
preclude  any  prospect  of  advantage  from  this  sur- 
gical procedure. 

The  method  of  all  others  which  seems  to  hold  out 
the  greatest  prospect  of  success,  when  it  is  decided  to 
penetrate  the  sac,  is  that  first  suggested  by  Moore, 
and  subsequently  modified  by  Corradi.  It  consists 
in  the  introduction  of  ten  or  more  feet  of  coiled  gold 
or  silver  wire  into  the  sac  through  a  hollow  needle, 
insulated  by  being  coated  with  French  lacquer,  com- 
bined with  the  passage  of  a  galvanic  current  of  fifty 
to  seventy-five  milliamperes,  the  anode  being  con- 
nected with  the  wire.  It  is  applicable  only  in  cases 
of  sacculated  aneurysms.  In  the  thorax  the  .r-ray 
is  an  indispensable  aid,  especially  the  fluoroscope,  in 
revealing  the  pulsating  sac;  a  local  anesthetic  is  used 
to  introduce  the  needle  through  the  skin.  In  one  case 
Finnic  removed  the  greater  portion  of  the  sternum 
and  three  adjacent  ribs  to  gain  better  access  to  the  sac. 
In  abdominal  aneurysm  an  incision  is  required  through 
the  abdominal  wall  in  order  to  apply  this  method 
of  treatment.  The  current  should  pass  for  at  least 
an  hour  and  Finnie  in  his  later  cases  has  continued  it 
for  two  hours. 

In  favorable  cases  decided  relief  to  pain  has 
been  obtained  with  lessening  of  pulsation;  and  in  a 
considerable  number  of  reported  cases  marked 
improvement  has  been  noted.  From  the  nature 
of  the  disease  cure  can  seldom  be  expected,  and 
has  been  reported  in  but  few  instances. 

Certain  risks  must  be  faced  in  undertaking  an  opera- 
tion of  this  character.  Embolism  has  occurred  and 
also  rupture  of  a  subsidiary  sac.  Sloughing  in  the 
course  of  the  wire  or  in  the  sac  itself,  with  subsequent 
hemorrhage  has  also  been  observed. 


Although  the  special  treatment  of  aneurj  m  in  the 
majority    of   cases    con  i  I     of    prolonged    rest    and 

the  administration  of  iodide  of  potassium,  a    al 

detailed,  (here  are  be  ide  the  e  certain  therapeutic 
measures  al  our  command  for  the  relief  of  individual 
symptoms. 

Excited  cardiac  action  and  palpitation  are  be  I 
relieved  by  the  judicious  use  of  morphine  and  the 
employment  of  a  bladder  of  ice  over  the  front  oi  the 
che  t. 

The  pain,  it  has  been  already  stated,  is  generally 
best  treated  by  the  iodide  of  potassium.  If,  how 
it  be  very  severe,  ii  may  be  necessary  to  use  hypo- 
dermic injections  of  morphine  until  the  iodide  shall 
have  had  time  to  act.  Moreover,  we  do  meet  with 
ran'  cases  in  which  the  effect  of  the  iodide  ultimately 

bee s  lost,  and  our  only  resort  is  the  frequent    use 

of  morphine  to  make  life  bearable.  ( Ine  very  marked 
ease  of  this  kind  came  under  my  notice  in  the  person 
of  a  hospital  patient.  His  aneurysm  was  as  large  as 
a  cricket  ball,  and  almost  as  solid.  Neuralgic  pains 
were  complained  of  persistently,  were  relieved  for 
a  considerable  time  by  the  iodide  treatment,  but,  for 
more  than  a  year  previous  to  his  death,  we  were 
obliged  to  administer  daily  hypodermics  of  mor- 
phine in  considerable  quantity.  Pain  of  well-defined 
neuralgic  character  (especially  along  the  intercostal 
nerve)  is  decidedly  benefited  by  the  application  of 
small  blisters  over  the  most  tender  parts. 

Dyspnea,  if  due  to  accompanying  catarrh,  must 
be  treated  with  reference  to  the  latter  disorder.  But 
if,  as  is  most  frequently  the  case,  it  is  the  result  of 
mechanical  pressure  and  irritation  of  nerves,  recourse 
must  be  had  to  sedatives  and  narcotics,  especially 
morphine  and  hydrocyanic  acid.  Alcohol  in  toler- 
ably full  doses  is  also  of  considerable  assistance. 

If  a  projecting  tumor  form,  care  must  lie  taken  to 
protect  it  from  injury  or  friction  by  some  arrangement 
of  pads  or  a  shield  of  some  smooth  metallic  substance 
lined  with  cloth. 

When  rupture  has  actually  taken  place,  we  can 
probably  do  nothing;  but  if  any  preliminary  bleeding 
should  occur,  we  may  endeavor  to  prevent  this  going 
on  to  rapid  hemorrhage  by  the  use  of  ice  externally 
and  the  administration  of  astringents,  while  the  most 
perfect  quietude  is  enjoined. 

Abdominal  Aneurysm. — Symptomatology. — Aneu- 
rysm of  the  abdominal  aorta  is  occasionally  latent, 
as  in  two  of  Osier's  series  of  eighteen  cases.  In  a  few 
instances,  again,  aneurysmal  tumors  may  reach  a 
considerable  size  without  the  distressing  symptoms 
which  usually  accompany  the  malady. 

The  earliest,  the  most  persistent,  and  the  most 
distressing  symptom  is  abdominal  pain.  As  Beatty 
long  ago  pointed  out,  the  pain  has  a  double  character, 
being  constantly  present  as  a  dull  aching  sensation 
in  the  abdomen  and  back,  and  subject  to  paroxysms 
of  extreme  violence  which  even  large  doses  of  mor- 
phine may  only  partly  allay.  The  site  of  pain  in 
these  crises  is  situated  in  the  abdomen  and  back, 
and  is  due  to  pressure  on  the  lumbar  nerves.  These 
paroxysms  may  also  radiate  more  widely,  down  the 
thighs  or  to  the  testicles;  they  may  simulate  renal, 
hepatic,  or  intestinal  colic  and  have  even  been  mis- 
taken for  the  abdominal  crises  of  tabes.  The  pain 
may  be  increased  by  the  taking  of  food,  as  in  Beatty's 
case;  Hoyle  records  cases  in  which  it  was  increased 
by  the  respiratory  movements. 

Other  symptoms  are  due  to  pressure  on  surround- 
ing structures.  Vomiting  is  present  in  many  in- 
stances, and  pressure  on  the  duodenum  may  induce 
partial  obstruction  with  dilatation  of  the  stomach, 
as  in  a  case  recorded  by  Osier.  Dilatation  of  the 
esophagus  from  compression  of  its  lower  end  has 
also  been  noted  by  the  same  observer. 

When  the  tumor  is  in  the  proximity  of  the  bile 
ducts,  jaundice  may  result  and  enlargement  of  the 


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liver  may  follow  pressure  on  the  hepatic  vein-;. 
Ascites  is  an  extremely  rare  manifestation  of  aneu- 
rysm, and  edema  of  the  extremities  and  trunk  is  of 
little  diagnostic  import.  Fever  is  usually  absent 
and  its  presence  denotes  a  complication.  The  nutri- 
tion of  the  patient  often  fails  to  some  extent,  but  in 
some  cases  extreme  emaciation  is  a  noticeable  feature 
and  may  be  attributed  to  loss  of  rest,  to  gastric  dis- 
turbance and  possibly  in  some  instances,  as  in 
Pepper's  case,  to  occlusion  of  the  thoracic  duct. 

Aneurysms  of  the  various  visceral  arteries  are 
usually  -mall  in  size  and  are  seldom  recognized 
during  life  or  until  fatal  rupture  lias  occurred.  They 
are  frequently  of  mycotic  origin,  or  follow  an  acute 
infection.  They  usually  run  an  acute  course  and 
occur  in  younger  individuals  than  the  more  common 
form  of  the  disease. 

The  branches  of  the  celiac  axis,  the  superior  mesen- 
teric and  renal  arteries  are  the  vessels  most  commonly 
involved. 

Dean  and  Falconer  refer  to  fifty  instances  of  aneu- 
rysm of  the  hepatic  artery  of  which  seventy-three 
per  cent,  followed  acute  infection.  In  their  ca 
jaundice  developed  twenty  days  after  pneumonia, 
and  hematemesis  and  melena  resulted  from  rupture 
into  the  dilated  bile  duct.  In  a  case  recorded  by 
Schultz,  aneurysm  developed  as  a  result  of  erosion  of 
the  outer  coats  of  the  vessel  from  gallstones. 

The  superior  mesenteric  is  more  commonly  affected 
than  other  vessels.  Aneurysms  of  the  renal  artery 
are  very  unusual  and  sometimes  lead  to  hematuria. 
In  a  case  of  Keen's  an  abdominal  tumor  was  removed 
with  the  kidney  and  subsequent  dissection  proved 
the  mass  to  be  an  aneurysm  of  the  renal  artery. 

By  far  the  most  common  termination  of  abdominal 
aneurysm  is  rupture.  In  233  cases  collected  by  Nixon 
this  occurred  in  152  instances;  of  these  there  were 
sixty-five  retroperitoneal,  forty-five  intraperitoneal, 
seven  pleural,  one  esophageal,  and  four  pulmonary. 

Melena  and  hematemesis  indicate  rupture  into  the 
intestines  or  stomach.  Elbe  has  reported  a  case  of 
rupture  to  the  vena  cava  and  states  that  there  are 
only  four  recorded  cases  (Deutsche  med.  Woch.,  1910). 
Rupture  into  the  peritoneum  is  usually  rapidly  fatal; 
when  retroperitoneal  the  termination  is  more  gradual 
and  the  symptoms  may  be  those  of  acute  peritonits. 
Osier  refers  to  four  cases  operated  on  for  appendicitis. 

The  recognition  of  aneurysm  rests  on  the  discovery 
of  a  pulsating  expansile  tumor.  If  large  it  is  visible, 
conveying  a  distinct  impulse  to  the  abdominal  wall. 
Careful  inspection  of  the  lumbar  region  in  a  good 
light  sometimes  reveals  pulsation  of  an  aneurysm 
not  seen  in  front. 

Pulsation  in  the  epigastrium  or  along  the  front  of 
the  normal  aorta  is  frequently  found,  particularly 
in  neurotic  individuals,  but  in  aneurysm  it  has  an 
expansile  character,  pulsating  not  only  from  before 
back  but  from  side  to  side  and  separating  the  observ- 
ers hands  when  laid  on  each  side  of  the  tumor.  A 
thrill  is  occasionally  felt.  The  consistence  of  the 
tumor  varies  with  the  amount  of  fibrin  deposited  in 
the  sac.  When  the  latter  has  thin  walls  it  is  soft  and 
fluctuating  and  can  sometimes  be  emptied  by  pres- 
sure. With  a  large  deposit  of  fibrin  the  tumor  has 
a  more  solid  character  and  pulsation  may  even  cease. 

When  connected  with  the  aorta  aneurysms  are 
commonly  fixed,  they  do  not  alter  with  change  of 
posture,  and  he  behind  the  alimentary  tract.  In  the 
case  of  large  tumors  these  may  however  come  for- 
ward and  give  rise  to  a  dull  note  on  percussion.  The 
surface  of  t  he  tumor  is  smooth  and  only  exceptionally 
lobulated. 

A  bellows  murmur  is  heard  in  a  considerable  number 
of  cases  and  in  suspected  cases  the  stethoscope  should 
be  carefully  used  in  the  lumbar  region  as  well  as  over 
the  abdomen. 

Diagnosis.  —  With  a  history  of  severe  and  persist- 
ent  abdominal    pain   aneurysm  is  one  of  the  condi- 


tions which  should  be  considered,  and  evidence  of 
syphilis  increases  the  probability  of  such  a  condi- 
tion being  present. 

The  difficulty  of  recognition  is  shown  by  Bryant's 
collection  of  fifty-four  cases  from  Guy's  Hospital,  in 
which  only  one-third  were  recognized  during  life.  l"n 
fortunately  the  .r-rays  render  little  or  no  assistance  in 
the  diagnosis  of  abdominal  aneurysm  owing  to  the 
impermeable  character  of  the  abdominal  viscera. 

Treatment. — See  the  section  on  Thoracic  Aneurysm. 

Cerebral  Aneurysms. — Miliary  aneurysms,  de- 
scribed by  Carcot  and  Bouchard,  are  visible  to 
naked  eye  and  vary  in  size  from  two-tenths  to  one 
millimeter.  They  are  most  readily  seen  in  the  i 
volutions  and  occur  in  order  of  frequency  in  the 
optic  thalami,  pons,  convolutions,  corpora  striata, 
cerebellum,  medulla,  middle  peduncles,  and  centrum 
ovale.  Their  number  is  very  variable,  from  two  to 
three  to  as  many  as  one  hundred.  They  derive  their 
importance  from  the  fact  that  they  are  sometimes  the 
source  of  cerebral  hemorrhage,  particularly  in  aged  in- 
dividuals. They  result  from  degenerative  changes  in 
the  minute  \ressels  and  are  frequently  accompanied  by 
atheroma  of  the  larger  cerebral  arteries. 

Aneurysm  of  the  larger  arteries  is  a  rare  condition, 
occurring  nineteen  times  in  9,000  autopsies  collected 
from  Guy's  Hospital  by  Pitt,  and  seven  times  in  501 
cases  of  aneurysm  according  to  Crisp's  figures.  'I 
seldom  attain  a  size  larger  than  a  walnut  and  fre- 
quently lead  to  fatal  rupture  when  no  larger  than  a 
pea.  The  middle  cerebrals  and  the  basilar  are  more 
often  affected  than  the  other  vessels,  then  the  internal 
carotids.  The  other  cerebral  arteries,  the  vertebrals 
and  the  communicating  arteries  occasionally  suf- 
fer. Beadles  (Brain,  Vol.  xxx.)  has  collected 
cases  and  classifies  them  symptomatically  in  four 
groups: 

1.  Those  in  which  rupture  and  apoplexy  have  been 
the  first  signs  of  cerebral  disease. 

2.  Those  in  which  fatal  apoplexy  has  been  preceded 
by  symptoms  suggesting  cerebral  tumor  or  other 
cerebral  lesion. 

3.  Those  in  which  there  have  been  symptoms  of 
cerebral  tumor  only. 

4.  Those  discovered  accidently  after  death  or 
latent  during  life. 

In  nearly  half  the  cases  (46.3  per  cent.)  apoplexy 
was  the  first  symptom,  and  in  only  a  little  over  a 
third  of  the  cases  |  :;7.1 1  per  cent.)  were  signs  of  tumor 
or  brain  lesion  present,  and  even  in  these  the  symp- 
toms were  by  no  means  always  distinctive  of  organic 
disease. 

In  thin-walled  sacs  early  rupture  is  apt  to  occur,  and 
symptoms  from  pressure  on  the  nerves  at  the  base 
or  on  the  cerebral  substance  are  often  absent.  Where 
the  sac  has  a  thicker  and  harder  wall  pressure  symp- 
toms appear  more  frequently.  These  cases  may 
last  for  years  and  death  often  results  from  pressure 
on  the  medulla  or  other  portions  of  the  brain. 

In  cases  where  the  symptoms  of  tumor  are  pres- 
ent, headache,  vomiting,  recurring  convulsions,  and 
optic  neuritis,  sometimes  with  retinal  hemorrhaj 
may  occur.  Owing  to  the  contiguity  of  the  vessels 
and  cranial  nerves,  one  or  more  of  these  may  suffer 
from  pressure.  Symptoms  due  to  pressure  on  the 
pons  and  medulla  result  most  frequently  from  dis- 
ease of  the  basilar  artery  with  which  these  structures 
are  in  close  contact. 

A  murmur,  according  to  Beadles,  is  seldom  hi 
and  a  diagnosis  based  upon  it  has  has  been  proved 
ci  hi  oct  in  only  two  instances  by  postmortem  examina- 
tion. This  fact  is  not  surprising  when  the  small  si/e 
and  deep  position  of  these  aneurysms  are  remembered 
So  many  other  conditions  may  produce  a  cranial 
murmur  that  no  significance  should  be  attached  to 
this  sign. 

In  these  cases  however  blood  extravasation  is  usu- 


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Angina  Abdominis 


ally  in   the   tumor  or  brain  substance,  and   is  less 
likely  to  reach  the  surface. 

(I,,-  diagnosis  of  cerebral  aneurysm  is  seldom  if 
over  made  with  certainty.  Wichern  (2>< 
Ztitschrift  fiir  S <  rv<  nln  ilkitttdr.  Kill')  puints  out  thai 
rigidity  of  the  nock  is  frequently  present  with  the 
apoplectic  attacks,  signifying  a  surface  hemorrha 
in  such  instances  lumbar  puncture  would  reveal  the 
presence  of  blood,  and  this  combination  of  signs  should 
suggest  aneurysm  as  the  probable  source  of  hemor- 

;e.     The  occurrence  of  apoplexy  in  an  individual 
who   has   suffered   from   signs  of   tumor   might   also 

-t  such  an  explanation,  and  the  finding  of  bl 1 

in  a  lumbar  puncture  would  be  further  evidenci 
in  its  favor.  On  the  other  hand  cerebral  growths  are 
occasionally  attended  by  sudden  apoplectic  attack 
usually  due  to  hemorrhage.  In  these  cases  howevei 
the  extravasation  is  usually  in  the  tumor  or  brain 
tance  and  blood  is  therefore  not  likely  to  be  pres- 
ent in  the  spinal  fluid.  F.  G.  Finley. 


Angelica. — Angelica  L.  (fam.  Umbelliferce)  is  a 
genus  the  limits  and  dimensions  of  which  are  greatly 
in  dispute  among  botanists,  the  various  sub-genera  of 
one  author  being  regarded  as  so  many  distinct  genera 
by  another.  As  recognized  by  Messrs.  Engler  and 
Prantl,  whom  we  follow,  it  contains  about  twenty- 
live  species,  most  of  them  natives  of  the  cool  tem- 
perate regions  of  the  northern  hemisphere.  The 
plants  abound  in  the  aromatic  principles  of  the 
family.  A  number  of  them  have  been  employed  in 
domestic  practice,  and  two,  under  the  names  "Euro- 
pean'' and  "American"  angelica,  have  been  very 
extensively  used  in  medicine. 

pean  Angelica  is  the  rhizome  and  roots  of 
lica  archangelica  L.,  a  biennial,  four  to  six  feet 
high,  with  a  stout,  hollow,  purple-green,  fluted  stem, 
large  decompound  leaves  with  clasping  petioles,  and 
large  umbels  of  white  flowers.  It  is  a  native  of  far 
Northern  Europe  and  Asia,  and  is  very  extensively 
Cultivated,  our  commercial  supplies  coming  mostly 
from    cultivated    plants    of    Germany    and    France. 

It  is  one  of  the  few  vegetables  whose  use  began  in 
the  extreme  north  of  Europe  and  extended  south- 
ward. It  was  an  article  of  food  in  Norway  and 
Iceland  many  years  ago,  when  its  spicy  taste  made  it 
a  grateful  addition  to  the  monotonous  diet  of  the 
North.  Later,  in  the  fifteenth  and  sixteenth  centuries, 
it  was  generally  cultivated  throughout  Central 
Europe.  .Since  then,  the  use  of  angelica  has  been 
gradually  diminishing,  milder-flavored  vegetables 
taking  its  place,  and  it  is  only  grown  at  present  to  fill 
a  very  moderate  demand  in  domestic  and  veterinary 
medicine,  confectionery,  and  liqueurs. 

It  is  important  to  note  the  extensive  use  of  the 
"candied"  stems  (Angelica  glare)  as  a  confection. 
since  important  cases  of  poisoning  sometimes  result 
from  the  ignorant  use  of  certain  toxic  plants  which 
bear  a  close  resemblance  to  this. 

The  "root"  consists  of  a  large  short  rhizome,  ter- 
minated above  by  a  hollow  stem,  and  often  worm- 
eaten.  Below,  it  divides  into  numerous  thick, 
fleshy  roots,  four  millimeters  (one-eighth  of  an  inch)  in 
thickness,  and  twenty  or  thirty  centimeters  in  length, 
of  a  blackish-brown  color,  much  wrinkled  longitudin- 
ally, and  tubereulated.  They  are  rather  soft  and  pli- 
able, brownish-white  within,  and  in  the  dried  speci- 
mens He  in  a  parallel  tress  or  bunch.  The  odor  is 
rather  pleasant:  the  taste  at  first  sweetish,  later  bitter 
and  musky.  Radially  arranged  oil-ducts  and  resin 
cells  are  to  be  seen  under  the  microscope  on  section, 
chiefly  in  the  cortical  portion. 

The  constituents  of  angelica  are,  first,  an  essential 
<~>il,  containing  phellandrene,  and  probably  pinene 
and  evmene,  of  which  it  yields  from  eight-tenths  to 
one  per  cent.;  this  has  the  odor  of  the  plant  and  the 
usual  carminative  qualities  of  the  oils  of  the  order. 


Second,  six  to  ten  per  cent,  of  resin.     Third,  angelic 
acid,  one-third  of  one  per  cent.,  discovered  bj  Buchni 
in  1843,  ami  since  found  in  a  number  of  other  plants, 
as  well  as  made  by  synthesis;  an  odorous  crystalline 

volatile  acid.     Fourth,  a    very  small  amount  ol   va- 
lerianic acid,  together  with  the  crystalline  angelii 
an  amaroid,  and  a  little  ea<  h  ol     tarch,  tannin,  and 
sugar. 

Its  properties  are  aromatic,  stimulant,  carmina- 
tive, and  flavoring,  as  usual  in  the  family.  The  dose 
is  from  0.5  to  2  grains  (gr.  viij.-xxx.). 

A  ml:  lica  oil  from  this  source  is  an  article  of  corn- 
ier  

American  Angelica  is  the  root  of  Angelica  airn- 
purpurea  L.,  a  plant  of  very  similar  habit  to  the  last, 

growing  in  Northeastern  North  America  The  tool 
;i'"«  in  the  same  manner  from  a  similar  rhizome,  but 
are  marketed  detached  therefrom.  They  are  some- 
what larger  than  those  of  the  European,  and  arc  of  a 
light  gray-brown  color.  The  composition  and  prop- 
erties are  practically  the  same,  though  the  root  and 
the  oil  have  a  perceptibly  different  odor  and   taste. 

II.    II.    Rusby. 

Angina  Abdominis. — This  term  was  apparently 
first  used  by  Baccelli  of  Rome,  according  to  Minella, ' 
who  reported  a  case  of  this  condition.  The  latter 
observer  defines  angina  abdominis  as  a  condition  in 
which  there  occur  paroxysms  of  severe  abdominal 
pain,  resulting  from  aneurysm  or  arteriosclerosis  of 
the  vessels  of  the  celiac  plexus.  In  Minella's  ease  at 
autopsy  there  was  demonstrated  an  aneurysm  of  the 
celiac  axis.  The  pain  may  be  associated  with  the 
symptoms  of  angina  pectoris,  in  which  case  the  diag- 
nosis is  not  difficult.  In  other  instances  the  pain  is 
confined  to  the  abdomen,  occurs  usually  in  elderly 
persons  affected  with  arteriosclerosis,  and  is  accom- 
panied by  the  feeling  of  impending  dissolution. 

The  subject  of  angina  abdominis  is  discussed  at 
length  by  J.  Pal  in  his  article  "  Ueber  Angina  Pectoris 
und  Abdominis"2  and  in  his  book  entitled  "Gefass- 
krisen."3  According  to  this  author  anginal  attacks 
belong  to  the  vascular  crises.  There  are  two  types  of 
angina:  the  pectoral  and  the  abdominal.  The  latter 
is  comparatively  rare,  but  has  been  described  by 
many  clinicians,  including  Huchard,'  Leydcn, 
Jaworski,  Neusser,5  and  Pauti  and  Kaufmann.  The 
vascular  crises  also  include  the  abdominal  crises  of 
tabes  and  of  lead  poisoning.  In  all  of  these  cases  the 
pain  is  the  result  of  the  contraction  of  the  blood- 
vessels  of  the  abdominal  viscera.  In  addition  to  the 
pain  there  is  an  inhibition  of  peristalsis.  But  the 
pain  controls  the  clinical  picture.  Huchard  also 
refers  to  the  similarity  of  the  attacks  of  angina 
abdominis  to  the  gastric  crises  of  tabes.  In  certain 
cases  it  is  difficult  to  differentiate  between  the  two 
conditions.  In  both  of  these  the  pain  is  severe  and  is 
localized  in  the  epigastrium,  but  it  may  radiate 
widely  from  this  region.  On  the  other  hand,  Pauli 
and  Kaufmann  believe  that  the  pain  is  localized  in 
the  visceral  blood-vessels,  and  is  the  result  of  lesions 
of  the  inner  lining  of  the  latter.  Their  conception 
agrees  with  Nothnagel's  views  regarding  vascular 
colic.  Pal  states  that  one  is  accustomed  to  localize 
abdominal  pain  in  some  definite  organ.  As  a  rule 
this  localization  is  deceptive,  for  the  objective  locali- 
zation of  pain  is  possible  only  if  this  symptom  is 
accompanied  by  manifest  lesions  of  the  suspected 
organ.  This  difficulty  is  further  complicated  by  the 
fact  that  the  nerves  of  the  abdominal  viscera  are  not 
particularly  sensitive,  for  gastric  and  typhoid  ulcers 
may  be  present  without  giving  rise  to  the  slightest  pain. 

Within  recent  years  there  have  been  describe.  1 
cases  of  paroxysmal  abdominal  pain,  which  has 
been  attributed  to  arteriosclerotic  changes  in  the 
visceral  blood-vessels,  which  changes  in  turn  give  rise 
to    intermittent    obstruction    and    ischemia.     These 


421 


Angina  Abdominis 


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cases  have  been  reported  by  Markwald,  Schnitz'ler,6 
Ortner,7  and  others.  To  this  group  belong  the  cases 
described  by  Ortner  as  the  intestinal  type  of  arter- 
iosclerosis, under  the  name  "dyspraxia  intermittens 
angiosclerotica  intestinalis."  According  to  Pal,  the 
pain  of  angina  abdominis  is  not  the  result  of  ischemia. 
He  believes  rather  that  the  peripheral  vasoconstriction 
is  accompanied  by  a  distention  of  the  proximal 
arterial  vessels.  In  this  view  Pal  agrees  with  Colin, 
who  attributes  the  pain  to  increased  tension  in  the 
mesenteric  vessels.  That  this  theory  is  a  plausible 
one  is  shown  by  the  fact  that  the  administration  of 
drugs,  such  as  the  nitrites  and  nitroglycerin,  which 
dilate  the  blood-vessels  in  other  parts  of  the  body, 
removes  the  tension  in  the  visceral  blood-vessels  and 
relieves  the  pain.  In  all  of  Pal's  cases  there  was  a 
generally  increased  arterial  tension.  In  most  of  the 
cases  there  was  an  increased  and  more  widely  diffused 
pulsation  in  the  region  of  the  abdominal  aorta. 

An  accompanying  phenomenon  of  angina  abdom- 
inis is  constipation,  which  also  occurs  in  the  visceral 
crises  of  tabes  and  plumbism.  In  some  cases  tnere  is 
a  retraction  of  the  abdominal  wall,  in  others  there  is 
meteorism.  There  may  also  be  a  segmental  dis- 
turbance of  sensibility  in  the  regions  supplied  by  the 
lower  dorsal  and  upper  lumbar  roots.  The  retracted 
abdomen  of  lead  and  tabetic  colic  is  not  as  characteris- 
tic in  angina  abdominis,  in  which  the  condition  is 
possibly  masked  by  a  hyperemic  liver.  Distent  inn 
when  it  occurs  is  caused  by  an  intestinal  atony  due  to 
vasoconstriction,  and  may  be  compared  to  the  dis- 
tention occurring  in  renal  and  biliary  colic.  Vomit- 
ing sometimes  occurs  as  a  secondary  manifestation. 
Pal  alludes  to  the  fact  that  the  vasoconstriction  may 
affect  only  certain  vessels  of  the  abdomen.  Angina 
abdominis  must  also  be  differentiated  from  neuralgia 
of  the  abdominal  sympathetic.  In  this  condition 
there  is  no  evidence  of  increased  arterial  tension. 
Neuralgia  of  the  abdominal  sympathetic  is  probably 
identical  with  the  "syndrome  solaire  aigu  d'excita- 
tion"  of  Jaboulay. 

Pals  in  his  paper  entitled  "Zur  Kenntniss  der 
abdominellen  Gefasskrisen  der  Tabetiker  und  ihrer 
Beziehung  zur  'Aortite  Abdominale' "  states  that 
angina  abdominis  may  occur  coincidently  or  al- 
ternately with  angina  pectoris.  Many  of  Pal's  cases 
suffered  from  tabes.  This  observer  recognizes  in  the 
latter  disease  two  varieties  of  gastric  crises.  In  one 
of  these  the  attack  is  purely  gastric;  there  is  vomiting 
with  or  without  pain,  and  the  blocd  pressure  does  not 
rise  to  any  marked  extent  during  the  attack.  In  the 
second  variety  of  tabetic  crises  there  is  marked 
abdominal  pain  associated  with  high  arterial  tension. 
In  these  cases  the  pain  comes  on  as  the  pressure  rises 
and  is  relieved  by  amyl  nitrite  or  the  other  nitrites. 

In  his  article  "On  Abdominal  Pain"  Sir  Lauder 
Brunton9  referred  to  an  observation  made  by  Dresch- 
feld  of  Manchester  in  a  case  presenting  paroxysmal 
abdominal  pain.  At  autopsy  the  only  abnormal 
condition  found  was  an  atheromatous  state  of  the 
intestinal  vessels.  In  this  article  Brunton  described 
a  condition  of  paroxysmal  abdominal  pain  occurring 
in  individuals  who  are  apparently  otherwise  perfectly 
healthy,  whose  digestion  is  good,  and  whose  bowels 
are  regular.  Brunton  attributed  these  attacks  to 
irregular  spasmodic  contractions  of  the  abdominal 
vessels  analogous  to  the  peripheral  contraction  and 
proximal  dilatation  of  the  temporal  artery  occurring 
in  migraine,  which  latter  condition  Brunton  had 
observed  in  his  own  case.  For  the  abdominal  pain, 
just  as  for  migraine,  he  advised  the  use  of  salicylate 
of  sodium  and  bromide  of  potassium  together  with 
carminatives  and  friction  of  the  abdomen  during  the 
attack. 

Sir  Lauder  Brunton  and  W.  E.  Williams10  report 
the  case  of  a  man  aged  sixty-eight  years  who  had 
been  suffering  from  diabetes  for  twenty-five  years. 
For    the    previous    eighteen    months    he    had    been 

422 


suffering  from  abdominal  pains  that  had  been  at- 
tributed to  flatulence,  and  that  had  been  accompanied 
by  marked  loss  of  weight  and  drowsiness.  The 
striking  feature  in  this  case  was  the  severe  spasmodic 
abdominal  pain  which  came  on  about  twice  daily 
mostly  after  the  exercise  of  walking  or  of  playing 
billiards.  An  unmarried  sister  aged  sixty-four 
years  had  also  suffered  from  similar  pains  for  the  past 
seven  years.  The  pain  resembled  that  of  angina 
pectoris  but  it  differed  in  its  localization,  being 
most  severe  in  the  umbilical  region.  It  gradually 
increased  in  severity  and  extent  so  that  it  spread 
all  over  the  front  and  back  of  the  chest  and  was  fol- 
lowed by  a  profuse  perspiration  that  broke  out  all 
over  the  body.  The  attacks  were  controlled  by  the 
administration  of  nitroglycerin. 

An  interesting  case  of  angina  abdominis  occurring 
in  a  patient  exhibiting  pronounced  symptoms  of 
cardiac  insufficiency,  is  reported  by  W.  K.  Hunter." 
The  case  was  that  of  a  man  aged  futy-six  years  who 
was  under  observation  in  the  ( rlasgi  iw  Royal  Infirmary 
for  one  month  previous  to  his  death.  The  attacks 
of  epigastric  pain  began  eighteen. months  before  he 
was  admitted  to  the  hospital.  The  pain  at  first  was 
dull  and  aching,  usually  began  about  one  hour  after 
meals,  and  was  relieved  by  the  taking  of  food.  It  was 
frequently  associated  with  flatulence.  Shortly  before 
the  patient  was  admitted  to  the  hospital  the  pain  had 
altered  its  characters,  being  now  sharp  and  shooting. 
and  coming  on  in  a  series  of  frequent  paroxysms 
which  had  no  relationship  to  the  taking  of  food.  There 
were  marked  loss  of  weight  and  slight  jaundice,  but 
there  was  no  history  of  alcoholism  or  of  syphilis.  His 
previous  health  had  been  good.  On  examination, 
the  patient  was  lying  in  the  semi-recumbent  position, 
very  restless,  with  a  good  deal  of  dyspnea,  and 
with  occasionally  a  C'heyne-Stokes  type  of  respiration. 
The  pain  in  the  epigastrium  was  more  or  less  constant, 
with  frequent  and  severe  exacerbations,  each  paroxysm 
lasting  about  one  minute.  With  each  paroxysm  the 
breathing  was  quickened  and  the  face  became  cy- 
anosed.  There  was  pronounced  cardiac  arrhythmia 
and  the  heart  sounds  were  indistinct  and  of  poor 
quality.  The  radial  arteries  were  atheromatous. 
There  were  signs  of  pulmonary  hypostasis,  the  liver 
was  enlarged,  the  feet  and  legs  were  edematous,  and 
the  urine  contained  a  small  amount  of  albumin  and 
easts.  During  the  month  the  patient  was  under 
observation  the  paroxysms  of  pain  occurred  nearly 
every  day  at  intervals  of  fifteen  to  twenty  minutes, 
and  would  last  about  one  minute.  This  would  go  on 
for  an  hour  or  an  hour  and  a  half  at  a  time.  At  one 
time  it  was  thought  that  the  patient  was  suffering 
from  hepatic  colic.  The  pains  seemed  to  be  too 
frequent  and  to  have  occurred  over  too  long  a  period 
of  time  to  be  due  to  gall  stones.  The  stools  moreover 
showed  no  evidence  of  the  latter,  and  the  jaundice 
lessened  in  intensity.  The  appetite  was  poor  and 
the  patient  frequently  complained  of  nausea.  The 
signs  of  myocardial  failure  became  more  marked. 
The  blood  pressure  was  unaffected  by  the  pain.  '1  he 
systolic  blood  pressure  ranged  from  150  to  155 
millimeters  of  mercury,  except  for  a  day  or  two  just 
before  death  when  it  fell  to  115  mil.imeters.  The 
pain  ultimately  became  so  severe  and  the  patient  so 
noisy  and  restless  that  it  was  necessary  to  keep  him 
under  the  influence  of  morphine.  He  died  with  all 
the  signs  of  heart  failure.  At  autopsy  the  heart  was 
found  to  be  hypertrophied  and  dilated,  and  the  seat  of 
myocardial  "degeneration  which  was  apparently 
due  to  the  patchy  sclerosis  and  narrowing  of  the 
coronary  arteries.  The  aorta  was  the  seat  of  wide- 
spaced  patchy  atheroma  which  also  extended  into 
the  larger  vessels.  The  lungs  wire  intensely  congested 
and  some  pneumonic  areas  were  present.  In  the 
tight  lung  there  were  a  number  of  large  infarctions, 
The  liver  was  considerably  enlarged  with  a  certain 
amount    of     old     perihepatitis.     The    gall    bladder, 


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Angina  Abdominis 


bile  ducts,   and  pancreas  were  normal.     The  spleen, 

kidneys,  ami  stomach  uVre  congested,  and  in  the  Last- 
named  organ  there  was  a  considerable  number  of 
small  hemorrhagic  ulcers. 

Hunter  believes  that  the  above  case  presented  a 

up  of  symptoms  and  postmortem  findings  that  is 

frequently  mei  with  in  angina  pectoris,  and  that  the 

0C8  e  corresponds  very  closely  in  its  clinical  and  pal  h- 

llogical   aspects    to   the    cases   described    by    lliiehard 

under  the  phrase  "angine  a  forme  pseudo-gastral- 
giqiic."  The  slight  amount  of  perihepatitis  would 
not  cause  the  pain  and  the  possible  role  of  chole- 
lithiasis was  ruled  out.  The  hemorrhages  into  the 
gastric  mucous  membrane  were  regarded  as  venous  in 
origin,  and  a  phase  of  the  marked  passive  congestion 

of  the  viscera.  It  was  very  doubtful  whether  these 
hemorrhages  could  cause  the  pain  and  the  author 
had  not  seen  any  ease  of  gastric  ulcer  with  pain  of  such 
great  severity  and  of  as  Ions  duration  as  in  the  case 
reported,  in  which  the  pain  had  the  characters  of  the 
pain  in  true  angina  pectoris.  The  pain  had  no 
relationship  to  the  taking  of  food.  It  is  pointed  out 
that  A.  F.  Hertz  has  shown  that  gastric  pain  even 
when  associated  with  ulceration  is  not  due  to  irrita- 
tion of  the  sensory  fibers  in  the  mucous  membrane, 
1ml  is  to  be  attributed  to  a  sudden  tension  of  the 
gastric  muscle  fibers,  such  as  is  met  with  in  very 
e  peristalsis.  Hunter  suggests  that  if  the 
origin  of  the  pain  in  angina  abdominis  is  to  be  sought 
tor  in  the  stomach  itself,  one  must  regard  this  pain  as 
being  due  to  spasmodic  contraction  in  the  muscle 
of  the  stomach  wall.  Indeed,  quoting  C.  F. 
Hoover,12  lie  states  that  at  the  present  time  there  is  a 
tendency  to  attribute  angina  abdominis  to  some 
fault  in  the  arterial  supply  of  the  stomach  wall,  and 
to  discard  the  older  view  that  it  is  a  referred  pain 
originating  in  the  heart  muscle  or  in  the  ring  of  the 
aorta.  An  analogy  is  pointed  out  between  the  pain  of 
angina  abdominis  and  that  of  intermittent  claudica- 
tion, in  both  of  which  conditions,  as  in  the  case  re- 
ported by  Brunton  and  Williams,  the  pain  is  induced 
by  a  muscular  effort  of  some  sort.  But  in  Hunter's 
case  the  pain  came  on  independently  of  muscular 
exercise,  without  rise  of  blood  pressure  and  with  no 
definite  relationship  to  the  taking  of  food.  This 
last  fact  would  seem  to  rule  out  the  possible  causative 
factor  of  increased  peristalsis  in  the  production  of  the 
pain.  Hunter  agrees  with  Pal  in  the  view  that 
ischemia  of  one  or  more  of  the  abdominal  viscera  is  not 
a  satisfactory  explanation  of  the  causation  of  angina 
abdominis.  There  is  greater  plausibility  in  Sir 
Clifford  Allbutt's  contention  that  in  most  cases  the 
condition  is  caused  by  a  painful  distention  of  an 
aorta  which  is  the  seat  of  an  inflammatory  lesion. 
H.  W.  Verdon13  advances  the  theory  that  the 
anginal  habit,  whether  of  the  abdominal  or  thoracic 
type,  results  from  a  state  of  increased  irritability  of 
certain  medullary  and  spinal  centers,  and  the  parox- 
ysm is  excited  by  impressions  reaching  these  centers 
from  the  muscular  coat  of  the  esophagus  and  stomach, 
when  this  muscular  coat  is  in  a  state  of  hypertonus  or 
tetany.  This  theory  is  based  upon  the  author's 
observation  of  four  cases  of  angina  abdominis.  In  all 
of  these  cases  there  was  pain  in  the  epigastric  region, 
which  pain  was  associated  with  hyperesthesia.  In 
three  of  the  cases  the  seat  of  the  hyperesthesia  was 
the  rectus  muscle,  and  in  one  case  the  skin  alone 
over  this  muscle  was  hyperesthetic.  In  two  of  the 
oases  pain  appeared  simultaneously  in  the  epigas- 
trium and  in  the  arm.  In  all  of  these  cases  the  dis- 
tribution of  the  pain  together  with  the  hyperesthesia 
can  be  explained  on  the  basis  that  the  pain  is  reflex 
or  referred,  according  to  the  views  advanced  by 
Mackenzie,  Head,  and  others.  According  to  Verdon, 
fullness  of  the  stomach  whether  occasioned  by  an 
excess  of  solids,  fluids,  or  gases,  seems  to  have  no 
effect  by  itself  in  exciting  a  seizure,  although  it 
heightens  the  tendency  to  an  attack.     The  attack  is  | 


usually  excited  by  the  act  of  walking  soon  after  a 

meal,  which  muscular  effort  apparently  induce-  hy- 
pe] tonus  of  the  gastric  muscle. 

To  recapitulate,  the  various  theories  that  have 
been  advanced  to  explain  the  causation  of  angina 
abdominis  are  as  follows:  aneurysm  or  arteriosclero  i 
of  the  vessels  of  the  celiac  plexus;  contraction  of  the 
peripheral  blood-vessels  ol  the  abdominal  viscera 
with  distention  of  the  proximal  vessels;  le  ion  ol  the 
inner  lining  of  the    visceral    blood-vessels;    ischemia 

due   to   arteriosclerosis   of   the   bl I  ve    els   <,f   the 

abdomen;  painful  distention  of  the  aorta  which  is  the 
seat  of  an  inflammatory  lesion;  and  a  state  of  hyper- 
tonus   of    the    stomach     induced     by    distention  and 

bodily  movements. 

The  symptoms  of  angina  abdominis  are  pain  in  the 
epigastrium,  which  may  be  associated  with  pain  in 
other  parts  of  the  body;  hyperesthesia  oxer  the  region 
of  the  rectus  muscle;  a  feeling  of  intense  anxiety  or  of 
impending  death,  as  in  angina  pectoris;  increased 
arterial  tension;  and  constipation. 

In  the  differential  diagnosis  the  main  conditions 
to  be  ruled  out  are  angina  pecti  ris,  the  gastric  crises 
of  tabes,  and  lead  colic.  E.  von  Neusser5  states  that 
violent  gastralgia  or  intestinal  colic  may  be  the  only 
manifestation  of  angina  pectoris.  Other  conditions 
to  be  considered  are  nervous  gast  ralgia;  ulcer  or  cancer 
of  the  stomach;  pyloric  stenosis;  duodenal  ulcer; 
malignant  disease  of  the  intestines;  ulceration,  chiefly 
tuberculous,  of  the  small  intestine;  intestinal  stenosis; 
constipation;  appendicitis;  Dietl's  crises;  renal  colic; 
tabes  mesenterica;  diseases  of  the  liver,  gall  bladder, 
and  pancreas;  aneurysm  of  the  aorta;  neuralgia  of  the  I 
abdominal  sympathetic;  and  caries  of  the  vertebral  / 
column.  Many  of  the  points  in  the  differential  dia'g=^ 
nosis  will  readily  suggest  themselves;  others  have  been 
dwelt  upon  in  the  preceding  lines. 

The  treatment  which  is  practically  the  same  as 
that  for  angina  pectoris  consists  in  reducing  arterial 
hypertension  by  means  of  amyl  nitrite,  nitroglycerin, 
or  any  other  of  the  nitrites.  The  hygienic  and  dietetic 
measures  which  are  suitable  for  cases  of  arteriosclero- 
sis should  be  enforced  during  the  intervals  between  the 
attacks.  Jacquet14  has  obtained  good  results  with 
the  combined  administration  of  iodide  of  potassium 
and  nitrite  of  sodium,  as  recommended  by  Lauder 
Brunton.  The  latter  has  also  advised  the  use  of 
salicylate  of  sodium  and  bromide  of  potassium,  along 
with  carminatives.  During  the  attack  gentle  massage 
of  the  abdomen  may  be  employed.  In  the  very  se- 
vere attacks  which  cannot  be  controlled  by  either 
measures  the  hypodermic  use  of  morphine  may  be  I 
necessary.  Alexander  Spingabn.  — 

References. 

1.  Minella:  Gazzetta  degli  Ospedale  et  delle  Cliniche,  1902, 
No.  120. 

2.  Pal,  J.:  Wiener  medizinische  Wochenschrift,  April  2,  1904, 
page  570. 

3.  Pal,  J.     Gefasskrisen,  Leipzig,  1905. 

4.  Huehard:  Maladies  du  Cceur  et  de  l'Aorte,  Paris,  1S99, 
vol.  ii.,  page  19;  also  Formes  Cliniques  de  1'Arterio-sclerose,  Paris, 
1909. 

5.  von  Neusser  E.:  Clinical  Treatises  on  the  Symptomatology 
and  Diagnosis  of  Disorders  of  the  Respiration  and  Circulation, 
English  Translation,  Part  III,  Angina  Pectoris,  New  York,  1909. 

6.  Schnitzler:  Zur  Symptomatologie  der  Darniarterienver- 
schhiss,  Wiener  medizinische  Wochenschrift,  1901. 

7.  Ortner:  Zur  Klinik  der  Angiosclerose  der  Darmarlerien 
(Dyspragia  intermittens  angiosclerotica  intestinalis),  Sammlung 
klinischer  Vortriige,  n.  f.,  Innere  Medizin,  No.  347. 

8.  Pal:      Medizinische  Klinik,  1908,  page  1790. 

9.  Brunton,  L.:  International  Clinics,  8lh  Series,  London, 
1S99,  vol.  iii.,  page  111. 

10.  Brunton,  L,  and  Williams,  W.  E.:     Lancet,  April  6,  1912 

11.  Hunter,  W.  K.:     Lancet,  July  6,  1912. 

12.  Hoover,  C.  F.:  Osier  and  McRae's  System  of  Medicine 
vol.  iv.,  p.  288. 

13.  Verdon,  H.  W.:     Lancet,  June  S,  1912. 

14.  Januet,  A.:  Zur  Symptomatologie  der  abdominalen 
Arteriosklerose,  Correspond. -Blatt  fur  Sehweize    Aerzte,  1906. 


423 


Angina  Ludovici 


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Angina  Ludovici. — Various  names  have  been 
applied  to  this  affection.  Among  them  may  be  men- 
tioned the  following:  acute  phlegmonous  pharyn- 
gitis, erysipelas  of  the  pharynx,  diffuse  cervical 
abscess  or  phlegmon,  submaxillary  bubo,  infectious 
submaxillary  angina,  sublingual  abscess  or  phlegmon, 
subhyoid  phlegmon,  gangrenous  induration  of  the 
neck,  cynanche  cellularis  maligna,  cynanche  sub- 
lingualis rheumatica.  As  will  be  seen,  these  terms 
are  not  definite.  In  late  years  phlegmonous  inflam- 
mations of  the  various  regions  of  the  neck  and  throat 
have  been  differentiated  and  given  each  its  own 
descriptive  name.  Thus  in  a  thesis  by  Broeckaert, 
of  Ghent  (Paris,  1909),  the  author  refers  to  no  less 
than  fifteen  different  anatomical  spaces,  each  one  of 
which  may  become  infected.  While  early  writers 
asserted  a  specific  individuality  for  this  disease,  later 
authorities  regard  it  as  a  septic  sore  throat  with  a 
peculiar  localization,  not  differing  etiologically  from 
phlegmonous  pharyngitis,  erysipelas  of  the  pharynx, 
or  acute  edema  of  the  larynx,  all  of  which  seem  to 
represent  merely  different  degrees  of  virulence  of  the 
same  infecting  agents. 

The  question  of  primary  development  and  localiza- 
tion depends  probably  upon  the  seat  of  original 
infection,  and  it  is  difficult  to  establish  definitely  a 
line  of  demarcation  between  the  purely  local  and  the 
less  complicated,  as  distinguished  from  the  edematous 
and  purulent  forms.  The  application,  clinically, 
of  general  bacteriological  principles  to  this  group  of 
septic  inflammations  harmonizes  to  a  certain  extent 
former  conflicting  views. 

Angina  Ludovici  is  a  diffuse  phlegmonous  inflam- 
mation of  the  floor  of  the  mouth  and  of  the  inter- 
muscular subcutaneous  tissue  of  the  submaxillary 
and  sublingual  regions.  It  may  end  in  resolution, 
abscess,  or  gangrene. 

Gerster  defines  it  as  a  phlegmonous  destruction  of 
the  submaxillary  gland  characterized  by  alarming 
and  extensive  dense  edema,  caused  by  the  unyielding 
character  of  the  fascial  envelope  of  the  gland,  which 
edema  is  most  manifest  about  the  latter  vicinity, 
namely,  the  floor  of  the  mouth. 

Its  possible  epidemic  character  can  be  explained 
by  the  simultaneous  exposure  of  various  patients  to 
the  same  septic  influence.  As  a  sequel  to  or  com- 
plication of  infectious  maladies,  it  has  been  observed 
more  often  in  typhus  fever. 

As  yet  no  special  pathogenic  germ  of  the  disease 
has  been  found,  and  where  examinations  have  been 
made  only  the  ordinary  bacilli  of  suppuration  have 
been  present.  Of  these  the  streptococcus  is  most 
frequently  found.  The  staphylococcus  is  also  often 
in  evidence.  It  is  only  in  respect  to  the  site  of  the 
disease  that  it  may  claim  special  consideration.  The 
location  in  which  the  pus  originates  is  a  triangular 
pyramidal  space  with  the  following  boundaries:  The 
apex  (below)  corresponds  to  the  point  where  the 
mylohyoid  muscle  borders  the  genioglossus.  The 
base  (above)  stretches  along  under  the  tongue.  The 
external  wall  (oblique)  is  made  up  of  the  internal 
face  of  the  inferior  maxilla  and  the  mylohyoid  muscle; 
the  internal  wall  (vertical)  by  the  genioglossus  and 
the  hyoglossus.  The  mucous  membrane  of  the  floor 
of  the  mouth  and  the  glandules  sublinguales  close  its 
cavity  on  top.  It  is  through  this  channel,  however, 
that  the  infection  gains  entrance,  so  that  the  affection 
of  the  submaxillary  gland  is  in  many,  if  not  all, 
instances  secondary. 

The  symptoms  are  constitutional  and  local.  The 
former  are  in  general  those  of  pus  formation,  but  it 
is  important  to  bear  in  mind  that  the  pathological 
process  may  also  give  a  distinctly  asthenic  type  of 
symptoms,  with  an  overwhelming  prostration  and 
low  temperature. 

The  local  symptoms,  in  addition  to  the  prominent 
swelling  of  the  neck,  present  the  following  diagnostic 
points:   first,  and  most  diagnostic  of  all,  there  is  a 

424 


peculiarly  hard  and  wooden-like  induration  of  the 
affected  region,  sharply  define'd  from  the  surrounding 
normal  tissue;  second,  the  thrusting  forward  and 
upward  of  the  tongue  toward  the  palatal  vault  by 
the  accumulating  inflammatory  products;  third, 
severe  dyspnea,  with  the  possibility  of  laryngeal 
edema;  fourth,  the  sensation  of  pressure  as  from  a 
hard  pad  or  button-like  swelling  at  the  inner  aspect 
of  the  dental  arcade.  With  all  of  these  there  are 
associated  the  ordinary  features  of  a  phlegmon. 
Swallowing  is  painful,  if  not  impossible,  on  account  of 
the  muscular  infiltration,  and  the  patient  may  not  be 
able  to  open  the  mouth. 

The  prognosis  is  always  grave  and  the  rate  of 
mortality  high,  one  series  of  cases  reporting  over 
fifty  per  cent,  of  deaths.  Death  most  frequently 
results  from  sepsis,  or  from  suffocation  due  to  laryn- 
geal edema. 

Diagnosis. — The  condition  must  be  differentiate  ,1 
from  osteomyelitis  of  the  lower  jaw,  simple  adeno- 
phlegmon of  the  submaxillary  gland,  and  the  rare 
disease  known  as  Fleiscliman's  hygroma.  In  the 
first  there  is  no  limited  focus  of  inflammation. 
The  entire  bone  is  affected,  the  inflammatory  process 
is  more  generalized,  and  the  subhyoid  region  is  rarely 
involved.  In  the  second,  adenophlegmon,  the  in- 
flammation is  superficial,  the  gland  and  its  capsule 
are  easily  accessible,  there  is  no  wooden-like  hardness, 
superficial  ineison  gives  exit  to  pus,  and  the  process 
is  localized  at  the  outset  behind  the  internal  face  of 
the  maxilla.  In  the  third  the  diagnostic  points  are 
suddenness  of  onset,  location  in  the  median  line,  and 
lack  of  either  constitutional  or  local  evidences  of 
inflammation.  In  Angina  Ludovici  the  diagnosis  may 
be  made  from  the  symptoms  described  above.  To 
these  must  be  added  two  signs  of  great  importance: 
fust,  pain  on  pressure  over  the  focus  of  the  inflam- 
mation; and  second,  the  withdrawal  by  aspiration 
from  the  focal  region  of  a  bloody  fluid.  These 
signs  call  for  immediate  operation,  never  by  limited 
incision,  but  always  by  careful  and  thorough 
dissection. 

The  treatment  must  be  based  upon  three  principles: 
First,  early  and  free  incision;  second,  careful  sub- 
sequent antisepsis;  and  third,  constitutional  support. 
The  condition  is  one  of  sepsis.  The  cause  must  he 
removed,  and  the  effects  already  produced  must  be 
vigorously  counteracted. 

Gerster  demonstrates  that  the  object  of  the  incision 
is  not  so  much  to  evacuate  pus  as  to  relieve  tension. 
He  supports  the  modern  view  that  the  submaxillary 
gland  is  the  focus  of  the  disease,  and  attaches  much 
importance  to  the  fact  that  pressure  over  the  edema- 
tous area  rarely  causes  pain  except  directly  over  the 
gland.  If  such  evidences  appear,  delay  in  operating 
is  not  justifiable. 

The  operation  must  be  done  under  general  anes- 
thesia, for  deej)  tissues  must  be  explored  in  close 
proximity  to  important  vessels  and  nerves. 

Fluctuation  may  be  delayed  because  of  the  pus 
being  confined  within  a  fibrous  capsule.  Early 
incision  may  evacuate  nothing  more  than  an  ichorous 
discharge,  while  pus  may  form  later,  but  tension  i- 
thus  relieved  and  the  consequent  dangers  of  suffoca- 
tion are  much  lessened. 

Deep  lateral  incision  over  the  submaxillary  gland, 
operation  through  the  mouth,  and  even  external 
incision  in  the  median  line  are  all  to  be  condemned. 

The  most  satisfactory  method  is  that  suggested  by 
Gerster,  namely,  to  lay  bare  the  entire  submaxillary 
region  by  a  careful  dissection  before  making  the 
incision  for  evacuating  the  abscess. 

To  be  effective  the  incision  must  penetrate  the 
mylohyoid  muscle. 

Following  incision  irrigation  with  bichloride  (1  to 
1,000)  or  boric  acid  (1  to  100)  must  be  carefullj 
carried  out,  and  stimulants  and  tonics  administered 
according  to  indication.     The  application  of  cold  to 


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Angina  Pectoris 


the  neck,  if  of  any  value  at  all,  can  be  of  service  only 
in  the  very  earliest  stages. 

Hydrogen  peroxide  may  assist  in  the  separation  of 
the  slougns. 

The  value  of  vaccines  and  serums  in  tins  condition 
lias  not   yet    been  demonstrated,  although   in  other 
somewhat  analogous  infections  due   to   the   strepto- 
coccus,  hopeful    results   arc   being  obtained.     (Ball, 
(,  June  8,  1!)12.) 
Prophylaxis. — To    guard    against    the    occurrence 
of  Angina  Ludovici,  the  mouth,   pharynx,  and  nose 
should  be  kept  carefully  cleansed  in  all  eases  of  dis- 
ease, such  as  typhus  fever,  in  which  infection  of  the 
sublingual   region   may   take  place.     Recently  some 
forms  of  grippe  have  shown  a  tendency  to  generate 
ical    phi  union.      Here    again    and    in    all    allied 
litions  of  the  mouth  and  throat   proper  aseptic 
precautions  may  avert  many  possibilities  of  danger. 

D.  Bkyson  Delavan. 


Angina  Pectoris. — Angina  pectoris  is  a  convenient 
name  for  a  group  of  .symptoms  in  which  the  pre- 
dominating feature  is  pain  of  varying  degrees  of 
intensity  over  the  precordial  region,  occurring  in 
paroxysmal  attacks,  occasionally  prolonged  to  be- 
come chronic,  and  in  rare  instances  associated  with 
the  subjective  symptoms  of  impending  death. 

The  pain  may  originate  in  distant  organs  or  in  the 
precordial  region  itself,  and  from  this  point  radiate 
in  various  directions,  usually  to  the  left  shoulder  and 
arm,  sometimes  to  the  right:  occasionally  to  both 
.shoulders  and  arms. 

There  are  two  main  divisions  of  angina  pectoris,  the 
true  and  the  false.  In  the  true  form,  or  angina 
vera,  there  is  an  anatomical  basis  in  the  heart  itself; 
the  false  form,  or  pseudoangina,  is  a  neuralgia  of  the 
heart . 

In  the  true  form,  affections  of  the  coronary  system 
are  noteworthy  among  the  pathological  findings, 
while  other  degenerative  changes,  in  either  the 
aorta  or  its  branches,  in  the  endocardium,  or  in  the 
walls  of  the  heart,  may  be  more  nearly  related  to  the 
cause  of  the  attacks. 

Although  the  name  angina  pectoris  does  not  de- 
scribe the  essence  of  the  disease,  it  is  likely  to  be  re- 
tained, because,  theoretically  at  least,  it  covers  a 
perfectly  recognizable  group  of  cases,  that  may,  in 
the  majority  of  instances,  be  relieved  and  usually 
cured  by  appropriate  management.  For  though 
true  angina  is  a  dangerous  disease,  with  a  very  un- 
favorable prognosis,  it  is  extremely  rare.  False 
angina,  on  the  contrary,  is  very  common,  if  we  in- 
clude under  the  name  all  the  minor  forms;  and  it  is 
amenable  to  treatment.  The  etiology  of  the  two 
forms  is  different  also,  though  unfortunately  they 
cannot  always  be  differentiated,  and  occasionally 
may  be  combined.  At  no  time,  however,  does  the 
angina  kill.  If  death  occurs,  it  must  be  attributed 
to  an  underlying  organic  disease. 

True  angina  pectoris  came  to  be  generally  known 
in  France  and  England  as  early  as  1768,  though  it  had 
been  described  some  years  earlier  by  Morgagni,  as  to 
both  its  clinical  and  pathological  features.  In  the 
year  above  mentioned,  Heberden  was  the  first  to 
differentiate  it  from  cardiac  asthma,  a  distinction  that 
is  not  always  maintained  at  the  present  day.  In  1772 
.leaner  and  in  178S  Parry  noted  the  coincidence 
between  sclerosis  of  the  coronary  arteries  and  angina 
pectoris.  Angina  pectoris  motoria  was  described  by 
Landois  in  1866.  He  held  it  to  be  an  exaggerated 
vasomotor  disturbance  causing  increased  arterial 
pressure,  or  vasomotor  paresis,  and  to  be  found  in 
chlorotic  and  anemic  girls  in  emotional  or  cerebrospinal 
crises.  Niemeyer  held  the  same  view,  and  Nothna- 
gel  recognized  this  form  also,  having  seen  it  in  cases 
of  exposure  to  cold.  Bamberger  held  analogous 
ideas.     This  is  a  variety  of  the  false  form.     Angina 


sine  dolore  is  the   m given   to  an  attack   where 

there  is  a  feeling  of  constriction  of  the  chest  without 
pain. 

Another  division  of  angina  pectoris  has  been  into 
the  smrf  and  mild  forms.  Hui  this  classification  is 
in. i  satisfactory,  because  it  misleads  as  to  results. 
A  severe  at  lack  may  be  of  the  pseudo  form,  or  a  mild 
uiie    of   the   true   variety.      i    have  seen   a    ease  of   the 

former  where  the  pain  was  intensely  excruciating,  and 
in  other  instances  attacks  of  the  true  form  that  were 
comparatively  mild. 

In    ls7:'.,    the    distinction    between    true    and    false 

angina  was  emphasized  by  Walshe.  This  distinction 
is   essential,    because   on    the   differential   diagnosis 

hang    the    prognosis    and    the    treatment. 

Statements  \  ary  as  1"  the  frequency  of  true  angina. 
In  England  it  is  not  regarded  as  an  unusual  disea  I  - 
However,  in  a  series  of  823  cases  of  my  own,  fairly 
complete  as  to  clinical  histories  and  autopsical  findings, 

and  covering  an  experience  of  ten  years  in  one  hospital 
and  fifteen  in  another,  I  did  not  find  mention  of  a 
single  case  of  true  angina  pectoris.  And  in  a  series 
of  2,31 » i  medical  eases  treated  by  one  of  my  colleagues 
at  the  Post-Graduate  Hospital,  there  was  not  a  single 
ease  of  true  angina  recorded.  Another  of  my 
colleagues,  who  had  an  even  larger  experience  in  the 
outdoor  medical  department  of  Bellevue  Hospital, 
did  not  remember  having  seen  during  the  years  of 
his  service  a  case  of  true  angina.  In  this  vicinity  at 
lea-i,  therefore,  true  angina  is  a  rare  disease. 

There  has  been  a  tendency  to  attribute  true  angina 
to  coronary  disease  with  sclerosis,  with  or  without 
embolism  or  thrombosis.  Gautier  and  Huchard  in 
a  series  of  seventy  cases  found  coronary  disease  in 
thirty-eight,  or  about  fifty-three  per  cent.  In  a 
later  series  Huchard  found  coronary  disease  in  128 
out  of  145  cases,  or  eighty-eight  per  cent.,  but  evi- 
dently the  myocardium  was  not  subjected  to  a  close 
examination.  Coronary  disease  without  angina  is 
common.  Indeed,  coronary  disease  between  the 
ages  of  fifty  and  sixty  is  the  rule.  And  yet  as  I  have 
said  it  may  exist  without  any  symptoms  of  angina. 
In  fact,  I  should  be  quite  willing,  from  own  experience, 
to  say  that  I  have  seen  hundreds  of  cases  of  coronary 
disease  at  autopsies  where  clinically  there  had  been 
no  symptoms  of  true  angina,  and  I  believe  that  the 
best  of  our  modern  pathologists  will  subscribe  to  this 
view.  In  fact,  Romberg  in  his  recent  work  admits 
that  angina  is  frequently  absent  in  coronary  disease, 
though  he  maintains  that  there  is  usually  a  localized 
contraction  of  the  arteries  round  about  the  points  of 
their  origin.  Embolism  or  thrombosis  he  believes 
may  cause  attacks,  and  this  view  is  well  sustained  by 
evidence. 

Etiology. — In  order  to  realize  the  diversity  of  opin- 
ion as  to  the  etiology  of  angina  pectoris,  a  brief  review 
is  necessary.  In  1768  Heberden  broached  the  idea 
that  the  pain  was  due  to  the  contraction  of  the  heart, 
which  being  a  hollow  organ  suffered  from  pains  some- 
what analogous  to  those  of  other  hollow  organs,  such 
as  the  intestines  and  uterus.  This  theory  is  now  main- 
tained by  Mackenzie  in  a  modified  form.  But  accord- 
ing to  this  theory  there  should  be  violent  alterations 
in  the  rhythm  of  the  pulse,  which  I  have  not  found. 
There  is  undoubtedly  some  hypertension,  however,  in 
the  early  part  of  attacks.  However,  Parry,  Stokes, 
and  Traube  claimed  that  the  pain  was  due  to  cardiac 
paralysis,  Traube  holding  that  there  was  acute 
dilatation  which  caused  laceration  of  the  cardiac 
nerves.  Of  course,  there  is  no  doubt  that  if  death 
impends  in  true  angina  there  is  cardiac  paralysis. 
Some  have  held  that  the  attacks  are  manifestations  of 
lithemia,  and  I  am  inclined  to  believe  that  in  lithemie 
cases  there  can  be  a  fibrosis  of  the  heart  inn  cle  that 
may  have  to  do  with  the  pain.  Laennec  and  Lartigue 
referred  the  pain  to  the  pneumogastrie,  while  Lancer- 
eaux,  Peter,  and   Bazy  laid  it   to  infiltration  of  the 


425 


Angina  Pectoris 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


cardiac  plexus.  But  as  a  matter  of  fact  infiltration 
of  this  plexus  by  the  new  growths  does  not  always 
produce  pain,  and  if  this  latter  view  were  correct  the 
pain  should  be  continuous,  not  spasmodic. 

Friedreich  thought  it  a  functional  affair,  a  neurosis. 
Trousseau  compared  angina  to  the  nerve  explosions 
of  epilepsy;  Bouillaud  ascribed  the  pain  to  phrenic 
and  intercostal  irritation;  while  Piorry  called  it  a 
brachiothoracic  neuralgia.  Allan  Burns  referred  it 
to  the  distention  of  the  cardiac  vessels,  and  Lauder 
Brunton  similarly  ascribed  it  to  the  overdistention  of 
the  coronary  vessels.  This  latter  theory  might  apply 
in  pseudoangina,  but  could  not  in  cases  of  stiffness 
of  the  coronaries,  which  characterizes  the  progressive 
stages  of  the  disease.  Nothnagel  advanced  a  theory 
that  the  pain  was  due  to  spasm  of  the  vasomotor  nerves 
of  the  heart.  Josueand  Allbutt  have  held  that  the  pain 
is  located  in  the  aortic  ring.  Romberg  in  his  latest 
edition  was  inclined  to  think  with  Charcot  and  Erb 
that  angina  is  related  etiologically  to  the  diminish,! I 
supply  of  blood  occasioned  by  the  narrowed  lumen  of 
the  degenerated  coronary  vessels.  According  to  his 
theory,  while  under  ordinary  circumstances  there  is 
a  sufficient  blood-supply  to  the  heart  to  admit  of  its 
functions  being  satisfactorily  performed,  under  the 
operation  of  certain  physical  and  psychic  influences 
the  relation  between  the  blood-supply  and  the  heart 
muscle  may  be  disordered  sufficiently  to  cause  pain. 

In  this  connection,  it  is  important  to  know  that  the 
coronaries  terminate  in  comparatively  large  trunks 
from  which  capillaries  are  given  off,  and  that  these 
unite  to  form  reservoirs  between  the  muscle  fibers, 
while  the  capillaries  freely  anastomose,  so  that  inter- 
ference with  the  circulation  within  a  cardiac  artery 
means  interference  with  a  large  amount  of  capillary 
tissue.  As  a  result  of  this  anatomical  peculiarity  of 
the  capillary  system,  its  contractions  might  cause 
sensations  of  pain  quite  unlike  those  of  any  other 
organ  in  the  body. 

It  will  be  noted  that  in  the  summary  of  veiws  given 
above  as  to  the  cause  of  the  attacks,  little  distinction 
was  made  between  the  true  and  the  false  forms.  In- 
deed, although  for  excellent  practical  reasons  we  may 
recognize  tin-  two,  it  may  well  be  that  in  all  cases  the 
cause  of  the  pain  is  neuralgic.  In  one  of  my  patient  - 
who  had  false  angina  (where  the  treatment  was  even- 
tually so  successful  that  she  has  now  for  about  ten  years 
been  enjoying  life,  with  only  an  occasional  intimation 
that  she  has  a  heart,  the  apex  was  brought  in  by 
treatment  one  and  five-eighth  inches,  and  was  con- 
tracted as  well),  I  believe  the  pain  was  located  in  the 
nerves  of  the  heart  walls,  and  arose  from  dilatation. 
It  may  arise  also  from  compression,  as  from  a  dis- 
tended stomach,  a  very  common  occurrence  in  people 
who  are  comparatively  well.  Recent  physiological 
studies  have  shown  us  that  there  may  be  irregular 
contraction  of  the  walls  of  the  heart  at  times,  i.e.  local 
spasms.  Besides,  in  fibrosis  of  the  heart  walls,  which 
seems  to  be  sometimes  a  feature  of  the  lithemic  heart, 
there  must  be  unequal  contraction  of  the  muscles. 
Any  ime  of  these  conditions  may  cause  unequal  ten- 
sion of  the  walls.  This  theory  I  proposed  some  years 
ago.  The  pain  may  originate  either  from  disease  of 
the  heart  or  great  vessels,  or  from  a  remote  locality. 

But  how  are  we  to  explain  on  the  ground  of  the 
unequal  tension  theory  the  fact  that  coronary  disease 
is  an  important  factor  in  the  causation  of  angina? 
The  answer  is  that  coronary  disease  may  be  a  cause 
of  degeneration  of  the  heart  because  it  diminishes 
the  supply  of  blood,  the  result  being  that  weak  spots 
are  developed  in  the  cardiac  walls  in  areas  where  the 
nourishment  is  imperfect.  Again,  fibrosis  eventually 
takes  the  place  of  infarcts.  The  heart  muscle  cannot 
therefore  contract  evenly,  and  the  uneven  contraction 
causes  the  pain.  Charcot  held  the  view  that  it  was 
due  to  local  spasm,  similar  to  the  local  spasms  of  the 
intestine  in  influenza,  the  fibrillary  contractions  of 
facial  muscles  in  cerebral  disease,  or  the  spasm  of  the 


muscles  of  the  extremity  in  the  "intermittent  claudi- 
cation" of  Bouley,  the  veterinarian,  who  first  saw  it  in 
horses.  After  a  number  of  these  attacks,  there  is  left 
in  the  cord  a  susceptible  area,  which  is  prone  to 
originate  successive  attacks. 

Among  the  lesions  that  have  been  described,  it  is 
noticeable  that  coronary  diseases  have  a  rather 
large  place,  while  atheroma  of  the  large  vessels, 
aortic  endocarditis,  pericarditis,  and  myocardial 
disease  have  been  subordinated.  However,  there  has 
been  a  tendency  of  late  to  look  upon  the  myocardium 
as  the  chief  tissue  implicated.  High  pressure  is  re- 
garded as  one  of  the  determining  causes  of  an  attack, 
but  it  may  be  the  result  as  well.  In  the  later  stage-  of 
an  attack,  a  normal  or  subnormal  pressure  i 
occur.  The  exciting  causes  may  be  disturbance  of 
the  function  of  any  organ  or  system.  I  have  known  in 
a  single  instance  that  one  at  tack  was  excited  by  conges- 
tion of  the  kidneys,  a  second  by  obstinate  constipation, 
and  a  third  by  overloading  of  the  stomach  with  in- 
digestible food.  Unusual  muscular  activity  may  also 
be  a  cause,  while  in  the  false  variety  emotional  causes. 
a  sudden  impression  on  the  sensitory  nerves,  walking 
in  the  face  of  a  sharp  wind,  or  toxic  causes  such  as  the 
use  of  tobacco,  tea,  or  coffee,  may  bring  on  an  attack. 
While  the  incitement  to  an  attack  of  angina  vera  may 
be  from  the  heart  itself,  as  in  a  sudden  attack  of 
cardiac  embolism,  or  from  without,  usually  from  an 
abdominal  organ;  in  the  false  form  the  seizure  origi- 
nates from  a  point  without  the  heart. 

True  angina  is  more  frequent  in  males.  Pye- 
Smith  found  the  proportion  seven  to  one;  Huchard 
about  five  to  one.  On  the  other  hand,  the  pseudo 
cases  are  much  more  common  in  women.  Huchard 
found  the  proportion  three  to  one  in  favor  of  women, 
and  the  proportion  is  undoubtedly  much  higher  in 
this  country.  True  angina  rarely  occurs  before  forty 
years  of  age:  in  Forbes'  eightyr-four  cases,  seventy- 
two  were  over  fifty,  or  eighty-six  per  cent. 

Symptoms. — In  an  attack  of  true  angina,  the  pain 
is  referred  to  the  sternum  about  its  middle.  From 
this  point  it  may  radiate  to  the  left  shoulder  and  arm, 
to  the  right,  or,  occasionally,  down  both  shoulders 
and  arms. 

In  a  well-marked  case  the  face  will  be  pallid,  and  the 
forehead  covered  with  sweat,  while  the  rate  of  respira- 
tion, in  uncomplicated  case-,  may  either  be  incrr 
or  remain  unchanged.  This  condition  of  the  respira- 
tion contrasts  sharply  with  the  increased  rate  of  the 
cardiac  asthma  in  valvular  and  myocardial  disease. 
Toward  the  end  of  an  attack,  or  after  successive 
attacks,  a  somewhat  increased  rate  of  respiration  may 
be  expected.  If  the  patient  gets  relief  promptly, 
the  respiration  should  fall  to  the  normal.  Inasmuch, 
however,  as  the  increased  action  of  the  weak  heart 
is  likely  to  produce  more  or  less  stagnation  of  blood 
in  the  pulmonary  cavities,  there  will  be  in  such  a 
case  a  proportionate  increase  in  the  respiratory  rate. 
While  the  heart's  rate  may  be  increased  or  unaffecti  d, 
in  mild  cases  it  is  apt  not  to  be  changed.  _  There  is, 
how-ever,  usually  some  degree  of  arrhythmia.  Blood 
pressure  is  usually  increased,  and  Mackenzie  reports 
that  he  has  found  it  as  high  as  200.  As  the  attack 
passes  off,  there  is  a  sense  of  weakness  proportionate 
to  the  severity  of  the  seizure.  During  the  attack 
there  may  be  great  belching  of  wind,  while  the  urine 
voided  is  apt  to  be  of  a  very  low  specific  gravity. 
In  a  case  where  the  neurotic  element  is  well  marked, 
these    two   latter   signs   may   be   pronounced. 

The  pain  is  a  distinctive  feature  of  true  at 
It  is  the  pain  of  an  intense  neuralgia,  so  excruciating 
that  tin-  patient  feels  that  he  must  keep  absolutely 
still  until  it  has  passed.  In  my  experience  the 
"  sense  of  impending  death"  has  not  been  a  prominent 
feature,  but  on  several  occasions  the  patients  have 
expressed  themselves  as  feeling  that  the  chest  was 
lieing  compressed,  as  if  in  a  vise.     In  one  instance  the 


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Angina  Pectoris 


patient  said  she  felt  as  if  ":i  house  wen-  resting  mi  her 
chest."      But  then'  are  degrees  in  the  amount  of  pain 

felt.     Tin'  attack    is  visually   brief c  especially 

after  the  first  attack,  for  then  the  patient's  experience 
ha<  taught   him  or  her  how  to  manage  the  seizure. 

But    while    it    is    usually    of    only    a    few    9 mis'    or 

minutes' duration,  it   may  last  several  hours,  and  in 

One    of    my    eases    an    intense    angina    continued    for 

eral    days.      This   constituted    what   is   called    the 

*is  anginosus. 

The   immediate   cause  of  an  attack  may  vary,  as 

has  already  I n  mentioned.     In  one  of  my  pseudo 

sit  was  produced  by  sexual  intercourse,  in  a  not  her 
by  the  smell  of  fresh  paint,  and  in  a  third  by  pro- 
longed   conversation.     A  common    cause    is    undue 
hurry,   or  walking  in   the  face  of  a  sharp   wind. 
Death  in  true  angina  has  been  ascribed  to  defective 
tabolism.     This  may  be  a  contributing  cause,  for 
if  the  disease  is  associated  with  uremia  the  muscular 
e  "f  the  organ  may  be  paralyzed  by  the  toxemia. 
\\  e  may  safely  assume  t  hat  actually  death  is  due  to  the 
disease  of  the  heart  walls  resulting  from  exhaustion  or 
defective  innervation.     The  heart  comes  to  a  standstill 
simply  because  it  is  worn  out. 

Diagnosis. — All  of  the  circumstances  of  a  case  must 
be  carefully  considered  in  making  a  differential  diag- 
nosis, and  it  will  not  always  be  easy,  because  the 
nature  and  gravity  of  the  underlying  disease  may 
not  at  first  be  readily  determined.  If  in  the  male 
sex,  after  fifty  years  of  age,  and  in  association  with 
general  arteriosclerosis  and  some  form  of  heart  dis- 
ease, particularly  of  the  aortic  valve,  or  pronounced 
evidences  of  the  lithemic  diathesis,  the  diagnosis  of 
true  angina  may  be  made  with  a  considerable  degree 
of  confidence.  On  the  other  hand,  in  young  people, 
especially  women,  and  those  of  neurotic  history  and 
lowered  vitality,  in  the  absence  of  arteriosclerosis  or 
any  form  of  heart  disease,  the  diagnosis  of  pseudo- 
angina  may  be  made  with  an  equal  degree  of  confi- 
dence. Then,  too,  in  the  false  angina  from  poisoning 
by  tobacco,  tea,  or  coffee  there  is  a  history  of  indul- 
gence in  these  luxuries,  with  their  associated  cardiac 
and  neurotic  symptoms  that  cease  when  the  cause  is 
removed.  As  regards  the  differential  diagnosis  from 
cardiac  asthma,  in  the  latter  there  is  actual  dyspnea, 
while  in  uncomplicated  cases  of  pseudoangina  there 
is  never  any  actual  dyspnea,  for  the  patient  can 
draw  a  long  breath  if  he  makes  the  attempt.  In 
cardiac  asthma  there  is  engorgement  of  internal 
organs,  and  externally  there  are  physical  signs  of 
venous  congestion. 

Treatment. — Nitroglycerin,  given  by  the  mouth 
in  doses  of  at  least  TJ0  to^j  grain,  is  indicated. 
I  do  not  hesitate  to  give  Jj  every  two  minutes  for 
ten  minutes  to  abort  an  attack.  If  the  patient  can 
swallow,  the  desired  effect  is  produced  more  quickly 
by  oral  administration  than  by  hypodermics.  A 
few  drops  of  the  nitrite  of  amyl  given  on  a  handker- 
chief may  relieve  mild  attacks,  and  the  delicate  glass 
capsules  containing  three  or  five  minims  of  the  drug, 
which  can  be  crushed  in  the  handkerchief,  are  con- 
venient for  administering  it.  But  the  nitrite  of 
amyl  alone  is  not  always  effective.  I  give  it  inter- 
nally also,  as  in  the  following  prescription: 

.     Glonoin grain  1J3 

Amyl  nitrite grain  i 

Menthol grain  53 

Oleoresin  of  capsicum grain  iha 

Place  in  air-tight  gelatin  capsules. 
S.  One  at  a  dose. 

When  properly  made,  these  capsules  are  effective 
in  mild  attacks.  Unfortunately  the  ingredients  are 
not  -table. 

In  cases  where  these  remedies  are  not  at  hand, 
morphine  should  be  used,  followed  up,  without  wait- 
ing  for   its   action,    by   inhalation   of  chloroform  or 


ether.     The   patient   may   pour   a   few    teaspoonfuls 

of   ether   into   a,    saucer   and    inhale    the    fumes.       Bal- 

four's  plan  i-  to  put  a  sponge  "il.ed  m  chloroform  in- 
to a.  wide-mouthed  bottle,  and  allow  the  patient  to 
inhale  the  fumes  until  relief  is  obtained.  Heat  ap- 
plied to  the  chest  by  a  hot-water  bottle  or  bag,  replaced 
by  mustard  leaves  or  poultices,  will  often  give 
relief. 

If  there  is  any  sign  of  heart  failure,  brandy,  whiskey, 
or  ammonium  carbonate  is  indicated,  the  latter  being 

almost  universally  applicable.       Digitalis]     too    low  in 

its  action  to  be  useful  during  an  attack,  but  is  valu- 
able afterward.     The  aromatic  spirit   of  am nia   is 

often  of  great  assistance,  and  also  promotes  the  expul- 
sion of  gas.  After  the  paroxysm  has  passed,  aconite 
will  be  found  useful,  in  two  minim  doses,  t.i.d.,  to 
regulate  the  pulse.  In  rass  where  there'  is  arterio- 
sclerosis, arsenic  should  be  kept  up  for  a  while,  and 
then  replaced  by  potassium,  sodium,  or  strontium 
iodide  in  doses  of  from  five  to  ten  grains,  or  even 
more.  In  rheumatic  or  gouty  cases,  a  prolonged 
use  of  the  iodides  gives  good  results. 

In  the  pseudo  cases  Hoffman's  anodyne  is  indicated, 
the  valerianate  of  ammonium,  the  monobromate  of 
camphor  in  one  or  two  grain  doses,  or  asafetida  in 
doses  of  from  three  to  ten  grains.  I  sometimes  give  a 
thirty  grain  powder  containing  equal  parts  of  the 
ammonium,  potassium,  and  sodium  bromides.  Some 
prefer  the  nitrites.  They  are  used  extensively  in 
England  and  France.  The  nitrite  of  sodium  is 
preferred,  and  the  dose  is  from  one  to  three  grains, 
given  cautiously.  In  one  of  my  cases  I  gave  entire 
relief  by  the  use  of  the  continuous  current. 

In  true  angina,  as  soon  as  the  paroxysm  has  been 
relieved  the  treatment  should  be  that  of  heart  failure, 
or,  in  other  words,  enfeeblement  of  cardiac  action 
due  to  the  strain  on  an  exhausted  heart.  Nothing 
equals  the  use  of  digitalin  and  strophanthin,  which 
should  be  given  together  with  glonoin  in  doses  of 
one  one-hundredth  grain  each,  at  first  administered 
every  four  hours,  and  later  after  the  pulse  has  fallen 
below  the  hundred  mark,  three  times  a  day.  This 
trea  tmentmay  be  kept  up  for  weeks  or  months  without 
discomfort  to  the  patient,  provided  the  amounts  of 
the  several  drugs  are  increased  or  decreased  according 
to  indications.  Nothing  but  the  very  best  makes  of 
digitalin  and  strophanthin  should  be  used.  The 
tinctures  and  fluid  extracts  of  digitalis  and  strophan- 
tus should  not  be  used. 

Owing  to  the  inflation  of  the  stomach  in  these  seiz- 
ures, it  may  be  desirable  to  pass  the  esophageal  tube. 
This  has  been  practised  successfully  by  Verdon  in 
several  cases.  It  is  called  gastric  deflation.  In  such 
instances  a  sudden  attack  of  vomiting  may  bring  the 
seizure  to  a  close.  Where  an  attack  is  associated 
with  constipation,  an  active  cathartic  will  accom- 
plish the  same  result. 

Protracted  rest  in  bed  after  a  severe  attack  may 
materially  aid  in  warding  off  another  seizure.  Car- 
bonated baths  and  resistant  exercises  are  also  effective. 
The  diet  should  at  the  same  time  be  carefully  regulated. 
If  uremia  has  superinduced  the  attack,  a  course 
of  milk  diet,  in  which  the  patient  may  take  as  much  as 
two  quarts  per  day,  may  relieve  the  uremia  and 
restore  the  patient  to  comparatively  good  health. 
One  must  guard,  however,  against  overloading  the 
stomach  with  milk,  and  remember  that  many  persons 
cannot  digest  much  milk.  Usually  sufficient  lime 
water  should  be  added  to  prevent  curdling. 

Coronary  disease  of  itself  is  quite  compatible  with 
a  long  life,  so  that  we  must  look  beyond  it  for  the 
cause  of  angina.  And  the  evidence  is  increasing  day 
by  day  that  it  is  disease  of  the  myocardium  that 
determines  angina  vera.  A  single  attack,  as  in 
embolism  or  thrombosis  of  the  coronary  arteries,  may 
cause  death.  Also,  if,  after  the  age  of  fifty,  anginal 
seizures  become  more  and  more  frequent  in  persons 
with  arteriosclerosis,  fatty  heart,  disease  of  the  great 


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vessels,  such  as  aortic  aneurysm,  advanced  lithemia, 
or  uremia,  the  prognosis  cannot  be  other  than  grave, 
and  the  danger  will  be  increased  if  there  is  a  neurotic 
element  superadded  to  these  conditions.  But  even 
in  these  cases  the  expectation  of  life  will  be  improved 
provided  the  patient  can  avoid  cold  weather  and 
excitement,  commits  no  excesses  of  any  kind,  and 
lues  a  methodical  life,  free  from  hurry  and  -worry. 
For  any  one  of  these  exciting  causes  may  bring  on  an 
attack  which  may  lead  rapidly  to  a  fatal  issue.  The 
violence  of  the  attacks  is  not  always  a  measure  of  the 
gravity  of  the  disease.  On  the  other  hand,  in  pseudo- 
angina,  which  is  not  only  very  frequent,  but  at  one 
time  or  another  affects  most  of  us  in  the  course  of  a 
long  life,  the  prognosis  is  not  grave.  Under  this 
head  I  classify  the  reflex  vasomotor  angina  of  Landois, 
which  is  associated  with  visceral  and  peripheral  dis- 
turbances without  any  gross  heart  lesions,  and  also 
the  so-called  angina  sine  dolore,  where  the  sensation 
is  constriction  rather  than  pain.  These  cases  are  in 
the  class  with  hysterical  seizures,  hyperesthetic  areas, 
and  peripheral  neuralgias.  All  we  have  to  do  in  these 
instances  is  to  control  the  neurotic  symptoms,  and 
we  control  the  angina.  There  is  seldom  much  diffi- 
culty in  accomplishing  this  result  by  the  use  of  such 
remedies  as  have  already  been  enumerated. 

Thomas  E.  Sattekthwaite. 


Angina  Vincenti. — Synonyms:  Plaut-Vince  nt 
angina,  ulcerative  angina  and  stomatitis,  ulcero- 
membranous angina  and  stomatitis,  angina  diphthe- 
roides,  angina  exudativa  ulcerosa,  angina  chanci- 
forme,  pharyngitis  ulcerosa,  pseudomembranous  an- 
gina, "spiroehatenbacillen  Angina,"  gangrenous  ton- 
sillitis, "ulcerative  sore-throat,"  "septic"  and  "pu- 
trid  sore-throat". 

This  is  a  peculiar  form  of  tonsillitis  or  stomatitis 
in  which  pseudomembranes  are  formed  upon  the 
affected  mucous  surface,  usually,  but  not  always, 
with  the  production  of  a  characteristic  ulcer,  and 
containing  in  the  exudate  the  so-called  fusiform 
bacillus  of  Plant  and  Vincent,  usually  in  association 
with  long  spirilla.  Vincent's  name  is  not  properly 
applied  to  this  condition,  as  it  had  been  previously 
described  by  a  number  of  French  and  Russian  observ- 
ers (Bartliez  and  Sanne,  Simonowsky,  Nevejin, 
Moure,  and  Mendel),  and  the  association  of  fusiform 
bacilli  and  spirilla  in  ulceromembranous  angina  had 
been  noted  in  1893  by  Rauchfus.  In  1894  Plaut 
described  the  organisms  in  five  cases  of  ulcerative 
angina  as  "Miller's  spirochetal"  and  "Miller's  bac- 
illi," giving  Miller  the  credit  of  having  observed  as 
early  as  1S83  the  association  with  spirochetes  of  a 
bacillus  longer  than  the  diphtheria  bacillus  and  pointed 
at  the  ends.  He  states  that  .Miller  had  found  these 
on  the  edge  of  inflamed  gums,  and  in  an  abscess  of  the 
finger-tip  caused  by  a  laceration  by  artificial  teeth, 
and  also  in  an  abscess  of   the  submaxillary   gland. 

In  1896  Vincent  described  fusiform  bacilli  and 
spirilla  in  cases  of  hospital  gangrene,  stating  that, 
similar  organisms  could  be  found  in  ulcerative  angi- 
nas. Bernheim  in  1897  reported  thirty  cases  of 
stomatitis  and  angina  in  all  of  which  fusiform  bacilli 
and  spirilla  were  present;  and  he  is  apparently  the 
first  to  show  the  etiological  identity  of  certain  forms 
of  angina  and  stomatitis.  In  the  next  year  Vincent 
reported  observations  of  fourteen  cases  of  ulcero- 
membranous angina  characterized  by  the  presence  of 
the  same  fusiform  bacilli  and  spirilla;  and  it  is  due 
to  tins  accurate  and  complete  study  that  his  name 
has  become  associated  with  this  form  of  angina  and 
with  the  fusiform  bacillus,  which  is  also  known  as 
"Bernheim's  bacillus"  and  the  "Plaut- Vincent  bac- 
illus," ''bacillus  fusiformis,"  "  bacillus  hastilis,"  "spin- 
dle-shaped bacillus,"  etc. 

Observations  upon  these  organisms  and  their 
association  with  ulceromembranous  angina  and  va- 


rious morbid  conditions  have  accumulated  rapidly 
in  recent  years  in  German,  French,  American,  and 
English  literature,  thus  showing  their  widespread 
and  frequent  occurrence.  They  have  been  found  in 
hospital  gangrene  (Vincent,  Matzenauer,  et  al.),  in 
noma  (Matzenauer,  Seiffert,  Perthes,  Rosenbergcr, 
and  many  others),  in  fetid  abscesses  about  the  mouth 
(Veszpremi,  Silberschmidt,  and  others'),  in  fetid  sub- 
pectoral abscess,  fetid  pleurisy,  mastoiditis,  laryngitis, 
bronchitis,  bronchiectasis,  abscesses  of  liver,  lungs, 
and  spleen,  phlegmon,  cerebral  abscess,  appendicitis, 
gangrenous  ulcers  of  the  penis,  in  syphilitic  lesions 
of  mouth  and  throat,  in  nasal  discharges,  and  in  the 
intestinal  contents  of  a  dog  affected  with  dysentery. 
In  the  great  majority  of  these  conditions  the  two  organ- 
isms are  found  together,   but  in  some  instances   the 


> 

%    . 

i 

/ 

\ 

\ 

!   \ 

A 

\ 

\ 

i 

V 

*> 

.      N 

( ; 

\ 

\ 

\ 

\ 

\ 

V 

V 

f\  * 

Fig.  239. — Fusiform  Bacilli  and  Spirilla  in  a  Throat  Smear  fn.m 
■a  Case  of  Vincent's  Angina.     (From  a  Text-Book  of  Bacteriol 
by  Hiss  and  Zinsser;  D.  Appleton  and  Company,  New  York.) 


bacilli  alone  are  present.  Other  bacteria,  particularly 
cocci,  are  usually  present  also;  although  in  some 
cases  the  bacillus  alone,  or  in  connection  with  the 
spirillum  occurs  in  pure  culture.  Both  organisms 
also  are  found  in  the  mouth  of  healthy  individuals, 
while  similar  spirilla  without  the  associated  bacilli 
have  been  found  upon  the  normal  genitalia  and  in 
the  vaginal  secretion.  The  presence  of  the  organ- 
isms in  all  of  the  conditions  named  has  usually  1  een 
determined  by  the  microscopic  examination  of  smears, 
and  occasionally  of  stained  sections  of  tissues,  i.f- 
forts  at  cultivation  have  usually  failed,  but  both 
organisms  have  been  grown  in  mixed  cultures,  and 
the  fusiform  bacillus  in  pure  culture  by  a  number 
of  observers  (Angelici,  Gross,  Niclot  and  Marotte, 
Seitz,  Silberschmidt,  Veszpremi,  Seiffert,  Perthes, 
Pruning,  Netter,  Veillon  and  Zuber,  Ellermann, 
and  Weaver  and  Tunnicliff). 


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\n:-iii.i  Vincent! 


Character  of  the  Organisms.— As  obtained  in 
smear-preparations  the  reported  descriptions  of  the 
bacilli  and  spirilla  correspond  very  closely.  The 
bacilli  appear  as  long  slender  rods,  pointed  at  the 
ends  and  somewhat  larger  in  the  middle.  They 
vary  greatly,  sometimes  the  rods  are  thick  with 
uled  i- m"ls,  sometimes  they  are  slightly  bent  or 
may  be  S-shaped.  They  are  six  to  twelve  microns 
long,  but  longer  thread-like  forms  are  occasionally 
seen.     They    occur    frequently    in   end-to-end    pairs, 

often  forming  re  or  less  obtuse  angles,  but  may  be 

nged  in  rows,  or  in  clumps,  or  in  radial  ins  groups. 
Observers  differ  as  to  their  inutility,  the  majority 
describing  them  as  no!  motile.  Graupner  described 
peritrichous  flagella,  and  found  that  motility  was 
quickly  lost.  According  to  Ellerman  the  .short 
curved  forms  are  motile  spirilla. 

I  he  bacilli  stain  well  with  carbolfuchsin,  Loeffler's 
methylene  blue,  anilin-water  gentian  violet,  and 
polychrome  methylene  blue,  but  do  not  stain  with 
Gram's,  although  some  writers  state  that  prolonged 
action  of  alcohol  is  necessary  for  complete  decolori- 
zation.  Babes-Ernst  granules  are  not  present, 
and  there  is  no  staining  with  Lugol's.  Spores  have 
nut  been  demonstrated,  although  light-staining 
as  ("vacuoles")  have  been  described.  Pure  cul- 
tures of  the  bacillus  have  been  obtained  by  Ellerman 
(1904)  and  Weaver  and  Tunnicliff  (1905),  as  a  non- 
motile,  obligate  anaerobe,  growing  best  at  30°,  but 
nut  at  room  temperature.  Horse-serum  agar,  ascites 
agar,  dextrose-free  broth,  plain  agar,  ascites  broth, 
horse-serum  give  growths  of  the  bacillus.  The 
cultures  may  have  an  offensive  odor,  but  no  gas  is 
formed. 

The  spirilla  are  long  and  delicate  with  three,  six, 
or  eight  turns.  They  stain  lightly  and  uniformly, 
and  are  quickly  decolorized  by  Gram's  method. 
They  are  usually  motile,  but.  may  quickly  lose  their 
motility,  especially  when  exposed  to  cold.  They 
have  been  grown  only  in  mixed  cultures.  Weaver 
and  Tunnicliff  used  human  pleuritic  exudate  and 
broth,  and  broth  containing  muscle-sugar.  The 
growth  was  always  slight,  and  was  not  influenced 
by  the  exclusion  of  oxygen. 

Veillon  and  Zuber,  and  Ellermann  also,  with  inocu- 
lations of  pure  cultures  of  Bacillus  J'usijorntis  caused 
small  abscesses  in  rabbits  and  guinea-pigs.  Weaver 
and  Tunnicliff  produced  abscesses  in  guinea-pigs  by 
intramuscular  injection  of  mixed  cultures. 

Mixed  cultures  containing  a  growth  of  fusiform 
bacilli  and  spirilla  with  cocci  also  produced  abscesses 
in  guinea-pigs.  Similar  results  were  obtained  with 
bacilli  and  cocci  without  the  spirilla. 

Relation  of  the  Organisms. — The  majority  of  writers 
believe  the  fusiform  bacilli  and  spirilla  to  be  different 
varieties  of  bacteria  acting  in  symbiosis,  the  virulence 
of  the  bacilli  being  increased  by  the  presence  of  the 
spirilla.  Numerous  observers  have  noted  that  the 
cases  of  angina  in  which  the  bacilli  alone  are  found 
are  of  a  milder  type  than  those  in  which  both  are 
present.  In  cases  of  deep  destruction  of  tissues  the 
spirilla  are  always  present.  Some  writers  (Seiffert, 
Perthes,  Sobel  and  Herrman,  and  Krahn)  believe 
that  bacillus  and  spirillum  are  developmental  stages 
of  one  organism,  but  there  is  no  positive  proof  of  this. 
Only  a  few  writers  (Bliihdorn)  are  inclined  to  regard 
the  spirillum  as  the  etiological  agent,  basing  this 
view  upon  Rumpel's  and  Gerber's  successful  treat- 
ment of  the  angina  with  salvarsan,  this  being  taken 
as  evidence  of  the  spirochetal  nature  of  the  infection. 

That  the  fusiform  bacillus  is  the  essential  etiological 
agent  in  the  conditions  in  which  it  is  found  remains 
yet  to  be  positively  demonstrated.  The  strongest 
evidence  in  favor  of  it  is  the  demonstration  in  the 
tissues  from  cases  of  noma  and  ulceromembranous 
angina  of  filamentous  organisms  that  resemble  the 
cultural  forms  of  the  fusiform  bacillus.  Ellermann 
has    demonstrated    the    presence    of    both    fusiform 


bacilli  and  spirilla  in  the  zone  separating  necrotic 
and  living  tissues  in  a  case  of  gangrenous  stomatitis. 
He  also  found  the  fusiform  bacilli  alone  in  the  tissues 

ui  the  uvula  from  a  case  of  ulceromembranous  angina. 

The    must     recent     writers    regard    the    organisms    as 

saprophytes  under  ordinary  conditions,  but  like 
the  colon  bacillus,  becoming  primarily  or  .secondarily 
pathogenic  under  certain  conditions. 

Predisposing    Causes. — Although    the    infection 

with  the  fusiform  bacillus  may  occur  in  apparently 
normal  individuals,  the  majority  of  observers  agree 
thai  certain  predisposing  factors  are  usually  present. 
Tobacco,  defective  teeth,  tartar,  inflamed  gums,  oral 
uncleanliness,  alveolar  abscesses,  scurvy,  syphilis, 
mercurial  stomatitis,  trauma  of  the  inucuus  mem- 
branes following  tonsillotomy  and  other  operations 
in  the  mouth,  and  primary  infections  with  other 
organisms  are  regarded  as  predisposing  factors. 
The  condition  is  often  associated  with  or  follows 
the  acute  infectious  diseases  (scarlet  fever,  dipht  heria, 
measles,  and  whooping  cough).  An  epidemic  of 
Vincent's  angina,  may  follow  one  of  diphtheria,  espe- 
cially in  institutions  and  hospitals,  and  under  such 
conditions  the  bacillary  angina  is  likely  to  run  a  more 
severe  and  malignant  course. 

Contagion*. — Vincent's  angina  is  regarded  as 
directly  ami  indirectly  contagious  within  rather  narrow 
limits.  The  affection  often  involves  definite,  groups 
of  students  living  in  close  association.  A  similar 
group-infection  of  nurses  and  hospital  attendants  has 
been  observed.  Institutional  epidemics  occur.  The 
infection  may  be  spread  by  the  use  of  common  eating 
and  drinking  utensils,  towels,  dental  instruments,  etc. 
Buhlig  calls  attention  to  the  possibility  of  transmis- 
sion through  the  purse-string  tobacco  bag,  the  strings 
of  which  are  often  drawn  tightly  with  the  teeth. 
As  a  rule  close  contact  is  necessary  for  the  spread 
of  the  infection. 

Occurrence. — The  report  of  cases  from  all  parts 
of  the  world  show  the  wide  distribution  of  the  infec- 
tion. While  many  observers  regard  the  angina  as 
rare,  it  certainly  is  not  an  infrequent  condition,  and 
the  most  recent  writings  upon  this  subject  regard  it 
as  of  frequent  occurrence.  Rodella  found  the  fusi- 
form bacillus  in  one-third  of  2,000  cases  of  pseudo- 
membranous angina.  Holm  in  20.)  cases  of  suspected 
diphtheria  examined  in  1908  at  the  laboratory  of  the 
Michigan  State  Board  of  Health  found  the  fusiform 
bacillus  present  in  seventy-three  cases  (thirty-three 
males,  forty  females).  Of  the  seventy-three  cases 
twenty-eight  had  been  diagnosed  as  diphtheria  clinic- 
ally but  the  diphtheria  bacillus  was  found  in  only 
one  of  the  twenty-eight.  In  over  three-fourths  of 
the  cases  of  pseudodiphtheria  the  fusiform  bacillus 
and  spirilla  were  found,  usually  in  association  with 
staphylococci  and  streptococci,  as  shown  by  culti- 
vation. Smears  from  these  cases  showed  the  bacillus 
fusiformis  as  the  most  prominent  organism.  Bliih- 
dorn examined  the  throats  of  222  patients  for  fusi- 
form bacilli  and  spirilla,  and  found  one  or  both  organ- 
isms present  in  all  but  twenty-seven  out  of  seventy- 
six  cases  of  diphtheria,  in  eleven  cases  out  of  forty- 
two  of  scarlatina,  in  thirteen  out  of  twenty-six  eases 
of  staphylococcus  or    streptococcus    sore  throat,   in 

two   out   of  four   cases   of   ulcerative   si atitis,   in 

twenty-one  out  of  thirty-one  cases  of  syphilitic  sore 
mouth  or  throat,  and  in  all  but  eighteen  of  forty 
healthy  persons.  In  healthy  persons  the  organism 
is  found  close  to  the  teeth,  and  it  is  probable  that  it  is 
responsible  for  certain  ulcerative  conditions  of  the 
gums.  Other  writers  confirm  the  frequent  occurrence 
of  the  organism.  As  to  the  angina  males  and  females 
are  equally  affected,  although  some  writers  give  a 
preponderance  of  cases  in  the  male.  It  is  common 
in  children  and  young  adults,  but  also  frequent  in 
middle  life  and  in  old  people.  It  occurs  more  often 
in  the  spring  than  in  the  autumn. 


429 


Anelna  Vincent! 


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Pathology. — The  local  lesions  vary  from  a  slight 
exudative  inflammation  to  an  ulceromembranous,  or 
even  gangrenous  process.  One  tonsil,  more  frequently 
the  right  (Koplik),  is  first  involved,  but  after  a  few 
days  the  process  may  spread  to  the  other.  Many 
cases  are  unilateral.  A  gray,  grayish,  yellow,  gray- 
ish-yellow, greenish-yellow,  creamy,  or  dirty  brown 
membrane  appears  upon  the  affected  tonsil,  varying 
in  size  from  a  lentil  to  that  of  the  entire  tonsil.  Be- 
neath the  membrane  is  formed  the  ulcer;  from  the 
first  the  base  of  the  ulcer  appears  as  if  covered  with 
membrane.  The  ulcer  is  rather  chancroidal  in  type. 
with  worm-eaten  base  and  sharp  overhanging  edges 
which  may  be  slightly  elevated  above  the  surface  of 
the  tonsil.  Depth  of  ulcer  varies  greatly,  from  one- 
eighth  to  one-half  inch  or  more.  On  removal  of  the 
membrane  the  ulcer  bleeds  freely  and  a  new  mem- 
brane may  be  formed.  In  the  majority  of  cases  the 
membrane  does  not  spread,  as  in  diphtheria;  but  in 
some  cases  it  may  spread  rapidly  and  involve  uvula, 
palate,  gums,  pharynx,  larynx,  or  trachea.  Sloughing 
of  the  uvula  and  soft  plalate  may  occur.  More  rarely 
the  ulcer  is  very  destructive,  the  process  becoming 
gangrenous  or  noma-like  in  character.  The  entire 
tonsil  may  be  destroyed,  and  the  necrosis  may  extend 
to  healthy  tissues.  An  ulcerative  stomatitis  is  often 
present,  and  ulcers  may  occur  in  the  tongue,  cheeks, 
and  gums.  As  a  rule  the  ulcer  heals  slowly,  and  not 
infrequently  becomes  subchronic  or  chronic  in  char- 
acter. The  submaxillary  glands  are  often  enlarged, 
as  are  the  lymph-nodes  at  the  angle  of  the  jaw. 
Suppuration  of  these  nodes  is  uncommon. 

Complications  and  sequeke  in  the  form  of  middle- 
ear  disease,  mastoiditis,  meningitis,  cerebral  abscess, 
bronchitis,  pneumonia,  edema  of  the  glottis,  pleuritis, 
empyema,  pericarditis,  arthritis,  etc.,  may  occur,  but 
are  relatively  rare.  In  all  of  these  conditions  the 
pus  has  usually  a  characteristic  stinking  odor,  similar 
to  that  produced  in  mixed  cultures  of  the  fusiform 
bacillus. 

Microscopically  the  ulceromembranous  lesions  show 
the  picture  of  a  necrotic  inflammation.  Fusiform 
bacilli  and  spirilla  are  found  in  the  zone  between  the 
necrotic  and  living  tissue. 

Symptoms. — The  symptoms  var}"-  greatly,  just  as 
the  local  lesions  differ  in  severity  and  extent.  Many 
cases  are  very  mild,  others  very  severe.  The  infec- 
tion may  occur  without  any  symptoms.  There  are 
no  characteristic  prodromal  symptoms.  A  feeling 
of  dryness  or  discomfort  in  the  mouth,  followed  by 
dysphagia  and  lassitude,  restlessness,  insomnia,  loss  of 
appetite,  headache,  coated  tongue,  constipation  or 
occasionally  diarrhea,  vomiting,  pain  in  the  stomach, 
epistaxis,  chills,  and  fever  gradually  develop 
during  one  to  five  days,  when  the  local  condition  is 
discovered.  The  fever  is  usually  slight,  rarely  higher 
than  103°.  A  marked  fetor  of  the  breath  is  often 
present,  especially  when  there  is  an  accompanying 
stomatitis.  Some  cases  show  a  pallor  of  a  distinctly 
septic  type.  The  average  case  gives  only  the  ordinary 
history  of  sore  throat  with  ulceration. 

The  cases  with  stomatitis  may  show  bleeding  from 
the  gums,  and  the  teeth  may  become  loose.  Earache 
and  nasal  discharge  are  not  infrequent.  In  the  severe 
eases  the  symptoms  may  be  very  violent;  there  is 
great  pain  and  difficulty  in  talking  and  swallowing, 
the  breath  is  very  fetid,  the  cervical  lymph-nodes  are 
enlarged  and  tender,  there  may  be  marked  gastro- 
enteritis, high  fever,  and  extreme  prostration.  The 
picture  of  noma  may  develop,  or  the  symptoms  re- 
semble closely  those  of  a  malignant  diphtheria.  In 
these  cases  albuminuria  is  common;  purpuric  and 
polymorphous  eruptions,  and  tender  edematous 
patches  may  appear  in  the  skin.  Appendicitis, 
empyema,  pseudorheumatism,  arthritis,  gastroen- 
teritis, endocarditis,  pneumonia,  or  peritonitis  may 
develop  as  a  complication  in  the  severe  cases. 

430 


Some  writers  attempt  to  recognize  several  forms  of 
Vincent's  angina.  As  the  differences  are  wholly 
those  of  extent  and  degree,  it  seems  inadvisable  to 
class  these  varieties  as  distinct  types.  Every  pos- 
sible stage  exists  between  them.  The  ulcerative 
stage  is  only  the  later  stage  of  the  membranous. 
While  the  constitutional  symptoms  may  be  slight  or 
absent,  the  local  condition  may  be  more  marked 
than  in  diphtheria.  The  more  severe  cases  are  likely 
to  occur  in  weakly  children  following  other  acute 
infections. 

A  subacute  or  chronic  course  of  the  infection  is  not 
infrequent.  Such  cases  may  run  three  weeks  to 
three  months  or  longer  without  healing  of  the  lesions. 
These  cases  are  especially  dangerous  in  transmitting 
infection  to  others. 

Prognosis. — Usually  good.  The  complications 
of  the  severe  form  are  relatively  infrequent,  but  ex- 
tension to  the  larynx  and  trachea  is  very  dangerous. 
Noma  and  other  of  the  serious  complications  may 
result  fatally.  The  occurrence  of  chronic  cases  must 
be  borne  in  mind,  however,  so  that  a  time-limit  for 
the  disease  cannot  always  be  safely  made. 

Diagnosis. — The  only  positive  test  is  that  of  the 
culture  tube.  Smears  from  the  base  of  the  ulcer 
will  reveal  the  presence  of  the  fusiform  bacillus 
either  alone  or  in  association  with  the  spirilla  or  other 
organisms.  Cultivation  is  necessary  to  exclude 
diphtheria  and  other  infections.  Many  cases  of 
suspected  diphtheria  are  undoubtedly  cases  of  Vin- 
cent's angina;  but  before  assuming  that  any  ulcero- 
membranous process  of  the  tonsils  or  mouth  is 
Vincent's  angina,  diphtheria  must  be  excluded  by 
cultivation,  as  the  clinical  picture  and  stained  prep- 
arations are  in  themselves  not  conclusive.  Chan- 
croid and  syphilis  must  also  be  excluded  by  the 
history,  other  symptoms,  Wassermann's  reaction, 
demonstration  of  Spirochete  pallida  and  chancroid 
organism. 

Treatment. — Local  applications  of  tincture  of 
iodine  or  methylene-blue  powder  have  been  used 
with  good  results.  The  base  of  the  ulcer  may  be 
touched  with  Lugol's  solution,  or  a  ten  per  cent, 
solution  of  silver  nitrate.  A  thirty-grain  solution 
to  one  ounce  of  zinc  sulphate  is  also  recommended. 
Weaver  and  Tunnicliff  advise  the  use  of  hydrogen 
peroxide.  Mouth  washes,  such  as  Seder's  solution 
and  potassium  chlorate,  are  also  used.  Orthoform 
in  powder  or  tablet  form  is  advised  for  relief  from  the 
pain.  Rumpel  and  Gerber  obtained  prompt  healing 
of  the  ulcer  after  the  administration  of  salvarsan 
with  no  other  treatment  and  in  cases  where  syphilis 
was  excluded.  Yates  used  North's  lactic  acid'  prep- 
aration in  a  chronic  case  of  mastoiditis  due  to  the 
fusiform  bacillus  and  obtained  prompt  healing  with 
disappearance  of  the  organisms.  Internal  medica- 
tion is  regarded  by  most  writers  as  unnecessary, 
although  some  advise  the  administration  to  children 
of  the  tincture  of  chloride  of  iron  in  doses  of  three  to 
five  minims,  combined  with  glycerin  ami  water,  every 
three  hours.  Complications  should  receive  appro- 
priate treatment  as  they  arise.        A.  S.  Warthin. 

Angioblast. — (From  the  Greek  aj-fetov,  a  vessel, 
and  /iXacrris,  a  sprout.)  The  word  A  ngioblast  was 
proposed  by  His  in  1900  to  designate  the  embryonic 
l  issue  that  gives  rise  to  the  blood-vessels  and  the 
blood.  For  a  discussion  of  the  origin  and  fate  of  this 
tissue  see  article  Blocrd-vascular  system,  origin  of. 

It.   P.    B. 


Angiokeratoma. — Synonyms:  Kerato-angioma :  Tel- 
angiectatic Wart;  Mibelli's  Disease. 

Definition. — An  unusual  chronic  skin  disease, 
chiefly  met  with  on  the  hands  and  feet  of  those  sub- 


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Angiokeratoma 


jecl  to  chilblains.  II  consists  of 
single  and  grouped  papular  and 
nodular  lesions  of  a  reddish  or 
purplish  color,  made  up  of  epi- 
dermic hypertrophy  covering  dila- 
tation 01  ill"  capillary  vessels  in 
the  papilla?. 

History.     Mibelli  ga\  e  the  first 
anatomical  description  of  I  In-  con- 
dition met   with  in  the  affection 
proposed    the  name  "angio- 
keratoma" for  the  disease.     The 
lesions  n  hich  formed  i  he  basis  of 
his  observations  occurred  on  the 
il     hi  face  of  the  fingers  of  a 
year-old    girl,    and    had 
existed  for  several  years.      They 
preceded  by  chilblains. 
Before  Mibelli's  careful  investi- 
gations, cases  of  the  same  affection 
hail  been  noted  by  other  writers 
under    various    names;    the    true 
nature    of    the     lesions    had    not, 
however,  been  determined. 

We  are  indebted  to  Pringle  for 
a  most  accurate  and  painstaking 
description  of  the  clinical  appear- 
and morbid  anatomy  of  the 
affection,  as  well  as  for  an  analysis 
of  most  of  the  cases  which  had 
been  met  with  up  to  the  time  of 
his  publication. 

Pringle  reported  two  cases  affect- 
ing girls  with  chilblains,  and  his 
histological  findings  agree  in  all 
essential  points  with  those  of 
iMibclli.  Since  the  publication  of 
these  cases  a  number  of  others 
have  been  reported,  among  them 
Zeisler's,  which  presented,  in  ad- 


d^10"  2J?.'TSe°?0n  throueh  Small  Blood  Cavity  Completely  Enclosed  by  Hypertrophied 
Kete.  thickened  epithelium  at  right  of  section.  Spencer,  one  inch;  ocular,  one  and  onc- 
iiuarter  inches. 


dition  to  characteristic  lesions  on 
the  hands  and  feet,  nevus-like 
patches  and  pedunculated  vascu- 
lar tumors  on  the  forearms,  over 
the  patellae,  the  legs,  thighs,  and 
auricles. 

In  the  case  reported  by  myself, 
the  skin  of  the  scrotum  was  the 
seat  of  a  number  of  small,  spheri- 
cal-shaped, dark  purple  tumors. 
They  were  arranged  in  a  linear 
manner  as  if  following  the  super- 
ficial vascular  supply  of  the  parts. 
The  small  growths,  from  the  size 
of  a  pin's  head  to  several  times 
that  size,  were  distinctly  elevated 
above  the  surface  of  the  scrotum, 
seeming  to  rest  on  it  rather  than 
to  be  embedded  in  the  skin.  Some 
of  them  were  covered  by  a  slightly 
thickened  horny  layer  under  which 
minute  dark  red  points  could  be 
seen,  giving  the  tumors  a  wart- 
like appearance.  In  this  patient 
the  hands  and  feet  were  not  in- 
volved, and  the  usual  etiological 
factor,  chilblains,  could  not,  of 
course,   be   invoked  to  explain  the 

development  of  the  lesions.  I 
have  also,  through  the  kindness 
of  Dr.  Leviseur,  seen  a  similar 
case  in  which  the  small  tumors 
were  seated  on  the  vulva  of  a 
young  girl.  The  diagnosis,  in  this 
case,  was  confirmed  by  the  micro- 
scope. 

Anderson  has  reported  a  case  in 
which  the  eruption  began  over  the 

431 


w  "41' — LarEe  Tumor  Showing  Cavernous  Spaces  Divided  by  Fibrous  Septa.      Organized 
blood  clots  on  the  left  of  section.     Spencer,  one  inch ;  ocular,  one  and  one-quarter  inches. 


Angiokeratoma 


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knees  at  the  age  of  eleven  years,  gradually  spreading 
to  the  trunk  and  upper  extremities,  and  finally  involv- 
ing almost  the  entire  surface  of  the  body  with  the 
exception  of  the  hands  and  feet. 

Symptomatology. — A  history  of  recurring  attacks 
of  chilblains  precedes  the  development  of  the  affec- 
tion on  the  hands  and  feet.  After  a  variable  time, 
usually  reckoned  by  years,  minute  telangiectases 
appear  over  the  dorsal  surfaces  of  the  phalanges  of 
the  fingers  and  toes,  which  eventually  cannot  be 
made  to  disappear  by  pressure.  The  points  of  vas- 
cular dilatation  become  grouped,  and  over  them  the 
epidermis  undergoes  thickening,  giving  rise  to  hemis- 
pherical lesions  from  the  size  of  a  pin's  head  to  that 


Fig.  242. — Cavernous  Space  Filled  with  Blood  Corpuscles  and  Divided  by  Fibrous  Septa. 
Hypertrophy  of  stratum  comeum  and  rete  Malpighii.  Spencer,  one-half  inch;  projection 
ocular,  2  Zeiss. 

of  a  spilt  pea,  or  larger,  having  a  rough  warty  surface 
and  a  dark  purple  or  lead  color. 

The  minute  vascular  points  beneath  the  thickened 
epithelium  can  be  detected  by  making  pressure  on 
the  growths. 

In  some  cases  lesions  in  all  stages  of  development 
from  minute  pink  points  to  the  commingled  warty 
growths  can  be  detected.  The  palms  and  soles  may 
be  involved.  On  parts  of  the  body  where  the  stra- 
tum corneum  is  thinner  than  on  the  hands  and  feet 
its  hypertrophy  is  less  marked  than  in  the  latter 
localities  and  may  not  be  perceptibly  thickened.  It 
is  usually  bilateral,  though  not  strictly  symmetrical. 
The  affection  may  persist  indefinitely,  become  sta- 
tionary, or  disappear. 

Patohology  and  Morbid  Anatomy. — The  primary 
change  is  undoubtedly  in  the  capillary  vessels  of  the 
papillae,  which,  subjected  to  repeated  congestions, 
become  permanently  dilated,  leading  to  the  for- 
mation of  cavernous  spaces,  and  by  pressure  alter 
the  normal  conformation  of  the  parts.  On  the 
hands  and  feet  the  stratum  corneum  covering  the 
lesions  is  greatly  thickened;  this  change  is  not  so 
pronounced,  however,  when  the  affection  is  met  with 


in  other  regions.  The  characteristic  pathological 
changes  are  shown  in  the  accompanying  photomi- 
crographs made  from  sections  of  tumors  removed 
from  the  scrotum. 

In  Fig.  240  a  small  cavity  filled  with  red  and 
white  blood  corpuscles  is  shown  completely  surrounded 
by  the  hypertrophied  rete  layer. 

On  the  right  of  Fig.  241  a  large  cavernous  space 
is  seen  to  be  filled  with  blood  corpuscles,  which  have 
by  pressure  caused  a  marked  atrophy  of  the  epidermis. 
On  the  left  of  this  section  the  circulation  has  been 
obliterated,  as  the  lacuna?  are  occupied  by  concen- 
tric layers  of  fibrin  containing  blood  corpuscles  and 
pigment. 

Fig.  242  represents  a  more  en- 
larged view  of  the  cavernous 
spaces  with  their  divided  septa. 
The  stratum  corneum  is  also 
shown  to  be  considerably  thick- 
ened. 

An  examination  of  the  sections 
shows  that  the  lesions  consist  of 
lacunar  spaces  filled  with  blood 
occupying  the  papillary  portion 
of  the  derma,  some  of  which  are 
enclosed  in  the  rete  Malpighii. 
These  cavernous  spaces  are  evi- 
dently the  essential  feature  of  the 
disease  and  the  primary  patholog- 
ical condition. 

Etiology. — The  disease,  when  it 
occurs  on  the  hands  and  feet,  as 
it  most  frequently  does,  is  an 
affection  of  early  life,  and  caused 
by  repeated  attacks  of  chilblains 
Some  cases  have  been  associated 
with  tuberculous  affections  of  the 
lungs,  glands,  and  other  regions. 
An  attempt  has  been  made  by 
Leredde  to  show  that  it  is  caused 
by  the  toxins  of  the  tubercle 
bacilli.  It  is  hardly  to  be  hoped 
that  the  von  Pirquet  reaction  will 
decide  this  point. 

Scheuer,  one  of  the  most  recent 
systematic  writers  on  this  affec- 
tion (1909),  like  many  of  his  pre- 
decessors, regards  it  as  due  to  an 
initial  congenital  weakness  of  the 
capillaries  aggravated  in  most 
cases  by  frost-bite.  The  subse- 
quent thickening  of  the  epidermis 
is  conservative  as  it  protects  the 
fragile  vessels  and  thereby  pre- 
vents hemorrhages. 

In  my  case,  in  which  the  skin  of  the  scrotum  was 
affected,  the  tendency  to  dilatation  of  the  blood- 
vessels as  manifested  by  a  double  varicocele,  and  the 
degenerative  state  of  the  vessels  and  surrounding 
connective  tissue  incident  to  old  age, 'were  probably 
the  most  potent  causes  in  bringing  about  the 
condition. 

Diagnosis. — A  well-developed  case  of  the  disease 
could  hardly  be  mistaken  for  any  other  affection. 
The  color  of  the  lesion  and  the  presence  of  the  vas- 
cular points  should  differentiate  it  from  tuberculous 
or  ordinary  warts. 

Treatment. — The  tumors  may  be  removed  bj 
excision  or  by  (he  application  of  the  Paquelin  or 
galvanocautery.  with  the  production  of  slight  scarring. 
Less  deformity  results  from  electrolysis. 

John  A.  Fohdtce. 

Literature. 

Mibelli:  Giornale  Italiano  delle  Mai.  Ven.  e  della  Pellc.  fasc  iii  . 
September,  1SS9.  Internat.  Atlas  of  Rare  Skin  Diseases,  No.  ii., 
1889. 

Dubreuilh:  Ann.  de  la  polyclinique  de  Bordeaux,  tomei.,  fascio 
i.,  January,  1S89,  p.  50. 


432 


REFERENCE    HANDBOOK    01    THE    MEDICAL   SCIENCES 


Angioma 


Pringle:    British  Journal  of  Dermatology,  vol.  iii.,  1891,  p,  237, 
Zeislor:  Trans.  American  Dermatol.    Association,    9even 

I  Motting,  Is'1  ; 
Fordyce:    Journ.  Cutan.  and  Genito-Urin.  Dis.,  vol.  \i\..  LS96, 
p.  81 

Vndorson:   British  Journal  ol  Dermatology,  vol   x.,  1898,  p.  113. 
\i.n.  do  Derm.,  1S98,  vol   i\  .  i>    10 
Arch    i    Derm,  u,  Syph.,  L909,  xoviii,,  p.  251, 


Angioma. — (iyytiov,   a    vessel.)      The   angioma,    a 
neoplasm  representative  of  the  connective-tissue  or 
histoid  type  of  tumors,  is  a  new  growth  composed 
eal  pari  of  blood-vessels  or  of  lymph  vessels. 

on.-    According   to  the  character  of  the 
sels   entering   into   the   structure   of   the    tumor. 
angiomata    are    classified    into — 1.  Hemangiomata; 
_'.  Lymphangiomata. 

Hemangioma. — The  hemangioma  is  a  tumor  the 
atial  structural  components  of  which  are  newly 
formed  blood-vessels  which  are  formed  from  the 
preexisting  ones  by  budding.  The  older  \< 
may  also  grow  lengthwise,  and  become  tortuous 
and   dilated. 

Varieties. — Two  varieties  of  hemangioma  are  rec 
ognued,  the   distinction   between  them  being    ba 
upon  differences    both  in   structure   and  in   location. 
These  varieties  are: 

Hemangioma  Simplex  (nevus  vasculosis;  birth 
mark;  telangiectatic  hemangioma).  This  form  of 
hemangioma  comprises  the  small  vascular  nevi,  and 
most  of  the  so-called  mother's  or  birth  marks,  it 
occurs  in  two  forms:  (1)  As  flat,  round,  or  irregularly 
outlined,  usually  sharply  contoured,  red  or  bluish-red 
patches  on  a  level  with,  or  but  very  slightly  elevated 
above,  the  surface  of  the  skin;  in  size,  varying  from 
that  of  a  flea-bite  to  that  of  the  side  of  the  face.  The 
skin  over  these  patches  is  either  smooth  or  thickem  I. 
and  is  sometimes  covered  with  lanugo  hairs.  (2)  As 
telangiectatic  warts,  from  pin-head  to  pea  size,  which 
appear  in  the  elderly.  The  blood  found  in  them  is 
venous  in  quality.  They  do  not  really  originate  in 
old  age,  but  become  conspicuous  at  this  time.  The 
blood-vessels  running  to  and  from  the  wart  suggest 
the  appearance  of  a  spider — the  "spider  cancer"  of 
er  quacks. 

currence. — This  variety  of  hemangioma  is  very 
common;  it  is  nearly  always  congenital.  From 
observations  made  by  Depaul,  it  appears  that  one- 
third  of  all  the  children  born  in  the  clinic  of  the  Fac- 
ulty of  Medicine  in  Paris  have  such  hemangiomata  at 
birth.  The  tumor  is  situated  most  frequently  in 
the  skin  of  the  face,  neck,  back,  chest,  abdomen, 
sometimes  of  the  extremities.  More  rarely  it  occurs 
in  mucous  membranes,  and  beneath  the  serous  sur- 
s  of  the  internal  organs.  It  may  be  single  or 
multiple,  and  may  attain  a  varying  size. 

Structure. — Histologically,  the  hemangioma  simplex 
consists  of  newly  formed,  much  convoluted,  more  or 
dilated  capillaries  lying  in  a  stroma  composed  of 
fibrous  connective  tissue  or  of  fat  tissue.  This 
stroma  varies  in  amount,  and  may  be  infiltrated  with 
lymphoid  cells,  or  contain  pigmented  connective- 
tissue  cells.  The  newly  formed  vessels  often  corre- 
spond in  distribution  to  the  vascular  districts  of  the 
sweat-glands  or  the  hair-follicles.  The  vessels  com- 
municate not  at  all  or  but  slightly  with  the  normal 
blood-vessels. 

Hi  mangioma  Cavernosum  (cavernous  tumor;   erec- 
tile tumor;  cavernoma). — This  form  of  hemangioma 

isists  of  lobulated,  sometimes  fungoid  tumors  of 
varyjng  size,  bluish  in  color,  single  or  multiple,  tending 

diminish  or  disappear  under  pressure.  Pressure 
upon  parts  adjacent  to  the  tumor  causes  it  to  swell  by 
venous  congestion;  other  conditions,  such  as  change 
of  position,  weeping,  sleep,  digestion,  the  ingestion  of 
alcohol,  and  the  like,  may  cause  alteration  in  size, 
owing  to  the  erectile  character  of  the  growth. 

Vol.   I.— 2S 


Occurrenci  rhe  ordinary  M-its  of  this  tumor  are 
the  lips,  check-,  tongue,  and  muscles  in  general.  In 
exposed  localities  they  cause  much  disfigurement. 
A  special  form  is  cavernoma  of  the  liver,  The  size 
\  anea  from  that  of  a  pea  to  t  hat  of  a  whole  lobe  of  the 
liver,     The    tumor    i.s    general!}     single,    sometimes 

multiple.     The  liver    of  old  i pie  pn   enl  this  form 

of  new  growth  in  a  great  number  of  instances.  Its 
occurrence  In  this  organ  seems  to  vary  in  frequency  in 
different  countries; according  to  the  report  of  patholo- 
gists, it  is  not  so  frequent  in  Norway  and  Swei 
as  it  is  in  Germany.  By  the  rupture  of  the  vessels  of 
large  cavernous  hemangiomata  through  the  capsule  of 
the  liver,  extensive  hemorrhage  has  taken  place  int.. 
the  peritoneal  cavity,  and  fatal  peritonitis  has  been 
caused. 


Fig.     243.-— Angioma     Cavernosum     Cutaneum     Congenitum 
Muller's  fluid;  hematoxylin.)  a,  Epidermis:  b,  coriumjc,  cavernous 
blood  spaces.      X20  diameters.      (After  Ziegler.) 


This  tumor  also  occurs,  although  less  commonly 
than  in  tin1  liver,  in  the  other  abdominal  organs,  as, 
for  example,  the  spleen  and  the  kidneys,  and  also  in 
the  brain.  It  is  found  in  the  skin  less  frequently  than 
are  the  simple  hemangiomata.  Esmarch  has  re- 
ported in  Virchow's  Archiv  a  very  interesting  case  of 
its  occurrence  in  this  position.  A  single  tumor  devel- 
oped upon  the  middle  finger  of  a  girl  eight  years  of  age 
was  followed  in  subsequent  years  by  t  lie  appearance  of  a 
great  many  others.  At  the  time  of  the  first  menstrua- 
tion there  was  a  great  increase  in  both  the  number 
and  the  size  of  the  tumors.  At  each  succeeding  cat- 
amenial  period  they  seemed  to  grow  more  than  at 
any  other  time.  In  size  they  varied  from  that  of  a 
pea  to  that  of  a  hen's  egg.  They-  were  all  successfully 
extirpated,  and  in  most  cases  were  found  to  be  situ- 
ated on  the  wall  of  a  vein,  with  which  they  were  in 
communication. 

Structure. — The  cavernous  hemangioma  upon  sec- 
tion presents  an  appearance  quite  similar  to  that 
of  the  cut  surface  of  the  corpus  cavernosum  penis.  It 
is  characterized  by  the  presence  of  a  firm,  tough, 
white  meshwork,  which  in  the  recent  state  is  empty 
or  contains  some  irregular  blood  clots.  The  meshes 
frequently  enclose  small,  round,  calcareous  masses 
known  as  phleboliths.  In  some  instances  this  cavern- 
ous structure  is  sharply  circumscribed  and  separated 
from  the  surrounding  structures  by  a  firm  capsule. 
In  others,  where  the  tumor  is  small  and  to  all  appear- 
ances in  a  state  of  rapid  growth,  it  is  surrounded  by  a 
zone  of  h/mphoid  cells.  The  consistence  of  the  tu- 
mor depends  upon  the  amount  of  the  fibrous  connec- 
tive-tissue meshwork,  or  stroma:  when  this  is  abun- 
dant, the  tumor  is  relatively  hard,  and  when  scanty, 
soft  and  flaccid. 

Microscopically-,  the  tumor  presents  trabecules  of 
fibrous  connective  tissue,  in  part  newly  formed,  in 
part  belonging  to  the  structure  in  which  the  tumor  is 
developed,  of  varying  thickness,  arranged  in  the  form 
of  a  meshwork.  The  cells  of  this  tissue  are  numerous, 
and  it  is  usually  infiltrated  with  lymphoid  cells  scat- 
tered singly  or  localized  in  groups.  The  spaces  of  this 
meshwork  are  lined  with  flat  endothelial  cells,  and 
contain  blood.  These  spaces  are  of  varying  size,  but 
whatever  their  extent,  they  always  represent  capil- 
laries, for  they  are  interposed  between  an  artery-  and  a 

433 


Angioma 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


vein.  Adjacent  large  spaces  may  be  separated  by 
exceedingly  thin  partitions.  The  connective-tissue 
stroma  in  some  cases  has  been  ,found  to  contain 
nerves,  smooth  muscle  fibers,  and  elastic  fibers. 
Ribbert  has  shown  abundantly  by  injection  experi- 
ments that  the  blood-vessels  of  the  tumors  do  not 
communicate  with  the  general  circulation  in  the  great 
majority  of  cases. 

Etiology. — The  cause  of  hemangiomata,  in  common 
with  that  of  most  new  growths,  is  not  understood. 
A  large  proportion  of  all  tumors  of  this  sort  are  con- 
genital, and  when  they  do  develop  after  birth,  it  is 
generally  in  the  early  years  of  life.  It  is  seldom  that 
hemangiomata  develop  in  adults,  a  fact  which  is 
remarkable  in  view  of  the  frequency  of  dilatation  of 
the  blood-vessels  in  old  age,  and  one  which  constitutes 


Fig.  244. — Dilated  Capillaries  from  a  Telangiectatic  Tumor  of 
the  Brain,  all  the  attached  portions  of  tumor  tissue  having  been 
shaken   off  in  water.      X200.     (After  Ziegler.) 


a  strong  objection  to  the  theory  that  these  tumors 
arise  from  a  simple  dilatation  of  preexisting  vessels. 
Heredity  seems  to  play  some  part  in  their  occurrence; 
numerous  cases  are  recorded  in  which  a  child  presented 
one  of  these  tumors  in  the  same  place  on  its  body  as 
that  in  which  one  of  the  parents  also  had  a  birth 
mark.  Popular  belief  in  all  ages  has  associated  the 
presence  of  these  growths  in  children  with  some  influ- 
ence exerted  upon  the  mother  during  pregnancy; 
maternal  impressions  cannot,  however,  be  regarded 
as  definite  factors  in  the  development  and  growth  of 
offspring. 

Different  views  have  been  held  regarding  the 
genesis  of  the  cavernous  form  of  hemangioma  and  the 
most  distinguished  pathologists  have  promulgated 
positive  views  on  the  subject.  The  cavernoma  of  the 
liver  is  well  suited  for  study.  Ribbert  regards  it  as 
the  result  of  an  error  of  development,  an  area  of 
embryonal  liver  tissue  being  involved  with  its  imma- 
ture cells,  trabecules,  and  vessels.  The  vessels 
develop  at  the  expense  of  the  other  structures. 
They  become  irregular  and  dilated.  This,  however, 
does  not  explain  the  tumor  formation,  which  develops 
on  the  basis  of  the  malformation  and  is  brought  about 
by  the  appearance  of  buds  in  the  walls  of  the  sinuses. 
These  force  their  way  between  the  liver  cells  in  the 
direction  of  the  capillaries.  In  this  way  large  tumors 
are  formed.  A  cavernoma  then  begins  by  dilatation 
of  embryonal  vessels  into  sinuses  and  extends  by  the 
continued  formation  of  new  vessels.  In  some  cases 
the  growth  undergoes  a  fibrous  transformation,  the 
connective  tissue  increasing  at  the  expense  of  the 
blood-vessels. 


Mmlc  of  Growth;  Clinical  Aspects. — The  hemangio- 
mata extend  always  by  growth  from  within  outward- 
they  show  no  tendency  to  infiltrate  surrounding  strut 
tures;  they  do  not  cause  metastases.  Instances  of 
seeming  exception  to  these  conditions  are  probably 
cases  in  which  sarcoma  with  dilated  blood-vessels 
was  mistaken  for  hemangioma.  The  pulsating  tu- 
mors of  the  long  bones,  whioti  have  been  described 
as  cavernous  tumors,  are  to  be  regarded  as  telangiei 
tic  sarcomata.  The  hemangioma  is,  therefore,  si  i 
as  its  mode  of  growth  is  concerned,  a  benigti  tumor 
although  the  accidents  incidental  to  its  development 
may  cause  death  from  hemorrhage  or  from  intra- 
cranial pressure.  The  growth  of  these  tumors  is 
generally  unaccompanied  by  pain;  it  is  slow,  ami 
may  be  irregular.  In  some  instances  the  tumor 
constantly  enlarges,  in  others  it  reaches  a  certain  size 
and  then  remains  stationary.  It  sometimes  under- 
goes spontaneous  cure  by  the  ulceration  of  the  overly- 
ing skin,  and  the  subsequent  formation  of  cicatricial 
tissue  which  includes  the  vessels  and  obliterates  them 
by  contraction.  When,  as  is  sometimes  the  case.  I ! 
tumor  is  connected  with  the  skin  by  a  pedicle,  I  lie 
vessels  in  the  pedicle  may  shrink,  and  the  tumor 
become  desiccated  and  drop  off.  In  yet  other  ca 
a  cure  may  be  effected  by  thrombosis,  and  the  con- 
sequent  deprivation  of  the  tumor  of  its  circulation. 

Lymphangioma. — The  lymphangioma  is  a  tumor 
composed  of  lymph  vessels  and  lymph  spaces  in  a 
state  of  greater  or  iess degree  of  dilatation,  lying  within 
a  fibrous  connective-tissue  stroma.  Strictly  speaking, 
the  term  lymphangioma  is  applicable  to  those  lymph- 
vessel  tumors  only  in  which  the  whole  or  the  greater 
part  of  the  vessels  is  newly  formed;  but  inasmuch  be 
in  any  single  case  it  is  often  difficult  to  determine 
how  far  the  vessels  are  newly  formed  and  how  far 
they  are  preexistent,  dilated  and  thickened,  it  is  con- 
venient to  include  under  the  lymphangiomata  certain 
abnormal  structures  in  which  the  essential  patholog- 
ical condition  is  lymphangiectasis.  This  form  of  new 
growth  occurs  in  a  great  variety  of  loci,  and  pre- 
sents an  external  configuration  determined  very 
largely  by  the  organ  or  structure  in  which  it  is  de- 
veloped, as  well  as  by  its  histological  characteristics. 
It  is  seen  in  warty  tumors  and  diffuse  thickenings  of 
the  skin  and  mucous  membranes,  in  macroglossia, 
in  certain  congenital  cysts,  and  in  various  other 
conditions. 


Fio.    245. — Section    through    the    Margin    of    a    Very    Small 
Cavernous  Angioma  of  the  Liver  at  a  Time  When  This  Mi 
Was    in    Process    of    Active    Growth.      (Carmine    preparation.) 
X  150  diameters.      (After  Ziegler.) 


These  growths  may  be  classified  as  follows: 
Lymphangioma  Simplex. — Asa  true  neoplasm  this  oc- 
curs in  the  form  of  a  circumscribed  tumor,  composed  of 
capillary  and  larger-sized  lymph  vessels.  As  lymph- 
angiectasis, it  is  seen  in  the  lymphatic  varix,  in  dilata- 
1  i< hi  of  the  lymphatics  resulting  from  obstruction, 
in  macroglossia  and  elephantiasis  following  erysipelas, 
and  in  elephantiasis  due  to  filaria.     There  are  numer- 


434 


REFERENCE    HANDBOOK    OK   THE    MEDICAL    SCIENCES 


Lngloma  Serplglnoguni 


.  dinical   forma  of    lymphangiectasia,   congenital 
I  acquired,  bul    Ribbert  does  not  regard  these  as 
angiomata,  neither  does  he  include  here  l\  inph- 

.u,„i atuberosum  multiplex.a  very  rare  skin  di  ea  e. 

lymphangioma    Cysticum. — Some    authors   distin- 
D  betwei  n  cavernousand  cysticforms,  bul  Ribberl 
mllk,     .  oab  olute  distinction  for  cystic  and  cavernous 
tumors  occur  side  by  side.  . 

growths  are  practically  isolated,  their  ve    el 

having  little  or  no  communication  with  the  normal 

lymphatics.      \  true  lymphangioma  should  shell  out 

,,,,,  the  surrounding  tissues.     The  size  may 

thai  of  an  apple  or  the  list. 

e  is,  however,   a  lymphangioma  cayernosum 

i     i  ricted  sense  «  hich  i urs  as  a  diffuse 

,:  ,    embling  in    structure    a    hemangioma, 

h  ig  congenital,  and  occurs  in  the  lips,  cheeks,  and 
tongue,  causing  an  elephantiasis  known  respectively 
tc'rocheilia,  macroglossia,  etc. 


j 


I  - 


.•9'n».'"      ,  .-- 
! 


Flo.  246.-  Lymphangioma  Hypertrophieum.  Rounded  summit 
of  :i  rather  large,  .soft,  smooth  wart.     (Formalin;  hematoxylin; 

Sharply    limited    nests   of   cells   in    the    corium.      X250 

diameters.     [After  Ziegler.) 

These  lymphangiomata  occur  in  various  parts  of  the 
body  with  especial  preference  for  the  axillae, 
groins,  mesentery,  and  intestinal  wall.  An  atypical, 
ill-defined  form  occurs  in  various  localities  about  the 
neck  and  is  known  as  congenital  cystic  hygroma, 
li  may  reach  as  high  up  as  the  ear,  may  extend  down- 
ward into  the  mediastinum  or  hang  loose  upon  the 
neck  or  shoulder. 

The  cystic  lymphangioma  of  the  neck  is  congenital; 
it  is  probably  not  derived  from  hemangioma  by  the 
obliteration  of  connections  with  blood-vessels  and  the 
development  of  secondary  communications  with  the 
lymphatic  system.  The  fact  that  the  cystic  spaces  are 
a  with  endothelium  and  not  with  epithelium  is 
evidence  that  these,  tumors  are  not  derived  from 
i-  the  salivary  glands  or  the  branchial  clefts. 
I'he  tumor  is  situated  upon  the  anterior  or  lateral 
surfaces  of  the  neck;  rarely  upon  the  back;  it  may 
be  unilateral  or  bilateral.  Its  size  varies;  it  tends 
to  burrow  and  to  extend  under  the  cervical  fascia 
between  the  muscles  of  the  neck.  In  this  way  it 
may  travel  down  the  sheath  of  the  subclavian  vessels 
to  the  axilla,  or  it  may  go  into  the  mediastinum. 

Sh'uctiirc  and  Nature. — Lymphangiectases,  like 
telangiectases,  are  not  to  be  regarded  as  tumors. 
Lymphangioma     proper    agrees     in     structure     and 


nature  with  hemangioma.    That  is,  there  i    lii  i    m 

ei  i  "i  ni  de\  'In | 'Hi,  which  re  nil     in  a  new  foi 

i  em  ..i  ves  els  and  connective  tissue,  together  with  fat 
and  smooth  muscle.  In  the  simpli  '  form  there 
new  formation  and  dilatation  01  lymph  vessels  and 
spaces.  There  is  a  tendency,  however,  to  multiple 
cyst  formation,  the  cysts  as  a  rule  having  communica- 
tion with  one  another.      \   sect! f  such  a  growth 

ihows  a  mass  of  cavernous  tissue  with   cavities  of 

various  size,  including  perhaps  one  largi '  ■  ity. 

The  dilatati E  the  lymph  spaces  to  form  cysl     i 

not  due  in  the  main  to  distention  and  wearing  away 
of  trabecular,  but  to  a  true  process  of  growth  which 
constantly  increase  the  internal  surface.  As  the 
spaces  thus  enlarge,  they  keep  filled  with  lymph. 

(  111, i.i. I        'ii    i.i,  M  LGRA1  II. 

Edward  Pbeble. 

Bibliography. 

Beneke:  Zur  Genese  der  Leberang Virch.  Archiv,  1S53. 

Burckhard:  Path,  Uiat.  d,  oavernoesen  Ang.  d.  Leber,  Wurz- 
burg,  I.  !>..  1894. 

Esmarch:  I  ebei  cavernoese  BlutgeschwOlste.  Virch.  Arch., 
1853. 

II.  rtzler:  Treatise  on  Tumors,  1912. 

Lang]  Beitrage  Lehre    iron    den    Gefat  sgei  chwulsten. 

\  irch    \ich..  1879. 

Losser:  Lymphangioma  tuberosum  multiplex.  Virch.  Arch., 
1891. 

Logez:  Le  Lpmphangiome  congenital.     These  de  Paris,   1902 

Luschka:  Cavern.  BlutgeschwOlste  des  Gehirns.  Virch.  Arch., 
1854. 

Muscatello:  Angiom  der  willkOrl.  Muskeln.     Virch.  Arch.,  1894. 

Ribbert:  Geschwulstlehre,   1904. 

Robin  ei  Laredde;  Arch,  de  med.  rap.  et  d'anat.  path.,  1896. 

Rokitansky;  Lehrbuch  d.  path,  Anat.,  1855. 

Samte:  Ueber  Lymphangiome  d.  Mundhohle.  Lang.  Arch., 
1891. 

Sutton:  Tumors,  Innocent  ami  Malignant  5th.  ed.,  1911. 

Virchow:  Ueber  cavern.  Geschwulste.     Virch.  Arch.,  1S54. 

Virchow:  Hygroma  cysticum  glutcale  congen.  Virch.  Arch. 
102. 

Virchow:  Die  krankhaften  Geschwiilste,  1SG3. 

Wegner:  Lang.  Arch.,  x\. 

Weil:  Beitriige  Zur.  Keuntniss  der  Angiome,  Prag,  1877 

Angioma  Serpiginosum. — This  rare  cutaneous  dis- 
order was  first  described  by  Mr.  Jonathan  Hutchinson, 
in  his  "Archives  of  Surgery,"  in  1891,  under  the  title 
of  infective  angioma  or  nevus  lupus.  Crocker's 
name,  angioma  serpiginosum,  would  seem  to  be  on  all 
accounts  the  more  appropiate.  But  a  handful  of 
cases,  six  or  seven  in  all,  have  been  reported,  and  it 
may  be  doubted  if  one  or  two  of  these  are  reallyentitled 
to  a  place  in  this  group  Hutchinson  has  also  pub- 
lished a  short  account  of  three  other  cases,  those  of 
Lassar,  Tay,  and  .lamieson.  Besides  White's  case 
one  other,  incompletely  reported,  has  been  described 
in  America,  and  Leslie  Roberts  refers  to  a  case  that 
may  belong  in  this  category,  although  differing  from 
I  he  type  in  many  respects.  Schamberg  has  described 
a  peculiar  progressive  pigmentary  disease  that  offers 
certain    resemblances    with    angioma    serpiginosum. 

In  all  the  cases  thus  far  reported  the  affect  ion  began 
in  early  life,  in  four  of  them  before  the  age  of  two  years. 
Small  bright  red  papules;  firmly  seated  in  the  skin,  are 
the  first  manifestations.  These  papules  do  not  dis- 
appear on  pressure,  and  have  been  likened  to  Cayenne 
pepper  grains.  They  increase  in  size  slowly,  and 
may  reach  the  size  of  a  pea,  when  central  involution 
occurs,  while  the  edges  continue  to  spread  so  that 
circinate  figures  are  produced.  Outside  these  circles, 
small  new  lesions,  called  satellites  by  Hutchinson, 
are  continually  making  their  appearance,  which  also 
enlarge  and  undergo  central  involution  so  that  new 
rings  are  formed,  which  may  unite  with  the  original 
ones.  There  is  no  apparent  atrophy  in  the  central 
part  that  has  undergone  involution,  but  in  White's 
case  there  was  a  dull  pigmentation  in  this  portion. 
In  none  of  the  cases  thus  far  reported  has  there  been 
any    breaking    down   or    ulceration    of    the   papules. 


435 


Angioma  Serpieinosum 


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In  Hutchinson's  cases  the  lesions  were  situated  on 
the  back  of  the  arm,  spreading  upward  to  the  shoulder 
and  downward  below  the  elbow.  In  the  other  cases, 
the  arm  and  side  of  the  thorax,  the  face  and  upper 
extremity,  and  the  lower  extremity,  have  been  the 
portions  affected. 

White's  case,  which  was  seen  and  studied  by  the 
writer,  concerned  a  boy  of  twelve  years,  who  had 
always  been  delicate  and  of  a  very  nervous  tempera- 
ment. At  birth  a  semilunar  red  mark  was  noticed 
below  the  right  shoulder  blade,  which  increased  very 
slowly  in  an  upward  direction  until  he  was  four  years 
old,  when  another  spot  the  size  of  a  pin's  head  made 
its  appearance  near  the  first  one,  which  gradually 
grew  larger,  and  since  then  other  spots  have  continu- 
ally appeared  and  grown  larger.  When  the  patient 
was  first  seen,  the  affection  formed  a  band  three  inches 
wide,  which  extended  from  the  anterior  edge  of  the 
right  scapula,  about  six  inches  forward  toward  the 
nipple,  and  was  composed  of  about  twenty-four 
different  lesions,  which  varied  in  size  from  a  pin's 
head  to  circular  patches  more  than  two  inches  in 
diameter.  Minute  elevated  points,  of  a  bright  red 
color,  first  made  their  appearance,  which  increased 
slowly  in  size  until  they  were  from  one-eighth  to  one- 
twelfth  of  an  inch  in  diameter.  They  were  of  firm 
consistence,  and  only  partially  disappeared  under  long 
pressure.  Involution  in  the  center  then  began, 
while  the  growth  spread  peripherally,  so  that  circles 
were  produced,  until  by  confluence  with  other  lesions 
near  by  this  shape  was  lost.  The  skin  in  the  center  of 
the  lesions  appeared  normal  except  for  the  presence  of  a 
distinct  pigmentation.  New  lesions  were  continually 
appearing  at  a  little  distance  from  the  older  areas, 
and  in  one  or  two  instances  small  foci  were  apparent 
in  the  old  central  portions.  The  anterior  group  of 
lesions,  some  seven  or  eight  in  number,  were  at  one 
time  destroyed  by  the  Paquelin  cautery.  Pale  cicatri- 
cial tissue  was  formed  at  the  site  of  the  cauterization, 
and  it  looked  as  if  the  operation  was  successful,  but 
after  a  time  the  lesions  appeared  on  the  borders  of 
these  scars,  and  the  original  condition  was  produced. 
In  this  case  there  was  the  greatest  sensitiveness  to 
slight  pressure  upon  the  affected  region,  but  it  is  not 
improbable  that  this  was  due  to  the  extreme  nervous- 
ness and  fear  of  the  patient.  There  was  also  some 
itching  complained  of. 

The  only  careful  histological  examination  that  has 
been  made  of  this  remarkable  disorder  was  that  of 
White's  case.  A  typical  lesion  was  excised  and  one- 
half  was  studied  by  Darier  of  the  St.  Louis  Hospital, 
Paris,  and  the  other  half  by  Councilman  and  the 
writer.  Microscopically,  the  epidermis  and  the 
epithelial  appendages  of  the  skin,  such  as  the  hair 
follicles  and  sweat  glands,  were  unaltered.  The 
lesion  was  characterized  by  groups  of  cells  throughout 
the  corium,  which  were  fairly  well  circumscribed,  and 
ran  in  their  general  arrangement  parallel  to  the  surface 
of  the  skin.  They  were  sometimes  round,  but  more 
often  elongated  in  shape,  and  sometimes  extended 
out  in  long  ribbon-like  masses,  which  seemed  to  be 
formed  by  a  coalescence  of  neighboring  groups.  The 
papillary  layer  of  the  corium  was  only  here  and  there 
invaded  by  the  process.  Under  a  high  power  the 
nuclei  were  seen  to  be  oval  in  form  with  a  general 
direction  parallel  to  the  course  of  the  mass.  They 
were  surrounded  by  a  small  amount  of  protoplasm, 
and  the  boundaries  of  the  individual  cells  could  not 
always  be  distinctly  made  out.  The  cells  of  all  the 
groups  were  arranged  in  smaller  groups  or  clumps, 
concentric  in  form,  and  in  the  center  a  lumen  could 
sometimes  be  seen,  showing  their  connection  with  the 
vessels  of  the  skin.  There  were  also  various  changes 
in  the  vessels,  consisting  in  a  swelling  and  proliferation 
of  both  endothelial  and  perithelia!  cells.  A  striking 
feature  was  the  presence  of  small  granular  masses 
here  and  there  in  the  cell  groups,  which  showed  no 
definite  structure,  and  which  were  evidently  produced 


by  a  degeneration  of  the  cells,  as  there  was  every 
gradation  from  slightly  granular,  poorly  staining  cells 
to  a  total  necrosis.  In  some  places  the  cell  groups 
were  situated  about  spaces  and  fissures  which  evi- 
dently corresponded  to  lymphatics.  Taken  as  a 
whole,  the  process  is  evidently  one  connected  with  the 
vessels  of  the  skin,  affecting  certain  groups  of  vessels 
notably  the  blood-vessels.  It  seems  to  begin  by  a' 
proliferation  of  the  endothelium  of  the  vessels  accom- 
panied also  by  a  proliferation  of  the  perithelium 
which  is  followed  later  by  a  degeneration  and  necrosis 
of  the  central  cells.  There  is  apparently  no  com] 
new  formation  of  blood-vessels.  Histologically,  the 
growth  is  to  be  compared  to  an  angiosarcoma,  and 
its  cause  is  possibly  that  underlying  tumor  formation 
in  general,  and  due  to  some  congenital  condition  of  the 
vessels.  Darier,  from  his  investigations  of  the  case 
in  question,  proposes  the  name  Sareome  angioplas- 
tique  reticule.  He  considers  that  we  have  to  do  with 
a  peculiar  form  of  sarcoma  which  is  not  massed  to 
form  a  single  tumor,  but  has  a  reticulated  structure 
following  the  vessels  of  the  skin,  and  that  there  i-  a 
tendency  to  form  clusters  of  capillaries,  approaching 
in  this  way  the  characteristics  of  a  true  angioma. 
He  refers  to  the  fact  that  in  some  of  the  soft  nevi  cell 
forms  are  found  very  similar  to  those  of  this  ca  i 

The  number  of  reported  cases  of  this  disease 
small  to  warrant  any  general  conclusions  as  to  its 
course.  In  Hutchinson's  case  there  was  a  recurrence 
of  the  growth  after  cauterization.  In  White's  case 
the  nodular  infiltration  made  its  appearance  in  the 
normal  skin  beyond  the  scar  left  from  cauterization. 
This  patient  was  seen  six  years  later,  when  he  had 
reached  the  age  of  eighteen.  There  had  been  some 
treatment  by  cauterization  in  the  meantime,  and 
again  the  appearance  of  lesions  jumping  over  the  part 
treated,  to  reappear  beyond  the  cicatrix  in  the  sound 
tissue,  was  seen.  There  had  been  no  breaking  dowa 
in  any  part,  and  on  the  whole  it  seemed  as  if  the  proc- 
ess was  gradually  becoming  less  active.  When  last 
seen,  several  years  later,  the  process  had  undergone 
still  further  involution. 

Treatment  of  this  affection  has  thus  far  proved 
most  unsatisfactory.  Caustics  or  excision  may  con- 
vert the  territory  occupied  by  the  lesions  into  a  cica- 
trix, but  hitherto  they  have  failed  to  stop  the 
peripheral  spread  of  the  disorder,  and  sometimes  new 
lesions  have  recurred  in  the  scar  tissue  itself.  Elec- 
trolysis applied  along  the  edges  that  are  progressim; 
has  been  advocated,  but  no  successful  results  from 
this  or  any  other  method  of  destruction  have  been 
reported.  John  T.  Bowen. 


Angioneurotic  Edema. — This  condition  is  better 
described  as  acute  circumscribed  edema  [Quincke], 
since  such  a  name  makes  no  attempt  to  explain  the 
phenomena  on  the  basis  of  a  hypothetical  vascular 
neurosis. 

The  more  striking  skin  edemas  were  described  as 
early  as  1778  by  Salpertus.  Erichton  in  1801  also 
observed  them,  and  Graves,  who  gave  such  an  excel- 
lent outline  of  exophthalmic  goiter  in  184S  described 
a  patient  with  localized  swelling  of  the  face,  forehead, 
and  eyes,  in  whom  the  edema  persisted  only  a  few 
hours.  Various  aberrant  localizations  have  bei  n 
reported,  often  under  different  names.  Naturally 
hysteria  bulked  large  in  the  diagnosis  in  the  earlier 
days.  Other  synonyms  indicate  under  what  dif- 
ferent rubrics  it  was  grouped:  Urticaria,  urticaria 
redematosa,  urticaria  tuberosa,  giant  urticaria,  all 
indicate  where  one  should  search  the  early  literature, 
further,  one  finds  rheumatic  edema,  arthritic  edema, 
repeating  rheumatic  edema,  intermittent  rheumatic 
edema,  neuroarthritic  edema,  in  the  period  when  the 
cases  would  be  grouped  among  the  rheumatisms, 
etc.  Then  again,  under  the  influence  of  the  edema 
concept,  we   find    wandering   edema,  non-inflamma- 


436 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Angioneurotic  Edema 


tory    edema,    transient     swellings,    local     transien< 

na    intermittent    edema,    etc,    etc.     Quincke 
ISS2  described  it  as  acute  circumscribed  skin  edema, 
,  |u-[e   in   a    Kiel    dissertation,    one   of   his   students, 
Dinkelacker,  broughl  together  many  of  the  older  de- 
scriptions  in  I  showed  the  unity  of  several  apparently 

dissimilar  pr .     He  termed  it  acute  edema. 

Since   Quincke's    time    a   large   bibliography    has 
accumulated,  must  of  which  is  to  be  found  in  Cassi- 

\  i  omotorisch-trophischen    Ne q,    second 

dition,   1912.     A  few  of  the  papers  in    English   are 
Bannister,  Journal  of  .Vervi  ' 

1894;     Bramwcll,    Clinical     Studies,     1907; 
i  f   the    Mt  dical     - 
1892  Kohn,      I  U  ■ ,     1901; 

Medicine. 

OCCURRENCE. — The   disorder  is  not   frequent,   yel 
nol  rare.     Men  and  women  appear  about  equally 
nvolved.     It    may   be   present   in   young   children— 
i    one-half    months,    Crozier,    Griffith;    three 
months,    Dinkelacker.     Alter  forty  it   appears  very 
•arely  as  an  initial  development,  although  in  affected 
ndividuals  it  may  persist  until  late  in  life.     Cas 
.-,.,1  cases  in  persons  oi   seventy-nine  and  sixty- 
urs   in  which  the  disease  appeared  compara- 
ite  in  life.     Raven  reports  a  case  in  a  woman 
ighty-six. 
Etiology. — Occupation  apparently  plays  no  role. 
idity  on  the  other  hand  is  conspicuous.     Many 
luthors  have  mentioned  this  feature.     Osier's  family 
;     been   freely  cited.     Ensor  reports  a  family 
if    eighty     members      with      thirty-three      aff' 
ndividuals,  twelve   of   whom   died  of  edema  of  the 
glottis. 

-    nilar  hereditary  features   an?   reported   by   sev- 
ral    observers.     The    question    of    its    transmission 
been  completely  cleared  up.     In  Apert  and 
Delille's  families  only  the  males  were  affected,   but 
:his  does  not  seem  to  be  the  rule. 
In  many  families,  similar  types  of  localized  edema 
ail  in  the  members,  while  in  others,  apparently 
nore  often,  all  of    the    possible  variants    disappear. 
;  I  ervous  system  involvements  appear  associated 
n  many  of  the  families:  how  much  of  this  is  largely 
^incidence,   how   much   general   neuropathic   causal 
bionship  is  difficult  to  determine  from  the  studies 
it  hand.     Much  depends  on  the  point  of  view  of  the 
ndividual,    whether   he    sees   a   relationship   of   the 
s  with  those  of  epilepsy,  migraine,  chorea,  gout, 
manic  depressive  insanity,  paresis,  etc.,  all  of  which 
lave  been  swept  into  the  hereditary  net.     Some  fami- 
show  no    heredity  factors  of    any  recognizable 
kind. 
In  the  search  for  etiological  factors,  much  industry 
been  evidenced,  and  the  disease  has  been  reported 
having  either  direct  or  concomitant  relationship 
with  acute  articular  rheumatism,  alcohol  poisoning, 
■arbon     monoxide     poisoning,     tobacco     poisoning, 
ating  of  fish,  oysters,  and  mushrooms,  and  malaria. 
ll   has  been  found  very  frequently  in  certain  places 
in  Lower  Sehleswig  where  Lowenheim  has  reported 
HO    cases    in    the    neighborhood    of    Liegnitz.     No 
family   tree   search   was    made,    and   this   author   is 
in-lined    to    make    certain    climatic   factors  respon- 
sible— damp  swampy  localities,  with  the  heat  of  July 
and  August.     Eschweider  has  reported  its  frequent 
irrenee  in  Diisseldorf   prison  where    certain    pas- 
tilles were  made. 

The  disease  infrequently  shows  itself  in  relation 
to  organic  nervous  diseases — tabes,  myasthenia 
gravis,  spinal  cord  tumor,  exophthalmic  goiter,  myx- 
na,  paraplegia — while  it  seems  very  frequently 
iciated  with  many  so-called  functional  neuro- 
pathic states — hysteria,  neurasthenia,  tics,  compul- 
sion neuroses,  migraine,  etc. — and  in  certain  psy- 
chotic individuals  with  schizophrenia,  manic  depres- 
sive psychosis,  idiocy,  amentia,  etc. 


Local  traumata  play  a  rule  at  limes,  particularly 
in  determining  the  location  of  the  swelling.  Emo- 
tional shock  seems  to  bulk  large  aa  a  direct  etiological 
in  tor,  as  does  also  the  action  of  thermal  influei  i 

Cold    is    very    frequently    an    exciting    factor    in    the 
reaction.      Menstrual    facto)        eem    to  enter  into   the 
i  iology  of  certain  cases. 
A    moment's    reflection    therefore   will    show  that 

under   the    term    Acute    Circumscribed    Edema    one    is 

dealing    with    phenomena    of    greal    variability  and 
multiform  pathogeny.     In  discussing  the  patholo 
a  return  will  be  made  to  this  many  Bided  etiology. 

Symptomatology. — The  original  conception  of 
Quincke  lias  been  much  employed,  and  Cassirer  in 
his  Large  monograph  shows  the  present  day  trend  to 
include  a  large  number  oi  is  o       sweUings 

within  tin  cal  group.     Thus  one  distingui 

localized   edema   of   the   skin,   edemas   of    the    mucous 

ol  thi   eyelids,  mouth,  glottis,  esophagus, 
stomach,  i  respiratory  tract:  i  the 

joints,  of  the  tendinous  aponeuroses,  possibly  of  the 
kidneys,  with  polyuria,  albuminuria,  hemoglobinu- 
ria, diminished  secretions,  etc. 

The  onset  is  usually  acute,  with  some  initial  pro- 
dromal signs  of  malaise,  fatigue,  chilliness,  anorexia, 
nausea,  and  slight  rise  in  temperature. 

A  .  This  is  localized, 

variable  in  size,  at  times  small,  resembling  urticarial 
blotches  (intermediary  forms  but  usually  as  distinct 
swellings,  with  an  elastic  feel,  and  due  to  a  local 
accumulation  of  clear  colored  serum  within  the  skin. 
The  color  of  the  swelling  is  usually  that  of  the  skin, 
or  paler,  rarely  red  or  reddish.  The  swelling  comes 
on  with  great  rapidity,  a  few  moments  only,  and 
remains  a  few  hours,  mostly  a  few  days,  and  then 
disappears  without  leaving  any  trace.  It  is  as  a 
rule  non-irritating,  painless,  and  causes  only  a  dis- 
comfort due  to  tension.  Certain  cases  show  burning, 
itching,  and  intense  pain. 

The  size  of  the  edematous  patches  varies  greatly. 
At  times  very  small — one-half  inch — they-  are  more 
apt  to  be  three  to  four  inches  in  diameter,  or  at  times 
involve  the  larger  part  of  a  limb.  The  scrotum  may 
at  times  swell  up  to  the  size  of  a  foot-ball.  The  penis, 
in  cases  reported  by  Bonier,  has  swollen  to  double 
its  diameter.  The  entire  body  was  swollen  also  in  a 
remarkable  case  reported  by  Diethelm.  At  times 
swellings  are  numerous,  polymorphous,  semi- 
confluent.  They  rarely  rise  more  than  one-fourth 
to  one-half  centimeter,  but  two  to  four  inch  swellings 
above  the  skin  are  reported.  The  margins  of  the 
sw-ellings  are  usually  sharply  circumscribed,  but  at 
times  may  shade  off  imperceptibly  into  normal 
anas.  Circular  or  sausage  shaped  are  the  usual 
descriptions  of  the  swellings.  The  swellings  invade 
almost  any  layer  in  the  skin,  or  musculature  or  even 
appear  periosteal.  Some  have  been  termed  pseudo- 
lipomas. 

The  consistency  is  semi-hard,  non-pitting,  or  slightly 
so.  The  color  as  stated  is  usually  that  of  the  normal 
skin,  or  it  may/  be  paler,  or  have  a  cadaveric  hue. 
Again  it  is  pinkish,  to  red,  or  even  deep  red.  Often 
the  color  disappears  on  pressure.  The  color  may 
change  during  the  rise  of  all  the  swelling. 

Local  temperature  varies.  At  times  the  skin  is 
colder,  again  it  is  warmer  than  that  of  the  non- 
affected  parts.  Exact  studies  are  wanting.  It 
seems  not  unlikely  that  there  is  an  initial  increase 
in  the  local  temperature. 

S<  nsory  changes  are  not  present  as  a  rule.  Certain 
cases  have  shown  preliminary  neuralgic  twinges,  no 
perceptive  sensory  defect  has  been  noted,  but  refined 
methods  of  examination,  such  as  those  demanded 
by  Head,  have  not  yret  been  made.  There  is  fre- 
quently the  subjective  sense  of  great  discomfort, 
especially  in  marked  swellings  about  the  face. 

There  are  rarely  any  residuals,  although  occasion- 


437 


Angioneurotic  Edema 

ally  scaling  or  peeling  has  been  observed,  probably 
for  the  more  superficially  lying  edemas. 

Si  cretory  symptoms  have  not  been  carefully  recorded. 
Local  hyperhidrosis,  dermatographia,  increased  tear 
secretion  have  been  noted.  • 

The  location  of  the  swelling  may  be  almost  any- 
where, it  cannot  be  said  that  one  place  more  than 
another  is  a  favorite  site  (statistically).  Exposed 
portions  of  the  body  seem  to  be  more  often  involved, 
but  when  it  is  on  the  hands  or  arms,  the  distribution 
is  not  of  the  glove  type,  nor  are  the  swellings  apt  to 
be  symmetrical,  nor  docs  there  seem  to  be  any 
radicular  or  spinal  distribution.  There  is  a  distinct 
tendency  for  a  recurrence  of  the  edema  to  occupy  a 
position  involved  during  a  former  attack. 

Periarticular  swelling  constitutes  a  peculiar  type, 
so  do  also  parotid  and  salivary  gland  edemas. 

The  mucous  membranes  are  frequently  involved 
The  lips,  mouth,  soft  palate,  tongue,  pharyngeal 
pillars,  nasal  membrane,  larynx  are  all  sites  of 
election.  The  last  is  particularly  frequent  and 
dangerous  to  life.  In  these  cases,  other  structures 
than  the  larynx  are  implicated,  especially  the  epi- 
glottis and  closely  associated  structures.  In  the 
larynx  the  mucous  membrane  is  swollen  and  tense; 
the  edema  infiltrates  throughout. 

When  the  larynx  is  involved,  the  symptoms  are 
apt  to  be  very  marked.  There  is  beginning  tickling, 
with  rapidly  oncoming  difficulty  in  breathing,  until 
marked  dyspnea  may  supervene,  with  death,  unless 
intubation  or  tracheotomy  is  performed.  Some  ot 
these  patients  die  within  a  few  hours.  Many  cases, 
on  the  other  hand,  clear  up  in  an  hour,  after  severe 
dyspneic  symptoms.  . 

Edemas  within  the  bronchi  occur  in  perhaps 
twenty  per  cent,  of  the  cases.  They  make  up  a 
certain  percentage  of  the  cases  of  asthma.  Certain 
hay  fevers  possibly  belong  in  this  group.  Lung 
edemas  have  been  described. 

In  edemas  of  the  walls  of  the  stomach,  external 
signs  are  also  usually  present.  There  may  be  inter- 
mittent vomiting,  or  sudden  acute  pains,  anorexia. 
The  attack  may  last  a  few  hours  with  severe  pain, 
and  more  or  less  continuous  vomiting  finally  ot  clear 
or  bile  colored  watery  masses,  marked  thirst,  and 
gradual  disappearance  of  all  of  the  symptoms.  Bits 
of  gastric  mucosa  have  been  accidentally  dislodged 
which  showed  marked  edematous  swelling. 

In  intestinal  localizations  profuse  diarrheas  are 
present,  with  colicky  pains,  meteorismus,  tenderness 
of  the  abdomen,  diminished  urination,  great  thirst, 
and  collapse.  The  diarrheas  are  purely  _  nervous 
diarrheas,  so  called,  and  occur  in  association  with 
other  signs  of  a  circumscribed  edema. 

Rarer  localizations  present  in  the  tendons  have 
been  described,  particularly  by  Schlesinger.  Muscle 
edemas  are  also  rarely  described,  although  it  is  prob- 
able that  they  are  of  frequent  occurrence.  Articular 
edemas  have  been  mentioned. 

Optic-nerve  edema  is  one  of  the  rarer  localizations, 
as  is  also  an  edema  in  the  labyrinth  leading^  to  a 
Meniere  syndrome.  Acute  conjunctival  edema  is  not 
infrequent. 

The  bladder,  kidney,  and  heart  structures  are 
among  the  rarest  localizations.  Meningitis  serosa, 
aphasia,  are  among  some  of  the  more  problematical 
occurrences  reported. 

Prognosis. — In  general  this  is  not  good,  lhe 
tendency  to  laryngeal  localization  must  always  be 
viewed  'with  gravity.  A  great  many  individuals 
have  died  from  edema  of  the  glottis.  Remissions 
are  to  be  expected.  Some  patients  suffer  many  years, 
others,  but  the  minority  it  would  appear,  have  but 
few  attacks.  There  is  some  general  tendency  for 
the  disorder  to  become  milder  as  the  affected  indi- 
vidual grows  older. 

Transition  forma  are  common,  especially  urticana- 
like  eruptions.     Acroparesthesias,   Raynaud-like  at- 

438 


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tacks,  local  asphyxias  of  the  extremities,  paroxysmal 
hemoglobinuria,  acroasphyxia  chronica,  erythro- 
melalgia,  epidermolysis  bullosa  hereditaria,  herpes 
zoster  are  all  affections  with  which  attacks  have 
been  combined,  singly  or  in  groups  of  two  or  three. 
Occasionally  edema,  acroparesthesia,  and  erythro- 
melalgia  may  alternate  in  one  and  the  same  patient. 

Pathogenesis. — Our  conceptions  concerning  edema 
are  undergoing  such  vital  modifications  that  it  is 
■  practically  impossible  to  interpret  the  findings  here 
outlined  along  those  present  day  lines  that  regard  all 
e  lemas  as  cell  phenomena  and  independent  of  the 
mechanical  conceptions  of  stasis,  pressure,  osmotic 
tension  of  the  vascular  and  lymph  vessels,  etc.,  etc. 

In  view  of  these  studies  in  edema  it  is  certain  that 
we  may  look  in  an  entirely  different   direction  than 
vascular  changes  to  account  for  this  series  of  phenom- 
ena.    The  term  angioneurosis  will  then  be  not  at  all 
applicable  to  this  disorder.     Whether  the  studies  of 
Fischer  and  others  in  edema  can    be   brought 
line  here  remains  to  be  seen.     At  all  events  the  sir 
statement  of  this  being  an  angioneurosis  cai 
weight  than  formerly,   and  one  is  tempted  to  look- 
further  I'm-  a  more  adequate  explanation. 

The  study  of  anaphylactic  phenomena,  especially 
as  seen  in  the  so-called  anaphylactic  serum  reactiOl 
or   serum    diseases,  has    offered    suggestive  glimpses 
indicating  certain  analogies  with  the  series  of  chai 
here  outlined.     We  cannot  go  into  these  in  any  detail. 
It  can  only  be  stated  that  precisely  similar  proce    e 
and  appearances  are  found  in  the  serum  reactions, 
and  that  it  is  not  without  profit  to  inquire  more  into 
the  mechanism  of  their  production  in  an  attempt  to 
understand    acute    circumscribed    edema.     Unfortu- 
nately the  mechanisms  of  the  changes  in  the  anaphy- 
lactic reactions  are  still  much  in  the  dark. 

One  of  the  disconcerting  features  of  acute  circum- 
scribed edema,  whether  one  views  it  in  the  light  of 
a  modified  colloid  absorption  reaction,  due  to  ti 
influences  brought  to  the  cells  of  the  deeper  layers  of 
skin,  muscle,  or  mucous  membrane,  or  whether  one 
views  it  as  a  modified  neural  reaction  passing  through 
intermediaries  of  the  vasomotor  system,  which 
in  their  turn  control,  in  some  unknown  way  reciprocal 
tension  relations,  or  chemical  composition  relations,  is 
the  total  irrelevancy  of  the  whole  process  either  to 
vascular  or  to  neural  distributions. 

This  makes  it  all  the  in.  .re  probable  that  there  are  a 
whole  series  of  things  in  so-called  acute  circumscribed 
edema.  It  is  no  unicum,  and  analysis  will  show  that 
a  number  of  different  pathological  processes  may 
underlie  precisely  similar  skin  phenomena. 

Cassirer  adopts  this  view  point,  but  consents  to 
make  only  two  groups  of  cases—  (a)  a  toxic  ante- 
toxic  group,  in  which  the  poison  works  in  some  mys- 
terious way,  which  a  wealth  of  language  can  conceal, 
better  than  it  can  reveal,  and  (b)  a  heredofamilial  m 
constitutional  neuropathic  group,  which  he  regains 
as  intimately  associated  with  instability  in  certain 
parts  of  the  sympathetic  or  vegetative  nervous  sys- 
tem. This  may  be,  he  says,  associated  in  some 
manner  with  modifications  in  the  internal  gli 
secretions.  Here  we  enter  another  dark  portal,  .u 
all  events,  Cassirer  is  loth  to  permit  so-called  angio- 
neurotic edema  to  wander  from  the  neurological  told, 
and  concludes  that  the  disease  is  conditioned— M 
least  his  group  (&)— by  the  lability  of  the  sympathetic 
nervous  system. 

Treatment.— This  is  purely  empirical.  It  con- 
sists first  in  avoiding  all  those  things  which  experi- 
ence has  shown  to  be  liable  to  bring  on  an  attack. 
If  one  has  one  of  the  more  pronounced  tOMC- 
anaphvlaxis-like  reacting  types,  careful  study  must 
be  made  of  all  of  the  patient's  protein  reactions,  and 
attempts  made  calculated  to  eliminate  such  from  J 
diet.  It  seems  plausible  that  it  is  through  the  gas- 
trointestinal canal   that  such   products  gain  entry, 


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Anldro-ls 


particularly  in  food,  yet  some  may  enter  the  respira- 
tory tract.  as  seems  to  be  the  case  in  the  related  hay- 
r  reactions  which  are   known  to  follow  certain 
tacts,    variously   ascribed  to  ragweed,  rose,  hay, 
r  poll, -us,  or  even  the  emanations  from  cattle. 
From   specific  exclusion   of   certain   protein 

.  the  general  hygiene  of  the  intestine.     This 
means  a  sort   of  search  in  the  'lark  10]    mysterious 
ncies  by  chemical  magic.     One  is  justified  not- 
withstanding in  trying  to  bring  about  altered  bowel 
liich   empirically    may   do  some   good, 
when  a  laissez-faire  attitude  seems  to  perpetuate  the 
disturbance.     Naturally    one    should    avoid    cloaca! 
ihould    the    patient    be   of   an   entirely 
different  type,  say,  the  intensely  neurotic  forms  with 
ilial    hereditary    burdens,    and    emotional    shock 
lions. 
Of  the   gastrointestinal   antiseptics  so   called,    few 
are    such.     .Menthol,    saline    laxatives,    carbonated 
careful  dieting  (?)   may  be  found  among  the 
eatises  on  the  subject.     The  taking  of 
a  milk-vegetable  diet  has  been  coincident  with  better- 
t  in  some  individuals  and  coincident  with  retro- 
sion  in  othi 
In  certain  cases  with  associated  toxemias,  such  as 

-..  a  specific  therapy  is  indicated. 
On  the  supposition  that   the  bloi  needed 

ing  up  to  prevent  transudation  through  their 
walls,  also  a  hypothetical  postulate,  apparently  ii 
quate,  such  drugs  as  strychnine,  ergot,  arsenic,  atro- 
pine, morphine  have  been  recommended.  While  all 
of  these  will  bring  about  vasoconstriction  it  is  not 
apparent  whether  they  can  alter  a  hypothetical  tran- 
quility or  not.  Calcium  lactate  is  the  modern 
weapon  for  this  latter.  The  writer  has  not  seen  it 
i  but  it  may  be  of  service  in  preventing 
transudates,  as  such  are  thought  to  be  conditioned  by 
a  diminution  in  the  calcium  content  of  the  body 
plasma  Cassirer  mentions  calcium  chlorate.  At 
all  events  the  vasoconstricting  drugs  have  not  been 
of  any  particular  service  clinically.  Xow  and  then 
they  seem  of  service;  none  has  been  proven  of  pro- 
phylactic value,  which  is  a  stricter  test  of  their  use- 
fulness, since  the  disease  is  so  self-limited. 

In  those  ca  mted  with  laryngeal  symptoms, 

intubation  is  often  necessary — even  tracheotomy. 
There  are  records  of  certain  patients  condemned  to 
the  persistent  tracheotomy  tube. 

In  the  more  strictly  neurotic  type — Cassirer's 
group  (6) — it  is  highly  important  that  they  be  taught 
a  healthy  morale.  The  substitution  of  reasonable 
and  intelligent  actions  for  purely  instinctive  and 
emotional  reactions  must  be  acquired  by  them  if  they 
can  hope  in  any  way  to  control  their  hair-trigger 
sympathetic  nervous  system.  Perhaps  it  was  so 
given  to  them,  defective  and  badly  coordinated;  even 
then  a  rational  pedagogy  will  prove  of  service.  Many 
will  be  helped  by  the  methods  outlined  by  Dubois  or 
Dejerine;  others  will  need  a  psychoanalysis.  Steckel 
has  reported  some  extremely  interesting  and  severe 
asthmatic  cases,  with  pronounced  symptoms  of  cir- 
cumscribed edemas  with  psychoneurotic  combina- 
tions or  complications.  Just  how  the  psychical 
pathways  become  involved  in  these  complex  neuro- 
biochemieal  relations  is  one  of  the  unresolved 
anatomical  problems.  Physiologically  it  is  known 
that  they  do,  as  Pavlov's  dogs  nave  demonstrated, 
and  as  even  the  man  in  the  street  knows  through  the 
profound  disturbance  of  his  bodily  functions  which 
may  be  brought  about  by  emotional  states  having 
perhaps  only  mental  representations,  memories,  as 
their  foundation.  Smith  Ely  Jellifie. 


Angiostomidse. — A  family  of  nematode  worms 
which  manifest  in  development  the  alternation  of  two 
types  of  sexual  generations,  of  which  the  first  is  free 
and    dioecious,    while    the     second    is    parasitic,    of 


different    structure  and  hermaphroditic.     The   genus 
Strongylaidea  is  found  in  the  intestine  of   man. 

oda.  A   S    P 


Anguillula. — A    genus    of    nematode    worms.     A. 
aceti   lives   in    vinegar   and    paste;    tin  has 

occasionally  b.  i  in  the  urine  of  man 

oda.  A   S.  P. 


Anguillulidc-e. — A   family  of   mi  orms,   for 

the  most    part   small  and  free  living.      The  esophagus 

usually  ha-  a  double  swelling,  or  two  "bulbs."     Many 
es  live  in  humus  or  decaying  matter,  other-  live 
on  or  in  plant-:  some,  such  ::      I  /.;  aceti,  \ 

in  vinegar,  paste, and  urine,  live  inorganic 
fluids.     See  A>  matoda.  A   s.  P. 

Angustura. — See  Cusparia. 

Anhalonium.— See  Mescal  Buttons. 

Anidrosis. — Anidrosis  in  the  usual  meaning  of  the 
term    denotes    a    disturbance    of    the    function    of    the 

piratory  glands  in  which  their  secretion  is  . 
absent      or      materially      diminished.      Under 
circumstances  tin-  skin  is  dry  and  harsh,  more  oi 
pruritic,  and  inclined  to  crack  or  fissure.      Cold  le 
the  amount  of  perspiration  and  heat  increases  it.  and 
this  increase  or  diminution  in  the  amount  of  sweat  is 
also  influenced  by  certain  drugs  which  may  be  readily 
called  to  mind.     The  close  connection   between  the 
several  functions  of   the   kidneys,    bowels,   and   skin 
may   al-o  lie   mentioned.      Certain   persons   normally 
sweat  but  little,  even  under  conditions  that  ordinarily 
provoke  the  secretion,  as,  for  example,  in  the  Turki>ii 
bath. 

Anidrosis  is  usually  symptomatic,  and  is  accord- 
ingly observed  in  connection  with  some  general  or 
local  pathological  condition.  A  general  diminution 
of  sweat  is  frequently  seen  in  diabetes  mellitus  and 
insipidus,  and  in  the  states  of  malnutrition  dependent 
upon  tuberculosis  and  the  cancerous  cachexia, 
ating  is  apparently  absent  in  the  patches  of 
anesthetic  leprosy  and  in  localized  areas  in  sclero- 
derma, psoriasis,  and  eczema.  The  ichthyotic 
notably  suffer  in  this  way.  Aubert  has  made  an 
extended  study  of  the  secretion  of  sweat  in  various 
diseases  of  the  skin,  to  which  the  curious  reader  may 
be  referred  {Ann.  de  derm,  et  de  syph.,  tome  ix., 
ls77-78).  The  association  of  anidrosis  with  various 
disorders  of  the  nervous  system,  and  as  following 
direct  nerve  injury,  etc.,  may  also  be  referred  to  in 
this  place.  Lastly,  deficient  perspiration  may  be  due 
to  simple  mechanical  plugging  of  the  sweat  ducts, 
the  result  of  uncleanliness.  Kaposi  declares  that 
there  is  no  absolute  anidrosis,  the  insensible  perspira- 
tion  never  becoming  abolished.  This,  he  states, 
becomes  noticeable  as  a  fluid  secretion  whenever  the 
skin,  however  dry  it  may  feel,  or  even  if  affected 
with  one  of  the  dry  dermatoses  (psoriasis,  ichthyosis, 
prurigo),  is  covered  with  some  material  that  prevents 
evaporation.  It  is  certainly  true,  however,  that 
under  certain  circumstances,  and  in  limited  areas. 
the  sweat  glands  may  be  entirely  destroyed  or 
undergo  atrophy  from  a  variety  of  causes,  or  that 
paralytic  conditions  arise  in  consequence  of  nerve 
lesions  due  to  the  presence  of  new  formations  (Geber). 
Persons  with  abnormally  dry  skins  are  probably 
more  subject  than  others  to  inflammatory  reactions 
and  to  pruritus,  especially  the  type  of  itching  known 
as  pruritus  hiemalis. 

The  prognosis  and  treatment  must  be  based  upon 
the  character  of  the  primary  cause.  In  a  general  way 
it  may  be  said  that  the  skin  should  be  stimulated  by 
warm  alkaline  baths  and  massage.  Pilocarpine  gives 
only   temporary  relief.     Cod-liver  oil  and  glycerine 


439 


Anidrosis 


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are  often  prescribed  in  considerable  doses.  Unna 
recommends  arsenic  and  ichthyol  separately  or 
together.  Five  lubrication  with  fats  gives  much 
comfort  in  ichthyosis.  William  A.  Hardaway. 

Anidrotics. — See  A  ntisudorifics. 

Aniline. — Aniline  oil,  phenylamine,  amidobenzol, 
C.II.H.N.  Aniline  is  an  aromatic  amine  presenting 
itself  us  a  thin,  oily,  volatile,  inflammable,  colorless 
fluid  of  a  vinous  odor  and  hot,  aromatic  taste.  It 
dissolves  only  very  slightly  in  cold  water,  but  freely 
in  alcohol,  ether,  and  fixed  and  volatile  oils.  It  is 
scarcely  used  in  medicine,  but  its  compounds  are  much 
employed  both  in  medicine  and  the  arts,  and  its 
repeated  handling  or  inhalation  results  in  poisonous 
effects. 

The  most  striking  effect  seen  in  aniline  workers  is 
cyanosis,  due  partly  to  methemoglobin  and  partly  to 
oilier  changes  in  the  blood.  It  is  believed  that  pig- 
ment granules  in  the  red  corpuscles,  or  free  in  the  blood, 
are  contributory  to  the  bluish  color  of  the  skin. 
The  cyanosis  is  identical  with  that  produced  by 
acetphenetidin  (phenacetin),  and  the  appearance  in 
the  urine  of  para-amido-phenol  both  from  this  sub- 
stance and  from  aniline  shows  the  close  relation  be- 
tween the  two  chemicals.  Following  the  appearance 
of  the  cyanosis  there  may  be  a  subnormal  temperature, 
shallow  respiration,  prostration,  and  even  convulsions 
and  coma.  The  drug  may  be  detected  in  the  breath 
by  its  odor. 

Chronic  poisoning  shows  in  anemia,  wasting,  loss  of 
appetite,  constipation,  lack  of  energy,  headache,  skin 
eruptions,  or  sometimes  itching  of  the  skin  without 
eruption. 

Aniline  is  sometimes  used  as  a  solvent  for  the  pure 
alkaloid,  cocaine,  for  use  in  the  external  ear,  the  usual 
watery  solution  of  the  hydrochloride  of  cocaine  being 
unable  to  penetrate  the  epithelium  and  therefore 
useless.  W.  A.  Bastedo. 


Anilipyrine. — This  drug  is  a  combination  of  one 
equivalent  of  acetanilide  with  two  equivalents  of 
antipyrine,  and  it  appears  as  a  crystalline  white 
powder  which  is  fairly  soluble  in  water.  It  combines 
the  antipyretic  and  analgesic  properties  of  its  com- 
ponents, and  is  claimed  to  be  less  toxic  than  either. 
Its  dose  is  gr.  v.  to  x.  (0.3-0.6). 

W.  A.  Bastedo. 


Animal  Experimentation. — The  Beginnings  of 
Experimental  Medicine. — Although  Galen  had 
studied  functions  of  nerves  by  deliberately  planned 
experiments,  although  centuries  later  Harvey  had 
"frequent  recourse  to  vivisections"  in  studying  the 
circulation,  and  although  Hooke,  Hales,  and  Hunter 
had  proved  the  value  of  the  experimental  method  in 
biology,  the  method  was  little  used  in  the  elucidation 
of  medical  problems  until  about  the  middle  of  the 
nineteenth  century.  Until  that  time  disease  had  been 
studied  mainly  by  observation  of  the  sick.  This 
observation  had  led,  to  be  sure,  to  various  theories 
regarding  the  nature  of  the  causes  of  disease,  such  as 
miasms,  the  influence  of  stars,  mysterious  humors,  and 
vitiated  air,  but  these  notions  were  not  put  to  test  in 
any  rigorous  fashion.  Methods  of  treatment  were 
founded  on  these  ill-supported  notions,  and  on  the 
experience  of  persons  who  tried  on  human  beings, 
quite  irrationally,  all   manner  of  curative  measures. 

By  tl bservational  method  alone  medicine  had  made 

only    slight    progress    in    many   hundreds   of   years. 

The  reasons  for  the  failure  to  test  experimentally 
the  notions  regarding  disease  were  many.  In  the 
first  place  the  experimental  method  appeared  late  in 
Western  Europe,  even  in  sciences,  such  as  chemistry 
and  physics,  in  which  it  is  readily  applied.     And  in 


biology  the  difficulties  of  experimentation  were  so 
great  and  the  problems  to  be  unravelled  were  so  com- 
plex that  the  application  of  the  experimental  method 
lagged  far  behind  its  application  in  chemistry  and 
physics.  The  lack  of  a  satisfactory  general  anes- 
thetic and  of  methods  for  recording  with  exactness 
the  rapid  changes  in  living  organisms  were  also 
obstacles  to  progress  in  experimentation  in  biology. 

It  is  perhaps  significant  that  the  greatest  impetus 
to  experimental  medicine  came  from  a  chemist 
Pasteur,  whose  labors  established  new  conceptions 
regarding  the  infectious  diseases.  Fortunately  his 
activities  began  about  the  time  when  ether  and 
chloroform  were  being  introduced  to  abolish  pain  in 
surgical  operations.  As  a  result  of  Pasteur's  ideas 
and  experiments  asepsis  was  devised.  And  nearh 
simultaneously  with  these  profoundly  important  con- 
ceptions and  discoveries,  the  graphic  method  was 
invented. 

Thus  within  a  brief  period,  about  1S60,  a  funda- 
mental and  inclusive  theory  was  propounded,  and  the 
means  were  presented  for  trying  on  animals,  painlessly, 
without  the  complications  of  sepsis,  and  by  exact 
methods,  experiments  which  could  not  justifiably  be 
tried  first  on  men.  Thus  the  era  of  experimental 
medicine  was  initiated.  And  even  in  the  first  fifty 
years  of  that  era  the  progress  in  knowledge  of  organic 
functions,  of  the  causes  of  disease,  and  of  new  methods 
of  treatment  has  surpassed  that  of  the  previous 
twenty-three   centuries  of  medical   history. 

This  extraordinary  advancement  of  knowledge  is 
doubtless  due  to  the  nature  of  experimentation. 
The  essential  characteristic  of  the  experimental 
method  is  such  control  of  the  conditions  affecting  the 
phenomenon  which  is  being  examined,  as  to  permit  an 
analysis  of  the  relations  normally  existing,  or  capable 
of  existing,  between  that  phenomenon  and  others. 
Thus  the  experimenter  deals  constantly  with  factors 
controlling  or  modifying  the  appearance  or  disappear- 
ance of  phenomena.  And  as  the  problems  of  medicine 
are  precisely  problems  of  control,  the  results  of 
experimental  study  have  often  been  immediately 
practical. 

The  Opposition  to  Animal  Experimentation. — 
In  spite  of  the  benefits  to  man  and  to  lower  animals 
which  have  resulted  from  the  application  of  the  ex- 
perimental method  to  medical  problems,  strong 
hostility  to  this  method  of  studying  disease  is  felt  by 
persons  who  designate  themselves  as  "  antivivisec- 
tionists."  Their  hostility  to  the  use  of  animals  for 
medical  research  is,  in  the  main,  based  on  two  assump- 
tions: (1)  that  pain  is  commonly  inflicted  on  animals 
in  laboratories  to  a  degree  too  horrifying  to  be  en- 
dured, and  (2)  that  no  good  to  man  has  come  or  can 
come  from  studies  of  lower  animals.  In  support  of 
the  assumption  that  great  pain  attends  animal 
experimentation  they  circulate  widely  leaflets,  pamph- 
lets, and  letters,  in  which  they  reveal  that  they  are 
quite  ignorant  of  the  methods  they  denounce,  that 
they  are  incapable  of  interpreting  intelligently  tin' 
technical  writings  of  the  investigators,  and  that  they 
let  imagination  play  uncontrolled  in  describing  places 
they  have  never  visited  and  procedures  they  have 
never  witnessed.  In  support  of  the  assumption  that 
animal  experimentation  is  futile,  they  quote  the 
hostile  statements  of  medical  men  long  since  dead, 
or,  ignoring  the  overwhelming  testimony  of  practical 
experience  and  the  consensus  of  medical  opinion 
throughout  the  W'orld,  they  cite  the  words  of  so 
unknown  person  possessed  of  a  medical  degree  and 
desirous  of  that  prominence  which  comes  to  one  who 
claims  that  the  earth  is  flat  or  the  sky  a  great  inverted 
bowl. 

However  well-meaning  the  motives  of  the  antivivi- 
sectionists  may  be,  the  literature  which  they  send 
broadcast  has  for  years  been  characterized  by  fraud, 
trickery,  and  evil  insinuation.     These  misstatements 


440 


REFERENCE    BANDBOOK    OF   THE    MEDICAL   SCIENCES 


Animal  Experimentation 


l,.n,.    been    repeatedly    pointed    out,    bul    with    no 
,  ,'|,.,.t.     in  this  respect  the  English  antivivisectionists 
are  like  the  American.     The  English  Royal  Commis- 
sion, which  reported  in  L912,  after  five  years  of  study 
and  consideration  of  the  subject,  declared  of  the  anti- 
vivisectionists   of    England    thai    their    "harrowing 
descriptions  and  illustrations  of  operations  inflicted 
animals,    which    are    freely  circulated  l>y    post, 
ment,  or  otherwise,  are  in  many  cases  calcu- 
lated to  mislead  the  public."     The  active  antivivi- 
sectionists of  both  countries,  therefore,  have  sought 
ough  garbled    statements,  false  evidence  and  in- 
irate   description,    to    give    the    impression    that 
almost    inconceivable  cruelty   is  involved   in  animal 
experimentation,  and  that  the  attempt  to  avoid  pain 
premature  death  by  animal  experimentation  is 
in  the  higl  ee  futile. 

Not    all   antivivisectionists  take  exactly   this  view. 
Seine    anion;;    them    have    been    SO    impressed    by    the 

evidence  of  benefits  to  man  derived  from  experimental 
thai  they  are  willing  to  grant  these  benefits. 

■  till  assuming  the  invoh  ement  of  great  pain  in  the 
experimental  processes  they  contend  that  the  method 
is  immoral,  that  it  has  a  brutalizing  influence  on  those 
who  use   it.   and   that    it    is   therefore   unjustifiable. 

holder  of  this  view  has  stated  that  he  would  not 
have  one  mouse  painfully  vivisected  to  save  the  great- 
est of  human  beings  or  the  life  dearest  to  him.  In 
short,  intentional  infliction  of  pain  is  a  sin  and  crime, 
and  not  to  be  tolerated. 

views  of  the  opponents  of  animal  experi- 
mentation raise  three  quest  ions:  What  is  the  evidence 
that  animal  experimentation  has  been  beneficial  in  its 
effects?     To  what  degree  is  pain  to  animal-  involved? 

the  use  of  animals  for  experimentation  be 
justified  morally?  These  questions  will  be  dealt 
with  in  order. 

P.F.XEFITS   FROM    ANIMAL   EXPERIMENTATION. The 

evidence  that  animal  experimentation  has  been  bene- 
ficial to  man.  and  to  the  lower  animals  also,  is  found  in 
a  wide  variety  of  results.  It  has  given  understanding 
of  bodily  functions,  insight  into  the  nature  of  many 
diseases,  means  of  cure  based  on  natural  proce^e-. 
for  the  detection  of  infection  and  for  the  quali- 
ties of  drugs,  knowledge  of  the  action  of  important 
new  medicaments,  and  numerous  contributions  to  the 
practice  of  surgery.  This  evidence  is  now  to  be 
a  ted. 
Physiology. — The  first  of  medical  sciences  in  which 
the  experimental  method  was  employed  was  physi- 
ry — the  science  of  normal  functioning  of  organs. 
In  judging  disease  the  physician  is  concerned  with  the 
abnormal  functioning  of  organs.  Necessarily,  there- 
fore, the  judgment  of  the  physician  must  be  based  on 
the  normal  standard  which  physiological  investiga- 
tions have  revealed.  It  has  been  truly  said  that  if 
there  were  taken  away  from  physiological  knowledge 
that  which  is  based  on  experiments  on  animals, 
almost  nothing  would  be  left.  Probably  no  system 
of  organs  in  the  body  more  frequently  requires  earnest 
study  by  the  physician  than  the  circulatory  system. 
Practically  all  that  is  known  of  the  course  of  events  in 
the  heart,  the  proper  interpretation  of  the  cardiac 
sounds,  the  factors  determining  blood  pressure,  the 
nervous  control  of  heart  and  arteries,  the  intelli- 
gent treatment  of  cardiovascular  disease — all  has 
resulted  from  studies  on  animals.  What  is  true  of 
the  circulation  is  true  also  of  digestion.  The  activi- 
ties of  a  succession  of  investigators  who  experimented 
on  animals,  have  revealed  the  changes  which  food 
undergoes  in  each  portion  of  the  alimentary  canal,  the 
nature  of  the  digestive  juices,  the  conditions  under 
which  they  are  poured  out.  and,  to  a  large  degree,  the 
esand  character  of  digestive  disorders.  Similarly, 
through  the  brilliant  researches  of  Sherrington  and 
others,  illuminating  insight  is  being  secured  into 
some  of  the  intricacies  of  the  nervous  system.     These 


and  many  other  notable  contributions  to  physiology, 

which  almost  i  b  1 1 1  \  stir  man's  wonder  at  the  marvcl- 
0US  Organization  Oi  t  he  body,  an'  t  he  direct  OUtCOl if 

operations  on  animals.  It  cannot  be  too  strongly 
emphasized    that    almost    the    entire    structure    of 

physiological  knowledge  on  which  the  modern  physi- 
cian bases  his  judgment     knowledge  which  in   the 

every-day  practice  of  licine  makes  all  tin'  dif- 
ference between  understanding  and  blind  bewilder- 
ment— has  grown  from  the  application  of  the  ex- 
perimental met  hod. 

Parasitic  Origin  of  Infectious  Diseases. — As  already 
stated.  Pasteur  s  ideas  of  the  nature  of  infection  gave 
the  greatest  impetus  to  animal  experimentation,  [s 
1853  his  crucial  discovery  that  the  fungus, Penicilium 
glaucum,  destroyed  dextro-tartaric,  but  not  levo- 
tartaric  acid  indicated  a.  significant  and  peculiar 
relation  between  fermentation  and  living  organisms. 
His  studies  disproving  spontaneous  genera  tii  n  i.  under- 
taken in  I860,  supported  his  views  mi  fermentation. 
And  by  actually  inducing  in  the  healthy  moths  of  silk 
worms,  solely  by  feeding  them  mulberry  leaves,  the 
disease  which  was  threatening  the  destruction  of  the 
silk  industry  in  France,  he  turned  his  ideas  to  practi- 
cal ace,, nut.  simultaneously  saving  France  from  great 
economic  disturbance,  and  bringing  clear  evidence  of 
the  parasitic  origin  of  silk  worm  disease.  The  infer- 
ence was  logical  that  other  diseases  which  spread 
rapidly  as  epidemics  or  epizootics  are  due  to  living 
organisms.  Thus  Pasteur  s  studies  stimulated  num- 
erous other  investigators  to  try  to  find  as  active  agents 
in  infectious  diseases,  microscopic  germs,  or  bactera. 
Through  the  activity  of  these  men  who,  like  Pasteur, 
carefully  tested  their  inferences  by  experiments  on 
animals,  the  parasitic  origin  of  infectious  diseases  be- 
came a  firmly  established  fact.  An  account  of  the 
role  played  by  animals  in  developing  our  knowledge 
of  some  of  the  more  important  of  these  diseases  will 
illustrate  the  value  of  animal  experimentation. 

Tuberculosis. — In  1S43  Klencke  had  demonstrated 
the  infectious  nature  of  "tubercle"  by  inoculating 
rabbits  with  "tubercle  cells"  and  producing  general 
miliary  tuberculosis.  Little  attention  was  paid  to 
these  experiments,  however,  until  Villemin,  in  1S45, 
repeated  and  confirmed  them,  and  thoroughly  proved 
the  infectiousness  of  tubercle  by  reinoculation  from 
animal  to  animal.  Villemin  also  found  that  inocula- 
tion of  other  morbid  material,  such  as  cancer,  pus, 
and  bits  of  pneumonic  lung,  into  rabbits,  did  not  re- 
sult in  tuberculosis,  and  he  inferred  that  the  disease 
was  due  to  a  germ.  Although  other  experiments  on 
animals  involving  injection,  inhalation,  and  ingestion 
tests,  showed  the  danger  from  tuberculous  sputum 
and  milk,  the  identity  of  scrofulous  disease  and 
tuberculosis  in  man,  and  tuberculous  disease  in 
animals  themselves,  and  proved  the  value  of  animal 
inoculations  for  purposes  of  diagnosis,  the  characteris- 
tics of  the  infectious  agent  were  not  known  until 
Koch  reported,  in  1SS2,  his  discovery  of  the  Bacillus 
tuberculosis.  By  rigorously  exacting  procedures — 
the  isolation  of  the  bacilli  in  "pure  cultures,"  the 
production  of  the  disease  in  animals  by  injection  of 
the  pure  cultures,  and  the  recovery  from  the  diseased 
tissues  of  the  injected  animals  bacilli  in  all  respects 
like  those  injected — Koch  brought  conclusive  proof 
that  tuberculosis  results  from  the  growth  of  this  germ  in 
the  body.  Later  (1S90)  through  animal  experiments 
he  demonstrated  the  value  of  tuberculin  as  an  aid  to 
the  early  diagnosis  of  tuberculosis  in  man  and  in 
cattle,  and  proposed  the  tuberculin  test,  as  a  practical 
method  of  eradicating  the  disease  from  infected 
herds. 

Through  animal  experiments  Cornet  (1S90)  proved 
the  danger  of  infection  from  the  dried  sputum  of 
tuberculous  patients.  Through  animal  experiments 
Flugge  (1S99)  showed  the  possibility  of  droplet  in- 
fection from  the  spray  of  saliva  in  violent  coughing. 
Through   animal  experiments  Trudeau   (18S6)   con- 

441 


Animal  Experimentation 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


finned  his  belief  in  the  efficacy  of  dietetic  and  open- 
air  treatment  as  a  means  of  combating  tuberculosis — 
a  treatment  now  everywhere  adopted.  Thus  all  the 
preventive  and  diagnostic  and  curative  measures 
employed  in  the  campaign  against  tuberculosis  are 
the  result  of  experiments  on  animals. 

The  new  knowledge  proved  that  tuberculosis  is 
notinherited,  that  because  infectious  it  is  preventable, 
and  that  in  its  beginnings  it  can  be  cured.  These  facts , 
together  with  the  possibilities  of  early  diagnosis, 
dependent  on  animal  tests,  have  led  to  a  widespread 
hope  that  the  disease  can  be  conquered.  This  hope 
serins  justified  by  the  decline  in  death  rate  from 
tuberculosis  in  various  parts  of  the  world  since 
hygienic  measures  began  to  be  adopted.  During  the 
twenty  years  before  Koch's  discovery  of  the  tubercle 
bacillus  (1SS2)  the  death  rate  from  tuberculosis  in 
Boston  was  forty-two  per  10,000;  during  the  twenty 
years  following  the  discovery  the  rate  gradually  fell 
to  twenty-one  per  10,000 — a  drop  of  fifty  per  cent. 
It  has  since  fallen  to  less  than  eighteen  per  10,000. 
In  New  York  City  the  death  rate  from  tuberculosis 
dropped  forty  per  cent,  between  1882  and  1902.  In 
Prussia  the  death  rate  was  fifty  per  cent,  less  in  100:; 
than  in  18S5.  In  Edinburgh,  after  partial  hygienic 
measures  had  been  enforced,  the  death  rate  was 
seventeen  per  10,000  in  1897;  during  the  following 
decade,  by  cooperation  of  the  agencies  tending  to 
control  the  infection,  the  death  rate  was  reduced  to 
eleven  per  10,000.  These  bare  statistics  imply  an 
immense  reduction  of  mortality  throughout  I  ln- 
civilized  world — a  saving  of  lives,  furthermore,  in 
large  degree  for  the  years  of  service  and  working 
efficiency. 

The  alternative  to  these  great  achievements  has 
been  vividly  stated  by  Trudeau  (1909):  "If  it  were 
not  for  the  knowledge  which  science  has  won  by 
animal  experimentation  in  the  field  of  this  disease 
in  the  last  twenty-five  years,  we  should  still  be 
plunged  in  the  apathy  of  ignorance  and  despair 
toward  it,  ami  tuberculosis  would  still  be  exacting 
its  pitiless  toll  unheeded  and  unhindered." 

Bubonic  Plague.- — The  terror  of  the  Black  Death 
is  well  founded  in  man's  experience  with  the  pesti- 
lence. Defoe,  in  his  "Journal  of  the  Plague  Year," 
in  London,  tells  how  the  streets  became  hushed  as 
the  infection  spread  insidiously  from  parish  to  parish, 
how  the  carts  moved  about  at  night  receiving  the 
heaped  bodies  of  the  dead,  and  how  the  bodies  were 
dumped  pell-mell  and  by  hundreds  into  huge  pits  dug 
for  their  burial.  Thousands  died  week  after  week 
in  London  alone.  What  was  true  of  London  in  1665 
has  been  true  of  every  other  large  population  in 
which  the  plague  has  raged  without  control.  In  one 
year,  1905,  the  number  of  recorded  deaths  from 
plague  in  India  was  1,040,429.  It  has  wrought 
disaster  and  desolation  in  China  and  other  portions 
of  the  orient  in  similar  degree. 

Because  of  increased  knowledge  of  the  disease, 
largely  gained  by  animal  experimentation,  plague  in 
any  well  organized  community  can  be  promptly 
controlled  and  even  eradicated.  Attending  the  large 
increase  in  commercial  relations  with  the  orient, 
epidemics  have  started  in  recent  years  in  several 
great  seaports — Oporto,  Rio  de  Janeiro,  Glasgow, 
Liverpool,  San  Francisco,  Seattle,  and  others — but 
have  been  promptly  stopped  by  radical  measures. 
In  India,  however,  opposition  to  the  sacrifice  of 
animals,  and  in  China  ignorance  and  apathy,  have 
hitherto  prevented  application  of  the  knowledge 
about  plague  which  animal  experiments  have  yielded. 

The  first  step  in  the  conquest  of  the  plague  was 
taken  in  1894  when  Yersin  and  Kitasato,  working 
independently,  discovered  the  Bacillus  pestis.  The 
concomitance  of  an  epizootic  in  rats  and  an  epidemic 
of  plague  had  been  previously  noted,  but  no  causal 
relation  had  been  established  between  the  two.  In 
1898,  Simond  found  that  fleas  placed  on  a  plague- 

442 


infected  rat  drew  blood  containing  the  plague  bacillus 
and  that  these  fleas  transferred  to  a  healthv  rat 
could  transmit  the  disease.  Then  it  was  shown  that 
healthy  rats  and  guinea-pigs  failed  to  take  the 
disease  from  infected  animals,  if  fleas  were  absent. 
Later,  monkeys  placed  in  cages  to  simulate  human 
beings  were  found  infected  by  rat  fleas.  These 
animal  experiments  led  to  observations  on  human 
conditions,  especially  in  India,  which  indicated  that 
the  great  majority  of  cases  of  plague  are  due  to 
infection  of  man  from  rats  through  rat  Ilea-. 

This  knowledge  revolutionized  the  methods  ef 
dealing  with  an  epidemic  of  plague.  When  formerly 
the  prevalence  of  the  disease  was  attributed  to 
climatic  conditions  or  soil  infection,  intelligent 
measures  for  the  suppression  of  the  epidemic  were 
impossible.  Now  rat  traps  are  set,  rookeries  and 
vermin-breeding  hovels  are  torn  down,  and  the 
victims  already  infected  are  isolated  so  that  they 
shall  not  be  the  occasion  for  further  spreading  of  the 
disease. 

The  part  played  by  animal  experimentation  in 
tracing  the  relation  between  the  pneumonic  ami 
bubonic  type  of  plague,  in  assuring  diagnosis,  and  in 
the  development  of  prophylaxis  and  treatment  of 
individual  human  beings  cannot  here  be  considered. 
It  is  sufficient  to  point  out  that  through  the  knowledge 
which  has  been  secured  the  panic  and  terror  formerly 
induced  by  the  Black  Death  have  been  reasonably 
dissipated — a  deliverance  from  bondage  for  which 
mankind  is  indebted  wholly  to  experiments  on  rats, 
guinea-pigs,  and  monkeys. 

Diphtheria. — The  search  of  the  internal  organs  of 
diphtheria  patients  by  Klcbs  (1881)  revealed  no 
constant  presence  of  bacteria.  Two  years  later  he 
demonstrated  small  rod-shaped  bacteria  in  micro- 
scopic sections  near  the  surface  of  the  diphtheritic 
membrane,  but  with  these  were  various  other  kinds 
of  bacteria.  It  was  necessary,  therefore,  to  test 
experimentally  for  the  organisms  which  excite  the 
production  of  the  membrane.  By  feeding  and 
inoculating  various  animals  with  pure  cultures  of  the 
accessory  bacteria,  Loeffler  (1884)  was  led  to  the 
conclusion  that  these  forms  are  of  secondary  import- 
ance. With  pure  cultures  of  the  rod-shaped  bacteria 
Loeffler  was  able  to  reproduce  both  in  guinea-pigs 
and  rabbits  characteristic,  grayish-white,  tough, 
false  membranes.  And  since  the  bacteria  were  found 
only  at  the  seat  of  inoculation,  and  not  in  the  orgs 
the  inference  was  drawn  that  a  poison  produced  at 
the  seat  of  inoculation  must  have  circulated  in  the 
blood.  By  these  experiments  on  animals  the  role 
of  the  Klebs-Loeffler  or  diphtheria  bacillus  in  the 
production  of  the  disease  was  definitely  determined. 

Loeffler's  idea  that  the  general  bodiiy  disturbances 
in  diphtheria  are  due  to  circulation  of  a  soluble 
poison  or  toxin  was  substantiated  by  Roux  and 
Yersin,  who  found  that  filtrates  from  bouillon 
cultures  of  the  Klebs-Loeffler  bacillus  produced  the 
same  changes  in  guinea-pigs  as  were  produced  by 
infection  with  the  bacteria,  and  were  highly  toxic 
in  small  doses. 

By  tests  on  guinea-pigs,  also,  the  identity  of  fatal 
croup  with  diphtheria  was  established,  mild  cases  of 
the  disease  were  discovered,  and  the  bacteria  were 
demonstrated  in  the  throats  of  some  persons  who  had 
recovered  from  the  disease  and  who  as  "bacillus 
carriers"  were  capable  of  innocently  spreading  the 
infection.  Thus  by  animal  experimentation  the 
bacteria  which  excite  diphtheria  were  discovered, 
the  manner  in  which  they  produce  their  effects  was 
indicated,  and  some  of  the  methods  of  extension  of 
the  disease  were  made  clear.  All  this  information 
was  highly  valuable  for  the  intelligent  management 
of  diphtheria  patients. 

More  important  than  these  discoveries,  however, 
was  that  which  gave  insight  into  the  mechanism  of 
immunity.     In  1890  von  Behring  and  Kitasato  found 


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\  niiii.ii  Experimentation 


that    laboratory    animals,    injected    with    weakened 
toxin-,  became  immune  to  doses  of  the  whole  toxin 
that  were  fatal  to  the  normal  animal.     <  H  still  greater 
practical  significance  was  the  demonstration  that  the 
blood  of  the  actively  immunized  animals  injected  into 
normal  animals  would  protect  these  animals  against 
later  injections  of  fatal  doses  of  toxin,  or  would  cure, 
within  reasonable  time  limits,  animals  that   already 
l,.1(|    received    a    fatal    dose.     That    the    toxin    was 
neutralized  by  a  definite  antidote  or  antitoxin   was 
shown  by  mixing  the  toxin  «  it  li  some  of  the  protective 
hi |  or  serum  in  vitro.     The  poison  wa     thus  com- 
ely counteracted,  and  when  the  mixture  was  in- 
ed  it  had  no  harmful  effect  whatever. 
ese  experiments  on  animals  were  t  he  basis  of  the 
antitoxin    treatment    of  diphtheria.     A  horse  is   Ln- 
ed  with  diphtheria  toxin,  and  when  he  has  devel- 
oped in  his  blood  the  maximum  amount  of  antitoxin, 
he  is  bled,  and  the  serum  of  the  blood,  which  contains 
the  antitoxin,  is  prepared  for  use  in  cases  of  diphthe- 
ria.    Thus   the   natural   antidote   to   the   poison   pro- 
duced by  diphtheria  bacilli  is  injected  into  persons 
by    the   disease,   and    the   persons  are   pro- 
nn  the  action  of  diphtheria  toxin  just  as  were 
laboratory  animals  studied  by  von  Behring  and 
Kitasato. 

Antitoxin  is  useful  both  for  the  prevention  and  the 
treatment  of  diphtheria.  Numerous  instance 
been  reported  in  which  diphtheria  has  broken  out  in 
large  institutions,  and  been  promptly  checked  by 
rophylactic  injection.  In  a  large  insane  asylum 
near  New  York  City  an  epidemic  started  in  the  sum- 
mer of  1910.  Many  cases  among  doctors,  nurses,  and 
patients  developed  within  a  few  days  after  the 
discovery  of  the  first  case.  As  soon  as  possible  over 
2,000  members  of  the  institution  were  given  antitoxin 
(1,000  units  each).  No  immunized  person  was  at- 
tacked and  the  epidemic  was  stooped  in  less  than  a 
week. 

When  antitoxin  is  used  for  treatment  of  diphtheria, 
it  does  not  restore  to  a  normal  state  tissues  that 
already  suffered  serious  injur}' — it  acts  solely  as 
a  preventive  of  further  poisoning.  Its  efficiency, 
therefore,  would  be  expected  to  be  greatest  when  it  is 
administered  on  the  first  days  of  an  attack.  Such  is 
the  fact.  In  the  Hospital  for  Contagious  Diseases  in 
New  York  City,  in  218  cases  of  diphtheria  treated  with 
antitoxin  on  the  first  day,  there  were  no  deaths;  in 
1,153  cases  treated  on  the  second  day,  the  death  rate 
was  4.59  per  cent.;  in  880  cases  treated  the  third  day, 
the  death  rate  was  12.50  per  cent.;  and  in  59S  cases 
treated  on  the  fourth  day.  16.4  per  cent.  These 
results  have  been  duplicated  elsewhere,  both  in  in- 
stitutions and  in  private  practice. 

Because  of  the  prevalence  of  epidemics  the  mortal- 
ity statistics  from  diphtheria  for  any  one  city  for  the 
period  of  a  few  years  will  show  variations  which  do  not 
permit  proper  conclusions  to  be  drawn.  By  taking 
the  records  of  death  from  diphtheria  and  "croup" 
from  nineteen  large  American  and  European  cities 
fin  which  records  are  carefully  kept),  from  187S 
(fifteen  years  before  antitoxin  was  introduced)  to 
1908  (fifteen  years  after),  W.  H.  Park  has  largely 
eliminated  these  errors.  Although  marked  fluctua- 
tions of  the  absolute  mortality  per  100,000  population 
occurred  in  the  preantitoxin  years,  in  no  period  did  all 
the  cities  show  a  decrease.  Not  until  1894  did  all  the 
cities  begin  to  show  uniformly  a  decrease  in  the 
mortality  per  100,000.  Furthermore  this  drop  has 
continued  until  the  present — a  betterment  doubtless 
due  to  more  extensive  use  of  antitoxin,  and  to  recog- 
nition of  the  value  of  large  doses  and  of  early  treat- 
ment. In  1894  the  average  mortality  in  these  cities 
was  79.9  per  100,000;  in  1907  it  was  17  per  100,000 
population.  This  difference  is  so  great,  the  time  of 
its  beginning  so  clearly  coincident  with  the  beginning 
of  antitoxin  treatment,  and  the  betterment  of  results 
so  progressive  since  that  time,  that  it  is  difficult  to 


give  any    other  explanation    than    that    the   saving  of 

life  was  due  to  antitoxin. 

Clinical  observati I  p  iti ho  appear  without 

having  had  antitoxin  treatment  indicates  that  there 
ha  been  no  marked  change  in  the  average  virulence 
of  diphtheria  Clinical  experience  has  from  the 
beginning  testified  to  the  remarkable  specific  effect 
which  antitoxin  has  in  checking  the  course  of  the 
di  ease.      Hospitals  for  the  care  of  diphtheria  patients 

througl t     the    world    employ    antitoxin    treatment. 

States  manufacture  antitoxin  and  provide  it   freely 
for  the  inhabitants.     Thus  the  action  ol  individ    > 
and    communities    supports    the    results    of    animal 

experimental  ton. 

In  1894  the  number  of  deaths  from  diphtheria  in  the 
nineteen  large  cities  previouslj  referred  to  was  15,1 25; 
then  the  steady  drop  began,  and  in  1904  the  number 
oi  deaths  was  1,917.     In  ten  pear    there  had  come  a 

red  in  i  i f  more  than  10,000.     This  great    aving  of 

human  lives,  which  is  to  continue  indefinitely,  is  the 
direct    re  ult    of   experiments   on    animals,    and    the 

I  ions  which  horses  have  to  undergo  in  suppl 
antitoxin. 

Epidemic  Cerebrospinal  Meningitis.—  Epidemic 
meningitis  has  in  the  past  brought  consternation  to 
the  laity  becau  e  of  its  mysterious  onset  and  its 
terribL  and  has  brought  distress  to  the  phy- 

sician   n  of  his  helplessness  in  its  presence.     The 

first  step  in  the  conquest  of  the  disease  was  taken 
when  Weichselbaum  discovered,  in  1887,  the  menin- 
ii  cus  which  is  always  associated  with  tin-  disease. 
The  final  practical  -tip  was  taken  in  1906 — 1907, 
when  Flexner  announced  the  effectiveness  of  intradural 
inoculations  of  antimeningitis  serum. 

Attempts  to  use  the  serum  subcutaneously  in 
human  cases  had  previously  been  made  in  Germany, 
but  had  proved  unsatisfactory.  The  reasons  for 
this  failure  appeared  when  the  problem  was  attacked 
experimentally.  Flexner  found  that  the  disease 
could  be  induced  by  injection  of  active  cultures  of  the 
meningococcus  subdurally  in  certain  species  of  lower 
monkeys.  The  antimeningitis  serum  was  found  to 
have  (1)  the  power  of  stopping  the  growth  of,  or 
destroying  outright,  the  meningococci,  (2)  the  prop- 
erty of  increasing  phagocytosis  and  intracellular 
digestion  of  these  bacteria,  and  (3)  the  ability  to 
exert  a  neutralizing  action  on  the  toxic  products  set 
free  by  their  growth  and  disintegration.  Weak 
dilutions  of  the  serum  have  little  or  no  effect,  however, 
in  destroying  the  meningococci — the  serum  must  be 
applied  in  full  strength  at  the  site  of  inflammation. 
When  administered  by  lumbar  puncture  to  monkeys 
sick  with  epidemic  meningitis,  the  inflammatory 
process  was  stopped,  the  meningococci  were  de- 
stroyed, and  the  monkeys  were  quickly  restored  to 
normal  condition.  Furthermore,  no  perceptible  in- 
jurious effect  resulted  from  the  serum  itself. 

By  further  animal  experiments  it  was  proved  that 
injection  of,  first,  heated  and  later,  living  cultures  of 
the  meningococcus  into  a  horse,  the  animal  became 
immunized,  and  his  blood  serum  rich  in  curative 
properties. 

The  mortality  from  this  disease  (in  cases  which 
received  bacterial  diagnosis),  wherever  it  has  been 
studied,  has  ranged  from  sixty-eight  to  ninety-one 
per  cent,  with  an  average  of  about  seventy-five  per 
cent.  It  has  been  highest  in  infants,  ranging  between 
ninety  and  one  hundred  per  cent.  In  1909  Flexner 
analyzed  712  cases  which  had  been  treated  by  the 
antiserum  prepared  under  his  direction.  The  mor- 
tality among  children  under  three  years  of  age  (104 
eases)  was  42.3  per  cent.  From  two  to  fifteen  years 
(326  cases)  it  was  23.4  per  cent.  After  the  fifteenth 
year  it  was  thirty  per  cent,  and  over.  As  in  diph- 
theria, the  mortality  is  less  if  the  serum  is  used  early 
in  the  attack.  In  180  cases  injected  within  the  first 
three  days  the  mortality  was  25.3  per  cent.;  in  179 
patients  injected  between  the  fourth  and  seventh  day 


443 


Animal  Experimentation 


REFEREXCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


it  was  27. S  per  cent.;  whereas  129  injected  later  than 
the  seventh  day  had  a  mortality  of  42.1  per  cent. 
In  seventeen  children  under  two  years  of  age  injected 
within  the  first  three  days  of  the  illness  only  one  died! 
Similar  results  have  been  attained  in  Germany  and 
France  with  serum  prepared  in  those  two  countries. 
In  general  by  methods  <  leveloped  in  animal  experimen- 
tation the  percentages  have  been  reversed — from 
about  seventy-five  per  cent,  mortality  to  about 
seventy-five  per  cent,  recovery — with  a  resultant 
saving  of  fifty  lives  in  every  hundred  cases. 

Besides  the  saving  of  life  there  is  a  noteworthy 
abatement  of  the  symptoms  of  the  disease.  Within 
twenty-four  hours  after  the  serum  is  injected  there  is 
often  a  permanent  return  of  consciousness,  disappear- 
ance of  the  mental  dulness  or  delirium,  removal  of  the 
racking  headache,  relief  of  the  hyperesthesia,  control 
of  the  vomiting.  "To  see  patients  pass  within 
twenty-four  hours,  after  one  or  two  injections  of  the 
scrum,  from  a  state  of  great  distress  or  unconscious- 
ness to  one  of  almost  normal  mentality  is  something 
the  impressiveness  of  which  is  not  easily  to  be  over- 
estimated." (Dunn).  When  one  considers  that 
epidemic  meningitis  is  an  infection  tending  to  a  fatal 
termination  or  to  a  prolonged  course  with  frequent 
relapses,  this  rapid  change  (about  twenty-five  per 
cent,  of  recovery  in  treated  cases  is  by  crisis)  is  one  of 
the   most   important  results  of  the   new   treatment. 

A  still  more  important  result,  however,  is  the  ab- 
sence of  disabling  permanent  sequelae  of  the  illness. 
In  former  times  deafness,  blindness,  paralysis,  and 
idiocy  were  not  unusual  consequences  of  epidemic 
meningitis.  To  increase  the  percentage  of  recovery, 
while  leaving  the  percentage  of  fixed  sequelae  un- 
changed, might  not  be  regarded  as  a  blessing.  Clin- 
ical observations,  however,  show  that  serum-treated 
patients,  who  recover,  rarely  have  the  serious  handi- 
caps which  afflicted  those  who  recovered  in  pre-serum 
days.  Some  instances  of  deafness  which  nave  been 
reported  were  noted  as  already  present  when  the 
serum  was  injected. 

In  the  animal  experiments  which  led  to  the  present 
serum  treatment  for  epidemic  meningitis  Flexner 
used  about  twenty-five  monkeys  and  perhaps  100 
guinea-pigs.  Already  records  of  approximately  1,000 
cases  treated  by  this  method  imply  a  saving  of  500 
human  lives — unafflicted  with  blindness,  paralysis 
or  mental  defectiveness. 

Pus  and  Pyemia. —  Within  the  memory  of  surgeons 
still  active,  pus  was  regarded  not  only  as  a  natural 
product  of  the  healing  process,  but  as  a  needful 
accompaniment.  In  amputations  the  ligatures  tied 
about  blood-vessels  were  left  hanging  from  the  lips 
of  the  wound;  soon  they  were  covered  with  pus 
which  poured  from  the  cut  surfaces;  the  patient  tossed 
about  the  bed,  sleepless  with  pain,  fever,  and  thirst; 
from  time  to  time  the  ligatures  were  pulled  upon 
to  determine  whether  they  had  "rotted"  loose;  not 
infrequently  the  tied  artery  was  not  closed  when  the 
ligature  was  pulled  away  or  loosened  by  inflammation, 
and  serious  secondary  hemorrhages  followed;  from 
ten  days  to  three  weeks  were  required  for  the  ligatures 
to  rot  loose,  though  they  might  remain  and  keep  the 
wound  open  for  months.  The  long  convalescence  \\  as 
complicated  in  many  cases  by  erysipelas,  lockjaw, 
blood  poisoning,  or  hospital  gangrene.  Hospital 
gangrene  in  the  Civil  War  had  a  mortality  of  45.6  per 
cent.;  lockjaw  89.3  per  cent.;  and  pyemia  or  blood 
poisoning  97.4  per  cent.  Of  these  complications  of 
wounds  there  were  thousands  during  the  War. 
Wounds  of  the  knee-joint  followed  by  amputation  had 
a  mortality  of  fifty-one  per  cent.,  and  without  amputa- 
tion sixty-one  per  cent.  About  sixty-six  per  cent,  of 
patients  with  compound  fractures  were  sure  to  die. 
To  open  the  cranial  case  or  the  abdomen  was  an 
operation  of  extreme  risk,  so  certain  was  fatal  inflam- 
mation to  follow. 

The   revolutionary   change   in   surgery  in   the   last 

444 


forty  years  is  traceable  to  Pasteur's  work  on  fermenta- 
tion. Struck  by  Pasteur's  studies  Lister  began  inves- 
tigations which  led  him  to  the  use  of  phenol  sprays  to 
keep  out  of  wounds  the  pyogenic  cocci.  Beginning 
with  compound  fractures  and  abscesses,  lie  obtained 
such  extraordinary  success  that  he  felt  justified  in 
trying  his  methods  in  surgical  operations.  By  means 
of  experiments  on  animals  he  developed  the  means  of 
tying  arteries  with  embedded  catgut  ligatures.  Later, 
to  be  sure,  what  is  now  known  as  surgical  cleanliness, 
asepsis,  took  the  place  of  antisepsis.  But  the  later 
development  grew  out  of  Listers  demonstration  of 
the  possibility  of  healing  without  pus,  if  bacteria  are 
excluded   from   wounded   surfaces. 

What  a  marvelous  change  these  conceptions  and 
experiments  have  wrought!  With  catgut  ligatures 
the  wound  is  closed  at  once,  the  ligature  i>  absorbed, 
the  wound  heals  in  less  than  a  week  with  little,  if  any, 
immediate  suffering  and  with  none  of  the  old  compli- 
cations. Pyemia  has  almost  wholly  disappeared, 
lockjaw  is  heard  of  only  occasionally  after  accidental 
cuts  which  have  not  been  cared  for,  and  erysipelas 
after  operations  is  exceedingly  rare.  Compound 
fractures  and  opened  joints  heal  as  if  there  had  been 
no  break  in  the  skin.  Arteries  can  be  tied  anywhere 
without  fear  of  secondary  hemorrhage.  The  body 
cavities  are  now  opened  for  surgical  conditions  with- 
out serious  risk.  In  short,  the  evolution  of  asepsis 
has  brought  to  pass  the  most  momentous  revolution 
in  the  entire  history  of  surgery — a  revolution  which  is 
of  immeasurable  benefit  to  mankind  and  the  lower 
animals  as  well. 

Surgical  Technique. — The  advancement  of  surgery 
has  depended  on  animal  experimentation  not  only  in 
the  development  of  asepsis,  but  also  in  the  devising 
of  operative  procedures.  Physiological  experimi 
on  monkeys  have  shown  the  surgeon  where  to  operate 
on  the  human  brain.  Experiments  on  dogs  and  cats 
have  shown  how  nerves  regenerate,  the  proper 
met  hod  of  suturing  cut  nerves,  and  the  possibilities  of 
cross-suturing  nerves  of  different  function — a  proced- 
ure now  being  employed  to  obviate  facial  palsy. 
The  principles  to  be  followed  in  suturing  the  severed 
bowel  were  discovered  on  animals.  The  amount  of 
small  intestine  that  maybe  removed  without  endan- 
gering life  was  also  learned  by  animal  experimentation. 
The  same  may  be  said  of  the  removal  of  kidney  sub- 
stance, of  spleen,  of  lungs,  liver,  and  other  viscera. 
The  surgery  of  the  widely  opened  chest  has  been  the 
direct  outcome  of  Sauerbruck's  studies  on  the  effects 
on  animals  of  differential  intrapulmonary  pressure. 
Through  experiments  on  animals  the  surgery  of  blood- 
vessels has  been  perfected  to  such  a  degree  that  now 
the  effects  of  hemorrhage,  or  the  requirement  of  fresh 
blood,  can  readily  be  met  by  transfusion.  What 
the  future  may  hold  for  surgical  ability  can  perhaps 
be  conjectured.  Already  in  animal  experiments, 
organs  such  as  kidneys  and  ovaries  have  been  im- 
planted and  have  continued  functioning;  pieces  of 
blood-vessel,  preserved  for  w-eeks  in  the  cold,  have 
been  sewn  into  gaps  in  large  arteries  with  no  per- 
manent disturbance  of  the  circulation;  parts  of  joints 
have  been  introduced  and  established  in  the  new- 
surroundings.  These  instances  must  be  regarded  as 
merely  hinting  the  part  played  by  animal  experi- 
mentation in  the  advancement  of  surgery  in  the  past, 
and  now  being  played  in  the  present  progress  of 
surgical  art.  Many  other  instances  might  be  cited. 
Enough  has  been  stated,  however,  to  indicate  that 
death,  distress,  and  enduring  pain  have  been  incal- 
culably lessened  by  the  application  of  experimental 
methods  to  surgical  problems. 

Puerperal  Fever. — In  preantiseptic  days  puerperal 
fever  ravaged  the  lying-in  hospitals  throughout  the 
world.  It  was  estimated  that  30,394  deaths  from 
this  disease  had  occurred  in  the  Paris  Lying-in  hos- 
pitals up  to  1S64.  From  18(50  to  lsc.-i  the  death 
rate  in  the  Maternite  (Paris)  was  12.4  per  cent.,  and  in 


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Animal  Experimentation 


December,  1864,  it  rose  to  the  appalling  height  of 
fifty-seven  per  cent,  [n  the  sixty  years  ending  with 
[895,  the  number  of  deaths  from  puerperal  lexer  in 
Prussia  alone  was  363,6241  On  the  assumption  thai 
each  marriage  would  resuh  in  four  or  five  children,  it 
was  estimated  thai  every  thirtieth  married  woman  in 
Prussia   would  fall  a  victim.     In  the   United  States 

serious    outbreaks    occurred    which     were    bej I 

control;  in  the  Bellevue  Hospital  in  1S7'_'  an  epidemic 
occurred  with  a  mortality  of  eighteen  per  cent.  In 
all  countries  the  usual  death  rate  ranged  between 
two  and  seven  per  cent. 

Although  Gordon  (1792)  had  staled  that  he  had 
himself  been  the  " means  of  carrying  the  infection  to  a 

freat  number  of  women,"  and  Oliver  Wendell 
[olmes  (1843)  had  argued  that  puerperal  fever  wa 
'•  a  private  pestilence,  "  and  Semmelweis  (1847),  after 
presenting  evidence  that  the  affliction  was  due  to 
contamination  of  patients  by  the  soiled  hands  of  the 
obstetrician,  had  greatly  reduced  the  mortality  by 

insing  his  hands  in  a  solution  of  chlorinated  lime, 

liscrepancy  of  opinion  on  the  subject  long  con- 
tinued to  prevail.  The  condition  was  regarded  as 
unavoidable,  and  was  attributed  to  cosmic,  atmos- 
pheric or  telluric  influences,  the  fainted  air  of  old 
wards,  the  power  of  mind  over  body,  the  visitation  of 
Providence,  and  to  various  other  conditions.  Not 
until  about  1875,  when  Lister's  views  of  wound  in- 
fection began  to  receive  attention,  was  credit  given  to 

bacterial  origin  of  puerperal  fever.  And  not  until 
Pasteur,  in  1879,  had  cultivated  the  streptococcus 
from  cases  of  puerperal  infection  and  demonstrated 
on  animals  its  power  to  produce  blood  poisoning,  was 
there  general  acceptance  of  the  opinions  long  pre- 
viously urged  by  Gordon,  Holmes,  and  Semmelweis. 
By  means  of  surgical  cleanliness,  which  is  practical 
bacteriology  directly  dependent  on  animal  experi- 
mentation, the  mortality  from  puerperal  fever  has 
been  greatly  reduced.  In  1909  Markoe  reported 
60,000  births  in  the  Xew  York  Lying-in  Hospital 
with  a  mortality  of  0.34  of  one  per  cent.;  Pinard 
reported  15,633  deliveries  between  1890  and  190S 
with  a  mortality  of  only  0.15  of  one  per  cent.;  and 
Mermann  in  1907  reported  on  S.700  patients  delivered 

ler  his  supervision  with  a  septic  mortality  of  only 
0.0S  of  one  per  cent!  In  other  words,  death  from 
child-bed  fever  litis  fallen  from  the  former  usual  rate 
of  four  or  five  in  every  hundred  mothers  to  approxi- 
mately one  mother  in  1,000.  As  Williams  has  said, 
"  Had  animal  experimentation  led  to  nothing  more 
than  the  discovery  of  the  bacterial  nature  of  puer- 
peral fever,  whereby  a  means  was  provided  for  doing 
away  with  its  former  hideous  mortality,  it  would 
abundantly  justify  the  sacrifice  of  all  the  animals 
which  have  thus  far  been  used  for  experimental 
purposes." 

Pharmacology. — The  whole  modern  science  of  drug 
relation  and  drug  action  is  founded  on  animal  tests. 
The  pharmacologist  is  a  chemist  studying  the  chemical 
character  of  substances,  and  a  biologist  studying  tin1 
action  of  these  substances  on  living  organisms.  Such 
experimentation  on  animals  has  yielded  all  the  sopor- 
ifics (chloral,  sulphonal,  trional)  that  have  been  dis- 
covered during  the  past  forty-five  years.  It  has 
yielded  also  all  the  local  anesthetics,  such  as  cocaine 
and  eucaine,  which  render  painless  small  surgical 
operations.  All  modern  drugs  which  reduce  fever 
fantipyrine,  acetanilide),  the  diuretics  caffeine  and 
tl bromine,  the  emetic  apomorphine  were  all  intro- 
duced by  animal  experimentation.  Adrenalin  also 
was  thus  found.  During  experimentation  on  animals 
aniyl  nitrite  was  discovered,  the  only  drug  giving 
prompt  relief  from  the  severe  pain  of  angina  pectoris. 
Through  animal  tests  some  drugs  have  been  proved 
worthless  and  have  been  discarded.  Others  have  had 
their  action  more  precisely  defined — digitalis  is  an 
example.  Others  have  been  proved  harmful.  With 
still   others   animal   tests  have  been   used  to  stand- 


ardize the  action.  Thus  no  method  of  chemical  anal- 
ysis has  been  devised  to  determine  the  efficiency  of 
a  given  preparation  of  ergot.  The  manufacturing 
ehenii  t  has  to  resorl  to  ti  physiological  tesl  of  every 
specimen  of  ergol  which  he  uses.  Any  woman  who 
takes  ergot  for  I  he  control  of  hemorrhage  becomes 
thereby  the  recipient  of  benefits  from  animal  experi- 
mentation. The  future  growth  of  our  knowledge  of 
alterations    which    drugs    Can    pro, Inc.-    in    the    body, 

whether  normal  or  diseased,  must  either  depend  on 
experiments  performed  on  animals  or  be  tested  firsl 
on  human  beings.  There  is  little  question  which  is 
(he  more  justifiable  procedure. 

Syphilis  and  Salvarsan. — One  of  the  most  interest- 
ing examples  of  the   use  of  animal      lor   the  study  of 

drug  action  is  found  in  Ehrlich's  discovery  of  salvar- 
san as  a  treatment  for  syphilis.     Of  the  calamitous 

nature  of  syphilis  little  need  here  be  stated.  It  may 
kill  in  its  acute  slage,  or  pave  the  way  for  other  dis- 
ease, or  lead  lo  mental  degeneration;  it  may  cau-e  an 
e 'mously  high  mortality  in  still-births  and  abor- 
tions; it  may  result  in  the  production  of  wizened 
offspring  lacking  in  vitality  and  subject  to  infections, 
or  idiots,  or  monsters,  or  those  unfortunates  whose 
syphilitic  heredity  falls  as  a  blight  upon  them  in 
their  youth  and  is  passed  on  as  a  scourge  to  their 
descendants. 

Although  clinical  study  had  revealed  many  of  the 
characteristics  of  syphilis,  knowledge  of  the  disease 
was  lacking  in  several  important  particulars.  It 
was  impossible  to  make  an  early  diagnosis;  and 
diagnosis  in  the  late  stages  or  in  "latent"  forms  was 
often  extremely  difficult.  Furthermore  no  one  could 
tell  how  long  treatment  must  be  continued  before  a 
complete  cure  was  obtained.  All  of  these  deficiencies 
in  knowledge  of  the  disease  were  of  great  social 
importance.  Fortunately  through  animal  experi- 
mental i<m  they  have  been  replaced  by  methods  of 
getting  positive  information. 

In  i903  Metchnikoff  and  Roux  succeeded  in  trans- 
mitting syphilis  to  the  chimpanzee,  and  later  they 
proved  that  the  infective  agent  would  not  pass 
through  a  Berkefeld  filter.  Then  Schaudinn  reported, 
in  1905,  the  discovery  of  the  Treponema  pallidum 
(or  Spirochceta  pallida)  as  a  peculiar  accompaniment, 
of  syphilitic  lesions,  and  Metchnikoff  and  Roux  found 
the  organism  in  the  experimentally  inoculated  ape. 
In  1906,  the  successful  inoculation  of  rabbits  was 
reported.  Thus  in  three  years  the  entire  subject  of 
syphilis  was  opened  for  experimental  study. 

Of  first  importance  was  the  devising  of  a  biological 
reaction,  the  "Wassermann  test,"  the  presence  of 
which  is  proof  of  the  existence  of  the  disease  in  the 
absence  of  other  signs  or  symptoms.  The  test  was 
the  practical  application  of  a  highly  theoretical 
research  by  Bordet  and  Gengou,  and  step  by  step 
was  the  outgrowth  of  experiments  on  animals.  The 
value  of  the  test  for  early,  doubtful,  or  latent  syphilis, 
or  during  treatment  is  immeasurable. 

At  about  the  time  the  transfer  of  syphilis  to 
rabbits  was  demonstrated  Ehrlich  became  interested 
in  the  three  diseases,  syphilis,  relapsing  fever,  and 
chicken  spirillosis,  which  are  caused  by  similar  micro- 
organisms. On  the  basis  of  his  idea  that  a  chemical 
substance  could  be  found  so  specific  in  its  effects 
that  it  would  destroy  the  invading  organism  without 
injury  to  the  host,  a  drug  was  finally  produced — 
number  606  in  the  series,  now  called  "salvarsan" — 
which  in  a  dose  one-seventh  the  maximum  caused 
the  Treponema  pallidum  to  disappear  entirely  from  a 
syphilized  rabbit,  without  injury  to  the  rabbit.  The 
drug  was  then  tested  on  dogs,  and  on  two  assistants 
wdio  volunteered  to  test  the  safety  of  the  drug  for 
human  beings.  Only  then  was  it  tried  on  patients. 
Scarcely  two  years  have  passed  (1912)  since  the 
laboratory  tests  were  made.  Enthusiastic  reports 
of  the  action  of  salvarsan  in  curing  cases  of  syphilis 
have  come  from  all  parts  of  the  world.     Even  if  this 


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Animal  Experimentation 


REFERENCE    HANDBOOK   OF   THE    MEDICAL    SCIENCES 


first  enthusiasm  should  to  some  degree  prove  to  be 
premature  or  excessive,  there  would  nevertheless  be 
ample  warrant  for  attributing  to  Ehrlich's  observa- 
tions on  syphilized  rabbits  a  highly  important  con- 
tribution to  practical  medicine. 

In  no  other  aspect  of  medical  investigation  has 
the  march  of  events  proceeded  with  more  logical 
precision,  or  in  briefer  time,  or  with  greater  or  more 
significant  results  for  human  welfare  than  in  the 
recent  experimental  study  of  syphilis.  If  practical 
achievement  is  to  be  the  test  of  animal  experimenta- 
tion, here  is  convincing  evidence  of  its  value. 

Animal  Tests  for  Disease. — As  may  be  inferred 
from  the  previous  consideration  of  tuberculo-i-. 
diphtheria,  and  epidemic  meningitis,  the  early 
diagnosis  of  infectious  diseases  is  of  greatest  import- 
ance both  for  the  treatment  of  individuals  and  for 
the  checking  of  epidemics.  In  tuberculosis,  for 
example,  the  tubercle  bacilli  in  the  sputum  may 
escape  detection  under  the  microscope  because  of 
I  heir  scarcity  in  early  stages  of  the  disease,  whereas 
the  same  material  injected  into  a  guinea-pig  would 
demonstrate  their  presence  with  certainty.  Since 
the  greatest  hope  for  recovery  from  tuberculosis  rests 
on  early  treatment,  the  sacrifice  of  a  single  guinea-pig 
may  save  a  human  life. 

The  recognition  of  typhoid  bacilli  depends  on  their 
being  clumped  or  agglutinated  by  the  serum  of  an 
animal  previously  injected  with  small  quantities  of 
pure  cultures  of  the  bacilli.  Usually  the  horse  or 
rabbit  is  employed  for  this  purpose.  The  presence 
of  typhoid  bacilli  in  the  feces,  urine,  or  blood  of  a 
person  sick  with  typhoid  fever  can  thus  be  detected, 
for  the  reaction  is  quite  specific.  The  serum  serves 
also  in  the  detection  of  bacteria  carriers,  who  have 
proved  a  serious  danger  to  public  health. 

Cholera  is  like  typhoid  in  being  easily  recognized 
by  specific  agglutination  when  placed  in  the  serum 
of  an  animal  injected  with  cultures  of  cholera  bacilli. 
Bacteria  carriers  are  common,  and  mild  cases  cannot 
be  recognized  clinically.  Yet  a  single  case  may 
infect  the  water  supply  of  a  large  community.  In 
1892  the  river  Elbe  became  infected;  17,000  in 
Hamburg  contracted  the  disease,  and  more  than  half 
of  this  number  died  between  August  17  and  October  3. 
The  protection  of  a  country  against  invasion  by 
cholera  depends  on  the  carefulness  of  the  quarantine 
officer,  whose  inspection  involves  the  discovery  of 
mild  cases  and  of  bacteria  carriers  by  methods  in 
which  animal  inoculation  is  an  important  feature. 

Plague  is  recognized  with  certainty  only  by  animal 
tests  in  which  the  guinea-pig  is  employed.  Animal 
experimentation  is  used  also  to  a  greater  or  lesser  de- 
gree for  the  diagnosis  of  dysentery,  anthrax,  glanders, 
actinomycosis,  Malta  fever,  and  other  microparasitic 
maladies. 

In  all  these  procedures  for  early  and  certain 
diagnosis  the  means  are  provided  for  the  most  effec- 
tive treatment  of  individuals  and  for  the  protection 
of  the  community  against  epidemics.  Since  pre- 
vention is  more  desirable  than  sickness,  even  if  cure 
follows,  it  is  clear  that  the  use  of  animals  for  diagnostic 
purposes  is  of  the  utmost  value. 

Animal  Diseases. — In  the  fierce  conflict  among 
animals  in  the  natural  state  seldom  does  the  sacrifice 
of  one  serve  as  more  than  a  temporary  preservation 
of  the  life  of  a  few  others.  An  interesting  comparison 
may  be  made  between  this  natural  relation  among 
animals  and  the  relation  which  is  established  through 
animal  experimentation.  By  the  use  of  relatively 
few  animals  in  the  preparation  and  testing  of  anthrax 
vaccine,  the  suffering  and  death  of  untold  numbers 
of  animals  can  be  prevented.  In  1894  Chamberland 
reported  that  up  to  that  time  tens  of  thousands  of 
sheep  and  cattle  had  been  thus  preserved  in  France. 
at  an  economic  saving  of  over  $2,000,000.  In  the 
United  States  outbreaks  here  and  there  have  been 
promptly  checked  by  vaccine  immunization. 


Contagious  pleuropneumonia  of  cattle  is  said  to 
have  cost  England  $450,000,000  in  deaths  alone  dur- 
ing the  first  quarter  of  the  nineteenth  century.  The 
disease  introduced  into  the  eastern  United  States 
began  to  spread,  and  its  possible  extension  into  the 
West  was  recognized  as  threatening  the  cattle  industry 
of  the  country.  By  animal  experiments  its  infectious 
nature  was  established  and  within  six  years  every 
trace  of  the  disease  was  eradicated. 

In  Prussia  alone,  from  1876  to  1886,  20,566  horses 
died  of  glanders.  The  knowledge  on  which  is  basi  d 
the  method  of  diagnosing  this  disease  was  the  direct 
outcome  of  careful  studies  and  experiments  on  animals. 
Now  the  disease  can  be  detected  in  early  stages,  in- 
fected horses  can  be  isolated,  and  thus  the  spread  of 
the  infection  can  be  stopped.  The  control  of  glanders 
is  of  great  economic  and  sanitary  importance. 

In  1SS4  Pasteur  reported  that  he  had  been  able  to 
immunize  dogs  against  rabies.  Rabies  is  a  disease 
which  appears  in  all  its  distressful  aspects  in  hi 
cattle,  sheep,  and  horses,  as  well  as  in  man.  The 
vaccine  treatment  of  rabies,  which  Pasteur  discovered 
by  animal  experimentation,  has  been  a  source  of  great 
relief  to  the  lower  animals. 

In  Iowa  alone  the  losses  from  hog  cholera  were 

estimated    in     1899    as    ranging    near    $15, 000. t 

annually.  This  disease,  introduced  into  the  United 
States  about  1830,  had  become  by  1870  a  general 
plague,  and  the  industry  of  hog-raising  was  seriously 
menaced.  By  experimenting  on  the  hogs  themselves 
it  was  shown  that  they  could  be  immunized  against 
the  disease  by  use  of  serum  from  hyperimmunized  pigs. 
Several  States  were  led  to  manufacture  the  protective 
serum.  The  result  has  been  an  abolition  of  the  suffer- 
ings of  hogs  from  the  cholera,  and  an  enormous 
economic  gain  to  the  country. 

What  is  true  of  the  foregoing  diseases  is  true  also  of 
such  diseases  as  Texas  fever,  tuberculosis,  and  foot- 
and-mouth  disease.  Foot-and-mouth  disease  has 
been  introduced  into  this  country  and  eradicated  at 
least  three  times.  As  soon  as  this  or  other  contagious 
disease  appears  as  an  epizootic  the  foreign  ports  are 
closed  against  animals  from  the  infected  district-. 
When  the  volume  of  export  trade  in  animals  and 
animal  products  from  the  United  States  which  amounts 
to  more  than  $250,000,000  annually,  is  considered, 
it  is  obvious  that  the  experimental  medicine  which 
has  given  man  control  of  the  infectious  diseases  of 
domestic  herds  is  of  immense  economic  importance. 

Preventive  Medicine. — The  measures  taken  to  pro- 
tect the  lower  animals  against  infection  can  be  more 
thoroughly  enforced  than  those  used  to  save  human 
life,  and  the  results  therefore  are  the  more  striking. 
That  human  .beings  can  be  protected  by  the  same 
measures  that  are  used  to  protect  the  lower  animals 
has  long  been  known. 

Vaccination  against  smallpox  is  the  oldest  of  the 
protective  measures.  Smallpox  in  prevaccination 
days  was  referred  to  as  a  "great  scourge,"  as  a  "rav- 
aging pestilence,"  as  "the  most  horrible  of  all  dis- 
orders. Besides  attacking  enormous  numbers  in 
every  population,  and  having  a  high  death  rate,  it 
disfigured  those  it  did  not  kill  and  was  one  of  the  most 
common  causes  of  blindness.  Wherever  vaccination 
has  been  employed,  morbidity  and  mortality  from 
this  dread  disease  have  been  markedly  reduced,  and 
the  reduction  has  corresponded  directly  to  the  thor- 
oughness with  which  vaccination  and  revaccination 
have  been  made  compulsory.  In  Germany  no  epi- 
demic of  smallpox  has  occurred  since  the  compulsory 
vaccination  law  began  to  be  enforced  thirty-eight 
years  ago;  in  Persia  and  Asiatic  Russia,  on  the  other 
hand,  where  vaccination  is  neglected,  the  disease  still 
rages.  In  six  provinces  near  Manila  over  6,000  deaths 
from  smallpox  were  reported  annually  until  1907. 
In  that  year  officers  of  the  United  States  completed 
vaccinating  the  million  inhabitants;  and  since  then 
(1911),  in  the  six  provinces,  not  one  person  who  had 


446 


REFERENCE    IIAXDHimik    OF    THE    MEDICAL   SCIENCES 


Animal  Experimentation 


been  successfully  vaccinated  has  died  of  smallpox, 
cases  have  occurred  among  all  cla  i  . 
Similar  triumphs  of  vaccination  again  I  this  dreadful 
plague  could  be  cited  in  large  numbers.  And  inas- 
much as  the  virus  is  obtained  by  operations  on  anim 
to  animals  must  be  given  the  credit  for  the  saving  of 

The  value  of  antirabic  virus  to  animals  bitten  by 
other  rabid  animals  has  already  been  mentioned, 
inal  experiments  of  Pasteur  and  his  coworkers 
i  cted  toward  the  prevention  of  hydrophobia 
in  man,  however,  and  by  use  of  rabbits  and  by  tests 
on  dogs  he  succeeded  in  preparing  an  attenuated 
virus  which  when  promptly  injected  in  increasing 
.  into  human  beings  bitten  by  rabid  animals, 
ff  the  attack.  VYhen  symptoms  once  appear 
tln-rc  is  no  known  cure  for  rabies.  Death  follows 
with  delirium,  mania,  violent  spasms  of  mouth  and 
larynx,  and  inability  to  swallow.  Between  six  and 
fourteen  per  cent,  of  persons  bitten  by  rabid  animals 
formerly  tell  victims  in  this  dreadful  death.  In  1905 
there  were  treated  in  Pasteur  institutes  in  different 
parts  of  the  world  104,347  people,  of  whom  560 — i.e. 
only  0.54  per  cent. — died  of  rabies  later  than  fourteen 
days  after  the  treatment  had  ended.  In  1910  more 
i  Mil)  persons  were  bitten  by  mad  dogs  and  treated 
by  the  virus  in  Paris,  without  a  single  death.  Animals 
used  in  the  original  investigations,  and  they  are 
tired  now-  in  the  manufacture  of  the  protective 
virus.  Thus  a  disease  conveyed  to  man  by  animals 
has  been  in  large  degree  conquered  by  animal  experi- 
mentation. 

In  birds  Danilewsky  found  (1S90)  blood  parasites 
resembling  human  malaria,  and  later  (1895)  Ross 
ceded  in  transmitting  bird  malaria  from  infected 
to  healthy  birds  by  means  of  the  anopheles  mosquito. 
Working  on  this  suggestion  and  using  field  mice  in 
part  for  their  study,  Italian  investigators  proved  that 
the  mosquito  plays  the  same  role  in  the  transmission  of 
human  malaria  that  it  may  play  in  transmitting  the 
malaria  of  birds.  In  a  series  of  brilliant  observations 
Reed  and  his  comrades  in  Cuba  demonstrated  (1900) 
that  yellow  fever  is  conveyed  by  the  stegomi/ia  mos- 
quito. These  experimental  studies  of  mosquito- 
borne  infections  have  already  produced  far-reaching 
effects.  Yellow  fever  and  malaria  can  be  stamped 
.mi  by  control  of  mosquitos  and  screening  of  patients 
suffering  from  these  diseases.  The  Roman  Campagna 
is  losing  its  malarial  dangers;  southern  cities  in  which 
yellow  fever  had  annually  been  claiming  hundreds  of 
victims  are  now  quite  free  of  the  pestilence;  the  Pan- 
ama Canal,  which  the  French,  afflicted  by  yellow  fever 
and  malignant  malaria,  had  failed  to  build,  is  now 
being  completed  under  conditions  as  healthful  as  in 
any  northern  city. 

The  efficacy  of  inoculation  against  typhoid  fever 
has  recently  been  tested  with  highly  significant  results. 
During  the  Spanish-American  War  20.73S  men  were 
disabled  by  typhoid  fever  and  1580  died  of  it.  In 
1911,  12,800  men  of  the  American  army  were  mobil- 
ized at  San  Antonio,  Texas,  for  several  months.  Only 
one  case  of  typhoid  fever,  that  of  a  hospital  attendant 
not  yet  immunized,  appeared  in  the  entire  force. 
Yet  typhoid  fever  was  prevalent  in  San  Antonio. 
This  freedom  from  typhoid  infection  after  protective 
inoculation,  has  been  duplicated  in  the  experience  of 
hospital  attendants  in  various  parts  of  the  world,  and 
in    the    experience    of    the    British    Army    in    India. 

The  whole  procedure  of  protective  inoculation  is 
the  direct  outgrowth  of  artificial  immunity  previously 
demonstrated  in  animals.  And  to  animal  experimen- 
tation must  be  given  credit  for  the  saving  of  untold 
suffering  and  myriads  of  lives,  as  well  as  the  rendering 
of  wide  areas  of  tropical  country  fit  for  civilized 
habitation. 

Pretautions  against  the  Infliction  of  Un- 
ne'Kssary  Pain. — The  second  assumption  made  by 


the  antivivisect that  animal  experimentation 

i  attended  by  the  infliction  of  atrocious  pain.  They 
speak  of  horrible  mutilations  daily  and  hourly  e  ecuted 

on    the    bodies   of    living   creatures    with    no   adeq 

security  for  insensibility.  These  tortures  have  not 
been  observed  by  the  antivivisectionists.     They  are 

inferred    from    various    sources     from    accounts    of 
i nts  performed  before  the  days  of  anesthi 

fr misapprehended   experimental    procedures  such 

a  the  stimulation  of  severed  nerves,  from  supposedly 
painful  diseases  or  surgical  conditions,  from  cata- 
logues of  laboratory  instruments,  and  from  some  opera- 
tions which  frankly  involve  pain.     "  Vivisection"  in 

other  words  moan:,  to  the  antivivisectionisl  tie'  cut- 
ting or  dissection  of  sentient,  living  animals,  bound 
or  rest  rained,  and  subjected  to  the  full  tortures  of 
extensive  operation  without  anesthesia. 

To  the  medical  investigator,  on  the  contrary,  the 
word  "vivisection"  means  something  quite  different. 
It  means,  to  be  sure,  opera t ions  on  living  animals,  but 
it  does  not  imply  attendant  pain.  If  an  animal  is 
anesthetized,  and  operated  on,  and  is  killed  without 
recovery  from  anesthesia,  evidently  the  operation  has 

not  caused  pain  to  the  animal.  So  far  as  tin'  experi- 
ence of  the  animal  is  concerned,  the  operation  would 
not  have  been  different  in  effect,  if  the  animal  had 
first  been  killed,  and  later  dissected.  Now  it  has  been 
shown  repeatedly  that  in  almost  all  physiological  ex- 
periments the  observations  of  the  living  proce 
are  made  in  precisely  this  way,  i.e.  while  the  animals' 
are  on  the  way  to  death  by  anesthesia.  In  patholog- 
ical and  bacteriological  investigation  injections  are 
made  and  sometimes  diseases  are  produced;  and  in 
surgical  and  some  physiological  research  it  is  oc- 
casionally necessary,  after  a  painless  operation,  to 
keep  the  animals  alive  in  order  to  observe  the  effects 
of  the  surgical  procedure.  It  is  probable,  in  these 
instances  of  inoculation  and  aseptic  operation,  that 
the  animals  feel  ill,  as  they  do  with  a  distemper. 
Even  if  the  lower  animals  were  as  sensitive  as  man, 
the  pain,  if  we  may  judge  from  human  experience, 
would  not  be  great.  There  is  abundant  evidence, 
however,  that  the  lower  animals  are  not  so  sensitive 
as  man.  And,  furthermore,  these  bacteriological  and 
surgical  experiments  are  precisely  the  experiments 
which  bear  most  directly  on  the  explanation  and  the 
cure  of  disease  in  the  much  more  sensitive  organism, 
the  human  being. 

In  England  the  exact  records  kept  of  all  experi- 
ments show  that  the  vast  majority  are  simple  inocula- 
tions. About  ninety-six  per  cent,  of  the  animals  used 
for  experiment  are  subjected  either  to  inoculation  or 
to  some  similar  treatment  not  involving  cutting.  Of 
the  remainder  all  are  anesthetized  throughout  the 
operation,  and  only  a  small  fraction  (about  1.5  per 
cent.)  of  the  total  number  are  permitted  to  recover 
from  the  anesthel  ic.  If  permitted  to  recover,  the  ani- 
mal must  be  operated  upon  aseptically,  and  if  the 
wound  suppurates,  the  animal  must  be  killed.  An 
inquiry  into  the  conditions  of  animal  experiments  in 
Massachusetts  has  given  figures  not  unlike  those  of 
England. 

In  England,  animal  experimentation  has  been 
legally  controlled  and  subject  .to  governmental  in- 
spection since  1S76.  To  obtain  permission  to  make 
experiments  on  animals,  the  following  steps  must  be 
taken.  The  investigator  must  (1)  procure  the  neces- 
sary form  or  forms  of  application;  (2)  get  them  signed 
by  two  Presidents  of  learned  Societies,  and  Professors 
of  learned  Sciences,  who  alone  are  qualified,  under  the 
Act,  to  sign  such  applications;  (3)  submit  his  applica- 
tion to  the  Home  Office.  The  Home  Office  (4)  sends 
it  to  the  Association  for  the  Advancement  of  Medicine 
by  Research.  The  report  from  that  Association  is 
received  and  considered  by  the  Home  Office,  and  the 
application  is  then  (5)  submitted  to  the  Inspector, 
who  considers  the  same,  and  (,6)  advises  the  Secretary 
of   State  on    it;   "frequently  having    to  make,  and 

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making,  further  inquiries  with  regard  to  the  proposals 
made,  before  he  finally  advises." 

No  other  country  has  followed  England  in  the  legal 
restriction  of  animal  experimentation.  The  reasons 
for  this  are  several.  The  English  requirements  in- 
volve much  delay  and  loss  of  time.  Permission  is 
granted  to  conduct  a  certain  research.  If,  as  nat- 
urally happens,  another  line  of  investigation  is  sug- 
gested by  the  first,  the  investigator  must  wait  for 
new  permission  before  he  can  continue.  Certain 
researches  have  had  to  be  stopped  or  completed 
abroad,  because  of  the  limitations  set  by  the  English 
Act.  Further,  during  the -entire  thirty-six  years  of 
tin-  administration  of  the  Act,  the  inspectors  have 
found  no  noteworthy  abuse  of  animal  experimenta- 
tion, and  yet  the  law  has  in  no  respect  decreased  the 
agitation  of  the  antivivisectionists  for  further  restric- 
tion in  Great  Britain,  where  no  less  than  fifteen  an- 
tivivisection  societies  exist,  urging  that  experiments 
on  animals  be  abolished.  In  spite  of  attempts  to 
secure  restrictive  legislation  elsewhere,  the  antivivi- 
sectionists have  thus  far  been  unsuccessful. 

In  the  United  States  practically  all  institutions  in 
which  animals  are  used  for  medical  and  biological 
research  have  adopted  by  public  and  corporate  action, 
regulations  which  place  control  of  experimentation 
with  the  laboratory  director.  These  regulations  are 
as  follows: 

I.  Vagrant  dogs  and  cats  brought  to  this  laboratory 
and  purchased  here  shall  be  held  at  least  as  long  as  at 
the  city  pound,  and  shall  be  returned  to  their  owners 
if  claimed  and  identified. 

II.  Animals  in  the  laboratory  shall  receive  every 
consideration  for  their  bodily  comfort;  they  shall  be 
kindly  treated,  properly  fed,  and  their  surroundings 
kept  in  the  best  possible  sanitary  condition. 

III.  No  operations  on  animals  shall  be  made  ex- 
cept with  the  sanction  of  the  director  of  the  laboratory, 
who  holds  himself  responsible  for  the  importance  of 
thf  problems  studied  and  for  the  propriety  of  the 
procedures  used  in   the  solution  of  these  problems. 

IV.  In  any  operation  likely  to  cause  greater  dis- 
comfort than  that  attending  anesthetization, _  the 
animal  shall  first  be  rendered  incapable  of  perceiving 
pain  and  shall  be  maintained  in  that  condition  until 
the  operation  is  ended. 

Exceptions  to  this  rule  will  be  made  by  the  director 
alone  and  then  only  when  anesthesia  would  defeat  the 
object  of  the  experiment.  In  such  cases  an  anes- 
thetic shall  be  used  so  far  as  possible  and  may  be  dis- 
continued only  so  long  as  is  absolutely  essential  for 
the  necessary  observations. 

V.  At  the  conclusion  of  the  experiment  the  animal 
shall  be  killed  painlessly. 

Exceptions  to  this  rule  -aill  be  made  only  when  con- 
tinuance of  the  animal's  life  is  necessary  to  determine 
the  result  of  the  experiment.  In  that  case,  the  same 
aseptic  precautions  shall  be  observed  during  the 
operation  and  so  far  as  possible  the  same  care  shall  be 
taken  to  minimize  discomforts  during  the  convales- 
cence as  in  a  hospital  for  human  beings. 

The  laboratory  director  is  more  likely  to  know  than 
any  inspector,  what  is  being  done  by  those  about  him. 
More  than  any  one  else  is  he  responsible  to  his  insti- 
tution for  the  character  of  work  performed  within  it. 
More  than  any  one  else  concerned  in  animal  experi- 
mentation, is  he  likely  to  be  considerate  of  public 
interest  in  the  manner  in  which  it  is  conducted.  More 
than  any  one  else  he  perceives  the  great  benefits 
which  will  continue  to  flow  from  use  of  the  experimen- 
tal method,  and  realizes  the  importance  of  avoiding 
any  action  which  might  lead  to  a  curtailment  of  the 
freedom  of  research.  And  the  fact  that  lie  is  the  head 
of  a  laboratory  is  a  warrant  of  his  trustworthiness. 

Both  in  Great  Britain  and  in  the  United  Si  ales. 
therefore,  precautions  are  taken  against  the  infliction 
of  unnecessary  pain.  The  pain  of  inoculation  is 
trifling.     The  aseptic  healing  of  wounds  in  the  vast 


majority  of  operations,  even  in  human  beings,  causes 
no  considerable  pain  after  full  recovery  from  the  anes- 
thetic. And  much  of  the  suffering  from  disease  is  due 
to  the  anxiety  for  friends  or  relatives  rather  than  to 
physical  distress.  The  total  pain  resulting  from 
animal  experimentation,  therefore,  is  in  all  antivivi- 
section  literature  grossly  exaggerated. 

The  Ethical  Question  in  Animal  Experimenta- 
tion.— The  attitude  of  those  opponents  of  animal 
experimentation  who  admit  its  benefits,  but  still 
denounce  it  as  immoral,  raises  the  question  of  its 
ethical  justifiability.  This  question  could  be  endlessly 
discussed  in  terms  of  ethical  theory.  For  present 
purposes  it  is  sufficient  to  indicate  that  one  very 
generally  accepted  basis  for  moral  action  is  the  happi- 
ness and  social  welfare  of  mankind  which  flows  from 
that  action.  On  that  basis,  society  permits  and 
itself  engages  in  practices  which  involve  pain  and 
death  to  animals,  unhesitatingly  so  long  as  they  are 
conducted  for  the  benefit  of  man.  Thus  the  harness!  1 1 
horse  is  forced  to  work,  and  in  times  of  crisis  may  be 
■driven  with  lash  and  spur.  The  mother  cow  is  robbed 
of  her  calf,  and  then  her  milk  is  appropriated  for 
human  beings.  Cattle  are  branded  with  hot  irons  to 
preserve  their  identity,  and  shocking  barnyard  opera- 
tions are  performed  to  make  meat  more  palatable. 
Myriads  of  birds  and  beasts  are  slaughtered  for  sport 
or  for  their  furs  and  feathers.  Every  year  in  the 
United  States  more  than  50,000,000  beeves,  sheep, 
and  hogs,  and  also  250,000,000  chickens,  turkeys,  and 
ducks  are  killed  for  food.  In  nineteen  of  the  largest 
cities  of  the  United  States  more  than  350,000  dogs  and 
cats  are  destroyed  annually  merely  to  clear  the  streets. 
Vermin  and  wild  animals  are  snapped  in  painful  and 
uncertain  traps  or  sent  to  death  by  distressing 
poisons.  If  all  this  injury  and  destruction  of  animal 
life  is  immoral  and  unjustifiable,  why  select  for  attack 
the  treatment  of  the  relatively  few  animals  employed 
in  laboratories  with  the  object  of  reducing  pain  and 
suffering  in  the  world? 

The  general  opinion  of  present  civilization  does  not 
support  the  view  that  the  lives  of  lower  animals  are 
so  sacred  that  they  must  not  be  used  for  the  better- 
ment of  society.  Society  protects  itself  from  harm 
by  holding  dangerous  human  beings  in  quarantine,  or 
by  incarcerating  them,  or  even  by  killing  them.  If 
attacked  by  a  foreign  foe,  society  does  not  hesitate  to 
send  into  battle  its  young  men,  chosen  for  their 
strength,  to  suffer  horrible  wounds  and  death  for  the 
social  welfare.  Such  necessary  sacrifices  of  human 
beings  are  among  the  tragedies  of  social  existence. 
Is  not  the  sacrifice  of  lower  animals,  in  various  ways 
so  essential  to  the  continuance  of  the  human  race, 
much  more  thoroughly  justifiable?  And  of  all  those 
sacrifices  what  could  be  more  thoroughly  justified 
than  those  of  experimentation,  which  have  con- 
tributed so  mercifully  to  reduce  suffering  and  prolong 
life  both  for  man  and  the  animals  themselves? 

The  reader  will  obtain  further  information  from  the 
publications  of  the  English  Research  Defense  Society, 
London;  from  Stephen  Paget's  "For  and  Against 
Experiments  on  Animals";  and  from  the  pamphlets 
prepared  by  experts  in  the  several  fields  for  the 
Bureau  for 'the  Protection  of  Medical  Research  of  the 
American  Medical  Association,  Chicago. 

W.  B.  Cannon. 


Anise. — Anisum,  Anise  Fruit  or  Sari.  "The  fruit 
of  Pimpinella  Anisum  L.  (lam.  Umbellifera)" 
(U.S.  P.).  The  anise  plant  is  a  small  annual,  from 
thirty  to  fifty  centimeters  high  (twelve  to  twenty 
inches),  a  native  of  the  Orient,  but  so  long  under 
cultivation  that  its  wild  form  and  original  home 
scarcely  known.  It  is  a  long-known  drug,  mentioned 
by  the  earliest  writers  on  medicine,  and  referred  to 
as  a  medicine  or  spice  in   nearly  every  period  since 


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\ni  I.    Joint 


i),,.n      ii  is  cultivated   in  nearly  all  warm-tern] 

countries.     The  principal  supply  comes  from  Sum  hern 
Europe. 

Tin1  mericarps  are  always  rather  loosely  united. 
1 1„.  whole  fruit,  so  formed,  is  small,  bard,  ovoid, 
i  lik.\  and  finely  bristly,  grayish-  or  yellowish- 
brown,  often  with  a  greenish  tinge,  occasionally 
small  and  stout  and  of  a  very  dark  greenish-brown. 
is  a  strong,  agreeable  odor,  resembling  fennel.  A 
transverse  section  is  nearly  circular  in  general  outline, 
with  ten  projecting  ribs.     The   Vittce  are  numerous, 

ir  three  times  as  many  as  the  ribs,  and  are  rather 

[1,     The  seed  on  section  is  so whal   crescentic. 

■  is  apl  to  be  pretty  dusty,  and  is  mixed  with 
-  and  various  coarse  impurities,  requiring 
frequently  to  be  win- 
nowed or  sifted,  hut  it  is 
not  often  adulterated. 
\  few  grains  of  couium 
are  often  present  in  In. 
dian  anise. 

The  properties  and 
uses  of  anise  are  wholly 
those  of  anethol,  which 
const  it  utes  about  ninety 
per  cent,  of  its  one  and 
one-half  to  three  per 
cent,  of  volatile  oil.  It 
contains  also  a  rather 
larger  amount  of  fixed 
oil  and  a  little  gum  and 
sugar.  The  dose  is  0.5 
Excepting  the  oil,  there 


Fia.  247. 


-Anise,  Enlarged  About 
Six   Elmes. 


to  2  grams    I  gr.  viij.-xxx.). 
i-  no  official  preparation. 

I  A  volatile  oil  distilled  from  anise. 

It  i<  colorless  or  pale  yellow,  of  characteristic  odor 
and  taste,  has  a  specific  gravity  of  0.975  to  0.985  at 
1\>.  and  rotates  very  -lightly  to  the  left. 
At  a  temperature  of  from  15°  to  19°  C.  it  congeals. 
More  than  ninety  per  cent,  of  it  is  anethol  (y.r.).  which 
gives  its  properties,  and  which  may  the  more  advan- 

ously  he  employed.  a<  uniformity  is  thus  secured. 
It  belongs  to  the  more  carminative  class  of  volatile 
oils,  and  shares  the  diffusive  stimulant  properties  of 
volatile  oils  in  general.  It  is.  at  the  same  time,  of 
an  unusually  pleasant  flavor  and  much  used  for  purely 

'ring  purposes,  especially  as  an  addition  to  liquors. 
[ta  pleasant  flavor  also  makes  it  of  special  use  in 
treating  the  flatulent  colic  of  infants,  and  in  adding 
ti>  medicines  which  have  a  tendency  to  gripe.  The 
dose  is  ntiij.  to  xv.  The  official  preparations  are  the 
Aqua,  of  one-fifth  of  one  per  cent,  strength,  and  the 
Spiritus,  of  ten-per-cent.  strength.  The  Spiritus 
Aurantii    Compositus   contains    one-half   of  one    per 

.  and  the  Tinctura  Opii.  Camphorata  two-fifths  of 
one  per  cent.    It  also  flavors  several  other  peparations. 

H.  H.  Rusby. 


Anise,  Star. — Illicium.  "The  fruit  of  IUicvum 
ri  rum  Hook.  (fain.  Magnoliacece)"  (U.  S.  P.).  The 
cies  here  named  is  the  Chinese,  or  sweet  star  anise. 
besides  which  there  is  a  poisonous  Japanese  species. 
When  I.inne  applied  the  name  /.  anisatum,  supposing 
that  he  had  the  former,  he  really  had  the  latter,  as  his 
description  and  figure  clearly  show.  As  a  result  of 
this  mistake,  the  poisonous  species  must  always  bear 
the  inappropriate  name  I.  anisatum  L.  (Syn.:  I. 
religiosum  Zucc),  and  Hooker's  later  name,  I.  vcrum, 
pertain  to  the  useful  species. 

The  plant  is  a  handsome  small  tree. 

The  fruit  consists  of  the  eight  carpels,  united  to  a 
carpophore,  from  which  they  can  be  easily  separated, 
hut  distinct  from  one  another.  Each  carpel  is  short, 
laterally  compressed,  "boat-shaped,"  pointed  at  the 
upper  and  outer  cxtremitv.  and  dehiscent  at  the 
upper  and  inner  border.  The  pericarp  is  deep  brown, 
rather    woody,    brittle,    fragrant,     and    spicy.     The 


seeds,   which  can   !><■  seen  through   the  -split   jn  the 

carpel,    although    this   is    not    usually    wide   enough    to 

lei  them  fall  out,  are  also  brown,  but  very  smooth  and 

shining.      They  are  less  fragrant   than  the  carpels,  hut. 

contain  considerable  fixed  oil  in  their  kernels.      Both 

te  la    and    pericarp    show,     under    the     mici pe, 

numerous  oil   cells,   and   the  parenchyma  of  the  seeds 

re\ eals  drops  of  fat. 

Composition.--  Re-ides  sugar,   gum.  and  fixed  oil, 

which,  although  abundant,  have  no  practical  value, 

tar    anise    is    remarkable    for    containing    a    large 

percentage   (from  three  to  live)  of  an  e-   I  niial   oil,   SO 


Fig.  2-ts — TUicium  verum  or  Star  Anise,     n.  Flower;  6.  gyneecium; 
c,  fruit;  d,  seed,  entire,;  e,  seed  in  longitudinal  section. 

similar  in  odor,  taste,  properties,  and  composition  to 
that  of  anise,  that  no  means  can  be  relied  upon  to 
distinguish  them  from  each  other,  except  by  the 
greater  percentage  of  anethol  in  the  latter,  on  account 
of  which  it  congeals  at  a  higher  temperature.  Illicium 
is  never  prescribed,  and  is  recognized  only  as  a 
commercial  source  of  "oil  of  anise."  This  oil,  owing 
to  its  weaker  action,  should  not  be  indiscriminately 
substituted  for  oil  of  anise.  H.  II.  Rusbi  . 


Ankistrodon. — A  genus  of  snakes  containing  two 
of  the  most  poisonous  species  in  North  America — ■ 
.1.  contortrix,  the  copperhead,  and  A.  piseivorus, 
the  moccasin.  A.  S.  P. 


Ankle  Joint. — As  this  joint  (Articulaiio  talocruralis, 

UNA)  supports  the  weight  of  the  body,  considerable 
stability  is  required  of  it.  This  is  secured  mainly  by 
the  shape  of  the  articular  surfaces,  which  interlock 
like  a  mortise  and  tenon.  The  tibia  and  fibula, 
strongly  united  by  ligaments  (interosseous  and  infe- 
rior tibiofibular,  Figs.  1214,  215,  and  21S),  form  the 
mortise  by  embracing  with  their  extremities  (malleoli) 
the  tenon-like  astragalus.  The  joint  is  a  hinge,  its 
movement  angular,  and  in  a  single  oblique  plane 
I  corresponding  to  the  outward  pointing  of  the  toes) 
through  an  arc  of  some  eighty  degrees.  A  slight 
anteroposterior  ridge  on  the  tibia  fits  into  a  corre- 
sponding depression  on  the  astragalus  giving  a 
"trochlear"  character  to  the  joint.  The  arc  of  the 
astragalus  is  from  a  circle  somewhat  smaller  than  that 
of  the  tibia,  but  it  comprises  about  one-third  of  the 
circumference  while  the  tibia  has  not  more  than  one- 
fourth.  While  standing  erect  the  facet  of  the  astrag- 
alus is  partially  uncovered  in  front  and  behind  and 
there  is  a  slight  interval  between  the  curves  at  these 
points.  In  the  fetus  of  six  weeks  (Henke  and  Rey- 
her)  the  joint  is  arranged  like  that  of  some  marsupials, 
so  as  to  admit  of  rotation,  the  astragalus  sending  a 
process  up  between  the  tibia  and  fibula.     To  guard 


Vol.  I.— 29 


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against  the  thrust  of  the  tibia  and  fibula  when  alight- 
ing on  the  extended  toes  (the  commonest  form  of 
dislocation  arises  thus),  the  astragalus  is  narrower  be- 
hind   than    in   front,    averaging  35  mm.  behind  and 


Interosseous  liga- 
ment. 


Ext.  lat.  ligament. 


Synovial  cavity. 
Deltoid  ligament. 


Tarsal  canal  with  astrag 
ealcanean  ligament. 


Fig.  249. — Froutal  Section  of  Right  Ankle. 

40  mm.  in  front.  It  is  doubtful  whether  lateral 
movement  is  possible  within  the  joint  itself,  that 
which  apparently  occurs  being  really  due  to  the  play 
of  the  small  bones  of  the  foot  upon  each  other.     The 


Post,  tibio-fibular  ligt. 
Ext.  lat.  ligt. 


Deltoid  ligt. 


Post,  astrag.  calc.  ligt. 


Fig.  250. — Rear  View  of  Left  Ankle. 

malleoli  are  held  against  the  articular  surfaces  in 
all  positions  by  the  elasticity  of  the  shaft  of  the  fibula 
which  bends  inward  when  the  wedge  pushes  the 
malleoli  apart,  springing  back  during  extension.     The 


Long  plantar  ligt. 

Tarsal  canal 
and  astrag.  calc.  ligt. 

Fig.  251. — Sagittal  Section  of  Right  Ankle. 

axis  of  rotation  of  the  curved  superior  surface  of  the 
astragalus  (Fig.  251)  passes  through  the  most  fixed 
part    of    the    bone,    viz.,    the  tarsal  canal,   touching 


the  outer  malleolus  but  passing  below  the  inner, 
which  does  not  descend  so  low  (Figs.  249  and  250). 
The  original  capsular  ligament  (see  Arthrology)  re- 
mains in  front  and  behind  as  a  thin  and  somewhat 
lax  layer  of  fibers  connected  with  the  synovial  mem- 
brane and  strengthened  by  the  extensor  tendons  in 
front  and  the  tendon  of  the  flexor  longus  hallucis  be- 
hind. Effusion  into  the  joint  usually  shows  first  in 
front.  On  the  sides  strong  bands  are  developed. 
The  internal  lateral  ligament 
(Figs.  249,  250,  and  252),  also 
called  the  deltoid,  from  its 
triangular  form,  is  the  strong- 
est of  these;  in  dislocations 
usually  tearing  the  bone  apart. 
It  is  a  thick  bundle,  ensheath- 
ing  the  internal  malleolus  and 
passing  to  the  calcaneum,  the 
astragalus,  the  scaphoid,  and 
the  calcaneoscaphoid  ligament. 
Although  these  are  not  dis- 
tinct from  each 
other  they  have 
received  special 


■■--   , 
Long  plantar  ligt.  Inf.  calc.  scaphd   ligt. 

Fig.  252. — Inner  Side  of  Right  Ankle. 

names  (ligamenta  calcaneotibiale,  talotibiale  anterhis, 
talotibiale  posterius,  and  tibionaviculare,  UNA).     The 

tendon  of  the  tibialis  posticus  strengthens  it.  Deeper 
fibers  also  pass  to  the  astragalus  (ligamentum  taloti- 
biale profundum).  In  amputating  at  the  ankle  the 
joint  is  opened  on  the  inner  side,  because  of  the  short- 
ness of  the  malleolus,  and  the  existence  of  this  deep 
band  should  be  remembered.  The  external  lateral 
ligament  (Figs.  249,  250,  and  253)  is  composed  of  three 


Post. 


Post.    Middle     Ant. 
hand.     band.     band. 


Ext.  lat.  ligt. 

Fig.  253.— Outer  Side  of  Right  Ankle. 

distinctly  separate  bands  which  radiate  from  the 
lower  part  of  the  malleolus,  the  anterior  and  posterior 
bands  passing  to  the  astragalus,  the  middle  one  to  the 
calcaneum.  The  names  of  these  are  quite  similar  to 
I  hose  of  the  internal  ligament,  viz.,  ligamenta  talo- 
fibulare  anterius  and  posterius,  and  calcaneofibulare. 
The  synovial  cavity  is  quite  extensive,  communicating 
above  with  the  inferior  tibiofibular  articulation.  It  is 
said  to  contain  more  synovia  than  that  of  any  other 
joint  (Morris).     Its  capacity  is  not  affected  by  the 


450 


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Ank>  losls 


position  of  the  foot,  and  no  change  of  posture  lake.-- 
place  during  inflammation  of  its  membrane. 

Sensations  of  pain  are  sometimes  fel<  in  t ho  ankle 
without  lesion  of  the  joint,  caused  by  some  injury  to 
the  long  nervous  trunks  which  supply  it,  viz.,  the  long 
saphenous,  connected  with  the  lumbar  plexus,  and  the 
anterior  tibial  (deep  peroneal  BNA),  with  the  sacral 
us,  The  vascular  supply  arising  from  twigs  from 
the  anterior  and    posterior   tibial   arteries,   ami   dis- 

trging  by  both  saphenous  veins,  may  be  interfered 
with  by  tight  boot  laces  and  occasion  a  dull  pain. 

FltANK    BaKEK. 

Ankylosis. — Synonyms:  English,  Stiff  joint,  fixed 
joint;  French,  Roideur  articulaire;  German,  Gelenk- 
verwachsung,  Gelenksteifigkeit. 

A    strictly    correct    definition    would    designate    a 

i  angular  position  of  a  joint,  but  this  restriction 

i  i .  longer  obtains,  t  he  word  now  being  used  to  describe 

joints  that    have   become   more  or  less  stiff  in  any 

position.     Qualifying  terms  are  used  to  indicate  the 

extent  of  the  stiffness,  such  as  false,  spurious,  true, 

bony,    ligamentous,    partial,    complete,    incomplete, 

all  of  which  can  be  best   understood  with  the 

i  i     possible    confusion    if    the    word    ankylosis   is 

ed  as  a  synonym  for  stiffness. 

i:  piologt. — Traumatism,  gonorrheal  rheumatism. 

uration  in  joints,  tuberculous  osteitis,  tuberculous 

01  itis,  syphilitic  affections  of  joints,  long  fixation 

ii   a  fracture  is   near    or   extends   into  a   joint, 

1  is  deformans,  etc. 

Pathology. — In  complete,  i.e.  bony  ankylosis, 
the  bones  forming  a  joint  are  limited  by  callus  in  the 
same  manner  that  union  takes  place  after  a  fracture 
in  the  shaft  of  a  long  bone,  or  bridging  by  callus  takes 
eat  one  or  more  places  around  the  joint.  Usually 
us  ankylosis  is  preceded  by  a  more  or  less  pro- 
longed stage  of  fibrous  or  cartilaginous  union.  In 
IUS  ankylosis  bands  of  fibrous  connective  tissue 
unite  the  bones  forming  a  joint,  thereby  limiting  the 
motion.  Accordingly  as  these  bands  are  short  or 
Jung  t he  stiffness  is  complete  or  partial. 

In  cases  of  joint  stiffness  produced  by  extra- 
articular, fibrous,  tendinous,  or  cicatricial  contracture, 
the  joint  remains  free  from  adhesions  for  years  when 
it  has  not  been  involved  in  inflammatory  action. 

Diagnosis  of  bony  ankylosis  is  usually  unattended 
with  difficulty  except  where  there  are  a  number  of 
joints  near  together,  as,  for  example,  the  carpus, 
tarsus,  and  spine.  This  limitation  of  motion  in  one 
joint  is  generally  compensated  for  by  excess  of  motion 
in  another,  thereby  rendering  all  the  surrounding 
parts  capable  of  functionating  in  a  very  nearly  normal 
manner. 

Fibrous  ankylosis  is  more  difficult  to  discern, 
especially  if  pain  accompanies  the  required  manipu- 
lative procedures.  It  is  most  apt  to  be  confused 
with  fibrous,  ligamentous,  or  cicatricial  contractures 
of  soft  parts  outside  of  a  joint,  but  having  direct 
functional  relations  therewith.  Extraarticular  con- 
tractions may  often  be  differentiated  by  the  existence 
of  resistance  to  free  joint  motion  in  one  direction 
only,  i.e.  that  produced  by  the  contracture,  while 
the  joint  moves  more  or  less  freely  in  other  directions. 
Muscular  contracture,  whether  voluntary  or  invol- 
untary is  but  temporary,  and  the  rigidity  of  the 
surrounding  parts  is  clearly  discernible. 

U  muscular  rigidity  is  one  of  the  most  important 
and  reliable  symptoms  of  joint  inflammation,  it  is  a 
serious  error  to  anesthetize  a  patient  for  examination 
oi  a  joint  until  the  absence  of  muscular  fixation  has 
been  clearly  proven.  In  such  cases  the  anesthetic 
relaxes  the  muscles,  leaving  the  joint  free  for  move- 
ments which  are  seriously  prejudicial  and  which  were 
instinctively  guarded  against  by  the  patient. 

If  there  has  been  no  muscular  fixation  much  may 


be   learned   by    I  lie  careful  study   of  a  joint    while  the 

patient   is  unconscious,     h   ran   be  definitely  deter- 
mined whether  it  is  ankylosed  or  only  partially 
The  yielding  of  the  soft   part    above  and  below  the 

joint  suspected  may  be  prevented  by  tightly  bandag- 
ing them,  the  joint  itself  being  left  uncovered. 

Treatment. — The  most  important  part  of  the 
treatment  lies  in  prophylaxis,  prevention  of  the 
occurrence  of  ankylosis,  or,  if  it  is  inevitable,  in  o 
disposing  the  parts  that  the  best  position  for  future 
usefulness  may  be  obtained.  The  trend  of  modern 
surgery  is  greatly  to  shorten  the  time  oi  fixation  of  a 

fractured  bone,  in  the  effort  to  avoid  impaired  joint 
function,  as  well  as  to  secure  a  freedom  from  mn  cle 
atrophy.  The  earlier  application  of  passive  motion 
and  massage  is  being  resorted  to,  and  many  of  the 
serious  deformities  which  formerly  followed  fractures 
are  now  less  frequently  seen. 

Bach  individual  joint  has  special  features  and 
presents  special  difficulties  that  must  be  carefully 
considered  in  applying  any  form  of  treatment.     The 

st  useful  position  for  a  stiff  joint  is  still  subject  to 

discussion ;  no  general  rule  can  be  laid  down.  Fibrous 
or  incomplete  ankylosis  may  require  attention  to 
overcome  a  faulty  position,  or  to  increase  the  extent. 
of  the  mot  ton.  This  is  to  be  accomplished  by  passive 
motion  made  in  the  direction  of  the  normal  action 
of  that  joint.  Brisement  force,  is  a  term  applied  to 
the  use  of  such  force  as  the  surgeon  can  judiciously 
apply,  bearing  in  mind  the  danger  of  breaking  the 
shaft  of  the  bone  used  as  a  lever  or  of  producing  a 
separation  of  the  epiphysis.  It  is  wise  to  begin  all 
manipulations  well  within  a  safe  limit,  and  gradually 
to  increase  the  power  employed  as  the  range  of 
motion  increases;  remembering  that  the  strength  of 
the  long  bones  often  diminishes  from  disuse  and  that 
they  will  break  if  a  sudden  corrective  force  is  applied. 
The  above  methods  are  greatly  facilitated  by  pre- 
viously subjecting  the  limb  to  dry  hot  air  at  a  tem- 
perature of  from  300°  to  400°  F.  for  an  hour.  For 
this  purpose  some  one  of  the  many  forms  of  ovens 
made  for  the  purpose  may  be  employed.  Care  should 
always  be  taken  to  wrap  thoroughly  the  parts  in 
flannel,  but  never  in  cotton.  The  latter  is  highly 
inflammable  and  holds  the  moisture.  The  interior 
of  the  oven  should  be  kept  as  dry  as  possible,  as  the 
perspiration,  which  is  often  profuse,  renders  the 
atmosphere  within  the  oven  moist,  and  is  apt  to 
result  in  scalding  the  patient. 

Ovens  are  now  made  for  use  with  alcohol,  gas,  and 
electricity  as  means  of  generating  heat.  Each  has 
its  peculiar  advantages,  but  the  results  are  not 
different.  The  effect  is  to  soften  the  fibrous  adhesions 
very  much  in  the  same  way  that  old  glued  joints  of 
wood  are  softened,  enabling  the  surgeon  to  obtain 
movements  of  a  partially  stiff  joint  with  very  much 
less  force  and  therefore,  with  less  danger  and  less  pain. 

The  pain  accompanying  corrective  manipulations 
following  the  use  of  the  oven  is  generally  inconsid- 
erable, although  varying  greatly  in  different  subjects. 
When  the  pain  is  very  great,  the  employment  of  an 
anesthetic  that  acts  quickly  enables  the  operator  to 
proceed  with  greater  despatch.  The  anesthetic  that 
I  have  found  most  satisfactory  for  this  purpose  is 
ethyl  bromide;  ethyl  chloride  is  also  satisfactory.  I 
have  also  used  chloroform  and  at  times  nitrous  oxide 
gas. 

Fixation  appliances  of  any  kind  are  contraindicated 
during  corrective  procedures  in  fibrous  ankylosis, 
as  increased  freedom  of  movements  is  desired  rather 
than  fixation.  Voluntary  motions  are  to  be  encour- 
aged to  increase  the  mobility  and  to  regain  the 
muscle  function  which  is  required  for  proper  use  of 
the  joint. 

The  employment,  of  electricity  has  been  extolled 
for  its  effect  in  restoring  lost  or  impaired  muscle 
function,    and  when  used  by  skilful  physicians  it  is 


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more  likely  to  produce  the  desired  effects  than  when 
crudely  applied  by  a  more  or  less  non-medical 
attendant. 

Massage  is  a  means  of  restoring  impaired  muscle 
power  that  should  not  be  overlooked,  and,  like  all 
other  therapeutic  measures,  should  be  carefully 
prescribed  as  to  methods  and  time.  The  object 
sought  should  be  the  voluntary  control  of  the  affected 
joint  and  the  mechanism  that  actuates  it;  this  should 
be  impressed  on  the  patient. 

In  true  ankylosis  the  object  sought  is  the  most 
useful  position  of  the  parts,  and  here  careful  study  is 
necessary  to  avoid  attempting  to  obtain  a  movable 
joint  when  greater  usefulness  could  be  had  from  a 
stiff  joint  in  an  approved  position.  The  greatest 
diversity  of  opinion  exists  as  to  the  most  desirable 
position  for  ankylosed  joints.  In  the  elbow  a  fully 
extended  position  of  the  arm  is  generally  conceded  to 
be  the  least  useful,  while  the  exact  angle  of  flexion  has 
been  the  cause  of  much  discussion.  Some  advocate 
a  right  angle,  others  a  lesser  angle,  to  enable  the 
patient  to  bring  the  hand  to  the  mouth;  and  yet 
any  rigid  position  is  more  or  less  conspicuous  and 
cumbersome. 

The  hip  when  ankylosed  at  various  angles  can  be 
made  useful  by  the  increased  latitude  of  motion  im- 
parted to  the  other  hip-joint  and  to  the  lumbar  verte- 
bral articulations.  To  such  an  extent  is  the  lower  spine 
reciprocal  in  loss  of  function  of  one  or  both  hip-joints 
that  it  has  been  called  the  third  hip-joint.  Ankylosis 
of  a  hip  at  right  angle  to  its  fully  extended  position 
has  frequently  been  observed  to  be  useful  for  progres- 
sion. The  third  hip-joint  has  also  developed  in 
efficiency  in  cases  in  which  a  hip-joint  was  ankylosed 
in  the  most  approved  position,  i.e.  that  of  almost  full 
extension,  facilitating  the  movements  of  the  entire 
pelvis  in  walking  and  especially  in  sitting,  and 
approaching  very  closely  normal  action. 

The  arguments  in  favor  of  a  fully  extended  leg 
versus  slight  flexion  in  cases  of  bony  ankylosis  of  the 
knee  appear  to  be  about  equally  divided.  _  The 
sl'ghtly  flexed  leg  is  certainly  somewhat  less  in  the 
way  in  sitting,  and  it  enables  the  patient  to  develop  a 
more  graceful  carriage,  but  all  of  these  are  cast  into 
insignificance  by  the  mechanically  faulty  position  of 
flexion.  Ashhurst  refers  to  a  case  in  which  the  knee 
remained  straight  with  apparent  bony  union  for 
eight  years  and  then  began  to  yield,  and  within  a  year 
was  bent  to  a  right  angle  and  rotated.  The  fully 
extended  or  straight  position  is  less  liable  to  bend 
because  its  weight-bearing  function  is  disposed  in  the 
mechanical  position  in  which  it  was  designed  to  act 
most  efficiently.  Where  the  quadriceps  attachment 
to  the  tibia  is  maintained  or  properly  substituted,  the 
powerful  flexors  will  have  less  opportunity  of  pro- 
ducing flexion,  which,  as  experience  has  shown,  tends 
to  increase  with  use. 

The  operative  procedures  most  frequently  resorted  to 
are:  excision  to  obtain  a  false  joint  (pseudarthrosis); 
excision  to  obtain  a  better  position  of  the  limb; 
osteotomy,  breaking  the  bone  after  partially  cutting 
it  with  an  osteotome;  and  osteoclasis,  breaking  the 
bone  without  any  cutting.  These  different  procedures 
have  especial  advantages  in  different  joints,  and  can 
be  fully  studied  and  appreciated  only  under  the  head- 
ings of  the  individual  joints. 

Adolf  Lorenz1  has  elaborately  considered  the  con- 
servative aspect  in  an  article  on  the  "  Indications  for 
Arthrodesis  and  Arthrolysis,"  the  latter  term  being 
the  one  that  is  now  generally  accepted  as  meaning  the 
intentional  production  of  mobility  in  ankylosis  by 
operative  procedure.  His  conclusions  arc  that  there 
are  only  two  joints  in  the  body  that  should  be  made 
mobile  after  ankylosis,  viz.,  the  elbow  and  the  jaw. 
He  bases  this  view  upon  the  fact  that  there  are  so  few 
cases  that  have  been  operated  upon  that  have  re- 
sulted in  permanent  restoration  of  function.  The 
inability  to  secure  a  restoration  of  muscular  control 


often  necessitates  the  employment  of  varying  forms  of 
apparatus  to  give  stability  to  a  joint  that  has  become 
mobile  by  operative  methods.  His  belief  is  that  an 
ankylosed  joint  in  proper  position  affords  higher 
degrees  of  efficiency  than  such  joints  offer  when  they 
are  made  free,  but  still  lack  muscular  control. 

The  very  many  methods  of  producing  mobile  joints 
following  ankylosis  may  be  taken  as  an  indication  of 
lack  of  success  of  any  of  them.  In  some  instances  a 
greater  number  of  successful  results  have  been  ob- 
tained than  in  others.  Rhea  Barton2  of  Philadelphia 
in  1826  removed  a  wedge  from  an  ankylosed  hip  and 
instituted  passive  motions  after  three  weeks,  and 
obtained  mobility  which,  however,  became  more  and 
more  limited,  finally  ending  in  recurrence  of  ankylosis. 

J.  R.  Rogers  in  1830  attempted  the  same  pro- 
cedure with  equal  results.  In  1S3S  Berard3  advised 
section  of  the  condyles  after  the  method  of  Rhea 
Barton  for  temporomaxillary  ankylosis.  In  1840 
J.  M.  Carnochan'  operated  on  a  case  of  pseudoarthro- 
sis by  division  and  inserting  wool  or  cotton  between 
the  cut  ends.  In  1853  Schuh  freed  an  ankylosed 
patella  with  a  chisel,  but  the  adhesion  returned. 

T.  Wolff5  reported  nine  successful  cases  following 
what  he  terms  "arthrolysis,"  i.e.  incision  by  scalpel 
and  chisel  of  all  the  fibrous  tissue  which  hindered 
movement.  Eiselsberg,  in  two  cases  in  which  he 
employed  this  was,  however,  successful  in  only  o 
and  Kocher,  while  in  favor  of  "arthrolysis,"  modi 
it  by  putting  the  components  of  the  new  joint  after 
"arthrolysis"  in  a  position  of  dislocation  for  a  week 
or  two,  when  he  reduced  the  dislocation. 

Helferich,  in  1S99,  proposed,  but  did  not  carry  out, 
his  suggestion  of  inserting  a  portion  of  the  vastus 
internus  between  the  patella  and  femur  to  prevent 
reunion.  Cramer6  reported  ten  cases  of  ankylosis  of 
the  patella  alone,  in  seven  of  which  the  vastus  inter- 
nus was  interposed,  and  six  were  successful. 

Chlumsky7  reasoned  from  the  reports  of  Mikulicz, 
Helferich,  Leuz,  and  Riegner,  that,  notwithstand- 
ing the  good  results  obtained  at  times  by  the  inter- 
position of  muscle  and  fascia,  in  large  joints  the 
procedure,  through  failure  of  preservation  of  the 
interposed  tissues  or  on  account  of  technical  difiienl 
ties,  was  not  all  that  could  be  desired.  He  therefore 
conducted  a  large  number  of  experiments  based  upon 
the  interposition  of  such  non-absorl:able  substances  as 
plates  of  ceDuloid,  zinc,  rubber,  silver,  cambric,  and 
layers  of  collodion  and  absorbable  material,  such  as 
magnesium,  ivory,  or  decalcified  bone.  In  some  in- 
stances there  was  a  tendency  to  joint  formation,  but 
the   end   results   were   unsatisfactory   on   the   whole. 

Mellhenny5  removed  in  the  inferior  maxilla  a  wedge 
of  bone  half  an  inch  wide  from  the  neck  of  each 
condyle  just  above  the  insertion  of  the  external 
pterygoid,  for  temporomaxillary  ankylosis,  with  a 
successful  result. 

Murphy9  in  October,  1901,  interposed  flaps  of 
fascia  and  muscular  tissue  from  the  vastus  externue 
between  the  patella  and  femur  and  tibia  and  femur 
for  an  ankylosed  knee,  with  fair  result.  He  reports 
twelve  cases  in  all,  up  to  January,  1905,  some  with 
remarkable  result,  for  the  correction  of  ankylosis  of 
the  knee,  hip,  and  elbow,  which  he  accomplished  by 
the  interposition  of  flaps  with  broad  p  dieles  obtaini  d 
from  fascia,  fat,  and  muscle  adjacent  to  the  anky- 
losed joint.  His  paper  is  most  interesting,  extensive, 
and  valuable. 

Hubscher10  failed  to  secure  permanent  freedom  of 
the  patella  by  the  use  of  the  interposition  of  magne- 
sium foil  half  a  centimeter  thick. 

Berger11  successfully  used  the  pronator  radii  teres 
between  the  extremities  of  the  bones  sutured  to  the 
brachialis  anticus  for  elbow  ankylosis,  and  attributes 
the  satisfactory  result  to  the  muscular  interposition. 
Hoffa'-  also  successfully  used  muscle  flaps.  Quenu.13 
in  1902,  interposed  soft  parts  after  re  ection  of  the 
elbow  for  ankylosis.     Delbet  also  praises  this  method. 


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.\no<i>  DBS 


Foderl"  after  experimental  ankylosis  produced  by 
resection,  produced  mobility  again  by  the  insertion  « »f 
pj  ,ces  0f  bladder  or  the  wall  ol  an  ovarian  cyst. 

Baer'  'in  1909  reported  three  cases  in  which  he  had 
used  Cargile  membrane  between  the  separated  com- 
ponents of  the  joints  with  no  resultanf  motion,  and 
with  fever  fur  a  few  days  alter  the  operation.     In  a 
fourth  case,  a  knee  in  which  he  used  Cargile  membrane 
Bnd  in  which  fever  occurred,  the  end  result   wa     10° 
lotion,      \iiir  the  method  of  Foderl,  he  then  also 
used  bladder  from  the  pig,  which  he  had  chromicized, 
this  he  sutured  in  the  newly  separated  articulation 
,  the  result  in  the  reported  cases  of  35    motion  in  a 
hip,  35°  in  a  knee,  50°  in  a  hip,  75°  in  a  knee;  and  100° 
in  the  upper  radioulnar  articulation.     The  objection 
to  the  method  seems  to  be  the  postoperative  fever, 
trusion  of  the  pieces  of  bladder  through   the 
wound   or  adjacent    tissue  at    times   with   resultant 
formation  and  suppuration,  and   in   some  in- 
stances return  of  ankylosis,  as  reported  by  Osg 1" 

and  in  personal  communications  from  three  cases  at 
Si.     Agnes'    Hospital    and    Ashbury's    observatioi 
I'lu'  advantages   claimed   by    Baer  over   the   bulky 
muscle  Hap  and  fascia  method  is  that  the  resultant 
illation   has  a  in  n  eh  more  stable  mot  ion  and  there 
less  waddling  gait. 
I  in  mi'7  reported  a  trail nia tie  ankylosis  of  the  elbow 
eleven  year  old  boy.     He  broughfabout  a  mobile 
!   then  interposed  a  free  transplanted  fascial 
from    the   thigh.     Systematic   mechanical   treat- 
t  movements  and  massage  were  used,  and  t  welve 
ths  after  the  operation  the  elbow  had  good  move- 
I    of    55°.      Recently    Ilauer    of    Johns    Hopkins 
Hospital  in    a    case  of  ankylosed  elbow,   used  a  flap 
i  the  fascia  lata  of  the  patient's  thigh  with  sat- 
isfactory results. 

R.  Tunstall  Taylor18  presents  for  consideration  the 
result  of  his  experiments  in  the  introduction  of  vary- 
ing formulas  of  white  wax  ami  lanolin  for  the  produc- 
tion of  mobility  ill  joints  that  have  been  ankylosed. 
The  latter  possessing  many  advantages  over  the  sepa- 
rating material  used  by  other  operators.  Taylor's 
results  indicate  a  successful  future  for  this  method. 

H.  Augustus  Wilson. 

References 

1.  New  York  Medical  Journal,  June  22.  1012,  page  1301. 

2.  North  American  .Medical  and  .Surgical  Journal,  1827,  p.  290. 

3.  Diet,  de  Medecine,  vol.  xviii.,  p.  440,  1838. 

4.  Lectures  on  .Surgical  Anatomy  and  Operative  Surgery. 

5.  Berliner  Chirurgen  Vereinigung,  1895  and  1897. 

0.  Thirtieth  Congress  of  the  Deutsche  Gesellschaft  fiir  Chirurgie, 
Berlin.  April  13,  1901;  Archiv  fiir  klinische  t'liirurgie,  1901, 
Ixiv.,  p.  696. 

7.  Centralblatt  fiir  Chirurgie,  Sept.  15,  1900;  Wiener  klinische 
Wochenschrift,  19(12-3. 

s    New  Orleans  Medical  Journal,  April,  1901. 

'.»    Journal  Am.  Med.  Association.   May   27,    1905,   p.    1671. 

in.  Correspondcnzblatt  fiir  Schweizer  Aerzte,  .Dec.  15,  1901, 
xwi..  p.  7SY 

11.  Bull,  e.t  Mem.  de  la  Soc.  de  Chir.,  1903,  xxix. 

12.  Zeitschrift  fiir  orthopadische  Chirurgie.  xvii. 
]:;    Societe  de  Chirurgie,  Paris,  June  25,  1902. 

1  1.  Ueber  Knochen  und  Knorpelersatz,  Wiener  klinische 
Wochenschrift,  1903,  xvi,  1424-1429;  Jour.  Am.  Med.  Ass'n., 
1905,  p.  1756 

l.">.   Amer.  Jour.  Orth.  Surg.,  August,  1909. 

16.   Boston  Medical  and  Surgical  Journal,  July  20,  1911. 

17    Zeitschrift  fiir  Chirurgie,  Bd.  cviii.,  H.  3-1.  S.  424. 

is  Surgery.  Gynecology  and  Obstetrics,  vol.  xiv.,  April,  1912, 
p.  327. 

Ankylostomiasis. — See  Uncinariasis. 

Ankvlostomum. — fT urinaria,  Dochmius.  A  genus 
of  nematode  worms,  family  Strongylidoe.     A.  duodenale 

lives  in  the  intestine  of  man.  causing  severe  loss  of 
blood.  The  eggs  develop  in  mud  and  moist  earth, 
and  enter  the  body  in  drinking  water  or  perhaps 
through  the  skin.     See  Nematoda  and  Uncinariasis. 


Annatio.  Aknotta  [Orleana).  This  coloring  mat- 
ter is  obtained  from  the  seed  of  Bixa  OreUana  I...  a 

mall   tree  of   South  America,  belonging  I"  tin    family 

,  ,r.     The  plant  is  also  cultivated  in  all  tropical 

countries.      Commercial      annatto     i       prepared     in    a 

variety  of  ways,  having  foi  theirobject  the  eparation 
from  the  seed  of  its  coloring  matter,  and  its  preserva- 
tion in  a is!  or  dry  condition.     The  bruised    eed  is 

sometimes  washed  over  a  ieve  and  the  liquid  allowed 
io  stand  until  the  annatto  subsides;  or  it  is  separated 
by   fermentation.     The   product    i     a    brownish-red, 

resinous  substance,  usually  in  moist  ma  se  .  but 
sometimes  in  dry,  brittle  cakes.       It   has  often  little  or 

no.  sometimes  a  sweeti  h,  re  i is  odor,  ami  a  saltish- 
bitter  ie-te.  Some  lots  have  a  very  disagreeable 
smell,  and  are  said  by  Hager  to  be  prepared  with 
urine.      Two    kinds    are    said     to    lie    imported     from 

French   Guiana,   one   without    unpleasant   smell,   the 
Me.     A   i  inrd  variety  comes  also  In. in 

I.  but   this  is  not.  so  highly  esteemed  as  the  be 

French. 

Annatto  is  a  mixed  substance,  nearly  insoluble  in 
water,  soluble  in  alcohol,  ether,  fatly  and  essential 
oils,  making  orange-red  solutions.  It  consists  princi- 
pally of  a  yellow  (firellin)  and  a  red  Qrixin)  resinous 
coloring  matter. 

The  principal  demand  for  annatto  is  for  dyeing 
fabric.-,,  I. m  it  is  also  extensively  employed  to  color 
butter  and  cheese.  In  the  tropics  it  is  largely  em- 
ployed tor  coloring  foods  for  table  use. 

II.    II.    RuSBY. 


Annonaceae. — (The  Custard-Apple  family.)  A  fam- 
ily of  nearly  fifty  genera,  pertaining  almost  wholly  to 
the  tropics,  of  both  hemispheres.  They  yield  a 
number  of  the  most  delicious  of  known  fruits,  such  as 
those  of  .1  mama  and  Duguetia.  They  are  classed  near 
the  Magnolias  and  Myristicas,  and,  like  them,  are 
rich,  chiefly  in  the  bark,  in  volatile  oils,  for  which 
they  are  considerably  used  in  domestic  practice. 

H.  H.  Rusby. 


Annulata. — An  old  term  used  to  include  the  leeches, 
earthworms,  and  other  segmented  worms. 

A.  S.  P. 


Anodynes. — This  term  (a,  privative,  and  &divq, 
jiain)  is  applied  synonymously  with  analgesics  (a, 
and  aKywia)  to  a  small  class  of  drugs  whose  peculiar 
action  is  to  relieve  pain.  The  anesthetics,  which  also 
relieve  pain,  but  by  suspending  all  sensation,  together 
with  consciousness  and   motility,  are  not  anodyne's. 

By  far  the  most  important  member  of  this  group  is 
opium  (which  see).  Though  other  remedies  occasion- 
ally relieve  the  milder  degrees  of  pain,  opium  alone  can 
be  relied  upon  to  remove  severe  suffering.  It  has  its 
limitations,  in  occasional  paroxysms  of  agony  such  as 
attend  the  passage  of  renal  and  gall  stones,  when 
nothing  short  of  absolute  anesthesia  will  bring  relief. 
Here  opium,  in  doses  so  high  as-even  to  endanger  the 
life  of  the  individual,  is  without  effect  on  the  pain.  In 
the  ordinary  forms  of  severe  pain  a  failure  of  opium  to 
give  relief  is  almost  always  due  to  improper  ad- 
justment of  the  dose.  Of  course,  the  subsequent  ill 
effects  of  opium,  such  as  nausea,  constipation,  and 
narcotic  addiction,  may  be  so  marked  as  to  form  a 
contraindication,  more  or  less  strong,  to  its  use.  Hut. 
the  point  here  emphasized  is  that,  as  an  anodyne  pure 
and  simple,  opium,  if  properly  administered,  is 
almost  always  successful.  In  certain  subjects,  partic- 
ularly women  and  nervous  persons,  the  intoxicating 
effect  of  opium  predominates  in  the  moderate  doses. 
In  such  cases  the  dose  must  be  cautiously  increased 
beyond  the  limits  usually  prescribed,  or  else  the 
opium  must  be  combined  with  some  nervous  sedative, 
as  bromide  of  potassium  or  chloral.     For  it  should 


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be  remembered  that  opium  is,  in  analgesic  doses,  by 
no  means  always  a  hypnotic.  In  many  cases  in  which 
it  completely  removes  pain,  the  patient  does  not  close 
his  eyes  in  sleep  the  whole  night. 

The  common  cause  of  failure  in  securing  the  anal- 
gesic effect  of  opium  is  conformity  with  a  strict  ami 
arbitrary  posological  standard,  and  forgetfulness  of 
the  fact  that  there  is  much  difference  in  the  capacity  of 
different  individuals,  and  of  the  same  individual  at 
different  times,  for  the  drug.  Under  the  influence  of 
severe  pain,  the  toleration  for  opium  increases  enor- 
mously. In  general  and  pelvic  peritoneal  inflamma- 
tions, for  instance,  it  may  be  necessary,  in  order  to  get 
the  full  effect  of  opium,  to  administer  it  in  doses  up  to 
four  grains  (or  its  equivalent  in  morphine)  at  a  time, 
and  to  repeat  with  sufficient  frequency  to  keep  the 
patient  just  short  of  narcotism.  This  bold  use  of 
opium  in  pelvic  inflammation  has  come  into  practice 
of  late  years,  and  some  of  the  figures  published  of  the 
amounts  actually  administered  are  very  large.  They 
are  not  given  here,  however,  for  the  reason  that  no 
definite  figures  reported  in  one  case  should  have  any 
weight  in  determining  the  amount  to  be  given  in  an- 
other case.  It  is  needless  to  say  that,  in  the  case  of  a 
patient  suffering  from  a  frank  peritonitis,  which  calls 
for  the  employment  of  these  heroic  doses,  and  when 
the  individual  is  held  just  on  the  verge  of  narcotism, 
with  respirations  perhaps  lowered  to  ten_  or  twelve 
per  minute,  no  standing  order  should  be  given  in  ad- 
vance for  a  stated  administration  of  the  drug,  and  that 
each  dose  should  be  given  by  the  practitioner  himself, 
who  should  on  no  account  leave  the  case,  and  who 
should  have  at  hand  atropine  and  a  faradic  battery 
ready  for  instant  use  in  case  the  narcotism  goes  too 
far. 

Among  the  derivatives  of  opium,  morphine,  as  an 
anodyne,  stands  facile  princeps.  Its  convulsant, 
constipative,  and  diaphoretic  properties  are  all  less 
than  those  of  opium,  while  as  an  analgesic  it  is  even 
more  active  than  the  drug  from  which  it  is  derived. 
Of  the  other  principal  alkaloids,  the  analgesic  effect 
upon  man  is  in  the  following  order:  narceine,  the- 
baine,  papaverine,  and  codeine.  The  interval  be- 
tween the  strongest  of  these  and  morphine  is,  however, 
great,  one  authority  claiming  that  narceine  is  four 
times  weaker  than  morphine,  and  in  practice  it  is 
found  that  none  of  them  can  be  relied  upon  with 
certainty  in  pain  of  a  severe  character.  The  prompt- 
ness and  effectiveness  of  morphine  as  an  anodyne  are 
usually  enhanced  by  the  hypodermic  method  of 
administration.  Dionin  is  an  opium  derivative  use- 
ful when  instilled  into  the  eye  in  5-10  per  cent. 
solution. 

Chloroform  is  at  times  an  anodyne.  This  is  es- 
pecially t he  case  when  injected  subcutaneous]}'  in 
the  vicinity  of  a  nerve,  as  in  sciatica  and  other  forms  of 
neuralgia.  Administered  by  the  mouth  it  also  has  a 
local  analgesic  effect,  due  partly,  no  doubt,  to  its 
revulsive  counterirritant  action.  It  is  thus  of  use  in 
gastralgia  and  flatulent  colic.  The  spirit  of  chloro- 
form, in  doses  of  o  i-  in  hot  water,  is  an  eligible  form 
for  the  internal  administration  of  chloroform,  and  the 
Spiritus  ^Etheris  Compositus,  commonly  called 
Hoffmann's  anodyne,  may  be  used  in  the  same  doses 
for  abdominal  pain.  The  so-called  chlorodyne,  a 
British  nostrum,  has  under  various  modifications 
been  pretty  widely  used.  One  of  its  many  formula? 
is  this: 

Morphina?  hydrochloratis gr.  viij. 

Aqua? fl  "  3S. 

Acidi  hydrochloriei fl  3ss. 

Chloroformi fl  .">  iss. 

Tinct.  cannabis  indicse fl  5i. 

Acidi  hydrocyanici  dil.  U.  8.  P.. .  .  n\  xij. 

Alcohol" fl  Bss. 

01.  menth  pip n^  ij. 

Oleoresinse  capsici n\  i. 


The  adult  dose  is  from  five  to  ten  drops.  This  may 
be  well  replaced  in  the  same  dose  by  the  Tinctura 
Chloroformi  et  Morphinse,  B.  P.,  which  was  intended 
to  be  its  official  substitute. 

Belladonna  may  be  considered  a  feeble  anodyne. 
Administered  with  opium  it  has  not  only  a  corrigent 
effect,  mitigating  some  of  the  unpleasant  symptoms  of 
the  latter  drug,  but  is  also  apparently,  to  a  certain 
extent,  an  adjuvant. 

The  various  coal-tar  products,  whose  name  is  now 
legion,  have  a  certain  anodyne  value.  Antipyrine, 
acetphenetidine,  acetanilide,  lactophenin,  are  a  few 
among  the  many.      (See  also  under  Antispasmodics.) 

Cannabis  indica  is  a  still  weaker  anodyne,  if  it 
deserves  the  name  at  all.  Its  hypnotic  action  can 
overcome  a  moderate  degree  of  discomfort,  but  not 
much  actual  pain.  It  is  of  some  repute  in  the  treat- 
ment of  chronic  migraine. 

There  are,  besides  the  foregoing,  one  or  two  drugs 
which  deserve  mention  as  local  anodynes,  although 
their  commoner  use  is  as  local  anesthetics.  For  ex- 
ample, cocaine  is  chiefly  employed  to  produce  an- 
esthesia, as  of  the  cornea,  or  by  injection  to  anesthe- 
tize the  field  for  a  circumscribed  operation.  Its 
anodyne  action  may  be  obtained,  however,  in  con- 
junctivitis, in  painful  hemorrhoids,  etc.  A  four-per- 
cent, solution  may  be  employed.  But  the  ever-pres- 
ent danger  of»  establishing  the  cocaine  habit  must 
always  be  borne  in  mind  before  resorting  to  cocaine 
as  an  anodyne. 

Cocaine  itself  is  much  less  soluble  in  water  than  its 
salts,  e.g.  the  muriate;  but  the  former  is  soluble  in 
fats,  while  the  latter  are  not.  Hence  in  ointments  the 
cocaine  itself  should  be  used,  and  not  its  salts. 

Eucaine  has  been  found  in  many  respects  a  useful 
substitute  for  cocaine. 

Charles  F.  Withington. 


Anopheles. — A  genus  of  mosquitos  which  transmits 
malaria.  No  other  genus  of  mosquitos  is  known  to 
carry  this  disease.  Anopheles  is  distinguished  from 
Culex,  a  mosquito  often  associated  with  it,  by  the 
fact  that,  though  the  body  is  straight,  when  at  rest  the 
anterior  end  is  lower  than  the  posterior;  Culex  stands 
with  its  body  nearly  parallel  to  the  surface  on  which 
it  rests  and  has  a  distinct  bend  or  hump.  A.  pun/li- 
pennis  and  A.  maculipt  mi  is  range  nearly  all  over  (he 
United  States;  A.  crucians  is  a  southern  species. 
See  Insects,  poisonous.  A.  S.  P. 

Anophelinae. — The  family  to  which  the  malarial 
mosquito  belongs.  The  eggs  are  laid  singly  on  the 
surface  of  the  water;  the  larvae,  or  "wigglers,"  when 
at  the  surface  of  the  water  hold  the  body  parallel 
with  it;  and  the  adults  have  palpi  that  are  as  long,  or 
nearly  as  long,  as  the  proboscis.    See  Insects,  poisonous. 

A.  S.  P. 


Anoplura. — Lice.  Small  wingless  insects:  the  head 
bearing  a  short  tube  furnished  with  hooks;  feet 
terminated  by  a  single  long  claw.  These  animals  are 
exclusively  blood  sucking  in  their  food  habits.  Man 
is  infested  by  three  species  of  the  genus  Pediculus. 
See  Insects,  parasitic.  A.  S.  P. 

Antacids. — See  Alkalies. 

Antenatal  Pathology. — See  Embryos,  Human. 

Anthelmintics. — Agents  rendering  harmless  or 
killing  worms.  A  vermifuge  is  an  agent  which  expels. 
worms,  a  vermicide  one  which  kills  them,  but  these 
terms  are  occasionally  used  as  synonyms. 

A  priori  any  agent  thus  used  must  cither  be  in- 
soluble in  the  gastrointestinal  juices,  and  therefore 
non-absorbable,  or  else,  if  soluble,  must  possess   the 


454 


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Aflthi'inls 


faculty  of  being  innocuous  to  the  host  at  the  same  time 
thai  it  is  destructive  to  the  intruder.  Drugs  of  this 
latter  class  arc  few,  and  the  employment  of  nearlj 
all  absorbable  drugs  is  distinctly  hazardous,  for  their 
dose  is  necessarily  large,  and  they  uot   infrequently 

luce  various  phenomena  of  poisoning. 

,,.  convenience  worms  may  be  divided  into  four 

p  ,  each  with  its  own  treatment:  tape  worms  or 

,  ;  round  worms;  hook  worms;  scat,  pin,  or 
thread  worms. 

Tapeworm  or  Tania. — Drugs  used  in  tins  condition 
arc:  male  fern,  pelletierine  and  pomegranate  from 
which  it  is  derived,  pumpkin  seed,  thymol,  kamala. 
and   numerous  others  of  minor  importance. 

In    the    treatment    of    tapeworms  the  method  of 

cedure  is  of  as  much  importance  as  is  the  choice  of 

edy  to  be  employed.     An  absolute  essential 

is  the  withholding  of  all  food  from  the   patient  for 

a  twelve  to  twenty-four  hours.  If  this  is  imprac- 
ticable the  drug  should  be  administered  before  break- 
fast, a  light  supper  only  having  been  partaken  of  the 
previous  night.  About  three-quarters  of  an  hour 
after  the  administration  of  the  anthelmintic  an  active 

e  should  be  administered.  Castor  oil,  from 
half  an  ounce  upward,  appears  to  be  preferred  to  all 
other.-.,  but   should  not  be  used  with  male  fern.     As 

desideratum  is  the  removal  of  the  head  or  heads 

e     ..inn  or  worms,  the  stools  should  be  carefully 

lined  for  their  presence,  and  in  any  case  a  high 
tal  injection  should  be  given,  preferably  of  saline 

'ion,  as  this  is  most  useful  in  bringing  away  the 
head  of  the  taenia,  which  may  be  narcotized  but  not 
dead.  It  is  of  the  utmost  importance  that  the 
bowel     discharges     be     destroyed. 

(if  the  agents  used  against  this  worm,  five  are 
largely  and  successfully  employed,  though  at  times 
two  or  even  three  drugs  may  have  to  be  successively 

I.  and  the  treatment  may  even  then  fail.  Male 
fern  (aspidium)  is  most  useful  in  the  form  of  the 
oleoresin,  given  in  four  capsules  of  fifteen  minims 
each,  at  one  dose,  or  in  two  doses  half  an  hour  apart 
in  combination  with  calomel.  Pepo  is  most  effective 
and  may  be  used  by  taking  two  ounces  of  the  pow- 
dered pumpkin  seeds  to  make  an  emulsion  or  a  con- 
fection, this  amount  being  the  usual  dose.  Thymol 
is  one  of  the  most  available  remedies,  and  may  con- 
veniently be  given  in  capsules  of  ten  grains  each,  one 

ule  being  taken  every  quarter  of  an  hour  until 
two  drams  are  taken.  Alcoholic  beverages  should 
be  avoided  when  thymol  is  used.  Pomegranate  is 
used  by  taking  two  ounces  of  the  bark,  adding  this  to 
two  pints  of  water  which  is  boiled  down  to  one  pint, 
and  of  this  a  wineglassful  is  taken  ever}'  half-hour;  and 
it>  alkaloid,  pelletierine,  in  the  form  of  the  tannate, 
may   also  be  used  in  three-grain  doses.     Kamala  is 

by  Brumpt  to  be  insipid  and  therefore  very  well 
suited  to  children,  but  inert  in  adults.  It  sometimes 
produces  gastroenteric  irritation.  Dose,  half  to 
one  gram  for  each  year.  All  other  teniacides  are 
either  inferior  to  the  preceding  or  dangerous  (chloro- 
form, turpentine). 

Children  under  two  years  of  age  react  badly  to 
teniacides  as  a  rule,  and  great  care  must  be  taken  in 
treating  them  for  this  condition. 

Round  Worm  or  Ascaris  Lumbricoides. — These 
worms  affect  children  rather  more  than  adults,  and 
infest  the  upper  part  of  the  small  intestine,  though 
rarely  they  work  their  way  up  into  the  stomach,  and 

n  into  the  esophagus  and  pharynx.  Santonin, 
the  active  principle  of  santonica,  is  regarded  as  a  true 

ific  vermicide  for  round  worms,  and  when  given 
with  castor  oil  (5ss)  in  doses  of  gr.  £  (0.01)  for 
each  year  of  the  child's  age  it  should  occasion  no 
toxic  symptoms.  The  adult  dose  should  not  exceed 
gr.  iii.  (0.2).  To  augment  its  action  thymol  or  calo- 
mel may  also  be  given.  The  older  drugs  like  worm- 
seed  and  pink  root  hardly  have  any  special  field  of 
usefulness,  being  less  certain  of  action. 


[n  treating  any  patient  for  the  presence  of  a  caride  . 
it  is  in  ce    ary,  as  in  the  case  of  tapeworm,  that  food 

lie  abstained  from  for  twelve  or,  better,  twenty-four 
hours;   that    an   active   puree   be   administered   about 

three-quarters  of  an  hour  after  the  re ly  ha     been 

taken;  and  that   the  bowel  discharges  be  destroyed. 
Haul:    Worms. — The   parasitism   of   Necator  ameri- 

cantlS  or  hook  worm,  and  il  -  closely  related  congi 

Ankylostomum    duodenale,    with    the    disease    which 

I  hey  produce  is  naturally  eon   idered  in  full  elsewhere. 

From  the  therapeutic  standpoint  thee  intestinal 
parasites  are  amenable  to  vermicides  like  the  preced- 
ing. As  in  the  case  of  the  teniae  th  mo  I  efficacious 
arc  male  fern  and  thymol.  In  the  mines  where  anky- 
lostomiasis prevails,  male  fern  (oleoresin)  is  freely 
combined  with  both  castor  oil  and  chloroform,  all  in 

full  doses,  very  energetic  treatment  being  necessitated. 

In    the   uncinariasis  of  the  United  States  thymol  is 

given  in  full  doses  of  the  powdered  drug.  Oils,  alco- 
hol, or  other  solvent  substances  must  be  avoided 
during  the  treatment  lest  fatal  poisoning  results. 
Water  is  of  course  permissible.  With  this  precaution 
the  drug  may  be  given  hourly  on  the  fasting  stomach 
in  fractional  doses,  the  full  amount  not  to  exceed 
150  grains  (10.0).  The  number  of  other  substances 
having  some  power  over  the  hook  worm  is  large. 
It  comprises  oil  of  wintergreen,  oil  of  eucalyptus, 
/3-naphthol,  etc. 

Seat,  Pin,  or  Thread  Worms;  Oxyuris  Vermic- 
\daris. — These  worms  generally  infest  the  rectum  and 
colon,  and  are  most  common  in  children.  Anthel- 
mintics used  against  the  tape  and  round  worm  can  be 
employed,  as  many  of  them  are  equally  destructive 
to  the  seat  worm.  The  only  rational  procedure,  in 
fact,  is  to  attack  the  worm  from  above.  Thymol, 
santonin,  and  calomel  are  all  eligible,  given  as  in  the 
case  of  round  worms  and  tapeworms. 

In  regard  to  local  injection  treatment  there  is  no 
good  reason  for  the  belief  that  infusion  of  quassia,  that 
time  honored  empirical  remedy,  is  superior  to  in- 
fusions of  wormwood  or  tansy;  or  that  these  vegetable 
bitter  infusions  are  superior  (when  internal  treat- 
ment is  used)  to  simple  clysters  of  oil,  glycerin,  and 
water  or  saline  infusion.  If  a  parasiticide  is  indicated 
there  is  nothing  superior  to  an  injection  of  infusion  of 
santonin  itself.  Before  using  this  or  any  other  injec- 
tion the  bowel  should  be  thoroughly  cleansed  with 
soap  and  water,  and  it  is  imperative  that  the  injec- 
tion be  retained,  by  pressure  over  the  anus,  for  fifteen 
or  twenty  minutes,  and  that  the  region  around  the 
anus  be  thoroughly  washed  with  salt  and  water. 
Failure  to  observe  these  precautions  will  render  the 
treatment  of  little  avail. 

For  cleansing  with  soap  and  water  and  for  injecting 
the  medicament  a  soft  rubber  catheter  or  rectal  tube 
will  be  found  most  useful  in  aiding  the  solution  to 
go  well  up  into  the  colon,  and  it  is  advisable  to  repeat 
the  treatment  two  or  three  times  at  intervals  of  a 
day  or  so.  Charles  Adams  Holder. 

Edward  Preble. 

Anthetnis. — Chamomile;  Roman,  English,  or  Garden 
Chamomile.  "The  dried  flower-heads  of  Anthemis 
nobilis  L.  (fam.  Compositie),  collected  from  cultivated 
plants"  (U.  S.  P.).  In  this  definition  the  Pharma- 
copoeia recognizes  the  fact  that  under  cultivation  the 
aroma  and  flavor  of  the  chamomile  grow  finer  and  less 
rank  and  heavy,  notwithstanding  that  the  percentage 
of  volatile  oil,  and  very  likely  the  medicinal  strength, 
are  somewhat  decreased. 

The  chamomile  plant  is  a  native  of  Europe  and  is 
largely  cultivated  in  temperate  regions.  It  is  a  low 
perennial,  hairy  herb  with  a  branching  rhizome, 
and  rather  numerous  stems,  most  of  which  are  short 
and  bear  leaves  only.  The  flowering  stems  are  long, 
slender,  prostrate,  often  rooting  at  the  base,  but 
ascending  and  branched  above,  and  bearing  the 
flowers  at  the  ends  of  the  branches.     Flower-neads 


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Fig.  254. — Chamomile, 
"Wild  or  Single-Flowered 
Plant.  One-third  natural 
size.     (Baillon.) 


radiate,  about  two  centimeters  (f  in.)  across  with, 
in  the  "single"  (natural)  form,  a  single  row  of 
white  rays  and  a  yellow  disk.  Involucre  of  two 
or  three  rows  of  blunt,  appressed,  scarious-margined 
.scales.  Receptacle  chaffy,  conical,  solid,  longer  than 
broad;  ray  flowers  fertile,  limb  three-toothed;  disk 
flowers  perfect,  tubular  below, 
bell-shaped  above.  Achenia 
obovate,  slightly  compressed, 
pappus  none.  The  oil  glands 
are  mostly  on  the  corolla  tubes, 
and  less  abundant  on  the  ray 
than  on  the  disk  flowers.  Un- 
der cultivation,  ligulate  flowers 
largely  replace  the  tubular 
disk  flowers,  so  that  the  heads 
become  "double"  and  large 
and  white,  which  condition,  by 
careful  and  rapid  drying, 
should  be  preserved  in  the 
dried  heads. 

Chamomile  contains  nearly 
one  per  cent,  of  a  blue  volatile 
oil,  turning  greenish  or  yellow- 
ish with  keeping  and  having  a 
specific  gravity  of  .905  to  .915. 
The  important  constituents  of 
this  oil  are  anthemol  (C,0H1(iO) 
and  cumin  aldehyde  (<',II4.C3- 
Hj.CHO).  The  composition  of 
the  remainder  of  the  oil  is  very 
complex.  With  the  oil  there 
are  an  amaroid,  some  resin, 
and  a  little  tannin. 

Chamomile  is  one  of  the 
very  best  of  the  aromatic  bit- 
ters, and  is  strongly  carmina- 
tive and  somewhat  antispas- 
modic. The  dose  is  gr.  xv.-lx. 
(1.0-4.0).  There  is  no  official  preparation.  The  best 
form  of  administration  is  a  tincture,  so  as  to  contain 
all  the  oil.  As  a  simple  stomachic  a  decoction  or 
infusion  is  excellent.  This  should  be  well  diluted, 
taken  slowly  before  meals,  and  the  dose  should  be 
small.  The  oil  is  often  given  as  a  carminative  and 
antispasmodic,  in  doses  of  iro  i.  to  v.  (0.00-0.3). 

Allied  Plants. — The  genus  contains  about  eighty 
species,  and  includes  the  common  mayweed  (Anthemis 
cotula  Linn.).  They  are  generally  less  agreeable 
than  chamomile,  and  although  of  simiar  qualities,  not 
in  use.  Chrysanthemum  parthenium  Pers.  (feverfew) 
is  sometimes  used  as  a  substitute  or  adulterant  of 
this  article.  It  can  be  told  by  its  flatter  and  less 
chaffy  receptacles.  Henry  II.  Rusby. 

Anthracosis. — The  deposit  of  fine  particles  of  carbon 
in  the  body  tissues  is  known  as  anthracosis.  Carbon, 
either  in  the  form  of  soot  from  smoke  or  dust  from 
unburned  coal,  is  one  of  the  most  common  forms  of 
dust,  and  under  the  ordinary  conditions  of  civilized 
life  is  almost  constantly  present  in  the  atmosphere. 
It  may  gain  entrance  to  the  tissues  either  through 
the  respiratory  tract  or  through  the  alimentary  canal. 
The  inhalation  origin  of  anthracosis  has  been  accepted 
without  question  until  recently  when,  through  the 
investigations  of  Calmette,  Guerin,  Van  Steenberghe, 
and  Grysez,  the  opinion  has  gained  ground  in  France 
that  the  deposits  of  carbon  dust  in  the  lungs  and 
bronchial  glands  are  the  results  of  ingestion  and  not  of 
inhalation.  Experiments  on  rabbits  showed  that 
ligature  of  the  esophagus  prevented  anthracosis; 
while,  when  swallowing  was  permitted  in  animals 
having  one  bronchus  plugged  with  cotton-wool,  the 
corresponding  lung  developed  anthracosis  in  the  same 
degree  as  the  other  lung.  Repeated  experiments  by 
the  investigators  named  have  shown  that  finely 
powdered  coal  dust,  cinnabar,  and  India  ink  may  pass 


the  intestinal  wall  into  the  lymphatic  system  and 
thence  into  the  lungs  and  bronchial  glands.  The 
intestinal  epithelium  apparently  plays  no  part  in  the 
transmission  of  the  dust  particles;  it  is  accomplished 
chiefly  or  wholly  by  the  leucocytes.  In  young 
animals  the  pigment  thus  taken  in  through  the 
intestinal  mucosa  is  largely  filtered  out  by  the  mesen- 
teric glands,  but  in  older  animals  a  larger  port  ion  of 
the  dust  or  pigment  particles  passes  on  through  the 
thoracic  duct  and  thence  into  the  lungs.  Feeding 
experiments  show  that  pulmonary  anthracosis  may 
develop  rapidly  in  this  way.  Calmette  argues, 
therefore,  that  physiological  anthracosis  is  chiefly  due 
to  an  ingestion  of  carbon  dust.  Only  after  a  pro- 
longed stay  in  a  very  smoky  atmosphere  does  inhala- 
tion play  an  important  role  in  the  production  of  this 
condition. 

Biondi  has  confirmed  Calmette's  statements  in  so 
far  as  experiments  with  powdered  graphite  are  con- 
cerned, but  points  out  that  metallic  dust  acts  in  a  very 
different  way  from  carbon  dust.  When  ingested  the 
former  is  dissolved  or  chemically  changed  and  is  nol 
deposited  in  the  lungs  or  bronchial  glands,  so  that 

deposits  of  metallic  dust  occurring  in  the  lungs i 

be  the  result  of  inhalation.  Petit  has  also  confirm.  1 
Calmette's  views  by  the  feeding  of  charcoal  dust  to 
infants  suffering  from  fatal  conditions  such  as  tuber- 
culosis and  marasmus.  To  prevent  the  entrance  of 
any  of  the  dust  into  the  respiratory  tract  it  was  given 
in  a  suspension  through  an  esophageal  tube.  At 
autopsy  the  mesenteric  glands,  lungs,  and  bronchial 
glands  of  the  tuberculous  infants  showed  anthracosis, 
but  it  was  absent  in  the  glands  of  the  marasmic 
infants. 

In  Germany  the  work  of  the  French  observers  has 
been  generally  discredited,  and  the  German  patholo- 
gists have  not  accepted  Calmette's  views.  Schultze 
found  in  feeding  experiments  carried  out  upon 
guinea-pigs  and  rabbits  that  deposits  of  the  pigment 
were  present  only  in  the  intestine  and  lung,  and 
regards  this  as  evidence  that  some  of  the  carbon  dust 
had  been  inhaled  accidentally.  Aschoff's  experi- 
ments with  the  feeding  of  carmine  were  negative. 
Miranescu  in  a  series  of  feeding  experiments  with 
India  ink,  carmine,  and  charcoal  emulsion  obtained  no 
pulmonary  deposits  as  the  result  of  ingestion  alone. 
Likewise  the  feeding  experiments  conducted  by 
Feliziani  proved  negative.  On  the  other  hand,  inhala- 
tion experiments  carried  out  by  various  workers  upon 
the  guinea-pig,  rabbit,  and  dog  show  that  inhaled 
carbon  dust  can  penetrate  the  lungs  and  after  entering 
the  lymphatics  pass  to  the  bronchial  glands. 

In  this  undecided  state  the  matter  stands  at  the 
present  time,  and  a  thorough  investigation  of  the 
whole  subject  of  anthracosis  seems  necessary  in  order 
to  settle  this  and  the  other  important  questions  arising 
out  of  Calmette's  claims.  If  the  ingestion  theory  of 
anthracosis  is  shown  to  be  correct,  it  would  appear 
not  at  all  improbable  that  many  of  the  inflammatory 
affections  of  the  lung,  as  well  as  tuberculosis,  are  the 
result  of  infection  by  way  of  the  intestinal  tract. 

Other  recent  contributions  to  our  knowledge  of 
anthracosis  deal  with  its  relation  to  tuberculosis. 
Among  these  may  be  mentioned  Ribbert's  view  that 
anthracosis  is  largely  determined  by  a  previous 
healed  tuberculosis,  although  he  rejects  wholly  the 
ingestion  theory.  Wainwright  in  a  study  of  the 
miners  of  the  anthracite  region  in  Pennsylvania  found 
the  death  rate  from  tuberculosis  among  them  to  he 
only  3.37  per  cent,  for  adults  as  opposed  to  9.97  per 
cent,  in  all  other  occupations.  Wainwright  and 
Nichols  have  also  carried  out  experimental  investiga- 
tions to  determine  if  pulmonary  anthracosis  rendered 
the  lungs  less  susceptible  to  tuberculosis,  as  has  been 
claimed  in  the  case  with  miners.  Two  sets  of  guinea- 
pigs  were  given  intratracheal  injections  of  tubercle 
bacilli.  One  set  had  been  kept  for  two  months  in  an 
atmosphere  saturated  with  coal  dust.     In  this  group 


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Anthrax 


of    animals    the    lungs    remained    practically    free, 
although    abdominal    tuberculosis    developed.     The 

control    group    developed    pulmonary    lesi 3.      No 

satisfactory    explanation    of    this    phenomenon    wa 
discovered,  bul  il  was  thought  thai  the  soluble    all 
0f  |ime  contained  in  coal  raighl   have  an  inhibiting 
,n  upon  the  growth  of  tubercle  bacilli,  or  thai 
. ., i,,  changes  occur  in  the  structure  of  the  lungs 
that  render  them  less  susceptible  to  infection.     On 
the  other  hand,  marked  anthracosis  of  the  lung     1 
often  associated  with  a  chronic  fibroid  tuberculosis. 

Avnn;  u  osi  ~  l'rl  M"sl  M-   "The  lungs  of  the 
arc  grayish-pink  wil  ;ment,  but  in  a  very 

ler  ordinarj  condit  ions  deposits  of  blai 
pigment  appear  in  spots  over  the  surface  of  the    ■ 
\.  a   rule  it    i     not    well  marked  before  the 
.,.  bul   may  be  -  arly  as  the  third  or 

fourth  month  after  birth.     It  increases  with  age  and 
ording  to  the  conditions  of  life  of  the  individual 
.,,..,,   engineers,   coal-miners,   dwellers  in   smoky 
:.).     Only  a  very  small  portion  of  the  carbon 
tied  cains  entrance  to  the  tissues,  the  greater 
g  thrown  out  in  the  exhaled  air,  in  mucu 
tic  cells,  aided  by  the  cilia  of  the  respiratory 
epithelium.     Desquamated  epithelial  cells  and  1> 

ntaining  carbon  pigment  are  always  presenl 
in  the  alveoli.  In  early  stages  of  anthracosis  the 
lungs    1  >ver  with   small   black  granules  on   the 

surface,  often  arranged  regularly  about  the  lobules. 
In  more  advanced  cases  the  pleural  surfaces  of  the 
lungs    may    -how    heavily    pigmented    bands    corre- 
iding  to  the  intercostal  spaces,  while  the  portions 
urface    corresponding    to    the    ribs    are    less 
:     pigmented.     The  posterior  and  middle  por- 
e  usually  chiefly  affected,  although  occasion- 
ally  the  apices  show  it.     The  parietal  pleura  may  be 
ilarly    marked    in   black   bars   or   stripes.     Small 
flattened  black  nodules  are  often  seen  in  or  beneath 
the  visceral  pleura.     They  are  hard  and  dense,  and 
often  calcified.     For  the  greater  part  they  repre- 
healed  tubercles;  in  these  the  pigment  shows  an 
cial    tendency    to    collect.     Microscopically    the 
nent  is  found  chiefly  in  the  primitive  lymph  nodes 
along  the  course  of  the  lymphatics  in  the  peri- 
bronchial     connective      tissue,      interlobular     septa. 
1   walls  of  the  arteries.     The  bronchial  nodes  arc 
heavily    pigmented.     In    the   ordinary   physiological 
■   the  anthracosis  does   not   extend   beyond    the 
bronchial  nodes,  and  no  ill  effects  result. 

In  the  more  marked  cases  (coal-miner's  lung)  the 
lungs  may  be  slaty  and  black  throughout,  and  either 
are   diffusely    indurated    (anthracotic    induration)    or 
present  nodular  areas  of  black  induration.     Softening 
of  the  latter  may  occur,  leading  to  the  formation  of 
ities  filled  with  a  black  granular  material  {phthisis 
a).     This  softening  may  be  non-bacterial  in  origin, 
1  should  not  be  regarded  as  tuberculous  without 
microscopical  examination.     On  microscopical  exami- 
nation   the    advanced    case    of    anthracosis    shows 
usually    chronic   bronchopneumonia   and   induration 
erstitial    pneumonia).     The    epithelium    of    the 
iles  and  alveoli  is  granular,  pigmented,  and 
quamating.     The  loss  of  the  epithelium  increases 
the  tendency  for  the  pigment  to  gain  direct  entrance 
into   the    capillaries.     Chronic   adhesive   pleuritis   is 
usually  present  also.     The  bronchial  glands  are  black 
and    indurated,    but   softening    (suppuration,    tuber- 
culosis) is  not  uncommon  and  the  softened  node  may 
break    through    into    the   blood-vessels,    bronchi,    or 
trachea.     The  pigment  may  then  be  carried  to  spleen, 
liver,  kidneys,  etc.     Even  without  such  a  rupture  into 
the  vessels,  pigment  may  be  found  in  these  organs  in 
severe  cases  of  anthracosis,  so  that  a  direct  passage  of 
carbon  granules  from  the  pulmonary  alveoli  into  the 
capillaries  must  be  regarded  as  possible.     In  severe 
anthracosis   the   lymph   nodes  of   the   mediastinum, 
cervical    and    retroperitoneal    regions    may    become 


anthracotic.  In  the  ca  e  ol  the  abdominal  lymph 
nodes  the  anthracosis  may  be  the  re  nil  of  a  retro- 
grade metastasis.  From  the  softened  bronchial 
nodes  the  pigmenl  ma}  be  carried  into  the  walls  of  the 

trachea,     bronchi,     bl [-vessels,     and     esophagus, 

u  ually    after    tdhi  to    these    si rucl urea    have 

occurred  as  the  resull  of  a  periadeniti  .     Ei n  and 

perforation  may  lead  to  the  establishment  of  com- 
munications between  esophagus  and  bronchus  with 
resulting    moisl    gangrene   of    the    hum.      Indurated 

anthracotic  bronchial  nodes  may  al    0  I  tion- 

dh  erticula  of  t  he  i   ophagus. 

Anthracosis  of  the  Spleen. — Following  the 
rupture  of  a  softened  or  tuberculoid    I hial  node 

into  the  bl l-ve    i  I    (pulmi  mai  j    '  ein      pari  ii  le    of 

carbon  enter  the  arterial  circulation,  and  tire  carried 
to  the  various  organs  where  they  lodge  first  upon  the 

helium.     They  are  then  passed  into  t  he  I 
ic    phagocytic  cells  so  thai   within  a  relatiyelj     hort 
time   the   pigmenl    disappears   from   the   circulation. 
In  the  spleen  it   is  cull, ■del  around  the  trabei     : 

the  adventitia  of  the  arterie  ,  and  follicles. _   Pign 

lies  may  til-"  be  found  in  the  endotheliui 
splenic  veins.  To  the  naked  eye  the  pigment  appears 
as  small  black  points,  scattered  over  the  cut  surface, 
but  in  very  severe  cases  the  spleen  may  be  slate 
colored  and  indurated.  A  moderate  degree  of  anthra- 
cosis of  the  -pleen  is  not  uncommon  in  old  people, 
particularly  those  with  emphysema,  and  who  live 
in  a  smoky  place.  It  is  probable,  therefore,  thai  the 
pigment  can  pass  directly  into  the  _  pulmonary 
capillaries,  and  thence  into  the  systemic  circulation. 

Anthracosis  of  the  Liver. — Carbon  gains  en- 
trance to  the  liver  under  the  same  conditions  as  jn  the 
case  of  the  spleen.  The  pigment  is  found  first  in  the 
endothelial  cells  of  the  liver  capillaries,  and  then  col- 
lect s  about  the  central  vein  and  the  periacinous 
tissue,  particularly  in  rudimentary  lymph  nodes. 
To  the  naked  eye  it  may  appear  as  small  black  dots 
beneath  the  capsule  or  on  the  surface.  The  portal 
glands  may  be  slaty  or  black.  In  very  severe  ca 
the  interlobular  connective  tissue  may  become  in- 
creased (anthracotic  cirrhosis);  or  the  deposit  of  the 
pigment  is  coincident  with  a  cirrhosis. 

Anthracosis  op  the  Kidneys. — This  occurs  under 
the  same  conditions  as  anthracosis  of  the  spleen  and 
liver,  but  is  more  rare,  and  is  usually  less  marked. 
The  pigment  is  found  about  the  larger  blood-vessels. 

Anthracosis  of  the  bone-marrow,  tonsils,  and  prr- 
iphi  ral  lymph  nodes  has  also  been  observed  in  cases  in 
wdiich  a  large  amount  of  carbon  has  gained  entrance 
to  the  circulation  through  the  rupture  of  a  softened 
bronchial  gland  into  a  pulmonary  vein.  In  the  case 
of  tuberculous  softening  of  these  glands  a  metastasis 
of  tubercle  bacilli  may  occur  at  the  same  time  as  that 
of  the  pigment.  Aldred  Scott  'Warthix. 


Anthrax. — Synonyms:  Carbunculus  contagiosus; 
Milzbrand;  Charbon;  Wool-sorter's  disease;  Mai  de 
rate;  Mycosis  intestinalis;  Anthracemia;  Malignant 
pustule;  Splenic  fever.  (See  also  Carbuncle  and 
Furuncle.) 

A  specific,  highly  infectious  disease,  common  to 
most  vertebrate  animals  and  communicable  to  man 
(though  in  varying  degree).  The  disease  is  not  con- 
tagious in  the  ordinary  sense  of  the  word,  but  it  is  in 
a  high  degree  transmissible  by  means  of  secondary 
media  of  infection.  It  maintains  its  virulence  for 
long  periods,  and  suffers  no  deterioration  from  trans- 
portation or  variations  of  climate  or  other  external 
conditions.  It  appears  as  an  acute  intoxication, 
usually  of  a  restricted  part  of  the  body,  but  later  of 
the  entire  body,  and  is  due  to  the  invasion  of  the 
tissues  of  its  host  by  the  Bacillus  anthracis.  The 
disease  is  primary  in  animals,  and  occurs  in  the  hu- 

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man  subject  in  two  distinct  forms,  viz.,  by  direct 
inoculation,  or  indirectly  by  eating  the  flesh  of  ani- 
mals infected  with  anthrax  or  by  inhaling  dust  which 
is  contaminated  with  the  poison  of  anthrax,  as  in  the 
operations  of  currying  hides,  upholstery,  mattress- 
making,  etc.  The  blood,  tissues,  and  excretions  of 
an  animal  dead  from  anthrax  are  found  to  contain  a 
minute  organism,  in  the  form  of  a  rod  bacillus, 
which  has  been  demonstrated  to  be  the  specific  and 
invariable  cause  of  the  disease,  and  may  be  obtained 
in  every  fully  developed  case  of  anthrax.  At  the 
point  of  invasion  the  bacillus  first  acts  as  a  purely 
local  poison,  producing  only  a  local  irritation,  but,  it 
soon  multiplies  rapidly,  and  later  is  conveyed  by  the 
circulating  blood  into  all  parts  of  the  body,  where 
by  its  enormous  numbers  it  blocks  the  capillaries 
with  embolic  masses  of  bacilli,  causing  innumerable 
hemorrhages  into  the  organs  and  tissues,  and  effu- 
sions into  the  serous  cavities  and  cellular  structures; 
and  by  its  specific  toxin  acting  upon  the  sympathetic 
nerve  centers  it  produces  great  depression  of  the 
vital  functions,  which  often  ends  in  death  within  a 
few  days. 

Koch  first  demonstrated  that  the  development  of 
anthrax  is  inseparably  associated  with  the  life  and 
development  of  the  Bacillus  anthracis,  and  that  only 
infected  substances  which  contain  bacilli  capable  of 
growth  and  development,  or  the  spores  of  the  anthrax 
bacillus,  are  able  to  produce  the  disease;  and  that  the 
propagation  of  pure  cultures  of  Bacillus  anthracis, 
obtained  from  actual  cases  of  the  disease  in  animals, 
through  more  than  a  hundred  generations  by  trans- 
plantation to  fresh  media,  does  not  change  the  nature 
of  the  infection;  but  that  material  from  the  last 
experimental  transplantation  possesses  the  power  to 
produce  anthrax  just  as  certainly  and  in  as  typical 
form  as  the  original  material  which  was  obtained 
from  the  diseased  animal. 

Anthrax  is  the  most  widely  spread  and  the  most  de- 
structive of  all  communicable  diseases  which  affect  ani- 
mals. The  malady  is  primary  in  the  herbivora,  and  is 
found  in  all  countries.  It  is  very  prevalent  in  parts 
of  France,  Germany,  Italy,  Persia,  North  and  South 
Africa,  and  South  America.  It  is  least  prevalent, 
though  not  absent,  in  Australia,  North  America,  and 
the  British  Isles.  Epidemics  of  the  disease  often 
appear  among  cattle  and  sheep  of  affected  regions,  ami 
may  be  fatal  at  the  rate  of  from  fifty  to  seventy  per  cent, 
of  the  animals  attacked.  It  also  attacks  human 
beings  in  infected  districts  by  inoculation  from  the 
lower  animals,  and  is  often  attended  with  great  fa- 
tality. All  classes  of  vertebrate  mammals  are  sus- 
ceptible to  anthrax.  The  disposition  of  the  mam- 
malia to  anthrax  may  be  expressed  in  this  ratio: 
herbivora,  omnivora,  carnivora — the  first  having  the 
greater,  the  last  scarcely  any  susceptibility  under 
natural  conditions.  Both  omnivora  and  carnivora 
appear  to  be  absolutely  immune  to  local  infection, 
even  when  living  in  notoriously  infected  districts, 
frequently  drinking  the  same  water,  and  roaming 
over  the  same  territory  in  which  herbivora  may  have 
been  infected,  and  are  dying  at  the  time. 

There  is  no  other  source  for  anthrax  in  man  than 
direct  contact  with  a  diseased  animal,  or  indirect 
acquisition  through  some  product  of  a  diseased  or 
dead  animal.  Of  two  hundred  persons  who  ate  of 
the  cooked  flesh  of  a  diseased  ox,  not  one  became 
diseased;  while  five  who  handled  the  fresh  meat 
became  diseased  and  three  died.  Whatever  the 
anthrax  toxin  may  be,  it  certainly  is  either  not  dan- 
gerous to  man  if  taken  into  the  stomach,  or  is  de- 
stroyed in  the  pickling  and  cooking  of  the  flesh. 
The  disease  does  not  spread  by  contact  or  associa- 
tion; it  can  be  acquired  only  by  the  introduction  of 
the  infective  organisms  into  the  body,  either  through 
an  abrasion  of  the  skin  or  a  defect  in  the  mucous 
membranes,  or  by  the  spores  of  the  bacilli  finding 
their  way  through  the  epithelial  lining  of  the  alimen- 


tary canal  or  respiratory  tract,  and  so  causing  gen- 
eral infection.  The  inoculation  of  these  organisms 
produces  the  same  fatal  effect  upon  animals  as  does 
the  infection  from  the  original  source  of  the  primary 
disease.  Blood  taken  from  a  diseased  animal  is 
also  fatal  if  introduced  into  the  tissues  of  another 
susceptible  healthy  animal;  but  if  the  blood  is  filtered 
previous  to  its  introduction,  so  as  to  remove  all  germ-, 
it  is  no  longer  infectious  to  a  healthy  animal  (Klebs, 
Pasteur). 

In  Great  Britain,  anthrax  is  included  among  the 
maladies  specified  under  "The  Contagious  Diseases 
Acts."  In  England,  numerous  outbreaks  of  anthrax 
have  been  traced  to  the  refuse  of  washings  from  wool, 
hair,  etc.,  which  are  discharged  into  streams  or 
sewers,  and  from  the  solid  residue  which  is  used  for 
manure. 

Animals  rarely  take  the  disease  from  other  animals, 
but  obtain  it  indirectly  from  the  soil  or  other  second- 
ary medium  of  infection.  Thus,  certain  restricted  re- 
gions or  localities  become  centers  of  infection  where 
the  disease  shows  itself  year  after  year.  This  may 
arise  from  the  superficial  burial  of  animals  dead  from 
anthrax,  which  leads  to  the  infection  of  the  soil, 
which,  once  produced,  is  not  easily  eradicated.  In 
portions  of  the  province  of  Brandenburg,  the  owners 
of  cattle  have  learned  by  oft-repeated  experience  the 
exact  boundaries  of  limited  districts,  and  even  of 
certain  fields,  where  anthrax  contamination  persists 
in  the  soil.  The  same  condition  prevails  in  certain 
portions  of  the  Bavarian  Alps. 

No  ordinary  changes  of  temperature,  such  as  freez- 
ing of  the  ground,  affect  the  vitality  of  the  organism. 
Stable  implements,  veterinary  surgical  instruments, 
etc.,  may  spread  the  disease  among  healthy  animals. 
The  bodies  of  animals  when  buried  are  not  so  dan- 
gerous for  the  propagation  of  anthrax  as  are  the 
blood,  intestinal  contents,  etc.,  which  may  be  scattered 
on  the  surface  of  the  ground  or  adhere  to  gra-s 
shrubs,  etc. 

Herbivorous  animals,  such  as  cattle  and  sheep, 
are  more  susceptible  to  the  intestinal  form  of  anthrax, 
but  are  less  often  affected  by  the  external  form  of  the 
disease,  the  so-called  "  malignant  pustule."*  Others, 
such  as  guinea-pigs  and  rabbits  and  white  mice,  are 
less  often  attacked  by  the  intestinal  forms,  but  are 
more  susceptible  to  subcutaneous  inoculation  by 
experiment.  The  carnivora  are  less  susceptible  than 
other  classes.  Animals  ordinarily  acquire  anthrax 
by  way  of  the  intestinal  canal,  through  infected  fodder, 
stable  litter,  manure,  or  from  water  polluted  by  an- 
thrax infection;  or  from  infection  of  the  pastures  or 
fields  ow-ing  to  the  exposed  bodies  of  animals  dead 
from  the  disease;  or  from  the  contamination  of  the 
grass  by  the  anthrax  germs  from  the  dead  body  of  an 
animal  which  has  been  buried  in  the  vicinity. 

Direct  inoculation  of  anthrax  in  man  is  not  very  com- 
mon. It  can  happen  only  in  those  whose  calling 
brings  them  in  direct  or  personal  contact  with  the 
diseased  or  dead  animal.  There  must  be  also  either 
an  abrasion  of  the  epidermis  or  a  wound  of  the  skin 
to  insure  infection.  Veterinaries  and  knackers  have 
been  more  frequently  affected  than  physicians,  nurses, 
undertakers,  or  butchers.  Herley  (the  Lancet,  Dec. 
4,  1909,  p.  1664)  reports  a  case  of  anthrax  in  a  butcher, 
one  of  whose  cows  had  suddenly  died;  he  skinned  and 
cut  up  the  carcass  the  same  day.  The  meat  was  sold 
to  his  neighbors,  and  the  hide  to  a  dealer.  Ten  days 
later  the  butcher  was  admitted  to  the  hospital  with  a 
typical  anthrax  "pustule"  on  the  front  of  the  left 
forearm,  where  he  had  received  a  scratch  while  skin- 
ning the  dead  cow.  The  whole  of  the  limb  was 
swollen,  and  there  were  several  bulla?  on  the  fore- 

*  "The  name  'malignant  pustule*  is  a  misnomer,  as  it  does  not 
contain  pus;  and  when    it    remains  the  only    manifestation    of 
the  disease,  is  not  particularly  malignant"    (Bryanl  and    Buck). 
"Suppuration  does  not  occur  unless  there  is  a  mixed  infect 
(Keen). 


458 


i;i:i  u;i:\ri.    n  wdkook   or    i  in:   mkdical  sen  mis 


Anthrax 


nnii.  Temperature  was  in:;  ,  pulse  92,  and  respira- 
tions 24.  This  patient  nil  imalely  recovered  after  a 
very  severe  illness.      The  flesh  of  the  cow,   as  stated, 

was  snlil  tn  "  neighbors"  at  reduced  prices,  ami  prob- 
ably over  inn  persons  partook  of  it.  One  woman 
who  handled  the   raw   meal    developed  a  malignant 

pustule  mi  her  face;  but    no  ea  se  (if  iiite-l  inal  ant  hra  \ 

was  recorded.  A  second  cow  in  the  same  herd  con- 
tracted anthrax  and  died,  bul  was  cremated  in  the 
orthodox  fashion.  There  is  danger  in  man  from  Hies 
about  those  affected  with  anthrax,  as  it  has  been 
ived  that  the  virus  of  many  infectious  diseases  may 
ved  by  insects,  either  from  soiling  of  their 
bodies  or  limbs  with  the  infectious  material,  or  from 
their  dejections  which  may  contain  the  germs  of  an 
infectious  disease. 

Anthrax  in  man,  in  this  country  at  least,  is  almost, 
exclusively  limited  to  those  working  in  animal 
products  imported  from  other  countries  where  I  he 
disease  exists.  The  dead  animal  is  far  more  dan- 
us  when  thus  distributed  than  is  the  living 
animal  to  the  human  beings  in  its  own  immediate 
vicinity.  Infection  may  occur  through  the  skin. 
the  intestines,  or  the  lungs.  In  a  guinea-pig  a  single 
Nils  of  virulent  anthrax:  is  capable  of  producing 
fatal  infection.  In  infected  localities  the  anthrax 
bacillus  lives  in  the  soil,  and  may  thus  render  certain 
portions  of  a  field  or  pasture  where  the  bodies  of 
animals  dead  from  the  disease  have  been  buried  a 
permanent  source  of  the  disease  to  other  susceptible 
animals  through  long  periods. 

The  greatest  source  of  danger  in  this  disease  lies  in 
the  fait  that  the  virus  may  be  introduced  through 
the  smallest  abrasion  or  injury  of  the  skin  or  of  the 
mucous  membrane  of  the  alimentary  canal.  The 
degree  of  susceptibility  of  different  animals  to  the 
poison  of  anthrax  is  not  uniform.  Strong,  healthy 
animals  are  more  easily  affected  than  the  lean  or 
sickly.  One  attack  affords  no  protection  against  a 
recurrence  of  the  disease.  To  show  the  ravages  of 
this  disease,  it  may  be  stated  that  in  Russia,  in  the 
year  1804,  no  less  than  72,000  horses  were  destroyed 
by  it.  In  the  province  of  Novgorod,  within  four 
years,  more  than  56,000  horses,  cows,  and  sheep,  as 
well  as  525  men,  fell  victims  to  this  terrible 
-  'nirge. 

Statistics  for  the  years  1901-1903  show  that  about 
150,000  cases  of  anthrax  were  reported  in  European 
Russia  and  the  Caucasus,  and  about  1,500  in  Ger- 
many, and  12,000  in  Italy.  The  source  of  infection 
from  horsehair  could  be  traced  to  that  brought  from 
China.  Russia,  Siberia  or  South  America.  In  hides 
and  skins,  those  imported  from  China,  Bombay,  and 
t lie  East  Indies  were  the  most  common  carriers  of 
lion.  In  1899,  Russell  traced  cases  occurring 
in  Wisconsin  to  hides  received  from  South  America 
and  China;  while  Revenal  in  1897,  attributed  twelve 
fatal  eases  in  man,  and  sixty  in  cattle  to  Chinese  hides. 
That  material  imported  from  these  countries  is  par- 
ticularly liable  to  contain  anthrax  infection  is  due  to 
climatic  conditions;  "Places  liable  to  be  flooded,  and 
drying  out  to  a  considerable  degree  in  summer, 
characterize  districts  in  Persia,  Asia  Minor,  and  the 
plateaus  of  Central  Asia"  (Billings).  Willard  col- 
lected ten  cases  near  Philadelphia,  with  a  mortality 
of  fifty  per  cent.  The  months  of  July  and  August 
witness  the  greatest  number  of  cases,  when  the  soil 
contains  much  putrefying  organic  matter  believed 
to  favor  the  growth  of  the  organism.  Males  are  af- 
fected far  more  frequently  than  females;  ninety-six 
per  cent,  of  261  cases  collected  by  Legge  in  Great 
Britain  being  males.     (Keen's  Surgery,  vol.  i.,  1906.) 

There  are  three  portals  of  entry,  corresponding  to 
the  three  clinical  types  of  the  disease:  when  the 
organisms  are  (1)  deposited  in  wounds  or  abrasions 
of  the  skin;  (2)  are  inspired;  and  (3)  when  they-  are 
ingested  into  the  gastrointestinal  tract.  In  Legge's 
oases,    six   only   were   of   the   internal    variety;   the 


remainder  occurred  in  eighty-five  per  cent,  upon  the 
head,  face,  and  neck.  In  923. cases  collected  bj  Koch 
(1886),  mo  i  of  which  were  contracted  from  hides 
and  skins,  the  head  and  face  were  affected  in  forty- 
eight  per  een!.,  a  n.l  I  he  1 1|  i|  ier  e\l  remit  y,  particularly 
I  In    hand  and  lingers,  in  forty  per  cent. 

The  disease  spreads  among  men  in  proportion  as 
they  are  exposed  to  infection  from  diseased  animals 
or  men.*  Shepherds,  farmers,  butcher-,  coach  lie  n, 
stablemen,  as  well  as  veterinary  surgeons  and  tho  6 
individuals  who  handle  animal  products,  such  as 
wool  sorters,  curriers,  mattress-makers,  etc.,  are 
especially  exposed.  Horsehair  is  particularly  dan- 
gerous. Further,  articles  like  hid.-,  horns,  wool, 
eie.,  from  countries  where  i he  disease  is  prevalent, 

which  may  be  transported  great  distances,  are  liable 
to  convey  I  he  infection  and  Ihus  give  rise  to  the  mal- 
ady among  those  employed  in  their  transportation  or 
manufacture.  Trousseau  mentions  two  factories  in 
Paris,  in  which  horsehair  from  Buenos  Avres  was 
used  in  upholstering  furniture,  and  in  which  not, 
more  than  six  or  eight  workmen  were  employed: 
during  ten  years  twenty  laborers  died  in  these  estab- 
lishments from  anthrax.  Even  after  the  hair  has 
been  long  in  use,  the  disease  may  be  induced  in  the 
form  of  true  malignant  pustule  in  those  employed 
in  renovating  the  upholstering.  A  small  scratch  or 
crack  in  the  skin  or  mucous  membrane  is  sufficient 
for  inoculation,  and  frequently  the  disease  is  intro- 
duced into  the  system  by  the  unclean  nails  or  fingers 
of  workmen  in  scratching  the  face  or  arms. 

At  an  inquest  held  recently  at  St.  Pancras  on  the 
body  of  Henry  Stephen  Thurston,  laboratory  at- 
tendant at  University  College  Hospital,  it  was  proved 
that  the  deceased  had  died  from  anthrax  poisoning. 
He  had  developed  a  boil  on  the  side  of  his  neck  which 
had  been  removed  after  microscopic  examination  of 
matter  from  it  had  shown  that  it  was  due  to  anthrax. 
After  the  operation  he  had  progressed  so  favorably 
as  to  appear  out  of  danger,  but  a  rise  of  temperature 
followed  and  he  died  several  days  after  the  opera- 
tion. The  actual  source  of  infection  was  obscure. 
Dr.  Francis  Thiele,  lecturer  on  bacteriology  at  the 
hospital,  stated  that  experiments  in  connection 
with  anthrax  had  been  conducted  in  the  laboratory, 
and  explained  to  the  jury  the  possibility  of  a  tube 
having  been  left  out  in  error,  in  which  case  it  might 
have  been  handled  by  the  deceased.  If  this  happened, 
the  tube  might  have  been  in  a  condition  to  require 
sterilization  outside,  and  it,  would,  in  fact,  have  been 
sterilized  if  the  attendant  had  reported  having  found 
it.  As  he  had  suffered  from  toothache,  he  might 
have  touched  his  face  and  neck  and  infected  the 
latter  through  a  scratch.  The  jury  returned  a  verdict 
of  "death  by  misadventure."  (The  Lancet,  July  22, 
1911,  p.  272.) 

The  deputy  coroner  recently  held  an  inquiry  into 
the  death  of  a  workman  in  the  Mersey  Docks  and 
Harbor  Board's  wool  warehouse,  which  occurred  at 
the  David  Lewis  Northern  Hospital  on  Dec.  2.  The 
deceased  had  been  employed  at  the  warehouse  for 
the  last  ten  years.  His  duties  were  to  deal  with 
bales  of  Persian  wool,  which  had  been  imported  into 
Liverpool  by  a  ship  from  Bombay.  Shortly  after 
6  p.m.  on  Nov.  29,  he  drew  his  landlady's  attention 
to  a  pimple  on  his  neck,  and  said  to  her,  "That's 
anthrax.  He  went  to  the  hospital,  where  the 
lesion  was  dressed,  and  returned  home.     He  returned 

*"An  extensive  outbreak  of  anthrax  among  cattle  has  been 
discovered  on  the  East  Kami,  which  has  evidently  been  in  progress 
for  some  time.  This  disease  is  always  specially  dangerous  in 
South  Africa,  as  most  natives  will  feed  readily  on  the  half-cooked 
flesh  of  animals  dead  from  disease.  A  large  number  of  cattle  are 
officially  reported  to  have  died  from  the  disease  already,  and  one 
adult  native.  It  is  probable,  however,  that  there  have  been  other 
deaths  which  have  not  been  recorded.  The  Agricultural  Depart- 
ment has  taken  up  the  matter  and  has  imposed  stringent  quarantine 
over  the  area.  It  was,  however,  uncommonly  slow  in  acting  in 
the  first  instance." — The  Lancet,  March  9,  1912. 

459 


Anthrax 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


to  the  hospital  on  the  following  day  and  was  advised 
to  heroine  an  in-patient,  where  an  operation  was 
subsequently  performed.  In  spite  of  this  he  died 
on  the  following  day.  A  verdict  of  death  from 
"anthrax  poisoning"  was  returned  by  the  jury. 
[The  Lancet,  December  16,   1911,  p.  1741.') 

Ih.  disease  may  be  spread  from  man  to  man.  The 
discharge  from  the  pustule  (anthrax  carbuncle) 
contains  the  bacilli  of  the  disease,  and  its  inoculation 
will  be  followed  by  the  development  of  anthrax. 
Repeated  transmissions  of  virus  do  not  cause  a  dimi- 
nution of  virulence:  the  last  generation  is  as  highly 
infectious  as  the  first.  Anthrax  is  observed  in  men 
in  the  proportion  of  fifty-nine  per  cent.,  to  forty-one 
per  cent,  in  women.  The  seat  of  the  primary  sore, 
the  malignant  pustule,  was  found  by  Virchow  to  be 
confined  to  the  face,  hands,  fingers,  forearm,  or  neck 
in  eighty-four  per  cent,  of  cases.  In  the  rest,  sixteen 
per  cent.,  the  arms  and  lower  extremities  were  the 
seat  of  infection,  and  in  these  cases  the  patients  were 
chiefly  women  and  children,  in  whom  these  regions 
are  more  exposed  than  in  men. 

There  is  a  varying  susceptibility  to  anthrax  among 
different  families  of  the  same  race.  This  has  been 
observed  in  both  men  and  animals.  Thus  the  negro 
is  less  susceptible  than  the  white  man,  and  certain 
breeds  of  sheep,  notably  the  Algerian  variety,  are 
less  susceptible  than  are  other  breeds.  Deer,  reindeer, 
and  elephants  are  also  liable  to  the  disease. 

The  bacillus  of  anthrax  is  famous  as  being  the  first 
microorganism  to  be  discovered  as  the  actual  cause 
of  an  infective  disease. 

"  The  bacilli  of  anthrax  can  live  only  a  relatively 
brief  time;  but  the  spores  have  unusual  tenacity 
of  existence.  They  may  remain  dried  up  for  year-. 
and  then  be  brought  to  further  development  if  placed 
in  favorable  conditions  of  heat  and  moisture.  If  the 
spores  are  transferred  to  animals,  they  develop  into 
bacilli,  and  there  is  scarcely  room  to  doubt  that  men 
and  animals  are  quite  as  often  infected  by  spores  as 
by  full-grown  bacilli.  There  are  facts  which  render 
it  nut  impossible  that  the  anthrax  bacilli  may  exist 
in  other  places  than  the  bodies  of  men  or  animals, 
and  may  there  complete  their  cycle  of  development. 
Such  places  are  marshes,  the  banks  of  streams,  and 
the  like.  If  it  is  possible  for  them  to  be  carried  by 
high  water  to  the  pasture  lands,  we  have  an  ex- 
planation of  those  sudden  endemic  appearances  of 
anthrax  which  sometimes  occur  in  places  pre- 
viously free  from  the  disease."  (Struempell,  ''Text- 
book of  Medicine,"  translated  by  Vickery  and  Knapp, 
1912,  Vol.  i,  p.  15S.) 

The  infection  with  anthrax  in  man  is  little  common 
in  comparison  with  its  ravages  in  certain  animals. 
In  the  years  1S93-1S99  in  Germany,  according  to 
statistics,  604  human  beings  were  infected  with 
anthrax,  with  ninety-six  deaths;  while  29,686  animals 
were  attacked  with  the  disease.  Even  in  "anthrax 
districts"  this  disease  occurs  only  in  single  occasional 
cases,  and  never  in  the  form  of  an  extensive  pestilence. 
A  partial  explanation  of  the  relative  exemption  of 
human  beings  is  an  apparently  lessened  disposition 
to  the  disease  in  the  human  subject  than  in  cattle, 
as  the  human  anthrax  in  the  great  majority  of  cases 
recovers,  while  this  disease  in  animals  gives  only  a 
small  percentage  of  recovery. 

In  Santo  Domingo  in  1770  it  was  the  cause  of  the 
death  of  15,000  persons  in  the  space  of  six  weeks 
from  eating  the  flesh  of  animals  dead  from  the  disease. 
Other  observers  in  mostly  tropical  countries  report 
as  low  as  twelve  per  cent,  or  even  five  per  cent, 
mortality.  Such  a  statement  should,  however,  be 
taken  with  some  amount  of  reservation.  In  forty- 
eight  cases  of  external  anthrax  treated  at  Guy's 
Hospital  in  London,  thirty-nine  recovered  after 
operation  for  the  destruction  of  the  local  disease. 
The  infection  of  a  wound  of  entrance  by  the  poison 
cannot   be    prevented    by    the    immediate    irrigation 

460 


of  the  wound  by  corrosive  sublimate  or  carbolic  acid 
if  the  bacilli  have  once  gained  entrance  into  the  flesh. 
The  disease  is  by  no  means  always  fatal  to  animals. 
Fagge  states  the  average  mortality  among  horses  and 
horned  cattle  to  be  seventy  per  cent. 

Clinical  Course. — External  Anthrax. — During 
the  first  day  the  seat  of  infection  is  more  or  less 
irritable,  sometimes  painful.  The  continued  itch 
of  the  part,  with  augmentation  of  the  redness,  an 
edematous  swelling,  together  with  shooting  pains  in 
the  locality,  with  red  lines  beneath  the  skin,  marking 
the  course  of  the  swollen  lymphatics,  are  among  the 
strongest  initial  symptoms  of  anthrax.  As  the  disease 
progresses,  these  conditions  increase  in  inter  it.y, 
and  the  tissues  about  the  point  of  infection  become 
discolored  and  variegated  in  tint.  The  formation 
of  a  vesicle  at  the  point  of  infection,  with  subsequent 
rupture,  and  the  appearance  of  a  crust  or  seal, 
decidedly  characteristic,  lever  is  often  pre 
even  at  this  stage,  though  it  may  not  be  observable 
in  the  early  stages.  Diarrhea  is  frequent.  Malig- 
nant cases  may  terminate  fatally  in  from  twenty- 
four  to  forty-eight  hours,  often  preceded  by  colla] 

During  the  second  day  there  usually*  app. 
vesicle  varying  in  size  from  one  to  three  centi- 
meters with  a  yellowish  or  brownish  exudation.  At 
about  the  third  day,  the  vesicle  bursts  and  shrinks, 
leaving  a  brownish  base,  exuding  serum.  On  the 
fourth  day  there  is  a  black,  dry.  depressed  crust  or 
scab,  often  called  the  eschar,  which  is  surrounded 
with  a  very  characteristic,  slightly  elevated  bolder 
or  wreath  of  small  new  vesicles.  There  may  be  other 
discrete  or  confluent  vesicles  in  the  neighborhood. 
Pus  is  first  observed  at  the  end  of  the  tenth  or  fif- 
teenth day,  if  the  patient  lives  so  long,  when  the 
separation  of  the  sloughing  eschar,  accompanied  with 
suppuration,  occurs  in  the  usual  manner.  There  is 
then  usually  a  mixed  infection. 

The  initial  symptoms  of  anthrax  are  similar  to 
those  of  other  acute  febrile  diseases:  weakness,  ma- 
laise, chilliness  or  moderate  rigor,  headache,  thirst, 
restlessness  with  or  without  mild  delirium,  some- 
times vomiting,  and  disturbed  sleep.  The  subse- 
quent symptoms  vary  in  character  and  intensity 
according  to  the  external  localization  of  the  disease. 
If  this  is  in  the  stomach,  there  may  be  obstinate 
vomiting;  if  in  the  intestine,  persistent  diarrhea;  if 
in  the  pulmonary  structures,  rapid  breathing,  with 
symptoms  similar  to  those  of  extensive  pneumonia, 
cyanosis,  and  speedy  collapse.  Serious  disturbance 
of  the  brain  may  be  associated  with  any  of  these 
conditions,  accompanied  with  convulsions  and  coma. 
The  temperature  curve  is  similar  to  that  in  other 
acutely  toxic  febrile  conditions,  ranging  from  102° 
to  105°  F. 

Dr.  Hamer  reported  a  mortality  of  forty  per  cent, 
in  eases  of  anthrax  of  the  neck,  while  the  mortality 
in  cases  in  which  the  primary  lesion  was  situated 
upon  other  parts  of  the  body  was  twelve  per  cent. 

Anthrax  is  less  fatal  in  tropical  countries,  where 
the  condition  of  the  climate,  heat,  sunshine,  etc.,  may 
produce  diminished  virulency  of  the  specific  organism 
of  the  disease.  Perhaps  a  greater  resistance  to  the 
effect  of  the  bacilli,  or  of  their  toxins,  on  the  part  ol 
the  inhabitants,  or  a  greater  toleration  of  the  infective 
poison,  may  account  for  the  less  fatal  character  of 
the  malady  in  those  regions  where  the  mortality  has 
been  reported  as  extremely  low,  varying  from  zero  to 
one  per  cent. 

A  pronounced  systemic  reaction  with  much  local 
inflammation  has  been  thought  favorable  to  recovery. 
In  asthenic  conditions  of  the  system  the  prognosis 
is  less  hopeful.  The  pulse,  respiration,  and  tem- 
perature are  not  always  indicative  of  the  gravity  of 
the  disease  or  of  the  probable  result. 

Dr.  Bell  gives  the  following  table  of  mortality  in 
relation  to  the  duration  of  the  disease: 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Anthrax 


2d 


:i,l        Ith      5th      6th      7ih      - 


1! 


1  I 


r  nine  days,  1  case;  total,  55  cases. 

Internal  Anthrax. — Fur  convenience  of  description 
anil  clinical  study,  this  type  of  the  disease  is  divided 
into  intestinal  anthrax  and  pulmonary  anthrax,  or 
wool-sorters,  disease. 

inal  Anthrax  (Myco       I  "alis). — In  some 

oases  tin-  primary  lesion  of  anthrax,  the   main 

En-nil^',  is  seated  upon  the  internal  surface  of  the 
id  produces  the  symptoms  known  as  those 
rycosis  intestinalis,  followed  by  the  same  train  of 
fatal  results  as  when  the  primary  lesion  is  upon  the 
external  surface.  Often  the  milk  and  the  flesh  of 
diseased  animals  are  taken  as  food,  and  doubtless 
the  infection  frequently  occurs  from  this  source. 
The  course  and  symptoms  of  this  form  of  the  disease 
are  not  well  understood.  Often  the  workmen 
engaged  in  slaughtering  diseased  animals  become 
infected  by  direct  inoculation,  while  those  eating  the 
flesh  of  the  same  animals  experience  no  harm.  It  is 
probable  that  the  bacilli  are  destroyed  bytheproi 
of  cooking,  which  generally  require  an  elevation  of 
temperature  sufficient  for  their  sterilization;  or  pos- 
sibly they  may  be  rendered  harmless  by  the  gastric 
digestion:  but  if  they  succeed  in  passing  the  stomach, 
they  may  then  become  seated  in  the  mucous  mem- 
brane of  the  bowel  and  there  produce  the  disease. 

Intestinal  anthrax  is  rare  in  man,  though  it  has 
bee  ally  reported.     (For  a  most  intere 

al  and  Surgical  Reports,"  Boston 
City  Hospital,  ls'.i;.  p.  126.)  The  distinction  be- 
tween the  intestinal  and  pulmonary  forms  of  anthrax 
is  not  easily  made,  and  doubtless  the  two  may  often 
be  confounded  with  other  acute  diseases  affei 
these  organs,  unless  the  anthrax  bacillus  is  identified 
by  microscopical  examination,  or  the  disease  is 
reproduced  by  inoculation  in  animals.  The  diag- 
nosis of  intestinal  anthrax  may  be  quite  impossible, 
owing  to  the  rapidity  of  its  progress  and  the  sim- 
ilarity of  its  symptoms  to  those  of  other  gastro- 
- 1 inal  diseases,  especially  to  those  of  so-called 
"ptomaine  poisoning".  The  course  of  intestinal 
anthrax  is  almost  uniformly  fatal,  and  Bell  states 
that  no  case  demonstrated  during  life  to  be  intestinal 
anthrax  has  recovered. 

The  actual  seat  of  the  primary  lesion  in  anthrax 
of  the  abdominal  organs  is  at  times  uncertain,  but  in 
general  the  disease  is  supposed  to  be  conveyed  by 
means  of  food,  which  has  been  contaminated  by 
the    anthrax    bacillus    or   its    spores.     Keen    in   his 

-  rgery"  has  called  attention  to  the  localization  of 
the  abdominal  focus  of  the  disease,  and  makes  the 
following  observation: 

Primary  Gastric  Anthrax. — "Though  infection  of  the 
stomach  by  anthrax  might  reasonably  be  expected 
to  occur  occasionally,  so  far  as  I  can  discover,  the 
condition  is  an  extremely  rare  one,  a  case  reported 
in  the  Medical  Press,  1904,  p.  199,  being  the  only  one 
1  ran  find  recorded."  An  original  article  by  Schmidt 
confirms  the  diagnosis  of  bacilli  from  a  necrotic 
anthrax  ulcer  in  the  stomach. 

Treatment  of  this  variety  of  the  disease  should 
comprise  rapidly  acting  evacuants,  followed  by  the 
administration  of  internal  antiseptics  (germicides), 
with  supporting  measures  according  to  the  conditions 
present;  but  the  nature  of  the  lesion  and  the  rapid 
progress  of  the  disease  would  preclude  the  hope  of 
much  benefit  from  any  available  means  of  internal 
medication. 

Pulmonary  Anthrax,  Wool-sorter's  Disease,  Anthra- 
cemia. — Primary  lesions  of  the  lung  occur,  but  they  are 
rare,  and  the  channel  through  which  the  exciting  bac- 
teria gain  entrance  to  the  pulmonary  tissue  remains 


in  question.     It   is  asserted  that   the  bite  of  certain 
cts,   particularly  the  fly  and  the  mosquito  nay 
convey  the  disease. 

As  an  aid  in  diagnosis,  the  nature  of  the  occupation 
of  the  patient  is  highly  suggestive.  This  form  of 
the  malady  may  be  acquired   by  inhalation  of  the 

dust    from   any   of   the   products  of   diseased   animal-. 

I'll  us  it  ha    bi  en  ob    i  red  among  those  employed  in 

the  handling  or  manufacture  of  animal  hairs  and 
woolen  rags;  among  wool-sorters,  rag-pickers,  and 
those  concerned  in  the  further  manipulations  of  these 

articles    into    woven    textures:    and    to    some    ' 

among  paper-makers.     Dr.  Bell   says:     "Thesoi 

of  wools  and  hair-  is  unhealthy  in  proportion  to  the 
contamination  they  produce  in  the  air  inspired  by 

the  workmen.  First,  the  dus(  and  fine  short  hair-, 
acting   mechanically,    excite   chronic   di  '    the 

lungs,     such    as    bronchitis    and    phthisis.     Se< 
ilu-t    from    dried    and    decomposing    animal    ma 
produces  a  low  form  of  septic  pneumonia.     Third, 
the   virus  arising  from   the   blood  and  discharges  of 
animals  that  have  died  from  anthrax  an-  specifically 

on  the  lungs." 

Pulmonary  anthrax  is  peculiarly  a  human  complica- 
tion. It  is  not  often  observed  as  a  coincident  con- 
dition in  either  cutaneous  or  intestinal  infection. 
'"From  the  paramount  dignity  in  the  human  econ- 
omy of  the  organ  invaded,  and  the  specific  tendi 
in  anthrax  to  the  development  of  edematous  condi- 
tions in  the  tissues  invaded,  il  is  not  surprising  that 
pulmonary  invasion  leads  to  a  most  acvite  and  ge 
ally  fatal  manifestation  of  anthrax,  rei  Hi- 

ring but  seldom."  (Billings,  "Twentieth  Century 
Practice  of  Medicine.") 

Laryngeal  Anthrax. — In  the  Munchener  medizinische 
Tier/,,  nschrift,  vol.  i.,  p.  40  >,  190d,  Emil  (das  reports 
a  case  of  this  rare  condition,  occurring  in  a  carpen- 
ter, forty-one  years  of  age,  who  was  brought  to  the 
Klinik  on  May  9.  The  disease  began  on  May  2,  with  a 
feeling  of  chilliness,  weakness,  and  a  swelling  in  the 
region  of  the  angle  of  the  lower  jaw  on  the  right  side. 
Three  days  before  admission  he  suffered  from  nausea 
with  acute  pain  in  the  region  of  the  stomach.  The 
patient  rapidly  became  worse  and  the  swelling  of  the 
jaw  increased  to  a  considerable  degree.  On  admis- 
sion the  patient  was  much  prostrated  and  presented 
the  appearance  of  a  severe  general  septic  infection, 
which  seemed  to  have  originated  in  the  phlegmonous 
inflammation  in  the  neck.  The  pulse  was  140,  very 
weak,  almost  imperceptible  at  wrist.  The  abdomen 
was  moderately  distended,  sensitive  only  at  epigas- 
trium. There  was  edema  over  the  sternum  as  well 
as  over  the  lower  portions  of  the  thorax  and  in  the 
region  of  the  lumbar  spine.  No  other  changes  were 
observed  on  the  cutaneous  surface  nor  in  the  region 
of  the  swelling  on  the  jaw,  nor  was  there  induration 
of  the  lymphatics.  Xo  pain  in  muscles  or  joints. 
There  was  much  swelling  of  the  right  wall  of  the 
pharynx  with  edema  of  the  adjacent  parts,  but  no 
ecchymosis  of  the  mucous  surfaces;  there  was  edema 
of  the  right  vallecula,  where  the  mucous  membrane 
hung  over  the  right  side  of  the  epiglottis  in  loose  folds 
and  presented  .numerous  punctate  hemorrhages  on 
its  surface.  The  patient  died  the  same  night.  At 
autopsy,  the  stomach  showed  numerous  confluent 
edematous  elevations  on  the  posterior  wall,  which 
at  many  points  were  ulcerated  and  presented  a  black- 
ish surface.  These  swellings  were  scattered  over  the 
interior  between  the  cardia  and  the  pylorus.  The 
aditus  laryngis  and  the  adjacent  portions  of  the 
pharynx  were  edematous,  the  mucous  membrane 
was  covered  with  gray  spots  of  superficial  necrosis  of 
the  epithelium.  Those  changes  extended  on  each 
side  to  the  interior  of  the  larynx  as  far  as  the  location 
of  the  vocal  cords.  In  the  hemorrhagic  edema  of 
these  portions  of  the  submucous  tissues  the  bacilli  of 
anthrax  were  found  in  great  abundance.  The  re- 
porter of   this   case  said  that  in  the  Handbook  of 


461 


Anthrax 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Larnygology  by  Heymann  no  mention  was  made  of 
such  a  case,  and  he  could  find  no  observation  of  this 
form  of  primary  anthrax  invasion  in  the  literature  of 
the  subject;  so  that  this  seemed  to  be  the  first  case 
of  anthrax  of  the  larynx  which  has  been  recorded. 

In  a  communication  to  the  Journal  of  the  American 
Medical  Association,  Feb.  3,  1912,  is  another  account 
of  this  rare  location  of  primary  anthrax.  The  patient 
was  a  young  woman  who  had  been  employed  in  manip- 
ulating  different  varieties  of  wool  mostly  of  the  gray 
and  brown  Persian  kind,  which,  however,  had  gone 
through  several  processes  before  it  had  reached  the 
combing-room  in  which  she  worked.  Exactly  how  the 
infection  occurred  is  not  known,  for  her  sister,  who 
had  had  anthrax,  stated  that  nothing  objectionable 
had  been  noticed  in  the  wool  which  they  had  been 
handling.  At  the  necropsy  made  by  Mr.  F.  W.  Eurich, 
bacteriologist  to  the  Anthrax  Investigation  Board, 
anthrax  was  found  in  the  larynx,  from  which  general 
infection  of  the  system  had  taken  place.  In  his  ex- 
perience a  lesion  in  the  larynx  is  unique  and  does  not 
appear  to  have  been  previously  observed.  The  lungs 
were  not  affected. 

The  general  duration  of  the  pulmonary  invasion 
before  the  fatal  termination  is  from  two  to  five  days. 
The  bacilli  are  often  present  in  the  sputum. 

Pathology. — The  pathology  of  malignant  pustule 
consists  of  the  series  of  changes  which  follow  inocula- 
tion with  anthrax  through  either  the  skin,  the  alimen- 
tary canal,  or  the  lungs.  These  changes  are  some- 
what different,  according  to  the  particular  circum- 
stances of  the  individual  case.  When  the  virus  is 
introduced  through  a  scratch  or  abrasion  of"  the 
skin,  the  period  of  incubation,  or  the  space  of  time 
before  the  local  symptoms  of  anthrax  appear,  may 
vary  from  a  few  hours  to  three  days;  in  rare  cases  a 
somewhat  longer  time  may  elapse. 

"No  matter  from  what  point  infection  occurs, 
when  the  bacillus  enters  the  circulation  widely  dis- 
tributed changes  occur  in  the  tissues.  The  muscles, 
including  the  heart,  are  darker  than  normal,  and 
frequently  contain  minute  hemorrhages;  ecchymoses 
may  also  be  found  beneath  the  serous  membranes; 
even  the  meninges  and  brain  are  affected.  In  man 
splenic  enlargement  is  less  constant  than  in  lower 
animals.  The  organ  is  usually  increased  in  size, 
dark  in  color,  and  the  pulp  diffluent.  The  bacilli 
may  readily  be  cultivated  from  all  the  organs  and 
are  often  present  in  enormous  numbers."  (Coplin, 
Manual  of  Pathology.') 

Anthrax  produces  upon  the  external  surface  a 
somewhat  elevated  papule,  five  millimeters  to  several 
centimeters  in  diameter,  with  a  central  depressed 
seal).  The  corium  and  papillary  body  become 
infiltrated  with  serocellular  exudate  and  with  bacilli. 
The  perivascular  and  connective  tissue  spaces  become 
filled  with  leucocytes,  and  the  pressure  of  this  serous 
and  cellular  infiltrate  together  with  the  toxins  of 
the  bacteria  cause  the  central  coagulation-necroses; 
though  suppuration  does  not  occur  unless  there  is  a 
mixed  infection.  When  the  serocellular  exudation 
extends  upward  to  the  epithelium,  •  it  elevates  the 
latter,  and  produces  the  typical  vesication.  In  the 
edematous  variety;  the  swelling  is  due  to  the  diffuse 
serous  infiltrate  and  to  the  effect  of  the  bacteria  block- 
ing or  inducing  coagulation  in  the  capillary  vessels. 

The  course  of  the  disease  may  be  divided  into 
three  stages.  The  first  or  prodromal  stage  is  that  of 
incubation  (period  of  latency).  During  this  period 
the  patient  presents  no  marked  symptoms  of  any 
serious  disturbance.  There  are  localized  burning 
and  itching  at  the  seat  of  infection,  which  are  gener- 
ally thought  to  be  due  to  the  bite  of  an  insect,  such  as  a 
flea,  which  the  spot  closely  resembles.  After  a  period 
of  incubation  lasting  from  a  few  hours  to  three  days 
(rarely  longer)  the  local  symptoms  suddenly  change. 
The  second  stage,  that  of  eruption,  now  ensues,  in 

462 


which  a  small  papule  is  seen  at  the  seat  of  the  pre- 
vious irritation.  This  rapidly  increases  in  height  and 
in  circumference,  and  generally  presents  a  spot  of 
dark  discoloration  at  its  summit.  The  itching  and 
burning  increase,  and  within  a  few  hours  a  vesicle 
appears  at  the  seat  of  discoloration  In  the  papule. 
The  vesicle  now  rests  upon  an  indurated  base,  and 
contains  a  small  amount  of  a  serous,  frequently 
bloody  fluid.  In  the  earliest  stage  the  bacilli  of 
anthrax  are  present  in  the  central  point,  but  as  these 
tissues  become  necrotic,  the  bacilli  approach  the 
confines  of  the  lesion,  where  they  are  present  in  great 
numbers  and  from  here  they  invade  the  tissues  in 
the  vicinity,  find  their  way  into  the  lymphatics  and 
lymph  glands;  eventually  they  gain  entrance  to  the 
circulation  and  are  distributed  by  the  blood  over  the 
system.  Bacterial  embolism  is  common.  The  sur- 
rounding skin  swells  so  as  to  form  a  slight  elevation 
around  the  vesicle,  which  now  exhibits  the  peculiar 
appearances  to  which  it  owes  its  name  of  "malignant 
pustule,"  although  this  is  not  an  accurate  definition 
of  the  pathological  condition  at  the  seat  of  the  local 
disease.  The  vesicle,  soon  ruptures  spontaneously, 
or  is  ruptured  by  the  scratching  of  the  patient,  and 
reveals  a  dark  red  base,  which  quickly  dries,  forming  a 
livid  or  brownish  crust.  This  is  the  commencement 
of  the  central  gangrene  or  necrosis  of  tissue  commonly 
observed  in  the  carbuncle  of  anthrax.  The  crust 
becomes  gradually  larger,  until  it  sometimes  reaches 
a  diameter  of  from  one  to  three  centimeters,  ami 
the  swelling  and  tension  of  the  surrounding  skin  be- 
come more  extensive.  A  line  of  new-formed  vesicles 
develops  around  the  margin  of  the  crust,  and  the^e 
vesicles  contain  a  yellowish  or  brown  fluid  content. 

The  crust  now  gradually  becomes  free  from  pain  and 
tenderness,  and  a  doughy  or  boggy  infiltration  is  felt 
for  some  distance  in  the  tissues  around  the  primary 
sore.  The  local  condition,  however,  has  no  diagnostic 
value  as  an  indication  of  the  infection  of  the  general 
system.  In  rare  instances  the  local  symptoms  be- 
come less  serious,  the  swelling  subsides,  the  slough 
separates  and  is  thrown  off,  and  the  ulcer  heals  by 
granulation.  In  such  cases  the  chief  danger  is  from 
septicemia  arising  from  the  absorption  of  gangrenous 
matter.  It  is  probable  that  in  such  conditions  there 
is  a  mixed  infection  from  the  presence  of  other  bac- 
terial organisms.  When  general  infection  occurs  the 
swelling  increases  and  becomes  doughy,  the  lymph 
channels  are  detected  as  reddened  lines  of  induration, 
the  glands  become  swollen,  and  burning  heat  is  felt 
in  the  part,  which  gradually  becomes  very  painful 
and  later  is  the  seat  of  stiffness  and  numbness. 
The  veins  are  often  seen  as  dark-colored  channels, 
and  are  sometimes  plugged  by  thrombosis. 

The  foregoing  appearances  are  caused  by  the  local 
multiplication  of  the  bacilli  of  anthrax  in  the  part 
which  is  the  seat  of  the  primary  infection.  The 
germs  may  be  found  in  the  central  part  of  the  car- 
buncle and  in  scattered  groups  in  the  rete  Malpighii. 
At  times  large  interwoven  masses  of  them  are  found 
in  the  tissues  at  this  early  period,  and  may  be  ob- 
served to  spread  into  the  neighboring  parts  by  ex- 
tension beneath  the  epidermis.  In  a  carbuncle 
extirpated  by  Bardeleben  on  the  twelfth  day,  which 
measured  five  centimeters  in  diameter,  the  bacilli 
were  present  in  such  enormous  numbers  that  the  tis- 
sues were  eve^where  crowded  with  them;  they  even 
filled  the  spaces  between  neighboring  cells  and  ob- 
scured the  normal  structures  of  the  part.  In  a  car- 
buncle examined  by  Wagner  the  bacilli  were  so 
abundant  as  to  hide  the  normal  tissues.  The  center  of 
the  pustule  is  generally  the  seat  of  hemorrhage,  and 
the  effused  blood  is  prone  to  undergo  putrefactive 
changes.  This  accident  is  also  frequently  observed 
in  the  edematous  tissue  immediately  surrounding 
the  pustule.  From  this  center  of  the  disease  gen- 
eral infection  of  the  body  (third  stage)  may  now 
quickly  take  place,  sometimes  requiring  but  a  few 


— 


REFERENCE    IIAXIHWniK    of    THE    MEDICAL    Si'llAU  - 


Anthrax 


hours  (so-called  cas  fovdroyants),  while  others  occupy 
from  three  to  four,  sometimes  eight  to  ten  days 
for  general    poNoning  of   the  system. 

\  second  form  of  the  disease  is  the  "ccdema  carbun- 

o  uiaseu  malignum,""Milzbrandoedem."     Thisis 

observed  in  rases  in  which  inoculation  occurs:  in  pails 

ered  with  thin  delicate  skin,  such  as  the  eyelids, 

axilla,   and   occasionally    the   extremities.      In    the  e 

.  the  local  sore,  the  pustule,  is  not  formed,  there 

is  no  crust,  no  central  gangrene,  nor  an  erupt  i f 

icles,  but  a  rosy,  bluish,  or  even  livid  swelling 
appears  at  the  scat  of  primary  infection,  and  rapidly 
spreads  in  all  directions.  Generally  the  spot  «  here  t  he 
Illation  occurred  may  be  seen  as  a  dark  point 
more  or  less  elevated  above  the  surface,  but  sometimes 
there  is  no  visible  point  of  origin.  The  swelling  is 
[uently  enormous,  so  that  the  arm  may  be  three 
or  four  times  its  normal  size,  or  the  eyes  may  be  en- 
tirely closed  by  large  effusions  of  translucent  fluid 
in  the  tissues.  Like  the  previously  described  local 
manifestations  of  anthrax,  this  malignant  edema  may 
subside  spontaneously  without  causing  destruction  of 
issues,  and  the  part  may  be  restored  to  its  normal 
condition.  There  is  generally  abundant  desquama- 
of  epidermis  after  the  disappearance  of  the 
na.  At  times  the  swelling  is  so  enormous  that 
the  skin  becomes  gangrenous  to  a  greater  or  less 
it,  and  often  the  edematous  area  is  the  seat  of 
vesicles  or  blebs  which  are  filled  with  a  bloody  serum, 
and  at  the  base  of  which  is  generally  found  a  slough 
comprising  the  entire  thickness  of  the  skin.  When 
the  neck  is  the  scat  of  extensive  edema  and  sloughing, 
the  loss  of  tissue  may  be  so  great  as  to  lay  bare  the 
i  vessels  or  other  important  structures,  and  death 
may  ensue  from  hemorrhage  or  from  some  other 
it  not  belonging  to  the  course  of  anthrax. 
<  leneral  infection  of  the  system  corresponds  to  that 
period  in  the  development  and  multiplication  of  the 
illi  in  which  they  have  penetrated  beyond  the  seat 
of  primary  infection,  have  reached  the  internal  organs 
by  means  of  the  blood  channels  or  other  paths,  and 
■  commenced  to  multiply  in  these  structures. 
The  bacilli  are  probably  carried  by  the  blood  corpus- 
el,-,,  which  often  contain  them  in  considerable  num- 
bers. The  disease  progresses  much  more  rapidly  in 
the  intestinal  form,  probably  from  the  sudden  libera- 
tion of  larger  numbers  of  bacilli,  which  enter  the 
circulation  from  many  points  at  once.  The  local 
tissue  changes  which  ensue  upon  inoculation  with 
bacillus  anthracis  whether  the  seat  of  infection  be  in 
the  skin,  the  lung  or  the  intestine,  are  due  to  a  block- 
ing up  of  the  capillaries  of  the  part  by  the  multiply- 
ing bacilli.  The  blood-stream  is  further  impeded 
by  the  inflammatory  swelling  of  the  tissues  sur- 
rounding the  vessels,  due  to  the  irritation  of  the  ba- 
cilli or  their  toxins,  causing  ischemia  and  necrosis. 
When  the  bacilli  enter  the  blood  stream  directly 
or  through  the  lymphatic  system,  and  the  infection 
becomes  general,  the  bacilli  are  found  most  abun- 
dantly in  the  spleen;  and  the  inflammation  and 
swelling  of  that  organ  are  characteristic  of  systemic 
anthrax.  They  are  found,  too,  occluding  the  capil- 
laries of  the  liver,  kidneys,  and  brain,  causing  tume- 
faction and  hemorrhagic  infarction  of  internal  organs, 
and  multiple  hemorrhages  into  the  skin  and  mucous 
membranes. 

The  anatomical  appearances  in  anthrax  are  those  de- 
pendent upon  a  multiplication  of  the  bacillary  organ- 
isms in  the  body,  and  there  is  hardly  a  structure  or  a 
tissue  in  the  dead  body  in  which  they  may  not  be 
found  in  great  abundance.  They  form  thrombi  in 
the  capillaries,  the  lymphatic  channels  and  glands; 
th  ■  brain,  kidneys,  and  intestinal  glands  are  found 
more  or  less  crowded  with  them.  The  most  striking 
changes  are  hemorrhages  in  the  tissues,  varying  in 
amount  from  mere  points  to  large  extravasations. 
Edematous  exudations  and  serous  effusions  in  the 
various    cavities,    and  serous  infiltration  in  internal 


■  ■mans  frequently  ensue.  The  abdominal  organ 
generally  found  in  a  normal  condition,  with  the  ex- 
ception of  the  spleen,  which  is  usually  enlarged  and 
softened  iii  structure,  and  contain-  enormous  col- 
lections of  bacilli.  There  is  a  marked  increase  in  the 
number  of  white  corpuscles,  and  death  is  quickly 
followed  by  strongly  developed  rigor  morti  . 

In  general  appearances  the  clinical  picture  of  fatal 
anthrax  closely  resembles  that  of  other  Form 
virulent  blood-poisoning.  As  a  rule,  cases  of  malig- 
nant pustule  terminate  fatally  in  from  three  to  seven 
days,  though  in  cases  of  special  virulency  death  may 
occur  within  a  few  hours. 

The  General  symptoms  of  anthrax  are  usually  the 
following:  Chilliness,  or  a  well-marked  rigor,  faint- 
ness,  pains  in  the  limbs,  loss  of  appetite,  sometimes 
seven'  distress  in  the  region  of  the  stomach,  colic, 
meteorism,  vomiting,  and  diarrhea,  frequently  accom- 
panied by  bloody  stools.  There  is  excessive  thirst. 
The  patient  retains  consciousness  to  the  end,  unless 
coma  should  supervene  shortly  before  death.  Fre- 
quently there  is  great  agony  with  distressing  anxiety; 
the  patient  begs  for  relief  in  the  most  piteous  manner, 
and  feels  that  dissolution  must  soon  ensue.  In  other 
cases  there  is  stupor  from  the  first,  or  the  patient 
becomes  delirious,  or  sinks  into  a  deep  coma,  or  the 
body  may  be  convulsed  by  clonic  cramps  or  contin- 
uous trismus  or  tetanic  contractions.  Occasionally 
there  are  harassing  cough  and  dyspnea  with  bloody 
expectoration.  There  may  be  frequent  hemor- 
rhages in  the  tissues  or  from  the  mucous  membranes, 
and  sometimes  secondary  pustules  are  formed  which 
are  similar  in  all  general  characters  to  the  primary 
lesion.  Usually  there  is  considerable  elevation  of  the 
body  temperature  at  the  period  of  invasion  of  anthrax, 
the  thermometer  often  registering  40°  C.  (104°  F.), 
or  higher,  for  some  days,  when  there  is  a  sudden  fall 
to  a  temperature  at  or  below  normal,  frequently  as 
low  as  36°  C.  (97°  F.).  The  pulse  is  generally  acceler- 
ated, and  increases  in  frequency  until  death.  The 
action  of  the  heart  is  often  feeble,  and  the  sounds  are 
hardly  audible.  Death  usually  occurs  from  collapse 
and  general  cyanosis. 

Cases  of  intestinal  anthrax  are  generally  more 
virulent  than  the  ordinary  forms  of  malignant  pus- 
tule, and  they  result  fatally  sooner  than  those  in 
which  the  infection  takes  place  from  the  external 
surface.  These  effects  seem  to  depend  upon  the  me- 
chanical action  of  enormous  masses  of  germs  within  the 
body,  and  upon  the  destruction  of  large  portions  of 
tissue  by  the  growth  and  multiplication  of  the  bacilli, 
together  with  the  added  action  of  the  specific  toxin 
produced  by  these  organisms,  which  may  be  sup- 
posed to  be  more  rapidly  disseminated  from  this  origin 
than  when  the  initial  lesion  is  situated  upon  the  cu- 
taneous surface.  See  a  very  interesting  account  of 
"Charbon"  by  Larrey  in  his  "Memoirs,"  vol.  i.,  p. 
59,  an  abstract  of  which,  by  Sir  H.  G.  Howse,  appears 
in  the  Lancet,  December  23,  1S99,  p.  1720. 

The  progress  of  anthrax  when  acquired  by  inhala- 
tion is  variable,  but  usually  the  course  of  the  disease 
is  rapid,  and  tends  toward  a  fatal  termination.  The 
symptoms  are  often  unimportant  or  insignificant 
until  near  the  end.  In  some  cases  the  invasion  of 
anthrax  is  followed  by  sudden  collapse  with  speedy 
death  of  the  patient,  as  from  shock;  but  generally 
there  is  more  or  less  reaction,  followed  by  collapse 
and  death,  without  the  signs  of  any  inflammatory 
lesion  in  the  lungs.  When  the  patient  survives  a 
sufficient  time  for  inflammatory  processes  to  develop 
in  the  lungs,  the  risk  from  the  anthrax  poison  is 
reduced.  The  duration  of  pulmonary  anthrax  varies 
from  one  to  ten  days.  A  large  proportion  succumb 
to  the  disease  within  the  first  four  days. 

The  bacilli  may  or  may  not  be  found  in  the  blood,  but 
if  the  disease  is  really  anthrax,  the  subcutaneous  injec- 
tion of  the  blood  in  a  mouse  will  certainly  prove  fatal. 


463 


Anthrax 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


The  specific  action  of  the  bacillus  upon  the 
body  of  its  host,  aside  from  its  presence  in  enormous 
numbers,  has  been  sought  in  the  morphological  char- 
acter of  the  organism;  the  germ  belongs  to  the  aero- 
bic class  of  organisms,  and  is  a  greedy  consumer  of 
oxygen;  and  it  has  been  thought,  that  the  great  pros- 
tration of  the  system,  and  the  signs  of  the  destructive 
action  of  the  disease,  as  well  as  its  rapid  progress, 
may  be  due  to  the  fact  that  it  depletes  the  red  blood 
cells  of  their  supply  of  oxygen,  and  thus  induces  a 
sudden  collapse  of  the  vital  powers.  This  view  is 
supported  by  the  appearances  presented  by  the  dis- 
ease in  grave  cases,  in  which  there  is  cyanosis  to  a 
marked  degree,  and  the  patient  dies  with  all  the 
appearances  of  asphyxia.  In  this  respect  the  organ- 
ism of  anthrax  produces  in  the  animal  system  an  effect 
similar  to  that  of  certain  poisons  of  the  cyanide  group, 
in  which  death  is  uniformly  associated  with  asphyxia. 

In  cases  in  which  the  disease  progresses  slowly,  the 
secondary  toxins  formed  by  the  bacilli  are  probably 
the  cause  of  the  fever  and  other  constitutional  disturb- 
ances. "There  can  be  but  little  doubt  that  in  the 
living  body  the  bacillus  elaborates  bodies  which 
either  directly  or  indirectly  are  toxic  to  the  tissues. 
In  no  other  way  can  the  extensive  inflammation  and 
edema  be  explained.  It  is  perfectly  possible  that 
in  the  body  substances  are  formed  which  are  not 
elaborated  in  cultures."  Osier,  "Modern  Medicine," 
iii.  46.) 

The  dissemination  of  the  bacilli  through  the  sys- 
tem is  chiefly  by  way  of  the  lymphatic  channels 
and  the  glands.  Only  after  passing  these  physio- 
logical barriers  can  they  obtain  entrance  into  the 
general  circulation  and  pass  to  all  parts  of  the  body. 
Therefore  they  would  not  be  detected  by  microscop- 
ical examination  of  the  blood,  as  an  aid  to  diagnosis, 
until  a  period  when  the  condition  of  the  patient  is 
beyond  relief. 

Very  instructive  results  relative  to  the  patholog- 
ical activity  and  the  paths  of  dissemination  of  the 
anthrax  bacilli  in  infected  animals  have  been  observed 
after  injection  into  the  anterior  chamber  of  the  eye 
of  the  guinea-pig. 

After  aseptic  introduction  of  a  pure  culture  of 
anthrax  bacilli  in  this  location,  the  death  of  the  ani- 
mal is  often  delayed  until  the  fourth  or  the  fifth  day 
or  even  longer.  No  trace  of  macroscopic  suppuration 
can  be  observed  in  the  eye ;  and  aside  from  a  more  or 
less  evident  chemosis  of  the  conjunctiva  bulbi,  one 
would  from  external  appearance  consider  the  eye 
perfectly  normal.  Examination  of  the  aqueous 
humor  shows  that  it  is  swarming  with  anthrax  bacilli. 
By  microscopical  sections  the  path  of  the  bacilli  may 
be  distinctly  traced  from  the  anterior  chamber 
through  the  space  of  Fontana,  following  the  lymph 
channels  of  the  sclera  and  conjunctiva,  as  has  been 
demonstrated  by  Weigert.  After  similar  injection 
into  the  vitreous  humor,  according  to  Clifford's 
statement,  the  bacilli  are  transported  by  means  of 
the  lymph  stream  which  leads  from  the  vitreous 
through  the  central  canal  and  the  central  vessels  to 
the  posterior  part  of  the  orbit,  and  from  here  to  the 
cavity  of  the  skull,  from  whence  they  are  carried 
along  the  sheath  of  the  optic  nerves  to  both  sub- 
arachnoidal spaces.  From  this  location  they  are 
borne  by  recognized  lymph  channels  to  the  thoracic 
duct,  and  thus  enter  the  blood  stream. 

After  entrance  into  the  general  circulation,  the 
organisms  of  the  disease  invade  every  tissue  and 
organ  in  enormous  numbers.  Bacterial  embolism 
is  common;  the  heart  muscle  is  invariably  swollen 
and  anemic,  and  at  times  the  seat  of  petechial  hemor- 
rhages. The  same  appearance  with  more  or  less 
ecchymosis  may  be  observed  beneath  the  endocar- 
dium, pleura,  and  pericardium,  as  well  as  in  the  sub- 
stance of  the  lungs.  The  same  condition  may  also 
exist  in  respect  to  the  vessels  and  serous  membranes 
around  and  within  the  brain. 


Diagnosis. — The  diagnosis  of  anthrax  is  often 
very  far  from  easy.  Dr.  Bell  says:  "The  slightest 
illness  occurring  in  those  exposed  to  infection  from 
anthrax  should  be  looked  upon  with  suspicion  until 
tin'  possibility  of  its  being  anthrax  has  been  nega- 
tived. Often  it  is  impossible  to  make  an  early  diag- 
nosis, as  the  symptoms  may  resemble  those  of  ordi- 
nary illness.  The  progress  of  the  disease  is  frequently 
not  characterized  by  alarming  indications  until  mar 
the  end  of  life,  hence  not  infrequently  it  is  unre 
riized  until  the  patient  is  cold,  livid,  almost  pulsi 
and  dying." 

The  bacillus  anthracis  will  be  found  in  blood  ob- 
tained from  the  initial  lesion,  both  by  culture  methods, 
and  from  stained  smears,  and  by  inoculation  of 
animals.  The  urine  becomes  scanty,  darker,  and  of 
high  specific  gravity.  In  1908,  Royer  and  Holmes 
reported  the  following  data:  Anthrax  bacilli  were 
frequently  discovered  in  the  circulating  blood  both 
in  smears,  and  by  cultural  methods.  In  thirteen 
cases,  study  was  made  in  reference  to  the  leucocytes, 
and  in  these,  leucocytosis  was  the  rule,  the  highest 
count  obtained  being  25,000  in  a  cubic  centimeter, 
whereas  the  average  count  for  all  the  cases  was  13 
In  two  fatal  cases  the  leucocytes  numbered  12,000 
and  9,600  respectively.  In  eleven  eases  differential 
count  gave  the  following  averages:  Polymorpho- 
nuclears 77.6  per  cent.,  large  lymphocytes.  17.7  per 
cent.,  small  lymphocytes  5.3  per  cent.,  eosinophils  :;  c 
per  cent.,  basophiles  0.1  per  cent.,  myelocyte-  0.4  per 
cent. 

The  occupation  of  the  patient  may  afford  a  valuable 
clew,  or  at  least  awaken  suspicion  of  the  disease  in 
a  given  case.  Under  such  circumstances,  a  papule 
upon  any  exposed  surface  of  the  body  would  exi 
apprehension  of  the  disease,  thoi  gha  positive  diagi 
might  at  this  time  be  impossible.  When  the  di 
has  advanced  to  the  vesicular  stage  with  serous  exuda- 
tion, there  would  be  less  uncertainty  as  to  its  nature. 
Implication  of  the  lymphatic  channels  and  swelling 
and  tenderness  of  the  neighboring  glands  would  add 
weight  to  the  probable  diagnosis,  though  all  these 
symptoms  may  be  associated  with  other  infections 
diseases.  The  most  certain  method  is  that  of  taking 
a  drop  from  the  contents  of  the  pustule  or  vesicle,  and 
subjecting  it  to  microscopic  examination.  If  the 
case  is  one  of  anthrax,  this  fluid  will  be  seen  to  con- 
tain the  bacillus.  This  at  once  establishes  the 
character  of  the  disease  in  distinction  from  simple 
non-specific  carbuncle  and  furuncle.  In  doubtful 
cases  the  liquid  may  be  subjected  to  cultivation  in  a 
moist  chamber,  when  a  definite  result  may  be  obtained 
within  a  few  hours.  Or  the  experimental  inoculation 
of  guinea-pigs  and  rabbits  or  other  animals  susi 
tible  to  the  disease  may  be  carried  out;  and  if  anthrax 
develops  in  them,  there  will  then  be  no  doubt  in  regard 
to  the  nature  of  the  malady ;  but  a  negative  result  does 
not  entirely  exclude  malignant  pustule. 

In  districts  in  which  malignant  pustule  is  known  to 
prevail,  the  surgeon  would  suspect  this  disease  in  the 
early  stages  of  simple  carbuncle,  or  of  furuncle,  and 
in  the  stings  of  wasps  and  other  insects.  Malignant 
pustule  also  resembles  to  some  extent  the  early  stages 
of  erysipelas.  Boils  or  furuncles  are  frequently  very 
similar  in  their  early  stages  to  the  first  appear- 
ances of  anthrax.  In  certain  tissues  they 
often  commence  by  the  development  of  a  vesicl 
the  seat  of  irritation.  In  furuncle,  however,  there  is 
not  so  extensive  inflammation  in  the  vicinity,  and 
the  central  gangrene,  the  crust,  the  wreath  of  vi  - 
ieles,  and  the  febrile  action  are  absent ;  these  symptoms 
belong  exclusively  to  anthrax.  The  ordinary  simple 
carbuncle  is  very  painful,  the  carbuncle  of  anthrax, 
on  the  contrary,  is  only  slightly  sensitive.  Bites  of 
insects  generally  show  a  small  yellowish  point,  which 
is  not  observed  in  anthrax.  Erysipelas,  especially 
when  accompanied  by  serous  effusions  (bulla:),  re- 
sembles  the  malignant  edema  of  anthrax  to  some 


464 


REFERENCE    HANDBOOK    OF   Till'.    MEDICAL   SCIENCES 


Anthrax 


extent,  but  in  erysipelas  the  chill  and  lever  usuallj 
precede  the  eruption  of  the  disease,  while  in  anthrax 
these  occur  simultaneously. 

Anthrax  distinguishes  itself  from  erysipelas  in  the 
following  ways:  Erysipelas  begins  most  often  with 
a  chill;  in  anthrax  edema  the  fever  appears  afterthe 
edema  is  present.  Erysipelas  has  always  the  vivid 
,  ,1  border,  which  is  slightly  above  the  level  of  the 
normal  skin  in  the  vicinity;  its  accompanying  edema 
is  much  less  pronounced  than  is  that  of  anthrax,  and 
is  limited  to  the  immediate  vicinity.  In  anthrax  the 
redness  gradually  shades  to  normal  color  and  the 
edema  extends  beyond  it  into  the  tissues  of  the  parts. 

The   Ascoli   reaction  by  precipitin  makes  possible 
the  diagnosis  of  anthrax  even  in  cases  in  which  the 
microscopical   and   cultural   evidence  and   that  from 
inoculation  of  animals  have  proved  negative.     There- 
in is  specific,  as  the   characteristic  "ring-forma- 
is  never  obtained  with  material  or  organs  from 
ces  not  containing  the  anthrax  infection.     The 
establishment   of   the   diagnosis   succeeds   also   with 
organs  infected  with  anthrax  even  when  they  have 
been  preserved  in  alcohol  for  four  months,  whether 
or  not  these  organs  have  previously  given  a  positive 
!  act  etiological   diagnosis.     The   "ring-formation,"   a 
peculiar    cloudiness,    appears    most    promptly     and 
distinctly  by  employment  of  extractive  sub- 
es    from    the    spleen.     This    method    makes    it 
possible  to  prove  the  precipitinogen  of  anthrax  not 
only  in  fresh  filtrates  of  visceral  organs,  but  also  in 
material  which  has  been  preserved  on  ice  for  more 
than  three  months.     The  extractive  may  be  prepared 
by  means  of  physiological  salt  solution,  or  by  dis- 
tilled water  or  ordinary  water.     The  intensity'  of  the 
reaction   and   the   promptness  of  its  appearance  are 
modified  by  the  dilution  of  the  extractive,  and  by 
the  reduction  of  the  amount  of  precipitin  contained 
in  the  serum;  while  putrefaction  of  the  extractive 
-  not  materially  interfere  with  its  accuracy. 

This  new  test  and  its  technique  are  thus  described 
by  Prof.  Dr.  Alberto  Ascoli,  in  Zeitschrift  fur  Initnii- 
mtatsforschung  vnd  experimentelle  Therapie,  1911, 
Erstes  Heft,  Lifter  Band,  p.  103.  The  technique  of  the 
thermoprecipitin  methods  consists  of  the  two  follow- 
ing proceedings:  (1)  Boiling  of  the  suspected  mate- 
rial in  five  to  ten  volumes  of  physiological  salt  solu- 
tion,  which  may  be  rendered  acid  by  addition  of 
acetic  acid  in  proportion  of  1:1,000,  if  desired:  this 
need  occupy  only  a  few  minutes,  and  the  resulting 
fluid  is  filtered,  preferably  by  means  of  an  asbestos 
filter.  (2)  Examination  of  the  clear  filtrate  by 
means  of  a  layer  of  precipitating  serum,  with  a 
control-tube  treated  in  the  same  way  with  normal 
M'i  am, 

This  method  has  been  in  constant  use  in  the  vet- 
erinary high  schools  of  Milan,  Modena,  Parma,  and 
Naples,  and  the  author  has  employed  it  in  hundreds 
of  personal  examinations,  with  the  result  that  its 
'""elusions  in  every  instance  agree  with  those  of 
microscopical  examination,  and  also  prove  effective 
even  when  the  material  obtained  for  examination  is 
already  in  a  stage  of  putrefaction.     This  peculiarity 

pecially  recommends  the  method  when  the  sus- 
pected material  is  obtained  from  animals  which  have 
been  found  dead,  or  are  removed  from  a  distance  to 
'he  place  of  examination. 

lor  the  ready  performance  of  this  test,  the  author 
has  recommended  the  following  simple  appliances; 
(  I  I  A  tall,  slender  reagent-glass  with  a  suitable  foot 
for  support;  (2)  a  small  funnel,  with  an  attachment 
at  the  lower  end,  which  is  drawn  out  into  a  long  tube, 
bent  at  nearly  a  right  angle,  and  ground  at  an  angle 
.-o  that  the  resulting  filtrate  will  be  discharged  on 
the  side  of  the  receiving  tube;  a  portion  of  asbestos 
in  the  bottom  of  the  funnel  makes  the  best  kind  of 
filter. 

The  test  is  carried  out  as  follows:  The  test-glass 
is  filled   to  a  certain  definite  point  with  water,   in 

Vol.  I.— 30 


which  is  then  dissolved  a  proper  amount  of  salt,  BO  as 

to  make  the  physiological  solution.  In  a  test-tube 
of  ordinary  character,  a  leu  grams  of  the  -u  pected 

material  is  suspended  in  water,  and  I  lie  iiiti.'  i-  placed 

for  a  lew  minutes  in  boiling  water.  When  the  tube 
litis  cooled,  this  fluid  i  poured  into  the  funnel  with 
the  asbestos  filter,  which  is  placed  in  the  top  of  the 
glass  first  described:  as  the  clear  fluid  Hows  slowly 
dow  n  the  inner  surface  of  the  reagent-glass  a  ring- 
formed  cloudiness  is  soon  observed  if  the  material 

added     contains     anthrax  infection.       With     material 

which  contains  no  anthrax  infection,  the  te  I     hi 
no  cloudiness.     This  reaction  therefore  would  appear 
to  be  a  valuable  and   time-saving  addition   to  our 
pie  ent  means  of  diagno  is  in  tin    di  ease. 

In  glanders  the  carbuncles  are  smaller,  generally 
multiple,  and  accompanied  by  intense  febrile  reaction. 

Cases  of  intestinal  anthrax,  mycosis  intestinalis, 
may  be  very  difficult  of  diagnosis.  The  symptoms 
often  resemble  those  of  poisoning  by  arsenic  or 
phosphorus,  though  the  appearances  due  to  anthrax 
are  frequently  more  suddenly  developed  and  advance 

i e  rapidly  to  a  fatal   termination  than  in  cases  of 

poisoning  by  these  substance  .  Often  the  patient 
is  dead  within  a  very  few  hours. 

Prognosis. — The  prognosis  in  anthrax  is  always 
very  grave,  but  is  least  so  in  the  cutaneous  form 
where  the  local  lesion  is  well  marked  and  lends  itself 
to  local  therapeutic  measures.  When  death  ensues, 
it  follows  as  a  result  of  general  infection.  The  pulmo- 
nary type  gives  the  highest  death  rate,  fifty  per 
cent.,  according  to  Eppinger;  seventy-five  per  cent, 
as  estimated  by  British  writers. 

The  collective  mortality  to  be  expected  from  all 
forms  of  anthrax  in  man,  treated  and  untreated,  is 
about  twenty-five  per  cent.  In  Great  Britain  during 
the  six  years,  1S99-1904,  267  cases  were  reported,  with 
sixty-seven  deaths.  Pulmonary  and  intestinal  an- 
thrax and  those  eases,-  at  first  localized,  in  which 
general  infection  supervenes  are  almost  invariably 
fatal.  The  mortality  varies  greatly  in  different 
countries  and  climates.  Anthrax  in  the  tropics  is 
less  fatal  than  elsewhere,  probably  because  of  the 
attenuation  of  the  virus  in  high  temperature  and 
sunlight. 

Extensive  eruption  and  multiple  pustules  render 
the  prospect  of  recovery  less  favorable.  In  children 
and  in  feeble  persons  the  disease  is  almost  always 
fatal.  Pregnant  women  are  especially  liable  to  abor- 
tion from  the  invasion  of  anthrax. 

The  prognosis  in  cutaneous  anthrax  bears  a  direct 
relation  to  the  promptness  and  thoroughness  with 
which  the  local  lesion  is  treated.  If  the  seat  of  the 
primary  invasion  be  destroyed  by  efficient  cauteriza- 
tion or  complete  excision  before  the  bacilli  have  entered 
the  lymph  channels  or  gained  access  to  the  blood-ves- 
sels, a  fatal  result  need  seldom  be  apprehended. 

Fagge  states:  "Hitherto,  so  far  as  I  am  aware,  no 
instance  of  recovery  from  the  intestinal  form  of  an- 
thrax has  been  recorded.  In  pulmonary  anthrax 
the  spleen  is  less  subject  to  enlargement  and  softening 
than  in  any  other  form  of  the  disease.  The  appear- 
ance of  any  illness  of  however  trifling  nature  in  a  per- 
son exposed  to  the  infection  of  anthrax  should  lead 
to  a  very  guarded  prognosis  until  such  a  time  as  the 
disease  may  prove  to  be  some  other  ailment.  The 
greater  number  of  cases  of  anthrax  are  fatal  within 
four  days  from  the  appearance  of  the  first  symptoms. 
Pronounced  febrile  reaction  with  chill  and  a  tempera- 
ture above  102.5°  F.  would  be  a  possible  sign  of 
successful  resistance  to  the  entrance  of  the  bacilli 
into  the  general  circulation,  and  the  localization  of 
the  disease  to  the  seat  of  invasion.  No  recorded  case 
in  which  the  presence  of  the  bacilli  in  the  blood  has 
been  proved  has  recovered." 

The  danger  to  life  cannot  be  estimated  by  the  extent 
of  the  local  lesion.     The  prognosis  is  more  favorable 

465 


Anthrax 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


■pith  a  high  temperature  than  with  a  lower  degree  of 
fever.  A  falling  temperature  with  increase  of  the 
gravity  of  the  general  symptoms,  is  a  precursor  of  a 
fatal  result. 

Duration  of  illness  in  intestinal  anthrax:  Number 
of  cases  fatal  within  3  days,  3 ;  -1  days,  23 ;  5  days, 
11;  6  days,  13;  7  days,  12;  8  days,  6;  9  days,  6;  over 
9  days,  2;  total  S3.  In  pulmonary  anthrax:  Number 
of  cases  fatal  within  1  day,  5;  2  days,  22;  3  days,  21; 
4  days,  16;  5  davs,  7;  6  days,  3;  7  days,  3;  10  days, 
2;  over  10  days,  3;  total  82. 

Mortality. — In  Europe,  about  twenty-five  per  cent, 
of  all  cases  prove  fatal.  Thus  in  Great  Britain,  of 
320  reported  cases  (1899-1905)  eighty-five  were  fatal^ 
26.6  per  cent.  Of  these,  thirteen  were  of  the  internal 
variety,  and  all  were  fatal.  Excluding  these,  the 
proportion  of  deaths  to  attacks  in  the  cutaneous  form 
was  23.4  per  cent.  In  Italv,  in  eleven  years  (18S0- 
1890),  of  24,052  cases  5,812  were  fatal — 24.1  per  cent. 
Koch  (18S6)  noted  422  fatal  cases  out  of  1,473  pub- 
lished cases  of  cutaneous  anthrax — 32  per  cent. 
In  pulmonary  anthrax  among  rag-sorters  in  Lower 
Austria  (1870-1SS6),  the  mortality  was  88.6  per  cent. 
It  is  universally  agreed  that  neglect  of  early  treatment 
in  cutaneous  anthrax  is  one  cause  of  its  high  death 
rate.  At  Guy's  Hospital  between  1S96-1904,  of  fifty- 
six  cases  treated,  only  four  proved  fatal — 7.1  per  cent. 
The  number  of  cases  of  anthrax  contracted  in  factory 
or  workshop  (England)  during  the  period  from  1899 
to  1905  was:  males,  270;  females,  50;  total,  320; 
fatal,  85;  the  mortality  was  therefore  26.6  per  cent,  of 
these  cases.  (Bell  and  Legge  give  a  valuable  resume: 
■  of  the  pathological  conditions  in  cases  of  the  various 
forms  of  anthrax,  with  records  of  autopsy  findings  in 
each  form.) 

Industrial  Anthrax. — Anthrax  is  still  a  fairly  com- 
mon disease  in  Great  Britain.  In  the  Journal  of 
Hygiene  for  June,  1912,  E.  E.  Glynn  and  F.  C.  Lewis 
present  the  following  table  of  cases' of  the  disease  in 
man  in  Great  Britain  and  Ireland: 


1906 

1907 

190S 

1909 

1910 

Total 

Cases 

76 

71 

69 

71 

79 

366 

Deaths 

26 

15 

13 

15 

12 

81 

The  total  number  of  cases  among  agriculturists 
was:  in  1906,  8;  1907,  12;  190S,  19;  1909,  15;  1910, 
24;  total,  78.  Of  these  78  cases,  5  occurred  in 
housewives,  16  in  farmers,  and  the  remainder  in 
butchers,  knackers,  etc. 

There  is  no  doubt  that  industrial  anthrax  is  con- 
tracted by  handling  infected  hides,  wool,  etc.,  but 
the  reason  for  the  dissemination  among  domestic 
animals  is  much  more  obscure.  Many  believe  such 
animals  contract  the  disease  by  feeding  upon  infected 
pastures,  but  recently  a  considerable  amount  of  evi- 
dence has  been  collected  which  indicates  that  arti- 
ficial foodstuffs  or  manures  may  carry  infection. 
With  regard  to  the  former  possibility,  Stockman 
(1911)  has  noted,  first,  that  S3  per  cent,  of  the  out- 
breaks of  anthrax,  in  the  six  worst  infected  counties 
in  Great  Britain  during  five  years,  1905-1909,  occurred 
upon  new  farms,  that  is  to  say  farms  in  which  there 
had  never  been  a  previous  case;  consequently  it  was 
unlikely  that  the  animals  contracted  it  from  infected 
pastures;  and  second,  that  in  6S  per  cent,  of  the 
outbreaks  the  evidence  pointed,  after  careful  elimi- 
nation of  other  causes,  to  infection  with  "artificial 
feeding  stuffs  or  manures."  Again  anthrax  is  least 
common  from  July  to  October  when  the  stock  are  on 
grass,  but  there  is  a  decided  rise  in  the  following 
months  when  they  may  be  "assumed  to  be  running  in 
and  receiving  artificial  food."  B.  anthracis  has  very 
rarely  been  found  in  these  artificial  foods,  though 
M'l'adyean  (1S95)  once  detected  it  in  a  linseed  cake, 
which  caused  the  death  of  six  shorthorns,  and  ampng 
.some  oats  responsible  for  an  outbreak  in  London 
horses;  similar  cases  have  occurred  in  Germany 
(Legge,  1905).     We  have  recently  detected  anthrax 


bacilli  in  a  sample  of  pea  meal,  used  for  feeding 
cattle,  one  of  which  died  of  anthrax;  the  investiga- 
tion will  be  alluded  to  subsequently. 

The  importance  of  ascertaining  the  origin  of  agri- 
cultural anthrax  is  seen  from  the  second  table,  which 
indicates  that  in  spite  of  Government  inspection  the 
disease  appears  to  be  spreading.  In  the  last  five 
years  the  number  of  deaths  among  domestic  animals 
have  increased  from  306  to  406  per  100,000,  i.e.  by 
59.3  per  cent.;  the  number  of  outbreaks  have  in- 
creased even  more,  i.e.  59.3  per  cent.;  and  lastly,  t he 
number  of  cases  amongst  agricultural  laborers  and 
others  have  also  increased  from  8  to  24  per  annum. 
Of  course  some  of  this  increase  may  be  due  to  more 
systematic  notification  of  the  disease. 

Anthrax  spores  have  been  demonstrated  by  the 
inoculation  method  in  21.3  per  cent,  of  141  samples 
of  industrial  material,  supposed  to  have  produced 
anthrax  in  Liverpool  amongst  those  who  handled 
them.  Of  these  samples  286  per  cent,  were  from 
hides,  20.2  per  cent,  from  wool,  20.6  per  cent,  from 
hair,  and  7.1  per  cent,  from  bones.  The  largest 
proportion  of  infected  samples  came  from  Singapore. 

Anthrax  appears  to  be  steadily  increasing  among 
domestic  animals,  and  consequently  a  larger  number 
of  agriculturists  are  becoming  infected.  The  rea- 
son for  this  dissemination  amongst  animals  is  still 
obscure. 

We  have  found  B.  anthracis  in  a  sample  of  pea 
meal  used  for  feeding  cattle  confined  to  a  shippon, 
one  of  which  died  of  anthrax.  The  meal  was  prob- 
ably infected  from  the  sack. 

Anthrax  is  preventable  among  men  and  domestic 
animals;  and  its  ultimate  suppression  depends  largely 
upon  the  certainty  with  which  bacteriologists  can 
demonstrate  the  presence  or  absence  of  bacilli  in 
suspected  industrial  food,  or  other  materials.  (Glynn 
and  Lewis,  Journal  of  Hygiene  June,  1912.) 

Prophylaxis. — As  the  diseased  or  dead  body  of  a 
human  being  or  an  animal,  and  the  substances  emanat- 
ing from  the  same,  form  the  source  of  danger  from 
anthrax,  it  is  evidently  important  that  these  sub- 
stances should  receive  special  attention.  The  excreta 
or  discharges  of  any  kind  from  those  sick  with  the 
disease  should  be  carefully  disinfected  and  burned, 
and  the  bodies  of  animals  or  human  beings  dying 
from  the  disease  should  be  immediately  wrapped  in 
some  efficient  disinfectant  and  cremated.  No  post- 
mortem examination  should  be  allowed,  as  thereby 
the  opportunity  for  further  infection  is  largely  in- 
creased. The  physician  should  warn  the  attendants,  in 
cases  of  anthrax,  of  the  danger  of  infection  from  the 
discharges  of  the  patient.  No  person  having  a  wound 
or  abrasion  on  an  exposed  part  of  the  body  should  take 
any  part  in  the  care  of  the  patient,  or  touch  anything 
which  has  been  in  contact  with  or  near  him.  All  band- 
ages, dressings,  etc.,  should  be  immediately  burned. 
Especial  attention  should  be  given  to  the  exclusion  of 
flies  and  mosquitos,  which  have  been  proved  to  be  the 
active  carriers  of  various  contagia.  Unneces 
persons  and  all  visitors  should  be  rigorously  excluded. 

The  prophylaxis  of  anthrax  must  at  present  be 
regarded  as  unsatisfactory,  until  other  and  more 
stringent  precautions  are  adopted  to  effect  efficient 
sterilization  of  the  commercial  animal  products  deri 
from  countries  in  which  anthrax  is  either  prevalent  as 
a  permanent  infection,  or  at  times  appears  in  epidemic 
form. 

Osier  states:  "The  ordinary  processes  of  tanning 
leather  do  no't  affect  the  spores  of  anthrax;  and  the 
writer  has  kept  them  immersed  for  240  days  in  the 
strongest  tanning  fluids — twice  the  usual  time  required 
for  the  process — without  any  perceptible  change  in 
their  vitality  or  viruleney.  Spores  are  not  formed 
in  cultures  "kept  at  temperatures  below  18°  C,  nor 
in  those  above  42°  C. ;  when  grown  at  a  temperature 
above  42°,  the  bacillus  loses  the  power  of  forming 


466 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Anthrax 


spores,  ami  becomes  gradually  attenuated,  and  ac- 
quires'vaccinal  properties.  When  brought  to  this 
condition,  the  attenuated  bacillus  may  be  cultivated 
at  ordinary  temperatures,  without  regaining  virulence 
or  the  spore-forming  power.  The  vaccines  of  Pasteur 
are  prepared  in  this  manner,  the  degrees  of  attenua- 
tion depending  upon  the  number  of  days  the  culture  is 

kept  at    1-'°  I"  -13°  C.      The  first  or  weakest  vaccine  is 

grown  for  about  twenty-four  days,  at  I  lie  end  of  which 

nine  it   has  lost   the  power  to  kill  larger  aninals  and 

i  guinea-pigs,  bin  will  still  kill  white  mice;  the 

,1  vaccine  is  grown  for  about  twelve  days,  and 

ild  kill  guinea-pigs,  but  not  rabbits.     In  practice, 

an  interval  of  twelve  to  fifteen  days  is  allowed  to 

elapse  between  the  two  inoculations,  which  are  made 

itaneously."      ("Modern     Medicine,"    vol.    iii., 

p    I'''.) 

Warren-Gould  in  the  last  edition  of  the  "Inter- 
national Text-book  of  Surgery"  (1902),  p.  191,  when 
ussing  human  anthrax,  add  the  following,  which 
M  properly  be  regarded  as  belonging  to  the 
n\  lactic  considerations  of  this  malady:  "The 
disease  is  transmitted  to  man  from  infected  animals; 
t  he  atrium  of  the  microbe  is  usually  an  abrasion  of  the 
skin,  but  the  bacteria  can  enter  by  the  lungs  and  the 
intestines  without  the  occurrence  of  wounds.  Flies 
are  said  to  transmit  the  disease  (Koch),  and  the 
bristles  from  which  brushes  are  made  have  conveyed 
microbe."  "Surgeons  have  repeatedh'  con- 
veyed the  infection  by  using  imperfectly  sterilized 
catgut  from  sheep  suffering  from  splenic  fever." 
"Pathologists  have  frequently  been  infected  while 
making  postmortems  of  experimental  animals  dead 
of  the  disease." 

The  inoculation  of  the  vaccines  and  toxins  of  an- 
thrax is  an  efficient  preventive  of  the  disease  in  ani- 
mals. The  blood  serum  from  an  immune  animal,  if 
injected  subcutaneously  into  a  susceptible  animal, 
will  afford  a  certain  degree  of  protection  against  sub- 
gequent  infection  with  anthrax.  The  following  state- 
ment is  from  Sajou's  Annual  for  1S9S:  "A  sheep  was 
immunized  until  it  could  bear  the  injection  of  seven 
agar  cultures  with  but  slight  elevation  of  temperature. 
A  lamb  was  immunized  likewise  to  the  highest  degree, 
and  blood  was  taken  from  the  carotid  to  obtain  serum. 
With  the  serum  of  the  sheep  it  was  actually  possible 
save  from  death  a  rabbit  in  which  an  extremely 
virulent  culture  of  anthrax  was  injected  either  after 
or  simultaneously  with  the  serum.  Evident  thera- 
peutic results  were  obtained  with  this  serum  in  animals 
that  had  received  the  anthrax  bacilli  previous  to  the 
injection  of  serum.  These  results  permit  us  to  hope 
that  anthrax  in  man  and  the  domestic  animals  may 
sometime  be  treated  by  serotherapy."  (Vaughan, 
"Twentieth  Century  Practice,"  vol.  xiii.)  It  is 
further  stated  that  "French  skins,  since  Pasteurian 
inoculation  has  been  employed  among  the  French 
flocks,  have  been  found  rarely  to  cause  anthrax." 

Bell  makes  the  following  statement:  "No  efficient 
system  in  relation  to  the  spread  of  anthrax  has  been 
yet  possible.  To  accomplish  this  end  there  should  be 
a  careful  separation  of  the  infected  wools,  hair,  hides, 
rags,  etc.,  at  their  source,  often  in  distant  countries. 
This  is  manifestly  very  difficult  to  accomplish."  In 
the  subsequent  handling  of  the  materials  during  the 
processes  of  preparation  and  manufacture,  every 
effort  should  be  made  to  protect  the  workers  from  the 
dust  arising  from  such  materials,  which  should  be 
removed  by  air  draught  and  burned.  Sterilization  of 
all  suspected  substances  by  steam  under  moderate 
pressure  has  been  found  useful  in  the  treatment  of 
other  infected  substances,  and  would  doubtless  pro- 
vide efficient  protection  against  this  disease. 

Page  says  (Journal  of  Hygiene,  December,  1909) 
that  "we  may  conclude  that  disinfection  of  horsehair 
by  steam  cannot  absolutely  be  relied  upon;  but  that 
with  due  care  the  number  of  anthrax  spores  may  be 
diminished,  and  the  vitality  of  the  remainder  lowered 


without     appreciable    damage     to     the     hair."      That 

steam  is  ever  likely  to  be  certainly  effective  in  disin- 
fecting   horsehair    is    improbable,    since    the    damper 

the  steam  the  better  chance  of  destroying  the  spon    , 

but  the  greater  the  damage  to  the  hair;  and  the  dryer 
t  he  steam  I  lie  less  chance  of  destroying  the  spore-  and 
the    less    damage    to     the    hair.      These    antagonistic 

results  produce  a  deadlock,  [n  Nuremberg,  one  of  the 
chief  brush-making  towns  in  Germany,  regulal ions  are 
carried  out,  all  raw  materials  being  disinfected  by 
steam;  yet  cases  of  anthrax  still  occur,  though  less 
in  number. 

The  vapor  of  formalin  would  probably  be  destructive 
to  the  germs  of  anthrax,  and  possesses  the  special 
advantage  thai  the  texture  of  the  suspected  materials 
is  not    injured  by  I  he  process. 

Fagge  says:  "The  system  of  prophylaxis  by  inocu- 
lation of  anthrax  virus  attenuated  by  transmission 
through  suitable  animals  promises  important  results, 
and  its  study  indicates  a  close  analogy  to  the 
relation  of  eowpox  to  smallpox." 

Tueatment. — From  the  earliest  times,  all  writers 
on  the  treatment  of  anthrax  have  recommended 
destruction  of  the  primary  focus  by  causticsor 
cauteries.  The  actual  cautery  is  still  the  chief  treat- 
ment in  many  parts  of  Russia,  Siberia,  Persia  and 
other  countries  of  Asia,  where  the  disease  is  most 
prevalent.  In  England,  surgical  interference  in 
cutaneous  anthrax  usually  takes  the  form  of  free 
excision,  and  swabbing  the  wound  with  pure  carbolic 
acid.  At  Guy's  Hospital,  in  addition  to  this,  powdered 
ipecacuanha  is  commonly  dusted  on  the  wound, 
and  is  given  in  ten-grain  doses  internally.  The  guide 
in  this  treatment  was  Muskett  in  South  Africa,  who 
regarded  ipecacuanha  as  a  specific  for  anthrax,  and 
by  this  means  had  treated  fifty  cases  without  a  fatal 
issue.  Washbourn  also  found  that  ipecac  destroyed 
the  bacilli  of  anthrax,  but  not  the  spores;  these  latter 
however  are  not  found  in  the  animal  body. 

The  usual  treatment  of  external  anthrax  in  the 
past  has  therefore  consisted  in  the  application  of 
varied  medication  to  the  local  lesion,  or  in  excision  of 
the  pustule:  a  glance  at  the  mortality  shows  how 
ineffectual  these  measures  are.  When  excision  is 
performed  early,  it  will  in  many  cases  be  followed 
by  a  diminution  of  the  edema  and  a  fall  in  the  tem- 
perature; but  the  mechanical  injury  done  to  the 
tissues  by  the  knife,  and  the  opening  of  new  paths  of 
infection  through  the  lymph-sinuses  and  the  blood- 
vessels, and  the  resulting  scarring  and  disfigurement, 
especially  about  the  face,  must  be  regarded  as  ob- 
jectionable   features    to    this    plan    of    treatment. 

More  recent  observers  have  discountenanced 
operative  interference  in  anthrax.  In  the  Muenchener 
mi  ilizinischer  Wockenschrift,  Dec.  26,  1911,  is  con- 
tained a  review  by  Wolff  and  Weiwioski.  This 
article  presents  an  account  of  the  cases  of  anthrax 
observed  in  that  Clinic  since  1900,  with  a  short 
abstract  of  the  clinical  history  and  the  course  of  each 
case;  with  the  treatment  in  each  patient.  There 
were  thirteen  cases,  of  which  six  are  classed  as 
"  severe, "  and  seven  as  of  a  mild  form.  In  estimating 
the  gravity  of  the  several  cases,  the  temperature  was 
considered  less  valuable  as  an  indication  than  the 
general  appearance  of  the  patient,  the  location  of  the 
lesion,  the  extent  of  edema,  and  the  degree  of  swelling 
of  the  lymph  glands. 

In  one  of  the  severe  cases,  a  physician  had  already 
made  an  incision  into  the  lesion,  and  in  the  Clinic 
the  patient  was  also  treated  by  the  Bier  method 
after  operative  treatment  by  another  practitioner. 
This  ease  was  the  only  fatal  one  in  the  series  of 
thirteen;  i.e.  7.7  per  cent.  In  one  other  severe 
case  the  primary  lesion  was  on  the  right  thumb:  the 
patient  was  a  brush-maker,  and  was  wounded  by  one 
of  the  implements  used  in  the  manufacture  of  brushes. 
Three  days  later,  when  admitted  to  the  hospital,  the 


467 


Anthrax 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


entire  thumb  as  well  as  the  corresponding  matacarpal 
region  was  of  a  livid  color,  and  presented  several 
bulla?  the  size  of  a  pea.  The  entire  hand  and  the 
forearm  were  much  swollen  and  indurated.  _  Two 
very  small  incisions  were  made  in  the  diseased  tissues 
near  the  root  of  the  nail  (not  in  the  healthy  tissues); 
no  pus  was  found;  but  anthrax  bacilli  were  found  in 
the  content  of  the  blebs.  The  patient  was  discharged 
on  the  eleventh  day.  with  the  wound  nearly  healed. 

The  treatment  employed  in  ten  of  these  cases  was 
absolutely  conservative,  and  consisted  with  slight 
variations,  in  dressings  of  boric  acid,  tincture  of 
iodine,  etc.,  and  light  bandaging.  The  great, -I 
reliance  was  placed  upon  absolute  quiet  on  the  part  of 
the  patient,  with  repose  of  the  seat  of  the  disease. 
The  writers  add:  "In  view  of  these  results,  we  can 
express  ourselves  in  thorough  approval  of  the  con- 
servative treatment  of  anthrax." 

Strumpell  ("Handbook  of  Medicine",  1912)  ex- 
presses his  opinion  as  follows:  The  treatment  of  malig- 
nant pustule  is  surgical.  Cauterization  with  caustic 
potash,  nitric  acid,  or  carbolic  acid  has  been  found 
ineffective  and  even  injurious.  In  mild  cases  moist 
applications  of  aluminum  subacetate,  ice-bags,  and 
the  like  are  sufficient.  In  severe  cases  experienced 
surgeons  advocate  the  division  of  the  pustule,  applica- 
tion of  the  thermocautery  to  the  circumference  of  its 
base,  and  the  injection  of  tincture  of  iodine  in  drops 
into  the  border  line  between  the  inflamed  and  the 
healthy  skin. 

Rigidly  conservative  measures  of  treatment  have 
been  advocated  by  many  writers.  Among  these, 
Mnller  treated  thirteen  cases,  and  Rammsted  seven 
cases,  by  rest,  fixation,  and  the  local  application  of 
mercurial  ointment:  Strubel  recommended  applica- 
tion of  very  hot  cataplasms,  supplemented  by  in- 
jection of  solution  of  carbolic  acid:  and  Schultze 
applies  hot  compresses  of  one-per-cent.  mercuric 
chloride  solution  in  eighty-per-cent.  alcohol.  (Musser 
and  Kelly,  "Handbook  of  Practical  Medicine",  1911.) 
The  most  important  progress  in  recent  years  is  the 
introduction  of  the  serum  treatment  for  both  local 
and  general  anthrax  infection.  Previous  to  this,  we 
find  in  the  literature  the  discussion  of  the  following 
methods  of  treatment:  (1)  Expectant,  (2)  antibacterial, 
(3)  complete  excision  of  the  local  infection. 

The  expectant  treatment  is  based  on  the  fact  that 
man  is  not  highly  susceptible  to  the  anthrax  bacillus, 
and  that  clinical  observations  have  indicated  that 
manipulation  of  the  local  infection  is  apt  to  be  followed 
by  death  from  general  infection.  Bacterial  in- 
vestigations have  demonstrated  that  anthrax  is  fatal 
to  man  only  when  the  bacilli  get  into  the  general 
circulation. 

Injection  of  Carbolic  Acid. — Strubell  is  the  chief 
advocate  of  this  method  of  treatment.  It  consists 
in  the  hypodermic  injection  of  a  three-per-cent. 
solution  of  carbolic  acid,  in  amounts  of  ten  to  fifteen 
minims.  These  injections  are  sometimes  given 
thirty  times  in  a  day,  and  as  many  as  400  such  in- 
jections have  been  required  in  one  case.  They  are 
made  around  the  area  of  infection.  Combined  with 
this  treatment,  the  infected  area  is  covered  with  poulti- 
ces at  a  temperature  as  high  as  63°  C.  He  reports  two 
cases,  both  of  which  recovered.  (Musser).  This 
treatment  as  described  by  Strubell,  on  the  whole, 
seems  popular.  I  find  a  successful  case  recorded  by 
Voigt;  recovery  took  place  after  300  injections  of 
carbolic  acid,  without  symptoms  of  any  toxic  effect 
therefrom.  Caforio  and  Corseri  advocate  similar  in- 
jections of  a  one-per-cent.  solution  of  corrosive 
sublimate.  Caforio  reports  eighteen  cases,  in  some 
of  which  the  infection  was  very  grave,  associated 
with  edema  and  genera]  symptoms.  Cipriani  advo- 
cates injection  of  a  one-per-cent.  solution  of  chinosol. 
His  experience  with  carbolic  acid  and  nitrate  of 
silver  solutions  indicated  danger  of  intoxication 
from    thee    substances.     Musser    adds:  "The    good 


results  in  these  various  methods  speak  favorably  for 
the  prognosis  of  anthrax  in  man.  On  the  whole,  I 
should  recommend  the  complete  excision  of  the 
pustule  if  possible,  and  the  disinfection  of  the  open 
wound  with  pure  carbolic  acid.  However  in  view  of 
the  results  after  conservative  treatment,  or  after 
injection  of  carbolic  acid,  one  would  hesitate  to  per- 
form a  mutilating  operation.  In  such  an  event,  I 
should  recommend  the  injections  of  pure  carbolic  acid; 
if  properly  performed,  it  is  distinctly  a  stronger 
antiseptic,  and  experience  with  carbolic  acid  has 
cli -a  rly  demonstrated  that  there  is  less  danger  of 
poisoning  when  the  pure  acid  is  used,  than  when 
solutions  are  employed.  The  very  hot  poultices 
recommended  by  Strubell  should  be  used,  whether 
excision  is  practised  or  not." 

Scharnowski  treated  fifty  consecutive  cases  by 
subcutaneous  injection  of  carbolic  acid  with  only  one 
death.  In  a  remarkable  case  reported  by  Strubell 
(Muenchener  med.  Wochenschrift,  xlviii.,  p.  152G),  the 
nose  was  the  seat  of  inoculation  and  of  the  primary 
lesion:  excision  was  impossible,  and  the  face  and  neck 
were  extensively  inflamed  and  edematous.  The 
patient  received  in  eighteen  days  more  than  400 
hypodermic  syringefuls  of  three-per-cent.  solution  of 
carbolic  acid  in  the  vicinity  of  the  affected  parts,  and 
recovered  without  having  at  any  time  showed  toxic 
symptoms  from  the  drug.  In  anthrax,  there  would 
appear  to  be  a  special  tolerance  for  carbolic  acid. 
When  the  primary  lesion  is  recognizable,  and  its 
size  and  location  permit,  most  surgeons  practise 
exi  ision,  followed  by  the  actual  cautery,  or  by  ninety- 
five-per-cent.  carbolic  acid.  This  is  the  usual  practice 
in  England,  even  when  Sclavo's  serum  has  been 
employed.  Where  excision  is  not  possible,  free 
multiple  incision  with  cauterization  has  been  recom- 
mended. Objection  has  been  raised  by  Mueller  to 
incision,  on  the  ground  that  it  may  open  the  way  for 
the  bacilli,  up  to  that  time  successfully  isolated  by 
nature,  to  enter  the  blood  stream.  Under  this  idea, 
Mueller  and  Ramsted  have  reported  twenty  consecu- 
tive cases  of  localized  external  anthrax  treated  ex- 
pectantly by  no  other  measures  than  rest,  fixation 
and  elevation  of  the  part,  with  local  cleanliness  or 
antisepsis  (in  some  cases  with  mercurial  ointment), 
good  diet  and  stimulation.  All  recovered,  though 
several  were  severe  cases,  and  in  one  the  tongue  was 
involved  in  the  disease.  (See  Milroy  Lectures, 
"Industrial  Anthrax,"  T.  M.  Legge,  Brit.  Med. 
Journal,  1905.) 

If  any  operation  is  done  in  a  case  of  anthrax,  it 
should  not  be  done  in  the  ordinary  operating-room  of 
a  hospital,  but  in  a  separate  room.  After  the  opera- 
tion, the  floor  and  walls  should  be  thoroughly  disin- 
fected, and  a  bacteriological  examination  of  the  floor 
should  be  made,  in  order  to  determine  if  disinfection 
is  effective.  In  Keen's  case  at  the  Jefferson  .Medical 
College  Hospital,  three  disinfections  were  required, 
with  formaldehyde,  pure  carbolic  acid,  and  strong 
bichloride  of  mercury  before  the  floor  was  germ-free. 
In  the  closing  sentences  of  the  section  on  the  treat- 
ment of  anthrax  in  the  previous  edition  of  this  Hand- 
book may  be  found  the  following:  "From  the  results 
obtained  in  the  study  of  other  specific  organisms 
affecting  the  human  body,  or  that  of  animals,  it, 
would  seem  reasonable  to  hope  and  expect  that 
further  research  may  furnish  an  efficient  remedy  in 
the  form  of  an  antitoxin  (or  vaccine)  in  anthrax, 
such  as  has  been  obtained  in  respect  to  some  of  the 
other  of  the  bacterial  infections,  particularly  human 
diphtheria."  This  prospective  ami  desired  result  has 
been  already  realized,  in  keeping  with  the  progress  of 
serum  therapy  in  other  diseases.  An  immunizing 
agent  has  been  developed  which  promises  to  be  .as 
effectual  in  the  treatment  of  anthrax,  as  the  antitoxin 
has  been  in  the  treatment  of  diphtheria.  Toussaint 
in  1880,  Pasteur  in  1SS1,  Marchoux  in  ISO"),  Sobern- 
heim  in  1898  and  again  in  1902  and  1904,  have  con- 


liis 


REFERENCE   HANDBOOK   OF   TIIK    MEDICAL   SCIENI  ES 


Anthrax 


tributed  important  papers  upon  the  subject  of  im- 
munity to  anthrax,  based  on  their  experimental  work. 
Bclavo  in  June,  L897,  began  treatment  of  anthrax  in 
man  by  means  of  a  serum  prepared  from  animals 
after  combined  active  and  passive  immunization 
treatment  (simultaneous  inoculations  of  serum  and 
virus),  from  which  the  most  powerful  serum  is  ob- 
tained. In  1903  he  collected  a  series  of  104  cases 
with    two    deaths,    a    mortality    of    three    per    cent. 

The  serum  has  no  deleterious  effects,  and  in  the 
hands  of  its  originator  and  others,  especially  in  Italy 
England,  the  results  substantiate  the  claims  thai 
have  been  made  for  it.  It  assists  in  the  destruction  of 
the  bacilli  before  they  become  so  numerous  that  their 
distribution  increases  the  danger  of  fatal  poisoning 
by  the  toxins  set  free  through  the  disintegration  of 
the  bacilli.  "Judging  from  the  experience  of  those 
who  are  best  qualified  to  speak,  the  treatment  of 
anthrax  should  consist  in  the  administration  of 
o's  serum,  in  the  excision  of  the  pustule,  and  in 
the     application     of     certain     bactericidal     agents.'' 

Prof.  Sclavo  of  Siena,  after  much  experimentation 
has  produced  a  bacterial  protective  serum  from  the 
a--,  which  he  asserts  to  be  harmless,  and  'which  he 
subcutaneously  in  doses  of  20  to  40  e.c.  or,  in 
cases,  of  additional  amounts  of  10  c.c,  intra- 
venously, to  be  repeated  if  necessary.  He  does  not 
practise  excision  or  cauterization  of  the  local  lesion. 
He  states  that  improvement  almost  immediately 
follows  the  injection  of  the  serum,  and  reports  16*0 
3,  with  a  mortality  of  six  per  cent.  In  two  of 
these  cases  that  recovered,  the  bacilli  had  been 
demonstrated  in  the  urine,  and  in  one  of  these,  in  the 
blood  as  well.  Recovery  in  a  case  of  anthrax  in  which 
the  bacilli  were  found  in  the  blood  has  never  been 
reported  from  any  other  form  of  treatment.  Within 
twenty-four  hours  after  the  treatment  the  bacilli 
disappeared  from  the  fluid  of  the  vesicle. 

In  July,  1S97,  Sclavo  began  to  treat  cutaneous 
anthrax  in  man  by  the  curative  serum  obtained  by 
his  method  from  proper  animals.  Sclavo  directs  as 
the  initial  treatment,  that  30  or  preferably  40  c.c. 
should  be  injected  in  four  doses  of  10  c.e.  each,  in 
four  different  places  in  the  abdominal  wall.  On  the 
following  day,  if  there  be  no  improvement  either  in 
the  local  or  general  symptoms,  30  or  40  c.c.  should  be 
again  injected  in  the  same  manner:  and  where  the 
symptoms  are  very  grave,  10  c.c.  additional  may  be 
injected  intravenously  into  one  of  the  veins  on  the 
back  of  the  hand,  and  repeated  if  necessary.  A  rise 
in  temperature  following  the  injection  is  regarded  as 
a  favorable  sign. 

If  kept  cool  and  in  a  dark  place,  the  serum  remains 
fully  active  for  at  least  two  years.  Sclavo  would 
rely  solely  on  the  use  of  his  serum.  In  England,  the 
inclination  has  decidedly  been  to  employ  it  in  all 
cases  in  the  doses  recommended  by  him,  but,  in 
addition,  to  excise  the  local  lesion,  or  inject  carbolic 
acid  in  five-per-cent.  solution  into  the  tissues  around 
the  local  focus.  Sclavo  refers  to  a  considerable 
number  of  cases  of  cutaneous  anthrax  in  Italy, 
treated  by  his  serum  with  a  mortality  of  6.09  per  cent. 
as  compared  with  a  mortality  of  24.1  per  cent,  for  all 
cases  in  Italy. 

Dr.  T.  M.  Legge  has  published  details  of  sixty- 
seven  cases,  in  fifty-six  of  which  serum  alone  was 
used:  excluding  one  fatal  case,  and  two,  in  which 
there  was  loss  of  tissue,  the  duration  of  the  illness 
from  commencement  of  the  treatment  until  recovery, 
appears  to  have  been  not  more  than  fourteen  days  in 
any  of  the  fifty-three  cases;  and  in  forty-four  of  them, 
the  average  duration  was  eight  days.  Among  these 
cases  were  none  of  the  intestinal  or  the  pulmonary 
variety.  Mendez  of  Buenos  Ayres  (1904)  refers  to 
1,073  cases  treated  with  serum  from  the  horse,  im- 
munized by  him  in  the  same  way  as  was  done  at  first 
by  Marchoux  and  Sclavo,  with  a  total  of  forty-four 
deaths — 1.19  per  cent.     "Sclavo's  (1903)  claim  as  to 


the  effects  of  antianthrax  serum  may  be  summarized 

as  follows: 

(1)  Antianthrax  serum  even  in  very  large  doses  is 
inocuous  and  can  be  well  borne  even  when  introduced 
into  the  veins. 

(2)  No  case  taken  in  an  early  stage  or  of  moderate 
Severity  is  fatal  if  treated  with  serum. 

(3)  With  serum  a ■  cases  arc  saved  when  the 

condition  is  most  critical,  and  the  prognosis  almost 
hopeless. 

I  I )  When  injected  into  the  veins  the  serum  quickly 
arrest  s  the  extension  of  the  edematous  process  so  a  to 
reduce  notably  the  dancer  of  suffocal  ion  which  exists 
in  many  cases  where  the  pustule  is  situated  on  the 
face  or  neck. 

(5)  The  serum,  if  used  soon  enough,  reduces  to  a 

minimum    the   destruction    of    the    tissues    where   the 

pustule  is  situated,  and  tints  avoids  deformity 

(6)  In  some  situations  of  the  pustule,  as  the  ej  e-lid, 

serum  must  be  used  in  preference  to  any  other  treat- 
ment, it  being  the  only  our  which  holds  out  hope  of 
success  without  permanent  injury,  and  in  cases  of 
internal  anthrax  the  early  injection  of  serum  intra- 
venously is  the  only  remedy  likely  to  be  successful." 
(From  contribution  to  "Industrial  Anthrax"  in 
Journal  <</'  Hygii  tie,  vol.  ix.,  No.  4,  p.  381,  by  Cecil 
H.  W.  Page.)'  ' 

Dasso  (Review  in  Jour.  Am.  Med.  Assn.,  March  2, 
1901,  p.  tWi)  claims  that  the  serum  prepared  against 
anthrax  by  Mendez  is  more  powerful  than  Sclavo's 
or  that  of  Sobernheim.  He  reports  130  cases  treated 
with  this  serum  (dose  10  c.c.)  injected  subcutaneously, 
with  nine  deaths,  all  but  two  being  caused  by  second- 
ary infections. 

As  early  as  18S9,  Bouchard  and  Carrhin  called 
attention  to  the  curative  effects  obtained  by  inject- 
ing the  Bacillus  pyocyaneus  into  guinea-pigs  and 
rabbits  suffering  from  anthrax;  and  in  the  same 
year  Woodhead  and  Wood  arrived  at  the  same  re- 
sults by  using  the  toxin  of  the  pyocyaneus.  In 
the  Annates  de  I'Institut  Pasteur,  1910,  vol.  xxiv.,  p. 
330,  is  contained  a  communication  by  Dr.  J.  d'Agata 
which  was  presented  at  the  XVI  International 
Medical  Congress  at  Budapest,  1909,  in  which  he 
describes  his  investigations  in  the  laboratory  of 
Prof.  Pane  at  Naples.  The  Bacillus  pyocyaneus  was 
attenuated  in  various  degrees,  and  infected  with 
bouillon  cultures  of  virulent  anthrax  bacilli,  which 
had  grown  in  culture  for  varying  periods.  Sheep 
were  employed  to  ascertain  the  action  of  the  com- 
bined bacilli.  The  inoculation  was  made  subcutane- 
ously^ in  each  case.  The  reporter  concludes  that  an 
antigen  is  produced  in  his  experiments  which  confers 
a  manifest  degree  of  immunity  in  the  sheep.  Fortineau 
of  the  Pasteur  Institute  at  Nantes  (1910)  proved 
that,  animals  vaccinated  with  Bacillus  pyocyaneus 
developed  a  marked  resistance  to  anthrax  and  that 
the  toxin  of  pyocyaneus  exerted  remarkable  curative 
effects.  He  was  also  able  to  obtain  the  same  result 
in  larger  animals,  by  injecting  the  toxin  at  the  point  of 
inoculation  some  hours  later  than  the  infection,  or 
at  some  other  point  than  that  of  the  inoculation 
with  the  anthrax  infection.  One  case  is  reported 
in  which  the  patient  was  a  girl  of  twenty  years, 
who  worked  in  a  brush  shop,  and  was  infected 
on  the  left  cheek.  Three  centimeters  of  the  toxin 
(pyocyaneus)  were  injected  two  centimeters  deep 
under  the  skin,  and  the  following  day  the  same  dose 
was  repeated,  and  again  two  days  later.  The  patient 
made  an  uninterrupted  recovery.  The  symptoms 
at  the  time  of  the  injection  were  exceedingly  acute, 
and  the  case  was  one  of  typical  anthrax.  This  is  a 
subject  of  considerable  importance,  and,  considering 
the  bad  results  obtained  by  the  ordinary  methods  of 
treatment,  it  is  certainly  worth  further  investi- 
gation. 

Fortineau  in  the  Annates  dc  I'Institut  Pasteur  de 
Nantes,  vol.  xxiv.,  p.  9o5,  offers  a  further  contribution 

469 


Anthrax 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


to  this  subject,  which  appears  to  confirm  his  previous 
conclusions;  and  he  reports  the  application  of  this 
treatment  in  a  case  of  human  anthrax,  in  a  patient  of 
Dr.  Bellourd  of  Nantes.  The  patient  was  a  work- 
man aged  twenty  years,  who  on  May  3,  1910,  noticed 
a  small  vesicle  at  the  level  of  the  left  cheek-bone; 
the  next  day  the  vesicle  was  replaced  by  a  crust,  the 
eyelids  and  "the  adjacent  regions  were  edematous,  and 
the  submaxillary  lymph  glands  were  engorged.  On 
May  6,  the  third  day,  the  patient  called  Dr.  Bel- 
louard.  The  scab  measured  two  centimeters,  and  was 
surrounded  with  a  circle  of  characteristic  vesicles. 
The  scab  was  deeply  cauterized  with  the  thermo- 
cautery, and  four  injections  were  made  around  it  of  a 
solution  of  iodine,  and  iodine  was  prescribed  internally. 
On  the  fourth  day,  there  was  extensive  edema 
embracing  the  eyelids  and  preventing  a  view  of  the 
eye,  which  was  the  seat  of  chemosis,  and  reaching  to 
the  lower  half  of  the  cheek.  The  serosity  accompany- 
ing the  edema  contained  anthrax  bacilli.  The 
glands  of  the  jaw  were  larger,  and  slightly  painful, 
the  spleen  palpable.  The  temperature  was  37.9°  O, 
pulse  120;  appetite  fair,  the  tongue  moist,  and  the 
general  condition  very  good.  Three  cubic  centimeters 
of  pyocyaneus  were  injected  at  a  location  two  centi- 
meters lower  down,  and  at  a  considerable  depth  in  the 
flesh.-  On  the  fifth  day,  the  edema  was  more  firm, 
the  area  larger,  extending  to  the  angle  of  the  jaw; 
the  pain  slight;  there  was  insomnia,  and  the  patient 
was  somewhat  depressed;  temperature  3S.9°;  pulse 
120;  3  c.  c.  were  injected  into  the  pustule,  and -tec.  into 
the  region  around  the  lesion.  During  the  succeeding 
night  the  condition  of  the  patient  improved;  the 
edema  became  less,  and  the  eye  could  be  partially 
opened.  On  the  seventh  day,  the  general  condition 
of  the  patient  was  good.  Six  days  later  the  patient 
was  sitting  up;  spleen  not  palpable:  chemosis  less. 
One  week  later,  "the  edema  is  confined  to  the  lower 
eyelid;  the  scab  shows  a  tendency  to  separate  at  the 
angle  of  the  eye;  the  crust  in  due  partially  to  the 
cauterization,  and  to  the  iodine  injections."  Five 
months  later  the  patient  presented  a  cicatrix  which 
was  hardly  noticeable  at  the  place  where  the  cautery 
had  been  used.  "The  general  condition  of  the 
patient  is  excellent." 

Internally,  the  treatment  should  embrace  wine, 
champagne,  coffee;  and  if  signs  of  failure  of  the  heart 
appear,  carbonate  of  ammonia,  camphor,  etc., 
should  be  added.  Ipecacuanha  locally  and  inter- 
nally has  also  been  highly  recommended,  and  reports 
of  recovery  from  its  use  have  been  published.  Nu- 
cleinic  acid  has  also  yielded  promising  results  in  the 
hands  of  Vaughan.  If  the  disease  has  been  induced 
by  the  use  of  infected  meat,  a  prompt  emetic  should 
be  administered,  followed  by  a  cathartic,  for  the 
purpose  of  removing  the  germs,  as  thoroughly  as 
possible,  from  the  alimentary  canal  before  general 
infection  of  the  system  occurs.  The  only  medicine 
which  can  be  looked  upon  as  in  any  sense  a  specific 
is  quinine,  of  which  one  to  two  grams  should  be 
prescribed  in  twenty-four  hours,  and  it  may  be 
advantageously  combined  with  carbolic  acid,  one 
gram  per  day.  The  constant  use  of  ipecacuanha 
after  excision  of  the  local  lesion,  both  by  the  mouth 
and  by  application  to  the  seat  of  the  pustule,  has 
been  followed   by  gratifying  results  in  many  cases. 

In  cases  in  which  the  limbs  are  the  seat  of  extensive 
edema  or  of  gangrene,  deep  incisions  should  be  made 
to  allow  the  evacuation  of  the  abnormal  products, 
and  antiseptic  dressings  should  be  rigidly  adhered  to 
until  granulations  have  formed. 

The  treatment  of  the  conditions  following  the 
immediate  effects  of  anthrax,  such  as  inflammatory 
and  suppurative  affections  of  the  lungs  or  of  other 
organs,  should  be  directed  by  the  considerations  and 
principles  applicable  to  the  treatment  of  similar  con- 
ditions arising  from  other  causes. 

Albert  N.   Blodgett. 

470 


Bibliography. 

The  literature  upon  the  subject  of  anthrax  is  very  large,  but 
among  the  most  valuable  contributions  may  be  mentioned: 

Heusinger:  Die  Milzbrandkrankheiten  der  Thiere  u.  des  Men- 
schen,  Erlangen,  1S50. 

Bollinger:   Art.  Milzbrand  in  v.  Ziemssen's  Handbuch. 

Waldeyer:    Virchow's  Arch.,  Bd.  hi.,  S.  541. 

Zuelzer:  Berl.  klin.  Wochenschrift,  1S74,  No.  25;  also  in  Eulen- 
burg's  Realencyclopiidie,  vol.  ii.,  p.  679. 

Quain:    Dictionary  of  Medicine,  p.  1302. 

Forbes:   International  Encyclopedia  of  Surgery,  vol.  i.,  p.  228. 

Fagge:    Principles  of  Practice  of  Medicine,  vol.  i.,  p.  367. 

Twentieth  Century  Practice  of  Medicine,  vol.  xv,  art.  Anthrax. 

Paul  v.  Baumgarten:  Lehrbuch  der  Pathogenen  Mikroorgcnis- 
men,  Leipzig,  1911. 

Keen's  Surgery:  1906,  vol.  i.  (Good  illustrations  of  bacillus 
anthracis  and  bibliography  of  Anthrax.) 

The  International  Text-book  of  Surgery.     Warren-Gould,  1902. 

William  Osier:    Modern  Medicine,  vol.  iii..  p.  46. 

J.  M.  Anders  and  Napoleon  Boston:  A  Text-book  of  Medical 
Diagnosis,  1911. 

Victor  C.  Vaughan:    Twentieth  Century  Practice,  vol.  xiii. 

Allbutt  and  Rollestone:  A  System  of  Medicine,  1909  (Good 
bibliography.) 

Bryant  and  Buck:    American  Practice  of  Surgery,  1909. 

H.  A.  Hare:    Progressive  Medicine,  vol.  i.,  March,  1912,  p.  115. 

John  H.  Musser  and  A.  O.  J.  Kelly:  Hand-book  of  Practical 
Treatment,  1911. 

Muench.  med.  Wochenschrift,  1911,  ii.,  p.  27S7. 

Adami  and  Nicholls:    "Principles  of  Pathology,"  1909. 

McFarland:    Text-book  of  Pathology,  1910. 

E.  Zeigler:  General  Pathology,  190S.  (Good  illustrations  and 
Literature.) 

Alfred  Stengel:   Text-book  of  Pathology,  1900. 

T.  Henry  Green,  London,  1911. 

Delafield  and  Prudden:    1900.      (Good  illustrations,  p.  222  ) 

"Sobernheim,"  Kollo  und  Wassermann,  Handbuch  der  Mikro- 
organismen. 

Kraus  R.  and  Levaditi  C. :  Handbuch  der  Methodik  u.  Technik 
der  Immunitatsforschung.      (With  list  of  references.) 

Kolle  and  Hetsch:  "  Experimented  Bakteriologie  u.  Infektions- 
krankheiten."     (Illustration,  and  bibliography),  190S. 

Anthrarobin. — Dioxvanthrol,  desoxy-alizarin,  leu- 
co-alizarin,  C„H4.  COH.  CH.  C„H2(OH),.  This  is 
prepared  by  the  reduction  of  commercial  alizarin  in 
warm  ammoniacal  solution  with  zinc  dust,  and  sub- 
sequent filtering  into  water  acidulated  with  hydro- 
chloric acid.  The  resulting  precipitate  is  washed 
and  dried. 

Anthrarobin  is  a  yellowish-white,  granular  powder, 
insoluble  in  water  and  dilute  acids,  slowly  soluble  in 
chloroform  and  ether,  and  freely  soluble  in  glycerin 
and  in  ten  parts  of  alcohol.  In  aqueous  solutions  of 
alkalies  or  alkaline  earths  it  dissolves  with  a  brownish- 
yellow  color,  which,  through  oxidation  and  the 
reformation  of  alizarin,  rapidly  turns  to  green  and 
then  blue.  Claimed  to  have  the  same  virtues  as 
chrysarobin,  this  substance  has  the  advantages  of 
being  non-irritating,  and  of  causing  but  slight  staining 
of  the  skin.  Clinical  reports  differ  as  to  its  efficacy; 
for  example,  Jackson  says  that  it  is  a  weak  prepara- 
tion and  not  of  much  value,  while  Behrend  and  others 
consider  it  superior  to  chrysarobin.  These  latter  use 
it  as  a  parasiticide  and  stimulant  to  the  skin,  and 
especially  commend  its  use  in  psoriasis,  pityriasis, 
tinea  tonsurans,  tricophyton,  and  herpes.  It  is 
employed  in  ten-  to  twenty-per-cent.  ointment,  or  in 
solution  in  glycerin  or  alcohol,  or  in  collodion.  It 
must  not  be  applied  in  the  immediate  neighborhood 
of  the  eye,  as  it  has  a  tendency  to  spread.  A  pre- 
scription (hat  is  recommended  contains  anthrarobin 
and  salicylic  acid,  of  each  one  dram,  in  alcohol 
sufficient  to  make  one  ounce.  Behrend's  mixture 
consists  of  anthrarobin  ten  parts,  borax  eight  parts, 
in  water  eighty-two  parts,  or  he  uses  a  ten-per-cent. 
solution  in  glycerin.  W.  A.   Bastedo. 


Anthropology,  Medical. — Anthropology  is  defined 
as  the  science  of  man.  It  treats  of  our  agreement 
and  divergence  from  other  animals  in  structure 
mental   make-up,    race   peculiarity,  social  condition, 


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Anthropology,  Hedlcal 


and  social  tendency.1  Medical  anthropology,  in 
order    to   comport    with    this   definition,    should    deal 

with  the  medical  features  pertaining  to  such  agree- 
ment and  divergence  and  should  seek  to  discover  the 
cause  thereof.  It  should  explain  why  some  diseases 
{ii i.ok  man  with  various  degrees  of  virulence  while 

cely,  if  at  all.  showing  any  tendency  to  attack 
other  animals.     Conversely,  it  should  be  able  to  tell 

liy  still  other  diseases  do  not  attack  man  but  do 
attack  certain  kinds  of  other  animals.  It  should 
.seek  to  explain  how  and  why  it  is  that  our  bodies  are 
subject  to  injuries  of  kinds  to  which  other  animals 

n  to  be  almost  immune,  and  why  we  carry  so  many 
organic  disharmonies  of  structure  if  we  are  products 

.lint  less  general  ions  of  selection  of  only  harmonies. 
1 1  should  be  able  to  enlighten  us  on  how  to  rid  our- 
selves of  these  disharmonies  or  minimize  their  evil 
influences.  It  should  treat  of  the  mental  maladies 
of  man  and  show  us  how  and  to  what  extent  they 
differ  from  the  psychic  maladies  of  the  lower  animals. 
It  should  deal  with  industrial  diseases,  teach  us  how- 
to  lessen  their  evil  consequences  upon  civilization 
and.  where  possible,  how  to  eliminate  them.  It 
should  enlighten  us  regarding  the  genetic  relation- 
ship of  the  pathogenic  organisms  peculiar  to  man, 
show  us  how  these  relationships  control  the  produc- 
tion of  disease  and  tell  us  to  what  extent,  if  at  all. 
the  lower  animals  act  as  carriers  or  producers  of  new 
human  diseases. 

In  nothing  else  is  medical  anthropology,  as  a 
special  branch  of  medical  study,  more  needed  than 
in  tracing  out  the  race  histories  of  bacteria,  protozoa, 
fungi,  and  metazoa  that  are  parasitic  upon  man, 
and  particularly  of  those  that  make  of  him  their 
exclusive  host,  either  during  their  entire  lives  or 
during  some  particular  part  of  their  lives.  We 
greatly  need  to  know  when,  where,  why,  and  how- 
such  parasites  first  came  to  choose  man  as  their  host. 
A  leading  American  pathologist  has  told  us  that 
parasitism  "will  be  for  some  time  to  come  the  most 
fruitful  field  for  research"2  and  this  is  undoubtedly 
true  of  anthropological  parasitism.  It  is  unfortunate 
that  the  subjects  here  referred  to  have  met  with  so 
little  attention  and  doubly  unfortunate  that  there  is 
not  a  united  body  of  research  workers  trying  to 
collect  them  into  a  department  of  medical  anthropol- 
ogy. It  is  probably  because  there  is  no  society  of 
this  kind  that  we  are  not  in  possession  of  any'satis- 
factory  explanation  of  why  gonorrhea,3  leprosy,4 
influenza,5  syphilis,  and  most  exanthemata,0  are 
exclusively  or  almost  exclusively  human  diseases. 
This,  too,  is  most  likely  responsible  for  our  inability 
to  tell  why  Laverania  malaria;,  Plasmodium  malarial, 
and  Plasmodium  rivax,  during  the  time  that  their 
sporozoites  are  passing  through  the  tropozoite  stage 
to  that  of  schizonts,  produce  in  man  their  three 
respective  kinds  of  malarial  fever,  while  kindred 
Hsmosporidia  do  not  at  all  affect  man  but  do  produce 
disease  in  other  mammals,  during  the  same  stages  in 
their  life  histories.  Our  lack  of  knowledge  in  this  line 
of  study  still  compels  us  to  ask  why  and  how  it  is  that 
Piroplasma  can  sicken  and  kill  our  cattle  and  not 
affect  man,  while  Plasmodium  can  injure  and  kill  man 
yet  do  no  harm  to  animals  below  man.  Cholera, 
typhoid  fever,  whooping  cough,  relapsing  fever, 
dysentery,  typhus  fever,  smallpox,  chickenpox, 
rubeola,  Malta  fever,  sleeping  sickness,  Madura  foot, 
and  frambeesia  are  all,  primarily,  human  diseases 
though  capable  of  inoculation  into  other  animals. 
If  there  was  a  body  of  organized  workers  in  medical 
anthropology  we  could,  doubtless,  soon  find  the 
meaning  of  the  affinity  of  the  parasites  of  these 
diseases  for  the  body  of  man  and  lack  of  affinity  for 
the  bodies  of  other  animals.  If  natural  selection  had 
anything  to  do  with  it  this  condition  must  have 
resulted  from  the  continuous  survival  of  such  of  the 
parasites  as  varied  in  ways  that  made  them  adapted 
to  man  as  a  host  while  those  of  them  that  failed  so  to 


vary    have   all   perished,     if   natural   selection    had 

nothing  to  do  with  it,  it   would  be  difficult  to  con i 

of  any   other  explanation   compatible   with    the   I  | 
Hut    if  it   is  due   to  selection,   since   the  environments 
of  parasites  are  usually,  after  immunity  is  established, 
free    from   any    marked    variation    during    multitudes 
of  generations,   we  are   compelled   to  assume   that    all 

such  organisms  have  been  man's  constant  companions 
dining  milleniums.  Why  among  fungi,  for  instance, 
should  Pityriasis  versicolor,  Microsporon  furfur, 
Oidium  albicans,  B,nd  Sarcina  oentriculi  die  out  every- 
where except  upon  or  within  human  bodies?  Why 
should  such  Nematodes  as  Oxyuris  vermicularis, 
Trichocephalus  dispar,  and  Filaria  hominis 
disappear  from  every  animal  on  earth  except  man, 
in  one  stage  of  their  life  histories.'  Why,  among 
Trematodes,  do  several  species  of  Distomum  make 
their  homes  in  man  rather  than  in  other  animals 
while  other  species  of  the  same  genus  prefer  exist- 
ing in  other  vertebrates  as  hosts?  Why,  even 
among  external  parasites,  do  Pulcxirritans,  Pediculus 
capitis,  Pediculus  vestimentorum,  Pediculus  pubis, 
and  Cimex  lectularius  refuse  to  make  their  homes 
on  animals  other  than  man?  Have  all  of  the  par- 
asites here  mentioned  clung  to  man,  and  kept  away 
from  other  animals,  voluntarily?  Were  they  in  their 
present  species-forms  before  accepting  of  man  as  a 
host?  Have  they  varied  into  the  species  now  known 
to  us  from  some  older  but  similar  species  and  has 
this  change  occurred  since  making  man  their  host? 
The  known  habits  of  parasites  as  a  class  suggest  a  choice 
between  these  alternatives  as  the  most  highly  prob- 
able. Prof.  P.  C.  Mitchell,  a  well  known  Engli-h 
parasitologist,  tells  us  that  "Parasites  tend  to  be- 
come so  specialized  as  to  be  peculiar  to  particular 
hosts;  ectoparasites  frequently  differ  from  species  to 
species  of  host,  and  the  flea  of  one  mammal,  for 
instance,  may  rapidly  die  if  it  be  transferred  to 
another  although  similar  host Al- 
though there  are  many  eases  in  which  the  parasites 
that  excite  a  disease  in  one  kind  of  animal  are  able  to 
infect  animals  of  different  species,  the  general  tend- 
ency is  in  the  direction  of  absolute  limitation  of  one 
parasite,  and  indeed  one  stage  of  one  parasite  to  one 
kind  of  host."8 

If,  as  we  are  here  informed,  all  kinds  of  parasites 
tend  to  confine  themselves  to  specific  hosts,  so  gen- 
eral a  law  indicates  that  each  species  of  parasite  has, 
as  a  rule,  varied  within  or  upon  its  host  into  its  pres- 
ent species.  We  cannot  possibly  imagine  so  general 
a  system  of  selective  distribution  to  be  due  to  a 
deliberate  choice  on  the  part  of  the  individual  para- 
site to  settle  on  a  definite  host  that  is  to  its  liking. 
Nor  can  we  believe  that  the  distribution  of  each  and 
every  kind,  as  now  found,  is  due  to  the  ubiquity  of 
their  scattering  upon  and  into  all  sorts  of  vertebrates 
with  their  dying  off  during  each  parasite  generation 
in  all  but  favored  hosts.  It  seems  much  more 
reasonable  to  believe  that  the  host  and  the  parasite 
must  have  varied  together  and  if  this  is  so  then  they 
must  have  been,  during  countless  numbers  of  genera- 
tions, constant  companions.  The  host  species  has 
shed  them  upon  its  own  species,  generation  after 
generation,  through  common  food  habits  or  other 
common  habits  that  favored  infection.  In  the 
"Analysis  of  Racial  Descent"  we  are  told  that  von 
Jhering  has  shown  how  the  "distribution  of  entero- 
parasites  helps  to  explain  genetic  relationships  of 
their  hosts.  His  argument  is  that  if  identical  species 
or  genera  of  parasites  occur  in  different  genera  of 
hosts,  the  latter  must  consequently  be  of  common 
descent.  That  is  to  say,  such  parasites  must  have 
come  from  a  common  ancestor,  the  diverse  hosts 
then  also  from  a  host  ancestor  infected  by  that  para- 
site ancestor."9  But  if  the  tendency  is  as  stated 
how  can  we  explain  the  exceptions  to  this  general 
rule?  How  do  the  parasites  of  one  species  of  host 
come  to  infect  some  wholly  different  or  alien  species 


471 


Anthropology,  Medical 


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of  host?  This  is  a  very  different  problem  from  where 
one  variety  of  a  species  supplies  infection  to  another 
variety  of  the  same  species.  Indeed  it  may  be  differ- 
ent from  where  two  very  closely  related  species  carry 
infection  to  each  other.  That  parasites  do  often  pass 
between  varieties  of  the  same  species  and,  possibly, 
between  closely  related  species  of  the  same  genus,  is 
generally    conceded. 

The  fact  has  been  pretty  thoroughly  established 
that  immune  hosts  are  a  fruitful  source  of  very  virulent 
infection  to  non-immune  varieties  and  closely  related 
species.  Indeed  great  virulence  is  now  believed  to 
be  evidence  of  recentness  of  invasion.  The  host  has 
had  no  opportunity  to  acquire  immunity  to  the 
strange  parasite  while  the  parasite  is  accustomed  to  the 
blood  or  tissues  of  its  near  of  kin  and  immune  host. 
When  influenza  reached  us  from  Asia  some  immune 
human  carrier,  of  a  somewhat  different  race  from 
ourselves,  probably  came  into  contact  with  a  non- 
immune stranger.  This  newly  infected  stranger 
carried  the  infection  to  other  non-immune  victims 
and  these  again  to  still  others,  thus  continuing  until 
the  disease  became  pandemic.  Commerce,  invasion 
of  remote  territories  by  armies,  and  religious  pil- 
grimages have,  no  doubt,  been  fruitful  sources  of 
epidemics  due  to  these  causes.  In  the  case  of  trans- 
ference between  species  that  are  not  akin  there  may 
be  a  number  of  explanations  possible.  One  suggests 
itself  in  the  case  of  human  tuberculosis.  A  few 
years  ago  a  lively  discussion  arose  over  the  possibility 
of  the  bovine  form  being  able  to  infect  Homo  sapiens. 
The  consensus  of  opinion  among  medical  men  was 
that  human  beings  are  under  a  constant  and  serious 
menace  from  bovine  tuberculosis.  This,  it  is  evident, 
is  a  most  pronounced  exception  to  the  general  rule  of 
infection,  if  true.  That  it  is  true  has  been  fairly 
well  proven.  What  then  can  be  the  meaning  of 
such  an  exception?  Did  human  tuberculosis  first 
arise  from  bovine  or  did  bovine  come  from  human? 
Man  has  had  the  ox  as  a  domestic  animal  since  long 
prior  to  the  dawn  of  history.  Some  anthropologists 
seek  to  show  that  the  earliest  dispersal  of  man  was 
from  the  region  of  the  original  home  of  Bos  taurus 
and  other  Boridoe.  If  bovine  tubercle  bacilli  preceded 
the  evolution  of  human  tubercle  bacilli  we  are  able  to 
surmise  a  possible  cause  of  such  a  change  but  if  the 
reverse  is  true  then  we  know  of  no  way  in  which  the 
matter  may  be  explained.  Morphologically  the 
bovine  and  human  bacilli  are  indistinguishable. 
Many  facts  point  to  the  probability  of  their  being 
variations  of  each  other,  or  of  some  original  progeni- 
tor of  both.  If  the  original  bovine  tubercle  bacillus 
was  wholly  unable  to  multiply  within  the  body  of 
man — if  it  followed  the  rule  of  parasitic  infection — 
would  not  the  adoption  by  prehistoric  manof  a  milk 
and  meat  diet  have  established  within  man's  alimen- 
tary canal  a  suitable  place  for  its  cultivation?  Its 
accustomed  food  would  be  there  and  other  conditions 
of  moisture  and  temperature  would  be  favorable. 
Would  it  not,  thenceforward,  by  incessant  partial 
contacts  with  the  cells  of  the  body  subject  itself  to 
a  slow  process  of  natural  selection?  After  number- 
less generations  of  such  selection  through  de- 
struction by  phagocytosis,  why  should  these  bo- 
vine tubercle  germs  not  finally  become  adapted 
to  our  bodies?  The  tissues  also  would  be  forced 
to  a  readjustment  favorable  to  such  a  change  in 
the  bacilli.  In  assimilating  the  alien  meat  and 
milk  there  would  be  at  first  considerable  anaphylactic 
sensitization  followed  by  immunity  to  such  alien  pro- 
tein. Human  cells,  in  overcoming  the  toxic  effects 
of  bovine  protein  would  be  compelled  to  adjust  their 
chemistry  of  intercellular  digestion  toward  that  pro- 
tein about  :is  the  bacilli  must  have  done  when  they 
became  immune  toward  the  same  protein.  Human 
protein  ami  bovine  tubercle  protein  would  thus  grad- 
ually aci|iiire  similar  finalities  in  their  relation  to  bovine 
protein.     This   would   tend   to  destroy   the  gulf  be- 


tween them  and  make  infection  possible.  Experi- 
mental research  along  such  lines  is  greatly  needed. 
It  is  a  common  belief  among  biologists  that  "ontog- 
eny repeats  phylogeny,"  i.e.  that  every  organism 
in  its  development  from  egg  to  adult  condition 
roughly  repeats  the  evolutionary  steps  of  its 
kind.  A  reverse  application  of  this  doctrine  leads 
to  the  suggestion  that  the  destruction  or  damage  of 
an  organism,  by  disease  or  other  cause,  might  often  tend 
to  place  the  organ,  tissue,  or  cell  group  that  function- 
ally preceded  the  damaged  part,  phylogenetically 
back  into  its  old  duty.  The  body  would  thus  revert 
back  to  the  physiological  level  of  stability  formerly 
normal  to  some  remote  ancestor,  but  only  to  the  ex- 
tent that  the  damage  demanded.  Adami  states  the 
case  thus:  "Characters  of  more  recent  acquirement 

are  those  which  are  most  easily  lost The 

older  the  character  or  property  the  more  tenaciously 
is  it  retained."10  Prof.  A.  G.  Pohlman  has  illustrated 
the  same  principle  in  the  following  manner:  "  The 
person  depressed  by  an  anesthetic,  such  as  chloro- 
form or  ether,  or  in  the  gradual  onset  of  drunkenness 
loses  his  faculties  in  about  the  following  order: 
first,  self-restraint  or  any  and  all  of  the  finer  sides  of 
human  nature  last  acquired;  speech  next  becomes 
more  or  less  incoherent;  balancing  becomes  difficult; 
speech  is  reduced  to  noises  before  the  individual  re- 
turns to  all-fours,  vision  is  next  lost,  and  when  gone 
hearing  next  follows."11  In  pulling  down  a  building 
the  last  laid  bricks  or  stones  are  usually  the  first  re- 
moved and  when  removed  the  parts  immediately  be- 
low must  sustain  the  strain  of  such  joists  or  rafters  as 
are  shifted  upon  them  from  the  removed  part  that  was 
above.  In  biology  another  element  enters  the  case. 
The  upper  parts  are  particularly  liable  to  damage 
and  thus  to  throw  their  supporting  function  upon  the 
lower.  Natural  selection  has  the  habit  of  often 
leaving  new  fitnesses  with  a  minimum  of  fitness  and, 
therefore,  quite  liable  to  damage  or  destruction.  It 
usually  requires  many  added  fitnesses  to  perfect  a 
newly  added  part.  These  come  as  gradual  accretions 
under  conditions  of  great  destruction.  Such  must 
have  been  the  conditions  under  which  some  early  an- 
thropoid became  the  producer  of  man.  Below  us  lie 
the  apes  and  lemurs.  Each  part  of  our  structure  in 
which  we  vary  from  these  is  a  part  in  which  we  should 
expect  to  find  relative  weakness— a  part  pretty  certain 
to  give  way  early  to  the  onslaughts  of  disease.  Our 
high  moral  natures  and  high  intelligence,  our  power  of 
speech,  our  power  to  balance  ourselves  in  the  up- 
right position,  our  ability  to  adjust  our  eyes  to  short 
vision,  our  remodeled  leg  and  arm  joints,  our  thumb 
and  finger  adjustments,  our  new  pelvic  floor,  our  new- 
functions  for  our  old  tail  muscle,  our  altered  vein 
valves,  and  the  numerous  minor  alterations  that  tend 
to  save  the  viscera  from  dangerous  pressure  are  all 
points  of  weakness  that  may  require  many  milleniums 
of  selection  to  correct  perfectly.  On  the  whole  these 
behave  very  well,  but  under  unusual  strain  and  in 
disease,  age,  poisonings,  etc.,  they  give  way  early. 
When  they  do  give  way  we  become  in  a  degree  corre- 
sponding to  the  damage,  so  much  more  the  ape,  lemur, 
or  quadruped.  We  suffer  from  e3'e-strain  because  of 
the  phylogenetic  newness  of  our  eye  adjustments, 
we  suffer  from  writer's  cramp  because  of  the  newness 
of  our  finger  adjustments,  we  suffer  far  more  fre- 
quently than  other  animals  from  joint  pains  because 
of  the  newness  and  consequent  weakness  of  these 
parts  in  ourselves.  Gout  and  rheumatism,  in  their 
great  frequency,  are  penalties  due  to  new  adjust- 
ments giving  way  easily  to  the  ravages  of  disease 
germs.  Our  joints  that  remain  unaltered  or  but 
slightly  altered  are  less  frequently  attacked.  Our 
muscles  that  function  as  in  quadrupeds  bring  few 
pains  to  the  aged.  No  other  animal  than  man  suf- 
fers from  genu  valgum  (knock-knee),  genu  veruin 
(bandy-legs),  pes  varus,  pes  equinus,  pes  valgus,  pes 
calcaneus,  and  other  forms  of  club-foot,12  because  no 


472 


REFERENCE    HANDBOOK   OF   TIIK    MEDICAL   SCIKWKS 


Anthropologic  Medical 


other  has  recently  milled  these  new  and  therefore 
weak  places  to  the  anatomy  of  these  parts.  True  in- 
sanity is  unknown  anions  the  lower  animals.  They 
manifest  no  symptoms  of  paranoia,  hypochondria,  or 
hysteria  as  their  Drains  have  not  the  new  and  higher 
nerve  centers. 

The  human   female  is  the  only  female  on  all   the 
earth  in  which  the  uterus  and  ovaries  are  hung  in  a 

way  the  reverse  of  the  one  our  judgments  are  inclined 
to  think  Ihey  ought  to  have  been  hung.  Instead  of 
being  supported  from  above,  so  as  lo  protect  them 
against  the  effects  of  gravity,  they  are  supported  (?) 
from  below  as  if  to  keep  them  from  going  upward,  a 
ten  lency  which  they  have  never  been  known  to 
display.  In  cows  and  ewes  such  a  hanging  is  exceed- 
ingly useful  inasmuch  as  it  prevents  the  gravid  uterus 
from  pitching  forward  and  damaging,  by  Sudden 
pressure,  the  various  internal  viscera.  In  woman 
such  a  hanging  is  inexplicable  except  as  we  view  it  as 
something  left  to  remind  us  of  our  quadrupedal 
ancestors.  Versions,  flexions,  and  prolapses  of  the 
uterus,  traceable  to  the  defect  named,  the  medical 
man  finds  to  be  most  easily  restored  to  their  normal 
place  by  having  the  patient  assume  the  knee-chest 
position — -the  quadrupedal  position.  Nature  has 
partly  overcome  this  serious  defect  in  human  anatomy 
by  converting  the  muscles  that  the  lower  animals  use 
to  control  the  movements  of  their  tails  into  a  levator 
ani  to  support  the  rectum  and  by  its  branchings  and 
fascias  into  an  additional  floor  for  the  pelvis.  Dr. 
F.  II.  Martin  thus  describes  this  transformation  of 
caudal  muscles  into  life-saving  supports  for  human 
females.     "In     the    lower     vertebrates,"     he     says, 

"with    few    exceptions the    levator    ani 

proper,  that  is,  a  muscle  of  support  for  the  rectum, 
does  not  exist,  but  appears  as  the  tail  muscle,  its 
principal  function  being  the  management  of  that 
caudal  appendage.  As  the  tail  disappeared  and  the 
higher  animal  developed,  with  a  disposition  to  assume 
the  perpendicular,  the  levator  ani  remained  attached 
to  the  coccyx  and  the  sides  of  the  sacral  vertebne, 
and  extended  its  other  pelvic  attachments  forward 
from  the  ischium  as  far  as  the  pubis,  and  while  it 
constituted  itself  in  this  extension  an  upper  floor  or 
second  diaphragm  to  the  pelvis  it  also  assumed  other 
functions.  Of  course  this  change  added  the  import- 
ant function  of  supporting  the  superimposed  viscera. 
As  the  rectum  became  a  perpendicular  tube  its  upper 
portion  required  additional  support,  and  this  was 
afforded  by  this  tail  muscle  through  which  it  passed 
and  the  pubic  extension  in  the  form  of  a  new  muscle, 
the  puborectalis,  which  extended  from  the  pubis  to 
the  rectum,  and  after  combining  with  the  extension 
backward  (the  pubococcyx)  grasped  the  rectum  in  a 
sling.  These  muscles  elevate  the  rectal  tube,  and  the 
anterior  one,  the  puborectalis,  elevates  it  and  draws 
it  toward  the  pubis  while  the  two  together  are 
powerful  factors  in  elevating  the  whole  human  pelvic 
Boor."  13  The  American  Text-book  of  Gynecology 
tells  us  that  "the  lavator  ani  is  covered  by  a  sheet  of 
the  pelvic  fascia,  known  as  the  obturator  fascia,  which 
gives  it  great  strength.  When  the  fibers  of  this 
fascia  and  muscle  are  separated  as  in  laceration  of  the 
perineum,   their  ends  retract  gradually   toward   the 

ischial    rami    of    either    side A  woman 

with  ruptured  perineum  on  defecating  relaxes  the 
sphincter,  but  the  levator  fibers  are  torn  asunder  and 
their  dilating  action  upon  the  sphincter  is  gone.  She 
has  to  strain,  and  as  she  does  so  the  vagina  can  no 
longer  be  closed  by  the  levator,  but  the  rent  allows 
the  intraabdominal  pressure  and  the  advancing  feces 
to  force  the  posterior  vaginal  wall  out  of  the  vulval 
orifice,  producing  a  rectocele.  In  this  way  is  prolap- 
sus produced."  1S  How  common  then  must  uterine 
prolapses  have  been  when  the  first  erect-walking, 
semihuman  woman  lacked  the  support  for  the 
abdominal  viscera  of  the  levator  ani  muscle  and  its 
fascias?     How  common,  too,  must  have  been  retro- 


versions and   retroflexions    under   such    conditions. 

When     women     lose,     damage,     anil     set I)      break 

through  this  relatively  recent  acquirement  to  their 
anatomy    and    they    are    forced    to    depend    upon    the 

quadrumanal  pelvic  Hour  it   is  easy  to  perceive  the 

cause  of  their  suffering.  The  facts  seem  to  indicate, 
however,  that  their  sufferings  are  considerably  less 
frequent  than  were  those  of  their  female  predecessors. 

Selection  has  been  improving  their  lot  by  picking  out 

for  reproduction  those  freest  from  simian  defect  of 
the  pelvis.      Such  picking  out  appears  to  have  begun 

at  or  near  the  lime  that  human  menstruation  began. 
Can  it  be  possible  that  they  are  associated?  Playfair 
I  el  Is  us  that  "Patients  who  are  the  subjects  of  retro- 
version or  retroflexion  usually  suffer  from  increase  of 
the  menstrual    How;    in    many   instances,   indeed,   it    is 

because  of  the  monorrhagia  that  they  seek  advice. "lt 
We  would  naturally  infer  that,  prior  to  t  lie  conver  ion 
of  the  levator  ani  into  an  extra  support  for  the  ab- 
dominal viscera,  retroversions  and  retroflexions 
would  have  been  exceedingly  common  and  very 
severe  in  all  female  primates  that  sought  to  assume 
the  erect  attitude.  But  severe  retroflexions  and 
retroversions  would,  temporarily,  have  rendered  all 
such  females  sterile.  The  spermatozoa  would  not,  in 
them,  be  able  to  pass  (he  occluded  cervix.  I'nder 
such  circumstances  should  the  uterus  till  with  blood, 
the  sufferer  for  a  season  assume  a  reclining  posture  in 
order  to  get  ease,  the  sympathetic  males  try  to  coin- 
fort  them  in  their  suffering,  and  menorrhagia  set  in, 
thus  forcing  the  uterus  to  approach  its  normal 
position,  what  would  happen?  When  the  menor- 
rhagia ended,  sterility,  for  the  time  being,  would  be 
at  an  end.  Until  selection  added  its  new  security  to 
the  pelvic  floor  this  sort  of  thing,  we  can  fairly  infer, 
must  have  been  very  common.  Is,  then,  menstrua- 
tion a  vestige  of  prehuman  menorrhagia  that  was  of 
decided  selective  value  to  our  progenitors?  Without 
it  many,  or  perhaps  most,  of  them  could  not  have 
become  pregnant.  With  it  they  could.  Under  such 
conditions  the  only  women  that  could  perpetuate  their 
kind  would  have  been  the  women  that  took  on  an 
exaggerated  form  of  menstruation.  The  supplying 
of  additional  strength  to  the  floor  of  the  pelvis  by  the 
spreading  out  of  the  levator  ani  muscle  and  its 
fascias,  while  giving  better  support  to  the  abdominal 
viscera,  had  its  disadvantages.  It  made  the  pelvis 
and  its  floor  less  mobile  and  greatly  reduced  the  exit 
space  in  parturition.  The  open,  box-shaped  pelvis 
of  quadrupeds  became  the  narrow  wedge-shaped 
pelvis  of  man.  It  materially  complicated  our  prin- 
ciples of  tocology  and  in  some  particulars  reversed 
what  they  would  have  been  had  such  anatomical 
changes  not  occurred.  In  women,  when  the  pelvis 
is  normal,  the  safest  presentation  of  the  child  is  by 
way  of  the  calvarium  while  one  of  the  most  unfavor- 
able is  the  face  presentation.  Among  the  lower 
mammals,  on  the  contrary,  the  most  favorable 
presentation  is  the  face  one  while  a  calvarium  pre- 
sentation constitutes  a  serious  complication.  The 
pelvic  anatomy,  in  all  domestic  animals  in  which 
parturition  can  be  observed,  is  seen  to  be  much  more 
favorable  to  labor  than  in  woman,  and  "in  addition  to 
the  anatomical  advantage  enjoyed  by  domestic 
animals,  there  is  the  fact  that  pathological  changes 
in  the  pelvis,  causing  a  diminution  of  the  pelvic 
diameters,  are  much  less  common."15  This  narrowing 
of  the  pelvic  outlet  is  generally  believed  to  be  a  grow- 
ing evil  of  civilization.  Intelligent,  brainy  people  are 
thought  to  choose  their  like  as  mates  thus  continu- 
ously increasing  the  size  of  the  human  head,  while 
increasing  pressure  from  the  weight  above  lessens  the 
diameter  of  the  birth  outlet.  Among  savage  races 
the  ill-formed  female  babies  are  usually  destroyed  as 
they  are  generally  unsalable  and  it  would  not  pay  to 
rear  them.  Among  civilized  women  all  sorts  of  pelvic 
shapes  get  a  chance  to  perpetuate  their  kinds. 
Natural  selection,   however,    tends   to   take   revenge 


473 


Anthropology,  Medical 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


upon  us  by  slowly  doing  what  artificial  selection 
accomplishes  for  the  savage.  The  lives  of  mothers 
having  narrow  pelves  are  constantly  jeopardized  and 
in  spite  of  the  physicians'  attempts  at  thwarting  such 
selection  many  mothers  perish.  If,  however,  in- 
creased brain-growth  continues  it  can  only  be  a 
matter  of  time  when  even  the  normal,  well-formed 
pelvis  will  be  inadequate. 

Hitherto,  however,  nature  has  sought  to  palliate 
this  danger  by  a  peculiar  device.  Natural  selection 
has  been  choosing  for  us  infants  mentally  immature 
until  now  the  new-born  among  all  vertebrates  other 
than  man  are,  relative  to  the  mature  standard  of 
their  adults,  exceedingly  mature.  Should  a  human 
infant,  prior  to  birth,  reach  the  same  relative  mental 
maturity  as,  say,  a  chicken,  it  would  almost  require 
the  calvarium  of  an  adult  to  hold  its  brains.  It  is 
obvious  that  such  heads  could  not  safely  pass  any 
ordinary  birth-canal  so  that  either  its  life  or  the  life 
of  its  mother  would  have  to  be  sacrificed.  The 
prenatal  delay  in  cerebral  development  which  has 
given  us  such  helpless  children  has  apparently  been  a 
saving  element  for  our  race,  and  this  same  delay, 
according  to  Prof.  John  Fiske,  has  been  the  chief 
factor  that  led  us  toward  family  coherence,  social 
coherence,  and  civilization.16  He  taught  that  the 
lengthening  period  of  helpless  immaturity  in  our 
babies,  by  compelling  our  early  ancestors  to  cling 
together  in  enduring  family  relationship,  to  acquire 
property  to  maintain  such  relationships,  and  to 
cohere  socially  for  the  protection  of  property  from 
marauders,  led  the  way  to  civilization.  Only  such 
fathers  as  became  sufficiently  altruistic  to  care  for  the 
mothers  and  attend  to  their  and  the  children's  food, 
shelter,  and  clothing  requirements  had  their  progeny 
survive  to  people  the  earth.  Let  this  sort  of  prenatal 
cerebral  regression  continue,  let  the  period  of  infancy, 
childhood,  and  adolescence  be  prolonged  far  beyond 
what  they  now  are,  let  our  mental  growth  proceed  to 
much  greater  lengths  in  adult  life  than  it  does  at 
present,  and  we  need  not  fear  an  extinction  of  our 
race  from  hypercephalic  danger.  Under  such  a 
combination  of  events  the  normal  human  female 
pelvis  will  remain  adequate  in  size  for  ages  of  mental 
progress. 

But,  considering  all  this,  we  are  forced  to  repeat 
that  "whatever  the  intrinsic  or  extrinsic  factors 
may  have  been  which  prompted  our  remote  fore- 
fathers to  assume  and  maintain  the  upright  position, 
this  much  is  true,  that  despite  the  myriads  of  years 
he  has  spent  in  readjusting  himself  to  the  self-imposed 
and  unnatural  posture,  it  has  been  far  from  complete 
and  will  probably  always  remain  imperfect."19  He 
has,  by  it,  had  his  principal  veins,  nerves,  arteries, 
and  viscera  exposed  to  numberless  accidents  from 
which  quadrupeds  are  well  protected.  Every  im- 
portant point  of  danger  is  exposed  when  he  is  on  his 
feet  but  protected  when  he  is  on  his  hands  and  knees. 
Arteries,  as  a  rule,  are  placed  deep  down  in  the 
tissues  and  below  the  veins.  This  enables  them  to 
escape  accidents.  The  femoral  artery  is  an  exception 
to  this  rule.  It  is  near  the  surface.  As  it  is  in  the 
inner  aspect  of  the  thigh  it  has  reached  the  _ very 
maximum  of  protection  in  a  quadruped  and  in  us 
when  we  an'  on  all-fours.  In  the  upright  position  it 
is  one  of  the  worst  exposed  arteries  of  the  body, 
despite  its  importance.  In  wars,  quarrels,  and 
accidents  of  various  kinds,  this  exposure  sacrifices 
many  lives.  Blows  on  the  abdomen  can,  in  man, 
rupture  the  Madder,  injure  the  pancreas,  liver, 
intestines,  and  other  parts,  or  start  peritonitis.  As 
quadrupeds  present  a  front  aspect  to  their  enemies 
all  these  parts  are  thoroughly  shielded.  "Disloca- 
tions of  the  sternal  end  of  the  clavicle  throw  it  for- 
ward, backward,  or  upward,  and  of  the  acromial  end 
upon  the  upper  surface  of  the  acromion  or  upon  the 
anterior  pari  of  the  spine  of  the  scapula.  These  are 
all  in  the  opposite  direction  to  which  blows  or  strains 


would  be  applied  in  a  quadruped.  Downward  dis- 
locations, the  kind  they  would  be  liable  to  have,  are 
next   to   impossible.     Where   they   are   safe   we  are 

exposed When    the    intestinal    tube    of 

man  forgets  proper  behavior  and  tries  to  turn  itself 

outside  in it  usually  does  so  from  above 

downward.  If  we  went  four-footed  we  would  not 
so  often  suffer  and  die  from  intussusception.  This 
disease  is  best  relieved  by  turning  tbe  patient  into  a 
position  the  reverse  of  that  we  are  proud  of  being 
able  to  occupy."20  In  man  the  ribs  are  exposed  at 
their  most  vulnerable  angle  and  are  therefore  subject 
to  an  unusual  number  of  fractures.  One  institution 
has  reported  thirty-five  per  cent,  of  all  the  fractures 
treated  as  being  rib  fractures.-1  Darwin  tells  us 
that  "  The  gradually  increasing  weight  of  the  brain 
and  skull  in  man  must  have  influenced  the  develop- 
ment of  the  supporting  spinal  column,  more  especially 
when  he  was  becoming  erect.  As  this  change  of 
position  was  brought  about,  the  internal  pressure  of 
the  brain  will,  also,  have  influenced  the  form  of  the 
skull,  for  many  facts  show  how  easily  the  skull  is 
thus  affected."22  Such  pressure  as  the  upright 
position  causes  must  produce  some  profound  result 
upon  all  tendencies  toward  curvature  of  the  spine  and 
toward  Pott's  disease.  Pavy  has  long  insisted  that 
it  has  much  to  do  with  the  production  of  albumin- 
uria.23 Pohlman  declares  that  "The  upright  position 
hampers  the  digestive  tract  in  many  ways.  In 
order  that  the  individual  breathe  properly  he  must 
'throw  his  chest  out  and  abdomen  in,'  and  crowd  the 
already  cramped  tract  against  a  curve  in  the  vertebral 
column  thrown  to  the  front  to  compensate  for  the 
unnatural  position.  The  peritoneum  must  now  be 
used  as  a  support,  and  about  twenty  feet  of  small 
intestine  is  hung  from  a  vertical  abdominal  wall  by 
this  thin  membrane,  attached  for  a  distance  of  say 
even  five  inches.  The  result  is  that  the  small  intes- 
tines crowd  down  into  the  pelvis  and  against  the 
weakest  part  of  the  now  vertical  front  abdominal 
wall.  Apart  from  this  tendency  toward  dislocation, 
they  may  even  come  through  the  abdominal  wall  in 
the  form  of  a  rupture  or  hernia.  Eighty-five  per 
cent,  of  these  ruptures  (conservative  estimate)  are 
due  to  the  upright  position  (gravity)  and  to  irrepar- 
able faulty  adaptation  of  the  viscera  to  withstand 
the  traction."24  During  the  entire  period  of  gestation 
the  uterus  and  its  fetus  are  subjected  to  varving 
degrees  and  kinds  of  pressure  and  distortion  due  to 
the  upright  posture.  Uneven  and  altering  pressures 
upon  the  uterus  and  developing  fetus  impair  the 
nutrition  of  parts.  We  have  experimental  evidence 
of  the  effects  of  such  varying  of  pressures  in  the  case 
of  plants,  polyps,  and  other  low  types  of  organisms, 
l.ut  little  or  none  in  mammals.  Where  such  pressures 
have  been  applied  nutrition  is  impaired  in  accordance 
with  the  degree  of  pressure  and  the  part  subjected 
to  the  pressure  is  arrested  in  its  development.  If  the 
pressure  is  sufficiently  heavy  there  is  injury  and 
malformation.  Since  we  know  that  similar  results 
are  seen  to  occur  during  the  development  of  the 
human  embryo,  and  as  we  also  know  that  abnormal 
pressure  is  often  present  during  such  development,  we 
can  infer  that  the  two  are  related  to  each  other  as 
cause  and  effect.  The  chapter  on  teratological 
anthropology  has  not  yet  been  written  but  when  it 
appears  we  can  be  sure  that  it  will  contain  much 
information  on  this  dark  subject.  In  quadrupeds 
the  directions  of  pressure  on  the  developing  fetus, 
because  of  the  way  it  lies  in  the  abdomen,  must  be 
quite  different  from  that  in  man.  The  amount  of 
pressure  in  the  former  is  relatively  small — even 
trifling  in  proportion  to  the  respective  sizes.  The 
dam  can  carry  with  safety  a  litter  of  young  because 
of  their  distribution  along  the  abdomen.  A  single 
fetus,  in  woman,  presses  down  into  the  pelvis.  The 
quadruped  is,  therefore,  not  so  likely  to  suffer  from 
varicose    veins,     nor    from    various    neuroses    that 


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Anthropology i  Medical 


accompany  pressure  upon  pelvic  nerves,  in  spite  of 
the  fact  that  ner  litter  weighs  much  more  than  the  one. 
Nor  is  the  quadruped  so  likely  to  suffer  from  pin  lapsus 
of  the  rectum  and  painful  hemorrhoids  both  of  which 
arc  often  partly  the  result  of  such  pressure.  In  the 
latter  affliction  the  lack  of  needed  valves  in  the 
hemorrhoidal  veins  contributes  greatly  to  the  same. 
On  this  phase  of  our  subject  Cramer  tells  us  that 
"  \iiaioniv  had  long  ago  established  the  presence  of 
valves  in  human  veins,  and  physiology  assigned  to 
them  the  only  intelligible  function — that  of  preventing 
the  blood  from  flowing  hack  toward  the  capillaries. 

Had  they  been  distributed  throughout  the  Venous 
system,  there  would  have  been  no  problem;  but  they 
are  present  in  some  veins  and  absent  mothers.  No 
law  regulating  their  distribution  could  be  assigned 
and  students  of  human  anatomy  had  to  learn  their 
distribution   by  sheer   force   of   memory 

Not  only  was  there  no  law  to  explain  their  distribu- 
tion—their actual  arrangement  was  utterly  irrational 
if  it  were  true  that  they  were  intended  to  prevent 
the  backward  tlow  of  blood.  It  was  easy  enough  to 
understand,  from  the  old  view  of  creation,  why  there 
should  be  valves  in  the  veins  of  the  arms  and  the  legs; 
but  it  was  stultifying  to  learn  that  the  spinal,  iliac, 
portal,  and  above  all  the  inferior  vena  cava,  the 
largest  vein  in  the  body  carrying  blood  upward,  are 
without  valves.  To  make  the  facts  and  their  func- 
tional explanation  still  more  incongruous,  there  are 
valves  in  the  intercostal  veins,  in  which  the  blood 
tlows  horizontally;  and  in  the  thyroid  and  internal 
and  external  jugulars,  in  which  the  blood  flows  down 
hill.  Valves  and  gravitation  apparently  had  nothing 
to  do  with  each  other."25  In  our  upright  attitude  we 
have  valves  where  they  are  not  needed  and  absence 
of  valves  where  they  are  greatly  needed.  When  we 
assume  the  quadrupedal  attitude  every  valve  in  every 
vein  in  our  bodies  is  placed  just  right  for  gravity. 
Where  there  are  no  valves  they  are  seen  to  be  un- 
needed  in  the  all-fours  position. 

Important  as  are  the  questions  of  valve  distribution, 
viscera  exposure  to  traumatisms,  organ  displacements 
through  weak  supports  and  gravity,  and  the  serious 
effects  of  great  and  unusual  pressure,  due  to  the 
defects  of  the  upright  position,  all  of  them  seem  to 
have  been  less  serious  handicaps  in  the  struggle  for 
existence  than  were  the  unknown  factors  that  forced 
man  to  assume  that  position.  The  gain  made  by 
giving  up  the  quadrumanal  attitude  has  evidently 
brought  a  substantial  balance  of  benefits,  notwith- 
standing the  numerous  handicaps  which  it  incurred, 
otherwise  man  could  not  have  increased  in  numbers 
and  power  until  he  dominates  the  earth.  But,  if 
natural  selection  is  true,  he  bears  its  evidences  of 
having  run  the  gauntlet  of  some  mercilessly  destruc- 
tive attack.  His  hands,  arms,  feet,  joints,  head,  face, 
pelvic  floor,  skin,  and  coccyx  all  tell  of  his  exceedingly 
severe  struggle  for  existence.  If  every  variation  in 
these  from  the  form  of  his  hypothetic  ancestor  is  a 
heaped-up  series  of  surviving  fitnesses  they  tell  a 
story  of  great  destruction.  Every  creature  attached 
to  but  not  in  the  direct  line  of  man's  descent,  because 
of  failing  to  vary  manward,  perished  without  issue. 
Their  type  of  joints,  tails,  long  arms,  weak  pelvic 
floors,  quadrumanal  hand-feet  and  hands,  peculiarly 
shaped  jaws  and  heads,  in  some  way,  led  to  their 
extinction.  The  disappearance  of  all  of  these  simian 
peculiarities,  along  the  human  line  of  descent,  is 
evidence  that  they  were  the  unfitnesses  which  led  to 
the  destruction  of  their  possessors.  Only  those 
lived  to  perpetuate  their  kind  who  lost  such  unfit 
features.  Most,  and  probably  all,  of  the  changes 
here  referred  to  are  adaptations  to  the  upright  posture 
and  essential  to  its  permanence.  If,  therefore,  some 
condition  existed  that  made  that  posture  imperative 
— that  saved  the  direct  human  line  from  extinction — 
to  such  condition  must  be  credited  these  various 
changes.     We  have  seen  that  at  the  time  that  the 


upright  attitude  was  firs!  assumed  the  floor  of  the 
prehuman  pelvis  underwent  some  very  great  changes. 

Prior  to  the  appearance  ol  these  changes,  hernias,  rec- 
tal prolapses,  uterine  prolapses,  versions,  and  flexions, 
with  malpositions  of  the  abdominal  viscera,  were 
probably  exceedingly  frequent.  The  attendant 
inflammatory   and   suppurative    processes   involving 

Ovaries  and  seminal   vesicles   would,   in   proportion    I" 

the  degree  of  in vc jI veinent ,  damage  ami  destroy  germ 

and  sperm.  The  resulting  pyemias  and  septicemias, 
together  with  kidney,  heart,  and  lung  inflammations, 

would  exact  a  heavy  selective  toll  upon  life.  The 
method  by  which  such  inflammatory  processes  may 

have  directed  the  hereditary  processes  of  the  germ- 
plasm  has  been  discussed  elsewhere  by  the  author.-1 
A  study  of  mammalian  anatomy,  coupled  with  a 
study  of  how  quadrumanal  movements  would  tend 
to  distribute  infection  from  suppurating  centers  in 

the  pelvis  to  the  viscera,  shows  how,  under  the  condi- 
tions named,  life  would  be  seriously  jeopardized. 
But  the  dow npressing  of  the  viscera,  due  to  gravity 
and  the  upright  attitude,  would  tend  to  seal  the  gates 
of  entry  against  the  infective  material,  and  that,  too, 
in  direct  proportion  to  the  persistence  of  the  upright- 
ness. Since  infective  material  has  weight  the 
immediate  action  of  gravity  upon  it  would  hinder  its 
ascent.  Here  likewise  the  hinderance  would  be  in 
direct  proportion  to  the  persistence  in  uprightness. 
It  is  thus  seen  that  in  the  conditions  named — condi- 
tions that  actually  appear  to  have  existed  in  the  past 
— the  upright  position  would  have  direct  selective 
value. 

Regarding  why  preman  took  to  the  persistent  use 
of  this  position  there  has  been  much  speculation. 
The  assumption,  however,  that  it  was  done  voluntar- 
ily runs  counter  to  all  we  know  of  animal  habits  and 
their  mental  inertia.  Either  the  theory  that  pressure 
of  population  forced  him  to  abandon  his  forest  home 
or  starve,  or  the  theory  that  in  beginning  to  lose  his 
hairy  covering  his  fellow  simians,  through  terror, 
drove  him  from  among  them,  meets  the  facts  better. 
If,  in  the  latter  case,  the  loss  of  hair  was  due  to  a  skin 
disease  the  suffering  it  produced  would  have  made 
uprightness  a  comfort  and  would  have  made  pelvic 
and  visceral  infection  the  more  certain  until  prevented 
by  uprightness.  Whatever  the  true  explanation  may 
prove  to  be  these  are  questions  that  await  solution  by 
the  science  of  Medical  Anthropology. 

R.  G.  Eccles. 

Bibliography, 

1.  Century  Dictionary,  vol.  i.,  p.  240. 

2.  Theobald  Smith,  Boston  Med.  and  Surgical  Journal,  July, 
1905,  p.  9. 

3.  Jordan's  "General  Bacteriology,"  p.  201. 

4.  Hopf's  "The  Human  Species,"  p.  392. 

5.  Encyloped.  Brittan.,  new  edition,  vol.  xiv.,  p.  554. 

6.  Theobald  Smith,  Trans.  Cong.  Amer.  Phvs.  and  Surg.,  vol. 
v.,  p.  3 

7.  Lankester's  "Treatise  on  Zoology,"  Part  I,  Fascicle  2,  pp. 
242,  243. 

8.  Encycloped.  Brittan.,  vol.  xx.,  p.  797. 

9.  Montgomery's  "Analysis  of  Racial  Descent,"  pp.  37,  3S. 

10.  Adami's  "Principles  of  Pathology,"  vol.  i.,  p.  109. 

11.  A.  G.  Pohlman,  The  Monist,  Oct,  1907,  p.  .".72. 

12.  Hopf's  "The  Human  Species,"  p.  425. 

13.  Dr.  F.  H.  Martin,  Jour.  Amer.  Med.  Assoc.,  July  29,  1911, 
p.  361. 

14.  Allbutt's  "System  of  Medicine,"  First  Edition,  vol.  ii.,  pp. 
414,  415. 

15.  Hopf's  "The  Human  Species,"  p.  439. 

16.  Fiske's  "Cosmic  Philosophy,"  vol.  ii.,  pp.  343,  344,  360. 

17.  Hopf's  "The;   Human;   Species,"  p.  436. 

18.  Amer.  Text-book  of  Gynecology,  p.  31S. 

19.  A.  G.  Pohlman,  The  Monist,  Oct.  1907,  p.  575.. 

20.  R.  G.  Eccles.Brooklyn  Medical  Journal,  Feb.,  18S9,  "  Descent 
and  Disease." 

21.  Journ.  Amer.  Med.  Assoc,  March  23,  1907,  p.  1063. 

22.  Darwin's  "Descent  of  Mm,"  1871,  vol.  i,  p.  141. 

23.  Hooker,  Archiv.  Inter.  Medicine,  May  15,  1910,  p.  493. 

24.  A.  G.  Pohlman,  The  Monist,  Oct.,  1907,  pp.  578,  579. 

25.  R.  G.  Eccles,  Medical  Record,  March  16, 1912,  pp.  501  to  509. 


475 


Anthropometry 


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Anthropometry. — The  .systematic  examination  of 
the  physical  characteristics  of  the  human  body. 
The  Bertillon  measurements  and  finger-print  identifica- 
tion will  also  be  considered  in  this  article.  In  a  report 
issued  by  British  Association  for  the  Advancement  of 
Science  in  1883  it  is  stated  that  variations  in  stature, 
weight,  and  complexion  existing  in  different  districts 
of  the  British  Isles  appear  to  be  chiefly  flue  to 
differences  of  racial  origin;  and  that  this  influence 
predominates  over  all  others.  Here  would  appear 
to  be  an  observation  of  general  application  to  the 
genus  homo. 

With  respect  to  latitude  and  climate  the  inhabitants 
of  northern  and  colder  regions  possess  greater  stature 
than  those  of  southern  and  warmer  regions.  In 
France  and  Italy  those  inhabiting  the  northern 
provinces  are  taller  than  in  the  south.  The  same  rule 
applies  to  the  whole  of  the  countries  of  Europe  with 
respect  to  each  other. 

The  Scotch  male  adults  average  in  height  68.71 
inches;  the  Irish  67.90;  the  English  67.68;  the  Welsh 
66.66  inches.  The  average  male  Scot  weighs  165.3 
pounds;  the  Welsh  15S.3;  the  English  155.0;  the 
Irish  154.1  pounds.  Foreach  inch  of  stature  a  Scotch- 
man weighs  2.406  pounds;  a  Welshman  2.375;  an 
Englishman  2.301;  an  Irishman  2.270  pounds.  The 
chest  girth  of  the  adult  British  male  varies  from 
forty-five  to  twenty-seven  inches,  the  mean  being 
thirty-six  inches.  The  strength  of  the  arms  exerted 
in  drawing  a  bow  ranges  from  one  hundred  and  fifty 
down  to  thirty  pounds,  the  mean  being  seventy  pounds. 

The  average  height  of  adult  females  in  England  is 
62.65  inches,  being  4.71  inches  less  than  the  male 
average;  the  average  weight  of  females  is  122.8 
pounds,  being  32.2  pounds  under  that  of  the  males. 
The  females  are  stated  to  average  little  more  than 
half  the  strength  of  the  males,  measured  by  straining 
the  arms;  these  observations,  however,  were  obtained 
from  pupils  in  training  schools  for  teachers,  and  from 
shop  assistants,  so  that  the  average  is  no  doubt  much 
lower  than  if  the  laboring  classes  had  been  included. 

The  average  height  in  inches  of  the  adult  males 
of  the  principal  races  or  nationalities  of  the  world  may 
be  given  as:  Polynesians,  69.33;  Patagonians,  69; 
Congo  Negroes,  69;  Scotch,  68.71;  Iroquois  Indians, 
68.2S;  Irish,  67.90;  English,  67. 68;  United  States 
"whites",  67.67:  Norwegians,  67.66;  Zulus,  67.19; 
Welsh,  66.66;  Danes,  66.65;  Dutch,  66.62;  American 
Negroes,  66.62;  Hungarians.  66.58;  Germans,  66.54; 
Swiss,  66.43;  Belgians,  66.38;  French,  66.23;  Berbers, 
66.10;  Arabs,  66.08;  Russians,  66.04;  Italians,  66; 
Spaniards,  65.66;  Esquimaux,  65.10;  Papuans,  64. 7S; 
Hindus,  64.76;  Chinese.  64.17;  Poles,  63. S7;  Finns, 
63.60;  Japanese,  63.11;  Peruvians,  63;  Malays,  62.34; 
Lapps,  59.2;  Bosjesmans,  52.78.  The  average 
stature  of  the  human  adult  male  is  thus  about  65.25 
inches. 

The  average  length  of  British  male  infants  at 
birth  is  19.52  inches  and  of  females,  19.32.  The  aver- 
age naked  weight  of  male  infants  is  7.12  pounds,  of 
females,  6.94.  Growth  is  most  rapid  during  the  first 
five  years  of  life — in  which  period  the  rate  of  increase 
is  about  the  same  in  both  sexes,  the  gain  being  21.51 
inches.  From  five  to  ten  years  boys  grow  a  lit  tie  more 
rapidly  than  girls,  the  male  increase  being  10.81 
inches,  the  female  10.50.  From  ten  to  fifteen  years 
girls  grow  more  rapidly  than  boys,  and  at  the  ages  of 
eleven  and  one-half  to  fourteen  and  one-half  are 
actually  taller  and  from  twelve  and  one-half  to  fifteen 
and  one-half,  actually  heavier  than  boys.  From  fifteen 
to  twenty  years  boys  again  take  the  lead,  and  grow  at 
first  rapidly,  then  gradually  more  slowly,  and  complete 
their  growth  at  about  twenty-three  years.  After 
fifteen  girls  grow  very  slowly,  and  attain  their  full 
Stature  aboul  the  twentieth  year.  The  strength  of 
males  increases  rapidly  from  twelve  to  nineteen  years 
and  at  a  rale  similar  "to  the  weight:  more  slowly  and 
regularly   up   to   the   thirtieth  year,   after  which   it 


declines  at  an  increasing  rate  to  the  age  of  sixty. 
The  strength  of  females  increases  at  a  more  uniform 
rate  from  nine  to  nineteen  years,  more  slowly  to 
thirty,  after  which  it  decreases  in  a  manner  similar  to 
that  of  males. 

The  primary  measurements  of  the  human  body, 
many  of  which  are  taken  by  the  Bertillon  system 
(taken  at  rest)  are  stature,  weight,  cranial  circumfer- 
ence, span  of  extended  arms,  circumference  and  ex- 
pansion of  chest,  length  of  arm  and  leg,  sitting  height, 
circumference  of  waist,  limbs,  hips,  and  shoulders, 
length  of  forearm  and  thigh,  size  of  foot,  length  of 
fingers,  size  and  position  of  ear,  facial  angle  (degree 
of  prognathism),  shape  of  head,  size  and  form  of  nose, 
position  and  attitude  of  eyes,  etc.  Only  a  few  of 
these  elements  are  of  ethnic  significance — stature, 
size,  and  shape  of  head,  facial  angle,  relative  length  of 
limb,  attitude  of  eyes.  Some  or  all  of  the  other 
elements  are  considered  in  comparisons  of  selected 
classes  of  the  population  (e.g.  school  children  at 
various  ages).  With  definite  quantitative  measure- 
ments other  individual  or  typical  attributes  are 
correlated — color  (of  skin,  hair,  eyes,  mucous  mem- 
branes, etc.);  character  of  pelage  (scalp,  hair,  beard, 
axillary  and  pubic  hair,  body  hair) ;  local  and  general 
texture  of  skin,  form  and  mobility  of  features,  etc. 
Other  measurements  are  of  the  skeleton,  especially 
the  skull  (craniometry),  of  arms  and  long  bones. 
There  are  formulas  for  determining  stature  from  the 
length  of  femur,  tibia,  humerus,  and  other  long  bones 
(Manouvrier,  Deniker).  The  forms  of  certain  bones 
are  deemed  ethnic  criteria — flattening  of  the  tibia 
and  the  perforation  of  the  humerus  in  the  olecranon 
fossa. 

The  measurement  of  the  progressively  increasing 
angle  subtended  by  the  bones  of  the  face  and  forehead 
with  the  base  of  the  cranium  (the  facial  angle),  from 
the  lower  animals,  through  the  anthropoids  and  the 
lowest  human  races  up  to  the  Caucasian,  affords 
striking  facts   (Camper,   Cloquet,   Jacquart,   Cuvier). 

By  the  "facial  index"  one  may  compare  crania  of 
different  types.  Cranial  specialists  have  devised  a 
series  of  points,  lines,  and  angles  by  which  cranial 
types  are  defined  with  great  detail. 

In  "dynamic  anthropometry"  the  measurement 
of  structures  has  been  supplanted  by  measurement 
of  function,  both  periodic  and  special.  Among 
period  data  are  rates  of  respiration  and  pulsation, 
which  vary  with  sex,  age,  and  race  as  well  as  in 
individuals.  Various  devices  have  been  made  to 
measure  the  interrelations  between  the  periodic  and 
special  functions  of  the  human  body  by  experimental 
psychologists  (Cattell,  Royce,  Baldwin,  Scripture, 
MacDonald,  Witmer).  Special  functions  are  such 
as  athletic  records,  the  military  step  in  various 
armies,  the  hours  of  labor  in  different  countries  and 
I  i  ises,  the  variation  of  faculty  with  race  and  culture, 
and  so  forth. 

The  Bertillon  System  is  a  plan  of  identifying  sus- 
pected criminals.  It  was  originated  in  March,  1879, 
and  set  forth  in  18S5  by  Dr.  Alphonse  Bertillon  of 
Paris.  This  is  not  now  a  single  system  but  a  com- 
bination of  that  invented  by  Bertillon  with  others 
approved  by  use.  The  original  system  is  that  of 
anthropometry,  or  exact  measurements  of  certain 
dimensions  of  the  human  body  and  its  members; 
the  additions  are  in  the  nature  of  descriptions,  as  of 
passports,  of  photographs,  finger  prints,  and  the  like. 

The  Bertillon  system  can  be  indexed  and  referred 
to  as  rapidly  and  as  readily  as  the  titles  of  books  in  a 
library  catalogue;  and  it  has,  for  this  and  other 
reasons,  become  a  standard  in  all  countries  with 
civilized  judicial  systems.  It  rests  on  three  prin- 
ciples: (1)  easy  and  precise  measurements  of  the 
parts  of  the  body  in  a  living  subject;  (2)  extreme 
diversity  of  such  dimensions  in  different  subjects, 
no  two  ever  closely  approximating  each  oilier:  (3) 
almost  exact  fixation  of  the  skeleton  after  the  age  of 


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Anthropometry 


twenty  years.  The  measurements  arc  taken  with 
eompasses  and  include:  height,  standing  and  sitting; 
reach  of  outstretched  arms;  length  and  width  of 
bead;  length  and  width  of  right  car;  Length  of  Left 
foot,  forearm,  middle  and  little  fingers.  The  descrip- 
tive elements  are:  color  of  eye-;  (the  mosl  Important 

detail  of  all,  because  it  never  changes  and  is  impossi- 
ble of  disguise),  hair,  beard,  and  complexion; 
deformities  and  peculiarities  of  shape;  marks  on 
the  body  (moles,  scar-.,  tattooing,  etc.).  These  are 
carefully  located  in  the  record,  as.  "mole  six  centi- 
meters i"  left  of  fifth  vertebra,"  or  "horizontal  scar 
on  back  of  second  phalanx  of  right  forefinger,  three 
millimeters  below  middle." 

A  photograph  of  the  full  face  and  one  of  the  profile 
are  taken,  when  thought  desirable,  from  a  fixed  chair 

a  fixed  camera.  The  entire  process,  carried  out 
i  measurer  and  a  secretary  writing  from  dictation, 
takes  less  than  seven  minutes;  the  measurements 
are  correct  to  one  thirty-second  of  an  inch.  Descrip- 
tions and  photographs  are  put  together  on  a  card 
of  uniform  size,  and  in  the  model  Paris  collection 
I'JM.OOO  are  thus  classified  for  reference.  First, 
approximately  'Jo, 000  females  and  10,000  minors 
are  separated  for  special  classification.  Second,  the 
'.lo.oiin  remaining  are  divided  into  three  equal  sections 
according  to  length  of  head — short  heads  of  1S7 
millimeters  and  less;  medium,  is?  to  194;  long,  194 
and  above.  Each  of  these  sections  is  divided  into 
three  of  10,000  each,  according  to  width  of  head, 
without  further  reference  to  length;  each  of  these 
again  into  three  of  about  3,300  each,  according  to 
length  of  middle  finger;  each  of  these  into  three  of 
about  1,000  each,  by  length  of  foot;  these  are  sub- 
divided successively  by  length  of  forearm,  full  height, 
length  of  little  finger,  and  color  of  eyes.  These  last 
groups  contain  from  twelve  to  fourteen  and  are 
classed  by  length  of  ear.  The  women  and  children 
are  similarly  classified. 

Thus  any  new  measurement  can  be  compared 
with  its  duplicate  in  this  enormous  mass;  or  the 
absence  of  such  record  can  be  shown  with  marvelous 
celerity  and  well-nigh  absolute  accuracy.  The  index 
value  alone  of  the  Bertillon  system  is  of  the  first  order. 
Under  the  old  systems  the  entire  mass  of  descriptions 
and  photographs  had  to  be  searched  and  compared 
with  any  given  individual;  and  with  the  immense 
number  of  records  accumulating  in  great  cities  it 
became  physically  impossible  to  apply  it  with  any 
certainty.  Thus  more  than  half  the  habitual  criminals 
remained  undetected,  while  the  innocent  were  often 
mistaken  for  them.  This  and  much  else  is  avoided 
by  the  combination  of  anthropometry  with  descrip- 
tive features  in  the  Bertillon  system.  Local  records 
should  be  gathered  into  national  and  even  interna- 
tional bureaus.  (See  Bertillon's  "Identification  An- 
thropometrique"  and  Major  McClaughry's  "Bertillon 
System  of  Identification.") 

Finger-print  Identification. — Francis  Galton  pub- 
lished his  "Finger  Prints"  in  1S92,  and  soon  after- 
ward his  "Index  of  Finger  Prints."  He  claimed  that 
the  chance  of  the  finger  prints  of  two  individuals  being 
identical  is  less  than  one  to  sixty-four  billion.  If 
therefore  two  such  prints  are  compared  and  found  to 
be  identical,  nothing  in  human  affairs  can  be  surer 
than  that  they  are  the  prints  of  the  same  person;  if 
they  are  not  identical,  they  must  belong  to  different 
p-ople.  The  chance  of  error  here  is  infinitesimal, 
and  is  still  further  eliminated  if  prints  of  three  or 
more  fingers  are  taken.  The  only  requisite  seems 
to  be  that  the  prints  be  taken  clearly  enough  to  bring 
out  all  the  lines.     It  is  considered  that  these  lines  and 

Erints  are  more  enduring  than  any  other  marks  of  the 
ody;  they  do  not  vary  from  youth  to  age;  they 
persist  even  after  death,  at  least  until  decomposition 
has  set  in.  Injuries  alone  change  them;  but  the  scar 
of  a  cut  that  has  been  printed  would  be  an  additional 
identification.     One  makes  an  impression  (the  natural 


moisture  suffices)  upon  a  pad  of  old i nary  white  paper; 
a  jet  black  adhesive  powder  i-  dusted  on  this,  and 
the  imprint  is  made;  or  a  white  powder  is  dusted  on 
a  black  surface. 

This  finger-print  system  of  identification  is  by  some 

accredited  to  Bertillon;  but  erroneou  ly.  It  was 
Galton,  that  amazing  genius  in  scientific  detail  and 
in  the  utilization  of  data,  who  proposed  and  fii  I 
reduced   the  finger-prinl    method    to  a  system;  and 

when  he  made  it    known   to    Bertillon,    the   latter  was 

for  a  long  time  very  sceptical  as  to  its  utility,  preferring 
his  ipw  n  S3   lem  of  measurement  i. 

The  finger-print  system  is  the  very  sine  I  method 
of  identifying  criminals;  and  such  evidence  has,  it 
seems,  been  deemed  incontrovertible  in  judicial  pro- 
cedures. So  cognizant  is  the  modern  burglar  of  its 
salue  in  this  respect  that  many  of  these  criminals 
now  use  gloves  in  their  nocturnal  visits.  About  a 
month  before  <  !a  I  ton  died  this  method  was  temporar- 
ily under  a  cloud:  A  man  was  charged  in  an  English 
police  court  with  loitering,  supposedly  in  order  to 
commit  a  felony.  A  previous  conviction  was  sought 
to  be  established  against  him  by  the  production  from 
the  police  records  of  finger  prints  identical  with  his 
own.  He,  however,  handed  in  papers  tendingtoshow 
that  he  had  been  serving  in  the  army  at  the  time  of  the 
alleged  conviction;  whereupon  lie  was  promptly 
discharged.  This  event  was  naturally  disconcerting 
to  finger-print  enthusiasts,  who  regarded  this  method 
as  infallible;  and  many  declared  (reasonably  enough) 


Fig.  255. — Two  Photographs  Each  of  Three  Men,  the  Lower 
being  of  the  Same  Man  as  the  Upper,  Showing  how  Unsatisfactory 
as  a  Means  of  Identification  a  Photograph  may  be.  The  men 
were  identified  by  their  finger-prints. 

that  this  single  failure  ought  to  discredit  the  whole 
system.  Nevertheless,  a  week  later  it  was  ascertained 
and  proved  beyond  peradventure  that  this  culprit  had 
stolen  the  army  papers  from  another  man;  what  is 
more,  it  was  shown  clearly  by  other  marks  of  identi- 
fication (as  well  as  by  his  handwriting)  that  he  was 
without  any  manner  of  doubt  the  man  to  whom  the 
police  had  referred. 

But  the  finger-print  system  has  a  number  of  uses  of 
no  relation  whatever  to  criminal  procedures.  Rail- 
roads are  using  it  as  a  means  of  identifying  employees. 
Some  of  the  Government  employees  in  the  Canal  Zone 
are  paid  by  means  of  it,  as  are  also  untutored  Indians. 
In  the  United  States  Army  the  finger  prints  of 
every  enlisted  man  are  recorded  as  a  means  of  identi- 
fication in  case  of  desertion.  Even  the  officers  have 
recorded  their  finger  prints  in  the  War  Department. 
In  actual  warfare  this  might  prove  the  only  way  of 


477 


Anthropometry 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


identifying  a  body  found  on  the  battlefield.  Thou- 
sand- perished  unidentified  in  our  Civil  War  who 
could  have  been  identified  had  this  system  been  in 
use;  and  many  a  "missing"  man  might  now  be 
revered  in  his  family  as  having  perished  with  the 
honors  of  war. 

One  may  conceive  here  a  veritable  revolution 
in  civilized  affairs.  For  example,  the  substitution  on 
behalf  of  a  citizen  who  cannot  write  his  name,  of  the 
finger  print  for  "his  mark"  on  documents.  The 
latter  which  is  just  a  cross,  is  no  identification  at  all; 
the  finger  print  is  even  more  positively  and  unforge- 
ably    a"  signature   than    the   writing    of    the    name. 

('apt.  Joseph  A.  Faurot,  the  head  of  the  Identifica- 
tion Bureau  of  the  New  York  City  Police  Department, 


tinually  increasing  in  number  by  reason  of  the  great 
strain  of  the  present-day  civilization.  The  crime  of 
abandonment  could  be  prevented  were  the  mother 
and  her  infant's  finger  tips  both  printed  on  the  same 
card.  (The  parental  finger  print  is  no  more  identical 
with  the  child's  than  any  other  print.)  The  printing 
of  policy  holders  would  absolutely  prevent  substitu- 
tion of  a  dead  body  for  a  live  man.  Election  frauds 
could  readily  be  ended.  If  all  chauffeurs  were  finger- 
printed, there  would  be  fewer  escapes  after  "  joy  ride" 
homicides  and  maimings.  A  universal  system  of 
recording  fingers  prints  would  do  away  with  our 
missing  list.  It  would  prevent  uncounted  mysteries; 
it  would  return  to  their  families  thousands  taken  ill 
away    from    their    homes.     It    would    identify    the 


the  Superiority  of  Finger-nrints  to  Photography,  the  above  being  the  pictures  and  finger-prints 
of  three  different  persons. 


urges  a  much  wider  utilization  of  the  finger-print  sys- 
tem than  at  present  obtains.  He  would  have  every 
new-born  babe,  every  school  child,  finger-printed, 
as  a  basis  for  really  adequate  vital  registration;  such 
prints  will  absolutely  identify  the  individual  from  the 
cradle  to  the  grave.  The  prints  will  be  enlarged  with 
growth;  but  as  to  their  lines  will  never  change. 
It  was  objected  in  New  York  City  that  persons  sus- 
pected (and  not  yet  convicted)  of  crime  should  not  be 
obliged  to  be  finger-printed;  but  the  leaders  of  the 
Men  and  Religion  movement  in  the  metropolis, 
believing  it  is  important  for  the  innocent  as  well  as 
for  the  guilty  to  have  it  ascertained  whether  they 
have  ever  been  under  arrest,  offered  to  persuade  all 
churchmen,  and  in  fact  all  residents  whom  they  could 
influence,  to  place  the  impression  of  their  fingers  in  the 
records  of  the  Police  Department. 

Captain  Faurot  would  do  away  with  lost  identity  in 
the  United  States  by  establishing  a  Central  Bureau, 
to  which  the  finger  prints  of  every  member  of  the  pop- 
ulation must  be  forwarded  for  classification;  to  this 
Central  Bureau,  which  should  be  a  Federal  institution, 
all  other  bureaus,  state,  county,  and  municipal, 
would  be  tributary.  There  would  be  two  sets  i  f 
print-  of  each  individual;  onemadeat  the  local  bureau; 
the  other  being  sent  to  Washington. 

Besides  many  other  advantages  of  such  a  plan,  the 
numberless  unknown  unfortunates  found  mysteriously 
dead  would  be  identified.  And  this  system  would 
solve  these  puzzles  which  aphasia  and  insanity  are 
constantly  presenting — puzzles  involving  cases  eon- 

478 


drowned.  Some  3S,000  people  die  each  year  in  the 
United  States  and  are  buried  without  identification; 
the  finger-print  system  would  enormously  minimize 
this  number. 

Mr.  Wm,  A.  Pinkerton,  the  head  of  the  detective 
agency  bearing  his  name,  observes  in  relation  to 
finger  prints  that  there  is  some  reason  for  the  saying 
that  "every  man  has  his  double."  Doubles  do  exist, 
though  not  of  course  for  every  man.  And  these  men, 
such  as  are  seen  in  the  accompanying  photographs, 
may  look  so  much  alike  that  it  is  impossible  to  dis- 
tinguish them  as  thus  portrayed.  But  there  is  one 
physical  characteristic  possessed  by  each  human  unit 
that  has  no  double,  so  far  as  human  experience  goes — ■ 
the  finger  print.  One  sees  in  the  accompanying. 
photographs  the  clearly  differentiating  fingerprints. 

Mr.  Pinkerton  declares  that  for  perhaps  thousands 
of  years  Chinese  merchants  have  used  the  impression 
of  their  thumb  rather  than  their  signatures;  for  this 
purpose  they  have  ever  with  them  a'cake  of  ink. 
Nor  in  all  the  history  of  China  (so  it  is  said)  have  two 
thumb  prints  exactly  alike  been  found.  From  China 
the  use  of  the  thumb  print  spread  to  the  North  of 
India.  "Now,"  says  Mr.  Pinkerton,  "the  system  is 
in  use  throughout  Great  Britain,  and  every  man  or 
woman  who  has  ever  been  in  custody  has  his  finger 
print  registered"  for  future  reference.  Oftentimes 
innocent  people  are  wrongly  accused  by  reason  of 
misleading  photographs;  but  if  thumb  prints  accom- 
pany the  pictures  the  suspected  person  ran  instantly 
prove  his  innocence.  John  B.  Huber. 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIEN"  I  3 


Antimony 


Aiitiarthrin  is  a  condensation  product  of  tannic  acid 
and  saligenin,  one  of  the  decomposition  products  of 
Balicin.  It  has  been  found  by  Schaeffer  to  be  of 
value  in  acute  and  chronic  gout  and  acute  rheuma- 
tism, and  he  claims  thai  it  possesses  the  advantages 
of  not  deranging  the  stomach  and  not  depressing  the 
heart.  The  compound  is  very  unstable,  and,  to 
prevent  decomposition,  it  must  be  kepi  dry  and  free 
from  admixture  with  other  drugs.  Dose:  15 
grains  |  L.O)  from  three  to  six  times  a  day. 

\V.   A.   Bastedo. 

Antibodies. — Following  inoculation  with  bacteria, 
their  toxins,  or  various  foreign  proteins,  an  organism 
is  stimulated  to  the  production  of  "reaction  bodies," 
which  for  the  greater  part  may  be  found  in  the 
Mating  blood  and  are  known  as  antibodies. 
Antibodies  were  divided  by  Ehrlich  into  three  classes 
or  orders. 

I.  Antibodies  of  the  First  Order. — These  comprise 
chiefly  the  antitoxins.  According  to  Ehrlich's  theory, 
the  presence  of  a  small  quantity  of  toxin  in  the  body 
fluids,  which  does  not  seriously  injure  the  cell,  will 
result  in  the  stimulation  of  the  cell  to  the  production 
of  that  particular  kind  of  receptor  to  which  the  toxin 
has  become  fixed.  Further  stimulation  results  in  an 
overproduction  of  these  receptors  and  many  are 
displaced  and  eventually  find  their  way  into  the  blood 
stream.  Here  they  are  able  to  unite  with  any  toxin 
which  may  be  present  in  the  blood  ami  thus  prevent 
the  union  of  this  toxin  with  the  body  cells.  They  are 
the  simplest  form  of  receptor  and  possess  only  one 
haptophore  or  combining  group.  Other  antibodies 
of  this  type  are  the  antiagglutinins,  antiamboceptors, 
anticomplement,  and  possibly  the  antiferments. 

II.  Antibodies  of  the  Second  Order. — In  this  class 
are  found  the  agglutinins  and  precipitins.  They 
also  are  cell  receptors  cast  off  into  the  blood  stream 
but  possessing  two  groups,  one  a  haptophore  or  com- 
bining group,  the  other  a  function  group  by  means 
of  which  they  cause  agglutination  or  precipitation. 

III.  Antibodies  of  the  Third  Order. — This  group 
consists  of  the  cytolysins,  which  are  much  more 
complicated  than  the  bodies  of  the  first  and  second 
orders.  They  are  also  called  '  amboceptors.  They 
consist  of  two  combining  groups,  one  the  haptophore 
group  which  unites  with  the  cell,  the  other,  the 
complementophore  group,  requiring  the  attachment 
of  complement  before  any  lytic  action  can  take  place. 

Antibodies  as  a  whole  are  distinguished  by  their 
specificity  which  is  more  marked  in  those  developed 
as  a  result  of  inoculation  than  in  the  ones  normally 
present  in  a  serum.  They  are  comparatively  resist- 
ant to  heat  and  age,  may  be  heated  to  55°  C.  for 
thirty  minutes  without  injury.  For  further  discus- 
sion of  these  bodies  see  the  articles  on  each  antibody 
and  also  the  article  on  Immunity. 

Ralph  G.  Stillman. 

Antidiabetic — Glycosolveol.  A  name  applied  to 
a  series  of  three  mixtures  of  mannite  and  saccharin, 
each  mixture  having  a  definite  sweetness  in  propor- 
tion to  that  of  cane  sugar.  Antidiabetinum  No.  1  has 
the  same  sweetening  power,  No.  2  is  ten  times  as 
sw  eet,  and  No.  3  is  seventy  times  as  sweet  as  sugar. 
They  are  used  as  substitutes  for  sugar  in  diabetes. 

W.  A.   Bastedo. 


Antidyspeptic  and  Tonic  Springs. — Nottoway 
County,  Virginia. 

Post-office. —  Burkeville. 

Access. — Via  Norfolk  and  Western  Railroad, 
thence  one  half  mile  to  springs. 

These  springs  are  located  in  a  fine,  salubrious  region 
about  530  feet  above  the  sea  level.     They  are  two  in 


number,   the  How  from  tin-  main  spring,   No.   I,  being 
about  -  HI  gallons  per  hour.       The  water  was  analyzed 

in   1890  by   Prof.    E.   T.   Fristoe,  ol   the  Columbian 

University,  with  the  following  results: 

One  United  States  Gallon  Contains: 

Solids.                                           •  Grains. 

Sodium  hydrate  (?) 0.51 

Sodium  chloi  ide 0.28 

Magnesium  chloride 0.20 

Magnesium  carbonate. (I  '.'  1 

Magnesium  Bulphate                        1  :to 

Calcium  sulphate          0.46 

Imt i  oxide Trim 

Aluminum 0.16 

Lit  1 1 iu mi Trace 

Calcium  carbonate 1 .65 

Nitric  acid Trao 

Organic  matter Trace 

Sulphuric  acid Trace 

Phosphoric  acid 0.78 

Silica 1.89 

Toed     8.17 

Free  carbonic  acid  gas,  large  amount. 

The  acids  and  elements  expressed  in  the  table  are 
undoubtedly  in  combination.  The  water  has  an 
extensive  reputation  in  the  treatment  of  dyspepsia, 
intestinal  disorders,  renal  colic,  and  the  uric  acid 
diathesis.  It  is  believed  to  possess  useful  properties 
as  a  tonic.  It  may  be  classified  as  a  light  sulphated 
saline.  The  water  of  Spring  No.  2  contains  about  ten 
grains  of  solid  matter  per  United  States  gallon,  includ- 
ing enough  iron  to  make  it  a  valuable  chalybeate. 
It  is  warmly  recommended  as  a  ferruginous  tonie. 
These  waters  are  bottled  and  shipped  to  any  point. 

Emma  E.  Walker. 

Antifebrin. — See  Acetanilide. 

Antigen.— According  to  Citron,  "any  substance, 
which,  when  injected  into  an  organism,  can  stimulate 
the  production  or  formation  of  an  antibody,  has  been 
conveniently  termed  'antigen.'"  Thus  the  produc- 
tion of  antitoxin  following  the  injection  of  toxin, 
the  development  of  lysins,  agglutinins,  etc.,  following 
the  injection  of  bacteria  are  instances  in  which  the 
toxin  and  the  bacteria  act  as  antigens.  These  sub- 
stances are  large  in  number  and  of  great  variety. 
Among  the  antigens  may  be  included  most  of  the 
pathogenic  bacteria,  many  bacterial  and  a  few  animal 
poisons,  and  a  number  of  animal  and  plant  proteins. 
A  single  antigen  may  induce  the  formation  of  a 
number  of  different  antibodies.  For  the  relation  of 
antigen  to  immunity  reactions  the  reader  should  con- 
sult the  article  on  Immunity. 

Ralph  G.  Stillman. 

Antimony. — Antimony  is  a  metallic  chemical  ele- 
ment, belonging  to  the  same  group  as  nitrogen,  phos- 
phorus, and  arsenic.  It  has  a  valence  of  iii  or  v,  and 
atomic  weight  of  120.  It  is  a  silvery  white,  crystal- 
line, brittle  substance  with  a  high  metallic  lustre.  It 
is  most  frequently  found  in  combination  as  the  Sul- 
phide (called  Stibnite)  and  in  several  minerals. 

General  Medicinal  Properties  of  Compounds 
of  Antimony. — As  usual  with  compounds  of  the 
heavy  metals,  all  antimonials  capable  of  absorption 
produce  essentially  similar  constitutional  effects. 
These  effects  are,  in  medicinal  dosage,  depression 
of  pulse  in  both  force  and  frequency,  with  fall  of 
arterial  tension,  diaphoresis,  increase  of  mucous 
secretions,  and,  with  rise  of  dosage,  nausea  and 
vomiting,  with  decided  muscular  debility.  In 
large  doses  antimonials  are  powerfully  poisonous, 
causing  heart  failure,  prolonged  and  violent  vomit- 
ing and  purging,  with  cramps  and  general  collapse. 
Locally,  soluble  antimonials,  such  as  that  most  com- 

479 


Antimony 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


monly  used  preparation  of  antimony,  tartar  emetic,  are 
irritant — much  of  the  emetic  effect  being  evidently 
due  to  local  irritation  of  the  stomach  upon  swallow- 
ing. Concerning  the  rationale  of  the  production  of 
the  various  effects  described,  the  only  points  of  clinical 
importance  are  that  the  effects  upon  the  pulse  seem  to 
arise  from  a  direct  depressing  action  upon  the  heart, 
and  not  secondarily'from  a  possible  excitation  of  the 
restraint  influence  exerted  through  the  vagus  nerve, 
and  that  the  vomiting  seems  to  be  induced  partly  by 
direct  local  irritation  of  the  stomach,  and  partly  by  an 
action  upon  the  nerve  centers,  after  absorption.  For 
tartar  emetic  causes  vomiting  when  injected  into  the 
veins,  but  yet  not  so  readily  as  when  given  per  os. 

The  Preparations  of  Antimony  Used  in  Medi- 
cine.— In  the  United  States  Pharmacopoeia,  antimony 
and  potassium  tartrate,  and  the  wine  of  antimony  are 
the  only  two  preparations  of  antimony  in  use. 

Antimony  and  Potassium  Tartrate,  2K(SbO)C4H4 
O0+H2O. — This  salt,  so  well  known  by  the  name 
tartar  emetic,  is  official  under  the  title  Antimonii  et 
Potassii  Tartras,  Antimony  and  Potassium  Tartrate. 
A  more  accurate  name  for  it  would  be  antimonyl  and 
potassium  tartrate,  for  the  antimony  in  it  is  in  the 
form  of  the  radical  antimonyl  (SbO).  It  is  com- 
monly made  by  boiling  together  in  water  antimonous 
oxide  and  acid  potassium  tartrate  (cream  of  tartar), 
and  obtaining  the  resulting  double  tartrate  by  crys- 
tallization from  the  solution.  Other  methods,  how- 
ever, are  resorted  to  by  some  manufacturers.  Tar- 
tar emetic  occurs  as  "colorless  transparent  crystals 
of  the  rhombic  system,  becoming  opaque  and  white 
on  exposure  to  air;  or  a  white  granular  powder, 
without  odor,  and  having  a  sweet,  afterward  disa- 
greeable, metallic  taste.  Soluble  in  15.5  parts  of 
water  at  25°  C.  (77°  F.)  and  in  three  parts  of  boiling 
water,  but  insoluble  in  alcohol,  which  precipitates 
it  from  its  aqueous  solution  in  the  form  of  a  crystal- 
line powder."  (U.  S.  P.)  Aqueous  solutions  of  tar- 
tar emetic  spontaneously  decompose,  and  are  pre- 
cipitated by  acids,  alkalies,  and  alkaline  carbonates, 
soluble  salts  of  lead,  and  vegetable  astringent  prep- 
arations, such  as  infusion  of  galls. 

In  modern  medical  practice  in  the  United  States 
tartar  emetic  is  practically  the  only  antimonial  used, 
and  is  available  for  all  the  effects  of  antimony  as 
already  described.  In  doses  of  gr.  -^  (0.005)  it  de- 
presses the  heart  and  promotes  secretion;  in  doses  of 
gr.  £  (0.01),  repeated,  it  nauseates,  and  in  doses  of 
from  gr.  ss.  to  ij.  (0.03  to  0.12)  it  acts  as  an  emetic, 
with  the  usual  prolonged  and  distressing  attendant 
nausea  of  the  antimonials.  In  quantities  beyond 
those  last  mentioned  it  is  a  dangerous  and  easily  fatal 
poison.  It  may  be  given  in  aqueous  solution,  and  if 
employed  to  provoke  vomiting,  should  be  prescribed 
in  doses  of  gr.  ss.  (0.03)  to  be  repeated  every  fifteen 
minutes  until  vomiting  ensues,  or  until  four  doses 
have  been  taken. 

Wine  of  Antimony. — When  wanted  in  small  dosage 
for  catarrhs  or  fevers,  the  official  Vinum  Antimonii 
is  more  commonly  prescribed.  To  make  this  wine, 
tartar  emetic,  4  gm.,  is  dissolved  in  65  c.c.  of  boiling 
distilled  water  and  175  c.c.  of  alcohol,  and  sufficient 
white  wine  is  added  to  make  1,000  c.c.  From  ten  to 
thirty  drops  is  the  average  dose.  Wine  of  antimony 
is  an  ingredient  of  the  Compound  mixture  of  licorice 
of  the  Pharmacopoeia.  (See  Glycyrrhiza.)  Tartar 
emetic  enters  into  the  composition  of  the  official  com- 
pound syrup  of  squill.      (See  Squill.) 

Tartar  emetic  is  powerfully  irritant,  and  applied  to 
the  skin  in  ointment  or  plaster  produces  after  a  while 
an  eruption,  papular  at  first,  but  passing  to  vesicles 
or  pustules,  much  resembling  the  eruption  of  small- 
pox, for  which  it  actually  has  been  mistaken.  The 
eruption  is  painful,  and  may  leave  scars.  Pustula- 
tion  by  tartar  emetic  is  a  possible,  but  disagreeable 
method   of  effecting  a  continuous  counter/irritation. 

480 


The  best  mode  of  application  is  to  prescribe  an  oint- 
ment of  one  part  of  tartar  emetic  to  four  of  simple 
ointment,  to  be  rubbed,  but  rubbed  lightly,  into  the 
skin.  Too  vigorous  inunction  may  produce  an  un- 
controllable inflammation. 

Toxicology. — Pure  metallic  antimony  is  not 
thought  to  be  directly  poisonous.  Symptoms  of  gas- 
troenteritis occasionally  followed  its  medicinal  use  in 
times  past,  and  serious  symptoms  are  said  to  have 
been  produced  by  the  metal  when  inhaled  in  the  state 
of  vapor;  but  the  effects  in  these  cases  have  usually 
been  attributed  either  to  the  partial  oxidation  of  the 
metal  or  to  the  presence  of  arsenic,  which  is  a  fre- 
quent impurity  in  commercial  antimony.  Many  of 
the  compounds  of  antimony  are  more  or  less  poison- 
ous. The  most  important  of  these  are  tartar  emetic 
and  the  trichloride  of  antimony. 

Tartar  Emetic. — This  may  give  rise  to  acute  poison- 
ing, as  a  result  of  a  single  large  dose,  or  to  chronic 
poisoning,  as  a  result  of  small  doses  frequently  ad- 
ministered. Its  poisonous  properties  are  due  to  the 
antimonyl  (SbO)  which  it  contains. 

Acute  Poisoning. — When  a  large  dose  of  tartar 
emetic  is  taken,  the  acrid  metallic  taste  of  the  poison 
is  usually  perceived  by  the  patient.  After  a  short 
time,  varying  from  a  few  minutes  to  half  an  hour, 
there  are  nausea  and  faintness,  followed  by  violent 
vomiting.  There  is  burning  in  the  throat  and  esopha- 
gus; sometimes  great  thirst  and  difficulty  of  swallow- 
ing, pain  in  the  stomach  and  abdomen.  The  vomit- 
ing is  usually  persistent.  The  vomited  matters  con- 
sist at  first  of  the  contents  of  the  stomach,  then 
of  mucus,  later  of  mucus  mixed  with  bile,  and  in 
some  cases  blood.  Violent  and  persistent  purging 
is  usually  an  early  symptom.  The  discharges  are 
liquid,  resembling  those  of  cholera,  and  frequently 
contain  blood.  Symptoms  of  extreme  depression 
and  prostration,  ending  in  collapse,  which  is  a  promi- 
nent feature  in  acute  tartar-emetic  poisoning,  soon 
appear.  The  skin  is  cold  and  covered  with  perspira- 
tion; the  pulse,  which  appears  to  be  increased  in 
frequency  till  immediately  before  vomiting  sets  in, 
is  at  this  stage  diminished  in  frequency  and  force, 
and  may  become  imperceptible;  the  respiration  is 
irregular,  but  for  the  most  part  slow,  with  hasty  and 
forced  inspiration  and  prolonged  expiration;  the 
temperature  is  lowered.  Cramps  in  the  extremities, 
delirium,  loss  of  consciousness,  and  convulsions,  not 
infrequently  precede  death.  The  urine  in  mild  eases 
is  increased  in  quantity,  as  it  is  also  in  the  begin- 
ning, even  in  fatal  cases;  but  in  such,  toward  the 
close,  it  is  generally  scanty  and  bloody,  and  even  sup- 
pressed (H.  C.  Wood,  Jr.).  Exceptionally,  vomiting 
is  absent;  in  such  cases  the  other  symptoms  are  said 
to  be,  as  a  rule,  more  prominent.  In  some  cases  a 
pustular  eruption,  resembling  that  produced  by  the 
external  application  of  tartar  emetic,  has  appeared 
on  the  body  on  the  third,  fourth,  or  fifth  day.  In 
fatal  cases  death  may  occur  within  a  few  hours, 
but  is  more  frequently  delayed  for  two,  three,  or 
more  days.     Recovery  is  very  frequent. 

Tartar  emetic  is  occasionally  employed  externally 
as  a  counterirritant,  producing  sooner  or  later  a 
burning  pain,  followed  by  a  pustular  eruption,  on  the 
parts  to  which  it  has  been  applied.  Its  use  for  this 
purpose  has  been  followed,  in  several  instances,  by 
symptoms  of  irritant  poisoning  as  a  result  of  its  ab- 
sorption through  the  integument.  In  two  cases,  at 
least,  death  has  been  caused  by  its  application  to 
the  broken  skin. 

Fatal  Quantity. — The  quantity  of  tartar  emetic  re- 
quired to  destroy  life  cannot_  be  stated  with  accu- 
racy, since  its  effects  are  variable  and  frequently 
depend  less  on  the  quantity  taken  than  on  other  con- 
ditions. Owing  probably  to  early  and  abundant 
vomiting,  recovery  has  frequently  taken  place  after 
doses  varying  from   7.S  to  31  grams  (5  ij.   to  viij.). 


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\  until. -n\ 


On  tl"'  other  hand,  as  a  result  probably  of  idiosyn- 
crasy alarming  symptoms,  and  even  death,  have 
followed  the  administration  of  doses  which  would 
ordinarily  be  considered  non-fatal.  In  sixteen 
fatal  cases  collected  by  Taylor,  the  smallest  fatal 
dose  was  i"  a  child,  0.048  gram  (gr.  0.75),  and  in 
an  adult.  0.130  gram  (gr.  ij.':  but  in  the  latter  case 
there  were  circumstances  which  favored  the  fatal 
operation  of  the  poison.  Taylor  quotes  a  case  in 
which  0.022  gram  (gr.  0.33),  given  in  divided  doses 
t,i  a  child  four  years  of  age,  produced  alarming  symp- 
toms. Serious  symptoms  have  followed  the  admin- 
istration of  0.032  gram,  0.26  gram  and  0.40  gram 
ss.,  iv..  and  vj.  respectively)  to  adults.  Dr. 
Draper  reported  a  ease,  at  a  meeting  of  the  Boston 
ety  for  Medical  Observation,  in  Isso,  in  which 
0.26  gram  (gr.  iv.'.  followed  in  ten  minutes  by  0.13 
gram  (gr.  ij.),  proved  fatal  to  a  healthy  adult  woman 
in  fifty-three  hours.  According  to  YVakley,  0.195 
gram  (gr.  iij.)  killed  an  adult  in  twenty-four  hours; 
gram  gr.  x.)  and  0.97  gram  (gr.  xv.)  have 
proved  fatal  to  children.  '_'.:',  grams  (gr.  xxxvi.),  2.4 
grains  (gr.  xxxvij.t,  3.24  grams  (gr.  1.),  and  3.9 
grams  (gr.  lx.)  to  adults.  Children,  aged  persons, 
i  hose  who  are  in  delicate  health  are  more  suscep- 
tible to  its  action  than  healthy  adults.  On  the  other 
hand,  there  are  certain  diseased  stages  of  the  body  in 
which  large  and  repeated  doses  have  been  adminis- 
tered without  producing  any  symptoms  of  poisoning. 
Taylor  concludes  that  under  favorable  circumstances 
0.65  to  1.3  grams  (gr.  x.  to  xx.),  taken  at  once, 
might  destroy  an  adult,  and  that  a  still  smaller 
quantity  than  this  might  suffice  if  taken  in  divided 
doses. 

The  mucous  membrane  of  the  stomach  and  intes- 
tines is  usually  more  or  less  inflamed  and  softened. 
The  inflammatory  appearances  in  the  intestines  are 
Usually  most  marked  in  the  duodenum,  cecum,  and 
rectum.  The  mucous  membrane  of  the  mouth,  throat . 
and  esophagus  is  sometimes  inflamed.  There  are 
isionally  aphtha?  and  pustules  in  the  mouth. 
throat,  esophagus,  or  stomach;  sometimes  aphthous 
ulceration  of  the  glands  of  the  small  intestines.  The 
stomach  and  intestines  contain  more  or  less  mucus, 
colored  with  bile  or  blood  or  both.  Hypostatic  con- 
gestion of  the  lungs  has  been  frequently  noticed. 
A  greater  or  lesser  degree  of  fatty  degeneration  of 
the  liver,  kidneys,  heart,  muscular  tissue  of  the 
diaphragm,  and  cells  of  the  gastric  glands,  sometimes 
recognizable  only  by  microscopic  and  chemical  exami- 
nation, is  a  well-recognized  result  of  the  action  of 
antimony  compounds.  This  was  first  pointed  out 
by  Salkowsky,  who  states  that  there  is  also  a  dimi- 
nution of  the  amount  of  glycogen  in  the  liver,  and 
in  some  cases  a  total  disappearance  of  it. 

Antimony  is  quickly  absorbed,  and  after  death 
may  be  detected  in  nearly  all  the  organs  and  tissues 
of  the  body.  It  is  rare  to  fine  more  than  a  trace  in 
the  stomach,  since  its  emetic  properties  usually  secure 
its  early  removal.  The  liver  and  kidneys  probably 
contain  the  largest  amount.  It  is  eliminated  in  the 
urine  and  bile,  also,  according  to  Lewald,  in  the  milk. 
When  tartar  emetic  is  injected  into  the  veins  it  is  said 
to  be  rapidly  eliminated  through  the  mucous  mem- 
brane of  the  stomach  (Brinton).  The  time  required 
for  its  complete  elimination  is  uncertain.  Millon 
and  Laveran  detected  antimony  in  the  urine  of 
patients  as  late  as  twenty-four  days  after  the  last 
administration  of  tartar  emetic.  They  also  found 
antimony  in  the  fat,  bones,  and  other  tissues  of  dogs, 
as  late  as  four  months  after  the  last  administration. 
They  state  that  there  are  well-marked  intermissions 
in  the  elimination. 

Treatment. — If  vomiting  has  not  occurred,  it  should 
be  provoked  by  tickling  the  throat  or  by  the  admin- 
istration of  warm  water.  The  best  antidote  is  tannic 
acid,  which  forms  with  oxide  of  antimony  a  com- 
pound insoluble  in   water.     A  solution  of  the  acid 


may  lie  used.       In   the  absence  of  thi-.  an   iiihi-n.ii   of 

green  tea,  decoctions  of  <,.-ik  bark,  gall  nuts,  or  I  ■•  - 
ruvian  bark,  or  tincture  of  kino  or  catechu,   all  of 

which    contain     tannic    acid,     may     be    a.  Iini  ni-t  • 

The  stomach  should  be  thoroughly  washed  oul  after 
the  administration  of  the  tannic  acid.     Opium  should 

then  be  given,  to  allay  pain  and  irritation.  Stim- 
ulants, external  and  internal,   may  be  required. 

Chronii    /' v.     The   symptoms  produced  by 

the  repeated  administrate  of  tartar 

emetic  are  of  the  same  general  character  as  those 
which  have  been  described  under  acute  poisoning. 
They  are,  however,  less  severe  and  less  rapid  in  their 
progress,  varying  in  these  respects  with  the  quantity 
administered  and  t  he  frequency  of  the  administration. 
The  most  prominent  are  nausea,  retching,  vomiting 
of  mucus  and  bile,  soreness  and  constriction  of  tin- 
throat,  a  sensation  of  burning  and  pain  in  tic  stomach, 
eling  of  uneasiness  and  sometimes  pain  in  tin 
abdomen,  a  constant  feeling  of  depression,  gradual 

loss  of  strength,  and  progressive  emaciation.  The 
nausea  and  vomiting  recur  after  each  administration 
of  the  poison.  Purging  i-  not  so  prominent  a  >ymp- 
tom  as  in  acute  poisoning.  The  stools  are  at  first 
normal:  later,  there  may  be  diarrhea,  usually  alternat- 
ing with  constipation.  The  time  at  which  death 
occurs  depends  chiefly  upon  the  size  of  the  doses  and 
the  frequency  of  their  administration.  Taylor  col- 
lected five  cases,  four  of  which  were  fatal.  In  throe, 
death  took  place  in  six,  eight,  and  nine  days  respect- 
ively; in  the  fourth,  the  poison  was  administered 
over  a  period  of  three  months  preceding  death. 

In  the  treatment  of  chronic  poisoning  it  is  essential 
to  prevent  the  further  administration  of  the  poison. 
Stimulants,  tonics,  and  nutritious  diet  are  required. 
In  chronic  cases  elimination  can  be  assisted  by  ad- 
ministration of  the  iodides. 

Trichloride  of  Antimony. — Butter  of  antimony  is  a 
transparent,  fusible,  crystalline  substance,  which,  on 
exposure  to  moist  air,  rapidly  deliquesces  to  a  clear 
liquid.  When  pure  it  is  colorless,  but  it  frequently 
contains  more  or  less  chloride  of  iron,  which  imparts 
to  it  a  color  varying  from  yellow  to  dark  brown. 
It  is  decomposed  by  water,  with  the  formation  of 
hydrochloric  acid  and  an  insoluble  white  basic  chlo- 
ride, which  may  be  distinguished  from  the  corre- 
sponding basic  chloride  of  bismuth  by  its  solubility 
in  tartaric  acid.  A  concentrated  hydrochloric  acid 
solution  of  the  chloride  has  some  uses,  and  has  given 
rise  to  a  few  cases  of  accidental  or  suicidal  poisoning. 
It  is  a  violent  corrosive  and  irritant. 

The  symptoms  resemble  closely  the  symptoms 
produced  by  the  mineral  acids.  They  come  on  very 
rapidly,  and  consist  of  violent  vomiting  and  severe 
pain  in  the  throat,  stomach,  and  abdomen,  soon  fol- 
lowed by  symptoms  of  collapse.  Death  has  taken 
place  in  two  hours,  and  has  been  delayed  for  ten  and 
one-half,  eighteen,  and  twenty-four  hours. 

The  smallest  quantity  required  to  destroy  life  is 
unknown.  Ninety  cubic  centimeters  (three  fluid- 
ounces),  approximately,  of  the  solution  has  proved 
fatal  to  adults  in  three  cases.  Recovery  has  taken 
place  after  30  c.c.  (oj). 

The  lips,  mouth,  and  throat  have  usually  been 
found  more  or  less  corroded.  The  interior  of  the 
stomach  and  upper  part  of  the  small  intestines  are 
intensely  inflamed,  corroded,  and  sometimes  black, 
as  if  charred.  In  a  case  related  by  Taylor,  the  whole 
alimentary  canal,  from  the  mouth  to  the  middle  of 
the  small  intestines,  presented  this  black  appearance. 
The  mucous  membrane  was  entirely  destroyed,  and 
the  parts  beneath  were  so  soft  that  they  were  easily- 
torn  with  the  fingers.  Fatty  degeneration  of  the  liver, 
kidneys,  heart,  muscular  tissue  of  the  diaphragm, 
and  cells  of  the  gastric  glands  was  observed  in  rabbits 
to  which  small  doses  of  trichloride  of  antimony  were 
administered   ( Salkowsky) . 

Treatment  consists  in  the  administration  of  sodium 


Vol.   I.— 31 


481 


Antimony 


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carbonate,  chalk,  or  magnesia,  to  neutralize  the  free 
acid,  and  of  preparations  containing  tannic  acid. 

Edward  Curtis. 

R.  J.  E.  Scott. 

Antiperiodics — The  various  malarial  fevers  are  all 
characterized  by  a  more  or  less  regular  recurrence  of 
their  characteristic  symptoms,  to  wit:  chill,  fever,  and 
sweating;  the  period  for  such  recurrence  varying 
according  the  the  life  cycle  of  the  particular  organism 
which  causes  the  special  type  of  fever.  These  phe- 
nomena are  therefore  spoken  of  as  periodical,  and  the 
remedies  which  are  known  to  exert  an  inhibitive  effect 
upon  them  are  called  antiperiodics.  This  term,  how- 
ever, is  a  relic  of  the  time  when  the  nature  of  malarial 
diseases  was  not  understood  and  their  distinguishing 
symptom,  periodicity,  attracted  an  undue  attention. 
It  is  not  as  mere  interrupters  of  a  periodic  morbid 
phenomenon  that  the  remedies  hereunder  mentioned 
are  to  be  regarded,  but  as  inhibitory  of  the  growth  in 
the  red  corpuscles  of  that  organism  whose  successive 
crops  produce  the  periodic  symptoms  of  chill  and 
fever. 

The  actual  antagonisn  of  quinine  in  the  circulating 
blood  to  the  development  of  the  malarial  plasmodium 
has  been  abundantly  demonstrated,  and  with  the 
.laying  of  stress  upon  this  fact  the  weakness  of  the 
term  antiperiodic  becomes  apparent.  It  is  retained 
here  out  of  deference  to  long  established  usage  rather 
than  for  its  present  appropriateness.  The  symptoms 
against  which  antiperiodics  are  most  commonly 
employed  are  those  constituting  the  seizure  in  the 
estivo-autumnal,  tertian,  and  quartan  types  of  ague, 
and  consisting  of  the  cold,  the  hot,  and  the  sweating 
stages.  In  the  milder  forms  of  intermittent  and 
remittent  fever,  the  breaking  up  of  the  recurrent  chills 
as  soon  as  possible  is  important  for  the  comfort  of  the 
patient,  but  in  the  so-called  "pernicious"  malarial 
fevers,  it  may  be  a  matter  of  life  or  death  to  stop  at 
once  those  congestive  chills  whose  effects  are  so 
alarming,  and  it  is  in  such  cases  that  the  great  value 
of  the  antiperiodics  is  seen.  Other  chronic  manifesta- 
tions of  the  malarial  cachexia,  such  as  neuralgia,  are 
amenable  to  antiperiodic  treatment,  but  it  is  notice- 
able that  the  success  of  quinine  in  the  relief  of  neural- 
gia is  in  proportion  to  the  regular  periodicity  of  the 
attacks,  i.e.  to  the  activity  of  the  malarial  organism, 
rather  than  to  its  sequelse. 

By  far  the  most  important  antiperiodic — of  more 
value,  in  fact,  than  all  the  others  taken  together — is 
cinchona,  with  its  derivatives.  Ever  since  the  cure 
of  the  Countess  of  Cinchon  of  an  ague  at  Lima,  in  the 
earlier  half  of  the  seventeenth  century,  first  gave 
name  and  fame  to  the  drug,  its  value  in  intermittent 
fever  has  been  acknowledged.  More  than  any  other 
remedy  in  the  Pharmacopoeia  it  deserves  to  be  con- 
sidered a  specific.  Its  direct  action  on  the  malarial 
parasite  in  the  blood  has  been  abundantly  shown. 

Quinine,  by  reason  of  its  more  concentrated  and 
convenient  form,  is  now  used  almost  entirely  to  the 
exclusion  of  cinchona  as  an  antiperiodic.  For  this 
purpose  the  dose  must  be  large,  corresponding  in 
quantity  to  the  so-called  antipyretic  dose  of  the  drug. 
The  quinine  should  be  so  administered  as  to  produce 
a  saturation  of  the  patient's  system  at  the  time  w  lien 
the  next  seizure  would  occur.  To  attain  this  object 
we  may  best  give  one  full  dose,  one  to  two  grams 
(gr.  xv.  to  xxx.)  on  the  drop  of  temperature  following 
a  given  paroxysm  in  order  to  abort  the  following 
paroxysm.  Or  it  may  be  given  in  divided  doses 
through  the  twenty-four  hours  before  an  expected 
chill,  the  last  dose  being  six  hours  before  the  time 
the  chill  is  due.  If  the  interval  is  much  shorter  than 
this,  the  chance  of  aborting  the  very  next  seizure  is 
diminished.  If  a  single  administration  of  the  drug 
anticipates  the  chill  by  only  four  or  five  hours,  the 
chances  are  about  equal  for  and  against  its  success. 
In  no  other  form  is  quinine  more  effective  than  in  that 


of  the  crystals  of  the  sulphate  in  an  acid  solution 
(bisulphate)  or  dissolved  in  lemon  juice.  The 
solubility  is  usually  somewhat  impaired  in  the  pill 
form,  and  the  administration  in  coffee  fails  to  give  the 
best  effect  because  of  the  imperfect  solubility  of  the 
tannate.  The  manufacturing  chemists  have  put  upon 
the  market  a  "compound  syrup  of  licorice,"  which 
quite  effectually  disguises  the  bitter  taste  of  the  drug, 
without,  so  far  as  the  writer  knows,  interfering  with 
its  solubility. 

When  the  periodicity  of  the  intermittent  fever  is 
irregular,  and  in  cases  of  remittent  fever,  cinchonism 
should  be  produced  as  soon  as  possible  after  a  seizure, 
and  maintained  by  moderate  but  sufficient  doses  for 
several  days.  In  the  cases  of  pernicious  malaria,  if 
there  are  not  ten  or  twelve  hours  before  the  expected 
time  of  attack  in  which  to  secure  complete  cinchonism 
by  the  oral  administration  of  the  drug,  it  should  be 
given  subcutaneously.  In  order  to  secure  its  com- 
plete solution,  acid  must  be  added,  one  minim  of 
dilute  sulphuric  acid  to  each  grain  of  quinine  usually 
sufficing.  But  this  solution  has  the  disadvantage  of 
being  irritating,  and  there  is  some  danger  of  abscess. 
This  risk,  however,  should  be  taken  in  preference  to 
that  of  a  severe  congestive  chill.  The  hydrobromate 
of  quinine  is  especially  adapted  for  subcutaneous 
use.  It  may  be  prepared  according  to  the  following 
formula: 

T?     Quininae  sulph 10  (gr.  clx.) 

Acidi    hydrobromici 

(Squibb) 4  (5  i.) 

Aqua?      (vel      spts.      fru- 

menti) ad  30  (3  i.) 

The  kinate  and  the  disulphate  of  quinine  are  preferred 
by  some  for  hypodermic  use.  The  dose  of  quinine 
subcutaneously  is  less  than  by  the  mouth,  and  its 
action  is  more  prompt.  When  for  any  reason  neither 
of  the  foregoing  methods  is  available,  the  drug  may 
be  given  by  the  rectum  in  doses  somewhat  larger  than 
by  the  mouth.  For  children  and  others  with  sensitive 
stomachs,  when  haste  is  not  an  especial  object, 
quinine  may  be  given  by  inunction.  For  this  purpose 
an  eligible  preparation  is  the  following: 

I?     Quininae  sulph. 5  (gr.  lxxx.) 

Acid,  oleic,  pur 30  (5  i.) 

01.  olivarum 30  (5  i.) 

Dissolve  the  quinine  in  the  acid  with  the  aid  of  gentle 
heat.     Add  the  oil.     The  solution  should  be  clear. 

There  is  considerable  choice  among  the  various 
salts  of  quinine  both  as  to  their  strength  and  as  to 
their  solubility.  For  example,  the  acetate  contains 
87  per  cent,  of  quinine,  the  basic  and  neutral  hydro- 
chlorate  each  nearly  S2  per  cent.,  the  basic  lactate  78, 
the  basic  hydrobromate  76,  the  basic  sulphate  74, 
the  neutral  sulphate  less  than  60  per  cent.,  while  the 
tannate,  much  is  favor  for  administration  to  children 
in  the  form  of  "chocolate  quinine  tablets,"  has  only 
20  per  cent. 

The  hydrochlorate  is  the  most  soluble  salt,  and  as 
it  is  one  of  the  richest  in  quinine,  it  is.  in  spite  of  its 
slightly  greater  cost  than  some  others,  the  most 
eligible.  The  neutral  hydrobromate  is  soluble  in 
6  parts  of  water,  while  the  basic  sulphate  is  soluble 
only  in  5S1  parts  of  water. 

In  old  malarial  cases,  in  many  of  which  the  liver  is 
enlarged,  we  must,  in  order  to  get  the  full  and  prompt 
effect  of  quinine,  preface  or  accompany  its  exhibition 
by  the  use  of  a  mercurial,  as  calomel  or  blue  pill, 
followed  by  a  saline. 

The  other  alkaloids  of  cinchona,  quinidine,  chinoid- 
ine,  c'nehonidine,  and  cinchonine,  have  some  an- 
tiperiodic value,  but  are  all  inferior  to  quinine,  and  if 
used  should  be  given  in  larger  doses.     Regarding  I  lie 


-IS  J 


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Antlpyrlne 


,\,, f  quinine,  it  should  be  said  that  it  varies  much 

q0I  only  with  the  individual,  but  with  the  place  In 
the  tropics  and  in  the  habitat  of  malaria  much  larger 
doses  are  tolerated  and  arc  necessary  to  break  up  a 
chill  than  in  temperate  climates  and  non-miasmatic 
localities.  The  prophylactic  value  of  quinine  against 
ague  is  even  greater  than  its  curative  action.  A 
moderate  amount— as,  for  instance,  a  grain  three 
times  a  .lay  -may  he  taken  constantly  for  years 
without  any  ill  effects.  This  precaution  is  one  that 
should  he  taken  by  every  one  compelled  to  live  in  a 
malarious  country.  Even  in  non-malarious  districts 
persons  who  have  contracted  ague  elsewhere  should, 
afi  r  breaking  up  the  chills  by  the  antiperiodic  dosi 

scribed  above,  continue  with  small  quantities  ol 
quinine  for  a  fortnight  or  more,  or  better,  with  a  full 
dose  once  a  week. 

Next  to  cinchona,  the  most  useful  antiperiodic 
which  we  possess  i-  probably  arsenic.  It  is  to  those 
chronic  cases  which  nave  assumed  a  somewhat  irregu- 
lar type,  and  in  which  we  hardly  know  at  what  time 
to  expect  a  chill,  that  arsenic  i-  particularly  adap 
It  may  he  given  in  the  form  of  Fowler's  solution. 
beginning  with  0.3  gram  (n\v.)    three    times    a    day, 

i  up  to  0.5  or  0.7  or  even  one  gram 
times  a  dav.  or  the  arsenousacid  may  be  given  in  gran- 
ule- of  at  first  0.0015  to  0.002  gram  (gr  ^  to^„)  three 
times  a  day.  pushed  till  the  physiological  effects  are 
reached.  \'\  itn  arsenic  we  do  not  attempt  to  stop  the 
very  next  paroxysm;  hence  it  is  not  adapted  for  perm- 
eases. It  should  always  be  well  diluted  and 
given  on  a  full  stomach. 

When  treatment  has  been  delayed  until  the  chill  is 
actually  "on,"  quinine  is  useless  for  that  seizure. 
Nothing  is  so  efficacious  to  check  a  chill  actually  in 
progress  as  a  full  dose  of  morphine  subcutaneouslv. 
Chloroform  is  also  recommended  for  this  purpose  in  a 
of  from  two  to  four  grams  ( 5  ss.  to  i.)  in  sweet- 
ened water  or  mucilage.  Good  effects  have  been 
claimed  for  the  administration,  during  the  chill,  of 
nitrite  of  amyl  by  inhalation,  and  nitrate  or  muriate 
of  pilocarpine  hypodermically. 

Nectandra,  or  bebeeru  bark,  has  met  with  some 

ess  as  an  antiperiodic.     The  alkaloid,  in  the  form 

of   the  sulphate   of  beberine,   contains   whatever   of 

virtue  the  drug  possesses,  and  may  be  given  in  the 

same   doses   and    at   the    same    times   as   quinine. 

Warburg's  Tincture,  formerly  in  much  repute, 
especially  in  India,  as  an  antiperiodic,  contains  some 
sixty-four  ingredients,  of  which  the  most  active  is 
quinine,  in  the  proportion  of  ten  grains  to  the  ounce. 

The  eucalyptus  seems  to  possess  some  antiperiodic 
virtue.  Among  the  peasantry  of  Southern  Europe 
it  has  quite  a  reputation.  Careful  observation  shows 
that  in  highly  malarious  localities  it  is  often  without 
it.  The  oil  of  eucalyptus  in  doses  of  0.1  to  0.3 
grain  (rn_  ij.  to  v.),  may  be  given,  or  the  tincture  in 
doses  of  one  to  two  grams  (nixv.  to  xxx.).  That  it  is 
of  use  in  the  milder  cases  is  made  probable  by  the 
fact  of  its  undoubted  power  as  a  prophylactic.  Since 
tree  was  introduced  into  Southern  Europe  in 
1856,  its  growth  has  much  improved  the  health- 
fulness  of  many  marshy  regions.  The  Trappist 
monks  devoted  themselves  to  cultivating  this  tree  in 
the  most  malarious  regions  of  Italy,  with  the  result  of 
making  places  habitable  that  were  formerly  highly 
unhealthy.  This  result  is  now  known,  however, 
to  have  been  due  merely  to  the  effect  which  the  trees 
had  in  sucking  up  standing  water,  which  had  been  a 
breeding  place  for  the  malaria-bearing  mosquito. 

Charles  F.   Withixgton. 


Antipyretics. — Antipyretics  are  therapeutic  agents 
or  measures  which  are  employed  to  lower  the  body 
temperature  when  it  is  abnormally  high.  As  a  rule 
they  exert  little  or  no  influence  upon  the  normal 
body   temperature.     The    temperature   of   the   body 


may  be  reduced  in  two  way-:  (1)  By  lessening  the 
production  of  heat;  and  (2)  by  increasing  the  dissi- 
pation of  leal. 

The  production  of  heal  may  bed  !:  (1)    By 

reducing  the  circulation;  and  (2)  by  a  general 
lessening  of   the   metabolism   of   the  body.      Vgents 

used      to     reduce      the     circulation,      are;       \uliinoi,\ 

preparations,  colchicum,  digitalis,  trimethylamine, 
and  veratrine:  also  I  he  appli  I  lips, 

and   leeches.     General   lessening  of   the   metabolism 

may  be  brought  about  by:  Act  anilide.  acetphenet- 
idin.  alcohol,  antipyrine  and  the  coal  tar  denvatj 
in  general),  benzoic  acid,  berberine,  camphor,  eu- 
calyptol,  phenol,  picric  acid,  quinine  and  it-  alka- 
loid-, resorcinol,  salicin,  salicylic  acid  and  the  sal- 
icylates, salol,  and  thymol. 

The  dissipal   i  at   may  be  I:  (1)   By 

abstracting  heat  from  the  body;  and  (2)  by  pro- 
ducing pcr-piration  and  increasing  evaporation. 
Heat  is  abstracted  from  the  body  by  cold  baths  and 
sprays,  cold  drinks,  and  the  application  of  ice  or  cold 
packs  to  the  surface  of  the  body.  This  method  is  the 
readiest,  the  most  rapid,  and  probably  the  safest 
way  to  reduce  the  body  temperature.  Diaphoretics 
used  for  this  purpose  are  Dover's  powder,  spirit  of 
nitrous  ether,  acetanilide,  and  antipyrine. 

Aconite  will  also  reduce  the  body  temperature; 
so  will  chloral;  but  how  many  of  these  antipyretic- 
act  is  not  known.  Antipyretics  as  a  class  (particu- 
larly the  coal-tar  derivatives)  are  depressing,  and 
dangerous.  As  in  other  conditions,  the  cause  of 
the  abnormally  high  temperature  should  be  sought 
and,  if  possible,  removed.  R.  J.  E.  Scott. 


Antipyrine. — Axtipyrixa  (Y.  S.  P.).  phenazonum 
( B. P.),  phenyldimethvl-isopvrazolone,  C'  HX.,0(CH,),. 
C  II,  or  (CH3)N.C  (CH3):  CH.CO.N(C.H5).  This  is 
one  of  the  earlier  so-called  coal-tar  synthetic  remedies, 
obtained  by  the  action  of  acetyl  acetic  ether  upon 
phenyl-hydrazine.  It  occurs  in  the  form  of  a  white 
crystalline  powder  or  scales,  of  a  bitterish  taste,  readily 
soluble  in  water  (the  only  substance  of  its  class  except. 
resinol  having  this  property),  alcohol,  and  chloroform, 
and  in  forty  parts  of  ether.  When  treated  with  a 
solution  of  ferric  chloride  it  gives  a  deep  red  color. 
It  is  chemically  incompatible  with  most  substances, 
with  some  of  which  indeed,  such  as  amyl  nitrite  and 
nitrous  ether  (when  containing  free  nitrous  acid),  it 
forms  poisonous  compounds,  and  should  therefore 
always  be  prescribed  alone,  or  with  caffeine,  salicylic 
acid,  or  potassium  bromide.  With  some  substances 
it  combines  to  form  definite  chemical  compounds,  such 
as  salipyrine  (antipyrine  salicylate),  tussol  (antipyrine 
mandelate),  hypnal  (antipyrine  chloral  hydrate),  etc. 

Antipyrine  is  analgesic,  antipyretic,  hemostatic, 
and  antiseptic.  It  was  introduced  as  a  febrifuge,  but, 
like  other  remedies  of  its  class,  was  seen  to  possess 
the  disadvantage  of  depressing  the  heart  action  and 
causing  profuse  sweating,  and  its  greatest  value  was 
f.  mud  to  reside  in  its  anodyne  and  analgesic  properties. 
It  may  be  given  for  the  relief  of  headache,  the  crises 
of  tabes  dorsalis,  neuralgia,  dysmenorrhea,  and  rheu- 
matic pains,  in  doses  of  gr.  iv.-x.  (0.25-0.6),  re- 
peated with  caution  every  two  or  four  hours.  In  the 
pyrexia  of  pneumonia  and  other  sthenic  fevers  it  is 
sometimes  useful  in  similar  doses,  but  should  not  be 
continued  if  depression  or  profuse  sweating  occurs. 
Locally  it  is  employed  in  four-per-cent.  solution  as  an 
antiseptic  and  local  anesthetic  in  acute  rhinitis,  pharyn- 
gitis, and  other  mucous-membrane  inflammations  of 
the  upper  air  passages.  Its  hemostatic  properties 
render  it  of  service,  applied  in  powder  or  strong 
solution,  in  epista.xis  and  in  bleeding  following  the 
division  of  urethral  stricture. 

A  rash  of  a  purplish  patchy  character  may  follow 
the  administration  of  antipyrine  in  susceptible  in- 
dividuals.    In  large  doses  it  causes  marked  depres- 


483 


Antipyrine 


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sion,  cyanosis,  sweating,  vertigo,  shallow  respiration 
and  dyspnea,  rapid  heart  action,  and  convulsions. 
These  symptoms  are  not  common  after  therapeutic 
doses,  but  may  occur  even  after  small  doses,  and 
caution  should  always  be  observed  in  its  adminis- 
tration. The  treatment  of  toxic  symptoms  caused  by 
antipyrine  consists  in  the  application  of  heat  to  the 
extremities  and  body  and  in  the  administration  of 
stimulants,  strychnine,  or  atropine;  inhalation  of 
oxygen  may  be  of  service.  T.  L.  S. 

Antisepsis. — See  Asepsis. 

Antiseptics. — This  term  was  originally  applied  to 
those  means  whereby  putrefactive  decomposition 
could  be  prevented,  but  has  gradually  acquired  a 
much  broader  meaning.  We  now  consider  as  antisep- 
tics only  those  agents  which  suppress  certain  functions 
of  microorganisms,  inhibiting  their  development  but 
nut  killing  them.  If  the  bacteria  are  removed  from 
the  influence  of  an  antiseptic  they  will  be  able  to 
resume  the  function  of  multiplication.  In  many 
instances,  substances  in  a  certain  dilution  act  as 
antiseptics,  but  when  employed  in  a  stronger  con- 
centration have  the  power  of  killing  bacteria,  that  is 
to  say,  become  germicides  or  disinfectants.  There  are, 
however,  notable  exceptions  to  this  rule.  A  detailed 
discussion  of  the  whole  subject  will  be  found  under 
the  heading  Disinfectants.        Ralph  G.  Stillman. 


Antiseptol  is  the  trade  name  for  a  substance  pre- 
pared by  mixing  a  solution  of  twenty-five  parts  of 
cinchonine  sulphate  in  2,000  parts  of  water,  with  a 
solution  of  ten  parts  each  of  iodine  and  potassium 
iodide  in  1,000  parts  of  water.  The  precipitate 
formed  is  washed  and  dried  and  constitutes  a  reddish 
or  dark  brown  powder,  without  odor,  almost  insoluble 
in  water  and  freely  soluble  in  alcohol  and  chloroform. 
It  is  an  odorless  iodoform  substitute  containing  fifty 
per  cent,  of  iodine,  and  when  used  internally  is  given 
in  dose  of  gr.  i.  to  v.  (0.06-0.3).  Antiseptol  is  also 
cinchonine  iodogallate  and  cinchonine  herapathite, 
although  its  chemical  formula  is  unknown. 

W.  A.   Bastedo. 

Antisera. — See  Antitoxins. 

Antispasmin  is  a  double  salt  of  sodium  salicylate  and 
narceine-sodium,  having  the  formula  C,3H,8NosNa  + 
3C6H4OHCOONa.  It  is  a  reddish,  slightly  hygro- 
scopic powder,  which  is  readily  soluble  in  water;  fifty 
per  cent,  of  it  consists  of  narceine.  As  an  antispas- 
modic and  sedative  it  is  given  in  whooping-cough, 
laryngismus  stridulus,  chorea,  asthma,  etc.,  especially 
in  children,  and  is  useful  in  allaying  irritating  cough  or 
intestinal  colic  in  adults.  On  account  of  its  affinity 
for  moisture  it  is  preserved  with  difficulty  in  the  dry 
state,  and  therefore  may  well  be  kept  in  five-per-cent. 
solution;  of  this,  five  to  eight  drops  are  given  to  a 
child  of  six  months,  or  forty  drops  to  a  child  of  five 
years;  an  adult  may  take  one  or  two  drams. 

W.  A.   Bastedo. 


Antispasmodics — If  we  are  to  interpret  the  term 
antispasmodic  in  its  literal  sense  as  a  means  of  pre- 
venting spasm,  nothing  so  completely  fills  the 
requirement  as  ether  or  chloroform,  pushed  to 
complete  anesthesia.  In  conducting  a  careful  phys- 
ical examination,  especially  in  diseases  of  the  abdomen 
or  pelvis,  such  relaxation  of  spasm  is  often  secured 
by  anesthetizing  the  patient.  But  as  ordinarily  used 
by  therapeutists  the  word  antispasmodic  is  given  a 
somewhat  loose  and  unscientific  application  to  a 
class  of  drugs  supposed  to  be  of  special  service  in 
controlling  at  tacks  of  muscular  spasm  depending  upon 
functional  nervous  derangement.     The  inappropriate- 

484 


ness  of  the  name  is  seen  from  the  fact  that  it  is  not 
alone  convulsive  phenomena  which  form  indications 
for  their  use,  but  that  they  are  also  useful  in  other  of 
the  multiform  manifestations  of  nervousness  or  of 
hysteria.  The  theory  of  their  mode  of  action — if, 
indeed,  any  one  method  of  action  is  common  to  all 
the  members  usually  included  in  the  class — is  not 
sufficiently  established  to  make  any  discussion  of  it 
profitable  in  this  place.  Suffice  it  to  say  that  it  is  not 
impossible  that  at  least  one  important  action  of  these 
drugs  is  a  local  one  upon  the  intestinal  tract,  where 
their  warming  and  stimulating  character  may  produce 
a  revulsive  effect.  For  the  detailed  description  of  the 
most  important  drugs  included  under  this  heading 
the  reader  is  referred  to  their  proper  titles. 

To  be  mentioned  in  connection  with  atropine,  which 
is  the  alkaloid  of  belladonna,  is  homatropine,  an 
artificial  tropeine  which  has  been  recommended  as 
a  desirable  substitute  for  atropine  as  a  mydriatic  on 
the  claim  (not  well  substantiated)  that  it  produces 
no  increase  in  the  intraocular  tension. 

Belladonna  has  a  considerable  power  of  relaxing 
spasm,  as,  for  instance,  in  the  unstriped  muscular 
tissue  of  the  intestine.  It  and  its  congeners,  stra- 
monium and  hyoscyamus,  are  also  much  used  in 
asthma,  which  is  a  disease  attended  by  spasm  of  the 
bronchi.  In  the  same  condition  opium  is  at  times 
of  the  greatest  value,  the  hypodermic  injection  of 
morphine  alone  causing  relief  in  some  asthmatic 
attacks.  In  "colic"  (meaning  spasm  of  the  muscular 
walls  of  the  intestine)  opium  is  also  invaluable. 
This  drug,  like  the  anesthetics  already  mentioned, 
while  distinctly  antispasmodic,  has  other  and  more 
important  therapeutic  qualities  which  lead  to  its 
classification  in  another  group  (see  Anodynes). 
Scopolamine,  identical  with  hyoscine,  is  of  value. 
It  has  been  combined  with  morphine,  in  which  com- 
bination it  must  be  used  with  care.  It  has  also  been 
used  instead  of  chloral  in  tedious  first  stage  of  labor. 
It  may  be  given  hypodermically  in  doses  of  gr.  -j-Jj 
grain. 

Apomorphine  is  sometimes  employed  as  an  anti- 
spasmodic in  delirium  tremens.  It  is  believed  by 
some  to  be  efficient  in  quieting  this  mania  in  less  than 
emetic  doses,  but  is  usually  employed  in  doses  of  gr.  ^ 
to  TV  hypodermically  which  not  only  relieve  the 
excitement  but  empty  the  stomach  as  well. 

Among  other  remedies  traditionally  called  anti- 
spasmodics, we  have  a  group  of  animal  origin,  strongly 
odorous,  but  of  little  therapeutic  value.  Moschus, 
musk,  an  oily  substance  obtained  from  the  preputial 
glands  of  the  Thibetan  musk-deer,  is  the  only  one  of 
this  class  which  is  used  to  any  extent.  In  the  last 
stages  of  adynamic  diseases,  as  typhoid  fever,  it  is 
given,  especially  by  German  physicians,  but  rather 
as  a  forlorn  hope  than  with  real  confidence.  Its 
former  use  in  hysteria  is  now  quite  superseded. 
Castorcvm,  a  corresponding  secretion  from  the 
Castor  fiber,  or  beaver;  ambergris,  a  morbid  product 
obtained  from  the  sperm  whale,  and  the  source  of  the 
oleum  suceini;  and  the  oleum  animate  of  Dippcl,  a 
substance  of  disgusting  origin  and  nature,  obtained 
from  "trying  out"  decomposing  animal  structures, 
deserve  mention  only  as  having  been  at  some  time 
used  as  antispasmodics. 

Another  group  consists  of  drugs  of  generally  feeble 
action,  but  occasionally  useful  in  infantile  hysteria 
and  allied  states.  Among  these  are  humulus,  hops, 
and  its  derivative,  lupulin.  The  former,  applied 
locally  in  the  form  of  poultices  or  embrocations,  has 
possibly  some  virtue,  and  the  latter  is  somewhat 
more  active  internally.  Lactucarium,  derived  from 
the  garden  lettuce,  is  even  more  feeble  than  hops, 
but  as  some  persons  are  made  drowsy  by  eating  let- 
tuce, it  is  not  impossible  that  lactucarium  may  have 
in  certain  cases  a  useful  medicinal  effect.  The  claims 
which  have  been  made  for  celery  as  an  antispasmodic 
and  anticephalalgic  do  not  seem  to  rest  on  reliable 


REFERENCE    HANDBOOK    OF   TIIF.    MEDICAL   SCIENCES 


A  III  i      IK]. .Ill  i.^ 


grounds.  Cimicifuga,  or  black  snakeroot,  belongs  in 
this  group.  It  has  been  chiefly  used  in  chorea,  and  in 
full  doses  it  has  seemed  to  have  some  effect  Dra- 
contium,  the  root  of  the  "skunk  cabbage,"  and  gaU 
..i  ingredient  with  asafetida  and  myrrh  in  the 
la  Oalbani  Comp.,  1".  S.  I'.  1880,  have  also  had 
antispasmodic  virtues  ascribed  to  them,  but  with 
little  reason. 

\\  ,■  n..u  cm 1 1. ■  lo  i  In-  group  which  contains  the  most 
important  drugs  of  this  class.  They  are  three  in 
number,  viz.,  camphor,  valerian,  and  asafetida.  They 
;ill  produce  a  sensation  of  warmth  in  the  stomach,  and 

probably  stimulate  the  whole  alimentary  canal.  Hut 
that  this  is  not  their  sole  action  is  proved  by  their 
rioritv  in  certain  nervous  states  over  the  essential 
oils  and  other  so-called  carminatives.  The  intestinal 
action  of  camphor  makes  that  drug  a  valuable  aid  in 
the  treatment  of  cholera  and  choleraic  diarrhea.  In 
the  delirium  of  adynamic  fevers  and  as  a  sedative  for 
"nervousness"  it  is  useful.  An  especially  quieting 
influence  lias  been  claimed  for  it  in  sexual  irritation 
and  excitement.  For  more  distinctively  hysterical 
symptoms,  camphor  is  often  combined  with  bromine 
in  the  form  of  bromated  or  monobromated  camphor, 
which,  despite?  its  disagreeable  taste,  difficult  solubil- 
ity, and  frequent  tendency  to  cause  irritation  of  the 
stomach,  is  considerably  used  for  chorea,  reflex  con- 
vulsions, etc.  Perhaps  no  drug  is  more  generally  used 
to  combat  the  true  hysterical  convulsive  seizure  than 
valerian,  and  certainly  in  many  cases  it  meets  the 
indication  better  than  almost  any  other  agent.  The 
fluid  extract  and  the  ammoniated  tincture  are  among 
the  most  eligible  palliatives  of  the  hysterical  attacks, 
sometimes  a  single  dose  serving  to  restore  conscious- 
ness. For  more  protracted  use  in  the  countless 
nervous  manifestations  of  hysteria,  hypochondria, 
and  neurasthenia,  the  salts  of  valerianic  acid,  notably 
the  valerianates  of  zinc  and  of  ammonium,  are 
especially  adapted,  serving  to  control  at  times  even 
i  positive  and  conspicuous  symptoms  as  neuralgia. 

Asafetida,  long  the  synonym  for  what  is  most 
loathsome  and  offensive  to  the  palate,  acts  very  like 
valerian  in  the  hysterical  attack.  The  flatus  which 
lias  been  rolling  about  in  the  intestine  is  expelled,  and, 
as  has  been  intimated  above,  there  is  some  reason  to 
believe  that  the  stimulation  of  the  intestinal  mucous 
membrane  and  the  revulsion  so  caused  may,  with  the 
relief  of  the  tympanites,  play  a  prominent  part  in 
the  alleviation  of  the  hysterical  spasm.  In  cases  in 
which  simulation  seems  to  have  any  part  in  the 
attack,  the  vile  taste  of  the  drug  may  become  of 
service  in  adding  to  its  effectiveness.  In  other  cases 
we  may  give  the  drug  by  enema,  and  its  action  upon 
the  intestine  and  also  its  effect  on  the  convulsions 
will  be  nearly  the  same  as  if  it  were  administered  by 
the  mouth. 

While  the  above-mentioned  drugs  constitute  the 
more  distinctive  antispasmodics,  there  yet  remain  two 
groups  to  which  the  term  is  often  applied,  and  of  which 
some  part  of  the  action  is  similar  to  that  above 
described.  The  compound  spirit  of  ether,  Hoffman's 
anodyne,  is  very  useful  in  controlling  nervous  dis- 
turbances, as  is  also  the  spirit  of  chloroform,  formerly 
known  as  chloric  ether.  The  substances  from  which 
these  are  derived — sulphuric  ether  and  chloroform — 
may,  administered  internally  in  appropriate  doses, 
be  employed  for  the  same  purpose,  although,  of 
course,  their  more  proper  classification  is  among  the 
anesthetics.  The  bromides  of  potassium,  ammonium, 
and  sodium  and  chloral,  though  in  their  most  promi- 
nent action  depressomotors,  are  yet,  in  moderate  doses, 
used  as  antispasmodics. 

Finally,  we  have  the  group  which  includes  coffee, 
tea.  mat<5,  and  guarana,  of  all  which  the  active 
principle  is  practically  identical  with  caffeine. 
Leaving  out  of  account  the  important  action  of  this 
substance  upon  the  heart  and  circulatory  system,  and 
limiting  our  attention  entirely  to  functional  nervous 


phenomena,  we  find  that  in  migraine,  which  in  the 
family  of  diseases  is  not  distant  of  kin  from  hysteria, 

of  the  mo  i    useful  remedies  are  caffeine  and 

guarana. 

The  newer  analgesics  of  the  coal-tar  series,  such  as 

antipyrine,  acetphenetidin,  acetanilide,  etc.,  are,  many 
of  them,  constituents  of  unethical  proprietary  remedies, 
which  as  used  by  the  public  for  headache  and  other 
nervous  symptoms  are  a  distinct  source  of  danger, 
causing  s etimes  profound  cyanosis  with  fatal  re- 
sult. I  lematopot  ■phyrinuria  has  thu  been  caused. 
The  employment  of  these  drugs,  especially  as  domestic 

ret lies,  should  be  forbidden. 

Marked  antispasmodic  elfects,  in  many  cases  fur 
superior  to  those  obtained  by  the  above  mentioned 
drugs,  are  to  lie  gained  by  the  external  use  of  water 
in  the  form  of  the  hot  bath,  the  warm  pack,  and  tin; 
ni  her  devices  of  hydrotherapy.     Moreover,  the  latter 

agency  is  devoid  of  some  of  I  he  dangerous  effects 
nf  the  drugs  above  mentioned.  Hydrotherapy  is 
destined  to  supersede  many  of  the  old-time  anti- 
spasmodics. Charles  F.  Withington. 


Antisudorifics. — Synonym,  antihidrotics.  A  group 
of  remedies  employed  to  check  excessive  secretion 
from  the  sudoriferous  glands.  It  includes  belladonna 
and  allied  plants,  agaricin,  picrotoxin,  mineral  acids, 
sulphate  of  copper,  oxide  of  zinc,  and  many  other 
drugs  which  possess  astringent  properties.  What 
may  be  termed  indirect  antisudorifics  are  creosote, 
sulphocarbolates,  and  other  antiseptic  remedies,  also 
strychnine,  iron,  and  tonics  generally,  which  act  by 
improving  the  tone  of  the  system  and  overcom- 
ing any  debility  which  is  often  the  predisposing 
cause. 

Excessive  sweating  may  occur  with  a  marked 
degree  of  pyrexia  or  an  entire  absence  of  fever.  It 
may  be  general  or  local,  affecting  a  paralyzed  limb 
only,  or  limited  to  the  hands  or  feet  during  perfect 
health.  (See  Hyperidrosis.)  That  form  which  is  of 
importance  to  the  practitioner  is  the  very  profuse 
sweating  met  with  in  phthisis  and  in  all  forms  of 
septic  absorption.  In  these  conditions  the  loss  of 
fluid  is  at  times  enormous,  and  as  there  is  also  present 
a  large  amount  of  solids,  it  becomes  a  very  exhaustive 
drain  upon  the  system.  This  secretion  is  not  an 
ordinary  transudation  of  water  in  the  form  of  serum. 
It  is  a  special  secretion  controlled  by  special  nerves, 
and  any  depression  or  paralysis  of  these  nerves  at 
once  lessens  the  secretion.  This  is  well  seen  in  the 
effect  of  poisonous  doses  of  belladonna,  when  the 
vasomotors  are  paralyzed  and  the  flow  of  blood  in 
the  skin  is  increased,  but  notwithstanding  this  the 
skin  remains  dry  on  account  of  the  sudoriferous 
glands  being  also  paralyzed. 

The  antisudorifics  are  useful  in  all  forms  of  hyperi- 
drosis. Their  action,  however,  is  but  the  relieving 
of  a  symptom  and  not  the  cure  of  a  disease.  For- 
merly they  were  given  very  empirically,  an  immediate 
effect  being  desired,  whatever  the  cause.  With  our 
increased  knowledge  of  the  action  of  toxins  and  the 
production  of  sepsis,  not  so  much  is  expected  of  the 
drugs.  More  attention  is  given  to  the  general  health 
of  the  patient  and  to  removing  the  cause  of  the  sweat- 
ing. In  tuberculous  and  septic  conditions  an  effort  is 
made  to  lessen  the  formation  of  toxins;  and  we  also 
realize  that  the  excessive  sweating  is  an  effort  of 
nature  to  cast  off  the  poisons,  and  unless  its  production 
is  lessened  much  harm  may  arise  if  its  excretion  is 
suddenly  checked.  The  most  valuable  of  antisudor- 
ific  drugs  is  belladonna  and  its  alkaloid.  One  of  its 
earliest  effects  is  to  parah'ze  the  secreting  glands  of 
the  skin  and  mucous  membranes,  and,  aside  from  its 
interfering  to  a  slight  extent  with  the  digestion,  its 
action  is  wholly  favorable.  The  effect  of  belladonna 
is  secured  by  the  administration  of  atropine  by  the 
mouth,  or  preferably  by  hypodermic  injection.     It 


485 


Antisudorlfies 


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may  be  commenced  in  moderate  doses  of  gr.  yi^, 
but  its  full  physiological  action  must  be  secured  and 
as  much  as  gr.  .,'„  may  be  required.  Too  frequently 
the  dose  employed  is  insufficient.  The  rapidity  of 
its  action  varies.  Sometimes  the  system  responds 
almost  immediately,  at  other  times  its  effect  is  not 
evident  for  three  or  four  hours.  Usually  the  effect 
of  a  full  dose  will  last  for  two  or  three  days.  Local 
application  of  the  ointment  and  liniment  of  bella- 
donna will  produce  the  same  effect,  but  is  less  under 
control. 

Hyoscyamus  and  its  alkaloids  have  also  the  same 
action.  Agaric  acid  has  been  used  with  much  suc- 
cess in  doses  of  gr.  -fo  to  J.  Picrotoxin  has  also  been 
recommended  in  doses  of  gr.  t^j  to  ^.  Zinc  oxide, 
gr.  ij.  to  iv.  at  bedtime,  and  sulphate  of  copper, 
gr.  ss.  are  very  old  remedies.  One  of  the  oldest 
remedies,  and,  next  to  belladonna,  one  that  is  the 
most  generally  employed,  is  the  aromatic  sulphuric 
acid.  This  requires  to  be  given  more  continuously 
until  it  produces  its  astringent  action.  At  first, 
ni  xx.  three  or  four  times  a  day,  should  be  given  for 
two  or  three  days,  after  which  a  single  dose  at  bedtime 
will  continue  "the  effects  of  the  drug.  The  dilute 
phosphoric  acid  is  also  of  service  when  administered 
in  the  same  way.  These  acid  astringents  have  not 
the  same  specific  action  as  belladonna,  but  are 
probably  excreted  in  part  by  the  sweat  glands,  and 
during  the  excretion  exercise  their  astringent  action. 
Camphoric  acid,  gr.  vii.  to  xii.,  has  been  highly 
recommended. 

Bathing  the  surface  of  the  body  with  weak  acid 
solutions  assists  in  allaying  perspiration  and  prevent- 
ing the  "night  sweats,"  for  it  is  known  that  all  acid 
solutions  will  lessen  the  secretion  of  acid-secreting 
glands.  Dilute  acetic  acid,  or  vinegar,  one  table- 
spoonful  to  the  pint,  applied  at  bedtime,  and  in 
severe  cases  repeated  a  short  time  before  the  ex- 
pected "sweat,"  will  allay  the  trouble  and  at  the  same 
time  prove  most  refreshing.  For  local  sweating  of 
the  hands  or  feet  the  general  health  of  the  patient 
must  be  attended  to,  after  which  the  above  drugs 
may  be  given  in  more  moderate  doses  and  extended 
over  a  greater  period.  In  addition  dusting  powders 
and  lotions  may  be  used,  salicylic  acid  five  per  cent, 
with  starch  and  talcum,  oxide  of  zinc,  tannin. 
Solution  of  formalin  ten  to  twenty  per  cent,  in  water 
or  alcohol  is  particularly  beneficial. 

Beaumont  Small. 


Antitoxins;  Antitoxic  Sera. — The  word  antitoxin  is 
at  present  usually  restricted  to  substances  found 
in  the  blood  of  animals  which  neutralize  the  toxins 
produced  by  bacterial  or  other  cells.  Other  substances 
exist  which  are  slightly  antitoxic.  These  are  found 
in  old  cultures,  and  Bolton  developed  them  from 
toxins  by  means  of  electricity.  An  antitoxin  is,  to 
a  large  degree  at  least,  specific  in  its  effects  on  poisons; 
that  is,  it  acts  only,  or  at  least  chiefly,  upon  the  toxins 
produced  by"  one  species  of  organisms. 

Thus,  a  given  quantity  of  antitoxic  serum  from  a 
horse  made  immune  to  diphtheria  will  absolutely 
neutralize  a  number  of  fatal  doses  of  diphtheria  toxin, 
so  t  hat  the  mixture  injected  into  an  animal  will  prove 
harmless. 

The  same  antitoxic  serum  mixed  with  the  toxin 
from  tetanus  bacilli  will  have  no  appreciable  neutral- 
izing effect.  In  a  few  instances  some  have  reported 
an  antitoxin  to  have  an  effect  on  more  than  one  toxin, 
but  even  here  this  effect  is  always  much  greater  upon 
some  one  than  upon  the  others. 

Antitoxins  are  present  to  some  extent  in  the  blood 
of  a  certain  percentage  of  animals  which  have  not 
passed  through  an  infectious  disease  or  been  injected 
with  bacterial  or  other  cell  poisons.  For  instance, 
li"i  i  usually  have  more  or  less  of  a  substance  an- 
titoxic to  the  diphtheria  toxin.     Thus  it  will  require 


5  c.c.  of  the  blood  of  one  horse  to  protect  a  250 
gram  guinea-pig  from  ten  fatal  doses  of  diphtheria 
toxin,  while  in  another  j'j  c.c.  will  suffice.  The 
blood  of  these  same  horses  may  have  no  neutralizing 
effect  upon  tetanus  toxin. 

Whether  these  antitoxic  substances  present  in  small 
amounts  in  normal  blood  are  the  same  as  those 
present  in  larger  amount  in  the  blood  of  immunized 
animals,  we  as  yet  do  not  know.  Neither  in  their 
chemical  nor  in  their  physiological  properties  can  we 
detect  any  difference. 

The  Nature  op  Antitoxins. — Up  to  the  present 
time  we  know  only  that  they  seem  to  have  the  prop- 
erties  of  globulins.  If  it  were  not  for  the  fact  that 
we  have  them  present  in  normal  blood,  we  might,  in 
order  to  account  for  their  specific  qualities,  consider 
them  as  partly  satisfied  combinations  of  globulins  and 
specific  toxins,  but  as  they  occur  without  the  pres- 
ence of  toxins  this  theory  seems  to  be  excluded. 

Blood  from  either  normal  or  immunized  animalx 
contains  a  number  of  globulins,  and  some  of  these, 
when  the  blood  is  antitoxic,  prove  antitoxic  also. 
By  no  known  method  can  we  separate  the  antitoxin 
from  all  the  globulin  so  that  if  antitoxin  be  not  a 
globulin  it  is  at  least  a  substance  very  closely  allied  to 
it.  Exactly  how  the  antitoxins  are  produced  we  do 
not  know,  but  we  believe  them  to  be  cell  products. 
Different  antitoxins  may  be  produced  by  different  cells. 

A  relation  which  exists  between  the  amount  of 
antitoxin  in  the  blood  of  an  immunized  animal  and 
the  amount  of  globulins  has  been  noted,  in  the  tests  of 
the  different  horses  under  the  care  of  the  Department 
of  Health  of  the  city  of  New  York,  by  Atkinson. 
He  found  that  the  globulin  increased  and  decreased 
roughly  as  the  antitoxin  increased  and  decreased. 

Antitoxins  are  only  fairly  stable  substances.  In 
sera  antitoxins  more  or  less  slowly  deteriorate, 
largely  according  to  the  conditions  under  which  they 
are  kept,  but  partly  also  in  proportion  to  the  abund- 
ance of  certain  blood  ferments.  In  sterile  serum, 
kept  cold  and  free  from  access  of  air,  antitoxins 
deteriorate  very  slowly,  diminishing  from  ten  to 
fifty  per  cent,  in  a  year.  Exposed  to  light,  air,  and 
slightly  elevated  temperature,  they  quickly  become 
altered,  and  especially  so  if  exposed  to  heat  above  50° 
C.  Exposed  to  70°  C.  for  ten  minutes,  a  portion  of 
the  antitoxin  in  a  solution  i-<  destroyed. 

As  the  antitoxins  of  diphtheria  and  tetanus  have 
been  the  most  studied  and  are  by  far  the  most  im- 
portant of  the  known  antitoxins,  they  will  be  con- 
sidered in  detail  as  types  of  the  others. 

Both  of  these  antitoxins  have  the  power  of  neutral- 
izing their  corresponding  toxins,  so  that  when  a 
certain  amount  is  injected  into  an  animal  before  or 
together  with  the  toxin  the  poisonous  effect  of  the 
toxin  is  removed.  There  is  still  some  difference  of 
opinion  as  to  whether  antitoxin  acts  by  direct  chemi- 
cal neutralization  of  the  toxin  or  indirectly  on  the 
cells.  The  facts  in  favor  of  a  direct  action  of  antitox- 
ins upon  their  corresponding  toxins  have  been  briefly 
summarized  by  Cobbett  as  follows. 

1.  Certain  reactions  have  been  observed  to  take 
place  between  these  substances  outside  the  animal 
body  (venom,  ricin,  crotin,  tetanus  toxin,  diphtheria 
toxin,  and  their  corresponding  antitoxins). 

2.  Various  attempts  by  filtration,  chemical  means, 
and  heat  to  separate  the  toxins  and  antitoxins  from 
neutral  mixtures  have  been  failures.  Partial  successes 
have,  at  least  in  some  instances,  been  shown  to  de- 
pend upon  the  fact  that  insufficient  time  for  the  com- 
plete union  of  toxins  and  antitoxins  was  allowed, 
separation  being  no  longer  possible  if  this  were 
granted. 

.;.  The  accuracy  of  the  titration  of  toxins  and  an- 
titoxins to  within  one  per  cent,  of  error. 

4.  The  fact  that  to  save  an  animal  from  one 
thousand  fatal  doses  of  toxin  requires  little  more  than 


1st; 


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\  rilitin    I.- 


a  hundred  times  as  much  antitoxin  as  is  required  to 
fully  protect  for  ten  fatal  doses,  the  resistance  of  the 
animal  itself  accounting  for  the  difference. 

;,.  Thefact  |liat  the  potency  of  antitoxin  is  greatly 
Increased  if  it  is  allowed  I"  remain  for  a  sufficient 
time  in  contact  with  the  toxin  at  a  suitable  tempera- 
ture to  allow  of  chemical  union. 

On  the  other  hand,  the  (■(inclusions  which  Buchner 
Rous  drew  from  their  experiments  have  been 
shown  to  have  been  based,  partly  at  least,  on  a  mis- 
eption,  for  they  ignored  the  capacity  of  an 
animal  to  deal  with  a  certain  minimal  quantity  of 
poison,  and  consequently  made  no  distinction  be- 
tween what  seemed  to  be  a  physiologically  neutral 
and  a  completely  neutral  mixture. 

The  facts  now  known,  therefore,  indicate  clearly 
that  the  antitoxins  of  tetanus,  diphtheria,  the  plague, 
and  cholera,  of  snake  poison,  of  ricin,  etc.,  enter  into 
direct  chemical  combination  with  their  respective 
toxins — a  combination  which  is,  perhaps,  not  exactly 
comparable  to  that  of  an  acid  with  an  alkali;  for,  as 
we  have  seen,  it  is  a  much  slower  one,  but  one  which 
possibly  as  Ehrlich  has  suggested — more  closely 
resembles  the  formation  of  a  double  salt.  Some  facts 
seem  to  indicate  that  the  antitoxin  has  a  stronger 
affinity  for  toxin  than  the  toxin  has  for  the  cells. 
Many  points,  however,  are  still  far  from  clear  as  to 
the  manner  in  which  both  toxins  and  antitoxins  act. 

The  Persistence  op  Antitoxin  in  the  Blood. — 
About  five  days  after  the  absorption  of  toxin  has 
Ceased,  either  after  a  natural  disease  or  after  an  arti- 
ficial infection,  the  production  of  antitoxin  in  the 
body  stops,  and  the  amount  in  the  blood  gradually 
ens,  partly  from  its  elimination  by  the  urine,  milk, 
and  partly,  perhaps,by  its  destruction  in  the  blood. 

The  blood  of  an  animal  highly  immunized  may 
retain  appreciable  amounts  of  antitoxin  for  from 
three  to  six  months. 

When  animals  are  immunized  with  the  antitoxic 
sera  of  animals  of  other  species,  the  antitoxin  is  much 
more  quickly  eliminated  than  when  sera  from  the 
species  are  employed.  For  this  reason  the 
immunizing  effect  of  sera  in  man  against  diphtheria, 
tetanus,  and  the  few  other  infections  for  which  we 
have  antitoxins,  is  of  quite  short  duration,  much  less 
than  if  antitoxins  had  been  developed  from  toxins 
injected.  Thus,  immunization  of  a  child  with  1,000 
units  of  antitoxic  horse  serum  insures  immediate 
safety,  but  only  ten  days  of  certain  protection  from 
diphtheria  or  tetanus. 

The  diphtheria  and  tetanus  antitoxins  are  the  only 
two  used  extensively  in  treatment.  All  the  other 
protective  -era  are  largely  bactericidal  in  their  action 
and  owe  what  value  they  have  to  this  characteristic. 
The  most  important  of  them  will  be  touched  upon  in 
the  article  on  immunity,  under  the  bactericidal  prop- 
5  of  the  blood. 

The  use  of  antitoxins  in  the  prevention  and  treat- 
ment of  diphtheria  and  tetanus  is  so  important  that 
some  details  as  to  how  to  choose  and  administer  the 
sera  may  be  of  value.  All  antitoxic  sera  must  be 
injected  subcutaneously,  or  intravenously,  for  they 
are  only  very  slightly  absorbed  by  the  stomach  or 
intestines.  The  sera  should  be  clear  and  have  no 
odor  except  in  cases  in  which  an  antiseptic  has  been 
added,  such  as  trikresol  or  carbolic  acid.  Let  us  now 
sider  in  detail  the  diphtheria  antitoxic  serum. 
The  dosage  is  regulated  by  units  of  effect  and  not  by 
weight,  for  we  have  nofr  as  yet  absolutely  isolated 
antitoxin.  A  unit  is  the  amount  of  antitoxin  which 
protects  a  250-gram  guinea-pig  from  about  100  fatal 
doses  of  diphtheria  toxin.  Toxins  produced  in  differ- 
ent ways  are  found  to  vary  in  their  relative  toxic  and 
neutralizing  forms.  In  Hygienic  Laboratory  of  the  U. 
S.  Public  Health  and  Marine-Hospital  Service  sup- 
plies a  standardized  toxin  to  be  used  by  the  different 
producers. 


Diphtheria   antitoxic   serum    is   put   up   in    dill,  tent 

"grades,"  the  lower  grades  having  800  to  1,000  units 
i  n  each  cubic  cen  timet  er(jf  globulin  solution,  the  higher 
grades  having    1,400   to  2,000  units.     Other   things 

being  equal,    the    higher  grades  are    better  and    more 

convenient   than  the  lower  ones.    Thi    concentration 

should  be  of  antitoxin  and  not  of  proteins,  for  thick 
sera  do  not,  absorb  as  quickly  as  when  more  diluted. 

The   Amount  of   Diphthebia    Antitoxin   to   be 

VdMINISTJ   10   D    k.ND  THI      \  I    MBEE  OF    [NJECTIONS  IN   A. 

Single  Case.     Therei    -till   ome  difference  of  opinion 

a ng  competent  observers  as  to  the  answer  to  the  B 

questions.  For  immunization,  500  units  in  infants 
and    1,000  in  adults  will  suffice.     In  treatment,  our 

practice  is  the  following:  Cases  seen  early,  in  which 
the  onset  is  mild,  2,000  units.  Cases  seen  early,  in 
which  the  onset  is  severe,  shown  either  by  local  sign-, 
such  as  swelling,  hyperemia,  or  the  extent  of  the 
exudate,  Or  by  constitutional  symptoms,  10,000  to 
20,000  units,  according  to  severity.  Cases  -ecu  after 
the  disease  has  progressed  so  far  that  its  probable 

local  extent  can  be  guessed,  mild  case-,  2,000  to  5,000 
units,  according  to  the  size  of  the  patient;  moderate 
cases,  3,000  to  5,000  units;  severe  cases,  showing 
necrotic  membrane,  swollen  glands,  or  laryngeal  sten- 
osis, 10,000  to  20,000  units.  For  these  severe  cases 
the  antitoxin  should  be  warmed  to  body  heat  and  then 
injected  intravenously. 

The  effects  to  be  expected  from  the  antitoxin  are, 
that  the  local  disease  should  not  extend,  that  the 
swelling  and  hyperemia  should  lessen  and  the  constitu- 
tional symptoms  abate.  If  twenty-four  hours  after 
the  injection  these  changes  have  not  begun  clearly  to 
manifest  themselves,  the  injection  of  antitoxin  should 
be  repeated.  The  extent  of  the  disease,  rather  than 
the  size  of  the  patient,  guides  the  dose;  still  size  should 
be  considered,  as  the  concentration  in  the  blood  is  of 
course  in  proportion  to  the  size.  When  antitoxin  is 
injected  subcutaneously  it  is  absorbed  very  slowly. 
At  the  end  of  twenty-four  hours  not  more  than  one- 
half  has  been  absorbed.  When  given  intravenously 
the  whole  amount  becomes  immediately  available. 
Second  injections  are  not  usually  required  if  the  full 
sized  initial  dose  is  given.  Larger  amounts  of  serum 
are  advised  by  some.  There  is  no  objection  in  giving 
more  except  for  the  expense.  With  the  serums  as  now 
used,  these  large  doses  have  produced  in  a  small 
percentage  very  disagreeable  results,  namely,  rashes, 
fever,  and  in  a  few  joint  inflammation. 

Whether  some  samples  of  serum  may  or  may  not 
cause,  along  with  their  beneficial  effects,  really  serious 
deleterious  effects,  is  still  undetermined;  but  we  do 
know  that  many  samples  of  serum  produce  practically 
not  even  disagreeable  effects.  Thus.  I  have  seen 
sixty  cases  treated,  with  only  one  rash.  Serum  as 
such  is  rarely  given,  but  instead  a  solution  of  globulins. 
Banzhaf,  Gibson  and  Atkinson  finally  succeeded  in 
eliminating  from  the  antitoxin  all  the  serum  constitu- 
ents except  a  portion  of  the  globulins.  Although 
rashes  occasionally  follow  the  injection  of  the  anti- 
toxic globulins  they  are  much  less  frequent  than  from 
the  whole  serum. 

The  Production  of  Diphtheria  Antitoxin  for 
Therapeutic  Purposes. — As  a  result  of  the  work 
of  years  in  the  laboratories  of  the  Health  Department 
of  New  York  City  the  following  may  be  laid  down  as  a 
practical  method: 

The  strongest  diphtheria  toxin  possible  should  be 
obtained  by  taking  a  very  virulent  culture  and  grow- 
ing it  in  slightly  alkaline  two-per-cent.  peptone 
bouillon.  The  culture,  after  a  week's  growth,  is  to 
be  removed,  and,  after  it  has  been  tested  for  purity  by 
microscopical  and  culture  tests,  is  then  to  be  rendered 
sterile  by  the  addition  of  ten  per  cent,  of  a  five-per- 
cent, solution  of  carbolic  acid.  On  the  following  day 
the  sterile  culture  is  filtered  through  ordinary  sterile 
filter  paper  and  stored  in  full  bottles  in  a  cold  place 

4S7 


Antitoxins 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


until  needed.  Its  strength  is  then  tested  by  giving  a 
series  of  guinea-pigs  carefully  measured  amounts. 
The  horses  used  should  be  young,  vigorous,  of  fair 
size,  and  absolutely  healthy.  A  number  of  such 
horses  are  severally  injected  with  an  amount  of  toxin 
sufficient  to  kill  1,000  guinea-pigs  of  250  grams 
weight.  After  from  two  to  three  days,  so  soon  as 
the  fever  reaction  has  subsided,  a  second  subcutaneous 
injection  of  a  slightly  larger  dose  is  given.  With  the 
first  three  injections  of  toxin  about  1,000  units  of 
antitoxin  are  given.  If  antitoxin  is  not  mixed  with 
the  first  doses  of  toxin,  only  one-tenth  of  the  doses 
advised  is  to  be  given.  At  intervals  of  from  two  to 
three  days  increasing  injections  of  pure  toxin  are 
made,  until,  at  the  end  of  two  months,  from  ten  to 
twenty  times  the  original  amount  is  given.  There 
is  absolutely  no  way  of  judging  which  horses  will 
produce  the  highest  grades  of  antitoxin.  Upon  a 
very  rough  estimate  I  may  say  that  those  horses 
which  are  extremely  sensitive  and  those  which  react 
hardly  at  all  are  the  poorest,  but  even  here  there  are 
exceptions.  The  only  way,  therefore,  is  at  the  end 
of  six  weeks  or  two  months  to  bleed  the  horses  and 
test  their  serum.  If  only  high-grade  serum  is 
wanted,  all  horses  that  give  less  than  150  units  per 
cubic  centimeter  are  discarded.  If  moderate  grades 
only  are  desired,  all  that  yield  100  units  may  be 
retained.  The  retained  horses  receive  steadily 
increasing  doses,  the  rapidity  of  the  increase  and  the 
interval  of  time  between  the  doses  (three  days  to  one 
week)  depending  somewhat  on  the  reaction  following 
the  injection,  an  elevation  of  temperature  of  more 
than  3°  F.  being  undesirable.  At  the  end  of  three 
months  the  antitoxic  serum  of  all  the  horses  should 
contain  over  200  units,  and,  in  about  ten  per  cent., 
as  much  as  600  units,  in  each  cubic  centimeter. 
Very  few  horses  ever  give  above  1,000  units,  and 
none  so  far  has  given  as  much  as  2,000  units  per 
cubic  centimeter.  The  very  best  horses  continue  to 
furnish  blood  containing  a  large  amount  of  antitoxin 
for  several  months,  and  then,  in  spite  of  increasing 
doses  of  toxin,  the  amount  of  antitoxin  gradually 
decreases.  If  every  nine  months  an  interval  of  three 
months'  freedom  from  inoculations  is  given,  the  best 
horses  furnish  high-grade  serum  for  from  two  to  four 
years.  The  toxin  injected  at  one  time  should  be 
divided  into  five  or  six  portions  so  as  to  reach  more 
tissue  and  lessen  the  liability  to  abscess. 

The  Production  of  Tetanus  Antitoxin. — The 
tetanus  antitoxin  is  developed  in  the  same  manner 
as  the  diphtheria  antitoxin — by  inoculating  the 
tetanus  toxin  in  increasing  doses  into  horses.  The 
toxin  is  produced  in  bouillon  cultures  grown  anaero- 
bically.  After  ten  or  fifteen  days  the  culture  fluid 
is  filtered  through  porcelain,  and  the  germ-free 
filtrate  is  used  for  the  inoculations.  The  horses 
receive  0.5  c.c.  as  the  initial  dose  of  a  toxin  of  which 
1  c.c.  kills  250.000  grams  of  guinea-pigs,  and  along 
with  this  a  sufficient  amount  of  antitoxin  to  neu- 
tralize it.  The  antitoxin  is  added  to  the  first  few- 
doses.  In  five  days  this  dose  is  doubled,  and  then 
every  five  to  seven  days  larger  amounts  are  given. 
The  dose  is  increased  as  rapidly  as  the  horses  can 
stand  it,  until  they  support  700  to  S00  c.c.  or  more 
at  a  single  injection.  After  some  months  of  this 
treatment  the  blood  of  the  horse  contains  the  anti- 
toxin in  sufficient  amount  for  therapeutic  use. 
When  the  animals'  temperatures  are  normal  and 
they  have  recovered  from  the  dose  of  toxin  last- 
given,  they  are  bled  into  sterile  flasks  and  the  serum 
collected. 

Technique  op  Testing  Tetanus  Antitoxic 
Serum  for  Value  in  Antitoxin. — Tetanus  anti- 
toxin is  tested  exactly  in  the  same  manner  as  diph- 
theria antitoxin,  except  that  the  unit  of  measure  is 
different.  A  unit  by  the  U.  S.  standard  is  the  amount 
of  antitoxin  which  will  neutralize  1,000  fatal  doses 

488 


of  a  standard  tetanus  toxin.  A  350-gram  guinea- 
pig  is  used  as  the  test  animal.  A  unit  in  the  German 
standard  is  the  amount  of  antitoxin  needed  to  neu- 
tralize 4,500,000  fatal  doses  of  toxin  for  1  gram  of 
white  mouse.  In  the  French  method  the  amount  of 
antitoxin  which  is  required  to  protect  a  mouse  from 
a  dose  of  toxin  sufficient  to  kill  in  four  days  is  deter- 
mined, and  the  strength  of  the  antitoxin  is  stated  by 
determining  the  amount  of  serum  required  to  protect 
1  gram  of  animal.  If  0.001  c.c.  protected  a  10-gram 
mouse,  the  strength  of  that  serum  would  be  1  to 
lo.ooo.  Guinea-pigs  are  frequently  used  in  place 
of  mice.  Knorr's  method  of  preserving  toxin  is  by 
precipitating  it  with  saturated  ammonium  sulphate 
and  drying  and  preserving  the  precipitate  in  sealed 
tubes.  As  required,  it  is  dissolved  in  ten-per-cent. 
salt  solution,  as  above  stated.  For  small  testing 
stations  the  best  way  is  to  obtain  some  freshly  stand- 
ardized antitoxin  and  compare  serums  with  this. 

The  Dosage  of  Tetanus  Antitoxin. — For  im- 
munization, one  dose  of  1,500  units  U.  S.  standard 
is  given.  This  will  suffice  unless  the  danger  seems- 
great,  when  the  injection  is  repeated  at  the  end  of  a 
week.  For  treatment,  an  intravenous  injection  of 
15.000  to  20,000  units  should  be  given,  according  to 
the  severity  of  the  case.  Not  a  moment's  unneces- 
sary delay  should  be  allowed.  In  the  gravest  cases  ao 
curative  effect  will  be  noticed  from  the  use  of  the 
serum,  but  in  many  moderately  severe  cases  it  is 
very  beneficial.  The  symptoms  cease  to  grow  worse 
and  then  gradually  lessen.  It  is  sometimes  injected 
into  the  spinal  canal,  the  lateral  ventricles,  or  even 
into  the  brain  substance.  Both  the  theoretical  rea- 
sons for,  and  the  actual  results  obtained  from,  this 
method  of  treatment  are  open  to  criticism.  The 
first  dose,  in  severe  cases,  should  be  given  intra- 
venously, but  if  for  any  reason  the  physician  hesitates 
to  give  it  in  this  way  it  should  be  given  subeutane- 
ously,  rather  than  allow  of  delay.  It  is  well  to  give 
5,000  to  10,000  units  daily  until  the  symptoms 
markedly  abate  so  as  to  keep  up  the  antitoxin  con- 
tent of  the  blood.  William  H.  Park. 


Antitrypsin. — Blood  serum  contains  a  substance, 
called  antitrypsin,  which  is  able  to  neutralize  the 
action  of  trypsin.  The  expression  of  the  quantity  of 
antitrypsin  thus  contained  is  called  the  antitryptie 
index  or  titer  of  the  serum.  There  are  two  methods 
for  the  determination  of  this  index.  One,  that  of 
Jochmann  and  M  tiller,  depends  upon  the  digestive 
action  of  trypsin  on  serum  albumin.  Loefner's  blood 
serum  plates  are  used  and  the  time  necessary  is  about 
twenty-four  hours.  This  method  will  give  results  of 
only  relative  value.  The  incubation  is  carried  out  at 
55°  C,  which  is  higher  than  the  optimum  tempera- 
ture for  tryptic  action.  The  variability  of  the  reac- 
tion and  composition  of  the  serum,  the  method  of 
measurement  by  loopfuls,  and  the  possibility  of 
bacterial  contamination,  all  may  prove  sources  of 
error.  The  other  method,  introduced  by  Gross  and 
Fuld,  is  much  more  exact.  It  is  based  upon  the  diges- 
tion of  a  clear  casein  solution  and  the  precipitation 
by  acid  of  any  casein  remaining  undigested  at  the 
end  of  the  period  of  incubation.  Citron  thus  de- 
scribes the  performance  of  the  test. 

The  casein  solution  is  made  up  by  dissolving  one 
gram  of  casein  in  100  c.c.  of  A'/ 10(decinormal  solution) 
NaOH,  neutralizing  with  A'/iO  HC1,  using  litmus,  and 
diluting  to  500  c.c.  with  physiological  salt  solution. 
The  trypsin  solution  is  prepared  by  dissolving  0.5  gm. 
of  trypsin  in  50  c.c.  of  NaCl  and  0.05  c.c.  of  normal 
sodium  hydrate  solution  and  diluting  with  physiolog- 
ical salt  solution  up  to  500  c.c.  The  acid  solution 
consists  of  5  c.c.  of  acetic  acid  with  45  c.c  of  alcohol 
and  50  c.c.  of  water. 

The  trypsin  solution  is  first  titrated.     "Gradually 


REFERENCE    EANDBOOK    "1     THE    MEDICAL   SCIENCES 


increasing  amounts  of  trypsin  (from  0.1  to  0.6  c.c. 
are  placed  into  six  test-tubes  and  to  each  2.0  <■.<■.  oi 
casein  solution  is  added.  These  tubes  are  placed 
In  an  incubator  at  37c  C.  for  one-half  hour,  and  then 
several  drops  of  acid  soution  are  placed  into  each 
tube.  The  first  tube,  and  all  of  those  above  it  that 
n't. iain  absolutely  clear,  contain  enough  trypsin 
fully  i"  digest  the  2.0  c.c.  of  casein."    For  the  test 

Itself: 

"Into  each  of  eighl  to  ten   test-tubes,  are  placed 

2 c.c.  of  the  casein  solutionand  0.5  c.c.  of  a  two-per- 
cent, dilution  of  the  serum  for  examination;  to  these  is 
next  added  the  trypsin  solution  in  successively  increas- 
ing amounts,  beginning  with  the  smallest  quantity 
which  in  the  first  part  of  the  test  was  sufficient  com- 
pletely to  digest  the  given  amount  of  casein.  Salt 
solution  is  then  added  to  each  of  the  test-tubes  so  that 
all  con  lain  an  equal  quantity  of  fluid,  and  the  mixtures 
arc  placed  into  an    incubator   at    37°    C.    for   one-half 

hour.     At  the  end  of  this  time,  several  drops  of  the 

acid  arc  added  to  each  tube.   Those  tubes  which  become 

cloudy  or  -how  a  precipitate,  designate  the  amounts 

vpsin  solution  which  have  been  neutralized  by  the 

C.  of  diluted  serum."  The  quantity  of  trypsin 
solution  in  the  first  tube  to  remain  clear  is  considered 
the  antitryptic  titer  of  the  serum.  That  is.  if  the  tubes 
containing  0.4,  0.5,  and  0.6  c.c.  of  the  trypsin  solution 
yield  a  precipitate  with  the  acid  and  those  with 0.7 
and  0.8  c.o.  remain  clear,  the  antitryptic  index  of  the 
serum  is  0.7. 

The  test  has  a  certain  amount  of  diagnostic  value. 
The  antitryptic  index  is  increased  in  from  seventy 
to  ninety-five  per  cent,  of  patients  suffering  with 
cancer,  also  frequently  in  acute  infections,  in  chronic 
Infections,  as  tuberculosis,  in  diabetes,  severe  anemias, 
and  in  Graves'  disease.  It  has  also  been  noted  in 
infants  on  the  inauguration  of  artificial  feeding  and 
in  pregnant  women  at  the  onset  of  labor.  It  evi- 
dently occurs  in  too  many  conditions  to  have  the 
value  of  a  specific  symptom,  but  on  the  other  hand 
it  has  a  distinct  negative  value.  A  low  index,  for 
instance  would  be  a  good  argument  against  the 
diagnosis  of  cancer. 

The  nature  of  antitrypsin  is  but  little  understood. 
It  is  probably  not  a  highly  .specific  immune  body,  but 
on  the  other  hand  it  is  almost  certainly  not  a  non- 
ific  antiferment.  It  will  act  only  in  the  presence 
of  lipoids.  Weil  concludes  that  "the  antitryptic 
function  is  exercised  by  an  albuminous  substance, 
thermolabile,  indeed,  like  the  true  antibodies,  but 
differing  essentially  from  these  in  the  lack  of  speci- 
ficity." The  normal  antitrypsin  probably  is  entirely 
distinct  from  that  produced  in  the  body  following 
the  injection  of  trypsin.  The  theory  of  its  origin  is 
that  it  is  produced  by  the  body,  stimulated  to  that 
effect  by  the  presence  in  the  blood  of  a  certain  amount 
of  trypsin,  which  latter  is,  in  part  at  least,  a  secretion 
of  the  polynuclear  leucocytes.  In  fact,  in  infections 
there  is  a  definite  relation  between  the  antitryptic 
index  and  the  polynuclear  leucocytosis.  In  cancer 
this  ferment  may  very  conceivably  be  produced  by 
the  cancer  cells.  At  the  present  time,  however,  the 
proved  facts  as  to  the  chemical  and  biological  nature 
of  antitrypsin  are  so  few  that  no  definite  statements 
can  be  made  concerning  them. 

Ralph  G.  Stillman. 

Anuria. — By  this  term  (derived  from  a-privative 
and  oipon,  urine)  is  understood  a  total  suppression 
of  the  secretion  of  urine.  It  is  to  be  distinguished 
from  retention  of  urine,  in  which  the  kidneys  are 
performing  their  function,  but  through  atony  of  the 
bladder,  spasm  of  the  vesical  sphincter,  enlarged 
prostate,  or  calculous  impaction  or  stricture  of  the 
ureters  or  urethra,  no  urine  is  passed;  and  from 
oliguria  (iklyos,  little,  and  ofrpov,  urine)  in  which 
the    secretion    is    greatly    diminished,    though    not 


entirely  suppressed,  the  very  -mall  amount  formed 
being  retained  for  a  long  time  in  the  bladder  until 
this  viscus  is  sufficiently  distended  to  excite  the 
urinary  reflex.  Anuria  occurs  rarely  in  uremic 
attacks  accompanying  acute  nephritis,  in  conditions 
in  which  there  is  extreme  loss  of'  fluids  through  the 
other  emunctories,  as  in  cholera,  colliquative  diarrhea, 
profuse  vomiting,  etc..  and  sometimes  in  hysteria. 

ahus.   Diseases  of  the.     See    R  '   Anus, 

!>.■■■ 

Anytin  i-  a  derivative  of  ichthyol  introduce, 1  by 
TJnna  in  dermatological  practice.  It  is  a  thirty-three- 
per-cent.  aqueous  solution  of  sulphoichthyolic  acid 
and  the  aromatic  oily  sulpho-compound  contained  in 
ichthyol.  Dark  brown  in  color,  if  contains  l(i..j  per 
cent,  of  sulphur  and  4.5  per  cent,  of  ammonium.  It 
is  decomposed  by  acids  and  strong  alkalies,  and 
possesses  the  peculiar  property  of  rendering  such 
sub-tances  as  phenol,  guaiacol,  cresol,  camphor,  etc., 
freely  soluble  in  water.  These  solutions  are  called 
"anytols"  and  promise  to  be  valuable  additions 
to  our  antiseptic  materia  medica.  Koelzer  used  a 
7.5-per-cent.  aqueous  solution  of  metacresol  anytol 
(metacresol,  forty  per  cent.)  in  erysipelas.  By 
painting  it  on  frequently  over  an  area  extending  some- 
what beyond  the  inflammation  he  obtained  a  good 
result  in  every  case.  These  anytols,  especially  those 
of  phenol  and  cresol,  may  be  used  in  five-  to  ten-per- 
cent, dilution  for  disinfection  of  the  hands  or  for 
vaginal  or  intrauterine  douches.  They  then  have 
much  the  same  effect  as  creolin. 

Anytin  itself  is  capable  of  setting  up  an  active 
dermatitis,  but  diluted  to  ten  per  cent,  it  is  very 
useful  in  chronic  eczema,  sunburn,  ami  ivy  poison- 
ins.  It  is  stated  to  be  directly  antagonistic  to  the 
diphtheria  bacillus.  W.  A.   Bastedo. 

Aorta. — From  the  Greek,  aoprr/,  from  aeipeh,  to  lift,  to 
carry.  Synonyms. — Arteria magna  (Harvey);  haemal 
axis  lOwen).  French,  aorte;  German,; grosse  Schlagarlcr. 
Originally,  in  the  plural,  aortae  iaoprai)  signified  the 
bronchial  tubes  (Hippocrates). 

Definition-.- — The  main  trunk  (single  in  mammals 
and  birds,  double  in  cephalopods  and  most  reptiles, 
triple  in  the  crustaceans)  of  the  systemic  arterial 
system,  by  means  of  which  the  oxygenized  blood  is 
carried  to  all  parts  of  the  body. 

Embryology. — According  to  Gibson,  "the  single 
median  tube,"  which  is  seen  at  one  stage  in  the 
development  of  the  vascular  apparatus,  begins  to 
pulsate  before  the  appearance  of  either  muscular  or 
nervous  elements.  "The  heart  movements  must  be 
due  to  some  as  yet  unknown  indwelling  property  of 
the  embryonic  heart  tissue."  In  the  development 
of  the  embryo  there  are  two  primitive  aorta1.  These 
unite  early,  and  to  them  four  lateral  pairs  are  succes- 
sively added,  and  all  develop  into  the  artery  seen  at 
birth — the  aorta  and  its  branches. 

Anatomy. — The  aorta,  although  the  main  arterial 
trunk,  is  at  its  commencement  generally  a  little  smaller 
than  the  pulmonary  artery,  but  in  the  aged  it  is  usually 
slightly  larger  than  that  vessel.  Its  position,  like  that 
of  other  arteries,  is  protected  in  proportion  to  its 
importance.  It  takes  its  origin  from  the  upper  part 
of  the  left  ventricle,  extending  upward  and  to  the 
left  for  a  short  distance;  then  curving  over  the  root 
of  the  left  lung,  it  descends  in  front  of  the  spinal 
column,  passing  through  the  aortic  opening,  hiatus 
aorticus,  which  is  in  the  middle  line  behind  the 
diaphragm,  and  which  also  transmits  the  vena  azy- 
gos  major,  the  thoracic  duct,  and  occasionally  the  left 
sympathetic  nerve.  The  vessel  descends  to  the  left 
side  of  the  fourth  lumbar  vertebra,  where  it  termi- 
nates, dividing  into  the  right  and  left  common  iliac 

4S9 


Aorta 


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arteries.  In  its  course  it  gradually  decreases  in  size 
from  twenty-eight  to  seventeen  millimeters,  giving  off 
at  different  points  branches  of  varying  caliber. 
Quain  divides  this  artery  into  the  ascending  aorta,  the 
part  within  the  pericardium;  the  arch,  that  part 
extending  backward  from  the  pericardial  limit  to  the 
spine  at  the  lower  margin  of  the  fourth  thoracic  verte- 
bra; the  descending  thoracic  aorta,  from  this  point  to  the 
diaphragm,  and  the  abdominal  aorta,  the  part  below 
the  diaphragm.  This  method  of  division  is  founded 
on  the  fact  that  the  first  part  is  intrapericardial  and 
has  its  origin  from  the  fetal  aortic  bulb;  while  the 
third  part  of  that  section,  which  was  formerly  known 
as  the  arch,  does  not  differ  in  relation,  direction,  or 
origin  from  the  rest  of  the  descending  portion.     The 

2     3  4  5  678     9  10  11  12      13 


Fig.  257. — Anterior  View  of  the  Great  Vessels  of  the  Heart. 
(From  His's  "Handatlas  der  Anatomie  des  Mensehen.")  1.  First 
rib;  2,  subclavian  vein;  3.  subclavian  artery;  4,  internal  jugular 
vein;  5,  right  branch  of  pulmonary  artery;  6,  vena  azygos;  7. 
inferior  thyroid  vein;  8,  left  innominate  vein;  9,  trachea;  10,  arch 
of  aorta;  11,  ductus  arteriosus;  12,  left  pulmonary  artery;  13, 
subclavian  vein;  14,  right  lung;  15,  right  pulmonary  veins;  1»>, 
vena  cava  superior;  17,  left  atrium;  IS,  ascending  aorta;  19, 
pulmonary  artery;  20,  left  pulmonary  veins;  21,  left  lung. 

older  anatomists  treated  the  arch  as  consisting  of  three 
parts — the  ascending,  transverse,  and  descending,  and 
comprising  that  part  of  the  artery  found  between  its 
ventricular  origin  and  the  lower  border  of  the  fifth 
dorsal  vertebra.  This  latter  division  seems  far  less 
logical  than  the  former  according  to  the  reasons  ju-t 
given.  The  first  parts  of  both  the  aorta  and  the 
pulmonary  artery  are  regarded  embryologieally  as 
parts  of  the  heart. 

Ascending  Aorta. — The  ascending  aorta  springs 
from  the  upper  and  fore  part  of  the  left  ventricle  on  a 
level  with  the  lower  border  of  the  third  costal  cartilage 
behind  the  left  half  of  the  sternum.  It  passes  up- 
ward, forward,  and  to  the  right  in  a  line  with  the 
heart's  axis  till  it  reaches  the  upper  border  of  the 
sternum,  at  which  point  its  direction  changes  and  the 
arch  begins.  The  ascending  aorta  measures  about 
two  inches  or  two  inches  and  a  quarter  in  length,  and 
it  curves  upward,  backward,  and  to  the  left.  Just 
ab.,\  ,■  its  origin  this  part  of  the  aorta  shows  externally 
three  -mall  dilatations  of  about  the  same  size,  known 

490 


as  the  sinuses  of  the  aorta  or  sinusi  s  of  Valsalva.  ( fne 
of  these  sinuses  is  anterior,  the  other  two  posterior. 
The  anterior  and  left  posterior  give  origin  to  the  two 
coronary  arteries  of  the  heart.  Opposite  to  these 
three  sinuses  are  the  semilunar  valves.  A  cross 
section  of  the  vessel  at  this  point  is  rather  triangular 
in  form,  while  below  the  valves  it  is  circular.  At  the 
commencement  of  the  arch  and  along  the  right  side  of 
the  ascending  aorta  there  is  generally  found  another 
bulging,  the  great  sinus  of  the  aorta.  Now  and  then 
this  sinus  is  not  present.  It  is  seen  more  distinctly 
in  the  aged.  The  fibrous  pericardium  embraces 
the  whole  length  of  the  ascending  aorta,  while  a  tube  of 
serous  membrane  extends  up  from  the  cardiac  surface 
to  invest  this  vessel  together  with  the  pulmonary 
artery,  except  where  they  are  in  contact  with  each 
other. 

Relations.- — At  its  commencement  the  ascending 
aorta  is  covered  anteriorly  by  the  pulmonary  artery 
and  the  right  auricular  appendix.  Higher  up,  the 
directions  of  these  vessels  diverge,  the  aorta  passing 
forward  and  to  the  right  and  the  pulmonary  artery 
backward  and  to  the  left.  At  this  point  the  aorta 
closely  approaches  the  sternum,  being  separated 
from  it,  however,  by  the  pericardium,  the  right 
pleura,  the  narrow  part  of  the  anterior  mediastinum, 
the  anterior  edge  of  the  right  lung,  besides  a  little  fat 
and  areolar  tissue,  as  well  as  the  remains  of  the  thymus 
gland.  Posteriorly  are  the  left  cardiac  auricle  and  the 
right  pulmonary  artery.  At  its  right  are  the  right 
auricle  and  the  superior  vena  cava.  On  the  left  is  the 
main  pulmonary  artery. 

Branches. — The  ascending  aorta  has  two  branches 
only,  the  right  and  left  coronary  arteries.  These 
vessels,  relatively  small,  spring  generally  from  that 
part  of  the  vessel  which  is  just  above  the  free  margin 
of  the  semilunar  valves,  in  the  upper  part  of  the  two  sin- 
uses of  Valsalva,  and  they  supply  the  heart.  The 
right  coronary  artery  is  about  the  size  of  a  crow  's 
quill,  while  the  left  is  somewhat  larger. 

Variations. — The  ascending  aorta  and  pulmonary 
artery  may  be  transposed,  i.e.  the  former  may  rise 
from  the  right  ventricle  and  the  pulmonary  artery 
from  the  left.  There  may  be  a  communication  be- 
t  w  cen  these  two  arteries  by  abnormal  openings.  One 
may  be  wholly  or  partly  obliterated,  while  the  other 
selves  as  a  passageway  for  the  blood  of  both  by 
means  of  communications  between  them.  There  is 
now  and  then  seen  one  simple  tube  connected  with  a 
simple  heart  like  that  in  fishes.  ,  Sometimes  the  coro- 
nary vessels  arise  by  a  common  trunk,  or  at  times 
from  the  same  sinus  of  Valsalva.  As  many  as  four 
arteries  have  been  observed,  in  which  case  the  sup- 
plementary vessels  are  smaller  than  normal  and  play 
the  part  of  branches  of  the  main  coronary  trunk, 
near  which  they  take  their  origin.  An  extra  coro- 
nary has  even  had  its  origin  in  the  pulmonary  artery. 
When  one  of  the  arteries  is  unusually  small,  the  other 
is  correspondingly  large  and  supplies  a  greater  area, 
especially  at  the  back  of  the  heart. 

Arch  of  the  Aohta. — The  arch  or  transverse 
aorta  begins  at  the  upper  margin  of  the  second  right 
costal  cartilage  at  the  right  border  of  the  sternum 
and  arches  around  the  trachea,  in  its  course  passing 
upward,  backward,  and  to  the  left  of  the  fourth 
thoracic  vertebra.  At  this  point  it  passes  downward, 
and  at  the  inferior  margin  of  this  vertebra  the  tho- 
racic aorta  begins.  The  arch  at  its  superior  border 
is  generally  about  an  inch  below  the  upper  margin 
of  the  sterum  in  the  median  plane. 

Relations. — The  arch  of  the  aorta  is  situated  in  the 
superior  mediastinum,  and  is  covered  in  front  by 
the  pleurae  and  lungs,  and  the  fatty  remnant  of  the 
thymus  gland.  ()n  the  left  it  is  crossed  by  the  left 
pneumogastric  and  phrenic  and  the  superior  cardiac 
branches  of  the  left  symphathetic  nerve  and  by  the  left 
superior   intercostal    vein,    while    the    left    recurrent 


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Aorta 


laryngeal  benda  upward  beneath  it.  Posteriorly  and 
to  the  right  lie  the  trachea,  the  deep  cardiac  plexus, 
the  lefl  recurrent  laryngeal,  the  esophagus,  the  tho- 
racic duct,  and  the  body  of  the  fourth  dorsal  verte- 
bra. The  anterior  part  of  the  upper  margin  of  the  arch 
is  in  contact  with  the  left  innominate  vein,  and  gives 
a  to  the  large  arteries— innominate,  left  caro- 
tid, and  left  subclavian  —which  supply  the  head  and 
upper  limbs.  The  border  is  just  above  the  left  bron- 
chus and  the  bifurcation  of  the  pulmonary  artery. 
and  is  joined  with  the  left  branch  of  that  vessel 
a  fibrous  cord,  representing  the  remains  of  the 
ductus  arteriosus,  which  is  connected  with  the  aorta 
just  beyond  the  origin  of  the  left  subclavian.  Be- 
tween the  arch  and  i  lie  bifurcation  of  the  pulmonary 
artery  are  found  the  superficial  cardiac  plexus  and  a 
few  large  bronchial  lymphatic  glands.  To  its  infe- 
rior, anterior  surface  the  fibrous  pericardium  is  at- 
tached. After  giving  off  its  branches,  the  arch  is  re- 
i    i  i     :  e   to  some  extent    (23   mm.).     There  is 


12 


.11 


—10 


8 
Fig.  258. — Arch  of  the  Aorta  with  its  Branches  (anterior  and 
from  the  left).  After  a  plaster-of-Paris  cast.  (From  His 's  "  Hand- 
ler Anatomie  des  Menschen,"  Band  ii.,  S.  387.)  1,  Right 
subclavian  artery;  2,  right  common  carotid;  3,  innominate  artery; 
4,  arch  of  aorta;  5,  ascending  aorta;  6,  bulbus  aorta-;  7,  right 
coronary  artery;  s.  sinuses  of  the  ai  irta  (  Valsalva);  9,  left  coronary 
artery;  10,  thoracic  aorta;  11,  aortic  spindle;  12,  aortic  isthmus; 
13,  left  common  carotid;  14,  left  subclavian  artery. 

often  seen  at  that  point  where  the  ductus  arteriosus 
is  attached,  a  constricted  part,  which  is  called  the 
aortic  isthmus.  The  isthmus  is  far  more  marked 
in  the  fetus  from  the  expan-ion  caused  by  the  open- 
ing of  the  ductus  arteriosus.  Beyond  comes  a  fusi- 
form dilatation  reaching  to  the  thoracic  and  called 
the  aortic  spindle  of  His. 

Branches. — The  aortic  arch  has  three  branches 
springing  from  its  upper  surface — the  innominate  or 
brachiocephalic  artery,  the  left  common  carotid,  and 
the  left  subclavian.  The  left  carotid  and  the  in- 
nominate arteries  are  generally  nearer  together  than 
the  left  carotid  and  the  left  subclavian.  These  ves- 
sels supply  the  head,  neck,  upper  extremities,  and 
part  of  the  thorax. 

I  arialions. — The  upper  limit  of  the  aorta  may  be 
found  in  some  subjects  as  high  as  the  third  thoracic 
bra,  at  the  level  of  the  top  of  the  sternum,  while 
in  others  it  is  as  low  as  the  fifth  thoracic.  Sometimes 
there  is  complete  lateral  transposition  of  the  aortic 
arch  and  pulmonary  artery  together  with  the  great 
veins  and  the  divisions  of  the  heart  (dextrocardia). 
This  abnormality  may  be  confined  to  these  parts  or 
may  embrace  all  the  viscera  (situs  inversus).  The 
aortic  arch  has  been  observed  to  be  completely 
double.     It  has  also  been  seen  to  pass  to  the  right  of 


the  trachea  and  esophagus  instead  of  t..  the  left,  and 
to  continue  its  downward  ci  'he  riL'ln   9ide 

mI'  the    pine..     I"  'his  case  the  three  branches  h 
an  arrangement  the  reverse  of  the  usual 

Variations  in  the  number  ami  position  of  the 
branches  of  the  arch  are  frequent.  There  may  be  only 
one  trunk,  or  there  may  be  fj i    i\  inclu 

Descending  Thoracic  Unn.  -  At  the  termina- 
tion of  the  arch,  at  the  lower  border  of  the  fourth 
thoracic  vertebra,  the  d<  cending  aorta  begins  at  d 
continues  down  along  the  -pine  to  the  fourth  lumbar 
vertebra,  where  it  divides  into  the  two  common 
iliac  arteries.  Its  direction  is  not  vertical,  for  as  it 
rests  against  the  spine  ii  rily  follows  the  spi- 

nal curve  .  being  concave  forward  in  the  dorsal  region 
and  convex  forward  in  the  lumbar,  As  it-  com- 
mencement is  to  the  left  of  the  spine  and  its  termina- 
tion nearly  in  the  median  line,  its  general  direction 

throughout  its  whole  length  is  inward,  this  being 
more  marked  in  its  upper  part.  The  lower  limit  of 
the  thoracic  aorta  is  the  hiatus  aorticus  at  the  level 
of  the  diaphragm.  This  part  of  the  aorta  is  from 
seven  to  eight  inches  long  and  is  contained  in  the  back 
part  of  the  posterior  mediastinum,  where  it  rests 
against  the  spine.  Its  branches  are  small,  and 
equently  its  diameter  is  little  diminished  (from 
23  to  21  mm.). 

Branches. — The  branches  of  the  descending 
thoracic  aorta,  though  numerous,  are  small.  They 
arc  the  pericardial,  bronchial,  esophageal,  posterior 
mediastinal,  and  intercostal. 

Variations. — Now  and  then  an  obliteration  of  the 
aorta  at  the  point  of  junction  of  the  arch  and 
thoracic  portion  is  observed  just  below  the  connection 
between  the  ductus  arteriosus  and  the  arch.  This 
condition,  known  as  coarctation  of  the  thoracic  aorta, 
results  in  the  establishment  of  an  interesting  collat- 
eral circulation.  Xot  infrequently  variations  in  the 
number  and  position  of  the  branches  of  this  section 
of  the  aorta  are  observed. 

Abdominal  Aorta. — This  name  is  given  to  the 
vessel  between  the  diaphragm  and  its  bifurcation 
into  the  two  common  iliac  arteries.  In  relation  to 
the  spinal  column  it  begins  about  the  lower  margin 
of  the  last  thoracic  vertebra  and  ends  at  a  point  about 
the  middle  of  the  fourth  lumbar  vertebra,  most 
g  inerally  slightly  to  the  left,  sometimes  almost 
exactly  in  the  median  line,  at  other  times  slightly 
to  the  right.  This  point  almost  corresponds  to  the 
level  of  a  line  drawn  between  the  two  iliac  crests  or 
to  a  point  just  below  and  to  the  left  of  the  umbilicus. 
In  length  it  is  about  five  inches.  As  its  branches 
are  both  numerous  and  large,  its  size  rapidly  di- 
minishes. As  mentioned  before,  its  curve  as  it 
rests  against  the  vertebrae  has  its  convexity  forward, 
being  most  prominent  at  the  third  lumbar  vertebra, 
slightly  above  and  to  the  left  of  the  umbilicus. 

Relations. — Anterior  to  the  abdominal  aorta  are 
the  lesser  omentum  and  stomach,  the  solar  plexus, 
splenic  vein,  pancreas,  left  renal  vein,  transverse 
duodenum,  mesentery,  aortic  plexus,  peritoneum, 
lymphatic  vessels  and  glands,  and  dense  areolar  tissue; 
posterior  to  it  are  the  bodies  of  the  vertebrae  and 
the  left  lumbar  veins,  the  thoracic  duct,  and  the 
cisterna  (receptaculum)  chyli.  On  the  right  are  the 
inferior  vena  cava,  right  crus  of  the  diaphragm,  vena 
azygos  (major),  thoracic  duct,  and  right  semilunar 
ganglion.  On  the  left  are  the  sympathetic  nerve  and 
the  left  semilunar  ganglion. 

Branches. — These  may  be  classified  under  two 
heads:  (1)  Visceral — celiac  axis  (gastric,  hepatic, 
splenic),  superior  mesenteric,  inferior  mesenteric, 
suprarenal,  renal,  and  spermatic  or  ovarian.  i2) 
Parietal — phrenic,  lumbar,  and  sacra  media.  The 
branches  of  the  aorta  mostly  pass  off  at  right  angles. 

Variations. — Instances  are  known  in  which  the  aorta 


491 


Aorta 


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| — -16 


—  15 


is  divided  by  a  septum  for  either  a  part  or  the  whole 

of  its  course,  so  that  two  closely  united  tubes  are  the 

resull.     Sometimes  this  condition  has  a  pathological 

foundation,  at  other  times 

M#>|  a .  21  it  is  due  to  an  embryological 

defect  in  the  fusion  of  the 
'20  double  fetal  aorta.  The 
19  vessel  has  been  known,  as 
iS  in  certain  quadrupeds,  to 
1 7  divide  into  an  ascending  and 
a  descending  branch,  the 
former  subdividing  into 
three  trunks  to  supply  the 
head  and  upper  extremities. 
The  abdominal  aorta  may 
vary  in  position  and  extent. 
Its  lower  limit  may  vary  to 
the  depth  of  a  lumbar  verte- 
14  bra,  so  that  its  bifurcation 
may  take  place  at  the  third, 
or  even  lower,  at  the  fifth. 
13  Its  deviation  from  the 
normal  position  with  refer- 
ence to  the  vertebral  column 
is  generally  due  to  patho- 
logical changes  rather  than 
to  congenital  causes.  Quain 
speaks  of  two  cases  of  a 
large  pulmonary  branch 
springing  from  the  aorta 
very  near  the  celiac  axis, 
which,  after  having  passed 
upward  through  the  esoph- 
ageal foramen  in  the  dia- 
Chragm,  separated  into  two 
ranches  and  entered  the 
lungs  near  their  bases.  Bal- 
four, in  writing  of  the  simu- 
lation of  aneurysm  by  mal- 
position of  the  aorta  due  to 
rickets,  says:  "In  rickety 
chests  the  aorta  may  be  so 
deflected,  without  any 
marked  dila.tation,  as  to 
make  its  pulsation  visible 
either  to  the  right  or  left  of 
the  sternum,  and  so  to  sim- 
ulate an  aneurysm.  It  is  of 
even  greater  consequence 
to  have  proof  that  in  certain 
comparatively  rare  cases  a 
similar  abnormal  pulsation 
may  be  due  to  a  trifling 
divergence  from  the  normal 
course  of  the  vessel  itself, 
apart  from  any  marked 
change  in  the  bony  skeleton. 
But  we  must  never  forget 
that  aortic  aneurysm  may 
coexist  with  malformation 
of  the  thorax  with  or  with- 
out scoliosis,  and  whatever 
may  be  the  condition  of 
the  skeleton,  any  abnor- 
mal pulsation  must  be  care- 
fully considered  from  every 
point  of  view  before  we 
are  able  to  give  any  defi- 
nite opinion  as  to  what  it 
really  is."  Virchow  has  pointed  out  the  relation 
of  the  reduction  in  size  of  the  aorta  to  chlorosis, 
and  he  named  the  condition  aorta  chlorotica.  Con- 
genital stenosis  of  the  aorta  is  seldom  seen.  Rosen- 
Bach  Iris  noted  this  condition  found  together  with 
hypert  rophy  of  the  heart.  It  may  cause  sudden  death, 
and  when  it  is  present,  otherwise  unimportant 
affections  may  assume  a  grave  aspect,  from  sudden 
untoward  cardiac  symptoms.     In  congenital  stenosis 


Fig.  259. — View  of  the 
Thoracic  and  Abdominal 
Aorta.  (From  Joessel- 
Waldeyer:  "  Lehrbuch  der 
Topographiseh  -  Chirurgi- 
schen  Anatomic ")  1.  Right 
common  carotid;  2,  innomi- 
nate artery;  3,  right  sub- 
clavian artery;  4,  right 
lymphatic  duct;  5,  right 
innominate  artery;  6,  su- 
perior vena  cava;  7,  pos- 
terior intercostal  glands; 
8,  vena  azygos;  9,  inferior 
vena  cava;  10,  right  lumbar 
lymphatic  duct;  11,  left 
lumbar  lymphatic  duct;  12, 
receptaculum  chyli;  13, 
thoracic  duct;  14,  posterior 
intercostal  glands;  15,  aorta; 
1G,  left  innominate  vein;  17, 
left  subclavian  vein;  IS,  left 
■subclavian  artery;  19,  mouth 
of  thoracic  duct;  20,  internal 
jugular  vein;  21,  left  common 
carotid. 


of  the  aortic  system,  a  striking  characteristic  is  the 
continuous  subnormal  temperature  present  in  infec- 
tious diseases  which  normally  show  a  high  temper- 
ature. In  women  this  condition  is  generally  asso- 
ciated with  infantile  uterus  and  other  signs  of  ar- 
rested development. 

Structure. — The  aorta  is  very  strong  and  elastic 
and  is  enclosed,  like  most  other  arteries,  in  a  sheath, 
which  has  more  connective  than  yellow  elastic  tissue, 
so  that,  when  cut,  the  vessel  shrinks  within  the 
sheath.  It  is  composed  of  three  coats — (1)  tunica 
Ultima;  (2)  tunica  media;  (3)  tunica  adventitia, 
The  internal  coat,  smooth  and  offering  but  little,  if 
any,  resistance  to  the  blood,  consists  of  three  layers 
(a)  Epithelial  layer  or  arterial  endothelium.  This 
is  made  up  chiefly  of  irregular,  flat,  polygonal  cells 
with  round  or  oval  nuclei  with  nucleoli.  (6)  Sub- 
epithelial layer,  which  is  well  marked  and  consists  of 
numerous  anastomosing  cells  resting  in  a  delicately 
fibrillated  ground  work  of  connective  tissue.  There 
are,  besides,  elastic  fibers  which  are  in  connection 
with  the  next  layer,  (c)  Elastic  layer,  which  forms 
the  principal  part  of  this  inner  coat.  Sometimes  this 
network  assumes  characteristics  which  have  caused 
it  to  be  designated  as  the  "perforated"  or  "fenes- 
trated" membrane  of  Henle.  At  times  it  is  rep- 
resented by  a  longitudinal  network  of  fibers.  The 
middle  coat  is  muscular,  consisting  of  bundles  of 
plain  muscle  fibers,  which  are  disposed  circularly 
around  the  vessel,  although  not  forming  a  complete 
ring.  These  fibers  contract  and  relax,  thus  changing 
the  caliber  of  the  vessel.  Elastic  fibers  are  also 
found  well  developed  in  this  tunic,  and  there  is  also 
considerable  connective  tissue.  This  coat  is  thicker 
than  the  corresponding  coat  in  other  arteries.  It  has 
also  relatively  more  elastic  tissue  and  less  muscular 
tissue  than  is  found  in  other  arteries.  The  external 
coat  consists  of  white  connective  tissue  and  elastic 
fibers.  The  connective-tissue  bundles  run  chiefly 
diagonally  around  the  vessel  and  connect  it  with  its 
sheath.     This  is  the  strongest  and  densest  coat. 

Vessels  and  Nerves. — Both  small  arteries  and  veins 
(xmsa  vasorum)  ramify  in  the  external  coat  of  the  aorta. 
They  serve  as  nutrient  vessels.  Ranvier  states  that 
in  health  in  the  human  subject  they  never  penetrate 
to  the  middle  coat.  The  inner  coat  is  thought 
to  be  nourished  by  the  blood  circulating  through  it. 
Alt  hough  the  aorta  is  supplied  by  nerves,  it  is  insensi- 
ble when  in  a  healthy  condition.  These  nerves  are 
chiefly  non-medullated.  The  finer  branches  are  dis- 
tributed chiefly  to  the  muscular  tissue  of  the  middle 
coat.  The  aorta  is  supplied  by  both  vasoconstrictor 
and  vasodilator  fibers.  Nerve  plexuses  are  formed 
around  the  vessel. 

Physiology.- — The  second  heart  sound,  short  and 
sharp,  occurs  just  at  the  closure  of  the  two  semilunar 
valves,  that  is,  immediately  after  the  end  of  ventric- 
ular systole.  This  sound  is  best  heard  over  the 
second  right  costal  cartilage  close  by  its  junction 
with  the  sternum.  At  this  point  the  aortic  arch  is 
nearest  to  the  surface,  and  here  sounds  generated 
at  the  aortic  orifice  are  best  transmitted.  The  sound 
is  due  to  the  vibrations  of  the  semilunar  valves  which 
are  made  tense  by  their  sudden  closure. 

The  sound  is  not  exclusively  of  aortic  origin  as  is 
instanced  in  those  cases  in  which  the  action  of  the 
semilunar  valves  on  the  two  sides  of  the  heart  is 
not  absolutely  simultaneous.  For  then  the  sound  is 
double  ("reduplicated  second  sound"),  one  due  to 
the  aorta,  the  other  to  the  pulmonary  artery.  A 
murmur  may  replace  the  normal  sound  when  the 
semilunar  veins  are  diseased. 

If  the  closure  of  pulmonary  and  aortic  valves  were 
absolutely  synchronous  the  second  sound  would  be 
shorter  and  sharper.  But  due  doubtless  to  local 
pressure  variations  that  sometimes  occur  in  the 
aorta   and   pulmonary   arteries,    the   closure   of  one 


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Aorta,  Diseases  <»f 


valve  may  lake  place  just  a  trifle  earlier  than  thai 
df  the  others.  The  sound  is  increased  by  the  trem- 
bling of  the  blood  column  set  in  vibration  by  the  ven- 
tricular systole  and  by  the  closure  of  the  valves  on 
the  sudden  passive  recoil  of  the  arterial  walls. 

Sudden  relaxation  follows  contraction  of  the  ven- 
tricles, intraventricular  pressure  falls.  The  pres- 
sure of  the  blood  column  as  it  tries  to  regurgitate 
closes  the  semilunar  valves,  the  central  orifice  is 
closed  by  the  corpora  Arantii,  and  both  aorta  and 
pulmonary  artery  are  cut  oil  from  the  heart. 

By  means  of  a  pair  of  elastic  manometers  or  by 
the  differential  manometer  the  pressure-curve  oi 
the  aorta  may  !»■  compared  with  thai  of  the  left 
ventricle  and  thus  may  be  determined  the  instant  at 
which  the  .semilunar  valves  open  and  close.  Tin 
closure  of  these  valves  is  estimated  to  occur  at  a 
period  corresponding  to  a  point  on  the  upper  portion 
of  the  descending  limb  of  the  intraventricular  curve. 
Clinically  speaking,  the  semilunar  valves  may  be 
said   to  close  "0.03  second   before   the  bottom  of  the 

aortic  notch  in  sphygmographic  tracings  from  (he 
carotid,  this  being  approximately  the  average  time 
taken  by  the  pulse-wave  in  traveling  from  the  aorta 
in  the  carotid."  At  the  abrupt  end  of  systole  when 
the  ventricular  outflow  ceases,  the  aortic  blood  col- 
umn continues  to  move  on  in  accordance  with  the 
law  of  inertia.  As  the  pressure  diminishes  there  is  a 
recoil  of  the  aortic  walls  behind  this  blood  column 
•  just  as  a  negative  wave  is  set  up  in  the  central  end 
of  the  elastic  tube  when  the  stroke  of  the  pump  is 
over."  Now  before  the  semilunar  valves  are  com- 
pletely closed  the  blood  is  forced  back  against  them 
under  the  combined  influence  of  lower  pressure  from 
relaxation  of  the  ventricular  muscle  and  diminished 
pressure  in  the  beginning  of  the  aorta.  The  valves  are 
ton  I'd  slightly  into  the  ventricular  cavity  and  a  neg- 
ative wave — "a  wave  of  diminished  pressure,  rep- 
resented in  the  pulse-curve  by  the  'aortic  notch' — 
travels  out  toward  the  periphery."  A  rebound 
quickly  follows  in  this  elastic  system  and  "the  re- 
coiling blood  meets  the  closed  semilunar  valves." 
Again  the  aorta  expands;  this  expansion  spreads 
throughout  the  arteries  and  is  known  as  the  dicrotic 
elevation. 

When  the  blood  pressure  within  the  contracting 
ventricles  exceeds  that  in  the  aorta  and  pulmonary 
artery  respectively,  the  closed  semilunar  valves  are 
burst  open  and  the  oncoming  blood  torrent  is  forced 
from  the  ventricles  into  these  arteries.  In  other 
words,  the  valves  open  when  the  pressure  below 
becomes  greater  than  that  in  the  arteries.  With  the 
distention  of  the  great  arteries  the  sinuses  of  Val- 
salva become  filled.  At  the  completion  of  ventricular 
systole  when  intraventricular  pressure  ceases  to  in- 
crease, the  passive  recoil  of  the  distended  walls  of  the 
arteries  forces  more  blood  into  the  sinuses,  thus 
pushing  together  the  cusps  of  the  semilunar  valves, 
and  aided  by  the  corpora  Arantii  they  entirely  ob- 
literate  the  openings. 

In  regard  to  the  relation  between  respiration  and 
blood  pressure,  it  may  be  said  briefly  that  unless 
the  respiratory  movements  are  very  shallow  a  record 
of  blood  pressure  gives  a  tracing  showing  waves 
that  are  synchronous  with  the  respiratory  move- 
ments. During  inspiration  the  aortic  pressure  rises. 
This  is  due  to  the  larger  output  of  blood  from  the 
heart.  During  expiration,  on  the  other  hand,  the 
reverse  occurs. 

The  arteries  are  always  somewhat  distended  with 
blood  but  with  each  cardiac  systole  from  two  to  four 
ounces  of  additional  blood  are  suddenly  forced  into 
the  already  distended  aorta.  With  ventricular 
diastole  the  aorta  recoils,  so  forcing  the  blood  for- 
wardin  a  steady  stream.  But  this  arterial  contrac- 
tion is  no  more  powerful  than  the  force  exerted  by 
the  heart  in  distending  the  artery.  Consequently 
the  force  propelling  the  blood  must  be  referred  to  the 


heart.  The  extra  aortic  distention  due  to  ventric- 
ular systole  gives  rise  lo  a   v\  a  \  e   in   the  blood   which 

is  transmitted  throughout  the  arterial  tubes.  This 
wave  as  felt  in  uperficial  arteries  is  known  a-  the 
pulse.     The  pulse  is  merely  a   wave  in   the  steady 

stream  of  blood,   for  tl (foci    of  an   ela    tie    tube  on 

an  intermittent  Bow  of  Quid  is  to  converi  it  practi- 
cally into  a  continuous  stream.  The  average  bio. id 
pressure  in  the  aorta  is  about  l"'ii  millimetei 

Emma  K.  Wai  k  i  r 


Aorta.     Diseases     of     the. — Congenital     Am 
tions:  (1)   Defects     «./'    Me     Aortic    Septum. — These 

result  from  failure  in  the  division  of  the  primitive 
aorta,  into  its  two  daughter  vessels,  the  aorta  and 
I  he  pulmonary  artery. 

In  both  its  complete  and  incomplete  forms,  this 

a  i aly  is  rare. 

The  complete  defect  known  as  persistent  truncus 
arteriosus  may  be  associated  with  absence  ..I  I  he  cardiac 
sept  uin,  but  in  all  cases  this  sepi  urn  is  deficient. 

The  truncus  may  in  Hie  latter  case  override  the 
septum,  receiving  blood  from  the  two  ventricles,  or 
may  spring  entirely  from  the  right  side,  in  which 
case  the  blood  from  the  left  enters  through  the 
septal  delect. 

The  pulmonary  blood-supply  may  arise  'near  the 
origin  of  the  main  trunk  or  may  come  off  at  the  site 
of  the  ductus  arteriosus. 

Partial  Defect  of  the  Aortic  Septum. — This  may 
take  the  form  of  an  opening  between  the  aorta  and 
pulmonary  artery  just  beyond  the  origins  of  the 
two  vessels,  or  a  communication  may  occur  between 
the  aorta  and  the  conus  arteriosus. 

(2)  Transposition  of  Aorta  and  Pulmonary  Artery. — 
This,  according  to  Abbott  after  Rokitansky,  may 
result  from  alteration  in  the  direction  of  the  aortic 
septum,  which  alteration  may  give  rise  to  a  number 
of  varieties  of  transposition. 

In  the  complete  form  the  aorta  arises  from  the 
right  and  the  pulmonary  artery  from  the  left  ventricle. 

Both  vessels  may  also  arise  from  one  ventricle, 
right  or  left,  or  again  both  may  arise  transposed 
from  a  common  ventricle. 

In  the  complete  form  of  transposition,  the  cir- 
culatory embarrassment  may  be  understood  when 
it  is  seen  that  venous  blood  from  the  right  heart 
passes  to  the  body  by  the  aorta  and  the  aerated 
blood  passes  from  the  left  heart  to  the  lungs  by  the 
pulmonary  artery.  Fortunately  there  is  nearly 
always  an  associated  defect  such  as  a  patent  foramen 
ovale  or  ductus  arteriosus  which  allows  of  mixing 
of  the  bloods. 

Cyanosis  appears  usually  within  a  few  weeks  of 
birth.     Clubbing  of  the  fingers  is  usual. 

The  cardiac  signs  are  inconstant  and  the  majority 
of  cases  die  before  the  second  year,  though  some 
have  reached  adult  life. 

(3)  Congenital  Narrowing  of  the  Aorta. — This  may 
be  (a)  Subaortic,  in  which  a  ring-like  thickening  occurs 
just  below  the  valves  which  becomes  the  seat  of  a 
chronic  inflammation  which  results  in  still  greater 
constriction. 

(6)  Stenosis  of  the  orifice  is  very  rare  and  is  ascribed 
to  fetal  endocarditis. 

(r)  Coarctation,  occurring  at  the  isthmus  near  the 
opening  of  the  ductus  arteriosus,  may  be  in  one  form 
developmental,  in  the  other  or  adult  type  an  abrupt 
strangling  of  the  aorta  by  the  presence  in  its  wall  of 
fibers  similar  to  those  in  the  ductus  itself,  which 
tends    to    contract    after    its    function    has    ceased. 

In  this  type  is  seen  the  excessive  development  of 
the  cephalic  vessels  and  atrophy  of  those  in  the  lower 
part  of  the  body  with  a  consequent  extensive  collat- 
eral circulation  between  them. 

(4)  Hypoplasia  of  the  Aorta. — This  affection,  in 
which  the  vessel  and  its  branches  are  small  of  caliber 


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and  thin  of  wall,  was  connected  by  Virchow  with 
chlorosis  and  by  others  with  a  tendency  toward  tu- 
berculosis  and   poor   resistance   to   other   infections. 

Cases  of  death  from  cardiac  disease  with  this  lesion 
as  a  cause  have  also  been  reported. 

On  the  other  hand,  Suter,  from  measurements  of 
2,719  cases,  considers  that  hypoplasia  as  such  has  no 
causal  relation  to  these  affections. 

(5)  Double  Aortic  Arch. — This  rare  anomaly  con- 
sists of  the  division  of  the  main  aortic  trunk  into  two 
branches  which  surround   the  trachea. 

The  posterior  branch  is  regarded  as  the  fourth 
right  arch  and  the  anterior  as  the  fourth  left  arch, 
which  join  to  form  the  descending  aorta  in  the  am- 
phibia (Abbott). 

Aortitis. — That  such  a  condition  as  aortitis  does  ex- 
ist is  nut  debatable,  but  concerning  the  place  it  should 
hold  as  a  clinical  entity  there  is  wide  difference  of 
opinion,  English  and  German  writers  looking  upon 
it  witli  distant  politeness,  while  the  French  embrace  it 
as  an  old  friend.  A  natural  conclusion  is  that  on  the 
one  hand  a  real  condition  may  often  be  overlooked,  or 
its  symptoms  attributed  to  some  other  cause,  while  on 
the  other  hand  the  early  stages  of  a  purely  regressive 
process  may  be  classed  as  an  inflammation. 

French  writers  divide  aortitis  into  three  groups: 
(a)  with  gelatiniform  plaques;  (b)  the  ulcerovegeta- 
tive  form;  (c)  suppurative  form. 

Concerning  group  (a)  with  gelatiniform  plaques, 
it  is  difficult  to  consider  this  as  other  than  an  early 
manifestation  of  the  intimal  proliferation  of  arterial 
sclerosis  and  not  a  true  inflammatory  process. 

(6)  The  vegetative  form  may  occur  alone  or  with 
valvular  vegetations.  Its  usual  seat  is  in  the  first 
part  of  the  ascending  aorta,  and  it  may  be  the  source 
of  embolus  or  the  seat  of  a  rupture  of  the  vessel. 

(c)  Suppurative  aortitis  is  practically  always 
associated  with  ulcerative  endocarditis;  the  inflam- 
mation commences  between  the  outer  and  middle 
coat  and  may  extend  like  a  dissecting  aneurysm  or 
may  rupture  into  the  lumen  of  the  vessel. 

Aortitis,  acute  or  subacute,  is  always  of  infectious 
origin  and  though  it  may  occur  in  the  previously 
healthy  vessel  it  more  readily  attacks  one  already 
atheromatous. 

Etiology. — It  may  occur  by  extension  from  tumors 
or  abscess  of  the  mediastinum  or  from  tracheal 
ulceration  or  in  the  course  of  the  infectious  fevers. 

Typhoid  fever,  chiefly  during  the  third  week,  may 
initiate  it,  and  in  syphilis  in  the  secondary  stage 
an  acute  form  may  arise. 

The  symptoms  of  aortitis  are  vague,  though  an  elab- 
orate symptomatology  has  been  formulated  by  some. 

Dj'sphagia  from  pressure  of  the  food  bolus,  epigas- 
tric pain,  and  vomiting  have  been  described  and  J. 
Tessier  mentions  crises  of  pain  in  the  abdomen  and 
diarrhea  in  inflammation  of  the  abdominal  aorta. 
Fever  is  absent. 

Though  the  symptoms  may  be  obscure  or  even 
absent  there  are  some  which  are  rather  characteristic. 
Dyspnea  is  most  important.  It  may  be  of  the 
ordinary  type  or  be  severe  and  paroxysmal  even  in 
the  absence  of  effort.  Inspiration  is  prolonged, 
painful,  and  difficult,  expiration  is  free  and  short. 
It  resembles  respiratory  obstruction  without  its 
signs  and  has  been  attributed  to  bronchial  spasm 
from  reflex  vagus  irritation.  Such  intensity  of 
symptoms  in  the  absence  of  physical  signs  is  diag- 
nostically  important. 

Cough  when  it  occurs  is  dry  and  sometimes  strident. 

Pain. — At  first  this  is  a  sensation  of  substernal 
constriction  which  later  may  appear  as  a  burning 
or  tearing  at  the  base  of  the  neck  spreading  to  both 
shoulders  and  down  the  back. 

The  ]iain  is  anginal  in  character  but  persists 
between  the  paroxysms  and  may  appear  during  rest 
as  (veil  as  on  exertion. 


The  physical  signs  consist  in  the  aortic  pallor  with 
usually  a  quick  and  often  dicrotic  pulse  and  in  cases 
of  some  standing  the  signs  of  dilatation  of  the  aorta 
described  below. 

Prognosis. — The  outlook  in  aortitis  is  not  good. 
After  from  two  to  six  months  of  symptoms,  as  a  rule 
death  ensues.  The  fatal  ending  may  result  from  an 
anginal  attack  or  acute  edema  of  the  lungs  or  more 
slowly  from  progressive  cardiac  failure.  Recovery 
may  take  place  chiefly  in  the  typhoidal  form. 

Other  cases  may  drift  into  a  condition  of  chronic 
aortitis. 

Diagnosis. — From  its  constant  association  with 
other  diseases  the  recognition  of  an  acute  aortitis  is 
no  easy  matter,  its  sign^  and  symptoms  being  usually 
attributed  to  the  coincident  malady.  In  the  words 
of  Barie  whose  description  of  the  condition  I  have 
largely  followed — "IV  aortite  aigue  demande  a  etre 
cherchee.'" 

With  dyspnea  and  pain  of  the  character  mentioned, 
in  association  with  a  bounding  and  dicrotic  pulse  and 
the  signs  of  aortic  dilatation,  increase  of  aortic  dulness 
and  elevation  of  the  subclavian  artery,  the  diagnosis 
is  fairly  well  assured. 

Treatment,  aside  from  that  of  the  primary  disease, 
is  symptomatic — morphine  and  belladonna  for  pain, 
ire  or  dry  cupping  to  the  sternal  region,  amyl  nitrite 
for  the  anginal  attacks,  and  when  the  acute  attack 
has  passed,  iodides  given  over  long  periods. 

Chronic  Retrogressive  Conditions.- — Though 
some  of  these  are  primarily  inflammatory  and  may  be 
spoken  of  as  chronic  aortitis,  the  majority  are 
degenerative  rather,  and  by  the  seat  and  the  type  of 
the  degeneration  are  to  be  classified. 

The  investigations  of  recent  years  by  Jares,  Klotz, 
and  others  have  done  much  to  classify  this  group  of 
diseases.  They  found  that  the  injection  of  such  drugs 
as  adrenalin,  barium  chloride,  and  digitalin,  as  well  as 
diphtheria  toxin  into  rabbits  resulted  in  destruction 
of  the  muscle  cells  of  the  media  which  later  under- 
went calcification,  while  injection  of  cultures  of  B. 
typhi  and  streptococci  of  low  virulence  gave  rise  to 
proliferative  intimal  changes  without  degeneration  of 
the  media.  Klotz  points  out  the  similarity  between 
the  first  or  adrenalin  type  with  the  common  or 
Monckberg  type  of  nodular  arteriosclerosis  in  man, 

The  second  or  "infective"  group  is  represented  in 
man   by  a   true   inflammatory  endarteritis. 

So  far  then  as  the  aorta  is  concerned,  the  following 
groups  may  be  recognized: 

1.  Chronic  Aortitis. — An  inflammatory  endarteritis 
following  typhoid  fever  and  other  infections. 

2.  Syphilitic  Aortitis. — This  is  primarily  a  peri- 
arteritis and  mesarteritis,  the  destructive  changes 
being  found  in  the  muscular  and  elastic  tissue  with 
infiltration  about  the  vasa  vasorum  running  in  from 
the  adventitia,  Thickening  of  the  intima  follows 
as  a  reactive  change,  but  when  the  process  is  acute, 
aneurysm  results.  The  site  of  election  of  this  type 
is  at  the  root  of  the  vessel,  in  the  lower  part  of  the 
thoracic  and  lower  part  of  the  abdominal  aorta. 
The  patches  may  be  of  small  size  and  separated. 

Irregularly  radiating  grooves  or  puckerings  are 
seen  on  the  intimal  surface. 

Such  a  condition  has  also  been  reported  by  Klotz 
in  an  infant  with  congenital  syphilis. 

3.  Atheroma. — Intimal  proliferation,  non-inflam- 
matory. Following  weakening  of  the  media  _  there 
develops  a  proliferation  of  the  cells  of  the  intima 
and  subendothelial  connective  tissue.  These  patches 
occur  in  order  of  frequency  in  the  ascending  aorta, 
anh,  thoracic  and  abdominal  portions. 

In  time  they  undergo  hyaline  and  fatty  degenera- 
tion and  calcareous  deposition  forming  atheromatous 
plaques  which  are  most  marked  over  the  curves, 
1«  in  lings,  and  divisions  into  branches  of  the  vessel. 

The  aorta  may   be   markedly  atheromatous    with 


494 


REFERENCE    IIWHH00K    OF   THE    MEDICAL    SCIENCES 


Aphasia 


but  little  sign  of  thickening  of  the  peripheral  arteries 

and  via   vi     a.  

I.  Medial  Degeneration. —  11ns,  the  Monckberg 
type,  has  been  mentioned  above  as  analogous  to 
lie  "adrenalin"  type  of  experimental  arteriosclerosis. 

[n  the  aorta  it  is  this  type  which  is  chiefly  associated 
with  thinning  of  the  walls  and  diffuse  dilatation  and 
in  the  peripheral  vessels  with  the  nodular  form  of 
gdero  i  I,  EClotz  makes  mention  of  a  group  of  eases  in 
which  the  aorta  is  macroscopically  healthy  but  in 
ch  microscopical  examination  shows  a  marked 
deposit  of  calcium  in  the  degenerated  muscle  cells  of 
the  middle  layer  of  the  media. 

The  outer  layer  nourished  from  tin'  vasa  vasorum 
ami  the  inner  from  the  blood  stream  being  little 
affected.  This  form  was  found  in  patients  in  the 
latter  half  of  life. 

\tion  or  thi:  Aorta. — This  condition  is 
in  which  tln>  vessel,  instead  of  giving  away  at  one 
point  with  the  gradual  development  of  an  aneurysmal 
tun, or.  becomes  uniformly  enlarged  and  this  enlarge- 
ment may  be  present  in  the  first  part  only  or  may 
Oi  i  upy  the  whole  vessel  as  far  as  the  opening  in  the 
diaphragm. 

As  distinguished  from  aneurysm  again,  dilatation 
of  the  aorta  is  not  a  sequence  of  syphilis  which  causes 
calized  weakening  of  the  aorta,  but  rather  of  an 
acute  aortitis  or  of  tin/  Monckberg  type  of  arterio- 
sclerosis, in  both  of  which  the  aortic  weakening  is, 
uniform  and  diffuse. 

[t  is  commoner  in  males  than  in  females  in  the 
proportion  of  9  to  1. 

I'd,  iw  the  age  of  thirty  and  over  that  of  sixty  years 
it  is  relatively  rare,  the  three  intervening  decades  con- 
tributing most  of  the  cases  in  equal  numbers. 

Alcohol,     tobacco,     and     hard     work,     especially 
periodical  exertion,  are  figures  in  the  etiology,  but  as 
mentioned  above  syphilis  appears  in  the  minority  of 
as  against  the  majority  in  aneurysm. 

Causation. —  Granted  a  diffuse  weakening  of  the 
aortic  wall,  the  impact  of  the  blood  column  causes  not 
only  a  widening  but  a  lengthening  of  the  artery  and  as 
it  is  fixed  at  the  heart  end,  it  N  pushed  sidewise  and 
upward  as  well  as  having  its  caliber  increased  and 
its  walls  thinned. 

Symptoms  are  sometimes  absent  but  usually  the 
two  complaints  are  made  of  dyspnea  and  pain  under 
the  sternum.  The  pain  may  be  referred  to  one  or 
the  other  shoulder  or  the  root  of  the  neck. 

The  physical  signs  correspond  with  the  anatomical 

condition.     They    are    (a)    visible    pulsation    in    the 

ud  space  with   some   lifting  of   the   manubrium. 

McCrae  points  out  the  contrast  between  the  marked 

visible  and  the  slight  palpable  lift  of  the  sternum. 

(b)  Increased  dulness  over  the  sternum.  The 
following  figures  are  given  of  the  dulness  in  the  second 
space  transversely. 

Average 

Mliii 5  cm. 

Woman 3  cm. 

If  the  figures  are  greater  than  these,  dilatation  is 
suggested. 

A^  a  matter  of  fact  measurements  of  7  to  10  cm. 
or  more  are  found  in  dilatation.  The  dulness  is 
Usually  greater  to  the  left  than  to  the  right. 

(c)  Elevation  of  the  subclavian  artery  so  that  its 
pulsation  is  felt  above  the  sternal  notch  and  above 
the  inner  end  of  the  clavicle. 

The  aortic  second  sound  has  usually  not  only 
the  high  pitch  of  increased  tension  but  a  clinking 
amphoric  character,  and  this  may  be  made  out  by 
auscultation  in  the  suprasternal  notch  more  readily 
than  in  the  second  interspace.  Contrary  to  what 
might  be  expected,  the  blood  pressure  is  raised  little, 
if  any,  above  the  normal. 

(e)  The  fluoroscope  shows  a  shadow  to  the  left  and 
sometimes  to  the  right  of  the  usual  aortic  area. 


laximum 

Minimum 

5.5  cm. 

4       cm. 

3.5  cm. 

2.5  cm. 

Diagnosis. — from   trui  oi    the    pp   ence  of 

the  above  sign-,   the  absence  of  localized  pre 
signs  and  of  expansile  pul  ation,  and  the  r-ray  picture 
b  ill  usually  m:ii  e  the  destine!  ton. 

Hodgson's  D    ■••■      i     thi    name  given  to  dilatation 
of  the  aorta   which  involves  the  aortic  ring,  cat 
coincident  aortic  insufficiency. 

Thrombosis  of  the  Aorta. — 'this  is  rare.  It 
oeriiis  in  atheromatous  arteries  nearly  always  in  the 
abdominal  aorta  a  short  distance  above  the  bifurca- 
tion. In  Barth's  case  it  extended  up  to  the  renal 
arteries.  The  thrombus  is  stratified,  with  a  soft 
center,  the  periphery  showing  primary  clotting  at 
the  intiina. 

If  the  thrombosis  is  complete  ii  results  in  severe 
jiaiu,  paraplegia,  later  gangrene  and  death. 

If  incomplete,  p;iin  and  1 1 1 1  111  1  mess  in  the  legs  ap- 
pear, followed  by  weakness  amounting  to  paresis. 

In  one  case  the  patient  is  reported  to  have  lived 
two  years  when  paraplegia  became  complete. 

Embolism  results  from  endocarditis,  simple  or 
malignant,  or  from  atheroma. 

The  onset  is  sudden  with  severe  abdominal  or  leg 
pains,  sometimes  with  rigidity  or  convulsive  move- 
ments. The  legs  become  cold  and  blue  and  gangrene 
later  develops. 

Rupture  of  the  Aorta. — This  is  usually  an 
accident  of  later  life  and  with  but  few  exceptions 
oceius  in  vessels  previously  diseased.  Acute  aortitis, 
atheroma,  and  tuberculosis  have  been  found,  while 
invasion  of  the  aorta  by  cancer  of  the  esophagus 
has  also  occurred. 

The  rupture  is  usually  intrapericardial  and  the 
tear  is  usually  single,  but  occasionally  multiple. 

The  rupture  is  nearly  always  in  two  stages,  through 
the  intima  first,  with  the  formation  of  a  dissecting 
aneurysm  and  from  minutes  to  days  later  and  at 
another  level  through  the  other  coats. 

The  symptoms  are  sudden,  severe,  thoracic  pain 
with  syncope  and  death. 

The  rupture  may  occur  into  any  of  the  neighbor- 
ing organs.  A.  H.  Gordon. 

Aphasia. — See  Speech,  Disorders  of. 

Aphonia  signifies  loss  of  the  voice.  It  may  result 
from  disease  or  injury  of  the  vocal  apparatus,  particu- 
larly the  larynx,  maybe  a  congenital  affair  (see  Deaf- 
mutism),  may  result  from  paralysis  of  one  or  more 
of  the  laryngeal  muscles,  or  be  purely  ideogenic  in 
origin,  forming  a  constituent  part  of  a  neurosis, 
psychoneurosis,  or  psychosis,  as,  for  instance,  in 
anxiety  neuroses,  hysteria,  compulsion  neuroses,  or 
dementia  pra?cox  respectively.  Only  the  neurological 
types  of  aphonia  are  discussed  here.  These  result. 
from  paralysis  of  the  laryngeal  muscles,  either  from 
definite  pressure  or  from  inflammation  of  the  motor 
nerves  or  from  psychic  causes.  The  superior  laryn- 
geal nerve  sends  motor  filaments  to  the  cricothyroid 
muscle  only,  the  recurrent  laryngeal  supplies  the 
greater  motor  innervation  to  the  larynx,  and  disease 
of  this  nerve  is  responsible  for  most  of  the  aphonias, 
partial  or  complete. 

Complete  aphonia  usually  results  from  bilateral 
lesions;  unilateral  recurrens  palsy  may  cause  an 
initial  aphonia,  but  later  the  voice  can  be  used, 
although  it  is  much  modified.  Central  laryngeal 
paNies  resulting  in  aphonia  are  most  frequent  in  tabes. 

Aphonia  is  often  then  associated  with  Iaryngea, 
crises,  excessive  coughing,  huskiness,  loss  of  voicel 
and  pain.  A  few  rare  instances  are  due  to  syringo- 
myelia. Rethi,  in  his  monograph  on  laryngeal 
symptoms  in  multiple  sclerosis,  has  collected  a 
comparatively  large  number  of  palsies  in  this  disease. 
Other  syphilitic  disorders  than  tabes  may  account 
for   recurrent   laryngeal    palsies.     Among    the    rarer 

495 


Aphasia 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


causes  are  various  growths  of  the  neck  and  mediasti- 
num pressing  on  the  nerve — carcinoma,  enlarged 
lymph  nodes  in  the  posterior  mediastinum,  foreign 
bodies,  aneurysm,  esophageal  growths.  Occasionally 
overuse  may  cause  fatigue  palsy.  Acute  toxemias, 
diphtheria,  measles,  typhoid  fever,  lead,  alcohol, 
copper,  antimony,  arsenic,  etc.,  may  occasionally  be 
the  etiological  factor. 

Hysterical  aphonias  vary  considerably.  Here  the 
mechanism  causing  the  conversion  may  be  very 
.superficial,  in  which  case  almost  any  hocus  pocus, 
from  a  faradic  spark  to  making  a  few  hypnotic  passes 
may.  for  a  time  at  least,  efface  the  symptom.  Many 
of  "these  aphonias  have  owed  their  origin  to  acute 
psychical  shock:  they  do  not  represent  the  conversion 
of  long  suppressed  complexes.  Many  of  the  so-called 
cures,  however,  prove  to  be  fallacious.  In  dispensary 
as  well  as  in  private  practice  such  patients  go  the 
rounds. 

Those  patients,  whose  aphonia  represents  a  definite 
psychic  conversion,  either  as  a  defense  or  a  retention 
mechanism,  are  rarely  cured  by  the  superficial 
psychotherapy  of  suggestion,  no  matter  what  its 
particular  form  may  be.  Such  patients  are  usually 
cured  only  by  a  complete  psychoanalysis. 

Smith  Ely  Jelliffe. 


Aphrodisiacs. — These  are  agents,  medicinal,  physical, 
psychic,  or  hygienic,  which  increase  sexual  desire  or 
ability.  Some  act  by  increasing  desire,  others  by 
increasing  or  restoring  the  ability  to  perform  the 
sexual  act. 

Loss  of  sexual  power  may  have  origin  in  various 
■ways  and  is  frequently  divided  into  organic,  psychic, 
irritable,  and  paralytic.  A  distinction  is  also  to  be 
made  between  anaphrodisia,  or  absence  of  desire,  and 
impotence,  or  inability  to  perform  the  sexual  act. 
Organic  impotence  is  dependent  upon  structural 
change,  either  congenital  or  acquired,  such  as  anoma- 
lies, malformations,  new  growths,  etc.,  for  which 
relief  must  be  sought  by  surgical  or  other  special 
treatment. 

For  nervous  or  irritable  impotence,  which  is  due 
generally  to  weakness  of  the  genital  organs  and  ab- 
normal excitement  of  the  reflex  centers  causing  pre- 
irature  ejaculations,  or  due  to  irritations  caused  by 
some  morbid  condition  of  the  urine  or  by  the  presence 
ot  strictures,  recourse  must  be  had  to  measures  such 
as  the  passage  of  a  cold  sound  and  other  local  treat- 
ment, which  will  relieve  the  causative  factor.  In 
paralytic  impotence,  caused  by  disease  of  the  central 
nervous  system,  syphilis,  anemia,  systemic  poisoning 
from  lead,  tobacco,  etc.,  the  indication  is  to  remove 
the  cause,  when  possible,  to  build  up  the  patient  by 
general  tonic  treatment,  and  to  restore  sexual 
tone  by  electricity,  mix  vomica,  and  other  aphrodis- 
iac drugs.  Psychical  loss  of  sexual  power  is  best 
treated  by  suggestion  combined  with  the  exhibition  of 
strychnine  or  mix  vomica.  Most  cases  are  due  to 
nervousness,  overwrought  desire,  indifference,  grief, 
fright,  and  mental  preoccupation. 

If  the  case  has  its  origin  in  nervousness  caused  by 
fear  of  the  consequences  of  early  abuse,  psychotherapy 
is  the  most  effective  measure.  Tin'  patient  must  be 
told  to  abstain  from  any  attempt  at  sexual  intercourse 
for  one  or  two  weeks  and  at  the  same  time  be  given 
strychnine  in  small  doses  or  cannabis  indica.  Those 
cases  depending  upon  overwrought  desire,  frequently 
seen  in  newly  married  men  after  long  engagements  or 
sexual  abstinence,  are  best  treated  by  tin-  temporary 
use  of  the  bromides,  together  with  suggestion.  For 
these  and  for  the  remaining  class  of  cases  indications 
will  be  found  for  prescribing  such  general  measures  as 
hydrotherapy  with  massage,  tonics,  such  as  mix 
vomica,  a  diet  consisting  of  highly  seasoned  food,  red 
meats,  and  freedom  from  exhausting  mental  or 
physical   work.     Among   the  aphrodisiac  drugs,  mix 

496 


vomica  (strychnine)  and  phosphorus  enjoy  the  most 
repute.  Ergot  is  said  to  be  of  value  in  those  case-,  of 
impotence  which  depend  upon  lack  of  erectile  power 
and  among  drugs  of  use  in  pure  anaphrodisia  as 
distinguished  from  impotence,  damiana,  caffeine,  and 
cannabis  indica  are  recommended.  Alcohol  in  small 
il(i<es  increases  sexual  desire  but  in  excessive  amount 
weakens  sexual  power.  Cantharis  and  various  of  the 
( >1  ii  'resins  cause  irritation  of  the  urinary  tract  and  may 
indirectly  stimulate  the  sexual  appetite,  but  their  use  is 
to  be  condemmed  as  unscientific  and  dangerous. 
Other  agents  used  are  alternate  applications  of  hot 
and  cold  water  locally,  electricity  applied  to  the 
urethra  or  to  the  rectum,  and  the  passage  of  a  sound 
reinforced  either  by  electric  stimulation  or  by  cold. 
In  general  more  can  be  accomplished  by  hygienic  and 
moral  measures,  tonics,  rest,  long  hours  of  sleep, 
and  the  avoidance  of  worry  than  by  the  use  of  any 
of  the  so-called  aphrodisiac  drugs. 

Charles  Adams  Holder. 

Aphthae. — See  Mouth,  Diseases  of  the. 

Aphthae  Tropica. — See  Sprue. 

Aplasia. — See  Agenesia. 

Apnea. — See  Asphyxia. 


Apocodeine. — A  grayish-yellow  amorphous  powder, 
ClsH19N07,  soluble  in  water  and  alcohol.  It  bears 
the  same  relation  to  codeine  as  apomorphine  does  to 
morphine.  The  hydrochloride  which  is  readily 
soluble  in  water  is  the  salt  employed.  Physiologically 
it  has  the  remarkable  property  of  depressing  or 
paralyzing  the  sympathetic  nerve-endings,  and  for 
this  has  come  into  extensive  use  in  experimental 
work.     It  is  directly  antagonistic  to  adrenalin. 

Therapeutically  its  only  use  is  as  a  purgative  that 
can  be  administered  hypodermatically,  its  action 
being  to  cut  off  the  splanchnic  impulses  which  are 
the  normal  inhibitory  stimuli  of  the  bowel.  It  has 
not  proven  to  be  of  very  great  value,  and  its  use  is 
not  without  the  danger  of  arterial  relaxation  with 
fall  in  blood-pressure.  The  hypodermic  dose  for 
cathartic  purposes  is  half  a  grain  (0.03). 

W.  A.   Bastedo. 


Apocynacese. — (The  Dogbane,  Oleander  or  Stro- 
phanthus  family.)  A  great  family  of  130  genera 
and  more  than  1,000  species,  very  abundant  in  the 
tropics  of  both  hemispheres,  a  few  extending  into 
the  temperate  zones.  The  plants  are  almost 
all  trees  or  erect  or  climbing  shrubs,  with  milky 
juice,  and  are  highly  ornamental  and  frequently 
cultivated  for  decorative  purposes.  The  juices  of 
Landolphia,  Hancornia,  and  some  others  are  utilized 
in  the  production  of  rubber.  Valuable  timbers  are 
yielded  by  several  species.  The  most  noteworthy 
characteristic  of  the  family  is  its  poisonous  nature, 
few  other  families  being  able  to  compare  with  it  in 
this  respect.  Many  of  the  species  have  been  utilized 
as  arrow  poisons,  and  a  number  of  these  have  been  in- 
troduced into  the  materia  medica.  The  active  consti- 
tuents are  mostly  glucosidal,  uncommonly  alkaloiihil. 

The  action  is  chiefly  upon  the  heart,  stimulant  in 
small  doses,  ultimately  paralyzant,  and  thus  fre- 
quently powerfully  diuretic.  Often,  also,  they  are 
irritant  emetico-cathartics.  Their  action  is  so 
powerful  that  even  minute  differences  between  them 
are  of  importance,  and  new  remedies  introduced 
from  this  family  are  always  worthy  of  careful  atten- 
tion. The  important  medicinal  genera  are  strophan- 
tus, aspidosperma,  apocynum,  and  alstonia. 

The  poisonous  principles  are  widely  distributed 
through  the  plant  bodies.  H.  H.  Rusby. 


REFERENCE    HAXDROOK    OF   THE    MEDICAL   SCIENCES 


Ippendlcostom; 


Apocynum. — Canadian  Hemp,  Dogbane.    The  root 
of  Apocynum    cannabinum    L.    (Fam.    Apocynaceai) 
l  .  S.  P.     Up  to  a  comparatively  recent  period  the 

fenus  Ipoeynum  was  supposed  to  contain,  in  the 
Astern  United  States,  bul  two  species,  A.  canna- 
binum L.  and  A.  andro&amifolium  L.  As  the  latter 
was  known  to  have  but  a  weak  physiological  action, 
it  was  supposed  to  1"'  necessary  to  exclude  only  this 
well-known  species  from  the  drug  in  order  to  insure 
it-  full  properties.  It  is  now  known  that  the  several 
supposed  varieties  of  A.  cannabinum  are  perfectly 
distinct  species.  A.  cannabinum,  then-fun',  as  it  has 
been  understood  and  collected,  is  in  reality  several 
ibably  four,  at  least)  distinct  species.  That  some 
one  Or   more  Of   these  species   is  a    powerful    and   im- 

int  medicine  is  indubitable,  in  view  of  the  evi- 
dence presented;  hut  in  view  of  the  aumerous  recorded 
failures,  it  is  equally  certain  that  not  all  of  them  are  SO. 
Wo  are  at  present  quite  ignorant  as  to  which  is  the  ac- 
tive species,  all  statements  of  manufacturers,  as  well  as 
tlie  Pharmacopoeia,  to  the  contrary  notwithstanding. 
The  entire  comparative  study  of  these  species  is  still 
before  us.  Under  these  circumstances  any  specific 
pharmacological  account  of  the  drug  is  out  of  the 
question. 

The  plants  are  erect,  perennial  herbs,  growing  by 
preference  along  railroads  and  roadsides.  They 
propagate  by  long,  horizontal  underground  struc- 
tures, which  appear  to  combine  the  characters  of 
both  root  and  rhizome.  The  latter  is  the  part  used. 
The  aerial  portion  may  be  smooth  or  pubescent,  and 
is  usually  purple  or  purplish.  The  leaves  are  oppo- 
site, oblong,  or  oval-ovate,  thickish,  mucronate. 
The  stem  is  branched  above  and  bears  very  small 
white  or  greenish-white  flowers  in  close  cymes.  The 
fruit  is  a  pair  of  long  slender  follicles,  filled  with 
small  plumose  seeds.  The  entire  plant  exudes  an 
abundant  milky  juice. 

The  drug  occurs  in  long,  rather  straight  pieces,  of 
about  the  thickness  of  a  lead  pencil  and  sparingly 
branched.  It  is  of  a  brown  color,  having  an  orange 
shade  if  not  old  and  stale.  The  very  thick  bark 
exhibits  few  coarse  wrinkles,  finer  nerves,  and  coarse 
circular  fissures,  and  is  pinkish-white  internally. 
The  wood  is  yellowish,  very  soft  and  brittle,  its  pores 
large  enough  to  be  visible  to  the  naked  eye.  It 
contains  resin,  tannin,  starch,  an  amaroid,  and  the 
peculiar  crystalline  body  apocynin,  soluble  in  alcohol, 
and  the  glucoside  apocynein,  soluble  in  water  and  of 
feeble  action.  The  chief  activity  is  believed  to  reside 
in  the  crystalline  bitter  principle  cynotoxin,  which 
occurs  in  white  rhombic  pyramids,  insoluble  in  water 
and  melting  and  decomposing  at  165°  C.  Quinemore 
assigns  to  it  the  formula  C\,0H2SO0.  Apocynum  is  a 
cardiac  stimulant  and  a  diuretic,  as  well  as  a  nauseat- 
ing expectorant.  The  most  important  use  of  the 
drug  is  in  causing  the  removal  of  dropsical  effusions. 
Y  fluid  extract  is  official,  the  dose  of  which  is  irt;  v. 
to  xxx.(0.o  to.'.O).  H.  H.  Rusbt. 


Apomorphine  fC,,HnNO,). — Apomorphine  is  an 
alkaloid  derived  from  morphine  by  abstracting  from 
the  latter  a  molecule  of  water.  This  is  done  by 
heating  it  in  sealed  tubes  with  zinc  chloride  or  hydro- 
chloric acid.  It  may  also  be  derived  from  codeine. 
Jt  is  commonly  used  in  the  form  of  the  hydrochlorate, 
which  is  official.  The  Pharmacopoeia  describes  it  as 
in  minute,  grayish-white  shining,  acicular  crystal-, 
without  odor,  having  a  faintly  bitter  taste,  and 
acquiring  a  greenish  tint  upon  exposure  to  light  and 
air.  Soluble  in  39.5  parts  of  water,  or  in  sixteen 
parts  at  Su°  C,  in  38.2  parts  of  alcohol,  or  in  thirty 
parts  at  f.o°  C:  verv  little  soluble  in  ether  or  chloro- 
form. When  heated  to  near  100°  C.  (212°  F.),  the  salt 
is  decomposed,  rapidly  if  in  solution,  slowly  when  dry. 

The  properties  of  apomorphine  are  totally  distinct 
from  those  of  morphine.     It  is  primarily  an  emetic, 

Vol.  I.— 32 


acting  altogether  centrally,  and  with  great  prompt- 
ness and  power.  It  is  secondarily  an  expectorant, 
increasing  and  greatly  thinning  the  bronchial  mucus. 
In  poisoning,  there  is  intoxication  or  delirium  and 
paralysis  of  the  motor  nerves,  with  failure  of  respira- 
tion and  especially  of  t  he  heart . 

In  use,  apomorphine  i-  probably  our  most    prompt 
and     energetic     emetic,     it       special     value    being    the 

promptness  and  certainty  with  which  vomiting  can 

be  induced  by  hypodermic  injection  when,  for  any 
reason,  the  stomach  cannot  be  acted  upon  to  produce 

it.     As  an  expectorant,  it  is  perhaps  our  most  useful 

agent  for  relieving  a  "dry ''cough.      [f  given  early,  it 
will  do  much  to  avert  bronchitis,  and    it    is  also   e 
eially  useful  in  the  hacking  cough  of  tuberculosis.    In 

infants,  or  in  the  aged,  it  is  possible  for  large  doses  to 

suffocate  by  the  excessive  transudation  into  the 
bronchioles.  The  emetic  dose  for  an  adult  is  gr. 
,'„  to  J  (0.006  to  O.01);  as  an  expectorant,  gr.  f  to 
..'„  (0.0015  to  0.003). 

II.  II.  Rusbt. 


Aponomma. — A  genus  of  parasitic  ticks  usually 
found  on  reptiles.  The  body  is  ornate  as  a  rule,  and 
broad-oval  in  shape.     See  Arachnida.  A.S.P. 

i 

Apoplexy. — See  Cerebral  Hemorrhage. 

Apoplexy,  Spinal. — See  Spinal  Hemorrhage. 

Appendicitis. — See  Cecum  and  Appendix,  Diseases 
of  the. 

Appendicostomy. — The  operation  termed  "appendi- 
costomy"  is  done  with  the  purpose  of  utilizing 
the  appendix  as  a  means  of  irrigation  as  well  as  for 
the  introduction  of  medicaments  through  its  lumen 
into  the  large  intestine.  The  operation  was  named 
appendicostomy,  according  to  our  usual  rules  of 
nomenclature,  by  the  present  writer. 

History. — The  operation  was  conceived  and  first 
carried  out  in  1902  by  Dr.  Robert  F.  Weir  of  New 
York  City.  He  was  to  operate  on  a  greatly  reduced 
man  thirty-one  years  of  age,  who  had  been  suffering 
for  three  years  from  frequent  bloody,  thin  stools, 
due  to  obstinate  colitis.  Dr.  Weir  entered  the 
abdomen  with  the  intention  of  doing  a  cecostomy, 
according  to  the  Kader-Gibson  method;  however, 
"as  the  cecum  was  exposed,  the  appendix  rose  so 
suggestively  into  view"  that  he  "determined  to 
employ  it  to  make  a  fistula."  It  was  accordingly 
fastened  to  the  skin  and  the  rest  of  the  wound  closed; 
soon  after  it  was  used  for  irrigating  the  large  bowel. 
The  final  result  proved  very  satisfactory. 

Indications. — As  stated  above,  the  operation  was 
originally  designed  for  the  surgical  treatment  of 
chronic  colitis  and  sigmoiditis  after  internal  medica- 
tion and  high  irrigation  had  proved  ineffectual  (Weir, 
Willy  Meyer,  Tut  tie).  Within  a  few  years  it  was 
tested  with  success  in  all  subdivisions  of  this  trouble, 
i.e.  the  mucous,  membranous,  ulcerative,  dysenteric, 
tuberculous,  syphilitic,  and  amebic  types.  It  has 
steadily  grown  in  favor  with  surgeons  all  over  the 
world  and  its  indications  have  been  gradually  widened. 
It  was  but  natural  that  soon  its  application  was 
extended  also  to  chronic  intractable  constipation.  • 
Splendid  results  were  seen.  It  was  further  found 
useful  in  the  following  diseases  and  conditions:  Acute 
appendicitis  (stump  not  to  be  tied,  amputated,  and 
inverted,  but  stitched  into  the  abdominal  wall  for 
saline  infusion  in  place  of  rectoclysis) ;  acute  septic 
general  peritonitis  with  meteorism;  in  the  treatment 
of  enteric  ulceration  in  cases  of  typhoid  fever;  for  the 
more  effectual  introduction  of  nourishment,  as  a 
substitute  for  rectal  feeding;  to  prevent  recurrence 
in  cases  of  intussusception  of  the  ileocecal  variety;  as 

497 


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REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


appendico-enterostomy  in  order  to  reach  for  irrigation 
also  the  lower  end  of  the  ileum.     (See  below.) 

Technique. — Examination  of  the  appendix  in  a 
hundred  autopsies  selected  at  random,  showed  that 
appendicostomy  could  have  been  done  in  ninety-six 
per  cent.  The  operation  (as  carried  out  by  the  writer) 
can  be  done  under  general,  regional,  or  local  an- 
esthesia. McBurney's  intermuscular  abdominal  in- 
cision is  used;  the  cecum  is  pulled  forward,  or,  in  the 
presence  of  adhesions,  loosened,  so  that  the  base  of  the 
appendix  corresponds  to  the  level  of  the  parietal 
peritoneum.  Careful  palpation  of  the  appendix  is 
made  to  determine  the  presence  or  absence  of  foreign 
bodies  or  fecal  concretions.  If  any  are  present,  an 
attempt  is  made  to  press  them  gently  into  the  cecum 
or  tip  of  the  appendix;  if  this  be  impossible,  careful 
tamponade,  incision,  removal  of  the  body,  and  suture 
of  the  opening  are  called  for.  The  further  steps  of  the 
operations  are:  ligation  of  the  distal  half  of  the 
mesenteriolum;  continuous  catgut  suture  of  the 
peritoneal  wound,  allowing  the  appendix  to  emerge 
at  about  its  middle,  one  to  two  stitches  to  catch  the 
caput  coli  near  the  base  of  the  appendix  (care  must 
be  taken  not  to  injure  or  constrict  the  blood-vessels 
of  the  mesenteriolum) ;  layer  suture  of  the  abdominal 
wall;  one  stitch  to  fix  the  mesenteriolum;  (care 
must  be  taken  that  fascia  does  not  strangulate  the 
appendix);  one  subcuticular  suture  to  penetrate  the 
appendicular  wall  superficially,  for  proper  outside 
anchoring;  layer  of  sterile  gauze  dressing  on  sutured 
skin  wound,  divided  to  surround  the  appendix;  gauze 
mops  on  top  near  base  of  organ;  amputation  about 
one-third  to  one-fourth  inch  above  the  level  of  the 
skin,  secretion  caught  on  mops,  latter  exchanged; 
introduction  of  small  flexible  bougie  to  ascertain  the 
permeability  of  the  appendicular  lumen;  (slight 
strictures  can  be  immediately  stretched,  in  which 
event  a  small  Nelaton  catheter  remains  in  place) ;  if 
no  strictures  are  found  removal  of  bougie;  gentle 
bow-knot  closure  of  the  stump  with  catgut;  final 
dressing;  removal  of  the  bow-knot  after  twenty-four 
hours;  beginning  irrigations. 

Varieties  of  Technique. — 1.  Sharp  muscular  and 
peritoneal  division  in  the  same  direction  as  the  skin  and 
fascia,  exit  of  the  base  of  the  appendix  at  the  lower 
angle  of  the  peritoneal  wound,  the  organ  being  then 
run  up  to  the  upper  angle  of  the  skin  wound — or 
reversed,  the  base  of  the  appendix  emerging  at  the 
upper  angle  of  the  peritoneal  wound,  the  organ  being 
run  obliquely  downward  through  the  abdominal 
parietes.  The  oblique  course  of  the  appendix 
can  also  be  arranged  for,  when  using  the  inter- 
muscular incision;  the  organ  would  then  run  sub- 
fascially  above  the  muscles  for  some  distance. 
Neither  modification  is  recommended,  as  the  re- 
quired frequent  introduction  of  catheters  or  rubber 
tubes  may  cause  traumatic  irritation  or  even  ulcera- 
ton  at  the  kink  (base  of  the  appendix).  The  straight 
outward  way  appears  to  be  the  best. 

2.  Total  ligation  of  the  mesenteriolum.  This  is  not 
advisable  as  a  rule,  since  it  may  cause  necrosis,  especi- 
ally in  diabetics.  It  may  be  indicated  in  cases  of  acute 
appendicitis  in  order  to  produce  gangrene  and  more 
rapid  closure  of  the  hole  in  the  cecal  wall  later  on. 
However,  this  appears  unsafe;  complications  may 
occur  in  the  healing  of  the  wound  in  the  abdominal 

.wall.  It  is  undoubtedly  best  to  preserve  the  mesen- 
teriolum either  entire  or  at  least  up  to  the  place  where 
amputation  is  comtemplated.  This  can  be  well 
determined  by  putting  the  appendix  on  the  stretch 
when  closing  tin-  wound. 

3.  Suture  of  the  appendix  in  place,  without 
fastening  the  caput  coli  to  the  parietal  peritoneum. 
This  is  dangerous,  as  the  intraabdominal  part  of  the 
appendix  would  present  a  band  that  might,  cause 
intestinal  obstruction.  The  intraabdominal  portion 
might  also  become  perforated  if  the  use  of  stiff  bougies 


or  catheters  (silver)  became  necessary  in  order  to  pass 
the  narrow  lumen  of  the  appendix.  One  such 
case  has  been  observed  in  which  perforation  resulted, 
followed  by  general  peritonitis  and  death. 

4.  Amputation  of  the  appendix  twenty-four  to 
forty-eight  hours  after  operation.  This  certainly 
guards  best  against  possible  infection.  However, 
if  the  lumen  be  found  absolutely  impermeable, 
cecostomy  would  become  necessary  at  a  second 
operation;  whereas,  if  it  were  so  found  at  the  comple- 
tion of  the  appendicostomy,  the  sutured  abdominal 
wound  could  be  quickly  opened  and  cecostomy 
added  at  once.  This  is  an  important  point.  With 
ordinary  precaution,  soiling  of  the  freshly  sutured 
wound  can  be  well  prevented.  It  is  self-understood 
that,  if  the  appendix  as  such  appears  large,  and  its 
walls  show  no  infiltration  suggestive  of  strictures, 
it  will  always  be  safer  for  the  patient  if  the  amputa- 
tion be  performed  twenty-four  hours  later. 

5.  Appendico-enterostomy  (Pringle).  Anastomo- 
sis of  the  tip  of  the  appendix  with  the  lower  end  of 
the  ileum.  The  appendix  is  fastened  in  the  abdom- 
inal wound  in  such  a  manner  that  its  middle  projects; 
it  is  fixed  to  the  abdominal  wall;  after  forty-eight 
hours,  an  incision  is  made  and  a  catheter  is  introduced 
to  either  side,  thus  reaching  the  large  intestine  as 
well  as  the  ileum  above  the  ileocecal  valve. 

Choice  between  Appendicostomy  and  Cecos- 
tomy.— Appendicostomy  appears  to  be  the  operation 
of  choice  in  all  cases  in  which  the  appendix  is  per- 
meable. It  is  simple,  safe,  and  effective,  and  is  also 
better  as  regards  the  after  treatment.  It  does  not 
necessitate  the  continuous  wearing  of  a  rubber  tube 
within  the  canal. 

Possible  Late  Complications. — Aside  from  the 
one  case  of  perforation  of  the  intraabdominal  portion 
of  the  appendix  mentioned  above,  prolapse  of  the 
cecum  through  a  large  appendicular  stump  has  once 
been  observed  by  the  writer.  (Amebic  dysentery; 
appendix  led  out  straight;  gradual  prolapse;  cured  by 
operation.  See  Annals  of  Surgery,  1908,  vol.  xlvii., 
p.  808.) 

In  one  case  the  catheter  left  in  place  slipped  into 
the  gut  and  was  later  passed  per  rectum  (Dawson). 
The  catheter  or  drainage  tube  should  always  be 
secured  with  a  safety  pin  outside,  better  still,  be 
introduced  for  each  irrigation  and  removed  again 
after  this  procedure. 

After  Treatment. — There  is  usually  no  leakage; 
a  small  dry  gauze  or  ointment  dressing  is  all  that  is 
required.  If  there  should  be  some  slight  leakage 
from  the  stump  of  a  large-sized  appendix,  a  gently 
pressing  truss  with  rubber  pad,  filled  with  water  or 
glycerin,  might  be  worn  on  top  of  the  piece  of  gauze 
covering  the  opening  during  the  time  of  utilization  of 
the  appendicostomy. 

Once  or  twice  a  day  a  rubber  catheter  or  small 
rubber  tube  is  introduced  through  the  appendicular 
stump  into  the  cecum,  and  the  colon  is  flushed. 
Quinine  solution  1:1500  alternating  with  nitrate  of 
silver  1:2000,  or  a  solution  of  sodium  bicarbonate 
two  per  cent,  and  one  of  thymol  1:1000,  alternating 
ice  cold  or  hot,  according  to  subjective  prefer 
may  be  used  for  amebic  dysentery;  bichloride  solution 
1:2000,  or  thymol  1:1000,  with  antispecific  general 
regime  for  chronic  syphilitic  ulcerative  colitis;  saline 
solution  for  cleansing,  to  be  followed  by  pure  balsam 
of  Peru  and  iodoform  emulsion  injections  in  tubercu- 
lous ulcerative  colitis,  giving  creosote  or  guaiacol 
internally,  with  a  carefully  selected  diet,  and,  of 
course,  the  observance  in  addition  of  a  general 
hvuienic  regime;  weak  solution  of  epsom  salts  and 
cascara,  etc.  in  small  doses,  even  plain  warm  water, 
in  cases  of  chronic  constipation. 

Two  quarts  of  fluid  introduced  through  a  tube 
Nos.  12  to  14  (French  scale),  can  be  made  to  pass  the 


■His 


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\  !•■•■- 1  i  I  .- 


entire  large  intestine  within  ten  or  fifteen  minutes. 
During  this  time  l lie  patient  had  best   lie  on  a   Kelly 

Eits  apron  hanging  into  a  pail,  or  on  an  ordinary 
ed-pan. 
Patients  easily  learn  to  flush  the  colon  themselves; 

they  certainly  are  not    in   need  of  hospital  treatment 

during  this  period. 

In  view  of  the  obstinacy  of  chronic  affections  of  the 

lame  intestine  and  the  tendency  of  the  trouble  to 
t.  it  is  unwise  to  bring  about  definite  closure  of 
appendicular  opening  at  too  early  a  date.     It 

represents  a  safetv   valve  in  the  true  sense  of  the 

I.    and    may    persist,    just    covered    with    a    crust, 
oticed     by     the     patient      (writer's    observation). 
If  t!i  g  is  to  be  kept   patent  and  more  secre- 

tion than  usually  seen  is  present,  the  serous  cover 
of  the  projecting  portion  of  the  appendix  above  the 
skin  may  be  removed  and  the  remaining  portion 
inverted  into  the  lumen  of  the  proximal  portion. 
If,  after  a  time,  reopening  of  the  appendicular  lumen 
be  desired,  this  is  a  simple  matter,  inasmuch  as  only 
the  most  distal  (intracutaneous)  part  contracts;  the 
rest  of  tlie  canal  remains  patent  (  Keatley). 

Definite   Closure   of  the   Appendicular   Opening. — 

erization  with  nitrate  of  silver  stick,  or  some 
kind  of  acid,  better  still,  with  a  pointed  Paquelin 
cautery,  will  be  found  effective. 

Results. — The  mortality  of  the  operation  is 
practically  nil.  The  few  deaths  that  have  been 
reported  were  not  due  to  the  operation  as  such. 
Immediate  as  well  as  late  results  have  been  very 
gratifying,  especially  in  cases  of  amebic  dysentery 
and  .he  various  forms  of  chronic  ulcerative  colitis, 
that  had  baffled  internal  medication  and  irrigation 
and  colonic  flushing  from  below.  The  great  majority 
of  patients  were  cured,  gaining  many  pounds  in  a 
short  time. 

It  has  also  been  very  gratifying  to  see  cases  of 
chronic  syphilitic  ulcerative  affections  of  the  colon, 
but  particularly  those  of  tuberculous  character  yield 
to  irrigation  and  medication  through  the  appendic- 
ular stump  in  a  way  that  one  might  rightly  call  the 
patients  cured  (Pringle,  Willy  Meyer). 

There  can  be  no  doubt  that  the  operation  of  appen- 
dieostomy  represents  a  most  effective  addition  to 
our  surgical  means  of  treating  diseases  of  the  large 
intestine.  Affections  that  proved  extremely  obstin- 
ate, if  not  incurable  by  former  methods,  have  been 
Been  to  yield  nicely  to  the  treatment  made  possible  by 
appendicostomy.  The  operation  has  also  proved 
useful  in  a  number  of  other  intraabdominal  troubles 
and  as  an  operative  preventive  against  recurrence 
in  cases  of  intussusception  of  the  ileocecal  variety. 

Willy  Meyer. 

Appetite. — While  frequently  used  to  include  sexual 
desire,  the  craving  for  various  narcotics  and  stimu- 
lants, and  while  it  might  appropriately  include  the 
appreciation  of  a  need  for  water,  oxygen,  etc.,  the 
term  appetite  is  commonly  limited  to  the  desire  to 
ingest  more  or  less  solid  and  nutritious  material. 
Hunger  indicates  an  actual  deficiency  of  nutriment, 
with  or  without  the  realization  of  such  deficiency. 
Appetite  implies  a  mild  degree  of  hunger,  but  em- 
phasizes the  subjective  sensation  and  implies,  also,  a 
greater  or  lesser  anticipation  or  realization  of  gustatory 
pleasures.  The  more  closely  we  approch  natural  con- 
ditions, the  more  nearly  synonymous  do  appetite 
and  hunger  become;  that  is  to  say,  appetite  consists 
more  of  an  actual  desire  for  food,  without  much  re- 
gard to  its  taste  and  flavor,  while  the  more  artificial 
the  conditions  and  the  less  genuine  hunger  exists,  the 
more  appetite  involves  social,  esthetic,  and  gustatory 
pleasures.  But,  even  in  a  state  of  nature,  most  ani- 
mals exhibit  certain  preferences  for  food,  not  en- 
tirely explicable  on  metabolic  grounds,  and  are  liable 
to  overeat  if  opportunity  presents  itself.     However, 


in  general,  the  rat  me  of  appetite  indicated  by  the 
herbivorous,  graminivorous,  carnivorous,  omnivi  u 
corresponds  quite  clo  ely  to  the  digestive  and  metab- 
olic capacities  of  the  organism       Vn  artificial  appetite 

i    nut,  as  is  sometimes  imagined,  confined  to  human 

beings,  but  is  displayed  by  many  lower  animals  in 
captivity  or  actually  domesticated.  Cattle  are  said 
to  be  fed  to  some  extent  on  salt  fish  in  arctic  region 
cats,  dogs,  and  horses  usually  develop  a  taste  for 
sugar,  and  in  the  la-t  feu  years  it  ha-  become  quite 
common  for  eats  kept  in  drug  stores  to  eat   ice  ,  i  ea  Da, 

while  dogs  not  belonging  on  the  premises  often  hang 
about  soda  fountains  on  the  chance  of  having  this 
appetite  gratified.  <  hie  of  the  strangest  appetites 
among  the  lower  animals  that  has  come  to  the  at  ten- 
don of  the  writer  was  instanced  by  a  cat  for  musk 
melons. 

Appetite  is  commonly  regarded  as  a  pneumogastric 
reflex  and  properly,  in  so  far  as  it  is  appeased  by  the 
distention  of  the  rugs  with  even  innutritious  material 
and  brought  into  play  by  the  emptiness  of  the  stom- 
ach. Except  in  this  transitory  sense,  appetite  cor- 
responds fairly  well,  both  quantitatively  and  qualita- 
tively, to  the  actual  needs  of  the  body,  for  caloric 
energy,  protein,  carbohydrate,  salines,  antiscorbutics, 
etc.  No  adequate  explanation  of  this  can  be  offered. 
In  diabetics,  the  use  of  saccharin  temporarily  cloys 
the  appetite  for  sweets  but  does  not  satisfy  the 
ultimate  desire  for  carbohydrates.  In  certain  in- 
dividuals, the  carbohydrate  appetite  is  mainly  for 
sugars,  in  others  for  starches,  but  free  indulgence  in 
cither  satisfies  the  appetite  for  both,  though  not 
necessarily  changing  the  general  personal  appetite; 
which  indeed  is  usually  persistent.  There  is  also  a 
qualitative  appetite  for  protein,  especially  for  meat 
protein  which  is  not  appeased  by  food  in  general, 
though  obviously  habit  has  much  to  do  with  such 
appetites  and  a  mera  preference  for  an  excess  of 
meat  may  be  controlled  by  an  abundance  of  other  food. 
It  is  doubtful  whether  an  appetite  for  iron,  iodine, 
and  various  salines  can  be  demonstrated,  but  there  is 
a  distinct  appetite  for  salt,  seen  in  both  man  and  the 
lower  animals;  and,  on  account  of  the  formation  of 
HC1  from  NaCl  and  the  special  need  of  HC1  in  pro- 
teolysis, the  craving  for  salt  is  especially  marked  in 
persons  with  relatively  carnivorous  tastes  and  ten- 
dencies to  hyperchlorhydria.  There  is  also  a  dis- 
tinct appetite  for  antiscorbutics.  For  instance,  dur- 
ing the  Civil  War,  a  company  of  soldiers  who  had 
subsisted  largely  on  hardtack  and  salt  meat  for  some 
weeks  and  among  whom  cases  of  camp  diarrhea  and 
mild  scurvy  had  developed,  entered  a  field  of  half  frozen 
and  decayed  cabbages.  Some  of  the  sick  men  were 
so  ravenous  for  fresh  vegetable  food  that,  despite  the 
protests  of  their  comrades,  they  ate  large  quantities  of 
cabbage — and  were  cured  of  their  prostration,  skin 
lesions,  and  diarrhea.  The  antiscorbutic  appetite  is 
sometimes  depressed  by  overindulgence  in  candy,  etc., 
or,  more  frequently,  in  alcoholics.  The  writer  has 
had  two  marked  cases  of  scurvy  develop  in  persons 
with  no  other  reason  for  deprivation  and  cured  by 
diet  of  fruits. 

Occasionally,  although  the  hunger  is  assuaged  by 
meals  and  the  appetite  is  small,  there  is  a  vague 
hankering  after  something  which  the  patient  cannot 
identify.  Finally,  usually  quite  accidentally,  some 
particular  viand  is  encountered  which  "hits  the  spot," 
satisfies  the  craving,  and  improves  the  appetite  and 
the  nutrition. 

There  is  considerable  dispute  as  to  the  degree  to 
which  a  natural  appetite  is  protective  against  actually 
toxic  or  harmful  substances.  Barring  actual  adultera- 
tion or  tainting  of  food,  many  persons  can  eat  with 
impunity  anything  for  which  they  have  an  appetite, 
however  unwholesome  it  may  seem,  while,  owing  to 
some  idiosyncrasy,  even  very  slight  amounts  of  theo- 
retically wholesome  food  which  is  distasteful  will  cause 
nausea,  diarrhea,  etc.     The  lower  animals  are  often 

499 


Appetite 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


supposed  to  be  protected  by  instinct  against  toxic  and 
harmful  foods.     This  is  not,  however,  the  case. 

It  is  also  contended  that  a  perfectly  natural  appetite 
corresponds  quantitatively  to  the  demands  of  the 
system,  and  that  ingestion  in  excess  of  metabolic 
demands  is  an  artificially  acquired  vice.  Observa- 
tion, however,  shows  that,  on  the  one  hand,  the 
average  appetite  of  civilized  persons  is  not  much 
beyond  the  theoretical  demand  in  calories,  not  far- 
ther beyond  this  limit, indeed,  than  a  fair  margin  of 
safety  requires.  On  the  other  hand,  among  both 
human  savages  and  the  lower  animals,  we  find  that 
periods  of  enforced  abstinence  alternate  with  periods 
of  excessive  ingestion. 

The  relation  of  the  appetite  curve  to  fasting  periods 
is  another  interesting  problem.  The  herbivorous 
animals  spend  most  of  their  time  when  awake  in  eat- 
ing. Carnivorous  animals,  including  omnivorous 
and  primitive  man,  eat  at  irregular  intervals,  but  it  is 
not  far  from  the  truth  to  say  that  they  eat  whenever 
and  as  much  as  they  can.  In  a  state  of  civilization, 
most  individuals  and  races  or  social  groups  have 
established  customs  regarding  the  frequency  and 
relative  amounts  of  different  meals.  To  some  degree, 
these  customs  depend  upon  occupation,  wealth,  etc., 
but  only  approximately  so.  The  change  in  meal 
hours,  in  the  relative  importance  of  different  meals, 
etc.,  which  has  occurred  in  this  country  within  the 
last  one  or  two  generations,  is  largely  due  to  diminu- 
tion of  physical  exercise  and  the  impossibility  of 
reaching  home  in  the  middle  of  the  day. 

The  relation  of  appetite  to  physiological  conserva- 
tion of  nutriment  is  an  interesting  corollary.  Not 
to  mention  the  various  problems  in  regard  to  storage 
and  utilization  of  fats,  it  is  commonly  held  that  the 
body  has  extremely  limited  capacity  for  storage  of 
protein  and  carbohydrate.  Yet  we  are  developing 
on  a  large  scale  an  appetite  for  a  very  small  breakfast, 
a  moderate  luncheon,  and  a  hearty  dinner,  the  last, 
representing  at  least  half  the  caloric  energy  of  the 
total  ration,  being  taken  at  the  close  of  one  day's 
work  and  about  fourteen  hours  before  the  next  begins. 
With  so  marked  a  discrepancy  between  empiricism 
and  theory,  the  whole  question  of  conservation  of 
protein  and  carbohydrate  needs  further  study. 

Appetite  is  well  known  to  depend  upon  a  great 
variety  of  sensory  impressions  and  mental  concep- 
tions. Taste,  smell,  and  to  a  scarcely  less  degree 
sight,  may  either  stimulate  or  inhibit  appetite. 
Sensations  of  temperature  and  touch  have  a  similar 
action,  according  to  rather  arbitrary  customs  that 
certain  foods  shall  be  hot,  others  cold,  and  that 
homogeneity  and  softness  are  a  desideratum  in  some, 
while  in  others,  as  crackers,  bread,  mousse,  etc.,  the 
opposite  qualities  are  desired.  The  sense  of  equi- 
librium has  an  important  negative  bearing  on  appe- 
tite, as  illustrated  in  seasickness.  Sound  can  scarcely 
be  said  to  have  any  influence  on  appetite  except  in 
the  general  way  that  any  agreeable  or  disagreeable 
sensation  may  act  upon  the  mind.  Excessively 
loud  noises,  however,  if  continued,  may  affect  the 
appetite  on  account  of  the  simultaneous  vibrations  of 
the  semicircular  canals.  Any  conception,  however 
suggested,  as  directly  through  any  of  the  special 
senses  or  indirectly  through  memory,  may  affect  the 
appetite  in  either  way.  Thus  there  is  a  germ  of 
truth  in  the  old  story  of  the  man  who  tied  his  com- 
panion before  taking  poison  but  whose  life  was 
nevertheless  saved  by  the  latter's  presence  of  mind 
in  narrating  a  disgusting  tale.  Pawlow's  investiga- 
tions have  verified  and  extended  what  has  long  been 
known:  That  smell,  taste,  and  sight  of  food  produce 
appetite  by  stimulating  digestive  secretions  which, 
on  the  contrary,  are  inhibited  by  fear,  anger,  and 
excitement. 

Disturbances  op  Appetite. — Anorexia,  lack  of 
appetite,    though    usually    a    symptom    of    disease, 

500 


locally  digestive  or  general,  is  often  conservative. 
Even  when  there  is  interference  with  the  special 
senses  of  taste  and  smell,  appetite  commonly  remains, 
indeed  in  a  purer  type  than  usual  because  these  two 
special  senses  are  eliminated.  Occasionally,  howe\  er. 
there  is  no  true  appetite  and  the  individual  eats 
merely  on  account  of  a  feeling  of  weakness  or  as  an 
intelligent  act  to  furnish  nutrition.  Such  cases  seem 
to.be  due  mainly  to  stoicism  and  habitual  repression 
of  self-indulgence,  but  they  are  also  found  in  mild 
cases  of  melancholia  among  which  may  perhaps  be 
included  nostalgia. 

Hi/pcrorexia  or  Bulimia. — As  the  limitation  of 
appetite  depends  mainly  on  a  reflex  from  the  disten- 
tion of  the  gastric  rugae,  bulimia  is  not  so  much  the 
cause  as  the  result  of  dilatation  of  the  stomach, 
without  marked  pyloric  obstruction.  It  is  also 
encountered  in  various  conditions  in  which  excito- 
reflex  stimuli  are  obtunded;  as  in  general  paresis, 
various  forms  of  insanity,  often  in  old  age.  Some- 
times, the  enormous  appetite  is  merely  an  expression 
of  a  delusion  of  grandeur.  Bulimia  is  popularly 
regarded  as  a  symptom  of  tape-worm  and  ascribed 
to  the  demands  of  the  parasite.  This  explanation  is, 
of  course,  absurd,  as  even  the  development  of  the 
fetus,  whose  size  and  metabolism  are  very  much 
greater,  causes  no  marked  bulimia.  The  more 
accepted  explanation  is  that  the  craving  is  due  to  the 
toxic  or  mechanical  irritation  of  the  parasite  but,  in 
the  writer's  experience,  it  is  very  seldom  that  an 
explanation  is  required,  as  the  bulimia  does  not 
exist  except  in  a  small  minority  of  cases.  It  should 
not  be  forgotten  that  the  diagnosis  of  bulimia,  like 
that  of  gastric  dilatation,  requires  a  weighing  of 
conditions  and  not  merely  a  measurement  of  ingesta. 
An  ox-appetite  is  normal  for  one  doing  ox  work. 
The  excessive  mental  and  physical  activity  and 
actual  building  of  tissues  by  growing  boys,  require 
an  amount  of  food  that  the  larger  adult,  repeating 
the  same  mental  tasks  instead  of  passing  constantly 
to  new  ones,  exercising  gently,  and  merely  making 
good  the  waste  of  fully  formed  tissues,  is  inclined  to 
regard  as  excessive.  In  young  adults,  an  excessive 
ingestion  is  often  due  not  to  a  genuine  appetite  but 
to  the  notion  that  physical  and  mental  strength  can 
be  increased  by  depositing  nutriment  as  one  would 
deposit  money  in  a  bank.  Idle  persons  also  eat  as  a 
means  of  diversion  and  it  is  probable  that,  in  addition 
to  mild  pathological  failures  of  digestion  and  absorp- 
tion, the  physiological  economy  of  utilization  really 
relaxes  so  that  more  food  is  needed.  It  is  said  that 
under  the  Roman  empire  it  was  quite  a  common 
practice  to  prolong  the  pleasure  of  eating  by  thrusting 
the  finger  down  the  throat  after  the  stomach  had  been 
filled,  so  as  to  allow  a  repetition  of  the  process  without 
delay.  The  writer  has  encountered  one  such  ease,  in 
an  otherwise  dainty  and  refined  old  maid.  This 
patient  is  thin.  Indeed,  bulimia  is  very  apt  to  be 
attended  by  poor  nutrition  and  slight  deposition  of 
fat  and,  conversely,  fat  persons  are  usually  light 
eaters. 

Perverted  Appetites  and  Cravings. — It  is  extremely 
difficult  to  draw  hard  and  fast  lines  between  natural 
and  artificial  appetites  and  between  the  latter  and 
perverted  cravings.  At  one  time  or  another,  nearly 
every  plant  and  animal  has  been  used  as  a  food,  and 
the  esthetic  notions  with  regard  to  what  substances 
are  proper  and  what  improper  foods,  are  difficult  to 
explain.  Many  persons  would  no  more  eat  frogs' 
legs  than  snakes;  or  horse  meat  than  dog  or  cat  flesh. 
In  the  eighteenth  century,  tea  leaves  were  eaten  like 
greens.  Until  about  the  middle  of  the  nineteenth, 
tomatoes  were  called  love  apples — the  term  persists 
in  some  sections — and  were  used  only  as  table  orna- 
ments. Urodipsia  may  be  merely  suggested  by 
olives  but  has  a  close  analogue  in  the  use  of  kidney. 
Coprophagia,  at  first  thought  not  merely  a  perversion 
but  an  insane  perversion  of  appetite,  is  duplicated  by 


REFERENCE    HANDBOOK    0]     THE    MEDICAL   SCIENCES 


A|ir;i  \la 


(he  routine  and  inevitable  use  of  deer  intestine  with 
oontents  by  the  Indians,  as  affording  the  only  avail- 
;,i,;.  anti  scorbutic  food  in  winter;  also  by  the  practice 
of  serving  with  game  the  "  trail"  which  is  the  intestine 
and  usually  infested  with  parasites.  We  may  also 
pause  to  reflect  thai  the  hulrs  in  Swiss  cheese  are 
§ue  to  the  colon  bacillus  and  that,  in  cheeses,  high 
meal,  sour  milk  delicacies,  liqueurs  of  various  kinds, 
etc.,  nearly  every  possible  method  of  decomposition 
is  duplicated  in  food  stuffs. 

Pica,  the  eating  of  gravel,  clay,  plaster,  magnesia, 
tale,  slate,  etc.,  is  often  seen  in  very  small  children, 
nt  puberty,  especially  in  girls,  sometimes  in  pregnant 
v, , wnen.  Among  savages  and  sometimes  among  the 
poorer  classes  of  civilized  nations,  clay  eating  is  a 
re-ort  in  famine.  The  clay  habil  favors  the  entrance 
of  the  hook  worm.  When  we  consider  the  custom  of 
Qg  children,  of  putting  all  sorts  of  articles  in  the 
mouth,  and  the  pleasure  which  many  adults  derive 
from  "dry  smoking,"  holding  a  tooth-pick,  straw,  etc., 
in  the  mouth,  and  the  commercial  importance  of 
chewing,  we  must  analyze  each  case  carefully, 
to  distinguish  between  a  genuine  perverted  appetite 
and  a  men'  habit.  It  is  also  worth  while  to  remember 
that  a  good  many  vegetables  consisting  of  leaves, 
stalks  etc.,  are  only  slightly  richer  in  nutriment  than 
the  mineral  matters  discussed  under  the  head  of  pica. 

Peculiar  and  often  highly  individualized  cravings 
are  quite  often  encountered  in  pregnant  women, 
sometimes  in  fever  patients,  often  in  invalids,  espe- 
cially in  the  neurotic.  It  should  not  be  forgotten 
that  some  such  cravings,  as  for  pickles,  salt,  etc.,  may 
possibly  represent  a  genuine  need  of  the  body.  At 
any  rate,  if  the  craving  can  be  gratified  with  a  flavor, 
without  introducing  any  appreciable  quantity  of  a 
deleterious  substance,  it  is  much  better  to  gratify  it. 
For  instance,  a  few  whiffs  of  a  cigarette  after  an 
operation,  or  during  typhoid  fever,  may  cause  greater 
subjective  relief  than  three  centigrams  of  morphine, 
the  actual  amount  of  toxic  substances  introduced 
being  infinitcssimal.  In  other  instances,  the  craving 
may  be  for  something  not  deleterious  at  all  except 
that  it  is  not  ordinarily  given  in  the  particular  condi- 
tion and  that  it  should  not  be  given  in  any  consider- 
able amount — for  example,  a  very  little  sugar  or  soft 
fruit,  weak  coffee,  chocolate,  or  the  like,  may  be 
introduced  into  almost  any  dietary. 

A.  L.  Benedict. 


Apraxia. — This  term  was  first  used  by  Gogol  in 
is;:;  in  a  Breslau  thesis  on  Aphasia.  His  patient 
ate  his  soap,  urinated  in  his  water  pitcher,  and  was  de- 
BCribed  as  having  lost  his  understanding  for  objects. 
Such  defects  had  been  noted  before,  and  it  is  worthy  of 
note  that  Hughlings  Jackson  in  1866  called  atten- 
tion to  a  similar  type  of  phenomenon,  and  attached 
much  importance  to  it.  Quaglino  in  1S67  described 
a  case,  Finkelnburg  in  1S70  another,  in  which  recog- 
nition of  tilings  and  people  was  lost,  and  he  created 
the  term  asymbolia.  Wernicke  in  1S74  expanded 
the  term  asymbolia,  while  Freud  finally  utilized  the 
term  agnosia  to  cover  all  types  of  loss  of  sensory  or 
motor  object  images,  apraxia  then  being  arranged 
as  a  form  of  loss  of  knowledge  of  objects,  really  a 
form  of  visual  agnosia. 

From  this  early  use  of  the  term  apraxia  there  has 
been  a  distinct  variation,  brought  prominently  into 
the  foreground  by  Liepmann  in  1900.  He  defined 
the  disturbance  as  a  lack  of  knowledge  of  the  use  of 
objects,  although  there  was  no  true  agnosia  or  loss 
of  recognition  of  what  they  were.  Out  of  the  later 
studies  of  Liepmann,  Pick,  von  Monakow,  D'Hollander 
and  others  has  come  the  following  general  definition 
of  apraxia: 

It  consists  in  an  inability  to  perform  certain  sub- 
jectively purposeful  movements,  or  movement  com- 
plexes,  the   motor   power,   sensation,   and   coordina- 


tion being  intact.     Such   an   inability  will   naturally 
depend    upon    at     least     three    factors;    one     may     be 

unable  to  recognize  the  object  which  is  to  be  u  ed,  in 

which  case  we  can  speak  of  a  sensmv  apraxia.  in  the 
sense  as  one  speaks  of  a  sensory  aphasia,  or  a 
visual  agnosia.  Should  the  patient  recognize  the 
object,  call  it  perhaps  by  name,  slate  its  use,  and  yet 
in  attempting  to  use  it  totally  fail  in  proper  motor 
act,  one  speaks  of  a  motor  apraxia.  It  being  under- 
stood   here   that,   there  is   no   necessary  change  in   the 

motor  tire,  with  either  incoming  sensory  or  outgoing 

motor  side.  Thus  one  can  speak,  as  \\  ilsmi  has  done, 
of  a  motor  aphasic  as  having  an  apraxia  of  his  speech 
musculature.  In  grave  intracerebral  changes  the 
knowledge  of  the  proper  kinetic  images  to  carry  out 
purposeful  actions  in  the  arms  and  legs  may  be  com- 
plexly involved.  Hen'  one  speaks  of  an  intrapsychic 
•da.  Clinically  it  is  usually  overlaid  in  the  gen- 
eral psychic  loss,  often  spoken  of  loosely  as  dementia. 

Apraxia  may  be  then  either  sensory  or  motor;  it 
may  be  unilateral  or  bilateral,  it  may  be  extensive, 
involving  many  muscular  groups  or  may  be  limited 
to  a  few,  such  as  an  inability  to  protrude  the  tongue 
on  demand  with  perfect  power  in  other  movements, 
or  closure  of  the  eyelids,  etc. 

A  certain  patient  with  motor  apraxia  on  being 
given  a  cigarette  holder  and  cigarette  recognized 
the  objects,  said  they  were  for  smoking,  but  on  being 
told  to  put  them  together  was  unable  to  make  the 
correct  movements,  and  finally  gave  up.  Another 
patient  was  given  a  candle  and  a  match-box.  She 
took  out  a  match,  made  rubbing  movements  with 
it  in  the  air  above  the  candle,  and  then  reinserted  it 
in  the  box. 

In  Liepmann's  celebrated  case  the  patient  was  able 
to  do  things  with  his  left  hand,  but  failed  entirely 
with  Iris  right.  When  told  to  brush  the  examiner's 
coat,  he  picked  up  a  corner  of  it  carefully  in  his  left 
hand,  then  picked  up  the  brush  in  his  right  hand, 
with  which  he  made  movements  as  if  to  brush  his 
hair.  Asked  to  pour  water  into  a  glass  from  a  carafe, 
he  grasped  the  carafe  with  his  left  hand  to  pour 
water  into  the  glass  held  in  the  right  hand,  after 
which  the  glass  was  brought  to  the  mouth  without 
any  water  in  it.  These  patients  fail  to  carry  out  the 
simple  commands  to  blow  a  kiss,  make  a  threatening 
fist,  soldier's  salute,  etc. 

In  ideomotor  apraxia  the  situation  is  more  compli- 
cated. One  patient  given  a  tooth  brush  recognized 
it,  then  began  to  brush  his  beard  with  it  clumsily; 
another  being  given  a  pistol  which  he  named  cor- 
rectly, on  being  told  to  shoot  it  grasped  the  barrel, 
blinked  and  put  the  muzzle  into  his  left  eye.  Another 
patient,  being  given  a  cigar  and  a  match-box  opened 
the  latter,  stuck  the  cigar  in  it,  and  tried  to  shut 
the  box  as  though  it  were  a  cigar  cutter.  Then 
taking  the  cigar  out  rubbed  it  on  the  side  of  the  box 
as  though  it  were  a  match.  The  entire  order  of  pro- 
cedure was  badly  devised. 

Like  aphasia,  apraxia  is  largely  implicated  in  left 
hemisphere  lesions.  It  is  usually  due  to  a  supra- 
capsular  lesion. 

In  left  hemisphere  disease,  the  apraxia  may  be 
homo-or  heterolateral,  and  in  homolateral  apraxias 
the  corpus  callosum  is  usually  involved.  In  left 
frontal  disease  apraxia  has  been  found  especially 
with  lesions  of  the  first  and  second  frontal  convolu- 
tions. Anything  that  brings  about  an  isolation, 
diaschisis  of  the  left  frontal  area  from  the  right, 
frontal  area  will  seem  to  bring  about  an  apraxia,  or 
when  there  is  any  isolation  of  the  left  frontal  from 
other  parts  of  the  cortex. 

Naturally  a  great  diversity  of  pathological  condi- 
tions may  happen  to  bring  such  associations  to  pass. 
Thus  an  apraxia  is  to  be  looked  for  in  tumors,  paresis, 
multiple  sclerosis,  hemorrhages,  etc. 

The  subject  of  apraxia  is  well  discussed  bv  Wilson, 
Brain,  vol.  xxxi.,  1908,  p.  164;  by  D'Hollander,  Bull. 


501 


Apraxia 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


delaSoc.de  med.  mentale  de  Belgique,  1907;  by  Liep- 
mann,  Drei  Aufsatze,  Berlin,  190S;  Pick,  Studien 
iiber  motorische  Apraxie,  1905;  and  Glascock, 
Journal  of  Nervous  and  Mental  Disease,  1903. 

Smith  Ely  Jelliffe. 


Aquas. — Waters,  or  medicated  waters,  are  clear, 
aqueous  solutions  of  volatile  substances;  these  latter 
may  be  solid,  liquid,  or  gaseous.  They  are  prepared 
in  various  ways:  By  simple  solution  in  cold  or  hot 
water,  by  nitration  through  an  absorbent  powder,  by 
percolation  through  cotton  saturated  with  the 
substance,  and  by  distillation.  As  a  class  the  aquffi 
have  but  slight  medicinal  value,  and  deteriorate  if 
kept  for  a  long  time.  They  are  mainly  used  as 
vehicles  and  solvents.  In  the  U.  S.  P.  there  are 
nineteen  official  waters: 


V.  S.  P.  Latin  Title. 


Aqua 

Aqua  ammonue 

Aqua  ammonia  fortior.  .  - 
Aqua  amygdalae  amane... 

Aqua  anisi 

Aqua  aurantii  florum 

Aqua      aurantii      florum 
fortior. 

Aqua  camphora1 

Aqua  chloroformi 

Aqua  cinnamomi 

Aqua  creosoti 

Aqua  destillata 

Aqua  fcrniculi 

Aqua  hamamelidis 

Aqua  hydrogenii  dioxidi. . 

Aqua  menthre  piperita?. .  . 

Aqua  mentha?  viridis 

Aqua  rosse 

Aqua  rosa?  fortior 


Water. 

Ammonia  water 

Stronger  ammonia  water. 

Bitter  almond  water 

Anise  water. 

Orange  flower  water 

.Stronger  orange  flower 
water. 

Camphor  water 

Chloroform  water 

Cinnamon  water 

Creosote  water 

Distilled  water. 

Fennel  water 

Witch  hazel  water 

Solution  of  hydrogen  di- 
oxide. 

Peppermint  water 

Spearmint  water 

Rose  water 

Stronger  rose  water 


HJxv. 

5i 
5ss. 

5«s. 
oij- 

3>.i- 
5ss. 

oss. 
3u- 

5ss. 

5i.i. 
5i. 

Sss. 
3ss. 
5ss. 
3ij. 


R.  J.  E.  Scott. 


Aquifoliaceae. — Ilicineoe  (the  Ilex  or  Holly  family.) 
A  family  of  three  genera  and  some  200  species, 
chiefly  of  North  and  South  America.  It  is  chiefly 
notable  for  the  presence  of  an  appreciable  amount 
of  caffeine  in  the  leaves  of  at  least  two  species, 
on  account  of  which  they  have  been  used  as  bever- 
ages (see  Mate  and  Cassine).  Other  species  have 
been  used  as  bitter  tonics  and  alteratives  (see  Alder, 
Black,  and  Holly).  H.  H.  Rusby. 


Araceae. — Aroidere  (the  Arum  family.)  A  largo 
family,  of  more  than  100  genera,  growing  mostly  in 
the  tropics  of  both  hemispheres.  Many  species,  as 
the  cultivated  calla,  are  highly  ornamental.  Calocasia 
produces  an  important  starch-yielding  corm,  and 
monstera,  an  edible  fruit.  Many  of  the  tropical 
species  are  known  as  poisons,  but  their  constituents 
and  actions  are  little  known.  It  is  remarkable  that 
a  few  northern  species  in  the  genera  Spathyema, 
Acorus,  Arum,  and  Ariswma,  should  represent  about 
all  the  medicinal  contributions  of  the  family,  and 
more  active  agents  may  be  expected  to  be  made 
known  in  it  in  future.  H.  H.  Rusby. 


Arachnida. — In  the  branch  or  phylum  Arthropoda, 
characterized  by  bilateral  symmetry,  by  meta- 
meric  segmentation  of  a  heteronomous  type,  and  by 
the  possession  of  jointed  appendages,  typically  a 
single  p.'iir  for  each  mctamere  of  the  body,  may  be 
distinguished  five  great  groups:  the  Crustacea,  includ- 
ing crabs,  lobsters,  water  fleas,  etc.;  the  Onychophora 


including  but  a  single  genus,  Peripatus;  the  Myria- 
poda,  including  millipeds,  centipeds,  etc.;  the  Insecta, 
including  the  true  insects;  and  the  Arachnidaor  Arach- 
noidea.  The  latter  may  be  defined  as  air-breathing 
arthropods,  characterized  by  the  fusion  of  head 
and  thorax  into  a  single  region,  the  cephalothorax, 
which  is  without  antennae,  but  bears  two  pairs  of 
appendages  more  or  less  closely  connected  with  the 
mouth,  and  four  pairs  of  walking  legs.  The  abdo- 
men, which  may  or  may  not  be  segmented,  is  usually 
distinct  from  the  cephalothorax,  though  in  the  mites 
it  is  fused  with  it. 

The  class  Arachnida  is  subdivided  by  various  au- 
thorities into  from  seven  to  nine  orders,  among  which 
are  the  Scorpionida  or  true  scorpions,  the  Pseudo- 
scorpionida  or  book-scorpions,  the  Phalangida  or 
"Daddy  Long-legs,"  the  Araneida  or  true  spiders, 
the   Acarida  or  mites,  and  the  Linguatulida. 

The  true  scorpions  have  the  power  to  inflict  a  pain- 
ful wound  by  the  sting  located  at  the  tip  of  the  abdo- 
men. In  the  case  of  large  tropical  species  the  effect, 
of  the  sting  may  even  cause  the  death  of  small 
children,  but  only  in  the  most  exceptional  cases  does 
it  seriously  affect  an  adult.  There  is  injected  at  the 
time  a  quantity  of  poison  from  a  gland  in  the  last 
joint  of  the  abdomen;  its  action  is  in  general  to  irri- 
tate nerve  centers  while  at  the  same  time  producing 
paralysis  of  motor  nerves.  The  sting  of  the  smaller 
species  found  in  the  United  States  is  harmless,  giving 
rise  to  a  slight  irritation,  which  lasts  at  most  seven  or 
eight  days.  Mr.  Herbert  H.  Smith,  the  well-known  col- 
lector in  South  and  Central  America  and  the  West 
Indies,  after  enumerating  symptoms  and  results  in  a 
number  of  carefully  observed  instances,  says:  "Prob- 
ably death  might  result  in  some  cases,  as  (if  reports  are 

true)  it  does,  rarely,  from  bee  stings My 

wife  was  stung  by  a  small  one;  the  wound  was  exceed- 
ingly painful.  By  the  advice  of  a  servant,  she  held 
the  finger  for  an  hour  in  hot  sweet  oil,  mixed  with  an 
equal  measure  of  laudanum.  There  was  no  swelling 
and  three  hours  after  all  pain  had  left  her." 

In  Africa  scorpion  sting  is  not  regarded  so  lightly 
and  the  occurrence  of  gangrene  as  a  result  is  on  record 
while  a  brawny  swelling  and  more  or  less  collapse  are 
the  usual  sequels  for  adults  save  in  natives  who  seem 
to  have  developed  some  immunity.  In  children 
under  twelve  the  sting  produces  an  effect  not  unlike 
tetanus.  An  antiserum  for  scorpion  venom  has  been 
prepared  and  used  by  Todd  at  Cairo  and  in  upper 
Egypt.  It  appears  to  have  a  marked  palliative 
effect  on  the  intense  pain  following  the  sting,  but  in 
spite  of  its  use  some  young  children  have  not  survived 
the  effects  of  the  scorpion  poison. 

Among  the  spiders  also  there  are  those  that  are 
able  to  pierce  the  human  skin  by  the  action  of  the 
jaws  or  chclicerce  which  also  contain  the  orifices  of  a 
pair  of  poison  glands.  The  effect  of  a  spider's  bite  on 
an  adult  has,  however,  been  much  exaggerated;  of 
itself  the  bite  produces  at  most  a  slight  dermal  swell- 
ing which  soon  disappears.  The  large  hairy  thera- 
phosids,  popularly  known  as  tarantulas,  are  not  to  be 
called  dangerous.  Their  bite  is  painful,  but  the 
inflammation,  though  often  violent,  subsides  rapidly. 
On  the  other  hand,  several  cases  on  record  of  death 
from  spider's  bite  have  been  traced  to  a  small  spider 
(Latrodectus  viactans)  which  is  related  to  supposedly 
poisonous  species  in  other  countries  of  the  world,  and 
it  is  not  unlikely  that  the  spiders  of  this  genus  secrete 
a  more  powerful  fluid  than  others.  The  condition  of 
the  patient,  his  susceptibility  to  poison,  and  other 
important  facts  are  not  on  record  in  these  cases,  and 
it  may  happen  that  the  chance  introduction  of  extra- 
neous matter  through  the  bite  has  given  rise  to  the 
more  serious  and  rarely  to  the  fatal  results  noted. 
There  are  no  spiders  in  this  country  of  which  it  may 
positively  be  affirmed  that  they  are  venomous,  though 
certain  South  American  species  enjoy  an  evil  reputa- 
tion which  is  undoubtedly  well  founded. 


502 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    Si'IKVKS 


Arachnlrla 


I.i\i;i!.\tulida. — The  highly  modified  forma  in- 
cluded in  this  group  have  a  certain  superficial  resem- 
blance  to  tapeworms,  From  which,  however,  they 
differ  radically  in  structure.  Their  closest  affinities 
are  doubtless  to  be  found  among  the  arachnids  of 
which  they  arc  here  considered  as  an  order.  Accord- 
ing to  Sambon  their  structure,  their 
blood-sucking  habit,  and  the  pari 
they  play  in  fostering  the  sporogonic 
cycle  of  the  haunogregarines  peculiar 
to  their  respective  reptilian  hosts, 
suggest  relationship  to  the  ectopara- 
site Ixodidse. 

The  body  (Fig.  260)  is  elongate, 
cylindrical  or  flattened;  the  anterior 
end  (cephalothorax)  is  more  or  less 
clearly  marked  off  from  the  rest 
(abdomen),  which  is  subdivided  by 
ambulations  variable  in  number  and 
distinctness.  At  the  blunter,  ante- 
rior end  the  mouth  is  located  on  the 
ventral  surface  and  provided  on  either 
side  with  two  protractile  hooks,  con- 
tained in  sheaths  or  pockets.  These 
hooks  represent  the  mouth  parts  of 
other  arachnids,  while  other  append- 
ages are  entirely  lacking.  There  is 
no  special  respiratory  apparatus,  and 
the  so-called  stigmata  are  but  the 
orifices  of  dermal  glands.  At  the 
posterior  end  may  be  found  the  anal 
opening. 

The  linguatules  are  of  separate 
sexes,  the  males  being  much  the 
smaller.  The  female  genital  pore  is 
located  near  the  anus,  the  male  on 
the  ventral  surface  near  the  anterior 
end  of  the  abdomen.  The  adults 
live  in  the  nasal  cavities  and  lungs 
of  mammals  or  reptiles,  and  the  eggs, 
produced  here  in  large  numbers,  must 
be  imported  by  chance  into  a  suitable 
guatula  rhinaria,  secondary  host  in  which  they  give 
female.  Natural  rise  to  tetrapod,  acariform  embryos 
size.  (After  (Fig.  261,  b)  that  metamorphose  into 
Br»un.)  a  second  stage  (nymph,  Fig.  261,  c), 

manifesting  the  main  features  of  the 
adult.  By  a  migration  usually  semi-passive,  this 
form  reaches  the  primary  host  and  attains  full  de- 
velopment in  it. 

Linguatula  Frohlich. —  Body  flattened,  with  arched 
dorsum  and  crenated  margins.  Body  cavity  extend- 
ing into  the  lateral  regions  of  the  rings  (pectinate). 


Fig.  261. — Linguatula  rhinaria,  Stages  of  Development. 
(  After  Leuckart.)  a,_  Egg  with  embryo;  6,  free  embryo;  c,  nymph 
or  pupa.     Magnified." 

Linguatula  rhinaria  Pilger  =  Pentastoma  tmnioides 
Rud. — Larva  =  P.  denticulatum  Rud.  and  P.  ser- 
ratum  Frohlich. — Body  lanceolate,  attenuated  pos- 
teriad;  head  rounded,  annuli  circa  90,  hooks  acumi- 
nate, enlarged  toward  the  base,  with  basal  joint 
elongated  proximad.    Female  S0-100  mm.  long,  8-10 


nun.  broad  anteriorly,  2  mm.  posteriorly.      Male  1  8-20 
mm.  long  by  '■'>  mm.  broad,  decreasing  to  0.5  mm. 

The  adult  inhabits  the  nasal  cavities  of  many 
mammals,  particularly  the  carnivora,  among  which 
the  dog  is  perhaps  most-  commonly  infested.  The 
larva  occurs  in  the  viscera  of  the  herbivorous  mam- 
mals. The  masses  of  eggs  containing  well-de- 
veloped embryos  are  deposited  by  the  adult  female 
n  the  nasal  mucus  and  distributed  over  grass,  etc., 
with  which  they  are  swallowed  chiefly  by  rabbits, 
but  even,  as  on  salads,  by  man  himself.  Hatched 
in  the  stomach  the  larva;  penetrate  the  intestinal 
wall  and  encyst  in  liver  or  mesentery,  where  after 
nine  eedyses  covering  a  period  of  from  five  to  six 
months,  they  reach  the  second 
stage,  characterized  by  the  rows 
of  retrorse  spines  on  each  an- 
nulus.  From  the  liver  they 
may,  as  some  maintain,  wander 
out  actively  and  if  eaten  by  a 
dog  reach  the  nasal  cavities  di- 
rectly; or  they  may  await  the 
consumption  of  the  flesh  by 
some  carnivorous  form,  in 
which  case  they  are  set  free  in 
the  stomach  and  wander  through 
the  tissue  to  the  lungand  thence 
by  the  air  passages  to  their 
final  location.  Some  authorities 
deny  the  possibility  of  the  larva 
deserting  its  cyst  and  wander- 
ing out,  and  maintain  that  the 
transmission  is  always  passive. 
In  man  older  cysts  regularly 
become  calcified. 

Rare  instances  of  the  occur- 
rence of  the  adult  in  man  are 
on  record,  probably  due  to  tin1 
consumption  of  poorly  cooked 
flesh  (mutton)  containing  the 
larva3.  The  larva  (Fig.  262)  has 
been  reported  frequently  as  a 
human  parasite,  chiefly  from 
Germany  and  Austria.  Most 
commonly  found  in  the  liver,  it 
has  also  been  met  with  in  other 
viscera.  Here  it  occurs  in 
sharply  defined  yellow  tumors,  embedded  in  the  sub- 
stance of  the  liver  or  protruding  somewhat  from  its 
surface.  The  tough  capsule  contains  caseous  or  cal- 
careous contents,  and  varies  in  diameter  from  about 
1  cm.  to  the  size  of  a  pea.  The  capsules  are  less  fre- 
quently found  scattered  irregularly  over  the  surface  of 
the  peritoneum.  The  parasite  is  probably  innocuous, 
as  its  presence  has  not  been  suspected  previous  to 
autopsies,  at  which  Virchow  reported  the  parasite  in 
Wurzburg  and  Berlin  and  Wagner  in  Leipsig.  Frerichs 
found  it  in  Breslau  five  times  in  forty-seven  autopsies, 
Zenker  found  it  in  Dresden  nine  times  in  168  cases, 
Heschl  at  Vienna  five  times  in  twenty;  Klebs  at 
Basel,  however  only  twice  in  1,914  cases.  Laengner 
recently  records  fifteen  in  500  autopsies  in  Berlin; 
the  larva?  were  found  seven  times  in  the  liver,  seven 
t  imes  in  the  intestinal  wall  and  once  in  the  mesentery. 
He  believes  this  parasite  is  frequent  and  often  over- 
looked. The  adult  occurs  in  seven  per  cent,  of  the 
dogs  examined  in  Berlin.  I  have  one  record  of  its 
presence  in  man  in  this  country,  although  it  has  been 
reported  rarely  from  other  hosts  (rabbit  and  cattle). 

This  case  of  infection  with  Linguatula  serrata,  the 
larval  form  of  L.  rhinaria,  has  been  reported  by 
Darling  and  Clark  from  the  Canal  Zone.  At  the 
autopsy  of  a  Nicaraguan,  a  larval  linguatulid  was 
found  crawling  over  the  cut  surface  of  the  lung  and 
along  the  pleura.  It  was  the  only  specimen  present 
and  its  exact  location  during  the  life  of  the  host  could 
not  be  determined  in  spite  of  careful  search.  This  is 
the  first  instance  on  record  cf  the  occurrence  of  this 


Fig.  262.— Lingua- 
tula denticulata,  Larva 
of  L.  rhinaria.  (After 
Leuckart.)    Magnified. 


503 


Arachnida 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Fig.  263. — Nymphal  Stage 
of  Porocephalus  arinillatus  in 
the  liver.     (After  Sambon.) 


parasite  in  a  native  of  the  American  continent. 
Two  cases  have  been  observed  at  Ancon  Hospital 
during  the  past  six  years.  The  other,  a  larva  also, 
having  been  taken  from  the  feces  of  a  resident.  _  The 
adult  parasite  has  never  been  found  in  that  territory. 
Porocephalus. — Body  cylindrical;  body  cavity  con- 
tinuous. 

Porocephalus  arniillatus  (Wyman)  =  Linguatula 
armillata  Wyman. — Larva  =  L.  diesingii  van  Ben.; 
Pentastomum  constrictuin  v.  Siebold;  Nematoideum 
hominis  (viscerum)  Diesing.  Color  in  life  lemon 
yellow;  in  preserved  specimens  ivory  white.  Elon- 
gate, vermiform;  female  9  to  13  mm.  long  by 
5  to  9  mm.  broad,  with 
eighteen  to  twenty-two 
rings  in  body;  male  3  to 
4.5  mm.  long  by  3  to  4 
mm.  broad,  with  sixteen  to 
seventeen  rings,  cylindrical 
anteriorly,  tapering  poste- 
riorly, end  bluntly  conical. 
Eggs  double  shelled,  0.10S 
by  0.08  mm.  Embryo  0.092 
by  0.072  mm.  Nymph 
when  encysted  coiled  in  a 
more  or  less  complete  circle 
with  ventral  surface  convex 
(Fig.  263)  occurring  in  a  great  variety  of  hosts. 
Sambon  lists  sixteen  positive  cases  from  man;  the 
list  would  doubtless  be  greatly  extended  by  full 
records  from  Africa  where  the  parasite  certainly 
is  common.  It  may  be  looked  for  in  travelers, 
missionaries,  and  others  who  have  visited  the  in- 
fected region.  Discovered  in  a  West  African  python 
by  Dr.  Savage  and  described  by  Dr.  Wyman  of 
Boston,  it  has  been  found  since  then  in  other  pythons 
and  puff  adders  throughout  the  Ethiopean  region. 
It  is  the  larval  form  which  occurs  in  man,  encysted 
in  the  liver,  lungs  and  mesenteric  glands.  This 
species  is  frequently  reported  in  Africa  and  once  from 
Jamaica  in  a  recently  introduced  slave.  Other 
records,  such  as  those  of  Flint  from  Missouri,  Sanchez 
from  Mexico,  and  Osier  from  Johns  Hopkins  Hospital, 
are  at  least  in  fault  in  diagnosing  the  species  pre- 
sent ;  in  some  of  these  cases  it  is  clear  that  the  para- 
site did  not  belong  to  this  group  at  all.  Successful 
artificial  infection  experiments  were  carried  out  in 
Africa  on  natives  suffering  from  sleeping  sickness. 

Porocephalus  moniliformis  (Diesing)  Adult  =  Pen- 
tastomum moniliforme  Leuckart.  Much  like  the 
former  species  but  slenderer,  tapering  more  caudad. 
Male  2o  mm.  long,  2.5  mm.  broad,  with  twenty-six 
rings;  female  with  twenty-eight  to  thirty-one,  70  to 
90  mm.  long,  4  to  7  mm.  broad  in  maximum. 

This  species  belongs  to  the  Oriental  region:  India, 
China,  Philippines,  East  Indies,  etc.,  where  the  adult 
occurs  in  the  pythons  and  the  nymph  encysted  in 
many  hosts,  including  man.  Of  the  two  human 
cases  on  record,  that  of  Herzog  and  Hare  concerns  a 
native  Filipino  who  died  in  Manila  of  tuberculosis. 
A  single  parasite  was  found  in  the  liver  at  necropsy. 

Acarida. — The  mites  are  throughout  of  small 
size,  even  the  largest  ticks  attaining  a  length  of  only 
half  an  inch  and  the  majority  being  but  a  fraction  of 
this.  The  body  is  circular  or  oval  in  outline,  with 
flattened  ventral  surface  and  arched  dorsal.  Ordina- 
rily it  manifests  no  separation  into  parts,  though  in 
some  forms  a  distinct  groove  makes  two  regions  distin- 
guishable. While  the  skin  is  commonly  marked  by 
transverse  striations  or  folds,  traces  of  metameric 
segmentation  are  only  rarely  to  be  found.  The 
chitinous  covering  is  frequently  provided  with  plates 
or  shields,  and  bristles  are  characteristically  pres- 
ent. A  small  projection  (rostrum  or  capitulum) 
carries  the  mouth  parts,  which  are  often  more  or  less 
fused  into  a  beak  and  modified  for  biting,  piercing,  or 
sucking.     As  mouth  parts  are  distinguished  (1)   the 


mandibles  or  chelicerae;  (2)  maxillipeds  or  pedipalpi, 
the  most  prominent  part  of  which  are  the  maxillary 
palps,  jointed,  highly  mobile  structures,  located  at 
the  sides  of  the  mandibles.  The  lower  lip  (hypos- 
toine),  anterior  and  inferior  to  the  maxilke,  is  ordina- 
rily fused  to  their  bases. 

The  four  pairs  of  legs,  composed  of  from  three  to 
eight  joints  each,  are  terminated  by  claws,  bristles, 
or  suckers  of  various  sorts.  They  may  be  attached 
directly  to  the  skin  or  reinforced  by  a  chitinous 
framework  (epimeres)  which  may  join  to  form  a 
median  ventral  ridge  (sternum).  A  special  respira- 
tory (tracheal)  system  is  lacking  in  most  parasites, 
though  present  in  some;  it  opens  by  paired  stigmata 
with  sieve-plate  coverings  (peritremes)  the  location 
of  which  is  characteristic  for  various  groups.  Eyes 
are    also    usually    wanting    in    the    parasitic    forms. 

The  separate  sexes  may  be  distinguished  generally 
by  difference  in  size;  in  some  forms  a  marked  sexual 
dimorphism  exists.  The  genital  orifice  is  surrounded 
by  a  system  of  chitinous  thickenings  known  in  the  male 
as  the  epiandrium  and  in  the  female  as  the  epigynium. 
The  vulva  serves  as  birth  opening,  whereas  a  special 
copulatory  orifice  occurs  at  the  posterior  end  of  the 
abdomen.  The  acarida  are  usually  oviparous,  and 
from  the  egg  emerges  a  hexapod  larva  which  metamor- 
phoses into  an  octopod  nymph,  and  finally  by  the 
development  of  the  sexual  organs  becomes  adult. 
This  metamorphosis  is  accompanied  by  a  variable 
number  of  moults,  and  in  the  SarcopticUe  by  histoly- 
sis and  complete  regeneration  of  the  animal  at  each 
ecdysis. 

The  following  table,  taken  -from  Railliet,  will  be 
convenient  in  recognizing  the  various  sub-orders  and 
families: 


o> 


No  tracheae. 
Legs  with 
epimeres. 


No  trachea?. 

Astigmata. 

Legs  with  epimeres. 

Trachea?  opening  in 
the  anterior  portion 
of  the  body,  atro- 
phied in  the  aqua- 
tic forms. 

Prostigmata. 

Legs  with  epimeres. 


Two  pairs  of  legs. 
Palpi  unarmed. 
Mandibles  styliform.  J 
Four  pairs  of  legs.  ] 
Palpi  uncinate.  [ 

Mandibles  styliform.  J 

Palpi  joined  at  base,  i 

unarmed. 
Mandibles  chelate.      J 
Palpi  free,  unarmed,  i 

antenniform. 
M ri in li  1  ill---  chelate 

Palpi     free,     armed 

(rapaci). 
M  andibles  with, 

hooks,  or  styliform. 


Trachea?  opening  in 
the  posterior  por- 
tion of  the  body,  at 
the  base  of  the  legs, 
sometimes  atro- 
phied. 

Metastigmata. 

Legs     without     epi- 
meres. 


Palpi  free  fusiform, 
mandil  ilea  chelate. 

Palpi  free,  filiform  or 
valvate. 

Mandibles,  pseudo- 
chelate. 

Palpi  free,  filiform. 

Mandibles  chelate. 


Phytopticke. 


Demodicida?. 


Sarcoptidae. 

Bdellidfe. 

Murine: 

Halicaridae. 

Freshwater: 

Hydrachnidse 

Terrestrial: 

Trombidiidffl. 

Oribatidse. 

Ixodidx: 
Argasidse. 

Gamasidae. 


DemodicidcB  (the  Follicle  Mites). — Small,  elongated 
mites;  anterior  region  undivided,  in  adult  with  rostrum 
and  four  pairs  of  short  legs;  the  posterior  transversely 
striated,  without  appendages.  Tracheae,  stigmata, 
and  eyes  wanting.  No  marked  sexual  dimorphism. 
Oviparous.  Larva  without  legs  or  with  three  pairs  of 
tubercles,  nymph  with  four  pairs  of. rudimentary  legs. 
Parasites  of  hair  follicles  and  sebaceous  glands  of 
mammalia.     Only     a     single     genus     with     several 

Species. 

Demodex  folliculorum  (G.  Simon)  =D.  foil.  var. 
hominis  auct.;  Steatozoon  foil,  E.  Wilson.  Rostrum 
short,  anterior  region  of  body  approximately  one- 
third  of  total  length.     Egg  eordiform,  0.06  to  0.0S  by 


504 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Arachnida 


Fig.  264.— Dem- 
odex  canis.  Ven- 
tral view  of  female 
and  of  egg.  X  100 
diameters.  (After 
Megnio.) 


nil  I  to  0.05  mm.  Male  0.3  mm. long;  female  0.38  mm. 
to  0.045  nun.  long. 

This  form,  which  presents  a  characteristic  appear- 
ance ( Fig.  264),  is  a  common  parasite  of  the  sebaceous 
elands  of  the  human  skin.  It  is  easily  discovered  in 
the  sebum  from  the  glands  of  the 
nose,  lips  and  forehead;  also  in  the 
ceruminous  and  Meibomian  gland  . 
and  from  the  abdominal  and  pubic 
regions.  Normally  the  mites  resf  in 
the  gland,  head  inward  (Fig.  265), 
and  but  a  few  arc  presenl  m  each 
V  gland;  occasional  increase  in  numbers 

is  said  tn  give  rise  to  stoppage  of  the 
dud  and  from  five  to  twenty  may  be 
found  in  a  comedo  plug.  The  state- 
ments of  some  authors,  according  to 
which  these  parasites  occur  in  two- 
thirds  of  the  persons  examined,  are 
held  by  other  investigators  to  be  far 
beyond  the  usual  percentage  of  in- 
fection. Precise  data  are  lacking. 
Henle,  who  discovered  this  species  in 
1841,  obtained  living  specimens  of 
the  mite  from  a  cadaver  six  days  after 
death.  In  spite  of  the  fact  that  this 
species  is  difficult  to  distinguish  from 
related  forms  of  the  dog,  cat,  and 
other  domestic  animals,  with  a  single 
doubtful  exception,  no  case  of  infec- 
tion transmitted  in  either  direction 
is  on  record,  and  all  efforts  to  accomplish  this  experi- 
mentally have  failed. 

Although  D.  cants  gives  rise  in  the  dog  to  a  serious 
dermal  disease  (Fig.  265)  which  is  rather  difficult  to 
handle,  no  similar  difficulty  is  reported  for  man  with 
D.  folliculorum,  even  in  the  case  of  those  individuals 
habitually  regardless  of  personal  cleanliness;  and  an 
etiological  relation  between  these  mites  and  acne,  as 
maintained  by  various  observers,  has  not  been  satis- 
factorily demonstrated. 

Sarcoplidce. — Small,  pale  mites,  writh  soft  body,  not 
elongated,  separated  into  two  regions  by  a  more  or 
less  distinct  transverse  groove.  Mandibles  chelate, 
maxillary  palpi  styliform.  Four  pairs  of  five-jointed 
legs  with  epimera,. in  two  groups  corresponding  to  the 
regions  of  the  body,  terminal  joints  (tarsi)  with  one 
or  two  claws,  a  sucker,  or  both,  or  with  long  bristle. 
Trachea?  wanting.  Sexual  dimorphism  general.  Met- 
amorphosis with  hexapod  larva  and  two  nymphs, 
oft i'n  complicated  by  the  appearance  of  a  h\rpopial 
nymph. 

Of  the  seven  sub-families  only  the  Sarcoptinae  or 
itch  mites,  and  the  Tyroglyphinae  or  cheese  mites,  are 
of  importance  here. 

Sarcopiince  (the  Itch  Mites). — Parasitic  mites  with 
transversely  striated  integument,  with  campanulate 
pedunculate  tarsal  sucker,  often  atrophied  and  re- 
placed by  bristles  on  the  third  and  fourth  pairs  of  legs. 
Vulva  transverse.  Found  in  the  skin  of  mammals 
and  birds,  where  they  produce  the  various  forms  of 
scab  and  itch. 

Sarcoptes  (the  Itch  Mite  of  Mammals). — Body 
round  or  slightly  oval.  Rostrum  short,  and  thick; 
posterior  feet  entirely  or  nearly  hidden  by  the  body. 
Tarsal  suckers  with  long,  simple  peduncle;  in  female 
on  the  first  and  second  pairs  of  legs,  in  the  male  also  on 
the  fourth  pair.  Anus  terminal. 

Some  authors  distinguish  but  a  single  species  with 
numerous  varieties;  it  seems  better,  however,  in  spite 
of  the  often  insignificant  and  in  part  inconstant  specific 
differences  thus  far  known,  to  follow  the  later  authori- 
ties in  regarding  these  forms  as  different  species,  even 
though  physiological  characters  must  still  be  used  in 
part  for  their  distinction.  They  apparently  do  not 
interbreed,  and  certainly  are  permanent  only  on  the 
appropriate  host  from  which  in  some  cases  they  can- 
not be  transferred  to  any  other,  even  for  a  short  time, 


A  earns  scabici  de 


though   usually   such  transfer  results   in    temporary 
existence  without  the  di  ea  e  reaching  a  serious  si  i 
and  often  disappearing  spontaneou  lv . 

Sarcoptes  scabiei  (de  Geer)    (the    Human    Itch) 
Acarus  siro,  .1.  exulcerans,  Linn. 
Geer;     Sarcoptes 
hominis    Hering; 

S.  se.var.  /mini n  is 

Megnin.  Dorsal 
scales  pointed, 
longer  t  ha  n 
broad.  Anterior 
projections  of 
e  p  i  a  n  d  r  i  u  m 
short ,  scarcely 
reaching  the  epi- 
meres.  Posterior 
spines  long, 
pointed.  Male 
(Fig.  267)  0.2- 
0.24  mm.  long, 
0.1.5-0.2  mm. 
broad:  female 
(Fig.  266)  0.3  to 
0.45  mm.  long, 
0.25  to  0.35  mm. 
broad. 

The  history  of 
the  disease 
caused  by  t  he 
itch  mite  is  con- 
nect e  d  with 
some  of  the  most 
momentous  dis- 
putes in  medi- 
cine. The  com- 
plaint is  recorded 
in  the  earliest 
writings,  ami  the 
mite  may  have 
been  known  to 
Aristotle;  but  the 
Arabian  physi- 
cians in  the 
twelfth  century 
were  the  first  to 
state  clearly  the 
existence  of  a 
minute  charac- 
teristic animal 
which  could  be 
removed  from 
the  skin  and 
"cracked"  on 
the    finger    nail.      FlG   o63._Transectioll  of  skin  o(  Dog, 

Ine  galleries  Showing  Demodex  canis  in  Position  in  Hair 
bored  in  the  skin  Follicle  and  also  in  Sebaceous  Gland.  (After 
were  discovered  Laulanie,  from  Neumann.)  e.  Epidermis; 
in  the  fourteenth  /"•  hair  follicle  containing  two  hairs,  p,  the 
centurv  and  the  hulbs  of  which  can  be  dislinquished  at  6 
'(-->  Hn  nrilinrl  a"d  &'  I  at  the  points,  a,  ai,  aii,  aiii  and  a&, 
H  "escrlDeJ?  the  follicle  has  undergone  dilatation,  by 
and  figured  reas0n  of  the  accumulation  of  the  follicle 
clearly  in  the  mites,  d\  sb,  sebaceous  glands  one  of  which 
s  e  v  e  n  t  e  e  n  t  h  ,  («&i)  contains  the  mites^  sd,  sudoriferous 
while  in  a  letter  glands.  X  40  diameters, 
to     the     famous 

Italian  anatomist  Redi,  in  16S7,  Bonomo  and  Cestoni 
gave  a  precise  description  and  figures  of  the  mites  and 
their  eggs,  inferring  correctly  that  the  animals  were 
of  separate  sexes  and  were  the  actual  cause  of  the 
disease,  so  that  a  cure  depended  upon  their  complete 
destruction.  Others  of  prominence  in  dermatology, 
however,  attributed  the  trouble  rather  to  "destructive 
juices,"  either  denying  the  existence  of  the  mites  or 
their  relation  to  the  itch,  or  holding  that  a  poison  was 
inoculated  into  the  blood  by  their  bite.  Early  in  this 
century  the  French  Academy  offered  a  prize  for  the 
rediscovery  of  the  mite,  whereupon  a  certain  Dr.  Gales 


505 


Araclinlda 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Fig.  266. — Sar copies  seab- 
iei,  female,  in  Dorsal  Aspect. 
X  100.  (After  Fiirsten- 
berg.) 


E  aimed  off  cheese  mites  on  a  learned  jury,  pocketing 
oth  the  medals  and  the  prize!  Finally,  in  1834, 
Renucci  demonstrated  in  Paris  the  method  by  which 
Corsican  women  were  accustomed  to  remove  the  mite 
on  the  point  of  a  needle  from  the  end  of  its  tunnel, 
and  thus  established  its  actual  presence  in  the  disease. 
The  male  was  discovered  by  Kramer  in  1S45,  and  the 
pathology  of  the  disease  established  upon  unimpeach- 
able experimental  and  clinical  evidence  particularly 
by  Hebra. 

The  mite  appears  to  the 
naked  eye  white  and  glisten- 
ing, and  was  aptly  described 
by  Bonimo  as  like  a  little 
bladder  of  water.  Viewed 
under  the  microscope  there 
is  seen  a  tortoise-shaped  head 
with  a  pair  of  short,  heavy 
legs  on  either  side,  which 
have  a  framework  of  chitin- 
ous  bands  like  the  garters  of 
an  Italian  bandit.  The  third 
and  fourth  pairs  of  legs  are 
concealed  under  the  posterior 
margin  of  the  body.  The 
male  is  much  smaller  than 
the  female  and  has  the  fourth 
pair  of  legs  terminated  by  a 
sucker  instead  of  the  bristle 
which  is  on  the  fourth  pair  in 
the  female.  There  is  also  on 
the  ventral  surface  of  the  male  a  complicated  chitinous 
frame-work  wanting  in  the  female. 

The  human  itch  mite  lives  in  the  skin  in  which  the 
female  tunnels  an  irregular  winding  passage,  where 
she  passes  her  entire  existence  (Fig.  268).  These 
burrows  vary  in  length  from  a  few  millimeters  to  two 
or  more  centimeters  and  are  excavated  preferably 
where  the  skin  is  thin,  as  between  the  fingers,  in 
elbow  or  knee  joint,  on  mamma?  or  penis.  The  gal- 
lery, directed  first  downward  through  the  stratum 
corneum,  is  extended  through  the  softer  cells  of  the 
Malpighian  layer  just  above  the  papilla?.  Eggs  and 
fecal  matter  fill  the  most  of  this  tunnel,  at  the  inner 
end  of  which  may  be  found  the  female.  The  male  is 
much  rarer;  its  existence  is  passed  on  the  surface  of 
the  skin,  hiding  under  scales  and  in  furrows.  After 
an  incubation  of  only  a  few  days  there  emerges  from 
the  egg  a  hexapod  larva, 
which  bores  through  the  roof 
of  the  tunnel  and  gains  the 
surface  of  the  skin,  where 
after  three  or  four  moults  and 
the  acquirement  of  a  fourth 
pair  of  legs  the  development 
of  the  sexual  organs  is  com- 

f)leted.  Copulation  is  fol- 
owed  by  the  last  moult  on 
the  part  of  the  female.  The 
latter  now  pregnant,  begins 
the  construction  of  a  gallery 
in  the  epidermis  (Fig.  2i>9) 
and  once  buried  in  the  skin, 
the  recurved  dorsal  spines 
prevent  her  escape. 

This  species  is  probably 
distributed  over  the  entire 
world;  it  is  very  common  on 
the  Continent  and  among  the  poor  in  England  where 
it  constitutes  eight  per  cent,  of  dermatologieal  cases 
in  hospital  practice  and  three  per  cent,  in  private 
practice.  It  is  much  rarer  in  the  United  States  and 
is  inn  I  frequent  in  the  East;  in  New  York  Bulkley 
had  two  per  cent,  in  the  hospital  and  one-fourth  of 
one  p«-r  cent,  in  private  practice.  In  Boston  White 
noted  an  increase  from  nine  cases  in  1880  to  16.5  in 
L888.  Of  318,500  cases  recorded  by  the  United 
States  Dermatologieal  Association  within  a  period  of 


Fig.  267. — Sarcoptes 
scabiei,  male,  in  Ventral 
Aspect.  X  100.  (After 
Fiirstenberg.) 


a  little  over  twenty-one  years  (from  July,  1877,  to 
January,  1898),  it  was  found  in  3.66  per  cent,  of  the 
total  number.  Although  rare  under  ordinary  circum- 
stances, it  increases  rapidly  under  conditions  of  crowd- 
ing; thus  in  1S93,  the  year  of  the  Chicago  Exposition, 
901  cases  were  reported  in  the  United  States,  while  in 
1895  the  total  was  only  3S3  cases.  Where  such  crowd- 
ing is  combined  with  faulty  sanitary  conditions,  it 
becomes  epidemic  in  a  severe  form.  Thus  during  the 
Civil  War,  the  "army  itch,"  "Jackson's  itch,"  and 


Fig.  268. — Sarcoptes  scabiei.  Impregnated  female  (s)  in  cunic 
ulus.  i  Ain-r  Ilaillu-t;  somi-diagrammatic  figure  adapted  from  Ger 
lach.)  oe,  oe',  oe",  Eggs,  those  farther  away  from  the  mite  being 
older;  c,  an  empty  egg  shell;  o,  orifice  through  which  a  larva  has 
escaped;  e,  excrementa. 

"seven  years'  itch,"  which  are  merely  aggravated 
forms  of  the  disease,  followed  the  movements  of  the 
troops. 

The  disease  is  produced  by  the  transfer  of  the 
parasite  by  actual  contact  from  an  infected  person 
to  one  not  infected.  Such  infection  must  transport 
both  sexes,  or  at  least  pregnant  females,  and  under 
such  conditions  that  they  can  successfully  form  bur- 
rows. In  spite  of  the  fact  that  in  large  continental 
hospitals  and  clinics,  yearly  thousands  of  cases  are 
treated  and  handled  by  nurses  and  students  without 
any  precautions  whatever  in  the  way  of  disinfection, 
no  trouble  is  experienced  from  the  disease. 

Infection  is  easily  and  most  commonly  brought 
about  by  long-continued  and  intimate  contact,  and 
the  nocturnal  habits  assigned  by  some  to  these  mites 


506 


REFERENCE    BANDBOOK    OF   THK    MEDICAL   SCIENCES 


\r.n  hnlil:i 


arc  due  to  their  increased  activity  under  the  influei 

of  the  warmth  of  the  bed.     The  disease  is  also  mo  I 
imon  among  men  and  of  such  classes  and  occu- 
pation- as  arc  wont  to  sleep  together.     A  transient 

infection  may  be  induced  by  the  transfer  of  this 
species  to  the  horse,  dog,  or  ape,  but  the  cat  is  ap- 
ently  immune  toward  it. 
The  itch  mite  excites  at  first  only  a  moderate 
irritation,  which  gradually  grows  in  intensity  and 
becomes  an  extensive  pruritus,  accompanied  by  ecze- 
niaiic  inflammation  with  the  formation  of  papules  and 
vesicles.  The  malady  increases  in  severity  with  dura- 
tion, and  especially  as  the  result  of  scratching,  until 


%faJ\S 


vv 


\y^< 


i^AA/J8 


c  g^ 

Fig.269. — Acarian  Furrows,  a,  Position  of  mho;  A,  themitehas 
gone  down  beneath  the  epidermis;  B,  the  mite  has  commenced  to 
dig  a  longitudinal  burrow,  and  the  place  (/)  where  it  was  in  A,  has 
by  the  growth  of  cells  come  up  nearer  to  the  surface;  C,  the  point  (/) 
<me  up  to  the  surface,  while  the  mite  has  gone  along  farther 
with  its  burrow.     (After  Jeffries.) 

it  may  acquire  the  character  of  a  severe  czema,  the 
vesicles  and  pustules  being  associated  with  extreme 
excoriations  and  the  formation  of  crusts.  The  itch 
may  be  confused  with  eczema  and  pediculosis,  which 
latter  may  in  fact  coexist  with  it. 

The  first  step  in  the  treatment  of  the  itch  is  the 
absolute  destruction  of  the  entire  colon3'of  mites  and 
their  eggs,  for  which  purpose  various  sulphur  oint- 
ments are  successfully  employed.  Naphthol  is  also 
highly  recommended.  In  severe  cases  some  eczema 
remains  to  be  treated  after  the  destruction  of  the 

mites. 

It  is  important  to  record  here  from  Nuttall  the 
view  of  Joly  that  the  itch  mites  may  serve  at  times  as 
carriers  of  lepra  bacilli.  In  parts  of  Norway  where 
much  leprosy  exists,  these  mites  are  also  abundant, 
and,  together  with  pediculi,  they  are  usually  found 
among  the  poorer  classes  in  Algeria,  from  which  the 
greatest  number  of  lepers  come.  "  In  the  Soudan  the 
sarcoptes  occur  on  almost  all  the  dogs  [most  probably 
not  the  S.  scabiei — W.],  and  often  attack  the  natives 
amongst  whom  there  are  numerous  lepers.  It 
is  to  me  that  the  possibility  of  this  mode  of 
transfer  cannot  be  denied,  and  it  is  also  conceivable 
that  the  pathological  changes  produced  in  the  skin 
by  the  parasites  may  even  favor  the  multiplication  of 
the  lepra  bacilli." 

Sarcoptes  scabiei  crristosce  (Fiirstb.)  (Norway  Itch 
Mites). — S.  scabiei  var.  lupi  Megnin.  Dorsal  scales 
obtuse.  Anterior  projections  of  epiandrium  well 
developed,  reaching  the  epimeres.  Posterior  spines 
long,  pointed,  easily  bent.  Male  0.17  by  0.15  mm.; 
female  0.41  by  0.34  mm. 

This  form,  though  much  like  the  preceding,  pro- 
duces such  radically  dissimilar  effects  on  the  human 
6kin   that   we  are   forced   to   regard   it  as  a  distinct 


ies.  It  was  first  discovered  in  Christiania, 
whence  the  name  Norway  itch,  by  which  it  is  com- 
monly known,  though  cases  have  been  reported  in 
mosl    European   nation-  and  one  from  this  country 

i  Indianapolis)  by   Hessler. 

The     malady     is     easily     distinguished     from     the 

common  itch  by  the  formation  of  coarse  crusts,  which, 

however,  do  not   usually  make  their  appearance  for 

ome  years.     This  give-  color  to  the  view  that  this 

form  of  the  itch  finds  its  explanation  in  individual 
differences  on  tin'  part  of  the  host  rather  than  of  the 
parasite.  Opposed  to  this  view  is  the  formation  of 
crusts  several  millimeters  in  thickness  and  several 
centimeters  in  extent,  the  enormous  numbers  of  mites 
found  in  the  midst  of  these  masses,  and  the  attacks 
of    the    mites   (in    face   and    scalp    where    the    common 

itch  mite  does  not  occur.     This  species  is  apparently 

transmitted  with  meat  ease,  and  its  attacks  do  not 
readily  yield  to  treatment.  Megnin's  idea  that  it  is 
identical  with  the  sarcoptes  of  the  wolf  is  entirely 
untenable. 

The  case  reported  by  Hessler  apparently  belongs 
here,  though  the  author  did  not  differentiate  the 
parasite  found  from  the  ordinary  itch  mite.  The 
patient  was  partially  paralyzed  and  entirely  helpless — 
hence  we  may  infer  absence  of  the  ordinary  scratching; 
its  sequelae  are  apparently  entirely  wanting.  The 
body  of  the  patient  was  literally  covered  with  thick, 
yellowish-white,  leathery  scales,  the  largest  measur- 
ing 25  mm.  in  diameter  and  nearly  3  mm.  thick;  these 
scales  consisted  merely  of  proliferated  epithelial  cells, 
and  bloody  or  serous  crusts  were  not  present.  They 
were,  however,  produced  by  moderate  friction.  In 
the  scales  on  the  body  the  author  estimates  the  number 
of  egg  cases  and  eggs  as  seven  million  of  which  one- 
half  to  three-fourths  were  empty,  and  the  number  of 
mites  as  two  million  of  which  only  a  small  fraction 
were  living. 

The  following  forms,  normally  parasitic  on  other 
hosts,  may  be  transmitted  accidentally  or  experi- 
mentally to  man  and  give  rise  to  an  itch,  rarely  severe 
and  usually  transitory.  No  doubt  other  forms  yet  un- 
described  will  fall  in  this  same  category.  Besides 
man,  only  the  most  common  host  is  given  for  each 
species. 

<S.  auchenice.  Male  0.24  by  0.18  mm.;  female 
0.34  by  0.26  mm.  On  the  llama;  transmitted  to 
attendants,  requiring  treatment  to  dislodge. 

S.  canis.  Male  0.19  to  0.23  by  0.16  to  0.18  mm.; 
female  0.3  to  0.45  by  0.23  to  0.35  mm.  On  the  dog; 
frequently  transmitted  to  man,  variable  in  severity. 

S.  caprce.  Male  0.243  by  0.1SS  mm.;  female, 
0.345  by  0.342  mm.  On  the  goat;  readily  transmitted 
to  man;  induces  an  itch  of  great  severity. 

S.  dromedarii.  Male  0.29  by  0.18  mm.;  female, 
0.36  by  0.33  mm.  On  the  camel;  readily  trans- 
missible and  severe;  in  Egypt  almost  all  camel  drivers 
are  affected;  the  Senegal  negroes  call  the  complaint 
larbisch. 

S.  equi.  Male  0.22  to  0.2S  by  0.15  to  0.2  mm.; 
female  0.45  to  0.5  by  0.31  to  0.37  mm.  On  the 
horse;  rare  on  man,  transit ory  and  usually  disappears 
spontaneously. 

S.  leonis.  Male  0.25  by  0.18  mm.;  female,  0.45  by 
0.35  mm.  On  the  lion;  easily  transmitted  to  man; 
disappears   spontaneously   in   thirty   to   forty   days. 

S.  oris.  Male  0.22  by  0.16  mm.;  female,  0.314  "by 
0.3  mm.  On  the  sheep;  very  rarely  transmitted  to 
man,  if  indeed  at  all. 

S.  suis.  Male  0.25  to  0.35  by  0.19  to  0.3  mm.; 
female  0.35  to  0.5  by  0.29  to  0.39  mm.  On  the  pig; 
transmitted  to  man,  sometimes  disappears,  sometimes 
grows  worse. 

S.  vulpis.  Male  0.245  by  0.185  mm.;  female  0.442 
by  0.315  mm.  On  the  fox;  its  transmission  to  man 
rests  on  doubtful  evidence. 

S.  wombati.  Species  not  described  in  detail;  forms 
a  crustaceousitchon  the  wombat;  readily  transmitted 


507 


Arachnida 


INFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


to  man;  produces  a  type  of  itch  intense  and  unlike 
the  ordinary  form;    yields  readily  to  treatment. 

Notoedres  cati  (Hering)  =  Sarcoptes  minor  Fiirstb. 
Tarsal  suckers  with  long,  unjointed  pedicle:  in  the 
female  on  the  first  and  second  pairs  of  legs,  in  the  male 
also  on  the  fourth.  Anus  dorsal,  near  posterior 
margin  of  abdomen.  Dorsal  scales  obtuse.  Male 
(Fig.  270,  C)  0.14  to  0.15  by  0.12  to  0.125  mm.;  female 
(Fig.  270,  A,    B)  0.21   to  0.23  by  0.16  to  0.175  mm. 

This,  the  itch  mite  of  the  cat,  attacks  on  its  normal 
host  the  skin  of  the  head  and  ears,  and  induces  a 
serious,  often  highly  epizootic,  malady  with  a  termina- 
tion usually  fatal.  This  species  is  of  importance  here 
because  of  its  easy  transmission  toman.  On  the  latter 
it  produces  a  limited  itch  which  disappears  spontane- 
ously at  the  end  of  from  ten  to  twenty  days.  It 
occurs  on  cats  in  Lincoln,  Nebr.,  and  doubtless  else- 
where; no  cases  of  transmitted  infection  are,  however, 
on  record  here. 

The  other  genera  and  species  of  itch  mites  common 
to  domesticated  animals  are  not  as  a  rule  transmissible 
to  man.  A  few  exceptions  are  on  record  from  various 
regions. 

Sub-family  Tyroglyphince  (Cheese  Mites). — Minute 
forms  with  soft  body,  without  eyes  or  tracheae.  In- 
tegument never  uniformly  striated,  but  smooth  and 
granulated  or  irregularly  verrucose.  Last  leg  with  claw 
ami  usually  also  with  foliate,  non-pedunculate  vesicle. 

These  mites  live  in  dry  or  slowly  decaying 
materials  (flour,  sugar,  cheese,  anatomical  prepara- 
tions, etc.).  From  their  minute  size  and  abundant 
occurrence  they  are  liable  to  be  introduced  on  to  or 
even  into  the  human  body,  and  may  even  make  the 
passage  of  the  alimentary  canal  without  being  entirely 
destroyed.  From  their  presence  on  the  body  or  in 
fecal  matter  under  circumstances  of  disease  they  have 
been  often  reported  as  corpora  delicto.  In  rare  in- 
stances certain  species  have  been  transitory  parasites 
of  man.  Where  abundant,  as  in  old  groceries  or 
warehouses,  they  have  been  known  to  give  rise  to  a 
temporary,  though  often  violent  dermal  irritation  on 
employees  handling  the  infected  products,  without 
the  evil  having  been  traced  in  all  cases  to  any  single 
species.  Such  a  complaint  is  the  "grocers'  itch"  of 
England.  Since  these  are  the  most  frequent  pseudo- 
parasites  with  which  the  physician  has  to  deal,  ex- 
treme caution  should  be  exercised  in  associating 
etiologically  any  species  which  belongs  in  this  group 
with  a  case  of  disease  in  which  it  has  been  discovered. 

Histiogaster    eiitoniophagiis    spermaticus,    described 


Tyroglyphus  jarinm  Gervais.  First  pair  of  legs  in 
male  much  heavier  with  spur  on  second  joint.  White, 
tip  of  legs  pale  violet.  Length:  male  0.33  mm.,  female 
0.55  mm.  Cosmopolitan  on  flour,  fruit,  tobacco, 
cheese,  and  other  organic  material  in  process  of  alter- 
ation by  age.    This  species  is  much  more  abundant 


Fie 


-Tyroglyphus  longior,  female,  in  Ventral  Aspect.   (After 
Megnin.J      Magnified. 


A 
Fig.  270.  —  Notoedres  cati:    A,  female,  from  abo 


by  Trouessart  from  a  painless  testicular  cyst,  had 
doubtless  been  introduced  accidentally.  It  had 
found  conditions  of  existence  possible  and  had  multi- 
plied abundantly,  thus  becoming  a  facultative 
para  ite  although  normally  a  free  living  species.  It 
had   produced  no  pathologic  effects  whatever. 

All  urobilin  farince  (De  (icer).      (The  Flour  Mite)  = 


than  the  following  even  in  cheese,  and  has  frequently 
been  described  as  that,  species  in  spite  of  evident  differ- 
ences.  It  was  observed  by  Moniez  as  the  cause  of  a 
cutaneous  eruption  on  workmen  unloading  Russian 
wheat  at  Lille. 

Tyroglyphus  siro  (L.)  (The  Cheese  Mite)  =. -Icarus 
siro,  A.  laclis,  A.  dysenteries  L.  Last  pair 
of  legs  with  both  claw  and  sucker,  with 
terminal  joint  short  and  with  proximal 
sucker  close  to  prox- 
imal end  of  terminal 
joint.  Length  0.6 
mm.  Found  on  de- 
composing sub- 
stances like  the  last, 
but  rarer.  This  is 
the  cheese  mite  re- 
ported by  various 
authors  from  dysen- 
teric stools  and  from 
urine.  Its  occur- 
rence was  undoubt- 
edly accidental,  and 
its  harmless  nature 
may  be  adjudged 
from  the  quantity 
taken  dailyin  chees6 
everywhere  and  the  absence  in  medical  works  of  any 
records  of  consequent  diseases.  Yet  Ziirn  records 
that  in  certain  districts  where  mites  are  raised  to 
impart  a  peculiar  flavor  to  the  cheese,  a  gastric  or 
intestinal  catarrh  is  prevalent  among  consumers  .if 
the  cheese  which  he  attributes  to  the  effect  of  the 
mites.     As  this  species  is  abundant  in  old  linseed  meal, 


X  100.      (After  Railliet.) 


508 


REFERENCE    HANDBOOK    OF   Till',    MKDIC'AL   SCIKXCKS 


Arachnlda 


its  reported  occurrence  in  poulticed  wounds  is  easily 
explained.  I"  cantharides  ii  is  also  abundant,  and  in 
vanilla,  where  its  presence  has  been  associated  with 
the  vanilla  complaint,  a  dermal  eruption   frequent 

;l ng  workers  handling  this  product.     The  famous 

Icarus    dysenteries    of    Linnaeus,    which    was    found 

abundantly  in  stools  of  one  of  his  scholars  and  traced 

back  to  the  wooden  vessel  from  which  the  young  man 

drank,  was  probably  this  species.     It  has,  however, 

reported  but   once  since  then  from  dysenteric 

ils,  those  df  infants  in  Prague,  and  the  etiological 

ion  may  certainly  be  called  in  question. 

iglyphus  longior   (Fig.  271),  which  is  similar  in 

habit   to  the  last   species,  though  less  abundant,  is 

easily  distinguished  by  its  larger  size  and  more  rapid 
movement.  It  enjoyed  transient  fame  in  ls:;7  as 
having  been  produced  (!)  by  the  electrical  experi- 
ments of  Cross  on  weak  chemical  solutions. 

The  mummification  of  bodies  in  cases  has  been 
shewn  by  recent  invest  igations  of  Meenin  to  be  due,  in 
some  cases  at  least,  not  to  chemical  or  atmospheric 
influences,  but  to  the  work  of  Tyroglyphus  infestans, 
which  is  abundant  in  such  localities.  The  external 
appearance  of  the  body  and  organs  of  the  mummy 
was  well  preserved,  but  microscopical  examination 
showed  the  tissue  to  be  filled  with  incalculable  myriads 
of  the  mite  in  all  stages 
of  development.  Numer- 
ous other  .species  of  this 
family  of  mites  have 
been  found  at  times  in 
the  human  body  or  its 
dejecta  without  having 
any  real  parasitic  rela- 
tion to  that  host  or  any 
pathologic  significance. 

Gamasidce  (Beetle 
Mites). — Skin  leathery, 
reinforced  by  chitinous 
plates;  mandibles 
chelate,  maxillae  filiform; 
.six-jointed  legs  termi- 
nated by  two  somewhat 
concealed  hooks.  Stig- 
mata lateral,  between 
legs  of  second  and  fourth 
pair,  with  peritreme  di- 
rected anteriad.  With- 
out eyes. 

The  Gamasida?  are 
abundant  small  mites,  often  free  or  semi-parasitic,  in 
the  latter  case  found  on  insects  especially.  Certain 
species  occur  on  the  fowl,  but  are  often  very  trouble- 
some to  man.  Of  the  large  number  of  forms  which 
belong  in  the  family  only  two  need  especial  mention 
here. 

Dermanyssus  gallince  (de  Geer)  (The  Poultry  Mite). 
Body  pyriform,  slightly  flattened;  in  the  male  0.6  by 
0.32  mm.,  in  the  female  0.7  to  0.75  by  0.4  mm.  Color 
varies  from  white  to  dark  red  according  to  the  con- 
tents of  the  alimentary  canal.  Legs  stout,  rather 
short.  Peritreme  extends  as  far  as  the  base  of  the 
second  pair  of  legs. 

These  mites  (Fig.  272)  swarm  in  the  crevices  of 
poultry  houses  and  in  the  refuse  of  the  floor,  even 
living  in  the  dung.  At  night  they  emerge  from  their 
hiding-places  and  suck  the  blood  of  the  birds.  Under 
circumstances  they  increase  to  such  an  extent  as  to 
become  a  veritable  pest,  even  to  man  himself.  Many 
cases  are  on  record  in  which  both  children  and  adults 
have  been  subject  to  repeated  attacks  of  the  mites, 
which  give  rise  to  an  itching  eruption  of  the  skin. 
Naturally  such  instances  are  observed  among  persons 
having  to  handle  fowl  or  to  resort  frequently  to  ill- 
kept  poultry  houses.  Kiichenmeister,  Railliet,  and 
others  record  details  of  cases  on  the  Continent;  I  have 
found  none  for  this  country. 

Dermanyssus  hirurtdinis  (Hermann)   (The  Swallow 


Fig.  LJ72. — Dermanyssus  gallina1,  a.  Adult;  b,  tarsus;  c,  mouthparts; 
d,  e,  youug.     Magnified.      (After  Osborn.) 


Mile).  Decidedly  larger  than  I  he  preceding,  reaching 
a  length  of  1  mm.  Peritreme  extends  barely  to  the 
third  pair  of  legs. 

This  >pecies,  which  normally  attack-  the  swallow, 

has  been  known  to  pass  from  the  nests  under  the  eaves 

into  sleeping-rooms  and  to  attack  the  occupants  of 
the  r i  giving  rise  to  severe  itching. 

Holothyrus  coccinella,  which  is  found  on  the  island  of 
Mauritius,  is  a  serious  pest  of  the  ducks  and  g(  I  e. 
It  attacks  man  frequently  and  incites  an  acute  derma- 
titis. H  often  migrates  into  the  buccal  cavity  with 
great  danger  to  children  especially.  Several  other 
Gama  ids  have  been  reported  in  Isolated  cases  from 
the  human  host. 

Trombidiidce  (The  Harvest  Mites).  Soft-skinned, 
velvety,   often    highly   colored   mites,  with   tracheae 

opening  at  the  base  of  the  rostrum  or  on  the  cephalo- 
thorax,  and  usually  with  eyes.  Sucking  rostrum  with 
styliform  mandibles  and  uncinate  palpi.  Legs  six- 
jointed,  terminated  by  a  double  hook  together  with 
a  .small  sucker. 

Of  the  large  number  of  terrestrial  mites  included 
in  this  family  only  a  few  species  are  parasitic,  but 
some  of  these,  though  only  occasionally  at  lacking 
man,  are  yet  among  his  most  disagreeable  chance  par- 
asites.     Doubtless    many    other   species   than    these 

noted  here  may  be  found 
to  attack  him  in  one 
place  or  another;  it  is 
desirable  that  accurate 
data  regarding  all  such 
species  be  on  record. 
According  to  Joly  and 
others,  these  mites  are 
the  passive  carriers  of 
infectious  agents,  but 
Nuttall  doubts  this  and 
thinks  the  cutaneous 
affections  produced  by 
their  presence  on  the 
skin  are  due  to  irritating 
secretions  of  the  mites. 
The  effect  Megnin  pro- 
duced by  binding  on  the 
skin  the  dead  bodies  of 
one  of  the  most  toxic 
species  tends  to  support 
this  view.  To  secondary 
bacterial  infection 
brought  about  by 
scratching  the  skin  and  to  reduced  vitality  of  the 
latter  referable  to  the  mites,  are  to  be  attributed  the 
extreme  effects  manifested  in  the  formation  in  some 
cases  of  ulcerous  and  running  sores. 

Pediculoides  ventricosus  (Newport)  =  Hcteropus 
Vi  ntricosus  Newport.  Male  0.12  by  0.0S  mm.,  oval, 
with  six  pairs  of  bristles  and  a  pyriform  plate  on  the 
dorsal  surface.  Female  cylindrical,  0.2  by  0.07  mm., 
with  four  pairs  of  bristles.  When  gravid  with  poste- 
rior region  inflated  to  a  sphere  filled  with  developing 
eggs,   nearly  2   mm.  in  diameter,  viviparous. 

This  form  lives  parasitic  on  insect  larva?,  particularly 
those  of  grain.  Numerous  cases  of  accidental  para- 
sitism on  grain  shovellers,  or  those  otherwise  engaged 
in  handling  it,  are  reported  from  different  parts  of 
France  and  Germany.  The  bite  of  the  mite  produces 
insufferable  itching  and  excites  a  considerable  cutane- 
ous inflammation. 

Similar  troubles  have  been  produced  by  Tarsonemus 
intectus  Karpelles  from  Bulgarian  grain  and  Pi/ymc- 
phorus  uncinatus  (Flemming)  from  Russian  wheat. 
Chelytus  eruditus  (Schrank).  Pale,  rarely  reddish 
in  color,  with  bifid  hook  on  the  palpi.  Length,  0.S 
mm. 

This  mite  occurs  at  times  in  old  books,  or  among 
dusty  rags,  but  more  commonly  in  stables,  chicken  or 
pigeon  houses,  in  old  feed  bins  and  in  tobacco  store- 
houses, or  wherever  mites  are  abundant.     In  spite  of 


509 


Arachnida 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


its  predacious  habits,  it  has  not  been  known  to  attack 
man,  and  its  presence  in  fecal  mailer  and  in  pus 
collected  from  the  ear,  as  reported  in  various  medical 
works,  was  undoubtedly  due  to  accidental  intro- 
duction. When  St.  Peter's  in  London  was  restored, 
this  form  swarmed  in  myriads  over  workmen  engaged 
in  repairing  the  ancient  tombs. 

Nephrophages  sanguinarius  Miyake  et  Scriba  is  a 
related  species  which  two  Japanese  physicians  found 
daily  in  the  bladder  of  a  patient  afflicted  inter  alia 
with  hematuria.  Although  its  presence  was  noted  for 
a  week,  its  relation  to  the  disease  was  by  no  means 
established.  They  showed  that  it  was  living  in  the 
bladder,  but  had  to  leave  undetermined  how  it  reached 
that  location.  This  may  have  been  due  to  contamina- 
tion of  instruments  and  such  contamination  in  one 
way  or  other  serves  to  explain  most  similar  cases. 
The  mites  which  van  der  Harst  discovered  in  urine 
he  showed  had  really  come  from  the  cork  of  the  bottle 
in  which  the  sample  had  been  sent  to  him,  and  similar 
confusion  has  arisen  in  other  cases. 

Yet  such  mites  may  be,  if  rarely,  still  sometimes 
actually,  endoparasites  of  man.  Miyake  and  Sciba 
in  Japan  found  one  species  in  a  cyst  of  the  wall  of  the 
vena  cava;  and  Castellani  in  Uganda  discovered 
another  in  a  cyst  of  the  omentum  of  a  negro.  New- 
stead  and  Todd  described  mites  of  this  family  as 
endoparasites  in  apes,  and  among  birds  such  an  occur- 
rence is  very  common. 

Leptus  irritans  Riley.  Color  brick  or  blood  red;  legs 
terminating  in  two  stiff  hairs.  Mandibles  tridentate 
at  end.  Length,  0.24  mm.  (Fig.  273,  C).  Adult 
unknown. 

This  is  the  larval  form  of  some  unknown  adult,  not  a 
plant-feeding  species,  as  formerly  believed  but  of  a 
form  parasitic  in  the  adult  condition  on  grasshoppers 
and  other  insects.  The  allied  European  species  are 
found  on  mammals,  birds,  and  Arthropods.  The 
latter,  especially  the  Insecta,  appear  to  be  the  normal 
hosts.  The  American  larva  under  consideration 
occurs  in  enormous  numbers  on  grass  and  herbage  and 
its  normal  habits  are  unknown.  But  under  temptation 
it  adopts  a  habit  as  fatal  for  itself  as  it  is  uncomforta- 
ble for  man.  Brushed  from  grass  or  shrubbery  on  to 
human  clothing,  it  finds  its  way  to  the  skin  into  which 
it  burrows  until  entirely  buried,  following  usually  the 
duct  of  a  sebaceous  gland.  The  skin  forms  a  fibrous 
sheath  about  the  proboscis  of  the  larva  in  the  midst  of 
a  dermal  swelling  the  size  of  a  pin-head.  The  re- 
sultant irritation  varies  considerably  with  the  indi- 
vidual and  in  some  cases  produces  extreme  torture. 
The  inflammation  gives  rise  to  a  large  red  blotch  with 
paler  spots  and  spreads  rapidly  when  the  body  is 
scratched  in  consequence  of  the  itching. 

This  mite  occurs  over  much  of  the  eastern,  central, 
and  southern  portion  of  this  country,  extending  in  the 
Mississippi  valley  as  far  north  as  central  Iowa  and 
being  very  abundant  in  parts  of  Indiana,  Illinois,  and 
Ohio,  even  as  far  north  as  the  islands  in  Lake  Erie. 
In  Washington  it  is  abundant  from  June  throughout 
the  summer,  and  farther  south  the  season  is  longer. 
Osborn  speaks  of  the  same  species  as  annoying  in 
Southern  Mexico  in  January.  Those  who  are  sus- 
ceptible to  the  pest  are  accustomed,  on  returning  from 
field  excursions,  to  resort  at  once  to  a  hot  bath  with 
strong  soap,  or  to  the  use  of  a  wash  of  dilute  carbolic 
acid  to  kill  the  mites  before  they  become  embedded  in 
the  skin.  Dilute  alcohol  is  also  recommended.  At 
this  time  it  is  also  possible  by  close  scrutiny  to 
recognize  the  mites  in  the  center  of  the  inflamed  area 
and  to  remove  them  individually,  doing  away  thus 
with  the  subsequent  discomfort  to  a  large  extent. 

It  is  interesting  to  note  that  the  invasion  of  the 
human  skin  causes  the  death  of  the  mite  and  prevents 
it-  reaching  maturity,  a  perverted  habit  being  thus 
fatal  to  the  species.  As  a  result  the  adult  form  is  not 
known,  but  assumed  as  possibly  one  of  the  genus 
7   otnbidium. 

510 


Leptus  americanus  Riley  (Fig.  273,  B)  is  an  associ- 
ated form,  the  effects  of  which  are  very  similar.  The 
Continental  species  is  L.  autumnalis  Shaw.  Similar 
forms  are  known  from  all  regions:  among  these  the 
one  known  as  Tlalsahuate  in  Mexico,  and  the  Colorado 
of  Cuba  deserve  mention. 


Fig.  273. — B,  Leptus  americanus.  Greatly  enlarged.  (After 
Riley.)  C,  Leptus  irritans.  Greatly  enlarged.  (Alter  Riley.) 
(In  B  and  C  the  dots  underneath  indicate  the  natural  size.) 


The  Kedani  mite  of  Japan  also  known  as  Tsutsuga- 
mushi  or  Akamushi,  is  a  small  hairy  mite  with  two  red 
eyes;  it  measures  0.1(3  to  0.38  mm.  long  by  0.1  to  0.2-1 
mm.  broad.  When  the  mite  is  torn  in  removing  it 
from  the  skin  or  by  accident,  a  small  blister  with 
a  painful  swelling  is  formed  at  the  site  of  the  bite. 
This  is  accompanied  by  enlargement  of  neighboring 
lymph  glands,  with  fever  and  general  prostration, 
which  in  extreme  cases  leads  to  sudden  death. 
Tanaka  has  isolated  from  the  body  of  the  mite  a 
toxic  substance  to  which  he  attributes  the  effects 
described.  The  mite  occurs  in  widely  separated 
provinces  of  Japan  and  is  greatly  feared  by  the 
populace. 

Telranychus  moleslissimus  Weyenberg  from  Uru- 
guay and  Argentine,  which  lives  normally  on  an  aster, 
is  of  like  evil  repute. 

The  case  of  Tydeus  molestus  Moniez,  a  blind,  rose- 
colored  mite  of  the  family  Bdellidaj  or  snouted  mites, 
which  was  discovered  on  a  large  estate  in  Belgium 
where  it  first  made  its  appearance  in  1S64  after  an 
importation  of  Peruvian  guano,  illustrates  the  chance 
introduction  of  an  undesirable  species.  Each  year 
it  appears  at  mid-summer  and  remains  until  frost, 
so  abundant  that  it  constitutes  a  veritable  pest.  It 
throws  itself  on  man  passing  through  the  grass  or 
shrubbery  and  produces  an  insupportable  itching, 
lasting  several  days. 

Ixodoidca  (Ticks). — Among  the  ticks,  which  con- 
stitute technically  speaking  the  superfamily  Ixodoi- 
dea  of  Banks,  two  families  are  recognized:  the 
Argasida;  and  the  Ixodidre.  The  former  are  covered 
by  a  uniform  leathery  integument  without  a  hardened 
shield  or  scutum.  The  Ixodicke  possess  such  a  scutum 
covering  the  entire  body  of  the  male  t  hough  on  the  back 
of  the  female  it  forms  only  a  small  patch  at  the  ante- 
rior end  while  the  distensible  posterior  region  pro- 
jects to  a  variable  extent  behind  it.  In  the  Arga- 
sicke  the  sexes  are  much  alike,  whereas  the  Ixodidse 
showed  marked  sexual  dimorphism.  Moreover  the 
former  feed  moderately  and  both  sexes  change 
thereby  only  slightly  in  thickness  when  gorged.  The 
replete  females  of  the  Ixodida?  are  enormously  in- 
creased in  size  and  changed  to  a  shapeless  round 
mass.  Numerous  other  minor  features  in  structure 
and  habits  serve  to  justify  further  the  separation  of 
the  two  families  but  may  be  omited  here.  The  work 
(if  recent  years  has  disclosed  the  hygienic  importance 
of  this  group  since  at  least  two  important  human  and 


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\ i.ii  liin'i.i 


many   animal   diseases   are    transmitted    specifically 
by  tin'  ticks. 

The  Argasidse  are  mostly  found  in  warm  dry 
regions  and  attack  primarily  birds  and  bats,  but  sev- 
eral species  seek  out  man  when  occasion  offers  and 
from  their  nocturnal  habits  as  well  as  their  flattened 
form  when  fasting  they  arc  mistaken  for  bedb 
Two  genera  only  arc  recognized:  Argas  and  0 
thodoros;  both  of  them  attack  man  and  both  serve  at 
times  as  transmitters  of  human  as  well  as  animal 
diseases.  Mos(  if  not  all  of  these  species  are  noted  for 
their  powers  of  endurance,  specimens  having  withstood 
absence  of  food  and  water  for  months  and  even  for 
two  to  three  years.  This  characteristic  accounts  for 
the  sudden  appearance  of  diseases  transmitted  by 
such  ticks  in  houses  or  shelters  that  arc  rarely  used  or 
been  abandoned  for  a  long  period. 

The  genus  Argas  is  defined  by  Xultall  as  follows: 
y  flattened,  oval  or  rounded,  with  a  distinct 
flattened  margin  differing  in  structure  from  the 
ral  integument;  this  margin  gives  the  body  a 
sharp  edge  which  is  not  entirely  obliterated  even  when 
Hi,'  tick  is  fully  fed.  Capitulum  (in  adult  sand  nymphs) 
entirely  invisible  dorsally,  distant  in  adults  by  about 
its  own  length  from  the  anterior  border.  On  both 
dorsum  and  venter  there  are  numerous  symmetrically 
arranged  disks,  generally  round  or  oval,  more  or  less 
disposed  in  radial  lines.  Elsewhere  the  integument 
is  minutely  wrinkled  into  irregular  zig-zag  folds. 
Eyes  absent.  This  same  author  recognizes  six  valid 
species  and  four  that  are  doubtful  among  w'hich  the 
following  onlv  are  of  importance  here: 

Argas    persicus    (Oken)    1818  (Fig.  274)   =  Rhyn- 

ekoprion   perscium   Oken;    Argas  persicus  Fischer  de 

Waldheim;  Argas mauritianus  Guerin-Meneville;  Argas 

miniatus  C.    L.    Koch;    Argas  americanus  Packard; 

s   sanchezi  Alf.  Duges;    Argas  chinche   Goudet; 

radiatus  Railliet. 


Fie.  L'74. — Argas    persicus;   Dorsal  and    Ventral  Aspects.     En- 
larged.     (After  Marx.) 


Body  oval,  widest  posteriad.  Margin  striate  with 
quadrangular  cells.  Spiracle  half  as  wide  as  anal 
ring.  Male  4  by  2.5  to  5  bj'  3  mm.  or  rarely  S  by  5  mm. 
Gravid  female  7  by  5  to  10  by  6  mm.;  when  gored 
11  by  S.5  mm.  Nymph  4  to  4.5  mm.  long  in  first 
stage;  5.5  to  6.7  mm.  in  second  stage.  Larva  0.7 
to  0.8  mm.  in  length.  Egg  spherical,  0.6  to  0.S  mm. 
in  diameter.  Host:  primarily  a  parasite  on  domestic 
fowl;  this  species  has  been  reported  also  from  duck. 
-e,  turkey,  quail,  canary,  ostrich,  and  once  from 
cattle  in  Texas,  as  well  as  from  man.  After  leaving 
the  host  it  hides  in  cracks  in  floors  or  walls,  or  under 
the  bark  of  trees. 

Though  originally  described  from  the  East  and  sepa- 
rated from  our  native  species  this  form  is  truly  the  same. 
It  is  cosmopolitan  in  its  distribution  even  though 
it  is  most  abundant  in  Persia  where  its  frequence  and 
bad  reputation  are  historic.  It  occurs  widely  on  the 
North  American  continent  and  in  the  United  States 
has  been  recorded  often  from  Texas  and  also  from 
New  Mexico,  Arizona,  California,  and  Florida.  In 
many  places  it  is  a  serious  fowl  pest. 


Arga     / IS  is   popularly  known   in   this   country 

as  the  fowl  tick,  or  adobe  tick  it,  Arizona  and  New 
Mexico.  In  Persia  it  is  called  the  Miana  bug  and  is  said 
to  behave  like  the  bedbug,  being  at  times  so  numerous 
as  to  drive  out  the  inhabitants  from  infested  villages. 
The  early  reports  regarding  the  fatal  re  ult  attending 
its  bites  are  probably  exaggerated  and  il    has  not 

been    shown    that     this      |  Veys     to    man    any 

specific  infectious  disease  as  it  does  to  fowls  to  whi<  h 
it  transmits  Spirochceta  <  thi   cau  e  of  a  fatal 

malady  capable  of  destroying  all  fowls  within  a 
in  the  course  of  a  few  day-.      'J  here  is,  however. 

evidence  that  in  man  also  its  bite  ] lui  il  effect  . 

Mans, m  states  that  miana  fever  is  certainly  trans- 
mitted  to   man  by  this  tick  and  this  view  is  generally 

found  in  scientific  literature,  but    Nuttall  questions 

the  truth  of  the  statement.  In  cases,  especially 
a  1 1  mug  infants  and  children,  or  individual  3U  Ceptible 
to  urticaria  fact  it  ia.  the  bite  causes  edema  of  the  part, 
or  even  of  the  entire  body,  together  with  intense 
pruritus  lasting  several  days. 

Argus  reflexus,  the  common  European  species, 
regularly  infests  pigeon  coops,  from  which  it  enters 
dwellings,  and  has  been  found  in  large  numbers  in 
house  lofts,  and  even  in  old  churches  in  which  pigeons 
had  been  kept.  It  seems  to  have  grown  rarer  in 
recent  years.  This  tick  has  been  shown  capable  of 
transmitting  pyogenic  bacteria  to  healthy  persons 
when  it  has  previously  had  access  to  the  skin  of  per- 
sons suffering  from  furuneulosis. 

Argas  brumpti  infests  the  burrows  of  the  porcupine 
in  Africa  and  attacks  men  sleeping  on  the  ground; 
it  hides  in  the  dust  during  the  daytime. 

Argas  chinche,  troublesome  to  man  in  Columbia,  is 
probably  identical  with  Argas  persicus,  described 
above. 

Ornithodoros  Koch,  1S44,  is  difficult  to  distinguish 
from  Argas  and  is  regarded  by  some  authors  as  hardly 
more  than  of  subgeneric  rank.  It  includes  eleven 
well  established  and  several  doubtful  species:  O. 
savignyi,  the  type  species,  occurs  in  Africa  where  it 
attacks  man  as  well  as  various  domestic  animals. 

Ornithodoros  moubata  (Murray)  =  Argas  moubata 
Murray,  Ixodes  ?noubata  Ornithodoros  savignyi,  var. 
cazca  Neumann. 

Adult  8  by  6  or  7  mm.;  gorged  females  up  to  11 
mm.  long.  Nymph  in  first  stage,  1  by  0.87  mm. 
Egg  0.9  by  0.S  mm.  Much  like  0.  savignyi,  but  less 
hairy  and  easily  distinguished  by  absence  of  eyes  and 
details  in  the  structure  of  the  appendages  (Fig.  275). 

Hosts:  Domestic  animals  generally,  also  monkey 
and  man.  Man  appears  to  be  the  chief  host.  The 
species  is  widely  distributed  in  Africa  south  of  the 
Sahara.  It  hides  in  the  dust  or  sand  and  attacks 
animals  at  their  resting  places.  Ticks  are  found 
particularly  along  much  traveled  highways  and  less 
frequently  if  at  all  in  isolated  native  villages.  This 
may  be  due  to  the  temporary  character  of  native 
huts  and  their  frequent  abandonment.  Along  the 
Congo  the  rest  houses  of  native  travelers  are  badly 
infected.  The  species  is  known  as  the  papaze  and  is 
evey where  plentiful  in  the  Arab  houses,  where  they 
hide  in  cracks  and  crevices  of  the  walls,  or  even  in 
thatched  roofs. 

Livingston  noted  that  its  bite  is  painful  and  that 
the  sensation  persists  and  he  also  referred  to  the  well- 
known  fever  that  follows  the  bite.  This  disease  is 
the  African  relapsing  fever  or  human  tick  fever 
found  through  Eastern  and  Central  Africa,  the  Congo, 
and  Angola.  It  is  caused  by  Spirochceta  duttoni 
which  is  transmitted  by  bite  of  the  tick  and  multiplies 
in  the  human  blood  where  maximum  numbers  are 
found  during  the  febrile  attacks.  These  follow 
five  to  ten  days  after  a  non-immune  has  been 
bitten. 

When  a  female  tick  sucks  blood  containing  Sp. 
duttoni,  the  organism  migrates  into  the  ovaries  of  the 
ticks  and  infects  the  undeveloped  eggs.     Thus  the 


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next  generation  of  ticks  is  infected  and  the  parasites 
are  transmitted  when  the  new  nymph  in  the  first 
stage  feeds  on  the  blood  of  a  new  host.  It  has  been 
shown  that  the  spirochete  is  even  transmitted 
through  the  ova  to  the  third  generation  of  ticks, 
although  the  second  generation  had  been  fed  on  non- 
infected  blood.  Such  infected  ticks  will  naturally 
transmit  the  disease  by  their  bites.  So-called 
coccoid  bodies  or  granules  demonstrated  in  the  tick 


Fig.    275. — Ornithodoros   moubata,  female,   X3;    dorsum   and 
venter;  specimen  from  British  Central  Africa.      (After  Nuttall.) 

ovary  constitute  the  infective  agents;  their  nature  and 
biology  have  not  been  fully  elucidated. 

0.  moubata  has  also  been  considered  capable  of 
transmitting  Filaria  perstans  to  man,  and  Wellman 
was  able  to  follow  in  part  the  development  of  such 
filaria  embryos  in  this  tick. 

0.  coriaceus  from  California  and  Mexico  is  feared 
by  natives  because  its  bites  are  severe  and  heal  very 
slowly.  0.  turicata  from  New  Mexico,  Arizona,  and 
California,  as  well  as  further  south,  attacks  pigs, 
cattle,  and  man.  It  may  cause  serious  injury  by  its 
bite  ami  Duges  says  people  are  reported  to  have  died 
therefrom.  0.  talaje  is  another  species  in  the  same 
region  that  at  times  attacks  man;  it  infests  normally 
old  houses  and  like  other  species  comes  out  at  night 
to   bite.     0.    thalozani   is   the   sheep   bug   of  Persia, 


Fig.  276. — Rostrum  of  Ixodes  hexajronus,  female,  from  below. 
X50  diameters.     (After  Delafoud,  from  Railliet.) 


■which   also   attacks  man  and  may  transmit  disease. 
It  is  locally  said  to  be  very  dangerous  to  man. 

0.  megnini  occurs  chiefly  on  the  ears  of  the  horse, 
OX,  and  ass,  and  has  been  recorded  from  the  human 
cur  in  Mexico.  The  species  has  been  reported  from 
the  Gulf  Stales,  and  as  far  north  as  Nevada,  Idaho, 
and  Iowa.  It  has  been  found  as  a  chance  parasite 
in  the  human  car  in  New  Mexico  and  Arizona  but 
was  readily  removed  by  introducing  a  pledget  of 
cotton   moistened   with   chloroform.       Most    of    the 


cases  on  record  are  among  children  in  infected 
regions.  Intense  pain  is  caused  by  their  presence  in 
the  human  ear  but  so  far  as  known  no  more  serious 
consequences. 

The  Ixodidae  are  most  easily  recognized  by  the  fact 
that  the  beak,  technically  designated  the  rostrum  or 
capitulum,  is  not  hidden  below  the  anterior  margin 
of  the  body  as  in  the  Argasidae  but  projects  con- 
spicuously beyond  it.  The  capitulum  (Fig.  27G) 
consists  of  (a)  the  flattened  maxiUo-labial  hypostome, 
ib)  two  maxillary  palps,  (c)  two  elongated  mandibles 
inflated  at  the  base  but  flattened  toward  the  tip.  The 
hypostome  and  the  terminal  joint  of  the  mandibles  are 
armed  with  retrorse  spines  or  teeth.  The  two  spiracles 
lie  just  posterior  to  the  coxae  of  the  fourth  pair  of  legs 

The  Ixodidae.  are  highly  specialized  parasites. 
Most  of  them  are  parasitic  on  wandering  hosts  and  all 
stages  are  found  on  the  same  host.  When  the  males 
occur  alongside  of  the  females,  both  sexes  are 
characterized  by  the  possession  of  hypostomes 
similarly  well  armed  with  prominent  teeth.  Species 
that  are  parasitic  on  hosts  with  more  or  less  fixed 
habitats  display  less  highly  specialized  parasitism  iu 
that  the  males  do  not  occur  on  the  hosts  and  do  not 
possess  armed  hypostomes.     The  male  feeds  sparingly 


Fig.  277. — Ixodes  ricinus,  L.,  male,  in  Ventral  Aspect. 
(After  a  drawing  by  A.  Dampf.) 


X  16. 


on  the  host  but  the  female  gorges  itself  with  blood 
until  the  leathery  distensible  hind  body  has  swollen 
to  the  size  of  a  castor  bean  which  it  resembles  strongly. 
Such  engorged  females  drop  to  the  ground  and  after 
a  quiescent  period  spent  in  hiding,  the  huge  masses  of 
eggs  are  laid.  The  hexapod  larvae,  which  emerge 
after  a  variable  time  depending  on  temperature, 
climb  to  the  tips  of  blades  of  grass,  bushes,  and  other 
vegetation,  and  attach  themselves  to  hosts  from 
which  a  meal  of  blood  is  taken.  Once  satiated  such 
a  larva  falls  to  the  ground  and  undergoes  a 
metamorphosis. 

The  octopod  nymph  repeats  this  history  on  a  new 
host  and  then  metamorphoses  into  the  adult  which 
again  seeks  out  a  host  and  completes  the  life  cycle. 
The  duration  of  this  cycle  s  about  six  months  under 
most  favorable  conditions  but  may  require  two  or 
three  years. 

These  ticks,  naturally  abundant  in  woods  and 
underbrush,  or  in  high  rank  grass,  select  their  hosts 
largely  by  chance.  .Many  of  them  may  occur  on  man 
and  the  frequence  of  this  depends  chiefly  on  the 
abundance  of  the  tick;  secondarily,  its  special  habits 
govern    its    appearance    on    the    human    host.     The 


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Araclinlda 


species  occurring  cm  1 1 1; :n i  have  iml  been  recorded  with 
desirable    accuracy.      They    arc    fre<  |ucnt  ly    found    Oil 

travelers  as  well  as  cm  workers  in  wooded  districts  and 
there  removal  is  effected  by  simple  methods  without 

medical  assistance.  I'sually  I  heir  presence  is  not  fol- 
lowed by  any  untoward  results. 

Many  authors  report  psoriasis-like  eruptions  and 
phlegmonous  inflammation  following  tick  bites.  Yet 
a  lick  may  hang  on  for  days  without  being  per- 
ceived and  experiments  to  inoculate  germs  through 
ink  bites  have  thus  far  proved  negative.  Whenever 
the  tick  is  forcibly  removed  and  the  rostrum  left 
imbedded  in  the  flesh  of  the  host  the  wound  is  painful 
i  much  more  serious.  A  drop  of  turpentine. 
benzine,  petroleum,  or  even  oil  or  melted  butter, 
placed  on  the  head  of  the  tick,  will  usually  cause  it  to 
loosen  its  hold  and  drop  from  the  skin.  Sometimes 
ticks  penterate  beneath  the  skin  of  the  host.  Several 
oases  are  on  record  in  which  living  ticks  have  been 
found  in  cysts  or  tumors  on  the  human  skin.  These 
reach  the  size  of  a  nut  but  are  easily  removed. 

Texas  fever  in  cattle  is  transmitted  by  ticks  and 
dipping  is  practised  extensively  to  relieve  these  hosts 
of  the  infecting  agents. 

Nine  genera  are  recognized;  of  these  only  Ixodes, 
I),  rmacentor,  and  Amblyomma  are  of  especial  signifi- 
cance here. 

Ixodes. — Anal  grooves  surrounding  the  anus  in 
front.     Xo  eyes;  without  festoons.     Spiracles  round 


278. — Ixodes   hexagonus,    male,    in    Ventral    Aspect.      X13. 
(After  Neumann.) 


or  oval.  Sexual  dimorphism  pronounced.  Ventral 
surface  of  male  covered  by  non-salient  plates.  Type 
species: 

/.codes  n'n7!t/.s(L)(  The  Cast  or  BeanTick)  =/.  reduvius 
of  many  writers.  Male  brown,  oval,  larger  posteriorly, 
2.5  mm.  long  by  1.5  mm.  broad.  Female  4  mm.  long 
and  :>  mm.  broad,  or  when  gorged  10  to  11  mm.  long  by 
ti  to  7  mm.  broad,  ashen  gray  tending  to  brown  or 
yellow. 

This  species  is  abundant  in  Europe  and  occurs 
throughout  the  United  States  from  Pennsylvania, 
Kansas,  and  California  to  Florida  and  Texas.  It  occurs 
apparently  by  preference  on  sheep  and  cattle,  though 
frequent  on  the  horse,  rabbit,  many  wild  mammals, 
and  less  often  on  birds  and  reptiles.  It  is  the  chief 
carrier  of  redwater  in  cattle  (bovine  piroplasmosis) 
with  which  its  connection  has  been  conclusively 
demonstrated  by  experimentation.  Cases  of  septi- 
cemia in  man  are  recorded  by  European  writers  as  the 
apparent  result  of  the  bite  of  this  species,  but  ex- 


perimental  work   has   thus  far  failed   to  confirm   this 

view. 
Ixodes  hexagonus  Leach(  The  European  Dog  Tick) 

(Fig.    278).     The    breadth  of  the  median  plate  and  the 

shorter   rostrum  distinguish  this  from  the  preceding 
pecies.     It  is  very  widely  distributed  in  Europe  and 


Fig.  '279. — Stigmal  Plate  of  Male  Dermacentor  anderBoni.  Notice 
the  relatively  large  aperture  and  chamber  and  the  prominent 
dorsolateral  prolongation  which  forms  a  right  angle  at  the  caudal 
margin;  the  goblets  are  numerous  (157)  and  evenly  distributed, 
but  areabsenl  from  the  margin;  the  middle  layer  is  visible.  Greatly 
enlarged.     (After  ritiles.) 


has  been  reported  from  a  wide  range  of  hosts.  It 
occurs  in  the  territory  east  of  the  Rocky  Mountains 
in  North  America.  Canine  piroplasmosis  is  trans- 
mitted by  this  species.  Blanchard  cites  cases  in  which 
it  has  penetrated  below  the  skin  of  man. 

Boophilus  annulatus  (Say),  the  Texas  fever  cattle 


Fig.  280. — Stigmal  Plate  of  Female  Dermacentor  andersoni. 
Notice  the  acute  angle  formed  by  the  dorsolateral  prolongation; 
the  anterior  margin  of  the  prolongation  is  broader  than  the  caudal 
margin;  120  goblets  are  present.  Greatly  enlarged.  (After 
Stiles.) 


tick,  exceeds  in  economic  importance  all  other 
species  as  the  form  by  which  Texas  fever  in  cattle  is 
transmitted.  The  organisms  of  this  disease  {Piro- 
plasma  bovis)  are  transmitted  through  the  eggs  from 
one  generation  of  ticks  to  the  second  or  even  the  third, 
which  can  accordingly  produce  the  disease  in  non- 


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immune  animals.  The  larvae  occur  only  very  rarely 
on  man.  Even  in  Texas  where  the  species  is  very 
abundant,  accurate  observers  have  found  it  on  the 
human  skin  only  half  a  dozen  times  in  ten  years. 
Apparently  it  does  not  transmit  any  germs  to  man 
here.  In  Africa,  however,  "tick-bite  fever"  with  a 
fairly  definite  train  of  symptoms  may  follow  the  bite 
of  a  variety  of  this  species. 


Fig.  2S1. — Dermacentor  andersoni,  young  female.     Dorsal   View. 
(After  Stiles.) 


Dermacentor. — Anal  grooves  surrounding  the  anus 
behind;  rostrum  short.  Ornate  with  eyes  and  fes- 
toons.     Basis  capituli  rectangular  dorsally. 

Stiles  has  demonstrated  that  the  stigmal  plates 
(Figs  279  and  280,  form  a  ready  and  accurate 
method  for  the  distinction  of  the  numerous  species. 
This  genus  includes  the  species  responsible  for  the 
transmission  of  Rocky  Mountain  spotted  fever,  and 


Fig.  282. 


Dermaeentoi    andersoni,   male  from  Montana. 
View.     (After  Stiles.) 


al~o  several  others  commonly  found  on  man  in 
various  sections  of  the  country.  The  most  impor- 
tant   species    uiniiiestionably  is: 

Dermacentor  andersoni  Stiles  (The  Rocky  Mountain 
Spotted  Fever  Tick)  =  D.  venustus  Banks;  D. 
occidentalis  < >f  writers  on  Rocky  Mountain  Spotted 
I  '    er.     Gray   to  red,  brown,  or  even  nearly  black. 


Stigmal  plate  large;  its  dorso-lateral  prolongation 
distinct.  Goblets  in  plate  very  numerous  and 
crowded.  Male  4  by  2.5  mm;  female  may  attain  16  by 
9.5  by  6  mm.  when  replete  (Figs.  2S1  to  284).  Hosts: 
man,  cattle,  horse,  dog,  rabbit,  gopher.  Habitat: 
Montana,  and  parts  of  Washington,  Oregon,  Idaho, 
Nevada,  Wyoming,  Utah,  and  Colorado.  It  is  the 
common  tick  of  the  Bitter  Root  Valley.     It  occurs 


Fig.  283.- 


-Dermacentor  andersoni,  young  female. 
(After  Stiles.) 


Ventral  View 


at  elevations  of  from  500  to  9,000  feet  but  reaches 
its  maximum  at  an  elevation  of  3,000  to  5,000  feet 
where  it  is  often  found  in  large  numbers. 

The  view  that  Rocky  Mountain  spotted  fever  is 
conveyed  by  the  wood  tick  of  that  region  was  ad- 
vanced in  1902  by  Wilson  and  Chowning.  By 
a  series  of  careful  and  convincing  experiments  ex- 
tending from  1906  to  1909,  the  late  Dr  H.  T.  Ricketts 


Fig.  2S4. — Dermacentor  andersoni.  male  from  Montana. 
View.     (After  Stiles.) 


Ventral 


demonstrated  that  the  disease  was  transmitted  chiefly 
if  not  exclusively  by  Dermacentor  andersoni.  This 
tick  is  especially  abundant  in  localities  having  much 
fallen  timber  and  underbrush.  The  immature 
stages  feed  upon  small  mammals,  such  as  gopher, 
chipmunk  and  ground  squirrel,  but  the  adults  attack 
only  the  larger  domestic  animals.      Ricketts  demon- 


514 


REFERENCE    HANDBOOK    OK    Till',    MEDICAL    SCIENCES 


\  I.M    lllllil    I 


strated  that  guinea-pigs  are  susceptible  to  t he  dis- 
ease; that  larval  or  nymphal  ticks  contract  the  dis- 
ease by  biting  an  infected  animal  and  can  transmit 
it  in  tin'  following  stage  (nymph  or  adult);  that 
adult  ticks  having  acquired  the  disease  can  transmit 
it  through  tl gg  to  the  succeeding  generation; and, 

finally,  that  infected  ticks  occur  in  nature.  It  has 
been  further  shown  that  the  actual  distribution  of 
the  tick  is  much  broader  than  the  limits  within 
which  the  disease  occurs.  This  is  an  evident  ele- 
ment of  danger  and  indicates  for  the  disease  a 
much  greater  possible  range  than  at  present  occupied. 
I  here  is  some  reason  to  believe  that  the  malady  is 
ading. 

This  tick  hibernates  through  the  winter  and  on 
emerging  seeks  a  host.  During  the  period  from  about 
March  15  to  July  1.5,  the  parasites  attack  man  and 
transmit  the  genus  of  the  disease.  The  eggs  laid  by 
the  earliest  mature  females  may  develop  to  adults 
by  September,  but  ordinarily  this  generation  does 
not  progress  so  far  and  hibernates  during  the  second 
winter,  thus  repeating  the  history  of  the  previous 
general  ion.  The  large  majority  of  these  ticks  re- 
quire two  years  to  finish  out  the  life  cycle  completely 
and  siime  take  even  three  years. 

At  present  the  virulent  form  of  the  disease  with  a 
death  rate  of  about  seventy  per  cent,  is  confined  to 
the  Bitter  Hoot  Valley.  Measures  have  been  formu- 
lated for  the  restriction  of  this  form  of  the  disease  to 
that  territory  and  the  ultimate  eradication  of  this 
tick  which  though  only  one  of  several  that  carry  the 
disease,  is  the  only  one  of  the  group  that  attacks 
man. 

The  plan  for  the  eradication  of  the  disease,  sug- 
gested   originally    by   Ricketts,   is    based   upon   the 


Flo.  285. — Dermacentor   variabilis,  Dorsal  view  of  male.      X10 
(After  Osborn.) 

practical  restriction  of  the  adult  ticks  to  the  larger 
domesticated  animals.  It  is  favored  by  the  limited 
population  and  the  isolation  of  the  region.  It 
Consists  in  dipping  all  live  stock,  or  in'  hand  treat- 
ment of  such  as  cannot  be  dipped.  The  plan  de- 
mands at  least  three  years  for  its  execution.  Even 
if  more  expensive  and  not  as  successful  as  pro- 
phesied, the  benefit  resulting  would  be  very  great. 

The  microorganism  which  produces  the  disease 
and  is  transmitted  by  the  tick  has  not  been  positively 
determined.  Ricketts  isolated  a  bacillus  that  may 
be  specific,  but  the  question  is  still  sub  judice. 


D.  andersoni  is  easily  confused  with  D.  venustus 
of  Texas  under  which  name  it  has  generally  been 
included,    and     with     I),   occidentahs     of     California, 

another    species    which    occupies    an    immediately 

adjacent    range.      Stiles    (Public    Health    Repts.,   July 

.;,  L908)  states  tin-  differences  which  are  adequate  for 
the  separation  of  the  three  species.     Fortunately  it 

appears  that  neither  of  these  closely  related  species 
and  contiguous  species'  can  transmit  the  Rocky 
Mountain  spotted  fever. 

The  Pacific  Coast  Tick,  Dermacentor  occidentalis 
Marx,  is  limited  in  distribution  to  western  Oregon, 
California,  and  probably  .Mexico,  where  it  is  the  most 
common  tick.  Abundant  on  live  stock,  it  occurs 
often  on  man.  especially  during  the  rainy  season  when 
it  is  most  numerous  and  the  source  of  great  annoyance. 

It  is  often  confused  with  the  previous  species  but, 
readily  distinguishable  by  numerous  red  points 
among  the  white  markings. 

The  American  dog  tick,  Dermacentor  variabilis  Say 
(Fig.  285),  is  the  most* common  species  east  of  the 
Mississippi  River;  its  range  extends  from  Labrador  to 
Florida.  It  displays  a  strong  tendncy  to  attach 
tself  in  the  ears  of  the  host.  No  evil  consequences 
are  known  to  follow  its  attack  on  man. 

Amblyomma  and  Hyalomma  are  readily  separable 
from  other  ticks  by  their  long  palps.  The  latter, 
found  in  Africa,  is  the  agent  in  transmitting  various 
piroplasmas  in  domestic  animals,  including  the  camel 
and  dromedary.  The  former  includes  two  important 
American  forms  and  may  be  distinguished  by  the 
absence  of  anal  plates  in  the  male.  Each  of  these 
species  are  frequent  on  man.  The  long  beak  enables 
it  to  maintain  a  firm  hold.  The  severe  results  follow- 
ing its  attachment  to  man  in  some  cases  appear  to  be 
due  to  the  introduction  of  bacteria.  In  Africa  it  gives 
rise  to  a  definite  train  of  symptoms  and  the  condition 
is  designated  "tick-bite  fever."  The  disease  affects 
new  comers  and  old  residents  appear  to  have  acquired 
immunity. 

Amblyomma  americanum  Koch  (The  Lone  Star 
Tick)  =  Ixodes  unipunctata  Packard.  Male:  body 
brownish  red,  oval,  much  elon- 
gated posteriorly,  3  mm.  long, 
2.5  mm.  broad.  Female  (young) : 
colored  like  the  male  with  a  white 
spot  on  the  back  of  the  living 
animal.  Length  4.5  mm.,  breadth 
3  mm.,  increasing  in  gravid  fe- 
males to  8  by  12  mm.  (Fig.  286). 

This  characteristic  American 
species  occurs  from  Labrador  to 
Florida  and  Texas  and  is  known 
from  South  America  as  well.  It 
is  common  on  cattle  in  the  south- 
ern part  of  the  United  States,  and 
is  reported  from  other  domesticated  as  well  as  wild 
species.  Packard  reports  a  case  in  which  a  specimen 
had  penetrated  into  the  arm  of  a  young  girl,  forming 
there  a  tumor.  It  is  said  to  be  very  annoying  to  man 
in  the  warmer  portions  of  the  country,  and  a  corre- 
spondent in  Texas  writes  that  he  removed  several 
females  from  his  own  children  in  one  evening. 

Amblyomma  maculatum  Koch,  the  Gulf  Coast  tick, 
occurs  along  the  Gulf  Coast,  especially  in  Louisiana 
and  Texas.  It  extends  far  south  into  South  America. 
In  size  and  general  appearance  it  resembles  the  pre- 
vious species  but  lacks  the  bright  metallic  star  on  the 
shield  of  the  female  Lone  Star  tick.  It  is  more  in- 
clined to  attack  man  than  any  other  North  American 
species,  except  the  Rocky  Mountain  spotted  fever 
tick.  Henry  B.  Wabd. 

Principal  Articles  Used. 

Braun:  Die  thierischen  Parasiten  des  Menschen;  vierte  Aufl.. 
Wiirzburg,  1895. 

Canestrini  und  Kramer:  Demodicidie  und  Sarcoptida1.  Das 
Tierreich;  7.  Lief.,  Berlin,  1899. 

515 


Fig.  286.— Ambly 
omnia  americanum 
Koch,  Adult  female. 
(Original.) 


Arachnida 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Darling  and  Clark:  Linguatula  serrata  (larva)  in  a  Native  Cen- 
tral American.     Arch.  Int.  Med.,  9;  401-5,  1912. 

Hessler:  An  Extreme  Case  of  Parasitism.  Indiana  Academy  of 
Science,  1893;  also  Amer.  Naturalist,  vol.  xxvii.,  pp.  346-52,  1893. 

Megnin:  Les  parasites  et  les  maladies  parasitaires,  Paris,  1880. 

Neumann:  Parasites  and  Parasitic  Diseases  of  Domesticated 
Animals.  Translated  by  Flemming,  London,  1892.  Revision  de 
la  famille  des  Ixodides.  Mem.  Soc.  Zool.  France,  vol.  ix.,  pp.  1-44; 
X.,  pp.  324-420;  xii.,  pp.  107-294,  1S96-99. 

Nuttall:  Insects,  Arachnids,  and  Myriapods  as  Carriers  of  Dis- 
ease. Johns  Hopkins  Hospital  Reports,  vol.  viii.,  pp.  1-154,  with 
3  plates,  1899. 

Nuttall,  Warburton,  Cooper,  and  Robinson:  Ticks,  A  Mono- 
graph of  the  Ixodoidas.     3  pts.  Cambridge,  190S-1911. 

Osborn:  Insects  Affecting  Domestic  Animals.  United  States 
Dept.  Agr.,  Div.  Entom.,  Bull.  5,  N.S.,  1S96. 

Railliet:  Traite  de  Zool.  Med.  et  Agric,  2me  ed.,  Paris,  1893-95. 

Ricketts:  Investigation  of  the  Cause  and  Means  of  Prevention 
of  Rocky  Mountain  Spotted  Fever.  Also  other  important  papers 
by  same  Author  Reprinted  in  Contrib.  to  Med.  Sci.,  Univ.  Chicago 
Pre-.,  1906-08:  reprinted  1911. 

Riley:  Poisonous  Insects.  First  edition  Reference  Handb.  of 
the  Med.  Soc,  Nov  York,  18S7. 

Salmon  and  Stiles:  Cattle  Ticks  of  the  United  States.  Ann. 
Rept.     Bur.     An.     Ind,     17:  3S0-492,  1910. 

Sambon;  Porocephaliasis  in  Man.  Jour.  Trop.  Med.,  13:  17-23, 
212-216,258-267,1910.  . 

Shipley:  Revision  of  the  Linguatulidse.  Arch.  Parasitol.  vol. 
i.,  pp.  52-80,  1898. 

Stiles:  Stigmal  Plates  in  Dermacentor.  Bull.  Hygienic  Lab., 
No.  62,  1910~     Also  smaller  papers  by  the  same  and  other  authors. 


Araliaceae.— (The  Ivy  Family.)  A  family  of  some 
forty  genera  and  about  400  species,  widely  distrib- 
uted through  temperate  and  tropical  regions  of  both 
the  old  and  the  new  worlds.  Its  plants  are  highly 
ornamental,  some,  like  the  ivy,  being  extensively 
cultivated  for  this  purpose.  Medicinally,  it  is  of 
note  as  yielding  the  famous  ginseng.  Its  constitu- 
ents are  simply  aromatic  and  without  special  prop- 
erties. The  spikenard,  and  several  other  species  of 
Aralia,  were  formerly  very  extensively  used,  and  are 
still  used  to  a  considerable  extent,  for  these  prop- 
erties. Some  of  them  contain  amaroids  in  connec- 
tion with  their  resins  and  volatile  oils. 

H.  H.  Rusby. 


Araneida. — Araneida,   Aranem.     The  order  of   the 

class  Arachnida,  which  includes  the  true  spiders, 
of  which  the  tarantula  is  an  example.  Respiration 
is  by  means  of  tracheal  tubes  and  "lung-hooks"; 
the  abdomen  is  provided  with  spinning  glands. 
See  Arachnida.  A.  S.  P. 


Aranzio,  or  Arantius.— Born  in  Bologna,  Italy,  in 
or  about  1530,  Aranzio  acquired  in  time  the  reputation 
of  being  one  of  the  most  skilful  anatomists  of  tin' 
sixteenth  century.  He  received  his  medical  educa- 
tion in  part  from  his  uncle,  Bartolomeo  Maggi,  a 
celebrated  surgeon  of  Bologna  (and  later  physician 
of  Pope  Julius  III),  and  in  part  from  the  illustrious 
Vesalius,  professor  of  anatomy  in  the  University  of 
Padua.  The  degree  of  Doctor  of  Medicine  was  given 
to  him  by  the  University  of  Bologna,  and  very  soon 
afterward  he  was  called  by  the  same  institution  to 
occupy  the  chair  of  medicine,  surgery,  and  anatomy. 
For  a  period  of  thirty-three  years— that  is,  up  to  the 
time  of  his  death  in  15X9— he  faithfully  performed 
the  duties  of  this  position.  Credit  is  due  him  for  a 
large  number  of  anatomical  discoveries.  His  most 
important  publications  are:  "  De  humano  fcetu 
opusculum.''  Rome,  1504;  " Observationes  anato- 
mical" (with  the  treatise  on  tumors).  Venice, 
1595;  "In  Hippocratis  librum  de  vulneribus  capitis 
conimentarius."     Lyons,  1579.  A.  H.B: 

Arbor  Vita;. — See  Thuya. 


Arbuthnot,  John. —  Born  in  Scotland,  near  Mont- 
rose; date  of  birth  not  known.  He  took  the  degree 
of  doctor  of  medicine  at  the  University  of  Aberdeen. 
He  began  his  professional  career  in  London,  and  his 
practice  grew  rapidly.  His  reputation,  however, 
was  based  rather  on  his  literary  labors  than  on  what 
he  accomplished  in  the  domain  of  medicine.  He 
became  in  turn  physician  extraordinary  to  Prince 
George  of  Denmark  and  one  of  the  regular  medical 
advisers  of  Queen  Anne.  In  1710  he  formed  a  close 
friendship  with  the  most  eminent  literary  men  of  that 
epoch,  such  men  as  Pope,  Swift,  and  Gay.  He  died 
in  London  in  1734  or  1735.  He  published  three 
essays  on  medical  topics,  viz.,  one  on  the  regularity 
of  the  births  of  both  sexes;  another  in  1731  on  the 
nature  and  choice  of  aliments;  and  a  third  in  1733  on 
the  effects  of  air  in  the  human  body.  A.  H.  B. 


Arcachon,  France,  (latitude  44°  7'),  is  situated 
thirty-five  miles  southwest  of  Bordeaux,  in  the  midst 
of  a  thick  forest  of  pine  trees,  where  once  was  only  a 
lowlying  sandy  desert  waste.  Some  sixty  or  more 
years  ago  this  waste  of  barren  sand  dunes  was  planted 
with  pine  trees,  which  thrive  in  sandy  soil,  by  the 
French  government,  for  the  purpose  of  fixing  the 
sand,  which,  by  the  action  of  the  wind  and  waves, 
was  constantly  encroaching  upon  the  country  of  the 
interior.  There  are  nine  thousand  acres  of  these 
pine  trees,  and,  owing  to  the  noiseless  sandy  roads  and 
the  silent  trees,  there  is  a  peculiar  and,  to  some  per- 
sons, a  depressing  stillness. 

Arcachon  is  about  nine  miles  from  the  actual  coast, 
at  the  south  of  a  large  landlocked  bay  or  basin,  con- 
nected by  a  narrow  channel  with  the  sea.  A  part  of 
the  town  is  directly  on  this  bay,  the  Ville  d'Ete\  and  a 
part  on  the  surrounding  sand  hills  in  the  midst  of  the 
pines,  the  Ville  d'  Hiver,  which  is  the  winter  resort  for 
invalids. 

The  features  of  the  climate  are  those  of  a  marine 
one,  characterized  by  a  very  considerable  amount  of 
moisture,  equability,  and  a  rather  mild  temperature. 
In  addition,  there  is  the  influence,  whatever  benefit 
it  may  be,  of  the  pine  forests,  the  air  of  which  is  said 
to  be  remarkably  rich  in  ozone,  and  "perceptibly 
impregnated  with  the  balsamic  odor  of  turpentine." 
The  winter  climate,  according  to  Yeo,  is  mild  and 
sedative,  yet  not  relaxing.  "The  calmness  of  the 
atmosphere,  the  silence  of  the  forest,  a  certain  isola- 
tion of  the  habitations,  and  resinous  emanations  from 
the  fir  trees,  constitute  a  combination  of  sedative  con- 
ditions of  which  not  one  is  superfluous,"  says  Black. 
("Southwest  France,"  Black.) 

Such  are,  doubtless,  most  excellent  sedative  condi- 
tions, but  it  would  generally  require  a  very  sedate 
person  to  endure  with  equanimity  such  monotony,  of 
which  invalids  too  often  complain,  says  the  same 
author. 

Lalesque  ("Cure  Marine  de  la  Phthisie  Pulmo- 
naire,"  Paris,  1897)  gives  the  monthly  mean  temper- 
ature for  the  three  seasons  of  winter,  spring,  and 
autumn,  as  follows,  the  observations  extending  over 
a  period  of  nine  months  (the  figures  denote  degn  es 
Fahrenheit). 


December 44   72     March 52.00     September  ...  fi!'  94 

January 43.37     April 58.09     October... 

February 45.77     May 63.83 


November  . . .  51  75 


From  which  we  find  the  mean  winter  temperature  is 
44.62°  F.;  that  of  spring,  57.64°  F.;  and  of  autumn, 
60.4°  F.  The  daily  and  monthly  variations  are  said 
by  the  same  authority  to  be  small.  The  average 
annual  humidity  is  seventy-seven  per  cent,  according 
to  Lalesque  and  eighty-five  per  cent,  according  to 
Weber. 


516 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Arco 


The  average  number  of  clays  of  rain  for  the  six 
years  from  1887  to  L892  is  as  follows: 


ISS7 
L8S8. 


117     [889 

IliS      IS'.IO. 


I7S 
151 


189] MO 

1892 liu 


making  an  average  of  152.6  days  for  the  entire  period. 
November  and  December  arc  the  rainy  monthsof 
tin'  year.  The  rains  are  most  severe  during  the  night 
or  in  the  morning,  and  least  so  toward  the  middle  of 
the  day. 

Arcachon  is  both  a  summer  and  winter  resort;  the 
portion  of  the  town  lying  directly  on  the  shore  or  the 
suit  water  lake,  or  basin,  being  the  resort  for  summer, 
which  is  much  frequented  for  sea-bathing,  which  is 
excellent,  and  for  boating,  yachting,  and  fishing.  The 
Boulevard  do  la  Plage  runs  the  entire  length  of  the 
town,  along  the  sea,  and  on  it  arc  situated  many  of 
the  hotels,  which  are  good.  There  are  clubs,  a 
casino,  English  or  English-speaking  physicians,  and 
an  English  church — "all  the  appliances  of  advanced 
ci\  ilizal  ion." 

The  winter  resort,  known  as  the  "Ville  d'Hiver," 
is  hack  from  the  summer  resort  portion  and  separated 
from  it  by  a  high  sand  dime,  between  the  two  por- 
tions of  the  town  is  a  large  public  garden.  There  are 
numerous  picturesque  villas  hidden  in  the  pines, 
hotels  and  boarding  houses. 

The  walks  and  drives  in  the  forest  offer  but  little 
variety  of  scenery,  and  one  is  advised  to  take  a  pocket 
compass  in  order  to  preserve  his  direction. 

Such  a  combination  of  pure  sea  air  and  pine  forests 
i<  applicable  to  various  maladies,  such  as  irritative 
bronchial  or  laryngeal  catarrh,  glandular  and  bone 
tuberculosis  in  children,  and,  according  to  Yeo 
("Health  Resorts  and  Their  Uses,  J.  Burney  Yeo," 
M.  D.),  " cases  of  dyspepsia  complicated  with  hysteria, 
hypochondriasis,  and  nervous  irritability."  Pulmon- 
ary tuberculosis,  however,  is  the  disease  to  which  the 
climate  of  Arcachon  has  been  applied  more  than  to  any 
other  and  the  place  has  a  local  reputation  for  the 
treatment  of  this  disease. 

Dr.  Lalesque,  who  has  written  a  book  upon  marine 
climates  in  general  and  that  of  Arcachon  in  particular 
(Cure  Marine  de  la  Phthisie  Pulmonaire,  Paris,  1S97), 
as  applied  to  the  treatment  of  tuberculosis,  speaks 
with  Gallic  enthusiasm  of  the  favorable  influence  of 
such  a  climate  upon  this  disease;  and  in  ISA  cases,  of 
which  79  were  in  the  first  stage,  45  in  the  second,  and 
60  in  the  third,  he  obtained  34  per  cent,  of  cures  and 
50  per  cent,  improved  of  the  first  stage  cases;  20  per 
cent,  and  53  per  cent,  respectively  in  the  second 
stage;  and  6.6  per  cent,  and  35  per  cent,  in  the  third 
stage.  In  the  whole  1S4  cases  he  obtained  21.7  per 
cent,  of  cures  and  46  per  cent,  improved.  He 
applies  very  rigorously  the  "cure  d'air  et  de  repos," 
although  his  patients  are  not  under  sanatorium 
control,  and  he  thinks  the  "cure  marine"  as  illus- 
trated by  Arcachon,  gives  results  comparing  favorably 
wilh  those  obtained  in  the  mountain  resorts. 

Undoubtedly,  constant  exposure  in  pure  air  is  the 
principal  climatic  factor  in  the  treatment  of  pulmon- 
ary tuberculosis,  wdiatever  the  climate  and  whatever 
the  resort,  other  things  being  favorable.  "I  can  cure 
tuberculosis  in  any  climate,"  once  remarked  the 
distinguished  Dettweiler  to  the  writer.  Nevertheless, 
the  high  altitudes  and  resorts  with  a  dryer  climate 
have  given  appreciably  better  results,  as  shown  by 
statistics.  We  are,  however,  more  and  more  realizing 
that  climate  is  only  one  factor  in  the  treatment  of 
tuberculosis,  and  others  are  quite  if  not  more  im- 
portant. It  is  only  in  the  skilful  combination  of  all 
by  the  expert  that  the  best  results  are  obtained. 

Edward   O.  Otis. 


Arco. — This  village  occupies  in  Austrian  estimation 
the  position  which  is  held  in  Italy  by  San  Rerao,  and 


in  France  by  Mentone.     li  is  situated  in  the  extreme 

southern  portion  of  the  Austrian  Tyro),  OH  the  line  of 

the  railway  between  Botzen  and  Verona,  three  miles 

distant  from  the  beautiful  Lake  (larda.  It  lies  in  a 
valley  enclosed,  on  all  ides  bul  the  south,  by  lofty 
mountains  rising  from  four  to  seven  thousand  feet. 
The  northern  opening  is  protected  by  a  ma  of  rock 
370  feel  high.  The  elevation  of  the  village  is  slight, 
viz.,  from  250  to  500  feel  above  sea  level.  It  is  aid 
to  be  almost  windless;  but  little  rain  falls  and  snow 

IS  seldom  seen.       Its  climate  during  the  winter,  which 

i  i  the  time  of  residence  for  invalids,  is  mild  and  equa- 
ble, as  following  chart  indicates: 


Observations  of  Temperature  at  Arco,  Winter,   1875-1876 

(From  Bulenburg's  "  Real  Bncyclopadie.") 

i  Fahrenheit  Sen!-  I 


Month. 


Monthly 

mean 


(  )(■(<. 1  hT.  ,  . 

Noveml  ier 
1  >ecember. 
January . . 
February. 
March .... 
April 


59  5° 

0 
41  s° 
43  ii' 
45  3° 
50.4° 
59.0° 


Mean 
ma  dmum 
(at  noon  i. 


Mean 

minimum 
(at  noon). 


71  ,9° 
60  6 
53. 6° 
61.7° 
64  I 
60.2° 
7.",   2° 


! 

42  8° 
3g 

41.0° 
44.6° 
50.0° 


The  relative  humidity  is  about  72  per  cent. 


Dr.     Weber     (Ziemssen's     "Handbuch     del     allg. 

Therapie,"  Bd.  ii.,  S.  173)  gives  the  following  facts 
concerning  the  climate  of  the  Italian  lake  region,  and 
includes  Arco  in  his  list  of  places  properly  belonging 
within  this  climatic  district.  The  relative  humidity 
of  such  points  he  states  as  being  between  72  and  78 
per  cent,  during  the  autumn  and  winter  months,  and 
somewhat  less  than  70  per  cent,  in  the  spring  season. 
The  average  number  of  rainy  days  is  from  36  to  40 
during  the  autumn,  from  34  to  36  during  the  spring, 
and  from  15  to  20  during  the  winter.  Snow  falls,  as 
a  rule,  in  this  region,  on  not  more  than  6  or  8  da\  s  of 
the  year,  and  seldom  lies  for  several  days  together 
upon  the  ground.  Among  the  local  winds  which  pre- 
vail about,  all  great  lakes,  those  blowing  from  the  north 
and  from  the  northeast,  are  of  most  frequent  occur- 
rence in  this  region.  Fogs  are  rare;  there  are  few  days 
during  which  an  invalid  must  keep  within  doors  from 
sunrise  to  sunset;  and  there  is  less  dust  than  is  found 
along  the  Italian  Riviera.  The  mildness  of  the 
climate  is  shown  by  the  fact  that  the  orange  ripens  in 
the  open  air,  and  the  olive  tree,  the  fig,  and  the 
pomegranate  also  flourish. 

The  invalid's  day  is  nine  hours  long  in  October, 
seven  in  November,  six  in  December,  five  in  January, 
six  in  February,  eight  in  March,  and  the  whole  time 
between  sunrise  and  sunset  in  April.  The  season  ex- 
tends from  September  1  to  April  1.  The  class  of 
diseases  for  which  Arco  is  suited  as  a  residence  are 
affections  of  the  chest  and  throat,  anemia,  want  of 
appetite,  nervousness,  chronic  catarrh  of  the  stomach, 
intermittent  fever,  rheumatism,  gout,  and  the  scro- 
fulous affections  of  children.  There  are  provisions 
for  the  various  forms  of  hydropathic  treatment,  and 
an  Oertel  Terrain-Cur. 

The  drinking-water  is  of  good  quality,  and  the 
accommodations  are  said  to  be  comfortable  and  easily 
obtained.  There  are  many  attractive  walks  and 
pleasant  excursions  in  the  neighborhood. 

Weber  classes  Arco  as  among  the  lowest  Alpine 
climates  and  says  its  winter  climate  is  "sufficiently 
mild  for  persons  with   stationary  phthisis,   or  con- 


517 


Arco 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


valescents  from  the  same  disease,  and  also  for  those 
whose  object  is  only  to  find  change  and  a  sunny 
climate." 

All  eases  of  pulmonary  disease  suitable  for  the 
medium  and  higher  altitudes  would  of  course  be 
suitable  for  this  climate,  which  offers  favorable  con- 
ditions for  the  open-air  treatment;  and,  after  all,  this 
is  the  principal  factor  in  any  climatic  treatment  of 
pulmonary  tuberculosis. 

For  the  above  account  of  Arco  the  writer  is  in- 
debted to  Dr.  Huntington  Richards'  report  in  a  pre- 
vious issue  of  the  Handbook,  and  to  Roe's  "Health 
Resorts    and    the     Bitter    Waters    of    Hungary." 

Edward  U.   Otis. 


Arctic    Springs. — Trempeleau    County,    Wisconsin. 

Post-office,  Galesville.     Hotels  in  Galesville. 

These  springs  are  situated  near  the  village  of 
Galesville,  at  the  terminus  of  a  branch  of  the  Chicago 
and  Northwestern  Railroad.  The  springs  are  at  the 
head  of  a  small  lake  called  "Marinuka,"  while  the 
village  is  at  the  foot,  about  a  mile  away.  During 
the  summer  a  small  steamer  carrying  fifty  passengers 
plies  between  the  two  points.  The  location  is  750  feet 
above  the  sea  level.  The  country  surrounding  the 
springs  is  broken  by  ranges  of  elevations  called 
"bluffs,"  between  which  are  beautiful  and  productive 
valleys  from  one  to  three  miles  wide.  The  main  val- 
leys are  intersected  by  smaller  depressions  at  inter- 
vals of  about  a  mile.  All  of  these  valleys  contain 
clear  trout  streams  coursing  down  their  centers. 
This  peculiar  conformation  gives  the  country  an  aspect 
of  picturesque  beauty  not  soon  forgotten  when  once 
seen.  The  springs  flow  from  beneath  a  precipitous 
bluff  out  of  the  rocks,  filling  a  pipe  six  inches  in 
diameter.  The  water  as  it  flows  has  a  temperature 
of  4N°  F. 

The  water  is  a  mild  alkaline-calcic,  with  light 
chalybeate  properties.  It  is  useful  in  acid  dyspepsia, 
chronic  constipation,  renal  congestion,  the  early 
stages  of   Bright 's  disease,   and   in  general   debility. 

Galesville  is  a  thrifty  village  of  about  1,000  inhab- 
itants, and  numbers  among  its  attractions  telegraph 
and  telephone  facilities,  electric  lights,  water-works, 
a  fine  water-power,  etc.  Emma  E.  Walker. 


Arcus  Senilis. — Gerontoxon  (from  Greek,  rtpcov, 
old  man,  and  zi£ov,  bow,  arch);  Macula  arcuata  or 
macula  cornea;  Marasmus  senilis  cornea;;  Annulus 
senilis;  German,  Greisenbogen;  French,  Arc  senile. 

Arcus  senilis  occupies  the  peripheral  portion  of  the 
cornea  as  a  light  gray  arc.  The  opacity,  smooth  on 
the  surface,  is  more  pronpunced  toward  the  limbus, 
bring  sharply  defined  from  it  by  a  narrow,  trans- 
parent strip,  while  the  concavity  of  the  arc  emerges 
gradually  into  the  transparent  cornea.  The  opaque 
arc  always  appears  first  above,  and  gradually  ad- 
vances downward.  It  always  remains  broadest  above 
and  is  at  the  same  time  more  opaque  in  this  part. 
Finally,  the  two  arcs  unite  at  the  outer  and  inner  side 
of  the  cornea  to  form  a  closed  ring. 

The  opacity  is  at  first  of  a  light  gray  color,  appear- 
ing like  a  silver  band.  At  a  later  period,  the  opacity 
a  nines  a  denser  and  more  creamy  tint,  increasing  at 
the  same  time  in  depth  and  width.  Arcus  senilis,  as 
the  name  indicates,  is  an  affection  of  advancing  years, 
and  rarely  occurs  under  fifty  years  of  age  except  in 
those  infrequent  cases  in  which  it  seems  to  occur  as  an 
inherited  characteristic.  Thus,  for  example,  I  know 
of  a  family  in  which  three  male  members  have  all 
bad  the  completed  arc  as  early  as  at  the  age  of  thirty- 
five,  and  in  none  of  them  is  there  any  apparent 
cachexia. 

I  he  condil  ion  is  usually  bilateral,  although  one  eye 
alone  may   be  affected.     It  occurs  more  frequently 


and  at  an  earlier  date  in  men  than  in  women.  In 
warm  climates  it  is  developed  earlier  than  in  cold 
latitudes,  and  it  is  frequently  seen  in  negroes  on  the 
north  coast  of  Africa. 

A  condition  resembling  very  much  arcus  senilis  is 
found  in  the  young,  but  is  not  to  be  confounded  with 
it.  It  has  been  called  by  Wilde  nreus  juvenilis,  and 
may  be  distinguished  from  the  former  by  the  presence 
of  a  diaphanous  ring  between  the  margin  of  the 
eornea  and  the  opacity. 

Arcus  senilis  never  interferes  with  vision,  although 
it  may  extend  somewhat  into  the  corneal  substance. 
Occasionally  a  genuine  example  of  this  affection 
appears  to  have  been   noted   in   children   (Hansell). 

A  rare  change  occurring  in  the  arcus  senilis  consists 
in  its  becoming  steadily  wider  while  the  cornea  in  the 
area  of  the  arcus  becomes  thin,  so  that  a  gutter- 
shaped  depression  is  formed  here,  which,  yielding  to 
the  intraocular  pressure  becomes  ectatic. 

Pathology. — Arcus  senilis  is  due  to  an  infiltration 
of  a  finely  granular  hyaline  substance.  It  is  com- 
monly stated,  even  in  the  more  recent  text-books, 
that  it  is  due  to  a  fatty  degeneration  or  infiltration  of 
the  cornea;  but  this  has  been  shown  by  Fuchs  not  to 
be  the  case,  for  he  says  it-  is  a  typical  example  of 
physiological,  non-inflammatory  opacity.  He  found 
that  the  infiltrated  material  never  has  any  relation 
to  the  cells  of  the  corneal  tissue,  but  lies  free  upon  the 
surface  of  the  connective-tissue  fibers.  Neither  ether 
nor  chloroform  has  any  effect  upon  it;  consequently  it 
cannot  be  of  a  fatty  character.  Fuchs  considered  it 
to  be  a  hyaline  degeneration  of  certain  fibers.  In 
Fuchs'  latest  edition  (English  translation  published 
in  1911),  he  accepts  Takayasa's  view,  and  figures  his 
section  of  the  cornea.  Takayasa  found  very  minute 
drops  of  fat  in  the  lamella?  of  the  cornea  even  as  far 
back  as  Descemet's  membrane. 

This  deposition  of  hyaline  masses  is  also  associated 
with  deposits  of  minute  particles  of  lime  on  the  more 
superficial  layers  of  the  cornea,  close  to  the  limbus, 
and  the  cause  is  assumed  to  be  a  senile  atrophy  of  the 
limbus,  with  involution  of  a  portion  of  the  vascular 
loops  contained  therein.  Gruber  attributes  the 
appearance  of  these  changes  in  this  particular  portion 
of  the  cornea  to  the  peculiarities  of  the  circulation  in 
the  cornea;  the  peripheral  zone  being  nourished 
mainly  by  transudation  of  nutritive  materials  from 
the  circumcorneal  plexus.  At  the  same  time  the 
changes  in  question  are  favored  by  the  fact  that, 
with  advancing  age,  the  circulation  grows  less 
active  and  consequently  the  nutrition  progresses 
more  feebly. 

Arcus  senilis  would,  therefore,  appear  to  be  a 
phenomenon  that  occurs  in  perfectly  healthy  people, 
is  due  to  the  decrease  of  nutrition  incident  to  advanc- 
ing years,  and  has  no  relation  to  fatty  degeneration 
of  the  heart,  as  was  formerly  supposed. 

There  are  no  symptoms.  The  slight  disfigurement 
and  the  apprehension  of  future  trouble  which  many, 
not  knowing  its  character,  anticipate,  constitute  the 
only  sources  of  annoyance.  So  far  as  the  patient's 
fears  are  concerned,  these  may  easily  be  allayed;  for 
the  condition  never  interferes  with  vision.  Incisions 
through  the  arcus  senilis,  as  in  the  extraction  of 
cataract,  heal  as  well  as  those  made  through  the  clear 
parts  of  the  cornea.  William  Oliver  Moore. 

Area  Embryonalis. — The  embryonal  area,  also 
called  germinal  disk  and  embryonic  shield,  is  that  part 
of  the  blastoderm  of  meroblastic  eggs  which  gives  rise 
to  the  body  of  the  embryo,  as  distinguished  from  the 
extraembryonic  part,  from  which  the  yolk-sac, 
amnion,  and  chorion  take  their  origin. 

In  the  vertebrate  series  there  are  two  types  of 
embryonal  area;  the  selachian  type,  found  in  the 
selachian  and  teleost  fishes;  and  the  reptilian  type, 
characteristic     of     reptiles,     birds,     and     mammals 


518 


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Ari'.i  Embryonalla 


( Amnio ta).     In  this  article  attention  will  be  confined 
to  the  latter  typo. 

In  an  early  stage  of  the  amniote  egg  the  embryonal 
area  (Fig.  289)  may  be  distinguished  as  a  circular  or 
oval  area  covering  the  animal  pule  of  the  egg,  and 
isting  of  two  membranes.  The  outer  membrane 
is  the  ectoderm  and  may  be  several  cells  thick;  the 
inner  membrane  is  the  endoderm  and  is  usually,  for 
the  must  pari,  a  single  layer  of  cells. 


Fig.  287. — Area  Embryonalis  of  a  Chick  Incubated  Fifteen  Hours, 
View  by  Transmitted  Light.  X  14.  ao,  area  opaca;  ap,  area 
pellucida;  c,  anterior  crescent;  in,  mesoderm;  p,  priniitive  streak. 
(From  Duval.) 


In  the  bird 's  egg,  the  embryonal  area  forms  the 
roof  of  a  shallow  cavity  excavated  in  the  yolk  and 
filled  with  fluid.  This  cavity  is  known  as  the  sub- 
mittal cavity  (Fig.  28S).  As  a  result  of  the  seg- 
mentation of  the  ovum,  the  yolk  forming  the  walls 
of  the  subgerminal  cavity  is  provided  with  nuclei, 
which  also  extend  some  distance  along  the  peripheral 

Cortion  of  the  floor.     The  nuclei  are  not  separated 
v  cell  walls.     The  syncytium  thus  formed  is  called 
the  periblast.     (Lillie  190S,  p.  4S.) 

If  at  an  early  stage  a  blastoderm  be  removed  from 

a    hen's    egg    and    examined    by    transmitted    light 

287),  it  will  be  seen  that  the  central  part  is  much 

more    transparent    than    the    peripheral    zone.     The 

central    part    is    known    as    the    area    pellucida,    the 


flattened  cells  containing  little  or  ao  yolk;  in  the 
opaque  area  the  endoderma]  cells  are  larger,  deeper, 
often  columnar,  and  filled  with  yolk  granules.  The 
endoderm  of  the  area  opaca  and  the  marginal  peri- 
bla  i  together  constitute  the  germ  wall.  (Lillie,  1908, 
1).  51.) 

In  the  area  opaca  three  zones  may  be  distinguished 


Fig.  289. — Diagrammatic  Reconstruction  of  a  Pigeon's  Blasto- 
derm, Thirty-eight  Hours  after  Fertilization.  E,  endoderm  of  area 
pellucida;  PA,  outer  boundary  of  ana  pellucida;  SO,  subgerminal 
cavity;  0,  region  of  overgrowth;  Y,  inner  germ-wall;  Z,  zone  of 
junction;  R,  mass  of  cells.      X22.     (After  Patterson.) 


(Fig.  289);  (1)  the  inner  germ  wall,  a  ring  of  thickened 
endoderm  continuous  with  the  endoderm  of  the  area 
pellucida;  (2)  the  zone  of  junction,  where  the  endo- 
derm merges  with  the  periblast,  or  rather  where  the 
periblast  nuclei  become  surrounded  by  cell  walls  and 
give  rise  to  new  cells  of  the  blastoderm;  and  (3)  the 
margin  of  overgrowth,  where  the  edge  of  the  blasto- 
derm, chiefly  ectodermal,  is  continually  extending 
over  the  surface  of  the  yolk  in  advance  of  the  expan- 
sion of  the  germ-wall. 


Fig.  288. — I.  A  Median  Longitudinal  Section  of  a  Blastoderm  of  a  Pigeon  Taken  Thirty-eight  Hours  after  Fertilization,  or  Three 
Hours  before  Laying.  X  57.  II.  Enlarged  anterior  portion  of  the  subgerminal  cavity  of  the  section  represented  in  I.  X  1.34. 
III.  Enlarged  posterior  portion  of  I.  X  134.  .4,  Anterior  end;  P,  posterior  end;  AC,  subgerminal  cavity;  D,  mass  of  cells  at  R 
in  Fig.  2S9;  E,  endoderm;  EC,  ectoderm;  GW,  germ  wall;  L,  anterior  limit  of  endoderm;  M ,  yolk  masses  in  subgerminal  cavity; 
0,  zone  of  overgrowth.     (From  Patterson.) 


peripheral  part  as  the  area  opaca.  Examined  in  situ, 
the  ana  pellucida  will  be  found  to  cover  the  greater 
part  of  the  subgerminal  cavity,  while  the  area  dpaca 
covers  only  the  edges  of  the  cavity  and  extends  out 
over  the  yolk  in  contact  with  the  marginal  periblast. 
The  difference  in  transparency  of  the  two  areas  is  due 
to  the  differences  in  their  endodennal  cells.  In  the 
pellucid   area   the   endoderm   is   composed    of   thin, 


The  first  indication  of  the  axis  of  the  future  embryo 
is  the  appearance  of  a  linear  opacity  in  the  area 
pellucida  extending  from  a  little  behind  the  center 
toward  the  posterior  margin  (Figs.  287  and  293).  This 
is  the  primitive  streak.  Soon  a  depression  appears 
along  its  median  line,  the  primitive  groove,  bounded 
on  the  side  by  two  slight  elevations,  the  primitive 
folds.     Examinations  of  sections  through  the  priuii- 


519 


Area  Embryonalis 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


tive  streak  i  Fig.  290  and  292)  show  that  it  is  produced 
by  proliferation  of  the  ectoderm,  which  eventually 
comes  into  contact  with  the  endoderm  and  appears 
to  fuse  with  it.  Behind  the  posterior  termination  of 
the  primitive  groove  the  primitive  streak  spreads  out 


gw 


en 
\ 


ec 


gw 


1 


Fig.  290. — A,  Transverse  Section  Through  the  Posterior  Part 
of  the  Blastoderm  of  a  Chick  Incubated  About  Ten  Hours,  X21. 
ii.  Median  portion  of  the  same,  X65.  ec, ectoderm;  en,  endoderm; 
gw,  germ- wall;  m,  mesoderm;  o,  zone  of  overgrowth;  ;>,  primitive 
groove;  s,  subgerminal  cavity;  y,  yolk.     (After  Duval.) 


forming  the  primitive  plate.  In  front  of  the  opposite 
end  of  the  groove  is  the  anterior  termination  of  the 
primitive  streak  in  an  ectodermal  thickening  known 
as  the  primitive  knob,  Hensen's  knob,  or  the  proto- 
chordal   wedge   of   Hubrecht    (190\S). 


-I" 


Fig  291  — Embryonal  Area  of  a  Dog's  Blastocyst  Thirteen  to 
Fifteen  Days  after  Coitus,  Showing  Primitive  streak  and  Primitive 
Knob,  a  and  6,  planes  of  sections  in  Fig.  292.  X  100.  (After 
Bonnet.) 


From  the  sides  and  posterior  end  of  the  primitive 

ik    the   cells  migrate  or  grow  out   laterally  and 

posteriorly    between    the   two  primary  germ-layers. 

The  middle  layer  thus  formed  is  the  mesoderm.     The 

lateral  portions  of  the  mesoderm  are  known  as  the 


mesodermal  wings,  and  the  posterior  parts,  with 
which  they  are  continuous,  is  the  ventral  mesoderm 
of  Hubrecht. 

Soon  after  the  establishment  of  the  primitive  streak 
a  new  axial  structure  appears  extending  forward  from 
the  primitive  knob.  This  is  the  head  process,  or 
forward  extension  of  the  protochordal  wedge  of 
Hubrecht.     In  a  surface  view  of  a  hen's  blastoderm 


■MKS 


§» — en 


■ 


fc  1  i  • 


Fig.  292. — Sections  of  the  Embryonal  Area  of  a  Dog  shown  in 
Fig.  291,  planes  a  and  b.  Upper  section  through  the  primitive 
knob,  lower  section  through  the  primitive  streak,  tc,  ectoderm; 
en,  endoderm;  p,  piimitive  pit;  ps,  primitive  streak.  X  180. 
(After  Bonnet.) 


it  looks  very  much  like  the  primitive  streak,  but  in 
sections  it  is  seen  to  be  separate  from  the  overlying 
ectoderm  and  to  be  continuous  with  that  layer  only 
at  the  primitive  knob,  from  which  it  appears  to  be  an 
outgrowth.  Below,  it  comes  into  contact  with  the 
endoderm  and  fust's  firmly  with  that  part  of  the  endo- 
derm lving  in  the  median  line  that  Hubrecht  calls  the 
protochordal   plate.     The   axial   cells   of   the   proto- 


■ 


j    J 


■ 


Mtiii.. . .    . 


Fig.   293. — Area  Embryonalis  of  a  Chick  Incubai 
Hours.      X  13.     c,  anterior  crescent;  ch,  notochord; 
plate;  p,  primitive  streak.     (From  Duval.) 


d  Nineteen 

,  medullary 


chordal  wedge  and  the  protochordal  plate  are  destined 
to  become  differentiated  into  the  notochord,  the  first 
rudiment  of  the  skeleton  of  the  embryo. 

In  the  primitive  knob  a  depression  appears,  the 
primitive  pit  (Fig.  292).  This  goes  no  further  in  the 
chick,  but  in  some  other  birds  and  in  the  reptiles  it 
penetrates  the  blastoderm,  so  that  there  is  an  opening 
from  the   subgerminal  cavity  to  the  exterior,  called 


520 


REFERENCE    IIAX11ROOK    or   T1IK    MKDICAL   SCIENCES 


Area  Embryonalis 


,1, nteric  canal.     In  mammals  the  pit  extends 

M  .,  lender,  horizontal  canal  into  the  head  proce 
where  at  first  it  ends  blindly,  and  is  culled  the  noto- 
chordal  canal.     The  cells  in  the  roof  of  the  canal  are 
ined  to  take  part  in  the  development  of  the  noto- 


n 


Fio.    294. — Area    Embryonalis   of  a  Chick  Incubated  Twenty 
Hours.       ■    11.     av,  area  va*   ilosa;  c,  anterior  crescent;  cA,  noto- 

.  ,  medullary  fold;  p,  primitive  streak.     (From  Duval.) 


chord.  The  floor  of  the  canal  acquires  one  or  more 
irregular  openings  into  the  underlying  yolk-cavity 
and  finally  disappears,  leaving  only  the  part  of  the 
canal  that  penetrates  the  knob;  this  part  then  becomes 
the  neurenteric  canal. 


"1 


L . -    -■ 1 

Fig.  295      Area  Embryonalis  of  a  Chick  Incubated  Twenty-one 
Hours.         11      a,    head-fold;    av,    area    vasculosa;    c,    anteri  ir 
ent;  ch,  notochord;  ms,  mesodermal  somite;  n,  medullary  fold; 
p.  primitive  streak;  st.  sinus  terminalis.     (From  Duval.) 


The  mesoderm  continues  to  spread,  not  only  pos- 
teriorly and  laterally,  but  also  forward  along  the  sides 
of  the  head  process,  with  which,  in  the  chick  and 
many    other   forms,    it   appears    to    be    continuous. 


According  to  some  authors  all  of  the  mesoderm  is  de- 
rived from  the  primitive  streak,  while  others  believe 
that  the  head  process  contributes  its  share  to  the 
anterior  portion  of  the  mesodermal  wings. 

In  the  course  of  its  growth  the  mesoderm  extends 
across  the  area  pellucida  and  in  ade  i  he  inner  zone  of 
the  area  opaca  i  Fig.  294).     In  this  portion  of  the  area 


Fie,.  296.— Embryonal  Area  from  a  Dog's  Blastocyst  Seventeen 
I  laj  9  and  Seven  and  ( (ne-half  Hours  After  the  Last  Coitus,  Show- 
ing Primitive  Streak,  Primitive  Knob,  and  Medullary  Groove. 
X  18.     (After  Bonnet   i 


opaca,  which  thus  becomes  three-layered,  the  first 
blood-vessels  arise,  and,  fusing,  give  rise  to  a  capillary 
net-work,  which  grows  across  the  area  pellucida  and 
enters  the  embryo.  The  part  of  the  blastoderm  that 
contains  this  net-work  of  blood-vessels  is  known  as 
the  area  vasadosa.  The  first  rudiments  of  the  blood 
vascular  system  consist  of  small  thin  walled  vesicles 
containing"  clumps  of  cells  that  soon  become  colored 
red  with  hemoglobin.  These  groups  of  cells  with 
their  envelopes  are  called  blood  islands.  They  lie 
between  the  endoderm  and  the  mesoderm,  and,  after 
lirsl  appearing  at  the  posterior  edge  oi  the  mesoderm, 
spread  rapidly  round  its  sides.  Because  of  their 
equal  proximity  to  two  germ-layers,  their  origin  is 
still  a  disputed  question.  The  best  view,  however, 
appears  to  regard  them  with  Hubrecht  as  mesodermal 
structures  of  endodermal  origin.  The  rudimentary 
blood-vessels  and  blood  were  regarded  by  His  as 
constituting  a  separate  tissue,  or  embryological  unit, 
to  which  he  gave  the  name,  angioblast.  The  origin 
ami  fate  of  this  layer  is  discussed  more  full}'  elsewhere 
(see  article  Blood-vascular  System,  Origin   of). 

Finally  the  area  embryonalis  is  completed  by  the 
appearance  of  the  medullar}!  jdale.  the  first  rudiment 
of  the  nervous  system.  This  is  differentiated  out  of 
the  ectoderm  in  front  of  the  primitive  knob  along  the 
median  line  and  for  some  distance  on  each  side  of  it. 
It  may  also  extend  backward  along  the  sides  of  the 
anterior  part  of  the  primitive  streak.  In  time  of 
appearance  it  is  nearly  synchronous  with  the  head 
process.    (Fig  295.) 

In   the  chick  the  medullary  plate  is  a  flat  layer  of 

521 


Area  Embryonalis 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


ectoderm,  several  cells  thick.  This  merges  without 
any  sharp  line  of  demarcation  into  the  surrounding 
ectoderm.  In  mammals  the  plate  appears  almost 
from    the   first  as  a   shallow  groove,    the   medullary 


amniotic  ectoderm  and  that  of  the  embryonal  area. 
The  endoderm  is  a  minute  vesicle  of  flattened  epithe- 
lium enclosing  the  so-called  yolk-cavity.     The  area 
embryonalis  is  represented  by  the  adjoining  portions 
of  the  ectoderm  and   endoderm   with  a 
very  thin  layer  of  rnesenchymatous  tissue 
between. 

In  Peter's  ovum  the  ectoderm  of  the 
area  embryonalis  is  composed  of  high 
cylindrical  cells,  and  is  thus  differentiated 
from  the  thin  amniotic  ectoderm.  Be- 
tween the  ectoderm  and  the  endoderm 
there  is  a  layer  of  mesoderm,  which  is 
separated  from  the  ectoderm  by  a  mem- 
brana  prima.  This  appears  in  sections  as 
a  fine  contour. 

Herzog  (1909)  has  described  a  human 
blastocyst  that  he  regards  as  of  about  the 
same  age  as  Peters's  ovum,  but  the  men- 
strual history  is  unknown.  The  embry- 
onal area  is  distinctly  differentiated  and 
is  0.112  mm.  in  length.  It  is  boat- 
shaped,  rounded  anteriorly,  and  pointed 
behind,  and  it  is  concave,  the  concavity 
being  toward  the  amniotic  cavity,  which 
is  circular  in  transverse  sections.  A 
transverse  section  through  the  middle  of 
the  embryonal  area  shows  all  three  germ 
layers  with  diagrammatic  clearness,  but 
at  the  extreme  anterior  end  the  meso- 
derm is  wanting.  The  ectoderm  of  the 
embryonal  area  is  two  or  three  cells 
deep,  and  in  the  median  sagittal  plane 
is  an  opening  that  is  regarded  as  possi- 
bly a  neurenteric  canal.  Rudimentary 
blood-vessels  are  observed  near  the  junc- 

Fig.  297.—  Area  Embryonalis  of  a  Rabbit  of  Eleven  Days,  with  the  Ectoplacenta  ture  of  yolk-sac  and  connective  stalk. 
Partly  Torn  Off.  (After  Van  Beneden  and  Julin.)  pr.a.,  Pro-amnion;  a. a.,  area  The  allantois  has  made  its  appearance  as 
amniotica;  a.v.,  area  vasculosa;  a.pl.,  ectoplacenta;  v.t,  sinus  terminalis.  a  rather  slender,  somewhat  curved  canal 

of  endodermal  cells  extending   into  the 


groove,   and   in    the    dog    (Fig.    296)    (Bonnet,    1901) 
it  is  only  one  cell  thick. 

The  appearance  in  the  blastoderm  in  front  of  the 
medullary  plate  of  a  crescentic  groove,  the  head 
fold,  (Fig.  295),  carries  the  embryo  beyond  the  scope 
of  the  present  article. 

In  some  animals,  of  which 
the  mouse  is  the  type,  the  area 
embryonalis  is  covered  perma- 
nently by  a  specialized  part  of 
the  trophoblast,  known  as  the 
ectoplacenta.  In  adaptation 
to  this  condition,  the  embry- 
onal ectoderm,  instead  of  form- 
ing a  fiat  surface,  becomes  the 
lining  epithelium  of  an  elon- 
gated sac  (Fig.  298).  This  sac 
is  covered  externally  by  the 
embryonal  endoderm,  and  is 
surrounded  by  the  cavity  of 
the  yolk-sac.  In  the  mouse, 
therefore,  the  development  of 
the  primitive  streak  and  other 
structures  of  the  area  embryo- 
nalis, is  modified  by  this  ex- 
traordinary condition,  which 
has  been  called  inversion  of 
the  germ-layers.  (See  Blasto- 
derm.) 

Descriptions  have  been  pub- 
lished of  a  number  of  human 
blastocysts  in  stages  showing 
the  area  embryonalis.  In  the 
youngest  of  all,  the  Teacher-Bryce  ovum,  this  area 
is  not  sharply  marked  off  from  surrounding  struc- 
tures. The  embryonal  ectoderm  is  a  spherical  vesicle 
composed  of  cubical  cells  and  enclosing  the  amniotic 
<a-  its.     There   i--  no  visible  difference   between   the 

522 


Fig.  298. — Blastodermic 
Vesicle  of  a  Mouse,  Mus 
Sylvalicus.  a,  cavity  of 
ectoplacenta;  Be,  embryo- 
nal ectoderm;  En,  embry- 
onal endoderm;  c,  yolk- 
sac;  "/.  trophoblast;  TV, 
ectopL ma. 


connective  stalk  (see  article  Allantois). 

In  Spee's  Von  Herff  ovum  the  embryonal  area  is 
oval  in  outline,  is  composed  of  cylindrical  cells,  and 
shows  a  median  furrow.  The  mesoderm  covering  the 
ectodermal  and  endodermal  vesicles  is  more  dense 
than  in  the  preceding  stages,  and  between  the  en- 
doderm and  the  mesoderm  of  the  yolk-sac  blood  is- 
lands are  present,  forming  little  irregular  elevations 


N 


cs 


Fig.  299. — Human  Embryo.  Diagram  of  Longitudinal  Section. 
a,  amnion;  alt,  allantois;  c,  chorion;  cs,  connective  stalk;  e,  area 
embryonalis;  ec,  ectoderm  of  chorion;  m,  mesoderm;  y,  yolk-sao. 
(After  Spee,  from  Hertwig's  Handbook.) 


and  knobs  on  the  surface;  the  oldest  of  these  arc  the 
ones  farthest  from  the  embryonal  area.  The  length 
of  the  embrvonal  area  is  0.37;  its  width  0.23  nun. 
(Figs.  299  and  300). 

Keibel's  ovum  has  an  embryonal  area  about  1  mm. 
long  and  is  the  youngest  to  show  a  primitive  streak. 
The  yolk-sac  has  numerous  blood  islands  with  distinct 
endothelial  walls. 


REFERENCE    HANDBOOK   OF  THE    MEDICAL   SCIENCES 


Arm  Embryonalis 


\  iiM.ro    advanced    stage    is    represented    by    the 

Frassi   ovum  (Fig.  :>()1)  with  an  embryonal  area   1.17 
mm.  long  and  0.6  mm.  wide.     The  primitive  streak 
(Fig'   302)   is  well  developed,  0.5  mm.  long.     A 
anterior   end    is    the    neurenteric    canal    and    at    its 


Fit  .  300. — Transverse  Section  of  Spee's  von  Herff  Ovum, 
a.  amnion;  <u\  embryonal  area:  c,  chorion;  cs,  connective  stalk; 
j/,  yolk-sac.     (Alter  Spee.) 

posterior  end  the  cloaeal  membrane.     In  front  of  the 

Erimitive  streak  is  a  flat  medullar}-  groove  bounded 
y  indistinct  medullary  folds.  Blood-vessels  from 
the  yolk-sac  penetrate  the  connective  stalk  as  far  as 
the  chorion. 

The  area  embryonalis  is  completed  and  the  head- 
fold   has  begun  to  form  in  Spee's  embryo  Gle  (Fig. 


Fie..  301. — Model  of  the  Embryonal  Area  of  Frassi's  Ovum  Re- 
constructed from  Sections.  Upper  view  from  above,  lower  view 
obliquely  from  the  left  side.     (After  Frassi.) 

303).     The   embryonal   area   is    1.54   mm.   long   and 

0.59  to  0.74  mm.  wide.     The  median  line  is  chiefly 

pied   by   the   medullary   groove   which   partially 

encloses  the  neurenteric  canal.     The  primitive  streak 


is  relatively  short   and  bends  downward  toward    the 
connect ive  stalk. 

The  origin  of  the  structures  included  in   the  area 


Fig.    .302. — Obliquely    transverse   Section   of    Frassi's    Ovum 
through  the  Primitive  Streak,     a,  amnion;  c,  chorion;  y.yoll 
In    tie  I  area   lying  between  amnion  and  yolk-sac  are 

seen  ectodermal  and  entodermal  layers  with  mesoderm  between, 

all  three  fused  together  in  the  primitive  streak.     (After  Frassi.) 


Cho 


Am 


Ent, 


Fig.  303. — Human  Embryo  "Gle".  Dimensions  of  Blastocyst, 
Exclusive  of  Villi,  8.5  X  10X6.5  mm.;  Length  of  Area  Embryo- 
nalis, 1.54  mm.  Reconstructed  Sagittal  Section.  All.,  allantois; 
Am.,  amnion;  b.s.,  connective  stalk;  cho.,  chorion;  Ec.  ectoderm: 
ICiil.,  endoderm;  mes.,  mesoderm;  Vi„  villi;  Yk.,  yolk  sac.  (After 
Spee,  from  Minot.) 

embryonalis  is  discussed  in  the  articles  Blastoderm, 
Gastrvla,  and  Gcrm-lai/crs.  Reference  should  be 
made  also  to  Neurenteric  Canal  and  Xotochord. 

Robert  Payne   Bigelow. 


References. 

Blount,  Mary  (1907).  Early  Development  of  the  Pigeon's 
Egg,  with  Especial  Reference  to  the  Supernumerary  Sperm  Nuclei, 
the  Periblast,  and  the  Germ-wall.     Biol.  Bull.  vol.  xiii.,  p.  231-250. 

Bonnet,  R.  (1S97-1901).  Beitrage  zur  Einbryologie  des  Hun- 
des.  Anat.  Hefte  27-30  (Bd.  9),  p.  419-512.  ...  1.  Fortset- 
zung.     I.  c.  Heft  51  (Bd.  16,  Heft.  2).  p.  232-413. 

Frassi,  L.  (1907-1908).  Ueber  ein  junges  menschliches  Ei  in 
situ.  Arch  f.  mik.  Anat.  Bd.  70,  Heft.  53,  p.  492-505,  L907. 
Weitere  Ergebnisse  I.  c.  Bd.  71,  190S.  Heft.  4,  p.  667-694. 


523 


Area  Embryonalls 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Hertwig,  O.  (1906).  Die  Lehre  von  den  Keimblattern.  Hert- 
wig's  Handbuch,  Bd.  I,  Teil  L,  p.  699-1018. 

Herzog,  M.  (1909).  Contribution  to  our  Knowledge  of  the 
Earliest  known  Stages  of  Placentation  and  Embryonic  Develop- 
ment in  Man.     American  Journal  of  Anatomy,  Vol  9,  pp.361— 400. 

Hubrecht,  A.  A.  W.  (1908).  Early  Ontogenetic  Phenomena  in 
Mammals  and  their  Bearing  on  our  Interpretation  of  thePhylogeny 
of  the  Vertebrates.     Q.  J.  Mic.  Sri.,  Vol.  liii,  p.  1-181. 

Keibel,  F.  (1910).  Young  Human  Ova  and  Embryos  up  to  the 
Formation  of  the  First  Primitive  Segment.  Keibel  and  Mail's 
Manual,  vol.  i.,  p.  21-42. 

Lillie,  F.  R.  (190S).  Development  of  the  Chick.  New  York: 
Holt,  1908. 

Patterson,  J.  T.  (1907).  On  the  Gastrulation  and  the  Origin  of 
the  Primitive  Streak  in  the  Pigeon's  Egg.  Biol.  Bull.,  vol.  xiii.,  p. 
251-271. 

Schauinsland,  H.  (1903).  Beitrage  zur  Entwickelungsgeschichtc 
unrl  Anatomic  der  Wirbeltiere.      Zoologica,  Bd.  16. 

-:>.'.  Ferdinand  Graf  (1889).  Beobachtungen  an  eincr  mensch- 
lichen  Keimscheibe  mit  offenen  Medullarrine  und  Canalis  neuren- 
tericus.     Arch.  Anat.  u.  Phys.,  18S9.     Anat.  Abt.,  p.  159-172. 

1906).     Neue    Beobachtungen   iiber  sehe  fruhe 

Entwickelungsstufen  des  menschlichen  Eies.     I.  c,  1896,  p.  1-30. 


Areca. — Areca  Nut;  Betel  Nut.  The  ripe  seed  of 
Areca  Catechu  L.  (Fam.  Palmos).  The  areca  palm  is 
a  fine  large  tree,  with  smooth,  graceful  stem  and  a 
handsome  crown  of  long  pinnate  leaves.  The  flowers 
are  monoecious;  the  fruit  is  egg-shaped,  with  a  fibrous 
mesocarp  and  a  hard  stone  consisting  of  the  seed 
and  adhering  eridocarp.  This  tree  is  a  native  of 
India,  the  Sunda  Islands,  and  probably  of  other 
neighboring  parts.  It  is  cultivated  there  and  else- 
where in  the  tropics  for  the  sake  of  its  seeds,  which 
have  been  an  article  of  Asiatic  commerce  for  centu- 
ries. There  is  still  an  enormous  consumption  of 
them  in  China  and  India,  chiefly  as  a  masticatory; 
for  this  purpose  they  are  boiled,  or  used  when  fresh 
and  soft.  They  are  often  chewed  with  the  leaves 
of  the  betel  pepper  and  lime.  Their  introduction  into 
European  medicine  is  rather  recent. 

Areca  nuts  of  our  market  consist  of  the  kernel  of 
the  seed  only,  the  testa  being  removed  with  the  peri- 
carp. They  are  about  two  centimeters  in  diameter, 
and  about  as  long  as  broad.  Their  shape  is  between 
spherical  and  conical,  with  a  very  blunt  rounded 
point,  and  a  broad,  flat,  or  sometimes  depressed  base. 
The  surface  is  of  a  cinnamon  brown  or  grayish  color, 
and  covered  with  a  network  of  vein-like  lines,  which 
radiate  irregularly  and  spirally  from  the  base  toward 
the  apex.  The  albumin  is  very  hard  and  bone-like, 
and  upon  being  sawed  through  presents  a  marbled 
surface  like  that  of  the  nutmeg,  caused  in  the  same 
way,  that  is,  by  the  infolding  of  the  brown  surface 
layer  of  the  seed  (endosperm),  which  takes  place  under 
the  reticulated  lines  above  described.  The  general 
color  of  the  section  is  whitish,  the  lines  are  brown. 

The  important  constituent  of  areca  is  its  alkaloid, 
arecoline,  which  is  oily,  volatile,  miscible  with  water 
or  alcohol,  strongly  alkaline,  very  poisonous,  and 
yields  crystalline  salts.  Its  other  three  alkaloids, 
arecaine,  arecaidine,  and  guvacine,  are  not  poisonous, 
and  apparently  not  active.  Areca  also  contains 
fourteen  per  cent,  of  fixed  oil,  much  tannin,  and  some 
resin.  Although  the  teniacidal  properties  of  areca 
reside  in  the  arecoline,  which  is  given  to  horses  for 
this  purpose  in  doses  of  0.03  to  0.06  gram  (gr.  ss.  to 
i.),  this  dose  acting  also  as  a  cathartic,  it  is  too  poi- 
sonous for  use  in  human  practice.  A  solution  of 
one-per-cent.  strength  is  instilled  into  the  human  eye 
as  a  niyni  ic. 

Powdered  areca  is  frequently  given  as  a  teniacide, 
in  doses  of  ~>ij.  to  iij.  (8.0  to  12.0).  It  also  acts  as  an 
astringent,  so  thai  the  usual  accompaniment  of  a 
cathartic  must  be  resorted  to. 

H.    II.    RXFSBT. 


Aretaeus. — It  is  uncertain  at  exactly  what  period  of 
time  Aretaeus  flourished,  but  the  consensus  of  opinion 


favors  the  belief  that  he  lived  from  the  middle  of  the 
first  century  of  our  era  to  about  the  year  138.  It  is 
also  not  known  surely  in  what  part  of  the  ancient 
world  he  practised  his  art,  although  it  is  generally 
believed  that  the  scene  of  his  labors  was  located  in 
Italy  (but  not  in  Rome).  His  birthplace  was  in 
Cappadocia,  in  Asia  Minor.  Notwithstanding  the 
fact  that  all  the  historical  documents  relating  to 
Aretreus  have  long  since  perished,  we  still  possess 
to-day,  in  almost  their  entire  completeness,  the 
monuments  of  his  remarkable  genius.  His  great 
treatise  on  the  causes,  symptoms,  and  treatment  of 
acute  and  chronic  diseases,  published  in  Latin  in 
Venice  in  1552,  is  a  model  of  carefulness  and  accuracy 
in  the  descriptions  of  disease  which  it  contains  and  in 
the  correctness  of  the  diagnoses  made.  The  methods 
of  treatment  advocated  by  Aretauis  would  be  pro- 
nounced to-day  unnecessarily  energetic.  A.  H.  B. 

Argas. — A  genus  of  ticks  which  contains  species 
which  sometimes  attack  man,  though  they  are 
usually  found  on  birds.  A.  americanus,  or  A.  persieus, 
is  a  pest  in  some  parts  of  this  country;  this  species  is 
said  to  be  able  to  live  four  years  without  food.  See 
Arachnida.  A.  S.  P. 

Argasinae. — A  subfamily  of  the  ticks,  Ixodidce, 
which  have  the  rostrum  below  the  anterior  margin 
of  the  body.  These  arachnids  are  parasitic  on  warm- 
blooded vertebrates,  particularly  birds.  Argas  is  a 
genus    sometimes    found    on    man.     See    Arachnida. 

A.  S.  P. 


Argemone. — Mexican  Poppy.  Of  these  plants  the 
most  important  thing  that  can  be  said  is  that  they  are 
eminently  worthy  of  careful  investigation.  They 
were  formerly  regarded  as  constituting  but  a  single 
species,  but  are  now  known  to  represent  several. 
Of  these,  it  is  not  certainly  known  which  supplied  the 
material  upon  which  previous  studies  were  based, 
so  that  we  are  able  to  speak  only  of  the  group  in  gen- 
eral. They  are  very  widely  distributed  through  the 
tropical  and  warm  parts  of  America,  as  well  as  widely 
introduced  into  Africa  and  tropical  Asia.  The  plants 
are  of  striking  appearance,  two  or  three  feet  high, 
with  large,  broad,  glaucous,  prickly-toothed  leaves, 
large  poppy-like  white  or  yellow  flowers  and  prickly 
capsules.  On  being  wounded,  they  exude  a  thick 
yellow  juice.  They  grow  in  great  abundance  in 
waste  places  and  over  dry  sterile  soil.  They  have 
been  used  medicinally  in  the  form  of  an  extract  of 
the  whole  plant,  of  the  expressed  juice,  of  the  si 
and  of  the  oil  expressed  from  the  seeds.  The  juice 
has  been  ignorantly  used  in  venereal  diseases,  and  in- 
stilled  into  the  eye  for  conjunctivitis.  This  juice 
contains  in  very  small  amount  an  alkaloid  which  has 
been  claimed  to  be  morphine.  The  fixed  oil  of  the 
seeds,  yielded  to  the  extent  of  about  thirty-six  per 
cent.,  has  received  the  most  attention.  It  has  been 
clearly  shown  to  be  mildly  cathartic,  without  bad 
effect,  in  doses  of  four  to  five  grams,  and  to  form  a 
tasteless  and  not  unpleasant  substitute  for  castor 
oil.  Taken  in  larger  doses  it  and  the  seeds  are  cinet- 
ico-cathartic,  with  the  symptoms  of  local  irritation. 

H.   H.   Rusby. 

Argentum. — Silver,  a  metal  of  lustrous  white  color. 
It  is  one  of  the  elements,  symbol  Ag,  atomic  weight 
107.88.  Metallic  silver  is  used  in  medicine  only  in  the 
shape  of  fine  wireasasuture  material,  and  occasionally 
in  the  form  of  a  thin  leaf  in  surgical  dressings. 

General  Medicinal  Properties  of  Compoum>s 
of  Silver. — In  medicinal  dosage  the  most  important 
effect  that  follows  persistent  internal  medication 
with  silver  is  the  tendency  to  a  bluish-black  discolor- 


524 


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ArRrnium 


alion  of  ( lie  skin  and  mucous  membranes.  (See  Argy- 
ria  )  This  staining  shows  first  cm  the  mucous  mem- 
hrancs,  so  tliat  liy  inspection  of  the  inner  surfaces  of 
I  he  lips  anil  of  the  fanees,  during  a  course  of  medical  ion 

by  silver,  and  by  stoppage  of  the  medicine  upon  the  first 
beginning  of  a  bluish  discoloration  of  those  parts,  no 

serious  risk  of  staining  of  the  skin  need  he  incurred. 
As  a  rule,  efficient  dosage  with  silver  can  be  maintained 

for  from  one  to  three  months  before  coloration  begins. 

In  overdosage  silver  is  a  constitutional  poison,  im- 
pairing nutrition  generally,  and  deranging  the  nervous 

System   particularly.       Therapeutically,    impregnation 

of  the  system  with  silver  tends  to  oppose   feebly   the 

onward   march   of  certain  diseases  of  the   nervous 
tern,   such   as  epilepsy  and  tabes  dorsalis.      Bui 

in    the    more    intractable    of    these    diseases,  such    a> 

i  abes,  t  he  influence  is  so  slight  as  to  be  of  no  value — if, 
indeed,  it  exists  at  all — and  in  epilepsy  other  remedies 
are  far  more  potent.  The  use  of  silver  for  con- 
stitutional effect  is,  therefore,  in  modern  practice 
quite  abandoned. 

Locally,  the  effects  of  silver  compounds  differ  with 
the  individual  preparations  according  to  their  solu- 
bility, and  will  be  described  in  connection  with  the 
several  compounds  themselves. 

The  Compounds  of  Silver  Used  in  Medicine. — 
These  comprise  the  oxide  and  nitrate.  The  cyanide  is 
also  official  in  the  United  States  Pharmacopoeia,  but 
for  pharmaceutical  purpose  only. 

Argenti  Oxidum. — Silver  oxide,  Ag,0,  is  a  heavy, 
dark  brownish-black  powder,  odorless,  but  of  a 
metallic  taste.  It  is  liable  to  undergo  reduction  upon 
exposure  to  light.  It  is  very  slightly  soluble  in  water 
and  is  insoluble  in  alcohol.  It  should  be  kept  in 
dark  amber-colored  bottles,  protected  from  the 
light.  This  oxide  readily  yields  its  oxygen  in  pres- 
ence of  oxidizable  matter,  and  hence  should  not  be 
triturated  with  any  such  material.  It  dissolves  in 
water  of  ammonia.  From  its  comparative  insolu- 
bility this  compound  has  little  local  effect,  but  when 
swallowed,  probably  through  chemical  conversion,  it. 
is  capable  of  absorption,  and  exerts  the  constitutional 
effects  of  silver  such  as  they  are.  In  such  operation 
the  oxide  is  thought  to  be  less  prone  to  discolor  the 
skin  than  the  nitrate,  but  it  is  certainly  not  wholly 
innocent  of  this  tendency.  Upon  the  stomach  and 
bowels  silver  oxide  has  quite  a  marked  potency  to  allay 
irritability,  tending  to  quell  vomiting,  even  in  such 
complaints  as  ulcer  and  cancer  of  the  stomach,  and  to 
control  diarrhea  when  arising  as  a  reflex  of  nervous 
irritation.  The  principal  employment  of  the  medicine 
is  iu  such  disorders  of  the  digestive  apparatus.  The 
average  dose  is  about  gr.  j.  (0.06),  best  given  in 
powder  or  capsule.  The  pill  form  is  bad,  because 
of  the  deoxidation  of  the  compound  by  the  organic 
matter  of  the  excipient,  which  reaction  may  even 
be  attended  by  explosion.  Gum  arabic  is  recom- 
mended as  the  least  objectionable  excipient. 

Argenti  Nitras. — Silver  nitrate,  AgN03.  This  title 
in  the  U.  S.  P.  signifies  the  salt  in  crystals.  These 
crystals  are  smafl,  transparent  rhombs,  originally 
colorless,  but  gradually  becoming  grayish-black  on 
exposure  to  light  and  air.  They  are  odorless,  but 
have  a  strong  metallic  taste.  They  dissolve  freely  in 
water,  in  twenty-four  parts  of  cold  alcohol,  and  in 
five  parts  of  boiling  alcohol.  When  heated  to  about 
200°  C  (392°  F.),  the  crystals  fuse  to  a  faintly  yellow 
liquid,  which,  on  cooling,  congeals  to  a  purely  white, 
crystalline  mass.  Silver  nitrate  should  be  kept  in  dark 
amber-colored  vials  protected  from  the  light.  These 
crystals  constitute  the  purest  form  of  the  nitrate,  and 
are  used  for  internal  administration  or  for  the  making 
of  solutions. 

_  Argenti  Nitras  Fusus. — Moulded  silver  nitrate,  fused 
nitrate  of  silver.  Lunar  caustic.  The  crystals  are 
melted  by  heat,  and  the  fused  sa.t  poured  into  moulds 
where  it  sets  on  cooling.     But  inasmuch  as  the  pure 


nitrate  is,  when  fused,  inconveniently  brittle,  the 
Pharmacopoeia  provides  for  a  trifling  admixture  of 
silver   chloride,    which    is   a   tough    compound.     To 

this  end  about  four   per  cent,  of   hydrochloric  acid   is 

added  to  the  melted  crystals,  whereby  a  small  portion 
of  the  nitrate  is  converted  into  chloride.     Reaction 

ha\  ing  ceased,  the  mixed  mass  is  ready  for  moulding. 
Lunar  caustic  is  cast  in  narrow  cylindrical  sticks 
which  are  hard,  brittle,  and,  when  freshly  made,  white 

i u  color.     As  commonly  found,  however,  I  hey  are  gray, 

or  even  blackish,  through  chemical  reaction  with  mat- 
ters present  in  the  atmosphere.  Fused  nitrate  of  silver 
should  be  used  only  for  its  legitimate  purpose,  that  of 
external  application.  The  sticks  should  be  kept, 
protected  from  the  light. 

Argt  nli  \  itras  Mitigatus. — .Mitigated  silver  nitrate. 
Silver  nitrate  and  potassium  nitrate,  the  latter  in 
double  the  quantity  of  the  former,  are  melted  to- 
gether by  heat  and  the  fused  mass  moulded  into  sticks 
like  those  I'f  the  simple  moulded  silver  nitrate.  The 
sticks  of  the  mitigated  nitrate  resemble  those  of  the 
pure  nitrate  except  that  they  are  granular  rather  than 
fibrous  in  texture.  They  should  be  kept  protected 
from  the  light.  The  sticks  dissolve  freely  in  water  and 
possess  the  same  properties  as  the  undiluted  lunar 
caustic,  only  in  milder  degree.  They  are  used  only 
for  local  application. 

Silver  nitrate  differs  from  the  oxide  in  the  essential 
particular  of  free  solubility,  on  which  property  depend 
the  most  valuable  medicinal  virtues  of  the  salt.  The 
most  important  reactions  of  the  nitrate  are  that  its 
solutions  are  precipitated  by  soluble  chlorides  to 
form  the  very  insoluble  salt,  silver  chloride.  This 
reaction  is  one  of  the  most  delicate  in  chemistry,  and 
since  traces  of  chlorides  are  present  in  almost  all 
natural  waters,  the  use  of  distilled  water  is  necessary 
for  solutions  of  siver  nitrate,  if  a  clear,  bright  solution 
be  desired.  Silver  nitrate  also  reacts  on  organic 
matter  generally,  suffering  decomposition,  and  form- 
ing with  the  organic  substance  compounds  insoluble 
and  acquiring  a  rusty  brownish-black  color  under 
the  action  of  light.  Hence  sticks  of  lunar  caustic 
grow  gray  and  black  on  the  surface  by  keeping,  by 
reaction  with  the  organic  dust  of  the  atmosphere,  and 
solutions  of  silver  nitrate  deposit  a  fine  black  sedi- 
ment and  stain  textile  fabrics  and  skin.  The  stain  on 
the  skin,  if  recent,  can  be  removed  fairly  well  by 
rubbing  with  a  moistened  lump  of  potassium  cyanide, 
and  washing — always  remembering  the  very  irritant 
and  poisonous  character  of  such  cyanide.  But  if  the 
stain  be  old,  and  fixed  by  exposure  to  sunlight,  the 
cyanide  fails,  and  the  following  means  may  be  re- 
sorted to:  Moisten  the  stains,  drop  on  them  a  little 
tincture  of  iodine,  and  then  wash  in  a  6  per  cent, 
solution  of  sodium  hyposulphite.  Or,  very  efficient, 
mix  in  a  saucer  a  few  bits  of  iodine  with  a  little  water 
of  ammonia;  rub  the  stains  quickly  with  the  resulting 
preparation,  and  immediately  wash  both  skin  and 
saucer  wdiile  they  are  still  wet.  This  latter  precau- 
tion is  necessary,  since  the  compound  of  iodine  and 
nitrogen  spontaneously  explodes  upon  slight  agitation 
when  dry.  Other  reactions  of  silver  nitrate  are  its 
precipitation  by  sulphuric,  phosphoric,  hydrochloric, 
and  tartaric  acids  and  their  salts;  by  the  alkalies 
and  their  carbonates,  lime  water,  and  the  vegetable 
astringents,  and  arsenical  and  albuminous  solutions. 

Silver  nitrate  is  an  irritant  astringent,  with  also  the 
peculiar  specific  effects  of  silver  compounds  already 
detailed,  viz.,  the  allaying  of  gastric  irritability,  and 
the  induction  of  certain  constitutional  control  over 
nervous  disease.  The  local  effects  are  the  more 
important  and  are  as  follows:  The  salt  readily  com- 
bines with  albumin  to  make  an  insoluble  compound, 
the  albuminate  of  silver;  hence,  when  in  strong  solu- 
tion or  in  solid  stick,  its  application  to  the  surface  of  a 
mucous  membrane  or  of  granulation  tissue  produces  a 
white  streak  of  cauterization,  which,  by  the  insolu- 
bility of  the  compound  formed,  limits  the  action  of 

525 


Argentum 


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the  caustic  to  the  production  of  such  shallow  slough. 
Concentrated  applications  to  the  skin  speedily  blacken 
the  epidermis,  and,  more  slowly,  raise  a  blister.  In 
solutions  less  than  ten  per  cent,  in  strength  the  salt 
is  hardly  caustic,  but  acts  only  as  an  irritant  astrin- 
gent. When  swallowed,  quite  small  doses  act  locally 
like  the  oxide,  while  large  dosesproduce  irritant  poison- 
ing. Therapeutically,  local  applications  of  silver  ni- 
trate judiciously  made  have  a  marked  tendency  to 
promote  absorption  in  such  tissues  as  are  capable  of 
undergoing  this  process;  to  induce  healing;  to  limit 
and  abate  the  catarrhal  process;  to  destroy  skin  para- 
sites, though  not  very  searchingly;  and  to  neutralize 
the  virulence  of  specifically  noxious  pus. 

The  medicinal  uses  of  silver  nitrate  are  such  as  may 
be  deduced  from  the  foregoing.  Internally  the  medi- 
cine may  be  given,  for  constitutional  or  local  effect,  in 
doses  of  about  gr.  £  (0.01)  in  pill  or  solution.  In 
neither  way  of  giving  does  the  salt  probably  reach 
the  stomach  as  nitrate;  for,  if  in  solution,  a  medicinal 
dose  must  almost  certainly  be  decomposed  in  the 
swallowing,  and,  if  in  pill,  be  acted  on  similarly  by 
the  necessary  organic  matter  of  the  excipient.  To 
obviate  this  effect  as  far  as  possible  in  the  case  of 
pills,  it  is  advised  that  bread-crumb  be  particularly 
avoided  as  an  excipient,  beeause  of  its  containing  a 
soluble  chloride  (common  salt)  as  well  as  organic 
matter,  and  that  some  vegetable  extract,  or  a  dry 
powder  made  sticky  by  a  minimum  of  gum,  be  selected. 
In  any  case  the  crystallized  silver  salt  should  alone 
be  prescribed.  Externally,  silver  nitrate  may  be 
used  as  a  caustic,  but  only  where  a  superficial 
effect  is  wanted,  as  for  the  destruction  of  the  lining 
membrane  of  a  cyst.  The  fused  stick  is  in  such  cases 
used,  its  moistened  surface  being  swept  over  the  sur- 
face to  be  destroyed.  More  common  is  the  applica- 
tion to  promote  absorption,  as  in  case  of  exuberant 
granulation  tissue  or  trachoma  bodies;  to  determine 
healing,  as  in  unhealthy  ulcers;  or  to  shorten  and 
abate  the  course  of  a  catarrh.  For  such  purposes 
various  strengths  of  the  nitrate  are  used,  from  appli- 
cation of  the  pure  or  mitigated  sticks  of  lunar  caustic 
to  that  of  solutions  of  not  more  than  the  one-fifth  of 
one  per  cent,  strength.  To  determine  absorption  the 
stronger  applications  are  necessary,  to  control  catarrhs 
the  weaker,  but  in  all  cases  care  should  be  taken  not 
to  overdo  the  matter,  and,  by  too  strong  or  too  fre- 
quent application  actually  to  interfere  through  excess 
of  irritation  with  healing  or  with  resolution.  In  the 
case  of  catarrhs,  moreover,  the  remedy  should  not  be 
used  at  all  until  the  second  stage  of  the  process  is 
reached,  as  betokened  by  the  establishment  of  the 
catarrhal  secretion  and  abatement  of  the  initial  pain 
or  sensitiveness.  Then,  too,  the  strength  of  the 
application  should  be  adjusted  to  the  different  degrees 
of  sensibility  of  the  different  mucous  membranes; 
for  while  the  comparatively  insensitive  membranes, 
such  as  those  of  the  fauces  or  vagina,  may  take  a  five- 
per-cent.  solution,  or  even  stronger,  hardly  more  than 
the  one-tenth  of  this  strength  can  be  applied  without 
undue  irritation  to  the  nasal  passages  or  to  the  male 
urethra.  ^Tien  a  very  brief  action  is  wanted,  the 
application  of  silver  may  be  followed  immediately  by 
one  of  a  solution  of  common  salt,  which  salt  immedi- 
ately precipitates  all  excess  of  nitrate  as  the  insoluble 
and  therefore  inert  compound  silver  chloride. 

Argenti  cyanidum,  silver  cyanide,  AgCN,  is  an 
insoluble  white  powder  not  used  in  medicine,  and 
official  only  for  the  making  by  the  pharmacist  of 
diluted  hydrocyanic  acid. 

Besides  the  foregoing,  a  number  of  unofficial 
preparations  of  silver  deserve  brief  notice. 

Argyrol. — Silver  vitelline.  A  salt  solution  of 
vitelline,  a  derived  protein  obtained  from  gliadin,  is 
precipitated  by  silver  oxide.  Such  precipitate — 
silver  vitelline — properly  dried,  appears  as  a  dark- 
brown  powder.  The  substance  contains  from  twenty 
to  twenty-five  per  cent,  of  silver,  and  is  remarkable 


for  being  extremely  soluble  in  water,  while  at  the 
same  time  it  does  not  precipitate  albumin  or 
sodium  chloride,  and  is  wholly  unirritating.  Its 
solution  also  penetrates  albuminoid  tissues  very 
readily  and  thoroughly.  Silver  vitelline  thus  pos- 
sesses all  the  desiderata  for  an  ideal  silver  preparation, 
and  has  been  used  with  great  success  as  a  local  appli- 
cation in  inflammations  of  the  mucous  membrane  of 
the  eye,  ear,  nose,  vagina,  urethra,  and  bladder. 
It  is  employed  in  aqueous  solution  ranging  in  strength 
from  one-tenth  of  one  per  cent,  to  twenty-five  per 
cent,  and  upward,  according  to  the  character  and 
sensitiveness  of  the  part.  Even  a  ten  per  cent, 
solution  applied  as  an  injection  in  acute  gonorrhea 
produced  no  irritation  (Christian). 

Collargol. — Colloidal  silver.  This  is  a  bluish-green 
substance  obtained  by  precipitating  with  silver  nitrate 
a  mixed  solution  of  ferrous  sulphate  and  sodium 
citrate.  Collargol  contains  about  eighty-five  per 
cent,  of  silver,  dissolves  in  twenty-five  parts  of  water 
forming  a  dark  reddish-brown  solution,  and  is  easily 
decomposed.  Its  aqueous  solution,  on  standing, 
deposits  a  small  sediment  of  insoluble  silver. 

Collargol  introduced  into  the  general  circulation  is 
said  to  exercise  curative  power  over  the  conditions  of 
general  septic  infection,  whether  by  action  on  the 
microorganisms  themselves  or  on  their  toxins  is  not 
clear.  At  the  same  time  the  remedy  is  non-poison- 
ous and,  being  rapidly  eliminated  after  absorption, 
does  not  produce  argyria.  The  only  untoward  effect 
observed  has  been  a  slight  chill  and  rise  of  tempera- 
ture, but  even  this  is  not  seen  if  (using  by  intraven- 
ous injection)  care  is  taken  that  the  solution  be  free 
from  sediment. 

Collargol  may  be  administered  by  inunction  or  by 
intravenous  injection.  For  the  latter  method  a 
carefully  prepared,  freshly  made  solution  in  distilled 
water  is  to  be  used,  of  a  strength  of  one-half  to  one 
per  cent.  If  a  sediment  forms,  the  supernatant 
liquor  must  be  decanted.  Of  such  a  solution  from 
half  a  fluidram  to  five  fluidrams  may  be  injected 
directly  into  some  superficial  vein  once  or  twice  daily, 
or  every  two  or  three  days.  The  more  common 
method  of  administration,  however,  is  by  inunction. 
For  this  purpose  a  fifteen  per  cent,  ointment  is  used, 
of  which  the  quantity  of  from  thirty  to  forty-five 
grains  is  rubbed  thoroughly  into  the  skin  of  the  inner 
side  of  the  arms  or  thighs,  or  of  the  back,  from  one 
to  three  times  daily.  Collargol  ointment  decom- 
poses readily  and  should  not  be  exposed  to  the  air. 
An  ointment  should  not  be  used  that  shows  white 
crystals  on  the  surface,  or  that  fails  to  color  the  skin 
black  on  inunction.  An  ointment,  "Unguentum 
Crede"  contains  fifteen  per  cent,  of  collargol  in  a  mix- 
ture of  lard,  wax,  and  benzoic  ether. 

Urol. — Silver  citrate,  Ag,C0H5O7.  This  compound 
is  a  fine  dry  powder  without  taste  or  smell,  very 
slightly  soluble  in  water.  Its  solution  is  immediately 
decomposed  by  organic  matter.  Like  silver  vitelline, 
it  is  non-irritant  and  penetrating,  and  has  been  pro- 
posed as  a  surgical  disinfectant  and  for  injection  in 
gonorrhea  and  cystitis.  The  strength  of  solution 
ranges  from  1  to  4,000  to  1  to  10,000. 

Actol. — Silver  lactate.  AgC3H503.  This  compound 
is  a  white  powder,  without  taste  or  smell,  and  soluble 
in  from  fifteen  to  twenty  parts  of  water.  It  is 
a  powerful  germicide,  and  penetrates  tissues,  although 
decomposed  by  contact  with  the  same.  It  is  used  as  a 
surgical  antiseptic,  and  strong,  even  saturated  solu- 
tions may  be  applied  to  infected  parts.  Ordinary 
strengths  are  from  1  to  100,  to  1  to  2,000  parts 
of  water. 

Argentamin. — This  name  is  given  to  a  solution  of 
silver  nitrate  (10  parts)  in  a  ten-per-ccnt.  aqueous 
solution  Of  the  organic  base  ethylendiamine.  It 
is  a  clear  fluid,  strongly  alkaline,  and  is  devised  to 
give  a  non-poisonous  and  unirritating  antiseptic  so- 
lution  which  shall  not   precipitate   albumin.     It    is 


.v_v, 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Areyrla 


used   in  the  anterior  urethra  in  0.25    to  1  per   cent, 
solution;  in  the  posterior  urethra  in  from  i  to  4  per 
solution;  and  in  the  eye  in  .">  per  cent,  solution. 

Argonin.  —Casein  silver.  This  name  is  given  to  a 
body  obtained  by  precipitating  with  alcohol  a  mixed 
tion  of  silver  nitrate  and  a  sodium  compound  of 
casein.  Argonin  is  a  white  powder,  neutral  in  reac- 
tion; insoluble  in  cold  water,  hut  readily  soluble  in 
u  or  albuminous  water.  Solutions  must  be  kept 
away  from  exposure  to  light.     It  has  been  used   in 

g >rrhea  in  solutions  of  from  1  to  7  parts  in  1,000 

Of  water. 

Protargol. — This  name  is  given  to  a  silver  albumose 
containing  eight  per  cent,  of  silver.  It  is  a  yellow 
der,  freely  soluble  in  water;  unaffected  by  heat. 
albumin,  or  sodium  chloride  in  weak  solution,  and 
wholly  unirritating.  It  may  be  used  with  great 
freedom  as  a  local  application,  being  employed  in 
.solutions  varying  in  strength  from  0.25  to  lit  per  cent. 

AVbargin.  -Gelatosilver.  A  compound  of  silver 
nitrate  with  gelatose,  containing  about  fourteen 
per  cent,  of  silver.  It  is  used  as  a  substitute  for 
silver  nitrate. 

—Colloidal  silver  oxide.  L'sed  as  a 
substitute  for  the  ordinary  compounds  of  silver  in 
treatment  of  inflamed  mucous  membranes,  and  as  an 
intestinal  antiseptic;  in  diseases  of  the  eye  and  of 
genitourinary  tract,  it  is  used  in  5  to  25  per  cent. 
colloidal  suspension;  on  other  mucous  membranes  in 
10  to  50  per  cent,     colloidal  suspension. 

Hcgoimn,  contains  about  seven  per  cent,  of  organ- 
ically combined  silver  and  is  used  as  a  substitute 
for  silver  nitrate. 

Ichthargan. — Argenti  ichthyol  sulphonas,  silver  ich- 
ilate,  said  to  contain  thirty  per  cent,  of  metallic 
silver,  and  fifteen  per  cent,  of  sulphur  in  organic 
combination.  It  is  chiefly  used  in  gonorrhea  in  0.04- 
tii  0.2  per  cent,  solution;  in  posterior  urethritis  in 
3  percent,  solution;  and  in  trachoma  in  0.5  to  3  per 
cent,  solution. 

tfovargan. — Argenti  proteinas,  silver  proteinate, 
contains  ten  per  cent,  of  silver.  It  is  said  to  be  use- 
ful in  gonorrhea,  especially  in  the  first  stage. 

R.  J.  E.  Scott. 


Argyria. — This  is  a  term  (also  argyrism,  argyrosis, 
argyriasis)  applied  to  the  discoloration  of  the  skin  and 
certain  other  tissues  of  the  body  resulting  from  the 
long-continued  medicinal  use  of  soluble  silver  salts, 
and  caused  by  the  deposit  in  the  affected  tissues  of 
metallic  silver,  or  some  of  its  lower  compounds,  in  a 
state  of  minute  subdivision.  The  same  condition  may 
be  produced  by  the  absorption  of  soluble  silver  com- 
pounds from  mucous  membranes  or  wound-surfaces. 
or  from  the  entrance  of  silver-dust  through  the  skin 
or  respiratory  tract. 

Clinically  the  condition  is  characterized  by  a  slaty 
or  grayish-brown,  or  in  the  most  severe  cases,  by  a 
bluish-gray  discoloration  of  the  skin  (Moor's  skin), 
conjunctiva?,  and  visible  mucous  membranes.  When 
caused  by  the  internal  administration  of  silver  the 
first  signs  of  the  pigmentation  appear  in  the  form  of  a 
blue  or  violet  line  on  the  gums,  resembling  the  lead 
line  but  usually  more  violet  in  color.  The  internal 
organs,  with  the  exception  of  the  central  nervous 
sy.-tem,  suffer  a  similar  pigmentation.  The  discolor- 
ation of  the  skin  appears  to  vary  in  different  regions, 
being  less  intense  where  the  horny  layer  is  thick,  as 
in  the  palms  of  the  hands  and  soles  of  the  feet;  and  of 
greater  intensity  where  the  horny  layer  is  thin.  The 
pigmentation  first  appears  in  those  portions  of  the  skin 
exposed  to  light.  The  hair  and  nails  are  not  affected, 
but  the  bed  of  the  latter  is  usually  deeply  pigmented. 
Scars  formed  before  or  during  the  period  when  the 
silver  was  taken  are  pigmented,  but  those  formed 
after  the  cessation  of  its  use  remain  white.  The 
apparent  intensity  of  the  pigmentation  also  varies 


with  the  tempera  t  ur.'  ,.i  the  surface  of  the  body,  being 
mosl  marked  in  the  cold,  and  greatly  decreased  when 
the  skin  is  warm  and  flushed, 

The  pigmentation  increases  as  long  as  the  internal 
use.  of  the  silver  salt  is  kepi  up  and  for  some  time 
after  its  use  is  stopped.  Its  degree  and  extent  are 
in  direct  proportion  to  the  amount  used  and  the 
period  of  time  through  which  it-  administration  is 
extended.  It  is  essentially  a  chronic  process.  The 
n  coloration  never  disappears,  and  il  is  doubtful  if  the 
silver  deposit  is  ever  removed  from  the  body,  though 
it   has  been  claimed  in  a  number  of  instances  that 

after   the   lapse  of   years  a  decrease  of   the   color  has 

taken    place.      (See   author'-,   case    mentioned    below.) 

The  condition  has  been  known  since  the  alchemistic 

period  when  the  internal  use  of  silver  salts  was  very 

popular,  and  descriptions  which  undoubtedly  refer  to 

argyria  exist  in  the  literature  of  that  time.  The  first 
i  e  mentioned  in  medical  literature  is  the  one  ob- 
served  by  Schwediauer  and  reported  by  Fourcroy  in 
1791.  In  the  early  part  of  the  nineteenth  century 
numerous  cases  were  described,  and  the  number  of 
these  increased  greatly  about  the  middle  of  the  cen- 
tury when   the  use   of  silver  nitrate  in  epilepsy  and 

tabe-    reached   it-  greatest    popularity.      At    that    ti 

a  generation  of  individuals  affected  with  argyria  may 
be  said  to  have  arisen,  and  frequent  examples  of  the 
condition  came  to  the  postmortem  tables  of  the 
great  European  hospitals.  That  generation  has 
now  practically  disappeared,  and  cases  of  general 
argyria  resulting  from  long-continued  use  of  silver 
salts  have  been  of  very  rare  occurrence  in  the  last  gen- 
eral ion.  In  recent  years  there  has  been  apparently  an 
increase  of  cases  of  argyria  as  the  result  of  the  careless 
use  of  the  newer  silver  preparations,  particularly  in 
geni  to-urinary,  ophthalmic,  and  otolaryngological 
practice.  The  present  cases  of  argyria  are  for  the 
greater  part  localized  discolorations  resulting  from 
local  medicinal  applications  of  silver  nitrate,  or 
from  absorption  through  the  skin  or  respiratory 
tract  of  silver  dust,  as  in  the  case  of  workmen  who 
file,  grind,  or  polish  the  metal.  Three  forms  of  argyria 
may  be  distinguished  clinically:  argyria  universalis, 
argyria  localis  circa  mscripta,  argyria  local  is  dissi  m  inala. 
Argyria  Universalis. — The  condition  of  universal 
pigmentation  of  the  skin  and  mucous  membranes  is 
usually  caused  by  the  long-continued  internal  use  of 
silver  nitrate  but  may  be  due  to  long-continued 
occupational  contact  with  silver,  or  to  prolonged 
local  use.  The  discoloration  develops  independently 
of  any  preexisting  condition  of  the  skin  or  body 
tissues,  and  its  intensity  is  in  proportion  to  the  amount 
of  silver  absorbed  and  the  period  of  time  covered  by 
its  administration.  As  a  rule  the  pigmentation  ap- 
pears several  months  after  the  use  of  the  silver  is  be- 
gun, and  develops  slowdy.  As  the  discoloration  is 
usually  not  observed  until  it  has  reached  a  certain 
degree  of  intensity,  it  is  impossible  to  speak  with 
certainty  of  the  exact  course  of  the  pigment  deposit. 
It  has  been  claimed  that  a  blue  or  violet  line  on  the 
gums  is  the  earliest  symptom,  but  this  does  not  oc- 
cur in  all  cases.  When  the  argyria  is  the  result  of  the 
internal  use  of  silver  the  blue  line  on  the  gums  is 
almost  always  present  and  is  an  important  diagnostic 
sign.  As  it  usually  appears  before  the  pigmentation 
of  the  skin  has  developed  it  should  be  regarded  as  an 
indication  for  stopping  the  use  of  silver.  The  degree 
and  extent  of  the  pigmentation  of  the  skin  vary  in 
different  cases:  the  face,  thorax,  and  abdomen  may 
show  it  earliest  and  to  the  greatest  degree  while  the 
extremities  may  remain  unaffected.  The  pigmenta- 
tion of  the  skin  appears  in  patches,  first  over  areas 
exposed  to  the  light;  the  patches  become  con- 
fluent until  ultimately  the  entire  surface  may  be- 
come pigmented.  The  discoloration  usually  increases 
for  some  time  after  the  use  of  the  silver  has  been 
discontinued  owing  to  the  presence  of  unreduced 
silver   still    in   the   body.     The   mucous   membranes 


527 


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REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


may  show  no  discoloration  in  intense  argyria  of  the 
skiii;  while  on  the  other  hand  a  marked  degree  of 
pigmentation  may  exist  in  the  internal  organs  without 
any  great  change  in  the  skin.  A  metallic  odor  of  the 
breath  accompanied  by  a  stomatitis  with  or  without 
salivation  has  been  described,  but  the  occurrence  of 
these  symptoms  is  very  rare  or  doubtful.  There  are 
no  symptoms  coincident  with  or  following  the  con- 
dition that  can  be  said  to  be  the  direct  result  of  the 
deposit  of  the  pigment. 

The  total  amount  of  silver  nitrate  which  must  be 
taken  in  order  to  produce  a  well-marked  case  of 
argyria  varies  greatly,  the  lowest  limit  being  placed  at 
live  to  thirty  grams.  The  administration  of  the  metal 
must  be  extended  through  a  considerable  period  of 
time.  Large  doses  given  within  short  periods  pro- 
duce symptoms  of  poisoning  without  the  deposit  of 
pigment,  while  minute  doses  administered  for  many 
months  or  years  produce  the  most  intense  discolora- 
tion. Slight  degrees  of  argyria  have  been  produced  by 
the  administration  of  two  grams  only  (thirty  grains). 
Lionville  reported  a  case  in  which  the  total  amount  of 
silver  nitrate  used  was  only  seven  grams,  but  there 
resulted  an  intense  argyria  of  the  internal  organs,  the 
skin  over  the  abdomen  alone  being  slightly  discolored. 
The  same  writer  also  claimed  to  have  seen  in  another 
case  the  appearance  of  the  blue  line  on  the  gums  after 
the  use  of  thirty  pills  each  containing  0.01  gram  of 
silver  nitrate.  The  skin  in  this  case  was  not  affected. 
It  is,  of  course,  evident  that  it  is  the  amount  of 
silver  absorbed  and  not  the  amount  taken  into  the 
body  that  influences  the  degree  and  extent  of 
pigmentation.  With  the  minute  doses  of  silver  nitrate 
now  given  and  the  relatively  short  periods  of 
administration  there  is  but  little  danger  of  the 
production  of  argyria;  but  if  the  salt  is  given  for 
any  considerable  period,  the  possibility  of  its 
occurrence  must  always  be  borne  in  mind  and  the 
patient  duly  informed. 

A  general  argyria  may  also  be  produced  by  the 
local  absorption  of  silver  nitrate,  as  in  the  long-con- 
tinued use  of  applications  of  the  salt  in  affections  of 
the  throat,  eye,  and  urethra.  It  may  also  be  caused 
by  the  long-continued  use  of  hair-dyes  containing 
silver  preparations.  Lavage  of  the  stomach  and 
large  intestine  with  dilute  solutions,  when  continued 
for  long  periods  of  time,  may  also  lead  to  general 
pigmentation.  These  cases  are  very  rare.  Neu- 
mann observed  a  case  in  which  after  twelve  lavages 
of  the  stomach  with  a  solution  of  1.45  gram  of  silver 
nitrate  to  ninety  of  water,  an  intense  argyria  of  the 
skin  of  the  face,  head,  neck,  thorax,  and  back 
was  produced.  The  skin  of  the  extremities  was 
but  slightly  discolored,  and  the  mucous  mem- 
branes remained  normal.  In  a  case  observed  by 
the  writer  the  daily  irrigation  of  the  colon  with 
a  one-per-cent.  solution  of  silver  nitrate  led  in 
eighteen  months  to  a  very  marked  grayish-brown 
discoloration  of  the  entire  skin,  which  was  most  in- 
tense over  the  face  and  extremities.  The  patient 
was  a  lad  of  fourteen  years,  suffering  from  a  chronic 
ulcerative  colitis  following  measles.  At  the  beginning 
of  the  treatment  there  was  present  a  severe  grade  of 
anemia  with  very  marked  pallor  of  the  skin,  the  con- 
dition having  persisted  for  about  two  years.  There 
were  also  very  severe  nutritional  disturbances  witli 
stunting  of  growth  and  delayed  puberty.  After  six 
months  he  had  so  improved  that  he  was  allowed  to  go 
home.  At  this  time  no  discoloration  of  the  skin  was 
noticeable.  The  treatment  was  continued  during 
his  stay  at  home,  and  when  he  returned  three  months 
later  the  pigmentation  of  the  skin  was  the  first  thing 
noted,  although  neither  the  patient  nor  his  friends  had 
observed  it.  The  visible  mucous  membranes,  especi- 
iilly  those  of  the  anus  and  rectum,  were  also  discolored, 
but  no  line  could  be  seen  upon  the  gums.  The  treat- 
ment was  continued  for  about  nine  months  longer. 
During  this  time  the  discoloration  of  the  skin  increased. 


He  was  then  discharged  as  cured.  Six  years  after,  he 
had  become  very  stout,  having  matured  rapidly. 
The  pigmentation  while  still  present  had  so  decreased 
in  intensity  that  the  patient  declared  that  it 
had  entirely  disappeared.  It  is  probable  that  the 
total  amount  of  silver  in  his  body  had  not  decreased, 
but  that  the  increase  of  tissues  made  it  less  prominent. 

Continual  exposure  to  atmosphere  laden  with  silver 
dust,  as  in  the  case  of  silver  grinders  and  polishers,  may 
lead  to  a  general  argyria  through  absorption  from  the 
lungs  (see  below). 

There  are  no  other  pathological  changes  associated 
with  general  argyria  that  can  in  any  way  be  said  to  be 
secondary  to  it.  Edema  of  the  skin  and  degenera- 
tive changes  in  the  kidneys  have  been  thought  to  be 
caused  by  the  deposit  of  the  pigment,  but  there  is  no 
definite  evidence  to  this  effect.  Chronic  interstitial 
changes  in  the  kidneys,  liver,  and  lungs,  associated 
with  arteriosclerosis  are  believed  by  some  writers  to 
be  due  to  the  deposit  of  silver  in  these  tissues;  but 
the  etiological  relationship  of  the  silver  deposit  to 
those  changes  has  not  been  definitely  shown.  Large 
or  frequently  repeated  doses  of  silver  nitrate  may 
lead  to  a  severe  gastritis  or  even  to  ulceration  of  the 
stomach.  Death  may  result  from  very  large  amounts, 
as  in  a  case  reported  by  Scattergood  of  a  child  whose 
death  was  caused  by  the  accidential  swallowing  of  a 
portion  of  a  stick  of  the  nitrate  which  had  been  used 
for  painting  the  throat. 

Argyria  Localis  Circumscripta, — The  local  absorp- 
tion of  silver  may  result  from  the  continued  use  of 
nitrate  of  silver  applications  in  solution  or  in  the  solid 
stick  to  mucous  membranes  or  to  a  wound  surface. 
The  single  application  of  the  salt  leads  usually  to  a 
precipitate,  which  is  cast  off  with  the  superficial 
slough;  but  after  repeated  applications  the  salt  pene- 
trates more  deeply  into  the  subepithelial  tissues,  where 
it  is  chemically  changed  and  precipitated  in  the  form  of 
minute  black  granules,  which,  according  to  their 
number,  lead  to  a  greater  or  less  pigmentation.  The 
discoloration  is  confined  to  the  seat  of  application  and 
is  as  permanent  as  that  of  general  argyria.  Such 
local  pigmentations  may  occur  in  the  conjunctiva", 
urethra,  throat,  gums,  tongue,  etc.  In  very  rare 
cases  the  local  condition  has  been  followed  by  general 
arg3rria.  This  is  most  likely  to  occur  in  the  treat- 
ment of  chronic  affections  of  the  mouth  and  throat, 
where  some  of  the  silver  application  may  be  swallowed 
and  absorbed  through  the  stomach. 

Argyria  Localis  Disseminata. — In  workmen  who  are 
engaged  in  cutting  or  polishing  silver  there  may 
appear  in  the  exposed  portions  of  the  body,  must 
frequently  in  the  hands  and  arms,  grayish  or  bluish 
spots.  These  may  also  appear  in  the  face.  The 
spots  are  pale  in  the  beginning,  but  gradually  increase 
in  intensity  and  remain  unchanged  throughout  the 
life  of  the  individual.  The  pigmentation  develops 
from  small  particles  of  silver  which  either  penetrate 
or  are  rubbed  into  the  skin.  The  condition  is  said 
to  be  not  so  frequent  in  silver  polishers  as  in  workmen 
who  cut  or  grind  the  metal.  Long-continued  expo- 
sure to  an  atmosphere  laden  with  silver  dust  may 
lead  to  absorption  of  the  metal  through  the  respira- 
tory tract  and  to  a  general  argyria.  Such  an  occur- 
rence can  be  explained  only  by  the  assumption  that 
the  silver  particles  taken  up  by  the  lung  are  dissolved, 
and  passing  into  the  general  circulation  are  precipi- 
tated in  other  parts  of  the  body  in  the  shape  of  tine 
black  granules.  As  a  support  to  this  view  is  the 
fact  that  silver  cannulas,  when  kept  in  tracheotomy 
wounds  for  long  periods  of  time,  show  signs  of  gradual 
dissolution.  Silver  wire  or  plates  remaining  in  the 
tissues  for  a  long  period  of  time  may  become  disin- 
tegrated and  the  local  lymph  nodes  show  a  heavy 
deposit  of  black  granules.  In  the  case  of  a  mattress 
of  silver  wire  retained  for  twenty  years  at  the  site  of 
a  hernial  operation  the  writer  has  seen  extensive 
argyrosis  of  the  regional  lymph  nodes,  the  deposit  of 


528 


REFERENCE    BAND-BOOK    OF   THE    MEDICAL   SCIENCES 


Argyria 


the  pigment  following  the  endothelium  of  the  lymph- 
sinuses. 

Microscopical  Appearances.— In  general  argyria  the 

pigment  appears  microscopically  as  very  fine  blacl 

granules  which  are  deposited  in  the  connective-tissue 

stroma  near  the  walls  of  the  capillaries;  and  maj   1" 

id  in  the  ill 'i'n lis,  mucosa  of  the  mouth,  larym 

tine,  kidney,  intima  of  the  larger  vessels,  adven- 

,;  the    mailer  ones,  mucous  glands,  peritoneum, 

icles,  bone  marrow,  liver,  spleen,  lymph  glands, 

,  horoid  plexus.     The  epithelial  structures,  brain, 

•Is,  muscle  fibers,  cartilage,  bone,  hair, 

nails  are  not  affected.     In  early  stages  the  leuco- 

are  said  I"  contain  silver-granules,  being  the 

i  :  lis  to  'how  them. 

In  the  .-~ k i ! i   the  deposit  of  the  pigment  is  most 

marked  in  the  stroma  of  the  papillse  just  beneath  the 

.■ind  around  the  glands.     Toward  the  subcutane 

tissues  the  pigmentation  decreases  in  intensity. 

In    the   intestine    the    basement    membrane   of    the 

mucosa,    the   connective   tissue   of   tl"'    muco  a    a 

submucosa,  together  with  the  Iymphadenoid  struc- 

how  the  pigmentation  in  the  greatest  degree. 

In  the  kidneys  the  deposit  is  greater  in  the  glomeruli, 

especially  about  the  afferent  vessels,  and  occurs  to  a 

much    less    degree    in    the    intertubular    connective 


■sss.^f^^*' 


Fh:.  304. — Silver  Deposits  in  the  Tunicie  Propria?  and  in  the 
Connective  Tissue  of  the  Renal  Papillie,  in  a  Case  of  General 
Argyriasis.      X230.     (Aschoff.) 

tissue.  In  the  liver  the  pigment  is  found  in  the  con- 
nective tissue  about  the  blood-vessels  and  bile  ducts 
and  in  the  intima  of  the  larger  branches  of  the  hepatic 
veins.  Of  the  other  organs,  the  mesenteric  glands,  the 
spleen,  choroid  plexus,  and  the  testicles  show  the 
greatest  intensity  of  pigmentation. 

The  microscopical  sections  of  the  spots  found  in  the 
skin  of  silver  workers  present  a  somewhat  different 
appearance  from  that  of  general  argyria.  The 
process  is  analogous  to  that  of  tattooing:  the  small 
particles  of  silver  which  have  been  rubbed  into  the 
skin  become  surrounded  by  a  connective-tissue  cap- 
As  a  rule  the  silver  granules  are  larger  than 
those  found  in  general  argyria.  In  recent  cases 
silver  particles  may  be  found  in  the  epithelium,  but 
the  epidermis  is  never  involved  in  argyria  due  to  the 
internal  use  of  silver.  In  the  neighborhood  of  the 
larger  particles  smaller  granules  are  found  scattered 
throughout  the  connective  tissue,  and  the  elastic 
tissue  of  the  papilla?  and  corium  is  colored  brown  or 


black  by  a  very  fine  precipitate  of  silver  granules 
similar  to  that  found  in  general  argyria.  As  in  the 
latter  condition,  these  granules  are  most  abundant 
just  underneath  the  rete.  Fig.  273  shows  a  section 
taken  from  such  a  silver  spot.  The  elastic  tissue 
network  of  the  papillse  and  corium  i  ontains  through- 
out a  fine  precipitate  of  silver  granules,  while  coa 
granules  are  seen  at  the  periphery  of  the  papillse  and 
t;ii  tered  through  the  coi  ium. 

With  the  exception  of  the  connective    < 
found  in  silver  spots  the  pre  i  nci  ol  thepigmenl  gi 
ules  dors  not  seem  to  lead  to  any    ei       lat      patho- 
logical change.     1 1  has  been  claimed  i  hal  inter 
nephritis  has  followed  the  deposit  of  the  pigment  in 
the  kidney-,  but  it  is  much  more  probable  that   the 

two  processes  were  coincident,  or  wholly  unrelated. 

The  problems  of  thepathogi  irgyria remain 

he  present  day  unsettled.  Animal  experiments 
have  aided  but  little  in  the  solution  of  the  que  tion, 
as  the  artificial  argyria  produced  in  animals  differs 
very  greatly  in  its  localization  and  intensitj  from  the 
argyria  of  the  human  body.  Cone,  ruing  the  patho- 
genesis  of    the    latter   various   views   are    held.      The 

olilest  of  ll i     the  one  introduced  by  Kramer  and 

supported  by  Frommann,  which  holds  that  the  silver 

nil  rate  taken  into  the  body  is  changed  by  the  stomach 
and  intestinal  juices  into  a  soluble  silver  albuminate, 
which  is  absorbed  from  the  intestines  into  the  circula- 
tion and  is  ultimately  passed  with  the  lymph  through 
the  walls  of  the  blood-vessels  into  the  tissues,  where 
it  is  precipitated  in  the  form  of  fine  granules. 

Opposed  to  this  view  is  the  theory  supported  by 
Virchow  and  Riemer  that  the  silver  nitrate  is  reduced 
in  the  intestinal  tract  and  taken  up  from  the  latter 
place  in  the  shape  of  line  granules,  partly  through  the 
lymph  and  partly  through  the  blood,  into  the  general 
circulation,  where  by  metastasis  these  are  deposited 
in  various  parts  of  the  body.  Jacobi  showed  that  the 
reduced  particles  of  silver  cannot  penetrate  the  epi- 
thelium of  the  intestine,  and  further  proved  experi- 
mentally that  the  greater  part  of  the  silver  nitrate 
taken  into  the  body  is  not  reduced  in  the  intestine, 
but  is  changed  to  silver  chloride  and  albuminate,  and 
absorbed  as  such,  the  reduction  taking  place  in  the 
tissues.  Loew  held  that  the  reduction  of  the  silver 
held  in  solution  in  the  circulating  blood  is  the  result, 
of  the  action  of  living  cell-protoplasm,  most  probably 
that  of  the  endothelium.  On  the  other  hand,  Robert 
holds  that  the  reduction  takes  place  only  in  certain 
organs — the  liver,  kidneys,  papillse  of  skin,  and 
intestinal  wall — and  that  the  reduced  silver  is  carried 
elsewhere  by  leucocytes,  for  the  greater  part  to  the 
spleen,  lymph  glands,  and  bone  marrow,  where  it  is 
ultimately  deposited  in  the  connective  tissue. 
Through  "the  agency  of  the  wandering  cells  containing 
silver  granules  a  part  of  the  silver  may  be  removed 
from  the  body.  The  reduction  in  the  wall  of  the 
intestine  he  holds  to  be  clue  to  the  absorption  by  the 
intestinal  wall  of  certain  gases,  hydrogen  and  hydro- 
gen sulphide,  which  are  formed  in  the  intestinal  tract 
by  the  growth  of  anaerobic  germs,  the  hydrogen 
leading  to  a  reduction  of  the  silver,  and  the  hydrogen 
sulphide  to  the  formation  of  a  silver  albuminate 
sulphide.  The  reduction  of  the  silver  in  the  papillse 
of  the  skin  Robert  holds  to  be  due  to  or  associated 
with  the  process  of  cornification,  which  he  regards  as 
a  reduction  process.  He  explains  the  fact  that 
argyria  in  human  skin  is  of  so  much  more  constant 
occurrence  than  in  the  skin  of  animals  by  the  assump- 
tion that  the  process  of  cornification  takes  place  to  a 
much  greater  degree  in  human  skin.  This  theory, 
however,  does  not  receive  the  support  of  the  actual 
facts. 

In  the  light  of  our  present  knowledge  the  most 
reasonable  hypothesis  is  that  the  silver  is  absorbed 
from  the  intestine  into  the  general  circulation  in  the 
form  of  a  soluble  albuminate  which  is  taken  out  of  the 
blood  and  reduced  by  the  protoplasm  of  the  endothe- 


Vol.   I. 


34 


529 


Argyrla 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Hal  or  perithelial  cells,  and  secreted  by  these  cells  into 
the  neighboring  connective  tissue,  where  it  may 
remain  or  be  further  transported  by  means  of  wander- 
ing cells.  The  deposit  of  the  silver  in  certain  parts 
of°the  bodv  cannot  be  explained  by  the  theory  of 
simple  metastasis,  and  as  it  has  been  established 
beyond  doubt  that  the  endothelium  in  different  parts 
of  the  body  has  a  selective  action,  it  seems  to  the 
writer  that  the  best  hypothesis  for  the  explanation  of 
the  pathogenesis  of  argyria  is  the  theory  of  endo- 
thelial-cell  activity.  In  surfaces  exposed  to  light 
reduction  may  take  place  as  a  result  of  photochemical 
action,  but  in  the  internal  organs  it  must  be  the 
result  of  cell  activity. 

The  chemical  nature  of  the  fine  silver  granules  in 
the  tissues  has  not  as  yet  been  definitely  determined. 
According  to  Kobert,  the  pigment  is  a  loosely  held 
organic  compound  of  silver  and  presents  the  following 
reactions:  The  granules  are  insoluble  in  acetic  and 
dilute  mineral  acids,  fixed  alkalies,  and  ammonia; 
they  lose  their  black  color  but  do  not  vanish  in  strong 
nitric  acid  and  in  moderately  strong  solutions  of 
potassium  cyanide;  the  black  color  may  be  restored 
by  means  of  hydrogen  sulphide.  Substances  which 
decolorize  the  organic  pigments  have  no  effect  upon 
the  silver  granules.  If  a  piece  of  tissue  heavily 
pigmented  with  silver  is  warmed  with  nitric  acid  until 
it  loses  its  color  and  the  acid  then  filtered  off,  the 
filtrate  will  contain  no  silver,  the  metal  remaining  in 
the  decolorized  tissue.  Other  investigators  hold  that 
the  pigment  is  metallic  silver  or  a  low  oxide  (AgO,  or 
AgOJ. 

The  amount  of  silver  deposited  in  the  tissues  is  very 
small  compared  to  the  amount  taken  into  the  body. 
Experimental  analyses  of  tissues  showing  a  high 
degree  of  argyria  have  yielded  only  minute  quantities 
of  silver.  Frommann  obtained  from  760  grams  of 
liver  which  had  been  preserved  in  alcohol  only  0.009 
gram  of  silver  chloride,  equalling  0.0068  gram  of 
metallic  silver.  Versmanns  found  the  same  amount 
of  metallic  silver  in  14.1  grams  of  dried  liver,  and  in 
8.6  grams  of  dried  kidney  0.053  gram  of  the  metal. 

Symptoms. — Pigmentation  is  the  essential  symp- 
tom. Gastric  ulcer,  chronic  nephritis,  neuritis, 
headache,  loss  of  memory  and  mental  depression 
have  been  associated  with  the  condition.  The 
relation  is  not  clear.  In  the  case  of  mental  depression 
and  melancholia  the  psychical  effects  of  the  disfigure- 
ment may  be  responsible. 

Diagnosis. — The  discoloration  of  the  skin  may  be 
mistaken  for  cyanosis  or  for  the  pigmentation  of 
Addison's  disease.  The  blue  line  on  the  gums  may 
be  confused  with  the  lead  line.  If  the  history  is  not 
clear,  small  bits  of  the  skin  or  gum  should  be  excised 
and  tested.  On  treating  with  potassium  cyanide  or 
concentrated  nitric  acid  the  pigment  granules  dis- 
appear, but  reappear  upon  the  addition  of  ammonium 
sulphide. 

Treatment. — Since  the  silver  pigment  is  deposited  in 
the  connective  tissue  outside  of  the  vessels,  its  com- 
plete removal  during  the  life  of  the  affected  individual 
is  very  improbable.  Through  the  agency  of  wander- 
ing cells  a  very  slow  removal  may  take  place,  but  it  is 
doubtful  if  in  well-marked  cases  this  leads  to  any 
noticeable  decrease  in  the  degree  of  pigmentation. 
Cases  of  recovery  have  been  reported,  but  they  are 
doubtful.  Rogers  affirms  that  blistering  will  lighten 
the  color  very  much,  and  Eichmann  claims  to  have 
produced  a  cure  by  means  of  potash  baths.  Yandell 
has  reported  two  cases  in  which  large  doses  of  potas- 
sium ioditle  were  given  in  connection  with  mercurial 
vapor  baths  for  several  months  in  the  treatment  of 
syphilis  with  complete  cure  of  the  existing  argyria, 
the  pigmentation  fading  very  gradually.  In  spite  of 
these  reported  cures  the  great  majority  of  cases  arc 
unaffected  by  treatment,  and  the  affected  individual 
canies  his  pigmentation  to  the  end  of  his  life.  In 
ca  es  similar   to   the  one  reported  by  the  writer  in 


which  the  argyria  is  produced  at  an  early  period  of 
life  before  puberty,  the  later  increase  of  tissues  may 
lead  to  an  apparent  decrease  in  the  intensity  of  the 
pigmentation.  The  prophylactic  treatment  consists 
in  the  exercise  of  great  care  in  the  administration  of 
silver  salts.  Very  small  doses  should  be  given,  and 
for  a  very  short  time.  Prescriptions  of  silver  com- 
pounds should  not  be  given  to  patients,  and  in  all 
cases  warning  should  be  given  as  to  the  danger 
attending  their  use.  De  Schweinitz  and  others  have 
given  warning  concerning  the  prolonged  use  of 
protargol.  Aldred  Scott  Warthin. 

References. 

De  Schweinitz :  Trans.  Am.  Ophthal  Soc,  1903. 
Eichmann  :  Husemann's  Toxicologie,  p.  871. 
Fourcroy:  La  medecine  eclairee   par  des  sciences  physiques, 
Paris,  1791. 

Frommann:  Virchow's  Archiv.,  1S59,  xvii. 

Jacobi:  Arch.  f.  exper.  Path.,  1S7S,  viii. 

Kobert:  Arch  f.  Derm.  u.  Syph.,  1S73,  xxv. 

Kramer:  Das  Silber  als  Arzneimittel  betrachtet,  Halle,  1S45. 

Liouville:  Gaz.  de  med.  de  Paris,  186S. 

Loew:Pfliiger's  Archiv.  f.  d.  ges.  Physiol.,  1S94,  xxxiv. 

Riemer:  Arch.  d.  Heilkund.,  1875,  xvi. 

Rogers:  Cited  in  Wood's  Therapeutics. 

Scattergood:  Brit  Med.  Jour.,  1871. 

Versmanns:  Virchow's  Archiv.,  1S59,  xvii. 

Virchow:  Cellularpathologie,  1S71,  p.  250. 

Yandell:  Amer.  Practitioner,  1872. 

Aristol. — See  Thymolis  Iodidum. 

Aristolochiaceae.— (The  Serpentaria  Family).  A 
small  family  of  some  five  genera,  widely  distributed 
over  the  warm  parts  of  the  earth.  A  species  of  Aristolo 
chia  produces  one  of  the  largest  of  known  flowers, 
some  five  feet  in  length.  Many  species  have  been 
ignorantly  reputed  as  antidotes  to  serpent  poisons. 
Medicinally,  the  family,  rich  in  volatile  oils  and  resin, 
is  well  represented  by  Virginia,  Texas,  and  Canada 
snake  roots.  Many  species  are  used  in  native  practice 
as  vulneraries.  H.  H.  Rusby. 


Arizona. — This  ancient  land  and  new  State,  situated 
on  the  Mexican  border  in  the  extreme  Southwest 
corner  of  the  U.  S.,  offers  to  the  archeologist,  the 
geologist,  and  the  climatologist  a  field  of  study  if 
surpassing  interest.  Here  prehistoric  races  once 
developed  a  civilization  of  no  mean  order,  as  evidenced 
by  the  traces  of  great  public  works  still  remaining. 
Here  later  came  the  Indian  races,  the  ancestors  of 
those  still  found  here,  in  various  degrees  of  civiliza- 
tion, to  the  number  of  24,000  or  more.  Then  came 
the  intrepid  and  restless  Spanish  explorer  and 
conqueror,  accompanied  by  the  Jesuit  or  Franciscan, 
exhibiting  a  self-denial  and  heroism  only  equalled  by 
his  brother  in  the  Canadian  wilderness,  and  devoting 
his  energies  to  the  bringing  under  Christian  denomina- 
tion the  native  whom  the  Spanish  warrior  had 
subdued  to  Spanish  rule. 

Later,  the  Presidios,  established  by  the  Spaniards, 
lose  their  hold,  and  the  Friars  are  expelled.  Indian 
wars  arise,  and  the  American  comes.  The  Mexican 
War  follows,  and  Arizona  becomes  American  territory. 
After  a  stormy  period  of  Indian  and  border  warfare, 
with  all  the  excesses  incident  to  the  occupation  of 
new  territory  by  a  motley  crowd  of  adventurers,  the 
territory  becomes  more  peaceful  and  grows  in  popula- 
tion and  prosperity  until  at  last,  with  a  population  of 
204,354  (1910),  it  arrives,  in  1912,  to  the  dignity  of 
statehood. 

Arizona,  with  the  adjoining  New  Mexico,  have  been 
aptly  called  the  Egypt  and  Arabia  of  America,  for 
both  in  archeological  interest  and  climatic  character- 
istics, the  resemblance  is  close.  Especially  is  south- 
ern Arizona  comparable  with  upper  Egypt  in  the 
lowness  of  its  humidity,  the  clearness  of  its  atmos- 
phere, and   the  absence  of  vegetation.     In  general, 


530 


REFERENCE    HANDBOOK    OF   TIIK    MKDIC'AI,   SCIKXCKS 


Arizona 


the  climate  of  Arizona  is  a  warm  and  very  dry  one. 
\,   .,   certain  season  of  the  year  (between    Ma\    anil 
October),  the  heat  is  extreme;  and  ai  another  season 
(April  i"  June),  there  is  no  rain.     The  thermometei 
.  high  as  130     F.  and  as  low  as    —8  '  I''. 
1 1 !,.  rainfall  varies  from  two  to  two  and  one-half 
Inches  at  various  points  in  the  lower  Gulf  valley  and 
on    the    western   borders,    to    twenty-five    to    thirty 
inches  on  the  plateau  and  in  the  mountains.     Tins 
scanty  rainfall  i~  distributed  from  July  to  April,  with 
marked    increase    from   July    to   September,   and   a 
lesser  increase  in  December.     In  the  holiest  portions 
ne  true  desert  on  the  Mexican  border,  the  daily 
maximum  temperature  is  about   1  10°  F.,  but  owing  to 
the  rapid  radiation,  the  temperature  frequently  falls 
,i  50°  at  night.     We  may  have  ice  at  high  levels 
ight  and  at  midday  the  thermometer  may  reg- 
ister over   100°  F.     Such  great  diurnal  variations  of 
ure   are   characteristic   of   desert    climates, 
and  we  have  the  same  phenomenon  in  Egypt.     These 
[en  changes  are  not  without  risk,  and  one  must 
ireful  as  to  underclothing.     It  is  safe  to  wear 
nels  the  year  around. 

fhe    sunshine    is    abundant.     The    proportion    of 

perfectly   clear   days  in   the  year  varies  at   different 

points,  from  one-half  to  two-thirds,  and  of  the  rest 

more  than  one-half  are  without  brilliant  sunshine 

part  of  the  day. 

In  so  large  an  area  as  is  embraced  in  Arizona,  with 
its   varied    topography,    there  is,   of   course,   a   wide 
variety  of  local  climate,  which  is  but  the  modification 
the   general    climatic    characteristics,    mentioned 
:ihi  ive,  by  the  latitude  and  local  conditions  of  altitude, 
moist  ure,  soil,  etc.    There  are  three  distinct  topograph- 
ical regions  into  which  Arizona  divides  itself,  and  within 
lin  limits  these  regions  have  their  own  peculiar 
climatic     characteristics.     We    have,     first,     in     the 
:    portion  of  the  State,    the  great   Colorado 
Plateau,  4.5,000  square  miles  in  area,  covering  more 
than   half  the  State,   with  an  average  elevation  of 
5,000  feet;  second,  a  broad  zone  of  mountain  ranges 
running  in  a   southeasterly  direction;  and,  third,  a 
on  of  desert  plains  embracing  about  one-third  of 
the  territory,  lying  in  the  southwest  quarter,  and  of 
an  elevation  below  3,000  feet. 

The  first,  or  plateau  region,  the  high  altitude  re- 
gion of  Arizona,  large  areas  of  which  being  from  6,000 
i"  s,(i00  feet  in  elevation,  consists  of  a  broken,  rough, 
rocky  region,  with  hills  and  isolated  barren  mountains 
studding  the  great  elevated  plain,  and  with  few 
rivers  running  in  narrow  canons.  On  account  of  the 
mountain  systems  near  which  it  lies,  this  division  is 
one  in  which  the  rainfall  is  heaviest,  being  from  ten 
to  twenty  inches.  The  climate  is  agreeable  and 
temperate,  the  mean  annual  temperature  being  45° 
to  "ill0  F.,  quite  like  that  of  many  of  the  northern 
States,  but  without  their  extremes.  The  summer 
temperature  is  moderate.  At  Flagstaff,  the  "Sky- 
light City,"  in  the  central  portion  of  the  State, 
with  an  elevation  of  about  7,000  feet,  and  which 
may  be  included  in  this  region,  the  mean  tem- 
perature for  the  hottest  months  does  not  ex- 
ceed 6S°.  For  the  three  summer  months  of  1901 
(Weather  Bureau  Observations),  the  mean  tem- 
perature was  64.6°.  The  highest  temperature 
recorded  was  92°  and  the  lowest  30°.  There  were 
twenty-seven  clear,  thirty-three  partly  cloudy  and 
thirty-two  cloudy  days  during  the  period.  The 
total  rainfall  was  4.56  inches  and  the  number  of 
rainy  days  was  twenty-eight.  For  the  same  year 
1901),  for  the  three  winter  months,  December, 
January  and  February,  the  mean  temperature  was 
31.6°  F.  The  highest  65°  and  the  lowest  -4°.  The 
total  rainfall  for  the  year,  at  Flagstaff,  in  an  average 
of  fifteen  years,  was  16.97  inches. 

The  mountain  region  has  a  width  of  from  seventy 
to  one  hundred  and  fifty  miles  and  consists  of 
short  parallel  ranges  of  mountains,  averaging  from 


7. IIIM)  to  9, OIK)  feet,  with  some  higher  peaks.  The 
climatic  characteristics  of  this  region  are  similar  to 
those  of  the  plateau  region  men!  toned  abo\  e,  and  Pre- 
scott  (5,320  feet),  some  eighty  miles  south  of  I  lag- 
staff,  may  betaken  as  an  illustration.  For  the  three 
summer  months  of    l'.MII    the    mean    temperature   was 

70.5°;  the  bighe  I    L02°  and  the  lowe  i  33  '.     There 

were  IS  clear,  36  partly  cloudy  and  s  cloudy  days; 
and  the  number  of  rainy  days  was  21,  the  total 
rainfall  being  5.29  inches.  For  the  three  winter 
months,  December,  January  and  February,  the  mean 
temperature  was  39.1°  F.;  the,  highest  70'  and  lie- 
lowest  1°  F.  The  total  rainfall  for  the  year  was  12  97 
inches.     Oracle  in    the  southeastern  portion    of  the 

State,  about  forty  miles  northeast  of  Tucson,  with 
an  elevation  of  4,500  feet,  may  bo  included  in  this 
mountain  belt,  and  is  known  a<  a  health  resort  of  im- 
portance, situated  in  a  beautiful  country,  free  from 
dust,  and  where  good  accommodations  can  he  obtained. 

()n  account  of  its  elevation,  the  climate  is  not  what 
the  latitude  would  indicate.  For  the  three  winter 
months,  December,  January,  and  February,  the  aver- 
age temperature  is  45.8°  F.,  and  for  the  three  sum- 
mer months,  June,  July,  and  August,  78.8°  F.  For  the 
year  1901,  there  wen'  269  clear,  fifty-eight  partly 
cloudy,  and  thirty-eight  cloudy  days.  The  mean  tem- 
perature for  the  year  was  62.7°  F.;  the  highest  was 
101°  and  the  lowest  19.  It  is  cooler  and  more  bracing 
than  Tucson. 

The  third  topographical  division  is  the  region  of 
the  plain,  a  desert  occupying  about  one-third  of  the 
southwest  quarter  of  the  State,  below  the  level  of 
3,000  feet.  On  this  low  plain  the  rainfall  is  only 
from  two  to  six  inches  during  the  year,  and,  including 
the  desert  on  the  California  side  of  the  Colorado 
River,  the  records  approximate  the  absolute  minimum 
of  rainfall  of  the  world.  In  the  lower  valley  of  the 
Gila  River,  the  highest  temperature  of  the  year  is 
near  130°,  and  the  mean  for  the  hottest  month,  July, 
is  about  98°,  while  the  mean  for  the  year  is  from 
68.9°  to  74.4°  F.  The  night  temperature  is  also  high. 
From  the  dryness,  there  is  a  great  amount  of  dust, 
particularly  in  summer,  but  with  the  completion  of 
the  great  Roosevelt  Dam  seventy  miles  from  Phoenix, 
which  is  said  to  confine  the  largest  artificial  lake  in 
existence,  a  body  of  water  one  and  one-half  miles 
wide  and  twenty-five  miles  long — Phoenix  and  an 
area  of  thirty  square  miles  about  it  will  be  transformed 
into  an  oasis  and  the  dust  annoyance  will  disappear. 
At  the  foot  of  the  Gila  Valley  also  the  Reclamation 
Service  will  conduct  water  under  the  Colorado  to 
irrigate  large  areas  of  the  desert  on  the  Arizona  side. 

It  is  mostly  in  this  plain  or  desert  region  that  the 
winter  health  stations  exist,  affording  an  admirable 
climate  in  winter,  but  too  hot  in  summer.  Phoenix 
(1,108  feet),  the  capital  of  the  State,  population 
11,134,  is  one  of  the  best-known  health  stations  in 
this  region,  and  its  winter  climate  is  favorable  for 
pulmonary  tuberculosis,  bronchitis,  asthma,  and 
such  conditions  as  require  a  warm,  dry  climate  without 
altitude.  The  annual  average  temperature  at 
Phoenix  is  69°.  The  average  January  temperature 
is  49°,  and  the  average  Jul}'  temperature,  90°.  The 
relative  humidity  is  about  forty-five  per  cent.  The 
rainfall  is  seven  inches,  and  for  the  winter  1.89  inches. 
There  is  a  very  large  amount  of  sunshine,  the  percent- 
age of  which  is  said  to  be  greater  at  Phoenix  than  that 
recorded  at  any  other  U.  S.  Weather  Bureau  office. 
In  the  year  1900  there  was  said  to  be  only  five  days 
in  which  the  sun  did  not  shine.  The  mean  daily 
range  of  temperature  is  great,  as  in  all  warm  desert 
regions  under  cloudless  skies.  The  mean  daily 
variability,  however,  that  is,  the  difference  in  the 
mean  temperature  from  day  to  day,  is  small.  There 
is  no  fog,  and  the  temperature  rarely  reaches  the 
freezing-point.  What  is  called  the  "sensible  tem- 
perature (M.  W.  Harrington)  is  that  which  is 
supposed  to  be  the  temperature  felt  at  the  surface 


531 


Arizona 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


of  the  skin,  especially  when  the  skin  is  exposed,  is 
considerably  lower  than  that  indicated  by  the 
ordinary  dry  bulb  thermometer,  more  nearly  approxi- 
mating  to  that  of  the  wet  bulb  thermometer,  for  the 
ible  temperature  depends  upon  evaporation,  and 
the  greater  the  dryness  of  the  air,  the  greater  the 
difference  between  the  ordinary  temperature  and  the 
sensible  temperature.  Hence,  in  Phoenix  the  sensible 
temperature  ranges  considerably  lower — from  0°  to 
IS0  (Hinsdale) — and  the  heat,  in  consequence,  is  less 
oppressh  e.  The  writer  recalls  a  June  day  in  Phoenix 
when  the  thermometer  registered  nearly  if  not  quite 
100°,  but  when  protected  from  the  sun  the  heat  was 
not  oppressive.  "It  appears,"  says  Mark  W. 
Harrington,  the  former  Chief  of  the  Weather  Bureau, 
"that  in  arid  regions  the  reduction  of  temperature 
caused  by  evaporation  (that  is,  the  sensible  tempera- 
ture) may  make  hot  weather  not  onty  endurable  but 
agreeable  and  refreshing."  Phoenix  has  good 
hotels  and  accommodations,  reliable  physicians,  and 
isfrequented  by  tuberculous  patients.  The  consump- 
tive, however,  should  not  go  to  any  health  resort 
without  the  advice  of  a  competent  physician,  and  on 
arriving  at  the  resort  should  at  once  place  himself 
under  a  physician's  care. 

Tucson  (2,400  feet),  population  13,193,  is  situated 
about  110  miles  southeast  of  Phoenix.  Being  higher, 
the  climate  is  more  bracing  and  the  air  cooler  than  in 
the  latter  city.  The  annual  average  temperature  is 
69°  and  the  average  winter  temperature  is  57°  F. 
The  average  relative  humidity  is  forty-two  per  cent. 
The  rainfall  is  twelve  inches  for  the  year.  The  roads 
are  said  to  be  good  and  the  scenery  attractive.  The 
accommodations  are  fairly  good.  "Cases  of  tubercu- 
losis, neuralgia  and  rheumatism  do  remarkably  well" 
here.  (Hinsdale,  "Climatology  and  Health  Re- 
sorts.")    Like  Phoenix  it  is  a  winter  resort. 

Yuma  (140  feet),  population  about  3,000,  is  in  the 
extreme  southwestern  corner  of  the  State,  at  the 
junction  of  the  Gila  and  Colorado  Rivers.  It  is  but 
a  few  miles  from  the  Mexican  border.  The  winter  is 
the  season  for  invalids,  the  summer  being  extremely 
hot.  In  the  former  season  the  climate  is  mild,  dry, 
warm,  and  pleasant,  and  the  peculiarities  of  the  desert 
air  are  here  best  illustrated.  The  mean  annual 
temperature  is  72°,  that  for  January  53°  and  for 
July  92°;  almost  exactly  the  same  as  the  averages  for 
Cairo,  Egypt,  except  that  it  is  a  little  hotter  in 
summer.  The  mean  monthly  winter  temperature  is 
56°.  The  average  number  of  davs  during  the  year 
above  90°  is  163;  below  32°,  4;  cloudy  days,  21  (mean 
for  six  years).  (Solly.)  In  1893,  from  April  to 
October,  inclusive,  out  of  214  days,  162  days  were 
over  90°.  The  maximum  temperature  for  the  year 
was  111°.  The  average  annual  relative  humidity  is 
46  per  cent,  and  average  annual  rainfall  2.9  inches. 
Yuma  is  rightly  famous  for  its  sunshine  and  heat. 
The  accommodations  are  ordinary. 

Castle  Creek  Hot  Springs  (2,300  feet),  about  fifty 
miles  northwest  of  Phoenix,  are  situated  in  the  foot- 
hills of  the  Bradshaw  Mountains,  in  the  midst  of 
beautiful  and  striking  scenery.  The  Springs  are 
reached  by  a  drive  of  four  hours  from  Hot  Springs 
Junction,  over  an  excellent  road,  affording  extended 
views  of  mountain  and  valley.  The  average  max- 
imum temperature  for  the  months  from  November 
to  April,  inclusive,  for  four  years  (1900  to  1904)  was 
72.16°  F.  and  the  average  minimum  for  the  same 
period,  44.67°  F.  In  these  observations  the  maximum 
temperature  was  taken  in  the  shade  during  the  day 
and  the  minimum  during  the  coldest  part  of  the 
night.  For  a  period  of  three  years  the  average 
number  of  clear  days  for  the  same  portion  of  the  year, 
November  to  April,  was  160;  of  cloudy  days,  15.6; 
of  rainy  davs.  ."..:;.  Months  are  said  to  go  by  without 
a  cloudy  day;  and  hardly  a  day  passes  throughout 
(lie  year  without  some  sunshine.  The  hot  water 
l!o',\     from  the  crevices  in  the  rocks  at  a  temperature 


of  115°.  Bathing  takes  place  in  the  open  pools,  and 
may  be  enjoyed  throughout  the  year.  The  character 
of  the  waters  is  that  of  a  mild  mineral  water,  contain- 
ing principally  sulphate  of  sodium,  chloride  of 
sodium,  and  bicarbonate  of  lime.  They  are  of 
benefit  for  rheumatism,  anemia,  and  disturbances  of 
metabolism.  The  climate  is  favorable  for  asthma, 
hay  fever,  chronic  bronchitis  with  much  secretion, 
convalescence  from  acute  diseases,  and  various 
nervous  disturbances.  The  accommodations  are 
excellent,  there  being  a  well-equipped  hotel  with  all 
modern  conveniences,  attached  to  which  are  a 
physician  and  nurses. 

Other  localities  in  Arizona  with  a  mild  winter  cli- 
mate are  Tombstone  (2,300  feet)  in  the  extreme 
southeastern  part  of  the  state;  Calabaras  (about 
4,000  feet);  Nogales  (4,000  feet);  Huachuca  (4,780 
feet);  Crittenden  (4,100  feet).  Comfortable  accom- 
modations, however,  at  these  places  are  questionable. 
There,  are  also  various  other  hot  and  cold  mineral 
springs.  One  of  them,  Agua  Caliente,  100  miles 
east  of  Yuma,  enjoys  a  local  reputation  for  the  cure 
of  rheumatism,  chronic  skin  diseases,  and  neuralgia. 

A  sort  of  acclimatization  has  to  take  place  when  one 
takes  up  his  residence  in  Arizona,  especially  if  in  the 
plain  or  desert  region.  The  extreme  dryness  of  t  In- 
air  exercises  a  marked  influence  upon  the  various 
secretions  of  the  body.  The  skin  becomes  hard  and 
rough,  as  there  is  no  sensible  perspiration;  the  upper 
respiratory  tract  becomes  irritated,  and  we  may 
have  chronic  inflammation  of  these  passages;  the  lipa 
crack;  cystitis  is  said  to  be  not  unusual  (Hinsdale, 
loc.  cit.)  and  the  kidneys  and  bladder  become  irritated 
on  account  of  the  concentrated  urine.  Constipation 
is  common  and  obstinate.  One  is  also  apt  to  lose  in 
weight.  On  account  of  the  heat,  one  is  not  inclined 
to  take  much  physical  exercise,  and  the  common  form 
of  it — walking — is  unpleasant  and  not  without  its 
dangers  from  the  alkali  dust.  It  is  also  to  be  remem- 
bered that  in  the  plain  country  where  most  of  the 
health  resorts  are  situated,  there  is  no  vegetation, 
except  where  irrigation  exists — it  is  but  one  great 
treeless  plain,  wonderful  in  its  clear  skies  and  perpet- 
ual sunshine,  but  desolate  and  dreary  from  its  waste 
of  desert  sands.  Edward  O.  Otis. 


von  Arlt,  Ferdinand. — Born  on  April  IS,  1812,  in 
Obergraupen,  near  Teplitz,  Bohemia.  His  father 
was  a  village  blacksmith  of  small  means.  He  re- 
ceived the  degree  of 
Doctor  of  Medicine  in 
1839.  His  prepara- 
tory training  as  an 
ophthalmologist 
carried  on  under  the 
guidance  of  Prof.  J. 
N.  Fischer.  From 
October,  1S46,  to 
July,  1S49,  he  acted 
as  a  temporary  sub- 
stitute for  the  regular 
occupant  of  the  Chair 
of  Ophthalmology; 
from  1S49  to  1850  ae 
served  as  full  Pro- 
fessor of  this  branch 
of  medical  science  in 
the  University  of 
Prague;  and  from  the 
latter  dale  until  1883J 
when,  according  to 
the  laws  of  Austria,  he  was  obliged  to  resign  his  chair, 
he  was  full  Professor  of  Ophthalmology  in  the  Fni- 
versity  of  Vienna.  Although  his  official  duties  then 
ceased,  he  continued  to  interest  himself  actively  in 
ophthalmology  up  to  March  7,  18S7,  the  day  on  which 
his  death  occurred  from  senile  gangrene. 


Fie,.  305. — Ferdinand  Kitlrr  von  Arlt. 


532 


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Arm  and  Forearm 


li  is  a  fact,  universally  admitted,  that  Aril  was  one 
of  the  most  conspicuous  representatives  and  promote] 
of  the  science  and  art  of  ophthalmology  in  the  nine- 
teenth century.  He  ranks  as  a  worthj  a  ociate  of 
such  heroes  in  this  special  field  as  von  Graefe  and 
I  londers.  of  his  published  writings  the  following  de- 
serve to  receive  special  ntion:  "Pfiege  der    ^.ugen 

ltn  gesunden  und   kranken    Zustande,    nebst  einem 
lange  ueber  Augenglaeser, "  Prag,    1846  (revised 
ion  in  1868);  "  Krankheiten  des  Auges,"  3  vols., 
j,  1851,  LS53,and  1856;  "  Operationslehre, "  Leip- 
lig,    ls~l.     In    is.")."),    In1    became    associated    with 
Donders  in  the  work  of  editing  the"Archiv  fur  Oph- 
thalmologic,"  founded  by  von  Graefe.     Pagel,  from 
whose    "  Biographisches      Lexikon     hervorragender 
des   neunzehnten   Jahrhunderts"  the  present 
sketch  has  been  compiled,  says  thai  "  Arit  was  a  man 
ie  intellectual  powers,  a.  very  close  observer,  and 
an  ardent  lover  of  truth.     He  was  a  very  skif  ul  opera- 
a   t nisi  worthy   diagnosticum,   and   an   admirable 
lecturer.     It  is  an  interesting  fact  that  von  Graefe's 
decision  to  devote  his  professional  life  to  ophthalmo- 
logical  work  was  largely  due  to  the  influence  exerted 
by  Arlt."  A.  H.  B. 

Arm  and  Forearm. — THE  ARM. — The  arm  (or  upper 

beginsat  the  lower  anterior  margin  of  the  axilla, 

tin'    lower    border    of    the   pectoralis    major  muscle, 

ami  ends  al   the  elbow-joint,  where  the  joint  capsule 

joins  the  humerus  before  and  behind. 

The  skin  of  the  arm  is  similar  in  structure  to  that 
of  other  uncovered  skin  surfaces  of  the  body,  is  thin, 
especially  at  the  front  and  sides,  loosely  attached  to 
lying  structures,  and  is  free  from  large  hairs. 


Cephali 

head    I 


Radial  n 


it  ifun- 1 

A irj 

Ti  iceps,  ex-  1  - 
tn  aal  head 


/  Biceps,  short 
1         head. 
Mnsculo-cut.  n. 
j  Median  neri  e 

jv^l—  Brachial  artery 

tlii —  Basilic  vein. 

Int.  cut   nerve. 
Ulnar  nei  \  e, 
Inf. profunda  a 
f  Triceps,    in- 
1  ternal  head 

Triceps,   long 
head. 


1         .106. — Transverse  Section  of  Arm  just  below  Insertion  of 
Deltoid        I  rom    Joessel:    "Lehrbuch    der    topographisch-chirur- 
.i  Anatomie,"  Bonn,  18S4.J 

The  superficial  fascial  layer  contains  fat  tissue  that 
rounds  out  the  contour  in  the  well-nourished,  and 
especially  in  the  female  and  female  art  figure. 

The  brachial  fascia  (deep  fascia)  is  derived  from  the 
deep  fascia  of  the  pectoralis  major  in  front,  and  from 
the  insertions  of  the  ten's  major  and  latissimus  and 
their  sheaths  behind;  from  a  prolongation  of  the 
deltoid  fascia  on  the  outer  side,  and,  through  the 
axillary  fascia,  from  the  deep  fascia  of  the  serralus 
magnus,  upon  the  inner  side  of  the  arm.  Coming 
together  from  these  origins  these  fasciae  join  to  form 
a  thin  but  firm  sheath  from  shoulder  to  elbow.  Aris- 
ing  from  the  external  condylar  ridge  of  the  humerus 
and  passing  outward  to  meet  this  sheath  is  the  ex- 
ternal intermuscular  septum,  which  extends  from  the 
condyle  to  the  deltoid  tubercle.  Arising  from  the 
internal  condyle  and  the  internal  condylar  ridge,  and 
■nding  from  the  coracobrachial  insertion  to  the 
v  is  the  internal  intermuscular  septum.  Just 
above  the  elbow  this  may  be  clearly  felt  as  a  whip- 
like  firm  cord.  These  two  septa  divide  the  arm 
into  two  regions,  the  front  and  the  back. 


The  front  compartment  of  the  arm  contains  bicep 
and   brachialis;  the  coracobrachialis  being  added  at. 
an  upper  third  arm  section,  and  the  brachioradiali  , 
and  io  a  certain  extent  al  o  the  extensor  carpi  radi- 
al is  long  us,  a  I  a.  lower  third  arm    ection. 

The  back  compartment  contains  triceps  andanconeu  . 

These  compartments  contain  also  their  respective 
blood  and  nerve  supplies.  The  mu  culo  piral  (radial) 
nerve  passes  backward,  downward,  ami  outward,  with 
its  accompanying  superior  profunda  (deep  brachial) 
artery,  through  the  intet  eptal  pace  between  the 
interna]  and  external  heads  of  the  triceps,  from  a 
point   high   up  in   the    back    compartment.     In    its 

course    it    supplies    various   blanches    to     the     triceps 

muscle;  and,  through  its  posterior  interosseous  divi- 
sion, the    anconeus.     The    musculocutaneous    nerve 

pa  es  forward,  downward,  and  outward  from  the 
brachial  plexus  in  the  axilla,  through  tin' coracobra- 
chialis and   between    the   biceps  ami    brachialis  above 

in    the    front   i partment,    supplying    the  e    three 

muscles;  (he  brachial  artery  supplying  this  compart- 
ment throughout.  Still  lower  down  in  the  arm, 
above  t  he  elbow,  we  ha  \  e  pi  act  ica  1 1  y  in  the  external 
intermuscular  septum  the  musculospiral  nerve  and 
the  superior  profunda  artery,  and  within  the  enfolding 
of  the  internal  inter  muscular  septum,  the  ulnar  nerve 
and  the  inferior  profunda  artery. 

The  conformation  of  the  front  of  the  arm  is  due  to 
the  form  of  the  biceps,  which  rounds  well  forward. 
\i  i  he  slight,  groove  at  the  inner  and  outer  base  ,,( 
the  biceps  are  placed  respectively  the  basilic  and  ceph- 
alic veins,  which  extend  from  their  ana  tomo  i  , 
at  the  elbow  upward  along  the  borders  of  the  biceps 
to  join  their  outlet,  the  axillary  veins,  at  the  inner 
and  outer  sides  of  the  arm  and  shoulder. 

In  association  with  the  skin  we  find,  forming  the  cu- 
taneous supply  of  the  outer  arm,  from  the  shoulder 
to  the  wrist:  circumflex,  upper  external  cutaneous 
branch  of  the  musculospiral,  lower  external  cutane- 
ous branch  of  the  musculospiral,  and  cutaneous 
branches  of  the  musculocutaneous.  In  the  skin  and 
superficial  fascia  of  the  inner  arm  and  forearm  is  the 
cutaneous  supply  of  the  inner  arm  and  forearm: 
intercostohumeral,  internal  cutaneous  branches  of  the 
musculospiral,  lesser  internal  cutaneous  (Wrisberg's), 
and  internal  cutaneous. 

A  few  small  lymphatic  nodes  upon  the  inner  side  of 
the  arm,  just  above  the  elbow,  may  be  found  in  the 
superficial  fascia  near  the  course  of  the  basilic  vein. 
I  I      e  nodes,  enlarged,  are  pathognomonic  of  syphilis. 

The  lowest  point  of  the  insertion  of  the  deltoid 
marks  the  middle  of  the  humerus,  the  middle  of  the 
musculospiral  groove  behind,  the  lower  border  of  the 
coracobrachialis  insertion,  and  the  upper  limits  of  the 
brachialis. 

The  Front  of  the  Arm. — Just  within  the  anterior 
fascial  compartment  is  the  biceps,  which  lies  upon  the 
brachialis,  while  the  latter,  in  turn,  lies  upon  the 
anterior  surface  of  the  humerus.  Along  the  inner 
border  of  these  two  muscles  is  the  brachial  artery. 
The  artery  winds  about  the  humerus  from  the  mid- 
axillary  space,  high  up  in  the  arm,  to  the  internal 
septum  in  the  mid-arm,  to  the  anterior  part  of  the 
brachium  at  the  elbow.  The  terminal  branches  of 
the  brachial  plexus  also  conform  to  this  route  through 
the  arm. 

The  biceps  arises  from  the  scapula  by  two  heads: 
the  long  head  above  the  glenoid  fossa  of  the  scapula, 
the  short  head,  in  common  with  the  coracobrachialis, 
from  the  tip  of  the  coracoid  process,  from  these 
two  tendinous  origins,  these  heads  swell  into  long 
muscular  bellies  that  converge  and  lie  side  by  side 
in  the  upper  third,  and  unite  at  the  lower  third  of  the 
arm.  Toward  the  bend  of  the  elbow  the  muscle 
libers  converge  upon  a  centrally  placed  short,  stout 
tendon,  which  is  inserted  upon  the  posterior  facet  of 
the  tuberosity  of  the  radius,  a  bursa,  not  connecting 


533 


Arm  and  Forearm 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


with  the  joint,  occupying  the  anterior  facet  over 
which  the  tendon  plays  when  the  forearm  is  flexed. 
As  rarely  happens  a  rupture  of  the  long  head  of  the 
biceps  causes  an  egg-like  swelling  of  the  muscle 
just  above  the  elbow;  while  the  still  more  uncommon 
rupture  of  the  tendon  of  insertion  causes  a  large 
muscle  swelling  above  near  the  insertion  of  the 
deltoid.  Pus  in  the  shoulder-joint  often  burrows  out 
following  the  long  tendon  of  the  biceps  to  appear  at 
the  anterior  of  the  arm  just  below  the  insertion  of  the 
pectoralis  major  tendon.  Itis  the  tendon  of  insertion 
of  this  muscle  that  becomes  so  "lame"  through  pro- 
longed cranking  of  gasoline  engines  and  motor  cars; 
and  it  is  the  muscle  proper  that  so  often  tires  in  pro- 
longed paddling.  In  pitchers  the  muscle-bundle 
tire  of  this  muscle  especially  allows  the  spontaneous 
fracture  of  the  humerus. 

The   fascial   sheath   of   the   arm   anteriorly,    after 
becoming  distributed  to  bony  parts  of  the  elbow  and 
condylar  ridges,  receives  in  front  of  the  elbow  a  strong, 
flattened  band  of  fibers  from  the  biceps  tendon,  the 
semilunar  or  bicipital  fascia, 
which  is  continuous  with  the 
deep  fascia  above  and  is  lost 
over  the  pronator  teres  below 
in    the    ulnar  fascia.       This 
fascia      bridges      over      the 
brachial  artery  and  separates 
it   from   the    median    basilic 
vein. 

The  brachialis  arises  from 
the  whole  lower  half  of  the 
inner  and  outer  surfaces  of 
the  humerus,  from  the  front 
of  the  internal  intermuscular 
septum,  and  from  a  part  of 
the  external  intermuscular 
septum  above  a  point  where 
the  musculospiral  nerve 
pierces  it.  Its  origin  em- 
braces the  insertion  of  the 
deltoid.  The  muscular  fibers 
converge  broadly  into  a  short, 
thick,  tendinous  insertion 
upon    the    coronoid    process. 

This  muscle  is  overlaid  by  the  biceps,  but  projects  be- 
yond it  inward  and  outward.  It  is  overlapped  on  the 
inner  side  by  the  brachial  artery,  by  the  median  nerve, 
and  by  the  pronator  teres;  also,  deeply,  by  the  anterior 
branch  of  the  anastomotica  magna  and  the  anterior 
ulnar  recurrent  artery.  Upon  its  outer  side  it  [s 
overlapped  by  the  radial  recurrent  artery,  by  the 
radial  nerve,  and  by  the  brachioradialis  and  extenso- 
carpi  radialis  longus;  also  deepl)',  by  the  musculo- 
spiral nerve  ami  by  the  terminal  branch  of  the  su- 
perior profunda  artery. 

The  coracobrachialis  is  an  elongated  muscle  arising 
in  common  with  the  short  head  of  the  biceps  from  the 
tip  of  the  coracoid  process.  It  is  inserted  on  the 
inner  border  of  the  shaft  of  the  humerus  at  about  its 
middle.  It  lies,  in  its  lower  part,  along  the  inner 
border  of  the  biceps,  the  two  muscles  lying  to  the 
outer  side  of  the  brachial  artery. 

The  brachial  artery  is  the  direct  continuation  of  the 
axillary  at  the  level  of  the  lower  border  of  the  teres 
major.  Therefore  the  lower  half  of  the  third  por- 
tion of  the  axillary  artery  lies  uncovered  by  muscle 
in  the  upper  ami.  The  brachial  extends  a  short 
distance  below  the  elbow  where  it  ends  in  its  two  ter- 
minal branches — the  radial  and  ulnar  arteries — on  o 
Opposite  sides  of  the  radius  near  the  junction  of  its  head 
and  neck.  The  course  of  the  artery  is  sinuous;  it  lies  at 
first  internal  to  the  humerus,  slightly  overlapped 
by  the  coracobrachialis  above,  then  in  front  of  the 
bone,  slightly  overlapped  by  the  biceps;  and,  at  the 
bend  Of  the  elbow  lies  midway  between  the  condyles. 
Compression  of  the  artery  at  any  point  in  the  arm 
should  be  outward  toward  the  bone  above,  outward 


and  backward  at  its  lower  third,  directly  backward 
below.  Throughout  its  course  the  artery  occupies  a 
position  near  the  surface  and  can  be  felt  pulsating. 
Not  pulsating,  it  may  be  found  upon  a  line  drawn 
from  the  inner  border  of  the  coracobrachialis  above 
to  mid-elbow  just  internal  to  the  biceps  tendon.  It 
lies  at  first  upon  the  long  head  of  the  triceps,  but  is 
separated  from  the  muscle  by  the  musculospiral 
nerve  and  superior  profunda  artery,  and  is  overlapped 
by  the  biceps.  Next,  it  rests  upon  the  inner  head 
of  the  triceps,  at  the  middle  third  of  the  arm,  ami  is 
overlapped  by  the  insertion  of  the  coracobrachialis. 
At  its  lowerthird,  just  before  bifurcation,  it  lies 
upon  the  brachialis.  It  lies 
beneath  the  skin  and  fascia 
and  is  partially  bridged  over 
by  the  coraco-brachialis  and 
biceps  upon"  its  outer  side. 
At  the  bend  of  the  elbow 
it  is  overlapped  again  by 
the  strong  bicipital  fascia, 
is  crossed  by  the  median 
basilic  vein,  and  dips  deep 
into  the  triangular  (anti- 
cubital)  space  between  the 
brachioradialis  and  the  pro- 
nator teres.  The  sheath  of 
the  artery  is  closely  incor- 


V 


porated  with  the 
deep  fascia  of  the 
biceps,  so  that  in 
ligation  of  the 
artery  it  moves  in 
its  position  accord- 
ing as  tension  is 
put  upon  the 
muscle. 

The  median 
nerve  follows 
closely  the  artery 
and  its  sheath, 
lying  first  to  its 
outer  side,  then  in 
front  of  it,  and 
finally  toward  the 
elbow  at  its  inner 

side.  The  ulnar  and  the  internal  cutaneous  nerves  lie 
to  the  inner  side  of  and  behind  the  artery  till  about 
the  middle  of  the  arm,  when  the  ulnar  diverge-  to  pass 
well  backward,  to  reach  the  internal  intermuscular 
septum  above  the  internal  condylar  ridge,  where  it 
enters  the  posterior  compartment  of  the  arm.  The 
internal  cutaneous  pierces  the  brachial  fascia  ami  pa 
forward  just  below  the  middle  of  the  arm,  and  it  lies 
between  the  brachial  artery,  to  the  outer  side,  and 
the  basilic  vein  upon  the  inner,  to  be  wholly  super- 
ficial at  the  elbow.  The  musculospiral  nerve  lies  for 
a  very  short  distance  behind  the  brachial  artery  upon 
the  long  head  of  the  triceps  before  it  is  joined  by  the 
superior  profunda  branch  and  gains  the  musculo- 
spiral groove. 


Fig.  307. — The  Inner  Ann.     Muscles 
contracted.     (After  Gerrish.) 


534 


REFERENCE    HANDBOOK   OF   THE   MEDICAL   SCIENCES 


Arm  and  Forearm 


The  artery  gives  off  the  superior  profunda,  the 
inferior  profunda,  tlio  anastomotica  magna,  t lu- 
QUtrient,  the  muscular,  and  the  terminals — the 
radial  and  ulnar  arteries. 

Tlit'  superior  prufu  mln  arlrri/  which  lies  first  to  the 
inner,  then  to  the  posterior  side  of  the  brachial,  rises 

usually  just   below  the  teres  major,  perforates  the 
septum,  and   then  penetrates  to  the  musculospiral 

>ove,  in  which  it  rims  for  a  certain  distance.  It 
gives  off  above,  an  ascending  branch  that  supplies 


ad£SL 


Fig.  308. — Course  and  Branches  of  the  Brachial  Artery. 
(Heitzmann.) 

the  triceps  and  forms  an  important  anastomosis  with 
the  posterior  circumflex.  The  cutaneous  branches 
follow  the  nerve  and  supply  the  skin  over  the  outer 
arm.  The  articular  branch  is  given  off  behind  the 
external  intermuscular  septum  and  runs  downward 
in  the  substance  of  the  triceps,  anastomosing  with 
the  interosseous  recurrent  below,  and,  across  the 
joint  behind,  immediately  above  the  olecranon  fossa, 
by  an  arch  with  the  anastomotica  magna.  The 
terminal  branch  perforates  the  septum  to  become 
anterior  at  the  elbow,  and  it,  anastomoses  with  the 
radial  recurrent.     It  often  gives  off  a  nutrient  artery 


or  arteries  to  the  upper  end  of  the  humerus,  and   it 

gives  muscular  branches  to  the  triceps. 

The  inferior  profunda  usually  rises  from  the  inner 
side  of  the  brachial  about  opposite  the  lower  part  of 
the  coracobrachial!-  in  11  lion.  It  passes  with  the 
ulnar     nerve     through      the     internal      intermuscular 

septum  to  the  back  of  the  condyle,  and  there,  under 
cover  of  the  tendinous  aponeurosis  of  the  lle\ or  carpi 
ulnaris,  it  anastomoses  with  the-  posterior  ulnar 
recurrent-  and  ana  tomotica  magna.  It  supplies  Ihe 
humerus,  triceps,  and  elbow-joint,  and  it  frequently 
gives  Off  a  branch,  that  passes  to  the  In  ml  of  the  joint 
and  anastomoses  with  the  anterior  ulnar  recurrent. 

The  anastomotica  magna  usually  rises  from  the 
inner  side  of  the  brachial,  a  short  distance  above  the 
bend  of  the  elbow,  runs  downward  and  inward  across 
the  brachialis,  and  divides  into  an  anterior  and  a 
posterior  branch.     The  anterior  branch  anastomoses 

in  front  of  the  internal  condyle,  beneath  the  pronator 
teres,  with  the  anterior  ulnar  recurrent.  From  this 
branch  a  branch  often  passes  behind  the  condyle  to  an- 
astomose with  the  posterior  ulnar  recurrent  and  the  in- 
ferior profunda.  The  posterior  branch  perforates  the 
internal  sept  uui,  passes  to  the  posterior  surface  of  the 
internal  condylar  ridge,  pierces  the  triceps,  and  there 
anastomoses  with  the  articular  branch  of  the  superior 
profunda  and  with  the  interosseous  recurrent. 

The  nutrient  artery  is  given  off  variably  from  the 
brachial  or  one  of  its  branches  and  passes  through  the 
nutrient  foramen,  downward  toward  the  elbow. 
After  entering  the  shaft  of  the  bone,  a  branch  passes 
upward  toward  the  head  and  neck. 

The  muscular  branches,  from  five  to  eight  in  number, 
are  variably  given  off,  from  the  outer  side  of  the 
artery,  to  the  coracobrachialis,  the  biceps,  and  the 
brachialis  muscles,  usually  at  the  points  where  the 
nerves  enter  these  muscles. 

The  musculocutaneous  nerve,  arising  from  the  outer 
cord  of  the  brachial  plexus,  soon  perforates  the 
coracobrachialis,  and,  still  inclining  outward,  reaches 
the  bend  of  the  elbow  and  there  piercing  the  fascia 
becomes  superficial  just  at  the  outer  border  of  the 
biceps  tendon. 

The  Back  of  the  Arm. — The  triceps  occupies  the 
whole  of  the  posterior  compartment  of  the  arm  and  is 
made  up  of  three  heads  of  origin.  The  long  head 
rises  by  a  flattened  tendon  from  the  upper  part  of  the 
axillary  border  of  the  scapula  and  its  adjacent  lower 
glenoid  rim.  This  tendon,  with  its  muscle  bundles, 
together  with  the  outer  (upper)  humeral  head,  forms 
most  of  the  superficial  part  of  the  muscle. 

The  inner  head,  rising  below  the  musculospiral 
groove,  is  more  deeply  placed.  The  muscle  bundles 
from  these  three  heads  converge  below  into  a  short 
common  tendon  which  is  inserted  into  the  posterior 
part  of  the  top  of  the  olecranon  process.  A  bursa 
underlies  the  tendon  over  the  rest  of  the  top  of  the 
process.  The  long  head  is  joined  upon  its  inner  side 
by  a  slip  of  aponeurotic  fascia  derived  from  the  lower 
border  of  the  tendon  of  the  latissimus.  The  outer, 
or  upper,  head  occupies  all  the  posterior  and  external 
surfaces  of  the  humerus  from  the  teres  minor  insertion 
to  the  groove.  It  also  has  fibers  which  are  attached 
to  the  external  intermuscular  septum  and  the  ap- 
oneurotic sheath  bordering  the  groove.  The  groove 
is  free.  The  inner,  or  lower,  head  rises  from  the 
posterior  surface  of  the  humerus  below  the  groove  and 
receives  a  narrow-pointed  slip  from  high  up  near  the 
insertion  of  the  teres  major,  upon  the  inner  side  of  the 
groove.  It  rises  also  from  the  whole  length  of  the 
internal  intermuscular  septum  and  from  a  small 
part  of  the  external  intermuscular  septum.  The 
fibers  of  origin  of  the  long  and  outer  heads  join  and 
form  a  broad,  flat  tendon  of  insertion.  Some  of 
the  fibers  of  this  tendon  are  given  off  especially  over 
the  outer  part  of  the  elbow-joint,  and  ultimately 
they  expand  so  as  to  form  a  strong  fascia  that  covers 


535 


Arm  and  Forearm 


REFERENCE    HANDBOOK   OF    THE    MEDICAL   SCIENCES 


the  forearm.  The  short  fibers  of  the  inner  head  are 
in  great  pan  inserted  upon  the  deep  surface  of  this 
tendon.  A  few  fibers,  however,  are  inserted  directly 
upon  the  olecranon  or  into  the  posterior  ligament  of 
the  elbow.  The  musculospiral  nerve  and  the  superior 
profunda  artery  supply  muscular  branches  to  each 
of  the  three  heads.  _  _ 

The  musculospiral  nerve  is  the  continuation  ot   the 
posterior  cord  of  the  brachial  plexus  after  there  have 
been  given  off,  in  the  axilla,  the  circumflex  and  the 
subscapulars.     After   passing    for    a   short    distance 
behind  the  lower  part  of  the  axillary  artery  and  the 
upper  part  of  the  brachial  artery,  it  dips  backward, 
downward,  and  outward,  from  the  position  where  it 
lies  upon   the  lower  part  of  the  triceps,   and   then, 
alter  being  joined  by  the  superior  profunda  artery, 
it  enters  the  musculospiral  groove.     Not  infrequently 
in  fractures  of  the  humerus  at  this  point  the  nerve  is 
pinched  or  stretched  over  a  fragment  or  caught  in 
repair  callus  with  resulting  "wrist  drop."     It  turns 
round  behind  the  shaft  of  the  humerus  and  appears 
at   the  outer  side  of  the  arm,  where,  at  about  four 
inches  above  the  elbow-joint,  it  pierces  the  external 
intermuscular  septum  and  lies  in  the  front  compart- 
ment of  the  arm,  deep  between  the  brachialis  on  the 
inside  and  the  brachioradialis  and  the  extensor  carpi 
radialis  longus  upon   the  outside.     In  front  _  of  the 
external  condyle  of  the  humerus  it  divides  into  its 
terminal  branches,  the  radial  and  the  posterior  inter- 
osseous.    It  gives  off  three  cutaneous  branches,  and 
supplies  muscular  branches  in  the  arm  to  the  three 
heads   of   the   triceps,    the   anconeus,    the   brachialis 
(in  part)    the  brachioradialis,  and  the  extensor  carpi 
radialis  longus.     The  last  three  muscles  are  supplied 
by   branches   given   off   in    the   front    compartment. 
The   internal   cutaneous   branch   usually   rises  in   the 
axilla   in   company   with   the  branch   which   goes   to 
the  long  head  of  the  triceps,  and  then  passes  back  of 
the  arm.     It   supplies  a   middle   dorsal    strip  of   in- 
tegument nearly  as  far  down  as  to  the  elbow.     The 
eT    external    cutaneous    branch    pierces    the    deep 
fascia  in  the  line  of  the  external  intermuscular  sep- 
tum   at  the  upper  third  of  the  arm,  accompanies  the 
cephalic  vein  in  the  lower  half  of  the  arm,  and  sup- 
plies a  -trip  of  skin,  from  exit  to  elbow,  on  the  antero- 
extemal    surface    of    the    arm.     The    lower    extern,,) 
cutaneous  branch,  which  is  much  larger    pierces  the 
ia  somewhat  lower  down,  and  supplies  the  skin 
of  the  middle  of  the  back  of  the  forearm  as  far  down 
as  to  the  wrist.     In  its  course  it  passes  between  the 
internal   cutaneous   nerve   upon  the  inside  and   the 
musculospiral  upon  the  outside. 

The  lesser  internal  cutaneous  nerve  ( Wnsberg  s) 
rises  from  the  inner  cord  of  the  brachial  plexus, 
passes  as  far  down,  in  the  front  compartment,  a  to 
the  inner  side  of  the  axillary  vein,  which  latter  sepa- 
rates it  from  the  ulnar  nerve,  at  the  middle  ot  the  arm. 
At  the  elbow  it  turns  backward  to  supply  the  skin 
over  the  olecranon.  . 

The  internal  cutaneous  nerve  rises  from  the  inner 
cord  of  the  brachial  plexus,  and  passes  down  the  arm 
to  the  inner  side  of  the  brachial  artery.  With  the 
basilic  vein  it  perforates  the  deep  fascia  and  supplies 
the  skin  of  the  upper  and  inner  arm.  Above  the 
elbow  the  terminal  branches,  anterior  and  posterior, 
diverge  slightly  at  the  anterointernal  side  ot  the  arm, 
to  pass  the  elbow,  where  they  supply  the  skin  of  the 
inner  forearm,  anteriorly  and  posteriorly,  as  far  down 
as  the  wrist. 

\  terminal  branch  of  the  musculocutaneous  nerve 
pa  ,  over  the  elbow  and  lies  below  in  front  of  the 
radial  artery.  It  supplies  the  outer  side  of  the  fore- 
arm, front  and  back. 

Should  the  shaft  of  the  humerus  need  to  be  cut 
,|(l  ,i  upon  for  wiring  fracture,  caries  and  the  like, 
with  least  injury  of  the  soft  parts  it  may  be  done: 
(1)  at  its  »/)/'"'  third,  anteriorly,  at  the  anterior  bor- 
der of  the  deltoid  muscle  just  external  to  the  bicipital 


groove,  thereby  avoiding  the  sheath  of  the  biceps 
and  severing  "only  the  small  anterior  circumflex 
artery;  (2)  at  its  upper  third,  posteriorly,  at  the 
posterior  border  of  the  deltoid  muscle,  care  being 
had  in  avoiding  the  circumflex  vessels  and  nerve 
exposed  above  and  the  musculospiral  nerve  below; 
(3)  at  its  lower  third,  posteriorly,  by  an  incision 
posterior  to  the  external  intermuscular  septum  from 
the  external  condyle  extended  upward. 

THE  FOREARM. — The  forearm  is  that  portion  of 
the  pectoral  girdle  or  upper  extremity  lying  between 
the  elbow  and  the  wrist  joint.  Its  various  structures 
are  most  intimately  associated  with  the  functions  of 
the  hand.  Its  bony  framework  comprises  two  bones, 
the  radius  and  the  ulna.  The  ulna  is  directly  con- 
tinuous with  the  humerus,  the  radius  with  the  hand 
and  its  functions  and  movements. 

The  skin  of  the  forearm  is  soft  and  is  usually  well 
supplied  with  hairs,  especially  along  the  postero- 
external surface.  Along  the  anterior  surface  the 
hairs  are  fewer  and  finer.  The  skin  is  freely  movable 
throughout  the  forearm  upon  the  deep  fascial  sheath. 
The  bursa  over  the  olecranon  gives  it  free  mobility  at 
that  point.  Lying  within  the  layers  of  the  super- 
ficial fascia  are  the  superficial  veins  and  the  cutane- 
ous nerves. 

The  superficial  veins  rise  in  two  plexuses:  the 
large  plexus  of  the  dorsum  of  the  hand  which  is  derived 
from  the  digital  veins,  and  the  smaller  plexus  of  the 
front  of  the  wrist,  from  the  palm  and  thumb.  These 
veins  are  larger  than  those  of  the  deep  set,  have  fewer 
valves  and  return  most  of  the  blood.  At  points  of 
communication  between  these  sets  of  veins,  valves 
are  regularly  found. 

The  vein's  arising  from  these  two  plexuses  are 
irregular  in  their  distribution  and  are  seldom  sym- 
metrical upon  the  two  sides  in  the  same  body.  Foi 
convenience  four  principal  vein  trunks  are  distin- 
guished upon  the  outer,  anterior,  and  inner  surfaces 
of  the  forearm:  the  radial,  the  median,  the  anterior, 
and  the  posterior  ulnar  veins  respectively.  The 
median  vein  as  it  reaches  a  point  opposite  the  inser- 
tion of  the  biceps  receives  a  communication  from  the 
deep  set  which  perforates  the  deep  fascia.  This 
trunk  is  short  and  is  known  as  the  profunda.  The 
median  at  once  divides  into  branches  that  diverge 
in  V-form,  the  median  cephalic  to  the  outer  side  and 
the  median  basilic  to  the  inner  side  of  the  biceps. 
The  n,,, Han  cephalic  ascends  to  a  point  a  little  above 
the  elbow,  is  joined  by  the  radial  vein,  and  this 
trunk,  called  the  cephalic,  lies  in  the  furrow  to  the 
outer  side  of  the  biceps  in  the  arm.  The  median 
cephalic  vein  overlies  the  cutaneous  branches  o :  the 
musculocutaneous  nerve  as  they  pass  the  elbow. 
The  median  basilic  vein  passes  upward  and  inward 
and  is  usuallv  joined  at  a  point  about  in  front  of  the 
internal  condyle  by  both  the  vlnar  veins.  1M 
trunk  so  formed  is  called  the  basilic  and  lies  to  W 
inner  side  of  the  biceps  in  the  arm.  The  median 
basilic  is  usuallv  larger  and  shorter  than  the  median 
cephalic;  the  basilic  is  usuallv  a  considerably  larger 
trunk  than  the  cephalic.  The  median  basilic  veil) 
overlies  from  without  inward  the  bicipital  fascial 
aponeurosis,  the  brachial  artery,  a  part  of  the  an- 
terior division  and  the  whole  of  the  posterior  division 
of  the  terminals  of  the  internal  cutaneous  nerve. 

Superficial  Nerves.— The  cutaneous  nerves  arc 
the  musculocutaneous,  with  a  few  fibers  from  Uic 
musculospiral  near  the  elbow,  for  supplying  the  outer 
side  of  the  forearm,  front  and  back;  the  internal 
cut  aneous,  for  supplying  the  inner  side  of  the  forearm 
front  and  back.  Lying  between  the  two  on  the  hack 
of  the  forearm  is  the  distribution  of  the  lower  (larger) 
cutaneous  branch  of  the  musculospiral.  All  these 
nerves  pass  the  elbow.  Behind,  over  a  small  area, 
limited  to  the  olecranon,  is  the  nerve  of  \\  risberg. 


536 


KKFKIMAi  !•:    HANDBOOK    o|'   THE    MEDICAL   SCIENCES 


Arm  ami  Forearm 


Piercing  the  fascia  at  the  Id  wit  third  of  the  forearm, 
the  following  nerves  become  superficial  or  cutaneous: 
(he  palmar  branches  of  the  ulnar,  median,  and  radial 
nerves  on  the  front,  and  the  dorsal  branch  of  the 
ulnar  nerve  and   the  radial  nerve  mi   the  back. 

The      brachial      (deep) 

at    the    elbow    is  j^_ 

firmly    fixed   to   the  bony 

p  ro  m  i  n  e  11  ees  ,  a  ml  is 
■ihened  ill  fniiil  by 
the  bicipital  fascia.  This 
slip  is  given  nil'  from  the 
on  of  insert  ion  of  the 
biceps,  which  bridges  o\  er 

the  brachial  artery,  and  is 

over     the    pronator 

and  its  sheath  at  the 
inner  side  of  I  he  forearm. 

fascia!  libers  are  al   '• 

Often    received    from    the 

hi      of     the     triceps. 

her  iii  the  upper 
third  of  the  forearm  this 
deep  fascia  forms  a  strong 
enveloping  sheath.  Near 
the  elbow  at    the  internal 

le  it  serves  in  part  as 
the  origin  of  several  mus- 

hich  spring  from  the 
condyle.  Lower  down  in 
the  forearm  septa  are 
given  oil'  from  its  deep 
surface  to  dip  down  be- 
tween the  various  muscle 
bellies.  In  the  lower  third 
the  fascia  is  continuous 
with    the  various    muscle 

ns  and  at  the  wrist 
forms  the  anterior  and 
posterior  annular  liga- 
ments. It  ends  in  the 
fascia  of  the  hand.  It  is 
attached  to  the  posterior 
triangular  area  of  the  ole- 
cranon and  to  the  whole  of 
the  posterior  ridge  of  the 
ulna,  and  is  much  thicker 
behind.  Between  the  su- 
perficial and  deep  layers  of 
muscles,  front  and  back,  is 
a  thin  membranous  layer 
of  fascia.  Below  and  be- 
hind, the  fascia  is  st  rength- 
ened  by  transverse  fibers 
to  form  the  posterior  an- 
nular ligament  of  the  wrist 
which  passes  from  the 
anterior  border  of  the 
radius  above  the  styloid 
process  backward  and  in- 
ward, over  the  series  of 
ridges  forming  grooves  for 
tendons,  over  the  ulna 
serving  as  an  orbicular 
ligament,  to  attach  itself 
to  the  inner  aspect  of  the 
wrist,  especially  over  the 
pisiform  and  cuneiform  bones. 

Muscles. — The  muscles  of  the  forearm,  for  con- 
venience, can  be  divided  into  groups:  those  of  the 
front,  those  of  the  back,  and  those  of  the  outer  side 
of  the  forearm.  Those  of  the  front  (anterior  radio- 
carpal) consist  of  a  superficial  set,  five  in  number: 
the  pronator  teres,  flexor  carpi  radialis,  flexor  carpi 
ulnaris,  tlexor  digitorum  sublimis,  and  (flexor)  pal- 
niaris  longus;  and  a  deep  set,  three  in  number:  flexor 
digitorum  profundus,  flexor  pollicis  longus,  and  pro- 


nator quadratus.  The  muscles  of  the  outer  ide 
i  radial),  three  in  number,  are:  brnchioradialis, 
extensor  carpi  radialis  longus,  and  extensor  carpi 
radialis  brevis.  'I'll.,  e  ..I  the  bad  (po  terioi  radio- 
carpal)   comprise  a   superficial   set,    four    ill    number: 


extensor  digitorum  communis,  extensor  digiti 
minimi,  extensor  carpi  ulnaris,  and  anconeus;  and  a 
deep  set,  five  in  number:  supinator  (brevis),  extensor 
ossis  metacarpi  pollicis,  extensor  pollicis  longus, 
extensor  pollicis  brevis,  and  extensor  mdicis. 

The  five  muscles  of  the  superficial  flexor  group  are 
intimately  associated  at  their  origin  from  the  internal 
condyle.  Arising  from  it  is  a  tendon  common  to  them 
all,  which  gives  libers  to  each  and  sends  septa  between 
every  two  contiguous  muscles.  The  muscles,  from 
without  inward,  are  the  following: 


537 


Arm  and  Forearm 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


The  -pronator  teres,  the  most  external,  crosses  ob- 
liquely the  upper  half  of  the  forearm.  It  rises  by  two 
heads:  one,  large  and  superficial,  from  the  inner 
condyle  of  the  humerus  by  a  tendon  common  to  both 


S 
< 


a 
& 


heads,  and  from  the  supracondylar  ridge,  fascia,  and 
intermuscular  septa;  the  other,  a  thin  and  deep  band, 
coming  from  the  inner  side  of  the  coronoid  proci 
and  sunn  joining  the  deep  surface  of  the  large  head. 
This  slip  separates  the  median  nerve  from  the  ulnar 
artery,  The  muscle  thus  formed  passes  outward 
anil  ends  in  a  Battened  Irndon  which  turns  over  Hie 
radius  and  is  inserted  into  a  rough  impression  on  the 


outer  surface  of  the  shaft  of  the  radius  about  at  its 
middle.  Near  the  insertion  the  muscle  is  crossed 
by  the  radial  artery  and  is  covered  by  the  brachio- 
radialis. 

The  flexor  carpi  radialis 
rises  from  the  flexor  tendon, 
from  fascia,  intermuscular 
septa,  and  adjacent  muscles. 
At  about  the  middle  of  the 
forearm  its  fleshy  belly  merges 
into  a  long  flattened  tendon, 
passes  in  a  special  compart- 
ment of  the  anterior  annular 
ligament,  grooves  the  trape- 
zium, and  inserts  itself  into 
the  base  of  the  second  and 
frequently  into  the  third 
metacarpal  bone. 

The  (flexor)  palmaris  longus 
is  a  long  slender  muscle,  the 
smallest  of  the  group.  It 
rises  from  the  flexor  tendon, 
fascia,  and  septa,  to  form  a 
small  round  belly.  It  soon 
ends  in  a  long  slender  tendon 
which  inserts  itself  into  the 
lower  border  of  the  annular 
ligament  and  the  palmar 
fascia.  This  muscle  is  very 
variable  and  is  often  absent. 
The  flexor  carpi  ulnaris,  the 
innermost  muscle  of  the 
group,  rises  by  two  head-: 
the  one  from  the  back  part  of 
the  flexor  tendon,  the  other 
from  the  inner  side  of  the 
olecranon  and,  by  an  aponeu- 
rosis, from  the  upper  two- 
thirds  of  the  posterior  border 
of  the  ulna.  The  two  heads 
bridge  the  space  between  the 
internal  condyle  and  the  ole- 
cranon and  between  and  be- 
neath them  the  ulnar  nerve 
is  transmitted.  The  muscle 
converges  into  a  tendon 
which  is  placed  along  its 
front  surface  and  inserts  itself 
into  the  pisiform  bone. 

The  flexor  digitorum  sub- 
limis  (flexor  perforatus)  is  a 
broad  flat  muscle  placed  be- 
hind the  preceding.  It  rises 
by  a  strong  head  from  the 
flexor  tendon,  from  the  in- 
ternal lateral  ligament  of  the 
elbow-joint,  from  the  inner 
border  of  the  coronoid  proc- 
ess, and  from  the  overlying 
muscles  and  septa;  and  by  a 
second  head,  a  thin  flat  band, 
from  the  anterior  oblique  line 
of  the  radius  and  its  anterior 
border.  It  merges  from  a 
broad  muscle  into  four  sepa- 
rate tendons  which  first  pass 
through  the  middle  compart- 
ment of  the  anterior  annular 
ligament,  then  diverge,  and 
continue  their  course,  each 
one  separately,  in  company  with  a  corresponding  ten- 
don from  the  profundus  (behind),  to  each  of  the  lust 
four  fingers.  At  the  wrist  the  tendons  pass  in  pairs, 
those  for  the  third  and  fourth  fingers  being  in  front, 
those  for  the  second  and  fifth  lying  behind  the  first  pair. 
The  tendons  opposite  the  first  phalanx  divide,  allow 
the  profundus  tendon  to  pass  between,  then  unite 
behind  to  insert  themselves  into  the  second  phalanx. 


538 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Arm  and  Forearm 


■ 


This  group  of  muscles  is  supplied  by  the  median 
nerve,  save  the  ulnar  flexor  which  receives  its  supply 

from  the  ulnar.  .  . 

The  '/'  i  p-si  'ii'  'I  flexor  group  comprises  the  following 
muscles:  . 

The  /?' j''"'  ilii/ii'intm  profundus  (flexor  penetrans;, 
•i  large  thick  muscle,  rises  from  the  upper  three- 
fourths  of 
the  front 
and  inner 
side  of  the 
ulna,  from 
the  ulnar 
half  of  the  in- 

-e  0  U  S 

in  b  ra  ne 

and   from  the 
urosis  ol 
the     flexor 
ulnaris. 
It     divides  \ 

Bnallyinto  four  ten 
for  the  inner 
four  fingers,  but  the 
tendon  for  the  index 
becomes  dis- 
tinct in  theforearm. 

tsses  behind  the  sublimis 
at  the  wrist,  behind  the  sub- 
limit tendons  in  the  palm,  and 
perforating  the  sublimis 
inserts  itself  at  the  buses  of  the 
phalanges  of  the  inner  four 
fingers.  The  lumbricales  take 
origin  from  its  tendons  in  the 
palm. 

The  flexor  pollicis  longus,  to 
the  outer  side  of  the  profundus, 
rises  from  the  front  of  the 
radius  between  the  oblique  line 
and  the  pronator  quadratus, 
the  adjacent  interosseous 
membrane.  From  a  fleshy 
belly,  a  round  tendon  passes 
under  the  annular  ligament 
thenar  eminence  to  its 
insertion  at  the  base  of  the 
id  (last)  phalanx  of  the 
thumb.  Occasionally  a  second 
head  rises  from  the  coronoid 
process  or  internal  condyle  in 
common  with  the  sublimis. 

The  pronator  quadratus  rises 
from  the  pronator  ridge  and 
from  the  front  of  the  ulna  at 
its  lower  fourth,  passes  close 
to  the  bones,  and  inserts  itself 
into  the  front  of  the  lower  end 
of  the  radius. 

This  group  of  muscles  is  supplied  by  the  anterior 
interosseous  branch  of  the  median  nerve;  with  the 
exception  that  the  ulnar  nerve  supplies  the  outer 
half  of  the  deep  flexor,  i.e.  the  ring  and  little 
fingers. 

The  muscles  of  the  outer  (radial)  extensor  group  are: 

The  brachioradialis  (supinator  longus)  rises  from 
the  upper  two-thirds  of  the  external  supracondylar 
ridge  and  from  the  front  of  the  external  intermuscular 
septum.  It  forms  a  long  slender  muscle  which,  near 
the  middle  of  the  forearm,  merges  into  a  flat  tendon: 
and  this,  in  turn,  inserts  itself  into  the  outer  side  of 
the  radius  near  the  base  of  the  styloid  process. 

The  extensor  carpi  radialis  longus  rises  just  below  the 
preceding  muscle  from  the  ridge  and  septum,  a  few 
fibers  being  derived  from  the  common  extensor  ten- 
don. From  this  origin  a  long  tendon  passes  under  the 
posterior  annular  ligament  in  its  second  compartment 
and  passes  to  its  insertion  into  the  base  of  the  second 


Fig.      313. — Skiagraph 

Showing  Relations  of  Bony 
Framework  of  the  Shoul- 
der, Arm.  and  Elbow  to 
the  Soft  Parts  which  Sur- 
round Them.  (After  Ger- 
rish.) 


icarpal.     In  its  course  ii  lie-  upon  the  following 

muscle. 

The  extensor  carpi  radialis  brevis  rises  by  the  com- 
mon extensor   ten. Inn   from    the  external   condyle   of 

the   humerus,    from    the   intennu  epta,   and 

from  the  external  lateral  ligament   of  the  elbow.       lis 

tendon  passes  with  the  longus  in  the  same  compart- 
ment at  tin'  wrist  and  is  finally  inserted  into  the  i, 

of  the  third  metacarpal. 

This    muscle    group    is   supplied    by    the    mUSCulo- 

spiral  nerve,  that  to  the  short  radial  extensor  being 
through  the  posterior  branch  of  the  nerve. 

The  group  from  without  inward, 

contains  the  following  muscles: 

Tile  by  the  c - 

iiiiin  extensor  tendon,  fascia,  and  septa.  1  rom  a 
fleshly  belly  four  tendons  are  ultimately  given  off, 

and  these  pass  through  the  fourth  compartment  of 
the  posterior  annular  ligament  on  their  way  to  the 
hand.  Here  they  diverge  ami  then  pass  on  to  the 
points  where  they  are  inserted  at  the  bases  of  the 
id  and  the  third  phalanges  of  the  inner  four 
fingers. 

The.  extensor  digit!  n  lies  a!  the  inner  side  of  the 

preceding  muscle.  It  rises  in  the  same  manner  as 
does  that  muscle  and  passes  through  the  fifth  com- 
partment at  the  wrist  (between  radius  and  ulna);  its 
points  of  insertion  are  the  same  a-  those  of  the  corre- 
sponding tendon  of  the  preceding  muscle. 

The  extensor  carpi  ulnaris  rises  in  the  same  manner 
as  the  preceding,  and  also  by  an  ulnar  aponeurosis 
common  to  it,  the  flexor  carpi  ulnaris,  and  the  flexor 
profundus.  The  tendon  emerges  near  the  wrist, 
passes  in  the  sixth  compartment,  and  i  inserted  into 
the  base  of  the  fifth  metacarpal  near  its  ulnar  border. 

The  anconeus  rises  from  the  lower  part  of  the  back 
of  the  external  condyle  and  from  the  adjacent  pos- 
terior ligament  of  the  elbow  and  is  inserted  into  the 
outer  surface  of  the  olecranon  and  the  upper  third  of 
the  back  of  the  ulna.  This  muscle  is  sometime-; 
continuous  with  the  triceps  and  is  usually  described 
in  connection  with  it,  as  a  fourth  head. 

This  group  is  supplied  by  the  posterior  interos- 
seous branch  of  the  musculospiral  nerve. 

The  deep  extensor  group  comprises  the  following: 

The  supinator  (brevis)  rises  from  the  back  of  the 
external  condyle,  the  external  lateral  ligament,  the 
orbicular  ligament  of  the  radius,  and  the  back  part 
of  the  bicipital  hollow  of  the  ulna,  from  which  point 
it  extends  a  variable  distance  down  the  outer  border 
of  the  ulna.  Over  these  fibers  of  origin  is  a  strong 
aponeurotic  cover.  The  muscle  passes  out  and  down 
over  the  back  of  the  radius  to  insert  itself  into  the 
back  of  the  neck  of  the  radius  and  upon  the  outer 
and  front  surfaces  of  this  bone  as  far  down  as  the 
insertion  of  the  pronator  teres.  The  muscle  is  divided 
into  superficial  and  deep  layers  by  the  posterior 
interosseous  nerve  as  it  passes  to  the  back  of  the 
forearm. 

The  extensor  ossis  metacarpi  pollicis  (abductor  pol- 
licis longus)  rises  from  the  outer  part  of  the  back 
surface  of  the  ulna  at  the  junction  of  the  upper  and 
middle  thirds,  from  the  corresponding  portion  of  the 
interosseous  membrane,  from  a  small  part  of  the  back 
of  the  radius  near  its  middle,  and  from  intermuscular 
septa.  The  muscle  extends  down  and  out,  emerges 
between  the  extensor  digitorum  communis  and  the 
extensor  carpi  radialis  brevis,  and  in  company  with 
the  extensor  pollicis  brevis  it  crosses  the  two  radial 
extensors.  At  about  this  point  it  merges  into  its 
tendon,  follows  down  the  outer  side  of  the  base  of 
the  radius,  and  enters  the  first  compartment  of  the 
posterior  annular  ligament.  It  is  inserted  into  the 
outer  side  of  the  base  of  the  first  metacarpal  bone  and 
by  its  aponeurosis  into  neighboring  structure-,  nota- 
bly the  back  of  the  trapezium,  and  also  into  the  pal- 
mar fascia,  especially  that  part  which  covers  the 
thumb. 


539 


Arm  and  Forearm 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


The  extensor  pollicis  brevis  (extensor  primi  inter- 
nodii  pollicis)  rises  from  the  middle  of  the  back  of  the 
interosseous  membrane  just  below  the  preceding, 
from  the  back  of  the  radius  extending  obliquely 
outward  and  downward,  and  from  the  intermuscular 
septa  of  this  group  of  muscles.  It  extends  obliquely 
down  and  out  and  forms  its  tendon  at  the  lower  third 
of  the  forearm.  From  this  point  it  accompanies 
the  tendon  of  the  preceding  muscle,  lying  behind  it, 
to  lie  inserted  into  the  base  of  the  first  phalanx  of 
the  thumb. 

The  extensor  pollicis  longus  (extensor  secundi  inter- 
nodii  pollicis)  rises  from  the  outer  part  of  the  back 
of  the  ulna  at  its  middle  third,  close  to  the  outer 
border,  from  the  interosseous  membrane,  and  from 
the  septum  between  it  and  the  extensor  indicis. 
This  muscle,  somewhat  stronger  than  the  preceding, 
passes  down  and  out  to  merge  into  a  tendon  placed 
along  its  back.  The  tendon  becomes  free  just  above 
the  posterior  annular  ligament,  passes  through  its 
third  compartment,  then  over  the  radial  extensors, 
lies  close  to  the  inner  side  of  the  tendon  of  the  pre- 
ceding, and  is  inserted  into  the  base  of  the  second 
phalanx  of  the  thumb. 

The  extensor  indicis  rises  from  the  back  of  the  ulna 
(from  a  [joint  just  below  the  preceding  muscle  to  one 
situated  nearly  at  the  lower  end  of  the  bone),  from 
the  adjacent  interosseous  membrane,  ami  from  the 
septum  between  it  and  the  preceding.  It  merges 
into  a  tendon  which  is  placed  along  its  radial  border. 
This  becomes  free  at  the  lower  third  of  the  forearm, 
passes  through  the  fourth  compartment  beneath  the 
tendons  of  the  extensor  digitorum  communis,  and 
after  it  emerges  from  this  it  is  inserted  into  the  inner 
border  of  the  tendon  of  the  common  extensor  of  the 
index  finger  at  about  the  metacarpophalangeal  joint. 

This  muscle  group  is  also  supplied  by  the  posterior 
interosseous  branch  of  the  musculospinal  nerve. 

Arteries. — The  brachial  artery  ends  just  below  the 
bend  of  the  elbow  where  it  divides  opposite  the  neck 
of  the  radius  into  its  two  terminals,  the  radial  and  the 
ulnar. 

The  radial  artery,  the  smaller  of  the  two,  extends 
downward,  in  direct  continuation  of  the  brachial 
artery,  along  the  outer  side  of  the  front  of  the  forearm 
to  the  lower  end  of  the  radius.  Here  it  turns  around 
the  outer  side  of  the  radius  to  the  back  of  the  wrist, 
over  the  external  lateral  ligament,  and  under  the 
extensors  of  the  thumb. 

In  the  upper  forearm  it  lies  in  the  outermost  inter- 
muscular space  between  the  brachioradialis  and  the 
pronator  teres,  and  is  covered  by  fascia?  and  skin. 
In  the  middle  and  lower  thirds  of  the  forearm  it  lies 
along  the  inner  border  of  the  muscle  and  tendon  of 
the  brachioradialis,  which  latter  serves  as  a  guide  in 
the  operation  for  ligating  this  vessel.  In  this  part 
of  the  forearm  it  is  covered  only  by  fasciae  and  skin, 
and  by  a  few  superficial  veins  and  cutaneous  branches 
of  the  musculocutaneous  nerve.  The  radial  at  the 
wrist  lies  directly  upon  the  bone,  and  forms  the  pulse. 
The  radial  nerve  approaches  the  artery  above  at  an 
acute  angle;  in  the  middle  and  lower  thirds  it  lies 
along  its  outer  side.  The  venae  comites  accompany 
the  artery  on  either  side. 

The  radial  artery  in  the  forearm,  besides  the  irregu- 
lar and  numerous  muscular  branches,  gives  off  the 
radial  recurrent,  the  anterior  radiocarpal,  and  the 
superficial  volar. 

The  rail  in}  rerun-,  ,.',.  a  branch  of  considerable  size,  is 
usually  given  oil  from  the  outer  side  of  the  radial 
just  below  its  origin  from  the  brachial.  It  runs  out- 
ward between  the  brachioradialis  and  the  supinator 
(brevis),  divides  into  several  branches  and  anastomoses 
with  the  interosseous  recurrent  and  superior  profunda, 
and  gives  of!  a  branch  to  supply  the  elbow-joint. 

The  superficial  volar  and  the  anterior  radiocarpal 
are  brain  In        i    en  oil'  just  above  the  wrist. 


The  ulnar  artery,  the  larger  of  the  terminals  of  the 
brachial,  from  the  inner  side  of  the  neck  of  the  radius 
l>a~<es  down  and  inward  to  the  front  of  the  inner 
(tilnar)  side  of  the  forearm,  thence  directly  to  the 
wrist,  and  over  the  anterior  annular  ligament  to  the 
palm. 


m 


Rmvscul.i 


jf,J 


>It,  vtuecuC 


ffl 
Tenia 

fiLsjp.  long.  !' 


M.  ulnar  im. 


'It.  dorsal 


Fig.  314. — Course  and  Branches  of  the  Arteries  of  the  Forearm 
(Heitzmann.) 

In  the  upper  half  of  its  course  the  artery  lies  deeply 
beneath  the  pronator  teres  and  the  superficial  flexor-; 
in  the  lower  half  of  the  forearm  it  is  overlapped  only 
by  the  flexor  carpi  ulnaris  muscle  and  tendon  which 
lie  to  its  inner  side  and  serve  as  a  guide  in  operations 
for  ligating  the  vessels.  Only  in  the  last  inch  or  so 
is  the  artery  superficial.  As  the  artery  lies  beneath 
the  pronator  teres  it  is  crossed  from  within  outward 
by  the  median  nerve,  the  deep  head  of  the  muscle 


540 


KKl'KliKNCK    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Ann  and  Forearm 


usually  separating  the  two.  The  ulnar  nerve  ap- 
proaches the  artery  from  behind  the  inner  condyle  at  an 
acute  angle,  being  separated  from  it  l>\  the  flexor 
ublimis,  and  in  the  lower  two-thirds  ii  lies  close  to 
the  inner  side  of  the  artery.  The  latter  is  covered 
by  superficial  ulnar  veins,  in  addition  to  fasciae  and 
i  is  crossed  by  branches  of  the   internal  eu- 

tane'o  '  he  arterj    is  ace panied   by   two 

coniites. 

The  ulnar  artery,  besides  m tous  and  irregular 

muscular  branches,  gives  off  the  anterior  and 

n  current    ulnar,    the   anterior   and    postei  ior 
llS|  the  anterior  and  posterior  ulnar  carpal, 
i-illv  the  nutrient  of  the  ulna. 
The  anterior  recurrent  ulnar,  the  smaller  of  the  two 
branches,  runs  up  in  front  of  the  inner  con- 
dyle of  the  humerus,   be- 
en   the  pronator  teres 
and    the    brachialis,    and 
anasi omoses  with  the  an- 
terior  branch   of  the  an- 
astomotica    magna  and  a 
branch  of  the  infei  ior  pro- 
funda. 

The  '  poxt<  Hot  r<  current 
ulnar,  the  larger,  passes 
inward  bet  ween  I  he  flexor 
sublimis  and  the  flexor 
profundus,  then  up  and 
back  of  the  inner  condj  le 

of  the  humerus,  and  t 3 

to  lie,  with  the  ulnar  nerve, 
ctween  the  two  heads  of 
he  flexor  carpi  ulnaris. 
t  anastomoses  with  the 
osterior  branch  of  the 
nastomotica  magna, 
ith  the  inferior  profunda, 
nd  with  the  intern  eous 
recurrent  to  form  the  ole- 
cranal  rete. 

The  interossei  rise 
from  the  ulnar  by  a 
common  trunk 
about  half  an  inch 
in  length  from  the 
outer  and  back  part 
of  the  ulnar  just  be- 
fore the  median 
nerve  crosses  the 
main  vessel.  This 
trunk  arises  about 
an  inch  below  the 
origin  of  the  ulnar, 
and  proceeds  back- 
ward to  the  interos- 
seous membrane, 
where  it  divides  into 
its  two  terminals. 

The  anterior  inter- 
osseous, the  smaller, 
fellows  the  front  of  the  membrane  in  company  with 
two  veins  and  the  deep  branch  of  the  median  nerve 
which  lies  to  its  outer  side.  It  usually  supplies 
nutrient  branches  to  both  bones. 

rhe  posterior  interosseous,  the  larger,  passes  back 
a  the  interosseous  membrane  and  the  oblique 
ligament  above,  descends  between  the  superficial  and 
de  ip  muscles,  and,  crossing  the  extensors  of  the  thumb 
and  index  finger,  anastomoses  below  the  latter  mus- 
cle with  the  anterior  interosseous. 

These  ulnar   recurrent   and    interosseous   branches 
supply  in  main  the  muscles  of  the  forearm,  the  large 
of   the    radial  and  ulnar  passing  through  to 
supply  the  wrist  and  hand. 

rhe  anterior  and  posterior  ulnar  carpals  are  small 
carpals  which,  in  company  with  the  anterior  radial 
carpal,  anastomose  and  form  the  carpal  arch. 


Yir..  .'. .  Eti  gion  of  Wrist, 

showing  Arrangement  of  Tendons,   Ar- 
tery, Nerve,  etc.     The  skin  and  fasciffl 
been    removed.      (After    M.    H. 
rdson.) 


.\ii:\i  in  iks.  rhe  nerve  trunks  of  the  forearm 
are  the  radial,   posterior  inteross -    median,   and 

ulnar. 

The  musculi  tior)  distance  abo>  e  the 

elbow,  lying  upon  the  brachialis  and  covered  by  the 
brachioradiali  ,  divides  into  its  terminals,  'lie  |" 
rior  interosseous  and  the  radial  nerves. 

Tin  1  >ack,  out . 

and  down  between  the  brachialis  and  i  carpi 

radialis  longu  .  through  the  supinatoi  o  the 

leep  layer. if  the  forearm  extensors.     It  approaches 

the  posterior intei i    artery  at  an  angle,  and  is  in 

relation  with  it  as  far  as  to  a  point  bi  i       in  of 

t  he  e\iii,  i  ir  pi  illici  li  mgu  where  it  approach  and 
is  in  relation  with  the  posterior  branch  of  the  anti  rioi 
interosseous  artery.  Lower  down,  it  pa  es  thro 
the  fourth  compartment  of  the  wrist,  with  the  exten- 
sores  communis  and  indicis,  to  the  back  of  the  wrist 
e  ii  be is  ganglionic. 

The  radial  nerve  passes  directly  downward  under 
co  er  of  the  brachioradialis.     At    the  middle   third 

Of  the  arm  it  lies  along  the  outer  side  of  the  radial 
artery,  then  winds  around  the  outer  side  of  the 
radius   under   cover  of   the   brachioradialis   tendon, 

and  pierces  the  deep  fascia  iii  the  lower  forearm, 
breaking  up  into  its  terminal  branches  on  the  back 
of  t  he  w  rist. 

The'  median  nerve,  from  the  bend  of  the  elbow, 
where  it  lies  to  the  inner  side  of  t  he  tendon  of  t  he  biceps, 
the  brachial,  and  the  beginning  of  the  ulnar  artery, 
passes  down  the  center  of  the  front  of  the  forearm 
beneath  the  condylar  head  of  the  pronator  teres  and 
over  the  ulnar  artery,  being  separated  from  the  latter 
by  the  deep  head  of  the  same  muscle.  Beyond  this 
point  it  passes  beneath  the  radial  head  of  the  flexor 
digitorum  sublimis,  and  later  still  it  lies  deep  beneath 
the  flexor  sublimis  and  on  the  flexor  profundus.  At 
the  wrist  the  nerve  becomes  superficial  and  lies  be- 
tween the  tendons  of  the  flexor  sublimis  to  the  inner 
side,  and  of  the  flexor  carpi  radialis  on  the  outer  side. 
It  passes  superficially  through  the  large  flexor  com- 
partment of  the  anterior  annular  ligament  and  soon 
divides  into  an  inner  and  an  outer  terminal.  Besides 
muscular  brain  lies  in  the  forearm,  the  median  gives 
off  thi'  anterior  interosseous  and  small  branches  to 
the  elbow-joint. 

The  anterior  interosseous  nerve  is  given  off  from  the 
median  opposite  the  insertion  of  the  biceps,  runs 
down  the  front  of  the  membrane  in  company  with 
the  anterior  interosseous  artery,  and  supplies  the  med- 
ullary arteries,  the  periosteum  of  the  radius  and  ulna, 
and  the  wrist-joint. 

The  xdnar  nerve,  from  the  angle  between  the  ole- 
cranon and  the  internal  condyle,  passes  between  the 
inner  and  outer  heads  of  the  flexor  carpi  ulnaris  to 
the  front  of  the  forearm.  It  passes  down  upon  the 
flexor  profundus  under  cover  of  the  flexor  carpi  ulnaris 
and  overlapped  by  it  upon  the  inner  side.  It  passes 
nearly  to  the  wrist  along  the  outer  side  of  this  muscle 
and  its  tendon,  when  it  becomes  superficial  and 
enters  the  hand  anteriorly  to  the  annular  ligament. 
In  the  lower  two-thirds  of  the  forearm  the  ulnar 
artery  lies  to  its  outer  side,  separating  it  from  the 
flexor  sublimis.  It  also,  besides  giving  off  mus- 
cular branches,  supplies  the  elbow-joint. 

The  interosseous  membrane  bridges  across  between 
the  interosseous  borders  of  the  radius  and  ulna 
from  a  point  a  little  below  the  bicipital  tubercle  of  the 
radius  to  the  wrist-joint.  Its  fibers  pass  mainly  in 
an  oblique  direction  from  the  radius  to  the  ulna. 
The  posterior  interosseous  vessels  pass  back  over  its 
upper  border  and  are  in  relation  with  its  back  surface 
low  down  in  the  forearm.  The  anterior  interosseous 
vessels  and  nerve  are  in  relation  with  the  front  sur- 
face throughout.  Except  in  supination  of  the  fore- 
arm and  in  full  pronation  this  membrane  is  usually 
tense.  It  serves  also  to  carry  strains  from  the  radius 
to  the  ulna  and  to  bind  the  bones  together. 


oil 


Arm  and  Forearm 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


The  forearm  is  subcorneal,  so  that  the  lateral  flap 
operation  is  a  necessity,  since  the  skin  cannot  be 
pushed  far  upward  in  the  lower  forearm.  The  skin 
is  also  quite  adherent  to  the  underlying  aponeurosis. 
Roughly  speaking,  the  intermuscular  septa,  the  bones, 
and  the  interosseous  membrane  form  a  front  and  a 
back  compartment.  The  ulna  is  subcutaneous  from 
olecranon  to  styloid  process,  so  that  any  injury  or 
fracture  is  readily  manifest.  The  radius  lies  deeply 
lodged  among  the  upper  forearm  muscles  and  it  is 
only  occasionally  that  its  head  can  be  felt.  In  the 
lower  forearm  the  radius  becomes  gradually  sub- 
cutaneous and  can  be  examined.  The  interosseous 
membrane  is  tense  in  the  semiprone  position  of  the 
foicarm,  which  indicates  the  best  position,  in  fracture 
of  the  radius  or  ulna,  for  splinting.  Care  should  be 
exercised  not  to  permit  the  fractured  ends  of  the 


Fig.  316. — Dissection  of  the  External  Region  of  the  Right  Wrist 
The  radial  artery  is  seen  between  the  relaxed  tendon  of  the  flexor 
carpi  radialis  below,  and  the  braehioradialis  on  the  outer  (upper) 
side.  It  then  passes  beneath  the  first  two  extensors  of  the  thumb 
and  a  small  branch  of  the  radial  nerve,  crosses  the  base  of  the 
thumb  obliquely,  and  disappears  under  the  tendon  of  the  extensor 
pollicis  longus.     (After  M.  H.  Richardson). 

radius  to  rest  upon  the  ulna,  thereby  causing  injury 
to  interosseous  vessels  and  nerves  and  favoring  an 
eventual  ankylosis.  Anteroposterior  splints  may 
press  too  much  upon  radial  and  ulnar  vessels  and 
nerves  and  injure  them. 

The  muscles  of  the  forearm  in  extremely  muscular 
subjects  after  too  long  and  severe  use  may  cause 
pressure  upon  arteries  and  nerves,  and  resultant 
pains  and  neuralgias.  Muscular  spasm  may  effect 
the  same  results.  Muscles  become  greatly  hyper- 
trophied  under  special  exercises  (as  occurs,  for  ex- 
ample, in  the  pronator  teres  muscle  of  the  "tennis 
arm").  A  spasm  of  the  same  muscle  may  take 
place,  as  in  the  "glass  arm"  of  baseball  pitchers. 
Hypertrophy  of  both  of  the  pronators,  the  result  of 
"feathering,"  may  take  place  in  the  ease  of  oarsmen. 
The  inner  edge  of  the  braehioradialis  is  the  guide  to 
the  radial  artery  and  nerve;  the  inner  edge  of  the 
pajmaris  tendon  is  that  for  the  median  nerve;  and  the 
outer  border  of  the  flexor  carpi  ulnaris  indicates 
where  the  ulnar  artery  and  nerve  are  to  be  sought  for. 
Both  arteries  may  be  ligated  at  any  point  above  the 
annular  ligament  for  severe  hemorrhage  of  the  palm. 
Above  the  anterior  annular  ligament  the  two  synovial 
tendon  sheaths  of  the  flexor  pollicis  longus  and  thai 
common  to  the  sublimis  and  profundus  extend  for  a 
distance  of  an  inch  and  a  half,  and  often  carry  infec- 
tion from  the  palm  to  the  tendon  spaces  of  the  fore- 
arm. In  case  of  pus  spreading  deeply  up  the  forearm 
the  median  nerve  should  be  used  as  a  guide  and 
ion-  made  upon  either  side  of  it. 

Through  the  posterior  annular  ligament  extend 
upward  six  such  sheaths,  all  of  which  save  the  la  i 
extend  well  above  the  ligament.  They  are:  one  for 
the    two   outer   thumb   extensors,   one  for   the   two 


radiocarpal  extensors,  one  for  the  long  thumb  ex- 
ten, or,  one  for  the  common  extensor,  one  for  the 
little  finger  extensor,   and  lastly   one  for   the  ulno- 


carpal      extensor, 
suppurative. 

Injuries  of  the 
symptoms.     (See 


These       sheaths       are     seldom 


nerve  trunks  may  cause  varying 
the  Section  on  the  Arm.)  The 
posterior  interosseous  nerve  may  be  injured  in  resec- 
tion of  the  head  of  the  radius  or  in  fracture  of  the 
radial  neck,  and  thus  may  cause  paralysis  of  the 
extensors.  The  posterior  interosseous  nerve  may 
suffer  loss  of  function  from  fracture  of  the  humerus 
at  some  point  near  its  middle.  Pressure  upon  the  me- 
dian nerve  in  muscular  spasm  and  in  compression  from 
long  and  severe  muscular  exercise,  may  cause  in- 
creased cramps  and  pain  or  even  a  prolonged  neu- 
ralgia. The  ulnar  mrve  may  be  injured  in  fracture 
of  the  olecranon  and  may  cause  loss  of  sensation,  or 
numbness;  or  it  may  becaught  in  the  callus  of  fracture, 
either  there  or  along  the  shaft  of  the  ulna,  and  cause 
pain;  and,  finally,  the  conditions  may  be  such  as  to 
necessitate  excision  of  the  nerve  from  the  callus. 
The  numbness  from  a  sudden  blow  upon  the  ulnar 
nerve  at  the  elbow — commonly  spoken  of  as  "striking 
the  funny  bone"— is  a  familiar  instance;  and  if 
severe,  this  numbing  and  tingling  may  be  persistent 
and  may  be  accompanied  by  loss  of  function  of  the 
flexor  muscles.  In  plumbism  the  ulnar  nerve  is 
regularly  involved,  causing  the  "claw  hand."  The 
ulnar  and  median  nerves  are  both  involved  in  alco- 
holic neuritis.  The  radial  nerve  may  be  painful  at  its 
points  of  distribution  if  the  trunk  is  injured  in  Colles' 
fracture.  Neuromata  along  the  nerve  trunks,  due 
to  injury,  may  demand  excision. 

Luzerne  Coville. 


Arm  and  Forearm,  Diseases  and  Injuries  of  the. — 

In  considering  the  diseases  and  injuries  of  the  arm  ami 
forearm,  I  shall  take  up  the  different  affections  of 
the  several  structures  under  the  following  heads: 
I.  Affections  of  the  Skin;  II.  Affections  of  the  Fa.-cia; 
III.  Affections  of  the  Bones,  the  Periosteum,  and  the 
Joints;  IV.  Affections  of  the  Muscles,  Tendons,  and 
Tendon  Sheaths;  V.  Affections  of  the  Blood-vessels; 
VI.  Affections  of  the  Lymphatic  Vessels,  Glands,  and 
Bursas;  VII.  Affections  of  the  Nerves;  VIII.  Hyster- 
ical Lesions;  IX.  Tumors. 

It  will  be  my  purpose  to  discuss  more  fully  .those 
affections  of  these  different  structures  which  show 
some  peculiar  manifestations  when  presenting  them- 
selves upon  the  upper  extremities,  and  to  deal  with 
them  less  in  detail  when  exhibiting  upon  the  arm 
merely  those  features  which  are  common  to  the  same 
affections  elsewhere  in  the  body.  Particularly  in  the 
case  of  diseases  affecting  the  skin  of  the  arm  and  fore- 
arm, not  all  the  dermatic  affections  which  may  be 
found  in  this  locality  will  be  entitled  to  extensive  con- 
sideration, but  such  forms  of  skin  trouble  only  as  are 
particularly  prone  to  develop  their  lesions  upon  the 
arms.  Furthermore,  it  will  suffice  with  regard  to  must 
of  these  to  call  attention  to  the  fact  that  certain 
lesions  may  be  expected  on  the  arms  and  forearms, 
and  to  describe  their  symptoms  and  appearance  with 
sufficient  accuracy  to  allow  of  their  diagnosis,  while 
more  extended  consideration  of  their  pathology  and 
treatment  is  to  be  sought  under  other  headings  in  this 
work. 

I.  Affections  of  the  Skin. 

With  regard  to  the  diseases  affecting  the  skin  of  the 
arms,  we  have  to  content  ourselves  for  the  most  part 
with  recording  the  observed  fact  of  their  appearance 
in  this  locality,  owing  to  our  ignorance  of  the  causes 
that  determine  the  outbreak  of  cutaneous  lesions  upon 
this  part  of  the  body. 

It  is  necessary  to  bear  in  mind  that  the  general  prin- 


542 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Ann  and  Forearm,  Diseases 
and  Injuries  <»f     * 


dplea  of  dermatology  are  applicable  here  as  in  other 
parts  of  the  body,  notably  those  which  teach  us  thai 

symmetrical  lesions  may  generally  bei ideredtobe 

,li,r  in  internal  causes,  while  for  unsymmetrical  lesions 
there  is  a  priori  reason  to  think  of  local  irritation  as  a 
oause  of  the  affection.  Similar  weight  .should  ln- 
givcn  in  considering  the  relation  of  the  cutaneous 
lesion  to  the  clothing  of  the  part,  inasmuch  as  certain 
lesions  are  prone  to  appear  on  unprotected  parts, 
while  others  appear  where  the  fricl  ion  of  the  clothing, 
or  vermin  which  the  clothing  may  harbor,  may  give 
i  to  local  irritation.  Other  matters  concerning  the 
of  lesions  of  the  skin  on  the  arms,  whieli  may  alTeet 
the  diagnosis,  are  the  lines  of  cleavage  of  the  skin,  and 

the  presence  of  (lie  lesions  upon  (he  flexor  or  upon  the 

nsor  surface  of  the  affected  limb,  and  finally  the 

in  course  of  certain  of  the  brachial  nerves  and 

els.      Nor  should   the  general   rule  of  der- 

itological  practice  be  forgotten  which  teaches  us  to 

compare  the  integument  of  the  arms  witli  that  of  the 

of  the  body  and  so  gain  an  accurate  knowledge  of 

the  anatomical  distribution  of  the  cutaneous  lesions. 

I  In  more  recent  nosological  systems  of  dermatology 
have  sought  in  group  the  various  lesions  of  the  skin  ac- 
.  irding  to  their  pathological  basis,  and  in  the  rapid 
a  which  I  purpose  to  make  of  such  cutaneous 
lions  as  have  their  common  site  upon  the  arms 
and  forearms,  I  shall  consider  the  different  lesions  in 
the  general  order  of  the  classification  of  Jessner — to 
wit,  functional  disorders,  circulatory  disorders,  and 
inflammations,  superficial  and  deep-seated;  finally, 
I   shall    consider    briefly    traumatisms    of    the    skin. 

Functional  Disorders  of  the  Skin. — Of  the  first 
class,  that  of  functional  disorders  of  the  skin,  such  as 
pruritus,  hyperidrosis,  seborrhea,  it  will  suffice  to  say 
that  none  of  them  have  any  predilection  for  the  arms  or 
inns  which  would  justify  their  consideration  here, 
if  we  except  the  entirely  unimportant  erythema 
Bolare  which  is  frequently  seen  on  the  arms  of  farmers, 
bathers,  and  laborers  who  work  in  the  open  air  with 
i in   sleeves  rolled  up. 

Circulatory  Disorders  of  the  Skin. — Of  the  dis- 
eases of  the  skin  classified  by  Jessner  as  circulatory 
disorders,  the  lesions  of  purpura  and  scurvy,  while 
undoubtedly  they  show  themselves  with  comparative 
frequency  on  the  arms,  yet  it  is  rare  that  they  should 
show  themselves  there  with  any  special  preponderance 
of  distribution  over  other  parts  of  the  body.  Peliosis 
rheumatica,  however,  is  a  purpuric  affection  whose 
predilection  for  the  arms  merits  our  attention  in  con- 
sidering the  cutaneous  affections  of  these  members. 

In  I'ELiosis  rheumatica,  also  called  purpura 
rheumatica,  a  period  of  invasion  precedes  the  erup- 
tion for  a  variable  length  of  time,  and  is  shown  by 
general  malaise,  systemic  disturbances  and  painful 
swelling  of  the  joints,  especially  of  the  knees,  wrists, 
and  ankles.  The  temperature  may  be  normal,  but 
more  often  it  rises  to  100°  F.  or  more.  In  a  few  days 
the  eruption  appears  and  the  pain  then  subsides. 
The  lesions  occupy  practically  the  same  regions  as  do 
those  of  erythema  multiforme  (vide  infra),  namely, 
the  wrists,  forearms,  and  lower  legs,  but  sometimes 
they  are  particularly  located  about  and  around  the 
inflamed  joints.  Some  authorities  indeed  classify  the 
affection  as  a  variety  of  erythema  multiforme.  The 
lesions  consist  of  bluish-red  patches,  and  slightly 
elevated,  bright-red  papules  which  quickly  become 
purplish;  they  may,  however,  be  purpuric  from  the 
first.  Their  color  cannot  be  effaced  by  pressure. 
After  persisting  for  a  few  days,  they  pass  through  the 
various  gradations  of  color  seen  in  a  contusion  and 
disappear  altogether.  The  disease  may  be  limited  to 
outbreak,  or  the  eruption  may  come  out  in  several 
crops  and  run  a  course  of  from  four  to  six  weeks,  or 
it  may  disappear  altogether  and  ten  days  or  more  later 
a  relapse  occur,  and  the  joint  and  other  symptoms 
again  become  manifest.  The  recognition  of  hem- 
orrhage into  the  skin  is  easy  when  it  is  borne  in  mind 


that  pressure  does  not  cause  the  redness  to  fade.    Such 
lesions  occupying  the  localities  mentioned,  ami  a    o 
ciated    with    the  systemic  disturbance  already    de- 
scribed,    with     the  joint  swellings,    pains,    etc.,    are 
sufficient    to    constitute    the    diagnosis    of    peliosia 

rheiimal  ica. 

Inflammatory  Diseases  of  the  Corium  mid  Sub- 
cutis.     of    the    inflammatory    diseases  of   the   skin, 

we    can    at    once   dismiss    the   specific   exant  hemal  oil  : 

fevers  of  childhood  as  having  no  special  predilection 
for  the  arms,  and  of  i  he  di  eases  under  the  nosological 
classification  we  are  following,  that  known  a  lichi  i 
planus  is  the  fii'st  that  arrests  our  attention.  This 
is  a  disease  whose  predilection  for  the  arms  as  a  site 
for  eruption  is  more  marked  than   is  the  ease  in  that 

just  described.  Indeed,  if  is  often  confined  to  the 
flexor  aspect  of  the  forearm,  though  it  manifests  a 
tendency  in  its  course  to  spread  over  a  greater  part  of 
the  lower  arm  and  of  the  forearm;  but  ii  never  involves 
the  whole  skin  as  do  eczema,  psoriasis,  and  lichen 
ruber  in  certain  cases.  The  following  description  of 
the  symptoms  and  course  of  t  he  disease  is  taken  from 
Gottheil:  Lichen  planus  occurs  most  frequently  as  a 
chronic  ami  localized  malady,  the  more  acute  and 
general  form  of  the  disease  being  rare.  The  site  of 
i  he  eruption  is  usually  the  flexor  surface  of  the  fore- 
arms, especially  around  the  wrists  and  on  the  backs 
of  the  hands  and  the  feet,  but  other  regions  are  not 
infrequent  ly  affected,  and  it  occurs  occasionally  on  the 
palms,  soles,  and  (he  genitals.  It  is  rare,  however,  on 
the  face  and  scalp.  It  is  frequently  symmetrical. 
The  lesions  appear  first  as  extremely  minute  papules 
of  a  characteristic  dusky  red  or  purplish  color,  with 
a  waxy  glance,  and  sharply  differentiated  from  the 
surrounding  skin.  Their  sides  are  steep,  and  (heir 
shape  is  distinctly  angular.  Their  tops  are  Hat.  and 
marked  with  a  central  depression  or  capped  with  a 
minute  scale.  On  the  palms  and  soles  the  individual 
lesions  may  be  hard  to  distinguish,  the  entire  epi- 
dermis of  the  affected  region  being  elevated  and 
thickened,  cracked  in  places  and  of  a  dusky  hue  and 
covered  with  whitish  scales.  On  the  mucosae  they 
appear  as  whitish,  flattened  papules.  They  may  be 
scattered  or  irregularly  grouped.  As  they  gradually 
enlarge  to  pea  size,  adjacent  papules  coalesce,  and 
thus  extensive  indurated  and  scaly  areas  are  formed; 
but  the  individual  lesions  do  not  increase  beyond 
their  original  size.  After  persisting  for  a  long  time, 
months  and  years,  they  slowdy  undergo  absorption, 
leaving  atrophic,  pigmented  areas  behind.  No 
vesicles  or  pustules  are  ever  formed,  nor  are  the  nails 
or  the  hair  affected.  The  subjective  symptoms  are 
confined  to  a  moderate  itching,  and  it  is  only  in  very 
extensive  forms  that  this  becomes  severe.  The 
patients  are  sometimes  debilitated  and  run  down  by 
excesses  or  overwork,  but  not  infrequently  they  are 
in  excellent  health.  The  malady  occurs  with  about 
equal  frequency  in  both  sexes.  It  is  seen  at  all  ages, 
but  is  most  frequent  during  middle  life. 

The  diagnosis  rests  upon  the  peculiar  shape,  size, 
grouping,  and  appearance  of  the  papules  as  described 
above.  Papular  eczema,  especially  when  situated  on 
the  forearm,  may  resemble  lichen  planus,  but  the 
papules  are  rounded  and  frequently  have  a  little 
serum  at  their  apices.  They  are  intensely  itchy, 
round,  run  a  rapid  course,  and  leave  no  pigmentation 
behind;  and  other  eczematous  changes,  excoriation, 
oozing,  or  crusting  will  probably  be  found  somewhere 
on  the  skin.  In  the  papular  syphiloderm  the  lesions 
are  round-topped  and  often  arranged  in  crescentic  or 
circular  form;  they  are  generally  distributed,  and 
more  or  less  polymorphic;  there  is  no  itching,  their 
color  is  reddish.  Other  signs  of  syphilis  are  probably 
present,  and  the  disease  responds  to  antiluetic  treat- 
ment. In  lichen  scrofulosum  the  round  papules  are 
grouped  upon  the  trunk  and  are  accompanied  by  no 
subjective  symptoms  whatsoever.  Finally  in  psori- 
asis the  lesions  are  pink,   covered   with   abundant, 


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heaped-up  scales,  and  are  situated  solely  on  the 
extensor  surface. 

The  prognosis  is  favorable  always.  The  disease  is 
chronic  and  obstinate,  but  it  tends  to  recovery.  It 
may  be  added  that  the  disease,  though  not  common, 
is    K  it  excessively  rare. 

The  grave  progressive  disease  known  as  lichen 
HUBEH  may  have  some  of  its  characteristic  lesions 
situated  upon  the  arms,  but  its  distribution  is  so 
rarely  limited  to  that  locality  that  its  discussion  need 
not  detain  us  here.  When  present  upon  the  arms 
its  tendency  to  follow  and  accentuate  the  folds  and 
lines  of  cleavage  of  the  skin  sometimes  leads,  in  the 
cubital  folds,  to  the  development  of  linear  strings  of 
papules,  constituting  what  is  known  as  "lichen  ruber 
moniliformis." 

Few  of  the  forms  of  eczema  confine  themselves  to 
the  arms,  though  small  patches  of  scaly  eczema  are 
not  infrequently  met  on  or  near  the  wrists. 

Eczema  papulosum,  however,  is  a  form  of  eczema 
both  common  and  obstinate  which  has  a  predilection 
for  the  limbs,  both  the  arms  and  the  legs,  though  it  is 
met  with  on  the  trunk  as  well.  Host  forms  of 
eczema  are  characterized  by  lesions  with  a  more  or  less 
fluid  exudation  which  loosens  the  superficial  portion 
of  the  epidermis  and  spreads  itself  over  the  affected 
surface.  In  some  cases  of  eczema,  however,  the 
tendency  to  exudation  is  lessened,  and  the  probabil- 
ities are  that  it  is  less  fluid  in  character,  and  under 
these  circumstances  does  not  gain  the  surface  but 
collects  at  points  beneath  the  epidermis,  raising  little 
solid  projections  which  have  received  the  name  of 
papules.  These  may  be  somewhat  closely  aggregated, 
or  there  may  be  an  appreciable  distance  between 
them,  and  the  surface  will  be  dry  unless  the  pruritus 
leads  to  scratching  and  the  edges  of  the  papules  are 
torn;  in  that  case  a  small  quantity  of  lymph  may 
exude  and  dry  into  minute  scales.  In  the  course  of 
time,  however,  the  papules  themselves  tend  to  subside, 
and  we  have  a  surface  somewhat  glossy  and  scaly, 
but  not  to  the  extent  usually  seen  in  other  varieties 
of  eczema.  This  papular  form  of  eczema  has  its  seats 
of  election.  It  is  perhaps  never  seen  on  the  scalp  and 
some  other  parts,  but  it  is  quite  common  on  the  arms 
and  forearms,  thighs,  and  legs,  especially  their  flexor 
aspects  (Piffard). 

Eczema  fissum  is  still  another  variety  of  eczema  in 
which  we  have  neither  vesicles,  pustules,  nor  papules, 
nor  the  extensive  exfoliation  which  characterizes  the 
exfoliative  form  of  this  disease.  We  may  have  a 
more  or  less  reddened  surface,  but  instead  of  the 
lesions  already  mentioned  we  find  small  cracks  or 
fissures  extending  through  the  stratum  corneum  and 
sometimes  through  the  stratum  Malpighii  as  well.  The 
exudation  in  this  fissured  variety  is  slight,  crusting  is 
slight,  and  after  a  time  the  skin  returns  to  the  normal 
condition  by  a  simple  closing  of  the  fissures  and 
disappearance  of  the  congestion.  These  fissures  are 
perhaps  more  frequently  met  with  behind  the  ears, 
on  the  palms  and  soles,  and  at  the  various  flexures 
(Piffard). 

Erythema  multiforme  is  the  next  disease  under 
the  head  of  cutaneous  inflammations  which  claims 
our  attention,  on  account  of  its  frequent  appearance 
on  the  forearms.  Gottheil  defines  it  as  an  acute 
inflammatory  disease,  characterized  by  the  appear- 
ance of  reddish  papules,  tubercles,  vesicles,  or  blebs 
of  symmetrical  distribution,  and  affecting  by  prefer- 
ence the  backs  of  the  hands  and  the  feet.  Elliot 
remarks  that  it  is  one  of  the  most  striking  and  con- 
stant features  of  erythema  multiforme  that  almost 
invariably  the  lesions  appear  first  on  the  backs  of  the 
hands  and  extend  to  the  forearms  and  then  to  the 
lateral  portion  of  (he  neck  ami  face.  Frequently 
simultaneously,  but  more  often  later  than  on  the  hands, 
the  eruption  is  manifested  on  the  dorsum  of  the  feet 


and  on  the  anterior  aspect  of  the  legs.  It  is  frequently 
absent  altogether  from  these  regions,  and  besidesl 
the  eruption  will  present  much  variation  in  individua 
cases.  The  eruption  is  always  symmetrical,  without, 
however,  presenting  absolute  symmetry.  Often  one 
side  of  the  body  will  be  more  severely  affected  than 
the  other.  Its  symptoms,  course,  and  the  differential 
diagnosis  are  described  by  Gottheil  as  follows:  After 
a  prodromal  period  marked  by  a  moderate  febrile 
movement  there  appear  on  the  backs  of  the  hands  and 
feet,  or  on  the  palms  and  soles,  and  more  rarely  on 
other  parts  of  the  body,  a  varying  number  of  slightly 
elevated,  firm,  reddish-violet  papules  fading  on 
pressure.  This  condition  is  known  as  erythema 
papulatum.  In  a  few  days  the  papules  grow  into 
tubercles  perhaps  one-third  of  an  inch  in  size  (ery- 
t  hema  tuberculatum).  The  centers  then  begin  to  flat- 
ten and  fade  out  and  assume  a  characteristic  bluish-red 
hue  (erythema  annulare).  At  the  periphery  where 
the  eruption  is  extending,  the  lesions  preserve  their 
elevated  form  and  reddish  tint.  Adjacent  patches 
may  coalesce  and  form  irregular  figures,  known  as 
erythema  gyratum  and  erythema  figuratum.  More 
rarely  the  appearance  of  blebs  gives  us  the  form 
known  as  erythema  bullosum.  Herpes  iris  is  the 
designation  given  to  a  vesicular  form  of  this  erythema 
in  which  new  concentric  rings  of  papulovesicles 
appear  in  the  depressed  purplish  center  of  an  annular 
erythema.  These  various  forms,  often  looked  upon 
as  distinct  diseases,  are  in  reality  merely  stages  of  the 
same  process  with  varying  amounts  of  exudation. 
A  case  may  go  through  several  of  them  and  even  show 
them  simultaneously,  for  multiformity  is  charac- 
teristic of  the  disease;  but  usually  one  type  only  is 
present,  and  the  commonest  by  far  is  the  papular 
one.  The  malady  occurs  especially  in  the  spring 
and  fall,  and  lasts  for  from  four  to  six  weeks.  It 
happens  at  any  age,  and  issomewhat  more  frequent 
in  females  than  in  males.  The  mucosa?  are  occasion- 
ally affected.  It  is  prone  to  relapse,  and  usually  re- 
aopears  in  its  original  type.  It  is  occasionally  com- 
plicated with  purpura,  acute  articular  rheumatism, 
and  endocarditis. 

Its  typical  course  and  location,  the  papules  or 
tubercles  whose  red  color  is  removable  on  pressure, 
and  the  absence  of  desquamation  are  sufficient  to 
characterize  the  disease.  An  eczema  has  exudations, 
scales,  and  crusts,  and  itches  intensely.  Urticaria 
has  papules  or  pinkish,  fugacious  elevations,  with 
much  itching  and  reflex  irritability  of  the  skin.  A 
papular  syphiloderm  is  copper  colored  and  not 
removable  by  pressure;  the  palms  and  soles  are  usually 
involved,  and  other  syphilitic  symptoms  are  generally 
present.  Prurigo  has  deep-seated,  colorless  pap! 
begins  in  childhood,  and  itches  intensely.  Tri- 
chophytosis corporis  is  scaly  in  the  center,  and  the 
parasite  can  usually  be  readily  found. 

While  the  arms  are  one  of  the  rarer  sites  for  the 
vesicular  eruption  of  herpes  zoster,  yet  the  fact 
should  be  borne  in  mind  that  this  disease  occasionally 
manifests  itself  in  the  course  of  the  brachial  nerves. 
Its  characteristic  symptoms  should  make  the  diagno- 
sis in  most  cases  easy.  Its  symptomatology  is  this: 
The  eruption  is  almost  regularly  preceded  by  distinct 
premonitory  symptoms,  consisting  mainly  in  neuralgio 
pains  of  variable  degrees  of  severity  over  the  area 
about  to  be  affected  and  lasting  from  a  few  hours  to 
several  days,  occasionally  even  for  weeks.  Some- 
times they  are  missing  entirely,  particularly  in  young 
children.  The  pain  may  be  of  a  diffuse  character,  or, 
again,  confined  to  certain  points  which  correspond 
anatomically  to  the  underlying  nerves  and  their 
ramifications.  The  cutaneous  phenomena  make 
their  appearance  always  in  an  acute  manner.  At 
first  there  are  redness  and  slight  swelling  over  the 
diseased  area.  This  is  soon  followed  by  groups  "f 
small  papular  elevations,  which  in  the  course  of  a  few 
hours  are  transformed  into  vesicles  from  the  size  of  a 


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Arm  and  Forearm,  Diseases 
and  Injuries  <u 


pin-head  to  that  of  a  small  split  pea,  closely  clustered 
together,  fully  distended,  and  filled  with  a  clear  serous 
Quid.  The  vesicles  arc  at  first  sharply  contoured  and 
surrounded  by  an  erythematous  halo.  Further  on 
they  may.  I>v  peripheral  extension,  become  confluent 
go  as  to  form  larger  bulla-.  They  have  generally  little 
dency  to  burst,  and  do  so  only  accidentally. 
Occasionally  a  larger  surface  may  be  uniformly  stud- 

.1  with  these  vesicles,  but  as  a  rule  there  are  several 

distinct  and  isolated  groups  of  them,  varying  in  size 

from  a  dime  to  the  palm  of  the  hand,  of  irregular 

tiape,  and  arranged  more  or  less  exactly  in  the  form 

i  simigirdle  when  situated  on  the  trunk.      In  other 

regions    the    unilateral    distribution    of    the    eruption 

ig  the  course  of  one  or  several  cutaneous  nerves 

forms    a    striking    feature.      These    groups    Come    Out 

icessively,  the  one  nearest  the  spinal  column 
Usually  appearing  first,  but  all  the  vesicles  constituting 
pat cli  are  formed  and  run  their  course  contem- 
poraneously. Their  contents  remain  clear  for  three 
or  four  days,  then  become  gradually  more  turbid, 
puriform,  and  by  and  by  dry  out,  forming  brownish 
crusts  which  finally  fall  off  and  leave  in  their  place 
reddish  or  bluish  discolorations.  These  persist  for 
.■■  time  and  gradually  fade  away.  In  some 
instances,  however,  permanent  marks  may  remain, 
which,  by  their  arrangement  and  distribution,  are 
quite  characteristic  of  the  preceding  eruption.  The 
time  consumed  for  the  completion  of  the  cycle  in  each 
individual  group  is  from  eight  to  ten  days,  but  through 
the  successive  appearance  of  fresh  crops  of  vesicles 
n  the  older  ones  have  almost  reached  the  point  of 
involution,  the  whole  process  may  last  up  to  four  or 
even  six  weeks. 

The  subjective  symptoms  which  accompany  the 
eruption  are  very  variable.  While  in  some  cases  the 
preliminary  neuralgia  ceases  with  the  advent  of  the 
cutaneous  manifestations,  it  is  more  often  present 
during  the  whole  duration  of  the  disease,  and  is 
intensified  by  a  burning  and  smarting  sensation  with 
which  every  new  crop  of  lesions  is  ushered  in.  Some 
patients  complain  very  little,  others  seem  to  suffer 
very  much,  particularly  from  nightly  exacerbations 
which  may  disturb  the  sleep.  Even  after  the  com- 
pletion of  the  eruptive  stage  there  may  remain  for 
some  weeks,  and  occasionally  for  a  long  period,  dis- 
turbances in  the  sensory  functions  of  the  affected 
area.  Fever  is  frequently  present  with  the  zoster, 
but  is  rarely  of  much  consequence.  A  very  remark- 
able fact  in  regard  to  zoster  is  that  it  attacks  a  person 
only  once  during  a  lifetime.     Exceptions  to  this  are 

-  few  and  far  between  that  they  do  not  materially 
affect  the  generally  accepted  law. 

The  termination  of  the  local  manifestations  does  not 
always  indicate  a  complete  restoration  in  the  affected 
territory-  Not  only  may  neuralgic  pains  persist  for 
some  time  and  become  the  source  of  agonizing  at- 
tacks which  deteriorate  the  patient's  health,  but  in 
ie  cases  there  remain  pruritus,  hyperesthesia,  or 
complete  anethesia  and  analgesia.  Of  particular 
interest  is  the  so-called  "  anesthesia  dolorosa,"  which 
occasionally  follows  a  zoster.  An  explanation  for 
this  peculiar  phenomenon  may  be  found  in  that  the 
pathological  changes  in  the  course  of  the  nerve  disturb 
the  transmission  of  sensation  from  the  surface  to  the 
center,  whereby  the  anesthesia  is  produced,  while  the 

use  of  the  pain  is  located  in  the  sensory  root  of  the 
spinal  column. 

U though  zoster  is  generally  attributed  to  disturb- 
ances in  the  sensory  nerves,  the  strange  fact  must  be 
recorded  that  often  muscular  atrophy  and  motor 
paralysis  are  caused  by  it.  Paralysis  of  the  arm 
muscles  after  zoster  brachialis  has  been  noted  by 
Schwimmer,  Joffroy,  Broadbent,  and  Gibney. 

The  characteristics  of  zoster  are  usually  so  marked 
that  little  difficulty  can  exist  in  recognizing  it.  Its 
unilateral  distribution  along  the  course  of  well- 
inown  cutaneous  nerves,  the  successive  appearance 

Vol.  I.— 35 


of  groups  of  vesicles,  their  cyclic  course,  and  the  con- 
comitant neuralgia  will  easily  establish  the  diagnosis. 
From  eczema  it  is  readily  differentiated  by  the  larger 
size  of  its  vesicles  and  their  tendency  to  pel  i-t  as 
such,  whereas  in  the  former  they  burst  very  won  and 
give   rise   to   characteristic   oozing   (Zei  sler). 

Psoriasis  is  a  disease  which  on  account,  of  its 
customary  distribution  merits  a  description  among 

the  cutaneous  affections  of  the  arm.  The  lesion  of 
psoriasis  are  characterized  by  the  formation  of  a 
thick  imbricated  covering  of  dry  scales  of  a  light 
yellow,  pearly  white,  or  silvery  color  situated  on  a 
reddish,   slightly   elevated,    well-defined     base.     The 

disease  appears  without  premonitory  symptoms,  and 
the  first  indication  of  its  presence  is  the  appearance  of 
small  pin-head  sized,  rose-colored  spots,  w  Inch  in  a 
day  or  1  wo  become!  covered  with  silvery  scales,  psoriasis 
punctata.  These  spots  increase  at  the  periphery, 
while  the  scales  become  piled  up  into  thick  crusts 
which,  from  their  resemblance  to  drops  of  mortar 
spattered  on  the  skin,  constitute  the  form  known  as 
psoriasis  guttata.  If  the  attack  runs  an  acute  course, 
the  patches  rapidly  increase  in  size,  and  in  a  week 
may  attain  the  dimensions  of  coins,  psoriasis  num- 
mularis. Generally,  however,  the  eruption  is  noted 
for  its  chronicity,  and  months  are  required  for  this 
development.  The  tendency  of  the  psoriatic  lesion 
is  to  disappear  of  its  own  accord,  although  the  time 
occupied  in  this  process  may  be  months  or  years. 
The  activity  of  the  scaly  proliferation  first  begins  to 
subside  in  the  middle  of  the  patch,  which  finally  goes 
on  to  complete  resolution,  leaving  a  ring-shaped 
margin  standing  out  in  bold  relief — psoriasis  annu- 
laris. If  the  disease  continues  to  extend,  the  rings 
meet,  giving  figure-of-eight-shaped  eruptions,  and 
as  the  healing  proceeds,  the  point  of  contiguity 
in  turn  disappears,  leaving  irregular  or  serpentine 
lines — psoriasis  gyrata. 

The  accumulation  of  scales,  which  is  the  most 
distinct  feature  of  psoriasis,  varies  in  different  cases 
as  well  as  on  different  parts  of  the  body  of  the  same 
individual.  On  the  scalp  the  scales  are  thick,  and  the 
eruption  tends  to  extend  beyond  the  margin  of  the 
hair.  On  the  extensor  surface  of  the  limbs,  also,  the 
scales  become  piled  up  on  elevated  bases  to  the 
height  of  several  lines.  On  the  face  and  penis  the 
scales  are  less  abundant.  Although  the  scales  are 
adherent  to  each  other  and  to  the  base  underneath, 
yet  they  may  be  detached  by  the  finger  nail,  when, 
if  the  disease  is  of  recent  origin,  a  pale  reddish  surface, 
which  readily  bleeds  and  is  but  slightly  raised  above 
the  surrounding  skin,  will  be  seen.  In  cases  of  long 
standing  the  base  is  of  a  dark  or  venous  hue  and 
markedly  thicker  than  the  normal  skin.  The  scales 
thus  removed  are  quickly  renewed  and  in  a  few  days 
attain  their  former  thickness.  There  is  no  discharge 
or  moisture  connected  with  the  eruption  at  any  time, 
and  the  sensation  of  itching  may  or  may  not  be  present. 
Although  all  parts  of  the  body  may  be  involved,  yet 
there  are  regions  of  predilection  which  are  generally 
involved,  especially  at  the  onset  of  the  disease.  These 
are  the  points  of  the  elbows  and  the  anterior  aspect 
of  the  legs  just  below  the  patella?.  The  scalp  is  also 
a  favorite  position,  and  in  typical  cases  the  disease 
is  more  marked  on  the  extensor  than  on  the  soft,  flexor 
surfaces  of  the  body.  In  all  cases  the  eruption  tends 
to  symmetrical  distribution. 

Although  psoriasis  is  usually  a  well-defined  disease 
and  easily  recognized,  yet  it  is  subject  to  variations 
and  in  atypical  cases  may  baffle  the  skilled  diagnosti- 
cian. In  appearance  it  varies  from  a  simple  furfura- 
ceous  desquamation  which  may  be  the  result  of  fric- 
tion, to  a  veritable  inflammation  as  in  scaly  eczema. 
Eczema  squamosum,  however,  is  less  frequently 
symmetrical,  the  flexor  surfaces  of  the  joints  are 
favorite  positions,  while  the  extensor  surfaces  of  the 
points  of  the  elbows  or  knees  are  not  affected  as  in 

545 


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psoriasis.  In  psoriasis  the  eruption  is  sharply  de- 
fined, and  its  margins  frequently  stand  out  like  a  bold 
headland,  while  in  eczema  the  patch  is  thickest  at  the 
center  and  its  margin  merges  gradually  into  the  healthy 
skin.  A  history  of  moisture  will  often  enable  one  to 
decide,  for  eczema  at  its  outset  is  always  moist, 
while  psoriasis  is  essentially  a  dry-eruption  from  the 
beginning.  In  eczema  the  accumulation  of  scales  is 
less  than  in  psoriasis,  and  they  are  of  a  bluish  color 
rather  than  white.  The  scales  in  eczema  are  more 
easily  detached,  and  the  base  when  scraped  be- 
comes bathed  with  serous  exudation  and  does  not 
bleed  as  in  psoriasis.  Eczema  of  the  palms  and  soles 
is  more  common  than  psoriasis  in  this  position.  It  is 
more  fissured  and  may  be  the  only  part  involved, 
while  psoriasis  does  not  attack  these  parts  alone. 
The  nails  are  affected  in  both  diseases,  but  in  eczema 
they  are  usually  all  affected  at  once,  while  in  psoriasis 
one  or  more  nails,  but  never  all,  are  involved  at  the 
same  time.  Lichen  planus  and  lichen  ruber  may  be 
mistaken  for  psoriasis  when  the  former  are  of  long 
duration.  Lichen  first  appears  in  the  form  of  small 
pin-head  to  split-pea  sized,  flat-topped  papules  which 
are  distributed  in  clusters  and  extending  at  the  peri- 
phery run  together,  giving  the  eruption  the  appearance 
of  one  continuous  patch,  not  unlike  psoriasis;  lint 
there  is  less  scaling  in  lichen  and  the  eruption  extends 
by  the  formation  of  characteristic  islets  which  may  be 
seen  on  the  outskirts  of  the  original  cluster.  The 
characteristic  position  of  lichen  is  on  the  flexor 
aspect  of  the  wrist,  a  position  seldom  occupied  in 
psoriasis.  Syphiloderma  squamosum  often  resembles 
psoriasis  very  closely,  and  next  to  eczema  is  most 
liable  to  be  mistaken  for  this  disease.  On  account 
of  the  close  similarity,  this  form  of  syphilodcrm  was 
formerly  called  syphilitic  psoriasis.  But  syphilis 
attacks  the  mucous  surfaces  as  well  as  the  skin,  and 
is  seldom  present  on  the  latter  without  appearing  on 
the  former;  while  psoriasis  never  attacks  the  mucous 
membranes.  Syphilis  but  rarely  occurs  on  the  el- 
bows and  knees,  but  it  is  very  commonly  met  with 
on  the  palms  of  the  hands  and  the  soles  of  the 
feet.  One  hand  may  be  affected  in  psoriasis,  while 
both  are  usually  involved  in  syphilis.  The  erup- 
tion in  syphilis  is  polymorphous,  presenting  from 
time  to  time  papules,  pustules,  and  moist  condy- 
lomata which  would  at  once  enable  one  to  distinguish 
it  from  psoriasis.  In  late  syphilis  the  destructive 
nature  of  the  disease  will  become  apparent  by  scars 
or  fissures,  while  psoriasis  leaves  no  mark  behind. 
The  scales  in  syphilis  are  muddy  gray,  and  the  base 
of  the  eruption  is  more  infiltrated  and  of  a  darker 
color;  moreover,  the  history  of  the  disease  should 
always  be  considered  (Corlett). 

Dehmatttis  venenata  is  seen  more  frequently,  per- 
haps, on  the  wrists  and  forearms  than  on  other  parts  of 
the  body,  for  the  simple  reason  that  these  parts  of 
the  body  are  those  most  frequently  exposed  to  tin' 
irritating  influences  which  occasion  the  affection. 
Surgeons  and  obstetricians  are  frequent  sufferers  from 
a  mild  form  of  this  difficulty,  due  to  the  application 
to  their  hands  of  strong  disinfecting  solutions.  In 
this  case,  the  prompt  sequence  of  the  symptoms, 
namely  burning,  swelling  of  the  skin,  redness,  and 
occasionally  the  development  of  vesicles,  upon  the 
application  of  the  disinfectant  render  the  diagnosis 
easy  and  unmistakable.  Workers  in  brass  and 
copper,  those  whose  occupation  brings  them  into 
frequent  contact  with  aniline  dyes  and  other  chem- 
icals, and  operatives  engaged  in  handling  gummy  and 
adhesive  substances  which  have  to  be  removed  with 
st  long  soaps  or  with  special  chemicals,  present 
similar  lesions  which  are  grouped  by  the  dermatolo- 
gists under  this  same  head.  In  many  cases  the  skin 
of  the  hands  will  escape,  while  that  of  the  wrists  and 
forearms  is  more  susceptible  to  the  causal  irritant. 
In   all    cases   of   dermatitis  affecting   exclusively   or 


preponderatingly  the  wrists  and  forearms,  the 
occupation  of  the  patient  and  the  opportunities  for 
special  exposure  to  specific  irritants  should  carefully 
be  considered  in  the  diagnosis. 

Deep-seated  Inflammations  of  the  Skin. — The  in- 
flammatory diseases  we  have  so  far  reviewed  are 
classified  in  the  nosological  scheme  of  Jessner  as 
inflammations  of  the  corium  and  subcutis.  Of  the 
deep-seated  inflammations  which  constitute  the  next 
category,  there  is  an  affection  classed  by  some  as  a 
form  of  erythema  multiforme,  and  by  others  as  a 
distinct  disease,  known  as  erythema  nodosum  which 
while  it  does  not  often  locate  itself  on  the  arms,  might 
yet  prove  puzzling  to  one  unacquainted  with  its 
course  if  met,  as  occasionally  occurs,  exclusively  in 
that  locality.  Its  prodromal  symptoms  are  practic- 
ally identical  with  those  preceding  an  attack  of  ery- 
thema multiforme  (q.v.),  namely,  fever,  gastric  dis- 
turbances, and  pains  in  the  joints.  It  attacks  like- 
wise a  similar  class  of  patients,  young  people  in  a 
condition  of  depressed  vitality.  Its  lesions  are  an 
exaggeration  of  those  of  erythema  multiforme,  but 
its  customary  distribution  is  less  frequently  upon  the 
forearms.  One  of  its  alternate  names,  dermatitis 
contusiformis,  is  descriptive  of  the  appearance  of  its 
lesions.  The  eruption  appears  in  nodes  of  a  con- 
siderable elevation,  rounded  or  oval  in  shape,  varying 
in  size  from  that  of  a  nut  to  that  of  an  egg.  They 
are  warm  to  the  touch,  surrounded  by  an  edematous 
area,  painless,  but  tender  to  pressure.  Their  color 
is  at  first  a  rosy  red,  changing  to  a  darker  and  more 
livid  hue,  and  not  removable  by  pressure.  They 
never  coalesce  nor  suppurate.  In  the  course  of  eight 
or  ten  days  they  gradually  disappear,  going  through 
the  color  changes  that  are  seen  in  blood  extravasa- 
tions and  leaving  a  dark  discoloration  behind. 
Three  or  four  nodes  only  are  usually  present,  and  their 
number  rarely  exceeds  a  dozen.  Though  the  indi- 
vidual lesions  last  only  a  few  days,  a  succession  of 
fresh  ones  often  prolongs  the  malady  for  two  or  three 
weeks.     Recurrences  are  rare. 

Ordinary  contusions  may  be  mistaken  for  the  nodes 
of  erythema  nodosum,  but  they  never  have  the 
peculiar  rosy  color,  are  not  usually  multiple,  are  not 
round,  there  are  no  general  symptoms,  and  there  is 
the  history  of  an  injury.  Syphilitic  gummata  may 
resemble  them  closely,  but  the  antecedent  pains  are 
much  severer.  They  are  slower  in  their  course,  are 
very  rarely  seen  in  the  young,  and  are  almost  always 
accompanied  by  other  symptoms  of  lues,  past  or 
present.  The  prognosis  is  generally  good,  though 
complications  may  arise  which  may  make  the  prog- 
nosis more  serious. 

It  may  be  stated  as  a  general  proposition  that  there 
is  but  little  tendency  for  the  cutaneous  lesions  of 
syphilis  to  localize  themselves  upon  the  arms  and 
forearms.  Particularly  is  this  true  of  the  earlier 
macular  and  papular  eruptions,  which  have  as  a 
pathological  distinction  the  involvement  of  the 
superficial  anatomical  elements  of  the  skin  and  a 
generalized  distribution  all  over  the  body;  in  which 
distribution,  indeed,  the  arms  are  not  exempt.  An 
occasional  tendency  toward  characteristic  localization 
upon  the  arms  is  manifested  in  some  of  the  later 
syphilides,  whose  characteristics  are  an  involvemi 
of  the  deeper  cutaneous  structures  and  a  less  general 
and  less  symmetrical  distribution  over  the  body. 
Accordingly  we  see  in  some  of  the  pustular  syphilidea 
a  certain  very  limited  tendency  to  a  location  of  the 
lesions  on  the  arm,  or  what  is  more  frequent,  a  tend- 
ency to  aggravation  on  the  arms  of  a  pustular  erup- 
tion elsewhere  present  in  a  milder  degree.  Thus  an 
acneiform  or  impetiginous  syphilide  upon  the 
and  the  trunk  may  be  accompanied  with  an  ecthy- 
matous,  exulcerated  syphilide  of  the  arms.  It  is 
also  to  be  regarded  as  somewhat  characteristic  of 
syphilis  that  an  acneiform  eruption  should  make  its 
appearance  upon  the  arms  in  portions  so  ill  supplied 


546 


];i:ii:i;i.N('i:  handbook  of  tih:   mi.dk  \i.  si  if.jtceS 


Arm  and  Forearm, 
and  Injuries 


Diseases 

of 


With    BebaceOUS    glands    anil    hair    follicles    as    to    be 

ordinarily  exempt  from  the  manifestations  of  acne 
vulgaris. 

ill,,  occasional  development  on  an  arm  or  forearm 
of  the  later  tubercular  or  gummatous  syphilides  can 
hardly  he  regarded  as  more  than  an  accident  to  which 
any  part  of  the  skin  of  the  body  is  liable  in  this  protean 
disease,  and  withal  the  arms  and  forearms  seem 
rather  exempt  than  otherwise  from  any  considerable 
frequency  of  accidents  of  the  kind. 

Farcy. — There  is  one  disease  which  presents,  among 

its  other  lesions  a  form  of  deep-seated  inflammation 

of  the  skin,   whose  pathological  importance  is   very 

t   though  the  disease  itself  is  not  at  all  common. 

namely,  farcy,  a  name  given  to  the  lesions  of  (jlami.  rs 

when  they  affect  portions  of  the  body  other  than  the 

respiratory  organs.     The  gravity  of  the  disease,  with 

a   mortality   estimated   at    upwards   of   seventy-five 

per  cent.,   the   comparative   rarity   of   the  affection, 

making  it  unfamiliar  to  most  practitioners,  and  its 

tsional   appearance   on   the  arms  as  a   result   of 

infection  of  the  hands,  are  the  reasons  which  lead 

ine  to  include  in  this  article  a  description  which  it  is 

will  suffice  to  make  possible  its  recognition. 

The  course  of  farcy  or  glanders  includes  a  stage  of 
incubation,  varying  from  two  to  fifteen  days,  a 
premonitory  stasre,  consisting  of  ordinary  pyrexia, 
febrile  excitement,  etc.,  and  including  pain  affecting 
the  muscles,  simulating  rheumatism,  and  sooner  or 
later  a  <;a>_'e  of  eruption,  which  develops  the  specific 
characters  of  the  disease.  In  acute  cases  the  stage 
of  eruption  appears  almost  at  once,  or  soon  after  the 
invasion,  but  in  the  more  chronic  cases  there  may  be 
an  interval  of  weeks. 

The  most  prominent  of  the  local  symptoms  is  the 
glanders  eruption,  consisting  of  a  crop  of  pustules, 
remarkably  hard,  simulating  those  of  small-pox,  and 
attacking  the  skin  like  an  exanthem.  Virchow 
their  development  as  follows:  At  first  there 
appear  some  red  spots  which  are  very  small  and 
resemble  flea-bites,  these  soon  acquire  a  papular 
elevation,  subsequently  rising  above  the  level  of  the 
ice  like  small  shot,  assuming  a  yellow  color. 
These  shot-like  nodules  are  either  flat  or  round,  and 
they  do  not  lie  in  a  bladder-like  elevation  of  the 
epidermis,  but  in  a  kind  of  hole  in  the  corium,  as  is 
the  latter  had  been  punched  out;  they  are  not  always 
solitary,  but  are  often  disposed  in  groups.  There  if 
•  surrounding  injection,  and  under  the  epidermis 
there  is  found  a  puriform  and  yellow  fluid,  seemingly 
homogeneous,  which  is  formed  chiefly  from  softening 
of  the  nodule.  These  nodules  attack  in  a  similar 
manner  the  mucous  membrane  of  the  nose,  where 
they  are  .-mall  and  linseed-shaped,  and  give  rise  to 
the  peculiar  nasal  discharge.  Softening  of  these 
tubercles  next  ensues,  the  skin  gives  way  and  ulcera- 
tion follows,  and  thus  are  formed  small  holes  filled 
with  debris,  producing  the  pus  of  glanders  and  the 
farcy  abscesses. 

These  tubercles  mayr  be  developed  in  other  situa- 
tions, such  as  in  the  subcutaneous  cellular  tissue, 
producing  circumscribed,  hard  and  painful  boils,  or 
diffused  swellings  of  great  extent,  which  either 
open  spontaneously,  or  give  rise  to  extensive  sloughing 
of  the  skin  and  deeper  structures.  In  rarer  instances 
the  tubercles  subside  and  reappear  in  other  parts,  a 
form  of  the  disease  which  is  termed  "flying  farcy." 

npanying  the  eruption  are  found  small,  soft 
tumors  about  the  extremities,  forming  a  kind  of 
pyemic  abscesses,  generally  seated  in  the  muscle-. 
seldom  attacking  the  glands,  and,  when  subcutaneous, 
remarkably  defined,  like  an  egg. 

In  acute  farcy,  which  is  generally  induced  by  the 
inoculation  of  a  scratch  or  an  abrasion,  there  is  the 
superaddition  of  inflamed  absorbents  and  lymphatics, 
and  in  these  cases  we  have  diffuse  suppuration  of  the 
limb  and  suppurating  glands. 


In  chronic  farcy  the  wound  degenerates  into  a  fotd 
ulcer,  and  the  inflammation  and  suppuration  of  the 
lymphatics  is  slow  and  tedious.  This  form  often 
terminates  in  acute  glanders. 

Traumatic    .1  of   the  Skin. — It    should    be 

borne  in  mind  that  the  forearms  and  bands  are  the 
portion  of  the  anatomy  nio-t  accessible  to  ; 
neurotic  patients  who,  for  purposes  of  exciting 
sympathy  or  from  oilier  morbid  impulses,  indie 
their  own  person  various  lesions,  rarely  severe,  yet 
occasionally  difficult  of  diagnosis.  Such  lesions  are 
ordinarily  such  as  would  result  from  the  application 
of  irritant  or  vesicant  drugs,  or  such  lesions  as  would 
result  from  prolonged  mechanical  irritation  with 
the  finger  tips,  the  nails,  or  some  rough  or  sharp 
instrument. 

In  considering  the  traumatic  affections  of  the 
cutaneous  tissues  of  the  arm  and  forearm,  two  forms 
of  injury  present  themselves  as  of  special  frequency 
and  importance,  owing  to  the  exposure  of  the  upper 
extremity  to  all  manner  of  vicissitudes  incident  to 
active  life.  These  are  extensive  abrasions  and 
extensive  burns.  The  treatment  of  burns  and 
abrasions  of  the  upper  extremity  does  not  differ 
essentially  from  the  treatment  of  similar  conditions 
elsewhere,  only  on  the  forearm  an  extensive  burn 
may  do  more  damage  than  elsewhere  on  account  of 
the  subsequent  contraction  which  may  involve  the 
subcutaneous  tissues  and  compromise  more  or  less 
seriously  the  independent  action  of  the  muscles  which 
move  the  hands  and  fingers.  On  this  account  skin 
grafting  according  to  the  method  of  Thiersch  is 
indicated  for  a  burn  on  the  forearm  many  times  when 
a  burn  of  like  extent  and  equal  depth,  if  situated  else- 
where on  the  body-,  might  be  left  to  granulate  with 
impunity. 

As  stated  above,  it  has  been  my  aim  in  considering 
the  cutaneous  diseases  liable  to  affect  the  arm  and  fore- 
arm, to  present  such  a  picture  of  the  lesion  as  would 
suffice  for  its  identification.  Further  discussion  of 
the  pathology,  etiology,  prognosis,  and  treatment  of 
the  different  diseases  enumerated  must  be  sought  in 
other  parts  of  this  work,  or  in  treatises  more  espe- 
cially concerning  themselves  with  dermatology. 

II.  Affections  of  the  Fascia. 

The  affections  to  which  the  fascia?  and  cellular 
tissue  of  the  arm  and  forearm  are  liable  are  of  three 
general  types:  erysipelatous,  tuberculous,  and  syphil- 
itic. To  these  we  may  add  certain  rare  cases  of  con- 
traction of  the  fascia  antibrachialis,  more  or  less 
analogous  to  Dupuytren's  contraction  of  the  palmar 
fascia,  and  of  an  equally  uncertain  pathology. 

Streptococcic  Invasion  of  the  Fascia. — Erysipelas  is 
usually  described  as  an  affection  of  the  integument, 
and  the  process  is  undoubtedly  frequently  confined 
to  the  skin,  proceeding  with  its  characteristic  red 
blush  to  extend  in  the  direction  of  the  lymphatic 
current  until  the  energy  of  the  infecting  streptococcic 
colonies  is  exhausted,  and  the  disease  subsides  after  a 
definite  run  of  from  six  to  fourteen  days.  This  form 
of  simple  cutaneous  erysipelas  occurs  with  greatest 
frequency7  upon  the  face,  but  may  make  its  appearance 
anywhere  on  the  integument  where  streptococci  may 
find  an  entrance,  through  an  abrasion,  perhaps 
extremely  minute,  or  may  have  found  lodgment  in 
the  glands  or  follicles  of  the  unbroken  skin. 

Identical  with  cutaneous  erysipelas  in  etiology7,  but 
differentiated  from  it  in  course  and  syTmptoms,  is 
streptococcic  invasion  of  the  fascial  and  connective- 
tissue  planes  of  the  extremities  and  occasionally  of  the 
head  and  trunk.  On  account  of  the  difficulty  of 
access  to  the  subcutaneous  tissues  through  the  un- 
broken skin,  the  history  of  fascial  and  cellular  ery- 
sipelas will  generally  reveal  a  preexisting,  probably 
bad-behaving  wound  on  the  distal  side  of  the  focus  of 
the  phlegmonous  process.     The  liability  of  the  fingers 


547 


Ann  and  Forearm,  Diseases 
and  Injuries  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


and  hands  to  traumatisms  small  and  great,  and  the 
exposure  of  these  parts  to  subsequent  infection,  ex- 
plain the  great  frequency  with  which  fascial  phleg- 
mons are  met  with  on  the  arms  and  forearms,  par- 
ticularly of  mechanics. 

The  "differentiation  between  the  several  types  of 
fascial  infection  is  not  in  all  cases  easy  from  clinical 
symptoms  alone,  but  the  behavior  of  typical  cases  is 
sufficiently  characteristic  to  permit  a  probable  diagno- 
sis, to  which  a  bacteriological  examination  will  in 
most  cases  add  confirmation.  Although  mixed  infec- 
tions doubtless  often  occur,  other  more  strictly  pyo- 
genic, infections  rarely  confine  themselves  to  definite 
anatomical  layers  as  do  infections  by  streptococci.  The 
course  of  streptococcic  invasion  of  the  fascia  and  cellu- 
lar tissue  is  accompanied  by  an  amount  of  fever  in 
general  commensurate  with  the  extent  to  which  the 
lymphatic  channels  are  opened  up  for  the  absorption 
of  the  products  of  the  germ  life,  rather  than  com- 
mensurate with  the  mere  extent  of  territory  involved. 
The  temperature  reaction  in  cases  of  infection  of  the 
fascial  and  cellular  tissue  of  the  forearm  is  rarely 
very  great,  it  being  rare  to  witness  a  temperature 
higher  than  102°  to  102.5°  F.  when  the  trouble  is  con- 
fined to  the  fascia  and  connective  tissue  of  the  arm. 
In  marked  contrast  to  this  is  the  course  of  the  strep- 
tococcic invasion  of  the  pelvic  tissues,  where  the 
abundant  lymph  channels  allow  the  absorption  of 
enormous  quantities  of  toxins  and  even  pus.  A 
similar  difference  is  seen  in  erysipelatous  infection  of 
the  arm  and  forearm  when  along  with  the  infection  of 
the  fascia  and  cellular  connective  tissue  there  is  like- 
wise an  invasion  of  the  skin  itself,  phlegmonous 
erysipelas,  stricto  sensu,  where  the  general  vascularity 
of  the  tissue  allows  a  much  more  active  inflammatory 
reaction  to  the  microbial  invasion.  For  this  reason 
the  temperature  is  a  much  less  fallacious  guide  to  the 
gravity  of  the  condition  in  this  than  in  many  other 
surgical  diseases.  The  onset  of  the  disorder  is  usually 
marked  with  sensations  of  chilliness  if  not  with  posi- 
tive rigors,  and  a  general  malaise,  anorexia,  and  more 
or  less  gastric  disturbances  are  pretty  constant  ac- 
companiments of  at  least  the  early  course  of  any  ex- 
tensive affection  of  the  kind.  The  amount  of  pain  is 
very  variable,  and  is  for  the  most  part  decidedly  less 
than  one  would  expect  to  meet  in  a  staphylococcic  in- 
vasion of  equal  extent.  This  difference  is  due  largely 
to  the  different  anatomical  tissues  for  which  the  two 
kinds  of  germs  seem  to  have  an  affinity.  Staphylo- 
cocci tend  to  form  circumscribed  colonies  in  the  more 
vascular  structures,  often  beneath  tough  and  resis- 
tant connective-tissue  planes,  where  the  resultant  pus 
or  exudation  gives  rise  to  great  and  painful  pressure 
upon  the  sensitive  nerve  fibers.  Besides  which  it  is 
very  probable  that  the  toxins  produced  by  the  staphy- 
lococci, particularly  the  staphylococcus  aureus,  are 
themselves  peculiarly  irritating  to  sensitive  nerve 
tissue. 

The  streptococcus,  on  the  other  hand,  has  a  pre- 
dilection for  the  connective  tissues  and  for  the  fascial 
membranes  themselves,  invading  by  preference  their 
superficial  surface;  the  resultant  pus  is  not  bound 
down  beneath  the  tough  and  resistant  membranes, 
and  does  not  cause  so  much  pain  from  pressure  under 
confinement,  and  it  is  perhaps  probable  that  the 
specific  toxins  of  the  streptococcus  are  somewhat  less 
highly  irritating  to  the  sensitive  nerves.  The  hu- 
man system,  furthermore,  seems  to  combat  the 
streptococcus  by  a  more  ready  manufacture  of  an- 
titoxin than  it  does  in  its  efforts  to  overcome  the 
staphylococcus,  and  thus  to  establish  a  temporary 
partial  immunity  to  the  attack  of  the  streptococcus. 
This  will  account  for  the  tendency  that  is  sometimes 
manifested  in  streptococcic  processes  to  linger  on  in  a 
mitigated  yet  protracted  manner,  continuing  to 
vegetate  in  the  tissues  in  an  obstinate  yet  less  virulent 
form  than  at  the  outset  of  the  attack.  Thisis  partic- 
ularly prone  to  be  the  case  in  cases  of  extensive  in- 


volvement of  tissues  of  low  vascularity.  The  vitality 
of  the  germs  permits  their  continuous  growth  in  tissues 
of  feeble  resisting-powers,  while  the  system,  through 
the  accumulated  stores  of  antitoxin,  can  so  far  neutral- 
ize the  toxic  products  of  the  bacterial  growth  that 
the  materials  absorbed  do  not  poison  the  body,  as  is 
shown  by  the  diminished  fever  and  the  general  sub- 
sidence of  general  constitutional  symptoms,  in  spite 
of  the  lingering  of  the  local  process  in  the  fascial 
layers.  Thus  arises  a  prolonged,  quasi-chronic 
form  of  the  trouble,  which  is  particularly  likely  to 
supervene  when  the  fascial  planes  of  the  extremities 
are  invaded.  The  streptococcic  invasion  of  the  fascial 
planes  of  the  arm  and  forearm  is  generally  first  along 
the  deep  fascia,  with  or  without  concomitant  involve- 
ment of  the  superficial  fascia  and  the  skin.  Only 
when  the  process  has  been  for  some  time  under  way 
do  the  muscular  septa  become  involved,  and  then  a 
most  formidable  condition  known  as  a  deep  dissecting 
phlegmon  results. 

The  systemic  effects  have  already  been  mentioned 
above.  The  local  symptoms  are  characteristic  in 
typical  cases,  and  allow  a  ready  diagnosis.  At  a 
point,  it  may  be  bordering  on  a  wound,  but  more  fre- 
quently at  a  greater  or  less  distance  to  the  proximal 
side  of  it,  the  skin  will  be  seen  to  have  a  somewhat 
livid  hue,  and  will  appear  somewhat  edematous;  yet 
there  will  be  lacking  the  dense  infiltration  of  all  the 
tissue  layers  which  characterizes  a  general  cellulitis 
depending  upon  infection  with  the  staphylococcus. 
Then,  too,  the  classical  signs  of  inflammatory  action 
will  be  less  marked,  unless  the  skin  and  superficial 
fascia  are  also  involved — i.e.  there  will  be,  as  coin- 
pared  with  the  staphylococcic  infection,  less  redness, 
less  swelling,  less  heat,  and  less  pain.  The  original 
wound  may  or  may  not  appear  to  be  involved  in  the 
infection,  or  if  the  wound  is  itself  the  seat  of  suppura- 
tion, the  channel  of  communication  between  the 
original  wound  and  the  seat  of  the  secondary  suppura- 
tive process  may  be  difficult  to  trace. 

The  limit  of  the  involved  area  is  very  indistinct,  as, 
owing  to  the  want  of  vascularity  of  the  affected 
tissues,  there  is  no  marked  inflammatory  induration 
acting  as  a  wall  of  circumvallation  about  the  focus 
of  infection.  To  the  examining  finger,  the  sensation 
imparted  on  palpation  is  rather  that  of  a  layer  of  fluid 
separating  the  tissues,  than  that  of  a  localized  abscess 
with  indurated  borders  and  softening  center. 

When  the  skin  and  superficial  fascia  are  also  in- 
volved, which  is  the  exception  rather  than  the  rule, 
the  implication  of  these  more  vascular  structures  in 
the  morbid  process  will  lend  the  appearance  of  a 
more  acutely  inflammatory  type  to  the  disease.  The 
redness  will  be  that  of  the  angry  blush  of  cutaneous 
erysipelas.  The  inflammatory  exudation  into  the 
interstices  of  the  skin  will  afford  a  more  marked 
swelling,  and  a  brawny  feel  to  the  tissues  on  palpa- 
tion. The  epidermis  may  be  lifted  in  more  or  less 
extensive  vesicles  or  blebs,  whose  original  serous  con- 
tents may  become  sanguinolent,  and  the  delimitation 
of  the  focus  of  infection  may  be  more  distinct,  the 
deep  fascia  being  rarely  involved  in  these  cases  much 
beyond  the  cutaneous  blush. 

The  disease,  if  untreated  or  if  refractory  to  treat- 
ment, though  it  tends  to  recovery  through  exhaustion 
of  the  virulence  of  the  infecting  germ,  yet  is  likely  to 
be  extremely  destructive  to  the  tissues  which  it  at- 
tacks; and  if  the  accumulating  pus  is  not  freely  evac- 
uated, the  process,  although  residing  by  preference 
in  the  layers  of  connective  tissue  first  attacked,  yet 
can  easily  transgress  these  limits  and  by  the  erosive 
and  solvent  action  of  the  pus,  or  by  the  progressive 
outgrowth  of  the  streptococci,  involve  contiguous 
structures  to  an  extent  that  may  be  dangerous  to  life 
through  secondary  hemorrhage,  due  to  erosion  of  an 
artery,  or  from  pyemia,  due  to  septic  thrombosis  in 
the  veins  followed  by  "yellow  softening"  of  the  clot 
and  embolism. 


548 


REFERENCE    IIAXDROOK   OF   THE    MEDICAL   SCI]  Ml  S 


Ann  ami  Forearm,  Diseases 
ami  Injuries  <>f 


The  prognosis,   in   the  forms  affecting  the  fascia 
alone  is  good,  if  opportunity  is  given  for  a  free  hand 
in  the  surgical  treatment  of  the  case,  ami  the  patient 
has  a  certain  strength  of  constitution  behind  him. 
In  the  form   mine  strictly  known  as  phlegmonous 
erysipelas    -i.e.  the  form  complicated  by  the  involve- 
ment of  the  skin  and  superficial  fascia  as  well     the 
ignosis  is  grave  if  any  considerable  portion  of  the 
limit  is  involved.      In  that  form  of  the  disease  in  which 
the  deeper  eonneet  ive-t  issue  planes  are  involved — i.e. 
the  intramuscular  sepia  and  the  perimysium — while 
the  prognosis  as  to  life  is  fair,  the  prognosis  as  to 
restoration  of  the  limb,  or  even  as  to  life  without 
ificing  the  limb,  is  uncertain. 
The  diagnosis  of  typical  cases  is  not  difficult,  the 
non-involvement  of  the  adjoining  structures  being 
more  or  less   readily   appreciable   ami   characteristic. 
ipelatous  infection  of  the  fascia  is  to  be  differ- 
iicd     from     the     general     inflammatory     edema 
ounding  a  focus  of  deep-seated  suppuration,  from 
malignant    edema,    and    from    the    tuberculous   and 
syphilitic    forms    of    connective-tissue    disease.      The 
ol      differentiation     from     deep-seated     and 
destructive  abscess  of  staphylococcic  origin  have  been 
ribed  above.     They  are  non-involvement  of  the 
,  or  its  involvement  under  a  strictly  erysipelatous 
type  of  inflammation  with  the  characteristic  blush; 
01 1 1 ci i  ion  of  blebs  and  superficial  infiltration  and 
thickening  of  the  skin  itself,  quite  different  from  the 
brawniness    accompanying    the    infiltration    of    the 
ler    la  vers,    which    is    characteristic    of    a    deep 
ess.     Furthermore,  there  is  wanting  in  this  form 
■  lamination  the  delimiting  wall  of  inflammatory 
exudate    which    marks   ordinary   abscess   formation, 
no  distinct  line  of  demarcation  separates   the 
ted  from  the  healthy  tissue. 
From  malignant  edema  an  erysipelatous  infection 
of  the  fascial  planes  is  likewise  to  be  differentiated  by 
the  less  malignant  and  acute  character  of  the  disease; 
by  the  absence  of  the  extreme  fetor  accompanying 
lesion,  and  by  its  tendency  to  confine  itself  to 
kind  or  to  one  layer  of  tissue.     Malignant  edema 
is  a  rare  disease  in  man,  and,  according  to  Park,  is 
ntially  a  specific  form  of  gangrene.    The  infected 
moreover,  frequently  contains  gas. 
From   the   tuberculous   form   of    the   disease,    the 
erysipelatous  form  is  to  be  distinguished  by-  its  rather 
prompt  following  upon  a  wound  on  the  distal  side  of 
the   phlegmon   (two  to  twelve  days'),   by  its  rather 
rapid  rise  to  an  acme  (four  to  six  days),  by  distinct 
evidences   of    sepsis   rather    than    cachexia,    by    the 
character  of  the  evacuated  discharge  (more  distinctly 
purulent  and  often  containing  more  or  less  extensive 
sloughs),  and  by  the  pain  and  heat,  which  are  much 
mure  distinct  than  in  the  cold  abscess. 

From  syphilis  of  the  fascia,  an  erysipelatous  process 
can  be  distinguished  by  the  absence  of  the  gummatous 
infiltration,  by  the  fever  and  pain,  by  the  sudden 
onset  often  consecutive  to  a  lesion  on  the  distal  side  of 
the  phlegmon,  and  by  the  absence  of  other  manifesta- 
tions of  syphilis.  It  must,  however,  be  borne  in 
mind  that  a  syphilitic  subject  may.  quite  as  readily 
as  any  other,  become  the  subject  likewise  of  a  non- 
syphilitic  infection  of  the  fascia. 

The  treatment  of  erysipelatous  disease  of  the  fascia 
consists  in  giving  the  freest  possible  vent  to  the  pus,  in 
vigorous  local  antisepsis,  and  in  stimulating  and 
supporting  the  general  system.  Further  means  to 
ider  in  combating  this  formidable  malady  are  the 
cautious  use  of  either  active  hyperemia  (induced  by 
the  local  hot-air  bath)  or  passive  hyperemia  (induced 
by  a  constricting  bandage  on  the  proximal  side  of  the 
lesion),  the  introduction  into  the  circulation  of  certain 
general  antiseptics  such  as  soluble  silver  or  some 
formaldehyde  derivatives,  the  use  of  specific  antitoxic 
sera,  and  the  use  of  specific,  autogenous  bacterial 
vaccines. 

As  long  as  the  disease  is  confined  to  the  deep  fascia, 


we    may    expect     by    free    incision    and    by    the    local 

application    of   antiseptics    to   arresl    the    infectious 

process.  Incisions  to  this  end  should  be  made 
subject    to    these    rules:    They    should    be    parallel    lo 

the  long  axis  of  the  limb;  they  should  penetrate  down 

lo,  but   not    beyond,  the  deep  fascia;  and  they  should 

be  numerous  enough  and  long  enough  to  give  ' 
access   to   all   demonstrably   affected    tissue.     With 
these  rules  in  mind  the  surgeon  -in  mid  and  may  Inci  e 

the  tissues  freely  and  extensively,  and  may  do  so 
without  great  danger  either  of  provoking  extensive 
hemorrhage  or  of  exposing  the  patient  to  sloughing  of 
t  he  -kin,  or  to  n lore  extensive  gangrene  of  the  extrem- 
ities, as  the  main  blood-vessels  run  beneath  the  deep 

fascia,  and  the  cutaneous  branches  are  fully  as  likely 
to  have  been  already  obliterated  by  the  -optic  process 
as  they  are  to  be  divided  by  the  knife.  It  is  well  to 
avoid  the  large  superficial  venous  trunks  of  the 
forearm,  and  particular  pains  should  be  taken  to 
avoid  the  mediana  profunda  vein  at  the  angle  of 
divergence  of  the  median  basilic  and  median  cephalic 
veins,  as  this  is  the  main  communicating  branch 
between  the  deep  and  superficial  sets  of  blood-vessels, 
and  by  extension  along  this  vein  a  thrombus  might 
communicate  the  septic  process  to  the  deeper 
tissues. 

After  free  incisions  have  been  made,  there  comes 
up  the  question  of  whether  or  not  it  is  best  to  use  the 
curette.  This  is  generally  to  be  answered  pretty 
decidedly  in  the  negative.  The  introduction  of  the 
curette,  even  of  the  rinsing  curette,  into  the  crevices 
between  the  deep  fascia  and  the  skin,  where  the 
infectious  process  is  mainly  located,  can  hardly  serve 
to  dislodge  septic  material  spread  over  a  large  area 
to  any  such  degree  of  thoroughness  as  will  compensate 
for  the  disadvantages  attending  the  mechanical  lifting 
of  one  anatomical  layer  off  the  other,  for  by  means  of 
this  disturbance  of  the  anatomical  layers  the  infecting 
germs  are  given  more  ready  access  to  still  uninvaded 
regions.  The  case  is  quite  different  from  that  of  a 
circumscribed  abscess,  where  over  a  region  of  com- 
paratively small  area  necrotic  tissue  needs  to  be 
removed  to  a  considerable  depth.  In  fascial  ery- 
sipelas a  large  area  is  affected  to  only  a  moderate 
depth;  and  weighing  the  results  of  the  unavoidable 
trauma  inflicted  by  the  instrument,  on  the  one  hand, 
with  the  proportionate  gain  in  the  removal  of  septic 
material  on  the  other  hand,  the  balance  will  in  most 
cases  be  against  the  use  of  the  curette  in  septic 
fascial  disease. 

Less  damage  is  likely  to  ensue  from  the  careful  use 
of  the  probe  in  exploring  the  extent  to  which  the  puru- 
lent process  may  have  undermined  the  skin;  in  fact,  a 
careful  exploration  of  this  kind  is  indispensable  to 
guide  the  surgeon  in  making  his  incisions.  It  is 
particularly  necessary  to  make  at  least  one  incision  at 
the  proximal  border  of  the  suppurating  area,  so  as  to 
permit  thorough  flushing  of  the  infected  tract  and  to> 
establish  through-and-fhrough  drainage,  and  the 
upper  limits  of  the  suppuration  can  most  conveniently 
be  determined  by  the  use  of  the  probe. 

When  once  the  limits  of  the  disease  have  been 
determined  and  the  necessary  incisions  have  been 
made,  a  thorough  flushing  of  the  diseased  area  with 
antiseptic  solutions  should  follow.  To  this  end  con- 
siderable hydrostatic  pressure  should  be  employed, 
and  every  effort  should  be  made  to  force  the  fluid 
injected  at  one  incision  to  escape  at  another.  If  this 
does  not  readily  follow  on  introducing  the  tip  of  the 
irrigating-tube  at  one  orifice,  it  is  quite  in  order  to> 
make  a  passage  for  the  fluid  by  subcutaneous  dissec- 
tion if  necessary,  either  by  dividing  the  obstructing 
tissue  bands  with  the  knife,  or  by  forcing  the  tip  of  the 
glass  irrigating-tube  under  the  skin  until  the  flow  is 
established  from  one  incision  to  another.  A  solution 
of  mercuric  chloride,  1  to  1,000,  is  frequently  used  for 
this  purpose,  and  should  be  passed  through  the 
wounds  in  large  quantities.      Stronger  solutions  of  this 


549 


Arm  and  Forearm,  Diseases 
and  Injuries  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


same  salt  may  be  used;  but  if  they  are,  a  second 
flushing  with  plain  water  should  follow  on  account  of 
the  poisonous  qualities  of  the  salt. 

Aside  from  its  value  as  an  antiseptic,  certain 
mechanical  advantages  attend  the  use  of  hydrogen 
peroxide  in  septic  infection  of  the  fascial  planes — 
namely,  the  liberated  gas  lifts  apart  the  layers  of 
tissue  and  opens  up  the  diseased  territory  to  the 
further  action  of  the  antiseptic,  yet  lifts  the  superficial 
layer  very  gently  and  evenly  without  carrying  septic 
material  into  uninvaded  areas.  Furthermore,  the 
development  of  the  oxygen  gas  can  be  felt  through 
the  integument,  and  the  bubbling  of  the  gas  may  be 
sufficiently  appreciable  to  the  touch  of  the  surgeon 
to  act  as  an  indicator  of  the  presence  of  suppurating 
tracts,  perhaps  unsuspected  from  investigation  with 
the  probe  alone. 

After  free  multiple  incisions  and  thorough  flushing, 
seton  drains  should  be  inserted,  passing  subcutane- 
ously  from  one  incision  to  another;  this  is  a  far  more 
useful  form  of  drainage  than  the  mere  packing  of  the 
wound  with  gauze.  In  fact,  distention  of  the  pockets 
is  to  be  avoided  on  account  of  the  undesirable  tension 
on  the  margins  of  the  affected  area  where  the  process 
is  likely  to  extend.  It  is  essential  to  the  usefulness  of 
the  seton  that  the  incision  through  which  it  enters 
and  that  through  which  it  emerges  should  be  suffi- 
ciently ample  so  that  the  lips  of  the  wound  shall  not 
hug  tightly  the  material  of  which  the  seton  is  composed, 
otherwise  the  object  both  of  the  seton  and  of  the  in- 
cision is  nullified.  The  object  of  the  seton  is  strictly 
that  of  a  wick,  and  this  function  is  much  better 
fulfilled  by  a  slender  seton,  easily  movable  to  and  fro 
in  its  bed,  than  by  a  large  mass  of  material  which 
chokes  the  orifices  of  entrance  and  of  exit  and  dis- 
tends the  cavity  which  it  meant  to  drain.  The  best 
material  for  a  seton  is  sterilized  absorbent  lamp- 
wicking,  or  perhaps  iodoform  lamp-wicking.  A 
good  substitute  for  this  is  a  ribbon  of  plain  or  iodo- 
form gauze,  from  one-half  to  one  and  a  half  inches 
wide,  folded  once  or  twice  on  itself.  Either  the  seton 
should  be  threaded  through  the  eye  of  a  seton  probe, 
or  through  the  eye  of  the  probe  should  be  threaded  a 
ligature  of  heavy  silk  and  this  loop  be  used  as  the 
carrier  for  the  bulkier  seton. 

After  the  incisions  are  made  and  the  wound  is 
flushed  out,  and  the  setons  are  drawn  through,  the 
question  of  dressings  comes  up. 

Just  here  it  is  necessary  to  suggest  caution  in  the  in- 
discriminate application  of  wet  dressings.  The  ad- 
vantages in  the  use  of  wet  dressings  lie  in  the  greater 
absorptive  powers  of  the  wet  dressing  by  which  the 
discharges  are  more  readily  withdrawn  from  the 
neighborhood  of  the  wounds,  and  in  the  more  efficient 
action  of  the  antiseptics  with  which  the  dressings 
may  be  permeated. 

The  dangers  from  wet  dressings,  however,  are  also 
twofold.  First,  they  provoke  a  certain  amount  of 
maceration  of  the  skin,  by  which  erysipelatous 
dermatitis,  an  ever-threatening  complication,  is  in- 
vited. Secondly,  the  relaxation  and  softening  of  the 
tissues,  which  is  advantageous  in  relieving  the  stasis 
in  the  capillaries  where  more  vascular  structures  are 
involved,  may  prove  equally  effective  in  furthering  the 
spread  of  the  streptococci  along  the  planes  of  soft  and 
comparatively  non-vascular  tissue  which  are  involved 
in  fascial  phlegmons,  allowing  the  process  to  extend 
in  tracts  which  might  otherwise  be  less  vulnerable  to 
their  attack. 

In  view  of  these  two  objections,  I  am  convinced 
that  wet  dressings  must  be  used  with  considerable 
caution  in  phlegmons  whose  principal  seat  is  between 
the  deep  fascia  and  the  skin,  to  avoid  encouraging  the 
extension  rather  than  the  arrest  of  the  disease.  The 
more  free  and  complete  the  drainage,  however,  the 
less  these  objections  hold,  and  where  the  incisions  are 
ample  and  numerous,  the  obvious  advantages  of  the 
wet    dressings    may   more   than   counterbalance   the 

550 


objections   to    them,    to   which   attention   has  been 
called  by  way  of  caution. 

In  any  case  the  need  of  frequent  renewal  of  the  dress- 
ings is  imperative.  When  it  is  impossible,  through 
too  great  fatigue  and  pain  to  the  patient,  to  redress 
the  wound  sufficiently  often  to  make  headway  against 
the  persistent  suppuration,  with  the  proviso  that  the 
incisions  shall  be  sufficient  in  number  and  in  extent, 
the  constant  drip  or  the  constant  bath  may  advan- 
tageously be  substituted  for  the  wet  dressing.  Inas- 
much, however,  as  the  disease  we  are  now  considering 
affects  principally  non- vascular  tissues,  the  great  bene- 
fits which  follow  this  form  of  treatment  when  another 
class  of  tissues  is  involved,  are  not  so  conspicuous  in 
cases  of  purely  fascial  disease.  In  cases  complicated 
by  cutaneous  erysipelas,  the  constant  bath,  however, 
will  be  found  of  great  value. 

At  subsequent  dressings,  after  abundant  provision 
has  been  made  for  the  speedy  discharge  of  pus,  great 
advantage  will  be  found  in  saturating  the  wicks 
which  are  drawn  beneath  the  skin  from  incision  to 
incision  with  Peruvian  balsam,  ichthyol,  or  some 
other  tissue  stimulant,  and  this  use  of  stimulant 
dressings  within  the  wound  cavities  will  be  found  use- 
ful as  long  as  these  remain  open. 

In  the  later  stages  of  the  disease  when  the  active 
spread  of  the  suppuration  seems  to  have  been  arrested, 
much  may  be  done  to  hasten  the  obliteration  of  the 
pockets  beneath  the  skin  and  fascia  by  the  skilful  dis- 
position of  compresses  so  as  to  cause  a  mechanical 
closure  of  the  portions  of  undermined  tissue  which  are 
farthest  removed  from  the  track  of  the  setons. 
Similarly  when,  in  the  process  of  healing,  the  under- 
mined tissues  have  become  once  more  agglutinated, 
with  the  exception  of  the  tracks  of  the  different  setons, 
each  seton  track  should  be  mechanically  cut  in  half 
by  the  pressure  of  a  compress,  and  be  kept  open  only 
in  that  part  which  is  near  the  incision.  For  this 
mechanical  obliteration  of  parts  of  the  undermined 
territory,  tolerably  firm  bandaging  of  the  limb  is 
necessary. 

The  constitutional  treatment  of  erysipelatous 
disease  of  the  fascia  is  simply  that  of  the  sepsis  which 
always  accompanies  it,  and  consists  in  pushing  nutri- 
tion, and  stimulating  the  circulation,  and  maintaining 
the  activity  of  the  emunctories. 

We  spoke  above  of  the  use  of  Bier's  "hyperemia" 
in  the  treatment  of  phlegmonous  erysipelas  of  the  arm. 
The  technique  of  "hyperemic  treatment"  must,  how- 
ever, be  fully  understood  before  it  is  safe  to  apply 
this  means  to  the  treatment  of  the  "type  of  difficulty 
we  are  now  considering.  For  those  who  are  less 
experienced  in  its  application  it  is  likely  that  "active 
hyperemia,"  induced  by  the  local  hot-air  bath  would 
present  the  safer  proceeding.  Those,  on  the  other 
hand,  who  have  had  a  certain  experience  in  the  use  of 
the  constricting  bandage  in  the  treatment  of  inflam- 
matory troubles  in  the  extremities  may  find  at  lea-t 
two  special  advantages  in  this  form  of  treatment; 
first,  the  constricting  bandage  will  act  in  a  way  anal- 
ogous to  its  action  in  snake-bite,  in  that  it  will,  for 
a  while  withhold  from  the  general  circulation  con- 
siderable stores  of  virulent  toxins,  thus,  for  such  time 
as  the  bandage  is  in  place,  protecting  the  heart  and 
the  nerve  centers  from  their  deleterious  influence  and, 
it  is  claimed,  modifying  and  mollifying  these  toxins 
while  locked  up  in  the  arm  distal  to  the  bandage  so 
that  they  are  rendered  less  pernicious  when  allowed 
to  flow  back  into  the  general  blood-mass,  such  periods 
of  mechanical  protection  of  the  heart  and  nerve  cen- 
ters being  marked  by  a  distinct  remission  in  the  fever; 
econdly,  in  a  process  tending  as  distinctly  as  does 
this  to  extensive  sloughing  and  gangrene,  the  use  of 
"obstructive  hyperemia"  (Stauungshyperilmie)  it  is 
claimed  will  decidedly  promote  the  nutrition  of  the 
threatened  parts,  enabling  them  to  withstand  a 
decree  of  inflammation  which,  without  this  protective 
means,  might  lead  to  extensive  local  necrosis.     For 


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Arm  and  Forearm,  Diseases 
and  Injuries  of 


details  of  the  technic  demanded  the  article  dealing 
with  the  subject  of  hyperemic  treatment  in  general 
should  be  consulted. 

Since  the  demonstration  of  the  presence  of  formal- 
dehyde or  of  its  derivatives  in  most  of  the  body 
Quids  after  the  administration  by  the  mouth  of 
bexamethylentetramin,  the  use  of  this  drug  has  been 
suggested  in  the  treatment  of  septic  conditions  such 
as  attend  a  phlegmonous  erysipelas.  French  surgeons 
lay  considerable  stress  on  the  advantages  of  intro- 
ducing by  hypodermic;  injection  considerable  quan- 
tities of  solutions,  or  suspensions  of  the  colloid 
metals,  particularly  colloid  silver,  into  the  circulation. 
I  he  condition  we  are  considering  would  seem  an 
appropriate  one  for  this  form  of  treatment. 

Antistreptococcus  serum  has  not  given  the  constant 
results  which  it  was  hoped  that  it  would  in  combating 
ptococcal  diseases.  This  is  probably  due  to  the 
immense  variety  in  the  attributes  of  the  different 
"strains"  of  streptococci  derived  from  different 
sources.  If  positive  results  are  to  be  expected  from 
the  use  of  a  streptococcus  antitoxin  this,  it  appears, 
must  be  a  highly  "polyvalent"  antitoxin,  derived 
from  as  large  a  number  of  different  virulent  sources 
as  possible,  in  the  hope  that  at  least  some  of  these 
sources  may  have  characteristics  nearly  parallel  to 
those  of  the  particular  "strain"  of  streptococcus 
which  we  are  combating.  The  uncertainty  of  such  a 
coincidence  has  caused  the  antitoxic  sera  to  become 
less  depended  on  than  streptococcus  vaccines  in 
combating  erysipelatous  processes. 

While  for  many  bacterial  diseases  the  use  of 
"stock  vaccines"  gives  generally  satisfactory  results, 
the  very  reasons  which  make  for  the  unreliability  of 
antistreptococcus  serum  make  it  imperative  that  in 
streptococcus  processes  an  "autogenous  vaccine" 
should  be  used.  In  the  intelligent  use  of  autogenous 
vaccinal  injections  we  have  a  potent  weapon  in 
combating  phlegmonous  erysipelas. 

Tuberculosis  of  the  Fascia. — Primary  tubercu- 
losis of  the  fascia  is  a  somewhat  rare  disease,  and  is 
prone  to  show  itself,  as  do  tuberculous  joint  lesions, 
much  more  frequently  on  the  lower  extremities  than 
on  the  upper.  Given,  however,  a  tuberculous  joint 
lesion  in  the  upper  extremity,  secondary  involvement 
of  the  fascia  is  probably  as  frequent  at  one  seat  as  at 
the  other.  Fascial  tuberculosis  differentiates  itself 
from  fascial  disease  of  other  kinds  by  all  the  charac- 
teristic signs  of  tuberculosis.  The  onset  of  primary 
fascial  tuberculosis  is  generally  comparatively  painless 
in  the  absence  of  secondary  infections,  and  it  is 
rarely  possible  to  trace  its  direct  connection  with  a 
coexistent  wound,  for  the  reason  that  the  development 
of  the  tubercle  germ  is  so  slow  that  the  wound  of 
ingress  may  long  have  healed  and  have  been  forgotten 
before  any  tuberculous  process  manifests  itself.  On 
the  other  hand,  secondary  involvement  of  the  fascia, 
where  tuberculous  joint  trouble  is  present,  is  generally 
of  easy  demonstration. 

Though  streptococcic  infection  of  the  fascia  may 
relapse  into  a  chronic  form,  it  does  not  begin  insid- 
iously as  does  a  tuberculous  process,  and  though 
in  the  latter  stages  of  a  tuberculous  fascial  phlegmon 
when  secondary  infection  has  occurred,  so  much  of  a 
distinctly  pyogenic  type  may  have  been  stamped  upon 
the  process  as  to  render  difficult  a  diagnosis  from  the 
signs  present,  yet  an  accurate  history  of  chronic, 
almost  latent  disease,  present  for  a  considerable 
number  of  days  or  weeks  before  the  onset  of  acute 
symptoms,  is  entirely  inconsistent  with  what  we 
know  of  the  behavior  of  the  streptococci,  and  is 
almost  pathognomonic  of  tuberculous  infection.  In 
the  absence  of  an  ingrafted  secondary  infection,  the 
febrile  reaction  to  tuberculous  disease  of  the  fascia  is 
slight,  and  when  the  local  process  is  not  extensive  the 
general  constitutional  reaction  may  be  almost  nil. 
The  tendency  to  involve  adjoining  structures  is  not 
marked,  the  skin  proving  resistant  for  a  long  period 


to  perioral  inn ;   on    the   other   hand,    the    tendency    to 

metastatic  involvement  at  a  distance  is  one  of  the 
most  considerable  perils  attaching  to  the  malady. 

The  slight  tendency  of  primary  fascial  tuberculo  is 
to  involve  adjacent  structures  may  be  due  to  the  slow 
growth  of  the  tubercle  bacillus  giving  an  opportunity 
to  the  surrounding  tissues  to  fortify  themselves  by  a 
defensive  leucocytic  infiltration  against  the  advance 
of  the  germ  into  more  vascular,  and  consequently 
more  resisting,  fields.  In  this  comparative  vulner- 
ability of  the  fascia,  and  comparative  invulnerability 
of  the  surrounding  tissues  lie  at  once  the  safeguard 
and  the  danger  of  this  form  of  tuberculosis.  So  long 
as  skin,  joints,  and  tendon  sheaths  are  not  involved, 
the  subjective  symptoms  and  the  impairment  of 
function  are  so  inconsiderable  that  the  process  may 
remain  unrecognized,  and  radical  measures  for  its 
extirpation  may  be  postponed  until  great  destruction 
of  tissue  has  taken  place  beneath  the  integument,  or 
until  with  the  final  involvement  of  the  skin  in  the 
tuberculous  process  a  mixed  infection  has  become 
imminent,  or  has  actually  taken  place.  On  the  other 
hand,  when  attacked  at  an  early  stage  the  restriction 
of  the  disease  to  one  tissue  favors  greatly  the  chances 
of  its  complete  eradication  by  appropriate  measures. 

The  disease  at  first  is  confined  to  the  surface  of  the 
fascia.  There  may  be  a  small  area  affected,  or  it 
may  be  quite  extensive.  There  is  a  layrer  of  tubercu- 
lous granulation  tissue  which  can  be  readily  scraped 
off,  leaving  the  protecting  wall  of  inflammatory 
tissue  which  nature  always  throws  round  a  tubercu- 
lous abscess.  With  the  occurrence  of  secondary 
pyogenic  infection,  or  with  a  primary  seat  in,  or  a 
later  involvement  of,  the  deeper  intermuscular  septa, 
the  prognosis,  which  is  otherwise  pretty  good,  be- 
comes very  much  more  grave  both  as  to  restoration  of 
the  function  in  the  limb  and  as  to  life  itself. 

This  knowledge  of  the  prospect  ahead  at  once 
gives  us  the  key  to  the  proper  treatment.  The  non- 
vascular nature  of  the  tissue  involved  in  fascial  tuber- 
culosis diminishes  very  greatly  the  chances  of  a  sponta- 
neous subsidence  of  the  disease  through  the  process  of 
encapsulation  and  calcareous  infiltration  of  the  tuber- 
cles. Mechanical  ablation  of  the  affected  tissue  is  the 
only  hope  of  safety.  Here,  too,  our  knowledge  of  the 
natural  history  of  the  infecting  agent  will  influence  the 
technique  of  the  operation.  Whereas  in  cases  of  strep- 
tococcic invasion  of  the  fascia  it  was  advised  to  keep 
instruments  out  of  the  focus  of  infection,  and  to  depend 
upon  copious  flushing  with  antiseptics  and  linear  in- 
cisions with  multiple  drains,  here  the  form  of  incision 
should  be  so  varied  as  to  allow  the  raising  of  large 
flaps  whose  under  surface,  as  well  as  the  beds  upon 
which  they  rest,  should  be  thoroughly  scraped  with  the 
sharp  spoon,  or  shorn  with  the  edge  of  the  knife,  or 
better  clipped  with  scissors  curved  on  the  flat.  Sinu- 
ses involving  the  skin  should  receive  still  more  radical 
treatment;  they  should,  if  possible,  be  resected 
through  their  whole  extent. 

It  may  be  well  to  point  out  that  V-shaped  flaps 
should  be  so  cut  as  to  have  their  apices  away  from 
the  trunk  in  order  to  secure  their  sufficient  blood- 
supply  and  to  avoid  sloughing. 

When  secondary  infection  has  not  taken  place,  or 
does  not  seem  to  be  virulent  in  character,  drainage 
should  be  dispensed  with  as  far  as  possible,  as  it  is 
more  than  doubtful  whether  tubercle  germs  can  be 
discharged  from  the  system  by  mechanical  drainage. 
If,  on  account  of  secondary  pyogenic  infection,  it  be 
considered  necessary  to  make  use  of  gauze  drains, 
they  should  be  few  in  number,  should  not  be  used  to 
stuff  the  cavities,  and  above  all  should  be  peremp- 
torily withdrawn  at  the  earliest  possible  moment. 
The  use  of  a  moderately  tight  bandage  by  mechanic- 
ally closing  all  "dead  spaces"  will  in  a  large  measure 
obviate  the  necessity  for  the  use  of  drains,  whose 
sole  function  it  is  to  prevent  the  accumulation  of 
wound  secretions,  but  whose  unfortunate  attribute 


551 


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and  Injuries  of 


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it  is,  in  many  cases,  by  the  irritation  they  cause  as 
foreign  bodies,  to  excite  secretion  from  the  tissues  with 
which  they  lie  in  contact.  A  condition  which  would 
seem  to  demand  a  longer  continuance  of  the  drain,  in 
reality  indicates  still  more  strongly  a  revision  of  the 
operation;  indeed,  in  all  cases  of  the  kind,  it  is  well 
for  the  surgeon  to  explain  to  the  patient  or  to  his 
friends,  before  undertaking  operative  measures,  the 
possibility,  or  even  probability,  of  further  operation 
being  required,  and  to  get  consent  to  necessary  revis- 
ional  operations  at  the  beginning. 

The  free  use  of  iodoform  within  the  wound  is 
strongly  to  be  recommended  in  tuberculous  processes, 
with  proper  caution  to  avoid  its  toxic  effects.  Pow- 
dered iodoform  should  be  rubbed  into  the  curetted 
surfaces  with  the  fingers  so  as  to  distribute  this  pre- 
eminent tuberculocide  into  the  pockets  and  crevices  of 
the  infected  cavity.  For  situations  where  the  turning 
up  of  flaps  is  not  possible,  iodoform  emulsion  may  be 
injected  with  a  syringe. 

The  studies  of  Beck,  of  Chicago,  have  demonstrated 
the  great  usefulness  of  bismuth  paste  in  many  surgi- 
cal tuberculous  processes.  This  paste  may  be  in- 
jected in  cases  of  fascial  involvement  by  puncture  of 
the  unbroken  skin  with  a  hollow  needle.  Where 
operation  has  laid  open  the  diseased  foci,  after  the 
thorough  surgical  treatment  of  the  diseased  area, 
bismuth  paste  may  be  applied  in  a  thick  layer  on  the 
under  surface  of  the  flaps,  or  it  may  be  injected,  after 
the  wound  is  stitched,  by  a  needle  introduced  be- 
tween the  apposed  lips  of  the  wound  in  the  interval 
between  two  sutures,  so  as  to  interpose  a  thick  layer 
of  the  paste  between  the  skin  and  the  underlying 
muscles. 

As  in  other  tuberculous  processes,  the  use  of 
tuberculin  should  be  considered,  both  in  establishing 
a  diagnosis  and  as  a  means  of  treatment.  It  should 
be  used  according  to  established  principles. 

Tuberculous  processes  affecting  any  of  the  structures 
of  the  extremities  are  particularly  favorably  situated 
for  treatment  by  passive  hyperemia.  According  to 
the  recommendation  of  Bier,  a  lightly  constricting 
bandage  applied  on  the  proximal  side  of  the  lesion,  as 
near  the  trunk  as  may  be,  for  from  one  to  two  hours 
daily  has  a  favorable  influence  on  most  cases  of  local 
tuberculosis  of  the  extremities  and  does  not  interfere 
with  the  use  of  other  therapeutic  means. 

Syphilis  of  the  Fascia. — Syphilitic  involvement 
of  the  fascia  is  almost  always  of  one  type — that  of  a 
gummatous  deposit.  This  type  of  syphilitic  lesion  is 
one  of  the  later  manifestations  of  syphilis,  and,  except 
in  the  precocious  or  malignant  type  of  the  disease,  is 
scarcely  to  be  looked  for  until  after  the  second  year. 
A  painless,  though  possibly  tender  subcutaneous 
tumor  extending  rather  widely  beneath  the  skin, 
without  the  characteristics  of  malignancy  on  the  one 
hand,  nor  the  encapsulation  and  lobulation  of  the 
lipoma  or  soft  fibroma  on  the  other  hand,  nor  yet  the 
fluidity  of  an  advanced  tuberculous  or  pyogenic  pro- 
cess, will  suggest  the  diagnosis  of  fascial  gumma. 
When  the  gummy  deposits  have  likewise  invaded  the 
skin  proper,  and  secondary  infection  with  pus  germs 
has  taken  place,  the  differentiation  between  syphilis 
and  tuberculosis  of  the  fascia  may  be  somewhat  am- 
biguous. Incision  into  the  mass  will  soon  reveal 
the  characteristic  appearance  of  the  gumma  if  the 
diagnosis  be  not  already  made.  If  still  not  made  at 
the  time  of  the  incision,  the  exceedingly  intractable 
character  of  the  lesion  under  ordinary  surgical  treat- 
ment will  suggest  the  diagnosis,  especially  when 
contrasted  with  its  readiness  to  heal  under  antisep- 
tic treatment  when  this  is  combined  with  the  exhi- 
bition   of   antisyphilitics. 

It  has  been  well  said  that  the  whole  responsibility 
of  the  surgeon  is  not  discharged  when  a  diagnosis  of 
syphilis  has  been  made,  and  gumma  of  the  antibra- 
chial  fascia  is  eminently  a  case  in  point.  Although  by 
stimulating  the  activity  of  the  lymphatics  with  po- 

552 


tassium  iodide,  even  an  extensive  gummatous  de- 
posit may  be  eventually  removed,  yet  the  complete 
and  speedy  restoration  of  the  arm  is  much  better 
insured,  especially  when  secondary  pyogenic  infection 
is  present,  by  free  incision  and  vigorous  clearing  away 
of  the  gumma  with  the  rinsing  curette,  depending  on 
the  constitutional   treatment   to   complete  the  cure. 

Contracture  of  the  Antibrachial  Fascia. — To  the 
diseases  of  the  fascia  which  have  thus  far  been  described 
must  be  added,  for  the  sake  of  completeness,  certain 
rare  cases  of  contracture  of  the  antibrachial  fascia  in 
which  this  membrane  impedes  the  action  of  the  mus- 
cles governing  the  hand  by  rendering  the  member  a-  it 
were  "hidebound."  Little  or  nothing  is  known  of 
the  pathology  of  this  rare  condition,  except  that  it  is 
sometimes  seen  as  the  sequel,  either  temporary  or 
permanent,  of  other  forms  of  fascial  disease.  The 
affection  is  sometimes  seen,  however,  in  a  strictly 
progressive  form  without  traceable  antecedent  dis- 
ease or  injury. 

Steaming  and  massage  would  suggest  themselves 
as  the  most  promising  means  at  hand  for  combating 
the  difficulty,  and  A.  Richet  has  recorded  one  case 
which  yielded  to  potassium  iodide,  and  was  in  con- 
sequence  deemed  to  be  of  syphilitic  origin. 

A  certain  number  of  cases,  seemingly  of  this  general 
character,  are  reported  to  have  beenfavorably  affected 
by  the  local  injection  of  fibrolysin. 

III.   Affections  of  the   Bones,  the  Periosteum, 
and  the  Joints. 

(o)  The  Boiies. — Of  the  bones  of  the  arm  and  fore- 
arm, the  ulna  or  radius  may  be  congenitally 
absent;  in  which  case  the  remaining  bone  undergoes 
a  compensatory  hypertrophy,  and  this  produce-  a 
lateral  curvature  of  the  wrist  away  from  the  enlarged 
side. 

The  bones  may  atrophy  as  a  senile  change  or  from 
disuse,  especially  in  long-standing  ankylosis,  unre- 
duced dislocation,  or  paralysis,  or  their  develop- 
ment may  be  arrested  in  the  later  stages  of  infantile 
paralysis. 

In  achondroplasia  the  bones  of  the  forearm  often 
appear  much  thickened  and  curved. 

Rickets,  as  Park  describes  it,  is  a  constitutional 
dystrophy  caused  by  improper  deposition  of  calca- 
reous material  in  the  soft  and  somewhat  perverted 
fetal  cartilages.  Pathologically  it  is  marked  both  by 
a  defect  in  the  calcium  content  and  also  by  the  irreg- 
ular epiphyseal  lines  and  excessive  amount  of  vascular 
tissue.  "  On  making  a  section  through  the  end  of  the 
bone,  one  sees  that  instead  of  the  two  sides  of  the 
epiphyseal  cartilage  being  parallel  to  each  other,  that 
next  the  diaphysis  is  quite  irregular,  there  are  islets 
of  cartilage  extending  into  the  bone,  the  epiphyseal 
line  is  very  much  thickened  and  the  ossification  is  very 
irregular"  (Cheyne).  The  result  is  that  at  the 
epiphyseal  lines  one  can  feel  a  distinct  enlargement, 
especially  noticeable  at  the  wrist,  the  lower  end  of  the 
radius  being  as  a  rule  the  first  part  affected.  Owing 
to  the  softening  of  the  bony  tissue,  curves  and 
deviations  of  the  bones  of  the  arms  occur  in  severe 
cases  in  infancy,  secondary  to  kyphosis  of  the  spinal 
column,  the  child  tending  to  assume  a  frog-like  posi- 
tion to  relieve  the  spine  of  the  weight  of  his  head  and 
shoulders.  In  some  instances  fractures  have  been 
observed  to  occur  in  rickety  bones  on  slight  provoca- 
tion. The  treatment  is  regulation  of  the  diet  and 
improvement  in  the  hygienic  conditions  together 
with  the  administration  of  tonics.  Phosphorus  and 
the  hypophosphites  are  especially  recommended. 
Extract  of  the  thymus  gland  has  been  shown  to  exert, 
in  some  cases,  an  appreciable  effect  in  disorders  of  the 
osseous  development.  Its  use  in  rickets  has  been 
recommended  as  a  means  of  promoting  the  fixation 
of  phosphorus  in  the  bones,  particularly  of  children. 
The  radius  is  a  common  place  for  the  commence- 


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Ann  and   Fercarin, 
and   Injuries 


Diseases 
of 


inellt      of      OSTEITIS      DEFORMANS.        Here      (lie      boneS 

enlarge  and  soften,  and  a  distinct  bowing  is  at  time 
noticed,  while  from  the  irregular  enlargement  of  the 
articular  ends,  the  hand  is  often  deflected.  This 
disease,  which  is  also  known  as  Paget's  disease  of  the 
bones,  is  a  rare  affection,  appearing  generally  after 
middle  age.  The  disease  is  essentially  a  symmetrica] 
one. 

The  articular  ends  of  the  humerus  and  ulna   may 
lie   involved    in    the    hypertrophy    characteristic    of 
uarie's  disease  or  ostioarthropathie  hypertrophiante 
lique. 

In  senile  atrophy,  osteomalacia  and  osteopsathy- 
rosis, as  also  in  rickets,  in  syringomyelia,  and  in 
metastatic  deposits  from  malignant  tumors,  <-.</. 
carcinoma  of  the  breast,  spontaneous  or  patho- 
logical fractures  are  prone  to  occur  due  to  the 
diminished  resisting-power  of  the  bony  tissue. 
Slight  falls,  as  from  a  chair,  or  even  moderately  severe 
muscular  strain  may  be  sufficient  to  cause  these 
injuries,  and  when  once  incurred  they  often  refuse  to 
properly. 

Of  the  rarer  forms  of  inflammatory  disease  of  the 

.us  system  occurring  in  the  upper  extremities, 

actinomycosis     occurs     as     a     secondary     deposit. 

1  si    may   attack    the   bones   directly   or   their 

nutrition  may  be  interfered  with  through  the  influence 
of  this  disease  upon  their  trophic  nerves.  Hydatid 
CTSTS  may  also  develop  in  the  bones,  leading  to 
spontaneous  fracture  or  to  circumscribed  swellings. 
In  scurvy,  hemorrhage,  either  of  a  subperiosteal 
nature  or  directly  into  the  epiphyseal  cartilage,  may 
lake  place  in  the  bones  of  the  arm,  especially  at  the 
distal  extremity  of  the  radius,  giving  rise  to  some 
swelling  and  much  tenderness  over  the  point  affected. 
Separation  of  the  epiphysis  is  apt  to  follow.  True 
scurvy  is  rarely  seen  to-day  except  in  artificially  fed 
infants.  Breast  feeding  is  the  most  obvious  remedy, 
but  where  this  is  not  possible  the  addition  of  fruit 
juice  to  the  diet,  with  the  substitution  of  fresh, 
uncooked  cow's  milk,  properly  modified  for  the 
desiccated  "infants'  food,"  is  generally  efficacious. 

Tuberculosis  of  the  bones  of  the  arm  may  take 
place  in  the  acute  miliary  form,  which  is  as  rapid  in 
its  ravages  in  this  tissue  as  elsewhere.  This  form  is 
fortunately  rare,  and  its  symptoms  and  treatment 
are  those  of  acute  osteomyelitis.  The  chronic  form 
of  bone  tuberculosis  is  quite  common,  and  most 
often  occurs  near  the  epiphyseal  lines  due  to  the 
plugging  of  the  terminal  arteries  (Warren).  From 
this  the  disease  spreads  by  the  formation  of  granula- 
tion tissue  with  a  tendency  to  sclerosis  and  thickening 
of  the  periosteum.  So  long  as  the  disease  is  active, 
the  tubercles  tend  to  spread,  and  following  the 
direction  of  least  resistance,  the  shaft,  the  periosteum 
(with  sinus  formation),  or  the  joints  may  be  invaded. 
This  tendency  to  invasion  of  the  joints  is  charaeterist  tc 
of  tuberculous  disease,  and  usually  occurs,  as  above 
stated,  by  direct  extension  from  a  focus  in  the  bone. 
It  leads  to  destruction  of  the  joint  structures,  and  is 
accompanied  by  tuberculous  or  inflammatory  infiltra- 
tion of  the  neighboring  parts.  Deformity  of  the  bone 
from  inflammatory  thickening  with  some  local  tender- 
ness will  indicate  chronic  bone  tuberculosis.  The 
amount  of  pain,  as  long  as  the  joint  is  not  involved, 
may  be  slight.  A  characteristic  afternoon  rise  of 
temperature  will  serve  to  differentiate  tuberculosis  of 
the  bone  from  gumma  and  from  osteosarcoma. 
_  The  treatment  of  bone  tuberculosis  is  both  constitu- 
tional and  local.  The  former  aims  to  maintain  the 
best  possible  hygiene  and  to  build  up  the  debilitated 
system  by  tonics,  and  among  the  constitutional 
remedies  should  also  be  considered  the  therapeutic 
use  of  tuberculin.  The  local  treatment,  consists  in 
immobilizing  the  part  by  proper  orthopedic  appli- 
ances, and  the  injection  directly  into  the  affected 
area  of  antitubcrculous  substances,  notably  a  ten-per- 


cent, emulsion  of  iodoform,   the  balsam  of  Peru,  or  a 

one  pei  cent,  solution  of  the  trichloride  of  iodine  as 
recommended    by    Senn.     [gnipuncture    i-    another 

measure  which  has  been  applied  ill  the  local  treatment. 

of  tuberculous  bone  lesions.     The  point  of  a  Paquelin 

cautery    at    a    white    heat     is    thrust     deep    into    the 

affected  area.  The  channel  thus  made  is  then  dre  ed 
with    iodoform.     The    local    treatment     may    al  o 

include  operative  measures  by  which  the  tuberculous 
focus  may  be  removed  with  a  sharp  spoon  and  the 
part  put  up  in  an  antiseptic  dressing  and  a  fixation 

splint. 

Bier's  passive  hyperemia  is  a  valuable  adjunct  to 
other  means  of  local  treatment,  whether  operative  or 
by  injection,  and  may,  in  some  cases  do  away  with 
the  necessity  of  joint  fixation. 

If  the  joint  is  extensively  involved,  its  resection 
may  be  necessary,  while  in  the  miliary  form  of  the 
disease,  or  when  a  condition  lias  been  reached  in 
which  resection  will  no  longer  eradicate  the  affection, 
amputation  of  the  limb  may  be  required. 

Syphilis  in  its  later  stages  may  attack  the  bones 
of  the  arm,  involving  first  the  periosteum  and  leading 
to  the  formation  of  granulation  tissue  that  tends  to 
bee., me  ossified,  or  to  the  growth  of  true  gumma 
which  tends  to  break  down.  When  the  bone  itself  is 
invaded,  which  is  rare  in  this  locality,  either  a  gumma 
or  granulation  tissue  is  formed  withageneral  tendency 
toward  ossification. 

The  differentiation  between  syphilis  and  tuberculo- 
sis of  the  bones  may  be  made  clear  by  observing  the 
following  points.  In  syphilis  we  have  a  history  of 
chancre  and  skin  lesions.  The  disease  usually  attacks 
the  periosteum,  and  affects  the  shaft,  rather  than  the 
epiphysis  of  the  bone.  It  does  not  tend  to  invade  the 
joint;  does  not  tend  to  suppurate  or  break  down;  the 
pain  is  usually  nocturnal,  anil  is  referred  at  first  to 
the  points  of  attachment  of  the  ligaments,  and  then 
to  exposed  portions  of  the  bone.  These  symptoms 
yield  to  the  exhibition  of  mercury  and  iodide  of 
potassium. 

Tuberculosis,  on  the  other  hand,  may  be  secondary 
to  tuberculous  disease  elsewhere;  it  first  attacks  the 
medulla  and  as  a  rule  tends  to  invade  the  joints, 
owing  partly  to  its  tendency  to  localize  itself  primarily 
in  the  epiphysis.  The  tuberculous  deposit  softens 
and  liquefies.  There  is  not  much  pain  except  on 
motion.  The  symptoms  do  not  yield  to  the  exhibition 
of  antiluetic  remedies.  There  is  a  characteristic 
pyrexia. 

The  treatment  of  bone  syphilis  is  first  the  adminis- 
tration of  the  usual  antisyphilitic  remedies.  Should 
secondary  local  pyogenic  infection  have  occurred,  it 
is  proper  to  cut  down  upon  the  part  and  thoroughly 
curette. 

Acute  osteomy-elitis  is  an  inflammatory  disease 
of  the  marrow  of  the  bone  terminating  in  suppuration. 
As  a  primary  disease  it  is  most  common  in  children. 
It  is  prone  to  occur  after  slight  traumatisms  followed 
by  injudicious  exposure  to  the  weather  or  other 
depressing  influences,  particularly  when  furuncles  or 
other  pyogenic  processes  are  active  in  other  parts  of 
the  body.  Thus  it  is  seen  after  slight  accidents  in 
bathers,  skaters,  where  sitting  on  the  ground,  or 
exposure  to  the  weather  when  incompletely  clad, 
allows  the  vital  forces  to  become  depressed.  It  may, 
of  course,  follow  upon  more  extensive  wounds, 
especially  upon  compound  fractures,  where  direct 
access  to  the  medullary  canal  is  afforded  to  the  infect- 
ing germ.  It  frequently  follows  as  a  sequel  to  acute 
exhausting  disease — typhoid  fever,  scarlet  fever,  etc. 
It  is  essentially  a  phlegmonous  inflammation  of  the 
marrow.  The  osteal  and  periosteal  veins  are  closed 
by  septic  thrombi,  and  true  pyemia  may  result  from 
their  liquefaction  and  the  discharge  of  septic  matter 
into  the  circulation.  The  medullary  canal  becomes 
filled  with  sanguineous  pus  that  permeates  the  bone 


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and  Injuries  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


from  within.  On  reaching  the  periosteum,  it  burrows 
beneath  it  denuding  the  bone.  After  a  longer  or 
shorter  period  of  restraint,  due  to  resistance  of  this 
membrane,  it  breaks  through  it,  and,  if  the  septic 
processes  have  not  already  destroyed  life,  sinus 
formation  occurs  with  profuse  and  obstinate  discharge 
of  pus.  Owing  to  the  interruption  of  its  nutrient 
supply,  more  or  less  extensive  necrosis  of  the  bone 
generally  occurs,  and  sequestra  are  formed  varying  in 
size  from  that  of  a  pin-head  to  those  involving  almost 
the  whole  bone. 

The  disease,  as  a  rule,  is  ushered  in  by  a  chill  and 
other  symptoms  of  an  acute  febrile  infection.  The 
local  symptoms  are  an  intense  pain  of  a  diffuse, 
boring  character  and  tenderness  over  the  portion 
where  the  disease  is  nearest  the  surface.  Marked 
swelling  and  redness  occur  only  when  the  inflamma- 
tion has  spread  to  the  soft  parts.  The  interference 
with  function  is  most  pronounced.  Characteristic  of 
this  disease  is  the  intense  pain  which  is  caused  by 
tapping  or  lightly  jarring  the  bone.  By  careful 
manipulation  it  is  usually  possible  to  exclude  disease 
in  the  adjacent  joints. 

If  left  to  itself,  the  disease  is  marked  by  most 
intense  pain  until  the  moment  when  the  restraining 
periosteum  gives  way,  yielding  an  avenue  for  the 
escape  of  the  confined  pus  into  the  surrounding  soft 
parts.  With  the  eruption  of  the  pus  through  the 
periosteum,  the  classical  signs  of  inflammation,  heat, 
redness,  and  swelling  become  much  more  marked. 
A  secondary  edema,  however,  accompanied  with  a 
more  or  less  distinct  marbleization  of  the  superficial 
veins,  is  often  evident  for  some  time  before  the 
perforation  of  the  periosteum  occurs.  High  fever, 
delirium,  and  all  the  symptoms  of  most  severe  sepsis 
attend  the  disease  from  its  outset.  Spontaneous 
fracture,  separation  of  the  epiphysis,  purulent 
synovitis,  thrombosis,  and  metastatic  infections  occur 
as  complications. 

Rest  and  elevation  with  the  use  of  the  ice-bag,  or 
continued  fomentation  may  be  of  service  in  arresting 
the  disease  in  its  earliest  stages.  In  no  disease,  how- 
ever, is  prompt  and  decisive  surgical  intervention 
more  urgently  demanded  than  in  osteomyelitis. 
When,  after  brief  trial  of  these  agents,  decided  sub- 
sidence of  the  symptoms  is  not  induced,  the  only  way 
of  limiting  the  ravages  of  the  infective  process  is  by 
cutting  down  upon  and  drilling  into  or  otherwise 
opening  the  medullary  canal;  nor  should  the  involve- 
ment of  the  adjacent  soft  parts  be  awaited  before 
proceeding  to  these  radical  measures.  The  point  of 
greatest  tenderness  will  indicate  the  most  favorable 
site  for  incision,  and  it  is  quite  possible  that  when 
through  early  and  free  incision  relief  is  afforded  to  the 
intense  congestion  of  the  surrounding  parts,  actual 
suppuration  of  the  bone  may  be  averted.  To  this 
end  the  incision  must  extend  not  only  down  to  the 
periosteum,  but  actually  to  the  bone  itself,  and  no 
damage  will  be  done  and  great  relief  may  be  afforded 
by  piercing  the  compact  layer  of  the  bone  in  one  or 
several  places  either  with  a  bone  drill  or  with  a  small 
trephine.  If  through  the  apertures  thus  made  into 
the  bone  pus  be  discovered  in  the  medullary  canal, 
it  will  be  necessary  in  almost  all  instances  to  open 
the  canal  with  a  chisel  throughout  the  greater  part  of 
its  length,  and  with  a  sharp  spoon  to  remove  very 
thoroughly  its  infected  contents.  The  wound  should 
then  be  packed,  and  under  the  use  of  frequent  dress- 
ings and  copious  irrigation,  we  may  in  most  instances 
hope  for  the  arrest  of  the  disease  without  too  exten- 
sive necrosis  of  the  bone. 

Under  any  other  form  of  treatment  the  destruction 
of  the  bone  throughout  the  greater  portion  of  its 
length  is  almost  certain,  and  withal  the  danger  to  life 
itself  from  acute  osteomyelitis  is  very  great;  so  that 
extensive  as  may  seem  the  operative  measures  taken 
for  the  relief  of  (lie  condition,  they  are  really  to  the 
lasl   degree  conservative.     It  is  astonishing  to  what 


extent,  particularly  in  children  in  whom  the  perios- 
teum has  survived  the  suppurative  process,  the  shaft 
of  the  long  bones  will  be  reproduced. 

When  extensive  portions  of  one  of  the  bones  of  the 
forearm  have  been  removed,  either  by  disease  or  by 
operative  measures,  it  is  necessary  to  take  great  pains 
during  the  process  of  repair  and  reconstruction  of  the 
tissues,  to  maintain  the  mechanical  support  which 
was  afforded  to  the  forearm  by  the  defective  bone,  as 
the  atrophy  consequent  upon  osteomyelitis  of  the 
ulna,  unless  proper  splints  be  provided,  will  cause 
great  deflection  of  the  hand  toward  the  affected  side. 
Still  more  markedly  is  this  the  case  when,  through 
similar  disease  of  the  radius,  the  integrity  of  the  shaft 
of  that  bone  has  been  compromised. 

The  fractures  which  occur  in  the  arm  and  forearm 
are  fully  treated  of  elsewhere,  but  certain  facts  in 
connection  with  them  deserve  mention  here.  The 
tip  of  the  olecranon  process  when  fractured  behaves  in 
a  manner  similar  to  the  patella.  On  account  of  the 
action  of  the  triceps  muscle  there  is  more  or  less 
diastasis  of  the  fragments,  precluding  the  development 
of  crepitation  and  interfering  with  bony  union.  The 
treatment  is  on  lines  analogous  to  that  pursued  in 
fractures  of  the  patella,  and  the  surgeon  is  called  upon 
to  decide  as  to  the  advisability  of  incision  for  the 
purpose  of  wiring  the  fragments  together. 

The  multiplicity  of  the  muscles  attached  to  the 
various  bones  of  the  arm  causes  many  deformities  in 
the  limb  after  fracture  of  the  bones.  If  the  tendency 
to  these  deformities  is  not  forseen  and  adequately 
provided  against  when  the  fracture  is  recent,  the 
fragments  may  unite  at  such  an  angle  as  to  impede 
considerably  the  function  of  the  limb.  This  is  partic- 
ularly the  case  in  fractures  above  the  elbow  joint,  and 
especially  in  fractures  of  the  condyles  and  in  separa- 
tion of  the  lower  epiphysis  of  the  humerus.  To 
obviate  this  accident  it  is  often  necessary  to  wire  the 
separated  processes  to  the  shaft  of  the  bone  and  to  each 
other. 

Exuberant  callus  produced  during  the  healing  of  a 
fracture  may  seriously  impede  any  or  all  of  the  func- 
tions of  the  elbow  joint,  and  synostosis  between  the 
radius  and  ulna  may  occur  to  such  an  extent  as  en- 
tirely to  destroy  the  functions  of  pronation  and 
supination.  Exuberant  callus  may  also  include  the 
nerves  and  vessels  of  the  arm  so  as  seriously  to  com- 
promise their  functions. 

The  Periosteum. — The  bones  of  the  arm  and  fore- 
arm are  also,  in  common  with  the  other  bones  of 
the  body,  frequently  the  seat  of  disease  affecting 
primarily  and  sometimes  exclusively  the  periosteum; 
often  of  traumatic  origin,  but  sometimes  due  un- 
doubtedly to  rheumatism  (met  with  particularly 
about  the  point  of  tendon  insertions),  and  not  in- 
frequently to  direct  or  indirect  pyogenic  infection,  or 
to  syphilis.  When  pyogenic  infection  has  taken 
place,  the  differential  diagnosis  between  the  periosteal 
and  endosteal  form  of  the  disease  will  be  suggested  by 
the  lessened  gravity  of  the  symptoms,  by  the  absen>  <• 
of  marked  evidences  of  general  sepsis,  together  with 
the  presence  of  similar  local  signs.  In  the  absence  of 
pronounced  suppuration,  we  are  justified  in  pursuing 
longer,  in  this  form  of  bone  disease  than  in  the  other, 
our  efforts  to  check  the  process  by  means  of  rest,  coun- 
ter-irritation, fomentations,  etc.,  but  with  the  advent 
of  signs  pointing  to  pus  formation,  free  incision  and 
drainage  are  as  positively  indicated  as  before. 

The  Joints. — The  articulations  of  the  upper  ex- 
tremities are,  like  those  elsewhere  in  the  body,  liable 
to  dislocation;  for  discussions  of  which  other  portions 
of  this  work  may  be  consulted.  It  will,  however,  be 
well  to  call  attention  here  to  a  somewhat  rare  affec- 
tion of  the  elbow,  occurring  exclusively  in  infants  and 
young  children,  resulting  from  forcible  dragging  on  the 
forearm,  often  by  the  nurse,  or  in  play.  In  this  con- 
dition the  forearm  is  held  flexed  in  a  prone  or  semi- 
prone  position,  and  supination  is  very  painful.     The 


554 


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Ann  and  Forearm,   Diseases 

ami   Injuries  of 


condition  is  probably  one  of  subluxation  of  the  radius 
,1(H\  award,  and  the  partial  escape  of  its  head  from  the 
grasp  of  the  orbicular  ligament;  the  normal  laxity  of 
the  ligaments  in  childhood  and  the  want  of  full  devel- 
opment of  the  head  of  the  radius  contributing  to 
make  the  condition  possible.  The  signs  may  be  re- 
moved by  complete  supination  followed  by  flexion, 
under  an  anesthetic  if  necessary.  The  forearm  should 
then  be  placed  in  a  sling  and  massage  and  careful  ex- 
ercise employed. 

Of  the  primary  inflammations  in  these  joints, 
SIMPLE  synovitis  is  perhaps  the  most  common.  The 
acute  form  may  be  due  to  trauma  or  to  overuse,  and 
gives  rise  to  pain  on  pressure  or  on  movement  of  the 
joint,  and  to  swelling  due  to  an  increase  in  the  amount 
of  synovial  fluid,  sometimes  to  an  effusion  of  blood. 
A  bulging  tumor  is  formed  where  the  joint  capsule 
is  thin;  in  the  elbow  joint  the  tumor  is  generally  shown 
i  riorly.  Purulent  infection  of  the  effusion  may 
take  place. 

The  treatment  of  simple  synovitis  consists  in  rest, 
enforced  if  necessary  by  fixation  of  the  joint,  pressure, 
by  careful  bandaging  or  by  the  wearing  of  a  woven  rub- 
ber sleeve,  the  application  of  cold  or  of  heat,  the  latter 
best  in  the  form  of  the  local  hot-air  bath,  and  passive 
hyperemia.  With  the  subsidence  of  acute  symptoms, 
massage  carefully  regulated  active  and  passive  mo- 
tion of  the  joint  are  always  helpful  and  are  frequently 
indispensable.  Active  and  passive  motion,  while 
they  may  be  administered  manually,  are  more  easily 
regulated  and  are  more  efficaciously  applied  by  means 
of  the  Zander  mcchanotherapeutic  machines. 

The  chronic  form  of  synovitis  may  date  from  a 
previous  acute  attack,  or  may  be  chronic  from  the 
start.  The  pain  in  this  form  is  either  small  or  absent. 
I  luctuation  can  usually  be  elicited,  while  creaking  on 
moving  the  joint  may  be  quite  a  noticeable  symptom. 
The  treatment  here,  too,  will  consist  in  pressure,  rest, 
massage,  counter-irritation,  etc.  It  is  particularly 
in  cases  of  chronic  synovitis  that  the  local  hot-air 
bath  together  with  active  and  passive  motion  accu- 
rately regulated  by  means  of  the  Zander  apparatus 
may  be  relied  upon  to  give  the  best  obtainable 
results. 

Tuberculosis  of  the  joints  is  usually  due  to  in- 
fection from  the  bone,  though  it  may  in  some  cases 
be  primary  in  the  synovial  membrane.  The  usual 
symptoms  are  swelling,  due  to  effusion  and  to  the 
thickened  capsule;  there  is  always  a  limitation  of 
motion,  and  usually  pain,  due  to  the  friction  of  two 
roughened  joint  surfaces,  and  marked  and  painful 
spasms  of  the  muscles  surrounding  the  joint,  while 
atrophy  of  these  muscles  is  generally  to  be  noted. 
Immobilization  of  the  j<3int,  together  with  extension, 
are  indicated  as  in  joint  tuberculosis  elsewhere.  This 
is,  however,  difficult  to  achieve  in  the  upper  ex- 
tremity by  any  portable  apparatus,  though  simple 
immobilization  at  the  elbow  and  the  wrist  may  be 
attained  by  proper  splints.  For  thoroughly  satis- 
factory  extension,  the  use  of  the  weight  and  pulley 
with  recumbency  in  bed  is  essential,  and  even  with 
these,  satisfactory  application  of  this  form  of  treat- 
ment to  the  shoulder  joint  is  very  difficult,  owing  to 
the  extreme  mobility  of  the  scapula.  On  account  of 
the  imperfection  of  methods  of  extension  and  im- 
mobilization in  treating  tuberculosis  of  the  joints  of 
the  upper  extremity,  we  turn  the  more  readily  to  the 
use  of  iodoform  emulsion  and  other  substances  by 
injection  into  the  joint  cavities,  and  in  severe 
cases  proceed  to  resection,  typical  or  atypical.  In 
conjunction  with  other  methods,  general  tonic  treat- 
ment should  not  be  foregotten,  including  open-air 
living  and  the  use  of  tuberculin. 

Acute  suppurative  arthritis  is  sometimes  found, 
due  to  the  infection  from  a  wound,  or  of  hematogen- 
ous origin.  All  the  signs  of  a  severe  and  acute  inflam- 
mation are  present.    The  treatment  is  in  all  cases  by  in- 


ei.sion  and  drainage  and  by  immobilization  of   the 

joint.      The  value  of  bacterial  vaccines  and  of  pa     ive 

hyperemia  should  not  be  overlooked  in  this  formid- 
able and  crippling  disease.  Ankylosis  is  often  a 
result  in  spite  of  our  best  efforts. 

Infectious)  arthritis  is  seen  following  the  acute 
infectious  diseases.  It  has  much  the  same  clinical 
character  as  rheumatism,  but  it  does  not  tend  to 
suppurate,  nor  is  it  migratory. 

The  wrist  is  the  most  prone  of  any  of  the  joints  of 
the  upper  extremity  to  succumb  to  GONORRHEAL 
arthritis.  Its  well-known  obstinacy  and  intracta- 
bility have  made  it  an  opprobium  medicorum.  Re- 
cently incision  and  irrigation  of  the  joint  have  been 
made  use  of  with  gratifying  results  in  this  form  of 
arthritis.  Bier's  passive  hyperemia  will  do  a  great 
deal  to  allay  the  truly  atrocious  pains  of  this  form  of 
infection,  and  often  it  will  go  far  toward  effecting  a 
cure.  The  brilliant  results  which  have  attended  the 
use  of  antigonocoecus  serum  and  of  gonococcus  vac- 
cines have  done  much  to  make  the  outlook  brighter  in 
this  formerly  most  intractable  disease. 

In  acute  rheumatism,  besides  the  systemic  mani- 
festations, the  joints  are  inflamed,  painful,  and 
tender,  and  the  articular  affections  tend  to  migrate. 
Rheumatic  arthritis  is  prone  to  attack  the  larger 
joints.  Incases  of  chronic  rheumatism,  the  joints  are 
stiff  and  painful  but  not  always  swollen,  while  on 
passive  motion  a  creaking  may  be  elicited.  The 
muscles  may  become  greatly  wasted,  and  there  is 
a  tendency  toward  fibrous  and  even  bony  ankylosis. 
The  treatment  of  the  acute  form  is  by  means  of 
alkalies  and  salicylates  and  other  appropriate  drugs, 
together  with  heat,  pressure,  and  rest.  In  the  chronic 
forms  the  best  results  are  obtained  from  massage 
and  mechano-therapy,  the  hot-air  bath,  the  copious 
and  long-continued  use  of  akaline  mineral  waters, 
and  a  strict  anti-rheumatic  regimen. 

Rheumatoid  arthritis,  or  arthritis  deformans,  is 
characterized  by  changes  in  the  cartilages  and  syno- 
vial membranes  with  periarticular  formation  of  new 
bone  and  great  deformity.  The  cartilage  is  either 
thin  or  entirely  absorbed,  laying  bare  the  bone,  while 
at  the  ends  of  the  joints  osteophytes  form  that 
may  cause  even  complete  ankylosis.  This  is  ac- 
companied by  a  thickening  and  contraction  of  the 
ligaments  and  great  atrophy  of  the  muscles.  Hyper- 
trophy of  the  articular  ends  of  the  bones  is  common, 
though  in  some  cases  atrophy  is  observed.  Neuritis 
is  prone  to  occur  as  a  complication. 

The  treatment  is  by  massage  and  hot-air  baths 
together  with  forced  passive  motion.  Both  active 
and  passive  motion  must  be  kept  up  long  enough  to 
remodel  deformed  articular  ends  of  the  bones  to  their 
normal  shape  by  the  effects  of  use  and  pressure.  The 
stiffened  joints  can  sometimes  be  advantageously 
broken  down  under  a  general  anesthetic,  but  this 
must  be  promptly  and  vigorously  followed  up  by 
long-continued  active  and  passive  motion  in  which 
the  mechanotherapeutic  machines  of  Zander  are  far 
superior  to  manual  work.  The  use  of  thyroid  extract 
in  moderate  doses  is  useful  in  some  cases,  as  an  ad- 
junct to  other  treatment,  and,  when  possible  the  pa- 
tient should  spend  the  winter  months  in  a  warm  cli- 
mate. The  disease  has,  however,  a  marked  tend- 
ency to  become  progressive,  and  in  severe  cases 
but  little  benefit  is  derived  from  treatment  of 
any  kind. 

The  shoulder,  the  elbow  and  the  wrist  occasionally 
show  a  form  of  arthritis,  arthritis  sicca  vel  senilis, 
which  is  much  more  commonly  found  in  the  hips 
and  in  the  knees.  This  is  due  to  atrophy  of  the  syno- 
vial membrane,  and  shows  itself  practically  as  a  defi- 
ciency in  the  lubrication  of  the  joint.  The  disease 
is  rarely  extremely  painful,  is  never  entirely  curable, 
but  may  be  helped  by  treatment  applicable  to  ar- 
thritis in  general,  with  the  important  exception  that 


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long-continued  disuse  of  the  joint,  and  above  all,  all 
fixation  of  the  joint  must  be  avoided  as  furthering 
the  atrophy  which  is  the  essential,  underlying 
pathological  lesion. 

A  spbain  is  produced  when  the  motions  of  a  joint 
are  carried  beyond  their  physiological  limits,  but  stop 
short  of  permanent  displacement  of  the  articular  ends. 
With  this  there  is  either  a  stretching  or  rupture  of 
portions  of  the  capsule  or  ligaments,  accompanied  by 
pain,  swelling,  ecchymosis,  and  limitation  of  joint 
motion  with  tenderness  over  the  joint.  Sprains  are 
especially  prone  to  occur  at  the  wrist,  though  the 
elbow  and  shoulder  are  frequently  affected.  It  is 
important  to  differentiate  a  wrist  sprain  from  a 
Colles's  fracture,  and  this  can  generally  be  done  by 
determining  the  absence  of  crepitation  and  of  an 
abnormal  point  of  motion,  and  also  by  the  fact  that  in 
Colles's  fracture  the  hand  is  drawn  toward  the  radial 
side  with  a  more  or  less  pronounced  "silver-fork" 
deformity.  This  last  condition  is  sometimes  better 
appreciable  to  firm  palpation  than  to  the  eye,  espe- 
cially when  some  time  has  elapsed  since  the  receipt  of 
the  injury.  The  use  of  the  x-ray  will,  however, 
in  most  cases  make  the  diagnosis  certain.  It  should 
not  be  forgotten,  however,  that  sprained  wrist  is  a 
constant,  and  often  a  serious  complication  of  Colles's 
fracture. 

The  treatment  of  a  sprain  is  rest,  elevation  of  the 
part,  and  compression,  with  the  use  of  cold  followed 
later  by  hot  applications.  The  use  of  massage  from 
the  beginning  is  quite  successful  in  skilful  hands, 
while  this  with  passive  motion  is  always  indicated 
after  the  subsidence  of  acute  symptoms. 

Ankylosis  may  be  due  to  contractures  of  the 
muscles  or  to  contractures  and  thickenings  of  the 
ligaments,  with  or  without  secondary  growths  of 
impeding  osteophytes  about  the  margins  of  the  joints. 
The  contractures  which  prevent  the  joint  from 
moving  may,  in  turn,  be  due  to  disturbed  innerva- 
tion or  nutrition  of  the  muscles,  or  to  myositis 
followed  by  degeneration  of  the  muscle-cells  proper 
and  substitution  of  fibrous  for  muscular  tissue;  but 
the  commonest  cause  both  of  muscular  and  of  liga- 
mentous contracture  is  unabsorbed,  and  more  or 
less  perfectly  organized,  inflammatory  exudate. 
Ankylosis  of  this  type  rarely  causes  complete  immo- 
bility of  the  joint;  it  is  termed  "false  ankylosis" 
in  distinction  from  a  "true  ankylosis,"  where  actual 
union,  either  fibro.us  or  bony,  has  taken  place  between 
the  opposed  articular  surfaces.  A  false  ankylosis  is  the 
result  of  an  extra-articular  process,  while  a  true 
ankylosis  is  the  direct  outcome  of  an  acute  suppura- 
tive arthritis,  joint  tuberculosis,  chronic  rheumatism 
or  rheumatoid  art  hritis. 

The  treatment  will  depend  upon  the  cause,  and 
may  consist  of  massage  and  forcible  flexion  and  ex- 
tension of  the  joint.  These  not  availing,  more  or 
less  extensive  tenotomy  and  myotomy  may  be 
practised,  or  the  joint  itself  may  be  excised.  At  the 
elbow,  where,  on  account  of  the  complexity  of  the 
joint,  ankylosis  is  particularly  prone  to  occur,  a 
flail  joint,  the  result  of  an  excision,  with  all  its  disad- 
vantages, gives  nevertheless  a  much  more  service- 
able arm  than  can  be  obtained  by  any  other  form 
of  treatment  for  extensive  fibrous  or  bony  ankylosis 
of  the  joint.  In  ankylosis  due  to  muscular  contrac- 
ture excision  is  less  to  be  recommended. 

Quite  a  large  number  of  cases  are  on  record  of 
loose  bodies  in  the  elbow-joint.  Their  pathological 
history  is  similar  to  that  of  loose  bodies  in  other 
joints,  such  as  the  knee.  The  only  treatment  is  re- 
moval by  arthrotomy. 

IV.    Affections  of  the   Muscles,   Tendons,  and 
Tendon  Sheaths. 

The  Muscles. — In  no  part  of  the  body  are  the 
muscles  and  tendons  grouped  in  such  numbers  about 


the  bones  as  in  the  forearm,  and  in  no  part  of  the  body 
do  the  affections  of  these  structures  stand  out  so 
prominently  as  in  the  upper  extremity. 

The  commonest  of  all  diseases  of  the  muscles,  if 
indeed  the  name  of  disease  is  applicable,  is  that  con- 
dition of  the  muscles  which  results  from  long-con- 
tinued use  without  sufficient  repose  to  which  the 
name  myalgia  has  been  given.  The  pathological  con- 
dition present  is  in  the  main  but  an  accentuation  of 
the  normal  condition  of  muscular  fatigue,  and  is  at- 
tended by  similar  symptoms,  namely,  tenderness  on 
pressure,  "lameness"  in  use,  and  deficient  response  to 
ordinary  physiological  nerve  impulse  (i.e.  weakness 
in  action1),  and,  finally,  involuntary  and  painful  spasm, 
"  twitching."  These  symptoms  in  turn  are  caused  by 
too  great  an  accumulation  in  the  muscle  of  the  chem- 
ical products  of  muscular  activity,  and  this  accumu- 
lation, again,  may  be  the  result  of  either  or  both  of 
two  factors:  excessive  production  on  the  one  hand, 
and  deficient  elimination  on  the  other.  As  to  the 
exact  chemical  bodies  involved,  the  reader  is  referred 
to  treatises  on  physiology;  their  exact  nature  is  still 
a  matter  of  dispute,  but  one  of  the  best  established 
of  the  waste  substances  is  lactic  acid,  present  in  suffi- 
cient quantity  to  affect  markedly  the  reaction  of  the 
muscle  substance  to  delicate  alkalimetric  tests,  and 
there  is  little  doubt  that  this  changed  reaction  of  the 
muscle  substance  induces  in  its  turn  the  precipitation 
of  various  ''leucomaines"  which  it  is  difficult  for  the 
ordinary  blood  current  to  remove  promptly.  So 
long  as  these  decomposition  products  (uric  acid, 
xanthin,  hypoxanthin,  acid  phosphates)  are  not 
removed  from  the  muscle  the  symptoms  enumerated 
above  will  continue;  with  their  disappearance  the 
normal  function  of  the  muscle  will  return. 

The  exact  locality  of  these  morbid  deposits  is  not 
entirely  settled,  but  many  facts  point  to  the  probabil- 
ity of  their  being  located  rather  in  the  sarcolemma 
and  in  the  perimysium  than  in  the  substance  of  the 
muscle  proper.  The  facts  which  would  indicate  this 
are  the  aggravation  of  the  tenderness  at  the  muscular 
origins  and  insertions,  and  the  spread  of  the  myalgio 
affection  throughout  the  fibrous  tissues  beyond  the 
points  of  actual  muscular  insertion;  indeed,  in  no  part 
of  the  body  is  what  passes  for  myalgic  affection,  or  as 
very  closely  akin  to  it,  more  obstinate  and  trouble- 
some than  in  the  fibrous  tissues  just  below  the  origin 
of  the  erector  spina?  muscles,  over  the  sacrum  and  the 
sacroiliac  synchondroses.  It  is  more  than  probable 
that  consecutive  upon  a  pure  myalgia  may  occur  a 
rheumatic  form  of  periostitis  from  extension  beyond 
the  point  of  bony  origin  or  insertion  of  a  muscle  by 
"contiguity  of  tissue."  This  is  exemplified  with 
peculiar  distinctness  in  cases. of  myalgia  affecting  the 
muscles  attached  to  the  coracoid  process  of  the  scap- 
ula, where  the  coracoid  process  itself  may  often  be 
found  to  retain  for  a  long  period  a  great  degree  of 
tenderness  when  pain  may  entirely  have  left  the 
bodies,  or  the  tendons  of  the  muscles  attached  to  it. 

Excessive  formation  of  waste  products  comes  from 
over-use  of  the  involved  muscle;  deficient  elimination 
may  be  caused  by  use  of  the  muscle  under  unfavorable 
conditions,  or  by  exposing  the  member  to  untoward 
conditions  after  its  severe  use,  thus  interfering  with 
its  prompt  rehabilitation.  An  amount  of  muscle 
work  whose  catabolic  products  would  be  speedily 
provided  for  under  other  circumstances  may  induce 
a  severe  myalgia  if  performed  when  the  patient  was 
suffering  from  want  of  sleep,  as  many  a  weary  obstet- 
rician can  testify;  and  it  is  notorious  that  sitting  in 
a  draught  after'  active  exercise  will  lead  to  "  cold  set- 
tling in  the  limbs." 

There  is  one  form  of  this  affection  whose  sudden  and 
severe  onset  may  lead  to  confusion  in  the  diagnosis; 
this  form  more  frequently  attacks  the  erector  spinas 
group  of  muscles,  or  those  of  the  abdomen,  when  it  is 
known  as  a  "stitch  in  the  side."  This  form  of 
myalgia  is  probably  due  to  a  gradual  accumulation  of 


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Arm 


umi  Forearm,  Diseases 
mid  Injuries  »>f 


fatigue  products  in  the  muscle,  or  possibly  only  in  the 

fibers  "f  a  small  portion  of  a  muscle,  to  the  point 

„f  irritating  the  affected  fibers  to  a  sudden,  painful, 

and  protracted  involuntary  contraction,  the   patient 

ing  been  unaware  of  the  soreness  of  that  particular 

muscle  through  the  accident  of  not  having  brought 

those    fibers    into    play.     When    once    the    painful 

traction  has  taken  place,  the  irritability  of    the 

cted    muscle   becomes   extreme    and    the    whole 

muscle   is   brought   more   or   less   involuntarily   into 

ited  action,   to  "test  its  soreness,"  and  a  more 

or  less  persistent  myalgia  is  found  to  be  established 

until  driven  off  by  the  activity  of  the  circulation  or 

by    the    exhibition    of    suitable    remedies.     Such    a 

levelopment  of  a  latent  myalgia  among  the 

muscles  of  the  forearm  has  led  in  one  instance  I  have 

known   of   to   an   erroneous   diagnosis  of  rupture  or 

dislocation  of  a  tendon.     The  patient  was  a  young 

woman  engaged  in  wiping  dishes;  of  a  sudden  a  severe 

-hooting    through    the   forearm    caused   her   to 

drop  the  dish  in  her  hand,  and  certain  movements  of 

the  fingers  were  from  that  time  on,  for  many  weeks 

after,  painful  and  feebly  executed. 

The  diagnosis  of  myalgia,  as  it  appears  in  the  arm 
and  forearm,  is  not  ordinarily  attended  with  great 
difficulty.  The  history  of  fatigue,  or  exposure,  or 
both,  will  generally  suggest  the  diagnosis,  while  the 
presence  of  the  gouty  or  rheumatic  diathesis,  as  condi- 
tions under  which  waste  products  are  imperfectly 
removed  from  the  tissues,  will  be  allowed  a  certain 
weight  in  establishing  the  probabilities.  In  the  upper 
arm  the  extensors  (triceps)  are  most  frequentl}' 
affected,  in  the  lower  arm,  the  flexors  and  extensors 
with  about  equal  frequency.  Occasionally  the  coraco- 
brachialis  or  the  anconeus  may  be  affected  alone, 
giving  rise  to  rather  obscure  pains  in  the  shoulder 
and  elbow  respectively.  Such  cases  are  readily  over- 
looked in  a  careless  diagnosis.  Incidentally  their 
deep  location  renders  treatment  more  difficult.  The 
tenderness  over  the  affected  muscle,  the  painful  and 
imperfect  function,  and  the  occasional  fibrillary  spasm 
are  the  positive  factors  upon  which  we  base  a  diagno- 
sis, while  the  absence  of  fever,  swelling  or  redness,  the 
absence  of  tenderness  about  the  joints,  along  the 
course  of  the  nerves,  or  along  the  tendon  sheaths  will 
weigh  against  rheumatism,  neuritis,  and  thecitis 
respectively.  The  absence  of  fibrous  crepitation  will 
also  serve  to  aid  in  excluding  this  last  affection. 
From  painful  affection  of  the  bone  or  the  periosteum 
it  may  be  extremely  difficult  to  differentiate  a  deep- 
seated  myalgia;  the  absence  of  pain  on  jarring  the 
limb,  and  its  ready  yielding,  if  recent,  to  the  faradic 
current  will  serve  to  aid  in  identifying  a  myalgia. 

The  prognosis  is  good  if  treatment  be  instituted 
earl}-;  if  treatment  be  too  long  postponed,  and  atrophy 
ensue,  due  partly  to  disuse  and  partly  to  local  poison- 
ing of  the  muscular  substance  by  the  "materies 
peccans"  of  the  disease,  the  affection  may  prove  very 
obstinate  and  intractable,  but  will  in  almost  all  cases 
eventually  yield  where  the  persevering  cooperation 
of  the  patient  can  be  secured.  It  is  my  firm  belief, 
however,  that  simple  myalgia,  if  severe  and  untreated, 
can  occasion  permanent  disability. 

The  treatment  of  myalgia  consists  in  efforts  to 
throw  again  into  solution  those  precipitates  in  the 
muscles  whose  presence  impedes  their  function  and 
causes  the  pain.  This  we  seek  to  accomplish  along 
certain  rational  lines,  all  tending  to  this  common  end. 

Probably  the  first  therapeutic  efforts  of  sufferers 
from  myalgia  were  directed  toward  keeping  the 
affected  part  warm.  The  rationale  of  this  lies  in 
inducing  a  dilatation  of  the  blood-vessels,  which 
brings  a  larger  supply  of  the  solvent  serum  into 
contact  with  the  offending  precipitates,  thus  pro- 
moting their  solution.  With  the  increased  advent 
of  blood  follows  in  turn  an  increase  of  heat,  which  in 
connection  with  the  heat  added  from  without  induces 
an  actual  rise  of  the  temperature  of  the  part,  which 


i<  likely  to  promote  considerably  tie-  solubility  of  any 
precipitates.  Recently  this  method  of  treatment 
has  had  its  efficacy  greatly  enhanced  by  the  devising 

of  methods  of  exposing  tin-  affected  limb  to  dry  an- 
al very  high  temperatures.  Local  hot-air  baths  may 
now  be  procured  from  instrument  dealers  by  means 
of  which  an  extremity  may  be  exposed,  without 
damaging  the  skin,  to  dry  air  at  a  temperature  of 
300    to  500°  E. 

Other  ways  of  increasing  the  afflux  of  fresh  serum 
to  aid  in  the  solution  of  precipitates  are.  first,  Bier's 
passive  hyperemia,  by  means  of  a  constricting  band- 
age; secondly,  counterirritation,  applied  to  the 
overlying  skin  by  the  use  of  iodine  or  other  rube- 
facients, cantharidal  blisters,  or  "firing"  with  the 
actual  cautery;  thirdly,  moderate,  active  use  of  the 
muscles,  when  practicable  without  causing  too  much 
pain;  every  athlete  is  familiar  with  the  disappearance 
of  "muscular  stiffness"  (the  mildest  grade  of  this 
disease)  under  fresh  exercise;  fourthly,  massage  of 
the  affected  parts  is  extremely  useful,  particularly  in 
the  more  obstinate  and  chronic  forms  of  myalgia;  it 
partly  by  mechanically  dislodging  crystals  or 
amorphous  masses  of  precipitated  matters,  forcing 
them  into  the  lymphatic  circulation,  and  partly  by 
greatly  stimulating  the  local  circulation. 

Antirheumatic  remedies,  and  the  antirheumatic 
regime  are  also  of  use  in  controlling  the  pain  of 
myalgia,  chiefly  by  the  solvent  affect  of  alkalies  and 
of  the  salicylates  on  the  morbid  deposits,  and  of  these 
measures  there  is  none  that  compares  in  importance 
with  the  ingestion  of  very  large  quantities  of  water. 

While  massage  is  our  best  weapon  against  chronic 
forms  of  the  malady,  especially  in  the  presence  of 
secondary  atrophy,  there  is  no  agent  whatsoever  that 
will  give  the  immediate  and  lasting  relief  that  is  to  be 
obtained  from  the  application  of  the  faradic  current, 
and  no  more  grateful  patients  are  encountered  than 
those  who  have  been  relieved  from  the  misery  of  a 
myalgia  by  the  brief  application  of  a  mild  current. 

Within  the  last  few  years  our  armamentarium  has 
been  enriched  with  a  multitude  of  new  and  efficacious 
means  of  treating  this  common  and  troublesome 
malady.  Among  these  are  a  variety  of  phases  of  the 
electric  current,  such  as  the  slowly  interrupted  gal- 
vanic current,  the  sinusoidal  current,  the  high  fre- 
quency alternating  current  and  the  franklinic  spark, 
also  violet  light,  and  the  many  candle-power  (500  or 
more)  incandescent  light.  Perhaps  the  simplest  and 
most  commonly  used  of  the  recent  methods  of 
treatment  is  the  application  of  mechanical  vibration. 

One  special  point  it  is  important  to  notice  in  the 
treatment  of  myalgia  of  the  upper  arm — namely,  this, 
t  hat  the  muscles  which  move  the  upper  arm  have  their 
origin  on  the  trunk;  and  that  their  function  is  twofold, 
first,  that  of  imparting  voluntary  movements  to  the 
upper  extremity,  and  secondly,  that  of  supporting 
the  weight  of  the  arm.  This  second  function  is  not 
appreciated  during  health,  but  in  the  presence  of  a 
severe  deltoid  myalgia,  the  six  to  ten  pounds  weight 
of  the  arm  dragging  upon  the  lame  muscle  is  a  very 
considerable  factor  in  increasing  the  pain  and  a  serious 
obstacle  to  recovery.  In  all  acute  myalgias,  there- 
fore, affecting  the  muscles  which  pass  from  the 
trunk  to  the  arm  it  is  necessary  to  support  the  weight 
of  the  member  by  a  firm  bandage  at  the  elbow-.  The 
most  effective  device  for  this  purpose  is  a  Moore's 
dressing  for  fracture  of  the  clavicle,  as  described  under 
the  head  of  fractures. 

Occasionally  one  sees  cases  of  what  are  called 
"chronic  sprains"  or  "strains,"  caused  by  the  overuse 
of  certain  muscles,  in  which  the  pain  is  principally  at 
the  origin  or  insertion  of  the  muscles.  Tenderness 
and  stiffness  are  prominent  symptoms.  Examples  of 
this  are  seen  in  the  so-called  "base-ball  pitcher's 
arm,"  "tennis  elbow,"  etc.  Such  persistent  over- 
use of  a  muscle  may  give  rise  to  a  local  periostitis  at 
one  of  the  points  of  attachment  of  the  muscle,  possi- 


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bly  resulting  in  necrosis,  and  occasionally  leading  to 
bony  infiltration  of  the  muscle,  due  to  proliferative 
periostitis. 

In  some,  rather  rare  cases  of  sudden  and  violent 
contraction  of  the  muscles,  as,  for  instance,  in  throwing 
a  stone,  in  swinging  on  the  trapeze  and  among 
washerwomen  in  wringing  clothes,  actual  rupture  of 
a  part,  or  even  of  all  the  fibers  of  a  muscle  may  occur. 
This  accident,  which  not  infrequently  befalls  the 
plantaris  longus  in  the  leg,  has  been  seen  in  the  arm 
to  affect  the  supinator  longus  (in  a  young  woman 
engaged  in  wiping  dishes),  the  coracobrachialis  (in 
wringing  clothes),  the  biceps,  and  occasionally  the 
triceps.  Subcutaneous  muscle-rupture  is  more  fre- 
quently, however,  the  result  of  direct  violence  exerted 
upon  the  muscle  when  tense  than  the  result  of  pure 
contraction.  Both  the  biceps  and  the  triceps  are  not 
very  infrequently  injured  in  this  way  when  the  front 
or  the  back  of  the  arm,  respectively,  is  struck  by  a 
blunt  object,  e.g.  a  base-ball  bat.  When  a  consider- 
able muscle,  like  those  mentioned,  is  thus  ruptured, 
the  picture  is  unmistakable  provided  the  injury  is 
recent.  There  is  characteristic  inability  to  flex  the 
arm  actively  and  fully  with  a  ruptured  biceps,  or  to 
extend  it,  with  a  ruptured  triceps,  while  passive 
flexion  and  extension  are  unimpeded.  There  is 
furthermore  evident  and  extensive  subcutaneous 
hemorrhage,  and,  as  a  pathognomonic  symptom, 
there  is  ordinarily  readily  discernible  a  diastasis 
between  the  two  portions  of  the  ruptured  muscle,  and 
the  proximal  portion  of  the  muscle  contracts  to  a 
quivering  fleshy  lump  when  spontaneous  efforts  are 
made  by  the  patient  to  contract  the  muscle.  The 
diastasis  is  frequently  wide  enough  to  permit  the 
finger  to  be  laid  between  the  ruptured  ends  of  the 
muscle.  The  I  reatment  is  obviously  by  suture  of  the 
divided  muscle,  with  the  arm  put  up  in  flexion,  for 
injury  of  the  biceps,  and  in  extension,  for  injury  of 
the  triceps. 

Occasionally  the  flexor  group  of  the  forearm,  but 
more  frequently  the  biceps,  and  rarely  other  individual 
muscles  of  the  arm  will  present,  either  as  the  result 
of  an  injury  with  a  blunt  instrument  or  missile,  or 
occasionally  spontaneously,  a  rent,  not  of  the  muscle 
fibers,  but  of  the  overlying  fascia  or  muscle  sheath. 
Through  such  a  fascial  rent  the  muscle  fibers  tend  to 
protrude,  forming  what  is  called  a  muscular  hernia. 
The  effect  of  such  a  herniation  of  the  muscle  sub- 
stance through  its  sheath  is  to  weaken  and  impede 
in  considerable  degree  the  forcible  contraction  of  the 
muscle,  the  patient  complaining  of  insecurity  and 
uncertainty  in  exercizing  the  limb,  and  occasionally 
of  pain.  Here  too  the  treatment  is  incision  and  suture 
of  the  torn  muscle  sheath,  after  first  undermining  it 
for  some  distance  from  the  margins  of  the  rent. 

Acute  myositis  is  occasionally  encountered  in  the 
muscles  of  the  arm  as  a  result  of  pyogenic  infection. 
The  pyogenic  type  of  this  disease,  however,  is  rare, 
and  when  present  is  but  a  secondary  accompaniment 
to  neighboring  extensive  septic  processes.  It  may 
lead  to  necrosis  of  the  muscles  en  masse,  or  to  frac- 
tional sloughing,  and  solution  of  the  muscle  fibers  in 
the  purulent  effusion. 

A  rare  form  of  myositis  is  the  tuberculous,  which 
in  many  respects  resembles  the  gummatous  myositis 
of  syphilis.  It  bears,  however,  the  characteristic 
tokens  of  tuberculosis,  including  characteristic  reac- 
tion to  tuberculin,  characteristic  temperature  curve, 
etc.  It  appears  generally  in  subjects  presenting 
other  and  extensive  tuberculous  lesions.  Its  treat- 
ment, in  the  absence  of  too  extensively  generalized 
tuberculous  invasion  to  make  the  operation  justifia- 
ble, should  be  by  partial  or  complete  excision  of  the 
affected  muscle. 

The  most  common  forms  of  myositis  are  those 
whose  origin  is  syphilitic,  indeed  it  is  more  than 
probable   that  part  of  the  "rheumatic"  pains  which 


precede  or  accompany  the  eruption  of  constitutional 
syphilis  depend  upon  a  light  and  acute  irritative 
myositis. 

A  commoner  form  of  syphilitic  myositis  is  the 
chronic  interstitial  variety  depending  upon  a 
small-celled  infiltration  rising  from  the  perimysium, 
and  extending  into  and  between  the  muscle  bundles. 
These  are  destroyed  by  pressure  atrophy,  and  become 
transformed  into  connective  tissue  with  gradual  loss 
of  the  muscle.  It  is  a  diffuse  process  within  the 
muscle,  and  is  at  first  generally  attended  with  pain. 

Gummatous  myositis  may  develop  as  a  slowly 
growing,  and  perfectly  painless  infiltrate  in  the 
muscles.  Accompanying  the  gummatous  process 
there  are  usually  found  more  or  less  extensive  inflam- 
matory changes.  More  commonly,  however,  the 
growth  of  the  gumma  is  more  rapid,  and  pain,  in- 
creased by  touch  and  motion,  is  a  marked  symptom. 
The  muscle  in  all  the  more  rapidly  growing  gummata 
is  in  a  state  of  constant  contraction,  the  growth  at 
first  moves  with  the  movements  in  the  muscle.  As 
it  increases  in  size  it  becomes  softer  in  consistency, 
and  the  muscle  assumes  a  condition  of  permanent 
contracture. 

Gummatous  myositis  often  advances  beyond  the 
muscle,  and  comes  to  involve  the  fascia  and  sub- 
cutaneous tissues.  It  becomes  more  prominent, 
softer  and  less  movable,  and  finally  breaks  through 
the  skin,  leaving  a  sinuous  ulcer  from  which  necrotic 
masses,  chiefly  fascial,  are  extruded.  After  healing, 
which  requires  weeks  or  months,  a  cicatricial  tissue 
remains  which  binds  together  the  muscle,  fascia,  and 
skin  (Hartley). 

Ischemic  atrophy  or  Volkmann's  contracture 
is  a  rather  peculiar  and  an  important  condition.  The 
following  description  is  taken  from  Keen's  Surgery. 
"The  cause  is  interference  with  the  circulation. 
Pressure  on  the  nerves  may  have  some  influence.  The 
circulation  may  be  interfered  with  by  the  too  tight 
application  of  splints  and  dressings,  by  the  unduly 
prolonged  use  of  the  elastic  constrictor  (tourniquet), 
by  injury  to  large  vessels,  and  by  exposure  of  the 
part  to  cold.  The  forearm  is  the  region  most  com- 
monly involved,  the  affected  muscles  become  densely 
infiltrated.  Unless  the  cause  is  removed  within 
twenty-four  or  forty-eight  hours  or  earlier,  the 
muscle  fibers  degenerate.  The  whole  muscle  (Fried- 
rich)  does  not  become  uniformly  degenerated,  but  the 
portions  attacked  undergo  contraction. 

"According  to  Dudgeon,  pain  is  absent  unless  the 
disease  is  accompanied  by  neuritis;  other  authors 
describe  pain  as  an  early  and  important  symptom. 
Within  a  few  hours  the  hand  becomes  swollen,  the 
phalanges  flexed,  and  there  is  paralysis  of  the  muscles. 
The  muscles  are  hard,  swollen  and  tender.  If  pain 
is  absent,  the  seriousness  of  the  condition  is  apt  to  be 
unrecognized.  If  splints  are  the  exciting  cause  of  the 
trouble,  their  pressure  may  occasion  necrosis  and 
ulceration  of  the  skin,  but  these  lesions  are  merely 
concomitants  unrelated  to  the  muscular  degeneration. 
When  recovery  takes  place  it  leaves  a  permanent  con- 
tracture. When  the  forearm  is  the  site  of  the  disease, 
the  resulting  deformity  is  characteristic.  The  pha- 
langes are  flexed  on  each  other,  but  the  metacarpo- 
phalangeal articulation  remains  extended.  The  pha- 
langes cannot  be  extended  while  the  wrist  is  extended, 
but  as  soon  as  the  wrist  is  flexed,  the  fingers  can  be 
straightened.  If  the  muscular  degeneration  has 
been  more  extensive,  the  wrist  becomes  flexed  as 
well  as  the  fingers." 

Progressive  muscular  atrophy  is  a  disease 
which  manifests  itself  most  distinctly  among  the 
muscles  of  the  arm.  It  is,  however,  essentially  a 
nervous  disease  and  not  a  disease  of  the  muscles;  its 
consideration  here,  in  connection  with  the  muscle-,  is 
for  greater  convenience  only.     The  nerves  supplying 


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Ami  and  Forearm,  Diseases 
ami  Injuries,  of 


the  atrophied  muscles  may  be  affected  anywhere 
along  their  course,  bul  the  principal  site  of  the  lesion 
is  in  the  anterior  gray  columns  of  the  spinal  cord. 
However    general     the    disease    may    subsequently 

heeunie.il  is  at  first  Idealized,  anil  t  lie  upper  ex  I  remit y 
I  hj  far  the  must  frequently  involved.  Affection  of 
the  right  hand  is  said  to  he  considerably  more  frequent 
than  thai  of  the  left,  and  of  the  muscles,  either  the 
interossei  or  those  of  the  bull  of  the  thumb  first 
succumb.  The  disease,  in  fact,  at  first  simulates  an 
ulnar  neuritis,   but   careful   study   will   indicate   the 

olvement  of  certain  muscles  which  are  supplied  by 

er  nerves.  From  the  thenar  muscles  and  the 
interossei,  the  disease  commonly  creeps  up  the  fore- 
arm and  thenee  to  the  arm.  or  it  may  skill  the  forearm 
pass  into  the  arm,  although  the  triceps  extensor 
muscle  is  usually  spared.  It  may  come  to  a  stand- 
Still  in  either  of  these  two  places,  but  may  involve  the 
muscles  of  the  shoulder,  especially  the  deltoid. 
Beginning  most  frequently  on  the  right  side,  both 
r  extremities  become  involved  sooner  or  later. 
In    other    instances    in    which    the    extremities    are 

lived  the  atrophy  begins  in  the  deltoid  (here  again 
the  right  first).  Succeeding  the  deltoid,  the  scapular 
and  trapezius  muscles  may  be  involved  in  any  order, 
while  a  grotesqueness  of  effect  is  often  produced  by 
reason  of  certain  adjacent  muscles  retaining  their 
natural   size  or  even  being  hypertrophied.     This  is 

ticularly  the  case  with  the  anterior  part  of  the 
trapezius,  which  is  almost  never  involved.  While  the 
shoulders  remain  exclusively  affected,  the  arm  and 
forearm  may  retain  their  usefulness  and  strength, 
I uit  the  power  of  lifting  the  arm  from  the  side,  and 
especially  of  raising  it  above  the  head,  is  lost,  and  if 
the  patient  wishes  to  lay  hold  of  anything  he  must 
swing  his  arm  forward  with  a  jerk  till  the  object  is 
brought  within  reach  of  his  fingers. 

The  muscles  of  the  trunk  become  at  times  involved: 
the  pectorales,  the  latissimi,  the  serrati,  and  the 
intercostales,  and  even  the  diaphragm  and  the 
abdominal  and  lumbar  muscles. 

The  muscular  atrophy  is  generally  accompanied  by 
responding  wasting  and  retraction  of  the  skin,  so 
that  this  continues  to  be  applied  to  the  muscles  in  the 
usual  manner.  In  some  instances,  however,  this  is 
not  the  case,  and  in  these  a  baggy  condition  of  the  skin 
is  added  which  gives  its  subject  an  appearance  which 
has  more  than  once  rendered  him  valuable  to  the 
showman  as  the  "elastic  skinned  man,"  etc.  It 
sometimes  happens,  on  the  other  hand,  that  the 
atrophy  is  obscured  by  an  accumulation,  between 
the  muscles  and  skin,  of  adipose  tissue,  and  an 
appearance  of  hypertrophy  rather  than  of  atrophy 
may  be  produced  in  consequence. 

\  second  muscular  symptom,  more  or  less  distinct, 
is  fibrillar  contraction.  This  consists  in  wave-like 
ractions  running  along  small  bundles  of  muscular 
fasciculi.  These  contractions  occur  spontaneously, 
or  are  excited  by  some  slight  stimulus,  as  a  breath 
of  air  or  a  dash  of  water,  or  by  tapping  the  patient 
with  the  fingers  or  passing  a  galvanic  current  through 
the  parts,  and  this  too  in  any  stage  of  the  disease, 
except  that  they  do  not  occur  in  muscles  wholly 
destroyed.  Sometimes  they  can  be  felt  by  the  patient; 
at  other  times  he  is  wholly  ignorant  of  them.  They 
are  not  invariably  present,  and  often  they  have  been 
seen  in  muscle  atrophy  from  other  causes;  they 
possess,  however,  a  certain  amount  of  diagnostic 
value,  especially  when  spontaneous.  Coincident 
with  the  wasting  of  muscles  is  their  loss  of  function. 
Sensibility  is  in  many  cases  unchanged,  the  tactile 
sense  being  as  delicate  as  ever,  and  pain,  except 
accompanying  the  cramps  and  chronic  contractions 
of  groups  of  affected  muscles,  which  sometimes 
occur,  is  absent.  At  times,  however,  the  atrophy  is 
preceded  by  painful  paroxysms,  which  may  or  may 
not  accompany  the  chronic,  contraction  referred  to. 
The  pain  is  sometimes  in  the  course  of  nerve  trunks, 


hut  is  as  often  diffu  e,  ■■>  if  the  muscles  themselves 
were  its  seat.  At  other  times  it  is  variously  described 
as  a  soreness,  an  aching  or  a  rheumatic  pain.     Morbid 

sensations,  as  those  of  cold,  numbness,  and  formica- 
tion may  be  experienced.  Keflex  excitability  may 
be  increased,  while  the  knee  jerk  is  said  to  be  absent. 

Unusual  sensitiveness  to  cold  is  sometimes  noted,  and 

SO  also  is  the  loss  of  muscular  power  under  its  in- 
llucnce,  which  is  again  restored  by  artificial  warmth 
(Tyson). 

The  lipomatosis,  which  has  already  been  alluded  to 
as  affording,  in  some  cases  of  muscular  atrophy, 
somewhat  the  appearance  of  the  pseudomuscular 
hypertrophy,  may  to  the  casual  observer  obscure  tho 
diagnosis  of  this  disease.  Pseudohypertrophic  par- 
alysis,  however,  almost,  invariably  first  asserts  itself 
in  the  lower  extremity. 

Syringomyelia  is  another  of  the  central  nervous 

diseases  which  finds  its  most  marked  expression  in  the 
secondary  changes  it  induces  in  the  sensory,  trophic, 
and  motor  functions  of  the  arms.  The  symptoms 
are  almost  always  bilateral,  but  a  few  cases  have 
been  observed  in  which  but  one  side  of  the  body  was 
affected.  The  most  common  type  is  that  in  which 
the  most  salient  features  are  loss  of  perception  of 
pain  and  temperature,  with  retention  of  the  tactile 
and  muscular  senses,  combined  with  atrophy  of  the 
arms  similar  to  that  observed  in  progressive  muscular 
atrophy.  The  atrophy  usually  appears  in  the  small 
muscles  of  the  hand  and  gradually  extends  upward, 
involving  consecutively  the  arm,  forearn,  and  shoul- 
der muscles,  or  it  may  first  appear  in  the  shoulder 
and  upper  arm  and  later  descend  to  the  hand.  The 
difference  depends  upon  whether  the  lower  cervical 
gray  matter  is  first  affected  with  extension  upward  of 
the  process,  or  whether  the  upper  cervical  enlarge- 
ment, in  which  are  located  the  centers  for  the  shoul- 
der muscles,  is  first  affected. 

Corresponding  with  the  atrophy  there  is  naturally 
a  weakness  of  the  muscles  which  may  go  on  to  com- 
plete paralysis.  Trophic  disturbances  are  common. 
Changes  in  the  joints  and  bones,  very  similar  to 
llio-e  observed  in  tabes,  occur  in  about  ten  per  cent, 
of  the  cases.  The  joint  changes  consist  principally 
of  enlargement  of  capsular  ligaments,  loosening  of  the 
joints,  thickening  of  the  capsule,  changes  of  form  in 
the  ends  of  the  bones,  and  development  of  bony 
spicule  in  the  capsular  walls.  The  further  changes 
resemble  those  in  tabetic  joints. 

Painless  fracture  of  the  bones  may  occur  from  very 
slight  causes,  as  in  the  case  of  a  man  who  fractured 
the  radius  while  kneading  dough.  Various  atrophic 
changes  in  the  skin  are  frequent,  such  as  herpes, 
eczema,  and  even  deep  ulceration  and  gangrene;  in 
rare  cases  amputation  of  the  hand  may  be  necessary; 
or  there  may  be  simply  vasomotor  changes  causing 
lividity  and  coldness  of  the  skin  or  the  opposite,  or 
edematous  swelling  of  the  hand.  There  may  be 
sweating  or  dryness  of  the  skin.  The  nails  may  be- 
come dry,   cracked,  and  brittle  and  may  drop   off. 

An  obtrusive  symptom  which  is  sometimes  ob- 
served is  the  painless  felon,  similar  to  that  which 
occurs  in  Morvan's  disease.  These  felons  occasion 
deep  ulceration  and  necrosis  of  the  distal  phalanges 
of  the  fingers  so  that  they  may  drop  off.  Notwith- 
standing this  extensive  ulceration  the  felons  are 
painless,   owing   to    the   analgesia   present    (Prince). 

For  a  more  accurate  differential  diagnosis  of  these 
different  secondary  muscular  dystrophies,  and  for  a 
more  exact  discussion  of  their  pathology  and  treat- 
ment, the  reader  is  referred  to  articles  in  this  work 
on  diseases  of  the  nervous  system. 

Spastic  rigidity  of  the  arms  is  often  one  of  the 
earliest  signs  of  chronic  hydrocephalus,  even 
before  the  skull  begins  to  enlarge,  and  convulsions 
may  be  present  from  time  to  time.  In  congenital 
spastic  rigidity,  due  to  sclerosis  or  defective  develop- 


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and  Injuries  of 


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ment  of  the  cortex  cerebri,   the  spastic  condition  is 
usually  confined  to  the  legs. 

In  paramyoclonus  mi'ltiplex,  as  the  name  of  the 
disease  implies,  the  contractions  of  the  muscles  ap- 
pear in  paroxysms  and  the  muscles  involved  are  usu- 
ally the  biceps,  deltoid,  and  triceps  in  the  arms,  and 
the  quadriceps  femoris  and  calf  muscles  of  the  lower 
limbs.  Myoclonus  multiplex  is  a  disease  of  adult 
life,  and  may  be  differentiated  from  chorea,  which  is 
usually  seen  in  childhood.  Sometimes  the  muscles 
in  myoclonus  are  exceedingly  irritable. 

Sometimes,  as  the  result  of  infantile  cerebral  par- 
alysis or  from  reasons  developing  later  in  life,  the 
muscles  of  the  hand  are  affected  by  a  slow,  constant 
movement,  so  that  the  fingers  assume  curious  con- 
strained and  unusual  postures,  being  moved  into  ex- 
treme or  forced  extension,  flexion,  pronation,  or 
supination.  This  condition  is  called  athetosis,  and 
is  separable  from  chorea  in  that  the  movements  are 
slower,  and  are  limited  to  the  fingers  and  wrists,  the 
arm  escaping. 

Absolute  loss  of  power  in  one  hand  and  arm,  with- 
out the  necessary  development  of  subsequent  de- 
formity, results  from  cerebral  or  peripheral  lesions  as 
a  rule,  being  rarely  spinal  in  origin,  and  is  called 
brachial  monoplegia.  Although  the  onset  of  a 
monoplegia  due  to  cortical,  subcortical,  or  capsular 
causes  is  sudden,  the  reactions  of  degeneration  do  not 
come  on  for  a  long  period  of  time  in  such  cases,  be- 
cause the  muscles  in  the  paralyzed  area  are  still  con- 
nected with  the  trophic  centers  in  the  cord,  and  this 
affords  us  a  valuable  point  in  differential  diagnosis. 
In  all  cases  of  brachial  monoplegia  due  to  peripheral 
lesions  we  find  that  atrophy  of  the  muscles  comes 
on  very  rapidly  from  cutting  off  of  the  muscles  from 
their  trophic  centers  in  the  spinal  cord. 

The  Tendons. — The  want  of  protection  of  the 
tendons  in  the  forearm  is  the  reason  of  their  frequent 
accidental  division  from  incised  wounds  near  the  wrist . 
In  the  event  of  such  division  the  proximal  end  will 
retract  an  inch  or  more  into  the  tissues  of  the  fore- 
arm, and  naturally  the  function  of  the  accompanying 
muscle  will  be  totally  suspended.  Where  several  of 
these  tendons  have  been  divided  at  once,  there  may 
be  considerable  difficulty  in  identifying  the  corre- 
sponding proximal  and  distal  ends.  In  any  clean 
wound,  however,  union  by  suture  should  be  attempted; 
nor  would  the  mistaken  apposition  of  the  proximal  end 
of  one  tendon  to  the  distal  end  of  another  prove  as 
serious  a  disaster  as  the  failure  to  unite  the  severed 
tendon  ends.  In  fact  an  intentional  transplantation 
of  the  proximal  end  of  one  tendon  to  the  distal  end 
of  another  has  recently  been  practised  with  brilliant 
success  in  some  cases  of  infantile  paralysis,  with  a 
view  to  imparting  vicarious  function  to  the  paralyzed 
members.  In  uniting  multiple  sections  of  the  ten- 
dons in  transverse  incised  wounds  of  the  wrist  and 
forearm,  it  is  important  that  the  union  should  be  at 
least  between  tendons  traversing  the  same  compart- 
ment of  the  annular  ligament. 

An  occasional  result  of  a  severe  sprain  is  the 
dislocation  of  the  tendons  about  the  affected 
joint.  The  long  head  of  the  biceps  is  oftenest  so 
affected,  being  displaced  from  its  groove  in  the  hu- 
merus. The  flexor  carpi  ulnaris  is  sometimes  in- 
jured in  this  way,  and  the  tendon  of  the  extensor  com- 
munis digitorum,  which  runs  to  the  index  finger,  is  not 
infrequently  torn  from  its  bed  at  the  back  of  the  wrist, 
owing  to  the  fact  that  the  portion  above  the  annular 
ligament  stands  at  quite  an  angle  to  the  portion  be- 
low. Its  displacement  is  always  to  the  radial  side. 
In  cases  of  dislocation  of  the  tendons,  the  muscles 
can  still  contract,  but  the  tendon  can  be  felt  to  move 
in  its  abnormal  position,  while  the  extremity  suffers 
a  partial  loss  of  function  from  the  mechanical  dis- 
advantage  under  which  the  muscle  works. 

These  accidents  may  be  treated  by  replacing  the 


tendon  and  keeping  it  in  position  by  a  splint.  This 
not  availing,  the  tendon  may  be  cut  down  upon  and 
the  torn  sheath  sutured  or  a  new  sheath  formed  by 
dissecting  up  a  band  of  periosteum. 

Among  the  traumatic  affections  of  the  tendons  we 
occasionally  meet  with  instances  of  complete  rupture. 
This  occurs  either  in  the  course  of  the  tendon  proper, 
or,  more  frequently,  at  the  attachment  of  the  tendon  to 
the  bone,  but  rupture  at  the  musculotendinous  junc- 
tion is  almost  unknown.  When  the  tendon  is  inserted 
into  a  special  epiphysis,  as  the  triceps  into  the  olecra- 
non process,  the  biceps  into  the  tubercle  of  the  radius, 
and  the  supinator  longus  into  the  styloid  process  of 
the  radius,  so-called  rupture  of  the  corresponding 
tendons  is  usually  accompanied  with  tearing  off  of  the 
epiphysis  and  more  or  less  stripping  up  of  the  adjacent 
periosteum,  constituting  what  is  known  as  a  fracture 
"par  arrachement."  The  tendons  of  the  arm  most 
frequently  the  subject  of  rupture  are  the  long  head  of 
the  biceps,  and  the  pronator  radii  teres;  the  radial 
attachment  of  the  biceps,  the  triceps,  the  deltoid,  and 
the  pectoralis  major  have  been  reported  as  torn  from 
their  insertions.  It  is  not  likely  that  rupture  of  a 
healthy  tendon  can  occur  except  when  the  muscle  is 
suddenly  and  unexpectedly  exposed  to  severe  ad- 
ditional strain  when  already  in  a  state  of  contraction. 
The  accident  is  generally  accompanied  by  sudden 
and  violent  pain,  by  complete  loss  of  power  in  the 
muscle,  and  by  considerable  impairment  of  function 
in  the  limb. 

The  treatment  will  vary,  according  to  the  importance 
of  the  affected  muscle  and  the  amount  of  disability 
incurred,  from  simple  rest,  with  pains  to  keep  the 
limb  in  a  position  to  relax  to  the  utmost  the  affected 
muscle,  to  more  or  less  elaborate  operative  procedures 
for  the  restoration  of  the  continuity  of  the  lacerated 
tissues  by  suture.  It  should  be  remembered  that 
contractures  may  subsequently  develop  in  conse- 
quence of  muscular  or  tendinous  ruptures. 

The  tendons  themselves  are  rarely  the  subject  of 
disease  which  does  not  also  involve  their  synovial 
sheaths  as  well.  They  may  become  necrotic  in  sup- 
purative processes  which  have  invaded  their  sheaths, 
and  in  this  case  their  separation  will  take  place  at  the 
point  where  their  intrinsic  blood-vessels  have  bci  n 
destroyed.  The  tendons  are  sometimes  the  seat  of 
deposits  of  urates,  and  not  infrequently  undergo 
calcareous  infiltration  in  advanced  life.  Ossification 
of  their  distal  ends  is  also  sometimes  observed,  and  in 
some  cases  there  is  an  anomalous  development  of 
sesamoid  bones  at  the  point  where  the  tendons  may 
form  an  angle  in  passing  over  bony  prominences. 
Rheumatic  deposits  are  sometimes  found  near  the 
proximal  end  of  the  tendons. 

The  Tendon  Sheaths. — Much  more  common 
than  disease  of  the  tendons  themselves  is  disease  of 
the  synovial  membrane  which  surrounds  them.  The 
exact  pathology  of  the  simple  irritative  form  of 
tenosynovitis  is  not  very  perfectly  understood. 
From  its  etiology  and  course  the  pathological  con- 
dition is  strongly  analogous  to  that  which  has  been 
discussed  under  the  head  of  myalgia,  and  is  prob- 
ably due  to  an  alteration  of  the  synovial  fluid  and 
possibly  of  the  endothelial  cells  lining  the  sac.  It  is 
observed  to  occur  under  conditions  strictly  analogous 
with  those  which  induce  an  attack  of  myalgia  i.e. 
exposure  to  cold  and  overuse  of  the  parts.  It  is 
generally  accompanied  with  lameness  and  tender: 
over  the  course  of  the  tendon,  and  characteristic  of 
the  condition  is  the  crepitation  which  follows  contrac- 
tion of  the  muscle.  Rest,  heat,  and  counterirrita- 
tion  are  the  best  means  for  relieving  the  difficulty. 

In  addition  to  the  simple  irritative  form,  a  septic,  a 
rheumatic,  a  syphilitic,  and  a  tuberculous  form  of 
tenosynovitis  are  recorded. 

The  septic  form  is  almost  invariably  secondary  to 
septic  processes  outside  of  the  tendon  sheaths,  and  in 
septic    tenosynovitis    of    the    forearm    the    locus   of 


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Arm  and  Forearm,  Diseases 
and  Injurlrs  ol 


primary  sepsis  is  most  frequently  the  hands  and 
fingers.  The  disease  is  accompanied  with  a  purulent 
effusion  into  the  tendon  sheaths,  giving  rise  to  tender 
oblong  swellings,  ill-defined  on  account  of  the  dis- 
tention due   to  accompanying   cellulitis,    and    lying 

iilrl  with  the  axis  of  the  limb.     The  surrounding 

tea  are  usually  sufficiently  involved  in  the  pyogenic 
process  to  give  rise  to  heat,  redness,  and  swelling  of 
the  surface.  Suppurative  tenosynovitis  has  been 
known  to  follow  gonorrheal  rheumatism  of  the  joints. 
The  treatment  of  purulent  thecitis  consists  in  laying 
open  the  tendon  sheaths  freely,  though  not  literally 
from  end  to  end  lest  the  tendon  escape  from  its  bed. 
Only  in  rare  cases  would  it  be  justifiable  to  divide  the 
annular  ligament  of  the  wrist  or  even  to  open  its 
compartments.  Great  effort,  however,  should  be 
made  to  irrigate  the  sac  most  freely  with  antiseptic 
solutions  through  the  liberal  incision  above  and  below 
the  bridge  of  tissue  which  it  may  be  deemed  wise  to 
leave  to  serve  as  a  bridle  to  hold  the  tendon  in  its 
bed,  and  particular  pains  should  be  taken  to  force  the 
irrigating  fluid  to  pass  under  this  bridge  of  tissue. 

In  dressing  wounds,  whether  operative  or  otherwise, 
of  the  tendons  or  of  the  tendon  sheaths,  it  must  be 
borne  in  mind  that  the  vascular  supply  of  these 
tissues  is  limited  and  that  in  consequence  when  they 
have  been  exposed  to  the  air  it  is  necessary  to  provide 
carefully  against  their  desiccation  in  order  to  avoid 
necrosis.     In   all   aseptic   conditions   of   the   tendon 

•lis  this  may  be  accomplished  by  covering  the 
exposed  tissues  with  impervious  protective  strips  of 

a-percha,  rubber,  or  prepared  mackintosh.  In 
septic  processes  the  use  of  impervious  dressings  is 
contraindicated,  and  provision  against  desiccation 
must  be  made  by  means  of  wet  dressings,  frequently 
renewed. 

serious  and  crippling  a  disease  is  purulent 
tenosynovitis,  and  so  indifferent  are  the  results 
obtained  by  ordinary  surgical  means,  that  I  have 
deemed  it  not  unwise  to  append  a  description  of  the 
treatment  by  passive  hyperemia,  as  outlined  by  Bier, 
in  his  book  "Hyperamie  als  Heilmittel." 

"Incipient  phlegmon  of  the  tendon  sheaths. 
whether  accompanied  or  not  by  a  wound  leading 
directly  to  the  sheath  of  the  tendon,  we  never  attack 
by  immediate  operation,  but,  on  the  contrary  the 
at  tempt  is  made  to  abort  the  process  at  the  outset  by 
vigorous  obstructive  hyperemia  (i.e.  by  means  of  a 
firm  constricting  bandage  applied  above  the  elbow). 
If  we  are  not  successful  in  this,  or  if  there  is  already 
unmistakably  present  a  considerable  accumulation 
of  pus,  the  abscess  is  opened,  either  through  one  large, 
or  through  multiple  small  incisions.  We  avoid  very 
long  incisions,  such  as  extend  the  whole  length  of  the 

;ed  tendons,  because  they  involve  the  danger  of 
having  the  tendon  disengage  itself  from  its  sheath, 
allowing  it  to  lose  its  proper  relations  with  the  sur- 
rounding soft  parts,  and  to  become  desiccated  and 
necrotic.  For  the  same  reason  we  abstain  from  the 
introduction  of  any  packing  or  any  drainage  appli- 
ances. Indeed,  a  most  important  consideration  is 
that  gauze  packing,  owing  to  its  capillarity,  with- 
draws the  nutrient  fluids  from  contact  with  the 
tendon  and  thus  favors  its  desiccation  and  necrosis. 
When,  on  the  other  hand,  the  wound  is  left  to  itself, 
the  exposed  tendon  presently  becomes  covered  with 
granulations  pushing  in  from  the  sides  of  the  sheath. 
Each  day  the  accumulated  pus  is  expressed  from  the 

1  incisions;  if  necessary,  the  pus  is  flushed  out 
with  a  stream  of  saline  solution.  If  fresh  abscess  - 
form  they  are  promptly  incised.  All  operative 
measures  are  conducted  under  narcosis,  for  the  sake 
of  more  thorough  work.  Xo  splint  is  used.  After 
any  operation  the  wound  is  simply  covered  with  a 
copious  absorbent  dressing,  because  the  obstructive 
hyperemia  generally  evokes  a  very  abundant  secre- 
tion. The  dressing  must  be  applied  very  loosely,  so 
that  the  limb  underneath  may  have  ample  opportun- 

Vol.  I. — 36 


it v   to  swell   under   the   influence   of   the  constricting 

bandage,  and  so  that  the  patient  shall  not  be  impeded 
in  malting  active  movements  of  tin-  fingers.     From 

the  very  first  day,  tin-  surgeon  executes  daily  pa 
movements  of  the  fingers  in  which  every  joint  of  each 
finger  is  both  Hexed  and  extended.  Only  in  this 
way  is  it  possible  to  obtain  full  restoration  of  function. 
Occasionally,  even  in  twenty-four  hours,  the  tendons 
will  have  contracted  adhesions  with  die  surrounding 
parts,  and  under  the  passive  flexion  and  extension, 
the  tearing  loose  of  these  adventit i<>us  attachments  is 
accomplished  only  with  a  very  perceptible  cracking. 
These  maneuvers,  which  under  other  conditions  would 
be  cruelly  painful,  are  relatively  easily  borne  owing  to 
the  conspicuous  analgesic  effect  of  the  obstructive 
hyperemia.  A  further  extension  of  the  suppuration, 
v.  Inch  one  would  perhaps  not  unnaturally  dread,  we 
have  not  encountered  as  the  result  of  such  passive 
movements.  The  constricting  bandage  is  removed 
from  above  the  elbow  a  certain  length  of  time  before 
beginning  the  passive  movements,  to  avoid  bleeding 
of  the  granulations.  The  best  time  to  undertake  the 
passive  movements  is  in  the  pause  between  two 
periods  of  hyperemization.  (The  general  recom- 
mendation in  the  treatment  of  acute  septic  processes 
is  to  leave  the  constricting  bandage  in  place,  above 
the  elbow,  for  from  twenty  to  twenty-two  hours  a 
day.)  The  patient,  furthermore,  is  urged  to  perform 
active  movements  of  the  fingers  at  frequent  intervals." 
The  results  which  Bier  has  attained  under  this 
method  of  treatment  are  most  satisfactory,  and  are 
far  in  advance  of  any  attained  before  his  method  of 
passive  hyperemia  was  introduced. 

It  is  likely  that  still  better  results  can  be  obtained 
by  combining  with  the  treatment  by  passive  hyper- 
emia, the  use  of  bacterial  vaccines.  This  would 
necessitate  a  careful  determination  of  the  nature  of 
the  infecting  germ,  and  the  application  of  a  corre- 
sponding vaccine.  If  the  streptococcus  were  found 
to  be  the  cause  of  the  septic  process,  such  a  vaccine 
would  probably-  prove  more  efficacious  if  grown  from 
autogenous  cultures. 

Like  all  diseases  of  the  fibrous  system,  tenosynovitis 
is  very  prone  to  occur  in  arthritic  subjects,  and  the 
rheumatic  form  of  texosyxovitis  has  a  very 
disagreeable  tendency  to  become  chronic.  In  the 
acute  stages  alkalies  and  the  salicylates  will  afford 
relief  to  the  patient.  In  the  later  stages  lithia  and 
the  iodide  of  potassium  are  the  most  servicable  drugs 
available;  while  the  exposure  of  the  limb  to  high 
temperatures  in  the  hot-air  bath,  together  with 
massage,  and  active  and  passive  motion  carried  on  in 
spite  of  the  soreness,  will  do  much  to  restore  the 
supple  action  of  the  arm. 

The  tuberculous  form  of  tenosynovitis  begins 
in  a  very  insidious  fashion.  It  may  be  primary  in  the 
tendon  sheath,  but  is  frequently  secondary  to  a 
tuberculous  process  in  the  adjacent  joints.  It  is, 
like  most  tuberculous  processes,  of  very  slow  growth, 
covering  a  period  sometimes  of  years,  with  times  of 
improvement  under  rest,  but  with  great  proneness  to 
recur  as  soon  as  the  limb  is  again  put  to  its  customary 
use.  It  develops  frequently  after  some  traumatism 
such  as  a  sprain  or  a  contusion,  and  the  differentiation 
from  the  simple  irritative  or  from  the  rheumatic  form 
is  not  at  first  easy.  After  a  while  there  will  almost 
always  be  developed  along  the  course  of  the  tendon 
the  characteristic  flat  or  oval  swelling,  caused  by 
eTusion  into  the  sheath  and  thickening  of  the  walls 
of  the  sheath  itself.  This  swelling  may  take  on  more 
or  less  of  an  hour-glass  shape  from  confinement  of 
the  tendon  beneath  the  annular  ligament.  The 
disease  may  remain  confined  to  one  portion  of  a 
single  tendon  -heath,  but  tends  to  extend  both 
upward  and  downward;  also  to  attack  neighboring 
tendons  and  even  to  invade  underlying  joints. 

According  to  Park,  there  are  two  pathological  forms 

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and  Injuries  of 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


of  the  disease:  one  is  a  fungous  form  distinguishable 
by  the  growth  of  exuberant  granulation  tissue  of  a 
gelatinous  appearance  surrounding  the  tendon  on  the 
inner  side  of' its  sheath.  In  the  other  form,  known  as 
hygroma,  the  inner  surface  of  the  tendon  sheath  is 
covered  with  small  growths,  which  become  detached, 
forming  small,  hard  kernels  known  as  rice  bodies. 
These  rice  bodies  are  the  result  of  fibrinoid  degenera- 
tion, i.e.  the  degenerated  villous  growths  which  are 
fibrinous  in  character  become  loosened,  forming  free 
kernels.  Until  recently,  this  form  of  disease  was 
supposed  to  have  no  connection  with  tuberculosis. 
It  is  now  distinctly  established  that  these  bodies  con- 
tain tubercle  bacilli.  The  same  condition  may  be 
found  in  tuberculous  joint  disease  where  they  develop 
from  a  fibrinoid  degeneration  of  tuberculous  granula- 
tions on  the  synovial  fringes.  If  the  disease  is  allowed 
to  run  its  course,  suppuration  ensues,  forming  sinuses 
involving  the  skin  which  eventually  breaks  down. 
These  with  the  resulting  cicatrices  greatly  impair  the 
use  of  the  hand. 

The  treatment  of  tuberculous  tenosynovitis  is 
essentially  the  same  as  that  of  tuberculous  joint 
trouble,  and  consists  at  first  in  the  immobilization  of 
the  arm  by  suitable  splints,  with  moderate  pressure, 
together  with  the  administration  of  appropriate 
tonics  and  careful  attention  to  hygiene.  It  is  essential 
to  differentiate  positively  the  tuberculous  form  of  the 
disease  from  the  simple  irritative  and  the  rheumatic 
form.  Massage  so  preeminently  useful  in  the  treat- 
ment of  the  two  latter  forms,  is  absolutely  and 
positively  contraindicated  in  tuberculous  synovitis. 
The  possible  usefulness  of  dry  heat,  by  means  of  the 
hot-air  bath  (active  hyperemia),  is  not  altogether 
settled,  though  it  would  seem  to  be  a  rational  thera- 
peutic measure.  Less  doubtful  is  the  beneficial 
effect  of  "obstructive"  or  "passive"  hyperemia  by 
means  of  a  constricting  bandage  above  the  elbow. 
The  application  of  this  method  of  treatment  to 
tuberculous  lesions  demands,  however,  considerably 
more  care,  judgment,  and  circumspection  than  its 
application  to  ordinary  septic  processes.  Three 
points  are  insisted  on  by  the  advocates  of  passive 
hyperemia  in  applying  it  to  all  tuberculous  lesions: 
first,  the  bandage  must  be  very  lightly  applied,  so  as 
to  induce  but  a  mild  degree  of  venous  obstruction,  as 
opposed  to  the  much  firmer  application  of  the 
bandage  in  ordinary  forms  of  sepsis;  secondly,  the 
bandage  should  remain  in  place  a  much  shorter  time, 
from  one  to  two  hours  a  day,  instead  of  twenty  to 
twenty-two  hours;  and,  thirdly,  the  treatment  must 
be  patiently  continued  for  a  long  period,  several 
weeks  or  months.  Where  this  method  of  treatment 
is  applicable,  it  has  the  further  great  advantage  that, 
at  least  during  the  time  that  the  constricting  bandage 
is  in  place,  both  active  and  passive  movements  of  the 
fingers  can  safely  and  advantageously  be  carried  out 
with  comparatively  little  pain.  Such  active  and 
passive  exercise  of  the  fingers  naturally  very  greatly 
favors  complete  restoration  of  function  after  eventual 
recovery  from  the  tuberculous  process  in  the  tendon 
sheaths.  Without  the  use  of  passive  hyperemia, 
such  movements  of  the  fingers  are  counterindicated 
in  tuberculous  tenosynovitis,  until  after  complete 
subsidence  of  the  infectious  process,  and  their  use  at 
so  late  a  date  can,  in  the  nature  of  the  case,  yield  only 
indifferent  results.  Failure  to  secure  improvement 
by  the  above  means  would  justify  us,  as  in  cases  of 
joint  tuberculosis,  in  proceeding  to  operative  meas- 
ures. The  simplest  of  these  consists  in  aspirating  the 
fluid  contents  of  the  tendon  sheaths  and  in  injecting 
into  them  a  tcn-per-cent.  emulsion  of  iodoform. 
Should  this  fail  to  control  the  process,  the  tuberculous 
area  should  be  cut  down  upon,  the  blood-supply  to 
i  lie  .inn  being  first  cut  off  with  an  Esmarch  bandage, 
and  any  suspicious  granulation  tissue  scraped  away 
with  a  small  curette.  At  any  point  where  the 
tendon  itself  seems  hopelessly  affected,  it  should  be 


freely  resected  and  an  effort  shoiuji  be  made  by 
splitting  and  grafting  the  tendon  to  compensate  for 
the  defect.  Even  should  this  be  impossible,  the 
function  of  the  tendon  may  better  be  sacrificed  than 
to  expose  the  patient  to  danger  of  loss  of  the  limb 
or  even  of  life. 

Syphilitic  tenosynovitis  may  exhibit  itself  in  an 
acute  and  chronic  form,  not  easy  to  differentiate  by 
symptoms  alone  from  simple  and  rheumatic  inflamma- 
tion of  the  tendon  sheaths.  Both  of  these  forms  of 
syphilitic  thecitis  are  seen  in  early  syphilis,  and  I 
have  myself  observed  one  marked  case  ending  in 
resolution  after  some  months  of  treatment,  in  a  case 
of  hereditary  syphilis  accompanied  with  syphilitic 
pachymeningitis. 

The  gummatous  form  is  almost  invariably  very 
late  in  development,  occurring  often  fifteen  or  twenty 
years  after  infection.  It  is  recognized  as  a  round  or 
spindle-shaped  swelling  involving  the  tendons.  It 
grows  slowly  and  painlessly,  remaining  as  a  gumma- 
tous swelling  becoming  calcareous,  or  extending  to  the 
surrounding  tissues,  the  fascia  and  the  skin. 

Synovial  cysts  of  the  tendon  sheaths,  other- 
wise known  as  weeping  sinews  or  ganglions,  occur 
with  greatest  frequency  about  the  wrist,  whether 
just  above  or  just  below  the  annular  ligament. 
There  are  cases  met  with,  however,  in  the  lower  part 
of  the  forearm,  both  on  the  flexor  and  on  the  extensor 
tendons.  Their  exact  pathology  is  a  matter  of 
dispute,  but  it  is  fairly  well  established  that  they 
rarely  communicate  with  the  synovial  sac  proper. 
They  not  infrequently  contain  rice  bodies  such  as  are 
found  in  the  synovial  sac  in  cases  of  tuberculous 
disease,  but  their  almost  invariably  benign  course 
would  make  it  seem  improbable  that  their  origin 
should  be  tuberculous.  These  little  cysts  frequently 
disappear  spontaneously,  and  often  their  disappear- 
ance can  be  hastened  by  moderate  pressure  long 
continued.  More  obstinate  cases  can  be  dealt  with 
by  free  subcutaneous  puncture  with  a  sharp  bistoury 
or  tenotome  and  the  expression  of  their  contents  by 
digital  pressure  into  the  surrounding  cellular  tissues. 
Some  cases  may  demand  free  incision  and  extirpation 
of  the  cyst  walls,  an  operation  which  must  be  con- 
ducted with  careful  antiseptic  precautions,  on 
account  of  the  close  association  and  occasional 
continuity  of  the  cyst  with  the  tendon  sheath  proper. 

V.  Affections  of  the  Blood-vessels. 

The  Arteries. — The  blood-vessels  of  the  arm 
are  subject  to  the  same  diseases  as  the  blood-vessels 
elsewhere  in  the  body.  The  anatomical  position 
of  the  radial  artery  is  important  from  its  frequent 
use  for  taking  the  pulse,  and  it  should  be  remembered 
that  it  may  be  absent  in  rare  instances;  or  it  may 
be  much  smaller  than  normal,  terminating  in  muscular 
branches  above  the  wrist;  or  it  may  lie  upon  the  deep 
fascia  instead  of  beneath  it;  or  it  may  be  covered  by 
fascia  so  thick  and  hard  that  the  pulsation  cannot 
readily  be  transmitted  to  the  finger  tips;  finally,  it 
may  turn  backward  beneath  the  extensor  muscles  of 
the  thumb.  When  in  its  normal  position  it  is  easily 
felt,  pulsating  almost  subcutaneously  over  the  bones 
of  the  wrist. 

Atheroma  of  the  arteries  manifests  itself 
through  thickening  of  the  vessel  wall,  either  localized 
or  diffuse,  and  often  accompanied  by  the  deposit  of 
calcareous  salts  until  a  condition  of  the  vessel  is 
produced  well  expressed  by  the  term  "pipe-stem 
artery."  It  is  most  readily  appreciable  in  the  radial 
artery  near  the  wrist.  Its  chief  importance  in  this 
connection  is  not  with  regard  to  the  function  of  the 
vessels  of  the  arm,  but  as  an  indication  of  the  condi- 
tion of  the  vascular  system  throughout  the  body. 
The  vascular  sclerosis  will  often  be  found  more 
marked  in  the  right  arm  than  in  the  left,  in  individuals 


562 


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Ami  and  Forearm,  Diseases 
and  Injuries  of 


such  as  stone  cutters  and  blacksmiths  who  habitually 
perform  much  heavier  labor  with  that  arm  than  with 
the  left.  When  this  condition  of  arteriosclerosis  is 
found  to  be  present,  it  is  an  important  guide  to  the 
surgeon  in  leading  him  to  make  a  guarded  prognosis 
aa  to  the  result  of  severe  operation  anywhere  in  the 
body. 

Aneurysms  occur  in  the  vessels  of  the  arm  as 
They  may  be  present  at  any  age;  indeed 
Schmidt  reports' an  aneurysm  of  the  radial  artery  in 
an  Infant  of  eight  weeks. 

The  traumatic  forms  affecting  the  arm  are  chiefly 
■  springing  from  the  axillary  artery  and  showing 
in  the  arm  pit.  The  arteriovenous  form  of  an- 
eurysm was  formerly  quite  a  common  occurrence 
v. lien  venesection  was  more  generally  practised. 
The  adjacent  artery  being  wounded  by  the  incision 

,-ii  opened  the  vein,  adlie-ions  form  Viet  ween  the 
two  vessels  and  part  of  the  arterial  blood  is  thrown 
into  the  vein  at  each  pulsation,  the  vein  greatly  dilat- 
ing under  the  strain. 

iiD  aneurysms  are  occasionally  met  with  on 
t  he  forearm.     They  are  formed  of  dilated  and  tortuous 
arteries.      In  a  ease  that  came  under  my  observation, 
tumor  extended  from  a  little  below  the  elbow 
almost  to  the  wrist,  and  was  about  three  inches  wide. 
On   operation   a  mass  of  dilated  arteries  was  found 
lying  in  the  superficial  fascia,  fed  by  numerous  branches 
"rating  the  deep  fascia  from  below.     The  treat- 
ment of  this  form  of  aneurysm,  which  stands  on  the 
der  line  between  tumors  and  malformations,  con- 
in  thorough  extirpation,  approaching  the  mass 
of  pulsating  vessels  from  the  periphery  and  tying  all 
the  feeder-  at  their  point  of  emergence  from  the  deep 
ia.      With   careful   dissection,   working  from   the 
-    toward    the    center   of    the    tumor,    dangerous 
hemorrhage  can  usually  be  avoided.     The  diagnosis 
of  aneurysm  can  usually  be  made  by  observing  that 
the  tumor  has  an  expansile  pulsation  which  ceases  on 
application  of  firm  pressure  on  its  proximal  side.     In 
the  case  of  cirsoid  aneurysm  in  which  the  feeders  are 
numerous  and  come  from  the  parts  directly  under- 
neath the  tumor,  pressure  on  the  proximal  side  will 
not  suffice  to  interrupt  the  pulsation  of  the  mass.     A 
characteristic  bruit,  can  in  most  cases  be  heard  over 
the  tumor.     The  treatment  of  aneurysm  of  the  upper 
extremity  does  not  differ  from  the  treatment  of  the 
condition  elsewhere. 

The  Veins. — The  veins  of  the  upper  extremity 
are  subject  to  the  same  affections  as  those  elsewhere 
in  the  body;  such  as  'wounds,  phlebitis,  thrombosis, 
and  varices. 

The  condition  of  the  veins  of  the  hand  and  fore- 
arm is  a  valuable  index  of  the  condition  of  the  general 
circulation  as  regards  aeration  of  the  blood  and  pos- 
olistruction  to  the  venous  circulation.  These 
veins  dilate  when  the  heart  is  weak,  or  when  there  is 
any  impediment  to  the  return  circulation  in  the  do- 
main of  the  vena  cava  superior. 

Phlebitis  may  be  caused  by  inflammation  near  the 
vessel,  by  thrombus  formation,  by  traumatism,  or  by 
direct  infection.  It  gives  rise  to  pain  and  tender- 
ness  in  the  course  of  the  vessel,  to  edema  and  discolo- 
ration of  the  skin,  and  if  at  all  extensive,  systemic 
symptoms  occur  which  are  those  of  mild  or  severe 
sepsis. 

The  treatment  of  simple  phlebitis  consists  first  of 
all  in  rest,  which  should  be  insisted  on  as  most  im- 
portant to  prevent  the  detachment  of  emboli.  Next 
it  is  necessary  to  secure  as  near  an  approximation  to 
asepsis  of  the  intestinal  tract  as  may  be  practicable, 
and  finally  some  benefit  may  be  expected  from  the 
use  of  antiseptic  and  stimulating  substances  applied 
along  the  course  of  the  affected  vein,  such  as  a  fifty- 
per  cent,  ointment  of  ichthyol  or  Crede's  silver  oint- 
ment; the  object  of  the  treatment  being  to  maintain 


the  intergrity  of  the  thrombus  within  the  inflan 

el  until  such  time  as  .shrinking  of  the  coagulated 
fibrin  may  allow  a  partial  restoration  of  the  vascular 
■  ■anal,  and  to  stimulate  the  absorptive  function  of  the 
perivascular  lymph  channels.  Upon  the  first  in- 
dication of  septic  infecti f  the  thrombus,  as 

denced  by  chills  and  septic  fever,  or  by  local  abscess 
formation,  it  is  proper  and  necessary  to  incise  the 
tissue-  freely  over  the  affected  vessel,  to  clean  out  the 
septic  clot,  and  establish  free  drainage.  During 
such  an  operation  it  may  be  possible  to  restore  the 
patulousness  of  many  adjacent  veins  which  may 
have  become  thrombotic,  by  extracting  from  their 
lumen  long,  more  or  less  linn  clots  oil  coagulated 
blood  and  fibrin.  Great  care,  however,  must  Be  used 
in  manipulation  of  the  affected  limb  to  avoid  break- 
ing loose   portions  of  the  blood  clot  within   the    vi 

which  might  be  carried  as  emboli  to  the  lungs  or  to  the 
brain,  and  give  rise  to  dangerous  or  even  fatal  in- 
farctions. 

Thrombosis  is  due  to  conditions  that  slow  the 
blood  stream  associated  with  abnormal  condition-  of 
the  endothelial  coat.  It  gives  rise  to  sudden  and 
severe  pain  and  to  edema  on  the  distal  -ide  of  the 
coagulum.  The  treatment  is  essentially  that  of  the 
phlebitis,   which  is  an  almost  invariable  attendant. 

Varices  are  rare  in  the  upper  extremity,  owing  to 
the  less  unfavorable  action  of  gravity  as  compared 
with  the  lower  extremity,  but  they  may  occasionally 
be  found. 

VI.  Affections  of  the  Lymphatic  Vessels, 
Glands,  and  Burs^e. 
The  Lymph  Vessels  and  Lymph  Glands. — In  con- 
sidering the  affections  of  the  lymphatic  system  of 
the  arm,  one  anatomical  peculiarity  should  be  borne 
in  mind — namely,  that  the  greater  part  of  the  lym- 
phatic current  from  the  hand  and  forearm  passes 
directly  to  the  axillary  and  subscapular  nodes  with- 
out traversing  the  epitrochlear  gland  and  the  other 
lymphatic  nodes  at  the  bend  of  the  elbow.  The 
importance  of  this  course  of  the  lymphatic  canals 
is  indicated  in  cases  of  septic  and  malignant  disease 
of  the  hand,  as  some  cases  on  record  tend  to  prove  that 
the  lymphatic  vessels,  as  compared  with  the  lymphatic 
nodes,  may  with  considerable  impunity  serve  in  the 
transmission  of  both  septic  and  malignant  particles. 
Thus  in  cancer  of  the  hand,  with  more  or  less  extensive 
involvement  of  the  axillary  nodes,  it  has  been  recorded 
in  some  cases  that  amputation  of  the  hand  and 
radical  extirpation  of  the  axillary  lymphatics  has 
succeeded  in  leaving  the  patient  free  from  recurrence 
of  the  disease,  and  in  a  similar  manner  we  frequently 
find  the  axillary  glands  fatally  compromised  and 
breaking  down  into  abscesses  with  the  lymphatic 
vessels,  by  which  infection  from  the  hand  must  have 
travelled,  remaining  to  all  appearances  intact.  It 
behooves  the  surgeon  in  all  cases  of  disease  of  the 
distal  part  of  the  upper  extremity  to  examine  with 
care  the  condition  of  the  cubital  and  axillary  glands 
and  to  palpate  also  the  course  of  the  deeper  lymphatic 
vessels,  which  is  to  all  intents  and  purposes  that  of  the 
main  arteries. 

The  epitrochlear  node  is  situated  in  the  bicipital 
sulcus  just  in  front,  of  the  inner  epicondyle  of  the 
humerus.  It  is  one  of  the  first  glands  to  become  en- 
larged and  indurated  in  the  general  adenitis  of 
syphilis. 

Elephantiasis  appears  occasionally  in  the  arms, 
but  more  rarely  than  in  the  lower  extremities. 
Lymphangioma  is  also  rarely  met  with,  but  may 
occur,  particularly  along  the  course  of  the  deep 
lymphatics.  Lymphadenitis  may  of  course  affect 
the  nodes  of  the  arm  as  those  elsewhere,  and  is  due 
either  to  infection  in  the  acute  form  from  some  focus 
of  sepsis  on  the  line  of  drainage,  or,  in  the  chronic 

563 


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and  Injuries  of 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


form,  is  usually  due  to  tuberculous  or  syphilitic  dis- 
ease. As  in  all  cases  of  adenitis,  it  is  important  to 
study  the  anatomical  distribution  of  the  lymphatic 
vessels  which  center  in  the  affected  node  with  a  view  to 
determine  the  portal  of  infection.  The  axillary 
glands  may  be  involved  as  a  result  of  disease  of  the 
upper  extremity,  but  more  frequently  as  a  result  of 
disease  of  the  thorax  and  of  the  neck. 

The  Bursa-. — of  the  bursa?  of  the  arm  that  most 
frequently  diseased  is  the  one  over  the  tip  of  the 
olecranon  process.  This  bursa  when  inflamed  and 
distended  gives  a  characteristic  alteration  of  the 
contour  of  the  arm.  It  is  sometimes  present  as  an 
occupation  lesion,  and  is  known  as  "miner's  elbow." 

The  type  of  inflammation  present  may  be  either  a 
simple  traumatic  bursitis,  a  septic  bursitis,  or  in  some 
cases  a  gummatous  bursitis.  In  addition  to  these 
are  the  various  forms  of  secondary  bursitis  due  to 
extension  of  disease  of  the  bone  or  of  the  joint.  The 
only  ease  in  which  the  diagnosis  of  bursitis  is  likely 
to  offer  any  difficulty  is  in  its  earlier  stages  before 
effusion  in  the  bursal  sac  has  taken  place.  In  this 
case  it  may  be  difficult  to  differentiate  it  from  perios- 
titis and  perhaps  from  rheumatism. 

The  treatment  of  simple  bursitis  should  be  direct- 
ed either  toward  causing  absorption  of  effused  fluid,  or 
in  default  of  this,  toward  the  obliteration  of  the  sac. 
To  this  end  it  is  wise  in  the  acute  form  of  the  disease 
to  try  the  effect  of  heat,  compression,  and  the  use  of 
various  agents  such  as  iodine  and  ichthyol,  whose 
function  it  is  to  stimulate  lymphatic  absorption. 
Later  in  the  disease  a  different  form  of  therapeutic 
effort  will  be  more  likely  to  be  successful,  ranging 
from  tapping  alone,  to  tapping  followed  by  the 
injection  of  irritating  fluids,  if  necessary  to  incision 
and  packing,  or  even  total  excision  of  the  walls  of 
the  bursa. 

In  the  septic  form  of  the  disease  the  contents  of 
the  bursa  will  probably  be  purulent  and  the  surround- 
ing tissues  will  be  angry  and  inflamed,  and  what  was 
in  the  simple  form  of  the  disease  a  painless  fluctuating 
tumor  may  take  on  all  the  characteristics  of  an  acute 
abscess.  In  this  case  no  treatment  is  of  avail  which 
does  not  involve  prompt  and  free  incision  and  the 
evacuation  of  the  pus.  It  is  particularly  in  septic 
cases  that  the  danger  of  joint  involvement  by  con- 
tiguity  of  tissue  must  be  considered.  In  the  other 
forms  of  disease  of  this  bursa,  the  liability  to  second- 
ary joint  involvement  is  slight. 

As  already  stated,  the  bursa  frequently  becomes 
sympathetically  involved  in  any  of  the  diseased 
processes  of  the  joint  (rheumatism,  tuberculosis, 
syphilis,  etc.) ;  and  in  view  of  this  we  are  not  surprised 
to  find  occasionally  an  acute  syphilitic  bursitis  over 
the  olecranon  appearing  at  the  time  of  the  severe 
joint  pains  which  characterize  the  earlier  stages_  of 
secondary  syphilitic  invasion.  This  type  of  bursitis 
tends  to  spontaneous  amelioration  and  subsides 
pari  passu  with  the  joint  affection. 

A  more  characteristic  form  of  syphilitic  bursitis 
occurs  in  this  region  as  a  late  secondary  lesion  (second 
or  third  year).  This  difficulty  is  independent  of  the 
joint  itself  and  consists  in  the  development  of  gum- 
matous nodules  in  the  wall  of  the  bursa,  presently 
enlarging  and  becoming  confluent  until  the  whole 
bursa  represents  one  large  gummatous  mass.  The 
process  soon  extends  beyond  the  walls  of  the  bursa 
and  involves  the  skin  in  gummatous  infiltration. 
When  the  skin  has  become  involved,  this  vulnerable 
mass  is  very  prone  to  pyogenic  infection  and  second- 
ary ulceration  of  an  obstinate  and  destructive 
character.  Like  syphilitic  affections  elsewhere,  in 
the  absence  of  special  constitutional  depression  the 
m  will  yield  readily  to  the  combined  use  of  anti- 
syphilitic  ami  antiseptic  measures,  neither  of  which 
may  suffice  for  a  cure. 

There  are  two  other  bursa?  connected  with  the 
upper  extremity  whose  surgical  importance  was  not 

564 


fully  appreciated  until  recently  emphasized  by  the 
work  of  Goldthwait,  of  Boston,  from  whose  work  on 
"Diseases  of  the  Bones  and  Joints"  the  following 
paragraphs  are  largely  taken.  These  two  bursas,  the 
subacromial"  or  "subdeltoid"  bursa  and  the 
"subcoracoid"  or  "coracobrachialis"  bursa,  are  both 
functionally  connected  with  the  shoulder  joint.  The 
subacromial  bursa  is  situated  under  the  acromial  proo 
cess,  outside  of  the  capsule  of  the  shoulder  joint,  and 
extends  over  the  greater  tuberosity  of  the  humerus 
and  out  under  the  upper  part  of  the  deltoid  muscle. 
In  raising  the  arm  from  the  body  at  the  side  (abduc- 
tion), the  surfaces  of  this  bursa  glide  over  each  other, 
and  if  for  any  reason  the  bursa  becomes  inflamed, 
this  motion  will  be  attended  with  pain,  and  if  such 
inflammation  exist  or  adhesions  have  formed,  motion 
will  be  limited,  and  the  extent  of  the  limitation  will 
depend  upon  the.  extent  of  adhesion  formation.  If 
the  cavity  of  the  bursa  is  wholly  obliterated,  all  rota- 
tion and  nearly  all  abduction  at  the  shoulder  joint 
will  he  impossible.  Pain  is  usually  referred  directly 
to  the  location  of  the  bursa  or  over  the  situation  of 
the  deltoid  muscle,  frequently,  likewise,  to  the 
attachment  of  this  muscle  to  the  humerus. 

The  subcoracoid  bursa  is  situated  betweed  the  tip 
of  the  coracoid  process  and  the  outer  surface  of  the 
shoulder  joint  as  it  extends  to  and  over  the  lesser 
tuberosity  of  the  humerus.  As  the  result  of  a  posture 
such  as  occurs  when  the  shoulder  is  habitually  carried 
forward  (the  round-shouldered  or  stoop-shouldered 
attitude),  the  lesser  tuberosity  of  the  humerus  rests 
against  the  tip  of  the  coracoid  process,  and  so  too  in 
many  occupations  the  arm  is  used  so  that  these  two 
bones  are  in  contact  more  constantly,  or  with  more 
force  than  is  normal,  under  which  circumstances  the 
subcoracoid  bursa  becomes  inflamed.  If  such  an 
inflammation  occurs,  there  will  be  pain  and  sensitive- 
ness with  limitation  of  motion.  This  limitation  of 
motion  at  the  shoulder  joint,  when  caused  by  adhe- 
sions between  the  two  layers  of  the  subcoracoid  bursa, 
is  such  as  one  would  expect  if  the  anterior  part  of  the 
capsule  of  the  joint  were  attached  to  the  coracoid 
process.  Such  an  adherence  of  these  structures 
would  not  materially  interfere  with  flexion  or  exten- 
sion of  the  arm,  as  long  as  motion  was  made  in  the 
anteroposterior  plane,  or  with  raising  the  arm  from 
the  side,  provided  the  motion  was  made  in  a  purely 
lateral  plane,  because  in  all  these  motions  the  sub- 
coracoid bursa  is  comparatively  little  used.  If, 
however,  rotation  is  attempted,  either  with  the  arm 
at  the  side  or  when  the  arm  is  raised,  limitation  is  at 
once  apparent,  because  in  rotation  the  lesser  tuber- 
osity of  the  humerus  must  either  glide  over  (in  inward  ' 
rotation)  or  move  away  from  (in  outward  rotation", 
the  coracoid  process.  It  is  this  limitation  that  makes 
difficult  the  putting  on  of  a  coat  or  similar  garments, 
the  dressing  of  the  hair,  the  fastening  of  the  bands  of 
shirts,  etc.,  all  of  which  involve  movement  of  these 
bones  in  rotation  one  upon  the  other.  If  the  sub- 
coracoid bursa  is  inflamed,  pain  is  usually  located 
just  outside  the  tip  of  the  coracoid  process.  At  times 
pain  is  referred  to  the  deltoid  region  or  down  the 
arm,  t lie  region  of  the  attachment  of  the  deltoid  to 
the  humerus  being  a  common  place,  or  along  the 
course  of  the  ulnar  nerve.  Occasionally  the  whole  arm 
and  hand  are  painful,  and  associated  with  this  there 
may  be  disturbances  of  circulation,  the  whole  condi- 
tion appearing  like  a  true  neuritis. 

The  treatment  of  subacromial  bursitis  is  practically 
that  outlined  above  for  bursitis  of  the  elbow,  with 
this  addition  that  the  weight  of  the  arm  must  be 
supported  by  a  sling,  either  a  "mitella"  or  the  more 
satisfactory  Moore's  dressing  for  fracture  of  the 
clavicle.  The  special  treatment  of  subcoraci 
bursitis  should  be  based  on  the  etiology  of  the  condi- 
tion, as  explained  above,  and  should  include  proper 
means,  either  by  gymnastics  or  by  shoulder-brai 
to  do  away  with  the  causative  round-shoulders.     Its 


REFERENCE    BANDBOOK    OF    THE    MF.DICAI.   SCIENCES 


Arm  and  Foreamii  Diseases 
and  in j uries  ol 


general  treatment  is  by  heat,  rest,  counterirritation, 
etc.  When  extensive  and  firm  adhesions  have  formed, 
these  can  sometimes  be  broken  up  by  forced  manipu- 
lation under  an  anesthetic.  In  sonic  cases  it  \\ill  be 
fouml  that  the  cavity  of  the  bursa;  lias  become  so 
completely  obliterated  that  in  spite  of  all  manipula- 
tions the  adhesions  re-form,  and  improvement  is 
impossible  from  such  methods.     Under  such  circum- 

uces  an  operation  should  be  performed  and  the 

bursa'   removed.      Both    of    these    bursa?   are   easily 

hed,  and  following  the  complete  removal  of  the 

bursal  tissue,  normal  function  is  often   obtained,    the 

nee  of  the  bursa;  seemingly  being  of  little  im- 
portance. 

VII.  Affections  of  the  Nerves. 

The  nerves  of  the  arm  and  forearm  are  liable  to  the 

usual    forms    of    disease    of    these    tissues    elsewhere 

(neuralgia,  neuritis,  etc.),  with  similar  symptoms  and 

demanding    similar    treatment.     The    main    interest 

hing  to  disease  of  the  nerves  of  the  arm  is  due 

anatomical  distribution,   giving  motor  and 

iiv  disturbances  in  certain  well-defined  regions. 

The  three-  chief  types  of  such  lesions  are  exhibited 

ectively  in  interference  with  the  function  of  the 

ulnar,  of  the  median,  and  of  the  musculospiral  nerve. 

In  ulnar  paralysis,  the  muscles  affected  are  the 
ulnar  half  of  the  deep  flexor  of  the  fingers  (perforatus), 
the  ulnar  flexor  of  the  wrist,  the  hypothenar  muscles, 
the  two  external  lumbrical  muscles,  all  of  the  interos- 
adductor  pollicis,  and  the  inner  head  of  the 
Bexor  pollicis  brevis.  The  position  assumed  by  the 
hand,  due  to  the  unopposed  action  of  the  antagonist 
muscles,  is  characteristic.  The  hand  becomes  more 
--  law-shaped  and  the  condition  is  known  as 
■'main  en  griffe.  This  typical  position  is  assumed 
by  the  hand  only  when  the  paralysis  has  lasted  some 
time  (three  or  four  weeks  or  longer).  The  wrist  is 
slightly  bent  backward  and  to  the  radial  side  of  the 
irm  by  the  unopposed  action  of  the  extensors  and 
flexors  of  the  radial  side  of  the  wrist  and  of  the  extensor 
carpi ulnaris.  It  is  the  defect  of  the  interossei  which 
gives,  however,  the  most  marked  and  characteristic 
deformity  of  ulnar  paralysis.  The  fingers  cannot  be 
Hexed  at  the  first  phalanges  nor  extended  at  the 
md  and  third,  and  in  consequence  of  this,  through 
the  continued  action  of  the  extensor  communis  digi- 
torum,  the  first  phalanges  are  markedly  over-extend- 

■  wing  to  the  w-ant  of  opposition  from  the  lumbri- 
cales and  interossei,  while  the  continued  action  of  the 
flexor  sublimis  and  the  unparalyzed  portion  of  the 
flexor  profundus  digitorum  bring  the  second  and 
third   phalanges  into  extreme   flexion.     The   loss  of 

ation  in  ulnar  paralysis  varies  considerably:  in 
some  eases  the  sensation  is  lost  in  the  little  finger  and 
the  ulnar  portion  of  the  ring  finger,  also  throughout  the 
ulnar  portion  of  the  palm  and  the  dorsum  of  the  hand. 
In  other  cases  there  is  but  little  attendant  anesthesia. 
The  second  marked  picture  of  nerve  lesion  in  the 
forearm  is  found  in  paralysis  of  the  median  nerve. 
Destructive  injury  to  this  nerve  above  its  muscular 
branches  causes  paralysis  of  the  flexors  of  the  fingers 
excepting  the  ulnar  half  of  the  flexor  profundus,  and 
Of  the  other  muscles  to  which  the  median  is  distrib- 
uted: to  wit.  the  pronators,  the  flexor  carpi  radialis, 
the  two  outer  lumbricales,  and  all  the  muscles  of  the 
ball  of  the  thumb,  except  the  abductor  pollicis  and  the 
inner  head  of  the  flexor  pollicis  brevis.  The  flexion 
of  the  wrist  and  of  the  hand,  and  the  pronation  of  the 
forearm  are  very  greatly  impeded  but  not  altogether 
abolished  by  the  loss  of  function  in  these  muscles. 
The    flexor    carpi    ulnaris    is     still    in     action    and 

■  pronation  is  possible  thourgh  the  weight  of  the 
hand  when  the  supinators  are  relaxed.  The  extension 
and  abduction  of  the  thumb  are  characteristic,  and 
the  thumb  cannot  be  made  to  touch  the  tips  of  the 
fingers.     Flexion  of  the  two  distal  phalanges  is  no 


longer  possible,  though  thi  Si  I  phalanges  are  flexed 
by  the  interossei.  The  loss  of  sensation  i-  again 
variable;  the  most  characteristic  distribution  ol 

thesia being  the  thumb,  index  and  middle'  fingers, 
and  the  radial  side  ol  the  ling  finger  with  the  radial 

side  of  the  pal f  t  he  hand.     'I  a<  ton  of  t  he 

dorsum  of  the  hand  is  not  greatly  affected.  Again,  a 
characteristic  appearance  of  the  hand  and  forearm  is 
produced,  with  great  atrophy  of  the  forearm    on  the 

radial  side  and  in  front .       I  he  wrist    is  inclined  ti 
ulnar  side,  and  the  thumb,  whose  flexor  and  adductor 

muscles  are  wasted,  is  usually  rotated  outward  so  that 

its  palmar  surface  is  on  a  plane  with  that  of  the  wrist 
and  t  he  fingers,  as  in  api 

The  third  characteristic  picture  of  injury  to 
nerves  of  the  arm  is  thai  afforded  by  paralysis  op 
hi  musculospiral  nerve.  In  paralysis  of  the 
musculospiral  nerve  loss  of  power  occurs  in  all  the 
extensors  of  the  forearm  and  of  the  wrist  and  in  the 
supinators,  with  the  occasional  exception  of  the  supi- 
nator  longus.  The  wrist  drops  and  the  finger 
flexed  at  their  distal  joints.  Sot xtension  of  the  fin- 
however,  can  be  obtained  through  the  action  of 
the  interossei  and  lumbricales.  The  typical  distribu- 
tion of  the  anesthesia  after  actual  division  of  the 
nerve  above  its  cutaneous  branches  is  along  the  outer 
part  of  the  arm  from  the  insertion  of  the  deltoid  to 
the  lower  third  of  the  forearm,  and  there  is  more  or 
less  affection  of  the  sensation  of  the  dorsum  of  the 
hand,  though  in  many  cases  there  is  little  or  no  involve- 
ment of  sensation. 

The  ulnar  nerve  is  more  exposed  to  injury  than 
any  other  nerve  in  the  body.  In  the  wrist,  at  the 
elbow,  and  in  the  upper  arm  the  nerve  is  liable  to 
division  from  incised  wounds,  to  pressure  or  contusion, 
or  to  involvement  in  fractures  of  the  bone.  Some- 
times an  apparently  spontaneous  ulnar  neuritis  is 
observed  in  persons  otherwise  in  good  health. 

One  peculiar  accident  is  liable  to  affect  the  ulnar 
nerve  as  it  passes  behind  the  inner  condyle  of  the 
humerus,  namely,  dislocation  from  its  bed.  This 
accident  is  accompanied  with  more  or  less  neuralgic 
pain  referred  to  the  region  of  distribution  of  its  cuta- 
neous branches,  and  with  more  or  less  involvement  of 
the  functions  of  the  muscles  to  which  it  is  distrib- 
uted. The  pain  as  well  as  the  motor  symptoms 
will  be  most  marked  when  the  arm  is  flexed.  In 
short  there  is  excited  in  the  nerve  at  this  point 
a  localized  neuritis.  The  accident,  which  is  rare, 
may  occur  spontaneously  during  violent  use  of 
the  arm,  as  in  ball-playing  and  gymnastic  exercise, 
or  as  the  result  of  a  contusion.  Pain,  numbness, 
and  tingling  along  the  ulnar  side  of  the  forearm  and 
of  the  hand  will  indicate  the  moment  of  its  occur- 
rence and  a  cord  can  be  felt  running  along  the  inner 
side  of  the  epicondyle  which  reveals  itself  as  the  dis- 
located nerve  through  the  aggravation  of  all  these 
symptoms  when  pressed  upon  by  the  examining  fin- 
ger. To  avoid  extension  of  the  neuritis  and  all  the 
undesirable  sequela;  of  nerve  degeneration,  it  is  im- 
portant that  the  nerve  should  be  returned  to  its  bed 
and  securely  fastened  there.  For  this  purpose  a  free 
incision  should  be  made  over  the  course  of  the  dis- 
located nerve  and  a  firm  flap  of  connective  tissue 
should  be  dissected  up  from  the  inner  side  of  the 
condyle  and  turned  outward  over  the  nerve  so  as 
to  bind  it  in  its  proper  bed.  The  edge  of  this  flap  of 
connective  tissue  should  be  sutured  to  the  capsular 
ligament  of  the  elbow  joint  or  to  the  periosteum  of  the 
humerus.  It  is  wiser  not  to  allow  the  needle  to  pass 
through  the  nerve  sheath  for  fear  of  exciting  neuralgic 
pains.  The  arm  should  be  put  up  and  fixed  in  ex- 
tension and  this  position  maintained  until  the  parts 
shall  have  firmly  united.  If  the  symptoms  of  neu- 
ritis in  the  mean  time  have  disappeared,  the  limb 
should  be  treated  with  massage,  faradization,  coun- 
terirritation, active  and  passive  motion,  etc. 


565 


Arm  and  Forearm,  Diseases 
and  Injuries  of 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


The  median-  nerve  is  often  injured,  most  fre- 
quently in  incised  wounds  of  the  wrist.  In  the  fore- 
arm it  suffers  in  case  of  fracture  of  the  ulnar  and 
radius,  and  just  above  the  elbow  its  course  to  the 
bicipital  groove  exposes  it  to  injury.  The  nerve  per- 
forates the  pronator  radii  teres,  and  it  is  possible 
for  it  to  be  injured  in  forcible  contraction  of  this 
muscle  without  direct  external  violence. 

The  muscclospiral  nerve  is  generally  the  sufferer 
in  crutch  paralysis  from  pressure  in  the  axilla.  Its 
close  connection  with  the  humerus  leads  to  its  fre- 
quent injury  in  case  of  fracture  and  to  its  frequent 
involvement  in  the  callus  or  between  the  fragments. 
The  most  frequent  cause  of  the  paralysis  is,  however, 
damage  to  the  nerve  during  sleep,  the  patient  lying 
upon  a  hard  bed  with  his  arm  under  him.  This  is 
seen  particularly  in  drunkards.  In  many  cases  this 
injury  of  the  musculospiral  nerve  is  due  not  so  much 
to'  pressure  as  to  stretching  of  the  plexus  by  prolonged 
extension  of  the  arm  above  the  head.  It  is  important 
for  the  surgeon  to  bear  this  in  mind,  as  it  is  the  fre- 
quent cause  of  arm  paralysis  after  anesthesia.  The 
prognosis  in  paralysis  of  this  description  is  almost 
invariably  good;  the  most  potent  therapeutic  agent 
being  faradization  of  the  affected  muscles. 

Progressive  muscular  atrophy  and  syringomyelia, 
together  with  the  other  spastic  and  paretic  affections 
of  the  arm,  though  more  properly  due  to  nerve  influ- 
ences than  to  actual  affections  of  the  muscle,  have 
nevertheless,  for  the  sake  of  convenience,  been  treated 
above  under  the  head  of  affections  of  the  muscles. 

VIII.   Hysterical  Lesions. 

The  elbow  is  a  favorite  seat  for  hysterical  lesions, 
and  the  arm  as  a  whole  is  frequently  declared  by  the 
patient  to  be  powerless,  or  may  be  held  by  perverted 
volition  in  some  constrained  attitude  which  may  be 
the  more  natural  one  of  extension,  or  of  partial 
flexion,  or  again  some  strange  or  bizarre  position 
from  which  the  patient  declares  herself  unable  to 
move  it. 

The  differentiation  of  hysterical  from  organic 
disease  of  the  arm  may  be  extremely  difficult. 
Hysterical  affections  simulate  especially  disease  of 
the  joints.  The  differential  diagnosis  has  been 
formulated  by  Dercum  as  follows:  Hysterical  disease 
of  the  joints  is  not  associated  with  deformity  and 
shortening  of  bone,  nor  with  the  formation  of  pus, 
nor  with  the  local  rigidity,  nor  with  the  septic  tem- 
perature that  is  seen  in  tuberculous  diseases.  The 
stiffness  is  caused  by  contracture  of  the_  muscles, 
which  is  usually  much  more  extensive  than  in  organic 
disease,  and  the  pain  is  usually  more  diffuse  and  more 
spontaneous.  There  are,  moreover,  characteristic 
mental  and  physical  stigmata  present.  The  hyster- 
ical patient  dreads  to  move  or  assist  in  the  examina- 
tion of  the  limb,  and  obviously  dwells  upon  each 
symptom,  while  she  is  very  apt  to  have  segmental 
anesthesia  in  the  affected  limb  or  even  hemianesthesia 
of  the  body.  A  very  significant  symptom  is  paralysis 
of  the  limb,  which  is  never  present  in  tuberculous 
joint  disease.  Finally,  under  full  etherization  the 
hysterical  joint  is  found  to  be  freely  movable  in  all 
directions.  It  must  not  be  forgotten,  however,  that 
hysterical  symptoms  may  be  added  to  those  of 
genuine  organic  disease  of  the  joint. 

Hysterica]  paralysis  may  be  caused  by  emotion, 
such  as  fright,  anger,  chagrin,  or  disappointed  love. 
It  may  vary  in  degree  from  slight  loss  of  power  to 
total  palsy.  The  deep  reflexes  of  the  affected  side 
are  usually  increased  and  the  skin  reflexes  abolished. 
The  tendency  to  contracture  is  often  marked:  some 
ca  es,  however,  present  a  flaccid  type.  In  mild  cases 
the  nutrition  of  the  limb  is  not  affected,  but  in  severe 
ca  es  of  long  duration  slight  but  distinct  loss  of 
volume  may  !"■  noted.  True  atrophy  with  reaction 
of  degeneration   is   practically   unknown,   and  when 


present  must  throw  a  doubt  over  the  exactness  of 
the  diagnosis.  Hysterical  paralysis  is  often  accom- 
panied also  with  anesthesia  or  hyperesthesia.  The 
anesthesia  is  likely  to  be  sharply  defined  and  limited 
to  the  paralyzed  "part.  The  boundary  of  the  anes- 
thetic area  will  be  at  right  angles  to  the  long  diameter 
of  the  limb.  The  paralyzed  part  may  become 
edematous  and  blue  or  mottled.  The  hyperesthesia 
accompanying  hysterical  paralysis  is  usually  hyper- 
algesia. This  hyperalgesia  may  be  attended  with 
contracture.  The  painful  cramp-like  state  of  the 
muscles  causes  the  patient  to  cry  out  and  to  shed  tears. 
Hysterical  paralysis  is  not  as  a  rule  confined  to  the 
distribution  of  particular  nerve  trunks;  in  other 
words,  it  is  central,  not  peripheral.  Contracture  is 
very  likely  to  coexist  with  paralysis  in  hysteria,  still 
this  is  not  a  constant  rule.  Neither  is  the  reverse 
true:  that  a  contracted  limb  or  muscle  is  always 
paralyzed.  Hysterical  contracture  is  most  obstinate 
and  resisting,  being  very  difficult  to  overcome  even 
with  great  force.  Moreover,  the  antagonistic  muscles 
are  involved;  in  other  words,  the  limb  is  drawn  into 
a  vise-like  immobility.  The  contracture  is  sometimes 
so  persistent  that  it  does  not  relax  even  in  sleep.  It 
does  relax,  however,  under  ether  or  chloroform. 

The  duration  of  hysterical  paralysis  may  be  greatly 
prolonged.  Some  cases  recover  promptly,  but  others 
persist  so  long  and  simulate  so  closely  the  effects  of 
organic  disease  that  even  the  most  careful  observer 
may  come  to  distrust  the  exactness  of  his  diagnosis. 
The  termination  of  hysterical  paralysis  is  sometimes 
sudden,  following  some  shock  or  strong  mental  or 
moral  impression.  Sometimes,  however,  recovery  is 
gradual  under  well-directed  treatment. 

IX.  Tumors. 

Of  the  tumors  affecting  the  arm  and  forearm  none 
is  peculiar  to  this  locality.  Keloids  following  si 
of  any  sort  are  found  here  as  elsewhere,  as  are  tin 
other  forms  of  neoplasm  which  may  develop  from  the 
skin  or  its  appendages.  Fibromata  may  occur  on 
the  arm  in  the  form  of  painful  subcutaneous  nodules 
over  the  course  of  the  superficial  nerves.  Lipomata 
are  found  with  considerable  frequency  upon  the 
upper  extremities.  They  are  most  commonly  of 
the  cutaneous  variety,  and  are  found  chiefly  upon 
the  posterior  side  of  the  arm  and  upon  the  ulnar  side 
of  the  forearm,  frequently  also  upon  the  shoulders 
and  over  the  scapula.  They  have  also  been  found 
burrowing  beneath  the  muscles  of  the  forearm. 

Sarcoma  sometimes  occurs  here  as  a  primary 
growth,  usually  in  the  callus  of  a  fracture  or  as  a 
tumor  of  the  bone.  Secondary  metastatic  sarcomata 
may  of  course  be  deposited  from  the  blood-vessels  in 
the  arm  as  elsewhere.  In  this  case  they  are  generally 
seen  as  subcutaneous  sarcomatous  nodules. 

Carcinoma  very  rarely  occurs  excepting  as  a 
secondary  growth  from  epithelioma  of  the  hand. 
Epithelioma  of  the  hand  in  turn  develops  with  com- 
parative frequency  in  old  age  from  purely  benign  \\ 
which  are  so  frequently  encountered  upon  the  fingers, 
and  a  case  has  recently  come  under  observation  in 
which  a  verrucose  condition  existed  symmetrically  on 
the  extensor  aspect  of  each  elbow,  suggesting  the 
possibility  of  a  primary  carcinoma  in  this  region 
with  a  pathological  history  similar  to  that  of  epithe- 
lioma of  the  hand.  Leonard  W.  Bacon. 

Army  Medical  Department.— The  Medical  Depart- 
ment of  the  U.  S.  Army  received  the  organizal  ion  « Inch 
it  has  at  the  present  time  (1912)  by  the  Act  of  April  23, 
190S,  by  which  it  was  largely  increased  and  greatlj 
improved  in  status  and  efficiency,  ruder  the  Army 
Regulations  "The  Medical  Department  is  charged 
with  the  duty  of  investigating  the  sanitary  condition 


566 


REFERENCE    HAND  ROOK    OF   THE    MEDICAL    SCIENCES 


Army  Medical  Department 


of  tlic  Army  and  making  recommendations  in  refer- 
ence thereto,  of  ad\  ising  with  reference  to  I  he  location 
,,i  permanent  camps  and  posts,  the  adoption  of 
s.   tenia  of  water  supply  and  purification,  and   the 

,li  |„,sal  of  wastes,  with  the  duty  of  caring  for  the 
sick  and  wounded,  making  physical  examinations  of 
officers  and  enlisted  men,  the  management  and  con- 
trol of  military  hospitals,  the  recruitment,  instruction, 
and  control  of  the  Hospital  Corps  and  of  the  Nurse 
I  lorps,  and  furnishing  all  medical  and  hospital  supplies 
except  for  public  animals." 

The  organization  of  the  Medical  Department  is  as 
follows: 

ill     I  he    Surgeon-General,     who     is     chief     of   the 
Department; 

the  Medical  Corps; 

The  Medical  Reserve  Corps; 

The  Dental  Corps; 

The  Army  Nurse  Corps; 

The  Hospital  Corps; 
7)  The  clerical  force  and  other  civilians  employed 
from  time  to  time  under  the  authority  of  the  annual 
appropriation  acts. 

To  these  might  be  added  the  civilian  physicians 

employed  under  contract,  once  a  large  and  important 

class  who  supplemented   the   commissioned   medical 

ris  and  made  good  the  deficiency  of  numbers  of 

the  latter  in  time  of  military  exigency.     Since  the 

lion  of  the  Medical  Reserve  Corps,  however,  it  is 

as    commissioned    officers    of    this    corps    that    civil 

physicians   are    called    into    the    Army    when    their 

services  are  needed  in  time  of  war  or  other  necessity 

only  a  few  contract  surgeons  are  now  employed 

for  duty  of  a  special  character  or  at  special  localities 

h  as  arsenals  and  remount  depots. 

The   status,    duties,    and   responsibilities   of   these 

several  classes  will  be  stated  in  order. 

(1)  The  surgeon-general  has  the  rank,  pay,  and 
.inres  of  a  brigadier  general  and  is  the  Chief  of 
Medical  Department.     As  the  head  of  a  bureau 
of    the    War    Department    he    is    charged    with    the 
supervision  of  the  expenditure  of  the  Medical  Depart- 
ment appropriations  and  is  the  adviser  of  the  Secre- 
tary of   War  and   the   Chief  of    Staff  upon   matters 
ins;  to  the  health,  sanitation,  and  physical  fitness 
of  the  Anny.  and  the  administration  of  the  medical 
service   in   all   its  branches.     He   exercises   military 
control  over   the   general  hospitals,   medical   supply 
lots,  hospital  ships  and  trains,  but  not  over  the 
medical  personnel  and  medical  units  which  are  under 
command  of  officers  of   the  line  of  any  grade, 
ept  in  so  far  as  relates   to  duties,   reports,  and 
supplies  of  a  purely  professional  nature. 

The  Surgeon-General  is  not  only  the  ranking  officer 
of  the  Medical  Corps  and  Chief  of  the  Medical  Depart- 
ment, but  is  also  at  the  head  of  the  Surgeon-General's 
office,  a  bureau  of  the  War  Department,  which  latter 
is  one  of  the  great  executive  departments  through 
which    the   government   is   administered.     The    War 
artment  is  not  a  part  of  the  Army,  although  the 
ruing   power   for   it,    and  containg   many   army 
officers  among  its  higher  personnel,  and  in  the  same 
way  the   Surgeon-General's  Office   is  a  civil  bureau, 
imed  by  a  permanent  clerical  force  belonging  to 
the  civil  service  and  paid  from  another  appropriation 
than  the  Army,  although  several  medical  officers  are 
on  duty  in  it  in  charge  of  divisions  of  the  office. 

Surgeon-General's  Office. — This  office  being  the  ad- 
ministrative agency  by  which  the  Surgeon-General 
rcises  his  authority  and  his  advisory  functions 
0  i-  the  medical  service  of  the  Army,  a  brief  descrip- 
tion of  it  is  appropriate,  although  as  above  shown  it 
is  not  strictlv  speaking  a  part  of  the  Medical  Depart- 
ment.  Besides  the  medical  officers  detailed  for  duty 
therein,  and  the  Superintendent  of  the  Nurse  Corps, 
the  personnel  of  the  bureau  consists  of  ninety-eight 


clerks  of  various  grades,  seven  specialist-  connected 

with  the  library  and  the  museum,  and  some  mechanic-, 
messengers,  laborers,  et  C. 

As  shown  by  the  diagram  the  office  is  divided  into 
five  divisions: 

The  first  under  the  Chief  Clerk,  a  civilian,  has 
charge  of  the  general  correspondence,    the   records, 

the    disposition    of    the    mail,     the    examinations    of 

property   and   money   accounts,   the   preparation   of 

plans  lor  t  he  const  ruction  and  repair  of  hospitals,  and 
the  control  of  the  clerical  force. 

The  second,  the  Supply  Division,  is  under  a  medical 
officer,  anil  has  charge  of  the  purchase  and  issue  of 
medical  supplies  and  equipment  of  every  sort,  and 
their  accumulation  for  war,  the  administration  of  the 
depots  for  medical  supplies,  and  the  disbursement, 
of  the  medical  and  hospital  appropriations,  and  those 
for  artificial  limbs  and  apparatus  for  pensioners. 

0  Commissioned  medical  officer 
■  Civil  official  or  clerK", 


Secretary  of  War 


Chief  of  Staff  J 


Surgeon  General 


Fia.  317. — Diagram  of  the  Divisions  of  the  Surgeon-General's  Office. 

The  third,  the  Sanitary  Division,  is  under  a  medical 
officer  and  passes  upon  all  medical  questions  which 
come  to  the  War  Department,  including  the  recom- 
mendations made  by  medical  officers  in  their  sanitary 
reports.  It  handles  also  all  questions  of  physical 
fitness  for  the  military  service  in  officers  and  enlisted 
men  and  reviews  the  proceedings  of  retiring  boards. 
It  tiles  and  collates  the  records  of  sick  and  wounded, 
tabulates  the  vital  statistics  of  the  army  and  prepares 
the  annual  report  of  the  Surgeon-general. 

The  fourth,  the  Personnel  Division,  is  under  a 
medical  officer.  It  keeps  the  personal  records  of,  and 
conducts  the  correspondence  relating  to  the  stations 
and  duties  of  all  individuals  of  the  Medical,  Medical 
Reserve,  Dental,  Nurse,  and  Hospital  Corps,  in  all 
about  4,3(10  persons  in  time  of  peace. 

The  fifth,  the  Museum  and  Library  Division,  is 
under  a  medical  officer  with  several  assistants,  of 
which  two  are  permanent  civil  appointments  con- 
nected with  the  library,  and  another,  a  medical  officer, 
is  curator  of  the  Medical  Museum.  This  division 
occupies  its  own  building  at  the  corner  of  Seventh  and 
B  streets,  S.  W.,  Washington,  D.  C.  The  Museum 
was  established  during  the  Civil  "War  and  contains 
in  all  more  than  34,000  specimens.  It  is  particularly 
rich  in  specimens  illustrating  gun-sliot  injuries  of  the 
skeleton;  in  colored  representations  in  wax  of  skin 
diseases;  in  specimens  snowing  the  historical  develop- 
ment of  microscopes,  ophthalmoscopes,  stethoscopes; 
and  in  specimens  illustrating  the  development  of 
surgical  apparatus.  It  has  also  a  large  collection  of 
medals  celebrating  medical  and  hygienic  subjects 
and  events. 

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REFERENCE    HANDBOOK   OF    THE    MEDICAL    SCIENCES 


The  library  was  developed  in  the  years  succeeding 
the  Civil  War  from  a  small  collection  of  books  for  the 
use  of  medical  officers  on  duty  in  Washington  into  the 
great  national  institution  which  it  is  at  present.  It 
has  over  175,000  bound  volumes  and  310,000  pam- 
phlets and  theses.  Its  collection  covers  the  literature 
of  medicine  since  the  invention  of  printing.  Besides 
the  fact  that  it  is  the  largest  medical  library  in  the 
world  its  distinctive  feature,  which  has  made  it 
famous,  is  the  index  catalogue  which  covers  the  en- 
tire range  of  medical  subjects,  being  arranged  both 
by  subjects  and  authors.  Osier  says  with  reference 
to  it  "While  there  is  not  in  American  medicine  much 
of  pure  typographical  interest,  a  compensation  is 
offered  in'one  of  the  most  stupendous  biliographical 
works  ever  undertaken.  The  Index-Catalogue  of  the 
library  of  the  Surgeon-general's  office  atones  for  all 
shortcomings,  as  in  it  is  furnished  to  the  world  a 
universal  medical  bibliography  from  the  earliest  times. 
It  will  ever  remain  a  monument  to  the  Army  Medical 
Department,  to  the  enterprise,  energy  and  care  of  Dr. 
Billings,  and  to  the  scholarship  of  his  associate, 
Dr.  Robert  Fletcher." 

(2)  The  medical  corps  consists  of  the  following 
grades  and  numbers  of  medical  officers  besides  the 
Surgeon-general,  all  of  whom  have  the  rank,  pay, 
and  allowances  of  officers  of  corresponding  grades  in 
the  cavalry  arm  of  the  service: 

14  colonels; 
21  lieutenant-colonels; 
in")  majors; 

300  captains  and  lieutenants;  the  officers  of  the 
latter  grade  being  promoted  to  the  former  after 
three  year's  service,  provided  that  they  have 
been  proven  proficient  by  passing  the  pre- 
scribed examination  for  such  promotion. 

Appointments  in  the  Medical  Corps  are  mad.  •  by  the 
President  and  confirmed  by  the  Senate  upon  the 
recommendation  of  the  Surgeon-general  after  the  ap- 
plicant has  passed  the  prescribed  physical  and  pro- 
fessional examination.  These  examinations  are  rigid 
'and  the  success  of  the  candidate  depends  upon  his 
own  merits  and  qualifications  alone,  official  and 
political  influences  being  powerless  to  make  good 
deficiencies.  The  candidate  must  be  a  citizen  of  the 
United  States,  between  twenty-two  and  thirty  years 
of  age,  must  have  satisfactory  general  education, 
must  be  a  graduate  of  a  reputable  medical  school 
legally  authorized  to  confer  the  degree  of  doctor  of 
medicine,  and  must  have  had  at  least  one  year's 
hospital  training,  including  practical  experience  in 
medicine,  surgery,  and  obstetrics. 

Th.'  examination  consists  of  two  parts,  a  prelimi- 
nary and  a  final  or  qualifying  examination.  The 
former  is  held  by  boards  convened  at  convenient 
places,  usually  military  posts  in  various  parts  of  the 
country,  which  make  the  physical  examination,  and 
then  conduct  the  professional  examination  which  is  in 
writing  and  by  questions  sent  to  the  board  from  the 
office  of  the  Surgeon-general.  Qualified  applicants 
are  then  appointed  to  the  Medical  Reserve  Corps, 
with  the  rank  of  First  Lieutenant,  and  ordered  to 
Washington  for  a  course  of  instruction  in  the  Army 
Medical  School.  They  receive  the  pay  and  allow- 
ances of  that  grade  for  the  journey  and  during  the 
session  of  the  school,  which  lasts  from  the  first  of 
i  ictober  to  the  last  of  May. 

This  school  was  established  in  1893  by  Surgeon- 
general  Sternberg  in  the  City  of  Washington.  It 
gives  advanced  and  very  practical  courses  in  hygiene, 
sanitary  chemistry,  clinical  microscopy  and  bacteri- 
ology, tropical  medicine,  the  military  aspects  of 
medical  and  surgical  practice,  ophthalmology  and 
optometry,  Roentgen-ray  work,  medical  department 
administration,  and  the  military  duties  of  medical 
officers,  hospital  corps  drill,  and  first-aid.     Lectures 


are  also  given  in  psychiatry  with  clinical  instruction 
at  the  Government  Hospital  for  the  Insane,  and  a 
short  course  in  military  law  by  the  Judge-advocate 
General.  Instruction  in  horsemanship  is  given  by 
officers  of  cavalry  at  Ft.  Myer.  The  laboratories  of 
the  Army  Medical  School  are  equipped  for  research 
work  as  well  as  clinical  instruction,  and  the  facilities 
of  the  Army  Medical  Museum,  and  the  Library 
of  the  Surgeon-general's  Office  are  available  for  its 
teachers  and  students. 

Candidates  who  fail  to  reach  a  satisfactory  standard 
at  the  qualifying  examination  or  whose  conduct  or 
scholastic  standing  is  not  satisfactory  during  the 
term,  are  discharged  and  returned  to  their  homes. 
Successful  candidates  are  at  once  given  commissions 
in  the  Medical  Corps,  if,  as  is  usually  the  ca~c, 
vacancies  exist  therein,  and  are  at  once  assigned  to 
duty  with  troops. 

The  pay  of  a  First  Lieutenant,  Medical  Corps,  is 
$2,000  a  year.  He  is  also,  as  are  all  medical  officers, 
furnished  with  a  house,  furniture,  fuel,  lights,  horses, 
forage,  and  professional  books  and  instruments.  He 
is  permitted  to  purchase  government  supplies  at  cost 
and  when  he  travels  under  orders  his  expenses  are  paid 
and  his  personal  property  transported  free  of  charge. 
At  the  end  of  three  years'  service  he  is  promoted  to 
Captain,  Medical  Corps,  provided,  however,  that  he 
passes  satisfactorily  a  prescribed  examination  which 
is  intended  to  demonstrate  whether  or  not  the  young 
officer  has  made  good  use  of  his  time  and  opportunities, 
In  ease  of  failure  in  this  examination  the  proceedings 
of  the  examining  board  are  reviewed  by  a  special 
board  and  if  their  findings  are  confirmed  the  officer  -o 
failing  is  given  an  honorable  discharge  from  the 
service  with  a  donation  of  a  year's  pay. 

In  this  and  subsequent  examinations  for  pro- 
motion, if  the  officer  is  found  to  be  physically  unfitted 
for  active  service  because  of  a  disability  incurred  in 
the  line  of  duty  he  is  promoted  and  retired.  In  less 
than  two  years  after  receiving  his  promotion  as 
Captain  the  medical  officer  has  completed  his  first  five 
years  of  service  and  becomes  entitled  to  an  increase 
of  pay  of  ten  per  cent,  and  for  each  additional  term 
of  five  years  a  further  increment  of  ten  per  cent,  is 
added  to  the  pay  of  his  grade  up  to  forty  per  cent,  at 
the  end  of  twenty  years  service.  These  increments 
are  colloquially  known  in  the  Army  as  "fogies."  Pro- 
motion to  the  next  grade  of  Major  depends  upon  the 
occurrence  of  vacancies  in  the  upper  grades,  and  is 
theoretically  assumed  to  occur  after  from  fifteen  to 
eighteen  years  of  total  service,  but  of  late  years,  owing 
to  increases  in  the  Medical  Corps  from  time  to  time, 
the  period  has  in  most  instances  been  much  less. 
The  promotion  to  the  grade  of  Major  is  after  an  ex- 
amination under  similar  conditions  but  differing 
in  scope  from  that  for  the  grade  of  Captain,  and  failure 
is  followed  by  a  like  penalty.  When  the  medical 
officer  reaches"  the  top  of  the  list  of  majors  he  under- 
goes the  third  and  last  examination  for  promotion, 
but  as  the  duties  of  the  next  grade  of  Lieutenant- 
colonel  are  mainly  of  a  supervisory  and  administra- 
tive nature,  this  examination  is  not  professional 
in  character  except  as  regards  the  applications  of 
preventive  medicine  and  general  and  military  hygiene, 
but  deals  largely  with  the  important  duties  of  Chief 
Surgeons.  Because  of  the  age  and  length  of  service 
of  officers  of  this  rank  the  penalty  of  failure  is  some- 
what different,  being  suspension  from  promotion  for 
a  year  and  a  second  trial  at  the  end  of  that  time.  If 
then  successful  the  promotion  accrues,  but  if  the 
officer  again  fails  he  is  placed  on  the  retired  list  with 
three-fourths  of  the  pay  of  the  grade  of  major.  _ 

Promotion  to  the  grade  of  Colonel  is  by  seniority. 
The  Surgeon-general  is  appointed  by  the  President 
by  selection  from  the  officers  of  the  Corps,  but  usually 
from  the  two  upper  grades,  for  a  term  of  four  years 
and  may  be  reappointed  for  a  second  or  third  term 
provided    he   does   not    meanwhile  reach  the  age  of 


.Vis 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENI  I  3 


Army  Medical  Department 


(sforty-four,  at  which  retirement  from  active  service  i 
compulsory  by  law  for  all  offii 

From    tin'   Colonels    and    Lieutenant-colonels   are 

selected  tin'  Chief  Surgeons  of  militarj  -  and 

departments,  tin'  Chief  Surgeons  of  the  larger  military 

commands  of  tin-  mobile  army  fur  sen  ire  in  the  Geld, 

tho  commanding   officers   of   general    hospitals,    and 

other  like  positions  of  importance  and  responsibility. 

Tin'  salary  of  medical  officers  of  the  several  grades 

depends  somewhat  upon  the  length  of  service  i>  i 

[e  lint    the  follow  inn   table  represents  what  may 

insidered  the  normal  rates  of  pay: 

<  !  .  .riers  With  quarters 

Grade,                                         furnished.  commuted. 

First  lieutenant V $2,432 

in -'.400  2.976 

in,  five  years' service 2,640  3,216 

in,  ten  years' service 2,880  3.456 

lin,  fifteen  years' service.. .  .      3,120  3,696 

fifteen  years' service 3,900  4,620 

ir,  twenty  years'  service     ....     4.000  4,720 

mant-colone] 4,500 

id 5,01    i  6,008 

Burgeon-general 6,000  7, 1  52 

Fuel  and  lights  are  furnished  in  kind,  the  allowance  being 
iberal  and  increasing  with  each  grade. 

The  distinguishing  color  of  the  Medical  Depart- 
ment was  formerly  green,  but  after  the  Spanish  War 
in  1902  maroon  was  adopted  because,  being  the  dis- 
tinctive color  of  the  medical  service  of  most  of  the 
great  military  powers,  its  advantages  in  war  were 
obvious.  This  color  appears  in  the  uniforms  of  all 
commissioned  officers  of  the  Medical  Corps,  Medical 
Reserve  Corps,  and  Dental  Corps  on  the  shoulder 
straps,  the  collar  of  the  full  dress  coat,  and  the  band 
of  the  dress  cap.  The  distinctive  badge  of  the  Medi- 
cal Department  is  the  caduceus  which  is  worn  on 
each  side  of  the  collar  of  the  service  and  dress  coats, 
on  the  sleeve  cuffs  of  the  full  dress  and  special  evening 
dress  coats,  and  the  overcoats  of  all  commissioned 
officers  of  the  Medical  Department.  In  the  case  of 
the  Reserve,  Dental,  and  Nurse  Corps,  the  caduceus 
is  surcharged  with  the  monogram  appropriate  to  each. 


W^ 


Fig.  318. — Badge  oi  the  Medical  Corps. 


(3)  The  medical  reserve  corps  was  created  1  ty  t  he 
reorganization  of  April  23,  1908,  to  take  the  place  of 
the  Acting  Assistant  Surgeons  and  Contract  Surgeons 
of  former  days,  who  were  civilian  physicians  attached 
to  the  Army  but  without  a  definite  military  status 
and  authority,  an  anomalous  and  trying  position, 
which  was  most  unsatisfactory  to  members  of  a 
dignified  and  learned  profession.  They  have  the 
rank  of  First  Lieutenants,  and  their  commissions 
"confer  upon  the  holders  all  the  authority,  rights,  and 
privileges  of  commissioned  officers  of  the  like  grade 
in  the  Medical  Corps  of  the  U.  S.  Army  except 
promotions,  but  only  when  called  into  active  duty 
and  during  the  period  of  such  active  duty.'' 

An  applicant  for  appointment  in  the  Medical 
rve  Corps  must  be  between  twenty-two  and  forty- 
five  years  of  age,  a  citizen  of  the  United  States,  and 
a  graduate  of  a  reputable  medical  school,  and  must 
pass  a  satisfactory  physical  and  professional  examina- 


tion.     Examinations  for  appointment  are  held  from 
time  to  time,  and  at  lea  year  al  convenient 

localities  throughout  the  country. 

I  he  number  of  officers  commissioned  in  the  Medical 
Reserve  Corps  is  not  fixed  by  law  and  the  inactive 
lis)  is  an  unlimited  one  from  which  the  Secretary  of 
War  may  call  to  active  duty  as  many  as  the  emer- 
gencies of  the  quire.  They  cannot  be  com- 
pelled to  accept  active  duty,  bul  should  it  be  declined 
by  a  reserve  officer  his  commission  will  lie  vacated. 
receive  1 1  I  [tenants  of  the  Medi- 
cal Corps,  viz.,  $2,000  a  year  with  an  additional  $200 
for  each  live  years  of  active  service.  They  receive  also 
fuel,  lights,  horses,  horse-equipmen)  and  fori 
when  necessary,  travel  allowances,  professional  luniks 
and  instruments,  and  quarters  in  kind  or  commuta- 
tion therefor  at  the  rate  of  $36  a  month.  It  i-  tin- 
policy  of  the  Medical  Department  to  appoint  each 
year  a  number  of  young  physicians  who  have  just 
pleted  their  medical  education  into  the  Reserve 
-  and  to  give  them  at  once  a  tour  of  active  service 
of  from  six  months  to  two  years  in  order  that  they 
may  become  familiar  with  the  conditions  and  admin- 
istrative methods  of  the  Army  medical  service.  De- 
tailed information  as  to  the  physical  and  professional 
requirements  for  appointment  can  be  obtained  upon 
request  of  the  Surgeon-general. 

The  uniforms,  side  arms  and  equipments  of  Medical 
Reserve  officers  are  like  those  of  the  .Medical  Corps 
with  the  difference  only  that  the  caduceus  bears  the 
letters  "  R.  C."  superimposed  in  monogram. 


Fig.  319. — Badge  of  the  Medical  Reserve  Corps. 

(4)  The  dental  corps  was  created  by  the  Act  of 
March  3,  1911,  and  consists  of  Dental  Surgeons  and 
Acting  Dental  Surgeons,  the  total  number  of  which 
together  cannot  exceed  the  proportion  of  one  to  each 
thousand  of  the  actual  enlisted  strength  of  the  Army. 
All  original  appointments  to  the  Corps  are  made  as 
Acting  Dental  Surgeons  after  passing  a  satisfactory 
physical  and  professional  examination  before  a  board 
composed  of  a  medical  officer  and  two  dental  surgeons. 
Applicants  must  be  citizens  of  the  United  States 
between  twenty-one  and  twenty-seven  years  of  age 
and  graduates  of  a  standard  dental  college.  Acting 
dental  surgeons  who  have  served  in  a  satisfactory 
manner  for  three  years  are  eligible,  after  passing  a 
satisfactory  professional  and  physical  examination, 
to  be  commissioned  as  First  Lieutenants  in  the  Dental 
Corps.  Lieutenants  of  the  Dental  Corps  rank  next 
after  the  Medical  Reserve  Corps  and  have  the  same 
pay  and  allowances  as  the  latter,  including  the  quin- 
quennial increase  for  length  of  service,  in  computing 
which  service  as  an  Acting  Dental  Surgeon  is  counted. 
Dental  Surgeons  on  attaining  the  age  of  sixty-four 
are  retired  from  active  service  with  the  pay  of  three- 
fourths  of  their  grade  including  the  increase  for  length 
of  service.  Their  right  to  command  is  restricted  to 
the  dental  corps. 

The  uniforms  of  commissioned  dental  surgeons  are 
the  same  as  those  of  medical  officers  of  like  grade, 
with  the  exception  that  the  caduceus  bears  the  letters 
"  D.  C."  superimposed  in  monogram.     Acting  dental 


5G9 


Army  -Medical  Department 


REFERENCE    HANDBOOK   OF    THE    MEDICAL   SCIENCES 


surgeons  are  not  required  to  have  the  full  dress  uni- 
form but  only  the  dress,  service,  and  white  uniforms 
which  conform  to  those  of  medical  officers,  but  with- 
out the  shoulder  strap  or  other  insignia  of  rank. 
Their  pay  is  at  the  rate  of  $150  a  month  with  fuel, 
lights,  quarters  in  kind,  and  travel  allowances.  They 
do  not  receive  the  increase  of  ten  per  cent,  for  each 
five  years  of  service  but  as  above  stated  their  service 
counts  therefor  when  commissioned. 


Fig.  320. — Badge  of  the  Dental  Corps. 

(5)  The  aemt  nurse  corps  was  created  by  the  act 
of  February  2,  1901,  and  amended  by  that  of  March  3, 
1910,  by  which  a  definitestatus  was  given  to  graduate 
female  nurses  who  before  had  been  employed  under 
contract  for  service  in  the  Army  but  had  not  been  an 
established  part  thereof.  At  its  head  is  a  superinten- 
dent who,  under  the  direction  of  the  Surgeon-general, 
has  general  supervision  of  the  Corps,  her  office  being  a 
part  of  the  Personnel  Division  of  the  Surgeon-general's 
Office.  The  Corps  is  composed  of  Chief  Nurses, 
nurses  and  reserve  nurses,  in  such  number  as  may  be 
needed  for  the  military  service.  The  number  of 
Chief  Nurses  and  nurses  in  active  service  is  125. 
They  are  stationed  only  at  General  Hospitals  and  a 
few  of  the  larger  post  hospitals.  Chief  Nurses  are 
appointed  from  members  of  the  Nurse  Corps  by  the 
Surgeon-general,  upon  the  recommendation  of  the 
Superintendent,  and  after  a  satisfactory  examination, 
one  being  stationed  at  each  hospital  or  station  where 
nurses  are  on  duty. 

Applicants  for  appointment  in  the  Nurse  Corps  are 
required  to  be  graduates  of  acceptable  training  schools, 
having  a  theoretical  and  practical  course  of  not  less 
than  two  years  and  attached  to  a  general  hospital  of 
not  less  than  100  beds.  They  must  pass  satisfactorily 
a  physical  examination,  preferably  made  by  a  medical 
officer  and  a  professional  examination  conducted  by 
the  Superintendent.  Appointments  are  made  for 
three  years  and  are  renewed  upon  application  by  the 
nurse  if  her  service  has  been  of  a  satisfactory  char- 
acter. 

The  list  of  Reserve  Nurses  of  the  Army,  contem- 


Fig.  321 — Badge  of  the  Red  Cross  Nurses. 

plated  by  law,  and  consisting  of  honorably  discharged 
our  es,  has  not  been  carried  out,  because  one  of  the 
functions  of  the  American  Red  Cross   is   to  furnish 


the  Medical  Department  of  the  Army  in  time  of  war 
or  other  emergency  with  nurses  and  other  personnel. 
In  order  to  be  able  properly  to  meet  this  obligation 
the  Red  Cross  has  enrolled  an  eligible  list  of  over  3,000 
carefully  selected  graduate  nurses,  and  these  now 
constitute  the  reserve  of  the  nurse  corps.  They  will 
be  called  into  service  through  the  central  office  of  the 
Red  Cross  with  their  own  consent,  and  will  then  be 
subject  to  the  same  regulations  and  receive  the  same 
pay  and  allowances  as  permanent  members  of  the 
Nurse  Corps. 

The  pay  of  the  Superintendent  is  $1,S00  a  year,  with 
the  same  allowances  as  other  nurses.  The  pay  of 
nurses  begins  at  S50  a  month  when  serving  in  the 
United  States  and  increases  at  the  rate  of  ten  per  cent, 
for  each  three  years  of  service  up  to  $05  for  over  nine 
years'  service.  To  this  is  added  .$10  a  month  for 
service  outside  the  continental  limits  of  the  United 
States.  Chief  Nurses  receive  $30  a  month  additional 
when  in  charge  of  the  nursing  service  at  general  and 
base  hospitals,  and  in  hospital  ships.  Other  chief 
nurses  get  $20  a  month  in  addition  to  their  pay 
except  when  on  duty  where  special  skill  and  capability 
are  required,  when  the  Surgeon-general  may  increase 
the  amount  to  $30  a  month.  Thus  while  a  nurse  who 
has  just  joined  at  a  hospital  in  the  United  States  gets 
$50  a  month,  the  Chief  Nurse  at  the  base  hospital  at 
Manila  may  receive  $105  a  month.  They  receive 
also  quarters,  subsistence,  travelling  expenses  when 
travelling  under  orders,  leave  of  absence  on  full  pay 
for  thirty  days  in  each  year,  which  may  be  cum- 
ulative up  to  four   months. 

The  quarters  provided  for  nurses  are  usually 
detached  from  the  hospital,  and  include  a  sitting- 
room,  dining  room,  kitchen,  the  necessary  toilet 
rooms  and  a  separate  bed  room  for  each  nurse. 
When  more  than  five  nurses  are  on  duty  at  a  hospital 
the  Chief  Nurse  is  entitled  to  an  office  and  a  separate 
sitting-room.  The  furniture,  equipment,  and  service 
of  nurses'  quarters  is  furnished  by  the  Medical  Depart- 
ment, which  also  provides  the  laundry  service  for 
table  and  bed  linen  and  nurses'  uniforms.  The 
uniform  of  the  Nurse  Corps  which  is  always  worn  when 
on  duty  consists  of  a  waist,  belt,  and  skirt  of  suitable 
white  material,  bishop  collar,  and  a  white  cap  made 
according  to  specifications  prescribed  by  the  Surgeon- 
general.  The  badge  of  the  Corps  which  is  worn  on 
the  left  side  of  the  collar  is  a  caduceus  of  gold  or  gilt 
with  the  letters  "A.  N.  C."  in  monogram  super- 
imposed in  the  center. 


Fia.  322. — Badge  of  the  Army  Nurse  Corps. 

The  history  of  expert  nursing  in  the  Army  is  of 
recent  date,  since  trained  nursing  as  a  profession  was 
not  introduced  into  this  country  until  1S73.  Women 
have  since  the  early  days  of  the  republic  been  em- 
ployed in  the  care  of  the  sick,  but  the  duties  of  the 
humble  predecessors  of  the  present  nurse  corpswere 
quite  different  from  those  of  their  accomplished  sisters 
of  to-day,  and  are  now  relegated  to  the  hospital 
orderlies'.  The  Army  Regulations  of  1S14  provide 
"  (3)  Every  regimental  hospital  shall  be  supplied  with 


570 


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Army  Medical  Department 


one  or  more  fciiialc  attendants;  it  shall  he  the  business 

df  these  lii  scour  and  cleanse  the  bunks  and  II -s  of 

the  rooms  or  tents,  to  wash  the  blankets  and  bed  sacks 
and  clothes  of  the  patients,  to  cook  the  victuals  of 
the  sick,  and   to  keep   clean  and  in  good  order  the 

inn  utensils."  The  functions  of  the  women 
nurses  in  the  Civil  War  were  of  a  much  less  menial 

.ntcr   and   except    for   lack   of   .scientific    training 

approached  those  of  the  graduate  nurses  of  a  later 

day.      An    authority*    on     this    subject     slates     thai 

"the  Civil  War  marks  the  beginning  of  all  organized 

concentration   of   women    in    this   country    in    public 

duties."     It    is   estimated    that    2,000    women  were 

engaged    in    nursing    ami    hospital    administration 

during   the   Civil    War.     Miss    Dorothy    L.    Dix   was 

lOinted  superintendent  of  women  nurses  in  general 

hospitals  in  1862,  and  it  was  ordered  that  except  in 

emergency    no    women   should    be   employed   as 

nurses    without    her    approval.     No    candidate    for 

position    as    nurse    was    considered    unless   she    was 

between   the  age  of   thirty-five  and   fifty;  matronly 

us  of  experience  and  those  of  superior  education 

and  superior  disposition  were  to  have  the  preference. 

Habits  of  neatness  and  order,  sobriety  and  industry 

were    essential.     Medical    officers    were    required    to 

organize   their  hospitals  so  as   to  have  one  woman 

e  lor  every  two  men  nurses  or  attendants. 

In  the  forty-three  years  between  the  termination 
of  the  Civil  War  and  the  outbreak  of  the  Spanish  War 
nursing  as  a  profession  had  become  well  established 
in  the  United  States  and  trained  nurses  of  excellent 
attainments  were  employed  in  large  numbers  by  the 
Medical  Department  of  the  Army.  Through  a 
miscarriage  in  the  legislation  authorizing  the  calling 
out  of  volunteers,  authority  was  not  given  for  the 
enlistment  of  a  volunteer  hospital  corps,  and  it  was 
impossible  to  obtain  a  sufficient  number  of  men  of 
good  character  and  capacity  by  enlistment  in  the 
Hospital  Corps  of  the  regular  army.  The  vacancies 
were  filled,  therefore,  by  the  clumsy  expedient  of 
transferring  the  least  desirable  men  who  were  not 
desired  by  their  company  and  regimental  commanders 
from  the  volunteers  to  the  regular  hospital  corps. 
The  results  were  most  unsatisfactory  until  the 
employment  of  trained  nurses  in  large  numbers 
brought  order,  neatness,  and  efficiency  into  the  wards 
of  the  general  hospitals. 

At  the  beginning  of  the  Spanish  War  the  Surgeon- 
general  was  authorized  to  employ  nurses  under 
contract  and  an  appropriation  was  made  for  their 
pay.  No  restriction  as  to  sex  was  made  but  as  the 
supply  of  trained  nurses  in  the  country  was  almost 
entirely  female  and  as  their  services  were  intended  to 
be  restricted  to  the  general  hospitals,  where  proper 
provision  for  the  comfort  and  privacy  of  women 
could  be  made,  the  number  of  men  nurses  employed 
instead  of  being  double  that  of  the  other  sex,  as  in  the 
Civil  War,  was  so  small  as  to  be  negligible.  At  the 
beginning  a  few  untrained  women  were  employed 
especially  for  the  purpose  of  getting  immunes  to  care 
for  the  cases  of  yellow  fever  which  had  occurred  in  the 
Army  in  Cuba,  but  soon  thereafter  the  national 
society  of  the  Daughters  of  the  American  Revolution 
offered  to  take  charge  through  committees,  of  the 
selection  of  those  of  proper  qualifications  and  char- 
icier,  and  this  offer  was  promptly  accepted  by  the 
^con-general.  Dr.  Anita  Newcomb  McGee  was 
appointed  director  of  the  board  designated  for  this 
purpose  and  was  later  appointed  an  acting  assistant 
surgeon,  and  assigned  to  duty  in  the  office  of  the 
Surgeon-general  to  act  upon  all  matters  relating  to 
Army  nurses.  The  committee  of  women  which  was 
auxiliary  to  the  American  National  Red  Cross  Relief 
Committee  of  New  York  also  examined  and  certified  a 
large  number  of  nurses  as  suitable  for  employment 
in  the  Army,  besides  paying  the  expenses  incident 

*  A  History  of  Nursing,  by  M.  Adelia  Nutting  and  Levina  A. 
Dock. 


In  their  arrival  al  their  places  of  assignment  to  duly. 
More  than  200  sisters  of  charily   were  also  furnished 

by  religious  orders.  One  thou  and  live  hundred  and 
sixty-three  nurses  in  all  were  employed  under  con- 
tract by  the  Medical  Department. 

(0)  The  hospital  coeps.  of  the  Army  was  created 
by  the  Act  of  March  1,  ls.sT  (24  Stats.,  135),  before 
which  lime  the  attendance  in  military  hospitals  was 
supplied  by  details  from  the  line  of  the  Army  and  by 
hired    civilians.     The    unsatisfactory    character    of 

this  service  will  be  referred   In  later.      The  act    above 

referred  to  provides:  "That  the  Hospital  Corps  of  the 

United  States  Army  shall  consist  of  hospital  stewards, 
acting  hospital  stewards,  and  privates;  and  all 
necessary  hospital  services  in  garrison,  camp,  or 
field  (including  ambulance  service)  shall  be  performed 
by  the  members  thereof,  who  shall  be  regularly 
enlisted  in  tin;  military  service;  said  corps  shall  be 
permanently  attached  to  the  Medical  Department, 
and  shall  not  be  included  in  the  effective  strength  of 
the  Army  nor  counted  as  a  part  of  the  enlisted  force 
provided  by  law."  This  law  was  amended  by  the 
Ad  of  March  2,  1903,  so  as  to  increase  the  number  of 
grades  in  the  corps  and  alter  their  titles  from  hospital 
stewards,  acting  hospital  stewards,  and  privates  to 
sergeants,  first  class,  sergeants,  corporals,  privates, 
first  class,  and  privates.  This  act  also  authorized  the 
organization  of  companies  of  instruction,  ambulance 
companies,  field  hospitals,  and  other  detachments  in 
the  Hospital  Corps  as  the  necessities  of  the  service 
may  require.  Acting  cooks  and  lance  corporals  have 
been  also  added  as  separate  gradings. 

The  corps  is  recruited  by  enlistments  therefor  and 
by  transfers  from  other  branches  of  the  service. 
All  first  enlistments  and  transfers  are  to  the  grade  of 
private.  The  strength  of  the  Hospital  Corps  is  not 
limited  by  law,  but  the  Secretary  of  War  is  authorized 
to  enlist  or  cause  to  be  enlisted  as  many  privates  of  the 
Hospital  Corps  as  the  service  may  require,  it  being 
clearly  the  intention  of  Congress  to  place  upon  the 
War  Department  the  responsibility  for  any  suffering 
which  may  be  caused  to  the  sick  and  wounded,  or  any 
inefficiency  of  the  medical  service,  which  may  result 
from  a  deficiency  of  enlisted  personnel. 

The  numbers  and  pay  of  the  various  grades  of  the 
Hospital  Corps  are  shown  in  the  following  table: 


Sergeants,  1st  Class 

Sergeants 

Corporals* 

Acting  eooksf 

Privates,  1st  Class.. 
Privates 


Num- 
bers. 


330 
350 
50 
100 
1,867 
963 


Enlistment. 


1st, 


IM. 


S50    $54 


If  re-enlisted  within 
three  months. 


3d.    HI. 
$58    Sr,L> 


5th.  J6th.    7th. 
Sfifi    S70    S74 


42 
36 

42 
30 
24 


4S 
4  J 
48 
36 
26 


If  discharged  at  termination  of  enlistment  and  re-enlisted  after 
three  months  the  soldier  is  only  entitled  to  pay  of  second 
enlistment. 

It  is  required  that  the  proportion  of  privates,  first 
class,  to  privates  shall  not  exceed  two  to  one.  Cor- 
porals are  appointed  for  duty  in  ambulance  com- 
panies, and  in  the  larger  hospitals  for  duty  principally 
of  an  outside  character.  Promotion  to  the  grade  of 
sergeant  is  made  after  an  examination  by  a  board  of 

*  Lance  Corporals  are  not  properly  a  distinct  grade,  being  simply 
privates  who  are  given  the  temporary  duties  and  authority  of 
corporals,  without  any  increase  in  pay. 

t  Acting  cooks  are  detailed  from  privates,  first  class,  and 
privates. 

571 


Army  Medical  Department 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


medical  officers,  which  reports  upon  the  candidate's 
qualifications  as  to  his  physical  condition,  character 
and  habits,  discipline  and  control  of  men,  knowledge 
of  regulations,  of  nursing,  of  dispensary  work,  of  cleri- 
cal work,  of  the  principles  of  cooking  and  mess 
management,  of  hospital  corps  drill,  and  of  minor 
surgery  and  first  aid  work.  Married  men  are  not 
eligible  for  promotion.  Chief  Surgeons  are  authorized 
to  hold  these  examinations  without  reference  to  the 
Surgeon-general. 

Examinations  for  appointment  to  Sergeant,  First 
Class,  are  conducted  by  boards  of  medical  officers  ap- 
pointed by  the  General  Commanding  the  Division. 
The  examinations  therefor  are  oral,  practical,  and 
written.  They  embrace  the  same  subjects  as  for  the 
grade  of  sergeant,  but  are  more  difficult.  Sergeants, 
first  class,  are  required  to  have  served  not  less  than 
twelve  months  as  Sergeants  before  being  eligible  for 
promotion. 

The  Sergeant,  First  Class,  ranks  with  the  Ordnance 
Sergeant,  Post  Commissary  Sergeant,  Post  Quarter- 
master Sergeant,  First  Class  Signal  Sergeant,  and 
Electrical  Sergeant,  First  Class,  of  the  Coast  Artillery, 
and  is  only  ranked  by  Sergeants  Major,  Master 
Electricians,  Chief  Musicians,  and  Engineers  of  the 
Coast  Artillery. 

The  duties  of  Sergeants,  First  Class,  and  Sergeants 
are  to  look  after  and  distribute  hospital  stores  and 
supplies,  the  care  of  medical  property,  to  compound 
and  administer  medicines,  to  supervise  the  prepara- 
tion and  serving  of  food,  maintain  discipline  in  hospi- 
tals, prepare  reports  and  returns,  supervise  the  work 
of  their  subordinates,  and  perform  such  other  duties 
as  may  be  required  of  them  by  their  superior  officers. 
No  other  noncommissioned  officer  requires  so  much 
special  knowledge  for  the  proper  discharge  of  his 
duties  or  has  such  a  variety  of  duties  to  perform  as 
the  Sergeant,  First  Class,  Hospital  Corps.  Like  the 
First  Sergeant  of  a  company  he  must  be  a  good  dis- 
ciplinarian, drill  master,  and  general  supervisor  of 
the  duties  of  the  men  under  his  control.  He  pre- 
pares or  supervises  the  preparation  of  numerous 
reports,  returns,  and  other  official  papers,  some  of 
them  voluminous  and  complicated,  which  must  be 
made  not  only  to  the  Surgeon-general,  but  to  the 
adjutant  of  the  command,  the  Adjutant  General  of 
the  Army,  and  to  the  officials  of  the  Quartermaster 
and  Commissary  Department.  He  must  keep  track 
of,  and  prevent  waste  of  a  great  number  of  articles  in- 
cluded under  medical  and  hospital  property;  he 
must  be  a  pharmacist  and  have  sufficient  knowledge 
of  medicine  and  surgery  to  act  as  an  assistant  to  the 
medical  officer.  It  is  commonly  supposed  that  skill 
in  pharmacy  is  the  essential  qualification  of  noncom- 
missioned officers  of  the  Hospital  Corps,  but  from  the 
enumeration  above  it  will  be  seen  that  knowledge 
of  drugs  is  only  one  of  the  many  qualifications  which 
are  demanded  of  them. 

One  of  the  most  important  duties  of  medical  officers  is 
the  instruction  of  the  Hospital  Corps  to  which  a  certain 
number  of  hours  every  week  throughout  the  year  is 
given,  and  which  never  ceases  so  long  as  the  soldier 
is  in  the  service,  in  connection  with  his  daily  round  of 
duties.  The  instruction  of  the  Hospital  Corps  soldier 
covers  the  Articles  of  War,  the  orders  and  regulationsin 
regard  to  his  behavior  and  bearing  upon  all  occa- 
sions, bearer  drill  and  field  work,  use  of  the  first  aid 
packet  and  other  articles  contained  in  the  hospital 
corps  and  orderly  pouches,  methods  of  transporting 
wounded  in  peace  and  war,  the  use  and  care  of  the 
field  hospital  equipment,  and  the  pitching,  striking, 
and  packing  of  tents.  All  members  of  the  Hospital 
Corps  arc  also  instructed  in  riding  and  in  the  care  of 
animals.  They  are  also  instructed  in  military  sanita- 
tion, especially  in  the  purification  of  water  and  proper 
di  posal  of  excreta  and  wastes,  and  the  care  of  the 
person. 

In  the  field  when  serving  with  infantry  or  other 

572 


troops  not  mounted,  only  the  noncommissioned 
officers  are  mounted  and  the  privates  who  serve  as 
orderlies  for  medical  officers,  the  latter  carrying  in- 
stead of  the  hospital  corps  pouch  an  orderly  pouch 
which  contains  a  pocket  operating  case,  hypodermic 
syringe,  scissors,  catheter,  and  ligature  material,  in 
addition  to  first  aid  dressings. 

The  equipment  of  privates  of  the  hospital  corps 
consists  of  a  hospital  corps  pouch  containing  first  aid 
dressings,  a  large  hospital  corps  knife,  carried  in  a 
scabbard  like  a  sword,  and  used  for  various  purposes 
in  the  field,  a  haversack  and  blanket  roll,  canteen,  cup, 
knife,  fork,  spoon,  meat  can,  and  a  shelter  tent,  half 
which  is  on  the  march  rolled  about  the  blanket  and 
in  camp  is  joined  to  the  tent-half  of  a  comrade  to 
make  the  shelter  tent  for  the  two  men. 

The  clothing  allowance  of  the  Hospital  Corps  is 
liberal,  amounting  to  $142.44  for  the  first  enlistment, 
and  $103.61  for  each  subsequent  enlistment.  The 
value  of  all  clothing  not  drawn  is  paid  to  the  soldier 
upon  his  discharge.  They  are  required  to  have  four 
uniforms:  a  field  uniform  of  khaki  and  one  of  olive 
drab;  a  dress  uniform  of  dark  blue,  to  which  is  added 
on  occasions  of  ceremony  a  maroon  breast  cord,  and  a 
blue  and  maroon  cap  band;  and  a  uniform  of  white 
duck,  to  be  worn  by  men  on  duty  in  the  wards,  dispen- 
saries, operating  rooms,  mess  rooms  and  kitchens,  and 
by  privates  who  are  detailed  as  assistants  to  dental 
surgeons.  The  overcoat  is  of  olive  drab  like  that  of 
the  line. 

The  distinctive  color  of  the  facings  of  the  Hospital 
Corps  is  the  same  as  for  the  other  personnel  of  the 
Medical  Department,  maroon,  which  is  however  piped 
with  white  to  distinguish  it  further  from  the  shade  of 
red  adopted  for  the  artillery,  which  is  scarlet.  The 
maroon  facing  appears  on  the  chevrons  and  trouser 
stripes  of  the  noncommissioned  officers,  on  the  piping 
of  the  dress  coat  and  mixed  with  white  in  the  breast 
collar,  and  the  dress  and  the  hat  cord  of  the  service 
uniform.  The  corps  insignia  are  worn  on  the  coat 
collar,  and  the  dress  and  service  cap.     They  are: 

For  the  dress  coat  a  caduceus  of  yellow  metal, 
similar  to  those  for  officers,  worn  on  the  collar  on  each 
side  in  the  same  manner  as  by  officers; 

For  the  service  coat  a  caduceus  of  dull  bronze  worn 
as  above  stated; 

For  the  dress  cap,  for  Sergeant,  First  Class,  a  cadu- 
ceus of  white  metal  enclosed  in  a  wreath  of  gilt  metal, 
and  for  all  other  men  of  the  Hospital  Corps  a  caduceus 
of  gilt  metal  without  the  wreath; 

For  the  service  cap  these  insignia  are  of  dull  bronze. 


Fig.  323. — Chevron  of  a  Sergeant,  First  Class,  Hospital  Corps. 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Army  Medical  Department 


7  The  clerical  force  at  large  ami  other  civilians 
attached   to  the  medical   corps  includes  the  clerks, 

engers,    mechanics,  and  laborers  employed  al    I  he 

ii.-al  supply  depots  in  Washington,  New  York, 
Louis,  San  Francisco,  and  Manila,  the  clerical 
force  of  the  offices  of  the  Chief  Surgeons,  Headquar- 
ters of  the  four  great  territorial  divisions,  and  the 
mechanics   and    laborers,    with    a   few    clerks,    at    the 

eral  hospitals.  It  will  be  observed  that  the  clerical 
force  of  the  Surgeon-general's  t  Iffice  is  not  included,  as 
it  is,  as  stated  above,  a  part  of  the  War  Department, 
which  is  one  of  the  executive  departments  and  quite 
distinct  from  the  Army.  The  total  number  of  clerks 
employed    at    the    stations    above    named    is    forty. 

ging   in   salary   from  $'2,000   to   $(>()().      There   are 

employed   sixteen   packers  and  four  mechanics 

al  annual  salaries  ranging  from  $1,200  to  $780,      The 

■I  number  of  employees,  including  the  variable 
number  of  laborers,  was  on  January  1,  1912,  two 
hundred  and  thirteen,  with  a  total  pay  roll  of 
about  $140,000. 

Historical  Resume. — The  Medical  Department  of 
the  United  States  Army  had  its  beginning  on  July  27, 
177",    when    the   Colonial    Congress   at   Philadelphia 

1  a  medical  establishment,  or  as  it  was  then 
railed,  "an  hospital,"  for  the  Army.     Prior  to  this 

tment  the  surgeons  of  the  forces  before  Boston 

been  appointed  by  the  colonels  of  regiments,  with 
the  wise  proviso,  however,  on  the  part  of  the  Provin- 
cial Congress  of  Massachusetts  that  they  should  be 
examined  by  a  medical  board  named  by  the  Provincial 

gress.  That  there  was  nothing  pro  forma  in 
these  examinations  is  shown  by  the  fact  that  no  less 
than  six  of  a  group  of  fourteen  were  rejected  on 
account  of  failure  to  come  up  to  the  standard.  After 
the  battle  of  Bunker  Hill  a  field  hospital  was  estab- 
I  at  Cambridge  for  the  care  of  the  wounded. 
Subsequently  general  hospitals  were  established  at 
Ticonderoga,  X.  Y.,  and  at  Williamsburg,  Va.  To 
provide  these  with  the  requisite  medical  officers 
surgeons  were  appointed  who  belonged  to  no  regi- 
ment, but  to  the  hospital  department  in  general  as 
staff  surgeons.  Tills  arrangement  aroused  a  strong 
feeling  on  the  part  of  the  regimental  surgeons  who 
protested  against  the  removal  of  their  sick,  and  their 
reduction  to  the  level  of  dispensary  surgeons  for  the 
-lighter  ailments  of  camp.  They  claimed  the  right 
to  take  care  of  their  own  sick  and  they  were  supported 
in  this  by  a  majority  of  the  regimental  and  company 
officers.     It  is  interesting  to  observe    how  mankind 

'ts  its  experiences.  More  than  120  years  after- 
ward during  the  Spanish-American  War  the  same 
clamor  was  raised  by  regimental  surgeons  of  volun- 
teers, their  colonels  and  company  officers,  against 
the  establishment  of  division  hospitals,  and  the 
necessary  disestablishment  of  regimental  hospitals 
as  incompetent  to  meet  the  exigencies  of  active  field 
service,  although  this  incompetency  had  meanwhile 
been  proved  during  the  long  years  of  the  Civil  War. 
Of  course,  among  these  surgeons  there  could  be  no 

-ion  or  effective  cooperation,  and,  as  General 
Washington  wrote  to  the  Congress  at  Philadelphia, 
affairs  were  in  a  very  unsettled  condition.  "There  is 
no  principal  director  nor  any  subordination  among 
the  surgeons;  of  consequence,  disputes  ami  conten- 
tions have  arisen,  and  must  continue  until  it  is 
reduced  to  some  system." 

The  first  department  consisted  of  the  director 
general  and  chief  physician,  four  surgeons,  twenty 
surgeons'  mates,  an  apothecary,  a  clerk,  two  store- 
keepers, and  a  nurse  to  every  ten  sick.  It  may  be  of 
interest  to  mention  that  the  pay  of  these  officers  was 
as  follows:  The  director  general,  $120;  the  surgeons, 
the  surgeons'  mates.  $20;  the  storekeepers,  $4, 
and  the  nurses,  $2  a  month. 

Dr.  Benjamin  Church  of  Boston  was  elected 
director  general,  and  he  was  given  the  appointment 


of  all  the  personnel  of  the  hospital,  except  the 
surgeons'  males,  «  i,,,  were  appointed  by  I  he  surgeons. 
Dr.  church  had  a  reputation  for  culture  and  profes- 
sional skill,  but  was  a  few  month-  after  hi-  appoint- 
ment detected  in  treasonable  correspondence  with  the 

enemy,    deposed    and    thrown    into    prison.       He    was 

succeeded  by  Dr.  John  Morgan  of  Philadelphia  a 
man  of  much  energy  and  administrative  ability  as 

well  as  professional  skill.  He  soon  gained  I  he  friend- 
ship and   support    of   General    Washington,  and    the  B 

he  always  retained. 

Willi  the  extension  of  the  theater  of  war,  the 
number  of  surgeons  was  increased,  and  Drs.  Skinner 

and  Shippen  were  named  chief  surgeons  for  the 
northern  department  and  the  forces  on  the  west  bank 
of  the  Hudson.  The  organization  was,  however, 
too  loose  to  secure  efficiency  or  concert  of  action. 
The  relations  of  the  regimental  surgeons  to  each 
oilier  and  to  those  in  charge  of  the  general  hospitals 
were  entirely  undetermined,  and  the  department 
surgeons  refused  to  admit  the  authority  over  them  of 
Dr.  Morgan.  There  was  beside  no  well-arranged  sys- 
tem of  medical  supply,  and  in  consequence  there  was 
much  suffering,  and  complaints  multiplied.  As  has 
happened  since,  more  than  once,  Dr.  Morgan  was 
punished  for  the  very  shortcomings  for  which  he  had 
in  vain  asked  Congress  to  provide  a  remedy,  and  he 
was  dismissed  in  January,  1777.  Congress'  the  next 
year  exonerated  him  from  all  blame,  but  did  not 
reinstate  him. 

A  complete  and  elaborate  organization  of  the 
medical  department,  modeled  on  that  of  the  British 
tinny,  was  adopted  in  April,  1777,  and  Dr.  William 
Shippen  was  elected  director  general  of  the  new 
establishment.  Deputy  director  generals  were  pro- 
vided for  the  northern  and  southern  departments,  and 
under  these  a  physician  general  and  surgeon  general 
in  each  district,  "whose  business  it  shall  be  to  super- 
intend the  practice  of  physic  and  surgery  in  all  the 
hospitals  of  the  district."  This  separation  of  the 
practice  of  physic  and  the  practice  of  surgery,  which 
obtained  in  Europe  at  that  time,  and  has  fasted  in 
civil  life  in  England  until  the  present  dav,  neces- 
sitated a  most  cumbrous  and  awkward  dual  organiza- 
tion, which  soon  disappeared  under  the  rudely  prac- 
tical test  of  war.  It  is  probable  that  most  American 
physicians  at  that  time  outside  the  larger  cities 
practiced  surgery  to  some  extent,  in  addition  to  the 
practice  of  physic.  The  regimental  surgeons  seem 
from  the  first  to  have  combined  the  two  arts,  and  we 
find  in  the  bill,  which  in  1780,  reorganized  and 
simplified  the  medical  establishment,  an  explicit 
provision  that  "there  shall  be  three  chief  hospital 
physicians  who  shall  also  be  surgeons,  one  chief 
physician,  who  shall  also  be  a  surgeon,  to  each 
separate  army,  fifteen  hospital  physicians  who  shall 
also  be  surgeons,"  etc.  But  although  the  medical 
officers  of  the  army  thereafter  appeared  to  have  been 
both  physicians  and  surgeons,  the  former  title  seemed 
to  have  been  rather  reserved  for  the  higher  grades, 
while  the  title  "surgeon"  became  bv  the  end  of  the 
Revolutionary  War  generic  for  alPmedical  officers. 

At  the  end  of  the  Revolution  the  Army  was  dis- 
banded, except  fifty-five  men  at  Ft.  Pitt  and  twenty- 
five  at  West  Point  to  guard  the  military  stores  at 
these  places.  The  officer  highest  in  command  was 
a  captain,  and  the  medical  department  was  reduced 
to  the  vanishing  point.  The  Revolution  had  pro- 
duced a  number  of  distinguished  military  surgeons, 
among  whom  were  Cochran,  John  Warren,  Craik,  and 
Tilton,  in  addition  to  those  already  named. 

The  pressure  of  Indians  on  the  western  frontier 
after  a  few  years  prevailed  over  the  morbid  fear  of  a 
regular  army  with  which  our  ancestors  of  a  century 
ago  were  possessed,  and  in  17X0  a  regiment  of  regular 
infantry  and  a  battalion  of  artillery  were  organized, 
with  a  medical  service  of  one  surgeon  and  four  sur- 
geons' mates.     This  small  force  was  divided  up  into  a 

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REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


number  of  small  commands  at  scattered  posts  along 
the  frontier  and  the  regimental  surgeons  were  entirely 
too  few  in  number  to  supply  them.  In  1802,  there- 
fun-,  a  new  departure  was  taken  in  the  employment 
of  post  surgeons  in  addition  to  the  regimental  medical 
officers.  If  general  hospitals  were  established  sur- 
geons of  a  higher  grade  and  rate  of  pay  than  the 
regular  post  surgeons  were  appointed  for  temporary 
service.  In  this  way  the  medical  department  was 
enlarged  to  meet  the  necessities  of  the  Army  in  the 
year  1912. 

The  War  of  1S12  brought  an  army  again  in  the 
field,  but  as  the  medical  department  was  without  a 
head  and  the  surgeons  had  not  even  assimilated  rank, 
good  medical  administration  was  impossible.  In 
March,  1S13,  Congress  created  the  positions  of 
physician-and-surgeon-general  and  apothecary  gen- 
eral, the  latter  to  act  as  assistant  to  the  former,  and 
as  medical  purveyor.  The  surgeons  were  divided 
into  hospital  and  regimental  surgeons,  of  which  the 
former  were  superior  in  rank  and  pay.  Both  had 
mates  and  assistants,  and  there  were  in  addition  post 
surgeons  who  ranked  with  the  mates.  Dr.  James 
Til  ton  who  had  been  a  hospital  surgeon  during  the 
Revolution  was  appointed  physician-and-surgeon- 
general  in  1S13.  His  management  of  affairs  during 
the  war  appears  to  have  given  universal  satisfaction. 
Many  hospitals  were  established  and  broken  up  during 
the  course  of  events,  but  all  appeared  to  have  been 
well  administered  and  well  supplied  and  competent 
for  the  work  thrown  upon  them.  Some  indeed  as 
that  at  Burlington,  Vt.,  under  the  superintendence 
of  Surgeon  Joseph  Lovell,  Ninth  Infantry,  appear  from 
the  reports  to  have  been  model  establishments. 

The  title  of  surgeon-general  appears  first  in  the 
Act  of  May  14,  1818.  Joseph  Lovell  was  appointed 
to  this  position,  and  in  that  year  he  made  the  first 
annual  report  of  the  surgeon-general  to  the  Secretary 
of  War,  and  also  drew  up  a  set  of  regulations  for  the 
medical  department.  He  remained  for  eighteen 
years  at  its  head  and  during  that  time  by  his  ability 
and  force  of  character  shaped  and  organized  the  corps 
of  army  surgeons  into  a  coherent  and  efficient 
medical  staff.  In  1821  a  further  advance  was  made 
in  the  organization  of  the  department  by  consolidating 
the  regimental  surgeons  with  the  staff  surgeons  so 
that  the  corps  consisted  simply  of  one  surgeon-general, 
eight  surgeons  with  the  rank  and  pay  of  regimental 
surgeons,  and  forty-five  assistant  surgeons  with  the 
pay  of  post  surgeons.  This  number,  however,  was 
insufficient  to  provide  one  medical  officer  to  each  of 
the  military  posts,  and  so  the  system  of  employing 
certain  physicians  under  contract  was  instituted. 
Surgeon-general  Lovell  died  in  1836. 

The  medical  department  was  fortunate  in  having 
so  able  a  man  as  Dr.  Lovell  appointed  as  its  chief.  He 
defined  the  duties  of  his  subordinates,  established  an 
excellent  system  of  accountability  for  property, 
improved  the  medical  reports,  inspired  his  officers 
with  the  idea  that  as  sanitary  officers  they  had 
greater  responsibilities  than  mere  practising  physi- 
cians and  surgeons,  and  labored  earnestly  to  have 
their  pay  increased  and  their  official  status  raised  in 
proportion  to  his  views  of  the  importance  of  their 
duties.  He  also  established  an  equitable  system  of 
exchange  of  posts  so  that  no  officer  would  be  retained 
unduly  at  an  undesirable  station. 

He  was  succeeded  by  Thomas  Lawson,  a  man  of 
strong  character  and  fine  professional  and  administra- 
tive abilities,  and  withal  a  brave  and  ardent  soldier, 
and  a  most  original  character.  He  entered  the  Navy 
in  1809  as  surgeon's  mate,  but  left  that  service  for  the 
Army  in  1811.  His  service  as  a  medical  officer  of  the 
Army  covered  the  remarkable  period  of  fifty  years  and 
three  months,  and  included  active  and  distinguished 
set-vice  in  the  War  of  1812,  the  Indian  Wars,  and  the 
Mexican  War.  At  the  outbreak  of  the  latter  he 
turned  over  the  office  in  Washington  to  an  assistant 


and  joined  his  old  friend  Gen.  Scott  with  whom  he 
made  the  campaign,  performing  the  duties  of  Chief 
Surgeon  in  the  field,  for  which  his  long  experience  so 
eminently  fitted  him.  When  he  became  surgeon- 
general,  in  1S36,  medical  officers  were  without  mili- 
tary rank,  and  in  addition  to  the  great  disadvantages 
of  such  a  status,  suffered  frequently  from  the  insolence 
and  contempt  with  which  the  line  officers  of  that  day. 
following  the  traditions  of  the  British  service,  were 
inclined  to  regard  the  medical  profession.  Surgeons, 
for  example,  were  not  entitled  to  a  salute  from  enlisted 
men,  and  when  serving  on  boards  were  ranked  by  the 
youngest  subaltern  in  the  service.  In  the  new  uni- 
form, adopted  in  1839,  they  were  allowed  a  s^ord, 
but  not  the  officer's  epaulettes,  an  aiguilette  being 
prescribed  instead;  "a  piece  of  tinsel  on  one  shoulder," 
as  Lawson  contemptuously  described  it. 

To  establish  and  maintain  the  dignity  of  his  pro- 
fession and  his  corps,  was  to  Thomas  Lawson  a 
sacred  mission,  to  which  he  devoted  himself  with  such 
courage,  pertinacity,  and  keenness  of  wit  that  he 
achieved  success  in  all  the  important  claims  advanced 
in  behalf  of  his  corps,  culminating  in  the  Act  of 
February  11,  1847,  which  conferred  on  medical 
officers  the  assured  and  honorable  status  of  definite 
military  rank.  It  is  a  tradition  in  the  service  that  on 
the  passage  of  this  act  the  grim  old  fighter  sent 
around  to  medical  officers  a  confidential  circular  to 
the  effect  that  now  that  the}'  had  the  status  of 
officers  they  must  promptly  challenge  any  other 
officer  who  failed  to  show  them  proper  respect. 

During  the  Mexican  War  the  senior  surgeons  were 
assigned  as  medical  directors  and  in  charge  of  field 
hospitals.  Certain  of  the  juniors  were  on  duty  at 
the  hospitals  and  purveying  depots,  while  others 
served  in  the  field  as  regimental  officers  with  regular 
troops.  Volunteer  surgeons  were  on  duty  with  their 
regiments  but  some  of  them  were  occasionally  detailed 
to  hospital  duties. 

The  medical  service  of  the  Mexican  War  seems  to 
have  been  performed  with  the  same  efficiency,  courage, 
and  devotion  to  duty  which  marked  all  the  operations 
of  the  small  but  glorious  armies  under  Scott  and 
Taylor,  and  such  men  as  Satterlee,  Tripler,  Simpson, 
Cuyler,  Wright,  Moore  and  Barnes  laid  in  it  the 
foundation  of  reputations  which  were  destined  to 
grow  under  the  far  wider  responsibilities  of  the  Civil 
War.  In  the  fierce  assault  of  Molino  del  Rey, 
Assistant  Surgeon  William  Roberts  was  killed  and 
Assistant  Surgeon  James  Simons  was  wounded. 

Although  the  Army  Regulations  for  1S25  contained 
a  clause  that  no  person  should  receive  the  appoint- 
ment of  Assistant  Surgeon  until  after  examination 
by  a  properly  authorized  board,  yet  this  rule  was  not 
at  first  carried  out  on  account  of  the  difheultv  of 
detailing  medical  officers  for  this  purpose.  It  is 
stated  that  Dr.  Charles  Tripler,  appointed  an  Assistant 
Surgeon  in  1S30,  was  one  of  the  first  officers  examined 
under  this  provision.  General  Orders  No.  5S  of  the 
War  Department,  dated  July  7,  1832,  reiterated  this 
regulation  and  directed  that  hereafter  it  should  be 
strictly  enforced,  and  the  regulation  has  been  steadily 
maintained  since  that  date,  even  in  time  of  war. 
This  regulation  was  embodied  in  the  law  by  the  Ait 
of  June  30,  1834,  which  not  only  required  that 
candidates  before  being  appointed,  should  "have  been 
examined  and  approved  by  an  Army  medical  board," 
but  also  required  that  an  examination  be  held  prior 
to  promotion  fo  the  grade  of  Surgeon. 

The  thirteen  years  which  intervened  between  the 
Mexican  War  and  the  outbreak  of  the  Civil  War  were 
years  of  activity  and  progress  for  the  medical  corp-. 
although  the  Utah  Expedition  against  the  Mormons 
in  1858  was  the  only  military  event  of  note.  \n 
important  advance  in  the  standard  of  the  examina- 
tion for  admission  was  made  in  1849,  when  a  knowl- 
edge of  Latin,  of  physics,  of  practical  anatomy  inthc 
form  of  dissection,  and  clinical  experience  acquired 


574 


KF.FF.KIMT.    HANDBOOK    OF    Till:    MFDIOAL    SCIENCES 


Army  Medical  nopartmcnt 


cither  in  a  hospital  or  in  private  practice  were  made 

prerequisites.      In    lN;jO   tin-    Medical    Department    of 

\nny  was  first  formally  represented  at  the  animal 

ting  of  the  American  Medical  Association. 

Surgeon-general   Lawson  died   in  L861,  shortly  be- 
fore the  outbreak  of  the  Civil  War.     From  the  calls 
fur  large  levies  of  troops  and   the  feeling   North  and 
h  thai   a  desperate  struggle  was  before  the  eoiin- 
ii   was  evident    that    without   la  rue  reinforcements 
the  medical  department  would  be  unable  to  do  its  work 
icessfully.     At  this  time  it  consisted  of  one  sur- 
Q-genera]  with  the  rank  of  colonel,  thirty  .surgeons 
•  ill   the  rank  of  major,  and  eighty-three  assistant 
eons    with    the   rank   of   first    lieutenant    and   of 
tin  after  five  years'  service.      In  August,  1861,  the 

1 1  in n  of  ten  surgeons  and  t  wenty  assistant  surg s 

authorized.      Some1  of  this  small  staff  corps  look 
irge,  as  medical    directors,    of    corps    and    armies, 
ructing   the   volunteer  officers  in    the   duties   per- 
taining to  camps  and  field  hospitals;  others  acted  as 
medical  inspectors,  aiding  the  directors  in  their  work 
of  supervision  and  education;  some  organized  general 
utals  for  the  sick  that  had  to  be  cared  for  on  every 
of  the  armies,  while  others  kept  these  hospitals 
and  the  armies  in  the  field  provided  with  medical  and 
iial  supplies.     The  remainder   were  assigned  to 
service  with  the  regular  regiments  and  batteries. 
Bach  volunteer  regiment  brought  with  it  a  surgeon 
and  two  assistants  appointed  by  the  governor  of  the 
e  after  examination  by  a  State  medical  board. 
The  senior  regimental  surgeon  of  each  brigade  became 
invested    with  authority  as  brigade-surgeon   on    the 
staff  of  the  brigade  commander,  but  as  seniority  in 
many   instances   was  determined   by   a  few  days  or 
-.  it  often  happened  that  the  best  man  for  the 
don  was  not  secured  by  this  method.     Congress 
•fore  authorized   a  corps  of  brigade  surgeons  of 
volunteers,  who  were  examined  for  the  position  by  a 
hoard  of  regular  medical  officers.     One  hundred  and 
ten  of  these  brigade  surgeons  were  commissioned. 

The  Civil  War  was  the  first  in  which  large  armies 
made  their  appearance  on  American  soil,  and  in  these 
army  corps  of  volunteers  many  of  the  glorious 
raditions  and  hide-bound  prejudices  of  the  old  Army 
disappeared  along  with  its  regiments  and  batteries. 
Yet  it  was  none  the  less  the  leaven  hid  in  three  meas- 
ures of  meal,  which  leavened  the  whole  lump,  and 
this  is  true  not  less  of  the  Medical  Department  than 
of  the  line. 

On  January  1,  1861,  the  Army  numbered  16,400 
and  the  medical  officers  115,  or  seven-tenths  of  one 
per  cent,  of  the  whole — a  considerably  greater  propor- 
tion, by  the  way,  than  exists  to-day.  In  April,  1862, 
a  bill  was  passed  by  Congress  to  meet  the  pressing 
needs  of  the  medical  department.  This  gave  the 
regular  army  an  addition  of  ten  surgeons  and  ten 
assistant  surgeons,  and  provided  for  a  temporary 
i  lease  in  the  rank  of  those  medical  officers  who 
were  holding  positions  of  great  responsibility.  It 
gave  the  surgeon-general  the  rank,  pay,  and  emolu- 
ments of  a  brigadier  general;  it  provided  for  an  assist- 
ant surgeon-general  and  a  medical  inspector  general 
of  hospitals,  each  with  the  rank  of  colonel,  and  for 
eight  medical  inspectors  with  the  rank  of  lieutenant 
colonel.  These  original  vacancies  were  filled  by  the 
President  by  selection  from  the  army  medical  officers 
and  the  brigade  surgeons  of  the  volunteers,  having  re- 
I  to  qualifications  only,  instead  of  to  seniority  or 
previous  rank.  At  the  end  of  their  service  in  these 
positions,  officers  of  the  regular  force  reverted  to  their 
former  status  in  their  own  corps  with  such  promotion 
as  they  were  entitled  by  the  casualties  of  the  service 
during  their  temporary  occupancy  of  these  war  posi- 
tions.  About  the  time  of  this  enactment  Surgeon- 
general  Finley,  Lawson's  successor,  was  retired  at  his 
own  request  after  forty  years'  service,  and  Assistant 
Surgeon  William  A.  Hammond  was  appointed  the 
first  surgeon-general  with  the  rank  of  brigadier  gen- 


eral, in  December  following  eight  more  inspectors 
were  authorized.  Their  duties  were  to  supervise  all 
that  related  to  the  sanitary  condition  of  the  army, 

whether  ill  transports,  quarters,   or  camps,   as   will  as 

the  hygiene,  police,  discipline,  and  efficiency  of  field 

and  general   hospitals;   to  See   that    all    regulations   for 

protecting  the  health  of  the  troops  and  for  the  careful 
treatment  of  the  sick  and  wounded  were  duly  ob- 
served; to  examine  into  the  condition  of  supplies 
and  the  accuracy  of  medical,  sanitary,  statistical, 
military,  and  property  records  and  accounts  of  the 
medical  depart  nieut ;  to  invest  igate  t  he  causes  of  dis- 
ease and  the  met  hods  of  prevent  ion.  They  were  re- 
quired also  to  be  familiar  with  the  methods  of  the 
subsistence'  department,  in  all  that  related  to  the 
hospitals  and  to  see  that  the  hospital  fund  was 
judiciously  applied.  Finally,  they  reported  on  the 
efficiency  of  medical  officers,  and  were  authorizci  to 
discharge  men  from  the  service  on  account  of 
disability. 

Shortly  after  this  the  corps  of  brigade  surgeons 
was  reorganized  to  give  its  members  a  position  on  the 
general  staff  similar  to  that  of  the  army  medical 
officer  and  to  render  their  services  available  to  the 
surgeon-general  at  any  point  where  they  might  be 
most  needed,  irrespective  of  regimental  or  brigade 
organizations.  They  henceforth  became  known  as  the 
corps  of  surgeons  and  assistant  surgeons  of  volun- 
teers; and  the  appointment  of  forty  such  surgeons  and 
one  hundred  and  twenty  assistants  was  authorized. 

The  medical  history  of  the  Civil  War  marks  an 
epoch  in  military  sanitary  organization  even  greater 
than  was  made  in  the  art  of  war  by  Sheridan's  use  of 
cavalry  or  the  hasty  entrenchments  of  Lee.  It  is  a 
glorious  chapter  of  American  history,  but  the  full 
story  of  the  ability  and  devotion  of  the  surgeons  of  the 
Civil  War,  regular  and  volunteer,  must  be  sought, 
not  in  the  limits  of  an  article,  but  by  those  who  have 
industry  and  good  eyesight,  in  the  ponderous  volumes 
of  microscopic  print  which  make  up  the  "  Medical  and 
Surgical  History  of  the  Rebellion." 

For  many  years,  during  and  after  the  revolution, 
the  selection  of  the  personnel  of  hospitals  was  left  to 
the  surgeons  in  charge.  The  stewards  and  ward 
masters,  nurses  and  cooks  were  either  detailed 
soldiers  or  civilians  at   the  option  of   the   surgeon. 

The  Army  Regulations  of  1S21  for  the  first  time 
distinctly  provided  that  cooks  and  nurses  in  hospitals 
should  be  taken  from  the  privates  of  the  army, 
although  such  had  doubtless  been  the  usual  practice 
before  that  date.  During  the  Civil  War  civilians, 
both  men  and  women,  were  largely  employed  as 
nurses,  especially  in  the  general  hospitals.  They 
may  also  have  been  employed  to  a  limited  extent 
in  the  war  with  Mexico.  With  these  exceptions, 
hospital  attendants  were  obtained,  from  1821  until 
the  organization  of  the  hospital  corps  in  1887,  wholly 
by  the  detail  of  soldiers  of  the  line,  an  arrangement 
which  was  always  unsatisfactory,  for  it  was  difficult 
to  secure  the  best  men  of  the  command  for  such  duty, 
and  the  length  of  the  detail  being  uncertain  and  pro- 
motion practically  unknown,  there  was  little  to 
stimulate   the  ambition   of   the  attendant. 

The  employment  of  civilians  as  hospital  stewards 
for  post  and  regiments,  as  well  as  for  general  hospitals, 
was  still  authorized  in  1821;  but  as  in  the  Indian 
wars  which  resulted  from  the  spread  of  civilization 
westward,  the  activity  of  the  army  was  transferred 
to  the  frontier,  it  no  doubt  became  increasingly 
difficult  to  hire  suitable  civilians,  while  experience 
showed  that  it  was  desirable  that  the  incumbent  of 
this  position  should  be  amenable  to  military  discipline 
and  held  to  a  definite  term  of  service. 

It  therefore  soon  became  the  rule  that  hospital 
stewards  should  be  detailed  from  the  line,  as  is  shown 
by  the  fact  that  in  1S33  an  order  from  the  War 
Department  gave  authority  for  the  enlistment  of  a 
hospital    steward    at    posts    where    a    suitable    man 


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could  not  be  obtained  from  the  command.  But 
even  though  specially  enlisted  as  hospital  steward  he 
was  still  mustered  with  a  company  and  regarded  as  a 
detailed  soldier  of  the  line,  and  in  1842  the  adjutant- 
general  decided  that  in  case  of  emergency  he  could 
be  required  to  perforin  military  duty  as  such.  Since 
the  hospital  steward  could  be  returned  to  the  line  at 
any  time  at  the  caprice  of  the  commanding  officer, 
the  necessity  of  securing  for  him  a  more  permanent 
status  was  felt,  and  Congress  in  1856  authorized  the 
appointment  of  hospital  stewards  from  the  enlisted 
men  of  the  army  who  should  be  permanently  attached 
to  the  medical  and  hospital  department.  Command- 
ing officers  were,  however,  still  permitted  to  detail, 
upon  the  recommendation  of  the  medical  officer,  a 
soldier  to  act  as  hospital  steward  for  field  duty  or  at 
stations  where  there  was  no  hospital  steward.  These 
men  were  at  first  known  as  acting  hospital  stewards. 
After  1S64  they  were  called  hospital  stewards  of  the 
second  class  if  detailed  for  duty  at  posts  of  more 
than  four  companies,  and  hospital  stewards  of  the 
third  class  if  at  posts  of  four  or  less  companies. 

In  18(52  the  employment  of  civilians  as  cooks  and 
nurses  in  the  general  hospitals  having  been  authorized, 
the  surgeon-general  published  regulations  for  the 
"Hospital  Corps,  U.  S.  Army,"  which  was  to  be 
composed  of  civilians  hired  under  contract  for  the 
period  of  one  year,  unless  sooner  discharged.  Except 
in  name  this  organization  bears  no  resemblance  to  the 
present  hospital  corps,  which  was  created  by  the  act 
of  Congress,  March  1,  1NS7. 

The  idea  of  medical  organizations  in  the  field,  drilled 
and  trained  to  gather  up  the  wounded  from  the  battle- 
field, transport  and  care  for  them,  developed  by 
Larrey  and  Percy  in  the  Napoleonic  wars,  had 
perished  with  the  armies  of  the  First  Empire  under 
the  retroactive  prejudices  of  the  old  monarchies,  and 
the  military  taboo  of  even  republican  America  forbade 
a  physician  to  exercise  the  sacred  function  of  "com- 
mand over  trained  enlisted  assistants  of  his  own 
department  or  even  to  have  a  permanent  and  un- 
questioned jurisdiction  over  the  mules  and  drivers  of 
the  medical  ambulances.  He  controlled  in  battle  his 
own  two  hands,  and  these  only,  unless  the  colonel  saw 
fit  to  give  him  the  uncertain  and  doubtful  assistance 
of  the  regimental  band. 

The  following  letter  taken  from  the  files  of  the 
Surgeon-general's  Office  permits  a  glimpse  of  the 
tragic  results  of  this  lack  of  an  organized  enlisted 
personnel  for  the  Medical  Department: 

SfrtGEON-GENERAL's  Office,  Sept.  7,  1SG2. 
Honorable  Edwin  M.  Stanton, 

Secretary  of  War. 
Sir: 

I  have  the  honor  to  ask  your  attention  to  the 
frightful  state  of  disorder  existing  in  the  arrangement 
for  removing  the  wounded  from  the  field  of  battle. 
The  scarcity  of  ambulances,  the  want  of  organization, 
the  drunkenness  and  incompetency  of  the  drivers, 
the  total  absence  of  ambulance  attendants  are  now 
working  their  legitimate  results,  results  which  I  feel  I 
have  no  right  to  keep  from  the  knowledge  of  the 
department.  The  whole  system  should  be  under  the 
charge  of  the  Medical  Department.  An  ambulance 
corps  should  be  organized  and  set  in  instant  operation. 
I  have  already  laid  before  you  a  plan  for  such  an 
organization,  which  I  think  covers  the  whole  ground, 
but  which  I  am  sorry  to  find  does  not  meet  with  the 
approval  of  the  general-in-chief.  I  am  not  wedded 
to  it.  I  only  ask  that  some  system  may  be  adopted 
by  which  the  removal  of  the  sick  from  the  field  of 
battle  may  lie  speedily  accomplished  and  the  suffering 
to  which  they  are  now  subjected  be  in  future  as  far 
a    |i< issible  avoided. 

I  p  to  this  date  six  hundred  wounded  still  remain 
on  the  battlefield  in  consequence  of  an  insufficiency 
of  ambulances  and  the  want  of  a  proper  system  for 


regulating  their  removal  in  the  Army  of  Virginia. 
Many  have  died  of  starvation,  many  more  will  die  in 
consequence  of  exhaustion,  and  all  have  endured 
torments  which  might  have  been  avoided. 

I  ask,  sir,  that  you  will  give  me  your  aid  in  this 
matter,  that  you  will  interpose  to  prevent  a  recurrence 
of  such  consequences  as  have  followed  the  recent 
battle,  consequences  which  will  inevitably  ensue  on 
the  next  important  engagement  if  nothing  is  done  to 
obviate  them.  I  am,  sir,  very  respectfully, 
Your  obedient  servant, 

William  A.  Hammond, 

Surgeon-General. 

Yet  even  this  picture  of  the  COO  men  who  had  lain 
ten  days  on  the  battlefield  of  Second  Bull  Run  could 
not  bring  the  commanding  general  to  lift  the  taboo 
and  approve  of  enlisting  men  for  the  Medical  Depart- 
ment. But  while  the  Surgeon-general  was  vainly 
struggling  with  the  prejudices  of  Gen.  Halleck,  light 
had  broken  in  another  quarter.  July  1,  1862,  Surgeon 
Jonathan  Letterman  reported  to  General  McClclIan 
to  be  medical  director  of  the  Army  of  the  Potomac 
He  was  only  thirty-eight  years  old,  having  entered 
the  service  in  1849,  and  had  just  received  his  pro- 
motion to  major.  The  Army  of  the  Potomac  was  at 
this  time  crowded  with  sick  and  with  the  wounded  of 
the  seven  day's  fight,  and  in  the  retreat  to  Harrison's 
Landing  most  of  the  medical  equipment  and  supplies 
had  been  lost  or  expended.  In  the  course  of  a 
month  he  brought  order  out  of  this  chaos,  and  at  the 
same  time  drew  up  a  plan  for  an  ambulance  corps — 
simple,  far-reaching  and  effective — which  General 
McClellan  was  quick  to  adopt.  The  personnel  for 
this  corps  was  obtained  by  transfers  of  officers  and 
men  from  the  line,  and  they,  as  well  as  the  ambulances 
and  other  transportation,  were  placed  entirely  in  the 
hands  of  the  medical  directors  of  the  several  army 
corps.  A  distinctive  uniform  and  a  simple  drill  were 
prescribed.  This  organization  was  announced  in 
orders  apparently  without  reference  to  Washington 
on  August  2,  and  was  soon  followed  by  a  scheme  for 
regimental  medical  service  and  the  establishment  of 
division  field  hospitals  in  October.  These  taken 
together  made  a  complete  workable  system,  which  at 
once  made  a  new  epoch  in  medical  organization,  and 
placed  the  Army  of  the  Potomac  far  ahead  of  any 
military  establishment  in  the  world  in  this  respect. 

Meanwhile  the  system  had  its  first  trial  at  Antietam 
September  7,  1862,  when  the  wounded  of  the  Army 
Corps  from  the  Army  of  the  Potomac  were  promptly 
removed  from  the  field  and  cared  for,  being  in  marked 
contrast  with  the  experience  of  the  wounded  of 
the  other  wing  made  up  of  troops  from  Pope's  army. 
In  the  bloody  battle  of  Fredericksburg,  where,  in 
addition  to  the  great  number  of  wounded,  was  added 
the  confusion  of  a  defeat,  the  ambulance  companies 
nevertheless  did  their  work  with  smoothness  and 
dispatch,  and  the  wounded  were  transported  without 
confusion  or  delay  to  the  division  field  hospitals.  As 
reported  by  Surgeon  Charles  O'Leary,  medical 
director  of  the  Sixth  Corps,  it  "afforded  the  most 
ploasing  contrast  to  what  we  had  hitherto  seen  during 
the  war." 

This  medical  organization  soon  spread  to  the  other 
armies  of  the  United  States,  and  was  formally  adopt- 
ed by  Congress  in  the  spring  of  1864.  It  was  not 
copied  from  European  models,  but,  on  the  contrary, 
has  been,  in  its  essential  features,  adopted  by  all 
civilized  nations,  and  it  is  probable  that  the  name 
and  fame  of  Jonathan  Letterman  are  better  known 
to-day  to  the  military  surgeons  of  Europe  than  in  lii-1 
own  country.  Nor  during  his  lifetime  did  this  great 
and  beneficent  genius  receive  any  promotion  or  any 
reward  other  than  the  commendation  of  his  general 
and  the  admiration  of  his  professional  comrades. 
This  splendid  constructive  work  was  done,  and  the 
vast  responsibilities  of  chief  medical  officer  of  a  great 


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Flo.  324. — Dr.  Jonathan 
Letterman. 


army  were  me(  and  surmounted  by  a  man  who     s 

■riven  only  the  rank  and  pay  of  a  major.     When  the 

Surgeon-general  proposed  thai  the  medical  directors 

of  the  armies  under  McClellan  and  Halleck  be  given 

the  temporary  rank  of  colonel,  which   was  enjoyed 

by  other  staff  officers,  the  War  Department  returned 

the  ungracious  and   fatuous   reply:   "Refused   unless 

ui  be  shown  that  the  skill  and  efficiency  of  sur- 

is  arc  increased  by  an  increase  of  rank  and  paj  ." 

This  rank  was  afterward  given  to  the  medical  direc- 

of  armies  in  the  field  by  the  Act  of  February  23, 

li    is  not   surprising  that    Letterman,   broken 

in  health  by  his  great   labors  ami  disgusted  at  the 

blind  ingratitude  of  those 
in  authority,  resigned 
from  the  service  in  De- 
cember, 1864,  and  died 
in  San  Francisco  some 
years  later. 

The  Army  General 
Hospital  in  San  Fran- 
cisco, which  receives  the 
sick  and  wounded  com- 
ing from  the  Philippine 
and  the  Hawaiian 
Islands,  and  which  is  the 
largest  general  hospital 
at  present  in  the  Army, 
has  recently  been  named 
the  Letterman  General 
Hospital,  in  memory  of 
this  great  organizer  for 
whom  it  is  hoped  that 
some  day  the  medical 
profession  will  demand 
official  recognition  which  was  denied  him  in  his  life- 
time, by  the  erection  of  a  statue  in  Washington. 

The  end  of  the  Civil  War  found  no  less  than  204 
general  hospitals  containing  136,000  beds  in  opera- 
in  the  territory  of  the  United  States  over  an  area 
extending  from  Maine  to  Florida,  and  westward  be- 
yond    the    Mississippi.     The     Medical     Department 
during  the  Civil  War  disbursed  over  847,000,000,  and 
id  for  1,057,423  sick  in  its  general  hospitals  alone, 
without  counting  those  that  passed  through  the  field 
regimental    hospitals.     Of    the    medical    staff, 
ll.">  were  shot  in  battle,  of   whom  42  died,  and  2bo 
died  of  disease. 

This  great  struggle  has  left  behind  it  as  monuments 
of  the  labors  of  the  medical  profession,  the  Army 
Medical  Museum  and  the  great  national  institution 
known  as  the  Library  of  the  Surgeon-general's  office. 
The  record  of  their  professional  work  is  given  in 
the  "Medical  and  Surgical  History  of  the  Rebellion," 
which  in  spite  of  the  advances  in  professional  knowl- 
edge since  that  time,  remains  an  inexhaustible  mine 
of  statistical  information,  while  the  reports  of  medical 
directors  in  the  appendix  are  of  permanent  value 
and  interest  to  all  who  are  interested  in  the  great  and 
ever-recurrent  problems  of  medico-military  ad- 
ministration. 

The  following  remarks  from  an  address  made  in 
1879  on  infectious  diseases  in  the  Army  by  the  great 
German  military  surgeon  Rudolph  Virchow,  show  an 
appreciation  of  the  accomplishments  of  the  medical 
department  of  the  Army  during  the  Civil  War  far  be- 
i  what  is  common  to  members  of  the  medical  pro- 
fession of  our  own  country: 

"It  has  been  sharp  necessity,  this  keenest  of 
monitors,  which  has  opened  men's  eyes  through  the 
heaviest  visitations,  so  that  they  are  compelled  to 
notice  what,  to  speak  accurately,  they  would  not  see. 
Yes,,  it  is  astonishing,  what  schools  of  suffering  the 
armies  have  had  to  pass  through  before  the  truth 
line  commonly  acknowledged!  Thus  in  the  Cri- 
mean war,  the  French  army  lost  one  man  out  of 
every  three,  in  their  wholearmy,  and  it  is  calculated 
that   of  the   96,615   men   who  forfeited   their  lives, 

Vol.  I.— 37 


only  Hi.Jlo  fell  before  the  enemy;  about  on  equal 
number  of  wounded  died  in  the  hospitals.  The 
re  l,  more  than  7.~>.(H)(l  men,  f,-||  a  sacrifice  to  dis- 
ea  e.  In  the  American  civil  War,  97,000  men  died  in 
battle,  and    184,000  from  epidemics  and  sickni 

What  a  huge  ma       "f  pain  and  suffering,  what  a  sea  of 

blood  and  tears  stands  revealed  in  these  figures  I  Hut, 

also,  w  hat  a  heap  of  fallacious  regulat  ions,  of  prejudices 

and  misunderstandings.  It  is  necessary  to  lav  bare  here 
the  long  list  of  these  -ins  ami  mi-iakes;  fortunately 
it  is  sufficiently  well  known  in  order  to  serve  as  a 
warning  for  others.  But  it  must  also  be  said  that  it 
was  not  necessity  alone  which  exposed  the  evil  and 
brought  redress.  That  the  French  learned  little  or 
nothing  in  the  Crimea,  and  the  North  Americans  so 
much  in  their  Civil  War,  that  from  that  date  onward 
begins  a  new  era  of  military  medicini — this  depends 
not  on  the  magnitude  of  the  necessity  which  the 
Americans  had  to  Undergo,  which  in  truth  was  not 
greater  than  the  French  underwent  in  the  Crimea. 
It  was  far  more  the  critical,  genuinely  scientific 
spirit,  the  open  mind,  the  sound  and  practical  in- 
telligence, which  in  America  penetrated  step  by  step 
every  department  of  army  administration,  and  which 
under  the  wonderful  cooperation  of  a  whole  nation 
reached  the  highest  development  that,  relative  to 
humane  achievements,  had  hitherto  been  attained  in 
a  great  war.  Whoever  takes  up  and  looks  into  the 
comprehensive  reports  of  the  military  medical  staff 
will  be  again  and  again  astonished  at  the  richness  of 
the  experiences  chronicled  therein.  The  utmost 
accuracy  of  detail,  painstaking  statistics  embracing 
the  minutest  particulars,  an  erudite  exposition  com- 
prehending every  aspect  of  the  practice  of  medicine, 
are  here  united  in  order  to  preserve  and  transmit  to 
contemporaries,  and  to  posterity,  in  the  most  thorough 
way  possible,  the  wisdom  purchased  at  so  tremen- 
dous a  price. 

The  admirable  medical  organization  of  Letterman 
disappeared  with  the  armies  of  Grant  and  Sherman, 
and  Congress,  weary  of  war,  could  not  be  induced  to 
take  interest  in  any  military  matter,  except  in  the 
direction  of  reduction  and  economy.  While  all  other 
nations  made  haste  to  apply7  the  lessons  of  our  war 
and  to  remodel  their  medical  organization  in  accor- 
dance with  them,  our  own  Medical  Department 
reverted  to  ante-bellum  conditions  and  went  back- 
ward. The  hospital  stewards  were  the  only  perma- 
nent enlisted  personnel,  and  all  nursing  and  other 
work  about  the  hospitals  was  done  by  an  uninstrueted 
and  constantly  changing  personnel  of  men  detailed 
from  the  companies. 

No  worse  system  could  have  been  invented,  and 
yet  it  lasted  twenty-two  years,  until,  in  1SS7,  the 
first  step  toward  a  modern  organization  was  made  by 
the  establishment  of  a  hospital  corps  consisting  of 
privates  and  two  grades  of  noncommissioned  officers. 
The  medical  officers  then  began  the  systematic  train- 
ing of  the  personnel  and  the  study  of  modern  medical 
organization  with  a  view  to  war  conditions.  This 
movement  unfortunately  was  misunderstood  by  the 
officers  of  the  line  and  met,  especially  at  first,  with 
much  ridicule  and  covert  opposition,  the  use  of 
military  titles  by  medical  officers  being  especially 
resented. 

The  outbreak  of  the  Spanish  War  in  189S  found  the 
Medical  Department  with  a  personnel  of  177  com- 
missioned officers  and  750  enlisted  men.  This 
number  was  barely  sufficient  to  perform  the  medical 
service  of  the  regular  army  of  25,000  men  in  time  of 
peace.  When  a  volunteer  army  of  250,000  men  was 
mobilized,  and  at  the  same  time  an  expedition  em- 
bracing practically  the  entire  regular  army  was 
organized  to  attack  Santiago,  it  was  immediately 
evident  that  if  the  regular  regiments  were  to  be  cared 
for  by  regular  medical  officers  but  few  would  be  left 
to  organize  the  medical  service  of  the  volunteer 
armies.     Each   of  the  volunteer  regiments  brought 

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with  it  into  service  three  regimental  surgeons  and 
three  hospital  stewards,  but  no  privates.  The  regi- 
mental and  field  hospitals  had  to  be  organized  at  the 
expense  of  this  regimental  medical  personnel.  The 
enlisted  strength  of  the  regular  hospital  corps  was 
inadequate  for  "25,000  men,  and  as  Congress  failed  to 
authorize  the  enlistment  of  volunteer  Hospital  Corps 
men,  the  situation  in  this  respect  became  at  once 
acute,  and  was  only  partially  relieved  by  the  clumsy 
expedient  of  authorizing  the  transfer  of  men  from 
volunteer  regiments  to  the  regular  Hospital  Corps. 
We  have  seen  how  this  emergency  was  relieved  in 
great  measure  in  the  general  and  stationary  hospitals 
by  the  employment  of  female  trained  nurses  in  large 
numbers.  This  assistance,  of  course,  could  not  have 
been  employed  in  the  regimental  and  field  hospitals. 
which  marched  with  the  troops  and  performed  the 
service  of  removal  of  the  sick  and  wounded  from  the 
front,  but  fortunately  the  short  duration  of  the 
Spanish  War  made  but  small  demand  upon  the 
activities  of  these  mobile  organizations.  The  volun- 
teer surgeons,  though  in  many  cases  appointed  with- 
out effective  examinations,  were,  as  a  rule,  capable 
and  efficient  physicians  but  were  lacking  in  admin- 
istrative experience,  and  in  practical  knowledge  of 
military  hygiene.  The  troops  were,  in  most  cases, 
kept  for  long  periods  of  time  in  their  camps  of  mobili- 
zation and  so  the  typhoid  infection,  which  almost 
every  regiment  brought  with  it  from  its  state  camp, 
had  good  opportunities  for  dissemination.  It  was 
the  accepted  belief  of  military  surgeons,  as  of  the 
medical  profession  at  large,  in  1S9S,  that  the  principal 
and  almost  the  only  method  of  dissemination  of 
typhoid  fever  was  by  polluted  water  supplies,  and  the 
typhoid  epidemic  that  swept  through  all  the  camps 
in  the  summer  of  1S9S,  regardless  of  the  fact  that  for 
many  of  them  the  water  supply  was  artesian,  created 
consternation  and  surprise.  The  true  conditions 
under  which  typhoid  fever  is  spread  as  a  camp  disease 
were  not  understood  until  the  publication,  some  years 
later,  of  the  remarkable  study  of  these  epidemics 
made  by  Major  Reed  of  the  Medical  Corps,  and  Majors 
Vaughan  and  Shakespeare  of  the  Volunteer  Medical 
i.e.  which  covered  20,738  cases  of  typhoid  fever 
among  107,973  officers  and  men  in  ninety-two 
regiments. 

The  military  and  sanitary  lessons  of  this  war  were 
most  instructive.  They  were  studied  with  much 
and  patience  and  every  facility  for  arriving  at  the 
truth  by  a  commission  appointed  by  President 
McKinley  to  investigate  the  conduct  of  the  War 
Department  in  the  war  with  Spain,  commonly  known 
as  the  Dodge  Commission,  from  the  name  of  its 
chairman.  Their  conclusions  were  as  regards  the 
Medical  Department: 

What  is  needed  by  the  Medical  Department  in  the 
future  is: 

1.  A  larger  force  of  commissioned  medical  officers. 

2.  Authority  to  establish  in  time  of  war  a  proper 
volunteer  hospital  corps. 

3.  A  reserve  corps  of  selected  trained  women 
nurses,  ready  to  serve  when  necessity  shall  arise,  but, 
under  ordinary  circumstances,  owing  no  duty  to  the 
War  Department,  except  to  report  residence  at 
determined  intervals. 

4.  A  year's  supply  for  an  army  of  at  least  four  times 
the  actual  strength  of  all  such  medicines,  hospital 
furniture,  and  stores  as  are  not  materially  damaged 
by  keeping,  to  be  held  constantly  on  hand  in  the 
medical  supply  depots. 

5.  The  charge  of  transportation  to  such  an  extent 
ill  secure  prompt  shipment  and  ready  delivery 

of  all  medical  supplies. 

G.  The  simplification  of  administrative  "paper 
work,"  so  that  medical  officers  may  be  able  to  more 
thoroughly  discharge  their  sanitary  and  strictly 
medical  duties. 

7.   The  securing  of  such  legislation  as  will  authorize 


all  surgeons  in  medical  charge  of  troops,  hospitals 
transports,  trains  and  independent  commands  to  draw 
from  the  Subsistence  Department  funds  for  the 
purchase  of  such  articles  of  diet  as  may  be  necessary 
to  the  proper  treatment  of  soldiers  too  sick  to  use  the 
army  ration.  This  to  take  the  place  of  all  commuta- 
tion of  rations  of  the  sick  now  authorized. 

To  these  should  have  been  added  the  creation  of 
a  corps  of  medical  inspectors  with  adequate  rank  and 
powers. 

In  the  reorganization  of  the  Army  by  the  Act  of 
February  2.  1901,  no  attention  was  "paid  to  the 
recommendations  of  this  commission  or  to  those  of 
the  surgeon-general,  and  the  proportion  of  medical 
officers  was  not  only  not  increased  but  was  greatly 
reduced,  while  their  prospect  of  promotion  was 
taken  away  by  disproportionate  increase  in  the  lower 
grades. 

The  injurious  effect  of  this  legislation  soon  became 
apparent  and  it  was  found  impossible  to  fill  the 
vacancies  created  by  the  act  or,  without  a  lowering 
of  the  standard,  to  get  more  recruits  for  the  medical 
corps  than  were  sufficient  to  replace  the  annual  1. 
by  death  and  retirement.  Surgeon-general  R.  M. 
O'Reilly  therefore,  on  December  24,  1903,  placed  in  the 
hands  of  the  Secretary  of  War,  Elihu  Root,  a  memo- 
randum in  which  the  defects  of  organization  of  the  act 
of  February  2,  1901,  were  carefully  and  fully  diseu- 
and  a  reorganization  proposed  which  would  earn,'  out 
the  recommendations  of  the  Dodge  Commission  >u 
far  as  specific  legislation  was  necessary  to  that  end. 
The  scheme  proposed  was  finally  enacted  into  law 
on  April  23,  190S,  and  has  resulted  in  the  excellent 
organization  of  to-day.  Meanwhile  the  Surgeon- 
general  has  kept  constantly  in  view  the  recommenda- 
tions of  the  Dodge  Commission  so  that  all  have  been 
carried  out  with  the  exception  of  No.  2 — authority  to 
establish  in  time  of  war  a  proper  volunteer  hospital 
corps.  This  has  been  for  some  years  before  Cong 
as  part  of  a  general  law  proposed  by  the  War  Depart- 
ment for  the  raising  of  volunteer  armies,  but  remains 
without  favorable  action.         Jeffeksox  R.  Kean. 


Army  Medical  Field  Service. — Where  any  large 
number  of  men  are  to  be  employed  in  a  given  task, 
their  organization  into  suitable  groups  is  essential  to 
the  accomplishment  of  satisfactory  results.  \ 
machine  must  be  created,  each  part  of  which  works 
in  harmony  with  the  others  and  all  are  domina 
by  a  single  will.  No  more  complete  and  intricate 
machine  exists  than  that  found  in  a  modern  army, 
and  that  part  of  the  mechanism  relating  to  the 
functioning  of  the  Medical  Department  is  one  of  great 
and  essential  importance.  This  point  has  been  too 
often  overlooked;  and  the  first  years  of  our  Civil  War, 
with  a  sad  experience  which  only  lack  of  time  and 
opportunity  kept  from  being  duplicated  in  the  Spanish 
War,  clearly  demonstrated  that  zeal  and  patriotism 
cannot  make  up  for  defective  organization  and  ab- 
sence of  team  work.  It  has  been  said  that  the  best 
preparation  for  war  is  war  itself.  This  is  but  a  half 
truth.     Ultimate  good  results  may  proceed  quite  as 


578 


KJEFERENCE  HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Army  Medical  Field  Service 


iiucli   f'"«'   -original    ii ii^i akes   recognized    and    sub- 

ieqUentJj   ftwciided  as  from  .successes  achieved  at  the 

,„,„,,(    '\,>i-    is    training    in    the   routine   duties   of 

ieaoe     from    its    entirely    different    character,    any 

eparation  for  Che  new  parts  and  changed 

cenery   staged    by   war.     We   can.   by   studying   in 

dvance  the  matter  of  medical  Held  service  from  the 

tandpoiat    of    theory,   make   our   mistakes    largely 

inder  conditiaaiLS  when  knowledge  is  not,  bought  by 

Wood,  suffering,  and  tears.     It  is  easy  enough 

:  to  care  for  wounded  actually  under  his 

ands,  bul  I  u  problem  in  war  is  to  bring  the  wounded 

irgeon,  and  the  surgical  supplies  together 

i  a  suitable  way  and  without  undue  interference  with 

uiitary   purposes.     Not   all    these   facilities   can    be 

rough!  up  I"  the  wounded  under  the  limitations  of 

ce    the    problem    becomes    largely    one    of 

vacuatiorj  of  the  wounded  from  the  zone  of  casualty 

i  where  fixed  hospital  establishments  admit  of 

ivision   of   every   facility    that   ingenuity   can 

.mil  money  can  buy.     The  problem  of  medical 

irk,   before  being  one  of  purely  professional 

is    thus  first  of  all  one  of  transportation  of 

ats. 

■neral  way,  there  are  three  zones  whose  borders 

it     overlap,     and     through     which     severely 

ounded  will  pass  from  front  to  rear,  viz.,  collecting, 

ing,  and  distributing.     Each  has   its  specific 

•lief  formations  in  which  convalescing  cases  will  be 

d    and    returned    to    the    front.     The    whole 

is  to  pass  the  cripple  back  as  quickly  as  pos- 

:i  point  where  he  will  be  out  of  the  way,  while 

■turning  the  sound  man  without  unnecessary  delay 

i    service  with  the  colors. 

loses  of  the  Medical-  Department  in  War. — These 
EBcially  l:nd  down  as  follows: 
:  The    preservation    of    the    strength    of    the 
)rces   in    the    field    (o)  by    the    necessary    sanitary 
res,   (6)  by   the  retention  of  effectives  at  the 
oat,  and  the  movement  of  non-effectives  to  the  rear 
obstructing  military  operations,  and  (c)  by 
ie  prompt  succor  and  removal  of  wounded. 
Second:  The  care  and  treatment  of  the  sick  and  in- 
ed  :it   the  front,  -on  the  lines  of  communications, 
ad  in  home  territory. 

The   primary    purpose    thus    relates   to   military 
tonomics  in  the  prevention  of  waste;  only  secondarly 

■i ^derations  of  humanitarianism  enter. 
The  specific  duties  of  the  Medical  Department  in 
ar  are  included  in  the  following: 
1)   The  initiation  of  sanitary  measures  to  insure 

ealth  of  troops. 
_  I    The  direction  and  execution  of  all  measures  of 
ublic   health   among    the    inhabitants   of   occupied 

ory. 
(3)  The  care  of  the  sick  and  wounded  on  the  march, 


in  camp,  on  the  battle-field,  and  after  removal  there- 
1 1 

ill  The  methodical  disposition  of  the  sick  and 
wounded,  so  as  to  insure  I  lie  retention  of  those  effec- 
tive ami  relieve  the  fight  ing  force  of  tin'  aon-i  ffecti  re. 
The  transportation  of  tin'  sick  and  wounded. 

(Ii)  The  establishment  of  hospitals  and  other 
formations  necessary  for  the  care  of  the  sick  and  in- 
jured. 

(7)  The  supply  of  sanitary  material  necessary  for 
the  health  of  the  troops  and  for  the  care  of  the  sick 
and  injured. 

(8)  The  preparation  and  preservation  of  individual 
records  of  sickness  and  injury,  in  order  that  claims 
may  l>e  adjudicated  with  justice  to  the  Government 
and  the  individual. 


The  Sanitary  Personnel. — A  very  large  person- 
nel is  necessary  to  carry  on  the  work  of  the  Medical 
Department  in  war.     It  is  drawn  from: 

(a)  Medical  officers  of  the  regular  army,  450  in 
number.  Also  from  the  officers  of  the  Medical 
Reserve  Corps,  both  on  the  active  and  inactive  lists. 
The  organized  militia  of  the  States,  on  mustering  into 
tin'  service  of  the  United  States,  brings  its  own  medical 
officers;  while  in  the  organization  of  any  volunteer 
foi'res  provision  is  made  for  the  necessary  attached 
sanitary  personnel. 

(b)  Physicians  employed  under  contract,  but  not 
commissioned  as  officers. 

(c)  Members  of  the  Hospital  Corps,  as  existing  in 
the  regular  army  and  organized  militia  and  as  ex- 
panded to  meet  war  conditions. 

(d)  Members  of  the  Army  Nurse  Corps  (female). 

(e)  Officers  and  soldiers  of  the  line  or  staff  detailed 
for  duty  with  the  Medical  Department. 

(f)  Civilians  employed  as  clerks,  drivers,  laborers, 
scavengers,  etc. 

(<?)  The  utilization  in  this  connection  of  the  Red  Cross 
Society,  and  of  individuals  offering  voluntary  service, 
as  subsequently  mentioned. 

The  number,  rank,  and  distribution  of  the  sanitary 
personnel  for  the  infantry  division — the  smallest 
tactical  unit  containing  all  branches  of  the  service 
and  capable  of  independent  action  under  ordinary 
conditions — is  summarized  in  the  following  table: 


Functions  of  the  Red  Cross  Society. — Following 
its  reorganization,  by  both  law  and  Presidential 
Proclamation,  the  American  Red  Cross  has  become 
the  sole  intermediary  between  all  humanitarian 
societies  and  associations  and  the  sick  and  wounded 
of  our  armies.  Any  organized  volunteer  aid  must 
be  furnished  through  it.     This  is  very  desirable,  since 


Lieut. - 
colonels. 


Majors. 


Captains 

and 

lieutenants. 


Total 
commissioned. 


Sergeants, 
first  class. 


Sergeants 

and 
corporals. 


Privates, 
first  class, 

and 
privates. 


Total 

enlisted. 


Grand 
total. 


ivision  hdqrs 

n 

ifantry,  '.)  regs 

i  reg  

-'  regs 

imineers,  1  bn 

!   Troops,  1  Im 

mmunition  train 

ipply  train 

mbulance  cos.  (4) 

'I'l  hospitals  (H 

esenre  medical  supplies. 
Total 


19 


27 
3 
4 
3 
2 
2 
1 
20 
16 
1 

80 


3 

1 

36 

4 

6 

3 

2 

2 

1 

21 

21 

1 


12 

1 


3 

4 
3 
o 
1 
1 
29 


6 

1 

180 

20 

36 

6 

4 

6 

3 

2S1 

193 


745 


7 

2 

216 

24 

42 

9 

4 

8 

4 

318 

230 

11 

S77 


10 

3 

252 

28 

48 

12 

8 

10 

5 

339 

251 

12 

|.I7S 


579 


Army  Medical  Field  Service 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


a  -ingle  central  head  is  not  only  able  better  to  coordi- 
nate and  utilize  relief  agencies  from  different  sources, 
but  enables  transactions  to  be  accomplished  with  a 
responsible  agent  in  the  avoidance  of  much  friction 
and  meddlesome  but  well  meaning  interference  on 
the  part  of  outsiders,  who  in  the  past  through  their 
ignorance  of  military  necessities  and  conditions  have 
often  hindered  where  they  hoped  to  help  and  paralyzed 
where  they  tried  to  quicken. 

But  though  organized  aid  other  than  that  of  the 
Red  Cross  may  not  be  accepted,  that  of  individuals 
may  in  emergency  be  utilized  by  chief  surgeons  acting 
under  authority  of  commanders.  This  permits  of 
the  use  of  civilian  physicians,  nurses,  cooks  and  others, 
under  such  conditions  and  assignments  as  the  Chief 
Surgeon  may  deem  best.  Such  civilians  may  be  used 
anywhere,  but  ordinarily  their  employment  would  be 
restricted  to  the  base  and  line  of  communications,  as 
the  presence  of  civilians  at  the  front  is  usually  highly 
undesirable  for  various  reasons. 

The  representatives  of  the  Red  Cross  have  offices 
in  the  War  Department,  and  keep  in  constant  touch 
with  the  military  authorities.  In  time  of  war,  the 
surgeon-general  is  kept  informed  as  to  the  nature, 
extent  and  distribution  of  the  assistance  which  the 
Red  Cross  is  prepared  to  furnish;  and  when  need 
arises,  the  Surgeon-General  may  call  for  such  assistance 
and  authorize  the  employment  of  the  Red  Cross 
personnel  under  the  Medical  Department.  This 
principle  of  subordination  to  the  Medical  Department 
is  paramount,  and  Red  Cross  personnel  serving  with 
troops  are  subject  to  military  orders  and  regulations. 

Ordinarily  the  Red  Cross  will  be  employed  only  in 
home  territory,  at  the  base,  and  on  the  line  of  com- 
munications. Legitimate  war  functions  of  the  Red 
Cross  would  relate  to  the  organization  of  a  trained 
personnel  into  columns  for  the  evacuation  and  care  of 
sick  and  wounded;  into  detachments  for  service  in 
military  hospitals  and  for  other  purposes;  for  the 
taking  over  of  certain  branches  of  hospital  work;  the 
establishment  and  management  of  rest  stations;  the 
collecting,  storing  and  supply  of  sanitary  material; 
the  forwarding  and  distribution  of  gifts;  the  organiza- 
tion and  management  of  information  bureaus  to 
advise  of  the  location  and  condition  of  sick  and 
wounded;  the  providing,  furnishing  and  management 
of  convalescent  homes  and  special  hospitals;  the 
provision  of  facilities  of  every  nature  for  the  trans- 
portation of  sick  and  wounded. 

Sanitary  Inspections. — An  important  and  inces- 
sant task  of  the  Medical  Department  in  field  service 
has  to  do  with  the  prevention  of  disease  among  troops. 
For  this  purpose,  high  ranking  medical  officers  are 
assigned  as  sanitary  inspectors  to  large  separate 
commands  by  the  Surgeon-General  himself,  being 
selected  by  reason  of  special  fitness  for  such  work. 
The  sanitary  inspector  may,  under  regulations,  be 
given  authority  to  issue  orders  in  emergency  in  the 
name  of  the  superior  commander,  and  it  is  also  laid 
down  that  it  is  the  duty  of  commanders  to  remedy 
sanitary  defects  reportecf  to  them  by  sanitary  inspec- 
tors. The  latter  make  monthly  reports  to  the  Surgeon- 
General,  through  military  channels,  showing  the 
nature  and  extent  of  their  activities,  the  defects 
found  and  the  measures  taken  to  remove  them.  In 
this  way  pressure  from  above  may,  if  necessary,  be 
brought  to  bear  on  the  derelict  authorities. 

The  Need  For  Sanitary  Organizations. — For- 
gtting  the  lessons  of  the  Civil  War,  until  quite  re- 
cently  it  seemed  to  be  complacently  accepted  that 
in  some  miraculous  way  the  sanitary  organiza- 
tions which  the  official  tables  called  for — but  which 
had  never  been  required  to  be  provided — would 
spring  up  full  grown  like  mushrooms  in  a  night.  In 
any  war  with  a  first  class  power,  and  as  we  did  in  our 


Civil  War,  we  would  need  to  muster  approximately 
a  million  men.  In  the  brief  and  trivial  affair  with 
Spain  we  raised  2.50,000  troops,  or  more  than  twelve 
divisions,  requiring  over  1,200  medical  officers  and 
over  9,500  Hospital  Corps  men  for  the  service  of  the 
front  alone,  and  not  considering  the  vast  personnel 
required  to  man  the  numerous  and  tremendous  hospi- 
tal establishments  of  the  line  of  communications  and 
home  territory  had  hostilities  been  protracted.  The 
Japanese  are  said  to  have  had  at  one  time  over  50,000 
officers  and  men  in  their  sanitary  personnel  during 
the  war  with  Russia;  and  in  any  great  war  our  own 
sanitary  personnel  would  probably  reach  at  least  the 
above  number.  To  shake  down  this  number,  or  even 
a  fair  fraction  of  it,  into  an  effective  sanitary  machine 
can  be  possible  only  at  the  expense  of  a  vast  amount 
of  suffering  and  sorrow — the  price  we  must  expect  to 
pay  for  our  national  policy  of'general  military  unpre- 
paredness.  Within  the  past  year,  some  attempt  has 
been  made  to  remedy  sanitary  deficiencies.  We  now 
have  four  ambulance  companies  and  four  field  hos- 
pitals for  the  regular  army  kept  as  organized  units — 
about  one-fourth  of  those  required.  The  organized 
militia  has  about  a  dozen  of  each,  again  about  a 
quarter  of  those  necessary.  Although  we  are  better 
off  now  than  in  the  past,  the  prospect  of  satisfactory 
results  at  once  in  ease  of  war  is  not  alluring.  Most 
of  the  men,  mules,  and  vehicles  needed  for  the  field 
sanitary  service  would  have  to  be  enlisted,  bought 
and  manufactured  after  war  breaks  out;  and  the 
efficiency  of  so-called  organizations  in  which — to 
slightly  exaggerate — the  new  sanitary  soldiers  never 
saw  mules  before,  and  the  medical  officers  set  over 
them  from  civil  life  never  saw  either,  is  probably  a 
legitimate  subject  for  some  speculative  pessimism. 

The  theory  of  course  is  that  as  troops  mobilize 
from  their  posts,  the  post  sanitary  personnel  mobilizes 
with  them  and  is  promptly  and  properly  organized 
and  equipped  as  sanitary  detachments  and  units 
This  is  largely  the  dream  of  a  visionary.  When  troops 
leave  posts  they  leave  their  sick  behind,  for  whose 
benefit  a  large  proportion  of  the  sanitary  personnel 
must  remain.  On  arriving  at  the  mobilization  camp, 
the  sanitary  personnal  which  will  be  present  will  be 
found  inadequate  for  both  the  regimental  detachments 
and  the  divisional  sanitary  units.  Experience  of  the 
past  warrants  great  doubt  as  to  whether  these  will  ever 
be  brought  up  to  theoretical  war  strength.  In  the 
meantime,  the  Quartermaster's  Department  will  be 
letting  contracts  for  equipment,  having  the  ambu- 
lances urgently  needed  to-day  built  for  delivery  many 
months  hence,  and  preparing  to  supply  the  sanitary 
service  with  animals  after  the  demands  of  approxi- 
mately every  combatant  organization  has  been  satis- 
fied. It  is  true  that  the  Medical  Department,  profiting 
by  past  experience,  has  now  vast  stores  of  sanitary  field 
equipment  in  stock,  but  this  will  not  greatly  avail  if 
there  are  insufficient  men  to  handle  it;  and  another  de- 
partment, not  held  responsible  for  sanitary  results  in 
the  public  eye,  fails  to  provide  the  animals  and  vehicles 
to  move  it  or  the  disabled  to  whose  care  it  ministers. 
Unless  this  transportation  is  on  hand  before  the  war 
begins,  and  in  the  hands  of  the  Medical  Department, 
it  is  no  vain  prophecy  to  predict  that  the  latter  will 
be  held  responsible  for  many  shortcomings  in  the 
handling  and  care  of  sick  and  wounded  for  which  it 
will  be  in  no  wise  accountable.  The  only  way  to  be 
ready  for  war  is  to  prepare  for  it  in  every  possible  re- 
spect during  peace.  To  this  rule,  the  Medical  Depart- 
ment is  no  exception,  and  to  its  demands  medical 
officers  are  very  much  alive.  Equally,  to  this  rule, 
many  of  our  legislators  are  apparently  indifferent  or 
oblivious. 

I.  Sanitary  Service  in  the  Collecting  Zone. — 
The  sanitary  formations  in  the  collecting  zone,  by 
their  location  from  front  to  rear,  are  the  regimental 
sanitary    detachments,     the    ambulance  companies, 


580 


kefehence  haxiihouk  of  the  medical  sciences 


Army  Medical  Field  Service 


the  stations  for  slightly  wounded,  the  Geld  hospitals 
..  ,,|  the  reserve  medical  supplies.  In  considering 
their  nature,  purposes,  and  methods  of  employment 
as  a  whole,  they  are  best  regarded  as  components  of 
the  infantry  division,  already  referred  to  as  the  small 
,  (complete  tactical  mobile  unit.  This  is  made  up  of 
three  brigades  of  three  infantry  regiments  each,  two 
regiments  of  field  artillery,  one  regiment  of  cavalry, 
nation  of  engineers,  one  battalion  of  signal 
troops,  the  ammunition  and  supply  trains,  and  the 
j  organizations  already  mentioned.  The  di- 
vision contains,  all  told,  a  total  of  19,850  men:  and 
when  on  the  road  in  single  column  it  is,  with  its 
trains,  capable  of  marching  about  its'own  length  in 
a  day. 

A  discussion  of  the  various  sanitary  formations 
which  go  to  form  the  sanitary  resources  of  the 
,!u  ision  follows. 

The  Regimental  Medical  Service. — Every  regiment, 
and  every  independent  organization  of  smaller  size, 
is  given  a  definite  allowance  of  medical  officers  and 
Hospital  Corps  men,  whose  functions,  while  so  at- 
tached, are  normally  limited  to  their  organizations. 

Pie  personnel  for  a  regiment  of  infantry  consists 
,i  i  medical  officers  (1  major  and  3  juniors);  1 
sergeant,  first  class,  H.  C;  3  sergeants:  4  orderlies; 
tli  privates,  first  class,  H.  C.  or  privates.  Of  the 
above  number,  all  the  medical  officers  and  S  enlisted 
men  are  mounted. 

The  above  number  permits  of  the  following  assign- 
ment to  each  of  the  three  battalions:  1  medical  officer, 
1  noncommissioned  officer,  1  orderly,  4  privates, 
leaving  a  similar  personnel  to  form  a  regimental 
.  reserve  which  is  crystallized  out  in  the  so- 
called  "first  aid  party".  However,  any  assignment 
of  the  personnel  most  suitable  under  the  situation 
may  be  made. 

The  regiment  has  no  ambulances  of  its  own.  One 
is  lent  to  it  from  an  ambulance  company  for  route 
marching — three  if  the  regiment  is  operating  inde- 
pendently. There  is  a  pack  mule  which  carries  the 
-anitary  supplies  for  the  first  aid  station. 

When  operating  as  a  part  of  a  larger  force,  a 
regiment  has  no  hospital  of  its  own.  In  camp,  it  has 
a  regimental  infirmary,  but  this  is  not  intended  for 
the  very  ill,  who  are  required  to  be  transferred  to  a 
field  hospital  for  further  care.  One  four-mule  wagon 
carries  the  equipment  for  the  infirmary.  If  the 
regiment  is  operating  independently,  it  is  given  a 
regimental  hospital,  which  is  really  a  small  field 
hospital  and  is  carried  in  two  wagons.  But  these 
wagons  and  equipment  will  probably  usually  be  sent 
away  with  the  field  train  when  a  battle  is  imminent, 
as  they  take  up  valuable  road  space  and  can  rarely 
follow  deployed  troops.  The  regiment  during  action 
thus  relies  upon  its  aid  station  supplies,  as  carried  by 
its  sanitary  personnel  and  on  the  pack  mule,  and  the 
further  assistance  derived  from  the  ambulance 
companies  and  field  hospitals. 

During  combat,  the  following  duties  devolve  on 
the  regimental  sanitary  personnel: 

First  aid  to  the  wounded  on  the  battlefield;  the 
removal  or  direction  of  wounded  to  places  of  compara- 
tive safety  near  the  firing  line;  the  establishment  of  a 
first  aid  station;  the  removal  or  direction  of  wounded 
to  such  station,  and  their  simple  treatment  there;  the 
direction  of  the  trivially  wounded  back  to  the  firing 
line;  the  direction  of  other  slightly  wounded  to  the 
dressing  station,  or  elsewhere  to  the  rear;  in  excep- 
tional circumstances  the  transportation  of  severely 
wounded  to  the  dressing  station. 

As  the  regiment  prepares  to  advance  into  action, 
the  band  is  usually  directed  to  report  to  the  regimental 
surgeon  to  assist  in  the  sanitary  work.  As  the 
strength  of  bands  is  twenty-eight  men,  a  large  number 
of  supplementary  litter  squads  is  thus  assured.  The 
litters  available  for  their  use  belong  to  the  company 
organizations,  each  of  which  has  one  carried  on  its 


battalion  ammunition   wagon.      The  supplies  used   in 

battle  are,  the  first  aid  packet  carried  by  each  officer 

and  soldier,   the  dressings  carried  in   the  pouches  and 

on  the  persons  of  the  sanitary  personnel,  and   the 

considerable  assortment  of  surgical  supplies  carried 
by  the  pack  mule  which  transports  the  lighl  aid 
station  outfit.     As  long  as  a  regiment  advances,  its 

salutary  personnel  moves  along  with  it,  treating  help- 
less wounded  where  they  were  hit,  and  not  pan  ing 
longer  than  to  give  first  aid.  But  as  soon  as  the 
advance  is  checked,   and   the   number  of   wounded 

bee s  so  considerable  as  to  require   the   lime  of  a 

part  of  the  sanitary  personnel,  first  aid  stations  will 
be  established  in  the  proportion  of  one  to  each  regi- 
ment. Any  personnel  not  needed  at  I  he  aid  station 
accompanies  the  line  under  fire.  Perhaps  two  medical 
officers,  threc>  noncommissioned  officers,  and  seven 
privates  take  part  at  the  aid  station  and  keep  in 
touch  with  the  firing  line.  The  equipment  of  the  aid 
station  is  very  simple,  merely  boxes  of  dressings,  and 
light  nourishment  with  facilities  for  preparation. 
This  is  an  advantage,  since  it  is  no  great  task  to 
establish  or  break  up  such  a  station,  which  may  need 
to  go  into  operation  in  more  than  one  location  during 
a  tight.  The  first  consideration  is  protection  from 
fire,  and  usually  the  nearer  the  aid  station  is  to  the 
front,  the  safer  it  is  from  dropping  projectiles.  The 
aid  given  on  the  firing  line  will  consist  of  the  applica- 
tion of  dressings,  the  stanching  of  hemorrhages,  and 
the  immobilization  of  fractures  where  practicable. 
It  must  be  confessed,  however,  that  the  actual  results 
accomplished  on  the  firing  line  will  probably  be  not 
great,  and  that  sanitary  assignments  thereto  are 
largely  to  encourage  the  soldier  in  a  belief  that,  if  hit, 
his  injuries  will  be  promptly  attended  to.  With 
such  encouragement  lie  will  stand  longer  and  fight, 
better.  When  troops  are  advancing  by  rushes  across 
an  open  country,  it  is  clear  that  to  attempt  san- 
itary work  under  such  conditions  is  to  invite  useless 
destruction. 

The  treatment  at  the  aid  station  will  usually  be 
limited  to  first  aid  for  wounded  coming  from  the  front 
who  have  not  already  received  it;  and  to  the  readjust- 
ment of  dressings,  if  necessary,  of  those  who  have. 
Fractures,  if  not  previously  immobilized,  are  here  put 
in  splints.  Restoratives  and  analgesics  are  given  as 
required.  If  practicable,  stimulating  food  and  drink 
are  prepared.  In  general,  as  much  as  possible  will  be 
done  here  to  reduce  the  burden  of  work  which  other- 
wise would  subsequently  fall  on  the  dressing  stations 
ami  field  hospitals,  as  well  as  relieve  the  sufferings  of 
the  injured.  As  a  rule,  no  operations  will  be  done 
here  except  such  as  are  urgently  needed  to  save  life, 
as  the  ligation  of  an  artery  or  performance  of  trache- 
otomy. It  must  be  remembered  that  the  further  to 
the  rear,  the  better  the  facilities  provided  and  the 
greater  the  chances  for  successful  surgical  work. 
Prompt  occlusion  of  wounds,  in  preventing  infection, 
is  the  great  thing.  By  great  attention  to  this  last 
point,  the  Japanese  are  said  to  have  had  a  third  of 
all  their  wounded  back  on  the  firing  line  within  a 
month. 

The  regimental  surgeon  must  not  permit  his  station 
to  be  overcrowded.  All  able  to  walk  will  be  promptly 
started  back  to  the  next  relief  point  in  the  sanitary 
chain  which  has  in  the  meantime  been  established 
to  the  rear.  Those  unable  to  walk  are  turned  over 
to  the  ambulance  company  bearers  as  soon  as  they 
arrive.  The  regimental  surgeon  therefore  must  make 
every  effort  to  get  into  touch  with  the  ambulance 
company,  charging  the  wounded  he  is  starting  to  the 
rear  to  report  his  location,  or  even  detaching  one  of 
his  sanitary  personnel  as  messenger.  Frequently  a 
rough  position  sketch  should  be  scut  showing  the 
location  of  the  station  and  the  best  means  of  access 
to  it. 

Darkness  affords  a  convenient  opportunity  to  evac- 
uate the  aid  stations  and  search  the  more  advanced 


581 


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REFERENCE    HANDBOOK    OF    THE    MFDtCAL    SCIENCES 


positions.  This  work  at  night  is  very  difficult  and 
ard,'1ous.  If  his  regiment  moves,  the  surgeon  closes 
his  aid  station  and  follows,  never  permitting  himself  to 
get  out  of  touch  with  his  organization.  ( ttherwise  an 
advance  might  leave  an  aid  station  so  far  behind  thai  it 
would  not  be  able  to  fulfill  its  purpose.  Any  wounded 
thus  left  behind  on  moving  the  aid  station  would 
probably  be  taken  over  by  an  ambulance  company,  or 
some  of  the  regimental  sanitary  personnel  may  be 
detached  to  remain  with  them.  Similar  action  is 
taken  in  case  of  retreat. 

It  appears  from  the  foregoing  that  the  first  brunt 
of  sanitary  work  is  done  on  the  firing  line  and  at  the 
aid  station.  The  volume  of  casualties  developing  in 
a  very  short  time  will  sometimes  be  tremendous,  and 
sanitary  assistance  must  be  promptly  rushed  up 
from  the  rear.  This  is  done  by  appeal  of  the  regi- 
mental surgeons  to  their  colonels,  and  by  the  latter 
to  higher  authority.  Regiments  have  not  rarely  lost 
from  one-half  to  two-thirds  their  strength  in  a  single 
battle.  Larger  forces  lose  less  in  proportion;  but  a 
division  may  well  lose  a  third,  and  in  five  great  battles 
of  the  Civil  War  the  winning  side  lost  twenty  per  cent. 
or  over.  These  losses  do  not  fall  equally  on  organiza- 
tions, but  some  are  shot  to  pieces,  while  others  in 
reserve  may  have  lost  scarcely  a  man.  To  meet  the 
needs  of  such  diversified  casualty,  the  regimental 
sanitary  service  is  not,  by  itself  alone,  sufficiently 
elastic,  and  further  formations,  about  to  be  described, 
are  necessarily  brought  into  play. 

The  Ambulance  Company. — There  are  four  am- 
bulance companies  to  a  division.  Like  the  field 
hospitals  and  reserve  medical  supplies,  they  are 
divisional  troops,  and  subject  only  to  the  commands 
of  the  Division  Commander  and  the  Chief  Surgeon. 
A  Director  of  Ambulance  Companies,  with  the  rank 
■of  major,  and  with  a  sergeant  and  private  of  the  Hospi- 
tal Corps  as  assistants,  directly  conducts  ther  manage- 
ment under  the  Chief  Surgeon. 

The  personnel  of  an  ambulance  company  is  as  fol- 
lows: 5  medical  officers,  1  captain  and  4  first  lieuten- 
ants; 9  noncommissioned  officers,  2  sergeants,  first 
class,  and  7  sergeants;  1  acting  cook;  69  privates,  first 
class,  and  privates.  In  order  to  keep  the  organiza- 
tion as  elastic  as  possible,  for  the  reasons  which  appear 
elsewhere,  specific  assignments  to  duty  are  not  made 
except  in  the  personnel  to  accompany  the  wheel 
transportation,  which  is  as  follows:  1  lieutenant;  1 
sergeant,  first  class;  1  sergeant;  1  acting  cook;  2 
musicians;  1  farrier;  1  saddler;  15  drivers. 

As  to  mounts,  of  the  above  company  personnel  the 
following  are  mounted:  five  officers,  thirteen  enlisted 
men. 

For  transport  of  sick  and  wounded  an  ambulance 
company  has  twelve  ambulances,  each  drawn  by 
four  mules.  The  official  capacity  of  an  ambu- 
lance is  four  recumbent  and  one  sitting  case;  or 
two  recumbent  and  five  sitting  cases;  or  nine  sitting 
cases.  For  short  distances,  good  roads  and  great 
emergency,  these  figures  for  sitting  cases  may  be 
slightly  exceeded. 

There  are  also  four  collapsible  travois,  one  of  which 
is  carried  on  every  third  ambulance.  These  may  be 
used  with  the  pack  mules,  cavalry  horses,  or  public 
or  private  mounts.  Automobile  ambulances  will 
probably  find  a  place  in  the  military  service. 

Each  ambulance  company  carries  twenty  litters, 
beside  which  there  are  four  on  each  ambulance.  The 
latter,  however,  are  needed  as  cots  for  the  recumbent 
cases  and  are  intended  to  be  exchanged  for  loaded 
litters  brought  to  the  ambulance.  For  moving  sup- 
plies, each  company  has  three  four-mule  wagons.  Two 
of  these  chiefly  carry  rations,  forage,  kitchen  outfit, 
bedding  rolls,  officers'  baggage,  etc.,  and  belong  with 
the  field  train.  The  third  wagon  carries  the  equip- 
ment for  the  dressing  station — a  load  of  about  1,300 
pounds.  For  use  in  country  not  practicable  for  wheel 
vehicles,    or    under   exposure   to   fire,    this   dressing 


station    equipment    is   loaded'   on:  fotnr  pack  mules 
which  form  part  of  the  company  transport. 

The  supplies  entering  into  the  dressing  statioi 
equipment  are  simple  yet  sufficient  far  their  purpose 
They  consist  chiefly  of  an  abundance  of  dressings 
an  operating  case,  commode  set,,  detached  servici 
medical  chest,  simple  fo>tos,  a  couple  of  rolls  ol 
blankets,  a  water  filter.,  two  tent  flies,  buckets 
basins,  and  lights  for  night  work. 

The  general  function  of  ambulance  companies  is  tt 
collect  the  sick  and  wounded  of  the  mobile  fo.  ci 
transport  thera  to  field  hospitals.  More  specifically 
their_  duties  in  battle  are  to  establish  and  operati 
dressing  stations,  help  the  regimental  sanitary  person- 
nel at  the  front,  and  collect  audi  remove  the  wounded 
by  litters  and  ambulances,  to  the  field  hospitals 
They  therefore  bridge  the  entire  gap  between  tht 
regimental  sanitary  service  and  the  field  hospitals. 

Generally  speaking,  an  ambulance  company  ordereci 
into  action  proceeds  about  as  follows: 

The  company  moves  as  a  whole  to  th<>  last  point 
sheltered  from  fire.  Here  the  wheel  (transport  i 
left  behind  under  cover  to  await  orders.  Th* 
ninainder  of  the  company,  with  its  dressing  station 
equipment  carried  on  pack  mules,  moves  to  the 
vicinity  designated  for  a  station  and  locates  in  a 
protected  spot,  preferably  near  roads  from  front  to 
rear,  possessing  a  water  supply  aard,  if  possible, 
buildings.  The  latter  are  not  only  shelter,  but 
convenient  landmarks  to  which  to>  direct  wounded. 
The  company  probably  leaves  her*  about  two  medical 
officers  and  about  nine  enlisted  men.  This  personnel 
at  once  establishes  and  prepares  the  dressing  station 
to  receive  and  care  for  patients.  The  remainder  ol 
the  company,  consisting  of,  say,  twenty  litter  squads, 
under  two  medical  officers  and  five  sergeants,  moves 
forward  either  as  a  single  detachment  or  several 
smaller  groups  to  get  into  touch  with  the  several 
regimental  aid  stations  in  the  sector  of  the  line  they 
are  ordered  to  handlo.  As  soon  as  they  get  into 
touch  with  these  stations,  they  start  the  flow  of 
wounded  back  to  the  dressing  station,  which  is  a 
variable  distance — perhaps  half  a  mile — further  to 
the  rear.  As  the  wounded  accumulate  at  this  point 
faster  than  they  can  be  cared  for  by  the  original 
dressing  station  personnel,  the  latter  is  reinforced 
from  time  to  time  from  the  litter  bearer  section. 
Ultimately,  most  of  the  latter  may  have  been  ab- 
sorbed into  the  dressing  station  and  the  work  of 
collecting  largely  turned  over  to  the  regimental  sani- 
tary service. 

The  time  when  ambulance  companies  ought  to  go 
into  action  is  decided  by  the  chief  surgeon  on  the 
number  and  location  of  wounded.  They  go  in  only 
when  the  local  regimental  personnel  can  no  longer 
handle  the  situation.  The  same  factors  decide 
number  and  location  of  the  stations  to  be  openi  d.  As 
soon  as  the  advance  of  troops  or  other  factor  has 
caused  the  enemy  to  so  modify  his  field  of  fire  as  to 
enable  the  fairly  safe  approach  of  the  wheel  transport, 
it  is  sent  for  to  come  up  to  the  dressing  station. 

The  dressing  station  is  marked  by  Red  Cross 
guidons  and  camp  colors.  If  off  the  road,  the  way  to 
it  is  indicated  by  these  colors  stuck  in  the  ground  as 
markers  at  convenient  intervals.  The  dressing 
station  itself  is  divided  into  the  following  depart- 
ments: Dispensary,  kitchen,  receiving  and  forwarding 
section,  slightly7  wounded  section,  seriously  wounded 
section,  and  mortuary.  Within  ten  or  fifteen  minutes 
after  being  ordered  to  establish,  the  stores  should 
be  unpacked  and  the  kitchen  in  operation  and  ret 
to  supply  liquid  nourishment.  All  wounded  pass 
through  the  receiving  section.  Trivial  injuries,  after 
treatment,  are  sent  back  to  their  organizations  with- 
out delay.  Those  disabled  from  fighting,  but  able  to 
walk,  may  be  sent  to  the  station  for  slightly  wounded, 
a  field  hospital  or  the  advance  base,  as  the  Chief 
Surgeon  may  direct;  they  are  usually  organized  into 


.".XL' 


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Army  Medical  I  leld  ><<r\  !«■<■ 


,,1-  when  thus  sent  back.  Wounded  not  able  t«i 
walk,  and  desperately  wounded,  are  transferred  to 
their  proper  departments.  Wounded  who  arrive 
from  the  front   without  diagnosis  tags  receive  them 

here.     Thr  great  proportion  of  the  work  done  here  is 

bandaging   and    the   occlusive   dressing   of    wounds. 

Btures  would  usually  bo  immobilized.     Only  such 

operations  will  ordinarily  be  clone  here  as  are  im- 
peratively demanded  to  save  life  or  permit  of  further 
transportation.  The  conditions  are  such  that  surgical 
asepsis  can  by  no  means  be  guaranteed;  nor  should 
5  be  held  here  for  whom  transportation  further 
to  the  rear  is  available.  Every  effort  should  be  made 
to  keep  a  steady  flow  of  wounded  to  the  rear  and  to 
keep  them  from  accumulating.  If  the  ambulances 
are  insufficient  for  the  purpose,  empty  ammunition 
or  other  wagons  may  be  ordered  by  the  commander 
,  placed  under  the  control  of  the  Medical  Depart- 
ir  civilian  wagons  may  be  hired  or  impressed 
for  the  purpose.  Such  wagons,  with  a  bedding  of 
hay,  straw,  leaves  or  blankets  in  the  bottom,  arc  not 
uncomfortable.  It  is  usual  to  consider  that  one  army 
wagon  will  carry  five  wounded  of  all  classes  as  an 
average  load.     Civilian  wagons  usually  carry  less. 

The  dressing  station  habitually  remains  in  opera- 
tion as  long  as  need  for  its  service  exists.  Comman- 
der- having  informed  their  troops  of  its  location, 
wounded  will  probably  continue  to  arrive  as  long  as 
any  remain  to  come.  As  soon  as  cleared  it  will  start 
pack  up  and  report  for  further  orders.  If  the 
zone  of  conflict  has  moved  forward,  it  may  very 
likely  have  to  go  in  in  a  new  location  further  to  the 
front.  If  immobilized  by  severely  wounded,  part  of 
the  supplies  and  personnel  may  be  withdrawn,  leaving 
only  enough  for  immediate  necessities. 

The  ambulance  companies  are  charged  with  the 
clearing  of  the  battlefield.  In  this  work,  the  following 
approximate  classification  of  casualties  is  of  much 
assistance,  but  must  be  regarded  as  relative  rather 
than  absolute: 

Killed  outright  20  per  cent. 

Non-transportable,     desper- 
ate cases,  S  per  cent. 
'  Can  walk  one  to 
three   miles,   or 
to  dressing  sta- 
tion   and    field 
hospital,                2S  per  cent. 
Can   walk    six    to 
ten  miles,  or  to 
advance  depot,    12  per  cent. 

iCan   go  sit- 
ting up,      20  per  cent. 
Must  go  ly- 
ing down,    12  per  cent. 

All  collection  and  transport  work  is  based  on  these 
figures,  subject  to  material  modification  as  a  result 
of  local  conditions.  All  cases  requiring  transporta- 
tion are  to  be  considered  litter  cases  for  purposes  of 
collection. 

After  all  the  wounded  have  been  conveyed  to  the 
field  hospitals,  the  ambulance  company  personnel 
may  be  directed  to  help  therein.  The  guards  for 
field  hospitals  habitually  come  from  the  ambulance 
companies.  Likewise  the  ambulance  train,  if  hostil- 
ities are  in  temporary  abeyance,  may  assist  in  the 
clearing  of  the  field  hospitals  by  removing  their 
wounded  to  points  further  in  the  rear.  Ordinarily. 
however,  the  line  of  communications  sanitary  service 
implishes  this. 

The  ambulance  company  is  essentially  an  organiza- 
tion for  war.  Properly  trained,  it  should  have  about 
the  mobility  of  a  batter.v  of  field  artillery.  Its 
service  varies  from  periods  of  relative  inactivity  to 
those  in  which  the  strength  and  endurance  of  men  and 


Wounded  ■ 


Walking  ■ 


animals   is   taxed    to    tie-   utmost.       Much    of   its    work 

is  of  the  mo  and  the  condil  ii 

of   modern    warfare  add    much    to    it<   difficulties    by 

making  it  necessary  that  much  of  its  work  shall  be 
done  under  the  protection  of  darkness  to  avoid 
hostile  fire.    The  work  of  collecting  the  wounded  on 

the  field  is  done  systematically.  Specific  area-  ad- 
joining one  another  are  assigned  to  the  imbu- 
lance  companies  in  action,  so  that  no  area  may  escape 

arched  and  helpless  wounded  be  left  to  die  a 
lingering  death.  Alter  buttle,  line  organizations  are 
frequently  detailed  to  help  ambulance  companief  in 
the  collection  of  wounded;  also  the  sanitary  detach- 
ments and  bands  of  regiments  continue  their  work. 
The  energies  of  all  are  directed  and  controlled  by  the 

I  (irector  of  Ambulance  <  tompanies. 

The  Fii  Id  Hospital. — There  tire  four  field  hospitals 
to  the  infantry  division,  their  energies  bring  co- 
ordinated and  directed  by  a  medical  officer,  with 
rank  of  major,  designated  as  Director  of  field  Hos- 
pitals. Like  ambulance  companies,  they  are  assigned 
to  zones  of  casualty  and  not  to  organizations.  Each 
field  hospital  litis  an  official  capacity  of  108  bed-; 
though  by  crowding.  162  patients  may  be  eared  for, 
and  the  capacity  may  be  ^till  more  increased  where 
the  hospital  can  be  established  in  connection  with 
buildings.  It  is  of  great  importance  that  its  resources 
be  husbanded,  for  with  an  ordinary  ten  per  cent, 
casualty  list  in  the  division  each  hospital  will  have  to 
care  for  at  least  three  hundred  wounded,  besides  an 
unusual  number  of  sick.  It  is  the  usual  experience 
in  war  that  the  capacity  of  field  hospitals  is  sorely 
overtaxed. 

A  field  hospital  is  organized  as  follows: 

In  personnel,  there  are  5  medical  officers,  1  major 
in  command,  1  junior  as  administrative  officer,  and  3 
as  ward  surgeons.  There  are  3  sergeants,  first  class, 
one  being  in  general  supervision  and  in  charge  of 
property  and  records,  one  in  charge  of  transport  and 
quartermaster's  property,  and  one  in  charge  of  cook- 
ing, mess,  and  commissary  supplies.  There  are  (5 
ants,  of  whom  2  are  ward  masters,  1  in  charge  of 
dispensary,  1  in  charge  of  operating  equipment,  1  in 
charge  of  patients'  effects,  and  1  in  charge  of  outside 
police.  There  are  4  acting  cooks,  27  ward  attendants, 
1  dispensary  assistant,  8  drivers,  1  artificer,  3  orderlies, 
and  4  supernumeraries.  Of  these,  the  5  officers  and 
S  enlisted  men  are  mounted. 

As  transport,  each  field  hospital  is  furnished  with 
S  four-jnule  wagons. 

As  shelter,  each  field  hospital  is  supplied  with 
23  hospital  tents,  with  flies.  Of  these,  18  are  ward 
tents,  1  for  office  and  dispensary,  1  for  operating  tent, 
1  for  general  stores,  2  for  kitchen  and  mess.  Addi- 
tional tentage  is  available  in  the  shelter  tents  carried 
by  the  Hospital  Corps  and  many  wounded. 

The  hospital  equipment  is  very  complete.  In  fact, 
there  are  not  wanting  many  able  medical  officers  who 
regard  this  equipment  as  somewhat  too  elaborate 
for  the  limited  work  it  will  ordinarily  be  expected  to 
perform.  However,  every  concession  has  been  made 
to  reduce  weight  and  promote  portability,  and  the 
various  articles  are  marvelously  light  and  compact. 
Nearly  a  hundred  varieties  of  medicines  are  carried, 
weighing  433  pounds  when  packed.  There  are  1,100 
pounds  of  special  foods;  4,5o4  pounds  of  furniture, 
bedding  and  clothing;  547  pounds  of  instruments; 
622  pounds  of  surgical  dressings,  etc.  The  allowance 
of  supplies  is  supposed  to  suffice  for  one  month.  The 
operating  tent  is  brilliantly  lit  by  a  small  but  powerful 
acetylene  generator.  The  hospital  is  marked  by 
large  Red  Cross  and  Xational  colors  by  day,  and  by  a 
green  lantern  at  night. 

The  name  "hospital"  is  here  a  misnomer,  if  we 
accept  it  as  meaning  an  institution  where  patients 
enter  to  remain  until  they  get  well.  The  field 
hospital,  on  the  contrary,  is  to  be  regarded  merely  as 
a  way  station  in  the  route  taken   by   the   wounded 


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whom  it  may  be  necessary  to  send  to  the  rear.  It 
is  more  often  packed  in  readiness  than  actually  in  use, 
and  it  never  retains  chronic  or  serious  cases  longer 
than  the  time  necessary  to  bring  about  their  removal. 
It  is  essentially  a  mobile  formation;  and  if  filled  with 
sick  and  wounded,  it  becomes  immobilized  and  loses 
its  essential  quality.  The  primary  function  of  the 
field  hospital  is  to  receive  the  seriously  wounded  from 
the  firing  line,  usually  by  way  of  the  first  aid  and 
dressing  stations,  to  care  for  them  while  they  remain 
in  the  zone  of  conflict,  and  to  prepare  them  for  trans- 
portation to  the  rear.  To  meet  these  indications,  as 
already  mentioned,  it  must  remain  mobile.  But  on 
the  march  and  in  camps  the  field  hospital  is  the  natural 
collecting  point  of  the  sick;  providing  for  their  care, 
however,  only  until  they  can  be  turned  over  to  the 
line  of  communications  or  some  local  civil  hospital. 
As  a  general  rule,  only  one  field  hospital  will  be  used 
for  this  latter  purpose,  leaving  the  others  empty. 
M  oreover,  only  so  much  of  the  equipment  should  be 
unpacked  and  set  up  as  is  absolutely  needed  by  the 
patients  cared  for.  As  field  hospitals  should  move 
when  their  division  moves,  every  effort  should  be 
made  to  keep  them  clear  by  expediting  evacuation 
of  the  disabled  to  hospital  formations  to  the  rear. 
When  a  field  hospital  becomes  immobilized  by  acci- 
dent or  intent,  it  changes  its  functions  to  that  of  an 
evacuation  hospital,  and  a  change  of  name,  personnel, 
and  equipment  in  that  connection  probably  shortly 
follows. 

In  combat,  the  duties  of  a  field  hospital  compre- 
hend the  opening  and  preparation  of  site;  reception 
of  wounded;  sheltering  wounded  for  a  variable  period; 
preparation  of  food;  the  extension  and  not  rarely 
the  definitive  treatment  of  wounds;  the  appropriate 
selection  and  dispatching  of  appropriate  cases  to 
front  and  rear;  closing.  Under  orders  of  the  Chief 
Surgeon,  the  personnel  of  one  field  hospital  may  be 
reinforced  by  that  from  another — and  after  action  is 
over  will  probably  be  often  so  reinforced  from  the 
ambulance  company  sanitary  personnel  and  that  of 
regiments.  Prior  to  a  battle,  the  field  hospitals, 
empty,  will  have  been  assembled    at  some  suitable 

Eoint  or  points.  In  the  case  of  a  division,  this  may 
e  from  five  to  ten  miles  in  rear  of  the  expected  zone 
of  casualty.  Their  attitude  at  this  time,  and  until 
the  action  is  well  developed,  is  purely  one  of  readiness. 
They  must  not  be  put  in  at  this  time — for  their  place 
of  greatest  usefulness  is  nearest  the  areas  of  greatest 
casualty,  and  the  latter  is  as  yet  largely  problematical. 
If  need  demands,  one  may  be  sent  in;  but  ordinarily 
the  result  of  the  battle  will  practically  have  been 
decided  before  the  field  hospitals  locate.  The  loca- 
tion cannot  be  told  in  advance,  nor  can  its  distance 
from  the  front.  The  books  mention  "  three  or  four 
miles  in  the  rear  of  the  dressing  station,"  as  a  suitable 
point  for  location,  but  this  is  of  course  dependent  on 
battle  conditions,  terrain,  etc.  A  cross  roads, 
draining  all  parts  of  the  line,  out  of  danger  of  fire, 
offers  obvious  advantages.  The  ideal  situation  for 
the  field  hospital  is  of  course  on  the  area  where  the 
wounded  are,  since  the  work  of  collecting  and  moving 
the  wounded — the  task  of  greatest  difficulty  in  war — is 
made  proportionately  easier  with  the  lesser  distance 
to  be  traversed.  Field  hospitals  should,  generally 
speaking,  be  easily  seen  from  front  and  rear,  yet  not 
be  in  the  way  of  troops  and  trains.  An  ample  water 
supply  is  necessary,  and  capacious  buildings,  with  their 
cooking  facilities,  fuel,  haystacks,  and  other  conven- 
iences are  of  tremendous  advantage.  Such  facilities 
will  rarely  be  found  on  the  battlefield  itself,  where  in 
case  of  victory  the  field  hospitals  will  locate,  possibly 
replacing  the  dressing  stations.  The  field  hospital  is 
established  with  the  following  departments:  dispen- 
sary; kitchen;  receiving  and  forwarding;  slightly 
wounded;  seriously  wounded;  operating;  mortuary; 
transportation.  Any  wounded  able  to  walk  who 
arrive  at  the  field  hospital,  will  be  started  for  the  rear 


immediately.  The  destination  of  such  wounded  will 
have  early  been  designated  by  the  Chief  Surgeon. 
Such  cases  are  not  regarded  as  admitted  to  the  field 
hospital,  and  are  not  taken  up  on  its  records.  But 
the  seriously  wounded,  and  the  slightly  wounded 
unable  to  walk,  are  taken  up  on  the  hospital  register. 
The  field  hospital  is  equipped  for  the  performance  of 
any  surgical  work,  but  its  facilities  are  inferior  to 
those  of  evacuation  and  base  hospitals — beside  which  it 
must  shortly  have  to  be  cleared.  Moreover,  the  in- 
flux of  a  large  number  of  injured  requires  that  the 
efforts  of  the  sanitary  service  shall  be  so  conserved  as  to 
bring  the  greatest  good  to  the  greatest  number.  For 
these  reasons,  no  operations  should  be  attempted  which 
can  be  safely  postponed,  and  surgical  effort  should  be 
limited  to  operations  immediately  required  to  save 
life  or  prepare  the  patient  better  to  stand  transporta- 
tion. Every  opportunity  to  move  to  the  rear  cases 
unable  to  walk  should  be  seized.  As  wounded  are 
brought  in  from  the  front  by  the  ambulance  company 
men,  other  wounded  prepared  for  evacuation  in  the 
rear  ought  to  be  in  process  of  being  turned  over  to  the 
transport  column.  Unless  every  effort  is  made  to  this 
end,  the  field  hospital  will  ultimately  become  choked 
with  wounded.  In  case  a  sudden  advance  of  the 
division  is  ordered,  there  is  nothing  to  do  but  concen- 
trate all  wounded  in  one  or  two  field  hospitals,  pack 
up  and  send  on  the  others,  and  have  the  hospitals 
which  have  been  left  behind  clear  themselves  and  re- 
join the  division  as  soon  as  possible.  In  case  they 
cannot  be  evacuated,  they  will  be  turned  over  with 
all  patients  and  property  to  the  sanitary  service  of  the 
line  of  communications.  A  new  field  hospital,  com- 
plete, is  rushed  up,  and  the  field  hospital  personnel, 
taking  this,  rejoin  their  division.  In  case  of  retreat 
and  imminence  of  capture,  here,  as  with  dressing 
stations,  property  not  in  actual  use  is  thrown  into 
wagons  and  started  for  the  rear,  and  such  wounded 
are  got  away  as  opportunity  offers.  Property  to 
meet  the  immediate  necessities  of  the  wounded, 
with  sufficient  sanitary  personnel  to  provide  for  their 
temporary  care,  are  left  behind  to  be  taken  over 
under  the  terms  of  the  Geneva  Convention. 

The  Station  for  Slightly  Wounded. — A  place  to 
which  the  slightly  wounded  should  resort  is  usually 
to  be  designated  for  forces  of  a  brigade  or  greater 
strength.  For  small  forces,  this  station  is  superfluous. 
It  may  be  designated  in  battle  orders,  prior  to  the 
beginning  of  the  action,  or  it  may  be  designated 
after  the  battle  has  begun  and  the  most  convenient 
place  for  its  location  has  become  apparent.  In  this 
latter  case,  notice  of  its  location  is  sent  out  from 
headquarters  to  higher  commanders,  and  by  them 
transmitted  to  their  subordinates.  Its  purpose  is  to 
relieve  dressing  stations  and  field  hospitals  of  the 
slightly  wounded  who  require  little  attention,  are  able 
to  walk,  and  by  virtue  of  the  latter  fact  arrive  early  at 
relief  points  and  congest  them  to  the  disadvantage  of 
others  more  in  need  of  comprehensive  treatment. 
Long  before  dressing  stations  or  field  hospitals  come 
into  operation,  the  slightly  wounded  of  the  early 
action,  leaving  the  field  under  fire  and  following  the 
directions  given  them  by  medical  and  line  officers, 
are  converging  on  this  point,  and  the  flow  of  such 
wounded  probably  keeps  up  until  the  issue  of  the 
battle  is  decided.  Sometimes,  if  conveniently  located, 
it  may  be  the  assembly  point  of  the  sick  on  the  morn- 
ing that  battle  is  expected. 

This  station  is  a  temporary  affair,  organized  to 
meet  the  emergency  of  the  moment.  It  has  no  per- 
manent personnel  or  fixed  supplies,  and  it  keeps  no 
records.  It  is  officially  stated  that  its  personnel, 
ordinarily  of  one  medical  officer,  two  noncommissioned 
officers,  and  eight  privates  of  the  Hospital  Corps, 
will  usually  be  drawn  from  the  regimental  sanitary 
service;  with  supplies  to  come  from  a  field  hospital 
or  the  reserve  sanitary  supplies.  As  a  matter  of 
fact,  both  will,  in  practice,  probably  come  from  the 


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nearest  available  sanitary  detachmenl  or  organiza- 
tion. The  distance  of  llii.s  station  from  the  front  is 
variablc;  il  may  be  from  a  couple  to  half  a  dozen 
miles  depending  on  terrain,  roads,  distance  to  ad- 
vance depot  or  base,  and  oilier  factors.  In  any  ease, 
il  is  outside  the  zone  of  casualty.  1 1  is  usually  on  a 
mail  leading  fairly  directly  to  the  rear,  and  draining 
the  center  anil  both  Hanks  if  possible.  Routes  by 
p  !,;,  I,  i  roops  would  advance  are,  as  far  as  pract  icable, 
avoided.      It  avoids  the  probable  vicinity  of  Held  hos- 

ii    and  dressing  stations;  but  its  local  desiderata 
the  form  of  shelter,  water,  fuel,  etc.,  are  the  same 


pll 

in 


as  for  the  two  formations  just  mentioned.  The  site 
should  be  prominent,  as  a  cross  roads,  school  house, 
or  village. 

No  special  preparations  at  this  station  are  necessary. 
A  building  is,  if  practicable,  secured — in  its  absence  a 
tent  fly  may  perhaps  be  hung.  The  facilities  and 
work  are  much  like  those  of  the  regimental  aid  slat  ion, 
except  that  it  will  be  rare  for  eases  to  arrive  in  which 
any  operative  treatment  will  lie  necessary.  A  large 
amount  of  dressings  will  be  needed,  stimulants  and 
anodynes  administered,  and  the  serving  of  simple 
liquid  nourishment  provided  for.  All  wounded  arriv- 
ing at  this  station  are  directed  to  rest.  Food  and 
Stimulants  are  given  them.  Dressings  are  examined 
and  if  necessary  are  replaced  and  readjusted.  Diag- 
tags  are  made  out  for  such  as  do  not  have  them; 
and  proper  entry  as  to  treatment  given  is  made  on 
lags  already  possessed.  Trivial  cases  are  ordered  to 
return  to  their  organizations,  and  note  of  the  same 
made  on  their  diagnosis  tags.  Much  care  will  be 
led  here  in  detecting  and  guarding  against  malin- 
gerers and  skulkers.  Severe  or  exhausted  cases  un- 
to inarch  further  are  set  aside,  and  their  presence 
and  number  reported  to  the  nearest  ambulance 
company  or  field  hospital.  But  the  great  majority 
of  patients  will  be  ambulant  cases  requiring  further 
treatment.  From  time  to  time,  these  will  be  organized 
into  squads  or  groups,  placed  in  charge  of  the  senior 
officer  or  non-commissioned  officer  present,  and 
started  by  a  designated  route  for  a  designated  point, 
probably  an  evacuation  hospital  or  a  transport 
column.  On  conclusion  of  the  engagement,  the  per- 
sonnel of  this  station  returns  to  the  source  whence 
drawn. 

The  Reserve  Medical  Supply. — This  is  a  movable 
depot  of  sanitary  stores,  one  of  which  accompanies 
each  division  of  mobile  troops  and  is  intended  to  keep 
replenished  the  medical  and  hospital  supplies  of  the 
organizations  composing  the  division.  It  is  carried 
in  six  four-mule  wagons,  and  is  administered  by  one 
medical  officer  of  junior  grade,  assisted  by  one 
■ant,  first  class,  one  sergeant,  one  acting  cook  and 
eight  privates,  six  of  whom  are  drivers  and  two  packers. 
The  officer,  two  noncommissioned  officers,  and  one 
orderly  are  mounted. 

This  outfit  is  a  divisional  organization  and  is  under 
the  direct  orders  of  the  Chief  Surgeon.  When  the 
division  moves,  it  marches  with  it,  ordinarily  march- 
ing with  the  supply  train.  When  necessary,  as 
after  an  action,  it  moves  up  near  the  front  and  issues 
supplies  to  the  several  sanitary  organizations  to  re- 
place those  which  they  have  expended.  As  soon  as 
issue  is  completed,  the  reserve  medical  supply  drops 
back  to  the  rear,  and  requisition  is  at  once  made  by 
it  on  the  nearest  fixed  medical  supply  depot  to  remove 
all  shortage.  If  the  division  remains  in  one  vicinity 
any  length  of  time,  the  reserve  medical  supplies  are 
preferably  put  into  buildings. 

The  kinds  of  material  chiefly  carried  are  as  follows: 
Medicines,  1,299  pounds;  disinfectants,  1S9  pounds; 
hospital  stores  chiefly  foods),  3,321  pounds;  bedding, 
etc  ,  :;,7.">n  pounds;  surgical  dressings,  5,991  pounds; 
official  blanks,  etc.,  492  pounds;  instruments,  4o0 
pounds    Most  of  the  articles  carried  are  expendable. 

These  articles  are  largely  contained  in  standard 
size  boxes  with  hinged  lids.     The  wagons  are  packed 


under  a  definite  scheme  to  tacilitate  getting  at  their 

Contents.      Three    wagons    are    SO    packed    as    each    to 

cany  practically  a  month's  allowance  of  medicim    . 

hospital    stores,   and    dressing   materials   for   one    field 

hospital.     The    fourth     wagon     carries    equipment; 

the    fifth,    baggage,  tentage.  and  forage;  and  the  sixth 

a  general    supply    wagon    largely    carrying    bedding. 

By  having  these  reserve  supplies  available  with  the 

division,  the  deficiencies  resulting  from  the  expendi- 
tures depending  upon  action  may  be  promptly  re- 
moved and  the  sanitary  organizations  as  well  supplied 
in  a  few  hours  after  action  is  over  as  they  wen: 
before  it  began. 

Sanitary  Tactics. — With  comprehension  of  the  num 
ber,  size,  and  functions  of  the  various  mobile  sanitary 
formations,  as  briefly  outlined  above,  must  come 
appreciation  of  the  fact  that  their  direction  and 
management  to  good  advantage  is  a  task  of  great 
magnitude  and  much  difficulty.  The  .Medical  Depart- 
ment has  a  well  defined  system  of  tactics  of  its  own, 
based  upon  and  coordinating  with  general  military 
tactics  as  a  whole,  under  which  its  formations  are 
handled,  moved  about,  and  administered  to  best 
advantage.  To  learn  this  properly  is  a  study  by 
itself,  and  one  absolutely  outside  the  sphere  of 
education  of  the  civil  physician,  who  is  largely  help- 
less in  such  an  administrative  position.  A  mere 
professional  training  is  only  one  of  several  necessary 
qualifications,  among  which  a  knowledge  of  the 
elements  of  strategy  and  military  organization,  pur- 
poses, and  methods  are  paramount.  In  this  sense, 
the  term  "Chief  Surgeon  is  a  misnomer,  for  he  is  an 
administrative  officer  rather  than  a  professional 
attendant.  The  responsibilities  of  such  an  officer 
with  troops  in  the  field  are  tremendous;  and  after  a 
severe  action,  with  wounded  by  the  thousands  to 
handle  under  conditions  which  always  partake  of  an 
emergency,  they  are  greater  than  those  of  almost 
every  other  officer.  He  must  be  an  organizer  and 
executive  of  a  higher  degree  of  ability,  so  that  the 
best  possible  provision  to  meet  sanitary  need  may 
always  be  available  at  the  right  time,  in  the  right 
place,  and  in  the  right  way.  Appreciating  that  a 
modern  army  is  the  most  elaborate  and  complex 
human  machine  ever  devised  by  man,  he  sees  that  the 
Medical  Department  functions  as  part  of  the  general 
mechanism  in  a  way  best  to  promote  the  military 
welfare  and  to  interfere  least  with  the  movements 
and  disposition  of  troops.  But  to  do  this  he  must  be 
informed  of  the  plans  of  his  commander  and  be  able 
to  apply  this  knowledge  to  suitable  modifications  in 
the  management  of  the  Medical  Department. 

Under  modern  military  organization,  the  infantry 
division,  of  almost  20,000  men,  is  regarded  as  the 
smallest  tactical  unit  possessing  the  elements  to  cope 
with  ordinary  conditions  and  emergency.  With  such 
a  force,  the  sanitary  personnel  at  the  front  is  very 
great,  as  already  mentioned,  and  as  adding  to  the 
difficulties  of  administering  it,  is  very  scattered. 
And  the  division  is  a  small  force  for  modern  war.  In 
any  great  battle,  at  least  a  dozen  such  divisions  would 
probably  make  up  one  of  the  contending  armies,  and 
such  a  force  would  occupy  a  wide  frontage.  It  is 
said  that  the  Japanese  had  over  400,000  men  before 
Mukden,  with  a  battle  line  sixty  miles  in  length.  To 
control,  direct,  and  smoothly  operate  the  vast  sanitary 
personnel  required  at  the  front,  scattered  as  it  must 
be  and  in  each  of  its  elements  required  to  play  a 
different  but  coordinating  part  under  dissimilar 
environment  and  conditions,  in  the  accomplishment 
of  a  single  common  purpose,  is  a  task  to  which  all  but 
the  best  administrative  capacity,  fortified  by  special 
training,  must  prove  unequal. 

Briefly,  the  great  problem  to  be  solved  at  the  front 
with  fighting  troops  is  one  of  transportation  and  con- 
centration of  the  disabled.  Conditions  are  utterly  at 
variance  with  what  they  are  in  civil  life.  Through 
every  problem  runs  the  dominant  requirement  that 

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everything — humanitarianism  included — shall  yield  to 
matters  of  military  efficiency.  Hence  the  army  sur- 
geon must  regard  his  military  obligations  required 
under  his  commission,  as  an  officer,  of  greater  effect 
than  his  Hippocratic  oath  as  a  physician;  and  to 
acquiesce,  if  need  demands,  in  the  subversion  of  the 
personal  interests  of  the  sick  and  wounded  in  the 
achievement  by  the  nation  of  the  common  ultimate 
purpose  of  military  success. 

The  disposition  of  sanitary  personnel  and  organiza- 
tions in  marching  columns  is  of  material  importance 
in  respect  to  the  provision  of  suitable  sanitary 
assistance  when  and  where  needed,  but  with  the 
reservation  that  the  assistance  thus  made  available 
shall  be  supplied  with  the  least  interference  to  military 
purposes  and  methods.  The  tactical  formation  of 
the  column — particularly  as  to  whether  advance  or 
rear  guard  formation — is  always  a  controlling  factor. 
There  are  no  hard  and  fast  rules  as  to  the  distribution 
of  sanitary  personnel,  transport  and  supplies  through 
the  column,  but  there  are  certain  general  principles 
relating  to  these  points,  the  observance  of  which  will 
contribute  greatly  to  having  sufficient  sanitary 
assistance  available  at  the  right  time  and  place.  In 
these  principles,  the  factor  of  distance,  or  its  equiva- 
lent in  marching  time,  is  basically  important.  To 
better  appreciation  of  the  matter,  a  little  knowledge 
of  the  common  dispositions  of  the  combatant  forces 
within  the  column  is  essential,  and  is  given  here  as 
follows: 

For  all  practical  purposes,  we  may  consider  that 
marches  are  to  be  classed  as  (a)  route  marches,  in 
which  troops  are  being  moved  from  one  place  to 
another  and  under  conditions  in  which  encounter 
with  an  enemy  is  not  to  be  considered;  (b)  marches 
with  an  advance  guard  formation,  in  which  an 
enemy  is  being  sought  out  and  will  be  attacked  or 
opposed;  (c)  marches  with  a  rear  guard  formation,  in 
which  the  column  is  retiring  from  a  nearby  enemy  and 
is  endeavoring  to  evade  a  general  action. 

In  route  marching,  the  component  units  march  in 
closed  column,  without  any  special  intervals  or  dis- 
positions for  offense  or  defense.  In  such  case,  the 
regimental  and  other  sanitary  detachments  accom- 
pany the  organizations  to  which  they  are  assigned. 
Their  exact  disposition  is  a  matter  of  no  great  im- 
portance, except  that  sufficient  of  the  sanitary 
personnel  must  be  assigned  to  the  rear  of  each  or- 
ganization to  pick  up  and  care  for  any  exhausted  or 
disabled  therefrom.  In  practice,  the  great  majority 
of  the  sanitary  personnel  would  be  aggregated  at 
the  rear  for  facility  of  control.  TV'ith  a  detached 
battalion,  all  its  sanitary  personnel  marches  here. 
With  the  regiment,  probably  all  except  the  regimental 
surgeon  and  his  orderly,  who  rides  with  the  colonel, 
and  the  surgeons  of  the  two  leading  battalions,  with 
their  orderlies  and  one  litter  squad  each,  who  march 
with  their  assigned  organizations,  follow  the  regimen- 
tal column.  To  each  regimental  organization  is 
temporarily  assigned  for  the  march  one  ambulance 
with  animals  and  driver.  This  outfit  belongs  to 
an  ambulance  company,  is  only  loaned,  usually  for  the 
day,  and  is  temporarily  under  the  jurisdiction  of  the 
regimental  commander  and  surgeon.  Its  function  is 
to  pick  up  and  carry  on  to  camp  such  sick,  ailing, 
and  footsore  as  may  require  transportation.  If  not 
otherwise  required,  it  may  carry  the  belongings  or 
even  persons  of  exhausted  soldiers;  but  its  function  is 
not  to  help  supply  transportation  to  a  jaded  army. 
Exhaustion  in  the  military  organization  as  a  whole 
should  be  avoided  by  appropriate  rests,  or  met  by  the 
later  forwarding  at  a  slower  rate  of  speed,  of  detach- 
ments formed  from  individuals  unable  to  keep  up 
with  the  column.  This  ambulance  on  the  march  is 
practically  a  regimental  hospital  on  wheels,  discharg- 
ing its  cases  in  the  regimental  area  when  camp  is 
reached,  to  be  there  restored  to  duty,  taken  up  in  the 
regimental  infirmary  or  transferred  to  a  field  hospital 

586 


as   need   requires.     The   medical  officer  marching  ii 
rear  of  the  regimental  organization  limits  admissions 
to   the  ambulance   to  cases  of  actual  necessity.     If  . 
company  commander  considers  that  one  of  his  mei 
needs  medical  assistance  or  transportation,  he  writes 
a  memorandum  to  this  effect  and  gives  it  to  a  non 
commissioned    officer;    the   latter,    with    the   soldier 
falls  out  of  column  and  waits  by  tin-  roadside  unti 
a    medical   officer  comes  up.     The  latter  authorize; 
the   admittance   of   the   man   to   the   ambulanci 
makes  such  other  disposition  of  him  as  seems  nec< 
sary,  sending  back  to  the  company  commander  thi 
note,  with  the  action  taken  by  him  in  the  case  of  thi 
soldier  endorsed  upon  it.     If  more  men  have  to  fall 
out  during  the  march  than  can  be  accommodate 
the  single  ambulance  with  the  regiment,  the  excess  i- 
directed  to  wait  at  some  convenient  point  beside  the 
road  until  the  rear  of  the  column  as  a  whole  arrives, 
bringing   the   intact   ambulance   trains   with   fun 
accommodations.     This  is  the  plan  habitually  employ- 
ed with  troops  in  advance  guard  formation  and  march- 
ing to  the  attack.     Any  still  greater  excess  of  disabled 
could  await  the  wagons  of  the  field  train,  or  those  of 
the  field  hospitals,  next  to  come  up.     Where  a  regi- 
ment  is   operating   independently,   it   is   assigned  a 
total  of  three   ambulances,  which  follow  as  a  train 
at  the  rear  of  the  regiment. 

In  the  column  moving  to  the  attack,  special  dis- 
positions of  the  sanitary  personnel  and  transpo-t 
are  necessary,  variable  with  length  of  column  and  de- 
pendent upon  the  advance  guard  formation  assumed. 
It  is  of  the  utmost  importance,  in  controlling  danger- 
ous hemorrhage  and  limiting  the  opportunities  for 
wound  infection,  that  sanitary  assistance  shall  be 
available  within  a  reasonable  period  after  receipt  of 
an  injury.  But  this  is  generally  practicable  only 
for  the  tactical  organized  units,  and  the  Medical  De- 
partment gives  no  assurance  that  each  and  every 
injury  will  be  reached  and  handled  as  promptly  and 
effectively  as  might  be  desired.  In  its  general  pla 
small  groups  and  individuals  have  of  necessity  to  be 
disregarded,  and  the  purpose  is  merely  to  endeavor  to 
bring  about  the  greatest  good  to  the  greatest  muni 

Assuming  an  infantry  regiment  moving  toward  an 
enemy  known  to  be  in  the  vicinity  in  front,  the  gem 
procedure,  somewhat  variable  with  terrain,  would  be 
about  as  follows: 

(1)  Six  or  eight  mounted  scouts,  rapidly  recon- 
noitering  the  roads  ahead  and  on  the  flank,  and  about 
a  mile  ahead  of  the  leading  foot  troops. 

(2)  A  "point,"  of  an  officer  and  four  men,  some 
500  yards  in  advance  of  the  next  element. 

(3)  "Flankers,"  variable  as  to  number  and  interval, 
and  radiating  from  the  "point"  out  to  400  to  500  yards 
on  each  side  of  1he  road;  thence  parallel  to  it  back  to    , 
the  "support"  of  the  advance  guard. 

(41  "Advance  party,"  probably  one  company,  |i 
details  as  "point"  and  "flankers,"  and  about  400  yards 
in  advance  of  the  next  element  of  the  column. 

No  sanitary  personnel  will  usually  accompany  the 
foregoing.  If  any  are  wounded,  they  must  dress  their 
hurts  themselves  with  the  first  aid  dressing  carried  on 
the  person,  and  await  the  coming  up  of  a  formation 
large  enough  to  warrant  sanitary  representation  bcit  g 
assigned  to  it. 

(5)  "Support,"  probably  of  the  remaining  three 
companies  of  the  battalion.  This  will  march,  say, 
1,000  yards  in  advance  of  the  "main  body  of  the 
column." 

In  the  rear  of  the  "support"  will  probably  be  found 
the  battalion  surgeon,  his  orderly,  a  noncommissioned 
officer,  and  two  litter  squads  of  the  Hospital  Corps. 

(6)  "Main  body,"  consisting  of  the  two  remaining 
battalions.  Each  battalion  is  accompanied  by  the 
sanitary  quota  just  given  above.  The  regimental 
surgeon  and  his  orderly  ride  with  regimental  head- 
quarters, probably  at  the  head  of  the  "main  body". 

(7)  The  remaining  sanitary  personnel,   consisting 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


\  i  in  v   Medical  Field  Service 


of  the  senior  noncommissioned  officer  and  four  private 
Hospital  Corps,  with  litters  and  park   mule,  forming 
the  aid  station  party. 

m  Regimental  band,  carrying  company  litters, 
officially    placed   under  direction   of   the   regimental 

.mi  and  under  immediate  direction  of  the  senior 
sergeant  firsl  class,  II.  C,  attached  to  the  regiment, 
rhe  three  ambulances,  closing  in  the  column. 

ini   [f  the   field   train   is  present,   it    follows   the 
buiances  at   a  suitable  interval,  depending  upon 
circumstances.     If  a   regimental   infirmary   or  regi- 
mental hospital  is  present,  its  transportation  probably 

edes  the  field  train. 
Communication  is  kept  up  between  these  different 
formations  by  individual  soldiers  marching  at  about 
100  yards  intervals  and  known  as  "connecting  fil 

In  this  formation  the  regiment,  excluding  the 
nioiintril  scouts,  extends  about  one  and  one-half 
milrs  from  front  to  rear.  Such  an  organization  will 
march  about  three  miles  per  hour,  whence  it  appears 
that  if  a  man  in  the  "point"  is  wounded  and  the 
'■column"  continues  to  advance,  the  surgeon  with  the 
support  will  reach  him  in  about  ten  minutes,  and  the 
rear  of  the  regimental  column  and  ambulances  in 
about  thirty  minute. 

In  this  formation,  if  the  advance  is  checked,  the 
'point"  is  reinforced  by  the  "advance  party"  and 
the  latter  in  turn  by  the  "support.''  The  whole 
battalion  previously  forming  the  advance  guard  is 
now  a  unit  on  the  firing  line,  and  the  battalion  surgeon 
makes  such  distribution  of  his  sanitary  personnel  as 
may  be  necessary.  The  other  battalions  successively 
arrive,  and  if  necessary  go  into  action.  Each  has  a 
.sanitary  personnel  directly  attached  to  it  sufficient 
for  its  immediate  needs.  The  field  train  is  probably 
halted  a  couple  of  miles  back.  The  ambulances  are 
halted  to  await  orders  at  the  nearest  point  to  the 
my  which  they  could  reach  while  protected  from 
his  fire.  The  aid  station  party,  reinforced  by  the 
band,  is  continued  on  to  a  convenient  point  near  the 
front,  probably  near  the  reserve,  where  it  is  held  in 
readiness  for  movement  to  the  proper  place  at  the 
proper  time. 

It  will  thus  be  seen  that  the  military  forces  arrive 
in     progressively     stronger     waves.     The     sanitary 

trees  likewise  accompany  and  immediately  follow 
the  latter.  If  opposition  is  slight,  the  column,  in 
prosecuting  the  march,  soon  crosses  the  zone  of 
casualty;  if  opposition  is  severe,  the  rear  of  the  column 
mines  up  to  the  halted  head  and  thus  arrives  within 
the  zone  of  casualty.  Either  contingency  is  favorable 
to  the  work  of  the  Medical  Department.  The 
wounded  men  will  not  have  to  march  or  be  carried 
back  to  the  surgeon,  for  the  surgeon  is  himself 
normally  moving  up  to  him.  The  contingencies  of 
tactics  here  naturally  tend  to  bring  the  patient,  the 
.surgeon,  and  the  sanitary  supplies  together  at  the 
earliest  possible  moment. 

A  rear  guard  formation  is  practically  the  same  as 
the  advance  guard  formation,  except  that  the  column 
is  headed  the  other  way.  In  other  words,  the  situa- 
tion is  the  same  as  if  all  combatant  individuals, 
detachments,  and  organizations  had  simply  faced 
about.  But  for  the  sanitary  personnel  the  above 
does  not  apply.  In  advance  guard  formation, 
reinforcements  of  combatant  troops  and  sanitary 
a^-istanee  are  steadily  moving  toward  the  firing  line 

ic  front;  but  in  rear  guard  formation  the  firing 
points  are  at  the  extreme  rear,  so  that  both  combatant 
and  sanitary  troops  steadily  tend  to  leave  the  suc- 
cessive zones  of  casualty  and  widen  the  distance  already 

ting  between  the  wounded  man  and  represen- 
tatives of  the  sanitary  service.  The  purpose  of  the 
rear  guard  formation,  moreover,  is  not  to  fight  but 
to  avoid  fighting  and  to  get  away.  The  correlated 
factors  of  time  and  distance  control  the  situation. 
Whatever  is  to  be  done  for  the  wounded  must  be  done 
quickly;   and    to   be   able  to  do  it  quickly  sufficient 


assistance  must  !>'•  available  at  tl  i  in  I  possible 
point  in  the  column.  Ami  inasmuch  a-  wounded 
must  be  promptly  removed  if  they  an-  not  ' 
captured  by  the  enemy,  the  need  for  plenty  of  wheel 
transportation  as  near  as  possible  to  the  rear  is  obvi- 
ous.      Probably   half   the  SS  i  innel  and  half 

the  band  will  thus  be  assigned  to  the  rear  guard,  at 
hast    two  litter  squads  with   t  he  rear  party.      One  or 

re   ambulances    would   immediately   precede    the 

"support"  of  the  rear  guard,  falling  out  on  ignal 
and  halting  until  reached  by  litter  parlies  bringing 
up  injured  men  from  the  rear.  Theaid  station  party, 
for  which  there  '.'.ill  be  little  use  unless  tin-  "com- 
mand" is  forced  to  turn  and  fight,  precedes  the  main 
body.  Any  hospital  supplies  arc  with  the  held  train 
a  variable  interval  in  advance  of  the  main  body. 

The  same  principles  as  illustrated  lor  the  regiment 
apply  to  larger  and  smaller  forces.  In  such  ins t a Qi  ■  . 
the  proportionate  strength  and  composition  of  per- 
sonnel, and  intervals  between  formation-,  vary.  The 
location  and  strength  of  sanitary  personnel  likewise 
varies.  With  larger  forces  than  the  regiment,  ambu- 
lance companies,  field  hospitals,  and  the  reserve  sani- 
tary supplies  have  to  enter  into  our  calculations  in 
connection  with  marching  troops.  With  a  brigade 
in  advance  guard  formation,  an  at  tached  ambulance 
company  ami  field  hospital  would  march  at  the  rear 
of  the  column.  As  a  brigade  in  such  formation 
marches  about  its  own  length  in  an  hour,  it  is  clear 
that  all  sanitary  assistance  available  can  be  up  in 
about  an  hour  after  the  head  of  the  column  is  fired 
upon,  and  by  this  time  a  general  action  has  been 
begun.  This  time  is  not  excessive  for  the  regimental 
detachments  to  handle  the  situation  by  themselves. 
In  rear  guard  formation  the  field  hospital  would 
precede  the  "main  body",  together  with  filled  ambu- 
lances, while  empty  ambulances  and  the  ambulance 
company  personnel  would  precede  the  rear  guard, 
ready  to  turn  and  assist  the  sanitary  personnel  of 
the  latter  if  need  requires. 

But  the  infantry  division  is  the  tactical  unit.  It 
would  normally  have  a  brigade  of  infantry,  with  some 
artillery,  in  its  advance  or  rear  guard.  Its  advance 
guard  is  6,000  yards  long  and  separated  by  some 
2,000  yards  interval  from  its  main  body.  The  latter  is 
10,000  yards  long,  total  18,000  yards.  The  trains  are 
about  10,500  yards,  or  a  total  of  say  29,000  yards. 
But  such  a  column  cannot  be  kept  closed  up  and  will 
elongate  on  moving  by  ten  per  cent,  and  probably 
more.  The  fighting  column  will  thus  be  20,000  yards 
from  front  to  rear — or  say  about  eleven  miles  long. 
The  trains  will  follow  the  column  at  a  variable  interval, 
say  three  to  five  miles.  From  a  tactical  standpoint,  it 
is  important  that  nothing  which  can  be  spared  should 
have  a  place  in  this  column  and  thus  interfere  with 
the  deployment  of  the  maximum  number  of  men  in 
the  minimum  time.  But  humanitarian  reasons  and 
the  need  for  getting  wounded  attended  to  reasonably 
promptly,  by  reason  of  its  psychological  effect  on  the 
uninjured,  combine  to  require  that  some  provision 
for  the  care  of  wounded  be  made.  The  disposition 
will  be  about  as  follows:  one  ambulance  company, 
less  all  its  wheel  transportation,  or  with  dressing 
station  wagon  merely,  will  follow  the  advance  guard. 
This  position  is  about  6,000  yards  from  the  extreme 
ftont,  or  about  an  hour's  march.  About  the  time  that 
the  advance  guard  deploys  and  gets  heavily  engaged, 
this  leading  ambulance  company  will  have  come  up 
and  be  on  hand  to  assist  in  caring  for  casualties.  No 
ambulances  are  sent  with  the  advance  guard,  as 
these  would  occupy  valuable  road  space  and  merely 
be  in  the  way.  Until  the  main  body  is  out  of  the 
road,  the  latter  is  blocked  for  removal  of  wounded. 
The  three  remaining  ambulance  companies,  complete, 
and  the  train  of  the  one  sent  with  the  advance  guard, 
follow  at  the  rear  of  the  main  body.  They  are  thus 
some  eleven  miles  from  the  front,  where  they  could 
probably  arrive  in  about  four  and  one-half  hours  as  a 


587 


Army  Medical  Field  Service 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


division  can  move  only  relatively  slowly;  or  three 
and  one-half  hours  after  the  first  ambulance  company 
arrived  on  the  scene,  and  shortly  after  deployment 
was  completed  and  the  action  become  general.  The 
field  hospitals,  heading  the  trains  whenever  battle  is 
imminent,  would  pull  on  to  within  half  a  dozen  miles 
of  the  action,  and  be  halted  at  a  convenient  place 
to  await  orders.  If  need  demanded,  the  field  hospitals 
could  reach  the  field  one  or  two  hours  after  the 
ambulance  companies,  dependent  on  the  length  of  the 
interval  between  the  rear  of  the  column  and  the 
trains.  The  reserve  medical  supplies  usually  bring  up 
the  rear  of  the  supply  train.  They  are  about  six 
miles  from  the  field  hospitals  at  the  head  of  the  train, 
and  could  thus  arrive  on  the  battlefield  about  two 
and  one-half  hours  later  if  the  sanitary  material  were 
needed.  It  thus  appears  that  as  the  casualty  situa- 
tion on  the  field  develops,  a  succession  of  organized 
sanitary  relief  units  comes  up  and  thus  are  sent  into 
action  according  to  the  needs  of  the  situation. 

The  actual  positions  of  the  foregoing  formations 
with  the  division  after  battle  is  on  is  wholly  variable 
with  local  conditions  and  terrain.  It  could,  in  the 
nature  of  things,  practically  never  be  twice  alike; 
but  perhaps  some  such  disposition  as  follows  would 
fairly  express  the  situation: 

In  the  First  Brigade,  the  First  and  Second  Infantry 
have  each  the  First  and  Second  Battalions  on  the  line 
and  the  Third  Battalion  under  cover  within  a  hundred 
yards  or  so  in  support.  The  Third  Infantry  forms  the 
brigade  reserve,  and  is  perhaps  several  hundred  yards 
in  the  rear  of  the  other  regiments.  This  brigade  has 
a  frontage  of,  say,  two-thirds  of  a  mile. 

The  Second  Brigade  is,  say,  immediately  on  the  right 
of  the  first.  Its  interior  disposition  is  approximately 
the  same  as  with  the  First  Brigade. 

The  Third  Brigade  is  the  divisional  reserve,  and  is 
under  cover,  say,  half  a  mile  to  the  rear  and  at  a 
central  point  whence  any  part  of  either  the  First  or 
Second  Brigade  can  be  quickly  reinforced. 

Under  such  conditions,  the  points  of  medical  relief 
in  operation  might  be  about  as  follows: 

With  the  First  and  Second  Battalions  of  the  First 
and  Second  Infantry,  sanitary  aid  on  the  firing  line  as 
expressed  by  the  presence  of  a  surgeon,  orderly,  non- 
commissioned officer  and  one  or  more  privates. 

Somewhere  back  of  the  First  and  Second  Battalions, 
as  near  them  as  possible  but  probably  near  the  reserve 
battalion,  would  be  the  aid  stations  of  the  First  and 
Second  Infantry.  The  sanitary  personnel  of  each  of 
these  is  that  of  the  aid  station  party,  plus  much  of  the 
sanitary  personnel  of  the  nearby  reserve  battalion, 
plus  the  band.  Wounded  from  the  two  battalions  of 
each  regiment  at  the  front  drain  into  each  of  these  aid 
stations.  Several  miies  to  the  rear,  preferably  on  a 
side  road  not  utilized  by  the  dressing  stations  and 
field  hospital,  is  the  station  for  slightly  wounded. 
The  battalion  and  regimental  surgeons  are  directing 
the  slight  cases  to  start  there  at  once. 

Back  of  the  two  regiments  on  the  firing  line  of  the 
First  Brigade,  preferably  at  a  point  near  the  center 
draining  both  flanks,  is  located  the  dressing  station. 
This  brings  it  somewhere  near — though  probably  in 
the  rear  of — the  brigade  reserve.  Wounded  from 
the  two  regiments  engaged  and  their  aid  station; 
converge  here.  Only  very  exceptionally  would 
sanitary  assistance  be  drawn  from  the  regiment  in 
reserve,  which  may  at  any  time  have  to  go  into  action. 

The  Third  Brigade,  in  reserve,  is  for  the  time  beipg 
inactive.  If  successful,  it  will  be  pushed  against  the 
enemy;  if  unsuccessful,  it  will  form  the  rear  guard  to 
hold  off  the  enemy  and  permit  of  an  orderly  retreat. 
It  is  not  suffering  casualty  and  has  no  sanitary  forma- 
tions in  operation.  It  may  not  be  needed  for  some 
hours.  Some  of  its  sanitary  personnel  may  be  tem- 
porarily detailed  by  the  Chief  Surgeon  to  assist  at  the 
dressing  station  nearby. 

The  dressing  stations  of  the  First  and  Second  Bri- 

588 


gades  are  evacuating  their  wounded  by  ambulance 
on  a  field  hospital  just  established  some  three  miles 
back  at  a  point  readily  accessible  from  both  the  First 
and  Second  Brigades. 

Perhaps  near  this  point  are  the  two  reserve  ambu- 
lance companies,  and  three  field  hospitals,  packed  up 
and  awaiting  orders. 

A  transport  column  has  just  arrived  here  from  the 
rear,  and  will  load  its  ambulances  at  the  field  hospital 
as  soon  as  the  cases  are  in  readiness  to  be  evacuated 
farther  to  the  rear. 

Back  some  five  miles  on  the  route  over  which  the 
division  advanced,  halted  with  the  trains,  are  the 
wagons  of  the  reserve  medical  supply. 

Eight  or  ten  miles  away  is  a  rest  station,  where  the 
transport  column  will  halt  to  rest  en  route  on  its 
return  with  wounded  from  the  field  hospital. 

Fifteen  or  twenty  miles  away  is  an  evacuation  hos- 
pital, located  at  railhead  and  serving  as  a  receiving 
and  forwarding  hospital  for  the  sanitary  train  service 
leading  to  the  base. 

Nearby  is  another  evacuation  hospital,  packed  in 
wagons  and  in  readiness  to  be  pushed  to  the  front 
when  and  where  needed.  An  advance  medical 
supply    depot    has    been    established    at    railhead. 

In  the  foregoing  scheme,  the  sanitary  service  with 
the  cavalry,  artillery,  and  other  troops  is  not  con- 
sidered, as  the  infantry  furnishes  all  but  a  small  per 
cent,  of  the  total  losses. 

In  the  rear  of  the  field  hospital  above  mentioned, 
the  sanitary  formations  relate  to  the  line  of  com- 
munications, or  zone  of  evacuation,  next  to  be  con- 
sidered. 

II.  The  Evacuation  Zone. — Prolonging  the  col- 
lecting zone  to  the  rear  comes  the  evacuation  zone. 
This  includes  the  line  of  communications,  the  great 
channel  through  which  the  military  force  at  the  front 
is  sustained  and  at  the  same  time  relieved  of  it- 
human  debris.  The  sanitary  formations  for  the  divi- 
sion in  this  zone  are  as  follows:  transport  column; 
evacuation  hospitals;  medical  supply  depots;  hospital 
trains  and  boats;  base  hospitals;  base  medical  supply 
depots.  All  these  formations  come  under  the  direc- 
tion of  the  Chief  Surgeon,  Line  of  Communications. 
They  are  depended  upon  to  take  over  the  wounded 
from  the  division  at  the  front  without  unnecessary 
delay,  and  thereby  free  the  military  force  at  the  front 
from  an  encumbrance  which  would  otherwise  largely 
paralyze  its  fighting  efficiency.  The  various  for- 
mations in  the  zone  of  evacuation  may  briefly  be 
discussed  as  follows: 

The  Transport  Column.-. — One  such  organization  is 
allowed  each  division.  Its  primary  function  is  the 
evacuation  of  field  hospitals,  and  transportation  and 
care  of  patients  therefrom  to  evacuation,  base  or 
other  hospitals  on  the  line  of  communications;  or  to 
points  with  train  or  boat  connection  by  rail  or  water 
to  such  hospitals. 

The  transport  column  has  4  medical  officers,  1 
major,  commanding,  assisted  by  3  junior  medical 
officers;  4  sergeants,  first  class;  16  sergeants  or  cor- 
porals; 4  acting  cooks;  16  drivers;  4  orderlies;  and 
40  litter  bearers.  Its  transportation  consists  of 
1*2  ambulances  and  3  wagons.  The  supplies  are 
identical  with  those  furnished  an  ambulance  com- 
pany, except  that  no  pack  mules  or  dressing  station 
equipment  are  supplied.  This  organization  is  weak, 
and  capable  of  meeting  ordinary  conditions  only. 
However,  its  work  partakes  much  less  of  emerge: 
than  does  that  of  ambulance  companies:  and  tin' 
time  factor  for  removal  of  the  disabled,  while  al v. 
important,  is  here  less  frequently  paramount. 

On  the  march,  transport  columns  or  sections  thereof 
keep  in  touch  with  the  column  and  are  brought  up  to 
take  over  patients  collected  by  field  hospitals,  which 
must  again  be  freed.  These  disabled  are  removed 
to   the   designated  point,  and  the  transport  column 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Army  Medical  Field  Service 


promptly  returns  toward   the   front.     Ordinarily   ii 
will  not  work   in  the  rear  of  evacuation  hospitals. 
Whin  battle  is  imminent,   the  transport   column  is 
usually    heavily    reinforced    by    both    vehicles    and 
bearers.     Empty    army    wagons   and    hired    or   iin- 
-,.,1   civilian    trams,   automobiles,   etc.,    are   em- 
ed,  Mini  extra  sanitary  personnel  sent  up  from  the 
casual  camp  at  the  base.     Just  before  battle,  all  the  e 
resources  should   be   moved  as  far  to   the  front    as 
ticable,  so  as  to  be  promptly  available.     As  soon 
sufficient   patients  requiring  return   to   the   rear 
imulate  at  one  or  more  lield  hospitals,  the  trans- 
port  column  will   receive,  provide  fur,  and  transfer 
them  to  the  rear.     It  also  provides  for  the  slightly 
wounded,  able  to  walk,  who  may  have  been  directed 

Rest  Station. — When  the  distance  to  be  travelled 
by  the  column  is  more  than  a  half  day's  march,  or  the 
lition  of  the  patients  require  it,  the  transport 
Mia  establishes  rest  stations  at  convenient  points. 
Hours  consumed  in  travel,  rather  than  distance  actu- 
ally traversed,  largely  determine  location.  These 
stations  may  correspond  with  quartermaster's  supply 
depots;  they  certainly  will  with  one  of  the  etapes 
established  along  the  line  of  communications. 

Rest    stations   are   formations   having   no   definite 

■  unci     or    equipment.     They     can     usually     be 

established  in  houses  and  can  be  materially  outfitted 

local    resources.     They  are  intended  only  for 

temporary  treatment  and  care  of  patients  until 

they  can   be  moved   further.     Ordinarily   the  duties 

of  the-  personnel  at  these  stations  are  limited  to  the 

readjustment  of  dressings  and  the  supply  of  food  and 

s'n.'lirr    to    patients.     Emergency    operations    may, 

however,  be  done  when  necessary. 

Tlic  personnel  for  rest  stations  may  very  legiti- 
ely  be  drawn  from  the  Red  Cross,  who  can  perform 
the  necessary  work  to  excellent  advantage.  Some- 
times rest  stations  may  be  kept  up  for  considerable 
periods  with   the   same  personnel,   or   they  ma)-  be 

iporarily  created  for  the  needs  of  a  single  stop 
or  night.  When  patients  must  be  left  behind  at 
I  stations,  sufficient  personnel  and  supplies  are 
left  with  them,  and  the  Chief  Surgeon  of  the  Line  of 
Communications  is  duly  notified.  The  general  re- 
lations and  functions  of  transport  companies  are 
analogous  to  those  of  ambulance  companies. 

Evacuation  Hospitals. — Two  of  these  hospitals  are 
mobilized  with  each  division.  Each  has  an  official 
capacity  of  324  patients,  or  a  total  of  624.  Under 
stress  of  emergency  they  may  be  expanded  to  accom- 
modate many  more  than  that,  since  the  nature  of 
their  service  will  frequently  cause  their  establishment 
in  communities  where  buildings  are  available  and 
supplies  and  personnel  may  be  materially  supple- 
mented from  local  resources. 

The  personnel  of  an  evacuation  hospital  is  as 
follows:  Fourteen  medical  officers,  divided  into  1 
lieutenant  colonel  in  command,  and  of  the  juniors, 
I  executive  officer,  1  quartermaster  and  commissary, 
1  operating  surgeon,  2  assistant  operating  surgeons, 
8  ward  surgeons;  8  sergeants,  first  class,  of  whom  1  is 

general  supervision,  1  in  charge  of  office,  1  in 
charge  of  quartermaster  and  commissary  supplies  and 
records,  1  in  charge  of  kitchen  and  mess,  1  in  charge 
of  detachment  and  detachment  accounts,  1  in  charge 
of  patients'  clothing  and  effects,  1  in  charge  of  prop- 
erty and  records,  1  in  charge  of  dispensary;  16  ser- 
geants, of  whom  1  is  in  dispensary,  2  in  store  rooms, 
1  in  mess  and  kitchen,  4  in  office,  2  in  charge  of 
police,  5  ward  masters,  1  in  operating  room;  10  acting 
cooks;  119  privates  first  class  and  privates,  of  whom 
76  are  ward  attendants,  1  in  dispensary,  3  in  operating 
room,  10  in  kitchen  and  mess,  4  in  store  rooms,  5 
with  transportation,  4  orderlies,  4  in  office,  and  12  on 
outside  police. 

The  evacuation  hospital  has  little  transportation. 
There  are  two  four-mule  wagons  for  ordinary  hauling, 


and  three  ambulances  for  the  movement  of  the  dis- 
abled.    The  latin'  is  sufficient,  as  although  the  num- 
ber of  patients  to  i»-  moved  is  large,  the  distano 
are  short  and  the  time  factor  is  rarely  of  importance 
Evacuation  to  the  rear  of  tin-  evacuation  hospital  will 
very  frequently  in-  bj  rail. 

The  equipment  of  an  evacuation  hospital  is  prac- 
tically that  of  three  lield  hospitals — into  which  it  can 
be  broken  up—  pin-  a  considerable  amount  of  heavy 
material,  such  as  folding  field  furniture,  etc.,  not  car- 
ried by  lield  hospital-.  It  is  fully  provided  with 
tentage  for  shelter.  It  weighs,  packed,  about  66,000 
pounds,  and  thus  requires  about  thirty  wagon  to 
move  it.  These  wagons  are  to  be  supplied  by  the 
Quartermaster's  Department  as  need  requires.  The 
institution  is  a  fairly  mobile  one,  but  it  does  not 
ordinarily  need  to  move  often,  suddenly,  or  to  very 
great  distances. 

The  evacuation  hospitals  form  a  central  point 
toward  which  the  collecting  zone  converges,  and  from 
which  tile  stream  of  disabled  Hows  toward  the  rear  to 

diverge  later  into  appropriate  relief  establishments. 
The  primary  function  of  the  evacuation  hospital  is  to 

replace  held  liospilals  so  'hat  the  latter  may  move 
with  their  divisions,  or  to  take  over  their  sick  with 
the  same  end  in  view.  Secondarily,  it  is  used  for 
ordinary  hospital  purposes  on  the  line  of  communica- 
tions. One  of  those  with  the  division  is  usually 
established  at  railhead  as  a  receiving  and  forwarding 
hospital,  while  the  other  is,  if  necessary,  pushed  out 
a  day's  journey  or  shorter  distance  nearer  the  front. 
Sometimes  an  evacuation  hospital  may  be  set  aside, 
in  whole  or  part,  for  the  treatment  of  infectious 
diseases.  The  military  situation  controls  the  location 
of  evacuation  hospitals,  but  they  should,  when  pos- 
sible,  be  located  on  a  railroad  or  navigable  stream. 
The  vicinity  of  a  town  or  hamlet  is  very  desirable; 
but  access  by  good  roads,  good  water,  and  plenty  of 
fuel  are  essentials.  If  suitable  buildings  are  available, 
the  evacuation  hospital  is  habitually  established  in 
them,  and  little  or  no  tentage  is  pitched.  Many  such 
buildings,  as  hotels,  are  already  supplied  with  every- 
thing for  the  comfort  of  patients  except  medical 
supplies;  other  buildings,  as  warehouses,  schools, 
halls,  etc.,  may  be  readily  converted  to  hospital  use 
by  the  supplies  and  equipment  carried. 

When  a  battle  is  expected,  the  evacuation  hospitals 
are  cleared,  packed,  and  brought  forward  to  a  point 
convenient  to  the  scene  of  expected  action.  As  they 
are  cumbrous  and  can  only  move  relatively  slowly, 
they  are  not  attached  to  troops,  whose  movements 
they  would  hamper.  They  are  held  in  readiness 
somewhere  conveniently  on  the  line  of  communica- 
tions, so  as  to  open  on  the  spot  or  move  further 
forward  as  the  Chief  Surgeon  of  the  Line  of  Communi- 
cations may  direct.  Once  established,  evacuation 
hospitals  are  not  ordinarily  moved  during  combat 
unless  the  troops  have  advanced  so  far  that  the 
distance  makes  it  easier  to  move  the  institution  to  the 
patients  than  the  patients  to  the  institution;  or  when 
the  natural  route  of  evacuation  of  wounded  no  longer 
passes  through  them;  or  when  the  field  hospitals  are 
so  overwhelmed  with  wounded  that  it  is  necessary  to 
supplement  them  without  delay.  After  a  battle,  the 
evacuation  hospital  may  move  up  to  or  near  the  field 
and  take  over  the  wounded  from  the  field  hospitals,  or 
take  over  the  latter,  equipment  and  all,  supplying 
similar  equipment  from  one  of  its  sections  for  a  new 
field  hospital  which,  with  the  field  hospital  personnel 
thus  released,  goes  forward  to  rejoin  the  division. 
The  duties  of  an  evacuation  hospital  are  much  like 
those  of  a  field  hospital,  except  that  it  is  not  so 
governed  by  emergency  and  is  intended  to  afford  a 
longer  and  better  opportunity  for  treatment  than 
field  hospitals  can  give.  In  a  general  way,  the 
organization  of  the  evacuation  hospital  into  depart- 
ments corresponds  with  those  already  outlined  for 
field  hospitals. 

589 


Army  Medical  Field  Service 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


The  character  of  surgical  treatment  given  wounded 
in  evacuation  hospitals  will  naturally  vary  with  con- 
ditions. When  during  or  after  battle  very  many 
wounded  are  coming  in,  the  treatment  which  can  be 
given  will  not  be  much  more  extensive  than  that 
afforded  in  field  hospitals,  viz.,  emergency  operations 
and  those  intended  to  fit  the  patient  for  further 
transport.  But  when  few  wounded  are  coming  in 
and  an  early  move  is  not  probable,  complete  treat- 
ment is  usually  given.  Excellent  facilities  for  surgical 
asepsis  are  almost  always  available.  Like  all  other 
medical  formations,  the  evacuation  hospital  is  in- 
tended to  facilitate  the  further  transport  to  the  rear 
of  serious  cases  liable  to  be  permanently  incapacitated, 
or  those  calling  for  more  protracted  treatment  than 
the  nature  of  such  establishment  is  intended  to  pro- 
vide; while  on  the  other  hand  it  is  intended  to  re- 
tain all  cases  offering  prospect  of  early  recovery  and 
return  them  to  duty  with  their  organizations  at  the 
front.  Every  effort  is  taken  here,  as  elsewhere,  that 
wounded  soldiers  shall  not  separate  themselves  from 
their  commands  further  than  is  absolutely  necessary. 
To  facilitate  administration,  two  or  more  evacuation 
hospitals  establishing  in  the  same  town  or  vicinity 
may  be  combined  under  one  head;  or  the  whole  or  part 
of  the  personnel  of  one  such  hospital  which  is  not 
itself  established  may  be  sent  to  reinforce  that  of 
another.  Such  matters,  together  with  the  opening  or 
closing  of  these  hospitals,  with  when,  where,  and  how 
their  patients  shall  be  evacuated,  are  decided  by  the 
Chief  Surgeon  of  the  Line  of  Communications.  Upon 
him  devolves  the  responsibility  of  freeing  the  forma- 
tions at  the  front  of  wounded,  and  keeping  the 
movement  of  the  latter  back  to  the  rear  uninterrupted 
so  that  congestion  at  any  point  or  points  may  be 
avoided.  Particularly  is  it  necessary  that  the  non- 
effectives shall  be  promptly  removed  from  the  zone 
of  operations.  An  appropriate  field  of  usefulness  of 
the  Red  Cross  is  in  taking  over  one  or  more  wards  of 
an  evacuation  hospital,  or  in  performing  such  other 
duties  in  connection  with  it  as  the  medical  officer  in 
command  may  deem  fit. 

Base  Hospitals. — These  are  sanitary  formations  of 
the  line  of  communications.  One  is  mobilized  for 
each  division,  and  has  an  official  capacity  of  500  beds. 
It  is  capable  of  caring  for  more  than  that  number  of 
disabled  under  stress  of  emergency;  and  probably, 
as  was  the  case  in  the  Civil  War,  many  would  be 
greatly  expanded. 

The  personnel  of  a  base  hospital  includes  20  medical 
officers,  of  whom  1  is  a  lieutenant  colonel  in  command; 
1  major,  as  operating  surgeon;  18  junior  medical 
officers  divided  into  1  executive  officer,  1  quarter- 
master and  commissary,  1  pathologist,  1  eye,  ear, 
nose  and  throat  specialist,  2  assistant  operating 
surgeons,  12  ward  surgeons.  There  is  also  1  dental 
surgeon.  There  are  8  sergeants,  first  class,  of  whom 
1  is  in  general  supervision,  1  is  in  charge  of  office,  1  in 
charge  of  quartermaster  and  commissary  supplies  and 
records,  1  in  charge  of  kitchen  and  mess,  1  in  charge 
of  detachment  and  detachment  accounts,  1  in  charge 
of  patients'  clothing  and  effects,  1  in  charge  of 
medical  property  and  records,  and  1  in  charge  of 
dispensary.  There  are  16  sergeants,  of  whom  1  is 
in  the  dispensary,  2  in  storerooms,  1  in  mess  and 
kitchen,  4  in  office,  2  in  charge  of  police,  and  6  are 
wardmasters.  There  are  14  acting  cooks;  and  1 1  ~> 
privates,  first  class  or  privates,  of  whom  68  are  ward 
attendants,  1  in  dispensary,  2  in  operating  room,  1  in 
laboratory,  14  in  kitchen  and  mess,  12  outside  police, 
1  dental  surgeon's  assistant.     Also  46  female  nurses. 

The  medical  supplies,  furniture,  and  equipment  of 
a  base  hospital  weigh  92,000  pounds.  It  might  some- 
times be  established  under  canvas,  and  for  such  con- 
ditions 121  hospital  tents  are  authorized  as  shelter. 
But  ordinarily  it  will  occupy  buildings  taken  over 
for  the  purpose,  or  erected  in  the  form  of  frame 
pavilions  especially  adapted  to  hospital  purposes  and 

590 


built  according  to  the  official  specifications  filed  in  the 
office  of  the  Surgeon  General.  The  base  hospital  is 
provided  with  3  ambulances  and  2  four-mule  wagons 
for  ordinary  hauling.  Any  additional  transportation 
required  is  secured  as  needed  from  the  Quarter- 
master's Department.  The  base  hospital  is  rarely 
if  ever  moved  in  wagons,  but  is  habitually  brought 
up  by  boat  or  rail  to  the  point  of  establishment  at  the 
base  from  which  the  military  movement  is  launched. 
Its  equipment  is  very  complete,  and  nothing  in  the 
way  of  supplies  or  personnel  is  lacking  to  facilitate 
the  recovery  of  patients. 

As  troops  advance  further  from  their  main  base, 
railroads  are  repaired  and  one  or  more  suitable  points 
become  advanced  bases.  New  base  hospitals  are 
established  at  these  points,  since  those  already  estab- 
lished further  back  are  very  likely  now  too  far  sepa- 
rated from  the  advancing  force.  The  ones  first 
established  still  continue  their  functions,  but  as  the 
line  of  communications  lengthens,  new  ones  are 
established  to  form  links  in  the  sanitary  chain  at 
suitable  intervals  more  convenient  for  the  handling 
of  sick  and  wounded.  Where  battle  by  a  large  force 
is  expected,  several  base  hospitals  may  be  opened 
and  held  empty  in  readiness  to  receive  the  wounded 
who  may  be  expected — or  the  personnel  of  those  al- 
ready in  operation  may  be  augmented  by  that  of  those 
not  yet  established 

Base  hospitals  are  intended  to  receive  cases  from 
the  field  and  from  evacuation  hospitals,  as  well  as 
cases  originating  on  the  line  of  communications  and 
the  base.  Being  completely  equipped  from  a  medical 
standpoint,  it  is  intended  that  they  shall  give  com- 
plete treatment  to  the  great  majority  of  cases  sent  to 
them,  forwarding  to  home  territory  only  such  cases 
as  require  special  treatment,  are  not  likely  to  be  fit 
for  service  for  a  considerable  period,  or  will  probably 
be  permanently  incapacitated  for  further  duty. 
But  where  their  capacity  is  being  exceeded,  or  where 
heavy  fighting  is  in  immediate  prospect,  they  will 
either  have  to  be  evacuated  of  suitable  cases  or  rein- 
forced by  the  opening  of  new  hospitals  or  the  expan- 
sion of  accommodations  already  existing.  These 
hospitals  send  out  the  necessary  personnel  to  meet 
sick  arriving  from  other  hospitals  or  from  the  trans- 
port columns,  but  such  receiving  parties  will  ordinarily 
not  go  further  than  the  adjacent  railroad  station  or 
points  of  debarkation.  When  evacuating  cases 
further  to  the  rear  from  advanced  base  hospitals,  the 
necessary  personnel  and  supplies  are  drawn  from  the 
latter.  Several  base  hospitals  in  the  same  vicinity 
may  be  combined  under  a  single  head.  As  frequently 
happened  in  the  Civil  War,  they  may  be  converted 
into  general  hospitals.  In  a  general  way,  the  internal 
management  of  base  hospitals  conforms  to  that  of 
general  hospitals.  No  man  capable  of  further  duty 
in  the  immediate  future  should  ever  be  sent  further 
to  the  rear  than  the  base  hospital,  for  experience 
amply  shows  that  the  services  of  a  great  proportion 
of  the  cases  getting  further  to  the  rear  will  probably 
be  lost  for  the  campaign  if  not  for  the  war.  While  it 
is  necessary  for  the  surgeon  at  every  field  establish- 
ment of  the  Medical  Department  to  exercise  great 
discretion  as  to  who  shall  go  further  back,  who  shall 
be  retained,  and  who  shall  be  returned  to  the  front, 
this  perhaps  applies  with  greater  force  to  the  base 
hospital.  It  is  most  important  that  those  formations 
shall  not  become  clogged;  for  if  this  occurs  the  more 
mobile  organizations  near  the  front,  having  no  place 
into  which  they  can  discharge  their  patients,  must 
inevitably  become  congested  and  immobilized. 

Convalescent  Camps. — When  necessary,  the  chief 
surgeon  of  the  line  of  communications  may  establish 
a  convalescent  camp  or  camps  at  the  base,  or  in  the 
vicinity  of  base  hospitals  established  along  the  line. 
Such  camps  are  branches  of  the  base  hospital  near 
which  they  are  situated. 

The  purpose  of  the  convalescent  camp  is  to  relieve 


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Army  Medical  Field  Service 


-Mire   in    the    base   hospital    by    permitting    the 

therefrom  of  all  such  cases  as  are  well  on 

ecov'i  ry,  and  which  rest  and  time  rather  than 

edical  care  are  needed  for  a  cure.     It  frees  many 

beds  which   would  otherwise   be  occupied, 

nl    holds    under    control    and    for    further    service 

any  who,  if  evacuated  further  to  the  rear,  would  be 

radically    lost     to     the    army.      Held     here    under 

•   oversight,   th?y  can   be  forwarded  to   their 

ions    at    the   front    as    their    condition    and 

iportunity    warrants.     These   convalescent    camps, 

practically    emergency    formations,    have    no 

i   or  organization.     In  the  Civil  War,  thej 

metimes  grew  to  such  vast  size  as  to  be  difficult  of 

lininistration   and   management.     One   being   now 

d  to  a  division,  it  is  probable  that  a  size  equal 

base  hospital   which  it   relieves  of  a  certain 

patients    will    not    be    exceeded.     Uniting 

es,  closed  but  healing  flesh  wounds,  cachexias, 

lility  following  any  cause  furnish  legitimate 

i  such  camps.     No  personnel  can  be  specified 

advance  for  these  camps,  as  it  naturally  depends' 

pon  the  number  and  character  of  cases  present   in 

ii    latter.     The  same  remarks  apply  to  the  equip- 

Facilities   for   shelter,    nourishment,   sleeping 

ausement    are    about    all    that    are    required. 

arge  buildings  with  grounds,  located  on  the  outside 

towns.    ina\    be   taken   over;   or   frame   partition 

uildings  may  lie  specially  constructed  for  the  pur- 

ose  on  attractive  sites.     Tentage  would  rarely  be 

sed     except     for     temporary     emergency.     Super- 

v  medical  officers  could  be  assigned  in  charge, 

ith  a   necessary   sanitary  personnel   detailed  from 

ial  camp. 

Disease   Hospital. — One   such   hospital 
iv  he  established  for  each  division  as  need  demands, 
personnel,   or  equipment   is  prescribed,   as 
arily  vary  with  the  number  and  nature 
f  the  cases  to  be  eared  for.     All   large  bodies  of 
■oops  not   infrequently   present  cases  of  dangerous 
issible  infections,   which  must   be  isolated  as 
on  as  possible.     The  contagious  disease  hospital  is 
branch  of  the  base  hospital  whose  need-  it  serves, 
cing  located  conveniently   thereto  yet   far  enough 
.ay  to  secure  the  necessary  isolation.     The  person- 
el  is  assigned  by  the  chief  surgeon  of  the  line  of 
immunications, .  who    makes    the    necessary    drafts 
lereto  from   the   casual    camp.     The  nature  of  the 
luipment  varies,  but  corresponds  in  a  general  way 
)  that  of  the  base  hospitals.     It  would  usually  be 
cured  direct  from  the  base  medical  supply  depot. 
he  use  of  buildings  is  preferable,  and  conditions  are 
-ually  such  that  these  can  be  obtained.     If  a  large 
umber  of  contagious  eases  have  to  be  treated,  the 
i.i.f  surgeon  of  a  field  arm}'  may  set  aside  an  evacua- 
ion   hospital    for    special    service    as    a    contagious 
isease    hospital.     Small    hospitals    for    contagious 
.ay  need  to  be  established  along  the  line,  so 
hat  these  cases  need  not  be  moved. 

ial  Camps. — These  camps  are  designated  for 
eption,  shelter,  and  control  of  the  unattached 
anitary  personnel  on  their  arrival  and  during  their 
tay  at  the  base  of  operations.  They  are  established 
>y  the  Chief  Surgeon  of  the  Line  of  Communications, 
nd  are  under  the  immediate  command  of  the  senior 
I  officer  on  duty  therein.  These  camps  are 
I  iblished  in  the  proportion  of  one  to  each  division, 
hough  several  may  be  merged  when  several  divisions 
re  operating  together  as  a  field  arm}-.  Sanitary 
ecruits,  Hospital  Corps  men  discharged  from  hospital 
>r  returning  from  furlough,  absentees  from  any  cause, 
md  special  detachments  returning  from  the  front 
'port  here,  and  are  taken  up  under  a  company 
irganization.  From  this,  drafts  are  made  on  request 
if  the  Chief  Surgeon  of  the  Division  to  replenish 
anitary  organizations  at  the  front  weakened  by 
leath,  sickness,  discharge  or  other  causes.  From  it, 
he  organizations  on  the  line  of  communications  are 


manned,  and  the  necessary  personnel  for  any  spei  ial 
put  pose  is  draw  n. 

Iia*'    U.     ■  ['he  1  t  he  point 

from  which  a  military  force  draws  it-  supplie  .  a 
sufficient  quantity  of  which  is  rapidly  accumulated 
to  meet  pn  ,ni  and  probable  needs,  lii  making 
this  provision  for  material,  the  Medical  Department 
has  its  part  to  play,  and  establishes  a  supply  depot 
thereat  for  the  purpose.  The  personnel  prescribed  for 
this  formation  is  2  medical  officers,  1  sergeant,  first 
class,  -  sergeants,  and  12  privates. 

The  amount  and  character  of  supplies  to  be 
carried  in  stock  by  the  base  medical  supply  depot  is 

fixed  by  >:  ieneral.     However,  they  must 

be  ample  to  constantly  meet  all  requirements  of  the 
sanitary  sen  ice  at  the  front ,  on  the  line  of  communica- 
tions, and  at  the  base.  Some  elasticity  is  necessary 
according  to  the  needs  at  the  front,  the  operations 
in  prospect,  facilities  for  transportation,  etc.  Among 
other  items,  a  large  number  of  iron  frames  as  litter 
supports,  lor  use  in  fitting  up  baggage  cars  for  the 
conveyance  of  wounded,  are  carried  in  stock.  As 
the  troops  advance  and  the  line  of  communications 
lengthens  to  a  degree  where  it  is  difficult  to  make 
issue  of  supplies  to  the  divisional  sanitary  units,  one 
or  more  branches,  or  advance  medical  supply  depots, 
may  be  pushed  to  the  front.  One  is  usually  if  not 
invariably  established  at  railhead.  Issues  are  made 
from  these  depots  to  organizations  along  the  line  of 
communications.  Ordinarily,  only  the  divisional 
-anitary  units  will  receive  supplies  direct  from  the 
base  medical  supply  depot.  Regiments  will  replenish 
their  stock  from  a  designated  field  hospital  or  the 
reserve  medical  supply.  The  base  medical  supply 
depot  is  habitually  established  in  a  building.  Its 
difficulties  are  many,  for  its  efficiency  largely-  depends 
upon  facility  of  the  transportation  of  supplies  called 
for,  and  transportation  is  in  the  hands  of  another 
department. 

Hospital  Trains. — There  are  two  kinds,  regular  and 
improvised.  The  regular  trains  are  made  up  of  ten 
cars  each,  of  which  eight  are  for  patients.  The  official 
capacity  is  200  patients.  The  personnel  of  such  a 
train  is  made  up  of  3  medical  officers;  1  sergeant,  first 
class;  2  sergeants;  2  acting  cooks;  2  orderlies;  20 
privates  as  nurses.  The  equipment  varies  with  the 
special  needs  of  the  situation. 

In  time  of  emergency,  improvised  trains  for  patients 
are  made  up  of  any  available  cars  and  turned  over 
to  the  use  of  the  Medical  Department.  Troop  trains 
moving  up  to  railhead  may  have  their  empty  coaches 
filled  with  less  severely  wounded  on  the  return  trip. 
Empty  baggage  or  freight  cars,  made  more  or  less 
comfortable  with  litters,  straw  or  hay,  may  carry 
back  recumbent  wounded.  On  many  occasions  it  is 
probable  that  wounded,  as  in  the  Russo-Japanese 
War  and  our  Civil  War,  will  be  sent  back  in  these 
trains  without  any  special  preparation  of  the  latter, 
as  a  result  of  unfavorable  military  conditions.  In 
ordinary  freight  or  baggage  cars,  all  patients  carried 
for  any  distance  must  be  regarded  as  recumbent,  and 
the  capacity  based  on  twenty-five  patients  per  car. 
Special  litter  fittings  for  the  conversion  of  box  cars 
for  hospital  purposes  are  supplied  by  the  Medical 
Department.  They  are  so  assembled  as  to  provide 
recumbent  transportation  for  twenty-four  patients 
per  car.  They  are  kept  in  stock,  knocked  down,  in 
the  base  medical  supply  depot,  and  are  sent  forward 
so  as  to  be  at  railhead  on  the  eve  of  impending 
battle.  The  personnel  of  improvised  trains  depends 
on  the  needs  of  the  situation.  It  comes  either  from 
the  casual  camp,  or  the  large  hospitals  at  the  base  or 
on  the  line  of  communications.  Supplies  would 
usually  come  from  the  base  medical  supply  depot. 

Hospital  trains  and  improvised  trains  for  patients 
may  operate  in  hostile  territory,  in  home  territory, 
or  both,  according  to  tactical  and  geographical  con- 
siderations.    Abroad  they  are  directed  by  the  Chief 


.391 


Army  Medical  Field  Service 


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Surgeon  of  the  Line  of  Communications;  in  home  terri- 
tory, by  the  Surgeon-General.  Medical  officers  com- 
mand these  trains.  In  transporting  patients,  they 
are  particularly  charged  to  give  due  warning  to  the 
institution  to  receive  them  of  the  time  of  arrival  and 
number  of  disabled.  The  schedule  of  train  service 
is  arranged  by  the  Chief  Surgeon  of  the  Line  of  Com- 
munications. 

Hospital  Slu'ps. — These  can  only  relatively  rarely 
be  used  on  the  line  of  communications.  However, 
in  the  Civil  War  they  rendered  invaluable  and 
tremendous  service,  particularly  on  the  Mississippi 
and  its  tributaries.  Where  navigable  streams  are 
available,  they  will  usually  offer  better  opportunities 
for  the  more  comfortable  and  expeditious  evacuation 
of  the  disabled  than  can  be  had  by  land,  and  the 
necessary  boat  service  should  be  at  once  organized, 
the  personnel  and  supplies  coming  from  the  sanitary 
service  of  the  line  of  communications. 

But  in  over-sea  expeditions,  hospital  ships  and 
ships  for  patients  are  required;  and  both  are  provided 
by  the  War  Department.  The  former  are  of  a 
permanent  and  elaborate  nature,  while  the  latter  are 
usually  transports  fitted  up  in  emergency  for  the 
return  trip  to  bring  back  the  less  severe  class  of  the 
disabled.  The  former  are  outfitted  at  home,  and  the 
latter  from  the  main  base  in  foreign  territory.  All 
these  ships  are  under  the  command  of  the  medical 
officers  in  charge,  who  have  exclusive  direction  of 
all  but  the  technical  handling  of  the  ship,  which 
latter  remains  vested  in  the  sailing  master.  The 
capacity,  personnel,  and  supplies  of  ships  for  patients 
naturally  varies  with  availability  and  requirements. 
Perhaps  about  one-third  of  its  troop  capacity  may  be 
regarded  as  a  fair  average  of  the  capacity  of  a  return- 
ing transport  to  carry  patients  of  the  less  severe 
class. 

Regular  hospital  ships  are  intended  to  have  a 
capacity  of  200  beds,  and  to  carry  the  more  severe 
cases.  As  a  matter  of  fact,  since  our  Government 
owns  no  army  hospital  ships  in  time  of  peace,  the 
capacity  of  those  in  war  will  vary  with  the  facilities 
afforded  by  the  most  available  ships  of  the  merchant 
marine,  remodelled  for  the  purpose.  In  the  Spanish 
War,  our  regular  hospital  ships  were  the  "Relief," 
"  .Missouri,"  and  "Bay  State, "all  utterly  dissimilar  as 
to  size,  tonnage,  and  construction.  The  personnel  of 
the  official  hospital  ship  is  1  major  and  4  junior  medical 
officers;  1  sergeant,  first  class;  4  sergeants;  5  acting 
cooks;  30  privates.  The  equipment  of  these  hospital 
ships  is  most  elaborate  and  complete,  nothing  being 
lacking  which  could  in  any  way  contribute  to  the 
comfort  and  welfare  of  the  patients. 

III.  The  Zone  of  Dispersion. — While  this  article  is 
supposed  to  deal  only  with  army  medical  field  service, 
it  is  impossible  to  conclude  the  discussion  without 
further  consideration  than  that  of  the  zone  in  which 
the  patients  fall  and  are  collected,  and  the  zone 
through  which  they  are  removed.  Many  of  the  dis- 
abled pass  into  a  third  zone,  or  zone  of  dispersion. 
In  this  latter  zone  they  will  be  scattered,  for  conven- 
ience and  availability  of  treatment  and  care,  through 
various  general  hospitals  and  the  convalescent  camps 
attached  thereto.  All  of  these  are  in  home  territory. 
We  now  have  two  such  army  hospitals  receiving  and 
caring  for  all  kinds  of  cases,  one  in  San  Francisco 
and  one  in  Washington,  D.  C.  Both  are  capable  of 
great  expansion.  In  addition,  as  many  other  such 
inst  itutions  as  may  be  needed  in  any  future  war  would 
be  established  at  strategic  points,  and  of  a  size  to  meet 
necessary  requirements.  Plans  and  specifications 
for  such  hospitals,  drawn  up  on  the  pavilion  system, 
are  already  prepared  in  the  office  of  the  Surgeon- 
General,  and  they  may  be  erected  out  of  lumber  and 
ordinary  building  materials  with  great  rapidity. 
During  the  Civil  War,  the  Northern  forces  had  at  one 
time  192  general  hospitals,  with  118,000  beds.     Some 


such  hospitals  accommodated  3,500  patients  each,  but 
it  is  not  now  believed  to  be  good  policy  to  have 
them  of  more  than  1,000  bed  capacity.  These 
general  hospitals  are  under  the  exclusive  control  of 
the  Surgeon-General,  and  are  set  outside  the  juris- 
diction of  department  commanders.  The  equip- 
ment of  the  general  hospital  is  varied  and  elaborate, 
approximating,  except  in  the  relatively  temporary 
nature  of  the  buildings,  that  of  high  class  civil  hospitals. 
The  personnel  is  very  complete,  and  in  these  general 
hospitals  will  be  found  the  best  expert  medical  as- 
sistance found  in  civil  life,  drawn  temporarily  to  the 
colors  through  motives  of  patriotism. 

Receiving  hospitals  may  be  established  at  posts 
habitually  utilized  for  the  discharge  of  troop  trans- 
ports. They  may  be  branches  of  neighboring 
general  hospitals;  or  they  may  themselves  be  ad- 
ministered as  general  hospitals. 

In  time  of  great  stress,  or  when  official  hospital 
accommodations  are  insufficient,  contracts  may  be 
made  with  civil  hospitals  conveniently  located,"  and 
patients  sent  there  for  necessary  treatment.  Usually 
such  cases  are  supervised  by  a  medical  officer,  to 
maintain  some  military  control  and  see  that  the 
necessary  records  are  properly  kept  up.  The  system 
is  undesirable,  as  tending  to  absenteeism  and  will 
probably  not  now  be  employed  any  more  than  ab- 
solutely necessary,  though  freely  used  in  the  Civil 
and  Spanish  Wars. 

In  the  past,  many  disabled  have  been  furloughed 
to  their  homes  as  soon  as  able  to  travel,  where  they 
have  received  private  medical  attention  subsequently 
paid  for  by  the  Government.  This  system  is  highly 
undesirable,  as  letting  the  patient  escape  absolutely 
from  military  control,  and  will  probably  not  be 
greatly  employed  in  the  future. 

Hospitals  for  prisoners  of  war  are  established  by 
the  Surgeon-General  at  points  designated  by  the 
Secretary  of  War.  They  have  the  status  of  general 
hospitals  and  are  managed  directly  under  the  Sur- 
geon-General, except  that  the  officer  charged  with 
the  custody  of  the  prisoners  will  maintain  such  guards 
over  the  hospital  as  are  necessary  to  prevent  libera- 
tion or  escape  of  prisoners  under  treatment  therein. 

A  total  necessary  bed  capacity  for  the  entire 
force,  front  to  rear,  is  fixed  at  the  equal  of  ten  per 
cent,  of  the  total  borne  on  the  muster  rolls.  This 
number  does  not  include  the  accommodations  of  the 
field  hospitals,  rightly  considered  as  being  unavailable 
except  for  brief  emergency  treatment. 

Edward  L.  Munson. 


Army  Medical  Statistics. — Broadly  speaking,  the 
main  causes  affecting  the  health  of  troops  are  the 
manner  of  living,  the  environment,  and  the  fond 
supplied.  The  first  relates  to  the  occurrence  of 
overcrowding,  imperfect  ventilation,  want  of  clean- 
liness, and  inattention  to  personal  hygiene.  The 
second  is  typified  in  the  accidents  arising  from  atmos- 
pheric or  telluric  influences,  such  as  rapid  death  from 

heat  and  cold,  the  comparatively  transient  influei s 

of  the  seasons,  and  the  slower  and  more  durable 
effects  of  climate  as  modifying  diseases  of  a  restricted 
habitat.  The  last  cause  concerns  the  diseases 
brought  about  directly  or  indirectly  by  vicious  ali- 
mentation. There  are  no  diseases  peculiar  to  the 
soldier;  but  military  conditions  are  frequently  such, 
particularly  during  a  campaign,  that  the  germs  of 
disease  are  widely  disseminated  among  an  especially 
susceptible  body  of  men — and  hence  a  larger  number 
are  attacked  and  succumb  than  would  probably  have 
been  the  case  in  civil  life.  In  character,  the  diseases 
developed  in  the  military  establishment  call  for  no 
remark  unless  it  be  their  unusually  severe  type,  the 
regularity  with  which  outbreaks  of  some  affections 
recur,  and  the  frequent  tendency  of  others  to  become 
endemoepidemic.     The  prevailing  diseases  in  armies 


592 


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Army  Medical  Statistics 


are,  naturally,  largely  acute;  and  a  large  propor- 
tion of  thein  arc  zymotic  and  hence  theoretically 
preventable. 

I  he  purpose  of  army  medical  statistics  i-  to  define 
the  influence  of  military  life  upon  health  and  ti>  per- 
mit the  ready  appreciation  and  accurate  comparison 
of  varying  conditions  of  service  and  environment 
in  their  relation  to  the  well-being  of  the  soldier. 
Since  each  case  of  sickness  in  the  military  establish- 
ment at  once  becomes  a  matter  of  official  record  at 
the  hands  of  competent  observers,  it  follows  that 
statistics  so  obtained  are  not  only  more  comprehen- 
bul   more  accurate  than  those  bearing  on   the 

irrence    of    disease     among    civilians.      Unfortu- 
v  tor  their  general    utility,    however,    they    are 
i  upon  a  physically  superior  class,  always  exist- 
under  restricted  and  unusual  conditions  and  fre- 
1 1  v    in    unfavorable    surroundings,    and    hence 

ictions  which  may  be  drawn  from  them  cannot 

legitimately  applied  outside  the  limits  of  the 
military  service.     Unfortunately,  also,  owing  to  the 

irent  systems  of  nomenclature  and  classification 
eases  which  have  prevailed  in  the  past,  as  well 

0  other  causes  which  will  be  referred  to  later,  it  i< 
not  always  possible  accurately  to  compare  the  sickness 
and  mortality  from  special  causes  occurring  in  differ- 

annies,  or  even  for  the  military  establishment 
and  civilian  classes  of  the  same  nation.     The  commit- 

on  international  military  medical  statistics  which 
met  at  Budapest  in  1894  has,  however,  formulated 
a  plan  which  overcomes  in  great  measure  the  difficul- 
ties with  which  army  statisticians  have  had  to  con- 
tend, leads  to  a  common  basis  of  comparison,  and 
will  ultimately  be  the  means  of  affording  a  large 
amount  of  information  hitherto  not  available. 

In  the  British  army,  statistics  with  regard  to  sick- 
and  mortality  were  first  compiled  shortly  after 
the  close  of  the  Peninsular  war,  but  were  published 
at  long  and  irregular  intervals.  They  gave  much 
information  with  regard  to  the  healthfulness  of 
various  stations,  but  the  advent  of  the  Crimean  war 
caused  their  temporary  discontinuance.  In  1S59 
their  publication  was  again  resumed  and  they  have 
since  been  issued  annually.  Army  statistics  have 
collected  in  France  and  Germany  since  the 
Napoleonic  wars,  but  have  not  been  regularly  made 
available  for  general  use,  frequently  being  issued 
only  in  part  or  not  at  all.  Of  late  years,  France  has 
not  given  out  full  information  as  to  the  occurrence  of 

ase  and  death  among  her  military  forces.  In  the 
Itiited  States  army,  satisfactory  data  for  the  period 
prior  to  1S40  are  not  available,  and  it  is  only  since 
Iss-t  that  figures  sufficiently  elaborate  to  be  of  any 
great  value  to  the  statistician  have  been  compiled 
and  published.  At  present  the  official  returns  show 
not  only  the  amount  of  loss  the  army  annually  incurs 
from  disease  but  also  the  causes  leading  thereto  as 
influenced  by  race,  age,  length  of  service,  arm.  of 
service,  season,  station,  and  other  factors. 

Little  information  is  gained  by  recording  the  statis- 
tics of  disease  as  a  whole,  since  so  many  factors  com- 
bine in  the  production  of  the  final  result  that  they 
must  be  separately   studied   to  arrive   at  a  proper 

^standing  of  the  whole. 
The  main  points  upon  which  army  medical  statistics 
are  based  are  as  follows: 

1.  The  number  of  admissions  to  sick  report  as 
compared  with  the  number  of  persons  furnishing  the 

This  is  accomplished  by  taking  the  actual 
lumbers  in  both  classes  and  reducing  them  to  a  com- 
parable standard  in  rates  per  "thousand.  The 
lumbers  furnishing  the  sick  are  reduced  by  those 
sick  in  quarters  or  hospital;  but  as  a  general  rule  an 
equivalent  number  of  men  are  returned  to  duty  or 
1  ulisted  to  replace  the  losses  through  death  or 
'Usability.  In  our  service  statistics  are  based  on 
ital  strength. 

2.  The  rate  of  deaths  per  thousand  strength.     This 

Vol.  I. — 38 


is    obtained    by    the  division  of   the   total   number   of 
CUrring  during  the  year  by  the  mean  at  Qua] 

strength,  including  the  absent  as  well  a  rving 

with  the  colors.  The  figures  thus  obtained  are  then 
reduced  to  rates  per  thousand. 

.').  The  rate  of  discharges  for  disability  from  dis- 
ease, per  thousand  strength — obtained  by  dividing 
the  losses  from  discharge  by  the  i  •  ngth  and 

then  reducing  to  the  above  standard  of  comparison. 

1.  The  total  ln-rs  from  disea-e;  as  determined  by 
the  sum  of  the  rates  for  mortality  and  for  discharge 
for  disability  from  this  cause. 

5.  The  rate  of  constant  sickness,  or  constant  ineffi- 
ciency. This  is  given  by  adding  the  numbers  put 
down  as  remaining  under  treatment  at  the  end  of  each 

week,  or  month  and  dividing  by  the  number  of 
days,  weeks,  or  months  in  the  period  desired,  again 
reducing  to  the  comparable  standard. 

6.  The  number  of  days  of  service  lost  by  each 
soldier.  This  is  found  by  adding  together  the  total 
number  of  sick  days  in  a  given  period  and  dividing  by 
the  mean  strength  of  the  command  for  that  period. 

In  all  computations  the  figures  are  reduced  to 
common  terms  of  one  year  and  one  thousand  strength. 

Comparative  Loss  in   C  from    Sich  d 

Wounds. — Since  the  great  military  epidemics  of  antiq- 
uity— the  destruction  of  the  Assyrians  under  Sen- 
nacherib; the  plague  described  as  occurring  during 
the  Peloponnesian  war;  the  pestilences  which  ravaged 
the  Roman  and  Carthaginian  armies;  the  great 
losses substained  by  the  army  of  Severus  in  the  mar- 
shes of  Caledonia — it  has  been  established  as  a  gen- 
eral rule  that,  in  protracted  wars,  armies  suffer  much 
less  from  wounds  than  from  disease.  The  con- 
stant advance  in  sanitation,  however,  based  upon 
an  accurate  knowledge  of  etiological  factors,  has 
exerted  a  marked  effect  in  diminishing  military  mor- 
bidity and  mortality;  and  while  in  the  future  a  com- 
paratively high  sick  and  death  rate  among  troops 
engaged  in  war  is  always  to  be  expected,  it  is  scarcely 
possible  that  such  disastrous  epidemics  as  have 
prevailed  in  times  gone  by  could  be  repeated  in 
the  future.  Wars  become  shorter  as  they  become, 
through  modern  refinements,  more  expensive;  and 
troops,  particularly  in  an  aggressive  and  decisive 
campaign,  are  not  exposed  to  unhealthful  influences 
to  as  great  a  degree  as  was  the  case  when  hostilities 
were  more  protracted.  With  improvement  in  the 
effectiveness  of  arms,  as  regards  both  range  and  ra- 
pidity of  action,  the  proportion  of  casualty  for  any 
period  of  action  must  naturally  be  increased — and 
hence  there  is  a  constant  tendency  toward  the 
approximation  of  the  rates  from  wounds  and  disease. 

From  the  records  of  the  past,  however,  many  valu- 
able lessons  can  still  be  drawn.  In  1809,  during  the 
Walcheren  expedition,  the  mortality  in  the  British 
army  from  disease  was  346.9  per  thousand  effectives, 
while  only  16.7  per  thousand  were  killed  by  the  enemy. 
A  few  j-ears  later  the  British  army  in  Spain  lost  three 
times  as  many  men  by  disease  as  by  the  result  of  con- 
flict, and  the  sick  rate  mounted  to  such  proportions 
that  more  than  twice  the  number  of  men  composing 
the  army  passed  through  the  hospitals  during  a  sin- 
gle year.  In  the  Russian  campaign  against  Turkey, 
in  1828,  it  was  estimated  that  SO, 000  men  died  of 
disease  and  "20,000  in  consequence  of  wounds.  During 
( teneral  Scott's  campaign  in  Mexico  the  losses  from 
disease  alone  exceeded  thirty-three  per  cent,  of  the 
effective  strength  of  the  forces  under  his  command, 
and  in  a  single  regiment  of  Indiana  volunteers 
which  entered  the  service  1.000  strong  only  400  re- 
turned to  the  State  for  muster  out.  Laveran  states 
that  in  the  Crimean  war  the  allies  [osl  52,000  men  in 
six  months,  of  which  number  50,000  men  were  un- 
harmed by  the  Russians;  while  during  the  entire  war, 
according  to  Viry,  the  French  lost,  in  round  numbers, 
out  of  a  total  force  of  300,900  men,  no  less  than 
95,000,   of   whom   75,000   died   of   disease   and   only 

593 


Army  Medical  Statistics 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


20,000  died  on  the  field  or  succumbed  to  wounds. 
In  this  campaign  nearly  one-fourth  of  the  French 
medical  officers  arc  said  to  have  succumbed  to  sickness. 
During  the  war  in  Italy,  in  1859,  a  period  of  hostilities 
of  only  short  duration,  there  were  from  the  French 
force  of  200,000  men.  129,950  admissions  to  hospital. 
In  the  war  carried  on  by  France  in  Mexico  the  mor- 
tality from  gunshot  and  that  from  sickness  was  as 
10  to  !",). 

The  mortality  among  the  Fnited  States  forces  in  the 
Civil  war  was  divided  as  follows: 


Mortality. 

White. 

Colored. 

Total. 

42,721 
I7.au 

157,004 
23,347 

1,514 

1,817 

29,212 

S37 

44  238 

19,731 

24,184 

Total 

270,989 

33,380 

304,369 

From  the  most  reliable  data  available  the  deaths 
in  the  armies  of  the  Confederate  States  during  this 
struggle  did  not  fall  short  of  200,000,  three-fourths  of 
which  number  were  due  to  disease  and  one-fourth 
to  the  casualties  of  battle. 

In  1866,  in  the  war  against  Austria,  out  of  a  total 
strength  of  437,260,  the  Prussians  lost  in  an  unusually 
brief  and  decisive  campaign  ii,427  men  by  sickness 
and  4,450  at  the  hands  of  the  enemy.  The  Franco- 
German  war,  in  1870-71,  furnished  the  only  exception 
up  to  the  time  of  the  Russo-Japanese  war,  to  tin' 
general  rule  that  more  men  are  killed  by  disease  than 
by  the  weapons  of  the  enemy,  since  of  the  German 
army  33.7  per  thousand  strength  fell  in  battle  while 
only  18.6  per  thousand  died  of  disease.  This  admir- 
able result  was  largely  due  to  the  proper  observance 
of  sanitary  precautions;  assisted,  no  doubt,  by  the 
brevity  of  the  campaign,  the  rapidity  of  the  move- 
ments, and  the  fact  that  active  operations  were  con- 
ducted during  the  most  healthful  season  of  the  year. 
In  the  Russo-Turkish  war  of  1878,  according  to  Viry, 
the  Russians  lost  102,799  men,  of  whom  only  10,578 
were  killed  by  the  enemy.  During  the  Spanish- 
American  war  of  1898,  for  the  five  months  which  in- 
cluded the  total  period  of  hostilities,  of  the  274,717 
officers  and  men  enrolled  in  the  United  States  forces 
there  were  only  34.5  men  killed  by  the  enemy  while 
2,565  succumbed  to  disease.  For  the  whole  year  of 
1S9S  the  deaths  from  wounds  in  our  service  gave  a 
rate  of  0.G2  per  thousand  strength,  the  killed  in  battle 
amounted  to  2.79  per  thousand  strength,  while  the 
deaths  from  all  causes  aggregated  30.31  per  thousand. 
Even  in  July,  the  month  in  which  aggressive  opera- 
tions against  Santiago  were  conducted,  the  killed  in 
action  amounted  to  only  1.25  per  thousand,  while  the 
deaths  from  disease  were  1.7S  per  thousand.  The 
British  in  the  last  South  African  war,  had  7411.0 
admissions  per  thousand  from  disease  and  but 
34.0  per  thousand  for  wounds  inflicted  by  the 
enemy;  while  the  deaths  from  disease  were  09.0  per 
thousand  and  deaths  of  those  killed  in  action  or  sub- 
sequently dying  of  wounds  amounted  to  but  12.0 
per  thousand.  But  the  Japanese  Army  reversed 
tliis  in  the  Russo-Japanese  war,  the  best  available 
statistics  giving  their  killed  at  72.0  per  thousand 
Strength;  their  wounded  at  266.8;  and  their  deaths 
from  disease  at    lis  per  thousand  strength. 

An  interesting  side  light  on  the  later  results  of  hard 
campaigning  is  given   by   Rosse,  in    his    statement 

thai  of  the  old  soldiers  carried  on  the  Fnited  State. 
pension  rolls  those  disabled  by  disease  are  more  than 
four  times  greater  in  number  than  those  pensioned 
for  wounds. 

Death  Rates  in  Civil  ami  Military  Life. — The  diffi- 

594 


culties  attending  an  accurate  comparison  of  death 
rates  for  the  military  service  and  those  of  civil  'life 
are  necessarily  very  great.  Owing  to  the  rejection 
of  intending  recruit-  many  individuals  are  at  once 
returned  to  private  life  whose  early  demise  would 
otherwise  have  gone  to  swell  the  military  death  rates 
Further,  the  army  is  maintained  as  a  s"elect  body  of 
physically  sound  men,  and  its  weaklings  are  constantly 
undergoing  elimination  from  the  service  ultimately 
to  increase  the  mortality  of  civil  life.  Hence 
civilian  rates  are  unduly  increased,  while  army  statis- 
t  ics  fail  to  show  all  the  deaths  presumably  due  to  mili- 
tary service — and  it  is  obvious  that  the  more  rigorously 
the  standard  for  the  soldier  is  maintained  as  regard's 
physical  excellence,  the  more  favorable  the  showing 
apparently  made  for  a  military  life.  Vallin,  in  France 
in  L871,  placed  the  probable  error  due  to  the  above 
causes  at  as  much  as  9.19  per  thousand,  thus  practi- 
cally doubling  the  figures  for  the  military  death  ri 
of  his  time.  Viry  considered  this  allowance  to  be  too 
high,  but  believed  that  a  rate  of  3.60  per  thousand,  for 
such  as  leave  the  colors  with  incurable  disease  should 
be  added  to  the  military  and  subtracted  from  the 
civilian  death  rates;  thus  making  a  difference  of  7.20 
per  thousand.  The  estimates  of  Marvaud  placed 
the  probable  error  at  four  per  thousand.  While  it  is 
probably  correct  for  the  French  service  to  add  3  60 
or  even  four  per  thousand  to  the  millitary  death  rate, 
to  deduct  the  same  number  from  the  civilian  rate 
involves  the  broad  assumption  that  the  numbers  in 
each  class  exactly  correspond.  For  our  own  service 
the  immense  disproportion  existing  between  the  pres- 
ent small  army  of  75,000  men  and  the  large  number 
of  males  of  the  military  age  living  in  the  United 
States  renders  the  influence  of  the  comparativi  ly 
small  number  of  soldiers  who  may  be  discharged 
for  incurable  disease  upon  the  civilian  death  rate  of  so 
little  importance  that  it  may  practically  be  disre- 
garded. The  census  returns  for  1S80  give  the  an 
death  rate  for  disease  as  6.97  per  thousand  for  all 
males  between  the  ages  of  twenty  and  forty-five  yi 
During  the  same  year  the  mortality  from  disease  in  the 
United  States  army  was  5.S8  per  thousand — appar- 
ently a  distinct  advantage  in  favor  of  the  military 
service.  If,  however,  Viry 's  factor  above  mentic 
be  accepted  as  correct  for  our  service,  the  true  mili- 
tary mortality  becomes  9.48,  or  2.51  per  thousand 
in  excess  of  the  civilian  rate  for  the  same  period.  As 
it  is  probable  that  since  that  time  the  death  rate  in 
the  military  service  has  diminished  in  proportionately 
greater  degree  than  has  been  the  case  in  civil  life, 
it  may  be  fairly  assumed  that,  under  conditions  of 
peace,  the  death  rate  in  our  army  is  at  present  but 
slightly  in  excess  of  the  mortality  for  the  same 
in  civil  life.  The  results  obtained  by  Farr  in  his  com- 
parison of  the  death  rate  in  the  British  army  with 
the  corresponding  classes  of  civil  life,  made  a  genera- 
tion ago,  are  as  follows: 

Death  rate 
Age.  per  1,000, 

20-25. — Soldiers 17.0 

Civilians 8.4 

25  30. — Soldiers IS. 3 

Civilians .         !>.2 

30-35.— Soldiers Is.  i 

Civilians 10.3 

35-40. — Soldiers I'LL' 

Civilians .11.6 

According  to  Notter  and  Firth,  the  present  death 
rate  of  the  civil  male  population  in  England,  at  the 
soldier's  age,  is  as  follows: 

Morta 
Age.  per  I  I 

-'11   25 5.  I 

25-35 7.1 

;  i   15 i-'  3 

Between  the  ages  of  twenty  and  thirty-four  the 
mortality  is  in  favor  of  the  soldier,  but  after  thirty- 


REFERKXCK    HAXDBOOK    OF    THE    MEDICAL   SCIENCES 


Army  Medical  Statistics 


the  mortality  is  reversed  and  the  civil  rates  are 
ower. 
[■'or  (lie  British  service  I  lie  death  rate  for  the  home 
ons  was  3.42  per  thousand  in   1897  and    l.iis  per 
fiousand  for  the  decade   IS87-1896.     If  the  civilian 
leath  rate  for  all  males  of  the  military  age  be  accepted 
i-  about  seven  per  thousand,  the  showing  made  com- 
iares  favorably  with  similar  figures  for  the  German 
in  and  is  superior  to  the  French  mortality  rates. 
I'liis  is  certainly  a  great  improvement  over  the  con- 
ns existing  in  1856,  when  it  was  shown  that  the 
mortality  in  the  army  at  large  was  twice  as  great  as 
ong  the  civilian  population,  and  in  the  case  of  the 
I  luards  three  limes  as  great. 
gards  t  he  <  lerman  army,  it  was  recently  stated 
iv  its  surgeon-general  that  during  the  early  part  of 
century  the  death  rale  of  the  male  civil  populat- 
ion of  Prussia,  between  twenty  and  thirty  years  of 
.  was  lower  than  that  of  the  military  death  rate, 
figures  being  fourteen  per  thousand  for  the  army 
ind  ten  per  thousand  for  the  civil  population.     This 
lit  ion  is  now  reversed,  and  in  1S93  the  death  rate 
i  Prussia  for  the  civil  male  population  from  twenty 
to  thirty  years  of  age  was  6.38  per  thousand,  while  at 
the  same  time  the  mortality  for  the  German  army 
;.(ili  per  thousand.      While  these  results  are  cer- 
tainly  admirable  and  are  undoubtedly  in  large  part 
due   to   careful   observance   of   sanitary   regulations, 
u  should  be  remembered  that  soldiers  unable  to  main- 
tain   the    required    physical    standard    are   probably 
more   thoroughly   eliminated   in   the   German   army, 
and  at  an  earlier  period  in  their  military  training, 
than  in  other  services. 

In   the   French   army,   on   the  home  stations,   the 

age  annual  death  rate  from  1882  to  1890,  inclu- 

was  7.88  per  thousand  strength;  while   Bertil- 

fixed   the  annual   mortality   among   the   civilian 

male  population,   between   the  ages  of  twenty  and 

ity-five  at  10.60  per  thousand.     Marvaud,  how- 

,  believed  that  the  estimate  made  by  Bertillon 

was  too  low,  and  placed  the  annual  death  rate  for 

civilians  of  the  military  age  at   two   per   thousand. 

nig  Marvaud's  coefficient  of  error  given  above,  the 

corrected  rate  for  the  French  military  service  would 

become  11.88,  while  it  would  be  eight  per  thousand 

for  the  same  class  in  civil  life.     Marvaud  concludes 

"that,  in  spite  of  all  ameliorations  which  have  been 

introduced,  chiefly  of  late  years,  into  the  hygienical 

Surroundings  of  the  French  soldier,  his  mortality  rate 

is  ^t ill  elevated   and   certainly  exceeds   that   of   the 

same  sex  and  age  in  civil  life." 

Loss  of  Time  from  Sickness. — In  the  United  States 
service  the  annual  average  number  of  days  lo<t  per 
man  for  the  decade  1880-1S95  was  14.64.  For  the 
year  1896  it  was  12.43,  and  in  1S97  it  was  13.08.  In 
1905  it  was  17. Mi,  largely  through  less  favorable 
surroundings  in  the  tropics,  but  in  1910  it  had  fallen 
again  to  13.23.  In  comparing  the  number  of  days 
I-  ist  by  white  soldiers  with  those  lost  by  colored  troops, 
the  showing  is  slightly  in  favor  of  the  latter.  For 
the  entire  British  army  during  the  decade  1887-1896 
the  number  of  days  lost  per  man  was  21.38,  while 
during  1897  it  was  22.72.  Among  the  British  troops 
at  the  home  stations  the  number  of  sick  days  per 
man  did  not  differ  very  greatly  from  those  of  our 
own  army  for  the  same  periods,  being  only  a  fraction 
ol  one  day  in  excess.  According  to  Rosse,  in  a 
ement  of  the  morbidity  of  various  armies  issued 
it  1884,  the  lowest  rates  given  were  those  of  the 
Portuguese,  Austro-Hungarian,  Italian,  and  (lerman 
armies,  the  sick  days  of  each  man  in  the  effective 
force  being  from  thirteen  to  fifteen  yearly  among  the 
ips  of  these  nations,  while  in  the  French  and 
lish  armies,  prior  to  that  date,  the  rate  had  been 
thirteen  to  seventeen  annually. 

As  compared  with  the  time  lost  by  the  correspond- 
ing (lasses  in  civil  life,  Rosse  noted  that  for  the  period 
1862  to  1892  the  average  annual  number  of  days  of 


sickness  was  six  to  eight  [or  each  I ■  rkingmnn  be- 
longing to  various  mutual  aid  ocietie  ;  he  fixing  the 
general  military  morbidity  for  the  same  period  al 
figures  two  and  one-half  time    greater  than  tho  e  oi 

the  corresp ling  civil  classes.     According  to  Page! 

the  following  rate  of  sickness  may  be  expected  for 

different  ages  for  males  of  the  English  wcirking  classes, 

such    as   incapacitates    for    work:    at    twenty    years 

expect  four  days  of  sickness  yearly;  at  twenty  to 
thirty  years  expect  five  to  six  days  of  sickness  yearly;  at 
forty-five  years  expect  seven  clays  of  sickness  yearly. 

Marvaud  states  that,  in  1894,  the  French  soldier 
I"  t  thirteen  days  annually  nine  in  hospital  and  four 
in  barracks — while  his  civilian  compatriots  of  eor- 
re  ponding  age  lost  on  an  average  only  about  half 
that  time;  notwithstanding  the  fact  that  the 
hygienic  surroundings  in  the  military  service  were 
much  superior  to  those  of  civil  life.  While  in  time 
of  war  or  active:  operations  the  existence  of  a  high 
rate  of  inefficiency  and  the  loss  of  a  greater  amount  of 
time  are  to  be  anticipated,  such  conditions,  as  com- 
pared with  those  of  the  corresponding  classes  of  the 
male  civil  population,  should  not,  theoretically, 
obtain  in  time  of  peace.  Their  actual  existence 
under  the  latter  condition  is  probably  due  to  the 
fact  that  the  workingman  does  not  feel  able  to  stop 
his  daily  task  except  for  serious  illness,  while  the 
soldier — whose  pay  and  living  are  assured  and  whose 
medical  attendance  is  gratuitous — is  inclined  to 
abuse  his  privileges,  often  endeavoring  to  get  his 
name  on  sick  report  for  the  slightest  indisposition,  or 
none  at  all,  and  to  have  it  retained  there  for  as  long  a 
period  as  possible;  this  being  particularly  attempted 
wlnn  any  unusually  irksome  or  disagreeable  task  is 
to  be  performed.  That  such  indeed  is  the  case  is 
demonstrated  by  the  fact  that,  according  to  Billings, 
it  may  be  estimated  that  for  every  case  of  death  there 
is  an  average  of  two  years  sickness  in  the  civil  com- 
munity; while  in  the  United  States  army,  for  the 
absolute  number  of  deaths  occurring  and  days  of 
service  lost  during  the  year  1897,  the  proportion  was 
such  as  to  show  a  total  of  3,867  days  of  sickness  to 
each  death  reported.  This  gives  a  total  of  10.6 
years  sickness  for  each  death;  a  rate  more  than  five 
times  greater  than  that  obtaining  in  civil  life  and  one 
which  can  be  explained  only  by  the  above  hypothesis. 
In  view  of  the  unfavorable  showing,  in  this  respect, 
made  by  military  statistics  it  would  appear  that 
greater  discretion  and  severity  should  be  exercised  in 
admitting  the  soldier  to  sick  report;  and  that,  if 
once  admitted,  his  earlier  return  to  his  duties  would 
usually  be  productive  neither  of  injury  nor  hardship. 

Race  as  Influencing  Military  Mortality  and  Mor- 
bidity.— While  satisfactory  data  on  this  subject  as 
regards  foreign  armies  are  naturally  not  available,  the 
several  rates  from  disease  in  our  ow:n  service,  with  its 
heterogeneous  personnel,  have  been  calculated  accord- 
ing to  nativity.  For  the  seven  years  1S90-1N96, 
they  were  determined,  per  thousand  strength,  to  be  as 
follows: 


Admis- 

Constantly 

Discharges 

Total 

sions  to 

non- 

for 

Deaths. 

hospital. 

effectit  e. 

disability. 

t>  s,-s. 

United  States 

1,043.43 

30.74 

12.98 

3 .  96 

16.94 

962.05 

26  87 

1  1  52 

.',.  16 

111    MS 

( lermany . . . 

sio, to 

24  .  67 

13.20 

4.11 

17.34 

907 . 1 1 

2  ;    16 

12.46 

4 .  'J6 

16.72 

1,033.14 

32.81 

18.87 

4.16 

23.03 

Scandinavia  . 

8S6.08 

26  -  55 

13  3  : 

5.17 

18.50 

Scotland 

S52.38 

25  64 

12.50 

1.  17 

13.97 

Switzerland. . 

893.75 

27  82 

12.31 

2 .  90 

15.11 

Austria 

807.1  1 

21.63 

16.53 

2.67 

19.20 

1  tanmark.  .  . 

s  ;r,  o:; 

26.21 

13.33 

5 .  55 

18.82 

t'i 

1,049.  13 

30.89 

in  56 

7  04 

17.68 

Ail  others..  .  . 

821.  12 

23 .  90 

13.66 

3.86 

15.70 

595 


Army  Medical  Statistics 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


It  should  be  noted,  however,  that  the  figures  given 
fur  the  countries  named  in  the  latter  half  of  the  above 
table  are  not  to  be  considered  as  absolute,  since  they 
are  not  based  upon  a  sufficiently  large  number  of  men 
to  avoid  the  possibility  of  error.  These  rates  are, 
however,  of  particular  interest,  since,  so  far  as  they 
go,  they  tend  to  bear  out  the  popular  belief  that  the 
native-born  American  possesses  a  greater  proportion 
of  vital  force  and  greater  power  of  resistance  against 
death  than  does  the  foreigner. 

Race  proclivity,  as  regards  sickness,  is  well  shown 
by  the  records  of  the  British  forces  in  the  West 
Indies,  in  which,  for  the  ten  years  1876—1885,  the  ad- 
missions per  thousand  of  strength  for  the  whites  were 
893.5,  colored  1,(174.1;  discharges,  whites  13.95, 
colored  26.79;  constantly  non-effective,  whites  44.68, 
colored   58.38;   deaths,   whites   1.3.42,   colored    15.38. 

In  the  United  States  service,  for  the  decade  1877-80, 
the  death  rate  among  the  whites  per  thousand  was 
9.97  and  for  the  colored  12.91.  There  has  been, 
however,  a  constant  tendency  for  the  past  twenty 
years  toward  the  approximation  of  the  rates  for  the 
whites  and  blacks  in  our  service;  and  therelative 
rates  per  thousand  for  the  white  troops  of  all  nation- 
alities as  compared  with  those  for  the  colored  troops, 
during  the  year  1S97,  were  as  follows: 


Admis- 
sions to 
hospital. 


Constantly 

non- 
effective. 


Discharges 

for 
disability. 


Deaths 


Total 
losses. 


35.72 

37.24 

11.04 
10.  S9 

9.62 
9.51 

5.05 

5.89 

14.67 
15.40 

But  since  the  Spanish  war,  new  factors  of  climate, 
environment,  and  race  have  entered.  For  the  year 
1910,    some    rates    per    thousand    were    as    follows: 


Whites,  in  United 
States 

Colored,  in  United 
States 

Whites,  in  Philippines 

Filipino  native  scouts. 


Admis- 

Con- 

sions to 

stantly 

,n 

hospital. 

non- 

c3 

effective 

Q 

1  lis- 

charges. 


903.31 

827.53 

1,242.65 

S76.10 


34.25 

4.25 

2.S .  72 

7.37 

45.  15 

5.19 

26.01 

4.31 

15.45 

12.39 

10.14 

6.79 


Total 
losses. 


19.70 

19.76 
1  J .  23 
11.13 


The  lower  rate  for  losses  in  the  Philippines  is  ex- 
plained by  the  practice  of  sending  home  to  the  United 
States  many  serious  cases  for  treatment  or  discharge 
for  disability. 

In  the  distribution  of  diseases  according  to  nativity, 
typhoid  fever  and  rheumatic  fever  had  their  greatest 
prevalence  in  our  service,  for  the  years  1890-1S96, 
among  the  Canadians  and  Scandinavians.  The  high- 
<■  l  admission  rates  for  consumption  were  5.70  among 
the  French  and  4.76  among  the  Scotch;  the  lowest 
rates  were  1.42  among  the  English  and  1.49  among 
the  Germans,  the  rate  among  the  nativesof  the  United 
States  being  3.33.  Pneumonia  was  more  frequent 
among  Canadians,  5. IS,  and  Scotch,  4.76,  than  in 
men  of  other  nativities.  The  rate  for  this  disease 
for  the  natives  of  the  United  States  was  3.90. 
Venereal  disease  prevailed  more  among  men  born 
in  the  United  Stales  and  Canada  than  among  the 
others,  the  admission  rates  for  these  two  classes 
being  93.98  and  91.92  respectively;  the  Irish  and 
Swiss  had  the  lowest  rates,  47.00  and  50.90. 
The  Irish,  however,  had  by  far  the  largest  relative 
number  of  cases  of  alcoholism,  90.96.  The  smallesl 
rales  for  this  cause  were  given  by  the  Danes,  12.59, 
and    Austrians,    19.00;    the   admission   rate   for   the 


native-born  American  soldier  having  been  28.51  for 
this  cause. 

Sickness  and  Death  Rates  as  Affected  by  Season. 

.Military  morbidity  and  mortality  are  to  a  certain 
extent  influenced  by  seasonal  changes;  varying  accord- 
ing to  the  climatic  conditions  prevailing  in  each 
country  or  locality,  by  which  the  propagation  of 
certain  affections  is  either  favored  or  retarded.  In 
the  French  army  the  admissions  to  hospital  for  disease 
in  time  of  peace,  reach  the  maximum  of  fifty-seven  or 
fifty-eight  in  January  and  fall  to  the  minimum  of 
about  thirty-eight  per  thousand  in  September.  In 
the  Italian  army,  for  the  period  1872-1S92,  the  great- 
est amount  of  sickness  occurred  in  March  and  the  least 
in  November.  In  the  United  States  service  the 
midsummer  period  is  the  most  unhealthful,  while  the 
late  fall  and  early  winter  gives  the  least  sickness. 
The  monthly  prevalence  of  disease  in  our  army,  in 
time  of  peace,  as  given  in  the  figures  for  the  year  i  vi_>, 
is  shown  in  the  following  table: 


Total  admissions  to 
hospital,  per  thou- 
sand of  mean 
strength,  for  dis- 
ease and  injury. 


Constantly  non-ef- 
fective,  per  thou- 
sand  of  in  .  :  . 
strength,  from  dis- 
ease and  injury. 


January. . . 
February. . 

March 

April 

May 

June 

July 

August. . . . 
September 
October. .  . 
November. 
December. 


148.65 

107. S7 

108.03 

92 .  53 

9S.66 

101.94 

108.26 

108.37 

108.57 

97.48 

91.97 

9S.34 


49.54 
41.69 
39.27 
37.34 

37.67 

:;s.3i 

37 .  46 
36.  S6 

38.  12 
38.79 
39.38 
111.44 


For  the  year  1898,  when  the  army,  if  not  entirely 
engaged  in  active  military  operations,  was,  after  the 
month  of  March,  still  in  the  field  and  on  a  war  footing, 
the  monthly  rates  per  thousand  strength  were  as 
follows: 


January.  .  . 
February. . 

March 

April 

May 

June 

July 

August. . . . 
September 
October.  . . 

\i  -\  .  ■  T  r  l  I  XT, 

December. 


Admissions 

from 

disease. 


Discharges 

from 
<li  -case. 


6S.11 

-'i  68 

65 .  75 

65.12 

GO.  90 

68.25 

150.15 

254.63 

271. 79 

200 . 48 

186.06 

212.63 


0.40 
0.  in 
0.50 
0.95 
0.31 
0.29 
0.31 
0.41 
n  :;5 
0.79 
1.11 
1.14 


Deaths 

from 
disease. 


Total  losses 
from 

ill- 


0.33 
0.18 
0.21 
0.24 
0.21 
0.36 
1.81 
6.14 
4.73 
2.06 
1.07 
list 


0.73 
ii  58 
0.71 

1.19 
ii  52 
0.6S 

212 
6      - 

.-,    MS 

2 .  85 

2    IS 

I     MS 


Outside  the  United  States,  our  army  is  scattered 
from  the  Arctic  Circle  to  the  Equator,  and  under  such 
varying  climatic  conditions  as  to  render  comparison 
by  season  wholly  impracticable. 

Branch  of  Service  as  Affecting  Health. — It  has  long 
been  noted  that  troops  of  certain  arms  are  more  prune 
to  disease  and  death  than  are  others:  this  bi 
explainable  by  the  character  of  the  duties  each  is 
required  to  perform,  as  well  as  by  the  diverse  condi- 
tions  of  environment  under  which  they  are.  through 
military  necessity,  forced  to  exist.  As  compared  with 
infantry  and  artillery,   the  cavalry  service  may  be 


596 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


\iinv  Medical  Statistics 


considered  to  be  somewhat  more  unhealthful  and 
dangerous  to  life;  this  being  duo  to  the  more  arduous 
,:,,.  of  the  service,  to  the  greater  opportunity  for 
accident,  and  to  the  uncleanly  nature  of  a  large  pari 
of  ilii'  duties  of  the  mounted  soldier.  In  time  of 
peace,  for  all  armies,  the  mortality  and  sickness  in  the 
nt'ry  is  usually  less  than  in  any  other  of  the  main 
branches  of  the  service,  but  in  war  this  favorable 
showing  does  not  continue. 

In   the   United   States  army,  for  the  seven  years 

1890-1896,  the  fates  for  disease  alone,  per  thousand 

led    men,  according  to  branch  of  service,  were: 


Admis- 

Constantly 

Discharges 

[•otal 

|<  isse 

sions  t< ' 

non- 

for 

Deaths. 

hospital, 

effective. 

disability. 

916.27 

27.96 

13.67 

i.  ;i 

18.01 

1,076.58 

30.87 

1.3.36 

3.98 

17.34 

Artillery 

1,163.61 

31.81 

15.61 

2.94 

1 8 .  55 

Ordnani 

[,007.15 

25.69 

9.79 

7.  I'll 

L6.99 

ere. 

1,371.55 

29.  SS 

7.56 

2.S4 

10.40 

Medical    d  ■- 

partment. . 

•168 .  So 

14.99 

11.24 

5.14 

16.38 

All  others.. 

941.51 

30.23 

10.15 

5.07 

15.22 

The  high  deatli  rate  noted  in  the  enlisted  strength 

nf    the    Ordnance    Department    is    probably    largely 

i.l.  mi   on   the  greater  age  of  these  men;  many 

g  old  soldiers,  superannuated,  unfit  to  stand  hard 

service  and  broken  in  constitution  by  the  hardships 

of  a  former  active  life. 

These  ratios  generally  hold  good  at  the  present 
time.  In  11)10  the  admission  rate  was  highest  for  the 
cavalry  and  lowest  for  the  Hospital  Corps;  the  death 
rate  was  highest  in  the  field  artillery  and  lowest  in  the 
cavalry. 

For  the  first,  period  above  noted  the  rates  for  all 
causes  were: 


Admis- 

Constantly 

Discharges 

Total 
losses. 

sions  to 

non- 

for 

Deaths. 

hospital. 

effective. 

disability. 

Infantry 

1,151.21 

35.36 

16.72 

6.49 

23.21 

1,464.10 

43.92 

17.61 

7.25 

21.SC, 

Artillery 

1,457.87 

41.11 

18.47 

5.3  i 

2.4 .  77 

ince. . . . 

1,187.38 

31. XI 

11.23 

10.65 

21.88 

i  tagii 

1.6S4.92 

3S.45 

7.8S 

4.73 

12.61 

1     de- 

■  ment. . 

527. nt 

17.08 

12.19 

6.09 

18.28 

All  others.. . . 

1.100.02 

34.77 

12.12 

6.13 

is.  25 

The  high  rate  of  admissions  among  the  engineer 
troops  was  due  to  injuries  and  malarial  fevers,  with 
a  considerable  excess  of  alcoholism,  bronchitis, 
diarrhea,  and  rheumatism.  The  disabling  causes 
which  produced  the  high  rate  in  the  cavalry  as  com- 
pared with  infantry  were  injuries,  which  gave  a  rate 
of  . is?. 5t  as  compared  with  the  infantry  rate,  2:17.0  1; 
luit  the  excess  of  admissions  among  the  cavalry  was 
not  thus  entirely  accounted  for,  since  disease  also 
e  a  slightly  higher  death  rate.  Malarial  affections 
were  the  principal  causes  of  this  excess,  but  diarrhea, 
boils  and  abscesses,  and  conjunctivitis  also  aided  in 
making  up  the  total. 

Among  the  officers,  for  the  above  period,  the  sick 
rate  was  largest  in  the  artillery,  980.11  per  thousand. 
Non-efficiency  was  greatest  among  officers  of  the 
cavalry  and  artillery — 53.90  and  52.57  respectively. 
Medical  officers  had  a  higher  rate  (47.07)  than 
infantry  officers  (46.05).  The  death  rate  per  thou- 
sand among  officers,  according  to  branch  of  service, 
was  as  follows: 


Infantry 8.81 

Cavalry 10.34 

ry 6.08 

Ordnance   17.11 

I  Ingi re 11 .07 

Medical  department 10.20 

All  others 12.32 


Death  from  injury  was  relatively  more  frequent 
among  ordnance  officers  than  in  those  of  other  corn  . 
Marvaud  gives  the  following  figures  as  showing  t  ho 
comparative  mortality  in  different  branches  ot  the 
I  rench  service  for  the  six  years  1880—1885,  inclusive. 


Engineers 

Light  infantry 

Artillery 

<  'a  \  airy 

I  'i  i  i  M 1 1  \  iii  i  he  1m  - 
Afrieati  light  infant  ry 
Foreign  legion 


I  loath 

rate. 


Loss  by 
invaliding. 


rotal 


7.0 
7.4 
8.8 

in..' 
17.2 
19.8 


1  I.  1 
11.7 
I  2. 'J 
13.2 

16.6 
11.5 

S.7 


19.6 

is. 7 
20 . 3 
22.0 
26 . 8 
31  .7 
28.5 


In  the  English  service,  in  1897,  the  following  rates 
per  thousand  obtained  fortroops  on  the  home  stations: 


Deaths. 


'  !i  instantly 

non-effective. 


Infantry 

Ri  iyal  engineers 

Cavalry 

Royal  artillery. 
Foot  guards. . . . 


41.79 
1 7 .  75 
42,39 
32 .  19 
63.03 


The  Influence  of  Length  of  •Service  upon  Morbidity 
and  Mortality. — The  most  extensive  figures  for  the 
United  States  army  upon  this  subject,  compiled  to 
include  a  period  of  seven  years,  merely  divide  the  men 
into  those  who  have  had  less  and  those  who  have 
had  more  than  one  year  of  service — and  these  show 
that  recruits  during  their  first  year  with  the  colors 
are  especially  liable  to  sickness.  For  the  entire 
period  (1890-1896),  the  admission  rate  to  hospital 
of  this  first  class  was  2,122.17,  while  that  of  the  older 
soldiers  was  only  1,093.07 — or  about  one-half  as 
much.  The  non-efficiency  for  recruits  was  of  61.76 
compared  with  32.99  for  men  of  longer  service;  and 
their  sickness  was  of  such  a  character  as  to  cause 
24.96  per  thousand  of  their  number  to  be  discharged 
on  certificates  of  disability,  as  compared  with  a 
discharge  rate  of  14.76  among  the  others. 

As  to  the  causes  affecting  the  above  figures,  the 
vaccination  practised  in  the  case  of  recruits  brought 
a  considerable  number  of  cases  on  sick  report,  a  little 
over  200  per  thousand  strength  being  thus  added  to 
their  admission  rate.  With  the  exception  of  alcohol- 
ism, these  young  soldiers  appear  to  have  been  more 
susceptible  to  all  disabling  causes  than  their  more 
experienced  comrades.  As  illustrative  of  this  may 
be  cited  their  admission  rate  for  injuries,  414.91,  as 
compared  with  242.93  among  the  others;  for  venerea] 
diseases,  156.52,  as  compared  with  65. SI;  malarial 
diseases,  137.84,  as  compared  with  70.97,  and  typhoid 
fever,  11.22,  as  compared  with  4.6S. 

For  the  single  year  of  1885  the  admissions  to  hos- 
pital in  the  United  States  army,  according  to  length 
of  service,  were  divided  as  follows: 


597 


Army  Medical  Statistics 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Period. 


Absolute  Kate  of  admis- 
nuniber  in  sions  per  1,000 
each  clas  -  strengl  h 


Fir>t  year  and  under. . . 

Second  year 

Third  year 

Fourth  year 

Fifth  year 

Six1  h  year 

N  '.  i  nth  year 

Eighth  year 

Ninth  year.  

Tenth  year        

Twelfth  year 

Fifteenth  year  and  over 


,205 
,632 
,645 
,2  I'J 
,053 
,148 
897 
629 
738 
921 
,351 
,587 


2,254 

l.t  «1 
98 1 
967 

1,064 
901 
97IJ 

1,057 
927 
991 

1,007 
823 


For  the  same  year  the   discharges  for  disability, 
divided  according  to  length  of  service,  were  as  follows: 

Discharges  for 
Service.  disability,  per 

1,000  strength. 

Under  1  year 64.9 

1  year  ...  .41.5 


2  years  . 

3  years . 

4  years  . 

5  years 

6  years  . 

7  years  . 

8  years  . 

9  years  . 
10  years  . 
12  years 


13.3 


19. 6 

2.3.1 


15  years  and  over 22  .  1 

For  the  same  year  the  death  rate  per  thousand 
strength,  according  to  length  of  service,  was  deter- 
mined to  be: 

Less  than  one  year  of  service 10.90 

One  year  of  service 4. SO 

First  five  years  of  service     4.54 

Second  five  years  of  ser\ice     5 .  22 

While  the  absolute  number  of  men  in  the  army  of 
the  United  States  during  the  year  1SS5  can  scarcely 
be  considered  as  sufficiently  large  to  warrant  any 
exact  deductions,  it  is  certainly  safe  to  assume  that 
the  processes  of  elimination  in  our  army  are  most 
active  by  far  during  the  first  twelve  months  of  service; 
after  which  the  total  losses  fall  below  the  general  rate 
for  the  whole  army,  not  to  rise  again  until  the  more 
mature  men  of  ten  years'  or  longer  service  succumb 
to  infirmity. 

Viry  states  that  in  the  French  service  the  annual 
losses  by  death  and  discharge  for  disability  amount 
approximately  to  forty  per  thousand  during  the  first 
year  of  service,  thirty  per  thousand  during  the  second 
year  with  the  colors,  and  twenty  during  each  of  the 
subsequent  years.  According  to  Ordronaux,  sta- 
tistics for  the  French  army  some  years  ago  showed 
the  following  to  be  the  average  annual  mortality: 

Service. 

1  year 

2  years 

ears 

4  years 4.3 

5  years 3.0 

6  years 2.0 

7  years 2.0 

In  comparing  the  amount  of  sickness  among  French 
soldiers  of  one  year  of  service  with  those  of  two  or 
three,  Viry  found  that  in  1888  there  were,  per  thou- 
and  of  each  class,  866  admissions  among  the  former 
and  132  among  the  hitter:  in  1889  the  numbers  were 
859  and  is:;,  and  in  1890  they  were  826  and  5.59 
respect  ively. 

The  proportionate  mortality  in  the  German  army 
for  the  year  1889-90,  out  of  each  1,000  deaths,  was  as 
follows: 


Loss  per  1  .111)0. 

7.5 

6.5 

5.2 


Less  than  1  year  of  service.  . 
From  1  to  2  years'  service.  .  . 
From  2  to  3  years'  service.  .  . 
From  3  to  4  years'  service.  .  . 
4  years'  service  and  upward, 


432.0 
248.0 
143.8 
29.5 
146.7 


Total 1,000.0 

In  the  discharges  for  disability  in  the  German  army 
for  the  same  year,  out  of  8,740  men  so  discha 
78.3  per  cent,  owed  their  incapacity  for  service  to 
causes  existing  prior  to  enlistment.  Hence  it  is  not 
surprising  that  the  majority  of  men  so  discharged 
should  have  been  less  than  one  year  with  the  colors. 
The  percentage  of  discharges  according  to  length  of 
service  was  as  follows: 

First  year SI. 4 

Second  ye:tr 8.6 

Third  year 5.0 

Fourth  year 2.0 

Under  conditions  of  tropical  service  the  raw  and 
unseasoned  recruits  are  proportionately  even  more 
prone  to  disease  than  is  the  case  in  temperate  cli- 
mates, as  is  well  shown  in  the  following  rates  for  the 
British  troops  in  India  during  the  year  1897. 


bV     ■ 

a 
o 

GO 

'a 

CJ 

c 
— 

> 

Ratios  per  1,000 
streng   h 

Length  of  service 
in  India 

Admis- 
sions. 

Deaths. 

1   e    i 

5  to  10  years 

10  years  and  up- 

1  1  6  10 
11,580 
11,368 

8.013 
8,874 

1,806 

1.111 

21,700 
18,795 
17,929 
14,866 
10,548 
11,728 

1  222 
36 

311 
217 
20S 
124 
131 
151 

31 
8 

302 
123 

477. 
446 
265 
288 

59 

1857.9  29.  15  25  86 
1G23.  1    is. 7  .    16.53 
1   77.1  1  ;.30  11.78 
1472.0  12. 2S  14.16 
1316.  1   16  :; 
1321  .6  17.02  32.  IS 

G76.fi  17.  17 

Not  stated 

32    1     7.20 

Total 

61,531 

96,824 

1,214 

2.25S 

1500.4  IS. SI  31.99 

1 

Age  as  Influencing  Sickness  and  Mortality. — In  the 
United  States  service,  for  the  seven  year*  189(1  IXOfi 
inclusive,  the  relation  between  disease  and  age  among 
the  enlisted  strength  existed  as  follows: 


3  e  u4 

©  ©       ■£ 

S   S       J3 

p  ,  ■s 

- 

«  o  o  u 

.£   §          H 

o>n 

7    '    » 

c  £  a  a 

■a  —  a  c 

u  a  c 

Age. 

■  -  —  -  t- 

tf 

»     -     *4     £ 

la -a  g-S 

i.{    '■*>    S    z. 

ba    *i    to  *J 

w    a  i. 
_   i  a 

—    -    *- 

-.2  3 

Admi 

hospi 

dise 

1,000 

z 
z 
- 

non- 
from 

1,000 

.£   '  -      '-    — 

-  °o 

7    S  7S  g 

Q^q 

19  years  and  less. 

2,244.79 

69.73 

■  61 

5  3  ' 

20  to  24  years 

I.  159  6  : 

39  52 

11.  12 

2  '   : 

25  i"  29  years. . .  . 

S96.6.5 

20.06 

11.96 

:    1  ; 

3  i  ("  -1  years, . .  . 

755.64 

21    53 

l:i  69 

::  7  ; 

35  to  39  years. . .  . 

718.43 

21.32 

L0.32 

4 .  32 

40  to  4  1  years. . .  . 

798.09 

24.87 

L6  65 

7.46 

24.11 

755.01 

21.16 

1 5 .  26 

10.97 

50  to  54  years. . . . 

843. is 

28  96 

31.11 

13.18 

1 

55  i  o  59  years. ,  ,  . 

875.22 

34.93 

1      5 

60  years  and  over. 

1.265.31 

72.91 

1-'2.01 

66.04 

188.68 

The  younger  men,  both  officers  and  soldiers,  appear 
particularly  susceptible  to  disease  as  well  as  prone  to 
injury.     For  the  period  noted  above   typhoid   ft 
v  as  observed  to  be  much  more  prevalent  among  1 1 
under  thirty  years  of  age.     The  rate  for  this  dist  B 
in  men  from  twenty  to  twenty-four  years  of  age  WM 
10.31;  from  twenty-five  to  twenty-nine  years,  .".71; 
from  thirty  to  thirty-four  years,  2.58.     Enlisted  men 
under  twenty-five  years  of  age  suffered   more  from 
malarial    fevers   than   did   officers  of   the   same   age; 
but  with  the  advance  of  years  the  rates  of  the 
came  to  differ  but  little  from  those  of  their  superiors. 


598 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Army  Medical  Statistics 


|,e  higher  rates  for  venereal  disease  were  given  bj 

nder  thirty  and  particularly  by   those  under 

i-enty-five  years  of  as;'1;  but,  on  the  other  hand,  the 

r  alcoholism  increased  with  age.     Tuberculo- 

:  appeared  to  be  equally  distributed  among  men 

the  ages  of  twenty  and  fifty  years,  hut   the 

[iarrheal  troubles  was  confined  to  soldiers 

twenty-five  years.     Rheumatic  fever  was  ,H,t 

lly  prevalent   among  young  men,  susceptibility 

eing  increased  after  the  age  of  forty  or  fifty  years. 

or   pneumonia    were   considerably   larger 

five  years  of  age — as  were  also  tho 

idney  disease. 

In  the  French  army,  for  the  decade  1875-1884,  pei 

trength,  the  average  annual  death  rate  for  all 

given  by  Marvaud,  was: 

Under  20  years  <>f  age 6.72 

oi  age 10.92 

irs  of  age 9.38 

o  26  years  of  age 8.59 

o  30  years  of  age 7.14 

Fta                  ■    ears  of  age 8.51 

'he  cla.ss  less  than  twenty  years  old  is  not  only  a 

iv  small  one,  amounting,  according  to  Bertillon, 

•  only  about   three  per  cent,  of  the  whole,  but  the 

oung  men  composing  it  are  all  volunteers  and  before 

ut    are  subjected   to  an  exceptionally  severe 

il  examination,  so  that  only  the  best  ii\<  -  are 

ccepted.     Hence  for  the  French  army  at  large  the 

ar  of  service  may  be  considered  to  begin  at  the 

iventy  to  twenty-two  years.      In  commenting 

ii  the  excessive  mortality  of  the  younger  soldiers, 

larvaud  says:  "It  is  during  the  first  year  of  service 

mber  of  deaths  attains  its  maximum,  a 

act  which  proves  the  dangers  provoked  by  acclima- 

ion  to  a  military  life."     The  influence  of  age  upon 

ickness,  in  time  of  war,  is  even  more  marked  than 

luring    peace.     According    to    Gayet,.  in    the    cam- 

laign  of  Benin  the  total  losses  by  deaths  and  disease 

repatriation  were  as  follow-: 

Per  cent. 

Foreign  legion 9.7 

Artillery  of  the  marine 23.3 

21.2 

Infantry  of  the  marine 39.0 

African  battalion 47.9 

in  the    lasl    two    classes   the    men   were  young  and 

v  developed,  ranging  from  nineteen  to  twenty-two 

rears  of  age;  in  the  foreign  legion  the  men  were  older, 

>eing  between  the  ages  of  twenty-five  and  thirty-five 

of  Military  Rank  as  Affecting  Health. — 

The  report  of  the  surgeon-general  for  1897  gives 
statistics  for  our  army  to  include  the  seven  years 
1S90-1S96,  this  being  equivalent  to  a  total  strength 
'or  one  year  of  14,859  officers  and  17  1,'Jss  enlisted 
men.     These  figures  show  a  sick  rate  of  76.5.69  per 

ad  for  the  officers  and  1.25S.90  for  the  men; 

nut  the  inefficiency  rate  of  the  former  class  was  much 

than    that    of    the    latter,    being    44.27    per 

nd  as  compared  with  37.63  per  thousand  in  the 

t  In1  enlisted  force.     The  average  death  rate  for 

was  9.56  per  thousand,  while  among  the  en- 

listed  men  the  annual  mortality  was  only  6.52  per 

'»1.  Such  an  unfavorable  showing  made  by 
the  officers  as  regards  the  rates  for  death  and  ineffi- 
i  iency  is  largely  to  be  explained  by  the  fact  that  the 
military  life  of  the  enlisted  soldier  practically  ceases 
at  the  age  of  forty-four  years,  only  6.50  per  cent,  of 
this  class  remaining  in  service  after  that  ace;  while 
ii  the  officers  included  in  the  tabulation  referred  to, 
37.25  per  cent,  were  over  forty-four  years  of  age. 
liter  class,  then,  while  sharing  largely  with  the 

1  men  in  the  hygienic  disadvantages  of  im- 
maturity, had,  in  addition,  the  diseases  of  beginning 
'ml  age  and  the  results  of  long  years  of  hard  service 
tn  increase  its  death  rate.  It  'is  to  be  noted  that 
during  this  same  period  young  officers  under  twenty- 


five  years  had  only  784.20  admissions  per  thousand 
for  disease,  w  here  thi  id  an 

admission  rate  <>f  1,359.63;  while  the  nor 
taie  oi  t  he  former  was  29.61,  a-  compared  with  t  he  rate 
of  39.52  for  the  hitter.     This  would  indicate  thai   if 
the  same  attention  "as  given  to  sanitary  details  by 

the  young  soldier  as  by  the  young  officer,  hi-  rate   of 

constant  -ickness  would  be  corn    pondingly  reduced. 

The  influence  of  petty  rank  ami  length  of  service 
on  sickness  in  the  French  tinny  is  shown  in  the  -lib- 
joined  table,  constructei  1  hum  data  given  by  Marvaud 
covering  the  year  1S88: 


per  1 ,000 

i 

in 

260 
567 

Men  having  more  than  one  year  of  service 

Men  h:iviiij_'  [i        1               yeai  of  service.. 

172 
2S9 

The  proportionately  large  number  of  non-conn 
sioned   officers   treated   in   hospital    is   explained   by 
Marvaud  as  being  due  to  lack  of  suitable  accommoda- 
tions in  the  detention  rooms  for  this  class. 

Health  of  Troops  in  Peace. — The  individual  signifi- 
cance of  the  several  factors  which,  taken  together, 
determine  the  sanitary  condition  of  our  army  in  time 
of  peace  will  be  readily  appreciated  by  reference  to  the 
subjoined  table.  Venereal  affections  have  the  high- 
.-t  admission  rate  for  sickness,  but  the  mortality  from 
this  cause  is  not  great.  Malarial  diseases  rank  second 
in  frequency,  but.  as  shown  by  statistics,  they  tire  not 
of  severe  type  and  are  readily  amenable  to  treatment. 
Pneumonia  occupies  third  place  in  importance  as  re- 
gards  admissions.  Rheumatism  and  myalgia  together 
furnish  a  large  proportion  of  admission-  and  dis- 
charges, as  does  also  bronchitis.  The  admissions  for 
alcoholism  are  slightly  above  the  general  mean,  but 
the  rates  for  death  and  non-efficiency  from  this  cause 
are  small.  All  the  rates  for  typhoid  fever  are  low. 
As  to  injuries,  the  several  figures  for  contusions  and 
sprains  are  all  large — those  for  wounds,  excluding 
gunshot  injuries,  being  considerably  lower  than'those 
for  contusions,  but  still  somewhat  in  excess  of  the 
general  average.  But  since  our  Colonial  expansion, 
our  troops  have  become  exposed  to  many  morbid 
influences,  practically  or  entirely  absent  from  this 
country.  The  effect  of  these  diseases  in  altering  siek 
rates  is  shown  in  the  following  table  for  the  year  1909. 

With  regard  to  sickness,  deaths,  and  non-efficiency 
in  the  British  service  for  the  home  stations,  the  fact 
which  at  once  attracts  attention  is  the  high  ratio 
given  by  venereal  affections;  the  admissions  from  this 
<•  being  more  than  half  again  as  high  as  from  any 
other  affection  or  group  of  diseases.  For  gonorrhea, 
primary  and  tertiary  syphilis,  the  individual  rates  for 
non-efficiency  are  much  higher  than  for  such  disi 
as  are  summarized  as  affections  of  the  respiratory  and 
tive  systems.  The  rates  for  rheumatism  and 
influenza  are  high,  while  diseases  of  the  -kin  and  of  the 
connective  tissue  are  common.  Alcoholism  is  a  mi- 
nor factor  in  increasing  the-  rates  for  sickness,  deaths, 
and  non-efficiency. 

Decreast  in  Rates  under  Conditions  of  Peace. — That 
improvement  in  the  sanitary  administration  and  state 
of  armies  is  constantly  being  made  will  be  unhesitat- 
ingly admitted,  but  few  are  aware  of  the  stupendous 
progress  in  this  respect  which,  particularly  during  the 
pasl  generation,  lias  been  accomplished  by  military 
hygiene.  Not  only  is  this  the  case  in  our  own  service, 
but  in  foreign  armies  also,  and,  on  reviewing  the 
sanitary  conditions  which  for  their  time  were  consid- 
ered to  be  excellent,  it  is  apparent  that  -till  further 
decrease  in  the  several  rates  may  justly  be  anticipated 
for  the  future. 


599 


Army  Medical  Statistics 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Table  of  Admission's  to   Sick    Report.  Discharges.  Deaths,  and  Nov- effectiveness,  with    Ratio?  per   1.000  of  Mean- 
•Strength,  fob  the  Abut — Officers  axd  Total  Enlisted — For  the  Year  1909. 


Officers  U.  S.  Army. 


American  troops,  army. 


Mean  strength. 


522— A.  G.  0 


•  >.,  74.319— A.  G.  O..  75,399. 


Causes  of  admission 
to  sick  report. 


Retirement 
Admissions,      for  disa- 
bility. 


Deaths.       Xon-effective.       Admissions.        Discharges.       Deaths. 


*"m-   Ratio.  N;um-  lurio  N;um-  Ratio 
b3T.  ber.    *"***"    ber. 


T"m-    Ratio.   N^m-     Batio. 
ber.  ber. 


*"m-  Ratio  "?°m-  Ratio 
ber.  ber. 


Xon-effe<-ive. 


Num- 
ber. 


Ratio. 


Typhoid    fever,    in- 
cluding P 

phoid  fever 

Fevers,  undetermined 
Malarial  fevers 

Intermittent 

Estivo-autumnal 
Malarial  cachexia, 
and      undeter- 
mined infection. 
Smallpox.  ... 
Measles 

Scarlet  fever 

Diphtheria 

Influenza 

Cholera  nostras 

Dysentery 

Amebic 

Bacillary. . 
Mixed    infections 
and    other  dys- 
enteries  

Leprosy 
Beriberi.. . . 

Erysipelas.. . 

Dengue 

Mumps 

Cerebrospinal    men- 
ingitis, epidemic 
*. 

.      . 
Purulent   infection 

and  septicemia. . 
Trichino-i- 
Tuberculosis 

Tuberculosis,  pul- 
monary . . .  . 
Tuberculo-i  - 
othei 
Venereal  disei 

.Syphilis    and    its 

resu!-. 
Chancroid  and  its 

resul'- 
Gonorrhea  a 

r     and     other 
malignant 
growths.  . 
Rheumatism,    artic- 
ular 
Rheumatic  fever. . 
Rheumatism,  sub- 
acute        and 
chronic,     artic- 
ular. .  . 
Alcoholism    and    its 

I 
Epilepsy 

Trachor:.:: 

earl 

Filari.'i- 
Chyluria. 


11  _ 

12  3.14  . 
102    26.69  . 

63     1 

S.63  . 


6      1.57  . 


1 

1 
- 
195    51.02  .  .  . 


18 
12 
2 


4.71 
3.14 


4      1.05 


3         .73 
93    24.33  . 

7       1.S3  . 


12 
11 


1 
3! 


18 
10 


23 
2 
1 
1 

11 
1 

1 


3.14         3 

2 

- 
- 

- 

1.05      . 

6.02       . 

4.71  .... 
2 .  r,2 


2.09 

6.02 

- 


.26 
.26 


0.23 


.47 


: 


.  17 


2       .47 

1        .23 


2.53 

3.02 

1.16 
1.43 


0.67  267 

470 

2,855 

2,096 

560 


99 


.04 
.19 

.01 
.05 

3.61 

" 

2.65       .69 
2.21 
.24       .06 


580 
2 

35 

2.00S 

_ 

675 

319 

155 


.21 


.07 

:    88 

.29 

.02 
.49 
.08 

.01 

.24 

.001 
.07 

11.39    2.98 
10.96     .    57 


.43       .11 
3.12    0.82 


201 

3 

31 

1,695 

72 

14 


11 

1 
3."* 

: 


.40 

- 

.S9 

1.  17 
.42 


.62 
.54 
.01 


2.44 
.50 
.02 


.23 

.10       _     •: 

: 'i.090 


.2:; 


.11 


10 


.2S 

413 

.16 

1  77" 

.14 

. 

.001 

.07 

_ 

.61 

^7 

.13 

9 

.004 

2 

' 

3.59 
6.32 

■       - 
29.55 

1.33 
.03 

1 

.01 

19 
2 

0.25 
.03 
.03 

.31 

.47 
27      . 

.o:; 

- 
i 

3 

1 

.11 
.01 
.04 
.01 

9. OS 
4.20 
2.09 

: 

- 

6 

5 

1 

.19 
.04 
.OS 

.07 
.01 

.01 
.04 

- 

.03 

- 

1 

.01 

2 

1 

.03 

.01 

9.69 

.19 

.01 
15.20 

.15 
.01 

- 
1 

.03 
.01 

S 
5 

.11 
.07 

-    " 

4.00 

.71 
196.99 

30.45 

77 

n 

171 

160 

1, 
206 

122 

- 

- 
2.12 

-    " 
1.11 

43 
35 

S 

.57 
.46 
.11 

.13 


13.1'' 


.05 


.34 

.03 


5.56 

I 
1.61 
1.74 

.43 

2.52 
.12 
.03 
.01 


24  .32 

22  .29 

109  1.43 

4  .05 


.01 
.01 


69 
6 


.91 
.OS 


26 
3 


.09 
.01 


.34 

.04 


47.71  0.64 

22  .10 

62. 3S  .84 

42.90  .58 

15.00  .20 


1.4S 

- 

36.19 

1.90 

1.90 

31.97 

- 

57.16 

35.05 

12.05 


10.06 

2.13 

.50 

1.64 

30.32 

1.57 

.42 
17.20 

1.05 

201.93 


.06 
.003 

.49 
.03 
.03 
.43 
.0003 
"- 
1 
.16 


.14 
.03 
.01 

.02 
.40 
.41 
.02 

.01 

.01 
.004 

- 


191.0.     2      " 


10.91 

-      - 

..      • 
134.67 

610.75 


.15 
13.07 

3.04 
.02 


.91 
34.46       .46 


33.63      .45 


21.07 

10.46 

3.69 

24.16 


.31 

.28 
.14 
.05 

.003 


GOO 


REFERENCE    HANDBOOK    "I"    THE    MEDICAL    SCIENi 


Army  Medical  MatlMi«.» 


Table  or  A  Repokt,  Discharges,  Deaths,  and   X 

StBE.VOTH,    POB    THE    ARMY — OpFICERS     i 


Officers  V.  S.  Army. 


Mean  strength 


0  .  74.319 


Admi  - 


for  disa- 
bility. 


Deaths.      Non-effective        Admiasi      -  I1  schargi  I  ■•  Non-effe 


Causes  of  admission 
port. 


Num- 
ber. 


Ratio.  N"um"  Ratio  N"um'  Ratio    N*™- 
ber.  ber.  ber. 


S»"'-     Ratio.     N;un'-  Ratio  *"■" 
ber.  ber. 


Num- 
ber. 


Ratio. 


Ly  m  phalli 

eKpli 

(ever 
Other  filai 

of  the  heart .  . 
Bronchitis.        acute 

and  chronic 

Bronchopneumonia 

Pneumonia   I  pneu- 

•iic  fever... 

Diarrhea    and     en- 

teriti- 

Tenia 

Tenia  sohum 

Hymenal 

nan  l 
Bothn<>cephalus 
latus 

ris  Jumbri- 
.    ■ 
.ris      vermic- 

ularis 

mum 
duodenal-- 
Necaior    Aineri- 

canus 

Other  intestinal 
parasite- 
Inguinal  and   other 

hernia? 
Hepatic  abscess 
Appen-li'      - 
Climatic  bub 
Tropical  ulcer 

\  pene- 
- 
Pemphigus     con- 

tagi»- 1~ 
Dhobie  itch 
Tenia  imbric; 
Prickly  heat 

■  ■-.'■-    is 
Chronic  nephritic. .  . 
Malingering 

External    causes, 
special. 

Fractures,  exclusive 

of  gunshot 

Dislf>ca*i  ins 

Sprains  and  muscular 

strains 
Wounds,  gui 
Wounds,  other  than 

gunhsot 

■  ke 
Frostbite  and  general 

freezing 

Drowning. . 

ing,  acute 

►us  bites,  etc 

-  bite 

Other  venomous 
bites,  etc 


.78 


155    40.55 
3         .78 


1.05 


23         1 
7       1 .45 


1 

.26 

1 

.26 

12 

3.14 

.52 

31 

S.ll 

120    31.40 
5      1.31 


42    10.99 

1  .26 


12       3.14 

S      2.09 


S      2.09 


!       1 
21       5.49         I 


34      8.90 
12      3.14 


- 


.70 


.004 


.1" 


62 
.06 


.10 


1 

2.521 

21 

1.34 


.01 

.01 

2.71 

.  55 

1.97 

.  06 


.001 

.001 

.71 

.14 

1.30 


.07 
.64 


4.13    1.08 
.99       .26 


4.1.5    1.09 
1.05 


.03 


.41 
.01 


.001 


4 
19 

136 
127 

1 

22 
■ 
7 

23 

10 

49 

212 
10 

20 

15 

70 


S04 

21d 

215 

- 

7 
85 


.19 

.09 


.05 

.02 


.09      .02 


315 

86 


84 


.HI 


.28 


.      i 


.54 

2.-507 

.01 

5.21 

.002 

65 

1 

31 

.12 

.03 

.05 
-.26 

.03 
1.83 
1.71 

.01 

3.61 

.30 

! 

.09 

.31 

.13 

_ 

.61 

.94 


10.82 

2.95 


56.92 

- 


43.30 
.09 


1.14 


1.16 
.03 

1.13 


32 

1 


18 


01 


.13 

24 

.21 
01 

51 

7 

.32 
.09 

04 

28 
11 

.1.5 

11.79 


1   08 
.  i; 


.12 
.03 


.01 

29.13 

■ 
33.58 


0004 
.16 


12.16      .16 


52 
.10 
.01 
.01 

.002 

.0004 

.01 

.0003 

.03 

.03 

.0001 

.40 
.06 

.4.5 
.01 


1.11 

.02 

.21 

.003 

1 .  55 

.02 

4.63 

.06 

.  15 

.002 

.005 

3.6.5 

.0.5 

7     5 

.10 

.03 

99.33 

1.34 

10.16 

.14 

1.20 

24.63 

.33 

79.01 

1.06 

.36 

.004 

2.10 

.03 

.hi 

1.50 

.02 

.09 

.001 

601 


Army  Medical  Statistics 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Tabls  of  Admissions  to   Sick  Report,  Discharges,  Deaths,  axd  Non-effectiveness,  with  Ratios  per    1,000  of  Mean 

riTREXGTH,    FOR    THE    AflMY OFFICERS   AND    TOTAL    ENLISTED FuR    THE    YEAR    1900. Continued. 


Officers  U 

S.  Army. 

American  troops,  army. 

S.  G.  0., 

1,822 

-A.  G.  O.,  4.2S3. 

S.  G 

ii..  74,316- 

-A.  G. 

'  '  ,  75.399. 

Causes  of  admission 

Admissions. 

Retirement 
for  disa- 
bility. 

Deaths. 

Non-effective. 

Admissions. 

Discharges. 

I  It'aths. 

Non-effective. 

to  sick  report. 

Num- 
ber. 

Ratio. 

Num- 
ber. 

Ratio 

Nuum"  Ratio 
ber. 

Num- 
ber. 

Ratio 

Num- 
ber. 

Ratio. 

Num- 
ber. 

Ratio 

Num- 
ber. 

Ratio 

Num- 
ber. 

Ratio. 

Diseases  find  '"- 
juries  grouped. 

Infectious  diseases 
Other          general 

Diseases  of  the  nerv- 
ous 
organs  of  special 

544 
439 

105 

188 

102 
60 
20 
59 
314 
601 
52 

120 

99 

142  33 

114. S6 

27.  17 

19.19 
26.69 
17.27 
5.23 
15.44 
82.16 
157.25 
13.61 

31  .  m 

25 .  90 

S 
3 

5 

15 

13 

2 
13 

1.87 

71) 

1.17 

3 
3.04 

.47 

:  04 

4 
1 

:: 

2 
2 

.93 
.23 

.70 

.  17 
.  17 

34 .  03 
14.35 

19.68 

17.  I-", 
12.70 
2.77 
1    92 
5.11 
7.33 
19.13 
4 .  53 

5.89 

4.08 

8  90 
3.75 

5.15 

4.57 
3.34 
.72 
.50 
1.34 
1  .92 
5.00 
1.18 

1  .  5  1 

1  .07 

28,396 

10.3S7 

IS, 009 
2,955 

1.253 
1,121 
5S1 
1,681 
5,209 
14,812 
1,050 

6,512 

2,308 
130 

1 
1,300 

382.08 
139.76 

242.32 

39.76 
16.86 
IS. OS 
7.S2 
22.62 
70.09 
199.30 
14.13 

S7.62 

31.06 

1  .  75 

.01 
17.49 

476 
11 

465 

2S0 
220 
32 
28 
112 
33 
72 
51 

9 

41 
71 

6.31 
.15 

6.17 

3.71 
2.92 
.  12 
.37 
1.49 
.  11 
.95 
.68 

.12 

.5  1 
-.94 

121 
60 

01 

10 
10 

1.60 
.SO 

.81 

.13 
.13 

1,612.09 

■    .    ■  . 

1,284. 12 

1 5:; .  :i  i 
si.  id 
39.96 

r>g    22 

in  ;. ill 

115.44 

317.80 

49.63 

170.09 

80.42 
12.84 

.02 

21.69 
4.41 

17.28 
2.06 

Of  the       nervous 

1.13 

Of  the  eye  and  its 

.54 

Of  the  ear  and  its 

.39 

Diseases  of  th 

latory  system.    . 
Diseases  ol  iherespir- 

3       .70 

33 

29 

22 
12 

.44 
.38 
.29 
.16 

1.39 
1.55 

Diseases  of  the  diges- 
tive system 

Diseases  of  thegeni  t  o- 
urinary  system 

Diseases  of  the  skin 
and  cellular  tis- 

1 
2 

2 

1 

.  17 
.17 
.23 

3 
3 

.70 
.70 

4.28 
.67 

2.29 

1  lisea  ses  of  the  or- 
gans    of     loco- 

1.08 

.17 

1                    suits  of 

1 

.0002 

35 

9   16 

.9.5 

.25 

1 

.01 

1 

.01 

.11 

Total  f'»r  diseases. 

2,012 
392 

526.  13 

102.56 

46 
5 

10.74 
1.17 

15 

3 

50 
.70 

98.50  25  77 
17.20    4.50 

04,354 
14,646 

S65.92 
197.07 

1.110 
121 

15.20 
1.61 

228 
142 

3.02 

1 .  88 

2,647.  19 
135.61 

35.62 
5.86 

Total  for  diseases 
and        external 

2.  mi 

628.99 

51 

11.91 

18 

t.20 

115.70  30.27 

79,000 

1.062.99 

1.270 

16.84 

370 

1.91 

3,083.10 

41. 4S 

For  the  U.  S.  army  the  accompanying  charts  (see 
pp.  505  and  506)  so  well  illustrate  the  remarkable 
decrease  in  sickness  and  death  which  has  occurred 
during  the  past  three-score  years  that  any  extended 
discussion  of  the  matter  would  seem  to  be  super- 
fluous. Suffice  it  to  say  that  the  death  rate  for  the 
five  years  preceding  the  Spanish-American  war  was 
about  three  and  one-half  times  less  than  that  for  the 
five  years  preceding  the  war  with  Mexico,  while  the 
rate  for  sickness  underwent  a  diminution  of  about  two 
and  one-third  times  during  the  period  included  by 
these  dates.  Since  1S72  the  death  rate  from  ail 
causes  has  dwindled  to  about  forty  per  cent,  of  what 
it  was  at  I  hat  time,  while  the  death  rate  from  sickness 
alone  has  fallen  almost  as  much;  and  during  the  same 
period  tin-  rate  for  admissions  to  sick  report  has 
diminished  more  than  one-half. 

In  the  German  army,  according  to  official  figures 
recently  submitted  to  the  Reichstag,  the  number  of 

602 


admissions  to  hospital  from  disease,  per  thousand 
strength,  underwent  a  decrease  from  1,496  in  the 
year  1868  to  867  in  1894.  In  1S6S  the  annual  death 
rate  per  thousand  was  6.9,  1.82  in  1S79,  3.24  in  1888, 
and  only  2.60  in  1896 — a  magnificent  result,  in  the 
attainment  of  which  the  due  observance  of  sanitary 
detail,  and  especially  the  careful  selection  of  recruits, 
were  main  factors.  .Military  epidemics,  in  thia 
showing  of  the  German  army,  have  above  all  lost 
ground.  Smallpox  is  rare,  and  caused  only  two 
deaths  during  the  twenty  year.-.  1S73-1S93.  Dysen- 
tery  was  reduced  from  6.S  per  thousand  strength  in 
1S74  to  0.39  in  1894.  Typhoid  fever  gave  a  rate  of 
sickness  of  33.8  per  thousand  strength  in  1868  and  2.4 
per  thousand  in  1894.  The  typhoid  death  tale  was 
2.2  per  thousand  in  186S  and'  0.S1  per  thousand  in 
is'U.  Malaria  showed  a  rate  of  sickness  of  27.fi 
in  1868and  o.sl  per  thousand  in  189  1 :  while  contagious 
eye  inflammations  fell  from  7.0  to  1.5  per  thousand. 


REFERENCE    HANDBOOK    OF    THE    MF.DK'AL   SCIENCES 


Army  Medical  statistics 


0           5          10         15         20        25         30          35        40 

45         50        55        60        65        70        75        80 

1      .1        8      8        11    13       16   18      21    23      26   28      31    33      36   38 

1    A  1       ffl   48         i    '             B                1  OS       ■ n  SB      71    7S      76   78 

2     4         7     0        12   14       17   19       22  24       27  20       32   34       37  39 

42   44        47  40       B2   -.4        '.7    _fl       62  64        67    E'.       72  74        77  79 

1840 

1840 

1841 

1842 

1843 

1844 

1845                       r L  -LL^ 

1845 

1846 

1846 

_*7!         |WAR    W  TH    MEXICO- 

YEAR    OF    CHOLERA    EPIDEMIC 

1850 

1851 

1856                                               -       --■__-           

1857                                 r                                    -■ 

1858            -----             ,-            

186c,      \.c   V,L    WAR 

loee           AN     ^PIDEvl'lC    OFr  SMALL-POX    DURING    THIS 

(■EAR    FuWhsWeC    877    DEAT  HS'.                                        iQfifi 

iofi7          A^l    :pPEVllC    OF  ]ch6_.Er|a   [FURNISHED    hlsiC 

'  deAths.       1 | — -tTT                                  1867 

iqco          lEPICEMIG    OF    CHOLERa]anD    YELLOW  _EEY-Ef 

-FURNISHED   6G1     DEATHS                                                           oc_ 

1871    — L-  I __  — _L 1 

1070        _u   __L       _i__   _'      _J _  ! 

1ft7o    !___/ \__     I 1 

18/(3                         /       ^< 

1074        _L      J_      '      ^£L                                    _        _    -_- 

18/4 

I875    ---I L^_L_' 

io^        Y£AR    ^FvcJsTER^m'a^SACRE     WHEN    2^7    Mb 

WE1E    KILLED                                                                        1876 

1879 

-     --                                                         1881 

1886                ^  \                                        _____________ 

1887            ---{ 

1888         )r-     ■    -        --    --    ----- 

1889            -{-£                    -- 

1895            {---                        -- --    --   -- 

1896           j-J.____.--__           -                 -     -         __   -. 

1897 L-L                                       -     _               

War  with  spain 

1898 

603 


Army  Medical  Statistics 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


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REFERENCE    HANDBOOK    <  >K    THK    MKDICAL    SCIENCES 


\r m\   Medical  Statistics 


A. — Ratios  of  Admission  to  Sick   Report,  Discharge;,  Death,  and  Constantly  Non-Effective  of  the 
United  States  Army  for  the  Decade  L886 


'..r  the   I 
I88fi 


Whii 


Colored. 


Indian. 


eta  strength..        A.  G  ,24,301      S.  G.,  22.071       A  G  ,2,379     S.  G..  2,188         A   G  ,  227.        S.  G..  213 


J  1,172 


of  admis- 
..  k  report 


. 

Lnia 

...id  fever. 
M  :il:uial  infect  ions 

Tuberculosis      of 
the  lui 
'  -     - 

irrhea 

\ll  venerea)  dis- 

housm     and 
direct  results. 
Jgia 

Hitis 

Colic  and  consti- 
pation  

Diarrheal  dis- 
eases  

Diseases  of  the 
heart 

-■:     ...... 

lir  tnchitis 

Pneumonia 

ases    of    the 

kidneys.  .  . 
Rheuniaiism  and 

myalgia 

Boils     and     ab- 


Conjunctivitis 

AH  diseases  of  the 


All  diseases  of  the 
ear 

Contusions  and 
sprains 

Dislocations 

Fractures.  not 
gunshot 

Wounds,  not  gun- 
shot   

Wounds,  gunshot. 

Grouped. 

Infectious  dis- 
general 

cal 

nutri- 
tion, general.    . 
Di -eases    of    the 

nervous 
I  'i    lases    of    the 
digestive    sys- 



if  the 
circula!  ory 

:i . 

if  the 
respirat  ory 

-    . 
Diseases    of    the 
-urinary 

m 

if  the 
lymphatic  sys- 
tem and 
ductless  glands. 


33.76 

0.004 

5.94 

.01 

96  _'  i 

.09 

5.11 

.07 

1    52 

17.  IS 

1.98 

.  26 

2.30 

42.37 

.07 

24  69 

.16 

41.37) 

.001 

32.10 

.02 

0.61 
.1  I 
.02 


1.06 
.91 

.59 


;  = 

&  1 


.44  .70 

.01'        1.6S 

- 

.02      5.26 


.47 
.62 


26 .21 

2.10  0.50 

64.50  0.04     .38 

5.76  .04 

3.93  1.85     .84 

.in 

:>2.ll  .ii! 

7s.  is  3.40     .04    5.21 


II 

76 

1 

71 

"7 

7 

02 

115. 6S 

5 .  79 

;    56 

67 . 9 1 

1.72 

7  ;   28 

43  7  1 
11.86 

17.95 

7.67 

130.04 

2 . 7.7 


50.21 
3.30 


.  22 
1.36 


.01 


.13 

.42 


.23 
.06 


.20 
1.59 


.02 
.06 


.9S 
.54 


.02 
.66 

.23 

.02 
.004 


.29 

1.34 

.53 

.29 

1    37 

.41 

.21 

3.65 

99 
.32 

.78 

.34 


4.  Ml 

49.18 
99.75 

4.94 

41.36 
69.26 

6.90 

2   -  . 
116.33    2 

26.51 

14.49 

26.71     1 
3 .  70 


.01 

.04 

.17     .13 
18      25 


.17 
.os  1.7,1 


29     .34 

02     ... 


.04 
.21 


.23 
.11 

.01 
.004 

3.33 

.20 

.52 

.10 

1.20 

.2'! 
.64 

.05 
.96 

1     1- 
.57 

145.86 

1.S7 


6S.07 

:     : 


302.66    4.15 

2.55       .59 

96.67    3.12 


278    10 


.  .   • 


1.73 

.09 

.7  ' 


13.18        276.73 
2.10 


2.  12 


7.14    1.71 


.05       4.40 
.51  .69 


77.07 
300.59 


.34 


ill 


.OS 


.08 


Ml    I.  (ill 


.  II 

1.14 

.30 

.30 

1.20 

.60 

.22 

4.56 

.67 

.  15 

1.04 

.16 

3.36 
.11 


1.99 

.•17 


5.76 
2.14 


.04 

.  16 


.IS 


5.30!   1.26    .50 


.47 

2     ■ 
4 . 2:; 


- 

1 5 .  5 1    2 

98   26    2 


4  .  70 
15.05 

31  .50 

45.01 

2 .  35 

12.09 

in  34 


5il   7s     1 


42.:>l 
44.67 


62.06 
S.46 


128  82 

6.11 


1 1 .  75 


91.20 
7.05 


II     7 
64 


64 


:;j 


SS    4 


in 


9 

BE 

d 

>- 

a 

1  lischa 

a 
a 
- 

~.  - 

3i 

4.14 

.iij 
.47 
.58 

3.55 
I  .76 

:;.17 
r. .  77 


,ii7 
.17 
.41 

.34 


.16 
.11 
.82 

.711 


0.004  1.06 

84 

.16       2.40 

5.16        .117        .02  58 


3.21  1.63 

17    75  2.11 

!8.6  J  I 

76    12  2.40 


1.54 


1.21 
1.21 


25.70 
42.  12 

33.62 

113.65 

5.69 

34.08 

67.97 

4.20 

1.S0 

76.94 


.07 
.11 
.004 

.02 

.21 

1.34 


.54         .75 
.02       1.71 

J   J  I 
.  1 12       5 .  26 


.20 
.01 


.22 
.06 


.20 
1.63 


.16 


3.02 

.52 


42.18 
12      - 


19.13 
7.32 


.02 
.07 


.99 

.50 


.13 
.41 


.112 
.74 

.24 

.02 

.004 


re   i . 52 


2.10 
1.05 


84 


131.46 

.23 

.01 

2.54 

.11 

.004 

6.S6 

.50 

.11 

52.16 

.20 

.05 

3.69 

.66 

1.05 

.43 
.62 
.66 

.30 

1.32 

.51 

.29 

1.35 

.43 

.21 

3.71 

.97 
.34 

.82 

.33 

3.33 
.20 


1.7:! 
.61 


2.40  11.55        350.26  15.41     7.04  17.45        300.76    4.39     1.84     13.09 


1.41 


1    57  41. 3S 

7         IS    4. us       180.54 


2.35 


1.32       .Ii        .us 
2 .  57 

.lii 


-- 


.  !■ 


2.7.0 

.56 

94 . 4  1 

3.02 

.7", 

113.1    !       .58       .78      2.49       130.55      .341.81    2.7.7         92.15    1.32       .8S     2.46 

11.33        .SI        .24  .85  14.49       .97     .31        .93  7. 99        .11        .  .21 


5.35       .07 


.004        .44 


6.95 


11.28 


.'i  : 


.09  .22 

.76  2.24 

.62  4.35 

6.93    1.66       .51  .66 

111.;'       .7,1'.       .s7  2.50 

11.58       .82       .25  .S5 

5.54       .06       .004  .45 


(a)  For  1SS7-95 — nine  years  of  decade;  (fe)  for  1891-95 — four  years  of  decade. 


605 


Army  Medical  Statistics 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


-Ratios  of  Admission   to  Sick   Report,  Discharge,  Death,  and  Constantly   Non-Effective  of  the 
■  United  States  Army  for  the  Decade  1SS6-95. — Continued. 


For  the  Decade 
1886-95. 


Menu   strength. 


1    Luses  of  admis- 
sion to  sick  report. 


White. 


i  'oli.n.-il. 


Indian. 


A.  G.,  24,301.     S.  G.,  22,071    A.  G.,  2,370.      S.  G  ,  2,188 


?  8 


^ 

IB 

a 

oj 

>>  > 

'tn 
cc 

1 

B1 

DQ 

0  8 

T3 

<u 

o  a 

< 

p 

(-1 

"S 

A.  G„  227. 


S.  G.,  213 


s 
<1 


>>.£ 


Total. 


A.  G.,  26,907.     S.  G.,  24,472 


I 


B  0 

Is 

8! 


Diseases    of    the 

muscles,  bones, 
and  joints 

Diseases    of    the 
integument 
and  subcu- 

taneous     con- 
nective tissue.  . 

Diseases  of  the 
organs  of  spe- 
cial sense 

Unclassified 

I  leneral  injuries.  . 

Injuries  to  special 
parts 

Total  for  dis- 
eases  

Total  for  in- 
juries  

Total  for  all 
causes 


79.16 


;.07 


.01 


79.47       .23 


27 .  53 

2.79 
3.  25 

245.13 


1.65 
!o2 


.01 
.004 

1.02 


1,005.77 
24S . 38 


1,254.15 


3 .  36    1 .  26 


16.34 
3.39 


1.S4 
2.2S 


19.72    7.12 


3.74 


1.27 

.07 
.08 

8.  17 


121.-11 


31.45 
5.21 
1.87 

2S9.26 


3.24 


1.39 

.111 

3.  15 


.01 


.42 
1.08 


:i    so 
8 . 5  1 


40.31 


1,022.31 
291.13 


1,313.43 


16. 4S  6.05 

I 
3.49  2.40 


19.97  8.45 


1.89 


1.26 
.08 
.04 

9.35 


29.53 
9.39 


53.60 


71.93 


72.40 
2 .  82 


302.30 


888.11 
302 . 30 


3S.92 


1,190.41 


2.64 


21.57 
2.61 


24.21 


.  II 

.  I  1 

6.60 


1.3S 


2.19 


2.19 
..01 


9.76 


S2.7H 


76.81 


28.27 
3.00 
3.10 

249 . 57 


2.71        .01 


.23 

1.62 

.03 

3.36 


9 .  76 


1,006.22 
252.67 


16.39 
3.39 


16.72  40.03    1,2S8.S9 


19. 7S 


.02       2.06 


.01 

.304 

.'.ill 

1.37 


4.99 
2.33 


7.32 


1.28 

117 
.07 

8.S7 


,i   62 


40.26 


(a)  For  1SS7-95 — nine  years  of  decade;  (6)  for  1S91-95 — four  years  of  decade. 


Decrease  of  Rates  for  the  German  Army. 


Year. 

Morbidity 
per  1,000. 

Mortality 
per  1,000. 

Invalided 

per  1,000. 

1879-80 

1.174.8 
1,136.2 
1,135.5 
S49.6 
S30.1 
S50.3 
S49.2 
808.0 
S04.1 
758.9 
S97.2 

4.S2 
1 .  82 
4 .  53 
4.25 
1    16 
3 .  93 
3 .  73 
3.79 
3 . 2  I 
3.19 
3.30 

1880-S1   .. 

18S1-82... 

1882  S3 

20  6 

1883  84 

20  7 

l.ssi  95 

20  4 

1885  86 

23  'i 

lSSli      7 

20  6 

1887-88... 

21   5 

188S-89... 

19  6 

1889-90 

25.9 

According  to  Boisseau  the  mortality  of  the  British 
army  on  the  home  station  prior  to  1853  was  17.5  per 
thousand  strength.  After  the  improvement  in  the 
sanitary  surroundings  of  the  soldier  in  that  service 
following  the  Crimean  war,  the  rates  for  death  and 
sickness  were  much  diminished,  and  for  the  decade 
1875-1884  had  fallen  to  7.20  deaths  per  thousand 
strength.  In  1889  the  death  rate  was  4.57,  the  sick- 
ness 730.4.  In  1S90  the  deaths  rose  to  5.53  and  the 
sick  rate  to  810.  For  the  decade  1887-1896  the 
admissions  were  735.9  and  the  ratio  of  deaths  per 
thousand  strength  was  4.68.  In  1897  there  died  only 
3.42  per  thousand  of  strength,  while  the  admission 
rate  had  fallen  to  640. 0  per  thousand  strength. 

The  reduction  in  the  rates  for  sickness  and  death 
in  the  Italian  army  during  the  past  twenty-five  years 
has  been  steadily  progressive  and  probably  presents 
less  fluctuation  than  is  the  case  in  any  other  military 
service. 

G0C 


Admissions      r>e.1(h  Admissions 

to  hospital     rat  Year        to  hospital 

or  infirmary     ,  n0(.  or  infirmary 

per  1,000.          '  I                       per  1,000. 


Death 
rate  per 

I  .nun 


IS  75 

1,031 

13.3 

1887 

760 

S.7 

1876 

1,001 

11.2 

1SSS 

732 

8.7 

1877 

987 

10.6 

1SS9 

7  19 

8.0 

1878 

'.117 

10.6 

1890 

796 

7  .7 

1879 

936 

9.9 

1S91 

811 

9.0 

1NSO 

935 

11.0 

1S92 

758 

7.1 

1881 

928 

10.6 

1S93 

735 

e  a 

1SS2 

833 

10.2 

1894 

723 

5  2 

1883 

842 

11.8 

1S95 

713 

7.0 

1884 

779 

11.6 

1896 

711 

5.8 

18S5 

791 

10.3 

1897 

694 

4.2 

1886 

798 

9.3 

Viry  gives  the  following  rates  for  mortality  in  the 
French  army  as  illustrating  the  progress  of  military 
hygiene: 


Period. 

Mortality  por             -.    .    . 
1,000  strength             Pennd' 

Mortality  per 
1,000  strength. 

1812 

27.9                  1873-81..                        9.0 

1820-  25 

1846 

21.4 
19 

16 
13 

1SS3 '           8.15 

1S89 

1846-58 

1862-72 

1S90 

5.81 

Dewey  states  that  in  the  French  service  the  average 
annual   death   rate   was   8.43   per   thousand  strength 
for  the  seven  years  1880-1886,  and  that  it  sank 
yearly  average  of  6.63  for  the  seven  succeeding  years. 


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his  decreased  death  rate  is  naturally  consequenl  to 
.  d  amount  of  sickness,  as  the  following  figures 
rom  Marvaud  illustrate: 


Period. 


L862 
L86 


L866     1884 
1869     1887. 


Amissions  t.)  hospital  per  thousand  strength 
dons  to  infirmaries  and  cases  treated 

lers  not  included) 264.5J259.5  177.0 

ani   ni  in-effei  I  i  i  es   pi  r  thousand 

1 2:;.:;   22.1    14.0 


Lindley,   writing  in   1S92,   states  that    during  the 

ng  forty  years  the  death  rates  in  the  Prussian 
n,l  Belgian  armies  had  shrunk  to  two-fifths,  the 
inglish  ami  Russian  rates  had  fallen  to  one-half,  and 
he  French  rate  had  diminished  to  one-third.  These 
igures  may  probably  be  accepted  as  being  approxi- 
uately  correct. 
The  lamentable  conditions  revealed  by  the  above 
s  as  existing  until  even  within  the  present 
generation  were  undoubtedly  largely  due  to  ignorance 
if  first  causes  of  disease,  by  which  measures  for  its 
ion  could  not  be  intelligently  applied,  as  well 
is  to  an  insufficient  knowledge  of  hygiene  and  lack  of 
appreciation  as  to  its  value  from  a  military  stand- 
>oint.  An  additional  factor  of  no  mean  importance, 
towever,  was  to  be  found  in  the  former  anomalous 
.ml  inferior  condition  of  the  medical  officer,  his  lack 
if  authority  to  recommend  in  sanitary  matters,  and 
lis  powerlessness  to  control  or  remedy  existing  eondi- 
ions.  It  was  long  held  that  his  duties  were  merely 
,<  rare  for  the  sick  and  wounded,  and  any  recom- 
nendations  bearing  on  the  general  care  or  manage- 
uent  of  the  men  were  deemed  intrusive  and  as  such 
usually  disregarded  and  resented.  The  compara- 
ivelv  recent  conferring  of  advisory  powers  upon  the 
mrgeon  lor  sanitary  purposes  has  undoubtedly  been 
i  potent  factor  in  the  gradual  betterment  of  the 
;anitary  condition,  and  hence  efficiency,  of  the 
loldier;  and  when  the  medical  officer  is  invested 
.vith  actual  authority  upon  all  matters  bearing  upon 
be  health  of  troops,  with  executive  powers  as  well  as 

I  Ivisory  privileges,  a  still  further  improvement  in 
his  direction  may  be  expected. 

Although  during  the  past  one  or  two  generations  a 
narked  diminution  has  occurred  in  the  sickness, 
nortality,  and  non-efficiency  among  the  troops  of  the 
States  and  those  of  European  nations  upon 
!ii  home  stations,  the  same  unfortunately  cannot  be 
:ii  1  with  regard  to  white  troops  doing  colonial  duty 

II  tropical  climates.  For  them  these  rates  continue 
0  be  high,  and  no  great  improvement  in  their  relative 

sanitary  state,  as  evidenced  by  statistics,  appears  to 
have  resulted  for  many  years.  Since  the  hygienic 
requirements  for  each  military  establishment,  wher- 

3  troops  may  be  stationed,  must  be  accepted 
1-  being  the  same  for  all  circumstances,  the  conclusion 
is  obvious  that  climatic  conditions  in  the  tropics  furnish 
:i  potent  obstacle  against  a  constant  reduction  in 
rates  proportionate  to  those  which  have  occurred  on 
the   home   stations.     While   undoubtcdl}-   much    lias 

lone  during  the  past  generation  to  render 
military  service  in  hot  countries  less  inimical  to  life 
and  health,  the  fact  none  the  less  remains  that  sani- 
i.'.ry  progress  in  the  low  latitudes  has  fallen  far  short 
of  that  obtaining  in  more  temperate  climates.  It  is 
that  figures  illustrating  this  point  are  best 
furnished  by  the  records  of  the  British  service,  and 
are  briefly  compared  as  follows: 

a  these  figures  it  is  evident  that  while  there  was 
a  considerable  diminution  in  the  morbidity  and  mor- 
tality rates  for  the  West  Indies  and  Ceylon  during  the 
past   twenty  years,  but  little  improvement   has  oc- 


curred in  the  general   rates  fur  China,    Egypt,  and 
Cyprus.      In    India,    a    country    long    occupied    b 
large  military  force  and  one  in  which  the  grea 
improvement  might  reasonably  be  expected  to  have 
occurred,  the  rate:  are  practically  what  they  wi 
decades  before   -the  death  rate  of  British  troo] 

home  having  fallen  from   7.20  to  3.58  per  thou 

while  the  same  rate  for  India  fell  only  from  17.43  t" 
15.29  during  the  same  period.  Further,  the  several 
rates  f"i'  the  Straits  Settlements  have  actually  in- 
creased. 


1  leatht 

1  lays 

Period. 

hospital 

|„T 

per 

1,000. 

1,111m. 

Decade  1S75-S4. 

885.0 

Decade  1886-95. 

111.",. 7 

'.1  23 

22  67 

Year  1S96 

1190.2 

6.19 

28  69 

Decade  1875-84. 

ins;,.  1 

14.51 

2U.II7 

Decade  1S86-95. 

1004.1 

11  ,38 

21  .  10 

Year   1896    . 

1321 .1 

8 . 23 

2:; .  711 

China 

Decade  L87 

Decade  1SS6-95. 

1030.4 

1256.0 

10.53 
11  .41 

18.07 

22  .  1 1 

Y'ear  1S96 

1856  5 

7.48 

32.05 

India 

Decade  1875  8  1 . 

1  182.9 

17.43 

23 .  06 

Decade  1886-95. 

1  153.5 

15.52 

30.26 

Year  1896 

1386.7 

1 5 .  211 

34.35 

Egypt  and  Cyprus.. 

Decade  1S75  8  1 

No  fig 

ures     gi 

ven. 

Decade  18S6-95. 

1069.7 

16.30 

24 .  56 

Year  1896. 

822.3 

1 3 .  28 

23.11 

Straits  Settlements. 

Decade  1875  S  1 

X"  fig 

are-     iri 

ven. 

Decade  18S6-95. 

1079.4 

7.27 

25.58 

Y'ear  1896 

11171.7 

8.88 

26.46 

In  this  respect  the  experience  of  Great  Britain  is 
duplicated  by  that  of  the  French  service;  in  which  in 
1862  the  mortality  for  troops  throughout  France  was 
9.42  and  for  those  in  Algeria  12.21  per  thousand;  while 
in  1890  the  death  rate  for  troops  at  home  was  5.81  and 
for  those  in  Algeria  11.94  per  thousand. 

TFor  as  Affectimj  the  Health  of  Armies. — The  rates 
of  sickness  and  death  of  troops  in  campaign,  inde- 
pendently of  the  circumstances  which  accompany 
conflict,  are  chiefly  influenced  by  the  standard  of 
hygiene  maintained;  and,  as  is  stated  elsewhere,  it  is 
difficult  to  cite  campaigns  in  which  the  death  rate 
from  sickness  has  not  been  greater  than  that  from 
casual  ty. 

The  diseases  observed  during  continued  warfare, 
according  to  Laveran,  are  largely  brought  about  by 
four  chief  influences:  atmospheric,  exhalations  from 
the  soil,  evil  condition  of  the  latrines,  and  poor  food. 
The  atmospheric  exposure  to  which  the  soldier  is  often 
subjected  is  one  of  the  greatest  hardships  of  a  cam- 
paign. Sleeping  on  the  bare  ground  and  often 
drenched  with  rain,  standing  in  trenches  exposed  to 
snow  and  cold,  or  making  long  marches  under  a 
tropical  sun,  are  a  few  of  the  influences  by  which  he 
is  debilitated  and  his  constitution  impaired.  Service 
in  a  malarious  country  is  notoriously  productive  of 
disease,  while  illy-policed  sinks  are  potent  factors  in 
the  occurrence  of  typhoid  and  dysentery.  The 
influence  of  insufficient  or  improper  food  in  lowering 
the  resisting  powers  of  the  soldier  is  well  recognized. 
Excessive  fatigue  and  moral  influences  also  play  an 
important  part  in  determining  the  sick  rate,  it  being 
well  established  that  victorious  forces  have  less  sick- 
ness than  armies  which  have  been  beaten  and  demoral- 
ized. The  endemic  and  epidemic  diseases  of  an 
occupied  country,  together  with  the  influence  of  a 
change  of  climate,  aggravate  also  to  a  considerable 
degree  the  sickness  and  mortality  of  an  expeditionary 
corps. 

For  our  own  service  the  influence  of  hostilities  upon 


607 


Army  Medical  Statistics 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


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608 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Army  Medical  Statistics 


mortality  from  disease  is  well  illustrated  in  the  accom- 
panying chart   (p.  608),  showing,  as  it  di>e>,  the  rates 
[or  certain  affections  in  the  United  States  army,  dur- 
M!r  the  Civil  war,  for  periods  before  and  subsequent 
Othat  war,  and  also  as  compared  with  the  death  rates 
or  the  corresponding  class  in  civil  life.      As  compared 
with    the    mortality    from    continued    fevers — which 
ins  may  he  considered,  in  the  light  of  present 
aowledge,  as  of  typhoid  natun — war  brought  about 
in     increase     of     tenfold.     Malarial     diseases     were 
1  and  diarrhea  and  dysentery  tripled.     Deaths 
mm  eruptive  fevers  became  about  twenty-two  times 
is  frequent  as  they  were  before  the  war,  while  those 
rotn  diseases  of  the   respiratory  organs  were   more 
[uadrupled.     Camp  life  appeared  to  have  little 
nlluenco   in    affecting    the    mortality    from    nervous 
ons.     Deaths  from  diseases  of  the  circulatory 
nl  digestive  organs  were  practically  doubled  in  fre- 
quency, as  was  also  the  mortality  from  consumption. 
Rheumatism,  as  regards  a  fatal  termination,  and  con- 
iaiy  to  expectation,  was  not  increased;  but  scurvy — 
be  former  bane  of  armies  in  the  field — was  doubled. 
The  average  annual  death  rate  from  disease  during 
the   entire    war    was    53.48   per    thousand    strength 
imong   white    troops,    while   it  was   18.98  for   these 
during   the   eighteen   years  before   the    war, 
xcluding  the  two  years  of  hostilities  against  Mexico, 
and  somewhat  over  six  per  thousand  for  the  decade 
[uent  to  the  war. 
The  following  table  shows  the  influence  of  the  war 
with  Spain  upon  the  rates  for  sickness  and  death,  as 
regards  the  prevalence  of  certain  classes  of  diseases: 


UNITED  STATES  TROOPS 


I    YEAR    1881-2 

\                                FROM  TYPHOID  FEVER 

MORTALITY  - 

1                                    FROM    DISEASE 
1   YEAR    1898-B 

FROM   TYPHOID   FEVER 



f4 

< 

MAY    IJUNC     JULY      AUO.|»EPT,    OCT.      NOV.  |  OCO.      JA*        ffl>,|M»H    '*>n 

JJ.O. 

5.5, 

_5.0 

I  5 

0.0 
0.5 
5.CL 

A 

/ 

\ 
\ 

\ 

1.5 

4.0- 
3.5- 
3  0- 

\ 

\ 

1  '1 

\ 

j 

\ 

\ 

.3  5- 

i 

• 

30L 

_2.5_ 

i 

: 

':/ 

\ 

2.5. 

-2.0- 

1/ 

A 

\ 

s 

20 

1.5 
1.0- 

!/ 

:<  \       \ 

/ 

1.5 
1  0 

y 

\ 

\ 

— 

0.5- 

1   ; 

• 

'"■■*" 

~~- 

05 

-0.0- 

•""" 

.-/  ' 

Fig.  326. — Mortality  from  All  Diseases  and  from  Typhoid  Fever 
during  the  War  with  Spain  and  during  the  Corresponding  Period 
of  the  Civil  War.     (After  Sternberg.) 


Table  Giving  Figures  for  the  Comparison  or  the  Year  of  Peace,  1897,  with  the  Year  of  War,  1S9S. 


Group. 


Admissions  per 
1,000  strength. 


I  lonstantly  non- 
effective per 
1,000  strength. 


Deaths  for 
1,000  strength. 


Discharges  for 
disability  per 
1,000  strength. 


1S97. 


isi.s 


IS',17 


1S9S. 


1898. 


1897. 


Total  losses 
per  1 ,000 
strength. 


1897.        1S98. 


Infectious  diseases,  general  and  local 

Diseases  of  nutrition 

of  the  nervous  system 

Diseases  of  the  digestive  system 

■  nf  the  circulatory  system 

Diseases  of  the  respiratory  system 

-  of  the  genitourinary  system 

Diseases  of   the   lymphatic   system   and 

ductless  glands 

Diseases  of  the  muscles,  bones,  and  joints, 
of   the  integument   and   subcu- 

ius  connective  tissues 

i  of  the  organs  of  special  sense... . 
[tied 

total  for  diseases 

Total  for  injuries 

Total  for  all  causes 


326.10 

2.05 

56.94 

244.05 

4. OS 

77.71 

9.76 

2.36 

72 .  .32 

72 .  55 

21.  17 

2.41 


1,034.97 
3.49 

52.81 

505.71 

6.73 

114.511 
11.77 

3.22 
77.34 

60.57 

17.39 
19.17 


S96.53 


l.'i::7   71 


290.08 


209.23 


1.1S6.61 


2,146.94 


12.59 

.19 

1.63 

3.75 

.41 

1.61 

.SO 

.17 
2.85 

1.70 
.92 
.09 


26.73 


9.12 


35.85 


57.90 

.21 

1.33 

7. CI 

.60 

2.04 

.67 

.17 
2.70 

1.06 
.79 
.59 


69.09 


1.35 


.33 
.55 
.37 


.04 


.04 
.04 


3.14 


1.97 


5.11 


15  '.19 
.09 
.92 
3.11 
.49 
.96 
.24 


.30 


24.94 


8.41 


33.35 


1.28 
.29 

1.79 
.55 
.95 
.40 
.44 


.31 


7.60 


2.01 


9.61 


2.14 
.13 
.86 
58 
.96 
.26 
.43 

.02 
1.33 

.04 
.62 
.02 


7.40 


4.1.8 


11.58 


2.63 

.29 

2. 12 

1.10 

1 .  32 

.62 

.66 

.01 
1.31 


.62 
.04 


10.74 


18.13 
.22 
1.78 
3.69 
1  .  15 
1.22 
.67 

.02 
1.33 

.34 
.62 
.02 


32.34 


44.93 


All  things  being  considered,  it  is  safe  to  assume  that 
I  outbreak  of  hostilities  will  be  followed  by  a  vast 
increase  in  the  death  rate,  probably  from  six  to  twelve 
or  more  times  that  normally  occurring  in  peace;  the 
proportion  naturally  varying  with  the  character  of  the 
campaign,  the  climatic  conditions  to  be  encountered, 
the  local  diseases  to  be  undergone,  the  efficiency  of  the 
commissary  and  transportation  departments,  the 
employment  of  seasoned  or  unseasoned  troops,  and 
many  other  factors.  The  rate  of  admissions  to  sick 
report  from  disease  in  time  of  war  is  not,  however, 
increased  proportionately  to  the  death  rate — a  fact 
.sufficiently  proving  the  more  serious  nature  of  dis- 

Vol.  I.— 39 


eases  when  affecting  troops  in  the  field.  As  to  the 
rate  for  non-efficiency,  this  is  largely  dependent  upon 
the  ratio  for  admissions,  and  naturally  bears  in  its 
fluctuations  a  close  relationship  to  the  prevalence  and 
character  of  disease.  If  the  records  of  the  Spanish- 
American  war  be  accepted  as  typical  in  this  respect, 
no  great  differences  in  the  rates  for  discharge  by 
reason  of  disability,  in  peace  or  war,  may  be  antici- 
pated.    (See  chart,  above.) 

In  comparing  the  results  of  the  Spanish-American 
war  with  the  corresponding  period  of  the  civil  war 
the  advantage  is  much  in  favor  of  the  former,  al- 
though the  progress  of  disease    by  months    is  quite 

609 


Army  Medical  Statistics 

dissimilar.  It  is  particularly  noticeable  that  not 
only  was  the  death  rate  during  the  war  with  Spain 
reduced  by  43.9  per  cent,  as  compared  with  the 
struggle  of  the  previous  generation,  but  the  amount 
of  epidemic  typhoid,  largely  resulting  from  the 
inexperience  of  the  volunteer  troops,  rapidly  decreased 
as  a  result  of  scientific  sanitary  measures  enforced 
as  soon  as  the  magnitude  of  the  typhoid  outbreak  was 
fully  understood.  And  in  future  wars,  through  pre- 
ventive inoculation  and  better  appreciation  of  the 
protective  value  of  good  sanitation,  the  amount  of 
typhoid  fever  to  be  expected  will  be  very  greatly 
reduced  below  past  standards. 


Comparison  of  Monthly  Death  Rates  (per  1,000)  from 
Disease. 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


1S61-1862. 

189S-1S99. 

Months. 

5    M 

l_     50 

o 
ogaj 

0 

a  » 

a  a 

3 

>-i  S 

iS  s 

3T3 

*-8 

K|^ 

« 

i~° 

16,161 

r.6,'.i.-.i> 

71,125 

112,359 

IS 

55 

106 

242 

1.11 

.82 
1.49 
2.15 

(i 

1 
5 

.26 
.44 

.72 
.21 

42 

90 

451 

1,400 

163.726 

_'  12,526 

July 

362,613 

August 

268,507 

September. .  .  . 

165,126 

365 

2.21 

5 

.89 

1,541 

261 ,824 

October 

256.SS4 

725 

2.S2 

:; 

.IV 

809 

_'.-,.-,, Ml  III 

November.  .  .  . 

.301,848 

1,145 

3.79 

1 

.51 

365 

242,000 

December 

343,184 

1,471 

4 .  29 

.84 

201 

240,000 

January 

352,760 

1,593 

4 .  52 

.85 

ISO 

211. 

327,734 

1,316 

4.11 

.87 

156 

iso.ooo 

328,S7S 

1,575 

4.79 

.90 

123 

l.;r.  ni  III 

410,116 
229,452 

l.SSl 
10,522 

4.. 58 
45.86 

25 

.71 
.73 

SO 
5,438 

113,000 

Annual 

211,350 

As  already  intimated,  so  many  factors  combine  to 
determine  mortality  from  sickness  in  campaign  that 
any  attempt  at  the  close  comparison  in  this  respect 
of  different  wars — carried  on  under  entirely  different 
conditions — can  yield  only  misleading  results.  Gen- 
eral deductions  can  of  course  be  drawn,  and  hence  the 
following  figures  may  be  of  advantage  as  well  as 
interest : 

Deaths   from   Disease   During   Certain  Wars   of  the  Past 
Century,      i  After  Bradford.) 


Name  of  War. 


Nation. 


Mortality  from 
disease  per 
or  period,  i  ,000  strength. 


Year 


Walcheren  expedition.. 
West  Coast  of  Africa.  . 

Mexican 

Crimean 

Chinese 

Civil  War 

Civil  War 

Franco-Prussian 

Cape  Coast . .    

Afghanistan 

Egypt 

Soudan 

Madagascar 

Chino-Japam-.' 
Spanish-American 


Great  Britain.. 
Great  Britain.. 
United  States. 
Great  Britain.. 

France 

United  States. 
United  States. 

Germany 

Great  Britain.. 
Great  Britain 
Great  Britain.. 

France 

France 

Japan 
United  States 


1S09 
1824 

1S46-4S 
1S54 
1S62 
1862 
1863 

1S70-71 
1S73 

187S-S0 
1SS2 

1SS3-86 
1S95 
1895 

lS'.lS 


346.9 

690.0 

100.0 

230.0 

118.0 

40.0 

60.0 

IS. 6 

173.0 

93.7 

72.1 

2S0.0 

i  i  il 

14.8 

25.0 


shown  in  the  following  diagram  from  the  report  of  the 
Surgeon  General  for  1910.  Since  1897,  the  chart 
illustrates  the  influence  on  our  medical  statistics  of 
the  Spanish  War;  the  Philippine  Insurrection;  the 
China  Relief  Expedition;  various  other  outbreaks;  the 
second  intervention  in  Cuba;  the  opening  up  of  new 
posts  in  Alaska,  along  the  seaboard  and  in  the  interior 
of  the  United  States,  and  in  Hawaii;  the  occupancy 
of  vast  tropical  territory  and  the  shifting  of  troops 
therein,  and  many  other  factors. 

It  will  be  noted  that  despite  the  far  less  favorable 
environment  that  surrounded  our  army  at  the  time  of 
the  outbreak  of  the  Spanish  war,  the  death  rate  from 
disease  is  now  about  what  it  was  then.  For  this,  an 
improved  sanitary  administration  is  responsible. 
The  rates  for  discharge  and  constant  inefficiency  still 
continue  high,  but  these  are  largely  the  result  of 
exposure  to  tropical  infections  together  with  the 
tremendous  increase  in  venereal  disease  which  has 
been  the  special  sanitary  feature  of  the  past  decade. 


The  results  of  the  Russo-Japanese  war  are  not  given 
here,  as  the  statistics  winch  have  been  published  are 
not  regarded  as  reliable. 

The  results  of  war,  supplemented  by  the  maintenance 
of  troops  under  unaccustomed  climatic  conditions, 
and  frequently  in  an  unhealthf  ul  environment,  are  well 

G10 


Pao.-ths 


Chart  Showing  Ratios  of  Deaths,  Discharges,  and  Non-efficiency 
in  the  U.  S.  Arm}  . 

With  regard  to  the  results  of  campaigning  undci 
tropical  conditions,  the  most  satisfactory  data  are 
naturally  furnished  by  the  two  great  colonizing 
powers,  Great  Britain  and  France.  The  figures 
given  for  these  services  are,  however,  so  widely  dis- 
similar as  to  furnish  no  foundation  for  any  general 
conclusions  based  upon  them  both.  For  pur) 
of  comparison  merely,  they  are  certainly  valuable; 
the  French  having  little  reason  to  be  proud  of  their 
sanitary  showing. 


REFERENCE    HANDBOOK   OF   TIIK    MKDICAL   SCIENCES 


Army  Medical  Statistic! 


ABU    OF    MORTALITY    PROM    DISEASE    IN   CAMPAIGNS  IN  TROPICAL 

Coi  .urn-,  Showing  Rati:  op  Death  pbh  1,000 
Strength.     (After  Bradford.) 


Briiish  Expeditions. 


French  Expeditions. 


oudan 

land 

lukim 

ludan 

I    ih,  n- 


ahanti 



'.II  orce 
land,  . 

kshaoti 

tiiuland 

hitraJ ... 

,'ile 

loogola 

Lfuhaaistan .  . 


1889 

I  s7ii 
INS.", 
lss:,  86 

1860 
189  i  96 
1882 

is.;,-  nn 
1877-78 
I860 
1896 

1S7I 
1S7'.> 

ISM.", 


0.6 

2  n 


1.1 


5 
5 
5 
12 
14 
14 
16 

17.4 
24.8 
25 . 1 
1SS4-S.-.  26.  I 
1896  16.6 
1878-8093.7 


Tonkin 

1884 

Tunis 

1881 

I,.     83 

Tim  kin 

1  ss:, 

1  tahomey. . . . 

[893 

Tonkin 

L886 

Tonkin     . 

|ss7 

(  i>.  Inn-China 

1863 

Soudan 

i  lochin-China 

1862 

1862 

Tonkin 

lsss 

lss.-, -si; 

Soudan 

1SS6-87 

Soudan 

1887  ss 

Soudan 

18S8-89 

Madagascar.  . 

1S95 

I ',11  II 
(il  .11 

71.0 
79.0 

S7.ll 
99.0 
I  in;  ii 
107.0 
116.0 
117.0 
118.0 
133.0 
200.0 
220.0 
225.0 
280.0 
HOO.O 


i  i  unities  of  the  French  expedition  in  Madagascar 
is  given  by  Gayet: 

Killed  by  the,  enemy 7 

Wounded 04 

Deaths  from  sickness 5,600 

Sick,  more  than  15,000,  or  S3  per  cent,  of  the  whole. 

From  the  above  table  it  will  be  observed  that  with 
lie  exception  of  the  Afghanistan  campaign,  in  which 
he  high  mortality  was  largely  the  result  of  an  out- 
ireak  of  cholera,  the  most  unhealthful  of  seventeen 
English  expeditions  in  warm  climates  had  a  lower 
1  :ath  rate  than  the  healthiest  of  an  equal  number  of 
pi  inn  campaigns  under  presumably  similar  climatic 
conditions.  The  British  expedition  against  the 
\diantis,  in  1874,  certainly  demonstrated  the  effi- 
•iency  of  military  hygiene  under  notoriously  unhealth- 
ul  conditions;  and,  in  the  excellent  results  obtained, 
he  second  expedition  against  this  same  tribe,  in 
1896,  even  surpassed  the  first.  In  our  own  expedi- 
ion  against  Manila,  during  the  war  with  Spain,  the 
■esults  were  admirable,  only  eight  per  thousand 
lying  from  disease.  During  the  Cuban  insurrection 
lie  Spanish  are  reported,  for  the  year  1S07,  to  have 
tad  a  death  rate  of  thirty-six  per  thousand  from  all 
auses.  The  admissions  to  hospital  for  the  same 
icriod  were  1,900  per  thousand,  of  which  420  per 
housand  were  for  malaria.  During  1897  the  Spanish 
roops  appeared  to  have  suffered  but  little  from  yellow 
ever;  this  being  probably  due  to  an  immunity  to  this 
iisease  acquired  through  previous  visitations. 

That  constant  exposure  to  infectious  disease  of  all 
kinds,  and  not  only  yellow  fever,  does  actually  exert  a 
seasoning  influence  on  the  survivors  and  reduce  their 
mortality  is  well  known.  As  illustrating  this  point,  it 
may  be  noted  that  the  sick  rate  of  colored  troops  during 
the  civil  war  fell  from  4,092  per  thousand  during 
the  first  year  of  their  service  to  2,797  in  the  last,  while 
their  death  rate  dropped  from  211  to  94  per  thousand 
strength.  The  total  rates  for  sickness  during  the 
civil  war  underwent  considerable  diminution,  as 
follows: 


First  year,  admissions  per  1,000  strength 2,983 

~  ■    n,l  year,  admissions  per  1,000  strength 2,696 

Third  year,  admissions  per  1,000  strength 2,210 

In  this  connection  the  chart  already  given  in  the 
section  showing  the  influence  of  race  as  affecting  the 
prevalence  of  disease  is  of  interest. 


It  is  not,  however,  dining  active  wars  or  on  ex- 
peditions that  the  highest  mortality  is  observed 
a  moiig  troops  in  tin-  field.  When  an  army  is  condemn- 
ed to  inaction  through  a  siege,  for  purposes  of 
mobilization,  or  even  in  cantonments  after  a  faborious 
expedition,  sickness  rages  with  the  greatest  violence. 
The  typhus  i bat  nied  tin-  Crimean  army  occurred  in 
the  winter  after  the  capture  of  Sebastopol  and  aftt  c 
conclusion  of  the  armistice;  and  examples  might  be 
indefinitely  multiplied  in  our  own  service  to  show 
that  the  stationary  force,  dining  war,  is  an  un- 
healthy force.  In  January,  lsi>2,  the  medical 
director  of  the  Army  of  the  West,  then  in  winter 
quarters,  reported  13.5  per  cent,  of  the  total  strength 
as  bring  excused  from  duty,  and  a  little  over  twelve 
per  cent,  in  March  of  the  same  year.  [n  August, 
1861,  of  some  troops  encamped  on  the  Arlington  flats 
on  the  Potomac,  thirty-three  per  cent,  were  reported 
sick  with  diarrhea  and  malarial  fever.  During  the 
war  with  Spain  the  typhoid  epidemics,  as  is  veil 
known,  occurred  in  the  large  fixed  camps.  An  ex- 
cellent instance  is  found  in  the  condition  of  the 
French  troops  during  the  Crimean  War,  a  struggle 
from  which  so  many  sanitary  lessons  have  been 
drawn.  According  to  Rawlinson,  reliable  estimates 
as  to  the  sickness  among  these  troops,  for  the  winter 
■  if  I  854—55,  were  as  follows: 


46,000 
55,000 
6.->,000 
75,000 
ss.000 

3,200 
.5,000 

December 

January 

February.                            .               

6,000 
9,000 
S.000 

These  figures  do  not  include  the  sick  treated  in  the 
regimental  infirmaries  or  in  the  hospitals  at  Constanti- 
nople. 

Comparison  of  Military  Statistics. — It  is  a  matter  of 
the  greatest  difficulty,  if  not  indeed  impossible, 
accurately  to  compare  the  sanitary  conditions  of 
various  armies,  since  their  statistical  tables  are  often 
differently  constructed,  the  physical  requirements  for 
recruits  are  not  identical,  and  diverse  regulations  as  to 
discharges  for  disability  prevail. 

In  attempting  to  institute  such  comparisons  it  is 
well  to  appreciate  at  the  outset  that  a  sick  rate  can  be 
kept  low  by  excluding  the  doubtful  or  milder  cases 
from  the  benefits  of  quarters  or  hospital,  and  so  pre- 
venting them  from  appearing  on  the  official  records; 
that  the  sick  rates,  mortality,  and  constant  non- 
efficiency  can  be  held  down  by  a  searching  system  of 
discharge  for  disability,  and  that  the  total  loss — as 
shown  by  the  sum  of  the  rates  for  death  and  discharge 
— is,  in  determining  the  sanitary  states  of  an  army, 
of  much  more  importance  than  either  of  its  com- 
plementary factors. 

In  comparing  the  rates  of  our  service  with  those  of 
foreign  armies  the  admission  rate  is  the  one  which,  by 
its  magnitude,  attracts  attention.  This  higher  rate  of 
admission,  however,  does  not  in  itself  imply  a  greater 
prevalence  of  disease  among  the  troops  of  the  United 
States;  since  with  us,  in  contradiction  to  the  practice  in 
other  armies,  the  soldier  is  officially  taken  on  sick 
report  whenever  he  is  excused  by  the  medical  officer 
from  any  part  of  his  duty,  whatever  be  the  cause. 
When  it  is  observed,  as  was  the  case  in  the  year  188S, 
that  796. .89  admissions  per  thousand  strength  from  the 
Italian  army  resulted  in  a  death  rate  of  9.31,  while 
1,270.73  admissions  for  each  thousand  United  States 
troops    for    the    same    period — divided    into    62J.61 


611 


Army  Medical  Statistics 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


cases  admitted  into  hospital  and  649.12  treated  in 
quarters — had  a  mortality  of  only  8.15  per  thousand, 
it  is  evident  that  the  admissions  in  the  two  instances — 
the  rates  for  discharge  for  disability  not  varying 
greatly — do  not  constitute  facts  of  equal  gravity  and 
are  therefore  not  available  for  comparison. 

The  rate  for  constant  non-efficiency  is  obviously 
largely  dependent  upon  the  admission  rate  and  that 
of  discharge  for  disability,  and  reflects,  to  a  con- 
siderable degree,  their  variations.  Taken  by  itself 
the  rate  is  misleading,  and  it  acquires  a  certain  value 
only  when  considered  in  connection  with  other  rates, 
particularly  that  for  admissions.  As  between  services, 
for  the  reasons  already  given,  it  is  evident  that  non- 
efficiency  rates  are  not  susceptible  of  proper  com- 
parison. 

The  death  rate  alone,  as  a  means  of  comparison  be- 
tween several  armies,  is  wholly  unreliable  and  merely 
productive  of  error;  since,  as  above  stated,  it  can  be 
marked  reduced  by  the  removal  from  the  service  of 
those  subject  to  or  predisposed  to  disease. 

Of  all  the  ratios  which  go  to  determine  the  health- 
fulness  of  any  army,  as  shown  by  statistics,  that 
giving  the  discharge  for  disability  is  of  the  greatest 
importance.  In  its  relation  to  military  morbidity 
it  is  at  once  evident  that  the  admissions  to  hospital 
will  be  largely  furnished  by  the  physically  less  sound, 
and  that  a  prompt  and  proportionate  diminution  in  the 
sick  rate  must  follow  the  elimination  of  these  weak- 
lings by  their  discharge  from  the  service.  In  addi- 
tion, the  number  of  men  withdrawn  from  the  ag- 
gregate strength  of  the  command,  the  rate  of  non- 
effectiveness  from  disease  or  inujry,  is  not  a  factor 
of  equal  importance  in  all  armies  and  cannot  be 
justly  used  for  purposes  of  comparison.  It  undoubt- 
edly embodies  the  number  of  admissions  and  the 
gravity  of  the  cases  so  admitted;  but  it  is  obvious 
tli  at  the  constant  non-efficiency  as  well  as  the  ad- 
mission rate  varies  inversely  with  the  rigor  of  the 
system  of  discharge.  As  to  mortality,  this  too 
depends  upon  the  physical  standard  maintained,  and, 
as  shown  in  the  German  army,  a  low  death  rate  is 
naturally  consequent  to  the  early  elimination  of  those 
soldiers  who  are  predisposed  to  or  actually  affected 
with  disease.  Hence  the  rate  of  discharge  for 
disability  is  the  controlling  factor  in  the  determination 
of  the  rates  of  admissions,  deaths,  and  constant  non- 
efficiency;  while  it  is  itself  largely  dependent  upon  the 
physical  standards  to  which  the  recruit,  before  en- 
listment, is  required  to  conform.  To  institute  ac- 
curate comparisons,  therefore,  a  constant,  unvarying 
standard  for  discharge  for  disability  should  obtain  in 
several  military  forces  to  be  compared;  and  such  a 
constant  standard  does  not — and  practically  cannot — 
exist.  Requirements  as  to  discharge  for  disability 
necessarily  vary  with  the  customs  of  each  military 
service,  and,  to  a  certain  degree,  with  the  personal 
equation  of  each  medical  officer.  As  an  instance  of 
the  former,  it  may  be  noted  that  the  Germans  are 
especially  assiduous  in  promptly  removing  the 
tuberculous  from  their  armies;  we,  on  the  other  hand, 
maintaining  a  sanitarium  for  soldiers  affected  with 
this  disease;  and  this  single  source  of  error,  to  which 
might  be  added  many  other  less  aggravated  instances, 
prevents  a  comparison  of  sick  rate,  mortality,  and 
non-efficiency  upon  anything  like  equal  premises. 
If  it  be  admitted,  however,  that  the  physical  re- 
quirements for  the  recruits  of  various  armies  are 
approximately  the  same,  the  total  losses,  irrespective 
of  either  non-efficiency  or  admission  rate,  should 
afford  a  somewhat  inaccurate,  but  still  the  most 
available  and  satisfactory  method  of  determining 
the  comparative  health  and  physical  efficiency  of 
various  services. 

The  following  figures,  taken  from  Marvaud,  show  the 
annual  sick  rates,  mortality,  loss  by  discharge,  and 
total  losses  in  various  European  armies  for  a  period 
about  ten  or  twelve  years  ago: 


X.'IMic 


<   o 


E  o 

f~  s 


a  S3 


S3S 


Belgium 

Austria 

Great     Britain     (home 

stations) 

France  (home  stations) 

Germany 

Italy 

Russia 

Spain 


1S87-S8 

338* 

3.9 

17.0 

1887 

995t 

6.9 

15. Of 

18S4-S5 

877 

5.2 

20.0 

1888 

500 

6.1 

21.0 

ink;:  m 

819 

3.9 

29.0 

1887 

760 

8.7 

28.0 

1880-S4 

845 

8.9 

31.3 

1886 

13.5 

30.8 

20.! 
21.1 

25.: 

27. 
32.! 
36.; 
40.: 
44.: 


During  the  year  1SS8  the  total  admissions  p< 
thousand  strength  in  the  United  States  army  amounte 
to  1,270.73,  the  deaths  were  8.1.5  per  thousand,  tl. 
constantly  non-effectives  were  41.91  per  thousanc 
the  discharges  for  disability  27.75  per  thousanc 
These  figures  give  a  total  annual  loss  of  35.90 — tin 
making  our  sanitary  showing  for  that  time  inferior  t 
that  of  the  above-named  nations  except  Italj 
Russia,  and  Spain;  all  countries  notoriously  the  lea> 
advanced  in  matters  pertaining  to  hygiene.  It  cai 
however,  scarcely  be  believed  that  our  men,  undi 
equal  conditions  of  selection,  broke  down  nearl 
twice  as  readily  as  the  Belgian  or  Austrian  soldiei 
and  half  again  as  rapidly  as  the  British  soldiers,  an 
hence  the  conclusion  would  seem  to  be  inevitabl 
from  the  above  figures  that  our  troops  were  at  th:i 
time  examined  on  enlistment  with  a  laxity  as  to  thei 
physical  condition  which  did  not  obtain  in  foreig 
services.  This  idea  is  further  strengthened  by  th 
fact  that  during  the  same  year  (1SSS)  out  of  742  me 
discharged  on  certificates  of  disability,  in  129  instance 
the  disability  was  specifically  declared  to  have  e:i 
isted  prior  to  enlistment.  About  this  time  the  larp 
number  of  discharges  for  disability  attracted  th 
attention  of  the  authorities,  and  recruiting  officer 
were  warned  to  be  more  strict  in  their  examination 
for  enlistment;  while  a  general  order  required  tha 
all  men  recommended  for  discharge  on  account  o 
disability  be  sent  to  the  headquarters  of  each  militar; 
department  for  observation  by  the  chief  surgeoi 
pending  final  action  in  their  cases.  As  a  result  > 
these  requirements  the  rates  for  discharge  weri 
decreased  by  nearly  one-half  in  a  single  year,  sine 
which  even  further  diminution  has  taken  place.  Fo 
the  year  1897  the  rate  for  discharge  on  account  c 
disability  was  only  9.61  per  thousand  as  compare) 
with  27.75  during  1SS8.  On  comparing  the  statistic 
of  the  above  armies  for  a  more  recent  period — exclud 
ing  France  and  Spain,  for  which  countries  no  late 
figures  are  obtainable — the  relative  status  of  th< 
United  States  service  is  found  to  be  as  follows: 


Country. 

Admissions 
to  hospital  or 
infirmary  per 
1,000  strength. 

Death  rate 
per  1,000 
strength. 

I  lischargeg  for 
disability  per 

1,000  strength. 

r. 

°        b 

a,        C 

-  i 

0      c 
H     o 

1S95 
1S97 
1897 

1897 
1S97 
1896 
1897 

819.0 

129.3 

1.1S6.61 

640.6 
694.0 
31  1.6 

332 . 7 

2.6 

2.0 
5.11 

3.42 
1.2 
5.40 
4.0 

9.0 
12.  1 
9.61 

1 9  87 

21.2 
21.9 
37.5 

11    6 

1  1     1 

United  States 

Great     Britain     (home 

11.7: 
11  B 

Italy 

*  General  hospitals  only,     t  Including  detention  in  barracks. 
%  Not  including  temporary  invalids. 


612 


REFERENCE    EANDBOOK    OF   Till:    MEDICAL   Si  T I 


Army  Medical  Statistics 


It  is  evident  from  the  above  that  much  had  ba  Q 
LCCOmplished  during  the  next  decade  toward  improv- 
es the  sanitary  condition  and  effectiveness  of  our 
irmy  and  it  is  safe  to  assume  that  at  the  present  time 
he 'United  States  soldier  is  better  card!  for  than  is 
he  man-at-arms  of  nearly  every  other  military  service. 
sanitary  standing  of  our  army,  as  com- 
iarea  with  that  of  other  armies  of  the  world,  and 
rearing  in  mind  that  the  climatic  and  other  conditions 
which  these  various  forces  are  serving  are 
[tiite  different,  is  quite  well  illustrated  in  the  follow  ins; 
■hart  from  the  report  of  the  Surgeon  General  for  1910. 

Although,  as  stated,  attempts  at  the  comparison  of 
tatistics  of  different  armies  are  at  best  necessarily  in- 


T)'l  ScKo>.RqeS  I  I 

Scale    io   -to    I     iviek. 


accurate  and  unsatisfactory,  within  the  limit  -  of  the 
same  service  such  action  is  both  feasible  and  desirable; 

the  standard  for  the  health  of  an  army,  as  expressed 

by  Smart,  being  its  own  best  annual  record,  i  lutside 
of  unusual  vicissitudes,  exposure,  and  epidemics,  and 

of  the  unsanitary  condition-  which  bri:  [  and 

death  into  the  ranks  of  a  military  command  during 

campaign,  the  sanitary  surroundings  of  the  soldier  <lo 
not  vary  much  from  year  to  year  except  as  they  are 
modified  by  intelligent  efforts  for  their  improvement. 
What  has  been  accomplished  in  the  past  should  there- 
fore be  effected  in  the  present;  or  satisfactory  explana- 
tion should  be  given  of  the  cause  of  failure,  which 
would  thus  be  converted  into  a  source  of  protection 
for  the  future. 

As  to  military  rates  as  affected  by  the  geographical 
distribution  of  troops,  the  following  table  shows  the 
illative  .sickness  among  the  forces  stationed  in  the 
various  military  departments  within  the  limits  of  the 
United  States  during  the  year  1V17: 
From  the  above  it  is  seen  that  the  Department  of 
California  is  the  most  healthful,  with  the  Department 
of  the  Columbia  and  Dakota  closely  following.  The 
Department  of  Texas  has  long  been  recognized  as  the 
most  unhealthful  military  division.  Lately,  however, 
the  shifting  of  troops  and  abandonment  of  certain 
garrisons  has  had  a  tendency  to  modify  the  above, 
and  the  Department  of  the  Lakes  now  presents  the 
highest  constant  inefficiency  from  sickness. 

The  statistics  for  the  entire  British  army  in  time 
of  peace  are  of  particular  importance,  covering  as  they 
do  a  large  number  of  geographical  divisions  under 
diverse  climatic  conditions  and  enabling  the  making 
of  accurate  comparisons  through  the  similar  sanitary, 
military,  and  administrative  conditions  prevailing 
throughout  the  whole.  The  figures  for  that  service, 
for  the  ten  years,  1887  to  1S96,  are  given  on  the  fol- 
lowing page. 

It  is  readily  seen  that  the  total  losses  van-  from  the 
minimum  of  12.26  per  thousand  at  Gibraltar  to  the 
maximum  of  57.SS  on  the  west  coast  of  Africa;  while 
the  death  rate  of  troops  at  home  is  only  about  half 
that  of  the  entire  army.  The  discharges  for  disability 
in  the  latter  instance  are  slightly  higher,  the  constant 
non-effective  considerably  lower,  as  is  also  the  number 
of  days  lost  by  each  soldier. 

The  mortality  among  the  European  troops  of  the 
French  army  on  foreign  service  per  thousand  strength 
is,  according  to  Gayet,  thus  proportioned  among  the 
following  stations: 

Algeria 11  to  12 

Antilles IS  to  22 

Senegal about  73 

Reunion  before  the  Madagascar  expedition., .  .  28  to  30 

Reunion  after  the  Madagascar  expedition SO  to  90 

New  Caledonia. .                        ...  9  to  10 

Cochin  China .  .         .  22  to  24 

Tonkin about  75 


Department. 


Annual        /n"u 
death  rate     d'«-harge 
per  1,000  B,e 

strength.       per  1'°?° 
strength. 


iri. 

I  'ilk"':! 

Platte 
Texas. 
Color:i 

rnia 
Columbia. . 


5.61 
5.30 
4.77 
7.27 
6.24 
3.56 
3.15 
6.20 


Duration 

of  treatment 

among  patients 

who  died. 


5.S5 
6.91 
9.55 
4.59 
7. 38 

13.93 
6.30 

10.33 


17.80 

16. 7S 
28 .  1  7 
22.37 
5.27 
73.45 
21.  10 
36.56 


Duration 

of  treatment 

among  patients 

who  where 

discharged  for 

disability. 


Average 
number  of 
sick  daily. 


,  1  Total  losses 

Average      fc     dfaih       d 

duration  of       ,.     , 

discharge 


treatment. 


for  disability. 


Admission      Constantly 

nee  non-effective 
per  1,000         per  1,000 
strength.         strength. 


S3. 40 

86.06 

109.54 

119.67 

100. 3S 

115.81 

66.40 

75.47 


157.36 

96.61 

69.88 

110.07 

41 .  81 

37.25 


10. 3S 
11.13 
12.70 
10.43 
9.51 
10.21 
11. SI 
11.94 


11.46 
12.21 
14.32 
11.86 
13.62 
17.49 
9.45 
16.53 


1.260.04 
L.1SS.89 

975 . 33 

1.294.41 

1 .522 . 1 4 

1.271.05 

S13.60 

7SS.44 


35.  S3 
36.25 
33.93 
36.99 
39.65 
35.06 
26 .  33 
25.65 


613 


Army  Medical  Statistics 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Ratio  per  1,000 

Strength. 

European 
Troops. 

< 

■a 

a 

c.a 

■9,  » 

a  a 

•a  S 

—    - 

Constantly 
non-effective 

from  sickness. 

o  u 

a  *\2 

hC  o  — 

'«  to 

Average 
duration  of 
each  case  of 

sickness. 

Troops     at 

Days 

Days 

home    and 

abroad .... 

997.4 

S.Sl 

23.65 

1 4 .  52 

58.57 

21.38 

21-47 

United 

Kingdom.  . 

735.9 

4.68 

16.27 

42.51 

15.52 

21.01 

Gibraltar. 

703.  S 

4.01 

15.23 

8.25 

16.65 

17.02 

21.01 

Malta 

666.9 

7.53 

19.20 

10.53 

4 1 .  29 

16.17 

24.25 

Egypt    and 

Cyprus.  .  .  . 

998.8 

11.08 

19.04  12.09  65.48 

23.90 

23.93 

Canada 

499.1 

4.37 

14.34  11  .',")  25  54 

9.32 

1  s .  68 

Bermuda.  .  . 

559.2 

10.07 

12.65    8.14  29.58 

10.80 

19.31 

West  Indies. 

1,119-3 

8.43 

20.23  13.40 

CI    is 

23.51 

21.08 

West  Africa* 

2,652.7 

45.02 

237.94  12.S6 

84.89 

30.98 

11.68 

South  Africa 

and      St. 

Helena.  .  .  . 

868.3 

6.63 

23.97  14.54 

55.85 

20.39 

23.48 

Mauritius. . . 

1,364.4 

15.04 

55.94  17.42  73.76 

26.92 

19.37 

Ceylon 

1,028.0 

11.10 

20.35  11.42  58.29 

21.27 

20.69 

China 

1,324.7 

11.31 

33.34 

14.28 

64.97 

23.71 

17.91 

Straits     Set- 

tlement 

1 ,072 . 1 

6.73 

IS. 14 

9.27 

72.48 

26.46 

24.68 

India 

1,443.9 

15.50 

25.17 

13.24 

84.87 

30.98 

21.45 

On  board 

ship 

1,132.8 

6.41 

*  For  eight  years,  only  1S89  to  1S96. 


5  YEAR  PERIOD 
1906-1910 


middle  and  eastern  Europe.  The  rhizome  and  root 
were  also  formerly  official  under  the  title  Amir, 
radix  or  Arnica  root.  Both  the  root  and  the  flower: 
but  especially  the  former,  are  very  subject  to  adui 
teration. 

The  plant  is  rather  pretty,  with  a  radical  rosett 
of  obovate  leaves,  from  which  rises  a  simple  stem 
foot  or  two  high,  bearing  one  or  two  pairs  of  leave 
and  terminated  by  from  one  to  several  large  yelloi 
flower  heads. 

Arnica:  Flores  are  thus  described:  "Heads  abou 
three  centimeters  broad,  depressed-roundish,  con 
sisting  of  a  scaly  involucre  in  two  rows,  and  a  smali 
nearly  flat,  hairy  receptacle,  bearing  about  sixtee 
yellow,  strap-shaped,  ten-nerved  ray  florets,  am 
numerous  yellow,  five-toothed,  tubular  disk  floret- 
having  slender,  spindle-shaped  akenes,  crowned  b; 
a  hairy  pappus.  Odor  feeble,  aromatic;  taste  bitte 
and  acrid. 

The  receptacle  of  this  head  is  very  apt  to  contain  th. 
larv:e  of  an  insect,  wherefore  some  pharmacopoeia 
direct  that  the  florets  only  shall  be  employed.  Severn 
other  yellow  flower  heads  have  been  employed  ti 
substitute  or  adulterate  arnica,  but  all  fail  to  combim 
the  one  to  two  serialled  nvolucre  with  the  pitted  ant 
hairy  receptacle. 

Arnica  rhizome  is  about  five  centimeters  long  ant 
three  or  four  millimeters  thick;  externally  brown  anc 
rough  from  leaf  scars;  internally  whitish,  with  i 
rather  thick  bark,  containing  a  circle  of  resin  cells 
surrounding  the  short,  yellowish  wood  wedges,  ant 
large,  spongy  pith.     The  roots  are  numerous,  thin 


NON-EFFECTIVES 
RER  1000  STRENGTH 
EACH  SMALL  SQUARE 
=  1  UNIT 


ADMISSION  TO 
HOSPITAL 

PER  1000  STRENGTH 
EACH  SMALL  SQUARE 
=10  UNITS 


TROOPS  IN  UNITED  STATES 
TROOPS  IN  PHILIPPINES 


Chart  Showing  Comparative  Death  Rates,  Sickness,  and  Non-efficiency  for  American  Troops  Serving  in  the  United  States 

and  the  Philippines. 


For  statistical  purposes,  our  troops  in  foreign 
service  may  be  studied  on  the  basis  of  occupancy  of 
the  Philippines.  At  present,  the  great  majority  of 
our  troops  outside  the  United  States  are  stationed 
there,  though  the  Hawaiian  Islands  are  being  heavily 
reinforced  and  steps  are  being  taken  to  protect  the 
Panama  Canal  with  a  large  force.  But  the  effect  of 
tropical  service,  as  a  whole,  compared  with  service 
at  home  stations,  is  probably  quite  well  shown  in  the 
following  diagram. 

Edward  L.  Mtjnson. 

References. 

Billings:  Hygiene.  American  Text-book  of  the  Theory  and 
Practice  of  Medicine,  Philadelphia,  1893. 

Bradford:  The  Expansion  of  Medicine.  Boston  Medical  and 
Surgical  Journal,  June  29,  1899. 

Dewey:  Sanitation  in  the  French  Army.  Popular  Science 
Monthly,  December,  1895. 

Gayet:  Guide  sanitaire,  a  l'usage  des  omciers  et  chefs  de  detache- 
ments  de  l'armee  coloniale,  Paris,  1897. 

Laveran:    Traite  d'hygiene  militaire,  Paris,  1S96. 

Lindley:  Transactions  of  the  Association  of  Military  Surgeons, 
1892. 

Marvaud:    Les  maladies  du  soldat,  Paris,  1895. 

Annual  Reports  of  the  Surgeon  General  of  the  Army. 


Arnica. — Arnica  flores.  Arnica  Flowers.  The  dried 
flower  heads  of  Arnica  montana  L.  (Fam.  Composites) 
(U.  S.  P.). 

The  arnica  plant,  known  at  home  as  Leopard's 
bane  or  Mountain   tobacco,   is  a  perennial  herb   of 


fragile,  grayish-brown,  with  a  thick  bark  containing 
a  circle  of  resin  cells.  Odor  somewhat  aromatic; 
taste  pungently  aromatic  and  bitter. 

Both  drugs  have  a  strongly  resinous  odor  and  a 
pungent  and  acrid  taste,  that  of  the  root  being  the 
stronger,  and  the  dust  of  both  is  sternutatory.  Their 
composition  is  similar,  the  rhizome  being  the  stronger, 
with  one-half  to  one  per  cent,  of  volatile  oil,  consider- 
able resin,  part  of  it  acrid,  ten  per  cent,  of  inulin,  a 
little  tannin,  and  the  crystalline  yellow  acrid  and 
bitter  amaroid  Arnicin  (C20H30OJ,  soluble  in  alcohol. 
The  flowers  lack  the  inulin,  and  their  percentages  of 
oil  and  resin  are  smaller.  Their  oil  does  not  appear 
to  be  identical  with  that  of  the  rhizome. 

Arnica  is  very  active,  both  locally  and  systemically. 
It  is  a  slow  but  powerful  rubefacient  to  the  skin,  and 
a  powerful  stimulant  to  raw  surfaces,  with  some 
antiseptic  power.  It  is  highly  irritating  to  mui 
surfaces,  being  a  stomachic  and  laxative  in  small 
doses,  but  an  emeticocathartic  poison  in  overdo 
Besides  its  irritant  poisonous  properties,  it  is  a 
systemic  poison.  Its  systemic  action  is  most  con- 
cisely stated  by  Bartholow  as  follows:  "In  small 
medicinal  doses  arnica  increases  the  action  of  the 
heart  and  arteries,  and  excites  the  functions  of  the 
skin  and  kidneys.  In  large  doses,  probably  after  a 
stage  of  excitement,  depression  of  the  circulation,  of 
the  respiration,  and  of  the  animal  temperature 
ensues;  violent  headache  is  experienced,  the  pupils 
are  dilated,  and  paresis  of  the  muscular  system  comes 
on.     In   toxic   doses,   arnica   paralyzes   the   nervous 


614 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    S(  ll'.NCLS 


\  rn-.i 


system  of  animal  and  organic  life,  and  death  ei 
ondition  of  collapse.  ' 
It    would    seem    that   some   more    important    use 
niehl  be  found  for  a  drug  possessing  such  pronounced 
,liysiological  actions  as  arnica  than  any  yet  developed 
(t   has  been   used    like    aconite    in    reducing    fever 
uul    decreasing    the    painful    symptoms    of    many 

itions,  especially  in  rheumatism,  erysipi 
mil  painful  menstruation.     Externally  it  is  a  favorite 
,  itinerary    and    rubefacient    in    domestic    practice. 
B'e  have  a  tincture  of  the  flowers  of  twenty  per  < 

agth,   the  dose  being   r^  x.  to  xxx.  (0.6  to  2.0 
\niica    preparations,    if    the   skin    be    abraded,    arc 
apable    of    setting    up    a    cutaneous    inflammation 
[y  resembling  erysipelas. 

II.    II.    RUSBY. 


\rnold,    Fricdrich. — Born    January    8,     1S03,    at 
ikoben,    near    Landau,    Germany.      In    1825    he 
ived  the  degree  of  Doctor  of  Medicine  from  the 
ity   of   Heidelberg.     In   1835,  after  teaching 
omy  for  one  year  in  the  latter  city,  he  was  elected 
Professor  of  Anatomy  and  Director  of  the  Anatomical 
institute  in   the   University   of  Zurich,  Switzerland. 
1840  he  accepted  a  call  to  occupy  the  Chair  of 
Anatomy  and  Physiology  in  the  University  of  Frei- 
burg in  Breisgau.     In  1845  he  was  elected  to  fill  the 
chair  in  the  University  of  Tubingen;  and,  at  the 
.'ii  years,  he  returned  to  Heidelberg,  where 
be  had  first  begun  his  career  as  a  teacher.     In  1876, 
he  ha<l  held  the  Chair  of  Anatomy  in  the  Uni- 
ity  of  Heidelberg  for  twenty-four  years,  he  was 
retired    as    Emeritus    Professor;    thus    meriting    the 
title  of  the  Nestor  of  German  anatomy.     His  death 
irred  July  5,  1S90.     From  1S66  to  1S76  Friedrich 
■Id  and  his  son,  Julius  Arnold,   were  both  full 
professors — the  one  of  normal  anatomy  and  the  other 
of   pathological   anatomy — in    the   same   university. 
ral   anatomical   structures — nerve,   canal,   gang- 
id  ligaments — are  named  after  Arnold. 
(If  the  published  writings  of  Fricdrich  Arnold  the 
following  may  rightly  be  considered  the  most  impor- 
tant: "Tabulae  anatomicae,  quas  at  naturam  accurate 
riptas     in     lucem     edidit,"     Turin,     1838-1843; 
ties  nervorum  capitis,"  second  edition,  in  1860; 
and  "Handbuch  der  Anatomie   des   Menschen,   mit 
nderer  Riicksicht  auf  Physiologie  und  praktische 
Medizin,"  three  volumes,  1843-1851.  A.  H.  B. 

Aroideae. — See  Aracem. 

Arosa,  Switzerland,  is  an  Alpine  high-altitude 
health  resort  of  the  Orisons  in  the  southeastern  por- 
tion of  Switzerland.  It  is  twenty  miles  from  Coire, 
the  railway  terminus,  and  is  reached  by  diligence  in 
five  and  three-quarters  hours.  It  is  5,900  feet  above 
level,  and  lies  in  a  sheltered  position  on  the 
tes  of  the  Tschuggen,  high  above  the  Aroserwasser 
valley.  From  the  fact  that  it  is  situated  on  the 
mountainside,  Dr.  Williams  ("  Aerotherapeutics") 
thinks  that  it,  as  well  as  St.  Moritz  and  Wiesen, 
an  advantage  over  Davos,  which  is  mainly 
ited  in  the  valley. 

Arosa  has  been  known  as  a  health  resort,  especially 
in  the  winter,  for  tuberculosis  patients  for  the  lasl 
twenty  or  more  years  and  is  particularly  popular 
with  the  French. 

It  is  surrounded  on  all  sides  by  massive  mountains 
which  protect  it  from  high  winds  with  the  exception 
of  the  foehn,  which  appears  occasionally  here  as  in 
all  Alpine  valleys.  The  village  is  picturesquely 
situated  in  the  midst  of  large  fir  forests,  and  tin' 
habitations  are  arranged  in  groups,  terraced  upon  the 
mountain  slope  and  facing  the  south.  The  hotel 
accommodations  are  good,  and  some  if  not  all  are 
now  arranged  for  winter  occupancy.  There  are  also 
a  number  of  good  sanatoria.     Dr.  Egger  here  made 


his  famous  experiments   upon   the   changes   in   the 

bl I   caused    by   altitude,   und    thus  attracted    the 

attention  of  the  Profession  to  An 

This     table    adapted     lion,     liegnard's    "La    Cure 

d'Altitude"  -hows   the  mean   temperatures  for 

period  1889   9 


Mean. 


Maximum. 


Minimum. 


January  10 

February 

March...  38.0 

April.... 

May 

June 48.3 

July 50  1 

August.  51.8 

er  47. 1 

October 37.4 

November.    .     .  31.3 

December 23.7 


40.8' 
11    3 

is      , 

.-.2  r, 
63.1 

73  7 
.  I  9 
66.7 
60.4 
47.5 
43.5 


1 


-  2.7° 

-  1.6 

-  3.8 
12.0 
21.5 
30.9 
30.4 

29.1 

9.7 

10.0 

-  0.9 


The  mean  temperatures  of  the  winter  (December, 
January,  and  February),  and  of  the  summer  (June, 
July,  and  August)  are  as  follows  (Regnard): 


Mean. 

Maximum. 

Minimum. 

Winter 

Summer 

23.0°F. 

50.2 

41  .3°F. 

71    i 

-    l.S°F. 
33.8 

The  mean  temperature  at  Arosa  is  about  three  and 
a  half  degrees  higher  than  that  at  Davos,  although  the 
hitter  station  is  nine  hundred  feet  lower  than  the 
former.  The  minimum  winter  temperature  at  the 
two  places  is  as  follows: 

Minimum. 

Winter  1S91-1892,  Arosa -    8.7"  1'. 

Winter  1S91-1S92,  Davos -12.6 

Winter  1892-1893,  Arosa     -16.6 

Winter  1S92-1893,  Davos -  24 . 5 

In  comparison  with  Zurich,  which  represents  the 
temperature  of  the  lowlands  of  Switzerland,  we  have 
the  following  for  summer  and  winter  (Regnard): 


Winter. 


Mean. 


Maximum. 


Minimum. 


Zurich,  elevation  1,600  26. r,    I  41.7°F.  11.48°F. 

feet. 
Arosa,  elevation  6,100  23.0  41.0  -   1.2 

feet. 


Mean. 


Maximum.         Minimum. 


Zurich,  elevation  1,600 

60 

S°F. 

81 

3°F. 

46 

7° 

F. 

feet. 

Arosa,  elevation  6,100 

4S 

4 

71 

8 

32 

7 

feet. 

Violent  variations  of  temperature  are  said  to  be 
rare  at  Arosa,  and  the  fogs  which  are  frequent  in 
summer  are  very  uncommon  in  winter. 

615 


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The  relative  humidity  for  the  winter  of  1S90  was 
as  follows:  The  mean  in  December  was  59  per.cent., 
in  January  62,  in  February  59,  in  March  65. 

The  greatest  amount  of  precipitation  occurs  in 
summer  in  the  form  of  rain;  in  winter  it  comes  as 
snow,  in  sudden  squalls  which  are  soon  over.  In 
1S90  there  were  1,SS6.4  hours  of  insolation  at  Arosa: 
and  for  the  months  of  December  and  January,  492 
hours  of  sun  in  comparison  with  197  at  Zurich  at  the 
same  season,  and  457.4  at  Davos — an  average  of 
about  five  and  a  half  hours  a  day. 

The  winter  climate  of  Arosa,  as  we  learn  from  the 
above,  is  characterized  by  a  dry,  cold,  pure  atmosphere, 
a  high  average  of  sunshine,  absence  of  winds  and  fog, 
and  the  attenuation  and  clearness  of  the  air  which  are 
the  accompaniments  of  high  altitudes.  None  of  the 
Alpine  health  resorts  would  seem  to  offer  more 
favorable  climatic  conditions  for  the  high-altitude 
treatment  of  phthisis.  The  cases  suitable  for  such 
a  climate  are,  in  brief,  the  incipient  ones  and  the 
moderately  advanced  which  still  exhibit  a  consider- 
able amount  of  resistance. 

The  writer  would  express  his  indebtedness  for 
much  of  the  above  data  to  Regnard's  "La  Cure 
d'Altitude."  Edward  0.  Otis. 


Arrhythmia,  Cardiac. — Introduction.  Anatom- 
ical and  Physiological. — The  heart  muscle  is  of 
two  kinds:  mature  and  primitive. 

The  mature  cardiac  muscle  forms  the  greater  part 
of  the  walls  of  both  auricles  and  ventricles.  It  is  not 
divided  into  separate  fibers  but  forms  a  branching 
network  or  syncytium  with  nuclei  at  frequent  in- 
tervals. Some  strands  of  muscle  are  limited  to  one 
auricle  or  one  ventricle,  others  are  common  to  both 
auricles  or  both  ventricles  bringing  them  into  func- 
tional continuity.  There  is  no  continuity  of  tissue 
from  auricles  to  ventricles  through  this  kind  of  muscle. 

The  primitive  cardiac  muscle  or  junctional  tissue 
of  the  heart  represents  the  less  differentiated  remains  of 
tlie  primitive  cardiac  tube  of  the  embryo.  Histolog- 
ically the  fibers  vary  considerably  in  different  situa- 
tions and  in  different  species.  In  the  auricles  they 
are  paler,  less  striated,  and  more  slender  or  spindle- 
shaped  than  those  of  the  mature  muscle.  In  the  ven- 
tricles a  transition  occurs  to  the  so-called  Purkinje 
fibers  which  are  large  branching  cells  with  a  swollen 
appearance  and  present  large  pale  nuclei  and  scanty 
striation.  The  primitive  muscle  is  widely  distributed 
throughout  the  heart  but  certain  portions  call  for 
special  mention. 

1.  The  sinoauricular  or  Keith's  node  is  situated  at 
the  junction  of  the  superior  vena  cava  with  the  right 
auricle.  It  is  believed  to  be  the  chief  representative 
in  the  adult  heart  of  the  primitive  sinus  venosus 
where  the  heart  beat  begins  in  the  embryo  and  in 
lower  vertebrates.  It  is  the  place  of  origin  of  the 
normal  heart  beat,  has  a  rich  blood  and  nerve  supply, 
and  contains  numerous  ganglion  cells.  From  it 
strands  of  primitive  muscle  pass  out  to  all  parts  of  the 
auricular  wall  and  especially  down  the  interauricular 
septum  to  the  following. 

2.  The  auriculoventricular  (A-V)  or  Taivara's  node 
is  situated  at  the  base  of  the  interauricular  septum 
near  the  mouth  of  the  coronary  sinus.  It  is  believed 
to  represent  the  auricular  ring  of  the  primitive  heart 
which  is  second  only  to  the  sinus  in  rhythmic  activity. 

3.  The  auriculoventricular  (A-F)  bundle  or  bumil, 
of  His  forms  the  only  muscular  connection  between 
auricles  and  ventricles.  It  arises  from  the  auriculo- 
ventricular node,  and  passes  down  beneath  the  septal 
cusp  of  the  tricuspid  valve  to  the  pars  membranacea 
of  the  ventricular  septum  where  it  divides  into  right 
and  left  branches.  The  right  branch  continues  on 
through  the  moderator  band  and  the  papillary  muscles 
to  subdivide  in  the  ventricular  wall.  The  left 
branch  pierces  the  septum  and  passes  down  under  the 

G16 


endocardium  as  a  thin  band  to  the  apex  where  it 
breaks  up  into  numerous  fine  threads.  In  both 
ventricles  the  smaller  branches  connect  with  a 
subendocardial  network  of  Purkinje  fibers  from  which 
the  ultimate  ramifications  penetrate  the  ventricular 
wall  to  fuse  with  its  musculature. 

The  extrinsic  nerves  of  the  heart  are  two  on  each 
side,  the  vagus  or  inhibitory,  and  the  sympathetic 
or  augmentor.  One  or  both  of  these  trunks  probably 
contain   afferent  fibers,   but  of   this  little  is  known. 

The  intrinsic  nerves  of  the  heart  consist  of  numerous 
ganglion  cells,  and  nerve  fibers.  The  exact  distribu- 
tion of  the  ganglion  cells  is  a  matter  of  controversy, 
but  they  are  abundant  around  the  sinoauricular  and 
auriculoventricular  nodes  and  on  the  interauric- 
ular septum,  and  scarce  in  the  ventricles.  Nerve  fibers 
are  distributed  very  widely.  They  form  a  network 
around  the  primitive  muscle  tissue  in  its  course 
through  the  heart  and  probably  surround  every 
fiber  of  the  mature  muscle. 

There  are  two  rival  theories  as  to  the  part  played 
in  cardiac,  function  by  nervous  and  muscular  elements 
respectively. 

The  neurogenic  theory  is  the  hypothesis  that  cardiac 
rhythm  depends  for  its  origin  and  propagation  on  the 
nervous  tissues  in  the  heart.  It  is  widely  held  by 
physiologists,  but  its  supporters  have  not  been 
fruitful  in  practical  results. 

The  myogenic  theory  attributes  the  essential  ac- 
tivities of  the  heart  to  the  muscular  elements,  and 
nearly  all  recent  advances  in  our  knowledge  of 
arrhythmia  have  been  made  by  its  adherents.  The 
views  expressed  in  the  remainder  of  this  article  will 
be  based  on  the  myogenic  theory. 

The  properties  of  heart  muscle  are  usually  tabulated 
as  follows: 

1.  Rhythmicity  (automatic  stimulus  production 
and  rhythmic  contraction). 

2.  Irritability. 

3.  Conductivity. 

4.  Contractility. 

5.  Tonicity. 

The  extrinsic  nerves  and  the  intracardiac  ganglia, 
control  but  do  not  initiate  these  functions.  Positive 
and  negative  influences  reach  the  heart  muscle  by  the 
sympathetic  and  vagus  respectively,  augmenting  or 
inhibiting  its  activities.  To  some  of  these  nerve 
influences  special  names  have  been  given  as  follows: 

1.  Chronotropic,  acting  on  rhythmicity. 

2.  Bathmotropic,  acting  on  irritability. 

3.  Dromotropic,  acting  on  conductivity. 

4.  Inotropic,  acting  on  contractility. 

The  nerves  also  influence  the  tonicity  and  nutrition 
of  the  heart  muscle  in  positive  and  negative  directions. 
Heart  muscle  differs  from  ordinary  skeletal  muscle 
in  the  following  particulars  which  may  be  referred 
to  as  the  peculiarities  of  heart  muscle. 

1.  The  All  or  None  Phenomenon. — It  responds  to  a 
stimulus  if  at  all  with  the  greatest  contraction  it  is 
capable  of  at  the  time,  irrespective  of  the  strength  of 
the  stimulus. 

2.  The  Refractory  Period.- — During  a  contraction 
irritability  and  conductivity  are  temporarily  in 
abeyance  and  recovery  is  gradual. 

3.  It  cannot  be  tetanized  on  account  of  the  loss  of 
irritability  during  the  refractory  period. 

The  Normal  Heart  Rhythm. — Any  part  of  l  lie 
heart  is  capable  of  developing  an  automatic  contrac- 
tion as  a  result  of  processes  taking  place  in  the  primi- 
tive muscle  cells.  An  essential  condition  is  the 
presence  in  the  cell  fluids  of  salts,  or  rather  ions,  of 
sodium,  potassium,  and  calcium  in  proper  proportions. 
The  exact  role  played  by  each  of  these  elements  is 
unsettled,  but  they  are  all  necessary.  Sodium  i* 
doubtless  the  principal  factor  in  preserving  a  proper 


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Arrhythmia,  Cardiac 


smotic   relation    between    the    ii-l I    fluids   and    the 
urrounding  lymph.     According  lo  Howell  the  auto- 
iatic  contraction   is   developed    by    the   progressive 
isplacement  of  potassium  by  calcium  in  some  constit- 
en(   of   the  cell   protoplasm,   converting   it  from  a 
table  to  an  unstable  state.     The  first  stage  is   the 
cvelopmenl  of  irritability  in  the  cell,  the  final  stage 
iay  be  an  automatic  contraction.      During  the  In   i 
tage  an  adequate  external  stimulus  will  result  in  the 
ociation  of  all  the  unstable  material  formed,  with 
liberation  of  energy   in   a  contraction.     In   the 
ence  of  an  external  stimulus,   the  final  stage  of 
laximal   irritability  is  ultimately  reached  in  which 
pontaneous  dissociation  and  automatic  contraction 
ccur.     While  such  an  automatic  contraction   may 
•clop    in   any  part  of    the   heart,    the    necessary 
hanges  leading  up  to  it  occur  at  different  rates  in 
ifferent  situations.     They  occur  most  rapidly  in  the 
inns  (sinoauricular  node)  and  least  so  in  the  ven- 
ricle.     When  a  contraction   develops   in   the  sinus, 
he  conductivity  of  the  heart  muscle  comes  into  play 
rid   the  contraction  wave  spreads  over  the  whole 
rt.     It  passes  first  to  the  auricles  over  which  it 
preads  so  rapidly  that  all  parts  of  the  auricles  con- 
net    practically   simultaneously,    and   some   of   the 
warmest  supporters  of  the  myogenic  theory   (Leon 
redericq)  are  prone  to  allow  a  part  in  the  conduction 
o  the  network  of  nerve  fibers.     To  reach  the 
entricles  the  contraction  impulse  has  to  pass  through 
he  auriculoventricular  node  and  the  auriculoventricu- 
ar  bundle  and  its  branches.     The  passage  through  the 
lode  and  through  the  comparatively  narrow  bundle 
lunts    for    the    delay    of    one-tenth    to    one-fifth 
ind  between  the  contractions  of  auricles  and  ven- 
riclcs  which  may  be  called  the  auriculoventricular  in- 
'/'.     As  soon  as  the  contraction  impulse  reaches  any 
iart  of  the  heart  all  the  unstable  material  there  is 
associated,    supplying  the  energy  for  a  contraction, 
ind  a  fresh  supply  has  to  be  formed  before  the  muscle 
■an  regain  its  irritability  and  tend  once  more  toward 
he    developement    of    an    automatic    contraction. 
Under  ordinary  circumstances  the  auricle  and  ven- 
ricle  never  have  time  to  reach  the  stage  of  automatic 
■ontraction  but  are  periodically   stimulated    by    the 
inpulse  descending  from  above.     Their  automaticity 
s    thus    potential    only.     The    sinus    region    (sino- 
luricular  node),  on  account  of  its  greater  facility  in 
developing  a  contraction,  is  said  to  possess  rhythmicity 
to  a  greater  degree  than  any  other  part  of  the  heart 
and  is  known  as  the   "pace  maker  of  the  heart." 

The  methods  op  investigating  the  cardiac 
rhythm  are  as  follows: 

1.  Palpation  of  the  radial  pulse. 

2.  Palpation  of  the  apex  beat. 

3.  Auscultation  of  the  heart  sounds. 

4.  Visual  study  of  the  jugular  pulse. 

5.  Arterial,  venous,  and  apex  beat  tracings. 

6.  Electrocardiagram. 

In  addition  to  the  above  methods,  tracings  have 
been  taken  from  the  left  auricle  by  means  of  an 
esophageal  sound  by  Minkowski,  Young  and  Hewlett, 
and  others,  and  somewhat  similar  tracings  have  been 
obtained  by  Mosso  and  by  Hirschfelder  through  a 
tube  in  the  nostril.  Radiography  has  also  been 
employed.  Of  the  above  mentioned  methods  of 
investigation  4,  5,  and  6  call  for  a  few  words  of 
comment. 

I  lal  examination  of  the  venous  pulse  is  carried  out 
with  the  patient  recumbent  and  the  head  as  low  as 
possible.  The  pulsations  are  usually  best  seen  out- 
side the  lower  third  of  the  sternomastoid.  The 
visible  movements  should  first  be  studied  by  compari- 
son with  tracings  taken  from  the  same  subject. 
After  some  experience  considerable  information  can 
be  obtained  from  visual  examination  alone.  The 
technique   of    taking   tracings   will   be   discussed   in 


another    volume    under    Sphygmography.     Tracings 

Of   the  arterial   pulse  and  apex    beat,  like  palpation  of 

the  same,  give  us  a  general   idea  of   the  sequence, 

Volume,  and  ti relations  of  the  hearl    beat  ;  bill    I  lie 

tracings  enable  us  to  measure  and  Compare  with  an 
exactness  that  is  impossible  by  mere  palpation. 
Stimultaneous  (racings  of  the  arterial  and  venous  pul  e 
enable  US  to  compare  the  activities  of  auricles  and 
ventricles  and  are  in  most  cases  the  most  conven- 
ient adequate  means  for  the  analysis  of  arrhythmia. 
An  example  from  a  case  of  normal  rhythm  is  shown 
in  Fig.  327. 


R.  I.  J. 

A   C 

^J\\   rU^ 

X'     Y 

/-£JW 

1  sec. 

R.Br. 

Fig.  327. — Normal  Tracing  from  Right  Brachial  Artery  (below) 
and  Right  Internal  Jugular  Vein  (above).  Corresponding  points 
in  the  two  tracings  are  marked  by  drawing  vertical  lines  equi- 
distant from  the  starting  points.  The  positive  waves  A,  C,  V 
and  On  are  marked  and  alio  the  negative  waves  X,  -V,  and  V. 
The  paper  travels  16  mm.  per  second,  which  is  indicated  by  the 
horizontal  line  between  the  tracings. 

The  vertical  lines  at  the  beginning  of  the  tracing 
represent  the  relative  positions  of  the  writing  levers 
before  starting  the  tracing,  and  points  equidistant 
from  these  vertical  lines  in  the  arterial  and  venous 
tracings,  respectively,  correspond  in  time.  By 
making  careful  measurements,  and  allowing  for  delay 
in  transmission  of  the  arterial  pulse,  we  can  mark  out 
the  wave  in  the  venous  pulse  corresponding  in  time 
to  the  systolic  wave  of  the  arterial  pulse  and  like  it 
dependent  on  the  ventricular  systole.  This  is  usually 
known  (Mackenzie)  as  the  carotid  wave  (C)  as  it  is 
synchronous  with,  and  some  think  caused  by,  the 
systolic  wave  of  the  carotid  pulse.  The  writer  does 
not  agree  with  this  view  and  would  prefer  to  call  it 
the  systolic  wave,  but  the  discussion  of  such  con- 
troversial points  will  be  taken  up  in  another  volume 
under  Pulse,  venous. 

The  wave  immediately  preceding  (C)  is  known  as  the 
auricular  wave  (A)  and  is  due  to  the  auricular  systole. 
The  wave  following  the  carotid  is  usually  called  the 
ventricular  wave  (V)  (Mackenzie).  It  occurs  during 
the  latter  part  of  the  ventricular  systole,  but  is  not 
necessarily  dependent  on  it  for  its  causation;  the 
writer  prefers  to  call  it  the  first  onflow  wave.  We 
sometimes  have  a  fourth  postive  wave  caused  by 
the  blood  flowing  in  from  the  extremities  and 
named  by  the  writer  the  second  onflow  wave  (0,). 
There  are  also  two  negative  waves  due  to  aspiration 
of  blood  into  the  heart  during  the  diastole  of  auricle 
and  ventricle,  respectively,  and  known  by  Mackenzie 
as  (Y)  during  auricular  diastole  and  (Y)  during 
ventricular  diastole.  They  are  sometimes  referred 
to  as  the  auricular  or  systolic  and  the  ventricular 
collapse,  especially  when  referring  to  the  visual  ex- 
amination of  the  venous  pulse.  By  marking  off 
these  waves  with  their  appropriate  letters,  it  is 
usually  possible  to  recognize  the  sequence  of  auricular 
and  ventricular  systole  when  present,  and  to  measure 
the  auriculoventricular  interval  normally  one-fifth 
second  or  less.     The  latter  is  done  by  measuring  the 


G17 


Arrhythmia,  Cardiac 


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origin   or  mode   of   propagation   of   the   contraction 
impulse,    or   else   some   displacement   of   the   heart. 

Classification  of  Arrhythmia. — A  perfect  classi- 
fication is  very  difficult  because  of  the  fact  that  cer- 
tain forms  which  bear  a  close  resemblance  to  one 
another  and  have  been  grouped  together  under  one 
name,  are  found  on  searching  analysis  to  differ  wid 
in  their  causation.  Most  cases  may,  however,  be 
grouped  under  one  or  other  of  the  following  heads: 


horizontal  distance  from  the  beginning  of  (A)  to  the 
beginning  of  (C)  and  estimating  the  time  to  which  it 
corresponds.  In  Fig.  327  it  will  be  found  to  be  almost 
exactly  one-fifth  second.  Where  normal  rhythm  is  not 
present  we  can  recognize  the  fact  by  some  variation  in 
the  venous  pulse,  and  can  usually  locate  the  seat  of 
the  disturbance. 

The  electrocardiogram  takes  us  still  deeper  into  the 
nature  of  the  events  taking  place  in  the  heart,  but  the 
necessary  apparatus  requires  a  special  laboratory 
so  that  this  method  is  scarcely  feasible  outside  of 
hospital  practice.  An  elect rocardiagram  (q.v.)  is 
taken  by  connecting  two  parts  of  the  body  through 
suitable  electrodes  to  Einthoven's  string  galvanom- 
eter, and  recording  the  delicate  movements  of  the 
string  by  means  of  photography.  We  thus  get  a 
record  of  the  changes  in  electrical  potential  ac- 
companying the  heart  beat.  The  connections  with 
the  body  are  usually  made  by  one  or  other  of  the  three 
following  leads. 

1.  Right  and  left  hands  (Lead  I). 

2.  Right  hand  and  left  foot  (Lead  II). 

3.  Left  hand  and  left  foot  (Lead  III). 


II 


mmAJ  UAmmW^'  'ai.«>tii«mfcj'^'W'twm mnA^^m 


III 

Fig.  328. — Series  of  Electrocardiagrams  showing  the  Results 
Obtained  by  the  Three  Leads  from  a  Normal  Heart.  (From 
Barker  after  Einthoven.) 

Of  these  lead  II  is  most  used  and  gives  the  biggest 
variations.  A  series  of  normal  electrocardiagrams  is 
shown  in  Fig.  328  and  a  key  diagram  in  Fig.  329. 
P  represents  the  auricular  systole  and  Q,  R,  S. 
and  T.  are  all  dependent  upon  the  ventricular  systole. 
Any  marked  departure  from  the  normal  picture 
represents  either  some  abnormality  in  the  place  of 

618 


1.  Sinus  arrhythmia. 

2.  Extra-systoles. 

3.  Auricular  fibrillation. 

4.  Tachycardia. 

R 


5.   Heart  block. 
G.   Bradycardia. 

7.  Pulsus  alternans. 

8.  Pulsus  paradoxus 


319. 


Q  s 

-Diagram  of  the  Electrocardiagram.     (Hoffman.) 


Sinus  arrhythmia  includes  those  forms  of  irregu- 
larity in  which  each  individual  heart  beat  originates 
in  the  sinoaurieular  node  and  spreads  over  the  heart 
by  the  usual  paths,  but  in  which  the  intervals  between 
the  beats  vary  in  duration.  It  is  caused  by  variation 
in  the  strength  of  the  impulses  passing  by  the  extrin- 
sic nerves  to  the  heart  and  modifying  its  rate  (chrono- 
tropic impulses).  These  impulses  may  pass  by 
either  the  sympathetic  (positive),  or  the  vagus 
(negative),  but  the  latter  are  the  most  important. 

Sinus  arrhythmia  is  known  by  a  number  of  different 
names  each  of  which  refers  to  some  characteristic  of 
one  or  other  of  the  forms  in  which  it  is  seen.  Besides 
sinus  arrhythmia,  the  following  terms  are  in  common 
use  and  are  more  or  less  synonymous:  respiratory, 
diastolic,  youthful,  and  vagus. 

Respiratory  arrhythmia  is  applied  to  those  cases  in 
which  the  variations  in  rate  correspond  with  (he 
phases  of  respiration.  It  would  seem  that  where 
the  medullary  centers  are  in  a  certain  condition  of 
excitability,  the  rise  and  fall  of  activity  in  the  re- 
spiratory center  is  able  to  communicate  itself  to  the 
neighboring  cardioinhibitory  center,  modifying  peri- 
odically the  inhibitory  influence  of  the  vagus.  This 
is  a  normal  phenomenon  in  the  dog,  in  which  animal 
the  pulse  is  often  more  frequent  during  inspiration 
(Fig.  330).  In  man  a  similar  condition  may  be 
induced  by  forced  breathing. 

Diastolic  arrhythmia  is  another  synonym,  and 
indicates  the  fact  that  this  form  of  irregularity  is 
due  to  variations  in  the  length  of  the  pause  or  diastole 
between  the  different  heart  beats,  and  not  to  any 
departure  from  the  normal  in  the  site  of  origin  of  the 
contraction  wave  or  in  its  course  over  the  heart, 
This  is  very  well  illustrated  in  Fig.  331,  in  which  there 
is  marked  irregularity.  In  the  venous  pulse  we  can 
see  the  normal  sequence  of  auricular,  carotid,  and 
ventricular  waves  in  each  cardiac  cycle,  but  there  is 
great  variation  in  the  length  of  the  second  onflow 
wave  which  represents  the  pause  or  diastole. 

The  youthful  type  of  arrhythmia  is  another  term 
which  has  been  applied  to  this  form  by  Mackenzie, 
on  account  of  the  fact  that  it  is  more  frequent  in 
childhood.  In  the  young  the  "pace  maker  of  the 
heart"  in  the  sinoaurieular  node  seems  to  be  more 
amenable  to  vagus  influences.  A  similar  condition  is 
present  in  convalescents  when  the  heart  is  slowing 
down  after  the  frequent  rate  of  fever.  It  is  also 
often  seen  in  the  neurasthenic  and  the  debilitated. 
In  all  such  cases  sinus  arrhythmia  is  common. 


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Arrhythmia,  Cardiac 


Vagus  arrhythmia  is  another  name  given  to   these 

,  es,  because  it  is  usually  through  the  vagus  thai 

chronotropic     influences    responsible     for     the 

irrhythmia  roach  the  heart.    While  the  vagal  effects 

ire  "usually  dependent  on  the  alternating  phases  of 

espiration,  this  is  not  always  the  case.     The  activity 

if  the  vagus  may  be  modified  by  a  great,  variety  of 

nfluences     reflex,  central,  and  peripheral.     It  must 

ui  he  forgotten  that  even  the  endings  of  the  vagus 

ii  the  heart  may  1"'  directly  all'ecteil  by  certain  drugs. 

\iiiung  the  conditions  which  have  been   thought  to 

a    causal    relation    to    vagus    arrhythmia    are 

.lion,    high   intracranial   pressure,     brain     tumor, 

neningitis,    injuries   and    diseases   of    the   upper   cer- 

i  spine,  tumors  pressing  on  the  vagus,  poisoning 

drugs  of  the  digitalis  group,   gastric  and  other 

■  I  reflexes. 


found  approximately  equal  in  duration  and  loudm 
in    succe    ive    cycles.     Simultan i      tracings  from 

arteries   and    veins  show    waves   of    normal    form    and 

sequence,  except  in  those  parts  of  the  tracings  which 
correspond  to  diastole,  which  vary  in  length.  The 
electrocardiagram  is  similarly  of  normal  form  except 
in  the  length  of  tin-  pauses.  Before  expressing  a  final 
opinion  the  possibility  of  extra-sy  toles,  heart- 
block,  and  auricular  fibrillation  must  be  excluded. 
Prognosis. — Sinus  arrhythmia  usually  tends  to 
pontaneou  ;  reco\  erj  ,  its  I  lie  \  mil  I,  g]  I1V,  \  into  I  he 
adult    or   as   eon\ale  renee   becomes   complete. 

Treatment  is  unnecessary  in  most  cases  and  where 
called  for  should  be  directed  to  the  general  health. 
Atropine  often  masks  the  symptom  temporarily,  but 
it  is  not  necessary  to  give  it  except  in  those  extreme 
cases  of  standstill  of  the  heart. 


Car 

-J 

See 

I 

~         J"9                      J^ 

c 

Flo.  3".0. — Tracing  from  the  Carotid  Artery  (above)  and  Jugular  Vein  (below)  in  a  Dog  showing  Respiratory  Arrhythmia.    /,  Inspi- 
ih.n;  K,  expiration.     In  the  venous  pulse  the  carotid  (O  and  ventricular  (V)  waves  are  much  the  same  in  inspiration  and  expiration, 
but  there  is  a  great  difference  in  the  length  of  the  second  onflow  wave  (On),  which  represents  the  pause.     Time  marked  in  seconds. 


dstill  of  the  heart  may  be  mentioned  in  connec- 
tion with  vagus  arrhythmia  as  it  is  brought  about 
by  the  same  mechanism  operating  more  powerfullj'. 
!  in-  patient  from  whom  Fig.  331.  was  taken  was  sub- 
to  attacks  of  syncope  which  raised  the  question 
of  heart  block.  No  tracings  were  obtained  during 
these  attacks,  but,  in  view  of  the  evident  activity  of 
the  vagus  inhibitory  mechanism  in  his  case,  they 
may  have  been  due  to  standstill  effected  through 
this  nerve.  Cases  have  been  recorded  by  Neubiirger 
id  Edinger,  Mackenzie,  Laslett,  and  others  in  which, 
in  a  result  of  some  vagus  irritation,  all  the  chambers 


Extra-systoles  or  premature  contractions  are  beats 
starting  from  some  cause  other  than  the  development 
of  the  normal  spontaneous  contraction.  They  are 
produced  by  the  action  of  mechanical,  chemical  or 
nervous  stimuli  acting  on  the  primitive  muscle,  and 
may  occur  in  any  part  of  the  heart.  They  will  be 
more  readily  understood  after  a  consideration  of  the 
terms  homogenetic  and  heterogenetic,  which  have  been 
recently  applied  (Lewis)  to  different  types  of  heart 
stimuli. 

Homogenetic  stimuli  are  those  which  result  from  the 
normal   development    of    unstable    material    in    the 


R.I.J 


ya  see 

iiiiiiiii  mi-iiA 


jaj^jjijJijLjjajjuuAJLUJUUiJjja^ 


luum  ujjojull 


Flo.  331. — Right  Internal  Jugular  Vein,  above.     Right  Brachial  Artery,  below.     .4,  Auricular  wave;  C,  carotid  wave;    V,  ventricular 
wave;  Os,  second  onflow  wave.     Time  in  1/5  second.     Taken  by  the  writer  from  a  patient  of  Dr.  G.  Gordon  Campbell. 


el  tjie  heart  have  remained  quiescent  for  two  or  more 
ordinary  pulse  intervals.  In  some  of  these  cases 
unconsciousness  may  supervene. 

Diagnosis  of  Sinus  Arrhythmia. — The  radial  pulse 
will  be  found  irregular  in  rhythm,  but  more  or  less 
constant  in  volume.  On  feeling  the  pulse  and  observ- 
ing the  respirations  at  the  same  time,  a  relation  may 
be  observed  between  the  phases  of  respiration  and 
those  of  the  arrhythmia.     The  heart  sounds  will  be 


muscle  cells  with  a  resulting  spontaneous  or  auto- 
matic contraction.  Under  normal  conditions  they 
materialize  only  in  the  "pace  maker"  or  sinus,  but, 
where  there  is  a  defect  of  conduction  so  that  the  con- 
traction impulse  from  the  sinus  cannot  spread  over 
the  heart,  homogenetic  stimuli  may  develop  in  other 
parts. 

Heterogenetic  stimuli  include  all  other  kinds.     We 
are  more  or  less  ignorant  of  the  nature  of  heterogenetic 


C19 


Arrhythmia,  Cardiac 


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stimuli,  but  the  following  varieties  may  be  suggested: 
irritation  from  patches  of  degeneration,  high  intra- 
cardiac pressure,  distention  of  the  heart  by  accumu- 
lated blood,  chemical  stimuli  resulting  from  faulty 
metabolism  or  ingestion  of  drugs  and  poisons,  and 
nervous  stimuli  reaching  the  heart  by  the  extrinsic 
nerves.  When  a  heterogenetic  stimulus  starts  a 
contraction  in  some  part  of  the  heart  before  the 
impulse  from  the  sinus  has  time  to  reach  it  the  con- 
traction is  called  an  extra-systole.  Such  extra- 
systoles  may  arise  in  either  auricles  or  ventricles, 
or  in  the  junctional  tissue  between.  They  are 
spoken  of  as  auricular,  ventricular,  and  auriculo- 
ventricular  respectively.  The  contraction  wave 
initiated  by  an  extra-systole  may  be  conducted  in 
any  direction  like  the  normal  impulse,  but  more 
readily  downward.  Ventricular  extra-systoles  are 
usually  limited  to  the  ventricle.  Auricular  extra- 
systoles  are  usually  conducted  down  to  the  ventricle 
and  somewhat  less  frequently  back  to  the  sinus. 
Auriculoventricular  extra-systoles  are  conducted 
down  to  the  ventricles  and  up  to  the  auricles,  pro- 
ducing more  or  less  simultaneous  contraction  of  the 
two  chambers. 

Vi  utricular  extra-systoles  are  produced  by  some 
unusual  stimulus  (heterogenetic)  acting  on  the 
muscle  of  the  ventricle  so  as  to  produce  a  contraction 
of  that  chamber  before  the  impulse  descending  from 
the  sinus  can  reach  it.  In  the  radial  pulse  we  find 
the  normal  rhythm  interrupted  by  a  small  beat 
occurring  before  a  regular  one  is  due,  and  followed 
by  a  long  pause.  The  premature  beat  may  be  too 
weak  to  be  felt,  in  which  case  the  pulse  seems  to 
intermit.  Tracings  from  the  radial  in  two  cases  of 
ventricular  extra-systole  are  shown  in  Fig.  332.  In 
both  these  cases  we  see  the  normal  rhythm  inter- 
rupted by  small  premature  beats  (A'),  each  of  which 
is  followed  by  a  pause  longer  than  the  usual  pulse 
interval  and  called  the  compensatory  pause  (4  to  5, 


-\1 

10 

10 

jV-vJ 

7 

13              10 

10 

/\~ 

B 

Fig.  332,  A  and  B. — Radial  Tracings  from  Father  (A)  and  Son 
(/?),  Both  of  Whom  have  had  Ventricular  Extra-systoles  for  Many 
Years  without  any  Obvious  Disease  of  the  Heart.  The  pulse  beats 
are  numbered  and  the  intervals  marked  in  millimeters  in  B  for 
reference  in  the  text.     The  extra-systoles  are  marked  by  an  X. 

Fig.  332,  B).  When  the  intervals  immediately  before 
and  after  the  extra-systole  are  together  equal  to  two 
normal  pulse  intervals,  we  say  that  the  compensatory 
pause  is  complete.  Such  is  usually  the  case  in  ven- 
tricular extra-systoles  and  is  so  in  the  two  tracings 
shown  in  Fig.  332.  In  B  the  intervals  are  marked  in 
millimeters. 

Hirschfelder  uses  a  different  nomenclature  to 
describe  the  compensatory  pause.  He  calls  the 
interval  from  the  beginning  of  the  last  normal  beat 
lo  the  end  of  the  pause  following  the  extra-systole 
(3  to  5,  Fig.  332,  B)  a  bigeminus;  he  would  say  that  in 
this  tracing  we  have  a  full  bigeminus,  meaning  that 


the  intervals  before  and  after  the  extra-systole  are 
together  equal  to  two  normal  pulse  intervals.  A 
complete  compensatory  pause  or  a  full  bigeminus  is 
strongly  suggestive  of  ventricular  extra-systole, 
but  is  not  pathognomonic  as  it  may  occur  with  other 
forms. 

The  pulse  beat  following  the  extra-systole  (5,  Fig. 
332,  B)  is  often  larger  than  normal.  This  is  because 
the  long  conpensatory  pause  gives  the  heart  time  to 
fill  more  completely  so  that  there  is  a  larger  amount 
of  blood  to  be  forced  out  and  consequently  a  greater 
pulse  volume.  The  fact  that  the  arteries  have  had 
more  time  to  empty  themselves  may  also  be  a  factor. 


Fig.  333. — Ventricular  Extra-systole  in  a  Dog  from  Unknown 
Cause.  RA,  Right  auricle;  RV,  right  ventricle;  X,  extra-systole 
wave  in  ventricular  curve;  A,  auricular  systole;  S,  ventricular 
systole;  1%  ventricular  wave  (better  first  onflow  wave);  Oit  second 
onflow  wave;  S',  from  fusion  of  wave  due  to  premature  contraction 
of  ventricle  with  second  onflow  wave;  .4',  high  wave  from  contrac- 
tion of  auricle  during  ventricular  systole.     Time  in  1/5  second. 

On  listening  over  the  heart  during  a  ventricular 
extra-systole  we  may  hear  the  normal  rhythm  in- 
terrupted by  a  weak  first  and  second  sound  occurring 
before  they  are  due  and  followed  by  a  long  pause. 
Sometimes  the  second  sound  of  the  extra-systole  is 
not  heard,  because  the  ventricular  contraction  has 
been  too  weak  to  open  the  aortic  valves,  "a  frustrane 
contraction"  as  the  Germans  call  it.  In  the  la 
case  as  well  as  when  the  pulse  is  too  small  to  feel, 
we  get  A  false  intermission. 

Fig.  333  shows  an  extra-systole  which  occurred  in 
a  dog  while  tracings  W'ere  being  taken  from  the  right 
auricle  and  ventricle  with  Hiirthle's  apparatus.  The 
cause  of  the  extra-systole  was  unknown. 

The  ventricular  contraction  marked  A*  occurred 
before  its  time  and  its  effect  is  seen  in  the  auricular 
tracing  in  the  wave  S' .  Shortly  afterward  the  auricle 
contracted  during  the  ventricular  systole  producing 
the  wave  A'.  This  wave  is  high,  showing  increased 
auricular  pressure  on  account  of  the  tricuspid  valves 
being  closed  while  the  auricle  is  contracting.  A  similar 
high  wave  is  seen  in  venous  tracings  in  cases  of  ven- 
tricular extra-systole  and  is  always  very  suggestive 
as  it  shows  that  the  ventricle  is  still  contracting  and 
keeping  the  tricuspid  valves  closed  at  the  time  of  the 
auricular  systole.  In  Fig.  333.  the  compensatory 
pause  is  complete  as  is  usually  the  case  with  ven- 
tricular extra-systoles.  The  intervals  3-4  and  4-6 
together  occupy  the  same  time  as  the  two  preceding 
normal  intervals  1-2  and  2-3.     Measurement  by  the 


620 


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Arrhythmia,  Cardiac 


time  tracing  below  will  show  that  this  is  the  case,  and 
also  thai  the  auricular  wave  A'  occurs  at  the  nor- 
mal interval  after  the  preceding  auricular  wave, 
showing  thai  the  auricular  rhythm  is  unaffected. 
334  .1  ami  H  shows  tracings  from  a  case  in 
which    every    third    beat    was    a    ventricular    extra- 


|  i,;.  334,   A  and  B. — Tracings  from  Radial  (A)  and  from  Carotid  and  Jugular  (B)  in  a  Case  of 

!'r.   Blackader's  in  "the  .Montreal  General  Hospital.     Patient  was  a  middle-aged  -woman  under 

meat  for  indigestion.      R.  Car.,  Right  carotid;  L.T.J.,  left  internal  jugular;  A",  A",  extra- 

iles;  A,  auricular  wave;  C,  carotid  wave;   I",  ventricular  wave;  C",  carotid  wave  of  extra- 

le;  A\  large  auricular  wave  occurring  during  ventricular  extra-systole. 


tole.  Note  the  large  auricular  wave  A'  during 
the  extra-systole  of  the  ventricle.  In  this  case  the 
.1'  waves  occur  a  little  prematurely,  but  as  they  fol- 
low the  carotid  waves  at  an  interval  of  one-fifth  sec- 
ond or  more,  it  is  probable  that  the  extra-systole 
has  started  in  the  ventricle  and  been  conducted 
backward  to  the  auricle. 

The  reason  for  the  compensatory  pause  has  yet  to  be 
explained.  It  is  due  to  the  fact  that  the  systole  of 
the  ventricles  is  still  in  progress  when  the  auricles 
contract.  During  systole  the  heart  is  refractory  to 
stimuli,  both  excitability  and  conductivity  being  in 
abeyance,  so  that  the  stimulus  from  the  auricle  is 
unable  to  descend  or  else  finds  the  ventricle  unable  to 


Apex 

1    \         N         s 
1  '■>    sec. 

X 

Fig.  335. — Apex  Beat  Tracing  from  a  Patient  of  Dr.  G.  G.  Camp- 
bell showing  Interpolated  Extra-systole  at  A\  By  measuring 
between  the  vertical  lines  drawn  it  will  be  found  that  thebigeminus 
including  the  extra-systole  is  just  equal  to  the  succeeding  normal 
interval 

respond.     The  consequence  is  that  the  normal  beat 
of    the   ventricle   immediately    following    the   extra- 
■  >le  is  missed,  giving  rise  to  the  long  compensatory 
pause. 

In  rare  cases,  where  the  heart  rate  is  infrequent, 
the  refractory  period  following  an  extra-systole  has 
time  to  pass  off  before  the  next  regular  contraction 
becomes  due.  In  such  a  case  the  extra-systole  is 
wedged  in  between  two  normal  heart  beats  and  there 
is  no  compensatory  pause  at  all.  Such  an  event  is 
known  as  an  interpolated  extra-systole  and  an  example 


i      hown  in  tin.  335,  where  it  is  very  well  -ecu  in  a 
i  racing  from  the  apex  beat. 

Pulsus  Bigeminus. — In  some  cases  every  regular 
heart    beat    is   followed    by   an   extra-systole.     This 

produces  a  pairing  of  beats  known  a-  pulsus  bigemi- 
ni]  .  It  is  probable  that  in  some  way  the  fir  I  I  .cat  of 
the  couple  supplie  the  stim- 
ulus for  the  second  beat  or 
extra-systole.  An  example 
occurring  in  a  dog  at  the  end 
of  a  long  experiment  is  shown 
in  I  'ig.  336. 

Similar  cases  have  been  re- 
ported  in  man,  especially 
after  the  prolonged  adminis- 
tration of  digitalis.  A  pulsus 
bigeminus  may  also  be  pro- 
duced by  a  true  or  false  in- 
termission after  every  two 
normal  beats.  These  differ- 
ent forms  are  very  different 
in  their  causation.  They  can- 
not always  be  distinguished 
from  one  another  in  the 
arterial  pulse,  but  from  the 
venous  pulse  or  electrocardia- 
gram  a  diagnosis  can  easily 
be  made.  False  intermission 
has  already  been  referred  to 
as  due  to  a  weak  extra-systole 
or  frustrane  contraction;  true 
intermission  will  be  ex- 
plained later  on. 

Sometimes    two    or    three 
extra-systoles     occur     after 
each  normal  beat  giving  rise  to  pulsus  trigeminus  and 
pulsus  quadrigeminus  respectively. 

The  electrocardiagram  in  ventricular  extra-sys- 
toles assumes  various  forms  according  to  the  part  of 
the  ventricle  in   which   they  start.     They  all  agree 


Fig.  336. — Tracing  from  the  Right  Auricle  and  Right  Ventricle 
of  a  Dog  showing  Pulsus,  or  rather  Cor,  Bigeminus.  This  was 
obtained  with  Hurthle's  apparatus  at  the  end  of  a  long  experiment, 
but  the  cause  of  the  irregularity  was  unknown.  A,  auricular 
systole;  S,  ventricular  systole;  A',  extra-systole. 

however,  in  differing  from  the  electrocardiagram  of 
the  normal  contraction  which  is  caused  by  a  stimulus 
descending  from  the  auricle.  Two  types  produced 
experimentally  are  represented  in  diagrammatic  form 
in  Fig.  337.     They  may  be  compared  with  the  nor- 

621 


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mal  shown  in  Fig.  329.  The  difference  is  due  to  the 
fact  that  in  an  extra-systole  the  contraction  wave 
and  the  electric  change  accompanying  it  follow  a 
different  path  over  the  ventricle  to  those  of  a  normal 
beat. 

Auricular  Extra-systoles. — In  the  arterial  pulse  the 
general  picture  is  much  the  same  as  in  ventricular 
extra-systoles,  but  the  compensatory  pause  is  usually 
incomplete.  In  venous  tracings  we  see  the  carotid 
wave  preceded  by  an  auricular  wave,  which  may 
show  itself  as  a  separate  wave  (Fig.  338)  or  as  an 
augmentation  of  the  preceding  ventricular  wave 
(Fig.  339).     Although    these    tracings    were    taken 


Fig.  337. — Diagram  of  the  Electrocardiagrams  Produced  Experi- 
mentally by  Stimulating  the  Right  {A)  and  Left  (B)  Ventricles. 
(Kraus  and  Nicolai.) 

from  the  same  patient  within  a  few  minutes  of  one 
another  they  present  considerable  differences  suggest- 
ing that  the  extra-systoles  arose  in  different  parts  of  the 
auricle.  In  Fig.  338  the  A  wave  of  the  extra-systole  is 
abnormally  short  showing  abbreviated  auriculoven- 
trciular  interval  and  suggesting  that  the  extra-systole 
originated  in  the  lower  part  of  the  auricle  or  even  in 
the  junctional  tissues.  In  Fig.  339  the  A  wave  is 
fused  with  the  ventricular  but  evidently  makes  itself 
felt  before  the  summit  is  reached  giving  us  a  length- 
ened auriculoventricular  interval  and  suggesting  an 
extra-systole  starting  higher  up  in  the  auricle.  In 
both  cases  the  compensatory  pause  is  incomplete,  sug- 


R  1 

J 

~^Y      1 

1  sec. 

X  I 

^_ 

Rl 

3r 

11                                       16 

10    1      18 

Fig.  338. — Auricular  Extra-systoles.  R.I.J.,  Right  jugular  vein ; 
R.  Br.,  right  brachial  artery;  .4,  auricular  wave;  C,  carotid  wave; 
V,  ventricular  wave;  Y,  X,  extra-systoles.  Paper  travelling  16 
mm.  per  second  indicated  by  horizontal  line.  Healthy  young 
man  patient  of  Dr.  A.  H.  Gordon. 

gesting  that  the  impulse  traveled  up  to  the  sinus 
causing  it  to  contract  prematurely  and  give  the  "  pace 
maker  "  of  the  heart  a  new  starting-point.  In  Fie. 
339  we  have  hardly  any  compensatory  pause  at  all, 
fifteen  and  one-half  millimeters  as  compared  with  i  he 
normal  interval  of  fifteen  millimeters,  which  is  also 
strongly  suggestive  of  an  extra-systole  arising  near 
the  sinus.  In  Fig.  338  the  compensatory  pause  is 
longer  though  incomplete,  measuring  eighteen  milli- 
meters as  compared  with  the  normal  interval  of  six- 
teen millimeters,  which  supports  the  idea  that  we 
have  to  do  here  with  an  extra-systole  arising  farther 
away  from  the  sinus. 

622 


In  some  cases  of  auricular  extra-systole  the  com- 
pensatory pause  is  shortened  in  accordance  with  the 
law  of  conservation  of  the  normal  pulse  periods.  This 
means  that  when  an  auricular  contraction  comes  be- 
fore its  time  the  auriculoventricular  interval  is  pro- 
lunged  and  when  the  auricular  contraction  follows  a 
long  pause  the  auriculoventricular  interval  is  short- 
ened, both  of  which  facts  tend  to  equalize  the  ven- 
tricular intervals.  In  Fig  340,  for  instance,  the 
auriculoventricular  interval  of  the  extra-systole  is 
longer  and  that  following  the  compensatory  pause 
is  shorter  than  normal  which  minimizes  the  effect 
on  the  ventricular  rhythm. 


RIJ 


1  sec. 


RBr 


15 


Fig.  339. — From  Same  Patient  as  Fig.*  338.  Showing  how 
auricular  wave  of  extra-systole  may  be  fused  with  preceding 
ventricular  wave  as  shown  at  X  in  the  venous  tracing. 

The  effect  of  the  long  pause  is  also  well  seen  in 
Fig.  341  where  the  auriculoventricular  interval  (au- 
ricular wave)  succeeding  the  pause  is  much  shortened 
and  helps  to  postpone  some  of  the  compensation  to 
the  next  pulse  interval.  Similar  changes  probably 
occur  in  the  sinoauricular  interval  in  other  forms  of 
arrhythmia. 

In  electrocardiagrams  from  cases  of  auricular  extra- 
systole  the  auricular  complexes  are  of  variable  form 
according  to  the  part  of  the  auricle  in  which  they 
originate  and  are  often  inverted.  The  ventricular 
complexes  are  usually  of  normal  form  as  they  occur 


Fig.  340. — Venous  Pulse  from  Case  of  Auricular  Extra-systoles. 
A,  Auricular  wave;  c,  carotid  wave;  .4',  auricular  wave  of  extra- 
systole  superimposed  on  ventricular  wave  of  preceding  cyclo, 
1,  Normal  A— V  interval;  2.  lengthened  A-V  interval  of  extru- 
sysU>le;  3,  shortened  A-V  interval  following  compensatory  pause. 

in  response  to  stimuli  reaching  them  by  the  usual 
channels  from  the  auricle.  Where  deviations  from 
the  normal  occur  they  may  usually  be  ascribed  to 
some  fault  in  the  conducting  path  (Lewis). 

A  iirirulori  utricular  extra-systoles  are  those  produced 
by  a  stimulus  acting  on  the  junctional  tissues  con- 
necting the  auricles  with  the  ventricles,  usually  per- 
haps the  auriculoventricular  node.  They  have  been 
produced  experimentally  and  are  believed  to  occur 
clinically.  They  form  a  link  between  auricular  and 
ventricular  extra-systoles  and  resemble  one  or  other 
of  these  according  to  their  exact  place  of  origin. 
As   already  stated   it   is  open   to   question  whether 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Arrhythmia,  Cardiac 


he  extra-systoles  shown   in   Fig.  338  should  be  re- 
garded   as    originating    low    down    in    the    auricle 
ir    in    the    junctional    tissues.     The    extra-systole 
town  in  Fig.  342  probably  originated   in  the  junc- 
ional  tissues,  but  is  of  the  ventricular  type  with  a 
ugh   combined    wave   A'.     It   differs   from    a  ven- 
ricular    extra-systole    in    that    the    wave    A'    comes 
the  auricular  contraction  is  due,  which  is  not 
■  til  the  vertical  dot  led  line  is  readied,  and  also  in 
hat  the  compensatory  pause  is  incomplete. 
In  a  ventricular  extra-systole  the  high   .1'  wave 
either  at  the  exact  time  the  auricular  wave  is 


1  to.  341. — Tracing  Taken  From  Same  <  'ase  as  Above.  Receiver 
I  on  neck  in  such  a  position  as  to  get  auricular  wave  of 
r  (.1)  added  to  carotid  arterial  tracing.  The  auricular 
belonging  to  the  extra-systole  is  masked,  but  the  shortened 
following  the  long  pause  is  well  seen  at  A".     The  intervals 

narked   above  are  in   1/5  second,   and  show  the  compensatory 

>ause  to  be  incomplete. 

Iue  or  else  sufficiently  long  after  the  ventricular 
beat  to  allow  of  conduction  backward  of  the  impulse. 
Moreover  the  compensatory  pause  is  usually  almost 

lite  complete. 
As  to  the  electrocardiagram  of  auriculoventricular 

i  systoles,  our  knowledge  is  limited  to  cases  in 
which  the  auricle  contracts  a  little  before  the  ventricle. 
In  these  eases  the  auricle  or  P  wave  is  inverted  on 

mt  of  the  stimulus  first  affecting  the  lower  part 
of  the  auricle,  the  P-R  (.4-1')  interval  is  reduced  and 
the  ventricular  complex  is  normal. 


symptoms,  while  others  complain  thai  their  heart 
gives  a  great  thump  or  that  il  seems  to  flutter  or 
I  top. 

Etiology  and  Prognosis. — The  writer  has  Been 
extra-systoles  in  a  great  variety  of  conditions.  They 
are  often  found  in  people  enjoying  excellent  health. 

I  ig.  332,   .1  and  />'.  were   taken  i'l'oiu   a  father  and  son 

aged  about  liity-iive  and  thirty,  in  good  health  and 
free  from  any  signs  of  heart  disease.  Fig.  340  waa 
taken  from  a  former  laboratory  boy  who  was  e - 

what   anemic   and    had    signs  of   old    rickets,    but    was 

otherwise  well.    Figs.  338  and  339  are  from  a  healthy 

youth  of  sixteen  who  had  no  symptoms  and  was 
able  to  play  football  and  run  races  up  to  220  yards. 
Fig.  342  was  from  a  man  of  forty-one  with  shortness 
of  breath  of  six:  months'  duration  following  physical 
overwork.  At  the  time  the  tracing  was  taken  he 
had  a  dilated  heart  and  pulmonary  edema.  1  have 
also  seen  extra-systoles  in  cases  of  indigestion, 
diabetes,  and  chronic  nephritis  and  in  menstruating 
women.  Mackenzie  has  found  them  common  in 
old  people  with  infrequent  pulse  and  cardiosclerosis, 
and  in  the  rheumatic  and  the  neurotic.  Extra- 
systoles  may  sometimes  be  attributed  to  excessive 
irritability  of  the  heart  muscle  which  may  be  present 
either  in  the  healthy  or  the  diseased,  sometimes 
it  may  indicate  the  action  of  a  mechanical  stimulus 
like  high  blood  pressure,  or  a  chemical  stimulus  from 
some  drug  or  poison  like  digitalis,  or  a  nervous  stim- 
ulus from  some  reflex  cause.  From  the  variety  of 
causes  which  may  give  rise  to  extra-systoles  it  can 
be  seen  that  in  any  given  case  their  significance  is 
hard  to  determine.  They  should  suggest  a  system- 
atic examination  of  the  patient,  including  an  esti- 
mation of  the  field  of  response.  If  there  are  no  other 
symptoms  or  signs  of  disease  their  presence  may  be 
disregarded. 

Treatment  of  extra-systoles  is  unnecessary.  If 
there  is  any  concomitant  disease,  whether  circulatory 
or  not,  it  should  be  attended  to.  The  writer  believes 
he  has  seen  temporary  relief  from  atropine  in  doses 
°f  tItt  grain  three  times  a  day  in  cases  where  the 
thumping  or  fluttering  of  the  heart  has  caused 
annoyance. 


Fig.  342. — Tracing  of  Extra-systole  at  X  Believed  to  be  Auricula-ventricular.  Large  wave  A'  can  only  be  explained  by  simulta- 
neous contraction  of  auricles  and  ventricles  and  it  differs  from  that  seen  in  ventricular  extra-systoles  in  that  it  occurs  before 
the  contraction  of  the  auricle  is  due.  The  arterial  pulse  is  poor  and  docs  not  show  the  extra  beat,  but  this  is  hardly  necessary. 
From  a  patient  of  Dr.  Ridley  .Mackenzie  with  chronic  bronchitis  and  dilated  heart. 


Sinus  extra-systoles  are  also  believed  to  occur  and 
experimental  work  has  been  done  on  them.  We  should 
expect  them  to  resemble  auricular  extra-systoles  but 
not  to  show  any  compensatory  pause.  Clinically  it 
would  be  impossible  to  distinguish  them  from  sinus 
arrhythmia  although  their  pathology  would  be 
different.  Sinus  extra-systoles  would  depend  on  a 
heterogenetic  stimulus  acting  before  the  homogenetic 
had  time  to  develop;  sinus  arrhythmia  in  its  restricted 
sense  is  due  to  the  homogenetic  stimuli  developing  at 
irregular  intervals  under  chronotropic  nerve  influence. 

Symptoms. — Many  patients  are  unconscious  of  any 


Auricular  fibrillation  is  the  most  important  of 
all  forms  of  arrhythmia  for  two  reasons.  It  is  the 
commonest  variety,  forming  about  fifty  per  cent,  of 
all  permanent  arrhythmias;  and  its  presence  offers 
clear  indications  for  treatment.  Our  knowledge  of 
auricular  fibrillation  has  been  a  gradual  growth, 
and  the  development  of  this  knowledge  is  marked 
by  the  various  terms  which  have  been  applied  to  it 
at  different  times.  Among  these  may  be  mentioned 
the  mitral  pulse,  the  irregular  pulse,  pulsus  irregu- 
laris perpetuus,  the  inception  of  the  rhythm  of  the 
heart   by   the   ventricle,   nodal   rhythm,   and   finally 


623 


Arrhythmia,  Cardiac 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


auricular  fibrillation.  We  are  indebted  to  James 
Mackenzie  for  most  of  our  knowledge  of  the  clinical 
farts,  one  of  the  most  important  contributions  in  any 
field  of  medicine  during  recent  years.  For  the  com- 
pletion of  our  knowledge  of  the  pathology  we  are 
under  obligation  to  Cushny  and  Edmunds  and 
especially  to  Thomas  Lewis. 

Auricular  fibrillation  is  sometimes  spoken  of  as 
the  absolutely  or  completely  irregular  pulse  and  these 
terms  very  well  describe  the  features  found  on  exam- 


Fig.  343. — Tracing  from  Case  of  Auricular  Fibrillation.  Points 
marked  in  venous  pulse  correspond  in  time  to  systolic  waves  in 
arterial  pulse.  Allowing  for  delay  in  conduction  to  the  elbow  the 
large  waves  in  the  venous  pulse  are  seen  to  be  systolic  in  time. 
There  are  no  auricular  waves  and  no  negative  waves  in  early 
systole.  These  facts  mark  the  venous  pulse  as  of  the  ventricular 
form  and  taken  with  the  irregularity  justify  a  diagnosis  of 
auricular  fibrillation. 

ination  of  the  radials.  The  radial  pulse  in  an  un- 
treated case  is  usually  frequent,  varying  in  rate  from 
100  to  200  per  minute.  In  exceptional  cases  slower 
rates  are  found.  The  pulse  beats  are  felt  at  irregular 
intervals  and  vary  greatly  in  strength.  On  listening 
over  the  heart  we  often  find  the  heart  rate  greater 
than  the  radial  pulse  gave  us  to  expect,  on  account 
of  many  beats  being  too  weak  to  reach  the  peripheral 
arteries  or  even  to  open  the  semilunar  valves.  The 
sounds  heard  are  irregular  in  rhythm  and  vary  in 


1  see 


RBr 
2 


Fig.  344. — Tracing  from  Case  of  Auricular  Fibrillation  under 
Influence  of  Digitalis.  In  the  early  part  of  tracing  the  beats  show 
a  characteristic  coupling  and  a  frequency  averaging  6S  per  minute. 
In  the  latter  part  of  the  tracing  the  coupling  has  disappeared 
and  the  rate  has  increased  to  about  106.  (Patient  referred  by 
Dr.  Garrow.) 

loudness  from  beat  to  beat.  Many  of  them  are 
short  and  sharp  like  extra-systoles.  They  may  or 
may  not  be  accompanied  by  murmurs. 

Under  appropriate  treatment  the  rate  of  the 
heart  may  become  less  frequent.  The  ventricular 
rhythm  may  ultimately  become  very  slow  and  fairly 
regular,  resembling  that  seen  in  complete  heart 
block,  and  we  may  notice  the  beats  occurring  in 
couples.  Simultaneous  tracings  from  arteries  and 
veins  show  a  venous  pulse  of  the  ventricular  form 

624 


without  any  auricular  wave  and  without  any  negative 
wave  X.  Fig.  34.3  shows  tracings  from  a  man  of 
forty-eight  with  a  dilated  heart,  but  without  any 
murmurs  or  any  history  of  rheumatism.  This 
tracing  was  taken  before  starting  treatment.  When 
the  patient  came  into  the  office  his  pulse  was  132 
but  when  the  tracing  was  taken  it  had  slowed  down 
to  120. 

Fig.  344  shows  tracings  from  a  young  man  of 
twenty-two  with  mitral  stenosis  and  dilated  heart, 
following  rheumatic  fever.     Two  months  before  this 


Fig.  345. — Tracing  from  Man  of  Seventy  Recovering  from  an 
Attack  of  Heart  Failure  with  Dyspnea  and  Edema.  At  time  of 
tracing  edema  was  gone:  dyspnea  was  noticed  only  on  exertion, 
heart  was  moderately  dilated,  no  murmurs,  diagnosed  as  myo- 
carditis. Pulse  is  irregular  and  venous  pulse  is  of  ventricular 
form.  Small  waves  of  auricular  fibrillation  are  noticed  in  some 
parts  of  venous  pulse  (A') . 

tracing  was  taken  the  patient  had  suffered  with 
severe  dyspnea  even  during  rest  and  was  compelled 
to  stay  in  bed  for  several  weeks.  Under  rest  and 
digitalis  he  improved  remarkably  so  that  he  attended 
college,  was  able  to  take  long  walks,  and  even  attended 
one  or  two  dances.  A  few  months  later,  however, 
he  had  another  attack  of  rheumatic  fever  which 
failed  to  respond  to  salicylates  and  he  died  after  a 
month's  illness.  In  some  cases  of  auricular  fibrilla- 
tion the  venous  pulse  may  approach  the  arterial 
form  as  seen  in  Fig.  345,  from  an  old  man  with 
myocarditis. 


R.I.J. 

c 

^J^.PC 

9 1 

1X     * 

c 

JJUJL    r 

1 

l.Br. 

1 

A^V 

/> 

Fig.  346. — Tracing  from  a  Case  of  Arrhythmia.  The  arterial 
pulse  is  like  that  seen  in  auricular  fibrillation,  but  the  venous 
pulse  is  not  of  the  typical  ventricular  form.  The  X  negative 
wave  is  sometimes  well  shown  and  the  carotid  wave  is  sometimes 
preceded  by  a  wave  which  may  be  auricular  (?).  Dunn-  the 
long  pause,  however,  a  number  of  small  waves  are  seen  which  are 
probably  due  to  frequent  contractions  in  the  auricle,  eitbtr 
fibrillation  or  flutter. 

This  patient  improved  remarkably  on  digitalis 
and  enjoyed  life  and  was  able  to  take  walks  for  somi 
months.  He  passed  from  under  observation  for  a 
time  and  discontinued  the  digitalis.  He  died  about 
a  year  later  from  another  attack  of  heart  failure 
following  influenza. 

Occasionally  the  venous  tracing  of  auricular  fibril- 
lation shows  a  succession  of  small  waves  during  the 
diastolic  pause.  These  are  seen  to  a  slight  extent  in 
Fig.  345,  but  better  in  Fig.  346.  They  are  usually 
referred    to   fibrillary   contractions   occurring  in   the 


REFERENCE    HANDBOOK    OF   Till:    MEDICAL   S(  1 1 :X<  1  :s 


Arrhythmia,  Cardiac 


uricle.  In  Fig.  346  a  negative  waveXmay  be  noticed 
i  early  systole.  This  does  not  necessarily  mean 
!uit  the  auricles  are  contracting  and  relaxing  in  a 
ormal  manner  as  the  negative  wave  .V  has  a  double 
ausation.  It  is  partly  due  to  the  drawing  in  of 
ilood  from  the  veins  by  the  auricular  diastole,  and 
artly  to  the  enlargemenl  of  the  auricle  by  the  <!<■- 
i  iriculoventricular  junction  in  ventricular 
•.  stole.  In  the  present  case  it  may  be  largely  due  to 
be  latter  cause,  but  further  remarks  on  this  ca 
,.  found  under  auricular  flutter.  The  patient  is  a 
oung  man  of  twenty-four  who  is  going  about  and 
irnine  his  living  as  a  custom  house  clerk  nearly  two 
ears  after  the  tracing  was  taken.  He  has  a  history 
I  rheumatism,  a  dilated  heart,  and  a  mitral  systolic 
nirmur. 

The  electrocardiagram  is  the  final  court  of  appeal 
-  of  auricular  fibrillation.  An  example  is 
down  in  Fig.  347.  It  shows  an  absence  of  the 
..ratal  P  wave  due  to  the  auricular  systole,  ami  in 
g  place  a  succession  of  small  waves  similar  to  those 
een  iu  animals  when  the  auricles  are  put  into  a  con- 


Fig.  347. — Electrocardiagram  from  a  Case  of  Auricular  Fibrilla- 
m.  Taken  from  the  right  arm  and  left  leg.  Patient  with  mitral 
enosis  of  rheumatic  origin.  Completely  irregular  heart  action  and 
10  ventricular  form  of  the  venous  pulse  were  present.  Note  that 
.  place  ot  the  normal  P  wave  there  are  a  number  of  small  oscilla- 
onsdueto  the  fibrillating  auricle.  Note  also  the  normal  character 
!  the  ventricular  complex.  Compare  with  the  normal  electro- 
Lrdiagram  in  Fig.  32S,  Lead  II.  (Fig.  taken  from  Lewis,  Auricular 
ibrUlatioa,  etc.,  Heart,  Vol.  I,  Xo.  4.) 

lition  of  fibrillation  by  the  faradic  current.  The 
■icture  given  by  cases  of  this  kind  of  arrhythmia 
:i  man  is  so  similar  to  that  seen  in  experimental 
ibrillation  in  animals  that  there  seems  no  room  for 
ing  that  a  similar  condition  is  present. 

We  have  to  picture  to  ourselves  the  auricles  con- 
racting  piecemeal,  the  waves  following  one  another 
n  an  irregular  manner  and  in  rapid  succession.  The 
tnpulses  generated  by  these  contractions  are  thrown 
nto  the  bundle  of  His  at  the  rate  of  some  hundreds 
ier  minute  and  overtax  the  ability  of  the  bundle  to 
onduct  and  of  the  ventricle  to  respond.  The  result 
<  that  the  bundle  conducts  as  many  as  it  can  and 
he  ventricle  responds  as  often  as  it  is  able,  but  not 
n  any  regular  way.  Hence  the  irregular  ventricular 
iction  seen  in  these  cases. 

Etiology  and  Pathology. — Auricular  fibrillation  is 
een  in  a  variety  of  conditions.  In  the  young  it  is 
often  seen  in  association  with  old-standing 
nitral  stenosis.  It  is  an  important  observation  of 
Mackenzie's  that  in  these  cases  the  presystolic  mur- 
mir  is  not  heard.  As  it  is  dependent  on  the  systole 
>f  the  auricles  it  disappears  when  these  chambers 
ass  into  fibrillation  and  cease  to  contract  in  any 
ffective  manner.  We  usually'  find  the  presystolic 
nurmur  replaced  by  a  diastolic  murmur  which  is 
troduced   while   the  blood   is  being   drawn   through 

■  constricted  opening  by  the  diastole  of  the  ven- 
ricle.  Auricular  fibrillation  is  still  commoner  in 
niddle  and  advanced  life  as  a  result  of  degenerative 
and  is  often  seen  without  any  indication  of 
.alvular  disease  being  present.  The  postmortem 
indings  in  auricular  fibrillation  have  been  mostly 
if  the  nature  of  fibrous  degeneration  of  the  heart 
nuscle,  especially  that  of  the  auricles.  In  a  number 
<  the  changes  have  been  well  marked  at  the 
junction  of  the  superior  vena  cava  and  right  auricle 
[S-A  node). 

The  symptoms  complained  of  are  chiefly  various 
of    shortness    of     breath.     Some     patients 


complain  of  feeling  a  fluttering  or  thumping  of  the 
heart  and  can  state  the  day  and  hour  when  the  irregu- 
larity suddenly  began. 

/'  agnosia. —  When  the  arterial  pulse  is  absolutely 
irregular  in  volume  and  rhythm  and  the  heart  Bounds 
also  show  great  irregularity,  auricular  fibrillation 
should   be  strongly  suspected.     When  at    the  same 

time  the  venous  pulse  is  found  to  be  of  the  ventric- 
ular form  the  diagnosis  is  almost  certain.  Whet,; 
an  electrocardiagram  can  be  taken  and  the  /'  v.. 
are  found  to  be  replaced  by  a  succession  of  smaller 
waves  the  diagnosis  is  fully  confirmed.  Where 
cardiac  compensation  is  good  the  veins  of  the  neck 
may  be  too  empty  to  give  a  good  venous  pulse  (racing 
ami  we  may  have  to  base  our  diagnosis  on  the  arterial 
pulse  and  heart  sounds  alone.  With  a  little  experi- 
ence i  hese  are  sufficient  for  nil  practical  purposes. 

Prognosis. — Sometimes  this  form  of  irregularity 
occurs  in  attacks  of  shorter  or  longer  duration  and 
there  is  a  return  to  the  normal  rhythm.  In  the 
majority  of  cases,  however,  when  once  established 
it  is  permanent.  The  prognosis  in  any  given  - 
must  be  based  on  the  degree  of  heart  failure  present. 
In  some  cases  the  fibrillation  of  the  auricles  repre- 
sents one  of  the  last  s;a!j,.^  ;n  the  downward  path 
of  a  case  of  heart  failure.  In  other  c:i-r-  the  patient 
may  live  for  many  years  in  restricted  activity,  but 
comfortable  and  able  to  earn  a  living.  Of  thirteen 
unselected  cases  taken  from  my  notes  of  the  past 
year  or  two,  six  died,  two  have  been  lost  sight  of,  and 
five  are  still  under  observation. 

Of  those  who  died  one  was  under  observation  two 
months  and  died  from  cardiac  failure  accompanied  by 
tricuspid  regurgitation  and  signs  of  venous  stasis. 
One  under  observation  for  five  months  died  of  chronic 
nephritis.  One  under  observation  for  seven  months 
died  of  rheumatic  fever  after  being  temporarily  re- 
stored to  activity.  One  a  year  after  being  first  seen 
died  from  multiple  emboli  following  mitral  stenosis. 
One  died  a  year  after  my  first  visit  from  heart  failure 
accompanying  an  influenzal  pneumonia.  One  at  the 
end  of  two  years,  during  which  I  had  several  times 
helped  to  restore  compensation,  died  under  another 
physician  from  heart  failure  which  was  proved  post- 
mortem to  be  due  to  a  chronic  fibroid  myocarditis. 
Of  the  five  alive  two  men  are  earning  their  living, 
one  old  man  of  seventy-one  is  enjoying  fair  health 
at  home,  one  woman  is  keeping  a  boarding  house, 
and  one,  a  married  woman,  is  able  to  do  housework 
and  walk  considerable  distances  at  a  leisurely  pace. 
One  of  the  men  has  had  the  irregularity  for  twelve 
years  to  my  knowledge. 

Treatment. — Auricular  fibrillation  is  the  condition 
in  which  rest  and  digitalis  give  their  most  brilliant 
results.  If  there  are  no  symptoms  of  heart  failure  it 
is  necessary  only  to  enjoin  caution  in  the  way  of 
physical  and  mental  work,  to  bring  the  heart  rate 
down  to  seventy  or  less  with  digitalis  and  to  keep 
it  there.  In  cases  of  noticeable  heart  failure,  as  shown 
by  shortness  of  breath  on  exertion,  by  marked  dila- 
tation, or  venous  engorgement,  a  rest  in  bed  should 
be  insisted  on.  Three  weeks'  rest  in  bed  is  sufficient 
for  some  cases  but  many  need  longer  than  this. 
During  the  time  the  patient  is  in  bed  the  opportunity 
should  be  taken  of  getting  the  heart  under  the  in- 
fluence of  digitalis.  The  form  of  digitalis  is  not  so 
important  as  the  selection  of  the  proper  case  and 
most  cases  of  auricular  fibrillation  will  be  found  to 
be  proper  cases  for  it.  Mackenzie  uses  the  tincture 
in  closes  of  twenty  minims  three  times  daily  until 
results  are  obtained.  Less  than  this  will  often  suffice, 
especially  if  time  is  not  important.  He  also  uses 
Nativelle's  granules  containing  one-fourth  milligram, 
three  times  daily.  I  have  used  both  these  prepara- 
tions as  well  as  the  infusion  and  several  proprietary 
preparations.  In  most  cases  any  of  them  will  give 
results  in  proper  doses. 

Digitalis  should  be  pushed  until  the  heart  is  slowed 


Vol.  I.— 40 


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down  to  the  point  where  the  patient  feels  best, 
which  will  be  found  somewhere  between  forty  and 
seventy  per  minute.  The  most  desirable  rate  of 
heart  beat  cannot  be  arbitrarily  stated  but  differs  with 
individual  peculiarities.  In  each  case  it  must  be 
determined  by  the  sensations  of  the  patient  and  the 
general  experience  of  the  physician.  The  inexperi- 
enced physician  should  be  cautious  and  watchful  when 
the  rate  gets  below  seventy.  For  the  full  effect  of 
digitalis  to  be  obtained  the  patient  must  be  under 
close  observation,  as  otherwise  toxic  symptoms  may 
develop  and  the  patient  may  be  afraid  to  persevere 
with  the  drug.  Among  indications  for  discontinuing 
digitalis  are  vomiting,  diarrhea,  dryness  of  the  mouth, 
aphasia,  drowsiness,  and  partial  heart-block.  When 
all  goes  well  digitalis  should  be  continued  until  the 
desired  rate  of  heart  beat  is  attained  and  then  the 
dose  should  be  reduced  to  the  amount  necessary  to 
keep  the  pulse  rate  under  control.  This  is  usually 
one-third  or  one-quarter  the  daily  amount  which  was 
necessary  to  slow  it  down.  Some  patients  may  need 
one  Nativelle's  granule  daily  or  twenty  minims  of  the 
tincture,  others  only  need  a  granule  every  two  or 
three  days  or  five  or  ten  minims  of  the  tincture  daily. 
These  smaller  doses  should  be  continued  as  long  as 
the  patient  lives  and  he  should  be  taught  to  regulate 
the  dose  by  his  symptoms.  The  action  of  digitalis 
in  these  cases  is  believed  by  Lewis  to  be  that  of  pro- 
ducing partial  heart-block  and  protecting  the  ven- 
tricles from  the  multiplicity  of  stimuli.  This  allows 
the  ventricles  to  beat  with  a  more  leisurely  rhythm 
which  conserves  their  energy  and  yet  enables  them  to 
maintain  a  better  circulation.  In  cases  in  which 
digitalis  cannot  be  taken,  which  are  fortunately  rare 
among  those  showing  auricular  fibrillation,  the  prog- 
nosis is  bad.  They  must  be  given  a  longer  rest  and 
have  their  strength  kept  up  by  tonics  such  as  a  com- 
bination of  iron,  arsenic,  and  strychnine.  In  some 
cases  adrenalin  seems  to  be  serviceable  in  doses  of 
twenty  to  thirty  minims  of  the  1-1,000  solution 
every  two  hours  by  the  mouth,  or  half  as  much  hy- 
podermicaUy.  In  cases  of  very  violent  heart  action 
with  frequent  pulse  and  great  distress  a  hypodermic 
of  morphine  gr.  J  with  atropine  gr.  Tlj  will  often 
give  relief. 

Auricular  Flutter. — Jolly  and  Ritchie  believe  that 
in  some  cases  the  auricles  may  beat  regularly  and  in 
their  entirety  but  with  a  frequency  of  200  or  300  per 
minute.  To  this  condition  they  give  the  name  of 
auricular  flutter.  In  the  cases  they  report  heart 
block  was  present  but  it  is  conceivable  that  such  a 
condition  might  exist  without  heart  block  and  give 
a  clinical  picture  scarcely  distinguishable  from  auric- 
ular fibrillation.  It  is  possible  that  we  have  such  a 
condition  in  Fig.  346,  where  the  small  waves  f,f,f, 
due  to  the  auricles  are  so  pronounced  a  feature. 

Nodal  rhythm  was  the  term  used  for  a  year  or  two 
by  Mackenzie  to  describe  cases  of  auricular  fibril- 
lation, in  the  belief  that  the  auricles  and  ventricles 
were  contracting  together  under  the  influence  of 
a  stimulus  originating  in  the  auriculoventricular 
node.  Since  the  real  nature  of  these  cases  has 
been  demonstrated  Lewis  has  come  forward  with  the 
statement  that  there  are  cases  corresponding  to  the 
condition  Mackenzie  had  in  mind  when  he  invented 
the  term  and  which  may  properly  be  called  cases 
of  nodal  rhythm.  Lewis  refers  to  a  case  of  Rihl's 
and  gives  one  of  his  own.  He  also  describes  an  experi- 
mental example.  The  main  feaures  are  that  auri- 
cles and  ventricles  contract  more  or  less  together, 
giving  high  combined  waves  in  the  venous  pulse, 
and  the  electrocardiagram  shows  a  normal  ventricular 
and  an  inverted  auricular  complex  with  shortened 
I'-R  interval. 

Tachycardia. — This  term  has  been  used  by  many 
authors  in  the  sense  of  frequent  heart  action  under 
whatever  circumstances  it  may  occur.  Among  the 
examples    which    naturally    suggest    themselves   are 


fever,  overexertion,  anemia,  organic  disease  of  the 
heart,  exophthalmic  goiter,  and  a  variety  of  emo- 
tional, reflex,  and  mechanical  disturbances  which 
will  be  discussed  in  the  article  on  functional  dis- 
orders of  the  heart.  In  all  these  cases  the  normal 
origin  (homogenetic)  and  sequence  of  the  heart  beat 
are  preserved,  but  beyond  this  they  have  little  in 
common  and  the  advantage  of  grouping  them  to- 
gether under  one  head  is  doubtful. 

Paroxysmal  Tachycardia  is  quite  another  matter. 
It  occurs  in  several  varieties  but  they  have  much  in 
common  both  clinically  and  pathologically.  It  may 
be  spoken  of  as  heterogenic  tachycardia  because  the 
heart  rhythm  is  due  to  abnormal  stimuli  which,  so 
far  as  yet  observed,  seem  to  be  of  a  different  nature 
from  the  normal  stimulus  and  act  upon  other  parts 
than  the  usual  "pace  maker."  Our  knowledge  of 
this  form  of  arrhythmia  is  still  limited  and  the  fol- 
lowing account  presents  a  somewhat  dogmatic  sum- 
mary of  current  opinion,  but  is  in  no  way  to  be  taken 
as  final. 

Paroxysmal  tachycardia  is  characterized  by  sud- 
den attacks  of  frequent  heart  action  which  last  for 
minutes,  hours,  or  days  and  then  cease  almost 
suddenly  as  they  begin.  During  the  attack  the 
pulse  rate  is  usually  very  high,  reaching  150  or  evi  D 
200  per  minute.  It  is  frequently  uncountable.  ]  i 
some  cases  the  increase  of  rate  represents  an  exact 
doubling  or  tripling  of  the  preexistant  rate  but  the 
frequency  of  this  occurrence  has  probably  been 
exaggerated.  During  the  attack  the  patient  may 
or  may  not  be  conscious  of  fluttering  of  the  hei 
and  sometimes  complains  of  precordial  distress  or 
pain.  As  a  rule  the  sensory  symptoms  are  slight 
in  comparison  to  the  motor  disturbance,  while  in 
palpitation  of  the  heart  the  reverse  is  the  case.  The 
breath  is  short,  especially  on  exertion.  The  short- 
ened diastole  does  not  give  the  heart  time  to  fill  - 
that  the  circulation  suffers.  The  arteries  are  com- 
paratively empty,  the  face  is  pale  and  the  vei 
engorged.  In  the  later  stages  the  liver  may  be 
enlarged  and  there  may  be  edema  of  the  legs  and 
lungs.  The  heart  too  may  become  dilated  and 
signs  of  tricuspid  regurgitation  are  often  found.  In 
attacks  of  short  duration  there  may  not  be  time  for 
many  of  these  signs  and  symptoms  to  develop. 

The  arterial  pulse  may  be  regular  or  irregular.  The 
rate  is  frequently  between  150  and  200  but  may  vary 
considerably  during  an  attack.  It  is  wise  to  confirm 
the  rate  by  listening  over  the  heart,  as  some  of  the 
pulse  waves  may  not  reach  the  wrist  with  sufficient 
force  to  be  palpable.  An  examination  of  venous 
pulse  tracings  throws  considerable  light  on  the  nature  j 
of  a  case  but  does  not  always  make  it  perfectly  clear. 
The  electrocardiagram  is  a  great  help  when  available. 

The   cases  of  paroxysmal   tachycardia  so  far  re- 
ported fall  under  the  head  of  either  extra-systoles  or 
auricular  fibrillation.     Most  of  them  may  be  classed 
as  due  to  extra-systoles  occurring  in  a   long  sei 
and  starting  from  a  single  focus  in  rapid  succession. 
The  seat  of  origin  may  be  in  almost  any  part  of  the 
auricles     or     junctional     tissues     and     more    rarely 
in  the  ventricles.     Some  cases  on  analysis  prove  1 1 
examples  of  auricular  fibrillation.     All  the  varieties 
have  much  in  common.     All  are  due  to  heterogenetic 
or  abnormal  stimuli  acting  upon  the  heart   muscle. 
The  difference  between  a  succession  of  extra-systi 
and  auricular  fibrillation  is  largely  one  of  degree.     In 
the  former  the  stimuli  affect    a   single  focus,  in    the 
latter    a    number    of    different    foci    simultaneously. 
The  differentiation  of  the  several  varieties  is  to  be 
made  by  the  examination  of  venous  tracings  and 
electrocardiagram.     The    general    characters    ot 
graphic  records  are  similar  to  those  already  descrii 
for  extra-systoles  and  auricular  fibrillation,  but 
tain  difficulties  arc  introduced  by  the  frequent  rate. 
The  different  waves  of  the  venous  pulse  are  crowded 
together.     The  auricular  wave  may  be  superimposed 


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Arrhythmia,  Cardiac 


ipon  the  ventricular  wave,  or  even  upon  the  carotid 

vave  of  the  preceding  cardiac  cycle.     In  the  latter 

,.,-  ii  may  be  hard  to  determine  whether  the  blend- 

Mc  of  auricular  and  carotid  waves  is  to  be  explained 

iy  the  auricular  wave  falling  upon  the  carotid  wave 

if  the  preceding  cycle  on  account  of  the  great  fre- 

of  the  heart  rate,  or  by  a  simultaneous  con- 

i  of  the  two  chambers  from  a  stimulus  alfeet- 
QB  the  junctional  tissues.  In  cases  due  to  auricular 
ibrillation  the  proper  auricular  waves  are  ali.-ent  and 
lie  venous  pulse  is  of  the  ventricular  form.  Before 
leciding  that  the  auricular  waves  are  absent  one 
■.elude  the  possibility  of  their  being  present 
cured  by  combination  with  other  waves  as 
•xplained  above.  Light  is  frequently  thrown  on  a 
ase  by  the  occurrence  of  single  extra-systoles  before 
ir  after  an  attack.  These  single  extra-systoles  often 
iriginate  at  the  same  focus  as  those  of  the  paro 

.,1  may  help  to  localize  the  point  from  which  the 
utter  start.  Some  cases  are  complicated  by  the 
e  of  partial  heart  block.  This  fact  may 
xplain  some  instances  of  exact  doubling  or  trebling 
>f  the  rate  which  has  been  ascribed  to  a  sudden 
cturn  to  normal  conductivity.  In  some  cases  of 
achycardia  we  find  an  alternating  pulse  due  to  a 
ailure  of  contractility. 

The  electrocardiagram  like  the  venous  pulse  is 
complicated  by  the  fact  that  the  auricular  complex 
lay  be  combined  with  some  part  of  the  ventricular 
omplex.  Where  the  paroxysmal  beats  originate 
a  the  auricle  the  P  wave  may  be  seen  in  its  normal 
nisition  but  is  liable  to  be  combined  with  the  T 
eave  of  the  preceding  cycle.  It  is  often  inverted. 
tYhcre  the  focus  is  in  the  A-Y  node  the  P-R  (.1-1) 
nterval  is  shortened  or  absent.  In  the  latter  case 
lie  P  and  fl  waves  fall  together  and  may-  be  difficult 
o  analyze.  Where  the  focus  is  in  the  ventricle  the 
entricular  complex  will  be  found  of  abnormal  form 
ike  those  shown  in  Fig.  338  but,  as  similar  pictures 
ire  occasionally  seen  where  the  auricles  are  the  seat 
if  the  disturbance,  caution  must  be  exercised  in 
(rawing  conclusions.  For  further  information  about 
he  electrocardiagram  in  these  cases  the  reader  is 
eferred  to  "The  Mechanism  of  the  Heart  Beat"  by 
Lewis,  as  the  subject  is  too  difficult  to  treat  in  a  short 
summary  like  this. 

In  Fig.  348,  A  and  B  pulse  tracings  are  shown 
rom  a  case  of  paroxysmal  tachycardia  during  and 
ifter  an  attack.  The  patient,  a  man  of  forty-one, 
same  to  my  office  October  24,  1910,  complaining  of 
i  heavy  feeling  in  the  epigastrium,  shortness  of 
ireath  and  inability  to  lie  on  his  back  or  left  side. 
Symptoms  began  suddenly  six  days  before  without 
my  known  cause.  He  had  had  a  similar  attack  four 
nonths  previously  lasting  two  days.  The  pulse 
ivas  found  to  be  irregular  and  to  vary  in  rate,  being 
sometimes  uncountable.  The  apex  beat  was  outside 
he  nipple;  the  heart  sounds  were  embryonic  in 
haracter.  A  murmur  was  heard  from  time  to  time 
ivhich  was  found  later  to  be  systolic  in  time  and  best 
Heard  at  the  apex.  The  tracing  shown  in  Fig.  348, 
1.  was  taken.  He  was  sent  home  to  rest  and  given 
incture  of  strophanthus  (strophanthone)  in  ten- 
minim  doses  every  three  hours. 

The  next  day,  October  2.5,  he  reported  that  he  had 
felt  better  a  few  hours  after  going  home  and  was 
able  to  lie  on  his  left  side.  His  pulse  was  S4  and 
regular. 

October  26,  pulse  65,  regular.  Pulse  tracings 
shown  in  Fig.  34S,  B,  taken. 

October  29,  pulse  70.  Apex  beat  in  nipple  line, 
c  murmur  still  heard  at  apex.  Felt  all  right. 
Passed  from  observation. 

Comparing  the  tracings  taken  during  and  after  the 
attack.  Fig.  348,  A  and  B,  we  seem  justified  in 
marking  as  partly  auricular  the  pointed  waves  A' 
seen  in  .4.  These  occur,  however,  at  the  time  of 
the  ventricular  systole   and  are  superimposed  upon 


the  carotid  waves.  As  they  preserve  this  relative 
position  with  varying  lengths  of  pulse  intervals,  they 
must  belong  to  tin-  same  cardiac  cycle  as  the  carotid 
es  on  which  they  fall.  These  facts  justify  us 
I  think  in  classing  this  case  as  due  to  extra-systoles 
originating  in  the  junctional  tissues  in  or  near  the 
.1-1     node.      (in    account    of    1  he   difficulty   of   getting 

good  tracings  of  the  -mull  frequent   waves  in   I 

cases  there  ts  often  room  for  difference  of  opinion  as 
to  the  interpretation  of  the  tr;n-itiL.'s.     in  th 
of  facilities  for  taking  an  electrocardiagram  we  have 
often    to    depend    a   good    deal    on    circumstantial 

evidence. 


Fig.  34S,  A  and  B. — Tracings  from  a  Case  of  Paroxysmal 
Tachycardia  During  and  After  an  Attack.  R  I  J,  Right  internal 
jugular;  R.  Br,  right  brachial  artery.  The  upper  figure  is  marked 
with  vertical  lines  marking  what  are  believed  to  be  the  beginnings 
of  the  brachial  pulse  beats  and  the  points  in  the  venous  pulse 
corresponding  to  these  in  time.  Allowing  for  delay  in  trans- 
mission the  A'  waves  are  seen  to  be  systolic  in  time  and  by  com- 
parison with  the  tracing  below  seem  to  be  partly  auricular  in 
origin.  The  pulse  rate  in  Fig.  A  is  about  190  to  200  per  minute. 
Patient  of  Dr.  Herbert  Tatley. 

Pathology. — A  disordered  action  of  the  heart 
resembling  paroxysmal  tachycardia  may  be  induced 
in  animals  by  tying  branches  of  the  coronary  arteries 
or  by  applying  the  strong  faradic  current  to  the 
auricles.  It  does  not  seem  possible  to  produce  the 
same  result  by  any  procedure  directed  to  the  nerves 
when  the  heart  is  in  a  normal  condition.  There  is 
some  evidence  however  that  an  attack  may  be  pre- 
cipitated by-  stimulation  of  the  cardiac  nerves  when 
the  heart  is  already  in  an  abnormal  condition.  The 
postmortem  changes  are  not  constant.  In  different 
cases  valvular  disease,  coronary  sclerosis,  degenera- 
tion of  the  heart  muscle,  and  various  nerve  lesions 
have  been  found  and  in  still  other  cases  the  findings 
have  been  negative.  We  have  to  admit  that  we  are 
ignorant  of  any  constant  underlying  cause.  The 
principal  seat  of  the  disease  is  probably  in  the  heart 

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muscle,  but  emotional  and  reflex  causes  have  an 
undoubted  influence  in  precipitating  attacks. 

Diagnosis. — Paroxysmal  tachycardia  has  to  be 
distinguished  from  simple  acceleration  of  the  heart 
due  to  anemia,  fever,  exophthalmic  goiter,  etc.,  from 
persistent  frequency  of  the  heart  rate  and  from 
palpitation. 

The  diagnosis  rests  on  the  occurrence  of  the  attacks 
in  recurring  paroxysms,  the  high  rate  suddenly 
attained,  the  comparative  absence  of  sensory  phe- 
nomena such  as  are  common  in  palpitation,  and  the 
evidence  in  the  venous  pulse  and  the  cardiogram 
that  the  pace  maker  of  the  heart  has  been  changed. 

Prognosis. — The  prognosis  depends  to  a  great 
extent  on  the  duration,  severity  and  frequency  of  the 
attacks  in  individual  cases.  A  number  of  cases  have 
been  reported  in  which  recovery  occurred,  others  have 
had  repeated  attacks  for  years  without  life  being 
endangered,  and  in  others  the  attacks  have  exhausted 
the  heart  and  led  after  one  or  more  seizures  to  a 
fatal  termination.  Sometimes  the  tachycardia 
becomes  permanent  for  a  while  before  death  occurs. 
The  best  guide  to  prognosis  is  the  extent  to  which 
indications  of  heart  failure  appear.  Of  these  the  most 
important  are  dilatation  of  the  heart,  shortness  of 
breath,  enlargement  of  the  liver,  and  dropsy. 

Treatment. — Many  methods  have  seemed  to  succeed 
in  individual  cases  and  none  is  of  universal  applica- 
bility. Absolute  rest  seems  indicated  and  is  usually 
to  be  recommended  although  Fairbrother  found  in 
his  own  case  that  violent  exercise  cut  short  the 
attacks  better  than  anything  else.  The  most  ap- 
proved measures  have  as  their  primary  object  the 
stimulation  of  the  vagus.  This  may  often  be  accom- 
plished by  mechanical  means.  Success  in  varying  de- 
grees has  been  reported  from  swallowing  movements, 
from  Valsalva's  experiments  of  taking  a  deep  breath 
and  exerting  strong  expiratory  pressure  against  a 
closed  glottis,  and  from  pressure  against  the  verte- 
bral column  of  one  or  other  vagus  nerve  where  it  lies 
beside  the  carotid  artery  outside  the  thyroid  cartilage. 
These  mechanical  methods  succeed  best  at  the  begin- 
ning of  an  attack.  Where  they  fail  strophanthus 
may  be  tried  either  intravenously  or  by  the  mouth. 
Digitalis  acts  well  in  some  cases  and  is  probably 
safer  than  strophanthus,  albeit  a  little  slower.  'Where 
all  these  measures  fail  a  trial  may  be  made  of  nerve 
sedatives  like  morphine,  bromides,  or  valerian.  An 
ice-bag  applied  to  the  precordium  has  been  recom- 
mended. Between  the  attacks  any  derangement  of 
the  nervous,  digestive,  or  sexual  systems  should'  be 
appropriately  treated  and  the  general  health  should 
be  looked  after.  Excesses  in  food  and  beverages 
should  be  warned  against  and  overstrain  of  all  kinds 
forbidden.  The  possibility  of  emotional  and  mental 
strain  should  be  considered.  If  any  organic  disease 
of  the  heart  is  present  it  may  require  attention. 
Heart  failure  may  be  combated  by  rest  and  digitalis. 
The  results  of  treatment  should  be  published  as  more 
light  is  needed. 

Heart-block  is  a  form  of  arrhythmia  which 
looms  up  too  large  in  the  perspective  of  most  physi- 
cians. It  may  be  that  the  term  is  catchy  and  easily 
understood,  or  it  may  be  that  it  has  borrowed  im- 
portance from  the  great  names  of  the  past  which 
have  been  associated  with  it.  To  many  it  is  one  of 
the  first  things  thought  of  when  an  irregular  pulse  is 
encountered  and  yet  it  is  comparatively  rare.  In 
any  large  general  practice  sinus  arrhythmia,  extra- 
systoles,  and  auricular  fibrillation  must  be  of  al- 
most daily  occurrence  but  months  and  even  years 
may   pass   before  a  single  case  of  heart-block  is  seen. 

Definition  ami  Subdivisions. — Heart-block  may  be 
defined  as  a  solution  of  physiological  continuity  be- 
tween different  parts  of  the  heart.  Under  heart- 
block,  however,  it  is  convenient  to  consider  all  con- 
ditions attended  bv  a  depression  of  conductivity. 

628 


The  following  subdivisions  may  be  made: 

According  to  location. 

1.  Sinoauricular  heart-block. 

2.  Auriculoventricular  heart-block. 

3.  Intraventricular  heart-block. 
According  to  degree. 

1.  Lengthened  conduction  time. 

2.  Partial  heart-block. 

3.  Complete  heart-block. 

Auriculoventricular  heart  block  which  is  the  com- 
monest and  most  important  form  will  be  considered 
first  in  the  three  degrees  in  which  it  occurs. 

Lengthened  A-Y  Interval. — The  A-V  interval  may 
be  measured  by  calculating  the  time  from  the  begin- 
ning  of  the  A  wave  (auricular  systole)  to  the  beginning 
of  the  C  wave  (ventricular  systole)  in  the  venous  pulse, 
see  Figs.  327,  331,  340.  It  may  also  be  estimated 
by  calculating  the  time  from  the  beginning  of  the  P 
wave  to  the  beginning  of  the  R  wave  in  the  electro- 
cardiagram  {P-R  interval).  This  is  rendered  pos- 
sible by  the  fact  that  a  time  marking  in  one-fifth 
second  can  be  photographed  on  the  same  plate  with 
an  electrocardiagram.  The  A-V  conduction  time 
as  estimated  by  either  of  these  methods  is  found  to  l)e 
from  .1  to  .2  second  normally.  It  is  claimed  by 
Lewis  that  it  is  commonly  a  little  shorter  when  e 
mated  from  the  electrocardiagram  than  when  the 
venous  pulse  is  used,  but  the  difference  is  slight. 
During  the  refractory  period  conductivity  like  other 
properties  of  the  heart  is  temporarily  in  abeyance 
and  recovers  gradually.  After  a  short  pause  the  con- 
duction time  is  long  and  after  a  long  pause  the  con- 
ductivity is  at  its  best  as  has  been  pointed  out  in 
writing  about  auricular  extra-systoles.  In  view  of 
the  above  it  seems  like  a  paradox  that  we  usually 
find  a  shortened  A-V  interval  with  frequent  heart 
rate  and  a  lengthened  interval  with  an  infrequent 
rate.  This  is  to  be  explained  by  the  fact  that  con- 
ductivity and  rhythmicity  are  both  under  nerve 
control  and  are  usually  influenced  in  the  same 
direction. 

Where  the  A-V  interval  is  more  than  0.2  second 
it  is  considered  abnormal  and  it  may  be  lengthened 
to  0.3  or  0.4  second  or  even  to  0.S  second.  Where 
lengthening  of  the  A-V  interval  is  found  we  may 
suspect  some  degeneration  of  or  interference  with 
the  junctional  tissues  between  auricle  and  ventricle. 
The  part  affected  may  be  either  the  A-V  node  or 
the  bundle  of  His.  Mackenzie  has  seen  a  case  shofl 
lengthened  A-V  interval  for  years  without  develop- 
ing any  arrhythmia,  but  these  cases  should  be 
watched  for  early  signs  of  partial  or  complete  heart- 
block.  It  may  also  be  said  that  lengthening  of  the 
A-V  interval  is  suggestive  of  widespread  degeneration 
of  the  heart  muscle,  such  as  is  seen  in  many  old 
people  with  arteriosclerosis. 

The  most  important  practical  point  in  connection 
with  lengthened  A-V  interval  is  the  bearing  of  this 
defect  upon  treatment.  Digitalis  has  been  shown 
by  Mackenzie  to  have  a  tendency  to  produce  heart- 
block  in  patients  where  the  conductivity  is  already 
depressed  and  in  such  cases  it  should  be  given  with 
discretion  and  its  effects  watched.  It  is  going  too 
far  to  say  that  digitalis  should  not  be  given  at  all 
in  these  cases  as  it  is  often  useful  in  restoring  i 
to  the  heart,  but  it  should  be  discontinued  as  soon  as 
any  tendency  is  shown  for  the  ventricle  to  drop 
beats. 

The  following  case  will  serve  as  an  illustration  of 
lengthened  A-V  interval.  An  old  lady  of  eighty 
with  a  past  history  of  rheumatism  came  under  my 
care  with  symptoms  of  heart  failure  following  over- 
exertion. There  were  signs  of  considerable  dilata- 
tion and  a  mitral  systolic  murmur.  She  was  ordered 
to  bed  and  given  tincture  of  digitalis  in  doses  of 
thirty  minims  per  day  for  several  weeks.  During 
this  time  her  heart  became  smaller  in  size  and  the 


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\  i  I  li\  lliini  ...  <  ardlac 


murmur  disappeared,  bul  she  began  to  suffer  from 
dry  mouth  and  somnolence.  On  listening  over  the 
heart  one  day  1  heard  it  drop  alternate  heals  three 
limes  ill  succession  anil  then  resume  ils  regular 
rhythm.  1  suspected  partial  heart-block  and 
discontinued  the  digitalis.  The  next  day  the  tracing 
shown  in  Fig.  349  was  taken  in  which  it  can  l>e 
seen  that  the  .1-1' interval  is  ahout  one-third  second 
or  considerably  longer  than  normal.  She  was  given 
a  rest  from  digitalis  and  no  more  dropped  beats 
were  observed. 


Fie..  349.-    Lengthened  .1-1'  Conduction  Time.     Jugular  vein 

Brachial  artery  below,     .4,  Auricular  wave;  C,  carotid 

I  ,    ventricular    wave.     Horizontal    line    shows    distance 

[led  by  kymograph  in  one  second  when  well  started.     A-V 

interval  about  1/3  secoud. 

Partial  Am  irulan  utricular  Heart-block. — In  cases 
where  the  conductivity  is  greatly  depressed  but  not 
entirely  lost  the  junctional  tissues  may  from  time 
to  time  fail  to  conduct  the  impulse  from  auricle  to 
ventricle  so  that  the  latter  is  not  stimulated  and 
drops  a  beat.  In  Fig.  350  a  tracing  is  shown  from 
:in  old  man  of  eighty-four  by  whom  several  different 
kinds  of  irregularity  were  exhibited.  To  the  right 
of  the  tracing  it  may  be  seen  that  the  ventricle 
responds  only  to  every  second  beat  of  the  auricle.  It 
is  somewhat  surprising  to  find  that  when  the  ven- 
tricle does  respond  the  A-V  interval  is  normal,  one- 


venous  tracing  fii  i  a  normal  A-V  interval  and  then 
a  gradual  lengthening  of  conduction  time  which 
becomes  longer  with  each  cardiac  cycle  until  ai  la  I 
a  ventricular  heal  is  dropped  anil  then  ue  start  all 
over  again. 

Partial  heart-block  may  occur  in  many  different 
degrees  such  as  one  ventricular  beat  dropped  out 
mi  rare  intervals  or  after  every  third  or  every  second 

auricular    heat.       In    some    eases    there    may    be  three 

or  four  or  more  auricular  beal     to  one  ventricular. 
lino  can  find  described  in  the  literature  every  deg 
from     Lengthened     A-V    interval     through     varying 
degrees  of  partial  heart-block  up  to  complete  heart- 
block. 

Complete  Auriculoventricular  HeartMoch. —  In  this 
condition  no  relation  whatever  can  be  established 
between  the  contraction  of  auricles  and  ventricle  . 
The  auricles  will  be  found  heating  from  sixty  to  a 
hundred  or  more  times  a  minute,  whili  the  ventricular 
rule  may  he  twenty  or  thirty  or  forty.  Where  an 
occasional   ventricular  heat,  seems  to  follow  a  heat 

of  the  auricles  it  can  lie  seen  to  lie  only  a  coincidence. 

Attention  is  usuallyfirst  attracted  by  the  infrequent 

pulse,  but  the  real  nature  of  the  case  is  de QStrated 

only  by  an  examination  of  a  venous  pulse  tracing. 

In  Fig.  35]  a  tracing  is  shown  from  a  patient  of  Dr. 
A.  II.  Gordon  in  the  Montreal  General  Hospital.  The 
patient  was  a,  man  of  thirty-six  with  a  dilated  heart 
and  an  almost  continuous  murmur  heard  over  a 
large  part  of  the  precordium.  He  showed  pronounced 
arteriosclerosis,  but  there  was  no  history  of  syphilis. 
He  was  said  by  his  friends  to  be  subject  to  frequent 
attacks  of  mental  excitement,  but  did  not  have  any 
of  these  while  under  observation.  Some  time  after 
leaving  hospital  he  became  so  maniacal  in  one  of  his 
attacks  that  he  was  taken  off  to  the  police  station, 
where  he  died.  During  his  stay  in  hospital  his  pulse 
kept  about  thirty  per  minute  and  was  not  affected 
by  full  doses  of  atropine.  On  exertion  he  readily 
became  dyspneic,  but  there  was  little  or  no  change 
in  his  pulse  rate. 


RBr 


IU-11  II  I   I    II  LLL 


I   I  I   I   I   I   I    I   I   I    I    I    I    '    I    I    I    II    I     I    '    I    I    I     I    I     I     I    I    I    I    I     I    I    I 


Fig.  350. — Tracing  from  a  Man  Eighty-four  Years  Old,  patient  of  Dr.  A.  D.  Blackader  in  the  Montreal  General  Hospital.  Admitted 
with  complaints  of  weakness  and  shortness  of  breath.  Heart  dilated,  systolic  and  diastolic  murmurs  present  at  first,  but  later 
disappeared.  Clinical  diagnosis  of  myocarditis.  Patient  was  in  hospital  for  six  weeks  ami  was  discharged  improved  and  able  to  walk 
.ibout.  R  I  J,  Internal  jugular  vein;  R  Br,  brachial  artery;  A,  auricular  wave;  C,  carotid  wave;  A\  premature  auricular  wave;  S,  wave 
ascribed  to  systole  of  right  ventricle.  This  tracing  is  believed  to  illustrate  three  different  kinds  of  arrhythmia.  1.  Hemisystole 
(1).  2.  Ventricular  extra-systole  (2).  3.  Partial  heart-block  (3,  4,  5).  Over  the  figure  1  in  the  tracing  are  seen  two  waves  A'  and  S, 
which  occur  before  the  carotid  wave  and  therefore  before  the  systole  of  the  left  ventricle.  These  waves  resemble  the  A  and  C  waves  of 
ither  cardiac  cycles  and  are  believed  to  represent  the  contraction  of  the  right  auricle  and  right  ventricle,  constituting  a  hemisystole. 
They  are  followed  by  an  ordinary  C  wave  due  to  the  contraction  of  the  left  ventricle.  In  the  absence  of  an  esophageal  tracing  there 
is  no  way  of  telling  when  the  left  auricle  contracts.  Note  that  the  A'  wave  is  premature,  which  may  help  to  explain  the  imperfect 
conduction.  At  2  is  seen  a  ventricular  extra-systole  with  a  high  combined  A  and  C  wave.  3,  4  and  5  show  auricular  waves  which 
are  not  followed  by  any  contraction  of  the  ventricles  constituting  partial  heart-block.  It  is  noteworthy  that  where  the  ventricle  follows 
the  auricle  the  A-V  interval  is  less  than  1/5  second  and  therefore  normal. 


fifth  second.  Other  observers  have  also  reported 
normal  conduction  time  alternating  with  partial  or 
complete  heart-block.  Some  have  assumed  that 
in  these  cases  it  is  the  excitability  of  the  ventricle 
that  is  depressed.  Such  an  explanation  will  not 
serve  in  this  case,  as  a  second  or  two  before  the  ven- 
tricle begins  to  drop  beats  in  Fig.  3.50  we  see  a 
ventricular  extra-systole  which  is  scarcely  compatible 
with  loss  of  excitability,  but  rather  the  reverse. 

In  some  cases  of  partial  heart-block  we  see  in  the 


In  complete  heart-block  the  contraction  wave  is 
unable  to  descend  to  the  ventricle  so  that  the  latter 
either  stops  altogether  or  beats  in  response  to  its 
own  homogenetic  stimulus  {idioventricular  rhythm). 
Experiment  seems  to  indicate  that  the  more  suddenly 
the  heart-block  becomes  established  the  more  liable 
the  ventricle  is  to  stop  permanently.  The  most 
dangerous  time  in  a  case  of  heart-block  is  at  the 
moment  when  a  partial  heart-block  is  changing  to 
the  complete  form  and  some  unexplained  cases  of 


629 


Arrhythmia,  Cardiac 


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sudden  death  are  probably  of  this  nature.  When  the 
idioventricular  rhythm  is  once  well  established  it 
may  go  on  for  months  or  years  with  little  change. 
The  rate  of  the  ventricles  is  usually  about  thirty,  but 
may  for  a  time  be  as  slow  as  eight  or  less,  and  it  has 
been  observed  as  frequent  as  sixty  per  minute. 

Pathology. — Heart-block  may  be  induced  in  animals 
in  all  its  degrees  by  compression  or  severance  of  the 
bundle  of  His.  Similar  effects  have  been  seen  to 
follow  the  intravenous  injection  of  poisonous  doses 
of  digitalis.  Temporary  heart-block  has  been  pro- 
duced by  stimulation  of  the  vagus  and  by  asphyxia. 
In   man  nearly  all  cases  so  far  observed  have  been 


Stokes-Adams  Disease  or  Syndrome. — Definition: 
•'  A  condition  of  slow  pulse  with  syncopal,  apo- 
plectiform or  epileptiform  attacks  associated  either 
with  (a)  derangement  of  the  junctional  system  of 
the  heart  or  (b)  disease  of  the  nerve  centers  of  the 
vagi  or  of  the  nerves  themselves"  (Osier). 

"The  cerebral  symptoms  are  a  direct  result  of  a 
circulatory  disturbance  following  a  momentary  fail- 
ure of  the  left  ventricle.  They  vary  in  ditT. 
cases.  Attacks  resembling  petit  mal  are  perhaps 
the  most  common  with  twitching  of  the  limbs  and 
face.  The  epileptic  fit  with  its  orderly  sequence  of 
events  is  rare.     A  slight  aura  may  precede  an  attack 


Fig.  ool. — Tracing  from  a  Case  of  Complete  Heart-block.  Patient  of  Dr.  A.  H.  Gordon  in  the  Montreal  General  Hospital.  Internal 
jugular  vein  above.  Apex  beat  below.  The  ventricular  rate  was  very  constant  at  30  per  minute  so  that  each  apex  beat  interval 
corresponds  to  2  seconds.  .4,  Auricular  wave.  Vertical  lines  show  points  of  time  in  venous  pulse  corresponding  to  the  beginning 
of  ventricular  systole  as  shown  in  apex  beat.  Note  the  total  absence  of  any  constant  time  relation  between  the  auricular  waves  and 
the  ventricular  systole.     The  auricles  contract  nine  times  while  the  ventricles  contract  four  times. 


associated  with  some  disease  or  anomaly  of  the  A— V 
bundle.  The  causes  are  various  and  include  syphilitic 
gummata  and  other  tumors;  fibrous,  calcareous,  and 
atheromatous  degeneration;  infarction,  necrosis,  and 
ulceration;  atrophy  from  pressure  or  stretching  or  from 
sclerosis  of  the  coronary  arteries;  lymphocytic  and 
fatty  deposits;  rheumatic  and  diphtheritic  infection. 
Vagus  stimulation  from  swallowing,  pressure,  or  the 
administration  of  digitalis  may  cause  temporary 
increase  in  a  preexistent  block.  Fulton  and  Judson 
have  reported  an  instance  of  heart-block  occurring  in 
a  father  and  two  children  which  they  ascribe  to  con- 
genital defect.  Cases  of  partial  or  complete  heart- 
block  alternating  with  periods  of  normal  conduction 
time  and  those  rare  cases  in  which  no  disease  of  the 
A-V  bundle  has  been  found  at  autopsy  cannot  at 
present  be  explained. 

S  imptoms. — The  symptoms  vary  according  to  the 
degree  of  cardiac  failure  present.  The  complaint 
to  be  expected  is  above  all  shortness  of  breath  on 
exertion.  To  this  may  be  added  various  degrees 
of  cardiac  palpitation,  oppression,  and  pain.  In 
some  cases  attacks  of  angina  have  been  seen.  Cya- 
nosis, dropsy,  and  other  signs  of  heart  failure  may 
be  present.  The  cerebral  symptoms  are  interesting 
and  important.  In  some  cases  symptoms  of  neuras- 
thenia may  be  present  and  the  patient  may  be  nervous 
and  apprehensive.  In  other  cases  transient  vertigo 
or  fainting  attacks  may  cause  alarm.  In  still  other 
cases  attacks  occur  in  which  cerebral  symptoms  are 
still  more  prominent  and  which  are  known  as  the 
Stokes-Adams  disease  or  syndrome. 

The  Stokes-Adams  syndrome  and  heart-block  are 
by  no  means  synonymous  and  each  may  occur 
without  the  other.  All  grades  of  heart-block  may 
occur  without  definite  cerebral  symptoms  and  attacks 
which  fully  meet  the  definition  of  Stokes-Adams 
di  ea  e  are  frequently  seen  from  other  causes  than 
heart-block.  The  two  conditions  are  so  frequently 
I.  however,  that  this  seems  the  most  con- 
venient place  to  describe  the  Stokes-Adams  disease. 


and  the  patient  may  be  able  to  ward  it  off.  After 
recurring  for  a  year  or  more  the  attacks  may  cease; 
in  other  cases  they  become  extraordinarily  frequent, 
thirty,  fifty,  or  even  one  hundred  and  fifty  in  a  day. 
and  consist  of  brief  periods  of  loss  of  consciou- 
with  twitchings  of  the  muscles.  During  these 
paroxysms  the  pulse  rate  may  fall  to  six  or  eight  and 
there  may  be  prolonged  intervals  between  the  ven- 
tricular beats"  (Osier). 

The  Stokes-Adams  syndrome  is  most  frequently 
seen  in  association  with  heart-block  (eardim-  gro 
under  two  conditions;  first,  when  a  partial  heart- 
block  suddenly  becomes  complete,  and  second,  when 
in  a  complete  heart-block  the  ventricular  rate  ■ 
denly  becomes  less  frequent.  When  a  patient  is  the 
subject  of  partial  heart-block  some  slight  cause  may 
suffice  to  render  the  block  complete  and  the  ventricle 
may  be  tardy  in  assuming  its  independent  rhythm. 
It  may  remain  perfectly  inactive  for  many  seconds 
(more  than  two  minutes — Stengel),  or  it  may  I 
u  it  li  an  extremely  slow  rhythm  for  a  time.  In  either 
case  the  cerebral  circulation  suffers  and  some  form 
of  "attack"  occurs.  The  causes  which  render  the 
block  complete  may  be  various  such  as  over-exertion, 
nerve  influence,  or  drug  action  and  in  some  cases  they 
escape  detection.  In  complete  heart-block  the 
ventricular  rate  may  suddenl}"  drop  from  thirty  or 
forty  a  minute  to  eight  or  ten,  or  the  ventricles  may 
stop  entirety  for  a  time  with  a  similar  disturbance 
of  the  cerebral  circulation. 

The  other  or  neurogenous  group  of  cases,  not  due 
to  heart-block,  are  caused  by  lesions  of  the  medulla 
or  vagi  and  present  similar  symptoms  of  slow  pulse 
and  cerebral  disturbance.  Among  the  principal 
causes  are  the  following: 

1.  Fracture  or  dislocation  of  the  cervical  spine. 

2.  Narrowing  of  the  vertebral  canal  or  occipital 
foramen. 

3.  Tumors  of  the  medulla  or  its  neighborhood 
(cerebellum). 


630 


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Arrhythmia,  Cardiac 


I.  Sclerosis  of  t ho  medulla  due  to  disease  of  the 
,  tebral  and  basilar  arteries. 

,.   Vagal  neuritis. 

i.  Pressure  on  the  vagi  in  the  neck. 

'.  Functional  affections  of  the  vagus  as  a  cause  of 
i  irt-block  are  regarded  by  Osier  as  of  doubtful 
,  urrence. 

\  case  has  been  reported   by  James  in   which  syn- 

I  ial    attacks    resembling    those    of    Stokes- A. lam 

■ase  were  caused  by  recurrent  groups  of  ineffect  ual 

ra-systoles   (frustrane   contractions).     Tt,   may    be 

cd  here  that  in  some  cases  of  complete  heart  -hi nek 

radial    pulse    shows    numerous    tiny    elevations 

i   ing   the   ions   pause.     These   are   believed    to   be 

the  beating  of  the  auricle  against  the  aorta 

I  I    must    be    carefully    differentiated    from    extra- 

1 1 iles  such  as  those  described  by  James. 

oris. — There   is    usually    nothing;    character- 
i  c  about   the   symptoms  of   the  slighter  forms  of 

k.     Lengthening    of    the    A-V    interval    is 

covered  only  when  a  venous  pulse  tracing  or  an 
i  'trocardiagram  is  taken.     In  some  cases  of  length- 
i   d  conduction  time  a  gallop  rhythm  is  heard  over 
heart.     This  is  due  to  the  fact  that  the  slight 
ml   produced   by   the   auricular   systole   is   heard 
I  arately  from  the  first  sound  when  the  A-V  interval 
i  I'tigthened,  but  is  fused  with  it  when  the  conduction 
c  is  normal.     Partial  heart-block  gives  rise  to  an 
gularity  of  the  pulse  which  may  be  noticed  in  the 
t  lial,   but   it  usually  requires  a  venous  tracing  for 
|   differentiation  from  other  forms  of  arrhythmia. 
complete  heart-block  attention  is  arrested  by  the 
i  rcquency  of  the  pulse  or  by  the  cerebral  symptoms. 
]  the  case  of  the  latter,  senile  bradycardia  accom- 
lied  by  vertigo  and  true  epilepsy  must  be  excluded. 
■  sounds  heard  over  the  heart  in  complete  heart- 
I  ek  vary  according  to  the  condition  of  the  heart 
i  -cle  and  valves.     In  many  cases  weak  sounds  due 
t  the  auricular  systole  are  heard  in  the  intervals 
I  ween  the  ventricular  beats.     Griffith  has  recently 
Biwn  attention  to  a  striking  alteration  in  the  first 
id   which  is  sometimes  heard  in  complete  heart- 
lick.     It  consists  of  a  "singularly   thumping  and 
:  phatic  sound"  which  is  heard  every  few  beats  and 
i  iscribed  by  Griffith  to  a  simultaneous  contraction 
i  auricle  and   ventricle.     In  complete  heart-block, 
i  in  other  forms,  venous  tracings  and  the  electro- 
i  diagram  are  of  great  help  in  making  the  diagnosis 
i  tain.     The     electrocardiagram     shows     complete 
i  sociation  in  the  time  relations  of  the  P  wave  and 
I !  ventricular  complex.     The  ventricular  complex 
i  usually  of  normal  form  indicating  that  the  idio- 
■  itrieufar    impulse    originates    above,    presumably 
i  the  main  trunk  of  the  bundle  of  His  below  the  seat 
disease.      Atropine   is    often    administered  in  full 
to  determine  how  much  of  the  block  can  be 
i  noved    by    paralyzing    the  vagus   endings.     Any 
lick   removed    by   atropine   may    be  considered  of 
i  irogenic  origin.     The  block  that  persists  in  spite 
;  atropine  may  be  ascribed  to  local  disease  in  the 
I  adle   of   His.     It  is   important   to   determine   the 
iture   of    the      disease   present   and   especially    its 
ise.     Slighter  forms  are  more  often  due  to  rheu- 
i  it  ism,  the  more  severe  forms  to  syphilis.     Where  the 
••stion   of  syphilis  is  in   doubt  one   should   apply 
■  therapeutic  test  of  a  thorough  course  of  iodide. 
Prognosis. — The  prognosis  depends  largely  on  the 
use.     In   eases   associated   with     infectious    fevers 
presence  of  heart-block  adds  to  the  gravity  of  the 
'■,  bul   where  recovery  from  the  fever  takes  place 
c  heart-block  is  likely  to  disappear  in  a  short  time. 
philitic  cases  are  the  most  favorable.     Most  eases 
complete  heart-block  which  have  recovered  have 
'■n  of  syphilitic  origin.     In  the  senile  and  degenera- 
c   oases    the    course   is   often   very    chronic.     The 
nkes- Adams  attacks  often  cease,  however,  when  the 
event ricular  rhythm   is  fully    established.      Some 


of  thee  patient-;  Buffer  with  marked  heart  failure, 
but  other-  are  able  to  get  about  and  even  to  earn  a 
living.  Osier  gives  five  to  six  years  as  the  average 
duration  of  life,  but  some  have  lived  for  t  weilty  J  eai 
or  more.  As  in  other  myocardial  affections  sudden 
death  is  apt  to  occur  while  the  patient  is  up  and 

about.      This  happened  in  ten  of  Osier's  cases  out  of 

a  total  of  twenty. 

Treatment. — There  is  no  specific  treatment  except 
for  the  syphilitic  cases  in  which  iodide  ef  potassium 
in  full  doses  should  be  given  and  mercury  or  salvar- 

an  if  necessary.     There  is  s difference  of  opinion 

as  to  whether  iodide  is  likely  to  do  good  in  the 
arteriosclerotic  cases.  Strychnine  is  another  drug  in 
which  some  have  confidence.  Heart  failure  is  to  be 
met  chiefly  by  rest  and  regulation  of  the  diet  and 
mode  of  fife.  Digitalis  is  regarded  as  contraindi- 
ca,ted  in  partial  block,  but  in  complete  heart-block 
with  indications  of  cardiac  failure  it  should  certainly 
be  tried  and  will  sometimes  do  good. 

Intraventricular  heart-block  occurs  in  two  forms, 
hemisystole  and  ataxia  of  the  heart  muscle. 

Hemisystole. — In  the  dying  hearts  of  animals  one 
Ventricle  often  stops  while  the  other  goes  on  beating. 
The  possibility  of  one  sided  ventricular  contractions 
in  man  has  been  disputed,  but  the  evidence  that  it 
sometimes  occurs  is  now  considerable.  Von  Leyden, 
beginning  in  1S68,  reported  a  number  of  cases,  but 
his  work  has  not  been  universally  accepted.  Riegel, 
for  instance,  explained  the  cases  as  frustrane  contrac- 
tions (weak  extra-systoles).  Mackenzie  in  his  book, 
"The  Study  of  the  Pulse,"  presents  one  very  convincing 
case  (page  294)  of  independent  contraction  of  the 
right  ventricle  in  a  boy  dying  of  dilatation  of  the 
heart  from  mitral  stenosis.  He  gives  another  case 
almost  as  convincing  in  which  the  right  ventricle 
seemed  to  contract  more  often  than  the  left.  Hewlett 
reports  a  case  following  the  administration  of  stro- 
phanthin,  in  which  the  ventricular  contractions  some- 
times caused  waves  in  the  venous  pulse  with  little 
or  no  effect  on  the  apex  beat.  The  presumption 
was  that  the  right  ventricle  was  contracting  alone. 
In  the  same  case  it  was  shown  that  the  right  ventricle 
sometimes  began  its  contraction  distinctly  later  than 
the  left  as  though  the  contraction  impulse  to  the  right 
ventricle  had  been  retarded.  The  parallelism  to 
lengthened  A-V  interval  is  obvious.  Stengel  and 
Pepper  report  a  case  showing  various  forms  of  heart- 
block  in  which  the  auricular  wave  was  followed  by 
a  beat  in  the  radial  pulse,  but  not  by  any  C  wave  in 
the  venous  pulse.  They  interpret  this  to  mean  that 
the  left  ventricle  had  contracted  without  the  right. 
They  agree  with  the  writer  that  the  C  wave  in  the 
venous  pulse  has  little  or  nothing  to  do  with  the  caro- 
tid, but  is  a  wave  sent  back  through  the  tricuspid 
valves  by  the  contraction  of  the  right  ventricle.  The 
tracing  shown  in  Fig.  350  shows  what  is  believed 
to  be  a  hemisystole  at  the  point  marked  with  the 
figure  1.  There  are  indications  here  that  the  right 
auricle  and  ventricle  contract  in  proper  sequence 
and  the  left  ventricle  follows  later. 

Ataxia  of  the  Heart  Muscle. — Schmoll  has  reported 
a  case  in  which  the  right  ventricle  and  perhaps  part 
of  the  left  contracted  independently  of  the  principal 
mass  of  the  left  ventricle.  He  compares  such  cases 
to  the  incoordination  seen  in  the  body  in  such  diseases 
as  locomotor  ataxia  and  for  partial  contractions  of 
the  heart  he  suggests  the  term  ''ataxia  of  the  heart 
muscle." 

Evidence  of  partial  contractions  of  the  heart 
muscle  is  sometimes  afforded  by  the  occurrence  of 
weak  ventricular  contractions  interrupted  by  stronger 
ones  without  any  pause  between  the  two.  It  is 
probable  that  some  cases  of  pulsus  bigeminus  such  as 
that  shown  in  Fig.  336  are  of  this  nature.  The  most 
extreme  degree  of  ataxia  of  the  heart  is  fibrillation. 
This  is  common  in  the  auricles,  but  fibrillation  of 
the  ventricles  is  probably  incompatible  with  life  so 


631 


Arrhythmia,  Cardiac 


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that  our  knowledge  of  it  is  limited  to  the  hearts  of 
dying  animals. 

Diagnosis. — The  recognition  of  intraventricular 
heart-block  is  to  be  effected  by  the  use  of  all  the 
methods  at  one's  command.  Besides  tracings  of 
the  arterial  and  venous  pulse  and  apex  beat,  esopha- 
geal tracings  may  be  helpful,  as  in  the  case  reported 
by  Schmoll.  It  is  onty  through  the  esophagus  that 
we  can  get  a  tracing  from  the  left  auricle.  Kraus 
and  Nicolai  claimed  at  one  time  that  separate  con- 
tractions of  the  right  or  left  ventricle  gave  charac- 
teristic clectrocardiagrams  by  which  they  could  be 
recognized,  but  this  is  called  in  question  by  Lewis 
who  makes  the  statement  that  the  authors  have 
themselves  receded  from  this  position. 

Prognosis. — The  presence  of  hemisystoles  or  ataxia 
of  the  heart  muscle  must  always  indicate  serious 
changes  in  the  heart  and  it  seems  only  a  step  from 
these  conditions  to  fibrillation  of  the  ventricles 
and  death.  From  the  fact,  however,  that  the  case 
figured  in  Fig.  350  and  also  those  reported  by 
Hewlett  and  by  Schmoll,  left  hospital  improved,  the 
condition  cannot  be  regarded  as  necessarily  pre- 
saging speedy  dissolution. 

Treatment. — This  must  be  carried  out  on  general 
principles.  Schmoll's  patient  was  given  digitalis  for 
his  general  heart  failure  with  benefit.  Stengel  and 
Pepper's  patient  improved  under  atropine  and  the 
block  disappeared.  Dr.  Blackader's  patient,  Fig. 
(3.50),  improved  during  his  stay  in  hospital  where 
the  principal  drugs  given  him  were  strychnine  and 
digitalis.  In  Hewlett's  case  the  block  seemed  to  be 
caused  by  the  administration  of  strophanthin  and 
passed  off  when  the  drug  was  discontinued. 

Sinoauricular  block  may  be  produced  in  animals 
by  ligating,  crushing,  or  cooling  the  sinoauricular 
border.  Under  these  circumstances  the  sinus  con- 
tinues to  beat  as  before  and  the  auricles  after  a  period 
of  standstill  begin  to  beat  with  a  slower  rhythm  of 
their  own.  Lesser  degrees  of  injury  may  produce  a 
partial  sinoauricular  block  with  one  beat  of  the 
auricle  to  two  of  the  sinus.  A  parallel  condition  in 
man  would  be  a  block  between  the  sinoauricular 
node  and  the  auricles.  In  the  absence  of  any  cri- 
terion of  sinus  activity  it  is  difficult  to  demonstrate 
it  clinically,  but  its  presence  has  been  inferred  on 
circumstantial  evidence  by  Hoffman,  Hewlett,  and 
Gibson.  To  it  have  been  ascribed  sudden  changes 
in  the  rate  in  paroxysmal  tachycardia,  and  also 
certain  cases  where  both  auricles  and  ventricles  have 
dropped  a  beat  without  permanent  dislocation  of  the 
cardiac  rhythm. 

Bradycardia  is  the  opposite  of  tachycardia  and 
means  slow  or,  better,  infrequent  pulse.  The  con- 
ditions embraced  under  this  term  do  not  form  a 
clinical  entity,  but  the  term  is  a  convenient  one  to 
use  in  any  given  case  until  we  are  able  by  careful 
analysis  to  allot  it  to  its  proper  class.  We  may 
classify  temporarily  as  bradycardia  any  pulse  below 
fifty  per  minute.  On  further  study  these  cases  may 
turn  out  to  be: 

1.  Complete  heart-block. 

2.  Combinations  of  auricular  fibrillation  with 
heart-block. 

3.  Extra-systoles  replacing  every  second  beat  and 
too  weak  to  be  felt  at  the  wrist. 

4.  Pulsus  alternans  in  which  the  weak  beat  is  not 
felt. 

5.  True  bradycardia  in  which  the  whole  heart 
beats  at  a  slow  rate,  but  in  normal  sequence. 

True  bradycardia  may  result  from  any  of  the  fol- 
lowing causes: 

1.  Personal  or  family  idiosyncrasy.  These  cases 
are  not  usually  pronounced  in  degree  and  may  be 
seen  in  individuals  otherwise  in  perfect  health. 

2.  Neurogenic,  from  lesions  of  the  medulla,  upper 
spinal  cord,  or  vagi  nerves,  from  functional  disorders 

632 


of  the  nervous  system  such  as  melancholia,  hysteria 
and  neurasthenia,  and  from  efforts  of  the  will  as  has 
been  reported  in  oriental  fanatics. 

3.  Reflex,  from  painful  and  other  affections  of  the 
thoracic,  abdominal,  and  pelvic  viscera.  Notable 
examples  are  hepatic  and  renal  calculi. 

4.  Infective,  as  influenza,  diphtheria,  and  typhoid. 

5.  Toxic,  as  seen  in  poisoning  with  lead  or  digitalis 
and  in  autointoxication  from  constipation,  jaundice 
or  nephritis. 

6.  Cardiac,  as  seen  in  the  bradycardia  of  senile 
degeneration  of  the  heart. 

These  cases  must  be  analyzed  in  accordance  with 
the  principles  already  laid  down  and  treated  accord- 
ing to  the  causes  which  seem  to  be  at  work. 

Pulsus  alternans  is  the  name  given  to  regular 
alternation  of  strong  and  weak  pulse  beats  at  ap- 
proximately equal  intervals.  An  example  borrowed 
from  Mackenzie  is  shown  in  Fig.  352.  Where 
there  is  any  irregularity  in  the  pulse  intervals  in 
pulsus  alternans  it  is  usually  the  weak  beat  that  is 
delayed.  This  has  been  explained  by  a  depression 
of  A-V  conduction  at  the  time  of  the  weak  beat 
(Wenckebach).  It  has  also  been  ascribed  to  a 
longer  presphygmic  interval  due  to  the  weak  beat 
taking  longer  "to  open  the  semilunar  valves  (Hering). 


Fig.  352. — Pulsus  Alternans.  The  numbers  show  a  slight  pro- 
longation of  the  pause  before  the  smaller  beat,  in  contrast  to  what 
occurs  in  pulsus  bigeminus.     (Mackenzie.) 

In  an  individual  case  the  venous  pulse  should  show 
which  is  the  proper  explanation.  The  venous  pulse 
is  usually  normal  in  form.  Pulsus  alternans  must 
be  differentiated  from  pulsus  bigeminus  due  to 
extra-systoles.  This  may  be  done  by  noting  the 
length  of  the  pulse  intervals,  and  by  examining  the 
venous  pulse  for  signs  of  extra-systoles.  In  pulsus 
bigeminus  a  longer  interval  precedes  the  large  beat. 
In  pulsus  alternans  the  intervals  are  equal,  or  if 
there  is  a  slight  difference  the  longer  interval  precedes 
the  small  beat  as  already  explained. 

Pulsus  alternans  is  regarded  by  Wenckebach, 
Mackenzie,  and  others  as  due  to  a  depression  of  con- 
tractility. It  is  seen  in  senile  hearts  where  there  is 
considerable  fibroid  degeneration,  and  after  exhaust-  . 
ing  strain,  such  as  after  an  attack  of  paroxysmal 
tachycardia.  It  is  frequently  associated  with  at- 
tacks of  angina  pectoris.  Where  predisposition 
exists  the  onset  of  pulsus  alternans  is  often  deter- 
mined by  exertion  or  excitement.  Sometimes  it  <•■ 
ushered  in  by  an  extra-systole.  Where  contractility 
is  impaired  the  large  beat  following  an  extra-systole 
exhausts  the  heart  muscle  so  that  it  has  not  time  to 
recover  completely  before  the  next  impulse  descends 
and  it  responds  with  a  weak  beat.  The  weak  beat 
being  small  and  of  short  duration,  the  heart  has  a 
longer  rest  before  the  descent  of  the  next  impulse 
and  responds  with  a  stronger  beat  and  so  the  alterna- 
tion goes  on. 

The  diagnosis  of  pulsus  alternans  can  be  made 
provisionally  by  feeling  the  radial  pulse.  The  alter- 
nating force  combined  with  the  regular  rhythm  of  the 
beats  is  often  recognizable.  Some  have  noticed 
variations  in  the  strength  of  the  heart  sounds  esp<  - 
cially  in  cases  where  systolic  murmurs  are  present. 
The  diagnosis  is  confirmed  by  taking  tracings  of  the 
arterial  and  venous  pulse  by  which  extra-systoles 
may  be  excluded.  The  diagnosis  is  sometimes 
rendered  difficult  by  the  fact  that  extra-systoles  and 
pulsus  alternans  may  be  present  in  the  same  tracing. 


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Ari'h> thini;u  Cardiac 


In  some  of  these  cases  the  irregularity  in  rhythm  and 
volume  is  so  great  that  the  question  of  auricular 
fibrillation  may  lie  raised  (W'imlle),  but  the  latter 
may  be  excluded  if  the  venous  pulse  is  found  to  be  oi 
the  auricular   form.     Pulsus  alternans  may  also  be 

plicated  by  the  presence  of  intraventricular  heart- 
block.      In  apex  beat  tracings  the  alternation  may  or 
may  not  show.    Where  the  ventricular  beats  seem  to 
he  iif  equal  force  the  alternation  in  the  arterial  pulse 
be  explained  by  variation  in  the  tilling  of  the 

ricles  due   to  unequal   activity   of   the  auricles. 

electrocardiagram  does  not  give  constant  results. 

the  complexes  are  of  normal  form.     There  may  be 

-nation  in  the  height  of  the  waves,  but  there  is 

onstant  relation  between  them  and  the  size  of  the 
arterial    pulse. 

The  prognosis  is,  generally  speaking,  unfavorable. 
As  this  form  of  irregularity  indicates  exhaustion  of 

heart  muscle,  the  degree  of  recovery  that  may  be 

cted  must  depend  to  some  extent  on  the  causes 

produced  it.     The  prognosis  is  naturally  better  in 

coming  on  after  severe  strain  than  in  those  due 

to  degeneration  of  the  heart  muscle  in  the  absence  of 

al   stress  of  work.      According  to  Mackenzie  the 

ecta  of  this  form  of  irregularity  usually  succumb 
within  a  few  years. 

Treatment. — This  form   of   arrhythmia  more  than 

any  other  calls  for  absolute  rest.     Digitalis  is  con- 

traindicated  as  drugs  of  this  class  have  been  seen  to 

ease  the  defect.     Chloral  may  do  good  by  pro- 

ting  sleep  and  lowering  blood  pressure.     Sugar  in 

large  quantities  as  a  heart  food,  and  tonics  like  iron 

arsenic  should  be  of  benefit.  A  patient  lately 
under  my  care  did  not  improve  much  after  several 
weeks  in  bed  with  treatment  along  the  above  men- 
tioned lines,  but  began  to  improve  as  soon  as  he  was 
given  adrenalin.  This  was  first  given  hypodermic- 
ally  in  doses  of  ten  to  fifteen  minims  every  two  hours, 
and  later  by  the  mouth,  six  to  eight  suprarenal 
tablets  daily.  The  result  was  that  attacks  of  pre- 
cordial pain  with  pulsus  alternans  ceased  and  his 
ability  to  stand  moderate  exertion  returned. 

Pulsus  intermittens  and  Pulsus  deficiens  are 
names  without  exact  pathological  significance.  Pulsus 
intermittens  is  used  for  dropping  of  beats  in  the  radial 
pulse.  Pulsus  deficiens  is  reserved  for  cases  where 
the  ventricle  itself  drops  a  beat.  A  beat  may  be 
dropped  by  the  ventricle  as  a  result  of  partial  or 
complete  heart-block.  A  beat  may  be  missed  from 
the  arterial  pulse  as  a  result  of  heart-block,  and  also 
from  a  beat  of  the  ventricle  being  too  weak  to  open 
the  semilunar  valves  or  to  reach  the  peripheral 
arteries,  as  in  early  extra-systoles  or  in  extreme 
degrees  of  pulsus  alternans. 


Flo.  353. — Pulsus  Paradoxus  (Schrotter).  Showing  how  the 
puke  volume  approaches  the  vanishing  point  at  the  end  of  each 
inspiration. 

Pulsus  paradoxus  is  the  name  given  by  Kussmaul 
to  a  diminution  in  size  or  absence  of  the  pulse  during 
inspiration.  It  is  often  spoken  of  as  pathognomonic 
of  adherent  pericardium,  but  this  is  not  the  case  as 
it  is  seen  in  cases  of  pericarditis  with  effusion  (Roberts) , 
splanchnoptosis  (Hirschfelder),  and  to  a  moderate 
degree,  it  is  said,  in  some  normal  individuals.  A 
converse  condition  known  as  Riegel's  pulse  is  the 
diminution  in  the  size  of  the  pulse  during  expiration 
which  is  seen  in  some  cases  of  adhesion  between  the 
heart  and  the  anterior  wall  of  the  chest.  These 
forms  of  arrhythmia  can  usually  be  recognized  by 


palpation  of  the  pulse  while  listening  to  the  heart 
sounds  and  watching  the  re  piration.  Their  diagno  tic 
significance  is  probably  not  very  great,     'they  usually 

indicate   some   pulling   upon    the    meal     vessels    which 

narrows  their  lumen  at  certain  stages  of  respiration. 
The  active  agent  is  often  a  fibrous  band  resulting 
from  luediasl  init  is  which  compresses  the  aorta  when 
drawn  down  by  the  diaphragm  in  inspiration  or  by 
the  descent  of  the  ribs  in  expiration.  Sometimes  the 
great  veins  are  also  compressed,  producing  ta  i  and 
-welling  in  the  veins  of  the  neck.  Very  few  tracings 
have  been  published.  That  shown  in  1  i^r.  353  is 
borrowed  from  ScbrStter's  article  in  Nothnagel's 
Encyclopedia. 

The  treatment  is  that  of  the  underlying  condition. 
Some  eases  of  adherent  pericardium  have  been  bem  - 
Sted  by  resecting  parts  of  the  third,  fourth,  and  fifth 
ribs  over  the  heart  (cardiolysit  I. 

William  S.  Morrow. 

Bibliography. 

I  desire  to  express  my  indebtedness  to  the  following  Looks, 
which  have;  been  freely  consulted: 

Allbutt  and  Rolleston's  System  of  Medicine.  Articles  by  Arthur 
Keith,  Sir  William  Osier,  and  F.  T.  Roberts. 

Hill's  Further  Advances  in  Physiology,  The  Heart,  by  Martin 
Flack,  and  Pulse  Records,  by  Thomas  Lewis. 

Diseases  of  the  Heart  and  Aorta,  by  A.  3).  Hirschfelder. 

Functionelle  Diagnostic  und  Therapie,  by  Aug.  Hoffmann. 

Text-book  of  Physiology,  by  W.  H.  Howell. 

Mechanism  of  the  Heart  Beat,  by  Thomas  Lewis. 

The  Study  of  the  Pulse  and  Diseases  of  the  Heart,  by  James 
Mackenzie. 

Nothnagel's  Encyclopedia  of  Practical  Medicine,  article  by 
L.  V.  Schrotter. 

Arrhythmia  of  the  Heart,  by  K.  F.  Wenckebach. 

The  following  have  also  been  referred  to  in  the  text  or  laid  under 
contribution; 

Barker,  L.  F.  Electrocardiography  and  Phonocardiography. 
The  Johns  Hopkins  Hospital  Bulletin,  vol.  xxi.,No.  237,  December, 
1910. 

Cushny  and  Edmunds:  Paroxysmal  Irregularity  of  the  Heart 
and  Auricular  Fibrillation.     Amer.  Jour.  Med.  Sci.,  January,  1906. 

Fairbrother,  H.  C:  A  Remedy  for  Paroxysmal  Tachycardia. 
Jour.  Am.  Med.  Asso.,  1909,  kii.,  300. 

Fredericq,  Leon:  La  Pulsation  du  Cceur  du  Chien.  Archives 
Internationales  de  Physiologie,  July,  1906. 

Fulton,  Judson,  and  Norris:  Congenital  Heart-block  Occurri-g 
in  a  Father  and  Two  Children.  Am.  Jour.  Med.  Sci.,  September, 
1910. 

Gibson,  G.  A.:    Bradycardia.     Edin.  Med.  Jour.,  July,  1905. 

Griffith  T.  W.:  Remarks  on  Two  Cases  of  Heart-block.  Heart, 
February,  1912. 

Hering,  H.  E.:  TJeber  den  Pulsus  pseudoalternans.  Prager  medic 
Wochensch,  1902,  Bd.,  xxvii. 

Hewlett,  A.  W.:  Heart-block  in  the  Ventricular  Walls.  Archives 
of  Int.  Med.,  September,  1908. 

Jolly  and  Ritchie:  Auricular  Flutter  and  Fibrillation.  Heart, 
May,  1911. 

James,  W.  B.:  A  Clinical  Study  of  Some  Arrhythmias  of  the 
Heart.     Am.  Jour.  Med.  Sci.,  October,  190S. 

Kraus  and  Nicolai:  TJeber  die  funktionelle  Solidaritat  dor 
beiden  Herzhiilften.  Deutsche  med.  Wochensch.,  1908,  xxxiv., 
1-5. 

Kussmaul:  TJeber  schwielige  Mediastino-pericarditis  und  den 
paradoxen  Puis.      Berliner  klin.  Wochensch.,  1873,  No.  37. 

Laslett,  E.  E.:  Syncopal  Attacks  Associated  with  Prolonged 
Arrest  of  the  Whole  Heart.     Quar.  Jour,  of  Med.,  July,  1909. 

Minkowski,  O.:  Die  Registrierung  der  Herzbewegungen  am 
linken  Vorhof.     Deutsche  med.  Wochensch.,  1906,  xxxii.,  1248. 

Neuburger  and  Edinger:  Einseitiger  fast  totaler  Mangel  des 
Cerebellums,  Varix  Oblongata?,  Herztod  durch  Accessorius- 
reizung.  Berliner  klin.  Wochensch.,  1S9S,  xxxv.,  69-72  and 
100-103. 

Riegel:  TJeber  extrapericardiale  Verwachsungen.  Berliner 
klin.  Wochensch.,  1S77,  Xo.  45. 

Rihl,  .:J  TJeber  atrioventrikulare  Tachycardie  beim  Menschen. 
Deutsche  med.  Wochensch.,  1907,  xxxiii.,  632-634. 

Schmoll,  E. :  Ataxia  of  the  Heart  Muscle.  Am.  Jour.  Med. 
Sci.,  November,  1908. 

Stengel  and  Pepper:  Heart-block  with  an  Indication  of  Genuine 
Hemisystole      Am.  Jour.  Med.  Sci.,  October,  1910. 

Windle,  J.  D.:  Observations  on  Pulsus  Alternans.  Heart, 
November,  1910. 

Young  and  Hewlett:  The  Normal  Pulsations  within  the  Esopha- 
gus.    Jour,  of  Med.  Research,  vol.  xvi.,  No.  3,  July,  1907. 

633 


Arrow-Head  Hot  Springs 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


-San  Bernardino  County, 


Arrow-head  Hot  Springs.  - 

California. 

Post-office. — Arrow-head  Springs. 

Access. — By  electric  car  from  San  Bernardino,  six 
miles  distant  to  the  south.  The  trolley  line  is  part 
of  the  extensive  system  covering  southern  California 
owned  by  the  Southern  Pacific  System.  San  Bernar- 
dino is  reached  by  the  Salt  Lake,  the  Southern  Pacific, 
and  the  Atchison,  Topeka,  and  Santa  Fe  Railroads. 
The  springs  and  lakes  are  situated  on  the  side  of 
the  Sierra  Madre  range. 

Thcs,.  springs  burst  from  the  mountain  slope  of  the 
Sierra  Madre,  2,000  feet  above  the  level  of  the  sea.  and 
1,000  feet  above  the  foot  of  the  mountain.  A  bench- 
like mesa,  containing  100  acres,  projects  at  this  point 
from  the  mountain,  and  is  bounded  on  the  east  and  on 
the  west  by  two  enormous  canons.  Down  the  deep 
ravine  or  canon  on  the  east  comes  a  mountain  stream 
of  water  as  cold  as  ice,  while  in  the  canon  on  the  west 
flows  a  stream  formed  by  the  boiling  spring  so  hot 
that  it  fills  the  air  with  steam  and  sulphurous  gas. 
The  springs  here  were  known  to  the  Indians  long  be- 
fore the  settlement  of  the  country  by  whites.  On 
the  face  of  the  mountain  back  of  the  hotel  is  the  figure 
of  an  arrow-head  1,360  feet  long  and  4~>0  feet  wide, 
believed  to  have  been  executed  by  the  aborigines. 
The  figure  gives  its  name  to  the  resort,  and  so  perfect 
is  its  contour  and  so  elevated  its  situation  that  it  can 
be  seen  from  almost  every  part  of  the  valley,  and 
stands  as  a  prominent  landmark  for  miles  around. 
The  tent  cottages  are  an  attractive  feature.  The 
Arrowhead  Hotel  is  located  near  the  springs,  on  the 
plateau  of  land  between  the  two  canons.  The  hotel 
built  in  mission  style  is  spacious,  with  broad  verandas, 
superb  200  foot  foyer  and  lobby,  with  great  fixed 
stone  fire  places  here  and  there.  The  bedrooms  are 
large  and  cool.  The  hotel  is  provided  with  elevators, 
electric  lights,  shower  baths,  and  every  modern 
comfort.  The  Arrow-head  estate,  hotel,  bath  house, 
grounds  and  surroundings  have  been  laid  out  and 
designed  for  a  "Kurort,"  a  great  natural  sana- 
torium. The  grounds  of  the  hotel  cover  1,800  acres, 
and  include  the  great  Cold  Water  Canyon  up  into 
the  heart  of  the  mountains  to  the  line  of  the  Govern- 
ment Timber  Reserve  and  a  long  reach  of  the  beautiful 
Waterman  Canyon  up  which  an  excellent  carriage 
road  leads  to  the  summit.  Arrow-head  is  on  a  fine 
highway  system  for  automobiles.  The  meteorological 
conditions  are  similar  to  those  usually  prevalent 
in  Southern  California,  the  weather  being,  as  a  rule, 
clear,  balmy,  and  bright.  The  winter  season  is 
most  favorable  for  visiting  the  springs.  These  are 
37  in  number,  the  aggregate  flow  of  water  being  equal 
to  10  miner's  inches.     Following  is  an  analysis: 


The  water  shows  a  very  high  temperature,  202°  F. 
The  analysis  bears  some  resemblance  to  that  of  the 
Carlsbad  springs.  The  water  is  soft,  clear,  and 
pleasant  to  drink.  The  springs  owe  their  chief  repu- 
tation, however,  to  the  beneficial  effects  of  the  water 
when  used  for  bathing  purposes.  It  is  employed  in 
the  form  of  vapor,  hot  mineral  water,  and  mud 
baths. 

Two  of  the  most  interesting  features  at  Arrow-head 
are  these  wonderful  mud  baths  and  the  natural  steam 
room.  The  diseases  and  morbid  conditions  most 
susceptible  to  the  beneficial  influences  of  the  Arrow- 
head waters  are:  Rheumatism,  especially  the  chronic 
form;  gout  and  the  uric  acid  and  lithemic  group; 
dyspepsia  and  many  chronic  digestive  disorders 
both  gastric  and  intestinal;  congestions  and  cir- 
rhoses  of  the  liver,  incipient  gall-stone  formation; 
the  early  stages  of  heart  disease;  incipient  Bright'.-, 
disease  and  acute  nephritis,  and  disturbances  of  the 
bladder  and  urinary  and  prostatic  disorders;  dia- 
betes; skin  affections;  neurasthenia,  neuralgias  and 
many  forms  of  neuritis,  as  well  as  asthma,  "colds", 
and  bronchial  affections  are  generally  benefited; 
relief  from  pain,  stiffness  and  incoordination,  is  often 
afforded  in  paralysis  and  paresis  together  with  locomo- 
tor ataxia  and  scleroses.  The  springs  offer  many 
advantages  for  rest  and  enjoyment  not  only  for  in- 
valids, but  for  those  in  good  health 

Emma  E.  Walker. 

Arrow=poisons. — The  use  of  poison  to  increase  the 
destructive  effect  of  the  arrow  is  probably  as  old  as 
the  use  of  the  arrow  itself.  In  the  Book  of  Job 
(vi.,  4)  the  poison  is  spoken  of  as  inseparable  from 
the  arrow:  "For  the  arrows  of  the  Almighty  are 
within  me,  the  poison  whereof  drinketh  up  my  spirit.1' 
That  the  poisoning  of  arrows  was  a  practice  of  the 
ancients  is  shown  by  our  word  toxic,  which  is  derived 
from  to&kos,  relating  to  the  bow,  to&k6v  cf>apfia.K6i>.  meaning 
arrow-poison.  The  manliness  of  the  fighting  men  of 
the  middle  ages  led  them  to  regard  the  use  of  poison 
for  their  arrows  and  spears  as  unworthy  of  a  knight, 
much  as  the  dumdum  or  soft-headed  bullet  is  con- 
demned by  the  moderns,  but  among  savage  races 
it  is  still  the  accepted  means  of  insuring  victory  in  war 
or  the  chase. 

Poisons  derived  from  the  three  kingdoms,  animal, 
vegetable,  and  mineral,  are  used,  but  for  the  most 
part  they  are  of  vegetable  origin.  Of  the  mineral 
poisons,  arsenic  and  antimony  are  the  most  common. 
The  animal  poisons  are  derived  from  the  venom  of 
snakes,  scorpions,  and  centipedes  and  from  poisonous 
fish.  Among  some  of  the  tribes  of  American  Indiana 
it  was  the  custom  to  stick  the  liver  of  a  buffalo  or 
other  large  animal  full  of  arrows  and  leave  it  to  rot 


ANALYSIS  OF  ARROW-HEAD  WATERS 
Grains  Per  Gallon 
By  PROF.  GILBERT  E.   BAILEY. 


Tem- 
pera- 
ture 

Sod- 
ium 
chlo- 
rid 

Sod- 
ium 
car- 
bon- 
ate 

Sod- 
ium 
sul- 
phate 

Sod- 
ium 
bor- 
ate 

Potas- 
sium 
sul- 
phate 

Potas- 
sium 
chlo- 
ride 

Cal- 
cium 
car- 
bon- 
ate 

Mag- 
nesium 

car- 
bonate 

Mag- 
nesium 
sul- 
phate 

Silica 

Lithia 

Hy- 
dro- 
gen 

sul- 
phide 

Iron 

Total 

Penyugal  Hoi  Spring. 
Wa  terman      H  o  t 

Springs. 
Graniti!  Hot  Spring. . 

202° 
200° 

100° 

ISO" 

7.070 
6.104 

6.607 
5.269 
2.733 
1  244 

1.045 
3.224 

2 .  243 
2   903 

42.650 
33.215 

34 . 6S7 
90    Q03 

0.887 

4  007 
1    594 

2.395 

i    !.;7 

4.246 
3.521 

4.211 
3  nss 

0.403 

0.210 
0.151 

0.531 

0.169 
0.629 

5.S06 
4. 70S 

5.301 
4.240 
0.911 
1  .  758 

Tr:ice 
Trace 

Trace 

Trace 

0.491 
0.140 

0.128 
0.134 

l',7   2D.5 
.',2.675 

55  78S 

47.062 

1   471     1    022 

n  n?n    l  sis 

8  303 
)   75J 

O   367                                         1)    128     O   7v>4 

Trace 

*  ''old  Water  Arrow-head  Canyon. 


t  Cold  Water  Canyon. 


g:u 


niir.HKxci:  handbook  of  the  medical  sciences 


Arrow-poisons 


i  a  damp  place.    The  Apaches  are  said  to  have 
|  the  beads  of  rattlesnakes  with  fragments  <>f 

i  '-  liver  ami  when  the  mass  had  become  putrid  the 
beads  were  dipped  in  it  and  dried  slowly.     By 

ome   tribes   the   heads   of   veni us   snakes   were 

I.  a  and  the  ashes  moistened  with  water,  the 

mil  so  formed  being  smeared  over  the  lame  points 

row  heads.     The  toxic  effect  of  such  a  prepara- 

ion  was  probably  more  imaginary  than  real,  unless 

here  was   some   other  substance  added,    the    nature 

[  which  was  not  revealed.     In  most  cases,  indeed, 

iparation  of  the  poison  was  a  secret  process 

DOWH   only    to    the    medicine    men    and    chiefs,  the 

lanipulations    witnessed    by    the    public   being  ex- 

in     nature     and     designed     to     impress     the 

lultitude  while  concealing  the  actual  methods  em- 

Comparatively  few  of  the  vegetable  arrow-poisons 
Asia,  Africa.  .South  America,  and  Australasia 
ave  been  analyzed  or  indeed  even  identified  with 
ertituds.  In  most  cases  an  extract  is  used,  the 
ource  being  kept  among  the  secrets  of  the  medicine 
nen  or  chiefs,  and  revealed  least  of  all  to  the  strange 
hite  man.  In  many  cases  there  is  a  mixture  of 
-itraets    from    several    plants    which    still    further 

es  the  difficulty  of  identification.     Xeverthe- 

e  number  of  natural  orders  of  plants  from 
uembers  of  which  arrow-poisons  are  known  to  have 
ieen  made  is  considerable  and  the  number  of  genera 
.irge.  The  natural  orders  best  known  in  this  con- 
icction  are  Apocynaceae,  and  Loganiaceae,  and 
^preventatives  of  each  are  used  in  widely  separated 
egions  of  the  world.  The  Apocynaceae  are  repre- 
ented  by  three  principal  genera,  Acocanthera,  species 
.mi  varieties  of  which  are  used  throughout  Africa 
.nd  in  the  Fast  Indies,  Strophanthus  and  Adenium, 
ihich  are  also  used  extensively  in  various  parts  of 
\frica.  The  Loganiaceae,  which  comprise  various 
of  Stryehnos  including  those  which  furnish 
•urare,  represent  all  the  arrow-poisons  of  the  Western 
lemisphere  and  also  are  used  extensively  in  the  East 

and  Malay  and  are  of  considerable  significance 
::  Africa.  Other  natural  orders  represented  in  force 
ire  the  Euphorbiaceae,  which  furnish  a  number  of  the 
ninor  poison  plants  of  Africa,  the  Urticaceae.  which 
urnish  species  of  the  Antiaris  much  used  in  the  East 
indies  and  Mala}-,  while  the  Ranunculaceae  are 
■epresented  in  the  Himalayas  by  Aconitum,  and  the 
Leguminosse  by  Erylhrophlaum  in  Africa  and 
Denis  in  Asia.     It  is  not  uncommon  to  find  com- 

ins  of  poisons  from  two  natural  orders  or 
genera.  To  go  a  little  more  thoroughly  into  the 
and  species,  at  least  four  species  of  Acocan- 
hera  are  the  main  sources  of  special  kinds  of  poison, 
ivhile  Strophanthus  is  represented  by  six,  Adenium 
>y  two,  and  Euphorbia  and  Stryehnos  each  by  a  large 
number.  Antiaris  and  most  of  the  other  toxiferous 
jenera    are    represented    apparently    b}'    a    single 

It  must  of  course  be  borne  in  mind  that  these  plants 
ire  only  the  ultimate  sources  of  the  chief  poisonous  sub- 
dances.  The  presence  of  other  ingredients  and  the 
technique  of  preparation  enter  extensively  into  the 
individuality  of  the  commercial  (so  to  speak)  articles. 
The  best  known  among  the  latter  are  waba  or  ouabaio 
which  is  obtained  from  one  species  of  Acocanthera 
and  used  extensively  in  Eastern  Africa.  The  poison 
known  as  fra  fra,  used  in  the  Gold  Coast  is  also  be- 
lieved to  be  derived  from  a  member  of  the  same 
g-'nus,  while  in  the  North  East  and  in  Southern  Africa 
other  species  are  used  for  the  same  purpose.  The 
mode  of  preparation  is  inspissation  of  a  decoction 
of  the  wood,  and  the  active  toxic  principle  is  a  gluco- 
side  which  is  a  cardiac  poison.  Other  ingredients  are 
added  to  this  extract.  It  is  affirmed  that  waba  used 
utow  poison  will  kill  a  man  in  a  few  minutes. 
Kombi,  a  poison  obtained  from  different  species  of 
Strophanthus  is  much  used   in  Central  and  Western 


Africa  and    is   far   less    toxic    than  i    fra    fra. 

i.  decoction  is  made  of  the  strophai  apo- 

rated  and  mixed  with  various  ingredients.     The  ti 
action  is  that  of  strophanthus,  arresting  the  heart  in 
systole  in  fifteen  or  more  mi  mite-.     /•;.  huja  i-  a  poison 
pn  pared  from  the  sap  of  species  of  Adenium  which 
exudes  through  the  action  of  heat.     This  Bap  is  very 

10US  and  is  wound  upon  wooden  bobbins.  I'n- 
like  mosl  of  the  arrow  poisons  it  is  a  pure  extract, 
and  is  used  just  as  prepared.  It  is  an  intense  cardiac 
poison    like   the   Others  enumerated  and    is   used   both 

in   German    Wesl     Africa    and   in   Somaliland.     The 
Pygmy  Arrow  Poison  so-called,  is  a  mixture  of  extract 
of    Erythrophlanim   judiciale   and    strychnine   and   is 
powerful    enough    to    kill    elephants.     The    M 
Arrow  Po  I  by  a  single  Central  African  people 

is  of  unknown  composition,  a  moderately  virulent 
cardiac   poison.      L  used    to   some   extent   in 

Herman  I  -last  Africa,  is  also  of  unknown  composition. 
It  is  perhaps  a  mixture  of  species  of  Acocanthera  and 
Euphorbia. 

The  arrow-poisons  used  in  Asia  are  limited  very 
largely  to  the  Malay  Peninsula  and  Fast  Indies.  They 
are  used  to  some  extent,  however,  in  Hindoostan  and 
the  Philippines.  A  poison  known  by  a  variety  of 
native  names,  one  of  which  is  upas,  and  another  poison 
dajaksch,  both  consist  of  or  contain  the  dried  sap  of 
ri's  toxiearia.  These  poisons  are — sometimes  at 
least — mixed  with  a  species  of  Stryehnos  and  other 
ingredients.  The  active  principle  of  the  sap  is  a 
glucoside  which  is  a  cardiac  poison,  the  action  of 
which  resembles  that  of  digitalis.  The  word  upas  or 
ipoh,  with  some  qualification,  is  also  used  for  arrow- 
poison  prepared  from  various  species  of  Stryehnos 
alone.  Some  of  these  poisons  as  they  actually  occur 
should  greatly  resemble  in  composition  and  action  the 
South  American  woorara,  or  curare.  They  are  used 
in  Malacia  and  Borneo,  and  to  some  extent  in  Hindoo- 
stan. The  principal  arrow  poison  used  in  the  latter 
country  contains  aconite;  but  although  it  is  used  very 
extensively  throughout  the  northern  part  of  the 
Empire,  and  is  even  known  in  China  and  Japan, 
authorities  have  little  to  say  about  it.  It  is  no  doubt 
complex  and  secret  in  its  composition.  It  has  re- 
cently been  claimed  that  at  least  one  arrow-poison  in 
India  (that  used  by  the  Abors)  contains  no  aconite 
but  some  other  substance  which  benumbs  the  tongue. 
According  to  Windsor  (British  Medical  Journal, 
Jan.  6,  1912)  the  active  principle  Is  from  the  croton 
oilplant  (not  the  seed).  In  the  Philippines  one  arrow- 
poison  is  in  use  by  the  Negritos.  It  is  said  to  be  pre- 
pared from  a  species  of  Rabelaisia  and  to  be  a  cardiac 
poison. 

The  arrow-poison  used  in  Australasia  is  a  mixture 
of  animal,  vegetable,  and  mineral  matter  and  little 
is  known  or  said  of  it.  While  arrow-poisons  have  been 
and  are  used  extensively  by  the  South  American 
aborigines  they  are  almost  all  of  one  character. 
Known  as  teoorara  or  curare  they  are  obtained  from 
various  species  of  Stryehnos  (see  Curare).  A  few  less 
virulent  poisons  are  used  to  some  extent  in  South  and 
Central  America. 

Authorities  give  sections  on  the  treatment  of  arrow- 
poisoning,  but  this  appears  to  be  largely  founded  on 
a  priori  considerations.  The  rapidity  with  which 
some  of  these  poisons  kill,  and  the  mixture  of  animal 
and  vegetable  poisons,  the  former  comprising  such 
substances  as  snake  venom,  and  cadaveric  and  sep- 
tic poisons  make  antidoting  difficult.  Despite  the 
fact  that  some  of  these  poisons  already  contain 
strychnine  it  is  advised  to  inject  the  alkaloid  to 
antagonize  the  cardiac  failure.  Aside  from  the  gen- 
eral management  demanded  by  any  poison  wound  it  is 
apparently  the  custom  to  apply  permanganate  of 
potash  in  3  per  cent,  solution  locally.  This  oxidizes 
and  destroys  some  of  the  toxic  material,  including  of 
course  all  venoms. 

Edward  Preble. 


G35 


Arrow-poisons 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Literature. 
The  number  of  journal  articles  on  individual  arrow-poisons  is 
too  great  to  be  given  here,  and  moreover  many  of  the  observations 
have  been  made  by  untrained  observers  and  add  little  to  the  knowl- 
edge of  the  subject.  The  reader  may  consult  with  advantage 
"Die  Pfeilgifte  "  by  L.  Lewin,  Berlin,  1894.  The  subject  is  also 
very  well  treated  in  Geissler-Moeller's  Real  Enzyklopiidie  der 
gesamten  Pharmazie,  1904-1912,  and  in  Castellani  and  Chalmer's 
Manual  of  Tropical  Medicine,  1910,  both  of  which  have  been  con- 
sulted in  the  preparation  of  this  article. 


Arrowroot. — Arroivroot  Starch;  Maranta  Starch. 
The  starch  obtained  from  Maranta  arundinacea  L. 
(fain.  Marantacece).  The  genus  Maranta  contains 
some  fifteen  species,  natives  of  tropical  America. 
They  are  perennial  herbs,  with  tuberous  or  thickened, 
starch-laden,  scaly  rhizomes,  and  leafy,  often  branched 
stems. 

The  arrowroot  plant  is  extensively  cultivated  in 
nearly  all  tropical  countries.  A  large  amount  of 
arrowroot  is  now  produced  in  Southern  Asia.  The 
Indian  plant  differs  somewhat  from  the  American, 
but  is  considered  as  only  a  variety  of  it. 

The  early  medicinal  application  of  arrowroot  among 
the  aborigines  appears  to  have  been  as  a  remedy  for 
the  wounds  of  their  arrows,  to  which  it  owes  its  name. 
It  was  both  given  internally  and  applied  as  a  poultice 
on  the  injured  part.  It  was  also  used  as  a  food. 
Accounts  of  its  cultivation  in  the  West  Indies  date 
back  about  150  years,  since  which  time  it  has  been 
an  article  of  general  commerce. 

Arrowroot  is  prepared  in  essentially  the  same  way 
as  other  starches,  namely,  by  washing  -it  out  of  the 
cellular  tissue.  The  yield  is  about  ten  per  cent,  of 
the  fresh  rhizome.  That  of  the  West  Indies,  generally 
called  Bermuda  arrowroot,  is  regarded  as  the  best. 
It  is  a  beautifully  white,  lumpy  powder,  without 
odor  or  taste.  Rubbed  between  the  fingers  it  gives 
a  slight  crackling  sound,  or  rather,  feeling,  for  the 
sensation  is  conveyed  more  through  the  fingers  than 
the  ears.  Its  other  properties  are  simply  those  of 
starch  in  general,  to  which  the  reader  is  referred. 

When  the  antiphlogistic  treatment  of  diseases  was 
more  in  vogue  than  at  present,  arrowroot  took  quite 
an  important  place  in  the  dietary  of  the  sick.  It  was 
also  extensively  used  as  an  ingredient  of  foods  for 
infants.  For  neither  of  these  purposes  is  it  to  be 
much  recommended.  As  a  food,  it  has  scarcely  any 
advantages  over  the  cheaper  indigenous  starches  now 
so  admirably  prepared. 

Florida  arrowroot  is  a  starch  prepared  from  the 
large  fleshy  stem  of  Zamia  integrifolia  Jacq. 

H.  H.  Rusbt. 

Arrowroot,  Indian.     See  Curcuma. 

Arsacetin. — Trade  name  of  sodium  acetyl-arsan- 
ilate,  C,H,O.NH.C„H4AsO(ONa)(OH)+5H_,0._  It  is 
derived  from  sodium  arsanilate  by  the  substitution 
of  a  hydrogen  atom  in  the  amino  group  by  an  acetyl 
radical,  and  may  also  be  prepared  by  adding  acetyl- 
arsanilic  acid  to  a  warm  concentrated  soda  solution. 
It  occurs  in  the  form  of  fine  light  aeicular  crystals, 
without  odor  or  taste,  soluble  in  ten  parts  of  cold 
water  and  about  three  parts  of  boiling  water.  It  is 
employed  in  the  treatment  of  trypanosomiasis,  for 
which  purpose  some  prefer  it  to  atoxyl,  than  which 
it  is  said  to  be  less  toxic  and  more  efficacious.  Good 
results  are  also  claimed  in  the  treatment  of  syphilis, 
given  hypodermically  in  doses  of  gr.  i.  (0.06)  on  two 
successive  days  in  each  week  for  ten  weeks.  In  try- 
panosomiasis (sleeping  sickness)  it  has  been  given  in 
doses  of  gr.  i.-v.  (0.06-0.3)  hypodermically. 


Arsanilates. — These  are  organic  arsenic  eom- 
pounds,  salts  of  arsanilic  acid,  the  latter  being  derived 
iron)  arsenic  acid  by  the  substitution  of  one  of  the 


hydroxyls  (HO)  by  an  aniline  radical.  The  arsan- 
ilates are  employed  in  the  treatment  of  various  pro- 
tozoal diseases,  such  as  trypanosomiasis,  syphilis 
and  yaws.  The  most  commonly  employed  arsan- 
ilates are  arsacetin  (sodium  acetyl  arsanilate)  and 
atoxyl  or  soamin  (sodium  arsanilate).  T.  L.  S. 


Arsenic. — Arsenic  is  a  member  of  the  group  which 
also  contains  nitrogen  phosphorus,  and  antimony. 
It  occurs  free,  but  is  more  often  found  in  combination 
as  a  sulphide.  Its  symbol  is  As,  valence.  III  or  V, 
and  its  atomic  weight  is  75.  It  possesses  a  steel-grav 
color  and  a  pronounced  metallic  lustre. 

General  Medicinal  Properties  op  the  Com- 
pounds  of  Arsenic. — The  predominant  feature  of 
the  action  of  arsenical  preparations  is  intense  irri- 
tation. Locally  applied  in  fairly  concentrated  form 
to  a  denuded  surface  the  irritation  is  so  severe  as  to 
excite  the  extreme  of  reaction,  namely,  gangrenous 
inflammation;  the  part  sloughs,  strangulated  by  con- 
gestion and  inflammation.  Arsenic  is  thus  indirectly, 
and,  because  indirectly,  is  slowly,  painfully,  and 
dangerously  caustic.  When  arsenic  is  used  to  cau- 
terize, there  is  also  a  risk  of  absorption  of  enough  of 
the  mineral  to  produce  constitutional  poisoning,  a 
risk  greater  when  the  application  is  weak  than  v. 
it  is  strong,  since  in  the  latter  case  congestion  is 
developed  early,  whereby  absorption  is  impeded. 
When  arsenic  is  taken  internally,  gastrointestinal 
irritation  is  easily  produced,  a  result  which,  in  acute 
arsenical  poisoning,  constitutes  the  most  prominent 
feature  of  the  derangement.  Apart  from  a  tendency 
to  irritate,  arsenic  is  fairly  antiseptic,  and  in  the, 
higher  organisms,  such  as  man,  has  an  action  upon  the 
nervous  system.  In  arsenical  poisoning  nervous 
symptoms  are  prominent,  and,  therapeutically,  much 
of  the  benefit  of  arsenicals  hinges  upon  the  allaying 
of  nervous  derangements. 

For  the  purposes  for  which  arsenic  is  used  in  medi- 
cine the  remedy  has  to  be  administered  continuously 
for  days,  weeks,  or  months.  In  this  medication  the 
rule  is  so  to  adjust  the  dosage  as  not  to  develop  con- 
stitutional disturbance.  The  initial  symptoms  of 
overdosage  with  arsenic  are,  first,  an  irritation  of  the 
conjunctiva,  showing  itself  in  suffusion  and  smarting 
of  the  eye,  and  edema  of  the  lower  lid;  and  secondly, 
an  irritation  of  the  stomach,  shown  by  failure  of 
appetite  and  soreness  and  sensation  of  weight  at  the 
epigastrium.  In  some  persons  the  gastric  symptoms 
precede  the  conjunctival.  The  two  sets  of  sympti 
should  be  watched  for  in  arsenical  medication,  and 
the  dosage  diminished  or  temporarily  discontinued 
until  their  abatement,  which  speedily  follows  the 
withdrawal  of  the  poison. 

Arsenic  is  valuable  therapeutically  on  account  of: 

Improvement  of  Nutrition. — Even  in  the  healthy 
carefully  graduated  dosage  with  arsenic  tends  to  im- 
prove general  nutrition,  the  individual  fattening,  the 
skin  being  specially  rosy  and  smooth,  or,  in  animals 
the  fur  sleek  and  glossy,  and  the  bones  thick  and  dense. 
In  the  case  of  the  so  called  arsenic  eaters  of  Styria,  the 
women  are  said  to  indulge  for  the  beautifying  of  their 
complexion,  and  the  men  for  an  improvement  of  wind 
and  increased  physical  endurance  which  they  claim 
to  derive  from  the  use  of  arsenic.  This  habit  of  regu- 
lar consumption  of  arsenic  among  certain  of  the  work- 
ing class  in  Styria  seems  now  established  as  a  fact  by 
competent  and  reliable  testimony.  Arsenous  acid 
is  the  preparation  commonly  used,  and  the  daily 
allowance  has  been  known  to  reach  five  and  even  tea 
grains.  But  attempts  in  other  countries  to  acquire 
the  tolerance  of  the  poison  which  the  Styrian  peas- 
antry show  commonly  end  in  disaster.  The  prop- 
erty of  arsenic  to  modify  nutrition  is  utilized  prin- 
cipally in  the  following  diseases:  Progressive  per- 
nicious anemia:     In   this  affection,  where  iron  is  so 


63G 


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Arsenic 


lotoriously  futile,  arsenic  has  in  many  cases  proved 

,i  great  benefit,  patients  even  recovering  fully  under 

tsuse.     Scaly  skin  diseases:   In  skin  diseases  arsenic 

more  or  less  used,  bu(  experience  shows  that  it  is 

•!,  more  likely  to  be  of  benefit  in  affections  of  the 

pidermis  than  in  those  involving  the  corium.     Psori- 

,    a  typical  disease  of  the  runner  kind,  and  in  its 

reatment  arsenic   is   a  standard    remedy.     At    the 

icginning  of  an  arsenical  course  the  symptoms  often 

utter  an  exacerbation,  but  this  commonly  subsides 

B   few  davs.     The   medicine  should   not    be  pre- 

oribed  during  the  inflammatory  stage  <>f  a  skin  dis- 

nit  when  used  should  bo  persisted  in  for  weeks 

en    months  after   apparent   cure.     Under   all 

imstances,  the  remedial  action  is  slow. 

o\     of     Veuroses. — The    property    of    arsenic 

o  affect  nerve   functions,  seen   in    the   nervous  phe- 

omena  that  attend  arsenical  poisoning,  shows  itself 

lerapeutically  in  a  tendency  to  abate  pain,  spasm, 

m.|  undue  reflex  irritability.     The  property  is  util- 

.1    most    especially    in    the    following    conditions: 

irritability:     In    idiopathic    dyspeptic    irri- 

abUity  of  the  stomach,  or  in  the  irritability  at  tend  ins; 

lie  chronic  gastritis  of  drunkards,  or  ulcer  or  cancer 

if  the  stomach,  arsenic  is  often  of  considerable  benefit, 

md  is  especially  efficacious  when  the  nervous  dis- 

urbance   is   disproportionately   great.     Neuroses   of 

he    respiratory    organs:      Some     asthmatics    find    a 

■rtain  amount  of  temporary  relief  from  arsenic,  a 

vlief  more  likely  to  be  obtained  in  the  pure  neurotic 

orni  of   the  disease   than   when   the  symptoms  are 

econdary   to  bronchitis,  emphysema,  or  disease  of 

he   hi':  rt.     Yet  the  nerve  irritation  in  coryza  may 

ie  relieved,   and,  according   to   Ringer,  paroxysmal 

rig   is  often  promptly   averted   by  the  remedy, 

tcept   when  caused  by  true  hay  fever  the  result  of 

lie  inhalation  of  pollen.     In  chorea  arsenic  is  prob- 

ibly  the  most  generally    serviceable    of   medicines. 

Simple   uncomplicated   cases   recover  under  the  use 

if  the  remedy  more  frequently  than  not.     Neuralgia 

tlso   sometimes   yields  to  arsenic,  more  particularly 

ivhen  the  attacks  show  a  regular  periodicity  of  onset; 

D   other  words,  when  the  affection  is  very  likely  of 

nalarial  origin.    Other  neuroses  also,  such  as  angina 

lectoris,  and  even  epilepsy,  have  occasionally  been 

rented    by    arsenic,    and    isolated   cases  have  been 

•eported  in  which  benefit  has  been  claimed  from  the 

medication. 

Besides  the  foregoing,  arsenic  has  been  used  in  a 
_'reat  variety  of  diseases  on  the  general  principle  of 
being  an  "alterative,"  with  alleged  success  in  many 
uses. 

The  Preparations  of  Arsenic  Used  in  Medi- 
cine.— The  arsenical  compounds  used  in  medicine 
ire  the  trioxide  (arsenous  acid),  triiodide,  and  the 
dts,  potassium  arsenite  and  sodium  arsenate. 

Arsenic  Trioxide,  As.,03.  This  well  known  com- 
pound is  official  in  the  U.  S.  P.  as  Arseni  Trioxidum. 
This  is  the  preparation  known  also  as  white  arsenic, 
or,  in  common  parlance,  simply  arsenic.  Arsenic 
trioxide  occurs  either  as  an  opaque  white  pow'der, 
or  in  irregular  masses  of  two  varieties:  one  amor- 
phous, transparent  and  colorless,  like  glass;  the  other 
crystalline,  opaque  or  white,  resembling  porcelain. 
Frequently  the  same  piece  has  an  opaque,  white, 
outer  crust  enclosing  the  glassy  variety  within.  Con- 
taot  with  moist  air  gradually  changes  the  glassy 
into  the  white,  opaque  variety.  Both  are  odorless 
and  tasteless.  In  cold  water  both  varieties  dissolve 
very  slowly,  the  degree  of  solubility  varying  according 
to  conditions  and  time,  the  glassy  variety  requiring 
about  30,  the  porcelain-like  about  100  parts  of  water 
at  25°  C.  (77°  F.).  Both  are  slowly  but  completely 
soluble  in  fifteen  parts  of  boiling  water.  In  alcohol 
arsenic  trioxide  is  but  sparingly  soluble,  but  it  is 
soluble  in  about  five  parts  of  glycerin.  Oil  of  turpen- 
tine dissolves  only  the  glassy  variety.    Both  varieties 


are  freely  soluble  in  hydrochloric  acid,  and  in  volu- 
tions of  alkali  hydroxides  and  carbonates.  (U.  S.  P.) 
Arsenic  trioxide  is  obtained  by  sublimation,  by  roast- 
ing ores  containing  arsenic,  and  is  subsequently 
purified  by  resubumation.  tor  medical  use  the 
mineral  is  pulverized,  appearing  then  as  a  very 
fine,  white,  smooth  powder,  In  this  condition  it  is 
easily  adulterated,  but  the  fraud  can  readily  be 
detected    by    submitting    the    sample   to  sublimation, 

when  the  arsenic  trioxide  will  till  disappear  by 
volatilization,  and  the  impurities  be  declared  by  a 
non-volat tie  residue. 

Arsenic  trioxide  possesses  all  the  physiological 
properties  of  arsenicals,  a-  set  forth  above.     It  does 

nni  act  upon  the  sound  skin,  but  upon  a  mucous 
membrane  or  denuded  surface  produces  violent  irrita- 
tion.    Taken    internally   it   is   capable   of   sufficient 

absorption  to  produce  the  constitutional  effects  of 
arsenic,  therapeutic  or  toxic,  and  so  may  be  used  as 
a  medicine,  in  doses  of  gr.  ,,\T  (0.002)  three  limes 
a  day,  generally  given  in  pill.  But  it  is  not  an 
eligible  preparation  for  internal  use,  because  of  the 
local  irritation  it  is  apt  to  set  up.  Externally  it  has 
been  employed  to  destroy  the  tissues  of  cancer  or 
lupus,  applied  in  ointment  or  paste.  For  such  pur- 
pose the  arsenic  trioxide  is  mixed  with  from  four  to 
eight  times  its  weight  of  inert  matter,  such  as  oint- 
ment or  a  paste  made  of  some  indifferent  powder 
mixed  with  mucilage.  Such  arsenical  ointment  or 
paste  is  then  applied  to  the  tissue  to  be  destroyed, 
the  point  being  observed,  if  the  part  be  covered  by 
skin,  first  to  remove  the  epithelium  by  blistering. 
The  application  is  to  continue  for  from  twelve  to 
twenty-four  hours.  Weak  arsenical  mixtures  are 
more  dangerous  than  strong,  because  of  the  greater 
likelihood  of  constitutional  poisoning.  Even  strong 
applications,  if  at  all  extensive,  are  risky,  and  at 
best  the  destruction  of  tissue  by  arsenic  is  a  slow, 
uncertain,  and  very  painful  process,  not  to  be  com- 
mended. Most  of  the  numberless  caustic  pastes  of 
quack  "cancer  doctors"  are  preparations  of  arsenic 
trioxide.  The  only  preparation  of  arsenic  trioxide 
official  in  the  U.  S.  P.  is  what  is  entitled  Liquor  Acidi 
Arsenosi,  Solution  of  Arsenous  Acid.  This  is  a  one- 
per-cent.  solution  of  the  arsenical  in  water  slightly 
acidulated  with  hydrochloric  acid.  The  preparation 
is  of  the  same  strength  as  Fowler's  solution  (see 
below),  and  is  given  in  doses  of  njt  iii.  (0.2)  three  times 
a  day,  largely  diluted  with  water. 

Arsenic  Triiodide,  Asl3. — This  compound  is  official 
in  the  U.  S.  P.  as  Arseni  Iodidum,  Arsenic  Iodide. 
It  is  "an  orange-red,  inodorous,  crystalline  powder, 
stable  when  protected  from  direct  sunlight  and  kept 
in  a  cool  place.  Soluble,  with  partial  decomposition, 
in  about  twelve  parts  of  water,  and  in  about  twenty- 
eight  parts  of  alcohol  at  25°  C.  (77°  F.);  completely 
soluble  in  chloroform,  carbon  disulphide,  or  ether. 
No  loss  of  iodine  occurs  when  arsenous  iodide  is 
heated  upon  a  water  bath,  but  at  higher  temperatures 
it  completely  volatilizes.  When  warmed  with  a  few 
drops  of  nitric  acid,  brown  vapors  of  nitrous  oxide 
are  evolved,  followed  by  violet  vapors  of  iodine. 
The  aqueous  solution  has  a  yellow  color,  is  neutral  to 
litmus  paper,  and  upon  standing  gradually  decom- 
poses into  arsenous  and  hydriodic  acids."  (U.  S.  P.) 
This  iodide  has  been  given  internally  as  an  arseni- 
cal in  doses  of  gr.  ^  (0.005),  and  used  externally  on 
malignant  growths  in  a  one-per-cent.  ointment;  but 
its  principal  purpose  among  medicines  is  to  furnish 
the  pharmacist  with  the  arsenical  ingredient  of  the 
official  preparation,  Liquor  Arseni  et  Hydrargyri 
lodidi,  Solution  of  Arsenous  and  Mercuric  Iodides, 
commonly  known  as  Donovan's  Solution.  This  is  an 
aqueous  solution  of  one  per  cent,  each  of  arsenous 
iodide  and  red  mercuric  iodide.  It  is  a  pale  yellow 
fluid,  slightly  astringent  in  flavor,  and  precipitating 
with  alkalies,  silver  solutions,  and  solutions  of  alka- 
loidal  salts.     It  is  used  as  a  composite  "alterative" 


637 


Arsenic 


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internal  medicine,  its  reputation  being  principally 
in  the  line  of  .scaly  skin  disease,  syphilitic  or  idio- 
pathic, and  in  rheumatic  affections.     Dose,  m>  iss.  (0.1). 

Potassium  Arsenite. — An  arsenite  of  potassium  is 
official  in  the  U.  S.  P.  only  in  the  solution  entitled 
Liquor  Polassii  Arsenitis,  Solution  of  Potassium 
Arsenite,  better  known  by  the  common  name  of 
Fowler's  Solution.  This  solution  is  made  by  boiling 
one  part  of  arsenic  trioxide  and  two  of  potassium 
bicarbonate  in  water  until  chemical  union  is  effected, 
then  bringing  the  solution  to  the  standard  strength 
of  one  per  cent,  of  arsenic  trioxide,  and  adding  three 
parts  of  compound  tincture  of  lavender.  This  latter 
addition  is  to  give  the  preparation  sufficient  taste  and 
color  to  prevent  its  being  mistaken  for  simple  water. 
Fowler's  solution  is  clear,  and  tastes  only  of  lavender. 
It  responds  to  the  usual  tests  for  arsenic.  Physio- 
logically it  acts  the  same  as  would  a  solution  of 
arsenic  trioxide  of  like  strength.  It  was  originally 
prepared  in  imitation  of  a  famous  remedy  known  as 
"tasteless  ague  drop,"  and  is  the  most  convenient 
and  commonly  used  arsenical  for  internal  administra- 
tion. The  average  dose  is  gtt.  iii.-v.  (0.2-0.3),  well 
diluted  with  water,  to  be  taken,  like  all  arsenicals, 
after  eating,  and  repeated  two  or  three  times  a  day. 

Sodium  Arsenate,  Na,HAs04 +7H,0. — The  salt  is 
official  under  title  Sodii  Arsenas,  Sodium  Arsenate. 
It  occurs  in  "colorless,  transparent,  monoclinic 
prisms,  odorless,  and  having  a  mild,  alkaline  taste; 
it  should  be  tasted  with  great  caution  as  the  salt  is 
very  poisonous.  Efflorescent  in  dry  air,  and  some- 
what deliquescent  in  moist  air.  Soluble  in  1.2  parts 
of  water  at  25°  C.  (77°  F.).,  and  very  soluble  in  boiling 
water;  very  sparingly  soluble  in  cold,  but  nearly 
insoluble  in  boiling  alcohol.  When  gently  heated, 
the  salt  loses  five  molecules  of  water  (28.8  per  cent.), 
and  is  converted  into  a  white  powder.  At  148°  C. 
(298.4°  F.)>  the  rest  of  the  water  of  crystallization  is 
lost,  the  salt  fuses,  and  at  a  red  heat  is  converted  into 
pyroarsenate."  (U.  S.  P.)  Sodium  arsenate  has  the 
usual  properties  of  the  arsenicals,  but  is  a  little  milder 
than  potassium  arsenite.  '  It  is  generally  prescribed 
in  the  official  Liquor  Sodii  Arsenatis,  Solution  of 
Sodium  Arsenate,  which  is  simply  a  one-per-cent. 
aqueous  solution  of  the  salt.  This  solution  may  be 
given  in  the  same  dose  and  manner  as  Fowler's 
solution. 

Exsiccated  Sodium  Arsenate,  Na2HAsO„  containing 
not  less  than  ninety-eight  per  cent,  of  the  pure  anhy- 
drous salt,  is  official  under  the  name  Sodii  Arsenas 
Exsiccatus.  "An  amorphous,  white  powder;  odor- 
less, and  having  a  mildly  alkaline  taste;  it  should  be 
tasted  with  great  caution,  as  the  salt  is  very  poisonous. 
Permanent  in  dry  air.  Soluble  in  three  parts  of  water 
at  25°  C.  (77°  F.),  and  very  soluble  in  boiling  water; 
very  sparingly  soluble  in  cold,  but  nearly  insoluble  in 
boiling  alcohol.  When  heated  to  150°  C.  (302°  F.), 
the  salt  should  not  lose  weight;  at  red  heat  it  is  con- 
verted into  pyroarsenate.  It  imparts  an  intense 
vellow  color  to  a  non-luminous  flame."  (U.  S.  P.) 
Dose,  gr.  ^  (0.003). 

R.  J.  E.  Scott. 

Arteries,  Anatomy. — See  articles  on  the  various 
regions — Abdomen,  Arm  and  Forearm,  Leg,  Neck,  etc. 

Arteries,  Anomalies  of. — Arteries  are  subject  to 
frequent  variations  of  size,  origin,  and  distribution. 
Some  of  these  are  so  common  that  it  is  difficult  to 
decide  what  is  the  normal  condition.  Many  anoma- 
lous arteries  are  merely  a  persistence  of  an  early  fetal 
condition,  others  are  reversions  to  forms  of  distribu- 
tion which  are  natural  in  the  various  species  of  the 
lower  animals,  while  some  are  due  to  an  abnormal 
enlargement  or  diminution  of  vessels  which  naturally 
exist.  I  propose  in  the  present  article  chiefly  to 
describe  those  anomalies  which  are  important  surgi- 
cally— that  is,  those  which  exist  in  parts  liable  to  dis- 


ease which  necessitate  a  surgical  operation  for  theii 
cure  or  relief.  However  interesting  would  be  a  con- 
sideration  of  anomalies  of  arteries  from  a  morpholog- 
ical point  of  view  to  pure  anatomists,  I  fear  the  sub- 
ject is  not  of  sufficient  interest  to  the  general  profession 
to  justify  me  in  devoting  much  space  to  it  here. 

Aorta. — This  vessel  is  subject  to  many  variations. 
It  may  vary  in  length  and  position.  The  summit  ot 
the  arch  has  been  seen  as  high  as  the  top  of  the  sternum 
and  as  low  as  the  fifth  dorsal  vertebra.  The  distance 
to  which  it  reaches  on  the  spine  before  dividing  into 
the  two  common  iliacs  also  varies,  the  point  of  division 
being  occasionally  as  low  as  the  fifth,  and  as  high  as 
the  third,  or  even  the  second  lumbar  vertebra.  The 
aorta  has  been  seen  consisting  of  two  closely  united 
tubes,  in  part  or  the  whole  of  its  course,  due  to  a  per- 
sistence of  the  original  double  aorta  of  early  fetal  life 
(Fig.  354).  The  aorta  is  sometimes  very  tortuous,  of 
large  size,  and  displaced  to  one  side,  especially  in  old 
people,  but  this 
condition  is  due  a  /^T\ 
more  to  patho- 
logical changes 
than  to  congen- 
ital malforma- 
tion. 

The  m  a  i  n 
trunks  of  the 
aorta  and  pul- 
monary artery 
are  (4,  Fig.  354) 
both  derived 
from  the  arte- 
rial bulb  of  the 
fetal  heart, 
"and  are  liable 
to  variations 
which  may  be 
traced  to  devia- 
tions from  the 
natural  mode  of 
their  septal  di- 
vision and  of 
th  eir  union 
with  the  left  or 
right  ventricles 
of  the  heart 
respectively" 
(Quain's  "An- 
atomy"). These  variations  are  generally  associated 
with  malformations  of  the  heart,  and  often  with  pa- 
tency of  the  ductus  arteriosus.  The  aortic  or  pul- 
monary trunk  may  be  almost  obliterated,  or  the  two 
trunks  may  communicate  freely  with  each  other,  ow- 
ing to  the  failure  of  complete  septal  division;  again, 
their  origins  may  be  transposed,  the  pulmonary  an 
arising  from  the  left  ventricle  and  the  aorta  from 
the  right.  A  very  rare  anomaly  has  been  reported 
where  the  pulmonary  artery  and  aorta  form  one 
stem  which  arises  from  a  simple  heart  like  that  seen  in 
fishes.  A  few  cases  are  reported  in  which  the  de- 
scending aorta  arose  from  the  pulmonary  artery  and 
gave  off  the  left  subclavian,  the  left  ventricle  giving 
off  only  the  innominate  and  left  carotid.  Most  of 
these  varieties  are  incompatible  with  life,  and  are 
fully  described  in  works  on  pathological  anatomy. 

Varieties  of  the  Aortic  Arch. — The  various  anomalies 
of  the  aortic  arch  depend  on  the  mode  of  develop- 
ment of  the  fourth  and  fifth  fetal  branchial  arches. 
In  man  and  nearly  all  mammalia  the  arch  is  a  left  one, 
produced  l\\  i  lie  per-  \  tence  of  i  he  fourl  h  left  branchial 
arch  (Fig.  355).  In  birds  the  permanent  aorta  i 
formed  from  the  right  fourth  branchial  arch;  and  in 
reptiles  both  the  right  and  left  fourth  branchial  arches 
are  persistent.  In  cases  in  which  there  is  transposition 
of  the  heart,  and  also,  of  course,  of  the  arch  of  the 
aorta,  the  aorta  is  a  right  one,  instead  of  the  usual  left, 


5' 

Fig.  354. — Diagrammatic  Outlines  of  Heart 
and  First  Arterial  Vessels  of  the  Embryo,  as 
Seen  from  the  Abdominal  Surface.  4.  Aortic 
bulb;  5,  5,  the  primitive  aortic  arches  and  their 
continuation  as  the  descending  aorta.  These 
vessels  are  separate  in  their  whole  extent  in  .1 
(36  to  38  mm.  in  thickness),  but  at  a  later 
period,  as  shown  more  fully  in  C,  have  coal- 
esced into  one  tube  in  a  part  of  the  dorsal 
region.  In  B,  below  upper  5.  the  second 
aortic  arch  is  formed  and  farther  down  the 
dotted  lines  indicate  the  position  of  thesuo- 
ceeding  arches,  numbering  five  in  all.  (Quain's 
"Anatomy.") 


638 


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Arteries,    Anomalies  Of 


md  this  is  owing  to  the  persistence  of  the  right  fourth 
branchial  arch,  as  in  birds.  The  pulmonary  artery  in 
hese  cases  i>  also  transposed  and  is  formed  from  the 
ighl  fifth  arch  in  place  of  from  the  left.     .Many  of 

these    cases    have 
ct\l\  <^«,  /I/0*       been  reported  and 

have  been  diag- 
nosed during  life, 
the.  direct  ion  of  I  he 
apex;  of  the  heart 
being  toward  the 
right,  the  apex  beat 

being    felt     on     the 

right  side  between 

the  fifth  and  sixth 
ribs.  A  very  good 
specimen  of  this 
anomaly  is  to  be 
seen  in  the  museum 
of  the  Pennsylva- 
nia Hospital  in 
Philadelphia. 

Occasionally  the 
aortic  arch  has 
been  observed  coin- 
Iil  itely  double  dig. 
356),  as  in  reptiles, 
due  to  the  persis- 
tence of  both  right 
and  left  aortic  roots 
(a,  a',  Fig.  355)  and 
the  fourth  bran- 
chial arches  of  both 
sides.  The  double 
aorta  embraces  the 
trachea  and  esoph- 
agus, and  unites 
below  to  form  a 
single  trunk  on  the 
left  side  of  the 
spinal  column,  as  in 
early  fetal  life   (B, 


Fig.  355. — Diagram  of  the  Fetal  Aortic 
,  Showing  Their  Transformation 
the  Permanent  Vessels  of  the  Mam- 
mal.   (After  Rathke.)     The  permanent 
are   represented    by    the   deep 
tg,  the  pulmonary  arteries  lighter, 
tporary  primitive  arehes  in  out- 
iv.    A,  P,  Primitive  aortic  stem, 

[  into  A,  aortic  arch,  P,  pul - 

nary  artery;  a,  right  aortic  root:  a'  left 

i<  root:  A' ,  descending  aorta;  1,  2,  3, 

1,  5,  primitive  vascular  arches;  pn,  pn' , 

ml  left  pneumogastric  nerves;  '', 

,-'.  right  and  left  vertebrals;  s,  s',  right 

Etnd  left  subclavians;  ce,  external  caro- 

.  ri',  internal  carotids.      (From 

Quoin's  "Anatomy.") 


Fig.  354). 

The  aorta  may  pass  to  the  right  of  the  trachea  and 
esophagus  instead  of  to  the  left,  and  this  without 
the  transposition  of  the  heart  mentioned  above. 
If  we  study  the  fetal  conditions  the  explanation  of 
this  anomaly  is  easy.  It  is  a  persistence  of  the  right 
fourth  branchial  arch  and  aortic  root  instead  of  the 
left  i  Fig.  355).  In 
these  cases  the  re- 
current laryngeal 
nerve  of  the  left  side 
hooks  around  the 
subclavian,  and 
that  of  the  right 
around  the  arch  of 
the  aorta.  In  some 
of  the  cases  of  right 
arch  that  have  been 
observed  the  left 
subclavian  arose 
from  the  back  part 
of  the  descending 
aorta,  passed  be- 
hind the  trachea, 
I  reached  its 
usual  position  in  the 
neck    between    the 

alene  muscles.  In 
9  of  this  kind 
tlie  first  part  of  the 
subclavian  being 
absent,  owing  to 
the  non-develop- 
ment,  or  rather  obliteration,  of  the  fourth  left 
ular  arch,  the  inferior  laryngeal  nerve  does 
not  hook  around  it,  but  goes  directly,  to  the  larynx, 


Fig.  356. — Example  of  a  Double 
Ascending  Aorta,  from  the  Arch  of 
Which  Arise  Six  Branches  —  Two 
Subclavian  and  Four  Carotid  Arteries. 
(After  Malacarne.) 


I'm,.    357.  - 


T  h  e 


Right  Subclavian  Ar- 
tery Displaced  or 
Proceeding  from  the 
Right  Aortic    Root. 


a,  right  aortic  root 
mg  as  thesub- 
claviau  artery;  a', 
left  aortic  root;  P, 
pulmonary  artery. 
(Q  u  a  in  's  "Anat- 
omy.") 


and  the   vertebral   artery  may  arise  directly  from  the 
arch. 

Variations  in  Number  and  I' f  the  Bran 

of  the  Arch  of  the  Aorta.-  These  variations  are  very 
numerous;  1  shall  mention  only  the  most  common 
and  important.  The  branches  of  the  aortic  arch 
may  be  gi-,  en  off  from  a  single  I  riink, 
which  forms  what  is  called  the  an- 
terior aorta.      This   arrangement   is 

seen  in  the  horse.  'I  he  common- 
e  t    abnormal  arrangement  of   the 

branches     is    thai     where     the    left 

carotid  arises  from  the  innom- 
inate; 1 1 1 1 1 3  only  two  bfanchi  are 
given  off  from  the  arch,  the  left 
subclavian    and    the    innominate* 

This  is  the  usual  distribution  in 
most  of  the  carnivora.  There  may 
lie  two  Denominates  given  oil'  from 
the  arch,  each  dividing  into  a 
carotid  and  subclavian,  as  in  the 
bat.  Three  branches  is  the  normal 
number  arising  from  the  arch  in 
man,  apes,  and  a  few  other  animals. 
i  Iccasionally  we  see  three  branches 
A,  A',  ascending  and  arisjng  from  the  arch  in  a  different 
descending     portion  from   the  normal.        We   may 

;  have  the  two  subclavians  arising 
separately,  and  the  two  carotids 
arising  from  a  common  stem  be- 
tween them.  This  is  the  normal 
disposition  in  some  cetacea.  Some- 
times  all  four  vessels  arise  sepa- 
rately from  the  arch.  Again,  the 
left  vertebral  may  arise  from  the 
arch,  while  the  other  branches  preserve  the  normal 
arrangement,  or  there  may  be  five  branches  given  off 
separately,  viz.,  the  two  subclavians,  two  carotids,  and 
left  vertebral.  As  many  as  six  branches  have  been 
seen  to  come  off  from  the  aortic  arch.  This  occurs 
when,  in  addition  to  the  above-mentioned  five 
branches  the  right  vertebral  is  also  given  off.  A 
curious  anomaly,  and  one  which  is  interesting  from  its 
rarity  and  manner  of  development,  is  that  form  of 
arch,  where  the  right  and  left  carotids  and  left  sub- 
clavian arises  separately  from  the  arch,  and  the  right 
subclavian  arises  from  the  back  part  of  the  descending 
aorta,  passes  behind  the  trachea  and  esophagus  and 
ascending  portion  of  the  arch, 
and  reaches  its  normal  place 
between  the  scalene  muscles 
(Fig.  357).  In  this  case  the 
right  inferior  laryngeal  nerve, 
instead  of  hooking  round  the 
subclavian,  passes  directly  to 
the  larynx.  The  subclavian 
here  represents  the  persistent 
right  aortic  root,  and  the 
right  fourth  branchial  arch  is 
obliterated  (see  Fig.  355). 
Some  years  ago  I  met  with  a 
curious  anomaly  having  some- 
what this  character.  I  looked 
upon  it  as  a  double  sub- 
clavian. The  right  subcla- 
vian was  given  off  as  usual 
from  the  innominate,  but  was 
joined  in  the  second  part  of 
its  course,  between  the  scalene 
muscles,  by  a  small  branch 
which  arose  from  the  back 
part  of  the  descending  aorta.  I  considered  this  a  case 
of  persistence  of  the  fourth  right  vascular  arch,  and  also 
of  the  right  aortic  root  (Fig.  358).  (lor  a  complete  de- 
scription of  the  very  many  varieties  of  the  arch  of  the 
aorta,  see  Turner  on  "  Varieties  of  the  Arch  of  the 
Aorta,"  in  Brit,  and  For.  M ,  d.-Chir.  I\<  r.,lS62;  Henle's 
"  Anatomy,  "  vol.  iii.;  Hyrtl;  and  Professor  Struthers.) 


Fig.  358.— Right  Aortic 
Root  Persisting  as  a  Small 
Branch  Which  Connects 
theDescending Aort;,  with 
the  Subclavian.  May  be 
regarded  as  an  example  of 
double  subclavian. 


039 


Arteries,  Anomalies  of 


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Innominate,  or  Brachiocephalic. — This  artery 
occasionally  varies  as  to  the  point  of  its  division.  In 
some  cases  it  divides  above  the  sternoclavicular  artic- 
ulation, and  in  others  considerably  below  it.  When 
there  is  a  high  division,  there  is  danger  of  its  being 
wounded  in  tracheotomy,  especially  in  those  cases  in 
which  the  artery  inclines  to  the  median  line.  In 
cases  of  ligature,  however,  the  operation  would  be 
much  facilitated  by  a  high  division,  and  rendered 
much  more  difficult  by  a  low  one. 

The  thyroidea  ima  or  middle  thyroid  (Fig.  359)  is  not 
infrequently  given  off  from  the  innominate,  and  as- 
cends to  its  destination  in  front  of  the  trachea.  When 
present  it  would  complicate  the  operations  of  trache- 
otomy and  excision  of  the  thyroid  gland.  In  observa- 
tions by  myself  on  250  subjects,  I  found  that  this  artery 
occurred  twelve  times  or  once  in  20.83  cases.  Richard 
Quain,  in  his  valuable  work  on  the  arteries,  found  it 
nine  times  in  291  subjects,  or  once  in  32.33.  It  is 
sometimes  of  large  size,  dividing  into  two  branches, 
one  of  which  goes  to  each  lobe  of  the  thyroid  gland. 

This  artery  sometimes  arises  from  the  right  common 
carotid,  and  rarely  from  the  arch  of  the  aorta  between 
the  left  carotid  and  innominate. 

Common  Carotid  Arteries. — These  vessels  may 
vary  in  their  origin  and  place  of  division.  The  right 
carotid  occasionally  arises  directly  from  the  arch  of  the 

aorta  either  alone  or  with 
the  left  carotid.  In  the 
latter  case  the  artery,  to 
reach  its  usual  position  on 
the  right  side,  crosses  the 
trachea  above  the  upper 
border  of  the  sternum,  a 
fact  worth  remembering 
in  connection  with  the 
operation  of  tracheotomy. 
It  may  arise  above  or  be- 
low the  sterno-clavicular 
articulation,  according  as 
the  innominate  is  longer 
or  shorter  than  usual.  The 
left  carotid  varies  more 
frequently  in  origin  than 
the  right,  as  it  is  derived 
from  the  innominate  in 
about  one  case  in  nine. 
It  may  also  arise  from  the 
arch  in  common  with  the 
right  carotid. 

Place  of  Division. — 
The  common  carotid  often 
varies  as  to  its  place  of  division.  The  normal  divid- 
ing point  is  opposite  the  upper  border  of  the  thyroid 
cartilage,  but  it  sometimes  divides  as  high  up  as  the 
hyoid  bone,  and  as  low  down  as  the  cricoid  cartilage. 
Morgagni  reports  a  case  in  which  it  divided  at  the  root 
of  the  neck.  Cases  are  recorded  in  which  it  did  not 
divide  at  all,  one  or  other  of  its  main  branches  being 
absent.  I  have  occasionally  seen  this  artery  give 
off  the  superior  thyroid  and  ascending  pharyngeal 
before  its  division,  and  also  a  small  laryngeal.  I 
also  once  saw  the  left  carotid  giving  off  the  left 
vertebral. 

External  Carotid  and  Its  Branches. — As  men- 
tioned above,  the  origin  of  the  external  carotid  varies 
considerably.  It  has  in  rare  cases  been  noticed 
arising  from  the  innominate,  and  even  from  the  arch 
of  the  aorta  itself.  Absence  of  this  artery  has  been 
met  with,  the  branches  arising  at  varying  intervals 
from  a  common  trunk,  representing  both  internal 
and  external  carotids.  The  artery  sometimes  passes 
between  the  digastric  muscle,  and  stylohyoid.  I 
have  in  one  case  seen  it  pass  up  to  the  parotid  gland 
superficial  to  both  the  posterior  belly  of  the  digastric 
and  the  stylohyoid,  instead  of  behind  them. 

The  origin  of  the  branches  varies  considerably;  they 

640 


T.I.— 


Fig.  359. — Showing  a  Middle 
Thyroid  Artery  (T.I.)  Arising 
from  the  Innominate  and  Run- 
ning up  the  Front  of  the  Trachea 
to  Supply  the  Thyroid  Gland. 
(From  R.  Quain,  sligh  tly 
altered.) 


may  be  crowded  together  at  the  commencement  ol 
the  vessel,  or  at  a  point  higher  up.  Sometimes  they 
arise  from  the  main  trunk  at  nearly  regular  intervals 
and  occasionally  we  find  several  branches  arising 
from  a  single  stem.  Accessory  arteries  may  arise 
from  _  the  external  carotid,  such  as  the  accessory 
superior  thyroid  and  accessory  ascending  pharyngeal. 
The  sternomastoid,  which  usually  arises  from  the 
occipital,  occasionally  arises  from  the  main  trunk, 
and  when  this  occurs  the  hypoglossal  nerve  hook- 
around  this  small  branch  instead  of  around  the  oci  i 
pital.  In  consequence  of  the  lower  origin  of  the 
sternomastoid,  the  nerve  in  such  eases  passes  lower 
down  the  neck  before  crossing  the  vessels  to  reach  the 
hyoglossus  muscle. 

Superior  Thyroid. — This  vessel  may  be  very  small 
or  absent,  its  place  being  taken  by  the  artery  of  the 
opposite  side  and  the  inferior  thyroid  of  the  same 
side.  It  sometimes  arises  from  the  common  carotid. 
The  cricothyroid  may  be  of  considerable  size,  and  its 
superior  laryngeal  branch  may  arise  from  the  main 
trunk,  or  pierce  the  thyroid  cartilage  instead  of  the 
thyrohyoid  membrane,  as  is  the  case  in  many  mam- 
mals. Mr.  Walsham  ("St.  Bartholomew's  Hosp. 
Rep.,"  1880)  has  several  times  met  with  a  large 
branch  from  the  superior  thyroid  crossing  the 
trachea  between  the  cricoid  cartilage  and  isthmus 
of  the  thyroid.  He  once  wounded  it  in  performing 
tracheotomy. 

Lingual. — This  artery  often  arises  in  common  with 
the  facial,  and  occasionally  with  the  superior  thyroid. 
Instead  of  passing  beneath  the  hyoglossus  muscle 
it  has  been  seen  to  pierce  it. 

In  some  rare  cases  it  has  been  absent,  and  its  place 
has  been  taken  by  a  branch  from  the  internal  maxil- 
lary. Its  place  has  been  taken  also  by  a  branch 
from  the  facial,  the  submental.  Its  sublingual 
branch  is  occasionally  derived  from  the  facial.  The 
hyoid  branch  is  often  wanting,  and  in  such  cases  the 
hyoid  branch  of  the  superior  thyroid  takes  its  place. 
The  lingual  sometimes  gives  off  the  submental 
and  ascending  palatine  artery.  In  one  case  of  opera- 
tion on  the  dead  subject,  the  writer  could  not  find 
the  artery  in  the  usual  place,  but  it  was  found  coming 
off  from  the  superior  thyroid  passing  up  to  the 
median  line  of  the  neck  on  the  thyrohyoid  muscle. 
It  crossed  the  hyoid  bone  internal  to  the  lesser  cornu, 
pierced  the  hyoglossus  muscle,  and  thence  onward 
its  course  was  normal  (Annals  of  Surgery,  vol.  ix. 
1889,  p.  33). 

Facial. — This  artery  is  very  variable  in  size  and 
also  in  extent.  When  the  facial  is  deficient  its  place 
is  taken  by  the  transverse  facial,  internal  maxillary. 
or  ophthalmic,  most  frequently  the  first  mentioned. 
Occipital. — This  artery  usually  arises  opposite 
the  facial,  but  its  place  of  origin  may  be  above  or 
below  this  point.  Sometimes  it  is  derived  from  the 
internal  carotid  or  the  ascending  cervical  branch  of 
the  inferior  thyroid.  It  occasionally  passes  to  its 
destination  superficial  to  the  trachelomastoid  mus- 
cle, or  it  may  pierce  the  sternomastoid  and  splenius 
capitis  muscles.  R.  Quain  mentions  a  case  in  which 
it  passed  superficial  to  the  sternomastoid  muscle. 
It  not  infrequently  gives  off  the  posterior  auricular 
and  ascending  pharyngeal. 

Posterior  Auricular. — Often  a  branch  of  the  occip- 
ital; sometimes  of  small  size,  ending  in  the  sterno- 
mastoid  muscle. 

Ascending  Pharyngeal. — Varies  greatly  in  its  place 

of  origin;  may  arsie  from  the  internal  carotid,  occipital, 

or  a  linguo-facial  branch.     It  is  occasionally  double. 

Superficial. — This   vessel    is   very   often   tortuous, 

especially  in  the  aged. 

The  transverse  facial  is  occasionally  of  large  size, 
and  takes  the  place  of  the  facial.  It  is  sometimes 
double. 

Internal  Maxillary. — This  artery  frequently  arises 
in  common  with  the  temporal.     R.  Quain  has  observed 


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Arteries.  Anomalies  of 


i,   two   instances  arising   from    the   facial,    "fr 

vhich  it  coursed  upward,  to  pass  beneath  the  ramus 
,f  the  maxillary  bone  in  the  usual  situation." 

It  very  frequently  (in  about  1.5  per  cent.)  is  cov- 
iv, I  by  the  external  pterygoid  muscle,  instead  of 
vine   superficially   to    that  muscle,     it    sometimes 

orates    the    external    pterygoid,    and    rarely    the 
niernal.      It     may     replace    the    facial    by    a    1. ranch 

i    the   posterior    dental,    buccal,   or   infraorbital 

[nternal    Carotid    and    Its    Branches. — This 

irlcry  in  the  neck  is  occasionally  very  tortuous.     It 
I   known  to  be  absent,  its  place  being  taken 
the  artery  of  the  opposite  side  or  by  a   branch 
the   internal   maxillary.      It   is   sometimes   very 
I,     smaller    than     the     vertebral     (Hyrtl).     The 
tiding   pharyngeal,    occipital,    lingual,    or    trans- 
facial  may  arise  from  the  internal  carotid. 

c  communicating  branch  has  been  seen  going 

this  artery,  while  in  the  cavernous  sinus,  to  the 

ia-ilar  artery;  in  such  a  case  the  posterior  communi- 

lating   branch    is   wanting.     The   posterior   cerebral 

ifrequently  comes  off  from  one  of  its  branches, 

terior  communicating. 

halmic  Branch. — This  has  been  seen  to  come 

>1T  from  the  middle  meningeal  artery.     Occasionally 

the  middle  meningeal  conies  off  from  the  ophthalmic. 

I  he  ophthalmic  may,  by  its  nasal  branch,  supply  a 

iency  in  the  facial.      In  fifteen  per  cent,  of  cases 

rosses  beneath  instead  of  over  the  optic  nerve. 

I;  has  been  seen  to  go  through  the  sphenoidal  fissure. 

Cerebral  Arteries. — The  anterior  cerebral  of  one  side 

is  often  much  larger  than  that  of  the  other.     In  some 

es    (lie    two    anterior    cerebral    arteries  are 

united  into  a  common  trunk,  like  the  basilar.     The 

nor  communicating  artery  is  sometimes  double; 

I  have  once  seen  it  treble.     It  is  often  very  short. 

The   posterior   cerebral   may   arise   from   the   internal 

carotid  by  a  large  posterior  communicating.     It  has 

seen  by  Hyrtl  to  give  off  the  middle  cerebral. 

The    posterior    communicating    artery    occasionally 

comes  off  from  the  middle  cerebral  instead  of  from 

ternal  carotid. 

Subclavian. — The  varieties  of  origin  of  this  artery 
have  ahead}'  been  mentioned  in  the  account  of  the 
anomalies  of  the  arch  of  the  aorta  and  innominate 
artery.  It  is  generally  given  off  from  the  innominate 
on  the  right  side,  opposite  the  sternoclavicular  articu- 
lation, but  occasionally  the  innominate  reaches  nearly 
as  high  up  as  the  cricoid  cartilage  before  it  divides, 
and  in  these  cases  the  artery  would  be  at  an  unusually 
high  level.  The  highest  part  of  the  artery  is  the 
second  portion,  and  it  is  normally  about  1.2  to  2.7 
em.  (one-half  to  three-quarters  of  an  inch)  above  the 
clavicle,  with  the  shoulder  depressed,  but  not  infre- 
itly  it  may  be  below,  or  on  a  level  with,  the 
clavicle,  and  sometimes,  especially  on  the  right  side, 
it  may  be  placed  as  high  as  3.7  cm.  (one  inch  and  a 
half)  above  the  level  of  the  clavicle.  It  may,  in 
those  rare  cases  in  which  a  cervical  rib  is  attached 
to  the  seventh  cervical  vertebra,  pass  over  this  rib 
in  place  of  the  first  dorsal,  and  be  raised  fully  two 
inches  above  the  clavicle.  I  have  seen  this  occur 
once  in  two  hundred  and  fifty  subjects  examined. 
In  the  living,  when  this  condition  exists,  it  may  be, 
and  has  been,  mistaken  for  aneurysm.  Sir  James 
Paget  has  diagnosed  this  anomaly  four  times  during 
life.  It  is  obvious  that  the  height  to  which  the  ar- 
tery reaches  is  important  in  cases  in  which  ligature 
is  necessary.  I  have  seen  in  one  case  in  which  there 
was  an  incomplete  left  first  rib  the  artery  pass  over 
the  second  rib.  On  the  right  side  there  was  also  a 
rudimentary  first  rib  completed  by  fibrous  tissue. 
There  was  a  deep  groove  in  this  rib,  in  which  rested 
the  artery;  before  complete  dissection  this  was  taken 
for  a  cervical  rib.  The  cases  for  which  ligature  is 
undertaken   are   chiefly    those   of   aneurysm    of    the 

Vol.  I.— 41 


axillary  artery,  in  which,  in  con  i  qui  nee  of  the  con- 
dition of  the  pan  ,  the  shoulder  is  elevated.     If  the 

artery  should  be  al  an  unusually  low  level,  or  even 
just    behind    I  he    clavicle,    tin-    operation,    a-    may    be 

conceived,   would    be    rendered   extremel]    difficult. 

The  third  part  of  the  artery  in  thin  people  with 
small  muscles  is  very  superficial,  bill  in  stout,  muscu- 
lar individuals  it  is  verj  deeplj   placed.     Dupuytren 

says:  "The  third  part  of  the  subclavian  lies  near  the 
skin  in  those  who  are  thin  and  have  -hauler  and  Long 
necks,  with  lean  and  pendent   shoulders;  it    i-.  on   the 

contrary,  deeply  hidden  in  persons  who  have  short, 

thick  necks  and  muscular  shoulders." 

Occasionally  the  subclavian  artery  pierces  the  sca- 
lenus anticua  instead  of  going  behind  it,  and  more 
rarely  passes  entirely  in  front  of  the  muscle;  of  the 
first  variety  I  have  seen  five  cases  in  I  wo  hundred 
and  fifty  subjects  (three  on  the  left  and  two  on  the 
right  side);  of  the  second,  in  the  same  number  of 
subjects   examined,    I    have    seen    only    one  example. 

The  vein  may  pass  with  the  artery  behind  the 
anterior  scalenus,  and  in  very  rare  cases  their  normal 
positions  may  be  reversed.  The  trapezius  may 
cover  the  third  part  of  the  subclavian,  or  it  may  have 
in  front  of  it  the  omohyoid  muscle.  These  condi- 
tions, however,  will  be  more  fully  described  under 
Muscles,  A  nomalii  .-.  of. 

Variations  of  Branches.—  It  is  important,  surgically 
speaking,  that  the  position  of  the  various  branches 
given  off  from  the  subclavian  should  be  considered. 

The  branches  given  off  from  the  first  part  do  not, 
as  a  rule,  vary  much  in  their  arrangement,  but 
several  may  be  transferred  to  the  second  or  third 
portions.  The  left  vertebral  may  arise  from  the 
arch  of  the  aorta  instead  of  from  the  first  part  of  the 
left  subclavian,  and  the  branches  of  the  thyroid  axis 
may  be  given  off  separately. 

The  first  part  of  the  right  subclavian,  having  been 
occasionally  ligated,  it  is  necessary  to  known  at  what 
distance  from  the  innominate  the  branches  arise. 
In  the  majority  of  cases  this  is  from  1.25  can.  (half  an 
inch)  to  2.4  cm.  (one  inch)  (R.  Quain);  but  it  often 
exceeds  this,  and  is  frequently  2.4  em.  (one  inch) 
to  3.S  em.  (one  inch  and  three-quarters).  In  a  small 
minority  of  cases  the  distance  is  under  1.2  cm.  (half 
an  inch). 

In  the  second  portion  of  the  artery,  one  branch,  as  a 
rule,  is  given  off,  the  superior  intercostal;  occasionally 
no  branches  are  seen  here,  and  again,  not  infrequently, 
there  are  two  or  three. 

The  third  portion,  in  a  little  more  than  half  the 
cases,  gives  off  no  branch,  in  a  little  less  than  half, 
one  branch,  occasionally  two,  and  in  very  rare  cases 
three  and  four. 

Vertebral  Artery. — Origin:  The  right  vertebral,  in 
those  rare  cases  in  which  the  right  subclavian  arises 
from  the  arch  of  the  aorta,  is  given  off  from  the  com- 
mon carotid  of  the  right  side.  The  right  vertebral 
has  been  seen  coming  from  the  arch.  Mr.  A.  M. 
Paterson  (Jour.  Anat.  and  Phys.,  April,  1SS4)  records 
a  case  of  right  vertebral  arising  from  the  aortic  arch 
beyond  the  left  subclavian,  and  reaching  the  vertebra- 
arterial  canal  by  passing  behind  the  trachea  and 
esophagus;  in  fact,  following  exactly  the  course  of 
the  subclavian  when  it  arises  from  the  back  part  of 
the  arch,  as  figured  above.  Mr.  Paterson  regards 
this  anomaly  as  a  persistence  of  the  right  aortic  root, 
with  obliteration  of  the  connection  between  the 
subclavian  and  vertebral  arteries  where  they  cross. 
The  left  vertebral  not  infrequently  is  given  off  from 
the  arch  of  the  aorta,  generally  between  the  left 
carotid  and  left  subclavian.  I  have  seen  this  arrange- 
ment twelve  times  in  two  hundred  and  fifty  subjects. 
I  have  once  seen  it  come  off  from  the  left  common 
carotid.  The  vertebral  has  been  seen  with  two, 
and  even  three  roots  (R.  Quain). 

Course:  This  vessel  may  fail  to  enter  the  trans- 
verse  process   of    the   sixth    cervical    vertebra,    but 

641 


Arteries,  Anomalies  of 


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continue  up  the  neck  between  the  inferior  thyroid 
artery  and  vein  to  enter  the  transverse  process  of  any 
of  the  vertebrae  from  the  fifth  to  the  second.  It  is 
not  uncommon  for  it  to  enter  the  transverse  process 
of  the  fourth  or  fifth  vertebra,  but  it  is  only  very 
occasionally  that  it  passes  up  as  high  as  the  third  and 
second  before  entering  the  foramen.  Again,  it  may 
enter  the  transverse  process  of  the  seventh  cervical 
vertebra,  instead  of  the  sixth. 

Size:  The  left  vertebral  is  frequently  much  larger 
than  the  right,  especially  in  those  cases  in  which  it  is 
given  off  directly  from  the  arch  of  the  aorta.  Some- 
times the  vertebral  is  nearly  as  large  as  the  common 
carotid,  at  other  times  as  small  as  the  ascending 
cervical  branch  of  the  inferior  thyroid. 

Branches:  The  vertebral  may,  as  a  very  rare  occur- 
rence, give  off  the  inferior  thyroid  or  superior  inter- 
costal artery.  I  have  seen  two  examples  of  the  first 
variety  occurring  on  both  sides  of  same  subject.  Its 
inferior  cerebellar  branch  is  frequently  absent  on 
one  side. 

The  thyroidea  ima  has  been  observed  in  rare  cases 
to  come  off  from  the  right  subclavian. 

The  upper  end  of  the  vertebral  artery  occasionally 
divides  into  two  branches,  which  unite  a  little  higher 
up,  thus  forming  a  loop  through  which  pass  filaments 
of  the  hypoglossal  nerve.  I  have  seen  this  anomaly 
in  two  instances. 

Thyroid  Axis. — This  trunk  occasionally  arises 
beyond  the  scalenus  anticus  muscle  (according  to 
R.  Quain  twice  in  two  hundred  and  seventy-three 
cases).  It  not  infrequently  gives  origin  to  the  inter- 
nal mammary.  It  is  sometimes  absent,  its  branches 
being  given  off  separately  from  the  subclavian. 

Inferior  Thyroid. — This  artery  frequently  arises 
as  an  independent  branch  from  the  subclavian.  It 
has  been  seen  to  arise  from  the  common  carotid,  and 


6.S 


Fig.  360. — Inferior  Thyroid  Artery  Dividing  into  Two 
Branches,  one  of  which  (a)  passes  in  front  of  the  carotid  sheath, 
the  other  (b)  behind  it.  (Anderson:  Jour.  Anal,  and  Phys., 
vol.  xiv.) 

not  infrequently  from  the  vertebral.  It  varies  con- 
siderably in  size,  and  when  small  its  place  is  taken 
by  the  superior  thyroid.  In  cases  of  enlarged  thyroid 
gland  (bronchocele)  it  is  often  nearly  as  large  as  the 
carotid.  Two  inferior  thyroids  have  been  found  on 
the  same  side,  one  having  the  normal  course  beneath 

642 


the  carotid  artery,  and  the  other  reaching  its  destina- 
tion by  passing  superficially  to  that  vessel  (Fig.  360). 
Its  branches  of  division  are  closely  connected  with 
the  recurrent  laryngeal  nerve,  which  may  pass 
beneath  or  above  them,  a  point  to  be  borne  in  mind 
in  extirpation  of  the  thyroid  gland.  The  inferior 
thyroid  may  be  wanting  altogether,  its  place  being 
supplied  by  an  enlarged  superior  thyroid  of  the  same 
side. 

The  ascending  cervical  branch  of  the  inferior  thyroid 
may  be  derived  directly  from  the  subclavian  or  one 
of  its  branches.  It  is  occasionally  of  large  size,  and 
may  take  the  place  of  the  occipital. 

Suprascapular. — This  artery  is  usually  derived 
from  the  thyroid  axis,  but  not  infrequently  has  a 
different  origin.  It  is  often  given  off  directly  from 
the  subclavian.  It  may  be  given  off  from  the  internal 
mammary.  I  have  several  times  seen  it  derived  from 
the  subscapular  and  also  from  the  axillary.  It  is 
often  very  small. 

Transverse  Cervical. — This  artery  when  given  off 
from  the  thyroid  axis  divides  into  two  terminal 
branches,  viz.,  the  superficial  cervical  and  posterior 
scapular.  Very  often  the  superficial  cervical  only  is 
given  off  from  the  thyroid  axis,  the  posterior  scapular 
coming  off  as  a  separate  branch  from  the  second  or 
third  part  of  the  subclavian,  rarely  from  the  first  part. 
It  is  well,  when  ligaturing  the  third  part  of  the  sub- 
clavian, to  remember  that  the  posterior  scapular 
comes  off  from  it  about  once  in  every  three  cases. 
When  the  posterior  scapular  artery  is  given  off  from 
the  third  part  of  the  subclavian  I  have  not  infre- 
quently seen  it  pierce  the  fibers  of  the  scalenus 
medius  muscle,  and  occasionally  go  between  the 
cords  of  the  brachial  plexus.  The  posterior  scapular 
artery  may  be  given  off  from  the  axillary,  or  it  may 
end  near  the  scapula  in  a  small  branch,  its  place 
being  supplied  by  branches  from  the  suprascapular. 
The  superficial  cervical  may  come  off  from  the  sub- 
clavian as  a  separate  branch,  the  posterior  scapular 
alone  being  derived  from  the  thyroid  axis.  When 
the  posterior  scapular  is  a  branch  of  the  third  part  of 
the  subclavian  it  often  gives  off  a  large  branch  to 
supply  the  trapezius,  which  represents  the  greater 
part  of  the  superficial  cervical,  the  latter  artery  in 
such  cases  being  very  small  ^r  absent. 

The  transverse  cervical  artery  is  occasionally 
given  off  from  the  subclavian  as  a  separate  branch. 

Internal  Mammary. — This  is  a  large  and  very  regu- 
lar branch  of  the  subclavian,  generally  arising  from 
the  lower  part  opposite  the  vertebral.  It  may  arise 
from  the  thyroid  axis,  axillary,  or  innominate,  or 
even  from  the  arch  of  the  aorta.  It  may  also  form 
a  common  trunk  with  either  of  the  scapular  arteries, 
and  be  given  off  from  the  second  or  third  part  of  the 
subclavian.  Hyrtl  describes  a  case  in  which  the 
trunk  of  this  artery  crossed  in  front  of  the  fifth  right 
costal  cartilage,  coming  out  of  the  thorax  through 
the  fourth  interspace  and  re-entering  it  by  the  fifth. 
In  one  case  the  author  saw  the  phrenic  nerve  pierced 
by  this  artery. 

A  branch  is  sometimes  given  off  from  the  upper 
part  of  the  internal  mammary,  called  by  Henle  the 
A.  mammaria  interna,  lateralis,  which  crosses  the 
inner  surface  of  the  upper  four  to  six  ribs  and  inter- 
costal spaces  at  right  angles,  about  midway  between 
the  spine  and  sternum,  anastomosing  in  its  course 
downward  and  outward  with  the  intercostal  arteries. 
In  penetrating  wounds  of  the  thorax,  fractured  ribs, 
and  other  injuries,  this  lateral  branch  might  be 
wounded  and  give  rise  to  dangerous  hemorrhage. 
It  might  also  be  wounded  in  the  operation  for  evacu- 
ating an  empyema. 

Superior  Intercostal. — Sometimes  arises  from  the 
thyroid  axis  or  vertebral.  I  have  seen  it  arise  from 
the  internal  mammary.  It  may  be  of  considerable 
size,  and  may  supply  three  or  four  intercostal  spaces. 
It  in  some  cases  passes  between  the  neck  of  the  first 


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Arteries,  Anomalies  of 


i  second  rib  and  the  corresponding  transverse  process 
f  the  dorsal  vertebra,     li  is  very  rarely  absent. 

Deep  Cervical. — This  artery  is  generally  a  branch 
i  the  preceding,  but  occasionally  is  derived  directly 
,,m  the  subclavian,  in  the  proportion  of  1  in  20 
tbiects  (R.  Quain).  In  rare  cases  it  arises  from 
po  terior  scapular  and  interna]  mammary.  It  is 
,,t  infrequently  of  small  size,  its  place  being  taken 
,  the  deep  cervical  branch  of  the  occipital,  a  branch 
:  the  inferior  thyroid,  the  ascending  cervical  or  a 
osterior  cervical  branch  of  the  transverse  cervical 
Henle). 

li  may  pass  between  the  transverse  processes  of  the 
ith  and  sixth   cervical,   first  and  second   dorsal,  or 

nil    and    third    dorsal    instead    of    between     the 

th  cervical  transverse  process  and  first  rib. 

Ih, re  is  sometimes  an  accessory  branch  accom- 
anyingit. 

Axillary  Artery. — The  most  important  anomaly 
f  this  vessel  is  its  early  division  into  two  trunks,  one 
f  which  may  give  off  all  or  most  of  the  branches,  or 
lay  be  a  high  origin  of  the  radial,  ulnar,  or  even  the 
iterosseous  artery  (Fig.  361).  When  one  of  the 
runks  gives  off  all  or  most  of  the  branches  it  is  nearly 
surrounded  by  the  brachial  plexus  of  nerves 
id  embraced  by  the  two  heads  of  the  median.  The 
ranches  given  off  from  this  common  stem  may  vary. 

I  have  seen  it  give 
origin  to  the  acromial 
thoracic,  long  thoracic, 
anterior  and  posterior 
circumflex,  subscapu- 
lar, and  one  or  both  of 
the  profunda  arteries  of 
the  arm;  the  anterior 
and  posterior  scapular 
with  the  subscapular 
arteries  not  infre- 
quently come  from  a 
common  stem.  This 
arrangement  of  the 
branches  of  the  axillary 
occurs  normally  in 
many  animals,  e.g.  the 
lemur,  tapir,  peccary, 
dolphin,  etc.,  and  much 
resembles  that  which 
takes  place  in  the  lower 
extremity,  viz.,  the 
common  femoral  divid- 
ing into  a  superficial 
and  a  deep  branch,  the 
deep  giving  off  all  the 
branches,  and  the 
superficial  going  down 
the  extremity  branch- 
less. According  to 
Richard  Quain,  this 
variation  occurred 
twenty-eight  times  in 
506  arms  examined.  I 
have  met  with  it  only 
fifteen  times  in  500 
irma  in  which  the  arrangement  of  the  axillary  was 
ibserved.  Quain  gives  the  proportion  of  cases  in 
vhich  one  of  the  arteries  of  the  forearm  is  derived 
rom  the  axillary  as  23  in  506;  Gruber,  21  in  1,200. 
(  have  found  this  condition  to  exist  twelve  times  in 
500  arms  examined. 

The  radial  is  the  branch  most  frequently  given 
iff  in  these  cases,  next  the  ulnar,  and  very  rarely  the 
nterosseous.  I  have  only  once  seen  the  interos- 
seous arise  from  the  axillary. 

An  aberrant  artery  is  occasionally  found  arising 
;rom  the  axillary;  it  generally  courses  down  the  arm 
alongside  the  brachial,  which  it  joins  near  the  elbow. 
Sometimes    this    aberrant    vessel    joins    the    radial, 


Fig.  361.— Origin  of  Radial  (R) 
rom  the  Axillary  (B).  (After 
teeves.) 


ulnar,  or  interosseous  artery  near  the  writ.  Our 
remarkable  case  Came  Under  my  observation  sonic; 
years  ago  in  which  this  aberrant  artery  passed  down 
the  arm  superficial  to  the  la  cia,  in  tic-  forearm  fol- 
lowed the  course  of  the  1 lian  nerve,  coininiinieated 

with   the   radial   by   several   transverse  branches,  and 

finally  ended  by  taking  the  place  of  the  superficial  volar, 
completing  the  superficial  palmar  arch  il  ig.  362). 

The   most   constant    branch   of   the   axillary    is   the 

long  thoracic  or  external  mammary;  this,  or  a  repre- 
sentative of  it,  is  nearly  always  seen  running  along 
tin'  lower  border  of  the  iieetoralis  minor  muscle;  it, 
however,  not  infrequently  arises  from  the  thoracic 
axis  and  occasionally  from  the  subscapular.  Then- 
may  also  be  an  accessory  external  mammary.  The 
subscapular  and  circumflex  branches  frequently 
arise  together.  The  dorsalis  scapula1,  instead  of 
being  derived  from  the  subscapular,  may  arise  directly 
from  the  axillary. 

The  posterior  circumflex  occasionally  fails  to  enter 
the   quadrilateral   space    (formed    by    the    humerus, 
subscapulars   muscle,   long 
head    of    triceps,    and    teres 
major),      but     reaches    the 
deltoid   muscle  by  winding 
round  the  lower  border   of 
the   tendons  of  the  latissimus  dorsi 
and  teres  major  muscles.     It  not  in- 
frequently  arises  from   the  superior 
profunda,  and  is  sometimes  double. 
In  rare  cases  the  internal  mammary, 
posterior  scapular,  or  suprascapular 
may  arise  from  the  axillary. 

Brachial  Artery. — The  varia- 
tions in  the  course,  relations,  and 
distribution  of  this  artery  are  very- 
numerous  and  of  special  surgical 
interest. 

Course:  The  brachial  artery  some- 
times, accompanied  by  the  median 
nerve,  courses  down  the  arm  to  the 
internal  condyle  of  the  humerus,  and 
thence  regains  its  normal  position  at 
the  bend  of  the  elbow,  by  passing 
forward  under  a  fibrous  or  bony  arch. 
This  arch  is  formed,  usually,  partly 
by  bone  and  partly  by  ligament;  the 
bony  process  is  called  the  supracon- 
dyloid  and  the  fora- 
men, which  is  com- 
pleted by  a  ligair°nt 
from  the  tip  of  the 
process  to  the  in- 
ternal condyle,  the 
supracondyloid  for- 
amen. In  these 
cases  it  is  usual  to 
have  a  high  origin 
of  the  pronator  radii 
teres  muscle  from 
the  supracondyloid 
process.  This  ar- 
rangement is  said  to 
be  more  common  in 
dark  races,  and  is 
the  normal  one  in 
all  the  cat  tribe  and 
in  monkeys,  lemurs, 
and  sloths.  In 
these  animals  the 
foramen  is  nearly  always  completed  by  bone,  and 
affords  protection  to  the  median  nerve  and  artery 
during  flexion  of  the  fore-limb,  and  also  affords  them 
a  more  direct  course  to  the  fore-limb.  In  man  the 
artery  may  occasionally  take  this  course  without  there 
being  present  a  supracondyloid  process;  there  may  be 
only  a  high  origin  of  the  teres  muscle. 

643 


Fig.  362. — Example  of  an  Aberrant 
Artery  from  Axillary,  Going  to  Com- 
plete the  Superficial  Palmar  Arch,  Tak- 
ing the  Place  in  the  Hand  of  the  Super- 
ficial Volar. 


Arteries,  Anomalies  of 


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Division:  I  have  once  soon  the  artery  divide  near 
its  commencement  into  two  branches  which  unite 
to  form  one  trunk  near  the  bend  of  the  elbow,  from 
which  the  ulnar  and  radial  arteries  are  given  off  at 
the  usual  place  (Fig.  363). 

In  4S1  arms  examined  by  R.  Quain  a  high  division 
was  found  sixty-four  times,  a  low  division  (that  is, 
below  usual  place)  only  once.  Gruber,  in  1,200 
arms  examined,  found  a  high  division  in  82.  In  500 
arms  examined  by  myself,  I  found  a  high  division  in 
only  27,  and  in  one  case  the  brachial  divided  below 
the  pronator  teres. 

Adding  to  these  the  cases  in  which  the  division 
takes  place  in  the  axilla,  in  4S1  arms  examined  by 
Quain  two  arteries  existed  in  the  arm  in  9-4  cases,  or 
1  in  about  5|.  My  statistics  are  quite  different 
from  the  above,  and  I  cannot  account  for  the  great 
diversity.  The  same  class  of  people  were  examined, 
and  they  were  of  the  same  race.  In  500  arms  I 
found  that  two  arteries  existed  in  only  43  cases. 
This  is  made 
up  as  fol- 
lows: divi- 
sion of  axil- 
lary, 12;  di- 
vision    of 

brachial,  27;  aberrant  arteries,  4 
— total,  43,  or  1  in  11.6  cases. 
W.  Gruber,  in  1,200  arms,  found 
a  high  division  in  103,  or  1  in 
11. (3,  the  same  proportion  exactly 
as  in  my  own  cases. 

The  point  of  division  is  in  most 
cases  in  the  upper  third  of  the 
arm.  It  is  also  seen  in  the  mid- 
dle and  lower  thirds,  but  much 


Fin.  363. — Brachial  Dividing 
High  up,  Reuniting  at  Elbow, 
and  then  almost  Immediately 
Dividing  into  the  Radial  and 
Ulnar.  V.  Vas  aberrans.  (After 
Reeves.) 


Fig.  364.— High  Or- 
igin of  the  Ulnar  Ar- 
tery(U).  Ab,  aberrant 
artery;  R,  radial,  giv- 
ing »ff  the  interos- 
seous arteries. 


less  frequently.  The  artery  which  is  given  off  thus 
prematurely  is  generally  (three  cases  out  of  four)  the 
radial;  this  vessel  is  most  frequently  to  the  ulnar  side, 
and  subsequently  crosses  to  the  radial.  Next  in  fre- 
quency comes  the  ulnar,  which  often,  in  these  cases, 
E asses  superficially  down  the  forearm  and  gives  off  no 
ranches,  the  interosseous  coining   from    the  radial 

644 


(Fig.  364).  In  rare  cases  the  interosseous  is  the 
branch  having  the  high  origin  (Fig.  365),  and  still 
more  rarely  it  is  a  vas  aberrans. 

Three  branches  have  been  seen  in  the  arm,  viz.,  the 
radial,  the  ulnar,  and  a  vas  aberrans. 

The  position  of  the  two 
branches  in  the  arm  when  a 
high  division  occurs  is  of 
surgical  importance.  They 
are  usually  in  the  ordinary 
position  of  the  brachial 
trunk  and  lie  close  together 


Fig.  365. — Anterior  Interos- 
seous (I)  Given  off  from 
the  Brachial  High  up.  (After 
Reeves.) 


Fig.  366.— Aberrant  Ar 
tery  (3),  separating  fron^ 
the  brachial  (1)  at  the  mid- 
dle of  the  arm,  passing 
with  the  median  nerve  (d) 
through  the  internal  intei- 
muscular  septum,  and 
joining  the  regular  ulnar 
(4)  lower  down.    (Quain  i 


but  the  radial,  as  mentioned  above,  often  arises  from 
the  inner  side,  and,  after  accompanying  the  large 
vessel  for  some  distance,  crosses  over  it  at  the  bend  of 
the  elbow. 

The  ulnar  artery,  when  having  a  high  origin,  may 
incline  toward  the  internal  condyle,  this,  however, 
occurs  only  when  it  nears  the  elbow.  When  there 
is  a  high  division  of  the  brachial  the  ulnar-interos- 
seous branch  may  pass  through  the  supracondyloid 
foramen  mentioned  above,  and  under  a  high  origin 
of  the  pronator  teres. 

The  aberrant  arteries,  which  are  given  off  occasion- 
ally, are  long,  slender  arteries,  which  are  derived 
from  the  brachial  or  axillary,  and  end  by  joining  the 
radial  most  frequently  and  sometimes  the  ulnar  ami 
interosseous.  They  are  loop  lines,  so  to  speak,  and 
in  cases  of  ligature  of  the  brachial  their  occasional 
occurrence  must  be  borne  in  mind  by  the  surgeon 
(Fig.  366).  The  two  arteries  in  the  arm  are  in  sonic 
instances  connected  together  by  anastomosing  trans- 
verse branches.  These  branches  may  number  two 
or  three,  or  even  four. 

A  median  artery  has  been  described  as  arising  from 
the  brachial  and  passing  down  over  the  muscles  of  the 
forearm  and  supplying  the  finger  to  which  is  distrib- 
uted the  median  nerve. 

The  brachial  artery  may  in  some  part  of  its  course 
(more  frequently  near  the  elbow)  be  covered  by  a 
muscular  slip.  The  median  nerve  sometimes  passes 
behind  instead  of  in  front  of  the  artery,  especially 


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Arteries.  Anomalies  of 


,,  those  cases  in  which  the  two  heads  embrace  a 
ommoo  trunk  from  which  the  axillary  branches 
,,.  riven  off. 

Superior  Profunda. — This  is  occasionally  derived 
i/.ni  a  trunk  common  to  it  and  several  of  the  axillary 
tranches,  as  mentioned  above.  It  nol  uncommonly 
arises  with  the  circumflex, 
ami  occasionally  gives  off  the 
inferior  profunda. 

Inferior  Profunda. — This  is 
often  absent.  It  is  frequently 
united  with  the  superior  pro- 
funda. 

A  nastomotica  M  nana.  — 
Frequently  of  small  size;  its 
place  is  sometimes  taken  by 
the  inferior  profunda. 

Radial  Artery. — Origin: 
I  have  found  that  the  radial 
has  a  high  origin  (Fig.  367) 
in  one  case  in  twenty-one, 
but  Quain  reports  the  high 
origin  to  occur  as  often  as 
one  in  eight.  Gruber  in  440 
arms  examined  found  the 
radial  had  a  high  origin  in 
twenty-six,  or  about  one  in 
seventeen  cases. 

Course:  The  radial  only 
very  occasionally  deviates 
from  its  usual  course  in  the 
forearm.  It  has  been  found 
lying  superficial  to  the  fa-'  ia 
of  the  forearm,  and  the  semi- 
lunar fascia  of  the  biceps. 
It  in  rare  cases  courses  down 
the  forearm  on  the  surface  of 
the  supinator  longus  instead 


Fig.  367.— Dissection  of 
Right  Arm.  Showing  an  ex- 
ample of  high  separation  of 
the  radial  artery  (3)  from 
the  brachial  V2);  a  large 
median  artery  (10)  is  seen  in 
forearm.  (From  Quain's 
"Anatomy,"  after  Tiede- 
mann.J 


Fig.  368. — No  Dis- 
tinct Superficial  Arch. 
Large  superficial  volar 
supplying  thumb  and 
index  finger  with  half 
middle  finger,  arid 
rest  supplied  by  ulnar. 
(Reeves.) 


of  along  its  inner  border.  It  not  infrequently  is 
erficial  to  the  tendons  of  the  extensor  muscles  of 
the  thumb.  It  is  occasionally  joined  by  a  vas  aber- 
rans.  It  may  leave  the  front  of  the  forearm  near  its 
middle,  its  place  being  taken  by  an  enlarged  superfi- 
cial volar.     This  would  cause  a  weak  wrist  pulse. 

Size :  It  does  not  vary  often  in  size.  It  is,  however, 
sometimes  much  smaller  than  usual,  its  place  being, 
to  a  considerable  extent,  taken  by  some  other  vessel, 
as  the  ulnar  and  anterior  interosseous. 

The  radial  has  been  described  as  absent  by  some 
anatomists.     Quain  never  saw  a  case  of  absence  of 


this  artery,  but  such  a  case  is  described  by  Professor 
t  »i  to,  and  1  have  seen  one  case. 

Branches.     Radial  recurrent:     This  ve    ''I  i      ome 
times  of  large  size,  or  it  may  eon  i  I  of  several  small 
branches.     Winn   the  radial   has  a  high  origin   1 1 >•  - 
recurrent  branch  is  given  off  from  the  ulnar-intero 
seous  trunk. 

Superficial  volar:  Very  often  of  small  size,  so  small 
thai  it  terminates  in  the  muscles  of  the  thumb,  and 
does  not  complete  the  superficial  palmar  arch.  It  is 
occasionally  entirely  absent.  It  may  be  of  large  size 
and  furnish  several  digital  branches  (Fig.  'MW),  and 
it   nitty  arise  much  higher  than   usual. 

I  once  saw  it  arise  as  high  as  the  middle  of  the  fore- 
arm, and  it  was  quite  as  large  as  tint  radial,  from 
which  it  was  derived;  this  is  the  normal  arrangement 
in   some  monkeys.     The  first  dorsal   interosseous  is, 

in  s e  cases,  of  large  size,  and  may  supply  several 

digits  and  end  by  completing  the  superficial  arch. 

The    carpal    and     dorsal 

interosseous     branches     are 

|f,\  w|MJ\    \  often    of    very    small    size, 

j      \  their  place  being  taken  by 

s^i'i   A   \  the  perforating  arteries. 


FlG.  369.-  Abnormal  Su- 
perficial Ulnar  Artery  (:i,  3'), 
Rising  Higher  than  Usual 
from  the  Brachial.  (Quain's 
"Anatomy,"  after  R. 
Quain.) 


Fig.  370. — Dissection  of 
Left  Arm.  Showing  an  en- 
larged median  arterj  (5) 
which  replaces  the  radial  [2) 
and  ulnar  (3)  arteries  in  the 
supply  of  the  palmar  digital 
arteries  to  half  the  fingers. 
(From  Quain's  "Anatomy," 
after  Tiedemanu.) 


Ulnar  Artery. — Origin:  Quain  found  that  this 
artery  deviated  from  the  usual  origin  in  our  case  in 
thirteen,  Gruber  one  in  twenty-nine,  myself  one  in 
thirty-seven. 

Where  the  origin  of  the  ulnar  is  unusual,  it  most  ci  im- 
monly  arises  from  the  brachial  in  the  arm,  and  less 
commonly  from  the  axillary.     In  one  case  out  of  five 

645 


Arteries,  Anomalies  of 


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hundred  I  found  it  coming  off  from  the  brachial 
below  the  pronator  radii  teres.  In  this  case  there 
was,  of  course,  a  low  division  of  the  brachial. 

Course:  In  the  forearm  this  artery  is  much  more 
subject  to  variation  than  the  radial.  When  it  has  a 
high  origin  it  nearly  always  courses  down  the  fore- 
arm superficial  to  the  muscles,  but  beneath  the  fascia; 
but  cases  occasionally  occur  in  which  it  is  immedi- 
ately beneath  the  skin  and  superficial  to  the  fascia 
(Fig.  369).  When  the  ulnar  is  superficial,  it,  as  a 
rule,  gives  off  no  branches  in  the  forearm,  these 
being  given  off  from  the  radial — interosseous  trunk — 
or  the  interosseous  itself,  which  is  invariably  given 
off  from  the  radial.  The  ulnar,  in  rare  cases,  has  this 
superficial  course  when  it  arises  in  its  usual  situation. 

Interosseous  Artery. — This  artery,  in  rare  cases, 
arises  from  the  axillary  or  brachial  artery  (Fig.  364), 
and  gives  off  the  recurrent  radial  and  ulnar  arteries. 
The  anterior  and  posterior  interosseous  may  arise 
separately  from  the  ulnar. 

Median  Artery  (Fig.  370). — This  branch,  which 
accompanies  the  median  nerve,  is  ordinarily  of  small 
size,  but  occasionally  it  is  developed  into  quite  an 
important  vessel.  It  is  usually  derived  from  the 
anterior  interosseous,  but  sometimes  from  the  ulnar, 
and,  in  rare  cases,  it  has  been  found  coming  from  the 
axillary  or  the  brachial.  It  accompanies  the  median 
nerve  and  reaches  the  hand  beneath  the  annular 
ligament,  but,  according  to  Tiedemann,  sometimes 
passes  over  the  ligament.  It  may  complete  the 
palmar  arch,  or  be  distributed  as  digital  branches  to 
certain  of  the  fingers,  generally  those  supplied  by 
the  median  nerve,  which  it  accompanies.  In  the 
cases  which  I  have  observed,  the  latter  arrangement 
was  the  more  frequent.  I  have  occasionally  seen 
this  artery  pierce  the  median  nerve. 

Arteries  of  the  Hand. — The  arteries  of  the  hand 
are  subject  to  man}'  variations. 

The  superficial  palmar  arch  is  sometimes  entirely 
wanting.     It  has  been  occasionally  seen  double.     In 


Fig.  371.  —  Superficial 
Arch  Formed  Entirely  by 
the  Ulnar  and  Joining  the 
Princeps  Pollicis  Artery. 
(Reeves.) 


Fig.  372.— Lars  e 
Median  Artery  (Af), 
Taking  the  Place  of  the 
Radial  in  the  Forma- 
tion of  the  Superfi- 
cial Arch  and  Giv- 
ing off  Outer  Digitals. 
(Reeves.) 


the  majority  of  cases  the  superficial  volar  branch  does 
not  complete  the  arch,  but  it  is  completed  often  by 
a  large  branch  from  the  radial,  which  emerges  between 
the  thumb  and  forefinger,  and  I  have  sometimes  seen 
it  completed  by  a  large  branch  from  the  radial, 
which,  after  coursing  over  the  back  of  the  hand, 
emerges  on  the  palm  between  the  index  and  middle 
fingers.  The  arch  is  also  often  completed  by  a 
transverse  branch,  which  comes  from  the  muscles 
of  the  thumb  and  is  derived  from  the  princeps  pollicis 
or  radialis  indicia  branch  of  the  radial  (Fig.  371). 
A  median  artery  may  complete  the  arch  (Fig.  372), 
or  it  may  go  to  the  digits  on  the  radial  side,  and  the 

646 


ulnar  to  the  digits  on  the  ulnar  side,  and  no  regular 
arch  be  formed.  The  superficial  volar  sometimes  has 
this  arrangement  (Fig.  372). 

The  superficial  arch  may  be  very  small  and  some 
of  the  digital  branches  be  wanting,  or  it  may  be  very 
large,  suppljing  all  the  digital  branches,  both  super- 
ficial and  deep. 

The  deep  arch  is  occasionally  formed  by  the  ulnar. 
It  is  sometimes  so  deficient  that  the  digital  arteries 
are  derived  from  the  superficial  arch.  A  large  meta- 
carpal branch  on  the  back  of  the  hand  may  give  off 
the  digital  branches. 

Abdominal  Aorta. — According  to  R.  Quain,  in 
ten  out  of  every  thirteen  bodies  the  division  of  the 
great  artery  took  place  within  half  an  inch  above  or 
below  the  level  of  the  iliac  crest.  Eckhard,  Boinet, 
and  Cruveilhier  record  cases  of  division  as  high  up  as 
the  second  lumbar.  Two  cases  are  on  record  (Quain, 
tenth  ed.)  of  a  large  pulmonary  branch  which  arose 
below  the  diaphragm,  passed  through  the  esophageal 
opening,  and  divided  into  two  branches  which  sup- 
plied the  lungs  near  their  bases. 

Celiac  Artery. — The  branches  of  this  artery  may 
arise  separately  from  the  aorta.  The  phrenic  arteries 
may  be  given  off  from  it,  and  it  may  be  connected 
with  the  superior  mesenteric. 

Renal  Arteries. — Now  that  the  operation  of 
nephrectomy  has  become  so  common,  the  variations 
of  these  arteries  have  been  rendered  important  surgi- 
cally. Professor  Macalister  has  reported  (Journ.  Anal, 
and  Phys.,  vol.  xvii.)  most  of  the  anomalies  of  the 
renal  artery. 

The  renal  artery  may  be  replaced  by  two,  three, 
four,  and  even  six  branches.  The  origin  of  these 
arteries  is  very  various;  they  are  usually  derived  from 
the  aorta,  and  are  separated,  at  their  origin,  by  a 
larger  or  smaller  interval;  the  lowest  may  arise  quite 
near  the  bifurcation  of  the  aorta,  and  the  highest  just 
below  the  celiac  axis.  In  some 
rare  instances  the  renal  artery 
has  been  described  as  arising 
from  the  common  iliac,  internal 
iliac,  and  middle  sacral.  The 
right  and  left  renal  arteries 
have  been  found  coming  from 
a  common  trunk;  they  may 
arise  from  the  anterior  or 
lateral  part  of  the  aorta.  The 
suprarenal  frequently  gives  off 
an  upper  renal,  and  it  less  fre- 
quently is  derived  from  the 
upper  lumbar,  hepatic,  and 
right  colic.  Frequently  when 
the  renal  arteries  come  off  from 
the  aorta  low  down  or  the 
iliacs,  the  kidney  on  that  side 
is  misplaced;  it  is  situated  lower  down  than  usual. 
opposite  the  bifurcation  of  the  aorta  and  even  between 
the  two  common  iliacs.  In  such  cases  the  hilum  is 
usually  placed  on  the  anterior  surface. 

The  branches  of  the  renal  artery,  instead  of  entering 
the  hilum,  may  penetrate  the  kidney  at  its  upper  or 
lower  end.  It  is  not  uncommon  to  see  the  normal 
artery  entering  the  hilum,  and  two  or  three  super- 
numerary branches  piercing  the  upper  and  lower  end 
of  the  gland.  In  two  subjects  I  found  that  the  kidney 
was  supplied  by  two  arteries  arising  from  the  aorta 
at  some  distance  apart,  one  going  to  the  extreme 
upper  end,  and  the  other  to  the  extreme  lower  end  of 
the  kidney;  no  artery  entered  the  hilum  (Fig.  373). 
The  vein  and  duct  were  normal.  This  variation  I 
once  met  with  while  performing  nephrectomy  on  the 
dead  body.  R.  Quain  met  with  a  case  of  absence  of 
the  renal  artery  on  one  side.  Multiple  renal  arteries 
occur  normally  in  fishes,  lizards,  snakes,  crocodiles, 


Fig.     373.  —  Abnormf., 

Right  Renal  Arteries.  An 
Artery  distributed  to  each 
extremity  of  the  kidney! 
but  none  entering  the 
hilum. 


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Arteries,  Anomalies  (if 


I'm.  374- — Obturator  Given  off 

Internal  1  pigastric,  and 

•sine  to  the  Inside  of  the  Crural 

Reach     the    Obturator 

..Mien.     (After  Gray.) 


,1  birds,  and  in  man  are  due  to  a  persistent  early 
Dndition. 

Inferior    Mesenteric. — It   may   be   absent,    its 
being  given  off  from  the  superior  mesenteric. 

SpBBMATIC  Artery. — Sometimes  double,  not  infre- 
iently  derived   from   the   renal.     Three  spermatic 

teries  have  been  seen. 

Common  Iliac  Arteries. — The  place  of  origin  of 

ese  arteries  depends  on  the  place  of  division  of  the 

dominal  aorta.     This  may  be  as  high  as  the  upper 

border  of  the  third,  or  as 

low  as  the  loner  border 

of  the  fifth  lumbar  ver- 
tebra. In  three  out  of 
four  eases  the  aorta  di- 
vides opposite  the  lower 
border  of  the  fourth 
lumbar. 

The  common  iliac  ar- 
teries vary  considerably 
in  length.     I  once   saw 
them  only  1.8  cm.  (three- 
fourths   inch)  long  in  a 
negress,  and,  in  another 
case,  2.5  cm.  (one  inch). 
In  the  large  majority  of 
cases,   according    to  R. 
Quain,  the  length  varies 
oin  3.7  cm.  (one  inch  and  a  half)  to  7.5  cm.  (three 
ches).     The  greatest  length  is  about  10  cm.  (four 
1  a   half  inches). 

The  right  and  left  common  iliacs  differ  in  length 
■ry  often,  the  right,  owing  to  the  aorta  dividing  to 
ie"  loft  side  of  the  spinal  column,  being  often  the 
tiger;  but  the  left  may  be  the  longer,  and  in  about 
rd  of  the  cases  they  are  of  equal  length  |  R. 
mitt  i. 

When  the  left  is  longer  than  or  equal  to  the  right, 

is  owing  to  the  left  artery  descending  to  a  lower 

vel    than    the    right.     The    artery    has    been    seen 

viding  into  internal  and  external  iliacs  as  low  down 

iliac  fossa. 

The  common  iliac  on  one  side  has  been  reported 

by  Cruveilhier  and   Walsham.     In  this  case 

to  aorta  divided  into  three  branches,  two  on  the 

\ternal  and  internal  iliac),  as  is  seen  in  birds, 

id  one  on  the  left  (common  iliac).     Surgically,  these 

ariations  are  of  great  interest. 

Internal  Iliac. — The   place   of  division   of   this 
aries  considerably;  it  may  divide  as  low  as 

ie  margin  of  the  sacro-sciatic  foramen  and  as  high 

-  tlie  upper  margin  of 
e  sacrum.     The  point 

f  division  is  of  impor- 
irgieally;    when 

ie  trunk  is  short  it  is 

tore    deeply    placed   in 

ie    back    part    of    the 

elvis,  but  when  it  is  of 

itne  length,  then  a  part 

f  the  artery  is  likely  to 

e  above  the  pelvic  cav- 

y,  and  therefore  would 

e     much    more    easily 

■ached  by  the  surgeon 

H.  Quain).     It  ha-  been 

Hind  as  short  as  1.2  cm. 

half  an  inch),  and  as  long  as  8.2  cm.  (three  and  a 

alf  inches). 
The  branches  are  given  off  from  this  artery  very 

ariously.     In  many  cases  there  is  no  division  into 

nterior  and  posterior  trunks.     The  artery  occasion- 

lly  gives  off  one,  and  sometimes  two  branches  he- 
re   it    divides.      The    variations   of    most    of    the 

•ranches  of  this  artery,  being  of  no  surgical  impor- 

ance,  will  not  be  discussed  here. 


Fig.  375.— TheObturatorGiven 
off  from  the  Internal  Epigastric 
and  Passing  to  the  Outside  of  the 
Ring.  (After  Gray.) 


Obturator. — According  to  li.  Quain,  the  obtura- 
tor artery  arises  from  the  epigastric  in  one  ca  e  in 
:;.;,,  His  conclusions  are  derived  from  observations 
in  36]  cases.  I  have  observed  500  cases  (250  sub- 
ject i.  and  have  found  this  abnormal  arrangement 
much  less  frequently  than  Quain.  I  have  found  the 
obturator  coming  from   the  epigastric  in   only   i 

Ca   e  in   ni .",.">  in  5011).      Quain  found  the  obturator 

derived  from  tlie  external  iliac  in  si\  ca  i  out  of 
361.  I  found  it  only  three  time-  in  500  cases.  Quain 
found  tin-  epigastric  giving  off  the  obturator  twenty- 
three  time,  ,,n  both  sides.  I  found  this  arrangement 
eleven  times. 

When  the  obturator  arises  from  the  epigastric  or 
external  iliac,  it  reaches  tlie  thyroid  foramen  ly 
arching  either  to  tlie  inner  or  to  the  outer  side  of 
the  femoral  ring.  If  it  arches  to  the  inner  side  of  the 
femoral  ring,  along  the  edge  of  <  limbernat  's  ligament, 
then,  in  case  of  strangulated  hernia  requiring  opera- 
tion, it  would  be  in  great  danger  of  being  wounded 
dig.  374);  in  fact,  this  accident  has  happened  more 
than  once. 

In  only  nine  out  of  the  fifty-eight  cases  in  which 
the  obturator  proceeded  from  the  epigastric  and 
external  iliac  did  I  see  the  artery  going  to  the  inner 
side  of  the  femoral  ring.  In  the  remaining  forty- 
nine  cases  it  either  crossed  it,  in  a  few  cases,  or  held 
a  position  well  to  the  outer  side  in  the  majority 
(Fig.  375),  so  that  in  only  about  one  case  in  fifty 
is  there  danger  of  wounding  the  obturator  in  the 
operation  for  strangulated  hernia.  The  explanation 
of  the  origin  of  the  obturator  from  the  epigastric  is 
simple  enough.  Normally,  we  have  the  pubic  branch 
of  the  obturator  anastomosing  with  the  pubic  branch 
of  the  epigastric;  these  vessels  become  enlarged, 
and  the  proper  obturator  branch  of  the  internal  iliac 
either  remains  undeveloped  or  becomes  obliterated. 

In  four  cases  I  have  seen  the  obturator,  epigastric, 
and  internal  circumflex  arise  together  from  the 
external  iliac,  and  once  these  same  arteries  were 
seen  to  arise  by  a  common  trunk  from  the  common 
femoral  2  cm.  below  Poupart's  ligament.  In  one 
case  the  epigastric  and  obturator  arose  together 
from  the  femoral,  a  little  below  Poupart's  ligament. 
In  some  cases,  in  which  the 
obturator  arises  from  the 
epigastric,  there  is  a  small 
branch,  representing  the 
obturator,  derived  from  the 
internal  iliac. 

Interna!  Pvdic  Artery. — 
This  vessel  is  occasionally 
of  small  size,  and  fails  to 
supply  all  the  usual 
branches;  in  s-uch  an  event 
these  are  given  off  from  an 
accessory  pudic.  The 
branches  furnished  by  the 
accessory  artery  are  usually 
those  branches  which  go  to 
the  cavernous  body  and 
dorsum    of   the  penis,    the 

,.       .,      ...  ,r  .,  course    .uiaway    oeiween    in 

pudic   itself  ending  as  the     Ischial    Tuberosity    and    th 
artery    of    the    bulb.      In    a     Coccyx.     (After  Henle.) 
few  instances  the  pudic  ends 

as  the  superficial  perineal,  the  other  branches  coming 
from  the  accessory  vessel. 

The  accessory  pudic  is,  as  a  rule,  given  off  from  the 
deep  pudic  within  the  pelvis;  it  then  passes  alongside 
the  bladder  and  prostate,  and,  after  piercing  the 
triangular  ligament,  supplies  the  dorsum  of  the  penis 
and  the  cavernous  body,  and,  perhaps,  the  bulb.  It 
may  be  given  off  from  the  obturator  in  the  pelvis,  or 
from  the  epigastric. 

The  pudic  artery  has  been  seen  passing  up  to  the 
perineum  midway  between  the  tuberosity  of  the 
ischium  and  the  coccyx,  and  ending  as  the  superficial 
perineal  and  artery  of  the  bulb  (Fig.  376). 

647 


Fig.  376. — Abnormal  Inter- 
nal Pudic  Artery,  Which  Has  a 
(nurse    Midway    between    the 


Arteries,  Anomalies  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Artery  of  the  Bulb. — Is  sometimes  of  large  size, 
placed  farther  back  than  usual,  and  ascends  obliquely 
to  the  bulb;  in  such  a  case  it  would  necessarily  be 
wounded  in  the  operation  of  lithotomy.  It  may 
arise  from  the  accessory  pudic;  when  this  happens 
it  would  be  placed  well  in  front  of  the  usual  incision 
for  lithotomy. 

The  dorsal  artery  of  the  penis  has  in  some  cases  been 
seen  to  arise  from  the  obturator  artery  near  the  thy- 
roid foramen,  from  the  external  pudic  of  the  femoral, 


Fig 


-Abnormal  Origin  of  the  Internal  Circumflex  Artery  (I): 
K,  epigastric  artery;  PF,  profunda  femoris. 


and  from  the  deep  femoral.  In  the  first  case  it  would 
be  in  danger  of  being  wounded  in  lithotomy.  The 
two  arteries  of  the  penis  sometimes  unite  to  form  a 
single  trunk,  or  are  united  by  transverse  branches. 
Mr.  Spence  has  described  a  large  prostatic  artery 
which  gained  the  perineal  surface  of  the  prostate 
without  dividing  into  minute  branches.  Wounds 
of  the  prostatic  arteries  have  led  to  fatal  hemorrhage 
in  cases  of  lateral  lithotomy. 

The  sciatic  artery  is  sometimes  replaced  by  a  branch 
from  the  gluteal.  In  a  few  cases  this  artery  has  been 
seen  of  large  size,  taking  the  place  of  the  femoral 
(see  under  Variations  of  Femoral).  There  is  some- 
times a  large  comes  nervi  ischiatici  artery.  The 
gluteal  artery  has  been  reported  as  absent  (Roberts), 
its  place  being  taken  by  a  large  branch  from  the  fem- 
oral, passing  outward  and  backward  to  the  gluteal 
region. 

External  Iliac  Arteries. — The  length  of  these 
arteries  varies  according  to  the  point  at  which  the 
common  iliacs  bifurcate;  they  usually  measure  7.50 
cm.  (three  inches)  to  10  cm.  (four  inches)  in  length. 
In  those  rare  cases  in  which  the  main  artery  of  the 
limb  is  a  continuation  of  the  sciatic,  it  is  much  reduced 
in  size. 

Epigastric  Artery. — May  arise  at  a  higher  point 
than  usual.  R.  Quain  reports  it  in  one  case  6.4  cm. 
(two  and  a  half  inches)  above  Poupart's  ligament. 
It  arises  from  the  femoral  in  about  one  case  in  twenty. 
The  usual  place  of  origin  is  close  to  or  opposite  Pou- 
part's ligament.  It  may,  in  rare  cases,  arise  from 
the  deep  femoral. 

The  origin  of  the  obturator  from  the  epigastric  has 
already  been  noticed.  In  a  few  cases  the  epigastric 
has  been  seen  coming  from  the  obturator  when  that 
vessel  is  a  branch  of  the  internal  iliac. 

I  have,  in  four  instances,  seen  the  epigastric  arise 
in  common  with  the  internal  circumflex  artery  of  the 
deep  femoral.  In  three  of  the  cases  the  common 
stem  arose  from  the  femoral  2  cm.  below  Poupart's 
ligament;  in  the  fourth,  2  cm.  above  the  ligament. 

648 


In  the  last-named  case  the  internal  circumflex  passe, 
beneath  Poupart's  ligament  in  the  same  compart- 
ment of  the  femoral  sheath  as  the  artery,  and  con- 
tinued down  the  thigh  about  5  cm.,  lying  betweei 
the  artery  and  vein;  it  ended,  after  giving  off  a  largt 
branch  to  the  adductor  muscles,  as  the  internal  cir 
cumflex  proper  (Fig.  377).  A  similar  anomaly  ha: 
been  observed  by  Mr.  A.  Thompson  (Journal  Anai 
and  Phys.,  April,  1SS3),  but  in  the  cases  describee 
by  him  the  artery  passed  internal  to  the  femoral  vein 
and  would,  he  thinks,  have  been  wounded  in  tht 
operation  for  relieving  strangulated  femoral  hernia 
A  similar  arrangement  of  vessels  exists  normally  ii 
the  American  black  bear.  I  have  met  with  foui 
cases  in  which  the  obturator,  epigastric,  and  interna 
circumflex  arose  by  a  common  stem,  two  below 
Poupart's  ligament  and  two  above. 

Circumflex  Iliac  Artery. — The  origin  of  this  artery  b 
sometimes  from  the  femoral.  It  is  occasionally  double. 
again  a  single  vessel.     Sir  Charles   Bell,  when  liga- 

Femoral  Artery. — The  femoral  artery  has,  in 
some  rare  cases,  been  found  of  small  size,  and  termi- 


\i  }''! 


FlG.  37S. — Posterior  View  of  the  Right 
Thigh.  The  ischiatie  artery  much  en- 
larged, accompanying  the  sciatic  nerve, 
and  taking  the  place  of  the  femoral  ar- 
tery.    (After  Dubreuil.) 


Fig.  370. — Bell's 
Case  of  Double 
Femoral  Artery, 
.showing  HgatuN 
of  one  of  the 
trunks  and  the 
aneurysmal 
below.  (After  Bell 
fr<  itn  London  Medr 
ical  Gazette.) 


nating  near  the  knee  joint.  When  such  a  condition 
exists,  the  main  artery  of  the  limb  is  furnished  by  a 
branch  from  the  internal  iliac,  generally  the  sciatic 
(Fig.  37S),  which  is  much  enlarged,  and  accompanies 
the  sciatic  nerve  to  the  popliteal  space,  whence  the 
course  of  the  artery  is  the  same  as  if  the  distribution 
had  been  normal.  This  is  the  usual  arrangement 
in  birds. 

Cases  have  been   reported   in  which   the  femoral 
divided  into  two  portions,  which  united  below  to  form 


kitfi:f.vt:  haxdkook  or  tiik  medical  SCIENCES 


Arteries,  Anomalies  of 


urine  tli'  femoral  for  popliteal  aneurysm,  met  with 
hi-c  anomaly.  Though  t li<-  ligation  of  the  femoral 
lid  not  arrest  the  pulsation  in  the  aneurysm,  the 
recognized  till  after  the  death  of  the 
tatient,  when  it  was  found  that  the  femoral  was 
louble.  and  only  one  of  its  divisions  had  been  liga- 
ured  (London  Sled,  and  Phys.Jour.,  vol.  lvi.,  1826 

Fig.     379.)     Tiedemann,     Houston,     Dubreuil, 
1'vrroll.   and    Quain   also   report    cases.     Mr.    11.    A. 
Kelly    (American   Journal   of  the    Medical    Sciences, 
lanuary,   1882)  reports  three  cases  (one  of  which  i 
loubtful),  met  with  in  the  dissecting  rooms  in  Phila- 
Iclphia.     In  two  of  these  cases  the  artery  divided 
.■low   the  profunda,   ami  reunited  just   above   the 
in  the  adductor  magnus.     The  division  has 
above  the  origin  of  the  profunda. 
The  two  femorals,  when  this  arrangement  occurs, 
run  down  the  thigh,  side  by  side,  in  separate  fibrous 
.lis.   m>  that   in  cutting  down  on  one  the  other 
would  not  be  seen. 

1  have  occasionally  seen,  in  cases  of  high  origin  of 
the  profunda,  the  latter  artery  quite  as  large  as  the 
rficial    femoral,    and    running    down    the    thigh 
parallel  to  it.  beyond  the  apex  of  Scarpa's  triangle. 
wch  a   case  it  would  be  difficult,   in  the  living. 
listinguish  between   the  vessels,   should  ligature 
of  the  femoral  be  necessary.     As  a  rule,  the  profunda 
li  -  to  the  outer  side.     The  appearance  of  the  above- 
l  cot  dition  in  Scarpa's  triangle  is  very  similar 
OS    cases  figured  as  double  femoral,  and  I   im- 
agine that   the  cases  of  double  femoral  reported  as 
seen  in  amputating  the  thigh  are  only  cases  of  larg - 
profunda   arteries,    especially   as   the   disposition    of 
the  vessels  below-  the  amputated  point  is  not  described. 
The    pro/undo,    or    deep    femoral   artery,    may    be 
given  off  from  the  inner  side  of  the  main  trunk,  or 
in  some  cases  from  the  back  part  of  the  vessi  I 
It  may  arise  above  Poupart's  ligament,  or  as  much 
as  10  cm.  (four  inches)  below  it.     It  not  uncommonly 
-    1.2   cm.    (half   an   inch)    below    the   ligament. 
When  it  is  given  off  low  down,  one  or  both  circumflex 
arteries  arise   from  the  femoral.     The  deep  femoral 
has  been  occasionally  altogether  wanting,  its  branches 
arising  separately  from  the  main  artery. 

The  external  circumflex  artery  not  infrequently 
arises  directly  from  the  common  femoral.  It  may 
be  represented  by  two  branches,  and  even  three. 
which  arise  from  the  femoral  or  profunda — I  have 
seen  it  arise  in  common  with  the  internal  circumflex. 
The  internal  circumflex  artery  also  frequently  arises 
directly  from  the  femoral.  It  occasionally  arises  in 
common  with  the  deep  epigastric,  ami  passes  down 
to  the  thigh  in  the  same  sh  ath  as  the  femoral  vessel. 
This  variety  I  have  described  under  the  Epigastric. 
It  may  arise  with  the  epigastric  from  the  femoral 
artery  before  the  profunda  is  given  off,  and  in  some 
cases  might  be  injured  in  the  operation  for  strangu- 
late.1  femoral  hernia.  I  have  twice  seen  it  arise  with 
the  obturator  and  epigastric  from  a  common  stem. 

Unusual  branches  are.  in  rare  cases,  given  off  from 
the  femoral.  I  once  saw  the  dorsal  artery  of  tie 
penis  given  off  from  the  common  femoral,  cross  the 
thigh  at  right  angles,  and  reach  the  dorsum  of  the 
penis  by  piercing  the  deeper  scrotal  tissue. 

A  large  saphenous  artery  has  been  found  which 
accompanied  the  great  saphenous  vein.  It  may 
arise  above  or  below  the  profunda,  course  down  the 
thigh  between  the  adductor  magnus  and  internal 
vastus,  and  pierce  the  deep  fascia  of  the  thigh  on  the 
inner  side  of  the  knee  joint,  where  it  reaches  the  inter- 
nal saphenous  vein  and  accompanies  it  to  the  internal 
malleolus.  This  arrangement  is  the  normal  one  in 
the  rabbit  and  in  some  other  mammals. 
_  I  once  saw  this  branch,  after  reaching  the  inner 
side  of  the  knee,  wind  round  to  the  front  of  the  joint, 
below  the  patella,  and  divide  into  a  cutaneous  branch 
and  a  branch  which  pierced  the  ligamentum  patella? 
to  supply  the  interior  of  the  joint. 


Popliteal  Ak  i  i  ry.  This  artery  is  not  Bubjecl  '.> 
many  variations.  '1  he  chief  deviation  from  the 
normal  disposition  consists  in  a  high  division  of  its 

terminal    branches.      1    saw     this    only    twice    in    2.~>0 
subjects;    in    both,    the    artery    divided    immediately 

above  the  upper  edge  of  the  posterior  ligament  of 
the  knee  joint.  In  -'-'7  subjects  Quain  found  a  high 
division  in  10.  Portal  reports  a  case  of  low  division 
of  the  popliteal,  the  artery  dividing  about  the  middle 
of  the  leg  into  anterior  an. I  posterior  til  ial.  In 
cases  of  high  division,  tic  peroneal  artery  arises  from 
the  anterior  tibial;  tin-  was  the  arrangement  in  one 
of  my  cases.  The  artery  and  vein,  usually  so  con- 
stant in  their  relation,  may,  in  rare  cases,  eh:; 
places.  When  there  is  a  third  head  to  the  gastroc- 
nemius muscle  it  usually  passes  between  the  artery 
and  the  vein.  Ward  Collins  has  seen  the  popliteal 
artery  dividing  in  the  upper  part  of  the  popliteal 
0  branches  which  united  again  below 
after  a  separate  course  of  two  inches. 

Cases  are  reported  (Otto)  of  branches  from  the 
popliteal  proceeding  upward  along  the  semin  em- 
branosus  muscle,  and  ending  in  one  of  the  perforating 
arteries  of  the  profunda.  Also  an  aberrant  artery 
is  described  as  being  given  off  above  the  knee  joint, 
and  joining  tin-  popliteal  before  its  division  (Hyrtl). 
A  small  saphenous  artery  lias  been  seen  which  accom- 
panies the  short  saphenous  vein  behind  the  external 
malleolus  and  anastomoses  with  one  of  the  tarsal 
branches  (Hyrtl).  The  azygos  artery  may  be  given 
off  from  one  of  the  articular  arteries.  I  once  saw  a 
common  trunk  give  off  the  two  superior  articular 
arteries  and  the  azygos.  One  or  other  of  the  articular 
branches  may  be  absent,  their  place  being  supplied 
by  an  enlargement  of  the  remaining  arteries. 

Posterior  Tibial. — In  cases  of  high  division  of  the 
popliteal  the  tibial  is  larger  than  usual.  It  may  be 
increased  or  diminished  in  size.  When  increased,  it 
partly  takes  the  place  of  the  peroneal  or  anterior 
tibial,  and  when  diminished,  it  may  be  reinforced  by 
transverse  branches  from  the  peroneal  near  the  ankle. 
The  posterior  tibial  may  be  of  very  small  size  and  end 
near  the  middle  of  the  leg,  its  place  being  taken 
by  a  large  peroneal  artery  which  furnishes  the  plantar 
arteries.  In  a  lesser  degree  of  diminution  of  the 
posterior  tibial,  the  anterior  tibial,  or  rather  its  dor- 
salis  pedis  branch,  furnishes  the  arteries  which  form 
the  plantar  arch  and  its  branches.  In  these  cases  the 
external  plantar  artery  ends  near  the  accessorius 
muscle.  I  have  several  times  seen  a  muscular  slip 
(flexor  accessorius),  which  arose  from  the  lower  end 
of  the  fibula,  or  more  commonly  from  the  tibia,  cross 
the  tibial  vessels  behind  the  internal  malleolus.  The 
nerve  is  occasionally  placed  to  the  inner  side  of  the 
artery,  at  the  lower  part  of  the  leg. 

Peroneal  Artery. — This  artery,  as  described  above, 
may  take  the  plaee  of  the  posterior  tibial,  or  it  may 
be  of  small  size,  and  its  place  be  supplied  by  a  branch 
of  the  posterior  tibial.  The  anterior  peroneal  branch 
may  be  of  large  size,  and  may  take  the  place  of  the 
lower  part  of  the  anterior  tibial,  furnishing  the  arter- 
ies supplying  the  dorsum  of  the  foot. 

In  cases  of  high  division  of  the  popliteal,  the  pero- 
neal artery  generally  arises  from  the  anterior  til  ial. 
It  also  arises  in  the  same  way.  occasionally,  when  no 
high  division  takes  place.  I  have  seen  it  furnish  a 
large  internal  calcanean  branch  as  well  as  an  external. 
An  accessory  peroneal  sometimes  exists. 

The  internal  plantar  artery  is  sometimes  of  very 
small  size,  ending  in  the  flexor  brevis  pollicis  muscle, 
or  it  may  be  of  large  size,  and  furnish  digital  branches 
to  the  great  and  second  toes. 

The  external  plantar  is  occasionally  very  small, 
ending  in  the  accessorius  muscle;  when  such  a  condi- 
tion exists  the  dorsalis  pedis  artery  furnishes  the  deep 
plantar  arch  and  digital  branches.  I  have  several 
times  seen  this  anomaly.  The  artery  is  occasionally 
of  large  size,  and  partly  takes  the  place  of  the  dorsalis 


649 


Arteries,  Anomalies  of 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


pedis  branch  of  the  anterior  tibial.  The  digital 
arteries  of  two  toes,  generally  the  second  and  third, 
not  infrequently  come  from  a  common  stem.  The 
deep  arch  is,  in  rare  cases,  double. 

Anterior  Tibial  Artery. — In  some  cases  this  artery 
is  given  off  from  the  posterior  tibial  in  the  middle  of 
the  leg.  When  there  is  a  high  division  of  the  popliteal 
it  may  give  off  the  peroneal,  and  may  pass  beneath 
the  popliteus  muscle.  In  the  leg  it  may  be  subcu- 
taneous, its  pulsations  being  easily  felt  under  the  skin. 
Velpeau  reports  a  case  in  which  this  artery  did  not 
pierce  the  interosseous  membrane,  but  passed  to  the 
front  of  the  leg  round  the  fibula  with  the  musculo- 
cutaneous nerve.  It  may  be  altogether  wanting, 
its  place  being  supplied  by  perforating  branches  from 
the  posterior  tibial,  or  it  may  end  in  the  muscles  about 
the  middle  of  the  leg.  When  there  is  such  a  distribu- 
tion the  deficiency  is  made  up  by  an  enlarged  anterior 
peroneal  or  plantar  artery.  It  not  infrequently  fails 
to  furnish  digital  branches,  which,  in  this  event,  come 
from  the  plantar  arteries.  The  artery  may  be  of 
larger  size  than  usual,  and  may  take  the  place  of  the 

Eeroneal  artery  in  some  eases,  and  of  the  plantar 
ranches  of  the  posterior  tibial  in  others;  the  dorsalis 
pedis  branch  being  of  very  large  size,  as  mentioned  in 
the  description  of  the  varieties  of  the  posterior  tibial. 
The  dorsalis  pedis  artery  sometimes  ends  in  the  neigh- 
borhood of  the  cuneiform  bone.  The  anterior  tibial,  in 
some  rare  cases,  gives  off  an  anterior  tibial  recurrent 
to  the  knee  joint.  Francis  J.  Shepherd. 


Arteries,  Compression  of. — Compression  of  arteries 
for  the  arrest  and  prevention  of  hemorrhage  and  for 
the  cure  of  aneurysm  is  a  very  old  procedure,  and  one 
which,  although  in  many  instances  superseded  by 
ligation,  made  safe  by  the  introduction  of  antiseptic 
surgery,  is  still  employed  to  a  considerable  extent, 
particularly  in  the  prevention  of  hemorrhage.  Com- 
pression of  the  carotids,  thereby  lessening  the  blood 
supply  to  the  brain,  has  been  recommended  and  prac- 
tised at  different  periods  in  the  treatment  of  epileptic 
convulsions,  maniacal  excitement,  congestive  head- 
ache, and  for  the  purpose  of  producing  sleep.  Corning, 
of  New  York,  in  1882,  strongly  urged  the  advantages 
of  this  procedure  and  devised  a  special  instrument  for 
the  compression  of  the  carotids. 

Compression  is  accomplished  either  by  means  of 
the  hand  or  by  some  mechanical  device.  Digital 
compression  may  be  either  direct  or  indirect,  that  is, 
in  the  wound  or  over  the  vessel  of  supply,  and  may  be 
employed  for  the  immediate  arrest  of  existing  hemor- 
rhage or  for  the  prevention  of  hemorrhage  during  an 
operation.  This  means  is  occasionally  still  used  in  the 
treatment  of  aneurysm,  but  has  largely  been  super- 
seded by  the  ligature,  by  the  combined  use  of  gold  or 
silver  wire  and  electricity,  and  more  recently  by 
Matas's  excellent  endoaneurysmorrhaphy.  For  the 
instant  arrest  of  bleeding  nothing  is  more  readily  and 
satisfactorily  employed  than  the  fingers,  placed  either 
directly  in  the  wound  or  over  the  arterial  trunk  sup- 
plying it.  The  greatest  disadvantage  of  the  method  is 
that  it  is  impossible  to  keep  it  up  for  a  great  length  of 
time  without  the  help  of  a  number  of  intelligent  assis- 
tants. There  are  two  ways  of  applying  digital  com- 
pression, one  by  pressing  the  vessel  between  the  fingers 
and  a  bone,  the  other  by  compressing  it  between  the 
forefinger  and  the  thumb.  The  former  method  is  more 
satisfactory,  because  it  can  be  kept  up  for  a  much 
longer  period  of  time.  When  a  change  of  hands  is 
made  the  fresh  hand  should  always  be  placed  above 
the  point  of  former  compression  before  the  first  hand  is 
removed.  Digital  compression  can  much  more  readily 
be  employed  when  a  wound  has  been  made,  thus  ex- 
posing the  vessel,  than  when  it  is  attempted  with  con- 
siderable tissue  intervening  between  the  finger  and 
the  vessel,  as,  for  instance,  in  compression  of  the 
abdominal  aorta. 

650 


Innumerable  forms  of  compression  apparatus  have 
been  invented  for  compressing  blood-vessels,  one  of 
the  oldest  and  most  universally  used  being  the  tourni- 
quet of  Petit  (Fig.  120),  which  consists  of  two  metal 
plates,  connected  by  a  spiral  screw,  whereby  they  may 
be  separated,  and  a  strap  which  buckles  around  the 
limb.  In  the  use  of  this  tourniquet  many  surgeons 
apply  a  roller  bandage  over  the  vessel  to  be  com- 
pressed and  buckle  the  strap  over  this.  The  separa- 
tion of  the  plates  by  the  screw  tightens  the  strap  and 
increases  the  pressure.  In  order  to  prevent  the  strap 
from  cutting  the  skin  it  is  well  to  apply  first  a  turn  or 


Flo.  380. — Esmarch's  Elastic  Compressor. 

two  of  muslin  bandage  about  the  part.  In  an  emer- 
gency, when  a  tourniquet  cannot  be  had,  a  fillet  may 
be  employed  by  passing  a  handkerchief  or  piece  of 
cloth  or  cord  about  the  limb  and  then  tightening  it  by 
twisting  it  with  a  piece  of  wooden  stick.  Only  suf- 
ficient pressure  should  be  made  to  arrest  the  bleeding 
or  stop  the  pulse  as  too  great  pressure  tends  to  pro- 
duce gangrene.  The  most  generally  used  means  of 
compression  to-day  is  the  Esmarch  bandage  and  tube 
(Fig.  3S0).  The  bandage  is  an  ordinary  rubber  roller 
applied  from  the  tip  of  the  extremity  up  to  the  p> 
where  it  is  desired  to  place  the  tube,  and  its  object 
is  the  saving  of  the  blood  in  the  extremity,  in  case  of 
amputation,  and  the  freeing  of  the  limb  of  blood 
when  any  operation  is  to  be  done  upon  it.  The  tube 
is  of  rubber,  flat,  and  about  one  inch  wide.  This 
is  passed  tightly  about  the  limb  and  fastened  by  a 
hook  at  one  end  of  the  tube  and  a  chain  at  the  other. 
Certain  precautions  must  be  observed  in  the  use  of 
this  form  of  compression.  One  is  to  move  the  pari 
as  little  as  possible  after  the  tube  is  applied,  as  tear- 
ing of  the  tightly  bound  down  muscles  may  occur, 
and  another  is  to  see  that  each  turn  of  the  bandage 
and  tube  overlaps  the  preced- 
ing, else  pinching  of  the  skin 
occurs.  When  a  limb  is  dis- 
eased, compression  with  the 
bandage  is  not  to  be  made 
over  the  diseased  area,  but  it 
is  to  be  applied  above  and 
below  it,  or  else  it  is  not  to  be 
used  at  all,  but  the  limb  is 
simply  to  be  elevated  for  a 
time,  after  which  the  tube 
alone  is  to  be  used.  This 
method  of  elastic  constriction 
has  the  great  advantages  of 
simplicity  and  cleanliness 
over  other  forms  of  mechan- 
ical compression. 

Other  forms  of  compression 
apparatus  are  so  constructed  that  the  pressure  is 
exerted  over  the  main  artery  without  constricting 
the  surrounding  tissue.  These  forms  are  specially 
advantageous  in  the  treatment  of  aneurysm,  for  they 
are  much  less  likely  to  cause  gangrene,  which  is  so 
apt  to  follow  the  prolonged  use  of  the  two  forms  of 
compression  above  described.  Esmarch's  elastic  com- 
pressorium  for  the  aorta  and  Skey's  compressor  (Fig. 
381)  illustrate  this  point. 

Wyeth,    of    New   York,   introduced   a  method  of 
compressing   the   vessels   of    the    thigh   in    hip-joir.t 


3S1. — Skey's  Arterial 
Compressor. 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Arteries,  Compression  of 


amputation  (see  Figs.  191,  192),  which  is  a  combina- 

h,u   of    the   older    methods   of   Trendelenburg   and 
Dieffenbach.     It    consists    in    passing    through    the 

muscular  tissue  and  skin  above  the  point  of  amputa- 
tion two  long  steel  mattress  needles,  and  then  apply- 
ing above  them  the  constricting  band  of  Esmarch. 
I  u~  recent  years  I  have  used  direct  digital  compres- 
sion of  the  common  iliac  or  the  femoral  in  hip  joint 
md  high  thigh  amputations  and  prefer  it  to  the 
Wyeth  method.  It  must  not  be  forgotten  that  all 
'orms  of  compression,  if  kept  up  for  a  great  length 
if  time  or  if  the  pressure  is  too  great,  may  be  pro- 
ductive of  destruction  of  tissue  at  the  point  of  ap- 
ilication  or  of  gangrene  in  parts  below.  Also  it 
QUSt  be  remembered  that  after  circular  constriction 
if  an  extremity  reactionary  hemorrhage  may  occur, 
md  hence  it  is  necessary  to  tie  all  bleeding  points 
h  fore  closure  of   the  wound. 

Great  improvement  has  been  made  in  the  tempo- 
rary control  of  large  arterial  trunks  by  mechanical 
compressors  applied  directly  to  the  vessel.  The  rub- 
ber-covered clamp  of  Crile  is  one  of  the  best.  The 
compression  to  be  put  on  the  vessel  is  regulated  by 
i  set  screw.  This  method  is  most  useful  but  care 
should  be  taken  to  avoid  too  great  pressure  as  injury 
jf  the  intima,  with  the  resulting  thrombosis,  will 
-ccur.  Matas  and  Halsted  have  done  an  enormous 
imount  of  experimental  work  in  the  gradual  com- 
iression  of  the  vessels  by  means  of  metal  bands  which 
-an  be  tightened  by  degrees.  In  all  likelihood  some 
method  of  this  kind  will  ultimately  prove  sat- 
sfactory  in  arresting  the  circulation  in  cases  of 
ineurysm  involving  vessels  which  cannot  be  ligated 
ir  dealt  with  according  to  the  Matas  method  of 
•ndoaneurysmorrhaphy. 


Fiq.  382. — Compression  of  the  Aorta.  (Dr.  W.  W.  Keen.) 
Right  hand  closed,  a  little  to  the  left  ol  the  median  line:  knuckles 
01  index  finger  just  touching  the  upper  border  of  the  umbilicus; 
left  hand  feels  patient's  pulse  (femoral)  at  brim  of  pelvis. 

Special  Arteries. — The  aorta  cannot  be  com- 
pressed until  it  has  passed  through  the  diaphragm 
into  the  abdomen,  and  then  only  with  difficulty,  un- 
less the  abdomen  be  opened.  Compression  of  the 
abdominal  aorta  is  resorted  to  as  a  means  of  pre- 
venting severe  hemorrhage  from  its  distributing 
branches  or  for  the  purpose  of  temporarily  arresting 


Fio.  383 


Compression  of  the 
Brachial. 


the  circulation  in  them:  for  example,  in  a  hip-joint 
amputation,  or  in  an  attempt  to  cure  an  aneurysm. 
It  can  be  satisfactorily  accomplished  without  abdom- 
inal section  iii  thin  persons,  but  in  those  with  thick 
abdominal  walls  it  is  i  erj  difficult  of  accomplishment. 
As  to  the  precise  mode  of  effecting  the  desired  pressure, 
one  may  employ  an  Esmarch 's  elastic  compressor  or 
that  of  Skey,  the  liitter  which  is  shown  in  the  illustra- 
tion (Fig.  381),  or  the  hand  of  an  assistant  may  be  em- 
ployed (Fig.  382).  All  of 
t  he  e  mel  hod  are  open  to 
objections:  they  may  cause 
an  injury  to  the  overlying 
intestine — and  this  is  more 
likely  to  happen  when  an 
apparatus  is   used — or   the 

compression  ma}-  prove  to 
be  inefficient,  as  when  the 
instrument  is  not  properly 
applied,  or  when  it  slip-,  or 
when  the,  assistant's  hand 
moves  to  one  side  of  the 
artery.  The  usual  position 
for  the  compression  pad  or 
the  hand  is  just  below  the 
umbilicus  and  a  little  to  the 
left;  but  the  pulsation  of 
the  vessel  must  be  definitely 
felt  before  compression  is 
applied,  and  after  the  ap- 
plication of  compression  no 
operation  should  be  done  until  all  pulsation  has  ceased 
in  the  vessels  below.  There  will  be  less  danger  of 
injuring  the  intestinal  canal  if  it  be  first  emptied  by 
means  of  a  cathartic  and  an  enema;  and  before  ap- 
plying the  pad,  the  bowels  should  be  pushed  to  the 
right  side  of  the  abdomen  by  rolling  the  patient  on 
that  side.  When  the  abdomen  is  opened  compression 
of  the  aorta  is  rendered  easier  and  safer;  it  may  be 
accomplished  with  the  fingers  or  with  a  specially  de- 
vised clamp  consisting  of  two  blades,  one  of  which 
fits  into  the  other  somewhat  after  the  style  of  a 
lithotrite.  Great  care  should  be  exercised  in  the  use 
of  such  an  instrument  or  an  injury  may  be  done  to  the 
vessel  itself  or  its  neighbors. 
Momburg  in  1908  de- 
scribed a  method  of  produc- 
ing ischemia  of  the  lower 
half  of  the  body  by  con- 
stricting the  abdomen  with 
several  turns  of  a  heavy 
elastic  bandage;  as  a  pre- 
liminary procedure,  the 
blood  in  the  lower  extremi 
ties  is  forced  out  by  apply- 
ing an  Esmarch  bandage. 
Although  this  method  of 
compressing  the  abdominal 
aorta  has  been  used  a  num- 
ber of  times  without  detri- 
ment to  the  intestine  it 
does  not  appear  to  be  a  per- 
fectly safe  procedure  and 
should  not  be  lightly  under- 
taken. 

The  common  iliac  may  be 
compressed  through  the  ab- 
dominal   wall,   through    the    Fig.  384. — Compression  of  the 
rectum,  or  through   an   in-  Femoral, 

cision  in  the  abdominal  wall. 

The  last  method,  which  enables  one  to  use  the  fingers, 
is  by  far  the  most  satisfactory  of  the  three  and  the  only 
one  that  has  been  practised  with  anything  like  good  re- 
sults. It  has  become  now  one  of  the  recognized  means 
of  preventing  hemorrhage  in  hip-joint  amputation, 
particularly  in  those  cases  in  which,  because  of  dis- 
eased anterior  flap,  the  Wyeth  pins  cannot  be  used. 
Dr.  Charles  McBurney  first  employed  this  method  of 

651 


Arteries,  Compression  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


preventing  hemorrhage  in  1S94.  Experience  has 
shown  that  the  common  iliac  can  very  readily  be 
compressed  with  the  fingers  in  the  abdominal  cavity 
without  the  exertion  of  much  force  and  without 
increasing  the  dangers  of  the  operation.  Compression 
through  the  rectum  by  means  of  Davy's  lever  is  not 
so  safe  or  so  satisfactory  as  are  the  other  methods. 

External  Iliac. — This  vessel  can  be  compressed  with 
tin-  fingers  or  with  an  instrument  placed  just  above 
Poupart's  ligament,  midway  between  the  symphysis 
pubis  and  the  anterior  superior  spine  of  the  ilium. 

Femoral. — The  course  of  this  vessel  is  covered  by  a 
line  drawn  from  the  point  midway  between  the 
symphysis  pubis  and  the  anterior  superior  spine  of 
the  ilium  to  the  adductor  tubercle  on  the  inner 
condyle  of  the  femur,  and  can  be  compressed  by  the 
fingers  (Fig.  3S4)  or  by  the  tourniquet  anywhere 
throughout  its  course,  the  force  being  exerted  tow  aid 
the  bone. 

The  popliteal  occupies  the  middle  of  the  popliteal 
space;  it  can  best  be  compressed  against  the  femur 
in  the  upper  part  of  its  course. 

The  posterior  tibial  can  readily  be  compressed  by 
the  finger  as  it  passes  midway  between  the  internal 
malleolus  and  the  point  of  the  heel. 

The  anterior  tibial  lies  between  the  tendons  of  the 
tibialis  anticus  and  the  extensor  longus  hallueis,  and 
can  best  be  compressed  after  it  becomes  the  dorsalis 
pedis  and  passes  under  the  annular  ligament. 

The  subclavian  can  be  compressed,  unless  exposed 
by  incision,  only  in  its  last  one-third,  where  ii 
crosses  the  first  rib.  Pressure  should  be  made  with 
the  thumb  in  the  angle  formed  by  the  posterior  border 
of  the  sternocleidomastoid  and  the  clavicle,  and 
should  be  directed  downward,  backward,  and  inward 
against  the  rib.  The  tip  of  the  shoulder  should  be 
depressed. 

Axillary. — Compression  of  this  vessel  can  be  made 
only  in  the  last  part  of  its  course,  and  is  accomplished 
by  making  pressure  from  within  outward  against  the 
upper  part  of  the  humerus. 

The  brachial  artery  can  very  readily  be  compressed 
against  the  shaft  of  the  humerus,  the  inner  edge  of 
the  biceps  being  the  guide  to  its  situation. 

The  radial  can  be  compressed  against  the  anterior 
surface  of  the  lower  end  of  the  radius  between  the 
tendons  of  the  supinator  longus  and  the  flexor  carpi 
radialis. 

The  ulnar  artery  can  be  compressed  against  the 
anterior  surface  of  the  ulna  between  the  flexor  carpi 
ulnaris  and  the  flexor  sublimis  digitorum. 

The  common  carotid  and  the  external  carotid  can  be 
compressed  with  the  fingers  or  by  means  of  one  of  the 
instruments  specially  devised  for  the  purpose.  The 
anterior  border  of  the  sternocleidomastoid  is  the 
guide  to  the  vessels,  and  the  pressure  should  be 
directed  backward  and  inward. 

The  facial  can  be  compressed  with  ease  as  it  passes 
over  the  lower  jaw  just  in  front  of  the  masseter  muscle. 

The  temporal  may  be  controlled  by  making  pressure 
on  the  zygomatic  process  just  in  front  of  the  tragus. 

The  labial  artery  may  be  controlled  by  compressing 
the  lips  between  the  finger  and  thumb. 

John   H.   Gibbon. 

Arteries,  Surgery  of  the. — Wounds  of  arteries  may 
be  complete  or  incomplete,  penetrating  or  nonpene- 
trating, perforating,  punctured,  incised,  contused, 
or  lacerated. 

It  is  generally  said  that  a  non-penetrating  wound 
that  does  not  injure  the  intima  is  not  followed  by 
hemorrhage  and  it  has  been  shown  experimentally 
many  times  that  such  wounds  are  not  followed  by 
aneurysm,  as  was  formerly  thought  to  be  the  case, 
1ml  by  a  scar  stronger  than  the  original  wall  of  the 
artery. 

Punctured  wounds  may  be  caused  by  various  for- 
eign bodies,  the  simplest  form  being  a  puncture  by  a 

652 


needle  or  pin.  In  these  cases  a  small  mural  thrombus 
forms  at  the  site  of  puncture  composed  of  blood 
plates,  fibrin,  and  leucocytes  (white  thrombus) 
comparable  in  a  general  way  to  a  tack  with  the  stem 
plugging  the  hole.  Healing  occurs  without  oblit- 
eration of  the  lumen.  Punctured  wounds  may  also 
be  caused  by  many  other  foreign  bodies  such  as  scis- 
sors, fish  bones,  spicules  of  bone  following  fractures 
etc.  Several  cases  have  been  reported  of  fatal 
hemorrhage  from  punctured  wounds  of  the  carotid 
and  aorta  by  foreign  bodies  swallowed. 

Penetrating  wounds  may  be  complete  or  incomplete 
longitudinal,  transverse,  or  oblique.  When  the  wound 
is  longitudinal  it  remains  as  a  slit  and  little 
hemorrhage  occurs,  but  when  transverse, 
the  edges  retract,  making  the  wound  oval 
and  the  hemorrhage  is  greater.  Oblique 
wounds  gape  somewhat  from  retraction, 
the  amount  depending  on  the  obliquity  of 
the  cut. 

Gunshot  wounds  vary  according  to  the 
type  of  missile  used.  The  lead  bullet  used 
in  former  times,  but  now  seen  only  in 
wounds  in  civil  life,  inflicts  a  contused  or 
lacerated  wound.  The  high  velocity  jack- 
eted bullet  of  modern  warfare  often  makes 
a  wound  of  the  same  type,  but  may  make 
a  clean-cut  complete  or  incomplete  wound. 
The  missile  may  also  wound  both  the 
artery  and  vein,  traumatic  aneurysm  and 
arteriovenous  aneurysm  being  common  in 
the  late  wars.  Shell  wounds  are  rarely 
followed  by  immediate  but  are  prone  to 
delayed  hemorrhage.  The  chief  symptom 
of  all  these  wounds  is  hemorrhage. 

Spontaneous  hemostasis  depends  on  the 
size  and  nature  of  the  wound,  the  artery 
injured  and  its  condition,  the  tension  in 
the  vessel,  and  on  many  other  factors. 
When  a  vessel  is  divided  the  ends  both 
contract  and  retract,  narrowing  the  lumen, 
and  the  intima  also  tends  to  roll  up,  thus 
still  further  reducing  the  caliber.  This 
contraction  is  due  to  the  muscles  of  the  Ar'terie" 
media  and  depends  more  or  less  on  the  (Schematic) 
aim mnt  of  stimulation.  Following  the 
injury  there  is  an  immediate  hemorrhage 
and  the  blood  coining  in  contact  with  the 
ad  vent  itia  sheath  into  which  the  rest  of  the 
vessel  has  contracted  formsaelotwhichex- 
tends  around  the  wound  for  some  distance  'jlhqeua^] 
and  up  into  the  lumen.  This  is  soft  and  c,  division  ol 
is  the  red  or  temporary  thrombus  caused  half  the  cir- 
by  chemical  action,  and  has  nothing  to  do  c  u  m  ferenee 
with  the  white  or  true  thrombus  formed  of  the  artety: 
later  as  the  forerunner  of  permanent  /»  l'"ll,i'1' t,! 
healing.     The    loss  of    blood    also   tends    ^l1  """] 

to   stop   the   hemorrhage  as  it  slows  the    <££2t0 

current,  and  the  bleeding  may  cease 
if  the  patient  faints,  only  to  recur  when  he  regains 
consciousness  and  the  pressure  rises.  Blood  in 
exsanguinated  subjects  is  said  to  clot  more  readily. 
The  permanent  or  white  thrombus  is  formed  on  the 
inside  of  the  temporary  or  red  clot  and  is  composed 
of  blood  plates,  leucocytes,  and  fibrin.  It  is  always 
seen  following  any  injury  to  the  intima.  The  white 
thrombus  is  laid  down  slowly,  and  plugs  the  vessel  to 
the  nearest  branch  given  off;  in  clean  wounds  it  is 
firm  and  of  a  grayish  color  but  in  septic  ones  is  soft, 
puriform,  and  loosely  adherent  to  the  vessel  wall.  It 
was  in  this  class  of  wounds  that  secondary  hemorrhage 
was  so  commonly  seen  in  the  days  before  aseptic 
surgery.  Spontaneous  hemostasis  is  retarded  by 
increased  tension  following  stimulation,  unrest  which 
dislodges  the  clot,  or  partial  division  only  of  the 
vessel,  which  prevents  retraction  and  contraction. 
It  is  also  retarded  by  anything  that  inhibits  clotting. 
Contusion   and   Rupture. — These   injuries    may   be 


Fig.  384a,— 


lougitudi- 
n  a  I;  6,  ob- 
1  i  q  u  e  ;    c, 

tran  SI  'i 

</,  division  of 


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ArterieSf  Surgery  of 


[  any  degree  from  slighl  tears  of  the  intima  following 

in  complete  rupture  and  severe  laceration 

ich  as  is  seen   following   a   railroad  injury   or   the 

ion  of  a  limb  by  machinery. 

Matas  divides  the  injuries  into  those  of  the  first, 

rod,  and   third  degree.     In  wounds  of  the  first 

there  is  a  small  tear  in  the  intima  only.     A 

mral  thrombus  is  formed  in   these  cases  and  the 

heals    usually    without    obliteration    of    the 

In  wounds  of  the  second  degree  the  intima 

id   media  are  both    turn.     These  coats    retract,  a 

o|  is  formed,  and  the  artery  heals  with  obliteration 

the  lumen.    This  is  probably  the  most   common 

id  may  be  associated  with  some  extravasation 

blood,     [n  wounds  of  the  third  degree  the  vesesl 

ipletely    ruptured.     Picquet    distinguishes   be- 

rupture  of    an    artery   by   traction    and    by 

lining.      He    maintains    that   the   intima   not   being 

istie  is  ruptured   by    comparatively   slight    traction 

ithout   injury  to   other  structures,  while  in  rupture 

iruising   the  injury  to   the  adjacent    parts    is 

more  severe. 

Rupture  of  large  vessels  is  seen  following  severe 

-  both  military  and  civil,  and  is  usually  asso- 

iated  with  other  injuries.      When  a  limb  is  struck 

he  artery,   owing  to  its  natural  resistance  and  its 

ma  by  the  surrounding  muscles,  slips  to  one 

ido  and  it  is  probably   rarely   ruptured   by   being 

iched  between  the  instrument  causing  the  trauma 

id  the  bone.     The  brachial,  femoral,  and  popliteal 

vessels  most  subject  to  injury.     Monod  and 

.inverts  collected  (1900)  107  cases  of  subcutaneous 

ipture    of    arteries.     The    popliteal    was    ruptured 

hirty-four     times,     the    femoral     twenty-one,     the 

rachial  nineteen,  the  axillary  ten,  the  subclavian  six, 

he  external  iliac  two,  and  the  smaller  arteries  four- 

■en.     Unless  the  trauma  is  very  severe,  incomplete 

ipture  is  more  common  than  complete,  fifty-eight 

t   these  cases  being  of  the  former  type  and  forty- 

ight   of   the   latter.     Rupture   is   also    occasionally 

■en  as  a   complication   of  fracture   and    Hefferann 

ias    collected   fifty-seven  cases  accompanying  dislo- 

ation  of   the  shoulder.     It   has  been  said    that   an 

rtery  may  be  ruptured  by  muscular  effort  and  in 

his  connection  Turner  reported  a  much  quoted  case 

\here  rupture  of  the  brachial  was  caused  by  a  man 

mtting  his  hand  behind  his  back.     It  is  probable 

hat  rupture  when  not  due  to  severe  trauma  is  caused 

iv  muscular  effort  with  slight  stretching  of  the  intima 

lithough   the   etiology   at    times   is   rather   obscure. 

Spontaneous  rupture   although  rare  does  occur  and 

-  usually  associated  with  syphilis  or  atheroma. 

Gangrene  of  the  limb  following  rupture  of  the  main 
irtery  is,  next  to  hemorrhage,  the  great  danger  and 
s  due  to  several  factors,  not  being  caused  solely  by 
he  destruction  of  the  main  vessels.  The  resulting 
lematoma  may  cause  so  much  tension  that  circula- 
ion  through  the  collaterals  is  prevented  or  the  origi- 
ial  trauma  may  have  been  so  great  that  the  small 
ollaterals  are  thrombosed  as  well  as  the  main 
irtery.  The  clot  in  the  distal  end  of  the  main  vessel 
it  times  forms  small  emboli  which  plug  the  terminal 
is  or  it  may  block  these  by  a  direct  extension 
>f  its  growth.  If  the  vein  is  destroyed  as  well  as 
the  artery,  gangrene  is  much  more  apt  to  occur  and 
to  be  of  the  moist  rather  than  the  dry  variety.  Out 
if  sixty-two  cases  of  ruptured  arteries  collected  by 
Berzog  in  1S90,  thirty-two  or  fifty-three  per  cent., 
i  -veloped  gangrene,  while  of  Monod  and  Vanvert's 
fifty-eight  cases  of  incomplete  rupture,  gangrene 
followed  in  thirty-five,  or  sixty  per  cent.  These 
cases  all  occurred  since  the  advent  of  aseptic  surgery 
and  were  as  follows:  Subclavian  four  cases,  no  gang- 
rene; brachial  seventeen  cases,  six  gangrene;  popli- 
teal seventeen  cases,  fifteen  gangrene  (although  in 
another  article  the  authors  state  that  ligature  of  the 
popliteal  should  never  be  followed  by  gangrene). 
Jensen  in  an   analysis  of   wounds   of  the  popliteal 


artery  found  gangrene  in  fifty-four  per  cent.  Fol- 
lowing ligature  hi  the  femoral  it  is  variously  esti- 
mated as  from  five  to  forty  per  cent.  Accordii 
the  e  statistic  there  ults  are  no  better  than  before  the 
advent  of  asepsis.  They  probably  give  a  fal  e  im- 
pre  ion,  however,  and  it  i-.  to  be  supposed  thai  a 
large  number  of  cases  of  rupture  are  treated  and 
recover  without  being  reported.  Probably  al  o  tl 
would  be  many  fewer  cases  of  gangrene  if  the  le  ion 
to  the  artery  was  recognized  and  treated  promptly 
and  in  a  systematic  manner.  In  general  it  may  be 
stated  that  simple  rupture  of  the  brachial  artery 
promptly  treated  u  never  followed  by  gangrene, 
that  of  the  axillary  rarely.  In  the  lower  extremity 
gangrene    is    more    common    but    practically   never 

should  OCCur  after  ligature  of  I  he  popliteal,  although 
it  should  bo  feared  after  ligature  of  the  femoral  or 
iliac. 

The  symptoms  caused  by  a  wound  in  an  artery 
may  be  divided  into  constitutional  and  local.  The 
constitutional  symptoms  are  primarily  those  of 
hemorrhage  and  shock  and  depend  on  the  amount 
of  blood  lost  and  the  type  of  the  wound.  The  local 
symptoms  are  In— or  diminution  of  the  pulse  in  the 
vessel  below  the  point  of  injury,  pallor,  a  cold  ex- 
tremity, and  hemorrhage.  The  hemorrhage  may  be 
active  and  visible,  when  the  skin  is  wounded,  or  it 
may  be  concealed,  in  which  case  a  diffuse  or  circum- 
scribed arterial  hematoma  forms.  The  hemorrhage 
may  also  be  delayed,  if  the  wound  is  incomplete,  or 
it  may  be  recurring. 

Arterial  hematoma  occurs  when  there  is  a  small 
wound  in  the  vessel  and  may  be  either  circumscribed 
or  diffuse.  In  the  diffuse  variety  the  tissues  are 
everywhere  infiltrated  with  blood  and  no  definite 
cavity  is  formed.  The  limb  is  swollen  and  cold,  and 
the  skin  is  tense  and  of  a  livid  or  bluish  color.  This 
causes  great  tension  and  pressure  on  the  collaterals 
and  predisposes  to  gangrene.  In  the  more  common 
or  circumscribed  form  (false  aneurysm)  there  is  a 
sac  formed  out  of  the  adjacent  structures  lined  with 
fibrous  tissue,  clot,  etc.,  and  containing  blood.  This 
sac  communicates  with  the  lumen  of  the  artery  by 
a  small  opening  and  gives  a  distinct  pulsating  tumor 
of  varying  shape  over  which  a  distinct  thrill  may  be 
felt  and  a  bruit  heard  synchronous  with  the  pulse. 
Lejars,  Haga,  and  Russian  surgeons  have  had 
occasion  to  treat  a  large  number  of  these  cases  fol- 
lowing gunshot  wounds  made  by  the  high  velocity 
jacketed  bullet  in  the  late  wars.  The  false  aneu- 
rysm may  form  rapidly  or  slowly  in  the  course  of 
months,  or  may  increase  in  size  for  a  time  and  then 
cease,  only  to  grow  again  later.  If  small  there  may 
be  spontaneous  cure,  the  cavity  becoming  filled  with 
clot  and  obliterated. 

The  treatment  may  be  divided  into  constitutional 
and  local  measures.  The  constitutional  treatment 
is  the  same  as  that  for  hemorrhage  and  shock  and 
consists  of  rest  in  bed,  morphine,  artificial  heat, 
stimulants,  saline  solution,  transfusion,  etc.,  as 
indicated. 

The  object  of  the  local  treatment  is  first  to  control 
the  hemorrhage  and  secondly  to  repair  the  damage 
done  and  prevent,  if  possible,  gangrene.  Imme- 
diately following  the  injury  a  tourniquet  is  generally 
applied  as  the  quickest  and  easiest  method  of  con- 
trolling the  hemorrhage.  The  patient  should  then 
be  removed  to  a  suitable  place  and  active  local  treat- 
ment instituted.  The  skin  should  be  very  carefully 
prepared  and  the  vessel  cut  down  upon  and  explored. 
The  surrounding  tissues  and  vessels  are  also  to  be 
carefully  examined  to  determine  the  amount  of  dam- 
age done  not  only  to  the  artery  itself  but  to  the 
satellite  vein,  the  soft  parts,  and  the  collateral  vessels. 
If  the  artery  is  lacerated  and  the  vein  intact  the  two 
ends  may  be  ligated,  the  wound  thoroughly  cleansed  of 
blood  clot,  and  the  skin  sutured.  The  wound  should 
be  drained   to  relieve  any  pressure   that  might  be 


653 


Arteries,  Surgery  of 


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caused  by  the  collection  of  serum.  A  thick  dressing 
is  then  put  on  and  the  extremity  kept  warm,  dry, 
elevated,  and  aseptic — in  fact,  everything  should  be 
done  to  promote  the  circulation.  The  above  is  the 
treatment  indicated  in  the  majority  of  the  cases. 

If  there  is  a  small  lateral  wound  in  the  artery  it  may 
be  closed  by  suture  or  if  it  extends  over  two-thirds  of 
the  circumference  the  artery  may  be  divided  and  end- 
to-end  suture  done.  When  the  artery  has  been 
destroyed  by  the  injury  the  bruised  portion  may  be 
excised,  the  clots  and  thrombi  washed  out  of  the 
vessel  with  saline  solution,  and  a  piece  of  vein  set  in 
to  remedy  the  defect.  This  is  particularly  indicated 
when  the  main  vein  is  injured  as  well  as  the  artery. 
The  actual  treatment  of  a  given  case  depends  on 
many  factors  and  no  definite  rules  can  be  laid  down, 
the  proper  procedure  being  a  matter  of  judgment. 

Treatment  of  Arterial  Hematoma. — Diffuse  hema- 
toma and  also  circumscribed  hematoma  when  large 
and  of  rapid  formation,  should  be  treated  on  the  lines 
already  laid  down.  When  circumscribed  and  of 
slow  formation  the  majority  of  observers  prefer  to 
wait  until  a  more  or  less  definite  connective-tissue 
sac  is  formed  (false  aneurysm)  and  the  collateral 
circulation  has  had  time  to  develop.  There  has 
been  much  discussion,  however,  as  to  the  proper  time 
to  operate.  In  these  late-forming  cases  the  Matas 
operation  is  usually  the  procedure  of  choice.  It  is 
always  well  before  operating  to  determine  if  possible 
the  extent  of  the  collateral  circulation,  which  may  be 
done  by  compressing  the  main  artery  and  noting  if 
this  obliterates  the  pulse  and  noting  also  the  ap- 
pearance of  the  limb  beyond  the  aneurysm.  Inter- 
mittent pressure  applied  in  this  manner  also  tends  to 
develop  the  collateral  circulation.  During  the  opera- 
tion some  form  of  temporary  hemostasis  should  be 
employed  and  the  vessel  treated  according  to  the 
condition  found.  In  many  cases  the  restorative 
Matas  operation  can  be  performed.  In  others  double 
mediate  ligation  is  necessary,  while  in  some  arterial 
suture  may  be  employed.  Monod  and  Vanvert  (1011) 
have  collected  215  operations  done  for  this  condition 
on  20.5  patients  since  1880.  Suture  was  performed  in 
thirty-two  of  these  with  twenty-nine  successes,  one 
death  and  one  failure,  while  in  one  the  result  was  not 
noted. 

Healing  of  Arteries. — This  subject  has  been  ex- 
tensively studied  by  Zahn,  Pitres,  Warren,  d'Eberth, 
Schimmelbusch,  and  others  and  is  essentially  the 
same  when  following  a  wound  as  when  following  ex- 
perimental ligature. 

When  a  large  artery  is  tied  in  its  continuity,  the 
intima  and  a  variable  portion  of  the  media  are  usually 
ruptured,  and  the  adventitia  is  gathered  into  a  dense 
tendinous  sheath  around  the  constricted  ends.  The 
first  noticeable  change  is  the  formation  of  the  thrombi. 
The  proximal  thrombus  is  much  larger  than  the 
distal  thrombus  and  owing  to  the  more  rapid  coagu- 
lation of  the  blood  the  vessel  has  an  ampulla-like 
distention.  The  vessel  on  the  distal  side  of  the  ligature 
is  contracted  and  the  thrombus  is  much  smaller. 
The  ligature  soon  becomes  embedded  in  a  cell 
growth  which  appears  to  proceed  from  the  peri- 
adventitial  tissue,  and  varies  according  to  the  amount 
of  injury  done  by  the  ligature  to  the  vessel  walls, 
or  to  the  irritation  which  it  produces.  If  the  coats 
of  the  vessel  have  been  unnecessarily  bruised  and  a 
certain  amount  of  extravasation  has  taken  place  in 
consequence,  or  if  the  ligature  itself,  for  some  cause, 
has  created  irritation,  the  surrounding  inflammatory 
tissue  will  form  a  well-marked  callus.  If  an  excessive 
irritation  has  been  produced,  the  growth  of  this 
protective  tissue  may  be  retarded,  or  it  may  be 
destroyed  and  the  danger  of  hemorrhage  correspond- 
ingly increased.  Following  the  development  of 
this  external  growth,  we  find  that  it  extends  some 
distance  up  and  down  the  sides  of  the  vessel  in  the 


periadventitial  tissue,  the  round  cells  of  which  it  is 
composed  invading  only  the  superficial  layers  of  the 
adventitia;  the  breadth  of  the  growth  is,  of  course, 
greatest  at  the  point  of  ligature;  in  length  it  reaches 
usually  to  a  point  on  a  level  with  the  ends  of  the  two 
a  _     6         c 

WM 


Fig.  385. — Ligatured  Vessel,  a,  Proximal  thrombus  in  ampulla, 
like  dilatation  of  the  vessel;  6,  media;  c,  adventitia;  I,  site  of 
ligature.     (Drawn  from  author's  specimen.) 

thrombi;  when  fully  developed  it  is  consequently 
spindle-shaped  (Fig.  3S5).  At  the  point  of  ligature, 
where  the  fibers  of  the  outer  wall  are  densely  packed 
(Fig.  385,  I),  the  cell  growth  does  not  penetrate  dur- 
ing the  first  few  days;  but  just  above  and  below  the 
ligature  they  may  be  found  already  invading  the 
media  as  early  as  the  second  day;  occasionally  the 
apex  of  a  pyramidal-shaped  mass  of  such  cells  will 
have  reached  the  thrombus. 
These  cells  appear  to  exert  a 
solvent  action  on  the  bunch 
of  fibers  projecting  from  the 
ring  of  the  ligature,  which 
thus  becomes  gradually  liber- 
ated from  all  connection  with 
the  vessel,  the  two  ends  of 
which  now  retract  and  leave 
the  knot  embedded  in  the 
center  of  the  callus.  The 
fibers  of  the  ligature  itself 
soon  become  infiltrated  with 
cells,  and  by  the  tenth  day 
they  may  have  already  dis- 
appeared, or,  if  its  resisting 
powers  are  greater,  may  re- 
main encysted  for  some 
time.  The  period  which  the 
ligature  requires  for  this 
separation  varies  greatly  ac- 
cording to  the  size  of  the 
vessel  and  character  of  the 
ligature,  and  is  longer  in  man 
than  in  animals.  If  the  artery 
has  been  properly  dissected 
out,  this  external  growth 
will  be  observed  forming  a 
callus-like  ring,  in  which  the 
two  ends  of  the  vessel  are 
embedded,  in  size  about 
twice  the  thickness  of  the 
vessel,  and  it  can  still  be  seen 
well  developed  at  the  end  of 
two  months  (Fig.  3S6).  In  the  specimen  from  which 
the  accompanying  drawing  was  taken  the  ligature 
had  caused  suppuration  about  it,  and  had  formed  a 
fistulous  track  at  the  fundus  of  which  some  fibers 
were   found   still  remaining.     By  the  end   of   three 


Fig.  3S6.— Carotid  Artery 
of  Horse  Two  Months  Alter 
Ligature.  I,  Sinus  at  site  of 
ligature;  the  ends  of  the 
artery  have  separated,  but 
are  enclosed  in  a  firm  callus. 
(Drawn  from  author's  .speci- 
men.) 


G54 


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Arteries,  Surgery  of 


callus    had  disappeared,  and 
united   the  peripheral  to  the 


onths  the  external 
,ly  a  slender  cord 
roxiroal  end. 

\lrcady   by   the  fourth   day   changes   are   noticed 
it  hin  the  vessel.     Observing  the  proximal  thrombus 
,  find  an  increase  in  the  number  of  while  corpuscles, 
irticularly    near   the   point   of   ligature,    not    in   an 
ulated    mass,     but    mingled    with    red    corpuscles. 
asses  of  coagulated  fibrin  with  young  cells  i  while 
irpuscles    of    clot,    wandering    cells    from    arterial 
,:its  and  rarely  also  periarterial  tissues)  are  at  Inched 
.  I  lie  frayed  ends  of  the  media  which   have   been 
i    by    the  ligature  and  are  more  or  less  inverted, 
lie  endothelial   cells,   when   not  firmly   compressed 
y  the  thrombus,  as  in  the  distal  end,  are  in  a  stale 
ity,   undergoing  proliferation  to  a  moderate 
stent.     Occasionally,  loop-like  masses  of  cells  may 
■  seen  projecting  into  the  clot,  or  a  delicate  anas- 
mosing  network  of  stellate  or  spindle-shaped  cells; 
nt  the  total  amount  of  this  cell  growth  is  small  as 
impared   with   the  size  of  the   thrombus.     In   the 
.an  time,  in  the  second  week,  masses  of  granulation 
lis  ate  seen  infiltrating  that  part  of  the  wall  which 
separating    or    has    already    separated    from    the 
ature.     Even    at   this   period,    with    the   external 
rowth  carefully  dissected  away,  as  is  the  custom  in 
iliseum  specimens,  the  vessel  appears  to  have  united 
\   first  intention,  that  is,  by  a  direct  union  of  the 
icdia  and  intima  side  to  side.      But  the  infiltration 
rid  softening  continue  until  the  walls  are  separated 
ad  expand,  like  the  petals  of  a  rose,  yielding  before 
he  advancing   growth   of   granulation   tissue.     The 
ceper  portions  of  the  clot  are  now  infiltrated  with 
wo  growths;  the  more  superficial  (that  is,  the  por- 
lon  nearest  the  open  lumen  of  the  vessel)  is  com- 
osed  of  tissue  grown  from  the  intima  and  media  and 
.andcring  cells,  and  the  deeper  is  composed  of  vas- 
ular  granulation  tissue  which  has  pushed  its  way  in 
roin  without.     Viewed  at  the  thisd  week,  the  ends 
f  the  vessel  will  be  found  expanded  and  the  space 
etween  them  filled  with  well-formed  granulations, 
Mrh  as  are  seen  on  the  surface  of  a  healthy  wound. 
\  portion  of  the  thrombus,  sometimes  a  large  portion, 
iss  not  been  infiltrated,  but  is  attached  firmly  to  the 
op.     A  longitudinal  section  of  such  a  specimen  gives  a 
triking  illustration  of  what  is  understood  as  "healing 
ly  scabbing."     As  the  clot  shrinks  the  spaces  left  be- 
ween  the  granulations,  which  have  now  rolled  over 
me  another  in  cloud-like  masses,  become  continuous 
\ith  the  open  lumen  of  the  vessel,  and  the  so-called 
canalization"  of  the  thrombus  is  thus  effected.     An 
njection  mass  can  be  forced  from  the  vessel  for  some 
listance  into  these  spaces,  but  as  yet  they  do  not 
•ommunieate    with    the    vessels   of    the    granulation 
issue.     This  communication  usually  does  not  occur 
mtil  the  second  month,  that  is,  until  the  provisional 
growth  has  reached  its  period  of  highest  development. 
The  vessel  walls  have  in  the  mean  time  been  under- 
ming  certain   changes.     A  proliferation  of  the  cells 
if  the  intima,  as  has  been  noticed  by  so  many  ob- 
servers, unquestionably  takes  place;  but  the  amount 
li-velopcd  is  not  sufficient  to   supply  more   than   a 
t  cry  small  part  of  the  provisional  tissue.     The  cells, 
however,  have  begun  to  grow  before  the  other  tissue 
lias  made  its  way  into  the  vessel,  and  at  this  period 
serve  the  purpose  of  attaching  the  thrombus  to  the 
walls  of  the  vessel,  but  even  in  this  work  they  are 
aided   by  other   cells    from    the   media.    They   also 
furnish  a  new  endothelial  covering  to  the  permanent 
cicatrix,  and  a  lining  to  the  new  vascular  spaces  that 
have  been   formed.     When   the  elastic   lamina   has 
been  ruptured   (and  this  is  frequently  seen  on  the 
-ides  of  the  vessel  near  the  ligature,  and  also  here 
and  there  higher  up  as  far  as  the  thrombus  extends), 
we  find  an  intimate  connection  at  such  points  of  the 
media   with   new   growing   tissue   within   the   vessel. 
In  the  second  week,  cells  may  be  seen  springing  from 
the  media  and  growing  into  either  the  clot  or  a  clump 


Fio.  387. — Carotid  Artery  of  Dog  Four 
Months  After  Ligature,  showing  shape 
of  cicatrix  as  modified  by  the  presence 
of  a  branch.  (Drawn  from  author's 
specimen.) 


of  cells  attached  to  the  inner  wall.  The  cells  are 
round   and   spindle-shaped,    frequently   in    bundle  . 

Evidences  of  cell  activity  in  the  media  are  abundant, 
and  in  some  specimens  in  animals  a  proliferation  of 
the   muscular   cells   through    the    whole    thickness   of 

the  media  is  ob- 
served, giving  a 
con   iderable  in- 

ffillllA  m»W  elrne    l.i   Ihr  width 

Uk  of  this  layer.      The 

clastic  lamina  is 
frayed  out  at  its 
divided  end,  and 
glistening  elastic 
lilier,  are  seen  ex- 
tending downward 
into  the  external 
growth  as  the  two 
ends  of  the  vessel 
gradually  retract 
from  each  other. 
At  the  end  of  three 
months  the  provi- 
sional t  issue  has 
been  absorbed,  and 
we  find  the  walls 
united  by  a  perma- 
nent cicatrix  which 
joins  the  sides  of 
the  vessel,  still 
somewhat  separ- 
ated from  each 
other.  It  consists, 
in  medium-sized 
arteries,  of  a  cres- 
cent-shaped mass  of 
tissue,  the  concave 
side  of  which  faces 
the  lumen,  while  the 
horns  run  up  on  either  side  of  the  vessel.  One  horn 
may  be  long  and  the  other  short,  the  crescent  being 
placed  somewhat  excentrically.  The  longer  horn 
may  be  sometimes  thickened  (see  Schultz  and  Thoma), 
as  in  Fig.  3S7,  if  a  branch  lies  opposite  to  it.  In  the 
largest  vessels  the  cicatricial  tissue  occupies  a  con- 
siderable portion  of  the  caliber  of  the  vessel. 

On  the  surface  of  the  cicatrix  is  seen  a  thin  layer 
of  endothelium;  beneath  this, 
in  medium-sized  vessels, 
there  can  be  seen  a  layer  of 
delicate,  tapering,  spindle 
cells  with  staff-shaped  nuclei, 
forming  a  continuous  layer 
from  one  horn  to  the  other. 
They  run  parallel  to  one 
another  and  to  the  arc  of  the 
circle  made  by  the  crescent, 
and  resemble  in  all  respects 
muscular  cells;  in  short,  a 
genuine  muscular  layer  is 
found  here  (Fig.  3S8).  Be- 
neath this  layer  is  a  mass  of 
cicatricial  connective  tissue 
which  plugs  the  space  lying 
directly  between  the  ends  of 
the  retracted  walls  (Fig.  389). 
The  cicatrix  is  pierced  by  a 
vessel  of  considerable  size 
which  rapidly  tapers  to  a 
point  and  anastomoses  with 
a  capillary  network,  ramify- 
ing both  in  the  cicatrix  itself 
and  in  the  ligamentous  band  outside.  This  central 
vessel,  which  in  larger  cicatrices  becomes  tortuous 
and  gives  to  the  cicatricial  tissue  a  "cavernous" 
appearance,  may  be  regarded  as  the  unobliterated 
residuum  of  the  lumen. 

We  find  in  this  anatomical  peculiarity  of  the  cica- 


Fig.  388.— New  Muscular 
Cells  in  the  Cicatrix;  from 
the  femoral  artery  of  a  dog 
three  months  after  ligature. 
(Drawn  from  author's  speci- 
men.) 


G55 


Arteries,  Surgery  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


fcrix  an  explanation  of  its  immunity  from  aneurysmal 
dilatation.  The  protective  influence  of  the  thrombus 
enables  the  process  of  cicatrization  to  complete 
itself  before  the  cicatrix  is  called  upon  to  withstand 
blood  pressure,  and  it  is  then  armed  with  a  muscular 
coat  (as  is  the  normal  vessel  wall),  which  acts  not  unlike 
a  levator  ani  muscle  in  sustaining  and  modulating 
the  force  of  the  blood  column. 

The  ligament  which  unites  the  two  ends  of  the 
vessel  represents,  in  part,  the  residue  of  the  external 
callus;  it  has  become  much  elongated  by  the  retraction 
of  the  two  ends.  During  the  healing  process,  a  small 
pi  lit  ion  of  the  vessel  walls  has  become  disintegrated 
by  the  new  growth,  and  a  portion  has  atrophied  and 

ML 

WW 

I    t.V 


FlO.  389. — External  iliac  Artery  of  Man  One  Hundred  and  Thirty 
Days  After  Ligature:  formation  of  permanent  cicatrix.  (Drawn 
from  author's  specimen.) 

has  been  absorbed,  the  remaining  walls  have  shrunk 
greatly  by  retraction,  and  their  caliber  has  been 
filled  to  a  greater  or  less  extent  by  a  cicatricial  tissue; 
so  that  the  vessel  has  become  practically  obliterated 
up  to  the  first  branches  of  the  collateral  circulation. 

The  thrombus  is  a  mere  passive  structure,  and 
takes  no  part  in  the  growth,  but  is  protective  and 
affords  an  excellent  medium  for  the  germination  of 
the  new  tissue.  Its  upper  portion  is  not  penetrated 
by  the  new  growth,  but  rests  upon  it  and  forms  a  sort 
of  protecting  scab.  It  is  deposited  gradually,  and 
has  a  stratified  appearance.  Its  size  appears  to  be 
dependent  upon  the  amount  of  injury  done  to  the 
vessel  and  the  resulting  inflammation.  If  the  intima 
or  the  elastic  lamina  has  been  ruptured  in  handling 
the  vessel,  as  can  frequently  be  demonstrated  by  the 
microscope,  some  distance  from  the  point  of  ligature, 
clots  will  form  at  these  points,  and  the  thrombus  will 
thus  become  elongated.  Occasionally,  the  apex  is 
formed  of  white  corpuscles  only,  and  may  be  free  or 
lightly  attached  to  the  wall  by  a  cell  growth  from  the 
intima. 

Thrombosis  and  Embolism. — Arteriotomy  for  the 
removal  of  a  clot  plugging  a  vessel,  either  a  thrombus 
or  an  embolus,  and  the  restoration  of  the  circulation 
has  been  practiced  a  few  times,  but  has  not  been 
generally  successful. 


There  are  three  types  of  embolism  that  have  been 
subjected  to  operative  treatment  or  for  which  opera- 
tion has  been  suggested,  viz.,  embolism  of  the  extremi- 
ties, pulmonary  embolism,  and  mesenteric  embolism. 

Emboli  of  the  extremities,  unless  of  traumatic  origin, 
are  practically  always  seen  only  in  disease  of  the  left 
side  of  the  heart  and  are  more  common  in  the  lower 
than  the  upper  extremity.  Barie  in  an  analysis  of 
fifty-four  cases  found  the  emboli  situated  as  follows: 
tioial  artery  fifteen,  femoral  twelve,  iliac  nine,  popli- 
teal seven,  dorsalis  pedis  one,  arteries  of  the  fore- 
arm four,  subclavian  three,  axillary  two.  They  may 
lodge  in  the  aorta  even,  in  which  case  there  is  sudden 
acute  pain  referred  to  the  abdomen  and  paralysis  of 
the  lower  extremities  in  addition  to  the  usual  symptoms 
of  cold  and  loss  of  pulse  below  the  obstruction. 
Mniiod  and  Vanvert  (1909)  collected  ten  cases  of 
arteriotomy  for  the  removal  of  a  clot  and  Delbet  and 
Mocquot  (1911)  mention  fifteen,  none  of  which  were 
perfectly  successful.  The  chief  difficulty  is  in  making 
the  diagnosis  early  enough  to  render  the  operation  of 
value,  as  secondary  degenerative  changes  take  place 
very  rapidly  in  the  intima  at  the  point  of  lodgment 
of  the  clot  so  that  even  if  the  embolus  is  successfully 
removed  a  second  clot  forms  at  the  same  site  on  the 
damaged  intima  in  a  short  time.  In  one  of  Stewart's 
cases  the  clot  formed  twice  after  repeated  arteriotomy, 
and  excision  of  the  damaged  portion  of  the  artery 
with  end-to-end  anastomosis  was  later  performed. 
This  also  became  plugged  and  amputation  was 
resorted  to  some  time  later.  Tixier  has  more  recently 
performed  an  excision  of  a  portion  of  the  brachial 
artery  for  an  embolus  with  end-to-end  anastomosis 
successfully.  Another  difficulty  in  these  cases  is  in 
exactly  locating  the  point  in  the  vessel  at  which  the 
embolus  is  impacted.  At  times  this  is  comparatively 
easy,  but  the  symptoms  are  as  a  rule  referred  to  a 
portion  of  the  limb  considerably  below  the  seat  of 
injury.  There  are  certain  points,  however,  at  which 
the  embolus  is  apt  to  lodge  such  as  the  bifurcation  of 
the  aorta,  at  the  division  of  the  popliteal,  or  in  the 
femoral  artery  where  the  profunda  is  given  off.  These 
cases  of  arterial  emboli  also  usually  occur  in  the 
a^ed  and  this  fact  makes  operative  interference 
difficult  as  the  walls  of  the  vessels  are  stiff  and 
atheromatous.  Thrombosis  or  embolism  of  the 
main  artery  of  a  limb  is  usually  followed  by  gangrene, 
but  this  is  not  necessarily  always  the  case. 

The  symptoms  of  emboli  of  the  extremities  are 
usually  acute  pain,  pallor,  and  loss  of  pulse  and  cold- 
ness below  the  obstruction.  Later  there  may  be 
both  motor  and  sensory  paralysis  in  a  varying  degree, 
followed,  if  there  is  no  collateral  circulation,  In 
gangrene.  In  a  few  cases  reported  the  symptoms 
nave  been  of  slow  onset  and  have  not  been  accom- 
panied by  great  pain.. 

Operative  treatment  consists  in  arteriotomy  with 
removal  of  the  clot,  followed  by  rest,  heat  to  the 
limb,  and  measures  to  promote  collateral  circulation 
and  prevent  the  reformation  of  the  clot.  If  gangrene 
supervenes  amputation  should  be  performed.  Hand- 
ley  has  tried,  unsuccessfully,  to  dislodge  a  clot  situated 
at  the  bifurcation  of  the  aorta  by  passing  a  catheter  up 
the  femoral  artery,  and  it  has  been  suggested  that  this 
be  done  in  emboli  of  the  femoral  artery  in  order  that 
amputation  might  be  done  at  a  lower  level  than 
would  otherwise  be  necessary.  The  operation  of 
arteriovenous  anastomosis,  or  biterminal  graft,  may 
also  be  performed  when  the  diagnosis  is  made  early 
enough  and  the  vessel  walls  are  in  good  condition. 

Pulmonary  Embolism. — In  1907  Trendelenburg 
devised  an  operation  for  the  removal  of  an  embolus 
in  the  pulmonary  artery  which  has  been  performed 
four  times,  twice  by  him  and  twice  by  other  surgeons. 
One  of  the  patients  lived  for  five  days. 

Mesenteric  Embolism. — Emboli  "of  the  mesenteric 
vessels  usually  lodge  in  the  superior  mesenteric 
artery  which  is  to  all  intents  a  terminal  artery.     No 


656 


REFERENCE    IIANDHt  >(>K    OF   Till',    MEDICAL    SCIENCES 


Artcrtcs,  Surgery  of 


ise  has  yet   been  treated  by  arteriotomy  and   the 
imoval  of  the  clot,  although  the  operation  has  been 
ted  by  several  obsen  ers. 

i  koi.  of  Hemorrhage.     The  methods  of  use 

control  of  hemorrhage  are  heat,  cold,  elevation, 

yptics,  compression  either  direct  or  indirect,  acupres- 

forcipressure,  torsion,  ligature,  and  suture. 

in  mimic  form,  as  cold  compresses,  ice,  cold 

etc.,  lias  I ii  used  in  the  control  of  he ■- 

from  ili"  earliest  times  and  has  a  distinct  \  alue 
ain  slight  forms,  but  is  not  adequate  to  control 
hemorrhage  from  a  large  artery. 

ii  the  form  of  the  actual  cautery  was  the  chief 
leans  of  controlling  bleeding  during  the  Middle  \v 
i.l  in  fact  was  used  by  many  surgeons  during  the 
ighteenth  century.  Although  discarded  at  the  pre 
it  day  for  the  ligature,  it  is  used  in  a  modified  form 
certain  cases,  as  in  the  clamp  and  cautery  opera!  ton 
i  hemorrhoids,  in  certain  operations  on  the  bladder 
id  nose,  and  as  the  electrothermic  angiotribe. 
Vhen  the  tissues  are  charred  an  eschar  forms,  plug- 
ing  tlic  vessel  and  later  separating  as  a  slough. 

\tion  of  a  part  is  of  value  in  controlling  slight 

emorrhage,  especially  when  it  is  venous  in  character. 

Styptics    are  rarely  employed  at  the  present  day. 

it    are    of    service    in    stopping    ooze    from    small 

Most    of    them    act   by  causing  the  blood 

.1  clot  at  once,  and   they  make  an  extremely  foul 

,ound.     Adrenalin  is  by  far  the  best  and  most  useful 

and   acts   by   causing   a   contraction    of    the 

essels.     It   is  used  in  strengths  of  from  1  to  10,000 

n  1  to  1.000. 

Compression  may  be  either  direct  or  indirect  and  is 
he  most  valuable  means  at  hand  for  the  immediate 
ontrol  of  hemorrhage  from  a  large  artery.  Indirect 
'impression  is  the  method  usually  employed  as  a 
rst  aid  measure;  this  may  be  either  mechanical  or 
ligital.  The  best  example  of  mechanical  compression 
3  the  well-known  tourniquet  or  Esmarch  bandage, 
tigital  compression  of  the  main  artery  of  a  limb  is  less 
pi  to  injure  the  structures,  but  is  very  difficult  to 
uaintain  for  any  length  of  time.  Nearly  all  the  large 
essels  can  be  compressed  against  some  bony  promi- 
"iice  with  comparative  ease  and  the  circulation  con- 
rolled  for  some  time  if  relays  of  assistants  are  at 
land.  While  indirect  compression  is  invaluable  as  a 
uethod  of  expediency,  it  cannot  be  employed  to  con- 
rol  the  hemorrhage  permanently.  In  direct  or  im- 
mediate compression  the  pressure  is  made  directly  on 
he  bleeding  point.  It  may  be  either  digital  or  by 
nuking  a  wound  with  gauze  sponges,  and  is  of  especial 
alue  in  stopping  a  general  ooze  from  a  large  raw 

Torsion  was  not  unknown  to  the  ancients,  and  was 
employed  by  certain  surgeons  in  the  Middle  Ages;  but 
a  more  modern  times,  practitioners  were  not  familiar 
•vith  it  until  it  was  brought  to  the  notice  of  French 
trgeons   by   certain   statements   of   a    visitor   from 
iennany.     Both   Velpeau  and   Amussat   apparently 
laimed  the  credit  of  introducing  it,   the  former  in 
onsequence  of  his  experience,  when  a  student  with  a 
veterinary  surgeon,  in  the  twisting  of  the  pedicle  in 
paying  and  castration,  and  both  as  the  result  of  their 
it  ions  on   the  immunity  from  hemorrhage  in 
edarteries.     The  method  employed  by  Velpeau 
is  thus  described:  "After  having  seized  the  vessel  by 
its   extremity.    I    separate   it   from    the   surrounding 
and  grasp  it.  at  its  deepest  point  in  the  wound, 
mother  forceps,   to  hold  it   firmly  while  it  is 
I  lined  on  its  axis,  three  to  eight  times",  by  the  first 
forceps."     He  appears  to  have  employed  the 
method  in  several  amputations.     Its  supposed  advan- 
-  the  avoidance  of  a  foreign  body  in  the  wound. 
'      ■    iignized  the  fact  that  animal  ligatures  would  be 
equally  good  for  this  purpose,  and  also  the  disadvan- 
tage  of   torsion  in  diseased   vessels,  and    that   small 
were  not  easily  isolated.     The  effect  of  torsion, 

Vol.   I.— 42 


according  to  Bryant,  is  a  twisting  of  the  ela  tii   B 
of  the  adventitia  bi  yond  the  end  of  the  vessel,  and  a 
retraction  and  incurvation  of  the  middle  and  inner 
coats;  the  twist  in  the  outer  coal  is  permanent  and 

cannot     lie    unfolded     by    any     legitimate    force;     the 

middle  and  inner  coats  are  una' ted  in  the  direction 
oppo  ed  to  tin'  lil I  stream,  approximated  and  over- 
lapped. The  safety  from  hemorrhage  rest  upon  the 
twist  of  the  external,  the  retraction  of  the  internal 
coats,  and  the  coagulation  down  to  the  firsl  branch; 
while,  in  acupre  ure,  the  permanent  safety  depends 
upon  the  lasl  alone,  temporary  protection  being 
afforded  by  the  needle. 

Kocher   found    numerous  and    irregular   In 

of  the  inner  coats  over  a  considerable  distance  of  the 

wall,  and  independent  of  one  aunt  her,  while  in  liga 

the  ruptures  were  circular  and  only  close  to  the  point 
of  liga!  inn.  I  n  unlimited  torsion  there  is  considerable 
nan-owing  of  the  lumen.  ( Iwing  to  these  peculiarities, 
it  has  the  advantage  of  favoring  a  rapid  coagulation. 

Acupn  ture. — The  introduction  of  this  method 
of  hemostasis,  which  at  present  is  chiefly  of  historic 
interest,  is  to  be  accredited  to  Sir  .lames  Simp  on 
unless  an  obscure  passage  in  John  de  Vigo's  writings 
be  interpreted  otherwise  than  as  a  description  of  the 
ordinary  ligature).  He  saw  in  the  ligature  a  foreign 
body  in  the  wound  which  cut  through  the  two  coats 
at  the  time  of  its  application,  and  ate  through  the 
outer  coat.  It  was  for  this  reason  principally  that 
amputation  stumps  healed  with  so  much  greater 
difficulty  than  wounds  in  the  operation  for  vesico- 
vaginal fistula,  although  the  latter  were  constantly 
bathed  in  leucorrheal  discharges  and  urine.  The 
application  of  the  ligature  isolated  a  portion  of  the  end 
of  the  vessel,  which  remained  in  the  wound  as  a  piece 
of  dead  flesh  until  it  came  away  with  the  ligature. 
The  needle,  on  the  other  hand,  did  no  injury  to  the 
vessel  and  caused  no  irritation,  its  use  being  based 
upon  "the  great  pathological  law  of  the  tolerance  of 
living  tissues  for  the  contact  of  metallic  bodies  em- 
bedded in  their  substance."  Bryant  showed,  how- 
ever, that  the  ligatured  portion  did  not  slough,  but 
became  adherent  and  vascularized. 

Although  English  surgeons  supposed  that  no  injury 
was  done  to  the  vessel  by  the  needle,  Kocher  and 
other  German  writers  demonstrated  longitudinal  slits 
in  the  intima,  but  not  so  extensive  as  those  occurring 
in  torsion.  The  vessel  is  thrown  into  longitudinal 
folds,  which  become  sufficiently  firmly  glued  together 
to  retain  this  shape  long  enough,  after  the  removal  of 
the  needle,  for  the  thrombus  to  form  and  become 
firmly  attached  to  the  walls.  A  specimen  examined 
by  Kocher  at  the  end  of  twenty-two  hours  showed  no 
thrombus,  the  walls  being  compressed  and  somewhat 
thickened,  but  a  fine  probe  could  be  introduced 
between  them.  At  thirty-six  hours  a  well-formed, 
egg-shaped  thrombus  is  represented  by  Shakespeare. 
A  drawing  by  Kocher  shows  a  specimen  fourteen  days 
old,  in  which  the  walls  have  already  separated  from 
each  other,  and  the  thrombus  is  short  and  wide, 
having  a  concave  surface  on  the  side  toward  the 
lumen,  and  a  convex  surface  at  the  other  end.  The 
relation  which  the  thrombus  bears  to  the  vessel  is 
that  of  a  cork  to  a  bottle,  beyond  the  neck  of  which 
it  does  not  project.  It  is  probable  that  the  apex  had 
been  detached. 

In  acupressure  in  the  continuity,  the  proximal  and 
peripheral  ends  of  the  thrombus  are  continuous,  as 
are  also  the  walls  of  the  vessel,  which  at  first  are 
thickened  by  a  connective-tissue  growth;  the  sub- 
sequent changes  differ  in  no  way  from  those  already 
described. 

Ogston  tested  mechanically  the  comparative 
strength  of  arteries  secured  by  ligature,  acupressure, 
and  torsion,  by  subjecting  them  to  the  pressure  of  a 
column  of  mercury.  It  was  found  that  a  column  one 
hundred  and  fourteen  inches  in  height  was  insufficient 
to    rupture    the    ligatured    artery.     Twisted    vessels 

657 


Arteries,  Surgery  of 


REFERENCE    HANDBOOK   OF    THE    MEDICAL   SCIENCES 


unfolded  at  an  average  height  of  thirteen  inches 
(or  a  pressure  of  6.5  pounds  to  the  square  inch).  In 
acupressure,  the  column  of  mercury  showed  an 
average  height  of  23.5  inches.  It  would,  therefore, 
seem  a  more  reliable  method,  he  says,  than  torsion, 
and  less  reliable  than  ligature. 

Forcipressure. — This  is  a  very  convenient  method 
of  stopping  bleeding  from  both  arteries  and  veins  and 
is  employed  universally,  but  chiefly  as  a  temporary 
expedient  preliminary  to  ligature.  It  was  used  by 
Desault  in  1786  only  to  fall  into  disuse  and  was 
reintroduced  about  1865.  The  clamp,  or  hemostatic 
forceps,  now  in  use  is  a  modification  of  that  invented 
by  Pean  in  1808.  When  a  vessel  is  clamped  the  two 
inner  coats  are  ruptured  and  the  ends  curl  back 
plugging  the  lumen  and  favoring  clotting  while  the 
adventitia  is  transformed  by  the  pressure  into  a  homo- 
geneous band.  Although  in  the  larger  vessels  it  is 
customary  to  follow  this  with  ligature,  in  the  smaller 
it  is  unnecessary.  Certain  operators  using  the 
angiotribe,  a  special  broad-bladed  crushing  forceps, 
do  not  ligate  even  the  larger  arteries.  In  certain 
other  cases  such  as  in  vaginal  hysterectomy,  where 
ligature  is  difficult  forceps  may  be  left  in  place  for 
several  hours  and  then  removed  with  but  little  danger 
of  hemorrhage.  The  length  of  time  necessary  to 
leave  a  clamp  in  place  in  order  to  insure  permanent 
hemostasis  has  been  estimated  by  Bothezat  at  sixteen 
hours  for  a  vessel  the  size  of  the  radial  artery,  and 
eighteen  for  one  as  large  as  the  femoral,  but  cases  of 
secondary  hemorrhage  have  been  reported  after 
vaginal  hysterectomy  when  the  clamps  have  been 
left  in  place  for  twenty-four  hours.  Hopfner, 
Payr,  and  Crile  clamps  exert  forms  of  forcipressure, 
but  they  are  used  only  for  temporary  hemostasis  and 
should  be  carefully  applied  in  order  not  to  injure  the 
intima.  Their  use  is  sometimes  followed  by  thrombus 
formation. 

Ligature. — Although  the  introduction  of  the  liga- 
ture is  commonly  ascribed  to  Par6,  there  is  suffi- 
cient evidence  to  show  that  it  was  employed  by 
surgeons  in  the  earliest  historic  times.  No  mention 
is  made  of  the  ligature  by  Hippocrates,  but  the 
ancients  used  not  only  styptics  and  the  actual  cautery, 
but  also  ligature  and  torsion.  It  is  highly  probable 
that  the  Alexandrians  were  familiar  with  the  use  of 
the  ligature  three  centuries  before  the  Christian  era, 
for  Celsus  (born  30  B.C.)  speaks  of  it  as  a  well-known 
fact  and  recommends  its  use.  Archigenes  and  Galen 
both  mention  tying  vessels  for  the  purpose  of  stopping 
hemorrhage;  the  name  of  Antyllus  also  bears  testi- 
mony to  the  skill  of  Roman  surgeons,  and  in  the 
Museum  at  Naples  there  may  be  seen  a  forceps,  with 
sliding  attachment,  evidently  intended  to  use  with  the 
ligature.  We  find  the  ligature  of  arteries  mentioned 
again  in  the  seventh  century  by  Paulus  of  yEgina, 
whose  teachings  were  still  preserved  by  the  Italians 
in  the  sixteenth  century. 

It  is  uncertain,  however,  whether  ligatures  were  em- 
ployed on  large  vessels  before  Pare's  time.  To  this 
great  surgeon  is  due  the  credit  not  only  of  fully  appre- 
ciating the  value  of  this  mode  of  hemostasis,  but  of 
making  it  a  universally  applicable  method.  At  this 
period,  the  middle  of  the  sixteenth  century,  the  imper- 
fect knowledge  of  the  anatomy  and  physiology  of  the 
circulation  prevented  a  due  appreciation  of  the  ad- 
vantages of  the  ligature,  and  even  Guillemeau,  who 
was  the  champion  of  his  friend  and  teacher,  confined 
the  use  of  the  ligature  to  primary  amputations. 
Although  Wiseman  in  England,  Fabricius  Hildanus  in 
Germany,  Fallopius,  and  others  favored  the  ligature, 
they  were  but  isolated  examples,  and  at  the  opening 
of  the  eighteenth  century  the  actual  cautery  was  still 
the  customary  method  of  arresting  hemorrhage  at  the 
Hotel-Dieu. 

The  contrast  between  the  two  methods  at  that  time 
was  not  indeed  as  great  as  it  would  seem  to-day.  A 
glance  at  Parti's  plates  shows  the  forceps  as  an  instru- 


ment of  rude  pattern  and  clumsy  make;  no  attempt 
was  made  to  isolate  the  vessel;  veins,  nerves,  and 
arteries  being  included  in  one  knot.  No  wonder  that 
surgeons  had  a  "  horrid  apprehension  of  compressing 
the  nerves,"  and  that  Petit,  with  whom  modern 
investigation  on  the  healing  of  arteries  may  be  said 
to  have  begun,  actually  proposed  compression  as  a 
substitute  for  the  ligature.  It  was  he  who  first  called 
attention  to  the  agency  of  the  thrombus  in  checking 
bleeding,  the  blood  around  the  end  of  the  vessel  being 
termed  the  couvercle,  and  that  found  within  the 
lumen  the  bouchon.  The  retraction  and  contraction 
of  the  vessel  w-ere  soon  recognized  by  Morand,  who  also 
called  attention  to  the  rupture  of  the  inner  walls  by  the 
ligature.  To  Jones  has  been  pretty  generally  accorded 
the  credit  of  producing  the  classical  work  upon  this 
subject.  By  a  large  and  varied  series  of  experiments 
on  animals  he  was  able  to  give  a  complete  account  of 
the  macroscopical  appearances  showing  injuries  to 
arteries,  which  account,  in  the  main,  holds  good  to- 
day. He  found  that  when  a  large  artery  was  divided 
it  retracted  into  its  sheath,  and  contracted  slightly 
at  its  extremity  (a  coagulum  forming  within  the 
sheath  and  external  to  the  vessel,  and  appearing  like 
a  continuation  of  the  artery);  and  that  later  a  slender 
and  conical  coagulum  formed  within  the  vessel,  being 
only  partially  adherent  to  its  walls.    • 

It  was  chiefly  due  to  Jones'  investigations  that  the 
modern  single  thread  was  adopted.  Cutting  short 
both  ends  of  the  knot  was  adopted  in  1798  by  an 
Ameriican  naval  surgeon.  The  disadvantage  of  a 
silk  or  hempen  ligature  was  supposed  to  be  due  to  its 
non-absorption.  The  introduction  of  the  absorbable 
ligature  is  generally  ascribed  to  Physick  whose  liga- 
tures were  made  of  chamois  leather  rubbed  on  a  slab 
to  render  them  hard  and  round.  Sir  Astley  Cooper 
tried  them  and  they  were  used  in  this  country  by 
Jamieson  of  Washington.  Absorbable  ligatures  did 
not  come  into  general  use  till  Lister  published  his 
method  of  preparation  with  carbolic  and  chromic 
acid.  At  the  present  day  absorbable  ligatures, 
represented  by  plain  and  chromicized  catgut,  are  more 
commonly  used  than  the  non-absorbable.  The 
chromic  gut  was  introduced  as  plain  catgut  is  absorbed 
at  times  very  rapidly,  while  the  chromic  gut  resists  the 
action  of  the  tissues  for  a  varying  period,  depending 
on  the  length  of  time  it  is  treated  with  the  acid,  and 
in  fact  occasionally  it  is  never  absorbed.  Of  the 
other  forms  of  animal  ligature  kangaroo  and  ox 
tendon  are  the  two  in  most  common  use.  Of  the 
non-absorbable  at  the  present  day,  Pagenstecher  and 
linen  are  used  as  freely  as  silk. 

There  was  formerly  a  great  deal  of  discussion  as 
to  the  tightness  with  which  the  first  knot  of  a  liga- 
ture should  be  tied  and  Ballance  and  Edmunds  tried 
to  introduce  a  soft  ligature  with  the  first  knot  tied 
so  as  to  approximate  the  intima  without  rupturing  it. 
It  is  accepted  now,  however,  that  the  first  knot  should 
be  tied  with  enough  force  to  rupture  the  intima  and 
part  of  the  media. 

Metallic  ligatures  are  rarely  used  to-day  except  to 
diminish  the  caliber  of  a  large  artery  leading  into  an 
aneurysm,  dishing  has  recently  suggested  the  use  of 
small  pieces  of  silver  wire  as  ligatures  applied  with  a 
special  clamp  for  the  control  of  bleeding  from  ve- 
in an  inaccessible  position.  These  are  comparable 
to  the  "skin  clips"  and  have  proved  of  value  in 
cerebral  surgery.  Temporary  ligatures  are  occasion-' 
ally  used  to  control  hemorrhage  and  for  this  purpose 
tape  or  floss  silk  is  the  best  material. 

Suture. — The  first  suture  of  an  artery  was  done  by 
Hallowell  at  the  suggestion  of  Lambert  in  1759.  He 
successfully  closed  a  wound  in  a  brachial  artery  made 
during  a  venesection,  by  pinning  the  edges  of  the 
wound  together  with  a  needle  held  in  place  by  B 
figure-of-eight  suture.  Asman  in  1773  did  a  series  of 
experiments  on  dogs  using  this  technique,  and  found 


658 


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Arteries*  Surgery  of 


ii  although  hemorrhage  was  perfectly  controlled  a 
rombus  always  resulted  and  these  views  have  held 
iil  comparatively  recent  times.  The  first  success- 
blood-vessel  anastomosis  was  performed  in  1879 
a  Russian  surgeon,  who  made  a  lateral 
istomosis  between  the  vena  cava  and  the  portal 
in — the  .so-called  Eck  fistula. 


reporting  in  a  classical  article  the  first  successful  <  i  i 
of  circular  suture  in  man.  Be  ha  In©  described  a 
modification  of  this  method  using  a  removable  cylinder 
in  two  pieces  as  a  support  which  brings  intima  more 
nearly  in  conjunction  with  intima.  The  original 
method  consisted  in  passing  a  suture  through  the  wall 
of  the  distal  end  of  the  vessel  which  is  brought  out 


W' 


.1  B 

Fig.  390. — Murphy's  Invagination  Mcih.nl.     A,  Two 

the  threads  designed  to  invaginate  the  proximal  into 
e  distal  end  of  the  artery  have  been   passed;  Bt  the 

agination    completed,    showing    also    the    superficial 
laptation  suture.     (Delbet  ana  Moequot.) 


A  B  C 

Fig.  392. — Payr's  Method.  .4,  The  tube  is  placed  in  the  proximal  end 
of  the  divided  artery;  Bt  the  proximal  end  of  the  divided  artery  is  turned 
back  over  the  tube  and   tied  to  it;  C,  the  invagination  is  complete,  the 

distal  end  of  the  artery  being  passed  over  the  proximal  end  and  tied  there. 
(Delbet  and  Moequot.) 


Gliick  in  1883  showed  that  the  repair  of  lateral 
"iiids  of  arteries  was  possible,  although  most  of  his 
vperiinents  were  failures.  In  1SS9  Jassinowski 
tade  a  series  of  experiments  and  showed  that  it  was 
ossible  to  get  healing  in  lateral  wounds  of  arteries 
ithout  thrombosis.  He  used  fine  silk  as  a  suture 
taterial  and  was  able  to  close  wounds  that  did  not 


through  the  lumen  and  caught  the  proximal  end 
through  the  outer  coats  only.  Three  such  sutures 
are  placed  about  three-fourths  of  an  inch  from  the  end 
of  the  artery.  By  traction  on  these  the  proximal  end 
is  then  invaginated  into  the  distal,  and  the  anastomo- 
sis is  completed  with  interrupted  or  a  continuous 
stitch  to  make  a  tight  joint.     (Fig.  390.)     Nitze  in 


I 

SB 
1 

[ 

fl 

-«t 

A 

LyX 

m 

V*   - 

If 
5?.  * 

3    .' 

«• 

'  fa 

1 

■i 

\       i.        :    .,' 

io.  391. — The  Jaboulay-Brian  Method  of  Vertical 
U-shaped  Sutures.     (Delbet  and  Moequot.) 


Fig.  393. — Showing  Repair  of  an  Artery  after  Suture. 
and  Obstetrics.) 


(iSwgery,  G'i//': 


•xceed  two-thirds  of  the  circumference  of  the  artery, 
twenty-four  of  his  twenty-six  experiments  being 
successful.  His  sutures  did  not  penetrate  the  intima. 
In  the  next  few  years  many  articles  were  written,  but 
Few  successful  cases  were  reported.  In  1894  Abbe  sug- 
gested doing  end-to-end  suture  over  a  glass  bobbin. 
In  1S97  Murphy  introduced  his  invagination  method 


the  same  year  performed  a  circular  suture  by  turning 
back  one  end  of  the  vessel  over  an  ivory  ring  making 
a  cuff  over  which  the  other  end  of  the  artery  was 
drawn.  Soon  after  this  Jaboulay  and  Brian  suggested, 
in  circular  suture,  splitting  the  vessel  up  for  a  short 
distance  and  suturing  the  ends  together  with  U- 
shaped  sutures  bringing  intima  to  intimr, — the  broad 


659 


Arteries,  Sui'scry  of 


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marginal  confrontation  method.  (Fig.  391.)  Dorfler 
in  1.S99  described  a  method  of  arterial  suture  in  which 
he  used  small  round  needles  and  silk,  the  suture  being 
continuous  and  penetrating  all  the  coats.  His  method, 
modified  and  perfected,  is  the  one  commonly  em- 
ployed to-day. 

In  1900,  Payr  published  a  method  which  was  popu- 
lar for  a  time  and  which  is  satisfactory.  He  used 
magnesium  cylinders  similar  to  Nitze's  ring,  but 
absorbable,  on  which  were  one  or  two  circular  grooves. 
One  end  of  the  severed  artery  was  passed  through  the 
cylinder,  turned  back  as  a  cuff  and  tied  into  the  upper 
groove.  The  other  end  of  the  vessel  was  then  drawn 
over  it  and  tied  into  the  lower  groove.  (Fig.  392.) 
Crile's  transfusion  cannula?  are  very  similar  to  (his 
ring.  Later  Payr  advocated  another  method,  using 
two  cylinders  with  a  broad  flange.  In  190.,  Berard 
and  Carrel  published  a  method  similar  to  the  Dorfler 
method  only  the  stitches  did  not  penetrate  the  intima. 
Later  as  the  result  of  experiments  with  Morel  and  in 
1905  with  Guthrie,  Carrel  developed  the  technique 
which  is  used  practically  without  modification  at  the 
present  day. 

Many  other  methods  of  arterial  suture  have  been 
published.  Salomoni  independently  published  a 
suture  similar  to  that  of  Jaboulay.  De  Gatano 
suggested  using  an  intravasal  apparatus,  while  Lepi- 
nasse  used  broad  metal  flanges.  Dorrance  has  a 
special  stitch  for  use  in  lateral  wounds,  and  Brewer 
in  these  cases  has  wrapped  the  vessel  with  adhesive 
plaster. 

Repair  after  Suture. — Healing  after  suture  occurs 
with  a  varying  amount  of  scar  depending  on  the  degree 
of  trauma  and  the  accuracy  with  which  the  parts  are 
brought  into  apposition.  In  a  well-performed  opera- 
tion the  resulting  scar  is  very  slight.  The  intima 
unites  completely  forming  a  smooth  lining  to  the  ves- 
sel. There  is  some  difference  of  opinion  as  to  the  fate 
of  the  elastic  tissue  and  while  in  some  cases  it  regen- 
erates, in  others  the  defect  is  filled  in  with  scar  tissue. 
The  media  often  completely  regenerates  and  shows 
no  visible  scar.     (Fig.  393.) 

The  success  of  arterial  suture  depends  on  absolute 
asepsis  and  good  technique  and  now  experimentally  in 
the  hands  of  men  accustomed  to  the  work  is  rarely 
unsuccessful.  The  history  of  the  repair  of  arteries  is 
thus  comparable  to  that  of  intestinal  repair,  where 
complicated  mechanical  devices  have  been  replaced 
by  the  simple  needle  and  thread  with  good  technique. 
In  1900,  Dorfler  stated  that  there  were  reports  of 
but  nine  successful  cases  of  arterial  suture  in  literature, 
while  in  1909  Monod  and  Vanverts  collected  sixty- 
five  and  Stich  in  1910  stated  there  were  over  one 
hundred. 

Operations  for  circular  suture  of  arteries  may  be 
divided  roughly  into  three  classes:  (1)  The  invagina- 
tion method  of  Murphy;  (2)  Suture  with  the  aid  of 
some  mechanical  apparatus  (Payr);  (3)  Direct  suture 
(Jaboulay,  Carrel).  In  the  invagination  method  the 
blood  comes  in  direct  contact  with  quite  a  large  raw 
surface  and  is  very  liable  to  clot.  In  many  of  the 
me;  hods  the  lumen  is  narrowed  by  the  use  of  a  cuff 
or  ring  and  a  large  amount  of  slack  vessel  is  necessary, 
or  a  mechanical  device  difficult  to  handle  must  be 
used. 

Suture  for  incised  longitudinal  or  transverse  wounds, 
lateral  suture,  is  almost  always  successful  at  the  pres- 
ent day  in  the  hands  of  men  trained  in  blood-vessel 
surgery  in  the  laboratory.  Of  the  sixty-six  cases 
collected  by  Monod  and  Vanverts  there  was  only  one 
failure,  but  it  was  impossible  in  many  of  these  to 
prove  the  permeability  of  the  vessel.  The  absence  of 
■  ragrene  after  the  suture  of  a  wound  in  the  main 
artery  of  a  limb  ami  the  presence  of  a  pulse  do  not  in 
any  way  prove  the  patency  of  the  artery,  as  gangrene 
does  not  necessarily  follow  ligature,  the  collaterals 
taking  care  of  the  circulation  very  rapidly.  In 
certain  cases,  however,  small  emboli  may  break  off 


from  the  mural  thrombus  at  the  site  of  the  suture  and 
give  rise  to  small  areas  of  gangrene.  The  scar  follow- 
ing  suture  is  as  strong  as  the  vessel  wall  and  never 
gives  rise  to  an  aneurysm. 

Comparative  Value  of  Suture  aud  Ligature. — The 
value  of  circular  suture  in  human  surgery  is  not 
yet  on  as  firm  a  basis  although  several  successful 
rases  have  been  reported.  Braun  has  reported  a  ci 
of  circular  suture  of  the  aorta  which  was  torn  in 
removing  a  large  adherent  pelvic  tumor  from  a  young 
girl;  convalescence  was  uneventful.  It  has  also  been 
done  several  times  in  reversal  of  the  circulation. 
Besides  end-to-end  and  lateral  suture,  end-to-side 
and  side-to-side  may  also  be  clone. 

Much  has  been  written  on  the  respective  value  of 
suture  or  ligature  in  wounds  of  special  arteries,  and 
the  question  is  not  yet  settled.  Suture  should  be 
preferred  in  all  longitudinal  wounds  of  the  large 
arteries  of  the  limbs  where  it  can  be  done  with  some 
hope  of  success.  It  should  also  be  done  when  liga- 
ture of  the  artery  in  question  is  apt  to  be  followed  by 
gangrene,  although  the  frequency  with  which  gan- 
grene occurs  as  the  result  of  ligature  of  a  given  artery 
varies  greatly  in  the  statistics  compiled  by  the  differ- 
ent observers.  If  the  ends  of  the  vessel  cannot  be 
brought  together  without  undue  tension  bj'  flexicn 
of  the  limb,  loss  of  substance  can  be  repaired  by 
grafting  in  a  piece  of  vein  to  take  the  place  of  the 
artery  destroyed  or  resected — the  biterminal  graft  of 
Carrel.  When  the  blood  is  allowed  to  pass  through 
the  vessel  again  the  grafted  portion  of  vein  becomes 
at  first  greatly  distended  but  in  course  of  time  it 
contracts,  the  walls  become  thickened,  and  it  takes 
on  the  general  characteristics  of  an  artery.  Grafts 
for  loss  of  substance  may  be  either  autoplastic,  where 
a  vein  of  the  patient  is  utilized,  or  heteroplastic,  where 
a  vessel  from  another  person  or  animal  is  used.  Ex- 
perimentally this  has  been  done  with  success,  portions 
of  dog's  vessels  having  been  grafted  in  the  fresh  state 
and  also  after  having  been  kept  on  ice  or  preserved  in 
formalin  for  weeks. 

Suture  of  arterial  wounds  is  a  recognized  surgical 
procedure  and  to  be  done  when  necessary  but  never 
when  the  collateral  circulation  is  sufficient  to  nourish 
the  part,  in  crushed  and  septic  wounds,  or  when  tension 
is  necessary  to  bring  the  ends  of  the  vessel  in  apposi- 
tion. It  should  be  done  only  on  large  arteries  and  it 
is  difficult  and  unnecessary  to  perform  suture  on 
anything  smaller  than  the  popliteal.  Ligature 
should  be  preferred  to  suture  unless  the  surgeon  has 
the  facilities  at  hand  to  perform  a  satisfactory  opera- 
tion and  has  had  laboratory  training  in  the  repair  of 
arteries. 

Besides  its  value  in  the  repair  of  wounds,  suture 
may  be  done  for  the  reversal  of  the  circulation,  in  the 
treatment  of  arteriovenous  aneurysm,  and  in  a  modi- 
fied form  in  the  repair  of  common  aneurysm  (Matas 
operation). 

Technique  of  Arteriorrhaphu. — In  arterial  suture 
special  light  instruments  are  necessary  such  as  are 
used  in  the  physiological  laboratory  in  experiments 
on  small  animals.  The  special  kit  consists  of  three  or 
four  pairs  of  fine  straight  or  curved  dissecting  forceps 
without  teeth,  or  jewelers  forceps  with  the  cuds 
rounded  and  smoothed;  two  or  three  pairs  of  fine  very 
sharp  scissors,  one  curved  on  the  straight;  six  M 
eight  mosquito  forceps,  and  a  sharp  fine-pointed 
knife. 

Temporary  hemostasis  is  absolutely  necessary  and 
may  be  obtained  by  several  methods.  When  the 
artery  to  be  repaired  is  in  the  extremity,  a  tourniquet 
maybe  applied  to  the  limb,  but  this  is  rarely  possil  le 
ami  it  is  also  usually  better  to  control  the  hemorrhage 
from  the  artery  by  some  form  of  hemostasis  in  the 
wound  itself.  Many  forms  of  clamps  have  been  in- 
vented but  probably  the  best  form  is  the  old-fashioned 
serrefine.  These  should  be  small  and  light  with  a 
spring  strong  enough  to  control  the  hemorrhage  but 


6G0 


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Arteries,  surgery  of 


,i  to  injure  I  In-  intima.  The  corrugated  blades  are 
i  protected  by  being  wound  with  thread  or  covered 
ith  thin  rubber.  Hopfner,  Payr,  or  Crile  clamps  may 
■  used  instead,  the  pressure  in  these  being  regulated 
v  a  thumb  screw.  In  large  arteries  it  is  probably 
ii,,-  to  place  one  of  these  on  the  artery  above  the 

e  to  prevent  accident  in  case  the  latter  should 
ip,  Another  method  of  temporary  hemostasis  is  by 
grounding  the  artery  with  a  piece  of  tape  which  is 
rawn  taut,  occluding  the  vessel,  the  ends  being  then 

Ivy  a  pair  of  hemostatic  forceps  (Fig.  394). 
irculation  may  also  be  slopped  by  kinking  the  vessel 
ith  a  piece  of  tape  passed  under  it.  by  digital  pres- 


u.  394. — Showing  Two  Efficient  Methods  of  Temporarily  Occlud- 
ing Vessels  for  Suturing.      (Guthrie.) 

ire  made  by  an  assistant,  or  by  temporary  liga- 
tre.  Floss  silk  or  tape  is  the  best  for  temporary  liga- 
on  but  none  of  these  methods  is  as  universally 
pplicable  or  satisfactory  as  the  small  serrefine  or 
lamp. 

The  needles  commonly  employed  are  Kirby  No. 
2,  14,  or  16,  depending  on  the  size  of  the  artery. 
luthrie  recommends  No.  12  for  arteries  four  milli- 
leters  in  diameter  or  more,  No.  14  if  the  vessel  is 
mailer.  The  needles  should  be  highly  polished, 
■ee  from  rust,  and  have  a  small  eye.  Silk  is  probably 
he  best  suture  material  although  human  hair  is 
ivored  by  some  surgeons.  The  silk  used  is  the 
ntwisted  floss  silk.  Guthrie  uses  "bead  silk"  com- 
osed,  as  are  all  silk  threads,  of  three  strands  each  of 
Inch  is  made  up  of  two  others.  The  silk  is  divided 
ito  its  three  strands  and  these  are  used  for  sutures  or, 

finer  ones  are  wanted,  each  of  these  may  be  again 
ivided.  Horsley  uses  No.  1  black  Chinese  silk  un- 
wisteil  into  its  three  component  strands.  Many 
f  the  surgical  supply  houses  now  have  special  silk 
ir  this  work  or  it  may  be  obtained  already  threaded 
ml  sterilized  in  oil  in  tubes,  similar  to  the  catgut 
gatures.  The  silk  should  be  of  good  quality, 
mooth,  and  with  a  tensile  strength  of  from  three 
unces  to  five  ounces.  Sutures  are  prepared  before- 
land,  tied  in  the  needle,  with  one  end  cut  off  short, 
ml  should  be  about  eighteen  inches  long.  Two  are 
nough  for  most  operations  although  it  is  well  to  have 
i'ic  at  hand.  After  being  threaded  the  needles  are 
hrust  through  a  card  and  the  silk  wrapped  around 
he  latter.  They  are  then  put  in  a  small  bottle  or 
iox  filled  with  liquid  vaseline  and  sterilized  by 
•oiling  cither  with  the  instruments  at  the  time  of 
iperation  or  beforehand.  Instruments  are  sterilized 
iy  boiling  as  for  any  operation. 

End-to-end  Anastomosis. — The  incision  is  made  in 
he  usual  manner  and  the  vessel  exposed.  The 
lamps  for  temporary  hemostasis  are  then  applied  to 


the  artery,  I  he  tourniquet .  il  one  i    i ,  i    removed, 

and  all  small  bleeding  points  arc  tied.  It  IS  well  to 
put  a  strip  of  lint-free  waterprool  material  undei  the 
artery  at   the  point   where  the  anastomosis  is  to  be 

made,  of  a  dark   color  if  white  silk   is  being   used  and 

white  if  the  silk  is  black.  Tin-  vessel  is  then  washed 
out  with  saline  soluti  in  to  remove  any  clot    and  tl  e 

edges  are  trimmed  smooth  and  even.  A  knife 
bruises  the  tissues  less  but  scissors  make  a  mole  .  i  ii 
cut  and  should  lie  preferred  if  t  hey  are  --harp.       If  the 

artery  has  contracted  into  its  sheath  the  ad ventitia  is 

pulled  down  and  cut  off.      Three  slay  or  guide  sul  urcs 

arc  then  applied  at  points  equidistant  about  the 
artery,  one  being  placed  directly  posterior.  They 
pass  from  without  inward  about  one  millimeter 
from  (he  edge  t  h rough  all  the  coat  oi  the  distal  end 
of  the  artery  and  from  within  outward  at  the  proxi- 
mal end.  The  suture  is  then  snapped  and  the  other 
two  are  placed  in  a  similar  manner,  after  which  all  are 
tied  and  theends  left  long.  If  there  is  no  tension  the 
sutures  may  be  tied  as  placed.  While  doing  this 
work  the  fingers  and  the  ends  of  the  vessel  are  kept 
smeared  with  a  thin  coating  of  sterile  vaseline  which 
prevents  the  tissues  from  drying  and  also  fends  to 
retard  coagulation.  Great  care  should  also  be  taken 
not  to  scratch  or  otherwise  injure  the  intima  in  any 
way  as  even  the  slightest  scratch  means  a  small 
clot.  The  stay  sutures  being  placed  and  tied,  the 
assistant  takes  one  in  either  hand  atid  by  gentle  trac- 
tion makes  the  segment  of  artery  between  them  a 
straight  line  (Fig.  395).  The  operator  starts  his  con- 
tinuous suture  at  one  of  the  stay  sutures  and  con- 
tinues  it    with   a  simple   over-and-over  stitch  to  the 


Fie.  305. — Apposition  of  the  Ends  of  Divided  Arteries  by  Means 
of  Stay  Sutures,  Preliminary  to  Continuous  Stitching  Together. 

other,  taking  care  to  include  all  the  coats  of  the  vessel 
in  each  stitch.  It  is  tied  to  the  second  stay  suture 
with  a  double  knot.  From  sixteen  to  twenty  stitches 
to  the  inch  should  be  taken  (Fig.  396). 

The  assistant  then  drops  the  first  stay  suture  and 
makes  traction  on  the  second  and  third,  bringing 
this  portion  of  the  artery  uppermost.  The  continuous 
suture  is  then  carried  to  the  third  stay  where  it  is 
again  made  fast,  care  being  taken  not  to  pucker  the 
vessel.  The  same  procedure  is  carried  out  between 
the  third  and  first  stay  sutures,  thus  finishing  the 
anastomosis.  The  distal  serrefine  is  next  taken  off 
and  the  stitch  holes  and  line  of  suture  are  inspected 
for  leakage.  There  is  practically  always  a  slight 
oozing  of  blood  from  the  stitch  holes  which,  if  the 
anastomosis  has  been  well  done,  will  stop  in  a  short 


661 


Arteries,  Surgery  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


time  if  gentle  pressure  is  made;  but  if  there  is  too 
much,  one  or  two  stitches  can  be  taken  through  the 
outer  coats  of  the  vessel.  The  proximal  serrefine 
is  taken  off  last  and,  after  inspection  to  see  that  the 
anastomosis  is  working  properly,  the  wound  is  closed. 
When  the  ends  of  the  vessel  cannot  be  brought 
together  without  tension  and  it  is  necessary  to  graft 
in  a  portion  of  a  neighboring  vein,  the  same  technique 
is  applied  but  the  grafted  portion  of  vein  should  be. 
inserted  with  the  valves  pointing  in  the  direction  of 
the  blood-current  in  order  that  they  may  not  hinder 
the  circulation.  The  saphenous  and  the  external 
jugular     are     the     veins     commonly     available.     In 


Fig.  396. — Stitching  Between  Stay  Sutures  shown  in  Fig.   395. 

human  surgery  the  autoplastic  graft  is  to  be  preferred 
to  the  heteroplastic  graft  from  animals  (Carrel, 
Guthrie). 

In  performing  end-to-end  anastomosis  between 
two  adjacent  vessels,  as  in  reversal  of  the  circulation, 
they  should  be  divided  at  different  levels  to  allow  for 
the  retraction  that  inevitably  occurs  and  makes  it 
difficult  to  approximate  the  ends  if  divided  at  the 
same  level. 

End-to-side  Anastomosis. — The  same  principles 
are  to  be  applied  in  end-to-side  anastomosis  as  in 
end-to-end.  The  wound  in  the  side  of  the  vessel  being 
made  triangular  by  the  use  of  three  stay  sutures,  or 
by  the  use  of  light  side  clamps  similar  to  gastro- 
enterostomy clamps,  the  suture  may  be  done  as  in 
intestinal  anastomosis.  If  the  stay  sutures  are  used 
they  transform  the  lateral  slit  into  a  triangle. 

In  lateral  or  longitudinal  wounds  stay  sutures  may 
be  employed  or  the  suture  may  be  made  with  the 
finger  passed  under  the  vessel  as  one  would  repair  a 
cut  in  a  piece  of  cloth.  When  the  lateral  wound  is 
transverse  and  embraces  more  than  two-thirds  of 
the  circumference  of  the  artery,  it  is  best  to  complete 
the  division  and  treat  it  as  an  end-to-end  anasto- 
mosis, as  the  retraction  of  the  edges  of  the  cut  makes 
any  other  procedure  difficult. 

Lateral  Anastomosis. — Bernheim  and  Stone  have 
described  a  method  of  doing  this  operation,  the 
essential  feature  of  which  is  to  make  the  wounds  in 
the  vessels  opposite  each  other,  transverse,  and  about 
one-third  the  circumference  of  the  artery.  Retrac- 
tion of  the  walls  of  the  vessels  transforms  these  slits 
into  ovals  the  edges  of  which  are  then  sutured. 

Arteriovenous  anastomosis,  or  the  reversal  of 
the  circulation  in  an  organ  or  limb,  has  been  proposed 
for  Mime  time  for  conditions  in  which  the  artery 
beyond  the  point  of  anastomosis,  because  of  injury 
or  disease,  is  incapable  of  transmitting  the  blood  to 


the  part.  Frank  in  1881  did  a  series  of  experiment 
on  reversal  of  the  circulation  in  animals,  none  o 
which  were  successful;  he  did  not  publish  them  til 
1896. 

The  first  operation  in  man  was  performed  by  Sai 
Martin  y  Satrustegui,  a  Spaniard,  in  1901'*  i'l, 
reported  two  cases  done  in  the  hope  of  relievini 
gangrene,  neither  of  which  was  successful,  and  late 
in  the  same  year  Jaboulay  reported  a  case  also  i 
failure.  The  operation  was  first  successfully  in- 
formed by  Carrel  in  1902,  and  since  then  has  beei 
done  experimentally  many  times.  In  1906  Carre 
and  Guthrie  reported  thirteen  cases  with  only  oni 
failure,  and  later  reported  the  result  of  an  autops; 
at  the  end  of  seven  months  in  which  the  anastomosi 
was  still  in  good  working  order. 

In  human  beings  reversal  of  the  circulation  ha 
been  performed  fifty-eight  times  on  fifty-six  patient 
(Halsted  and  Vaughn,  1912).  These  observers  bavi 
analyzed  carefully  forty-two  of  the  cases.  In  thirty 
one  the  anastomosis  was  done  for  actual  gangrene 
and  in  eleven  for  threatened  gangrene.  Three  of  th< 
operations  were  for  presenile  gangrene,  two  in  case: 
of  embolism,  three  for  traumatic  obliteration,  am 
one  in  a  case  of  sepsis. 

Reversal  of  the  circulation  in  the  extremities  ha 
been  advocated  for  presenile  gangrene,  Raynaud' 
disease  or  Judaische  krankheit,  common  senili 
gangrene,  and  for  the  obliteration  of  the  artery  by  i 
thrombus  or  an  embolus  or  an  injury. 

Although  there  are  many  cases  reported  there  i. 
much  difference  of  opinion  as  to  the  value  of  thi 
operation.  Weitung,  whose  name  is  intimate! 
associated  with  the  operation,  strongly  advocate-  it 
while  Coenen  and  Wirwiorowski  after  careful  experi- 
mental work  consider  it  unjustifiable  and  against 
anatomical  and  physiological  principles.  In  thi; 
country  Halsted  and  Vaughn  conclude  that  it  b 
indicated  only  in  traumatic  surgery  when  the  arten 
is  destroyed  and  then  should  be  done  simply  wit] 
the  object  of  supplying  more  blood  to  the  part  unti 
the  circulation  can  be  taken  up  by  the  collaterals 
On  the  other  hand,  Bernheim  (1912)  who  has  hac 
several  cases  and  has  analyzed  fifty-two  of  those 
reported,  considers  it  a  well-recognized  operatic-] 
justified  by  the  clinical  results. 

The  experimental  and  clinical  observations  are  at 
variance.  Carrel  showed  that  in  animals  the  blood 
pressure  in  the  artery  overcame  the  resistance  of  the 
valves  in  the  veins,  while  Coenen  and  Wirwiorowski, 
experimenting  on  the  cadaver,  were  unable  to  force 
the  injecting  fluid  past  them.  Bernheim  ami 
Weitung  take  exception  to  this  and  say  that  in  life! 
it  is  different  and  the  constant  pounding  of  the 
arterial  blood  soon  breaks  down  the  resistance  of  the 
valves  as  is  proved  by  the  clinical  results.  Halsted 
and  Vaughn  conclude  that  there  is  enough  clinical 
and  experimental  evidence  to  show  that  the  opening 
is  not  permanent  and  that  in  the  few  cases  in  which  a 
thrombus  does  not  immediately  form  the  endothe- 
lium gradually  obliterates  the  opening,  although 
they  admit  the  operation  may  be  successfully  done 
on  animals.  They  also  say  that  even  in  the  I  I 
where  the  stoma  remains  open  and  the  resistance  ol 
the  valves  is  overcome,  the  blood  never  reaches  the 
capillaries  but  is  returned  to  the  heart  by  the  anasto- 
mosing veins.  They  consider  that  in  only  two  of  the 
forty-two  cases  was  the  circulation  enough  restore 
to  prevent  the  progressing  gangrene,  although  local 
changes  showing  improvement  in  the  circulation 
were  noted  in  twenty-three  cases.  Lejars,  in  com- 
menting on  Weitung's  paper,  says  that  Weitung 
advocates  the  operation  only  in  the  case  of  vigorous 
people  with  no  infection,  in  whom  the  gangrene  is  nol 
advancing,  and  he  thinks  that  in  this  class  of  cases 
expectant  treatment  is  usually  indicated  and  is  much 
less  dangerous. 

Bernheim  in  his  analysis  of  fifty-two  cases  con- 


662 


llEKEKEXCE   handbook  OF  THE   MEDICAL  sciences 


Arteries,  Burger;  of 


iIits  fifteen  successful  and  remarks  that  in  the  last 

teen  cases  reported   there  were  nine  sueeesses  an. I 

.,■  failures  while  the  result  in  one  was  questionable. 
1,11  hen  of  the  patients  died  immediately  after  the 
[,,11  while  the  course  of  tin-  ili  :ea  e  was  uninflu- 
|  in  i  he  remaining  twenty-two. 
i  >ne  of  the  chief  causes  of  failure  is  the  poor  surgical 
-k  which  the  average  patient  who  is  submitted  i"  the 
i. ration  presents.     Nearly  all  are  old  witli  existing 
e  which  is  advancing,  and  there  is  often  more 
less  infection.     The  arteries  are  usually  throml  >o  ed 
.   distance  around  the  gangrenous  ana,  and  in 
cases  the  operation  is  done  as  a  last  resort. 
cases  in  which    the  best   results   have  been  ob- 
oe those  of  "  threatened  gangrene."  Raynaud's 
ease,  Judaische  krankheit,  and  allied  conditions, 
it  li  pain,  cold  extremities,  and  loss  of  pulse  but  with- 
uil  gangrene.     The  other  chief  cause  of  failure 
thrombosis  from  faulty  technic  or  sepsis,  and  of  the 
ported  cases  infection  has  occurred  in  an  unusually 
rge  number.     As  to  technique,  it  is  impossible  for  a 
an    who    has    not    done    considerable    blood-vessel 
irgery  in  the  laboratory  to  do  a  satisfactory  anasto- 
losis  on  the  human  with  any  hope  of  success. 
The  success  of  the  operation  is  to  be  judged  by  the 
■lief  of  symptoms,  i.e.  increased  warmth,  improved 
lor,  relief  from  pain,  pulsation  in  the  vein,  and  the 
■turn  of  the  part  threatened  to  normal. 
The  last  word  on  the  reversal  of  the  circulation  has 
nt  been  said  and  it  is  unfortunate  that  the  opinions 
f  good  observers  are  so  diametrically  opposed.     It 
ould  seem  to  be  a  justifiable  operation  in  the  hands 
t  competent  surgeons  in  certain  selected  cases  and  to 
e  of  especial  value  in  cases  of  traumatic  destruction 
f  an  artery,  or  where  the  vessel  is  plugged  by  an 
inhiilus.     The  operation  may  also  be  resorted  to  with 
Hue  hope  of  success  in   certain  cases  of  gangrene, 
articularly  the  presenile  type,  such  as  Raynaud's 
isease,  be/ore  infection  or  marked  actual  gangrene 
as  occurred. 

The  technique  of  the  operation  is  the  same  as  that 
~cd  in  the  suture  of  any  blood-vessel.  There  are 
nur  chief  methods:  (1)  Proximal  end  of  artery  to 
listal  end  of  vein  (Carrel);  (2)  End  of  artery  to  side 
t  vein  (Weitung);  (3)  Side  to  side  with  ligature  of 
he  vein  proximal  to  the  anastomosis  (Bernheim  and 
'tone);  (4)  Anastomosis  with  a  biterminal  graft 
■.hen  there  is  loss  of  substance.  It  has  been  shown 
hat  a  complete  reversal  of  the  circulation  is  unneces- 
ir\  ,  it  being  sufficient  to  anastomose  the  proximal  end 
if  the  artery  to  the  distal  end  of  the  vein  and  ligate  the 
ihcr  ends,  as  the  collateral  anastomosing  veins  are 
ufneient  to  take  care  of  the  return  flow  of  blood. 
klarked  edema  of  the  extremity  is  usually  noted, 
lowever,  after  the  operation  when  it  is  done  in  this 
iianner. 

The  Matas  Operation  fob  Aneurysm. — The 
Uatas  operation  for  the  cure  of  aneurysm  was  first 
icrformed  by  Rudolph  Matas  in  March,  188S,  and 
eported  in  October  of  the  same  year.  At  the  present 
lay  it  has  replaced  in  nearly  all  cases  the  older  opera- 
ionsof  Vntyllus,  Hunter,  and  Basedow.  The  opera- 
ion  consists  in  opening  the  sae  under  temporary 
lemqstasis,  closing  the  orifices  of  all  vessels  leading 
it"  it  by  direct  suture,  and  obliterating  the  sac  by 
Occasionally,  in  very  favorable  cases,  the 
trtery  may  be  reconstructed.  The  object  of  the  oper- 
itioa  is  to  cure  the  aneurysm  and  relieve  the  pressure 
on  the  surrounding  parts  with  as  little  interference  to 
the  circulation  as  possible.  It  is  simpler  and  easier 
o  perform  than  many  of  the  other  operations,  such 
as  dissecting  out  the  sac  after  ligature,  and  has  a  great 
advantage  in  that  the  artery  is  controlled  in  all  cases 
at  the  point  of  hemorrhage  and  not  in  continuity,  thus 
interfering  very  little  with  the  collateral  circulation 
and  reducing  the  possibility  of  gangrene  to  a  minimum. 

The  principle  of  the  operation  is  as  follows:  The 


Fig.  397. — Restorative  Operation. 
The  Lembert  sutures  are  closing  the 
single  stoma  of  a  sacculated  aneu- 
rysm. 


sac  is  regarded  as  a  serous  lined  cavity  the  endothe- 
lium being  continuous  with  that  of  the  artery;  this 
endothelium  acts  when  drawn  together  and  irritated 
in  the  same  manner  as  does  the  peritoneum,  and  the 

surfaces  unite  by  the  formation  anil  organization  of  a 
plastic  exudate.  The 
•  list  urbance  of  circula- 
tion is  reduced  to  a 
minimum  by  I  he  intra- 
saccular  suture  of  the 
bleeding  points.  If 
the  aneurysm  is  saccu- 
lar the  sac  may  be  ob- 
literated and  the  con- 
tinuity of  the  vessel 
restored  or,  if  it  is 
necessary  to  obliterate 
the  artery,  the  small- 
est amount  of  vessel  is 
destroyed.  The  col- 
lapse of  the  sac,  by 
emptying  its  contents 
and  its  further  obliter- 
ation by  suture,  re- 
lieves all  pressure  on 
neighboring  parts  and 
the  satellite  vein  is  not 
destroyed  as  is  often 
the  case  when  an  at- 
tempt is  made  to  dis- 
sect out  the  sac. 

The  operation  is  ap- 
plicable,  in  one   form 

or  another,  to  all  aneurysms  except  the  intrathoracic 
and  abdominal  varieties.  It  should  be  used  in  trau- 
matic aneurysm  only  after  the  formation  of  a  true 
sac  and  not  in  the  early  stages  when  the  tumor  is 
in  reality  a  pulsating  hematoma.  Arteriorrhaphy, 
which  is  an  entirely  different  procedure,  should  be 
clone  in  these  cases. 

There  are  three  types  of  the  operation,  called  by 
Matas  obliterative,  restorative,  and  reconstructive 
endoaneurysmorrhaphy. 

Obliterative  Endoaneurysmorrhaphy. — This  is  the 
operation  applicable  in  the  largest  number  of  cases 
and  is  used  where  the  vessel  is  dilated  into  a  fusiform 

aneurysm  involving  all 
the  coats  for  a  varying 
distance.  The  opera- 
tion consists  in  open- 
ing the  sac  and  closirg 
all  the  openings  into  tl 
with  continuous  su- 
tures. There  are 
always  two  openings, 
representing  the  main 
artery,  besides  a  vary- 
ing number  of  smaller 
ones.  After  closing  all 
the  openings  the  sac  is 
obliterated. 

Restorative  Endo- 
aneu  rysmorrhaphy. — 
This  is  the  ideal  oper- 
ation but  is  applicable 
only  in  a  compara- 
tively small  number  of 
cases.  It  is  used  in 
sacciform  aneurysm 
where  there  is  a  dis- 
tinct sac  on  one  side  of 
the  artery  communi- 
cating with  the  lumen 
of  the  vessel  by  a  comparatively  small  opening.  In 
these  cases  the  opening  into  the  artery  is  closed  with 
a  continuous  stitch  and  the  sac  obliterated  by  several 
rows  of  sutures.  These  also  reinforce  the  first  suture 
and  strengthen  the  arterial  wall. 

663 


Fig.  398. — Restorative  Operation. 
The  stoma  closed. 


Arteries,  Surgery  of 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


K(  c  «  nst  ruct  i  ve  Endoaneurysmorrhaphy. — This 
method  is  applicable  to  aneurysms  of  the  fusiform 
type  where  the  openings  of  the  parent  artery  are  on 
the  same  level,  on  one  side  of  the  sae,  and  not  far 
apart.     The    utility    of    the    operation   is   somewhat 


Fig.  399. — Reconstructive  Operation.  Sacculated  aneurysm 
opened  and  seen  from  within.  Note  the  opening  of  a  collateral 
to  one  side  of  the  main  stomata. 

questioned  and  it  should  be  used  only  in  very  favor- 
able eases  where  the  walls  of  the  sac  are  elastic  and  in 
good  condition,  and  the  danger  of  gangrene  of  the 
part  supplied  by  the  artery  is  great.  Since  thrombosis 
is  very  likely  to  occur  it  is  of  value  in  these  cases  as  a 


Fm.  400. — Reconstructive  Operation.      Aneurysmal  sac  shown  in 
Fig.  399.     Stomata  partly  closed  by  Lembert  sutures. 

temporary  expedient  to  supply  blood  to  the  part  until 
the  development  of  the  collateral  circulation.  The 
operation  consists  in  passing  a  catheter  into  the  two 
openings  of  the  main  artery  over  which  the  sac  is 
drawn   together  and  sutured,   making  a  new  artery. 

664 


Technique. — Temporary  hemostasis  is  a  necessity 
and  is  best  obtained  by  a  tourniquet.  When  this  is 
impossible,  as  in  aneurysm  of  the  iliac  or  axillary 
artery,  clamps  of  some  form  may  be  applied  to  the 
main  vessel  or  it  may  be  tied  temporarily  with  a  tape 
but  severe  hemorrhage  from  collaterals  entering  the 


Fig.  401. — Reconstructive  Operation.     Catheter  in  situ. 

sac  should  be  expected.  The  incision  should  lie  made 
longitudinally  directly  into  the  tumor  without  prelim- 
inary dissection,  the  clot  turned  out,  and  the  walls 
examined  for  the  openings  of  the  vessels.  All  of 
these  are  closed  by  an  intrasaccular  suture.  The 
sutures  used  are  either  fine  silk,  No.  1,  or  chromic 


Fig.   402.- 


-Detail  of  Reconstructive  Operation, 
being  withdrawn. 


The  catheter  is 


catgut,  No.  00,  on  fine  straight  or  curved  needles, 
both  sutures  and  needles  being  coarser  than  those  used 
in  arteriorrhaphy.  The  sutures  are  sterilized  in  oil 
and  in  general  the  rules  applying  in  arterial  surgery 
are  observed,  but  the  operation  is  less  difficult.  In 
the  closure  of  the  orifice  of  the  vessel,  the  suture  is 


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\rterloflderoslfl 


arted  one-half  inch  to  one  side  of  the  opening  and 

deep  into   the  tissues.     A  continuous  over- 

Id-over  stitch  is  used  and  in  the  restorative  opera- 

,.  lumen  of  the  artery  is  made  someM  hat  smaller 

ian  that  of  the  original  vessel.     After  the  closure  "I 

[  openings   the  sac  is  obliterated.     This  may  be 

,ne  in  several  ways.     When  opened  and  the  con- 

iracuated,   the  sac  collapses  and  forms  longi- 


1G.  403. Obliterative  Operation,  Showing  Insertion  of  Second 

Row  of  Sutures. 


udinal  folds  which  are  sutured  together  with  a  con- 
inuous  stitch.  When  the  sac  is  small  this  may  be 
one  and  the  soft  tissues  and  skin  closed  over  it. 
V  lien  the  sac  is  large  several  superimposed  layers  of 
uture  are  used  and  the  skin  edges  are  freed  and  slid 
ver  (lie  unobliterated  portion  to  which  they  are 
utured.  In  certain  cases  of  stiff  walled  sac  which 
annot  be  sutured,  a  skin  flap  can  be  slid  in  and  fast- 
ned  in  the  same  manner  that  skin  flaps  are  used  to 
ate  stiff  walled  cavities  in  bone.     When  the  sac 


1(14. 


-Detail  of  Imbricating  Stitches  for  Obliteration  of  Dead 
Spaces. 


is  trabeculated  and  it  is  impossible  to  close  it  at  all  by 
suture  a  part  may  be  excised  and  the  rest  packed  and 
allowed  to  heal  by  granulation.  In  post-peritoneal 
aneurysm,  aneurysm  of  the  iliac,  the  same  principle  is 
applied,  the  peritoneum  being  used  in  the  same 
manner  as  the  skin. 

The  results  of  the  intrasaccular  operation  are  very 
much  better  as  regards  cure  and  freedom  from  gan- 


e,  than  those  of  the  older  operation  Monod 
and  Vanverts  (December,  1911)  have  collected  from 
the  literature  L05  cases  with  the  following  results: 
Cures  eighty-five  (82  per  cent  i;  mortality  11.6  per 
cent.;  gangrene  I  9  per  cent.;  failures  14.5  per  cent. 
The  remote  results  are  given  in  only  thirty-seven  <>f 
1 1,,  e  cm  e  and  in  many  I  he  patienl  had  been  ob- 
served but  a  few  weei  .     01  the  twi  Ive  death  .  two 

occurred    in   eases   of   aneurysm   of    the   aorta   which 
should  not  be  included  in    this   series.     The  others 


1  i...  403. — Cross-section  ol  the  I  issues,  Showing  Imbrication  in 
the  Reconstructive  Operation. 

were  caused  by  shock,  hemorrhage,  gangrene,  sepsis, 
and  pulmonary  embolism.  The  failures  consisted 
in  postoperative  hemorrhage,  of  which  six  cases  were 
fatal,  or  recurrence  of  the  aneurysm.  Presence  of  a 
pulse  was  noted  in  thirty-five  case  immediately  after 
the  operation,  while  in  others  it  did  not  appear  for 
several  hours. 

The  results  were  very  much  better  in  long-standing 
traumatic  aneurysm  in  young  people  where  the 
vessels  were  elastic  and  in  good  condition,  than  in  the 
common  aneurysm  in  old  subjects.  In  the  former 
class  were  seveiitv  cases  with  sixty-one  cures,  88.4  per 
cent,  while  in  the  latter  class  numbering  twenty- 
five,  there  were  fifteen  cures,  sixty  per  cent,  and  twenty 
eight  per  cent,  mortality.  These  authors  were  struck 
by  the  large  number  of  postoperative  hemorrhages, 


Fig.  406.- 


Cross-section  of  the  Tissues  in  the  Obliterative 
Operation. 


twelve  cases,  six  of  which  were  fatal.  In  the  recon- 
structive cases  there  were  twenty-nine  per  cent,  of 
recurrences.  . 

Matas  in  190S  reported  the  results  of  eighty-five 
cases  and  later  said  he  had  knowledge  of  110  cases 
operated  upon  bv  his  method.  Of  the  eighty-five 
operations  fifty-nine  were  of  the  obliterative  type, 
thirteen  restorative,  and  thirteen  reconstructive. 
Of  the  reconstructive  cases,  four  or  2S.9  per  cent. 

recurred.  _    _ 

Channing  C.  Simmons. 
J.  Collins  Warren. 

Arteriosclerosis.— See  Blood-vessi  Is,  Pathological 
Anatomy  of,  and  BloocLpressure. 

665 


Arthritis,  Acute 


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Arthritis,  Acute. — Anatomy.  All  diarthrodial  joints, 
that  is,  all  joints  possessing  motion,  are  bounded  by 
two  tissues,  the  cartilage  and  the  synovia.  Under- 
neath the  synovia  is  the  ligament  (or  fascia),  under- 
neath the  cartilage  is  lymphoid  marrow.  If  the 
synovia  is  inflamed,  this  inflammation  constitutes  an 
arthritis.  The  cartilage  itself  is  probably  not  capable 
of  inflammation  (see  Artliritis,  Chronic),  but  an  in- 
flammatory process  in  the  subjacent  bone  marrow 
readily  finds  access  to  the  joint  at  the  circumference 
of  the  .cartilage,  or  even  through  the  cartilage  itself 
by  depriving  it  of  its  nutrition  and  so  perforating  it. 
Thus  a  myelitis  may  easily  become  an  arthritis,  and 
usually  does,  when  the  lymphoid  marrow  is  involved. 
On  the  other  hand,  an  arthritis  starting  in  the 
synovia,  may  involve  the  marrow  by  making  its  way 
into  the  bone  at  the  circumference  of  the  cartilage. 
These   two   tissues,    the  synovia  and    the  lymphoid 


Fig.  407. — Low  Power  Photomicrograph.  Normal  capsule  of 
joint,  showing  smooth  surface  of  synovia  above,  and  the  vascular 
spaces. 

marrow  are  the  important  ones  in  all  cases  of  acute 
arthritis.     Some  diseases  affect  one,  some  both. 

Lymphoid  marrow  is  found  in  the  short  and  flat 
bones,  in  the  ends  of  long  bones,  and,  in  children,  in 
the  shafts  also.  It  consists  of  a  delicate  reticulum  of 
connective  tissue  in  whose  meshes  are  cells  of  various 
kinds,  and  it  is  these  cells  which  distinguish  lymphoid 
marrow  from  the  fatty  marrow  of  the  shafts. 

Synovial  membranes  resemble  so  closely  the  serous 
membranes  that  they  are  often  classified  with  them. 
But,  although  structurally  much  the  same,  they  differ 
from  the  serous  membranes  in  secreting  a  peculiar 
fluid — the  s\rnovial  fluid.  In  all  joints  where  motion 
takes  place  (diarthrodia)  a  lubricating  fluid  is  neces- 
sary, and  this  fluid  is  furnished  by  the  synovial  mem- 
brane. Every  diarthrodial  joint  is  lined  with  a  layer 
of  synovial  membrane,  except  in  the  places  where  the 
articular  cartilages  are  in  contact.  Here  there  is  no 
membrane,  except  at  the  edge  of  the  cartilages, 
which  the  synovial  membrane  may  overlap  for  two 
or  three  millimeters  before  merging  into  the  carti- 
laginous structure.  Fasciculi  and  folds  of  the  capsule, 
the  internal  ligaments,  and  fatty  internal  protrusions 
are  all  covered  by  the  membrane.  The  limits  of  the 
synovial  membrane  an-  most  easily  made  out  in  in- 
flammation, when  a  red  collarette  is  seen  surrounding 
the  while  cartilages. 

Synovial  membranes  or  synoviie,  classed  among 
structures  of  the  lymphatic  system,  are  connective 


tissue  membranes,  very  thin  and  delicate,  whost 
limits  in  health  can  hardly  be  defined  from  the  under- 
lying fascia  or  ligament.  In  disease,  however,  thf 
membrane  may  became  greatly  thickened  and  have  c 
thickness  of  perhaps  twenty  millimeters. 

In  gross  the  inner  surface  of  a  joint  presents  p 
smooth  and  shining  surface,  interrupted,  especially 
where  the  membrane  folds  to  pass  from  one  surface  U 
another,  by  the  synovial  fringes  (plicce  sync 
villous  structures  of  varying  size  and  length,  some- 
what resembling  intestinal  villi,  the  largest  beine 
perhaps  one  centimeter  long.  They  are  richly 
supplied  with  blood-vessels,  for  each  villus  contains  thi 
convoluted  twig  of  an  artery.  Some  of  the  fringe?, 
however,  are  merely  hernia-like  prolusions  into  the 
joint  of  small  masses  of  fat  covered  with  synovial 
membrane;  these  fill  up  unoccupied  spaces.  Th; 
nerves  are  derived  from  the  same  nerve  trunks  that 


Fig.    408. — Photomicrograph.     Capsule   of   joint,    near  a  recess 
showing  folds  of  synovia. 

supply  the  muscles  of  the  limb.  The  nerve  fila- 
ments terminate  in  small  plexuses  equally  distributed 
under  the  synovial  membrane.  Coloring  matter 
injected  into  the  joint  disappears  very  quickly,  to 
reappear  in  the  lymphatic  channels  of  the  limb. 

Synovia  is  a  clear,  alkaline  fluid,  much  like  the 
white  of  egg  in  general  appearance;  when  rubbed 
between  the  fingers  it  imparts  an  oily  sensation.  It 
is  largely  secreted  by  the  cells  which  cover  the  -_ 
vial  fringes.  In  composition  it  contains  albumin, 
mucin,  some  fat,  leucocytes,  and  epithelial  cells.  A 
fluid  identical  in  composition  with  synovia  can  be 
reproduced  by  rubbing  up  a  portion  of  the  epidermis 
is  a  weak  alkaline  solution.  This  fact  suggests  that 
most  of  the  mucin  is  derived  from  the  endothelial 
cells  soaking  in  the  weak  alkaline  fluid  secreted  by  the 
fringes,  and  this  view  is  strengthened  by  the  fact 
that,  when  joints  are  quiet,  the  synovia  in  them 
contains  only  half  as  much  mucin  as  when  they  are  iu 
motion.1 

Etiology. — Acute  arthritis  may  be  caused  either 
by  injury  or  by  infection,  though  the  propriety  of 
including  the  first  factor  as  a  cause  is  questionable. 
However,  as  a  trauma  to  the  lining  of  a  joint  ran 
hemorrhage  into  the  joint  itself,  and  as  the  physical 
signs  are  manifest  in  the  joint,  we  shall  give  that 
phase  of  the  subject  a  few  words,  before  taking  up 
arthritis  proper. 


6GG 


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Arthritis,  Arutc 


Traumatic    Arthritis. — The    usual    cause    is    a 
,-rench,  a  "strain,"  a  "sprain,"  or  a  dislocation. 
ures  involving  the  joint  form  another  important 
,  :  penetrating  wounds  of  the  joint,  if  absolutely 
septic,  a  in  it  her.    If  the  ligament  and  with  il  thesyno- 
be  torn,  a  greater  or  lesser  amount  of  blood,  and 
iter  of  inflammatory  products,  is  poured  out  into  tin' 
.nit  cavity,  and  it  is  these  that  cause  the  symptoms 
i  thr  joint,  symptoms  persisting  until  the  effusion  is 
orbed  and  until  the  synovia  is  healed.      Much  the 
ame  may  be  said  of  fractures  which  involve  the  joint 
hrough  lesion  of  the  cartilages. 
Morbid  Anatomy. — Besides  the  actual  damage  of 
joint  structures  by  the   trauma   itself,    the   palho- 
igical  changes  are  not  of  great  moment.     The  joint 
lins  the  effusion  from  the  ruptured  blood-vessels. 
ably  the  synovia  proliferates  somewhat,  and  the 
artilage  will  become  more  or  less  fibrillated  if  the 
lint   be  immobilized.     Another  result   of  immobili- 
ation  is  the  encroachment  of   the  synovia  on   the 
artilage  at  its  borders.     All  these  changes  disappear 
ipon   the  healing  of   the   original   trauma  and   the 
esumption    of    function.     If    the    joint    has    been 
lennanently  damaged,  as  a  machine,  so  to  speak,  by 
lie   interference    with    its   function    from    displaced 
nine  fragments,   it   will  be  exposed   to  constant  in- 
even    after    the    fracture    has    healed.     These 
i. id  bone  fragments  may  keep  up  a  continued 
rritation  of  the  joint. 

Symptomatology. — Immediately  after  the  injury,  or 
it  a  short  interval  of  time  the  joint  becomes  painful 
•  tiff,  and  swollen.  Motion  of  it  causes  increased 
tain,  a  id  as  a  rule  it  contains  more  or  less  fluid. 
Increase  of  local  temperature  and  reddening  may  or 
not  be  present.  Frequently  in  the  case  of  a 
torn  ligament  (or  semilunar  cartilage  in  the  knee) 
.!  of  lmal  tenderness  may  be  made  out.  After 
i  few  days  or  weeks  these  symptoms  subside  and 
leave  the  joint  practically  normal. 

The  prognosis  is  usually  good.  Except  in  the 
knee,  whose  complicated  structure  predisposes  to  a 
recurrence  of  the  damage,  there  is  little  chance  of 
pse.  It  is  to  be  borne  in  mind  that  whatever 
remains  behind  after  the  "synovitis"  has  run  its 
>e  is  not  due  to  it  but  to  the  injury  that  caused 
it.  Again,  there  is  little  prospect  of  the  disease 
"running  into"  anything  else.  Indeed,  some  writers 
maintain  that  those  cases  of  joint  tuberculosis  which 
seem  to  have  been  caused  by  an  injury  are  only 
lighted  up  by  it. 

The  treatment  consists  in  the  first  place  of  hot  or 
cold  applications,  or  of  tight  compression  by  bandages 
and  a  splint,  to  restrict  the  effusion  into  the  joint  as 
much  as  possible.  Afterward  rest  and  support  are 
indicated.  Plaster-of-Paris  is  rarely  necessary,  nor 
i-  rest  in  bed.  If  the  joint  be  properly  strapped,  so  as 
to  exert  pressure  and  to  restrain  motion,  the  patient 
may  usually  be  allowed  to  go  about. 

Massage  and  hydrotherapy  are  excellent  in  the 
later  stages. 

Ankylosing   Arthritis. — Another  form  of  traumatic 

arthritis,    whose  exact  pathology  is  not  thoroughly 

■  stood,   has  been  described  by  several  writers.2 

After  an  injury  a  joint  slowly  becomes  stiffened,  until 

plete  bony   ankylosis  takes  place.     No  fracture 

ran  be  demonstrated  by  the  most  careful  examination. 

Treatment   hitherto   has   been  fruitless.      A  peculiar 

deformity  sometimes  occurring  in  the  spine  may  be 

analogous  to  this.     Shortly  after  a  severe  injury,   a 

kyphosis  makes  its  appearance,   and,   if   untreated, 

ly    increases.     The  Roentgen  rays  show  no  dis- 

and   no  fracture.     The  treatment  consists  of  a 

well-fitting   plaster  jacket  to  control  the  increase  of 

deformity.3 

Acute  Infectious  Arthritis. — Under  this  head 
we  include  every  case  of  acute  joint  inflammation  not 
falling  in  the  preceding  class.     The  infection  may  be 


of  the  most  varied  nature.  The  ordinary  pus  COCCI 
may   be  responsible  for  it,   the  pneumococcus,   the 

typhoid  bacillus,  or  the  gonoCOCCUS.  Some  '.'.titers 
maintain  that  toxins  circulating  in  the  blood  ran 
cause  a  joint  inflammation.      Probably  acute  inflam- 


Fig.  409. — Low  Power  1'nuionu 
InfectioD — probably  gonorrheal — 
lymphoid  elements. 


•lugraph  of  a  Joint  with  Mixed 
showing    proliferation    of    the 


matory  rheumatism  belongs  in  this  category,  but  it 
will  be  discussed  elsewhere. 

Penetrating  wounds  of  a  joint  and  infection  follow- 
ing operation  cause  not  a  few  cases  of  the  disease. 
As  might  be  expected  the  disease  often  accompanies 
or  follows  one  of  the  acute  infectious  diseases,  gonor- 


Fig.  410. — Same  as  fig.  409;  High  Power. 

rhea,  pneumonia,  typhoid  fever,  scarlatina,  smallpox, 
and  septicemia.  Pregnancy  and  labor  favor  the 
appearance  of  gonorrheal  arthritis  in  women.  In 
the  arthritis  complicating  an  infectious  disease  the 
microorganism  responsible  for  the  joint  lesion  may 


G67 


Arthritis,  Acute 


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be  that  of  the  disease  itself,  it  may  be  that  of  a 
secondary  infection,  or  it  may  be  mixed. 

When  an  arthritis  complicates  an  infectious  disease 
its  origin  is  easily  understood,  but  in  some  cases  the 
port  of  entry  of  the  poison,  and  its  appearance  in  the 
joint,  cannot  be  ascertained.  A  sharp  dividing  line 
i-  not  always  present  between  an  acute  and  a  chronic 
infectious  arthritis.  At  the  start  many  chronic 
joint  diseases  appear  to  be  acute.  On  the  other 
hand,  the  disability  and  deformity  remaining  after 
an  acute  arthritis  must  not  be  confounded  with  an 
active  chronic  arthritis. 

Pathology. — The  three  essential  tissues  in  a  joint 
inflammation  are  the  synovia,  the  marrow,  and  the 
deep  layer  of  the  periosteum.  Sometimes  one  is 
involved,  sometimes  another,  sometimes  all  three. 
The  morbid  changes  in  the  bone  and  in  the  cartilage 
are  to  be  regarded  as  secondary  to  those  of  these  three 
tissues.  Certain  infectious  agents  seem  to  have  a 
predilection  for  one,  certain  for  another  of  these 
tissues;  thus,  the  gonococcus  affects  by  preference 
the  synovia,  and  more  rarely  the  periosteum;  the 
ordinary  pus  cocci,  all  three.  An  arthritis  may  have 
its  origin  in  the  marrow  and  spread  to  the  synovia, 
or  the  process  may  be  reversed.  Occasionally  a 
myelitis  of  the  shaft  may  spread  to  the  joint,  but  as  a 
rule  the  ordinary  infectious  osteomyelitis  of  the 
shaft  stops  at  the  epiphyseal  line.  (Infectious 
osteomyelitis  of  the  shaft  is  usually  found  in  adoles- 
cence.) If  the  disease  start  as  a  myelitis  in  the  end 
of  a  long  bone,  it  quickly  becomes  an  arthritis. 

The  ordinary  phenomena  of  inflammation  follow 
the  infection,  and  an  exudate  is  poured  into  the 
joint.  The  disease  has  been  classified  upon  the  basis 
of  this  exudate — serous,  serofibrinous,  purulent,  etc. 
The  synovia  hypertrophies,  thickens,  and  may 
undergo  a  marked  villous  change. 

If  the  infection  be  a  mild  one,  the  exudate  may  be 
absorbed  after  a  longer  or  shorter  time  and  the  joint 
may  return  to  its  normal  condition.  If  the  infection 
be  more  severe,  some  thickening  of  the  synovia  and 
adhesions  in  the  joint  may  remain.  In  the  very 
severe  infections  the  inflammation  spreads  through- 
out the  joint  with  great  rapidity,  killing  the  bone  and 
cartilage,  perhaps  bursting  through  the  ligament, 
and  destroying  the  joint.  In  certain  diseases  (e.g. 
typhoid  fever)  a  marked  tendency  to  dislocation 
exists. 

Symptomatology. — Pain  is  usually  the  earliest 
symptom  and  the  most  prominent  one.  It  is  wont 
to  be  very  severe  and  to  be  increased  by  motion.  It 
is  usually  in  direct  proportion  with  the  severity  of 
the  infection.  Coincident  with  the  pain  appear 
local  heat,  swelling,  and  change  of  contour.  The 
limb  is  held  in  the  most  comfortable  attitude — usually 
.slight  flexion.  Fever  and  constitutional  involve- 
ment are  present  in  the  severer  forms.  Fluid  can 
usually  be  demonstrated  in  the  joint  cavity. 

In  the  milder  forms  the  symptoms  may  soon  sub- 
side. In  the  severe  forms  the  march  of  the  disease  is 
rapid  and  alarming,  and  unless  timely  treatment  is 
carried  out,  or  in  spite  of  it,  the  outcome  may  be 
fatal. 

Diagnosis. — The  fact  that  a  joint  is  acutely  inflamed 
is  patent  to  the  casual  observer.  The  important 
fact  to  be  ascertained  is  as  to  the  character  of  the 
inflammation,  for  upon  the  early  recognition  of  this 
may  depend  the  life  of  the  patient. 

The  milder  forms  of  the  disease — those  that  should 
be  treated  conservatively,  those  with  a  simple  serous 
exudate — are  accompanied  by  few  constitutional 
symptoms  or  by  none  at  all.  The  entire  trouble  is 
local,  and  the  patient  is  not  sick.  The  temperature 
may  be  slightly  above  the  normal,  but  not  much 
above  it.  The  severe  forms,  on  the  contrary,  are 
accompanied  by  marked  constitutional  symptom  . 
as  well  as  by  severe  local  signs — great  swelling,  pain, 
heat,   etc.      An  arthritis  following  typhoid  fever  may 

668 


belong  in  the  former  class,  and  by  a  secondan 
infection  may  be  converted  into  one  of  the  latter, 
The  same  may  be  said  of  a  gonorrheal  joint  and  of 
others.  An  acute  inflammation  in  one  or  more  joints 
of  an  adult  always  should  awaken  the  suspicion  of  a 
gonorrhea.  The  detection  of  a  lesion  in  the  genito- 
urinary  tract  practically  clinches  the  diagn. 
Often  the  gonococcus  may  be  cultivated  from 
aspirated  fluid,  especially  in  recent  cases.  Acute 
inflammatory  rheumatism  is  always  fleeting,  and 
its  high  fever,  its  acid  sweats,  etc.  If  an  inflammation 
remains  in  one  joint  it  is  not  due  to  acute  inflam- 
matory rheumatism.  In  case  of  doubt  as  to  the 
origin  of  the  arthritis,  careful  inquiry  should  be 
made  as  to  the  previous  occurrence  of  an  acuti 
infectious  disease.  Aspiration  of  the  joint  will  often 
reveal  the  pathogenic  organism.  Scurvy  might 
cause  confusion  in  infants.  The  history  of  bottle 
feeding,  the  bleeding  gums,  the  exquisite  sensitive- 
ness of  a  joint,  without  constitutional  or  marked 
local  signs,  should  clear  up  the  doubt.  A  hemon 
into  a  joint,  sometimes  seen  in  hemophiliacs,  is  not 
wont  to  be  accompanied  by  many  symptoms,  either 
constitutional  or  local.  Tuberculosis  is  usually  slow 
and  chronic.  Sarcoma  affects  the  end  of  one  articu- 
lating bone,  but  not  the  joint  itself. 

Treatment. — This  depends  largely  upon  the  cause 
and  upon  the  severity  of  the  infection.  Milder  ta 
are  best  treated  by  rest— weight  and  pulley  extension. 
splinting,  plaster-of-Paris,  etc. — by  hot  or  cold 
applications,  and  sometimes  by  aspiration,  though 
this  last  is  not  often  necessary.  In  the  later  sta| 
massage,  passive  motion,  hot  and  cold  douches,  hot 
air,  are  all  serviceable. 

In  the  more  severe  forms  aspiration  and  washing 
out  of  the  joint  with  sterile  water,  or  with  a  solution 
of  iodine,  boric  acid,  or  carbolic  acid  have  been 
recommended.  They  should  not  be  continued  for 
long,  and  too  much  reliance  should  not  be  placed 
upon  them. 

In  the  ordinary  purulent  arthritis,  the  treatment 
should  be  that  of  any  abscess,  namely  free  and  early 
incision,  and  thorough  drainage. 

Gonorrheal  arthritis  should  be  treated  locally  on 
the  lines  laid  down.  The  genito-urinary  tract, 
especially  the  prostate  and  seminal  vesicles  in  a  man, 
should  also  receive  attention.  Often  with  the  curing 
of  the  primary  lesion,  the  joint  affection  will  subside 
Antigonococcic  serum  and  vaccine  are  not  always  oi 
service,  but  sometimes  their  beneficial  effect  i 
marked.  Leonard  W.  Ely. 

References. 

1  Frerichs:    Wagner's  Handworterbuch  der  Physiologie,  iii.f  1, 

146. 

2.  Murphy:  Journal  of  the  American  Medical  Association,  April 
27,  1912. 

3.  Mauclaire   et    Burnier:      Archives   Generates    de   Chirurgie, 
March  25,  1912. 


Arthritis,  Chronic. — The  student  of  chronic  diseases 
of  the  joints  meets  at  the  outset  a  very  perplexing 
problem.  He  finds  the  greatest  confusion  in  all  aspei  ta 
of  the  subject.  Various  authorities  describe  different 
diseases  or  types  of  disease  under  the  same  name,  and 
the  same  disease  under  different  names.  Many  differ- 
ent classifications  have  been  put  forward.  One 
writer  holds  fast  to  infection  as  a  cause  of  certain 
types,  and  disturbed  metabolism  as  the  cause  of  ot  hers; 
another  writer  may  reverse  these  classes  completely. 

Some  maintain  that  all  chronic  joint  diseases  arc 
infectious  in  their  nature.  To  set  forth  all  the  various 
theories  and  classifications  is  not  possible  lure. 
Many  of  them  err  as  being  based  on  clinical  data, 
always  an  unsatisfactory  procedure,  others  again  as 
based  on  the  Roentgen  picture,  which  can  show  merely 
the  results  of  disease.  What  follows  is  based  mainly 
upon  laboratory  study,  corrected  by  clinical  observa- 


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Arthritis.  Uiroiilt- 


ion.  li  is  not  all  demonstrated  truth,  bul  it  is 
imple,  easily  comprehended,  and,  if  carefully  dige  ted, 
rill  furnish'  the  render  with  a  nidus  on  which  tu 
n  stallize  his  nun  ideas.  In  order  tn  avoid  hopeless 
, .nfusiim  une  must  perforce  have  some  such  working 
iasis. 

Etiology. — All  chronic  joint  diseases  whose  cause 

lf  know  are  infectious  in  their  nature,  and  it  seem 

iesl  to  regard  those  whose  exact  cause  we  do  not  know 

-  belonging  in  the  same  category.     One  after  another 

diseases  have  been  placed  in  it.     .Nut   long 

onorrheal  arthritis  was  considered  as  due  to  a 

irritation''  from  the  urethral   mucous  tiieni- 

and  joint  tuberculosis  formed  a  great  mystery 

uilil  its  exacl   cause  was  known.     Some  authorities 

laim  that  "faulty  metabolism"  is  a  cause  of  some 

but  faulty  metabolism  in  a  joint  is  the  result  of 

,  not  its  cause.      It  is  present  in  any  di  i 

An  increased  excretion  of  lime  salts  has  been 

I  in  the  urine  of  some  patients.     This  is,  of 

what   one   would   expect    with    a   rarefying 

isteitis. 

Various    observers    (Schiller,    Banantyne,    Fayer- 

eather,  et  al.)  have  isolated  pure  cultures  of  bacteria 

rom  certain  cases  of  chronic  arthritis,  and,  because 

iese  bacteria  are  not  always  identical,  doubt  has  been 

hrown    upon    the    result    of    the    investigations.     It 

vere  better  to  regard  them  as  authentic,  and  to  con- 

lude   that   different  organisms  are   capable  of  pro- 

lucing  the  same  joint  changes,  or  changes  which,  in 

he  present  state  of  our  knowledge,  appear  the  same. 

<  Ither  investigators  have  been  unable  to  obtain  any 

lacteria  from  these  chronically  inflamed  joints,  but 

he  organisms  may  be  there,  nevertheless.     One  must 

iear    in    mind    that     until    recently    the  Spirochwta 

escaped    recognition,    and    that    it    is    often 

lillieult  to  find  tubercle  bacilli  in  tuberculous  joints. 

Igain,    if    the    organisms   are    in    the    bone  marrow 

nay   easily    escape   detection. 

In   many   of   these   patients   a   possible   source  of 

nfection  has  been  found,  and,  when  this  was  removed, 

ase  died  out  or  became  quiescent.     Diseased 

onsils,  a  purulent  otitis,  or  nasal  sinusitis,  an  intes- 

mal    indigestion,    a    suppurating    tooth    cavity,    a 

yphilitic  or  gonorrheal  infection,  have  all  been  linked 

i])  in  this  way  in  a  causal  relation  to  the  di  ease. 

>i  casionally  one  obtains  a  history  of  a  severe  attack 

if   "dysentery"    which    immediately   antedated    the 

ymptoms.     The  more  thoroughly  one  searches  the 

ii  tory,  the  more  often  will  one  find  evidences  of  an 

nfection,  so  often  indeed  as  to  render  improbable  the 

elation  of  coincidence,  and  to  make  the  causal  rela- 

iOD  almost  certain. 

No  age  is  exempt  except  the  earliest  infancy, 
'orae  types  are  found  in  the  earlier  periods  of  life 
nost  frequently,  and  other  types  in  the  later  periods. 
Mental  emotion  is  thought  by  some  to  stand  in  a 
ausal  relation.  This  is  possible,  but  the  relation  is 
irobably  not  a  direct  one.  If  we  regard  intestinal 
lection  as  a  cause  of  the  disease,  we  can  easily  see 
tow  mental  emotion  might  predispose  by  disturbing 
he  digestion. 

It  is  not  likely  that  occupation  is  a  factor.  Chronic 
irthritis  affects  the  rich  and  the  poor,  the  hard- 
working and  the  idle. 

cently   the   influence   of   the   ductless   glands — 
thyroid,    pituitary,    suprarenal — has    been 
I  'bated,    but     nothing    has    yet     been    established. 
I  tic  thymus  gland  particularly  has  been  held  responsi- 
ve, and  the  administration  of  its  powdered  extract 
has  been  recommended  in  some  cases  as  a  cure,  but 
i  I  ick  of  the  secretion  of  a  gland  which  normally  has 
ed    to  functionate  can   hardly  be  regarded   as  a 
cause  of  the  disease. 
Finally,  let  it  be  said  that  certain  of  the  changes 
occurring  in  some  types  of  the  disease  are  analogous 
to  those  often  taking  place  as  age  advances.     Indeed, 


the  nodes  found  on  the  terminal  phalangeal  joints— 
Herberden's  nod.-  are  aid  to  !»'  an  evidence  of 
longevity.  Beitzke  in  a  series  of  consecutive  autop- 
found  localized  ero  ion  ol  the  cartilage  in  a  very 
large  proportion.8 

Classification. — It  is  manifest   that  if  our  theory 

of  t  he  infect  ions  nut  ure  of  every  case  of  chronic  art  hri- 

tis  is  correct,  no  form  of  classification  we  'an  adopt 
will  stand  until  we  liml  out  everj  infection  that  will 
cause  the  disease,  and  i  he  exact  pathological  changes 
that  each   causes.      This   we   have   doni  01    i      i   g 

in  tuberculosis,   but    not    in  all,  and  our  task   will   not 
be  lightened  by  bestowing  meaningless  and  im 
terms  such  as  arthritis  deformans,  rheumatoid  •<• 
tie,  metabolic  arthritis,  etc.,  upon  the  whole  class  or 
u  I  ion  certain  divisions  ol  it .     For  the  present  it  seems 
wiser,   if   possible,    to   classify    upon   a   pathological 

basis,    and    this    we    can    do. 

All,  or  almost  all,  cases  of  chronic  arthritis  fall 
into  one  of  two  I  ipe,  and  while  some  present  the  char- 
acteristics of  both  types  in  t  he  same  joint  or  in  differ- 
ent joints,  the  preponderance  oi  Set   of  changes  is 

usually  so  great  as  to  leave  no  doubt  as  to  the  type  in 
which  the  joint  should  be  placed. 

In  our  study  of  joint  diseases  we  come  to  deal  with 
five  tissues,  namely  the  red  or  lymphoid  marrow  and 
the  trabecular  in  the  ends  of  the  bone,  the  articular 
cartilage,  the  synovia,  and  the  ligament. 

The  marrow  consists  of  a  delicate  reticulum  of 
connective  tissue  and  fat,  in  whose  meshes  are  many 
cells  of  various  kinds.  It  is  these  cells  which  distin- 
guish the  marrow  in  the  ends  of  the  long  bones  of 
adults  from  that  of  the  shafts.  In  children  the 
marrow  in  the  shafts  also  is  of  the  lymphoid  variety. 
The  custom  has  been  to  regard  the  marrow  as  more 
or  less  of  a  "filling"  for  the  bones  and  of  compara- 
tively slight  importance  in  bone  diseases.  On  the 
contrary,  it  is  probably  the  tissue  of  prime  importance 
in  all  bone  disease,  as  can  be  seen  by  a  study  of 
specimens  under  the  microscope.  From  the  marrow 
the  bone  trabecular  derive  their  nutrition  (they  have 
no  blood-vessels  of  their  own)  and  any  changes  in  it 
are  reflected  in  them.  A  mild  irritation  in  the 
marrow  is  wont  to  cause  an  hypertrophy  of  bone,  a 
stronger  one,  an  atrophy,  and  a  severe  inflammation 
results  in  death  of  the  bone.  Certain  forms  of 
degeneration  of  the  marrow,  as  we  shall  see,  are  also 
follow-ed  by  an  hypertrophy  of  bone.  Various 
authors  have  mentioned  the  marrow  changes  in  bone 
disease,  but  as  a  rule  have  failed  to  attach  much 
importance  to  them. 

All  bone  tissue  is  the  same,  and  that  in  the  ends  of 
the  long  bones  and  in  the  short  and  Hat  bones — can- 
cellous bone — differs  from  that  in  the  shafts — compact 
bone — only  in  its  arrangement  and  in  its  amount. 
Bone  is  not  subject  itself  to  inflammation,  or  directly 
to  disease.  The  changes  in  it  simply  reflect  the  pro- 
cesses in  its  contained  marrow.  The  trabecular  be- 
come thicker  and  more  numerous  from  the  action  of 
-mall  round  cells  called  osteoblasts,  that  may  be  seen 
under  the  microscope  lining  their  surface — produc- 
tive osteitis.  The  bone  atrophies  by  the  action  of 
osteoclasts,  giant  cells,  which  lie  in  small  excavations 
in  the  trabecular — Howship's  lacuna'.  This  form  of 
absorption  of  the  bone  is  known  as  rarefying  osteitis 
or  rarefaction.  Again,  the  bone  may  atrophy  by 
the  absorption  of  lime  salts. 

The  articular  cartilage,  like  the  bone,  is  a  connec- 
tive tissue  structure,  and  like  the  bone  again,  has  no 
blood-vessels,  but  draws  its  nutrition  from  the  sub- 
jacent bone  marrow,  and,  to  a  lesser  extent,  from  the 
synovia,  with  which  it  is  continuous  at  its  periphery. 
The  transition  from  the  structure  of  the  cartilage  to 
that  of  the  synovia  is  a  gradual  one,  and  immobiliza- 
tion causes  an  encroachment  of  the  latter  on  the 
former.  When  motion  is  resumed  in  the  joint  the 
cartilage    again    pushes    out    its    borders.      Lack  of 

669 


Arthritis,  Chronic 


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motion  is  said  to  be  the  cause  of  the  fibrillation  one 
often  sees  in  the  cartilage  of  diseased  joints.  Possi- 
bly this  fibrillation  may  also  be  caused  by  the  inter- 
ference with  the  nutrition  of  the  cartilage  by  disease 
in  the  subjacent  marrow. 

A  proliferation  of  the  bone  marrow  causes  an  atro- 
phy of  the  cartilage,  and  sometimes  an  erosion,  but 
the  cartilage  is  never  attacked  by  diseases  from  the 
joint  side.  An  exudate  in  the  joint  is  without  effect, 
on  the  structure  of  the  cartilage.  The  precipitation 
of  "layers  of  fibrin,"  if  it  exists,  is  not  of  great 
importance. 

The  synovia,  a  connective  tissue  structure,  lines 
the  joint  except  that  part  of  it  formed  by  the  articular 
cartilage.  It  is  a  delicate  membrane  consisting  of  a 
single  layer  of  cells,  and  produces  the  fluid  which 
lubricates  the  joint.  Its  reduplications,  folds  and 
villi,  are  said  to  be  in  direct  proportion  to  the  amount 
of  motion  required  of  the  joint.  In  inflammations 
the  synovia  usually 
proliferates  and  be- 
comes thickened, 
spreading  out  over 
the  cartilage,  and 
partially  hiding  it 
but  seldom  if  ever, 
becoming  attached 
to  it.  As  the  mem- 
brane proliferates, 
it  encroaches  on  the 
substance  of  the 
cartilage  at  its  per- 
iphery, and  often 
causes  an  erosion  of 
it,  but  it  is  probably 
true  that  no  amount 
of  proliferation  or 
disease  in  the  syno- 
via avails  to  dam- 
age the  cartilage 
from  its  joint  sur- 
face. There  is  a  sort 
of  reciprocal  rela- 
tion between  the 
synovia  and  the 
cartilage  where  they 
meet  at  the  circum- 
ference of  the  latter: 
as  one  advances  the 
other  recedes.  Hy- 
pertrophy of  the 
one  is  followed  by 
atrophy  of  the  other 
and  vice  versa. 

The  ligament  con- 
sists of  bundles  of 
fibrous  tissue,  and 
is  continuous  with 
the  superficial  layer  of  the  periosteum.  The  deep  or 
cellular  layer  of  the  periosteum,  on  the  contrary,  par- 
takes more  of  the  nature  of  the  subjacent  bone  marrow 
and  seems  to  be  affected  by  the  same  diseases. 

In  the  study  of  joint  diseases  the  bone  and  cartilage 
have  hitherto  received  most  attention,  but  with 
confusing  results.  It  is  probable  that  these  two  tissues 
play  a  passive  role  in  all  joint  diseases.  They  form 
the  '"stroma"  of  the  joint,  so  to  speak.  For  a  better 
understanding  of  joint  disease  we  turn  to  the  active 
tissues — the  "parenchyma" — and  these  the  synovia 
and  the  lymphoid  marrow  constitute.  If  we  focus 
our  attention  on  these  two  tissues  we  can  compre- 
hend the  changes  in  the  others,  and  upon  the  changes 
in  these  two  we  base  our  classification,  dividing  all 
chronic  joint  diseases  into  two  main  types: 

Type  I.  Cases  characterized  by  a  proliferation  of 
th^  synovia  or  of  the  lymphoid  marrow,  or  of  both, 
with  a  resulting  atrophy  of  bone  and  cartilage. 

Type  II.  Cases  characterized  by  an  inflammation 

670 


Fig.  411. — Bone  Tuberculosis.  Note  the  two  isolated  tubercles  (n),  surrounded  by 
apparently  healthy  marrow.  They  are  merely  a  part  of  an  extensive  disease  in 
the  bone.  This  photomicrograph  shows  well  the  futility  of  attempting  to  eradi- 
cate the  disease  with  a  curette.  The  ordinary  bone  curette,  magnified  propor- 
tionally, would  be  about  as  large  as  a  shovel. 


and  degeneration  of  the  marrow  and  synovia,  with 
a  resulting  hypertrophy  of  bone  and  cartilage. 

Under  the  first  heading  we  place  tuberculosis 
the  'various  forms  of  chronic  synovitis  of  obscure 
origin,  intermittent  hydrops  (probably),  syphilitic 
synovitis,  Still's  disease,  and  that  large  group  of 
cases  known  by  various  names  by  different  writers— 
the  atrophic  arthritis  of  Goldthwait,  the  proliferate  e 
type  of  Nichols  and  Richardson,  the  rheumai 
arthritis  of  the  English  writers,  etc. 

The  second  group  includes  those  cases  variously 
known  under  the  terms  osteoarthritis,  hypertropl 
form  (Goldthwait),  degenerative  form  (Nichols  and 
Richardson),  etc.  In  this  group  would  be  placed 
Heberden's  nodes,  also  morbus  coxa?  senilis,  and 
probably  Charcot's  joint. 

Type  I.  Tuberculosis.  Etiology. — The  disease  is 
caused  by  the  tubercle  bacillus,  which  is  brought  to 

the  joint  ale 
invariably  in 
blood  stream,  ac- 
cording to  our 
present  knowledge. 
Autopsies  show  in 
the  great  majority 
of  cases  some  otli  r 
tuberculous  foi 
in  the  body.  En- 
vironment and 
heredity  play  the 
same  rule  here  as  in 
tuberculosis  of 
other  organ-. 
Trauma  is  decidedly 
subsidiary  as  a 
cause.  It  may  be 
responsible  to  a  cer- 
tain degree  in  an 
occasional  case  of 
synovial  origin,  but 
even  here  its  action 
is  probably  that  of 
lighting  up  a  latent 
disease.  The 
trauma  is  a  strain 
or  a  wrench.  Frac- 
tures and  disloca- 
tions are  not  fol- 
lowed by  tubercu- 
losis. Anon-tuber- 
culous inflamma- 
tion does  not  "run  [ 
into"  a  tubercu- 
lous one.  The  dis- 
ease is  much  more 
frequent  in  child- 
hood than  in  adult 
life.  The  reason  for  this  we  shall  presently  see.  The 
two  sexes  are  about  equally  afflicted.  Roughly  the 
joints  may  be  said  to  be  affected  in  proportion  to 
their  size.  The  sacroiliac  joint  forms  an  exception  to 
this;  disease  of  this  joint  is  rare.  Various  observers 
differ  in  their  estimate  of  frequency  of  involvem 
of  the  various  joints,  but  following  is  the  appoximate 
order:  Spine,  hip,  knee,  ankle  and  tarsus,  \vri>t, 
shoulder,  elbow,  fingers.  Other  joints  are  rarely 
involved. 

The  question  as  to  the  relative  number  of  cases 
caused  by  the  bovine  and  by  the  human  type  of 
tubercle  bacillus  is  not  yet  definitely  settled.  Some 
writers  maintain  that  the  bovine  type  is  responsible 
for  the  great  majority,  others  deny  this. 

Pathology. — The  primary  focus  is  always  locate.] 
in  the  synovia  or  in  the  lymphoid  marrow,  and  at  no 
time  are  any  other  tissues  directly  involved,  so  long 
as  the  infection  is  a  simple  unmixed  one.     The  d 
layer  of  the  periosteum  forms  an  exception  to  this 


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Arthritis,  i  In. ,i,l. 


In  all  bone  diseases  this  layer  seems  to 
lake  of  the  nature  of  the  subjacent  mar- 
aud to  !"•  vulnerable  to  the  same  dis- 
When  we  speak  of  the  marrow  here- 


rv, 


i   es. 

jjer   this  layer  of  the  periosteum  is  to  be 

i  luilecl.     The  disease  may  remain  indefi- 

elj  in  its  original  seat,  or  it  may  spread 

I  ,,i' the  synovia  to  the  marrow  or  from  the 

to  the  synovia.     .Many  authorities 

,  :,,,   thai    the   primary  affection  is  often 

by   a   tuberculous   plus   in   an   end 

This  may  be  so  in  some  cases,  but 

it  is  rare. 

infection  here,  as  in  most  organs  in 
is    by   a   bacillus  or  by  several 
I   illi  that  are  thrown  out  from  the  blood 
earn.     This  brings  us  to  the  vexed  ques- 
.  by  tuberculosis  occurs  in  the  region 
lints  and  not  in  the  shafts  of  the  long 
les.    Tuberculosis  is  essentially  a  disease 
ymphoid  tissue  (endothelial  and  epithelial 
also)    and  ill   the  region  of  the  joints 
two   lymphoid   tissues,   the  synovia 
red  or  lymphoid  marrow.     When 
30  two  tissues  disappear  from  the  joint 
el  a  bony  ankylosis,  spontaneous  or  oper- 
jve,     the    disease    disappears,    provided 
(vays  there  has  been  no  secondary  infec- 
|  n.     If  a  secondary  infection  be  added,  the 
:  'I'bid  process  may  attack  other  tissues  pre- 
msly   invulnerable.     This   is   why    tuber- 
affects    children    more    often   than 
:  ults — their  bones  contain  more  red  mar- 
a.     The  synovial   form   is  comparatively 


H2. — Bone  Tuberculosis,  Showing  the  Spread  of  the  Tubcr- 
'rocess  under  the  Periosteum  and  Cartilage;  Specimen  from  the 

xternal  Condyle  in  a  Twelve-year-old  Child.  The  joint  is  not  yet 
I;    X  8   diameters      A,  Articular  cartilage;    B,  epiphysis;  C, 

)iphyseal  line;  D,  periosteum;  E,  area  of  tuberculosis. 


Fig.  413. — Tuberculosis  of  Boue  Marrow  at  Margin  of  the  Articular  Cartilage. 


rare  in  children,  but  much  more  frequent  in  adults, 
but  again  in  infants,  whose  bone  ends  are  com- 
posed mostly  of  cartilage  (immune  to  tuberculosis) 
Rovsing  declares  that  the  disease  is  always  synovial. 
The  shafts  of  children's  bones  contain  red  marrow. 
Various  observers  have  described  primary  tubercu- 
losis of  their  long  bones.  It  will  simplify  our  com- 
prehension of  tuberculosis  of  the  bones  if  we  regard 
it,  not  as  an  osteitis  but  as  a  myelitis.  Tuberculosis 
exists  in  bone  but  not  of  it. 

Let  us  briefly'  trace  the  disease  from  its  start, 
taking  up  first  the  cases  with  a  bony  focus,  and  then 
those  with  a  synovial. 

The  tubercle  bacilli  in  the  marrow  cause  a  certain 
reaction  of  the  tissues,  which  results  in  the  formation 
of  the  characteristic  tubercle,  with  its  tendency  to 
break  down  at  the  center  and  to  spread  at  the 
periphery.  On  the  other  hand,  nature  strives  to 
wall  off  the  disease  by  the  production  of  fibrous 
tissue  and  by  the  strengthening  of  the  bone  about 
the  tuberculous  area,  and  according  as  one  process 
or  the  other  is  more  active,  the  disease  tends  to 
spread  or  to  be  circumscribed.  New  tubercles  form 
in  the  marrow,  spreading  in  all  directions,  and 
coalescing.  Away  from  the  joint  the  disease  may 
extend  as  far  as  the  lymphoid  marrow  extends,  out- 
ward to  the  periosteum,  and  toward  the  joint,  to 
the  cartilage.  When  the  tuberculous  granulations 
reach  the  periosteum,  they  are  arrested,  and  must 
turn  aside  to  follow  along  underneath  it,  in  its  deep 
layer.  In  this  ray  they  may  reach  the  joint  and 
break  into  it.  Very  rarely  they  break  through  the 
periosteum,  and  never  reach  the  joint.  When  the 
tuberculous  granulations  make  their  way  to  the 
cartilage,  as  they  usually  do,  they  interfere  with  its 
nutrition.  The  cartilage  degenerates,  either  in  a 
small  spot,  or,  if  the  spread  of  the  granulations 
under  it  has  been  rapid,  in  a  wide  area.  This 
degeneration  of  the  cartilage  permits  the  disease 
to  reach  the  joint,  but  a  normal  cartilage  is  a  bar 
to  the  disease. 

In  children  the  march  of  the  granulations 
is  arrested,  for  a  time  at  least,  by  the  epi- 
physeal    cartilage.        The     primary      focus      may 


C71 


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be  located  on  either  side  of  this  cartilage.  Stiles  of 
Edinburgh  maintains  that  it  is  always  on  the  "shaft 
side,"  in  what  he  aptly  terms  the  metaphysial  We 
see,  then,  that  the  joint  may  be  involved  either  at 
the  periphery  of  the  articular  cartilage  or  through  an 
opening  in  the  cartilage  itself.     When  the  tuberculous 


Fig.  414. — Lifting  off  of  Cartilage.  Disease  of  subjacent  bone  marrow.  The 
cartilage  near  the  joint  surface  has  undergone  fibrillation.  This  is  probably 
what  has  been  mistaken  for  fibrin. 

granulations  have  reached  the  joint,  they  infect  the 
synovia,  and  now,  instead  of  a  simple  tuberculous 
myelitis,  we  have  a  tuberculous  joint.  Previous  to 
the  irruption,  the  joint  may  have  been  the  seat  of  a 
serous  exudate. 

The  next  step  is  usually  the  involvement  of  the 
other  bone  of  the  joint,  and  the  attack  must  be  made 
at  the  periphery  of  the  cartilage  where  it  joins  the 
synovia,  for,  as  normal  cartilage  is  a  barrier  to  the 
disease,  and  as  the  cartilage  of  the  other  bone  is  until 
now  normal,  the  disease  must  make  its  way  into  the 
bone  where  it  is  not  protected  by  cartilage.  When 
the  tuberculous  granulations  have  made  their  way 
into  the  other  bone,  the  morbid  process  is  repeated 
in  it. 

The  granulations  in  the  marrow  interfere  with  the 
nutrition  of  the  bone  trabecule  and  kill  them  as  they 
do  the  cartilage.  Sometimes  one  may  see  evidences 
of  a  productive  osteitis  in  the  neighborhood  of  the 
disease,  but  the  essential  process  is  a  rarefaction,  and 
an  "eating  away."  If  the  spread  be  rapid,  the  bone 
may  be  killed  in  large  pieces  with  the  formation  of 
sequestra,  if  slow,  then  in  small  pieces — bone  sand. 

The  cartilage,  as  it  degenerates,  becomes  fibrillated. 
Under  the  microscope  the  tuberculous  granulations 
can  be  seen  pushing  their  way  up  through  it.  A 
quite  characteristic  picture  is  that  of  a  thin  layer  of 
granulations  pushing  their  way  along  immediately 
under  the  cartilage,  but,  in  the  early  stages,  showing 
no  tubercles.  We  have  never  been  able  to  identify 
the  "layers  of  fibrin"  described  by  some  authors  as 
precipitated  en  the  surface  of  the  cartilage,  and  doubt 
i  heir  existence. 

The  synovia  when  attacked  becomes  thickened 
and    is  often  thrown  into  folds.     It  tends  to  spread 

672 


out  over  the  cartilage  and  to  hide  it,  especially  at  tin 
margins.     It  encroaches  on  the  cartilage,  but  prob 
ably  does  not  often  become    adherent    to   it.     Tin 
characteristic    change    in    the    synovia    is   a   villoui 
hypertrophy,    seen    by    the    naked    eye,    and    ven 
beautifully   under   the   microscope.     Instead  of  thi 
membrane  consisting  of  a  thin  delicate  lavei 
of   cells,    hardly    distinguishable   under  "thi 
microscope  from  the  fibrous  connective  tis^n. 
beneath  it,  it  attains  an  appreciable  thick 
ness,  perhaps  up  to  a  quarter  of  an  inch.  lik. 
moss   on   a  rock.     In  the  substance  of  thi 
membrane  the  tubercles  may  be  seen.  <li- 
or  coalescing.     Often  they  an-  encapsulate! 
to  a  greater  or  less  extent  by  fibrous  tissui 
and  a  fair  idea  of  the  course  of  the  disi 
may  often  be  had  by  a  microscopical  exaini 
nation  of  the  synovia.     Slow,  chronic  case: 
show  an  abundance  of  fibrous  tissue  and  :i 
definite  encapsulation  of  the  tubercles.     Tin 
converts  the  membrane  into  a  mass  of  fibrous 
tissue,  forming  adhesions — fibrous  ankylosi 
Rapid,  acute  cases  show  little  tendency  t( 
encapsulation.     These  are  the  cases  usually 
attended    by    abscess    formation.      Chei 
tubercles    may  be  seen  by   the   naked  eyi 
studding  the  surface  of  the  synovia,  or  thej 
may  not  be  present.     The  membrane  ma; 
present  an  appearance  which  permits  an  im- 
mediate diagnosis  of  tuberculosis  on  opei 
the  joint,  or  it  may  not  be  distinguishable 
from   the  inflamed  synovia  of  other  arthri- 
tides.      Sometimes   the   synovia   may  show 
polypoid  growths. 

Cases   with   Synovial   Origin. — The  initial 
tubercle  is  formed  in    the  substance  of  the 
membrane   itself.     The  disease  may  remain 
more    or    less    localized   or  it   may    spread 
through  the  entire  membrane.     The  tuber 
culous   granulations   may    make    their  waj 
into  the  marrow  of  either  articulating  bone 
at    the   periphery  of    the   cartilage,   and  in 
many  cases  of  long   standing   it  is  impossible  from 
the  examination  of  the  specimen  to  tell  where  the  dis- 
ease started.     After  the  marrow  has  become  infected 
the  process  is  the  same  as  in  the  primary  marrow  type. 

Cold,  or  Tuberculous, 
Abscesses . — At  any 
time  in  the  course  of  a 
joint  tuberculosis 
serum  may  be  added 
to  the  broken  down 
and  caseous  tissue,  and 
a  cold  abscess  may  re- 
sult. This  abscess, 
sterile  except  for  the 
presence  of  a  few- 
tubercle  bacilli,  con- 
tains shreds  and  floc- 
culi  of  necrotic  tissue 
and  sometimes  bone 
sand.  Its  fluid  con- 
tents may  be  thin  and 
watery,  or  thick.  It 
may  be  in  the  bone 
itself  or  in  the  joint. 
It  has  a  tendency  to 
break  through  the 
joint  capsule  and  to 
s  vk  the  surface  in  the 
line  of  least  resistance. 
It  may  at  any  time  be- 
come secondarily  infected  by  pus  germs,  and  then  it- 
contents  will  resemble  pus  and  the  abscess  will  .-ln>« 
acute  inflammation.  Again,  at  any  time  before 
secondary  infection  takes  place,  the  contents  may  be 
absorbed  and  the  abscess  may  spontaneously  disap- 


Fig.  415. — Whin-  Swelling;  Small 
Focus  in  Upper  Epiphyseal  Line  of 
Tibia.  Synovitis  of  joint,  but  no 
tuberculous  process  aparl  from  the 
focus  as  noted;  a,  epiphysis;  >>, 
primary  focus;  c,  shaft.      (Nichols.) 


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Arthritis,  Chronic 


,.ar.  The  walls  of  an  uninfected  tuberculous  abscess 
,-,'•  composed  of  the  necrotic  tissue  of  the  structure  in 
hich  it  lies.  The  walls  of  an  infected  abscess  are 
ijckened,  porky,  suppurating,  and  contain  tubercles. 
fter  an  abscess  has  opened  spontaneously  or 
as  been  opened  by  the  knife,  it  almost  invaria- 
K  becomes  secondarily  infected. 

.  ,dies. — These  are  small,  hard,  slippery, 

nooth,  shiny  bodies  resembling  melon  seeds, 

uiue-    found    in    tuberculous    joints    (and 

mi  sheaths),  especially  in  the  synovial  forms 

f  relatively  benign  course.     Their    origin    has 

disputed.     In  one  joint,  evidently  diseased 

I  years  before,  I  found  a  collection  of  them 

acked  in  a  capsule,  like  the  seeds  in  a  pome- 

ranate,  and  from  study  of  this  unique  specimen, 

am  inclined  to  regard  rice  bodies  as  the  result 

urative  process  of  nature  which  walls  off 

..m lenses  the  tuberculous  granulations. 

— As  has  been  said,  nature  attempts  to 

ure  a  tuberculous  joint  by  walling  off  the  gran- 

lations  with  fibrous  tissue,  and  in  the  bone  by 

ing  the  bone  trabecules  and  by  the  forma- 

new  trabecule.     This  process  often  goes 

and  in  hand  with  the  extension  of  the  disease. 

i-  therefore  inexpedient  to  attempt  the  divi- 

m   of  the  disease  into  periods  of  invasion  and 

The  damage  often  is  spreading  in  one 

if   the  joint,  and  is  undergoing  repair  in 

tiother  part.     It  is  seen  also  that  whereas  rare- 

iriiiu,  is  the  characteristic  change  in  tubercu- 

ius  bone,  the  process  of  repair  will  cause  areas 

tdi  nsation  of  bone. 

In  children  complete  cure  is  probably  possible 

ith   good    function.      Fibrous    ankylosis,    or, 

arely,  bony  ankylosis,    may  be  the  outcome. 

(.my  ankylosis  only  occurs  after  a  secondary 

ifection,  or  after  operation.     In  adults  cure  without 

radical    operation,    except    perhaps   in   the    mild 

ynovial    forms,     never    takes    place.      Function    is 

badly  damaged  in  adults,  and  bony  ankylosis 

ever  occurs,  except  after  operation. 


tilled  with  necrotic  material,  especially  directly 
beneath  the  cartilage.  It  may  cut  easily  with  a 
knife  and  float,  in  water,  or  it  may  be  denser  than 
normal.      Drops  of  fat  may  follow  the  saw  on  section — 


Fia.  416.- 


-Fibrillation  of  Cartilage;  Granulation  Tissue  Pushing  its 
Way  Through. 


The  net  result,  of  a  tuberculosis  may  be  summed 
up  as  follows:  The  bone  contains  grayish  or  yellowish 
ireas  surrounded  by  hyperemic  zones.  It  has  a 
worm-eaten  appearance,  and  often  presents  cavities 

Vol.  I.— 43 


Fig.  417. — Entire  Thickness  of  Tuberculous  Synovia — 40  mm.  objective. 


fatty  osteomalacia.  The  cavities  may  contain 
sequestra;  abscesses  may  be  found  in  the  joint  or 
near  it.  The  cartilage  is  degenerated  and  eroded. 
In  bone  cases  the  erosion  is  often  located  near  the 
center  of  the  cartilage.  In  fairly  early  synovial 
cases,  the  erosion  may  be  mostly  at  the  periphery. 
On  the  other  hand,  when  a  badly  diseased  tuber- 
culous joint  (synovial  or  bony)  is  opened  for 
inspection  the  cartilage  may  appear  practically 
normal.  The  joint  cavity  may  be  the  seat  of  an 
abscess  or  may  contain  one  of  several  kinds  of 
fluid,  or  it  may  have  practically  disappeared, 
leaving  little  else  than  a  mass  of  fibrous  adhesions 
binding  the  ends  of  the  bones  together.  The 
synovia  may  be  thickened  and  succulent,  or 
fibrous  and  dense.  It  may  present  villous  hyper- 
trophy or  not.  Cheesy  tubercles  may  be  evident 
to  the  naked  eye  or  they  may  not  be  evident. 

The  secondary  effects  of  the  morbid  process  in 
the  joint  upon  the  rest  of  the  limb  are  marked. 
Although  a  slight  primary  lengthening  may  be 
perceived  by  careful  measurement  in  a  growing 
child  (due  to  the  stimulation  of  growth  by  the 
irritation  near  the  epiphyseal  line)  this  soon  gives 
place  to  a  shortening.  All  the  tissues  of  the 
affected  limb  are  atrophied  and  ill-nourished. 

Symptoms  and  Physical  Signs. — A  thorough 
knowdedge  of  the  morbid  process  in  joints 
enables  one  to  foretell  with  a  fair  amount  of 
accuracy  what  the  symptoms  and  physical  signs 
will  be.  The  inflammatory  process  in  and  about 
the  joint  causes  pain.  Nature  attempts  to  place 
the  joint  at  rest  by  tightening  up  the  muscles — 
muscular  spasm.  The  inflammatory  products, 
the  pain  and  the  muscular  spasm  cause  limitation 
of  motion  and  often  a  fixed  position  in  the  most 
comfortable  attitude  of  the  joint — usually  semi- 
flexion. From  these  factors  result  disturbance  of  func- 
tion, and  muscular  atrophy.  If  the  joint  be  superficial, 
change  of  contour,  sensitiveness  to  pressure,  and  in- 
creased temperature  may  be  perceived.      If  fluid  be 


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present  in  the  joint  it  can  be  detected  by  palpation, 
abscess  formation  also.  Constitutional  involvement 
and  secondary  infection  will  give  their 
peculiar  signs.  Amyloid  degeneration  of  the 
viscera  sometimes  follows  prolonged  second- 
ary infection.  Deformity  is  the  sum  of  the 
muscular  spasm,  the  inflammatory  products, 
the  muscular  atrophy,  and  the  change  in 
contour. 

Pain  is  almost  invariably  present  in  some 
degree,  and  varies  from  a  slight  pain  upon 
use  to  the  most  agonizing  paroxysms.  It 
is  greater  in  the  bony  than  in  the  synovial 
type,  and  is  usually  worse  during  the  forma- 
tion of  an  abscess,  while  the  contents  are 
under  tension.  The  pain  is  often  peculiar 
during  the  earlier  stages  of  the  disease,  by 
reason  of  its  presence  in  the  morning  when 
the  joint  is  first  being  used,  wearing  away 
during  the  day.  Again,  the  pain  may  come 
on  during  the  night  when  the  muscular 
spasm  relaxes,  waking  the  patient  up,  often 
with  a  cry — the  notorious  "night  cry"  of 
tuberculous  joint  disease.  The  pain  may 
be  felt  in  the  joint  itself  or  at  a  point  some 
distance  off,  whose  nerve  supply  is  the  same 
as  that  of  the  joint — referred  pain.  Thus, 
in  hip-joint  disease  the  patient  for  a  long 
time  may  refer  his  sensation  to  the  knee, 
or,  in  disease  of  the  spine,  to  the  lower  ex- 
tremities. 

Muscular  spasm  is  an  early  physical  sign 
and  a  most  important  one  in  the  diagnosis. 
It  is  greater  in  the  bony  forms  of  the  disease 
than  in  the  synovial,  and  is  to  be  viewed  as 
a  conservative  process  of  nature  — an  at- 
tempt to  put  the  joint  at  rest.  It  is  well 
brought  out  by  attempting  to  put  the  joint  through 
its  arc  of  motion.  All  muscles  passing  over  the 
joint  take  part  in  the  .spasm. 


ankylosis,  and  is  wont  to  persist  even  after  the  dis 
ease  is  cured.     If  due  to  muscular  spasm  it  disappear; 


Fig.  418. — Tuberculous  Synovia,  Showing  Well-marked  Effort  at  Encapsula- 
tion of  the  Tubercles — Discrete  Tubercles. 


Limitation  of  motion  is  also  an  early  sign,  varies 
from  a  slight  limitation  at  the  extremes,  to  a  complete 


Fig.  419. — Synovial  Tuberculosis,  with  Little  Tendency  to  Encapsulation. 


on  the  administration  of  an  anesthetic,  but  not  il 

due  to  inflammatory  products. 

The  change  in  attitude  is  more  or  less  complex  ii 
its  causation.  It  is  partly  due  to  thi 
mechanical  effects  of  the  inflammatory 
products  and  partly  due  to  the  muscuiai 
spasm.  The  most  logical  explanation  ol 
the  muscular  factor  has  been  set  forth  by 
Mark  Jansen.4  Jansen  reasons  that  th< 
muscles  that  pass  over  the  diseased  join' 
alone  are  those  which  often  give  it  it- 
early  attitude.  These  soon  atrophy,  and 
then  the  attitude  is  determined  by  the 
polyarticular  muscles. 

Disturbance  of  function  of  course  mani- 
fests itself  in  various  ways.  If  the  upper  _ 
extremity  be  affected  the  patient  will  be 
awkward  in  its  use,  and  will  use  the  other 
vicariously;  if  the  lower  extremity,  he  will 
limp.  Very  young  children  may  refuse  to 
use  the  diseased  joint  at  all. 

Muscular  atrophy  of  a  certain  degree 
would  naturally  be  expected  in  a  limb 
which  is  put  more  or  less  at  rest  from  any 
cause,  but  the  degree  of  muscular  atrophy 
which  accompanies  tuberculous  joint  dis- 
ease, especially  the  bony  type,  is  greater 
than  that  of  any  other,  and  has  never  been 
explained  satisfactorily.  It  is  so  charac- 
teristic a  sign  of  this  disease  that  its  pres- 
ence should  always  be  sought  carefully,  by 
comparing  the  actual  circumference  of  the 
limb  above  and  below  the  joint  with  that  of 
the  opposite  limb.  A  tape  measure  is  re- 
quisite for  this.  The  eye  is  not  reliable 
enough.  The  difference  in  the  circumfer- 
ence of  the  two  limbs  may  amount  to  two 
or  three  inches.  The  bones  of  the  affected 
limb    after   a   while   lag    behind    in  their 

growth  and  are  not  only  shorter  than  on  the  normal 

side,  but  atrophied  as  well. 


674 


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Arthritis,  (  lirnnlc 


Change    of  contour   will   usually   be  easily   dc- 

i,,l  in  the  superficial  joints.  The  normal 
mcavitii's  will  have  disappeared,  and   .swelling 

,,ften  present.  Of  ten  the  bones  look  enlarged, 
ii  this  enlargement  is  only  apparent,  and  is  due 
,  the  atrophy  above  and  below  the  joint,  and.  in 
Id  oases  especially,  to  the  shrinking  that  ensues 
,  the  contraction  of  the  new  fibrous  tissue. 
welling  Of  some  degree  is  almost  always  present 

the  early  stages  except  in  the  shoulder.      In 

ie  limbs  the  swelling  is  often  distinctly  fusiform. 

aess  to  pressure  and  increased  tempi  ra- 

often  significant.     The  sensitiveness  may 

e  localized  or  it  may  be  present  all  about  the 

Fluid   is    often    present  but  not  always.     A 

"  infiltration  is  more  frequent.     Abscesses 

, 'bin'  the  joint  and  without  it,  will  give  signs 

f   fluctuation.      The    character  of  fluid  in   the 

lint  cannot  be  told  without  aspiration. 

\    peculiar   appearance   of   some    tuberculous 

lints,  especially  of  the  knee,  has  given  a  name  to 

his  disease — white  swelling.      It  is  frequent   in 

with  a  profuse  proliferation  of  the  synovia. 

lie  so-called  fungous  type.     Swelling  is  marked 

osiform,  the  skin  is  pearly  white,  the  veins 

re  dilated. 

Constitutional    involvement     may     be    due    to 

econdary  infection  with  pus  germs.     Fever  and 

maciation   may   then   be  marked.     Tuberculous 

in  ningitis    is    a    fairly    frequent    complication, 

dly  in  children,  and  is  invariably  fatal.     Pulmo- 
iary  tuberculosis  is  frequent  in  adults. 

Poncet   describes  a  disease  which  he  terms  "tuber- 
ulous  rheumatism,"  due  probably  to  the  action  of 


Fig.  420. — Tuberculosis  of  the  Elbow;  synovial  type,  showing  the 
tuberculous  process  making  its  way  through  the  periosteum  into  the 
bone  under  the  margin  of  the  articular  cartilage.  Section  through 
the  corouoid  process ;  X  about  20  diameters. 


Flo.  421. — Portion  of  Wall  of  Tuberculous  Bone  Cavity. 

"attenuated  bacilli,"  but  in  spite  of  great  insistence, 
he  has  not  yet  succeeded  in  establishing  the  truth  of 
his  position. 

Under  the  head  of  symptomatology  it  is  proper  to 
mention  also  the  reaction  that  patients  with  tubercu- 
lous joints  give  to  the  various  tuberculin  tests,  and  to 
describe  the  appearance  of  joints  in  a  Roentgen 
picture. 

The  tuberculin  tests  are  suggestive  but  not  con- 
clusive. Usually  a  patient  with  a  tuberculous  joint 
will  react,  but  not  always.  Again,  patients  with  non- 
tuberculous  joint  lesions  may  give  the  reaction. 

A  skiagram  of  a  tuberculous  joint  may  or  may  not 
be  very  valuable.  If  it  shows  anything  it  will  show 
the  lesions  characteristic  of  cases  in  Type  I  of  the 
chronic  arthritides,  and  these  are:  a  thickening  of 
the  synovia,  a  rarefaction  of  the  bone,  and  a  thin- 
ning of  the  cartilage.  Old  cases  may  show  areas  of 
thickened  bone.  Rarefaction  of  bone  appears  as 
dark  areas  in  the  plate,  thickening  as  light  areas. 
The  cartilage  sometimes  disappears,  but  more  often 
is  present  in  spots,  though  thinned.  The  bone  has  a 
"worm-eaten    appearance. 

The  diagnosis  is  to  be  made  on  the  basis  of  a 
chronic  disease  with  characteristic  symptoms  and 
physical  signs,  and  upon  the  Roentgen  picture. 
These  will  evidence  a  lesion  of  type  I.  If  the  lesion 
be  uniarticular  and  if  the  tuberculin  test  be  positive, 
the  joint  is  almost  certainly  tuberculous,  especially 
if  the  patient  be  a  child.  The  injection  of  some  aspi- 
rated fluid  into  a  guinea-pig  is  a  most  valuable  aid. 

In  the  past  a  tendency  has  existed  to  call  every 
chronic  uniarticular  joint  disease  tuberculous.  This 
is  an  error  and  is  responsible  for  many  therapeutic 
systems.  No  pains  should  be  spared  in  making  a 
diagnosis  that  will  stand  the  test.  A  careful  history 
is  essential,  and  the  patient  should  be  stripped,  if  a 
man  or  a  child.  If  the  patient  be  a  woman,  access  to 
most  regions  of  the  body  is  possible,  and  the  history 
should  bring  out  any  essential  matters  of  disease  in 
the  others. 

Differential  Diagnosis. — From  other  uniarticular 
diseases  in  type  I  joint  tuberculosis  may  be  ex- 
tremely difficult  to  differentiate.  Often  a  number  of 
examinations  may  be  necessary  at  intervals  of  two  or 
three  months.  In  the  meantime  the  joint  should  be 
immobilized  if  the  bone  be  affected.     The  tuberculin 


675 


Arthritis,  Chronic 


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tests  are  suggestive,  the  animal  test  may  be  final,  if 

fluid  can  be  drawn  from  the  joint.     Cold  abscesses  or 

tuberculous   sinuses  will  clear  up  the  case. 

A  piece  of  the  wall  of  an  infected  sinus  will 

show  tubercles  under   the   microscope      In 

the  spine  an  angular  kyphosis  occurring  in 

a  chronic  joint  disease  means  tuberculosis. 

Secondary    infection    never    occurs    in    the 

other  diseases  of  this  type.     In  children  the 

chances  are  heavily  in  favor  of  tuberculosis. 

Often  evidences  of  the  specific  infection  of 

other    disease    may    be    detected,  such   as 

gonorrhea. 

A  uniarticular  arthritis  of  type  II  may 
simulate  tuberculosis,  especially  in  the  hip, 
but  the  obstruction  to  motion  is  mechanical, 
and  not  due  to  muscular  spasm.  The  x-rays 
show  a  production  of  new  bone  and  cartilage. 

Syphilis  is  wont  to  affect  the  shafts.  If 
it  affects  the  ends  of  the  long  bones,  the 
joint  is  seldom  if  ever  involved.  A  form  of 
synovitis  is  occasionally  met  in  tertiary 
syphilis,  which  resembles  synovial  tuber- 
culosis. The  patient  will  show  a  reaction  to 
the  Wassermann  or  Noguchi  tests,  and  will 
quickly  react  to  antisyphilitic  treatment. 

Sarcoma  may  be  located  in  the  bone  end, 
but  does  not  affect  the  joint  itself  or  the 
other  bone.  Fractures  occur  frequently,  and 
the  Roentgen  picture  reveals  a  growth  on 
the  bone,  or  a  destruction  of  large  masses 
of  it,  not  the  "worm-eaten"  appearance  of 
tuberculosis. 

Charcot's  joints  are  practically  painless. 
In  them  disorganization  is  evident  but  not 
inflammation.  Masses  of  loose  bone  and 
cartilage  can  be  felt  in  the  joint,  and  appear 
in  a  skiagram.  Evidences  of  a  cord  lesion 
can  be  easily  made  out,  if  sought. 

Tuberculous  joints  are  often  treated  for  long  pe- 
riods under  a  diagnosis  of  rheumatism,  but  the  diseases 
are  so  different  that  the  mistake  is  inexcusable. 


Acute     infectious    arthritis     (suppurative)    accom 
panies  one  of  the  acute  infectious  diseases,  such  a 


Fro.  422. — Uninfected  Tuberculous  Sinus.  No  tubercles  were  found  in  the 
walla  of  this  sinus,  but  the  joint  from  which  it  came  was  demonstrated  to  be 
tuberculous. 


Fig.  423. — Cross  Section  of  Old  Infected  Tuberculous  Sinus,  Showing 
Tubercles  in  the  Walls.     Contrast  with  Fig.  422. 

scarlet  fever,  pneumonia,  and  typhoid  fever,  or 
follows  it  shortly.  It  occurs  also  without  antecedent 
disease.  The  acute  nature,  the  pyrexia,  great  pain, 
leucocytosis,  and  early  abscess  formation  will  dis- 
tinguish this  disease  from  tuberculosis. 

Gonorrheal  arthritis  is  usually  acute  in 
its  onset,  and  is  accompanied  by  great  pain 
and  swelling.  When  the  disease  has  run 
its  course,  the  joint  is  left  more  or  less 
damaged,  but  w-ithout  active  symptoms. 
The  history  and  the  examination  of  the 
urethra  and  the  urine  are  most  important. 
Scurvy  comes  on  acutely,  especially  in 
bottle-fed  children,  and  is  accompanied  by 
great  pain  and  sensitiveness  of  one  or  i 
more  joints.  The  child  cries  on  being 
moved,  and  may  have  swollen,  bleeding 
gums.  Fruit  juice  internally  causes  a 
rapid  abatement  of  the  disease.  Joint 
tuberculosis  in  children  is  rare  during  the 
first  year,  the  age  when  scurvy  most  often 
occurs. 

Symptoms  of  fracture  in  the  neighbor- 
hood of  a  joint  follow  immediately  on  an 
injury  or  at  a  very  short  interval.  The 
skiagram  is  most  important  in  the  diag- 
nosis. 

Sprain. — Frequently  a  child  is  seen  who 
complains  of  pain  in  a  joint,  and  shows 
marked  limitation  of  motion  in  it.  A 
diagnosis  is  not  always  possible  at  the  firs; 
examination,  but  if  the  joint  be  immobilized 
the  symptoms  disappear,  and  force  the 
conclusion  that  a  sprain  or  a  wrench  was 
at  the  bottom  of  the  trouble. 

Hemarthrosis. — The  patient  will  com- 
plain that  on  one  or  more  occasions  one  or 
more  of  his  limbs  has  been  greatly  swollen, 
without  any  known  cause,  and  usually 
without     much    pain.      An    examination 


67G 


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Arthritis,  (  (ironic 


iows  marked  swelling  and  a  large  amount  of  fluid  in 

ie  joint,  but  no  muscular  atrophy   nor  spasm.     A 

ireful  questioning  will  brine  out   the  fact  that  the 

t  is  a  "bleeder."     In  the  later  stages 

the  absorption   of  the  fluid,  the  joint 

he  seat  of  dense  fibrous  adhesions. 

Hysterical  Joints. — A  marked   dispropor- 

m  is  present  between  the  subjective  and 

ie  objective  symptoms.     A  certain  amount 

dstance  to  motion,  but  no  true  muscu- 

-m  is  present,  and  the  resistance  dis- 

iU  the  patient's  attention  be  diverted. 

jperficial  sensitiveness  is  often  present,  and 

ysterical  stigmata.     No  definite  anatomical 

ran    be  detected.       A  diagnosis  of 

ysterical  joint  should  never  be  made  until 

id  examinations  have  failed  to  reveal 

"  al  pathological  change. 

Prognosis. — In  general  this  may  be  said  to 

e  good  quoad  litam,  but  bad  so  far  as  func- 

concerned.       A    joint    tuberculosis 

ithout    secondary    infection    presents    no 

nmediate  danger  to  life,  but  we  must  not 

irget  that   the  presence  of   the  disease  in 

lie  joint   shows   a    vulnerability   to  tuber- 

and   a  probability  that  some  other 

sists  in  the  body.     The  chief  dangers 

berculous  involvement  of  other  organs 

lungs,  meninges,  etc.)  and  secondary  infec- 

ion.     Abscesses  always  make  the  prognosis 

but  if  they  can  be  kept  from  ruptur- 

hey  rarely  do  much  damage,  except  in 

he  spine. 

Tuberculosis  of  the  lungs  or  of  the  men- 
nges  carries  off  many  patients  even  after 
lealing  of   their   joint   lesion.      Secondary 
nfection  is  always  a  dreaded  complication, 
tid  adds  greatly  to  the  danger.      Amyloid 
{(•generation   is   almost   invariably   fatal.      Tubercu- 
■  sis  of  the  spine  is  more  serious  than  tuberculosis 
>f    the   smaller   joints.     Tuberculosis   of    the    sacro- 
liac  joint  is  usually  fatal.     As  to  function,  this  may 


are  wont  to  recover  with  better  function  than  the 
larger.  In  adults  spontaneous  bony  union  never 
occurs,  and  a  movable  Joint   seldom  if  ever,      fibrous 


Fig.  424. — Rice  Bodies  In  their  Capsule.    40  mm.  objective. 

vary  in  children  from  good  motion  to  complete 
ankylosis,  according  to  the  location  of  the  disease, 
and  the  efficacy  of   treatment.     The  smaller  joints 


Rice  Body.     Zeiss  objective  aa.  ocular  3. 

ankylosis  is  the  rule  with  them.  In  adults  Pott's 
disease  always  has  a  bad  prognosis,  especially  if 
any  destruction  of  bone  has  taken  place. 

Constitutional  Treatment. — We  must  keep  in  mind 
always  that  the  joint  tuberculosis  as  a  rule  is  a 
comparatively  harmless  local  manifestation  of 
a  very  serious  constitutional  disorder,  and  that 
while  we  are  giving  the  joint  its  proper  local 
treatment,  we  must  at  the  same  time  endeavor 
to  treat  the  patient  himself.  We  therefore  insist 
upon  fresh  air  all  the  time,  and  upon  plenty  of 
nourishing  food.  The  patient  should  live  out  of 
doors,  and  sleep  out  of  doors  except  in  the 
bitterest  and  most  inclement  weather.  If  this 
be  impossible,  his  windows  should  be  wide  open 
day  and  night.  Sun  parlors  are  an  abomination. 
The  child  is  better  off  in  a  tenement  than  in  the 
wards  of  the  ordinary  hospital.  The  influence 
of  climate  does  not  seem  as  important  as  in  pul- 
monary tuberculosis.  It  is  doubtful  if  any 
climate  is  specific.  Many  of  the  younger  patients 
do  well  at  the  seashore,  but  possibly  this  is  be- 
cause most  children  thrive  at  the  beach.  I  doubt 
if  the  course  of  the  disease  is  shortened  there. 

Drugs  are  of  little  use  in  the  disease.  Cod- 
liver  oil  is  a  well-tolerated  form  of  fat  for  the 
winter  months.  The  bowels  should  move  regu- 
larly, of  course.  The  mouth  and  teeth  should 
be  kept  in  good  condition.  The  tonsil  is  consid- 
ered to  be  a  frequent  port  of  entry  for  the  tuber- 
cle bacilli.  Therefore  enlarged  tonsils  should  be 
enucleated.  Occasionally  tuberculous  nodules 
will  be  found  in  them,  especially  in  the  medium 
sized,  tough  ones.  Adenoids  also  should  be  re- 
moved. Frequently  these  operations  will  have  a 
favorable  effect  upon  the  cervical  adenitis  often 
present  in  children.  Although  the  statement 
may  sound  heretical,  I  believe  that  radical  opera- 
tions for  cervical  adenitis  in  children  are  rarely  in- 
dicated.     Without  wishing  to  seem  jocular,   I   think 


077 


Arthritis,  Chronic 


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they  are  like  the  attempt  to  kill  a  dog  by  cutting  off 
his  tail. 

Local  Treatment. — If  we  have  properly  digested 
the  morbid  anatomy  of  joint  tuberculosis  we  have 
perceived  two  things;  first,  that  the  entire  patho- 
logical process  may  be  interpreted  as  an  effort  of 
nature  to  deprive  the  joint  of  function,  and  second, 
that  the  uncomplicated  disease  is  strict  ly  localized, 
affecting  but  two  tissues,  namely,  the  synovia  and 
the  lymphoid  marrow,  but  that  when  secondary 
infection  has  been  added  other  tissues  are  involved, 
and  the  danger  is  greatly  increased. 

From  these  facts  we  draw  our  two  main  rules 
of  treatment:  (1)  deprive  the  joint  of  function; 
(2)  avoid  secondary  infection. 

Certain  other  facts  should  stand  out  also.  Cure 
of  tuberculous  joints  in  adults  is  very  rare  under 
conservative  treatment,  if  it  ever  occurs.  The 
best  that  can  possibly  be  attained  in  them  is  a 
stiff  joint  under  any  form  of  treatment.  Radical 
treatment  cures  the  disease  in  a  few  months, 
while  conservative  treatment,  granting  that  it 
ever  cures,  takes  years.  Therefore,  we  say  that 
the  treatment  to  be  pursued  among  adults  is 
almost  invariably  radical,  and  the  object  of  the 
radical  treatment  is  to  destroy  function  in  the 
joint.  The  red  marrow  and  the  synovia  owe  their 
presence  in  the  joint  to  function.  If  function  be 
destroyed  they  disappear,  if  they  disappear  the 
disease  dies  out.  There  can  be  no  joint  tubercu- 
losis where  they  are  not.  The  disease  gets  well 
because  it  has  no  food.  It  is  starved  out,  so  to 
speak.  If  this  destruction  of  the  joint  cannot  be 
done,  then  the  operation  must  be  planned  to  re- 
move every  particle  of  infected  tissue.  We  modify 
this  rule  of  radical  treatment  by  the  statement 
that,  as  the  diagnosis  is  often  uncertain,  a  six 
months  trial  of  conservative  treatment  is  advisable, 
and  that,  if  secondary  infection  is  present,  a  vigorous 
effort  should  be  made  to  overcome  it  before  proceed- 
ing to  operation. 

Among   children    the    case   is   different.     In    their 


children  have  red  marrow  in  their  bone  shafts.  Henet 
to  destroy  the  joint  in  them  is  not  necessarily  to  curt 
the  disease. 

Again,  radical  operations  on  children's  joints,  bj 


Fig.  426. — Section  through  Rice  Body.     Zeiss  objective  C. 

joints  conservative  treatment  often  yields  good 
function,  and  frequently  cures  the  disease.  Radical 
treatment,  even  properly  carried  out,  often  fails  to 
cure,  and  the  reason  of  this  is  that,  unlike  adults, 

678 


Fig.  427.— Old  Calcined  Tubercle  in  Bone. 

interference  with  the  center  of  growth,  cause  a  marked 
lagging  behind  in  development,  and  a  resulting 
deformity  of  great  degree  as  the  child  grows  up. 
The  treatment  of  joint  tuberculosis  in  children, 
therefore,  is  almost  invariably  conservative.  We 
follow  it  in  the  face  of  all  obstacles  until  all  hope  of 
saving  the  child's  limb  is  gone,  or  until  amyloid 
degeneration  begins,  and  then  we  amputate. 

In  adolescents  the  treatment  is  as  in  children, 
until  they  have  attained  their  growth.  Then,  if 
the  disease  is  not  cured,  we  adopt  radical  measures. 
Conservative  Treatment. — The  main  object  of  con- 
servative treatment  is  to  deprive  the  joint  of  func- 
tion, and  the  measures  that  will  most  effectively 
deprive  the  joint  of  function  are  the  measures  we 
adopt.  We  are  forced,  however,  to  compromise. 
Complete  deprivation  of  function  means  rest  in 
bed  with  apparatus  in  addition,  but  the  knowledge 
that  we  are  dealing  with  a  dangerous  constitutional 
disorder  makes  us  eager  to  get  the  patient  up  and 
about  in  order  that  his  nutrition  may  be  maintained 
at  par. 

There  are  two  general  methods  of  carrying  out 
conservative  treatment:  1.  Recumbency,  with  ap- 
propriate apparatus;  2.  Ambulatory  treatment, 
with  apparatus.  The  first  is  an  excellent  routine 
treatment  for  the  disease  in  its  early  stages,  say 
for  the  first  six  months  or  a  year,  especially  in 
children,  for  the  acute  painful  exacerbations,  and 
to  meet  special  indications,  such  as  large  abscesses. 
It  is  not  ordinarily  practicable  for  adults  for  any 
length  of  time. 

Ambulatory  treatment  with  apparatus  is  the  usual 

means   we   adopt  for  most  cases.     In  general  the 

apparatus    comes    under    two    classes;    plaster-of- 

Paris,  and  steel  "braces."     Some  prefer  one,  some 

the  other,  but  plaster  seems  to  be  making  its  way  as 

the  preferred  form  in  this  country.     It  is  cheap,  fits 

accurately,    can    be   changed   and    thrown    away,   is 

obtainable  everywhere,  and  cannot  be  removed  by 

the    patient    without    the    surgeon's    knowledge.     It 


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Arthritis,  Chronlo 


oeds  some  skill  for  its  application,  but  so 

;ll.s   u   brace.       Braces   are   heller   to   meet 

.tain  indications.     They  are  much  prefer- 

blein  the  presence  of  sinuses.      \o  patient 

,ul,l  ei  er  be    en(  to  a  brace-maker  with 
istructions  to  gel  a  brace.      The  surgeon 
peoify  the  kind  of  brace  he  wislies, 
ml  must  oversee  the  application.     If  un- 
to do  this  lie  should  use   plaster,     if 
knows  what  he  wants,  a.  blacksmith  and 
essmaker  can  carry  out  his  instruc- 
ts.    The  task  of  measuring  for  a  brace 
implified  by  taking  a  ca>t  of  the  member 
ien  by  having  the  brace  made  over 
lis. 

\n  brace  nor  plaster  dressing  should  be 
upon  to  correct  deformity.     The  de- 
Tinity  should  be  corrected  before  the  ap- 
aratus  is  applied. 

iith.r  Methods  of  Conservative  Treatment. 

treatment,     passive      hyperemia 

lungshyperaemie"),  is  based  on  the 

that   venous  stasis  is  hostile  to  the 

[opment  of  tuberculosis.     Its  method 

nation  is  by  an  Esmarch  bandage 

above  the  joint  just  tightly  enough 

.  cause  a  reddening  of  the  part,   and  a 

armth  of  it.     It  must  not  cause  pain  nor 

lake  the  part  cold.     The  bandage  is  ap- 

lied    for  about   two   hours   daily.      This 

i;it  meat    is   designed    especially    for  the 

[bow.  the  wrist,  and  the  ankle  and  tarsus. 

iMy  is  of  use  in  some  cases,  but  too 

inch  should  not  be  expected  of  it.     It  is 

.•r  tor  in  open  eases,  i.e.  those  with  sinuses, 

tian  in  closed  ones.     Klapp  has  devised  a 

odification  of  the  treatment  by  the  use  of 

i    apparatus — glass    chambers    into 

liich   the  member  is  inserted,   and   from 

hich  the  air  is  exhausted.     This  is  sometimes  used 

ir  tuberculosis  of  the  bones  of  the  hands,  especially 

be    lingers,    and  of   the  feet.     Klapp    also    recom- 


Fio.  428. — Old  Encapsulated  Tubercle  in  Bone.  It  lay  directly  under 
urtilage.  Its  site  could  be  told  from  the  joint  side  by  a  dimple  in  the 
artilage.  Note  the  fibrous  capsule,  and  outside  of  this  the  strengthening 
f  the  bone  trabecular.  The  dotted  lines  lead  to  two  small  islands  of 
arulage.  Although  we  possess  no  history  of  the  resected  adult  knee 
rum  which  this  specimen  was  taken,  it  is  evidently  a  case  of  fighting  up 
f  an  old  process. 


Flo.  429. — Old  Encapsulated  Cheesy  Tubercle,  from  Ankle-joint  of  a  Boy 
about  Eighteen  Years  Old.  The  joint  had  been  treated  conservatively  for  a 
number  of  years,  and  was  supposed  to  be  well.  A  resection  was  done  because 
the  joint  had  again  become  painful.  The  ankle  was  found  full  of  fibrous  ad- 
hesions, and  in  a  recess  of  the  joint  this  tubercle  was  discovered  after  a  pro- 
longed search.  The  hospital  laboratory  had  reported  "chronic  arthritis,  no 
tuberculosis." 

mends  his  treatment  by  suction  cups  for  tuberculous 

abscesses. 

Focal  Operations. — These  were  designed  with  the 
idea  of  cutting  down  on  an  early  tuberculous 
bone  focus,  and  of  removing  it  before  it  had  in- 
volved the  joint,  but  our  study  of  the  pathology 
will  teach  us  why  they  are  so  rarely  successful. 
The  focus  is  almost  never  discrete,  but  ramifies 
in  the  marrow,  and  there  is  no  known  way  of 
telling  its  full  extent.  Again,  one  of  the  favorite 
locations  of  the  tuberculous  granulations  is  di- 
rectly beneath  the  articular  cartilage,  and  if  we 
attempt  to  eradicate  them,  we  immediately 
destroy  the  nutrition  of  the  cartilage,  and  give 
the  disease  access  to  the  joint. 

Tuberculin.  Vaccines,  etc. — Much  has  been  ex- 
pected of  this,  but  up  to  date  the  expectations 
have  not  been  fulfilled.  Possibly  the  future  may 
make  us  reverse  our  opinion,  but  for  the  present 
tuberculin  treatment  should  be  pursued  very 
cautiously  at  least.  It  seems  to  have  little  bene- 
ficial effect,  if  any. 

Treatment  by  Injections. — Certain  observers 
have  asserted  that  they  could  influence  the  course 
of  a  joint  tuberculosis  by  the  injection  of  various 
substances  in  and  about  the  joint.  Here  again 
our  knowledge  of  the  morbid  anatomy  teaches 
us  scepticism.  No  substance  injected  into  the 
joint  can  influence  in  any  way  the  disease  in  the 
bone,  while  blindly  to  inject  fluids  into  the 
circumarticular  structures,  with  the  idea  that 
they  will  pick  out  the  diseased  tissues  and  leave 
the  healthy  ones,  seems  irrational.  There  is  no 
known  specific  against  tuberculous  granulations. 
Again,  in  many  tuberculous  joints  there  is  prac- 
tically no  joint  cavity  at  all.  The  joint  is  a  mass 
of  fibrous  adhesions,  and  what  synovial  mem- 
brane is  left  contains  tubercles  deep  in  its  sub- 
stance.   Formalin,  carbolic  acid,  iodine,  iodoform 


679 


Arthritis,  Chronic 


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Fig.  432. — Tuberculous  Knee,  Anteroposterior  View.  Child 
about  ten  years  old,  treated  conservatively  for  about  three  years. 
Discharged  cured  from  Sea  Breeze  Hospital,  with  a  fair  amount 
of  motion. 


Fig.  430. — Tuberculous  Elbow  after  About  Eighteen  Months  of 
Treatment  by  Plaster  of  Paris.  Note  disorganization  of  joint, 
erosion  of  cartilage,  and  areas  of  rarefaction  and  condensation  of 
bone. 


Fig.  431.— Same  Case  as  Fig.  430,  Side  View.  Note  the  atrophy 
of  the  humerus.  Patient  about  twenty-five  years  old.  The 
pictures  of  this  elbow  may  be  said  to  be  more  or  less  typical  of 
joint  tuberculosis. 


Fig.  433. — Tuberculosis  of  the  Knee,  Lateral  View  of  Joint  shown 
in  Fig.  432. 


680 


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Arthritis,  Clirnnfr 


!'[,:.  434.— Tuberculous  Knee  in  Adult.     About  ten  years  dura- 
Mi.     Note   disappearance   of  joint   cartilage   and    the   areas  of 
and  condensation  of  the  bone.     These  were  demon- 
rated     at     operation.     Fatty    osteomalacia    was    present    to    a 
larked  degree. 


Fig.  436. — Bone  Syphilis;  duration  four  or  five  months.  Pain, 
sensitiveness,  etc.,  but  no  involvement  of  joint.  Distinct  history 
of  paternal  syphilis.  This  child  had  shown  other  symptoms  of 
syphilis. 


Fig.  435. — Tuberculous  Knee,  Lateral  View  of  Preceding  Case. 
These  skiagrams  are  more  or  less  typical  of  a  well  advanced  case 
of  long  standing. 


Fig.  437. — Sarcoma  of  Femur;  Operated  on  for  Tuberculosis. 


681 


Arthritis,  Chronic 


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have  all  had  their  vogue.     Whatever  use  they  possess 
is    from    their    irritating  properties.      Possibly   they 


Fig.  438. — Old  Hemarthrosis  of  Knee. 

increase  the  production  of  fibrous  tissue  and  so  help 
to  deprive  the  joint  of  function.  Function  may  be 
abolished  by  much  quicker  means. 

Roentgen  rays  have  their  advocates,  but  as  yet 
they  have  not  proved  their  efficacy. 

The  application  of  any  substance  whatever  to  the 
surface  is  without  effect.  This  includes  heat  and 
cold.  Massage  and  passive  motion  are  distinctly 
contramdicated. 

Treatment  <f  Abscesses.— A  cold  tuberculous  ab- 
scess should  never  be  opened  and  drained.  If  it  be 
treated  in  this  way  it  will  almost  invariably ibecome 
secondarily  infected,  and  will  add  greatly  to  the 
danger  of  the  disease.  If  an  abscess  be  small,  deeply 
located,  of  slow  growth,  and  if  it  cause  no  great  dis- 
turbance, it  should  be  let  alone,  in  the  lively  hope 
of  its  disappearance.  If  it  be  large,  rapidly  growing 
and  near  the  surface,  it  should  be  aspirated  under 
asepsis,  through  a  large  cannula,  repeatedly  if 
necessary.  Some  authorities  inject  the  cavity  with 
various  substances,  iodoform  (in  ether  and  olive  oil 
in  glycerin,  etc.),  bismuth  paste,  etc.,  but  whether  this 
injection  if  ry  has  not  been  decided. 

_  Treatment  of  Sinuses.— These  result  from  the 
infection  of  cold  abscesses  by  pus  germs,  and  are 
often  hard  to  heal.  Beck1  has  recommended  their 
injection  by  a  paste  composed  of  one-third  bismuth 
submtrate  and  two-thirds  vaseline,  heated  in  a  warm 
bath  until  fluid.  Many  abscesses  have  been  healed 
by  this  treatment,  but  a  number  of  fatalities  from 
bismuth  poisoning  has  caused  the  resort  to  other 
pastes  without  the  poisonous  ingredient.6  A  mixture 
of  white  wax,  1  part,  and  vaseline,  8  parts,  makes  a 
good  injection  paste.  The  ingredients  should  be 
mixed  while  boiling.  Pastes  should  not  be  used  in 
tne  presence  of  a  sequestrum,  and  their  efficacy  is 
greater  in  old  than  in  recent  cases. 

Radical  Treatment.— This  may  be  considered  under 
three  heads:  1.  synovectomy  (erasion);  2.  resection: 
3.  amputation. 

Synovectomy  consists  in  opening  the  joint,  dis- 
ing  out  the  diseased  soft  parts,  and  usually  in 
addition  scraping  out  such  tuberculous  foci  in  the 
bone  as  may  be  easily  reached.  It  was  designed  to 
avoid  interference  with  the  epiphyseal  lines  in  chil- 
dren, and  to  avoid  extensive  bone  operations  in  adults 
and  at  one  time  enjoyed  quite  a  vogue.     It  has  fallen 

682 


into   disrepute.     Subsequent   contractures   are  hard 
to  avoid,  and  the  results  of  the  operation  have  not 
met  expectations.     It  i- 
practised  now-a-da\ 

Resection  or  excision  is  the 
man-  operation  in  I 
culous  joints.      Its  sole  object 

lestroy  the  joint  am 
to  cause  a  disappearance  < 
vulnerable     tissues,     i.e.     the 
synovia  and   the  red  marrow 
It    is   quite   unnecessary  ordi- 
narily to  attempt  the  removal 
of  all  the  infected  sv 
marrow.     The  destruction  can 
be  brought  about  in  either  one 
of  two  ways,  by  dislocation  or 
by  bony  ankylosis.    The  former 
ten  done  in  the  hip.     ln 
disease  of  the  carpus  and  tar- 
sion    to   be   of  vabe 
must  remove  every  particle  of 
infected  tissue,  for  ankyl 
operations  are  almo- 
ble  here.     Scraping  and  ; 
ing    tuberculous  joints  should 
never  be  practised.     If  draia; 
be  used  after  an  excision  they 
should      soon     be     rei: 
When  we  attempt  to  provide 
,  ,  by    drainage    for   the  exit   of 

tuberculous  material,  we  actually  provide  for  the  en- 
trance of  pus  germs.     Wire,  nails,  screws,  bone  i 
sutures,  etc.,  may  be  used,  but  are  unnecessary 


Fig.     439— Skiagram    of    Knee,     Resected    About    Two    Yearn 
Previously.     Note  density  of  bone. 

sometimes  are  harmful.  Iodine,  carbolic  acid,  etc., 
should  be  avoided.  Anv  foreign  body  is  an  irritant. 
After  the  excision  the  joint  should   be  immobilized 


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ArthrltK,  Chronic 


plaster  until  bony  union  has  taken  plai  e.  !:■ 
.-  should  not  be  done  in  the  face  of  secondary 
a  if  they  can  possibly  be  postponed.  A  vigor- 
effort  should  be  made  to  check  the  infection  first. 
injection  of  sinuses,  passive  hyperemia,  etc.  The 
eral  health  of  the  patient  often  improves  after  an 
ptic  re~ection. 

.. — This  may   be  said  to  be    the  treat- 
last  resort.      It  is  never  indicate, 1  in  a  patient 
ed"  joint  tuberculosis,   whose  health  is 
1.     Its  main  indication  is  to  remove  a  secondarily 
i  joint  which  resists  milder  methods  of  treat- 
is  undermining  the  patient's  constitution,  and 
ins  his  life.     In  addition  it  is  often  justifiable 
a  closed 
.  rculosis 
e    • 

ondary  in- 
when 

fatient's 
i  t  y  i  s 
ry  low.  In 
e  often 
boi 
;  uniteafter 
simple  re- 
tion. 

TrBERCU- 

pSIS   of   the 

v  dividual 

in'ts. — The 

PINE.  — 

'ott's  dis- 

ise,      Caries 

linalis,  Spon- 

.litis   tuber- 

ilosa,    etc.). 

he  disease 

Tects  mostly 
le  marrow  of 

ie  spongy 
"ne  in  the 
odies  of  the 

e  r  t  e  b  r  ;e. 
ometimes  it 
>  said  to 
iread  along 
nder  the  an- 
trior  liga- 

■  •n  t  s  and 
an.  A 
■  ■structionof 
lie  vertebral 
ody  often  re- 
ti Its,  and  of 
he  interver- 
cbral  discs. 
"he  support 
f   the  super- 

m  p  o  s  e  d 
olumn  is  re- 
noved  and  it 

wings  forward  on  the  articular  process  as  on  a  hinge, 
ansing  a  protrusion  of  the  vertebral  spines  at  the 
evel  of  the  disease — the  so-called  "knuckle,"  or 
cyphosis,  or  humpback,  almost  diagnostic  of  Pott's 
ise.  Sometimes  one  vertebra  is  affected,  some- 
imes  two  or  more.  The  bending  of  the  spine  causes 
til  manner  of  deformities  of  the  chest,  and  displaces 
he  contents  of  the  chest,  and,  to  a  lesser  extent,  of 
he  abdomen.  A  peculiar  facies  often  ensues.  The 
runk  is  shortened  as  a  whole.  The  arches  of  the 
iertebra  are  sometimes  involved,  with  their  articula- 
tors. The  region  most  frequently  attacked  is  the 
iumbothoraeie.  According  to  the  location  of  the  dis- 
it  is  known  as  cervical,  thoracic,  or  lumbar 
Pott's  disease.     The  sacrum  is  seldom  affected  alone. 


Fig.  440. — Tuberculosis  of  the  Seventh  Cervical  Vertebra. 


Abscesses  are  frequent.     They  usually  form  on  the 

rior  aspect  of  the  -pine  and  make  their  wa 

surface  by  the  lines  of  least   resi  d  by 

gravity.     Those  of  the  upper  cervical  region  appear 

in   the  back  of  the  throat,  and  fficulty  in 

ig.     They  may  then  appear  on  the  aid 
the  neck,  or  in  the  !  A.  Schmidt). 

Abscesses  of  the  lower  cervical  region  pass  into  the 
posterior  mediastinum,  follow  the  aorta  downward, 
and  may  appear  in  the  thigh.     Al  tho- 

racic spine  rarely  penetrate  the  pleura,  but  usually 
sink  by  the  side  Of  the  aorta,  and  reach  the  pelvis. 
Later  they  pass  under  Poupart's  ligament  into  the 
thigh,  or  occasionally  through  the  great  sciatic  fora- 

into   the 
glu;> 

Abscesses  of 
the  lumbar 
region  follow 
the  course  of 
the  iliopsoas 
muscle  under 
Poupart's  lig- 
ament. All 
sorts  of  devi- 
ations from 
these  courses 
are  met. 
Sometimes 
the  ab 
disappears 
without 
reaching  the 
surface.  In 
disease  of  the 
vertebral 
arches  the  ab- 
scess usually 
appears  in  the 
back. 

The  spinal 
cord  may  be 
damaged  by 
the  pressure 
of  the  prod- 
ucts of  in- 
flammation in 
the  vertebral 
bodies,  but 
rarely  if  ever 
by  the  pinch- 
ing of  the  cord 
by  the  angu- 
lar deformity. 
The  lumen  of 
the  canal  is 
not  dimin- 
ished. 

A  kyphosis 
once  formed 
is  permanent. 
It  may  be  re- 
duced some- 
what by  persistent  treatment,  but  cannot  be  made 
permanently  to  disappear. 

Symptomatology. — Spasm  of  the  back  muscles  is 
early  and  prominent.  The  attitude  of  the  patient 
is  often  changed,  and  the  normal  contour  of  the  spine 
disappears.  Sometimes  the  kyphosis  appears  early, 
sometimes  late.  The  patient  stoops  awkwardly, 
and  sits  and  stands  stiffly.  Sensitiveness  to  pressure 
is  not  ordinarily  present,  for  the  diseased  portion  of 
the  spine  is  deeply  located.  The  pain  is  occasionally 
felt  in  the  back,  but  more  often,  on  account  of  the 
involvement  of  the  spinal  nerves,  shoots  down  the 
arms,  around  the  trunk  or  down  the  lower  extrem- 
ities, according  to  the  location  of  the  disease.  The 
knee-jerks  are  often  exaggerated,   the  gait  spastic. 


683 


Ahrtritls,  Chronic 


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Fig.  441. — The  Whitman-Bradford  Frame. 


Paralysis  of  the  lower  extremities  (Pott's  paraplegia) 
is  fairly  frequent,  and  the  functions  of  the  bladder 
and  rectum  may  be  compromised,  causing  incontin- 
ence or  retention  of  the  feces  and  of  urine.  Respi- 
ration may  also  be  ab- 
normal; grunting  respi- 
ration or  a  peculiar 
"futile"  cough  may  be 
present.  The  spine  may 
show  a  lateral  curvature. 
Diagnosis. — In  rotary 
lateral  curvature  the  apex 
of  the  curve  is  on  the 
ribs,  not  on  the  spine 
itself.  Pain  is  absent  or 
practically  so,  spasm 
also.  There  is  no  true 
kyphosis  in  this  disease. 
Spinal  fractures  are  often 
followed  by  a  kyphosis, 
but  the  symptoms  follow 
immediately  on  severe 
injury.  Certain  injuries 
of  the  spine  without 
demonstrable  fracture 
are  also  followed  by  a 
slowly  developing 
kyphosis,  and  may  sim- 
ulate Pott's  disease,  but 
the  signs  of  active  dis- 
ease are  absent.  T;/- 
phoid  spine  follows  ty- 
phoid fever,  is  wont  to 
be  very  acute  and  pain- 
ful,  and   very    rarely   is 


Fig.  442. — Ordinary  or  Old-fashio 
jacket  on  the  left  fails  to 


accompanied  by  a  kyphosis.  The  psoas  abscesses  of 
Pott's  disease  may  be  mistaken  for  appendicitis  but 
they  are  less  acute  in  their  course,  and  have  not  the 

684 


symptoms  of  an  inflammatory  lesion. 

Chronic  non-tuberculous  arthritis  is  wont  to  involve 
a  large  segment  of  the  spine,  and  other  joints  of  the 
body.     Masses  of  new  bone  may  often   be   detected 

in  the  skiagram. 

Rickets,  new  growths, 
hip  disease  and  nem 
must  also  be  carefully 
excluded.  "Lumbagi 
and  "sciatica"  are  often 
caused  by  Pott's  disease. 
Progn  osis. — T  his  is 
somewhat  more  grave 
than  in  tuberculosis  of 
other  joints,  especially 
in  adults.  The  length 
of  time  necessary  for  a 
cure  by  conservative 
means  ranges  from  two 
to  about  ten  years. 
Disease  of  the  cervical 
region  runs  a  somewhat 
shorter  course  than  that 
of  the  thoracic  and  lum- 
bar regions,  but  has  an 
added  danger  in  the 
proximity  of  vital  struc- 
tures. Relapses  are  fre- 
quent. Often  the  ap- 
pearance of  an  ali- 
long  after  the  apparent 
cure,  shows  the  activity 
of  the  process. 

Radical     Treatment. — 

Until    very   recently   all 

fruitless,    but    the   work    of 


ned  Jackets.     Observe  how  the 
control  the  deformity. 


radical    treatment   was 

Hibbs7  and  Albee8  in  the  line  of  producing  complete 

bony  ankylosis  promises  a  future  for  it.     Albee  splits 


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Arthritis,  Chronic 


ie  spinous  processes  and  grafts  into  them  a  piece 
bone  removed  from  the  patient's  tibia.  The 
Deration  is  based  on  sound  pathological  principles, 
n,l  should  be  a  success  in  adults,  for  ii  destroys  mo- 
on i"  1 1"'  spine,  and  hence  must  cut  off  the  pabulum 
ir  the  disease. 

rvative    Treatment. — The   best  routine  treat- 
the  firsl  six  months  or  a  year  is  by  recuro 


Flo.  443. — Application  of  the  Calot  Jacket  wiih  Officer's  "Collar"; 
trimming  the  jacket. 

bency  in  a  jacket  or  on  some  rigid  form  of  apparatus, 
■  7.  the  Whit  man- Bradford  frame  or  a  plaster-of- 
I  'aris  bed.  The  Whit  man-  Bradford  frame  is  composed 
of  an  oblong  frame  of  gas-pipe  with  elbows  at  the 
corners.     Over    this    is    stretched    a     canvas    cover 

I  up  the  back.  The  frame  is  bent  backward 
at  the  seat  of  the  disease,  and  the  patient  is  strapped 
to  it  by  means  of  an  "apron''  over  his  chest.     He  is 

rpermitted  to  sit  or  to  stand  for  an  instant  from 
I  lie  time  the  treatment  is  begun  until  it  is  finished. 
The  frame  is  also  suitable  for  cases  with  large  abscesses, 
or  for  those  complicated  by  paraplegia,  and  for  all 
cases  when  the  pain  cannot  be  checked  by  other 
means.  It  finds  its  greatest  usefulness  among  children. 
Ambulatory  treatment  is  useful  during  most  of  the 


di  ease.     Ii   ran   be  carried  ouf    by  plaster  jackets 
or  bv  brace 

Plaster  jackets  arc  of  two  kind-,  thai  devised  by 
Sayre  the  ordinary  jacket  and  thai  by  Calol  \ 
jacket  to  be  of  use  must  extend  well  beyond  the  -eat 

of  disease    in     both    directions    in    order     to    obtain 

proper  leverage,  it  must  l»-  padded  over  i  in-  bony  prom- 
inences, must  be  strong  enough  to    stand  the  -train, 
but     must    not     be      '>   thick   a      to   be    unwieldy.      It 

should  be  applied  over  a  seamless  shirt.     It  may  be 

put   on  while  (he  patient  is  strung  up,  or  while  i,,    i 
prone    or    supine.      The    first     is  the   usual   method. 

Ordinary  plaster  jackets  may  be  supplied  with  a 
''jun  ma  i  '  tu  support  the  head  in  disease  of  the 
cervical   region,  but    this   is  not   a   very  efficacious 

met  ho,  I  ol  I  real  i  ne  1,1       A  "  window"  may  be  cut  in  I  lie 

plaster  over  t  he  abdomen  to  provide  for  the  increa  e 
in  size  after  eating.  A  strip  of  linen  under  the  shirt- 
ing in  front  and  back  adds  to  the  comfort  of  the 
patient  by  giving  his  skin  a  rub  under  the  plaster, 
aided    by    dusting  powder.     An  excoriation  imme- 


Fig.  444. — Grand  Calot  Jacket.  Anterior  View.  This  was  a 
case  of  subluxation  of  the  atlas,  wrongly  diagnosed  at  first  as 
cervical  Pott's  disease. 

diately  makes  its  presence  known  by  a  foul  odor, 
(are  should  be  taken  not  to  permit  any  foreign  body 
to  slip  down  inside  the  jacket. 

The  Calot  jacket  (see  illustration)  is  an  excellent 
means  of  treatment  for  disease  of  the  upper  thoracic 
and  of  the  cervical  vertebra?.  It  needs  considerable 
practice  for  its  proper  application. 

Braces. — These  are  the  original  brace  devised  by 
Fayette  Taylor,  and  the  various  modifications  of  it. 
The  brace  consists  of  a  pelvic  band,  and  of  two 
upright  steel  bars  springing  from  it.  one  on  either 
side  of  the  spinous  processes.  The  brace  is  held  to 
the  body  by  its  attachment  to  an  apron  in  front 
and   by   shoulder  straps.      In   cervical   disease  it  is 


685 


Arthritis,  Chronic 


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provided  with  various  kinds  of  head  pieces  and  chin 
pieces. 

Tuberculous  Hip-joixt  Disease. — (Coxitis,  Mor- 
bus coxarius).  Pathology . — The  primary  focus  may 
be  in  the  head,  or  probably  in  the  inner  portion 
of  the  ueck,   in  the  acetabulum,  or  in  the  synovial 


Fig.  445. — Early  Hip  Disease  of  Right  Leg,  Showing  Abduction. 

membrane  The  head  may  be  almost  entirely  eaten 
away,  but  rarely  sufficiently  to  cause  a  luxation. 
The  acetabulum  may  be  perforated,  giving  the  prod- 
ucts of  disease  access  to  the  pelvis.  The  spasm  of 
the  muscles  in  a  set  attitude  (adduction  and  flexion) 
crowds  the  femoral  head  against  the  upper  portion  of 
the  acetabulum,  and  often  by  pressure  wears  it  more  or 
less  away,  so  that  the  upper  borderis  pushed  upward  and 
a  subluxation  takes  place — "wandering  acetabulum". 

Symptomatology. — Pain  and  limp  are  early  and 
prominent  symptoms.  The  pain  may  be  felt  in  the 
hip  or  in  the  knee.  In  the  latter  case  the  disease 
in  the  hip  is  often  entirely  overlooked.  At  first  the 
thigh  may  be  in  an  attitude  of  extension  and  abduc- 
tion, but  this  soon  gives  place  to  the  characteristic 
attitude  of  flexion,  adduction,  and  internal  rotation. 
Sensitiveness  of  the  head  of  the  bone  to  pressure  may 
or  may  not  be  present.  Abscesses  when  present 
usually  break  through  the  joint  at  its  weaker  lower 
portion   and  appear  on  the  front  of  the  thigh. 

Diagnosis. — In  lower  Pott's  disease,  the  thigh  may 
be  held  in  semiflexion,  but  limitation  of  motion  as 
a  rule  is  manifest  only  in  the  direction  of  extension. 
In  some  cases  the  diagnosis  can  be  made  only  after 
several  examinations.  In  non-tuberculous  arthritis 
of  Type  II,  muscular  spasm  is  absent,  the  obstruction 

686 


to  motion  is  purely  mechanical,  the  Roentgen  ra\ 
show  the  production  of  new  bone,  and  as  a  rule  th 
thigh  is  in  abduction.  Sprains  in  childhood  cles 
up  after  the  hip  has  been  put  in  plaster  for  a  few  week 
Fracture  of  the  neck,  and  epiphyseal  separation  ar 
differentiated  by  the  history  and  by  the  use  of  th 
x-rays.  In  coxa  vara  the  thigh  is  in  extensioi 
adduction  and  external  rotation,  and  the  skiagrai 
shows    the    bend    in    the    femoral    neck.     CongeniV 


Fig.  446. — Severe  Hip  Disease,  with  Adduction. 

dislocation  gives  a  history  of  existence  since  the  time 
the  child  began  to  walk,  absence  of  pain  or  signs  of 
inflammation,  and  free  motion  in  all  directions  except 
abduction.  Examination  and  the  Roentgen  rays 
reveal  the  femoral  head  out  of  the  acetabulum. 

Conservative  Treatment. — The  first  indication  is  a 
reduction  of  the  deformity.  The  desired  position 
is  one  of  extension  and  slight  abduction.  Then 
one  may  use  any  of  several  kinds  of  apparatus.  A 
good  routine  treatment  is  by  the  short  plaster-of- 
Paris  spica  with  or  without  crutches  and  a  high  shoe 
on  the  sound  limb.  The  traction  brace  in  one  of  it? 
numerous  forms  has  enthusiastic  advocates.  The 
Thomas  brace  is  sometimes  used,  but  is  difficult  to 
fit,  and  seems  to  possess  few  advantages  over  the  spica. 
In  Germany  the  long  plaster  dressing  is  much  used. 
Treatment  in  an  ordinary  case  should  be  continued 
for  about  three  years.  Toward  the  end  the  brace  ia 
left  off  at  night,  "then  one  or  two  hours  a  day,  and  the 
joint  is  carefully  watched  for  symptoms  of  a  return 
of  the  disease.  If  spasm  and  pain  reappear,  the  ap- 
paratus should  be  reapplied. 

Radical  Treatment. — It  is  quite  manifest  that  no 
operation    has    been    devised    that    could    certainly 


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Arthritis,  Chronic 


Fig.  417. — Traction  in  Hip  Disease 


remove  nil  infected  tissue,  fur  the  ot  innomina 
offers   do  field   fur  extensive  a.     The  re 

after  hip-joint  resections  has  been  said  to  be  bad, 
I'm  tin-  i-  perhaps  because  drainage  has  been  used 
and  the  joint  has  been  secondarily  infected.  Our 
sole  object  must  be  to  d<  troy  the  joint.  This  may 
be  done  in  either  one  of  two  ways.  1.  The  head  of 
the  femur  may  he  removed,  causing  a  dislocation. 
In  this  ca>e  the  joint  as  such  ces 
to  exist,  and  the  stump  of  the 
femoral  neck  is  slung  by  the  liga- 
ments upon  the  ilii.  Vari- 
ous routes  of  access  to  the  joint 
have  been  proposed.  Possibly  the 
simplest  is  through  the  anterior 
incision  downward  from  the  ante- 
rior spine,   going   outside  the 


Nr-J 


Ha.  448.— Hip  Splint  in  Use  at  the  Children's  Hospital.  Boston. 
(Courtesy  of  Dr.  Bradford.) 


lorius  in  order  to  avoid 
the  branches  of  the  crural 
nerve.  Drainage  is  not 
necessary.  A  plaster 
spica  should  be  worn  for 
two  or  three  months 
afterward.  The  func- 
tional result  is  usually 
good.  The  shortening 
amounts  to  about  two 
and  one-half  inches,  and 
the  patient  walks  fairly 
well  with  the  aid  of  a 
high  shoe  and  a  cane. 
Albee,  of  New  York,  has 
proposed  an  ankylosing 
operation  which  appears 
to  be  quite  efficacious 
(see  page  697).  The 
ankylosis  resulting  from 
it  should  give  a  better 
result  for  walking  than 
the  dislocation,  but  not 
so  good  for  sitting. 


Tuberculosis  op  the 
K.vee. — (White  swelling, 
etc.).  Pathology. — The 
primary  focus  may  be  in 
any  one  of  the  three  bones, 
or  in  the  synovia.  The 
most  frequent  bony  site 
is  in  the  head  of  the  tibia. 
The  proliferation  of  the 
synovia  is  sometimes 
more  marked  in  this  joint  fiG.  449.. 
than  in  any  other  and 
causes  great  swelling,  giv- 
ing the  disease  its  common  names  of  "joint  fungus" 
or  "white  swelling."  On  the  other  hand,  the  synovia 
may  be  fibrous  and  contracted,  causing  the  bone  ends 
to  stand  out  and  to  look  enlarged.  The  enlargement 
is  only  apparent. 

Symptoms  and  Physical  Signs. — Atrophy,  both  of 
the  thigh  and  calf,  especially  in  the  bony  type,  is 
early  and  marked.  The  knee  is  held  in  semiflexion. 
In  this  attitude  the  flexors  work  at  an  advantage 
over  the  extensors,  and  often  pull  the  head  of  the 
tibia  backward,  subluxating  it  on  the  femoral  con- 
dyles. At  the  same  time  the  leg  is  rotated  some- 
what outward.  The  ligaments  adapt  themselves 
to  this  position,  so  that  even  if  the  hamstrings  be 
divided  and  manual  force  be  exerted  to  extend  the 
leg,    the   normal   attitude  is   not   attained,   but    the 


-Long  Traction  Splint 
Applied. 


687 


Arthritis,  Chronic 


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Fir,.  450.—  Thomas'  Hip 
Splint,  Single.    (Itidlon.) 


head  of  the  tibia  is  levered  backward,  and  the  bone 

adopts  a  position  in  a  plane  posterior  to  that  of  the 
femur.  Sensitiveness  of  the 
synovia  can  often  be  detected 
if  the  joint  be  semiflexed.  Fluid 
may  be  present  or  it  may  not. 
The  patella  may  float.  A  boggy 
feel  of  the  soft  parts  is  charac- 
teristic of  the  cases  with  great 
synovial  proliferation. 

Diagnosis.- — The  special  diffi- 
culty presented  in  this  joint  is 
the  differentiation  between 
tuberculosis  and  the  non-tuber- 
culous forms  of  Type  I.  Fre- 
quently one  can  decide  only 
after  months  of  observation, 
unless  the  animal  test  be  used. 
Conservative  Treatment.- — If 
one  elects  the  traction  treat- 
ment, one  applies  the  Thomas 
knee  brace,  made  two  or  three 
inches  longer  than  the  limb,  to 
swing  the  foot  clear  of  the 
ground,  and  provides  the  other 
foot  with  a  high  shoe  to  com- 
pensate. If  one  elects  immob- 
ilization, one  encases  the  limb 
in  a  plaster-of-Paris  dressing 
reaching  from  the  perineum 
to  the  malleoli.  In  the  late 
stages  of  the  disease  the 
Campbell      brace      is      useful, 

jointed  at   the  knee  to  allow  the  desired  amount  of 

motion. 

Radical  Treatment. — The  sole  object  of  this  is  to 

stiffen  the    knee.       An 

excellent  means  of  do- 
ing    this     is     to     saw 

through  the  patella,  to 

dissect    this    out,   and 

then  to  remove  by  the 

chisel  and  saw  a  small 

slice  from  the  tibia  and 

from  the  femoral  con- 
dyles.    No  time  should 

be  wasted  in  dissecting 

out  the  synovia.    If  the 

semilunar      fibrocartil- 

ages   be   removed    the 

subsequent     pain    will 

probably  be  less.     The 

wound  should  be  sewn 

up    without    drainage, 

and  the  limb  should  be 

put  up  in  full  extension 

in  plaster-of-Paris.9 

Ankle  and  Tarsus. 
— Pathology. — The  dis- 
ease is  complicated  in 
this  situation  by  the 
presence  of  a  number 
of  small  spongy  bones 
and  of  six  or  seven 
synovial  cavities.  A 
focus  in  one  bone  may 
soon  involve  two  or 
three  synoviae,  and  the 
disease  may  run  riot 
through  the  other 
bones  and  synovial 
membranes.  The  pri- 
mary focus  is  most 
often  located  in  the 
talus.  Abscess  forma- 
tion in  these  joints  is 
early  and  frequent. 


A  peculiar  form  of  the  disease,  found  most  oftei 
in  children,  is  located  in  the  anterior  portion  of  th> 
calcaneus,  ruptures  externally,  and  shows  litt], 
tendency  to  involve  the  joint.  Sequestra  are  oftei 
formed  in  disease  of  the  calcaneus. 

Symptomatology. — The  foot  may  be  in  any  one  of : 
number  of  different  attitudes.  In  disease  of  thi 
ankle,  the  patient  often  walks  on  his  toes — equinus 
In  disease  of  the  midtarsus  the  attitude  is  frequent!' 
calcaneovalgus. 


Fig.  451.— The  Lorenz  Short  Spica. 
A  Sea  Breeze  Case. 


1 


Fig.  452. — The  Lorenz  Short  Spica.  Note  the  calf  develop- 
ment on  the  affected  side,  and  the  excellent  condition  of  the 
children. 

Diagnosis. — Painful  flat-foot  with  rigidity  may 
simulate  tuberculosis,  but  it  lacks  all  signs  of  acin< 
inflammation.  A  peculiar  puffiness  under  the  exter- 
nal malleolus  seen  often  in  normal  women  is  not  to 
be  mistaken  for  disease. 

Conservative  treatment  is  carried  out  by  a  plaster- 
of-Paris  dressing  reaching  from  the  level  of  the  head 
of  the  fibula  to  the  toes.  Inasmuch  as  the  impfti  I 
of  this  dressing  with  the  ground  would  soon  destroy 
it,  the  foot  must  be  swung  clear  by  the  use  of  a 
Thomas  knee  brace.  The  other  foot  must  be  pro- 
vided with  a  high  shoe.  The  treatment  by  Bier's 
hyperemia  is  supposed  to  be  especially  adapted  for 
use  in  this  region.  Conservative  treatment  is  usually 
very  efficacious  in  children. 

Radical  Treatment. — If  the  disease  be  diagnosed 
early  enough,  while  still  located  in  one  bone,  befi 
synovial  involvement,  it  may  possibly  be  cured  bj 
the  simple  removal  of  that  bone.  Otherwise  the 
most  extensive  resection  will  be  necessary,  removing 
every  particle  of  infected  tissue.     This  will  often  be 


css 


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Arthritis,  (  hroiilr 


possible,  and   we  shall  be  obliged   to  amputate, 
tie-joint  alone  be  involved,  the  disease  may 

en  be  cured  by  ablation  of  the  talus  and  dostruc- 
the  joint.     The   operation   of   curetting   for 
berculosis  of  the  ankle  and  tarsus  can  be  based  only 
an  ignorance  of  the  underlying  morbid  process. 

Iiif  Wrist. — The  pathology  and  principles  of 
:atment  in  disease  of  this  joint  are  much  the  same 
those  already  laid  down  for  the  ankle. 


must  be  differentiated  from  Duplay's  bursitis — sub- 
deltoid or  subacromial  bursitis.  In  this  the  limitation 
of  motion  is  always  in  the  direction  of  abduction  and 
externa]  rotation.  The  skiagram  is  most  important, 
in  t  he  different  iation. 

Conservative  treatment  consists  in  bandaging  the 
arm  to  the  chest,  or  in  the  use  of  apparatus  to  restrict 
its  motion.  The  value  of  the  popular  shoulder-cap 
is  illusory. 

Radical   treatment   consists   of   subperiosteal    re 

tion,  which  gives  anankylo- 

sis,  a  fairly  useful  result  on 
account  of  the  mobility  of 
[in-    capula. 


-t 


i 


158. — From  Left  to  Right:  Schultze  Pelvic  Rest,  Authors'  Modi6eation  of  the  Lorenz 
Plevic  Rest,  Loreuz  Stirrup,  Head  and  Shoulder  Rest. 

The  Elbow. — Disease  of  the  elbow  possesses  cer- 
in  peculiarities.  There  are  two  joints  here,  one  of 
Inch  may  be  affected  alone  or  both  together.  The 
ses  with  bony  focus  are  said  to  begin  most  fre- 
in  the  ulna.  The  attitude  of  the  elbow  is 
ually  semiflexion.  If  the  radio-ulnar  joint  be  impli- 
i  the  forearm  is  in  semipronation. 

i  motive  treatment  is  carried  out  with  the  elbow 
Id  by  a  plaster  bandage  at  a  right  angle.      A  sling 
-   the  patient  to  bear  the   limb  with   comfort. 
the  case  comes  under  observation 
it h  the  elbow  at  a  greater  angle  of 
-ion,  it  should  be  flexed  under 
sthetic,  or  better  still,  it  should 
i   slung  from   the  wrist  about   the 
ick    with   the   patient's   head   well 
xed.     As  he  slowly  straightens  his 
ick  up  he  will  flex  the  elbow.     This 
rocedure  is  repeated  each  day  until 
le   required   amount    of  flexion  is 
'tired. 

Radical  Treatment. — Either  one  of 
vo  conditions  results  from  a  resec- 
on,  a  rather  loose,  movable,  and 
lirly  useful  relation  of  the  two  bones 
h  other  (it  is  probably  not  an 
ticulation  in  the  usual  acceptation 
:"  the  word),  or  a  bony  ankylosis. 
he  latter  is  said  to  result  if  the  joint 
e  put  up  for  a  week  or  two  in  exten- 
di and  then  be  flexed.     Resection 

"ild  always  be  done  subperiosteally,  and  care 
lould  be  taken  to  avoid  injury-  of  the  ulnar  nerve, 
"ine  operators  insist  on  the  use  of  apparatus  for 
while  after  the  plaster  is  removed. 

The  Shoulder. — This  is  the  joint  in  which  the 
»rm  of  the  disease  known  as  caries  sicca  most 
ften  occurs.  The  head  of  the  humerus  in  this  is 
aten  away,   without   the  formation  of  abscess.     It 


The  Sacroiliac  Joint. — 
Tuberculosis  is  a  very  serious 
disease  in  this  joint,  but  a 
very  rare  one.  The  pain  is 
Located  at  the  seat  of  disea  e 

or  runs  into  tin-  buttock  or 
down  the  thigh.  A  marked 
limp  is  present,  and  the  trunk 
is  inclined  toward  the  sound 
side.  Abscesses  are  a  fre- 
quent complication,  are  prone 
to  early  infection,  and  bur- 
row in  every  direction. 
Sometimes  they  rupture  into 
the  pelvis,  sometimes  exter- 
nally. Fluctuation  may  be 
detected  by  inspection,  or  by 
the  finger  in  the  rectum; 
sensitiveness  also.  The  prog- 
nosis is  bad.  The  conserva- 
tive treatment  is  best  car- 
ried out  by  a  plaster  spica, 
crutches,  and  by  a  high  shoe 
on  the  opposite  extremity.  Radical  treatment  might 
meet  with  better  success  than  it  has  in  the  past  if  it 
were  undertaken  early  and  strove  only  for  ankylosis. 

The  Fingers  and  Toes. — This  is  known  also  as 
tuberculous  dactylitis  and  spina  ventosa.  In  adults 
the  joints  themselves  are  usually  diseased,  in  children 
the  shafts  of  the  bones.  To  the  latter  the  term 
spina  ventosa  should  be  limited.  The  disease  often 
affects  two  or  more  fingers.      Abscess  is  usual. 


Fig.  454. — Subluxation  in  Tumor  Albus. 

Spina  ventosa  must  be  differentiated  from  syphilitic 
dactylitis — not  always  an  easy  task.  The  problem  is 
sometimes  solved  with  the  aid  of  the  Wassermann 
and  the  tuberculin  tests,  by  the  examination  of  a 
piece  of  the  wall  of  an  existing  sinus,  or  by  a  course 
of  antisyphilitic  treatment.  In  disease  of  the  meta- 
tarsophalangeal joint  in  the  adult  gout  must  be 
excluded  by  the  .r-rays  and  by  the  course  of  the 
disease. 


Vol.  I.— 44 


689 


Arthritis,  Chronic 


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The  treatment  in  children  consists  largely  of  clean- 
liness, and  sometimes  of  suction  by  hyperemia.  It 
is  usually  efficacious  if  persisted  in. 

Radical  Operations. — Extirpation  of  the  diseased 
bone,  and  bone  grafting  have  been  practised  with 
success." 

In  tuberculosis  of  the  finger-joints  of  adults  the 
question  arises  as  to  the  advisability  of  resection  or 


\    » 


k 


Fig.     455. — The     Tin 


Knee     Splint. 
Report.) 


(Children's     Hospital 


of  amputation,  and  this  question  must  be  decided 
according  to  the  importance  of  the  member  and  the 
severity  of  the  disease.  If  secondary  infection 
have  already  taken  place  an  amputation  is  probably 
preferable. 

NON-TUBEHCTJL.OTJS     ARTHRITIS     OP     TYPE     I. All 

the  other  forms  of  disease  included  in  this  type  shade 
into  one  another  without  sharp  dividing  line,  and  to 
various  of  them  special  names  are  given;  thus,  Still's 
disease  is  a  form  occurring  in  young  children,  but 
a  similar  disease  exists  in  adults.  A  synovitis  may 
occur  as  a  tertiary  manifestation  of  syphilis,  but  if 
the  marrow  in  the  bone  ends  be  involved  then  the 
disease  comes  under  the  head  of  chronic  arthritis. 

It  will  be  best  therefore  to  take  up  first  the  main 
group,  and  later  to  describe  the  special  forms,  and  in 
order  to  avoid  confusion  we  shall  simply  consider 
this  main  group  under  the  name  of  chronic  non- 
tuberculous  arthritis  of  Type  I. 

Pathology. — The  morbid  anatomy  is  much  the 
same  as  that  of  joint  tuberculosis,  lacking  only  the 
characteristic  tubercle,  the  areas  of  necrosis,  and 
the  formation  of  cold  abscesses.  Hale  White"  shows 
a  photomicrograph  of  a  section  of  a  joint  obtained  at 
autopsy  which  needs  only  the  presence  of  tubercles 
to  be  characteristic  of  tuberculosis. 

The  main  features  of  this  type  are  a  proliferation 
of  the  synovia  and  of  the  lymphoid  marrow.  Some- 
times one  occurs  alone,  sometimes  both  occur  together. 

690 


In  the  latter  case,  some  writers  say  that  one  is  t 
earlier  manifestation,  some  say  the  other.  We  i 
justified  in  believing,  then,  that  both  may  be  right' 
the  cases  they  have  examined,  and  that  either  t 
synovia  or  the  marrow  may  be  first  affected. 

This  proliferation  in  the  synovia  and  in  the  mam 
is  the  essential  factor  of  the  disease,  and  all  bony  a 
cartilaginous  changes  are  to  be  reckoned  as  due  to 
The    synovia    is    thickened    and    inflamed.     It 
thrown  into  folds  and  shows  marked  villous  hyp< 
trophy.     Parenthetically  it  may  be  said   that  tin 
is  do  such  clinical  entity  as  "villous  arthritis."     T 
formation   of  synovial    "tags"    is    rather   frequei 
Under  the  microscope  the  ordinary  signs  of  chroi 
inflammation  may  be  seen,  namely",  thickened  blon 
vessels,  round-cell  infiltration,  etc.     The  synovia 
stead  of  consisting  of  a  single  layer  of  cells, 
posed  of  a  layer  of  lymphoid  tissue.     It  reminds  o 
of  moss  on  a  rock. 

Not  only  is  the  synovia  thickened  and  in  fok 
but  it  extends  its  border  at  the  expense  of  the  arti 
ular  cartilage. 

The  .Marrow. — Various  changes  have  been  d 
scribed  by  different  writers.  Hale  White"  fout 
foci  of  recent  inflammation.  Nichols  ami  Richai 
son12  regard  a  proliferation  of  the  connective  tissi 
as  the  chief  change.  Nathan13  describes  a  cyst  l 
mation  and  the  formation  of  dense  conneeti\< 
in  spots  like  "foci." 

The  proliferating  marrow  impairing  the  nutritif 
of  the  overlying  cartilage  bursts  through  it  and  ii 
vades  the  joint.  Here  it  meets  the  proliferatii 
synovia  and  the  proliferating  marrow  from  tl 
other  bone  of  the  articulation,  and  forms  adhesio* 
with  them.  Sometimes  the  joint  is  but  a  mass 
adhesions.  This  proliferating  cellular  tissue  lati 
may  change  to  fibrous  tissue. 


Fig.  456. — Tuberculous  Disease  of  the  Ankle;  Advanced  Stage. 

Most  writers  affirm  that  the  synovia  is  the  first 
tissue  to  show  proliferation,  but  Nathan  assert- 
that  the  marrow  changes  precede  those  in  the  synovia. 

The  Bone. — The  essential  feature  of  the  bone  change 
in  this  type  is  an  atrophy.  Although,  accord- 
ing to  Nichols  and  Richardson,  in  the  early  stages 
no  evidence  of  this  atrophy  can  be  seen  under  the 
microscope,  nevertheless  the  bone  is  distinctly  more 
permeable  to  the  Roentgen  rays.  Usually  the  re- 
sult of  the  morbid  process  is  seen  in  thinning  of  the 
bone  trabecules. 


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Arthritis,  Chronic 


||„.  Curtilage.  -The  cartilage  is  aiVeeled  in  a  man 
,    perhaps   mere  striking  than  any   other  of   the 
sues. 


It  becomes  thinned,  atrophic,  ami.  de- 


•  *  \ 


I  i.:.  457. — Tuberculosis  of  the  Tarsus.     Talo-navicular  joint  lai'l 
Note  erosion  of  articular  cartilage. 


rived  of  its  nutrition  by  the  proliferating  marrow, 

rates,  and  is  perforated  by  the  granulations  in 

marrow.     It   is  probably  never  lifted 

md  .hrown  off  in  a  leaf,  as  in  tubercu- 

isia.     At  the  same  time  it  is  assaulted,  so 

ik.    by    the   synovia,  and  suffers  a 

■  linking  of  its  borders.     As  a  result  of  a 

motion  or  of  a  disturbance  in  nutri- 

.11  or  of  both,  the  cartilage  undergoes  a 
illation,  and  as  the  result,  again,  of  the 
tree  processes  just  detailed,  it  may  disap- 
e:ir  more  or  less  completely.  Sometimes 
mall  islands  or  strips  of  cartilage  are  seen 
•abedded  in  granulation  tissue. 

\s  the  cartilage  disappears  a  fibrous 
nkylosis  is  formed  in  the  joint.  Accord- 
ig  to  some  writers,  an  occasional  complete 
r  bony  ankylosis  takes  place. 

The  ligaments  are  said  to  be  thickened. 

Symptomatology  and  Course. — It  is  neces- 
ary  to  keep  in  mind  the  difference  be- 
a  joint  that  has  been  the  seat  of  an 
disease,  and  in  which,  after  the  sub- 
idenceof  the  disease,  stiffness  and  loss  of 
unction  remain,  and  a  joint  which  is  the 
eat  of  an  actual  chronic  disease  or  of  a 
isease  which  manifests  itself  by  a  series 
■f  acute  exacerbations.  It  is  only  the  lat- 
er type  of  joint  disease  with  which  we  have 
o  deal  here. 

The  onset  of  the  type  under  discussion 
nay  be  sudden,  with  high  fever  and  con- 
titutional  disturbance,  or  it  may  be  slow 
nd  insidious.  One  joint  may  be  affected 
lone,  or  many  joints  may  be  involved, 
it  her  at  the  same  time,  or  one  after  another 
n  quick  succession,  or  at  long  intervals. 
\fter  a  joint  has  been  invaded  the  symp- 
oma  and  physical  signs  in  it  do  not  clear 
ip  completely  when  other  joints   are   in- 

olved,  as  they  do  in  acute  inflammatory 
heumatism,  but  the  joint  is  permanently 
lamaged  by  the  structural  changes  in  it. 

In  what  may  be  termed  the  classical 
onn  of  this  type,  the  tendency  to  involve- 
nent  of  many  joints  is  marked,  the  char- 
icter  is  wont  to  be  symmetrical,  and  in  a 
leneral  way  the  disease  manifests  a  "  cen- 
ripetal"  nature,  that  is,  the  joints  of  the 


hands  and  feel  suffer  fir  t,  then  the  knees  ami  elbows. 
The  proximal  interphalangeal  joints  and  the  meta- 
carpophalangeal, are  often  affected. 

The  hips  often  escape,  bul  the 
pine  i    \  ulnerable.      In  anol her 

the  spine  and  hip 
seal  "i  disease—  ■■  on  I  iechtei  ■ 
i  j  pe.  \  arious  write]  -  ha\  e  at- 
tempted to  build  up  clinical  etiti- 
i-  of  locality  of  the 
joint  inflammation — such  as  von 
Bechteiv  npell- 

Mai  ie'  di  ea  e,  etc.—  bul  t  heir 
claims  have  not  received  general 
recognii  ion. 

The  anemia  which  so  often  ac- 
com] tanii  evi  re  fi inns of  the  dis- 
ease is  hard  to  explain.     1 1   may 

be  said  i  e  i arac- 

teristic  bl 1  changes.    Si  >me  ob- 

ser\  ers  ha-,  e  found  a  decrea 
red  blood  cells,  but  as  a  ruli 
number  is  about  normal       Leuco- 
i'\  ti  -is  may  or  may  not  be  pi  i 

Except   possibly  in  its  mild 
forms    this    type   is   wont    to   be 
multiarticular. 

Sometimes    the    onset    is    pre- 
ceded  by   various   local   nervous 
dist  urbances — tingling,    numbness, 
stiffness,  weakness,  hyperesthesia, 


and    circulatory 

muscular  cramps, 


Fig.  45S. — Tuberculosis  of  the  Calcaneus. 


691 


Arthritis,  Chronic 


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change  in   color,   etc.      In   other   cases  the  onset   is 
unheralded. 

The  affected  limbs  may  be  atrophic  or  they  may 
be  the  seat  of  a  sort  of  pseudoedema.  The  skin 
and  nails  often  show  trophic  disturbances.  Extreme 
sweating  may  be  present,  and  various  paresthesias. 
Pigmentation  of  the  skin  is  occasionally  seen.  The 
occasional  coexistence  of  Raynaud's  disease,  exoph- 


r 


Fig.   459. — Tuberculosis  of  the  Carpus. 

thalmic  goiter,  nephritis,  paralysis  agitans,  and  arterial 
sclerosis  has  been  observed.11 

The  general  condition  of  the  patient  varies.  He 
may  be  able  to  go  about  with  more  or  less  comfort, 
especially  in  the  intervals  of  the  paroxysms,  or  he 
may  be  completely  bedridden,  and  unable  to  move 
hand  or  foot.  Often  with  the  steady  progression  of 
the  disease,  the  patient  becomes  gradually  more 
helpless. 

Contractures  are  often  present 
in  the  affected  limbs,  and  the 
reflexes  are  wont  to  be  exag- 
gerated. 

Local  Symptoms  and  Physical 
Signs. — Pain  is  almost  invariably 
present,  and  ranges  from  mild  to 
very  severe.  The  slightest  motion 
may  occasion  great  agony.  Stiff- 
ness and  loss  of  function  accom- 
pany the  pain.  The  joints  are 
swollen,  and  often  reddened.  In 
the  later  stages  of  the  disease  the 
swelling  may  give  place  to  a 
shrinking  and  atrophy,  which 
gives  a  certain  constriction  at  the 
level  of  the  joint.  The  charac- 
teristic swelling  is  "boggy," 
caused  less  by  the  effusion  in  the 
joint  than  by  a  thickening  of  the 
synovia.  Where  the  synovia  is 
accessible  to  the  examining  finger, 
sensitiveness  can  be  elicited.  The 
usual  deformity  is  flexion. 

Motion  in  the  affected  joint  is 
limited,  not  only  by  the  pain,  but 
also  by  the  products  of  inflam- 
mation. Creaking  and  grating 
can  often  be  detected. 

The  severe  "classical"  form  of  the  disease  is  really 
not  the  common  one,  but  represents  the  morbid 
process  carried  to  an  extreme.  In  the  majority 
of  cases  of  this  type  the  patient  experiences  more  or 
less  pain,  stiffness,  and  disability  in  one  or  two  joints. 

The  skiagram  of  the  joint  reveals  what  one  would 
expect  after  a  study  of  the  pathology.  If  the  in- 
flammation is  confined  to  the  synovia,  this  will  be 


seen  thickened  and  swollen.  If  the  bone  is  affected, 
it  will  show  in  the  picture  as  rarefied,  and  the  car- 
tilage as  thinned  and  eroded.  Bony  hypertrophies 
and  exostoses  do  not  belong  in  this  type. 

Differential    Diagnosis. — At    the   start   the   differ- 
entiation  may  be  impossible   between  acute  inflam. 
matory  rheumatism  and  the  chronic  forms  of  arthritis 
which  begin  acutely,  but  the  subsequent  course  will 
always  suffice.     A   higher   tempera- 
ture is  the  rule  with  rheumatism,  and 
its  acid  sweats  are  probably  peculiar 
to  it.     Heart  complications  are  rare 
with    chronic   arthritis.      Above  all, 
rheumatism  flits  from  joint  to  joint 
involving  one  at  a  time,  and  leaving 
no  trace  behind. 

A  gonorrheal  joint  inflammation  i.> 
wont  to  run  a  distinctly  acute  course, 
and,  when  it  subsides,  to  leave  the 
joint  damaged,  but  not  the  seat  of  a 
progressive,  active  disease.     On  the 
other  hand,  it  is  probably  a  fact  that 
a  gonorrheal  joint  may  closely  simu- 
late   the    disease    under    discussion, 
and  possibly  may  be  pathologically 
so  allied  to  it  as  really  to  belong  in 
the  same   class.       The   condition  of 
the    genito-urinary    apparatus   may 
enable    us    to  place   the  gonorrheal 
joint  in  its  proper  class,  or  perhaps 
the    cultivation   of    the    gonococcus 
from  some  aspirated  joint  fluid. 
We   have   seen   that   the  pathological    process  i: 
tuberculosis  is  almost  identical  with  that  in  the  ordi- 
nary proliferating  type  of  arthritis.     It  follows,  then, 
that  the  symptoms  and  physical  signs  are  the  same, 
or  so  nearly  the  same  as  often  to  prevent  a  diagnosis 
from   them  alone.     The  skiagram   is  also  the  same. 
The  main  points  which  distinguish  tuberculosis  clin- 
ically are  its  slow  and  steadily  progressive  course,  its 
almost  invariable  uniarticular  nature  and  its  tendency 


[ 


Fig.   460. — Tuberculosis  of  the  Carpus. 

to  produce  abscess.  The  tuberculin  reactions  are 
not  of  conclusive  value  in  adults,  but  the  animal  test 
or  a  laboratory  examination  of  a  piece  of  the  synovia 
are  of  much  more  importance. 

The    chief    difficulty    in    diagnosing    this    type  o( 
chronic  arthritis  will  be  found  in  the  very  mild  ■ 
in  which  the  synovia  alone  of  one  joint  is  involved, 
and  which  occasion  practically  no  symptoms  exi 
moderate  pain  of  more  or  less  constancy,  and  it  is 


G9L' 


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Artlirltl-.  Chronic 


these  cases  that  the  painstaking  complete 
Mica]  examination  is  most  important.  In 
,'.m.  often  the  detection  of  the  source  of  the 
'ection   and   its  removal,   not   only  cures   the 

disease,  but  clears  up  the  diagnosis. 
Tin-  prognosis  is  fairly  good  if  one  can  find  out 
e  of  the  disease.     If  it  cannot  be  cured 
may  at  least  be  checked,  and  t lie  patient  may 
restored   to   a   fair   degree  of   health.     The 
|<jer   forms   may    recover  spontaneously,  and 
,\e  almost    no   traces.     The  severe  forms  pre- 
nt  a  serious   problem.      If  we   are   unable  to 
lie   cause,   the  disease  advances   with  re- 
march,    and,   involving  one  joint  after 
other,  changes  the  patient  to  a  hopeless,  bed- 
cripple,  undergoing  the  greatest  suffering. 
I  he  spine  be  badly  atl'ected,  the  function  of  I  lie 
■:;;*  may  be  impaired,  and  a  pulmonary  com- 

|  i.in  "may  end  the  scene. 
Treatment" — The  first  requisite  in  these  cases  is 
iugh  and  complete  history,  the  next  is  a 
orough  physical  examination  of  the  entire  body. 
ie  functions  of  every  organ  must  be  interro- 
ted.and  every  possible  source  of  infection  must 

■  -ought — the  intestinal  canal,  the  ears,  the  nose 

accessory   cavities,   the   throat  and   the 

nito-urinary  canal.     If  a  cause  be  found  for 

•  -\  mptom's,  measures  must  be  taken  to  remove 

The  treatment  of  the  joints  themselves  is  a 

condary   consideration.      If   the   source  of  the 

i  i ion' be  discovered  and  removed,  the  joints 

;ll  often  clear  up. 

Certain  things  must,  not  be  done;  the  patient 

list  not  be  sent  traveling  about  the  country  to 

irious   baths    whose    action    is   unknown   and 

lenefits  often  are  doubtful.      He  must  not 

subjected  to  diets  which  are  supposed  to  be 

inti-rheumatic."     If  the  source  of  infection  be 

the  intestinal  canal,  naturally  the  diet  must  be 

losen  with  a  view  to  this  condition,  and  it  must 

■  such  as  the  patient  can  easily  digest,  while 
ill  being  nourishing.     Sweets  disturb  the  diges- 

nn,  and  therefore  should  be  cut  down,  but  so  should 


Flu.   46J 


-Tuberculous  Shoulder.     Patient  seven  years  old. 
(Courtesy  of  Dr.  McCartney.) 


Fie.   461. — Tuberculous  Elbow.     Patieut  nine  years  old. 


all  other  indigestible  food.  Further  than  this,  the 
influence  of  diet  is  problematical. 

The  salicylates  may  have  a  small  effect  in  the 
intestinal  cases,  as  being  intestinal  antiseptics. 
Combined  with  castor  oil,  salol  is  said  to  be  effica- 
cious. The  iodides  are  useful  if  the  infection  be  an 
old  syphilitic  one,  but  they  are  not  as  reliable  as  the 
various  forms  of  mercury.  Extract  of  the  ductless 
glands  has  been  praised.* 

In  the  severe  cases  we  must  guard  carefully  against 
bed  sores,  which  will  often  form  a  troublesome 
complication. 

Local  Treatment. — The  first  indication  in  all  the 
acute  manifestations  is  rest,  as  complete  as  possible. 
In  the  intervals,  massage,  vibratory  massage,  baking, 
etc.,  may  all  be  tried.  The  patient  should  be  en- 
couraged to  take  what  gentle  exercise  he  can,  in 
order  to  maintain  his  nutrition.  Sometimes  a 
plaster  splint  on  a  very  painful  joint  will  enable  the 
patient  to  go  about  with  a  fair  degree  of  comfort. 

The  Spine. — Disease  of  the  spine  certainly  exists 
in  patients  who  are  suffering  with  the  manifestations 
of  this  type  of  arthritis  in  the  other  joints  of  their 
bodies,  but  unfortunately  the  reports  of  its  morbid 
anatomy  are  not  such  as  to  render  an  exact  knowl- 
edge possible.  Probably  the  tissues  of  the  joints  of 
the  spine  are  affected  much  as  are  those  of  the  other 
joints.  Sometimes  all  the  joints  are  affected,  some- 
times the  upper  one  or  two  are  spared. 

The  symptoms  are  more  or  less  influenced  by  ana- 
tomical conditions.  Owing  to  the  deep  situation  of 
the  affected  joints,  swelling  and  sensitiveness  cannot. 
be  made  out.      Again,   the  pain,  on  account  of  the 

*  Nathan  recommends  powdered  thymus  extract  in  10-graia 
doses  3  times  daily. 


693 


Arthritis,  Chronic 


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irritation  of  the  spinal  nerves,  is  felt  not  only  in  the 
back,  but  also  down  the  trunk  and  down  the  limbs. 
A  persistent  sciatica  may  constitute  the  chief  com- 
plaint of  the  patient. 

Stiffness  and  limitation  of  motion  of  the  spine  are 
almost  invariably  present.  An  unevenness  of  involve- 
ment of  the  two  sides  of  the  column  may  occasion  a 


Fig.   46a. 


-Tuberculous  shoulder.     Same  patient  as  Fig.  462,  two 
years  later.     Treatment  by  vaccines. 


lateral  curvature.  Severe  implication  of  the  thoracic 
region  will  occasion  a  rigidity  of  the  chest,  and  ren- 
der the  quality  of  respiration  distinctly  abdominal. 

Treatment. — The  principles  are  the  same  as  those 
laid  down  for  other  joints.  A  well-fitting  brace,  or 
corset,  or  plaster  jacket  may  be  necessary  to  relieve 
the  pain  and  to  prevent  the  increase  of  deformity. 

Still's  Disease. — This  is  a  form  of  chronic  arthri- 
tis occurring  in  children,  before  the  second  dentition, 
accompanied  by  enlargement  of  the  spleen  and  lymph 
nodes.  The  synovia  is  involved,  but  not  the  bone 
marrow,  according  to  Still.  It  is  a  question  whether 
the  disease  is  a  clinical  entity,  or  whether  the  general 
lymphoid  involvement  is  due  to  the  greater  vulnera- 
bility of  lymphoid  tissue  in  children  to  disease. 
None  of  the  patients  mentioned  in  Still's  original 
monograph15  recovered.  Other  writers  have  reported 
recoveries.  It  would  be  interesting  to  investigate 
the  fausal  relation  to  this  disease  of  the  oral  sepsis 
which  prevails  during  the  loss  of  the  first  teeth. 

Type  II. — Cases  characterized  by  an  inflammation 
and  degeneration  of  the  synovia  and  marrow,  followed 
by  an  hypertrophy  of  the  bone  and  cartilage. 

The  infectious  nature  of  this  class  of  cases  has 
been  denied  by  some  writers,  partly  on  the  ground 
that  they  were  degenerations  and  not  inflammations. 
It  is  true  that  in  the  later  stages  of  the  disease,  after 
the  active  period  has  subsided,  no  sign  of  inflamma- 
tion may  be  present,  but  this  is  true  of  other  degen- 
erations that  are  known  to  follow  inflammations 
(anterior  poliomyelitis,  for  instance),  and  we  can  see 
from  the  study  of  the  stained  slide  that  foci  of  inflam- 
mation are  found  in  the  earlier  stages  of  the  disease. 

694 


Etiology. — Little  definite  is  known  of  the  cause 
these  cases,  even  less  than  of  those  of  Type  I.  F 
the  present  it  is  perhaps  best  to  believe  that  th 
are  all  due  to  some  infection,  and  generally  thisinfi 
tion  is  supposed  to  be  located  in  the  gastrointestii 
tract.  Many  of  the  patients  suffer  with  flatulen 
and  indigestion,  and  frequently  a  history  is  obtain 
of  a  severe  diarrhea  immediately  antedating  i 
symptoms,  a  diarrhea  that  has  been  checked  I 
drugs. 

Again,    trauma  often  precedes   the   disease,   est 
cially  in  its  uniarticular  manifestation  in  the  hip. 

Morbid  Anatomy. — The  changes  in  this  type  in 
be  said  to  be  the  reverse  of  those  seen  in  Type 
Following  well-marked  degenerative  changes  in  | 
synovia,  in  the  marrow,  and  in  the  deeper  layer  of  t 
periosteum,  the  bone  and  cartilage  hypertrophy, 
we  may  express  it  so,  t lie  parenchyma  of  the  joi 
degenerates  and  the  stroma  hypertrophies.  T 
picture  of  the  disease  during  its  active  periods  dillY 
from  that  observed  later.  We  shall  briefly  tra 
the  change  in  the  various  tissues  of  the  joint,  ;u 
shall  show  to  what  these  changes  lead. 

The  synovia  is  often  thickened,  but  instead  of  tl 
proliferation  found  in  Type  I,  there  is  here  a  dege 
eration.     On  the  surface  of  the  membrane  there  in. 


Fig.   454. — Tuberculosis  of    Metatarsophalangeal  Joint  of   Grea' 
Toe. 

be  a  slight  lymphoid  proliferation.  In  its  substanci 
areas  of  fat  cells  are  seen,  and  much  fibrous  tissue 
Localized  villous  hypertrophies  occur  and  collec- 
tions of  round  cells.  Occasionally  cartilage  cells  art 
see,n  in  the  new  fibrous  tissue  (an  encroachment  ol 
cartilage  on  the  synovia).  The  arteries  have  thick- 
ened walls. 


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Arthritis,  Chronic 


I  he  marrow  invariably  or  almost  invariably  shows 
departure  from  the  normal.  The  change  may  not 
J    reneral,   but   may  occur  in  spots.     The  marrow 


I  10.  10.}. — Tuberculosis  of  the  Phalanx  in  a  Child.     This  patient 
i   a  suppurating  process  in   the  head   of  his   tibia,   with 
.jucstruni  formation. 

ay   bo  almost   replaced   by   fibrous   tissue,   or   the 
arrow  cells  may  be  seen  lying  in  a  coarse  granular 

iicrial.     Islands  of  cartilage  are  often  seen  under 

ic    microscope,    occasionally    also   cysts.     As   com- 

ucd  with  the  normal,  there 

marrow  and  more  bone. 

The  bone  trabecule  are 
ticker  than  normal  and  often 
(1  in  number.  The 
lands  of  cartilage  mentioned 
bove  probably  represent  new 
abeculae  in  process  of  fornia- 
on.  Often  instead  of  the 
ormal  buttresses  of  bone 
nder  the  cartilage,  one  sees 
thickening  and  increase 
tat  may  amount  to  a  solid 
tyer  of  bone. 

The  cartilage  is  thickened 
nd  in  various  stages  of  de- 
cneration.  It  Is  wont  to 
how  a  decided  fibrillation, 
nd  may  be  roughened.  It 
underlaid  with  a  layer 
•  id  tissue. 

The  gross  changes  to  which 
tiese  processes  lead  are  the 
ollowing:  The  thickened 
artilage  renders  the  head  of 
be  bone  unfitted  for  its  artic- 
ilation;  hence  the  distortion. 
rhe  thickening  is  irregular 
>ut  more  or  less  general,  and 


produces  cartilaginous  outgrowths  and  spurs,  which 
may  later  undergo  transformation  into  bone,  The 
bone  under  nca  ih  the  articular  cartilage  hypertrophies 
at  t  ho  --a mo  time.  Now  ,  i  he  cartilage  draws  its  nutri- 
tion from  the  marrow,  and  when  this  nutrition  has 
I n  loit  oil'  i.\  i he \  bone,  t he  carl ilage  degener- 
ate .  and  wears  away,  often  leaving  the  bone  exposed 

and  ebumated,  grooved  in  the  line  of  joint  motion. 
The  peripheral  portions  of  the  cartilage,  drawing  their 
nutrition  probably  from  (he  synovia    do  out   suffer 

in  this  manner,  bul  maintain  their  hvpertrophiod 
condition,  and  give  (o  the  bone  end  an  enlarged  and 

flattened  contour,  adding  to  the  distortion,  .-11111 
sometime  causing  subluxations.  Between  the  ebur- 
nated  bone  ends  there  is  no  tendency  to  ankylo  is 
as  in  Type  I,  and  there  is  no  proliferating  marrow 
to  break  through  the  cartilage.  Whatever  obstruc- 
tion to  motion  is  present,  is  purely  mechanical. 

Symptomatology. —  As  a  rule  the  onset  of  the  dis- 
ease is  insidious,  with  moderate  pain  and  stiffness, 
and  the  course  is  more  or  less  progressive,  until  the 
process  is  finished,  when  the  joint  is  left  more  or  le  3 
damaged  functionally.  The  pain  is  rarely  great,  and 
lesions  of  this  type  are  not  so  severe  in  their  effects 
as  are  those  of  Type  I.  The  joints  as  a  rule  are  not 
much  swollen,  but  the  bone  ends  show  irregular  en- 
largements. Subluxations  are  frequent,  on  account 
of  the  change  in  shape  of  the  articulating  surfaces. 
Sensitiveness  to  pressure  is  rarely  present.  In  the 
hip  the  usual  deformity  is  flexion,  abduction  and 
external  rotation;  in  the  knee,  flexion;  in  the  fingers, 
lateral  distortion.  Creaking  and  grating  can  be  dis- 
tinguished on  palpation,  and  motion  is  limited.  The 
atrophy  of  disuse  may  be  detected  with  the  tape. 
Disturbed  digestion  is  often  present,  but  no  fever  nor 
other  constitutional  disturbances. 

Roentgen  rays  show  the  bony  and  cartilaginous 
growths,  the  thickening  of  the  cartilage  and  of  the 
bone  near  the  joint,  and  the  wearing  away  of  the 
cartilage  near  the  center,  in  the  line  of  joint  motion. 

Diagnosis. — Cases  in  Type  I.  are  wont  to  be  ac- 
companied by  more  constitutional  disturbance,  are 
more  painful,  and  show  more  acute  manifestations. 
A  skiagram  shows  a  rarefaction  of  the  bone,  no  bony 
nor  cartilaginous  growths,  and  a  thinning  of  the  car- 
tilage. Inflammation  is  more  marked  in  cases  of 
Type  I,  and  bony  and  cartilaginous  growths  do  not 
occur  in  it. 

Tuberculosis  may  be  hard  to  differentiate  from  the 


Fiu.  166.- 


-Dactylitis  in  Boy  of  about  Nine  Years.     He  had  a  distinct  history  of  a  syphilitic 
parent,  but  the  lesions  did  not  heal  up  under  anti-syphilitic  treatment. 


695 


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uniarticular  forms,  but  tuberculosis  also  shows  more 
signs  of  active  disease  and  inflammation,  more  mus- 
cular spasm,  and  greater  pain  and  sensitiveness  as  a 
rule.  The  tuberculin  reaction  may  be  present. 
One  misses  in  tuberculosis  also  the  cartilaginous  and 
bony  spurs.     The  obstruction  to  motion  in   tuber- 


Fig.    467. — Photomicrograph,    Low    Power,    Showing    Bizarre 
Appearance  of  Cartilage,  from  Knee  with  Mixed  Infection. 

culosis  is  caused  by  inflammatory  products  and  by 
muscular  spasm;  in  cases  of  Type  II,  by  mechanical 
impediment.  The  Roentgen  rays  are  the  most  useful 
means  of  diagnosis.  Sometimes  the  differentiation 
can  be  made  only  by  several  examinations  at  intervals 
of  time. 


Fig.  46S.- 


-Low  Power  Photomicrograph  Showing  Fibrous  Change 
in  the  .Marrow. 


The  prognosis  quoad  vitam,  unless  the  spine  is 
involved,  is  good;  as  to  function  it  is  bad.  The  dam- 
age once  done  to  a  joint  is  permanent,  and  a  return 
to  perfect  function  usually  impossible. 

Treatment. — Here,  as  in  other  forms,  one  endeavors 
to  find  a  source  of  infection,  and  to  remove  it.      If 


this  be  possible,  one  may  arrest  the  march  of  tt 
morbid  process.  Intestinal  fermentation  is  to  t 
corrected,  and  also  enteroptosis.  Passive  motion  an 
massage  are  contraindicated.  They  harm  the  joir 
by  the  trauma  they  inflict  through  the  medium  i 
the  rough  bony  surfaces.     Sometimes  a  well-fittii 


Fig.  469. — Photomicrograph  of  Marrow  Cyst  from  Hip  Joint. 


brace,  which  allows  motion  through  a  painless  arc 
may  enable  the  patient  to  use  the  affected  joint  witl 
a  reasonable  degree  of  comfort.  If  one  or  two  bom 
spurs  be  identified  as  causing  most  of  the  restrictioi. 
they  may  be  chiseled  away,  in  the  uniarticular  form: 
especially.     In   the  case  of  a   badly   damaged  singk 


Fig.  470. — Low  Power  Photomicrograph  Showing  Degeneration  of 
Cartilage  in  Type  II — the  so-called  Cartilage  "Tatters." 

joint  a  stiffening  operation  may  be  thought  advisable, 
for  a  perfectly  stiff,  painless  joint  is  far  preferable 
to  a  painful  one  with  a  small  range  of  motion.  In  the 
knee  this  may  easily  be  done  by  the  removal  of  the 
articular  cartilages,  with  a  small  slice  of  bone.  In 
the  hip  Albee's  operation  is  perhaps  the  best  resort.'" 


696 


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Arthrllls,  <  hniiilr 


yibee  removes  the  upper  part  of  the  head  of  the 
cmur  the  upper  portion  of  the  acetabulum,  and  as 
nuch'as  possible  of  the  cartilage  from  the  head  of 
he  femur,  subluxates  the  femur  upward,  and  puts 
lie  thigh  up  '"  slight  abduction  and  flexion  until 
>ony  union  takes  place.  With  the  destruction  of 
he  joint,  the  disease  disappears. 


Fig.  471. — Same  as  tig.  470;  High  Power. 


Special  Forms. — Hebcrden's  nodes  are  small 
bony  growths  usually  occurring  at  the  terminal  inter- 
phalangeal  joints  of  the  fingers,  and  have  been  said 
to  be  an  evidence  of  longevity.  They  occasion 
slight  discomfort,  and  slight  interference  with  func- 
tion.    The  deformity  resulting  is  usually  lateral,  in 


Fig.  472. — Lower  Power  Photomicrograph  Showing  Irregularity  of 
Joint  Cartilage. 

contradistinction  to  the  flexions  caused  by  lesions 
of  Type  I.  The  latter  form  affects  more  often'  the 
proximal  interphalangeal  joints  or  the  metacarpo- 
phalangeal. Treatment  of  Herberden's  nodes  is  not 
often  necessary. 

Spinal  Form. — The  lesions  in  the  spine  are  wont  to 


be  severe,  not  only  from  the  extent  of  the  damage, 
and  its  crippling  effect,  l>ut  also  on  account  of  the 
effect  upon  the  vital  means  through  the  interference 
with  their  function.  A  part  of  the  spine  maj  be 
involved  or  the  whole  column.  Of  ten  the  two  upper- 
most  joints  escape.     The  joints  become  ankyli      I 

more  or  less  c pletely.     Sometimes  masses  of  bone 

form  on  the  anterior  aspect  ot   the  -pine,  turnii 
into  a   bony  ma  I'lie  intervertebral  discs  may   be 

lied,  or  the  joints  may  persist,  though  surround- 
ed by  masses  of  bone.  If  they  persist  the  spine  may 
lose  its  normal  curve  and  be  converted  into  a  more 
or  less  straight  rod — "poker  pine."  If  they  be 
absorbed  tie-  spine  may  possess  one  long,  rounded 
posterior  curve. 

The  symptoms  are  pain,  disability,  stiffness,  and 
weakness.  The  pain  is  caused  by  pressure  on  the 
spinal  nerves,  and  is  felt  not  only  in  the  back,  but 


Fig.  473. — Charcot's  Disease.     (Weigel.) 

also  down  the  limbs  and  about  the  trunk.  The  knee- 
jerks  are  often  increased.  The  disability  may  be 
extreme,  especially  if  a  complicating  lesion  of  other 
joints  be  present. 

Probably  the  best  form  of  special  treatment  is  by 
the  use  of  a  brace,  or  better  still,  of  a  plaster  jacket, 
to  prevent  the  increase  of  the  deformity  if  not  the 
spread  of  the  disease.  It  is  seen  that  if  the  ante- 
rior bowing  of  the  spine  be  prevented,  while  the  inter- 
vertebral discs  are  being  absorbed,  but  before  bony 
union  has  taken  place,  the  subsequent  condition  of 
the  patient  will  be  bettered.  Of  any  attempt  to 
break  up  bony  union  here  there  should,  of  course, 
be  no  thought. 

Charcot's  Joint,  Trophic  or  Neuropathic 
Joint. — This  form  of  joint  disease  probably  belongs 
in  this  tvpe.  though  it  possesses  features  of  both  types. 
It  sometimes  complicates  a  tabes  or  a  syringomyelia. 

G97 


Arthritis,  Chronic 


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The  knee  is  most  frequently  affected,  then  the  hip, 
then  the  ankle,  then  the  spine.  The  joint  becomes 
badly  disorganized,  and  often  contains  loose  pieces  of 
bone  and  cartilage.  Pain  is  absent,  but  the  swelling 
and  loss  of  function  are  marked.  The  joint  becomes 
very  lax,  and  motion  is  possible  in  abnormal  direc- 
tions. The  conservative  opinion  seems  to  be  that 
operative  measures  are  useless  in  this  affection.  A 
jointed  brace  affording  limited  motion  gives  the  best 
prospect  of  relief. 

Poncet's  tuberculous  rheumatism  is  a  form 
of  joint  disease  which  Poneet  has  considered  to  be  due 
to  a  sort  of  attenuated  virus  acting  upon  the  tissues 
of  the  joint.  He  thinks  that  a  large  proportion  of 
cases  of  chronic  rheumatism  are  due  to  this  cause,  but 
as  yet  his  observations  are  viewed  with  some  degree 
of  scepticism.  It  is  possible  that  the  fleeting  joint 
symptoms  often  observed  in  tuberculous  patients 
are  due  to  a  secondary  infection. 

Bier  Treatment  (Stauungshyperaemie). — In  various 
forms  of  chronic  arthritis,  tuberculous  and  other,  a 


Ankylosis. — After  any  chronic  joint  disease  has 
run  its  course,  or  indeed,  after  any  acute  one,  a 
certain  amount  of  stiffness  is  wont  to  be  left  behind 
and  to  this  stiffness  the  name  ankylosis  lias  been 
applied.  It  is  necessary  to  have  a  thorough  com- 
prehension of  this  subject  if  one  would  undertake 
the  after  treatment  of  these  joints,  and  to  know  the 
exact  pathological  condition  in  them.  Otherwise 
one  risks  disaster  in  attempting  to  mobilize  them. 

Two  kinds  of  ankylosis  are  recognized,  namely, 
true  or  complete  or  bony,  and  false  or  incomplete  or 
fibrous.  Fibrous  ankylosis  may  be  so  firm  as  to  simu- 
late the  bony  variety,  and  may  possibly  be  differen- 
tiated only  by  an  examination  under  ether,  or  by  a 
Roentgen  picture. 

First,  let  it  be  said  that  immobilization  probably 
never  causes  ankylosis  by  itself.  If  a  normal  joint 
be  immobilized  for  a  length  of  time,  the  synovia 
encroaches  upon  the  joint  cartilage  and  the  latter 
becomes  fibrillated.  Some  stiffness  will  be  present 
when  the  dressing  is  removed,  but  this  stiffness  will 
disappear    upon    the    resumption    of    function,    and 


Fig.  474. — Patient  in  Bed  on  Fixation  Frame,  with  Traction  in  Line  of  Deformity. 


treatment,  named  after  its  originator,  has  been 
advocated,  which  consists  of  the  production  of  a 
venous  stasis  in  the  limb,  to  be  continued  for  one  hour 
to  three  hours  daily.  The  stasis  is  brought  about 
by  the  application  of  an  elastic  band  above  the  joint, 
which  should  be  applied  just  tightly  enough  to  make 
the  portion  of  the  limb  distal  to  it  bluish-red  and 
warm  but  not  -painful.  Klapp,  Bier's  assistant, 
devised  a  modification  of  the  treatment  for  use  in 
tuberculous  joints  with  open  sinuses  or  open  absces- 
ses. He  used  specially  devised  cupping  glasses.  To 
i*duce  a  suction  hyperemia  in  a  limb  he  inserts  it  in 
a  glass  chamber,  whose  open  extremity  is  provided 
with  an  open  cuff  for  bandaging  on  the  limb.  The 
air  is  then  exhausted  from  the  air  chamber. 

The  Bier  treatment  at  one  time  had  a  wide  vogue, 
but  seems  to  be  falling  into  disrepute.  It  certainly 
merits  a  trial  in  some  cases,  but  too  much  should  not 
be  expected  of  it.  The  amelioration  of  the  symptoms 
of  pain  and  sensitiveness,  which  often  takes  place, 
may  lie  due  to  a  reduction  of  the  disease  process,  or 
possibly  may  be  due  to  simple  pressure  on  the  nerves. 


some  observers  have  said  that  the  obstruction  to 
motion  in  this  case  is  located  in  the  tendons,  and 
disappears  when  they  are  divided.  This  fact  should 
be  kept  firmly  in  mind. 

The  principles  governing  the  treatment  of  ankylosis 
vary  according  to  conditions,  and  according  to  the 
disease  which  has  caused  it,  but  no  mobilizing  opera- 
tion should  ever  be  undertaken  in  a  tuberculous  joint 
while  the  disease  is  in  its  active  stage  or  when  it  has 
run  its  course,  and  is  apparently  well.  When  the 
disease  is  active  it  will  be  aggravated  by  motion,  and 
one  can  never  tell  when  it  is  well."  An  old,  appar- 
ently healed  joint  usually  contains  encapsulated  foci  of 
tuberculous  material,  which  occasion  no  disturbance 
until  trauma  or  ill-advised  operations  set  them  free, 
and  light  up  the  trouble  afresh.  If,  in  the  active 
stages,  one  undertakes  the  treatment  of  a  tuberculous 
joint  in  a  faulty  attitude,  one  should  reduce  the  de- 
formity as  gently  as  possible,  either  by  gradual  cor- 
rection by  plaster-of-Paris,  by  traction  in  bed,  or  pos- 
sibly, if  "the  obstruction  be  not  very  resistant 
reduction  under  ether.     If  the  disease    has    run  its 


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Arthrology 


h 


nurse,  and  the  fibrous  ankylosis   is   very   firm,   an 
steotomy  should   be   the   corrective  operation,  fol- 
,,,1  i,\    plaster-of-Paris.     Fibrous  ankylosis  is  the 
je.     Bony  ankylosis  probably  never  follows  tuber- 
losis  in  an  adult,  and  only  a  mixed  infection  in 
i.     Bony    ankylosis    requires    an    osteotomy 
,,.  its  correction,   with  subsequent   retention  of  the 
,1,  ,n  pla  ter  for  several  months.      Division  of  con- 
ted  tendons  may  be  :essary  in  addition.     The 

,.iiiinv  should  not  lie  done  through  the  joint,  for 

chiseling  into  an  old  tuberculous  focus. 

Cases    in    Type    1. — After    the   disease    has 

ached  its  quiescent  stage,  attempts  to  restore  mo- 

in  the  joint  are  permissible.     If  the  ankylosis  be 

much  may  often  be  done  by  the  use  of  me- 

apy,  hot  and  cold  douches,  massage  and  pas- 

otion.     Occasionally  this  may  be  preceded  by 

reaking  up  the  adhesions  under  an  anesthetic  and 

lien  by  putting  the  joint  up  in  an  entirely  different 

ttitude   in   plaster  for   a   month   or   two,   especially 

■  hip.     The  use  of  muscle  flaps,  animal  membranes, 

has  its  advocates  here  as  in  bony  ankylosis.     Var- 

IUS  surgeons  have  reported  excellent  results 

<    /',/"   II. — All  attempts  to  increase  motion 

orce  here  are  decidedly  contraindicated,  and  do 

In  some  instances    the   use  of   animal    mem- 

iranes,  or  muscle  flaps  would  seem  indicated;  in  others 

obstructions   may   be   chiseled   away.      In   still 

rs   an  operation   to   produce   bony   ankylosis    is 

able. 

If  the  surgeon  will  picture  to  himself  the  exact  state 

[fairs  in  any  old,  diseased  joint  he  will  hardly  go 

istray.      It  is  the  lack  of  exact   knowledge  which   is 

.  sponsible  for  most  errors.  Leonard  W.  Ely. 

References. 

1    Allbutt'a  System  of  Medicine,  1901.  vol  iii 

2.  Beitlike     Zeitschrift  fur  klinische  Medizin,  1912,  S.  215. 

3.  Stiles:     Journal  of  the  American  Medical  Association,  Feb. 
,.  1912 

4.  Jansen:    Archiv  fur  klinische  Chirurgie,  November,  1911. 

"     Heck:    Transactions  of  the  Sixth  Inter.  Congress  on  Tuber- 
190S. 

6  Wallace  Blanchard:    Medical  Record,  May  IS,  1912. 

7  Hibbs:  N  V.  Med.  Journal,  May  27,  1911;  Journal  Am.  Med. 
Us'n.  Aug.  in,  1912. 

8  Albee:    X    V    Medical  Journal.  March  9,  1912. 

9.  Ely:  Tuberculosis  of  the  Adult  Knee.  Transactions  of  the 
>n  on  Surgery  of  the  American  Medical  Association,  1912: 
loiat  Tuberculosis,  Wni.  Wood  &  Co.,  1911. 

111.  Stubenrauch:  Munch,  med.  Woch.,  1909,  No.  36.  Ahrens: 
Berliner  klin.  Woch.,  1909.  No.  48. 

11.  Hale  White:    Guy's  Hospital  Reports.  1902. 

12.  Nichols  and  Richardson:  Journal  of  Medical  Research,  vol 
\\i.    No.  2. 

13.  Nathan:  American  Journal  of  the  Medical  Sciences,  June, 
1909. 

I  t.   Llewelyn  Jones:    Arthritis  Deformans.     Win.  WTood  it  Co., 

IV  Still:  Allbutt's  System  of  Medicine.  1901,  vol.  iii.  See  also 
Llewelyn  Jones,  Arthritis  Deformans,  1909. 

16.  Albee:    Surgery,  Gynecology  and  Obstetrics,  March,  1910. 

17.  Ely:  Joint  Tuberculosis,  IVm,  Wood  &  Co.,  1911. 

Arthritis,  Deformans. — See  Rheumatoid  Arthritis. 

Arthrology. — That  part  of  anatomy  which  treats 
of  the  joints  or  connections  between  the  denser  parts 
if  the  skeleton.  By  means  of  these  joints,  or  articu- 
lations, the  skeleton,  originally  an  apparatus  for 
support,  becomes  an  apparatus  for  locomotion.  In 
its  primitive  condition  the  human  skeleton  is  without 
joints,  being  represented,  in  the  human  fetus  before 
the  fifteenth  day,  by  a  simple  non-jointed  rod  of 
condensed  embryonic  tissue  called  the  notochord, 
a  form  permanent  in  the  lowest  vertebrate  (amphi- 
is).  This  becomes  ensheathed  with  tissue  (Fig. 
175),  which  changes  to  cartilage  at  regular  intervals, 
thus  becoming  segmented  (Fig.  476).  Vestiges  of 
the  notochord  are  found  in  the  adult  as  pulpy  masses 
within   the  discs   which   unite   the   vertebra?.     Else- 


where   in    the    human    body   joints   are    formed    in   a 
similar    way.       I  •      laid    down    and     then     seg- 

mented   by    the   differentiation    of   certain    port 
into   cartilage,    which    may    aftei  ify.     The 

structures   by    which    union   is  effected   at    thi     joint 
may,  therefore,  be  considered  as  the  altered  remains  of 
the  original  skeletal   matrix.      Ground  the   segnu 
this   matrix    remains  as   fibrou     ti    ue,   termed   the 
perichondrium,  becoming  periosteum  when  ossifica- 
1 1 1  ■  1 1  i  ;i  ue  .  and  i  <•  I    ei  □   the      gments  it  occui     ■ 


Notl  "lion! 


Skeletogen- 
oua  layer. 


I  ii  . 


I  ,<  moinsox 
uotochord. , 


176. — Joints  Derived  from 
It.     tChUd  at  birth.) 


Fio.    475. — Notochord    without    Fit; 
Joints.     (Fetus  fifteen  days.) 

similar  fibrous  tissue,  changing  to  fibrocartilage  in 
certain  cases.  When  in  the  form  of  bands,  straps, 
or  membranous  sheets,  these  transegmental  struc- 
tures are  termed  ligaments.  They  may  unite  not 
only  the  apposed  ends  of  segments,  but  also  Un- 
related sides.  Sheets  of  this  sort  passing  laterally 
from  one  bone  to  another  in  the  same  plane  are  known 
as  interosseous  membranes.  Examples  are  seen 
between  the  radius  and  ulna,  and  between  the  tibia 
and  fibula.  The  entire  ligamentous  system  is 
closely  connected  with  the  fasciae,  of  which  it  may  be 
considered  a  specialization. 

The  prime  characteristic  of  joints  is,  therefore,  the 
movements  which  become  possible  by  reason  of  seg- 
mentation. These  movements  vary  according  to 
the  varying  functions  of  the  segmented  members, 
and  thus  produce  corresponding  modifications  of 
structure  in  the  parts  composing  the  joint.  Upon 
these  modifications  the  classification  of  joints  de- 
pends. In  all  joints  there  is  originally  sufficient 
intersegmental   tissue   to  permit   slight   and   limited 


Periosteum 


Bone 


Intersutural  \ 


ligament.    J 


Periosteum 
Bone . . . 


Cartilage  . 


suture. 


Fig.  47S. — Synchondrosis. 


motion.  Such  are  called  primitive  or  amphiarthro- 
dial  joints.  Examples  occur  in  the  adult  between 
the  bodies  of  the  vertebra;.  In  the  course  of  de- 
velopment the  osseous  or  cartilaginous  tissue  of  the 
segments  usually  tends  to  encroach  more  and  more 
upon  the  intersegmental  structure.  If  no  alteration 
occurs  in  this,  the  joint  becomes  less  and  less  movable 
until  complete  fixation  ensues.  It  is  then  termed 
synarthrodial  or  immovable.  Examples  are  seen 
in  the  adult  skull.     The  process  may  be  carried  so 


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Segment. 


far  a*  wholly  to  obliterate  the  joint.  When  the 
connecting  substance  is  fibrous,  the  joint  is  termed 
a  suture  (Fig.  477);  when  cartilaginous,  a  synchon- 
drosis (Fig.  478).     Strictly  speaking,  the  union  of  the 

shaft  of  a  long 
bone  with  its 
epiphysis  is  a 
s  y  nchondrosis. 
There  being  no. 
strain  caused 
by  movement 
i:i  this  class  of 
joints,  the  peri- 
osteum [lasses 
over  the  inter- 
segmental tis- 
sue without 
thickening  into 
ligamentous 
structures. 

Sutures  are 
found  only  be- 
t  w  e  e  n  bones 
that  are  developed  in  membrane,  like  those  of  the  face 
and  the  vault  of  the  skull.  They  form  a  special  class 
of  articulations,  their  function  being  not  so  much  to 
permit  movement  of  the  parts  united  as  to  separate 
those  parts  and  thus  allow  for  the  expansion  of  the 
inclosed  structures.  They  are  classified  according 
to  the  manner  of  apposition  of  the  edges;  when 
these  are  nearly  smooth  the  articulation  is  called  an 
harmonia,  when 


Segment 

i li.lllii'illll 

Fig.  479. — Formation  oi  the  Synovial  Cavity. 


Interarticular  \ 
ligament. 


Vertebra. 


Rib. 


they  are  cut 
obliquely  and 
override  in  a 
marked  degree 
it  is  a  sutura 
squa?nosa,  when 
they  interlock 
by  toothed 
edges  a  sutura 
serrata,  when 
an  edge  is  re- 
ceived into  a 
groove  and  en- 
sheathed,  as  occurs  w-ith  the  sphenovomerine  artic- 
ulation, it  is  a  schindylesis. 

Some  authors  describe  the  articulation  of  the 
teeth  with  their  sockets  as  an  additional  form  of 
synostosis,  giving  it  the  name  of  gomphosis. 

In  by  far  the  greater  number  of  cases  the  inter- 
segmental tissue  of  the  joint  becomes  altered.  Be- 
tween certain  of  the  cells,  vacuoles  or  small  cavities 

form    (proba- 


Synovial  \  , 
cavities.  / 
Fig.  480. — Costovertebral  Joint. 


Synovial  cavities. 


bly  by  the  en- 
largement of 
the  1  y  m  p  h 
lacunae  of  the 
connective 
tissue),  and 
these  join  to- 
gether, mak- 
ing a  larger 
cavity  or 
cleft.  The 
cells  immedi- 
ately around 
the  cavity 
form  a  secret- 
ing surface, 
the  synovial 
membrane 
(stratum  syn: 
oviale),  the 
product  of  secretion  being  a  glairy  fluid  called 
synovia.  The  membrane  resembles  the  similarly 
formed  serous  membranes  of  the  body,  though  it  is 
not  lined  with  endothelium.     Like  the  serous  mem- 

700 


m 

Interarticular  cartilages. 
Fig.  481.- — Formation  of  Arthrodial  Joints. 


branes,  it  is  very  vascular  and  is  liable  to  suddei 
and  dangerous  inflammations.  Synovial  cavitie 
are  formed  not  only  between  the  apposed  segment 
of  a  joint  (Fig.  479),  but  also  where  tendons  ml 
over  hard  surfaces,  or  where  the  skin  is  closel- 
applied  to  such  surfaces  and  friction  is  frequent  (se 
Bursce).  Small  and  imperfect  synovial  cavitie 
exist  in  a  few  amphiarthrodial  joints,  but  usualh 
the  joints  where  such  cavities  occur  are  freely  mov 
able  throughout  their  extent,  and  are,  therefore 
called  diarthrodial.     The  intersegmental  tissue  mai 


Perios 
teum 


Bone 


Cartilage. 


Perios-    ) 
teum.    j 


Bone. 


Fig.  482. — Fully  Developed  Arthrodial  Joint. 

not  be  wholly  obliterated  by  the  cavity.  When  the 
movement  of  the  segments  is  perfectly  regular  and 
small  in  amount,  it  may  remain  as  a  central  band 
with  a  cavity  on  each  side  and  ligamentous  structures 
surrounding  the  whole,  forming  a  capsule  or  envelope. 
This  is  a  peculiarity  of  the  articulation  of  the  heads 
of  the  ribs  with  the  spine  (Fig.  4S0).  When  the 
movement  is  such  that  the  articular  surfaces  do  no 
correspond,  a  synovial  cavity  is  sometimes  formed 
along  the  surface  of  each  segment,  leaving  an  inter- 
vening disc  of  fibrous  tissue,  which  becomes  partly 
cartilaginous  and  is  then  known  as  an  interarticular 


Fig.  4S3.- 


-A  Sesamoid  (Knee 
Joint). 


Fig.  484. — Planiform  or  Glid- 
ing Joint  (Patellofemoral). 
Sliding  and  coaptative  motion 
only. 


fibrocartilage  (meniscus  articularis)  (Fig.  481), 
Example,  lower  jaw  joint.  The  disc  may  become 
thinned  and  disappear  in  the  center,  leaving  a  ring 
(Fig.  4S1  shows  this  in  vertical  section).  This 
occurs  in  the  knee-joint.  Its  complete  disappear- 
ance is  shown  in  Fig.  482. 

Joints  may  be  formed  under  pathological  condi- 
tions, the  process  being  similar  to  that  just  described. 
After  fracture  the  ends  of  the  bone  are  first  united 
by  fibrous  tissue,  constituting  an  amphiarthrodial 
joint,  which  may  remain  permanently,  or  by  process 


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Arlliniliity 


|  repair  be  converted  into  synarthrodia!  and  finally 

jsappear;  or,  if  mobility  of  the  apposed  ends  be  riot 

strained,  there  may  be  developed  a  false  arthrodial 

tat  with  synovial  membrane  and  ligaments  formed 

,,m  the  surrounding  connective  tissue. 

II, ,.  action  and  relations  of  muscles  are  important 

in   shaping  and  otherwise   modifying  joints. 

mounding    they    afford    protection,    and    also 

lively  assist   the  ligaments  in  holding  together  the 

i  ends  of  the  segments;  differing  in  this,  thai 

nsion  can  be  adjusted  to  the  stress  placed  on 

rments.      They  are  invariably  attached  so  as 

,ort   the  articular  surfaces  with  reference  to 

ich  other,   never  pulling   them  apart.      Dislocations 

therefore    more   likely    to   occur   if   the   force    is 

pplied  suddenly,  before   the  muscles  can  be  put  in 


Transv.  ngt 


Syn.  cavities. 

|85. — Pivot  Joint  (Atlauto-epittrophic). 

A,  top  view;  B,  front  view. 


Rotation  only. 


etion,    and   are   rare    among    professional    athletes, 
v, (vantage  is  taken  of  this  peculiarity  of  the  muscles 
ng  a  dislocation,  this  being  much  more  easily 
en    the    patient    is    taken   off    his   guard,   or 
ulution  of  muscular  force  is  produced  by  an 
thetic.      Expansions   from   the   tendons  of    mils- 
strengthen  and  support  the  joints,  uniting  with 
!  iint  capsule.      When  the  strain  put  upon  these 
insions  is   habitually  great,  as  in  case  a   tendon 
o   er   the   angle   made  by   the   two  segments, 
he  connective   tissue  of  the  tendinous  expansion  is 
■  to  take   on  some  denser  form,  as  cartilage  or 
>one.     These  appear  as  small  nodular  bodies  known 
samoids,    and    possess    true    articular   surfaces. 
patella  is  the  largest  and  most  notable  example 
■f  these  (Figs.  483  and  484). 


First  meta- 
carpal. 


•  .  -Hinge  Joint  (El-  Fir,.  487.— Saddle  Joint  (Thumb). 
tow).  Angular  motion  in  one  Angular  motion  freest  in  two 
plane.  planes. 

Comparative  anatomy  shows  that  a  considerable 
number  of  the  ligaments  of  adult  joints  represent 
muscles  that  have  undergone  a  phylogenetic  change 
in  location  and  character.  Thus  the  internal  lateral 
ligament  of  the  knee  (lig.  collateral  tibiale)  represents 
a  former  extension  of  the  adductor  magnus,  the  ex- 
ternal lateral  ligament  (lig.  collaterale  fibularc)  an 
insertion  of  the  peroneus  longus,  the  great  sciatic 
ment  (lig.  sacrotuberosum)  an  insertion  of  the 
biceps  femoris. 

The  shapes  of  articular  surfaces  depend  mainly 
upon  the  direction  and  preponderance  of  the  muscu- 
lar force  applied  to  the  segments.  The  simplest 
movement  possible  is  the  sliding  of  one  nearly  plane 
-urface  upon  another.  This  is  the  ordinary  move- 
ment of  the  sesamoids.     Joints  in  which  this  is  the 


prevailing  movement  are  called  planiform  or  arthro- 
dial   (Eig.    -LSI).       There    are,    however,    no    articular 

surfaces  that  are  perfectly  plane,  there  being  no  .-it na- 
tion where  a  pulling  force  i^  applied  in  a  continuous 
straight  line  throughout  the  extent  of  the  move- 
ment. For  this  rea  on  there  i  al  o  found  in  plani- 
form joints  a  slight  rolling  of  convex  surfaces  on  each 
other.  This  is  called  coaptation.  When  the  sur- 
faces are  markedly  curved  a  variety  of  movements 
may  take  place.  Motion  around  an  axis  passing  lon- 
gitudinally through  one  of  the  segments  is  called 
rotation.     Pivot  joints  (trochoides)  possess  only  this 


Thumb. 


Fig.  4SS. — Pommel  Joint  (Wrist) .     Angular  motion  in  all  planes. 


movement,  and  are  exemplified  in  the  atlanto-epis- 
trophic  and  proximal  radio-ulnar  articulations  (Fig. 
185).  Bending  the  segments  so  as  to  alter  the 
angle  they  make  with  each  other  is  called  angular 
movement.  When  lateral,  to  or  from  the  axis  of  the 
body  or  limb,  it  is  further  distinguished  as  adduction 
and  abduction;  when  forward  or  backward,  folding 
or  unfolding  the  segments,  as  flexion  and  extension. 
A  hinge  joint  (ginglymus)  is  one  in  which  such  motion 
is  allowed  in  a  single  plane  only.  The  elbow  is  the 
best  example  (Fig.  4S6).  The  shape  of  the  surfaces 
may  allow  free  angular  movement  in  some  directions 


'?n\  Hip  bone. 


Fig.  4S9.— BaU-and-Socket  Joint  (Hip).     All  movements. 

while  limiting  it  to  some  extent  in  others.  In  the 
saddle  joint  (articulatio  sellaris,  Fig.  4S7),  and  the 
pommel  joint  (articulatio  ellipsoidea,  Fig.  48S),  the 
motion  is  freest  in  two  planes  at  right  angles  to  each 
other.  In  the  former,  each  surface  is  convex  in  one 
plane  and  concave  in  the  other;  in  the  latter,  the  sur- 
faces are  reciprocally  ellipsoidal.  These  two  classes 
of  joints  allow  all  "movements  except  rotation,  it 
being  possible  to  perform  circumduction  or  such 
swinging  of  the  distal  segment  through  a  series  of  an- 
gular positions  as  to  make  it  generate  a  conical  sur- 
face.     When  the  joint  consists  of  a  head  nearly  spher- 

701 


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ical  received  into  a  closely  fitting  cavity,  it  i.s  known 
as  a  ball-and-socket  joint  (enarthrosis,  Fig.  489),  in 
which  great  freedom  of  motion  is  allowed,  all  move- 
ments being  possible. 

The  following  table  shows  how  joints  may  be  classi- 
fied according  to  a  genetic  system: 


Patellofemoral. 
Tibiofibular. 

Tarsal,    except   talonavicular  and  calcaneo- 
cuboid. 
Tarsometatarsal. 
Intermetatarsal. 


CLASSIFICATION  OF  JOINTS. 

Primitive  Joints   (Amphiarthroses). 


Without  Synovial  I 


With  Synovial  Cavity. 


Immovable  Joints   >  Synarthroses). 


United 

by  cartilage. 

Synchondroses. 


United  by 

connective  tissue. 

Suture. 


Freely  Movable  Joints  (Diarthroses). 


Motion  sliding  or  coaptu 
surface-  nearly  fiat. 
I'la.mform. 


Motion  curvilinear, 
surfaces  curved. 

XoN-PLANIFORM. 


Edges  smooth. 

Edges 

Edges 

Edges  en- 

Rotation 

Hakmonia. 

i  iverlap. 

toothed. 

sheathed. 

only. 

StJTURA 

StJTURA 

SCHINDYLE- 

Pivot Joints. 

Squaw  ISA 

Serrata. 

SIS. 

Angular  Angular  Angular         All  movements 

motion  one        motion  freest       motion  all  Ball-and- 

plane.  in  two  planes.  planes.  Socket  Joints. 

Hinuk  Joints.  Saddle  Joints.  Pommel  Joints. 


The  following  is  a  list  of  the  joints  of  the  human 
body  arranged  upon  the  foregoing  principles  of  clas- 
sification. As  in  all  natural  classification,  perfectly 
clear  and  sharp  distinctions  do  not  exist,  many  joints 
being  somewhat  mixed,  blending  the  characters  of 
two  or  more  classes. 


TABLE  OF  THE  JOINTS. 

Order  I. — Primitive  Joints,  or  Amphiarthroses. 
Class   1. — Without  a  Synovial  Cavity. 

Intervertebral — of  bodies. 

Lumbosacral. 

Sacrococcygeal. 

Sternal. 
Class  2. —  With  an  Imperfect  Synovial  Cavity. 

Sacroiliac. 

Interpubic  (symphysis  pubis). 

Order  II. — Immovable  Joints,  or  Synarthroses. 
Class  1. — Sutures. 

Joints  between  the  bones  of  the  skull,  ex- 
cept    occipitosphenoid    and    ethmovo- 
merine. 
Class  2. — Synchondroses. 
Occipitosphenoid. 
Ethmo  vomerine. 
Chondrosternal  of  first  rib. 
Costochondral. 

Order  III. — Movable  Joints,   or  Diarthroses. 
Class   1. — Planiform  Joints,  or  Arthrodia. 
Intervertebral,  of  articular  processes. 
Lumbosacral,  of  articular  processes. 
Costovertebral  (costocentral). 
Costovertebral  (costotransverse). 
Chondrosternal,  second  to  seventh  ribs. 
Interchondral,  sixth  to  ninth   costal  carti- 
lages. 
Sternoclavicular. 
Acromioclavicular. 
Radioulnar,  distal. 
Carpal — between  single  bones. 
Carpometacarpal,  except  thumb. 
Intermetacarpal. 

702 


Class  2. — Pivot  Joints,  or  Trochoides. 

Atlantoepistrophic. 

Radioulnar,  proximal. 
Class  3. — Hinge  Joints,  or  Ginglymi. 

Elbow-joint  (humeroulnar). 

Phalangeal,  of  hand. 

Knee-joint  (femorotibial). 

Ankle-joint  (talocruraltibia  and  fibula  with 
astragalus). 

Phalangeal,  of  foot. 
Class  4. — Saddle  Joints. 

Carpometacarpal,  of  thumb. 

Calcaneocuboid,  of  ankle. 
Class  5. — Pommel  Joints  (Condyloid). 

Temporomaxillary  (mandibular) . 

Atlantooccipital. 

Radiocarpal. 

Intracarpal    (os    magnum    with    semilunar 
and  scaphoid). 
Class  6. — Ball-and-Socket   Joints    (Enarthrodia). 

Shoulder-joint  (scapulohumeral). 

Metacarpophalangeal. 

Hip-joint  (coxal  =  coxofemoral). 

Tarsal,  (talonavicular). 

Metatarsophalangeal. 

An  examination  of  the  intimate  structure  of  adult 
joints  involves,  (1)  the  ends  of  the  segments  (usually 
bones);  (2)  the  articular  cartilages  which  protect 
them;  (3)  the  fibrocartilages  which,  when  present, 
adapt  the  surfaces  to  each  other;  (4)  the  ligaments 
which  prevent  their  separation;  (o)  the  synovial 
membranes  which  by  their  secretion  lubricate  the 
surfaces. 

At  joint  surfaces  pressure  and  movement  occasion 
a  modification  in  the  ordinary  structure  of  bone. 
The  ends  are  enlarged  and  the  surfaces  are  of  ex- 
tremely compact  tissue,  protected  by  a  layer  of  hyaline 
cartilage,  the  remains  of  the  original  cartilage  from 
which  the  bone  was  formed.  Acting  as  a  buffer  to 
break  shocks  and  to  prevent  wear,  it  is  invariably 
thickest  where  the  pressure  is  greatest  (see  Fig.  482). 
Under  normal  conditions  it  never  ossifies,  although 
in  old  age  and  in  persons  of  inactive  life  it  becomes 
thinned  and  infiltrated  with  lime  salts.     Should  it 


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Artlirolncy 


& 


ly 


'% 


B  M 


■i  i 


K'i 


V 


7  . 

3! 


egg 


ough,    the    bone    becomes    rapidly    worn    smooth 
burnated)   and   the  joint    is  disabled.     The  super- 
nal  cells   of   tlic   cartilage  are 
■d.  but  in  the  deeper  parts 
iey  multiply  in  the  line  of  the      yj   -. 
stress,  and  arc  therefore 
I  in  columns  perpendicu- 
,   to  the  articular  surface  (Fig. 
which  directions  sudden 
may  cause  the  cartilage  to 
ilit.     The  fibrocartilages  found 
joints  arc  composed  of  while 
tissue,  n  ith  -parse  elastic 
to    impart    the  necessary 
siliency.       Their  usual  form  is 
■  'discs  or  rings  attached 
ainlv  to  the  more  movable  sen: 
either  by.  their  edges  (knee, 
or  by   the  edge    and    one 
irfaoe    (hip,    shoulder).       The 
be  i    completi    enlarg- 
es the  cavity  on  one  side  only 
ih&langi 

original  capsular  arrange- 
lent    of  the  ligaments  remains 
s  in   which   the  joint    is 
e||  protected  by  muscles  and 
ie  strain  is  evenly  distributed. 
a    most    joints,    however,    the 
ring    much    greater    in 
>uie  directions  than  in  others, 
capsule  becomes  thickened 
>  counteract  it,  forming  bands 
Inch     nave     received     special 
aines.      Atmospheric    pressure, 
.ting  against  the  force  of  grav- 
sists  in  keeping  thearticu- 
ir  surfaces  in  apposition,  thus 
re  venting    a    constant    strain 
pon    the    ligaments.      An  im- 
ortant  office  of  the  ligaments  is  to  limit  the  motion 
f  the  segments  and  prevent  the  shocks  which  would 
otherwise  occur  from  the  sud- 
,  den  contact  of  bony  surfaces. 

In  some  cases  they  greatly 
economize  muscular  force  by 
holding  the  joint  in  a  set 
position.  Thus  but  little 
force  is  required  to  maintain 
the  body  erect,  as  it  is  sup- 
ported mainly  by  the  tension 
of  the  ligaments  of  the  spinal 
column,  by  the  iliofemoral 
ligament  at  the  hip,  and  by 
the  posterior,  lateral,  and 
crucial  ligaments  at  the  knee; 
these  lying  always  on  the 
convex  side  of  arcs  subtended 
by  the  line  of  the  center  of 
gravity  (Fig.  491).  Owing  to 
their  function  as  limiters  of 
motion,  it  follows  that  the 
position  of  greatest  relaxation 
for  all  the  ligaments  of  a  joint 
is  one  midway  between  flexii  in 
and  extension.  In  case  of  the 
distention  of  a  joint  cavity  by 
a  morbid  effusion,  the  patient 
involuntarily  places  the  joint 
in  such  a  position. 

Synovial  membranes  origi- 
nate as  continuous  and  closed 
sacs,  but  over  the  articular 
surfaces,  where  pressure  oc- 
curs, portions  of  them  disap- 
pear; so  that,  at  the  latter 
part  of  fetal  life,  they  merely 
line   the   capsule  and  extend 


m 


X-  • 


Fig.  490. — Articular  Cartilage.      .4,  Flattened 

cells;    B,  cells  in  column-;   C,   region  infiltrated 
with  lime;  Z>,  bone.     (After  Sappcy.) 


Fig.  491. — Ligaments 
Supporting  Erect  Posture. 
A,  Anterior  set;  B,  poste- 
rior set. 


but  a  shorl  di  tance  upon  the  cartilages  of  the  joint. 
In  adult  age  they  frequently  are  further  extended  by 

< ' ' '  m  1 1 1 1 1 1  r  i  i .  ■ ;  i !  Km  u  illi  I  he  -\  ],.,\  ial 

cavities   of   neighboring   bu 

;-~  "    .  .--                       and      nil    ci  ii  be- 
come   re  i  "  quenl  and  exten- 

more   lax  than  the  surroum 
ligaments,     being     thrown     into 
folds  to  increase  the  blood  supply 

and    In   pad   0U(    i 
~  ,  a     isted    in    this   by    interstitial 

deposits  of  fat.     Along  the  inter- 
articular   lines  lln  vil- 

.}     '.      Inns   pr or  fringe-,  some 

of   which   contain   cartilaginous 
les  (Fig.  492). 
It   is  at  or  near  the  joints  that 
at  \  ascuiar  trunk-  di 
an  arrangement  \\  hich  is  p 
bly  connected  with   the  centrip- 
etal    development     of     bl I- 

vessels  and  the  bud-like  forma- 
tion of  limbs  in  the  embryo. 
The  immediate  supply  of  the 
joint  is  obtained  from  small 
vessels  that  anastomose  freely 
with  otn  anot  her.  By  them  the 
collateral  circulation  is  estab- 
lished when  the  main  trunk  is 
occluded.  From  these  vessels  a 
rich  arterial  network  penetrates 
the  capsule  to  supply  the  syno- 
vial membrane.  Abundant  cap- 
illaries lie  in  loops  along  the 
synovial  folds,  and  by  exudation 
from  them  the  synovia  is  ap- 
parently formed.  The  articular 
cartilages  and  the  compact  layer 
of  bone  immediately  contiguous 
are  normally  destitute  of  vessels,  but  capillaries  rapidly 
extend  into  them  during  inflammation.  The  fibro- 
cartilages are  stated  by  Sappey  to  contain  vessels,  and 
may  therefore  take  an  active  part  in  inflammatory 
processes.  Lymphatics  are  numerous  near  joints. 
Klein  considers 
the  joint  cavity 
itself  as  a 
lymph  space 
communicating 
directly  with 
the  lymphatics. 
The  nerves  of 
joints  are  dis- 
tributed mainly 
to  the  synovial 
membrane  and 
the  ligament- 
ous structures. 
It  is  probable 
that  in  these  sit- 
uations special 
nerve  endings 
e  xist,  as  de- 
scribed by 
Krause  and 
Xicoladoni,  for 
it  is  difficult 
otherwise  to  ac- 
count for  the 
peculiar  sensi- 
bility of  the 
structures.      A 

ligament  or  a  synovial  membrane  may  be  touched,  cut, 
or  pinched  without  giving  much  pain,  but  if  it  be 
stretched  beyond  its  physiological  limit,  threatening 
the  integrity  of  the  joint,  the  suffering  is  excruciating, 
as  is  well  known  to  those  who  have  suffered  from  a 


FlQ.  492. — .Synovial  Fringes.      X  200. 
(Modified  from  Henle.) 


703 


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sprain  or  a  dislocation.  Articular  cartilage  has  no 
nerves,  and  the  gnawing  pain  which  occurs  during  its 
ulceration  is  probably  caused  by  inflammatory 
products  affecting  the  nerves  of  contiguous  tissues. 
A  remarkable  law  of  correlation  has  been  noted  by 
Hilton  with  reference  to  the  nerves  of  joints,  viz., 
that  they  also  supply  the  muscles  w-hich  move  the 
joint  and  the  skin  over  the  insertion  of  such  muscles; 
the  whole  apparatus  being  thus  under  the  control  of 
associated  central  influences.  There  is  besides 
strong  clinical  evidence  of  this.  Remak  and  Bene- 
dikt  have  pointed  out  the  strong  probability  that 
many  diseased  conditions  of  the  joints  originate  in 
irritable  states  of  the  spinal  cord  and  of  the  sym- 
pathetic, and  Charcot  has  published  some  cases 
showing  remarkable  atrophy  of  the  muscles  of  a 
joint  after  an  injury  to  the  articular  surfaces  com- 

£aratively  slight   and   inadequate   to  such   a  result. 
ocomotor  ataxia  is  usually  accompanied  by  joint 
lesions. 

For  the  anatomy  of  special  joints  see  the  following 
heads:  Ankle  Joint;  Elbow  Joint;  Foot,  Joints  of; 
Hand,  Joints  of;  Hip  Joint;  Knee  Joint;  Pelvis, 
Joints  of;  Shoulder  Joint;  Skull;  Thorax;  Wrist. 

Frank  Baker. 

References. 

Besides  the  systematic  work  on  anatomy  by  Quain,  Gray,  Allen. 
Morris,  Piersol,  Cunningham,  Sappey,  Cruveilhier,  Henle,  Hyrtl, 
Gegenbaur,  Testut  and  Poirier,  the  following  authorities  have 
been  consulted  in  preparing  this  article: 

Morris,  William:     The  Anatomy  of  the  Joints,  London,  1S79. 

Turner:  An  Introduction  to  Human  Anatomy,  Edinburgh, 
1SC7. 

.Marshall:     Anatomy  for  Artists,  London,  1SS3. 

Humphry:  The  Human  Skeleton,  including  the  Joints,  London, 
1S58. 

Henke  und  Reyher:  Ueber  die  Entwickelung  der  Gelenke, 
Sitzungsber.  der  Wiener  Acad,  der  Wissensch.,  Bd.  lxx. 

Aeby:     Der  Bau  des  menschlichen  Korpers,  Leipzig,  1S71. 

Martin:  Ueber  die  Gelenkmuskeln  beim  Menschen,  Erlangeri, 
1874. 

Meyer:  Die  Statik  und  Mechanik  des  menschl.  Knochengeriistes, 
Leipzig,  1873. 

Fick,  Rudolf:  Handbuch  der  Anatomie  und  Mechanik  der 
Gelenke,  Jena,  1904-1911. 


Arthropathy.  —  Hypertrophic  Osteoarthropathy. 
Unider  this  head  it  has  until  lately  been  the  custom 
to  nclude  a  variety  of  disorders  with  osseous  hyper- 
trophy, more  particularly  of  the  ends  of  the  long 
bones.  General  hyperostosis,  osteititis  deformans, 
acromegaly,  and  chronic  pulmonary  osteoarthro- 
pathy have  been  fully  described  by  Freidrich, 
Paget,  Marie,  Emerson,  and  others  and  their  forms 
of  bony  change  and  enlargement  have  been  ascribed 
to  syphilis,  tuberculosis,  disease  of  the  hypophysis, 
and  toxic  influences. 

Hypertrophic  Pulmonary  Osteoarthropathy  describes 
the  condition  more  familiarly  known  as  "clubbed 
fingers"  which  is  found  in  patients  suffering  from 
pulmonary  tuberculosis,  or  chronic  disease  of  the 
lungs  and  of  some  other  organs,  such  as  bronchitis, 
bronchiectasis,  empyema,  pleurisy,  malignant  and 
gangrenous  disease,  as  well  as  cirrhosis  and  congenital 
cardiac  affections,  and  as  the  result  of  toxic  absorption 
of  various  kinds.  It  is  generally  considered  to  be 
directly  due  to  bacterial  changes. 

The  striking  appearance  of  the  fingers  or  toes  of 
such  patients  is  quite  characteristic,  being  due  to 
enlargement,  which  is  found  on  both  sides  of  the 
body.  This  is  associated  with  changes  in  the  nails 
which  are  incurved  or  flattened,  with  resulting  de- 
formity. The  root  of  the  nails  is  elevated  and  when 
pressure  is  made  there  is  the  feeling  as  if  fluid  was  be- 
neath. The  nails  are  often  brittle  and  sometimes  cre- 
nated.  The  curving  may  be  longitudinal,  or  again 
only  the  ends  are  bent  downward.  The  onset  of  the 
disorder  is  attended  by  pain,  which  may  be  acute,  and 

704 


by  awkwardness  of  movement  and  stiffness,  and  an  in 
ability  to  flex  and  close  the  hand.  This  is  not  due  t 
muscular  paresis  but  is  rather  the  result  of  mechanics 
difficulty,  due  to  the  thickening  of  tissue  and  en 
largement.  In  aggravated  cases  there  is  a  "paw 
like"  appearance  of  the  hand,  which  resembles  tha 
of  an  animal. 

Sternberg  and  others  have  sought  to  classify  th 
symptoms,  but  as  Emerson1  has  pointed  out,"  it  j 
probable  that  the  three  divisions  of  this  observe 
are  but  different  periods  of  the  disease.  A  shor 
acute  stage  ordinarily  precedes  the  chronic,  and  it  i 


Fig.  493. 


-The  Hand  in  Hypertrophic  Pulmonary  Osteoarthro- 
pathy. 


quite  possible  that  the  remarkable  bony  enlargements 
that  are  subsequently  found  are  but  an  advance  in 
the  conditions.  Marie's  cases,  however,  are  so  striking 
and  the  hypertrophy  so  general  as  to  suggest  acrome-  , 
galy.  All  the  large  joints  except  the  hip  may  he  ' 
involved,  and  the  inclusion  of  the  vertebrae  in  the 
process  may  give  rise  to  a  kyphosis.  The  deformity 
of  the  hands  in  well  marked  and  advanced  examples 
is  remarkable. 

The  metacarpal  joints  seem  to  be  the  favorite  site 
of  the  enlargement  rather  than  the  phalanges,  but  the 
whole  finger  may  have  a  "drumstick"  appearance. 
The  skin  is  likely  to  be  wrinkled  and  blue,  tense  and 
glossy. 

There  seem  to  be  variations  in  the  amount  and 
degree  of  the  swelling  proportionate  to  the  activity 
and  gravity  of  the  purulent  disease;  in  empyema  the 
clubbing  may  appear  in  a  few  weeks  and  disappear 
when  the  pus  is  removed  by  paracentesis,  and  sub- 
sidence or  cure  of  other  conditions  leads  to  diminution 
of  the  hypertrophy. 

The  advanced  disease  when  at  all  formidable, 
resembles  acromegaly,  but  there  are  decided  differ- 
ences. The  mental  condition  of  the  latter  as  well 
as  the  polyuria  and  glycosuria,  optical  changes, 
peculiar  enlargement  of  the  lower  jaw  with  prog- 
nathism, squareness  of  the  face,  prominence  of  the 
malar  bones,  elongated  appearance  of  the  upper 
lip,  and  swelling  of  the   tongue  are  all  features  of 


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Arthropathy 


■romegaly  but  not  of  the  arthropathia  condition, 
he  nails  are  .small  in  acromegaly  and  neither  cur\  ed 
,r  deformed. 

Hypertrophic  pulmonary  osteoarthropathy  is  some 
mes  mistaken  for  arthritis  deformans  because  of 
the  presence  of  enlarged  nodes  in 
the  fingers  corresponding  to  the 
insert  ion  of  t  he  extensor  tendons, 
but  the  diagnosis  should  not  be 
difficult. 

An  examination  with  Roentgen 
rays  shows  the  new  bone  forma- 
tion and  considerable  swelling. 
The  ends  of  the  long  bom 
especially  the  ulna  and  tibia,  are 
found  to  be  increased  in  size. 

The  disease  is  rarely  found 
among  negroes,  and  as  a  rule  is  a 
condition  affecting  adult  males. 

The    prognosis    depends   upon 
the  course  of  the  underlying  dis- 
ease, for  if  the  latter  is  cured,  the 
enlargement  often  subsides.    The 
pain  and  swelling  of  the  fingers 
in   the  acute  stage  may  be  best 
relieved  by  moist  heat,  or  by  the 
e  of  a  mixture  of  Fuller's  earth  and  glycerin,  which 
sold  as  a  proprietary  article  known  as  antiphlogis- 
tic, or  as  cataplasma  kaolini  (U.  S.  P.). 

Arthropathies  of  Neurotic  Orioin. — As  far 
ick    as    1S31    the    elder    Mitchell2    first    described 

i  uliar  joint  troubles  that  affected  individuals  who 
id  suffered  from  cerebral  disease;  and  in  1846  Scott 
lison'  of  London  more  fully  described  these 
quote,  presenting  several  cases  in  which  the  joints 


194      Arthro- 
uliy  of  Right  Knee 
I  Buzzard.) 


the    par 

iritis  lie 


(iritis  tie  believed  to  be  due  to  a  condition  of  the 

ticular  surface  which  results  from  the  diminished 

itality  of  the  paralyzed  parts  and  the  presence  of 

ric  acid,  which  under  such  circumstances  acted  as 

u  irritative  agent. 

hater,  Brown-Sequard4  and  Charcot5  directed 
I  tention  to  the  really  important  nature  of  such  com- 
lications  of  organic  paralysis,  and  the  early  researches 
I  Alison,  Durand-Fardel,  Valleix,  Grisolle,  and 
have  been  collected  and  carefully  considered 
y  them.  Buzzard  later  investigated  these  arthro- 
athies,    especially    in    connection    with    locomotor 

:i\ill. 

It  would  appear  that  such  morbid  changes  are 
sually  associated  with  those  forms  of  cerebral  and 
final  disease  in  which  the  sensory  tracts  are  most 
ively  invaded,  though  this  is  by  no  means  the 
[variable  rule.  They  are  common  in  posterior 
■  I  sclerosis  and  rare  in  essential  spinal  paralysis, 
ii  affection  in  which  disorders  of  sensibility  are  the 
xception.  They  are  rare  in  cerebral  disease  without 
ome  ascending  degeneration  symptomatized  by  pain, 
ad  the  observations  of  Charcot  regarding  the 
■ntral  lesion  would  bear  this  out.  Arthropathies 
nay  be  either  cerebral  or  spinal,  and  the  former  are 
nuch  more  rare  than  the  latter.  They  have  been 
1 'served  in  connection  with  coarse  brain  disease,  such 
3  softening  with  hemorrhage,  tumor,  or  sclerosis; 
.iid  are  usually  early  symptoms  of  established  cerebral 
ii  i  ttief;  especially  is  this  true  in  the  matter  of 
lemorrhage.     After  a  period  of  from  fifteen  days  to 

■  oral  months  after  the  acute  central  trouble  we  find 
hat  the  joints  of  the  paralyzed  hand  or  foot  become 

ected  — the  former  more  often  (Charcot) — coin- 
idently  with  the  contractions  which  mark  the 
vdyent  of  rigidity  and  secondary  degeneration.  In 
uison's  cases  the  knee  and  ankle  were  affected. 

Symptoms  and  Course. — The  joint  disturbances 
"'gin  in  one  of  two  ways:  (1)  Suddenly,  the  large 
"hits  being  affected;  (2)  slowly,  the  joints  of  the 
land  and  foot  being  the  parts  attacked.     In  the  first 

Vol.  I.— 45 


form  there  develops  rather  suddenly,  within  a  few 
weeks,  a  swelling  which  is  unattended  by  any  marke  I 
rise  of  tempera!  ure  al  lea  t  by  anj  uch  n 
would  expect  to  find  in  an  acute  arthritis  of  purely  rheu- 
matic origin.  There  are  but  little  local  heat  and  pain, 
but  a  great  deal  oi  soreness  when  the  limb  is  moved. 
Jarring  produces  only  incon  iderable  sniveling.  1 
have  never  met  with  the  degree  of  pam  described  by 

Urown-Sequard.      There  is  more  Or  fe       pain  produci    I 

by  pressure  over  the  tendons,  the  sheaths  of  which 
seem  to  be  involved.  The  joint  is  greatly  swollen, 
the  enlargement  being  made  much  more  prominent 
in  old  cases  by  reason  of  the  atrophy  of  muscular 

ma     es    in    the   vicinity.      There   seems    to   be   a   deep 

involvement  of  the  joints  and  of  adjacent  parts,  and 
though  t  here  may  be  a  synovitis,  il  is  of  a  low  grade, 
and,  as  Buzzard"  has  pointed  out,  there  is  really  great. 

tumefaction,  which  characterizes  the  familiar  form  of 

chronic  synovitis,  in  which  there  are  three  points  of 
swelling,  viz.,  above  the  patella,  and  on  either  side  of 
the  ligament  um  patella. 

The  appearance  of  the  affected  joint  is  peculiar. 
The  swollen  limb. shows  a  duskiness  and  hardness  in  the 
beginning,  and  a  cold,  "white  hardness"  in  the  old 

cases.  In  some  cases  there  is,  after  a  few  days  or 
weeks,  a  .subsidence  of  the  swelling,  and  I  hen  certain 
osseous  changes,  to  be  presently  described,  take 
place. 

The  occurrence  of  spinal  arthropathy  may  follow  a 
variety  of  conditions.  As  has  been  pointed  out  by 
Mitchell,  it  may  be  connected  with  Pott's  disease, 
with  myelitis  (Gull),  with  tumors  of  the  gray  sub- 
stance of  the  cord  (Buzzard),  with  posterior  spinal 
sclerosis  (Charcot),  and  with  traumatic  injury  of  the 
cord  (Vignes  and  Joffroy). 


Fig.  4U5. — Progressive  Atrophy  Resembling  Acromegaly. 

According  to  Charcot  the  condition  is  often  an 
earlj' complication  of  tabes  dorsalis,  but  others  think 
that  it  belongs  to  the  late  stages  of  the  disease. 
It  is  quite  true  that  in  acute  myelitis  we  may  have  a 
rapidly  developing  arthropathy,  but  in  cases  in  which 
it  is  associated  with  a  tumor  of  the  cord  or  with 
locomotor  ataxia  the  affection  is  a  much  more  slow 
affair.  Charcot  believes  that  those  arthropathies 
which  affect  the  upper  extremities  in  the  disease 
under  consideration  are  always  secondary  to  others 
involving  the  lower  extremities,  and  come  only  late 
in  the  disease  as  a  result  of  extension  of  the  morbid 
process.  Buzzard  reports  a  case  which  contradicts 
this,  and  the  author  has  seen  others. 

The  enlargement  in  the  chronic  variety  is  slow, 
and  a  point  is  finally  reached  when  deep  destructive 
processes  begin,   the  articular  surface  of  the  bones 

705 


Arthropathy 


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being  worn  away  or  absorbed,  so  that  movement  of 
the  joint  on  manipulation  will  produce  a  peculiar 
creaking  or  cracking  sound;  and  when  the  joint  has 
for  some  time  been  the  seat  of  the  trouble  it  is  com- 
mon for  luxation  to  occur.  The  position  of  the  ex- 
tremity upon  the  bed  is  peculiar,  and  the  patient 
often  presents  a  most  strange  deformity.  Happily 
the  arthropathy  need  not  always  go  on  to  this  stage 
and  it  occasionally  happens  that  cures  are  made. 
On  the  other  hand,  the  erosion  and  destruction  may 
be  very  rapid:  Charcot  says:  "Even  within  two 
weeks,  or  sooner,  the  'craquements'  may  be  detected, 
which  indicate  a  profound  alteration  in  the  articular 
surfaces."  At  the  end  of  three  months  the  head  of 
the  humerus,  in  one  of  his  cases,  was  found  to  be 
almost  completely  destroyed. 

Progressive  Arthropathy. — There  is  a  form  of 
arthropathy  of  a  progressive  nature  of  which  I  have 
seen  but  one  true  case,  and  I  do  not  know  that  any 
other  has  been  reported.  In  the  patient  who  came 
under  my  notice,  a  sudden  swelling  of  both  ankles 
occurred,  with  little  or  no  pain,  and  in  less  than  one 
year  both  thumbs  and  ring  fingers  became  in  turn 
affected,  and  ultimately  both  little  fingers.  The 
metacarpal  joints  were  the  seat  of  a  hard  and  quite 
extensive  swelling,  with  some  general  edema,  more 
marked  on  the  palmar  surface.     The  patient  could 


a' 


Fig.  496. — A,  A',  Right  and  left  anterior  horns;  B,  posterior 
gray  commissure  and  central  canal;  C,  anterior  fissure;  6,  b' ,  an- 
terior internal  group  of  great  cells;  a,  a',  anterior  external  group 
of  great  cells;  <r\  posterior  external  group  of  great  cells  on  right 
side;  c,  locality  where  corresponding  cells  have  disappeared  on 
left  side.     (Charcot.) 

flex  neither  the  thumb  nor  the  other  affected  fingers, 
but  the  second  and  third  fingers  seemed  to  be  unim- 
paired so  far  as  their  mobility  was  concerned.  The 
ankle  joints  were  lax  and  some  absorption  of  bone  had 
evidently  taken  place.  There  was  no  history  of 
gout  or  pulmonary  disease  in  this  case.  The  affected 
parts  had,  before  the  appearance  of  swelling,  been  the 
seat  of  neuralgic  pains.  The  right  pupil  was  smaller 
than  the  left,  and  there  were  interesting  nutritive 
skin   changes   and   a   peculiar   slowness   of   gait.* 

Diagnosis. — The  history  of  arthropathies  in  gen- 
eral furnishes  us  with  points  which  enable  us  to  make 
a  comparatively  clear  diagnosis.  The  antecedent 
cerebral  or  spinal  disease  is  a  determining  factor,  and 
the  peculiar  nature  of  the  joint  affection  itself  is  con- 
clusive. It  is  unnecessary  to  repeat  here  what  has 
already  been  said  about  the  possibility  of  confusing 
the  condition  in  question  with  ordinary  chronic  syno- 
vitis. I  may,  however,  remind  the  reader  that  the 
effusion  is  always  beneath  the  muscles,  and  the  skin 
has  a  polished  appearance  and  presents  no  appear- 
ance suggestive  of  inflammation.  There  is  often  great 
embarrassment  in  flexion,  though,  as  in  Buzzard's 
case,  extension  is  not  interfered  with,  and  there  is 
no  pitting  at  the  joint.  In  the  case  alluded  to,  he 
made  an  application  of  the  electrodes  of  an  induction 

*  This  case  was  reported  in  the  first  edition  of  this  work,  and 
since  then  it  has  in  many  ways  resembled  the  disease  which  was 
afterward  described  as  acromegaly. 


battery  over  the  quadriceps  muscle,  just  above  the 
patella.  When  the  swelling  was  very  great,  he  ob- 
tained a  powerful  contraction,  which  proved  the 
fact  that  the  muscle  was  superficial  to  the  fluid.  The 
affection  sometimes  resembles  arthritis  deformans, 
but  it  rarely  involves  the  hip  joint.  It  is  of  sudden 
appearance,  is  often  cured,  the  effusion  is  greater 
and  the  swelling  more  general  than  in  the  latter  dis- 
ease, and  there  are  luxations  as  the  result  of  erosion, 
which   is    not    the    case    in   rheumatoid    arthritis. 

Pathological  Anatomy. — Charcot  has  found  in 
one  case  evidences  of  a  true  synovitis^multiplication 
of  nuclear  elements  and  thickening  of  fibrous  tissue — 
increase  in  size  and  number  of  capillary  vessels,  and 
an  increased  amount  of  exudation  containing  leuco- 
cytes. In  this  case  he  found  macroscopic  lesions  of 
the  cartilages  or  of  the  ligamentous  parts. 

In  the  cases  of  cerebral  origin  a  variety  of  interest- 
ing changes  were  found  by  Alison,  but  none  threw 
much  light  upon  the  pathology  of  the  condition,  and 
the  same  thing  may  be  said  of  the  autopsies  presented 
by  other  observers.  Charcot,  however,  found  that 
in  locomotor  ataxia  there  was  a  disappearance,  upon 
the  same  side  of  the  body,  of  the  posterior  lateral 
group  of  large  cells  in  the  anterior  cornu.  A  case 
presented  by  Joffroy  and  himself  was  carefully  studied, 
and  it  was  found  that  the  anterior  gray  horns  were 
"remarkably  atrophied  and  deformed."  Fig.  496 
represents  a  section  made  through  the  anterior  horns 
in  the  cervical  cord  of  a  patient  who  presented  an 
arthropathy  of  the  shoulder  joint.  In  a  second  case 
which  was  examined  by  these  investigators,  and  in 
which  the  knee  joint  was  affected,  it  was  found  that 
the  anterior  gray  substance  in  the  lumbar  region  had 
undergone  a  conspicuous  alteration.  Charcot  does 
not  believe  that  this  degeneration  is  a  result  of 
functional  inertia,  because  in  his  cases  there  was  con- 
siderable freedom  of  movement,  and  central  appear- 
ances did  not  resemble  in  the  least  those  found  after 
amputation. 

Prognosis. — The  prognosis  of  progressive  arthro- 
pathy is  by  no  means  good,  although  it  has  been 
claimed  that  cures  have  been  effected.  The  benefit 
of  therapeutic  measures,  if  to  be  obtained  at  all, 
must  be  shown  at  an  early  period,  and  if  the  morbid 
process  has  gone  so  far  as  to  result  in  destruction  of 
the  articular  surfaces,  little  or  nothing  can  be  gained 
by  any  treatment.  It  must  be  admitted  that  in 
spinal  disease,  especially  when  the  arthropathy  is 
associated  with  gastric  crises  and  with  other  symp- 
toms suggestive  of  advanced  cord  destruction,  the 
prognosis  is  wellnigh  hopeless. 

Treatment. — The  treatment  of  these  joint  affec- 
tions consists  in  the  exhibition  of  the  iodide  of  potas- 
sium in  very  large  doses — even  one-half,  or  in  sunn' 
cases  two-thirds,  of  an  ounce  daily  in  Vichy  water — 
and  in  the  free  application  of  the  actual  cautery  to 
both  the  spine  and  the  affected  joints.  Careful 
bandaging  and  the  application  of  straps  of  the 
ammoniated-mercury  plaster  are  of  use,  while  perfect 
rest  is  indispensable. 

Allan  McLane  Hamilton. 

1.  Modern  Medicine,  1909.  vol.  vi.,  pp.  704  et  seq. 

2.  American  Journal  of  the  Medical  Sciences,  vol.  viii.  ,1831,  p.  65, 

3.  London  Lancet,  1S46,  vol.  i.,  p.  277. 

4.  London  Lancet,  July,  1861. 

5.  Lecons  sur  les  maladies  du  systeme  nerveux,  1S72-73,  p.  100 
et  seq. 

6   Diseases  of  the  Nervous  System,  p.  214  et  seq. 


Arthropoda. — The  phylum  of  ;mimals  which  includes 
those  having  a  hard  chitinous  exoskeleton,  segmen- 
tation, and  jointed  legs.  Con.mon  representatives 
are  crabs,  spiders,  scorpions,  centipedes,  insects, 
and  ticks.     See  Insects,  -poisonous,  A.  S.  P. 


706 


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Artificial  Eyes 


Artificial  Eyes. — (French,  (Eil  artificiel;  German, 
KUnstliche  A  uqe.) 

History.-  The  use  of  an  artificial  oyo  to  hide  the 
ugliness  of  an  empty  socket  or  to  conceal  the  deformity 
ofa  shrunken  and  discolored  eyeball  dates  from  very 
early  times.  Historians  have  traced  its  origin  to  the 
Egyptians  of  the  third  and  second  century,  B.C., 
basing  their  claim  on  the  discovery  of  mummies  and 
animals  in  whose  orbital  cavities  artificial  eyes  had 
been  placed.  Artificial  eyes  are  also  mentioned  in 
the  works  of  Ambroise  Pare'  (1582),  and  of  Hierony- 
nms  Fabricius  (1613).  Crudely  constructed  of  gold, 
silver,  glass,  and  painted  wood,  the  ancient  eyes  bore 
but  little  resemblance  to  the  modern  finished  article, 
but  were  rather  imitations  of  eyes  than  artificial  eyes. 
These  materials  later  gave  way  to  specially  prepared 
glass  or  porcelain,  and  toward  the  commencement  of 
the  eighteenth  century  the  porcelain  eyes  were  still 
further  improved  by  an  enamel,  which,  by  reason  of 
its  durability,  its  resistance  to  the  action  of  tears,  and 
the  facility  with  which  it  received  and  retained  colors, 
was  generally  adopted.  The  industry  was  brought  to 
a  scientific  basis  by  Boissonneau,  who  introduced 
between  IN  III  and  1S06  many  improvements,  and 
created    practically    the    eye    that    is    worn    to-day. 

Manufacture. — First  class  artificial  eyes  are  made 
in  many  of  the  large  cities  of  Europe  and  America. 
The  art  consists  in  the  preparation  of  the  material 
from  which  the  shell  is  made  and  in  its  shaping  and 
coloring.  The  chemicals  that  enter  into  the  com- 
position of  the  glass  are  antimony,  calcium,  borax, 
uranium  or  manganese,  oxide  of  tin,  arsenic,  and  fine 
flint.  The  artist  is  seated  before  a  table  with  a  blow- 
pipe attached,  the  flame  being  regulated  by  hydraulic 
pressure  so  that  it  is  strong  and  steady.  To  this  heat 
the  glass  tube,  closed  at  one  end,  is  subjected.  As 
soon  as  it  is  at  a  white  heat  the  maker  blows  the  ball 
and  shapes  it,  then  at  the  proper  moment  he  takes  a 
slick  of  pigmented  glass  and  places  a  drop  on  the 
summit  of  the  ball;  it  is  then  heated  again  and  at  the 
same  time  flatened.  This  colored  glass  represents  the 
iris.  By  a  process  of  teasing,  the  iris  is  made  to  have 
a  blending  of  colors,  a  highly  artistic  process;  then  a 
darker  stick  of  glass  is  fused  to  the  center  of  the  iris  to 
form  the  pupil;  as  the  next  step,  the  cornea  is  formed 
of  transparent  crystal.  The  colored  tubing  is  now 
drawn  out  until  it  has  the  diameter  of  the  finest  silk 


Fig.  497. 


Fig.  49S. 


Figs.  497  anil  498. — Fig.  497,  Anterior  View  of  Eye  Adapted  to 
Deep  Upper  Fornix.  Fig.  49S,  Profile  View  of  Same  Eye.  1, 
Nasal  extremity;  2,  temporal  extremity. 

thread,  and,  by  using  its  melted  tip  as  a  brush  or  pencil, 
the  delicate  shadings  and  vein  tracery  are  produced. 
After  this  the  ball  is  again  heated,  is  cut  from  the 
stem  on  which  it  was  previously  held,  and  its  sharp 
edges  are  rounded  off.  When  completed  the  shell 
has  an  ovoid  form,  concavoconvex,  the  surfaces  being 
smooth  and  enamelled.  The  pupil  in  the  artificial 
eye  is  made  of  the  average  size,  or,  when  made  to 
order,  of  the  size  of  the  patient's  pupil  in  daylight.* 
Within  the  past  few  years  ophthalmic  surgeons  and 
opticians,  having  become  dissatisfied  with  the  results 
obtained  by  prescribing  practically  the  same  shaped 

*  This  description  is  taken  the  from  first  edition  of  the  Reference 
Handbook.  Its  accuracy  was  verified  by  me  during  a  visit  to 
the  factory  of  Miiller  Bros.,  Wiesbaden,  Germany,  in  the  summer 
of  1899. 


eye  for  all  orbits,  have  paid  greater  attention  to  the 

fitting  of   individual   orbits   with   individual   eyes,   by 

making  such  alterations  in  their  outlines  and  changes 

in  their  etirval  lire  that  I  hey  may  he  adapted  not  only 
to   normally   shaped   orbital   beds,   but    to    those    that 

present  cicatricial  bands  or  other  obstacles  to  tin; 
wearing  of  the  average  eye.  Such  modifications  are 
represented  in  I  he  accompanying  figures. 


Fie.  499.— Lateral  and  Poste- 
rior View,  showing  expanse  of 
sclera  upward  and  backward 
for  adaptation  into  shallow 
lower  fornix. 


Fio. 500. — Solid  Eye.  Oneof 
three  patterns  described  by  Mr. 
Si m1  I  in  Ophthalmic  Review,  and 
devised  to  avoid  the  suction 
incident  to  the  usual  concavo- 
convex  shell. 


The  ingenious  adaptation  of  the  common  eye  of  the 
shops,  shown  in  Figs.  504  and  505,  was  suggested 
by  Dr.  J.  L.  Borsch,  Jr.,  of  Paris,  France.1  It 
may  with  little  trouble  be  adapted  to  most  orbits 
with  entire  satisfaction.  In  a  normal  socket  the 
plate  will  be  at  right  angles  to  the  sides  of  the  shell. 
The  plate  is  fastened  to  the  eye  by  means  of  silicate 
paste  and  the  line  of  juncture  is  protected  by  a  thin 
layer  of  wax.  In  order  to  overcome  the  expansion 
of  the  air  contained  between  the  plate  and  shell  that 
would  necessarily   follow   when   the   temperature   of 


Fig.  501. — The  Average  Eye. 
1.  Nasal  extremity;  2,  tem- 
poral extremity. 


Fig.  502. — A  Complete  Ball 
with  Indentations  on  Superior 
and  Inferior  Sides  for  Lids. 


the  eye  is  raised  to  that  of  the  socket,  the  shell  and 
plate  are  brought  to  the  temperature  of  100°  F.  or 
over  while  being  cemented.  At  Snellen's  suggestion 
Miiller3  in  1898  blew  some  eyes,  so  that  the  posterior 
surface  of  the  shell  was  more  or  less  convex  instead 
of  concave  as  heretofore  and  the  space  between  the 
front  and  back  of  the  eye  was  airblown.  The  eye 
weighs  about  three  grams.  It  is  comfortable,  has  some 
motion  and  presents  quite  a  life-like  appearance3. 
The  objection  to  the  hollow  prothesis  is  the  danger 
of  expansion  of  the  air  contained 
in  the  cavity  and  the  explosion  of 
i  lie  eye. 

The  solid  eye  of  Snell  (Fig.  500,) 
combines  the  advantageous  feat- 
ures of  those  of  Borsch  or  Snellen 
and  is  the  model  generally  selected. 

The  object  of  inuring  an  artificial 
eye  is  cosmetic,  to  conceal  a  glar- 
ing deformity,  and  therapeutic,  to 
prevent  asymmetrical  growth  of 
those  bones  of  the  face  which  enter 
into  the  formation  of  the  orbit. 
A  further  object  is  to  give  relief  to  the  conjunctival 
irritation  caused  by  distorted  eyelids  and  inturned 
eyelashes,  often  the  accompaniments  of  eyeless 
orbits. 

The  Comparative  Value  of  Substitute  Operations. — 
Formerly,  enucleation — removal  of  the  ball — was  the 
only  radical  operation  performed,  but,  with  the  object 
of  preserving  or  creating  a  bed  over  which  an  artificial 
eye  may  be  worn,  and  by  which  movement  and 
concomitant  rotation  will  be  imparted  that  will  be 
superior  to  that  following  simple  enucleation,  various 

707 


Fig.  503.— Complete 
Ball  for  Implantation 
in  Tenon's  Capsule 
after  Enucleation. 


Artificial  Eyes 


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other  operations  have  been  suggested:  opticociliary 
neurectomy,  or  division  of  the  optic  and  ciliary 
nerves  with  retention  of  the  ball;  sclerooptic  neurec- 
tomy, or  resection  of  the  posterior  part  of  the  sclera 
andof  the  adjoining  optic  nerve;  evisceroneurotomy, 
or  emptying  the  scleral  sac  and  dividing  the  nerve; 
evisceration,  or  emptying  and  retention  of  the 
scleral  sac;  evisceration  with  the  insertion  of  an 
artificial  vitreous;  implantation  of  a  glass  or  metal 
globe  (such  as  is  shown  in  Figs.  502  and  503)  in 
Tenon's  capsule  after  enucleation;  abscission  of  the 
anterior  third  or  fourth  of  the  ball;  and  complete 
keratectomy  or  abscission  of  the  cornea.  But  most 
of  these  operations  have  few  advocates  because  of  their 
failure  to  accomplish  the  objects  for  which  they  were 
devised  or  because  they  have  been  proven  to  be  an 


Fig.  504.  Fig.  505. 

Fig.  504. — Shows  the  Common  Eye  with  a  Glass  Plate,  which 
Forms  the  Base  of  the  Concavity  of  the  Eye.  The  plate  may  be 
cemented  forward  or  backward,  or  to  one  or  the  other  side,  in  order 
to  tilt  the  cornea  into  any  desired  direction. 

Fig.  505. — Showing  the  Plate  Used  with  the  Eye  in  Fig.  50S. 

insufficient  barrier  to  sympathetic  inflammation. 
The  strongest  rival  to  enucleation  has  been  the 
Mules'  operation — evisceration  with  the  insertion  of 
an  artificial  vitreous.  Operators  are  divided  in  their 
opinion  as  to  the  value  of  this  procedure.  It  is  con- 
ceded that  it  will  give  ideal  cosmetic  results  when 
successful.  It  has,  however,  not  been  generally 
adopted  for  the  following  reasons:  the  reaction  is  far 
more  severe  than  that  after  enucleation;  the  recovery 
is  more  prolonged — a  serious  obstacle  to  the  bread- 
winner; the  danger  of  sympathetic  inflammation  is 
not  avoided;  the  artificial  vitreous  is  subject  to 
fracture  or  alteration  in  shape  from  accidents; 
primary  success  is  no  assurance  that  the  vitreous 
substitute  will  be  permanently  retained;  enucleation 
of  the  scleral  sac  may  be  demanded.  The  advantages 
claimed — viz.,  that  the  artificial  eye  is  more  movable, 
owing  to  the  better  stump  secured,  and  that  the 
operation  can  be  safely  performed  in  panophthalmitis 
— do  not  warrant  its  frequent  performance  or  its 
unqualified  adoption  as  a  substitute  for  enucleation. 
Mules'  operation  has  been  in  great  degree  supplanted 


Fig.  507. — Aluminum  Vitreous 
with  Flat  or  Concave  Base. 


Fig.  506. — Aluminum  Button- 
shaped   Vitreous. 

by  the  operation  suggested  by  Frost  and  Lang.  The 
entire  eyeball  is  removed  and  into  the  serous  sac  in 
which  it  was  formerly  held,  is  transplanted  a  hollow 
gold  sphere,  made  perfectly  smooth  and  as  light  as 
possible.  The  operation  accomplishes  perfect  cos- 
metic results,  the  wound  heals  perfectly,  and  the 
reaction  is  little  if  at  all  greater  than  that  following 
simple  enucleation;  it  gives  mobility  to  the  prothesis 
and  may  be  selected  in  the  proper  cases  without 
apprehending  danger  of  sympathetic  inflammation. 
If  for  any  reason  there  exists  an  obstacle  to  the 
transplantation  of  any  artificial  vitreous  or  ball,  the 
most  movable  support  for  the  prothesis  is  afforded 
when  as  the  first  step  of  enucleation  the  distal 
extremities  of  the  recti  muscles  are  united  by  suture, 
forming  a  mass  that  is  covered  by,  and  later  becomes 
amalgated  with,  the  conjunctiva. 

Choice  of  an  Artificial  Eye. — In  the  choice  of  an 
artificial  eye  one  must  be  guided  by  the  size  and 


Fig.  50S.— GIuj- 
Shell. 


shape  of  the  socket  and  by  the  condition  of  tl 
orbital  contents.  Only  in  exceptional  cases  is  tl 
selection  from  the  large  stock  carried  by  opticiai 
difficult.  When  irregularity  of  the  conjunctival  bi 
demands  a  specially  constructed  eye  a  leaden  pattei 
may  be  moulded  from  which  the  artificial  eye 
fashioned.  In  cases  of  small  sockets  a  series  , 
leaden  scales  or  glass  shells  (Fig.  3G0)  of  inereasii 
size  may  be  successively  worn  until  the  cul-de-si 
has  been  sufficiently  stretched.  It  is  essential  ru 
only  that  the  eye  shall  look  well  but  that  it  shall  1 
comfortably  worn  and  not  cause  irritation.  Tl 
points  to  be  considered  are  that  it  shall  resemble  tl 
sound  eye,  that  it  shall  have  both  mobility  aii 
stability,  and  that  it  shall  easily  be  adapted  to  tl 
orbital  contents. 

The  stability  depends  upon  the  accurate  adjup 
ment  to  the  conjunctival  bed  behind  and  to  the  li 
in  front,  upon  the  degree  of  curvature,  and  upon  tl 
length  of  the  prothesis  in  relation  to  the  length  of  tl 
commissure.  The  size  of  the  eye  must  be  particular! 
regarded;  if  it  is  too  large  the  lower  lid  is  pushed  ii 
the  cul-de-sac  is  effaced,  and  the  eye 
is  spontaneously  protruded;  if  it  is 
too  small  it  shifts  its  position  inde- 
pendently of  the  movements  of  the 
other  eye,  and  engages  itself  in  the 
superior  cul-de-sac,  so  that  its  lower 
border  is  protruded  from  the  inferior 
cul-de-sac.  A  contraction  of  the  con- 
junctival sac  may  form  a  bridle  that  will  necessitat 
cutting  a  piece  out  of  the  eye  or  surgical  interventio 
in  the  orbit  for  the  destruction  of  the  bridle  an 
rehabilitation  of  the  sac. 

A  defective  or  misfitted  prothesis  will  cause  pai 
throughout  the  entire  orbit  or  at  that  portion  of  tli 
conjunctiva  which  is  wounded  by  the  imperfecta 
and  aggravated  by  all  movements.  If  the  eye  is  to 
convex  forward,  it  encroaches  upon  the  lid  at  an  acui 
angle  and  wounds  it;  if  it  is  too  flat,  its  posteri< 
surface  rests  in  contact  with  the  cornea  or  with  tli 
cicatrix  and  produces  pain.  An  old  eye  that  has  los 
its  polish  gives  the  sensation  of  a  foreign  body  in  tl. 
orbit. 

To  Insert  an  Artificial  Eye. — The  upper  lid  i 
elevated  by  traction  on  the  skin  below  the  orbit: 
margin;  the  upper  edge  of  the  shell  is  introduci 
under  the  upper  lid  and  almost  in  contact  with  it  in  • 
the  superior  border  of  the  cornea  is  hidden  by  tli 
ciliary  border  of  the  lid. 

The  lower  lid  is  now  retracted  and  partly  everted 
sufficiently  far  to  permit  the  lower  edge  of  the  ey 
to  escape  it  and  to  pass  into  the  lower  cul-de 
By  easy  movements  vertically  and  laterally  tin 
is  forced  into  the  socket,  where  it  is  held  by  the  lids 
To  Remove  the  Eye. — The  head  of  a  large  pin  or  : 
similar  instrument  is  inserted  under  the  lower  bo 
of  the  eye,  during  eversion  of  the  lower  lid,  anil  1 ; 
this  means  the  artificial  eye  is  gently  pried  out  si 
that  the  inferior  edge  may  pass  over  the  lower  lid 
when,  by  holding  the  head  slightly  forward,  the  cyi 
will    fall    into    the    extended    hand.     After   a   sin  r 
experience  the  insertion  and  removal  of  the  eye  an 
easily  and  safely  done. 

Care  of  the  Eye. — The  eye  should  not  be  worn  foi 
twenty-four  consecutive  hours.*     At  night  it  sh< 
be  taken  out  and  cleansed  with  soap  and  water  am 
allowed    to    remain    in    oil    until    morning.     I 
favorable  circumstances  an  artificial  eye,  when  wel 
made  and  fitted,  will  retain  its  polish  and  smooth 
for  about  two  years.     In  cases  of  much  dischargt 
mucus  and  tears  it  corrodes  in  a  few  months,  vni'i 
its   edges   must   be    ground    down    and    its   surfact 
repolished  or  it  must  be  replaced  by  a  new  one. 
Care  of  the  Orbit. — How  soon  after  operation  in:" 

♦Chisolm  has  reported  a  case  in  which  an  artificial  eye  fcafl 
been  worn  for  twelve  years  without  ever  having  been  removed 
and  with  no  bad  symptoms. 


ros 


i;kii:i:i:.\<t.   handbook   OF  THE   MEDICAL  SCIENCES 


Artificial  i.imbs 


ire  '"'  worn?    The  interval  depends  upon  the 

tction  following  operation,  upon  the  disease  of  the 

thai  necessitated  its  removal,  and  upon  the  time 

quired  for  perfect   healing  of  the  tissues.     Writers 

iecify  the  average  interval  after  the  usual  operations 

weeks.      \Ve  have,  in  a  number  of  instance  . 

lien    it    was    important     that     the    patient    should 

to  his  occupation  as  soon  as  possible,  inserted 

seven  days  after  enucleation  and  have  had  no 

:ison  to  regret  the  action.      When  all  signs  of  previ- 

ase  and  of  reaction  from  the  operation  have 

appeared,   and    there    has    been    no   complaint    of 

thetic  trouble,   the  eye  may  be  worn  without 

ar  of   consequences.     After   enucleation    for   sym- 

ithetic  irritation,  at  least   two  months  should  elapse 

of    the    danger    of   exciting    a    pathological 

that   may  he  destructive  to  the  opposite  eye. 

ive  been  recorded  by  Lawson,  Mooren,  Keyset', 

tlomon,    and     Warlomont    in    which    sympathetic 

ihthahnia  litis  followed  the  wearing  of  an  artificial 

r    atrophied    globes    and    after   enucleation. 

cident  is  all  the  more  probable  in  the  case  of 

stump  that  is  ossified  and  painful.     In  threatening 

.  inpathetic  disease  the  prothesis  is  badly  tolerated. 

a  the  other  hand,  unnecessary  delay  enhances  the 

!tiiculties  of  inserting  and  wearing  an  artificial  eye, 

equence  of  shrinking  of  the  contents  of  the 

it,   which   is  prone   to  be  rapid  and  progressive. 

..r  the  first  few  days  after  fitting  an  eye  it  should  be 

orn  only  an  hour  or  two  at  a  time,  so  that  the  tissues 

ay  become  gradually  accustomed  to  its  presence. 

hould  inflammation  of  the  mucous  membrane  arise, 

is  to  be   treated  by  desistance  from  wearint  the 

rothesis  and  by  applications  of  cauterants  or  astrin- 

■nts,  such  as  silver  nitrate,  tannic  acid,  alum,  etc. 

Howard  Fokde  Hansell. 


1.  Transactions  of  flip  Section  on  Ophthalmology,  College  of 
:i*  of  Philadelphia,  February,  1N'.)7. 
ihth  tlmic  Heyiew,  December,  1S9S. 
U  ood:  Ophthalmologics!  Operations,  1911,  p.  640. 


Artificial  Limbs. — Artificial  limbs  are  designed  to 
ike  the  place  of  the  natural  members  when  the  latter 
re  lacking  either   from   congenital   defect,   or  from 

irgieal  operation,  or  from  traumatism.  Deformities 
re  corrected,  and  to  some  extent  function  is  restored, 
y  these  appliances. 

Extremity. — The  making  of  artificial  limbs 
i  a  comparatively  modern  industry.  Prior  to  the 
ixteenth  century  any  one  so  unfortunate  as  to  lose  a 
mb  had  to  depend  upon  the  services  of  some  in- 
cnious  friend  or  mechanic  (carpenter  or  blacksmith) 
ir  such  substitute  as  could  be  obtained.  The  pro- 
3  of  this  period  were  for  locomotion  only,  and 
lade  no  pretence  to  conceal  the  loss  of  the  limb, 
rom  this  time  to  the  end  of  the  eighteenth  century 
ttlc  progress  was  made;  although  in  the  writings  of 
he  celebrated  Ambroise  Par6  (1509  to  1590)  we  find 
lention  of  an  elaborate  and  ingenious  leg,  with 
oints  at  both  knee  and  ankle;  and,  about  a  century 
iter,  the  Dutch  surgeon  Verduin  constructed  an 
rtificial  leg  for  an  amputation  below  the  knee.  This 
ppliance  consisted  of  a  wooden  foot  connected  by 
trips  of  steel  to  a  copper  socket  lined  with  leather; 
his  socket  received  the  stump,  and  the  weight  of  the 
iody  was  supported,  not  on  the  flexed  knee,  but  bv 
;i'eral  pressure  on  the  stump  and  thigh.  The 
'reductions  of  a  Pare  and  a  Verduin  were  for  the  few, 
tot  for  the  masses;  and  were  heavy,  intricate,  and 
Iittnsy  affairs  as  compared  with  modern  appliances. 
\t  the  beginning  of  the  last  century  an  impetus  was 
Jiven  to  the  construction  of  artificial  limbs  by  the 
Napoleonic  wars;  whatever  claims  to  glory  Napoleon 
nay  have,  he  certainly  made  many  cripples  and 
Oiould  be  hailed  as  the*  patron  saint  of  prosthetists. 
'ti   the   battle   of    Waterloo,    the    Earl   of    Uxbridge 


(afterward  Marquis  of  Angle  ej  I  I"  I  a  leg,  and  a 
wooden  one  was  made  for  him  by  Pott.  1'his  was 
the  famous  "Anglesey  leg"  which  for  a  long  time 
represented  the  highest  pro  thetic  art,  and  was  the 
pattern  for  many  that  followed;  it  was  subsequently 

mo. titled  by  Selpho  and  Palmer,  and  as  such   may   be 

regarded  as  the  "leg"  on  which  the  American  p 
thetic  industry  stands.     Tic  Anglesej    leg  con  isted 
of  a  bucket  or  socket  of  wood  to  receive  the  stump,  a 

steel  joint  for  the  knee,  and  a  Wooden  joint  for  the 
ankle;  this  latter  was  moved  by  a  Spiral  spritig 
anteriorly,  and  by  catgut  cords  posteriorly. 

The  Civil  War  may  be  taken  as  the  start ing-poinl  of 

the     modem    prosthetic    industry.     The    countless 

mutilations  suffered  at  this  time,  and  the  liberality  of 
the  United  States  Government  in  providing  the 
sufferers  with  artificial  limbs,  brought  out  the 
ingenuity  of  several  American  prosthetists,  and  it  is 
no  exaggeration  to  say  that  in  this  branch  of  industry 
the  Americans  lead  the  world.  But  peace  and  the 
arts  of  civilization,  such  as  the  steam  engine,  the 
electric  motor,  the  factory,  and  agricultural  imple- 
ments continue  to  manufacture  cripples  quite  as 
rapidly  as  war  ever  did. 

To  give  an  account  of  every  improvement  and 
peculiarity  claimed  by  the  various  manufacturers  of 
artificial  limbs  in  this  country  would  be  to  fill  many 
pages  with  reprints  from  their  catalogues;  the  space 
at  the  writer's  disposal  will  allow  only  a  brief  mention 
of  some  of  the  chief  features  with  which  he  is  ac- 
quainted; there  may  be  others  just  as  good,  and 
better.  The  Anglesey  leg  is  practically  the  model 
from  which  all  subsequent  attempts  are  derived. 
It  was  introduced  into  America  by  Selpho,  who,  later 
on,  improved  it  by  making  the  knee-joint  of  two 
broad  steel  plates,  the  upper  one  convex,  the  lower 
concave  and  covered  with  leather;  it  had  india-rubber 
buffers  to  prevent  concussion  at  the  ankle  joint. 
The  Palmer  leg  had  an  excentric  hinge  at  the  knee 
to  prevent  sudden  flexion,  and  wooden  joints  with 
spiral  springs  to  straighten  them  after  flexion. 
Dr.  Bly  further  modified  the  'Anglesey  leg"  by 
making  the  ankle-joint  without  bolts  or  ordinary 
hinge;  in  their  place  he  used  a  ball  of  glass  or  ivory 
which  was  inserted  in  a  bed  of  rubber  and  by  this 
means  lateral  as  well  as  anteroposterior  motion  was 
obtained. 

The  ankle-joint  is  the  crux  with  most  manufac- 
turers; here  we  find  most  variety,  and  here  too  are 
the  strong  and  weak  points  of  the  various  limbs. 
Advocates  of  the  "no  ankle-joint"  claim  that  wearers 
of  their  limbs  are  relieved  of  all  jarring  and  are  also 
freed  from  the  disagreeable  noise  or  thumping  caused 
by  the  ordinary  ankle-jointed  foot;  cords  and  springs 
are  not  necessary,  and  a  soft  and  resilient  step  is 
assured.  On  the  other  hand,  the  advocates  of  the 
"ankle-joint  "  assert  that  walking  is  rendered  more 
natural  and  less  fatiguing,  and  they  triumphantly 
ask  why  Nature  has  provided  man  and  beast  with 
ankle-joints,  if  they  arc  not  necessary. 

The  "Marks"  leg  has  no  ankle-joint  at  all,  but  a 
foot  of  rubber  with  a  wooden  core.  The  "Frees" 
limbs,  on  the  other  hand,  by  means  of  an  ingenious 
double  joint  at  the  ankle  (duplex  ankle  joint),  give 
both  lateral  and  anteroposterior  motion  at  that 
joint.  Between  these  two  extremes  of  universal 
motion  and  no  joint  at  all  there  arc  many  with  antero- 
posterior motion  only;  and  each  variety  has  excel- 
lencies claimed  for  it.  The  "  Doerflinger "  leg  has  a 
steel-bearing  rocker-plate  ankle-joint  without  cords, 
and  also  a  foot  of  felt.  In  Fuller's  "walkeasy"  leg 
there  are  ball-bearing  knee-joints  for  amputation 
below  the  knee,  and  sponge-rubber  foot  with  articu- 
lated ankle-joint;  Fuller  furnishes  three  varieties  of 
ankle-joint,  as  well  as  a  sponge-rubber  foot  with  rigid 
ankle.  The  adjustable  double  slip  socket  of  the 
"Winkley  Artificial  Limb  Company"  is  designed  to 
secure  an  artificial  leg  that  does  not  chafe,  rub,  or 


ro9 


Artificial  Limbs 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


pull  on  the  end  of  the  .-stump,  or  irritate  or  make  sore 
the  place  of  bearing.  The  "  Chicago  Artificial  Limb 
Company"  makes  a  leg  with  a  ball-bearing  ankle- 
joint,  and  a  felt  foot,  which  is  lighter  than  wood  or 
rubber,  also  an  aluminum  limb.  Which  of  all  these 
varieties  of  legs  and  ankle-joints  is  the  best,  we  cannot 
undertake  to  decide. 

The  first  real  artificial  foot  was  made  about  one 
hundred  and  fifty  years  ago  by  Ravatau.1  "This 
apparatus  was  intended  for  a  dragoon  whose  right 
foot  had  been  amputated  above  the  ankle.  The 
whole  mechanism  consisted  of  a  boot  which  reached 
above  the  knee,  where  it  could  be  fastened  with 
leather  straps;  the  boot  was  laced  its  entire  length. 
In  its  interior  a  metal  strip  extended  on  each  side 
from  top  to  bottom,  and  at  the  end  was  attached  to 
a  hollow  metal  cylinder,  which  was  intended  to 
replace  the  missing  ankle-joint.  The  boot  had  a 
metal  sole.  Inside  of  the  cylinder  was  a  coiled 
spring,  with  convolutions  like  a  snail  shell,  forming  a 
contour  of  the  foot.  Thus  an  elasticity  was  imparted 
in  walking.  The  empty  spaces  in  the  inside  of  the 
boot  were  filled  with  horsehair.  The  dragoon  by 
means  of  this  contrivance  was  able  to  serve  many 
years  in  the  army." 

The  foot  has  presented  grave  difficulties  to  the 
prosthetists,  who  are  almost  unanimous  in  condemn- 
ing the  various  foot  amputations  as  being  unsatis- 
factory from  the  point  of  view  of  their  art.  After 
Chopart's,  Lisfranc's,  and  Hey's  operations,  as  the 
extensor  tendons  have  been  divided,  the  heel  is  apt 
to  be  drawn  up  by  the  tendo  Achillis.  Of  all  the  foot 
amputations  Syme's  presents  the  best  possibilities 
to  the  makers  of  artificial  limbs. 

In  the  case  of  children,  it  is  a  most  mistaken  policy 
to  wait  till  they  have  finished  growing  before  supply- 
ing them  with  an  artificial  leg.  Such  a  course  of 
delay,  as  is  often  adopted,  makes  the  child  grow  up 
round-shouldered  and  one-sided;  and,  to  say  nothing 
of  the  appearance,  a  properly  fitting  apparatus  is 
more  healthful.  Self-lengthening  limbs  or  extension 
apparatus  can  be  procured  from  most  makers;  the 
"Chicago  Artificial  Limb  Company"  furnishes  a 
self-lengthening  limb,  perfectly  adjustable,  and 
capable  of  being  lengthened  by  the  purchaser. 

Upper  Extremities. — Previous  to  the  last  century  we 
find  little  mention  of  artificial  arms  and  hands.  We 
read  of  an  iron  arm  made  for  a  captain  in  the  sixteenth 
century,  and  an  iron  hand  weighing  about  three 
pounds  with  fingers  that  could  be  flexed  by  the  other 
hand,  and  extended  by  pressing  a  knob  on  the  side  of 
the  hand.  But  most  of  these  early  hands  and  arms 
were  designed  to  enable  the  wearer  to  hold  a  sword  or 
shield,  or  to  handle  the  reins.  A  monk  and  a  lock- 
smith figure  in  the  early  manufacture  of  artificial 
hands,  but  their  productions  have  only  an  historic 
interest.  The  first  really  useful  hand  was  devised  by 
Pierre  Ballif,  a  dentist  of  Berlin,  about  a  hundred 
years  ago;  most  of  the  modern  hands  being  simple 
modifications.  As  the  need  for  artificial  hands  and 
arms  is  more  urgent  than  is  that  for  lower  extremities, 
so  the  manufacture  of  the  same  seems  more  difficult; 
some  prosthetists  do  not  supply  them  at  all,  and  some 
others  supply  them  but  do  not  make  them.  Artificial 
hands  of  delicate  workmanship  will  enable  a  patient 
to  write,  use  a  ■  nife  and  fork,  raise  and  lift  a  glass,  or 
shake  hands:  t  t  where  strength  is  required,  as  for 
laborers  and  1  :hanics,  it  is  better  to  have  a  solid 
stock  into  wh;  >  can  be  inserted  the  various  imple- 
ments required.  Almost  any  tool  or  agricultural 
implement  can  be  used  efficiently;  in  some  cases  they 
are  inserted  into  the  hand,  and  in  others  they  take 
the  place  of  the  hand.  The  attachments  are  generally 
by  means  of  a  screw  or  the  "bayonet  lock." 

An  artificial  limb  should  be  applied  as  soon  as 
possible;  that  is,  as  soon  as  the  wound  is  healed,  and 
there  is  a  good  healthy  stump.  When  amputation 
has  been  performed  for  disease  a  longer  delay  will  be 

710 


necessary  than  when  traumatism  has  been  the  caus 
of  the  mutilation.  As  soon  as  healing  is  complet 
and  there  is  no  longer  any  tenderness,  the  stum 
should  be  prepared  by  daily  bathing  and  massage 
followed  by  bandaging.  This  will  give  a  firm  stum 
without  superfluous  adipose  tissue.  Joints  shoul 
receive  passive  motion,  not  only  to  prevent  ankylos^ 
but  also  lest  the  muscles  by  contracting  should  limi 
motion.  In  case  of  delay  the  stump  is  apt  to  becom 
flabby  and  enlarged,  and  while  in  that  condition  i 
totally  unfit  for  the  application  of  an  artificial  linil 
Ordinarily  a  limb  can  be  applied  in  from  one  to  thre 
months. 

With  regard  to  the  stump  most  suitable  for  th 
application  of  artificial  limbs  it  may  be  said  thai 
while  the  general  rule  in  amputation  has  been  to  sav 
all  that  is  possible,  this  should  be  interpreted  somi 
what  laxly  with  regard  to  the  lower  extremity.  I 
the  upper  extremity  any,  even  the  smallest  remaining 
part  of  a  hand  is  far  more  useful  than  any  arti:> 
appliance;  but  in  the  lower  extremity  the  loss  of  ft 
extra  inch  or  two  is  of  no  moment  compared  with 
serviceable  stump.  An  artificial  arm  applied  to  th 
shoulder,  and  artificial  fingers,  have  merely  a  cos 
metic  effect,  and  cannot  be  of  much  service.  A 
artificial  arm  of  considerable  utility  can  be  appliei 
to  a  stump  when  the  amputation  has  been  made  any 
where  between  the  upper  third  of  the  humerus  am 
the  wrist.  In  the  lower  extremity,  amputations  a 
the  hip  do  not  allow  of  the  application  of  a  limb  tha 
can  be  of  much  use.  In  thigh  amputations,  a  service 
able  stump  can  be  obtained  anywhere  between  a  poin 
within  five  inches  of  the  hip  and  one  situated  witliii 
about  three  inches  from  the  knee.  Amputation 
within  three  inches  of  the  knee,  either  above  or  bekn 
the  joint,  should  (from  the  prosthetist's  point  of  view 
be  avoided. 

Whenever  possible  the  patient  should  be  measure, 
for  and  fitted  with  the  artificial  limb  by  the  mami 
facturer.  It  is  true  that  many  makers  are  willing  ti 
have  the  physician  or  even  the  patient  or  some  lai 
friend  take  the  measurement,  and  they  will  si 
full  directions  for  the  purpose;  but  every  effort  shoul 
be  made  to  have  the  manufacturer  himself  assiinu 
this  responsible  task.  An  artificial  limb  is  not  ! 
luxury,  to  be  indulged  in  for  a  short  time,  but  h 
meant  to  be  a  daily  companion  for  many  years,  ant 
if  it  is  not  comfortable  and  does  not  fit  properly,  i 
will  never  be  of  much  use.  To  the  writer  it  seem 
rational  to  order  an  artificial  limb  from  one's  owr 
measurements,  as  it  would  be  to  order  a  set  of  artificia 
teeth  in  the  same  manner;  doubtless  it  could  be  donr 
but  fortunately  there  are  other  and  better  ways. 

In  choosing  an  artificial  limb,  bear  in  mind  the  re- 
quirements of  the  patient;  the  weight  and  construc- 
tion of  the  limb  are  more  important  than  the  price. 
As  a  rule,  the  simpler  the  apparatus  the  greater  it- 
utility.  A  complex  piece  of  mechanism  which  can- 
not be  got  at  without  taking  to  pieces  the  whole  limb, 
and  which  is  liable  to  be  constantly  in  need  of  atten- 
tion, adds  considerably  to  the  cost,  and  in  the  case  ol 
a  laborer  keeps  him  from  his  work.  Generally,  it  v\  ill 
be  found  best  to  obtain  the  catalogues  of  various 
makers  in  the  vicinity,  and,  on  selecting  one,  to  be 
guided  largely  by  his  opinion.  A  reputable  maker 
cannot  afford  to  supply  a  poor  limb,  and  as  a  rule 
he  knows  a  great  deal  more  about  the  matter  than  the 
average  physician. 

There  is  no  reasonable  limit  to  the  possibilities  of  an 
artificial  leg.  Not  only  do  patients  stand,  walk,  and 
run  on  it,  as  well  as  attend  to  their  daily  avocations, 
but  many  also  dance,  skate,  and  ride  a  bicycle 
with  apparently  as  much  ease  as  before  they  - 
crippled.  Without  indorsing  the  glowing  descriptions 
put  forth  by  some  makers,  which  would  make  one 
think  that  their  productions  are  improvements  even 
on  the  natural  limbs,  one  cannot  but  recognize  the 
truth  of  the  following:2  "It  is  of  no  small  advantage 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Artificial  Ti-oth 


idiIi  in  surgeon  ami  to  patients  to  realize 

:ii  the  loss  of  a  limb  is  not  necessarily  a  disfiguring  or 

in;,'  affair,  but  that  very  frequently  an  artili- 

il  limb  well  lifted  will  he  of  vastly  more  sen  ice  and 

mble  and  annoyance   than  a   member  already 

by  disease,  or  left   in  a  condition  where  life 

en  is  thereby  threatened.      In  other  words,  the  art 

instrument    maker   has   done    very    much    to 

the  surgeon,  and  to  make  patients  willing  to  un- 

.  i  ions  operations  who  otherwise  would  be  very 

i  lose  SO  useful  a    part   of    their  bodies  as  one 

limbs.      It   has  done  much  also  to  alone  for 

irrible    injuries    and    mutilations    inflicted    by 

v  and  other  accidents." 

K  ight  of  an  artificial  limb  is  a  matter  of  some 

race.     Legs  vary  from  two  or  three  pounds  to 

or  eight  pounds.     It  is  a  mistake  to  buy  one 

too  light.      One  must  bear  in  mind  the  weight, 

rupation,   age,   sex,    and   stature   of   the   patient. 

liings  being  equal,  a  heavy  leg  lasts  longer  than 

one.     Some   patients   prefer   a   fairly   heavy 

ithers  a  lighter  one.     As   a  rule,  it  is  well  to 

leg  sufficiently  heavy  to  bear  more  than  any 

ai n  that  is  likely  to  be  put  upon  it.      Beyond  this 

would  have  the  leg  as  light  as  possible.      It  must 

■  noted  that  it  is  the  weight  of  the  foot  which  makes 

apparently  heavy  limb. 

The  cost  of  an  artificial  limb  varies  according  to  the 
iker  and  the  length  of  the  limb.  The  present 
arket  price  of  a  first-class  leg,  thigh  amputation,  is 
.1111  $100  to  $150;  below  the  knee,  about  $50  to  $100; 
ot,  $30  to  $50;  arm  and  hand,  above  the  elbow, 
5  to  S100;  below  the  elbow,  $50  to  $75. 
The  durability  of  artificial  limbs  is  quite  variable. 
ime  will  last  fifteen  years  or  even  longer,  others,  by 
•  same  maker,  only  three  or  four  years;  the  differ- 
ice  depending  mainly  on  the  amount  of  care  and 
i cation  bestowed  upon  the  limb;  much,  too,  de- 
■nds  on  the  habits  and  occupation  of  the  wearer. 
oni  five  to  seven  years  may  be  taken  as  the  average 
ife"  of  an  artificial  leg;  an  arm  lasts  ordinarily 
ioat  twice  as  long.  Alterations  in  the  stump 
ten  necessitate,  if  not  a  new  limb,  some  modification 
the  socket.  Many  limbs  are  cast  aside,  not  because 
ey  are  worn  out  but  because  the  wearer  wishes  for  a 
wv  one.  The  United  States  Government,  with 
irked  generosity,  supplies  its  pensioners  with  new 
nbs  every  three  years.  R.  J.  E.  Scott. 

I     Scirntific  American,  Supplement,  No.  1374. 

-'.  Trunx:  Johnson's  Encyclopedia,  vol.  v.,  p.  270,  1S94.. 

Artificial  Respiration. — See  Resuscitation. 

Artificial  Teeth. — Even  before  the  foundation  of 
orae,  B.  C.  753,  the  dental  art  flourished  among 
le  Etruscans  or  Toschi,  a  highly  civilized  people 
>ing  in  that  part  of  middle  Italy  known  now  as 
.-.  Although  the  Etruscans  learned  dentistry 
urn  the  Egyptians  and  Phoenicians,  they  far  out- 
ripped  these  nations  in  skill  and  ingenuity.  In 
lite    of    cremation    and    other    destructive    agents 

tive  during  the  ages,  a  number  of  prosthetic  pieces 

Etruscan  workmanship  have  been  preserved  to  us. 

In  one  appliance  the  Etruscan  dentist  of  3,000 
"ars  ago  replaced  missing  incisors  with  an  ox  tooth. 

uman  teeth  were  not  used  as  the  dead  w-ere  con- 
dered  sacred  and  such  an  act  would  doubtless  have 
■en  thought  to  be  sacrilegious.  The  dentist  had 
rooved  the  ox  tooth  in  order  to  give  the  appearance 
f  two  teeth.  The  tooth  was  firmly  anchored  to 
16  encircling  gold  band  by  means  of  two  rivets. 
he  second  bicuspid  was  also  artificial  and  was 
led  by  a  rivet. 

Another  Etruscan  dental  piece  now  in  the  Civic 
luseum  of  C'orneto  is  formed  of  two  bands  of  rolled 

ild  soldered  together  at  the  ends.  Four  partitions 
lock  out  five  square  spaces.  In  two  of  these  the 
atural   teeth  fill   and  support   the   appliance.     The 


other  two  arc  riveted  teeth,  li  is  believed  that  the 
original  teeth,  lost  by  alveolitis,  were  replaced  by 
this  arrangement. 

Another  type  of  Etruscan  dental  appliance  con- 
sisted  of  a   small    horizontal   bar  of  gold   .soldered   to 

two  rings  thai  embraced  the  left  upper  canine  and 
the  left  middle  inn  or  respectively.  The  intervening 
tooth  which  was  missing  was  not    replaced,  but    by 

this    Contrivance    the    remaining    teeth    were    held    in 

normal   position  and  any   tendency   to  convergenci 
was    prevented.      This    appliance    is    now    called    a 
splinl    and   is  in  general   use.      In   the   Etruscan   pros- 
thetic pieces  made  for  holding  teeth   the  appliance 

was     not     supported     by     the    gum,     but     constituted 

veritable  bridge  work. 

Long  before  the  existence  of  the  medical  profession 
dentistry  was  practised  in  Rome.  In  1007,  in  Italy 
in  a  Greek-Roman  necropolis  was  found  a  very 
ingenious    dental    appliance.     This    piece    consi  ted 

of  three  ring>  of  laminated  gold  wire  wound  around 
the  teeth  and  soldered.  It  dales  back  lo  a  period 
between  the  third  and  fourth  centuries  B.  C.  The 
dentist  who  fashioned  the  appliance  was  quite  pos- 
sibly a  Greek. 

One  of  the  first  Roman  writers  to  speak  definitely 
about  artificial  teeth  was  Martial.  These  teeth  were 
fashioned  of  ivory  and  bone  and  without  much  doubt 
were  made  both  in  partial  and  in  full  sets,  and  it 
may  be  inferred  were  remarkably  well  constructed. 
It  is  interesting  to  note  that  artificial  teeth  antedate 
artificial  eyes. 

A  most  ingenious  appliance  representing  crown 
work  has  been  recently  excavated  at  Satricum. 

As  the  Etruscans  made  a  crude  bridge  work  so  the 
ancient  Roman  dentists  made  crown  work. 

Par6  in  the  sixteenth  century  speaks  of  artificial 
teeth. 

The  first  mention  of  models  in  dental  prosthesis 
was  made  by  Matthias  Gottfried  Purmann,  1648- 
17121.  It  may  be  inferred  that  this  model  was  not 
taken  from  a  cast.  It  is  probable  that  the  wax 
model  was  both  worked  by  the  hand  and  carved 
until  the  fit  was  satisfactory.  It  was  then  ready  for 
the  craftsman,  who  reproduced  it  in  bone  or  ivory. 

Anton  Nuck,  1650-1602,  a  brilliant  Dutch  surgeon 
and  anatomist,  was  greatly  interested  in  dental  sur- 
gery and  prosthesis.  Calling  attention  to  the  fact 
that  ivory  teeth  soon  turn  yellow  under  the  influence 
of  food,  drink,  and  saliva,  he  advocated  the  use  of 
the  hippopotamus  tusk  for  artificial  teeth,  saying 
that  this  material  preserves  its  color  for  seventy 
years. 

In  the  same  century  Dionis,  in  speaking  of  the 
composition  of  artificial  teeth,  tells  us  that  they  were 
made  of  ivory  or  ox  bone.  He  also  describes  a  com- 
position devised  by  one  Guillemeau  that  was  made 
by  the  fusion  of  white  wax  and  a  little  gum  elemi  to 
which  was  added  ground  mastic,  powdered  white 
coral,  and  pearls.  In  this  description  we  see  the 
beginning  of  mineral  teeth. 

In  the  eighteenth  century  Johann  Adolph  Goritz 
of  Regensburg  advocated  the  preservation  of  the 
natural  teeth  by  every  known  means.  He  also 
expressed  disapproval  of  artificial  teeth.  If  neces- 
sity should  arise  he  suggested  filling  in  the  gaps  by 
an  "imitation"  made  of  soft  wood. 

The  invention  of  mineral  teeth  was  introduced  at 
the  end  of  the  eighteenth  century.  The  credit  of 
this  work  must  be  ascribed  to  two  men,  one  a  French 
chemist,  Duehateau,  the  other  the  dentist,  Dubois  de 
Cliemant. .  The  former  being  annoyed  by  the  dis- 
agreeable odor  of  the  hippopotamus  ivory  denture  in 
his  own  mouth  was  the  first  to  conceive  the  idea  of 
using  porcelain  for  dental  prosthesis.  Dubois  de 
Chemant  put  the  idea  to  practical  use.  It  was  the 
latter  who  after  years  of  experimentation  finallv 
attained  satisfactory  results,  and  thus,  although 
there  was  long  controversy  as  to  whom  the  real  merit 

711 


Artificial  Teeth 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


of  the  invention  belonged,  Dubois  de  Chemant  may 
with  truth  be  considered  the  inventor  of  mineral 
teeth. 

Among  those  who  first  manufactured  mineral  teeth, 
at  the  same  time  adding  improvements,  were  Dubois, 
Foucou,  and  Fonzi,  the  latter  Italian  by  birth  but 
Parisian  by  adoption.  Fonzi  invented  the  terro- 
metallic  teeth  which  were  single  teeth  applied  to  a 
base  by  small  platinum  hooks.  He  also  attained  to  a 
certain  extent  the  translucent  effect  of  natural  teeth. 

America,  however,  stands  at  the  head  in  the  manu- 
facture of  mineral  teeth.  Among  the  leaders  in 
this  work  were  Charles  W.  Peale,  Samuel  W.  Stockton, 
James  Alcock,  and  Dr.  Elias  Wildman.  The  most 
distinguished  of  all  in  the  improvement  of  mineral 
teeth,  however,  was  Samuel  S.  White. 

While  in  ancient  times  the  dentist,  were  he  barber 
or  blacksmith,  was  chiefly  concerned  with  the  pull- 
ing of  teeth,  the  trained  dentist  of  modern  days 
rarely  extracts.  Rather  does  he  bend  all  his  energies 
to  the  preservation  of  teeth. 

The  three  great  functions  of  teeth,  beauty,  speech, 
and  mastication,  demand  that  these  organs  receive 
the  best  of  care.  The  art  of  caring  for  the  teeth 
has  now  become  a  science.  If  a  tooth  is  lost  it  should 
be  replaced. 

The  chief  modern  appliances  in  relation  to  arti- 
ficial teeth  are  (1)  dentures  (artificial  teeth),  (2) 
crowns,   (3)  bridges. 

A  denture  consists  of  plate  and  teeth.  The  plate 
is  made  of  a  thin  sheet  of  metal  or  rubber  so  mod- 
eled as  to  fit  perfectly  the  hard  palate.  Among  the 
metals  used  for  dental  bases  are  gold,  platinum,  and 
aluminum.  Whatever  is  used  should  be  of  the  best 
material.  The  most  common  and  also  the  most 
serviceable  material  is  hard  rubber.  This  is  colored 
to  the  tint  of  the  gums.  The  plate  is  made  from  a 
model  taken  from  an  impression  of  the  mouth. 
Various  materials  are  used  for  taking  impressions, 
the  most  important  being  wax,  guttapercha,  modeling 
compound,  and  plaster-of-Paris,  the  latter  two  being 
the  most  desirable.  Many  delicate  manipulations 
and  processes  are  concerned  in  the  perfect  adjust- 
ment of  plates.  The  firm  position  of  the  plate  is 
greatly  aided  by  adhesion  and  air-pressure — com- 
monly called  "suction."  The  hard  palate  and 
plate  are  two  perfectly  occluding  surfaces.  By 
their  contact  the  air  between  them  is  driven  out, 
giving  full  play  to  the  action  of  adhesion  and 
atmospheric  pressure. 

The  teeth  are  anchored  to  the  plate  to  correspond 
as  far  as  possible  to  the  natural  denture.  The  teeth 
are  made  of  porcelain  which  is  a  composition  of  silex, 
feldspar,  and  kaolin.  This  material  is  tinted  to  a 
cream  white. 

Certain  objections  have  been  raised  against  the 
employment  of  artificial  dental  appliances.  Some 
individuals  are  ashamed  to  wear  artificial  teeth. 
Again,  it  has  been  urged  that  such  appliances  taint 
the  breath  and  destroy  the  sense  of  taste.  The 
superstition  that  artificial  teeth  are  taken  from  the 
dead  has  been  entertained.  Some  feared  that  a 
dental  prosthesis  could  not  be  firmly  retained  in 
place.     In  a  word,   these  objections  are  groundless. 

The  attachment  of  artificial  crowns  (pivot  teeth) 
is  probably  one  of  the  first  dental  operations  at- 
tempted. The  terms  "pivot  teeth"  and  "pivoting" 
are  misnomers  and  are  gradually  being  replaced  by  the 
correct  terms  "  artificial  crowns  "  and  crown  setting." 
The  crown  is  attached  to  a  badly  decayed  tooth  or 
to  the  root  by  a  piece  of  metal  which  is  a*  veritable 
dowel  or  dowel-pin.  Tne  latter  term  is  defined  as 
"  a  piece  of  wood  or  metal  used  for  joining  two  pieces 
by  inserting  part  of  its  length  into  one  piece,  the  rest 
of  it  entering  a  corresponding  hole  in  the  other." 
This  is  a  perfect  description  of  the  dental  piece  con- 
necting crown  and  root.  Various  methods  of  mount- 
ing   and   a    number  of   crowns  have  been  devised. 

712 


As  a  rule  thin  gold  in  the  form  of  a  cap  is  used  fa 
crowning  back  teeth,  although  all-porcelain  crowi: 
may  be  employed.  For  front  teeth  porcelain  crowi 
or  crowns  with  a  porcelain  face  are  commonly  en 
ployed.  If  there  is  left  a  firmly  embedded  root  th 
tooth  can  be  artificially  and   satisfactorily  i-i 

If  there  are  two  or  more  sound  teeth  or  roots  lei 
in  the  mouth  plates  may  be  dispensed  with,  tin 
place  being  taken  by  bridge  work.  A  bridge  i 
crowns  is  fitted  into  the  space  left  by  the  missil 
teeth,  the  median  crowns  being  soldered  to  each  otbi 
while  the  terminal  pieces  are  securely  fixed  to  th 
sound  roots  or  teeth.  The  special  construction  of  th 
bridge  should  be  appropriate  for  the  individual  casi 
Skill  and  ingenuity  on  the  part  of  the  dentist  ai 
necessary  to  adapt  the  appliances  to  the  particula 
needs  under  consideration,  for  there  are  many  methoi 
of  bridge  construction.  By  the  employment  of  crow 
and  bridge  work  teeth  that  otherwise  would  dcmai 
extraction  are  preserved. 

The  appliance  of  crown  and  bridge  work  has  reaclie 
a  high  degree  of  perfection,  and  when  correctly  mad 
and  fitted  offers  the  closest  approach  to  the  natur: 
teeth  that  modern  science  affords. 

Emma  E.  Walker. 


Arylarsonates. — An  arylarsonate  is  an  aromatic  ai 
sonate  or  salt  of  arylarsonic  acid,  that  is  to  say,  oil 
of  the  organic  arsenic  compounds  containing  a  radici 
of  the  aryl  group.  Arsonic  acid  is  a  derivative  i 
arsenic  acid  in  which  one  of  the  hydroxyls  (HO)  ha 
been  replaced  by  an  organic  radical,  either  an  alphj 
radical  (i.e.  one  of  the  fatty  or  aliphat  series)  or  a 
aryl  radical  (i.e.  one  of  the  aromatic  series),  the  lal 
ter  being  arylarsonic  acid.  The  arylarsonates  ar 
employed  therapeutically  chiefly  in  the  treatment  c 
diseases  due  to  trypanosomes  or  treponemas,  suck  B 
the  African  sleeping  sickness,  syphilis,  and 
The  best  known  and  most  commonly  employed  of  it 
arylarsonates  are  atoxyl  (soamin)  and  salvarsa 
{q.v.).  T.  L.  S. 

Asafcetida. — The  gum  resin  obtained  by  ineisin 
the  roots  of  various  species  of  Ferula,  particularly  I 
Asafcetida  Linn6  and  F .  foetida  (Bunge),  Regel  (Fan, 
UmbeUiferae).  (U.  S  .  P.)  The  adulteration  of  asafel 
ida  has  been  so  general,  and  its  forms  so  varied  tlia 
none  knows  which  of  its  elements  are  normal  am 
proper.  The  Pharmacopoeia  says  "various 
of  Ferula,"  but  not  one  of  its  editors  knows  whetln 
a  perfect  asafetida  ought  to  contain  the  prodmt  o 
more  than  one  of  these  species. 

Over  the  desert  steppes  of  Western  Asia  grow  ii 
great  abundance  a  variety  of  gigantic  perennial 
of  Umbelliferce,  which  perpetuate  themselves  durin: 
the  long  dry  seasons  by  very  large  fleshy  roots  pro 
tected  against  decay  and  foraging  animals  by  aim 
septic  and  obnoxious  resins  and  volatile  oils.  S( 
abundant  are  these  plants  that  immediately  aft i 
the  occurrence  of  the  first  rains,  it  is  their  germinatini 
leaves  which,  according  to  the  traveller  Aitchisoti 
chiefly  impart  the  tinge  of  green  to  the  land-rap' 
Later,  these  huge  leaves  interlace  so  thickly  as  t< 
become  obstructive  to  travel,  and  huge  flower  stalk 
shoot  up  to  the  height  of  many  feet.  These,  liki 
their  branches,  terminate  in  great  umbels  of  sum! 
greenish  or  yellowish-white  flowers.  Among  thesi 
plants  are  numerous  species  of  the  genus  Ferula  L 
It  is  fairly  well  established  that  asafetidais  collectei 
from  the  two  species  named  above,  assuming  thi 
be  distinct.  It  is  probable  also  that  the  produrl  >i 
F.  narthex  Boiss.,  and  perhaps  also  of  F.  attiac 
Boiss.  and  F.  pcrsica  Willd.  is  added,  but  whether  foi 
the  betterment  of  the  resulting  product,  or  purely  Si 
a  fraudulent  and  injurious  adulterant,  is  not  known, 
Asafetida  is  also  largely  adulterated  with  ammoniac. 


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As;i|irnl 


ie  young  leaves  and  shoots  of  these  plants  are  used 

rbs  in  their  native  home. 
fhe   history   of   asafetida   in    Europe   before    the 
century  is  not  clear,  although  it  has  been  held 
have  been  an  article  of  commerce  from  near  the 
iiiniiinti  of  tlir  Christian  era;  but,  from  the  twelfth 
ntiirv  down,  there  is  no  doubt   of  its  presence  in 
n  drug  lists.      On  the  other  hand,  of  it 
Asia   there   is   evidence   in    Arabian   and    Sanscrit 
ritinss  of  groat  antiquity. 

The  principal  supply  of  this  drug  is  collected   in 

fgbanistan,    and    exported     tn     India     (Bombay), 

it  conies  to  Europe  or  America.     It  is  usually 

in   large   cases,    but   sometimes   in   bags   or 

mats." 

Our  knowledge  of  the  collection  of  asafetida  rests 
incipally  upon  the  evidence  of  two  travellers,  who 
id  the  fortune  to  see  it  at  an  interval  of  nearly  two 
1  years  from  each  other.     The  first  of  these 
celebrated  Kaempfer,  who  observed  it  in  the 
■rsian   province  of   Laristan.     His   description  has 
in  repeatedly  quoted,  and  is,  in  the  main,  as  fol- 
\ I m  nit  the  middle  of  April,  when   the   leaves 
nine   growing,    the   fields   are   visited   by    the 
ts,    who    dig    away    the    ground    around    the 
klcr  roots,  tear  off  the  leaves  from  the  crown,  and 
ii  n   carefully   cover  it    up   with   earth   and   leaves, 
i  protect  it  from  the  rays  of  the  sun.     After  leaving 
■  plants  in  this  way  for  several  weeks,  they  again 
them,    remove   a   portion   of    the    top    and 
them  again,  being  careful  that  nothing  touches 
v   newly   cut    surface.     In  one  or   two   days   more 
ided  juice  is  scraped  off  with  a  knife,  a  fresh 
irface  is  made  by  cutting  off  a  thin  slice,  and  the 
overing   is   repeated.     This   is   continued   until    the 
10I  ifi  exhausted,  the  product  growing  better  as  the 
eason  advances.     The  soft  juice  is  mixed  with  earth 
o  give  it  body." 
the  other  authority  is  Staff  Surgeon  Bellew,   who 
afetida  collected  during  a  visit  to  Afghanistan 
i   ls.">7.     The  process  was  something  like  that  ob- 
erved  by  Kaempfer,  but  it  was  done  at  a  season  when 
lie   young    leaves    were   sprouting,    and    instead    of 
itting  off  the  top  of  the  root  they  cut  or  gashed  it  in 
era!  places;  the  digging  away  of  the  earth  and  the 
overing  of  the  roots  to  keep  off  the  heat  of  the  sun 
were  the  same  in  both  cases.     Mr.  Bellew  states  that 
he  juice  is  mixed  with   gypsum  or  flour,  although 
some  very  fine  juice,  obtained  from  the  bud,  is  usu- 
illy  sold   pure.     This  latter,   like   the   fine  juice  of 
Kaempfer's  later  cuttings,  rarely  reaches  the  Euro- 
markets. 
Good  asafetida.  when  the  cases  are  first  opened, 
is  a  moderately  soft,  yellowish-gray,  rather  tenacious 
mass,  of  a  not  very  homogeneous  texture.     Sometimes 
whitish  or  yellowish  tears  are  common  in  the 
mass;  oftener  coarse  impurities  are  the  cause  of  its 
unevenness.     Upon  exposure,  this  light-colored  asa- 
fetida turns  first  pink,  or  reddish  plum  or  violet  pink, 
and    then    gradually    becomes    brown.     Its    odor    is 
characteristic;  strongly  alliaceous,   penetrating,   and 
ent.     It  is  exhaled,  like  that  of  onions,  in  the 
breath   of   persons    taking   it.     The   taste    is   bitter, 
acrid,  and  nauseous.     When  in  lumps,  even  if  long 
kept,  asafetida  is   usually  not   quite   brittle,   but    if 
finely  broken  and  dried  it  can  be  ground  to  powder, 
in  the  cold.     This,  however,  involves  the  loss  of  its 
volatili  oil,  the  most  valuable  constituent. 

The  quality  is  considered  fine  according  to  the 
abundance  of  clear,  whitish  tears  which  it  contains, 
and  the  absence  of  impurities  and  insoluble  residue. 
Occasionally  specimens  are  met  with,  consisting 
wholly  of  tears,  but  these  are  rare.  These  tears  are 
of  two  varieties,  one  of  which  does  not  turn  red  on 
exposure.  The  U.  S.  P.  requires  that  not  less  than 
forty  per  cent,  of  asafetida  should  be  soluble  in 
alcohol,  and  that  it  should  not  yield  more  than  thirty 
per  cent,  of  ash.    This  was  done  by  the  Committee 


of  Revision  for  the  definite  and  expre    <-d  purpo  e  of 
authorizing    adulteration    with    about  five 

per   cent,    of   mineral    matter.       Many    lot      ha 

offered  which  were  nol   nearly  so  good,  from  eighty 
ety  per  cent    consisting  ol 

When  it  is  considered  thai  the  chief  cosl  of  the 
article  is  the  result  of  its  long  transportation,  much 
of  it  over  very  expert  ive  tagi  ,  it  will  be  n 
nized  as  exceedingly  wasteful  to  import  a  consider- 
able percentage  of  sand  and  crushed  stone.  Polisek 
in  1897  determined  the  composition  of  a  -ample  of 
asafetida  that  he  believed  pure  to  be  as  follows: 
"Ether-soluble  resin  (ferulic  acid  ester  of  asaresinol 
tannol,  r.,11  ;m, mil),  61.4;  ether-insoluble  resin 
(free  asaresinol  tannol),  0.60;  gum,  25.1;  volatile  oil, 
(i.7;  vanillin,  0.06;  free  ferulic  acid,  1.28;  moisture, 
_'.:'>f.;  foreign  matter,  L'.o."  This  composition  is  by 
no  means  constant,  as  the  relative  proportions  of 
resin  and  gum,  and  to  a  less  extent  of  the  oil  and 
vanillin,  are  quite  variable.  The  impurities  and  ash 
should  not  exceed  ten  or  fifteen  per  cent.  The  gum 
is  mostly  insoluble  in  water.  The  resin  yields  resorcin 
when  fused  with  potassa,  and  umbelliferon  and  oils 
when  subjected  to  destructive  distillation.  The 
oil  is  light  yellow  and  possesses  very  strongly  the  odor 
of  the  drug.  It  is  related  to  the  volatile  oil  of  mus- 
tard, but  is  not,  like  it,  a  strong  local  irritant.  It  is 
of  a  very  complex  composition,  which  has  not  yet 
been  perfectly  worked  out.  It  contains  about 
twenty-five  per  cent,  of  sulphur. 

Ammoniac  and  galbanum  are  common  adulterants, 
and  it  has  been  claimed  that  the  ammoniac  is  added 
in  Hamburg.  The  best  test  of  purity  is  the  deter- 
mination of  the  lead  number  of  the  re- in. 

Asafetida  is  a  typical  antispasmodic,  as  well  as  one 
of  our  best  carminatives.  It  stimulates  the  appetite 
and  the  gastric  secretions  and  movement-,  as  well  as 
the  internal  functions.  As  an  antispasmodic  it  is  par- 
ticularly useful  in  hysteria,  and  is  sometimes  useful 
in  spasmodic  affections  of  the  respiratory  organs, 
as  pertussis  and  asthma.  It  frequently  permits 
sleep  by  allaying  excitement,  and  especially  by 
removing  intestinal  irritation.  It  is  very  largely 
used  in  veterinary  practice.  The  dose  is  gr.  v.  to  xx. 
(0.3  to  1.5).  Three  preparations  are  official:  The 
Pilulae  Asafcetidae  contain  each  0.2  gram  (gr.  iij.) 
asafetida  and  three  times  as  much  soap;  the  Pilulae 
Aloes  et  Asafcetidae,  formerly  official,  contain  0.09 
gram  (gr.  1$)  each  of  aloes,  asafetida,  and  soap; 
the  Emulsum  Asafcetidae  (formerly  "Mistura")  has 
a  strength  of  4  per  cent,  and  the  dose  is  fl.  5  ss.  to  i. 
(15  to  30).  This  preparation  is  remarkably  effective 
when  used  as  an  enema,  in  which  case  the  dose  may 
be  doubled.  The  tincture  has  a  strength  of  twenty  per 
cent,  and  the  dose  is  fl.  5  ss.  to  i.  (20  to  40).  Asafet- 
ida is  frequently  used  externally  in  plasters,  being  a 
mild  rubefacient. 

It  may  be  added  that  asafetida  renders  bait  attrac- 
tive to  certain  fishes,  notably  bullheads. 

H.  H.  Rusby. 


Asaprol.  —  Abrastol-betanaphthol-alphamonosul- 
phonate  of  calcium — C10H„.OHtSO  )  ( 'a  +3H20.  An 
aqueous  solution  of  betanaphthol-alphamonosul- 
phonie  acid  is  saturated  with  calcium  carbonate,  and 
the  salt  crystallized  out.  It  is  a  white  or  pale  reddish 
crystalline  powder  without  odor  and  soluble  in  one 
part  and  a  half  of  water  and  three  parts  of  alcohol. 
It  is  of  neutral  reaction,  is  not  changed  by  heat,  and 
is  incompatible  with  the  sulphates,  and  with  quinine 
and  antipyrine.  It  is  antiseptic,  antineuralgic,  and 
antirheumatic,  and  is  eliminated  by  the  kidneys  in 
the  form  of  a  naphthol  sulphuric  ether.  It  may  be 
detected  in  the  urine  by  the  formation  of  a  blue  ring 
on  the  addition  of  ferric  chloride.  As  an  antirheu- 
matic it  is  claimed  by  Dujardin-Beaumetz,  Buck, 
Stackler,  and  others  that  asaprol  is  equal  in  value  to 


•13 


Asaprol 


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the  salicylates,  and  at  the  same  time  does  not  cause 
headache,  buzzing  in  the  ears,  and  depression  of  the 
heart.  It  has  been  tried  with  moderate  effect  in 
influenza,  malaria,  and  chorea,  and  with  relief  of  the 
pain  in  neuralgia. 

Locally,  as  antiseptic,  astringent,  and  styptic  it 
may  be  applied  in  one  to  four-per-cent.  solution  or 
ointment,  and  in  whooping-cough  a  one-per-cent. 
solution  may  be  sprayed  into  the  throat.  Internally 
it  may  be  employed  as  an  antiseptic  in  intestinal 
indigestion,  enteritis,  and  typhoid  fever.  The  dose 
internally  is  gr.  xv.  to  lx.  (1.0-4.0)  or  more,  three 
times  a  day,  given  in  gaultheria  water  or  elixir  of 
orange,  or  in  capsules.  W.  A.  Bastedo. 

Ascaridse. — A  family  of  round  worms.  The  body 
is  relatively  thick,  the  mouth  is  surrounded  by  three 
lip  lobes,  one  of  which  is  dorsal.  All  are  intestinal 
parasites.  The  principal  genus  is  Ascaris,  in  man  and 
other  mammals.     See  Nematoda.  A.  S.  P. 

Ascaris. — An  important  genus  of  parasitic  round 
worms,  containing  more  than  200  species.  The  three 
lip  lobes  are  prominent;  the  males  have  two  penial 
setae;  the  vulva  is  in  advance  of  the  center  of  the  body. 
A.  lumbricoides  is  the  common  round  worm  of  children 
and  has  a  world-wide  distribution;  the  embryos  may 
live  within  the  egg-shell  for  as  much  as  five  years 
after  leaving  the  host.  Sometimes  this  worm  bores 
through  the  wall  of  the  intestine  into  the  peritoneal 
cavity.  A.  canis,  usually  found  in  cats  and  dogs, 
and  another  species  have  also  been  found  in  man. 
See  Nematoda.  Arthur  S.  Pearse. 

Ascites. — (Synonyms,  Hydrops  ascites,  Hydroperi- 
toneum,  Dropsy  of  the  peritoneum.) 

Definition. — Ascites  is  an  accumulation  of  free 
fluid  in  the  peritoneal  cavity. 

It  is  either  (1)  a  part  of  a  general  dropsy  involving 
the  pleurae,  pericardium,  and  subcutaneous  tissues  of 
the  body,  or  (2)  a  strictly  localized  dropsy  caused  by 
disease  in  the  peritoneal  cavity.  Class  (2),  if  of  long 
standing,  may  secondarily  cause  edema  of  the  legs,  as 
a  result  of  the  anemia  which  usually  develops,  or  as  a 
result  of  pressure  upon  the  iliac  veins.  Class  (1) 
depends  upon  diseases  of  the  heart,  kidneys,  lungs,  or 
blood.  Class  (2)  occurs  with  atrophic  and  hypertrophic 
cirrhosis  of  the  liver,  cancer  and  syphilis  of  the  liver, 
amyloid  liver,  atrophy  of  the  liver  due  to  external 
pressure  or  growth,  abscess  or  echinococcus  of  the 
liver  causing  pressure  upon  the  portal  vein.  Tumors 
of  the  stomach  and  pancreas,  peritoneal  adhesions 
and  enlarged  lymphatic  glands  may  cause  ascites  by 
pressing  upon  the  portal  vein.  Thrombosis  of  the 
portal  vein  or  of  the  inferior  vena  cava  likewise  may 
cause  ascites.  Chronic  peritonitis,  either  simple, 
tuberculous,  or  cancerous,  and  perihepatitis  chronica 
(icing  liver,  sugar-coated  liver)  are  causes  of  ascites. 
Leukemia  and  splenic  anemia  are  occasionally  asso- 
ciated with  this  condition ;  and  so  also  are  intrathoracic 
growths  and  mediastino-pericarditis.  A  small  as- 
cites may  occur  in  apoplexy;  it  has  also  been  noted  in 
intestinal  obstruction.  Occasionally  on  the  post- 
mortem table  there  have  been  found,  in  the  different 
cavities  of  the  body,  collections  of  fluid  which  had  not 
been  demonstrated  by  physical  signs  during  life. 
Immediately  preceding  death  there  is  an  intense  con- 
gestion of  the  viscera  which  frequently  results  in  an 
outpour  of  serum.  This  condition,  when  involving 
the  peritoneal  cavity,   is   termed  preagonal  ascites. 

Pathology. — From  an  etiological  standpoint  all 
varieties  of  ascites  (chylous  ascites  is  discussed  under 
the  heading  Lymphatic  vessels,  diseases  of)  may  be 
classed  under  three  heads: 

714 


1.  Ascites  due   to  stagnation  of  blood  in  blood 
vessels. 

2.  Ascites  due  to  interference  with  the  escape  o 
lymph. 

3.  Ascites  due  to  disturbance  of  capillary  secretioD 
i.e.  alteration  in  the  walls  of  the  capillaries. 

In  certain  diseases  we  have  combinations  of  th 
above  causes;  for  example,  a  chronic  heart  disi 
with  incompensation  may  secondarily  produc 
changes  in  the  capillary  walls,  as  a  result  of  lack  o 
nourishment  resulting  from  the  imperfect  renewa 
of  blood. 

The  third  class  is  distinctly  a  conception  of  moden 
pathologists  and  will  require  more  detailed  discussion 
The  former  belief  that  the  process  which  resulted 
dropsy  was  merely  a  filtration  of  fluid  through  an  ani 
mal  membrane  has  been  discarded.  It  is  now  heli 
that  the  capillary  walls  are  to  be  regarded  as  living 
organs  with  a  capacity  for  secretion.  The  prompt 
passage  of  the  crystalloids  from  the  blood  and  tlu 
lymph  is  accomplished  with  the  aid  of  a  force  inherent 
in  the  capillary  walls.  The  fact  that  the  proportioi 
of  salts  or  of  sugar  in  the  lymph  is  often  greater  that 
that  in  the  blood  suggests  a  capillary  secretion.  Tin 
fact  that  the  proportion  of  albumin  in  pure  transu- 
dates in  different  parts  of  the  body  varies  considerably 
points  to  a  differing  constitution  of  the  vessel  wall  in 
these  several  regions.  According  to  Reuss'  table, 
transudates  in  different  parts  of  the  body  give  the 
following  percentages  of  albumin: 

Pleura 22.5  pro  mille. 

Pericardium 18.3  pro  mille. 

Peritoneum 11.1  pro  mille. 

Subcutaneous  cellular  tissue 5.8  pro  mille. 

Cerebral  and  spinal  fluid 1.4  pro  mille. 

Heidenhain  believes  that  the  specific  function  of  the 
capillary  wralls  plays  a  controlling  part  in  the  forma- 
tion of  lymph.  Whenever  the  removal  of  lymph 
fails  to  keep  pace  with  its  formation,  dropsy  results. 
This  investigator  has  demonstrated  that  the  forma- 
tion of  this  material  can  be  influenced  by  various  sub- 
stances present  in  the  blood.  Subcutaneous  injec- 
tions of  an  infusion  of  crabs  or  leeches  so  increa 
the  transudation  of  water  from  the  blood-vessels  into 
the  lymph  that  the  quantity  of  lymph  flowing  from 
the  ductus  thoracicus  was  increased  even  to  fifteen- 
fold.  This  exciting  substance  must  stimulate  the 
specific  functions  of  those  capillary  cells  in  the  capil- 
lary walls  which  secrete  the  lymph.  Class  3  inclui 
the  varieties  of  ascites  usually  termed  inflammatory 
and  cachectic.  In  the  majority  of  cases,  the  chant 
in  the  vessel  walls  are  the  result  of  protracted  ische- 
mia,  of  imperfect  ox}'genation,  or  of  chemical  changi  s 
in  the  blood,  or  are  due  to  the  effect  of  high  or  low  ti 
perature  or  to  active  traumatism.  It  is  also  probable 
that  either  irritation  or  paralysis  of  the  vasomotor 
nerves  may  lead  to  an  increased  vascular  secretion. 
The  exact  changes  in  the  vessel  walls  are  not  known, 
but  there  are  probably  alterations  of  the  endothelial 
cells  and  of  the  cementing  substance  between  them. 
It  is  quite  possible  that  Class  3  may  include  Class  1 
and  that  our  so-called  pure  transudates  of  obstruct  "d 
circulation  are  capillary  secretions  rather  than  nitra- 
tions, the  capillary  cells  being  stimulated  to  secretion 
by    irritating   substances    circulating   in    the   blot 

In  cases  of  hydremia  with  edema.  Ziegler  looks 
upon  the  increase  in  the  amount  of  water  in  the  blood 
as  only  one  factor  which  is  favorable  to  the  occurrence 
of  edema.  In  cachectic  and  nephritic  subjects  edema 
occurs  often  when  no  hydremic  plethora  is  present, 
and  conversely  edema  may  be  absent  when  hydremic 
plethora  is  present.  So  it  is  held  that  the  edema  of 
cachectics  and  nephritics  is  due  to  alteration  in 
vessel  walls  caused  either  by  the  hydrated  condition 
of  the  blood  or  by  a  poison  circulating  in  the  blood. 

Two  factors  are  present  as  causes  of  ascites  in  in- 
flammatory changes  in  the  peritoneum,  viz.,  altera- 


•REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Ascites 


ina  in  the  walls  of  the  bloods  essels  and  thedesl  ruc- 

,.,  ,,i  g  large  Qumber  of  lymphatic  vessels  through 

the  fluid,  secreted  in  excessive  amount,  should 

■  carried.     The  ascites  almost  invariably  associated 

ith  perihepatitis  chronica  is  to  be  explained  by  the 

existence  of  a  chronic  peritonitis.     In  some  cases  of 

[hepatitis   in   which   there  is  no  ascites,  general 

mitis  is  absent. 

/  is  cither  a  transudate  or  an  exudate. 

idates  are   found   in   non-inflammatory   condi- 

id  are  usually  light  yellow  in  color,  while  exu- 

ites  are  found  in  inflammatory  conditions  and  are 

irker  in  eolor.     There  are  essential   differences   in 

imposition,  a  fact  which  may  be  of  aid  in  diag- 

Peritoneal  transudates  have  a  specific  gravity 

trying  between    1.005   and    1.015,   while   that  of 

es  frequently   reaches    1.030.     The  difference 

.  the  specific  gravity  is  due  to  the  difference  in  the 

nount  of  albumin;  exudates  contain  from  four  to 

l  per  cent.,  while  transudates  contain  from  one  to 

vo  and  a  half  per  cent.     Transudates  do  not  coagu- 

lontaneously;  in  exudates  a  coagulum  is   fre- 

lently    observed    after    standing    for    twenty-four 

ours. 

Microscopically  the  transudate  shows  only  a  few 

1     leucocytes    and    endothelial    cells    derived 

om  serous  surfaces  and  undergoing  fatty  degenera- 

on.     Exudates  contain  many  more  formed  elements 

od    may    be    serous,     serofibrinous,     seropurulent, 

undent,  putrid,  hemorrhagic,  chylous,  or  chyloid.    In 

■,io  cases  the  ascitic  fluid  contains  mucoids  the  pres- 

ace  of  which  is  due  apparently  to  degeneration  of 

eritoneal    endothelium.     Cholesterin    crystals 

tetimes  seen  in  it.     The  protein  content  varies 

reatly  in  different  cases  of  ascites,  being  especially 

i  cardiac  eases. 

wing  the  administration  of  potassium  iodide 
ossible  to  obtain  the  iodine  reaction  in  ascitic 
uids. 

r.noLOGT. — Atrophic  cirrhosis  of  the  liver  is  the 

ommon  cause  of  ascites.     It  is  less  commonly 

Kind  in  the  hypertrophic  form.     The  frequency  of 

in  diseases  of  the  heart  and  kidneys  is  illus- 

i  :>•  the  statistics  of  300  cases  of  general" dropsy .  as 
evealed  after  death,  taken  consecutively  from  the 
lostmortem  books  of  St.  George's  Hospital,  London, 
rom  1SS8  to  1897.     One  hundred  and  sixty-three  of 

were  due  to  affections  of  the  heart  or  aorta. 
Vs  regards  ascites,  1  in  2.5  of  the  cardiac  cases  and 
in  2.2  of  the  renal  (not  lardaceous)  cases  presented 
his  condition.  Any  of  the  organic  heart  lesions 
vhen  incompensated  may  be  followed  by  ascites.  It 
s  most  frequently  associated  with  mitral  stenosis. 
I  he  pleura1  and  peritoneum  are  especially  liable  to 
liopsical  invasion  with  the  large  white  kidney  of 
lepnritis  and  the  advanced  granular  kidney  in  which 
econdary  cardiac  changes  have  been  added  to  the 
enal.  Diseases  of  the  lungs,  such  as  emphysema  and 
ibroid  changes,  may  cause  ascites  by  obliterating 
Pulmonary  vessels.  This  results  in  an  increase  of 
Pressure  in  the  right  heart,  and  secondarily  in  the 

:ind  capillaries,  with  transudation. 

Diagnosis. — Inspection. — In  ascites  of  moderate 
legree  with  the  patient  lying  down,  the  abdomen  is 
full  at  the  sides  and  flat  on  top;  in  the  upright  posi- 
tion it  projects  belo.w  the  navel.  If  the  ascites  is 
enormous  there  is  a  uniform  distention  and  little  or 
no  change  of  shape  with  change  of  position.  The  super- 
ficial abdominal  veins  become  enlarged  in  cases  of 
Ion?  standing.  In  cirrhosis  of  the  liver  the  veins 
-unwinding  the  umbilicus  may  become  very  promi- 
nent and  form  the  so-called  caput  medusae.  When  the 
amount  of  fluid  is  excessive  there  is  a  marked  hernial 
protrusion  of  the  navel. 

Palpation. — Fluctuation  is  obtained  by  placing  one 
hand  flat  upon  one  side  of  the  abdomen,  and  tapping 
gently  on  the  opposite  side  with  the  other,  as  in  direct 


percussion.  A  similar  sensation  may  be  felt,  how- 
ever, if  the  abdomen  !"■  very  fat  or  tympanitic.  In 
order  to  exclude  this  pseudo-fluctuation,  an  assistant 
presses  the  edge  of  his  hand  along  the  linea  alba;  this 
maneuvre  does  not  interfere  with  the  transmission 
of  the  wave  in  ascites,  but  effectually  interrupts  it 
in  the  other  conditions  mentioned. 

Percussion. — In  the  horizontal  position  there  is 
duli less  at  the  sides,  and  tympany  over  tic  upper  arid 

middle  portions  of  the  abdomen.  The  fluid  seeks 
the  dependent  parts  and  tin'  intestines  float  to  the  top 
so  far  as  the  mesentery  will  permit.  The  area  of 
dulness  changes  with  the  position  of  the  patient.  On 
assuming  the  side  position,  dulness  is  obtained  over 
the  lower  side  and  tympany  over  the  upper.  If  the 
ascites  is  enormous,  the  intestines  and  stomach  do 
not  reach  the  surface,  consequently  there  is  dulness 
over  the  entire  abdomen.  The  amount  of  fluid  neces- 
sary for  demonstration  varies  with  the  size  and  sex  of 
the  patient. 

Toma's  sign  has  been  employed  to  distinguish  be- 
tween an  exudate  and  a  transudate,  or  inflammatory 
and  non-inflammatory  conditions.  In  inflammatory 
conditions  of  the  peritoneum  the  mesentery  contracts, 
drawing  the  intestines  over  to  the  right  side.  As  a 
result,  the  patient  assuming  a  horizontal  position, 
tympany  is  elicited  over  the  right  side  and  dulness 
over  the  left. 

Exploratory  puncture  is  the  crucial  test,  and  should 
always  be  employed  before  operation. 

Differential  Diagnosis. — The  ascites  of  heart 
disease  is  associated  with  a  dusky  skin,  while  that  of 
Bright's  disease  is  associated  with  a  pale  skin. 
Diseases  of  the  heart,  lungs,  kidneys,  and  blood 
should  be  excluded  by  careful  examination.  A 
satisfactory  examination  of  the  abdomen  by  palpa- 
tion can  be  made  only  after  the  withdrawal  of  the 
fluid.  Palpation  is  then  very  easy  on  account  of  the 
relaxed  abdominal  muscles.  An  enlarged  liver  or 
spleen,  or  growths  on  the  liver  or  in  the  neighborhood 
of  the  portal  vein  can  then  be  easily  felt.  At  times 
the  nodules  of  tuberculous  or  carcinomatous  peritoni- 
tis can  be  made  out.  If  primary  cancer  or  tuber- 
culosis is  found  in  other  parts,  the  problem  is  simpli- 
fied. The  great  value  of  microscopical  examination 
of  the  fluid,  as  a  material  aid  in  differential  diagnosis, 
should  be  strongly  emphasized.  The  fluid  should 
be  centrifugated,  the  sediment  spread  on  cover  slips, 
dried  in  the  air,  fixed  in  absolute  alcohol  and  ether, 
then  stained  with  hematoxylin.  Quincke,  Rieder, 
Dock,  and  Warthin  have  found  in  exudates  cells 
which  seem  peculiar  to  cancer  and  sarcoma  of  serous 
membranes.  Rieder  found  cells  undergoing  division, 
their  nuclei  presenting  numerous  caryocinetic  figures, 
especially  asymmetrical  division  forms,  which  are 
found  to  a  slight  degree  or  not  at  all  in  endothelial 
cells.  Dock  found  in  cancerous  effusions  more  cells 
showing  mitoses  than  in  simple  or  tuberculous 
inflammations.  Warthin  concludes  from  his  inves- 
tigations that  the  presence  of  numerous  cell-division 
forms  in  the  cells  of  the  sediment  of  serous  exudates 
may  be  taken  as  strong,  perhaps  conclusive,  evidence 
that  the  effusion  is  due  to  the  presence  of  a  new  growth, 
inasmuch  as  mitoses  are  but  rarely  found  in  cells  of 
purely  inflammatory  exudates.  Quincke  claims  that 
carcinoma  probably  exists  if  a  marked  glycogen 
reaction  can  be  obtained  in  the  endothelial  cells. 
Endothelial  cells  are  sometimes  mistaken  for  the 
so-called  cancer  cells.  Quincke  states  that  the 
diagnosis  should  be  made  only  when  large  epithelial 
cells  of  variable  form,  measuring  'at  times  120  a  in 
diameter,  are  found  in  large  numbers,  especially 
when  arranged  in  groups,  unless  indeed  cancerous 
nodules  presenting  the  characteristic  alveolar  struc- 
ture are  found.  Hemorrhagic  exudates  are  as  a  rule 
tuberculous  or  cancerous.  The  fluid  should  be 
centrifugated,  spreads  made  and  stained  for  tubercle 

715 


Ascites 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


bacilli,  though  those  are  rarely  found  even  in  un- 
doubted cases  of  tuberculosis  of  the  peritoneum.  A 
guinea-pig  should  be  inoculated  with  the  sediment, 
since  even  when  the  bacilli  are  not  found  the  pig 
often  develops  tuberculosis.  The  diazo  reaction  is 
occasionally  present  in  the  urine  of  tuberculous  and 
cancerous  peritonitis,  but  does  not  help  in  differen- 
tiating one  from  the  other,  as  it  has  been  found  in 
both.  The  quantity  of  fluid  varies  greatly  with  the 
disease,  but  is  usually  largest  in  atrophic  cirrhosis 
of  the  liver  and  in  perihepatitis  chronica.  AV.  Hale 
White  reports  the  case  of  a  patient  with  perihepatitis 
who  was  tapped  thirty-five  times;  the  total  amount 
of  fluid  withdrawn  was  790  pints;  the  largest  quantity 
taken  out  at  one  time  was  thirty-one  and  a  half 
pints.  Piitz's  case  of  atrophic  cirrhosis  of  the  liver 
was  tapped  forty-seven  times,  with  the  removal  of 
1200  liters  of  fluid,  during  a  sickness  of  four  years' 
duration. 

Prognosis. — The  majoritj'  of  the  patients  die 
within  two  years.  Some  patients  suffering  from 
uncompensated  heart  lesions  recover  under  cardiac 
treatment  and  live  for  many  years.  Occasionally  a 
patient  with  cirrhosis  of  the  liver  recovers,  if  a  suffi- 
cient collateral  circulation  is  established.  Numerous 
recoveries  have  been  reported  in  cases  of  tubercu- 
lous peritonitis  with  ascites,  treated  by  laparotomy. 
Many  theories  have  been  advanced  to  explain  the 
cause  of  recovery  in  these  cases.  There  are  tuber- 
culous diseases  of  the  peritoneum  which  heal  spon- 
taneously. Hildebrandt  believes  that  laparotomy 
only  increases  the  natural  healing  factors.  This 
author  believes  that  the  venous  hyperemia  which 
ensues  is  the  important  factor  in  the  healing  of 
tuberculous  peritonitis.  Following  operation  he  has 
observed  an  involution  of  the  tuberculous  process,  and 
in  isolated  cases  a  complete  healing  with  disappear- 
ance of  the  tubercles  which  he  had  seen  in  the  first 
laparotomy. 

Treatment. — The  ascites,  if  troublesome,  should 
be  relieved  immediately,  and  treatment  directed  to 
the  causative  disease  instituted  if  advisable.  The  first 
is  most  successfully  accomplished  by  the  simple 
surgical  procedure  of  tapping.  This  operation  is 
strikingly  free  from  the  danger  of  infecting  the 
peritoneum.  Flint  refers  to  a  patient  who  frequently 
tapped  himself  with  a  jack-knife  and  used  a  clay  pipe 
stem  for  a  cannula. 

Aspiration,  or  the  introduction  of  Southey's  tubes, 
may  be  resorted  to. 

If  the  diagnosis  of  tuberculous  peritonitis  seems 
probable,  then  laparotomy  should  be  performed. 
The  fluid  may  collect  so  rapidly  that  it  is  necessary 
to  tap  every  fortnight  or  oftener,  but  frequent  tap- 
pings do  no  harm.  In  ascites  due  to  heart  disease 
and  anemia,  treatment  appropriate  to  these  diseases 
should  be  given.  The  use  of  diuretics  and  hydra- 
gogue  cathartics  is  usually  unsatisfactory.  The  value 
of  the  dehydrating  effect  of  dry  diet  should  be 
emphasized.  Care  should  be  taken,  however,  in 
selecting  appropriate  cases,  since  a  dry  diet  is  well 
borne  in  caidiac  dropsy  and  poorly  borne  in  renal 
dropsy.  James  R.  Arneill. 

Edward  Preble. 

Bibliography. 

Cohnheim:  Allgem.  Pathologie,  1SS2. 

Cohnheim  u.  Lichtheim:  Ueber  Hydramie  u.  hydramisches 
Ii  in,  Virchow's  Archiv,  Bd.  69,  1S77. 

I  luck:  The  Value  of  Cells  in  Effusions  in  the  Diagnosis  of  Cancer 
of  the  Serous  Membranes.  The  American  Journal  of  the  Medical 
Sciences,  .Tune,  1897. 

Halliburton:  Allbutt  and  Rolleston's  System  of  Medicine,  iv.,  i, 
521,  1908. 

Heidenhain:  Zur  Lehre  von  dor  Lymphbildung.  Yerhandl.  d. 
X.  [nternat.  Med.  Congr.,  ii.  Berlin,  1S91,  u.  Arch.  f.  d.  ges.  Phys  , 
Bd    19,  1891. 

716 


Herrick:  Journal  of  Experimental  Medicine,  ix.,  93,    1907. 

Hildebrandt:  Munchener  med.  Wochenschrift,  51  and  .j_'   ivi 

Lazarus:  The  Pathol,  of  Edema.     British   Med.  Jour.,  i.,  Igc 

Lazarus  Barlow:  Manual  of  Pathology,  1904. 

Quincke:  Deutsches  Archiv  f.  klin.  Med.,  vol.  xxx. 

Reuss:  Verhaltnissd.  spec.  Gew.  z.  Eiweissgehalt  in  seroscn  Flu 
sigkeiten.  Deut.  Arch.  f.  klin,  Med.,  28  Bd.,  u.  Beurtheilung  vn 
Exudaten  u.  Transsudaten,  ib.,  Bd.  24. 

Rieder:  Deutsch.  Arch.  f.  klin.  Med.,  vol.  liv. 

Simon:  Clinical  Diagnosis,  Seventh  Ed.,  1911. 

Starling:  On  Absorption  from  and  Secretion  into  the  Serot 
Cavities.  Journ.  of  Phys.,  xvi.,  1S94;  The  Influence  of  Mechanic: 
Factors  on  Lymph  Production,  ib.,  1S94;  Action  of  Lymphagogue 
ib  ,  xiv.,  1896;  Absorption  of  Fluids  by  Blood-vessels,  ib.,  189f 
The  Causation  of  Dropsy,  Lancet,  1896. 

Vierordt:  Medical  Diagnosis. 

Warthin:  The  Diagnosis  of  Primary  Sarcoma  of  the  Pleura  froi 
the  Cells  found  in  the  Pleuritic  Exudate. 

Ziegler:  Text-book  of  Pathological  Anatomy. 


Ascites,    Chylous    and    Adipose. 

Vessels. 


-See    Lymphati 


Asclepiadaceae. — Milkweed  Family.    This  immens 
family,    of    more    than     two    hundred      genera   an, 
fifteen  hundred  species,  is  an  exceedingly  difficult  on 
for  botanists.     There   is   probably   no   other  famib 
the  relations  of  whose  members  are  so  poorly  known 
so  that  any  present  system  of  classification  must  l>< 
regarded  as   arbitrary.     Nevertheless,    the  composi 
tion   and   properties    of  its   members   are    singularl; 
uniform.     Its   plants,   with   few   exceptions,   abound 
in  a  milky  juice  which  possesses  acrid  and  nauseating 
properties,  so  that  a  great  many  of  them  have  beci 
used    as    nauseating    expectorants,    alteratives, 
mild     counterirritants.     The     glucoside     asclepiw 
occurs  frequently   in   this  juice,   as   do  many  othei 
glucosides.     The  only  plants  which  have  been  m 
used  in  professional  medicine  are  several  specie 
Asclepias  (see  Pleurisy  Root)  and  Condurango.     Man'. 
are,  however,  used  in  native  and  domestic  pra< 
In  India  especially,  a  large  number  of  species  hav 
been  used,   the  principal  of  which  are  described  bj 
Dymock    and    Hooper    in    the    "Pharmacograpld 
Indica"     as     follows:   Cryptostegia     grnndiflora     Br., 
which  is  poisonous  and  yields  a  rubber.     Calotri 
gigantea    R.    Br.,  and  C.   procera  R.    Br.,  which 
irritant  purgatives;   Tylophorn  asthmatica  AY.  and  A. 
which   is   a   nauseating  expectorant ;    Dcemia   ext 
Br.;    Dregea   volubilis    Benth.;    Hemidcsmus   Ind 
Br.,  the  root  of  which  is  a  much-used  and  powi 
diuretic;  Cosmostigma  racemosum   Wight.;  Gymm 
sylvestre  Br.,  and  many  others  less  well  known. 

II.  H.  Rusby. 

Asclepiades. — Born  about  124  B.  C.  in  Prusa  in 
Bithynia.  He  studied  medicine  under  Cleophantus, 
a  writer  on  pharmacology,  but  did  not  follow  bis 
teachings  in  practice,  becoming  a  professional 
therapeutic  nihilist.  He  went  to  Rome  as  a  teacher 
of  rhetoric,  but  soon  abandoned  that  calling  fur 
medicine.  His  theory  was  that  disease  is  caused  I 
over  tension,  strictum,  or  over  relaxation,  laxum,  the 
problem  of  the  physician  being  to  restore  the  equi- 
librium. This  he  endeavored  to  do  chiefly  by  did, 
exercise,  rubbing,  and  baths,  his  favorite  maxim 
being  "nature  convenienter  vivere."  He  is  said  in 
have  been  the  first  to  advocate  the  operation  of 
tracheotomy  to  relieve  asphyxia  in  severe  angina, 
Asclepiades  was  the  type  of  the  fashionable  physii 
he  was  an  eloquent  speaker,  had  an  extensive  acquaint- 
ance with  the  Roman  aristocracy,  was  filled  with  the 
enthusiasm  of  a  reformer  or  the  man  with  a  fixed 
idea,  had  an  engaging  amenity  and  great  tact, 
favoring  the  whims  of  his  patients  yet  usually 
persuading  them  to  follow  his  counsels.  *  He  had  an 
enormous  practice  among  the  wealthy  and  acquired 
a  large  fortune.  Cicero  said  of  him:  "  Asclepiadi 
quo  nos  medico  amicoque  usi  sumus,  turn 
eloquenlia   vincebat   omnes   medicos,   in   eo  ipso,  quod 


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Asepsis,  Surgical 


diet  bat.     medicince     facilitate 
■oittntia."     (    De    Oratore.  ')     The 


a/'  I'nlitr,     non 
collected    frag- 
in 


Miiis  nf  his   works   were   published  ai    Weimar   ii 
;mi.    under   the    title:  "Asclepiadis    Bithyni    frag' 


lenta." 


The  name,   \.sclepiades,  strictly  applied  only  to  the 

mi,  of  Asklepios,  or  JTisculapius  (q.v.),  came 

10  be  given  to  the  priests  who  officiated  at  the 

of     the    god    of    medicine.      These    men.    who 

to  he  the  ministers  of  a  beneficent  god,  the 

pen  'is  of  life  and  health,  ami  the  depositories 

thi   healing  lore  revealed  by  their  ancestor,  were 

ir  many   centuries   Hie  only   physicians   that   existed 

Greece.     Hippocrates  was  accounted  to  be  one  of 

■ir  number.  A.  H.  B. 


\sclepius. — See  /Esculapius. 


Vselli. —  Born  in  Cremona,  Italy,  toward  the  end  of 

ixteenth   century    (about   the   year    1581).      He 

i<  professor  of  anatomy  and  surgery  in  the  Univer- 

of  l'avia,  and  surgeon-in-chief  of  the  royal  army 

the  cisalpine  war.      lie  resided,  the  greater  part  of 

i-  life,  in  .Milan,  and  it  was  while  living  in  that  city 

he  discovered  the  lacteal  vessels.     On  July  23, 

J,  as  he  himself  relates,  he  was  dissecting  a  dog,  for 

purpose  of  showing  the  distribution  of  the  recur- 

nerves.     As  it  happened,  the  animal  had  been 

,  I  just   at   the  time  when  digestion  was  in  active 

peration.     When  the  abdominal  cavity  was  opened, 

Iselli's  attention  was  at  once  drawn  to  the  presence. 

he  folds  of  the  mesentery  and  in  the  walls  of  the 

line,    of   numerous   ramifying,    delicate,   whitish 

His    first    impression    was    that    these    lines 

sented  nerve  filaments;  but,  upon  closer  exami- 

lation  and  after  he  had  pierced  some  of  them  with 

he  point  of  a  sharp  scalpel,  he  became  convinced 

nit  they  were  actually  hollow  vessels  in  which  flowed 

i  creamy  fluid.     Many   persons  were  present  when 

I  lis  discovery  was  made,   and   among   the   number 

vere    two    physicians    of    considerable    celebrity — 

Uexander   Tadino   and    Settala.     Three   days   later 

ic  dissected  another  dog,  under  precisely  the  same 

iitions,  and  again  he  found  the  same  ramifying 

■  hite  vessels  in  the  same  abdominal  organs.     Aselli 

lied  in  1626,  before  he  had  been  able  to  announce  to 

he  scientific  world   the   important   discovery  which 

bad   made.     One  year    after    Aselli's    death,   his 

riends  Tadino  and  Settala  published  a  full  account 

if  the  facts.     This  book  was  printed  in  Milan   in  1627. 

A.  H.  B. 

Asepsis,  Surgical. — That  wound  infection  and 
suppuration  are  the  result  of  the  presence  of  vegetable 
microorganisms  is  no  longer  a  theory  but  a  fact 
proven  by  experimental  research  and  clinical  experi- 
While  no  one  will  deny  that  wounds  may, 
under  certain  conditions,  heal  kindly  without  the 
use  of  any  precautions  to  prevent  the  entrance  of 
minute  living  organisms,  such  result  obtains  with 
Creat  rarity,  and  not  in  consequence  of  a  lack  of  these 
precautions  but  despite  such  negligence.  The  almost 
complete  disappearance  of  hospital  gangrene,  the 
greatly  diminished  frequency  of  other  forms  of 
ivound  infection,  the  very  low  mortality  rate,  the 
y  with  which  the  abdominal  and  cranial  cavities 
are  invaded  at  the  present  time,  render  unassailable 
evidence  of  the  value  of  surgical  asepsis.  The  term 
asepsis  now  indicates  an  absence  of  germs  in  a  wound. 
Unfortunately,  we  are  as  yet  unable  to  obtain  a  con- 
dition of  absolute  asepsis.  There  is  perhaps  in  every 
wound  some  form  of  organism  present,  but  by 
proper  application  of  the  means  now  at  hand,  aided 
by  the  resistance  in  the  tissues,  we  are  enabled,  in  a 


large  percentage  of  wound- btain  healing  without 

inflammation  or  suppuration.  In  the  development 
of  our  pre  out  methods  of  asepsis,   Listi  i     tand    out 

as  I  he  pioneer,  and  although  his  idea  thai  air  infection 
was  very  dangerous  has  lien  proven  in  pari  fallacious 
and  the  spray  has  fallen  into  disuse,  the  pre  en( 
technique  is  the  direct  outcome  of  his  teaching,  other 
investigators  having  added  to  our  knowledge  during 
the  time  thai  has  elapsed  since  his  writings.  The  ob- 
ject in  wound  t  real  me nt  is  to  prevent  anything  coming 

into  contact  with  I  he  \\  ound  surface  which  can  convey 

infection,  and  to  limit  the  number  and  the  virulence  of 
bacteria  whose  en  I  ranee  cannot  lie  prevented.  To  ac- 
complish this  end  requires  unremitting  care  and  atten- 
tion to  detail  as  well  as  a  thorough  appreciation  of  the 

dangers  resulting  from  the  slightest  oversight.  The 
more  cleanly  a  surgeon  is  in  his  daily  life,  the  more 
easily  can  he  form  habits  of  surgical  cleanliness. 
Many  surgeons  obtain  poor  results  because  of  an  im- 
perfect technique  and  fail  to  perceive  such  imperfec- 
tion. Only  by  a  careful  investigation  of  poor  results 
can  the  evil  be  remedied.  The  young  surgeon  educated 
to-day  under  the  influence  of  the  present  teaching 
more  readily  learns  and  practises  aseptic  surgery 
than  one  who  was  taught  and  practised  under  the 
old  regime.  The  writer  found  some  years  ago  a 
marked  improvement  in  wound  healing  when  his 
staff  were  trained  to  avoid  at  all  times  bringing  their 
hands  into  contact  with  pus.  The  infectious  agents 
are  bacteria  of  different  forms  which  exist  in  the  air, 
the  soil,  and  the  clothing,  upon  the  skin  and  mucous 
membranes  of  the  healthy  body,  in  the  beard  and 
hair,  and  especially  under  the  nails.  The  number 
of  bacteria  in  the  air  is  inconsiderable  compared  to 
the  number  found  in  the  other  places  mentioned. 
Virulent  cultures  of  pyogenic  bacteria  have  been 
obtained  by  investigators  from  the  crowded  operating 
theaters  of  some  clinics.  On  this  account  and  for 
other  reasons  the  seating  capacity  of  operating  rooms 
recently  constructed  has  been  limited.  If  the  air 
becomes  contaminated  in  this  way  vigorous  steps 
must  be  taken  to  remove  this  possible  source  of 
infection.  Air  exhaled  by  the  operator  and  his 
assistants  may  carry  bacteria,  hence  at  present  the 
head,  mouth,  and  nose  of  the  operator  and  his  staff 
are  covered  by  a  mask,  which  has  the  additional 
advantage  of  preventing  any  perspiration  dropping 
into  the  wound.  The  infection  occurs  as  a  rule  by 
contact  with  a  broken  surface.  If  the  chances  of 
contact  infection  are  excluded,  air  infection  can  be 
almost  entirely  eliminated  by  care  to  prevent  dust 
being  raised  in  a  room.  No  sweeping,  brushing, 
taking  down  of  curtains,  opening  windows  or  doors 
on  opposite  sides  of  a  room  should  be  allowed  just 
before  an  operation.  A  moist  cloth  can  remove 
dust  and  dirt  with  the  least  possible  disturbance. 
Bacteria  can  scarcely  leave  a  moist  surface  and  pass 
into  the  air. 

The  methods  of  handling  dressings  and  wound 
discharges  will  determine,  to  a  large  extent,  the 
number  of  bacteria  which  reach  the  air.  It  is  im- 
portant, therefore,  to  destroy  all  wound  dressings 
and  not  allow  them  to  lie  about  in  a  dry  condition. 
That  flies  and  other  insects  can  be  the  medium  of 
transportation  is  well  established,  and  while  perhaps 
not  a  frequent  means  of  infection  yet  it  is  well  to 
exclude  them  from  hospitals,  for  this  reason  as  well 
as  for  the  comfort  of  the  patients,  by  the  use  of 
screens.  The  most  frequent  source  of  wound  infec- 
tion is  the  hands  of  the  surgeon  and  his  assistants. 
This  can  be  readily  appreciated  when  we  consider 
the  great  frequency  with  which  the  surgeons  and 
their  helpers  are  called  upon  to  handle  cases  in  which 
bacteria  are  present  in  countless  numbers,  all  possess- 
ing some  degree  of  virulence.  In  the  language  of 
Keith,  "It  is  the  willing  and  tender  though  unclean 
hand"  which  conveys  the  infection.  Therefore  the 
fewer  and  better  trained  the  assistants,  the  better  the 


717 


Asepsis,  Surgical 


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results  obtained.  If  the  chain  of  careful  technique  is 
broken  by  any  of  these,  the  result  will  be  infection 
with  its  consequent  inflammation,  suppuration,  and 
sepsis. 

The  very  greatest  care  cannot  prevent  the  occur- 
rence of  an  occasional  contamination  of  the  wound 
surface.  But  in  direct  proportion  to  the  care  exer- 
cised will  the  danger  of  infection  be  lessened.  Every 
surgeon  should  assume  the  right  to  inspect  the  hands 
and  nails  of  his  assistants  and  accept  or  reject  them, 
for  he  alone  is  responsible  for  the  outcome  of  the  case. 
No  mere  washing  for  one  minute  in  this  and  for  one 
minute  in  the  other  solution  will  render  the  hands 
sterile.  Rubber  gloves  sterilized  for  each  case  will 
prove  very  useful  in  handling  septic  cases  with  the 
least"  chance  for  contamination.  Those  working  in 
the  deadhouse  or  in  putrefying  materials  should  not 
perform  or  assist  at  surgical  operations. 

All  who  handle  wounds  should  keep  the  idea  of 
asepsis  always  before  them  and  should  carefully  avoid 
needless  contamination  of  their  hands.  In  dressing 
wounds  which  are  suppurating  or  are  infected,  con- 
tact should  be  avoided  as  much  as  possible.  From 
fifteen  to  thirty  minutes'  careful  scrubbing  with  soap, 
water,  and  freshly  sterilized  brush  are  necessary  for 
the  mechanical  cleansing  of  the  hands.  The  water 
either  should  be  running  or  should  be  changed  fre- 
quently during  this  process.  The  soap  should  be 
carefully  selected  and  germ  free.  Ordinary  green 
soap  is  very  frequently  used  for  this  purpose.  A 
cheap  brush  of  vegetable  fiber  can  be  obtained  which 
has  the  advantage  of  not  being  injured  by  boiling. 
Each  person  engaged  in  the  operation  should  have 
an  individual  brush  for  his  final  scrubbing.  The 
nails  should  be  kept  short  and  all  visible  dirt  should 
be  removed  by  a  sterilized  scraper  after  a  primary 
washing  and  before  the  final  scrubbing  which  should 
extend  above  the  elbows.  Such  mechanical  cleans- 
ing is  the  first  step  in  all  plans  of  sterilization  of  the 
hands.  In  hospitals  the  final  cleansing  of  the  hands 
is  preceded  by  a  complete  change  of  the  clothing, 
the  operator  and  assistants  removing  the  outer 
clothing  and  donning  a  white  sterilized  suit  and  cap. 
Some  operators  go  so  far  as  to  change  the  shoes  as 
well.  In  private  practice  such  a  change  is  not  often 
possible,  therefore  the  coat,  vest,  collar,  and  tie  are 
removed  and  a  large  sterilized  apron  is  used  to  cover 
the  clothing  to  within  a  few  inches  of  the  feet.  In 
such  way  the  object  desired  can  be  accomplished.  If 
the  apron  and  clothing  beneath  become  saturated 
with  water,  care  must  be  used  to  prevent  such  spot 
coining  into  contact  with  the  wound,  hands  of  sur- 
geon,   or    anything    which    will    touch    the    wound. 

A  number  of  investigators  have  made  bacteriologi- 
cal tests  of  the  efficiency  of  different  methods  for  the 
preparations  of  the  hands.  In  1S85  Kiimmel  made 
a  number  of  experiments  to  determine  the  value  of 
different  antiseptic  solutions,  such  as  boric  acid, 
thymol,  carbolic  acid,  and  corrosive  sublimate. 
After  rinsing  the  hands  in  soap  and  water,  and  im- 
mersing in  one  of  the  above  solutions,  he  drew  his 
finger  tips  over  the  surface  of  a  sterile  nutrient  gela- 
tin. He  found  the  colonies  least  abundant  when 
five  per  cent,  carbolic  or  1  to  1,000  bichloride  of 
mercury  was  used.  He  concluded  that  primary  im- 
portance should  be  attached  to  the  mechanical 
cleansing,  while  chemical  agents  were  of  secondary 
importance.  Forster  about  the  same  time  obtained 
the  same  results.  Furbringer  in  1S88  showed  that  a 
sterile  culture  resulting  after  such  a  test  by  no  means 
indicated  that  the  fingers  were  sterile,  for  scrapings 
from  beneath  the  nails  of  such  fingers  would,  when 
thrown  on  gelatin,  produce  an  excessive  growth  of 
bacteria.  This  result  was  obtained  even  after  the 
utmost  care  in  cleansing  and  scraping  this  part  prior 
to  the  disinfection.  He  was  led  to  believe  that  the 
grease  adherent  to  the  skin  protected  the  germs 
from   the  action  of  the  chemicals.     Acting  on   this 

718 


idea  he  used  a  strong  solution  of  alkali,  which  provii 
inadequate  he  abandoned  for  ether.  This  was  ni 
satisfactory  owing  to  its  rapid  evaporation.  A 
cohol  was  found  to  have  the  solvent  property  of  eth 
without  the  rapid  evaporation.  His  method  was  . 
follows: 

1.  Thorough  cleansing  of  subungual  space. 

2.  Scrubbing  the  hands  for  one  minute  with  wat 
and  soap. 

3.  Scrubbing  the  hands  with  sterile  brush  in  eigb 
or  ninety-five  per  cent,  alcohol  for  one  minute. 

4.  Rinsing   in   three   per   cent,    carbolic   or  tlin 
tenths  of  one  per  cent,  bichloride  solution. 

He  did  not  claim  germicidal  action  for  the  aleohc 
The  more  recent  investigations  show  that  the  tes 
with  alcohol  give  as  good  results  without  the  fouri 
step  as  when  the  germicides  are  used.  The  gre: 
objection  to  bichloride  of  mercury  is  the  cracking 
the  hands  which  follows  its  use.  Some  operate] 
notably  Kelly  and  others,  use  a  solution  of  pota 
sium  permanganate  and  oxalic  acid  (Schatz'  methoi 
in  addition  to  the  mechanical  cleansing  mentiom 
before;  others  "use  turpentine,  and  still  others  u 
sterilized  ground  mustard  in  their  technique.  Le 
depends  upon  plans  used  than  upon  the  thoroughne 
with  which  the  preparation  is  accomplished.  Tl 
method  most  in  vogue  is  some  modification  of  Fii 
bringer's  with  the  use  of  a  longer  time  for  the  prepar; ' 
tion  than  his  instructions  would  indicate.  Fir. 
scrub  the  hands  and  arms  to  the  elbows  with  soa 
and  water,  after  cleansing  the  nails  thoroughly  unt 
no  dirt  is  visible.  Then  scrub  thoroughly  the  hand 
arms,  and  crevices  about  the  nails  in  a  basin  of  alec 
hoi  for  at  least  five  minutes.  This,  with  or  withoi 
the  use  of  bichloride  of  mercury,  will  give  the  he- 
results  and  has  the  advantage  of  being  very  simp] 
and  easy  of  application.  After  this  preparation  El 
been  completed,  the  greatest  care  should  be  exercise 
to  keep  from  touching  anything  which  is  not  sterili 
That  almost  irresistible  desire  to  scratch  the  nose  c 
to  adjust  spectacles  must  be  controlled. 

Mikulicz  advised  the  use  of  sterile  cotton  gloves  t 
protect  against  infection  from  the  hands.  As  migh 
be  expected,  this  was  not  successful  owing  to  th 
facility  with  which  fluids  passed  to  and  from  tli 
hands  carrying  microbes  through  the  gloves.  Moi 
recently  thin  rubber  gloves  and  finger-cots  hav 
been  introduced  to  provide  a  sterile  finger  and  ham 
These  are  not  injured  by  boiling  or  by  steam,  there 
fore  can  be  made  perfectly  sterile,  and  will  undoubted!; 
have  a  large  field  of  usefulness.  The  chief  object  i> 
that  can  be  offered  to  rubber  gloves  is  that  they  in 
terfere  to  a  greater  or  lesser  extent  with  the  manipula 
tions.  Some  surgeons,  however,  become  quite 
pert  in  their  use  and  claim  that  the  tactile  sense  is  no 
perceptibly  lessened. 

In  the  experience  of  the  writer  the  use  of  rubbe 
gloves  has  been  a  decided  advance  in  asepsis  and  hi 
believes  that  they  should  be  employed  in  wounds  whicl 
do  not  require  an  exceeding  delicacy  of  touch 
They  have  been  generally  adopted  by  the  profession 
and  when  employed  with  the  usual  care  in  techniqui 
wound  infection  has  practically  become  an  unknowi 
quantity.  Finger-cots  are  not  to  be  employed  ir 
operations  unless  it  is  necessary  to  cover  an  injured 
glove.  The  glove  will  prove  of  great  service  in  thi 
treatment  of  accidental  or  infected  wounds.  Sterili 
glycerin  or  sterile  talc  will  aid  in  putting  the  glo 
on  the  hand.  The  cleansing  process  must  be  ju 
thorough    as    when    operating    without    the    gloves. 

Dr.  A.  C.  Wiener  of  Chicago  has  suggested  the  u  i 
of  celluloid  dissolved  in  acetone  as  a  substitute  for 
collodion.  Enough  celluloid  is  dissolved  in  the  proper 
amount  of  acetone  to  produce  a  thin  syrupy  liquid. 
For  holding  small  dressings  in  place,  sealing  wounds 
and  abrasions  of  the  hands  before  operation,  and 
like  purposes,  it  appears  to  be  superior  to  collodion, 
as  it  adheres  much  more  tenaciously. 


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Asepsis,  Surgical 


Dr.  James  B.  Bullitt,  of  Louisville,  Ky.,  has  pro- 
ved the  possibility  of  eliminating  the  finger  nail  and 
,  ,  ice  as  a  factor  in  wound  infection  by  sealing  up  the 

nls  by  i  lira  lis  of  1 1  lis  preparation.      Ho  lias  found  that 
a  thin  solution  be  first  applied  to  the  nail  and  the 
uiis  skin  and  thru,  after  this  has  dried,  in  a 
.  minutes  a  further  coat,  or  coats,  of  a  thicker  solu- 
the  consistence  of  cream  be  applied,  that   the 
:i  l.i' completely  sealed.      If  a  half-hour's  time  be 
.n  given  for  drying  and  hardening  it  will  be  found 
he  hands  can  be  thoroughly  washed,  scrubbed 
ith  a  brush,  and  subjected  to  all  of  the  usual  prep- 
ations  for  a  surgical  operation  without  the  celluloid 
ing  its  hold.     In  using  this  material  forsuch  pur- 
it  is  recommended  that  the  hands  and  nails  be 
ghly  washed  and  prepared  just  as  is  usual  for 
ion,  and  that  the  celluloid  be  then  applied,  after 
liich  it  is  desirable  to  permit  a  half-hour  to  elapse 
the  hands  are  again  placed  in  water.     Sealing 
■nails  in  this  way  leaves  the  tactile  sense  of  the  fin- 
impaired,   thus  obviating  an  objection  offered 
many  operators  to  the  use  of  gloves,  whether  of 
or  of  cotton  fabric.     Bacteriological  investi- 
upon  this  point  will  be  of  interest,  and  if  the 
.  achieves  the  object  desired  it  will  prove  quite 
djuvant  to  our  present  technique. 
The  Patient. — It  is  undoubtedly  a  fact   that   the 
ion  of   the  patient   is  often  responsible  for  a 
infection.     It  has  been  proven  that   bacteria 
d  do  exist  in  the  blood  of  apparently  healthy 
lals,  becoming  localized  only  after  a  trauma, 
nd   in  other  cases   the   resistance   of   the   tissues   is 
i:ir;  therefore,  when  time  is  allowed,  the  patient 
be  placed  on  tonics  and  nutritious  food.     The 
.    skin,    and    intestines    should    be    rendered 
.  live.     In  this  way  the  bacteria  present  are  elimi- 
and  the  resistance  of  the  tissues  to  infections 
eased.     A  number  of  warm  or  Turkish  baths 
.mild,    whenever    practicable,    be    given    prior    to 
ion.     One  warm  bath  should  be  insisted  upon 
i  all  cases  in  which  it  does  not  endanger  the  patient. 
i  bichloride  of  mercury  bath  will  render  the  bacteria 
surface  less  active,  but  is  irritating  to  sensitive 
kins.     On  the  afternoon  before  an  operation  is  to  be 
■erformed  the  field  should  be  shaved  and  thoroughly 
id   with   soap,    water,    and   soft   gauze.     This 
hould  extend  some  distance  away  from  the  point  of 
in.     The  scrubbing  should  be  done  gently  when 
'Ver  a  suppurating  lesion  in  the  abdomen,  to  prevent 
upture.     After  scrubbing  with  eighty  to  ninety-five 
icr  cent,   alcohol   and   rinsing   with   plain   sterilized 
vater  a  sterile  gauze  dressing  should  be  applied  to 
iroteet  the  field.     Especial  attention  must  be  given  to 
he  axilla,  the  umbilicus,  the  pubes,  and  also  the  scalp. 
A'ithin  recent  years  there  has  been  an  effort  upon  the 
>art  of  some  operators  to  revive  the  use  of  iodine  for 
terilization   of    the   operative   field.     This    drug   in 
ratery  as   well   as  alcoholic  solutions  was  employed 
ome  years  ago,  according  to  Parkas  early  as  1876,  but 
i  was  not  considered  an  efficient  germicide.     Grossich, 
n  1908,  published  an  article1  advocating  its  use  for 
kin  sterilization  and  claimed   that  a  dry  field  was 
ary  to  obtain  success,  since   the    iodine  pene- 
■  lies  more  deeply  through  the  dry  epidermis.     Bovee" 
ays  that  failure  to  heed  this  injunction  may  bring 
nto  disrepute  this  method  of  preparation  of  the  field 
jf  operation.     He  has  made  a  number  of  experiments 
inline  the  efficiency  of  iodine  in  solutions  of 
i    strengths   for   this   purpose   and   concludes 
thai  "tincture  of  iodine  diluted  with  an  equal  quan- 
tity of  absolute  alcohol  may  be  considered  reliable 
i    a  local  application  in  preparation  of  the  skin  or 
mucosa  in  any  part  of  the  body.      Dilutions  of  less 
strength  are  unreliable  if  hairs  or  large  hair  follicles 
are  in  the  field  of  operation.     The  fifty  per  cent,  dilu- 
tion of  tincture  of  iodine,  if  not  carelessly  applied,  is 
not  likely  to  injure  the  skin." 
The  writer  has  personally  no  experience  with  this 


method  of  skin  preparation,  having  found  the  one 
previously   described    to   be    very   satisfactory,   and 

believes  thai   if  dependence  is  placed  upon  a  chemical 

method  of  skin  sterilization  sufficient  attention  will 
not  be  given  to  the  other  methods  of  asepsis  which 
have  been  found  so  useful,  and  that  its  adoption  will 
be  rather  a  step  backward  than  an  advance  in  prcpa- 
ra(  ion  for  operal  ion. 

The  preparation  of  mucous  surfaces  w  ill  of  necessity 
be  more  or  less  i m perfect.  The  object  is  to  promote  the 
highest  degree  of  asepsis  possible  with  the  least  injury  to 

the  mucous  membrane,  for  the  intact  membrane  will 
resist  infections  much  better  than  one  which  has  been 
damaged.  The  eye  cannot  be  scrubbed  and  cannot 
-'and  any  strong  germicides  to  promote  asepsis. 
Moreover,  the  normal  secretions  in  this  part  seem  to 
have  some  antiseptic  action.  The  integumentary 
surfaces  of  the  lids  and  brows  should  receive  a 
thorough  scrubbing  with  soap  and  water.  The  con- 
junctival sac  should  be  irrigated  thoroughly  with  a 
saturated  solution  of  boric  acid  or  Thiersch's  solution. 
If  the  conjunctiva  or  the  tear  sac  is  infected,  no  opera- 
tions upon  the  eye  should  be  undertaken  except  those 
of  emergency.  The  results  will  certainly  justify 
waiting  until  the  process  subsides  under  proper 
treatment.     The  nose  can  be  cleansed  only  by   the 

use  of  the  spray  or  douche  and  s e  of  the  simpler 

antiseptic  solutions,  of  which  an  ordinary  saline  is  one 
of  the  best.  Dobell's  solution  is  also  very  popular. 
Prior  to  operations  about  the  mouth  it  is  advisable  to 
have  a  dentist  care  for  the  teeth  in  order  that  the 
chance  of  infection  may  be  diminished.  Before  an 
operation  the  teeth  should  be  thoroughly  scrubbed 
with  brush  and  tooth  wash  or  powder.  The  mouth 
should  then  be  washed  out  with  tincture  of  myrrh, 
peroxide  of  hydrogen,  or  bichloride  of  mercury 
solution,  and  subsequently  rinsed  with  plain  sterilized 
water.  The  anus  and  rectum  can  be  cleansed  by 
means  of  two  or  more  scrubbings  of  external  parts 
followed  by  plain  enemata  prior  to  the  operation. 
And  when  the  patient  is  anesthetized,  the  bowel  can 
be  thoroughly  scrubbed  with  soap  and  water  and 
flushed  with  a  weak  solution  of  corrosive  sublimate 
followed  by  one  of  plain  boiled  water.  The  same 
plan  can  be  followed  with  the  vagina,  using  a  small 
nail  brush,  a  jeweller's  brush  (Gerster),  or  a  small 
piece  of  gauze  on  forceps  to  reach  the  upper  part. 

The  room  should  be  light  and  well  ventilated,  devoid 
of  curtains  or  superfluous  furniture.  The  tempera- 
ture should  be  about  75°  F.  It  should  be  so  arranged 
that  cleaning  can  be  easily  accomplished  by  means  of 
a  mop  and  wet  cloths  without  impregnating  the  air 
with  dust.  When  one  is  operating  in  private  houses 
the  furniture,  carpets,  and  curtains  must  not  be  dis- 
turbed at  the  time  of  the  operation.  The  utensils 
should  be  glass,  porcelain-lined,  or  granite  ware 
which  can  readily  be  rendered  clean  and  sterile  by  hot 
water.  Hard  rubber  makes  the  best  portable  trays, 
owing  to  its  light  weight.  The  tables  and  other  fur- 
niture for  the  operating  room  should  be  of  the  simplest 
kind,  and  those  made  of  iron  and  enamelled,  with  or 
without  glass  tops,  are  the  best.  Where  these  cannot 
be  obtained  a  plain  table  made  of  hard  wood  will  an- 
swer every  purpose.  They  must  be  kept  scrupulously 
clean.  All  basins,  pitchers,  etc.,  which  will  be  used 
should  be  well  scoured  and  boiled  or  scalded  'just 
prior  to  use.  Sheets  and  blankets  should  be  sterilized 
and  the  patient  should  be  well  covered  except  at  the 
site  of  operation.  The  towels  must  be  sterilized  and 
kept  tightly  wrapped  until  ready  for  use.  These 
materials  may  be  sterilized  in  the  same  way  that 
gauze  and  dressings  are  prepared. 

Sponges. — The  best  silk  sponges  are  expensive  so 
that  resterilization  would  be  necessary,  and  this  is 
more  or  less  unreliable.  Boiling  unfortunately 
hardens  the  sponges  and  destroys  their  usefulness. 
This  has  rendered  their  thorough  sterilization  some- 
what difficult.     Very  good  sponges  can  be  obtained 


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Asepsis,  Surgical 


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for  about  two  dollars  and  a  half  per  pound,  and  these 
can  be  thrown  away  after  an  operation.  Many 
methods  of  preparing  sea  sponges  have  been  proposed. 
The  following  (Schimmelbusch)  is  useful  and  very 
simple:  The  sponges  are  beaten,  washed,  and  kneaded 
repeatedly  in  cold  and  warm  water  until  the  dirt,  shells, 
and  other  foreign  matter  are  entirely  removed. 
They  are  then  pressed  together,  surrounded  by  gauze, 
and  put  into  a  one-per-cent.  solution  of  soda,  just 
removed,  while  boiling,  from  the  fire.  They  are  kept 
in  this  solution  for  half  an  hour.  The  soda  is  then 
washed  away  with  boiled  water  and  the  sponges  are 
stored  in  a  tight  jar  and  covered  with  a  solution  of 
bichloride  of  mercury  (1  to  2,000). 

Still  another  method  of  sterilizing  sea  sponges  is  the 
following:  After  the  usual  beating  and  rinsing  to  free 
from  dirt  and  lime,  they  should  be  immersed  in  a  solu- 
tion of  hydrochloric  acid,  2  drachms  to  the  pint,  for 
twenty-four  hours.  They  should  next  be  soaked  in  a 
saturated  solution  of  permanganate  of  potassium,  and 
then  decolorized  in  a  hot  saturated  solution  of  oxalic 
acid.  The  latter  is  removed  by  passing  the  sponges 
through  lime  water.  After  being  washed  in  plain  steril- 
ized water  they  are  placed  in  a  solution  of  bichloride  of 
mercury  (1  to  1,000)  for  twenty-four  hours  and  are  kept 
in  threo-per-cent.  solution  of  carbolic  acid  until  neei  led. 
In  the  latter  steps  of  preparation  the  sponges  should 
be  handled  by  means  of  sterilized  rubber  gloves  and 
sterile  forceps.  The  difficulty  of  sterilization  and  the 
cost  are  objections  to  sea  sponges,  and  while  the 
advantages  of  a  good  sponge  are  apparent,  its  place  is 
being  largely  taken  by  pads  of  absorbent  gauze  and 
mops  or  wipers  made  of  cotton  covered  by  gauze 
(Tupfers).  These  can  easily  be  made  by  squares  of 
gauze  with  diagonal  corners  tied  together  and  enclos- 
ing a  small  pledget  of  cotton.  'When  desired  they 
can  be  made  of  very  small  size  for  use  in  cavities. 
They  are  easily  sterilized  by  steam  and  are  very 
convenient  and  inexpensive.  As  far  as  possible  the 
edges  should  be  turned  in  to  prevent  ravellings 
being  left  in  the  wound.  These  mops  and  pads 
should  be  wrapped  in  gauze,  one  dozen  in  a  package, 
and  so  sterilized.  In  this  way  they  can  readily  be 
counted  so  that  none  shall  remain  in  the  wound. 
Large  flat  gauze  pads  with  a  string  attached  are  now 
often  used  in  abdominal  work  in  place  of  the  large  flat 
sponges  formerly  so  much  in  vogue. 

The  instruments  should  be  made  entirely  of  metal, 
of  very  simple  design  and  easily  cleansed.  They 
should  be  kept  perfectly  clean  by  thorough  scrubbing 
with  brush,  soap,  and  water  before  and  after  each 
operation.  This  should  have  the  most  careful  at- 
tention lest  shreds  of  tissue  and  clots  of  blood  re- 
main. Proper  cleansing  having  been  obtained,  the 
instruments  may  be  rendered  sterile  by  boiling  in 
one-per-cent.  solution  of  carbonate  of  sodium  for 
five  minutes.  The  sodium  salt  seems  to  aid  in  the 
destruction  of  microorganisms  which  may  be  present 
(Schimmelbusch).  It  also  prevents  rusting  of  the 
instruments  which  occurs  in  plain  water.  The  ordi- 
nary fish  kettle  is  very  useful  for  boiling  instruments, 
as  the  tray  can  be  lifted  and  the  instruments  trans- 
ferred to  another  tray  or  towel  without  being  handled. 
"Wiping  them  and  placing  in  a  towel  exposes  them  to 
a  chance  of  contamination  and  is  not  as  a  rule  ad- 
visable. Cutting  instruments  unfortunately  lose 
their  edge  when  boiled,  hence  other  means  are  neces- 
sary to  render  them  germ  free.  Immersion  in  pure 
carbolic  acid  for  five  or  ten  minutes,  then  in  alcohol 
which  dissolves  the  carbolic  acid,  and  finally  in  freshly 
boiled  water  will  lie  the  best  plan  for  sterilization. 
Germicidal  drugs  other  than  carbolic  acid  are  seldom 
used  for  the  preparation  of  instruments.  Bichloride 
of  mercury  acts  destructively  upon  metal.  After 
sterilization  the  instruments  should  be  kept  in  basins 
and  covered  with  hot  water  or  towels  and  should  not 
be  handled  again  before  the  operation.  One  assist- 
ant should  have  entire  charge  of  the  instruments,  or, 

720 


perhaps  better,  the  table  containing  them  is  ; 
placed  that  the  operator  can  get  them  himself, 
an  instrument  falls  upon  the  floor,  is  handled  by  set 
tic  hands,  or  is  soiled  by  infectious  material  diirir 
an  operation,  it  should  be  discarded  or  resterilizei 
When  not  in  use  instruments  should  be  kept  in  a  cleat 
dust-proof  case. 

The   Dressings. — Butter  or  cheese  cloth  is  almo: 
universally  used  at  the  present  for  a  wound  dressir 
and  is  known  to  the  profession  as  gauze.     Surgeon 
absorbent  cotton  is  also  very  largely  used  as  a  woui. 
dressing.     Other  materials,  such  as  oakum,  jute,  etc 
are  used  less  frequently.     The  materials  most  suital 
for  bandages  are  butter   cloth,   unbleached  curt, 
flannel,  and  crinoline.     The  dressing,  gauze,  cotto 
and   bandages,   also  aprons,    towels,   gauze  spongi 
blankets,  and  sheets,   can  all  be  rendered  aseptic  1 
exposure  to  steam  in  a  sterilizing  apparatus  for  oi 
hour    on    three    successive   days.     The   sterilizer  < 
Arnold,  E.   Boeckman,  or  a  similar  one  may  be  t; 
for   this   purpose.     The    chief   object   is  to  obtain 
moving  or  live  steam  with  sufficient   pressure  to  1 
forced    into    all    parts    of    the    material    undergoin 
sterilization.     Heat  applied  before  closing  the 
zer  will  tend  to  prevent  condensation  of  the  steai 
and  saturation  of  the  dressings.     The  same  end  ca 
be  reached  by  allowing  the  steam  to  pass  through  th 
materials  after  opening  the  sterilizer.     When  tab 
from  the  sterilizer  they  should  be  dry  and  should  I 
subsequently  handled  as  little  as  possible  and  wit 
the  greatest  precaution  to  prevent  contamination.    1 
folded  in   gauze  before  sterilization   they  should  b 
opened  only  when  ready  for  use  and  in  the  meanwhil 
confined  in  closed  retainers. 

Sutures  and  Ligatures. — The  suture  and  ligature  ma 
terials  now  in  use  are  catgut,  silk,  silkworm  gut,  liner 
kangaroo  tendon,  silver  wire,  and  horsehair,  eacl 
having  its  peculiar  indications  for  use.  Of  these,  cat 
gut  and  kangaroo  tendon  are  sterilized  with  mos 
difficulty.  The  other  materials  are  less  readily  affectn 
by  heat  and  are  therefore  the  more  easily  renderei 
sterile.  The  former  have,  however,  the  advantage  o 
being  readily  absorbed,  and  will  be  on  this  accoun 
less  likely  to  act  as  a  foreign  body  and  prove  sub 
sequently  a  source  of  irritation.  Silkworm  gut  i 
not  absorbent,  has  no  tendency  to  become  softened  bj 
wound  secretions,  and  is  therefore  not  so  likely  ti 
carry  infection  into  the  wound  as  catgut  or  silk.  1 
is  very  useful  when  a  firm,  strong,  and  non-absorbablc 
material  is  indicated.  Silk  sutures  and  ligature; 
should  be  rolled  on  glass  spools  and  sterilized  will 
the  dressings  by  steam  or  by  boiling  in  plain  wat<" 
just  before  use,  or  the  method  in  use  at  the  Jolir.r 
Hopkins  Hospital  (Halsted)  can  be  adopted.  Thi 
silk  is  cut  in  lengths  of  from  nine  to  twelve  inches,  ami 
ten  of  these  strands  are  wound  on  a  glass  reel, 
eral  of  these  reels  of  desired  sizes  of  silk  are  placed  in  a 
glass  tube,  which  is  loosely  plugged  with  cotton. 
The  tube  is  then  placed  in  a  steam  sterilizer  for  an 
hour  on  the  first  day  and  on  the  two  following  days  for 
half  an  hour  each  time.  When  the  tubes  are  removed 
from  the  sterilizer  the  cotton  is  pushed  tightly  into 
them,  and  they  are  kept  in  aseptic  glass  jars  until 
wanted.  Frequent  boiling  of  silk  appears  to  lessen  its 
strength  to  some  extent.  Boiling  silk  or  silkworm  gut 
in  soda  solution  will  soften  it  and  cause  deterioration. 
The  sterilization  of  catgut  is  a  more  difficult  task,  and 
most  methods  have  been  far  from  satisfactory.  The 
prepared  gut  offered  for  sale  is  as  a  rule  most  satis- 
factory. Catgut  kept  in  alcohol  in  a  sealed  glass  tube 
can  be  sterilized  by  boiling  for  two  hours.  Kelly  for 
some  years  used  catgut  that  had  been  soaked  in  ether 
and  then  boiled  in  absolute  alcohol  under  pressure, 
but  he  abandoned  the  method  after  several  cases  of 
infection,  which  were  thought  to  be  due  to  imperfect 
sterilization  of  the  gut,  had  occurred.  He  has  recently 
used  Kronig's  cumol  method  modified  by  Clark  and 
Miller.     This    he    describes    as    follows:  1.  Cut    the 


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Asepsis,  Surgical 


feut  into  desired  lengths  and  wind  twelve  si  rands 

,7  a  figure-of-eight  form  so  that  it  may  be  slipped 

,,  g  large  test  tube.     2.   Bring  the  catgut  gradually 

i  temperature  of  80°  C.  and  hold  it  at  this  point 

,  hour.     3.  Place  the  catgut  in  cumol,  which  must 

I  be  above  a  temperature  of  100°  ('.;  raise  it  to 

(J,   ami    hold    il    at    this  point    for  one  hour.       1. 

nr  oil  the  cumol  and  cither  allow  the  heat  of  the 

H|  bath  to  dry  the  catgut  or  transfer  it  to  a  hot-air 

!    a    temperature    of    100°    C.   for    two    hours. 

rransfer   the    rings    with   sterile   forceps   to    test 

previously    sterilized    as    in    the    laboratory. 

n, I  is  not  explosive  but  very  inflammable; care  must 

e  be  used  to  keep  it  from  the  flame.     Kanga- 

.  tendon  is  not  generally  used,  but   is  useful  when 

bsorption  is  not  desired.     It  can  be  prepared 

inner  similar  to  that  employed  for  the  sterili- 

ion   of   catgut.     The   irregularity   of    the    tendon 

ikes   it   .somewhat   difficult    to   handle.     Silkworm 

be  readily  sterilized  by  steam  or  by  boiling 

I  can  then  be  kept  immersed  in  alcohol.     It   can, 

,  be  boiled  with  the  instruments  at  the  time 

operation    and    thus    rendered    perfectly-    sterile. 

cutting  oil'  the  two  irregular  ends  of  the  required 

of  strands  and  making   the  first    turn  of  a 

f  knot,  they  can  easily  be  handled  and  one  strand 

1  a  I  a  time  by  holding  at  the  knot  and  pulling 

fmm   the   convexity   of   the  loop..   Another  good 

to  place  the  strands  in  test  tubes  in  which  they 

n  be  sterilized  and  kept  aseptic  until  ready  for  use. 

ver  wire  is  easily  sterilized  by  boiling  with  the  in- 

uments.     It  is  a  favorite  suture  with  many  opera- 

,  vially  when  a  considerable  thickness  of  tissue 

to  be  approximated.     Some  abdominal  operators 

3  it  in  suturing  the  abdominal  wall  in  tiers.     It  is, 

r,  not  so  frequently  used  as  some  of  the  other 

terials  and  often  causes  irritation  when  embedded 

the    tissues.      Horsehair   makes  a  very  valuable 

I I  rial  for  suturing  the  skin  where  tension  will  be 
slit.     Black  hairs  are  best  as  they  are  larger  and 

r.     The  hairs  are  readily  prepared  as  follows: 

Ice  a  small  bunch  of  hair  from  the  horse's  tail  and 
ush  it  in  a  direction  opposite  to  its  growth  to  re- 

1  !•  the  short  hairs.  Then  wash  it  thoroughly, 
-I  in  soap  and  water  to  remove  grit  and  dirt,  and 
I'U  in  ether  to  remove  fats.  Finally,  boil  and 
ep  in  alcohol  until  needed  for  use.     Or  the  small 

ndles  can  be  put  into  a  test  tube  and  sterilized  by 
"am  as  is  done  in  the  case  of  silkworm  gut.  The 
ir  suture  is  best  inserted  as  a  buttonhole  suture  or 

the  chain  stitch  of  Billroth.     In  order  to  do  this, 

■  the  first  stitch  as  in  simple  continuous  sutures, 
en  pass  the  needle  through  both  lips  of  the  wound 
d  hook  the  emerging  end  of  the  suture  under  the 
lirr  to  lock  the  stitch. 

Fluid  for  Irrigation. — Water  as  generally  seen  is  not 
rm  free.  The  best  and  simplest  method  to  render 
sterile  is  by  boiling  with  or  without  previous  filtra- 
m.  The  latter  is  to  be  preferred,  because  there 
II  be  less  sediment  and  the  vessels  will  the  more 
idily  be  kept  clean.  These  vessels  should  be  pro- 
led  with  covers  which  are  put  in  place  after  the 
•rilization.  It  is  well  to  supplement  the  cover  by 
few  folds  of  sterile  gauze  or  a  towel.  Some  of  the 
liould  be  sterilized  long  enough  before  the 
'(ration  to  allow  time  for  cooling.  The  dipper  for 
nveying  the  water  from  one  vessel  to  another  can 
sterilized  with  the  water.  In  fresh  and  clean 
iunds  germicidal  solutions  are  to  be  used  only  in 
(•paring  the  field  and  the  hands  prior  to  operation, 
id  only  plain  sterile  water  or  physiological  salt  solu- 
>n,  6  to  1,000,  used  during  the  operation.  In  acci- 
ntal  wounds  and  septic  conditions  an  effort  is  to 

■  made  to  destroy  the  organisms  by  the  use  of 
emicals  such  as  1  to  1,000  bichloride  of  mercury 
ration,  or  from  one  to  five  per  cent,  solution  of 
rbolic  acid,  or  one-per-cent.  solution  of  acetate  of 
uminum.     In  fresh  aseptic  wounds  many  surgeons 

Vol.  I. — 46 


use  the  dry  method  of  operating  and  obtain  excellent 

results.  No  fluids  of  any  kind  come  into  contact 
with  the  wound,  and  dry  gauze  sponges  remove  the 
blood.      In    this    way    one  of  I  he   thine-    necessary  for 

bacterial  growth,  moisture,  is  markedly  1'     i  oi  d 

The  Drainage. —  Material  for  drainage  is  used  to 
remove  from  wound  spaces  the  serum  which  would 
form  a  pabulum  for  bacterial  growth,  and  in  accidental 
or  infected   wounds   to   remove   pus   and   incidental 

colonies  of  bacteria,  but  in  many  cases  some  addi- 
tional drainage  material  is  necessary.  This  object 
may  be  accomplished  by  a  simple  counteropening  at 
:i  dependent  part.  Strands  of  sterilized  silk,  horse- 
hair, catgut,  and  silkworm  gut  are  frequently  used 
for  this  purpose.  The  other  materials  which  are 
employed  for  drainage  an1  gauze  and  tubes  made  of 

decalcified  bone  (Neuber),  of  glass,  or  of  pure  rubber, 

fenestrated  as  desired.  The  latter  is  one  of  the  best 
and  most  universally  Used.  Glass  tubes  an1  used 
almost  exclusively  in  abdominal  and  pelvic  work,  and 
are  less  useful  in  other  parts  of  the  body.  Tubes  of 
glass  and  rubber  can  be  made  perfectly  sterile  by 
boiling,  and  they  produce  as  little  irritation  :i-  any  of 
the  other  forms  of  drain.  Owing  to  the  tendency  tin' 
tissues  have  to  become  adherent  to  the  meshes  of  the 
gauze,  it  has  been  proposed  to  surround  the  gauze 
drain  by  gutta-percha  tissue.  This  tissue  cannot  be 
boiled  as  it  is  destroyed  by  heat,  and  dependence 
must  be  placed  on  alcohol,  bichloride  of  mercury,  or 
other  chemical  disinfectant  which  is  washed  away 
before  the  drain  is  inserted. 

Drainage  should  be  employed  only  when  there  i^  a 
distinct  reason  for  so  doing,  as  where  there  is  excessive 
wound  secretion,  where  contamination  of  the  wound 
has  occurred,  where  dead  spaces  are  unavoidable,  and 
where  the  wound  is  connected  with  mucous  surfaces. 
The  danger  of  contamination  of  the  wound  through 
drainage  must  not  be  overlooked.  When  the  object 
for  which  the  drain  has  been  inserted  has  been 
accomplished,  or  when  its  presence  produces  irritation, 
its  use  should  be  discontinued.  The  size  of  the  drain 
must  be  suited  to  the.  amount  of  fluid  to  be  removed. 
If  rubber  tubing  is  used,  it  should  just  emerge  from 
the  skin  to  prevent  flexion  and  obstruction,  which 
may  occur  if  it  projects  too  far  out,  and  it  must  not 
be  choked  by  the  pressure  of  the  nearest  suture. 
A  sterilized  safety  pin  passed  through  the  margin 
will  prevent  the  tube  slipping  into  the  depths  of  the 
wound. 

The  Wound. — In  making  a  wound  the  surgeon 
should  endeavor  to  injure  the  tissues  as  little  as 
possible,  using  sharp  knives  and  making  a  clean-cut 
incision.  The  tissues  should  be  torn  asunder  as  little 
as  possible  so  that  the  amount  of  dead  tissue  will  be 
small,  thus  lessening  the  favorable  soil  for  bacterial 
growth.  For  the  same  reason  rough  sponging  and 
injurious  chemicals  are  to  be  avoided.  Hemostasis 
must  be  complete,  and  suitable  drainage  arrangements 
should  be  made  for  the  removal  of  the  wound  secre- 
tions in  the  larger  wounds  and  in  those  in  which 
infection  is  likely  to  take  place.  The  dead  spaces 
must  be  as  nearly  as  possible  effaced  by  position, 
suturing,  and  bandaging;  in  fact,  everything  should 
be  excluded  from  the  wound  which  will  lessen  the 
vitality  of  the  part  or  form  a  nidus  for  the  growth  of 
bacteria.  It  is  a  well-known  fact  that  too  much 
tension  upon  a  suture  will  favor  the  formation  of  a 
stitch  abscess;  therefore  the  stitches  are  to  be  drawn 
only  tight  enough  to  approximate  the  edges  without 
tension.  When  the  suturing  is  complete,  the  wound 
and  adjoining  field  should  be  freed  from  blood  by  a 
piece  of  moist  gauze  and  dried  thoroughly.  The 
dressing  is  then  to  be  applied,  the  character  of  which 
will  depend  largely  upon  the  situation  and  size  of  the 
wound.  The  small  and  superficial  wounds  can  be 
-ealed  by  the  use  of  collodion  or  celluloid,  and  if  a 
drain  is  needed  its  point  of  emergence  can  be  left  open. 
In  the  latter  case  it  is  wise  to  apply  a  sufficient  quan- 

721 


Asepsis,  Surgical 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


tity  of  gauze  over  the  wound  to  take  up  the  secretion, 
and  then  to  cover  this  with  cotton  and  a  bandage.  In 
the  larger  wounds  plain  sterilized  gauze  in  voluminous 
folds  should,  after  being  shaken  up,  be  applied  and 
covered  with  cotton  and  a  bandage.  The  part  is 
then  to  be  placed  at  rest,  and  if  an  extremity,  in  an 
elevated  position.  The  application  of  chemical 
dusting  powders  to  the  wound  will  depend  largely 
upon  the  experience  of  the  operator.  The  substances 
most  used  for  this  purpose  are  iodoform  and  boric 
acid,  neither  of  which  is  germicidal  or  sterile  as 
usually  seen.  Iodoform  can  be  made  sterile  by  plac- 
ing it  in  a  gauze  bag  and  immersing  in  a  strong  solu- 
tion of  mercuric  chloride. 

For  some  years  the  writer  has  adopted  the  practice 
of  dressing  aseptic  wounds  -without  any  dusting 
powder,  and  has  found  that  they  remain  dry  and 
heal  as  kindly  as  with  the  use  of  such  substances. 
When  an  inspection  of  the  wound  is  demanded  there 
is  no  crust  covering  the  wound  to  prevent  the  dis- 
covery of  a  small  focus  of  suppuration,  and  there  is 
no  obstruction  to  the  free  removal  of  wound  products 
by  the  dressing.  When  it  is  found  necessary  to  use 
adhesive  plaster  for  coaptation  or  to  prevent  separa- 
tion of  wound  surfaces,  several  folds  of  sterilized 
gauze  should  be  placed  between  the  wound  and  the 
adhesive. 

Subsequent  Dressings. — The  same  degree  of  care 
in  the  preparation  of  the  hands  should  be  observed 
for  the  dressing  of  wounds  as  at  the  time  of  the 
operation.  Rubber  gloves  and  finger-cots  will  find  a 
very  useful  field  where  many  wounds  are  to  be  dressed 
in  succession.  If  drainage  has  been  used,  the  wound 
should  be  dressed  at  the  end  of  twenty-four  or  forty- 
eight  hours,  and  the  gauze  or  tube  removed.  After 
this  time  there  should  be  some  distinct  indication  for 
such  interference  before  the  wound  is  again  disturbed. 
Repair  will  not  be  hastened  by  needless  inspection. 
Fever,  pain,  odor,  and  saturation  of  dressings  will 
indicate  the  necessity  for  an  examination.  The 
sutures  should  be  removed  when  they  have  fulfilled 
the  indication  of  their  insertion  or  when  they  are 
producing  irritation  and  thus  are  failing  in  this 
purpose. 

Accidental  Wounds. — A  large  percentage  of  such 
wounds  are  infected  before  they  reach  the  surgeon 
and  therefore  require  especial  efforts  at  sterilization. 
The  wound  and  surrounding  skin  must  be  thor- 
oughly cleansed  with  soap  and  water,  and  washed 
with  an  antiseptic  solution,  either  of  corrosive 
sublimate  (1  to  2,000)  or  of  carbolic  acid  (1  to  100). 
The  solution  is  removed  by  flushing  with  sterile 
water.  Complete  approximation  is  not  often  advis- 
able and  drainage  is  the  rule  rather  than  the  exception. 
Van  Arsdale  has  recommended  the  use  of  a  five-per- 
cent, solution  of  balsam  of  Peru  in  castor  oil  as  a 
wound  dressing.  This  can  be  sterilized  by  heat  and 
will  be  found  useful  especially  in  accidental  and 
suppurating  wounds.  It  prevents  the  dressings  from 
adhering  to  the  wound  and  permits  of  their  easy  and 
almost  painless  removal.  The  appearance  of  infec- 
tion in  a  wound  demands  the  establishment  of  free 
drainage  and  the  use  of  antiseptic  irrigation.  The 
application  of  a  hot,  moist  antiseptic  dressing  will 
often  prove  beneficial. 

Asepsis  of  Special  Operations. — In  abdominal 
operations,  in  which  contamination  of  the  cavity  by 
pus,  feces,  bile,  or  urine  may  be  feared,  it  is  essential 
that  the  general  peritoneum  be  protected  by  the 
interposition  of  gauze  pacts  or  sponges  to  taKe  up 
such  material.  These  sponges  or  pads  are  removed 
after  the  field  has  been  cleansed  and  the  danger  of 
further  contamination  is  passed.  Following  this,  the 
general  cavity  is  to  be  sponged  carefully  and  a 
complete  toilet  made.  Similar  steps  are  necessary 
in  opening  a  cerebral  abscess  wrhich  is  likely  to  be 
followed  by  a  general  inflammation  of  the  meninges. 
Minor  surgical   procedures   demand   aseptic   precau- 


tions, such  as  aspiration  and  injection  of  caviti( 
saline  infusion — hypodermic  injections — and  the  u 
of  catheters  and  sounds  for  urethra,  bladder,  at 
ureters.  Aspirators  and  syringes  should  be  so  co 
structed  as  to  be  easily  sterilized.  A  hypodern 
syringe  is  now  on  the  market  which  is  made  entire 
of  metal  and  can  be  boiled.  Overlach's  syringe  wi 
rubber  piston,  glass  barrel,  and  metal  mountings  c: 
also  be  sterilized  by  boiling.  The  needles  should 
boiled  in  soda  solution  before  they  are  used.  T 
fluid  to  be  injected  into  the  tissues  should  be  boile 
unless  it  is  itself  germicidal.  Fountain  syring 
made  of  rubber  or  glass  can  be  boiled  and  are  ft 
quently  used  for  making  saline  injections  into  t 
blood  and  tissues.  They  must  be  freshly  sterilizi 
before  they  are  used.  It  is  essential  that  the  sk 
should  also  be  sterilized  in  such  procedures. 

It  is  claimed  by  Cazeneuve  and  others  that  the  uri 
from  healthy  kidneys  in  a  healthy  bladder  is  ahva 
sterile.     Decomposition  of  the  urine  and  inflammatii 
of  the  bladder  occur  only  as  the  result  of  the  presen 
of  microorganisms,  which  as  a  rule  enter  from  withot 
The  entrance  of  septic  germs  does  not  always  produ 
an  inflammation  of  the  bladder,  as  they  are  rapid 
expelled  with  the  urine.     Any  obstruction  to  outfk 
will  favor  their  retention  and  growth,  and  the  develu 
ment  of  inflammation  in  the  ureters  and  kidneys 
well.     Every    effort    must    be    made,    therefore, 
prevent  infection  of  this  tract.     Catheters  are  mai 
of  soft  rubber,  metal,  silk,  or  linen  sealed  by  gin 
The  metal  and  soft  rubber  are  best.     They  should  1 
sterilized    by    boiling    for    five    minutes,    and    tin 
anointed  with  sterilized  glycerin  or  oil  before  they  a 
introduced.     Sounds   and   other   instruments  shou 
be    treated   in    the   same    w-ay.     If   such   procedu 
would   injure   the   instrument,    dependence   must  t 
placed  on  a  strong  carbolic  solution.      Brisk  frit-tic 
for  one  minute  with  a  wet  towel  followed  by  simili 
treatment   with    a   dry    cloth    will    make    the   soli 
instruments    sterile     (Schimmelbusch).     A    viruk-i 
urethritis  contraindicates  catheterization,  and  befoi 
any   instrument   is    passed,    the    urethra   should  I 
cleansed  by  the  evacuation  of  the  urine  or  by  flusliii 
the  canal  with  water  or  plysiological  salt  solutioi 
Constant  watchfulness  in  all  surgical  procedures,  hot 
large  and  small,  is  absolutely  essential  for  tl  e  pn 
vention  of  septic  contamination.     This  watchfulnes 
can  be  cultivated  to  a  very  high  degree  so  that 
becomes  more  or  less  a  matter  of  habit.     When  th 
occurs,  however,  there  enters  the  danger  of  careless 
ness.     Therefore    it    is    well    to   remember    that   on 
technique  is  always  open  to  improvement  and  that  tli 
danger  lies  in  indifference  and  a  lack  of  care. 

J.  Garland  Shereili. 

1.  Grossich:  Centralblatt  fur  Chirurgie.  Oct.  31,  1908. 

2.  Bovee:  Am.  Journal  of  Obstetrics,  January,  1911. 


Aseptol  is  the  trade  name  of  a  solution  of  sozoli 
acid,  of  the  strength  of  thirty-three  per  cent.  S02 
olic  acid,  C8H1(HS03)OH,  is,  chemically,  ortho-phenol 
sulphonic  acid.  It  is  formed  when  carbolic  acid  i 
dissolved  in  concentrated  sulphuric  acid.  It  is  : 
syrupy,  reddish-brown  fluid,  miscible  in  ail  proper 
tions  in  water,  alcohol,  and  glycerin.  It  is  les 
poisonous  and  less  irritating  than  carbolic  acid  am 
has  a  more  agreeable  odor,  but  it  is  not  so  powerfu 
an  antiseptic.  A  ten  per  cent,  solution  may  bi 
employed  as  an  antiseptic  wash,  and  as  a  local  ajjpli 
cation  to  the  throat  in  diphtheria.  It  may  be  givei 
internally,  but  the  official  salt,  sodium  sulphocarbi 
kite  is  to  be  preferred.     Dose,  gr.  xx.  (1.3). 

W.    A.    B.VSTEDO. 

Ash  Bark. — See  Fraxinus. 


Ash,  Prickly. — See  Xanthoxylum. 


722 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Asheville,  N.  C. 


vshcville,  N.  C. — Asheville  is  situated  in  Western 

,ih  Carolina  upon  a  hilly  table-land,  at  an  elevation 

,n  feet,   in   the   culmination  of  the   Alleghany 

]l.u'ntains,    between    the    diverging    ranges    of    the 

i  :ii  Smoky  Mountains  and  the  Blue  Ridge. 

Jompletely  surrounding  this  plateau  of  some  thirty 

i  les  in  width,  with  the  Blue  Ridge  to  the  south,  ea  t, 

northeast,  and  the  Smoky  Mountains  to  the  wesl 

:  I  northwest,  are  the  projecting  spurs  and   peaks 

e  ranges  with  an  elevation  double  and  almost 

diat    of  Asheville.     The    meteorological    con- 

of  the  plateau — the  temperature,   the  purity 

.   the   air,    and    the    amount   of    precipitation — are 

v  influenced  by  these  high  mountain  chains. 

e  rain  clouds,  especially  those  approaching  from  a 

li.rly  direction,  are  saturated  at  a  higher  tem- 

ature  than  they  meet  on  approaching  and  pa  sing 

ise  mountain  ranges,  and  on  that  account  they 

cipitate  their  moisture  before  reaching  the  plateau. 

equence  there  is  a  difference  of  from  fifteen  to 

inches  of  annual  rainfall,   and   from   ten   to 

■Ive  degrees  in  relative  humidity,  between  places 

i  immediately  in  the  surrounding  mountains 

Lsheville  plateau. 

i  ille  is  practically  an  all-year  resort,  having, 

the  parlance  of  climatologists,  a  medium  elevation, 

ring  favorable  conditions  for  out-of-door  life 

-casons  of  the  year. 

The     Winter     Months. — January     and     February 

,    however,    periods   of   cold   weather,   lasting 

w  days,   and  exceptionally  for  a  week,   and 

i.cral  of  such  "cold  spells"   are  observed   during 

r  mi  11  ths.     Such  a  spell  is  as  a  rule  initiated  with 

onsiderable  wind  movement  from  the  north,  during 

■  h  the  temperature  falls  rapidly  to  10°  F.  or  to 

o,  and  temperatures  below  zero  have  been  observed 

everal  of  the  twelve  winters  during  which  the 

iter  has  had  charge  of  the  local  weather  bureau. 

already  stated,  these  cold  spells  do  not  last,  the 

nd  subsides  after  from   twenty-four   to   thirty-six 

lire,  and  then  the  temperature  rises.     The  days  are 

ight,  and  during  the  hours  of  sunshine  invalids  can 

oul    of   doors,    when   properly   clothed,    without 

tiering  from  cold. 

The  humidity  averages  between  fifty  and  fifty-five 
r  cent,  in  the  two  winter  months,  and  the  dry 
mosjphere  and  large  amount  of  sunshine  have  a 
ululating  and  exhilarating  effect  upon  all  cases 
lich  are  otherwise  in  a  condition  to  profit  from 
inatic  treatment.  The  amount  of  ozone  in  the  air 
aches  its  greatest  proportion  in  these  months,  and 
Miity  per  cent.,  of  a  scale  from  0  to  100,  has  fre- 
icntly  been  recorded. 

In  some  years  the  winters  have  been  very  mild,  but 
ists  occur  in  the  spring  months  as  late  as  the  latter 
ii  of  April.  Snow  rarely  falls,  and  when  it  does,  it 
I's  away  under  the  sun  upon  the  same  day  or 
thin  a  day  or  two  thereafter.  The  average  snow- 
II  is  less  than  two  inches. 

The  spring  season,  has  its  beginning  between  Febru- 
y  20  and  March  10,  during  which  the  vegetation 
gins  to  spring  up,  and  the  trees  to  leaf  out.  The 
e  comfortable,  and  while  not  hot,  temperatures 
>  to  75°  F.,  during  the  hours  from  10  a.m.  to  3  p.m., 
e  quite  common. 

Thunder  storms  occur  with  the  advent  of  such 
armer  weather,  and  are  attended  with  brisk  showers, 
pecially  upon  the  environing  high  mountain 
where  one  can  often  see  such  storms  in  pro- 
esa  while  the  plateau  enjoys  bright  sunshine.  The 
lative  humidity  during  the  spring  months  averages 
itween  sixty  and  sixty-five  per  cent. 
<  >ne  of  the  features  of  the  spring  is  the  beautiful 
id  varied  flora  of  this  region,  and  the  azalea,  laurel, 
id  rhododendron,  as  well  as  the  smaller  flowers  of 
te  mountains,  are  the  delight  of  all  visitors. 
The  Summer. — In  some  years  past  June  has  been  as 
arm  as  any  of  the  summer  months,  and  the  highest 


maximum   temperature  may   fall   in   this  month  or  in 

July  or  August.     The  highest  temperature  recorded 

in   the  past    twelve  years   was  91. 3°-  F.,  but    90°   1'.    is 

frequently    reached    during    the    summer    of  every 

year. 

I'sually  there  are  c 1  breezes  during  the  day,  and 

Unless  one   is  exposed    to   the   direct    rays  of   the  sun, 

there  is  no  discomfort  on  account  of  heat.  When  tin- 
sun  goes  down  the  air  cools  rapidly,  and  the  nights  are 
always  comfortable  and  bed  covers  are  necessary,  at 
least  after  midnight. 

The  rainfall  (hiring  the  summer  months  is,  as  a 
rule,  greater  than  in  the  winter,  and  heavy  rains  of 
short  duration  occur  more  frequently.  I  have 
known  an  inch  of  rain  to  fall  in  tin'  course  of  an  hour 
or  two,  but  the  excellent  natural  drainage  carries  the 
water  off  quite  rapidly  and  tic-  streets  become  dry 
in  a  few  hours.  The  average  rainfall  for  the  summer 
is  four  inches  per  month,  and  the  average  humidity 
varies  between  seventy  and  seventy-five  per  cent. 

The  Autumn. — With  but  few  exceptions  in  the 
twelve  years  of  my  experience,  the  fall  weather  has 

I u     continuously     pleasant    and    enjoyable     until 

January,  when,  as  stated  above,  colder  weather 
usually  sets  in.  With  frosts  in  October  the  foliage 
of  the  great  variety  of  trees  and  shrubs  begins  to  turn, 
assuming  every  possible  shade  and  hue  from  the 
green  of  the  pine,  to  yellow,  crimson,  red,  purple,  and 
brown,  and  this  change  goes  on  until  December  or 
even  later,  when  the  leaves  begin  to  fall.  Visitors 
never  tire  in  their  admiration  of  this  ever-varied  play 
of  colors  in  the  closely  adjacent  forests,  and  thousands 
of  boxes  of  leaves  and  branches  of  myrtle,  mistletoe, 
holly,  and  galax  are  mailed  from  Asheville  during 
the  fall  and  winter  months  to  distant  friends  and 
relatives.  The  fall  months  are  always  delightful, 
the  temperature  declining  in  average  and  maxima 
gradually;  and  after  October  1  artificial  heat  is 
frequently  required  in  houses  in  the  early  morning 
and  evening. 

The  total  annual  rainfall  is  forty  inches,  and  is 
nearly  equally  distributed  over  all  the  months,  with 
a  slight  increase  in  summer.  There  is  no  distinctly 
rainy  season  or  month,  and  no  distinctly  dry  season 
for  any  part  of  the  year. 

The  city  has  a  permanent  population  of  eighteen 
thousand  and  a  floating  population  of  several  thou- 
sand more,  the  latter  consisting  of  people  who  are  in 
search  of  health  and  pleasure.  The  railway  station 
is  situated  in  the  valley  near  the  confluence  of  the 
French  Broad  and  the  Swanannoa  Rivers,  at  a 
distance  of  a  mile  from  the  center  of  the  city,  which  is 
located  on  a  bluff  about  three  hundred  and  fifty  feet 
above  the  river  valley.  The  streets  are  well  paved 
with  bitulytic  or  brick,  there  are  good  sidewalks 
mostly  of  concrete  or  cement,  and  a  brick  pavement 
and  macadam  extend  to  Biltmore,  a  distance  of  two 
miles,  to  the  Vanderbilt  estate.  Electric  trolley  lines 
connect  the  different  parts  of  the  city  with  the  de- 
pot and  with  Biltmore,  and  also  extend  to  other 
suburbs,  giving  ample  facilities  and  good  service  for 
all  purposes.  The  business  part  of  the  city  is  well 
and  substantially  built,  and  the  business  establish- 
ments compare  favorably  with  those  of  even  larger 
cities  either  North  or  South. 

Apart  from  its  mercantile  business,  Asheville  is 
practically  a  town  of  hotels  and  boarding-houses,  and 
the  available  accommodations  are  ample  in  kind  and 
good  in  quality  according  to  the  rates  charged.  As 
to  the  latter  it  must  not  be  forgotten  that  provisions 
and  fuel  are  more  expensive  than  in  thickly  populated 
centers,  which  are  nearer  to  their  sources  of  supply 
and  have  low  rates  of  transportation. 

The  rates  in  the  cheaper  boarding-houses  vary  from 
$4  to  $8  per  week,  but  most  of  these  do  not  offer 
accommodations  suitable  for  invalids.  The  better 
houses  charge  from  $10  to  $15  per  week  and  give 
good   accommodations.     A  few   of   them   refuse   in- 


723 


Asheville,  N.  C. 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


valids  altogether,  catering  to  well  people  and  pleasure- 
seekers  only. 

There  are  several  good  commercial  hotels  in  the 
center  of  the  city,  with  daily  rates  of  from  $2  to  S3. 
These  are  suitable  for  a  brief  stay  when  one  first 
arrives;  but  invalids  should  be  advised  to  avoid 
such  hotels  for  permanent  quarters  on  account  of  the 
want  of  facilities  for  out-of-door  life.  The  more 
fashionable  hotel  at  the  present  time  is  the  Battery 
Park,  open  all  the  year,  and,  though  centrally  located, 
it  has  large  grounds  and  abundant  piazza  room,  and  is 
otherwise  first  class  in  all  its  appointments.  "The 
Manor,"  also  a  first  class  hotel,  is  situated  in  the 
Albemarle  Park  and  is  often  preferred  by  those 
desiring  more  seclusion;  having  a  number  of  separate 
cottages  it  offers  the  best  facilities  for  a  prolonged 
sojourn.  The  cottages  are  rented  furnished  and  have 
a  complete  equipment  for  housekeeping,  but  are 
near  enough  to  the  main  building  for  those  who 
desire  to  take  their  meals  there.  Two  new  hotels 
are  in  process  of  building,  one  in  the  center  of  the 
city;  the  other  in  the  outskirts  is  located  in  Grove 
Park,   and   is   planned   especially  for  visitors. 

A  special  institution  for  tuberculous  patients  was 
established  over  thirty  years  ago  by  Dr.  J.  W. 
Gleitsman,  now  of  New  York.  After  it  had  been 
conducted  for  several,  years  and  had  shown  excellent 
clinical  results,  it  was  closed  in  1SS3.  The  Winyah 
Sanatorium  for  tuberculous  patients  was  established  in 
18S8  and  has  been  in  successful  operation  since. 
New,  modern,  and  perfectly  appointed  buildings  and 
cottages  were  erected  during  1S99,  and  were  opened 
for  patients  in  1900.  This  institution  is  situated  in 
a  small  wooded  park  of  seventeen  acres,  in  the  out- 
skirts of  the  city,  and  the  electric  car  line  passes 
through  its  grounds.  The  admissions  are  limited 
to  such  patients  only  as  have  a  reasonable  prospect 
for  improvement  and  recovery,  and,  as  far  as  there  is 
room,  accompanying  friends  can  also  obtain  accom- 
modations. 

While  there  is  no  city  hospital  receiving  all  patients 
free,  the  Mission  hospital  has  facilities  for  caring  for 
the  city  poor,  as  well  as  for  those  who  can  afford  to  pay 
for  private  rooms.     It  admits  no  contagious  diseases. 

The  water  supply  of  the  city  is  from  the  headwaters 
of  the  Swanannoah,  reaching  the  city  by  a  gravity 
line  extending  to  the  intake,  a  distance  of  about 
twenty  miles,  which  latter  is  within  the  water  shed 
of  Black  Mountain,  fenced  in,  and  owned  and  con- 
trolled by  the  city  of  Asheville  under  the  care  of 
special  watchmen.  The  supply  is  ample  and  the  water 
system  is  the  pride  of  the  city. 

The  city  is  well  sewered  and  under  the  diligent 
labors  of  a  competent  board  of  health,  the  general 
sanitary  conditions  of  Asheville  have  been  much 
improved,  and  are  now  as  good  as  those  of  other 
progressive  cities.  The  city  has  a  hygienic  labora- 
tory in  charge  of  the  Board  of  Health.  Meat  and 
milk  inspection  is  obligatory  and  thoroughly  en- 
forced, and  the  dairies  supplying  milk  are  supervised 
and  controlled  in  regard  to  the  health  of  animals, 
cleanliness  and  care  of  the  milk  until  it  reaches  the 
consumer.  The  expectoration  ordinance  is  strictly 
enforced  in  the  streets,  sidewalks,  street  cars,  and 
other  public  places,  and  the  streets  are  regularly 
flushed  by  the  Sanitary  Department.  Notification 
of  infectious  diseases  including  tuberculosis  is  ob- 
ligatory, and  rooms  and  houses  in  which  such  diseases 
occur  are  disinfected  by  the  Health  Department  of 
the  city,  which  was  one  of  the  first  to  inaugurate  a  war 
against  the  house  fly,  with  evident  success.  The 
mortality  of  the  city  is  very  low,  especially  among 
the  white  population;  malaria  is  unknown,  and 
phthisis  among  the  natives  is  rare. 

Asheville  has  a  system  of  good  graded  schools,  a 
military  academy  for  boys,  and  several  colleges  for 
girls,  and  these  private  institutions  are  of  a  high 
standard  and  well  conducted.     Students  from  locali- 


ties in  which  the  climate  is  unfavorable  to  delica 
and  rapidly  growing  youths,  and  invalided  paren 
who  come  to  Asheville  for  permanent  homes  wit 
their  children,  are  offered  excellent  educational  ai 
vantages.  The  principal  religious  denominations  a 
all  represented  and  their  church  edifices  would  1 
creditable  to  a  larger  city. 

Opportunities  for  amusement  and  recreation  a 
chiefly  limited  to  driving,  horseback  riding,  and  wal' 
ing  amid  the  beautiful  scenery  of  this  region.  Gc 
links,  said  to  be  among  the  finest  in  the  countr 
baseball  grounds,  two  opera  houses,  and  the  gayetii 
of  the  fashionable  hotels  furnish  their  part  in 

Carriage  hire  and  riding  horses  may  be  obtained 
Asheville  at  very  reasonable  rates. 

Asheville  is  on  the  Southern  Railway,  about  ha 
way  between  Salisbury,  N.  O,  and  Knoxville,  Ten 
Through  sleepers  leave  New  York  City  over  tl 
Pennsylvania  Railway  via  Washington  at  4:1 
p.  m.  and  arrive  at  Asheville  at  3:30  p.  m.  the  ne: 
day. 

Through  sleeping  car  accommodations  exist  all 
from  Jacksonville,  Fla.,  New  Orleans,  La.,  Loui.-vil! 
Ky.,  Nashville,  Tenn.,  and  Cincinnati,  Ohio. 

Karl  von  Ruck. 


Ashhurst,  John. — Born  in  Philadelphia,  Pa.,  Ai 
gust  23,  1839.  He  studied  medicine  in  the  medic; 
department  of  the  University  of  Pennsylvania,  an 
received  from  that  institution  the  degree  of  Doctor  c 
Medicine  in  1860.  He  afterward,  during  the  Civ 
War,  served  three  years  as  Acting  Assistant  Surgeoi 
United  States  Army.  In  1877  he  was  elected  Pre 
fessor  of  Clinical  Surgery  in  the  University  of  Peni 
sylvania,  and  a  few  years  later  he  received  froi 
the  same  institution  the  appointment  of  Professi 
of  Surgery.     His  death  occurred  January  7,  1900. 

Ashhurst  was  widely  known  as  a  surgeon  of  gri 
skill  in  the  planning  and  performance  of  an  operatic 
and  of  unusually  sound  judgment.  The  two  wort 
which  will  hand  down  his  reputation  to  posterity  ai 
his  "Principles  and  Practice  of  Surgery,"  Phflade 
phia,  1871  and  1885;  and  the  great  "Internation: 
Encyclopedia  of  Surgery"  (six  volumes,  New  Yorl 
1881  to  1886)  which  he  edited  and  to  which  a  lar<> 
number  of  the  leading  surgeons  of  the  countr 
contributed.  A.  H.  B. 

Asiatic  Cholera. — See  Cholera,  Asiatic. 

Asparagus. — The    common    garden    asparagus,    A 
officinalis  Linn.  (Fam.  Liliaceo?),  will  hardly  be  mad' 
more   familiar   by    description.     It    is    a   native   i 
Europe,     and     cultivated     everywhere.     Both     tli 
underground  portion  and  stems  are  official  in  Franc 

"Asparagus  root"   contains  resin,  glucose,  dextr 
bitter  extractive  and  other  simple  constituents,  but  n 
asparagin.     The  fresh  sprouts  have,  in  addition,  th 
interesting   compound  asparagin,  discovered  in  180 
by  Vauquelin  and  Robiques. 

As  a  medicine  asparagus  is  of  little  use.  Its  prop 
erty  of  modifying  the  odor  of  the  urine  is  known  i 
every  one,  and  is  caused  by  methyl  mercaptan, 
decomposition  product  of  protein.  It  may  incrcas 
the  quantity  of  urine  excreted,  but  does  not  do  si 
always.  It  appears  to  make  it  slightly  irritating,  ani 
to  prompt  to  more  frequent  micturition.  At  man; 
European  watering-places  it  occupies  an  importan 
position  in  the  articles  of  diet  in  lithiasis  and  in  tin 
treatment  of  gouty  patients.  It  may  cause  vesica 
irritation,  and  should  be  used  with  caution  wb 
renal  tissue  is  diseased.  In  cardiac  dropsy  it  i 
recommended,  as  its  action  is  said  to  resemble  tlia 
of  convallaria. 

Asparagin  is  regarded  as  the  active  constituen 
of  asparagus  shoots.  It  is  also  widely  distribute! 
in   nature,   having  been   found   in   almonds,   liconw 


724 


liKl'I'.RENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Asphyxia 


0t    belladonna  leaves,  potatoes,  lily  of  the  valley. 

arshmallow,    and    many    other   plants.     It    occurs 

i.  brilliant,  colorless  crystal-,   with  a  Faintly 

line,   cooling   taste,   soluble   in    water,   one    pari    in 

■"Ivc. 

Ii  may  be  administered  in  doses  of  one  grain  and 
half  three  times  a  Jay.  II.  II.   I!i  shy. 

Aspergillosis,  Aural; — See  liar:  Diseases  of  ti 

\        ory  <  'anal. 


Aspergillosis,  Pulmonary. 


-See  Lungs,  Aspergillosis 


Aspermia. — See  Sterility  in  the  Male. 

Asphwia. — This  term  which  really  signifies  absence 
pulse    (a-    privative    and   <r<pi£is)    came    into    gen- 
e  to  denote  the  condition  which   immediately 
is  death  by  suffocation,  or  in  other  words  by 
lion  of  the  respiratory  rhythm.     The  phenom- 
,.ii  of  asphyxia  must  intervene   between  the   edi- 
tion of  extreme  dyspnea  on  the  one  hand  and  sus- 
■nded  animation   on   the   other  and   is   somewhat 
applied  to  both  conditions.     It  is  hardly  worth 
hile  to  speculate  as  to  the  precise  mechanism   of 
phyxia.  whether  due  to  absence  of  oxygen  or  excess 
carbonic  acid,   for  either  case  causes  progressive 
a,  and   some  authors   therefore   mention    two 
nds  of  asphyxia.     Since  arrest  of  respiration  may 
mie  about  either  rapidly  or  deliberately,  the  term 
.phyxia  is  best  reserved  for  the  former;  for  in  slow 
uth  failure  of  the  circulation  and  other  elements 
;iy    cooperate.     In    violent    death     moreover     the 
phyxia  syndrome  is  in  full  evidence.     The  respira- 
■m  may  be  arrested  suddenly  in  many  ways,  but  they 
iay  all    be    summed    up    as    external    or    internal, 
he  latter  are  made  up  of  certain  poisonings  which 
complish  the  results  in  manifold  ways,  but  these 
1  belong  to  the  subject  of  toxicology  as  does  also 
irbon    monoxide    death.     Asphyxia   is    practically 
stricted  to  sudden  suspension  of  respiration  from 
.itward  violence  of  a  sort  to  constrict  or  occlude  the 
ir   passages.     Asphyxia    of    the    newly    born    is    a 
implicated  condition  the  consideration  of  which  does 
nt  belong  here.     Neither  should  such  expressions  as 
■condary    asphyxia,     local     asphyxia,    apnea     (as 
istinct  from  asphyxia)  detain  us  for  consideration, 
he  entire   subject  of  dyspnea  should  of   course  be 
nderstood  before  taking  up  the  study  of  asphyxia. 
Phenomena  of   Asphyxiation. — The   manifestations 
hich  precede  the  sudden  arrest  of  respiration  cannot 
e  thoroughly  studied  in  the  actual  human  subject 
ir  obvious  reasons.     Their  sequence  has  therefore 
■in  worked  out  in  animal  experiment,  and  is  seen 
o  be  quite  constant  as  a  rule.    The  method  consists 
f  shutting  off  the  air  in  a  tracheotomy  tube.  It  is  then 
ladily  apparent  that  what  we  call  asphyxia  consists 
f  four  stages,  which   in  their  respective  chronolog- 
:al    order     are     dyspnea,     convulsions,     respiratory 
rrest  and  terminal  respiratory  movements   (Ziemke). 
is  soon  as  the  respiratory  gas  exchange  is  interrupted, 
iolent    inspiratory    dyspnea    sets    in,    which    may 
ist  a  full  minute,  the  duration  depending   on  the 
ontent  of  air  already  in  the  lungs.     This  inspira- 
ory    dyspnea   is    then    succeeded    by    violent    ex- 
liratory  efforts  which  end  in  spasm  of  the  respiratory 
auscles.     The    latter    now    become   exhausted,    the 
luration  of  the  asphyxia  cycle  at  this  point  being  not 
nore  than  ninety  seconds.     Synchronous  with   the 
xpiratory  dyspnea  general  clonic  convulsions  appear, 
ignifying    the    high    point    or    culmination    of    the 
isphyxia.     The  pupils  are  now  strongly  dilated,  the 
vrnea  is  insensitive  and  the  eyeballs  protrude.     The 
convulsions  cease   promptly  with  exhaustion  of   the 
inspiratory   muscles.     The   third   stage   now   sets   in 
vith  arrested  respiration,  the  lungs  being  in  the  pas- 
sive  expiration    position.    This   stage    may    last    for 
ieveral  minutes.     The  fourth  and  last  stage,  that  of 


the   terminal   respiratory    movement      coi    ists  of  a 

certain  number  of  slow  deep  in  piratione  '.vith  long 
pauses.  The  mouth  sometimes  gasps.  The  entire 
cycle  lasts  from  three  to  eight  minutes. 

As  the  dyspnea  begins  lie-  blood  pressure  ri>es  in 
token  of  air  hunger,  reaching  its  maximum  at  the 
convulsive  period,  'rim  air  hunger  a.l-,,  soon  makes 
ii  ill  lilt  on  the  vasomotor  center,  «ith  resulting 
slowing  of  the  heart.  The  inhibition  may  In-  com- 
plete for  a  few  moments,  but  eventually  ceases,  the 
heart  pulsating  anew  and  gradually  failing.  The 
Organ  may   In'    found    contracting   after    the  asphyxia 

cycle  is  completed.     This  cardiac  survival  may  also  be 

seen  in  mankind. 

In  mankind  and  even  in  animal  experiment 
asphyxia  may  lie  atypical,  and  cases  may  show 
gnat  individuality.  Sometimes  one  or  more  stages 
may  be  absent,  and  death  may  occur  with  such 
rapidity  that  tin-  stages  cannot  be  distinguished. 
Much  depends  on  the  constitutional  vigor  of  the  sub- 
ject. In  some  instances  of  supposed  asphyxia  death 
nally  occurs  from  sudden  cardiac  paraly-is. 

Postmortem  Appearances. — The  vast  number  of 
data  recorded  as  postmortem  asphyxia  finds,  shows 
such  a  volume  of  conflicting  evidence  that  Ziemke 
is  forced  to  conclude  that  not  a  single  find  is  path- 
ognomonic of  death  by  suffocation  when  considered 
alone.  This  conclusion,  however,  has  chiefly  a 
forensic  import  to  be  considered  elsewhere.  The 
death  agony  with  its  effects  in  the  individual,  is 
evidently  not  so  much  modified  by  sudden  suffocation 
as  to  result  in  any  special  or  distinctive  anatomical 
changes.  We  are  not  concerned  here  with  the  finds 
in  particular  types  of  suffocative  death,  but  entirely 
with  suffocation  per  se.  It  will  be  noted  under 
asphyxia  due  to  special  causes,  that  the  pathological 
finds  depend  essentially  on  the  particular  causes  of 
asphyxia. 

Special  Causes  of  Asphyxia. — These  comprise 
constriction  of  the  air  passages  by  hanging  or  choking 
(with  apparatus  or  the  fingers);  arrest  of  respiration 
by  thoracic  compression;  occlusion  of  the  external 
orifices;  obstruction  from  foreign  bodies,  and  drown- 
ing. Other  causes  might  be  enumerated,  such  as 
confinement  in  a  narrow  space,  and  inhalation  of 
smoke  and  irrespirable  gases,  but  the  further  we  get 
away  from  immediate  direct  arrest  of  respiration 
the  more  the  situation  becomes  complicated  with 
other  factors.  Instead  of  asphyxia  we  have  to  deal 
with  a  complex  conition. 

Constriction  of  heAir  Passages. — In  asphyxia  from 
this  cause  not  only  the  windpipe  but  the  great 
els  and  nerves  in  the  neck  are  compressed. 
Hence  the  brain  is  largely  cut  out  of  the  circulation, 
as  is  also  to  some  extent  the  spinal  cord.  Com- 
pression of  the  vagus  also  in  itself  tends  to  disturb 
further  the  circulation  and  respiration.  It  is  there- 
fore apparent  that  we  are  somewhat  removed  here 
from  the  picture  of  pure  asphyxia,  so  that  it  is  not 
advisable  to  discuss  further  these  deaths  which  will 
be  considered  under  their  proper  titles. 

Compression  of  the  Thorax. — Asphyxia  from  this 
cause  occurs  in  connection  with  falling  masonry,  etc., 
but  most  of  the  victims  of  compression  are  young 
infants  overlain  in  bed  by  parents  or  others,  or 
compressed  by  heavy  material  which  they  cannot 
remove. 

Occlusion  of  the  Nostrils  and  Mouth. — Asphyxia 
from  smothering  represents  a  pure  type,  and  from 
the  absence  of  collateral  lesions  and  evidences  of 
violence  is  of  great  forensic  interest.  Bedding  is 
chiefly  employed  and  the  victims  are  nearly  always 
young  children. 

Occlusion  of  the  Windpipe. — Suffocation  from 
foreign  bodies  in  the  air  passages  or  compressing  the 
latter  from  the  esophagus  represents,  when  the 
occlusion    is    complete,    a    pure    type    of   asphyxia. 


725 


Asphyxia 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Suicide  or  homicide  is  hardly  involved  in  this  mode 
of  death;  and  since  in  very  many  cases  occlusion  is 
not  complete,  the  condition  of  the  patient  is  often 
one  of  dyspnea  only.  Its  proper  consideration, 
therefore,  is  under  Air  passages,  Foreign  Bodies  in  the. 

Submersion  or  Drowning. — This  is  a  well-recognized 
individual  subject  in  which  asphyxia  is  largely 
involved.  If  there  is  simple  occlusion  of  the  nostrils 
and  mouth,  as  when  a  subject  is  rendered  helpless 
while  in  a  bath,  the  mode  of  death  is  ordinary  smoth- 
ering. When  a  subject  is  submerged  while  in  the 
water,  the  stages  of  asphyxia  tend  to  succeed  one 
another  in  typical  fashion,  and  this  occurs  when  for 
any  reason  he  is  relatively  helpless,  as  during  a  fit. 
Ordinarily,  however,  the  efforts  of  self  preservation, 
and  the  fact  that  the  body  is  in  reality  light  enough 
to  float  so  modify  the  act  that  it  demands  and  receives 
separate  consideration  (See  Drowning).  Further- 
more, the  postmortem  appearances  of  a  submerged 
body  have  a  special  literature. 

It  is  still  customary  to  speak  of  asphyxia  as  one  of 
the  common  causes  of  death  in  general.  All  deaths 
of  this  type  would  naturally  be  preceded  by  progress- 
ive dyspnea  and  cyanosis,  and  in  certain  affections 
the  various  stages  of  asphyxia,  as  already  related 
would  be  in  evidence — for  example  in  edema  of  the 
glottis,  or  tetanus  causing  arrest  of  respiration 
through  the  muscles.  Other  forms  of  mechanical 
impediment  are  seen  in  clogging  of  the  bronchi  in 
bronchopneumonia  and  compression  of  the  lungs  by 
double  hydrothorax,  etc.,  etc.  Death,  when  not 
violent,  is  a  very  complicated  process,  and  unless  the 
stages  of  asphyxia  are  recognizable,  and  the  direct 
relationship  between  causes  and  effects  is  in  evidence, 
it  would  be  difficult  to  show  that  death  was  due  to 
such  cause.  The  mere  presence  of  antemortem 
dyspnea  and  cyanosis  is  not  enough.  And  as  already 
emphasized  postmortem  appearences  cannot  decide 
the  case. 

Treatment. — In  many  instances  of  apparent  death 
from  asphyxia,  resuscitation  may  be  effected  by  means 
of  artificial  respiration,  early  resorted  to  and  per- 
severed in  for  a  sufficient  length  of  time.  For  a  con- 
sideration of  the  various  methods  of  artificial  respi- 
ration see  the  article  Resuscitation. 

Medicolegal  Relations.* — In  .its  medicolegal 
sense,  asphyxia  is  the  cessation  of  the  heart's  action 
which  arises  from  interrupted  respiration,  caused 
either  by  expelling  the  air  from  the  body  or  by  pre- 
venting the  entrance  of  pure  air  into  the  body. 
When  air  is  eliminated  from  the  body,  or  pure  air  pre- 
vented from  entering  the  body,  the  action  of  the  lungs 
is  paralyzed,  and  the  blood,  no  longer  aerated,  loses 
its  vital  qualities  and  circulating  powers.  The  com- 
bination of  these  conditions  causes  death.  Death  so 
resulting  is  called  death  from  asphyxia,  and  the  con- 
dition  produced   by    this   combination   is   asphyxia. 

There  are  four  divisions  of  asphyxia  which  it  is  the 
province  of  this  paper  to  treat,  namely:  (1)  As- 
phyxia from  the  want  of  respirable  air  and  the  inhala- 
tion of  noxious  gases;  (2)  asphyxia  from  suffocation; 
(3)  asphyxia  from  strangulaion  other  than  from 
hanging;  (4)  asphyxia  from  hanging.  Asphyxia 
from  drowning  is  considered  under  that  head. 

Asphyxia  from  the  Want  of  Respirable  Air  and  the 
Inhalation  of  Noxious  Gases. — The  older  authorities, 
and  the  laity  fall  into  the  error  of  calling  by  the  name 
of  asphyxia,  certain  conditions  which  are  actually 
gas  poisoning.  Indeed,  if  an  intelligent  layman  were 
asked  to  give  an  example  of  asphyxia,  he  would  prob- 
ably cite  poisoning  by  illuminating  gas,  or  fumes  of 
burning  charcoal.  The  more  recent  standard  writers 
have  placed  these  cases  where  they  belong — under 
toxicology. 

*  In  this  section  the  writer  has  drawn  largely  from  the  article 
on  the  same  subject,  by  the  late  Professor  John  Bell  Keeble,  in  the 
second  edition  of  the  Handbook. 

726 


A  theoretical  form  of  suffocation  from  exhausti 
of  atmospheric  oxygen  in  a  confined  space  does  i 
appear  to  occur  in  forensic  medicine.  Such  ca 
should  not  differ  materially  from  those  produced 
smothering,  etc. 

Suffocation. — Following  the  definition  in  Whart 
and  Stille's  work  on  "  Medical  Jurisprudent 
suffocation  may  be  said  to  ensue  when,  "  by  a 
means  air  is  excluded  from  the  larynx  or  chest,  or  t 
chest  is  prevented  from  receiving  it." 

Suffocation  is  most  commonly  accomplished  in  t 
ways: 

(a)  By  expelling  the  air  from  the  lungs,  by  press) 
upon  the  abdomen  and  chest,  and  by  such  contim 
pressure  preventing  the  physical  action  necessary 
respiration.     Cases  of  this  kind  are  more  usually  foi 
where  small  children  have  been  overlaid  by  older  j 
sons  during  sleep,  and  occasionally  where  a  person  ] 
been  caught  in  a  jam  of  heavy  material,  or  pre?, 
excessively  in  a  great  crowd.     Death  in  such  case! 
attributed  to  the  fact  that  pressure  upon  the  abdom 
and  chest  compresses  the  vital  organs,  expels  the 
from  the  lungs,  and  so  closes  the  lungs  and  windpipe 
to  prevent  other  air  from  entering.     Death  of  tl 
character     usually     results     from     accident.     Br 
reports   the   case    of  a   child   who   died   from  bei 
wrapped  up  too  closely  by  the  parents,  when  it  n 
being  taken  to  a  nurse. 

(b)  By  covering  the  mouth  and  nostrils  so  as 
prevent  the  ingress  and  egress  of  air,  most  frequent 
accomplished  by  the  use  of  bedclothes.  In  tl 
division  should  also  be  included  those  cases  in  whi 
the  victim  has  been  covered  by  dirt,  ashes,  sno 
or  the  like,  as  by  being  buried  alive  or  caught  undo 
slide  of  snow.  And  in  the  same  connection  should 
mentioned  those  cases  in  which  feeble  or  intoxicat 
persons  have  fallen  face  downward  in  snow  or  sa 
or  other  similar  substance,  and,  being  unable  to  ri 
have  been  suffocated. 

Suffocation  is  not  often  adopted  as  a  method 
suicide,  and  it  is  infrequently  resorted  to  for  the  pi 
pose  of  homicide.     Perhaps  it  more  frequently  occi, 
by  accident. 

Unless  some  facts  are  proven  which  point  to  t 
cause  of  the  death,  the  expert  is  at  a  great  disadva 
tage  in  attempting  to  determine  whether  or  net  dea 
was  due  to  external  cause,  or  was  the  result  of  ap 
plexy,    faucial    disease,    or    pulmonary    congestii 

Some  of  the  most  common  physical  indications 
death  by  suffocation  are  lividity  of  the  face  and  sa 
guineous  engorgement  of  the  viscera  of  the  thorax  ai 
abdomen.  There  are  frequently  bloody  infiltratii 
of  the  eyes  and  eyelids,  and  very  small  ecchyi 
the  neck  and  chest;  a  partial  engorgement  of  the  Inn 
little,  if  any,  blood  in  the  left  ventricle  of  the  beat 
while  the  right  ventricle  of  the  heart  is  general 
engorged.  Sometimes  a  reddish  froth  is  found  in  tl 
trachea  and  bronchi.  As  a  rule,  the  body  is  slight 
if  at  all  discolored,  and  the  vascular  system  of  tl 
brain  shows  rarely  any  evidence  of  disorder.  Ol 
of  the  most  common  indications  is  congestion  of  tl 
kidneys.  When  a  dead  body  is  found  in  earth,  ashc 
or  snow,  or  the  like,  the  question  presents  itself  ; 
once  whether  the  death  preceded  the  fall  or  the  burin 
Perhaps  the  best-recognized  test  is  to  examine  tl 
stomach,  gullet,  and  air  passages.  If  the  foreiti 
matter  is  found  in  the  stomach  or  in  the  gullet,  this 
regarded  as  very  positive  evidence  that  death  followr 
the  fall  or  burial,  as  only  by  the  action  of  a  bod 
instinct  with  life  could  the  foreign  matter  be  so  draw 
in.  On  the  contrary,  if  the  foreign  matter  is  foun 
only  in  the  nostrils  and  mouth,  this  is  positive  <  > 
dence   that   death   was   not   caused   by   suffocatioi 

Suffocation  frequently  is   caused  by  foreign  sut 
stances  becoming  lodged  in  the  windpipe  or  in  th 
esophagus.     Children    and    infirm    people    more   fr< 
quently    suffer    in    this    way.     This  often    makes 
necessary,  in  order  to  determine  the  cause  of  death,  t 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Asphyxia 


j,ke  an  examination  of  the  windpipe  and  gullet, 

MMontly  by  incision. 

[svhyxia  from  Strang ultil ion  Other  Hunt  hi/  Hanging. 

first  question  to  be  determined  in  this  division 

i  of  course:  Was  death  caused  by  si  rangulat  ion,  and 

,,,  by  what  means?     Under  this  head  we  shall  con- 

r  ill.'  indications  of  strangulation  other  than  that 

unplished  by  hanging. 

\>  in  all  eases  of  asphyxia,  the  trouble  in  strangula- 

ii  is  the  lark  of  air  in   the  body.      Hut    the  means 

>d  to  create  this  lack  is,  in  strangulation,  different 

:,  the  means  employed  in  either  of  the  two  preced- 

divisions. 

la  strangulation,  the  access  of  air  into  the  lungs  is 

pted  by  a  pressure  upon  the  windpipe  at  the 

This    method    provides   a   double    means   of 

and  in  the  majority  of  instances  death  is  the 

suit  of  combined  causes,  namely,  the  lack  of  breath 

by   the  pressure   upon   the   windpipe  and   the 

of  the  larynx,  and   congestion   of   the   brain 

bo    by   pressure    upon    the    veins   of   the    neck. 

ther  of  these  might  be,  in  itself,  sufficient  to  cause 

according  to  the  violence  of  the  attack,  bid  it 

irely    the    case  'that    the   expert   can   definitely 

.•portion  the  responsibility. 

In  the  majority  of  eases,  there  are  many  apparent 
lysical  signs  that  point  with  great  clearness  to  the 
a  of  death,  and  give  great  aid  in  arriving  at  a 
iper  conclusion. 

Some  of  the  physical  indications  that  tend  to  lead  to 
elusion  that  death  has  resulted  from  strangula- 
m  may  be  enumerated  here.  One  of  the  most  com- 
on  indications  is  the  presence  of  ecchymoses  upon 
e  face,  neck,  and  chest  caused  by  extravasated 
ood.  The  presence  of  these  ecchymoses  points 
rongly  to  death  by  strangulation,  although  it  is 
uaUy  conceded  that  the  absence  thereof  will  not  be 
ive  proof  to  the  contrary.  Frequently  these 
chymoses  are  so  minute  as  to  fail  to  attract  the 
tention  of  the  lay  observer,  and  for  this  reason  a 
refnl  examination  by  the  medical  expert  is  often 
valuable. 

An  examination  of  the  brain  will  disclose  more  or 

ss  congestion  and  disarrangement  of  the  vascular 

generally;  and  congestion  of  the  kidneys  and 

irer  is  very  common. 

iside   from    these   indications,    the    swollen   face, 

ten  the  protruding  tongue  and  eyes,  and  the  distortion 

the  features  generally  throw  much  light  upon  the 

ibject. 

is  strangulation  other  than  by  hanging  is  usually 

imicidal,  great  attention  should  be  paid  to  noting 

ly  mark  of  violence  upon  the  body,  any  evidence  of 

niggle  either  upon  the  body  itself  or  upon  the  sur- 

mndings.     The  condition  of  the   clothing  may  be 

rongly  indicative  of  attack  and  resistance. 

Death  from  manual  strangulation  may  be  aecom- 

lished  by  means  of  the  hands,  cord,  or  other  ligature. 

i'hen  the  hands  are  used,  it  is  very  easy,  as  a  gen- 

ral  thing,  to  determine  that  the  strangulation  was 

lanual;  but  when  a  cord  or  ligature  was  used,  the 

inclusion  cannot  be  so  safely  or  easily  arrived  at. 

n  such  cases,  the    mark    of    the    cord    or    ligature 

ill  give  aid.     Where  the  strangulation  was  manual, 

-  distinguished   from    strangulation    from    hanging, 

I'.'  mark  of  the  cord  will  be  very  nearly  horizontal, 

'hereas  in  strangulation  from  hanging,   the  mark  will 

«  higher  on  one  side  than  on  the  other,  and  will  at  the 

■chit  of  the  knot  approach  near  the  head.     The  mark 

f  the  cord  or  ligature  in  manual  strangulation  is  also, 

s  a  rule,  much  lower   on  the   neck  than   when  the 

trangulation  results  from  hanging,  as  the  weight  of 

lie  body  invariably  causes  the  cord  to  slip  as  high  as 

ible,  it  being  stopped,  as  a  rule,  only  by  the  head. 

There  are  seldom   (in  manual  strangulation)   any 

n juries  to  the  vertebra?,  and  the  ligaments  of  the  neck 

ire  rarely  torn;  while,  on  the  contrary,  such  results 

ire  frequent  when  strangulation  is  caused  by  hanging. 


And,    finally,    it    may    lie   observed    that    in    manual 
Strangulation  the  throat  is  rarely  so  perfect  l\   clo  ed 
in  strangulation  from  hanging,  for  the  suddenness  of 
the  fall,  combined  with  the  weight  ol   I  he  body,  tends 
thoroughly    to   shut    all    tin-   an    pa   sages.       While    the 

position  of  i he  body  u  iiaiiv  throws  some  light  upon 
the  question,  yet  this  is  by  no  means  decisive,  for  it  is 
an  easy  matter  for  the  assassin,  after  accomplishing 
murder  by  manual  strangulation,  to  suspend  the  body 

by  a  cord  in  order  to  east  about,  the  death  the  appear- 
ance Of  suicide.  The  foregoing  signs  are  merely  help- 
ful, and  rarely  unconnected  with  collateral  evidence 
entirely  satisfactory  to  the  conscientious  administra- 
tors  Of   the   law. 

Human  experience  has  demonstrated  that  few  signs 
of  l  his  nature  are  to  be  absolutely  relied  upon,  for 
oftentimes  incidental  and  accidental  physical  facts 
tend  to  incriminate  an  innocent  man,  and  frequently 
the  guilty  deliberately  make  evidence  of  this  character 
in  a  skilful  manner  for  the  purpose  of  creating  the 
impression  of  self-murder. 

The  importance  of  a  careful  investigation  and  physi- 
cal examination  is  very  apparent,  when  it  is  considered 
that,  while  the  law  takes  great  care  to  punish  the  de- 
struction of  human  life,  it  also  takes  greater  care  that 
no  innocent  man  shall  suffer.  To  such  a  degree  is 
this  carried  that  if  from  the  evidence  the  jury  should 
have  a  reasonable  doubt  as  to  the  fact  that  the  death 
was  homicidal,  under  the  instructions  of  the  court  an 
acquittal  is  necessary. 

Asphyxia  from  Hanging. — In  determining  whether 
or  not  death  was  caused  by  hanging,  either  when  the 
dead  body  is  found  suspended  or  when  it  shows  certain 
external  evidences  of  such  a  death,  although  no  longer 
suspended,  many  of  the  evidences  found  in  death 
from  manual  strangulation  should  be  considered  and 
sought  for. 

The  congestion  of  the  brain  and  the  derangement  of 
the  organ  in  other  respects  are  largely  alike  in  the  two 
forms  of  asphyxia,  although  more  pronounced  in 
death  from  hanging;  the  ecchymoses  are  also  in  evi- 
dence again,  usually  in  a  more  pronounced  manner, 
and  the  same  physical  distortions  and  swellings  of  the 
face  and  neck  will  be  found,  save,  as  in  the  congestion 
and  ecchymoses,  to  an  accentuated  degree.  But  to 
the  unskilled  observer  these  indications  may  be  said 
to  be  similar  in  death  from  hanging  and  in  death 
from  manual  strangulation.  After  having  observed 
these  indications,  which  are  largely  alike,  as  just  set 
forth,  it  is  probably  best  to  look  carefully  for  those 
marks  which  are  common  in  both  cases,  but  different 
in  form  or  degree.  The  first  should  be  the  mark  of 
the  cord.  In  hanging  it  vul\  be  found  to  be  not 
horizontal,  one  side  usually  being  much  higher  and 
terminating  in  something  like  a  point;  the  mark, 
furthermore,  is  invariably  higher  than  in  manual 
strangulation,  the  weight  of  the  body  drawing 
downward  and  forcing  the  cord  to  the  base  of  the  head, 
while  the  air  passages  are  closely  shut  by  virtue  of  the 
weight  of  the  body  or  the  sudden  force  of  the  fall. 
The  marks  of  the  cord  are  usually  deeper  and  more 
distinct,  and  there  will  rarely  be  the  same  evidence  of 
finger  marks  upon  the  face  and  throat.  There  are 
more  pronounced  excoriations  in  connection  with 
the  marks  of  the  cord.  The  great  majority  of  deaths 
from  hanging  are  due  to  the  combined  causes  of  as- 
phyxia and  apoplexy;  while  in  manual  strangulation, 
perhaps  a  majority  of  deaths  ensue  from  asphyxia 
alone. 

One  of  the  most  common  physical  evidences  found 
upon  a  body  when  death  is  attributable  to  hanging 
consists  of  injuries  to  the  ligaments  of  the  spinal 
column  and  the  tearing  of  the  carotid  arteries  in  the 
neck. 

The  lens  of  the  eye  is  said  to  be  often  cracked  by 
the  sharp  shock  of  descent,  and  this  sometimes  gives 
help  to  the  expert  in  his  examination. 

The  effect  upon  the  genital  organs  of  both  the  male 

727 


Asphyxia 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


and  the  female  victim  often  throws  great  light  upon 
the  question.  It  is  mentioned  by  the  authorities  that 
hanging  causes  congestion  and  erection  of  these 
organs  both  in  the  male  and  female,  but  usually 
more  pronounced  in  the  male.  However,  evidences  of 
this  are  not  always  present,  and  in  view  of  the  fact 
that  this  condition  may  be  found  after  death  from 
other  forms  of  violence,  it  alone  will  not  suffice  to 
prove  that  death  was  caused  by  hanging.  The  usual 
effect  upon  the  male  genitals  is  a  state  of  tumefac- 
tion; spermatozoa  are  found  in  the  urine  and  in  the 
urethra,  and  frequently  there  is  an  emission  of  semen. 
In  the  female,  there  is  often  found  a  dilated  and  in- 
flamed condition  of  the  genitals,  and  sometimes  a 
bloody  discharge. 

Another  indication  commonly  observed  is  a  dis- 
charge from  the  bowels. 

As  many  deaths  resulting  from  hanging  are  suicidal, 
it  is  often  a  question  of  grave  importance  to  deter- 
mine whether  the  hanging  was  in  fact  suicidal  or 
homicidal.  It  is  the  unanimous  opinion  of  those 
who  have  made  profound  study  of  this  subject  that  in 
the  absence  of  collateral  evidence  the  presumption  is 
that  the  death  was  suicidal. 

Hanging  is  such  an  easy  and  convenient  method  of 
exit  from  the  world  that  the  wretched  and  despond- 
ent frequently  adopt  it,  in  ridding  themselves  of  those 
"ills  they  have."  This  is  probably  due  in  a  certain 
measure  to  the  fact  that  unlike  many  other  methods 
of  suicide,  hanging,  when  once  begun,  can  rarely  be 
stopped  by  the  would-be  suicide.  The  first  com- 
pression of  the  air  passages  tends  to  benumb  all 
sensibilities,  to  stupefy  the  will,  and  to  paralyze  those 
other  members  of  the  body  which,  upon  a  change  of 
mind,  would  be  necessary  to  effect  a  self-rescue. 
Therefore,  doubtless,  in  many  instances  in  which  the 
resolution  to  destroy  one's  self  is  only  partially  fixed, 
when  the  first  step  has  been  taken  there  is  rarely  an 
opportunity  to  go  back. 

Hanging  can  be  accomplished  in  so  many  ways,  and 
with  such  simple  appliances,  as  also  to  present  a  royal 
road  to  death  to  the  melancholy  and  desponding. 

The  main  things  to  consider  in  this  connection  are: 
the  position  of  the  body,  whether  it  swings  clear  or 
barely  touches  the  ground;  whether  the  hands  and 
feet  are  bound;  whether  or  not  the  cord  or  other 
device  gives  evidence  of  being  prepared  by  another; 
and  sometimes  the  manner  in  which  the  knot  is  tied. 

There  is  no  doubt  also,  as  a  rule,  that  in  suicide  there 
are  no  marks  of  violence  upon  the  body,  and  rarely 
any   evidence    that    would    tend    to    show    struggle. 

But,  in  the  end,  evidence  purely  expert  and 
ln-pothetical,  in  this  as  in  all  methods  of  determining 
the  cause  of  injury  and  death,  is  to  be  received  with 
caution,  and  is  most  valuable  when  considered  to- 
gether with  proven  facts  that  point  to  a  cause  of  the 
death.  Edward  Preble. 


Aspidium. — Male  Fern,  Filix-mas.  The  dried 
rhizome  and  stipes  of  Dryopteris  filix-mas  (L.)  Schott. 
(Fam.  Polijpodiacew.)  This  is  a  large,  robust,  and 
handsome  fern.  It  is  one  of  the  commonest  in  the 
cooler  parts  of  Europe,  and  abundant  also  in  the 
temperate  parts  of  Asia,  in  the  northern  and  southern 
extremes  of  Africa,  and  in  both  North  and  South 
America.  It  is  not  found  in  the  Eastern  United 
States,  but  occurs  in  British  America  and  in  the 
Western  States.  Its  employment  as  a  teniacidal 
agent  is  of  great  antiquity,  as  it  is  mentioned  by 
some  of  the  earliest  writers  upon  medicine.  The  in- 
troduction of  the  "oleoresin"  (ethereal  extract)  dates 
from  the  recommendation  of  an  apothecary  of  Geneva 
named  Peschier,  in  1825  (Fliickiger).  The  horizontal  or 
decumbent  rhizome  is  collected  and  either  dried  and 
marketed  in  its  natural  state,  or  (as  now  usual)  after 
stripping  it  of  its  dense  coat  of  leaf  bases  and  chaffy 
scales,  then  constituting  the  "peeled  fingers." 


Description. — Before  being  peeled,  ten  to  fifi.  i 
centimeters  (4  to  6  in.)  long  by  five  to  seven  cei 
timeters  (2  to  5  in.)  thick,  including  the  dense 
imbricated,  dark  brown,  cylindraceous,  slight 
curved  stipe-bases  and  the  dense  mass  of  brow 
glossy,  transparent,  soft,  chaffy  scales;  when  peelr 
one  to  two  or  three  centimeters  (f  to  about  1  n, 
thick,  slightly  curved  or  claw-shaped,  somewli: 
narrowed  toward  one  end,  bearing  several  coari 
longitudinal  ridges  and  grooves,  pale-green  when  fir 
peeled,  becoming  pale-brown,  or  when  too  long  kei. 
rusty-brown,  smoothish  (or  somewhat  roughly  scan 
with  remains  of  the  stipe-bases);  texture  rati. 
spongy,  pale-green,  with  age  becoming  gradual 
brown  from  the  outside  inward,  showing,  on  cross-si 
lion,  about  ten  steles  in  a  loose  and  interrupted  c 
cle.  The  marginal  hairs  of  the  stipe-scales  of  A.fih. 
mas  consist  each  of  two  parallel,  slender  cells,  neitln 
of  them  glandular;  those  of  A.  marginalis  are  almo 
identical  in  appearance,  being  directed  slightly  moi 
toward  the  apex  of  the  scale,  and  their  lowet  ci 
often  a  little  narrower.  Upon  the  older  scales  the 
are  nearly  wanting.  Male  fern  has  a  disa.L'i 
odor  and  a  bittersweet,  acrid,  astringent,  and  nat 
seous  taste. 

The  chaff,  together  with  the  dead  portions  of  tli 
rhizome   and   stipes,   should   be   removed,   and  en! 
such  portions  used  as  have  retained  their  green 
The  powder  should  be  freshly  prepared  and  brigl 
green. 

Several,  perhaps  many,  adulterants  and  subsl 
tutes  have  been  and  are  sold.  Some  of  these  can  1 
distinguished  by  their  different  numbers  of  steli 
while  the  distinctions  of  others  are  microscopic! 
and  obscure.  It  is  not  indeed  practicable,  without 
very  elaborate  description,  to  exclude  all  the  possibl 
adulterants.  Some,  not  readily  detected  in  the  peele 
drug,  are  so  when  the  covering  of  stipes  is  present, 
condition  which  is,  for  other  important  reasons,  al- 
to be  preferred. 

Of  late  years,  the  market  has  afforded  very 
more  male  fern  only  an  inch  and  a  half  in  Ieng 
quarter  or  a  third  of  an  inch  thick,  than  of  the  large 
sort.     The  size,  however,  does  not  appear  to  aflVr 
the  quality  greatly,  except  that  the  larger  form  re 
tains  its  freshness  longer. 

Few  drugs  are  more  certain  to  prove  effective  thai 
male  fern  of  good  quality  and  properly  prepared,  ye 
there  are  few  whose  preparations,  as  found  in  phar 
macies,  are  more  uncertain.  The  quality  of  tin 
genuine  drug  appears  to  depend  wholly  upon  it 
freshness  and  correct  and  careful  preparation.  Tin 
freshness  is  at  once  determinable  by  the  color,  and  m 
pharmacist  is  excusable  for  accepting  or  using 
inferior  article.  The  outer  surface  at  first  lose- 
green,  and  assumes  a  very  pale-brown,  then  a  dn  i 
rusty-brown  color.  At  the  same  time  a  similai 
change  of  color  is  occurring  internally,  beginning  a: 
the  exterior  and  gradually  working  inward.  Tin 
quality  is  in  a  general  way  proportional  to  the  re- 
tention of  the  green  color. 

The  composition  of  male  fern  is  very  complex  and 
variable  with   the  length  of   time   that   the  drug 
retained.     Many  compounds  have  been  from  time 
time  described  and,  being  found  to  act  more  or  less 
like  the  drug,  have  been  credited  as  the  active  con- 
stituents.    We  are  unable,  however,  to  state  positii 
to  what  the  action  is  due.     There  appears  to  be  little 
doubt   that  several   of  the   constituents  are  aeti\>', 
upon  both  the  system  and  the  parasite.     Filicic  acid, 
which   is   certainly   somewhat   active,   was  long  re- 
garded as  the  chief  teniacidal  agent,  but  since  it  in- 
creases   upon    keeping    the    drug,    while    the   latter 
becomes  less  effective,  this  view  has  become  modifi 
Aspidin  is  more  abundant  in  the  fresh  drug  and  bas 
been  proven  to  be  active,  as  has  aspidinin.     With 
these  substances  occur  six  or  seven  per  cent,  of  fixed 
oil,  a  variable  amount  of  volatile  oil  and  tannin,  and 


728 


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Aspiration 


■irious    less    known    bodies.      The    twenty    per    cent. 
.  thirty  per  cent,  of  filicic  anhydride  or  JUicin  is  not 

■live. 

In   medicinal   doses  of   7>    ]    to   i.   (1.0  to   I I 

„■  oleoresin,  the  preparation  almost  entirely  em- 
loved,  mule  fern  ordinarily  has  a  purely  extraneous 
affecting  only  the  parasite,  lint,  when  very 
rge  doses  are  taken,  or  when  absorption  occurs,  this 
ling  favored  by  the  use  of  fats  while  the  oleoresin  is 
ill  in  the  intestine,  for  which  reason  castor  oil  is  an 
ii  adjuvant,  poisonous  symptoms  may  occur, 
id  the  results  may  be  fatal.  '1  he  symptoms  of 
lisoning  are  those  of  great  intestinal  irritation  and 

nation,     purging   and      vomiting,      convulsive 

lents  ami  powerful  depressi ending  in  coma. 

irablc  result  from  the  use  of  male  fern  depends 

mea  mi  re  upon  the  method  of  ad  m  in  is  (rat  ion. 

ie  of  the  most  important  points  in  its  administration 

the  dietetic  preparation  of  the  patient.     F'or  ten  or 

elve  hours  before  the  first  dose  he  should  eat    no 

•  iiil  food  whatever,  and  the  bowels  if  full  should  be 

nptied  by  a  cathartic.      Milk  may  be  taken  freely, 

■  thin   soup;    then  about    four   grams   (5i)   of  the 

in  should  be  given  at  one  dose;  after  several 

i  second  dose  may  be  given,  to  be  followed  by 

cathartic,  if  needed.     The  discharges  should  always 

I  nlly  examined  for  the  head  and  upper  portions 

i lie  worm.     Unless  these  are  passed  the  cure  cannot 

■  considered  certain,  and  it  may  be  found  necessary 
i  repeat  the  treatment.  H.   H.   Rusby 

\spidocotylea. — An  order  of  trematodes  or  flukes, 
he  adhesive  apparatus  occupies  nearly  the  whole 
entral  surface  of  the  body,  from  which  it  is  usually 
istinctly  constricted  off.     The  order  contains  but 

single  family,  and  none  of  the  representatives  is 
mud  in  warm-blooded  vertebrates.     See  Trematoda. 

A.  S.  P. 

Aspidosperma. — Quebracho.  White  Quebracho.  The 
ried  bark  of  Aspidosperma  quebraeho-blanco  Schlech- 
■ndahl  (fain.  Apocynacea:). 
This  plant  is  not  to  be  confused  with  the  Quebracho 
ilorado  (red  quebracho),  the  wood  and  bark  of  which 
re  very  largely  employed  for  the  preparation  of  an  ex- 
•act  used  in  tanning,  and  pertaining  to  the  Quebra- 
'■iia  morongii  Britton  .(fam.  Anacardiacece).  The 
.tie  "quebracho"  means  axe-breaker,  and  is,  for 
bvious  reasons,  applied  to  various  trees.  In  the  last- 
amed  species  it  is  the  ironlike  wood  which  has  given 
.ie  name.  In  that  under  consideration,  it  is  the  great 
bundance  of  stone  cells  in  the  bark  which,  occurring 
i  masses,  chip  out  the  edge  of  the  axe.  The  tree  is  of 
tedium  size,  widely  spreading,  evergreen  and  hand- 
sale, and  inhabits  the  northwestern  portion  of  the 
,rgentine  Republic  and  adjacent  countries.  The 
apply  of  bark  is  irregular,  and  it  is  usually  scarce  and 
ear.  It  occurs  in  irregular  chiplike  or  blocklike 
ieees,  and  is  about  the  thickest  and  roughest  medicinal 
ark  of  commerce,  resembling  only  dita  bark  in  this 
articular.  The  gray  outer  surface  is  most  coarsely 
ad  deeply  fissured,  while  the  texture  is  so  compact 
ad  tough  that  there  is  little  tendency  for  it  to  scale 
ff.  Half  the  thickness  or  more  consists  of  cork  and 
ortex,  the  latter  filled  with  large  groups  of  stone  cells, 
"he  color  of  this  layer  may  be  either  of  a  yellowish- 
,'hite  or  pale  yellow,  or  more  or  less  rusty  or  brick 
ed.  The  inner  bark  consists  of  several  thick  layers 
f  very  coarse  bast  fibers  and  varies  from  nearly 
vhite  to  a  rather  dark  brown.  It  is  very  compact, 
ough,  hard  and  woody,  and  of  splintery  fracture. 
Ul  parts  of  the  bark  have  an  intensely  bitter  taste. 
The  variation  in  the  color  of  the  bark  cannot  be  ex- 
ilained  in  the  present  state  of  our  knowledge.  It  is 
iot  the  darkening  of  age,  as  the  writer  has  bark 
vhieh  has  been  kept  for  many  years,  but  which  is 
ilmost  white  throughout.     It  is  not  improbable  that 


two  or  more  closely  related  species  arc  in  use.      [I    o 

the  matter  is  in  much  need  of  investigation,  a  the 
composition  and  properties  may  differ  with  the 
phj  lical  characterisl  ics  of  the  bark. 

Composition.  U  though  aspidosperma  contains, 
along  with  a  small  amount  of  tannin,  no  less  than  six 
alkaloid-,    its   action    is   remarkably    simple,    owing    to 

the  fact  thai  the  alkaloids  agree  rather  clo  ely  in  their 
general  action.  Aspidospermine,  quebrachine,  que- 
brachamine,  and  aspidospermatine  are  crystalline, 
aspidosamine  and  hydroquebrachine  arc  not. 

Properties. — Their  combined  action  is  first  to 
stimulate,  then  to  depress  the  respiratory  centers  and 
to  produce  a  nauseating  expectorant  effect,  followed 
by  muscular  depression  or  weakness,  including 
moderate  cardiac  depression.  Abnormal  temperature 
may  be  reduced.  The  drug,  used  in  moderate  doses, 
thus  becomes  capable  of  increasing  both  the  number 

and  the  depth  of  the  respirations,  and  of  relieving 

spasmodic  Conditions,  while  in  large  doses  it  induces 
convulsive  breathing  and  may  end  in  fatal  respira- 
tory paralysis.  Vomiting  very  rarely  accompanies 
the  nausea.  It  is  said  thai  aspidosamine,  used  alone, 
acts  as  an  emetic.  Little  has  been  done  therapeutic- 
ally with  the  individual  alkaloids,  that  usually  sold 
as  aspidospermine  being  an  alkaloidal  mixture. 
Neither  has  the  therapeutical  use  of  quebracho  in  any 
form  been  greatly  developed.  It  is  said  to  be  used  in 
its  native  home  partly  as  an  antiperiodic,  and  partly, 
like  coca,  to  overcome  the  dyspnea  of  mountain 
travel.  Its  chief  use  in  professional  medicine  is  to 
relieve  the  dyspnea  of  asthma  and  other  spasmodic 
conditions,  as  well  as  of  emphysema.  Owing  to  its 
weakening  effect  upon  the  heart,  it  is  contraindicated 
in  case  of  organic  disease  of  that  organ.  The  results  of 
its  continual  use  have  not  been  found  satisfactory, 
being  those  of  continued  depression  of  the  nerve 
centers,  with  salivation  and  nausea.  A  peculiar 
effect  has  been  reported,  in  some  cases,  of  promptly 
curing  erysipelas  by  the  hypodermic  injection  into  the 
affected  part  of  a  half-grain  of  commercial  aspido- 
spermine. The  dose  of  aspidosperma  is  5  i  to  i. 
(1.0-4.0).  The  extract,  in  five-grain  (0.3)  doses,  is 
commonly  employed.  H.  H.   Rusby. 


Aspiration. — Dr.  George  Dieulafoy,  in  a  paper 
presented  to  the  French  Academy  of  Medicine  in 
1869,  described  the  first  perfected  aspirating  appara- 
tus, to  replace  the  hollow  needles  and  trocars  then  in 
use.     The  process  he  termed  pneumatic  aspiration. 

This  instrument  was  shortly  followed  by  the  larger 
and  more  useful  one  suggested  by  Potain.  These  two 
instruments  remain  in  use  to  the  present  day,  and, 
although  many  modifications  have  been  proposed, 
the  originals  have  not  been  replaced  by  any  more  mod- 
ern invention.  The  only  improvement  of  decided 
value  has  been  the  introduction  of  trocars  in  the  place 
of  hollow  needles  in  Potain's  aspirator.  The  advan- 
tage being  that  the  withdrawal  of  the  trocar  leaves  a 
blunt-pointed  canula  which  may  be  freely  moved 
about  without  endangering  the  soft  tissues,  also 
any  obstruction  in  its  lumen  is  readily  removed  by 
reintroducing  the  trocar. 

The  Dieulafoy  aspirator  (Fig.  509)  consists  of  a 
glass  syringe  holding  three  or  four  ounces,  and  having 
two  outlets  at  its  lower  end,  each  of  which  has  a  stop- 
cock, B,B;  a  rubber  tube,  into  which  is  let  a  glass 
index,  E;  and  four  needles  of  various  sizes.  The 
apparatus  is  used  as  follows:  The  needle  having  been 
connected  with  the  syringe  by  means  of  the  tube,  and 
the  outlets  closed,  the  piston  is  withdrawn  to  its  full 
extent,  and  secured  by  a  quarter  turn.  The  needle  is 
now  to  be  introduced  at  the  proper  place,  and  as  soon 
as  its  point  is  buried  in  the  tissues  the  corresponding 
cock  is  to  be  opened,  thereby  extending  the  vacuum 
to  the  extremity  of  the  instrument.  The  needle  is 
carefully  pushed  forward  as  far  as  is  desirable,   or 


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Aspiration 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


until  fluid  is  found,  which  will  be  indicated  by  its 
appearance  in  the  index,  if  not  in  the  syringe.  The 
latter  may  be  emptied  by  closing  its  outlet  leading  to 
the  tube,  opening  the  other,  and  unlocking  and  driv- 
ing the  piston  home.  Another  vacuum  is  to  be  made 
as  before,  and  the  process  may  be  repeated  indefinitely 
without  removing  the  needle  or  disconnecting  the 
syringe. 

Should  the  needle  become  stopped  up  during  the 
operation  efforts  may  be  made  to  clear  it  by  reversing 
the  action  of  the  syringe,  and  forcing  a  little  fluid 
back,  or  it  may  be  partially  withdrawn,  or  carried  a 


«.$^K> 


Fig.  509. — The  Uieulafoy  Aspirator. 

little  deeper,  or  its  direction  may  be  changed.  These 
maneuvers  failing,  it  must  be  taken  out,  cleared,  and 
introduced  in  another  place. 

With  this  instrument,  liquids  may  be  injected  into 
a  cavity  by  filling  the  syringe  with  the  fluid,  instead 
of  exhausting  the  air. 

Potain's  aspirator  (Fig.  510)  comprises  an  air  pump, 
A,  having  two  openings,  C,  D,  each  of  which  is  supplied 
with  a  metallic  valve,  working  in  opposite  directions, 
the  former  allowing  an  exit,  and  the  latter  an  entrance, 
of  air  to  the  pump;  a  bottle,  with  a  capacity  of  a  pint 
or  more,  fitted  with  a  rubber  stopper,  B,  which  is  per- 
forated by  a  double  metallic  tube,  whose  outer  portion 
terminates  in  two  branches,  each  having  a  stop- 
cock, K,  L;  two  rubber  tubes,  with  the  necessary 
needles,  complete  the  apparatus. 

It  is  made  ready  for  use  by  connecting  the  bottle 
with  the  needle  by  the  indexed  tube,  E,  and  with  the 
pump  by  the  tube,  G.  The  cock,  K,  nearest  the  pump, 
is  opened;  the  other  is  closed.  The  air  is  exhausted 
from  the  bottle  by  a  few  sharp  strokes  of  the  piston, 
and  the  cock,  K,  is  closed.  The  puncture  is  now 
made,  and  as  soon  as  the  point  of  the  needle  is  under 
the  skin  the  corresponding  cock,  L,  is  to  be  opened, 
and  the  exploration  carried  to  completion.  Another 
vacuum  is  readily  established  without  disturbing 
the  needle  or  its  connections. 


By  attaching  a  rubber  tube  to  the  inner  end  of  tl 
metallic  one,  long  enough  to  reach  to  the  bottom  of  tl 
bottle,  and  by  changing  the  tube  G  from  D  to  ( 
so  as  to  force  air  into  the  bottle,  instead  of  exhaustii 
it,  the  apparatus  may  be  used  for  injection  or  irrigatio; 
or  the  bottle  may  be  emptied  of  its  contents  by  simp] 
working  the  pump.  This  action  is  due  to  the  fa* 
that  the  inner  orifice  of  the  tube  K  is  on  the  side  ju: 
below  the  stopper,  and  hence  independent  of  the  till 
in  the  bottle. 

As  a  more  perfect  vacuum  can  be  obtained  wit 
Dieulafoy's  instrument,  it  is  the  best  one  for  diagnost; 
purposes.  It  is  also  well  suited  for  evacuating  or  ii 
jecting  small  quantities  of  fluid,  especially  when  it 
desirable  to  be  exact  as  to  the  amount.  But  fr 
drawing  off  large  effusions,  or  for  irrigating  larp 
cavities,  Potain's  apparatus  saves  time  and  labo 
And  it  may  be  said  that  for  general  use  the  latt ■ 
instrument  is  the  more  serviceable  of  the  two,  as  i 
can  be  made  to  do  the  work  satisfactorily  in  most  c 
the  cases  requiring  this  operation. 

The  peculiar  feature  of  the  aspirator,  which  di.< 
tinguishes  it  from  the  trocar,  and  which  makes  i 
so  much  more  valuable,  lies  in  what  Dieulafoy  call 
the  "previous  vacuum."  As  this  extends  to  tli 
point  of  the  needle  the  operator  is  notified  of  th 
presence  of  fluid  the  instant  it  is  reached,  and  there 
fore  there  is  little  danger  of  passing  through  a  sma! 
collection  of  fluid  without  knowing  it,  or  of  wound 
ing  deeper  structures  unnecessarily,  a  matter  of  mud 
importance  in  tapping  joints  and  other  cavities.  Tb 
strong  suction  power  of  this  instrument  enables  on< 
to  use  smaller  needles,  as  well  as  to  evacuate  fluid 
which  are  too  thick  to  be  withdrawn  with  an  ordinar; 
trocar. 

The  aspirator  should  always  be  tested  just  before  i 
is  used  upon  a  patient,  because,  from  its  peculiar  con 
struction,  it  is  very  liable  to  get  out  of  order.  Tin 
piston  gets  loose,  the  needles  are  easily  plugged  witl 
rust  or  dirt,  the  tubes  crack  and  break,  the  coeb 
stick,  the  stopper  may  not  fit  the  bottle.  All  of  thest 
points  require  attention  in  order  to  avoid  embarrass 
ment  and  delay. 


Fig.  510. — Potain's  Aspirator. 

After  having  been  used,  the  needles  should  be 
thoroughly  cleansed  with  hot  water  (carbolized), 
dried,  and  threaded  with  a  wire  to  keep  them  patent. 

Pleuritic  Effusions.- — Potain's  aspirator  is  almost 
universally  employed,  its  early  and  repeated  use  being 
generally  accepted.  With  proper  care  and  as- 
precautions  it  has  become  a  harmless  procedure. 
General  anesthesia  has  been  replaced  by  the  local  use 
of  ethyl  chloride  or  cocaine,  which  should  always  be 
employed.  Asepsis  is  of  the  utmost  importance, 
equally  in  the  preparation  of  the  site  of  puncture,  in 
the  instrument  and  needles,  and  particularly  in  the 
hands  of  the  operator. 

The  patient  is  usually  placed  in  the  semi-recumbent 
position,  but,  in  suitable  cases,  he  may  sit  upright 
with  the  body  bent  forward,  the  arms  raised  and  rost- 


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REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Aspirin 


ie  on  some  firm  object.     Some  operators  prefer  to 

lair  t lie  hand  of  the  affected  side  upon  the  opposite 

loulder,  as  this  tends  to  widen  the  intercostal  spaces 

n  the  affected  side. 

In  selecting  the  site  for  puncture,  the  anatomy  of 

ie  oavity  and  its  contained  organs  must  be  kepi  in 

lind.    The  arch  of  the  normal  diaphragm  in  t  he  nipple 

no  rises  to  the  fourth  interspace,  in  the  mid-axillary 

ne  from  this  to  the  sixth,  and  in  the  line  of  the  angle 

i  the  scapula  it   is  on  a  line  of  the  eighth  interspace. 

\  hen  there  is  much  fluid  the  diaphragm  is  displaced 

I  th.re  is  not  much  danger  of  its  being  injured, 

it  in  chronic  cases  where  there  is  not  much  fluid,  or 

here  adhesions   have  formed,   the   relation  of   these 

arts  is  important.     Usually  one  of  the  posterior  sites 

selected,   the   sixth  interspace   at    the   axillary   line 

ng  most  desirable,  as  the  walls  are  less  thick  and 

lie  interspaces  most  marked.      When  the  chest-wall 

thin  it  may  be  more  satisfactory  to  select  the  more 

isterior  and  lower  site.      Whichever  site  is  selected. 

lid  be  carefully  selected  and  precisely  marked 

ire  puncturing.     The  fluid  should  be  withdrawn 

Iv  with  intervals  of  rest,  and  the  conditions  of 

he   patient's    respiration    and    pulse    being   closely 

itoned.      If   the   removal   of  pressure  is  too  rapid 

heart    and    vessels   may   be   suddenly   engorged 

ausing    distressing    and    even    fatal    consequences. 

rapid  distention  of  the  lung  tissue  may  also  give 

ise  to  an  acute  edema.     The  amount  of  fluid  that 

hould  be  withdrawn  has  been  much  discussed.     This 

s  best   determined   by   the   extent   of   the   effusion. 

Alien  it  is  very  extensive  more  may  be  withdrawn 

i  when  the  quantity  is  less,  but  it  must  not  be 

orgotten  that  in  such  cases  the  structures  have  been 

rreatly   compressed  and  there  is   correspondingly  a 

treater    reaction    and    strain    upon    the    heart    and 

■insulation.     It  is  advisable  to  stop  the  withdrawal 

if  fluid  after  the  earliest  signs  of  trouble  and  if  neces- 

ary  repeat  the  operations  in  a  few  days.     In  other 

ises,  where  the  amount  of  effusion  is  not  great,  a 

omplete  emptying  of  the   cavity  may  be  effected 

without  any  but  beneficial  result. 

There  is  not  much  danger  in  inserting  the  needle 
<r  of  injuring  the  lung  tissues  during  the  operation. 
The  intercostal  arteries  are  not  in  the  path  of  the 
juncture  and  the  lung  tissue  may  be  pierced  without 
11  effects.  Unfavorable  results,  however,  occasionally 
supervene.  These  may  invariably  be  traced  to  septic 
nfection  or  some  error  of  detail.  Sudden  death  is 
rare,  but  instances  have  occurred,  due  to  syncope  or 
pulmonary  edema.  These  emphasize  the  importance 
if  the  greatest  care  of  patients  who  have  been  ill 
for  some  time  and  are  anemic  and  debilitated,  par- 
ticularly as  regards  the  position  of  the  patient  and  the 
careful  withdrawal  of  the  fluid. 

Aspiration  of  the  pericardium  is  now  a  well  recog- 
nized procedure  and  is  frequently  resorted  to  in  serous 
effusions  accompanying  pericarditis,  when  sufficient 
to  interfere  seriously  with  the  action  of  the  heart. 
The  amount  of  fluid  in  the  pericardium  will  vary 
greatly.  It  has  been  estimated  that  up  to  eight 
ounces  may  be  present  without  great  discomfort,  and 
as  much  as  sixty  ounces  have  been  removed  at  one 
time.  The  operation  is  simple  and  easily  performed, 
any  accidental  irritation  of  the  heart  being  of  no  con- 
sequence. For  the  puncture,  the  site  of  election  is  in 
the  fourth  or  fifth  interspace  an  inch  to  the  left  of  the 
margin  of  the  sternum.  Some  recommend  as  much  as 
two  and  a  half  inches,  and  others  direct  the  puncture 
to  be  made  at  the  margin  of  the  sternum.  Mc- 
Phedran,  in  Osier's  System  of  Medicine,  advises  the 
puncture  to  be  made  high  in  the  angle  between  the 
left  costal  cartilage  and  the  xiphoid  cartilage,  the 
needle  being  inserted  close  to  the  margin  of  the  costal 
cartilage  and  then  directed  upward  and  to  the  left. 

In  hydrocephalus,  aspiration  should  be  done  with 
the  smallest  needle.  The  puncture  should  be  made 
through  the  anterior  fontanelle,  far  enough  from  the 


median  line  to  avoid  the  longitudinal  sinus.  Experi- 
ence gives     light   encouragement   for  the  performance 

of  this  operat  ion. 

Abscess. — Aspiration   is   frequently   of   I  he   greatest 

value  in  determining  the  presence  and  character  of 

fluids,  but  as  a  method  of  treating  ordinary  abscesses 
it  is  far  inferior  to  free  incisions,  drainage  tubes,  and 

antiseptics.     The  pus  usually  reaccumulates  after  each 

evacuation,  until  finally  a  Spontaneous  opening  takes 
place,  unless  it  is  anticipated  by  an  artificial  one. 
Hepatic,  perinephritis  and  some  other  deep  collections 

of   pus    may    occasionally    be    treated    by    aspirations. 

The  diagnosis  is  thus  rendered  certain,  and  in  a  certain 

proportion  of  cases  a  fa \  oral ile  result  will  be  obtained. 

Hematoma. — Collections  of  blood  in  the  cellular 
tissue  resulting  from  contusion  or  other  injur}'  may 
often  be  satisfactorily  treated  by  aspiration,  one  or 
two  operations  being  sufficient.  A  large  needle  or 
trocar  may  be  used  to  evacuate  the  contents,  and 
firm  pressure  should  be  applied  to  prevent  a  return  of 
t  he  affection. 

Retention  of  Urine. — In  the  severer  stages  of  this 
affection,  aspiration,  as  a  temporary  resource,  is  often 
of  great  service.  It  is  safe,  speedy,  and  effectual. 
So  little  pain  attends  the  operation  that,  as  a  rule, 
anesthetics  are  not  required.  If  relief  is  not  obtained 
in  these  cases  from  milder  measures,  together  with  a 
moderate  trial  of  the  catheter,  it  is  far  better  to  aspi- 
rate the  bladder  above  the  pubes  than  to  irritate  and 
perhaps  lacerate  the  urethra  by  prolonged  and  often 
fruitless  efforts  at  catheterization.  The  operation  is 
best  performed  with  Potain's  apparatus.  It  being  in 
readiness,  the  needle  is  entered  on  the  median  line 
just  above  the  symphysis,  and  carried  backward  and 
downward  toward  the  hollow  of  the  sacrum,  to  such  a 
depth  that  the  point  will  not  escape  as  the  bladder 
contracts.  When  the  viscus  is  nearly  emptied  the 
patient  is  apt  to  experience  a  pricking  sensation,  which 
is  due  to  the  needle's  impinging  on  the  posterior  wall. 
It  should  be  withdrawn  a  short  distance,  and  the  urine 
allowed  to  escape  as  long  as  it  will  without  producing 
too  much  pain.  The  puncture  in  the  skin  may  be 
covered  with  a  bit  of  adhesive  plaster.  This  operation 
can  be  safely  repeated  as  often  as  may  be  necessary 
for  two  or  three  days,  by  which  time  the  urethral 
irritation  is  generally  so  far  subdiied  by  appropriate 
measures  that  the  power  of  voluntary  micturition  is 
restored,  and  the  primary  obstruction  can  receive 
the  required  attention. 

Aspirating  the  bladder  is  preferable  to  the  operation 
of  tapping  by  the  rectum,  because  it  is  safer,  it  is  more 
easily  performed,  there  is  less  liability  to  mistakes, 
and  it  is  not  followed  by  rectovesical- or  other  fistula;, 
by  extravasation  of  urine,  or  by  pelvic  or  prostatic 
inflammation  and  suppuration,  accidents  which  have 
occasionally  supervened  upon  the  rectal  operation. 

On  account  of  the  delicacy  of  the  instrument  and 
the  well  recognized  importance  of  aseptic  methods, 
almost  any  organ  or  part  of  the  body  may  be  safely 
explored  with  the  aspirator.  The  brain,  lungs, 
stomach,  fiver,  gall-bladder,  intestines,  arteries,  joints 
and  tumors  of  all  descriptions  have  been  punctured 
without  unfavorable  results. 

Beaumont  Small. 


Aspirin. — Acetyl  salicylic  acid,  C„H4.O.COCH3.- 
COOH,  is  prepared  by  acting  upon  salicylic  acid  with 
acetic  anhydride.  It  crystallizes  in  white  needles, 
which  are  soluble  in  about  100  parts  of  water,  and 
practically  insoluble  in  acids.  Alkaline  fluids  dis- 
solve it  freely,  but  split  it  up  into  its  components. 
Its  taste  is  slightly  sour. 

This  recently  introduced  salicylic  compound 
has  come  into  extensive  use  as  a  substitute  for  the 
salicylates  in  acute  rheumatism,  chorea,  tonsillitis, 
and  the  so-called  rheumatic  conditions  in  which 
sundry  joint  and  muscular  pains  are  manifest.     It  has 


731 


Aspirin 


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also  come  much  into  vogue  for  the  treatment  of  ordi- 
nary colds,  and  the  laity  have  become  familiar  with 
this"  use  of  it.  The  theory  on  which  it  is  preferred 
to  the  salicylates  is  that,  being  insoluble  in  the  gas- 
tric juice,  it  passes  through  the  stomach  unchanged, 
and  in  this  state  has  little  tendency  to  produce  nausea 
and  vomiting.  In  alkaline  fluids,  as  of  the  intestine, 
it  is  broken  up  and  is  absorbed  as  salicylate  and  ace- 
tate. It  is  true  that  nausea  is  much  less  frequent 
with  aspirin,  yet  in  equivalent  doses  many  persons 
are  just  as  much  affected  as  they  are  by  sodium  salicy- 
late. The  sweating,  the  ringing  in  the  ears,  and  the 
light  headedness  occur  just  as  frequently  from  the 
larger  doses.  A  few  cases  have  been  reported  of 
serious  depression  of  the  cardiac  muscle,  and  of 
swelling  of  the  face  and  throat,  but  as  a  rule  the  drug 
can  be  taken  in  amounts  up  to  oij.  or  oiij.  (S.Oor  12.0) 
in  twenty-four  hours  without  danger.  The  dose 
varies  from  5  grains  (0.3)  every  three  hours  for  a 
cold,  to  gr.  xv.  (1.0)  every  two  hours  for  serious 
rheumatic  fever.  It  is  administered  in  capsule  or 
tablet.  W.  A.   Bastedo. 


Asporocystinea. — A  suborder  of  the  Coccidiidia 
in  the  Sporozoa.  The  sporoblasts  have  no  sporocysts. 
Perhaps  the  malarial  parasites  should  be  included 
in  this  group.     See  Protozoa.  A.  S.  P. 


Association. — This  term  has  come  to  have  much 
more  psychological  and  physiological  meaning  and 
denotation  than  appears,  so  to  say,  on  its  surface — the 
developed  outgrowth  from  the  now  mostly  outworn 
Herbartian  psychology  or  ideology.  If  we  artifi- 
cially abstract  and  attend  only  to  the  mental  aspects 
of  human  processes,  association  in  its  widest  usage 
indicates  little  short  of  the  sequence  of  events  thought 
of  as  psychical,  that  is,  in  consciousness,  whether 
obvious  in  experience  or  not  (subconscious).  On  the 
other  hand,  when  we  look  at  association  in  its  somatic 
or  physiological  aspects,  wre  find  it  standing  for  the 
sum  of  the  processes,  mostly  or  wholly  in  nerve  and  in 
muscle,  which  are  most  closely  related  to  the  mental 
process,  especially  in  its  broader  ideational  phases, 
In  a  narrower  usage  of  the  term  association  it  means, 
in  the  one  aspect,  the  relationships  that  appear  to 
exist  between  ideas  in  the  mind,  and  in  the  other 
aspect,  the  physiological,  the  neuromuscular  and 
particularly  the  neural  "basis"  of  thought  proper. 
Practical  science,  however,  medical  psychology, 
should  seemingly  outgrow  so  artificial  a  narrowing  of 
terms  as  is  implied  in  the  usage  last  noted,  for  thus  to 
abstract  out  of  the  complex  unity  of  the  mental 
process  and  ignore  all  of  the  many  influences  that 
affect  the  order  and  sequence  of  our  thoughts,  is 
simply  to  mislead  the  searcher  after  facts,  leading  him 
on  to  think  simplicity  exists  where  in  reality  is  the 
utmost  complexity.  The  corollary  of  this  general 
principle  is  direct  enough:  Let  the  psychological 
aspect  of  personal  processes  establish  the  nature  of 
things  as  experienced,  unified  into  greater  or  smaller 
continuums,  but  keep  close  to  the  physiological  aspect 
for  explanation  and  understanding  of  these  personal 
processes.  With  this  reservation  we  may  use  this 
narrower  meaning  of  the  term  association  (of  ideas, 
for  the  term  is  not,  illogically  enough,  applied  to  fele- 
ings  or  volitions)  in  its  most  frequently  employed 
sense  as  the  relations  that  inhere  between  ideas  in  the 
process  of  becoming  in  the  mind. 

On  the  association  of  ideas,  thus  artificially  sim- 
plified for  the  purpose  of  shoring  up  a  philosophical 
system,  the  literature  is  forbiddingly  ponderous,  but 
its  mere  mass  no  longer  misleads  at  least  the  well- 
guided  student  of  the  nature  of  man  into  believing 
that  ideas  and  their  relationships  are  the  sum-total 
of  human  values,  nor  that  the  association  of  these 
concepts  or  general  ideas  is  a  preordained  simplicity  of 


pure  facultative  psychology.  For  purposes  of  t 
description  of  this  association  from  the  psycholoi 
cal  viewpoint  and  for  the  groundwork  at  least  of 
neurological  "explanation,"  no  discussion  is  mi 
scientific  than  that  of  James,  physiologist,  psycho! 
gist,  and  philosopher. 

"The  manner  in  which  trains  of  imagery  and  co 
sideration  follow  each  other   through   our  thinkii 
the  restless  flight  of  one  idea  before  the  next,  the  tran; 
tions   our    minds  make  between  things  wide  as  t 
poles  asunder,  transitions  which  at  first  sight  startle 
by   their  abruptness,   but   which,   when   scrutinizi 
closely,  often  reveal  mediating  links  of  perfect  natm, 
ness  and   propriety — all  this   magical,  Impond 
streaming  has  from  time  immemorial  excited  the  ; 
miration    of    all    whose    attention    happened   to  1 
caught    by   its   omnipresent   mystery.     And   it  h; 
furthermore  challenged  the  race  of  philosophers 
banish  something  of  the  mystery  by  formulating  tl 
process   in   simpler  terms.     The  problem  which  tl 
philosophers  have  set  themselves  is  that  of  ascertaii 
ing   principles  of  connection   between   the   though 
which  thus  appear  to  sprout  one  out  of  the  otne 
whereby  their  peculiar  succession  or  coexistence  ma 

be    explained The    only    summary   A 

script  ion  of  these  infinite  possibilities  of  transition, 
that  they  are  all  acts  of  reason,  and  that  the  mind  pn 
ceeds  from  one  object  to  another  by  some  ration: 
path  of  connection.  The  trueness  of  this  formula 
only  equalled  by  its  sterility  for  psychological  pu 
poses.  Practically  it  amounts  to  simply  referrin 
the  inquirer  to  the  relations  between  facts  and  thing 
and   to  telling  him   that  his  thinking  follows  then 

"  But  as  a  matter  of  fact,  his  thinking  only  Bomi 
times  follows  them,  and  these  so-called  'transitions  ( 
reason'  are  far  from  being  all  alike  reasonable.  1 
pure  thought  runs  all  our  trains,  why  should  she  ru 
some  so  fast  and  some  so  slow,  some  through  dull  flat 
and  some  through  gorgeous  scenery,  some  to  mou: 
tain-heights  and  jewelled  mines,  others  throne 
dismal  swamps  and  darkness? — and  run  some  off  th 
track  altogether,  and  into  the  wilderness  of  lunacy 
Why  do  we  spend  years  straining  after  a  certai 
scientific  or  practical  problem,  butall  in  vain- — thou«l 
refusing  to  evoke  the  solution  we  desire?  And  win 
some  day,  walking  in  the  street  with  our  attentin 
miles  away  from  that  quest,  does  the  answer  saunti 
into  our  minds  as  carelessly  as  if  it  had  never  bee 
called  for — suggested,  possibly,  by  the  flowers  on  th 
bonnet  of  the  lady  in  front  of  us,  or  possibly  by  noth 
ing  that  we  can  discover?  If  reason  can  give  u 
relief  then,  why  did  she  not  do  so  earlier?  The  trutl 
must  be  admitted  that  thought  works  under  conj 
ditions  imposed  ab  extra." 

This  surprising  combination  of  poetry  and  insight 
characteristic  of  James  in  all  his  phases,  expresses  tin 
problem  and  the  solution  both  at  once:  "There  art- 
then,  mechanical  conditions  on  which  thought  de 
pends,  and  which,  to  say  the  least,  determine  th< 
order  in  which  is  presented  the  content  or  materia 

for  her  comparisons,  selections,  and  decisions 

Association,  so  far  as  the  word  stands  for  an  eflfeel 
is  between  things  thought  of — it  is  things,  not  idea.- 
which  are  associated  in  the  mind.  We  ought  to  tall. 
of  the  association  of  objects,  not  of  the  association 
of  ideas.  And  so  far  as  association  stands  for  a 
cause,  it  is  between  processes  in  the  brain — it  i? 
these,  which,  by  being  associated  in  certain  ways, 
determine  what  successive  objects  shall  be  thought. 

It  is  things,   and   objective  properties  in 

things  which  are  associated  in  our  thought." 

Things  and  the  properties  in  things  are  represented 
in  the  brain  by  the  relations  of  the  neurons;  just  how 
of  course  no  man  can  begin  as  yet  to  imagine.  The 
fact,  however,  in  some  mode  or  other,  remains  the 
fact,  or  else  all  our  physiological  psychology  and  all 
our  neurology  are  wholly  wrong.  It  remains  then 
to  see  and  then  to  try  to  understand  just  what  prin- 


732 


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AssiM-hitlon 


lies  of  nervous  action  in  the  total  nervous  system 
,  relate  the  empirical  association  or  interrelation  of 

■  !<.  As  has  boon  implied  already,  .lames  pointed 
i  the  road  and  went  along  it  no  small  way.  We 
q  do  no  less  than  to  quote  again  his  own  description 

this  important  course: 

■  \.  11  the  materials  of  our  thought  arc  due  to  the 
,v  in  which  one  ele ntary  process  of  the  cerebral 

i  pheres  tends  to  excite  whatever  other  elemen- 
iv  process  it  may  have  excited  at  some  former  t  hue. 
,'•  number  of  elementary  processes  at  work,  how- 
,  and  the  nature  of  those  which  at  any  time  are 
|ly  effective  in  rousing  the  others,  determine  the 
er  of  the  total  brain-action,  and.  as  a  conse- 
nt  this,    they    determine    the   object   [or    the 
alien]  thought   of  at   the  time.      According  as  this 
lltanl  object   is  one  thing  or  another,  we  call  it  a 
oduct  of  association  by  contiguity  or  of  association 
similarity,  or  contrast,  or  whatever  other  sorts  we 
iv  have  recognized  as  ultimate.     Its  production. 
er,  is,  in  each  one  of  these  cases,  to  be  explained 
,  a  merely  quantitative  variation  in  the  elementary 
Bin-processes   momentarily  at  work  under  the  law 
habit,  so  that  psychic  contiguity,  similarity,  etc., 
.■  derivatives  of  a  single   profoundcr  kind  of  fact. 
....      Let  us  then  assume  as  the  basis  of  all  our 
i  -incut  reasoning  this  law:   When  two  elementary 
ain-processes    have    been    active    together    or    in 
.mediate   succession,    one    of    them,    on    recurring, 
mis   to  propagate   its   excitement   into   the   other. 
....     The   amount   of    activity   at    any   given 
oint  in  the  brain-cortex  is  the  sum  of  the  tendencies 
:  all  other  points  to  discharge  into  it,  such  tendencies 
eing  proportionate  (1)  to  the  number  of  times  the 
aent  of  each  other  point  may  have  accompanied 
hat  of  the  point  in  question;  (2)  to  the  intensity  of 
ich   excitements;  and    (3)    to   the   absence   of   any 
■  al  point  functionally  disconnected   with  the  first 
oint,  into  which  the  discharges  might  be  directed. 
....     To  sum  up,  then,  we  see   that  the  differ- 
i  ween  the  three  kinds  of  association  [redinte- 
rative,  associative,  and  similar]  reduces  itself  to  a 
imple  difference  in  the  amount  of  that  portion  of 
he  nerve-tract  supporting  the  going  thought  which 
operative  in  calling  up  the  thought  which  comes. 
lu(    the  modus  operandi  of  this  active  part   is  the 
ante,  be  it  large  or  be  it  small.     The  items  consti- 
tuting the  coming  object  waken  in  every  instance 
lecause   their   nerve-tracts   once   were   excited   con- 
inuously  with  those  of  the  going  object  or  its  opera- 
lve  part.     This  ultimate  physiological  law  of  habit 
mong  the  neural  elements  is  what  runs  the  train, 
."he  direction  of  its  course  and  the  form  of  its  transi- 
ents, whether  redintegrative,  associative,  or  similar, 
ire   due    to    unknown    regulative    or    determinative 
onditions  which  accomplish  their  effect  by  opening 
his  switch  and  closing  that,  setting  the  engine  some- 
itnes  at  halfspeed,  and  coupling  or  uncoupling  cars." 
'Principles  of  Psycliology,"   Vol.   1,  Chapter  XIV.) 
The  neurility  of  ideational  association,  then,  is  the 
icurility  of  habit,  and  at  the  same  time  is  almost 
"distinguishable    physiologically     from     the     nerve- 
iction  in  attention,  in  recall,  and  in  neuromuscular 
nnervation.     This    circumstance    can    scarcely    be 
iveremphasized — that     habit,      association,      recall, 
intention,    and    muscle-innervation    (more    or    less 
voluntary)  are  in  the  brain-maze  one  and  the  same 
process   probably,    the   interaction   of   millions   and 
millions   of    neurones    connected    in    still    unknown 
ways,  and  then  functionally  separated  by  ways  quite 
is  unknown.     We  may  call  this  mode  of  connection 
uid  of  disconnection  a  synapse  after  the  fashion  of 
the  English  neurologists,  but  the  term  means  nothing 
histological   and    little    even   in    terms   of    chemical 
physics,  in  whose  doctrines  of  osmotic  membranes 
dominated  by  the  ions,  it  had  its  birth. 

In  the  thirty  years  since  James  published  his  epoch- 
making  psychological  theories  (which  are  as  much 


physiology   as  psychology),   some  speculations  have 

been  added   to  the  neurology  of  associative  processes 

in  the  brain.     Noi  much  advance,  however,  ha    been 

possible  for  lack  of  a  coherent   theory  of  the  nervous 

impulse.     Bow  the  neurons  are  related  functionally 

and   the  nature  of  the  traces  of  habit  and  of  memory 
"on"  or  "in"   them   cannot    of  course   be   learned   :i 

long   as   this   great   gap   in   elementary    physiology 
remains  unfilled. 

William  McDougall  of  England  has  made  a  simple 
suggestion  in  this  direction  which  has  become  known 
as  the  drainage  theory.  In  the  shifting  of  attention 
at  the  basis  of  association,  the  neuronal  group  rep- 
resenting the  "coining"  object  (or  relation)  of 
association  would  drain  off  from  the  "center"  rep- 
resenting the  "going"  object  (or  relation),  so  to 
say,  much  of  its  energy  through  the  connecting 
channels.  This  transference  of  nerve-energy  along 
this  path  of  association,  as  in  all  cases  of  habit-forma- 
tion, exercises  the  pathway,  opens  il  np  somehow, 
and  makes  it  mere  likely  to  be  traveled  ever  after- 
ward. In  other  words,  an  association  has  been 
formed  in  the  brain  ready  at  any  time  to  make  con- 
scious more  or  less  an  association  in  "the  mind." 

As  Ladd  and  Woodworth  ("Principles  of  Physio- 
logical Psychology,"  1911,  page  618)  point  'out, 
however,  we  have  reasons  to  suspect  that  this  "drain- 
age" is  never  more  than  partial,  since  "the  fiuld  of 
consciousness  is  broader  than  the  field  of  attention" 
(that  is,  subconsciousness  fringes  the  "focus"  of 
attention).  In  general  terms  then  we  may  well 
agree  that  for  complicated  cases  of  association  (and 
how  immensely  complicated  is  the  neurology  of  every 
easel)  this  drainage-theory  adds  little  or  nothing  to 
the  becoming  supposition  as  to  the  neurology  of 
brain-action  in  general,  further  than  putting  emphasis 
on  the  important  notion  itself  of  drainage  out  of 
brain-regions  as  opposed  to  action  along  sharply  de- 
fined neuronal  paths.  But  this  in  itself  is  much, 
I  take  it,  for  it  marks  a  distinct  step  in  our  conception 
of  brain  action,  a  progress  still  further  away  from 
the  neurofibrillar  theory  of  neuronal  conduction. 

Ladd  and  Woodworth  themselves  lay  much  ex- 
planatory stress  on  the  force  of  expectant  attention 
in  directing  the  neural  paths  in  those  associations 
where  it  is  involved.  The  present  writer  would  be 
inclined  to  urge  the  implication  of  this  idea  of  ex- 
pectant attention  as  an  important  factor  in  many  if 
not  in  all  associations,  whether  conscious  or  subcon- 
scious. If  it  mean  anything  of  an  exact  kind  in  psy- 
chophysiology,  this  "  expectation"  stands  for  an  affec- 
tive tone,  and  it  is  affective  tones  that,  through 
determinations  of  interest,  temperament,  mood,  etc., 
furnish  the  motive  force,  the  exciting  "fiat"  at  least, 
of  the  nervous  influences  endlessly  "draining"  out 
of  and  into  the  different  blossoming  flower-beds, 
so  to  say,  of  the  brain  (the  efflorescence  in  this 
metaphor  standing  of  course  for  conscious  or  sub- 
conscious associations).  It  has  been  hinted  above 
that  feelings  and  volitions  as  well  as  ideas,  associate. 
Certainly  feelings  and  volitions  combine  with  every 
idea  neurally  if  not  consciously  and  partake  of  their 
reactions,  helping  indeed  to  determine  them  by  virtue 
of  their  impelling  motivity  which  cold  ideas  largely 
lack. 

In  general,  then,  we  would  broaden  out  the  neurology 
of  association  like  the  term  itself,  to  include  the  actual 
conditions  of  brain  action  unemasculated  and  un- 
artificialized  by  academic  analysis  and  abstraction. 
What  we  seek  in  the  strife  after  the  true  basis  of 
human  efficiency  is  not  the  "laws"  of  the  association 
of  ideas  merely,  but  much  rather  the  conditions  of 
those  kinetic  associations  and  reactions  of  which 
the  relations  of  concepts  are  an  aspect,  but  which 
include  factors  quite  as  important,  namely,  those 
we  speak  of  as  volitions  and  affective  tones.  These 
are  allied  to  the  impulse,  to  activity  and  there  through 
to  the  basal  metabolism  of  the  central  nervous  system. 


733 


Association 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


To  study  the  association  of  ideas  with  these  influences 
or  guides  ignored,  is  certainly  to  be  wandering  in  a 
ring.  George  V.  N.  Dearborn. 

Assouan. — See  Egypt. 

Astasia-Abasia. — This  is  a  name  given  by  Charcot  to 
define  certain  types  of  gait  characterized  by  loss  of 
coordination  power  (astasia)  with  reference  to  walk- 
ing (abasia).  The  phenomenon  had  been  known 
many  years  before  Charcot  (Blocq)  gave  it  a  definite 
nosological  position.  The  early  French  authors 
established  a  paralytic  and  an  ataxic  type.  In  the 
paralytic  type  the  patients  are  usually  unable  to 
rise  from  their  beds;  tneir  limbs  are  usually  drawn  up, 
and  in  rare  instances  contractures  develop.  Some 
are  apparently  unable  to  make  any  progressive  move- 
ments of  their  limbs.  They  have  lost  all  movement 
memories.  In  others  the  trouble  is  less  pronounced. 
Again  in  others  the  paralysis  alternates  with  periods 
of  complete  power — all  grades  of  power  are  observed 
in  these  patients,  with  a  constant  variation.  A  weak, 
bed-ridden  astasic-abasic  will  suddenly  rise  from  the 
couch  to  look  at  a  parade  going  by,  or  to  answer  a 
telephone  if  no  one  responds.  All  the  rest  of  the  time 
she  must  be  wheeled  about  or  carried. 

Patients  of  the  ataxic  type  try  to  get  about,  but 
the  Jesuits  are  often  painful  in  the  extreme.  The 
grade  of  incoordination  is  marked. 

The  essential  feature  in  astasia-abasia  is  an  hyster- 
ical mechanism;  either  a  pure  hysteria,  or  the  conver- 
sion mechanism  of  an  anxiety  neurosis,  a  compul- 
sion neurosis  or  a  psychosis — principally  dementia 
praecox.  Existing  in  the  course  of  an  anxiety  neuro- 
sis, an  hysteria,  or  a  compulsion  neurosis,  it  is  usually 
susceptible  of  cure  by  psychanalysis.  Certain  astasic- 
abasic  syndromes  are  readily  cured.  They  are  super- 
ficial conversion  phenomena,  and  may  be  dissipated 
by  cold  water,  a  faradic  brush,  or  by  persuasion. 
Others,  however,  require  continuous  psychanalysis 
of  the  most  intricate  character. 

Smith  Elt  Jelliffe. 


Astereognosis. — Apparently  a  simple  matter,  in 
reality  astereognosis,  meaning  in  short  the  inability 
to  recognize  objects  by  the  sense  of  touch,  is  an 
extremely  complex  affair.  Vouters  who  has  given 
us  the  latest  monograph  entitled  "Tactile  Agnosia," 
devoted  200  pages  to  it.  Astereognosis,  in  the  more 
limited  sense  simply  means  inability  to  recognize  the 
form  of  an  object.  Tactile  agnosia  is  the  better 
term  in  clinical  medicine,  since,  after  all,  the  tests 
usually  revolve  about  the  recognition  of  an  object, 
the  question  of  the  form  being  but  one  constituent. 
Tactile  agnosia  then  may  depend  upon  a  number  of 
factors:  (a)  There  may  be  loss  of  touch  receptivity, 
such  as  is  found  for  instance  in  a  neuritis,  toxic  or 
traumatic;  (6)  the  memories  of  the  surfaces  touched, 
i.e.  the  motor  memories,  the  sensory  memories, 
may  be  interfered  with;  (c)  the  association  of  the 
object  with  other  gnostic  forms  of  perception  may  be 
impossible. 

Liepmann  would  exclude  the  first  category  entirely 
from  the  agnosias.  Depending  as  they  do  upon  the 
tactile  organ,  they  constitute  a  perceptive  agnosia. 
They  are  analogous  to  blindness  for  optical  impres- 
sion, or  deafness  for  auditory  stimuli.  In  practice 
it  is  essential  to  bear  this  distinction  in  mind,  al- 
though the  rough  and  ready  methods  usually  em- 
ployed to  test  touch  recognition  are  not  adapted  to 
obviate  this  source  of  fallacy.  Head's  methods 
alone  will  prevent  the  errors  which  one  finds  strewn 
about  in  the  literature. 

For  this  reason  it  is  preferred  to  retain  here  the 
agnosias  of  sensory  perception,  depending  solely  upon 
peripheral  loss,  which  technically  of  course  are  anes- 
thesias.    This  is  not  the  place  to  discuss  the  impor- 

734 


tance  of  our  touch  perception  in  building  up  our  cor 
cepts  of  the  world  of  things.  The  most  superfici; 
attention  must  show  how  vast  is  the  symbolism  c 
touch  in  our  mental  processes,  especially  in  connei 
tion  with  the  gradual  use  of  speech  symbols.  Th 
intricacies  of  this  analysis  have  introduced  a  hos 
of  conflicting  and  overlapping  synonyms  now  i 
use.  Vouters  in  the  monograph  quoted  speak 
of  objective  agnosias  and  verbal  agnosias;  the  forme 
are  the  true  agnosias,  the  latter  the  aphasias.  Tli 
former  may  be  separated  into  the  true  agnosias  an 
the  secondary  agnosias  or  asymbolias.  Of  th 
former  he  recognizes  a  collective  agnosia,  and  a 
agnosia  of  elaboration,  either  optic,  acoustic,  <_ 
tactile,  giving  rise  to  either  a  peripheral,  spina 
intercentral,  or  cortical  blindness,  deafness,  or  ane> 
thesia.  These  are  the  true  agnosias.  The  asyn 
bolias  consist  of  psychic  deafness,  psychic  blindnes- 
or  psychic  anesthesia.  All  of  these  some  author 
have  called  astereognoses. 

True   tactile   agnosia  may   depend   upon  at 
three  factors:   (a)  loss  of  motor  power  of  the  palpatin 
hand   which   is    seen    frequently   in   hemiplegia,   to 
instance,   (b)  loss  of  sensibility,  and  (c)  loss  of  sen 
sibility  without  any  recognizable  loss  of  motion. 

In  the  first  instance,  the  importance  of  contrac 
tures  is  often  extremely  important,  for  even  witl 
some  loss  of  sensibility  unimpaired  motion  has  quii. 
independent  gnostic  perceiving  qualities.  Loss  o 
touch  sensibility  may  be  due  to  impairment  am 
where  in  the  touch  sensibility  pathway  to  the  thai 
amus  and  thence  to  the  cortex.  The  peripheral 
spinal,  and  thalamic  type  of  touch  sensibility  ha 
been  elaborated  most  carefully  by  Head  and  need  no 
be  entered  into  here.     (See  Anesthesia  and  Analgesi 

Cortical  touch  differs  greatly  in  its  disturbance 
from  other  forms  in  spite  of  the  fact  that  Dgjerim 
has  maintained  that  thalamic  tactile  loss  and  cor- 
tical tactile  loss  could  not  be  separated.  The  wori 
of  Head  and  Holmes  points  in  an  entirely  different 
direction. 

Head,  in  particular,  has  shown  that  the  ordinary, 
sensation  of  touch  is  by  no  means  a  unit.     Tour 
resolvable    into    several    entities    or  groups.     Tin- 
groups  have  special  receptors  and  probably  spe 
pathways.     These  pathways  occupy  certain  relative 
positions  in  the  peripheral  nerves,   the  spinal  cot 
the  mid-brain,  the  thalamus,  and  the  cortex.     These 
relations    undergo    certain    definite    regroupings    in 
different  parts  of  the  nervous  system  so  that  certain 
pathways  common  to  two  or  more  modes  of  sensi- 
bility in  one  place  shift  their  position,  dissociations 
occur,  and  hence  one  is  able  to  pick  out  at  differi 
levels  certain  variations  in  touch  sensibility  due  to 
these  altered  or  rearranged  pathway  groupings. 

Thus  in  the  analysis  of  tactile  agnosias  a  distinct 
step  in  advance  has  been  made,  and  on  the  strength 
of  Head's  findings  an  exact  topographical  localiza- 
tion is  possible  in  the  successive  levels  to  the  cortex. 

Within  the  peripheral  neurone  all  of  the  set 
bility  fibers  are  gathered  in  one  bundle.  A  se 
peripheral  lesion  therefore  should,  other  things  being 
equal,  annihilate  all  the  modalities  of  sensation, 
epicritic  touch,  protopathic  touch,  epicritic  and  pro 
topathic  heat  and  cold,  pain,  and  deep  sensibility, 
When  such  a  program  occurs,  the  peripheral  nature 
of  a  tactile  agnosia  is  certain,  and  no  other  localiza- 
tion is  possible  to  explain  the  tactile  agnosia. 

Within  the  cord  a  rearrangement  takes  place.  All 
pain  pathways  are  collected;  heat  and  cold  path- 
ways separate  and  may  be  independently  involved. 
The  familiar  dissociation  of  pain,  heat,  and  eold 
from  the  epicritic  touch  is  seen  in  intramedull 
lesions — syringomyelia,  hematomyelia,  cysts,  tu- 
mors, etc.;  these  are  well  known  clinical  syndromes 
in  which  this  dissociation  takes  place.  Tactile  agno- 
sia from  spinal  cord  lesions,  therefore,  has  its  special 
accompanying  differentials  of  certain  value. 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Asthenia 


On  passing  into  the  thalamus,  a  regrouping  of  the 
.  tsory  pathways  again  takes  place  and  those  under- 
jng  tactile   recognition   of   object    qualities   again 

■liny   new   relations.      A   thalamic  syndrome   arises 

,m  lesions  here  with  its  well  recognized  association. 

;i>  briefly  consists  of  a  persistent  loss  of  superficial 

isation  in  one-half  of  the  body  and  face.     This  loss 

touch,  pain,  and  temperature  is  more  or  less  defi- 

quI   the  loss  of  deep  sensibility,  postural  sense, 

,v  sensibility  is  always  more  pronounced.      There 

slight  hemiataxia  and  tactile  gnostic  loss  with  ac- 

;,,,  .  on  the  affected  side.     There  may  be  slight 

,i,,r  iietniplegie  weakness  and   choreoid  or  atheto- 

ivements   in   the   limb   on   the   affected    side. 

Ive  ei ional  response  to  stimulation  of  the 

esthetic  side  is  a  special  feature  brought  out  by 

ad  Holmes. 

finally,  in  cortical  sensory  loss,  the  whole  picture 

Primary    sensibility   becomes    related.     The 

cortex  is  the  organ  by  which  attention  may 

focussed  on  any  part  of  the  body  that  is  stimulated. 

nies  of  response  to  sensory  stimuli  unknown 

r  levels  are  found   in  cortical   lesions.     The 

BT  the  area  affected  between  the  precentral  fissure 

occipital  lobe,  the  more  certainly  will  sensi- 

bow  these  characteristic  changes. 

iccuracy  of  response  to  measured  tactile  stim- 

gradually    reduced.     The     answers     become 

jrular  and  uncertain.     Contact  sensibility  is  not 

it.     Tactile  sensations  tend  to  persist,  and  almost 

hallucinate."     Fatigue  comes  on  readily.     Estima- 

oti  of  warmth  and  cold  suffers,  if  the  thermal  sen- 

bility  has  suffered.     Tests  for  recognition  of  pos- 

e,  of  passive  movement,  and  spatial  discrimina- 

bow  profound  loss. 

Further  detail  of  these  important  researches  must 

consulted   in   the  original  studies  (see  also  Anes- 

■nd  Analgesia).    Enough  has  been  said  to  show 

e    main  outlines  of   differentiation  of   localization 

lesions  causing  tactile  agnosia. 

\-ymbolia  is  due  to  a  purely  cortical  lesion  in 
Inch  the  angular  gyrus  is  very  often  involved. 

Smith  Ely  Jelliffe. 


Asterol. — Para-sulpho-phenol  mercurv  and  ammo- 
ium  tartrate— C1,HI0OsS2Hg.4C4H1O8(NH4)2+8H!O. 
his  is  a  preparation  claimed  by  its  manufacturers 
i  contain  fifteen  per  cent,  of  mercury,  to  have 
iss  action  on  metals  than  other  mercury  com- 
ounds,  and  to  precipitate  albumin  to  only  a  small 
egree.  Steinmann's  investigations  have  sustained 
claims,  and  he  states  that  1  to  10  per  cent, 
ilutions  of  albumin  are  precipitated  by  0.1  per  cent, 
ilution  of  mercuric  chloride,  while  they  are  made 
nly  slightly  opalescent  by  a  solution  of  asterol  of  the 
ame  strength.  Vertun  has  questioned  the  claims 
f  the  manufacturers,  stating  that  he  found  only 
leven  per  cent,  of  mercury,  and  that  it  would  attack 
urgical  instruments  and  precipitate  albumin.  As- 
erol  is  a  brown  powder,  slowly  soluble  in  cold  water, 
nd  rapidly  soluble  in  hot  water  with  the  formation 
f  a  permanent  solution.  It  is  used  as  an  antiseptic 
ubstitute  for  mercuric  chloride  in  0.1  to  4  per 
cnt.  aqueous  solution.  Such  a  solution  of  0.7  per 
cut.  strength  is  equivalent  in  antiseptic  power  to  a 
1.1  per  cent,  solution  of  mercuric  chloride. 

W.   A.   Bastedo. 


Asthenia. — This  term  (meaning  without  strength, 
lebility,  weakness,  loss  of  power)  was  used  by  Brown 
n  1780  for  general  weakness  or  prostration,  and 
inployed  by  him  in  his  theory  of  disease.  He  sought 
he  cause  of  all  disease  in  a  departure  from  a  mean 
>r  medium  degree  of  excitability  or  irritability,  either 
n  an  increase  above  the  normal  mean  (sthenic  or 
lyperslhenic  disease),  or  in  a  decrease   (asthenic  dis- 


ease). Asthenology  is,  therefore,  the  theory  of  asthenia 
diseases  according  to  Brown's  conceptions;  astheno- 
macrobiotic,  the  art  of  prolonging  an  asthenic  life. 
Some  survival  of  these  views  is  found  at  the  pre 

in  our  use  of  sthenic  and  asl  henic  as  applied  to  levers. 
Asthenic  fiver  (adynamic  or  torpid  fever)  is  one 
characterized  by  extreme  weakness  and  prostration, 
dulled  sensorium,  small,  weak  and  frequent  pulse, 
weak  heart,  and  low  blood  pressure.  In  sthenic  fever, 
on  the  other  hand,  these  characteristics  are  absent, 
the  pulse  is  full  and  bounding,  arterial  pressure  high, 

and  the  patient  excited  and  active.  In  modern 
medicine    these    terms    have    bul    little   significance 

beyond  describing  the  patient's  condition,  or  the 
degree  of  toxemia  (asthenic  fever  in  septicemia, 
pyemia,  typhoid  fever,  severe  variola,  diphtheria, 
pneumonia,  scarlatina,  meningitis,  acute  tubercu- 
losis, etc.);  they  are  not  in  any  sense  diagnostic  or 
used  with  reference  to  the  nature  of  the  disease. 
The  present  generation  uses  these  terms  more  and 
more  seldom,  and  they  arc  employed  almost  wholly 
by  older  medical  men. 

Still  more  nearly  obsolete  is  Yirchow's  classifica- 
tion of  inflammations  as  sthenic  and  asthenic.  His 
idea  of  a  sthenic  inflammation  as  a  pure  form  under 
favorable  circumstances  and  conditions,  and  of  an 
asthenic  inflammation  as  one  occurring  in  weakened 
parts  or  bodies,  is  entirely  out  of  harmony  with  our 
present  conceptions  of  inflammation,  and  has  no 
longer  any  practical  value,  so  that  these  designations 
are  now  rarely  employed. 

In  the  sense  of  weakness  or  impaired  strength,  asthe- 
nia has  gained  a  wide  use  as  a  general  term;  and  in 
combinations,  such  as  myasthenia,  neurasthi  raid,  ■psych- 
asthenia,  etc.,  is  used  to  designate  certain  special  forms 
of  weakness.  By  some  neurologists  motor  asthenia  is 
used  as  a  synonym  for  paralysis.  Internists  apply 
asthenia  to  any  marked  weakness,  but  particularly 
to  the  loss  of  energy  and  extreme  weakness  seen  in 
Addison's  disease.  In  the  majority  of  cases  of  this 
condition  the  first  symptom  is  an  unusual  tendency 
to  fatigue  from  either  physical  or  mental  exertion. 
So  marked  is  this  symptom,  even  before  any  other 
sign  of  the  disease  develops,  that  any  severe 
asthenia  should  always  excite  a  suspicion  of  Addison's 
disease.  Asthenia,  in  the  sense  of  a  motor  insuffi- 
ciency characterized  by  difficulty  or  impossibility  of 
prolonged  muscular  effort,  is  a  symptom  found  in 
the  beginning,  course,  or  decline  of  a  number  of 
diseases,  particularly  in  affections  of  the  abdominal 
organs,  certain  nervous  diseases,  disorders  of  the 
cerebello-sympathetic  system,  etc.  In  these  condi- 
tions the  asthenia  is  symptomatic  and  secondary. 

A  primary  constitutional  asthenia  dependent  upon 
a  congenital  weakness  of  the  cerebello-sympathetic 
system  has  within  recent  years  been  described  by  a 
number  of  writers  (Londe,  etc.).  This  condition  mani- 
fest itself  at  different  ages  as  a  difficulty  or  impossi- 
bility for  prolonged  or  repeated  muscular  effort.  In 
infants  the  crying  is  feeble,  sucking  movements  slow 
and  weak,  the  stomach  empties  itself  slowly,  and 
constipation  is  the  rule.  Such  infants  show  a  lowered 
resistance  to  colds  and  infections,  and  especially  to 
gastrointestinal  intoxications.  Dentition  is  slow, 
and  accompanied  by  gastrointestinal  disturbances. 
All  muscular  movements  are  slow  and  learned  with 
difficulty.  Walking  is  not  acquired  until  in  the 
second  year.  The  child  is  feeble ;  its  motor  apparatus 
is  capable  of  only  a  small  amount  of  work. 

During  adolescence  the  asthenic  shows  his  constitu- 
tional weakness  in  many  ways  (amyosthenia,  diges- 
tive disturbances,  familial,  orthostatic  or  cyclic 
albuminuria,  cardiac  weakness,  various  functional 
disorders,  cerebral  dullness,  apathy,  etc.,  inconti- 
nence of  urine,  chorea,  scoliosis,  etc.).  In  the  female 
disorders  of  menstruation,  migraine,  membranous 
enteritis,  vomiting  of  pregnancy',  etc.,  are  to  be 
regarded   as   signs   of  a   weaker   organism.     Gastro- 


735 


Asthenia 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


enteroptosis  is  an  especial  feature  of  constitutional 
asthenia.  The  adult  asthenic  knows  his  weakness, 
and  is  either  pessimistic  or  attempts  to  conceal  it. 
The  abuse  of  coffee,  alcohol,  and  other  stimulants  is 
common  to  these  asthenic  individuals.  Drug  habits 
often  result  from  the  attempt  to  mask  the  condition. 
The  adult  asthenic  is  also  especially  susceptible  to 
intoxications,  autointoxications,  and  infections.  Ac- 
cording to  the  conditions  of  existence  and  predis- 
position the  effects  of  constitutional  asthenia  are 
shown  at  certain  times  in  one  or  another  organ. 
Periodical  attacks  of  migraine,  dyspepsia,  jaundice, 
grippe,  bradycardia,  uremia,  etc.,  are  the  results  of 
a  digestive  or  nervous  insufficiency.  Chronic  inter- 
stitial nephritis  is  of  frequent  occurrence  in  the 
asthenic.  Slowness  characterizes  all  vital  move- 
ments, mental  as  well  as  physical.  The  asthenic 
does  not  care  for  active  sports,  and  is  incapable  of 
planning  far  ahead.  His  faculty  of  adaptation  is 
limited.  Not  all  asthenics  may  be  recognized  by 
their  slow  reactions  or  apathy,  since  their  asthenia 
may  be  wholly  relative.  The  asthenic  who  recog- 
nizes his  weakness  may  defy  it.  and  with  a  strong 
will-power  compensate  for  it.  This  compensation  by 
means  of  the  will  may,  however,  be  suddenly  broken 
by  some  shock,  and  the  asthenia  increased.  From 
neurasthenia  the  condition  is  differentiated  by  the 
ability  of  the  asthenic  to  compensate  for  his  inferior 
organism  by  means  of  his  will-power.  In  the  as- 
thenic, failure  of  memory  or  attention,  or  of  judgment 
is  the  result  of  fatigue.  Hypochondria  does  not 
characterize  the  asthenic.  Sexual  power  is  not  lost 
in  asthenia  as  it  so  often  is  in  neurasthenia;  it  requires 
only  conservation,  excess  is  impossible.  The  diag- 
nosis of  primary  constitutional  asthenia  rests  upon 
the  history  of  a  delicate  infancy  and  signs  of  asthenia 
in  adolescence,  the  necessity  for  rest,  the  inability  to 
commit  excess,  and  the  frequent  attacks  of  illness 
during  adult  life  and  old  age. 

Stiller's  publication  in  1907  of  his  monograph  on 
"  Die  asthenische  Konstitutionskrankheit"  gave  to 
asthenia  a  much  more  specific  significance,  inasmuch 
as  he  makes  Glenard's  disease  (enteroptosis)  one  of 
the  most  prominent  features  of  constitutional  asthenia. 
Tuffier  (Scmainc  Medicate,  1894)  had  previously 
expressed  the  view  that  enteroptosis  was  a  feature 
of  a  general  disease  characterized  by  an  alteration 
of  all  tissues,  "a  congenital  insufficiency  of  the 
tissues";  and  in  1899,  Strauss  (Berliner  klinische 
Wochenschr.,  1S99)  also  spoke  of  constitutional  forms 
of  ptoses.  Stiller's  especial  service  has  been  in  giving 
a  broader  view  to  the  conception  of  enteroptosis, 
considering  this  condition,  not  as  the  result  of  local 
mechanical  factors,  but  as  a  feature  in  a  constitu- 
tional peculiarity  characterized  by  a  definite  type  of 
body,  the  habitus  asthenicus.  The  chief  features  of 
this  are  a  slender  skeleton,  slight  panniculus,  slight 
musculature,  pale  skin,  flat  and  narrow  thorax, 
narrow  thoracic  aperture,  narrow  epigastric  angle, 
floating  tenth  ribs,  prominent  abdomen,  ptosis  of 
stomach  and  colon,  low  or  floating  kidney,  small 
heart,  perpendicular  position  of  heart,  and  tendency 
to  hemorrhoids  and  varices.  Hausmann  ( Wiener 
klin.  Wochenschr.,  1909,  Bd.  22,  109S)  considers  the 
following  anatomical  peculiarities  to  be  constitutional 
signs  of  morbus  asthenicus: 

1.  Pylorus  palpabilis — pylorus  mobilis. 

2.  Deep-lying  greater  curvature. 

3.  Deep-lying  transverse  colon. 

4.  Cecum  mobile. 

5.  Flexus  mobilis. 

6.  Low  umbilicus. 

7.  Floating  tenth  rib. 

With  the  anatomical  peculiarities  of  asthenia 
universalis  congenita  go  hyperesthesias  and  lability 
of  the  nervous  system,  muscular  weakness,  gastric 
disorders    (atony,  nervous    dyspepsia,    hyperacidity, 

736 


spastic  obstipation,  gastric  ulcer,  etc.).  Stiller 
views  of  the  constitutional  nature  of  enteroptos 
have  been  opposed  by  some  gynecologists,  an 
accepted  by  others.  It  remains  to  be  seen,  howeve 
whether  his  asthenia  universalis  congenita  can  \ 
given  a  distinct  nosological  position.  The  relatic 
to  rachitis  and  infantilism  is  not  yet  worked  ou 
Strauss  (Berl.  klin.  Woch.,  1910,  Bd.  47,  S.  20' 
regards  the  habitus  asthenicus  as  a  result  of  disturbe 
development  related  to  infantilism  (habitus  infm 
tilis).  The  condition  is  not  found  in  infants,  he  i> 
lieves,  but  develops  during  adolescence,  and  is  moi 
frequent  in  females.  As  to  the  treatment  he  coi 
siders  preventive  measures  the  only  ones  likely  to  I 
of  value.  Both  operative  and  orthopedic  procedun 
often  fail.  If  the  enteroptosis  and  floating  kidnc 
are  but  single  features  of  a  constitutional  anomah 
operations  are  not  likely  to  offer  much  relief,  and  tl 
experience  of  many  operators  bears  this  out.  Nep] 
ropexy  is  considered  useless  by  some  writers.  ] 
should  be  borne  in  mind  that  some  of  these  ea 
habitus  asthenicus  have  been  operated  upon  U 
chronic  appendicitis  without  relief.  Gynecologist 
are  divided  in  their  views  as  to  the  value  of  operation 

As  etiological  factors  there  have  been  suggeste 
too  frequent  and  too  close  pregnancies  on  the  par 
of  the  mother,  rachitis,  thyroid  insufficiency,  an 
other  forms  of  autointoxication;  but  no  causal  nlj 
tionship  has  yet  been  demonstrated.  Further  stud 
is  needed  to  clear  up  the  matter  of  eonstitutiona 
asthenia  and  its  nosological  position  can  hardly  bi 
regarded  as  a  settled  one. 

The  prognosis  in  constitutional  asthenia  depend 
largely  upon  the  will-power  of  the  asthenic.  Hi 
cannot  change  his  constitutional  anomaly,  but  recog 
nizing  it,  he  may  rise  above  it,  and  by  conservatii 
of  his  powers  live  as  long  and  accomplish  as  much  ai 
the  average  normal  individual  who  does  not  have  i 
concern  himself  with  conservation  of  his  functions 
Some  asthenics  show  a  high  plane  of  moral  elevati.., 
General  hygiene,  and  especially  mental  and  mora 
hygiene,  are  the  chief  factors  by  which  congenital  oi 
acquired  constitutional  asthenia  may  be  foughl 
The  education  of  the  asthenic  child  should  be  eon 
ducted  along  especial  lines,  and  in  this  respect  shouk 
be  begun  as  early  as  possible. 

Aldred  Scott  Warthi.v 


Asthenopia   (from     cuiQivb-:,  weak,  and  &<f<,  eye)  is 
the  name  proposed  by  Mackenzie  (1843)  to  designi 
a  complex  of  symptoms  constituting  so-called  mi 
ness   of  sight.     "  By   asthenopia   is   understood   that 
state  of  vision  in  which  the  eyes  are  unable  to  sust 
continued  exercise  upon  near   objects   although  the 
patient    upon   first  viewing  such    objects    generally 
sees  them  distinctly,  can  employ  his  sight  for  any 
length  of  time  in  viewing  distant  objects,  and  presents 
no  external  appearance  of  disease  in  his  eyes.    .    . 
In   the  open  air  the  patient   makes   no  complaint, 
being   able    to    discern   distant   objects   clearly   and 

without   fatigue In   reading,  sewing,  and 

the  like,  he  is  obliged,  partly  from  the  confusion 
which  seems  to  spread  over  the  objects,  partly  from 
a   feeling   of  fatigue  in   the  eyes,    to   interrupt    the 

exertion A  very   short   period  of  rest  is 

in  general  sufficient  to  recruit  the  sight,  so  that  the 
power  of  perceiving  small  objects  returns  and  the 
patient  is  in  a  condition  to  resume  his  employment 

When  near  objects  fade  away,  as  it  were, 

from  the  asthenopic  sight,  some  patients  feel  it  a 
sufficient  relief  to  turn  their  attention  to  remote 
objects,  which  they  continue  to  see  perfectly:  others 
find  remote  objects  also  to  appear  confused,  and 
require  to  shade  their  eyes  till  the  attack  wears  off. 
The  most  complete  relief  is  in  all  cases  obtained  by 

shutting    the    eyes Asthenopia   is   rarely 

observed  to  commence  in  those  who  have  already 


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Asthenopia 


iched  the  middle  period  of  life,  but  almost  exclu- 

,[\   takes  its  origin  in  childhood  or  youth.       .    .    . 

|w  patients,  not  even  those  who  arc  mere  children, 

,  itiniie  to  ho  Ions;  affected  with  asthenopia  without 

iking    use    of    convex    glasses A    child 

,1    in    learning    its    lesson    complains    thai    it 

,nol  gee,  and  repeats  the  complaint  so  frequently, 

,  „'(i:illv  by  candle-light,  that  his  father  or  grand- 

a"t    last    says.    'Try    my    glasses.'      The    child 

v    sees  perfect  ly.  ami  night   after  night   the  loan  of 

glasses  is  required  before  t  he  task  can  be  finished." 

complete  the  picture  drawn    by   Mackenzie   it   is 

cessary  to  add  that  the  young  asthenope  sees 

at    a    distance    through    the    convex    glasses 

,  li   make   it   easy  for  him   to  read,  and   that   he 

only   to  wear  convex   glasses,   of  the  greatest 

compatible  with  distinct  vision  at  a  distance, 

relieved  definitively  of  his  asthenopia. 

\,i  allusion   to  asthenopia  is  to   be  found   in   the 

J  writings  of  antiquity.     Taylor  (1760)  sketched 

symptoms  in  a  few  lines  under  the  name  "debili- 

vi-as."     Scarpa   (1807)    makes  passing   mention 

.  it  as  "incomplete  amaurosis,"  remarking,  however, 

it  it  is.  "properly  speaking,  not  so  much  an  amau- 

B  weakness  of  sight  from  fatigue  of  the  nerves, 

!  especially  of  those  which  constitute  the  imme- 

.  ite  organ  of  vision,"  i.e.    of    the  optic  nerve  or 

■.a.     Several  later  writers  on  the  diseases  of  the 

■  have  given  excellent  descriptions  of  asthenopia, 

t   still   confounding  it    with   amblyopia  or  amau- 

m,  of  which  it  was  thought  to  be  an  early  stage, 

.  d,    therefore,    the   precursor   of   blindness.     Grad- 

iv  ir  came  to  be  recognized  that  asthenopia,  even 

■  many  years'  duration,  does  not  result  in  actual 

pairment  of  vision;  and  it  was  regarded  for  a  time 

.  a  condition  of  "morbid  sensibility  of  the  retina." 

inewhat  later  it  was  remarked  that  the  dominant 

niptoms  are  distinctively  those  of  muscular  fatigue; 

rich  was  attributed  to  weakness  of  one  or  more  of 

e  exterior  muscles  of  the  eyeball.     Still  later,  with 

rdy  acceptance  of  the  proofs  of  an  active  accommo- 

tive  adjustment  in  near  vision,  it  was  thought  to 

dependent  on  weakness  of  that  function;  and  was 

issea   with    so-called    presbyopic  vision    in    young 

Finally  through  the  demonstration  of  the 

ichanism  of  accommodation,  and  the  investigation 

its  relation  to  convergence  as  affected  by  errors  of 

fraction,  the  way  was  opened  for  the  recognition 

the  true  cause  of  asthenopia  in  overloading  of  the 

commodation  incident  to  the  displacement  of  the 

gion  of  accommodation  in  hypermetropia.     (Don- 

858.) 
Hypermetropia  may  be  defined  as  a  structural 
iomaly  in  which  the  refractive  power  of  the  eye,  in 
state  of  rest,  is  insufficient  to  focus  parallel  rays 
ion  the  retina.  In  very  high  grades  of  hyperme- 
opia,  the  total  accommodative  power  of  the  eye 
bsolute  range  of  accommodation)  may  be  inade- 
uite  to  meet  the  requirements  of  distinct  vision 
en  at  a  distance,  and  the  condition  may  then 
■ar  a  superficial  resemblance  to  amblyopia.  In 
'permetropia  of  medium  or  low  grade  there  is  ordi- 
irily  developed  a  state  of  increased  accommodative 
nsion  under  which  the  adjustment  for  distance,  and 
■  ..  ■■■'  ■■-  i<  if  the  near  also,  is  maintained  without 
mscious  effort.  In  other  cases,  little  or  no  incon- 
'nience  is  felt  in  distant  vision;  but  prolonged  exer- 
se  of  the  accommodation  in  reading  or  other  near 
ork  is  attended  with  fatigue,  and  blurring  of  sight, 
itigue  in  near  work  does  not,  however,  imply  a 
strlcted  range  of  accommodation;  as  is  shown  by 
le  fact  that,  a  young  hypermctrope  with  convergent 
rabismus,  in  which  condition  the  crossed  eye  takes 
i  part  in  the  visual  act,  is  seldom  conscious  of 
ouble  in  reading  at  even  less  than  the  ordinary 
stance.  The  determining  cause  of  asthenopia  is  in 
•■  conflict  between  accommodation  and  conver- 
?nce,  under  which  an  excessive  demand  is  made  on 


the  accommodation  in  the  effort   to  maintain  distinct 

vision  at  the  distance  of  the  point  of  intersection  of 
the  \  isual  axes. 

Asthenopia  may  be  defined,  then,  as  the  expres  rion 

of  relative  insufficiency  of  accommodation  under 
normal  convergence,  in  binocular  vision.  (See 
Accommodation  and  Refraction.) 

Astigmatism  may   be  either  the  determining  or  an 

aecc    in\    cat f  asthenopia.     Thus  in  simple  or 

compound  hypermetropic  astigmatism  or  in  mixed 
astigmatism,  when  the  ocular  meridian  of  least  re- 
fraction is  horizontal  or  approximately  horizontal, 
the  hypermetropia  in  this  meridian  may  give  rise  to 
displacement  of  tin-  region  of  accommodation,  as  in 
simple  hypermetropia.  But  astigmatism  connotes 
also  defective  definition,  which  may  lead  to  a  notable 
shortening  of  the  reading  distance;  and  for  this 
reason  the  disability  may  be  greater  than  in  uncom- 
plicated hypermetropia  of  the  same  or  even  a  higher 
grade.  Hence  it  is  often  more  important  to  correct 
an  existing  astigmatism,  by  convex  cylindrical  gla  ■ 
than  a  hypermetropia  of  the  same  grade,  by  convex 
spherical  glasses.      (See  Astigmatism.) 

The  clinical  picture  of  asthenopia,  as  drawn  by 
Mackenzie  and  interpreted  by  Donders,  is  often 
obscured  by  the  operation  of  concurrent  causes 
other  than  displacement  of  the  region  of  accommoda- 
tion. Disability  from  habitual  forcing  of  the  accom- 
modation in  near  work  or  in  reading  during  convales- 
cence from  exhausting  illness — formally  designated 
as  "asthenopia  ex  hyperopsia,"  or  as  "asthenopia 
ex  anopsia,"  is  oftenest  the  expression  of  acquired 
weakness  of  accommodation  in  a  hypermetropic 
subject.  Paresis  of  accommodation  with  dilated 
pupils,  induced  by  the  use  or  abuse  of  mydriatic 
collyria  or  of  internal  remedies  containing  belladonna 
or  hyoscyamus,  and  paresis  of  accommodation  with 
undilated  pupils,  in  diphtheria,  may  give  rise  to 
asthenopia  in  the  strict  derivative  sense  of  the  word, 
which  in  a  middle-aged  hypermetrope  may  persist 
as  premature  old  sight  or,  in  a  younger  hypermetrope, 
as  typical  asthenopia. 

A  condition  of  hyperesthesia,  with  over-sensitive- 
ness to  bright  light  and  discomfort  or  pain  in  or  about 
the  eyes,  is  not  infrequently  developed  in  persons 
of  neurotic  temperament.  Use  of  the  eyes  in  near 
work  brings  on  headache,  dizziness,  nausea,  or  other 
reflex  nervous  symptoms;  the  headache  often  per- 
sisting for  many  hours,  or  until  relief  comes  with 
sleep.  In  these  cases,  conveniently  designated  as 
neurasthenic,  the  correction  of  an  error  of  refraction 
(hypermetropia,  anisometropia^  astigmatism),  of  so 
low  a  grade  as  ordinarily  to  be  regarded  as  negligible, 
may  afford  relief  seemingly  disproportionate  to  the 
means  employed.  Continuous  wearing  of  appropriate 
spectacles,  and  carefully  regulated  exercise  of  the 
eyes  in  reading  for  a  prescribed  number  of  minutes 
at  a  time,  should  be  strictly  enforced;  with  tentative 
progressive  increase  in  the  length  and  frequency  of 
the  reading  sessions  as  the  patient  gains  in  confidence 
and  the  eyes  develop  increased  capacity  for  work.1 

Ocular  hyperesthesia,  with  disabling  supra-ciliary 
or  frontal  headache,  has  been  recognized  by  Ewing 
as  the  frequent  accompaniment  of  acute  or  chronic 
affections  of  the  frontal  sinuses,  of  which  sensitive- 
ness to  pressure  made  against  the  roof  of  the  orbit 
at  the  site  or  to  the  nasal  side  of  the  pulley  of  the 
superior  oblique  tendon  is  a  distinctive  diagnostic 
sign.  Sluder,  in  collaboration  with  Ewing,  found  the 
cause  of  the  affection  in  occlusion  of  the  opening  of 
the  sinus  into  the  nose,  and  showed  the  way  to  its 
successful    treatment.2 

A  special  type  of  reflex  ocular  hyperesthesia  has 
been  described  by  Forster  as  eopiopia  hysterica  (from 
KOTriaui,  to  grow  weary,  and  &>p,  eye).  This  affection 
stands  in  close  relation  to  parametritis,  and  is  rebel- 
lious to  all  therapeutic  measures  directed  to  the  eyes; 
its  course  is  extremely  tedious,  but  recovery  generally 


Vol.  I.— 17 


737 


Asthenopia 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


takes  place  when  the  pelvic  disease  has  been  arrested 
or  has  run  its  course. 

Muscular  Asthenopia. — As  in  hypermetropia,  with 
accurate  covergence,  the  accommodation  is  forced 
to  perform  its  work  at  a  disadvantage,  so  in  myopia 
the  habitual  relaxation  of  the  accommodation  in  near 
vision  may  be  attended  with  disabling  inhibition  of 
convergence. 

Fatigue  of  the  recti  interni  muscles  was  recognized 
by  Scarpa  (1807)  in  some  cases  of  asthenopic  vision, 
but  the  recognition  of  muscular  asthenopia  as  a 
distinct  type  was  possible  only  after  the  demonstra- 
tion of  the  interrelation  of  accommodation  and  con- 
vergence as  affected  by  errors  of  refraction. 

The  name  "asthenopia  muscularis"  was  given  by 
von  Graefe  to  the  complex  of  asthenopic  symptoms 
in  which  muscular  fatigue  gives  way  to  crossed 
double  vision,  in  near  work.  Myopia  was  recognized 
as  an  important  etiological  factor;  but  equal  or  greater 
stress  was  laid  on  contributory  insufficiency  of  the 
recti  interni  muscles  and  the  indications  for  prescrib- 
ing prismatic-concave  glasses,  or  for  neutralizing  the 
relative  preponderance  of  the  recti  externi  muscles 
by  tenotomy. 

The  clinical  observations  of  von  Graefe,  and  the 
study  of  myopia  from  the  anatomical  and  physio- 
logical stand-point,  by  Donders,  proved  that  as  over- 
loading of  the  accommodation  in  hypermetropia  is 
the  predominating  cause  of  accommodative  astheno- 
pia, and  of  convergent  strabismus,  so  relaxation  of  the 
accommodation  in  myopia  is  a  principal  cause  of 
muscular  asthenopia,   and  of  divergent  strabismus. 

As  accommodative  asthenopia  is  the  expression  of 
relative  insufficiency  of  accommodation  under  normal 
convergence,  so  muscular  asthenopia  is  the  expression 
of  relative  insufficiency  of  convergence  under  relaxed 
accommodation. 

Treatment. — As  regards  the  curability  of  astheno- 
pia opposite  opinions  have  prevailed  at  different 
times.  So  long  as  it  was  supposed  to  be  a  form  of 
amblyopia,  the  prognosis  was  unfavorable.  When 
it  had  come  to  be  regarded  as  the  expression  of  "morbid 
sensibility  of  the  retina,"  so-called  derivative  med- 
ication, local  abstraction  of  blood  by  cupping  or 
leeching,  counterirritation  above  the  eyebrows, 
blisters  or  setons  in  front  of  or  behind  the  ears  or  at 
the  back  of  the  neck,  and  protection  from  strong 
light  by  green  or  blue  glasses  were  thought  to  be 
curative.  Reading  or  other  near  work  was  forbidden, 
and  out-door  life  enjoined.  In  obstinate  cases  the 
sufferer  was  advised  to  "live  on  a  farm,"  or  to  "go 
to  sea,"  in  the  hope  of  benefit  from  prolonged  rest  of 
the  eyes. 

The  fact  that  many  asthenopes  discover  for  them- 
selves that  convex  glasses  are  helpful  in  reading  was 
known  to  physicians  long  before  they  ventured  to 
prescribe  them  for  young  persons.  Later,  when 
asthenopia  was  explained  as  a  special  form  of  presby- 
opia occurring  in  childhood  or  youth,  it  was  thought 
that  the  guarded  use  of  convex  glasses  might  be  per- 
mitted in  near  work,  but  the  very  idea  of  a  young 
person  wearing  glasses  "strong  enough  for  his  grand- 
father" was  regarded  with  horror,  as  fraught  with 
untold  danger.  Hence  convex  glasses  were  pre- 
scribed of  the  least  power  compatible  with  fairly  easy 
use  of  the  eyes,  with  a  view  to  changing  them  for 
progressively  weaker  glasses  and  ultimately  to  doing 
without  them.  That  this  plan  of  treatment  was  not 
altogether  irrational  is  evident  from  the  experience 
of  the  very  large  number  of  young  hypermetropes 
who  are  able  to  use  their  eyes  freely  in  prolonged 
near  work;  a  fact  entirely  in  accordance  with  the 
observation  of  Donders,  that,  with  parallel  visual 
axes  and  also  under  moderate  convergence,  a  hyper- 
metrope  ordinarily  brings  into  use  much  more  of 
his  accommodation  than  does  an  emmetrope  under 
like   conditions.     Moreover,   it  is  not  uncommon  for 


asthenopic  symptoms,  occurring  in  connection  wit] 
hypermetropia  of  moderate  grade,  to  disappear  aftc 
a  few  weeks  or  months  of  relief  from  strain  affordei 
by  the  use  of  weak  convex  glasses  in  reading  am 
study.  In  these  cases  the  glasses  give  great  relic 
when  first  worn,  but  after  a  time  the  need  of  then 
comes  to  be  less  urgently  felt,  so  that  the  child  be 
gins  to  do  without  them  and  at  last  forgets  to  us 
them  at  all.  But  these  cures,  however  satisfactor 
they  may  be  for  the  time  being,  are  apt  to  be  foi 
lowed  by  relapses,  which,  again,  may  yield  to  a  ne\ 
course  of  treatment  by  glasses,  until,  with  increasin 
age  and  the  physiological  limitation  of  the  rang 
of  accommodation,  the  habitual  use  of  con\c. 
glasses  becomes  imperative. 

Asthenopia  may  be  treated  with  some  measure  o 
success  by  the  methodical  use  of  myotics.  In  hi 
original  study  of  the  action  of  Calabar  bean 
Donders  observed  that  the  range  of  accommodatioi 
is  positively  increased,  and  that  this  incret 
which  is  greatest  after  about  two  hours,  dimin 
ishes  rather  slowly.  He  observed,  also,  a  materia 
increase  in  accommodation  as  related  to  con 
vergence,  amounting  to  rather  more  than  ().; 
dioptrie  eleven  hours  after  the  instillation;  and  In 
makes  the  very  significant  remark  that  "hyperme 
tropes,  under  the  double  advantage  of  smaller  circle 
of  diffusion  and  of  easier  tension  of  accommodation 
lose  for  a  time  their  asthenopia."3  The  introductioi 
of  pilocarpine  in  ophthalmic  therapeutics  has  made  i 
practicable  to  maintain  a  condition  of  mild  stimula 
tion  of  the  accommodation  for  an  almost  indofiniti 
period.  In  cases  of  asthenopia  in  young  perso 
with  hypermetropia  of  low  grade,  pilocarpine  may  bi 
employed  in  a  weak  solution,  instilling  any  desirec 
fraction  of  a  minim  measured  by  means  of  a  slendei 
glass  pipette.  The  treatment  may  be  begun  with  i 
two  per  cent,  solution,  used  night  and  morning,  am 
the  observed  effect  regulated  by  varying  the  quantity 
used  or  the  strength  of  the  solution.  In  this  way  it 
is  sometimes  possible  to  tide  over  an  intercurrent 
asthenopia  in  a  young  hypermetrope,  and  in  some 
cases  to  postpone  recourse  to  glasses  perhaps  foi 
years. 

In  asthenopia  dependent  on  hypermetropia  of  high 
grade,  the  only  effective  resource  is  in  the  use  of  oo 
vex  glasses,  and  these  should  be,  as  a  rule,  of  the  highest 
power  compatible  with  distinct  vision  at  a  distance 
Owing  to  the  fact  that  a  part  of  the  hypermetropia 
is  almost  always  latent  (see  Hypermetropia),  fully 
correcting  (neutralizing)  glasses  often  prove  less 
acceptable  in  the  beginning  than  those  of  less  power, 
but  in  every  case  the  selection  of  glasses  should  be 
made  with  distinct  reference  to  the  total  hyperme- 
tropia, and  in  the  expectation  of  ultimately  applying 
the  full  correction.  In  a  few  cases  of  asthenopia,  in 
which  any  exercise  of  the  accommodation  is  attended 
with  pain  or  fatigue,  a  bifocal  combination  of  a 
neutralizing  convex  glass  for  distance  with  a  stronger 
correction  for  reading  may  be  indicated.  In  still 
rarer  cases,  in  which  the  attempt  to  read  indu 
accommodative  spasm,  it  may  be  necessary  to  ha 
recourse  to  atropine,  to  assure  complete  physiolog- 
ical rest.  During  the  maintenance  of  the  mydriasis 
reading  may  be  permitted  with  the  aid  of  strong  ci 
vex  glasses,  which  must  be  exchanged  for  neutraliz- 
ing glasses  when  the  accommodation  is  allowed  to 
resume  its  function.  A  young  hypermetrope  who 
requires  convex  glasses  for  reading  sees  perfectly  at  a 
distance  with  the  same  glasses,  and,  as  a  rule,  finds  it 
convenient  and  agreeable  to  wear  them  constantly; 
but  in  this  he  may  generally  be  permitted  to  follow 
his  own  pleasure.  If  for  any  reason  he  is  disinclined 
to  wear  glasses  constantly,  a  compromise  may  often 
be  effected  by  prescribing  spectacles  for  reading  or 
study,  and  a  pince-nez  for  occasional  use. 

In    muscular    asthenopia    the    treatment   consists 
primarily  in  the  correction  of  the  myopia,  together 


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Asthma 


itli  any  astigmatism  that  may  be  present,  by  means 

■  neutralizing  concave  spherical,  spherico-cylindrical, 
•  toric  glasses.  The  glasses  should,  as  a  rule,  be 
iounted  in  a  spectacle  frame  rather  than  as  a  pince- 

and   they   should   be   worn   continuously.     The 

lief  afforded  by   neutralizing  glasses  is  generally 

imediate  and  complete,  but  in  a  few  cases  it  may 

>sary  to  prescribe  stronger    concave   glasses 

hich,  by  over-correcting  the   myopia,  compel  some 

of  the  accommodation  in  distant  vision  and 

immensurately   increased  accommodation   in   near 

ork.     This  over-correction,  which  may  be  carried 

.  high  as  three  or  even  four  dioptries  in  children  or  in 

nine  adults  with  ample  range  of  accommodation,  is 

, |, •fully   accepted,   and  appears  not    to  be  attended 

ith  the' danger  commonly  attributed  to  the  wearing 

irons  concave  glasses  by  myopes. 

lei  ■.■Titration  of  concave  glasses   outward,   or, 

amounts  to  the  same  thing,   the  grinding  of 

spherical  or  spherical  and  cylindrical  surfaces 

1  convergent  prisms,  is  often  of  advantage  by  cor- 

■ctlng   the    refractive  error   and   at  the  same  time 

vine  some  measure  of  direct  relief  to  the  recti  interni 

In  the  higher  grades  of  relative  muscular 

[sufficiency,   division  of  the  tendon  of    the    rectus 

cternus  muscle  in  one  eye  or  in  both  eyes  may  be 

i  id,     but    operative    interference     should    be 

insidered  only  after  an  exhaustive  investigation  of 

ich  particular  case,  and  a  full  trial  of  other  methods. 

In  the  treatment  of  asthenopia,  whether  accommo- 

utive  or  muscular,  the  principal,  and  oftenest  the 

ngle  indication  is  to  correst  the  underlying  error  of 

■fraction     (hypermetropia,     myopia,     astigmatism, 

lisometropia)  by  giving  neutralizing  glasses  (convex, 

mcave,   cylindrical,   or  of   different   power  for   the 

vo  eyes).     A  practically  normal  relation  of  accommo- 

ition  to  convergence  is  thus  established,  and,  except 

i  progressive  myopia,  the  same  optical  connection 

iffices  until,  with  beginning  presbyopia,  other  glasses 

■    required    in    reading,   (see    Accommodation    and 

fraction,     Astigmatism,     Hypermetropia,     Myopia, 

esbyopia).  John  Green. 

1.  E.  Dyer:  Transactions    of    the  American  Ophthalmological 

■  ii-ty,  1S65. 

_  \.  E.  Ewing  and  G.  Sluder:  Transactions  of  the  American 
phthalmological  Society,  1900. 

3.  F.  C.  Donders:  On  the  Anomalies  of  Accommodation  and 
efraction  of  the  Eye,  1864. 


Asthma. — This  disease  well  illustrates  the  harm 
hich  may  follow-  upon  interference  with  normal 
■ivsiological  habits.  The  most  uniform  habit  in  the 
nly  is  that  of  the  succession  of  expiration  upon  the 
id  of  inspiration  without  a  pause  between  the  two 
ts.  Xow  all  coughing  interferes  with  the  act  of 
tpiration.  Prolonged  coughing,  therefore,  is  one 
the  commonest  causes  of  asthma,  as  it  is  shown  by 
te  frequent  supervention  of  asthma  upon  measles 
id  whooping  cough  in  childhood,  the  formative 
■riod  in  life  of  physiological  habits.  These  habits 
re  organized  in  the  respiratory  centers  of  the  medulla 
ilongata,  so  as  to  produce  a  perfectly  rhythmical 
ving  of  the  pendulum,  so  to  speak,  in  the  act  of 
reathing.  But  anything  which  interferes  with  the 
ivthinical  succession  of  expiration  upon  the  end  of 
ispiration  will  itself  sooner  or  later  become  a  morbid 
ahit  of  checked  or  prolonged  expiration.  Now 
nighing  does  this  because  it  is  exclusively  an  expira- 
)ry  act. 

This  derangement  of  the  rhythm  in  the  function  of 
le  medullary  centers  may  sooner  or  later  originate 
titer  morbid  habits  excited  by  afferent  stimuli,  which 
ould  not  have  any  such  effect  in  previously  healthy 
ersons;  hence  those  curiously  varied  excitants  of 
le  asthmatic  paroxysm  in  chronic  asthmatics, 
ometimes  a  simple  mental  impression  in  such 
atients    may    induce    an    attack.     At   other    times 


afferent  impressions  starting  from  the  nose  as  the 
mosl  sensitive  part  of  the  breathing  apparatus  will 

bring  on   fits  of  dyspnea  from   certain  odor     mch   B 
the    smell    of    violets,   or    of    animal    I  iiianat  ions,    like 

those  from  cats  or  horses,  or  bj  avi  it  to  a  menagerie. 
As  might  be  expected,  therefore,  di  ea  e  conditions 
in  the  nose  itself,  such  as  nasal  polypi,  may  be  the 
cause,  and  will  be  relieved  only  by  suitable  attention 
to  conditions  of  the  nose.  But  this  morbid  excitabil- 
ity to  afferent  impressions  may  become  widely 
spread,  so  as  to  be  induced  through  those  branches 
of  the  pneumogastrie  nerve  which  supply  the  organs 
of  digest  ion,  thus  giving  origin  to  w  hat  is  called  peptic 
asthma.  Afferent  excitations  from  other  parts  of  the 
body  rarely  have  anything  to  do  with  asthma, 
because  those  parts  have  no  connection  with  breath- 
ing. Asthma,  therefore,  may  be  properly  termed  a 
pure  neurosis  involving  the  respiratory  centers,  while 
all  changes  of  an  anatomical  kind  in  the  bronchi  or 
in  the  air  vesicles  are  simply  secondary  in  their 
nature.  Asthma-like  paroxysms  may  be  caused  by 
blood  poisons,  such  as  in  gout  and  in  uremia,  but 
these  can  be  readily  distinguished  and  treated  apart 
from  the  functional  nervous  symptoms  which  accom- 
pany them.  There  is  one  normal  change,  however, 
which  occurs  in  breathing  during  sleep,  which  may 
affect  the  respiratory  rhythm  in  asthma.  In  sleep, 
particularly  if  it  is  profound,  the  breathing  is  much 
slower  than  in  the  waking  state,  with  a  prolonged 
inspiration  and  a  shortened  expiration,  the  opposite 
of  the  breathing  in  asthma.  But  as  this  itself  is 
unnatural,  so  it  is  a  frequent  cause  of  asthmatic 
attacks  at  that  time,  the  patients  often  beginning  to 
breathe  asthmatically  even  before  they  wake. 

The  dyspnea  in  a  developed  attack  of  asthma  is 
so  great  that  if  it  happened  in  any  other  disease 
would  denote  actual  peril  to  life.  In  asthma,  how- 
ever, though  the  distress  be  great,  alarm  is  signifi- 
cantly absent  from  the  patient,  which  it  is  not  in 
asthma-like  paroxysms  due  to  such  blood  poisoning 
as  in  uremia. 

Symptoms. — The  leading  symptom  of  asthma  is  a 
marked  difficulty  limited  to  the  act  of  expiration. 
Unlike  croup,  asthma  allows  the  air  to  enter  readily 
with  inspiration,  but  the  expiration  is  labored 
throughout,  rendering  this  act  two  to  four  times  the 
length  of  the  inspiration.  This  disproportionate 
expiration  is  characteristic,  for  though  the  expiration 
is  prolonged  in  emphysema,  yet  it  never  equals  the 
delay  of  asthma.  The  patients  dread,  therefore,  the 
most  ordinary  acts  which  entail  a  prolongation  of 
expiration,  such  as  coughing,  or  even  speaking,  though 
in  some,  laughing  of  itself  is  sufficient  to  induce  an 
attack,  while  on  the  other  hand  a  deep  inspiration 
may  serve  to  break  the  paroxysm. 

No  consideration  of  this  subject  would  be  complete 
without  alluding  to  the  supervention  of  asthma  in 
chronic  bronchitis.  Many  cases  of  chronic  bronchitis 
end  in  time  in  the  condition  which  differs  but  little 
from  true  asthma,  but  the  practical  point  is  that  if 
you  cure  the  bronchitis,  you  cure  the  asthma.  These 
cases  from  their  long  standing  are  apt  to  cause  enlarge- 
ment of  the  right  side  of  the  heart,  with  regurgitation 
into  the  great  venous  vessels  to  such  a  degree  as  to 
cause  general  dropsy,  beginning  like  other  forms  of 
cardiac  dropsy  in  the  feet.  Like  other  asthmatics 
they  can  scarcely  undergo  any  muscular  exertion, 
such  as  rising  from  bed,  without  bringing  on  severe 
coughing  along  with  asthmatic  breathing.  These 
cases,  therefore,  ought  to  be  called  examples  of 
asthmatic  bronchitis,  the  bronchitis  being  the  chief 
factor  in  the  general  derangement.  They  ought, 
therefore,  to  be  treated  as  cases  of  bronchitis  and  not 
of  asthma. 

Owing  to  this  impeded  exit  the  residual  air  increases 
in  the  lungs  to  such  an  extent  that  the  intercostal 
spaces  become  much  widened  and  the  girth  of  the 

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chest  so  expanded  that  the  ordinarily  worn  clothes 
of  the  patient  will  not  come  together  by  from  one  to 
three  inches.  The  upper  abdomen  also  becomes 
similarly  distended  by  the  forced  descent  of  the 
diaphragm  pushing  down  the  liver,  stomach,  and 
spleen.  The  walls  of  the  chest  finally  seem  too  fixed 
to  allow  of  any  but  the  slightest  expansion  and 
retraction  in  breathing,  and  this  condition  gives  to  the 
patient  a  sense  of  suffocative  tightness,  as  if  caused  by 
some  external  compression.  Salter  notes  also,  as  a 
frequent  symptom,  a  persistent  itching  of  the  chin, 
and  often  between  the  shoulder  blades  and  sternum 
as  well,  supervening  with  the  first  symptoms  of 
asthmatic  breathing  and  passing  off  with  the  full 
development  of  the  paroxysm. 

Diagnosis. — Physical  exploration  of  the  chest  now 
affords  a  group  of  characteristic  symptoms  which 
render  the  diagnosis  of  asthma  a  matter  of  no  great 
difficulty.  The  lung  distention  exaggerates  the 
pulmonary  resonance  on  percussion  and  extends  its 
area  in  every  direction,  behind  the  clavicles,  over  the 
heart,  and  downward  over  the  regions  of  normal 
splenic  and  hepatic  dulness.  From  the  same  cause 
the  vocal  fremitus  either  disappears  or  is  much 
diminished  in  those  localities  where  it  is  well  marked 
in  health.  Auscultation,  however,  is  the  most  decisive 
in  its  indications,  for  the  normal  vesicular  murmur  is 
quite  displaced  by  high-pitched  sibilant  rales,  which 
often  attract  the  attention  of  bystanders,  as  they 
become  audible  to  some  distance  from  the  patient. 
On  applying  the  ear  to  the  chest,  however,  one 
distinguishes  very  fine  rales,  mingled  with  others 
larger  and  graver  in  tone,  which,  moreover,  seem 
to  shift  in  location  as  if  sometimes  near  to  the  ear, 
and  then  farther  off,  like  a  wavy  passage  of  air  over 
various  musical  tubes.  In  simple  asthma  these  rales 
are  purely  sibilant,  but  in  prolonged  attacks,  or  when 
bronchitis  is  also  present,  they  become  more  or  less 
crackling. 

As  the  disordered  respiration  continues,  the  suffer- 
ings of  the  patient  for  breath  become  extreme. 
His  whole  frame  partakes  in  the  struggle  for  air, 
which  leads  him  involuntarily  to  try  to  expand  the 
chest  yet  more  and  more.  He  strives  to  make 
immovable  his  back,  shoulders,  and  head,  so  that 
from  them  the  accessory  muscles  of  respiration  may 
pull  upon  the  already  tense  walls  of  the  thorax. 
Hence  he  fixes  his  arms  or  plants  his  elbows  on  a 
table  or  other  support,  while  his  head  is  thrown  back, 
his  mouth  panting,  his  eyes  widely  opened  and  fixed, 
and  his  face  pale  and  bedewed  with  perspiration.  He 
speaks  only  in  monosyllables,  and  resents  everything 
which  calls  him  off,  even  for  a  moment,  from  his 
efforts  to  breathe.  The  pulse  grows  small  and  feeble, 
and  the  patient  becomes  so  cyanotic  and  cold  that  his 
wet,  clammy  skin  and  ghastly  expression  are  apt  to 
inspire  strangers  with  fear  of  his  near  dissolution. 

The  duration  of  an  attack  varies  greatly,  not  only 
in  different  patients,  but  in  the  same  patient  at  differ- 
ent times.  The  attack  may  come  on  in  the  night  and 
pass  off  soon  after  daylight,  or  it  may  be  prolonged 
into  a  series  of  exacerbations  and  incomplete  remis- 
sions for  several  successive  days  and  nights,  until  the 
sufferer  becomes  almost  fatally  exhausted.  In  like 
manner  the  subsidence  bears  little  relation  to  the 
severity  or  duration  of  the  attack.  Either  as  the 
effect  of  remedies  or  spontaneously,  the  breathing 
may  become  suddenly  easier,  the  rigidity  of  the  chest 
walls  pass  off,  the  inspirations  grow  fuller  and  the 
expirations  shorter,  and  the  patient,  who  but  a  few 
moments  before  seemed  about  to  perish  in  his  distress, 
will  soon  return,  after  a  moderate  expectoration  of  a 
clear  frothy  mucus,  to  regular  and  natural  breathing, 
with  no  other  indication  of  his  recent  sufferings  than 
an  expression  of  fatigue.  At  other  times,  especially 
if  bronchitis  supervenes,  the  attack  passes  off  in  a 
series  of  irregular  paroxysms  of  difficult  breathing, 


alternating  with  coughing  and  free  expectoration. 
In  many  fully  developed  attacks,  however,  the 
patient  has  carefully  to  watch  for  its  decline  by  avoid- 
ing all  causes  of  exacerbation  or  relapse,  especially 
from  eating,  so  that  some  asthmatics  are  obliged  to 
go  to  bed  fasting  if  they  are  to  pass  that  night  free 
from  dyspnea. 

Etiology. — In  asthma,  as  in  other  markedly  spas- 
modic diseases,  the  afferent  impression  which  induces 
the  attacks  varies  indefinitely,  both  in  kind  and  in 
seat.  The  sensory  nerves,  however,  which  are 
distributed  to  the  mucous  membrane  of  the  respira- 
tory tract,  including  the  olfactories,  afford  the  most 
frequent  instances  of  the  curious  impressibility  which 
excites  refiexly  the  asthmatic  spasm.  On  this 
account  bronchitis  itself  takes  the  lead,  for  asthmatic 
breathing  occurs  in  so  large  a  proportion  of  both 
acute  and  chronic  forms  of  this  affection  that  some 
writers  have  gone  the  length  of  ascribing  all  asthmas 
to  bronchitis.  It  is  easy  to  show,  however,  that 
asthma  lacks  no  element  of  a  true  neurosis,  and  that 
in  many  typical  cases  there  is  no  bronchitis  whatever. 
In  the  initial  or  "dry"  stage  of  acute  bronchitis, 
along  with  the  sense  of  soreness  and  tightness  across 
the  chest,  auscultation  reveals  the  presence  of  true 
asthmatic  wheezing,  while  in  chronic  bronchitis 
asthmatic  attacks  often  occur  upon  very  slight 
provocations,  such  as  by  rising  too  suddenly,  or  from 
attempting  too  long  a  sentence  in  talking. 

After  the  irritation  of  bronchitis,  the  list  of  excitants 
of  asthma  which  take  their  start  from  the  sensory 
nerves  of  the  respiratory  mucous  membrane  varies  in 
a  most  extraordinary  degree.  Nearly  every  asthmatic 
has  his  specialty  of  the  kind,  so  to  speak,  often  with 
a  most  unaccountable  caprice  of  choice.  The  writer 
has  known  of  a  gentleman  who,  while  in  his  room  on 
an  upper  floor,  yet  could  tell  at  once  by  his  breathing 
that  buckwheat  flour  had  just  been  brought  into  the 
house.  The  smell  of  powdered  ipecacuanha  is  often 
mentioned  as  a  similar  excitant,  but  although  this 
may  be  ascribed  to  irritation  by  minute  particles  of 
ipecac  inhaled — and  the  like  may  be  said  of  asthma 
from  the  inhalation  of  mustard  or  of  the  fumes  of  a 
sulphur  match — yet  such  an  explanation  cannot 
hold  good  in  asthma  caused  by  the  smell  of  violets  or 
of  other  fragrant  flowers.  In  fact  nothing  can  be 
more  whimsical  than  the  behavior  of  asthma  as 
regards  either  what  may  be  resented  as  an  ingredi- 
ent of  the  air  inspired,  or  simply  the  general  char- 
acter of  the  outer  atmosphere.  One  asthmatic  may 
find  comfort  in  the  air  of  a  particular  locality  which 
another  asthmatic  can  enter  only  at  his  peril.  Salter 
mentions  the  instance  of  two  friends  who  could  not 
exchange  visits  at  their  country  houses,  which  were  on 
opposite  sides  of  a  ridge,  though  both  were  suited 
with  the  air  of  London.  The  air  of  large  cities,  in 
fact,  despite  its  smoke  and  dust,  agrees  oftener  with 
asthmatics  than  does  the  pure  air  of  the  country. 

Next  to  the  respiratory  tract,  the  most  frequent 
excitants  of  asthmatic  attacks  proceed  from  the 
alimentary  canal,  especially  from  its  gastroduodenal 
portion.  Most  asthmatics,  indeed,  are  also  dyspep- 
tics, and  are  thus  doubly  obliged  to  be  particular  in 
their  dietary.  The  list  of  forbidden  articles  is 
singularly  varied,  as  we  might  expect  from  the  range 
in  this  respect  among  dyspeptics  as  a  class.  Some 
will  have  asthma  if  they  take  cheese,  others  almonds, 
others  apples  or  wine  or  tea  or  tobacco,  etc.;  the 
peculiarity  being  that  the  particular  idiosyncrasy  is 
generally  consistently  adhered  to,  perhaps  for  many 
years,  or  at  least  as  long  as  natural  tastes  or  likings 
are  apt  to  last.  With  many  patients,  however,  it  is 
not  so  much  a  particular  article  which  brings  on  a 
paroxysm,  but  a  too  hearty  meal  for  them  of  any 
kind.  On  the  other  hand,  constipation  is  the  sure 
provocative  with  some  who  are  also  often  promptly 
relieved  by  a  cathartic.     In  women,  uterine  derange- 


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Asthma 


merits  have  their  share  in  1 1 1 « ■  causation  of  asthma, 
though  not  as  frequently  as  they  serve  t<>  excite  ot  her 
spasmodic  diseases ;  while  a  certain  proportion  remains 
whose  attacks  seem  to  be  induced  solely  by  mental 
excitement,  particularly  of  a  depressing  kind. 

Among  the  special  predisposing  causes  of  asthmatic 

seizures  is  the  stale  of  sleep,  for  the  majority  of 
distinct  attacks  set  in  after  the  patient  lias  been 
asleep  for  some  time,  and  oftenest  during  the  hours  of 
profound  slumber,  after  midnight,  tin  that  account 
the  majority  of  attacks  occur  after  the  patient  has 
been  asleep  for  some  time.  Most  asthmatics,  there- 
fore, have  to  take  their  heartiest  meal  about  noon, 
and  not  dine  in  the  evening.  Some  asthmatics  are 
obliged  to  keep  awake  after  noting  certain  of  their 
usual  premonitory  signs',  or  the  attack  will  surely 
develop  if  they  happen  to  sleep  at  all.  The  relation 
of  sleep  to  the  attacks  is  also  well  illustrated  in  peptic 
asthma,  for  though  the  offending  article  of  diet  be 
taken  in  the  morning,  yet  it  will  not  be  until  its 
customary  hour  in  the  night  that  the  asthma  which 
it  induces  will  come  on.  This  chronometry  of  asthma 
exemplifies  the  real  but  unperceived  continuousness 
of  the  spasmodic  nervous  diseases,  in  all  of  which  the 
outbreaks  are  sudden  only  in  the  manifestation  of 
certain  symptoms,  and  which  mere  symptoms,  like 
spasm,  etc.,  are  therefore  too  often  mistaken  for  the 
whole  disease.  The  reasons  which  have  been  adduced 
by  various  writers  for  this  nocturnal  feature  of 
asthma,  as  in  the  analogous  instance  of  nocturnal 
epilepsy,  are  too  hypothetical  to  call  for  extended 
discussion.  It  is  interesting,  however,  to  note  that 
the  mere  fact  of  darkness  seems  to  dispose  to  the 
attacks.  Not  a  few  patients  can  prevent  them  by 
keeping  a  light  burning  brightly  in  their  rooms, 
while  if  the  light  be  put  out  they  will  soon  wake  up 
with  difficult  breathing. 

Asthmatic  dyspnea  is  also  occasionally  secondary 
to  other  diseases  or  morbid  states,  in  which  case  it 
ranks  only  as  a  symptom  of  them.  Thus,  in  heart 
disease,  particularly  in  mitral  stenosis,  the  widespread 
congestion  of  the  bronchial  mucous  membrane  may 
excite  real  asthmatic  symptoms,  which,  moreover, 
should  not  be  confounded  with  true  cardiac  dyspnea. 
In  the  latter,  the  patient  resembles  one  who  is  out  of 
breath  from  muscular  exercise,  as  after  running,  but 
cardiac  asthma,  properly  speaking,  shows  the  same 
derangement  of  expiration  as  ordinary  asthma,  and  is 
evidently  due  to  the  bronchial  hyperemia  acting  as  a 
reflex  excitant.  Toxemia  also  sometimes  produces 
asthmatic  attacks,  especially  in  gout  and  in  uremia. 
In  the  gouty  cases  the  attacks  are  sudden,  nocturnal, 
and  quickly  accompanied  by  a  great  bronchial  flux, 
which  may  be  pinkish  from  capillar}7  hemorrhage. 
A  patient  of  mine  once  expectorated  two  large  basinfuls 
of  such  mucus  between  midnight  and  morning,  but 
after  three  such  attacks  they  ceased  and  never  recurred 
afterward.  In  gouty  asthma  alarm  is  wholly  absent, 
but  not  so  in  uremic  asthma.  Here  again,  as  in  the 
cardiac  cases,  the  dyspnea  should  not  be  mistaken 
for  asthma,  if  it  be  due,  as  it  commonly  is,  to  pul- 
monary edema  or  to  pleuritic  effusion.  True  uremic 
asthma  is  characterized  by  sudden  attacks  of  difficult 
breathing  with  great  terror,  and  often  also  with  severe 
palpitation  of  the  heart,  which  is  usually  much  hyper- 
trophied  from  the  arterial  obstruction  of  chronic 
renal  disease.  After  a  few  attacks,  if  not  after  the 
first  one,  the  breathing  remains  permanently  short- 
ened, and  the  patient  dreads  the  slightest  cause  of  car- 
diac excitement.  In  most  cases  uremic  asthma  is  a 
late,  and  not  a  favorable  symptom  of  chronic  Bright's 
disease,  particularly  of  interstitial  nephritis,  and  it  is 
commonly  associated  with  abundant  light-colored 
urine  of  low  specific  gravity,  with  or  without  albumin, 
and  with  evidence  of  general  endarteritis  as  illustrated 
by  the  tortuous  and  rigid  temporal  and  radial  arteries. 
In  one  case,  however,  seen  by  me  in  consultation,  the 
kidney  affection  seemed  to  follow  the  asthma  rather 


than  to  precede  it.  The  patient,  a  gentleman  about 
fifty  years  of  age,  was  suddenly  seized,  while  appar- 
ently in  perfect  health,  with  extreme  dyspnea.  His 
physician  on  arrival  tested  his  urine  and  found  it 
heavily  loaded  with  albumin.  This  albumin,  how- 
ever, wholly  disappeared  in  a  few  days,  until  after  a 
fortnight,  when  he  had  another  exactly  similar 
seizure,  also  in  the  daytime.  The  interesting  circum- 
stance connected  with  the  second  seizure  was  that  he 
had  sent  a  specimen  of  urine,  passed  only  an  hour 
before  the  attack,  to  be  examined,  and  it  was  found 
to  be  wholly  free  from  albumin  and  of  normal  specific 
gravity;  but  some  tested  immediately  after  the 
seizure  set  in  became  nearly  solid  on  boiling.  This 
observation  of  the  reappearance  of  albumin  only  at. 
the  attacks,  with  its  gradual  but  ultimately  final 
disappearance  until  another  fit  of  dyspnea  arrived, 
was  repeated  a  number  of  times,  once  by  myself,  as 
daily  examinations  of  his  water  were  kept  up.  He 
finally  succumbed,  some  months  later,  to  extensive 
effusions  in  both  pleura?. 

Asthmatic  attacks  are  also  sometimes  plainly 
associated  with  the  disappearance  of  chronic  skin 
eruptions.  A  patient  of  mine  always  became  asth- 
matic whenever  an  old  eczema  of  the  chest  began  to 
subside,  until  he  found  that  he  could  rid  himself  of 
the  infliction  by  an  artificially  induced  eczema  with 
croton  oil. 

Age. — Asthma  may  begin  at  any  age.  An  intelli- 
gent patient  of  mine,  seventy  years  old,  stated  that 
the  disease  was  observed  in  him  on  the  first  day  of  his 
life.  There  is,  however,  a  special  proclivity  to  it  in 
the  first  decennial,  owing  to  the  predisposition  of 
children  to  bronchitis.  Of  225  cases,  Salter  had 
seventy-one  under  ten,  and  in  eleven  of  them  it  began 
in  the  first  year.  The  prognosis  of  asthma  is  better  in 
childhood  than  later  on,  as  it  is  frequently  outgrown 
after  puberty,  particularly  if  the  causes  of  bronchitis 
be  carefully  avoided.  The  cases  which  begin  in 
adolescence  are  relatively  few,  and  are  then  gen- 
erally of  the  purely  spasmodic  form.  But  in  middle 
life  the  proclivity  to  asthma  again  increases  with  the 
greater  exposure  from  outdoor  occupations,  but,  un- 
like bronchitis,  asthma  as  a  new  disease  begins  to  fall 
off,  and  progressively  decreases  in  its  ratio  till  seventy. 
The  common  impression  that  asthma  is  a  disease  of 
old  age  is  a  mistake,  arising  rather  naturally  from 
the  frequency  of  chronic  bronchitis  with  asthmatic 
wheezing  among  elderly  persons. 

Sex. — The  influence  of  sex  is  considerable,  the 
preponderance  of  males  being  about  double  that  of 
females.  That  this,  however,  is  due  to  the  greater 
exposure  of  men  to  causes  of  bronchitis,  is  shown  by 
the  fact  that  the  cases  of  the  pure  spasmodic  variety 
are  about  equally  divided  between  the  sexes. 

Heredity. — Asthma  belongs  also  to  the  markedly 
hereditary  diseases,  as  might  be  expected  from  the 
characters  of  its  common  accompaniments.  An 
inherited  proclivity  to  bronchitis  is  observable  as 
often  as  a  family  tendency  to  phthisis,  while  neuroses, 
on  the  other  hand,  are  more  frequently  of  constitu- 
tional origin  than  any  other  class  of  affections. 
About  thirty-five  per  cent,  of  all  asthmatics,  there- 
fore, will  show  some  sign  of  heredity,  and  oftener 
from  the  paternal  than  from  the  maternal  side — a 
fact,  moreover,  in  keeping  with  the  greater  frequency 
of  the  disease  among  men. 

Pathology. — Asthma  has  no  characteristic  ana- 
tomical lesions.  That  extensive  pathological  altera- 
tions are  often  found  postmortem  is  quite  true,  but 
in  most  cases  they  are  caused  by  intercurrent  affec- 
tions, particularly  by  bronchitis.  Under  this  head 
come  hypertrophy  of  the  circular  muscular  fibers, 
with  consequent  narrowing  of  the  bronchioles,  it  may 
be  even  to  occlusion,  collapse  of  lobules,  emphysema, 
and  dilatation  of  the  right  side  of  the  heart,  with  the 
various  sequela;   of  these  conditions.     But  there  are 


(41 


Asthma 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


some  organic  alterations  which  may  be  ascribed  to 
the  labored  respiration  of  asthma  alone,  when  severe 
and  prolonged  attacks  come  so  often  that  the  parts 
have  no  opportunity  to  return  to  their  normal  state 
during  the  intervals.  That  this  is  the  occasion  of  such 
changes  appears  from  their  complete  absence  in  those 
patients  who  have  perfect  intermissions  between  the 
attacks.  The  first  of  these  effects  is  dilatation  of  the 
right  heart,  caused  by  long  labor  in  the  difficult 
propulsion  of  blood  through  the  lungs  so  soon  as 
apnea  occurs  in  any  form.  During  a  paroxysm  of 
asthma,  the  left  heart  and  the  systemic  arteries  are 
relatively  empty  and  the  pulse  is  small,  while  the 
systemic  venous  system  from  the  right  auricle  back- 
ward is  everywhere  overloaded.  The  heart  beat  is 
then  found,  not  under  the  nipple,  but  in  the  scrobicu- 
lus  cordis;  partly,  it  is  true,  from  the  displacement 
caused  by  the  dilated  left  lung,  but  equally  also  from 
the  distention  of  the  right  ventricle.  Another  con- 
stant result  is  emphysema,  or  permanent  overdisten- 
tion  of  the  air  vesicles,  caused  by  the  progressive 
accumulation  of  the  residual  air  from  the  imperfect 
expiration.  Emphysema  may  thus  be  found  in  old 
asthmatics,  whether  they  have  had  chronic  bronchitis 
or  not.  Lastly,  from  the  combined  derangement  of 
the  pulmonary  circulation  caused  by  the  intermittent 
apnea  and  the  permanent  emphysema,  we  have 
a  tendency  to  bronchial  flux  to  relieve  the  congested 
vessels,  which  finally  adds  chronic  inflammation  to 
chronic  hyperemia,  and  thus  establishes  the  vicious 
circle  of  impeded  circulation  causing  bronchitis,  and 
bronchitis  in  turn  causing  progressive  circulatory 
impediment. 

These  slowly  induced  effects  finally  produce  those 
changes  of  personal  appearance  which  mark  old 
asthmatics.  As  the  general  nutrition  suffers  from 
the  persistent  congestion  of  the  liver  caused  by  the 
impeded  outflow  of  the  right  heart,  these  patients  are 
usually  thin,  pale,  or  cyanotic,  and  with  deficient 
muscular  power.  The  eyes  are  prominent  and 
watery,  the  voice  is  weak,  the  gait  slow  and  measured, 
and  the  back  rounded,  often  to  great  deformity.  The 
head,  however,  is  always  thrown  back  between  the 
elevated  shoulders,  and  the  trunk  of  the  body  is  kept 
so  rigid  that  the  arms  hang  passively,  swmng  by  the 
movements  of  walking. 

Leyden  endeavored  to  demonstrate  that  the  cause 
of  asthma  lies  in  the  presence  of  sharply  tipped 
octahedral  crystals,  found  abundantly  in  the  expecto- 
ration which  terminates  a  paroxysm  of  asthma,  and 
which,  he  supposed,  by  their  numerous  fine  points 
set  up  a  reflex  irritation  of  the  terminal  branches  of 
the  vagus  in  the  bronchial  mucous  membrane. 
This  theory,  however,  is  sufficiently  negatived  by  the 
discovery  of  the  same  crystals  in  the  secretions  of 
other  bronchial  affections  in  which  there  is  no  asthma. 
That  asthma,  instead,  is  essentially  a  functional 
neurosis  is  readily  apparent  when  the  disease  is 
studied  in  uncomplicated  cases,  for  in  them,  though 
there  be  neither  bronchitis,  heart  disease,  nor  toxemia, 
we  have  typical  attacks  developing  in  association 
with  phenomena  which  belong  to  nervous  diseases 
alone.  Of  such  phenomena  we  would  cite:  1. 
Extreme  suddenness  of  onset,  as  the  immediate 
a-thma  caused  in  some  by  certain  odors.  No  loss 
sudden  also  in  many  cases  is  its  departure,  as  upon 
the  inhalation  of  certain  fumes.  This  feature  mili- 
tates also  against  the  theory  of  Weber,  who  ascribes 
asthma  to  turgescence  of  the  mucous  membrane, 
narrowing  the  caliber  of  the  bronchi  as  an  acute  coryza 
impedes  breathing  through  the  nose.  Storck  lent 
support  to  this  view  by  laryngoscopic  observation  of 
tumefaction  of  the  tracheal  mucous  membrane  as  far 
as  the  right  bronchus  in  an  asthmatic  during  an 
attack.  Bristowe,  moreover,  cites  the  rapid  sub- 
sidence of  cutaneous  turgescence  in  some  cases  of 
urticaria  evanida  as  affording  some  support  to  con- 
gestive swelling  of  the  bronchial  mucous  membrane 


being  a  factor  in  the  etiology  of  asthma.     But  thoue 
it  be  freely  granted  that  the  agonizing  struggles  of  a 
asthmatic  for  air  may  have  considerable  effect  upo 
the  circulation  of  the  bronchial  walls,  yet  the  fa< 
remains  that  no  known  swelling,  however  evanescen 
vanishes  so  quickly  as  some  true  asthmatic  dyspnes 
vanish,   the   patients  becoming  natural  often  mot 
speedily   than   is   common   after  either  epileptic  r 
neuralgic  attacks.     2.  Like  other  spasmodic  ne 
whether  sensory  or  motor,  asthma  often  has  chara- 
teristic  prodromes  of  the  attacks.     One  of  the  mo- 
common  is  a  feeling  of  almost  irresistible  drov 
giving  way  to  which,  the  patient  well  knows,  will  j 
followed  by  the  old  dread  awakening.     With  so 
on  the  other  hand,   unusual   wakefulness  is  a  sur 
precursor.     As  in  epilepsy  and  in  migraine  some  ar 
warned  by  the  temper  becoming  very  irritable,  or  I 
spirits  causelessly  depressed,  while  others  experi' 
unwonted  buoyancy  of  spirits.     Moreover,  as  in  tl 
neuroses,   the  attacks  are  sometimes  preceded, 
oftener  followed,  by  an  abundant  flow  of  pale,  limpii 
urine.     3.  Mental  influences  alone  are  known  bot 
excite  and  to  suspend  the  attacks  with  some.    I 
certain  patients  a  fit  of  anger  may  induce  an  attac; 
immediately,   in   others,    more   significantly   still,  i 
invariably  insures  the  attack  during  the  succeedini 
night,  long  after  the  angry  emotion  is  gone  or  forg 
ten.     4.  It  is  only  in  functional  neuroses  that  we  fin 
many   and   widely   differing   exciting   causes.     Thu 
epilepsy  has  been  wholly  relieved  by  the  expui 
of  a  tapeworm,  or  of  a  renal  calculus,  or  by  trepanni 
But  in  this  respect  asthma  surpasses  ail  other  com 
plaints,  and  the  bearing  of  this  fact  upon  the  nervou. 
character   of   the   disease   appears   when   contra - 
with  bronchitis,  which  involves,  moreover,  just  th( 
same   parts  which   asthma  affects.     Bronchitis  cer 
tainly,  as  well  as  any  other  disease  with  palp; 
lesions,  cannot  be  excited  by  such  a  motley  arrat 
influences  as  the  smell  of  cats  or  of  violets,  the  ear 
of   raisins  or   nuts,   by   constipation,   by  depre-- 
emotions,  or  by  the  extinguishment  of  a  light.     5 
decisive    consideration   is   to   be    noted   also  in  th< 
intermediate  condition  between  the  paroxysms.     In 
typical  asthmatics  in  whom  no  organic  changes  have 
yet  been  induced,  such  as  emphysema  or  the  effect - 
of  chronic  bronchitis,  the  existence  of  asthma  cat 
be  even  guessed.     The  patient  shows  to  inspect 
and   to  physical  exploration  of  the  chest   no  more 
signs  of  being  subject  to  violent  and  prolonged  attacks 
of  dyspnea  than  an  epileptic's   muscles   tell  of  his 
convulsions. 

Mechanism. — Asthma,  therefore,  may  be  regar 
as  essentially  a  derangement  of  the  innervation  of  the 
respiratory    apparatus,    disturbing    the    rhythmical 
succession  of  contraction  and  relaxation  by  a  muscular 
cramp,  W'hich  interferes  chiefly  with  the  act  of  expi- 
ration.     But  the  mechanism,  so    to    speak,    of    the 
asthmatic  paroxysm  itself  is  by  no  means  agreed  upon. 
The  majority  of  authorities  ascribe  it  to  narrowing  of 
the   bronchioles   by   spasm   of   their   muscular  coat, 
while  others  maintain  that  it  consists  in  spasm  of  the 
diaphragm     and     costal     muscles.     Each    of    ti 
theories  may  be  said  to  explain  what  the  other  lea 
unexplained,  and  hence  it  is  doubtful  if  either  of  them 
alone  can  be  regarded  as  adequate.     The  argument- 
in  favor  of  the  latter  theory  are: 

1.  During  the  attacks  the  whole  aspect  of  the 
patient  is  that  of  extreme  external  muscular  rigidity. 
Both  the  thorax  and  abdomen  appear  fixed  and 
immovable,  and  show  none  of  those  strong  heavin; 
and  expansive  efforts  which  are  visible  in  other 
forms  of  dyspnea.  Thus,  in  asthma,  the  diaphragm 
remains  depressed,  as  if  arrested  in  inspiration,  and 
the  muscles  of  the  distended  abdomen  grow  hard  and 
tense  as  they  labor  in  vain  to  overcome  the  resisting 
diaphragm  and  thus  assist  expiration.  From  the 
powerful    contraction    of  the  abdominal  muscles  it 


742 


REFERENCE    HANDBOOK    ( >F    Till:    MEDICAL    SCIENCES 


Asthma 


,  'ii  happens  that  the  lower  ribs  often  bulge  during 

■  efforl  al  expiration.     On  the  other  hand,  when 
,K  is  obstruction   in   the  respiratory   Iran,  as  in 

,1  croup,  edema  glottidis,  etc.,  the  phenomena 

!  all  different.     The  difficulty  is  then  plainly  in  the 

Ipiration,  and  not  in  the  expirati and  the  ribs 

■  which  tin-  diaphragm  is  attached  actually  sink  in. 
,11  (luring  inspiration.  Why  obstruction  in  the 
i  mohi  should  reverse  all  these  effects  is  not  explained. 

■  II-  theory  of  bronchial  spasm  fails  to  account 
the  difficulty  of  expiration  in  asthma.     If  con- 

!  occurs  in  the  tubes,  it   must    interfere  with 

ih   inspiration   and   expiration   equally,    unless   it 
i  be  shown  thai  the  circular  libers  have  a  valvular 
lion  at    the   points  of  contraction,   admitting   the 
g,  hut  interfering  with  the  outgoing,  current, 
nomenon,  however,  has  never  been  induced 
animals  experimentally,   and   is  even   difficult    to 
Moreover,  that  nothing  of  the  kind  occurs 
d  by  auscultation,  for  a  valvular  obstruction 
the  expiration  would  totally  alter  both  the  quality 
!  the  pitch  of  the  expiratory  sibilus,  which  is  not 

a  the  other  hand,  the  theory  of  diaphragmatic 
ism  explains  why  inspiration  is  easier  than  expira- 
n  in  asthma,  because  it  is  well  known  that  partially 
imped  voluntary  muscles,  like  the  diaphragm,  can 
be  stimulated  to  further  contraction,  though 
inclined  to  yield  to  relaxation.  This  appears 
ikingly  in  tetanus,  in  which  disease  the  tonic 
liility  of  the  muscles  never  wholly  gives  way, 
hough  every  few  moments  fresh  and  powerful 
ntractions    occur    in    response     to    the    slightest 

iinal  impressions.  Meantime,  the  statement  that 
depressed  state  of  the  diaphragm  is  a  passive 
ndition  due  to  the  overdistention  of  the  lungs  with 
-idual  air,  is  negatived  by  the  active  muscular 
u traction  of  the  abdomen  above  referred  to,  which 
quite  different  from  the  passive  distention  of  the 
.luminal  walls  when  the  diaphragm  is  depressed 

emphysema. 

1.  The  asthmatic  paroxysm  is  always  aggravated 

certain  movements  which  confessedly  occur  only 

the  diaphragm  itself.  Patients,  on  this  account, 
pecially  dread  to  laugh  or  to  do  anything  which 

.s  or  checks  the  relaxation  of  the  diaphragm. 
i  h  as  loud  talking.  But  how  these  actions  could 
any  way  affect  bronchial  constriction  is  difficult  to 
mceive. 

On  the  other  hand,  there  is  one  incontestable  proof 
lat  constriction  of  the  bronchi  does  take  place  in 
ery  case  of  real  asthma,  and  that  is  the  invariable 
esence  of  general  sibilant  rales  of  every  variety  of 
/.e,  from  fine  whistling  to  large  cooing  sounds.     In 

■  asthma  these  sounds  are  purely  tubular,  and 
om  their  shifting  character,  above  alluded  to,  it  is 
ain  that  they  are  produced  by  progressive  waves  of 
infraction  in  the  bronchial  walls,  and  not  by  a 
lifortn  diminution  of  their  caliber,  such  as  general 

tion  (Weber)  would  occasion.  Those  rales, 
oreover,  are  simultaneous  with  the  onset  of  the 
tack,  as  they  are  audible  sometimes  in  the  breathing 
an  asthmatic,  even  before  he  is  awakened  by  a  fit, 
id  so  constant  are  they  that  no  dyspnea  can  be 
Tined  asthmatic  if  there  be  no  wheezing.  Now,  the 
icory  of  diaphragm  spasm  wholly  fails  to  account 
ir  these  characteristic  bronchial  rales.  If  we  had 
iaphragm  spasm  alone,  the  symptoms  then  would 
itner  resemble  burking,  or,  more  properly,  the 
yspnea  which  is  often  the  fatal  complication  of 
in  which  disease  death  results  from  tonic 
lasm  of  the  respiratory  muscles.  Here,  as  I  have 
ad  personal  occasion  to  note,  there  is  no  wheezing 
hatever. 

From  these  considerations  the  view  of  Lebert  seems 
i  us  preferable,  namely,  that  the  asthmatic  paroxysm 
egins  with  spasm  of  the  bronchial  muscles,  much  as 
lie  first  discharge   of  epilepsy   often  begins  with  a 


special  group  of  muscles,  and  then  pread  to  ether 
and  wider  muscular  association  .  Con  idering  hoi 
intimately  and  constantly  the  muscular  actions  of 
re  piration  are  associated,  it  is  easy  to  conceive  how 
disordered  innervation  of  the  bronchial  muscles  may 
become  quickly  accompanied  by  disordered  innerva- 
tion Of  the  diaphragm,  and   thus  click   the   return  of 

in-piled    air.     Some    ten    such    re  pirations    would 

suffice    to    inflate    the    lungs    to    the    extremes!    degree 

observable  in  asthma,  until  the  whole  muscular  appa- 
ratus of  expiration  would  join  in  the  spasm  and 
'■ plete  the  picture  of  this  dyspnea,  in  which  con- 
dition almost  the  only  movements  which  remain  in 
the  distres  ful  breathing  are  the  Lifting  actions  of  the 

in  el.   and  shoulder  muscles.       Lebert   justly   insists  on 

the  contrast  between  the  pulmonary  dilatation  in 
asthma  and  its  absence  in  fibrinous  bronchitis,  in 
which  disea.se,  1  hough  I  he  obstruction  is  great  and  the 
constriction  of  the  bronchioles  a  tubular  narrowing, 
yet  there  is  but  slight,  if  any,  dilatation;  which 
proves,  therefore,  that  something  more  than  bronchial 
constriction  is  needed  to  explain  all  the  clinical 
features  of  asthma. 

Treatment. — The  treatment  of  asthma  may  be  by 
remedies  which  relieve  its  symptoms  but  do  not  cure 
the  disease.  Thus  the  symptom  of  bronchial  spasm 
may  be  relieved  at  once  by  such  agents  as  stramon- 
ium, compound  spirit  of  sulphuric  ether,  niter,  and 
lobelia.  Of  these  the  most  noted  is  the  inhalation  of 
the  fumes  of  burning  stramonium  leaves.  Individual 
asthmatics,  therefore,  usually  have  their  own  reme- 
dies of  this  sort,  but  though  the  paroxysms  may  for 
years  be  relieved  each  time  by  the  use  of  these  reme- 
dies, yet  the  action  is  no  different  from  the  effect  of  the 
first  dose,  and  the  disease  itself  remains  as  settled  as 
ever.  This  is  all  due  to  the  important  distinction 
between  functional  remedies  and  constitutional  or 
disease  remedies.  Constitutional  remedies  are  given 
not  for  the  symptoms,  but  for  the  morbid  condition 
itself,  and  they  never  produce  their  effects  by  one 
dose,  but  only  by  prolonged  and  repeated  doses. 
Thus  iron  cannot  cure  anemia  until  it  has  been 
administered  for  several  weeks,  nor  mercury  cure 
syphilis  until  it  has  been  given  in  small,  repeated 
doses  for  prolonged  periods.  With  such  remedies 
the  symptoms  of  the  disease,  therefore,  disappear- 
only  with  the  disappearance  of  the  disease  itself. 
Practically,  asthma  can  be  cured  only  by  two  reme- 
dies, namely,  arsenic  and  potassium  iodide. 

Much  the  greater  number  of  reputed  remedies 
for  asthma  are  little  else  than  palliative,  because 
their  operation  merely  relieves  a  paroxysm  or  attack 
of  the  complaint,  just  as  opium  may  relieve  the  pain 
of  a  syphilitic  node  without  producing  the  least 
effect  on  the  cause  of  the  symptom  itself.  The 
peculiar  motor  spasm  of  asthma  is  not  the  disease, 
but  only  a  symptom  of  it,  the  same  in  nature  with 
pain,  and  hence,  like  other  mere  symptoms  in  nervous 
diseases,  it  can  be  affected  by  a  great  variety  of  in- 
fluences. Thus,  such  unlike  agents  as  caffeine, 
chloral,  ether,  and  tobacco,  or  the  inhalation  of 
stramonium  or  of  niter  fumes,  are  each  spoken  of  as 
marvellously  relieving  certain  confirmed  asthmatics. 
No  sooner  does  the  patient  begin  to  experience  the 
special  effects  which  these  drugs  produce  in  a  healthy 
man  than  the  agony  of  his  breathing  subsides,  and 
a  restful  calm  succeeds  as  by  magic.  But  the  great 
disappointment  with  these  seemingly  effective  reme- 
dies is  that  the  longest  use  of  them  brings  the  patient 
no  nearer  getting  rid  of  his  enemy  than  when  he 
began.  He  may  break  up  his  attacks  for  years  with 
his  special  prescription,  but  the  asthmatic  fit  is  as 
ready  to  return,  and  as  severely,  as  if  no  remedy  for 
it  ever  had  been  tried. 

The  reason  for  this  failure  is  fundamental.  These 
so-called  remedies  for  asthma  are  all  nervines,  and  no 
agent    like    opium,    or    aconite,    or    stramonium,  or 

743 


Asthma 


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ether,  whose  whole  medicinal  action  is  obtained  by 
one  dose,  can  do  anything  more  than  that  one  dose 
does.  However  often  repeated,  no  cumulative  pro- 
gressive effect  follows  upon  the  administration  of 
nervines,  and  hence  they  can  affect  only  the  functional 
manifestations  of  a  constitutional  disease.  All  that 
such  medicines  can  do  is  to  produce  some  immediate 
but  temporary  change  in  some  symptom  of  the 
complaint,  but  no  more.  There  is  hence  a  parallel 
between  the  curious  variety  of  the  exciting  causes  of 
asthma  in  different  persons  and  the  like  variety  both 
in  the  nervines  themselves  and  in  their  disproportion- 
ate efficacy  in  different  patients.  For  while  the 
exciting  causes  show  by  their  incongruity  that  they 
are  not  true  but  only  accidental  elements  in  the  case, 
so  the  diverse  nervines  recommended  for  asthma 
show  that  they  affect  only  some  accessory  but  not 
essential  factor  in  the  disease.  When  a  nasal  polypus 
makes  one  patient  an  asthmatic  and  a  loaded  rectum 
another,  neither  of  these  cases  throws  the  least  light 
on  the  true  cause  of  asthma.  Likewise  when  a 
nauseant  emetic  and  a  glass  of  hot  spirits  and  water 
are  each  said  to  "work  like  a  charm"  in  some  asth- 
matics, we  can  scarcely  say  of  such  remedies  that 
they  bring  us  nearer  the  true  therapeutics  of  the 
malady,  for  it  is  plain  that  they  modify  only  some 
chance  association  of  perverted  function. 

In  this  class  of  palliative  remedies  we  would  assign 
the  first  place  to  the  mydriatics,  belladonna,  hyoscy- 
amus,  stramonium,  and  duboisine.  The  wide  range  of 
disorders  in  which  these  medicines  have  been  found 
beneficial  is  due  to  a  general  principle  in  their  opera- 
tion, which  also  suggests  the  explanation  of  their  use 
in  asthma — viz.,  that  they  relieve  disordered  innerva- 
tion of  involuntary  muscular  fiber  by  a  motor  stimu- 
lant action  which  restores  its  rhythmical  contraction 
when  it  has  been  arrested  by  spasm  from  any  cause. 
Spasm  and  paralysis  are  associated  phenomena  in 
unstriped  muscle,  tetanic  contraction  of  one  portion 
and  relaxation  of  the  remainder  taking  the  place  of  the 
normal  wave  movement  throughout  the  whole. 
Hence  the  use  of  belladonna  and  its  allies  in  spasmodic 
action  of  the  bladder  in  cystitis,  in  nocturnal  in- 
continence of  urine,  in  the  constipation  of  women 
from  reflex  pelvic  irritation,  in  spasmodic  gastrodynia, 
in  cardiac  pains  when  due  to  left  hypertrophy  derang- 
ing the  rhythm  of  the  two  sides  of  the  heart,  etc. 
As  with  other  nervines,  the  earlier  they  are  given  in 
the  attack  the  more  pronounced  and  speedy  is  the 
effect.  A  full  dose  of  the  tincture  or  of  the  fluid  ex- 
tract of  belladonna  should  be  given,  enough  to  produce 
well-marked  constitutional  effects,  and  then  the  dose 
should  be  repeated  in  two  hours  if  there  be  only  im- 
perfect relief.  If  the  second  dose  fails  to  affect  the 
breathing,  a  very  effective  method  is  to  give  a  hypo- 
dermic of  atropine  injected  deeply  into  the  nape  of  the 
neck,  a  locality  which  is  the  seat  of  a  sensation  of 
great  weariness  in  severe  attacks  of  asthma,  and 
which  this  measure  often  mitigates  at  once,  after 
other  employment  of  the  remedy  has  failed.  Hyoscy- 
amine  sometimes  affords  more  relief  than  atropine, 
but  in  most  cases  is  not  superior  to  it.  Other  patients 
are  best  relieved  by  the  inhalation  of  the  smoke  of 
stramonium  leaves,  for  which  purpose  they  may  be 
lit  at  the  bottom  of  a  cup,  or  used  like  tobacco  in  a 
pipe,  or  made  into  cigarettes;  the  effort  being  to 
inhale  the  fumes  as  deeply  as  possible,  when  the  dysp- 
nea sometimes  is  found  to  vanish  with  surprising 
rapidity. 

Coffee  should  be  reckoned  also  among  the  nervines 
which  are  effective  in  asthma  by  a  stimulant  action. 
It  should  be  made  very  strong,  taken  always  on  an 
empty  stomach  and  taken  hot,  for  the  sipping  of  the 
potion  is  not  without  its  own  effect,  as  it  has  been 
shown  by  Kronecker  that  the  act  of  swallowing 
itself  powerfully  stimulates  the  cardiac  and  pul- 
monary branches  of  the  vagus.  Coffee  taken  after 
eating  aggravates  asthma  by  interfering  with  diges- 

744 


tion.  In  some  cases  I  have  found  the  alkalo 
caffeine  of  temporary  benefit,  but  on  the  whole 
regard  it  as  inferior  to  the  freshly  made  and  strong  i 
fusion.  Hot  coffee  is  particularly  good  in  asthmat 
bronchitis,  as  it  facilitates  the  expectoration  while 
relieves  the  spasmodic  condition.  It  is  in  the  sari 
class  of  cases,  also,  that  the  muscle  stimulant,  ni 
vomica,  is  sometimes  beneficial.  Here  again  t] 
tincture  or  the  fluid  extract  of  the  drug  is  preferab 
to  its  alkaloid,  strychnine. 

Next  in  order  come  the  nervines  which  probab 
relieve  the  asthmatic  paroxysm  by  a  sedative  aetii 
on  the  initial  irritant  impression.     Among  these  v 
would   enumerate   alcohol,    the   ethers,    chloral,  ai 
opium.     It  should  be  noted  that  while  alcohol  is 
stimulant  to  the  heart  and  to  some  cerebral  function 
it  is  an  immediate  sedative  to  the  sensory  nem 
and  this  sedation  steadily  increases  in  proportion 
the  dose.     Sulphuric  ether,   when   taken  internal! 
resembles  alcohol  in  these  respects,  though  its  sed 
tive  effects  are  much  more  pronounced.     Hence  tl 
use  of  both  alcohol  and  ether  in  the  muscle  cramp 
intestinal  colic  and  in  spasmodic  affections  of  due 
generally.     Full  doses  of  spirits,  therefore,  taken  ho 
will  relieve  some  asthmatics  to  the  exclusion  of  n 
other  remedies;  but  the  relief  does  not  occur  general 
until  enough  is  taken  to  intoxicate  a  well  perso 
though  it  rarely  does  so  with  an  asthmatic.     Sulphur 
ether,   however,    is   much   more   generally  effectiv 
especially    in    the    preparation  of  the   spirit  us  con 
positus,  or  Hoffman's  anodyne,  owing  to  the  oil  i 
wine  which  it  contains.     As  this  latter  ingredient 
expensive,    it    is    sometimes    fraudulently    omitto 
with  a  plain  falling  off  in  remedial  power  over  tl 
attacks.     The  dose  for  the  paroxysm  should  be  nc 
less  than  two  drams.     As  the  latter  acts  in  a  diffe 
ent  way  from  the  belladonna  (being  more  conneete 
with  the  sensory  element  of  the  spasmodic  conditioi 
while  the  belladonna  affects  the  motor),  an  unqur 
tionable  gain  is  secured  by  administering  these  tv. 
remedies  together. 

As  might  be  expected,  there  is  much  contradictor 
testimony  about  the  value  of  opium  in  asthm: 
This  need  not  be  wondered  at  in  view  of  the  widel 
different  effects  of  opium,  e.g.  as  a  soporific,  in  diffei 
ent  individuals.  The  mode  of  administration.  ho« 
ever,  counts  more  with  this  remedy  than  with  an 
other,  for  the  speedy  effect  of  a  hypodermic  of  moi 
phine  is  much  oftener  successful  than  morphine  < 
opium  taken  by  the  mouth.  This,  however,  is  i 
accordance  with  the  general  rule  that  the  mor 
quickly  a  nervine  is  felt,  the  more  effective  it  i 
against  any  spasmodic  affection — e.g.  arresting  a 
epileptic  fit  by  a  sudden  irritant  impression,  bu 
which  it  fails  to  do  if  applied  gradually.  Chloral  i 
large  doses,  thirty  to  sixty  grains,  is  claimed  as  a 
excellent  remedy  for  asthma;  but  the  patient' 
tolerance  of  this  drug,  sometimes  fatal  in  onl; 
fifteen-grain  doses,  should  be  well  established  beion 
this  treatment  is  tried.  Inhalations  of  nitrite  o 
amyl  often  arrest  a  commencing  attack,  but  are  no 
of  much  use  in  a  fully  developed  paroxysm.  Thi 
fumes  of  the  nitrate  of  potassium,  however,  inhale* 
by  burning  cigarettes  made  of  rice  paper  dipped  in: 
saturated  solution  of  the  salt  and  then  dried,  an 
much  more  generally  effective.  This  remedy  un 
doubtedly  acts  by  virtue  of  the  well-known  locall} 
sedative  properties  of  potash  itself,  and  hence  ma; 
well  cooperate  with  the  different  action  of  the  funic; 
of  stramonium  leaves  rolled  up  with  the  niter  paper 

Lastly,  we  have  the  pure  sedatives  whose  actio' 
cannot  be  secured  until  nausea  has  been  occasioned 
by  them.  Asthmatic  spasm,  like  every  other  cramp 
rarely  holds  out  against  the  sickening  effect  of  tobacco. 
lobelia,  or  even  of  ipecacuanha.  Tobacco,  therefore. 
is  effective  only  with  those  who  are  not  used  to  it. 
Lobelia  has  the  disadvantage  of  producing  too  much 
prostration,   and   the   same   may  be   said   of  tartar 


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\  -Ihni.i 


ictic.     This  class  of  remedies  works   much  better 

'  bronchitis  than  in  peptic  asthma. 

Besides  these  there  arc  but  few  nervines  left  in  the 

tcopeia  which  are  not   recommended  by  some 

asthma,  although   no  one  is  ever  permanently 

nefited  by  any  of  them. 

Better  results,   however,   may  be  hoped  for  from 

directed  to  other  aims  than  simply  to  relieve 

i|  of  the  dyspnea  when  present.     Asthma  is  at   no 

ibsent    from    the    asthmatic    any    more    than 

ilepsy  from  the  epileptic,  though  the  manifestations 

rare  only  occasional,      1'rophylaxis,  therefore. 

es  an  exceptional   importance,   because,  as  in 

spasmodic     neuroses,     the     malady     becomes 

ate    in    proportion    to    the   frequency   of    the 

As  in  the  case  of  epilepsy  also,  the  slightest 

-  of  asthma  are  as  much  to  be  avoided  as  the 

ones,  if  there  is  to  be  any  hope  of  the  patient 

coming  ultimately  free  from  "them,  and  hence  the 

g  causes  in  each  instance  should  be  carefully 

and    jealously    provided    against.     In    those 

i  which   the  susceptibility  to  odors  indicates 

e  upper  respiratory  tract  as  the  seat  of  the  irritabil- 

..    the    inhalation   of   carbolized   steam   should   be 

The  steam  should  be  made  to  surround  the 

•ad  by  the  simple  device  of  directing  it  under  an 

i'lrelia,  held  low  by  the  patient  himself,  so  that  he 

ty   inhale   without   more   effort   than   in   ordinary 

piration,  because  breathing  by  will  is  too  fatiguing 

0  be  kept  up  for  long  by  any  one,  and  it  is  this 

which  accounts  for  the  uniform  failure  of  the 

inhalers    and    atomizers    which    have    been 

ed  during  the  past   century.     This  treatment 

iould  be  kept  up  twice  a  day  for  months,  the  object 

■ing  to  produce  a  permanent  change  in  the  suscep- 

bility  of  the  sensory  nerves  distributed  to  the  nasal 

laryngeal    mucous   membranes.     Occasionally 

e  vapor  of  turpentine  may  be  substituted  for  that 

carbolic  acid.     It  is  in  these  cases  also  that  much 

lay  be  expected  from  the  French  procedure,   origi- 

by  Ducros,  of  painting  the  posterior  wall  of  the 

liarynx  with  aqua  ammonia?,  although,  to  prevent 

irae    being    made    worse    by    the    irritant    fumes, 

•  ousseau  recommends  inhalations  of  ammonia  first 

•om  a  vial  and  then  touching  the  pharynx  with  a 

eak  solution,   to  be  made  stronger  as  the  patient 

ecomes    accustomed    to    it.     Trousseau    refers    the 

amunity  of  many  patients  from  visits  of  asthma  so 

ing  as  they  reside  in  the  vicinity  of  gas-works  to  the 

ce  of  ammonia  in  the  air  of  the  locality;  but 

bile  this  possibly  may  be  operative,  yet  we  would 

scribe  it  more  to  the  unmistakable  sedative  effect 

pon  the  bronchial  nerves  of  air  charged  with  creosote, 

arbolic   acid,    and   other   allied    products   of   wood 

i-t  illation.     It  is  in  this  class  of  patients  also  that 

lie  bromides  are  useful,  owing  to  their  paralyzing 

be  reflex  excitability  of  the  pharyngeal  nerves.     A 

lose  of  thirty  grains  of  potassium  bromide,  with  a 

Iram  of  Hoffman's  anodyne  at  bed-time,  will  often 

vard  off  a  nocturnal  visit  of  the  enemy. 

It  is,  however,  in  bronchitic  asthma  that  prophy- 
ixis  is  particularly  imperative.  As  comparatively 
ew  cases  of  bronchitis  originate  from  direct  irritation 
if  the  bronchial  mucous  membrane,  but  much  more 
■nmmonly  from  some  partial  exposure  of  the  skin 
o  unequal  degrees  of  temperature,  so  the  partic- 
llar  susceptibility  of  different  cutaneous  regions 
Oinuld  be  tested  and  preventive  measures  adopted 
iccordingly.  As  a  general  rule,  in  bronchitis  which 
legins  usually  with  a  coryza  it  is  the  nape  of  the  neck, 
•vhile  in  phthisical  cases  it  is  the  anterior  surface  of 
the  chest,  and  in  pharyngeal  or  tonsillar  cases  the 
eet,  which  are  the  most  susceptible  to  those  impres- 
sions of  passing  cold  that  set  up  their  special  tracks 
3f  inflammation  or  hyperemia  in  mucous  membranes. 
After  a  few  days'  continuance  of  the  catarrhal  state, 
however,  the  skin  of  the  whole  surface  partakes  in 
this  specific   irritability,   so   that   the   patients   may 


bee e  aware  of  a  draught  from  a  distant  open  door 

which  others  do  not  feel.  Many  cs  es  of  bronchitic 
asthma,  therefore,  are  promptly  relieved  by  putting 
on  a  whole  suit  of  buckskin  over  a  ligh<  under-flannel, 

and  wearing  the  same  until  settled  summer  weather. 
These  patients  also  should  guard  against  nocturnal 
perspiration  about  the  neck  and  shoulders,  by  the 

of  light  flannel  instead  of  cotton  or  linen  night-shirt  s. 
Daily  inunctions  with  oil  also,  applied  especially  to 
the  feet,  and  preferably  done  on  rising,  do  much  to 
lessen  the  tendency  to  catching  cold.      The  bronchitis 

itself,  of  course,  should  be  treated  according  to  its 
indications,  with  especial  benefit  to  be  hoped  for  in 

asthmatics  from  the  emulsion  of  linseed  oil.  We 
need  also  only  allude  here  to  the  importance  of  making 
the  utmost  of  the  intermediate  summer  period  of 
mitigation  of  bronchitis  with  many  patients  before 
the  malady  has  become  too  chronic. 

Peptic  asthma  is  so  much  influenced  by  the  Btate 
of  the  alimentary  canal  that  some  have  spoken  of  the 
treatment  of  asthma  in  general  as  if  it  were  mainly  a 
matter  of  regimen  and  diet.  Indigestible  food,  even 
a  single  meal  of  such,  is  to  be  scrupulously  avoided 
in  every  form  of  spasmodic  disease.  The  patient, 
must  not  endeavor  to  reconcile  his  digestive  apparatus 
to  any  second  trial  with  an  offender.  Whether  the 
proneness  to  spasmodic  or  convulsive  disorder  be  due 
here  to  the  greater  susceptibility  of  the  nerve  centers 
to  reflex  excitation  from  the  alimentary  canal  than 
from  any  other  nerve  distribution,  or  whether  the 
susceptibility  is  caused  by  the  absorption  of  nerve 
poisons  generated  in  some  intestinal  fermentation, 
it  is  unquestionable  that  any  departure  from  good 
digestion  is  to  be  dreaded  in  treating  such  complaints, 
and  in  none  more  so  than  in  asthma.  Experience 
will  best  teach  each  one  all  the  particulars  as  regards 
what  he  can  and  what  he  cannot  eat,  and  its  verdict 
must  be  accepted.  Moreover,  with  all  asthmatics, 
the  digestive  power  decreases  as  the  day  wears  on,  as 
previously  stated. 

But  as  the  prevention  of  peptic  asthma  wellnigh 
involves  the  treatment  of  all  the  varied  forms  of 
dyspepsia,  we  can  direct  attention  here  only  in  a 
general  way  to  the  subject,  for  each  case  is  to  be 
managed  according  to  its  own  indications.  Wo 
may  remark,  however,  that  bismuth  appears  to  be 
one  of  the  most  effective  preventives  of  peptic  asthma, 
probably  owing  to  its  antiseptic  properties.  A  good 
form  of  administration  is  in  capsules  of  five  grains 
each  of  bismuth  carbonate  and  of  pulvis  calumbse,  two 
such  to  be  taken  an  hour  after  meals  and  at  night. 
Ten  grains  of  sodium  benzoate  and  ten  grains  of 
bismuth  salicylate,  administered  in  two  capsules,  will 
also  often  be  found  effective  in  preventing  intestinal 
fermentation. 

In  conclusion,  we  would  recommend,  besides  pro- 
phylactic measures,  the  recourse  to  certain  remedies 
whose  benefit,  when  secured,  can  properly^  be  termed 
lasting  or  curative,  instead  of  merely  palliative. 
Want  of  success  with  them  may  be  due  often  to  a 
failure  to  recognize  the  fact  that  to  be  truly  curative 
in  such  a  deepseated  and  lifelong  malady  as  asthma  a 
remedy  must  be  given  continuously  without  reference 
to  the  attacks,  and  long  enough  to  produce  a  decided 
modification  in  the  system  itself.  Such  a  result 
never  can  be  obtained  from  agents  which  merely 
affect  nerve  functions,  however  steadily  or  largely 
they  be  taken,  as  is  proved  by  the  absence  of  any 
recognizable  sign,  either  during  life  or  after  death, 
of  the  years  spent  by  many  in  consuming  tobacco 
or  opium.  In  arsenic  and  potassium  iodide,  how- 
ever, we  possess  truly  constitutional  medicines,  whose 
value  in  asthma  has  been  repeatedly  demonstrated. 
If  these  medicines,  however,  have  any  effect  on 
asthma,  that  effect  is  wholly  different  in  kind  from 
the  immediate  relief  produced  by  a  transient-acting 
nervine,  for  it  must  be  by  causing  a  more  or  less 
organic  alteration  in  the  lesion  itself.     Their  proper 

745 


Asthma 


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administration  in  asthma,  therefore,  should  be  like 
the  administration  of  iron  for  anemia,  or  mercury  for 
syphilis,  or  the  bromides  for  epilepsy,  the  effect  being 
obtained  not  by  one,  or  by  the  first  dose,  but  only 
after  months  of  steady  use.  I  feel  assured  that  if  a 
combined  or  alternate  arsenical  and  iodide  treatment 
were  as  systematically  adopted  in  the  treatment  of 
asthma  as  fhe  above-named  constitutional  remedies 
are  used  in  other  maladies,  many  a  case  of  this 
disease  would  be  finally  got  rid  of  which  now,  under 
the  deceptive  recourse  to  mere  functional  agents, 
becomes  at  last  an  incurable  habit  of  the  nervous 
respiratory  mechanism. 

To  obtain  the  best  results  with  constitutional 
remedies,  two  therapeutical  rules  should  be  steadily 
followed.  The  first  is  to  administer  along  with  them 
one  or  more  of  the  restoratives,  in  order  to  prevent 
the  injurious  effects  of  the  continued  taking  of  such 
unnatural  substances  into  the  system  as  arsenic  or 
iodine.  No  symptoms  of  iodism  or  of  arsenic  should 
be  allowed,  because  the  remedial  effects  of  these 
medicines  cease  at  once  upon  the  appearance  of  any 
signs  of  their  poisonous  operation.  If  diminishing 
the  dose  is  not  followed  by  a  cessation  of  the  symp- 
toms, these  drugs  must  be  omitted  for  a  time,  and 
then  resumed  in  small  doses,  to  be  increased  again 
only  as  the  patient  can  tolerate  them.  The  best 
restoratives  with  arsenic  are  quinine  and  codliver  oil, 
while  phosphorus  and  the  muriated  tincture  of  iron 
best  prevent  the  injurious  effects  of  iodine. 

The  second  rule  is  to  secure  the  cooperation  of 
functional  medicines,  for  though  these  latter  cannot 
be  curative  in  themselves,  yet  experience  proves  that 
they  unquestionably  promote  the  action  of  constitu- 
tional remedies  when  they  relieve  some  of  the  symp- 
toms of  the  disease.  Thus  I  have  repeatedly  noted 
potassium  iodide  fail  adequately  to  cure  a  syphilitic 
node  until  opium  and  conium  were  added  to  the 
prescription.  And  on  the  same  principle  I  have  been 
accustomed  in  asthma  to  prescribe  a  combination 
somewhat  as  follows:  Py  Potass,  iodic!.,  o  iss.;  Liq. 
pot.  arsen.,  o  i.;  Spts.  eth.  sulph.  co.,  §  iiss.;  Tr. 
belladonna,  o  ij.;  Syr.  aurant.  cort.  ad  5  vi.  M. 
S.:  Two  teaspoonfuls  in  water  an  hour  after  meals. 
Belladonna  is  introduced  because  it  is  in  the  same 
botanical  family  as  stramonium.  The  active  prin- 
ciple of  belladonna  or  atropine  is  often  effective  when 
given  hypodermically  at  the  nape  of  the  neck  in  a 
dose  of  1/100  to  1/75  of  a  grain. 

In  a  certain  proportion  of  cases  a  curative  effect 
is  secured  by  counterirritation  applied  along  the 
cervical  and  upper  dorsal  vertebrae.  The  actual 
cautery  is  to  be  preferred,  and  one  form  of  this 
irritation  is  both  effective  and  readily  applied  without 
expensive  apparatus,  namely,  by  the  not  glass  rod. 
Spots  of  ink,  half  an  inch  or  so  apart,  made  along  the 
spinous  processes,  are  to  be  lightly  touched  by  the 
tip  of  a  glass  rod  raised  to  a  white  heat  in  the  flame 
of  an  alcohol  lamp.  This  simple  procedure  causes  but 
little  pain,  and  immediately  after  the  application 
shows  a  continuous  red  line  as  if  made  by  the  passage 
of  a  hot  iron.  The  application  should  be  repeated 
about  every  fourth  day. 

If  there  is  any  history  of  the  alternation  of  asthma 
with  the  disappearance  of  a  cutaneous  eruption,  an 
artificial  eczema  by  croton  oil  on  the  chest,  as  already 
mentioned,  is  often  positively  remedial  if  persevered 
in  on  the  first  sign  of  a  return  of  the  dyspnea.  Asth- 
ma secondary  to  other  diseases  must  be  treated  with 
them.  In  the  cardiac  cases,  and  in  gouty  patients  as 
well,  a  continued  use  of  saline  waters,  like  the  Congress 
or  Hathorn  of  Saratoga,  will  afford  the  best  prospect 
of  relief. 

In  all  cases  of  asthma,  however,  a  careful  examina- 
tion of  the  nasal  passages  should  be  made  at  the 
beginning  and  repeated  throughout  the  treatment. 
The  innervation  of  the  outlets  of  all  long  tubular 
tracts  is  closely  associated  with  the  nervous  mechan- 


ism controlling  the  muscular  movements  of  the  who] 
tract,  examples  of  which  are  seen  in  the  heighten? 
irritability  of  the  whole  genito-urinary  apparatus  b 
a  narrowed  meatus,  or  orifice  of  the  prepuce;  by  tli 
pylorus  remaining  patent  so  that  the  stomach  is  to 
quickly  emptied  in  dysentery,  etc.  We  need  n< 
wonder,  therefore,  if  the  normal  rhythm  of  respiratio 
is  readily  deranged  by  a  polypus  or  other  obstructio 
in  the  nose,  and  all  such  conditions  should  be  full 
remedied  when  found.  But  aside  from  such  lesion, 
many  asthmatic-attacks  may  be  prevented  or  aborte 
early  by  a  spray  of  carbolized  oil — one  part  of  carboli 
acid  to  forty  of  sweet  almond  oil — used  especially  o 
retiring  at  night.  William  H.  Thomson. 


Astigmata.— A  subdivision  of  the  Acarina,  or  mite> 
in  which  the  body  contains  no  tracheal  respirator 
tubes  and  in  which  the  legs  bear  small  appendage 
or  epimeres.  This  group  contains  the  itch  am 
cheese  mites.     See  Arachnida.  A.  S.  P 


Astigmatism,*  As  (from  a,  privative,  and  0-7(7^0 
a  point)  is  the  name  proposed  by  Whewell  (1846)  ti 
designate  the  visual  anomaly  which  results  fron 
unequal  refraction  in  the  planes  of  the  several  ocula 
meridians.f  Accurate  measurements  of  the  cornel 
reveal  some  degree  of  asymmetry  in  nearly  ever 
eye,  and  not  infrequently  the  difference  in  curvatun 
in  different  meridians  is  so  great  as  to  give  rise  t< 
serious  imperfection  of  vision.  As  a  rule,  the  merid 
ian  of  greatest  curvature  is  vertical  or  approxi 
mately  vertical,  and  the  meridian  of  least  curvature 
at  right  angles  to  the  former,  is  horizontal  or  approxi- 
mately horizontal.  To  this  rule  there  are,  however 
many  and  conspicuous  exceptions. 

The  crystalline  lens,  also,  is  the  seat  of  asym- 
metrical refraction,  either  from  inequality  of  curva- 
ture in  different  meridians  or  from  imperfect  cen 
t  rat  ion  of  its  two  surfaces,  together  with  the  cornea, 
in  a  common  axial  line.  Astigmatism  of  the  crystal- 
line lens  is  generally  of  comparatively  low  grade, 
and  the  meridian  of  greatest  lenticular  refraction  i 
oftenest  approximately  horizontal.  Hence  lenticular 
astigmatism  tends  oftener  to  correct  than  to  increase 
the  astigmatism  due  to  asymmetry  of  the  cornea 
the  total  astigmatism  falling  short  of  rather  than 
exceeding  that  which  would  result  from  the  corneal 
asymmetry  alone. 

From  the  fact  that,  as  a  rule,  neither  the  cornea  nor 
the  anterior  or  posterior  lens  surface  is  a  perfect 
surface  of  revolution,  and  that  not  one  of  these  sur- 
faces is  quite  accurately  centered  with  reference  .11 
the  visual  axis,  it  follows  that  the  ocular  refraction, 
whether  symmetrical  or  asymmetrical,  is  the  resultant 
of  three  more  or  less  asymmetrical  refractions.  In 
practice,  however,  these  complications  are  disre- 
garded; and  the  investigation  of  any  case  of  astig- 
matism is  limited  to  the  measurement  of  the  asym- 
metry of  the  cornea  and  the  determination  of  the 
refractive  error  as  a  whole. 

The  characteristic  property  of  a  pencil  of  light  after 
a  single  astigmatic  refraction  (or  reflection)  is  that  it 
has  no  focus,  properly  so  called,  but  that  all  its  rays 
pass  through  two  nearly  straight  lines  at  right  angles 
to  the  axis  of  the  pencil  (focal  lines).  The  construc- 
tion of  such  a  pencil  is  shown  in  Fig.  511,  in  which  I. 
represents  a  luminous  point;  M  N,  OP  lines  intersecting 

*  Asligmia,  astigmie,  of  French  writers. 

t  For  convenience,  the  system  of  lines  and  circles  used  in  ?< 
raphy  is  extended  to  the  topography  of  the  eyeball.     Designs 
ing  the  center  of  the  cornea  and  the  central  fovea  of  the  retina 
the  anterior  and  posterior  poles,  the  line  connecting  them  is  the 
axis;  all  great  circles  passing  through  the  poles  are  meridians;  tli" 
great  circle  which  cuts  all  the    meridians  at  right  angles  is  tho 
equator;  and  the  surface  included  between  any  two  parallels  ia  a 
zone. 


746 


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Astigmatism 


Ltrighl   angles  at    L    and   parallel,   respectively,   to 

[i    and    A  C,  B  D  bounding  an  asymmetrically 

ng  surface  of  which  the  meridian  of  greatest 

ll(  iii.u  is  assumed  to  be  vertical;  .V  .M',  parallel  to 

\V  the  first  focal  line  (/,);  and  P"  O",  parallel  to 

i  •  the  second  focal  line  (/.).     Cross-sections  of  the 

ted    pencil,    elsewhere    than   in    the    two    focal 

re  indicated  by  the  three  rectangles,  a,c,b,  one 

ii  (c)  falling  between  the  two  focal  lines   but 

to/,  than  to  f2,  is  of  the  same  form  as  the 

lion  of  the  pencil  before  refraction   (shown 

|  he  diagram  as  a  square).     The  other  cross-sections 

I  all  rectangles  having  their  longer  sides  parallel  to 

nearer  focal  line.     The  distance  separating   the 

ocal  lines  i  /,  and/.)  is  called  the  focal  interval* 

rem  the  construction  it  follows  that  if  the  pencil  is 

v  the  retina  at/,,  the  luminous  point  at  L  will 

seen  as  a  horizontal  bright  line,  and  that  if  it  is 

at  f .  the  point  L  will  be  seen  as  a  vertical  line. 

lencil  is  cut  by  the  retina  at  c,  the  point  will 

as  a  small  illuminated  area  having  the  form 


drical  lens  rendering  an  emmetropic  eye  myopic  in  all 
i  ne  iid  ia  ns  other  than  that  of  the  axis  of  the  cylinder — 
simple  myopic  astigmati  m  I  \xo)\  and  a  concave 
cylindrical  lens  rendering  an  emmetropic  eye  hyper- 
metropic in  all  meridian-  Other  than  that  of  I  he  a  ■•.  i  of 
the  cylinder — simple  hypermi      i  gmati  m  <  \h). 

A  convex  spherico-cylindrical  lens  renders  an  emme- 
tropic eye  myopic  in  all  meridians,  but   the  myopia 

is  greatest    in   its  meridian  of  greatest    refraction   and 

[east    in  its  meridian  of  least    refraction     compound 

myopic  asliymatixm  i  M  +  Am  I ;  ami  a  concave  spherico- 
cylindrical  len  renders  an  emmetropic  eye  hyperme- 
tropic in  all  meridians,  but  the  hypermetropia  is 
■i'  a i est  in  its  meridian  of  greatest  (negati\e)  retrac- 
tion and  least  in  its  meridian  of  least  (negative) 
refraction — en  m  pi>  n  11  d  hypermetropic  astiymtilixm 
til  +  Ah).  A  tilth  typi  —  mixed  astigmatism  (Anih 
or  Ahm)  is  reproduced  by  looking  through  a  convex 
spherical  lens  combined  with  a  concave  cylindrical 
lens  of  greater  power,  or  through  a  concave  spherical 
lens  combined  with  a  convex  cylindrical  lens  of  greater 


Fio.  511. 


i  the  refracting  surface,  which,  in  the  eye,  is  deter- 
l  ned  by  the  form  of  the  pupil  and  is  therefore  ap- 
I  'xiniately  circular.  If  the  pencil  is  cut  at  any 
i  ier  part  of  its  course  the  point  will  be  seen  as  an 
id,  approximating  an  ellipse.     The  section*  of  the 

I  at  c  is  called  the  circle  of  least  confusion. 

If,  instead  of  a  single  luminous  point  at  L,  we 

I  nine    an    indefinite    number    of    points    arranged 

jmg  the  horizontal  line   M  N,  these  points  will  be 

ed  at  /,,  each  as  a  horizontal  line,  and  these 

es,  overlapping  each  other  in  the  greater  part  of 

i  'ir  length,  will  appear  fused  in  a  longer  horizontal 

Ie.     So  also  a  series  of  points  arranged  along  the 

it ical  line  O  P,  or  the  vertical  line  0  P  itself,  will 

projected  as  a  vertical  line  at  /,.     Lines  lying  in 

ie  or  the  other  of  these  two  directions  (parallel  to 

X  or  to  O  P)  are,  in  fact,  the  only  objects  projected 

the    astigmatically    refracting    surface    without 

Dspicuous  alteration. 

^s,  by  construction,  the  first  focal  line  (/,)  is  par- 

M  N,  and  the  second  focal  line  (/,)  is  parallel 

0  P  (drawn  perpendicular  to  M  N),  planes  passed 

rough  M  N,  N'  M'  and  through  O  P,  P"  (_)"  intersect 

■  asymmetrical  refracting  surface  in  its  meridians 
least  and  of  greatest  curvature.  These  two  planes 
erpendicular  to  each  other)  and  the  two  meridians 

which  they  intersect  the  refracting  surface  (also 
rpendicular  to  each  other)  are  called,  respectively, 
6  principal  planes  and  the  principal  meridians. 
ie  principal  meridian  of  greatest  corneal  curvature 
designated  by  the  symbol  Mc,  and  that  of  greatest 
ular  refraction  by  M0. 

V  normally  seeing  (emmetropic)  eye  may  be  ren- 
ired  astigmatic  by  wearing  a  piano-  or  spherico- 
lindrical  lensf  in  a  spectacle  frame;  a  convex  cylin- 

*The  form  of  the  refracted  pencil  may  be  shown  in  three  di- 
visions by  projecting  it  on  the  fine  particles  of  dust  in  the  air, 
a  't:irkened  room. 

■  \  piano-cylindrical  lens  has  one  surface  plane  and  the  other 
mind  to  a  cylindrical  curvature,  which  may  be  either  convex  or 
'leave.  Lenses  are  also  ground  with  a  convex  or  concave  spher- 
il  surface  on  one  side  and  a  convex  or  concave  cylindrical  sur- 
ue  on  the  other  side,  and  may  be  imitated  by  cementing  to- 


power.  These  five  types  include  all  forms  of  regular 
astigmatism. 

Astigmatic  vision  is  best  studied  in  the  case  of 
simple  myopic  astigmatism  (Am),  in  which  a  distant 
bright  point  is  seen  elongated  in  the  direction  of  the 
ocular  meridian  of  greatest  refraction.  Figs.  512 
and  513  show  arrangements  of  dots  and  lines  as  seen 
by  an  emmetropic  eye  and  by  a  myopically  astigmatic 
eye  when  the  meridian  of  greatest  refraction  is  vertical. 
It  will  be  observed  that  in  Fig.  512,  b,  the  dots  appear 
elongated  vertically,  and  that  in  Fig.  513,  6,  the  hori- 
zontal and  oblique  lines  appear  blurred  in  the  same 
direction — the  vertical  lines  appearing  sharply  defined, 
but  somewhat  elongated. 

For  the  detection  and  measurement  of  astigmatism, 
as  of  ametropia  generally,  both  objective  and  sub- 
jective methods  are  employed.  In  the  examination 
of  the  eyes  of  very  young  children  objective  methods 
are  alone  available;  and  in  nearly  all  cases  they  afford 
important  data,  to  be  utilized  in  further  tests. 

For  convenience  and  general  applicability  the 
ophthalmometer  of  Javal  and  Schiotz  (see  Ophthal- 
mometer) holds  a  foremost  place.  By  means  of  this 
instrument  the  smallest  deviations  from  symmetrical 
curvature  of  the  cornea  are  detected;  and  both  the 
direction  of  the  meridians  of  greatest  and  of  least 
curvature  and  the  difference  in  the  corneal  refraction 
in  these  meridians  are  measured  with  great  accuracy, 
and  at  minimum  cost  of  time  and  effort.  Working 
from  these  corneal  measurements  as  a  starting  point, 
the  way  to  the  determination  of  the  refraction  of  the 
eye  as  a  whole  is  shortened  and  made  clearer,  and  in 
the  end  a  more  comprehensive  diagnosis  is  reached 
than  is  otherwise  possible. 

The  presence  or  the  absence  of  astigmatism  of  high 
or  of  medium  grade  is  generally  discovered  at  a  first 
glance  on  looking  into  an  eye  with  the  ophthalmo- 
scope. Viewed  in  the  erect  image,  the  fundus  of  an 
astigmatic  eye  appears  to  the  observer  as  an  enlarged 

gether,  by  their  plane  surfaces,  an  ordinary  plano-convex  or 
plano-concave  lens  and  a  piano-cylindrical  lens.  Such  a  com- 
bined lens  is  called  a  spherico-cylindrical  lens. 


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Astigmatism 


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reproduction  of  its  details  would  appear  if  viewed  by 
the  same  eye  at  long  range.  In  the  higher  grades  of 
astigmatism  the  fundus  presents  the  strikingly  char- 
acteristic picture  of  a  diffuse  red  ground  marked  by 
conspicuous  parallel  streaks  of  a  deeper  red  in  which 
the  double  contour  of  a  retinal  artery  or  vein  is  here 
and  _  there  recognizable,  and  by  a  lighter  oval  area 
(optic  disk)  blurred  in  the  direction  of  its  longer  axis. 
The  examination  is  best  made  with  the  ophthalmo- 
scope specially  adapted  to  this  use  by  Loring1  in  which 
any  one  of  a  series  of  selected  convex  and  concave 
lenses,  mounted  in  a  revolving  disk,  may  be  rotated 
at_  will  into  a  position  behind  the  sight-hole  in  the 
mirror.  By  means  of  this  instrument  the  refraction 
is  measured  in  each  of  the  principal  meridians;  the 
difference  of  the  two  measurements  representing  the 
grade  of  astigmatism  within  a  margin  of  error  of  less 
than  one  dioptrie.  The  diagnosis  of  astigmatism  may 
also  be  made  in  the  inverted  image,  but  with  less  ac- 
curacy than  in  the  erect  image.  (See  Ophthalmoscope.) 
Another  application  of  the  ophthalmoscope  to  the 
investigation  of  the  refraction  is  by  the  method 
known  as  retinoscopy,  shadow  test,  etc.,  which  con- 
sists essentially  in  the  observation  of  the  direction 
in  which  the  dark  border  of  the  image  of  a  flame, 
reflected  into  the  eye  by  the  mirror,  moves  across  the 


Fig.  512. 


Fig.  513. 


strongly  illuminated  pupil.  (See  Shadow  Test.) 
By  this  method  measurements  of  the  ocular  refrac- 
tion in  the  two  principal  meridians  and  an  estimate 
of  the  direction  of  one  or  of  both  meridians  may  be 
made  within  a  narrow  margin  of  error.  Preliminary 
dilatation  of  the  pupil  is  helpful,  and  often  indispen- 
sable. It  is  not  necessary  or  desirable  to  paralyze 
the  accommodation. 

Subjective  tests  for  astigmatism  turn,  on  the  visual 
analysis  of  the  confused  retinal  image  as  exemplified, 
for  a  case  of  simple  myopic  astigmatism,  in  Figs.  512, 
513.  The  technique  must  be  suited  to  the  determina- 
tion: (a)  of  the  presence  and  the  type  of  astigmatism, 
whether  myopic,  hypermetropic,  or  mixed;  (6)  of 
the  direction  of  the  ocular  meridians  of  greatest  and 
least  refraction;  and  (c)  of  the  difference  in  refraction 
in  these  meridians.  The  examination  is  best  con- 
ducted at  long  range;  with  the  visual  axes  virtually 
parallel,  and  the  accommodation  relaxed  to  the 
extent  habitual  in  unconstrained  distant  vision.  The 
test-object  should  be  large  enough  to  admit  of  easy 
recognition  of  its  finer  details  by  a  person  of  normally 
acute  perception,  and  not  so  large  as  greatly  to 
exceed  the  size  of  the  field  of  direct  vision  at  the 
distance  at  which  the  tests  are  made.  Examples  of 
such    test-objects,    made    up    of    radiating    lines    or 


groups  of  lines,  or  of  rows  of  holes  punched  in  opa 
card-board  and  viewed  by  transmitted  fight 
shown,  of  about  one-tenth  of  the  actual  size,  in  ) 
514.  The  transparent  tests  are  intended  to  be  h 
in  a  window,  from  the  small  holes  at  the  top  of 
card,  against  a  bright  background  of  frosted  glass  o 
thin  paper;  the  other  test-cards  are  arranged  to  t 
interchangeably  on  a  pivot  at  the  center  of  a  lai 
card  representing  the  face  of  a  clock.* 


Fig.  514. 

Viewed  by  an  astigmatic  eye  at  a  distance  of  fh 
to  eight  meters,  the  lines  corresponding  in  directk 
to  one  of  its  principal  meridians  are  seen  more  clear 
denned  than  those  in  any  other  meridian;  the  brigl 
dots  appearing  fused  in  a  continuous  bright  hi 
in  the  same  meridian   (cf.  Figs.  512,  513).     In  tl 

*  A  small  figure  made  up  of  radiating  fine  lines  was  used  1 
Helmholtz2  and  by  Donders3  in  illustration  of  the  proposition  th: 
lines  corresponding  in  direction  to  the  two  principal  meridians 
an  astigmatic  eye  are  seen  alternately  sharply  defined  or  blum 
according  as  the  eye  is  accommodated  in  one  or  the  other  of  i 
two  focal  lines  (cf.  Fig.  511).  Donders4  and  Burow5  mounU 
such  a  diagram  in  an  optometer,  with  a  view  to  determining  tl 
grade  of  astigmatism  by  observing  the  distance  through  which 
was  necessary  to  move  the  test-object  within  or  beyond  the  prii 
cipal  focus  of  a  convex  lens  in  order  to  see  a  line  distinctly  in  tl 
alternate  meridians  of  greatest  and  of  least  ocular  refractioi 
Javal6  adapted  this  method  to  practical  use  by  the  invention  ( 
a  binocular  optometer,  in  the  form  of  a  stereoscope,  in  which  th 
two  eyes  were  fixed,  respectively,  upon  two  small  dials  (Fig.  515, 
The  test-objects  shown  in  Fig.  514  are  reproduced  from  a  papei 
bj-  the  writer  of  this  article,  in  the  Transactions  oi  the  An 
<  'phthalmological  Society,  186S;  diagrams  -/,  l>,  c,  were  pubttshe< 
with  an  introductory  note  by  Donders,  in  an  appendix  to  the  Re 
port  of  the  Netherlands  Ophthalmic  Hospital  for  1S67.7 


748 


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Astigmatism 


e£  of  simple  myopic  astigmatism  (Ami  oro! 

myopic  astigmatism   (M+Am)   this  meridian 

f.  Kit  of  greatest  ocular  refraction;  tin-  lines  appear- 
i   mspicuously  blurred,  and   the  dots   most 

ri  inctly  separated,  in  the  ocular  meridian  of  least 
on,  at  right  angles  to  the  first.  In  simple 
idropic  astigmatism  (Ah)  and  in  compound 
•tropic  astigmatism  (11+ Ah)  the  lines  are 
tarply  defined  and  the  dots  fused  together 
meridian  either  of  greatest  refraction  or  of 
Fraction,  according  as  they  are  viewed  under 
mi    or    minimum     accommodation     for    the 

i  ance  at  which  they  are  exposed.     In  mixed  astig- 


Fig.  515. 


ism   (Amh  or  Ahm)   the  lines  are  seen  sharply 

(  tued  and   the  dots  confused  in   the   meridian   of 

refraction  under  accommodation  equivalent 

t  the  hypermetropia  in  the  meridian  of  least  refrac- 

i.  the  lines  and  dots  then  appearing  as  in  the  case 
pie  myopic  astigmatism  (Am). 

The  differentiation  of  the  several  types  of  astigma- 
|  a  turns  on  their  transformation  to  a  common  type 
(in)   by  looking   through   a  concave  or  a   convex 

lerical  lens.  The  lens  by  which  this  transformation 
i  -fleeted  is  the  weakest  concave  lens  (in  M+Am) 
<  the  strongest  convex  lens  (in  H+Ah,  Ah,  and 
.  lh  or  Ahm)  through  which  the  lines  in  any  meridian 
i-ular  meridian  of  greatest  refraction)  are  seen 
I  urly  defined.  The  (negative  or  positive)  power 
i  this  spherical  lens,  in  dioptries,  is  the  measure  of 
ametropia    (myopia   or   hypermetropia)    in    the 

Jar  meridian  at  right  angles  to  that  indicated  by 
direction   of   the    sharply    defined    line   or   lines 

ular  meridian  of  least  refraction).  The  deviation 
■  the  meridian  of  greatest  refraction  from  the  vertical 

found  by  directing  the  attention  of  the  patient  to  a 
■igram  showing  a  large  number  of  radiating  lines  or 
| ! tors,  and  requiring  him  to  indicate,  in  minutes  of 
ae  on  the  clock-dial,  the  angle  of  declination  of  the 
-  e  or  sector  which  he  sees  most  distinctly. 
The  refraction   in   the   second   principal  meridian 

greatest  refraction)  may  be  measured  by  making 
stive  additions  of  concave  spherical  glasses  to 

■  concave  or  convex  lens  by  which  the   eye   has 

n  brought  into  the  condition  of  simple  myopic 
tigmatism  (Am).  In  making  this  examination  it  is 
nvenient  to  use  a  test-object  showing  parallel  lines 
:  I  c)  set  at  right  angles  to  the  previously  de- 
r mined  meridian  of  most  distinct  vision;  controlling 
e  measurements  for  both  meridians  by  further 
iala  with  test-objects  (Figs.  514,  d,f,  and  h),  display- 
g  crossed  lines,  or  sectors,  or  rows  of  bright  dots. 
Direct  measurements  of  the  grade  of  astigmatism 
made  by  correcting  the  eye  for  the  meridian  of 
•st  refraction,  and  making  tentative  additions  of 
ncave  cylindrical  glasses  until  a  lens  is  found 
rough  which  the  lines  or  rows  of  dots  in  the  two 
incipal  meridians  appear  equally  distinct.  Deter- 
ined  in  this  manner  the  expression  for  the  refractive 
lomaly  is  in  the  form,  M+Am  or  H+Am,  which 
ay  often  be  reduced  to  simpler  terms.     Thus  when 

=0,  or  H=0,  the  ease  is  one  of  simple  myopic 
itigmatism  (Am);  when  H=Am.  the  case  is  one  of 
mple  hypermetropic  astigmatism  (Ah);  when 
>Am,  the  case  is  one  of  compound  hypermetropic 
;tigmatism  (H  +  Ah);  and  when  H<Am,  the  case 
one  of  mixed  astigmatism  (Ahm  or  Amh). 


The  optical  correction  of  astigmatism  is  by  wearing 

a  spectacle  lens  of  asymmetrical  refraction,  of  such 

mounted  as  to  equalize  the  refraction 

of  the  eye  in  its  two  principal  meridians.     The  ^in- 
form of  lens  for  this  purpose  is  a  plano-cylin- 
di  ical  lens  mounted  so  that  the  axis  of  the  cylindrical 
surface  shall  lie   in   the   plane  of   the  ocular 'meridian 
of    greatest    retraction    when    the    cylindrical    SU1 
is  convex,  or  in  the  plane  of  the  "meridian  of 
refraction    when    the    cylindrical    surface    is   cones 
A  convex  piano-cylindrical  lens  in  the  case  of  -imple 
hypermetropic  astigmatism  (Ah),  or  a  concave  piano- 
cylindrical  lens  in  the  case  of  simple  myopic  astig- 
matism   (Am),    corrects    the   refractive   error    in    all 
meridians,     reducing     the    eve     to     the    condition     of 

emmetropia  (E).  In  all  other  cases  the  effect  of  the 
piano-cylindrical  lens  which  corrects  the  astigmatism 

i-  to  re, lu.e  the  eye  either  to  simple  hypermetropia 
(H)  or  to  simple  myopia  I  M).  Tocorrecl  this  residual 
hypermetropia  or  myopia  a  convex  or  a  concave 
spherical  surface,  of  appropriate  radius  of  curvature, 
may  be  ground  on  the  Lack  of  the  piano-cylindrical 
lens,  thus  making  a  spherico-cylindrical  lens  suited 
to  the  correction  of  the  combined  refractive  error. 

In  any  case  of  astigmatism,  the  equalization  of  the 
refraction  in  the  two  principal  meridians  may  be 
effected  either  by  a  convex  cylindrical  or  by  a  con- 
cave cylindrical  lens,  as  may  be  preferred.  Thus, 
in  Am,  it  is  usual  to  prescribe  a  plano-concave  cylin- 
drical lens;  but  we  may,  at  pleasure,  prescribe  an 
alternative  form  of  lens  combining  a  convex  cylin- 
drical with  a  concave  spherical  surface  of  equal 
(negative)  power.  In  M+Am,  we  ordinarily  pre- 
scribe a  lens  combining  a  concave  cylindrical  with  a 
concave  spherical  surface;  but  we  may,  at  pleasure, 
prescribe  an  alternative  lens  in  which  a  convex 
cylindrical  surface  is  combined  with  a  concave  spher- 
ical surface  of  a  (negative)  power  equal  to  the  sum  of 
the  (negative)  powers  of  the  concave  cylindrical  and 
the  concave  spherical  surfaces  in  the  former  com- 
bination. In  mixed  astigmatism  (Amh  or  Ahm), 
we  may,  at  pleasure,  combine  a  concave  cylindrical 
with  a  convex  spherical  surface,  or  a  convex  cylin- 
drical with  a  concave  spherical  surface.  In  Ah  it  is 
usual  to  prescribe  a  plano-convex  cylindrical  lens; 
but  we  may,  at  pleasure,  prescribe  a  lens  in  which  a 
concave  cylindrical  surface  is  combined  with  a  convex 
spherical  surface  of  equal  power.  In  H+Ah  we 
may  choose  between  a  lens  in  which  a  convex  cylin- 
drical surface  is  combined  with  a  convex  spherical 
surface  or  a  lens  in  which  a  concave  cylindrical  sur- 
face is  combined  with  a  convex  spherical  surface  of  a 
power  equal  to  the  sum  of  the  powers  of  the  convex 
spherical  and  the  convex  cylindrical  surface  in  the 
first  combination. 

The  greatest  latitude  of  choice  in  prescribing 
glasses  in  particular  cases  of  astigmatism,  is  afforded 
by  the  use  of  lenses  in  which  one  of  the  surfaces  is 
ground  to  a  curvature  of  unequal  radii  in  its  two 
principal  meridians.  Such  lenses,  having  either  a 
convex  or  a  concave  surface  ground  to  the  configura- 
tion of  a  segment  of  a  torus.*  are  made  of  any  required 
radius   of   curvature   in   each   of   the    two   principal 

*  Torus  is  a  word  used  in  architecture  to  designate  a  moulding, 
of  convex  cross  section,  carried  around  the  base  of  a  column.  In 
geometry,  a  torus,  or  tore,  is  the  surface  generated  by  the  revolu- 
tion of  a  circle  about  a  right  line  in  its  own  plane;  when  the  right 
line  is  taken  outside  the  circle  the  torus  has  the  form  of  a  ring — ■ 
anchor  ring.  A  strip  of  metal  of  this  cross  section.  )  or  (,  bent 
around  a  cylinder,  takes  the  form  of  an  equatorial  zone  of  a  torus, 
and  may  be  used  as  a  tool  for  grinding  either  a  concave  or  a  con- 
vex toric  lens  surface. 

The  designation  "toric,"  as  it  has  been  exploited  of  late  by 
makers  and  vendors  of  spectacles,  is  a  misnomer.  Many  of  the 
glasses  advertised  and  sold  under  this  misleading  name  are  such 
as  were  formerly  catalogued  as  "coquilles  of  positive  or  negative 
power,"  properly  designated  as  periscopic,  as  that  word  has  been 
understood  since  its  introduction  by  Wollaston  more  than  a  cen- 
tury ago. 


r49 


Astigmatism 


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meridians;  the  difference  in  power  in  the  two  merid- 
ians representing  the  required  astigmatic  correction, 
and  the  power  of  the  lens  in  one  or  the  other  of  these 
meridians  representing  the  correction  for  any  residual 
hypermetropia  or  myopia.  A  concave  toric  com- 
bined with  a  convex  spherical  surface,  or  a  concave 
spherical  combined  with  a  convex  torie  surface,  may 
be  prescribed  for  the  correction  of  any  case  of  simple, 
compound,  or  mixed  astigmatism.  Such  a  lens,  with 
the  concave  surface  (spherical  or  toric)  turned 
toward  the  eye,  may  be  so  proportioned  as  to  realize 
any  advantage  that  may  accrue  from  wearing  a 
spectacle-glass  of  the  periscopic  (concavo-convex  or 
meniscus)  configuration.  Lenses  ground  with  two 
unequal  cylindrical  surfaces  with  crossed  axes  do  not 
differ  appreciably  in  effect  from  equivalent  com- 
binations of  a  spherical  and  a  cylindrical  surface. 

Any  lens  set  obliquely  to  the  direction  of  a  pencil  of 
rays  refracted  through  its  center  develops  an  increase 
of  power  in  all  meridians,  but  most  in  the  meridian 
in  the  common  plane  of  the  axis  of  the  pencil  and  the 
axis  of  the  lens.  A  convex  or  concave  spherical 
spectacle  lens  may  thus  have  its  power  so  increased, 
by  tilting  it  forward,  as  to  render  it  equivalent  to  a 
spherical  lens  of  somewhat  greater  power  with  the 
addition  of  a  cylindrical  lens  mounted  with  its  axis 
horizontal.  This  property  of  lenses  is  sometimes 
utilized,  intentionally  or  unintentionally,  in  cases  of 
compound  myopic  astigmatism  (M+Am),  when  the 
ocular  meridian  of  greatest  refraction  is  vertical,  and 
in  cases  of  aphakia  after  cataract  extraction,  when, 
as  is  oftenest  the  case,  the  meridian  of  greatest  refrac- 
tion is  horizontal. 

As  the  ordinary  convex  or  concave  spherical 
glasses,  worn  in  hypermetropia  or  myopia,  have  the 
incidental  effect  of  increasing  or  diminishing  the 
apparent  size  of  objects,  so  the  effect  of  a  convex  or 
concave  cylindrical  glass,  worn  for  the  correction  of 
astigmatism,  is  to  increase  or  diminish  their  apparent 
magnitude  in  the  direction  at  right  angles  to  the  axis 
of  the  cylinder.  Thus  a  circle  is  made  to  appear  as  a 
somewhat  elongated  or  as  a  somewhat  compressed 
ellipse,  a  square  as  an  elongated  or  shortened  rect- 
angle or  as  a  rhombus,  etc.  This  distortion,  which 
is  in  proportion  to  the  power  of  the  cylindrical  glass 
required  to  correct  the  astigmatism,  may  cause 
temporary  annoyance;  or,  in  the  case  of  unequal  or 
unsymmetrical  correction  of  the  two  eyes,  it  may 
give  rise  to  special  stereoscopic  illusions.  Errors  of 
judgment  from  this  cause  are,  however,  speedily 
corrected,  as  the  patient  becomes  accustomed  to  the 
new  conditions. 

As  a  consequence  of  imperfect  acuteness  of  vision 
in  the  higher  grades  of  astigmatism,  an  astigmatic 
person  may  be  compelled  to  hold  his  book  very  near 
to  the  eyes  in  reading  fine  print.  The  effort  to 
differentiate  certain  characters,  through  intermittent 
forcing  or  rapid  changes  of  the  accommodation,  may 
also  be  a  cause  of  fatigue.  Particular  forms  of  astig- 
matism may,  therefore,  contribute  materially  to  the 
development  of  asthenopia,  either  accommodative 
or  muscular  (see  Asthenopia),  of  excessive  accommo- 
dative tension  and  progressive  myopia  (see  Accom- 
modation and  Refraction),  or  of  convergent  or  diver- 
gent strabismus  (see  Accommodation  and  Refraction). 

Irregular  Astigmatism. — Under  this  title  Don- 
ders  included  all  visual  defects  due  to  irregular  con- 
figuration of  the  cornea,  and  also  to  inequality  in  the 
refraction  of  the  crystalline  lens  in  its  different  sectors. 

Some  degree  of  irregular  astigmatism  is  present  in 
every  eye,  and  is  therefore  to  be  regarded  as  normal. 
Under  this  head  falls  the  irregularity  in  refraction 
which  results  from  scattering  of  the  rays  of  light  in 
passing  through  the  crystalline  lens.  If  we  prick  a 
very  small  hole,  with  the  point  of  a  fine  needle,  in  a 
blackened  card  and,  holding  it  a  little  within  the 
anterior   focus   of   the   eye    (14.8   mm.  =0.6   inch   in 

750 


front  of  the  cornea),  look  through  the  hole  at  a  brig 
light,  the  shadow  of  the  pupillary  opening  and 
radiating  lines  reproducing  structural  details  of  t 
crystalline  lens  will  be  thrown  upon  the  retina  a 
will  be  seen  as  delineated  in  Fig.  516  (Donders).' 
a  greater  distance  the  point  of  light  appears  as 
group  of  elongated  brght  spots  radiating  from  acoi 
mon  center  (Fig.  517)9  which,  with  further  increase 
distance,  takes  on  the  aspect  of  the  familiar  fieu 


Fig.  516. 

which  we  call  a  star.  If,  instead  of  a  luminous  pom 
we  look  at  a  minute  speck  of  white  pigment  on  a 
intensely  black  ground,  the  speck  will  appear  broke 
up  into  a  number  of  minute  white  specks,  with  pel 
haps  some  indication  of  a  stellate  arrangement  (po 
yop ia  in o u ophthal m ica). 

If  we  look  with  one  eye  at  a  figure  made  up  ( 
concentric  circles,  as  in  Fig.  51S  (after  Helmholtz)  th 
circles  will  appear  wavy  and  confused  in  partieula 
sectors,  and  will  also  appear  abruptly  bent  or  broke 
along  the  radii  which  separate  one  sector  from  anothei 


Fig.  517. 

From  this  and  from  the  preceding  experiment  it  if 
evident  that  the  eye  does  not  focus  individual  points 
sharply  upon  its  retina,  but  that  each  point  of  the 
object  is  represented  by  numerous  points  in  a  diffuse 
retinal  image  which,  in  the  case  of  a  distant  bright 
point,  is  perceived  as  a  spot  of  light  surrounded  by 
a  halo  of  divergent  bright  rays. 

In  general,  a  white  spot  or  line  on  a  black  ground 
is  visible  at  a  greater  distance  than  a  black  spot  on  a 
white  ground;  and  the  more  brilliant  the  object  the 
more   conspicuously   does  it  appear  expanded    and 


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Astringents 


Through  this  ''irradiation" 


,.  fused  i"  i<s  outline. 

I    twin  stars  (if  a  binary  system  are  seen  asji  single 


and  the  shining  crescent  of  the  planet  Venn-  is 

istinguishable  in  form  from  the  full  disk  of  Mars 

df  Jupiter-      !■"•"■    ,<l".   :ln   electric   arc   looks   like   a 

,.<it   star,  and   the   incandescent    loop  of  an  electric 

lb  appears   many   times   thicker   than   the   actual 

i.     Furthermore    a    star    appears    larger   and 

,  mi  less  brilliant  to  a  short -sighted  person  than  to 

"trope,  and,  in  the  presence  of  regular  astig- 

it  also  appears  elongated  in  the  direction  of 

ocular  meridian  of  greatest  (or  perhaps  of  least) 

m  (c/.  Fig.  512). 

n  irregular  astigmatism  from  altered  configuration 

ornea  following  the  healing  of  wounds,  ulcers, 

and  especially  in  cases  of  conical  cornea  (kerato- 

ilie  visual  disturbance  may  often  be  resolved 


Fig.  518. 

part  into  regular  astigmatism,  and  vision  may  then 

materially    improved    by    wearing    appropriate 

lindrical   or   spherico-cylindrical   glasses;   in   other 

sea  the  definition  of  objects  is  much  improved  by 

.king  through  a  small  hole  or  narrow  slit  punched 

a  blackened  card  or  in  a  thin  plate  of  metal  (steno- 

ic  slit,  from  arevbs,  narrow,  and  d-n-q,  on  opening). 

Abnormal    irregular    astigmatism,    with    multiple 

■;ion,  may  occur  as  a  result  of  changes  in  the  crys- 

ine  lens,  incident  to  the  incipient  stages  of  cataract; 

|iii'  refraction  also  may  be  developed  at  the  same 

ae,  probably  through  an  increase  in  the  convexity 

the   lens.  Johx  Green. 


References. 

1.  E.G.  Loring:  Transactions  of  the  American  Ophthalmological 
..•ty,  1S69,  1874,  1878. 

2,  H.  Helmholtz:  Handbuch  der  Phvsiologischen  Optik,  PI.  II., 
6,  1856. 

i.  F.  C.  Donders:   On    the    Anomalies  of  Accommodation  and 
lotion  of  the  Eye,  1864. 

4.  F.  C.  Donders:  Archiv  fur  Ophthalmologic,  vii.,  i.,  1860. 

5.  A.  Burow:  Ibid.,  ix,  ii,  1S63. 

i     Jural:  Annales  d'  Oculistique,  liii.,  1865. 

nth    Annual   Report   of   the    Netherlands    Ophthalmic 
apital,  Utrecht,  1867. 
8.  F.  C.  Donders:  Op.  tit. 
8.  II.  Helmholtz:  Op.  tit. 


Astrocytoma. — A  form  of  glioma  composed  of  cells 
iih  relatively  short  radiating  fibrillar,  the  so-called 
drocytes.      (See  Glioma.)  A.  S.  W. 


Astringents. — Astringents,  from  ad,  to,  and  stringere, 
o  bind),  are  agents  which,  acting  locally,  produce 
indensation  and  corrugation  of  tissues  by  preci- 
itating  their  contained  albumin  and  gelatin,  and  by 


diminishing    the    amount    of    fluids    present    ill    pi"!"- 

plasm.  They  also  cause  contraction  of  living  muscu- 
lar fiber,  possibly  bydireel  irritation.     Secretion  from 

muCOUS    membranes    and    from    denuded    surfaces    is 

lessened  by  astringents,  which  produce  a  constricting 
effect  upon  the  capillary  1>1 [-vessels  and  also  per- 
haps at  the  Mime  time  upon  the  glands  and  their 
duets.  All  the  astringents  except  alcohol  produce 
some  sort  of  chemical  action  which  promotes  destruc- 
tive metamorphosis.  Alcohol,  on  the  other  hand,  re- 
tards these  retrograde  changes  in  the  tissues.  Astrin- 
gents are  classified  as  vegetable  and  mineral;  but  their 
action  is  always  a  local  one;  and  t  he  attempt  to  make 
a  division  into  those  whose  action  is  local  and  those 
whose  action  is  remote  is  unwarranted. 

Vegetable  astringents  depend  for  their  action  upon 
the  contained  tannic  and  gallic  acids.  Arranged 
a.phabetically,  the  chief  vegetable  astringents  are 
galla,  gambir,  geranium,  granatum,  hamamelis, 
hcmatoxylon,  kino,  krameria,  quercus,  rhus  glabra, 
uva  ursi,  and  all  other  substances  which  contain  tan- 
nic acid.  Among  the  mineral  astringents  may  be 
mentioned  the  dilute  acids  (acetic,  carbolic,  hydro- 
chloric, nitric,  sulphuric),  alcohol,  alum,  bismuth  sub- 
nitrate  and  other  bismuth  salts,  cadmium  sulphate, 
chalk,  cocaine,  cerium  oxalate,  copper  sulphate,  creo- 
sote, ferric  chloride  and  ferric  salts,  lead  acetate  and 
subacetate,  zinc  preparations,  especially  the  oxide 
and  the  sulphate,  and  several  other  metallic  salts. 

Astringents  are  valuable  styptics  and  hemostatics 
and  they  also  harden  and  restore  tone  to  relaxed 
tissues.  They  cause  capillary  vessels  to  contract, 
and  they  constrict  glands  and  their  ducts.  They 
exert  some  control  over  inflammation  and  they  di- 
minish the  secretion  from  mucous  membranes  and  from 
denuded  surfaces.  They  excite  contractions  in  mus- 
cular fiber,  and  they  cause  spongy  granulations  to 
wither  away.  When  applied  to  an  ulcerated  or 
denuded  surface  they  bring  about  (through  coagula- 
tion of  the  protoplasmic  albumin)  the  formation  of  a 
pellicle  which  covers  and  protects  this  surface  from 
the  atmosphere  and  from  external  irritants.  Thus, 
pain  is  lessened  at  the  same  time  that  healing  is  pro- 
moted by  astringents.  With  three  exceptions  all 
astringents  irritate  more  or  less.  They  are  there- 
fore contraindicated  in  acute  inflammation.  The 
three  sedative  astringents  are  lead  acetate  or  (sub- 
acetate),  cerium  oxalate,  and  bismuth  subnitrate. 

Antagonists  and  Incompatibles. —  Vegetable  astrin- 
gents are  incompatible  with  the  "ic"  and  "ous" 
salts  of  iron  also  with  the  salts  of  antimony,  copper, 
lead,  silver,  and  zinc;  with  alkalies,  alkaloids,  and 
glucosides;  and  with  pepsin,  albumin,  gelatin,  emul- 
sions, and  the  mineral  acids. 

Uses  and  Therapeutic  Applications. — To  check  ex- 
cessive secretion  from  the  skin,  as  in  hyperidrosis 
or  in  night  sweats,  to  check  secretion  from  mucous 
membranes,  as  in  the  various  catarrhs,  to  lessen  secre- 
tion from  denuded  and  ulcerated  surfaces,  and  to 
arrest  bleeding.  It  must  always  be  remembered  that 
astringents  are  not  to  be  used  until  the  inflammation 
reaches  that  stage  in  which  the  secretion  from  the  in- 
flamed part  is  beginning  to  be  excessive.  Where  the 
part  can  be  directly  reached,  as  in  epistaxis,  hemate- 
memesis,  hemorrhage  from  lower  bowel,  hemorrhoids, 
rectal  fissure  or  ulcer,  prolapsus  ani,  subacute  or 
chronic  conjunctivitis,  otorrhea,  etc.,  tannic  acid  is 
preferable  to  gallic.  In  bed  sores  or  where  excoriation 
is  taking  place,  as  in  dermatitis  intertrigo,  alcohol, 
bismuth,  or  tannic  acid  will  be  found  useful  as  a  means 
of  hardening  the  skin.  Finally,  since  tannic  acid  is 
chemically  incompatible  with  the  alkaloids  and  gluco- 
sides, it  may  serve  as  a  useful  chemical  antidote  in 
poisoning  from  these  active  principles.  It  accom- 
plishes this  good  effect  by  throwing  down  a  very 
slowly  soluble,  or  entirely  insoluble,  therefore  inert, 
tannate  of  the  alkaloid  or  glucoside  in  question. 

R.  J.  E.  Scott. 


751 


Asynergia 


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Asynergia. — This  is  a  complex  of  syndromes 
described  by  Babinski  as  being  characteristic  of 
cerebellar  defect.  He  speaks  of  it  as  a  decomposi- 
tion of  movements  and  of  their  elementary  constitu- 
ents. The  patient  is  incapable  of  combining  the 
series  of  movements.  It  is  a  constituent  of  certain 
ataxias,  or  perhaps  more  properly  speaking,  a  sub- 
variety  or  separate  group  which  is  included  in  the 
larger  and  more  heterogenous  group  of  ataxias. 
(See  Ataxia.)  Babinski  has  included  it  with  adiado- 
chokinesia  and  cerebellar  catalepsy,  under  the 
general  head  of  a  "  cerebellar  syndrome." 

Asynergia  he  defines  as  of  two  types.  The  major 
type  shaws  itself  in  walking.  Such  a  patient,  sup- 
ported by  each  arm,  raises  his  legs  very  high,  and 
gradually  walks  away  from  beneath  himself,  and 
would  fall  if  not  supported.  In  minor  degree  this 
would  cause  the  symptom  of  retropulsion  so  fre- 
quently observed  in  paralysis  agitans.  There  is 
moreover  a  wavy  line  in  the  progression  of  the  patient. 

Patients  with  the  minor  type,  on  standing  erect  and 
then  bending  the  head  backward,  fail  to  arrange  the 
back  and  lower  limbs  in  an  adaptive  series  of  arches. 
The  legs  are  held  straight  and  stiff,  and  the  whole 
bend  takes  place  from  the  hips  or  mid-dorsal  region. 
Naturally  such  attempts  result  in  falling  backward. 
Again,  such  patients  find  it  impossible  to  assume  a 
sitting  position  when  lying  flat  upon  their  backs 
with  their  arms  folded.  The  legs  come  in  the  air  in 
spite  of  all  effort  to  hold  them  down. 

Asynergia  thus  described  by  Babinski,  with  the 
other  features  of  his  cerebellar  syndrome,  cerebellar 
catalepsy  and  adiadochokinesia,  indicate  lesions  of 
the  cerebellum,  but  just  where  has  not  yet  been 
determined;  certainly  not  all  lesions  of  the  cerebellum 
result  in  this  syndrome. 

Thomas's  olivo-ponto-cerebellar  atrophy,  a  dis- 
tinct cerebellar  defect,  does  not  show  the  syndrome 
in  its  completeness — thus  no  catalepsy  is  known. 

Lesions  of  the  inferior  cerebellar  peduncle  may 
produce  asynergia.  It  is  not  infrequent  in  multiple 
sclerosis  of  the  cerebellum,  and  is  also  present  in 
some  cerebellar  tumors.  Its  absence  will  not  nega- 
tive a  tumor  of  this  organ,  but  such  a  negative  finding 
probably  would  exclude  the  implication  of  the  corpus 
restiforme  at  least.  As  asynergia  is  rarely  present 
without  a  fairly  rich  complex  of  other  symptoms  the 
topographical  diagnosis  is  thereby  rendered  possible. 

Smith  Ely  Jelliffe. 

Atavism. — See  Reversion. 

Ataxia. — This  will  be  considered  here  only  as  a 
descriptive  symptom,  not  characteristic  of  any  one 
disease,  such  as  tabes,  since  such  a  disorder  may 
exist  without  it,  and  moreover  a  disturbance  of 
motor  function  may  be  found  in  a  number  of  different 
disorders. 

It,  like  practically  all  other  so-called  symptoms, 
is  nothing  but  a  rough  grouping  of  functional  derange- 
ments which  becomes  manifest  when  certain  con- 
ducting tracts  of  the  nervous  system  are  out  of 
service,  either  temporarily  or  permanently. 

The  integrity  of  the  conducting  paths,  both  sen- 
sory and  motor,  maintains  the  normal  quality  of  a 
function  which  is  of  value  to  the  human  animal 
either  in  maintaining  his  own  life,  constructively  or 
defensively,  or  in  perpetuating  the  species.  Out  of 
these  primary  needs  movements  have  resulted 
which,  as  is  well  known,  in  man  get  to  be  smooth, 
exact,  and  definite,  i.e.  they  become  related  with 
reference  to  time,  space,  and  weight.  They  are 
properly  timed — agonist  and  antagonist — to  control 
time  and  spatial  relations  and  to  judge  and  choose 
among  relations  between  masses.  They  are,  in 
other  words,  adjusted  to  do  useful  work. 

There  are  many  disorders  of  movement,  but 
ataxia  has   been   chosen   from  among   them   as   the 

752 


subject  matter  of  this  short  sketch.  Here  the  d 
turbance  of  movement  shows  itself  largely  as  a  d 
turbance  of  space  and  time  relations.  There  is 
paralysis,  no  loss  of  ability  on  the  part  of  the  mus* 
to  move  masses,  either  its  own  or  external  ma,-.-. 
but  the  movements  have  become  illy  timed  ( 
jerky,  and  illy  spaced;  they  overshoot,  or  undi 
shoot,  or  pass  by  the  object  intended  to  be  moved 
acted  upon. 

The  movements  designed  for  useful  work  becoi 
jerky,  irregular,  inexact,  and  strained  or  floppy. 

The  defect  in  time  relation  expresses  itself  in  d 
turbance  of  order  or  sequence,  that  of  space  in  t 
rhythm,  while  that  of  estimation  of  molar  resistai 
shows  in  variations  in  strength. 

Every  motor  act  is  extremely  complex,  and  i 
volves  a  number  of  innervation  factors.  These  a 
both  motor  and  sensory,  and  a  complete  analysis 
ataxia  renders  it  necessary  to  scrutinize  both  seri 
of  arcs.  These  arcs  moreover  are  not  exclusive 
spinal;  they  involve  the  whole  cerebrospinal  a s 
It  is  by  reason  of  this  wide  anatomical  distribution 
the  sensorimotor  arcs  that  an  ataxia  may  result  fro 
lesions  in  very  diverse  portions  of  the  anatomii 
paths;  such  as  for  instance,  a  posterior  column  lumb 
cord  lesion,  a  cervical  cord  lesion,  a  cerebellar  corti 
lesion,  cerebellar  peduncle  lesion,  a  cerebellorubr 
tract  lesion,  a  thalamocortical,  or  corticothalam 
tract  lesion,  a  vestibular  path  lesion,  etc. 

Theoretically,  one  could  obtain  identical  types 
ataxia    from    these    variously    located    lesions,   h 
practically   this  rarely   occurs,   since   few  lesions 
nature's  experiment,  disease,  are  strictly  limited 
their  application  to  isolated  functional,  anatomic 
pathways.     For  this  reason,  largely,  it  is  found  th; 
these    various    ataxias    are    associated    with    oth< 
defects  which,  in  greater  or  lesser  degree,  stamp  the 
as    spinal    ataxias,     mid-brain     ataxias,     cerebefh 
ataxias,  cerebral  ataxias,  labyrinthine  ataxias,  etc. 

Classical  peripherospinal  ataxias  are  seen  chief) 
when  the  peripheral  sensory  pathways  convcyii 
knowledge  of  mass  (i.e.  weight  relations),  are  inte 
fered  with.  These  occur  in  tabes  (posterior  root.- 
in  neuritis,  alcohol  or  lead  diabetes  (peripher: 
neurone),  in  rare  cases  of  multiple  sclerosis  or  syringi 
myelia,  hypertrophic  interstitial  neuritis,  or  in  pre: 
sures  from  tumors,  bone  disease,  etc.,  on  the  po: 
terior  columns  of  the  cord. 

In  the  arms  such  an  ataxia  shows  itself  in  th 
finger-nose  test  (F.  N.  T.)  or  the  finger-finger  tet 
(F.  F.  T.)  by  the  wavy  irregular  approach,  the  ovei 
shooting,  or  undershooting,  or  passing  the  nose  o 
finger,  and  the  general  attitude  of  uncertainty  an  | 
apparent  clumsiness  of  the  whole  movement.  1 
the  lower  extremities  such  an  ataxia  shows  itelf  i 
the  knee-heel  test  by  a  precisely  similar  series  o 
uncertain  wavering  movements,  and  in  walking  b; 
the  classical  irregular,  staggering,  uncertain  gail 
which  is  usually  rendered  much  worse  the  moo  ei 
the  help  of  the  eyes,  which  aid  in  judging  space  rela 
tions,  is  removed.  The  Romberg  test  brings  thi 
out  to  perfection.  Certain  tabetics  with  opt  i' 
atrophy  and  blindness  either  show  no  ataxia,  o 
show  an  improvement  in  the  ataxia  with  advancinj 
blindness.  The  reason  for  this  is  a  matter  of  con 
jecture. 

Many    such    ataxias    are    associated    with    othci 
signs  of  sensory  loss  or  defect. 

Ataxias  of  the  head  and  neck  are  rarer  but  an 
found,  especially  in  tabes.  The  muscles  of  the  fact 
may  show  ataxias  in  grimacing,  in  speech,  in  swallow- 
ing. These  movements  may  be  mistaken  for  choreii 
movements,  but  are  usually  less  rapid  and  forced. 
Ataxia  of  the  tongue  (of  tabetic  peripheral,  peripbero- 
central  origin)  is  not  infrequent.  In  general  pan 
where  central  neurones  are  also  involved,  it  is  usually 
an  early  and  marked  feature. 

In  tabes  it  may  be  borne  in  mind  that  any  portion 


REFERENCE    HANDBOOK   OF   THE    MEDICAL    SCIENCES 


Ataxia,  Fried  relch'H 


(  the  anatomical  pathway  may   be  involved  so  thai 
.,   may  have  a  spinal  tabetic  ataxia,  a  medullary  or 
.  |  brain  tabetic  ataxia,  or  a  cerebral  tabetic  ataxia 
aeral  paresis).  _ 

!  peripheral  am!  antral  ataxias  arc  the  clas- 

,1   ataxias   of   developed    tabes    of   certain    spinal 

d  degenerations,  such  as  those  seen  in  pernicious 

in    syphilis,    Addison's    disease,    in    pellagra, 

|  ergotism,   in    certain   arterioscleroses  of   (he   spinal 

and    in     that     complex    group    of    disorders, 

i  mlly  classed   under  the  name  of  Friedreich's  dis- 

whieh  there  is  defect  of  cerebellar  tracts  to  a 

or  lesser  extent. 

of   the   peripheral  or  spinomedullary  ataxias 

ociated  with  the  loss  of  tendon  reflexes,  as 

las  disturbances  in   deep   sensibility    (tuning-fork 

These  are  aids  in  determining  which  anatom- 

i  hways   are   involved    in    the   process    which 

about   the  functional  disturbance.     Thus  for 

ani-e  it   has  been  assumed   that   Romberg's  sign 

Largely  due  to  involvement  of  the  peripherospinal 

■  of    the    vestibular.      This    is   now    considered 
ibtful. 

,  In  liar  ataxias  quite  similar  phenomena  are 

i    with.     Here,   however,    there   is   usually    more 

plication  of  time  and  space  relations.     The  ataxias 

e   callable  of   separation   into  subgroups — the 

Brgias  and  the  adiadochokinesias  (q.i\).     In  the 

ibeUar  ataxias  per  se  one  obtains  with  the  F.  N.  T. 

I   1'.   F.  T.   wider  excursions  with  usually   slower 

ions  in   the  directions.     The  overshooting   is 

Inounced    (asynergia)    and    may   be   brought   out 
having  the  patient  mark  out  a  line  of  definite 
I  gth    on   a   blackboard    or    on    paper.     Here    the 
:ixic  (asynergic)  will  make  a  shorter  or  longer  line 
in  the  example  set.     In  grasping  a  glass  of  water 
;  •  fingers  are  opened   unnecessarily   wide,   and   in 
■  Iking  the  patient  makes  much  wider  excursions — 
liken  reeling  gait — as  Duchenne  (who  first  pointed 
the  differences  of  spinal  and  cerebellar  ataxia) 
led  it — the  action  of  the  antagonists  being  either 
essive  or  insufficient,   from   the   imperfection   of 

■  knowledge  of  space  and  time  relations  conveyed 
i  the  cerebellar  mechanisms.1 

Asynergia  of  the  lower  extremities  may  show 
i  elf  in  the  tendency  of  the  patient  to  walk  out  under- 
lth  himself,  or  vice  versa.  This  is  a  feature  of  the 
^pulsions  and  retropulsions  of  paralysis  agitans, 
heating  that  cerebellar  mechanisms  are  involved 
that  disease. 

This   inability    to    time    the   related    impulses    in 

lonist  and  antagonist  is  seen  in   the  special  sub- 

riety  of  ataxia — adiadochokinesia.     Here  attempts 

perform  rapidly  alternating  movements — turning 

ists,  five-finger  exercises,  etc. — brings  out  clumsy, 

j'kward    actions.     These    signs    characterize    more 

rticularly    the    ataxias,    which    result    when    the 

ebellar  paths  are  implicated.     They  are  frequent 

multiple   sclerosis,   in    cerebellar   disease,   tumor, 

enesis,    abscess,    hemorrhage,    in    Marie's    ataxia, 

d  in  severe  choreas,  in  some  beginning  cases  of 

ralysis  agitans,  before  the  spasticity  has  developed. 

■e  eye  control  of  space  relations  bears  little  upon 

fir  exhibition,   hence   these   phenomena,   drunken 

it,    asynergias,    adiadochokinesias,  etc.,     are     not 

ile  much  worse  by  closing  the  eyes.     There  is  no 

imberg.     Certain    associated    oculomotor  phenom- 

a    however     are    very      frequent.       These     often 

list  in  certain  forced  positions  of  the  head,  which 

nil  altered  bring  about  equilibrium  disturbances. 

inthine  ataxias,  in  addition  to  the  symptoms 

typical    cerebellar    ataxias,    also    show    various 

pes  of  horizontal  and  rotatory   nystagmus.     This 

a  complicated  field,  and  is  best  taken  up  in  the 

Of  nystagmus  d/.v.). 
Pontine    ana    mid-brain    ataxias    are    difficult    to 
alyze.     There  are  rarely  pure  in  type  since  they 
e  due  to  lesions  which  are  apt  to  include  several 

Vol.  I.— 48 


sensory  and  motor  pathways.  They  are  apt  to  con- 
lain  elements  of  both  the  spinal  and  cerebellar  ten- 
dencies. Lesions  of  the  inferior  cerebellar  peduncle 
alone  are  apt  to  can-"  a  lypieal  asynergia. 

Cerebral  ataxias,  for  the  I  pari  develop  par- 
ticularly from  frontal  lobe  affections,  wherein  certain 
thalamocortical  pat hs  are  involved,  The  anatomical 
localizations  of  these  t halmocortical  paths  are  not 
yet  definitely  ascertained.  The  ataxia  manifests 
itself  clinically,  so  far  as  gait  is  concerned,  in  a 
manner    closely    related    to    the    gait    of    cerebellar 

ataxias,   but    the  alaxia   is   less   frequently   associated 

with    the    more    special    cerebellar    Bubvarieties    or 

asynergia     or      adiadochokinesia.      Moreover      other 

pecial    sensory    symptoms   should    permit    a    clinical 

separation   of  a  cerebral  from  a  cerebellar  ataxia. 

Cerebral  ataxias  are  apt  to  be  unilateral,  are  rarely 
so  complete,  although  at  times  the  titubation  is  very 
pronounced. 

Pronounced  posthemiplegic  cerebral  ataxias  are 
not  infrequent.  They  are  naturally  unilateral,  are 
rarely  as  complete  as  tabetic  ataxias  and  are  of  I  en 
associated  with  sensory  defect — incomplete  or  mixed 
thalamic  syndrome. 

Cerebral  ataxias  when  in  .the  gait  seem  to  show- 
little  change  if  the  eyes  are  closed.  Slight  increase 
of  staggering  only  may  appear. 

The  special  ataxias  of  speech — dysarthria,  anar- 
Ihria,  etc.,  have  precise  analogies  with  the  spinal, 
cerebellar,  and  cerebral  ataxias  of  other  muscle 
groups.  They  are  more  difficult  of  analysis  how- 
ever by  reason  of  the  greater  complexity  of  the 
speech  mechanism. 

Ataxias  are  present  in  the  neuroses,  psychoneu- 
roses,  and  psychoses.  Their  individual  separation 
would  carry  one  too  far  afield. 

Smith  Ely  Jelliffe. 

1.  Thomas:  Cerebellar  Functions;  Nervous  and  Mental  Disease, 
Monograph  Series  No.  12,  1912. 


Ataxia,  Friedreich's. — The  condition  known  also 
as  hereditary  ataxia  was  first  described  by  Fried- 
reich in  1861,  and  a  detailed  account  was  published 
by  him  in  1863,  with  three  autopsies.  In  1876  he 
published  a  further  paper  on  the  subject,  with  a 
description  of  three  new  cases.  From  this  time  on, 
through  the  investigations  of  Schultze,  Rtitimeyer, 
DeMe>ine  and  others,  the  affection  came  to  be  clearly 
recognized  as  an  hereditary  disease  of  childhood, 
affecting  chiefly  the  spinal  cord,  and  characterized  by 
a  type  of  ataxia  hitherto  undescribed.  W.  Everett 
Smith  in  1885  published  an  important  paper  on  the 
subject  of  "hereditary  or  degenerative  ataxia."  in 
which  he  described  six  cases  in  one  family,  with  an 
autopsy.  He  was  able  at  that  time  to  collect  fifty- 
seven  cases  from  the  literature.  In  1890  Ladame 
made  a  critical  digest  of  the  subject,  published  in 
translation  in  Brain,  in  which  he  summarized  the 
knowledge  up  to  that  year,  and  gave  full  bibliograph- 
ical references.  Nine  autopsies  only  had  been  record- 
ed, and  five  of  these  were  in  Friedreich's  own  cases. 
Oscar  Richardson  has  recently  described  the  post- 
mortem findings  in  a  second  ease  from  the  familv 
reported  in  1885  by  W.  Everett  Smith.  In  1893 
Marie  described  a  condition  which  he  called  cerebellar 
heredoataxia  allied  to  Friedreich's  ataxia,  but  as  he 
I  hen  thought  sufficiently  characteristic  to  be  deserving 
of  a  separate  classification.  He  based  his  conclusions 
upon  sixteen  cases,  in  which  among  other  symptoms, 
the  knee-jerks  were  increased  instead  of  decreased  or 
lost,  as  in  Friedreich's  ataxia.  Further  investigation 
has  shown  that  this  condition  is  more  properly  to  be 
regarded  as  a  stage  in  or  variety  of  the  fundamental 
process  than  as  a  distinct  disease  entity. 

Pathological  Anatomy. — The  spinal  cord  has 
usually  been  found  small  and  somewhat  imperfectly 

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developed,  which  is  in  accordance  with  the  apparently 
hereditary  character  of  the  disease.  The  alterations 
first  described  by  Friedreich  consisted  in  a  degenera- 
tion of  the  dorsal  tracts,  atrophy  of  dorsal  roots,  and 
certain  changes,  slight  in  degree,  in  several  peripheral 
nerves.  Later  study  has  shown  that  wider  areas  of 
the  white  matter  are  involved  than  was  at  first 
supposed,  and  that  the  gray  matter  also  takes  part 
in  the  degenerative  process,  though  to  a  much  less 
marked  degree.  Degeneration  of  the  dorsal  tracts  to 
a  very  considerable  extent  is  constant,  with  a  probable 
constant  accompaniment  of  degeneration  of  dorsal 
nerve  roots,  giving  an  appearance  wholly  analogous 
to  tabes,  and  leading  to  the  assumption  that  the 
primary  sensory  neurone,  as  such,  is  involved.  The 
direct  cerebellar  tract  is  degenerated;  Gowers'  tract 
and  Lissauer's  bundle  may  be.  Various  observations 
have  been  made  regarding  the  motor  pyramidal  tracts, 
and  it  is  still  in  dispute  whether  they  are  in  themselves 
involved  as  neurone  systems  in  the  same  way  that  the 
dorsal  tracts  are.  Degeneration  in  the  region  of  the 
pyramidal  tracts  decreases  from  below  upward,  and 
disappears  (Leyden-Goldscheider)  at  the  lower  level 
of  the  oblongata.  In  Richardson's  case,  the  patho- 
logical anatomy  of  which  he  has  described  and  which 
he  has  given  me  the  opportunity  of  studying,  the 
following  lesions  of  the  white  matter  were  definite: 
degeneration  of  dorsal  columns  throughout  the  cord, 
and  of  dorsal  nerve  roots  in  the  lumbar  region; 
degeneration  of  pyramidal  tracts,  of  somewhat 
iessening  intensity  toward  the  upper  portions  of  the 
lord,  including  the  uncrossed  tracts  in  the  cervical 
cegion;  degeneration  of  direct  cerebellar  tracts,  and 
rn  less  degree  of  the  region  of  Gowers'  anterolateral 
ascending  tracts  (see  Fig.  519). 

In  the  gray  matter  the  cells  of  Clarke's  columns 
have,  in  certain  cases,  shown  degenerative  changes, 
along  witli  the  myelinated  fibers  of  that  nucleus. 
Alterations  in  other  portions  of  the  gray  matter  of 
the  cord  have  been  described,  but  are  of  somewhat 
doubtful  character.     Very  few  observations  on   the 


Fig.  519. — The  Spinal  Cord  in  Friedreich's  Ataxia. 

peripheral  nerves  have  been  made,  but  certain  degen- 
erations have  been  described  which  would  be  in 
accord  with  the  theory  of  a  neurone  degeneration. 
The  type  of  lesion  in  the  cord  is  similar  to  that  found 
in  other  sclerotic  processes,  an  overgrowth  of  neuroglia 
following  a  greater  or  less  degree  of  destruction  of 
myelinated  fibers.  The  theory  of  a  primary  over- 
growth of  neuroglia  has  not  been  generally  accepted. 
Alterations  in  the  blood-vessels  in  degenerated  areas 
occur,  and  also  have  been  described  in  the  pia  and 
nerve  roots,  but  no  characteristic  significance  is  to  be 
attached  to  the  changes  found. 

The  cause  of  the  foregoing  anatomical  alterations 
has,  in  general,  been  sought  in  a  defect  of  develop- 
ment, of  hereditary  character,  leading  to  early 
degenerative  changes  in  the  spinal  cord.  The  dis- 
tribution of  these  changes  in  the  relatively  few  cases 
examined  postmortem  has  led  certain  observers  to 
the    assumption    of    a    combined    systemic    disease, 


which  gains  weight  from  the  fact  that  the  disea* 
occurs  as  a  family  affection,  and  apparently  does  nt 
depend  upon  faulty  blood  states  or  vascular  cond 
tions  within  the  cord  itself.  Certain  cases,  howeve 
do  not  show  a  sharply  systematized  degeneratioi 
although  the  lesions  are  always  of  a  quasi-system 
character.  The  study  of  Richardson's  case,  to  whic 
I  have  already  alluded,  leads  to  the  conclusion  thi 
neurones,  as  systems,  are  involved,  though  it  canm 
be  said  with  certainty  that  groups  of  neurones, 
which  our  knowledge  is  as  yet  deficient,  may  'n< 
also  be  degenerated.  In  support  of  this  assumptio 
is  the  distinct  degeneration  of  dorsal  nerve  roots  an 
of  direct  pyramidal  tracts,  as  well  as  the  characterise 
degenerations  of  the  recognized  neurone  system 
The  most  satisfactory  conception  of  the  disease 
fore,  is  that  in  congenitally  defective  nervous  systen 
early  degenerations  of  a  systemic  or  quasi-systemi 
character  take  place,  chiefly  limited  to  the  spin; 
cord,  which  progress  exceedingly  slowly,  ultimate! 
leading  to  characteristic  motor  and  sensory  disorder: 

Symptomatology. — The  most  conspicuous  featur 
of  (lie  disease  is  a  characteristic  incoordination,  whic 
is  best  described  as  a  combination  of  a  tabetic  and 
cerebellar  ataxia.  The  gait  is  uncertain,  slrro 
highly  incoordinate,  and  accompanied  by  a  considei 
able  degree  of  swaying  from  side  to  side.  Stati 
ataxia  is  well  marked  in  the  extremities  and  lieu 
after  the  disease  has  progressed  beyond  its  iaitii 
stages.  The  Romberg  sign  (swaying  with  the  eye 
closed)  is  much  less  constant  than  in  tabes,  but  ha 
been  described  in  certain  cases.  A  further  charactei 
istic  motor  disturbance  is  peculiar  involuntarj 
chorea-like  movements  involving  the  head,  whir 
persist  during  rest,  but  are  increased  on  intends 
movement.  At  times  a  definite,  so-called  intentio 
tremor  may  develop.  True  paralyses  do  not  occtl 
in  the  long  course  of  the  disease,  except  in  the  latt 
more  or  less  helpless  stage,  when  weakness  of  niuscl 
groups  may  develop,  and  finally  paraplegia  wil 
contractures,  which  renders  locomotion  impossibl 
Another  very  constant  motor  disorder,  but  not  on 
the  earliest  signs,  is  nystagmus,  which  is  usually  no 
present  when  the  eyes  are  at  rest,  but  may  be  ekcite 
by  fixation,  particularly  in  a  lateral  direction.  Thi 
sign  should,  however,  be  interpreted  with  caution 
Disturbance  of  speech  is  a  further  important  sign;  it  i 
slow,  difficult,  irregular  in  utterance,  and  hard  t< 
understand.  The  tongue  is  tremulous  and  is  the  sen 
of  twitching  movements,  suggesting,  in  conjunctioi 
with  the  speech  disorder,  disturbances  of  coordina 
tion  similar  to  those  observed  in  the  extremitie 
and  possibly  bearing  some  analogy  to  multipli 
sclerosis. 

For  reasons  not  easy  of  explanation  the  sensorj 
sphere  suffers  in  very  slight  degree,  in  marked  con 
trast  to  tabes.  With  but  few  trifling  exci  ption 
muscle  sense  and  skin  sensibility,  as  well  as  thi 
special  senses,  have  been  found  unimpaired.  Tin 
occasional  occurrence  of  sharp  pains  and  of  abnorma 
subjective  disorders  of  sensibility  in  the  extremities 
is  of  interest  only  because  of  the  rarity  of  these.  Ii 
view  of  the  constant  extensive  degeneration  of  sensor; 
areas  in  the  cord,  and  the  high  degree  of  incoordina 
tion  early  developed  in  the  disease,  this  lack  o: 
objectively  demonstrable  sensory  disorders  must  1" 
regarded  as  one  of  the  striking  peculiarities  of  th< 
disease.  An  appeal  to  vicarious  or  certainh  addei 
function  in  neurones  remaining  intact  in  an  affectioi 
of  very  gradual  progression,  may  be  suggested  by  waj 
of  explanation.  Spiller1  has  recently  called  attention 
to  the  fact  that  the  lesions  of  Friedreich's  ataxia  are 
by  no  means  limited  to  the  cerebellum  and  spinal  cord. 
On  the  basis  of  a  painstaking  pathological  examina- 
tion, he  concludes  that  changes  occur  in  the  brain, 
peripheral  nerves,  ventral  horn  cells,  and  in  the  mus- 
cles.    It    remains    obscure,    however,    why    sensory 


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Atelectasis 


irdera  are  so  conspicuously  lacking  in  spite  ol 
feneration  of  the  dorsal  tracts.  Spiller  also 
'cribes  for  the   first    time  a  degeneration    in    the 

<orv  portion  of  the  tifth  nerve  and  the  appearance 

naked   axones    in    degenerated    columns   of    Goll. 

,,.,'r.  in  a  study  (if  :«>•>  cases,  finds  thai  in  1  13  08  e 

disorders  of  sensibility  are  described,  and  in 

mention    whatever    is   made  of  sensory  dis- 

Pain  appears  to  be  particularly  unusual. 

The  superficial  skin  reflexes,  the  pupil,  bladder,  and 

tal  reflexes  show  essentially  no  alteration,  whi 

loss  of  knee-jerk  is  constant  in  all  well-developed 

["rophic    ami    general  vasomotor  disturbances 

lom  been  observed,  and  the  sexual  function 

unimpaired.     A  frequent  occurrence,  which 

n  i  eived  as  yet  a  satisfactory  explanation,  is  a 

\  of  the  foot  of  the  nature  of  a  talipes  equinus, 

ovarus,  often  with  an  elevated  arch,  shorten- 

■  of  the  foot  as  a  whole,  development  of  so-called 

Ot,  with   particularly  strong  dorsal  flexion  of 

great  toe.     Scoliosis  is  also  an  occasional  accom- 

. Incut.     Cerebral    symptoms    do    not    occur,    ex- 

:  vertigo,  and  in  the  later  stages  of  the  disease  a 

ieral  impairment  of  the  mental  faculties. 

Diagnosis,  Prognosis,  and  Course. — The  symp- 
M — early  ataxia,   loss  of  knee-jerk,  choreic  move- 
club-foot,    disorders    of    speech,    nystagmus, 
igressive  helplessness,   beginning  before   the 
■i    year — point   unmistakably   to  Friedreich's 
With  the  possible  exception  of  so-called  cere- 
taxia,  tabes,  and  multiple  sclerosis,  the  differen- 
;i  isis  from  other  organic  cord  affections  should 
no  difficulties.     The  grouping  of  symptoms 
en  above   is  usually  well  marked  and  is  unique. 
The  course  of  the  disease  is  steadily  progressive, 
ginning  in  childhood  and  lasting  for  from  twenty 
forty  years  or  even  longer,  death  ultimately  being 
.  e,   in  "many   cases,   to   intercurrent   disease,   or   to 
-this  or  decubitus,  induced  by  the  cord  changes. 

ogy. — The   actual   cause   of   the   disease   re- 
obscure.     The  facts  that  it  occurs  in  children 
i  at  the  age  of  puberty,  that  cases  have  fre- 
entiy  been  observed  in  the  same  family,  though  by 
means  constantly,    that  the  cord,   post  mortem, 
es  indications  of  faulty  development,  have  led  to 
ijestion  that  it  is  due  to  hereditary  influences. 
than  this  nothing  of  value  has  been  found. 
appeal  to  syphilis,  alcohol,  or  various  neuroses  or 
i-choses   in   ancestors  does  little  to    elucidate   the 
ttter.     Nor  is  it  profitable  in  a  disease  of  this  char- 
ier to  lay  stress  upon  possible  exciting  causes.     As  in 
disease,  there  is  a  predisposition,  which  is  rather 
statement  of  a  self-evident  fact  than  an  explana- 
'ii,  so  long  as  we  remain  in  complete  ignorance  of 
iat    constitutes    predisposition.     The    fact  of   ira- 
te is  that  in  certain  families  the  affection  has 
1  in  several  members.     As  given  by  Gowers, 
ty-five  cases  were  distributed  in  nineteen  families, 
:  1  ten  occurred  in  one  family.     Sporadic  cases  are 
ibably  more  frequent  than  is  ordinarily  supposed, 
has  been  a  frequent  observation  that  many  cases 
i  ur   in   one    generation   in   families   in   which    the 
rents  or  ancestors  were  not  victims  of  the  disease 
-o-called    indirect    inheritance.      The   affection   is, 
■refore,    to    be    regarded  as  one  of  the    group    of 
ainily  diseases." 

Treatment. — In  the  present  state  of  our  knowl- 
ige,  treatment  must  remain  essentially  unavailing, 
icept  as  directed  toward  the  amelioration  of  symp- 

ns.  Systematic  exercises  (Frenkel),  avoidance  of 
terexertion,  careful  attention  to  general  hygiene, 
lod  food,  and  fresh  air,  with  such  drugs  as  are 
itnptomatically     required,     must     constitute     our 

tin  reliance.  E.  W.    Taylor. 


I;  i  i  i  hi  nces. 
Partial    I  PHT. 

1.  Spiller:  Jour.  Ncrv.  and  Meat.  Dis.,  1910,  xxxvii.,  411. 

2.  Singer:  Monat  wh.  f.  Psych.,  \  wn  ,  480. 

Friedreich  :  \  Irchxra      in  oil .  I  B63,  i  ■•'■  <  p.  30]      td<  m, 

1876,  Ixviii..  p.  145,  1877,  Inc.,  p.  I  M). 

Smith:  Host.  Med.  and  Sun;.  Joum.,  1885,  <■  x iii  .  p,  361. 

Ladazne:  Brain,  1890,  xiii.,p.  167.  Critical  Review  with  bibliog- 
raphy up  t<i  tha  I  I  inn'. 

Richard  on:  Joum.  Host,  Soc.  Med   Sci.,  1808,  iii.,  p.  :.'".. 

Vincelet:  Monograph,  Carre  et  Naud    Pari  .  1900, 

Scl nbom:  Neurolog.  Centbl.,  1901,  xx.,  p    10. 

Barker:  Transactions  Ass'n  of  American  Phj  Bicians,  1903. 

Ataxia,  Locomotor.     Set    /  -'      dorsalis. 

Atelectasis.-  Synonyms:  ^.pneumatosis;  colla] 
of  lung.  The  term  atelectasis  (dwAijs,  imperfect,  and 
tATttrris,  dilatation)  is  used  to  designate  all  non- 
inflammatory conditions  by  which  either  the  whole 
or  sharply  defined  portions  of  the  lungs  are  undis- 
tendedbyair.  Prior  to  the  researches  of  .Im-g  in  1S32 
atelectasis  was  regarded  as  inflammatory  in  origin, 
and  was  confounded  with  the  pneumonia  which  is 
found  SO  often  as  a  secondary  development  in  the 
collapsed  anas.  Atelectasis  may  be  congenital  or 
acquired. 

In  congi  nital  atelectasis,  more  or  less  extensive  areas 
of  the  lungs  are  unexpandod  by  the  forcible  extrance 
of  air  into  the  alveoli.  This  condition,  which  is  nor- 
mal in  fetal  life,  becomes  pathological  when  it  con- 
tinues after  birth. 

In  acquired  atelectasis,  although  the  respiratory 
functions  have  been  thoroughly  established,  collapse 
is  induced  as  a  consequence  of  some  mechanical  im- 
pediment to  the  movement  of  air  through  the  bronchi, 
and  a  tract  of  lung  of  variable  extent  becomes  again 
condensed  and  airless,  as  in  the  fetal  state.  There 
are  two  varieties:  collapse  from  obstruction  and 
collapse  from  compression. 

Atelectasis  is  comparatively  rare  in  adults,  but  is 
quite  common  in  early  infancy  and  childhood.  A 
considerable  percentage  of  the  mortality  in  infants  is 
attributable  to  this  cause.  The  liability  to  the  occur- 
rence of  pulmonary  collapse  adds  gravity  to  all 
es  at  this  period  of  life,  but  especially  to  those 
of  the  respiratory  organs. 

Etiology. — Congenital  atelectasis  is  not  commonly 
due  to  \  ice  or  disease  of  the  pulmonary  organs,  but  is 
produced  by  any  condition  which  prevents  the  prompt 
and  efficient  establishing  of  the  function  of  respiration 
after  birth.  It  may  be  the  result  of  causes  which 
have  been  in  operation  during  the  intrauterine  life  of 
the  child,  or  which  have  originated  during  or  im- 
mediately succeeding  birth.  Probably  the  plugging 
of  the  bronchioles  by  liquor  amnii  and  mucus  sucked  in 
by  efforts  at  respiration  before  the  head  has  cleared 
the  maternal  passages  is  the  most  frequent  single 
cause.  Physical  weakness,  premature  birth,  placen- 
tal separation,  compression  of  the  cord,  protracted 
labor,  and  kindred  conditions  are  common  predis- 
posing causes.  Intracranial  effusions,  the  result  of 
severe  protracted  or  instrumental  deliveries,  may  be 
placed  among  the  rarer  causes  of  this  affection  in  the 
new-born. 

The  obstructive  form  of  acquired  atelectasis  is 
always  secondary  to  some  disease  or  accident  which 
interferes  mechanically  with  the  access  of  air  to  the 
lung  cells.  The  lodgment  of  a  foreign  body  in  a 
bronchus  may  result  in  alveolar  collapse.  But,  as 
pointed  out  by  Babcoek,  the  occlusion  of  the  tube 
must  be  complete  or  emphysema,  and  not  atelectasis, 
is  likely  to  occur.  In  the  vast  majority  of  instances 
this  impediment  is  the  presence  of  mucus  in  the 
bronchial  tubes,  the  effect  of  an  acute  or  chronic 
bronchial  catarrh,  and  collapse  is  therefore  a  frequent 
complication   of    those   diseases,    like    pertussis   and 

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measles,  in  which  bronchitis  is  a  part  of  the  natural 
history. 

Whenever  one  or  more  terminal  bronchioles  are  oc- 
cluded by  viscid  mucus  and  swelling  of  the  mucosa, 
the  collapse  of  that  portion  of  the  lung  fed  by  the 
obstructed  tube  inevitably  takes  place  as  soon  as  the 
imprisoned  air  is  expelled  or  absorbed.  This  purely 
mechanical  explanation  of  collapse,  first  advanced  by 
Gairdner  of  Edinburgh  and  adopted  by  nearly  all 
writers  on  the  diseases  of  children,  has  been  challenged 
by  Holt  and  others. 

Weakness  of  the  inspiratory  muscles,  and  the  conse- 
quent inability  to  overcome  the  obstacles  in  the  tubes, 
is  a  powerful  auxiliary  factor  in  bringing  about 
collapse,  and  hence  any  condition  which  decreases  the 
physical  vigor  of  the  child  strongly  predisposes  to  this 
accident.  It  is,  therefore,  a  common  malady  among 
those  enfeebled  by  a  bad  inheritance,  by  chronic  and 
wasting  diseases,  or  by  unsanitary  surroundings. 
Rickets  also  plays  an  important  role  in  the  causation, 
associated  as  it  is  with  softening  of  the  ribs  and 
narrowing  of  the  thorax. 

The  compression  form  of  atelectasis  is  the  result  of 
pressure  displayed  on  a  lung  or  some  portion  of  it, 
or  on  the  bronchus  by  which  it  is  fed  with  air.  The 
air  is  mechanically  forced  out  of  the  alveoli  and 
cannot  reenter.  Intrathoracic  growths  or  exudations, 
spinal  deformities,  and  upward  displacement  of  the 
diaphragm  by  abdominal  tumors  or  effusions  may 
cause  collapse  of  such  portions  of  the  lung  as  are  sub- 
jected to  pressure. 

Cockle  reports  a  case  in  which  the  upper  lobe  of  the 
right  lung  had  become  atelectatic  through  com- 
pression of  the  bronchus  by  swollen  lymph  glands. 

Rosenbach  has  shown  that  at  first  it  is  not  a  true 
compression  that  brings  about  the  condition  known 
as  compression  atelectasis  but  a  force  which,  counter- 
acting the  expanding  pressure  within  the  thoracic 
cavity,  enables  the  elasticity  of  the  lungs  to  contract 
to  their  smallest  volume. 

It  is  only  through  a  continuance  of  the  pressure 
after  the  lung  has  become  completely  collapsed  that 
its  parenchyma  is  actually  compressed  and  even 
then  the  compression  is  chiefly  expended  on  the  ves- 
sels and  bronchi. 

Morbid  Anatomy. — The  collapse  may  involve  con- 
siderable areas  of  the  lung  (diffuse  atelectasis) ,  or  it  may 
be  limited  to  small  and  scattered  patches  (lobular 
atelectasis).  These  varieties  are  found  in  both  the 
congenital  and  the  acquired  forms  of  the  disease,  but 
in  the  former  the  lesion  usually  involves  larger  tracts 
of  tissue,  the  half,  or  even  the  whole,  of  one  lobe;  it  is 
most  frequently  observed  in  the  posterior  and  inferior 
portions  of  the  lungs,  in  the  tongue-shaped  projec- 
tions, and  in  the  apices;  while  in  acquired  atelectasis 
the  patches  are  oftener  limited  to  isolated  lobules  or 
groups  of  lobules,  and  are  more  widely  disseminated 
through  the  parenchyma  of  both  lungs. 

The  collapsed  portions  are  depressed  below  the 
general  surface  of  the  lung,  feel  tough  and  dense, 
like  soft  leather,  and  are  of  a  dark  blue  or  steel  color. 
They  are  airless,  do  not  crepitate  upon  pressure,  and 
sink  when  thrown  into  water.  When  incised,  the 
section  is  smooth,  non-granular,  and,  if  scraped, 
exudes  a  small  quantity  of  bloody  serum.  After 
death,  if  the  lesion  is  recent,  the  atelectatic  portions 
can  be  readily  inflated  through  the  bronchus,  and 
assume  the  color  and  qualities  of  normal  lung;  but 
if  the  lesion  is  of  long  standing  profound  changes  in 
the  affected  zone  are  noted.  The  walls  of  the  alveoli 
become  adherent,  the  connective  tissue  is  increased 
in  quantity  and  a  total  disappearance  of  the  vesicular 
structure  is  the  end  result.  The  pleura  is  normal  in 
uncomplicated  cases. 

When  a  considerable  tract  of  lung  is  disabled, 
important  changes  ensue  in  the  unaffected  tissues 
and   also   in   the  organs  of  circulation.     Pulmonary 

756 


emphysema  is  a  common  sequel.  The  impedime 
to  the  movement  of  the  blood  through  the  lun 
results  in  stasis  in  the  pulmonary  artery  and  the  ent 
venous  system,  and  leads  to  hemorrhagic  infarctio 
and  edema  of  the  unaffected  lung  tissue.  The  sai 
condition  also  tends  to  prevent,  in  congenital  cases,  t 
closure  of  the  fetal  channels  of  circulation,  especial 
the  foramen  ovale. 

Symptoms  and  Course. — The  symptoms  of  atelc 
tasis  are  chiefly  those  of  "inefficient  breathing  a 
incomplete  decarbonization  of  the  blood."  Th 
exhibit  varying  degrees  of  severity  in  proportion 
the  rapidity  of  development  and  the  amount  of  lu 
tissue  involved.  When  the  collapse  is  limited 
scattered  lobules,  the  symptoms  are  by  no  mea 
marked  or  distinctive.  But,  on  the  other  hand,  if 
be  so  extensive  as  to  arrest  the  function  of  a  large  ps 
of  both  lungs,  death  may  take  place  suddenly.  Tl 
occasionally  occurs  in  whooping-cough  or  capilla 
bronchitis,  affecting  feeble,  young  children. 

The  symptoms  of  congenital  atelectasis  are  usual 
present  from  birth.  In  a  large  majority  of  instanc 
the  infant  is  born  more  or  less  deeply  asphyxiate 
respiration  is  established  with  difficulty  and  is  notab 
inefficient,  but  not  always,  for  occasionally  the  chil 
although  less  vigorous  than  usual,  exhibits  no  serio 
lung  symptoms  for  some  days  or  weeks  after  birt 

The  literature  of  the  subject  furnishes  numero 
examples  of  children  who  have  lived  for  weeks  wi 
a  considerable  portion  of  the  lung — even  an  ent i 
lobe — atelectatic,  and  so  altered  in  structure  as  to  I 
incapable  of  inflation  after  death. 

A  noted  case  is  reported  by  Ryan1  of  England, 
child,  aged  five  weeks  and  in  good  condition,  diedsui 
denly.  At  the  coroner's  inquest,  both  lungs  we 
found  shrunken,  inelastic,  non-crepitant  on  pressur 
and  when  cut  into  many  pieces  no  portion  of  the 
floated.  The  microscope  showed  an  absence  of  cclli 
lar  structure.  Holt  comments  on  the  frequency  wil 
which  the  discovery  is  made  that  a  child,  using  lc 
than  one-half  of  its  lung  tissue,  has  lived  for  niontl 
without  showing  marked  signs  of  cyanosis. 

The  breathing  is  fast  and  shallow.  The  child  lii 
quietly  without  attempting  muscular  movement 
and  his  whole  demeanor  indicates  lack  of  vigo 
Most  of  the  time  is  passed  in  sleep.  The  cry  is  in 
loud  and  strong,  but  is  a  piteous  moan  or  mere  whin 
per,  and  at  times  almost  inaudible.  The  chil 
nurses  feebly  or  not  at  all.  The  surface,  especiall 
the  face  and  finger  tips,  become  cyanotic  and  tl 
extremities  cold.  The  temperature  is  normal  I 
subnormal,  and  the  pulse  feeble  and  rapid.  Tl: . 
fontanelle  is  depressed. 

In  the  unfavorable  cases,  these  symptoms  becom 
more    pronounced,    and    muscular    twitchings    fori 
shadow    the    coma   or   convulsions    which   so   ofte 
immediately   precede    the   fatal    termination.     It 
not  at  all  uncommon  for  still-born  children  who  hav 
been  resuscitated  with  difficulty,  perhaps  by  the  pr( 
longed   use  of  artificial   respiration,  to  die  suddenl 
after  a  feeble  existence  of  a  few  hours  or,  at  most, 
day  or  two.     In  many  of  these  cases,  even  win  o  to 
breathing  has  been  apparently  thoroughly  establishes 
and  the  cry  is  fairly  strong,  the  postmortem  examine 
tion  has  shown   that  only  very   limited  portions  i 
the  lungs  had  been  inflated.     The  autopsy  reveals 
patulous  foramen  ovale   and   ductus  arteriosus  am 
sometimes  thromboses  of  the  cerebral  sinuses. 

Acquired  atelectasis  is  always  a  secondary  affection 
and  the  clinical  picture  is  dominated  by  the  symp 
tom-complex  of  the  antecedent  disease.  It  almos 
invariably  occurs  as  a  complication  of  primar 
bronchitis,  or  of  one  of  those  specific  diseases  of  whicl 
bronchial  catarrh  is  an  essential  element.  W  be' 
collapse  of  a  considerable  area  of  lung  occurs  in  thi 
course  of  a  pulmonary  catarrh,  the  symptoms  a]  ono 
assume    a  graver    physiognomy.     The  breathing  i* 


ItFFFKKXCF.    IlAXDIiooK    OF    THE    MEDICAL   SCIENCES 


Atelectasis 


re  hurried,  very  shallow,  and  altered  in  rhythm; 
i    respirations  sometimes  number  from  seventy  to 
,1:1V  in  tin-  minute.     The  dyspnea  is  directly  pro- 
i  [-donate   in    the   extent   of    the   atelectasis.     The 
J  id  grows  more  restless,  the  lips  become  cyanosed, 
tremities  cold,  ami  the  whole  appearance  indi- 
profound    depression.     The    temperature   falls 
lew  normal.     The   nares  dilate   widely    with   each 
jlpiration.     The    suprasternal    depression,    and    the 
,  p  sulcus  around  the  base  of  the  chest  which  forms 
ery  inspiration,  attest    the  physical  difficulty 
.  getting  sufficient  air  into  the  lungs.      When  these 
.  uptoms  are  present,  unless  the  obstruction  in  the 
,1  tubes  is  promptly  removed,  permitting  the 
if  air  to  the  closed  vesicles,  tie-  child  sinks 
jo  a  state  of  stupor,  and  dies  asphyxiated  or  in 
,  ivulsions.     Such    severe    symptoms  are,  however, 
•  nal.      In    most    cases,    the   collapse   involves 
ed  lobules,  and  is  indicated  by  symptoms 
.-  lilar  to  those  just  enumerated,  but  less  violent. 
file  physical  signs  of  atelectasis  vary  with  the  ex- 
ilic lesion.     If  several  contiguous  lobules,  or 
■iter  part  of  a  lobe  is  affected,  so  as  to  cause  con- 
la  lion  of  a  considerable  area,  the  physical  signs 
pronounced;  but    when,    as   happens   in    a   fair 
portion  of  cases,  the  collapsed  patches  aredissemi- 
arough  both  lungs  and  vary  in  size  from  a  pea 
a  filbert,  each  consisting  of  one  or  more  lobules 
iarated  by  a  network  of  normal  cells,  the  physical 
i-  are  necessarily   negative.     However,   the  very 
■   of   signs   in    the   presence   of   decided   lung 

■  uptoms  will  assist  in  the  diagnosis.  For  example, 
(in  the  progress  of  a  mild  bronchitis,  -without  cor- 

ding  increase  in  fever,  grave  symptoms  sud- 

<aly    arise — the    dyspnea,     lividity,    and     general 

•  tress    being    greatly     aggravated — and     physical 

i  errogation  of  the  chest  reveals  no  solidification  of 

lungs,    the  occurrence   of  lobular  collapse  offers 

only    satisfactory    explanation    of    the   sudden 

physical  signs  are  those  of  consolidated  lung. 
sonority  of  the  chest  is  diminished  over  the 
(ected  spnts,  but  the  dulness  has  a  marked  tympa- 
i  ic  quality  owing  to  the  proximity  of  normal  lung, 
id  especially,  as  commonly  occurs,  if  emphysemat- 
i>  patches  surround  the  collapsed  lobules.  The 
:rmal  breathing  sounds  are  absent,  and  may  be 
:  >laced  by  bronchial  respiration  and  bronchophony. 

ical  resonance  is  increased,  and  in  acquired  atelec- 
-is  abundant  mucous  rales  are  audible  over  the  en- 
je  chest.  A  very  important  and  characteristic 
hture  of  atelectasis  is  the  suddenness  with  which  the 
I  signs  are  changed.  Occasionally,  during  an 
lamination,  dulness  and  bronchial  breathing  will  be 

ilaced  by  normal  resonance  and  vesicular  murmur; 
i  within  a  brief  period,  abnormal  sounds  may  appear 

1  disappear  in  different  portions  of  the  lungs.     This 

i  happen  in  no  other  pulmonary  disease,  and  de- 
;nds  upon   the  closing  of  the  bronchi  by  plugs  of 

icus  and  their  speedy  removal  by  forced  expiration 

coughing,  crying,  etc. 

Diagnosis. — The  recognition  of  congenital  atelec- 
iis  if  extensive  enough  to  give  rise  to  symptoms,  is 
mparatively  easy.     The  postnatal  form  is  always 

■  ■iociated  with  other  morbid  conditions  which,  in 
Id  cases,  render  the  diagnosis  difficult  and  some- 
ues  impossible. 

Capillary  bronchitis,  catarrhal  pneumonia,  and 
iar  pneumonia  are  the  diseases  for  which  collapse 
most  liable  to  be  mistaken.  Catarrhal  pneumonia 
rarely  developed  except  in  portions  of  the  lung 
■  ady  collapsed  and  hence  cannot  be  differentiated 
physical  signs  alone.  Diffuse  atelectasis  differs 
mi  lobar  pneumonia  in  the  absence  of  fever,  the 
m  note  is  more  tympanitic,  bronchial  respira- 
iii  is  less  marked,  and  the  crepitant  rale  is  absent. 
ie  suddenness  with  which  the  physical  signs  are 


manifested  and  reach  their  full  development  in 
collapse   is  an  important  diagnostic  point.     If  in  tic 

course  of  a  bronchial  catarrh  Bymptoms  of  COD  id.  r- 
able  severity  suddenly  supervene,  such  as  rapid  and 
shallow  breathing,  duskiness  of  the  face,   fainl   cough 

and  feeble  cry,  with  little  or  no  increase  in  fever,  the 
nature  of  the  attack  can  Bcarcelj  be  doubted.  If 
along   with    these   symptoms   tic   physical    signs  of 

solidified    lung    are    present,    tic    chain    ol  evidence  is 

complete. 

The  thermometer  renders  valuable  aid  in  differen- 
tiating     between      the      above      diseases.      Capillary 

bronchitis  is  normally  attended  with  only  moderate 
febrile  movements,  the  mercury  fluctuating  between 
H)l°  F.  and  103°  F.  A  sudden  exacerbation  of  fever 
in   bronchitis,   in   which    the   thermometer   registers 

104°    F.    or   higher,  strongly    suggests    the    onset   of 

catarrhal    pneumonia;   on    tl tier  hand,  a  sudden 

fall  nt  the  mercury,  without  corresponding  improve- 
ment ill  the  symptoms,  points  strongly  to  collapse. 
The  careful  diagnostician  will  rarely  have  difficulty 
in  correctly  interpreting  die  symptoms  of  so-called 
compression  atelectasis  due  to  tumors  of  lung  and 
pleura,  pleuritic  exudates  or  lesions  of  the  abdominal 
viscera. 

Prognosis. — In  congenital  atelectasis,  if  restorative 
measures  are  adopted  early  and  the  lesion  is  not 
extensive,  the  prognosis  is  good.  But  if  the  child  be 
premature  or  feeble,  or  if  the  fetal  circulatory  openings 
are  unclosed  the  outlook  is  bad.  The  prognosis  in 
acquired  atelectasis  is  always  grave,  and  this  is 
especially  so  when  whooping-cough  is  the  complicating 
disease.  Convulsions  are  of  bad  omen.  Lobular 
collapse  is  the  initial  lesion  in  many  cases  of  catarrhal 
pneumonia,  of  which  caseous  degeneration  and 
phthisis  are  not  infrequent  sequels.  Emphysema  and 
bronchiectasis,  both  in  a  measure  compensatory,  are 
nearly  always  left  behind  when  any  considerable  tract 
of  lung  has  been  involved. 

Treatment. — The  treatment  of  congenital  atelec- 
tasis consists  in  the  adoption  of  measures  and  remedies 
to  clear  the  air  passages  of  obstructions,  and  to 
strengthen  the  respiratory  acts.  First  of  all  the 
mouth,  nose,  and  throat  should  be  thoroughly  and 
speedily  cleansed,  the  surface  of  the  body  stimulated 
by  the  alternate  application  of  hot  and  cold  water, 
with  an  early  resort  to  artificial  respiration  should 
these  measures  prove  ineffectual.  Probably  of  the 
man3'  methods  of  artificial  respiration  in  use  that  of 
Schultze  is  the  most  efficient.  S.  J.  Meltzer2  of  the 
Rockefeller  Institute  for  Medical  Research  has 
recently   described   a  new   method   of  resuscitation. 

The  condition  of  asphyxia  in  the  newborn  is  an 
emergency  and  there  is  little  time  to  secure  special 
appliances.  Meltzer's  outfit  is  very  simple  and 
could  always  have  place  in  the  obstetrical  bag. 
In  crying  and  coughing,  deep,  full  inspirations  are 
instinctively  taken,  and  hence  these  acts  should  be 
provoked.  Nothing  conduces  more  strongly  to 
perpetuate  atelectasis  than  to  indulge  a  feeble  infant 
in  a  vegetative  existence.  Infants  should  not  be 
permitted  to  sleep  too  long  at  one  time,  or  to  remain 
any  great  length  of  time  in  the  same  position.  The 
body  heat,  often  subnormal,  should  be  carefully 
maintained  by  swathing  the  infant  in  cotton  or 
flannel,  and  in  extreme  cases  it  may  be  kept  for  days 
or  weeks  in  an  incubator.  In  acquired  or  post-7iatal 
atelectasis  remedies  addressed  to  the  bronchial  catarrh, 
pleurisy,  or  other  associated  diseases  are  indicated 
and  will  be  discussed  in  other  volumes  of  the  Hand- 
book. It  is  only  proper  to  remark  here  that  those 
remedies  should  be  chosen  which,  like  the  prepara- 
tions of  ammonium,  increase  the  flow  of  serum  and 
lessen  the  viscidity  of  the  tough  secretion  which 
occludes  the  bronchioles.  If  not  contraindicated  by 
debility,  emetics  serve  the  twofold  purpose  of  expel- 
ling  viscid    phlegm  from    the    bronchial    tubes    and 


757 


Atelectasis 


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producing  powerful  inspirations.  Those  emetics 
only  are  admissible  which  act  promptly  and  with 
little  depression,  as  sulphate  of  copper  and  ipecac. 
Rapidly  acting  stimulants  are  indicated.  Hot 
immersion  baths,  made  more  stimulating  by  the 
addition  of  mustard,  and  mildly  irritating  embroca- 
tions to  the  chest  are  useful.  Nutritious  diet  and 
tonics,  by  which  the  respiratory  muscles  gain  per- 
manent volume  and  vigor,  constitute  our  chief 
reliance,  as  soon  as  the  immediate  danger  is  tided 
over.  W.  J.  Conklin. 

1.  Ryan:  The  Lancet,  1868,  i. 

2.  Meltzer,  S.  J.:  Journal  of  the  Anier.  Med.  Association,  May 
11,  1912. 


Ateleiosis.- — This  is  the  name  given  by  Hastings 
Gilford1  to  the  most  important  variety  of  essential 
infantilism,  i.e.  infantilism  for  which  no  apparent 
antecedent  or  coexistent  cause  can  be  assigned.  (See 
Infantilism.)  The  term  is  derived  from  Greek  arfkeux, 
meaning  incompleteness  or  not  arriving  at  perfection. 
Ateleiosis  is  the  result  not  of  an  arrest  of  development 


Fig.  520. — A  Case  of  Ateleiosis  in  a  Boy  Twelve  Vears  Old  (on 
the  Left) ;  the  Boy  on  the  Right  is  a  Normal  Chil  1  of  Six  Years, 
the  Brother  of  the  Other  One.       (Gilford.) 

but  rather  of  a  retardation  of  development.  This 
retardation  may  affect  different  parts  of  the  body  to 
a  varying  degree.  It  may  be  more  pronounced  in  the 
bony  and  muscular  systems,  in  the  glandular  organs, 
in  the  nervous  system,  in  the  sexual  apparatus,  or  in 
any  other  part  of  the  body.  The  rate  of  this  retard- 
ation may  vary  in  different  cases.  It  may  begin  at 
any  period  in  the  life  of  the  individual.  The  rarest 
forms  of  ateleiosis  are  those  in  which  the  retardation 

758 


of  development  begins  during  fetal  life.  In  most 
the  cases  this  retardation  begins  during  infancy  a 
early  childhood.  There  are  cases  recorded  in  wh 
the  delay  in  development  did  not  manifest  itself  ui 
after  the  period  of  adult  life  had  been  attained,  i 
characteristics  of  a  case  of  ateleiosis  are  strikiii) 
seen  in  an  instance  of  the  infantile  type  of  the  disea 
Although  the  individual  may  have  attained  tl, 
of  maturity,  he  still  has  the  comparatively  large  "in 
and  the  comparatively  long  body  and  short  limbs 
the  child;  at  the  same  time  he  has  the  unmistaka 
physiognomy,  intelligence,  and  thin  high-pitch 
voice  of  the  child.  The  degree  to  which  the  indiv 
ual  manifests  these  characteristics  of  immatur 
depends  upon  the  period  of  onset  of  the  i 
The  most  striking  symptom  is  the  retardation 
growth,  associated  with  the  failure  of  the  epiphy: 
to  unite  with  the  shafts  of  the  bones.  In  one  record 
case  the  increase  in  length  and  weight,  which  uric 
normal  conditions  should  have  been  attained  in  ii 
years,  was  spread  over  a  period  of  thirty-five  yea 
The  limbs  are  short,  the  proximal  segments  Dei 
conspicuously  so  when  compared  to  the  distal, 
that  the  midpoint  of  the  body  is  near  or  at  t 
umbilicus,  instead  of  being  at  the  pubis,  as  in  t 
normal  adult.  Dwarfism,  although  present  in  t 
large  majority  of  cases,  is  not  an  essential  charach 
istic  of  this  disease,  for,  as  stated  above,  the  delay 
development  may  not  begin  until  the  individual  h 
attained  his  maximum  stature.     The  sexual  orga 


Fig.  521. — Ateleiosis  in  a  Man  Aged  Forty-two  Years;  Front 
and  Back  Views.     (Weber.) 

may  or  may  not  reach  their  full  development.  1 
the  former  case  puberty  may  be  postponed  for  man 
years.  In  the  latter  case  the  sexual  organs  ma 
retain  their  infantile  characteristics  throughout  lif 
This  is  observed  in  the  most  pronounced  forms  of  tl 
disease.  Based  upon  the  degree  of  sexual  develoj 
ment,  the  cases  of  ateleiosis  are  subdivided  into  tl 
sexual  and  asexual  forms.  In  sexual  ateleios 
the  sexual  organs  mature,  the  epiphyses  unit'1,  sn 
the  remainder  of  the  body  undergoes  to  a  certai 


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Alilrlosls 


,..  «nt  a  corresponding  transformation.     Then  growth 

and  the  individual,  although  sexually  mature, 

,.  therwise  a  child  in  his  development.     The  nose 

..  .■ more  prominent  ami  sexual  hair  may 

Occasionally,  in  the  male,  hair  may  grow 
,   he  face. 

ne  of  the  important  characteristics  which  serves 
t(  listinguish  ateleiosis  from  other  forms  of  infan- 


Fig.  522. — Skiagram  of  the  Hands  in  the  Case  of  Ateleiosis  shown  in  Fig.  521. 
(F.  Parkes  Weber.) 

ism  is  the  fact  that  the  former  condition  is  trans- 
ited  by   heredity,   and   the  latter  are   not.     The 
redity  may  be  direct,  as  in  the  instance  cited  by 
lford,  in  which  the  disease  was  transmitted  through 
ree  generations,  implicating  at  least  four  individ- 
ls;  or   the   heredity    may    be   familial,    appearing 
ily  in  two  or  more  children  in  the  same  family. 
le  latter  form  of  inheritance  is  the  usual  one.     When 
fferent    members    of    a    family    are    affected    with 
eleiosis,   they  may  exhibit  different  types  of  the 
sease.     On  account  of  the  failure  or  retardation  in 
e  development  of  the  sexual  organs,   the  natural 
ndency  for  ateleiosis  is  to  die  out,  as  is  the  case 
ith    other    degenerative    manifestations.     Another 
sential  distinguishing  characteristic  of  ateleiosis  is' 
ie  fact  that  unlike  other  forms  of  infantilism  there 
an   entire   absence   of   disease   or   debility   in   the 
•evious  history  of  the  individual  affected. 
The  ateleiosic  may  live  the  usual  span  of  years, 
id  may  even  approach  the  age  of  the  centenarian. 
>seph    Boruwlasky,    the    celebrated    dwarf    of    the 
ghteenth  century,  lived   to   be   ninety-eight  years 
id.     He  lived  in  England  during  the  greater  part  of 
is  life   and  earned  a  comfortable  livelihood  as  an 
bject  of  curiosity,  being  carried  about  in  a  sedan 
hair  by  groomed  attendants.     In  his  autobiography 
'  Memoirs  of  Count  Boruwlaski")  he  states  that  he 
id  not  attain  puberty  until  the  age  of  twenty-five. 
Gilford  believes  that  ateleiosis  may  be  explained  on 
he  ground   that  it  is  a  discontinuous  variation  or 
mtation.     This   belief   is   based   on  the    facts   that 


ateleiosis   appears   spontaneously,   possesses   a    pro- 
nounced  individuality,  and  in  occasional  instanci 
transmitted    by    heredity.     In    contradistinction    to 

ateleiosis,  Bympl atic  infantilism  is  regarded 

continuous  variation  or  fluctuation,  depending  upon 
environmental  conditions  either  within  or  without. 
the  organism,  but  bring  also  of  a  minor  degree  and 
non-heritable. 

The  accompanying  figure  (1  ig. 
520),  taken  from  Gilford',  Ulus- 
trates  a  ease  of  ateleiosis.  The 
shorter  boy  aged  twelve  years, 
affected  with  this  condition,  is 
standing  beside  his  normal  six 
year  old  brother.  The  former 
shows       the       rounded       contour, 

height,  proportions,  and  physi- 
ognomy of  the  young  child.  No 
cause  of  the  retarded  develop- 
ment could  be  disco\  ered  in  this 
Ca  ■'.  The  patient  was  the  only 
abnormal  member  of  a  family  of 
eight  children,  and  the  delay  in 
development  began  at  the  age  of 
two  years.  At  the  time  the  pho- 
tograph was  taken  the  patient 
was  of  the  height  and  weight  usual 
in  a  boy  four  years  old.  There 
were  no  signs  of  cretinism  or  of 
rickets.  The  patient's  epiphyseal 
ossification  was  about  one  year 
behind  that  of  his  brother  of  six; 
dentition  was  delayed,  and  the 
teeth  were  crowded.  The  patient 
was  a  bilateral  cryptorchid.  He 
was  of  fair  intelligence,  and  two 
years  after  the  portrait  was  taken 
played  in  one  of  the  London 
theaters  "  the  double  role  of  baby- 
in-arms  and  man-about-town." 

F.  Parkes  Weber3  reports  a  case 
of     ateleiosis     in    a    man     who 
although   forty-two  years  of  age 
had   the  physical  development  of 
a  child  of   nine  years  (Fig.  521). 
But   his  expression,  the  wrinkles 
on  his  face,  his  attitude,  his  man- 
ner of  speaking,  and  his  general  behavior  were  rather 
more  those  of  an  adult.      With  the  exception  that 
during  infancy  he   had  had  hydrocephalus,  he  was 
much  like  other  children  until'he  was  nine  years  of 
age.  _  Then  his  growth  and  development  ceased.     At 
the  time  he  was  observed  by  Weber  his  height  was 
47.7  inches  and  his  weight  was  69  pounds.     His  head 
was  rather  large  for  the  diminutive  size  of  his  body. 
There  was  no  hair  on  his  face  or  pubes.      No  testicle 
could  be  felt  on  the  right  side;    the  left  testicle,  of 
about  the  size  of  a  small  cherry,   was  incompletely 
descended.      Mentally    the    patient     was    somewhat 
childish.     Skiagrams  showed  persistence  of  some  of 
the  epiphyseal  cartilages,  but  the  amount  of  union  of 
the  epiphyses  with  the  diaphyses  varied  considerably 
in  different  bones.     It  is  pointed  out  that  in  the  skia- 
grams of  the  hands  (Fig.  522),  those  epiphyses  which 
are  not  yet  joined  to  the  diaphyses  are  seen  to  be 
bordered  by  a  very  deep  shadow. 

In  all  other  forms  of  infantilism,  apart  from  the 
dwarfed  stature  and  generally  childish  appearance, 
there  is  no  distinctive  facial  expression.  But  in 
ateleiosis  the  physiognomy  is  distinctive,  so  that  the 
affected  indi:  viduals  all  tend  to  resemble  one  another. 
This  "  stereotyped  "  expression  of  infancy  or  of  per- 
petual babyhood  is  referred  to  by  Gilford  as  one  of 
the  most  striking  manifestations  of  ateleiosis.  The 
characteristics  of  this  expression  are  the  large  size  of 
the  head,  the  broad  flat  face,  the  great  breadth  of 
the  nose  and  undeveloped  condition  of  its  bridge,  and 
the  small  size  of  the  upper  jaw,  as  the  result  of  which 


759 


Ateleiosls 


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there  is  a  tendency  for  the  upper  teeth  to  be  crowded 
together.  In  the  fetal  type  of  ateleiosis  there  is  a 
combination  of  imbecility  and  dwarfism. 

Alexander  Stingarn. 

1.  Gilford.  Hastings:  "The  Disorders  of  Postnatal  Growth  and 
Di-velopment",  London,  1911. 

2. .     The   British  Journal  of  Children's  Diseases,  July, 

1911. 

'.i.  Weber,  F.  Parkes:  Proceedings  of  the  Royal  Society  of  Medi- 
cine, June,  1910. 

Atheroma. — See  Blood-vessels,  Pathological  Anat- 
omy of. 

Athetosis. — This  consists  in  a  series  of  involuntary, 
slow  muscular  movements  usually  most  prominent  in 
the  upper  extremities,  during  which  grotesque,  fanciful 
positions  are  taken.  The  patients  have  little  or  no 
control  over  them.  Clinically  speaking  they  usually 
follow  a  hemiplegic  or  diplegic  attack,  and  hence  were 
referred  by  the  original  describers  (W.  A.,  Hammond, 
who  gave  the  name,  Charcot,  and  others),  to  lesions  in 
the  internal  capsule.  An  immense  amount  of  study 
with  exact  anatomical  data  began  with  Bonhoeffer 
in  1901,  since  which  time  a  large  number  of  studies 
have  been  made,  but  it  cannot  be  asserted  with  defi- 
niteness  as  to  the  pathways  necessarily  involved  which 
can  bring  about  athetosis.  The  chief  results  seem  to 
locate  themselves  about  the  mid-brain  structures, 
yet  various  points  of  view  are  held. 

One  scheme  is  as  follows: 

1.  Spinal    paths  =  Athetoid    Movements    (Wallen- 
berg). 

2.  Rubrothalamic  Paths  =  Tremor  (Touche). 

3.  Rubrocortical  =  Chorea  (J.  J.  Putnam). 
Another  arranges  these  as  follows: 

1.  Tegmentocerebellar  =  Athetosis. 

2.  Rubrothalamic  =  Chorea. 

3.  Rubrocortical  =  Tremor — paralysis  agitans. 

Jelliffe  in  a  paper  on  Benedikt's  Syndrome  ascribes 
the  athetoid  movements  to  interference  with  the  rubro- 
thalamic and  thalamorubral  fibers;  such  movements 
are  frequently  seen  in  the  thalamic  syndrome  of 
Roussy.  Choreiform  and  choreoataxic  movements 
are  referred  by  him  to  interference  with  the  cerebello- 
rubral pathways  either  in  their  mid-brain  course,  or 
possibly  in  their  cerebellar  origins,  whereas  the  purely 
paralysis  agitans  and  multiple  sclerosis-like  tremors 
he  believes  are  due  to  cutting  off  of  the  rubrocortical, 
or  corticorubral  fibers  chiefly  in  and  about  Forel's 
field  (H2),  as  Jelgersma  and  Winkler  have  suggested. 
They  may  be  due  to  lesions  in  the  red  nucleus  itself, 
in  which  case  they  should  play  a  greater  role  in  the 
Weber-Gubler  syndrome. 

These  athetoid  movements  have  been  treated, 
with  a  small  degree  of  success  only,  by  section  of  the 
posterior  roots.  Smith  Ely  Jelliffe. 

Athrepsia. — See  Marasmus. 

Atlantic  City. — In  order  to  facilitate  a  better  under- 
standing of  the  climate  of  Atlantic  City,  it  becomes 
necessary  to  refer  to  some  of  the  differences  in  the 
topography  between  the  southern  section  of  the 
State  of  New  Jersey,  in  which  Atlantic  City  is  located, 
and  that  of  the  adjacent  and  nearby  territorial 
sections,  such  as  the  northern  section  of  New  Jersey, 
and  adjoining  portions  of  Pennsylvania  and  New 
York.  Therefore,  I  shall  endeavor,  first,  to  point  out 
briefly  some  of  the  physical  differences  that,  doubtless, 
influence  favorably  the  climate  of  this  section. 

If  we  draw  an  imaginary  line  from  the  Atlantic 
Ocean  through  the  Newark  Bay,  west  to  the  east 
bank  of  the  Delaware  River,  at  Trenton,  for  all 
purposes  herein  required,  this  will  separate  New 
Jersey  into  two  territorial  divisions  which,  for  the 
purpose  of  comparison,  we  will  call  the  northern  and 
southern   sections.     The   former,    like    the   adjacent 

760 


territory  of  Pennsylvania  and  New  York,  thoug' 
separated  from  the  former  by  the  Delaware,  an 
from  the  latter  by  the  Hudson  River,  is  rolling  an. 
mountainous,  with  intervening  dale  and  plain, 
large  portion  of  which  has  an  underlying  clay  subs'oi 
and  other  portions,  trap  and  shale  rock.  Th 
southern  section  of  New  Jersey  is  composed  chief! 
of  sand  and  an  alluvial  soil,  undulating  and  slopin 
eastward  and  southward  to  the  water  line,  alon 
which  the  coast  is  fringed  with  salt  marshes,  shalloi 
bays,  and  broad  lagoons. 

The  mean  annual  difference  in  temperature  betwee 
these  two  sections  is  8°  F.  This  fact  has  given  rb 
to  may  discussions,  and  has  been  the  subject  of  muc 
scientific  speculation  and,  naturally  enough,  amon 
the  many  solutions  offered,  the  influence  of  the  Gu 
Stream  has  been  much  impressed  upon  the  mind 
of  the  populace  in  this  section.  There  is  little  doulj 
but  that  the  difference  in  soil,  geological  formation: 
direction  and  velocity  of  the  wind,  humidity,  etc.,  ar 
more  directly  concerned,  not  only  in  the  differenc 
in  temperature,  but  also  in  other  differences  which 
shall  endeavor  to  show  do  exist. 

First,  referring  to  the  possible  influence  of  th 
Gulf  Stream  upon  the  climate  of  Atlantic  City,  i 
becomes  necessary  for  one  to  understand  the  relativ 
distance  of  the  Gulf  Stream  from  the  coast  at  thi ' 
point  which,  in  fact,  is  about  100  miles.  Studie 
from  the  standpoint  of  physical  laws  governing  th 
wind  and  water  currents,  one  can  scarce  admit  of  an 
perceptible  influence  that  the  heated  currents  froi 
the  Gulf  Stream  could  exercise  upon  the  local  win 
currents  in  the  immediate  vicinity  of  this  city,  th 
distance  between  the  two  being  too  great.  Neithe 
can  we  appreciate  that  there  would  be  any  very  grea 
change  in  the  ocean  temperature  exercised  by  th 
Gulf  Stream,  at  a  point  so  far  distant  from  the  paren 
source,  though  it  is  a  fact  well  known  that  simila 
or  like  bodies  tend  to  an  equalization  of  temperatun 
but,  in  this  instance,  the  body  of  water  lying  betwei 
the  shore  at  Atlantic  City  and  the  Gulf  Stream  i 
too  varied  and  enormous  for  one  to  conceive  of  an 
great  temperature  change  being  effected  in  the  equai 
ization  of  temperature  at  this  point.  However,  ii  i 
my  purpose  to  recite,  rather  than  discuss  the  differ 
ences,  and  I  shall  leave  this  part  of  the  subject  for  th 
more  versatile  and  scientific  of  my  readers  to  deter 
mine  for  themselves. 

The  fact  that  a  great  difference  does  exist  in  the- 
different  localities  is  emphasized  by  a  fact  long  Bine 
present  and  proven,  in  the  monumental  health  resorl 
which  dot  the  southern  coast  of  New  Jersey,  clue 
among  which  is  Atlantic  City  where,  in  no  other  par ' 
of  the  State  has  there  been  such  expenditure  for  tin 
comfort  and  interest  of  the  health  seeker;  here 
climate  and  comfort  combine  in  their  efforts  t< 
restore  peacefully  wearied  muscles  and  tired  brain 
in  a  manner  not  to  be  found  elsewhere.  It  is  well  f" 
those  contemplating  climatic  changes  for  improve 
ment  of  health,  or  a  health  building  sojourn,  to  knov 
that  those  visiting  the  shores  of  the  southern  part  o 
New  Jersey,  where  the  temperature  and  climatii 
differences  are  found  most  favorable,  are  not  to  b( 
numbered  by  the  hundreds,  nor  by  the  thousands,  bu: 
by  the  hundreds  of  thousands,  and  while  the  objeei 
with  some  is  primarily  pleasure,  secondarily,  th< 
stimulus  given  the  functional  activities,  menta 
impetus,  and  general  renovation  of  the  varied  foree: 
of  the  body  are  sure  to  follow.  Again,  while  con 
templating  the  above  advantages,  it  is  well  to  know 
that  here  one  escapes  the  debilitating  influence 
incident  to  the  more  severe  and  less  equable  climate! 
of  other  resorts. 

Before  introducing  the  detailed  summary  of  ll" 
observations  made  in  this  city,  some  reference  is  due 
Atlantic  City  not  only  as  the  chief  health  resort  of  the 
New  Jersey  coast  but,  in  truth,  the  most  nearly  ideal 
health   resort  in   America,   if  not  in  all   the  world. 


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Atlantic  City 


lantic  City  is  situated  on  Absccon  Island,  five  miles 

mi   the   main    land;    the   island    ranges  from  one- 

;lith  of  a  mile  to  three  miles  in  width  and  eleven 

lung,  and  is  entirely  surrounded  by  sea  water. 

ie   older   or    principal    business    part    of    the    city 

located  on   the   northern  and    north-central  part  of 

■  Island;  however,  the  growth  of  the  city  of  late 

-    been   so   rapid,    when    considered    in    conjunction 

th    the    suburban    residence    sections    of    Chelsea, 

ntnor,   Margate  City,  and  Longport,  that   it    now 

es  the  greater  part  of  the   island,   and   has  a 

iident  population  of  50,000  or  more;  its  migratory, 

.  i-iting.  population  varies  from  20,000  to  more 

in  300,000,  according  to  the  season  of  the  year. 

s  patrons  are  no   longer  of   the  States,  or  of  one 

.,    for   one   may    easily    touch    the    customs, 

■tilth,   and    industries    of   a   dozen   countries   in    a 

orning's  conversation  in  the  corridors  of  the  various 

ml,  not  infrequently,  the  greater  number  in  the 

■rridors  of  his  own  hotel. 

situated,  by  rail,  fifty-seven  miles  southeast  from 

liladelphia,  and  150  miles  south  by  east  from  New 

iving  respectively  one  hour  from  the  former, 

1  three  hours  from  the  latter,  connecting  therewith 

ie    many     trunk    lines    throughout     the    country, 

antic  City  becomes  more  responsive  to  the  interests 

id  comforts  incidental  to  the  demands  of  the  health 

g  public  than  any  other  coast  health  resort.     In 

Idition  to  the  climatic  advantages,  there  are  to  be 

iund  many  accessories  in  the  way  of  large,  commodi- 

is,  and  comfortable  hotels;  splendidly  arranged  and 

nitarily     equipped     cottages;  good     markets     and 

luntiful  certified  milk  supply;  varied  and  pleasant 

itertainments;  piers    extending     into     the     ocean, 

cess  to  which   may  be  had  at  a  nominal  figure, 

here  the  advantages  of  an  ocean  trip  are  possible 

ithout  any  of  the  inconvenience  and   disturbance 

icidental    to    motion    and    limited    space,    such    as 

- sarily  attaches  to  an  ocean  trip,  the  assurance  of 

cilled  and  readily  attainable  medical  service  in  case 

illness  or  injury;  but  these  facts  are  so  well  and 

■nerally  known  that  a  mere  reference  is  all  that  is 

-ary  in  this  article. 

One  of  Atlantic  City's  greatest  and  most  attractive 

■attires   is    the    Board-walk,    where    the    aged,    the 

ebilitated,  and  the  convalescent,  together  with  the 

leasure  seeker,  may  all  freely  enjoy  the  stimulating 

a  breezes  and  the   hours  of   sunshine,  through  the 

g!  ncy  of  the  rolling  chair,  as  is  not  possible  in  any 

her  place.     Here  Atlantic  City's  patrons  may  tra- 

e    this  elevated   highway  along  the  ocean  front, 

nd  immediately  on  the  strand,  for  a  distance  little 

•s  than  ten  miles,  the  same  varying  in  width  from 

ity  to  eighty  feet,  in  the  central  portion  of  which 

ial  comfort  rooms  have  been  accessibly  arranged 

ath  the  walk.     Here,  through  the  agency  of  the 

hair,  or  a  spirited  walk,  one  can  easily  imagine  him- 

'lf  on  an  ocean  voyage  for  any  period  from  an  hour 

o    that  of  several  months,  and  repeating  it  as  fre- 

Itiently  as  the  opportunities  afforded  may  permit. 

With  this  introduction,  I  submit  the  important 
iart  of  this  article,  bearing  directly  upon  the  climate 
if  Atlantic  City,  for  which  I  am  indebted  to  L.  A. 
fudkins,  Section  Director,  TJ.  S.  'Weather  Bureau, 
ocated  in  Atlantic  City. 

"  The  official  records  of  the  TJ.  S.  Weather  Bureau, 

■overing  a  period  of  nearly  forty  years,  show  con- 

lusively   that    Atlantic   City   possesses   a  favorable 

limate,   whether   the  subject  be   viewed  from  any 

me  or  all  of  the  several  elements,  such  as  temperature, 

trecipitation,    wind,   sunshine   and   cloudiness,   etc., 

hat   are    comprehended    in    the    climatology    of    a 

lace.     The  most  important  advantageous  climatic 

ires  of  this  celebrated  watering  resort  are,  per- 

.  the  comparative  mildness  of  the  winter  season, 

the  coolness  of  summer,  the  abundance  of  sunshine 

throughout   the   year,    and    the    general   exemption 

from  heavy  snows. 


Atlantic  t'ity  has  an  average  winter  temperature 
of  34°,  the  normal  for  th.-  colde  I  m.. nth,  January, 
being  32.5°.  The  summer  temperature  a  ■ 
70.5  ,  with  July  and  August,  as  a  rule,  furnishing  the 
warmest  weather.  The  normal  temperature  for  -pring 
i-  18°,  and  for  autumn,  .">7°.  The  annual  mean  temp- 
erature is  r,2°.  For  purpose  of  comparison,  the 
average  winter  and  summer  temp,  i.i ....  of  several 
of  the  large  eastern  cities  an-  herewith  given: 


Boston 

\.'\\   York.  • 
Philadelphia. 
Baltimore .  . . 
Washington .  . 
Pittsburgh. 
Atlantic  City. 


Winter. 

69° 

32°  71' 

33°  74° 

75° 

34°  7;',° 

:i."  73° 

34°  70° 


"Figures    sometimes   fail    to    describe   adequately 

the  conditions  or  circumstances  to  which  they  are 
applied,  and  it  is  proper  to  say  in  this  connection  that 
there  ;ue  many  days  in  winter  with  seemingly  low 
temperatures    that    are    a    delight  to    the    Atlantic 

City  visitor  because  of  the  fact  that  the  sunst  reamed 
Boardwalk  is  a  number  of  degrees  warmer  than  the 
figures  representing  the  shade  temperature.  On  the 
other  hand,  the  heat  of  summer  is  nearly  always 
tempered  by  the  refreshing  and  cooling  southwest 
breezes,  blowing  directly  from  the  broad  expanse  of 
the  ocean.  The  only  wind  directions  that  produce 
excessive  heat  in  summer  are  west  and  northwest,  and 
these  are  infrequent.  The  average  number  of  day-  in 
Atlantic  City  with  a  summer  maximum  temperature 
of  90°,  or  higher,  is  only  two,  as  against  from  about 
ten  to  twenty  such  days  at  places  in  the  interior. 
The  highest  temperature  on  record  for  the  city  is  99°, 
this  having  occurred  twice  since  the  year  1S74. 
During  the  period  1874-1911  there  have  been  five 
years  with  the  highest  annual  temperature  less  than 
90°,  and  twenty-seven  years  with  less  than  95°.  The 
lowest  temperature  for  Atlantic  City  is  7°  below  zero, 
this  having  been  recorded  once  in  December,  18S0, 
and  on  two  successive  days  in  February,  1899.  The 
average  number  of  days  per  year  with  "minimum 
temperature  32°,  or  below,  is  eighty-four,  and  with 
zero,  or  below,  one.  There  have  been  twenty-seven 
years  since  1S74  without  zero  temperature,  and  the 
actual  number  of  days,  1S74-1912,  on  which  the 
temperature  has  fallen  to  zero,  or  lower,  is  only 
twenty-one. 

"The  several  seasons  of  the  year  are  occasionally 
subject  to  marked  departures  from  their  normal 
weather  elements,  but,  with  respect  to  temperature, 
the  comparative  equability  of  Atlantic  City's  climate 
is  well  illustrated  by  the  fact  that  the  warmest  and 
coldest  seasons  on  record  have  not  been  excessively 
above  or  below  their  respective  averages,  except  in 
a  few  instances.  The  mean  temperature  for  the 
warmest  and  coldest  winter,  spring,  summer,  and 
autumn,  with  the  departures  from  the  normal  tem- 
perature, are  as  follows: 


Mildest  winter 

Coldest  winter 

Mildest  spring 

Coldest  spring 

Wannest  Bummer. . 
Coolest  summer.  .  . 
Warmest  autumn. . 
Coolest  autumn 


Mean  Departure 
temperature,      from  normal. 

42°  +S° 

29°  -5° 

52°  +4° 

44°  -4" 

72°  + 1 . 5° 

69°  - 1   5° 

60°  +3° 

53°  -4° 


"It  will  be  seen  that  the  average  temperature  ol 
the1  warmest  summer  on  record  was  only  1.5°  above 
the  normal,  and  that  of  the  coldest  winter  5°  below 
the  normal.  The  average  date  of  the  last  killing 
frost  in  spring  is  April  11,  and  of  the  first  killing 
frost   in   autumn,    November   4.     The   earliest   date 


7G1 


Atlantic  City 


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on  which  a  destructive  frost  has  occurred  in  autumn 
is  October  1,  and  the  latest  date  in  spring  April  25. 
The  earliest  date  on  which  freezing  temperature  (32°) 
has  occurred  in  autumn  is  October  10,  and  the  latest 
in  spring  April  30. 

"  September  and  October,  with  average  tempera- 
tures of  67°  and  56°,  respectively,  are  ordinarily  two 
of  the  most  pleasant  months  of  the  year,  on  account 
of  their  moderate  temperature,  the  large  amount  of. 
clear  weather,  and  a  marked  decrease  in  the  humidity 
that  is  present  in  the  midsummer  months. 

"It  is  a  popular,  but  in  the  opinion  of  Weather 
Bureau  officials  an  erroneous,  supposition  that  the 
Gulf  Stream  exerts  a  marked  influence  on  the  climate 
of  the  New  Jersey  sea  coast.  This  ocean  current  is 
distant  100  miles,  or  more,  from  the  New  Jersey  shore, 
and  although  its  temperature  is  somewhat  higher 
than  that  of  the  surrounding  water,  there  is  hardly  a 
possibility  that  the  stream  has  any  effect  whatever 
on  the  climate  of  this  locality.  The  comparative 
mildness  of  the  winter  season  is  due  to  the  influence 
of  the  ocean  itself  rather  than  to  the  Gulf  Stream. 

"The  temperature  of  the  ocean  at  Atlantic  City  is 
exceptionally  favorable  for  bathing  in  summer.  In 
the  summer  of  1911  the  surface  water  temperature 
rose  to  above  70°  in  the  latter  part  of  June,  and  was 
not  below  70°  thereafter  during  the  season,  except 
occasionally  and  briefly  in  July.  The  water  tem- 
perature was  80°  and  slightly  higher  numerous  times 
in  August,  and  remained  above  70°  until  about 
October  1. 

"The  average  precipitation  (rain  and  melted  snow) 
at  Atlantic  City  is  40.82  inches.  The  precipitation  is 
quite  uniformly  distributed  through  the  several 
seasons  as  follows:  Winter,  10.41  inches;  spring, 
9.72  inches;  summer,  11.11  inches;  autumn,  9.58 
inches.  August,  with  an  average  of  4.30  inches,  is 
the  wettest  month.  There  are  four  months,  April, 
May,  June,  and  September,  that  are  classed  as  dry, 
each  having  an  average  rainfall  close  to  3  inches. 
The  average  annual  number  of  days  with  measurable 
precipitation  is  about  125,  the  greatest  annual  number 
on  record  being  143,  and  the  least  101.  Virtual 
immunity'from  heavy  snowfall  during  winter  is  one 
of  the  several  favorable  climatic  characteristics  that 
attracts  many  winter  visitors,  whether  bent  on  pleas- 
ure or  seeking  restoration  to  health.  That  the 
resort  escapes  in  large  measure  the  heavy  snowfalls 
that  are  common  to  the  interior  is  accounted  for  by 
the  simple  fact  that,  when  conditions  are  opportune 
for  snow,  the  temperature  often  tends  upward  with 
the  approach  of  the  storm  center,  thus  frequently 
changing  the  precipitation  to  rain.  The  average 
annual  snowfall  is  only  eighteen  inches,  and  the 
average  number  of  days  with  snow  (November  to 
April  inclusive),  twelve.  The  normal  amount  for  the 
three  winter  months  is  about  thirteen  inches,  January 
and  February  naturally  having  the  heaviest  falls. 
Snow  is  infrequent  in  November,  and  there  have  been 
so  few  appreciable  amounts  in  April  in  the  past 
thirty  years  that  the  average  for  the  latter  month  is 
merely  "  trace."  It  is  uncommon  for  snow  to  remain 
on  the  ground  for  any  considerable  time;  on  the 
contrary  it  often  disappears  within  twenty-four  hours 
after  ending. 

"  Atlantic  City  is  abundantly  supplied  with  sun- 
shine— an  important  climatic  factor.  The  average 
annual  number  of  hours  of  sunshine  is  61  per  cent,  of 
the  possible  number.  The  averages  for  the  summer 
months  range  from  63  to  68  per  cent.;  September  has 
an  average  of  67  per  cent.,  and  October  63  per  cent. 
Less  sunshine  is  received  in  winter  than  in  summer, 
but  each  winter  month  has  an  average  percentage 
exceeding  50,  that  for  December  being  55  per  cent., 
for  January,  52  per  cent.,  and  for  February,  60  per 
cent.  No  winter  month  in  the  last  16  years  has 
received  less  than  40  per  cent,  of  the  possible  amount 
of  sunshine,  and  several  winter  months  have  had  as 


much  as  seven-tenths  of  the  possible  number  o 
hours.  The  average  cloudiness  (scale  0  to  10)  is  5.( 
The  average  number  of  clear  days  per  year  is  122 
partly  cloudy,  135;  cloudy,  108.  Southwest  wind 
prevail  from  May  to  September,  inclusive,  an 
northwest  at  other  times. 

"  The  foregoing  statements  cover  the  subject  of  th 
climate  of  Atlantic  City  only  in  a  general  mannci 
It  must  not  be  inferred  from  them  that  disagreeab! 
weather  is  unknown  here,  although  the  authenti 
Weather  Bureau  records  prove  beyond  doubt  tha 
the  sum  of  the  good  qualities  of  the  climate  largel 
outweighs  the  unpleasant  conditions  that  are  en 
countered  in  this  city,  as  well  as  elsewhere,  at  times. 

Philip  Marvel. 


Atlee,  Washington  L. — Born  in  Lancaster,  Pa 
February  22,  1808.  He  received  the  degree  o 
Doctor  of  Medicine  from  the  Jefferson  Medica 
College,  Philadelphia,  in  1829.  In  1834  he  began  th 
practice  of  his  profession  in  his  native  city.  In  1- 
he  removed  to  Philadelphia.  He  died  in  that  city 
September  6,  1S78. 

Stone,  in  his  "  Biography  of  Eminent  America? 
Physicians  and  Surgeons,"  says:  "As  a  practitione 
Atlee  was  most  famous  for  his  advocacy  of  tin 
difficult  operation  of  ovariotomy.  Commencing  it 
performance  and  defending  its  propriety  at  a  periei 
when  hardly  another  surgeon  in  the  land  darn 
support  him,  he  triumphantly  vindicated  its  nierii 
by  the  statistics  of  over  three  hundred  cases  in  hi: 
own  hands,  a  large  part  of  them  successful  in  al 
respects.  From  his  own  history  of  ovariotomy 
sketched  in  his  annual  address  as  president,  before  tin 
Philadelphia  County  Medical  Society,  we  cull  th. 
more  important  facts.  To  Dr.  Ephraim  McDowel 
is  accorded  the  honor  (now  generally  conceded)  ol 
being  the  first  to  perform  the  operation,  in  the  year 
1809.  (See  under  the  heading  McDowell,  Ephraim,  in 
a  later  volume  of  this  Handbook,  for  further  details.) 
Dr.  John  L.  Atlee,  of  Lancaster,  Pa.,  brother  of  the 
subject  of  this  sketch,  performed  it  on  June  29,  1843, 
on  an  unmarried  lady,  aged  twenty-five  years. 
*****  rjr_  Washington  Atlee  performed  his  first 
operation  March  29,  1844,  on  a  married  lady,  sixty-one 
yearsofage.  It  proved  fatal.  *****  His  second 
operation  was  performed  in  the  city  of  Lancaster, 
August  2S,  1844,  on  an  unmarried  lady,  twenty-four 
years  of  age.  She  recovered.  *****  His  third 
operation,  the  first  case  in  Philadelphia,  was  per- 
formed March  15,  1849.  Upon  moving  to  Phila- 
delphia he  found  ovariotomy  everywhere  decried. ' 
It  was  denounced  by  the  general  profession,  in  the 
medical  societies,  in  all  the  medical  colleges.  The 
opposition  went  so  far  that  a  celebrated  professor,  in 
his  published  lectures,  invoked  the  law  to  arrest  him 
in  the  performance  of  the  operation."  In  1853,  only 
a  few  years  after  the  excitement  regarding  the  opera- 
tion of  ovariotomy  had  in  large  measure  subsided, 
Atlee  again  "startled  the  profession  by  his  method  of 
heroically  attacking  uterine  tumors  with  the  knife." 
His  successes  were  numerous,  and  although  few  at 
first  dared  to  imitate  him,  he  lived  to  see  the  opera- 
tion approved  and  himself  commended  by  the  best 
gynecologists  of  his  time. 

Of  the  various  writings  published  by  Dr.  Atlee  it 
will  be  sufficient  here  to  mention  the  titles  of  only 
the  following:  "General  and  Differential  Diagnosis nf 
t  Ivarian  Tumors,  with  Special  Reference  to  the 
Operation  of  Ovariotomy,"  1S73;  and  "The  Treat- 
ment of  Fibroid  Tumors  of  the  Uterus,"  1876. 

A.  H.  B. 


Atophan. — The  trade  name  of  an  antipyretic  and 
analgesic  synthetic  compound,  C10HUNO,  (2-phenyl- 
chinolin-4-carbonic  acid),  introduced  as  a  substitute 


762 


REFERENCE    IIAXDRt  ><>K   OF   THE    MEDICAL   SCIENCES 


Atresia 


[  the  salicylates.     It  occurs  in  the  form  of  small, 

lorless,  acicular  crystals,  of  a  slightly  bitter  taste, 

soluble  in  pure  water,  but    readily  soluble   in  nlku- 

olutions    and    hot    alcohol.     Experiments    by 

icolaier  and  Dohrn  have  shown  thai  the  exhibition 

ihan  is  followed  by  a  greatly  increased  output 

uric  acid  ami   the  urates.     According   to   Wein- 

this    increased    elimination    is    not     ,lue    to    a 

production   or   to   an    increased   solubility   of 

id  in   the  organism,  but  rather  to  a  selective 

of   the   drug   upon    the   secreting   epithelium 

the   convoluted    tubules   of   the    kidney    causing 

0  excrete  larger  quantities  of  this  substance. 

te   drug   is    therefore    recommended    as   of   special 

in   the   treatment  of  acute   gout    and   gouty 

ons   believed   to  depend  upon  a  retention   of 

id  in  the  economy  and  a  deposit  of  urates  in 

its  and   fibrous   tissues.     It   has   been   found 

cful  also  in  acute  rheumatism  and  in  sciatica  and 

her   neuralgias,    lumbago,    and    migraine.     In   cer- 

es  the  administration  of  atophan  causes  more 

;astric  disturbance  which  may  be  avoided  by 

.    simultaneous  exhibition  of  small  doses  of  sodium 

arbonate.     Obviously,  the  greatly  increased  excre- 

ol    uric  acid  by  the  kidneys  might  produce  a 

v   to  renal  colic  or  the  formation  of  vesical 

and  it  is  advisable  therefore  to  combine  the 

'ministration  of  atophan  with  large  doses  of  sodium 

icarbonate  and  copious  water  drinking.     The  drug 

i-  tint  1 n  observed  to  have  any  depressant  action 

i  the  heart. 

Vtophan  is  given  in  doses  of  gr.  vijss.  (0.5)  four 

t8E  a  day  to  gr.  xv.  (1.0)  three  times  a  day.     So- 

ini  bicarbonate  should  be  given  at  the  same  time 

doses  of  5i.  (4.0)  three  times  a  day,  and  a  glass  of 

ain  water  or  mineral  water  should  be  taken  with 

ich   dose  of  atophan.     The   drug   is  found   in   the 

:irket  in  tablets  of  seven  and  one-half  grains  (one- 

alfgram).  T.  L.  S. 


\to\yl. — Trade    name    of    sodium    arsanilate    or 

idium    aniline    arsonate,    C6H,N.As03Na  or  C6II,- 

, Tl  AsO.OH.ONa  +3H20.     Similar  preparations  are 

nown   as   soamin   and   arsamin.     It   occurs   in    the 

inn  of  a  white,   odorless  crystalline  powder,  of  a 

lightly   saline   taste,    soluble   in   five   parts   of   cold 

rater.     Its  therapeutic  action  is  believed  to  be  due 

o   the  very   gradual   elimination   of   arsenic   in   the 

issues,    producing    thereby    a    continuous    but    less 

oxic  and  less  irritating  effect   than  arsenous  acid. 

t   has  been  employed   to   meet   the   indications   of 

lie  in  anemia  and  in  the  malarial  cachexia,  but  its 

hief  use  is  in  the  treatment  of  syphilis  and  of  trypano- 

omiasis,  especially  sleeping    sickness.     It    is    given 

lodermically  in  doses  of  gr.  i.-iij.  (0.06-0.2)  every 

r  day;  it  has  also  been  given  in  much  larger  doses, 

ven  up  to  gr.  x.   (0.6),   by  intramuscular  injection 

nto    the    buttock.     Although    the    drug   has    given 

xcetlent  results  in  the  treatment  of  sleeping  sickness, 

t  has  fallen  more  or  less  into  disfavor  in  consequence 

if  many  cases  of  blindness  from  degeneration  of  the 

iptic  nerve  which  have  followed  its  use.     Muscular 

md  abdominal  cramps  and  renal  irritation  have  also 

jeen  observed  after  large  doses.  T.  L.  S. 

Atresia. — Imperforation,  closure,  or  absence  of  a 
natural  opening  or  passage.  (Gr.  a  =  priv.  and  rp^o-is, 
i  piercing.)  There  may  exist  an  atresia  of  any  one 
of  the  external  orifices  or  internal  passages  of  the 
body:  Atresia  pupillae,  A.  palpebrarum,  A.  oris,  A. 
inris,  A.  trachea1,  A.  oesophagi,  A.  bronchi,  A.  in- 
ini,  A.  recti,  A.  ani,  A.  vagina?,  A.  urethrae,  A. 
c,  A.  uteri.  The  imperforation  may  be  the 
result  of  disturbances  of  development  in  fetal  life,  or 
it  may  arise  secondarily  to  local  inflammatory  pro- 
cesses either  before  or  after  birth,  or  may  be  produced 


by   mechanical  obstruction,  pressure,  etc.      According 

to  the  etiology  we  may  therefore  distinguish  two 
classes  of  atresia,  the  congenital  ami  the  acquire^. 

Pupil. — Congenital   closure  of  the  pupil   of  tie 

not  infrequently  occurs,  and  is  usually  the  result  of  a 
persistence  of  the  pupillary  membrane  which  in  fetal 
life  covers  the  lens  and  as  a  rule  disappears  in  the 
last  month  of  pregnancy.  Variou  forms  of  this 
malformation  occur:  the  pupil  may  be'  entirely 
covered    by    a    thick    grayish    membrane    containing 

blood-vessels,  or  by  a  network  of  fine  threads  in 
which  vessels  run,  or  irregular  brown  or  grayish 
patches  may  appear  in   the  pupil. 

Acquired  atresia  of  the  pupil  is  of  rather  frequent 
occurrence  in  adult  life  as  tin-  result  of  inflammations 

of  the  iris  and  choroid,  but  it  may  take  place  at  any 
time,  even  before  birth.  In  chronic  iritis  the  pupil 
may  be  partially  or  completely  closed  by  vascular 
connective  tissue. 

Eyelids. — Total  imperforation  of  the  eyelids  is  not. 
of  frequent  occurrence.  The  congenital  form  is 
usually  associated  with  grave  defects  of  development 
which  do  not  permit  of  extrauterine  life.  The  edges 
of  the  lids  may  be  firmly  adherent  to  each  other  and 
to  the  eyeball  (symblepharon).  The  condition  may 
be  caused  by  a  failure  of  separation  of  the  conjunc- 
tivae, intrauterine  inflammations  of  the  eye,  or  it 
may  be  caused  by  amniotic  adhesions.  The  latter 
cause  is  probably  the  most  frequent.  One  or  both 
eyes  may  be  affected.  Remains  of  the  amniotic 
adhesions  may  be  found  in  the  shape  of  tags,  bands, 
or  firm  membranes  covering  the  lids  and  adherent 
to  them. 

Acquired  atresia  of  the  eyelids  (symblepharon, 
ankyloblepharon)  occurs  after  severe  ulcerations,  diph- 
theritic conjunctivitis,  burns  caused  by  lime,  hot  metal, 
and  explosives.  In  cases  in  which  there  is  complete 
occlusion  the  edges  of  the  lids  are  firmly  united  to 
each  other  and  to  the  eyeball. 

Nostrils. — Complete  atresia  of  the  nostrils  is  rare 
and  is  usually  found  in  association  with  cyclopia.  In 
this  type  of  monster  the  nostrils  are  represented  by 
one  or  two  fleshy  imperforate  tags  which  are  usually 
placed  in  the  forehead  above  the  solitary  eye.  The 
atresia  of  one  nostril  through  a  congenital  obliquity 
of  the  septum  is  not  infrequent,  and  is  of  great  practi- 
cal importance  because  of  the  habit  of  mouth-breath- 
ing and  the  chronic  catarrhs  of  nose  and  pharynx 
which  are  associated  with  it. 

Acquired  stenoses  of  one  or  both  nostrils  are  also 
not  rare.  The  closure  may  be  caused  by  new  growths, 
polypi,  injuries,  chronic  catarrhal  conditions,  etc. 
This  condition  is  likewise  of  great  practical  impor- 
tance. 

Mouth. — Complete  absence  of  the  mouth  is  a  very 
rare  occurrence,  and  is  always  associated  with  marked 
defective  development  of  the  head  and  face.  It  is 
most  frequently  the  result  of  amniotic  adhesions, 
or  of  an  abnormal  tightness  of  the  cephalic  cap  of  the 
amnion.  Partial  atresia  (microstomia)  is  of  more 
frequent  occurrence,  but  is  rarely  found  in  a  viable 
fetus.  Congenital  closure  of  the  fauces  is  likewise  of 
rare  occurrence. 

Ears. — Complete  failure  of  development  of  the 
external  auditory  meatus  occurs  very  rarely.  The 
lumen  of  the  meatus  may  be  filled  with  compact 
bone  or  cartilage,  or  it  may  be  closed  by  a  firm  mem- 
brane of  connective  tissue  in  which  small  islands  of 
bone  or  cartilage  may  be  present.  With  this  mal- 
formation there  is  almost  always  associated  a  de- 
fective development  or  entire  absence  of  the  external 
ear,  and  imperfect  development  of  the  tympanum  and 
internal  ear.  The  site  of  the  ear  may  be  indicated 
only  by  a  slight  indentation.  In  other  cases  a  carti- 
laginous canal  may  be  present  which  is  closed  at  a 
slight  depth  by  bone  or  membrane.  Partial  atresias, 
hour-glass  or  symmetrical  narrowing  of  the  external 
canal,  are  of  rather  frequent  occurrence.     In  these 


7G3 


Atresia 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


cases  the  external  ear  may  be  normally  developed  or 
show  greater  or  less  malformation. 

Acquired  atresia  of  the  external  canal  is  not  rare. 
Inflammations  may  cause  thickenings  of  the  wall  of 
the  meatus,  and  stenosis  or  constriction  may  result 
from  the  formation  of  connective  tissue.  Very  fre- 
quently there  is  a  polypoid  growth  of  granulation 
tissue  into  the  canal,  and  through  the  adhesion  of  the 
granulating  surfaces  complete  atresia  of  the  canal 
may  result;  or  bands,  bridges,  and  septa  of  connec- 
tive tissue  may  be  formed.  A  subperiosteal  forma- 
tion of  new  bone  may  lead  to  osseous  atresia;  in 
other  cases  exostoses  may  block  the  canal.  De- 
tached osteomata  sometimes  develop  in  the  granula- 
tion tissue  formed  in  inflammatory  processes.  Fur- 
ther, eholesteatomata  are  rather  frequently  found 
blocking  up  the  external  canal.  In  these  cases  all 
parts  of  the  ear  may  be  perfectly  developed  and  the 
tympanum  intact.  It  is  therefore  probable  that 
these  formations  owe  their  origin  to  a  desquamative 
inflammation  of  the  lining  of  the  canal.  In  very 
rare  instances  they  may  develop  from  epidermoidal 
cells  which  during  the  period  of  embryonic  life  have 
found  their  way  into  the  meatus.  Plugs  of  cerumen, 
foreign  bodies,  tumors,  parasitic  growths,  etc.,  may 
also  lead  to  an  acquired  atresia  of  the  auditory  canal. 

Trachea,  Bronchi,  etc. — Atresia  of  the  larynx 
through  the  formation  of  connective-tissue  membranes 
or  through  the  adhesion  of  the  walls  is  of  very  rare  oc- 
currence, and  has  been  observed  only  in  cases  showing 
marked  malformations  of  the  face.  There  may  be 
complete  absence  of  the  trachea,  the  bronchi  being 
given  off  directly  from  the  larynx.  In  other  cases 
the  trachea  may  be  represented  by  a  fibrous  cord- 
like structure,  or  its  walls  may  be  united  by  the  for- 
mation of  connective  tissue.  Similar  formations  of 
connective  tissue  may  block  the  main  bronchi,  the 
trachea  ending  in  a  blind  tube.  Partial  narrowing  of 
the  respiratory  passages  is  not  uncommon. 

The  acquired  forms  of  stenosis  of  the  trachea  and 
bronchi  are  for  the  greater  part  produced  by  con- 
ditions external  to  these  structures,  new  growths  in 
the  neighboring  lymph  glands,  aneurysms,  etc.  Ob- 
struction of  the  passages  themselves  may  be  produced 
by  inflammatory  conditions,  foreign  bodies,  etc. 
New  growths  within   them  are  of  rare  occurrence. 

Cardiac  Orifices. — Atresia  of  the  aorta  is  rare. 
On  the  other  hand,  atresia  of  the  pulmonary  orifice 
is  a  relatively  common  cardiac  anomaly. 

Esophagus. — Atresia  of  the  esophagus  throughout 
its  entire  length  is  very  rare.  Congenital  imperf ora- 
tion of  this  organ  is  most  frequently  found  in  the 
lower  two-thirds,  the  upper  third  being  open  and 
ending  in  a  blind  tube,  while  the  lower  closed  portion 
is  represented  by  a  thin  cord-like  structure.  Associated 
with  the  congenital  atresia  there  is  almost  always  an 
abnormal  communication  with  the  trachea  either 
at  the  lower  end  of  the  upper  portion  or  at  the  upper 
end  of  the  lower  portion,  which  may  be  continued  as 
an  open  canal  from  the  point  of  communication.  In 
other  cases  the  middle  portion  of  the  esophagus  may 
be  obliterated,  so  that  the  upper  and  lower  portions 
are  separated  from  each  other  by  an  imperforate  cord 
of  connective  tissue.  In  these  cases  no  connection 
with  the  trachea  may  exist.  As  a  rule  this  form 
occurs  late  in  fetal  life  and  is  most  probably  due 
to  inflammatory  processes. 

Acquired  stenoses  of  the  esophagus  are  of  relatively 
frequent  occurrence  and  are  of  great  clinical  impor- 
tance. They  may  be  caused  by  pressure  of  tumors 
in  the  cervical  or  mediastinal  lymph  glands  and 
thyroid,  by  mediastinal  tumors,  aneurysms,  etc.  The 
lumen  may  be  obturated  by  polypoid  growths  of 
the  mucosa,  carcinoma,  thrush,  foreign  bodies,  etc. 
Strictures  are  produced  by  contractions  of  scars  re- 
sulting from  the  effects  of  alkalies,  acids,  carcino- 
matous and  syphilitic  ulcerations,  etc. 

Stomach. — Complete  occlusion  of  the  stomach  is  ex- 

764 


tremely  rare.  Occasionally  the  organ  is  very  sma] 
resembling  a  portion  of  the  intestine.  Congenital  o 
elusion  of  the  pylorus  is  quite  rare,  while  acquire 
stenosis  at  this  point  is  relatively  frequent.  1 
almost  every  case  the  latter  is  due  to  the  obstructio 
or  constriction  of  the  orifice  by  new  growths,  but 
may  be  caused  by  healing  ulcers  or  by  pressure  froi 
without.  Partial  constriction  of  the  stomach  ma 
occur  in  any  part  of  the  organ  through  the  contraetii 
of  healing  ulcers,  new  growths,  etc.  (hour-gla: 
constriction). 

Intestine. — Congenital  atresia  or  stenosis  may  occi 
at    any    portion    of    the   intestinal    tract.     There 
usually  only  a  single  such  closure,  but  occasionall 
multiple  atresias  may  be  found.     The  intestine  ma 
be  entirely  absent  for  a  portion  of  its  course,  or  t 
represented  by  a  cord-like  band  of  connective  tissui 
The  portion  of  mesentery  belonging  to  the  obliterate 
intestine   is  also   absent.     The   entire  jejunum  an 
ileum  may  be  absent,   the  duodenum  ending  in 
blind  sac.     In  such  cases  both  stomach  and  duods 
num    may  be    greatly  dilated.     The    most   commo 
site  of  intestinal  atresia  is  in  the  region  of  the  openin 
of  the  ductus  choledochus.     If  it  is  below  the  openin 
the  collection  of  secretions  together  with  the  swallowe 
amniotic  fluid  may  cause  an  extreme  dilatation  i 
the    duodenum    and    stomach.     The    lower   portio 
below  the  imperforation  begins  in  a  blind  sac.    I 
other  cases  the  atresia  is  located  above  the  opening  t 
the  common  duct,  so  that  bile  passes  into  the  lowe 
portion  of  the  intestine,  as  shown  by  the  presence  o 
meconium.     The    genesis    of    the    larger    congenita 
defects  of  the  intestine  has  not  yet  been  satisfactoril; 
explained.     Peritoneal  adhesions,  embolic  infarctioi 
of    the   mesentery,   etc.,   have   been   thought    to  b 
primary  causes,  but  no  conclusive  evidence  has  yi 
been  shown.     It  is  more  probable  that  some  essentia 
defect   of  development,   such  as  an   abnormal  axi 
rotation,     lies     behind     these     malformations.    Thi 
smaller  localized  atresias  occurring  in  late  fetal  lifi 
are  most  probably  the  result  of  pathological  proces 
in  the  peritoneum,  and  in  some  cases  this  has  bi 
definitely    shown.     Such    conditions    are    most    fre 
quently  found  in  children  with  congenital  syphilis  whe 
die  a  few  days  after  birth. 

Acquired  stenosis  of  the  lumen  of  the  intestines  is 
not  uncommon,  the  most  frequent  causes  being  m\\ 
growths,  constriction  of  healing  ulcers,  peritonea] 
bands  and  adhesions,  etc.  They  may  be  found  in 
any  portion,  but  are  more  common  in  the  large  in- 
testine, particularly  in  the  region  of  the  sigmoid  flexurf 
and  rectum. 

Atresia  of  the  bile-ducts  is  not  rare.  The  common 
duct  may  be  represented  by  a  fibrous  cord;  the 
gall-bladder  may  be  absent,  and  the  intrahepatic 
ducts  may  show  obliteration.  Some  of  these  cases  are 
distinctly  inflammatory,  and  may  be  due  to  congeni- 
tal syphilis;  in  others  both  etiology  and  nature  are 
obscure. 

Anus. — Of  all  the  congenital  atresias  the  most 
common  and  important  is  that  of  the  rectum  and 
anus.  According  to  the  location  of  the  imperforation 
a  number  of  varieties  of  this  malformation  exist,  the 
most  important  of  which  are: 

(a)  In  the  simple  form  the  anus  is  closed  by  a 
connective-tissue  septum  of  varying  thickness.  It 
may  be  a  very  thin  membrane  so  that  the  contents 
of  the  rectum  may  be  easily  felt  through  it,  or  the  rec- 
tum may  end  in  a  blind  sac  some  distance  above  the 
anus.  In  other  cases  the  free  end  of  the  rectum  lies 
in  the  pelvis  and  is  usually  greatly  dilated.  This 
malformation  is  not  always  a  primary  defect  of  de- 
velopment, but  may  be  caused  by  an  abnormal 
growth  of  connective  tissue.  In  other  cases  there 
may  be  a  complete  failure  of  development  of  the 
lower  end  of  the  intestine.  In  place  of  the  anus 
there  is  usually  only  a  slight  depression  in  the  skin. 
The  sphincter  is  usually  formed. 


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Atrophia  PUonun  Propria 


(b)  The  large  intestine  may  end  in  a  blind  sac  far 

ove  the  anus,  which  is  usually  not   unhealed  al  all, 
only  by  a  very  slight  groove  in  (he  skin. 
i,  i  The  anus  may   lie   perfectly   formed,   but  the 
nun    fails   entirely   or   is   converted   into  a  solid 
•and  of  connective  tissue. 

In    these    forms    the    sinus    urogenitalis    may    be 

irmally  developed,  or  the  original  communications 

tween  the  intestine  and  the  anterior  portion  of  the 

iaoa    may    remain    preserved,   or   the   rectum    may 

en  into  the  perineum  anteriorly  to  the  anus,  or  into 

irotum,    penis,    bladder,    vagina,    uterus,    or 

ethra.      VVe    may,     therefore,    further    distinguish 

ch   forms  as:  atresia   ani   vesicalis,   atresia   of    the 

ith  fistula  of  the  bladder;  atresia  ani  urethralis, 

resia  of  the  anus  with  opening  into  the  urethra — 

mlly  the  membranous  portion,  as  this  malforma- 

found  almost  exclusively  in  male  individuals; 

ani  vulvovaginalis  and  uterina,  atresia  of  the 

lis   with   communication   of   the   rectum   into   the 

vulva,  or  uterus.     In  other  forms  both  the 

mi  ami  the  sinus  urogenitalis  may  open  into  a  con i- 

,:i  closed  space  which  has  no  external  opening  and 

lich  through  the  collection  of  urine  and  meconium 

ay    become    greatly    dilated.     The    more    marked 

alformations  of  this  class  preclude  life,  but  some  of 

08  es    are   capable   of   surgical    cure.     Acquired 

resias  of  the  anus  or  rectum  are  not  infrequent  and 

produced  by  new  growths,  cicatricial  contraction 

healing  ulcers,  syphilitic  processes,  etc. 

Urethra  and  Bladder. — Total  atresia  of  the  male  ure- 

ira  occurs   rarely,    and  is  found  in  association  with 

ilete  absence  of  the  external  genitals.     As  a  result 

the  collection  of  urine  in  the  bladder  an  enormous 

latation  of  the  abdomen  may  occur  which  may  be  so 

it    as   to   prevent   normal   delivery.     Rauber  ob- 

rved  an  adult  male  with  complete  absence  of  penis 

hose  urethra  communicated  with  the  rectum.     The 

osl  frequent  localized  atresia  of  the  male  urethra  is 

the  external   meatus  and  orifice  of  the  prepuce. 

nperforation  of  the  anterior  urethra  occurs  rarely 

a  result  of  defective  development  of  the  urethral 

iptum,  and  in  the  posterior  portion  as  a  result  of 

roliferations     and     adhesions.     Congenital     atresia 

the   female   urethra   also   ocurs  rarely,   and   may 

feet  the  entire  length  of  the  urethra  or  only  a  por- 

on.     As  a  result  of  the  congenital  imperforation  of 

le  urethra  in  both  sexes,  congenital  dilatation  of  the 

ladder,   ureters,   and   pelvis  of   the   kidneys  results 

om  the  retention  of  urine.     Occasionally  the  urachus 

mains  open  and  there  is  an  escape  of  urine  from 

le  umbilicus,  or  there  may  be  abnormal  communica- 

ons  with  the  intestines,  vagina,  uterus,  etc.,  by  which 

hich  the  urine  passes. 

Acquired  atresia  of  any  portion  of  the  urinary  pas- 

•  may  occur  as  the  result  of  cicatricial  adhesions 

nd  contractions,  new  growths,  tuberculosis,  syphilis, 

irnal  pressure,  etc.     Gonorrhea  and  direct  injury 

re  the  most  common  of  these  factors. 

Vagina  and  Uterus. — A  congenital  total  atresia  of 

i"  female  genital  tract  may  exist  in  connection  with 

total  defect  of  the  external    genitals.     The  vagina 

lay  end  in  a  closed  space  in  common  with  the  bladder 

nd  rectum   (persistence  of  the  cloaca).     The   most 

ommon  site  of  congenital  atresia  of  this  tract  is  at 

1   opening  of  the  vagina,  which  is  closed  by  a  mem- 

irane  of  greater  or  lesser  thickness  (gynatresia).     The 

nperforation   may   be  due  to  an  abnormally  thick 

iymen    (atresia   vaginalis   hymenalis).     The   closure 

nay    extend    throughout    the    entire    length    of    the 

agina  or  occur  at  any  portion.     Complete  absence 

•  f  the  vagina  is  rare,  more  frequently  the  organ  is 

epresented  by  a  fibrous  cord.     The  closure  is  due  to 

i  failure  of   the   epithelial   layers   to   separate  or   to 

econdary  adhesions.     Congenital  atresia  of  the  uterus 

3   also   rare.     The   occlusion   occurs   usually   at   the 

ervix,   which  may  be   closed  partly  by  mucosa  or 

>artly  by  muscle  and  connective  tissue.     This  con- 


dition  may   exist    without    other   malformations   and 

remain  undiscovered  until  puberty,  when  the  collec- 
tion of  the  menstrual  discharges  within  the  dilated 

uterus  and  tubes  may  give  rise  to  very  important 

symptoms.  The  atresias  of  the  vagina  may  similarly 
assert  themselves. 

(Induct*. — Complete  absence  of  the  tubes  occurs 
in  connection  with  marked  malformations  of  the 
uterus.  Atresia  of  either  the  abdominal  or  uterine 
end  may  occur,  or  an  imperforation  may  exisl  in  any 
part  of  the  tube.  Acquired  atresias  of  the  tubes 
are  very  Common,  and  most  frequently  involve  the 
distal  and  proximal  portions.  Chronic  gonorrheal 
salpingitis  and  tuberculo  is  :iv  the  most  common 
causes.      Tubal  gestation  and  sterility  may  result. 

Acquired  atresias  of  the  female  genital  trad  may  be 

the  result  of  cicatricial  contractions  following  ulcera- 
tions, etc.  (gangrenous  vaginitis,  tears,  use  of  caustics, 
Cervical  amputations,  retained  pessary,  tumors,  etc.). 
The  majority  of  the  atresias  of  the  vagina  and 
uterus  which  are  not  associated  with  marked  malfor- 
mations are  amenable  to  surgical  treatment. 

Aldbed  Scott  Wakthin. 


Atrophia  Cutis  Idiopathica. — This  term  which 
implied  originallj-  a  spontaneous  primary  atrophy 
of  the  skin  has  largely  given  way  to  the  designation 
"dermatitis  atrophicans  idiopathica,"  by  which  the 
idea  is  conveyed  that  this  form  of  atrophy  depends 
for  its  origin  on  a  special  dermatitis.  The  nature  of 
the  latter  is  obscure,  and  it  is  conceivable  that  if 
sufficient  predisposition  is  present,  due  to  structural 
peculiarity  (as  defect  of  elastic  fibers),  any  dermatitis 
might  result  in  atrophy.  In  a  certain  number  of 
cases  external  insults  of  the  skin  (the  sun,  wind,  etc.) 
appear  to  precipitate  the  dermatitis.  There  are 
believed  to  be  three  clinical  types  of  dermatitis 
atrophicans  which  are  parallel  to  the  three  types  of 
scleroderma:  (1)  a  generalized  or  diffuse  form;  (2)  a 
form  which  affects  the  extremities — forearms  and 
hands,  legs  and  feet,  and  face;  (3)  an  isolated,  circum- 
scribed form.  These  differ  among  themselves  only 
in  respect  to  localization.  They  have  nothing  in 
common  with  the  primary  atrophies  of  the  skin 
which  are  usually  described  as  atrophodermata. 
Further  information  as  to  atrophying  dermatitis 
may  be  found  under  Acrodermatitis  atrophicans. 

E.P. 


Atrophia  Pilorum  Propria. — By  this  term  is  meant 
simple  atrophy  of  the  hair  uncomplicated  with  ap- 
parent disease  of  the  scalp.  Under  it  are  included 
at  least  three  forms,  namely:  fragilitas  erinium, 
trichorrhexis  nodosa,  and  monilethrix.  They  have 
one  feature  in  common,  which  is  that  the  hairs  are 
friable,    splitting   or   breaking   with   slight    traction. 

Fragilitas  Crinittm. — This  is  also  called  scissura 
pilorum.  The  characteristic  of  this  disease  is  that  the 
hair  is  dry  and  splits  either  at  its  ends  or  in  its  con- 
tinuity.    It    may   be     symptomatic     or     idiopathic. 

1.  Symptomatic  Fragilitas  Crinium. — This  is  a  very 
common  affection  of  the  hair,  and  is  met  with  in 
many  diseases  of  the  scalp,  such  as  eczema,  ringworm, 
favus,  and  seborrhea.  Whenever  the  scalp  is  abnor- 
mally dry,  and  also  in  general  constitutional  diseases 
in  which  the  nutrition  of  the  body  is  lowered,  the  hair 
may  become  dry  and  split.  It  is  seen  chiefly  in  the 
long  hair  of  women.  If  the  hair  is  viewed  in  mass  it 
looks  as  if  it  had  been  singed,  if  the  case  is  a  severe 
one.  In  any  case,  if  the  hair  is  held  in  the  hand  in  a 
good  light  it  will  be  noticed  that  the  ends  of  the  hair 
are  split  into  several  diverging  filaments. 

2.  Idiopathic  Fragilitas  Crinium. — In  this  form, 
which  is  much  rarer  than  the  preceding,  the  hair  splits 
at  the  end  without  any  apparent  disease  of  the  scalp. 
The  split  may  be  at  the  free  end,  in  the  continuity  of 


765 


Atrophia  Pilorum  Propria 


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the  shaft,  or  within  the  bulb.  The  hair  may  be  cleft 
only  at  the  end,  or  the  cleft  may  run  up  the  shaft  for 
a  variable  distance.  If  the  cleft  occurs  in  the  con- 
tinuity of  the  shaft  the  filaments  may  hold  together 
or  separate  widely.  The  disease  is  seen  most  often  in 
the  long  scalp  hair  of  women.  It  occurs  also  in  the 
beard.  There  may  be  but  a  few  hairs  affected  or 
there  may  be  many,  giving  the  singed  appearance 
spoken  of  above.  In  some  cases,  as  the  hair  splits 
and  breaks  off  before  it  has  attained  any  great  length, 
the  woman  in  unable  to  dress  her  hair, 
and  has  to  wear  it  cut  short. 

Pathology  . — Usually,  nothing 
fin  I  her  abnormal  is  found  aboul  I  he 
hair  than  that  it  splits.  The  hair 
bulbs  may  be  normal  or  atrophied. 

Etiology. — We  do  not  know  what 
the  cause  of  the  disease  is.  We 
assume  that  it  is  a  disturbance  of 
nutrition.  In  very  long  scalp  hair 
it  may  be  due  simply  to  a  lack  of 
nutrition  on  account  of  the  length  of 
the  hair. 

Treatment. — The  split  hairs  should 
be  cut  off  above  the  cleft.  Every 
effort  must  be  made  to  improve  the 
nutrition  of  the  patient,  ami  to  cure 
any  disease  of  the  scalp.  A  little  oil, 
vaseline,  or  pomade  should  be  rubbed 
into  the  scalp  several  times  a  week. 
In  massage  we  have  the  best  stimu- 
lant, when  properly  done. 


l/'i 


Fig.  523.—  Trichor 
rhexis  Nodosa. 

in  pediculosis. 


Trichorrhexis  Nodosa. — Also 
called  clastothrix,  and  nodositas 
crinium.  This  is  a  disease  of  the  hair 
characterized  by  the  appearance 
along  its  shaft  of  one  or  more  nodose 
swellings,  and  by  the  breaking  of  the 
hair  through  the  nodes. 

Symptoms. — The  disease  affects 
most  often  the  hair  of  the  beard.. 
The  patient  notices,  when  handling 
the  beard,  that  there  are  irregulari- 
ties upon  some  of  the  hairs;  or  else 
he  sees  that  his  beard  looks  ragged. 
( )n  examining  the  hair  there  will  be 
found  one  or  more  whitish,  gray,  or 
normal  colored,  shiny,  transparent, 
nodular  swellings,  not  unlike  the  nits 
of  pediculi,  excepting  that  they  are 
oval  and  involve  the  whole  circum- 
ference of  the  hair,  not  pear-shaped 
and  fixed  on  one  side  of  the  hair  as 
There  have  been  found  as  many  as 
five  nodes  on  one  hair.  The  diameter  of  the  nodes 
varies  with  the  diameter  of  the  hair.  The  nodes  are 
usually  on  the  upper  third  of  the  hair.  The  hair  is 
very  brittle  and  easily  broken  by  combing  or  handling 
it,  or  the  break  may  occur  seemingly  spontaneously. 
The  fracture  takes  place  almost  invariably  through 
the  node.  When  the  hair  breaks  completely  the  re- 
maining end  will  have  a  frayed-out  appearance.  If 
the  ends  do  not  separate,  but  the  break  is  through  the 
node,  then  the  appearance  will  be  that  of  two  small 

Caint  brushes  pressed  end  to  end.  The  fracture  may 
e  longitudinal  through  the  node.  When  many  hairs 
are  affected  we  see  the  same  singed  appearance  met 
with  in  fragilitas  crinium. 

While  the  disease  was  first  described  as  affecting 
the  beard,  it  is  seen  also  on  the  scalp  hair,  especially 
in  women.  The  scalp  hair  being  so  much  finer  than 
is  the  hair  of  the  beard,  the  nodes  are  very  much 
.smaller  and  more  apt  to  be  overlooked.  Sometimes 
the  nodes  on  the  scalp  hair  are  found  only  with  the 
microscope.  The  disease  has  also  been  met  with  on 
the  pubic  hair,  the  scrotal  hair,  and  the  hair  of  the 
labia  majora,  the  axilla?,  and  the  eyebrows. 


Etiology. — The  cause  of  the  disease  has  not  bee 
determined.  It  may  be  a  disturbance  of  the  nutr 
tion  of  the  hair.  By  some  it  is  thought  to  be  a  nei 
rosis.  McCall  Anderson  has  reported  a  case  in  whic 
the  disease  seemed  to  be  hereditary.  In  some  com. 
tries,  as  about  Constantinople,  it  is  far  more  prevalen 
in  the  scalp  than  in  other  countries.  By  some  invesl 
gators  parasites  are  believed  to  be  the  cause  of  th 
disease,  and  a  microorganism  is  said  to  have  beei 
found.  Others  deny  the  presence  of  a  microorg 
Simple  handling  of  the  beard  has  also  been  c 
with  producing  the  disease. 

Treatment. — Thus  far  treatment  has  been  mos 
unsatisfactory.  Mercurial  ointments  may  be  tried 
Gamberini  recommends  bathing  with  a  lotion  of  thre 
drams  of  subcarbonate  of  potassium  in  four  ounci 
of  distilled  water;  or  using  inunctions  of  tannic  acii 
or  oil  of  cade.  Schwimmer  advises  an  ointment  o 
seven  grains  of  oxide  of  zinc,  fifteen  grains  of  sulphui 
lotum,  and  two  drams  and  a  half  of  simple  ointmenl 
This  is  to  be  rubbed  in  night  and  morning.  As  far  a 
the  beard  is  concerned  the  chief  reliance  is  upoi 
shaving,  with  the  hope  that  after  a  time  the  hair  wil 
grow  in  properly. 

Monilethrix. — This  is  also  called  aplasia  pilorun 
propria. 

Symptoms. — This  form  of  atrophy  of  the  hair  | 
often  mistaken  for  trichorrhexis  nodosa,  because  lib 
it  it  is  marked  by  the  presence  of  nodes  on  the  hair 
It  differs  from  it  in  that  the  nodes  are  the  normal  part 
of  the  hair,  and  in  that  the  fracture  in  it  takes  plan 
through  the  internodular  part. 

In  the  vast  majority  of  cases  the  disease  is  con' 
genital,  though  it  may  come  on  late  in  life.  Thi 
subjects  are  therefore  usually  in- 
fants. They  are  commonly  born 
with  normal  appearing  hair,  but 
after  a  few  weeks  the  hair  breaks 
off  from  the  whole  head   or  from        |||  v 

patches,  giving  a  stubbly  appear- 
ance to  the  hair,  similar  to  what  is 
seen  in  ringworm.  In  some  cases 
the  scalp  is  reddened  and  has  on  it 
a  number  of  small,  scaly,  elevated 
cones,  or  perhaps  pustules.  From 
the  little  cones  protrude  short  hairs. 
Many  of  them  are  bent,  and  all 
break  easily  on  slight  traction. 
They  are  seldom  longer  than  a 
quarter  of  an  inch,  and  often  are 
no  more  than  black  points.  To  the 
naked  eye,  or  under  the  microscope, 
these  little  hairs  show  fusiform  swell- 
ings with  contractures  between, 
through  which  the  fracture  has  oc- 
curred. Sometimes  complete  bald- 
ness results.  All  the  hairy  regions 
may  be  affected.  A  general  kera- 
tosis pilaris  may  be  present. 

Pathology. — Under  the  micro- 
scope the  hairs  will  be  found  to  Fig 
have  on  them,  at  regular  intervals, 
alternate  swellings  and  constric- 
tions. The  swellings,  or  nodes,  are  about  one  milli- 
meter long,  fusiform  in  shape,  and  darker  in  color 
than  the  constricted  parts.  The  latter  arc  aboul 
one-third  the  length  and  diameter  of  the  nodes. 
The  constricted  parts  contain  neither  medulla  nor 
pigment  and  may  consist  of  the  cuticular  layer  oi 
the  hair  alone.  There  is  atrophy  of  the  hair  bulbs. 
The  nodes  are  all  along  the  hair  from  the  root  to  t'i'' 
point.  Fracture  invariably  takes  place  through  the 
internodular  portion,  and  frayed-out  ends  may  be 
found.  Sabouraud  found  that  the  constrictions 
formed  at  two  days'  interval.  Gilchrist  believes  that 
the  disease  originates  in  the  hair  follicle  very  near 
to  the  papilla.     He  was  able  to  trace  the  fusiform 


524.-  V 
thrix. 


7GG 


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Atrophy 


s- lling  to  the  lower  fourth  of  the  hair  shaft,  where 

i   .,,    „,.,-,.    constrictions    in    the    walls    i>f    the    hair 

He  found  no  change  in  the  hair  papilla'. 

In  many  cases  the  disease  is  hereditary. 

observers  have  reported  instances  of  a  number 

-   in   the   same  family.      At    times   it    shows  a 

t   lency  to  descend  in  the  same  sex,  a  peculiarity 

I  mi  iii  other  dermatoses.     It  is  probably  a  tropho- 

'reatment  has  thus  far  been  without  effect.     Stimu- 
1:  on  might  be  tried,  but  the  prognosis  is  bad. 

lesides  these  well-defined  forms  of  atrophy  of  the 

have  reports  of  allied   diseases  from  single 
jervers.     Thus    Crocker    describes    a    case    ol 
a 'phy  of  the  hair  in  which   the  distal  ends  of  the 
e  bulbous  and  of  lighter  shade  than  the  rest 
liair. 

>HAGMESls  is'  another  abnormality  of  the  hair  in 

■  ich  feathers  instead  of  hair  are  met  with.     This  is 

t  doubtful   character  and   comes  down   to  us  from 

,    which   time  a   boy   showing  this  anomaly  is 

en  on  exhibition  in  Bremen. 

peculiar  changes  in  the  texture  of  the  hair  are 

.  by  Ferber     Virchow's  Archiv,  1S66,  xxxvi.. 

both  patients  were  of  nervous  temperament, 

I  :   their   hair   in   a   few   hours   would   change  from 

ft  and  curly  to  become  .straight  and  bristly. 

.  r   a    time    the    hair   would   assume   its   natural 

ion. 

\"om-Li  Laqtjeati   is  an  anomaly  of  the  hair  in 
\  ich  it  seems  to  tie  itself  into  knots.     The  loops  of 
t'  knots  catch  dust.     The  hair  looks  as  if  ii 
>  h  nits,  but  under  the  microscope  it  is  seen  that 
i  -  the  knots  that  give  this  appearance. 

George  Thomas  Ja<  ksox. 


\trophy. — Wasting,   lack   of  nourishment,  wasting 
ody  due  to  defective  nutrition.      (Gr.  a-priv. 
3d  Tpo$Ti.  nourishment.)     The  word  is  at  the  pi 

ed  in  pathology  to  signify  the  decrease  in  size 

irgan    or    tissue    which   results  either  from  a 

in  the  size  of  its  individual  elements,  or  from 

iliminution  in  the  number  of  these  elements,  or  from 

combination  of  these  two  factors.      We  may  speak, 

re,  of  a  quantitative  and  of  a  numerical  atro- 

]  y,  but  a  practical  distinction  cannot  always  be  made 

i  these  two  forms,  as  a  diminution  in  the  num- 

jr  of  the  tissue  elements  almost  always  accompanies 

:  Increase  in  size. 

In  its  narrowest  sense  the  term  is  used  to  indicate  a 

rcase  in  size  of  the  individual  histological  elements 

■  ■  to  a  simple  loss  of  substance  without  including 

e  idea  of  other  retrograde  changes.     The  essential 

'a  of  atrophy  is,  therefore,  separated  from  that  of 

generation,  and  the  term  should  be  applied  only  to 

onditions  in  which  the  primary  pathological 

ange  is  a  loss  of  bulk.     This  loss  of  bulk  is  not  the 

suit  of  a  loss  of  essential  form  or  structure,  but  is 

te  chiefly  to  a  loss  of  the  paraplastic  material  of  the 

II.     Only  rarely  is  it  associated  with  the  appearance 

any  new  substances  outside  the  cell.     The  ordinary 

generations  and  infiltrations  (fatty,  mucoid,  colloid, 

aline,    amyloid,    etc.)    may    be    associated    with 

rophy,  and  such  combinations  are  usually  spoken  of 

erative  atrophy.     The  diminution  in  size  and 

imber  without  the  presence  of  degenerative  changes 

usually  called  simple  atrophy. 

On  the  other  hand,  the  meaning  of  atrophy  must 
)t  be  confused  with  the  ideas  expressed  by  the  words 
rcnesia,  hypoplasia,  and  aplasia.  These  terms 
ifortunately,  have  been  used  rather  loosely  as 
nonyms  with  atrophy,  but  the  best  usage  is  to 
■sign  to  each  one  a  distinct  technical  meaning: 
;enesia,  total  failure  of  development  or  destruction 
a  part  after  it  has  begun   to   develop;   aplasia, 


marked  defective  development  of  an  organ:  hypo- 
plasia, under-development;  atrophy,  decrease  in  size 
after  development   has  b  m  this  it 

will  be  seen  that  the  causes  leading  to  these  chat 
operate  at  different  period-  of  life:  thus  and 

aplasia  are  the  results  of  disturbances  in  early  fetal 

life:  hypoplasia  the  result  of  changes  occurring  later, 
bul  at  any  period  before  complete  development  is 
reached;  while  atrophy  may  occur  at  any  time  in  the 
history  of  the  organism  when  any  tissue  or  structure 
has  reached  its  full  anatomical  and  physiological 
maturity.  The  latter  process  i-.  therefore,  a  r< 
grade  change  occurring  in  parts  that  were  originally 
normal  and  perfectly  formed. 

All  stunting-  and  defective  development  of  the 
body  and  it-  parts,  either  intra-  or  extrauterine,  are 
to  be  considered  under  the  head  of  aplasia  or  hypo- 
plasia, and  not  under  that  of  atrophy.  Hut  the  cells 
of  an  aplastic  or  hypoplastic  organ  may  also  undergo 
a  decrease  in  size  due  to  the  same  causes  that  lea 
atrophy  of  perfectly  formed  organs.  A  hypoplastic 
organ  may  become  atrophic:  hence  in  its  broadest 
sense  the  meaning  of  atrophy  m  ended  to 

include  the  retrograde  decrease  in  size  of  imperfectly 
developed  cells  and  organs.  The  fundamental  idea 
of  atrophy  is,  therefore,  a  retrograde  decrease  in  size  of 
either  perfect  or  imperfect  fills. 

The  decrease  in  size  and  the  disappearance  of  the 
tissue  element  -  in  atrophy  must  be  referred  to  a  failure 
of  the  processes  of  restoration  to  keep  equal  step  with 
the  never-ceasing  processes  of  tissue  waste  and 
destruction.  All  cells  possess  a  histogenetic  energy 
which  is  manifested  in  the  functions  of  nutrition, 
assimilation,  and  reproduction.  For  all  cells,  for 
every  organ,  for  every  individual,  and  for  every 
species  there  is  a  certain  limit  to  the  ultimate  amount 
of  inherent  histogenetic  energy.  This  limit  is  fixed 
by  intrinsic  forces  acquired  through  the  agency  of 
external  forces  in  the  process  of  evolution  of  the 
species,  and  represents  the  physiological  duration  of 
life  of  each  organ,  and  of  each  individual  of  that 
species.  Could  all  external  injurious  influence- 
avoided  the  organism  would  after  a  certain  period  of 
time  come  to  a  physiological  death  through  physio- 
logical atrophy,  or,  in  other  words,  a-  soon  as  such 
a  limit  of  histogenetic  energy  is  reached  that  the 
ary  vital  functions  of  the  body  fail  to  be  prop- 
erly performed  in  a  degree  sufficient  to  preserve  life. 
We  may,  therefore,  speak  with  propriety  of  a  physio- 
logical or  histogenetic  atrophy. 

Further,  the  histogenetic  energy  of  the  cells  is  to  a 
certain  extent  maintained  by  means  of  certain  stimuli, 
and  as  a  result  of  the  removal  of  these  stimuli  an 
inaction  atrophy  may  result.  Atrophy  must  result 
also  from  any  deficiency  or  disturbance  in  the  supply 
of  nutrition,  and  likewise  excessive  consumption  or 
waste  of  tissue  must  lead  to  atrophy.  Further, 
atrophic  changes  may  be  set  up  by  mechanical 
hindrances  to  growth,  as  in  pressure,  constriction,  etc. 
On  the  other  hand,  the  loss  of  normal  pressure  or 
ten-ion  may  produce  atrophic  changes  in  the  tissues 
so  affected,  and  the  separation  of  an  organ  or  tissue 
from  its  nerve  centers  is  usually  followed  by  a  similar 
condition.  We  may  consequently  classify  the  various 
forms  of  atrophy  as  histogenetic,  inaction,  lack  of 
nutrition,  neuropathic  and  pressure  atrophy.  Only 
the  first  of  these,  the  histogenetic  form,  is  essentially 
an  active  process  (endogenous  cellular  atrophy):  the 
cells  are  unable  to  assimilate  the  food  brought  to 
them.  The  other  forms  are  passive  in  character: 
either  insufficient  food  is  brought  to  the  cells,  or 
harmful  substances  are  formed  which  injure  their 
nutritive  function  (exogenous  nutritive  atrophy). 

Histogenetic  or  Physiological  Atrophy. — This  form 
of  atrophy  is  the  result  of  a  decrease  in  the  histogenetic 
energy  of  the  cells.  As  stated  above,  the  potential 
energy  of  each  cell  and  organ  is  limited  in  direct 
relation  to  the  part  which  its  function  plays  in  the 

767 


Atrophy 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


general  economy  of  the  organism.  Hence  the  dura- 
tion of  life  varies  with  different  organs  and  tissues, 
and  in  the  life  history  of  the  organism  from  the  very 
beginning  the  processes  of  atrophy  go  hand  in  hand 
with  those  of  development.  In  the  earliest  stages  of 
growth  up  to  the  time  of  puberty  there  is  a  pre- 
ponderance of  cell  growth  over  cell  decay;  in  adult 
life  there  is  a  period  of  equilibrium;  but  with  the 
beginning  of  old  age  the  loss  of  histogenetic  energy  is 
shown  in  the  fact  that  cell  decay  preponderates  over 
cell  restoration. 

Even  in  earliest  fetal  life  certain  structures  fulfil 
their  function  and  pass  out  of  existence.  In  the 
formation  of  the  fetal  placenta  portions  of  the  mem- 
branes disappear  at  a  very  early  stage,  and  in  the 
development  of  the  chorion  there  is  from  the  begin- 
ning a  progressive  atrophy  of  the  villi.  The  placenta 
at  term  must  be  regarded  as  a  senile  organ.  Portions 
of  the  fetus  itself,  as  the  Wolffian  bodies,  the  Wolffian 
ducts,  the  ducts  of  Muller,  the  umbilical  vesicle,  the 
omphalomesenteric  duct,  etc.,  disappear  very  early, 
even  in  the  period  of  most  vigorous  development  of 
the  fetus.  Numerous  blood-vessels  undergo  oblitera- 
tion even  before  birth,  and  very  soon  after  this  event 
the  closure  of  the  ductus  Botalli  and  the  umbilical 
vessels  takes  place.  Likewise  the  casting  off  of 
the  umbilical  cord  must  be  considered  under  this 
head;  and  later  the  shedding  of  the  milk  teeth  is 
another  example  of  the  disappearance  of  structures 
that  have  fulfilled  their  aim  and  reached  their  limit 
of  existence.  The  disappearance  of  the  thymus  after 
the  fifteenth  year  is  one  of  the  most  striking  of  the 
histogenetic  atrophies.  During  the  period  of  most 
active  development  it  is  one  of  the  largest  lymph 
glands  of  the  body,  but  soon  after  puberty  it  disap- 
pears, becoming  entirely  replaced  by  fat  tissue. 
During  middle  life  single  portions  of  tissues,  as  certain 
portions  of  the  petrous  and  sphenoid  bones,  vanish. 
Hyaline  cartilage  may  also  be  regarded  as  an  essen- 
tially temporary  structure,  as  in  many  individuals 
it  entirely  disappears  from  the  body  during  middle 
life  and  is  replaced  by  bone. 

Some  organs  do  not  atrophy,  but  very  early  suffer  a 
cessation  of  growth,  so  that  they  become  no  larger  in 
the  adult  than  in  the  new-born  (adrenals,  male 
mammae,  etc.).  The  failure  of  these  organs  to  increase 
in  size  is  not  due  primarily  to  any  failure  of  nutrition 
or  disturbance  of  circulation,  and  can  be  explained 
only  by  the  assumption  that  the  original  histogenetic 
potentiality  of  growth  has  reached  its  limit.  The 
atrophy  of  the  ovaries  and  of  the  uterus  after  the 
forty-fifth  year,  before  all  of  the  ova  are  discharged, 
must  be  similarly  explained.  In  the  case  of  the  ovary 
the  primary  change  is  in  the  blood-vessels  of  the 
organ,  which  normally  show  sclerotic  changes  before 
the  blood-vessels  of  any  other  part  of  the  body.  The 
menopause  is  essentially  a  process  dependent  upon 
changes  in  the  ovarian  vessels,  and  to  these  changes 
the  atrophy  of  the  Graafian  follicles  must  be  con- 
sidered secondary.  The  atrophy  of  the  ovary  at  the 
menopause  may,  therefore,  be  explained  by  the 
assumption  that  the  histogenetic  energy  of  the  ovarian 
vessels  has  an  earlier  limit  than  that  of  the  systemic 
vessels. 

In  the  atrophy  of  old  age  (senile  atrophy)  the  blood- 
vessels, lymphadenoid  tissues,  muscles,  and  bone; 
suffer  most.  The  changes  in  facies,  posture,  and  gait 
of  the  old  individual  are  dependent  upon  these  condi- 
tions. The  brain  may  also  undergo  a  marked  atro- 
phy, and  of  the  internal  organs  the  kidneys,  liver, 
and  lungs  ma}'  suffer  to  a  greater  or  less  extent.  On 
the  other  hand,  there  are  certain  organs  and  tissues 
which  undergo  but  little  senile  change:  the  formation 
of  the  red  blood  cells  continues  in  old  age  without 
decreased  energy,  and  defects  of  epithelium,  blood- 
vessels, and  connective  tissue  are  as  completely 
repaired  as  in  earlier  life.  There  are  very  marked 
individual  differences  as  to  the  organ  which  shows  the 

768 


greatest  degree  of  senile  change:  environmen 
disease,  etc.,  may  lessen  the  inherent  histogenet 
energy  of  certain  organs  so  that  they  may  beccm 
prematurely  senile,  or  atrophy  to  a  greater  degn 
than  others.  Further,  there  are  individual  different 
dependent  upon  the  amount  of  histogenetic  enert 
inherited;  the  variation  in  this  is  a  well-know 
pathological  fact.  Nevertheless,  in  spite  of  the. 
individual  differences  typical  senile  atrophy  is  alvw 
confined  to  certain  organs  and  tissues. 

Senile  atrophy  is  not  only  active  but  is  also  paasiv 
as  it  depends  not  only  upon  the  gradual  decrease 
energy  on  the  part  of  the  cells,  but  is  in  part  tl 
result  of  the  narrowing  and  obliteration  of  the  bloui 
vessels  supplying  nutrition  to  the  cells.  The  changi 
in  the  blood-vessels  are,  therefore,  to  be  regarded  i 
the  most  important  of  the  senile  processes,  and  it 
probable  that  the  chief  part  of  the  glandular  atrophia 
is  secondary  to  these.  For  some  of  the  so-ealle 
histogenetic  or  physiological  atrophies  an  absence  < 
loss  of  stimuli  (retrogression  of  male  mamma;,  etc 
may  be  in  part  responsible  for  the  atrophy.  Autc 
intoxications  may  also  play  a  part  in  the  productio 
of  forms  of  atrophy  included  under  this  head. 

Atrophy  of  Disuse. — The  histogenetic  energy  < 
many  organs  and  tissues  is  dependent  upon  certai 
regular  stimuli.  If  these  stimuli  are  removed  for  an 
length  of  time  an  atrophy  results  which  we  may  cs 
an  inaction  or  disuse  atrophy.  The  atrophy  of  th 
optic  nerve  after  destruction  of  the  eyeball;  tli 
atrophy  of  peripheral  nerves  and  portions  of  th 
spinal  cord  following  amputations  of  the  limbs,  ar 
familiar  examples  of  this  form.  Likewise,  if  throng 
any  influence  glands  or  muscles  (myotenotomj 
dislocation,  paralysis,  etc.)  remain  inactive  for " 
certain  period  of  time  atrophic  changes  occur.  I 
the  case  of  muscle  the  loss  of  substance  is  usually  no 
very  great.  Even  the  bones  undergo  a  loss  of  sub 
stance  when  kept  in  undisturbed  rest  for  severe 
years.  Further,  the  physiological  atrophy  of  th 
uterus  and  mammae  after  pregnancy  may  be  includei 
in  this  class.  The  common  belief  that  sexual  absti 
nence  may  cause  atrophy  of  the  sexual  glands  has  ni 
more  foundation  than  the  occurrence  of  atrophy  o 
the  lacrimal  glands  through  abstinence  fron 
weeping.  There  can  be  no  disuse  atrophy  of  thh 
kind  of  these  glands.  Such  an  atrophy  can  follow 
the  blocking  or  ligation  of  the  vasa  deferentia  or  tin 
lacrimal  ducts. 

In  the  case  of  nerves,  glands,  and  muscle,  inaction 
atrophy  is  essentially  active,  but  as  the  result  of  the 
cessation  of  function  there  is  also  a  decrease  in  the 
nutritive  activity  of  these  structures  and  a  lessened 
blood  supply  which  leads  to  further  disturbances  of 
nutrition.  In  other  tissues  the  chief  cause  of  the 
atrophy  is  a  decrease  in  the  nutrition  of  the  unused 
part,  but  with  this  there  is  also  a  lessened  power  of 
assimilation.  The  involution  of  the  puerperal  uterus, 
by  means  of  which  the  organ  is  restored  to  verj 
nearly  its  original  size,  is  a  very  complicated  process, 
partly  atrophy  and  partly  degeneration,  involving 
all  of  its  structures,  endometrium,  muscle,  and  blood- 
vessels. It  is  essentially  active  in  its  nature,  but  the 
obliteration  of  its  enlarged  blood-vessels  through 
sclerotic  changes  and  the  organization  of  thrombi 
plays  a  very  important  part  in  the  retrogression. 
Lessened  tension  and  removal  of  certain  stimuli 
may  play  a  role  here  also. 

If  the  conditions  leading  to  the  inactivity  of  certain 
parts  are  in  operation  during  the  period  of  develop- 
ment and  the  tissues  in  consequence  of  disturbed 
nutrition  fail  to  reach  their  normal  size,  the  process 
is  to  be  regarded  in  the  light  of  a  hypoplasia  rather 
than  of  atrophy.  It  is.  however,  impossible  in  all 
cases  to  separate  these  processes,  since  in  hypoplastic 
organs  there  may  be  an  atrophy  or  disappearance  of 
tissues  which  had  undergone  a  certain  degree  of 
development. 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Atrophy 


trophy   Dependent    upon   Impaired   Nutrition. — If 

is  a   deficiency    in    the    amount    of    nutritive 

il    brought    to    the    colls    these    will    undergo 

.,  ,pliic  changes.     The  degree  and  rapidity  of   the 

B  iphyare  indirect  relation  to  the  degree  of  meta- 

b  c  change  of  which  the  affected  organ  or  tissue  is 

,,  ihle.     Hence  adipose  tissue  quickly  disappears  if 

it-forming  substances  are  not  adequately  sup- 

i  it.     The  bones  become  softened  and  fragile  if 

it  supply  of  lime  salts  is  withheld  for  a  period  of 

and  it   is  also  probable  that  a  decrease  in  the 

a  'tint  of  hemoglobin  contained  in  the  red  blood  cells 

result    of   deficient   absorption   of   iron.     The 

ii  ire  of  rachitis,  osteomalacia,  and  the  various  forms 

i  memia  is  as  yet  but  little  understood,  and  these 

may  he  the  result  of  more  complicated  disturb- 

than    the   mere    withdrawal   of   certain   food 

'.IS. 

ical  atrophies  may  result  from  disturbances  in  the 
.   id   supply   of   certain   regions   following   arterio- 

-.    thrombosis,  or  inflammatory  processes  in- 

v  .  ing   the   vessels.     Degenerative    changes   almost 

ii  iriably  accompany  this  form  of  atrophy.     If  the 

b  id   supply   of   any   part    is    completely   shut   off, 

results.      When     there     is     an     insufficient 

of  food  to  the  body  as  a  whole,  or  if  the  fluids 

body  are  not  adequately  restored,  a  general 
a  iphy  of  the  body  takes  place.  The  fat,  muscles, 
bid,  and  abdominal  organs  suffer  to  the  greatest 
d  ree.  The  fat  disappears  first  and  may  be  reduced 
■   seven    per    cent,    of    its    original    amount.     The 

-  may  lose  as  much  as  fifty  per  cent,  in  weight. 
C  the  abdominal  organs  the  liver,  spleen,  and  in- 
t>  ines  suffer  most.     The  brain,  spinal  cord,   bones, 

:rt  muscle  undergo  but  little  loss  of  substance 
e  n  in  cases  of  death  from  starvation.  Lipomata 
a  v  remain  unchanged  in  spite  of  the  almost  com- 
.1  e  loss  of  the  normal  fat  tissue  of  the  body.  This 
r  larkable  phenomenon  has  not  as  yet  been  ex- 
■ined. 

'uric   Atrophy. — The   histogenetie    energy   of    the 

i'  3  is  most  intimately  connected  with  their  physical 

al  chemical  integrity,  and  disturbances  of  the  latter 

mi  to  a  decrease  of  this  energy.     The  presence  of 

lain    foreign    elements    in    the    circulation    leads 

Diasionally    to    atrophy     associated     with     degen- 

Bftive  processes.     The  protracted  use  of  iodine  may 

itrophy  of  the  thyroid  and  mammary  glands, 

a  1  in  chronic  lead  poisoning  the  extensor  muscles  of 

forearm    may    become    atrophic.     Toxic    or    in- 

t 'amatory  atrophy  occurs  also  in  various  infectious 

lases     typhoid   fever,  diphtheria,   mumps,  gonor- 

r  a,  syphilis,  etc.)  and  also  in  cachectic  conditions. 

tointoxications  also  probably  play  a  large  role  in 

t    production  of  atrophy,  particularly   in   the   case 

c  the   kidneys,    liver,    heart,    and    nervous    system. 

1-use  and  neuropathic  atrophy,  perhaps  senile  atro- 

i,  are  probably  due  in  part  to  autointoxication. 
"ressure  Atrophy. — Closely  allied  to  the  atrophy  re- 
£  ting  from  insufficient  nutrition  is  that  produced  by 
utinued  slight  pressure.  As  the  result  of  artificial 
i  chanieal  pressure  may  be  mentioned  the  exam- 
]s  of  "corset  liver"  and  "corset  spleen,"  the  con- 
iiction  produced  by  rings,  belts,  and  garters,  the 
(inese  foot,  the  flat  head  and  flat  nose  of  certain 
1  !ian  tribes,  etc.  Skin,  muscles,  and  bone  may  dis- 
ipear  as  the  result  of  pressure  from  aneurysms  and 
1  ni ns.  Varicose  veins  may  likewise  lead  to  the 
Sophy  of  the  neighboring  structures.  In  scoliosis, 
f  1U  valgum,  and  pes  valgus,  atrophy  of  certain 
irtions  of  the  joints  may  be  caused  by  the  abnormal 
ssure  produced  by  an  oblique  position  of  the  bones. 
iter  loss  of  the  teeth  the  alveolar  processes  of  both 
.  vs  may  disappear  as  the  result  of  the  pressure 
bught  to  bear  upon  them  in  mastication.  The 
lull  cap  may  present  erosions  which  have  been 
pduced  by  the  pressure  of  atheromata  of  the  scalp 
<  by  hypertrophic  Pacchionian  bodies.     The  inner 


surface  of  the  skull  cap  may  present  atrophil 

as  the  result  of  increased  intracerebral  pressure. 
In  hydrocephalus  ami  hydronephrosis  tie-  brain  and 
kidneys  respectively  may  undergo  extreme  atrophy, 
and  in  any  gland  in  which  cysts  develop  the  glandular 
epithelium  may  become  atrophic  through  pn 
Further,  atrophic  changes  may  be  caused  in  any  part 
of  the  body  as  the  result  of  pressure  from  inflamma- 
tory exudates. 

The  various  forms  of  pressure  atrophj  are  caused, 
as  a  rule,  by  -light  pressure  continued  through  long 
periods  of  time.  It  is  the  result  of  direct  injury  to 
the  tissue  and  of  circulatory  disturbances.  It  is 
therefore  passive  in 
its  nature.  If  the 
pressure  is  so  great 
that    thi'  blood 

sels  becoi tli 

degeneration  ami 
necrosis  must  fol- 
low. Inmany  cases 
the   causes    of    the 

atrophy  resulting 
from  pressure  are 
complicated,  me- 
chanical force  and 
disturbances  of  nu- 
trition playing  the 
chief  parts  in  its 
production. 

Neuropathic  Atro- 
phy.— The  question 
of  the  existence  of 
trophic  nerves  and 
trophic  centers  and 
their  relation  to  the 
individual  tissues  is 
still  unsettled,  and 
the  existence  of  a 
neuropathic  or  tro- 
phoneurotic atrophy 
must  at  the  present 
time  be  viewed  more 
in  the  light  of  a 
possibility  than  as 
being  an  established 
fact.  It  is  not  to  be 
doubted  that  as  the 
result  of  disturb- 
ances of  innervation 
both  atrophic  and  degenerative  changes  arise,  though 
it  is  probable  that  these  changes  are  not  entirely  de- 
pendent upon  the  loss  of  nerve  influence,  but  for  the 
greater  part  are  secondary  to  the  loss  of  functional 
activity  and  to  disturbed  nutrition  caused  by  vaso- 
motor changes  in  the  regions  supplied  by  the  affected 
nerves.  As  a  result  of  these  changes  inflammations 
are  easily  set  up,  even  by  slight  causes  which  ordi- 
narily produce  no  lesions,  and  the  result  of  the  inflam- 
matory process  may  be  either  atrophic  or  degenera- 
tive in  its  nature.  The  majority  of  the  changes 
following  disturbances  of  innervation  are  not  of  the 
nature  of  a  true  atrophy,  but  are  degenerative  in 
character.  The  application  of  the  term  atrophy  to 
these  processes  is  justifiable  only  by  the  fact  that  the 
ultimate  condition  is  a  loss  of  tissue. 

Disease  of  the  anterior  horns  of  the  spinal  cord  or  of 
the  motor  roots  is  followed  by  atrophy  of  the  corre- 
sponding nerves  and  muscles.  Anterior  poliomyelitis, 
progressive  muscular  atrophy,  and  bulbar  paralysis 
are  well-known  examples  of  this  form  of  atrophy. 
In  syringomyelia  and  tabes  dorsalis  atrophy  of  the 
bones  and  joints  not  infrequently  occurs.  Injuries 
of  the  peripheral  nerves  may  be  followed  by  thinning 
of  the  skin,  exfoliation,  loss  of  hair,  and  atrophy  of 
the  glands  of  the  skin.  Disease  or  injury  of  the  nerve 
trunks  of  one  side  of  the  face  may  lead  to  atrophy 
of  the  tissues  of  that  side.     Unilateral  affections  of 


Fig.  525. — Pressure  Atrophy  of  the 
Spinal  Column,  Caused  by  the  En- 
croachment of  an  Aneurysm  of  the 
Aorta.     (After  Ziegler.) 


Vol.  I.— 49 


r69 


Atrophy 


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the  brain  in  fetal  life  or  during  early  childhood  may 
cause  an  atrophy  of  the  opposite  side  of  the  body 
(congenital  or  infantile  hemiatrophy).  General 
atrophy  of  the  body  occurs  in  progressive  paralysis 
and  to  a  less  extent  in  melancholia  and  dementia. 
It  is  denied  by  many  authors  that  these  forms  of 
atrophy  are  neuropathic,  and  it  is  much  more  probable 
that  vasomotor  disturbances,  loss  of  function,  and 
general  as  well  as  local  disturbances  of  nutrition  are 
the  chief  factors  in  their  production. 

Atrophy  Due  to  Excessive  Waste. — In  all  conditions 
in  which  the  repair  of  the  tissue  is  exceeded  by  tissue 
consumption  a  loss  of  substance  must  occur.  In  fetal 
life  and  in  the  period  of  early  development  only  a 
portion  of  the  substances  taken  into  the  body  is 
completely  oxidized,  the  greater  part  is  used  in  the 
building  up  of  tissue.  In  adult  life  the  larger  part 
is  burned  up,  the  smaller  remaining  portion  is  used  in 
tissue  repair.  The  two  processes  of  waste  and  repair 
stand  in  different  relations  to  each  other  at  different 
periods  of  life,  and  must  be  considered  as  independent 
processes.  This  is  very  clearly  shown  in  those 
pathological  conditions  in  which  tissue  waste  exceeds 
tissue  repair.  Overuse  of  any  organ  leads  to  fatigue, 
poisonous  products  of  metabolism  are  retained,  and 
the  cells  are  not  given  sufficient  time  for  rebuilding. 
If  a  condition  of  chronic  fatigue  develops  as  a  result 
of  chronic  overuse,  anatomical  changes  occur.  Chief 
of  these  is  a  loss  of  substance.  The  brain  is  the  most 
important  organ  which  may  be  so  affected.  Of  the 
glandular  organs  the  testicles  most  frequently  suffer. 
Atrophy  of  the  heart  and  voluntary  muscles  may  also 
occur  as  the  result  of  overuse.  The  failure  of  compen- 
sation in  chronic  valvular  disease  is  also  to  be  placed 
in  this  category.  Exposure  to  Roentgen  and  radium 
rays  produces  atrophy  of  the  testes,  lymphoid  organs, 
and  developing  tissues.  This  atrophy  is  in  part  due 
to  an  inhibition  of  cell-growth,  but  is  also  the  result 
of  the  death  of  individual  cells  and  tissue-elements, 
cell-regeneration  failing  to  keep  the  organ  to  its 
normal  size. 

Repeated  severe  hemorrhages,  chronic  suppurative 
processes,  long-continued  excretion  of  albumin, 
diabetes,  fever,  rapidly  growing  tumors,  and  many 
other  similar  processes  produce  general  wasting  of 
the  body  with  marked  atrophy  of  certain  tissues. 
In  general  the  various  cachectic  atrophies  are  in 
their  nature  and  course  very  closely  allied  to  senile 
atrophy,  and  the  microscopical  appearances  are 
identical. 

Atrophy  Caused  by  Decreased  Tension. — Through  a 
permanent  loss  or  decrease  in  the  normal  tension,  as 
in  the  case  of  muscles,  tendons,  fasciae,  and  blood- 
vessels after  amputations,  or  of  tendons  after  tenot- 
omy, atrophy  may  take  place.  The  involution  of 
the  puerperal  uterus  may  also  be  considered  under 
this  head. 

A  large  number  of  conditions,  such  as  the  decrease 
in  size  of  the  orbital  cavity  after  removal  of  the 
eyeball  and  of  the  sockets  of  joints  after  unreduced 
dislocations,  are  not  properly  included  in  this  class, 
as  the  decrease  in  size  of  the  cavity  is  not  of  the 
nature  of  an  atrophy,  but  is  usually  caused  by  an 
increase  of  tissue  in  and  about  the  cavity. 

Macroscopical  Appearances. — The  most  striking 
change  in  atrophic  organs  is  their  decrease  in  size. 
This  is  directly  dependent  upon  the  decrease  in  size 
and  the  diminution  in  number  of  the  structural 
elements.  The  muscles,  kidneys,  liver,  and  spleen 
show  this  decrease  in  size  to  the  most  marked  degree. 
In  extensive  atrophy  of  the  muscles  as  seen  in  pro- 
gressive muscular  atrophy  the  disappearance  of  the 
tissues  may  be  so  marked  that  the  impression  is  given 
that  there  is  nothing  between  the  skin  and  the  bone 
(so-called  living  skeleton).  In  many  cases,  however, 
there  is  a  deposit  of  fat  in  the  atrophic  tissues  which 
may  be  so  extensive  that  the  normal  size  may  be  pre- 

770 


served  or  an  actual  increase  may  take  place  (atrophi 
musculorum  lipomatosa).  The  atrophic  liver  an 
heart  may  likewise  be  increased  in  size  throiw 
fatty  infiltration.  •> 

The  size  of  atrophic  lungs  may  be  increased  throue 
the  stretching  of  the  atrophic  alveolar  walls  and  tli 
consequent  dilatation  of  the  air  spaces  (atronhi 
emphysema). 

In  the  case  of  atrophy  of  fully  developed  bi 
decrease  in  size  takes  place,  but  the  Haversiai 
and  medullary  cavity  become  enlarged  (excenti 
atrophy  or  osteoporosis).  The  spleen  as  a  rule  suffei 
a  symmetrical  decrease  in  volume,  while  the  livi 
usually  shows  more  marked  loss  of  substance  in  li 
left  lobe  than  in  the  right. 

If  the  atrophy  of  an  organ  proceeds  symmetric:;! 
in  all  parts  a  uniform  decrease  in  size  results  \. 
preservation  of  normal  form.     It,  however,  progress^ 


Fig.  526. — Excentrie  Atrophy  of  the  Lower  Ends  of  the  Tibia  u 
Fibula,  with  Osteoporosis.     Natural  size.     (After  Ziegler.) 

most  frequently  with  greater  rapidity  in  one  part  than 
in  another,  and  as  the  result  of  this  unequal  atrophy 
nodules  and  furrows  are  formed  so  that  tin 
comes  to  present  a  nodular  or  granular  surface.     This 
is   especially    marked    in   atrophy    of    the   glai 
structures,    liver,    kidney,    etc.     As   a   rule   atrophic 
organs  contain  less  blood  and  are  drier  than  normal 
ones.     The    increase    of    connective    tissue,    either 
relative  or  actual,  causes  an  increase  in  cons) 
with  loss  of  elasticity.     As  a  result  of  the  di ■■■■ 
blood  content  the  natural  color  of  the  organ  stands 
mil  more  distinctly;  hence  atrophic  muscle,  especially 
heart  muscle,  is  much  browner  in  color  than  ni 
An  increase  of  the  normal  pigment  or  an  increased 
deposit    of   hematogenous    pigment   is   also   a    verj 
frequent  accompaniment  of  atrophy  (brown  atrophy 
of  heart  and  liver).     In  other  cases  the  color  of  the 
atrophic  organ  is  lighter  or  more  grayish  than  normal 


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Atrophy 


hlauseof  the  relative  or  actual  increase  of  connective 

I   ue_      In  all   cases  in   which   much  tat  is  deposited 
I    colur  becomes  yellowish. 

[icboscopical  Changes. — The  microscopical  ex- 
.,  nation  of  atrophic  organs  shows  a.  decrease  in 
.    ami  a  diminution  in  number  of  the  normal  ele- 

its.  This  may  occur  without  other  changes,  or 
i  atrophy  may  be  accompanied  by  a  deposit  of  fat 
,,  pigment,   or  an   increase   in   the   amount    of   the 

ml  pigment,  or  it  may  occur  in  association  with 
degenerative   processes.      We   may    therefore 


i.  5127. — Section  of  an  Atro| 
ular    Atrophy.       (Miiller's 


liver  cells  of  the  central  zone  of  the  lobule  contain 
much  hematoidin,  while  those  of  the  peripheral 

show  an  increased  a unl  of  fat. 

In  tin'  atrophic  kidney  there  is  a.  decrease  in  the 
size  of  the  tubules  due  to  a  decrease  in  ize  ami  to  a 
diminution  in  number  oi  the  epithelial  cells.  Many 
tubules  may  be  found  containing  few  cells  or  com- 
pletely Collapsed.  As  a  result  of  the  loss  of  inter- 
vening tissue  the  glomeruli  are  bronchi  closer  together, 
so  that  from  twenty  to  forty  may  be  found  in  one  low- 
power  field.  The  epithelium  ami  capillaries  Ol  Hie 
glomeruli  also  disappear,  and  as  a  result  numerou 
obliterated  glomeruli  are  found.      In   atrophy  of 

the  central  nervous  system  the  ganglion  cells  dis- 
appear or  become  smaller,  u  Idle  the  neuroglia  re- 
mains in  normal  amount  or  becomes  increased. 
Atrophy  of  the  lymph  glands  and  spleen  is  shown 
by  a  disappearance  of  the  follicles  and  a  diminu- 
tion in  the  number  of  the  lymphndenoid  cells. 
The  trabecuhe  are  brought  more  closely  together, 
and  the  finer  stroma  is  increased  in  amount.  In 
atrophy  of  bone  the  bone  substance  is  decreased 
in  amount  and  the  marrow  spaces  are  increased. 
With  this  there  is  usually  an  increase  in  the  fatty 
marrow,  but  it  occasionally  disappears,  leaving 
cystic  spaces  filled  with  fluid. 


hied  Muscle,  from  a  Case  of  Progressive 
iuid;    Bismarck  brown.)     a,  a.  Normal 
liar  fibers;  b,  atrophic  muscular  fibers;  c,  perimysium  internum,  the 
i  , . f  which,  at  ci,  seem  to  be  increased  in  number.     Magnified  200 
t  rioters.     (After  Ziegler.) 


(tinguish:  simple    atrophy,   fatty    atrophy,    pigment 

I,    serous    atrophy,    and    degenerative    atrophy. 

Itty  and  pigment  atrophy  are  so  closely  related  to 

i  lple  atrophy   that   they   are   to   be   considered   as 

t  iple  atrophy  followed  by  or  associated  with  fatty 

i  titration    and    pigment    formation.     They    should 

1  carefully  distinguished  from  the  true  degenerative 

i  ophies  in  which  changes  in  the  nature  of  the  pro- 

t  ilasm  occur  from  the  very  beginning.     As  a  result 

c  these  changes  new  substances  are  formed  in  the  cells 

i  about  them  (mucous,  fatty,  hydropic  degenerations; 

liyloid,  hyalin,  etc.,  deposits).     In  these  conditions, 

oecially   in   the   case  of   the  pathological   deposits 

td  infiltrations,   the  atrophy  of  the  cells  must  be 

i  ;arded    in    many    cases    as    a    secondary    process. 

J  serous  atrophy  the  tissue  presents  the  picture  of 

t  ophy    associated    with    edema.     It    occurs    most 

i  quently  in  adipose  tissue. 

As  a  rule  the  more  highly  specialized  portions  of  the 

i  -ties  suffer  to  a  greater  extent  than  the  connective- 

tsue  framework.     This  may  be  unchanged  or,   as 

list  frequently    occurs,    increased    in   amount.     Tu 

newly  formed  connective  tissue  there  is  usua'Iy  a 

;  ater  or  less  degree  of  fatty  infiltration.     Through 

3  increase  of  connective  tissue  and  the  fat  deposit 

3    normal    pressure    upon    surrounding    structures 

iv  be  preserved  unchanged.     The  fatty  infiltration 

ty,  therefore,  be  regarded  as  being  of  the  nature  of 

:  -ompensatory  process. 

In  atrophy  of  striped  muscle  the  contractile  sub- 

tnce  disappears  while  the  nuclei  of  the  endomysiutn 

nliferate  to  a  greater  or  less  extent.     In  atrophy  jf 

e  lung  the  alveolar  walls  become  greatly  thinned, 

e  capillaries  disappear,  and  the  air  spaces  become 

reased  in  size  or  confluent  through  the  disappear- 

ce  of  the  wall.     As  a  result  of  the  obliteration  of 

my   of   the   smaller   capillaries   the   larger   vessels 

ow  a  state  of  chronic  congestion.     The  liver  lobules 

come  very  much  smaller  in  atrophy  of  that  organ, 

connective  tissue  of  Glisson's  capsule  is  relatively 

actually  increased,  and  is  more  hyaline  in  character, 

sembling  scar  tissue.     The  liver  rods  and  cells  are 

leased    in    size,    and    there    is    a    great    variation 

the  size  of  the  individual  liver  nuclei,  many  of 

nich     show     a     compensatory     hypertrophy.     The 

ntral  veins  and  capillaries  are  congested,  and  the 


Course. — The  course  of  the  various  forms  of 
atrophy  depends  wholly  upon  their  nature.  Total 
atrophy  occurs  as  the  result  of  the  exhaustion  of 
the  inherent  histogenetic  energy,  as  in  the  case  of 
many  of  the  fetal  structures,  the  thymus,  etc. 
In  partial  atrophies  due  to  other  causes,  such  as  dis- 
turbances of  nutrition,  pressure,  etc.,  a  greater  or  less 
degree  of  restoration  is  possible  in  all  structures  in 
which  the  histogenetic  limit  has  not  been  reached.  If 
the  causes  leading  to  atrophy  operate  in  the  early 
periods  of  development,  agenesia  or  aplasia  may  re- 
sult. Certain  organs,  as  the  thyroid  or  sexual  glands, 
may  be  thus  affected  and  their  lack  of  development 
may  lead  to  retarded  growth  of  other  tissues.  As 
stated  above,  these  processes  are  not  of  the  nature  of 
true  atrophies,  but  it  is  difficult  in  all  cases  to  make 


Fia.  528. — Lipomatosis  of  the  Muscles  of  the  Calf  of  the  Leg, 
Together  with  Atrophy.  (Miiller's  fluid,  carmine.)  Transverse 
sections  of  a  normal  («)  and  an  atrophied  (ai)  muscular  fiber;  a>, 
transverse  section  of  a  tubular  sarcolemma  containing  contractile 
substance  in  a  condition  of  disintegration;  6,  bands  of  connective 
tissue;  c,  fat  tissue.     Magnified  60  diameters.     (After  Ziegler.) 

sharp  distinction.  The  atrophy  of  certain  fully 
developed  organs  likewise  may  affect  the  growth  of 
other  organs  or  even  of  the  whole  body,  as  in  progres- 
sive muscular  atrophy  where  atrophic  changes  in  the 
bones  follow  those  in  the  muscles. 

In  so  far  as  the  function  of  the  organ  is  concerned, 
the  atrophy  of  its  elements  is  of  the  greatest  import- 
ance. Atrophic  muscles  lose  their  contractile  power, 
atrophic  glands  their  secretory  function,  osteoporotic 
bones  are  easily  broken,  and  atrophic  skin  is  easily 
injured    by    a    very    slight    trauma.     Further,    the 


771 


Atrophy 


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atrophy  of  one  organ  or  set  of  tissues  disturbs  the 
function  of  other  organs  and  leads  to  a  general  dis- 
eased condition  of  the  organism. 

The  prognosis  in  atrophy  is  favorable  only  in  those 
pathological  conditions  in  which  the  cause  of  the 
atrophy  may  be  removed,  and  in  tissues  in  which  the 
physiological  limit  of  growth  has  not  been  reached. 
Atrophy  of  the  vital  organs,  heart,  medulla  oblongata, 
kidneys,  respiratory  muscles,  etc.,  not  infrequently 
leads  to  death.  There  may  also  result  a  complete 
disappearance  of  certain  structures  caused  by  the 
atrophy  of  the  matrices  which  form  them.  In 
atrophy  of  the  periosteum  the  bone  disappears,  in 
atrophy  of  the  skin  there  is  a  loss  of  the  hair  and  nails, 
and  in  atrophy  of  the  lymph  glands  there  is  a  decrease 
in  the  formation  of  leucocytes. 

Treatment. — It  is  evident  that  only  the  purely 
passive  forms  of  atrophy  admit  of  treatment.  The 
removal  of  the  cause  and  the  restoration  of  the 
normal  nutrition  are  the  chief  indications. 

Aldred  Scott  Warthin. 

Atropine. — See  Belladonna. 

Attention. — A  definition  of  attention  may  run  per- 
haps something  like  this :  Attention  is  an  aspect  or  state 
of  psychophysical  activity  (will)  pointed  by  interest 
and  expediency  in  certain  directions  for  the  purpose 
of  aiding  efficiency,  and  is  expressed  in  consciousness 
in  terms  especially  of  the  feeling  of  bodily  movement 
or  innervations,  active  or  inhibitory,  and  hence  it  is 
discrete  in  occurrence,  and  either  reflex  or  voluntary. 
It  is  the  direction  aspect  of  organic  activity. 

Plato  long  ago  said  that  attention  was  "a  motion 
which  informs,  improves  and  preserves  the  soul." 
About  eight  hundred  years  after  him,  the  great 
Augustinus  rather  more  definitely  characterized 
attention  as  "an  active  psychological  operation, 
associating  images  and  ideas  for  memory,  and  inhibit- 
ing images  and  desires  in  recollection."  He,  as  Plato, 
laid  much  stress  upon  its  practical  aspect,  as  important 
in  acquiring  knowledge;  it  will  be  noted  also  that  the 
profound  author  of  the  "Confessions"  suggested  the 
important  theory  of  inhibition,  one  of  the  latest  to  be 
elaborated  in  its  physiological  relations  in  our  day, 
notably  by  Ribot. 

The  varieties  of  attention  have  been  very  variously 
named,  and  with  consequent  diverse  degrees  of  appro- 
priateness. Of  them  all,  the  classification  of  James 
Mill  and  of  Sir  William  Hamilton  seems  the  most 
accurate  in  the  light  of  modern  physiology:  namely, 
as  reflex  and  voluntary.  Attention,  then,  is  sensory, 
spontaneous,  passive,  involuntary,  or,  as  we  may  pre- 
fer to  call  it  by  analogy  from  physiology,  reflex. 
On  the  other  hand  it  is  voluntary  or  active;  this  term 
"active"  when  applied  to  attention  has  little  dis- 
criminative use,  however,  for  it  appears  that  con- 
sciousness is  always  an  active  state  of  experienced 
succession. 

Motion  and  change  are  the  conditions  of  attention 
even  as  they  are  apparently  the  essence  of  the  whole 
universe  without  and  within — Heraclitus,  the  philoso- 
pher of  change,  surely  had  an  insight  unexcelled. 
Consciousness  vanishes,  if  allowed  to  lapse  into  un- 
changingness,  and  the  conscious  aspects  of  mind  tem- 
porarily are  gone.  Attention  is  then  somewmat  like 
the  needle  swinging  lightly  to  and  fro  over  the  card 
of  consciousness — it  is  well  for  the  human  vessel  when 
it  swings  so  free,  but  it  is  even  death  to  consciousness, 
perhaps,  when  it  grows  rusted  in  its  place!  This 
basal  principle  the  physician,  like  the  teacher,  must 
ever  keep  in  mind  as  the  underlying  means  to  the 
avoidance  of  fatigue. 

In  reflex  attention  the  direction  line  evidently,  as 

has  been  said,  other  things  equal,  tends  to  follow  the 

course  of  the  least  resistance.     Just  in  proportion  as 

.  the  attention  is  passive,  reflex,  mechanical,  will  this 

772 


be  true.  This  "direction  of  least  resistance"  means 
in  its  simplest  terms  that  the  strongest  stimulation 
would  attract  the  consciousness,  as  indeed  it  actually 
does  or  tends  to  do  under  certain  conditions.  Under- 
lying always,  however,  the  sensorium  of  a  man  or 
woman  are  the  personal  concerns,  and  invariably 
underlying  these  are  the  racial  and  other  biological 
interests.  These  facts  mean  that  the  determination 
of  reflex  attention  will  normally  tend  to  be  a  rcsul 
of  the  nerve  forces  always  pressing  into  the  spinal 
cord  from  the  numerous  sense  organs,  reacting  against 
floods  of  central  nervous  influence  always  preset 
themselves  there.  These  latter  come  on  the  one  hand 
from  the  habit-complexes  of  the  brain  and  anterior 
gray  cord  and  on  the  other  from  the  syndrome-ganglia 
(sympathetic)  of  the  vegetative  life.  Balance  is 
apparently  the  universal  condition  in  bodily  relation- 
ships for  at  least  all  physiological  advance  in  whatever 
direction  emphasizes  the  basal  nature  of  this  counter- 
vailing principle:  action  is  almost  invariably  the 
result  of  the  intermingling  of  energies  more  or 
opposed  in  kind,  in  strength,  in  direction  or  in  all  i  i 
these.  It  is  so  everywhere  else  and  there  is  no  reason 
apparent  why  the  physiological  conditions  of  reflex 
attention  should  be  unlike  the  rest.  In  the  central 
gray  matter  of  the  neural  system  the  intermingling 
forces,  we  may  surmise,  are  streams  of  nen 
influence  coming  from  the  many  lesser  circuit 
nerve  activity  into  which,  as  w-e  have  seen,  the  whole 
is  functionally  divided. 

In  reflex  attention,  then,  w-e  must  think  in  general 
terms  of  the  line  of  direction  as  the  resultant  of 
influences  coming  into  the  cord  from  myriad  sense 
organs,  from  the  brain,  and  from  the  sympath 
and  must  suppose  that  these  fuse  and  result  in  some 
one  or  other  of  the  innumerable  adjusting  movements, 
partly  phylogenic  and  partly  ontogenic,  of  the 
organism. 

Voluntary  attention  has  similar  general  neural  con- 
ditions behind  it  adapted  to  its  different  nature. 
Instead  of  being  the  plaything  of  the  most  conspicuous 
sensory  stimulation  reacting  against  a  basis  of  biolog- 
ical and  personal  interest  and  habit,  voluntary  atten- 
tion may  rise  (apparently)  superior  to  these  vegetative 
and  mechanical  conditions  and  be  free  as  the  will  of 
man  is  free.  Theoretically  and  ideally  the  attention 
may  be  independent  of  bodily  conditions  to  any  logical 
extent.  Moreover,  the  interest  that  is  concerned  in 
this  kind  of  attention,  as  in  the  other,  may  be  as 
arbitrary  as  you  please  even  to  pure  caprice,  or  it 
may  be,  theoretically,  even  entirely  lacking.  Hereof 
course  the  theory  of  attention  coincides  with  that  of 
the  will  as  Bastian,  for  example,  years  ago  so  well 
pointed  out. 

In  practice,  as  in  theory,  then,  the  actual  voluntary 
attention  has  in  the  foundations  of  its  neurology 
apparently  the  same  influences  that  are  determinants 
of  reflex  attention.  Here,  however,  the  most  "con- 
spicuous" stimulation  exerts  very  little  influence  and 
may  even  be  quite  subconscious,  however  great  its 
objective  and  physiological  intensities.  Again,  the 
stream  of  nervous  influence  coming  as  "biological 
interest"  (from  the  organs  by  way  of  the  syn 
thetic  circuits  of  sensorimotor  impulses)  are  reduced 
so  as  to  exert  little  seeming  effect  on  the  attention 
line.  That,  however,  under  the  usual  conditions  of 
voluntary  attentive  activity  in  ordinary  degrees  these 
bodily  states  do  exert  a  considerable  influence  on  the 
attention  we  need  not  stop  to  further  explain. 

The  stream  of  nerve  impulses  that  exerts  the 
strongest  control  in  voluntary  attention  comes  usually, 
it  is  clear,  from  these  cerebrospinal  unit-complexes 
of  correlated  activity  known  as  habit-complexes. 
These  have  their  neural  locus  chiefly  in  the  mazes  of 
the  brain,  but  none  the  less  are  mechanically  under- 
laid and  executed  by  circuits  of  neuromuscular 
activity  correlated  in  the  spinal  cord.  These  furnish 
the  mechanical  neuromotor  guides  by  which  appar- 


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Augusta 


<  ly,  either  in  actuation  or  in  inhibition,  forced 
i  ention  maintains  its  bodily  course  of  action,  be  it 
\  ;ing  or  looking  or  whatever  else  the  attentive 
I  ivity  may  be. 

Alien   we   seek   the   general   neural   conditions  of 

-    ,(|  thought  without  intentional  expression  of  any 

i  ..I,  then  are  we  turned  back  as  usual  on  the  psy- 

,r    impulses   that    innervate   the  expression-ap- 

us  of  languaye-conct  /its. 

The  notion  of  forced  attention  to  trains  of  feeling  in 
1  ins  other  than  more  or  less  articulated  words,  is 
,  entially  a  contradiction,  such  trains  of  experience 
I  ng  inherently  reflex  and  so  subconscious  or  else 
,  ouonally  and  plainly  motor.  (See  G.  V.  N. 
larborn:  "Notes  on  the  Discernment  of  Likeness 
i  1  tjnlikeness, "  Jour.  Philos.,  Psychol,  and  Sci. 
,  vii.,  3,  February  3,  1910,  pp.  57-64.) 

The  universal  group  action  of  the  nervous  system 

i  special  reason  why  we  need  look  for  no  simplicity 
i  the  action  of  the  mechanism  of  efficiency.  In  those 
t  nplex  reactions  and  adjustments  that  are  at   the 

da  of  attention  this  group  action  is  particularly 
t  idamental.  But  another  reason  for  the  complexity 
lie  conditions,  a  more  general  one,  lies  in  the  cor- 
l  ponding  complexity  of  the  behavior  of  the  human 
i  inal.  Such  considerations  are  trite,  however 
i  portant,  and  would  not  be  rehearsed  here  were  it 

I  a  habit  of  the  psychologists  at  times  to  speak  of 

1  to  expect  a  simple  "  theory  of  attention"  like  the 
i  ic-relations,  for  example,  of  the  contraction  of  a 
1  g's  gastrocnemius.  Obviously  the  intricacy  of 
i  •  human  action  system  and  of  the  behavior  that 
i  responds,  precludes  hope  of  any  such  thing,  of  any 
»  t  of  simple  action  rule  behind  (or  in  front  of)  the 
i  ection  of  the  attention-line.  It  is  idle  to  seek  a 
lu'fl  theory  of  attention.  The  best  one  may  hope  for 
i  •  at  least  so  it  seems  in  our  present  relative  ignor- 
ice  of  the  nervous  system)  is  a  concise  descriptive 
i  ninary  of  the  influences  and  conditions  involved 
i  this  phase  of  viatility.  We  may  call  such  a 
f  nmary  a  theory,  but  with  a  use  of  the  term,  less 
i  icise  than  usual,  now  sufficiently  suggested.  If  all 
I  empts  at  solution  of  the  problem  be  thought 
:  angely  incomplete,  let  us  recollect  how  the  philoso- 
]  er  Herbart  characterized  attention  in  his  awakening 
I  >sis  of  1N22:  "  Hanc  rem,  philosophis  nostri  temporis 
:  ram,  incredihilem  abominandam.  Surely  the  mod- 
i  i  physiologist  has  at  least  an  equal  right  to 
hsphemel 

Conspicuous  among  the  many  determining  in- 
I  onces  of  the  central  nervous  system  for  any  at- 
lltive  innervation  we  may  note  four;  viz.,  1.  The 
]  ative  degree  of  vasomotor  congestion  in  various 
1  ictional  groups  of  psychomotor  neurons  of  the 
jmpathetic,  the  cord,  the  cerebellum,  and  the 
'.  enspheres.     This  we  may  suppose  of  special  im- 

rtance  as  a  determinant  of  the  reflex  attention  line. 

may  be  partially  under  the  control  of  enzymic 
bstances  secreted   in   various   parts   of   the   brain. 

2.  Streams  of  nervous  influence  on  the  one  hand 
;>m  numberless  habit  groups  of  neurons  in  the 
i:itral  nervous  system  proper,  representing  the 
;rsonal  interests  (mostly  habits)  of  the  individual; 
id  on  the  other  hand  from  the  sympathetic  ganglia 
:  d  plexuses,  standing  for  the  person's  basal  bioli  igica] 

crests  (instincts  and  vegetative  habits,  nutritional, 
■tabolic,  sexual,  etc.). 

3.  In  manner  more  or  less  like  the  relative  vasomo- 
Dongestion,  the  relative  "fatigue-rest  balance"or 

bility  to  action,  exerting  influence  on  the  attention- 
e  impulses  in  the  nervous  system,  tending  to  draw 
e  effective  balance  of  nerve  action  over  its  pathway 
cause  the  latter  is  the  way  of  the  least  resistance, 
'lis  determinant,  with  the  "next  included,  is  essen- 
illy  the  "drainage"  notion  used  in  discussing  the 
sociation  of  ideas. 

4.  Tides  of  sensation  influence  from  all  the  sensory 
Ids  pouring  into  the  central  nervous  system,  with 


a  tendency  for  the  effectively  strongest  or  im.-t 
unusual  to  determine  the  attention  line  on  the  still 
unknown  principles  of  reflex  distribution.  In  forced 
voluntary  attention  this  factor  of  viatility  might  be 
nil,  serving  only  to  increase  the  inhibition  strain. 
The  practical  medical  and  educational  bearings  of 
attention  are  too  numerous,  or  too  voluminous,  to  be 
here  rehearsed.      Underlying  them  all.  more  or  less,  is 

this  corollary:  the  necessity  of  movement,  change, 
variety,  for  the  best  direction-control  of  both  the 
body  and  the  mind.         George  V.  N.  Dearborn. 

Auchmeromyia.  —  Bina-alia.  A  genus  of  flies, 
family  Muscidm,  which  contains  a  species,  .1.  de- 
pressa,  whose  larva  is  parasitic  in  man  in  South 
Africa.      The  "Larva'  of  Natal"  belong  in  this  genus. 

The  larva  of  .1.  luteola,  called  the  Congo  floor-mag- 
got, is  a  nocturnal  blood-sucker,  biting  persons  sleep- 
ing on  the  floor  of  the  hut  but  not  those  in  ordinary 
beds  The  bite  is  not  believed  to  transmit  disease. 
The  fly  is  harmless  so  far  us  known.  See  Insects, 
Parasitic.  A.  S.  P. 


Audition. — See  Hearing. 

Auditory  Canal. — See  Ear,  Anatomy  and  Physiology 

of  the. 

Auditory  Nerve. — See  Ear,  Anatomy  and  Physiology 

of  the. 


Auenbrugger,  Joseph  Leopold. — Born  in  Graetz, 
Austria,  November  19,  1722;  died  in  1S09.  Only  one 
of  the  few  short  treatises  which  he  published  possesses 
any  special  merit;  but  that  one,  which  calls  attention 


Fig.  529. — Joseph  Leopold  Auenbrugger. 

for  the  first  time  to  the  valuable  aid  afforded  by 
percussion  of  the  human  thorax,  in  the  diagnosis  of 
obscure  diseases  of  the  organs  contained  within  the 
chest,  is  alone  of  sufficient  importance  to  render 
Auenbrugger  justly  celebrated.  A.  H.  B. 

Augusta,  Georgia. — Augusta  is  situated  upon  the 
Georgia  side  of  the  Savannah  river,  which  through 
this  region  separates  the  states  of  Georgia  and  South 
Carolina.  Its  latitude  is  32°  28"  north  and  its  longi- 
tude is  81°  54"  west.  By  the  river  route  it  is  231 
miles  from  the  Atlantic  Ocean  and  in  an  air  line 
about  ninety  or  one  hundred  miles.  The  city  proper 
has  an  elevation  of  about  160  feet  above  the  sea-level. 
With  its  immediate  suburbs  it  has  a  population  of 
approximately  sixty  thousand  people.  It  is  one  of 
the  oldest  as  Veil  as  one  of  the  most  beautiful  cities 
in  the  south;  and  in  industrial  importance,  the  third 
in  the  state. 

773 


Augusta 


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A  canal  seven  miles  in  length  furnishes  water  to 
run  its  mills  and  other  industries.  Besides  its  public 
schools,  it  has  a  high  school  for  boys,  the  Richmond 
Academy;  The  Tubman  High  School  for  Girls;  a 
Jesuit  College;  the  Summerville  Academy;  well  con- 
ducted public  schools;  several  private  schools;  and 
1  m  Medical  I  leparl  menf  of  t  he  Cni\  ersil  v  of  <  leorgia. 
Strangers  sojourning  in  Augusta  may,  therefore,  have 
excellent  school  facilities  for  their  children  if  they 
desire.  There  are  also  an  opera  house,  a  public 
library,  and  churches  of  the  more  prominent  religious 
denominations. 

The  old  portion  of  the  city  is  quite  level,  and  the 
streets  are  wide  and  beautiful.  The  chief  residence 
thoroughfare,  Greene  Street,  is  175  feet  wide,  and 
through  its  length  of  several  miles,  extend  four  rows 
of  majestic  elms  and  oaks,  many  of  which  are  a 
century  or  more  old.  In  the  middle  avenue,  vehicles 
are  not  allowed;  this  being  stone  curbed  and  grass 
plotted,  is  reserved  for  pedestrians  and  as  a  play- 
ground for  children.  The  city  has  a  water  supply 
that  can  hardly  be  excelled.  It  comes  from  the 
Savannah  river,  which  from  its  origin  in  the  water- 
shed of  the  Blue  Ridge  to  Augusta,  has  on  its  banks 
neither  city  nor  village.  As  if  for  additional  pro- 
tection, it  breaks  into  shoals  which  extend  irregularly 
for  many  miles  above  Augusta. 

This  water  is  taken  five  miles  above  the  city, 
carried  by  mains  to  reservoirs  on  the  hill  top,  where 
it  is  filtered  and  thence  delivered  to  the  city  mains. 

This  water  which  is  used  for  drinking  and  household 
purposes,  and  in  addition  for  protection  from  fire,  on 
analysis  shows  as  follows,  after  filtration  and  delivery 
into  the  city's  mains: 

Nitrogen  as  free  ammonia 008 

Nitrogen  as  albuminoid  ammonia .044 

Nitrogen  as  nitrites 000 

Nitrogen  as  nitrates 090 

t  txvgen  absorbed 1 .  100 

Chlorine 4.000 

Alkalinity 11.000 

Iron 200 

Free  carbonic  acid 4.S00 

The  city  has  an  excellent  sewerage  system,  which 
plays  an  important  part  in  its  healthfulness.  Accord- 
ing to  the  report  of  the  Department  of  Health  for 
1909  the  total  mortality  (white  and  colored)  has  been 
reduced  from  27.78  per  cent,  in  1880  to  12.78  per 
cent,  in  1909. 

Augusta  is  easy  of  access  by  nine  railroads  centering 
here,  and  also  by  the  Savannah  river,  which  is  navi- 
gable from  the  Atlantic  Ocean  to  Augusta.  Crossing 
the  river  at  Augusta,  there  is  a  row  of  sand  hills 
which  beginning  in  the  region  of  Chester,  South 
Carolina,  pass  through  Aiken,  Augusta,  and  far  on 
into  Georgia.  On  the  crest  of  these  hills  at  this 
point  are  the  villages  of  Summerville  and  North 
Augusta.  Summerville  on  one  side  of  the  river  and 
North  Augusta  on  the  other. 

Summerville,  has  for  more  than  a  hundred  years 
been  an  aristocratic  suburb  of  Augusta,  and  on 
account  of  its  healthfulness,  was  early  known  as 
Mount  Salubrity;  it  is  also  perhaps  more  generally 
known  as  the  Sand  Hills.  This  suburb  is  connected 
with  Augusta  by  fine  gravel  roads  and  by  a  modern 
electric  [line  which  runs  a  fifteen-minute  schedule  to 
and  from  the  city.  Since  January  1,  1912,  the 
villages  of  Summerville  and  Monte  Sano  have  been 
incorporated  by  Augusta  and  are  now  within  the 
city's  limits. 

From  these  elevations  one  gets  a  sweep  of  land- 
scape that  is  rarely  excelled  by  mountain  scenery, 
the  view  extending  far  over  the  hills  of  South  Carolina 
anil  the  plateau  and  hills  of  Georgia.  The  hills  are 
covered  with  pines,  elms,  and  oaks  and  such  grasses 
as  will  grow  in  a  sandy  soil.  Wild  flowers  are  abun- 
dant,   and    the   honeysuckle,    Cherokee   rose,    yellow 

774 


jassamine,  dog-wood,  and  other  flowers,  wild  ant 
cultivated,  vie  with  each  other  to  make  the  landscape 
beautiful;  and  a  multitude  of  feathered  singers — mock 
ing  birds,  cardinals,  thrushes,  robins,  blue  jays  am 
toward  the  latter  part  of  the  season,  the  whip-poor 
will  make  the  region  a  veritable  fairyland  in  tin 
spring. 

The  soil  is  very  sandy  and  it  is  necessary  to  gi 
down  from  eighty  to  one  hundred  feet  on  the  hill  ton 
before  striking  water.  No  water  accumulates  oi 
the  surface  of  the  ground,  it  being  like  a  huge  filter 
and  one  can,  in  a  few  minutes  after  the  hardest  ra 
go  out  and  walk  for  miles  without  wetting  the  feet 
Bad  drainage  is,  therefore,  practically  impossible 
This  is  not  true,  however,  of  the  older  and  flatter  por 
tion  of  the  city. 

The  meteorological  data  for  this  health  resort  are  ii 
a  measure  misleading  since  the  main  recorded  dati 
that  we  have  are  from  the  United  States  Weathe 
Bureau,  located  300  feet  below  Summerville  or  Nonl 
Augusta.  It  is  unfortunate  that  the  Governmen 
does  not  locate  its  bureau  at  its  arsenal,  which  i-  i 
splendid  property  on  the  summit  of  the  hill,  on  thi 
Georgia  side.  A  register  was  kept  at  this  arsena 
from  1849  to  1869.  The  observations  taken  then 
during  that  period,  at  sunrise,  at  9  A.  M.,  3  p.  M.,  am 
9  p.  m.  show  the  mean  average  temperature  to  b<  a 
follows: 

January,    46.7°;    February,    50.7°;    March. 
April,  65.1°;  May,  72.2°;  June,  S0.9°;  August,  79 
September,  72.0°;  October,  63.5°;   November,  53.8' 
December,  46.3°;  mean  temperature  of  spring,  65.3 
summer,  79.9;  autumn,  63.4;  and  winter,  47.9. 

The  mean  annual  rainfall  for  the  same  period  was 
spring,  37.17;  summer,  14.4;  autumn,  6.95;  winter 
5.92. 

Mean  number  of  fair  days  238;  cloudy  days  seventy. 

Snow  about  two  days  in  every  three  years.  Un- 
fortunately no  record  of    the  humidity  was    ma 

Dr.  Kenworthy,  in  an  article  on  the  "Climate  i 
Florida"  has  shown  that  Augusta  has  a  mean  tempera- 
ture for  the  months  of  November,  December,  Jannai  \ 
February,  and  March  of  51.4°  F.  while  that  of  Canne 
is  50.8.  He  also  pointed  out  that  for  these  months 
the  mean  relative  humidity  of  Augusta  (the  city  in  the 
valley,  not  the  village  of  Summerville  on  the  hill  top) 
was  2.5°  less  than  that  of  Cannes  and  Mentone;  and 
one-tenth  of  a  degree  more  than  that  of  Jacksonville. 
Florida. 

The  accompanying  table  for  the  city  of  Augusta 
extends  over  a  period  of  thirty-nine  years  and  is 
furnished  by  Mr.  Emigh,  of  the  United  States  Weather 
Bureau  Office  in  Augusta. 

In  studying  this  table  it  will  be  noted  that  Augusta 
has  not  a  tropical  climate,  but  a  bracing  one,  with  a 
large  percentage  of  sunny  days.  Rain  falls  here  oft-  ., 
when  there  is  sleet  or  snow  further  north;  but  the  soil 
is  so  sandy  that  it  quickly  sinks  in,  and  there  is  rarely 
a  day  when  one  cannot  play  golf  part  of  the  day. 

On  the  brow  of  the  hill  on  the  Georgia  side  and  in 
the  old  corporate  limits  of  Summerville  is  the  Bon 
Air  Hotel  accommodating  about  400  guests,  Par- 
tridge Inn  with  a  capacity  of  about  120,  many 
select  boarding  houses,  and  a  large  number  of  furnished 
cottages,  which  rent  by  the  season.  Here  is  located 
the  Country  Club  with  its  tennis  courts  and  tun 
unsurpassed  golf  courses  of  eighteen  holes  each. 
This  section  is  growing  with  great  rapidity  and 
beautiful  suburban  homes  are  constantly  being  erected. 
In  order  to  accommodate  the  increasing  number 
of  guests,  a  lage  property  about  a  mile  beyond 
limit  of  Summerville  has  been  purchased  on  which 
will  be  erected  a  large  fire-proof  hotel,  golf  links,  ;i 
lake  for  fishing  and  boating,  etc. 

On  the  summit  of  the  North   Augusta  hills,  over- 
looking  Augusta,   is  located   the   Hampton   Ten 
Hotel,  with  its  accommodations  for  400  guests;  and 
around  it  are  numerous  boarding  houses  and  cottages 


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A  iir.iiilimil 


Climate  op    \      nSTA    Georgia;  Latitude,  32  28°  N\,  Longitude,  81  54*  W 


— 
1        S       "3       J        § 

«     \     *s  *s  <  / 


7Vmpero7Hre. 

\i  age  of  normal 

.... 
highest.  . 
west   ..... 

maximum 

of  minimum 

:  last  killing  frost,  .March  19 
late  of  first  killing  frost,  November  9. 
imidity  (8  &.  u    plus  S  p.  m.,  divided  by  2). 

relative 

.    ng«  absolute    gr.  per  cu.  ft.) 


Precipitation. 
A  ago  in  inches 

Wind. 

I'i  tiling  direction. . 

elocity  in  miles  per  hour. . .  . 


Weather  (days). 

age  number  clear 

imber  partly  cloudy 

-t  number  clear  for  ten  years 
Uest  number  clear  for  ten  years. 

age  number  cloudy 

mber  cloudy  for  ten  years. 

imber  cloudy  for  ten  years 

_'■■  No,  with  1-in.  or  more  rain. . 

rainy 

iber  rainy 


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79 

82 

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2.36 

2 .  72 

3.20 

3.88 

7.04 

7.94 

6.56 

1.15 

1.38 

1.85 

3.50 

3.23 

l..v; 

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3.71 

W 

W 

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6.4 

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6.9 

6.7 

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.-..  i 

5.1 

4.7 

5.2 

5.6 

5.4 

5.9 

11 

10 

12 

13 

13 

10 

10 

9 

13 

17 

13 

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9 

10 

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1 .  75 


47.89 


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5.9 


113 

12V 


115 


I  rent.     This  suburb  is  connected  by  an  electric 

li-   with   Augusta  and   Aiken.     Contiguous  to   the 

re  the   tennis  courts  and   Hampton  Terrace 

: '  links  of  eighteen  holes.     In  the  business  portion 

0  Augusta  the  Albion  Hotel  and  the  Genesta  Hotel 

i  for  the  reception  of  guests  the  year  round. 

'he  roads  about    Augusta  are   perhaps   the   besl 

vouth,  being  built  by  convict  labor  and  con- 

I  with  a  natural  mixture  found  in  the  region, 

ijich    consists    of    pebbles,    clay,    and    sand.     This 

r  kes  motoring,  riding,  and  driving  pleasant.     Work 

i  low  being  done  on  a  boulevard  between  Augusta 

ai  Aiken,  a  distance  of  sixteen  and  a  half  miles. 

To  sum  up.  from  a  health  and  pleasure  standpoint, 

i    is  easily  the  best  all-winter  resort   in   the 

.v  ith  and  is  indeed  excelled  by  few  places  anywhere. 

1  climate  is  bracing  and  holds  neither  the  inhospi- 

trors  of  the  North  nor  the  debilitating  and 
c  massing  influences  of  the  far  South;  it  is  moderately 

and  increased  or  diminished  humidity  can  be  en- 
j  ed  by  getting  down  into  the  river  valley,  or  farther 
i  on  the  hill  top;  there  is  an  absence  of  sudden  and 
cided  atmospheric  changes  which  characterize  the 
lions  farther  north,  and  the  large  percentage  of 
e  my  days  makes  it  possible  to  spend  most  of  the 
t  le  out  of  doors. 

or  the  reasons  mentioned  it  is  especially  adapted 
i  diseases  running  a  more  or  less  chronic  course,  e.g. 
.  iahN  disease,  heart  disease,  bronchitis,  asthma,  etc.. 
i  1  indeed  as  a  place  in  which  convalescence  after 
i  te  diseases  may  be  speedily  and  satisfactorily 
i  omplished.  Thomas  D.  Coleman. 


\urantium. — Sweet 
trus.) 


and    bitter    orange.     (See    also 


1.   AriiAXTii  Amari  Cortex. — Bitter  Orange  Peel. 
ed  rind  of  the  unripe  fruit  of  Citrus  aurantuim 
i  ara   Linne   (Fam.   Rutacea:)    (IT.   S.   P.). 

i2.  ArRAXTii  Dri.cis  Cortex. — Sweet  Orangt  Peel. 

'  e  outer  rind  of  the  fresh  ripe  fruit  of  Citrus  auran- 
l  in  sinensis  Gallesio  (Fam.  Rutacen)  (U.  S.  P. ). 


The  orange  is  a  native  of  tropical  Asia  and  is  now 
cultivated  in  all  warm  regions.  Whether  the  bitter 
and  sweet  forms  were  distinct  species  from  the  begin- 
ning, or  the  sweet  is  a  cultivated  derivative  of  the 
bitter,  is  a  long-disputed  question.  Both  are  now 
cultivated.  The  official  sweet  orange  peel  is  used  only 
for  its  volatile  oil  and  almost  altogether  as  a  flavoring 
agent  although  the  oil  possi s  some  stomachic,  car- 
minative, diuretic,  and  diaphoretic  properties. 

The  properties  and  uses  of  bitter  orange  peel  are 
quite  distinct  and  it  is  an  important  medicinal  agent. 
Its  aromatic  constituent  is  chiefly  in  the  outer,  its 
bitter  ones  in  the  inner  layers,  so  that  the  properties 
will  vary  with  the  relative  amounts  of  these  two  parts. 
It  occurs  in  ribbons,  shreds,  or  quarter-sections,  rarely 
in  irregular  pieces.  The  inner  layer  is  white,  the 
outer  of  a  dark  or  blackish-green  or  green-brown,  and 
more  or  less  roughened  with  papillae.  Its  odor  is 
characteristic  and  its  taste  strongly  aromatic  and 
bitter.  Its  volatile  oil  is  described  below.  Its  bitter 
properties  are  due  to  narangin,  aurantiamarin,  and 
aurantiamaric  acid.  Hespcridin  is  not  bitter.  It  will 
be  noted  that  this  is  used  after  drying,  while  the  sweet 
orange  peel  is  to  be  used  fresh.  Bitter  orange  peel  is 
an  ordinary  aromatic  bitter,  to  be  employed  like 
others  of  its  class.  The  dose  is  two  to  four  grams 
30  to  60  grains).  There  is  an  official  fluid  extract, 
dose  npxv.  to  lx.  (1.0  to  4.0)  and  a  twenty-per-cent. 
tincture,  floss,  to  ii.  (2.0  to  8.0).  Of  the  sweet, 
we  have  a  fifty-per-cent.  tincture,  dose  4  to  S  e.c. 
(1  to  2  fl.  dr.  )  and  a  five-per-cent.  syrup,  used 
wholly  a<  a  vehicle  and  for  flavoring. 

Oil  of  Orange  Peel.   Oh  A  Corticis. — "A 

volatile  oil  obtained  by  expression  from  the  fresh  peel 
of  the  sweet  orange."  This  is  purely  a  diffusive 
stimulant,  but  is  almost  wholly  used  for  flavoring. 
Its  preparations  are  the  five-per-cent.  spirit  and  the 
twenty-per-cent.  compound  spirit,  made  with  five 
per  cent,  of  oil  of  lemon  and  two  per  cent,  of  oil  of 
anise.     This  latter  enters  into   the   aromatic   elixir. 

Oil  of  Orange  Flowers.  Oil  of  Neroli.  Oleum 
Aurantii  Florum. — A  volatile  oil  distilled  from  the 
fresh  flowers  of  the  bitter  orange.     (Neither  the  oil  nor 


i  to 


Aurantlum 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


the  flowers  are  longer  official.)  This  is  used  purely  as 
a  perfuming  and  flavoring  agent.  The  following  are 
the  preparations:  Stronger  Orange  Flower  Water 
(Aqua  Aurantii  Florum  Fortior)  is  obtained  as  a 
by-product  in  the  distillation,  being  the  water  so  used, 
saturated  with  the  oil.  From  this  is  made  the  Orange 
Flower  Water  (Aqua  Aurantii  Florum)  by  mixing  it 
with  an  equal  volume  of  distilled  water.  From  this, 
in  turn,  is  made  the  syrup,  by  adding  to  S50  grams  of 
sugar  enough  of  the  water  to  make  1,000  c.c. 

Oil  of  Petit  Grains,  not  official,  is  distilled  from  the 
unripe  fruits  of  the  bitter  orange,  and  is  very  similar 
to   oil   of  orange   flowers,   but  much  less  agreeable. 

The  use  of  orange  fruit  is  like  that  of  other  laxative 
fruits,  with  the  special  effect  of  citric  acid.  It  is  to  be 
borne  in  mind  that,  while  a  moderate  use  of  oranges  is 
wholesome,  the  excessive  use  can  bring  on  very 
stubborn  and  severe  dyspepsia,  especially  in  tropical 
countries.  Henry  H.  Rusby. 


Aurelianus,  Cselius. — Born  in  Sicca,  in  Numidia, 
but  it  is  not  known  at  what  time  his  birth  occurred; 
some  authorities  stating  that  he  was  a  contemporary 
of  Galen,  who  lived  in  the  second  century  of  our  era, 
while  others  claim  that  he  must  have  been  born  in  the 
fifth  century.  Nor  do  we  possess  any  knowledge 
with  regard  to  his  life.  The  treatise  which  is  attrib- 
uted to  him  makes  it  clear,  however,  that  he  must 
have  been  one  of  the  greatest  and  at  the  same  time 
most  practical  physicians  of  ancient  times.  The 
book  here  referred  to  bears  the  title:  "Cselii  Aureliani 
de  morbis  acutis  et  chronicis  libri  viii."  An  edition 
was  published  in  Amsterdam  in  1709.  It  is  known 
that  Aurelianus  wrote  other  medical  treatises,  but 
unfortunately  they  have  all  been  lost.  A.  H.  B. 

Auricle. — See  Ear,  Anatomij  and  Physiology  of  the. 

Aurora  Springs. — Miller  County,  Missouri. 
Post-office. — Aurora  Springs. 

Access. — Via  Jefferson  City,  Lebanon  and  South- 
western Railroad — a  branch  of  the  Missouri  Pacific 
system — thirty-five  miles  southeast  from  Jefferson 
City.     Hotels. 

This  resort  is  located  on  a  spur  of  the  Ozark 
Mountains,  at  an  elevation  of  about  1,000  feet  above 
the  sea  level.  The  climatic  conditions  here  are  of  a 
most  salubrious  and  attractive  character  and  the 
scenic  beauties  are  unsurpassed.  It  was  a  visit  to 
this  locality  which  led  Bayard  Taylor  to  remark: 
"  I  have  travelled  all  over  the  world  to  find  in  the 
heart  of  Missouri  the  most  magnificent  scenery  the 
human  eye  ever  beheld."  The  country  may  be 
described  as  a  succession  of  narrow  ravines,  and  well- 
wooded,  high,  dividing  ridges,  running  in  a  general 
cast  and  west  direction,  with  picturesque  streams  of 
clear  water  winding  through  and  cutting  the  ridges 
at  right  angles,  forming  narrow  gorges,  which  have, 
coursing  down  their  sides,  sparkling  rivulets  and 
saucy  brooks,  fed  by  springs  situated  on  the  hillsides. 
The  springs  are  located  under  a  magnesium  limestone 
formation  at  the  entrance  to  a  charming  park  and 
near  the  headwaters  of  Saline  Creek.  The  surround- 
ing country  slopes  gradually  to  the  southeast,  and  is 
protected  from  the  winter  winds  by  the  higher  ground 
to  the  north,  while  the  cooler  breezes  of  the  summer 
come  from  the  south  and  west — down  the  Osage 
valley.  There  are  numerous  springs  in  the  neighbor- 
hood, the  principal  ones  being  known  as  the  "  Round," 
the  "Bluff,"  the  "Healing,"  and  the  "Bath"  spring. 
A  sulphur  spring  is  located  about  seven  miles  farther 
down  Saline  Creek.  The  Round  spring  has  been 
analyzed  by  Prof.  Clifford  B.  Richardson,  analytical 
chemist,  Department  of  Agriculture,  Washington, 
1).  ('.,  with  the  following  result: 


One  United  States  Gallon  Contains: 
Solids.  Grains. 

Calcium  sulphate 2 .  42 

Magnesium  chloride 6.95 

Sodium  chloride 4 .  01 

Ferrous  carbonate 5.13 

Ferrous  oxide 0-93 

Lithia 1   43 

Total 20 .  87 

This  water  is  almost  a  pure  chalybeate.  It  has  a 
sharp  tonic  effect  on  the  physical  economy,  bracing 
up  the  digestion,  promoting  the  appetite,  and  inducing 
healthful  sleep  and  rest.  Its  best  effects  have  been 
observed  in  cases  of  dyspepsia,  rheumatism,  scrofulous 
complaints,  and  renal  diseases,  and  in  the  debility 
resulting  from  nervous  affections  and  uterine  com- 
plaints. Visitors  will  find  excellent  hotel  accom- 
modations and  all  facilities  for  hot,  cold,  and  steam 
baths.  Emma  E.  Walker. 


Aurum. — So  far  as  determined,  the  action  of  gold 
upon  the  animal  system  resembles  that  of  mercury 
more  nearly  than  that  of  any  other  of  the  well-known 
heavy  metals.  Locally,  soluble  gold  salts  are 
powerfully  irritant,  and  constitutionally,  gold  com- 
pounds affect  nutrition.  In  therapeutic  doses  they 
tend,  like  mercurials,  to  improve  nutritive  tone,  but 
in  poisonous  quantities  to  derange  it,  with  the 
development  of  stomatitis  and  gastroenteritis,  and, 
in  continued  dosage,  of  emaciation  and  progressive 
general  enfeeblement. 

The  sole  compound  of  gold  official  in  the  United 
States  Pharmacopoeia  is  that  entitled  Auri  et  Sodii 
Chloridutn,  Gold  and  Sodium  Chloride.  This  is  "a 
mixture  of  equal  parts,  by  weight,  of  anhydrous  gold 
chloride  and  anhydrous  sodium  chloride."  (U.  S.  P.) 
The  compound  is  easily  obtained  by  mixing  in  proper 
proportion  solutions  of  the  two  salts  and  evaporating 
to  dryness.  It  crystallizes  in  elongated  prisms,  but 
is  commonly  found  as  "an  orange-yellow  powder, 
odorless,  having  a  saline  and  metallic  taste,  and 
deliquescent  when  exposed  to  damp  air."  (U.  S.  P.) 
The  compound  is  very  soluble  in  water,  and  the 
solution  has  a  slightly  acid  reaction.  This  prepara- 
tion is  locally  irritant  even  to  causticity;  and  con- 
stitutionally is  said  to  be  of  some  slight  value  in 
nervous  diseases,  hysteria,  neurasthenia,  chronic 
alcoholism,  tertiary  syphilis,  and  diabetes.  The 
dose  is  about  one-tenth  grain  (0.005)  three  times  a 
day,  in  lozenge  or  pill.  R.  J.  E.  Scott. 

Auscultation. — See  Diagnosis,  Physical. 

Auspitz,  Heinrich. — Born  in  1S35  in  Nikolsburg, 
Germany.  After  studying  the  different  branches  of 
medical  knowledge  under  such  teachers  as  Bruecke, 
Rokitansky,  Skoda,  Oppolzer,  and  Hebra,  he  began 
his  career,  in  1863,  as  a  "Privatdozent"  of  dermatol- 
ogy and  syphilis,  and  then  later  (in  1S75)  he  was 
made  a  professor  of  the  same  branches  in  the  Univer- 
sity of  Vienna.  In  1S72  he  was  chosen  Director  of  the 
General  Policlinic;  and,  upon  the  death  of  Zeissl,  in 
18S4,  he  was  given  the  control  of  a  Clinic  for  Derma- 
tological  and  Syphilitic  Cases  in  the  Allgemeine 
Krankenhaus.     His  death  occurred  May  23,  1886. 

Auspitz  deserves  to  rank  as  one  of  the  leading 
authorities  in  dermatology  and  syphilology  of  the 
second  half  of  the  nineteenth  century.  He  was  a 
prolific  contributor  to  medical  literature,  his  most 
important  publication  being  a  "System  der  Haut- 
krankheiten,"  Vienna,  1881.  A.  H.  B. 


Australia. — Owing  to  its  great  size,  extending  from 
10°  to  40°  south  latitude  and  113°  to  153°  east  longi- 
tude,   Australia    presents    many    different    climates, 


776 


i;i:iT.]:r.\ci:  handbook  OF  the  medical  SCIENCES 


Autogamy 


On  account,  however,  of  its  distance  from  the  Ant- 
arctic Circle  (_\S°)  and  from  the  Equator  (11°),  there 
are  in  reality  fewer  climatic  variations  than  in  other 
great  continents.  (Encyclopaedia  Britannica,  1911.) 
The  topographical  features  of  the  land  also  naturally 
influence  the  climate.  There  is  a  low-lying  coast 
region,  a  highland  or  mountain  region,  and  a  great 
arid  interior  region. 

Before,  however,  considering  the  climate  of  this 
country,  it  may  be  well  to  speak  of  the  voyage 
hither,  which,  whether  from  Europe  or  America,  is  a 
long  one  and  may  be  considered  as  a  health  measure 
in  itself.  Formerly  long  sea-voyages  were  one  of  the 
established  means  of  treating  tuberculosis,  but  now 
are  no  longer,  or  rarely,  recommended  for  this  pur- 
pose, although  they  may  be  of  advantage  for  other 
conditions.  According  to  Weber  (Climate  and  Sea- 
Voyages  in  the  Treatment  of  Tuberculosis:  Boston 
Medical  and  Surgical  Journal,  June  8,  1S99J,  the 
following  characteristics  are  to  be  attributed  to  sea- 
voyages:  (1)  purity  of  air;  (2)  slight  range  of  tem- 
perature; (3)  abundance  of  light;  (4)  constant  move- 
ment of  the  air;  (5)  mental  rest.  As  this  author, 
however,  wisely  remarks:  "If  one  examines  the 
conditions  of  an  ocean  voyage  more  exactly,  he 
finds  that  these  advantages  are  not  always  com- 
pletely presented."  The  purity  of  the  air  is  wanting 
10  the  sleeping  cabins  and  saloons;  the  heat  of  the 
tropics  is  oppressive;  the  treatment  of  a  serious 
illness  on  a  sea-voyage  is  difficult;  and  there  are 
storms  and  calms.  "From  what  I  have  observed," 
concludes  Dr.  Weber,  "  I  would  give  it  as  my  opinion 
that  sea-voyages  can  do  good  service  in  a  certain 
number  of  tuberculosis  cases,  but  that  in  most  cases 
other  climatic  and  hygienic  methods  of  treatment 
exercise  at  least  just  as  good  an  influence."  From 
our  present  knowledge  and  experience,  we  should 
modify  this  opinion  by  saying  that  "other  climatic 
and  hygienic  methods"  are  greatly  superior  to  sea- 
voyages  in  the  treatment  of  tuberculosis,  and  only  in 
very  exceptional  cases  would  one  recommend  them 
in  the  treatment  of  this  disease. 

The  climate  of  the  Coastal  or  Littoral  region  has  an 
average  summer  temperature  ranging  from  7S°  in 
the  north  to  07°  in  the  south,  and  a  winter  tempera- 
ture of  from  59°  to  52°;  the  difference  between  the 
mean  summer  and  the  mean  winter  temperature  being 
not  more  than  20°,  a  range  smaller  than  in  most  other 
parts  of  the  world.  In  summer  the  heat  is  at  times 
excessive,  frequently  exceeding  100°  F.  at  Melbourne, 
Sydney,  and  Adelaide;  but  the  air  is  so  dry  that  one 
is  not  rendered  particularly  uncomfortable  nor  is  it 
enervating.  The  hot  wind,  which,  "arising  in  the 
great  central  Australian  desert,  sweeps  across  the 
pastoral  plains,  rises  over  the  range  of  mountains,  and 
descends  with  fury  upon  the  coast,"  may  raise  the 
temperature  to  110°  F.  These  hot  winds  are  often 
followed  by  cold  blasts  from  the  Antarctic  Circle — 
blasts  which  lower  the  temperature  thirty  or  forty 
degrees  in  as  many  minutes.  That  such  hot  winds 
are  not  very  frequent  may  be  judged  from  the  fact 
that  Melbourne,  for  instance,  has  only  fourteen  hot 
windy  days  annually. 

There  is  the  usual  amount  of  dust,  that  inseparable 
accompaniment  of  a  hot,  dry  climate.  "  In  no  coun- 
try in  the  world,"  says  Lindsay,  "  is  the  sky  so  seldom 
overcast,  or  the  interruptions  to  the  pursuit  of  busi- 
ness or  pleasure  so  few." 

The  winters  are  mild.  Snow  and  frost  are  rare 
upon  the  lowlands  and  coast,  and  in  many  places  are 
quite  unknown.  The  rainfall  is  fifty  inches  per 
annum  at  Sydney,  thirty  at  Melbourne,  and  twenty 
at  Adelaide.  The  rain  comes  in  sudden  deluges,, 
as  in  tropical  regions,  and  days  of  drizzling  rain  are 
unknown.  Owing  to  the  variability  of  the  climate, 
the  winds  above  mentioned,  the  heat,  and  the  dust 
this  region  is  not  to  be  recommended  to  invalids. 

The    highland    regions,    embracing    the    mountain 


range  of  the  Australian  Alps  and  (he  Blue  Mountains, 
which  vary  in  height  from  :;, 1)11(1  to  7,0(10  feel,  extend 
from  Queensland  to  South  Australia.  The  mean 
summer  tempera!  ore  of  this  region  is  05.4°  F.,  and  the 
mean  winter  temperature,  11.  Is.  In  winter,  accord- 
ing to  Lindsay,  the  mountains  are,  for  the  most  part, 
deluged  with  rain  and  swept  by  winds.  There  are 
but  few  places  available  in  the  mountains  for  invalids. 
At  Mt.  Macedon,  in  Victoria,  forty-four  miles  from 
Melbourne,  connected  by  railway,  there  is  a  good 
sanatorium,  " Braemar  Woodend,"  situated  upon  a 
plateau  at  an  elevation  of  2, 500  feet,  and  at  Katoomba 
and  Mt.  Victoria  in  New  South  Wale  ,  seventy-seven 
miles  from  Sydney,  the  latter  at  an  elevation  of  3,490 
feet,  are  mountain  resorts.  The  mean  annual 
temperature  of  the  latter  resort  is  53°  F.,  and  the 
annual  rainfall  about  35.7  inches. 

The  region  of  the  Inland  Plains,  whose  climate  is 
characterized  by  heat,  dryness,  and  sunshine,  is 
divided  into  two  districts:  the  Riverina  in  New 
South  Wales,  and  the  Darling  Downs.  The  Riverina 
is  the  center  of  the  sheep  farming  industry,  and  con- 
sists of  "undulating  downs  and  rolling  prairies, 
destitute,  for  the  most  part,  of  trees  or  grass,  but 
producing  large  quantities  of  the  salt-bush,  which 
affords  excellent  fodder  for  sheep."  To  the  west  of 
this  region  is  the  great  central  Desert,  and  to  the 
east  is  the  Darling  Downs.  The  summer  heat  is 
severe,  the  thermometer  occasionally  rising  to  110°  F., 
but  on  account  of  the  extreme  dryness  it  is  not  much 
felt.  "  Hot  winds  and  dust  storms  are  frequent, 
but  days  of  still,  cloudless  sunshine  form  the  rule  in 
summer."  "In  winter  there  is  a  little  morning 
frost,  but  the  midday  is  always  warm.  Autumn  and 
spring  present  an  almost  ideal  perfection  of  climate." 
Accommodations  are  afforded  in  the  towns,  and 
"almost  every  squatter's  house  has,  or  has  had  its 
invalid  visitant."  There  is  railroad  connection  with 
Sydney  and  Melbourne  from  this  district.  The 
average  rainfall  is  fourteen  inches  or  less. 

The  Darling  Downs,  in  Queensland,  to  the  north- 
east of  the  Riverina  plain,  have  an  elevation  of  2,000 
feet  and  are  somewhat  cooler  and  less  exposed  to  the 
hot  winds;  otherwise,  the  climatic  characteristics 
are  similar  to  those  of  the  Riverina.  The  range  of 
temperature  is  small,  and  so  is  the  rainfall.  Droughts 
are  not  infrequent  in  these  inland  plains,  and  Hann 
mentions  the  report  of  a  reliable  person,  that  at  a 
station  in  Darling,  it  had  not  rained  for  thirty 
months.  At  times  much  suffering  is  caused  by  the 
drought. 

The  inland  regions  of  Australia  offer  undoubted 
favorable  conditions  for  early  cases  of  tuberculosis, 
such  as  have  "pastoral  tastes,"  as  Williams  says, 
and  "  who  are  prepared  to  spend  years  in  the  recovery 
of  their  health."  To  anyone  in  America,  however, 
the  great  southwestern  plains  of  the  United  States — 
Arizona,  New  Mexico,  portions  of  Texas,  or  the 
plateau  of  Mexico — offer  similar,  if  not  more  favor- 
able, climatic  conditions  nearer  at  hand. 

For  further  information  regarding  Australia  and 
its  climate,  the  reader  is  referred  to  Lindsay's  "Cli- 
matic Treatment  of  Consumption,"  London,  1887; 
Williams' "Aero-Therapeutics,"  London,  1S94;  the 
"Encyclopaedia  Britannica,"  1911;  and  "Climatology 
and  Health  Resorts"  by  Weber  and  Hinsdale,  1901; 
to  all  of  which  the  writer  is  indebted  for  much  of  the 
above  information.  Edward  O.  Otis. 


Autogamy. — A  reproductive  process  occurring  in 
protozoans  in  which  "secondary  nuclei"  are  formed 
from  idiochromidia,  and  there  is  also  sometimes  a 
differentiation  into  somatic  and  germ  nuclei.  The 
secondary  masses  of  idiochromidia  in  an  individual 
animal  fuse  in  pairs,  a  sexual  union,  and  then  become 
encysted.  Such  a  process  occurs  in  Entamoeba.  See 
Protozoa.  A.  S.  P. 


777 


Autointoxication 


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Autointoxication. — This  term  is  employed  in  a 
very  comprehensive  as  well  as  somewhat  indefinite 
fashion,  for  the  subject  which  it  denotes  is  specula- 
tive in  character  rather  than  strictly  scientific.  Thus 
intestinal  autointoxication  is  a  condition  sui  generis 
which  has  no  connection  with  other  forms  of  so-called 
self  poisoning.  The  term  food  poisoning  usually 
implies  that  the  toxic  substances  are  entirely  exo- 
genous— that  they  preexist  ready  formed  in  the 
food.  It  is  however  confidently  asserted  that  the 
cleavage  products  of  food,  especially  of  protein, 
formed  in  ordinary  digestion,  comprise  some  essen- 
tially toxic  substances,  and  that  these  are  rendered 
harmless  ordinarily  by  conjugation  or  pairing. 
Should  the  latter  for  unknown  reasons  fail  to  occur, 
there  would  be  free  toxie  material  formed  in  the 
intestine.  In  some  alleged  cases  of  ptomaine  poison- 
ing, in  which  the  accused  food  showed  no  evidence 
of  decomposition,  this  possibility  of  toxic  non-con- 
jugated cleavage  products  must  be  borne  in  mind. 
Technically  this  represents  a  type  of  autointoxica- 
tion, for  the  poisons  should  be  formed  within  the 
digestive  tract.  In  intestinal  auto-intoxication  of 
another  type,  in  which  the  symptoms  are  likewise 
acute,  the  question  of  anaphylaxis  enters;  and  we 
know  that  anaphylaxis  may  be  transmitted  from 
one  generation  to  another,  and  may  become  of 
familial  incidence.  Under  this  influence,  even  the 
blandest  substances  may  cause  violent  gastroenteric 
irritation,  the  mucosa  being  supersensitive  to  the 
contact  of  substances  which  do  not  disturb  the  ordi- 
nary subject.  Very  little  is  known  of  the  character 
of  the  substances  which  cause  these  manifestations. 
From  the  analogy  of  drug  anaphylaxis  we  infer  that 
they  are  definite  chemical  compounds,  chiefly  con- 
taining nitrogen — akin  in  fact  to  ptomaines.  Many 
cases  of  food  poisoning  so  called  are  clearly  anaphy- 
lactic in  character,  the  subject,  or  perhaps  some  of  his 
ascendants,  having  previously  become  sensitized  to 
the  action  of  the  toxic  substance. 

A  third  somewhat  theoretical  form  of  acute  or 
subacute  intestinal  autointoxication  is  believed  to 
be  due  to  absorption  of  the  end-products  of  intestinal 
putrefaction,  especially  in  intestinal  insufficiency, 
which  are  prevented  from  escaping  by  the  natural 
outlet.  This  somewhat  speculative  condition  is  known 
as  stercoremia.  In  extreme  cases  the  systemic  reaction 
is  similar  to  that  in  ptomaine  poisoning.  The  syn- 
drome associated  often  with  constipation — headache, 
mental  depression,  etc. — is  sometimes  spoken  of  as 
mild  stercoremia.  Experiments  on  animals  in  which 
the  intestine  is  ligated  have  shown  that  actively  toxic 
substances  are  formed  in  the  intestine.  The  condition 
known  as  cholemia,  due  to  disturbed  excretion  of  bile, 
may  be  thought  of  in  this  connection.  This  general 
type  of  intestinal  autointoxication,  however,  stands 
in  a  definite  relationship  with  the  self  poisoning  due 
to  defective  elimination  to  be  dealt  with  later. 

We  may  now  consider  quite  a  different  type  of 
intestinal  autointoxication;  to  wit,  one  eminently 
chronic,  producing  its  harmful  effects  only  after 
many  years.  This  is  highly  speculative  in  character, 
and  in  recent  years  has  been  greatly  exploited  as 
the  cause  of  premature  senility.  The  accused  sub- 
stances are  the  result  of  putrefaction  of  protein,  and 
are  universally  present  in  the  intestine,  from  which 
they  are  taken  up  in  the  blood  and  excreted  by  the 
kidneys.  The  constant  presence  in  excess  of  these 
substances,  generally  known  as  indoxyl,  sulpho-con- 
jugated  acids,  etc.,  is  believed  to  be  the  most  fruit- 
ful cause  of  arteriosclerosis.  The  amount  of  these 
substances  in  the  urine  is  usually  the  measure  of 
the  degree  of  intestinal  putrefaction.  One  set  of 
authorities  would  eliminate  these  substances  in  excess 
from  the  intestine  by  diet,  while  Metchnikoff  and  his 
school  seek  to  prevent  their  formation  by  encouraging 
lactic  acid  fermentation  in  the  intestine.  (See  Auto- 
intoxication, Intestinal.) 

778 


From  intestinal  autointoxication  we  pass  to  another 
form  due  to  incomplete  metabolism  or  oxidation 
In  theory  all  nitrogen  which  requires  expulsion  from 
the  body  should  be  in  the  form  of  urea.  If  this  proc- 
ess is  slow,  incomplete,  or  disordered,  a  host  of  inter- 
mediate substances  may  be  formed  which  are  believed 
to  be  more  or  less  toxic,  to  the  extent  of  setting  up 
types  of  disease.  This  sort  of  autointoxication,  how- 
ever, is  discussed  fully  elsewhere — under  Gout  and 
Metabolism. 

Another  conception  of  autointoxication,  differing 
radically  from  any  of  the  preceding,  is  bound  up  in 
the  fact  that  the  internal  secretions  or  hormones 
which  preside  over  many  of  the  functional  activities 
of  the  body,  are  essentially  toxic  when  produced  in 
excess  or  when  the  natural  physiological  antagonists 
are  not  present  to  neutralize  them.  Some  of  these 
substances  when  extracted  from  the  proper  organs 
are  found  to  possess  a  toxicity  which  is  never  exerted 
in  the  state  of  nature  upon  the  individual  who 
secretes  it.  A  familiar  example  of  a  toxic  substance 
produced  by  an  individual  and  toxic  to  the  latter  is 
seen  in  Graves'  disease,  in  which  an  excess  of  thyroid 
secretion  sets  up  a  well-known  toxic  syndrome.  Were 
it  not  for  the  natural  antagonists  or  correctives,  all 
of  the  enzymes  and  other  physiological  principles 
would  produce  toxic  or  destructive  effects.  This 
subject  is  considered  under  Thyroid,  Thymus,  Pan- 
creas, Suprarenal  Glands,  etc. 

Finally,  there  remains  to  be  considered  autointoxi- 
cation from  defective  renal  and  hepatic  excretion 
which  is  summed  up  under  uremia  and  cholemia,  and 
the  cognate  subject  of  the  autointoxication  of  preg- 
nancy which,  however,  constitutes  a  subject  apart. 

Still  another  type  of  antointoxication  is  fatigue 
poisoning  which  is  considered  in  the  article  with  this 
title.  These  do  not  exhaust  the  subject,  for  there  are 
a  number  of  detached  viewpoints,  such  as  the  tox- 
icity of  urine,  blood,  sweat,  etc.,  of  healthy  and 
diseased  subjects.  There  is  the  matter  of  cytotoxic, 
involving  the  essential  toxicity  of  organ  extracts  to 
animals.  The  original  doctrine  of  Bouchard  in  drill- 
ing with  autointoxication  was  the  demonstration 
of  the  toxicity  of  animal  fluids  to  experiment 
animals.  Diabetes  with  its  terminal  acidosis  fur- 
nishes an  admirable  example  of  autointoxication  in 
which,  as  a  result  of  defective  metabolism,  a  normal 
food  substance  exerts  toxic  activity.  It  is  not  worth 
while  to  pursue  to  its  limits  the  subject  of  autointoxi- 
cation, for  it  would  come  to  mean  almost  the  whole 
of  pathology.  Edward  Preble. 


Autointoxication,  Gastrointestinal.  —  Autointoxi- 
cation may  be  defined  as  a  state  of  poisoning  of  the 
organism  by  products  arising  during  the  physical  life 
processes  of  the  organism.  Gastrointestinal  autoin- 
toxication, which  is  the  narrower  subject  of  this 
article,  includes  all  those  intoxications,  the  sources 
of  which  are  found  in  the  normal  or  abnormal 
processes  that  take  place  in  the  gastrointestinal  tract 
and  its  appendages;  these  processes  include  the  usual 
chemicophysical  changes  that  take  place  in  the  food 
during  its  digestion  as  well  as  the  products  due  to  the 
life  activity  of  the  microorganisms  that  inhabit  the 
digestive  canal.  It  will  be  seen  that  our  definition 
at  once  excludes  such  pathological  states  as  are  due 
to  poisons  accidentally  introduced  into  the  body, 
or  to  processes  not  usually  encountered  in  the 
organism,  such,  for  example,  as  occur  because  of  the 
successful  invasion  of  the  organism  by  infectious 
agents  of  disease.  It  is  true,  of  course,  that  every 
clinical  picture  of  an  infectious  disease,  accompanied 
by  a  toxemia,  is  a  picture  of  autointoxication  as 
well,  because  of  the  failure,  complete  or  partial,  of 
the  usual  defensive  and  excretory  functions  of  the 
organism,  now  overcome  by  the  toxins  of  disease. 
The   latter,    however,   are    the  dominant  factors  in 


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Autointoxication, 
Gastrointestinal 


ich   cases,   and   they    will    be    excluded    from    our 
msideration. 

In  treating  of  gastrointestinal  autointoxication 
e  have  the  digestive  ferments  and  juices,  the 
ni-mal  and  abnormal  products  of  digestion,  and  the 
ormal  and  abnormal  products  of  bacterial  activity 
,  consider. 

It  has  been   pretty   conclusively   shown   that   the 

igestive  juices  when  introduced  into  the  blood  of 

[mals  prove  very  toxie.     Charrin  states  that  the 

istric  juice  of  a  dog  produces  in  a  rabbit  death 

ceded    by    spasms    and    convulsions.     Pancreatic 

lice  leads  to  lowering  of  blood  pressure,  respiratory 

tnbarrassment,  convulsions,  and  finally  death.     The 

iwcrful  ferments  contained  in  such  juices  may  lie 

artially    responsible;    that    they   are    not    the    only 

ictors  is  shown   by   the  fact   that  boiled  digestive 

i ices   are    likewise   somewhat    toxic.     It   has   been 

uggested    that    the   toxie   action    of   such   material 

lay  be  due  to  the  products  of  digestion  of  the  small 

mount  of  protein  matter  which  is,  of  course,  present 

11    all    digestive    juice.     Clinically,    the    destructive 

ction  of  pancreatic  juice  in  acute  affections  of  the 

lancreas,  and  the  highly  irritant  action  of  free  bile 

n  the  peritoneum,  as  well  as  the  toxic  symptoms 

ccompanying  jaundice,  are  well  known. 

It  is  very  doubtful,  however,  whether  any  auto- 

ntoxication  is  traceable  to  the  digestive  juices.     The 

erments  undergo  destruction  during  digestion;  the 

alivary  ferments  are  destroyed  by  pepsin  and  hydro- 

hloric  acid,   pepsin  itself  is  destroyed  by   trypsin. 

iVhile  bile  or  its  elements,  when  they  reach  the  tis- 

;ues  or  are   introduced   into   the  blood,   have   been 

hown    to    be    toxie    clinically  and    experimentally, 

n  the  normal  course  of  digestion  bile  is  changed  in 

he  intestines  and  certain  of  its  elements  are  regularly 

eabsorbed   without    giving    any    evidence    of    ever 

laving  any  toxic  effect. 

What  has  been  said  of  trypsin  and  pepsin  holds 
rue  of  the  ferments  contained  in  the  intestinal  juice. 
Such  juice  is  toxic  when  introduced  into  the  cir- 
nlating  blood  of  animals,  but  such  toxicity  may  be 
;lue  to  products  of  digestion  as  well  as  to  the  ferments. 
That  such  entrance  of  intestinal  juice  into  the  cir- 
culating lymph  or  blood  takes  place  in  autointoxica- 
tion has  not  been  shown. 

It  may  be  concluded  that  the  digestive  juices  and 
other  elements  of  the  secretion  of  the  gastrointesti- 
nal tract  add  to  the  toxicity  of  the  intestinal  con- 
tents, but  that  they  do  not  play  any  role  in  causing 
autointoxication. 

It  is  certain  that  various  intermediate  and  final 
products  of  digestion  of  the  usual  foodstuffs  are 
toxic.  Albumoses  and  peptones  have  produced 
acute  poisoning  in  animals  when  administered  sub- 
cutaneously  or  through  the  circulation;  what  is 
more  important  from  our  standpoint,  peptone  has 
proved  to  be  very  irritant  when  introduced  directly 
into  the  gastrointestinal  canal.  Such  further  prod- 
ucts of  digestion  of  proteins  as  no  longer  give  the 
biuret  reaction  have  likewise  been  shown  to  be  fairly 
toxic  to  animals.  This  question,  however,  is  bound 
with  the  problem  of  disturbances  of  intermediary 
metabolism  and  does  not  belong  directly  to  our 
subject. 

We  now  come  to  the  processes  of  fermentation 
and  putrefaction  upon  which  has  been  built  the 
theory  of  gastrointestinal  autointoxication  by  Bou- 
chard and  his  followers.  It  may  be  stated  at  the 
outset,  that  while  the  possibility  of  mammalian  exist- 
ence without  the  intervention  of  bacterial  activity 
in  the  digestive  tract  may  have  been  shown  by  some 
experimental  data  and  by  the  examination  of  the 
gastrointestinal  contents  of  animals  of  the  Arctic 
Zone,  the  normal  human  being  harbors  an  enormous 
number  of  bacteria  of  many  varieties  in  his  alimentary 
canal,  and  their  activity  is  as  much  a  part  of  the  di- 
gestive process  as  the  action  of  the  digestive  juices. 


Strassburger  lias  shown  thai  from  one-fifth  to  one- 
third  of  dried  feces  consists  of  bacterial  bodies  and 

Roger  has  enumerated  over  two  hundred  varieties 
of  microorganisms  that  have  been  found  in  the  di- 
gestive canal.  Many  of  the  varieties  are  nol  patho- 
genic; others  are  strongly  pathogenic  for  animals. 
II  is  fairly  certain,  however,  that  most  of  them  pro- 
duce substances  in   the  course  of  their  metabolism 

which  are  partly,  at  least,  re  |i"ii  ible  lor  tin'  l.i  ic 
character  of  human  excreta  and  of  the  content  oi 
I  lie  gastrointestinal  canal.      On  the  <  it  her  hand,  tic  e 

very  substances  probably  react  upon  the  bacteria 
themselves  and  hinder  their  overgrowth  when  they 
reach  a  certain  concentration.     Most  of  the  bacteria, 

though  toxie  outside  of  the  gastrointestinal  canal, 
have  adapted  themselves  to  the  defensive  action  of 
the  body  juices  and  have  become  harmless  to  the 
host.  Iterter  strongly  believes  that  the  chief  sig- 
nificance of  such  "obligate"  intestinal  bacteria  lies 
in  their  potential  capacity  to  check  the  develop- 
ment of  others,  not  adapted  to  the  organism,  perhaps 
casually  introduced  into  it  and  capable  of  causing 
injury.  The  number  and  variety  of  organisms  in 
individual  eases  vary  greatly  and  depend  upon  the 
character  of  the  food,  the  character  of  the  digestive 
juices,  the  mechanical  elements  of  digestion,  and 
finally  the  interaction  of  the  bacteria  between 
themselves. 

From  our  standpoint  the  products  of  bacterial 
activity  in  the  digestive  tract  are  the  important  ele- 
ments. The  processes  of  decomposition  may  be 
divided  into  "fermentative"  or  those  involving  car- 
bohydrates, and  "putrefactive"  or  those  involving 
the  cleavage  of  proteins  and  allied  substances.  The 
latter  are  much  more  important  because  of  the  tox- 
icity of  the  resulting  products. 

Of  the  products  of  fermentation,  carbonic  acid  gas 
may  be  produced  in  quantities  large  enough  to  result 
in  "flatulence,"  but  cannot  be  looked  upon  as  causa- 
tive of  any  but  strictly  local  disturbance.  More 
important  are  organic  acids,  such  as  lactic,  acetic, 
propionic,  and  butyric,  especially  the  first  two.  In 
sufficient  concentration  these  acids  act  as  local 
irritants,  and  may  cause  vomiting  or  diarrhea.  In 
addition,  if  rapidly  absorbed,  they  may  rob  the  body 
of  alkali  and  thus  favor  acidosis  or  acid  intoxication 
of  the  organism.  "  Beyond  this  fermentative  proc- 
esses probably  play  no  role  in  autointoxication. 

The  products  of  putrefactive  cleavage  include 
inorganic  substances  such  as  ammonia  and  sulphu- 
reted  hydrogen;  compounds  of  the  fatty  series, 
methane  and  methyl  mercaptan;  aromatic  sub- 
stances, phenol,  scatol,  indol;  and  finally  organic 
substances  of  basic  nature  and  indefinite  composi- 
tion, ptomaines,  toxalbumins,  toxins,  etc. 

Ammonia  is  produced  by  many  bacterial  inhabi- 
tants of  the  digestive  tract,  and  locally  may  have  a 
slight  irritant  action.  Numerous  investigators  have 
shown  that  the  blood  of  the  portal  vein  contains 
more  ammonia  than  the  general  circulating  blood, 
the  excess  being  changed  in  the  liver  and  elsewhere 
into  urea.  If  this  detoxieating  action  of  the  liver 
is  impaired,  ammonia  may  be  considered  as  a  pos- 
sible factor  in  autointoxication.  Proof  of  this  pos- 
sibility, however,  is  wanting. 

Hydrogen  sulphide  is  constantly  produced  in  the 
intestines,  the  formation  of  iron  sulphide  with  con- 
sequent dark  color  of  the  feces  after  administration 
of  iron  salts  serving  as  proof  of  its  presence.  In  vitro, 
many  varieties  of  the  intestinal  bacteria  produce 
this  gas  in  abundance.  The  gas  has  been  proved  to 
be  somewhat  toxie  when  introduced  directly  into 
therectumsof  dogs.  Two  actual  conditions — hydro- 
thionemia  and  enterogenic  cyanosis — have  been 
traced  to  the  excessive  formation  of  hydrogen  sul- 
phide in  the  intestines;  these  are  among  the  few 
authentic  varieties  of  autointoxication  and  will  be 
considered  in  the  clinical  section. 

779 


Autointoxication, 
Gastrointestinal 


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Methane  is  formed  in  too  small  a  quantity  to  be 
of  any  import.  Nencki  has  attempted  to  show  that 
mercaptan  is  formed  during  putrefaction  in  the  intes- 
tine and  others  have  proved  that  this  gas  is  toxic 
for  animals.  Still  others,  however,  (Herter)  doubt 
even  the  formation  of  the  gas  in  the  intestines. 
Of  the  aromatic  substances  phenol  and  cresol  are 
found  in  the  intestine  in  small  amounts  at  any  one 
time,  though  the  total  excretion  for  the  twenty-four 
hours  may  be  fairly  high.  The  only  probable  role  of 
these  substances  in  producing  autointoxication  is  the 
damage  to  the  liver  cells  which  are  called  upon  to 
pair  phenol  to  sulphuric  acid,  preparatory  to  its 
excretion  as  phenol  potassium  sulphate  in  the  urine. 

Scatol  behaves  like  indol,  which  is  next  to  be  con- 
sidered, but  is  formed  in  much  smaller  quantities. 
Its  only  significance  may  likewise  be  the  damage  of 
the  liver  consequent  upon  its  detoxication. 

Much  of  the  common  lore  about  autointoxication 
is  bound  up  with  indol  or  rather  with  its  derivative 
indican.  Indol  cannot  be  produced  from  proteins 
without  the  intervention  of  bacteria,  being  derived 
from  the  breaking  down  of  tryptophan.  Its  quantity 
in  the  stools  varies  from  very  small  to  very  large 
amounts  and  it  may  be  looked  upon  as  a  fair  index 
of  the  amount  of  putrefaction  going  on  in  the  intes- 
tine. Indol  in  the  stools,  however,  is  not  of  as 
much  significance  as  indican  in  the  urine,  for  thj 
latter  is  a  measure  of  the  amount  of  indol  that  goes 
through  the  intestinal  wall.  Herter  has  shown 
pretty  conclusively  that  indol  is  toxic  for  animals, 
having  a  distinctly  specific  effect  on  their  nervous 
systems.  Normally,  however,  the  nervous  system  is 
screened  by  the  protective  action  of  the  liver,  and  the 
condition  of  the  latter  organ  and  its  ability  to  oxidize 
indol  may  be  responsible  for  the  variety  of  effects 
accompanying  increased  formation  of  indol  in  tha 
body.  We  shall  return  to  this  subject  in  consider- 
ing indicanuria  clinically. 

We  have  but  to  consider  now  those  bacterial 
poisons  which  have  at  first  been  looked  upon  as  tli2 
specific  causes  of  gastrointestinal  autointoxication, 
namely,  toxalbumins,  ptomaines,  etc.  Putrescin 
and  cadaverin  are  basic  diamins  which  are  produced 
in  the  intestines  under  certain  conditions  (Brieger), 
but  there  is  no  proof  that  these  substances  which  are 
admittedly  toxic  are  found  normally  or  in  the  usual 
cases  termed  "autointoxication."  The  most  inter- 
esting fact  about  these  bodies  is  their  occurrence 
in  the  urine  and  feces  of  patients  suffering  from 
cystinuria  (see  below).  Other  vaguely  defined  bodies, 
that  have  been  described  by  Selmi  as  ptomaines  and 
are  somewhat  related  to  plant  alkaloids,  have  not  been 
studied  sufficiently  or  indeed  their  existence  verified, 
to  see  in  them  the  cause  of  autointoxication.  Brieger 
himself  has  cast  grave  doubt  on  any  relation  between 
these  bodies  and  symptoms  of  poisoning  referred  to 
the  gastrointestinal  canal. 

Of  the  bases,  neurin  and  cholin,  neurin  has  been 
shown  to  be  quite  toxic  and  there  is  some  evidence 
to  show  that  cholin  may  be  formed  in  the  decomposi- 
tion of  lecithin-containing  substances,  as,  for  example, 
eggs.  The  well-known  clinical  fact  that  many  per- 
sons are  very  adversely  affected  by  eggs  in  the  food 
may  find  explanation  in  this  fashion;  however,  the 
newer  observations  on  anaphylaxis  in  general  show 
that  such  idiosyncrasies  are  much  more  complex 
than  mere  susceptibility  to  this  or  that  actual  or 
hypothetical  substance  derived  from  food. 

It  must  be  concluded  from  the  above  review  and 
from  a  study  of  the  voluminous  literature  on  autoin- 
toxication that  very  little  that  is  definite  has  been 
done  in  the  way  of  experimental  proof  of  autoin- 
toxication, and  especially  in  regard  to  the  substances 
that  can  be  accused  of  playing  a  role  in  causing  this 
condition.  It  has  been  shown  that  the  human  feces 
and  human  urine  are  toxic  to  animals;  that  the 
gastrointestinal  tract  contains  substances  that  may 

780 


be  very  toxic  when  introduced  into  the  tissues  or  th< 
circulating  blood  of  animals;  that  occasionally  sub 
stances  are  formed  there  that  have  some  local  in 
jurious  effects,  that  a  few  substances  of  this  natun 
are  absorbed  and  may  prove  injurious  either  by  vir- 
tue of  their  own  toxicity  or  indirectly  by  damagim 
the  organs  concerned  with  their  elimination.  Thesi 
conclusions,  however,  are  far  from  substantiating  thi 
claims  of  Bouchard  and  his  followers,  who  looker 
upon  the  human  body  as  a  "laboratory  of  poisons' 
ever  in  the  danger  of  being  greatly  injured  by  the 
results  of  its  own  life  processes.  They  are  far  fron 
giving  support  to  the  numerous  physicians  who  look 
upon  gastrointestinal  autointoxication  as  a  very 
definite  condition  diagnosed  by  the  study  of  th'i 
stools  or  the  urinary  coefficient.  Instead  it  mav 
be  said  that  the  laboratory  has  given  almost  nothine 
upon  which  to  hang  a  diagnosis  of  this  sort.  W< 
must  therefore  turn  to  those  clinical  observations 
which  seem  to  support  the  doctrine  of  gastrointestinal 
autointoxication. 

It  may  be  stated  at  the  outset  that  the  same 
chaos  reigns  in  the  clinical  aspect  of  gastrointestinal 
autointoxication  as  in  the  laboratory  study  of  it. 
Numerous  physicians,  especially  among  the  French, 
accept  unreservedly  this  diagnosis  and  have  at- 
tempted to  explain  varied  clinical  states  by  the  con- 
dition. Still  others  are  absolutely  sceptical  of  its  ex- 
istence. On  the  other  hand,  everyday  medical  practii :e 
accepts  the  significance  of  autointoxication  from  the 
gastrointestinal  canal  almost  as  an  axiom.  Witness 
the  care  with  which  the  digestive  canal  is  cleansed 
by  various  mechanical  and  medicinal  means  at  the 
outset  of  any  acute  disease;  the  readiness  with  which 
the  clinician  attributes  mild  indisposition,  slight  rise  in 
temperature,  malaise,  any  obscure  untoward  symp- 
tom in  the  course  of  a  prolonged  illness,  to  a  toxemia 
dependent  upon  disturbance  of  the  gastrointestinal 
canal,  upon  constipation,  etc.;  witness  the  improve- 
ment in  symptoms  and  indeed  the  frequent  "cure'' 
consequent  upon  clearing  the  intestinal  canal  of  its 
contents  in  the  course  of  a  short  and  obscure  febrile 
indisposition — a  "  febricula. "  It  may  be  granted,  then, 
from  the  outset,  that  autointoxication  is  a  real  far- 
tor  in  disease;  that,  on  the  other  hand,  its  actual 
role  is  very  difficult  to  estimate;  that  many  condi- 
tions presumably  dependent  upon  it  are  due  to 
other  unknown  causes. 

A  utointoxieation  in  Infants.- — Finkelstein  has  re- 
cently promulgated  the  theory,  founded  upon  nu- 
merous and  thorough  clinical  observations,  that  in 
infants  food  may  become  a  source  of  autointoxication 
not  because  of  the  changes  produced  by  bacterial 
life,  but  per  se,  because  of  a  specific  weakness  of  the 
functions  of  digestion  and  absorption.  Such  poi- 
soning usually  takes  place  in  infants  already  weak- 
ened by  chronic  digestive  disorders  and  is  dependent 
not  so  much  upon  the  proteins  of  the  food,  which 
were  blamed  in  the  recent  past,  but  upon  fats  and  car- 
bohydrates. Bacterial  toxins  are  to  him  only  second- 
ary etiological  factors,  simply  showing  that  the 
digestive  canal  of  infants  suffering  from  insufficiency 
of  nutritive  functions  is  a  very  favorable  field  lor 
the  growth  of  various  more  or  less  pathogenic  organ- 
isms. His  evidence  for  blaming  food  rather  than 
bacteria  he  finds  in  the  very  direct  relation  between 
the  administration  of  an  excess  of  fats  or  carbohydrates 
and  the  appearance  of  toxic  symptoms;  in  the  fre- 
quently favorable  effect  of  diminishing  these  elements 
in  the  food;  in  the  total  absence  of  any  specific  bac- 
terial infections  of  the  gastrointestinal  canal  of  in- 
fants thus  affected,  and  finally,  in  the  absence  of 
any  symptoms  of  intoxication  in  numerous  infants, 
in  whom  bacterial  processes  seem  to  be  quite  marked, 
but  who  do  not  suffer  from  the  specific  intolerance  for 
certain  food  elements. 

The  following  symptoms  have  been  named  by 
Finkelstein  as  signs  of  autointoxication   from  food 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Autointoxication, 
Gastrointestinal 


Hong  infants:  (1)  Disturbances  of  consciousness 
aging  from  men'  torpor  to  coma;  (2)  changes  in 
spiration,  with  irregularity  and  increase  in  fre- 
iency;  (3)  alimentary  glycosuria;  (4)  fever;  (5)  fall 
blood  pressure;  (6)  diarrhea;  (7)  albuminuria,  and 
en  the  appearance  of  casts  in  the  urine;  (8)  loss  of 
light;  (9)  leucocytosis;  (10)  collapse,  not  explain- 

ile  by  oilier  causes. 

Finkelstein's  teachings  have  found  a  great  deal  of 
pport  in  the  observations  of  other  podiatrists  and 
ive  had  a  very  marked  influence  upon  the  practice 
-o-called  artificial  feeding;  fats  and  sugars,  rather 
m  proteins,  being  now  specially  watched,  in  the 
od  mixtures  of  infants  suffering  from  malnutrition. 

res     of    Circulation     and     Respiration.  - 

arious  cardiac  neuroses  have  been  referred  to  the 

fects  of  autointoxication,   especially  by   writers  of 

le   French    school.      Among    these   conditions   have 

i    named    bradycardia,    tachycardia,    pseudoan- 

a,   etc.     The   dependence   of  any   of   these   upon 

1'iiing  from  the  gastrointestinal  canal  has  not  been 

roved.     In    1.S76    Henoch    described    an    "asthma 

t'spepticum"  a    condition    resembling  usual  cardiac 

l  lima  of  patients  suffering  from  insufficiency  of  the 

art:  '■asthma  dyspepticum,"  however,  is  supposed 

p  occur  only  in  persons  suffering  from  gastrointesti- 

d  disturbances,  and  is  improved  or  cured  when  the 

r  are   alleviated.     However,   mechanical  causes, 

ich  as  "high  diaphragm"  because  of  distention  of 

le  stomach  and  intestines  with  gases,  and  complex 

s  conditions  cannot  be  excluded  in  the  etiology 

f  this  affection  and  indeed  they  explain  it  as  well  as 

ny  predicated   poisoning  from   the  gastrointestinal 

mal.     Rapid  evacuation  of  the  stomach  and  intes- 

nes  in  some  eases  has  been  followed  by  immediate 

nprovement  in  symptoms,  and  this  sequence  speaks 

gainst  the  presence  of  absorbed  poisons  in  the  blood. 

Diseases  of  the  Liver  and  Kidneys. — Many  authors 

ave  been  tempted  to  explain  chronic  degenerative 

hanges  in  these  organs  by  the  effects  of  autointoxica- 

on.     Direct  proof,  however,  has  not  been  put  forth, 

hough   there  is   much    that   is  logical   in  supposing 

hat   these  two  great  organs  of  transformation  and 

Hmination  may  suffer  from  small  but  constant  and 

prolonged   damage   consequent   upon   the   action   of 

poisons   absorbed    from    the    gastrointestinal    canal. 

Is  a  general    theory    for    the    explanation    of   liver 

irrhosis   of  obscure  origin,  of  chronic  nephritis,  etc., 

he  idea  of  autointoxication  has  its  strong  points,  but 

t  must  be  understood  that  the  poisons  supposedly 

tive  in  the  case  have  not  been  isolated  and  very 

ittle  experimental   evidence   to  support   the   theory 

"ecu  adduced;  moreover,a  great  many  cirrhotics 

.nd  nephritics,  who  show  no  cause  for  their  condi- 

ion  in  their  history  or  physical  state,  likewise  show 

10  symptoms  that  can  be  interpreted  as  evidence  of 

issive  gastrointestinal   putrefaction    or   fermenta- 

ion.     The   explanation   of   such   chronic  conditions, 

herefore,  remains  a  mystery  still. 

Neuroses  and  Psychoses. — It  is  not  surprising  that 
uitointoxication  should  have  been  looked  upon  as  a 
lossible  cause  of  nervous  and  psychic  disturbances, 
,vhen  it  is  remembered  how  obscure  is  the  etiology 
if  such  conditions.  Chorea,  migraine,  neurasthenia, 
•ecurring  vertigo,  epilepsy,  etc.,  have  been  explained 
n  this  fashion,  and  it  cannot  be  denied  that  disturb- 
inces  of  the  gastrointestinal  tract  have  much  to  do 
n*ith  exacerbations  in  the  course  of  some  of  these 
liseases.  However,  the  condition  of  the  digestive 
tract  has  everything  to  do  with  the  state  of  nutrition 
of  the  organism,  and  it  is  probable  that  frequently 
■nough  disturbances  of  absorption  and  assimilation 
cause  increase  in  the  symptoms  of  nervous  and  psy- 
chic disease,  rather  than  the  hypothetical  poisons  of 
autointoxication.  The  truth  probably  is  that  in 
such  conditions  as  migraine,  recurrent  vertigo, 
epilepsy,  etc.,  absorption  from  the  gastrointestinal 
tract  incident  upon  increased  putrefaction  or  upon 


simple  .stagnation  of  feces   be*  an f  constipation 

acts  as  an  exciting  but  not  as  a  primary  can 
explains   the   frequenl    relief  of  symptoms  following 
upon  evacuation  of  the  gastrointestinal  tract  in 
condition     as     migraine.     However,     no     authentic 
"cures"   of   migraine    ha   e    been    demonstrated    by 

any  methods  that    take   the  digl     live  canal  only  into 

consideration. 

Tetany  has  been  pointed  out  by  numerous  authors 
as  a  good  example  of  autointoxication,  being  fre- 
quently accompanied  by  dilatation  of  the  stomach, 
ami  presumably  absorption  of  toxins  from  that  organ. 
that  this  is  not  the  only  can-'-  of  so-called  "gastric 
tetany"  is  evident  from  the  fact  that  this  condition 
is  much  more  frequent  in  certain  Localities,  than  else- 
where, and  among  certain  trades  (tailors  in  Vienna). 
Recently,  the  close  relation  between  tetany  in  gen- 
eral and  the  functions  of  the  parathyroid  glands  has 
been  demonstrated.  It  seems  probable  that  the  pri- 
mary cause  of  this  condition  is  some  insufficiency  of 
the  parathyroids;  the  state  of  the  stomach  may  fur- 
nish the  exciting  cause,  either  because  of  absorption 
of  toxins  or  because  of  rellex  conditions  following  the 
frequently  enormous  distention  of  that  organ.  On  the 
whole,  it  seems  more  logical  to  rank  tetany  with 
diseases  due  to  disturbances  of  internal  secretions  of 
glands,  rather  than  as  a  pure  example  of  gastro- 
intestinal autointoxication. 

Attempts  to  explain  psychoses,  with  their  baffling 
etiology,  by  the  theory  of  autointoxication  have  been 
frequently  made.  However,  no  direct  relation  be- 
tween the  digestive  tract  and  these  diseases  can  be 
shown  and  to  predicate  digestive  toxins  as  the  cause-  of 
them  is,  as  one  author  properly  states,  simply  "to 
explain  the  unknown  by  unknown."  Mere  disorders 
of  digestion  and  of  mechanical  functions  of  the  di- 
gestive tract  are  said  to  be  very  frequent  among  the 
insane,  but  they  may  be  secondary  to  inappropriate 
diet  or  bad  habits  due  to  the  mental  disease  and  not 
the  cause  of  it. 

Discuses  of  the  Blood. — Simple  and  pernicious 
anemia,  leukemia,  chlorosis  have  all  been  looked 
upon  by  some  authors  as  due  to  autointoxication. 
That  absorption  from  the  digestive  canal  is  quite 
sufficient  to  cause  marked  changes  in  the  blood  has 
been  shown  by  the  demonstration  of  the  relation 
between  certain  severe  anemias  and  intestinal 
parasites.  Tallquist  has  even  succeeded  in  isolating 
a  specific  hemolytic  toxin  from  the  body  of  Bothrio- 
cephalic, and  his  observations  have  been  largely 
confirmed.  But,  of  course,  such  anemia  is  not  due 
to  autointoxication  in  the  narrow  meaning  of  the 
word. 

Grawitz  looks  upon  autointoxication  as  a  frequent 
cause  of  pernicious  anemia.  He  points  out  the  fre- 
quent history  of  digestive  disturbances  in  such  cases, 
the  granular  degeneration  of  the  red  cells  which 
speaks  for  the  action  of  some  hemolytic  toxin,  the 
increase  of  indican  in  the  urine,  etc.  The  organic 
changes  in  the  mucous  membrane  of  the  digestive 
tract  and  the  disturbances  of  secretion  may  likewise 
be  looked  upon  as  favoring  the  absorption  of  poisons. 
Moreover,  it  has  been  fairly  clearly  shown  that  great 
improvement  in  the  general  condition  of  patients 
with  pernicious  anemia  as  well  as  a  favorable  change 
in  their  blood  follows  careful  treatment  of  the  diges- 
tive canal  with  gastric  lavage,  frequent  irrigations 
of  the  colon,  the  administration  of  simple  food  least 
apt  to  undergo  putrefaction,  etc.,  etc.  It  is  true 
that  the  blood  of  such  patients  at  no  stage  reaches  a 
perfectly  normal  appearance — prolonged  search  usu- 
ally shows  cells  and  morphological  changes  typical 
of  a  primary  anemia — and  that  they  usually  relapse 
after  the  treatment  has  been  suspended.  However, 
this  does  not  exclude  autointoxication  as  a  possible 
cause  of  the  disease,  for  such  patients  may  suffer 
from  constant  inability  to  protect  themselves  from 
the  poisons  produced  in  the  digestive  canal;  appro- 

781 


Autointoxication, 
Gastrointestinal 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


priate  treatment  takes  the  place  of  such  protection 
for  a  time,  but  only  for  a  time. 

It  may  then  be  granted  that  the  condition  of  the 
digestive  tract  has  a  close  relation  to  the  development 
of  severe  anemia,  it  will  not  be  surprising,  therefore, 
if  a  closer  relation  between  these  will  some  day  be 
discovered;  showing  that  a  specific  infection  of  the 
digestive  tract,  comparable  to  the  effects  of  Bothrio- 
cephalus,  is  responsible  for  this  grave  disease  of  the 
blood. 

Still  more  insistent  is  the  explanation  of  chlorosis 
by  autointoxication  from  the  digestive  tract.  The 
frequency  of  constipation  and  the  increase  of  ethereal 
sulphates  in  the  urine  of  chlorotics  have  been  pointed 
out  as  showing  the  truth  of  such  relation.  More- 
over, laboratory  and  experimental  evidence  has  been 
adduced.  Thus  Forchheimer  claims  to  have  isolated 
peptone-like  bodies  from  the  urine  of  chlorotics, 
whose  origin  he  refers  to  the  imperfect  function  of  the 
gastrointestinal  tract.  He  has  likewise  shown  that  the 
blood  in  the  mesenteric  veins  is  eighteen  per  cent  richer 
in  hemoglobin  than  the  blood  in  the  corresponding 
arteries,  and  he  concludes  that  chlorosis  may  be  due 
to  the  disturbance  of  a  hemoglobin-making  function 
of  the  intestinal  epithelium.  He  has  found  clinically 
that  intestinal  antiseptics  act  very  favorably  on 
the  course  of  the  disease.  The  incidence  of  chlorosis 
at  puberty  is  explained  by  some  authors  by  the 
increased  demand  for  blood  by  the  generative  organs 
with  consequent  diminution  in  the  supply  of  blood 
to  the  digestive  canal;  others  see  a  simple  mechanical 
relation,  pressure  by  the  internal  organs  of  generation 
causing  constipation  and  this,  chlorosis. 

It  must  be  said,  however,  that  all  such  arguments 
are  very  inconclusive.  Constipation  is  so  frequent 
in  young  women  that  its  occurrence  with  chlorosis 
is  not  surprising.  Moreover  many  chlorotic  girls 
are  not  constipated,  though  they  may  suffer  from 
other  disturbances  of  the  digestive  canal.     One  other 

Eoint  is  of  importance:  with  exact  diagnosis,  chlorosis 
as  become  a  much  rarer  condition;  incipient  tuber- 
culosis or  a  latent  gastric  ulcer  has  explained  numerous 
cases  of  severe  anemia  in  young  girls,  who  clinically 
seem  to  have  answered  the  old  conception  of  "green 
sickness." 

Leukemia. — Because  the  digestive  tract  is  fre- 
quently diseased  in  cases  of  leukemia,  gastrointesti- 
nal autointoxication  has  been  suggested  as  a  possible 
cause  for  this  obscure  disease.  However,  numerous 
cases  of  leukemia  run  their  course  without  showing 
any  involvement  of  the  digestive  tract,  and  others 
develop  such  involvement  only  after  the  leukemia 
itself  has  existed  for  a  long  time.  Most  striking  in- 
volvement of  the  tract  is  seen  in  cases  of  acute  leu- 
kemia in  which  degenerative  and  necrotic  changes  are 
found  in  numerous  portions  of  the  mucous  membrane 
from  the  mouth  to  the  rectum.  The  whole  question 
of  leukemia  is,  however,  in  a  transitional  stage,  at 
present,  older  conceptions  being  changed  because  of 
recent  studies  of  the  blood  and  pathological  material. 
Infection  with  some  unknown  organism,  rather 
than  intoxication,  may  explain  the  etiology  of  this 
disease,  acute  instances  of  which  run  a  course  very 
similar  to  that  of  other  severe  infections,  while  chronic 
cases  show  exacerbations  marked  by  fever,  chills, 
great  weakness,  etc.,  that  are  not  incompatible  with 
the  idea  of  a  chronic  infective  process. 

Skin  diseases. — Specific  causative  factors  have 
not  been  found  for  a  great  number  of  skin  diseases 
and  it  was  to  be  expected  that  autointoxication 
should  be  blamed  for  some  of  them.  There  is  no 
question,  indeed,  of  the  close  connection  between 
the  proper  functioning  of  the  skin  and  of  the  digestive 
tract,  and  the  everyday  "hives"  or  urticaria  shows 
what  absorption  from  the  digestive  canal  may  pro- 
duce so  far  as  the  skin  is  concerned.  This  condition, 
however,  seems  more  to  do  with  food  products  per  se 
rather  than  with  results  of  digestion  or  decomposition 


of  food  and  therefore  belongs  more  properly  to  ex- 
amples of  food  poisoning.  We  must  leave  undis- 
cussed, too,  the  more  alluring  hypothesis  of  anaphy- 
laxis, under  which  head  such  idiosyncrasies  as  suscep- 
tibility to  strawberries,  shell  fish,  etc.,  in  the  food  have 
been  classed. 

If  other  conditions,  such  as  eczema,  psoriasis,  etc. 
little  definite  can  be  said.  Indeed,  there  are  I 
schools  of  dermatologists,  one  looking  upon  most 
skin  diseases  as  local  conditions  only,  another  seeinp 
in  them  but  the  evidence  of  disturbance  elsewhere, 
especially  in  the  digestive  tract.  These  two  school 
differ  accordingly  in  the  treatment  recommended. 
No  definite  proof  of  autointoxication  has  been  given 
in  these  chronic  skin  conditions,  and  while  it  may 
be  true  that  in  numerous  instances  regulation  of  the 
digestive  tract  has  led  to  improvement  of  the  ski: 
condition,  it  is  no  less  true  that  numerous  sufferers 
from  eczema,  psoriasis,  etc.,  are  in  the  best  general 
health,  and  show  no  signs  or  symptoms  of  trouble  with 
the  digestive  tract. 

We  shall  now  note  several  rare  conditions  in  which 
the  direct  proof  of  autointoxication  has  been  fairly 
well  established. 

Hydrothionemia. — Violent  gastrointestinal  symp- 
toms have  been  observed  by  Betz,  Senator,  Ewald. 
and  others  in  a  few  patients  in  whom  an  excessive 
amount  of  H„S  was  demonstrated  both  in  the  fei  - 
and  the  urine.  Somewhat  related  are  the  cases  of 
i  nil  rogenous  cyanosis  described  by  Stokvis  and  others: 
in  these  patients,  sulphemoglobin  and  methemoglobin 
were  demonstrated  in  the  blood,  during  attacks  of 
severe  enteritis  accompanied  by  the  clouding  of  con- 
sciousness, prostration,  etc.  Both  these  condition; 
appear  to  be  actual  ones  and  in  them  autointoxication 
seems  to  explain  all  the  facts.  They  are,  however, 
very  rare,  and  this  very  rarity  may  be  used  as  a  good 
argument  against  the  light  acceptance  of  autointoxi- 
cation as  a  cause  of  numerous  other  pathological 
conditions.  Certainly,  if  autointoxication  were  a- 
universal  as  some  authors  believe,  then  typical 
examples  of  it  due  to  one  or  another  specific  element 
should  be  very  frequent.  This,  however,  is  not  at 
all  the  case. 

Acetonuria. — The  appearance  of  acetone  in  the 
urine  occurs  in  several  conditions  and  is  usually 
accompanied  by  nervous  symptoms,  by  disturbances 
of  digestion,  by  vomiting,  etc.  Among  the  clinical 
pictures  showing  this  symptom  may  •  be  named 
coma  dyspepticum,  cyclic  vomiting,  and  sudden  dis- 
turbances in  infants.  However,  neither  the  origin 
of  acetone  in  the  intestinal  tract  has  been  shown  nor 
indeed  its  relation  to  the  symptoms.  There  are 
some  conditions,  in  which  acetone  appears  in  the 
urine  in  large  quantities  and  for  a  long  time  without 
causing  any  such  grave  symptoms  as  coma  or  violent 
vomiting.  It  is  possible,  of  course,  that  acetone  i- 
but  an  index  of  intoxication  in  such  cases,  and 
the  cause  of  it.  It  seems  probable,  too,  that  acetonu- 
ria depends  upon  a  disturbance  of  intermediary 
metabolism  rather  than  intoxication  from  any  proc- 
esses in  the  digestive  tract. 

Cystinuria  and  Diaminuria. — Persons  who  show 
cystin  in  the  urine  are  remarkable  because  of 
presence  of  diamins,  cadaverin  and  putrescin,  in 
their  feces  and  urine.  It  seems  quite  proba 
that  the  appearance  of  these  substances  is  due  to  the 
putrefactive  changes  caused  by  certain  bacteria. 
However,  treatment  of  the  digestive  canal  frequently 
has  no  effect  upon  the  cystinuria,  and  again  some 
patients  have  shown  cystinuria,  indeed,  but  no  evi- 
dence of  intoxication.  In  any  case,  cystinuria  is  a 
very  obscure  and  rare  disturbance  of  metabolism 
and  cannot  be  discussed  here  at  length  without  fur- 
ther reasons  for  classing  it  among  evidences  of  auto- 
intoxication. The  same  may  be  said  regarding 
atcaptonuria.  In  this  connection  we  may  point  out 
that  numerous  conditions,  such  as  uremia,  diabetic 


782 


i:i  1  I  RENCE    HANDBOOK    OF    THE    MEDICAL    si  II  v  ES 


Autolntoxlcatlonf 
Gastrointestinal 


.,, ma,  exophthalmic  goiter,  acute  yellow  atrophy   of 

lu>  liver,  etc.,  etc.,  are  more  properly  autointoxications 

nan  numerous  conditions  we  have  noted,  and  have 

:i  treated  a-  such  by  older  writers  on  the  subject 

Bouchard,     Ubu).     However,    increased    knowledge 

ho    a  that  many  of  these  conditions  are  due  to 

irbances  of  internal  secretions  of  glands,  and  nol 

my  processes  in  the  digestive  tract;  that  othersare 

ily     related     to    disturbances     of     intermediary 

ibolism,    and  not    the  simpler  catabolic  processes 

hat   take  place  during  digestion;  that    still    others, 

<uch  as  uremia,  are  as  obscure  as    they  have  ever 

a   and   should   not   be    without   sufficient    reason 

Deluded     among     autointoxications      such     as     are 

Mered  above.     The  reader  is  referred  to  special 

irticles  in  this  Handbook  on  these  topics. 

Ozaluria. — In  health  only  a  trace  of  oxalic  acid  is 

Bed  in  the  body,  the  greater  part  of  oxalates  in  the 

urine   being   taken   with   the  food.      Many   hold   that 

-dve     oxaluria     is     accompanied     clinically     by 

finite  symptoms  of  nervous  irritability,  lassitude. 

melancholia,  etc.     Actually,  the  oxalates,  if  deposited 

ire  the  urine  is  voided,  may  cause  irritation  of  the 

urinary  tract  and  form  calculi.     Osier  thinks  that  the 

symptoms    accompanying    oxaluria    are    dependent 

upon    some    disturbance    of    metabolism    of    which 

oxaluria  is  one  of  the  manifestations.     It  is  frequently 

found  in  gouty  persons. 

Indicanuria. — We  are  discussing  this  symptom 
specially  because  of  the  importance  which  has  been 
attached  to  it  in  the  diagnosis  of  autointoxication. 
Herter  says  that  the  term  "indicanuria"  is  used  to 
pate  the  presence  of  an  abundance  of  indican 
in  the  urine  as  demonstrated  by  strong  reaction  on 
the  use  of  Obermayer's  or  similar  tests.  Normal 
children  and  many  adults  never  show  indican  in  the 
urine;  many  apparently  perfectly  healthy  individuals 
show  indican  frequently;  finally,  some  persons  show 
at  times  intense  reactions  with  Obermayer's  reagent, 
and  Herter  thinks  that  such  persons  are  seldom 
free  from  clinical  evidences  of  intestinal  disorder  and 
may  show  evidences  of  intoxication  as  well.  The 
symptoms  in  various  individuals  differ  very  much, 
however,  and  the  probable  explanation  is  to  be  found 
in  the  different  ability  of  individual  organisms  of 
disposing  of  indol  by  oxidation.  As  the  oxidizing 
power  of  the  cells  seems  to  diminish  with  the  advanc- 
ing age  of  the  individual,  Herter  thinks  that  older 
persons,  especially  those  over  fifty,  are  more  liable 
to  suffer  from  the  production  and  absorption  of  indol. 
Moreover,  the  state  of  such  organs  as  the  liver  and 
kidneys  has  much  to  do  with  the  effects  of  indol, 
for  upon  their  integrity  depends  the  defence  of  the 
organism;  it  may  be  inferred  that  a  patient  with  a 
cirrhosis  of  the  liver  or  a  chronic  nephritis  will  show 
more  symptoms  in  the  presence  of  indicanuria  than 
an  otherwise  healthy  organism.  Indicanuria,  there- 
fore, while  surely  a  sign  of  the  existence  of  intestinal 
putrefaction,  must  be  judged  in  connection  with 
other  evidences  of  health  or  disease  of  the  individual. 
(For  a  further  discussion  of  the  indolic  type  of  intes- 
tinal putrefaction  the  reader  is  referred  to  the  very 
•  stive  monograph  of  the  late  Christian  A.  Herter. 
led  "The  Common  Bacterial  Infections  of  the 
Digestive  Tract.") 

In  conclusion  mention  must  be  made  of  perhaps 
the  most  striking  application  of  the  theory  of  auto- 
intoxication, recently  put  forth  by  the  Franco- 
Russian  savant,  Metchnikoff.  He  has  tried  to  show- 
that  old  age  is  nothing  but  the  consequence  of  gradual 
and  continuous  deterioration  of  tissues  by  the  poisons 
absorbed  from  the  gastrointestinal  tract.  According 
to  him,  the  products  of  bacterial  activity  are  the 
important  poisons  of  this  nature,  and  this 
explains  the  comparatively  early  old  age  and  short- 
ness of  life  in  mammals  whose  digestive  tract  is  most 
abundantly  supplied  with  various  bacteria.  Metch- 
nikoff saw   the  futility  of  trying  to  get  rid  of  such 


bacteria  in  the  human  being  by  the  use  of  drug-  or 
by  mechanical  mea  refore  proposed  1  he 

use  in  the  diet  of  milk  soured  by  a  certain  specie*  of 
bacilli,  with  the  hope  that  these  bacilli  will  gain  foot- 
hold in  the  11, 1,    tinal  canal  and  replace  tl 
factive  organisms.     Metchnikoff 'a  theory 
zenith  a  year  or  two  ago,  and  milk  soured  by  vai 
cultures  of  lactic  acid  formers,  as  well  as  puri 

of    such    bacilli,    were    widely    used    in    therapy.       We 

believe  the  general  consensus  of  opinion  is  aga 
Metchnikoff 's  theory;  there  is  no  question   that 
work  has  popularized  in   the   Western  world  thi 
of   variously    soured    nailka   so    long   and    favorably 
known  in  the  East,  but  it  ha     no  ived  that 

the  bacilli  thus  introduced  into  the  intestinal  canal  re- 
its  usual  inhabitants.    Frequently,  however,  the 
■  of  such  milk  or  of  pure  cultures  of  the  bacilli,  ex- 
erts a  gooil  effect  on  various  symptoms,  constipation 

for  instance.  Quite  recently  Metchnikoff  himself  lias 
admitted  the  failure  of  his  former  method  by  pro- 
posing to  use  bacilli  derived  from  the  digestive  canal 
of  the  dog,  in  conjunction  with  the  Bulgarian  bacilli, 
in  the  therapy  of  gastrointestinal  autointoxication. 

It  may  be  concluded  from  this  brief  review,  that 
little  scientific  proof  has  been  adduced  to  show  that 
absorption  of  poisons  from  the  gastrointestinal  tract 
is  frequently  responsible  for  pathological  states  of  the 
organism.  Such  poisons  as  have  been  isolated  have 
not  been  brought  into  relation  with  clinical  symp- 
toms, outside  of  a  few  rare  conditions;  the  bacteria 
of  the  digestive  tract  have  been  shown  to  be  for  the 
most  part  harmless  inhabitants  of  the  tract,  the 
organism  having  adapted  itself  to  their  existence. 
The  attempt  to  explain  obscure  diseases,  or  common 
conditions  of  unknown  origin,  such  as  diseases  of  the 
blood  or  chronic  degenerations  of  the  fiver  and 
kidney,  by  the  effects  of  autointoxication,  has  failed. 

On  the  other  hand,  the  development  of  our  knowl- 
edge of  the  role  of  bacteria  in  disease  has  cleared  up 
many  conditions,  showing  them  to  be  specific  infec- 
tions, and  not  intoxications.  The  better  under- 
standing of  immunity  has  shown  that  the  organism 
has  much  more  to  fear  from  occasional  invaders  of  its 
tissues  than  from  the  constant  inhabitants  of  the 
digestive  tract,  however,  pathogenic  these  may  prove 
to  animals.  Friedrich  Midler  very  properly  points 
out  the  analogy  between  such  accidental  infections 
of  the  gastrointestinal  system  and  the  condition  of 
affairs  in  a  puerperal  uterus;  the  latter  is  not  affected 
by  numerous  organisms  in  the  vagina  and  cervix, 
while  a  foreign  streptococcus  introduced  by  the  hand 
or  instruments  of  physician  or  midwife  causes  intense 
inflammatory  reaction  and  general  poisoning  of  the 
whole  organism. 

The  increased  understanding  of  the  importance 
of  the  glands  furnishing  an  internal  secretion  has 
brought  us  to  realize  that  numerous  obscure  con- 
ditions, which  have  formerly  been  explained  as  con- 
sequences of  autointoxication,  are  due  to  some 
perversion  of  function  of  such  glands.  Tetany, 
exophthalmic  goiter,  and  myxedema  have  been  ex- 
plained in  this  fashion.  Furthermore,  such  diseases  as 
diabetes  and  gout  have  been  firmly  established  as 
dependent  upon  anomalies  of  intermediate  metabo- 
lism, and  only  indirectly  affected  by  the  processes  in 
the  digestive  tract  alone.  Still,  what  Brieger  calls  the 
"compulsion  (Zwang)  of  clinical  observations"  must 
lead  to  the  admission  that  absorption  of  toxins  from 
the  gastrointestinal  tract  is  a  common  condition  and  is 
responsible  for  various  indefinite  symptoms  accom- 
panying chronic  constipation,  gastric  and  intestinal 
etory  disturbances,  and  diseases  of  the  pancreas, 
liver,  kidneys,  and  other  organs  of  detoxication  and 
elimination.  But  the  effects  of  such  absorption  are 
general  and  not  specific,  and  the  agents  responsible  for 
the  untoward  symptoms  are  more  subtle  than  our 
present  methods  of  investigations  can  discover.  It 
must  therefore  be  accentuated  that  the  older  methods 

783 


Autointoxication, 
Gastrointestinal 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


of  studying  autointoxication  by  the  determination  of 
the  toxicity  of  the  intestinal  contents,  of  the  excreta, 
or  of  the  nrine  are  not  adapted  to  clear  up  the  problem, 
and  diagnosis  of  autointoxication  on  such  basis  has  no 
firm  foundation  in  fact.  Other  methods  must  be  dis- 
covered for  determining  the  causative  factors  in  such 
actual  slates  of  autointoxication  as  are  present  in 
constipation,  intestinal  obstruction,  and  copremia  of 
any  nature;  what  these  methods  will  be  remanis  to  be 
seen. 

B.    MlCHAILOVSKT. 
Bibliography. 

Bouchard:  Lectures  on  Autointoxication  in   Disease.     Second 
revised  Edition,  1906.     F.  A.  Davis  Company,  Philadelphia. 

Albu:    Ueber    die    Autointoxicationen     des    Intestinaltractus. 
Hirschwald.  Berlin,  1895. 

Miiller  and  Brieger:  Autointoxicationen  intestinalen  Ursprungs. 
Vcrhandlungen  des  xvi  Kongress  fur  Innere  Medizin. 

Weintraud:  Gastrointestinale  Autointoxication.    Lubarsch  und 
Ostertag's  Ergebnisse  der  Pathologie,  Wien,  1897. 

A.  Combe:  Intestinal  Autointoxication,  Translation  by  W.  G. 
States.     Rebman  Company,  New  York,  1908. 

Alonzo  E.  Taylor:  Autointoxications.     Modern  Medicine,  vol.  i. 

v.  Korenchevsky:  Gastrointestinal  Autointoxication.     Moscow, 
1909  (Russian  text). 


Autolysis. — Synonyms. — Autodigestion,  self-diges- 
tion, autocytolysis. 

Definition. — The  digestion  of  cells,  protoplasm,  or 
the  proteins  of  body  fluids,  by  the  enzymes  which  they 
normally  contain. 

As  the  first  step  in  the  discovery  that  living  cells 
may  contain  enzymes  capable  of  digesting  proteins, 
may  be  counted  the  old  observation  that  ameeba?  are 
able  to  digest  solid  masses  of  protoplasm  that  they 
have  engulfed,  by  virtue  of  digestive  enzymes  con- 
tained within  their  own  cytoplasm.  The  next  step 
was  the  observation  by  Hoppe-Seyler,  in  1871,  that 
the  dead  tissues  within  the  body  may  undergo 
liquefaction  without  putrefaction,  and  that  the  proc- 
ess resembles  the  action  of  the  digestive  enzymes. 
It  was  not  until  1890  that  the  real  nature  of  autolysis 
was  first  brought  out  by  Salkowski,  who  showed  that 
the  softening  of  dead  tissues  preserved  from  putre- 
faction was  a  true  process  of  digestion  brought 
about  by  intracellular  proteolytic  enzymes,  and 
yielding  tyrosin  and  leucin  just  as  in  pancreatic 
digestion.  But  little  more  work  was  done  upon  this 
subject  until  1900,  when  it  was  again  opened  up  by 
the  studies  of  Jacoby,  and  since  that  time  it  has  been 
investigated  extensively  and  with  very  fruitful 
results. 

Autolysis  is  generally  studied  by  the  method  first 
used  by  Salkowski,  which  depends  upon  the  fact  that 
the  bacteria  of  putrefraction  may  be  held  in  check  by 
certain  antiseptics  that  have  relatively  little  injurious 
influence  upon  the  enzymes.  The  common  method 
of  procedure  is  to  grind  up  the  organs  or  cells  that  are 
to  be  examined  to  a  fine  pulp,  place  the  mass  in  flasks 
after  diluting  with  water,  salt  solution,  or  very  dilute 
acid  solution,  and  then  add  the  antiseptic.  Toluol, 
chloroform,  and  thymol  are  most  commonly  used,  but 
comparative  studies  seem  to  show  that  of  these  toluol 
has  the  least  depressing  effect  upon  the  autolytie 
processes.  It  is  also  possible  to  secure  tissues  in  an 
aseptic  condition  and  permit  them  to  autolyze  aseptic- 
ally  without  the  presence  of  antiseptics;  the  rate  of 
autolysis  under  these  conditions  is  more  rapid  than 
in  antiseptic  autolysis,  but  the  practical  difficulties 
are  so  great  that  it  is  employed  but  relatively  little. 
Autolysis  proceeds  most  rapidly  if  the  material  is 
kept  at  body  temperature,  but  will  go  on  slowly 
even  at  nearly  the  freezing-point,  as  shown  by  the 
slow  "ripening"  of  meat  in  storage,  which  is  an 
autolytie  process.  The  presence  of  any  substances 
that  will  impair  or  destroy  ordinary  proteolytic  enzy- 
mes will  prevent  autolysis,  e.g.  formalin,  alcohol, 
bichloride  of  mercury,  etc.     To  determine  the  rate  or 


amount  of  autolysis  the  usual  method  employed  is 
to  heat  the  autolyzing  material  to  boiling  at  the 
close  of  the  experiment,  filter,  and  determine  the 
proportion  of  the  total  nitrogen  that  is  in  a  soluble 
non-coagulable  form;  this  figure  can  then  be  com- 
pared with  the  results  obtained  from  control  specimens 
that  have  been  first  heated  to  destroy  the  enzymes 
and  thus  the  amount  of  disintegration  of  the  tissue 
proteins  into  soluble  substances  can  be  estimated. 
Another  method,  suitable  for  many  kinds  of  studies 
has  been  advocated  by  Wells  and  Benson;  this  con- 
sists in  estimating  the  amount  of  changes  in  the 
freezing-point  and  the  electrical  conductivity  of  the 
autolyzing  mixture,  which  are  greatly  modified  during 
the  course  of  the  digestion  because  of  the  conversion 
of  the  large  molecular  complexes  of  protoplasm  into 
smaller  crystalloidal  molecules  that  increase  the  con- 
ductivity and  depress  the  freezing-point.  The  latter 
method  is  particularly  advantageous  where  the 
amount  of  material  available  is  limited,  and  where 
large  numbers  of  determinations  must  be  made  for 
the  plotting  of  curves. 

One  may  also  determine  by  analysis  the  proportion 
of  proteoses,  peptones,  and  free  amino  acids;  the 
formalin  titration  method  of  determining  amino  acids 
is  especially  useful.  Some  cellular  enzymes,  espe- 
cially those  of  leucocytes,  can  be  demonstrated  by 
their  digestive  action  upon  serum  plates  kept  at  55° 
to  60°  C.1 

Since  the  publication  of  Jacoby's  paper  awakened 
interest  in  the  subject  of  autolysis,  extensive  investi- 
gations have  been  made  by  many  workers,  who  have 
demonstrated  that  the  property  of  autolysis  is 
inherent  in  every  cell,  whether  animal  or  vegetable, 
including  not  only  the  actively  metabolizing  cells  of 
such  organs  as  the  liver,  but  even  the  stroma  cells; 
and  also  unicellular  organisms,  such  as  yeasts  and 
bacteria.  However,  the  rate  at  which  autolysis 
occurs  in  different  sorts  of  cells  varies  greatly,  such 
active  cells  as  those  of  the  liver  disintegrating  very 
rapidly  as  compared  with  stroma,  muscle,  and  nerve 
cells.  As  commonly  observed  in  experimental  work, 
autolysis  does  not  begin,  or  at  least  does  not  become 
appreciable  in  amount,  during  the  first  two  or  three 
hours  after  the  tissue  has  been  removed  from  the 
body;  then  the  rate  of  protein  disintegration  begins 
to  increase  rapidly,  reaching  a  maximum  from  the 
twelfth  to  the  twentieth  hour  (at  body  temperature), 
then  subsiding  until,  after  the  forty-eight  hour,  the 
daily  increase  is  almost  inappreciable.  Total  disinte- 
gration of  the  protein  seems  not  to  be  reached;  after 
fifty  days'  autolysis  of  liver  tissue  in  one  experiment 
but  twenty-nine  per  cent,  of  the  amino  acids  had 
been  set  free  (Abderhalden  and  Prym).  The  intracel- 
lular proteolytic  enzymes  which  accomplish  this 
disintegration  are  not  altogether  like  either  pepsin  or 
trypsin;  they  resemble  the  latter  in  carrying  the 
digestion  beyond  the  stage  of  peptones  to  their 
ultimate  constituent  amino  ucids,  but,  like  pepsin, 
for  the  most  part  they  act  best  in  a  faintly  acid 
medium,  and  are  inhibited  almost  entirely  by  alkalies 
no  stronger  than  0.4  per  cent.  NaOH.  The  cleavage 
products  that  they  produce  from  proteins  differ  from 
those  of  tryptic  digestion  in  containing  a  much 
larger  proportion  of  the  nitrogen  in  forms  simpler 
than  the  amino  acids,  especially  ammonia  compounds; 
this  extreme  cleavage  is  probably  the  result  not  of 
one,  but  of  several  intracellular  enzymes,  including 
not  only  enzymes  that  decompose  proteins  into 
amino  acids,  but  also  those  that  decompose  the 
amino  acids  into  ammonia  compounds  (deamidizing 
enzymes).  Probably  as  a  result  of  this  deamidizing 
process,  organic  acids,  especially  lactic,  acetic,  and 
butyric,  are  formed  in  considerable  quantities.  Some 
doubt  has  been  thrown  upon  the  supposed  formation 
of  free  acids  in  autolysis,  since  Wolbaeh,  Saiki,  and 
Jackson  showed  the  difficulty  of  securing  tissues  free 
from  anaerobic  bacteria.     Small  quantities  of  salts  of 


784 


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Alltoh  sK 


raenic,  calcium,  and  silver,  phosphorus,  and  diph- 
hcria  toxin  seem  to  accelerate  autolysis. 

\s  cells  contain  substances  other  than  the  proteins, 

In-   changes   of   cellular   autolysis   are    by    no    means 

imiteil     to    proteolysis.     Glycogen     is    split     very 

piickly  into  glucose,   which  in   turn  is  further  disor- 

anized.     The   intracellular   fats    are   split     by    the 

-e  which  every  cell   contains,   so   that    free  fatty 

may  be  found  in  autolyzing  organs.     Microscopic- 

Uy  there   may   be   found   what    seems    to    be    an    in- 

rease  in  the  amount   of  fat  in  the  cells,  resembling 

changes    of    fatty    degeneration;  but    analysis 

hows  that  there  is  not  an  actual  increase  in  fat,  but 

ather  a  decrease,   the  fat  microscopically  observed 

leing  simply  the  result  of  the  liberation  of  fats  held 

iiually    in    an    unstainable    condition    in    the   pro- 

oplasm  of  the  living  cell.     Lecithin  is  also  decoin- 

ed,  yielding  cholin.     Reducing  substances  appear, 

ml.   as   before   mentioned,    volatile   fatty   acids   are 

■  need.     The   nucleo-proteins  are  attacked   early, 

iag  the  nuclei  to  lose  their  characteristic  staining 

iperties,  and  the  nucleic  acids  which  are  liberated 

decomposed   by  special   enzymes,   the   nucleases, 

that  free  purin  bases  appear;   these  in  turn  may 

altered,  adenin  and    guanin    being  changed   into 

anthin  and   hypoxanthin  by   the  enzymes,   adenast 

nd  guanase. 

Autolysis  as  a  Physiological  Process. — In 
tew  of  the  fact  that  every  living  cell  so  far  as 
:nown,  is  provided  with  proteolytic  enzymes,  it 
iould  seem  probable  that  these  must  be  of  impor- 
le  to  the  cells  in  performing  their  normal  functions, 
or  it  scarcely  seems  reasonable  to  contend  that  the 
ells  are  equipped  with  these  enzymes  solely  for  the 
Tiirpose  of  acting  as  scavengers  of  the  dead  cells, 
urthermore,  we  have  ample  reason  to  believe  that 
he  cells  have  need  of  proteolytic  enzymes  in  order 
o  be  able  to  utilize  the  protein  supplies  brought  in 
lie  blood,  and  perhaps  also  for  the  purpose  of  build- 
tig  up  the  cell  proteins  themselves.  Therefore,  it 
i  cms  very  likely  that  the  autolytic  enzymes  are 
imply  the  proteolytic  enzymes  that  have  to  do  with 
iormal  cellular  metabolism,  and  that  they  act  auto- 
ytically  only  when  the  cell  is  killed,  or  shut  off  from 
is  supply  of  nourishment,  or  under  other  abnormal 
onditions,  and  there  is  some  evidence  in  favor  of 
his  view.  For  example,  Jacoby  found  that  if  he 
igated  off  a  portion  of  the  liver  of  a  dog,  and  let  the 
inimal  live  a  few  days,  the  necrotic  tissue  showed  an 
iccumulation  of  leucin,  tyrosin,  and  other  products 
if  protein  hydrolysis,  which  suggests  that  these  same 
irocesses  of  hydrolysis  are  going  on  in  the  liver  con- 
tantly,  only  the  products  of  the  hydrolysis  are, 
tnder  normal  conditions,  removed  by  the  circulating 
>lood  as  fast  as  formed.  Furthermore,  actively 
unctionating  tissues,  such  as  the  uterus  and  mam- 
nary  gland  in  pregnancy,  show  much  more  active 
mtolysis  than  do  the  same  tissues  when  in  the  resting 
tate;  and  Schlesinger  found  that  autolysis  is  most 
apid  in  newborn  animals.  Schryver  found  evidence 
hat  animals  which  had  been  fed  on  thj-roid  gland, 
vhich  increases  the  protein  metabolism,  showed  a 
nore  rapid  autolysis  of  the  liver  than  control  animals; 
lowever,  the  writer  has  been  unable  to  find  any  evi- 
lence  that  thyroid  extract  increases  the  rate  of  autolys- 
is under  experimental  conditions.  Nevertheless,  in 
pile  of  this  supportive  evidence,  it  must  be  admitted 
hat  at  the  present  time  we  are  by  no  means  certain 
hat  the  enzymes  that  cause  autolysis  of  dead  tissues 
lerform  any  part  in  normal  metabolism,  or,  indeed, 
hat  these  same  enzymes  really  exist  in  the  intact, 
iormal  cell  in  an  active  contidion. 

Another  interesting  problem  is  the  manner  in 
vhich  the  autolytic  enzymes  are  kept  from  digesting 
he  living  cells,  and  why  they  attack  only  dead  or 
njured  cells;  it  will  be  noted  that  this  question  is 
nuch  the  same  as  the  old  problem  of  the  defence  of 


Vol.  I. 


-50 


the  gastrointestinal  mucosa  from  the  enzyme-  of  the 
digestive  fluids.  There  an-  several  observations  that 
bear  upon  this  point.     One  is  thai   the  blood  serum 

has  a  powerful   inhibitory   action   upon   the  autolytic 

processes,  so  thai  if  a  large  exce     oi  serum  i    pn   •  q( 
m  proportion  to  the  amount  of  cells,  as  In  e    ■ 
exudate,   autolysis    may    be   held   entirely   in  check. 

This  inhibition  seems  to  be  due  to  pecific  anti- 
bodies present  in  the  serum,  which  are  readily  de- 
stroyed by  heat,  by  acids,  and  also  by  alkalies  in  any 
considerable  concentration.     A    bhi   e  antibodie    are 

particularly  susceptible  to  acid-,  the  development  of 
an  acid  reaction  in  an  autolyzing  area  greatly  facili- 
tates   the    process,    while,    SO    long    as  the    tissues  are 

kept  alkaline,  autolysis  is  prevented.     Furthermore, 

the  autolytic  enzy s,  independent  of  any  question 

of  antibodies,  with  a  few  exceptions  act  much  better 
in  an  acid  than  in  an  alkaline  or  neutral  medium.* 
Therefore,  it  may  well  be  that  in  the  living  tissues, 

bathed  with  the  normal  quantities  of  constantly 
changing  blood  and  lymph,  the  autolytic  enzymes 
are  held  in  check  by  the  antibodies  of  these  fluids; 
and  at   (he  same  time  the  great  neutralizing  power  of 

the   bl 1   plasma  prevents   the   de\  olopmenl    of  an 

acid  reaction  from  any  of  the  products  of  cellular 
metabolism.  As  soon  as  circulation  is  stopped  by 
any  cause,  since  the  supply  of  antibodies  is  thus  cut 
off,  autolysis  can  begin  after  a  latent  period  during 
which,  presumably,  the  effect  of  the  antibodies 
present  is  being  exhausted;  once  autolysis  is  started, 
the  formation  of  volatile  fatty  acids  favors  greatly 
the  activity  of  the  enzymes,  and  so  the  process  soon 
begins  to  increase  greatly  in  rapidity. 

Another  possible  factor  in  the  defence  of  the  cells 
against  their  own  enzymes  is  that  to  a  certain  degree 
the  autolytic  enzymes  of  each  organ  are  specific  for 
the  cells  of  that  organ  (Jacoby).  For  example, 
liver  extract  will  not  digest  lung  tissue,  or  kidney,  or 
spleen.  Leucocytic  enzymes,  however,  seem  to  be 
capable  of  splitting  foreign  proteins  of  all  sorts. 
(The  digestion  of  one  cell  by  enzymes  derived  from 
some  other  cell  is  called  hctcrolysis.)  Still  another 
reason  that  may  be  advanced  to  explain  the  attacking 
of  a  cell  by  its  own  enzymes  immediately  after  its 
nourishment  is  shut  off,  is  to  be  found  in  the  con- 
ditions of  chemical  equilibrium.  During  life  constant 
new  supplies  of  proteins  are  being  brought  to  the  cell, 
and  the  products  of  proteolysis  are  carried  away  or 
oxidized  as  fast  as  formed;  when  circulation  stops, 
the  process  of  splitting  goes  on  without  the  introduc- 
tion of  any  new  supplies  of  material,  and  hence  the 
tissues  are  not  replaced  as  fast  as  they  are  destroyed, 
and  the  products  of  their  decomposition  accumulate 
for  lack  of  any  means  of  destroying  or  removing 
them.  There  can  be  no  question  that  the  supply 
of  food-stuffs  is  of  essential  importance  in  determining 
autolytic  changes,  for  it  has  been  found  that  bacteria 
and  yeasts  begin  to  undergo  autolysis  when  they  are 
taken  out  of  nutrient  media  and  placed  in  distilled 
water  or  salt  solution.  So  long  as  the  bacteria  are 
supplied  with  nourishment,  autolysis  is  not  marked, 
but  when  nutrient  material  is  lacking  the  autolytic 
decomposition  is  no  longer  repaired,  and  the  bacteria 
disintegrate.  Presumably  the  same  rules  apply  to 
the  individual  cells  of  complex  organisms. 

Lastly,  it  must  be  considered  that  enzymes  exist  in 
the  cell  to  greater  or  less  extent  in  their  inactive 
zymogen  form,  and  are  perhaps  changed  into  the 
active  form  as  needed,  and  inhibited  or  changed  back 
again    when    their    work    is    temporarily    finished. 

Autolysis  in  Pathological  Conditions. — All 
absorption  of  dead  or  injured  tissues,  and  of  organic 
foreign  bodies,  seems  to  be  accomplished  by  means  of 
the  digestive  action  of  the  enzymes  of  the  cells  and 

*  There  are  a  few  autolytic  enzymes,  notably  those  of  the  leu- 
cocytes and  bone  marrow  (Opie),  anil  an  enzyme  in  the  spleen 
(Hedin),  that  act  best  in  a  slightly  alkaline  medium. 

785 


Autolysis 


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tissue  fluids.  We  may  distinguish  between  the 
digestion  brought  about  by  the  enzymes  of  the  di- 
gested tissue  itself,  or  autolysis  in  the  limited  sense  of 
the  word,  and  digestion  by  enzymes  from  other  cells  or 
tissue  fluids,  or  heterolysis,  although  in  ordinary 
usage  the  word  autolysis  covers  both  processes. 
Heterolysis  is  accomplished  particularly  by  the 
leucocytes,  which  contain  enzymes  capable  of  digests 
ing  not  only  leucocytic  proteins  but  apparently 
every  other  sort  of  protein,  from  serum  albumin  to 
catgut  ligatures.  The  heterolysis  may  be  intracellu- 
lar, in  the  case  of  substances  engulfed  by  phagocytes; 
or  extracellular,  either  by  enzymes  normally  con- 
tained in  the  blood  plasma  and"  tissue  fluids,  or  by 
enzymes  liberated  by  the  leucocytes  and  fixed  tissue 
cells.  On  the  death  and  dissolution  of  a  cell  the 
intracellular  enzymes  are  released,  but  it  is  not 
known  to  what  extent  the  enzymes  may  be  secreted 
from  intact  living  cells.  So  far  as  pathological  proc- 
esses show,  the  amount  of  liberation  of  enzymes 
from  normal  cells  is  very  slight,  if  any;  and  the  diges- 
tive enzymes  present  in  the  blood  plasma  seem  to  be 
very  feeble,  but  this  is  perhaps  because  they  are  held 
in  check  by  the  antisubstances  of  the  serum.  Patho- 
logical autolysis  and  heterolysis,  therefore,  are  brought 
about  chiefly  by  enzymes  liberated  from  dead  or 
injured  cells,  and  both  these  processes  seem  to  take 
place  in  the  softening  of  pathological  tissues,  etc. 
An  infarct  undergoes  gradual  absorption  because  the 
dead  cells  are  digested  by  their  intracellular  en- 
zymes, exactly  as  they  are  when  the  tissue  is  removed 
from  the  body  and  allowed  to  undergo  experimental 
autolysis.  In  addition,  in  the  case  of  the  infarct, 
leucocytes  wander  in  and  disintegrate,  and  their 
liberated  enzymes  help  in  the  process.  It  is  because 
of  the  heterolysis  by  leucocytic  enzymes  that  a 
septic  infarct  becomes  softened  so  much  more 
rapidly  than  does  an  aseptic  infarct,  and  by  compar- 
ing the  rate  of  autolysis  in  these  two  kinds  of  infarcts 
we  see  that  cellular  autolysis  is  a  very  slow  process 
as  compared  with  the  heterolysis  accomplished  by 
leucocytes. 

It  is  probable  that  the  products  of  autolysis  are 
toxic,  and  the  aseptic  febrile  condition  occurring  in 
patients  with  large  areas  of  aseptic  necrosis,  or  with 
sterile  hematomas,  and  sometimes  called  "ferment 
fever,"  may  perhaps  be  the  result  of  the  absorption 
of  the  substances  produced  by  the  action  of  the 
autolytic  enzymes.  It  is  well  known  that  albumoses 
and  peptones  are  toxic,  and  it  is  quite  probable  that 
some  of  the  other  products  of  proteolysis  are  poison- 
ous; and  it  has  been  repeatedly  shown  that  they  are 
hemolytic.  Some  of  the  symptoms  of  suppuration, 
particularly  the  fever  and  chills,  have  been  ascribed 
rather  to  the  autolytic  products  than  to  the  bacterial 
poisons,  particularly  as  aseptic  suppuration  is  accom- 
panied by  fever.  In  all  conditions  associated  with 
autolysis  albumoses  may  appear  in  the  urine,  and  it  is 
quite  probable  that  they  would  cause  more  or  less 
intoxication  before  being  eliminated. 

As  specific  instances  of  autolysis  in  pathological 
conditions  may  be  mentioned  the  following: 

Necrotic  Areas  and  Exudates. — The  processes  that 
take  place  in  a  local  area  of  necrosis  must  be  funda- 
mentally quite  similar  to  those  occurring  in  a  corre- 
sponding piece  of  tissue  kept  in  an  incubator  under 
aseptic  conditions.  The  rate  of  the  changes  as 
actually  observed,  is,  however,  very  much  slower  in 
the  case  of  the  dead  tissue  within  the  living  body, 
which  is  probably  due  to  the  inhibitory  effect  of  the 
blood  serum;  indeed,  if  we  add  a  large  volume  of 
blood  serum  to  tissues  placed  in  the  flasks  for  experi- 
mental autolysis  it  will  be  found  that  the  rate  of 
autolysis  is  greatly  lessened.  In  the  case  of  very 
large  areas  of  necrosis  the  central  portions  are  found 
to  undergo  softening  much  faster  than  the  peripheral, 
undoubtedly  because  removed  from  the  inhibitory 
action  of  the  serum.     The  disappearance  of  nuclear 


staining,  which  is  the  usual  microscopic  indication  of 
necrosis,  is  probably  due  to  the  digestion  of  the 
nucleoproteins  by  the  proteolytic  enzymes  and  the 
nucleases,  for  if  sterile  pieces  of  tissue  which  have  had 
their  enzymes  destroyed  by  heating  are  implanted 
into  animals  they  are  found  to  retain  their  nuclear 
staining  for  several  weeks.  The  rate  of  autolysis 
under  experimental  conditions,  as  shown  by  the 
nuclear  changes,  is  in  decreasing  order,  as  follows: 
Liver,  epithelium  of  the  convoluted  tubules  of  the 
kidneys,  spleen,  pancreas,  collecting  tubules  and 
glomerules  of  the  kidney,  alveolar  and  bronchial 
epithelium  of  the  lung,  thyroid  epithelium,  myo- 
cardium, voluntary  muscle,  squamous  epithelium 
of  the  skin,  cortical  cells  of  the  brain,  connective- 
tissue  cells,  endothelium  of  blood-vessels. 

If  chemotactic  substances  are  formed  in  a  necrotic 
area  the  leucocytes  that  enter  cause  very  rapid 
heterolysis.  In  caseation,  for  example,  there  is 
practically  no  autolysis,  but  if  iodoform  is  injected 
the  leucocytes  that  invade  the  area  at  once  cause 
rapid  softening,  with  the  formation  of  "sterile  pus." 

Suppuration  is  an  example  of  very  rapid  autolysis 
and  heterolysis,  particularly  the  latter  brought  about 
by  the  great  number  of  leucocytes  that  are  always 
present.  As  living  cells  do  not  undergo  digestion,  we 
do  not  get  suppuration,  no  matter  how  many  leuco- 
cytes there  may  be  present,  unless  there  is  also  present 
necrosis  or  some  non-living  protein  material,  such 
as  fibrin,  for  the  enzymes  to  attack;  this  is  well 
illustrated  by  the  absence  of  suppuration  in  erysipelas, 
in  spite  of  extreme  infiltration  with  leucocytes. 

Exudates  undergo  autolysis,  as  Opie  has  pointed  out, 
in  direct  proportion  to  the  number  of  leucocytes,  and 
in  inverse  proportion  to  the  amount  of  serum.  If  the 
amount  of  serum  is  relatively  very  great,  as  in  many 
forms  of  serous  pleuritis,  the  antibodies  of  the  serum 
hold  the  enzymes  of  the  leucocytes  in  check,  and  there 
is  little  or  no  autolysis;  but  if  the  leucocytes  are  very 
abundant  and  the  amount  of  serum  small,  th<  u 
autolysis  will  occur.  In  this  connection  it  should  be 
recalled  that  the  enzymes  of  polymorphonuclear 
leucocytes  are  remarkable  in  acting  best  in  an  alkaline 
medium,  so  that  it  is  not  necessary  for  an  acid  reac- 
tion to  be  developed  in  order  that  they  may  become 
active.  The  mononuclear  cells  seem  to  contain  an 
enzyme  acting  best  in  slightly  acid  solution. 

Pneumonia. — The  resolution  of  the  exudate  in  lobar 
pneumonia  is  a  striking  example  of  autolysis  by 
leucocytes,  and  its  great  rapidity  undoubtedly  de- 
pends upon  the  fact  that  the  process  occurs  in  the 
alveoli,  and  out  of  direct  contact  with  the  circulating 
blood  and  its  antibodies.  The  important  fact  that  in 
the  resolution  of  pneumonia  the  alveolar  walls  escape 
digestion  while  the  exudate  is  being  taken  away,  is 
due  to  the  normal  resistance  of  living  cells  to  digestive 
enzymes,  which  in  this  case  is  certainly  at  least 
partly  due  to  the  presence  of  abundant  blood  in  the 
alveolar  walls;  in  case  the  nutrition  of  a  pneumonic 
area  is  cut  off  by  thrombosis  the  autolytic  changes 
then  involve  also  the  affected  lung  tissue,  resulting 
in  purulent  pneumonia,  gangrenous  softening,  or 
abscess  formation.  As  evidence  of  the  autolytic 
nature  of  resolution  we  have  the  presence  of  albumi 
and  peptones  in  the  sputum  and  urine  of  patients 
after  the  crisis  of  lobar  pneumonia,  and  leucin  and 
tyrosin  have  been  found  in  pneumonic  lungs. 

Liver  Degenerations. — In  a  number  of  pathological 
conditions  of  the  liver,  of  which  acute  yellow  atrophy 
is  the  type,  autolytic  destruction  of  the  parenchyma- 
tous elements  is  the  chief  cause  of  the  anatomical 
changes  observed,  and  perhaps  also  of  many  of  thi 
clinical  features.  In  acute  yellow  atrophy,  for 
example,  we  have  a  rapid  decrease  in  the  size  and 
weight  of  the  liver  because  of  disappearance  of  a 
large  proportion  of  the  hepatic  cells,  and  in  this  condi- 
tion leucin  and  tyrosin  may  be  found  in  the  urine, 
while  in  the  blood,  and  especially  in  the  liver  itself, 


786 


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Automatic   Actions 


ere  may  be  found  any  and  al    of  the  products  of 
oteolysis.     Similar  conditions  exist  in  pho  phoru 
lisoning,  in  the  diffuse  necrosis  observed  in  the  liver 
i  <■--  of  delayed  chloroform  poisoning,  in  some  ca  es 
puerperal    eclampsia,    and    in    certain    infectious 
mditions  with  hepatic  necrosis,  especially  in  Weil's 
e.     It  would  seem  that  in  these  conditions  we 
,,■    the   liver   cells   injured   by   some   poison    that 
0ps  the  synthetic  activities  or  kills  the  cells  outright, 
it  does  nol  injure  the  an l oly tic  enzymes,  so  that  the 
accomplish    the    disintegration    of    the    cells. 
ably  the  reason  that  the  liver  is  peculiarly  liable  to 
,ch  intra  vitam  autolytic  destruction  lies  in  the  fact 
it  is  notably  possessed  of  the  most  active  auto- 
enzymes. 
1'imliiiorlcm  Changes. — These  are  undoubtedly  due 
.  two  factors,  bacterial  action  and  autolysis.     Under 
linary  conditions  the  former  effect  is  so  conspicuous 
nit  autolysis   is  not  prominent,   but    there  are   in- 
in  which  postmortem  decomposition  is  purely 
itolytic.     The   best   example   is   furnished    by    the 
gration  of  the  fetus  that  is  retained  within  the 
idy  of  the  mother  after  its  death  from  whatever 
se;  the  maceration  of  the  tissues,  and  the  disin- 
ation  of  the  viscera,  are  the  result  of  autolytic 
rocesses.     In  the  "ripening"  of  meat  kept  at  low 
•mperature  to  prevent  bacterial  action  we  have  a 
ise  of  slowly  continued  autolysis,  and  even  in  fish 
id  meat  cured  with  brine,  autolysis  seems  to  take 
ice  in  spite  of  the  strength  of  the  salt  solution  used, 
he  softening  of  the  muscles  after  rigor  mortis  is 
robably  also  the  result  of  autolytic  decomposition 
the    clotted    muscle    proteins.     The    microscopic 
langes  that  occur  in  tissues  undergoing  postmortem 
composition  are  readily  explained  as  the  effect  of 
itolytic  attack  upon  the  cellular  structures,  and  are, 
i  fact,  quite  the  same  as  those  occurring  in  necrotic 
eas  within  the  living  body. 

Tumors. — As  necrosis  is  a  prominent  feature  of 
talignant  tumors,  autolysis  results  in  their  softening 
iid  breaking  down,  showing  that  tumor  cells  possess 
titolytic  enzymes  as  well  as  the  normal  cells  of  the 
idy,  and  there  is  no  conclusive  evidence  that  these 
izymes  are  at  all  different  from  those  of  normal 
^sites.  It  is  possible  that  the  products  of  this 
vtensive  autolysis  that  occurs  in  tumors  have  an 
nportant  influence  in  the  production  of  cancer 
ichexia.  Extracts  of  malignant  tumors  have  a 
ecided  hemolytic  property,  which  very  probably  is 
ue  to  these  products  of  autolysis,  and  their  absorp- 
on  into  the  blood  may  have  to  do  with  the  anemia 
f  cancer  patients.  On  account  of  this  hemolytic 
roperty,  blood-stained  exudates  produced  by  malig- 
ant  growths  in  the  serous  cavities  usually  will  be 
>und  to  owe  their  color  to  hemoglobin  rather  than 
)  red  corpuscles.  The  action  of  radium  and  x-rays 
pon  malignant  growths  has  been  ascribed  to  the 
(feet  of  these  agencies  upon  the  autolytic  enzymes; 
>*euberg  found  that  although  most  enzymes  are 
estroyed  or  inhibited  by  radium  emanations, 
titolytic  enzymes  form  an  exception,  for  cancer 
te  exposed  to  radium  rays  undergoes  autolysis 
ister  than  control  specimens.  Products  of  protein 
ydrolysis  may  be  found  in  tumors  on  account  of  their 
utolytic  disintegration.  The  fact  that  ulcerating 
arcinoma  of  the  stomach  liberates  its  intracellular 
nzymes  into  the  gastric  juice  has  been  utilized  in 
liagnosis,  the  stomach  contents  in  such  cases  being 
ble  to  hydrolyze  polypeptids  and  liberate  free 
mino-acids,  which  normal  gastric  juice  cannot  do. 
N'eubauer  and  Fischer,2 

Leukemia. — The  abundant  elimination  of  uric  acid 
ind  other  purin  bodies  in  leukemia  is  probably  due 
o  the  autolysis  of  leucocytes  that  occurs  in  this 
lisease.  Leucocytes  obtained  from  cases  of  myeloid 
eukemia  show  very  active  autolytic  properties,  which 
ire  comparatively  slight  in  leucocytes  from  lymphatic 
eukemia.     Corresponding  with  this,  the  evidences  of 


autolytic  proct     e    are  much  more  prominent  is  t 
of  myelogenous  leukemia,     h    seems  quite  probable 
that  an  important  factor  in  this  autolysis  i-  thai  the 

proportion  of  ieucocj serum  in  the  circulating 

blood  is  greatly  raised,  80  that  the  antibodies  pre  enl 
in  the  blood  are  inadequate  in  amount  to  bold  the 
leucocytic  enzymes  in  cheek,  as  normally  occurs.  It 
has  been  found  experimentally  that  leukemic  orj 

especially    the    spleen,    undergo   autolysis    more    com- 
pletely  and    more    rapidly    than    do    normal    orga 
The  effect  of  x-rays  upon  thi-    (    ea  e  i     po     iUv  the 

result  of  their  action  upon  the  intracellular  enzymes, 
as  in  the  case  of  cancer. 

Autolysis  of  Bacteria. — As  previously  men- 
tioned, bacterial  cells  present  no  exception  to  the 
general  rule  that  all  living  cells  contain  autolytic 
■  ■  i i / \  iocs.  This  property  of  bacteria  is  shown  as  soon 
as  they  are  removed  from  culture  media  and  placed 
in  non-nutrient  fluids,  such  as  water  or  salt  solution: 
then  the  bacteria  begin  to  undergo  Si  If-digestion  in  a 
few  hours,  as  if  their  enzymes  attacked  the  bacterial 
cells  when  there  is  nothing  else  for  them  to  act  upon. 

Likewise,  if  bacterial  cells  are  placed  in  antiseptics 

that  do  not  destroy    the  autolytic   enzymes,   such   as 

toluol  and  chloroform,  autolytic  disintegration 
begins  to  take  place  at  once.  In  this  way  it  has  been 
possible  to  liberate  from  bacterial  cells  the  poisonous 
substances  that  they  contain,  the  etnlotoj-ins.  It  is 
probable  that  such  bacteria  as  owe  their  pathogenic 
properties  to  endotoxins  produce  their  effects  only 
when  these  are  released  through  disintegration  of  the 
bacterial  cells  by  autolysis  or  when  the  bacteria  are 
digested  by  the  enzymes  of  the  infected  organism. 
On  this  account  it  is  possible  for  a  perfectly  immunized 
animal  to  be  killed  by  the  injection  of  large  numbers 
of  such  bacteria  (e.g.  typhoid,  colon,  cholera)  through 
overwhelming  with  great  quantities  of  endotoxins. 
even  when  every  bacterium  has  been  killed  by  the 
protective  agencies  of  the  animal,  since  when  the 
bacteria  are  killed  the  endotoxins  are  liberated  by 
digestion  of  the  dead  bacterial  cells.  Autolysis  of 
many  pathogenic  bacteria  liberates  poisons  producing 
the  same  symptoms  as  are  characteristic  of  anaphy- 
lactic shock  (Rosenow). 

Part  of  the  tissue  digestion  that  occurs  in  infected 
areas  may  be  due  to  the  action  of  enzymes  liberated 
by  the  infecting  bacteria,  but  as  compared  with  the 
effect  produced  by  the  leucocytes  this  influence  is 
probably  negligible.  Certain  of  the  products  of 
autolysis  of  tissues  are  antiseptic  and  it  is  possible 
that  a  certain  degree  of  resistance  is  conferred  by 
these  substances  in  local  infections  accompanied  by 
tissue  destruction.  Conradi  believes  that  it  is  the 
accumulation  of  these  antiseptic  products  of  the 
autolysis  of  bacteria  that  accounts  for  the  gradual 
dying  out  of  bacteria  grown  on  artificial  media.  It  is 
quite  possible  that  bacterial  toxins  may  be  destroyed 
by  autolytic  enzymes,  for  it  is  known  that  toxins  are 
attacked  by  proteolytic  enzymes. 

H.  Gideon  Wells. 

1.  Midler  und  Joohmann:  Deutsches  Arch.  f(ir  klin.  Med.,  Vol. 
xci.,  1907;  Miinchener  rned.  Wochensehrift,  No.  26,  1906. 

2.  Neubauer  und  Fischer:  Deutsches  Archiv  fiir  klin.  Med  . 
Vol.  xcvii.,  1909. 

The  Bibliography  of  this  subject  is  given  by  Salkowski,  Deutsche 
Klinik,  1903  (11),  147;  A.  Oswald,  Biochemisches  Centralblatt, 
1905  (3),  365;  and  hi  the  chapter  on  Autolysis,  in  Wells'  "Chem- 
ical Pathology." 


Automatic  Actions. — By  the  term  automatic  ac- 
tions, as  applied  to  living  bodies,  we  mean  those  move- 
ments which  go  on  without  any  outside  stimulus,  the 
causes  being  in  the  body  itself.  For  the  sake  of  under- 
standing them  more  clearly  it  is  necessary  to  divide 
them  into  certain  classes,  which,  so  far  as  the  higher 
animals  are  concerned,  are  as  follows: 

787 


Automatic  Actions 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


The  Automatic  Actions  of  Vegetative  Life. 
— Under  this  head  we  have:  (a)  those  of  the  re- 
spiratory neuromechanism;  (6)  those  of  the  cardiac 
neuromechanism;  (c)  those  of  the  vasomotor  neuro- 
mechanism; (d)  those  rhythmical  movements  of  the 
stomach,  intestines,  spleen,  and  bladder  which  occur 
without  apparent  reflex  stimulus. 

The  automatic  actions  in  these  classes  may  be 
modified  by  voluntary  or  other  extrinsic  influences, 
but  they  are,  nevertheless,  essentially  independent  of 
them.  Thus  the  respiratory  movements  may  be 
modified  by  volitional  impulses,  but  they  in  the  main 
go  on  rhythmically  and  independently.  The  mechan- 
ism of  this  process  of  automatism  is  well  illustrated 
in  the  cardiac  movements.  The  pulsations  of  the 
heart  depend  upon  the  stimuli  rhythmically  sent  out  by 
the  intrinsic  ganglia  and  the  cardiac  muscle  cells. 
The  cells  which  originate  these  stimuli  receive  no 
excitation  themselves  except  that  furnished  by  the 
aliment  from  the  blood.  This  aliment  is  constantly 
building  up  these  motor  cells  into  a  more  and  more 
unstable  condition.  When  the  instability  reaches  a 
certain  limit,  the  cell  decomposes  or  explodes  with  a 
discharge  of  its  force,  after  which  it  immediately 
begins  to  build  up  into  instability  again;  and  so  the 
process  goes  on.  This  explanation  applies  to  all  the 
rhythmical  automatic  movements  of  vegetative  life. 
The  movements  are  performed  by  unstriped  muscles, 
or  the  muscles  of  internal  relation.  The  more  detailed 
knowledge  of  the  process,  with  the  chemical  changes 
and  electrical  phenomena  are  to  be  found  in  the 
larger  technical  works  on  physiology.  They  have  no 
specially  enlightening  value  on  the  intimate  nature 
of  automatism.  After  all  it  is  a  question  of  a  steady 
supply  of  fuel  to  a  pulsating  engine. 

The  Autonomic  System. — Some  physiologists  have 
given  the  name  autonomic  to  the  activities  of  the 
sympathetic  nervous  system.  This  is  well  enough, 
only  it  is  to  be  remembered  that  the  autonomic 
actions  are  not  the  same  as  automatic.  Thus  many 
of  the  activities  of  the  sympathetic  are  reflex.  Auto- 
matic actions,  however,  are  done  not  only  by  the  sym- 
pathetic but  by  the  cerebrospinal  nerves  or  by  both 
acting  together. 

The  Automatic  Actions  of  Voluntary  Life. — 
A  second  and  much  more  striking  class  of  auto- 
matic activities  includes  those  involving  voluntary 
muscles  and  the  mind.  They  appear  in  various  forms 
and  in  varying  complexity  according  to  the  part 
of  the  nervous  system  which  they  involve.  They 
may  be  divided  as  follows: 

(a)  The  Motor  Automatisms. — The  harmonious 
movements  of  the  eyes,  the  muscular  adjustments 
called  forth  in  the  use  of  the  voice,  and  of  the  jaws, 
mouth,  and  throat  in  suckling  are  illustrations  of 
motor  automatism.  The  movements  of  the  body 
and  limbs  in  standing,  sitting,  walking,  and  in  the 
various  acquired  dexterities,  such  as  those  of  dancers, 
players,  jugglers,  acrobats,  and  skilled  artisans,  all 
are  done  automatically.  Being,  in  man,  acquired  by 
practice,  they  may  be  spoken  of  as  secondary  auto- 
matic actions.  They  have  for  their  anatomical 
substratum  certain  arrangements  of  nerve  fibers  and 
cells  in  the  cerebellum,  basal  ganglia,  and  spinal  cord. 
The  conscious  mind,  though  taking  no  active  share, 
first  fathered  them,  and  stands  in  ready  connection 
with  them.  It  starts  or  stops  the  machinery,  just 
as  by  touching  the  pendulum  we  start  or  stop  a  clock 
that  has  been  wound.  Physiology  teaches  also  that 
all  voluntary  acts  tend  by  repetition  to  become 
automatic.  For  voluntary  movements,  by  repeti- 
tion, are  more  and  more  easily  and  quickly  performed, 
until  at  last  they  no  longer  possess  the  elements, 
such  as  duration  and  intensity,  necessary  to  arouse 
consciousness,  and  they  are  then  done  automatically. 

(6)  Psychical  Automatism. — There  is  another  class 
of  automatic  activities  closely  related  with  the  fine- 


going.  Here  volition  and  normal  consciousness  have 
no  share  at  all,  and  the  whole  psychical  life,  so  far  a- 
it  appears  at  all,  is  automatic.  The  mind  becomes  a 
real  machine,  working  in  certain  established  grooves 
unmodified  by  any  volition  or  by  any  external  01 
internal  stimulus  except  such  as  gives  it  the  start; 
just  as  the  boy  trims  the  sails  and  fastens  the  rudder 
of  his  toy  boat,  then  launches  it  to  sail  as  its  mechan- 
ism directs. 

This  psychical  automatism  is  represented  in  lower 
animals  by  many  of  their  instinctive  acts.  In  fol- 
lowing its  instincts  the  animal  obeys  no  consciou 
purpose,  but  is  impelled  by  unfelt  stimuli  from  within, 
these  stimuli  being  furnished  by  the  peculiar  anatom- 
ical arrangements  and  nutritive  needs  of  its  nervous 
system,  inherited  from  its  ancestors.  Instinct  cover- 
in  the  lower  animals,  however,  both  the  acquired 
aptitudes   and    the   psychical   automatisms  in  man. 

This  psychical  or  cerebral  automatism  is  perfectly 
illustrated  in  the  conditions  known  as  trance  and 
somnambulism.  Here  consciousness,  while  not  ex- 
actly abolished,  is  in  an  aberrant  state  (see  Conscious- 
ness, Disorders  of), volition  is  suspended,  but  thought, 
feeling,  and  sensorimotor  activities  continue,  and 
the  body  responds  in  systematized  and  apparently 
intelligent  acts. 

Subconscious  Menial  Actions. — The  following  state- 
ments regarding  subconscious  action  made  ov;-r 
twenty  years  ago,  were  even  then  a  commonplace 
among  psychologists  and  physiologists.  It  has 
recently  been  "rediscovered"  and  extraordinary  em- 
phasis laid  on  the  importance  of  the  subconscious 
activities.  These  activities  are  in  a  way  automatic 
i.e.  they  may  go  on  from  one  phase  to  another 
through  the  stimulus  of  association.  But  technically 
psvchic  or  cerebral  automatism  must  be  accom- 
panied by  some  definite  motor  act. 

There  are  two  distinctions  which  in  a  medical  study 
of  psychical  automatism  must  be  made:  First,  sub- 
conscious cerebration  is  a  different  thing  from  the 
psychical  automatism  which  we  are  describing. 
The  term  subconscious  cerebration  should  be  limited 
to  that  very  large  share  of  our  mental  life  which  runs 
on  beneath  consciousness.  Few  persons  in  carrying 
on  a  train  of  thought  bring  every  link  in  the  logical 
chain  into  consciousness.  We  pass  with  a  step  from 
the  first  term  to  the  last,  the  intermediate  process  beii? 
subconscious.  In  the  association  of  ideas,  one  menial 
picture  is  often  followed  by  another  apparently  re- 
mote, the  missing  links  not  rising  into  conscious  view. 
Subconscious  cerebration,  therefore,  refers  simply  to 
the  subconscious  part  of  our  ordinary  thoughts  and 
feelings,  and  is  one  of  the  modes  in  which  the  mind 
naturally  acts.  Second,  cerebral  automatism,  as 
understood  by  some  writers,  is  made  to  include 
cerebral  reflex  acts,  i.e.  all  the  mental  acts  which 
arise  involuntarily  in  response  to  a  stimulus.  Thus 
we  are  told  that  the  ready  response  of  emotion  at  a 
dramatic  climax,  the  instant  formation  of  judgment 
where  certain  simple  and  common  conditions  are 
present,  are  all  examples  of  cerebral  automatism. 
From  this  same  point  of  view,  the  common  sense  of 
mankind  is  but  the  automatically  formed  judgment 
upon  the  various  affairs  of  life,  which  rises  alike  in  the 
great  mass  of  men.  There  is  propriety  in  this  view, 
and  lines  of  distinction  must  be  somewhat  arbitrarily 
drawn.  Nevertheless,  the  acts  referred  to  are  much 
more  typically  reflex  than  automatic  acts,  as,  for 
example,  when  a  novel  situation  excites  at  once 
spontaneously  a  burst  of  laughter.  And  it  is  better 
to  limit  the  term  cerebral  automatism  to  those  con- 
ditions of  the  mind  in  which  spontaneity  is  abolished 
for  a  time  and  the  psychical  mechanism  acts  entirely 
apart  from  any  conscious  stimulus  with  this  result  of 
purposeful  acts. 

Cerebral  automatism,  as  thus  limited,  is  patholog- 
ical and  has  a  medical  importance.  It  is  a  condition 
that  is  brought  about  by  a  number  of  causes,  and 


788 


REFERENCE    HANDBOOK    or    TDK    MKDICAI,   SCIENCES 


Automatic  Actions 


.ikes  a  somewhat  different  clinical  picture  accord- 
Ely.  Cerebral  automatic  slates  may  be  classified  as 
ilovvs:  The  epileptic,  the  somnambulic,  the  hyp- 
itic,  the  automatism  of  inebriety,   of   insanity,  of 

reotic  intoxication,  of  syphillis,  of  injuries  to  the 
ad,  and  of  overwork  or  cerebral  exhaustion. 

Epileptic  Cerebral  Automatism. — The  anio- 
nic menial  stale  which  occurs  in  epilepsy  accom- 
nics  much  more  frequently  petit  mal  than  hunt  mal. 

generally    follows    the    attack,    but    someti 

ecedes  it,  and  still  more  rarely  takes  its  place,  in 
lioh  latter  case  the  terms  psychical  epilepsy 
lines  Jackson),  masked  epilepsy  (Esquirol), 
ilepsia  larvata  (Morel)  have  been  applied.  It  is  a 
msitory  psychical  disturbance,  and  only  one  of 
i  era)  forms  which  occur  at  this  period  (see  Epilt  psy). 
of  epileptic  automatism  are  numerous.  In  the 
npler  forms,  the  patient  proceeds  to  do  some  ordi- 
rv  but  inapposite  act.  Often  he  begins  suddenly  to 
idress,  or  tries  to  go  upstairs,  and  will  climb  upon 
hair,  or  table,  or  shelf.  Sometimes  he  picks  up  an 
ject  and  destroys  it  of  throws  it  down  or  puts  it  in 
s  pocket.  Much  more  complicated  acts  may  be  done. 
patient  of  Le  Grand  du  Saule's,  after  an  at  tack,  found 
at  he  had  taken  passage  in  a  steamer  for  Bombay. 
■  wet's  tells  of  a  carman  who,  after  an  attack,  drove 
r  an  hour  through  the  crowded  streets  without 
cident.  Trousseau  relates  the  case  of  an  architect 
10,  when  seized  with  an  attack,  would  run  quickly 
nn  plank  to  plank  without  falling;  and  Gowers, 
ain,  had  a  young  lady  patient  who,  during  the 
ileptic  automatism,  would  play  the  most  difficult 
isic.  A  patient  of  mine  while  riding  a  bicycle  would 
,ve  an  attack  and  continue  to  ride  skilfully  through 
e  city  streets.  In  some  cases  the  emotional  faculties 
e  more  involved,  and  attacks  of  transitory  mania, 
furious  impulse,  occur. 

Artificial  Cerebral  Automatism,  Hypnotism, 
IANCE. — In  the  condition  known  as  hypnotism, 
vnce,  or  the  mesmeric  state  the  phenomena  of 
rebral  automatism  are  very  well  shown,  and  an 
iderstanding  of  it  gives  the  key  to  all  the  cerebral 
tomatic  states.  When  the  hypnotic  condition  is 
oduced  artificially  in  a  man  lie  is  instructed  first 

fix   his   attention   upon   some    particular   object, 

a  bit  of  glass,  which  is  held  slightly  above  the  level 

vision,  so  as  to  put  the  ocular  muscles  upon  a 
rtain  strain.  After  a  few  minutes,  in  sensitive 
Meets,  the  psychical  activities  seem  to  lose  their 
uilibrium  and  to  be  concentrated  in  one  particu- 
'  direction.  Little  force  is  left  to  supply  the  rest  of 
e  conscious  functions  of  the  brain,  and  the  mental 
e  of  the  subject  is  working  in  one  field.  The 
ind  is  but  a  point.  The  equilibrium  of  psychic 
ice  being  once  overturned,  it  continues  unstable, 
d  can  be  turned  in  one  direction  or  another, 
cording  to  the  suggestion  of  the  manipulator, 
ms  the  hypnotic  thinks  that  he  sees  a  beatific 
sion,  and  every  capacity  of  his  mental  being  is 
pended  on  the  feelings  that  such  a  vision  excites. 
•  he  is  told  that  he  is  a  murderer,  and  must  die,  and 

is  overpowered  with  fear  and  remorse.  Or  his 
ind  is  directed  to  the  idea  that  one  side  of  his  body 

insensible;   he   then   feels   no   pain   on   that   side. 

any  case,  his  mental  energies  are  all  so  absorbed 
'  some  single  dominant  feeling,  that  ordinary 
nsory  impulses  coming  up  to  the  brain  impinge 
ritlessly  upon  consciousness,  but  they  cannot  pass 
e  fchreshhold  and  awaken  no  sensations.  The  hyp- 
itic  is  to  all  intents  and  purposes  anesthetic, 
ind  and  deaf  to  everything  except  an  expected 
ggestion  from  the  operator,  which  is  the  only 
ik  that  holds  him  at  the  time  to  the  external 
irld.  Under  the  domination  of  some  particular 
ea  or  feeling,  his  mind  may  automatically  cause  him 

perforin  many  complex  and  apparently  intelligent 
ts.     The  concentration  of  nervous  force  upon  some 


particular  function,  such  as  thai  of  sight,  hearing, 
or  touch,  exalts  these  senses,  so  thai  vision  is  clearer, 
hearing  more  acute,  and  the  touch  more  sensitive 
ee  Hypnotism,  Somnambulism).  Such  is,  in  brief, 
the  physiology  of  hypnotic  automatism. 

The   psychology  of   this  Condition  may  be  staled  in 

oiher  ami  more  technical  and  elaborated  terms,  I  or 
example,  there  is  an  intense  concentration  of  atten- 
tion, a  morbid  degree  of  Suggestibility  and  self-ab- 
sorption or  a  lowering  of  the  threshold  of  conscious- 
ness to  the  suggestion. 

It  is  not  the  purpose  of  the  writer,  however,  to  inter- 
pret the  subject  in  terms  of  the  modern  psychologist. 
Sue  1 1  interpret  at  ions  seem  simply  to  add  to  our  voca- 
bulary but  not.  to  our  knowledge. 

Although  the  hypnotic  condition  is  usually  pro- 
duced artificially,  certain  persons  of  a  highly  sensitive, 
nervous  temperament  an?  subject  to  spontaneous 
attacks,  just  as  other  persons  suffer  from  the  similar 

c tit  ion  of  somnambulism.     Indeed,   spontaneous 

hypnotic  attacks  are  a  kind  of  day  somnambulism. 
Individuals  thus  suffering  are  generally  of  a  hysteri- 
cal temperament,  with  deficient  will  power,  and 
their  hypnotic  attacks  may  accompany,  or  be  com- 
plicated with,  attacks  of  catalepsy,  ecstasy,  or 
hysterical  seizures  of  various  kinds.  There  are  per- 
sons who  have  a  congenital  tendency  to  fall  spon- 
taneously into  hypnotic  states.  Such  was  the  case 
with  a  patient  of  Le  Grand  du  Saule's,  who,  whenever 
he  got  into  a  state  of  excitement  or  expectancy, 
would  fall  off  into  a  hypnotic  sleep.  Some  of  the 
reported  cases  of  morbid  somnolence  belong  to  this 
class  (see  Sleep,  Disorders  of).  In  other  instances 
the  tendency  to  spontaneous  trance  states  is  ac- 
quired, as  in  a  case  reported  by  Finkelnburg:  a  young 
woman,  having  been  once  mesmerized  by  a  pro- 
fessional, ever  after  was  subject  to  spontaneous 
attacks  of  trance. 

The  condition  of  trance,  or  one  closely  allied  to  it, 
is  induced  voluntarily  by  the  so-called  trance  speakers. 
It  may  also  be  brought  on  by  some  periodically  occur- 
ring affection,  as  was  shown  in  a  case  related  by 
Dr.  B.  F.  Berkley.1  A  married  woman,  aged  thirty- 
nine,  for  years  suffered  from  trigeminal  neuralgia, 
which  finally  ended  in  a  severe  form  of  tic  douloureux 
occurring  every  two  weeks.  After  each  attack  she 
fell  into  a  state  of  "somniloquence"  lasting  for  an 
hour  or  two.  During  this  time  she  would  preach  on 
religious  topics  with  some  amount  of  eloquence.  She 
was  a  modern  illustration  of  the  similar  states  into 
which  the  priests  of  the  Delphic  oracle  went  when 
uttering  their  prophecies. 

Hypnotic  states  are  generally  brought  to  an  end  by 
the  passes  of  the  manipulator.  If  the  patient  is  left 
alone  the  hypnotic  state  continues  for  some  hours, 
passing  finally  into  true  sleep,  from  which  he  awakens 
spontaneously.  In  some  persons  who  are  subject  or 
have  been  subjected  to  periodical  attacks  of  hyp- 
notism, the  mind  recalls  in  one  attack  what  occurred 
in  the  previous  one.  After  such  a  person  comes  out 
from  an  attack  he  has  no  recollection,  as  a  rule,  of 
what  was  done  in  it.  There  are  considerable  varia- 
tions in  the  degree  or  intensity  of  the  hypnotic  state. 
In  the  slighter  degrees  it  resembles  considerably  that 
of  profound  reverie  or  abstraction.  There  is  a  distinc- 
tion, however,  between  the  absorbed  reverie  of  the  stu- 
dent and  the  absorbed  contemplation  of  the  hypnotic. 
In  the  former  case  the  mind  is  constructing  and  build- 
ing under  a  certain  kind  of  voluntary  direction;  in  the 
latter  the  mind  is  going  automatically  over  old  ground. 

Traumatic  Cerebral  Automatism. — Very  rarely 
injuries  of  the  head  produce  such  a  pathological 
change  in  the  brain  as  to  make  the  person  injured 
the  subject  of  periodical  attacks  of  cerebral  auto- 
mat ism.  In  these  cases  the  mental  condition  is  the 
same  as  if  the  patient  walked  in  his  sleep  or  had  been 
artificially  hypnotized. 

789 


Automatic  Actions 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


One  of  the  most  typical  cases  of  this  kind  is  that 
related  by  Mesnet,  of  the  French  soldier  who,  after 
suffering  from  a  severe  injury  of  the  head,  used  to  pass 
into  automatic  states  lasting  for  days.  He  would 
then  unconsciously  go  through  all  the  routine  actions 
to  which  he  had  been  accustomed,  such  as  dressing, 
taking  a  walk,  smoking,  etc.  These  attacks  are  gen- 
erally in  form  of  epilepsy. 

The  Cerebral  Automatism  op  Inebriety. — ■ 
Medical  literature  contains  striking  instances  in  which 
the  effect  of  the  long-continued  abuse  of  alcohol  has 
been  to  induce  periodic  attacks  of  cerebral  auto- 
matism. Under  the  influence  of  excessive  drink  with 
perhaps  some  pathological  condition  associated  with 
it  the  patients  fall  into  a  state  very  much  resembling 
that  of  hypnotism.  In  this  condition  they  may  go 
through  the  ordinary  routine  of  life  in  so  perfect  a 
manner  that  no  one  would  recognize  the  peculiar 
aberration  of  the  mind.  After  a  period  of  hours,  or 
even  of  a  day  or  more,  normal  consciousness  returns 
and  they  remember  nothing  of  what  they  have  been 
doing.  One  of  the  most  remarkable  illustrations 
of  this  kind  was  that  of  a  railway  conductor  who, 
after  passing  into  the  automatic  state,  would  take 
charge  of  his  car,  run  the  train,  collect  tickets,  make 
change,  and  do  all  the  other  duties  of  his  position. 
Finally,  after  returning  home  and  awaking,  he  could 
remember  nothing  of  what  he  had  done. 

Briefer  and  less  typical  attacks  of  cerebral  autom- 
at ism  occur  undoubtedly  in  very  many  cases  of 
chronic  inebriety.  They  are  perhaps  often  only  cases 
of  amnesia  from  drink. 

Syphilitic  Cerebral  Automatism. — Cerebral 
syphilis  sometimes  produces  states  of  automatic 
mental  action,  though  these  are  not  of  a  very  typical 
kind.  The  syphilitic  poison  causes  a  kind  of  somno- 
lent or  stuporous  condition,  in  which  the  patient 
appears  incapable  of  voluntary  intelligent  acts. 
When  roused  and  set  upon  ordinary  tasks  or  routine 
duties,  he  goes  through  them  automatically  and 
almost  unconsciously.  Such  cases  are  certainly  rare 
at  the  present  day  and  under  modern  methods  of 
treatment.  When  they  occur  the  suspicion  of  a 
luetic  petit-mal  should  be  entertained. 

The  Automatism  op  Brain  Exhaustion  and 
Brain  Disease. — Luys2  relates  the  history  of  a 
young  man  who  had  been  for  several  days  engaged  in 
making  calculations  of  compound  interest,  w'hich  had 
caused  a  great  tension  of  his  mind.  One  evening, 
after  dinner,  he  was  about  to  go  to  sleep  when,  as  he 
says:  "Without  the  slightest  encouragement  on  my 
part,  in  a  state  between  sleeping  and  waking,  I  began, 
without  the  smallest  volition  on  my  part,  to  calculate 
and  go  over  again  exactly  the  same  problems  as  when 
in  my  office.  The  cerebral  machine  had  been  set  in 
motion  too  violently  to  be  stopped,  and  this  involun- 
tary work  went  on  in  spite  of  me,  and  in  spite  of  all 
the  means  I  endeavored  to  employ  to  cause  its  cessa- 
tion, that  is  to  say,  for  from  about  three-quarters  of  an 
hour  to  an  hour  and  a  quarter."  Many  persons,  after 
an  evening  of  exhausting  study,  on  retiring  to  bed 
have  experiences  somewhat  similar  to  the  above. 
Healthy  persons  also  discover  a  little  of  this  cerebral 
inertia  in  their  disinclination,  or  even  absolute  inabil- 
ity, voluntarily  to  leave  a  task  in  which  they  are 
absorbed. 

Dr.  O.  O  Gibbs8  relates  the  history  of  a  large, 
muscular  man,  aged  fifty-five,  who  showed,  in  a 
permanent  and  exaggerated  form,  this  kind  of  auto- 
matic condition.  The  person  in  question  had  been  a 
hard  drinker  and  smoker,  but  had  suffered  from  no 
disease.  His  family  at  last  noticed,  however,  that 
his  mind  was  somewhat  affected.  His  memory  failed, 
and  he  would  tell  the  most  absurd  stories.  Gradually 
his  intelligence  diminished  and  his  will  became 
impaired.     When  he  began  to  do  a  certain  thing  he 

790 


had  no  power  to  stop  himself.  If  he  went  to  the  ban 
to  throw  down  hay  he  would  never  stop,  unless  inter 
fered  with,  until  he  had  pitched  off  the  whole  mow 
If  sent  out  to  bring  in  an  armful  of  wood  he  wool 
never  stop  until  the  pile  was  all  in,  or  the  room  \va 
full.  When  he  once  commenced  to  eat,  it  seemed  a 
if  he  could  never  cease.  As  his  mind  became 
affected  he  gradually  lost  the  power  of  balancini 
himself,  and  showed  a  constant  tendency  to  go 
ward  when  standing,  and  to  tip  over  backward  whei 
sitting.  He  slept  much.  His  strength  gradual!' 
failed,  and  he  died  with  no  marked  symptoms 
The  diagnosis  of  cerebral  softening  was  probabl' 
correct,  although  no  post-mortem  examination  wa 
made. 

The   Cerebral  Automatism  op  Insanity. Th. 

condition  of  cerebral  automatism  has  been  incorrect!' 
classed  as  one  of  the  forms  of  insanity.  Cerebri 
automatic  acts  occur  in  various  forms  of  insanity 
perhaps  most  strikingly  in  primary  dementia  and  Ii 
epileptic  insanity. 

Perhaps  the  automatic  cerebral  life  in  the  insane  i 
best  shown  in  dementia,  in  which  disease  only  th 
lowest  of  the  mental  functions  remain,  and  the  suffer, 
is  guided  only  by  the  impulses  and  stimuli  of  hi 
vegetative  system. 

In  secondary  dementia,  and  in  idiocy  and  othe 
states  of  mental  enfeeblement,  the  mental  activities 
so   much   as   remain,    are   more   or   less   automatic 

Medicolegal  Relations  op  Cerebral  Autoiu 
tism. — In  conclusion,  I  have  space  only  to  call  atten- 
tion to  the  very  evident  medicolegal  importance  of  e 
knowledge  of  cerebral  automatic  states.  This  applie- 
especially  to  the  more  frequently  occurring  form- 
such  as  those  of  artificial,  epileptic,  and  possibh 
inebriate,  automatism.  There  is  no  doubt  thai 
an  epileptic  automatic  is  irresponsible,  morally,  foi 
his  acts,  while  in  inebriate  automatism  the  court? 
would  sustain  the  medical  view. 

Charles  L.  Dana, 

References. 

1.  Berkley,  B.  F. :  Western  Journal  of  Medicine  and  Surgerv 
X.   S  ,  vol.  vi.,  p.  204. 

2.  Luys,  J.  B.:     The  Function  of  the  Brain,  p.  1S3. 

3.  Ciibbs.  O.  C. :  Pennsylvania  and  Independent  Medical 
Journal,  1S59,  ii.,  p.  12. 


Automobile,  Hygienic  Relations  of  the. — The  motor 
car  has  provided  a  source  of  health  to  a  great  many 
people;  in  others  it  has  developed  some  quite  un- 
pecedented  ailments,  and  even  diseases.  Many  gel 
physical  benefit  from  the  motoring  that  could  hardly 
come  to  them  in  any  other  way.  Used  rationally, 
that  is,  with  moderate  speed,  by  those  unable  for  one 
reason  or  another  to  exercise  themselves  in  walking, 
rowing,  riding,  or  the  like,  it  is  a  veritable  blessing. 
While  plenty  of  fresh  air  is  inhaled,  the  appetite  is 
improved,  the  emotions  are  soothed  and  satisfied  by 
ever  changing  scenes;  and  hitherto  unfamiliar  aspects 
of   life  interest  and   divert    from   introspection. 

Among  the  functional  and  other  disorders  attribut- 
able to  the  habitual  use  of  the  automobile  the  fol- 
lowing are  worthy  of  mention. 

Neuroses. — The  nervous  system  is  affected  in 
many  by  reason  of  the  excessive  strain  consequent 
upon  high  speeding  over  uncertain  roads,  minute 
attention  being  constantly  essential  for  the  avoidance 
of  obstacles.  The  eyes  are  strained  to  discern  wind- 
ings in  the  roads  and  conceivable  obstructions. 
Collisions  with  other  vehicles  must  be  guarded 
against.  The  brain  is  strained  in  the  constantly 
repeated  effort  to  decide  on  the  instant  which  way  lo 
turn  to  avoid  danger  of  all  kinds.  The  nerve-;  are 
strained  because  they  must  be  ever  ready  to  signal  to 
the   muscles    essential    for    the    government    of  the 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    S<  IKXCF.S 


\  ill'. in. -Ml.' 


nachine.     The     nerve     messages     hurry    upon     one 

mother  trying  to  shorten  the  time  of  their  delivery 

I  this  in   l  urn  exhausts  and  paralyzes  the  neurons 

vliicli  must  take  ami  forward  these  messages.     The 

notorist,  if  his  psychism  is  not  to  be  badly  affected, 

nusl    !»'  a  man  of   naturally  <|uiek   perception,  iron 

htvc,  and  imperturbable  self  control.     Then  the  pas- 

engers  constantly  fear  sudden  jar  or  accident;  their 

cles    are     fixed     involuntarily;     the    hands    are 

•lenched,  die  jaws  set;  the  whole  nervous  system  is 

igid    at    attention,    in    anticipation    of    untoward 

lopments. 

Attacks  of   hysteria   are  common  among  women. 

specially    young    married    women,    who    motor    ex- 

tvely;  these  attacks  are  due  to  relaxation  after 

train  in  a  long  and  rapid  run.  and  are  not  serious  in 

itherwise    normal    people.     There    is    also    nervous 

irostration  to  which  men  are  at  least  as  prone  as 

.11.     These   affections   seem   to   be   increasingly 

ommon   among    motorists.     They    yield    slowly    to 

reatment  and   (except   in  naturally  healthy  people 

vho  motor   infrequently)  have   a  cumulative  effect 

.Inch  it  is  difficult  to  treat   successfully. 

Women  seem  more  susceptible  than  men  to  all  the 
lihnents  brought  on  by  fast  riding,  and  they  are  not 
.1  by  nature  to  cope  with  wind  and  weather,  and 
he  strenuous  outdoor  life  contingent  upon  motoring; 
he  meeting  with  hard  knocks  and  hairbreadth  escapes 
■xhausts  rather  than  fortifies  them.  Their  nerve  re- 
ictions  have  not  been  trained  for  fast  motoring  and 
heir  more  timid  natures  require  increased  effort  in 
>rder  for  self  control.  Such  cases  of  hysteria  arise 
avariably  in  women  not  up  to  par  as  to  their  nervous 
ystems.  Yet  the  excitement  of  automobiling  ap- 
>eals  to  them;  the  more  they  get  of  it  the  more  they 
The  ever-increasing  stimulation  inherent  in 
his  indulgence  is  bound  sooner  or  later  to  end  in 
ollapse.  Deafness,  paralysis,  melancholia — such 
iffeetions  then  supervene.  For  such  cases  complete 
ibstinenee  from  motoring  and  entire  rest  are 
ibsolutely  essential,  though  mild  motoring  later  on 
nay  help  in  the  cure. 

Nervous  prostration  is  due  to  the  general  psychic 
iverstrain,  increased  perhaps  by  having  the  body 
jrotectcd  with  impervious  wraps.  This  affection 
■omes  on  gradually,  maybe  not  till  after  several  years. 
Jne  is  perhaps  unaware  of  any  illness  until  he  gives 
nit,  loses  power  and  control  over  his  nerves,  and 
suffers  a  final  breakdown.  Sports  too  liberally 
ndulged  in  are  just  as  prostrating  as  overwork  or 
worry. 

Sexual  impotence  has  been  observed  by  Notthafft  of 
Berlin  in  several  cases  of  wealthy  married  men  fond  of 
automobile  speeding,  and  in  one  case  of  a  chauffeur. 
Notthafft  slates  that  others  among  his  colleagues  have 
noted  the  same  phenomenon.  The  sexual  depression 
1  \  eloped  in  from  three  months  to  three  years  after 
lal  devotion  to  the  sport.  It  seems  due  to  a 
erebral  neurasthenia  induced  by  the  nervous  strain 
of  speeding,  for  the  normal  tone  is  recovered  when  the 
patients  drive  their  cars  at  a  low  speed,  such  as  does 
not  require  the  mental  concentration  and  the  anxiety 
which  would  tend  to  neurasthenia. 

Obstetrical  and  Gynecological  Conditions  are 
what  affected  by  the  automobile.  Edgar1  is 
inclined  to  believe  that  the  unfavorable  influ- 
ence of  the  motor  on  pregnancy  has  been  somewhat 
'•xaggerated,  and  that  the  motor  is  in  many  instances 
unfairly  set  down  as  causative  of  miscarriage.  The 
middle  third  of  pregnancy  is  more  liable  to  be  thus 
affected  than  any  other.  Certain  women  appear  to  be 
cially  susceptible  to  the  abortifacient  influence  of 
the  motor  and  certain  conditions  within  the  pelvis 
appear  to  favor  this  tendency.  One  type  is  especially 
prone  to  the  unfavorable  influence  of  the  vibration  and 
the  circulatory  changes  induced  by  excessive  motor- 
ing; this  is  found  in  women  with  relaxed  uterine  sup- 


ports, not  only  multigravidae,  but  also  primigra 
in  whom  even  in  the  middle  third  of  pregnancy  tl 
is  a  tendency  to  procidentia   ulirn.  even  after  the 

Uterus  rises  well  out   of  111''  pelvis,  the  presenting  part 

hangs  low.     Thi   i  are  cases  in  which,  in  prim 

ami  occasionally  in  multigravids,  the  lira. I  .  i 

the  pelvis  and  di   a  ad    •.'.ell  down  toward  tin-  pel   ic 

lloor    before    the   fortieth    week.       I      CI       ivi     

in  these  cases  is  liable  to  interrupt  pregnancy.     With 
limitations  regarding  speed  and  fill  igue,  Fdgar  permits 

even  patients  who  have  suffered  from  abortion  to  use 

the  auto bile  subsequently.  In  threatened  mis- 
carriage, presumably  caused  by  excessive  motoring, 
Edgar  finds  low  implantation  of  the  placenta  an  im- 
portant factor.  On  the  whole  he  considers  the  effect 
of  automobiling  either  a  negative  or  a  wholesome  one. 
E.  P.  Davis,- speaking  of  Motor  Car  .Miscarriages  says 
he  has  observed  that  a  great  shock  or  injury  may  bo 
better  borne  by  pregnant  women  than  frequently  re- 
peated shock,  such  as  that  transmitted  by  the  sewing 
machine  to  the  foot.  Cases  cited  by  him  illustrate  that 
motoring  during  the  early  months  of  pregnancy  is  fre- 
quently followed  by  abortion.  The  danger  seems  to  bo 
that  the  rapid  motion  of  the  automobile  subjects  the 
patient  to  small  and  frequent  jars.  Abortion  follow- 
ing motoring  is  slow  and  insidious,  without  bright 
hemorrhage  and  pain.  These  abortions  are  likely  to 
be  incomplete  and  to  require  curetting.  Motoring  is 
dangerous  in  the  early  months  of  pregnancy,  but  in 
the  later  months,  and  with  reasonable  precautions  as 
to  smoothness  of  roads  and  moderation  of  speed,  it 
may  prove  very  salutary. 

Eye  Troubles. — C.  Clements,3  points  out  that 
the  chauffeur  must  be  an  accurate  judge  of  pace  and 
distance,  and  this  necessitates  perfect  and  binocular 
sight  and  quite  unusual  acuteness  of  vision.  In  a 
series  of  cases  of  motorists  who  consulted  him  regard- 
ing their  eyesight  after  having  undergone  a  number  of 
minor  mishaps,  most  of  these  latter  might,  have  been 
much  more  serious  but  for  sheer  luck.  In  all  these 
cases  there  were  errors  of  refraction — mostly  hyper- 
metropia;  in  all,  too,  the  danger  of  accidents  that 
might  arise  from  visual  abnormality  disappeared 
with  correction  of  the  error  of  refraction.  In  most 
of  these  cases  the  accidents  occurred  about  dusk  and 
at  turns  of  the  road,  the  motorist  miscalculating  the 
distance  and  running  into  a  ditch  or  bank.  Both  eye 
and  nerve  strain  will  emphasize  an  error  of  vision  or 
a  deficiency  of  muscular  tone.  Clements  has  observed 
that  the  convex  goggles  worn  by  autoists  are  practi- 
cally hyperopic  lenses;  and  that  they  may  just  turn 
the  balance  in  favor  of  spasm  of  accommodation. 
We  have  long  subjected  locomotive  engineers  to 
certain  visual  test;  this  should  certainly  also  obtain 
for  motorists. 

"Auto-eye"  is  a  spasmodic  affection  of  the  ciliary 
muscles;  speeding  over  an  unknown  country,  at  a 
rate  approaching  a  mile  a  minute,  is  a  greater  strain 
than  the  normal  human  eye  has  thus  far  had  to  bear. 
The  "auto-eye"  will  not  be  a  long  time  in  developing 
if  the  organ  is  not  fit  to  begin  with,  and  if  the  strain 
of  business  life,  strong  cigars,  and  other  excesses  have 
diminished  capacity  for  meeting  the  unnatural 
demands  upon  the  sight. 

Conjunctivitis  is  due  to  wind  and  dust  coupled  with 
high  speed;  it  has  various  forms  from  a  simple  hyper- 
emia to  a  contagious  purulent  exudation.  The  treat- 
ment is  that  ordinarily  given  for  this  inflammation. 

Muscular  Strains. —  Wryneck  is  frequent  among 
women  motorists;  the  head  becomes  twisted  by 
reason  of  the  tense  strain,  the  result  being  manifest 
when  the  run  is  over.  The  return  to  the  natural 
position  causes  severe  pain  from  the  strained  tendons 
and  ligaments.  Women  have  been  made  hysterical 
by  this  affection;  there  is  no  occasion  for  alarm,  for 
the  return  to  the  normal  is  quickly  achieved  by 
massage. 


791 


Automobile 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


"Auto-leg,"  that  is,  stiffness,  lameness,  and  pain  in 
walking,  is  due  to  sitting  in  a  fixed  position  for  hours, 
while  the  nerves  and  muscles  are  under  strain.  It 
is  a  form  of  cramp  and  passes  off  within  a  reasonable 
time  unless  the  patient  has  passed  middle  life,  when 
it  may  be  obdurate.  Even  the  latter  cases,  however, 
yield  to  massage  and  to  a  lotion,  except  when  there  is 
a  tendency  to  sciatica.  Sciatica,  indeed,  is  brought 
on  by  the  strain  of  a  long  series  of  rides  in  which  the 
nerves  and  muscles  undergo  consecutive  shocks 
through  bumping  and  jolting— strain  of  which  the 
patient  may  hardly  be  conscious  at  the  time,  but 
which  may  manifest  itself  perhaps  a  day  afterward. 
Only  time,  _  nutrition,  and  temporary  avoidance  of 
the  cause  will  bring  such  patients  back  to  the  normal. 

Respiratory  Disorders. — For  most  people  unac- 
customed to  motoring  a  speed  beyond  twenty  miles 
an  hour  makes  respiration  difficult  by  reason  of  the 
pressure  of  the  wind.  All  grades  of  exhaustion  may 
result  from  this;  and  possibly  the  heart  may  be 
dilated.  _  D.  Bryson  Delavan,1  makes  some  valuable 
observations:  Whilst  in  theory  pulmonary  diseases 
should  be  much  increased  by  motoring,  such  is  practi- 
cally not  the  case.  Nevertheless  acute  catarrhal 
states  of  the  ears  and  the  air  passages,  and  advanced 
tuberculosis  with  elevated  temperature  should  cer- 
tainly contraindicate  motoring.  In  suitable  cases  the 
automobile  is  a  valuable  agent;  but  Delavan  insists 
upon  good  roads,  well-paved,  dust-free  streets,  and 
the  enforcement  of  laws  against  smoke  and  fumes — 
laws  such  as  have  been  made  and  are  enforced  in  most 
European  cities. 

The  occupation  of  tester  of  automobiles  is  a  natural 
concomitant  of  this  industry.  Such  an  one  passes  a 
number  of  hours  daily  in  the  automobile,  and  is 
subject  to  the  ill  effects  of  the  exhaust  pipes  while 
thus  engaged.  Nasal  deflections  and  like  abnormal- 
ities which  in  other  occupations  may  pass  unnoticed 
develop  in  this  class  of  men  pathological  conditions 
requiring  treatment.  The  use  of  the  motor  predis- 
poses to  the  extension  of  acute  conditions  that  are 
present;  and  these  individuals  suffer  especially  from 
extensive  complications  when  they  use  the  open 
machine.  Cases  of  facial  paralysis  develop,  with 
the  motor  car  as  the  especial  causative  factor,  and 
attending  ear  and  throat  complications.  When 
these  testers  take  high  speed  they  are  apt  to  keep 
their  mouths  upon;  with  speeding  they  develop  the 
"automobile  face,"  and  so  are  prone  to  extra  danger 
of  infection. 

_  Mouth  breathing  is  here  as  vicious  as  in  any  other 
circumstances;  the  air,  unwarmed  as  it  would  be  in 
nasal  passage,  enters  the  bronchi  and  is  bound  to 
result  in  congestion  or  catarrh.  Extensive  pneu- 
mococcus  infections  are  said  to  have  resulted  in  this 
way.  And  motorists  certainly  "take  cold"  by 
exposure  and  by  dust  irritation. 

Before  the  wind-shield  came  into  use  the  motor  car 
was  responsible  for  many  cases  of  sinus  disease — 
especially  of  the  frontal  sinus,  induced  by  the  air 
pressure  and  strong  currents  of  cold  air  against  the 
face. 

Tetanus. — An  odd  iniquity  attributed  to  the 
automobile  is  that  in  England  at  least  tetanus  has 
increased  despite  the  use  of  tetanus  antitoxin  and  of 
increasing  knowledge  of  the  mode  of  invasion  of  the 
disease.  Between  1SS9  and  1900  the  average  number 
of  deaths  from  this  cause  in  England  and  Wales  was 
between  thirty  and  forty.  In  1900  there  were  sixty- 
six;  in  1902  there  were  201;  from  1903  to  190S  257, 
257,  248,  254,  226  and  180  such  deaths  respectively. 
The  British  Medical  Journal  has  suggested  that  the 
motor  car  is  the  cause  of  this  increase.  One  would 
think  the  contrary,  because  the  concomitant  reduc- 
tion of  the  number  of  horses  in  the  streets  and  roads 
would  diminish  the  amount  of  animal  excreta  lying 
in  them.     But  simultaneously  the  distribution  of  the 

792 


remaining  excreta  has  been  greatly  increased  by  the 
dust-raising  powers  of  the  motor  cars,  so  that  the 
germs  harbored  therein  have  been  scattered  far  and 
wide. 

Most  human  beings  are  at  present  not  fitted  for 
high-speeding;  those  who  thus  indulge  themselves 
must  generally  pay  somehow  for  the  undue  and  lone- 
protracted  stress  and  strain.  All  motorists  should 
from  time  to  time  consult  their  physicians  regarding 
any  possible  conditions  which  may  develop,  and  which 
they  would  themselves  be  unable  to  detect. 

Chauffeur's  fracture  is  practically  a  Colics' 
fracture  produced  from  a  "back  fire"  of  the  motor 
which  suddenly  throws  the  crank  handle  back  in  the 
opposite  direction  from  which  it  is  being  turned. 
The  cause  is  a  premature  explosion  in  the  cylinder' 
from  the  spark  lever  being  too  far  advanced,  or  by 
reason  of  a  short  circuit  in  the  electric  wiring,  or  of  a 
slipping  of  the  commutator.  The  fracture  always 
comes  upon  the  handle  being  pushed  down,  the 
resulting  back-kick  producing  a  blow  on  the  palm 
exactly  the  same  as  falling  on  the  ground  and  striking 
the  palm.  The  shock  is  transferred  to  the  radius 
which  fractures  at  its  weakest  point — the  epiphyseal 
line.  However,  the  line  of  fracture  does  not  follow 
this  epiphyseal  line  entirely  through  the  radius  from 
side  to  side,  but  separates  the  triangular  piece  on  the 
outer  thumb  side.  This  is  by  reason  that  the  epiphy- 
seal line  takes  this  direction;  and  most  of  the  force  of 
the  blow  is  on  this  side,  due  to  the  way  the  handle  is 
grasped  with  the  thumb  around  it,  the  pressure  being 
exerted  at  this  point.  There  is  little  or  no  displace- 
ment of  the  fragment,  reduction  is  unnecessary,  and 
the  permanent  results  are  usually  good. 

The  injury  is  not  always  of  the  type  thus  described; 
the  line  of  the  fracture,  the  number  of  fragments,  the 
amount  of  impaction,  the  backward  displacement,  the 
involvement  of  the  styloid  process  of  the  ulna,  the 
swelling,  tenderness,  and  pain  may  be  just  as  varied  as 
in  the  Colles'  fracture  produced  in  the  usual  way. 
If  the  patient  is  aged  eighteen  or  younger,  a  com- 
parative radiograph  of  the  normal  wrist  should  lie 
made,  as  union  of  the  epiphysis  will  not  take  place 
until  that  age. 

A  crank  handle  has  been  patented5  to  prevent 
this  accident;  there  is  in  this  handle  a  crank  lever 
which  is  composed  of  two  parts  held  together  by  a 
spring  clutch.  This  will  withstand  any  steady  pull; 
but  a  sudden  shock  will  break  the  handle  in  two, 
fracturing  the  handle  rather  than  the  wrist.  Many 
cars  are  now  being  equipped  with  "self-starter.-." 
so  eventually  the  "chauffeur's  fracture"  will  be  of 
historical  interest  only. 

The  radiograph  has  been  most  valuable  in  the 
diagnosis  and  treatment  of  these  fractures.  There 
should  be  two  views:  anteroposterior,  with  the  palm 
on  the  plate;  and  lateral,  with  the  thumb  up,  the  tube 
centred  directly  over  the  radius.  The  lateral  view  is 
very  important,  as  it  will  show  what  deformity  may 
be  present;  the  anteroposterior  view  may  disclose  no 
deformity,  though  there  may  be  great  displacement. 
If  any  deformity  is  shown  by  the  radiographs  the 
fracture  should  be  reduced,  placed  in  an  antero- 
posterior splint  in  the  usual  way  and  then  radio- 
graphed in  the  lateral  position  only,  to  see  if  the 
position  is  good.  The  typical  chauffeur's  fracture 
can  be  taken  out  of  splint  within  a  week,  massage  and 
passive  motion  begun,  and  recovery  completed  within 
three    weeks.     Severer    types    will    take   longer. 

John  B.   Hubkr. 

References. 

1.  Edgar,   James  Clifton:  American  Journal  of  Obstetrics  and 
Disease  of  Women  and  Children,  June,  1911. 

2.  Davis,  E.  I'.:  .Medical  Record,  January  30,  1909. 

3.  Clements,  f'.:  British  Medical  Journal,  December  .8.  1906. 

4.  Delavan,  D.  Bryson:  Medical  Record,  August  20,  1910. 

5.  Scientific  American,  January  6,  1912. 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Autopsy 


Autopsy. — Synonyms:    Postmortem      examination; 

ropsy;  Latin,  Autapsia  rmlan  rica,  sectio,  obductio; 

Frencn,     nicropsie,     autopsie    cadaveriuqe;     German, 

•henschau,  Sektion,  Obduktion.     An  examination 

>f  the  body  after  death,  to  investigate  the  condition 

of  the  various  part-  of  tin'  body,  to  note  any  changes 

in   the   organs,   and   to   determine  as  far  as 

possible  tin'  cause  of  any  such  changes. 

[The  modifications  of  the  technique  of  an 
autopsy,  advisable  in  cases  in  which  medi- 
colegal considerations  may  be  involved,  are 
i  in  the  article,  following  this,  entitle, 1 
Autopsy,  medicolegal  relations  of  tin  .] 

General    Coxsideratioxs. — An    article 

intended,   as  this  is,  to  aid 

the  general  practitioner  in 

making  a  postmortem   ex- 
amination would  fall  short 

of  the  mark  were  it  to  give 

simply  the  various  cuts  to 

be  made  in  order  to  expose 

and  permit  of  the  examina- 
tion of  the  different  organs. 

While  it  would  be  out  of  the 

question,  in  a  handbook,  to 

detail  all  the  possible  alter- 
ations in  the  viscera,  and 

the  method  of  their  recog- 
nition, yet  there  are  several 

points,  apart  from  the  ques- 
tion of  the  cuts  to  be  made, 

which  deserve  attention. 
The    sooner  after  death 

an   autopsy   is    made,   the 

better,     as    putrefactive 
Fia.  530.    changes  modify  the  appear-  Fig.  531. 

ances    of    pathological    as 
well  as  of  normal  organs. 

In  case  an  autopsy  is  to  be  held,  the  undertaker 
should  be  requested  to  postpone  the  injection  of  any 
embalming  fluid  until  the  examination  has  been 
made,  as  the  preservative  fluids  modify  considerably 
the  appearances,  owing  to  the  coagulation  of  albumen 
and  the  alteration  of  color  produced  thereby.  If  for 
any  reason  the  autopsy  is  to  be 
made  late,  it  is  desirable,  where 
this  is  possible,  to  have  the  body 
kept  on  ice. 

What  shall  the  physi- 
cian  take   to  the  house, 

and  what  ma}-  he  rely  on 

finding  there?   He  should 

take  instruments,  twine, 

a  sponge,   and  a  rubber 

sheet  a  yard  square.    The 

fewer  instruments  he  can 

get  along  with  the  better; 

there    is    less    to    carry; 

fewer    to    soil,    and    less 

liability  of  leaving   any 

behind. 

One     needs     a    stout 

knife  from  seven  to  nine 

inches  in  length,  of  which 

half  belongs   to  the 

handle,  half  to  the  blade. 

The  blade  should  be  from 

three-quarters  of  an  inch 
Fig.  532.    to  an  inch  and  a  quarter 

in  width,  varying  accord- 
ing to  the  length  (Fig.  530). 

Also  a  sharp-pointed  scalpel  and  a  medium-sized 
pair  of  scissors.  A  pair  of  small,  probe-pointed  scis- 
sors, as  represented  in  Fig.  531,  is  very  useful,  though 
not  absolutely  necessary. 

One  needs  also  a  pair  of  forceps  (Fig.  532)  and  a 
large  needle  (a  sail    needle   that   can   be  bought   at 


Fig.  533. 


a  hardware  store  for  a   few    cents    will   answer   the 
purpose). 

Two  other  instruments,   not   absolutely  essential, 
though   very  convenient,   are 
the    costotome    (Fig.  533),  a 

StOUt  pair  of  shears  for  cutting 

the  ribs  when  calcified,  and 
the  enterotome  1 1  ig.  ."::  i  .  a 
pair  of  long-handled  scissors 
having  one  blade  terminating 
in  a  rounded,  hooked  end, 
used  in  opening  the  intesl 

This  outfit  \\ill  serve  for  any 
autopsy  in  which  the  brain  and 
cord  are  not  to  be  removed. 

To  open  the  head,  a  saw 
(Fig.  5Sr,).  a  chisel  I  ig.  536), 
and  a  hammer  having  the 
handle  terminating  in  a  hook 
(Fig.  537)  are  necessary. 

To  remove  the  spinal  cord, 
a  chisel  known  as  a  rachitome 
(Fig.  538)  is  very  useful, 
though  the  ordinary  straight 
chisel  will  answer  the  purpose. 

One  of  the  first  requisite-  in 
an  autopsy  made  in  a  private 
house  is  cleanliness,  and  in  no 
way  is  this  so  much  aided  as 
by  having  a  good  sponge;  a 
medium-sized,  soft,  lamb'  — 
wool  sponge  is  the  best.  The 
physician  should  never  rely  on  Fig.  534. 

finding    this    article    at     the 

house,  but  should  take  one  with  him.  After  the 
autopsy  it  can  be  washed  with  soap  and  water,  and 
i-  1  lien  ready  for  use  at  the  next  autopsy.  The  better 
the  quality  of  the  sponge  the  longer  it  will  last  and 
the  better  work  it  will  do. 

nAt  the  house  there  can  be  obtained  the 
following  articles:  half  a  dozen  newspapers, 
several  pieces  of  old  cotton  cloth,  a  slop 
pail,  and,  if  there  be  no  running  water,  a 
J  pitcher  of  water. 

The  physician  cannot  be  too 
;  t  careful  to  avoid  wounding  the 
|  If  feelings  of  the  family  in  the  house 
where  the  autopsy  is  made.  A 
room  left  in  a  state  of  confusion, 
or  the  soiling  of  carpet,  chairs,  or 
utensils  with  drops  of  blood,  not 
only  gives  offence  to  the  friends, 
but  often  prevents  the  careless 
physician  getting  permission  for 
autopsies  in  the  future,  as  the 
family  are  very  likely  to  give 
their  neighbors  an  account  of  Dr. 
A.'s  slovenliness. 

In  making  an  autopsy  in  a  pri- 
vate house,  it  is  often  necessary 
to  alter  the  position  of  table, 
chairs,  or  the  like.  Before  any 
change  is  made,  it  should  be  the 
duty  of  the  physician  to  take 
mental  note  of  the  arrangement 
of  articles  in  the  room,  in  order  pIG  ggg 
that,  when  the  autopsy  is  finished, 
everything  may  be  restored  to  its  former 
place. 

All  articles  required  in  making  the  ex- 
amination should  be  obtained  before  the 
autopsy  is  begun. 

The  body  will  be  found  either  upon  a 
Fig.  535.     bed,  with  or  without  a  board  under  it,  or 
upon  an  undertaker's  frame  set  on  horse-, 
or  in  an  ice  box.     In  any  of  these  positions  the  ex- 
amination  can   be  made  without   moving  the  body, 
unless   the   head   is   to  be  opened,  which  cannot  be 

793 


Autopsy 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Fig.  537. 


done  with  the  body  in  an  ice  box  except  the  head  be 
raised  and  supported  above  the  level  of  the  box. 

The  clothing  covering  the  trunk  should  be  torn 
down  the  middle  line,  in  front,  and  drawn  to  either 
side.  Newspapers  should  then  be  tucked  in  at  the 
sides  of  the  body,  beneath  the  head  and  over  the 
pubes,  so  as  to  cover  the  clothing,  but  to  leave  exposed 
the  whole  anterior  surface  of  the 
trunk  from  the  chin  to  the  pubes. 
Should  any  fluid  be  spilled  later,  it 
will  fall  upon  the  paper  and  not  soil 
the  clothing. 

The  rubber  sheet  should  be  spread 
out  on  the  floor  near  where  the 
operator  stands;  the  slop  pail  is  to 
be  placed  upon  it;  the  sponge 
should  be  moistened  and  be  laid 
near  the  hand,  ready  for  instant 
use;  the  instruments  are  to  be 
placed  upon  a  newspaper  spread 
out  upon  the  thighs  of  the  corpse. 
All  appliances  are  to  be  made  ready 
before  any  cutting  is  done.  Once  a 
beginning  is  made,  the  performer's 
hands  become  so  bloody  that  noth- 
ing can  be  touched  later  without 
soiling. 

The  physician  should  examine 
his  hands  carefully  with  reference 
to  the  presence  of  cuts  or  abrasions 
of  any  sort.  If  there  be  any,  they 
should  be  covered  with  contractile 
collodion.  Do  not  use  flexible 
collodion;  it  is  likely  to  peel  off 
during  the  autopsy.  [The  use  of 
rubber  gloves  is  preferable.]  While 
performing  the  autopsy  the  operator 
should  be  careful  to  avoid  scratch- 
ing, cutting,  or  pricking  his  hands. 
If  there  is  a  suspicion  in  his  mind  of  a  wound  received, 
it  is  best  to  wash  and  examine  the  .place  at  once. 
The  man  who  performs  an  autopsy  may  well  apply  to 
himself  Spenser's  line,  "  Of  hurt  unwist  most  daunger 
doth  redound."  Any  wound  should  be  thoroughly 
washed,  squeezed,  sucked,  disinfected,  and  covered 
with  collodion.  The  writer's  experience  leads  him  to 
believe  that  specialists  in  pathological  anatomy, 
having  their  hands,  as  they  do,  almost  daily  in  contact 
with  dead  bodies,  are  far  less  liable  to  infection  from 
scratches  or  cuts  than  are  those  who  only  occasionally 
make  an  autopsy.  Hence  the  greater  importance 
of  care  in  this  respect  on  the  part  of  the  general 
practitioner. 

Every  autopsy  should  be  thorough,  and  should 
be  made  according  to  some  definite  method.  The 
physician  ought  always  to  bear  in  mind  the  fact  that 
an  autopsy  once  made  is  made  for  all  time.  There 
is  no  going  back,  as  there  is  to  the  bedside,  for  further 
examination  in  regard  to  obscure  points.  Whatever 
is  to  be  observed  must  be  observed  before  the  physi- 
cian leaves  the  house.  Further,  when  organs  or 
parts  are  separated  in  the  dissection  their  relations 
are  lost.  Hence  the  importance  of  noting  certain 
points  before  organs  have  been  removed  or  their 
relation  to  other  parts  lost.  A  proper  order  in  the 
various  steps  in  an  autopsy  is  of  the  first  consequence. 
That  method  is  obviously  the  best  by  means  of 
which  the  most  will  be  discovered  and  the  least  over- 
looked. Nothing  but  practical  experience  can  deter- 
mine such  a  method,  and  the  one  given  here  is  that 
which  has  been  found  by  repeated  trials  to  give  the 
best  results.  It  is  essentially  the  method  taught  by 
Virchow  and  his  pupils. 

Method  of  Making  a  Postmortem  Examination. 
— An  autopsy  consists  of  two  parts — the  external 
examination  or  inspection,  and  the  internal  examina- 
tion.    In  a  medicolegal  autopsy  the  inspection  is  of 

794 


the  first  importance.  In  the  ordinary  autopsy 
inspection  should  consist  in  noting  the  size,  develop- 
ment, and  nutrition  of  the  body.  Under  the  head  of 
nutrition  the  amount  of  subcutaneous  adipose  tissue 
and  the  size  of  the  muscles  should  be  observed,  the 
former  by  pinching  up  a  fold  of  the  skin.  The  pres- 
ence or  absence  of  rigor  mortis,  the  degree  of  lividity 
of  the  dependent  portions,  should  be  noted.  Among 
the  common  abnormalities  are  variations  in  the  color 
of  the  skin,  edema  of  subcutaneous  connective  tissue, 
localized  or  diffuse,  and  localized  lesions  of  many 
kinds.  A  greenish  discoloration  of  the  abdomen,  if 
present,  should  always  be  noted,  as  it  indicates  that 
putrefactive  changes  have  begun,  and  this  fact 
modify  the  interpretation  of  appearances  observed  in 
the  internal  organs. 

Internal  Examination. — In  the  majority  of  autopsies 
performed  by  the  general  practitioner  the  examination 
is  limited  to  the  thorax  and  abdomen.  In  case  the 
head  is  to  be  opened  it  should  be  done  before  the 
thorax,  otherwise  much  of  the  blood  in  the  veins 
will  have  escaped  through  the  divided  superior  cava, 
and  a  correct  determination  of  the  amount  of  blood 
originally  in  the  brain  cannot  be  made.  The  spinal 
cord  is  best  removed  after  the  brain,  but  before  the 
thoracic  and  abdominal  cavities  are  opened,  espe- 
cially in  a  private  house,  because  of  the  soiling  which 
is  sure  to  take  place  from  escape  of  blood  from  the 
latter  cavities,  if  they  have  been  first  examined, 
when  the  body  is  turned  on  its  face. 

The  best  order  of  procedure,  then,  is  brain,  spinal 
cord,  thoracic  and  abdominal  organs.  Inasmuch  as 
only  the  thorax  and  abdomen  are  examined  in  the 
majority  of  cases,  the  method  of  doing  these  will  be 
given  first,  then  the  method  of  examination  of  the 
brain,  and  finally  that  of  the  spinal  cord. 

The  character  of  the  incisions  in  an  autopsy  is  the 
opposite  of  that  of  the  incision  in  an  ordinary  dissec- 
tion. In  a  dissection  one  uses  the  point  of  a  scalpel 
held  like  a  pen,  the  fingers  and  wrist  alone  being 
moved.  The  point  of  the  knife  describes  the  arc  of  a 
circle,  thus  making  a  series  of  irregular 
nicks.  Although  such  cuts  are  well 
adapted  to  the  isolation  of  parts  in  an 
anatomical  dissection,  yet  tliey  are  the 
worst  possible  for  removing  organs  and 
displaying  the  interiors,  requiring  much 
time  and  leaving  an  irregular,  hacked 
surface.  The  cuts  to  be  made  in  an 
autopsy  are  long,  sweeping  ones,  using 
the  whole  cutting  edge  of  a  large  knife 
held  firmly  in  the  fist  in  a  line  with  the 
forearm;  the  wrist  should  be  kept  im 
movable,  the  elbow  and  shoulder  joints 
alone  being  moved.  In  this  way  one 
may  rapidly  make  large  incisions  having 
smooth  surfaces  and  a  straight  bottom. 

One  other  point  is  wwthy  of  mention. 
All  parts  should  be  put  upon  the  stretch 
when  they  are  incised;  but  put  them 
upon  the  stretch  first,  then  cut.  Never 
try  to  seize  and  cut  at  the  same  time,  as 
one  is  in  this  way  liable  to  cut  one's  self. 

To  examine  the  thorax  and  abdomen, 
take   the  large  knife  already  described 
(Fig.   530,    grasp   it   firmly  in  the  fist, 
make   an   incision   in   the   middle   line 
anteriorly,    beginning    at    the    sternal 
notch  and  ending  at  the  pubes.      The 
knife   should    be   held    parallel    to   the      Fig.  538. 
body,  so  that  its  whole  cutting  edge  is 
brought  into   use.      Over   the   sternum    the  incision 
should  be  carried  to  the  bone;  over  the  abdomen,  to 
a  depth  varying  with  t lie  thickness  of  the  abdominal 
wall,  going  nearly  but  not  quite  through  it. 

It  is  best  to  carry  the  long  primary  incision  to  the 
left  of  the  umbilicus,  so  as  to  avoid  the  round  liga- 
ment.     Next,  by  means  of-  several  short  cuts  carry 


REFERENCE    IIAXDHOOK    OF   THE    MEDICAL    SCIENCES 


Autopsy 


the  incision  through  tin;  abdominal  wall  at  the  tip  nf 
the  sternum,  making  it  long  enough  to  admit  two 
fingers.  Insert  the  fore  and  middle  lingers  of  the 
left  hand  into  this  incision,  and  make  strong  upward 
and  outward  traction  on  the  right  half  of  the 
abdominal  flap.     This  serves  the  double  purpose  of 

drawing  away  the  flap  from  the  intestines,  thereby 
lessening  the  risk  of  cutting  them,  and  it  puts  the 
abdominal  wall  upon  the  stretch,  permitting  of  its 
easier  incision.  Now  complete  the  cut  through  the 
abdominal  wall  to  the  pubes. 

\e\t  divide  the  pyramidales  muscles  at  their 
attachment  to  the  pubes;  this  allows  of  a  greater 
ral  withdrawal  of  the  flaps,  and  gives  better 
opportunity  for  the  examination  and  removal  of  the 
abdominal  organs.  In  some  countries  it  is  customary 
to  make  transverse  counter  incisions  in  the  abdominal 
wall  from  the  umbilicus  outward.  This  is  a  bad 
practice.  It  is  unnecessary  so  far  as  room  is  con- 
cerned, and  there  is  the  disadvantage  of  increased 
mutilation,  more  sewing,  and  greater  liability  of 
leakage. 

While  the  long  primary  incision  is  being  made  the 
operator  should  have  the  sponge  ready  to  absorb  any 
fluid  that  may  escape.  If  there  be  much  fluid  in  the 
abdominal  cavity,  it  should  be  removed  at  this  stage. 

The  next  step  in  the  autopsy  is  to  determine  the 
position  of  the  arch  of  the  diaphragm.  To  do  this, 
insert  the  right  hand,  palm  upward,  beneath  the  ribs; 
pass  it  along  the  inner  surface  of  the  ribs  until  the 
highest  point  of  the  diaphragm  is  reached,  remember- 
ing to  go,  on  the  right  side,  to  the  outside  of  the 
falciform  ligament  of  the  liver.  Put  the  forefinger  of 
the  left  hand  upon  the  external  surface  of  the  thorax 
corresponding  to  the  position  of  the  fingers  inside. 
Withdraw  the  right  hand  and,  beginning  at  the 
clavicle,  count  downward  ribs  and  interspaces  until 
the  finger  of  the  left  hand,  previously  placed  on  the 
outside,  is  reached.  This  gives  the  position  of  the 
arch.  Its  usual  position  is  the  fourth  rib  on  the 
right,  and  the  fourth  interspace  or  fifth  rib  on  the 
left.  It  is  lowered  when  the  lung  is  solidified,  and 
when  there  is  fluid  or  gas  in  the  pleural  cavity.  The 
fluid  or  gas  may  be  so  abundant  as  to  bulge  the 
diaphragm  downward.  (To  determine  presence  of 
gas  in  pleural  cavity,  see  later.) 

The  next  step  is  the  removal  of  skin  and  muscle 
from  the  anterior  surface  of  the  thorax,  so  as  to  lay 
bare  the  sternum,  cartilages,  and  bony  ribs  for  a 
distance  of  two  to  three  inches  outside  the  articular 
line. 

The  abdominal  flap  is  seized  in  its  upper  part  by  the 
left  hand,  and  turned  forcibly  outward;  by  doing  this 
the  rectus  abdominis  at  its  point  of  origin,  the  lower 
margin  of  the  ribs,  and  the  attachment  of  the  dia- 
phragm are  exposed.  The  heel  of  the  blade  of  the  large 
knife  is  now  placed  upon  the  origin  of  the  rectus,  and 
by  means  of  a  single  sweeping  stroke,  carried  just 
above  the  lower  border  of  the  ribs,  the  rectus  and  the 
diaphragmatic  attachments  are  severed.  Then  seize 
the  flap  a  little  higher  up,  turn  it  forcibly  outward  so  as 
to  put  the  muscles  on  the  stretch,  and  divide  the  parts 
which  have  been  made  tense.  Continue  the  cuts 
in  like  manner  until  the  ribs  on  the  right  side  are  ex- 
posed, removing  all  the  muscle  with  the  flap  so  as  to 
leave  the  ribs  clean.  Repeat  the  process  on  the  left 
side.  Then  expose  the  sternoclavicular  articulation 
by  dividing  subcutaneously  the  tissues  that  cover  it. 

Before  removing  the  sternum  a  general  inspection 
of  the  abdominal  cavity  should  be  made,  to  note 
whether  there  be  an  increase  in  the  amount  of  the 
serous  fluid  normally  present,  or  abnormal  contents. 
The  reason  for  making  the  cursory  examination  at 
this  stage  of  the  autopsy  is  that  if  there  be  fluid  in 
either  of  the  pleural  cavities,  some  of  it  will  be  likely 
to  escape  into  the  peritoneal  cavity  on  removal  of  the 
sternum;  hence  it  would  be  impossible  to  determine 
later  whether  fluid  found  in  the  abdominal  cavity 


was    there    originall\    or    had    come    from    the    pleural 

r:i\  ity. 

If  pneumothorax  is  suspi  cted,  the  pre  ence  of  gas 
in  the  pleural  cavity  should  be  determined  at  this 
stage  of  the  autopsy.  It  is  best  done  by  making  a 
double  fold  of  the  skin  flap  over  the  anterior  portion 

Of  the  I  liorax  On  the  suspected  side.       Water  is  poured 

into  the  space  between  the  folds,  making  a  little  pool. 
The  sharp-pointed  scalpel  is  now  driven  through  the 

muscle  of  an    intercostal   space,    where   the   water  lies, 

and  the  effect  noticed.     If  there  be  gas  in  the  pleural 

cavity,  it  will  escape  by  bubbling  through  the  liquid; 
otherwise  the  water  will  disappear  through  the 
opening.  One  must  not  mistake  the  collection  of 
gas  from  putrefactive  changes  in  the  pleural  cavity 

for   gas    winch    has   collected    during   life.       If   present 

from  putrefaction,  it  will  be  double-sided,  and  then- 
will  be  other  evidence  of  putrefactive  changes  in  the 
tissues. 

The  sternum  is  now  to  be  removed.  This  is  done 
by    opening    the    sternoclavicular   articulation,    and 

dividing  the  cartilages  of  the  ribs  about  one-eighth  of 
an  inch  from  their  junction  with  the  bony  ribs.  The 
knife  to  be  used  is  the  small  pointed  scalpel  already 
described.  The  guide  to  the  position  of  the  sterno- 
clavicular articulation  is  the  tendon  of  the  sternal 
attachment  of  the  sternocleidomastoid  muscle.  In- 
sert the  knife  above  the  clavicle  about  one  inch 
outside  this  tendon;  then  by  an  up-and-down 
motion  divide  the  soft  parts  till  the  tendon  is  reached; 
turn  the  knife  so  as  to  enter  the  joint;  then  follow 
the  joint  in  a  semicircle,  with  the  same  up-and-down 
motion  of  the  knife,  not  trying  to  guide  it,  so  far  as  its 
vertical  direction  is  concerned,  for  the  plane  of  the 
joint  is  a  constantly  varying  one;  hence  the  import- 
ance of  holding  the  knife  loosely  in  the  fingers  and 
letting  it  take  its  own  course.  Do  not  remove  the 
knife  after  the  joint  has  been  opened,  but  continue 
the  incision  outward  along  the  under  border  of  the 
clavicle  for  an  inch  outside  the  joint,  then  turn  the 
knife  at  right  angles  to  its  former  position  and  cut 
the  first  rib.  In  opening  the  sternoclavicular  joint, 
care  should  be  taken  not  to  carry  the  point  of  the 
knife  below  the  inner  part  of  the  joint,  as  the  in- 
nominate veins  lie  beneath  and  are  liable  to  be  cut. 

The  costal  cartilages  are  to  be  cut  in  the  place  indi- 
cated above  by  a  quick,  forcible  stroke  with  the  scalpel, 
the  heel  of  the  knife  striking  upon  the  next  rib  below 
as  the  blade  incises  the  rib.  In  this  way  the  blade  is 
prevented  from  going  too  deeply,  and  thereby  in- 
juring the  lung.  All  the  cartilages  having  been 
divided,  the  sternum  is  to  be  depressed  below  the 
level  of  the  bony  ribs  and  the  intercostal  muscles  cut, 
the  knife  being  held  parallel  to  the  ribs  to  avoid 
cutting  the  lung.  Remove  the  sternum  by  lifting  its 
lower  end  up,  cutting  the  attachments  of  the  dia- 
phragm to  it,  and  also  the  tissues  of  the  anterior 
mediastinum,  keeping  as  close  as  possible  to  the 
posterior  surface  of  the  sternum  so  as  to  avoid  opening 
the  pericardium.  When  the  under  surface  of  the 
sternoclavicular  joint  is  reached  some  difficulty  will 
be  experienced  in  removing  the  sternum,  owing  to  the 
resistance  offered  by  the  firm  ligaments  of  the  joint, 
but  by  prying  the  sternum  outward  these  ligaments 
are  put  upon  the  stretch,  and  can  then  be  readily  cut 
with  the  point  of  the  knife. 

The  sternum  having  been  removed,  a  general  view 
of  the  anterior  mediastinum  should  be  taken,  espe- 
cially with  reference  to  the  presence  of  serous  fluid  or 
pus  in  its  meshes. 

The  Heart. — Although  the  heart  is  the  first  organ  of 
the  thorax  to  be  examined,  yet  the  pericardium  should 
not  be  opened  until  a  cursory  view  of  the  pleural  cavi- 
ties has  been  taken  with  reference  to  the  presence  of 
fluid;  for  here,  as  in  the  peritoneal  cavity,  fluid  present 
may  have  come  from  the  pericardium,  if  that  be  first 
opened. 

Open  the  pericardium  by  seizing  the  anterior  por- 


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REFERENCE    HANDBOOK   OF    THE    MEDICAL   SCIENCES 


tion  of  the  parietal  layer  with  the  forceps  and, 
lifting  it  up  (if  there  be  adhesion  of  the  pericardial 
surfaces,  as  a  result  of  earlier  inflammatory  processes, 
it  will  be  made  apparent  by  the  inability  to  raise  the 
anterior  portion  of  pericardium),  nick  it  with  the 
scissors;  cut  upward  as  far  as  the  reflection  of  the  peri- 
cardium upon  the  aorta;  then  cut  downward  to  the 
right  and  also  toward  the  apex.  The  incision  will 
have  the  form  of  an  inverted  Y.  Lift  up  the  heart 
and  note  the  contents  of  the  pericardium  and  their 
character  (serum,  fibrin,  pus,  blood).  Also  note  the 
appearance  of  both  pericardial  surfaces.  Examine 
the  heart  with  reference  to  its  size,  shape,  and  the  con- 
traction of  its  walls.  Then  open  the  four  cavities  of  the 
heart  in  situ,  to  determine  the  character  and  amount 
of  their  contents.  The  method  is  as  follows:  Let  the 
heart  rest  upon  the  palm  of  the  left  hand,  with  the 
thumb  upon  the  upper  surface;  turn  the  heart_  to- 
ward the  left;  this  will  make  prominent^  the  right 
auricle,  and  will  bring  into  view  the  superior  and  in- 
ferior cava?  where  they  join  the  auricle.  Make  an 
incision  into  the  auricle  at  right  angles  to  the  cava?. 
Next  turn  the  heart  back  to  its  former  position; 
lift  the  thumb  from  the  anterior  surface  and  incise  the 
right  ventricle  by  a  cut  parallel  and  close  to  its  right 
border,  remembering  not  to  carry  the  cut  to  the  apex, 
as  this  is  formed  by  the  left  ventricle  only.  Open  the 
left  ventricle  by  an  incision  along  the  left  border  a 
little  to  the  right  of  and  parallel  to  the  coronary 
vessels.  To  open  the  left  auricle,  put  the  fore- 
finger in  the  cut  in  the  left  ventricle  and  the  thumb  into 
the  cut  in  the  right  ventricle,  then  lift  up  the  heart  and 
carry  it  toward  the  right  of  the  body;  in  this  way  the 
left  auricle,  with  the  two  left  pulmonary  veins  enter- 
ing it,  will  be  seen.  Open  the  auricle  by  a  crescentic 
cut,  beginning  in  the  upper  vein,  thence  into  the 
auricle,  and  outward  into  the  lower  vein.  Introduce 
one  or  more  fingers  into  the  incisions  and  note  the 
amount  of  the  contents  and  their  character.  The 
left  ventricle  is  contracted  and  empty,  unless  the  in- 
dividual has  died  from  paralysis  of  this  part  of  the 
heart,  when  it  will  be  found  distended  with  blood. 

The  right  ventricle  and  both  auricles  are  usually 
distended  with  blood,  which  may  be  fluid,  as  in  death 
from  suffocation,  or  more  or  less  coagulated.  In 
every  case  of  sudden  death  it  is  desirable  to  open  the 
pulmonary  artery  in  situ,  in  order  to  determine  the 
presence  or  absence  of  emboli. 

Now  remove  the  heart  from  the  body  by  lifting  it 
vertically  upward,  cutting  across  in  succession  the 
inferior  cava,  superior  cava,  pulmonary  veins,  aorta, 
and  pulmonary  artery. 

After  removal  of  the  heart  from  the  body  it  is  to  be 
further  examined  with  reference  to  its  valves,  cavities, 
muscular  substance,  and  blood-vessels.  Remove  all 
clots  from  the  pulmonary  artery  and  aorta,  hold  the 
heart  vertically  by  seizing  in  turn  the  walls  of  each  of 
these  vessels,  and  allow  water  to  run  into  them  from 
above.  Note  whether  each  of  these  vessels  "holds" 
the  water,  or  whether  it  escapes — if  the  former,  the 
valves  are  sufficient;  if  not,  they  are  insufficient,  and 
an  idea  of  the  degree  of  insufficiency  may  be  obtained 
by  noting  the  rapidity  with  which  the  water  escapes. 

The  ventricles  are  now  to  be  further  opened — the 
right  by  a  cut  beginning  at  the  lower  end  of  the 
incision  already  made  and  carried  upward  to  and 
through  the  pulmonary  artery;  the  left  by  continuing 
the  incision  already  made  directly  upward  into  the 
aorta,  between  the  left  auricular  appendage  on  the 
right  and  the  pulmonary  artery  on  the  left. 

( Opportunity  is  now  afforded  for  an  examination  of 
the  cusps  of  the  aortic  and  pulmonic  valves.  Having 
completed  this,  insert  as  many  fingers  as  possible  into 
the  mitral  and  tricuspid  orifices.  Normally  the 
mitral  admits  three,  the  tricuspid  four.  Nexl 
examine  the  segments  of  these  valves  and  their 
chorda?  tendineae. 

Note   the   size   and   shape   of   the   cavities  of   the 


ventricles.  Continue  the  incisions  already  made  in 
the  auricles  into  the  auricular  appendages  as  far  as 
the  tips,  noting  the  size  of  the  auricles  and  whether 
thrombi  are  present  in  the  appendages.  Next 
examine  the  muscular  wall  of  the  heart  and  the 
papillary  muscles  with  reference  to  thickness,  color, 
and  consistency.  Follow  out  the  coronary  arteries 
as  far  as  possible,  with  the  probe-pointed  scissors, 
with  reference  to  narrowing  of  lumen  from  end- 
arteritis or  to  presence  of  emboli  or  thrombi.  This 
completes  the  examination  of  the  heart. 

The  lungs  and  pleurce  next  deserve  attention. 

In  the  previous  cursory  examination  of  the  pleural 
cavities  with  reference  to  the  presence  of  fluid,  the 
presence  or  absence  of  adhesions  of  the  pleural  sur- 
faces, over  a  larger  or  smaller  area,  will  also  probably 
have  been  noticed.  If  there  be  any  adhesions  they 
should  now  be  torn.  If  the  two  surfaces  are  so 
adherent  that  they  cannot  be  separated  except  at 
the  risk  of  injuring  the  lung,  the  costal  pleura  should 
be  removed  with  the  parietal  pleura  and  lung,  by  fir;-!; 
cutting  the  pleura  along  the  under  surface  of  the 
ribs  near  the  anterior  border,  then  inserting  the 
finger  nails,  and  then  the  fingers,  and  tearing  it  away 
from  the  costal  wall. 

The  left  lung  is  now  removed  by  lifting  it  out  of  the 
pleural  cavity  and  supporting  it  with  the  left  hand  in 
such  a  way  that  the  primary  bronchus  comes  in  the 
fork  between  the  middle  and  ring  fingers.  The 
bronchus  should  now  be  cut  across,  and  the  small 
amount  of  connective  tissue  of  the  posterior  medias- 
tinum which  supports  the  lung  behind  should  be 
divided  with  the  knife,  keeping  close  to  the  lung  to 
avoid  injuring  the  esophagus,  which  lies  beneath. 

Remove  the  right  lung  in  the  same  way.  Note  the 
volume  of  the  lungs,  the  density,  whether  crepitant 
or  whether  in  part  or  wholly  solidified.  Also  note 
whether  or  not  there  are  false  membranes  upon  the 
pleura.  The  incision  into  the  lung  is  to  be  made 
by  resting  the  organ  on  its  base,  then  making  a 
sweeping  cut  from  apex  to  base  in  the  direction  of 
the  bronchus,  beginning  on  the  convex  surface  and 
carrying  it  sufficiently  deep  to  open  the  bronchus. 
This  gives  two  large  surfaces  for  examination.  The 
bronchi  are  now  to  be  opened  with  the  scissors,  to  the 
smallest  tubes  in  which  the  blade  of  the  scissors  will 
go.  If  there  be  any  evidence  of  embolism  in  the 
lung  the  branches  of  the  pulmonary  artery  should 
also  be  followed  out. 

Next  examine  the  bronchial  lymph  glands. 

This  completes  the  examination  of  the  thoracic 
cavity  for  the  present,  and  attention  should  be  turned 
to  the  abdominal  cavity.  The  method  to  be  given 
for  its  examination  is  the  one  to  be  followed  out  in 
case  there  is  no  evidence  of  there  having  been  an  acute 
peritonitis.  The  variation  in  the  method  in  this 
circumstance  will  be  described  later. 

The  spleen,  is  to  be  removed  first.  It  should  be 
seized  in  the  left  hand  and  drawn  outward  and 
upward  from  its  position,  then  lifted  upward  above 
the  lower  margin  of  the  ribs.  In  this  way  the  gastro- 
splenic  omentum  is  put  upon  the  stretch  and  can  be 
readily  divided,  together  with  the  splenic  vessels  at 
the  hilus.  The  organ  is  now  free.  Its  size,  shape, 
color,  and  density,  together  with  the  appearance  of 
the  capsule,  should  be  noted.  An  incision  is  then  to 
be  made  into  it  parallel  to  its  flat  surface.  The 
follicles,  trabecular,  and  pulp  are  the  individual  parts 
in  the  cut  surface  that  demand  attention. 

The  intestines  are  now  to  be  removed.  Lift  up  the 
omentum,  examine  it,  then  cut  away  its  attachments 
to  the  transverse  colon.  Next  separate  the  trans- 
verse colon  from  the  stomach  by  dividing  the  two 
folds  of  lesser  omentum  which  unite  them.  Then 
draw  the  small  intestines  over  to  the  right;  by  so 
doing  the  descending  colon  will  be  exposed.  It 
should  be  seized,  lifted  upward,  and  its  mesocolon 
divided  close  to  the  intestine.     The  sigmoid  flexure 


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Autopsy 


|g  to  be  freed  next,  and  the  rectum  cul  across  a  little 

below   the  brim   of   the   pelvis.     The   folds  of  small 

tin.-  are  now  carried  over  to  the  left  half  of  the 

abdominal  cavity  so  as  to  uncover  the  ascending  colon. 

The  dissection  to  remove  this  should  be  begun  at  the 

hepatic  flexure,  freeing  it  from  the  surrounding  parts, 

using  special  care  nut  to  injure  the  duodenum,  which 

in  contact   with  the  ascending  colon  in   its  upper 

terior  portion.     Continue  the  di    ection    until  the 

cecum  is  reached,   which   can  he   removed   with   the 

vermiform  appendix  by  first  cutting  the  peritoneum 

that    binds    it    down    laterally,    and    later    the    loose 

connective    tissue    that    holds    it    down   posteriorly. 

The  large  intestine  is  now  free. 

The  small  intestine  is  to  be  freed  from  its  mesentery 
by  cutting  the  latter  close  to  its  attachment  to  the 
-tine.  This  is  best  accomplished  by  making 
traction  on  the  intestine,  thereby  rendering  the 
ritery  tense,  which  can  then  be  readily  and 
rapidly  divided  by  a  -cries  of  fiddle-bow-motion  cuts 
made 'with  the  large  knife.  The  separation  of  the 
intestine  from  the  mesentery  should  be  continued 
until  the  point  is  reached  where  the  jejunum  passes 
behind  the  peritoneum. 

At  tin-  stage  in  the  autopsy  the  duodenum  is  to  be 
Opened  in  situ  by  an  incision  made  with  the  scissors 
along  the  outer  convex  border.  This  is  done  that  the 
.  ommon  bile  duct  and  its  orifice  may  be  examined — 
a  point  of  the  first  importance,  in  cases  of  jaundice, 
for  determining  the  cause.  The  orifice  of  the  dint 
forms  a  papilla  situated  on  the  pancreatic  side  of  the 
duodenum  about  the  middle  of  the  descending  portion 
and  directly  opposite  the  incision  already  made.  The 
bile  duct,  in  the  latter  part  of  its  course,  lies  beneath 
the  mucosa  of  the  duodenum.  This  portion  of  the 
duct  should  be  pressed  upon  by  the  finger,  and  the 
latter  moved  toward  the  orifice,  which  is  to  be  watched 
with  reference  to  the  expulsion  from  it  of  bile  or  a 
plug  of  mucus.  Pressure  may  now-  be  applied  to  the 
gall  bladder,  and  the  appearance  or  non-appearance 
of  bile  at  the  orifice  be  noted.  If  no  bile  flows,  the 
common  duct  should  be  opened  with  the  fine,  probe- 
pointed  scissors  and  the  cause  of  the  obstruction 
sought.  It  may  be  a  plug  of  mucus  formed  as  the 
result  of  an  inflammatory  process  extending  to  the 
duct  in  a  case  of  gastroduodenal  catarrh,  or  it  may  be 
a  biliary  calculus. 

The  stomach,  connected  with  the  intestine,  together 
with  the  pancreas  and  mesentery,  must  now  be 
removed.  To  do  this,  the  left  lobe  of  the  liver  should 
be  lifted  up;  the  diaphragm  cut  through  its  middle 
as  far  down  as  the  esophagus;  the  esophagus  divided 
transversely  about  two  inches  above  the  stomach; 
the  cut  end  compressed  between  the  thumb  and 
forefinger  of  the  left  hand;  the  stomach  lifted  and 
dissected  away  from  the  underlying  tissues;  the 
pancreas  and  mesentery  dissected  from  the  aorta  and 
inferior  cava,  and  the  gastrohepatic  and  duodeno- 
hepatic  omenta  divided.  The  whole  gastrointestinal 
tract,  together  with  pancreas  and  mesentery,  is  now- 
freed  and  can  be  removed  from  the  body. 

Although  the  examination  of  the  intestines  is 
usually  postponed  until  the  last,  to  avoid  soiling 
others  parts  with  its  contents,  yet  the  method  will  be 
given  here.  The  gastrointestinal  tract  should  be 
opened  its  entire  length,  either  with  an  ordinary  pair 
of  scissors  or  with  an  instrument  which  renders  the 
operation  far  easier,  the  enterotome  (Fig.  534),  the 
hooked  blade  being  introduced  into  the  inside.  The 
stomach  is  to  be  opened  along  the  greater  curvature, 
the  reason  being  that  the  common  lesions — ulcers — 
are  usually  situated  on  the  lesser  curvature.  The 
small  intestine  should  be  opened  along  the  mesenteric 
attachment,  for  the  reason  that  Peyer's  patches,  the 
usual  seat  of  typhoid  and  tuberculous  processes,  are 
situated  on  the  opposite  side.  The  large  intestine  is 
to  be  opened  along  one  of  the  three  teniae,  or  bands, 
the  object  being  to  avoid  getting  the  point  of  the 


scissors  caught  in  the  pouches   lying  between   the 
bands. 

.Much  time  can  be  saved  by  using  the  scissors,  not  in 

the  ordinary  way  by  Opening  and  closing  the  blade-, 
but    by    keeping   the  blades   tmmo  ;    carrying 

the  scissors  forward  with  the  right  band,  at  the  same 
time  drawing  the  intestine  backward  with  the  left 

hand. 

The  amount  and  character  of  the  contents  of  the 
various  portions  of  the  gastrointestinal  tract  should 
be  noted;  the  mucosa  is  to  be  freed  of  it-  adhi 
materia]  either  by  water,  when  this  can  be  obtained, 

Or  else  by    the   linger-,   and    the   mucosa  of   the  entire 
ti:ei    is   then  to  be  carefully  examined  for  evidi  I 
of   inflammatory   processes — ulcers,   perforations,  or 
other  lesions. 

The  stomach  and  intestines  having  been  n  moved 
from  the  abdominal  cavity,  a  view  can  I"-  obtained 
of  the  kidneys,  ureters,  and  bladder  in  situ — a  point 
of  value,  as  the  illation  of  one  to  the  others  is  often 
needed  in  explaining  the  association  of  lesions.  It  is 
the  custom  of  the  German  pathological  anatomists  to 
remove  the  kidneys  before  the  intestine,  hence  at  a 
stage  in  the  autopsy  when  it  is  impossible  to  get  a 
view  of  the  urinary  tract  in  its  continuity.  It  seems 
to  the  writer  that  nothing  is  gained  by  removing  the 
kidneys  before  the  intestine,  but  that  much  ma\  be 
lost;  for  if  one  finds,  as  the  kidneys  lie  in  situ,  that 
they  present  changes,  it  may  be  very  advantageous 
to  remove  them  with  the  renal  artery  and  aorta,  on 
the  one  hand,  as  in  cases  of  atrophy,  especially  when 
dependent  upon  a  chronic  interstitial  nephritis,  or, 
on  the  other  nand,  with  the  ureters  and  bladder  and 
perhaps  the  penis,  if  there  be  hydronephrosis  or 
pyelonephritis. 

Urinary  Organs. — A  general  inspection  of  the  urinary 
tract  having  been  made  as  the  parts  lie  in  situ,  one 
should  then  open  the  bladder  by  an  incision  from  one  to 
two  inches  in  length  along  its  upper  wall.  The  amount 
and  character  of  the  contents,  and  especially  the  ap- 
pearance of  the  mucous  membrane,  should  be  noted; 
for  if  there  be  evidence  of  an  inflammatory  process  it 
will  be  desirable  to  remove  the  kidneys,  ureters,  and 
bladder  in  a  single  mass,  owing  to  the  fact  that  in- 
flammatory processes  in  the  mucosa  of  the  bladder  may 
extend  upward  through  the  ureters  and  involve  the 
pelves   of   the   kidneys  and  the  kidneys  themselves. 

If  there  be  no  evidence  of  a  cystitis,  no  further  ex- 
amination of  the  bladder  is  now  to  be  made,  but  atten- 
tion is  to  be  directed  to  the  kidneys.  Inasmuch  as 
these  organs  lie  behind  the  peritoneum,  it  is  necessary 
to  cut  this  in  order  to  get  at  them.  The  incision 
should  be  made  just  to  the  outside  of  the  kidney 
along  its  convex  border.  The  fingers  of  the  right 
hand  should  now  be  introduced  into  the  cut  and  the 
kidney  "shelled  out''  of  its  perinephritic  fat,  lifted 
upward,  the  blood-vessels  at  the  hilus  cut  transversely 
and  traction  made  upon  the  kidney,  which  will  strip 
up  the  ureter  as  far  as  the  brim  of  the  pelvis,  where  it 
may  be  divided.  The  suprarenal  capsules  may 
either  be  removed  with  the  kidney  or  may  be  left  in 
situ  until  a  later  stage  of  the  examination.  On  the 
right  side  it  is  less  easy  to  remove  the  suprarenal 
capsule  with  the  kidney  than  on  the  left,  owing  to 
its  closer  adhesion  to  the  under  surface  of  the  liver. 

The  examination  of  the  kidney  consists  in  noting 
its  size,  shape,  color,  and  density;  and  in  the  removal 
of  the  capsule,  observing  whether  it  comes  off  easily 
or  with  difficulty,  also  whether  portions  of  renal 
substance  adhere  to  it.  An  incision  in  the  kidney  is 
made  by  holding  the  organ  between  the  thumb  and 
fingers  of  the  left  hand,  with  the  hilus  resting  upon  the 
palm,  and  cutting  along  the  whole  convex  border 
through  the  kidney  to  and  into  its  pelvis.  In  the  ex- 
amination of  the  cut  surface  the  ratio  of  cortex  to  pyra- 
mids, as  to  thicknes>.  should  first  be  noted,  and  then 
the  cortex  studied  with  reference  to  the  appearance 
presented  by  the  glomeruli  and  the  regions  of  convo- 

797 


Autopsy 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


luted  and  straight  tubules.  The  degree  of  injection  of 
the  vessels  of  the  cortex  and  pyramids,  as  determined 
by  the  color,  is  to  be  observed;  then  the  mucous  mem- 
brane of  the  pelves  is  to  be  examined;  finally,  the 
ureters  are  to  be  opened.  If  there  be  evidence  of  atro- 
phy involving  one  or  both  kidneys,  the  corresponding 
renal  artery  should  be  opened  to  the  aorta  to  deter- 
mine whether  the  lumen  is  narrowed  from  chronic 
endarteritis. 

The  next  step  in  the  autopsy  is  the  removal  of  the 
pelvic  organs,  either  with  or  without  the  external 
genitals.  In  the  female,  the  external  genitals  should 
be  removed  with  the  internal  genitals  in  cases  of 
death  following  puerperal  fever  or  abortion;  in  the 
male,  when  there  is  a  suspicion  of  stricture  or  wound 
of  the  urethra,  or  of  a  periurethral  abscess. 

In  case  it  is  not  necessary  to  remove  the  external 
genitals  the  method  of  procedure  for  removal  of  the 
pelvic  organs  is  as  follows:  Sweep  the  knife  around  the 
true  pelvis,  keeping  as  close  to  the  bony  wall  as  pos- 
sible; in  this  way  the  loose  connective  tissues  will  be 
severed.  Seize  the  bladder  by  its  upper  portion  and 
draw  it  backward,  away  from  the  pubes;  cut  its 
attachments  to  the  pubes,  and  then,  while  still 
making  strong  backward  traction,  cut  the  vagina 
and  rectum  transversely  as  far  forward  as  possible. 
In  this  way  the  vagina  as  far  as  the  hymen  may  be 
obtained.  The  same  procedure,  so  far  as  the  drawing 
back  of  the  bladder  and  cutting  its  attachments  are 
concerned,  is  to  be  carried  out  in  the  male,  the  pros- 
tate and  rectum  being  then  divided  transversely 
as  far  forward  as  possible. 

The  removal  of  the  external  genitals  connected  with 
the  internal  pelvic  organs  is  accomplished  in  the 
following  way:  The  pelvic  organs  are  freed  from  their 
surroundings  as  already  described;  then  incisions  are 
made  on  the  outside,  beginning  at  the  lower  end  of 
the  primary  incision,  which  had  been  carried  to  the 
pubes,  and  carried  to  the  outside  of  the  labia  majora 
on  both  sides  in  the  form  of  an  ellipse,  the  two  cuts 
meeting  again  in  the  median  line  behind  the  anus  at 
the  tip  of  the  coccyx. 

The  vulva  is  now  dissected  away  from  the  pubes 
until  the  bony  pubic  arch  is  reached.  The  knife  is 
then  to  be  inserted  beneath  the  pubic  arch  with  the 
blade  close  to  the  bone,  and  then  pushed  into  the 
cavity  of  the  pelvis  so  that  its  point  can  be  seen. 
With  the  knife  held  horizontal^,  it  is  swept  around 
in  the  two  curved  incisions  described  above  until  the 
coccyx  is  reached.  This  will  free  the  attachments  to 
the  pubic  arch  anteriorly  and  laterally,  and  to  the 
coccyx   and   lower  part  of   the   sacrum   posteriorly. 

The  external  genitals  are  now  to  be  drawn  under  the 
pubic  arch  into  the  cavity  of  the  pelvis.  This  puts 
the  attachments  to  the  sacrum  on  the  stretch,  and 
gives  a  better  view  of  the  parts  that  still  require 
to  be  divided  in  order  wholly  to  free  the  organs  in 
question. 

In  the  male  the  penis  may  be  removed  with  the 
internal  organs  by  drawing  the  dartos  toward  the 
glans;  cutting  with  the  scissors  the  small  amount  of 
connective  tissue  that  holds  the  skin  to  the  body  of  the 
penis;  then  dividing  the  penis  by  a  transverse  cut  just 
behind  the  corona,  unless  it  is  thought  desirable  to 
remove  the  glans  also,  in  which  case  the  dartos  should 
be  cut  circularly  where  it  is  reflected  upon  the  glans, 
i.e.  in  the  corona.  The  attachments  of  the  penis  to 
the  pubic  arch  are  divided  by  transfixion,  as  in  the 
female;  the  organ  is  drawn  under  the  arch  into  the 
cavity  of  the  pelvis,  and  the  adhesions  to  surrounding 
parts  divided. 

If  there  be  anything  abnormal  about  the  perineum, 
it  is  desirable  to  remove  with  the  penis  and  pelvic 
organs  an  elliptical  or  lozenge-shaped  portion  of  skin, 
its  anterior  apex  being  just  behind  the  scrotum, 
having  its  posterior  apex  at  the  coccyx.  This  will 
include  perineum  and  anus.  The  removal  is  accom- 
plished   by    transfixing    with    the    knife    held    in   a 

798 


horizontal  position,  the  point  being  carried  well  into 
the  pelvic  cavity. 

The  further  examination  of  the  male  pelvic  organs 
consists  in  prolonging  the  incision,  made  in  the 
bladder  while  in  situ,  to  the  urethra  through  the 
prostate  with  the  scissors.  If  the  penis  has  hern 
removed,  the  incision  should  be  continued  along  the 
dorsum  to  the  meatus.  The  interior  of  the  bladder 
and  urethra  can  now  be  examined.  Trans\ 
incisions  are  to  be  made  in  the  prostate.  The 
vesiculae  seminales  and  the  prostatic  and  vesical 
venous  plexuses  should  next  receive  attention.  The 
plexuses  are  of  importance,  as  likely  to  be  the  seat  of 
thrombi. 

The  rectum  is  now  to  be  opened  along  its  posterior 
wall,  and  the  mucous  surface  examined. 

In  the  female  the  bladder  and  urethra  are  first  to  be 
opened  and  examined.  The  vagina  is  then  to  be 
exposed  along  its  whole  length  by  an  incision  along 
its  left  lateral  wall.  In  this  way  one  avoids  injuring 
the  bladder.  When  the  cervix  is  reached,  the  incision 
should  be  carried  at  right  angles  to  its  first  direction, 
and  the  anterior  wall  of  the  vagina  be  cut  transversely 
as  far  as  the  middle  line  of  the  uterus.  The  scissors 
are  then  introduced  through  the  os  into  the'  cervical 
canal,  and  the  uterus  opened  by  cutting  in  the  middle 
line  anteriorly  as  far  as  the  fundus.  Counter  incisions, 
beginning  at  about  the  middle  of  the  body,  are  now 
to  be  made  in  the  direction  of  the  orifice  of  each 
Fallopian  tube. 

If  the  tubes  are  enlarged  they  should  be  opened 
with  the  probe-pointed  scissors.  In  the  normal  tube 
the  canal  is  so  small  that  it  is  almost  impossible  to 
follow  it  out,  and  it  is  furthermore  unnecessary. 

The  ovaries  are  to  be  opened  by  an  incision  begin- 
ning on  the  free,  convex  border  and  continued  to  the 
hilus,  i.e.  to  the  broad  ligament.  The  vaginal  and 
uterine  plexuses  are  then  to  be  examined. 

If  death  has  occurred  in  the  puerperal  state  or  after 
an  abortion,  the  external  genitals  and  vagina  should 
be  examined  carefully  with  reference  to  lacerations, 
and  numerous  incisions  be  made  in  the  vaginal  wall, 
extending  into  the  perivaginal  connective  tissue,  to 
determine  whether  a  purulent  lymphangitis  is  pre 

In  the  puerperal  uterus  the  inner  surface  is  to  be 
examined  for  evidence  of  an  endometritis.  The 
uterine  sinuses,  the  pampiniform  plexuses,  and  the 
ovarian  veins  ate  to  be  examined  for  thrombi  under- 
going septic  softening.  The  tubes  are  to  be  opened 
to  discover  evidence  of  a  purulent  inflammation  of 
their  mucosa  (salpingitis  purulenta).  Numerous 
incisions  are  to  be  made  in  the  wall  of  the  uterus  for 
evidence  of  suppurative  lymphangitis. 

The  examination  of  the  testicles  can  be  readily 
made,  without  injuring  the  scrotum,  by  pushing 
them  upward  through  the  canal,  so  that  they  will 
appear  at  the  rings  on  either  side.  The  peritoneum 
and  then  the  tunica  vaginalis  are  to  be  divided,  and 
the  testicle  can  be  removed  by  severing  the  cord.  It 
should  be  opened  by  an  incision  parallel  to  its  long 
diameter,  beginning  on  the  side  opposite  the 
epididymis. 

The  liver  is  removed  by  cutting  the  ligaments.  In 
noting  the  dimensions  of  this  organ  one  should  take 
cognizance  of  the  relations  of  the  right  to  the  left  loin 
as  regards  size.  The  shape,  color,  density,  ami  any 
points  relating  to  the  capsule  are  to  be  observed. 
The  incision  for  examining  the  interior  should  he 
made  transversely,  beginning  at  the  left  bonier  and 
ending  at  the  right  border.  The  appearances  of  the 
single  lobules  are  now  to  be  studied;  the  relative 
proportions  of  central  and  peripheral  parts  and  the 
color  of  each  being  the  important  points  to  be 
observed. 

The  gall-bladder  is  to  be  opened  by  an  incision 
parallel  to  the  long  diameter. 

The  order  in  the  examination  of  the  organs  of  the 
abdominal  cavity  is  to  be  varied  in  case  of  acute 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Autopsy 


eritonitis.     In  making  an  autopsy  one  should  nol 

1st  satisfied  in  finding  evidence  of  acute  peritonitis, 

,it    should    always    search    for    the    cause.     Of    the 

mses,  the  most  common  arc  extension  of  an  inflam- 

lation  from  the  pelvic  organs,  this  especially  in  the 

■male;  perforation  of  the  vermiform  appendix  from 

ppendicitis;  and  perforation  of  the  gastrointestinal 

aol  at  some  part.     In  case  of  acute  peritonitis,  no 

rgan  should  be   removed   until   the  probable  source 

as   been    made   out.     This   is   done   by    lifting   and 

■parating   the   folds  of   intestine,   and   observing   in 

hich  part  of  the  peritoneal  cavity  the  inflammatory 

rocess  is  farthest   advanced.      Then    the   parts   may 

e    dissected    away    from    this    organ,    whichever    it 

lay  I"',  and  the  al  tempi  made  to  find  the  perforation 

i   oilier  lesion  which  is  primary.     The  questionable 

,ii  may  then  be  removed  and  further  examined. 

Po  proceed  with  the  method  ordinarily  carried  out. 

Liter  the  removal  of  the  liver  there  remain   in  the 

r.ity  of  the  chest  and  abdomen  the  trachea  and  its 

ifurcation,   the  greater  part  of  the  esophagus,   the 

orta,   and    the   inferior   cava.     The  aorta  is    to  be 

pened  in  situ,  with  the  scissors,  along  the  anterior 

all  from  the  arch  to  the  bifurcation,  and  then  the 

iac  arteries   are   to  be   opened   to   the   groin.     The 

i'erior  cava  and  the  iliac  veins  are  also  to  be  opened. 

hese  vessels  are  opened  in  situ  that  no  injury  may 

e  done  to  thrombi  if  they  be  present  wit  Inn. 

The  aorta  and  as  much  of  the  trachea  and  esophagus 

-  possible  are  now  to  be  removed  by  cutting  the  two 

itter  as  high  up  in  the  neck  as  they  can  be  reached, 

nd  dissecting  them  and  the  aorta  from  the  vertebral 

olumn,   the  aorta  being  attached  to  the  vertebral 

olumn  by  a  small  amount  of  connective  tissue. 

Tin-  trachea  is  to  be  opened  along  its  posterior  wall 
i  he  cartilaginous  rings  being  interrupted  at  this  part) ; 
he  esophagus  along  the  anterior  wall. 

The  larynx  and  tongue  may  be  removed  with  the 
lings,  or  simply  with  the  trachea.  The  knife  is 
lassed  upward  under  the  skin  of  the  neck  and  the 
ttachments  of  the  trachea  and  larynx  to  the  anterior, 
ateral,  and  posterior  parts  severed  by  sweeping  cuts 
tarting  in  the  median  line  and  carried  to  the  side  and 
hen  to  the  back.  The  attachments  of  the  muscles 
if  the  tongue  to  the  lower  jaw  are  divided,  the  knife 
)eing  carried  up  from  below  preferably  to  being 
ntroduced  through  the  mouth.  The  soft  palate  is 
eparated  from  the  hard  palate,  and  the  pillars  of  the 
auces  are  cut  laterally  so  as  to  include  the  tonsils. 
The  tongue  is  now  seized  with  the  fingers  of  the  left 
land  passed  upward  through  the  neck  and  drawn 
lownward,  and  the  muscles  and  connective  tissue 
tolding  the  pharynx  to  the  vertebral  column  are 
iivided. 

In  this  way  the  soft  palate,  tonsils,  wall  of  pharynx, 
arynx,  and  upper  part  of  esophagus  may  be  removed 
ogether,  and  a  good  opportunity  afforded  for  their 
■xamination — a  point  of  value  in  diphtheritic  proc- 
:sses  and  the  like. 
The  larynx  should  always  be  opened  anteriorly. 
The  cavity  of  the  trunk  is  now  empty  and  a  good 
ipport unity  is  afforded  for  the  examination  of  the 
todies  of  the  vertebra?,  if  there  be  anything  in  the 
iase  which  renders  such  an  examination  desirable. 

Unless  the  brain  or  cord  is  to  be  removed,  the 
lamination  is  now  completed.  Before  returning  the 
organs  to  the  body  cavity  it  should  be  sponged  dry, 
and  the  pelvis  packed  with  pieces  of  old  cotton  cloth 
to  prevent  leakage  through  the  anus.  After  the 
organs  have  been  put  back  the  sternum  is  to  be 
replaced  and  held  by  two  stitches  on  either  side, 
taken  through  the  intercostal  muscles. 

The  flaps  are  next  brought  into  apposition  pre- 
paratory to  sewing  them  together.  To  do  this  take 
a  piece  of  stout  twine  one  and  a  half  times  the  length 
of  the  incision;  after  threading  it,  take  a  stitch  at  the 
extremity  of  the  long  incision  and  tie  a  hard  knot  in 
the  end  of  the  string.     For  sewing,  the  glover's  stitch 


is  to  be  used,  i.e.  from  inside  out.  The  Btitches 
Bhould  be  about  three-quarters  of  an  inch  apart  and 
three-eighths  of  an  inch  from  the  edge  oi  thi  Bap, 
taking  up  only  the  skin  and  subcutaneou  ti  ue, 
but  not  the  fat  ii  ue.  When  the  seam  Is  finished  a 
double  knot  is  made  in  the  string  and  the  end  drawn 

under  the  skin. 

Certain  final  details  will  be  considered  after  the 
method  of  removal  of  the  brain  and  cord  oa  bet  □ 
explained. 

Method  of  Removal  and  Examination  of  the  Brain. — 
Note  the  ratio  of  the  head  to  the  body,  and  of  the 
cranium  to  the  face. 

Make  an  incision  in  the  scalp,  beginning  half  an 
inch  behind  the  right  ear,  near  its  lower  bonier,  and 
extending  over  the  middle  of  the  vertex  to  the  cor- 
responding point  behind  the  left  ear.  In  women  the 
hair  should  first  be  roughly  parted,  along  the  line 
where  the  incision  is  to  be  made,  with  the  handle  of 
the  scalpel.  After  the  incision  li.-i  been  started  by 
cutting  with  the  edge  of  the  knife  downward,  it  is 
best  to  reverse  the  blade  so  that  its  back  comes 
against  the  bone  and  to  cut  upward.  The  incision  is 
to  be  carried  to  the  bone  except  in  the  temporal 
region,  where  it  should  be  carried  only  to  the  apo- 
neurosis covering  the  temporal  muscle. 

The  anterior  flap  is  first  to  be  freed  from  the  tem- 
poral muscle  on  either  side,  leaving  the  muscle  at- 
tached to  the  bone,  as  it  is  through  this  that  the 
stitches  will  be  taken  later  that  are  to  hold  the  calva- 
ria  in  place.  The  flap  is  now  to  be  seized  by  the  left 
hand  and  strong  forward  traction  made,  while  a 
series  of  sweeping  cuts  through  the  pericranial  con- 
nective tissue  are  made  with  the  scalpel  held  in  the 
right  hand.  This  dissection  should  be  continued 
until  the  frontal  eminences  come  into  view.  The 
posterior  flap  of  the  scalp  is  now  to  be  dissected  from 
the  bone  as  far  back  as  the  occipital  protuberance. 
While  the  scalp  is  being  removed  the  condition  of  the 
loose  pericranial  tissues  should  be  noticed  with  ref- 
erence to  evidence  of  edema,  hemorrhage,  or  puru- 
lent inflammation.  The  skull  is  now  bare  over  the 
vertex,  and  note  should  be  made  of  any  abnormalities 
of  its  surface. 

The  next  step  is  the  removal  of  the  calvaria.  This 
is  sometimes  done  by  sawing  through  the  skull  in  a 
circle;  but  this  is  bad  practice,  in  that  the  calvaria 
cannot  be  later  held  firmly  in  place  when  it  is  sewn  up 
— it  will  wobble.  The  best  way  is  to  saw  along  three 
lines  to  be  marked  in  the  periosteum,  as  a  guide,  with 
the  scalpel.  The  first  or  anterior  cut  begins  above 
and  behind  the  ear,  and  is  carried  directly  over  the 
vertex  to  a  corresponding  point  on  the  other  side, 
the  line  passing  just  behind  the  edge  of  the  hair 
above  the  forehead.  The  other  two  incisions  in  the 
bone  are  to  begin,  one  at  each  end  of  the  cut  just 
described,  and  be  carried  backward  to  the  median 
line  behind,  the  two  lines  meeting  at  an  angle  of 
about  one  hundred  and  sixty  degrees,  well  in  front  of 
the  occipital  protuberance.  Each  of  these  two  lines 
just  described  should  meet  the  anterior  line  at  an 
obtuse  angle  in  the  temporal  region. 

If  the  hair  be  long  it  should  be  wrapped  up  in  a 
towel,  so  as  to  form  a  ball,  and  the  whole  mass  placed 
beneath  the  nape  of  the  neck.  This  is  to  prevent,  the 
sawdust  getting  into  it. 

The  calvaria  is  now  to  be  sawn  along  the  lines 
already  marked,  the  head  being  steadied  by  placing 
the  left  hand  upon  the  calvaria;  a  towel  placed  be- 
tween the  hand  and  the  bone  prevents  slipping. 
The  incision  in  the  bone  should  be  carried  through 
the  outer  table  and  diploe,  and  nearly  through  the  in- 
ner table.  One  can  readily  determine  when  the  saw- 
has  reached  the  diploe  by  the  red  color  of  the  sawdust 
and  the  softer  feel  conveyed  to  the  hand  through  the 
saw  blade.  What  remains  unsawn  can  be  readily 
cracked  with  the  chisel  and  hammer,  placing  the 
chisel  in  the  incision  and  striking  with  the  hammer  a 


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quick,  sharp  blow  known  as  a  recoil  blow;  this  ob- 
viates the  danger  of  driving  the  chisel  into  the  brain. 

If  there  be  a  suspicion  of  fracture  of  the  skull,  the  in- 
cision with  the  saw  should  be  carried  through  the 
bone  and  no  cracking  whatever  done  with  the  chisel 
and  hammer. 

The  calvaria  being  now  loosened,  the  wedge- 
shaped  end  of  the  hammer  head  is  to  be  introduced 
in  the  middle  of  the  anterior  cut  and  pressed  down- 
ward with  the  left  hand,  while  the  handle  is  rotated 
in  the  horizontal  plane  with  the  right  hand.  In  this 
way  a  powerful  leverage  is  obtained,  and  the  calvaria 
can  be  forced  backward  sufficiently  to  introduce  the 
hook  on  the  end  of  the  hammer  handle  into  the  cut 
in  the  bone.  By  pulling  backward  on  the  hammer 
the  calvaria  may  be  separated  from  the  dura  and  so 
removed. 

Generally  the  adhesion  between  the  calvaria  and 
dura  is  not  a  firm  one,  but  occasionally  in  adults  the 
separation  requires  the  aid  of  the  end  of  the  enterotome, 
introduced  between  the  dura  and  the  bone  and  the 
two  pried  apart.  Occasionally  in  old  people,  and 
always  in  young  children,  the  adhesion  is  so  firm  that 
the  dura  has  to  be  removed  with  the  bone.  This  is 
accomplished  by  incising  the  dura  along  the  incision 
in  the  bone  and  then  cutting  the  attachment  of  the 
falx  to  the  crista  galli  in  the  superior  longitudinal 
fissure,  when  the  calvaria  may  be  drawn  backward 
and  the  falx  cut  posteriorly. 

After  the  removal  of  the  calvaria,  its  thickness,  the 
relation  of  diploe  to  tables,  and  the  appearance  of  the 
inner  surface  should  be  noticed. 

The  examination  of  the  dura  is  now  in  order. 
First  observe  whether  the  alternation  of  fissures  and 
convolutions,  as  darker  and  lighter  areas  lying  be- 
neath, can  be  determined  through  it.  If  so,  the 
dura  has  the  normal  degree  of  translucency,  and  is  of 
the  normal  thickness.  If  this  alternation  of  dark  and 
light  cannot  be  made  out  the  dura  is  thicker  than 
normal.  Next  open  the  superior  longitudinal  sinus 
and  note  its  contents,  whether  fluid  or  coagulated 
blood  or  a  thrombus.  With  scissors  and  forceps 
cut  through  the  dura  along  the  line  of  incision  in  the 
bone;  then  reflect  it  toward  the  median  iine  so  as  to 
expose  its  inner  surface.  The  presence  of  hemor- 
rhagic or  pigmented  false  membranes  or  patches  is 
the  important  pathological  condition  to  be  looked  for 
here. 

The  knife  is  now  to  be  introduced  into  the  superior 
longitudinal  fissure,  the  dura  drawn  backward,  and 
the  attachment  of  the  falx  to  the  crista  galli  severed. 
The  dura  can  now  be  drawn  backward  as  far  as  the 
posterior  incision  in  the  skull;  it  should  not  be  cut 
off,  but  should  be  allowed  to  hang  down.  The  veins 
of  the  pia,  where  they  enter  the  superior  longitudinal 
sinus,  offer  slight  resistance  to  the  removal  of  the  dura. 
They  may  be  divided  with  the  knife  or  scissors  or  else 
torn. 

The  greater  portion  of  the  convexities  of  the  brain 
is  now  in  view.  One  should  note,  in  connection  with 
the  pia,  the  degree  of  fulness  of  its  blood-vessels; 
whether  it  is  translucent  or  opaque;  whether  ab- 
normally dry;  whether  its  meshes  contain  clear  serous 
fluid,  and,  if  so,  the  amount;  also  whether  there  be 
fibrin  or  pus  in  its  meshes.  One  should  then  note 
whether  the  brain  fills  the  cavity  of  the  skull;  also 
the  relation  of  the  convolutions  to  the  sulci  as  to 
proportionate  size. 

The  brain  is  now  to  be  removed  from  the  skull. 
Insert  the  two  forefingers  between  the  dura  and  the 
frontal  lobes  on  either  side  of  the  median  fissure  and 
hook  them  around  these  lobes;  draw  brackward  on 
the  brain  until  the  optic  nerves  can  be  seen;  then 
making  slight  traction  backward  on  the  brain  by  two 
fingers  of  the  left  hand  hooked  around  its  tip,  cut 
across  the  cranial  nerves  and  carotid  arteries  close  to 
their  foramina  until  the  tentorium  is  reached;  cut 
the  latter  close  to  its  attachment  to  the  petrous  por- 


tion of  the  temporal  bone.  Next  divide  the  crania 
nerves  given  off  from  the  medulla  oblongata.  Thei 
carry  the  knife  as  far  down  in  the  vertebral  canal  a 
possible,  and  cut  the  cord  by  an  inverted  V-shape< 
cut,  starting  in  the  median  line,  and  cutting  first  t< 
the  right,  then  to  the  left.  The  vertebral  arteries  an 
divided  by  the  same  stroke. 

The  brain  is  now  readily  removed  by  hooking  tin 
fingers  of  the  right  hand  under  the  cerebellum,  sun 
porting  the  brain  from  behind  with  the  left  hand 
and  then  lifting  it  out  by  the  same  turn  employee 
in  delivering  the  aftercoming  head  in  a  breed 
presentation. 

The  further  examination  of  the  brain  is  to  b< 
postponed  until  the  basal  portion  of  the  crania 
cavity  has  been  looked  at.  The  lateral  sinuses  an 
to  be  opened  and  their  contents  noted.  If  there  be  ; 
suspicion  of  a  fracture  the  whole  of  the  dura  is  to  bi 
stripped  off,  it  being  usually  impossible  to  discover  ; 
fracture  of   the   base   while   the   dura  is  in  situ. 

The  posterior  part  of  the  eye  may  be  exposed  and 
removed  by  chipping  away  with  the  chisel  the  thii 
orbital  plate  which  forms  the  roof  of  the  orbit  and  tin 
greater  part  of  the  floor  of  the  anterior  fossa. 

The  middle  ear  can  be  exposed  by  chipping  off  its 
roof,  which  lies  in  the  middle  of  the  petrous  portion 
of  the  temporal  bone.  If  the  inner  ear  is  to  be  exam- 
ined, the  whole  petrous  bone  must  be  sawn  out  by  a 
V-shaped  incision  in  the  squamous  portion  of  the 
temporal,  the  apex  of  the  V  extending  below  tin 
external  meatus. 

The  mastoid  cells  can  be  opened  either  from  the 
inside  of  the  skull  or  from  the  outside. 

An  excellent  view  of  the  nares  can  be  obtained  by 
removing  those  portions  of  the  ethmoid  and  sphenoid 
lying  in  the  middle  line,  from  the  cribriform  plate  of 
the  ethmoid  in  front  to  the  posterior  clinoid  proc- 
esses behind. 

By  removing  the  basilar  process  of  the  sphenoid  and 
the  sphenoidal  process  of  the  basilar,  the  so-called 
clivus  Blumbachii,  an  excellent  view  of  the  pharynx 
and  larynx  can  be  obtained. 

The  examination  of  the  brain  is  now  to  be  resumed. 
If  it  is  desired  to  weigh  it,  this  should  be  done  before 
it  is  incised.  The  brain  is  placed  upon  the  convexi- 
ties, the  base  uppermost.  The  pia  of  the  base  is  to 
be  examined  especially  for  evidence  of  inflammation 
or  tuberculosis.  The  blood-vessels  should  then  re- 
ceive careful  attention — first  the  circle  of  Willis,  then 
the  vertebrals  and  basilar,  then  the  anterior  cerebrals. 
The  fissure  of  Sylvius  is  now  to  be  opened  by  cut- 
ting the  pia  that  forms  a  bridge  across  the  fissure 
from  the  frontal  to  the  temporal  lobes,  and  the 
branches  of  the  middle  cerebrals  followed  out  as  far  as 
the  island  of  Reil.  These  are  the  most  important  of 
the  cerebral  vessels,  owing  to  the  liability  of  lodgment 
of  emboli  in  them  and  because  they  supply  the  larger 
and  most  important  part  of  the  brain.  Evidences  of 
endarteritis  should  be  looked  for,  and  the  vessels 
opened  with  the  probe-pointed  scissors.  Emboli 
or  thrombi,  if  present,  can  now  be  readily  discovered. 

This  examination  completed,  the  brain  should  be 
placed  upon  its  base  and  the  incisions  made  to  o]  eo 
the  lateral  ventricles.  This  is  a  curved  incision 
following  the  direction  of  the  ventricle,  the  convexity 
being  inward,  the  anterior  end  about  the  middle  of 
the  frontal  lobe,  the  posterior  end  near  the  middle 
of  the  occipital  lobe,  the  middle  of  the  curve  about  a 
quarter  of  an  inch  from  the  longitudinal  fissure.  The 
hemisphere  should  be  supported  by  placing  the  fingers 
of  the  left  hand  under  the  base  and  the  thumb  of  the 
same  hand  in  the  longitudinal  fissure,  lifting  the 
hemisphere  upward.  This  serves  to  separate  the  roof 
from  the  floor  of  the  ventricle. 

The  anterior  portion  of  the  cut  should  be  deep, 
made  with  the  knife  held  at  an  angle  of  forty-five 
degrees,  point  downward  (to  reach  the  anterior  horn). 
The  middle  portion  of  the  cut  should  be  less  deep, 


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Autopsy 


nade  with  the  knife  held  horizontally  (so  as  not  to 
inure  the  floor  of  the  ventricle).  The  posterior  cut 
hoiilc]  be  deep,  made  with  the  knife  held  at  an  angle 
if  forty-five  degrees,  handle  downward  (to  reach  the 
„, -tenor  horn). 

line    lateral    ventricle    having    been    opened,    the 
.rain  is  to  be  turned  half  around  and  the  other  lateral 
, ■utricle  opened  in  the  same  way.     The  knife  is  now 
oduced  in  the  foramen  of  Munro,  and  an  incision 
made    vertically    upward    through    the    anterior 
us  of  the  fornix  and  the  corpus  callosum.     The 
terior  portions  of  the  fornix  and  corpus  callosum 
now    drawn   backward   as  far   as   possible.      By 
loing  the  velum  interpositum  and  choroid  plexuses 
rr  brought  into  view.     These  are  also  to  be  drawn 
.ivard,    thus  exposing   the   third   ventricle.     The 
posterior  pillar  of  the  fornix  and  the  adjoining 
lain  substance  are  now  cut  transversely  and  carried 
to  the  left.     This  procedure  exposes  the  corpora 
]uadrigemina.     The  fourth   ventricle  is  now   to  be 
.■.I  by  an  incision  made  through  the  middle  line 
rebellum,  from  above  downward,  at  the  same 
dividing  the  corpora  quadrigemina  and  valve  of 
i  sens  by  extending  the  median  cut  to  the  aque- 
of  Sylvius. 
The  whole  ventricular  tract  is  now  exposed  to  view. 
Vote  should  be  taken  of  the  size  of  the  ventricles,  the 
racter  and  amount  of  their  contents,  and  the  con- 
lit  ion  of  the  ependyma. 

The  hemispheres  are  next  examined.  In  doing  this 
i  is  essential  to  expose  as  large  an  area  of  white  and 
*ray  matter  as  possible,  but  without  disturbing  the 
(ions  of  the  parts.  The  first  incision  is  a  curved 
jne  just  to  the  outside  of  the  basal  ganglia  and  follow- 
ing the  line  of  their  outer  borders.  It  should  extend 
near  to  the  pia  below.  A  series  of  cuts  are  now  to  be 
made,  each  succeeding  cut  being  made  in  the  middle 
of  the  preceding  cut  and  extending  to,  or  nearly  to, 
the  pia.  In  this  way  the  hemisphere  is  rolled  out, 
unfolded  as  it  were,  and  a  large  surface  or  series  of 
surfaces  is  exposed  to  view.  The  pia  is  to  be  left 
uninjured,  serving  as  a  binding  to  retain  the  parts  in 
their  normal  relation;  so  that,  2  a  lesion  be  discovered 
in  the  white  or  gray  matter,  the  parts  may  be  replaced 
and  the  situation  localized  as  to  convolution. 

The  basal  ganglia  (corpora  striata  and  thalami 
optici)  are  now  to  be  examined  by  means  of  a  series 
of  transverse  incisions,  the  cuts  being  about  one- 
twelfth  of  an  inch  apart.  These  are  most  readily 
made  by  supporting  the  ganglia  by  one  hand  placed 
underneath,  while  with  the  knife  in  the  other  hand 
the  cuts  are  made  and  the  slices  turned  to  one  side  so 
as  to  expose  the  cut  surface.  The  necessity  of  the 
numerous  incisions  in  the  basal  ganglia  is  owing  to 
the  fact  that  lesions  sufficient  to  lead  to  a  fatal  result 
are  often  small,  and  might  go  unobserved  were  the 
incisions  made  far  apart. 

The  cerebellum  is  now  to  be  examined  by  a  primary 
incision  beginning  in  the  middle  of  the  cut  made  in  it 
in  opening  the  fourth  ventricle  and  extending  through 
the  greatest  breadth  of  the  organ.  This  divides  it  into 
two  equal  portions,  exposing  a  large  surface  of  gray 
and  white  matter  and  the  arbor  vitce.  A  series  of 
radiating,  fan-shaped  incisions  should  then  be  made 
in  each  of  these  lateral  portions,  the  cuts  extending 
to  the  pia. 

The  pons  is  now  to  be  lifted  by  the  left  hand  placed 
beneath  it  and  a  series  of  transverse  incisions  is  to  be 
made,  beginning  anteriorly  in  the  corpora  quad- 
rigemina and  crura  cerebri  and  extending  through 
pons  and  medulla  to  the  spinal  cord.  As  in  the  basal 
ganglia,  so  here,  the  slices  should  be  as  thin  as  pos- 
sible, that  even  a  minute  lesion  may  not  escape 
observation. 

The  remaining  step  in  the  examination  of  the  brain 
is  to  strip  the  pia  from  the  convolutions  of  the  organ, 
especially  on  the  convexities,  and  note  whether  it  is 
readily   removed   or   whether   it   comes   away   with 


difficulty  and  removes  portions  of  brain  substance 
with  it,  leaving  a  worm-eaten  appearance  r,i  the 
cortex  beneath.  Such  an  adhesion  indicates  a  men- 
ingoencephalitis, common  in  dementia  paralytica. 

The  examination  of  the  brain  being  now  completed, 

the  cavity  of  the  cranium  should  be  sponged  dry  and 
tilled    with    a  sand    ban.    made    by    taking    a    piece    of 

cotton  cloth  eighteen  inches  square  and  putting  on  it 
as  much  house  sand  as  corresponds,  in  the  judgment 
of  the  operator,  to  the  capacity  of  the  cranium;  then 
gathering  the  corners  into  a  mass  and  tying  them 
together  with  a  string.  A  sand  bag  serves  the  double 
purpose  of  giving  weight  to  the  head  and  supporting 
the  calvaria.  The  calvaria  is  to  be  replaced  and  held 
there  by  stitches  taken  through  the  temporal  nm  i  le 
on  either  side,  care  being  taken  to  draw  the  twine 
tight  to  prevent  slipping  of  the  calvaria.  The  two 
Saps  of  the  scalp  are  now  drawn  together  and  sewn, 
alter  the  method  described  in  connection  with  the 
body.  The  seam  requires  a  piece  of  twine  twice  the 
length  of  the  incision. 

Examination  of  the  Spinal  Cord. — To  remove  the 
cord  the  body  should  be  placed  face  downward,  with 
a  block  under  the  thorax.  An  incision  is  made  along 
the  ridge  formed  by  the  spinous  processes  of  the  verte- 
bras from  the  occiput  to  the  sacrum.  The  skin  to- 
gether with  the  muscles  filling  the  vertebral  grooves 
should  be  dissected  from  the  arches,  leaving  the 
lamina?  bare.  The  lamina}  are  now  sawn  nearly 
through  in  a  line  with  the  roots  of  the  transverse 
process.  By  means  of  the  straight  chisel,  or,  better, 
with  the  rachitome  (Fig.  538)  and  the  hammer  the 
arches  are  freed  and  then  pried  off.  The  arches  of 
the  upper  cervical  vertebra?  are  best  divided  with  the 
costotome  (Fig.  533). 

The  membranes  and  cord  are  now  divided  trans- 
versely at  the  lower  end;  the  dura  is  seized  with  the 
forceps  and  the  cord  lifted  upward,  and  the  spinal 
nerves  are  divided  with  the  scalpel  close  to  the  for- 
amina. When  the  atlas  is  reached  the  cord  is  held 
only  by  the  dura,  where  it  is  reflected  on  the  margin 
of  the  foramen  magnum  to  become  the  periosteum  of 
the  inner  surface  of  the  skull.  This  is  divided  by  a 
circular  incision  a  little  below  the  foramen  magnum. 
The  cord  is  now  free. 

The  dura  of  the  cord  is  now  incised  anteriorly 
and  posteriorly  throughout  its  entire  length,  and  its 
inner  surface,  as  well  as  the  pia  of  the  cord,  examined. 

The  cord  is  examined  by  a  series  of  transverse 
incisions  half  an  inch  apart,  the  pia  on  the  anterior 
surface  being  left  intact  to  serve  as  a  binding  to  hold 
the  parts  together.  The  incision  in  the  back  is  to 
be  sewn  up  in  the  same  way  as  the  one  in  front. 

Cultures  of  bacteria  from  the  blood  are  best  made 
from  the  right  ventricle  of  the  heart.  The  surface 
of  the  right  ventricle  is  sterilized  by  a  case  knife 
heated  in  a  Bunsen  lamp,  laying  it  flat  on  the  surface 
of  the  heart.  An  incision  is  made  through  the  wall 
with  another  knife  sterilized  in  the  same  way,  and  the 
platinum  wire  introduced  through  the  cut  and  the 
culture  made. 

Cultures  from  any  of  the  solid  organs  may  be  made 
in  the  same  way. 

The  examination  of  the  whole  body  being  now  com- 
pleted, the  soiled  newspapers  are  to  be  removed  and 
burned  in  the  furnace  or  kitchen  fire.  The  operator 
should  himself  attend  to  the  emptying  of  the  slop 
pail,  which  will  contain  bloody  fluid  and  more  or  less 
intestinal  contents;  and  should  also  see  that  all 
utensils  are  thoroughly  cleaned,  that  all  spots  of 
blood  are  removed  from  the  body,  and  that  the  body 
is  restored  to  the  position  it  was  in  before  the  au- 
topsy was  begun. 

Report  of  the  Autopsy. — A  word  as  to  the  report 
of  the  autopsy.  A  proper  report  should  consist  of  two 
parts.  The  first,  to  consist  of  a  description  of  what  is 
seen,  should  be  purely  objective,  and  should  contain 


Vol.  I.— 51 


SOI 


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REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


no  expression  of  opinion.  The  second  part  is  to  con- 
tain the  anatomical  diagnosis;  in  other  words,  the  in- 
ferences drawn  from  the  appearances  presented  by  the 
organs. 

If  the  report  consists  (as  unfortunately  it  so  often 
does)  simply  of  the  inferences  of  the  operator,  with- 
out a  description  of  the  appearances  upon  which 
those  inferences  are  based,  it  is  of  little  value  to  any 
one  else,  and  of  no  value  as  evidence. 

Let  the  physician,  then,  in  his  report,  describe  to 
the  best  of  his  ability  what  he  sees,  and  if  he  is  in 
doubt  as  to  what  the  meaning  of  the  appearances  is, 
any  specialist  taking  his  report  can  give  him  much 
more  assistance  than  if  the  inferences  only  are  stated. 

W.  W.  Gannett. 


Autopsy,  Medicolegal  Relations  of  the. — When  death 
is  due  other  than  natural  causes,  the  data  upon  which 
such  a  conclusion  is  based  may  become  the  subject  of 
legal  inquiry.  This  article  concerns  itself  with  such 
data  as  may  be  furnished  by  the  performance  of  an 
autopsy.  The  lesions  found,  the  method  of  their 
observation,  and  the  deductions  to  be  drawn  there- 
from are  the  subjects  for  discussion.  (For  signs  of 
death,  rigor  mortis,  putrefaction,  etcv  subjects  em- 
braced in  an  external  examination  of  the  cadaver, 
see  Cadaver,  Legal  Status  of.) 

"Natural  cause  of  death,"  is  rather  difficult  to 
define  tersely.  The  importance  of  its  full  compre- 
hension is  apparent,  not  only  to  avoid  error  in  reach- 
ing such  a  conclusion,  but  also  from  the  fact  that  an 
effort  to  show  the  evidence,  including  data  from  the 
autopsy,  compatible  with  natural  causes  is  frequently 
made  by  the  defence.  "Senile  changes  or  disease 
unassociated  with  poisoning  or  traumatism,"  al- 
though it  might  answer  in  the  majority  of  cases,  is 
nevertheless  faulty,  as  the  following  considerations 
show.  The  acute  infectious  diseases  accepted  as 
natural  causes  are  all  associated  with  poisoning  from 
the  toxins  produced  by  the  bacteria.  Even  the  acute 
Infectious  diseases  may  come  under  the  category  of 
unnatural  causes  if  the  bacteria  are  accidentally 
or  deliberately  inoculated. 

If  we  adopt  the  above,  with  these  restrictions,  as 
a  working  definition,  it  becomes  necessary  in  exam- 
ining lesions  to  differentiate  between  those  produced 
by  disease  and  those  produced  by  poisoning  or  trauma- 
tism. Nor  is  this  an  easy  matter,  as  might  at  first 
appear.  A  lesion  apparently  traumatic  may  be  due 
to  disease.  Lesions  apparently  due  to  disease  alone 
may  prove  to  be  dependent  upon  trauma  primarily, 
as  when  infection  follows  a  wound.  Again,  a  diseased 
condition  (as  cerebral  arteriosclerosis,  or  pachy- 
meningitis luemorrhagica)  may  be  an  important 
contributing  cause  (vertigo)  of  an  accident  in  which 
traumatism  is  sustained,  causing  death;  or  disease 
may  directly  predispose  to  a  result  (fatal  hemorrhage) 
out  of  proportion  to  the  comparatively  slight  trauma- 
tism. Finally,  traumatism  and  disease  not  depend- 
ent in  causation  upon  one  another  may  both  con- 
tribute more  or  less  equally  in  causing  death.  The 
lesions  of  disease  may  so  closely  resemble  the  effects 
of  poison  (in  the  toxicological  sense)  that  their  differ- 
entiation by  gross  examination  is  almost  impossible, 
chemical  and  bacteriological  examinations  being 
necessary  to  clear  up  the  case. 

Technique. — The  method  of  observation  includes 
the  technique  employed  in  the  performance  of  the 
autopsy.  Not  only  the  data  and  the  deductions 
drawn  therefrom,  but  the  way  in  which  these  data 
were  acquired  may  be  subjected  to  searching  investi- 
gation in  court.  By  faulty  methods  incorrect  data 
may  be  obtained.  Direct  mistakes  in  observation 
are  not  here  referred  to,  but  unintentional  and  unob- 
served artifacts,  and  their  diagnosis  as  lesions.  It 
is  absolutely  necessary  to  be  fully  cognizant  of  all 


methods  and  manipulations  by  which  such  artifacts 
may  be  produced,  not  only  to  avoid  them,  but  also 
to  be  able  to  testify  to  that  effect.  In  considering 
the  technique  of  medicolegal  autopsies,  only  these 
points  will  be  dwelt  upon  here,  the  reader  being 
referred  to  the  preceding  article  for  a  detailed  descrip- 
tion of  the  technique  ordinarily  employed  when  no 
medicolegal  considerations  are  involved. 

Head. — In  removing  the  vertex  the  bone  should 
be  sawed  through  completely.  The  wedge,  or  chisel 
and  mallet,  had  better  not  be  used.  Although  the 
physician  may  be  certain  that  a  fracture  was  pro- 
duced during  life  and  not  post  mortem  by  the  use  of 
chisel  and  mallet,  yet  if  their  use  is  admitted  a  reason- 
able doubt  may  be  cast  upon  his  testimony.  The 
brain  should  be  removed  with  special  care,  raising 
the  frontal  lobes  sufficiently  to  cut  nerves  and  vessels 
close  to  the  foramina  of  exit  and,  raising  the  temporal 
lobes,  to  sever  thoroughly  the  anterior  and  lateral 
attachments  of  the  tentorium,  first  on  one  then  on  the 
other  side,  and  divide  the  remaining  nerves  and 
vessels  below,  in  doing  which  the  brain  should  not 
be  raised  from  the  base  of  the  skull  more  than  neces- 
sary. After  division  of  the  tentorium  the  brain 
should  be  supported,  as  the  final  division  of  nerves, 
vessels,  and  spinal  cord  proceeds,  lest  by  its  own 
weight  dragging  upon  these  structures,  it  cau- 
ait ifieial  lacerations.  The  brain  should  be  perfectly 
free  before  its  removal  is  attempted,  and  should  be 
allowed  to  slide  backward,  the  convex  surface  resting 
in  the  palm  of  the  hand. 

Spinal  Cord. — To  avoid  artifacts  a  complete  divi- 
sion of  the  lamina?  on  either  side,  one  centimeter  from 
the  spinous  process,  should  be  made  with  a  straight 
saw  curved  on  the  end,  the  serrations  extending  a 
short  distance  upon  the  curve.  Chisel  and  mallet 
had  better  be  avoided.  Test  the  complete  division  In- 
pressing  each  spinous  process  from  side  to  side.  If 
free,  the  lamina?  and  spinous  processes  can  readily  be 
removed  together  from  below  upward,  by  grasping 
the  lowest  and  using  the  knife  alone.  After  the 
attachment  of  the  dura  spinalis  to  the  foramen  ovale 
within  the  skull  has  been  severed,  the  spinal  cord 
should  be  removed  together  with  its  dural  sheath,  the 
spinal  nerves  being  cut  close  to  the  intervertebral  for- 
amina on  either  side  from  below  upward.  The  dura 
should  be  opened  in  the  median  line  anteriorly  and 
posteriorly  after  the  removal. 

Mouth  and  Neck. — The  examination  of  the  fauces 
and  aditus  laryngis  is  of  importance,  more  especially 
in  infants,  great  care  being  required  to  prevent  occur- 
rence of  artifacts.  The  tongue,  anterior  and  pos- 
terior pillars  of  fauces,  tonsils,  soft  palate,  pharynx, 
esophagus,  larynx,  and  trachea  may  be  removed 
together.  The  incision  is  extended  to  the  chin,  or, 
after  the  thorax  has  been  opened,  they  may  be  re- 
moved, without  extending  the  incision  over  two 
inches  above  the  episternal  notch,  by  separating  t he 
skin  from  the  clavicle  and  working  up  from  the 
thorax,  separating  the  unincised  skin  from  larynx, 
hyoid  bone,  and  muscles  of  the  floor  of  mouth.  Re- 
traction of  the  skin  by  hooks  or  a  finger  of  an  assist- 
ant on  either  side  in  an  upward  direction  gives  ample 
room  if  the  sternum  and  costal  cartilages  have  been 
removed;  and  the  space  may  be  still  further  increased 
by  partial  incision  of  the  sternocleidomastoid  muscle 
near,  or  at  its  insertion  into  the  clavicle.  With  a  sharp- 
pointed  knife  the  floor  of  the  mouth  is  punctured  in 
the  median  line  close  to  the  inferior  maxilla,  and  the 
muscles  and  mucosa  cut  through  along  the  body  of  the 
bone  to  the  angle  on  both  sides.  The  tongue  is  drawn 
down  through  the  incision,  and  with  the  knife  passed 
over  the  dorsum  of  the  tongue,  an  incision  is  made 
through  the  soft  palate  close  to  the  bone  from  the 
median  Hue  outward,  then  anteriorly  to  the  anterior 
pillar  of  the  fauces,  downward  to  the  incision  through 
the  floor  of  the  mouth  on  both  sides.  The  loose 
areolar  tissue  on  either  side  of  the  trachea  and  larynx, 


802 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Auio|i-\,  Medicolegal 
Bclatlona 


esophagus  and  pharynx,  and  posterior  to  the  latter, 
is  separated  well  up  to  the  occipital  bone,  where  the 
attachment  of  the  pharynx  is  cut  across.  The  sty- 
loid muscles  arc  cut  and  the  organs  drawn  gently 
downward,  care  being  taken  to  observe  whether 
there  are  any  points  at  which  attachments  still  re- 
quire to  be  divided.  It  is  possible  for  the  stomach 
(•(intents  to  reach  the  larynx  or  the  aditus  laryngis 
posi  mortem,  either  in  moving  the  cadaver  about  or 
during  the  performance  of  the  autopsy.  During  the 
removal  of  the  stomach  its  contents  may  be  forced 
into  the  esophagus  and  pharynx  and  larynx.  To 
guard  against  this  a  ligature  should  be  applied  to  the 
cardiac  end  of  the  esophagus  before  dissecting  out 
the  stomach. 

Abdomen. — The  abdomen  should  invariably  be 
ned  before  the  thorax,  the  skin  and  muscles  of 
the  latter  being  dissected  off  to  give  more  room  for 
inspection.  The  height  of  the  vault  of  the  diaphragm 
in  the  mammillary  line  on  either  side  should  be  deter- 
mined. The  organs  should  be  examined  as  far  as 
possible  in  situ  and  the  contents  of  the  peritoneal  cav- 
ity, if  any,  their  character,  amount,  and  distribution 
ii 'ted.  In  cases  of  injury  special  care  is  to  be  taken 
in  the  removal  of  organs,  the  incisions  necessary 
being  deliberately  and  cleanly  made  and  laceration 
of  tissue  avoided.  In  cases  of  bullet  and  stab  wounds 
their  site  should  be  accurately  determined  and  their 
measurements  carefully  made  so  that  the  direction 
of  the  course  of  the  bullet  or  knife  may  be  determined. 
The  abdominal  organs  may  be  removed  together 
with  the  thoracic  organs  and  diaphragm,  in  order 
to  determine  more  accurately  the  relations  of  certain 
traumatisms.  The  esophagus,  aorta,  vena  cava,  and 
ligaments  of  the  liver  are  not  divided.  An  incision 
is  made  through  the  parietal  peritoneum  on  the  right 
side  external  to  the  right  kidney  and  ascending  colon, 
on  the  left  side  external  to  the  left  kidney,  descending 
colon,  and  sigmoid  flexure.  The  loose  connective 
tissue  between  the  organs  and  the  posterior  abdominal 
wall  is  readily  separated  by  blunt  dissection,  the 
lumbar  branches  of  the  aorta  and  the  common  iliac 
vessels  requiring  the  knife. 

Pelvis. — The  pelvic  organs  may  also  be  removed  to- 
gether, the  connection  of  ureters  with  bladder  and  the 
sigmoid  with  rectum  remaining  intact.  The  female 
genital  organs,  after  examination  in  situ,  should  be 
removed  together.  A  circular  incision  is  made 
through  the  peritoneum  around  the  margin  of  the 
true  pelvis,  the  loose  areolar  tissue  stripped  up  with 
the  fingers  down  to  the  levator  ani  et  vaginae,  and  an- 
teriorly well  down  behind  the  symphysis  pubis.  With 
a  few  sections  of  the  knife  the  ostium  vaginae  to- 
gether with  the  urethra,  the  bladder,  vagina,  uterus 
and  appendages,  and  rectum  are  removed.  After 
examination  of  the  rectum,  bladder,  urethra,  and  the 
appendages,  especially  the  ovaries  for  a  corpus  luteum 
of  pregnancy,  the  vagina  is  laid  open  with  knife  or  scis- 
sors. The  cavity  of  the  uterus  should  not  be  opened 
by  thrusting  the  blade  of  the  scissors  or  knife  into 
it.  A  clean  incision  should  be  made  in  the  median 
line  posteriorly  until  the  cavity  is  reached  so  as  to 
avoid  all  chances  for  the  occurrence  of  artificial  lacera- 
tion or  puncture. 

Thorax. — In  cases  of  hemorrhage,  great  care  should 
be  exercised  so  that  its  origin  may  be  accurately 
determined,  and  its  cause,  whether  traumatic  or  due 
to  disease  or  possibly  to  both  conditions,  determined. 
The  examination  of  the  organs  in  situ  should  be  made. 
To  determine  the  presence  of  pulmonary  thrombosis 
the  pulmonary  artery  should  be  opened  with  organs 
in  situ.  If  the  examination  is  unsatisfactory,  the 
organs  of  the  thorax  may  be  taken  out  together 
with  those  of  the  neck  and  mouth  if  necessary.  Pleu- 
ral adhesions  are  then  separated,  or  if  they  are  too  dense 
(rather  than  risk  an  artificial  laceration  of  the  lung), 
the  costal  pleura  having  been  stripped  off,  the  attach- 
ments of  the  diaphragm  are  cut  away  from  the  ribs, 


and  its  pillai  •  i  red,  an  incision  is  made  through  the 
parietal  pleura  along  the  vertebral  column  external 
and  posterior  to  I  he  aoi  ta  on  i  he  ;  il  ide,  t  he  lung 
being  brought  forward  for  tha  i  po  i  and  the  lefl 
subclavian  vessels,  common  cat  iticf,  and  jugulat 
cut.  <  In  tin-  righl  side  the  ini  i  ion  i  made  e  ternal 
and  posterior  to  the  vena  cava  superior,  right  auricle, 
and  vena  cava  inferior,  and  the  innominate  arter;    <     1 

vein  are  cut  across.     '|i phagu     neat   the  cardia 

is  ligated  and  cut  above  the  Ligature.  The  aorta, 
inferior  vena  cava,  and  suspensory  Ligament  ol  the 
Liver  are  then  severed.  By  this  technique  injuries 
may  he  clearly  demonstrated  which  by  the  usual 
technique  might  escape  ob  ervation,  or,  if  observed, 
their  origin  or  relations  might  be  doubtful. 

Cases  op  Poisoning. — Cases  of  suspected  poison- 
ing require  special  consideration.  The  presence  of 
the  chemist  at  the  autopsy  and  his  direct  reception 
of  the  organs  for  examination  from  the  pathologist 
simplify  matters  considerably.  If  this  plan  cannot 
be  followed,  it  devolves  upon  the  pathologist  to  re- 
move such  organs  and  fluids  in  which  the  suspected 
poison  may  be  detected,  in  such  a  manner  as  to  a\  oid 
contamination,  and  to  place  them  in  possession  of  the 
chemist  with  the  least  possible  delay  and  by  as  direct 
means  as  circumstances  will  allow.  It  "should  be 
remembered  that  every  step  from  the  performance  of 
the  autopsy  to  the  reception  of  the  material  for  exami- 
nation by  the  chemist  may  be  made  the  subject  of  a 
searching  examination  in  court,  namely,  how  the 
organs  were  removed,  what  instruments  were  used 
and  what  condition  they  were  in,  what  receptacles 
the  material  was  placed  in  for  transportation,  how 
these  receptacles  were  treated  before  and  after  the 
material  was  placed  in  them,  whether  any  preserva- 
tive fluid  was  used,  were  they  properly  sealed,  and 
what  means  were  employed  in  transporting  them  to 
the  chemist.  These  points  may  appear  trivial,  yet 
too  much  attention  cannot  be  paid  to  the  minutest 
detail.  Carelessness  in  this  regard  may  nullify  the 
entire  work  of  the  chemist  and  cause  a  break  in  an 
otherwise  intact  chain  of  evidence.  On  the  other 
hand,  such  carelessness  may  be  the  means  of  unwitt- 
ingly convicting  an  innocent  person.  Glass  jars 
that  have  been  used  for  no  other  purpose,  carefully 
cleaned  with  soap  and  water,  rinsed  with  water, 
then  with  alcohol,  closed  preferably  with  a  ground 
glass  stopper  or  clean,  well-fitting  cork,  should  be 
used.  Stomach  or  intestinal  contents,  urine,  and 
blood  should  be  placed  in  separate  jars.  When  the 
determination  of  the  amount  of  poison  in  individual 
viscera  is  of  importance  they  should  be  placed  in 
separate  jars.  The  condition  of  preservation  or 
decay  of  the  material  should  be  noted.  If  the  mate- 
rial cannot  be  placed  in  the  hands  of  the  chemist  di- 
rectly, a  sufficient  amount  of  strong  alcohol  should  be 
added  to  cover  the  organs  in  the  jars,  in  order  to 
check  decomposition  and  prevent  breakage  by  the 
gases  of  decomposition.  If  this  is  done  a  portion  of 
the  same  alcohol  that  was  used  in  the  jars  should  be 
sent  to  the  chemist  also.  Finally  all  jars  should  be 
separately  tied  with  tape,  properly  sealed  and  labelled. 
By  this  means,  although  the  material  may  have  neces- 
sarily passed  through  several  hands,  provided  it 
reaches  the  chemist  with  intact  seal,  the  chain  of 
evidence,  so  far  as  the  examination  of  the  organs, 
fluids,  etc.,  is  concerned,  remains  unbroken. 

The  evidence  already  at  hand  before  the  perform- 
ance of  an  autopsy  may  point  to  a  given  poison  as  the 
cause  of  death,  either  from  the  clinical  history  of  the 
case,  or  from  the  discovery  of  the  empty  poison  bottle 
or  package,  or  of  some  of  the  poison  suspected  to 
have  been  given  to  or  taken  by  the  deceased.  This 
evidence,  although  a  valuable  guide,  cannot  be  en- 
tirely relied  upon  and  should  not  bias  the  judgment  of 
the  pathologist.  Cases  occur  in  which  an  entirely 
different  poison  is  found  to  have  been  the  cause  of 


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Autopsy,  Medicolegal 
Relations 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


death,  and  some  in  which  the  presumptive  evidence 
appeared  very  strong  have  proved  to  be  deaths  from 
natural  causes,  or  the  alterations  found  have  turned 
out  to  be  merely  postmortem  changes.  Cases  occur 
in  which  there  is  no  suspicion  whatever,  and  yet 
poisoning  is  proved  by  autopsy  and  chemical  examina- 
tion. Such  are  not  merely  cases  of  sudden  death 
without  any  clinical  history,  but  often  enough  cases 
that  have  been  ill  for  some  time  and  treated  for 
disease  by  a  physician,  competent  enough  compara- 
tively, who  may  have  filed  a  death  certificate  giving 
the  disease  diagnosed  by  him  as  the  cause  of  death. 
In  fact,  it  is  well  known  that  the  results  of  some 
poisons  may  so  closely  resemble  disease  clinically  and 
even  pathologically  that  mistakes  can  easily  be  made. 
The  only  safe  way  to  avoid  error  is  for  the  clinician 
to  insist  upon  an  autopsy  before  signing  the  death 
certificate,  and  for  the  pathologist  to  employ  chem- 
ical and  bacteriological  aid.  In  the  performance  of 
autopsies,  whether  poisoning  is  suspected  or  the  cause 
of  death  is  unknown  or  doubtful,  a  complete  exami- 
nation of  the  body  should  be  made;  and  the  pathol- 
ogist should  be  ever  mindful  of  those  conditions, 
which  although  often  resembling  the  results  of  dis- 
eases such  as  cholera,  dysentery,  nephritis,  malig- 
nant jaundice,  or  acute  yellow  atrophy  of  the  liver, 
may  nevertheless  be  the  results  of  poisons  such  as 
arsenic,  mercury,  potassium  chlorate,  or  phosphorus. 

Some  poisons  produce  no  characteristic  changes  in  the 
tissues  of  the  body,  so  far  as  gross  or  even  microscop- 
ical examination  is  concerned;  their  presence  cannot 
be  positively  affirmed  until  chemical  examination  is 
made.  The  pathologist  may,  however,  be  able  to  state 
that  no  pathological  condition  of  the  organs  due  to  dis- 
ease or  traumatism,  and  sufficient  to  cause  death,  has 
been  found.  When  the  organs  are  found  in  a  normal 
condition  it  may  be  easy  enough  to  reach  this  conclu- 
sion. When,  however,  pathological  changes  are  pres- 
ent, it  is  often  very  difficult  to  estimate  their  impor- 
tance in  the  causation  of  death.  Although  our  knowl- 
edge of  the  morphology  of  disease,  and  of  the  bacter- 
iology of  many  of  the  infectious  diseases,  is  extensive, 
that  of  its  chemistry  is  not  nearly  so  well  advanced. 
Pathological  conditions  are  found  which  in  the  absence 
of  any  suspicious  circumstances  are  assumed  to  be  the 
cause  of  death;  yet  we  meet  with  cases  in  which 
these  conditions  are  present  and  may  even  be  very  pro- 
nounced, but  nevertheless  death  is  the  result  of  vio- 
lence or  of  some  other  intercurrent  disease.  When 
the  circumstances  of  a  death  are  suspicious,  a  chemical 
examination  is  usually  called  for.  There  are  cases, 
however,  of  sudden  death  in  which  no  suspicions  are 
entertained  at  the  time,  but  in  which,  though  a  care- 
ful autopsy  is  performed,  a  conscientious  pathologist 
cannot  satisfy  himself  of  the  cause  of  death,  even  with 
the  aid  of  microscopical  and  bacteriological  exami- 
nations. In  such  cases  a  chemical  examination  alone 
can  affirm  or  exclude  poisoning. 

Other  poisons  do  produce  effects  more  or  less 
characteristic  by  their  direct  local  action,  by  their 
absorption,  and  by  their  excretion.  The  task  in  the 
performance  of  the  autopsy  is  to  determine  whether 
the  changes  found  may  have  been  produced  by  a 
poison,  and  if  possible  by  what  poison.  Of  course, 
the  positive  proof  in  every  case  must  be  furnished  by 
chemical  examination.  The  work  of  the  patholo- 
gist, however,  is  of  importance,  on  the  one  hand  to 
obviate  useless  chemical  examinations,  on  the  other  to 
insist  upon  a  chemical  examination  when  necessary, 
and  to  select  such  organs  and  fluids  as  are  of  impor- 
tance forexamination.  On  this  account  it  is  impor- 
tant to  know  what  changes  are  characteristic  of  poison- 
ing, and  what  are  characteristic  of  special  poisons. 

Certain  physical  characteristics  of  poisons  may 
lead  to  the  suspicion  of  their  presence.  A  green 
color  may  indicate  the  presence  of  acetoarsenite  of  cop- 
per; yellow,  potassium  chromate  or  iodine;  blue,  sul- 
phate of  copper;  or  certain  dyes,  such  as  those  used  in 


corrosive  sublimate  tablets,  or  in  the  heads  of  matches 
may  furnish  an  indication.  The  odor  characteristic 
of  phosphorus,  or  of  bitter  almonds,  of  alcohol  of 
chloroform,  of  laudanum,  or  of  carbolic  acid  may 
furnish  an  indication.  The  granular  or  crystalline 
appearance  of  the  substance,  its  insolubility,  may 
furnish  a  clew.  The  chemical  reaction,  whether  acid 
or  alkaline,  is  important,  and  the  contents  of  stomach 
and  intestine  should  always  be  tested  in  this  regard. 

In  the  greatest  number  of  poisoning  cases,  the 
poison  is  introduced  by  way  of  the  mouth;  unusually, 
by  rectal,  vaginal,  intrauterine,  or  hypodermic  in- 
jection. Some  poisons  produce  no  effect  upon  the 
mucous  membrane;  others  are  irritants  and  <>ause 
effects  varying  in  intensity  from  congestion  and 
ecchymoses  to  complete  corrosion  with  production 
of  eschars.  Those  poisons  which  produce  the  corro- 
sive effect  upon  the  mucosa  may  act  either  by  coagu- 
lating its  albuminous  constituents — as  happens  in 
the  case  of  the  mineral  acids,  oxalic  acid  and  car- 
bolic acid,  and  mercuric  chloride — or  by  dissolving 
them  and  causing  a  sw-elling  and  softening  of  the 
mucosa — as  is  true  of  sodium,  potassium,  and  ammo- 
nium hydrate  and  potassium  cyanide.  Concentrated 
sulphuric  acid  dissolves  coagulated  albumin;  if 
dropped  on  a  mucous  membrane  a  spot  is  formed  that 
is  transparent  in  the  center  and  white  at  the  per- 
iphery where  the  acid  has  been  diluted  by  the  fluid  of 
the  tissue  and  the  albumin  precipitated.  When  the 
caustic  alkalies  have  acted  upon  a  mucous  membrane, 
if  neutralized  or  if  the  reaction  is  changed  by  addition 
of  acid,  the  albumin  is  precipitated  and  a  grayish 
eschar  appears. 

These  effects  may  be  further  changed  in  appearance 
by  the  action  of  the  poison  upon  the  blood  with  which 
it  comes  in  contact.  If  the  poison  separates  hematin 
from  hemoglobin  and  dissolves  it,  the  eschar  or  the 
tissue  may  be  discolored  brown  or  brownish-black  by 
imbibition,  as  with  sulphuric  acid,  hydrochloric  acid, 
oxalic  acid,  and  the  caustic  alkalies.  Carbolic  acid 
and  corrosive  sublimate  coagulate  blood  but  do  not 
cause  a  separation  of  hematin.  Each,  however, 
produces  a  change  of  color  in  the  coagulum,  namely, 
carbolic  acid  a  bright  brick  red,  and  sublimate  a 
grayish-violet. 

The  effects  may  vary  according  to  the  amount  of  the 
poison,  its  concentration,  the  duration  of  its  action, 
and  the  condition  of  fulness  or  emptiness  of  the  stom- 
ach and  intestines.  The  lips  and  skin  of  the  face  and 
neck  may  show  corrosive  action  of  the  poison.  The 
mucous  margin  may  present  grayish-white  or  brown- 
ish eschars.  Crescentic  streaks  on  either  side  of  the 
upper  lip,  extending  upward  from  the  corners  of  the 
mouth,  may  be  present  when  the  poisonous  fluid  has 
been  imbibed  from  a  tumbler;  there  may  be  streaks 
from  either  corner  of  the  mouth  passing  downward 
over  the  cheek  or  chin,  and  down  the  neck,  when  the 
poison  has  been  spilled  while  drinking.  Corrosion 
of  the  lips  and  skin  may  be  absent  when  the  poison 
has  been  swallowed  from  a  bottle.  The  mucosa  of 
the  mouth  may  show  swelling  and  eschars,  but  from 
short  duration  of  contact  these  may  not  be  well 
marked.  The  mucosa  of  the  esophagus  may  show 
111 1  lc  action  from  the  short  duration  of  contact  and  the 
relatively  slight  amount  of  poison  that  remains  in 
contact. 

The  stomach  usually  shows  the  greatest  amount 
of  change.  This  may  affect  its  entire  surface,  or  be 
confined  more  especially  to  the  region  of  the  fundus, 
greater  curvature,  and  posterior  surface.  Excep- 
tionally, the  corrosive  action  may  be  confined  to  the 
smaller  curvature  and  anterior  surface,  the  most 
probable  explanation  being  the  ingestion  of  poison 
upon  a  full  stomach,  which  shortly  thereafter  has 
emptied  its  contents  into  the  duodenum,  in  which 
case  the  duodenum  and  jejunum  show  the  effects  more 
markedly.  The  summits  of  the  folds  in  the  mucosa 
show  more  decided  effect  on  account  of  greater  ex- 


804 


REFERENCE    HANDBOOK    or    Till:    Mr.lHi    \l.    SCIENI  I  - 


Autopsy,  Medicolegal 
Relations 


oosure,  tlie  sulci  being  in  part  protected  by  contact 

,f  opposite  surfaces.     Thus  the  eschars  in  the  stom- 

ich  Form  longitudinal  streaks  separated  sometimes  by 

intervening  mucosa  nol   escharotic  or  less  markedly 

so.     The  corrosive  action  varies  in  depth  and  may 

extend   through   the  peritoneum,  involving  adjacent 

ins  such  as  the  spleen,  colon,  pani  rea  .  and  liver, 

without  perforation  of  the  stomach;  or   the  stomach 

have  been  perforated  by  the  action  of  the  poison, 

contents    having    escaped    into    the    peritoneal 

1-avitv  anil  produced  characteristic  changes  wherever 

the    poison     has    come    in    contact.     Autodigestion 

oi  the  stomach  with  perforation  may  occur  without 

the  presence  of  corrosive  poisons. 

In  the  duodenum  and  jejunum  the  crests  and 
superior  surfaces  of  the  valvula-  arc  especially  ex- 
posed and  show  the  greatest  amount  of  corrosive 
aiiion.  usually  more  intense  nearer  the  pylorus  and 
iming  less  severe  further  down.  Exceptionally, 
duodenum  as  well  as  the  stomach  may  escape, 
and  a  coil  of  jejunum  further  along  show  severe  cor- 
ion.  The  ileum  rarely  shows  the  effect  of  direct 
local  action,  and  the  same  may  be  said  of  the  colon, 
except  in  those  cases  in  which  the  poison  has  been 
introduced  directly  into  the  rectum.  The  caput  coli 
and  first  portion  of  the  ascending  colon  may  occasion- 
ally show  the  effect  of  local  action,  probably  from  the 
longer  duration  of  contact  of  poisons  that  have  passed 
with  greater  rapidity  through  the  small  intestine. 
The  colon  and  lower  part  of  the  ileum  ma}-  show  the 
effects  of  poison  by  excretion.  This  is  a  character- 
istic effect  in  bichloride  of  mercury  poisoning,  espe- 
cially if  a  period  of  a  week  or  two  has  elapsed  after  its 
ingestion. 

The  effects  upon  the  tissues  from  the  absorption 
of  poisons  is  shown  in  the  degenerative  changes, 
parenchymatous  or  fatty,  in  the  functional  epi- 
thelial cells  of  the  organs,  as  the  stomach  and  liver:  in 
the  muscle  fiber  of  the  heart  and  sometimes  of  the 
voluntary  muscles;  and  in  the  epithelium  of  the 
kidney,  more  especially  of  the  cortex,  when  excretion 
of  the  poison  has  taken  place. 

Carbolic  Acid  Poisoning. — Eschars  on  the  lips  may 
be  white,  grayish,  or.  when  drying  has  occurred, 
dark  brown.  The  eschars  on  the  cutaneous  surfaces, 
if  any,  are  usually  brown,  dry,  and  leathery.  The 
mucosa  of  the  tongue  and  mouth  may  be  white  or 
grayish-white,  or  show  no  change.  Pharynx  and 
hagus  usually  show  grayish-white  eschars.  There 
is  generally  more  or  less  edema  of  the  aryepiglottic 
folds  about  the  aditus  laryngis  and  the  loose  sub- 
mucous tissue  over  the  arytenoids  and  anterior  wall 
of  the  pharynx. 

The  eschars  in  the  stomach  are  usually  longi- 
tudinal, involving  the  crests  of  the  folds,  and  of  a 
white  or  grayish  color,  while  the  intervening  mucosa, 
where  not  escharotic,  will  present  a  light  red  tint  due 
to  the  action  of  carbolic  acid  on  the  blood.  The 
entire  wall  has  a  dense  leathery  feel,  and  the  stomach 
may  be  markedly  contracted.  The  action  of  car- 
bolic acid  may  extend  to  the  peritoneal  coat  and 
even  to  the  spleen  and  liver,  the  color  usually  being 
pink,  or  light  red,  upon  a  grayish-white  base. 

The  distribution  of  effects  varies  according  to  the 
concentration  and  amount  of  the  carbolic  acid,  and 
the  condition  of  the  stomach,  whether  empty  or  full 
when  the  acid  was  taken.  The  escharotic  action  may 
extend  to  a  variable  distance  down  the  small  intes- 
tine, the  valvula?  of  the  duodenum  and  jejunum  per- 
haps showing  grayish-white  eschars,  while,  further 
along,  the  mucosa  may  present  a  pink  discoloration 
and  marked  swelling  and  softening.  The  other  organs 
show  but  little  change,  in  the  great  majority  of  cases, 
since  death  occurs  within  a  few  minutes.  Passive 
hyperemia  is  usually  present.  In  cases  of  survival  of 
the  ingestion  of  a  smaller  amount  for  some  hours, 
the  characteristic  phenol  urine  is  found,  with  marked 
parenchymatous  degeneration  of  the  kidneys. 


Sulphuric  Acid  I'"  The  eschars  on  the  lips 

and   -kin  are  usually  brow  n,   leathery,  and  dry.      The 

mucous  membrane  of  the  mouth  and  esophagus 
presents  grayish-white  eschars.  The  stomach  wall  is 
thick  and  dense,  the  mucous  membrane  corroded, 
the  eschars  brown  or  black  from  the  imbibition  of 
dissolved  hematin,  Wherever  the  blood  has  been 
acted  upon,  whether  extravasated  or  in  tl. 

the  coagulum  is  black,  dry,  and  brittle.      Either  from 

the  action  of  the  acid  or  from  casting  off  of  necrotic 

portions  of  mucous  membrane  the  surface  may  pre- 
sent an  irregular  nodular  appearance.  The  fundus 
of  the  stomach  may  be  perforated  either  during  life 
or  post  mortem,  ami  wherever  the  acid  come-  in  eon- 
tact  with  tissue  a  cloudy  appearance  is  presented, 
due  to  coagulation  of  albumin.  The  mucosa  of  the 
small  intestine  may  present  a  variegated  appearance 

of  grayish-white  eschars,  where  the  acid  ha-  caused  a 
coagulation  of  the  albumin  of  the  tissue,  with  inter- 
vening dark  brown  or  black  areas,  where  eeihyin 

have  occurred  or  where  a  previous  eschar  has  ex- 
foliated laying  bare  the  submucosa  stained  with 
hematin.     The  kidneys  show  parenchymatou 

elation  or  nephritis.      In  prolonged  cases  thi 

mucosa  of  the  stomach  and  inte  tine  may  be  thrown 
off,  showing  a  hemorrhagic,  edematous  submucosa, 
with  more  or  less  imbibition  of  hematin. 

Hydrochloric  Acid  Poisoning.—  Hydrochloric  acid 
produces  no  corrosive  action  on  the  skin.  The  eschars 
are  grayish-white  when  simple  coagulation  of  albumin 
has  taken  place,  and  dark  brown  or  black  when  ecchy- 
moses  have  occurred  or  when  imbibition  of  dissolved 
hematin  has  taken  place.  The  effect  is  very  much 
like  that  of  sulphuric  acid,  except  that  the  drying 
of  the  eschars  and  of  the  blood  clot  is  less  pronounced, 
owing  to  the  fact  that  hydrochloric  acid  has  not  so 
strong  an  affinity  for  water. 

Nitric  Acid  Poisoning. — The  eschars  present  a 
yellowish  stain,  due  to  the  formation  of  xanthoproteic 
acid;  otherwise  they  are  not  markedly  different  from 
those  described  above,  except  as  regards  the  fact 
that  nitric  acid  does  not  separate  and  dissolve  hem- 
atin. The  brown  or  black  discoloration  of  the 
eschars  produced  by  both  sulphuric  and  hydro- 
chloric acids  does  not  occur. 

Concentrated  Acetic  Acid. — A  case  of  poisoning 
from  this  acid  is  on  record;  death  was  due  to  pneu- 
monia, and  a  grayish-white  corrosion  of  the  mucous 
membrane  of  the  mouth  and  respiratory  passages  was 
observed.  A  sponge  saturated  with  concentrated 
acetic  acid  was  held  at  the  mouth  and  nose. 

Oxalic  Acid  and  Oxalate  of  Potassium. — In  concen- 
tration they  produce  white  or  grayish  corrosion  of 
the  mucous  membrane  of  the  pharynx  and  esophagus. 
The  mucosa  of  the  stomach  is  swollen,  injected,  and 
escharotic,  with  imbibition  of  hematin;  it  is  easily 
removed  by  washing.  The  escharotic  action,  how- 
ever, is  never  as  great  as  with  sulphuric  acid.  White 
opacities  (oxalate  of  lime)  are  found  in  the  blood  of 
the  corroded  portions,  also  in  the  uriniferous  tubules. 
Perforation  of  the  stomach  may  occur,  with  the  re- 
sulting effect  of  a  local  peritonitis,  due  to  the  escape 
of  the  contents  of  the  organ  into  the  peritoneal  cavity. 
These  perforations,  however,  are  in  most  instances 
a  postmortem  occurrence.  Wherever  the  poison 
acts  upon  the  blood,  black  clots  occur  in  which  ox- 
alate of  lime  crystals  may  be  found. 

Caustic  Potash.  Soda,  mid  Ammonia. — The  mucosa 
of  the  mouth  may  be  swollen  and  red,  the  epithelium 
partlj-  exfoliated,  partly  still  adherent  in  whitish 
shreds.  The  esophagus  may  have  lost  its  epithelium, 
and  may  be  swollen  and  hyperemic.  its  lower  portion 
being  brownish  and  soft.  The  mucosa  of  the  stom- 
ach is  thrown  into  thick  folds,  markedly  swollen  and 
ecchymotic,  with  superficial  losses  of  substance;  it  is 
dark  brown,  from  imbibition  of  hematin.  The 
submucous  tissue  is  markedly  edematous.  Croupous 
gastritis  may  follow  the  action  of  the  caustic.     Croup- 


Ml.-, 


Autopsy,  Medicolegal 

Relations 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


ous  bronchitis  and  circumscribed  areas  of  broncho- 
pneumonia may  result  from  aspiration  of  the  caustic 
soda  or  potash  and  may  be  the  immediate  cause  of 
death.  In  other  cases  the  cicatricial  tissue  following 
the  exfoliation  of  the  sloughs  may  finally,  if  not 
relieved  surgically,  cause  death  by  stricture  of  the 
esophagus. 

(  drbon.  Monoxide  Poisoning. — The  appearance  of 
the  cadaver,  in  poisoning  by  carbon  monoxide,  is 
very  characteristic,  more  especially  in  the  cases  of 
poisoning  from  illuminating  gas.  The  postmortem 
spots  are  of  a  pink  hue,  and  give  the  cadaver  an 
almost  life-like  appearance.  The  blood  is  fluid  and 
cherry  red  in  color.  The  mucous  and  serous  mem- 
branes are  of  a  rosy  tint,  and  the  organs  (especially 
those  containing  much  blood)  present  a  cherry  red 
appearance.  This  is  especially  well  marked  where 
the  blood  is  seen  upon  a  white  background,  as  in  the 
brain.  The  color  should  be  determined  at  once  as 
soon  as  the  blood  or  organs  are  exposed  to  the  air, 
as  after  a  longer  exposure  blood  that  does  not  contain 
carbon  monoxide  hemoglobin  may  become  light  red 
in  color,  the  reduced  hemoglobin  changing  to  oxy- 
hemoglobin, the  oxygen  being  absorbed  from  the 
atmosphere.  The  appearance  of  the  blood  in  some 
cases  of  carbon  monoxide  poisoning,  although  car- 
bon monoxide  hemoglobin  is  present,  may  present 
a  dark  color  from  excess  of  reduced  hemoglobin,  from 
carbon  dioxide  absorption.  This  occurs  more  com- 
monly in  poisoning  from  coal  gas,  and  from  inhala- 
tion of  smoke  at  conflagrations.  The  appearance  of 
the  blood  may  also  vary  when  several  hours  have 
intervened  between  the  cessation  of  inhalation  of 
carbon  monoxide  and  death.  Since  vomiting  is  a 
symptom  of  carbon  monoxide  poisoning,  persons  may 
die,  in  an  atmosphere  of  carbon  monoxide,  from 
aspiration  of  vomit,  the  formation  of  carbon  mon- 
oxide hemoglobin  being  as  yet  insufficient  in  amount 
to  cause  death. 

Carbon  monoxide  hemoglobin  is  readily  demon- 
si  rated  by  the  spectroscope,  producing  two  absorp- 
tion bands  near  D  and  E  like  oxyhemoglobin,  but  not 
reduced  like  the  latter  by  addition  of  ammonium 
sulphide.  In  doubtful  cases,  therefore,  a  specimen  of 
the  blood  should  be  saved  for  this  examination. 
II  has  been  found  that  carbon  monoxide  hemoglobin 
can  be  demonstrated  in  the  blood  of  extravasations 
and  in  muscle  when  its  demonstration  fails  in  the 
blood  taken  from  the  heart.  When  persons  have 
died  in  an  atmosphere  of  carbon  monoxide,  or  shortly 
after  being  removed  therefrom,  the  blood  resists 
decomposition  for  a  considerable  time,  and  the 
spectroscopic  examination  may  be  of  value  even 
after  the  lapse  of  two  or  three  months.  Such  blood 
also  keeps  its  bright  red  color.  A  note  on  the  color 
and  condition  of  preservation  of  blood  that  is  taken 
for  examination  is  of  importance,  since  with  decom- 
position (especially  if  ammonia  is  present  in  abun- 
dance) hematin  is  formed.  Such  blood  is  of  dark 
color  and  becomes  cloudy  when  mixed  with  water. 
The  absorption  bands  are  not  clear,  or  there  is  only 
a  shading  in  the  green.  On  addition  of  ammonium 
sulphide  two  bands  appear — i.e.  the  spectrum  of 
reduced  hematin. 

The  differential  diagnosis  between  illuminating-gas 
and  coal-gas  poisoning  may  not  be  easy  to  make. 
Cases  of  poisoning  by  illuminating  gas  present  the 
most  characteristic  appearances  postmortem  and  on 
spectroscopic  analysis;  those  of  poisoning  by  coal  gas, 
from  the  larger  percentage  of  carbon  dioxide,  present 
less  characteristic  appearances,  and  the  spectroscope 
may  show  the  bands  at  D  and  E,  after  the  addition 
of  ammonium  sulphide,  together  with  a  more  or 
less  deep  intervening  band  between  them.  In  cases 
of  death  in  conflagrations  the  effect  of  inhalation  of 
smoke,  as  shown  by  the  presence  of  black,  sooty 
deposits  upon  the  respiratory  mucosa,  is  quite 
characteristic. 


Besides  spectroscopic  analysis  there  are  a  number 
of  chemical  tests,  very  easy  of  application  at  the  au- 
topsy  table,  which  prove  of  aid  in  doubtful  cases. 
The  addition  of  a  drop  or  two  of  a  ten-per-cent. 
sodium  hydrate  solution  changes  the  color  of  other 
blood  to  a  dirty  brown  or  brownish-green;  carbon 
monoxide  blood  remains  bright  red.  Solution  of  a 
copper  salt  changes  the  color  of  other  blood  to  choco- 
late brown;  carbon  monoxide  blood  remains  red. 
Tannin,  ferrocyanide  of  potassium,  and  acetate  of 
lead  form  a  brown  precipitate  with  other  blood,  a  red 
one  with  carbon  monoxide  blood. 

These  tests,  and  also  the  spectroscopic  test,  may 
produce  recognizable  results  in  some  cases  in  which 
death  has  occurred  even  sixty  hours  after  exposure  to 
carbon  monoxide;  in  other  cases,  however,  the  re- 
action can  barely  be  made  out  even  when  the  interval 
amounts  to  only  two  hours. 

A  certain  number  of  lesions  which  sometimes  occur 
subsequently  to  carbon  monoxide  poisoning  may  aid 
the  examiner  in  reaching  a  diagnosis  when  from  the 
length  of  time  between  cessation  of  exposure  and 
death  the  above  tests  fail.  Croupous  inflammation 
of  the  fauces  has  been  noted  where  death  followed 
seventeen  hours  after  coal-gas  inhalation.  In  some 
cases  there  are  vasomotor  and  trophic  disturbance  3 
of  the  skin  which  predispose  to  necrosis  from  pres- 
sure. A  case  with  dermatitis  bullosa  on  both  hands 
has  been  reported,  death  taking  place  five  days  after 
exposure  to  coal  gas.  In  another  case  death  occurred 
at  the  end  of  eight  days.  Symmetrical  softening  of 
the  anterior  part  of  the  inner  capsule  and  adjoining 
portion  of  the  head  of  the  caudate  nucleus,  also  of  the 
inner  part  of  the  lenticular  nucleus,  has  occurred 
in  a  number  of  cases  in  which  a  day  or  more  has 
intervened.  Its  occurrence  has  been  explained  by 
Kolisko  on  the  ground  of  the  peculiar  course  of  the 
arterial  branch  (the  long  anterior  perforating  branch 
of  the  anterior  cerebral)  which  supplies  the  part,  its 
course  being  in  the  reverse  direction  to  that  of  the 
artery  from  which  it  springs,  so  that  with  the  de- 
crease of  pressure,  which  is  the  result  of  carbon 
monoxide  poisoning,  a  diminution  in  the  flow  of 
blood  or  even  stasis  may  occur. 

Hydrocyanic  Acid. — This  acid,  alone,  produces 
merely  injection  and  ecchymoses  of  the  mucosa  of 
the  stomach,  which  may  in  part  be  explained  by  the 
condition  of  asphyxia,  death  occurring  rapidly  there- 
from. Besides  the  odor  of  bitter  almonds  there  is 
nothing  characteristic. 

Cyanide  of  Potassium. — The  mucosa  of  the  stomach 
over  its  entire  surface  or  at  the  fundus,  or  especially 
upon  the  crests  of  the  folds,  is  deep  red  in  color,  swollen 
and  softened,  and  presents  sometimes  almost  a 
translucent  appearance;  a  thick  mucus,  which  is  tinged 
a  light  red  or  brownish-red  from  blood,  covers  the 
surface.  The  stomach  contents  are  usually  blood 
tinged  and  stringy.  The  reaction  is  strongly  alkaline. 
The  mucosa  is  soapy  or  slippery  to  the  touch.  The 
characteristic  odor  of  bitter  almonds  is  present  in  the 
stomach,  and  also  in  other  organs,  as  the  brain  and 
lungs.  The  odor  of  ammonia  may  be  distinguished 
cither  from  its  presence  in  the  cyanide,  or  through  the 
effects  of  decomposition  in  the  stomach.  The  red- 
ness and  swelling  of  the  mucous  membrane  an'  due  to 
injection  and  ecchymoses,  the  primary  effect  of  irri- 
tation, and  to  the  secondary  action  of  solution  of  the 
albuminous  constituents  of  the  tissue  and  imbibition 
of  the  superficial  layers  with  hematin  due  to  the  strong 
alkaline  action.  The  secondary  effect,  therefore,  may 
lie  absent  or  poorly  marked  when  the  dose  is  small  or 
when  its  effects  have  been  counteracted  by  the  acid 
■  ■.intents  of  the  stomach.  In  such  cases,  unless  a 
characteristic  odor  is  present,  the  diagnosis  can  be 
made  only  by  chemical  examination. 

The  same  effects  may  be  apparent  in  the  mucosa  of 
the  duodenum,  pharynx,  esophagus,  larynx,  trachea, 
and  bronchi,  especially  if,  during  vomiting,  some  of 


Mill 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    M  II  AH  - 


Autopsy,  Medicolegal 
ftelatloiu 


(he  potassium  cyanide  has  been  aspirated.  In  some 
cases  the-  crests  of  the  folds  in  the  mucous  mem- 
brane of  the  stomach  may  present  a  grayish-white 
appearance. 

Ilir  blood  usually  presents  the  condition  found  in 
asphyxia,  i.e.  it  is  dark  and  fluid.  The  spectrum  is 
tical  with  that  of  oxyhemoglobin  and  is  reduced 
by  ammonium  sulphide.  Occasionally  it  is  light  red. 
This  color  may  be  due,  according  to  Hoffmann,  to 
the  hyperalkalinity  of  the  blood,  which  is  easily  and 
quickly  produced  by  the  ammonia  contained  in  cya- 
nide of  potassium,  more  especially  in  old  samples. 
ices  of  ammonia  cause  the  appearance  of  a  light 
red  color  in  blood  solution,  and  clarify  turbid  solu- 
tions. ( Ithers  ascribe  the  light  red  color  to  the  forma- 
tion of  a  compound  of  cyanogen  with  methemoglobin 
or  hematin.  If  to  a  dilute  solution  of  normal  blood 
ferricyanide  of  potassium  be  added,  there  is  an  imme- 
diate change  in  color  from  red  to  brown,  and  in  the 
itroscope  a  methemoglobin  band  appears  between 
C  and  I>.  A  trace  of  hydrocyanic  acid  or  of  cya- 
nide of  potassium  will  change  the  solution  to  a  red 
color,  and  in  the  spectroscope  there  will  appear  in  the 
n  a  broad  band  which,  after  the  addition  of  ammo- 
nium sulphide,  changes  to  two  bands. 

Xitrobenzol  Poisoning. — The  mucosa  of  the  stom- 
ach and  small  intestine  is  injected  and  ecchymotic. 
The  odor  of  bitter  almonds  in  the  stomach,  brain, 
and  lungs  is  even  more  marked  and  persistent  than 
in  hydrocyanic  acid  poisoning.  The  blood  and  mus- 
cle are  brownish  in  color.  From  the  presence  of 
brownish  methemoglobin  in  the  uriniferous  tubules. 
especially  in  the  pyramids,  a  resemblance  to  chlorate 
of  potassium  poisoning  is  produced. 

Arsenic. — Arsenous  acid  usually  does  not  produce 
corrosive  effects  upon  the  mucosa.  These  effects, 
although  they  have  been  observed  in  several  cases, 
are  evidently  of  rare  occurrence.  This  poison,  how- 
ever, does  produce  an  intense  gastroenteritis.  There 
is  nothing  characteristic  about  the  external  appear- 
ance of  the  cadaver,  or  about  the  condition  of  the 
mouth,  pharynx,  or  esophagus.  The  mucosa  of  the 
stomach  is  intensely  congested  throughout  or  in 
patches;  it  is  edematous,  swollen,  and  sometimes 
ecchymotic.  It  is  covered  with  blood-tinged  mucus, 
and  scattered  over  its  surface  may  be  found  granules 
or  crystals  of  arsenous  acid.  These  are  sometime- 
large  enough  to  be  felt  or  even  to  be  seen.  The 
small  intestine  is  filled  with  thin  fluid,  almost  watery, 
with  flocculi — the  characteristic  rice-water  contents. 
The  mucosa  is  congested,  markedly  swollen,  edema- 
tous, and  flaccid.  In  the  lower  portion  of  the  small 
intestine  and  in  the  large  intestine,  the  mucosa  may  be 
pale.  There  is  marked  parenchymatous  or  fatty 
degeneration  of  the  glands  of  the  stomach  and  intes- 
tine, of  the  epithelial  cells  of  the  kidney  and  liver, 
and  of  the  heart  muscle.  In  some  cases  the  stomach 
may  present  few  or  no  changes,  but  the  changes  in 
the  intestine  are  far  more  constant. 

The  appearance  of  yellowish  streaks  occasionally 
Been  on  the  stomach  mucosa  are  due  to  the  formation 
of  yellow  sulphide  of  arsenic. 

The  colon  may  be  covered  with  thick  mucus  con- 
taining desquamated  epithelial  cells  and  many  lym- 
phocytes. There  may  be  a  croupous  colitis.  Themes- 
enteric  lymph  nodes  may  be  swollen.  There  maybe 
ecchymoses  in  the  pericardium  and  pleura,  but 
especially  under  the  endocardium.  The  blood  is 
usually  poorly  coagulated,  and  in  the  peripheral  vessels 
may  be  thick  and  tarry,  due  to  loss  of  water.  In 
some  cases  there  is  slight  jaundice,  and  ecchymoses 
may  appear  in  the  faucial  mucous  membrane  and  in 
th  ■  cellular  tissue  of  the  neck,  but  not  in  the  muscle. 
When  ecchymoses  appear  in  the  pleura  and  mediasti- 
num, and  fatty  degeneration  of  the  heart,  liver,  and 
kidney  is  present,  the  case  may  resemble  phosphorus 
poisoning.  The  hemorrhagic  spots  in  the  mucosa  of 
the    stomach    may    become    eroded    by    the    gastric 


contents,  and  this  doubtless  explains  why  a  corrosive 
action  is  ascribed  to  arsenic,  which  it  most  probably 

does  not  possess. 

Arsenic  is  more  rapidly  eliminated  than  other 
metallic  poison-,  and  it  is  conceivable  that  death  may 

occur  from  arsenic  poisoning  and  yef  quite  small 
amounts  of  arsenic  be  found.  It  is  therefore  of  im- 
portance to  preserve  for  examination  in   suspected 

cases  not  only  the  stomach  and  intestine  arid  their 
contents  separately,  but  also  the  heart,  kidney,  liver, 
bone,  and  muscle,  since  in  some  cases  arsenic  has  been 
demonstrated  in   these  organs,    more    especially    in 

the  liver  and  bi.ne,  when  its  demon  I  rat  ion  ha-  failed 
in  the  stomach  and  intestine  or  in  their  contents, 
by  reason  of  its  having  been  already  eliminated. 
Much  of  the  arsenic  that  has  been  taken  internally 
may  have  been  got  ten  rid  of  by  vomiting  and  diarrhea, 

common  with  arsenic  poisoning.     In  cases  in  which 

examination  is  made  after  burial  it  is  important  not 
only  to  take  portions  of  every  organ  and  tissue  of  the 
body,  inasmuch  as  it  is  well  known  that  arsenic  may 
diffuse  itself  through  the  tissues  post  mortem,  but 
also  to  take  samples  of  the  objects  surrounding  the 
cadaver,  including  wood  of  the  casket  and  surround- 
ing earth.  In  add  it  ion  to  t  his  it  is  also  of  importance 
to  take  another  sample  of  earth  from  another  pari  of 
the  cemetery.  All  organs  should  be  carefully  weighed 
at  the  time  of  the  autopsy,  and  if  possible  the  entire 
organ  should  be  given  to  the  chemist.  If  this  cannot 
be  done,  provided  the  weights  of  the  organs  are  known, 
a  basis  for  calculation  of  the  amount  of  arsenic  is 
furnished.  It  is  both  affirmed  and  denied  that  the 
cadaver  after  arsenic  poisoning  resists  decomposi- 
tion for  a  considerable  length  of  time.  Mummifi- 
cation has  been  described  as  a  characteristic  appear- 
ance. This  may,  however,  be  due  to  other  conditions, 
such  as  burial  in  sandy  soil,  etc. 

Aceto-Arsenite  of  Copper,  Paris  Green. — The  appear- 
ance of  this  substance,  its  characteristic  color,  its 
insolubility,  and  the  fact  that  it  appears  in  the  stom- 
ach in  pasty  masses,  loosely  adherent  to  the  mucosa, 
which  is  swollen,  edematous,  congested,  and  ecchy- 
motic beneath  the  attached  mass,  renders  the  diag- 
nosis of  this  form  of  poisoning  quite  easy.  The 
small  intestine  shows  the  same  appearance  as  in 
poisoning  by  arsenous  acid.  The  Paris  green  may  be 
covered  by  a  brownish  magma,  the  reduced  iron 
given  as  an  antidote. 

Phosphorus. — Red  phosphorus  is  not  poisonous; 
the  yellow  variety  is  intensely  so.  Acute  cases 
(death  in  from  four  to  eight  hours)  may  show  but 
few  pathological  changes.  The  contents  of  the  stom- 
ach and  intestines  may  smell  of  phosphorus  and  may 
shine  in  the  dark  on  being  shaken;  pieces  of  matches 
may  be  found.  The  gastric  mucosa,  heart  muscle, 
and  epithelial  cells  of  liver  and  kidney  may  show 
cloudy  swelling.  The  subacute  cases  (death  after 
from  three  to  seven  days)  commonly  show  character- 
istic changes.  The  stomach  is  not  corroded,  ecchy- 
moses and  hemorrhagic  erosions  are  common;  the 
gland  cells,  especially  the  adelomorphous  cells,  are 
in  marked  fatty  degeneration,  so  that  the  ducts  are 
marked  by  yellowish  points  (gastradenitis  phosphor- 
ica).  The  contents  may  be  dark  brown  from  the 
presence  of  blood.  Phosphorus  may  no  longer  be 
demonstrated  chemically  in  the  stomach  and  its 
contents,  in  the  subacute  cases.  The  lower  part  of 
the  small  intestine  and  the  colon  are  more  likely  to 
contain  phosphorus.  Jaundice  is  regularly  present 
and  marked.  Ecchymoses,  which  are  a  character- 
istic lesion  in  poisoning  by  phosphorus,  are  abun- 
dantly present  in  the  gastric  and  intestinal  mucosa, 
in  all  the  serous  membranes,  especially  the  pleura 
and  the  pericardium,  in  the  adventitia  of  the  aorta 
and  its  branches,  in  the  conjunctiva,  in  the  subcu- 
taneous areolar  tissue,  in  the  intermuscular  tissue,  and 
in  the  mediastinum.  Hemorrhages  may  occur  from 
the  stomach  and  intestine,  and  from  the  uterus,  in 

807 


Autopsy,  Medicolegal 
Relations 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


some  cases  causing  death.  The  blood  is  fluid  in 
acute  cases,  poorly  coagulated  in  subacute  cases. 
The  red  cells  are  disintegrated,  the  white  cells  may  be 
fatty.  Fatty  degeneration  of  the  liver,  kidney,  mus- 
cle of  the  heart,  and  arteries  is  very  well  marked. 
The  organs  are  bile-stained  and  the  fecal  masses  in 
the  lower  part  of  the  small  intestine  and  colon  are 
grayish.  The  jaundice,  excessive  fatty  degenera- 
tion, and  hemorrhagic  changes  are  so  well  marked 
that  the  diagnosis  usually  presents  no  difficulty. 

Acute  yellow  atrophy  of  the  liver,  and  septicemia 
with  jaundice,  ecchymoses,  and  fatty  degeneration  of 
the  viscera,  may  closely  resemble  phosphorus  poison- 
ing; this  being  specially  true  of  the  former.  In 
acute  yellow  atrophy,  although  a  primary  enlarge- 
ment of  the  liver  may  take  place,  the  characteristic 
conditions  are:  marked  diminution  in  size  and  con- 
sistency, the  occurrence  of  reddish  softened  areas 
where  the  epithelial  cells  are  disintegrated  into  a 
granular  detritus,  and  the  appearance  of  round-celled 
infiltration  of  the  connective  tissue.  Many  bacteria 
have  also  been  observed  in  acute  yellow  atrophy. 
The  liver  in  phosphorus  poisoning  is  usually  large, 
and  although  of  doughy  consistency,  it  is  atill  firmer 
than  in  acute  yellow  atrophy.  Punctate  hemor- 
rhages may  be  present,  but  the  reddish  areas  described 
above  are  absent.  In  septicemia  with  jaundice 
and  ecchymoses,  the  fatty  degeneration  is  usually 
not  so  far  advanced  as  in  phosphorus  poisoning. 
The  resemblance  may,  however,  be  so  close  as  to 
render  a  decision,  simply  from  the  gross  appearances, 
impossible,  in  which  case  the  demonstration  of  phos- 
phorus by  chemical  examination,  or  the  demon- 
stration of  bacteria  by  bacteriological  examination, 
will  clear  up  the  diagnosis. 

Bichloride  of  Mercury  Poisoning. — In  the  acute 
cases,  in  which  death  occurs  in  collapse  after  a  few- 
hours,  the  corrosive  effect  upon  the  mucosa  of  the 
mouth,  pharynx,  esophagus,  and  especially  the  stom- 
ach, is  apparent  in  the  presence  of  grayish-white 
eschars.  From  the  action  of  mercury  upon  the  blood 
the  eschar  may  show  a  grayish-violet  tinge.  In 
cases  that  have  survived  a  few  days  the  eschar  may 
in  part  have  been  cast  off,  presenting  ulcers  with 
undermined  edges,  the  submucous  tissue  being  con- 
gested and  ecehymotic.  Where  the  action  has  not 
been  sufficiently  strong  to  cause  corrosion,  the  mucosa 
may  be  congested  and  ecehymotic.  The  upper  por- 
tion of  the  small  intestine  may  also  show  the  same 
effects,  which  gradually  become  less  marked  as  we 
advance  downward  from  the  stomach  in  the  course  of 
our  examination.  In  subacute  cases,  these  portions 
of  the  alimentary  tract  may  show  no  changes  or 
merely  those  of  a  diphtheritic  inflammation.  In 
the  lower  portion  of  the  ileum  and  in  the  large  in- 
testine, the  characteristic  changes  are  found,  con- 
sisting of  an  inflammation  of  an  acute  exudative 
type  with  necrosis  and  the  formation  of  a  membrane, 
affecting  more  especially  the  crests  of  the  folds  and  the 
areas  in  and  about  the  lymphadenoid  tissue.  The 
submucosa  is  considerably  distended  with  serum  and 
infiltrated  with  pus  cells.  The  gross  appearances 
closely  resemble  thosfe  of  dysentery.  This  effect  is 
not  due  to  the  local  action  of  sublimate;  it  seems  to  be 
due  to  the  excretion  of  the  poison,  especially  by  the 
large  intestine,  since  it  is  equally  well  marked  in  cases 
of  mercury  poisoning  by  inunction,  by  subcutaneous 
injection,  and  by  intrauterine  injection.  The  kidneys 
are  enlarged,  soft,  and  edematous.  The  cortex  is 
markedly  swollen,  and  of  a  light  yellow  or  grayish 
color.  The  pyramids  are  dark  and  congested.  These 
changes  are  due  to  parenchymatous  or  fatty  degenera- 
tion of  the  epithelium  of  the  uriniferous  tubules, 
especially  in  the  cortex,  and  to  an  acute  exudative 
inflammation.  A  marked  proliferation  and  des- 
quamation of  epithelium  may  occur.  The  stroma  of 
the  kidney  is  infiltrated  with  serum. 

Potassium    Chlorate. — The    oxyhemoglobin    is    re- 


duced to  methemoglobin,  and  in  addition  the  red 
blood  cells  are  disintegrated.  The  blood  presents 
the  appearance  of  thick  chocolate  or  coffee  grounds. 
The  postmortem  spots  are  grayish  or  grayish-violet. 
Jaundice  may  be  present.  The  spleen  may  be  en- 
larged. The  kidnej-s  present  a  characteristic  appear- 
ance. An  acute  exudative  nephritis  of  hemorrhagic 
type  is  invariably  present.  It  is  characterized  by 
especially  well-marked  changes  about  the  glomeruli, 
tin'  uriniferous  tubules  being  filled  with  brown  blood 
clots  which  give  the  appearance  of  brownish  stria- 
tions  more  marked  in  the  pyramids. 

Opium  anil  Morphine. — If  opium  has  been  taken  in 
substance  or  in  tincture,  the  characteristic  odor  may 
be  present.  If  a  decoction  of  poppy  heads  has  been 
taken,  particles  of  the  plant  may  be  discovered  and 
identified  by  the  microscope.  As  far  as  the  postmortem 
appearances  are  concerned,  there  is  nothing  character- 
istic upon  which  the  diagnosis  can  be  made  positively. 
Passive  hyperemia  of  the  brain  and  lungs  may  be 
found.  The  blood  in  acute  cases  is  usually  fluid,  in 
others  it  is  clotted.  The  appearance  of  the  pupils  is 
of  minor  importance,  since  the  marked  contraction 
may  not  be  preserved  post  mortem. 

Strychnine. — Early,  intense,  and  persistent  rigor 
mortis  has  been  noted,  but  this  occurs  in  other  con- 
ditions. The  blood  is  dark  and  fluid  (asphyxia); 
passive  hyperemia  of  the  brain  and  lungs  and  ecehy- 
motic spots  may  be  present. 

Atropine  and  its  group,  digitalis,  veratrine,  aconite, 
aloes,  colocynth,  jalap,  scammony,  savin,  croton  oil, 
colchicum,  hellebore,  elaterium,  may  all  produce  the 
effects  of  gastrointestinal  irritation,  depending  upon 
the  amount  of  the  drug — namely,  hyperemia,  ecchy- 
moses, intense  catarrhal  or  sometimes  croupous 
inflammation,  or  even  necrosis. 

Ptomaine  Poisoning. — The  postmortem  appearance 
is  not  characteristic;  a  more  or  less  intense  gastro- 
enteritis may  be  the  only  lesion  found.  In  addition, 
parenchymatous  degeneration  of  the  liver,  kidney, 
and  heart  muscle,  general  passive  hyperemia,  ecchy- 
moses, and  dark  fluid  blood  may  be  present. 

Muscarine  Poisoning  (poisonous  mushrooms). — 
Cases  have  been  described  with  jaundice,  ecchymoses 
in  the  cutis,  acute  fatty  degeneration  of  the  liver, 
kidney,  and  heart  muscle.  The  remains  of  the  mush- 
rooms in  the  gastrointestinal  tract  and  their  botanical 
determination  may  lead  to  the  diagnosis. 

Chloroform. — Death  from  narcosis  may  leave  no 
characteristic  signs  except  those  of  asphyxia.  The 
odor  of  chloroform  may  be  present  or  absent  in  the 
lungs,  stomach,  and  brain.  In  some  cases,  the  pres- 
ence of  chloroform  may  be  demonstrated  in  the  blood 
or  in  the  brain  by  chemical  examination.  If  swallowed, 
the  odor  of  chloroform  may  be  apparent  in  the 
stomach  contents,  and  the  mucosa  of  the  stomach  may 
present  a  soft  grayish  slough  where  the  chloroform  lias 
come  in  contact.  In  one  case  in  which  death  from 
pneumonia  occurred  five  days  after  swallowing 
chloroform,  extensive  ulceration  of  the  stomach  and 
jejunum  was  found;  and  similar  lesions  were  observed 
in  another  case  in  which  death  occurred  after  twenty- 
seven  hours.  The  blood  is  fluid  or  poorly  clotted 
according  to  the  rapidity  or  slowness  with  which 
death  has  set  in.  Decomposition  after  chloroform 
poisoning  takes  place  rapidly,  and  there  will  be  gas 
bubbles  in  the  blood — a  certain  indication,  as  was 
formerly  believed,  of  chloroform  poisoning.  In  < :a 
in  which  death  has  occurred  some  time  after  chloro- 
form narcosis,  parenchymatous  degeneration  of  the 
heart,  liver,  and  kidney  has  been  found. 

Chloral  hydrate  may  produce  merely  a  marked 
hyperemia  of  the  lungs,  brain,  and  spinal  cord.  It 
is"  important  to  take  a  specimen  of  the  urine  for 
chemical  examination. 

Ether. — Poisoning  from  ether  narcosis  may  simply 
show  the  signs  of  asphyxia,  viz.,  fluid  and  dark- 
colored  blood  and  the  occasional  presence  of  ecchy- 


808 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Aii(iii»n> ,  Medicolegal 

ItHallons 


loses.     In  recent  cases  the  odor  of  ether  may  be 
etected  in  the  lungs,  stomach,  and  brain.     Poison- 
ii;  from  ingestion  of  ether  produces  the  effects  of 
itense  gastrointestinal  irritation. 
It  is  of  interest ,  and  also  of  medicolegal  importance, 
,  examine  the  lymphadenoid  tissue  throughout   the 
iody-    namely,  the  nasopharynx,  tonsils,  dorsum  of 
he  tongue  posteriorly,  solitary  follicles  of  the  stom- 
ich  and   small  and   largo   intestine,    Payer's  plaques 
if    the   small    intestine,    the    mesenteric    and    retro- 
itoneal  lymph  nodes,  the  Malpighian  bodies  of  the 
leen,   and    the   thymus  gland.     A    hyperplasia  of 
hese   structures — termed   status   lymphaticus — pre- 
lisposes  to  the  occurrence  of  sudden  death  from  causes 
hat  otherwise  appear  insufficient.     In  a  number  of 
ases  of  death  following  chloroform  and  ether  nar- 
nsis  this  condition  has  been  found.     In  some  of  these 
es  very  small  amounts  of  etlier  and  chloroform  hail 
i  given  and  had  been  very  carefully  administered. 
Alcohol. — Concentrated  alcohol  coagulates  albumin 
mil   extracts   water,   and   may   therefore   produce   a 
direct    corrosive    action    upon    the    gastrointestinal 
mucosa.     Numerous  cases  of  sudden   death   follow- 
ing ingestion  of  large  amounts  have  occurred  in  adults, 
comparatively   small  amounts  have  sufficed  to 
cause  death  in  children.     Post  mortem  there  will  be 
found  the  signs  of  asphyxia,  with  alcoholic  odor  from 
imach  contents,  lungs,  and  brain,  and  with  intense 
roenteritis.     It  is  stated  that  in  chronic  alcoholics 
intolerance  of  alcohol  increases  with  the  advancement 
of  the  chronic  pathological  changes  due  to  its  long- 
continued  use,  so  that  comparatively  small  amounts 
may  finally  cause  death. 

Glass,  if  finely  pulverized,  is  not  poisonous,  as  is 
commonly  believed  by  the  laity.  If,  however,  the 
particles  are  larger,  an  intense  irritant  effect  on  the 
mucosa  of  the  stomach  and  intestines  may  be  mechan- 
ically produced,  and  cases  of  death  from  this  cause  are 
on  record. 

Trichinosis. — As  deaths  occasionally  occur  from  an 
invasion  of  Trichinella  spiralis  due  to  the  ingestion  of 
diseased  pork,  the  vender  of  such  meat  or  sausage 
might  be  held  responsible.  In  such  a  case  the  con- 
tents of  the  stomach  and  upper  portion  of  the  intes- 
tinal tract  should  be  examined  for  free  trichinellae, 
and  the  muscular  tissue,  especially  of  the  diaphragm, 
chest,  and  neck,  for  encapsulated  trichinelke.  At 
the  same  time  due  consideration  must  be  given  to  the 
history  of  the  case,  and  to  such  other  points  as  may 
throw  light  upon  the  source  of  the  infection. 

Anthrax. — Intestinal  anthrax  has  occurred  in  a 
number  of  cases  in  which  an  invasion  of  the  bacillus 
has  been  directly  traced  to  infected  meat.  In  some 
cases  the  meat  had  been  thoroughly  cooked.  This  is 
not  surprising  in  view  of  the  resistance  of  anthrax 
spores  to  high  temperatures. 

Mortal  Injuries. — The  medicolegal  questions 
that  arise  are  the  following: 

1.  Differentiation  between  postmortem  changes 
and  the  effects  of  injury. 

_'.  Differentiation  between  injuries  inflicted  before 
death  and  postmortem  injuries. 

3.  The  determination  of  the  immediate  cause  of 
death,  whether  directly  due  to  the  injury,  and,  in  the 
presence  of  more  than  one  injury,  the  determination 
of  which  one  immediately  caused  death,  or  whether 
more  than  one  injury  was  necessarily  fatal. 

4.  The  determination,  if  possible,  of  the  character 
of  the  injury,  and  of  the  means  and  method  of  its 
infliction;  also  whether  the  means  and  method  alleged, 
and  the  circumstances  reported  as  having  attended 
the  act,  are  compatible  with  the  character  of  the 
injury. 

5.  Whether  the  conditions  found  are  compatible 
or  not  with  suicide,  and,  in  the  case  of  more  than  one 
fatal  injury,  whether  or  not  the  injuries  might  have 
been  self-inflicted. 


6. -Tlie  determination  of  tin-  ran  e  ol  death  where 
id  ease  follows  injury,  and  also  the  determination  of 
the  question  whether  tin-  disease  i-  the  direct  re  ult 

of  tin'  injury  or  not.  When  an  injui  OCI  11  in  a 
subject    already    diseased,    it    is    important     to    learn 

whether  or  n..i  tin-  di  ea  ed  condition  might  have 
predisposed    to   the   occurrence  of   the   accident    in 

which  injury  was  sustained,  or  whether  the  outcome 
of  the  injury  was  influenced  for  tin-  worse  by  reason 
of  such  preexist  tng  disease. 

1.  After  deatli  the  blood  remaining  fluid  in  the 
veins  ami  capillaries  naturally  Hows  to  the  mo  I 
dependent  pott  inn  of  the  cadaver,  collecting  especially 
where  the  skin  is  not  subjected  to  pressure.     With 

the  occurrence  of  decomposition   tile   red    blood    cells 

disintegrate,  and  the  serum  tinned  with  blood-coloring 

matter    may    transude    through    the    vessel    wall    and 

infiltrate  the  surrounding  loose  areolar  tissue.  There- 
fore the  early  postmortem  spots  may  be  entirely 
obliterated  by  pressure.  When,  however,  po  t- 
mortem  transudation  has  occurred  the  spots  are 
permanent.  When  decomposition  is  advanced  the 
cutis,  Milieu  I  a  neons  tissue,  fascia,  and  even  the  muscle 
may    lie    markedly  infiltrated   and    succulent.       I'nder 

these  conditions  ordinary  postmortem  changes,  unless 
their  character  and  the  fact  of  decomposition  having 
taken  place  are  noted,  may  be  mistaken  for  contusions, 

ecchymoses,  or  hematomata.  Indeed,  it  is  found  that 
after  death,  even  without  the  presence  of  injuries, 
when  the  veins  and  capillaries  are  distended  with 
blood  from  the  parts  being  in  a  dependent  position, 
minute  lacerations  may  occur  and  thus  give  rise  to 
the  formation  of  ecchymoses.  Such  have  been  found, 
for  instance,  in  the  conjunctiva  on  one  side  when  the 
head  has  been  lying  on  that  side,  and  in  the  skin  of  the 
lower  extremities  when  death  has  occurred  by  hang- 
ing, the  cadaver  having  been  suspended  for  some  days. 
Where,  however,  such  effusion  of  blood  does  occur 
its  extent  is  not  usually  equal  to  that  following  actual 
contusion  or  that  due  to  the  formation  of  a  hematoma 
during  life.  When  a  contusion  occurs  or  a  hematoma 
develops  during  life  the  effused  blood  usually  clots; 
if,  however,  decomposition  is  far  advanced,  the  clot 
may  be  partially  disintegrated  and  some  difficulty 
may  be  experienced  in  determining  the  exact  condition 
of  things.  If  we  take  into  consideration  all  the  above 
points,  and  the  fact  that  it  is  just  this  formation  of 
clot  that  hinders  the  further  transudation  into  the 
tissues,  a  conclusion  can  generally  be  reached. 

2.  Besides  obvious  mutilations  of  the  cadaver, 
embracing  wounds,  fractures,  and  lacerations  of  tissue, 
]  lost  mortem  injuries  may  be  unknowingly  produced 
during  the  performance  of  an  autopsy.  A  wound 
sustained  during  life,  however,  will  present  certain 
easily  distinguishable  characters.  There  will  be  some 
inflammatory  reaction  about  the  wound,  or  granula- 
tion tissue  will  be  present,  or  the  edges  of  the  wound 
will  have  become  adherent.  The  effusion  of  blood  in 
the  tissues  about  the  wound,  especially  the  clotting  of 
blood  in  these  tissues,  forms  additional  evidence. 
Evidence  of  hemorrhage  internally  or  externally  is  in 
favor  of  injuries  sustained  during  life.  It  is  possible, 
however,  for  blood  to  flow  from  a  wound  made  after 
death  if  the  wound  has  been  made  in  a  dependent  por- 
tion of  the  body,  if  a  large  vein  has  been  opened,  or  if 
decomposition  is  somewhat  advanced.  Gaping  of  the 
wound  where  the  subcutaneous  areolar  tissue  is  loose 
favors  the  idea  that  the  injury  was  sustained  during 
life.  Where,  however,  the  skin  is  thick  and  the  sub- 
cutaneous tissue  denser  and  more  adherent,  gaping 
may  not  occur.  Gaping  of  the  wound  or  eversion 
of  its  edges  may  occur  when  subcutaneous  fat  is  pres- 
ent in  considerable  amount,  and  when  decomposition 
has  taken  place.  The  sign,  therefore,  is  not  an  abso- 
lutely reliable  one  for  or  against,  but  may  be  of  value 
if  these  restrictions  are  taken  into  account.  Frac- 
tures may  occur  post  mortem  and  may  be  unknow- 
ingly  produced,   during   the   autopsy,   especially    in 

809 


Autopsy,  Medicolegal 
Relations 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


senile  cases  of  osteoporosis,  by  overextension  of-  the 
cervical  vertebrae.  The  absence  of  hemorrhage  and  of 
inflammatory  reaction  readily  excludes  the  possibility 
of  a  fracture  having  occurred  during  life.  By  the 
same  manipulation  transverse  laceration  of  the  sterno- 
cleidomastoid muscles  may  be  produced.  In  de- 
ciding the  question  of  postmortem  occurrence  or  of 
infliction  during  life  the  same  restrictions  hold  as  were 
discussed  above. 

Injuries  may  occur  just  before  death  in  cases  of 
sudden  death  from  disease  or  in  cases  of  poisoning, 
as  the  result  of  a  fall.  These  may  evidently  be  of 
slight  importance.  In  cases  of  cerebral  hemorrhage 
of  this  type  it  may  be  of  considerable  importance  to 
determine  whether  such  hemorrhages  are  of  this 
character  or  have  followed  some  primary  lesion. 

3.  An  injury  may  be  sufficient  of  itself — if  it  should 
seriously  damage  or  destroy  some  vital  organ — to 
cause  death.  There  are  cases,  however,  in  which  the 
decision  that  a  given  injury  must  necessarily  have 
been  fatal  is  very  hard  to  reach.  This  is  due  to  the 
fact  that  in  rare  cases  the  patient  will  recover  from 
injuries  which  are  commonly  looked  upon  as  neces- 
sarily fatal.  Then  again,  even  if  he  does  not  recover, 
he  may  live  for  days  or  weeks  after  the  infliction  of 
the  injury. 

Secondary  mechanical  effects  following  the  injury 
may  be  the  immediate  cause  of  death.  Among  these 
may  be  mentioned  compression  of  the  brain  by  blood 
clot,  interference  with  heart  action  by  hemorrhage 
into  the  pericardial  sac,  pneumothorax  from  a  pene- 
trating wound  of  the  chest  wall  or  also  of  the  lung 
itself,  and  laceration  of  the  lung  by  a  fractured  rib. 

Hemorrhage,  external  or  internal  into  one  or 
another  body  cavity,  may  be  the  immediate  cause  of 
death.  If  it  is  internal,  the  actual  amount  of  blood 
lost  to  the  circulation  may  be  directly  measured; 
if  it  is  external,  and  the  evidence  of  the  autopsy 
alone  is  at  hand,  we  must  depend  for  our  diagnosis 
upon  the  anemia  of  the  organs.  If  death  is  due  to 
hemorrhage,  all  the  organs  are  pale  and  almost  blood- 
less; the  heart  and  vessels  contain  much  less  blood 
than  normally  and  are  contracted.  This  applies,  of 
course,  to  cases  in  which  death  immediately  follows 
the  loss  of  blood.  If  some  time  has  intervened  be- 
tween the  occurrence  of  the  hemorrhage  and  death, 
there  will  be  an  anemic  condition,  an  hydremia; 
but  the  organs  will  not  be  found  in  the  bloodless, 
dry  condition  characteristic  of  those  cases  in  which 
death  follows  immediately  after  hemorrhage. 

The  immediate  cause  of  death  may  be  shock. 
There  is  no  positive  postmortem  evidence  upon  which 
such  a  diagnosis  could  be  based  independently  of 
the  history  of  the  case.  Multiplicity  of  injuries, 
extent  of  injury,  evidence  of  compression  or  con- 
tusion of  the  abdomen  as  afforded  by  marked  dilata- 
tion of  the  abdominal  veins,  might  all  favor  such  a 
conclusion.  The  clinical  history,  especially  the  time 
intervening  between  injury  and  death,  taken  in  con- 
nection with  the  above  data,  is  probably  better  evi- 
dence. In  this  connection  it  should  be  remembered 
that  there  are  undoubted  cases  of  death  from  shock 
alone  without  the  infliction  of  injury.  In  many,  of 
course,  a  neurotic  predisposition  may  be  presumed, 
or  the  existence  of  heart  lesions  or  disease  of  the 
cerebral  vessels  may  explain  the  cause  of  death, 
the  shock  in  such  cases  producing  a  nervous  or 
vascular  effect  determining  the  occurrence  of  syn- 
cope and  death. 

In  the  presence  of  more  than  one  injury,  the  effects 
of  each  should  be  carefully  weighed  and  its  importance 
in  the  causation  of  death  determined.  Each  injury 
should  be  separately  considered  and  the  probable 
result,  if  such  injury  alone  were  present,  determined. 
This  is  a  matter  of  considerable  importance,  as 
the  injuries  may  have  been  inflicted  by  different 
individuals,  or  by  the  same  individual  under  different 
circumstances;  as,  for  instance,  when  a  first  shot  is 

810 


fired  in  self-defence  and  a  second  when  the  assailant 
has  turned  in  flight.  The  question  might  arise 
whether  one  of  the  wounds  might  have  been  self- 
inflicted,  the  other  having  been  admittedly  inflicted 
by  the  defendant  on  trial.  Such  might  possibly  be 
the  case  in  a  struggle,  both  the  participants  being 
armed,  or  where  an  officer  in  pursuit  of  a  fugitive 
revolver  in  hand,  is  afterward  found  dead  with  two 
bullet  wounds.  Even  though  there  may  be  evi- 
dence of  his  weapon  having  been  recently  dischan 
this  of  course  would  not  be  conclusive  of  one  wound 
having  been  self-inflicted. 

4.  An  accurate  description  of  all  injuries,  their 
character,  location,  tissues  involved,  measurements 
direction,  and  external  appearance,  including  that 
of  surrounding  parts,  not  only  of  the  body  but  also  of 
the  clothing  if  possible,  should  be  made  in  every  case. 
This  is  of  the  greatest  importance,  and  may  be  the 
only  admissible  evidence  upon  which  a  case  can  be 
decided  by  the  jury. 

A  contusion  according  to  its  severity  indicates 
more  or  less  forcible  contact  with  some  flat  or  blunt 
firm  substance — i.e.  either  a  blow  or  a  fall.  Which 
is  the  case  in  a  given  instance  may  be  impossible  to 
decide  from  the  contusion  alone.  Its  size  may  afford 
some  help;  its  location  may  be  of  more  importance. 
Such  situations  compatible  with  a  fall  will  readily 
suggest  themselves,  yet  many  of  these  contusions  may 
not  be  distinguishable  from  those  which  are  the 
result  of  a  blow.  If,  however,  the  area  of  contusion 
is  smaller  than  the  area  which  might  readily  have 
come  in  contact  with  given  surrounding  objects,  the 
conclusion  would  be  in  favor  of  a  blow. 

Abrasions  favor  the  conclusion  of  a  glancing  fall 
or  blow. 

A  hematoma  may  occupy  the  site  of  contact  in  a 
blow  or  fall,  or  may  be  secondary  to  a  fracture  the 
result  of  such  blow  or  fall,  and  may  occupy  a  position 
near  or  at  a  distance  from  the  immediate  site  of 
contact. 

Wounds  are  described  as  incised,  contused,  lacer- 
ated, and  punctured.  These  adjectives  readily  sug- 
gest a  cut  or  a  thrust  with  a  sharp,  blunt,  ragged,  or 
pointed  instrument;  or  a  fall  upon  such  sharp,  blunt, 
ragged,  or  pointed  object.  It  should  be  remembered, 
however,  that  the  appearance  of  an  incised  wound 
may  be  simulated  when  such  wound  occurs  over 
projecting  bony  ridges,  as  the  supraorbital  ridge, 
nose,  margin  of  jaw,  tibia,  etc.,  although  really  pro- 
duced by  blunt  objects  either  from  a  blow  or  from  a 
fall.  Even  a  bullet  wound  may  occasionally  resemble 
an  incised  or  punctured  wound  from  the  splitting  of 
the  skin  over  a  bony  surface. 

Bullet  Wounds. — The  accurate  description  of  their 
special  characteristics  is  of  the  greatest  importance, 
not  only  in  proving  the  presence  of  a  bullet  wound 
when  the  bullet  cannot  be  found,  but  also  in  furnishing 
data  from  which  valuable  conclusions  may  be  drawn. 
The  points  for  examination  and  description  are  as 
follows: 

(a)  The  skin  and  surrounding  parts  externally. 

(1)  The  solution  of  continuity  in  the  skin. 

(2)  The  immediate  surrounding  narrow  zone  of 
contusion,  abrasion,  and  lead  staining.  Both  of  these 
are  effects  produced  by  the  bullet. 

(3)  The  stain  or  smudge  which  can  readily  be 
wiped   off  or  washed  off,   the  effect  of  the  smoke. 

(4)  The  embedded  powder  particles,  some  of  which 
from  their  very  superficial  location  can  be  washed 
off,  while  others  more  deeply  situated  remain — tlie 
effect    of    incomplete    combustion    of    the    powder. 

(5)  Burning  of  the  surrounding  skin  and  singeing 
of  the  hair,  the  effect  of  the  flame. 

(G)  The  zone  of  contusion  about  the  wound  larger 
than  that  produced  by  the  bullet — the  effect  of  con- 
cussion of  the  explosive  gases. 

(b)  Immediately  beneath  the  wound  in  the  skin 
the  following  effects  may  be  noted: 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIKXCF.S 


Autopsy,  Medicolegal 

Relations 


li   Contusion    and    laceration    of    tissue    by    the 
tplosh  e  gases. 
(2)   Staining  by  sinoko  and  by  particles  of  powder 
uchanged  it  incompletely  burned. 

Burning    or    charring    by    the    flame,    ignited 

aider,  or  wad. 

c)    the   track   of   the   bullet   and   the   tissue  sur- 

. muling  it   may  present  the  above  effects  of  lacera- 

I'rom  the  explosive  gases,  charring  from  the  flame, 

ad  blackening  from  embedded  particles  of  powder; 

nd   in   soft    parts   these   effects    may    be   even    in. ire 

larked  than  directly  beneath  the  skin  on  account  of 

lie    centrifugal     distribution     of     these    effects.      In 

.ullet  wounds  of  the  brain  still  other  effects  may  be 

iroduced;  some  of  them  being  due  to  the  fact   thai 

mailer  or  larger  fragments  of  bone  are  carried  in 

projectiles,  and  others  resulting  from  the  fragmen- 

m  of  the  bullet,  the  result  either  of  the  composi- 

l  of  the  bullet  or  of  the  manner  in  which  it  has 

truck  the  bone. 

If  we  take  these  facts  into  account,  it  can  readily 
>e  understood  how  these  effects  vary  according  to 
he  size,  caliber,  length,  shape,  consistence,  and 
tructure  of  the  bullet;  the  kind,  condition,  and 
imount  of  the  powder  charge;  the  character  of  the 
veapon,  whether  a  rifle,  gun,  pistol,  or  revolver;  and 
he  range  from  which  the  shot  was  fired.  Inter- 
vening clothing  and  hair,  depending  upon  its  amount, 
exture,  and  arrangement,  may  influence  certain  of 
hese  appearances,  causing  their  absence  in  the  wound 
>r  upon  the  skin  when  otherwise  they  would  cer- 
ainly  have  been  present. 

From  experiments  performed  upon  the  cadaver 
,vith  different  weapons  of  different  caliber,  at  ranges 
varying  from  contact  onward,  and  upon  different 
parts,  results  have  been  produced  which  with  cer- 
tain minor  limitations  form  a  basis  upon  which, 
when  the  effects  produced  in  a  wound  are  known  and 
the  circumstances  set  forth  above  are  taken  into 
account,  the  range  at  which  the  shot  was  fired  can  be 
rmined  with  considerable  accuracy.  It  is  not 
meant  that  the  distance  can  always  be  determined 
within  an  inch;  nor  is  such  determination  always 
called  for.  We  can  determine,  however,  that 
certain  effects  could  not  have  been  produced  beyond 
a  certain  range,  or  within  a  certain  range,  and  thereby 
we  shall  be  able  to  exclude  suicide  or  to  admit  its 
possibility.  The  effects  produced  in  the  wound  may 
then  be  the  onty  evidence  upon  which  a  decision  can 
be  reached,  or  may  prove  strong  corroborative 
evidence,  or  may  be  the  only  means  of  preventing 
an  unjust  conviction. 

The  wound  in  the  skin  may  be  round,  its  edges 
roughened  by  contusion;  or,  by  reason  of  small 
lacerations  of  its  margin,  it  may  present  the  appear- 
ance of  a  rosette.  Again,  it  may  be  quite  large  and 
may  have  a  triangular  or  ovoid  shape;  or  it  may  be 
slit-like  and  resemble  an  incised  wound,  the  bullet 
having  caused  a  splitting  of  the  skin.  Such  a  wound 
may  heal  by  primary  union  and  obscure  the  character 
of  the  injury.  It  is  produced  more  frequently  with 
revolvers  of  smaller  caliber  and  by  pointed  bullets. 
Aberrations  from  the  circular  or  round  form  of 
wound  may  be  produced  by  the  bullet  striking  the 
skin  surface  at  a  more  acute  angle.  Larger  lacera- 
tions leading  from  the  wound  may  in  some  cases  be 
explained  by  the  effect  of  the  explosive  gases  beneath 
the  skin.  (For  further  details  in  regard  to  the 
different  characteristics  of  bullet  wounds  the  reader 
is  referred  to  the  article  on  Gunshot  Wounds  in  a 
later  volume.) 

The  limit  of  the  range  beyond  which  grains  of 
powder  cannot  become  embedded  in  the  skin  adjacent 
to  the  wound  varies,  according  to  the  caliber  of  the 
weapon  used  and  the  amount  of  the  charge  of  powder 
from  about  one  foot  with  a  small  revolver  to  three 
feet  and  more  with  those  of  large  caliber,  six  feet  with 
the  old-style  army  pistol,  and  still  greater  distance 


with  a  shotgun.  Embedded  powder  grains  are 
found  within  these  ranges  f..r  weapons  cited.  They 
are  few  in  number  and  scattered  with  tin-  higher 
range,  and  more  concentrated  and  abundant  as 
contact  is  appi lied  on  account  of  their  centrifu- 
gal distribution.  With  contact  they  are  usually 
absent  in  the  skin  but  present  in  larger  amount  in  the 
tissues  beneath,  f he  depth  depending  upon  the 
caliber  of  the  weapon  ami  the  amount  of  powder  in 
the  charge.  With  a  revolver  "i  medium  caliber  the 
deposit  of  powder  grains  in  the  wound    diminishes 

with  increase  of  range  to  mere  staining  of  the  bullet 
track,  so  that  beyond  one  inch  the  effect  of  powder 
grains  in  the  wound  cea   i-   to  In  cd.       When  the 

muzzle  is  not  held  in  immediate  contact  the  powder 
grains  appear  in  the  skin  about  the  wound,  and  the 
appearance  varies  with  the  distance  as  stated  above. 

At  contact  the  effect  of  the  explosive  gases  and  the 
staining  and  charring  of  the  subcutaneous  wound  are 

most  marked,  varying  according  to  caliber  and  powder 

charge.  Laceration  of  tissue  thus  produced  is  almost 
constant  with  0.32  to  0.44  caliber,  but  is  exceptional 
with  0.22. 

Burning  of  the  hair  is  more  extensive  than  burning 
of  the  skin,  and  varies  according  to  the  caliber  and 
the  range.  With  a  0.22  caliber  it  varies  from  con- 
tact to  three  inches;  with  a  0.44  caliber,  from  con- 
tact to  fifteen  inches.  At  contact  there  may  be  no 
singeing  of  the  hair  at  all,  or  if  present  it  is  confined 
to  a  few  hairs  immediately  about  the  wound.  With 
a  revolver  of  medium  caliber,  at  one-quarter  of  an 
inch,  singeing  is  invariably  present  but  may  be 
limited  to  an  area  of  one  inch  or  less.  At  a  range  of 
from  three  to  five  inches  singeing  is  no  longer  constant. 

Burning  of  the  skin  varies  in  the  same  way  and 
within  narrower  limits.  At  contact,  with  a  revolver 
of  medium  caliber,  there  may  be  charring  of  the  edge 
of  the  wound,  but  the  greatest  effect  is  produced 
on  the  underlying  tissues.  At  a  distance  of  from  one- 
quarter  of  an  inch  to  three  inches  charring  is  usual 
but  not  constant;  at.  greater  ranges  it  is  absent. 
With  larger  weapons  it  may  occur  at  greater  ranges. 

To  recapitulate,  the  effects  will  disappear  in  the 
following  order,  as  the  range  is  increased  from  con- 
tact to  the  maximum  limit: 

(1)  Effect  of  explosive  gases. 

(2)  Effect  of  smoke  stain  or  smudge  which  can 
be  wiped  or  washed  off. 

(3)  Effect  of  the  flame  in  burning  of  the  skin. 

(4)  Singeing  of  the  hair. 

(5)  Embedded  powder  grains. 

Protection  of  the  part  by  clothing  or  hair  will 
explain  the  absence  of  some  effects,  namely,  smoke 
stain,  embedded  powder  grains  in  the  skin,  or  burning 
of  the  skin  at  short  range.  In  such  cases  we  may 
have  the  valuable  sign  of  singeing  of  the  hair  to 
guide  us. 

The  track  of  the  bullet,  besides  presenting  effects 
already  noted,  may  be  of  importance  in  establishing 
the  direction  from  which  a  shot  was  fired  or  the 
position  of  the  body  when  the  shot  was  fired.  Care 
should  be  taken  in  reaching  conclusions,  since  it  is 
well  known  that  the  course  of  a  bullet  may  be  deflected 
especially  by  bone,  and  that  a  bullet  may  wander 
not  only  after  being  in  the  body  a  considerable  time, 
but  also  in  fresh  cases.  The  track  is  of  importance 
also  as  a  guide  to  the  location  of  a  bullet.  The  track 
may  contain  the  wad,  and  in  an  interesting  case  in 
literature  such  a  wad  served  to  convict.  A  game- 
keeper was  found  dead  in  the  forest;  the  wad  was  not 
burned  and  proved  to  be  part  of  a  calendar  in  posses- 
sion of  a  notorious  poacher. 

Although  the  bullet  may  be  markedly  deformed  or 
flattened,  the  rim  at  its  base  is  usually  sufficiently 
intact  to  determine  its  caliber.  Certain  markings 
upon  the  bullet  may  prove  valuable  evidence  of  its 
having  been  fired  from  a  given  weapon.     Moreover, 

811 


Autopsy,  Medicolegal 
Relations 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


its  presentation  to  the  jury  is  the  best  evidence  that 
the  wound  was  really  produced  by  a  bullet. 

Multiple  wounds  may  be  caused  by  the  same  bullet 
passing  through  the  upper  extremity  and  thorax,  or 
lower  extremity  and  abdomen,  or  through  mamma 
and  thorax;  three  or  more  wounds  being  present  in  the 
skin.  It  is  necessary  to  distinguish  wounds  of  en- 
trance from  wounds  of  exit.  As  far  as  the  soft  parts 
are  concerned,  this  has  been  discussed  above.  In  the 
calvarium  the  fracture  produced  is  an  excellent 
criterion.  The  table  upon  which  the  bullet  impinges 
first  is  fractured  to  a  less  extent.  Thus,  in  wounds 
of  entrance  the  outer  table  presents  the  smaller 
opening,  the  inner  the  larger  opening;  the  fracture 
shelves  inward.  In  wounds  of  exit  the  inner  table 
presents  the  smaller  opening;  the  fracture  shelves 
outward. 

The  opening  made  by  the  bullet  in  passing  through 
bone  is  usually  larger  than  the  caliber  of  the  bullet, 
and  in  the  case  of  bullet  wounds  of  the  brain  the 
canal  of  the  bullet  may  also  be  considerably  larger, 
this  effect  being  due  in  part  to  the  flattening  of  the 
bullet  against  the  bone,  and  in  part  to  the  carrying  in 
of  fragments  of  bone. 

Where  deflection  has  occurred  and  where,  as  in  the 
abdominal  cavity,  the  bullet  may  traverse  a  consid- 
erable distance  without  causing  lesions,  the  track  or 
canal  of  the  bullet  may  not  lead  directly  to  the  bullet 
itself.  In  one  case  the  wound  of  entrance  was  located 
in  the  right  hypochondriac  region  and  with  it  was 
associated  a  wound  of  the  transverse  colon  and  its 
mesentery.  The  direction  of  the  track,  up  to  this 
point,  was  backward,  inward,  and  slightly  down- 
ward, yet  the  bullet  was  found  embedded  beneath 
the  iliopsoas  muscle  on  the  left  side  of  the  fifth 
lumbar  vertebra.  In  another  case  the  wound  of 
entrance  was  located  on  the  anterior  and  inner  aspect 
of  the  left  thigh,  with  perforation  into  the  peritoneal 
cavity  below  Poupart's  ligament.  The  bullet,  how- 
ever, was  found  in  the  stomach,  and  there  was  a 
wound  in  its  posterior  wall  near  the  greater  curvature, 
with  a  second  wound  in  the  transverse  mesocolon.  In 
bullet  wounds  of  the  brain  the  amount  of  deflection 
may  be  considerable,  so  that  the  canal  may  pass 
through  the  superficial  part  of  the  cortex,  from  one 
side  of  the  cranium  to  the  other.  The  angle  of  deflec- 
tion may  be  very  acute.  Thus  in  one  case  the  wound 
of  entrance  was  located  over  the  left  parietal  boss, 
while  the  track  passed  downward  and  across  the 
median  line  through  the  brain  to  the  right  side  of  the 
frontal  bone,  causing  comminution  at  the  junction  of 
the  orbital  plate  and  perpendicular  portion.  A 
second  canal  was  found  in  the  right  hemisphere 
leading  to  the  bullet;  the  latter  being  very  much 
flattened  beneath  the  right  parietal  boss,  which  was 
excessively  comminuted. 

The  discharge  of  a  weapon  at  contact,  provided  the 
powder  charge  is  sufficiently  large,  even  though 
there  is  no  bullet  and  consequently  no  bullet  wound 
through  the  skin,  may  cause  death.  A  case  is  re- 
ported of  laceration  of  the  heart  through  such  a  dis- 
charge at  contact  against  the  precordial  region.  The 
skin  presented  the  usual  appearances  with  the 
exception  of  a  bullet  wound,  i.e.  smoke  stain, 
burn,  and  embedded  powder  grains  were  visible. 

Cases  have  occurred  in  which  the  mouth  was 
filled  with  powder,  which  was  then  ignited. 

The  extent  of  comminution  of  bone  varies  with  the 
character  of  the  bullet,  its  soft  or  hard  consistency, 
its  structure,  its  caliber,  powder  charge,  and  range; 
in  addition  the  thickness  of  bone  must  be  taken  into 
account. 

5.  The  decision  whether  a  bullet  wound  was  self- 
inflicted  may  be  difficult  to  reach  when  the  wound 
presents  the  appearance  of  a  shot  at  contact,  or  wit  h in 
a  range  at  which  self-infliction  is  possible.  Such 
wounds  may  of  course  have  been  inflicted  by  another 
individual.     The  wound  in  suicide,  although  usually 


inflicted  at  or  nearly  at  contact,  need  not  of  course 
have  been  so  inflicted.  From  the  situation  of  the 
wound  of  entrance,  and  the  direction  of  the  track 
valuable  conclusions  may  be  drawn;  but  the  possi- 
bility of  suicide  should  not  be  excluded  except  after 
the  most  careful  consideration,  since  peculiar  methods 
of  handling  the  pistol  may  have  been  employed,  such 
as  steadying  the  barrel  with  one  hand  against  the 
part  and  pulling  the  trigger  with  the  other.  From 
the  reflection  of  smoke  and  powder  grains  the  ban 
may  become  stained.  Careful  examination  of  both 
hands  with  this  end  in  view  should  be  made,  and 
from  the  above  it  can  easily  be  understood  how  the 
stain  may  appear,  not  only  upon  the  hand  used  to 
discharge  the  weapon,  but  where  the  barrel  has  been 
si  radied  with  the  other  hand  this  may  be  stained,  and 
yet  the  stain  be  absent  upon  the  hand  that  has  pulled 
the  trigger.  This  will  explain,  for  instance,  the  pres- 
ence of  a  bullet  wound  on  the  right  side  of  the  head, 
and  a  powder  stain  on  the  left  hand.  The  palm  and 
flexor  aspect  of  the  thumb  should  be  examined  fur 
scratches  or  contusions  that  might  have  been 
produced  by  the  recoil  of  the  revolver.  All  attend- 
ing circumstances  should  be  noted.  Of  course,  the 
revolver  still  grasped  in  the  hand  of  the  deceased 
does  not  necessarily  prove  suicide,  as  it  is  conceivable 
that  before  rigor  mortis  has  set  in  such  a  condition 
may  be  directly  produced  post  mortem. 

The  question  of  multiple  self-inflicted  wounds  comes 
up  for  decision  in  cases  in  which  one  or  more  were 
necessarily  fatal,  and  it  may  be  important  to  decide 
whether  one  was  immediately  fatal.  The  presump- 
tion may  arise  that  the  second  wound  could  not  have 
been  inflicted  after  the  infliction  of  the  first..  Double 
bullet  wounds  in  the  heart  have  been  self-inflicted. 
Whether  a  bullet  wound  of  the  brain  necessarily 
prevents  a  further  voluntary  action,  is  often  hard  to 
decide.  Of  course,  if  a  vital  center  has  been  lacer- 
ated death  must  have  occurred  immediately  there- 
after. Still  it  is  quite  possible  that  laceration  of  the 
brain,  and  sometimes  quite  considerable  laceration, 
may  occur  in  uncommon  cases  without  being  imme- 
diately fatal. 

Bullet  wounds  together  with  other  injuries  may 
occur  in  cases  of  suicide,  all  having  been  self-inflicted. 
In  addition,  numerous  cases  have  been  reported  of 
poisoning  and  traumatism  in  the  same  individual. 

6.  The  estimation  of  the  relative  importance  of 
disease  and  injury  and  of  their  dependence  upon  each 
other  is  best  considered  regionally.  Certain  con- 
siderations apply  in  all  cases.  Thus,  for  example,  it 
must  be  remembered  that  a  wound  infection — such 
as  septicemia,  pyemia,  erysipelas,  and  tetanus— may 
follow  an  injury.  Local  tuberculous  processes  may 
be  secondary  to  traumatism.  Pneumonia  may 
follow  an  injury  and  may  prove  fatal.  When  injuries 
occur  in  a  subject  of  chronic  disease,  the  injury  and 
the  disease  should  be  separately  considered,  and  the 
attempt  should  be  made  to  determine  the  part  played 
by  each  in  the  causation  of  death.  Post  mortem, 
the  differentiation  between  the  results  of  disease  and 
those  of  traumatism  should  be  made,  and  in  this 
connection  the  subject  of  hemorrhage  is  important, 
as  it  may  be  the  result  of  either.  Mistakes  may  be 
made  in  determining  the  origin  of  hemorrhage. 

Brain. — In  cases  of  concussion  of  the  brain,  external 
signs  of  violence  may  be  present,  but  cases  may  occur 
of  even  fatal  concussion  with  little  or  no  evidence 
of  external  violence.  The  brain  is  usually  conge 
and  sometimes  shows  multiple  and  very  fine  contu- 
sions over  the  entire  surface.  The  floor  of  the  fourth 
ventricle  is  a  spot  where  important  evidence  may  In- 
found  in  these  cases,  and  it  should  be  examined  from 
above,  the  brain  having  been  laid  on  its  base  with  the 
cerebellum  toward  the  observer.  After  section  of  the 
cerebral  hemisphere  on  either  side,  a  median  incision 
is  made  through  the  cerebellum  until  the  ventricle 
is   reached.     Then   the   incision   is    to   be   extended 


812 


REFERENCE    IIAXDHOOK    OF    THE    MEDICAL    SCIENCES 


Autopsy,  Medicolegal 
Bela  lions 


nteriorly  to  the   corpora  quadrigemina  and   poste- 

,,1-lv  to  the  divergence  of  I  lie  restiform  bodies.      Fin- 

||y  the  separation  of  the  two  halves  of  the  cerebellum 

ill  bring  into  view  the  floor  of  the  fourth  ventricle. 

n    fatal    concussion    ecchymotic    spots    varying    in 

umber    and    extent    are    usually    found    here.      Care 

liould  be  taken  not  to  confuse  the  prominent  veins 

sually  found  on  either  side  of  the  anterior  part  of  the 

id  of  the  fourth  ventricle,  with  ecchynioses. 

Contusion   of     the    brain    is   practically    a   minute 

face   laceration   of   the   cortex.      It    is   marked    by 

ed  spots  that   remain  after  pressure  on  the  pia  and 

h  on  section    prove  to  be  a  thin  surface  hemor- 

bage  beneath  the  pia  in  the  brain  substance. 

Laceration  of  the  brain  is  always  a< mpanied  by 

aorrhage  and  may  be  due  to  violence  or  to  the 
•(fusion  of  blood  from  spontaneous  rupture  of  a 
eased  vessel.  In  the  latter  case  the  typical  loca- 
.111  of  the  hemorrhage  is  in  the  lenticular  nucleus, 
he  blood  having  come  from  a  rupture  of  one  or 
ither  of  the  anterior  perforating  arteries,  most 
lommonly  the  lenticulostriate.  The  hemorrhage 
ind  laceration  may  vary  in  extent;  they  may  involve 
inner  capsule,  the  head  of  the  caudate  nucleus  or 
the  optic  thalamus,  and  sometimes  they  extend  into 
the  ventricle;  or  the  extension  may  take  place  in  an 
nut  ward  direction  through  the  outer  capsule,  the 
.laustrum,  and  the  cortex  of  the  island  of  Reil.  Vio- 
lence, however,  may  cause  just  such  a  hemorrhage, 
although  in  such  a  case  other  lesions  are  likely  to  be 
present  in  addition.  As  a  general  rule,  multiplicity 
of  hemorrhages  and  lacerations  point  to  violence. 
A  spontaneous  hemorrhage  may  occur  in  the  usual 
site  described  above,  and  when  the  violence  is  due  to 
a  fall  upon  the  back  of  the  head  following  loss  of 
consciousness  multiple  hemorrhages  with  laceration 
of  brain  tissue  may  occur  in  the  brain  substance  and 
in  the  cortex.  In  laceration  of  the  brain  due  to 
violence,  the  lesions  are  usually  most  marked  in  the 
cortex,  on  the  surface,  and  they  become  less  exten- 
sive in  the  deeper  portion  of  the  brain  tissue.  Such 
laceration  may  be  due  to  a  comminuted  depressed 
fracture  of  the  skull,  the  actual  tearing  being  caused 
by  fragments  of  bone;  far  more  commonly,  however, 
the  seat  of  laceration  is  directly  opposite  the  point  of 
application  of  violence  as  indicated  by  a  lacerated 
scalp  wound,  contusion  or  hematoma  of  the  scalp. 
The  brain  is  apparently  capable  of  enduring 
considerable  compression  without  the  occurrence 
of  laceration.  Where,  however,  the  brain  tissue 
is  called  upon  to  fill  out  an  increased  space,  i.e. 
where  distention  occurs,  laceration  results.  When 
violence  is  exerted  upon  one  point  of  the  cranium, 
the  convexity  of  the  bone  is  suddenly  reduced,  while 
at  a  point  directly  opposite  the  convexity  is  increased 
by  compensation.  At  the  point  of  application, 
therefore,  the  brain  may  be  compressed  without  lacer- 
ation, while  at  the  opposite  point  the  brain  is  dis- 
tended and  laceration  results.  With  a  blow  or  fall 
upon  the  side  of  the  head,  with  a  hematoma  in  the 
temporal  or  parietal  region,  the  surface  of  the  cau- 
date nucleus  and  optic  thalamus  on  the  same  side  is 
sometimes  the  seat  of  laceration,  without  laceration 
of  the  temporal  or  parietal  cortex  on  that  side.  Here, 
again,  the  cortex  has  been  compressed  and  an  oppo- 
site brain  surface,  though  an  internal  one,  has  become 
lacerated  by  distention.  Laceration  of  the  cortex, 
although  commonly  occurring  with  fracture  of  the 
skull,  either  at  some  point  in  the  skull  cap  or  at  its 
base,  may  also  occur  without  fracture,  the  bone 
having  been  sufficiently  elastic  to  accommodate 
itself,  without  breaking,  to  the  sudden  change  in 
shape  due  to  the  violence.  With  laceration  of  the 
brain  a  blood  clot,  more  or  less  extensive,  may  form 
between  dura  and  pia.  When  the  laceration  does  not 
involve  the  pia  mater,  blood  may  be  infiltrated  in  the 
meshes  of  the  pia  arachnoid  and  may  infiltrate  the 
sulci  beneath  the  pia  mater. 


Injuries  to  the  <\r,h,,ii    \,     els.  —Isolated   laci 
Hon  of  one  or  anothei  cerebral  vessel  may  be  due  to 
violence  either  with  or  without  fracture  ol  the  skull. 

The  vessel  may  or  may  not  have  previously  ben  tin- 
seat  of  fatty  degeneration  or  of  aneurysm.     Iii  such  a 

case  the  blood  is  usually   poured  OUl    beneath   the  pia 

mater,  more  commonly  at  the  base  of  the  brain; 
it  may  infiltrate  both  fissures  of  Sylvius,  and  passing 
beneath   the  velum  interpositum,  through  the  large 

transverse  fissure,  may  break  through  the  single 
layer  of  epithelium  constituting  the  ependyma  and 
gain  access  to  the  ventricles.  An  accurate  examina- 
tion of  all  the  cerebral  vessels  is  a  matter  of  consider- 
able importance.  In  the  case  of  an  aneurysm,  sponta- 
neous rupture  is  quite  possible;  but  when  tin 
are  the  seat,  of  tatty  degeneration  and  atheroma, 
spontaneous  rupture  is  infrequent,  if  we  except  the 
lenticulostriate  and  anterior  perforating  branche  . 
Atheroma  will,  however,  account  for  conditions  — 
namely,  vertigo  and  sudden  loss  of  consciousness — 
which  in  themselves  may  be  responsible  for  the  occur- 
rence  of    traumatism. 

Traumatic  Meningitis. — Acute  purulent  or  pro- 
ductive meningitis  may  occur  from  traumatism,  and 
may  be  the  immediate  cause  of  death.  Where  a 
wound,  with  or  without  fracture  of  the  skull,  has 
opened  the  way  for  infection,  or  where  fracture  of  t  In- 
base  of  the  skull  has  permitted  infection  through 
nasal,  buccal,  or  aural  orifices,  the  connection  of  a 
purulent  meningitis  with  the  traumatism,  although 
indirect,  is  quite  evident.  Such  a  purulent  menin- 
gitis may  not  follow  the  traumatism  directly,  as  infec- 
tion may  take  place  later  and  is  possible  as  long  as  the 
wound  or  fracture  is  not  completely  healed. 

Where,  however,  a  purulent  or  an  acute  productive 
meningitis  is  found  without  an  apparent  avenue  of 
infection,  but  following  a  traumatism  (as  contusion 
of  some  part  of  the  head  with  concussion  of  the  brain), 
the  connection  between  the  meningitis  and  the  trau- 
matism is  more  difficult  to  establish.  All  other 
causes  of  meningitis  would  have  to  be  excluded. 
In  addition,  the  clinical  history  of  onset  of  menin- 
gitis within  at  least  a  few  days  from  reception  of  the 
traumatism,  would  be  most  important  evidence. 
The  stage  of  the  inflammatory  process  as  found  at  the 
autopsy  is  of  great  importance.  Although  it  might 
not  be  possible  to  determine  absolutely  the  duration 
of  the  disease,  still  it  might  be  ascertained  that  the 
duration  was  or  was  not  longer  than  a  given  time, 
namely,  the  date  of  the  occurrence  of  the  traumatism 
in  evidence. 

The  important  bearing  of  an  inflammatory  process, 
with  invasion  of  pyogenic  bacteria  in  some  other 
portion  of  the  body  adjacent  or  remote,  should  not  be 
forgotten  as  a  possible  source  of  infection. 

The  occurrence  of  acute  exudative  inflammations  of 
serous  membranes  in  subjects  of  chronic  interstitial  or 
diffuse  nephritis  without  traumatism,  would  render 
the  acceptance  of  these  diseases  as  predisposing 
conditions  of  meningitis  from  traumatism  quite 
plausible. 

Hemorrhagic  meningitis  is  not  necessarily  trau- 
matic. It  may  occur  as  a  complication  of  typhoid 
fever  and  other  infectious  diseases. 

Acute  pachymeningitis  may  be  secondary  to  frac- 
ture of  the  skull,  from  infection,  or  to  an  infected  scalp 
wound  or  erysipelas.  The  inflammation  may  affect 
the  external  layer  of  the  dura  (usually  in  the  form  of  a 
purulent  pachymeningitis)  or  the  internal  layer  (in 
the  form  of  a  fibrinous  pachymeningitis),  or  both 
layers  may  be  inflamed. 

Pachymeningitis  interna  hoemorrhagica  may  give 
rise  to  a  hemorrhage  with  formation  of  clot  between 
the  dura  and  the  pia.  When  one  or  more  layers  of 
tissue  result  from  attacks  of  this  form  of  inflamma- 
tion— layers  which  may  be  stripped  off  from  the 
dura — the  diagnosis  is  readily  made  from  a  simple 
macroscopic     examination.     An     excessive     hemor- 


813 


Autopsy,  Medicolegal 
Relations 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


rhage  may,  however,  occur  at  an  early  stage  when  the 
membrane  is  as  yet  very  thin,  and  when  microscopic 
examination  may  be  necessary  to  substantiate  the 
diagnosis.  Pachymeningitis  interna  hemorrhagica 
must  be  suspected  whenever  a  blood  clot  is  found 
between  the  pia  and  the.  dura,  especially  over  the 
convexity  on  one  side,  in  the  absence  of  laceration  of  the 
brain.  Such  a  clot  might,  however,  result  from  lacera- 
tion of  the  veins  in  the  pia  as  they  pass  over  to  the 
dura,  to  gain  access  to  the  longitudinal  sinus.  Pachy- 
meningitis may  at  any  time  cause  a  spontaneous  hem- 
orrhage with  compression  of  the  brain  and  death.  _  It 
Is  conceivable  that  violence,  not  necessarily  excessive, 
may  at  any  time  determine  such  a  hemorrhage;  it 
should  be  remembered,  however,  that  vertigo  and 
loss  of  consciousness  (common  symptoms  of  this 
affection)  may  be  responsible  for  the  occurrence  of 
trauma,  which  in  its  turn  may  determine  the 
hemorrhage. 

Meningeal  Arteries. — Laceration  is  due  to  trauma- 
tism, and  occurs  most  commonly  with  fracture  of  the 
skull  (vertex  or  base),  the  site  of  laceration  corre- 
sponding to  the  point  where  the  line  of  fracture 
crosses  the  course  of  the  artery.  Laceration  may 
occur  without  fracture.  The  middle  meningeal  or 
one  of  its  branches  is  most  exposed  to  laceration  from 
its  course  and  its  position  in  a  deep  groove,  or  even  a 
canal,  of  bone.  The  effusion  of  blood  occurs  between 
dura  and  bone,  unless  the  dura  is  completely  lacerated 
by  a  comminuted  depressed  fracture.  Compression 
of  the  brain  by  the  resulting  clot  is  usually  sufficient, 
if  unrelieved,  to  cause  death.  However,  when  the 
effusion  of  blood  is  not  too  excessive  the  compression 
may  not  be  sufficient  to  cause  death.  A  clot  three 
inches  in  diameter  and  three-fourths  of  an  inch  in 
thickness  compressing  the  right  frontal  lobe,  and  due 
to  laceration  of  a  branch  of  the  anterior  meningeal 
artery,  with  stellate  fracture  of  the  right  orbital 
plate,  was  found  in  a  case  in  which  death  was  due  to 
pneumothorax  from  perforation  of  a  tuberculous 
focus.  There  was  no  history  of  cerebral  symptoms. 
The  organization  of  the  peripheral  part  of  the  clot 
showed  that  it  must  have  been  present  for  several 
weeks. 

As  regards  fracture  of  the  skull,  vertex  or  base,  as 
a  cause  for  death,  it  should  be  remembered  that  the 
fracture  in  itself,  except  in  so  far  as  it  may  open  the 
way  for  infection,  is  of  minor  importance.  The 
lesions  of  the  vessels  and  consequent  hemorrhage, 
the  accompanying  concussion,  contusion,  laceration, 
and  compression  of  the  brain,  are  the  important  fac- 
tors. The  fracture  is  of  importance,  and  its  descrip- 
tion should  always  be  accurately  made,  as  it  may 
indicate  not  only  the  degree  of  violence  sustained, 
but  in  addition  may  serve  to  indicate  the  character 
of  the  weapon  employed  or  the  manner  in  which  the 
injury  was  sustained. 

Neck. — The  injuries  produced  by  strangulation  and 
hanging  are  considered  in  the  section  on  Asphyxia. 
Contusion  of  the  larynx  may  cause  sudden  death  by 
shock,  by  reflex  paralysis  of  respiration,  or  by 
spasm  of  the  glottis.  Fractures  of  the  laryngeal  or 
tracheal  cartilages,  from  the  edema  of  the  submucous 
areolar  tissue  accompanying  them,  may  cause  occlu- 
sion of  the  respiratory  passage  and  asphyxia.  Lacer- 
ation of  the  mucosa  accompanying  such  fractures  or 
occurring  alone  may  be  followed  by  cellular  emphysema 
and  by  asphyxia.  A  case  in  point  has  been  observed 
in  which  a  laceration  of  the  mucosa  between  the 
larynx  and  the  trachea,  followed  by  cellular  emphy- 
sema of  the  neck,  glottis,  upper  half  of  the  thoracic 
wall,  and  mediastinum,  although  tracheotomy  had 
been  performed,  caused  death  from  asphyxia.  The 
laceration  in  this  case  was  produced  by  sudden  over- 
extension of  the  neck,  in  a  fall  upon  the  chin. 

Incised  wounds  of  the  neck,  as  in  cases  of  suicide, 
may  cause  death  from  hemorrhage;  more  commonly, 
however,  the  larger  vessels  are  not  cut,  but  the  inci- 


sion passes  between  the  hyoid  bone  and  the  larynx 
through  the  larynx  or  trachea,  into  the  respiratory 
passage.  Death  in  such  cases  may  be  due  to  a  com- 
plicating bronchopneumonia  from  aspiration  of  the 
discharges  from  the  wound. 

Direct  contusion  of  the  posterior  part  of  the  neck 
may  be  accompanied  by  contusion  of  the  medulla  and 
spinal  cord  without  fracture  of  the  cervical  vertebra. 

Fracture  and  dislocation  of  the  cervical  vertebra 
are  more  often  due  to  a  fall  or  blow  upon  the  vertex 
of  the  cranium  than  to  direct  violence  upon  the  neck. 

A  wound  of  the  jugular  veins  immediately  above 
the  thorax  may  be  followed  by  entrance  of  air  into 
the  right  heart  and  pulmonary  circulation,  causing 
sudden  death. 

Thorax. — Simple  fracture  of  the  ribs  is  not  usually 
in  itself  a  cause  of  death.  If,  however,  an  inter- 
costal artery  has  been  lacerated,  or  the  lung  or  the 
heart  punctured,  death  may  follow  hemorrhage  or 
pneumothorax. 

Compound  fracture  may  be  followed  by  cellular  em- 
physema, and,  if  perforation  of  the  pleural  sac  has  oc- 
curred, by  pneumothorax. 

Contusion  and  laceration  of  the  lung  may  accom- 
pany fractured  ribs,  or  there  may  be  few  or  no  signs  of 
violence  in  the  thoracic  wall.  This  is  particularly 
likely  to  be  the  case  in  children.  These  lesions  may 
produce  ecchymoses,  parenchymatous  hemorrhages, 
interstitial  emphysema,  or  pneumothorax. 

Pneumothorax  may  result  from  the  perforation  of 
a  tuberculous  focus  into  the  pleural  sac. 

Wounds  of  the  lung  may  cause  death  by  hemor- 
rhage, pneumothorax,  cellular  emphysema,  or  by 
complicating  pneumonia. 

Pneumonia  may  be  secondary  to  cerebral  injuries, 
and  to  other  injuries  besides  those  of  the  respiratory 
tract  mentioned.  Infection  of  wounds  may  explain 
a  secondary  pneumonia  in  some  cases;  in  others  a 
condition  of  passive  hyperemia,  followed  by  "hy- 
postatic" pneumonia,  may  be  due  to  the  confinement 
and  enfeebled  condition  following  such  injuries,  or 
to  the  advanced  age  of  the  individual. 

Rupture  of  the  heart  may  be  spontaneous  and  duo 
to  fatty  degeneration  or  necrosis  of  a  portion  of  its 
wall  from  occlusion  of  the  afferent  branch  of  the 
coronary  artery.  Such  rupture  usually  occurs  in 
the  anterior  wall  of  the  left  ventricle.  Contusion  and 
laceration  of  the  heart  may  occur  from  direct  con- 
tusion, or  from  compression  of  the  thorax.  In  the 
latter  case,  laceration  is  far  more  likely  to  occur  in  the 
wall  of  the  right  auricle.  Laceration  of  the  posterior 
wall  of  the  left  ventricle,  where  it  comes  in  relation 
with  the  tendon  of  the  diaphragm,  was  found  in  i 
of  fall  from  a  height;  the  accompanying  lesions  in 
this  case  being  contusions,  fractured  ribs,  and 
lacerations  of  both  lungs. 

Stab  and  bullet  wounds  of  the  heart  cause  death 
through  the  compression  exerted  upon  the  heart  bj 
the  effused  blood  in  the  pericardial  sac.  This  serves 
to  explain  the  fact  that  death  in  such  cases  is  not 
necessarily  instantaneous.  A  few  cases  of  recovi 
from  such  wounds  are  on  record.  Depending  ujion 
the  character  of  the  wound  and  the  rapidity  or  slow- 
ness of  the  resulting  hemorrhage,  a  shorter  or  longer 
period  may  intervene  between  reception  of  the  injury 
and  death.  Voluntary  action  may  occur  ^  after  a 
wound  of  the  heart  has  been  received.  Thus  the 
wounded  person  may  run  a  short  distance,  or  may 
close  the  clasp  knife  with  which  the  wound  had  been 
inflicted.  Multiple  bullet  wounds  of  the  heart  have 
been  self-inflicted,  usually  with  weapons  of  small 
caliber.  Multiple  self-inflicted  stab  wounds  of  the 
heart  and  other  organs  are  on  record. 

Fatty  embolism  of  the  pulmonary  artery  may  follow 
fractures  of  cancellous  bone,  especially  if  considerable 
comminution  occurs.  Embolism  of  the  pulmonary 
arteries  may  also  occur  as  a  result  of  a  primary  per- 
ipheral thrombophlebitis  due  to  injury. 


814 


REFEHI'.XCK    HANDBOOK    or    TIM-:    Ml  I'M    \l     -<  [EXCF.S 


Autopsy,  Medicolegal 
Relations 


Aneurysms  in  this  region  may  rupture  spontane- 
isly,  or  rupture  may  follow  an  injury  of  compara- 
ble minor  violence. 

Abdomen. — Shock    with    comparatively   slight    evi- 
ences  of  injury  due  to  contusion  of  the  abdomen  or 
f   the   solar    plexus,    may    occur.     Contusion,    com- 
-  .j,,n.  and   laceration  of  organs  without   apparent 
ijury   of    the    abdominal    wall,    are    not    infrequent, 
ration  of  an  artery  may  occur  alone  from  trau- 
-iii,    and    without     previous    disease.      In    other 
-  the  artery  may  be  the  scat  of  some  disease  like 
neurysm  or  tuberculosis,  and  a  spontaneous  hema- 
,ma  or  hemorrhage  may  occur,  or  such  hemorrhage 
iay  be  the  result  of  an  injury  otherwise  of   insuffi- 
:    violence    to    cause  rupture.     Septic  peritonitis 
nay   follow   perforation  of  a  hollow   viscus   due   to 
or  perforation  may  have  been  immediately 
irought  about  by  injury.     Hemorrhagic  peritonitis, 
orrhagic  pancreatitis,  with  or  without  fat  necro- 
tic be  mistaken  for  the  results  of  injury.     Hema- 
oma   of    the    suprarenal    capsule    due    to   excessive 
lassive  hyperemia,  with  or  without  rupture  into  the 
eritoneai  cavity,  is  another  condition  that  may  be 
Mistaken  for  the  result  of  violence. 

Pelvis. — Spontaneous  rupture  of  the  bladder  with- 
lut  disease  may  occur  in  subjects  of  hysteria.  A 
with  fatal  hemorrhage,  in  which  traumatism  was 
ibsolutely  excluded,  has  come  to  notice.  Septicemia 
nay  follow  infiltration  of  urine  due  to  laceration  by 
■areless  catheterization.  Injury  to  the  female 
genitalia,  not  only  in  cases  of  criminal  abortion  but 
ilso  in  non-pregnant  cases,  may  be  produced  by 
lirect  violence,  or  during  coitus.  Such  injuries  are 
•ommonly  lacerations  of  various  extent,  either  simply 
involving  the  hymen  or  ostium  vagina,  or  extending 
upward  into  the  vagina,  or  involving  the  fornix  and 
perforating  into  the  peritoneal  cavity.  In  such  cases 
death  may  be  due  to  hemorrhage,  or  to  septicemia, 
or  to  septic  peritonitis.  Rupture  of  the  pregnant 
uterus  may  be  the  result  of  a  fall  or  blow;  on  the  other 
hand  it  may  occur  spontaneously.  In  the  latter  case, 
however,  rupture  occurs  after  labor  pains — that  is, 
contractions  of  the  uterus — have  set  in,  and  usually 
after  a  more  or  less  prolonged  duration  of  labor  due  to 
obstruction  to  delivery. 

Abortion. — The  questions  for  investigation  are: 
Has  abortion  occurred?  If  so,  has  it  been  induced? 
Is  it  responsible  for  the  death  of  the  individual? 

Abortion  may  be  defined  as  the  termination  of 
gestation  before  the  viability  of  the  fetus,  this  term 
being  accepted  as  about  thirty  weeks  or  seven  cal- 
endar months.  The  postmortem  conditions  upon 
which  the  diagnosis  of  gestation  that  has  been  termi- 
nated may  be  based,  may  readily  be  remembered  by 
recapitulating  the  changes  produced  in  the  uterus 
and  ovary  by  gestation.  If  in  addition  some  por- 
tion of  the  products  of  conception  is  still  retained  in 
utero,  its  demonstration  affords  positive  proof. 
Nevertheless,  if  no  such  portion  be  found,  the  changes 
produced  in  the  uterus  and  ovary  are.  sufficiently 
characteristic,  provided  too  long  a  time  has  not 
elapsed,  to  warrant  a  positive  diagnosis. 

If  a  portion  of  the  fetus  or  its  membranes,  more 
especially  chorionic  or  placental  villi,  be  demon- 
strated, this  alone  is  proof  of  gestation,  but  is  not  in 
it-elf  proof  of  criminal  abortion.  The  signs  so  far 
as  the  uterus  and  ovary  are  concerned  may  individ- 
ually, at  least  in  part,  be  produced  by  other  condi- 
tions. These  signs  are,  in  the  first  place,  enlargement 
of  the  uterus,  especially  its  body,  and  enlargement 
of  its  cavity;  second,  hypertrophy  of  the  uterine 
wall,  a  softer  consistency  and  enlargement  of  its 
veins  with  formation  of  sinuses,  especially  at  the 
placental  site;  third,  thickening  of  the  endometrium 
with  the  characteristic  change  in  its  morphology — 
namely,  the  production  of  the  true  decidua  of  preg- 
nancy, and  over  the  anterior  or  posterior  wall  at  the 


fundu-,  where  the  chorionic  villi  become  attached  to 
tin1  decidua  serotina,  the  formation  of  the  placenta. 
Even  though  all  the  chorionic  portion  of  the  placenta 

has    been    -eparated,    a    raw    surface    i      left,    differing 

from  the  otherwise  smooth  lining,  which  ran  readily 
be  recognized,  even  from  the  gross  appearand 

the  placental  -ite. 

The  size  of  the  uterus  will  vary,  in  the  fir-t  place, 
according  to  the  period   i  has  been 

reached,  and,  in  the  second  place,  according  to  the' 
time  elapsed  between   the  cessation  of  gestation  or 

abortion  and  death.      The  i i   tencj    "I    the  uterus 

will  vary  according  to  the  period  of  gestation,  the 

presence  or  absence  of  metritis,  and  the  advancement 
of  postmortem  changes.  The  decidua  will  vary 
according  to  the  time  at  which  gestation  v. a-  inter- 
fered with,  according  to  the  time  which  has  elapsed 
between  then  and  death,  and  also  according  to  the 
degree  of  inflammatory  reaction  that  may  have  taken 

place. 

The  ovary  that  has  supplied  the  ovule  which  has 
been  fructified  presents  a  change  in  its  Graafian 
follicle  that  is  quite  characteristic,  especially  in  the 
earlier  periods  of  gestation,  namely,  .the  true  corpus 
luteum.  At  the  end  of  the  third  week  this  presents 
a  cyst  of  two  centimeters  in  diameter  with  a  wall 
three  millimeters  in  thickness  and  of  a  characteristic 
yellow  color,  usually  distended  at  this  period.  Shortly 
thereafter  this  wall  shows  a  slight  convolution, 
while  the  cavity  is  often  filled  with  a  clear,  slightly 
viscid  fluid,  sometimes  blood-tinged,  or  entirely 
bloody.  From  this  period  onward  the  change  con- 
sists in  a  gradual  shrinkage  of  the  entire  cyst  with 
more  marked  convolution  of  its  yellow  wall,  and  with 
absorption  of  its  fluid  contents,  coincident  with  a 
growth  of  connective  tissue  which  occupies  the  place 
of  the  fluid.  The  corpus  luteum  persists  throughout 
the  entire  period  of  gestation,  and  does  not  diminish 
markedly  in  size  until  the  end  of  four  or  five  months. 
Although  in  structure  the  corpus  luteum  of  preg- 
nancy does  not  differ  from  the  normal  corpus  luteum 
of  menstruation,  yet  from  its  larger  size,  and  its 
persistence  in  size  up  to  the  fourth  or  fifth  month, 
together  with  the  thickness  of  its  yellow  border,  it 
forms  a  valuable  additional  sign  of  gestation,  espe- 
cially during  the  period  when  criminal  abortion  is 
more  commonly  committed.  The  corpus  luteum  of 
menstruation  under  certain  disease  conditions — as, 
for  instance,  when  there  are  fibroid  tumors  of  the 
uterus,  or  cystic  oophoritis — may  reach  one  centi- 
meter or  even  more  in  diameter.  It  is  then  filled 
with  clotted  blood  and  has  a  yellow  margin,  some- 
times convoluted,  and  measuring  one  or  two  milli- 
meters in  thickness;  yet  its  appearance,  when  one  has 
become  familiar  with  the  true  corpus  luteum  of  preg- 
nancy, is  quite  different.  Moreover,  a  number  of 
such  corpora  lutea  are  usually  found.  The  absence 
of  diseased  conditions  in  which  they  occur  would  be 
additional  evidence  in  doubtful  cases. 

To  recapitulate,  the  only  positive  evidences  that  a 
fetus  in  utero  has  existed  are  these:  The  presence  of 
chorionic  villi,  which  from  their  adhesion  to  the 
placental  site  may  be  readily  enough  found,  and  the 
demonstration  of  a  true  decidua  of  pregnancy,  both 
of  which  structures  must  have  their  true  character 
verified  by  microscopical  examination.  To  these  two, 
perhaps,  should  be  added  a  third,  viz.,  the  demonstra- 
tion of  a  true  corpus  luteum  in  one  or  the  other  ovary. 
All  the  other  signs  are  not  in  themselves  positive,  but 
taken  together  they  may  form  sufficient  evidence  of 
recent  gestation. 

Signs  of  Abortion  having  been  Induced. — Induction 
of  abortion  may  under  certain  circumstances  and 
after  consultation  be  perfectly  justifiable.  When 
there  is  no  lawful  reason  for  the  termination  of  gesta- 
tion,  induction  of  abortion  is  criminal.  What  signs 
may  we  rely  upon,  in  the  postmortem  examination, 
to  "conclude   that  abortion   has  been   criminally   in- 

815. 


Autopsy,  Medicolegal 
Relations 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


duced?  In  the  first  place,  the  examination  of  the 
fornix  of  the  vagina  and  cervical  canal,  especially  at 
and  just  below  the  internal  os,  for  punctures  and 
lacerations,  may  furnish  strong  evidence  of  such 
interference.  A  large  number  of  cases  of  criminal 
abortion  are  produced  by  mechanical  means,  employed 
by  persons  lacking  anatomical  knowledge  and  surgical 
skill.  A  stylet,  sound,  catheter,  or  syringe  is  intro- 
duced, or  the  cervix  is  clumsily  dilated  with  some  in- 
strument, all  these  procedures  leaving  a  mark  by  rea- 
son of  their  unskilful  employment.  Examination  of 
the  fundus,  the  anterior  wail  or  the  posterior  wall  of 
the  uterus  may  show  a  partial  or  complete  puncture 
or  laceration.  The  effect  of  certain  corrosive  fluids 
may  be  quite  noticeable  upon  the  endometrium,  for 
these  fluids — such  as  carbolic  acid  or  bichloride  of 
mercury  solutions — are  sometimes  used  as  intrauterine 
injections  for  the  production  of  abortion. 

The  effects  of  the  mechanical  means  mentioned 
above  are  to  cause  the  uterus  completely  to  empty 
itself;  and,  provided  the  woman  escape  infection  or 
withstand  it,  death  may  not  result.  In  many  cases, 
however,  the  abortion  remains  incomplete  and  hemor- 
rhage from  the  partially  separated  placenta,  or  from 
the  actual  lesions,  lacerations  or  perforations,  pro- 
duced, may  prove  fatal.  Or  infection  may  take  place 
and  death  may  result  from  a  septic  endometritis, 
metritis,  parametritis,  and  peritonitis. 

Besides  mechanical  means  for  the  induction  of 
abortion,  there  are  numerous  drugs  and  nostrums 
which  are  taken  internally  for  this  purpose.  The 
danger  in  their  use  is  twofold:  in  the  first  place  they 
may  cause  direct  poisoning,  since  many  of  them  in 
increased  doses  are  intense  gastrointestinal  irri- 
tants; in  the  second  place,  the  effect  is  usually  partial, 
the  fetus  being  killed  but  not  expelled,  or  its  mem- 
branes and  the  placenta  are  either  incompletely 
expelled,  or  they  remain  in  the  uterus  and  subsequently 
lead  to  death  from  hemorrhage  or  from  septic 
infection. 

Asphyxia. — Asphyxia  may  be  due  to  mechan- 
ical causes  preventing  the  entrance  of  oxygen  into 
the  lungs  or  interfering  with  the  movements  of 
respiration;  or  it  may  be  due  to  the  presence  of  irrespir- 
able  gases  or  to  causes  acting  upon  the  respiratory 
center  in  the  medulla.  The  following  list  includes 
many  of  the  different  ways  in  which  asphyxia  may  be 
produced  in  a  mechanical  manner:  Occlusion  of  the 
mouth  and  nose,  larynx,  trachea,  and  bronchi, 
either  by  foreign  bodies  or  by  intrinsic  tumors; 
occlusion  of  these  same  channels  by  pressure  exerted 
from  the  outside — as  by  an  aneurysm,  a  new  growth, 
or  an  enlarged  thyroid  gland,  or  by  an  accumulation 
of  fluid  or  air  in  the  pleural  sac;  compression  of  the 
chest  wall,  direct  compression  of  the  trachea,  or 
more  commonly  the  compression  of  the  hyoid  bone, 
base  of  the  tongue,  and  epiglottis,  over  the  aditus 
laryngis,  as  in  strangulation;  aspiration  of  stomach 
contents  in  vomiting;  entrance  of  pus  from  a  tuber- 
culous lymph  node  which  in  breaking  down  has 
perforated  the  trachea  or  bronchus;  submersion  as  in 
drowning,  or  conditions  in  which  the  mouth  and 
nose  alone  become  submerged  below  the  level  of  the 
fluid,  as  in  some  cases  of  death  of  the  new-born,  or  of 
intoxicated  or  unconscious  persons. 

(For  information  in  regard  to  the  various  forms  of 
poisoning  by  carbonic  acid  gas,  see  the  article  entitled 
Carbon,  Oxides  of.) 

Asphyxia  may  be  caused  by  inhalation  of  irrespir- 
able  gases  such  as  chlorine,  bromine,  iodine,  nitrous 
acid,  sulphurous  acid,  and  sulphureted  hydrogen. 
In  these  cases  death  is  usually  caused  immediately  by 
the  shutting  off  of  oxygen.  There  have  been  cases  in 
which  death  has  occurred  some  time  after  such 
exposure  from  bronchopneumonia.  In  regard  to 
sulphureted  hydrogen,  it  has  been  thought  that  it 
forms  a  compound  with  hemoglobin.     If  the  gas  is 


passed  through  blood  the  latter  becomes  dirty  green- 
ish in  color  and  shows  a  spectrum  somewhat  like 
that  of  oxyhemoglobin,  but  with  an  absorption  band 
in  the  red.  The  blood  in  cases  of  death  by  asphyxia 
from  sulphureted  hydrogen  does  not  show  this 
spectrum.  In  animals  killed  by  exposure  to  sul- 
phureted hydrogen  much  less  gas  is  required  (one- 
tenth  to  one-half  per  cent.l  than  is  needed  to  cause 
the  appearance  of  the  sulphureted  hydrogen  spec- 
trum in  their  blood. 

The  respiratory  center  in  the  medulla  may  be  the 
seat  of  various  pathological  alterations:  there  may  be 
some  gross  injury,  or  a  hemorrhage  may  have  taken 
place,  either  of  traumatic  origin  or  the  result  of 
disease;  or  the  medulla  may  be  compressed  by  a  new 
growth,  or  it  may  be  directly  affected  by  the  action  of 
drugs  capable  of  causing  a  paralysis  of  respiration. 

When  respiration  has  been  suddenly  interfered 
with  by  any  of  the  foregoing  causes,  ecchymotic 
spots,  varying  in  size  from  one  millimeter  to  one 
centimeter  in  diameter,  are  usually  found  in  the 
visceral  and  parietal  pleura,  the  mediastinal  pleura, 
the  visceral  pericardium,  sometimes  the  parietal  peri- 
cardium, the  endocardium,  the  meninges,  and  more 
rarely  the  peritoneum.  This  sign  is  a  valuable  one, 
although  not  in  itself  absolutely  diagnostic  of  as- 
phyxia. In  cases  of  slow  asphyxiation  no  ecchymoses 
may  be  found. 

Again,  ecchymoses  may  be  found  in  these  sites  in 
conditions  other  than  asphyxia,  namely,  in  septicemia, 
purpura  hemorrhagic,  nephritis,  hemorrhagic  pleu- 
ritis,  pericarditis  and  peritonitis,  in  many  infectious 
diseases,  and  in  poisoning  by  phosphorus,  arsenic, 
and  other  poisons.  When,  however,  these  conditions 
can  be  excluded  the  presence  of  ecchymoses  indicates 
asphyxia;  their  absence  does  not  exclude  asphyxia, 
if  otlier  conditions  are  present  upon  which  the  diagno- 
sis can  be  based.  In  some  cases  of  sudden  occlusion 
of  the  larynx  by  a  foreign  body,  as  a  piece  of  meat, 
or  by  a  laryngeal  tumor,  death  occurs  very  suddenly, 
apparently  by  reflex  paralysis  of  respiration.  The 
same  condition  is  sometimes  met  with  in  infants  with 
very  large  thymus  glands,  yet  in  these  cases,  in  spite 
of  the  sudden  cessation  of  respiration,  ecchymoses 
may  be  entirely  absent. 

When  death  is  due  to  occlusion  by  a  foreign  body, 
by  aspiration  of  vomit,  or  by  the  other  conditions 
described  above,  these  will  be  apparent  at  the  autopsy 
and  in  most  cases  the  ecchymotic  spots  will  be  present 
also.  The  blood  is  usually  fluid,  very  dark,  from 
reduced  hemoglobin,  and  distends  the  right  auricle 
and  ventricle,  pulmonary  artery,  and  vena  cava. 
The  lips  and  the  skin  of  the  face  and  nfeck  may  be 
cyanotic. 

In  death  from  smothering  or  overlying,  the  ecchy- 
moses are  almost  invariably  found.  The  lungs 
and  the  bronchial  mucosa  are  usually  intensely  con- 
gested; there  may  be  vesicular  emphysema,  more 
especially  of  the  anterior  edges  and  external  margins 
at  the  base  of  the  lung;  in  some  places  an  actual 
rupture  of  vesicles  takes  place,  with  suffusion  of 
air  beneath  the  pleura,  probably  from  spasmodic 
expiratory  efforts.  The  brain  is  intensely  congested, 
the  face  is  usually  markedly  cyanotic,  the  lips  almost 
black.  The  internal  organs  are  engorged  with  dark 
fluid  blood;  the  pulmonary  artery,  right  auricle  and 
ventricle  are  distended  with  dark  blood,  mostly 
fluid,  rarely  and  then  poorly  clotted. 

When  death  is  due  to  strangulation  by  garroting  or 
to  compression  by  the  hands,  scratch  marks  are 
usually  found  over  the  neck  and  sometimes  upon  the 
chin  and  cheeks.  The  hyoid  bone  and  base  of  the 
tongue  with  the  epiglottis  may  be  found  pressed  over 
and  occluding  the  aditus  laryngis.  There  is  usually 
contusion  of  muscles  and  fascia  and  effusion  of  blood 
into  the  loose  areolar  tissue.  There  may  be  fracture 
of  the  hyoid  bone,  of  the  thyroid  cartilage,  or  of 
tracheal   rings. 


S16 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


A  ii lops \ ,  Medicolegal 
Relations 


In  asphyxia  due  to  strangulation  by  hanging,  tin- 
nark  of  the  cord  or  band  is  usually  found  about   the 
ieck  forming  a  single  or  double  furrow  whose  depth 
,  pale,   ami   whose   margins  are   deeply   congested, 
11,1  under  which  in  the  connective  tissue  and  muscle 
he  effects  of  contusion,  laceration,  and  hemorrhage 
re  found.     Laceration  of  the  intima  of  the  arteries 
,1m'  site  of  compression  may  occur.     The  course  of 
his  furrow  may  vary,  and  according  to  the  position 
e  knot  or  loop  of  the  noose  a  con  verge  nee  behind 
me  or  the  other  ear.  under  the  angle  of  the  jaw  on 
her     nh',    under   the   chin,    or   under   the  occiput 
:iv  lie  apparent.      The  trachea  may   be  compressed 
I  some  of  its  rings  broken,  the  thyroid  curtilage  or 
he  hyoid  bone  may  be  fractured,  or  most  commonly 
hyoid  bone  with  the  base  of  the  tongue  and   the 
piglottis  is  pressed  backward,  occluding  the  opening 
f  the  larynx. 

The  tongue  may  be  pressed  forward  and  clenched 
men  the  teeth.     Cyanosis  of  the  head  and  neck 
hove    the   furrow    may    be    present.     Fluidity    ami 
lark   color   of    the   blood,    ecchymoses,    and    general 
ive  hyperemia,  especially  of  the  lungs  and  brain, 
nay  all  be  present. 
It  is  possible  that  death  may  be  caused  by  com- 
sion  of  the  vagi,  with  sudden  paralysis  of  respira- 
ion  and  heart  action,  in  which  case  cyanosis,  exces- 
sive hyperemia,  and  ecchymoses  may  be  absent  or 
xiorly  marked. 

In  some  cases  of  hanging,  with  the  loop  or  knot 
placed  behind  the  ear,  and  with  sudden  tension  of  the 
>ody  weight  upon  the  noose,  fracture  or  dislocation 
if  the  atlas  upon  the  axis,  with  crushing  of  the  medulla 
by  the  odontoid  process,  occurs,  and  death  is  instanta- 
neous. The  signs  mentioned  above  might  then  be 
'■nt. 

In  asphyxia  by  submersion,  as  in  drowning,  or 
where  mouth  and  nose  are  alone  submerged,  the  lungs 
are  increased  in  size  and  weight,  and  congested,  the 
bronchi  are  filled  with  a  frothy  fluid,  and  on  section  a 
msiderable  amount  of  fluid  escapes.  The  condition 
-  quite  different  from  an  ordinary  edema,  even  though 
very  excessive.  It  is  not  possible  to  diagnose  sub- 
mersion with  certainty  from  chemical  examination 
of  the  fluid  in  the  lung,  as  one  might  at  first  think. 
If  specific  substances  are  contained  in  the  fluid,  such, 
for  instance  as  portions  of  vegetable  matter,  such  a 
diagnosis  might  be  positively  made  by  microscopical 
examination.  In  addition  to  the  water  in  the  lungs, 
which  is  very  probably  aspirated  in  the  last  moments 
of  life,  there  is  usually  in  the  stomach  a  considerable 
amount  of  fluid  that  has  been  swallowed.  The  ques- 
tion may  arise  as  to  whether  or  not  in  a  given  case  in 
which  a  body  has  been  removed  from  the  water,  death 
was  due  to  drowning.  If  the  above  signs  are  present 
the  cause  of  death  would  be  asphyxia  by  submersion, 
since  if  life  is  extinct  water  cannot  gain  access  to  the 
lungs  or  stomach.  On  the  other  hand,  if  these  signs 
are  absent  it  might  not  be  safe  to  reason  that  life 
was  extinct  before  the  body  entered  the  water,  since 
it  is  conceivable  that  in  an  unconscious  condition 
there  might  be  no  struggle,  no  dyspnea,  and  conse- 
quently no  swallowing  or  aspiration  of  water. 

Infanticide. — The  following  points  should  be 
determined: 

1.  The  viability  of  the  fetus;  that  is,  whether  it  can 
be  assumed  that  the  fetus  was  capable  of  sustaining 
life. 

2.  Was  the  child  born  alive,  or  in  a  state  of  sus- 
pended animation? 

3.  The  immediate  cause  of  death. 

The  accepted  period  of  uterogestation,  upon  the 
termination  of  which  the  fetus  is"  viable  and  capable 
of  sustaining  life  under  favorable  conditions,  is  reck- 
oned as  thirty  weeks.  Some  cases  have  been  reported 
in  which  the  infant  was  born  alive  at  twenty  weeks, 

Vol.  I. — 52 


ami  some  even  at  twenty-live  vvei  cap- 
able  of  sustaining   life    foi    B    lon»  I    01      tei    time. 

At    thirty    week  -    t  he   fetu     i     forty    centimeti  i 
length.     Its  weight  varies  from  1,500  to  2,000  grams. 
The  skin  is  covered  with   fine  hair,   tin-  finger  nails 

reach  the  tips  of  the  linger-,  the  pupillary  mem- 
brane is  either  absent    or  only  a  vestige   remain-,   the 

te  i  icle  i  ha   e  de  i  ended  or  at  l<  b  I  eii  e  Id  I  hi   canal, 
the  center  of  ossification  in  the  os  calcis  is  live  milli- 
meters in  diametei     thai  in   the  astragalus  half   thai 
size.     There   are    no   centers  of   ossification    in 
epiphyses  at  the  knee. 

The  presence  of  air  in  pulmonary  vesicles,  provided 
decomposition  or  direct  mechanical  inflation  can  be 
excluded,  is  plain  evidence  that  the  child  has  breathed, 
although  it  is  not  necessarily  evidence  thai  complete 
birth    alive   has   occurred.     [nspiratory    movements 

anil  aspiration  of  air  may  even  occur  in  utero  iluiing 

obstetrical  manipulations  or  operations,  ami  it  is 
conceivable  thai  after  birth  of  the  head  inspiration 

may  occur  and  through  delay  asphyxia  may  take 
place.  Again,  it  is  well  known  that  a  child  may  be 
born  in  a  condition  of  apnea,  anil  even  after  it  has 
remained  for  hours  in  a  condition  almost  resembling 
death,  with  an  occasional  heart  beat,  it  may  finally 
be  resuscitated  by  artificial  respiration.  In  such 
cases,  although  the  child  is  born  alive,  it  may  never 
have  breathed,  and  consequently  the  lungs  will  be 
found  in  a  condition  of  fetal  atelectasis.  In  some  of 
these  cases  the  presence  of  air  in  the  stomach  or 
intestine,  provided  decomposition  can  be  excluded, 
may  be  the  only  sign  of  this  condition.  In  other 
cases  aeration  of  the  lungs  of  the  fetus  may  be  inter- 
fered with  by  the  presence  of  some  pathological 
condition  of  the  lungs,  namely  hepatization,  due  to 
desquamation  and  fatty  degeneration  of  respira- 
tory epithelium  (forming  whitish  areas),  by  the  pres- 
ence of  an  interstitial  pneumonia,  or  by  compression 
of  the  lungs  by  the  abdominal  organs  (either  from 
partial  absence  of  the  diaphragm  or  from  a  large 
cystic  kidney).  Again,  by  the  aspiration  of  liquor 
amnii  or  blood,  or  by  the  membranes  being  unrup- 
tured, or,  though  ruptured,  by  a  portion  thereof  occlud- 
ing mouth  and  nose,  the  lungs  may  fail  to  become 
aerated  although  the  child  was  born  alive. 

The  differential  diagnosis  between  atelectasis 
and  aeration  of  the  lung  from  inspiration  is  practic- 
ally and  readily  made  even  from  a  gross  examination, 
provided  decomposition  is  not  excessive;  in  fact, 
it  can  be  made  even  though  decomposition  be 
considerably  advanced.  The  atelectatic  lung  is 
smaller,  and  therefore  the  vault  of  the  diaphragm  is 
higher  (at  the  third  rib  or  intercostal  space).  When 
inspiration  has  occurred  the  lung  is  increased  in 
volume,  and  the  vault  of  the  diaphragm  is  found 
at  the  level  of  the  sixth  rib.  Atelectatic  lung 
is  denser  and  darker  in  color,  its  edges  are  sharper, 
it  does  not  crepitate,  and  it  cuts  like  liver,  differing 
from  hepatization  due  to  inflammation  in  the  absence 
of  a  granular  surface  on  section,  and  in  the  absence 
of  pleuritis.  The  consistence  of  aerated  lung  is 
softer,  it  crepitates  on  pressure,  is  light  red  in  color, 
and  presents  on  the  surface  and  on  section  a  character- 
istic mottled  appearance  due  to  the  occurrence  of 
aerated  vesicles  between  areas  of  blood-vessels. 
Magnified  by  an  ordinary  hand  lens  the  aeration  is 
seen  to  be  distributed  throughout  all  the  vesicles  in 
the  area.  In  this  it  differs  from  the  appearance 
presented  by  vesicles  which  are  filled  with  gas  due  to 
decomposition,  for  this  gas  is  never  distributed  in 
such  a  regular  manner.  Aerated  lung  may  become 
dark  from  congestion,  and  often  enough  post  mortem 
the  posterior  portions  are  found  congested  and  dark, 
while  the  anterior  or  upper  portions  are  quite  light. 
Such  hypostatic  congestion  is  not  at  all  a  marked 
feature  in  atelectatic  lungs  when  respiration  has  not 
taken  place.  Moreover,  in  the  aerated  lung,  on 
scraping  the  section  frothy  blood  is  found;  while  in 

817 


Autopsy,  Medicolegal 
Belations 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


the   atelectatic    lung,     from     which     air     is     absent, 
blood  if  present  in  any  amount  is  fluid. 

The  specific  gravity  of  the  lung  tissue  itself  being 
rather  low,  when  any  air  is  present  in  its  meshes  it 
readily  floats.  This  is  called  the  hydrostatic  test, 
and  is  quite  reliable  under  certain  limitations.  It 
must  be  remembered  that  if  a  lung  or  portion  of  a 
lung  floats,  it  simply  means  that  it  contains  air  or 
gas,  which  may  be  the  air  of  inspiration  or  the  gas  of 
decomposition.  Therefore,  if  decomposition  can  be 
excluded  and  the  lung  floats,  it  is  a  positive  evidence 
of  aeration.  Even  though  decomposition  be  present, 
it  may  still  be  possible  to  determine  the  fact  that  the 
lung  is  aerated;  for  the  gas  is  never  as  finely  dis- 
tributed throughout  the  air  vesicles  as  is  the  air  in  an 
aerated  lung,  but  occurs  in  larger  bubbles  throughout 
the  tissue.  If  after  these  are  pricked  and  the  piece 
of  lung  is  squeezed,  it  still  floats,  it  is  highly  probable 
that  the  lung  is  aerated,  since  it  is  difficult  entirely  to 
squeeze  out  all  the  air  from  aerated  lung  tissue. 
Another  point  in  regard  to  decomposition  depends 
upon  the  fact  that  this  process  develops  earlierin  the 
liver  and  spleen  than  in  the  lung.  If  portions  of 
spleen  or  liver  float,  and  the  lung  does  not,  it  is  posi- 
tive evidence  of  atelectasis. 

All  the  other  tests  are  not  as  reliable  as  the  exami- 
nation of  the  lung  and  the  demonstration,  under  the 
restrictions  given  above,  that  air  is  or  is  not  present 
in  the  stomach  and  intestines.  In  uncommon  cases 
a  child  may  breath  for  a  number  of  hours,  or  even 
days,  and  then  die  with  atelectasis,  usually  partial 
and  only  rarely  complete. 

It  may  be  necessary  to  determine  if  possible  the 
length  of  time  that  the  child  lived.  The  appearance 
of  the  umbilical  cord  with  attached  placenta,  or  of 
only  a  portion  of  the  cord,  in  a  moist  and  white  con- 
dition, is  a  very  reliable  sign  of  a  recently  born  infant. 
The  same  may  be  said  of  the  presence  in  abundance 
of  the  vernix  caseosa.  If,  however,  the  umbilical 
cord  is  dry  and  mummified  this  does  not  neces- 
sarily mean  that  the  child  has  lived  a  number  of  days, 
since  the  same  drying  may  occur  post  mortem.  A 
better  criterion  is  found  in  the  retrogressive  changes 
of  atrophy  in  the  umbilical  arteries,  and  later  in  the 
umbilical  vein.  The  appearance  of  the  umbilicus, 
if  the  cord  has  come  away,  may  not  be  a  reliable 
criterion,  inasmuch  as  it  may  have  been  torn  out  in 
the  fresh  state,  or  may  have  dried  off,  or  have  been 
torn  off  post  mortem.  If,  however,  some  granula- 
tion tissue  is  present,  this  might  be  of  help  in  approxi- 
mately determining  the  age — for  the  cord  usually 
separates  after  the  lapse  of  from  four  to  seven  days. 
The  so-called  fetal  vessels,  besides  the  umbilical 
arteries — namely,  the  umbilical  vein,  the  ductus 
arteriovenosus,  and  the  foramen  ovale — may  remain 
patent  for  a  week  or  two,  so  that  this  does  not  help  us 
in  absolutely  determining  the  age  within  the  first 
week.  The  presence  of  food  in  the  stomach  is  of 
course  a  valuable  sign  that  the  child  has  lived.  The 
caput  succedaneum  is  a  reliable  sign  of  a  recently  born 
child,  and  should  not  be  mistaken  for  an  ordinary 
hematoma. 

In  determining  the  immediate  cause  of  death  special 
care  is  necessary  to  avoid  mistaking  normal  fissures 
and  divisions  of  the  cranial  bones  for  fractures,  and 
also  not  to  misinterpret  the  peculiar  rachitic  growth 
of  bone  both  in  the  skull  and  in  the  long  bones  for 
fractures.  In  cases  of  passive  hyperemia  with  patent 
ductus  arteriovenosus,  a  hematoma  may  form  in  the 
medulla  of  the  suprarenal  gland  and  may  even  rup- 
ture into  the  peritoneal  cavity,  thus  simulating  a 
traumatism.  In  cases  of  melena  neonatorum  an 
effusion  of  blood  may  occur  in  the  stomach  or  in 
the  intestine,  or  in  the  loose  areolar  tissue  about  the 
kidney  and  behind  the  peritoneum. 

Special  care  should  be  used  to  avoid  the  production 
of  artifacts  in  the  removal  of  the  tongue,  fauces,  soft 
palate,  pharynx,   larynx,  etc.,   together,  as  already 


described,  and  a  careful  search  should  be  made  for 
evidences  of  injury  or  lodgment  of  foreign  particles 
or  lacerations  which  ma}'  have  been  produced  by  the 
finger  having  been  passed  into  the  pharynx  to  cut  off 
respiration.  What  has  been  said  about  other  causes 
of  death,  both  traumatism  and  poisons,  applies  of 
course  to  infants  as  well. 

Death  from  Electric  Shock. — The  medicolegal 
importance  of  death  from  lightning  stroke  is  slight. 
Postmortem  appearances  may  be  negative  or  the 
cadaver  may  present  peculiar  arborescent  markings 
of  the  skin,  probably  due  to  vasomotor  paral 
and  subsequent  decomposition.  Internally,  lac 
tions  of  various  organs  have  been  described  and  even 
fractures,  but  the  conditions  are  not  constant. 

Death  from  currents  of  high  electromotive  force 
(fifteen  hundred  to  two  thousand  volts). — The  skin  and 
subcutaneous  tissues  may  be  burned  even  down  to 
the  bone,  in  parts  that  have  come  in  contact  with  the 
wire  or  other  charged  object,  or,  as  has  sometimes 
been  observed,  the  cadaver  may  show  no  external 
signs  whatever.  The  postmortem  conditions  are 
not  sufficiently  characteristic,  unless  such  burns  are 
present,  to  base  a  diagnosis  of  death  from  electric 
current  upon  them.  They  are  practically  the  signs 
that  are  seen  in  other  conditions  producing  asphyxia. 
The  blood  is  fluid,  the  right  side  of  the  heart  being 
filled  and  dilated.  The  left  ventricle  may  be  con- 
tracted. There  may  be  ecchymoses  in  the  endocard- 
ium, in  the  pericardium,  in  the  pleura,  and  rarely  in 
the  peritoneum.  There  may  be  minute  hemorrhages 
in  the  floor  of  the  fourth  ventricle.  The  blood  is 
dark  in  color. 

Death  from  Burns  and  Scalds. — Deaths  in 
conflagrations  are  more  commonly  than  is  generally 
believed  due  to  asphyxia  from  inhalation  of  smoke, 
or  to  actual  burns  of  the  respiratory  passages  and 
acute  edema  of  the  glottis  from  the  inhalation  of 
hot  air  or  flame.  Postmortem  appearances  in  such 
conditions  are  discussed  in  the  section  on  Asphyxia. 
When  death  occurs  from  actual  burns — as  may  happen, 
for  example,  as  a  result  of  a  conflagration — it  will 
be  found  that  the  extent  of  cutaneous  surface  burned 
is  a  more  serious  factor  than  the  mere  depth  of  the 
burn.  Although  recovery  has  occurred  in  cases  in 
which  a  greater  area  has  been  involved,  if  one-third 
of  the  surface  of  the  cutis  is  burned  the  individual 
usually  dies.  The  cause  of  death  in  these  cases  may 
be  shock,  or  it  may  be  due,  judging  from  postmor- 
tem appearances,  to  the  action  of  some  poisonous 
substance  either  absorbed  from  the  wound  surface 
(namely,  some  ptomaine-like  product,)  or  from  the 
invasion  of  bacteria,  or  from  an  autointoxication  due 
to  suspension  of  function  of  the  skin  involved. 
The  heart  muscle  and  the  epithelial  cells  of  the  liver 
and  kidney  present  the  appearances  of  parenchy- 
matous degeneration,  or,  if  death  occurs  somewhat 
later,  of  fatty  degeneration.  It  has  been  reported 
that  round  ulcer  of  the  duodenum  is  a  frequent  accom- 
paniment of  extensive  burns.  It  is  supposed  to  be 
due  to  ecchymosis  of  the  mucous  membrane  and 
subsequent  erosion.  In  many  cases  of  fatal  burns, 
however,  such  ulcers  are  not  found. 

The  external  appearances  of  the  burns  vary  with 
the  degree.  A  burn  that  during  life  has  merely  pro- 
duced erythema  may,  by  reason  of  the  postmortem 
distribution  of  the  blood,  escape  attention  after 
death.  If  the  burn  is  intense  the  spot  may  remain, 
and  forms  good  evidence  of  the  burn  having  been 
produced  during  life.  Even  though  redness  may  have 
vanished,  the  epidermis  may  show  some  change. 
In  burns  of  the  second  degree  vesicles  are  produced, 
serum  exuding  in  the  lower  layers  of  the  epidermis, 
and  lifting  up  the  horny  layer.  These  vesicles  may 
be  small  or  large,  and  after  death  they  may  remain 
unbroken,  and  may  be  surrounded  by  an  area  of 
hyperemia,  or  the  latter  appearance  may  be  absent. 


818 


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Avrrroi's 


f  the  vesicle  has  been  broken,  and  if  this  lias  recently 

iccurred,   the  denuded   corium   underneath   is   moist 

uul  light  in  color,  ami  the  shrivelled  epidermis  may 

,ill  be  partlj-  attached.     If,  however,  the  part   has 

ieen  exposed   to  air  for  a  longer  time  the  denuded 

orium    becomes    dry,    hard,    yellowish    or   yellowish 

irown,  or  dark  brown   in  color,  and   like  leather  or 

larchment    in    consistence.      In    burns   of    the    third 

ree  involving  the  corium  down  to  the  subcutane- 

ius  tissue,  if  recently  produced  by  scalding,  the  ti    tie 

nay  be   white  or  grayish  white,  as  if  cooked,   from 

-illation  necrosis,  or,  if  produced  by  a  burn,  may 

ent  the  appearance  of  having  been  roasted.     The 

le  filled  with  serum  is  a  fairly  good  indication  of 

burn  having  occurred  during  life.     Although  some 

claimed    to    have    been    able    to    produce  such 

les    post     mortem,    in    most  of  the  experiments 

performed  on  the  cadaver  such  vesicles  contain  gas. 

but    not    serum.      When   burns   of    the    third    degree 

e  occurred  during  life,  the  blood  in  the  vessels  is 

immediately  coagulated.     If  a  burn  is  produced  posl 

mortem,  unless  possibly  in  a  dependent  portion  of  the 

adaver,  the  coagulated  blood  will  be  found  only  in 

the    veins   and    capillaries,    and    not   in    the   arteries 

as    well.       Histological    examination   of   such    tissue 

may,    under    these    circumstances,    prove   of   value. 

It     is     said      that       the      network      presented     post 

mortem  by  leathery,  dried-out  burns,  is  due  to  the 

coagulation  of  blood  in  the  vessels,  and  if  the  burn 

been    produced    during    life    such   a  network   is 

very  much  finer  than  if  the  burn  is  produced  after 

death. 

Where  complete  charring  of  the  skin  has  been  pro- 
duced in  conflagrations  spontaneous  rupture  may 
occur,  its  usual  site  being  the  flexor  aspects  of  joints 
and  the  perineum.  Such  spontaneous  lacerations 
have  been  mistaken  for  wounds.  They  present, 
however,  no  reaction,  no  hemorrhage,  and  through 
adipose  tissue  from  one  surface  of  the  laceration  to 
the  other,  vessels  and  nerves  may  pass.  With  the 
charring  of  the  skin,  rupture  not  having  as  yet  occurred, 
a  contraction  and  shrivelling  of  the  tissue  be- 
neath may  take  place.  The  charred  skin  protects 
the  underlying  parts  from  further  charring.  On  this 
account  complete  incineration  at  conflagrations 
3  not  usually  occur.  Besides  a  bursting  of  the 
scalp,  fracture  of  the  bone  or  the  formation  of  holes 
in  the  bone  with  exfoliation  of  burned  bone  after 
charring,  or  in  addition  a  diastasis  of  the  sutures  or 
an  actual  fracture  of  the  skull,  produced  by  the  vapor 
from  the  tissues  within  the  cranium  being  subjected 
to  a  high  degree  of  heat,  may  occur.  Such  conditions 
may  be  mistaken  for  the  results  of  inflicted  violence. 
If  injury  has  been  sustained  during  life  hemorrhage 
occurs,  or  the  tissues  may  become  infiltrated  with 
blood  as  already  discussed.  If  evidence  of  such 
reaction  is  found  the  injury  must  have  occurred 
during  life.  Another  valuable  criterion  is  the  exami- 
nation for  carbon  monoxide  hemoglobin  in  the  blood 
that  has  not  been  exposed  externally.  The  demon- 
stration of  carbon  monoxide  in  the  blood  in 
internal  parts  that  could  not  have  come  in  con- 
tact with  carbon  monoxide  after  death  clearly 
proves  that  carbon  monoxide  was  inhaled.  This 
tesl  may  be  of  value  in  determining  whether  life 
was  extinct  or  not  when  the  individual  was  exposed 
to  the  smoke. 

The  question  may  arise  as  to  the  time  which  must 
have  elapsed  before  the  effects  found  in  charring  of  the 
body  could  have  been  produced.  It  has  been  found 
that  an  hour's  exposure  to  flame  will  cause  a  com- 
plete charring  of  the  soft  tissues,  and  a  further  hour's 
exposure  to  the  heat  of  glowing  embers  will  cause 
calcining  of  the  bones  of  a  newly  born  child.  At 
conflagrations  the  result  is  probably  produced  after 
a  much  longer  exposure.  The  exact  time  might  be 
very  difficult  to  determine. 

The  identification  of  charred   bodies   or  portions 


thereof  may  present  great  difficulties.     The  mat       I 

shrinkage  of  the  tissues  (with  the  exception  I 

due  to  prolonged  exposure  to  heat,  should  !»■  remem- 
bered.     \  ca  e  is  reported  in  which  a  part  found  con- 

i   ted  of  a  pelvis,  clearly  that  of  a  male  adult,  which 
was  embedded  in  a  mass  about   the  size  of  a  man's 

head.  In  it  were  also  found  the  heart,  liver,  coils 
Of    intestine,    and    tl \teinal    genitalia    which 

very  small.     The  organs  presented  an  ap]  '  1 1:1 1 

would  have  led  one  to  estimate  the  age  of  the  sub 

as  between  four  and  six  years.      The  I ■      although 

completely    charred,     may     -till     sufficiently    sustain 

their  form  to  be  a  valuable  guide  in  determining 
probable  age,  or,  at  least,  height  of  the  subject,  and 
the    pelvis    may  aid    in    determining   the  sex  after 

puberty. 

Death    from    Exposure   to  Cold.      Appearances 

due  to  frosl   bite  may  or  may  not  be  present.       Light 

red  spots  of  postmortem  decomposition  are  supposed 
to   be    characteristic   by   some   and    are   denied    by 

others.  The  heart,  and  central  veins  have  been 
described  as  abnormally  filled  with  blood,  this 
being  supposed  to  be  due  to  contracture  of  the  per- 
ipheral part  of  the  vascular  system.  The  diagnosis 
must  be  made  by  exclusion,  and  from  the  circum- 
stances of  the  case. 

Death  from  Starvation-. — The  proof  of  this 
may  be  of  medicolegal  importance,  more  especially  in 
cases  of  children  who  have  been  subjected  to  cruel 
and  inhuman  treatment.  The  blood  is  markedly 
anemic  and  clotted,  and  may  be  quite  thick  in  cases 
in  which  the  subject  has  in  addition  been  deprived  of 
water.  The  heart  may  be  small,  soft,  and  flabby. 
The  liver,  spleen,  and  kidneys  may  be  smaller  than 
is  natural,  from  atrophy.  Stomach  and  small  intes- 
tine may  be  empty,  and  there  is  a  marked  diminution 
of  subcutaneous  fat  and  also  of  internal  fat,  namely, 
in  the  omentum,  mesentery,  perinephritic  tissue, 
and  subpericardial  tissue.  Fat,  however,  is  never 
entirely  absent.  The  external  appearance  of  the 
cadaver  presents  the  characteristic  appearance  of 
marked  emaciation.  Otto   H.   Schultze. 


Avens. — Under  this  name  are  known  various  spe- 
cies of  the  genus  Geinn  L.  (Fain.  Rosacea),  of  which 
there  are  some  thirty  or  forty,  distributed  through 
both  temperate  zones,  especially  the  northern.  By 
Avens  is  generally  understood  the  rhizome  and  root 
of  G.  urbanumLi.,  while  that  of  G.  riralc  L.  is  known 
as  Purple  Avens,  in  allusion  to  the  purple  flowers  of 
the  plant.  G.  virginianum  L.  and  some  others  are 
known  as  White  Avens.  None  of  them  is  much  used 
at  present,  but  they  were  formerly  largely  employed, 
both  in  domestic  and  in  professional  practice,  as 
astringents  and  tonics.  They  contain  volatile  oils, 
amaroids,  and  much  tannin.  The  oil  quickly  disap- 
pears from  them  during  and  after  drying.  The 
combination  of  tannin  and  volatile  oil  (when  fresh  or 
recently  dried)  gives  them  a  much  better  control  of 
summer  diarrheas  than  do  drugs  which  are  astrin- 
gent merely,  and  this  is  their  proper  field  of  usefulness. 
They  are  given  in  doses  of  gr.  xv.  to  ,~i.(1.0  to  4.0). 

II.   II.  Busby. 


Averroes. — Born  in  Cordova,  Spain,  in  the  early 
part  of  the  twelfth  century;  died  in  Morrocco,  Dec. 
12,  1198.  His  true  name  was  Abul  Walid  Mohammed 
ben  Ahmed  ibn  Roshd,  and  he  came  of  a  distin- 
guished Moorish  family.  Averroes  himself  acquired 
considerable  celebrity,  but  rather  as  a  philosopher 
than  as  a  physician.  The  following  remark  is  attrib- 
uted to  him:  "An  honest  man  may  derive  pleasure 
from  the  study  of  the  theory  of  the  medical  art, 

819 


Averroes 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


but  the  practice  of  this  art  should  cause  him  to  trem- 
ble; for,  no  matter  how  well  equipped  with  medical 
knowledge  he  may  be,  it  will  never  be  possible  for 
him  to  ascertain  the  true  relationship  existing  between 
the  patient's  temperament,  the  real  degree  of  severity 
of  his  malady,  and  the  remedy  which  may  advan- 
tageously be  administered."  From  which  remark 
it  may  easily  be  inferred  that  his  published  works  on 


Fig.  539. — Averroes. 


medicine  contain  a  much  larger  proportion  of  theory 
than  of  actual  observation.  However,  we  find  in 
them  for  the  first  time  the  statement  that  one  cannot 
have  smallpox  twice.  A.  H.  B. 

Aviation. — A  fundamental  distinction  between  the 
animal  and  the  vegetable  world  lies  in  the  power  of 
locomotion  which  the  former  somehow  developed  in 
the  process  of  evolution.  The  earliest  locomotion 
was  aqueous,  since  all  life  was  in  the  beginning  marine. 
The  lazy,  plastic  movements  of  the  ameba  and  the 
jellyfish  were  replaced  by  the  more  purposeful  wrig- 
gling of  the  squid  and  then  progressively  to  the 
perfect  and  always  attractive  swimming  of  the  fish. 
Next  came  the  pelagic  reptile  which  could  swim  more 
vigorously  than  the  fish  and  could,  by  reason  of 
improved  respiratory  apparatus,  lift  its  head  above 
the  water  and  breathe  in  the  animal  sense. 

The  recession  of  the  waters  from  the  drying  land 
tempted  the  reptile  upon  the  latter.  Some  reptiles 
continued  to  crawl  on  their  bellies — snake  fashion. 
Others  developed  fins  into  feet,  and  vestiges  of  this 
are  evident  to-day  in  the  web-fingered,  web-footed 
individuals  that  occasionally  turn  up  in  dispensaries. 
Certain  reptiles  now  finding  the  land  pretty  fully 
occupied  (and  that  with  belligerent  neighbors)  by 
endless  patient  and  cunning  adaptation  succeeded 
in  flapping  clumsily  into  the  air,  these  first  ptero- 
dactyls being  the  first  aviators  among  animals;  from 
them  developed  all  bird-life  with  its  wonderful  adapta- 
tions to  the  conditions  of  aerodynamics. 

Space  does  not  permit  a  notice  of  the  development 
of  man  from  the  simian  state  to  his  fashioning  of 
weapons;  his  capture  and  use  of  the  horse,  his  making 
beasts  of  burden  of  this  and  other  creatures;  of  his 
achieving  a  boat  and  making  even  the  winds  of 
heaven  his  servants;  of  his  discovery  of  the  uses  of 
steam  by  which  the  whole  modern  field  of  mechan- 
ics was  developed.  The  discovery  of  the  uses  of 
electricity  and  of  gasoline,  and  the  development  of 
the  motor,  have  made  possible  aviation,  the  latest 
step  in  cosmic  evolution,  at  least  in  so  far  as  the 
earth  and  its  inhabitants  are  concerned. 

Man's  assured  conquest  of  the  air  by  means  of  the 
aeroplane  and  the  dirigible  has  been  and  is  contin- 
gent  upon  the  recognition  of,  and  the  adaption  to, 


conditions  unfamiliar  to  the  race  previous  to  our 
generation.  And  the  situation  has  developed  aspects 
most  important  for  the  physician  to  consider. 

The  aviator  must  accustom  himself  to  an  alto- 
gether unusual  environment.  He  must  maintain 
himself  in  a  medium  compared  with  which  water  is 
solidity  itself — the  inconstant  air  with  her  fitful 
winds,  her  dreadful  vacua,  or  rather  variation  of 
pressure,  and  her  insidious  currents  (the  study  of 
which,  from  the  bird-man's  viewpoint,  has  hardly 
as  yet  begun).  We  marvel  at  the  rapid  flight  of  the 
aeroplane;  it  has  to  be  at  least  as  swift  as  the  fastest 
express  train,  if  it  is  to  keep  in  the  air. 

Aviation  again  requires  three  dimensional  steering. 
All  other  vehicles  (automobiles  and  the  rest)  move  in 
a  single  plane;  except  perhaps  the  bicycle  which 
must  be  both  balanced  and  guided,  but  the  balancing 
gives  no  difficulty  after  the  start,  upon  the  princi- 
ple of  the  gyroscope.  "The  aviator  can  make  mis- 
takes all  around  the  sphere."  He  must  be  constantly 
on  the  watch  lest  disaster  befall  him — lest  a  side- 
way  gust  suddenly  overtake  him,  or  lest  he  drop  all  of 
a  sudden  thousands  of  feet,  as  in  vacuo,  like  a  shot 
fowl.  He  must  listen  anxiously  to  every  sound  from 
a  complicated  motor;  lie  must  manipulate  one  rudder 
for  up  and  down,  another  for  right  and  left,  and  two 
more  at  the  ends  of  the  wings;  and  all  these  intricate 
movements  must  be  coordinated.  And  the  tyro, 
equally  with  the  expert,  must  at  once  attain  and 
maintain,  so  long  as  he  remains  in  the  air,  a  complex 
interrelation  of  mind  and  muscle,  of  psychism  and 
corporeal  engine,  never  before  the  present  genera- 
tion demanded  of  the  human  species.  Is  it  not 
indeed  true  that  aviation  is  developing  a  type  of 
superman? 

Consider  only  this  among  the  many  thrilling  experi- 
ences which  have  been  detailed:  Morane — he  of 
the  French  temperament — decided  "to  go  up  as 
high  as  possible.  When  I  was  up  1,000  meters  I 
began  to  feel  cold,  but  kept  facing  the  sun  as  much  as 
possible  to  keep  warm.  At  2,000  meters  my  motor 
began  to  work  more  feebly;  at  2,600  meters  the  motor 
became  weaker  and  weaker  and  I  felt  I  must  descend. 
On  cutting  off  the  ignition  I  slid  through  the  air  for 
500  meters,  when  I  felt  sick  and  heard  a  buzzing  in 
my  ears.  I  started  the  motor  again  and  after  a  few- 
seconds  repose  I  again  cut  off  the  ignition  and  recom- 
menced planing.  All  went  well,  but  the  speed  was 
too  fast.  At  1,500  meters  I  again  pressed  the  contact 
button;  but  the  motor  refused  to  start  properly. 
There  were  some  explosions,  but  many  misfires. 
My  apparatus  underwent  extraordinaiy  twistings. 
I  was  thrown  over,  sometimes  on  the  right  wing,  and 
sometimes  on  the  left.  This  lasted  for  perhaps  forty 
seconds,  which  I  truly  thought  were  the  last  forty 
of  my  life.  When  the  propellor  finally  came  to  a 
complete  stop  I  was  again  master  of  the  machine. 
I  planed  down  in  an  enormous  circle.  The  landing 
was  perfect;  but  you  can  assure  the  world  that  I 
am  not  in  a  hurry  to  complete  the  experiment." 
And  certainly  once  was  enough  for  any  man  to  have 
ascended  in  a  heavier-than-air  vehicle  one  and  three- 
fifths  miles  into  the  ether  (8,472  feet);  10,000  feet 
has  since  been  achieved. 

What  wonder  is  it  then  that  a  new  disease — 
aviation  sickness — has  developed.  Seasickness  is 
a  terror  to  most  who  venture  upon  the  ocean;  should 
aviation  gain  many  votaries,  air  sickness  is  like  to  he 
an  even  worse  phenomenon.  Many  feel  unpleasant 
even  in  an  elevator,  or  in  a  swing.  Almost  everyone 
has  realized  Poe's  meaning  in  The  Imp  of  the  Pern  rst , 
everyone  who  has  dared  to  stand  upon  the  edge  of  a 
precipice  and  to  look  down  into  the  chasm  below— 
the  resulting  giddiness  and  the  fear  of  falling,  due  to 
a  sense  of  jeopardized  equilibrium.  People  speak 
glibly  of  the  probability  of  aero-traffic  being  an 
accomplished  fact  in  the  near  future.  If  so  the  physi- 
cian will  have  to  know  about  aviation  sickness,  which, 


820 


REFERENCE    HANDBOOK   OF   Till:    MEDICAL    SCIENCES 


\\  on  sulphur  Springs 


•athcr    than    any    defect    in    the    mechanism    of    the 
leroplane,   lias  probably   been   the  cause  of  most   of 
lie  all-too-frequent    deaths  among  bird-men.     To  bi 
;tricken  in  this  way  is  to  lose  control  of  the   machine 
["here  is  nausea,   with  a  swimming  sensation  in  the 
id,  frontal  headache  and  a  desire  to  sleep,  perhaps 
i  lapse  into  unconsciousness.     The  turning  of  sharp 
■ircles    while    descending    would    tend    i"    dizziness, 
chel    and    Monlinier    ("  Le    .Mai    des    Aviateurs," 
i,   pliysiol.  1 1  <li   pathol.  gin.,  lull.   \iii.,  387) 
have  investigated   the   increase   in   blood  pressure  of 
i\  iators  ainr  ascents  to  1,200  to  2,000  meters  (3,937 
to    6,501    feet).      The    blood    pressure    is    invariably 
increased  during  such  a  flight    and   there  is  often  a 
;ht    headache,    together  with   a   tendency   to  sleep. 
lerienced   sometimes  even   during   the   flight,     in 
one   instance,    before    a   flight,    the    constant    radial 
.id   pressure    was    nine    centimeters    (3. .">  1    inches) 
of  mercury  and  the  maximum  pressure  eighteen  cent  i- 
meters  (7. OS  inches)  as  measured  on  a  Pachon  sphyg- 
ueter.      The  pulse  was  seventy.      After  a  twenty- 
minute   flight,   during  which,   at   the   twentieth 
minute,  a  height   of    1,100  meters    (3,009  feet)   was 
reached,    the    constant    pressure    was    twelve    centi- 
meters (4.72  inches)   of  mercury  and  the  maximum 
nineteen  (7.4S  inches) ;  the  pulse  had  risen  to  eighty. 
The  aviators  were  athletes  in  full  training.     The  rise 
in   pressure   was   less    marked   in    fatigued    aviators; 
but   these   showed   cardiac   palpitation   and    marked 
pulse  acceleration  (108).     In  one  case  after  a  flight 
of  an  hour,  in  which  1,000  meters  was  reached,  the 
aviator   manifested    tachycardia — functional    cardiac 
insufficiency  with  vertigo.      Xo  rise  in  blood  pressure 
noted  in  aviators  who  flew  at  altitudes  less  than 
500  feet.     The   cause  of  the  blood   pressure  rise   is 
probably  the  sudden  descent  to  earth,  in  four  to  five 
minutes,  from  heights  of  1,000  to  2,000  meters — in 
one-fourth  or  one-fifth  the  time  required  in  ascending. 
At  2,000  meters  elevation  the  atmospheric  pressure 
i-  591  millimeters  (23.3  inches)  of  mercury  as  against 
760    millimeters    (29.9    inches)    at    sea    level.     The 
circulatory   system   does   not   have   time   to  become 
adapted  to  the  change  of  pressure  when  a  swift  descent 
is  made.     There  is  also  the  dangerous  fatigue  of  the 
circulator}'  apparatus  caused  by  high  flying,  which 
provokes   increased    and    irregular   heart   action.     A 
sound  heart  and  supple  arteries  are  absolutely  essen- 
tial to  aviation.     It  is  considered  that  safety  lies  in 
height  because  the  aviator,  in  case  of  accident,  has 
time  in  which  to  get  control  of  his  machine:  yet  a 
sudden  plunge  from  a  height    of    several    thousand 
fret  is  liable  to  strike  the  aviator  helpless  if  not  uncon- 
scious,  and  therefore  to  seal  his  doom.     An  examina- 
tion of  the  body  of  Maloney,  in  California  in  190"), 
showed  no  broken  bones  or  bruises  sufficient  to  have 
caused  death;  evidently  he  was  stricken  with  heart 
failure  and  died  during  his  descent. 

Other  manifestations  of  vial  des  aviateurs  are 
sensation  of  intense  cold;  desire  to  urinate;  irregu- 
larity in  the  movements  of  voluntary  muscles  and 
reflex  aberrations — probably  the  expression  of  the 
combined  effects  of  cold,  accelerated  heart  beat, 
nervous  tension,  and  fatigue.  On  landing  there  is  an 
intense  sensation  of  warmth  over  the  surface  of  the 
body;  the  face  is  flushed;  the  eyes  "sting."  There 
is  an  almost  invincible  desire  to  sleep.  Some  of  the 
symptoms  noted  in  caisson  workers  find  a  counterpart 
in  those  reported  by  aviators. 

Of  course  only  fit  men  should  take  to  the  air. 
Flights  call  for  continuous  effort,  both  physical  and 
intellectual,  under  conditions  to  which  the  human 
organism  is  not  as  yet  primarily  adjusted.  By  way 
of  prevention  of  all-too-frequent  deaths  some  system 
of  automatic  stability  should  be  invented  (if  such  a 
thing  were  possible)  so  that  an  aeroplane  may  not 
dive  to  earth  should  an  aviator  become  stricken 
while  in  flight.  The  aviator  should,  moreover,  always 
carry  a  parachute,  or  wear  a  parachute  garment  so 


i  hal    he  may  jump  or  i  umbl it  aa  end  to 

earth  in    a  iuld  hi-  machim    !„  come  unman- 

ageable.    \\  here  the  mai  :  than 

250  feel  he  had  best  bi     I  rapped  in,  a    in  B 

ground    the   mosl    danger  is   from   collisions   or 
hoi  i  di\  is,  from  u  hidi  the  a\  iator  is  like  ■ 
uninjured  h   he  cannot  be  flung  oul  when  the  crash 
comes,   or  even   before,   as   was    Moisanl    < 

"'leans,  Johm    B.   Ill 

A\icenna. — Abou  Ali  Ben AbdaUah Ebn Sina,  better 
known  to  the  Western  World,  thi  ransmuta- 

tion  oi  the  last  two  components  of  this  name,  as 
A\  icenna,  was  born  in  Bokhara,  Turkestan,  in  August, 
980  of  the  present  era.  He  studied  medicine  and  phil- 
osophy in  Bagdad,  and  in  dui  time  was  looked  upon 
by  the  Arabs  a  md  Galen;  they  went  so  far, 

in  fact,  as  to  bestow   upon   him   the  appellation  of 


I 


Fio,  540. — Aviceuna. 


Prince  of  Physicians.  His  "Canon  Medicinse,"  a 
Latin  translation  of  which  was  first  printed  in  Padua, 
Italy,  in  1470,  was,  for  several  centuries,  the  standard 
work  on  medicine.  As  a  result  of  his  luxurious  habits 
and  frequent  excesses  Avicenna contracted  a  dysentery 
that  carried  him  off  at  Hamadon,  Persia,  in  the  year 
1038,  at  the  comparatively  early  age  of  fifty-eight 

A.  H.  B. 


Avon  Sulphur  Springs. 

York. 


-Livingston  County,    New 


Post-office. — Avon.     Hotels. 

Access. — There  are  four  railroad  outlets.  The  town, 
located  on  two  branches  of  the  Erie  Railroad,  is  made 
accessible  from  all  points.  Avon  is  in  direct  commu- 
nication with  New  York,  36j  miles  distant,  Rochester 
twenty  miles,  and  Buffalo,  sixty-six  miles.  Man}' 
fine  state  roads  emanate  in  four  directions  from  the 
village. 

The  village  has  a  surpassingly  beautiful  location, 
nestled  as  it  is  in  the  charming  and  picturesque  valley 
of  the  Genesee.  The  springs  are  on  a  somewhat  lower 
level,  about  three-quarters  of  a  mile  from  the  village. 
The  surrounding  country  is  delightfully  interspersed 
with  charming  lakes  and  streams.  The  Avon  Mineral 
Springs  were  known  to  the  Indians  who  resorted  to 
them  for  the  cure  of  skin  diseases  and  so-called  wast- 
ing disorders.  The  use  of  the  Avon  Springs  for  medic- 
inal purposes  by  white  men  dates  from  1792.  Those 
found  to  possess  the  greatest  efficacy  are  known  as  the 
"Upper"  and  the  "  Lower"  spring.  The  "  Congress  " 
and  the  "  Magnesia"  springs  are  also  used  to  some  ex- 
tent, the  latter  being  the  favorite  for  drinking.  The 
following  analyses  show  the  chemical  ingredients  in 
one  United  States  gallon  of  three  of  the  springs: 


821 


Avon  Sulphur  Springs 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Solids 

Upper  spring, 

J.  Hadley, 

analyst 

drains. 

Lower  spring. 

Dr.  Samuel 

Salisbury, 

analyst. 

Grains. 

Ci  ingress 

Hall  spring, 

11.  M.  Baker, 

analyst. 

Grains. 

Calcium  carbonate.  .  .  . 
Sodium  sulphate 

Magnesium  sulphate. 
S  tdium  chloride 

8.00 
16.00 
84.00 
10  00 
IS.  40 

29.33 
13  73 

57    I-' 
49   61 

9  25 

21    02 
27   61 
19.07 
29 . 1 1 

8.41 
Trace. 

Sodium  sulphide. . . .  1 
Calcium  sulphide.  .  .   ) 

99.55 

Total. 


158.50 


_'ll.-,   .11 


Gases. 


Sulphureted  hydrogen 

Carbonic  acid 

Oxygen 

Nitrogen 


Cubic  inches.   Cubic  inches.   Cubic  inches. 


12.00 
5.60 


Total. 


10.02 
3.92 

0 .  56 
5.42 


19.92 


27.63 

22  H4 

0.97 

3.88 


54.52 


The  well  or  New  Bath  Spring  was  discovered  by 
R.  K.  Hickok  in  1S35,  while  digging  for  pure  water. 
The  soil  through  which  the  excavation  was  made  is 
hard  blue  clay,  having  a  strong  sulphurous  odor. 
The  temperature  of  this  water  is  46°  F. 

Long's  Spring  has  been  in  use  since  1833.  It 
rises  from  the  surface  of  an  alluvial  deposit  through 
the  center  of  which  passes  what  is  termed  Black 
Creek,  a  small  stream  having  its  rise  some  miles  to 
the  south.  It  is  about  a  mile  southwesterly  from  the 
upper  spring. 

Following  are  the  analyses  of  these  two  springs: 


New  Bath  spring,  Long's  spring, 

Dr.  L.  C.  Beck,  Dr.  J.  R.  Chilton, 

analyst.  analyst. 

Grains.  Grains. 


8.08 

3.52 
3S.72 

13.10 
109.05 

3.27 

19.31 

5. 68 

57.89 

27.09 

26.96 

2.45 

.81 

Total 

82.96 

232.97 

Gases. 

Cubic  inches. 

Cubic  inches. 

Sulphureted  hydrogen 

31.28 

43.58 
5.87 

These  waters  are  of  the  saline-calcic,  sulphocar- 
bonated  variety.  The  chemical  constituents  of  the 
magnesia  spring  are  believed  to  be  quite  similar  to 
those  of  the  lower  spring,  with,  however,  a  greater 
proportion  of  magnesium  sulphate.  In  consequence 
of  the  considerable  proportion  of  this  ingredient  the 
latter  two  springs  have  valuable  laxative  and  pur- 
gative properties.  They  thus  become  useful  in  dis- 
orders of  the  gastrointestinal  tract  accompanied  by 
torpor  of  the  liver  and  constipation.     The  water  also 


produces  an  increased  activity  of  the  functions  of  the 
skin,  and  free  diaphoresis  often  ensues.  The  water 
also  possesses  antacid  properties  and  has  been  found 
of  special  benefit  in  cases  of  dyspepsia  attended  bv 
flatulence,  heart-burn,  and  gastric  catarrh.  Both 
internally  and  in  the  form  of  baths,  these  waters  have 
been  found  beneficial  in  cases  of  obstinate  rheuma- 
tism, diseases  of  the  urinary  tract,  and  in  various  skin 
disorders.  Facilities  for  all  kinds  of  hot.  cold,  and 
electric  baths  are  supplied.  Emma  E.  Walker. 

Axilla. — See  Shoulder. 

Azedarach. — Pride  of  China  or  India.  China- 
berry  Tree;  China-tree.  The  bark  of  the  root  of  Melia 
azedarach  L.  (fam.  Meliaceoe).  This  is  a  fine,  medium- 
sized,  ornamental  tree  from  India,  but  long  cul- 
tivated in  all  the  warmer  parts  of  the  world. 
It  has  delicate,  twice  pinnated  leaves,  fragrant 
clusters  of  lilac-colored  flowers,  and  yellow  globose 
fruits  of  the  size  of  small  grapes.  Azedarach  has  been 
occasionally  used  for  one  or  another  purpose  in  various 
countries  where  it  grows,  and,  in  deference  to  a  slight 
reputation  in  the  Southern  States  was  some  time 
ago  admitted  to  the  Pharmacopoeia.  It  is  now, 
however,  excepting  as  an  extemporary  country 
medicine,  nearly  obsolete.  The  bark  of  the  roi 
thus  described:  "Incurved  pieces  or  quills,  varying  in 
size  and  thickness;  outer  surface  red  brown,  with 
irregular,  blackish,  longitudinal  ridges;  inner  surface 
whitish  or  brownish;  longitudinally  striate;  fracture 
more  or  less  fibrous:  upon  transverse  section  tangen- 
tially  striate,  with  yellowish  bast  fibers;  almost  in- 
odorous, sweetish,  afterward   bitter  and   nauseous." 

It  contains  a  whitish-yellow  resin,  which  is  claimed 
to  be  the  active  principle. 

Azedarach  disturbs  the  digestive  tract,  causing,  in 
large  doses,  vomiting  and  diarrhea.  It  is  a  fatal  nar- 
cotic poison  in  still  larger  ones,  but  its  qualities  are  not 
well  known.  It  is  usually  given,  however,  for  intesti- 
nal worms  in  decoction,  or  in  syrup  of  the  fresh  root. 
Dose,  four  to  eight  grams  oi.  to  ij.(4.0  to  8.0). 

Birds  become  stupefied  by  eating  the  berries,  and 
fatal  cases  of  poisoning  by  the  seeds  have  occurred  in 
India.  H.  H.   Rusby. 


Azores. — The  Azores  or  Western  Islands  lie  about 
2,000  miles  from  Boston,  1,400  miles  from  the  Lizard 
Point,  in  England,  and  800  from  the  coast  of  Portugal, 
of  which  they  are  a  possession.  The  islands  are  nine 
in  number  and  are  divided  into  three  distinct  groups, 
about  one  hundred  miles  apart:  Santa  Maria  and  San 
Miguel  forming  the  southeastern  portion,  Flores  and 
Corvo  the  northwestern,  and  the  remaining  five  the 
central  division.  The  total  area  of  the  islands  is 
about  1,000  square  miles,  and  the  population  is  esti- 
mated at  300,000.  San  Miguel  is  the  largest  island, 
being  forty  miles  long  and  ten  broad.  Fayal  and 
San  Miguel  are  the  two  islands  which  are  generally 
visited  and  with  which  there  is  the  best  communica- 
tion. One  can  reach  them  by  steamers  from  New 
York  and  Portugal,  and  from  Boston.  The  whole 
system  of  islands  is  of  volcanic  origin,  and  their  out- 
lines in  consequence  are  rugged  and  picturesque. 
The  coast  line  is  precipitous,  and  the  central  portion 
of  each  island  rises  in  mountain  peaks,  which  vary  in 
height  from  1.SS9  feet  (San  Miguel)  to  7,613  feet 
(island  of  Pico).  There  are  no  natural  harbors,  and 
vessels  lie  in  the  open  roadstead  off  the  principal  ports. 
A  breakwater  has  been  under  construction  for  a  long 
time  at  San  Miguel,  but  it  is  not  yet  completed. 

The  vegetation  is  rich  and  luxuriant,  and  both 
tropical  and  subtropical  fruits — the  fig,  orange, 
banana,  loquot,  pineapple,  prickly  pear,  guava,  pome- 
granate, and  lemon — grow  in  the  open  air.  Flowers 
bloom  in  nearly  infinite  variety,  and  the  gardens  of 
San   Miguel   and   Fayal   contain   an   almost   endless 


822 


REFERENCE    HANDBOOK    OF    Till"    Ml  DI(   \l.    S(  [ENCES 


Back,  Diseases  and  injuries  <>f 


iversity   of   tree,   flower,   and  fruit.     There  an-   no 
•wer  than  forty  plants  peculiar  to  the  islands.      Be- 
-    these    there   are   about     100   species   which    are 
iund  in    Europe,   and  340  which  are  not  found   in 
ipe,    but    are   common    to    Madeira,    the   Canary 
Is,  and  the  Azores  (  Roundell). 
The  climate  is  a  mild  and  moist   marine  one,  and 
cry  equable  at   all  seasons  of  the  year.     The  mean 
niiual     temperature     is    ti'2J    F.      The    extremes    are 
;  to  be  Sti°  and  45°  F.     The  range  between  win- 
in, I  summer  is  from  10°  to  15°.      The  night   tem- 
■  uro    is    generally   not   more    than    four    degrees 
■■  than  the  day.      The  summer  is  enervating  at 
,  and  one  is  drenched  with  perspiration  on  the 
lightest  exertion.     The  mean  temperature  for  winter 
58     for  spring  61°,  for  summer  68  .  and  for  autumn 
1  .      The  three   coldest  months   are   usually   Janu- 
nv.  February,  and    March.     In  winter  it  sometimes 
chilly  and  damp,  and  one  seldom  leaves  home 
without  an  umbrella.     The  humidity  is  so  great  that 
rail-paper  will  not  adhere,  and  the  veneering  of  fur- 
liture  strips  off.     The  mean  annual  relative  humidity 
cinv— ix  per  cent,  and  for  winter  it  is  seventy- 
n   per   cent.     The   mean   animal   rainfall   is   38.5 
5.      The  wind  blows  with  great  force  at  timi  s 
ind    there    are    frequent    storms. 
Ponta  Delgada,  in  San  Miguel,  is  the  largest  city  of 
islands.     It  has  a  population  of  25,000  inhabi- 
-.     There    are    a  good  theater,  a  public  library, 
lers  of  fine  gardens,  ancient  churches  and  govern- 
ment   buildings,     public    markets,    etc.     There    are 
fortable  accommodations  here  as  well  as  at  Horta. 
principal  town  of  Fayal,  and  the  food  is  generally 
Twenty-seven  miles  from  Ponta  Delgada  by 
triage  road,   through   beautiful  and   wild    scenery, 
le  Valle  das  Furnas,  where  are  hot  sulphur  springs 
temperature  of  from  56°  to  212°  F.     All  contain 
sulphur,  iron,  alum,  and  silica  in  varying  proportions. 
Besides  the  public  bath  houses,  built  by  the  Govern- 
ment  and  free  to  all,   there  are  also  private  baths. 
The  bath  tubs  are  cut  out  of  solid  limestone  or  lava 
reck,  and  have  taps  for  hot  and  cold  water,  the  hot 
coming  from  the  sulphur  spring,  and  the  cold  from 
the    water    impregnated    with    iron.     The    bathing 
in  begins  in  June  and  lasts  for  six  months,  dur- 
ing which  time  a  large  number  of  people  frequent  Las 
Furnas.     The  general  custom  is  to  hire  lodgings  and 
to  take  meals  at  the  hotels.     The  various  diseases  for 
which  these  springs  are  beneficial  are  chronic  rheuma- 
tism, which  is  almost  invariably7  benefited;  paralysis, 
syphilis,  skin  diseases  (especially  eczema),  dyspepsia, 
and  internal  troubles. 

Las  Furnas  itself  is  situated  in  the  valley  of  the 
Furnas,  which  is  the  bottom  of  a  vast  crater  of  an 
extinct  volcano.  In  this  valley  are  the  various  boil- 
ing springs,  with  masses  of  white  vapor  hanging  over 
them.  A  roaring  noise  is  heard,  as  the  hot  gases 
le  from  the  earth.  The  Caldeira  Grande  supplies 
the  sulphur  water  to  the  baths,  and  is  enclosed  by  a 
wall  some  six  feet  in  height.  The  water  in  this  tank- 
like enclosure  boils  in  a  most  furious  manner  and  with 
a  great  noise.  It  furnishes  nineteen  gallons  per 
minute  (Roundell).  The  ground  about  is  covered 
with  patches  of  white  sulphur  and  alum,  streaked 
with  orange  and  red.  In  another  part  of  the  valley  is 
the  Boca  do  Inferno,  or  "  Mouth  of  Hell,"  a  dark  pit  of 
unknown  depth  filled  with  boiling  mud,  constantly- 
thrown  up  with  a  great  smoke  and  noise.  This  mud 
is  collected  by  the  people  and  used  as  an  external 
application  in  skin  diseases.  All  the  geysers  or 
springs  are  said  to  boil  most  furiously  when  the  wind 
is  east. 

So  far  as  the  climate  in  general  of  these  islands  is 
concerned  it  is  applicable  to  such  cases  as  require  a 
mild,  equable,  moist  climate.  It  is  therefore  suitable 
for  patients  who  are  suffering  from  neurasthenia, 
from  Bright's  disease,  from  nervous  affections,  from 
hay  fever,  etc.,  and  for  those  who  are  convalescing 


from    the    grippe    and    from    other    acute 
The  water  supply  is  from  springs,  wells,  and 

and  i^  generally  good. 

From  a  personal  visil  to  Fayal  and  Pico,  the  writer 
can  testify  to  the  charm  and  fascination  of  these 
strange    islands    with    their    ancii         and    primit 

uis,  beautiful  scenerj  .  and  I  ful  and  ever- 

varied  walks,  drives,  and  excut  ioi  0  -in  hardly 
conceive  of  a  more  entrancing  place  for  the  lover  of 
nature,  or  one  more  restful  and  refreshing  for  the 
weary  and  overworked.  The  only  drawback  is  the 
long  journey  there,  which  is  almost  prohibitory  to  a 
sufferer  from  sea-sickness. 

I  ■>!■  a  very  interesting  and  extended  account  of 
these  islands  the  reader  is  referred  to  Mi  .  Charles 
Roundell's  "A  Visil  to  the  Vzores, "  and  also  to  the 
two  papers  by  Canfield  and  Junkin  on  "  The  Azores  as 
a  Health  Resort."  Edward  O.  Otis. 

Azule  Springs. — Santa  Clara  County,  California. 
Location,  twelve  miles  wesl  of  San  JosI,  in  the  foot- 
hills of  the  Santa  Cruz  Range  of  mountains,  900 
feet  above  sea  level. 

Access. — Electric  cars  run  from  San  Jos<5  to  ' 
gress  Springs,  one  and  one-half  miles  from   there  to 
Azule.     Trains    on    the    Southern    Pacific     Railroad 
from  San  Francisco  to  Santa  Cruz  stop  on  signal  at 
Azule  Station,  two  and  one-fourth  miles  from  Azule. 

The  following  analysis  was  made  some  years  since 
by  James  Howden,  State  Chemist: 

One  Gallon-  of  "Water  Contains: 

Grains. 

Sodium  chloride 90  ss 

nesium  chloride 18    18 

Potassium  chloride r_'    14 

Magnesium  carbonate 77  20 

Sodium  carbonate 50  ^ 

<  :t Uium  carbonate 9.00 

Free  carbonic  oxide 152.24 

Total 431 .  12 

This  is  a  natural  seltzer  water.  The  water  pos- 
sesses antacid,  aperient,  diuretic,  and  tonic  properties. 
There  are  cottages  for  rent,  and  camping  privileges. 

Emma  E.  Walker. 

Babesia. — Pyroplasma,  Pirnplasma.  A  pathogenic 
genus  of  Sporozoa,  order  Hiemosporida.  B.  hominis 
causes  Rocky  Mountain  tick  fever,  "spotted  fever.  " 
or  " piroplasmosis  hominis"  in  man  This  disease 
appears  to  be  local  in  distribution,  occurring  in 
spring  and  early-  summer  in  the  mountains  of 
Montana  and  Idaho,  and  may  be  transmitted  to 
man,  rabbits,  guinea-pigs,  and  monkeys  by  ticks. 
The  Texas  cattle  fever  is  caused  by  B.  biaeminum 
a  sporozoan  carried  by  the  tick,  Boophilus  bovis.  In 
this  case  some  of  the  blood  sucked  by  the  mother  is 
enclosed  with  the  eggs  she  lays  so  that  young  are 
born  with  the  fever  infection  if  the  blood  contained 
it.  East  Coast  feyrer  is  caused  by  a  similar  sporozoan. 
See  Protozoa.  A.  S.  Peakse. 

Bacillus. — A  genus  of  the  family  Baeteriacea?,  com- 
prising cylindrical  rod-shaped  or  oval  forms,  with 
peritrichal  flagella,  often  with  endospores.  Division 
occurs  in  the  transverse  plane  and  the  individual  cells 
may  remain  attached,  forming  chains  or  threads  of 
varying  lengths.  The  term  bacilli  is  often  incorrectly 
used  to  denote  the  Schizomycetes,  or  fission-fungi,  in 
general. 

Back,  Diseases  and  Injuries  of  the. — In  wounds 
and  injuries  of  the  back,  as  in  those  of  the  chest  and 
abdomen,  we  have  to  consider  first,  the  injury  inflicted 
upon  the  superficial  tissues,  and  secondly,  that 
sustained  by  the  subjacent  organs.  The  wounds  of 
the  superficial  structures  present   no  characteristics 

823 


Back,  Diseases  and  Injnri.-  of 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


peculiar  to  this  region.  The  back  is,  however,  by 
reason  of  its  numerous  articulations,  very  liable  to 
sprains.  These  may  vary  greatly  in  degree,  and 
since  it  is  impossible  always  to  determine  at  the 
moment  how  serious  the  injury  may  have  been,  a 
sprain  of  the  back  should  never  be  neglected,  but 
should  be  watched  and  treated  as  though  it  were  an 
important  affair  until  its  true  nature  is  ascertained. 
The  spinal  ligaments  may  be  simply  strained,  or  they 
may  be  ruptured;  or  an  injury  of  the  back,  which 
may  at  first  seem  of  comparatively  slight  moment, 
may  be  accompanied  with  fracture  or  dislocation  of  a 

vertebra,  with  con- 
sequent compres- 
sion or  concussion 
of  the  cord;  or 
compression  may 
be  caused  by  hem- 
orrhage within  the 
canal.  The  loca- 
tion of  the  sprain 
may  be  indicated 
by  a  swelling,  or 
there  may  be  no 
external  evidence 
whatever  of  in- 
jury. Sprains  in 
the  lumbar  region 
are  not  infre- 
quently followed 
by  hematuria,  but 
this  symptom,  al- 
though apparently 
so  serious,  is  usu- 
ally of  little  mo- 
ment and  disap- 
pears without  any 
further  complica- 
tion. The  treat- 
ment of  simple 
sprains,  without 
injury  to  the  cord, 
is  essentially  rest 
in  bed  with,  later, 
coun  terirritation 
over  the  affected 
region. 

Neuroses  of 
varied  character 
are  very  liable  to 
follow  concussion 
or  other  violence  applied  to  the  spine.  The  fre- 
quency with  which  nervous  symptoms  follow  spinal 
injuries  received  in  railway  accidents  led  Erichsen  to 
apply  the  term  "railway  spine"  to  such  conditions. 
Whether  the  resultant  neurosis  is  spinal  or  mental 
in  essence  is  still  sometimes  a  matter  of  dispute,  with 
the  weight  of  opinion  inclining  to  the  latter.  (See 
Neuroses,  Traumatic.) 

Penetrating  wounds  of  the  back  are  serious  because 
of  the  injury  inflicted  upon  the  internal  organs.  In 
determining  what  organs  may  have  suffered  in  any 
particular  case,  if  we  leave  out  of  consideration  for 
the  moment  the  direct  evidence  afforded  by  the  symp- 
toms, it  is  necessary  to  ascertain  the  nature  of  the 
wounding  object,  whether  a  knife,  a  bullet,  etc.,  and 
also  the  direction  of  the  wound.  If  a  knife  or  other 
sharp  instrument  have  been  used,  it  should,  if  possi- 
ble, be  ascertained  how  deeply  it  has  penetrated,  and 
whether  the  blow  was  struck  from  above,  from 
below,  or  laterally;  and  if  it  be  a  gunshot  wound, 
whether  the  weapon  was  discharged  at  close  quarters, 
or  whether  the  ball  was  nearly  spent  before  pene- 
trating the  back.  It  must  not  be  forgotten  also  that 
the  course  of  a  bullet  is  often  very  erratic,  and  that, 
while  it  has  seemingly  penetrated  the  abdominal  or 
thoracic  cavity,  it  may,  in  reality,  have  glanced  along 
a  rib  and  be  lodged  in  the  muscles  on  the  other  side  of 


Fig.  541.— The  Relations  of  the  Thor- 
acic and  Abdominal  Viscera,  as  seen  from 
Behind.  The  stars  indicate  the  location 
of  the  spinous  processes  of  the  seventh 
cervical,  fourth  and  ninth  thoracic,  and 
third,  and  fi.th  lumbar  vertebne.  (Modi- 
fied from  Quain.) 


the  back,  or  anteriorly.  The  position  of  the  person 
at  the  time  the  injury  was  received  is  also  to  be  con- 
sidered,  since,  when  he  is  in  the  recumbent  position  or 
when  stooping,  the  liver  and  some  of  the  other  organs 
are  higher  than  when  the  person  is  sitting  or  standing 
erect.  And  another  point  to  be  determined  in  certain 
cases  is  the  time  at  which  the  wound  was  received, 
whether  after  a  hearty  meal  or  while  the  individual 
was  fasting.  Fig.  541  represents  diagrammaticaJly 
the  ordinary  position  of  the  thoracic  and  abdominal 
viscera,  but  of  course  only  in  a  very  general  way. 

The  movements  of  the  back  are  chiefly  in  an 
anteroposterior  and  lateral  direction,  though  a  slight 
amount  of  rotation  is  also  possible.  In  the  upper 
portion  but  little  motion  of  any  character  takes  place, 
and  it  is  in  the  lumbar  region  chiefly  that  flexibility 
exists.  A  "'stiff  back"  may  be  due  to  chronic 
rheumatic  arthritis  of  the  spine,  to  Pott's  disease,  to 
spinal  ankylosis,  to  inflammation  or  rheumatism  of 
of  the  spinal  or  abdominal  msucles,  to  psoitis,  or  to  a 
sprain. 

Pain  in  the  back  is  a  common  symptom,  and  may 
be  due  to  any  one  of  a  variety  of  conditions,  as  6.3. 
neurasthenia,  muscular  rheumatism,  rhachialgia, 
Pott's  disease,  nephritis,  cystitis,  renal  or  vesical 
calculi,  an  accumulation  of  gas  in  the  intestines, 
uterine  disease,  myositis,  or  hysteria.  (See  Lumb 
and  Spine,  Diseases  of  the.) 

The  back  is  frequently  the  seat  of  tumors  and  other 
swellings,  the  nature  of  which  it  is  important,  while 
at  the  same  time  not  always  easy,  to  determine.  V,  e 
have,  in  the  first  place,  the  ordinary  fatty  and  fibrous 
tumors,  naBvi,  epitheliomata,  and  sarcomatous  and 
sebaceous  tumors  (the  last  two  rarely),  the  diagnosis 
of  which  offers  nothing  peculiar  in  this  region.  Spi 
bifida  is  a  not  very  uncommon  affection,  and  is  usually 
not  difficult  of  diagnosis.  (See  Spina  Bifida.)  Ab- 
scesses of  the  back  are  by  no  means  rare.  They 
be  idiopathic,  or  the  result  of  traumatism,  or  the  pue 
from  an  empyema  may  point  posteriorly.  It  should 
not  be  forgotten  that  an  abscess,  pointing  in  the 
back  or  elsewhere,  may  be  referable  to  spondylitis 
even  though  there  be  no  angular  curvature  visi 
The  kyphos  of  Pott's  disease  can  hardly  be  mistaken 
for  anything  else,  but  in  lateral  curvature  with  so- 
called  rotation,  the  resulting  prominence  of  the 
muscles  on  the  side  of  the  convexity  might,  if  ci 
lessly  inspected,  be  taken  for  a  tumor.  Sometimes 
this  apparent  tumor  is  at  some  distance  from  the 
spine,  and  is  the  expression  of  a  secondary  deformity 
and  bulging  of  the  ribs. 

The  back  is  the  ordinary  seat  of  bed-sores,  whether 
occurring  from  pressure  or  of  neurotic  origin.  There 
is  no  other  condition  with  which  a  bed-sore  is  liable 
to  be  confounded,  though  it  is  not  always  an  easy 
matter  to  discriminate  between  the  different  varic 
of  this  distressing  affection.     (See  Decubitus.) 

Diseases  of  the  skin  and  muscles  of  the  back  do  not 
differ  in  any  essential  points  from  similar  affections  in 
other  parts  of  the  body,  and  their  consideration 
need  not  therefore  be  entered  upon  here. 

T.  L.  S. 


Bacon,  Francis. — Born  at  New  Haven,  Connec- 
ticut, October,  6,  1831.  His  father  was  a  distin- 
guished theologian,  Rev.  Dr.  Leonard  Bacon.  He 
studied  medicine  at  the  Yale  Medical  School,  and 
received  the  degree  of  Doctor  of  Medicine  from  that 
institution  in  June,  1S52.  Very  soon  after  the 
termination  of  his  medical  course  he  went  to  Galves- 
ton, Texas,  where  he  had  charge  of  the  hospital  of 
that  city.  He  remained  there  for  several  years, 
until  the  outbreak  of  the  Civil  war. 

During  the  Civil  War  he  served  first  as  Assistant 
Surgeon,  and  afterward  as  Surgeon,  in  one  of  the 
Connecticut  regiments.  He  was  then  appointed 
Medical  Inspector  in  the  Department  of  the  Potomac, 


824 


REFERENCE    II. WDM <    <  U-    Till:    MLDICAL    scl  i:\TES 


Bacteria 


and,  still  later,  Medical  Director  of  the  Department 
of  the  Gulf,  with  headquarters  at  New  Orleans. 
\t  the  close  of  the  war  he  resigned  his  commission 
:i  id  returned  to  New  Haven,  having  been  invited  to 
fill  the  Chair  of  Surgery  in  the  Vale  Medical  School, 
upon  the  retirement  of  Dr.  Jonathan  Knight.     In  1906 

University  conferred    upon   liim    the   hono 
title  of  Doctor  of  Science.     He  died  in  New  Haven 
on  Vpril  26,  1912. 

Dr.  Bacon  made  very  few  contributions  to  medical 
literature.  He  was  not  fond  of  writing,  and  his  very 
large  surgical  practice  left  him  scarcely  enough  time 
for  needed  rest  and  recreation.  The  various  official 
positions,  however,  which  he  held — first  during  the 
Civil  war  and  afterward  during  his  life  in  Nev 
Haven — testify  sufficiently  to  his  ureal  ability  as  an 
executive  officer  and  as  a  surgeon,  and  to  the  high 
esteem  in  which  he  was  held  by  his  professional 
brethren  and  by  his  fellow  citizens. 


Bacon,  Francis,  Baron  Verulam,  Viscount  of 
Saint  Albans.  —  Born  in  London,  January  22,  1561. 
His  lather,  a  celebrated  jurist  and  one  of  the  most 
influential  advisers  of  Queen  Elizabeth,  gave  him 
every  possible  educational  advantage.  From  his 
earliest  childhood  young  Bacon  manifested  unmis- 
takable evidences  of  possessing  a  mind  of  a  superior 
order.  During  his  course  of  studies  at  the  University 
of  Cambridge  he  made  astonishing  progress  in  all  the 
departments  of  learning.  Already  at  the  early  age  of 
sixteen  he  displayed  remarkable  independence  of 
character,  as  evidenced  by  the  fact  that,  in  complete 
disregard  of  the  philosophical  views  held  at  that  time, 
he  did  not  hesitate  to  begin  laying  the  foundal 
of  a  new  general  system  of  philosophy — the  one, 
namely,  which  subsequently  brought  him  imperish- 
able fame.  After  completing  his  university  career 
in  1576,  he  visited  Paris  in  company  with  Sir  Amyas 
Paulet,  Queen  Elizabeth's  ambassador  at  the  Court 
of  Trance,  remaining  there  until  the  death  of  his  father 

in  1579.  While  he 
was  still  in  Paris,  be- 
ing then  not  nineteen 
y.ars  of  age,  Bacon 
began  writing  his 
essay  On  Life  and 
Death,  "  Historia  vitae 
et  mortis"  (not  pub- 
lished, however,  until 
1623  in  London)— 
that  one  of  his  treat- 
ises which  touches 
more  especially  on 
purely  medical  science 
than  does  any  other 
of  his  writings.  The 
Dictionnaire  Histor- 
ique  de  la  Medecine 
makes  the  following 
analysis  of  this  essay: 
"In  animated  bodies 
there  exists,  as  Bacon 
assumes,  a  spirit  which  is  purer  than  air  and  less  ener- 
getic than  fire,  and  which  is  held  fast  in  the  tissues  by 
substances  of  a  viscous  nature.  This  spirit  (or  prin- 
ciple of  life)  gradually,  in  the  course  of  time,  consumes 
the  bonds  which  hold  it  fast  and  is  thus  eventually  and 
Completely  set  free — this  is  the  direct  cause  of  natural 
death.  One  may  hope  to  prolong  life  by  moderating 
all  vital  activities,  by  avoiding  the  different  impressions 
made  by  the  air,  by  restoring  the  humors  of  the  body 
to  their  normal  state,  by  bringing  back  to  the  viscera 
the  vital  spirit  which  they  may  have  lost,  and  by 
closing  the  pores  or  channels  through  which  it  tends 
to  make  its  escape.  These  ends  may  be  attained  by 
a  proper  degree  of  repose,  by  a  somewhat  debilitating 
regimen  or  diet,  and  by  the  use  of  the  two  drugs — 


Fig.  542. — Francis  Bacon. 


and  opium.      I  bi  ii    Bacon  cites,  in  Bupporl  of 
I  heory,  mi  tances  of  m 

great    longer  ity.     He  also  i  ntion 

to  thi   fact  that  the  longest  duration  of 
in  those  animals  which  have  a  long  period  ol  ge  'at  ion 
and    which   are   alow   in  attaining  their  full  growth. 
I  i'  illy,  he  describes  t  he  < Mil.  Is  oi  life,  and 

i  xplains  the  phenomena  of  death. 

The    most    important    of    Bacon's    works    wire,    in 
addition    to   those    j  tioned,    "The     '■ 

on  hi   of   Learning."   1605;   "Novum   Organum, 
indicia    vera    de    interpretatione,"    1620;    and    "De 
Augmentis  Scientiarum,"    L624,   the  latter  being  an 
id  ami  revised  Latin  translation  of  the  earlier 

work  mi  "The  Advance nt  of  Learning." 

Bacon  died  April  9,  1626.  A.  II.  B. 


Bacteria,  Pathogenic. — The  Schizomycetes  or  Bac- 
teria are  among  the  smallest  and  at   the  same  time  the 

most  int  cresting  of  all  known  living  organisms.     \\  hile 

most    bacteria   are   harmless — some  of   them,    indeed, 

being  of  the  greatest   use  in  ll 'otiomy  of  nature, 

by  producing  the  decomposition  of  dead  animal  and 
vegetable  matter,  without  which  life  on  the  earth  would 
be  impossible — others  are  the  cause  of  various  infec- 
tious diseases  in  man  and  animals.  Bacteria  are 
very  widely  distributed  in  nature,  and  are  present 
in  the  air,  water,  soil,  and  also  in  the  food  and 
bodies   of   animals. 

Historical  Review  of  the  Development  of 
Bacteriologt. — Although  most  of  the  important 
discoveries  of  bacteria  in  their  relation  to  disease  are 
of  comparatively  recent  date,  from  the  earliest  days 
of  medicine,  and  long  before  these  microorganisms 
were  known  to  exist,  minute  living  germs  were  thought 
to  be  concerned  in  the  production  of  many  disea 
Before  entering,  therefore,  into  a  detailed  considera- 
tion of  pathogenic  bacteria,  it  may  be  interesting  and 
instructive  to  review  briefly  the  more  important 
-tips  which  lead  up  to  the  development  of  bacterio- 
logy as  a  science. 

The  first  authentic  observations  of  living  micro- 
organisms of  which  there  is  any  record  are  those  of 
Athanasius  Kircher,  a  Jesuit  priest,  in  1659.  The 
compound  microscope  dates  from  1590,  but  this 
observer  was  the  first  to  find  in  putrid  meat,  milk, 
vinegar,  cheese,  etc.,  minute  living  organisms  or 
"worms,"  invisible  to  the  naked  eye,  which  he  con- 
cluded must  be  the  cause  of  putrefaction.  Kircher, 
however,  did  not  describe  the  form  or  character  of 
these  "little  worms,"  and  with  the  microscopes  in 
use  in  his  day  he  probably  did  not  see  bacteria,  as  we 
now  understand  them.  Nevertheless,  his  observa- 
tions seemed  to  substantiate  the  view-  that  infective 
diseases  might  be  caused  by  .substances  which, 
introduced  into  the  body,  give  rise  at  first  to  no  symp- 
but  increase  till  they  bring  about  disease;  the 
opinion  held  at  that  time  by  many  physicians  being 
that  if  putrefaction  is  produced  by  living  organisms 
outside  the  body,  when  these  organisms  are  found 
in  the  blood,  etc.,  they  must  necessarily  cause  putre- 
faction there  also. 

Not  long  after  this,  in  1675,  Anthony  van  Leeuwen- 
hoek,  a  citizen  of  Delft,  Holland,  a  linen  draper  by 
trade,  who  practised  the  art  of  grinding  and  polishing 
lenses,  constructed  a  microscope  with  which  he  was 
able  to  observe  in  rain  water,  in  putrid  infusions,  in 
human  saliva,  in  intestinal  evacuations  of  man  and 
animals,  and  in  the  scrapings  between  the  teeth, 
numbers  of  living  "animalculae"  as  he  called  them, 
varying  in  form  and  size  and  in  the  character  of  their 
motion.  Of  these  he  gave  descriptions  and  drawings 
which  are  remarkable  for  their  accuracy,  considering 
the  imperfect  optical  instruments  at  his  command, 
and  there  is  little  doubt  that  he  really  saw  some  of  the 
larger  species  of  bacteria,  probably   spirilla.     Leeu- 

825 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


wenhoek  made  no  attempt  to  assign  any  importance 
to  these  organisms  regarding  the  role  they  might 
play  in  relation  to  disease,  his  work  being  conspicuous 
for  its  purely  objective  and  unspeeulative  nature. 
But  his  contemporaries  and  those  who  immediately 
succeeded  him  seized  upon  the  idea  of  these  animal- 
cules causing  a  great  number  of  diseases,  even  in 
cases  in  which  they  were  not  found,  reasoning  from 
analogy  that  they  must  be  present,  until  there  arose  a 
veritable  craze  of  the  germ  theory  of  disease  or 
contagium  animatum.  Then  later  followed  a  reaction, 
and  the  idea  for  a  time  was  ridiculed  out  of  existence. 
And  so  throughout  the  history  of  medicine  this 
theory  continued  to  be  often  asserted  and  as  often 
again  denied,  on  speculative  grounds,  until  well  into 
the  present  century,  when  the  question  was  finally 
settled     by     actual     observation     and    experiment. 

Among  those  who  at  this  early  date  (the  end  of  the 
sixteenth  and  beginning  of  the  seventeenth  century) 
held  to  the  doctrine  of  contagium  animatum  were 
Lange  and  Hauptmann,  who  shortly  after  Leeuwen- 
hoek's  investigations  advanced  the  opinion  that 
puerperal  fever,  measles,  smallpox,  typhus,  ple- 
urisy, epilepsy,  gout,  and  many  other  diseases  were 
due  to  animal  contagion.  And  in  1701  Andry  and 
Linne  assumed  the  same  origin  for  syphilis,  and 
Lancisi  (1718)  for  malaria.  Antonius  Plenciz,  a 
physician  of  Vienna,  who  published  his  deductions  in 
1762,  maintained  that  not  only  were  all  infectious 
diseases  due  to  microorganisms,  but  that  the  infective 
material  could  be  nothing  else  than  living  animals  or 
plants.  On  these  grounds  he  endeavored  to  explain 
the  variations  in  the  incubation  period  of  different 
diseases.  He  insisted  also  that  special  germs  were 
concerned  in  the  production  of  each  infectious  disease. 
Plenciz  believed,  moreover,  that  these  microor- 
ganisms were  capable  of  multiplication  in  the 
body,  and  suggested  the  possibility  of  their  being 
conveyed  from  place  to  place  through  the  air,  etc. 
Besides  these  deductions  he  also  made  original  in- 
vestigations into  the  processes  of  putrefaction  and 
fermentation,  and  having  found  animalcules  in  all 
decomposing  material,  he  became  so  thoroughly 
convinced  of  their  causative  relation  to  these  processes 
that  he  formulated  the  law  tha.t  decomposition  of 
animal  and  vegetable  matter  takes  place  only  by 
means  of  and  through  the  increase  of  living  organisms. 

Still  all  this  was  entirely  a  matter  of  speculation 
only,  unproved  by  direct  experiment;  but  the  theory 
advanced  was  so  plausible  and  the  arguments  used 
in  its  support  were  so  logical  and  convincing,  that  in 
spite  of  great  opposition  and  ridicule  it  continued  to 
gain  ground,  and  in  many  instances  the  conclusions 
reached  by  these  early  philosophers  have  since  been 
shown  to  be  correct. 

Meanwhile  the  question  which  most  attracted  the 
interest  of  all  investigators  into  the  cause  of  in- 
fectious diseases  was:  What  is  the  source  of  the 
microorganisms  which  are  supposed  to  produce  these 
processes?  Are  they  the  result  of  vegetative  changes 
in  the  substances  in  which  they  are  found — the 
theory  of  generatio  oequivoca,  or  spontaneous  genera- 
tion; or  are  they  reproduced  from  similar  preexisting 
organisms — the  vitalistic  theory?  This  question  is 
intimately  connected  with  the  investigations  into  the 
origin  and  nature  of  fermentation  and  putrefaction, 
for  it  was  in  these  experiments  that  the  theory  of 
spontaneous  generation  was  overthrown  and  the 
germ  theory  established. 

Of  those  who  most  vigorously  advocated  the  idea  of 
generatio  oequivoca  was  Needham,  who,  in  1749,  at- 
tempted to  prove  experimentally  the  truth  of  his 
opinions.  He  placed  a  grain  of  barley  in  a  watch 
glass  containing  water,  covered  it  carefully,  and 
allowed  it  to  germinate.  On  later  examination  he 
found  living  microorganisms  present  which  he  main- 
tained  were  the  effect,  not  the  cause,  of  the  decompo- 
sition and  due  to  vegetative  changes  in  the  grain  itself. 


Again,  he  boiled  meat  infusions  and  kept  them  in 
tightly  corked  flasks;  in  these  also  living  organisms 
developed.  As  all  life  must  have  been  destroyed 
by  the  boiling,  and  the  closed  flasks  shut  out  appar- 
ently everything  from  without,  Needham  concluded 
that  the  organisms  present  could  have  been  pro- 
duced only  from  the  dead  material  by  spontaneous 
generation. 

This  conclusion  seemed  indeed  irrefutable  at  the 
time,  but  Bonnet,  in  1702,  suggested  that  possibly 
there  were  certain  germs  which  were  able  to  resist  the 
boiling  temperature,  or  that  the  flasks  were  not  so 
tightly  closed  that  no  germs  could  enter.  Then  in 
1769  Lazarus  and  Spallanzani  showed  experimentally 
the  falseness  of  Needham's  results,  by  demonstrating 
that  if  putrescible  infusions  of  organic  matter  were 
placed  in  hermetically  sealed  flasks  and  boiled  for  an 
hour  the  infusions  remained  sterile;  neither  were  living 
organisms  found  in  the  liquids,  nor  did  they  decom- 
pose. It  was  objected  to  these  experiments  that  the 
high  temperature  to  which  the  liquids  were  subjected 
so  altered  them  that  spontaneous  generation  could  not 
occur.  Spallanzani  then  simply  cracked  one  of  the 
flasks  a  little  and  allowed  air  to  enter,  when  organisms 
and  decomposition  again  appeared  in  the  boiled  solu- 
tions. Again  it  was  objected  that  in  excluding  the 
oxygen  of  the  air  by  hermetically  sealing  the  flasks  the 
essential  condition  for  the  development  of  putrefaction, 
which  required  the  free  admission  of  this  gas,  was 
interfered  with.  This  objection  was  met  by  Schultze 
in  1836,  who  showed  that  the  air  could  have  access  to 
sterilized  infusions  without  causing  putrefaction,  if  it 
were  first  freed  from  germs  by  passing  it  through 
strung  sulphuric  acid.  Schwann  effected  the  same 
thing  in  1837  by  passing  the  air  through  red-hot  tubes; 
and  Helmholtz  in  1843  repeated  and  confirmed  these 
experiments  with  calcined  air.  Again  the  point  was 
raised  that  the  heating  of  the  air  had  perhaps  brought 
about  some  chemical  change  which  prevented  the 
production  of  putrefaction.  Schroeder  and  von 
Dusch  then  showed,  in  18.54,  that  if  the  air  was  fil- 
tered through  cotton  wool,  by  simply  placing  stoppers 
of  this  material  in  the  mouths  of  the  flasks  before 
boiling — a  device  which  has  since  proved  of  inestim- 
able value  in  bacteriological  work — the  contained 
liquid  was  incapable  of  producing  putrefaction. 
Similar  results  were  obtained  by  Hoffmann  in  1860, 
and  by  Chevreul  and  Pasteur  in  1861,  without  a  cotton 
filter,  by  drawing  out  the  neck  of  the  flask  and  bending 
it  downward,  the  mouth  being  left  open.  Here  the 
force  of  gravity  prevents  the  suspended  bacteria  in  the 
air  from  ascending,  and  there  is  no  current  to  carry 
them  upward  into  the  liquid.  Tyndall  later  (1876) 
showed  by  his  investigations  upon  the  floating 
substances  in  the  air  that  in  a  closed  chamber  in 
which  the  air  is  not  disturbed  by  currents,  all  sus- 
pended particles  settle  to  the  bottom,  the  super- 
incumbent air  being  optically  pure.  He  demonstrated 
beyond  all  doubt  that  the  presence  of  living  organisms 
in  decomposing  fluids  was  always  to  be  explained 
either  by  the  preexistence  of  similar  living  forms  in 
the  fluid  or  upon  the  walls  of  the  vessels  containing  it, 
or  by  the  liquid  being  exposed  to  air  which  was  con- 
taminated by  organisms. 

But  still  another  matter  required  explanation. 
A  certain  percentage  of  the  experiments  with  infu- 
sions, which  had  been  boiled  for  a  considerable  time 
and  carefully  protected  from  subsequent  contamina- 
tion, would  now  and  then  fail  despite  every  precaution. 
Bonnet  in  1762  had  suggested  the  explanation  of  this, 
on  the  assumption  that  some  organisms  were  perhaps 
capable  of  withstanding  the  boiling  temperature, 
and  still  grow  when  the  infusion  cooled.  Then  Past- 
eur found  that  he  could  sterilize  milk  only  at  a  tem- 
perature of  110°  C,  and  later  (1865)  showed  that  the 
organisms  which  resist  boiling  temperature  are  re- 
productive bodies,  now  known  as  spores.  But  it 
was  not  until  1876  that  the  nature  of  spores  was  care- 


826 


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Bacteria 


fully  studied  and  explained  by  Cohn,  and  afterward 
confirmed  by  Koch.  These  investigators  proved  thai 
certain  rod-shaped  bacteria  possess  the  power  of 
passing  into  a  resting  or  spore  stage  under  peculiai 
conditions  of  growth,  and  thai  when  in  this  stage 
they  are  much  less  susceptible  to  the  injurious 
action  of  higher  temperatures  and  other  deleterious 
influences  than  when  in  their  normal  vegetative  con- 
dition. 

With  this  discovery   the  question  of  spontaneous 

generation  was  finally  settled  in  the  negative  and  the 

germ  theory  established.     If  living  microorganisms, 

ie  of  them  capable  of  producing  the  more  resistant 

res,  were  present  in  the  air,  soil,  water,  etc.,  it  was 

easy  enough  to  understand  how  irregularities  occurred 

in  previous  experiments;  nor  eon  1.1 1  here  longer  beany 
doubt  that  bacteria  were  the  cause,  not  the  effect,  of 

fermentation  and  putrefaction,  and  possibly  also  of 
iase. 

But,  in  the  mean  time,  little  or  nothing  had  been 
accomplished  in  the  systematic  classification  of  bacte- 
ria, although  their  forms  were  zealously  studied  tniero- 
scopically  as  matters  of  curiosity.  The  first  attempt 
at  classification  was  made  by  Midler,  of  Copenhagen, 
in  17SH,  who  divided  microorganisms  into  two  main 
divisions — monas  and  vibrio.  But  he,  like  all  the 
earlier  naturalists,  owing  to  lack  of  sufficiently  power- 
lid  microscopes  and  inadequate  knowledge  of  the 
biology  of  bacteria,  fell  into  grave  errors  of  classifica- 
tion. Thus  various  motile  organisms,  which  are  now 
ignized  to  be  of  vegetable  origin,  were  commonly 
included  among  the  infusorians  or  unicellular  animal 
organisms.  Even  Ehrenberg,  in  1838,  and  Dujardin, 
in  1841,  though  their  work  shows  considerable  pro- 
gress in  this  direction,  failed  to  arrive  at  a  satisfactory 
classification  of  bacteria;  these  authors  dividing 
bacteria  into  four  orders — bacterium,  vibrio,  spirillum, 
and  spirochete — and  including  them  with  the  in- 
fusorians. Perty,  in  18.52,  was  the  first  apparently  to 
draw  attention  to  the  vegetable  origin  of  bacteria;  and 
Robin,  in  1S53,  then  suggested  their  relationship  to 
the  alga*.  But  it  remained  for  Cohn  in  1S54,  and 
Naegelt  in  1S.57,  to  bring  anything  like  system  into  the 
confusion  which  had  previously  existed  regarding  the 
classification  of  bacteria.  It  was  Naegeli  who  estab- 
lished their  resemblance  to  the  fungi,  in  that  they  were 
chlorophyll-free  plants,  and  gave  them  the  name  of 
Bchizomycetes  or  fission  fungi  to  indicate  their  mode  of 
reproduction;  and  Cohn  confirmed  and  emphasized 
this  relation  of  bacterial  species  to  the  vegetable 
kingdom,  and  first  employed  the  term  bacteria  for  the 
entire  class  of  these  microorganisms,  studying  their 
various   groups   more   carefully. 

At  the  same  time,  the  physiological  properties  of 
bacteria  were  studied,  with  as  much,  if  not  more, 
success  than  their  morphology  and  classification. 
Stimulated  by  the  discovery  of  the  microbic  origin 
of  the  processes  of  fermentation  and  putrefaction — 
the  specific  cause  of  one  form  of  which,  alcoholic 
fermentation,  was  found  by  Latour  and  Schwann,  in 
1837,  to  be  the  yeast  plant  (Saccharomyc.es  cerevisice) — 
the  study  of  the  causal  relation  of  microorganisms  to 
disease  was  again  taken  up  with  renewed  vigor.  So 
far  the  bacterial  source  of  infectious  diseases  was 
founded  only  on  hypothesis,  and  although  belief  in  this 
theory  was  much  strengthened  by  the  foregoing 
experiments,  it  had  not  yet  been  proved.  It  was  not 
long,  however,  before  the  necessary  proof  was  forth- 
coming at  least  for  one  disease,  for  in  the  same  year  as 
Schwann's  discovery  of  the  yeast  plant,  Bassi  dis- 
covered  that  a  fatal  infectious  malady  of  silkworms 
was  due  to  a  parasitic  microorganism;  and  later  a 
similar  origin  was  found  for  various  infectious  dis- 
eases in  grains,  potatoes,  etc.  Just  about  this  time, 
too  (1S40),  Henle  published  his  "Pathological  In- 
vestigations," in  which  he  described  the  relation  of 
bacteria  to  disease  with  remarkable  clearness  and 
precision,   the   weight  of   the   opinion  of   this  great 


authority  contributing  much  to  i  interest  i 

doctrine  of  infection.     Although  Henle  failed  to 

organisms  in  111.'  1 1     ue    in  various  infect 

this  did  not  lead  him  to  change  his  opinion,  for  he  con- 
tended rightly  that  there  were  no  means  at  that  time 
of  distinguishing  between  tissue  cells  and  bacteria. 
Nor  did  he  consider  the  presence  of  microorganisms 
alone   sufficient    proof   of    their  etioloi  ition, 

but  postulated  the  conditions  later  confirmed  to  the 
letter  by  Koch,  which  must  be  fulfilled  to  dec 
that  a  disease  is  due  to  a  specific  microorganism. 
These  conditions  were  constant  presence  in  the  dis- 
ease, isolation,  and  evidence  of  tne  infectious  nature 
of  the  isolated  germ  by  inoculation.  Similar  con- 
clusions were  also  reached  by  Mitchell,  independently, 
reasoning  by  deduction. 

Very  soon  after  this  it.  was  shown  experimentally 
that  microorganisms  were  thi  causi  "f  various  skin 
diseases  in  man,  as  favus  and  ringworm.  About  this 
time  also.  Pollender  (1849)  Observed  certain  rod- 
shaped  bacteria  in  the  blood  of  animals  dying  from 
anthrax   or   splenic    fever,    and    he    was    followed    by 

Davaine  (1850);  but  the  e  observers  attached  no 
special  significance  to  their  discovery  until  Pasteur 
made  public  his  researches  in  regard  to  fermentation 
and  the  role  played  by  bacteria  in  the  economy  of 
nature.  Then  Davaine  resumed  his  studies,  and  in 
1S63  e-tabli.-hed  by  inoculation  experiments  the 
bacterial  origin  of  anthrax — which  was  later  con- 
firmed by  Pasteur,  Koch,  and  others. 

Schwann  had  already  shown  the  connection  be- 
tween certain  organisms  and  alcoholic  fermentation, 
but  Pasteur,  in  1857,  deserves  the  credit  of  finally 
establishing  the  fact  that  the  various  kinds  of  fermen- 
tation— lactic  acid,  butyric  acid,  acetic  acid  fermen- 
tation, etc. — are  all  caused  by  microorganisms,  which 
not  only  differ  in  physiological  action,  but  are  charac- 
terized by  morphological  and  biological  peculiarities. 
In  this  connection  Pasteur  also  made  the  discovery  of 
certain  bacteria  which  were  incapable  of  growth  in 
free  oxygen,  assigning  to  them  the  name  of  anaerobes 
to  distinguish  them  from  the  aerobes,  or  those  re- 
quiring the  presence  of  free  oxygen.  Others,  again, 
he  found  were  capable  of  growth,  either  with  or  with- 
out free  oxygen,  and  these  he  called  facultative 
anaerobes.  Pasteur's  investigations  demonstrated 
the  fact  that  since  bacteria  are  the  cause  of  fermenta- 
tion and  putrefaction,  they  are  necessary  for  the  life 
of  plants  and  animals,  for  without  their  agency  the 
higher  plants,  incapable  of  feeding  upon  the  complex 
substances  of  dead  animals  and  plants,  would  die  if 
these  substances  did  not  undergo  decomposition 
into  their  elements  through  the  instrumentality 
of  bacteria;  and  thus  the  earth  would  be  unin- 
habitable. 

The  next  important  discoveries  related  to  the  cause 
of  infection  in  wounds.  Lemaire,  following  up  the 
experiments  of  Pasteur,  had  observed  that  when  car- 
bolic acid  was  added  to  putrescible  substances  fer- 
mentation was  prevented,  and  he  came  to  the  conclu- 
sion that  the  carbolic  acid  destroyed  the  germs  which 
produced  fermentation.  The  processes  of  fermenta- 
tion and  suppuration  he  believed  to  be  analogous. 
If  the  addition  of  carbolic  acid  solution  inhibited 
fermentation,  why  should  it  not  be  applicable  to  the 
prevention  of  suppuration  in  wounds? 

Upon  these  suggestions  Lister  now  (1863-70) 
instituted  his  famous  antiseptic  treatment  of  wounds, 
which  has  led  to  such  brilliant  results  in  modern 
operative  surgery.  The  publication  of  Lister's  work 
exerted  a  powerful  influence  upon  the  general  recog- 
nition of  the  germ  theory  of  infectious  diseases,  and 
had  much  to  do  in  lessening  the  number  of  its  oppo- 
nents. Then  Rindfleisch,  in  1S66,  and  Waldeyer 
and  von  Recklinghausen,  in  1871,  drew  attention  to 
the  constant  occurrence  of  microorganisms  in  pyemic 
processes  resulting  from  wound  infection — observa- 
tions which  have  since  been  amply  corroborated  by 

827 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


others  for  all  suppurative  processes  under  whatever 
condition  produced. 

From  this  time  on  followed,  in  comparatively  rapid 
succession,  the  discoveries  of  a  number  of  microorgan- 
isms as  the  cause  of  various  infectious  diseases.  In 
1S73,  Obermeier  announced  having  found  in  the  blood 
of  patients  suffering  from  relapsing  fever  a  minute 
spiral,  motile  organism — the  Spirochete  obermeieri — 
which  is  now  recognized  as  the  specific  infective  agent 
in  this  disease.  In  1S78,  Koch  published  his  im- 
portant work  on  traumatic  diseases.  In  1879 
Hansen  reported  the  discovery  of  bacilli  in  the  cells  of 
leprous  tubercles,  which,  from  subsequent  investiga- 
tions, are  believed  to  be  the  cause  of  leprosy.  Neisser, 
in  the  same  year  (1879),  discovered  the  "gonococcus" 
in  gonorrheal  pus.  In  1880,  Eberth  and  Koch, 
independently,  observed  the  typhoid  bacillus,  which 
Gaffky,  in  1884,  proved  to  be  the  cause  of  typhoid 
fever.  In  the  same  year  Pasteur  published  his 
discovery  of  the  bacillus  of  fowl  cholera  and  his 
investigations  upon  protective  inoculation  against 
this  disease  and  anthrax.  Sternberg  and  Pasteur,  also 
in  the  same  year,  independently  observed  a  patho- 
genic microorganism  in  human  saliva,  which  was  subse- 
quently (1885)  proved  by  Fraenkel  and  others  to  be 
the  organism  most  commonly  associated  with  acute 
lobar  pneumonia  and  now  recognized  as  the  usual 
cause  of  that  disease — the  Diplococcus  pneumonice. 
In  1881,  Koch  made  his  fundamental  researches  upon 
pathogenic  bacteria,  which  form  the  basis  of  our 
modern  bacteriology.  He  introduced  solid  culture 
media  and  the  "plate  method"  for  obtaining  pure 
cultures,  and  showed  how  different  organisms  could 
be  isolated,  cultivated  artificially,  and  by  inoculation 
of  pure  cultures  into  susceptible  animals  made,  in 
many  cases,  to  reproduce  the  specific  disease  of  which 
they  were  the  cause — thus  carrying  out  Henle's 
suggestions.  It  was  also  in  the  course  of  this  work 
that  the  Abbe  system  of  substage  condensing  appara- 
tus on  the  microscope,  and  the  Ehrlich-Weigert 
method  of  staining  bacteria  for  microscopical  prepara- 
tions were  first  generally  used.  In  1882,  Koch 
published  the  discovery  of  the  tubercle  bacillus.  The 
same  year  Pasteur  made  his  investigations  upon  hog 
erysipelas;  in  this  year  also  his  communication  upon 
rabies  appeared.  In  1S82  also  Loeffler  and  Schiitz 
discovered  the  bacillus  of  glanders.  In  1884  Koch 
discovered  the  spirillum  of  Asiatic  cholera,  the  "comma 
bacillus."  This  year,  too,  Klebs  and  Loeffler  dis- 
covered the  diphtheria  bacillus.  Rosenbach  also,  by 
the  application  of  Koch's  methods,  fixed  definitely 
the  characters  of  the  various  pus-producing  organisms. 
And  the  same  year  Nicolaier  discovered  the  tetanus 
bacillus  which  Carl  and  Rattone  afterw-ard  showed  to 
bs  the  true  cause  of  the  disease,  and  Kitasato  obtained 
in  pure  culture.  In  1892,  Pfeiffer  discovered  the 
bacillus  of  influenza;  and  finally,  in  1S94,  Kitasato 
discovered  the  bacillus  of  bubonic  plague. 

This  closes  our  brief  historical  sketch  of  the  develop- 
ment of  bacteriology,  including  all  the  more  important 
facts  which  are  of  special  interest  to  physicians. 
But  no  review  of  the  progress  which  has  been  made  in 
this  branch  of  science  would  be  complete  without 
reference  to  the  recent  discoveries  of  antitoxins  in  the 
treatment  of  diphtheria  and  tetanus,  the  protective 
inoculations  against  rabies,  cholera,  the  plague,  etc., 
and  the  peculiar  reactions  of  the  blood  serum  of  per- 
sons ill  with  infectious  diseases.  These  discoveries, 
in  which  the  names  of  Pasteur,  Koch,  Behring, 
Kitasato,  Roux,  Pfeiffer,  Gruber,  and  Widal  are  the 
most  prominent,  not  only  mark  an  epoch  in  the 
history  of  bacteriology  in  relation  to  medicine,  but 
have  served  to  establish  beyond  all  doubt  the 
microbic  origin  of  many  diseases,  the  cause  of  which 
was  until  then  in  dispute.  Attention  has,  moreover, 
been  directed  of  late  to  the  group  of  animal  micro- 
parasites,  the  protozoa — to  which  class  belong  the 
Plasmodium   malaria  and  the  Amoeba  coli,  the  cause 

828 


of   malaria  and   epidemic  dysentery,   respectively 

which  may  prove  to  be  the  source  of  infection  in  many 
affections  the  origin  of  which  is  still  unknown,  as  the 
exanthemata.     And  quite  recently  interest  has  been 
awakened   in   the   possible  pathogenic   properties  of 
certain  of  the  fungi,  among  which  it  is  suggested  may 
be  found  the  cause  of  other  unexplainable  diseases 
as  cancer,  smallpox,  scarlet  fever,  measles,  and  rabi 
Several  bacteria  also  not  mentioned  in  this  list  hj 
created    considerable   discussion    of   late;    but    tl 
organisms  have  not  yet  been  positively  shown  to  be 
the  specific  cause  of  the   diseases   with   which  they 
are  found  associated,  and  hence  have  been  omitted. 

General  Characteristics  op  Bacteria. — Clax- 
sification  and  Definition. — Under  the  general  term 
"microorganism"  may  be  included  all  the  minute 
lower  forms  of  life  which  are  of  biological  or  hygienic 
interest,  and  which  are  the  cause  of  fermentation 
putrefaction,  and  disease.  They  are  both  of  the 
vegetable  and  of  the  animal  kingdom;  among  the  latter 
of  these  are  the  protozoa,  and  among  the  former  the 
fungi  and  bacteria.  Bacteria  are  classed  among 
plants  from  the  fact  that  they  are  able  to  derive  their 
nourishment  both  from  organic  and  inorganic  mater- 
ials. They  are  of  the  class  of  cryptogamons  plant*, 
that  is,  plants  which,  having  no  seeds  or  flowers,  are 
reproduced  by  means  of  spores,  such  as  the  fungi, 
lichens,  and  algae.  Of  these  they  are  most  nearly 
allied  to  the  alga?,  but  differ  from  them  in  that  they  are 
without  chlorophyll,  the  green  coloring  matter  by 
means  of  which  the  higher  plants,  under  the  influence 
of  sunlight,  decompose  carbon  dioxide,  ammonia,  and 
sulphurated  hydrogen  into  their  elementary  con- 
stituents. In  many  respects  bacteria  resemble  the 
mycetes  or  fungi,  which  are  also  without  chlorophyll; 
but  they  differ  from  these  again  in  their  mode"  of 
reproduction,  being  reproduced  by  division  or 
simple  fission.  Hence  bacteria  have  been  called 
schizomycetes  or  fission  fungi.  A  few  varieties  of 
unicellular  organisms  have  also  been  found  resembling 
bacteria  in  all  points,  except  that  they  possess  chloro- 
phyll or  some  pigment  substance  similar  to  it.  Other 
organisms,  again,  have  been  observed  which,  though 
they  are  without  chlorophyll,  are  able  to  build  up 
organic  compounds  synthetically  and  even  in  the 
absence  of  light.  Some  bacteria,  moreover,  especially 
the  motile  forms,  are  closely  allied  to  certain  micro- 
organisms belonging  to  the  animal  kingdom.  It  is 
therefore  difficult  to  classify  or  define  bacteria 
scientifically,  under  our  existing  knowdedge  of  them. 
Excluding  the  microorganisms,  however,  which 
contain  chlorophyll,  bacteria  may  be  defined  ac- 
curately enough  for  all  practical  purposes  as  ex- 
tremely minute  living  vegetable  organisms,  without 
chlorophyll,  which  arc  reproduced  by  division,  con- 
sisting  of  single  spherical,  rod-shaped,  or  corkscrew- 
like  cells  or  aggregation  of  such  alls,  between  irliose 
protoplasm  and  nucleus  it  has  not  been  possible  to 
differentiate  with  certainty. 

Bacteria,  then,  belong  to  the  family  of  mycetes  or 
fungi,  of  which  there  are  four  groups: 

1.  Hyphomycetcs,  or  mould  fungi. 

2.  Blastomyci  U  a,  or  yeast  fungi. 

3.  Streptothrices. 

4.  Schizomycetes  or  bacteria. 

But  besides  this  classification  of  bacteria  it  becomes 
necessary  to  divide  them  into  saprophytes  or  refuse- 
eaters,  and  parasites.  Saprophytic  microorganisms 
are  such  as  commonly  exist  independently  of  a  living 
host,  obtaining  their  supply  of  nutriment  from  soluble 
food  stuffs  in  dead  organic  matter.  Parasitic  micro- 
organisms, on  the  contrary,  live  on  or  in  some  other 
living  organism,  from  which  they  derive  their  nourish- 
ment for  the  whole  or  a  part  of  their  existence. 
Those  microorganisms  which  depend  entirely  upon 
a  living  host  for  their  existence  are  known  as  strict  or 


REFERENCE    HANDBOOK   OF   THi:    MEDICAL   SCIENCES 


Bacteria 


>bligatory  parasites;  those  which  can  lead  a  saprophytic 

istence,  bul  also  thrive  within  the  body  o 
animal,   arc  called  facuttatir,  .     The   sapro- 

phytes strictly  so  called,  which  represent  the  larger 
number  of  microorganisms,  are  not  only  harmli 
but  perform  the  useful  function  of  the  destruction  of 
dead  organic  matter  through  fermentation  and 
putrefaction.  The  parasites,  on  the  other  hand, 
though  Mime  of  them  may  multiply  in  the  secretions 
or  on  the  surface  of  the  body  without  injury  to  the 
animal  upon  which  they  exist,  are  usually  harmful 
iders,  giving  rise,  through  the  lesions  brought 
about  in  the  body  by  their  growth  and  products,  to 
various  acute  and  chronic  infectious  diseases. 

Numerous  attempts  have  been  made  by  various 
authors  to  classify  bacteria  systematically,  but 
usually  with  the  proviso  that  the  system  was  only  a 
temporary  one.  As  a  rule,  the  genera  are  based  upon 
morphological  characters  and  the  species  upon 
biochemical,  physiological,  or  pathogenic  properties. 
While  the  form,  size,  and  method  of  division  are  the 
most  permanent  characteristics  of  microorganisms, 
and  so  are  naturally  utilized  for  classifications, 
nevertheless  on  this  basis  of  arrangement  there  are 
ided  difficulties.  Thus  while  the  form  and  size 
of  bacteria  are  fairly  constant  under  the  same  condi- 
tions, they  are  in  many  quite  different  under  diverse 
conditions.  Another  serious  drawback  is  that  I 
morphological  characteristics  give  no  indication 
whatever  of  the  relation  of  bacteria  to  disease,  etc. — 
the  very  characteristics  for  which  as  physicians  we 
study  them.  <  Ither  properties  of  bacteria  which  are 
fairly  constant  under  uniform  conditions  are  those  of 
spore  formation,  motility,  reaction  to  staining  agent-, 
relation  to  temperature,  to  oxygen  or  other  food 
materials,  and  finally  their  relation  to  disease,  fermen- 
tation, and  pigmentation  (pathogenic,  zymogenic,  and 
chromogenic  bacteria). 

Taking  any  one  of  these  properties  of  bacteria  as  a 
basis,  we  can  classify  them;  but  even  here  there  will  be 
groups  which  under  certain  conditions  would  be  placed 
in  one  class  and  under  other  conditions  in  another. 
Thus  the  power  to  produce  spores  11133-  be  totally  lost 
or  held  in  abeyance  for  a  time.  The  relation  to  oxy- 
gen may  be  gradually  altered,  so  that  an  anaerobic 
species  grows  in  the  presence  of  oxygen.  Parasitic 
bacteria  ma3'  be  so  cultivated  as  to  become  saprophy- 
tic varieties,  and  those  which  have  no  power  to  grow- 
in  the  living  body  given  pathogenic  properties.  The 
possibility  of  making  any  thoroughly  satisfactory  clas- 
sification is  rendered  still  more  difficult  by  the  fact 
that  many  necessarily  imperfect  attempts  have  already 
been  made,  so  that  there  is  a  great  deal  of  confusion, 
which  is  steadily  increased  as  new  varieties  are  found 
or  old  ones  reinvestigated  and  classified  differently  in 
the  various  systems.  We  shall,  therefore,  simply  use 
the  commonly  accepted  nomenclature,  without  any 
attempt  at  classification,  except  to  consider  together 
as  far  as  practicable  certain  groups  of  bacteria  whose 
members  are  closely  allied  to  one  another  in  some  one 
or  more  important  features. 

Morphology. — There  are  three  basic  forms  of  the 
individual  bacterial  cells:  the  sphere,  the  rod,  and 
the  segment  of  a  spiral.  Although  under  different 
conditions  the  form  of  any  one  species  may  vary 
considerably,  yet  these  three  main  divisions  under 
similar  conditions  are  permanent;  and  so  far  as  we 
know,  it  is  never  possible  by  any  means  to  bring 
about  changes  in  the  organisms  that  will  result  in  the 
conversion  of  the  morphology  of  the  members  of  one 
group  into  that  of  another — that  is,  cocci  always, 
under  suitable  conditions,  produce  cocci,  bacilli  pro- 
duce bacilli,  and  spirilla  produce  spirilla. 

The  form  of  the  bacterial  cells  at  their  stage  of  com- 
plete development  must  be  distinguished  from  that 
which  they  possess  just  after  or  before  they  have 
divided.  As  the  spherical  cell  develops  preparatory 
to  its  division  into  two  cells,  it  becomes  elongated 


ami  appears  as  a  -hort  oval  rod  at  thi  of  its 

division;  on  the  contrary,  the  tran  verse  diameter  of 

each  of  its  two  halvi  ater  than  their  long  di- 

ameter.    A  shorl  rod  becomes  in  the  same  way,  al  the 

"-tit  of  its  divi     1  1  cells,  the  long  diameter 

"i  each  of  which  may  he  even  a  trifle  less  than  its 
shorl  diameter,  and  thus  they  appear  on  superficial 
e  lamination  as  spheres. 

As  bacteria  multiply  the  cells  produced  from  the 
parent  cell  hai  ea  1  ncy  to  remain 

at taihed.     In  some  varieties    this    tendency    is   ex- 
tremely marked,  in  others  it   is  slight.     This  union 
may  appear  simply  as  an   aggregation   of  separate 
bacteria    or    so    close    that     the    group    present- 
appearance  of  a  single  cell.      According  to  the  method 
ot  the  cell  division  and  the  tenacity  with  which 
cells    h,,i(i    together   we   get    different    grouping 
bacteria,    which   aid    us   in    their    identification  and 
differentiation.     Thus    whether    the    bacteria]    cell 
divides  in  one,   two,   or  three  plane-,   we  get    forms 
built  in  on.-,  two,  or  three  dimensions.      If  we  gi 
bacteria  according  to  the  characteristic  forms  of  the 
cells,  and  then  subdivide  according  to  the  manner  of 
their  division  in  reproduction  and  the  tenacity  with 
which  the  newly  developed  cells  cling  to  one  another, 
we  -hall  have  the  following  varieties: 

1.  Coccus  or  Micrococcus. — Spherical  or  sub- 
spherical  forms. 

(a)  Single  coccus,  grouped  irregularly. 

(b)  I  ■  is,  forming  pairs. 

(c)  Streptococcus,  forming  chains,  often  showing 
paired  cocci. 

T<  tracoccus,  forming  fours  by  division  through 
two  planes  of  space. 

■  Sarcina,  forming  packets  of  eight  by  division 
through  three  planes  of  space. 

(J)  Staphylococcus,  forming  irregularly  shaped, 
grape-like  bunches  by  division  apparently  in  any  axis. 

2.  Bacillus. — Oblong  or  cylindrical  forms,  having 
one  dimension  greater  than  any  other,  more  or  less 
straight,  and  never  forming  spirals,  dividing  only  in 
one  plane  perpendicular  to  its  long  axis. 

(a)  Single  bacillus. 

(b)  LHplobacillus  and  streptobacillus,  forming  twos 
or  longer  chains,  the  bacilli  attached  end  to  end. 

(c)  Filaments  or  thread-like  growths,  in  which 
division  into  bacilli  of  the  normal  length  are  not 
apparent,  or  occur  irregularly  and  transversely  to 
the  long  axis  of  the  growth. 

3.  Spirillum. — Cylindrical  and  curved  forms,  con- 
stituting complete  spirals  or  portions  of  spirals. 
Spirilla.  like  bacilli,  divide  only  in  one  direction.  A 
single  cell,  a  pair,  or  the  union  of  two  or  more  elements 
may  thus  present  the  appearance  of  a  short  segment 
of  a  spiral  or  a  comma-shaped  form,  an  S-shaped 
form,  or  a  complete  spiral  or  corkscrew-like  form. 

The  term  bacterium  has  also  been  used  by  some 
authors  for  bacilli  or  rod-shaped  organisms;  while  to 
spirilla  the  terms  vibrio  and  spirochcete  have  some- 
times been  applied.  But  as  there  is  no  uniformity 
among  bacteriologists  as  to  the  exact  meaning  of 
these  terms,  we  shall  employ  only  the  terms  bacillus 
and  spirillum  to  denote  these  different  groups. 

Structure  of  Bacterial  Cells. — A  bacterial  cell  con- 
-i-t-  of  protoplasm  enveloped  in  a  cell  membrane; 
the  cells  as  a  rule  being  homogeneous  and  without 
visible  nucleus.  The  cell  is  generally  colorless, 
though  in  some  species  it  contains  chlorophyll  or 
other  similar  coloring  matter.  The  protoplasm  may 
at  times  also  contain  minute  granules  of  sulphur  and 
1  iccasionally  refractive  oily  particles  or  colorless  spaces 
in  stained  specimens,  which  have  been  mistaken  for 
spores,  but  are  supposed  to  be  due  to  the  shrinkage 
of  the  protoplasm  with  partial  dissolution  of  the  cell 
wall  caused  by  abstraction  of  water,  known  as 
plasmolysis.  In  many  species  of  bacteria,  as  in  the 
diphtheria  bacillus,  there  is  observed  in  the  interior 

829 


Bacteria 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


of  the  cells  on  suitable  staining,  a  peculiar  granular 
appearance,  to  which  has  been  given  the  names 
metachromatic  bodies  or  sporogenous  granules.  The 
cell  membrane  is  sometimes  colored,  and  sometimes 
surrounded  by  a  gelatinous  envelope  or  capsule, 
which  can  be  occasionally  brought  out  by  staining. 
The  demonstration  of  this  capsule  may  be  of  assist- 
ance in  differentiating  between  certain  bacteria,  as, 
for  example,  some  forms  of  the  streptococcus  and 
pneumococcus.  A  peculiarity  of  the  capsule  bacteria 
is  that,  except  very  rarely,  they  exhibit  this  envelope 
only  when  grown  in  the  animal  body  or  in  special 
culture  media,  such  as  liquid  blood  serum,  bronchial 
mucus,  etc.  The  outer  surface  of  bacteria  when 
occurring  in  the  form  of  spheres  and  short  rods  is 
almost  always  smooth  and  devoid  of  appendages; 
but  the  larger  rods  and  spirals  are  usually  provided 
with  fine  hair-like  cilia  or  flagella,  which  are  their 
organs  of  motility.  These  flagella,  either  singly  or 
in  numbers,  are  sometimes  distributed  over  the 
entire  body  of  the  cell,  or  they  may  form  a  tuft  at  one 
end  of  the  rod,  or  only  one  polar  flageltum  is  found. 
The  polar  flagella  appear  in  the  cells  shortly  before 
division.  They  are  believed  to  be  formed  of  proto- 
plasmic material,  which  penetrates  the  cell  mem- 
brane, and  probably  to  have  the  property  of  pro- 
trusion and  retraction;  but  their  nature  is  imperfectly 
understood.  So  far  as  we  know,  the  flagella  are  the 
only  means  of  locomotion  of  bacteria.  They  are  not 
readily  stained,  special  mordants  being  required  for 
this  purpose.  Bacteria  may  lose  their  power  of 
producing  flagella  for  several  generations,  whether 
permanently  or  not  is  not  known. 

Vegetative  Reproduction. — The  process  of  vegetative 
reproduction  of  bacteria,  which  is  to  be  distinguished 
from  spore  formation,  takes  place  by  division,  and 
may  go  on,  under  favorable  conditions,  indefinitely. 
When  development  is  in  progress  a  single  cell  will  be 
seen  to  elongate  in  one  direction.  Over  the  center  of 
the  long  axis  thus  formed  there  appears  a  slight 
indentation  in  the  outer  envelope  of  the  cell;  this 
indentation  increases  until  there  exist  two  distinct 
cells.  As  a  rule,  the  cells  separate  soon  after  division, 
but  occasionally  they  remain  together  for  a  time, 
forming  pairs  and  chains,  or  under  certain  conditions 
of  nutrition  long  threads  or  filaments  which  break 
up  into  fragments,  however,  when  placed  under 
other  conditions.  Although  elongation  in  one  direc- 
tion and  transverse  division  is  the  rule  for  most 
bacteria,  there  are  certain  groups  (as  the  sarcina, 
for  example)  which  divide  more  or  less  regularly  in 
three  directions.  Division  in  two  directions  results, 
as  already  mentioned,  in  the  formation  of  tetrads; 
while  division  irregularly  in  all  directions  produces 
grape-like  clusters.  Bacilli  and  spirilla,  as  far  as 
we  know,  never  divide  longitudinally. 

Spore  Formation. — This  is  the  process  by  which 
bacteria  are  enabled  to  enter  a  stage  in  which  they 
resist  deleterious  influences  to  a  much  higher  degree 
than  is  possible  for  them  in  the  growing  or  vegetative 
condition.  It  is  not  a  process  of  multiplication  of 
bacteria,  but  only  one  of  reproduction  for  the  preser- 
vation of  the  species  under  conditions  unfavorable 
to  their  growth,  and  occurs  when  the  organism  has 
nearly  exhausted  its  supply  of  nutrition  or  poisoned 
it  with  products  of  its  growth,  etc.  The  fungi,  on 
the  other  hand,  form  spores  under  the  most  favorable 
conditions,  even  requiring  an  abundant  supply  of 
nutrition  for  their  production,  the  life  history  of  the 
fungi,  indeed,  being  incomplete  without  the  formation 
of  spores.  But  in  bacteria  the  process  is  compara- 
tively rare,  and  all  the  conditions  which  tend  to  bring 
it  about  are  not  yet  known. 

Two  kinds  of  spores  have  been  described  in  bacteria: 

1.  Endospores,  which  are  strongly  refractile  and 
glistening  in  appearance,  oval  or  round  in  shape, 
and  developed  within  the  interior  of  the  cell.     They 

830 


are  characterized  by  the  power  of  resisting  to  a 
considerable  extent  the  injurious  influences  of  heat, 
desiccation,  and  chemical  disinfectants,  which  would 
kill  vegetative  cells.  2.  Artitrospores  or  jointed 
spores,  developed,  not  within  the  cell,  but  as  a  sprout- 
like projection  from  one  of  its  extremities.  These 
jointed  bodies  are  believed  by  Hueppe  to  have  also 
more  or  less  power  of  resistance  to  desiccation,  etc., 
than  the  ordinary  cells,  though  less  than  endospori 
but  they  have  been  but  little  studied,  and  their  exist- 
ence in  bacteria  is  still  an  open  question.  In  describ- 
ing the  biological  characters,  therefore,  of  the  varioi 
species,  whenever  their  property  of  spore  formation 
is  mentioned  it  will  be  understood  that  endogenous 
spores  are  meant. 

The  production  of  endospores  in  the  different 
bacterial  species,  though  not  identical,  is  very  similar. 
Spores  represent  a  state  of  suspended  activity,  and 
motile  organisms  always  come  to  a  state  of  rest  or 
immobility  previous  to  spore  formation.  The  fol- 
lowing description  of  the  method  of  spore  form  i- 
tion  in  the  anthrax  bacillus  may  serve  as  an  illustra- 
tion of  the  process:  Under  suitable  conditions  of 
temperature,  moisture,  etc.,  the  cell  is  elongated  and 
at  first  the  protoplasm  is  clear  and  homogeneous,  but 
after  a  time  it  becomes  turbid  and  finely  granular. 
These  fine  granules  are  then  replaced  by  a  smaller 
number  of  coarser  granules,  which  are  finally  amal- 
gamated into  a  spherical  or  ovoid  refractile  body. 
This  is  the  spore.  As  soon  as  the  process  is  completed 
there  appears  between  two  spores  a  delicate  partition 
wall.  For  a  time  the  spores  are  retained  in  a  linear 
position  by  the  cell  membrane  of  the  rod,  but  this 
later  is  dissolved  or  disintegrated  and  the  spores  are 
set  free. 

The  following  types  have  been  observed:  (n) 
Spores  lying  in  the  interior  of  a  short,  undistended  cell; 

(b)  spores  lying  in  the  interior  of  a  short,  undistended 
cell,  forming  one  of  the  elements  of  a  long  filament; 

(c)  the  spores  lying  at  the  extremity  of  an  undistended 
cell  much  enlarged  at  that  end — the  so-called  "head 
spores";  and  (d)  the  spores  lying  in  the  interior  of  a 
much  enlarged  cell  in  its  central  portion,  giving  it  a 
spindle  shape. 

The  germination  of  spores  takes  place  as  follows: 
By  the  absorption  of  water  the  spores  become  swollen 
and  paler  in  color,  losing  their  shining,  refractile 
appearance.  Later  a  little  protuberance  is  seen  to 
project  from  one  side  or  at  the  extremity  of  the  spore; 
this  rapidly  grows  out  to  form  a  new  rod,  which 
consists  of  soft  protoplasm  enclosed  in  a  membrane 
formed  of  the  inner  layer  of  the  cellular  envelope,  or 
endosporum.  The  outer  envelope,  or  exosporum,  is 
then  cast  off,  and  may  often  be  seen  in  the  vicinity  of 
the  newly  formed  rod.  In  some  species  the  vegetative 
cell  emerges  from  one  end  of  the  oval  spore,  and  in 
other  species  the  exosporum  is  ruptured  and  the 
bacillus  emerges  from   the  side. 

Involution  Foryns. — In  old  cultures  of  bacteria  in 
which  deleterious  substances  have  been  produced  or 
the  supply  of  nutriment  has  been  exhausted,  there  air 
frequently  found  irregular  or  distorted  forms,  which 
are  thought  to  be  due  to  abnormal  development  of  the 
bacterial  cells  under  unfavorable  conditions.  These 
are  generally  spoken  of  as  involution  or  degenerated 
forms,  though  sometimes  the  terms  pleomorphism  and 
polymorphism  are  applied  to  them.  Placed  under 
suitable  conditions  these  irregular  or  deformed  cells 
again  produce  normally  shaped  organisms. 

Chemical  Composition. — Qualitatively  considered, 
bacterial  cells  consist  of  carbon,  hydrogen,  oxygen, 
and  nitrogen,  for  the  most  part  in  the  form  of  water, 
salts,  fats,  and  albuminous  substances.  There  are 
also  present,  in  smaller  quantities,  extractive  sub- 
stances soluble  in  alcohol.  Glucose  has  not  been 
found  in  any  bacteria,  but  many  species  contain 
starchy  substances  which  give  a  reaction  with  iodine. 


REl'ERKXCi:    IIANDHooK    uF    Till'.    MI'.llK'AI,    Si  II   WES 


Bacteria 


Cellulose  has  also  been  detected  in  certain  species,  as 
i he  Bacillus  subtilis,  some  of  the  colon  group,  and 
the  tubercle  bacillus.  The  nuclein  bases,  xanthin, 
guanin,  ami  adenin,  moreover,  have  been  found  in 
considerable  amounts.  There  is  also  a  group  of  bac- 
teria, l  lie  Bcggiatoa,  which  contain  sulphur,  and 
another  group,  the  Cladothrix,  has  the  power  of  sepa- 
rating ferric  oxide  from  water  containing  iron,  as  in 
iron  and  sulphur  springs.  Hut  very  little  is  known 
about  the  chemical  composition  of  bacteria  quanti- 
tatively, only  a  few  species  having  been  completely 
analyzed;  but  the  percentage  composition  would 
appear  to  depend  largely  upon  the  character  and 
constituents  of  the  culture  media  in  which  they  are 
grown. 

Conditions  of  Growth. — Although  there  are  some 
pathogenic  bacteria  which  grow  only  in  I  In'  bodies  of 
Uving  animals  and  plants,  and  are  therefore  apparently 
strict  parasites,  yet  the  majority  of  pathogenic  micro- 
organisms can  be  cultivated  more  or  less  readily  in 
artificial  culture  media,  and  are  thus  facultative 
parasites.  The  saprophytic  bacteria,  as  a  rule,  are 
easily  cultivated  artificially,  though  some  of  these,  as 
certain  organisms  met  with  in  the  saliva  and  in  water, 
are  very  difficult  or  impossible  to  cultivate. 

The  essential  condition  for  the  cultivation  of  all 
bacteria  is  water;  salts  are  also  indispensable,  and 
organic  matter  for  the  supply  of  carbon  and  nitrogen. 
Most  of  the  important  bacteria  and  all  the  pathogenic 
species  thrive  best  in  media  containing  albumin  and 
of  a  neutral  or  slightly  alkaline  reaction.  The  de- 
mands of  bacteria,  however,  with  regard  to  nutrition 
are  various.  Some  water  bacteria,  for  instance, 
require  so  little  organic  food  that  they  will  grow  in 
water  that  has  been  twice  distilled,  and  in  which  no 
nutritive  material  can  be  chemically  demonstrated. 
But  the  pathogenic  bacteria  are  seldom  so  easily 
satisfied,  though  there  are  several  species  which  will 
develop  in  comparatively  simple  culture  media  and 
without  albumin. 

Considering  more  in  detail  the  source  of  the  im- 
portant chemical  ingredients  of  bacteria,  we  find  that 
their  nitrogen  is  most  readily  obtained  from  diffusible 
albuminous  material  and  less  easily  from  ammonium 
compounds.  Their  carbon  they  derive  from  carbo- 
hydrates, albumin,  peptone,  sugars,  glycerin,  fats, 
and  other  organic  substances.  Some  bacteria  grow- 
best  in  special  culture  media,  such  as  bouillon, 
gelatin,  agar,  blood  serum,  potato,  milk,  etc.  The 
majority  of  bacteria  absolutely  require  the  presence 
of  free  oxygen  for  their  growth,  although  a  consider- 
able number  fail  to  develop  at  all  unless  oxygen 
is  excluded.  Between  these  two  groups  of  aerobic 
and  anaerobic  bacteria,  we  have  those  which  grow 
either  with  or  without  oxygen.  Some  of  the  strictly 
anaerobic  species  require  for  their  full  development 
the  presence  of  fermentible  substances,  such  as 
sugars,  from  which  they  obtain  their  oxygen.  In 
so  far  as  the  amount  of  oxygen  present  acts  un- 
favorably upon  bacteria,  there  will  be  more  or  less 
restriction  in  certain  of  their  life  processes,  such  as 
pigment  and  toxin  production,  spore  formation,  etc. 
Some  aerobic  bacteria,  however,  can  be  accustomed 
to  grow  without  oxygen,  while  certain  of  the  anae- 
robes can  be  gradually  made  to  develop  in  its  presence. 
Among  other  food  stuffs  required  by  bacteria  are 
sulphur  and  phosphorus;  calcium  or  magnesium  and 
sodium  or  potassium  are  also  usually  needed.  Very 
few  species  require  iron. 

With  regard  to  the  more  complex  culture  media, 
whether  naturally  existing,  such  as  blood  serum, 
ascitic  fluid,  etc.,  or  artificially  made,  as  bouillon, 
glycerin,  and  agar,  beyond  the  necessary  amount  of 
soluble  nutrition  present,  the  points  of  greatest  im- 
portance are  the  relative  proportion  of  each  form  of 
food  and  its  total  concentration.  Very  wide  differ- 
ences, however,  may  exist  in  the  composition  of  the 


culture  media  with  but  slight  effect  upon  ihe  develop- 
ment of  bacteria,  the  growth  usually  ceasing  on  ac- 
counl   of  (he  accumulation  of  deleterious  substat 
in  the  media  rather  than  from  exhaustion  ol  the  food 
supply. 

'Ihe  reaction  of  culture  media  is  of  great  importance. 

Most    bacteria  grow   besl  in  neutral  or  -lightly  alkaline 

media,  very  few  requiring  an  acid  medium,  and  Done 
of  the  parasitic  species.  \n  amount  of  acid  <,r  alkali 
insufficient  to  prevenl  the  development  of  bacteria 
may  yet  suffice  to  rob  them  of  some  of  their  mo  I 
important  functions,  as  the  production  of  toxins. 

The  influence  of  one  species  of  bacteria  upon  the 
growth  of  another,  either  w  hen  cultivated  together  or 
following  one  another,  is  very  noticeable.  The  develop- 
ment of  one  species  of  bacteria  in  a  medium  causes 
that  substance  usually  to  become  less  suitable  for  the 

growth   of  other  bacteria.      This  is  due  partly   to  the 

impoverishment  of  the  medium,  but  also  to 'the  pro- 
duction of  chemical  substances  or  enzymes  which  are 
antagonistic  not  only  to  the  growth  of  the  bacteria 
producing  them,  but  to  many  other  species;  very 
rarely  are  the  changes  produced  by  one  species  of 
bacteria  in  the  media  favorable  to  some  other  specie-. 
A  suitable  temperature  is  also  essential  for  the 
growth  of  bacteria.  The  most  favorable  or  optimum 
temperature  varies  for  different  species,  but  for  any 
bacteria  a  range  of  about  2.5°  C.  above  or  below  the 
optimum  covers  the  limits  of  their  most  vigorous 
growth.  Few  bacteria  grow  well  under  10°  C.  or  over 
lit  C;  2°  C.  is  about  the  lowest  temperature  at  which 
bacterial  species  has  been  known  to  grow,  and 
70°  C.  is  the  highest.  In  many  cases  the  temperature 
of  the  natural  medium  in  which  the  bacteria  have  been 
deposited  is  the  controlling  factor  in  deciding  the 
temperature  at  which  they  will  or  will  not  grow  under 
artificial  conditions.  Thus  nearly  all  parasitic 
bacteria  require  a  temperature  near  that  of  the 
body  (36°  -38°  V.)  for  their  development,  while  many 
saprophytic  bacteria  can  grow  only  at  much  lower 
temperature.  Bacteria  exposed  to  lower  temper- 
ature than  suffices  for  their  growth,  while  having 
their  activity  inhibited,  are  not  otherwise  injured; 
but  exposure  to  a  higher  temperature  than  that 
which   permits  growth   destroys  the  life  of  bacteria. 

Vital  Phenomena  of  Bacteria. — Motility. — 
.Many  bacteria  when  examined  in  the  hanging  drop 
are  seen  to  exhibit  active  movements.  This  motility 
is  produced  by  the  fine  hair-like  flagella  attached  to 
all  motile  species.  The  movements  are  various — 
creeping,  rotary,  undulatory,  etc.,  at  one  time  being 
slow  and  sluggish  and  at  another  so  rapid  that  no 
detailed  observation  is  possible.  The  spontaneous 
movements  of  bacteria  are  to  be  distinguished  from 
the  so-called  Browtuan  or  molecular  movement, 
which  is  a  dancing,  trembling,  stationary  motion 
possessed  by  all  finely  divided  organic  particles. 
Not  all  species  of  bacteria,  however,  which  have 
flagella  exhibit  spontaneous  motility  invariably; 
in  certain  culture  media  and  at  too  low  or  too  high 
temperatures,  and  when  there  is  an  insufficient  or 
excessive  supply  of  oxygen,  motility  may  be  absent. 
The  property  of  motility,  therefore,  evidently  depends 
upon  other  factors  than  flagella.  Some  chemical 
substances  apparently  exert  a  peculiar  attraction  for 
bacteria,  known  as  positive  chemotaxis,  while  others 
repel  them,  negative  chemotaxis;  not  all  varieties, 
however,  are  affected  alike,  for  the  same  substances 
may  exert  on  some  bacteria  an  attraction  and  on 
others  a  repulsion.  Oxygen,  for  example,  attracts 
aerobic  and  repels  anaerobic  species,  and  for  each 
different  species  there  is  a  definite  amount  of  oxygen 
which  most  strongly  attracts  or  repels.  Possibly 
these  chemotactic  properties,  which  are  as  yet  but 
little  understood,  may,  under  certain  conditions, 
have  something  to  do  with  the  motility  of  bacteria, 

831 


Bacteria 


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independently  of  their  organs  of  locomotion,  the 
flagella. 

Production  of  Light. — Some  bacteria  have  the  prop- 
erty of  emitting  light;  these  are  quite  widely  dis- 
tributed in  nature,  particularly  in  sea  water,  salt  fish, 
etc.  The  emission  of  light  or  phosphorescence  is  a 
property  of  the  living  protoplasm  of  bacteria,  and  is 
not  usually  due  to  the  oxidation  of  any  photogenic 
substance  produced  by  them.  Anything  which  is 
injurious  to  the  life  of  the  organism  affects  this  prop- 
erty, as  too  cold  or  too  high  a  temperature,  chloro- 
form, etc.  But  while  the  organism  is  unable  to  emit 
light  except  during  life,  it  can  live,  as  in  an  atmos- 
phere of  CO.,,  without  exerting  this  property.  The 
power  of  phosphorescence  is  soon  lost,  unless  the 
organism  is  constantly  transplanted  to  fresh  media, 
the  presence  of  oxygen,  carbon,  and  nitrogen  being 
usually  required  to  preserve  the  property. 

Thermic  Effects. — Most  bacteria  possess  the  power 
of  producing  heat,  although  this  does  not  ordinarily 
attract  attention  because  of  the  slight  amount  of 
heat  produced  in  cultures.  Careful  tests,  however, 
have  shown  that  heat  is  produced.  The  increase  of 
temperature  in  organic  substances  when  stored  in  a 
moist  condition,  as  tobacco,  hay,  manure,  etc.,  is 
partly,  at  least,  due  to  the  action  of  bacteria.  The 
high  temperature  thus  exhibited  may  be  caused,  as 
Rabinowitsch  suggests,  by  the  so-called  thermo- 
philic bacteria. 

Chemical  Effects. — The  processes  which  substances 
undergo  in  being  decomposed  depend,  first,  on  the 
chemical  composition  of  the  substances  involved  and 
the  conditions  under  which  they  exist,  and,  secondly, 
on  the  action  of  bacteria  present.  Bacteria  are  able 
to  construct  their  body  substance  out  of  various 
kinds  of  nutritive  materials  and  also  to  produce 
fermentative  products  and  poisons,  and  they  can  do 
these  things  either  analytically  or  synthetically  with  al- 
most equal  facility.  In  the  chemical  building  up  of 
their  cell  substance  we  may  distinguish  several  groups 
of  phenomena:  polymerization,  a  sort  of  doubling  up 
of  a  simple  compound;  synthesis,  a  union  of  different 
kinds  of  simple  substances  into  one  or  more  complex 
compounds;  formation  of  anhydrides,  by  which  new 
substances  arise  from  a  compound  through  loss  of 
water;  and  reduction  or  loss  of  oxygen,  which  is 
brought  about  especially  by  the  entrance  of  hydrogen 
into  the  molecule.  The  breaking  down  of  organic 
bodies  of  complicated  molecular  structure  into  sim- 
pler combinations  takes  place,  on  the  other  hand, 
through  the  loosening  of  the  bands  of  polymerization, 
by  hydration  or  entrance  of  water  into  the  molecule, 
or  by  oxidation. 

The  chemical  effects  of  bacteria  are  greatly  in- 
fluenced by  the  presence  or  absence  of  free  oxygen. 
The  access  of  pure  atmospheric  oxygen  makes  the 
life  process  of  most  bacteria  more  easy,  but  it  is  not 
indispensable  when  available  substances  are  present 
which  can  be  broken  up  with  sufficient  ease.  Life 
processes  carried  on  without  oxygen  do  not  effect  any 
profound  molecular  changes  in  the  organic  material 
which  is  decomposed;  but  in  order  that  the  living 
organism  may  obtain  the  requisite  amount  of  energy 
from  this  mode  of  life,  a  proportionately  large  quan- 
tity of  material  must  be  decomposed.  Therein  lies 
the  power  of  a  small  amount  of  ferment  to  produce 
much  alcohol  or  lactic  acid,  and  of  parasites  which 
have  invaded  the  living  body  to  generate  intensely 
poisonous  substances  out  of  the  body  proteids.  In  the 
presence  of  oxygen  the  decomposition  products 
formed  by  the  action  of  anaerobic  bacteria  are 
further  decomposed  and  oxidized  by  the  aerobes, 
being  thus  rendered  inert,  as  a  rule,  and  consequently 
harmless.  Some  bacteria  have  adapted  themselves 
to  the  use  of  oxygen  compounds,  from  which  they 
are  able  to  obtain  their  oxygen;  and  others — the 
obligatory  or  strict  aerobes — are  able  to  live  only  in 
the  presence  of  oxygen.     The  facts  of  anaerobiosis  are 


of  great  importance  to  technical  biology  and  path- 
ology. Under  strictly  anaerobic  conditions,  second- 
ary oxidation  of  the  products  of  decomposition  being 
impossible,  the  latter  accumulate  without  the  forma- 
tion of  by-products.  Thus  parasitic  bacteria  are 
often  found  to  produce  far  more  poison  in  the  ab>i 
than  in  the  presence  of  air. 

Fermentation;  the  Production  of  Organized  and 
Unorganized  Ferments. — The  chemical  effects  of 
bacteria  are  largely  dependent  upon  the  composition 
of  the  culture  media.  Thus  many  species  which  in 
albuminous  media  produce  no  visible  changes,  when 
sugar  is  added  give  rise  to  fermentation  with  the 
formation  of  gas.  The  term  fermentation  is  differently 
applied  by  different  authors.  Some  call  even  kind 
of  decomposition  due  to  bacteria  a  fermentation; 
others  limit  the  term  to  the  process  when  accompanied 
by  the  visible  production  of  gas;  while  others  again 
take  fermentation  to  mean  only  the  decomposition  of 
carbohydrates,  with  or  without  gas  production.  Fer- 
mentation may  be  properly  defined  as  a  chemical 
decomposition  of  an  organic  compound,  induced  by 
living  organisms  or  substances  contained  within  them 
(organized  ferments),  or  by  chemical  substances 
thrown  off  from  the  bacteria  (unorganized  ferment-i. 
In  the  first  the  action  is  due  to  the  growth  of  tin: 
organisms  producing  the  ferments,  as  in  the  formation 
of  acetic  acid  from  alcohol  by  the  action  of  the 
vinegar  plant,  and  in  the  second  the  enzyme  causes  a 
structural  change  without  losing  its  identity,  as  in 
digestion.  These  ferments  or  enzymes,  even  when 
present  in  the  most  minute  quantities,  have  the  power 
of  splitting  up  or  decomposing  complex  organic  com- 
pounds into  simpler,  more  easily  soluble  or  diffus- 
ible molecules.  Ferments,  like  albuminoids,  are  not 
dialyzable.  They  withstand  dry  heat,  but  are  de- 
stroyed in  watery  solution  by  a  temperature  of  over  70° 
C.  They  are  injured  by  acids,  especially  mineral  acids, 
but  are  resistant  to  alkalies.  All  fermentation  has 
for  its  object  the  acquisition  by  the  organism  of  a 
store  of  energy.  This  storing  up  of  energy  is  acquired 
in  either  of  the  ways  above  mentioned.  The  common- 
est example  of  fermentation  by  decomposition  is  that 
of  sugar  into  alcohol  and  carbonic  acid.  Exactly 
opposite  to  this,  and  far  less  common,  is  fermentation 
by  oxidation,  as  in  the  production  of  acetic  acid  from 
alcohol.  Proteolytic  or  peptonizing  ferments,  which 
are  similar  to  pepsin  and  trypsin,  in  that  they  decom- 
pose insoluble  albuminoids  into  soluble  or  digestible 
substances,  are  very  widely  distributed.  The  lique- 
faction of  gelatin,  produced  by  many  species  of  bacte- 
ria, is  due  to  the  presence  of  these  peptonizing  fer- 
ments. Diastatic  ferments,  which  convert  starch  into 
sugar,  like  ptyalin,  are  also  produced  by  bacteria. 
Other  bacterial  ferments  are  the  invertive  ferments,  or 
those  which  convert  cane  sugar  into  grape  sugar; 
and  the  rennet  ferments  having  the  power  of  coagulat- 
ing milk. 

The  process  of  fermentation  also  gives  rise  to  prod- 
ucts that  are  destructive  to  the  ferments;  hence 
fermentation  ceases  when  the  nutriment  is  exhausted. 
Different  kinds  of  fermentation  are  called  by  different 
names  according  to  the  products  they  yield.  Thus, 
aeetic  acid  fermentation,  alcoholic  or  vinous  fermenta- 
tion, lactic  acid  fermentation,  butyric  acid  fermenta- 
tion, etc.,  are  produced  by  different  species  of  bacteria. 

Putrefaction. — By  putrefaction  in  the  common 
acceptation  of  the  term  is  understood  the  decomposi- 
tion of  animal  or  vegetable  matter,  accompanied  by 
the  generation  of  fetid  odors.  Scientifically  con- 
sidered it  is  a  kind  of  fermentation  or  the  decomposi- 
tion of  complex  organic  compounds,  albuminous 
substances  and  the  like,  into  simpler  combinations, 
produced  by  microorganisms  called  putrefactive 
ferments.  Typical  putrefaction  occurs  only  when 
oxygen  is  absent  or  scanty.  As  putrefactive  products 
we  have  peptone,  ammonia,  and  the  amines — leucin, 


832 


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Bacteria 


tyrosin,  and  other  amido-substances;  oxyfatty  acids, 
indol,  scatol,  phenol;  and  finally  sulphureted  hydro 
gen,  mercaptan,  carbon  dioxide,  hydrogen,  and 
possibly  marsh  gas. 

,1,1      Production. — Various      bacteria      form 

characteristic  pigments  as  products  of  their  growth, 

S  ime  of  these  have  been  isolated  and  have  been  round 

to  possess  many  of  the  properties  of  the  aniline  dyes. 

fhey  have  no  known  importance  in  connection  with 

ase,  bii t  are  of  interest  and  value  in  identifying 

certain  species  of  bacteria.     The  principal  pigments 

need  by  chromogenic  bacteria  which  have  been 

ideally  studied  are:  red,  yellow,  violet,  bine,  and 

in  pigments.     All  conditions  which  are  unfavorable 

he  growth  of  the  bacteria  decrease  their  power  oi 

pigment  production,  as  cultivation  in  unsuitable  media 

or  too  low  or  too  high  a  temperature,  etc. 

Alkaline  Products  and  the  Decomposition  of  Urea. — 
ibic  bacteria  sometimes  produce  alkaline  products 
albuminous   substances   in   culture   media   free 
from  sugar.     Most  species  produce  acids  in  the  pres- 
ceoi  sugar,  neutral  or  slightly  alkaline  cultures  thus 
often    becoming    acid    at    first,    owing    to    the   small 
quantity   of  sugar  contained  in   the   meat  used  for 
making  nutrient  media;  and  later  when  the  sugar  is 
(  \luiusted   they   become   alkaline   again.     The   sub- 
stances producing  the  alkalinity  of  cultures  are  chiefly 
ammonia,    the    amines,    and    the    ammonium    salts. 
The  conversion  of  urea  into  carbonate  of  ammonia  is 
due  to  the  action  of  bacteria.     Several  organisms  also 
have  been   isolated   which  separate  ammonia  from 

Ptomaines. — Brieger  has  recognized  a  number  of 
complex  alkaloids,  closely  resembling  those  found  in 
ordinary  plants,  which  are  the  products  of  bacterial 
growth;  and  these  alkaloids  he  has  named  ptomaines 
(from  TTTUfia,  a  cadaver),  because  obtained  from 
putrefying  or  dead  bodies.  Nencke,  and  later 
Brieger,  Vaughan,  and  others,  have  succeeded  in 
preparing  organic  bases  of  definite  chemical  compo- 
sition out  of  putrefying  fluids — meat,  fish,  old  cheese, 
milk,  etc.,  as  well  as  from  pure  cultures  of  bacteria. 
Some  of  these  were  found  to  exert  a  poisonous  effect, 
and  for  a  long  time  were  looked  upon  as  the  specific 
bacterial  poison,  while  others  were  harmless.  The 
nis  are  particularly  interesting,  as  they  may  be 
present  in  the  putrefying  cadaver,  and  hence  must  be 
taken  into  consideration  in  medicolegal  questions. 
They  may  also  be  formed  in  the  living  body,  and  if 
not  rendered  innocuous  by  oxidation  may  come 
to  act  therein  as  self-poisons  or  leucomaines.  Recent 
investigations  have  shown  that  these  are  not  the  sub- 
stances to  which  are  due  the  specific  toxic  effects  of 
bacteria,  which  are  designated  toxins  and  have  quite 
different  characteristics. 

The  best-known  ptomaines  are:  CoUidine  from 
putrefying  meat  or  gelatin,  cadaverine  from  decom- 
posing dead  bodies,  neurine,  and  muscarine.  The  first 
two  of  these  contain  no  oxygen,  and  are  non-poisonous, 
while  the  last  two  ptomaines  contain  oxygen  and  have 
a  poisonous  action  the  opposite  of  atropine.  Tyro- 
toxicon,  a  ptomaine  decomposing  milk,  and  found  by 
Vaughan  in  poisonous  cheese,  is  apparently  derived 
from  butyric  acid.  Pyocyanine,  which  produces  the 
color  of  blue  and  green  pus,  is  a  ptomaine  pigment. 
Similar  bodies  may  also  be  found  in  the  intestinal 
contents  as  products  of  bacterial  decomposition. 
Some  of  them  are  poisonous  and  can  be  absorbed 
into  the  body,  where  they  play  the  part  of  self- 
poisons  or  leucomaines;  and  it  has  been  thought  that 
the  symptoms  designated  as  coma  and  tetany  may 
be  ascribed  to  the  absorption  of  substances  of  this 
nature.  The  name  ptomaine  was  formerly,  and  is 
still  by  some  authors,  applied  to  all  bacterial  poisons, 
as  in  cases  of  so-called  food  poisoning  due  to  de- 
composing meat,  sausage,  cheese,  or  milk.  But  in- 
stead of  ptomaines,  which  are  now  commonly  under- 
stood   to   include   only   the   crystalline   products   of 

Vol.  I.— 53 


bacterial  grow  ths,  these  effects  maj  be  cau  ed  to  the 

p"i  onon       protein       or     toxins,     which     an 

formed  in   the  beginning  of  putrefactive  proce    •   . 

Some  of  the  ptomaines  obtained  bj  cl I    an   not 

due  to  put refact ive  cha ngi  at  all,  but  to  i he  chemical 
on  i  boas  employed  in  separat  ing  them. 

Toxins. — Any  poisonous  sub  tance  formed  in 
growth  of  bacteria  or  other  microorganism  ma  be 
called  a  toxin.  The  different  bacterial  toxins  vary 
greatly  in  their  characteristics.  As  little  is  km 
concerning  their  chemical  nature,  thej  cannot  be 
definitely  classified.  But  for  practical  porposes  they 
may  lie  divided  into  two  group-:  i.  Extracellular 
toxins — specific    toxic    producl  ,    soluble    in    water, 

which  are  excreted  by  \  ai  iet bactei  ia  in  ordi 

nary  culture  media.  Type  diphtheria,  tetanus.  2. 
Intraculhdar  toxins  or  endotoxin  true  toxins,  which 
are  more  or  less  closely  bound  to  the  living  cell,  and 
which  are  only  in  a  small  degree  separable  in  un- 
changed condition  outside  of  the  body.  Type — 
cholera,  typhoid,  pneumococcus.  Among  the  intra- 
cellular toxins  some  which  are  resistant  to  heat  are 
somet  imes  called  prott 

Of  the  properties  of  the  extracellular  toxins  the 
following  are  the  most  important:  They  are,  so  far  as 
known,  uncrystallizable,  and  thus  differ  from  pto- 
maine-; they  are  soluble  in  water  ami  they  are  slowly 
dialyzable  through  thin  but  not  through  thick  mem- 
branes; they  arc  precipitated  along  with  proteins  by 
concentrated  alcohol,  sixty-live  per  cent,  or  over,  and 
also  by  ammonium  sulphate;  if  they  are  proteins  they 
are  either  albumoses  or  allied  to  the  albumoses;  they 
are  relatively  unstable,  Inning  their  toxicity  dimin- 
ished or  destroyed  by  heat  as  well  as  by  chemial 
manipulation.  Their  potency  is  often  altered  in  the 
precipitation  practised  to  obtain  them  in  a  pure  or 
concentrated  condition,  but  among  the  precipitants 
ammonium  sulphate  has  but  moderately  harmful 
effect.  They  are  highly  specific  in  their  properties 
and  have  the  power  in  the  infected  body  to  excite 
the  production  of  antitoxins — which  is  their  most 
remarkable  characteristic. 

Regarding  the  properties  of  the  intracellular  toxins 
much  less  is  known,  but  it  is  probable  that  their 
chemical  nature  is  somewhat  similar,  though  they 
differ  in  their  resistance  to  heat.  For  instance,  some 
of  the  toxins  elaborated  by  tubercle  bacilli  withstand 
boiling,  while  others  do  not.  In  the  case  of  all 
toxins,  the  fatal  dose  for  an  animal  varies  with  the 
body  weight,  age,  and  general  conditions. 

The  most  important  of  the  extracellular  toxins  are 
those  produced  by  the  diphtheria  and  tetanus  bacilli. 
The  toxicity  of  the  purest  tetanus  toxin  now  obtain- 
able is  almost  incredible  and  is  perhaps  the  most 
powerful  poison  known;  0.0005  mgm.  of  it  kills  a 
mouse  of  15  gm.  weight;  hence  a  man  of  150  pounds 
weight,  if  he  were  equally  susceptible,  would  be 
killed  with  0.23  mgm.  In  order  to  appreciate  the 
activity  of  this  toxin,  we  have  only  to  consider  that  it 
requires  a  dose  of  from  30  to  100  mgm.  of  strychnine 
to  kill  a  man  under  ordinary  circumstances. 

Similar  Vegetable  and  Animal  Poisons. — Substances 
similar  to  the  bacterial  endotoxins  and  soluble  toxins 
are  formed  by  many  varieties  of  cells  other  than 
bacteria.  The  ricin  and  abrin  poisons  obtained  from 
the  seeds  of  Ricinus  communis  and  Abrus  precatorius 
have  a  number  of  properties  similar  to  those  of  diph- 
theria and  tetanus.  Such  substances  have  been  called 
toxalbumins.  Poisonous  snakes  also  secrete  a  venom 
having  many  of  the  characteristics  of  the  bacterial 
albumoses. 

Reduction  Processes. — All  bacteria  possess  the  prop- 
erty of  converting  sulphur  into  H2S  in  the  pres- 
ence of  nascent  hydrogen.  This  is  a  very  common 
bacterial  product.  It  may  be  formed:  (1)  From 
albuminous  substances;  (2)  from  powdered  sulphur; 
(3)  from  thiosulphates  and  sulphites.  The  presence 
of  sugar  in   the  culture   media  does  not  effect  the 

S33 


Bacteria 


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production  of  H2S,  but  saltpetre  reduces  it,  with  the 
formation  of  nitrites.  The  following  reduction 
processes  brought  about  by  bacteria  also  depend  in 
part  upon  the  action  of  nascent  hydrogen:  The 
reduction  of  blue  litmus  pigments,  methylene  blue 
and  indigo  to  colorless  substances;  the  reduction  of 
nitrates  to  nitrites  and  ammonia,  and  even  to  free 
nitrogen.  The  so-called  "cholera-red  reaction"  de- 
pends upon  the  reduction  of  nitrates  to  nitrites  by 
the  cholera  spirillum  together  with  the  production 
of  indol.  When  chemically  pure  nitric  or  sulphuric 
acid  is  added  to  nutrient  peptone  cultures  of  the 
cholera  spirillum  a  rose-red  or  violet  color  is  produced. 
The  mineral  acid  splits  up  the  nitrites  present,  setting 
free  nitrous  acid  which,  with  the  indol,  gives  the  red 
reaction.  Although  called  "  cholera  red,  this  nitroso- 
indol  reaction  is  not  confined  to  the  cholera  spiril- 
lum, but  may  be  applied  to  many  other  bacteria. 
Out  of  sixty  species  examined  by  Lehmann,  twenty- 
three  gave  the  indol  reaction;  but  the  test  is  of  practi- 
cal value  in  differentiating  the  cholera  spirillum  from 
several  other  similar  species  for  which  it  may  be 
mistaken. 

Denitrification. — This  process  is  brought  about  by  a 
number  of  bacteria  which  separate  nitrogen  from  the 
nitrates  and  nitrites.  The  practical  significance  of 
these  organisms,  the  denitrifying  bacteria,  is  that 
by  their  action  large  quantities  of  nitrates  in  the  soil 
and  in  manure,  which  are  necessary  for  plant  food, 
may  thus  become  lost  through  conversion  into  free 
nitrogen. 

Assimilation  of  Nitrogen. — Although  so  far  as  we 
know  none  of  the  higher  plants  have  the  power  of 
assimilating  nitrogen  from  the  atmosphere,  this 
property  is  possessed  by  at  least  one  species  of 
bacteria,  the  Bacillus  radicicola  of  Beyerinck.  This 
organism  is  found  in  the  root  nodules  of  various 
leguminous  plants  (peas,  clover,  lupine,  etc.),  and 
can  be  isolated  from  these.  Different  varieties  of 
this  bacillus  exist  in  different  kinds  of  legumes,  each 
legume  apparently  having  a  special  variety  adapted 
to  its  needs.  There  are  also  certain  neutral  varieties, 
however,  existing  free  in  the  soil.  By  the  aid  of  these 
root  bacteria,  leguminous  plants  are  enabled  to 
assimilate  nitrogen  from  the  atmosphere,  thus  en- 
riching sandy  soils  which  are  naturally  poor  in  nitro- 
gen, so  that- they  yield  good  harvests. 

Formation  of  Acids  from  Carbohydrates. — Many  bac- 
teria form  free  acids  in  culture  media  containing 
carbohydrates  (sugar).  Acid  formation  occurs  some- 
times with  and  sometimes  without  the  production 
of  gas.  Excessive  formation  of  acid  may  cause  the 
death  of  the  bacteria  from  the  increased  acidity 
of  the  media  in  which  they  are  cultivated.  All 
anaerobic  and  facultative  anaerobic  species  form 
acids  from  sugar;  the  strictly  aerobic  species  do  not, 
or  they  do  it  so  slowly  that  the  acid  is  hidden  by 
the  almost  simultaneous  production  of  alkali  (Theo- 
bold  Smith).  If  after  the  sugar  is  used  up  not  enough 
acid  has  been  formed  to  kill  the  bacteria,  the  medium 
becomes  again  neutralized  and  finally  alkaline. 
Among  the  acids  produced  the  most  important  is 
lactic  acid,  also  traces  of  formic,  acetic,  propionic, 
and  butyric  acids,  and  not  infrequently  ethyl  alcohol 
and    aldehyde. 

Gas  Formation. — The  only  gas  produced  by 
bacteria  in  visible  quantity  in  culture  media  free 
from  sugar  is  nitrogen.  In  the  presence  of  sugar, 
so  long  as  lactic  or  acetic  acid  is  produced,  there  may 
be  no  gas  production;  but  frequently  gas  may  be 
abundantly  formed,  especially  by  anaerobic  bacteria 
or  in  the  absence  of  air.  About  one-third  of  the 
acid-producing  species  also  develop  gas,  consisting 
chiefly  of  carbon  dioxide  and  hydrogen.  Bacteria 
which  decompose  cellulose  also  produce  marsh  gas. 

Acid  Production  from  Alcohol. — It  has  long  been 
known    that    the    conversion   of   ethyl   alcohol   into 


acetic  acid  is  due  to  the  action  of  bacteria.  The 
conversion  of  the  higher  alcohols — glycerin,  mannit 
etc. — into  acids  is  also  caused  by  bacterial  action' 
as  is  also  the  conversion  of  the  fatty  acids  and  their 
salts  into  other  acids,  as  for  instance  the  salts  of 
lactic,  malic,  tartaric,  and  citric  acids  into  butyric 
propionic,  valerianic,  acetic  acids,  etc. 

Effects  of  Outside  Influences  upon  Bacteria. 
—  Very  little  is  known  about  the  influence  of  electricity 
on  bacteria;  but  the  observations  heretofore  made  on 
this  subject  would  seem  to  indicate  that  there  is  no 
direct  action  of  the  galvanic  current  on  microorgan- 
isms, though  the  effect  of  heat  and  electrolysis  may 
produce  changes  in  the  culture  which  finally  sterilize  it 

Slight  agitation  of  cultures  of  bacteria  seems  to 
act  favorably  on  their  development,  but  protracted 
and  violent  shaking  destroys  the  vitality  of  bacteria 
by  causing  a  molecular  disintegration  of  their  cells. 

Pressure  exerts  comparatively  little  influence  on 
bacteria.  A  culture  of  the  bacillus  pyocyaneus 
subjected  to  a  pressure  of  fifty  atmospheres  unde 
C02  still  grew  at  the  end  of  four  hours,  but  the 
power  of  pigment  production  was  lost.  After  six 
hours'  exposure  to  this  pressure  a  few  colonies  still 
developed,  but  after  twenty-four  hours  no  growth 
occurred. 

Light. — A  large  number,  perhaps  the  majority,  of 
bacteria  are  inhibited  in  growth  by  the  action  of 
diffuse  daylight,  still  more  by  that  of  direct  sunlight. 
Dieudonne  found  that  the  bacillus  prodigiosus 
exposed  to  the  action  of  direct  sunlight  during  the 
months  of  March,  July,  and  August  were  killed  in 
an  hour  and  a  half;  during  the  month  of  November, 
in  two  and  a  half  hours.  Diffuse  daylight  in  March 
and  July  inhibited  development  after  three  and  a 
half  hours'  exposure;  in  November  after  four  and  a 
half  hours,  and  vitality  was  completely  destroyed 
in  from  five  to  six  hours.  Exposure  to  the  action  of 
the  electric  arc  light  inhibited  development  in  five 
hours  and  destroyed  vitality  in  eight  hours;  incan- 
descent light  inhibited  growth  in  from  seven  to  eight 
hours  and  killed  in  eleven  hours.  Similar  results  have 
been  obtained  with  other  bacteria,  as  the  Bacillus  coli 
communis,  Bacillus  typhosus,  and  Bacillus  anthracis. 
The  tubercle  bacillus  was  found  by  Koch  to  be  killed 
by  the  action  of  direct  sunlight  in  from  five  minutes 
to  several  hou*s,  depending  upon  the  thickness  of  the 
layer  exposed  and  the  season  of  the  year.  Diffuse 
daylight  had  the  same  effect  in  from  five  to  seven 
days.  It  has  been  shown  that  it  is  only  the  ultra 
violet,  violet,  and  blue  rays  of  the  solar  spectrum 
which  possess  marked  bactericidal  action;  the  green 
rays  very  much  less,  and  the  red  and  yellow  rays  not 
at  all.  The  action  of  light  is  apparently  aided  in 
most  cases  by  the  admission  of  air;  but  anaerobic 
bacteria,  like  the  tetanus  bacillus,  and  facultative 
anaerobic  species,  as  the  colon  bacillus,  are  able  to 
withstand  the  action  of  sunlight  quite  as  well  in  the 
absence  as  in  the  presence  of  oxygen.  The  mechanism 
of  the  action  of  light  has  been  partially  explained,  at 
least,  by  the  demonstration  of  the  formation  of  hydro- 
gen peroxide  in  cultures  exposed  to  light  for  a  short 
time. 

Influence  of  One  Species  of  Bacteria  upon  Another. — 
If  we  examine  water,  milk,  or  the  contents  of  the 
intestinal  canal  of  either  sick  or  healthy  persons,  we 
invariably  find  several  species  of  bacteria  occurring 
together.  This  association  may  at  first  seem  to  be 
purely  accidental;  but  on  further  investigation  it 
will  be  found  that  there  are  among  bacteria  synergists 
and  antagonists,  or  at  least  certain  species  which 
apparently  assist  or  oppose  one  another  mutually 
or  one-sidedly.  This  action  is  sometimes  spoken  of 
as  symbiosis  and  enantobiosis  (Nencke).  Thus  it 
has  been  found  that  many  species  of  bacteria  will  not 


834 


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Bacteria 


row  at  all  or  only  scantily  in  cultures  when  m  close 
roximity  to  other  species,  the  action  Lent;  mutual 
,•  one-sided.     The  practical  application  of  tins  tact 
in  making  plates  for  the  isolation  of  pure  cultures 
r  for  the  counting  of  colonies,  to  have  the  plates  as 
liin    as    possible.      Bacteria    may    also    oppose    one 
,u,ther   antagonistically    in   the  animal  body.      Km- 
lerich  has  shown  that  animals  infected  with  anthrax 
,-iy  often  be  cured  by  a  secondary  infection  with  the 
treDtococcus.     The  symbiotic  or  cooperative  action 
,    Bacteria    is    of    still    greater    importance      Some 
,-u-teria    thrive    better    in    association     with    other 
necies   than   alone.     Certain   anaerobic    species    for 
mce    as  the  tetanus  bacillus,  grow  even  in  the 
iresence  of  air,   if  associated   with  aerobic   species. 
\eain   certain  chemical  effects  of  bacteria,  as  denitn- 
icatio'n  of  nitrates,  can  be  produced  only  when  two 
ics  are  associated.     In  like  manner  it  has  been 
,Wrved  that  some  soil  bacteria,  though  non-patho- 
ic  in  pure  culture,  when  inoculated  into  animal-  in 
combination  with  other  species  may  produce  disease. 
,lly,  slightly  pathogenic  species  gain  in  virulence 
alien  cultivated  with  common  saprophytic  bacteria,  as 
the  attenuated  tetanus  bacillus  with  Proteus  vulgaris. 
Lack  of  Food  and  Desiccation.— Most  bacteria,  and 
especially  the  pathogenic  species,  which  require  much 
.rganic    nutriment    for    their    development,     when 
placed  in  distilled  water  soon  die;  and  even  in  ster- 
ilized water  they  live  from  eight  to  ten  days  only 
and    rarely    multiply.     Desiccation    affects    bacteria 
in  various  ways.     In  dry  culture  media  development 
soon  ceases,   although  in  media  dried  gradually  at 
the    same    temperature    bacteria    may    retain    their 
vitality  often  for  several  months  even  in  the  absence 
of    spores.      Also    under    natural    conditions,    when 
these  are  favorable,  many  non-spore-bearing  bacteria 
live  a  long  time  when  exposed  to  desiccation,     bpore- 
bearing  species,   however,   are  much  more  resistant 
to   desiccation    as    also    to    other    injurious   outside 
influences  such  as  heat,  light,  chemicals,  etc. 

Behavior  toward  Oxygen  and  Other  Gases.— As 
already  noted  it  is  customary  to  divide  bacteria  into 
three  classes  according  to  their  behavior  toward 
oxygen:  aerobic,  anaerobic,  and  facultative  aerobic 
and  anaerobic  species. 

Aerobic  bacteria  grow  only  in  the  presence  of 
oxvgen;  the  slightest  restriction  of  air  inhibits  their 
development,  spore  formation  especially  requiring 
the  free  admission  of  air. 

Anaerobic  bacteria  grow  and  form  spores  only  in  the 
total  exclusion  of  oxvgen.  Among  this  class  of  organ- 
isms are  many  soil  bacteria,  such  as  the  bacillus  of 
malignant  edema,  the  tetanus  bacillus,  and  the  bacillus 
of  symptomatic  anthrax.  Exposed  to  the  action  of 
oxvgen,  the  vegetative  forms  of  these  bacteria  are 
readily  destroyed;  their  spores,  however,  are  very 
resistant.  Anaerobic  bacteria  being  deprived  of  the 
oxygen  of  the  air,  are  dependent  for  their  nutriment 
upon  decomposable  substances  such  as  glucose. 
Hence  for  their  cultivation  they  require,  as  a  rule, 
media  containing  from  one  to  two  per  cent,  of  glucose 
or  some  other  equivalent. 

Facultative  Aerobic  and  Anaerobic  Bacteria. — The 
greater  number  of  aerobic  bacteria,  including  most  of 
the  pathogenic  species,  are  capable  of  withstanding, 
without  being  seriously  affected,  a  considerable 
restriction  of  oxygen,  and  many  grow  equally  well  in 
the  partial  exclusion  of  this  gas.  Life  in  the  animal 
body,  for  instance,  necessitates  an  existence  with  a 
diminished  supply  of  oxygen.  Pigment  production 
usually  ceases  with  the  exclusion  of  oxygen,  but 
toxins  are  more  abundantly  formed.  The  presence 
of  living  or  dead  aerobic  species  may  facilitate  the 
aerobic  growth  of  anaerobic  species.  Moreover, 
certain  species  which  in  their  isolation  at  first  show 
more  or  less  anaerobic  development,  have  been 
observed  after  a  time   to  become  aerobes,  growing 


only   on    the   surface   of   media.     The  fact, 

therefore,  of  an  organism  showing  aerobic  01  anaerobic 
growth  is  nol  suffii  ienl  to  make  oi  i)  a  distim  I 

Although    all    facultative    as    well    a-    obligati 
anaerobes  grow  luxuriantly  in  nitrogen  or  hydrogen 
gas,  the  same  is  not  true  of  carbon  dioxide  gas.      Ma 
species  do  not   grow  at  all  but   are  inhibited  or  killed 

bj   rti  ,  while  others  exhibit  only  a  scanty  growth, 

and  very  few  are  not  affected.  Sulphureted  hydro- 
gen in  large  quantity  is  a  strong  bacterial  poison,  and 
in  small  amount  even  it  destroys  some    pi  i  ie  - 

Effect  of  Temperature.-  Every  bacterial  species 
makes  certain  demands  on  temperature  foi  it  -  growth. 
Vegetative  life  is  possible  within  the  limits  of  0°  and 

70°  C;  but  there  are  some  species  of  bacteria  which 
grow  at  the  lower  and  others  at  the  upper  limit  ol 
this  range.  The  maximum  and  minimum  tempera- 
ture- for  each  species  lie  about  30°  C.  apart.  Bacteria 
have  thus  been  classified,  according  to  the  tempera- 
ture at  which  they  develop,  into:  (1)  Psychrophilic 
bacteria.  .Minimum  growth  at  0°  C,  optimum  at 
15°  to  20°  C,  maximum  at  about  30°  C.  To  this 
class  belong  the  water  bacteria  having  the  power 
of  emitting  light.  (2)  Mesophilic  bacteria.  Mini- 
mum  growth  at  10°  to  15°  C,  optimum  at  37°  C., 
maximum  at  about  45°  C.  These  include  all  the 
pathogenic  species,  the  conditions  for  their  growth 
in  the  animal  body  requiring  acclimatization  to  the 
body  temperature.  (3)  Thermophilic  bacteria.  Mini- 
mum growth  at  40°  to  49°  C,  optimum  at  50°  to  55° 
C,  maximum  at  60°  to  70°  C.  This  class  includes 
many  soil  bacteria  and  almost  exclusively  spore-bear- 
ing species.  They  are  found  widely  distributed  in 
feces. 

By  carefully  elevating  or  reducing  the  temperature 
it  is  possible  to  extend  the  limits  within  which  different 
species  of  bacteria  will  grow.  Thus  the  anthrax 
bacillus  has  been  made  gradually  to  accommodate 
itself  to  a  temperature  of  42°  C,  and  pigeons,  which 
are  comparatively  immune  to  anthrax  infection,  on 
account  of  their  high  body  temperature,  wdren 
inoculated  with  this  modified  organism  succumb  to 
the  disease.  In  the  same  way  the  anthrax  bacillus 
has  been  acclimated  to  a  temperature  of  12°  C,  so 
that  it  killed  frogs  kept  at  this  temperature  (Dieu- 
donne)  A.  very  virulent  diphtheria  bacillus  has 
been  so  cultivated  that  it  grew  at  43°  C.  and  produced 
strong  toxin  (Park). 

Bacterial  growth,  though  retarded  by  temperatures 
just  below  the  minimum  of  the  species,  is  not  other- 
wise injured.  Cultures  of  bacteria  which  readily  die 
fas  the  streptococcus)  are  often  preserved  in  labora- 
tories by  keeping  them  in  the  refrigerator  at  4  to 
6°  C  Temperatures  even  far  below  0°  C.  are  only 
slowly  injurious  to  bacteria,  different  species  being 
affected  with  varying  rapidity.  Ordinarily,  low- 
temperatures,  though  arresting  the  growth,  do  not 
destroy  the  vitality  of  bacteria.  Microorganisms 
have  been  exposed  for  hours  in  a  freezing  mixture 
at-lS°  C  and  have  been  kept  in  an  open  tube  in 
liquid  air  at-  175°  C.  for  two  hours,  and  yet  have  been 
found  to  grow  when  placed  again  under  favorable 
conditions. 

Temperatures  from  5°  to  10°  C.  over  the  optimum, 
however,  affect  bacteria  injuriously  in  several  ways. 
The  effects  produced  are  the  production  of  varieties 
of  diminished  activity  of  growth,  weakening  of 
virulence  and  decrease  of  the  property  of  causing 
fermentation,  and  finally  gradual  loss  of  power  of 
spore  formation.  One  or  other  of  these  effects  may 
predominate  under  varying  conditions. 

If  the  maximum  temperature  is  exceeded  the 
organism  soon  dies;  the  thermal  death  point  for 
psychrophilic  species  being  about  37°  C,  for  meso- 
philic about  45°  to  55°  C,  and  for  thermophilic  about 
75°    C.     There    are    no    non-spore-bearing    bacteria 

S35 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


which,  when  moist,  are  able  to  withstand  a  tempera- 
ture of  100°  C.  even  for  a  few  minutes.  According 
to  Sternberg,  ten  minutes'  exposure  to  moist  heat 
"will  kill  the  cholera  spirillum  at  -52°  C,  the  strepto- 
coccus at  54°  C,  the  typhoid  bacillus  at  50°  C,  the 
diphtheria  bacillus  and  gonococcus  at  60°  C,  and  the 
staphylococcus  at  62°  C.,  the  last  mentioned  being 
the  most  resistant  of  pathogenic  organisms  without 
spores.  When  bacteria  in  a  desiccated  condition  are 
exposed  to  the  action  of  heated  air  the  temperature 
required  for  their  destruction  is  much  above  that 
needed  when  they  are  moist  or  exposed  to  the  action 
of  hot  water  or  steam.  A  large  number  of  bacteria 
are  able  to  resist  dry  heat  at  a  temperature  of  over 
100°  C.  for  an  hour.  A  temperature  of  120°  to  130°  C. 
maintained  for  an  hour  and  a  half  is  required  to 
destroy  all  bacteria,  in  the  absence  of  spores,  if  hot 
air  is  used. 

Spores  are  far  more  resistant  to  all  injurious  in- 
fluences than  vegetative  forms,  and  can  withstand 
also  a  greater  degree  of  both  moist  and  dry  heat. 
.Many  spores  are  able  to  resist  a  temperature  of  130°  C. 
dry  heat,  the  spores  of  the  anthrax  and  the  hay 
bacilli  requiring,  for  instance,  an  exposure  of  three 
hours  to  a  temperature  of  140°  C.  to  insure  their 
destruction.  Moist  heat  at  a  temperature  of  100°  C, 
either  boiling  water  or  streaming  steam,  destroys 
the  spores  of  all  known  pathogenic  bacteria  within 
ten  minutes;  the  spores  of  some  non-pathogenic 
species  resist  this  temperature,  however,  for  hours. 
While  steam  under  pressure  is  more  effective  than 
streaming  steam  in  practical  disinfection,  it  is  scarcely 
necessary  to  give  it  the  preference,  inasmuch  as  all 
known  pathogenic  bacteria  and  their  spores  are 
quickly  destroyed  by  the  temperature  of  boiling 
water.  "Superheated"  steam  has  about  the  same 
germicidal  power  as  hot,  dry  air  at  the  same  tem- 
perature, and  is  less  effective,  of  course,  than  moist 
steam. 

Tyndalization;  Fractional  Sterilization. — Certain 
nutrient  media,  such  as  blood  serum  and  the  transu- 
dates of  the  body  (ascitic  and  hydrocele  fluids,  etc.), 
and  some  fluid  food  stuffs,  require  at  times  to  be 
sterilized  and  yet  cannot  be  subjected  to  temperatures 
high  enough  to  kill  spores  without  suffering  injury. 
The  property  of  spores,  when  placed  under  suitable 
conditions,  to  germinate  into  vegetative  forms,  is 
here  taken  advantage  of  by  heating  the  fluids  to  55° 
or  78°  C.  for  one  hour  on  six  consecutive  days.  By 
this  means,  upon  each  exposure,  all  the  bacteria 
which  have  grown  in  the  interval  are  killed  in  the 
vegetative  form.  Experience  has  shown  that,  with 
few  exceptions,  this  method  of  fractional  sterilization 
will  completely  sterilize  all  fluids  thus  treated. 

Pasteurization. — It  is  often  undesirable  to  expose 
milk  and  other  food  stuffs  to  such  a  high  tem- 
perature, because  of  the  deleterious  effects  produced, 
and  yet  a  partial  sterilization  is  required.  According 
to  the  method  of  Pasteur,  however,  milk,  etc.,  may  be 
heated  for  thirty  minutes  to  70°  C,  which  will  kill  all 
vegetative  bacteria  present,  allowing  only  the  spores 
to  remain  alive.  But  even  this  partial  sterilization 
greatly  retards  the  process  of  fermentation  or 
putrefaction. 

Attenuation  of  Virulence. — Although  pathogenic 
bacteria  seem  to  have  retained,  for  centuries  at  least, 
their  principal  characteristic  in  producing  disease,  they 
have  been  found  to  suffer  under  certain  unfavorable 
outside  influences  a  marked  diminution  in  power,  or 
attenuation  of  virulence.  This  loss  of  power  may  be 
effected  artificially  by  several  methods,  all  of  which 
depend  upon  subjecting  the  cultures  to  adverse  con- 
ditions of  one  kind  or  another.  The  first  and  simplest 
method  is  by  allowing  the  cultures  to  grow  old.  Ob- 
viously a  pure  culture  cannot  last  forever,  and  in 
order  to  retain  the  virulence  of  species  it  is  often 
necessary  to  subculture  upon  fresh  media.     Another 

S36 


mode  is  to  raise  the  pure  culture  to  a  temperature  a 
little  below  that  which  destroys  the  vitality  of  the 
organism.  A  third  way  is  to  expose  the  culture  to  the 
action  of  antiseptic  agents.  A  fourth,  but  rarely 
necessary  method,  is  cultivation  in  the  blood  of  au 
immune  animal. 

Increase  of  Virulence. — It  is  much  more  difficult  to 
restore  lost  power  or  to  increase  the  virulence  of  bacte- 
ria than  to  weaken  their  toxicity.  The  method  usually 
employed  is  by  the  frequent  replanting  of  cultures 
or  by  successive  inoculations  into  susceptible  animals! 
In  general,  pathogenic  virulence  is  increased  by  succegl 
sive  inoculation  into  susceptible  animals,  and  dimin- 
ished by  cultivation  in  artificial  media  under  unfavor- 
able conditions. 

Effect  of  Chemical  Agents. — Many  chemical  sub- 
stances when  brought  in  contact  with  bacteria  unite 
with  their  cell  substance,  forming  new  compounds  and 
usually  destroying  the  life  of  the  organisms.  Bacteria 
are  much  more  easily  killed  by  chemicals  when  in  the 
vegetative  than  in  the  spore  stage,  and  their  life 
functions  are  inhibited  by  substances  less  injurious 
than  those  required  to  destroy  their  vitality.  But 
both  in  the  vegetative  and  spore  forms  they  differ 
considerably  in  their  resistance  to  chemical  agent - 
The  reason  for  this  is  but  imperfectly  understood,  but 
it  probably  depends  upon  the  composition  of  tin  h 
cell  substance,  and  is  due  to  a  true  chemical  combina- 
tion taking  place.  Chemicals  are  more  destructive  to 
bacteria  at  a  high  than  at  a  low  temperature,  and  they 
act  more  quickly  when  the  bacteria  are  suspended 
loosely  in  fluids  than  when  in  masses.  In  estimating 
the  extent  of  the  action  of  chemical  agents  upon 
bacteria  we  usually  distinguish  the  following  degrees: 

1.  Attenuation. — The  growth  is  not  permanently 
interfered  with,  but  the  pathogenic  and  zymogenic 
functions  of  the  organism  are  diminished. 

2.  Asepsis  or  Inhibition. — The  organisms  are  not 
able  to  multiply,  but  they  are  not  destroyed. 

3.  Antisepsis,  or  Incomplete  Sterilization.— The 
vegetative  development  of  the  organism  is  destroyed, 
but  not  the  spores. 

_  4.  Disinfection,  or  Complete  Sterilization. — Vegeta- 
tive forms  and  spores  are  destroyed. 

Many  substances  which  are  strong  disinfectants 
become  altered  under  the  conditions  in  which  they 
are  used,  so  that  they  lose  a  part,  if  not  all,  of 
t  heir  germicidal  properties.  Thus  quicklime  and  milk 
of  lime  are  disinfecting  agents  only  so  long  as  sufficient 
calcium  hydroxide  is  present.  If  this  is  changed  by 
the  carbon  dioxide  of  the  air  into  carbonate  of  lime  it 
becomes  inert.  Bichloride  of  mercury  and  other 
chemicals  form  compounds  with  many  organic  and 
inorganic  substances,  which,  though  still  germicidal, 
are  much  less  so  than  the  original  substances. 

Disinfectants. — Among  the  more  commonly  used 
disinfectants    may    be    mentioned: 

1.  Mineral  Disinfectants. — Bichloride  of  mercury. 
This  substance  in  the  proportion  of  1  to  1,000,000  in 
nutrient  gelatin  or  bouillon,  prevents  the  develop- 
ment of  parasitic  bacteria.  In  the  proportion  of  1  to 
500,000  in  water  it  will  kill  many  species  in  a  few  min- 
utes, but  in  bouillon  twenty-four  hours  may  be  needed. 
With  organic  substances  its  power  is  lessened,  so  that 
1  part  in  1,000  may  be  required.  Spores  are  killed  in 
1  to  1,000  watery  solution  within  one  hour.  Corrosive 
sublimate  is  therefore  less  effective  as  a  germicide  in 
alkaline  solutions  containing  much  albumin  than  in 
aqueous  solutions.  In  such  fluids,  besides  loss  in  other 
ways,  albuminate  of  mercury  is  formed,  which  is  at 
first  insoluble,  so  that  a  part  of  the  mercuric  salt  is 
reallj-  inert.  In  alkaline  solutions,  such  as  blood, 
blood  serum,  pus,  tissue  fluids,  etc.,  the  soluble  com- 
pounds of  mercury  are  converted  into  oxides  or  hy- 
droxides. The  soluble  compounds  can  therefore 
remain  in  solution  only  when  there  are  present 
sufficient  quantities  of  certain  bodies   (the  alkaline 


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I!  I.  lc  I  l.i 


■hlorides     and     iodides,     sodium     and     ammonium 
■hlorides)   which  render  solutions  possible.     The  ad- 
lition  of  a  suitable  quantity  of  common  salt  to  the 
'orrosive  sublimate   thus  prevents   the  precipitation 
if  tile  mercury.     Compounds  of  mercury  which,  like 
he  cyanides,  are  not  precipitated  with  alkalies,  be- 
ause  they  form  double  -alts,  require  no  addition  of 
•  nit.     For  ordinary  use,  solutions  of  1  to  500  and  1  to 
[000  of  bichloride  of  mercury  will  suffice  to  kill  the 
etativc  forms  of  bacteria  within  fifteen  minut 
ii  much  organic  matt  it  is  present  the  .-tronger  solu- 
tion should  be  used. 

Biniodide  of  mercury  i-  very  similar  in  its  effects  to 
the  bichloride,  and  is  even  more  powerful. 

•  in  solution  has  about  one-fourth  the 
germicidal  value  of  bichloride  of  mercury,  but  nearly 
same  antiseptic   value. 
3   Iphale  of  copper  has  about  five  per  cent,  the  value 
of  mercuric  chloride. 

S   Iphale    of    iron    is    a    very    feeble    disinfectant. 
istic   soda   in   a    thirty    per   cent,   solution    kills 
anthrax  spores  in  about  ten  minutes;  in  four  per  cent . 
solution  in  about  forty-five  minutes. 

rarbonale  even  in  concentrated  solution  kills 
spores  with  difficulty,  but  at  85°  C.  it  kills  spore-  in 
from  eight  to  ten  minutes;  a  five  per  cent,  solution 
kills  the  vegetative  forms  of  bacteria  in  a  short  time, 
i  Irdinary  soap  suds  have  a  slight  bactericidal  as  well 
aarked  cleansing  effect.  The  bicarbonate  of  so- 
dium has  almost  no  destructive  action  on  bacteria. 

\in m  hydroxide  is  a  powerful  disinfectant;  the 
carbonate  has  little  or  no  germicidal  action.  A  one 
per  cent,  solution  of  calcium  hydroxide  in  water  kills 
bacteria  in  vegetative  form  within  a  few  hour-:  a 
three  per  cent,  solution  kills  typhoid  bacilli  in  one 
hour;  a  twenty  per  cent,  solution  added  to  equal  parts 
of  feces  and  thoroughly  mixed  completely  sterilizes 
them  in  one  hour. 

Mineral  acids,  bulk  for  bulk,  are  more  germicidal 
than  vegetable  acids.  But  any  acid  which  equals 
40  c.c.  of  normal  hydrochloric  acid  will  prevent  the 
growth  of  all  species  of  bacteria  and  will  kill  many. 
Twice  this  amount  destroys  most  bacteria  in  a  short 
time.  A  1  to  500  solution  of  sulphuric  acid  kill< 
typhoid  bacilli  within  an  hour.  Hydrochloric,  citric, 
tartaric,  malic,  formic,  and  salicylic  acids  are  similar 
t^  acetic  acid  in  germicidal  properties.  Boric  acid 
destroys  the  less  resistant  bacteria  in  two  per  cent, 
solution  and  inhibits  the  growth  of  others. 

II.  Organic  Disinfectants. — Alcohol  in  ten  per  cent, 
solution  inhibits  the  growth  of  bacteria;  absolute  al- 
cohol kills  bacteria  in  the  vegetative  form  in  from  sev- 
eral   to    twenty-four   hours. 

Chloroform,  even  when  chemically  pure,  does  not 
destroy  spores,  but  a  one  per  cent,  solution  will  kill 
bacteria  in  vegetative  form. 

Iodoform  has  but  little  destructive  action  on  bacte- 
ria, and  upon  most  species  has  no  appreciable  effect 
at  all.  Winn  mixed  with  pus  from  wounds,  etc  , 
iodoform  is  reduced  to  soluble  iodine  compounds, 
which  partly  act  destructively  upon  the  bacteria  and 
partly  unite  with  the  poisons  produced  by  them. 
Carbolic  acid  in  aqueous  solutions  1  to  1,000  inhibits 
the  growth  of  bacteria;  in  the  proportion  of  1  to  400 
it  kills  the  less  resistant  organisms,  and  in  1  to  100 
solution  destroys  all  vegetative  forms.  A  five  per 
cent,  solution  kills  the  less  resistant  spores  in  a  few 
hours  and  the  more  resistant  in  from  one  day  to  four 
weeks;  a  slight  increase  of  temperature  aids  the  de- 
structive action.  A  three  per  cent,  solution  kills  strep- 
tococci, staphylococci,  anthrax  bacilli,  etc.,  within  one 
minute.  Carbolic  acid  loses  much  of  its  value  when  in 
solution  with  alcohol  or  ether,  but  the  addition  of  0.5 
per  cent,  hydrochloric  acid  aids  its  activity.  Carbolic 
acid  is  so  permanent  and  comparatively  so  little  influ- 
enced by  the  presence  of  albumin,  that  it  is  one  of  the 
best  agents  for  general  use  in  practical  disinfection. 


Cresol  is  the  chief  ingre -called  "  crude  car- 
bolic acid."      It   is  al si   insoluble  in  water  and  has 

therefore  little  germicidal  value.  Mixed  with  equal 
parts  of  sulphuri  render  it  soluble  it  i-  a  power- 

ful disinfectant,  but  it  i-  then  strongly  corn. 

Creolin  i-  an  alkaline  emulsion  of  tin-  cresols  and 
other  products  contained  in  crude  carbolic  acid  with 

snap,  ami  is  as  powerfully  disil  pure  carbolic 

acid;  it  is  used  in  live  per  cent,  emulsions. 

Lysul  is  similar  to  creolin  and  has  about  the  same 
germicidal  value. 

TricTi  \ol  i-  a   refined    mixture  of   the   three   en 
(meta-,  para-,  and  orthocresol) ;  it  is  soluble  in  water 
to  the  extent  of  2.5  per  cent.,  and  is  about  thi 
as  s(  rung  as  carbolic  acid. 

The  many   of   them,    possess   marked 

germicidal  propei  ii  Methyl  violet  ami  malachite 
green  destroy  the  typhoid  bacillus  in  bouillon  cul- 
tures in  1  to  .'Oil  solution  in  two  hours,  ami  the  pyo- 
genic cocci  in  less  time.  Even  in  1  to  100,000  solution 
they  are  -aid  In  inhibit   bacterial  growth. 

The   essential  oils   an-   also   strongly   disinfectant. 

The  oils  of  cinnamon,  clove.-,  thyme,  -am  la  I  v. I.  it.    . 

oy  most  bacteria  in  from  one  to  twelve  hours. 
Thymol  and  eucalyptol  have  about  one-fourth  the 
strength  of  carbolic  acid,  t  > i L  of  peppermint  in  1  to 
.Union  inhibits  bacterial  growth.  Oil  of  turpen- 
tine in  1  to  200  solution  does  t ho  same.  Camphor 
has  very  little  anti.-eptic  action.  (See  also  article 
on  I>  Is.) 

III.  Gaseous  Disinfectants. — Formaldehyde  is  a 
gaseous  compound  of  strongly  disinfectant  properties 

and  posse 1  of  an  extremely  irritating  odnr.       At   a 

temperature  of  68°  F.  the  gas  is  polymerized,  that  i-  in 
say,  a  second  body  is  formed  composed  of  a  union  of 
two  molecules  of  CH20.  This  is  known  as  "para- 
formaldehyde," and  is  a  white  soapy  substance, 
soluble  in  boiling  water  and  alcohol;  it  exists  in  the 
solution  of  commerce  ordinarily  called  "formalin," 
which  is  a  clear  watery  liquid  containing  from  33 to 
40  per  cent,  of  the  gas  and  10  to  20  per  cent,  of  methyl 
alcohol,  its  chief  impurity.  When  this  is  concen- 
trated, about  40  per  cent,  paraformaldehyde  results. 
Pried  over  sulphuric  acid  a  third  body — "trioxy- 
methylene" — is  produced,  consisting  of  three  mole- 
cules of  CH,0,  and  is  a  white  substance  almost  in- 
soluble in  water  or  alcohol,  and  giving  off  a  strong 
odor  of  formaldehyde.  The  solid  polymers  of  form- 
aldehyde when  heated  are  again  reduced  to  the  gaseous 
condition;  ignited  they  finally  take  fire  and  burn  with 
a  blue  flame,  leaving  but  little  ash. 

Formaldehyde  has  an  active  affinity  for  many 
organic  substances  and  forms  with  snme  of  them  defi- 
nite chemical  combinations.  It  combines  readily  with 
ammonia  to  produce  a  compound  called  ammoniacal 
aldehyde  which  possesses  neither  odor  nor  the  anti- 
septic properties  of  formaldehyde.  This  action  has 
been  made  use  of  in  neutralizing  the  odor  of  for- 
maldehyde when  it  is  desired  to  dispel  it  rapidly  after 
disinfection  of  habitations.  Formaldehyde  also  forms 
combinations  with  certain  aniline  colors,  viz.,  fuchsin 
and  safronin,  modifying  their  shades.  The  most 
delicate  fabrics  of  silk,  wool,  cotton,  fur,  leather,  etc., 
however,  are  unaffected  in  texture  or  color  by  formal- 
dehyde. Iron  and  steel  are  attacked  after  long 
exposure  to  the  gas  or  its  solution:  but  copper,  brass, 
nickel,  zinc,  silver,  and  gold  work  are  not  at  all  acted 
upon.  Formaldehyde  unites  with  nitrogenous  prod- 
ucts of  decay,  fermentation,  and  putrefaction,  form- 
ing true  chemical  compounds,  which  are  odorless  and 
sterile.  It  is  thus  a  complete  deodorizer.  Formal- 
dehyde has  a  peculiar  action  upon  albumin,  which  it 
transforms  into  an  insoluble  and  indecomposable 
substance.  It  is  to  this  property  of  combining  chem- 
ically with  albuminous  substances  forming  the  proto- 
pla-in  of  bacteria  that  formaldehyde  owes  its  ger- 
micidal powers.     It  is  also  an  excellent  preservative  of 

S37 


Bacteria 


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organic  products  for  the  same  reason;  and  use  has 
been  made  of  it  to  preserve  meat,  milk,  and  other  food 
products.  But  according  to  Trillat  and  others  it 
renders  these  substances  indigestible  and  unfit  for 
food.  It  has  been  successfully  employed,  however, 
as  a  preservative  of  botanical,  pathological,  and 
histological  specimens. 

The  vapors  of  formaldehyde  are  extremely  irritating 
to  the  mucous  membrane  of  the  eyes,  nose,  and  mouth, 
causing  profuse  lacrymation,  eoryza,  and  secretion  of 
saliva.  Aronson  has  stated  that  rabbits  and  guinea- 
pigs,  allowed  to  remain  for  twelve  to  twenty-four  hours 
in  rooms  which  were  being  disinfected  with  formal- 
dehyde gas,  were  unaffected  by  the  fumes.  But 
other  experimenters  have  found  that  animals,  such  as 
dogs,  cats,  etc.,  accidentally  exposed  for  some  time 
to  the  action  of  the  gas,  suffered  severely,  and  some 
have  died  from  its  effects.  It  would  seem,  therefore, 
that  although  formaldehyde  is  comparatively  non- 
toxic to  the  higher  forms  of  animal  life,  nevertheless 
a  certain  degree  of  caution  should  be  observed  in  its 
use.  Roaches,  flies,  bedbugs,  and  other  insects  are, 
as  a  rule,  not  killed  by  formaldehyde  gas  in  the  process 
of  disinfecting  a  room. 

The  results  of  numerous  experiments  in  practical 
disinfection  with  this  agent  have  shown  that  two  and 
one-half  per  cent,  by  volume  of  the  aqueous  solution 
of  formaldehyde,  or  one  per  cent,  by  volume  of  the  gas, 
is  sufficient  to  destroy  the  vegetative  forms  of  patho- 
genic bacteria  in  a  few  minutes,  when  they  are  freely 
exposed  to  its  influence  and  in  a  moist  condition.  The 
germicidal  power  of  the  gas  depends  not  only  upon  its 
concentration,  but  also  upon  the  temperature  and 
the  condition  of  the  object  to  be  sterilized.  As  with 
other  gases,  it  has  been  found  that  the  action  is  much 
more  rapid  and  complete  at  higher  temperatures 
(35°  to  45°  C),  and  when  the  test  objects  are  moist 
and  freely  exposed,  than  at  lower  temperatures  and 
when  the  objects  are  dry  and  in  mass;  the  gas  possesses 
when  dry  little  or  no  penetrative  power.  Still  it  has 
been  repeatedly  demonstrated  that  it  is  possible  to 
disinfect  the  surface  of  rooms  and  articles  contained 
in  them,  under  the  conditions  of  temperature  and 
moisture  ordinarily  found,  by  an  exposure  of  a  few 
hours  to  a  saturated  atmosphere  of  the  gas. 

Sulphur  dioxide  gas  has  been  extensively  used  for 
the  disinfection  of  hospitals,  ships,  apartments,  etc. 
Its  action  depends  upon  the  formation  of  sulphurous 
acid  in  the  presence  of  moisture.  In  its  pure  state 
S02  does  not  destroy  spores,  and  even  on  vegetative 
forms  its  germicidal  effect  is  uncertain.  An  exposure, 
however,  for  eight  hours  to  an  atmosphere  containing 
at  least  four  volumes  per  cent,  of  this  gas  in  the  pres- 
ence of  moisture  will  destroy  most,  if  not  all,  the  com- 
mon non-spore-bearing  pathogenic  bacteria.  It  is 
not  so  prompt  or  powerful  in  its  action  as  formalde- 
hyde gas,  which  in  many  respects  is  a  preferable  dis- 
infectant, especially  in  cases  where  the  sulphurous 
acid  formed  from  the  sulphur  dioxide  may  have  an 
injurious  effect  upon  the  articles  to  be  disinfected. 

Peroxide  of  hydrogen  is  an  energetic  disinfectant, 
and  in  two  per  cent,  solution  (about  forty  per  cent,  of 
the  ordinary  commercial  article)  will  kill  the  spores  of 
anthrax  in  from  two  to  three  hours.  A  twenty  per 
cent,  solution  of  good  commercial  peroxide  of  hydrogen 
will  quickly  destroy  the  pyogenic  cocci  and  other  non- 
spore-bearing  bacteria.  On  account  of  its  rapidity  of 
action  and  non-poisonous  character  it  is  a  useful  and 
safe  disinfectant,  but  it  combines  with  organic  matter 
and  becomes  inert,  being  apt  to  deteriorate  if  not  prop- 
erly kept. 

Chlorine  is  a  powerful  gaseous  germicide,  owing  its 
activity  to  its  affinity  for  hydrogen  and  consequent 
release  of  nascent  oxygen,  when  it  conies  in  contact 
with  microorganisms  in  a  moist  condition.  Like 
formaldehyde  gas  and  sulphur  dioxide  it  is  much  more 
active  in  presence  of  moisture  than  in  a  dry  condition. 
Dried   anthrax   spores   exposed   for   an   hour   in   an 

838 


atmosphere  containing  44.7  per  cent,  of  dry  chlorine 
were  not  destroyed;  whereas  when  the  spores  were 
previously  moistened  and  exposed  in  a  moist  atmos- 
phere for  the  same  time,  four  per  cent,  was  effective 
and  when  the  time  was  extended  to  three  hours,  one 
per  cent,  destroyed  their  vitality.  The  anthrax 
bacillus,  in  the  absence  of  spores,  was  killed  by  an 
exposure  in  a  moist  atmosphere  containing  1  part 
to  2,500  for  twenty-four  hours.  In  watery  solution 
0.2  per  cent,  kills  spores  within  five  minutes,  and  the 
vegetative  forms  almost  immediately. 

Chloride  of  lime  owes  its  efficacy  to  the  chlorine  it 
contains  in  the  form  of  hypochlorites.  A  solution  of 
one-half  to  one  per  cent,  of  fresh  chloride  of  lime  in 
water  will  kill  most  bacteria  in  from  one  to  five 
minutes;  a  five  per  cent,  solution  usually  destroys 
spores  in  an  hour. 

Bromine  and  iodine  are  of  about  the  same  germicidal 
value  as  chlorine,  in  the  moist  condition;  but,  like 
chlorine,  they  are  not  applicable  for  general  use  in 
house  disinfection  on  account  of  their  poisonous  and 
destructive  properties.  They  are  useful  for  the 
disinfection  of  sewers,  and  other  similar  places. 
Trichloride  of  iodine  in  0.5  per  cent,  solution  destroys 
the  vegetative  forms  of  bacteria  in  about  five  minutes, 

(The  relation  of  bacteria  to  disease — infection, 
immunity,  etc. — will  be  considered  elsewhere;  as 
will  also  the  subject  of  Bacteriological  technique.) 

Special  Bacteria. 

Under  this  heading  will  be  described  the  chief 
characteristics  of  the  more  important  bacterial  species 
pathogenic  for  man  and  other  animals.  There  are 
many  bacteria  which  have  been  found  in  certain 
diseases,  but  their  causal  relation  to  the  disease  has 
not  yet  been  proven,  and  they  have  also  been  found 
in  other  affections.  These  we  cannot  treat  of  here. 
Nor  will  space  allow  us  to  consider  the  non-patho- 
genic species,  or  those  which  do  not  affect  man,  but 
are  pathogenic  for  the  lower  animals  only. 

The  Tubercle  Bacillus  (Koch's  Bacillus  tubercu- 
losis).— The  infectious  nature  of  tuberculosis  was 
first  demonstrated  by  Villemin  in  1865,  when  by 
inoculation  with  tuberculous  material  he  communi- 
cated the  disease  to  healthy  susceptible  animals. 
In  1882  Koch  discovered  the  Bacillus  tuberculosis, 
which  is  now  known  to  be  the  specific  cause  of  the 
disease. 

Microscopical  Appearances. — The  tubercle  bacillus 
occurs  in  sputum  and  in  cultures  as  slender  rods  from 
1.5  to  4  [i  long  and  about  0.3  a  broad,  often  slightly 
curved.  The  bacilli  usually  occur  singly,  but  in 
cultures  sometimes  form  chains  of  four  to  six  elements; 
occasionally  peculiar,  club-like  forms  and  branches 
have  been  met  with,  from  which  they  have  been 
supposed  to  be  allied  to  the  actinomyces  group  of 
fungi  or  streptothrices  (see  Plate  VIII.,  Fig.  1). 

Motility. — Non-motile. 

Spore  Formation. — The  clear  spaces  or  vacuoles 
which  are  present  in  stained  preparations,  and  which 
have  been  described  by  some  authorities  as  spores,  are 
probably  due  to  degenerative  processes,  as  they  do 
not  show  the  form  of  spores  nor  is  anything  known 
as  to  their  power  of  resistance  or  germination. 

Staining  Reaction. — The  tubercle  bacilli  stain  with 
difficulty,  but  once  stained  they  retain  the  dye  with 
great  tenacity.  At  present  the  methods  most  com- 
monly employed  for  staining  tubercle  bacilli,  though 
there  are  many  modifications  of  these,  are  the  Ziehl- 
Neelsen  with  carbol  fuchsin,  and  the  Koch-Ehrlich 
with  aniline  water  and  gentian  violet.  For  special 
methods  of  preparing  and  staining  cover-glass  speci- 
mens and  sections,  see  Bacteriological  Technique. 

The  peculiar  staining  reaction  found  in  the  case  of 
the  bacillus  tuberculosis  is  not  confined  to  that 
organism   alone,   as   other   similar   organisms,   when 


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Bacteria 


treated  in  like  manner,  react  in  the  same  way.  Thus 
it  has  in  be  differentiated  from  the  smegma  bat 
located  in  the  smegma  often  seen  beneath  the  prepuce 
and  upon  the  vulva,  both  normally  and  in  disease; 
Lustgarten's  bacillus  of  syphilis  found  principally  in 
the  primary  lesions  associated  with  that  disease; 
the  bacillus  of  loprosy;  ami  acid-resisting  or  grass 
bacteria  found  in  butter.  Hueppe  differentiates  tin- 
first  three  organisms  and  the  tubercle  bacillus  a^ 
follows: 

1.  Treat  the  preparation,  stained  with  carbol 
fuchsia  with  sulphuric  acid,  and  Lustgarten's  bacillus. 
if  present  is  at  once  decolorized. 

2.  If  not  immediately  decolorized,  treat  with 
alcohol  and  if  it  is  the  smegma  bacillus  it  will  lose 
color. 

:i.  If  it  is  still  not  decolorized,  it  is  either  the  leprosy 
or  the  tubercle  bacillus.  According  to  Baumgarten, 
the  leprosy  bacillus  is  stained  by  an  exposure  of  six 
or  seven  minutes  to  a  cold  saturated  watery  solution 
of  fuchsin  and  retains  the  stain  when  subsequently 
treated  with  acid  alcohol  (nitric  acid  1  part  to  alcohol 
10  parts).  When  treated  for  the  same  length  of 
time,  the  tubercle  bacillus  does  not  ordinarily  become 
stained. 

Biological  Characters. — Aerobic;  does  not  grow  in 
the  absence  of  oxygen.  Growth  takes  place  between 
29°  and  42°  C;  optimum  temperature  at  37°  C. 
Fader  all  circumstances  the  growth  is  slow.  On  the 
ordinary  agar  and  gelatin  culture  media  development 
is  very  scanty;  for  the  cultivation  of  tubercle  bacilli 
practically  the  only  media  employed  are  coagulated 
blood  serum  and  four  to  six  per  cent,  glycerin  agar 
and  glycerin  bouillon. 

It  is  very  difficult  to  obtain  a  pure  culture  of  tubercle 
bacilli,  because  they  grow  so  slowly  and  require  for 
their  development  an  incubator  temperature,  and 
because  owing  to  the  slow  growth,  the  other  bacteria 
present  in  tuberculous  material,  as  sputum,  grow 
more  rapidly  and  take  possession  of  the  culture 
medium  before  the  tubercle  bacillus  has  had  time  to 
form  colonies.  It  is  therefore  best,  unless  human 
tissues  can  be  obtained  free  from  other  infection,  first 
to  inoculate  guinea-pigs  (which  are  very  susceptible) 
both  subcutaneously  and  intraperitoneally,  with  the 
sputum,  and  then  to  obtain  cultures  from  the  animal 
as  soon  as  the  tuberculous  infection  has  fully  devel- 
oped. The  animals  thus  inoculated  usually  die  at 
the  end  of  three  to  four  weeks  or  more.  It  is  better, 
however,  to  kill  a  guinea-pig  which  by  its  enlarged 
glands  shows  evidence  of  tuberculosis,  and  to  remove, 
with  the  greatest  antiseptic  precautions,  one  or  more 
nodules  from  the  lungs,  spleen,  or  lymphatic  glands, 
and  inoculate  with  this  the  solid  culture  medium 
(blood  serum)  by  rubbing  it  directly  over  the  surface; 
or  a  part  of  it  may  first  be  crushed  between  two 
sterilized  glass  slides  and  then  transferred  to  the 
serum  and  gently  rubbed  over  its  surface. 

Growth  on  Coagulated  Blood  Serum  {Dog  or  Bovine 
Serum)  or  on  Egg. — On  this  medium,  which  is  gen- 
erally employed  to  obtain  the  first  culture,  the  growth 
becomes  visible  after  ten  to  fourteen  days  at  37°  C, 
and  at  the  end  of  three  to  four  weeks  a  distinct, 
characteristic  development  has  occurred.  Small, 
grayish-white,  dry,  crumbly  scales  first  appear  on  the 
surface;  then  as  development  progresses  there  is 
formed  an  irregular,  membranous-looking  layer.  On 
removing  a  small  portion  of  this  and  placing  it  on  a 
cover  glass  without  rubbing,  then  staining  and  examin- 
ing under  the  microscope,  the  bacilli  will  be  seen  to 
present  a  characteristic  appearance  and  to  be  arranged 
in  parallel  rows  of  variously  curved  figures. 

Growth  on  Glycerin  Agar. — Owing  to  the  greater 
facility  of  preparing  and  sterilizing  glycerin  agar,  and 
the  more  rapid  and  abundant  development  of  the 
bacilli,  which  have  become  accustomed  to  growth 
outside  the  body,  this  medium  is  now  usually  em- 


ployed   in    prefer  to    blood    serum    preserving 

cultures.  At  the  end  of  fourteen  to  twenty-one  daya 
the  developmenl  is  more  luxuriant  than  upon  blood 
-'■nun  after  several  weeks.  When  numerous  bacilli 
ha\  e  been  distributed  over  the  surface  of  the  medium, 
a  rather  uniform,  thick,  white  layer,  which   later  be- 

'■ a  yellowish   in   color,    is   developed;    when   the 

bacilli  are  few  in  number,  separate  colonies  ar« 
developed  with  more  or  less  irregular  outlini 

Growth  on  Glycerin  Bouillon. — On  bouillon  con- 
taining about  five  per  cent,  of  glycerin  the  tubercle 
bacillus  also  grows  readily  if  a  fresh  thin  film  of  grow  th 
from  the  glycerin  agar  is  floated  on  the  surface.  '1  his 
medium  is  used  for  the  production  of  "tuberculin." 
The  small  piece  ol  pellicle  removed  from  the  previous 
culture  continues  to  enlarge  while  it  floats  on  the 
surface  of  the  liquid,  and  in  the  course  of  from  three 
to  six  weeks  covers  it  completely  as  a  single  film, 
which  on  agitation  breaks  up  and  settles  to  the 
bottom  of  the  flask,  where  it  ceases  to  develop  fur- 
ther. The  liquid  remains  clear,  containing  in  solution 
the  products  formed  by  the  growth  of  the  bacillus. 
Vitality. — Tubercle  bacilli  in  pure  cultures  are 
very  susceptible  to  the  action  of  direct  sunlight, 
being  destroyed  in  from  a  few  minutes  to  some  hours, 
according  to  the  thickness  of  the  growth.  Exposed 
to  diffuse  daylight  they  are  killed  in  a  week.  Though 
they  do  not  form  spores,  so  far  as  known,  the  bacilli 
have  a  somewhat  greater  resisting  power  to  heat  and 
desiccation  than  many  other  pathogenic  bacteria, 
frequently  retaining  their  virulence  in  a  dried  condi- 
tion at  the  ordinary  temperatures  for  months. 
Portions  of  the  lung  from  a  tuberculous  cow,  dried 
and  pulverized,  produced  tuberculosis  in  guinea-pigs 
at  the  end  of  one  hundred  and  two  days.  Dried 
tuberculous  sputum  may  retain  its  virulence  for  two 
or  three  months  or  more.  An  instance  is  reported 
by  Ducor  of  a  healthy  family  having  become  infected 
with  tuberculosis  from  living  in  a  room  which  had 
been  occupied  by  a  consumptive  patient  two  years 
before,  and  on  examining  the  sputum-stained  wall- 
paper not  only  were  tubercle  bacilli  found  in  it,  but 
when  guinea-pigs  were  inoculated  with  it  they  died  of 
the  disease.  Exposure  to  100°  C.  dry  heat  does  not 
kill  the  bacilli  in  twelve  hours;  but  moist  heat  at  60°  C. 
destroys  them  in  fifteen  minutes.  Cold  has  little  or  no 
effect  upon  them.  The  resisting  power  of  this  bacillus 
against  chemical  disinfectants  is  considerable,  espe- 
cially in  sputum,  where  the  organisms  are  protected 
by  mucus  from  penetration  by  the  germicidal  agent. 
They  are  not  always  destroyed  by  the  gastric  juice 
in  the  stomach,  as  has  been  shown  by  successful 
experiments  in  feeding  to  susceptible  animals.  They 
are  killed  in  sputum  in  about  six  hours  by  an  equal 
amount  of  a  three  per  cent,  solution  of  carbolic  acid, 
and  in  about  one  hour  by  a  five  per  cent,  solution. 
Bichloride  of  mercury  is  unsuitable  for  the  disinfec- 
tion of  sputum  unless  used  in  very  strong  solution 
(1  to  500).  Pickling  and  smoking  are  said  not  to 
destroy  the  virulence  of  tuberculous  meat. 

Occurrence. — The  tubercle  bacillus  is  a  strict 
parasite — that  is  to  say,  it  does  not  grow  under 
natural  conditions  outside  of  the  bodies  of  man  and 
animals.  It  has  frequently  been  found,  however,  in 
the  dust  of  hospitals,  dwellings,  railways,  street  cars, 
etc.,  in  places  where  consumptives  have  expectorated. 
Very  rarely  has  it  been  found  in  the  air.  The  milk 
of  tuberculous  cows,  even  when  the  udder  is  not 
affected,  very  often  contains  tubercle  bacilli;  they  are 
also  found  in  butter. 

Postmortem  examinations  of  many  individuals  who 
have  died  from  some  other  cause  than  tuberculosis 
have  revealed  the  presence  of  healed  tuberculous 
foci.  It  has  been  estimated  that  sixty-six  per  cent. 
of  all  mankind  have  some  evidence  of  tuberculosis, 
old  tuberculous  lesions,  of  primary  or  secondary 
origin.     Tubercle  bacilli  are  said  to  have  been  found 

839 


Bacteria 


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also  in  the  secretions  of  the  nose  and  throat  of  healthy 
persons,  nurses  and  doctors,  who  have  been  in  con- 
stant association  with  tuberculous  patients. 

The  tubercle  bacillus  is  the  essential  cause  of  all 
forms  of  tuberculosis:  the  various  affections  of  the 
lungs  and  other  organs,  lupus,  scrofula,  and  inflamma- 
tion of  the  bones  and  joints.  The  following  diseases 
have  also  been  traced  to  tuberculous  infection:  so- 
called  "inoculation  lupus,"  tuberculosis  verrucosa 
cutis,  and  scrofuloderma;  choroidal  tuberculosis,  idio- 
pathic pleurisy,  etc.  Indeed,  all  organs  and  portions 
of  the  body  may  become  affected  with  this  disease. 

Many  cases  of  tuberculosis  are  produced  by  the 
tubercle  bacillus  alone,  but  very  frequently  strepto- 
cocci and  other  pyogenic  cocci  play  an  important  part 
in  the  production  of  fever  and  the  destruction  of 
tissue,  as  in  phthisis,  by  suppurative  processes. 

Tuberculosis  is  very  common  among  cattle,  chiefly 
in  cows  and  rarely  in  calves.  According  to  Klepp, 
from  abattoir  inspections  in  Germany,  up  to  thirty- 
five  per  cent,  of  cattle,  eighty  per  cent,  of  cows,  and 
three  per  cent,  of  calves,  are  commonly  found  tubercu- 
lous. The  disease  is  also  quite  frequent  in  young  pigs; 
less  so  in  sheep,  goats,  horses,  dogs,  and  cats.  Rab- 
bits and  guinea-pigs  are  also  not  uncommonly 
spontaneously  affected  with  tuberculosis,  when  kept 
in  cages  together  with  infected  animals.  Monkeys 
in  confinement  almost  invariably  die  from  tubercu- 
losis. Wild  animals  are  comparatively  free  from 
the  disease;  and  so  are  birds,  except  canaries  and 
parrots. 

Pathogenesis. — As  seen  from  the  above  many 
animals  besides  man  are  naturally  susceptible  to 
tuberculosis.  Among  test  animals  guinea-pigs  are  the 
most  susceptible,  and  on  this  account  they  are  com- 
monly used  for  the  detection  of  tubercle  bacilli  in 
suspected  material  by  inoculation.  When  inoculated 
with  the  minutest  quantity  of  living  tubercle  bacilli 
they  usually  succumb  to  the  disease.  Infection  is 
most  rapidly  produced  by  intraperitoneal  injection, 
d  ■ath  following  a  large  dose  in  from  ten  to  twenty 
days.  On  autopsy  the  omentum  is  found  to  be  con- 
stricted in  sausage-like  masses  and  converted  into 
hard  knots  containing  many  bacilli.  There  is  often 
no  fluid  in  the  peritoneal  cavity,  but  generally  in  both 
pleural  sacs.  The  spleen  is  enlarged,  and  the  various 
organs  contain  tubercle  bacilli.  After  smaller  doses 
death  may  be  deferred  from  four  to  eight  weeks, 
when  the  peritoneum  and  interior  organs  are  found  to 
be  filled  with  tubercles.  On  subcutaneous  injection 
into  the  abdominal  wall  there  is  thickening  of  the 
tissues  about  the  point  of  inoculation,  which  breaking 
down  in  a  week  leave  a  sluggish  ulcer  covered  with 
cheesy  matter.  The  neighboring  lymph  glands  are 
swollen,  and  after  two  or  three  weeks  they  may  attain 
the  size  of  hazelnuts.  Soon  an  irregular  fever  is  set  up, 
and  the  animal  becomes  emaciated,  usually  dying 
within  four  to  eight  weeks.  If  the  injected  mate  rial 
contain  only  a  few  bacilli,  the  wound  at  the  point  of 
inoculation  may  heal  and  death  be  postponed  for  a 
long  time.  The  lymphatics  undergo  cheesy  degen- 
eration, the  spleen  is  much  enlarged,  and  throughout 
its  substance,  which  is  dark  red  in  color,  are  masses  of 
nodules.  The  liver  is  also  enormously  swollen, 
streaked  brown  and  yellow,  and  the  lungs  are  filled 
with  grayish  tubercles;  but  the  kidneys,  as  a  rule, 
contain  no  tubercles.  Tubercle  bacilli  are  always 
found  in  the  diseased  tissues,  but  the  more  chronic  the 
process  the  fewer  are  the  bacilli  present. 

Rabbits  are  also  quite  susceptible  to  tuberculosis  by 
inoculation,  but  much  less  so  than  guinea-pigs.  In 
these  animals  death  almost  always  follows  injection 
of  tuberculous  material  into  the  anterior  chamber  of 
the  eye;  producing  local  lesions,  softening  of  the 
neighboring  lymph  glands,  lesions  of  the  lungs, 
general  miliary  tuberculosis,  and  death  in  several 
wi'cks  or  months.  Subcutaneous  inoculations  are 
very  much   less  effective;  but  intravenous  and  intra- 


peritoneal inoculations  usually  cause  general  tubercu- 
losis and  death  in  a  few  weeks.  Field  mice  and  cats 
are  also  readily  infected  by  artifical  inoculation;  rats, 
white  mice,  and  dogs  only  when  very  large  doses  are 
given.  Canaries  and  parrots  are  susceptible;  fowls 
and  pigeons  only  slightly  so;  and  other  birds  and  cold- 
blooded animals  are  apparently  immune. 

Besides  the  artificial  modes  of  infection  already 
alluded  to,  tuberculosis  may  be  produced  in  animals 
susceptible  to  the  disease  by  feeding  them  with  tuber- 
culous material.  This  has  been  repeatedly  done  with 
milk,  sputum,  etc.,  containing  tubercle  bacilli.  Here 
evidence  of  infection  is  usually  shown  in  the  mesen- 
teric glands  before  the  intestinal  walls  are  affected; 
indeed,  there  may  be  no  local  lesions  in  the  intestines 
at  all.  Under  such  conditions,  infection  is  probably 
caused  by  absorption  of  the  poisons  through  serous  or 
mucous  membranes. 

The  experimental  production  of  tuberculosis  by 
inhalation  of  bacilli  has  been  demonstrated  by  Koch 
in  guinea-pigs,  rabbits,  mice,  etc.  In  these  cases  the 
bacilli  were  usually  administered  in  the  form  of  fine 
spray;  the  inhalation  of  dry  tuberculous  dust  has 
seldom  proved  experimentally  successful. 

The  tubercle  bacillus  acts  upon  the  tissues  by 
means  of  the  poisons  which  it  produces  as  the  result 
of  its  growth.  Soon  after  entrance  into  the  tissues  of 
either  living  or  dead  bacilli,  the  cells  surrounding 
them  begin  to  show  signs  of  irritation.  The  connect- 
ive-tissue cells  become  swollen  and  undergo  mitotic 
division,  the  resultant  cells  being  distinguished  by 
their  large  size  and  pale  nuclei.  A  small  focus  of 
proliferated  epithelioid  cells  is  thus  formed  about  the 
bacilli,  and  according  to  the  intensity  of  the  inflamma- 
tion these  cells  are  surrounded  by  a  larger  or  smaller 
number  of  the  lymphoid  cells.  When  living  bacilli 
are  present  and  multiply,  the  lesions  progress,  the 
central  cells  degenerate  and  die,  and  a  cheesy  mass 
results,  which  later  may  lead  to  the  formation  of 
cavities.  Dead  bacilli,  on  the  other  hand,  give  off 
sufficient  poison  to  cause  less  marked  changes  only, 
and  never  produce  cavities.  Of  the  gross  pathological 
lesions  produced  in  man  by  the  tubercle  bacilli  the 
most  characteristic  are  small  nodules,  the  so-called 
miliary  tubercles.  These  when  young,  and  before 
they  have  undergone  degeneration,  are  gray  and 
translucent  in  color,  somewhat  smaller  than  a  millet 
seed  in  size,  and  hard  in  consistence.  But  miliary 
tubercles  are  not  the  sole  tuberculous  products.  The 
tubercle  bacilli  may  cause  the  diffuse  growth  of  tissue 
identical  in  structure  with  that  of  miliary  tubercles — 
that  is.  composed  of  a  basement  substance  containing 
epithelioid,  giant,  and  lymphoid  cells.  This  diffuse 
tubercle  tissue  also  undergoes  cheesy  degeneration. 

When  caseation  is  rapidly  spreading,  as  in  acute 
tuberculosis,  the  bacilli  are  usually  abundant,  being 
scattered  in  irregular  groups  through  the  tissues. 
Occasionally  they  are  found  in  the  leucocytes,  and  in 
the  giant  and  epithelioid  cells.  The  more  chronic  the 
lesions  the  fewer  they  are  in  number. 

Modes  of  Infection. — The  chief  modes  of  infection  by 
the  tubercle  bacillus  are  through  the  respiratory  tract 
or  the  intestines,  more  rarely  through  wounds  of  the 
skin,  and  still  more  rarely  through  the  sexual  organs. 
Pulmonary  tuberculosis,  as  a  primary  infection,  and 
not  occurring  in  young  children,  may  be  considered  to 
be  caused  chiefly  by  the  direct  transmission  of  tubercle 
bacilli  through  kissing,  soiled  hands,  handkerchiefs, 
etc.,  or  by  the  inhalation  of  tuberculous  dust.  Intes- 
tinal and  mesenteric  tuberculosis,  which  is  rare  among 
adults  and  common  with  children,  is  probably  due 
not  only  to  swallowing  the  bacilli  received  in  the 
above-mentioned  ways,  but  also  to  the  ingestion  of 
tuberculous  milk.  Lupus  is  probably  always  pro- 
duced by  the  inoculation  of  tubercle  bacilli  on  the  skin 
or  mucous  membranes,  the  original  seat  of  the  disease 
being  often  on  a  wounded  surface.  Localized  skin 
tuberculosis   is   sometimes   produced    by    accidental 


Sill 


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Bacteria 


aoculation   at   autopsies.     The   transmission   of   in- 
ection   through   the   sexual   organs   of   the   mule   or 
emale,    though    possible,    is  extremely  rare.     There 
,..  to  b<-  some  evidence  of  the  communication  of 
uberculous  infection  from  the  mother  to  the  fetus  in 
mimals;   and    two   rases   are   recorded   of   probable 
ilacental  tuberculosis  in  the  human  fetus.     But   we 
ao    reason    to    suppose    that   infection   of    the 
ivum  of  healthy  mothers  from  the  paternal  side  ever 
occur,  even  when  the  father  has  tuberculosis  of 
be  scrotum  or  seminal  vesicles.     The  mere  fact  that 
statistics   show   a  greater   frequency   of   tuberculous 
[iseases  in  children  during  the  first  than  in  the  follow- 
ears  of  life  does  not  strengthen  the  hypot  hesis  of 
tion  in  ulero;  for  nursing  babies  would  naturally 
...    i    posed  to  infection  through  the  moth 
milk  and  through  personal  contact  than  others;  and, 
besides,  the  more  tender  the  life  of  the  infant  the  more 
eptible  it  would  be  ordinarily  to  indirect  infection 
a  t uberculous  mother. 
By  far  the  commonest  mode  of  infection,  therefore, 
is  undoubtedly   by    means  of  tuberculous  sputum, 
which,  being  coughed  up  by  consumptives  and   care- 
.    expectorated,  dries  and  distributes  numerous 
virulent  bacilli  in  the  dust.     As  long  as  the  sputum 
remains  moist  there  is  no  danger  of  dust  infection,  but 
only  of  direct  contact.     A  great  number  of  the  ex- 
pectorated and  dried  bacilli  very  probably  die,  espe- 
cially when  exposed  to  the  action  of  direct  sunlight ; 
but  when  we  consider  the  enormous  masses  which  are 
expectorated,*  it  is  evident  that  a  sufficient  quantity 
remains  alive  to  produce  infection  in  the  immediate 
vicinity    of    consumptives     unless    precautions    are 
n  to  prevent   it.     There  is  comparatively  little 
danger  of  infection  in  the  streets  or  at  a  distance  from 
consumptive  patients,  because  even  if  present  in  the 
.  the  tubercle  bacilli  have  become  so  diluted  that 
they  are  not  much  to  be  feared.     It  may,  therefore, 
be  said  that  the  probability  of  infection  from  tubercu- 
losis in  general  is  not  so  great  after  all,  but  at   the 
same  time  it  is  all  the  more  to  be  dreaded  and  guarded 
against  in  the  immediate  neighborhood  of  consump- 
tives.    Those  who  are  most  liable  to  infection  from 
this  source  are  the  families,  nurses,  fellow-workmen, 
fellow-prisoners,  etc.,  of  persons  suffering  from   the 
disease.     In  this  connection,  also,  attention  may  be 
drawn  to  the  fact  that  rooms  which  have  been  re- 
cently occupied  by  consumptives  are  not  infrequently 
the  means  of  producing  infection  (as  has  been  clinic- 
ally and  experimentally  proved)  from  the  deposition 
of    tuberculous  dust  on  furniture,  walls,  floors,   etc. 
Fliigge  has  lately  pointed  out  that  in  coughing,  sneez- 
and   even   in   speaking,    very   fine   particles   of 
secretion,  containing  tubercle  bacilli,  may  be  thrown 
out  and  carried  by  air  currents  many  feet  from  the 
patient  and  remain  suspended  in  the  air  for  a  con- 
siderable time.     For  this  reason  consumptives  should 
be   careful   to  hold    their   hands  or  a  handkerchief 
before  their  mouths,  or  at  least  avoid   as   much   as 
possible    contaminating    other    persons    with    whom 
they  come  in  contact. 

Phthisical  sputum,  however,  cannot  be  held  re- 
sponsible for  the  occurrence  of  all  human  tubercu- 
losis. .Milk  also  serves  as  a  frequent  conveyer  of 
infection,  whether  it  be  the  milk  of  nursing  mothers 
suffering  from  consumption  or  the  milk  of  tuberculous 
cows.  The  transmission  of  tubercle  bacilli  in  the 
milk  of  tuberculous  cows  has  been  abundantly 
proved  by  feeding  and  inoculation  experiments  on 
animals.  Formerly  it  was  thought  that  in  order  to 
produce  infection  by  milk  there  must  be  local  tubercu- 
lous infection  of  the  udder;  but  it  is  now  known  that 
tubercle  bacilli  may  be  found  in  milk  when  an 
internal  organ  is  infected,  and  when  no  disease  of  the 

*  Xuttall  has  estimated  that  from  one  and  one-half  to  three 
billion  virulent  tubercle  bacilli  may  be  expectorated  by  a  single 
tuberculous  individual  in  twenty-four  hours. 


udder,  so  far  aj  careful  is 

The  milk  of  all  cows,  then  fore,  which  have  any  tuber- 
culous infection   whatever,    m  considered   as 
ibly  containing  tubercle  bacilli.     'With  regard  to 
the  flesh  of  tuberculous  cattle,  ti  conditions 

hold  g 1  as  in  the  infection  by  milk,  only  the  danger 

iderably  less  from  the  fact  thai  meat  I 
cooked,  and  also  because   the   muscular  ti 

seldom  attacked.     In   view  of  the  great    rtality 

from    tuberculous    diseases    among    mankind, 
legi  lative  control  and  inspection  of  cattle  and  milk 
would  seem  to  be  an  absolute  necessity.     A-  a  practi- 
cal   and    simple     method    of    preventing     it 
e   pecially  among  children,  the  sterilization   (by  hi 
of  the  milk  used  as  food  must   commend  itself  to  all. 

With  regard  to  bovine  infection  in  man  numerous 
investigations  have  been  made.  To  Ravenel  properly 
belongs  the  credit,  of  isolating  the  firsl  bovine  bacillus 
from  a  child.  It  has  been  shown  that  children  are 
especially  the  ones  infected,  and  usually  the  point  of 
entry  is  clearly  alimentary.  Cervical  adenitis  and 
abdominal  tuberculosis  are  the  most  frequent  types 
of  infection.  Generalized  tuberculosis  due  to  bovine 
infection  is  less  frequent  and  bone  and  joint,  tubercu- 
losis is  almost  exclusively  of  the  human  type,  infec- 
tion of  adults  is  very  uncommon.  According  to 
I'arth,  a  careful  study  of  all  the  factors  leads  to  the 
belief  that  about  ten  per  cent,  of  all  tuberculosis  in 
children  under  five  is  due  to  bovine  infection. 

Individual  Susceptibility. — Another  most  important 
factor  in  the  producion  of  tuberculosis,  as  of  all  infec- 
tious diseases,  is  individual  susceptibility.  That  this 
susceptibility  or  "predisposition,"  improperly  so 
called,  may  be  either  inherited  or  acquired  is  now  an 
accepted  fact  in  medicine.  There  is  no  doubt  that 
great  differences  exist  in  different  persons  in  their 
susceptibility  to  tuberculosis,  as  there  are  also 
differences  in  the  intensity  of  the  tuberculous  process 
in  the  lung.  The  fact  that  individuals  contracting 
tuberculosis  from  the  same  source  are  attacked  with 
different  severity,  and  that  there  is,  as  a  rule,  no  great 
variation  in  degrees  of  virulence  in  the  tubercle 
bacilli  of  different  origin,  shows  that  this  depends 
upon  something  else  than  a  variation  in  virulence  of 
the  infection.  The  results  of  postmortem  examina- 
tions also  demonstrate  that  many  cases  of  pulmonary 
tuberculosis  evidently  occur  without  showing  any 
visible  signs  of  disease,  and  heal  spontaneou-ly. 
The  possibility  of  favorably  influencing,  in  an  existing 
tuberculosis,  "the  course  of  the  disease  by  treatment 
proves,  too,  that  under  natural  conditions  there  is  a 
varying  susceptibility.  Clinical  experience  teaches 
likewise,  that  the  children  born  of  tuberculous 
parents,  and  persons  living  in  poor  hygienic  conditions 
and  depressing  surroundings,  as  in  prisons,  asylums, 
and  convents,  and  those  suffering  from  exhausting 
diseases,  more  especially  bronchial  affections,  diabe- 
tes, typhoid  fever,  etc.,  are  more  susceptible  to 
tuberculosis  than  others  not  so  situated  or  affected. 
Animal  experiments,  moreover,  have  shown  that  not 
only  are  there  differences  of  susceptibility  in  various 
species,  but  also  an  individual  susceptibility  in  the 
same  species.  The  doctrine  of  individual  suscepti- 
bility, therefore,  is  apparently  founded  on  fact, 
although  the  reasons  for  it  are  only  partially 
understood. 

Immunization:  Koch's  Tuberculin. — As  in  other 
infectious  diseases,  many  attempts  have  been  made 
to  produce  an  artificial  immunity  against  tubercu- 
losis, but  so  far  the  results  have  been  unsatisfactory. 
Among  the  numerous  agents  that  have  been  tried  to 
protect  animals  against  the  action  of  the  tubercle 
bacillus,  the  most  important  is  Koch's  tuberculin. 
Tuberculin  contains  all  the  products  of  the  growth  of 
the  tubercle  bacillus  in  nutrient  bouillon  and  certain 
substances  extracted  from  the  bodies  of  the  bacilli 
themselves;  also  the  albuminoid  and  other  materials 


841 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


originally  contained  in  the  bouillon  which  are  unaf- 
fected by  the  growth  of  the  bacilli.     There  are  two 
preparations   known   respectively   as   the    "old"   or 
original    ("T.    O.")    and    the    "new"    tuberculin  or 
"tuberculin  T.  R.,"  or  Bacillus  Emulsion  ("  B.  E."). 
Old  tuberculin  is  prepared  as  follows:  The  tubercle 
bacillus    is    cultivated    in    peptone-glycerin-bouillon. 
At  the  end  of  from  three  to  six  weeks,  according  to 
the  rapidity  with  which  the  culture  grows,  an  abund- 
ant development  takes  place  with  the  formation  of  a 
thick,  dry,  white  crumpled  layer,  which  finally  covers 
the  entire  surface  of  the  bouillon.      (It  was  originally 
inoculated     on     the     surface.)     After     development 
ceases,  this  layer  breaks  up  and  sinks  to  the  bottom 
of  the  flask.     Fully  developed  cultures,  having  been 
tested  for  purity  by  microscopical  examination,  are 
evaporated  by  boiling  to  one-tenth  of  their  original 
bulk.     The    liquid    is    then    filtered,    and    the    crude 
tuberculin  thus  obtained  contains  forty  to  fifty  per 
cent,  of  glycerin  (the  broth  medium  contained  four  to 
five  per  cent.),  and  keeps  well,  retaining  its  activity 
indefinitely.     This    substance    when    injected    into 
tuberculous     individuals     affects     the     tuberculous 
process  in  a  peculiar  way.     Very  small  doses  produce 
a    moderate    increase    of    inflammation    with    slight 
elevation    of    temperature    in    tuberculous    persons, 
while    healthy    individuals    have    neither    fever    nor 
marked     local     symptoms.     The    following    is     the 
method   of   treatment  employed.     After  each  injec- 
tion, which  should  be  large  enough  to  cause  a  slight 
but   not  a  great  rise   of  temperature,   a  noticeable 
change    in    the    tuberculous    process    results.     The 
amount  of  tuberculin  injection  is  constantly  increased, 
so   as   to   continue    the   moderate   reactions.     After 
several    months    all    reactions    cease,    the    patients 
having  become  temporarily  immune  to  the  toxin,  but 
not  to  the  growth  of  the  bacillus.     Further  injections 
are   now   useless,   until   this   immunity   has   passed. 
Inasmuch  as   the  bacilli   themselves  have   not   been 
directly  affected  by  the  treatment,  when  this  is  inter- 
rupted  the   tuberculous  process  is  apt   to  progress 
(Koch). 

Although   Koch  and  some  of  his  followers  appar- 
ently, from  their  reports,  obtained  satisfactory  results 
in    the    treatment   and    immunization    of   man    and 
animals  with  old  tuberculin,  the  majority  of  invest  i- 
gators,  after  a  short  period  of  enthusiasm,  abandoned 
its  use  as  very  rarely  beneficial,  if  not  often  injurious. 
Koch  therefore  attempted  to  improve  his  method  and 
recommended  a  new  preparation  under  the  name  of 
"Tuberculin    T.  R.,"  or   new  tuberculin  or    Bacillus 
Emulsion   ("  B.  E  ").     The   substances   produced   in 
the  body  by  the  old  tuberculin  neutralized  the  tuber- 
culous toxins,  according  to  Koch,  but  were  not  bac- 
tericidal.    This  he  considered  due  to  the  nature  of  the 
envelope  of  the  tubercle  bacillus,  which  rendered  it 
difficult  to  obtain  the  substance  of  the  bacilli  in  soluble 
form  without  so  altering  it  by  heat  or  chemicals  that 
it  was  useless  for  immunizing  purposes.     Immunity, 
he  thought,  was  not  produced  in  man  for  similar  rea- 
sons, the  bacilli  never  giving  out  sufficient  toxin,  per- 
haps, to  bring  about  the  production  of  curative  sub- 
stances.    He  therefore  decided  to  grind  up  the  dried 
bacilli  and  soak   them  in  water,  and  thus  obtain,  if 
if  possible,  without  the  aid  of  heat,  a  soluble  extract  of 
the  cell  substance  of  the  bacilli,  which  he  hoped  would 
1«-  immunizing.      Buchner,  by  crushing  under  a  great 
pressure  tubercle  bacilli  mixed  with  sand  and  thus 
squeezing    out    their  protoplasm,   obtained   a  simi- 
lar  substance,    which  he  called  "tuberculoplasmin." 
The  new  tuberculin  is  thus  a  watery  extract  of  the 
soluble   portions   of   the    unaltered    tubercle   bacilli. 
Owing  to  the  method  of  preparation,  it  is  evident 
that    contamination    is    difficult    to    avoid,    freedom 
from  intact  bacilli  is  uncertain,  and  the  strength  of 
the  solution  is  variable.     Twentv  per  cent,  of  glycerin 
is  added  to  preserve  the  preparation.     Dilutions  are 

842 


made  in  0.5  per  cent,  carbolic  acid  in  O.S  salt  solution 
Before  marketing  the  preparation  is  usually  subieetpri 
to  heating  at  (30°  C.  ""jeciea 

Bouillon    Filtrate    Tuberculin    ("B.  F."). This  is 

the  unheated  filtrate  from  bouillon  cultures  of  human 
tubercle  bacilli,  suggested  by  Denys.  Many  other 
tuberculins  have  been  proposed  during  the  last 
twenty  years,  all  of  which  are  vaccines  made  from 
either  the  body  substance  of  the  germ  or  the  liquid 
medium  in  which  it  has  grown,  or  both,  and  their  aim 
is  to  stimulate  the  defensive  resources  of  the  system 
or  to  induce  antitoxic  and  antibacterial  immunity 
They  all  produce,  when  given  in  sufficient  doses 
local  reactions  in  tuberculous  foci,  and  the  well-known 
but  little  understood  phenomena  of  general  tuberculin 
reaction.  These  new  tuberculin  preparations  are 
now  considered  superior  to  those  obtained  from  the 
older  product  of  Koch  in  the  treatment  of  human 
tuberculosis. 

Regarding  the  results  from  tuberculin  treatment 
it  has  been  demonstrated  by  bitter  experience  that 
tuberculin  is  not  the  vaunted  and  long-looked-for 
specific  it  was  at  first  thought  to  be.  Trudeau,  and 
other  reliable  investigators,  however,  have  formed 
favorable  impressions  of  its  influence  by  noticing 
that  the  disease  seemed  to  progress  more  rarely  with 
the  usual  exacerbations  and  relapses  in  patients 
who  were  tolerating  the  tuberculin  treatment  than 
in  those  who  had  the  climatic  and  open-air  treatment 
only. 

The  chief  use  to  which  the  old  or  original  tuberculin 
has  been  put  is  as  an  aid  to  the  diagnosis  of  obscure 
cases  of  tuberculosis  in  cattle  and  man,  and  for  this 
purpose  it  has  proved  to  be  of  inestimable  value. 
Cows  are  generally  injected  subcutaneously  with  0.3 
to  0.5  c.c.  (diluted  with  water  to  30  or  50  c.c.)  of 
tuberculin  and  watched  to  see  whether  there  is  a  rise 
of  temperature  of  1.5°  to  3°  C.  in  twelve  to  fifteen 
hours.  Occasionally  the  reaction  does  not  occur 
when  the  animals  are  in  an  advanced  stage  of  the 
disease,  but  in  such  cases  the  test  is  not  needed.  The 
reaction  never  takes  place,  or  one  very  much  less 
marked  occurs,  in  healthy  animals,  though  small 
centers  of  infection  are  often  difficult  to  locate  later 
on  autopsy.  Latent  tuberculosis  is  rarely  if  ever 
stimulated  to  renewed  activity.  It  is  important 
to  note  that  an  animal  frequently  requires  an  interval 
of  a  month  to  give  a  second  positive  reaction,  if  it 
has  reacted  typically  on  the  first  trial.  In  man  it  is, 
of  course,  much  more  difficult  to  form  any  opinion  as 
to  the  reliability  of  the  tuberculin  test,  from  the  fact 
that  it  cannot  be  controlled  by  postmortem  examina- 
tions. It,  is,  however,  of  great  value  in  selected  cases, 
both  surgical  and  medical,  where  slight  tuberculosis 
is  suspected,  and  yet  no  decision  can  be  reached. 
In  the  first  small  dose  advised  (0.5  mgm.  in  adults 
and  0.3  in  children)  an  absolutely  latent  infection 
should  usually  give  no  rise  of  temperature. 

Von  Pirquet's  cutaneous  tuberculin  test  has  for 
many  purposes  supplanted  the  subcutaneous  injec- 
tions, as  it  is  perfectly  harmless.  This  is  carried  out 
by  placing  a  drop  of  a  25  or  50  or  100  per  cent,  solution 
of  tuberculin  upon  the  skin  of  the  forearm  and  then 
with  a  needle  or  instrument  making  through  it  a 
slight  abrasion  without  drawing  blood.  A  central 
abrasion  without  tuberculin  is  made  at  another  point. 
Within  twelve  to  twenty-four  hours  a  papule  with  a 
surrounding  congested  area  forms  about  the  inocu- 
lated point.  In  Moro's  test  equal  parts  of  tuberculin 
and  lanolin  are  mixed  together  to  make  an  ointment, 
which  is  rubbed  upon  the  skin.  A  crop  of  papules 
develops  in  twelve  to  twenty-four  hours  in  cases  in 
which  the  test  proves  effective.  In  the  ophthalmo- 
tuberculin  test,  two  solutions  of  different  strengths 
are  employed,  one  of  the  alcohol  precipitate  of  tuber- 
culin in  0.5  per  cent,  and  1  per  cent.,  and  the  other 
of    1    and   2    per   cent,  tuberculin   ("T.    O.").     The 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   S<  [EN(  ES 


Bacteria 


weaker  and  stronger  are  used  successively  ineacheye. 
In  from  three  to  twelve  hours,  or  longer,  reaction 
occurs,  unci  occasionally  conjunctivitis,  keratitis,  or 
iritis  results.  Preference  is  therefore  given  to  the 
cutaneous  tes( . 

Haragliano  and  others  claim  to  have  obtained  with 
an  antituberculous  scrum,  prepared  chiefly  from 
horses,  encouraging  results;  and  Behring  hopes  to 
be  able  to  make  an  antitoxic  serum  which  will  be 
curative  and  protective.  Rut  whether  serum  therapy 
is  destined  to  solve  the  problem  of  the  treatment  ol 
tuberculosis  remains  for  the  future  to  decide.  Judg- 
ing, however,  from  the  progressive  nature  of  the 
disease,  there  is  not  much  ground  to  hope  for  the 
abundant  development  of  curative  substances  in  the 
blood  of  animals. 

Meanwhile  all  energies  should  be  directed  to  the 
prevention  of  tuberculosis,  nol  only  by  the  enforce- 
ment of  proper  sanitary  regulations  as  regards  the 
care  of  sputum,  milk,  meat,  disinfection,  etc.,  but 
also  by  continued  experimental  work  and  by  the 
establishment  of  consumptive  hospitals;  and  by  efforts 
to  improve  the  character  of  the  food,  dwellings,  and 
condition  of  the  people  in  general  we  should  endeavor 
to  build  up  the  individual  resistance  to  the  disease. 
It  may  be  years  yet  before  the  public  are  sufficiently 
educated  to  cooperate  in  adopting  the  necessary 
hygienic  measures  to  stamp  out  tuberculosis  entirely; 
but  from  the  results  which  have  already  been  obtained 
in  reducing  the  mortality  from  this  greatest  scourge 
of  the  human  race,  we  have  reason  to  hope  that  in 
time  it  may  be  completely  eradicated. 

The  Leprosy  Bacillus  (Bacillus  lepra:). — This 
organism,  discovered  by  Hansen  in  1879,  is  found 
chiefly  in  the  interior  of  the  peculiar  round  and  oval 
cells  met  with  in  leprous  tubercles.  The  bacilli  have 
also  been  observed  in  the  lymphatic  glands,  liver, 
spleen,  and  testicles,  and  in  the  thickened  portions  of 
nerves  involved  in  the  anesthetic  forms  of  the  disease. 
According  to  some  authorities  they  occur  likewise  in 
the  blood.  The  bacilli  lie  in  the  leprous  cells  in  great 
numbers,  and  also  in  the  lymph  spaces  outside  of  these 
cells.  They  are  not  found  in  the  epidermal  layers 
of  the  skin,  but,  according  to  Babes,  they  may 
penetrate  the  hair  follicles. 

Microscopical  Appearances. — The  bacillus  lepra? 
resembles  the  tubercle  bacillus  in  form,  but  is  some- 
what shorter  and  not  so  frequently  curved.  The 
rods  have  pointed  ends;  and  in  stained  preparations, 
unstained  spaces,  similar  to  those  observed  in  the 
tubercle  bacillus,  are  seen.     (See  Plate  VIII.,  Fig.  2.) 

Motility. — Non-motile. 

Staini?tg  Reactions. — The  leprosy  bacillus  cannot 
be  positively  differentiated  from  the  tubercle  bacillus 
by  staining  reactions.  It  stains  readily  with  the 
a  liline  colors  and  also  by  Gram's  method.  Although 
di.Tering  from  the  tubercle  bacillus  in  the  ease  with 
which  it  takes  up  the  ordinary  aniline  dyes,  it  behaves 
like  the  former  in  the  manner  in  which  it  retains  its 
color  when  subsequently  treated  with  strong  solutions 
of  the  mineral  acids  and  alcohol.  Inasmuch  as 
leprosy  and  tuberculosis  not  infrequently  occur 
together  in  the  same  person  (according  to  Hansen  and 
Looft  tuberculosis  being  the  cause  of  death  in  forty 
per  cent,  of  the  cases  of  leprosy),  in  making  a  differen- 
tial diagnosis,  all  the  various  points,  histological 
and  pathological,  must  be  considered  and  animal 
inoculations  made,  in  addition  to  microscopical 
examination. 

Biological  Characters. — Attempts  to  cultivate  the 
bacillus  lepne  have  frequently  been  made,  but  so  far 
with  only  questionable  results,  as  none  of  the  cultures 
obtained  has  produced  a  similar  disease  when  inocu- 
lated into  animals.  The  etiological  relation  of  this 
bacillus  to  leprosy  is  based,  therefore,  chiefly  upon  its 
constant  presence  in  the  leprous  tissues.     It  has  been 


shown  by  Spronk,  however,  thai  the  blood  serum  of 
many  lepers  even  in  weak  dilution  give-,  the  agglu- 
tinating reaction  with  cultures  "I"  the  bacillus  lepi 
a  fact  which  goes  to  prove  thai  the  organism  culti- 
vated is  the  true  cause  of  the  disease  with  which  it 
is  associated. 

Pathogenesis. — Some  investigators  claim   to   ha 
had  positive  results  in  Inoculation  experiments  on 

animals  with  portions  of  leprous  tubercles,  excised  for 
the  purpose;  Dul  none  has  succeeded  in  producing  the 

typical  lesions  of  the  disease  a-  tmi  in  man.  Arning 
inoculated  a  condemned  criminal  in  the  Sandwich 
Islands  with  fresh  leprous  tubercles,  bis  death  occur- 
ring from  leprosy  five  year-,  later;  bul  there  i-  no  con- 
clusive evidence  of  the  transmissibility  of  the  di 
in  this  way,  as  tin-  man,  according  to  .Swift,  had  oilier 
opportunities  for  becoming  infected. 

It  is  generally  assumed  that  infection  takes  place 
through  the  mucous  membranes  ami  through  slight 
skin  wounds.  There  is  said  to  be  no  infect  ion  by  way 
of  the  digestive  tract.  With  regard  to  the  question 
of  direct  inheritance  from  the  mother  to  the  unborn 
babe,  there  is  considerable  difference  of  opinion. 
Some  cases  of  intrauterine  infection  have  been  repor led 
but  they  are  at  least  very  rare.  Leprosy  bacilli  are 
frequently  present  in  the  spermatic  fluid  and  in  the 
milk,  but  they  have  never  been  found  in  the  ovaries. 
Most  commonly  they  are  met  with  in  purulent  nasal 
secretions  (one  hundred  and  twenty-eight  out  of  one 
hundred  and  fifty-three  cases  examined  by  Sticker), 
and  in  the  mucous  membranes  of  the  mouth,  throat, 
etc.;  but  they  have  also  been  found  in  various  other 
organs  of  the  body,  in  the  nerves,  and  in  the  blood. 
The  widespread  opinion,  which  was  held  before  the  dis- 
covery of  the  leprosy  bacillus,  that  the  disease  was 
associated  in  some  way  with  the  eating  of  certain 
kinds  of  food,  as  salt  fish,  has  now  been  generally 
abandoned.  The  negative  results  obtained  from 
inoculation  experiments,  together  with  the  fact  that 
infection  is  not  readily  transmitted  to  persons  exposed 
to  the  disease,  have  been  explained  by  the  assumption 
that  the  bacilli  contained  in  the  leprous  tissue  are 
mostly  dead  and  non-virulent;  but  it  is  much  more 
probable  that  a  special  susceptibility  to  the  disease, 
inherited  or  acquired,  is  requisite  for  its  production. 

The  great  similarity  in  many  respects  of  leprosy  to 
tuberculosis  has  recently  been  still  more  emphasized 
by  the  observations  of  Babes  and  Kalindero,  who 
state  that  leprosy  reacts,  both  locally  and  generally, 
to  an  injection  of  tuberculin  in  the  same  manner  as 
tuberculosis. 

The  Smegma  Bacillus  (Bacillus  srnegmatis). — 
Found  by  Tavel  and  Matterstock  in  the  smegma 
pra?putii,  between  the  scrotum  and  thigh,  and  between 
the  labia;  also  in  the  cerumen  and  occasionally  on  the 
skin.  The  bacilli  lie  in  clusters  either  in  or  between 
the  epithelial  cells,  the  rods  being  very  similar,  in  size 
and  form,  to  those  of  the  tubercle  bacilli.  They  stain 
with  difficulty,  and  resist  decolorization  with  acid 
when  stained  by  the  methods  for  staining  the  tubercle 
bacillus,  but  are  decolorized  when  treated  for  one 
minute  with  absolute  alcohol.  This  bacillus  is  most 
likely  to  be  mistaken  for  the  tubercle  bacillus  in  the 
examination  of  urine. 

Lustgartex's  Bacillus. — This  organism,  which 
very  closely  resembles  the  tubercle  bacillus,  was  found 
by  Lustgarten  (1SS4)  in  the  secretions  of  syphilitic 
ulcers  and  believed  by  him  to  be  the  specific  cause  of 
syphilis.  Doutrelepont  about  the  same  time  also 
observed  a  similar  organism  and  came  to  a  like 
conclusion.  It  has  since  been  shown  that  in  nor- 
mal smegma,  bacilli  are  found  in  great  abundance 
similar  in  their  morphology  to  the  bacillus  of  Lustgar- 
ten, but  differing,  as  a  rule,  in  certain  staining 
peculiarities. 

Lustgarten's  bacillus  stains  with  equal  difficulty  as 

S43 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


the  tubercle  bacillus,  but  is  much  less  resistant  to  the 
action  of  acids;  it  is  also  more  resistant,  as  a  rule, 
to  the  decolorizing  action  of  alcohol  than  is  the 
smegma  bacillus. 

Numerous  attempts  have  been  made  to  cultivate 
this  bacillus  artificially  but  without  success.  The 
inoculation  of  animals  with  syphilitic  tissues  and  secre- 
tions  has  also  given  only  negative  results,  though  in 
man,  as  is  well  known,  infection  by  inoculation  fre- 
quently takes  place,  the  tertiary  lesions  only  being 
non-infectious. 

Lustgarten's  bacillus  has  been  found  in  various 
syphilitic  tissues,  in  beginning  sclerosis,  in  the  papules, 
in  condylomata  and  gummata,  and  not  only  in  the 
vicinity  of  the  genitals,  but  also  in  the  mouth,  throat, 
heart,  and  brain.  No  satisfactory  experimental  evi- 
dence has  been  given,  however,  of  its  causative  rela- 
tion to  syphilis.  It  is  now  recognized  that  Trep- 
onema pallidum  (spirochata  pallida),  discovered  by 
Sehaudinn  and  Hoffman,  in  1905,  is  the  specific 
cause   of   syphilis. 

The  Influenza  Bacillus  (Bacillus  influenza'). — 
Discovered  by  Pfeiffer  and  isolated  in  pure  cultures 
(1S91-92)  from  the  purulent  bronchial  secretion^  of 
patients  suffering  from  epidemic  influenza.  Pfeiffer's 
discovery  has  been  fully  confirmed  by  others,  the 
results  of  whose  researches  give  us  reason  to  believe 
that  this  bacillus  is  the  chief  etiological  factor  in  the 
production  of  influenza  or  "la  grippe." 

Microscopical  Appearances. — Extremely  small,  mod- 
erately thick  bacilli,  about  two  or  three  times  as  long 
as  broad,  with  rounded  ends,  occurring  singly  or  in 
pairs,  but  threads  or  chains  of  three  or  four  elements 
are  occasionally  met  with  in  cultures;  often  found  in 
the  interior  of  cells.     (See  Plate  VIII.,  Fig.  3.) 

Motility. — Non-motile. 

Spore  Formation. — Does  not  form  spores. 

Staining  Reactions. — The  influenza  bacillus  stains 
with  difficulty  with  the  ordinary  aniline  colors;  best 
with  dilute  ZiehFs  solution  of  carbol  fuchsin  or 
Loeffler's  methylene  blue  solution,  with  heat.  When 
faintly  stained  the  two  ends  of  the  bacilli  are  somewhat 
more  deeply  stained  than  the  middle  portion.  It 
does  not  usually  stain  with  Gram's  solution,  though 
some  investigators  report  such  staining  reaction. 

Biological  Characters. — Strictly  aerobic;  no  growth 
occurs  below  26°  C,  or  above  43°  C,  or  in  the  entire 
absence  of  oxygen;  optimum  temperature,  37°  C. 
Grows  on  the  surface  of  solid  nutrient  media  contain- 
ing hemoglobin  or  pus  cells,  as  blood  agar  or  blood  se- 
rum. At  the  end  of  eighteen  to  twenty-four  hours  on 
such  culture  media  in  the  incubator  very  small,  drop- 
like colonies  are  developed,  which  under  a  low  mag- 
nification appear  as  shining,  transparent,  homogene- 
ous masses;  older  cultures  are  sometimes  colored 
yellowish  brown  in  the  center.  A  characteristic 
feature  of  the  growth  of  the  influenza  bacillus  is  that 
the  colonies  tend  to  remain  separate,  although  when 
thickly  sown  in  a  film  of  moist  blood  upon  nutri- 
ent agar  they  may  occasionally  become  confluent. 
Spread  out  in  a  thin  layer  upon  the  surface  of  blood 
bouillon  the  growth  develops  as  delicate  white  flakes. 
According  to  Grassberger  a  mixture  of  nutrient  agar 
and  defibrinated  blood,  which  has  been  kept  for  one 
hour  at  50°  to  60°  C,  makes  an  especially  good  soil 
for  their  growth. 

Vitality. — The  influenza  bacillus  is  very  sensitive  to 
desiccation;  a  pure  culture  diluted  with  water  ami 
dried  is  destroyed  with  certainty  within  twenty-four 
hours.  In  dried  sputum  vitality  is  retained  for  from 
twelve  to  twenty-four  hours,  according  to  the  degree 
of  drying.  It  does  not  grow,  but  soon  dies  in  water. 
The  thermal  death  point  is  60°  C.  with  five  minutes' 
exposure.  In  bouillon  cultures  at  20°  C.  the  bacilli 
remain  alive  for  from  a  few  days  to  two  or  three  weeks. 

Pathogenesis. — The  bacillus  of  influenza,  so  far  a-;  is 
known,  produces  the  disease  by  artificial  infection  only 

844 


in  monkeys  and  rabbits.  From  numerous  experi- 
ments made  in  guinea-pigs,  rats,  mice,  and  pigeons 
these  animals  seem  to  be  immune  to  influenza.  When 
a  small  quantity  of  a  twenty-four-hour-old  culture  on 
blood  agar  is  injected  intravenously  into  rabbits 
Pfeiffer  found  that  a  characteristic  pathogenic  effect 
was  produced.  Within  one  and  one-half  to  two  hours 
after  the  infection,  the  animals  became  very  feeble 
and  suffered  from  dyspnea,  the  temperature  rising  to 
41°  C.  or  more.  At  the  end  of  five  or  six  days  they 
were  able  to  sit  up  and  move  about  again,  and  later 
they  recovered.  Larger  doses  caused  death.  When 
cultures  were  rubbed  into  the  nasal  mucous  mem- 
branes of  monkeys,  these  animals  showed  a  febrile 
condition,  lasting  for  a  few  days,  but  in  no  instance 
has  Pfeiffer  observed  a  multiplication  of  the  bacilli 
introduced,  the  results  being  due  to  toxic  products. 
Cantani  has  shown  that  it  is  possible  to  produce 
an  infection  of  influenza  in  rabbits  when  inoculated 
with  small  doses  (0.25  to  0.5  c.c.)  of  living  bacilli, 
provided  the  point  of  least  resistance  is  chosen,  viz., 
the  brain,  the  toxic  products  of  the  influenza  bacillus 
acting  most  powerfully  upon  the  central  nervous 
system.  The  cell  bodies  of  the  bacilli  seem  to  posse- 
considerable  pyogenic  action. 

It  is  possible  that  an  immunity  against  the  influenza 
poison  lasting  for  a  short  period  may  be  established 
after  an  attack.  At  least  in  three  experiments  made 
by  Pfeiffer  on  monkeys,  these  animals,  after  recover- 
ing from  an  inoculation,  seemed  to  be  less  susceptible 
to   a   second   injection. 

The  influenza  bacillus  has  not  been  found  outside  of 
the  body.  In  patients  suffering  from  influenza  the 
bacilli  are  chiefly  met  with  in  the  nasal  and  bronchial 
secretions  more  especially  in  the  characteristic  light 
yellowish  to  green  purulent  sputum.  The  older  the 
process  the  fewer  bacilli  will  be  found,  and  the  more 
frequently  will  they  be  seen  lying  within  the  pus  cell?. 
At  this  time  they  stain  less  readily  and  present  more 
irregular  and  swollen  forms.  Very  often,  perhaps 
almost  invariably,  the  process  invades  portions  of  the 
lung  tissue.  In  severe  cases  a  kind  of  lobular  pneu- 
monia results,  and  is  accompanied  by  symptoms 
almost  identical  with  bronchopneumonia.  In  fatal 
cases  the  bacilli  have  been  found  to  have  penetrated 
not  only  into  the  peribronchial  tissue,  but  even  to  the 
surface  of  the  pleura.  The  pleurisy  which  follows  in- 
fluenza, however,  is  usually  a  secondary  infection,  due 
to  the  streptococcus  or  pneumococcus.  Ordinarily 
the  disease  runs  an  acute  or  subacute  course,  and  not 
infrequently  it  is  associated  with  a  mixed  infection  of 
the  pneumococcus  or  streptococcus.  But  sometimes 
a  chronic  condition  may  be  produced  depending  upon 
the  influenza  bacillus;  the  bacilli  remaining  latent  for  a 
while  and  then  becoming  active  again,  with  a  resulting 
exacerbation  of  the  disease.  Phthisical  patients  are 
particularly  susceptible  to  attacks  of  influenza.  It 
would  appear,  therefore,  that  given  proper  climatic 
conditions,  we  have  at  all  times  the  seeds  of  influenza 
present  in  sufficient  numbers  to  start  an  epidemic. 

The  discovery  of  this  bacillus  enables  us  to  explain 
many  things  previously  unaccountable  in  the  cause  of 
epidemic  influenza.  We  now  know  from  the  fact  that 
the  bacillus  cannot  exist  for  any  considerable  length  of 
time  in  water  or  in  dust,  that  the  disease  is  not  trans- 
missible to  great  distances  through  these  means.  We 
also  know  that  the  infective  material  is  contained 
chiefly  in  the  catarrhal  secretions.  The  occurrence  of 
sporadic  cases,  or  the  sudden  eruption  of  an  epidemic 
in  a  locality  from  which  the  disease  has  been  long  ab- 
sent, and  where  there  has  been  no  new  importation  of 
infection,  may  possibly  be  explained  by  the  supposi- 
tion, as  already  noted,  that  the  influenza  bacilli  re- 
main latent  in  the  air  passages  of  certain  individuals 
for  months  at  a  time,  and  then  become  active  under 
conditions  favorable  for  their  growth,  when  the  in- 
fection mav  be  communicated  to  others  in  close  con- 


REFERENCE    IIAXDHooK    OF    THE    MEDICAL    SCIENCES 


i:  i.  i.  1 1. 1 


tart  with  them.  The  bacteriological  diagnosis  of  in- 
fluenza is  of  considerable  importance  for  the  identifi- 
i,  of  clinically  doubtful  cases,  which  from  the 
symptoms  may  be  mistaken  for  other  diseases,  such,  as 
bronchitis,  pneumonia,  or  tuberculosis. 

In  acute  uncomplicated  cases  the  probable  diag- 
nosis can  be  frequently  made  by  microscopical 
nination  of  stained  preparations  of  the  sputum, 
there  being  present  enormous  numbers  of  the  small 
bacilli.  In  chronic  cases  or  those  of  mixed  infection 
the  culture  method  must  usually  be  employed  if  we 
wish  to  arrive  at  positive  results.  The  bacillus  of 
influenza  is  so  well  characterized  by  its  morphological, 
staining,  and  cultural  peculiarities  that  it  may  be 
distinguished  from  all  other  bacteria  by  an  expert 
bacteriologist  with  sufficient  certainty  for  diagnostic 
purposes.  The  only  bacillus  which  at  all  closely 
resembles  it  is  the  pseudo-influenza  bacillus  found  by 
Pfeiffer  in  three  cases  of  bronchopneumonia;  and 
this  is  distinguished  from  the  genuine  influenza 
lus  by  its  larger  size  and  tendency  to  grow  out, 
iu  cultures  on  blood  agar,  into  long  threads. 

The  Koch-Weeks  Bacillus  op  Conjunctivitis. — 
This  bacillus  was  first  observed  by  Koch  in  1883, 
later,  in  1887,  it  was  specifically  described  by  Weeks, 
who  obtained  it  in  pure  cultures.  The  infective 
disease,  of  which  it  is  the  cause,  seems  to  be  widely 
distributed,  no  land  or  clime  being  exempt  from  it. 
In  this  country  it  occurs  epidemically  during  the 
spring  and  fall  months.  It  is  known  commonly  as 
"pink  eye." 

Motility. — Non-motile. 

Spore-Formation. — Absent;  in  culture  media  the 
bacilli  die  rapidly,  seldom  living  more  than  five  days. 
They  resist  a  temperature  of  50°  for  ten  minutes. 
They  cannot  resist  drying  for  any  length  of  time. 

Morphology. — The  "bacilli  from  the  purulent  secre- 
tion are  small  and  slender,  being  not  unlike  the 
influenza  bacilli  but  somewhat  longer.  The  shorter 
bacilli  not  infrequently  have  the  appearance  of 
diplococci  and  sometimes  they  exhibit  polar  staining. 
Their  width  is  constant.  The  ends  are  rounded. 
They  are  rapidly  decolorized  by  Gram. 

Staining. — They  are  best  stained  by  dilute  solutions 
of  carbol  fuchsin  or  Loeffler's  methylene  blue,  but  do 
not  stain  readily.  In  smear  preparations  the  Koch- 
Weeks  bacilli  are,  as  a  rule,  seen  alone  or  associated 
with  isolated  cocci  and  bacilli  within  the  cells,  and 
are  very  rarely  associated  with  gonococci  and  pneu- 
mococci,  such  mixed  infections  being  very  uncommon. 

Biological  Characters. — The  Koch-Weeks  bacillus 
grows  only  at  temperatures  near  to  37°  C.  of  the 
ordinary  culture  media.  None  but  moist  and  slightly 
alkaline  peptone  agar  can  be  employed.  The  best 
results  have  been  obtained  with  serum  agar  or  a  mix- 
ture of  glycerin  agar  and  ascitic  fluid,  2  to  1.  Pure 
cultures  are  rarely  obtained  at  first,  being  usually 
associated  with  colonies  of  xerosis  bacilli  or  staphylo- 
cocci. After  twenty-four  to  forty-eight  hours  the  colo- 
nies are  noticeable  as  moist,  transparent,  shining  drops. 

Microscopically  examined  under  low  power  they  ap- 
pear like  small  gas  bubbles;  on  closer  examination  they 
are  seen  to  be  round,  lying  loosely  on  the  surface,  and 
are  readily  removed.  Under  higher  power  a  number 
of  fine  points  are  observable.  The  colonies  resemble 
t  hese  of  influenza,  have  a  tendency  to  confluesce,  but  are 
not  so  sharply  defined  as  the  latter  and  become  more 
quickly  indistinguishable.  In  serum  or  blood  bouillon 
a  slight  cloudiness  is  produced  which  finally  settles 
down. 

Pathogenesis. — The  Koch-Weeks  bacillus  is  not 
pathogenic  for  animals.  Man,  on  the  contrary,  is 
extremely  susceptible  to  infection.  Transmission 
of  the  disease  occurs  only  by  contact  either  by  direct 
or  indirect  conveyance  of  the  moist  infective  material. 
Infection  is  not  communicated  through  the  air  by 


ans  of  dust,  as  the  bacilli   soon  die  when  dried. 

it  may,  however,  be  conveyed  by  flies,  etc.  Im- 
munity    is     not      produce, 1     to    any    extent     by    i 

attack,  but  there  doe  i  seem   to  bi      i  dual 

susceptibility. 

The    only    mic-roc, i  from    which    the    Koch- 

Weeks  bacillus  would  seem  to  require  differentiation 
are  those  of  the  influenza  group.  These  latter 
bacilli,  however,  grow  well  only  on  hemoglobin  media, 
which    the    Koch-Wi  I   iculus   does    not    require. 

The    colonies    on    ,-ei  uin  agar    are    also    .-mailer    than 

those  of   the   influenza  bacilli  and   thi  more 

granular. 

The    Diphtheria    Bacilli  dipht) 

Klebs-Loeffler     b  -This     bacillus     was     first 

ol    erved    by     Klebs    (1883)     in    diphtheritic    false 

membrane.      Ii  ated   in   pure  cultures  and   its 

pathogenic  properties  demonstrated  by  Loeffler  in 
L884.  In  lss7  ss  further  studies  by  Loeffler,  Roux, 
an,l  Yer-in  added  to  the  proof  of  the  dependence  of 
diphtheria   upon  this  bacillus.     The  results  of  thi 

investigations  have  since  been  confirmed  by  a  gri 
number  of  combined  clinical  and  bacteriological 
observations  both  in  animals  and  man.  All  the 
conditions  have  been  fulfilled  for  diphtheria  which  are 
necessary  to  the  most  vigorous  proof  of  the  causative 
relation  of  a  given  microorganism  to  an  infectious 
disease,  viz.,  the  constant  presence  of  the  organism 
in  the  lesions  of  the  disease,  the  isolation  of  it  in  pure 
culture,  the  failure  to  produce  the  disease  by  any 
other  bacteria,  and  the  additional  demonstration  (if 
the  immunizing  value  of  the  specific  antitoxic  sub- 
stances developed  in  animals  subjected  to  injections 
of  diphtheria  toxin.  In  view  of  these  facts  we  are 
justified  in  concluding  that  all  cases  of  U-iir  or  primary 
diphtheria  are  due  to  the  Klebs-Loeffler  bacillus. 

Microscopical  .1  /ipcaranccs.  —  .Somewhat  slender 
rods  of  variable  size,  1  to  6 /i  long  and  0.3  to  0.8  ». 
broad,  either  straight  or  slightly  curved,  with  rounded 
ends,  occurring  singly  or  in  pairs.  Irregular  forms 
are  very  common,  and  indeed  are  characteristic  of 
this  bacillus.  In  the  same  culture  and  in  unfavorable 
media  great  differences  in  form  and  dimensions  occur; 
one  or  both  ends  may  appear  swollen,  or  the  central 
portion  may  be  thicker  than  the  extremities,  or  the 
rod  may  consist  of  irregular  spherical  or  ovoid  seg- 
ments. The  rods  sometimes  lie  in  clusters  alongside 
of  one  another  in  a  characteristic  manner,  like  a 
bundle  of  fagots.  Threads  with  swollen  ends  and 
branching  forms  sometimes  occur,  but  these  are  com- 
paratively rare.     (See  Plate  VIII.,  Fig.  4.) 

Motility. — Non-motile. 

Spore  Formation. — Absent,  but  cultures  retain  their 
vitality  for  months. 

Staining  Reactions. — Stain  readily  with  the  ordinary 
aniline  dyes  and  retain  fairly  well  their  color  after 
staining  by  Gram's  method.  When  Loeffler's  alkaline 
solution  of  methylene  blue  is  applied  cold  for  five 
minutes  or  warm  for  one  minute,  the  bacilli,  from 
blood-serum  cultures  especially  and  from  other  media 
less  constantly,  stain  in  an  irregular  and  extremely 
characteristic  way.  Carbol  fuchsin  and  gentian  violet 
stain  the  bacilli  too  intensely,  obscuring  the  struc- 
ture of  the  organisms. 

Neisser  has  recently  described  a  double  stain  which 
brings  out  the  metachromatic  bodies  of  the  diphtheria 
bacillus,  and  which  he  claims  may  be  used  as  a  method 
of  differential  diagnosis  between  the  virulent  and  non- 
virulent  diphtheria  bacilli  without  the  delay  of  in- 
oculating animals.  The  cover-slip  smear  of  diphtheria 
bacilli  is  placed  for  two  or  three  seconds  in  a  solution 
composed  of  alcohol  (96  per  cent.)  20  parts,  methylene 
blue  1  part,  acetic  acid  (glacial)  50  parts,  and  distilled 
water  950  parts,  and  then,  after  washing,  in  a  second 
solution  (for  from  three  to  five  seconds)  composed  of 
Bismarck  brown  1   part,  and  boiling  distilled  water 

845 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


500  parts.  By  this  method  the  bacilli  are  usually 
stained  brown  and  at  one  or  both  ends  a  blue  granule 
is  seen;  while  the  non- virulent  bacilli  ordinarily  are 
not  so  stained.  But  sometimes  the  pseudodiphtheria 
bacilli  show  the  same  dark  bodies,  and  occasionally 
the  virulent  bacilli  fail  to  take  the  Neisser  stain. 
Neither  this  nor  any  other  stain,  therefore,  can  be 
depended  upon  to  give  positive  information  as  to  the 
virulence  of  the  bacilli,  the  only  certain  way  of 
obtaining  a  differential  diagnosis  between  the  pseudo- 
and  true  diphtheria  bacilli  being  by  animal  inocula- 
tions with  control  injections  of  antitoxin.  (See  Plate 
VIII,  Fig.  5.) 

Biological  Characters.  —  Aerobic  and  facultative 
anaerobic;  grows  best  in  the  presence  of  oxygen,  but 
also  less  readily  without  it.  Development  is  good  and 
abundant  only  at  37°  C,  the  extremes  being  20° 
and  41°  C.  It  grows  on  all  the  ordinary  culture 
media,  glycerin  agar  being  a  favorable  medium, 
though  blood  serum  and  ascitic  fluid  are  still  better. 
Loeiller's  blood-serum  mixture  (see  Bacteriological 
Technique)  is  much  used  and  is  the  best  culture 
medium  for  diagnostic  purposes  in  examining  cul- 
tures from  the  throats  of  persons  suspected  of  having 
diphtheria.  The  growth  in  gelatin  at  22°  to  24°  C. 
is  not  characteristic,  and  is  so  scanty  that  it  is  seldom 
employed  for  the  cultivation  of  the  diphtheria  ba- 
cillus.    The  gelatin  is  not  liquefied. 

Growth  on  Blood  Serum. — On  Loeffler's  blood- 
serum  mixture  at  the  end  of  eight  to  twelve  hours 
small  colonies  develop  which  appear  as  pearl  gray, 
or  more  rarely  yellowish  gray,  slightly  elevated  points. 
The  borders  are  usually  uneven.  After  forty-eight 
hours  the  colonies  when  separated  may  so  increase  in 
size  that  they  are  one-eighth  of  an  inch  in  diameter; 
these  lying  close  together  become  confluent  and  fuse 
into  one  mass,  if  the  serum  be  moist.  During  the 
first  twelve  hours  the  colonies  of  the  diphtheria 
bacilli  are  about  equal  in  size  to  those  of  other 
pathogenic  bacteria  which  are  often  present  in  the 
throat;  but  after  this  time  the  diphtheria  colonies 
become  larger  than  those  of  the  streptococci  and 
smaller  than  those  of  the  staphylococci.  The  blood 
serum  is  not  liquefied. 

Growth  on  Agar. — On  one  per  cent,  slightly  alkaline, 
nutrient  or  glycerin  agar  the  growth  of  the  diphtheria 
bacillus  is  less  certain  and  luxuriant  than  upon  blood 
serum,  but  the  appearance  of  the  colonies  when  ex- 
amined under  a  low-power  lens  is  often  more  charac- 
teristic; the  growth,  however,  is  variable,  and  when 
obtained  fresh  from  pseudo-membranes  the  colonies 
develop  slowly  or  fail  to  develop  at  all.  On  agar 
plates  the  deep  colonies  are  usually  round  or  oval  and 
as  a  rule  present  no  extensions,  but  the  surface  colonies 
commonly  from  one  and  sometimes  from  both  sides 
spread  out  an  apron-like  extension  which  exceeds  in 
area  the  rest  of  the  colony.  These  surface  colonies 
are  more  or  less  coarsely  granular  in  structure  and 
usually  have  a  dark  center.  Some  are  almost  trans- 
lucent, others  are  thick  and  luxuriant  with  irregular 
borders  shading  off  into  a  delicate  lace-like  fringe, 
though  sometimes  the  margins  are  more  even  and  the 
colonies  are  nearly  circular.  With  a  high-power  lens 
the  edges  show  sprouting  bacilli,  the  colonies  being 
gray  or  grayish  white  by  reflected  light  and  pure  gray 
with  olive  tint  by  transmitted  light.  A  mixture  com- 
posed of  two  parts  of  a  one  and  one-half  per  cent, 
nutrient  agar  and  one  part  of  sterile  ascitic  fluid 
makes  a  medium  upon  which  the  bacillus  grows  much 
more  luxuriantly  but  not  so  characteristically.  Nut- 
rient plain  or  glycerin  agar,  with  or  without  the  addi- 
tion of  ascitic  fluid,  is  the  medium  employed  for  the 
isolation  of  the  diptheria  bacillus  by  plate  methods  from 
the  original  serum  tube.  The  agar  should  be  freshly 
melted  and  poured  into  the  Petri  dish  for  this  purpose, 
and  after  it  has  hardened  streak  cultures  from  the  colo- 
nies on  blood  serum  are  made  upon  this,   the  plates 

846 


being    left    in    the    incubator    at  37°  C.  for  twelve 
hours. 

Growth  on  Gelatin. — The  growth  on  gelatin  is  much 
slower  and  more  scanty  than  that  on  blood  serum  or 
agar,  on  account  of  the  lower  temperature  at  which  it 
is  used.     Gelatin  is  not  liquefied. 

Growth  in  Bouillon. — In  slightly  alkaline  or  neutral 
bouillon  the  diphtheria  bacillus  grows  in  fine  grains 
which  are  deposited  along  the  sides  and  on  the  bottom 
of  the  tube,  leaving  the  broth  nearly  clear.  Some- 
times the  bouillon  may  appear  diffusely  clouded  to 
the  naked  eye,  but  when  examined  microscopically 
in  the  hanging  drop  the  clumpy  arrangement  is 
readily  observed.  Frequently  a  whitish  film  forms 
over  part  of  the  surface,  but  in  shaking  this  breaks  up 
and  slowly  sinks  to  the  bottom.  This  film  is  more 
apt  to  develop  in  cultures  which  have  been  long 
cultivated  in  bouillon.  The  reaction  of  the  bouillon 
is  subject  to  changes — the  diphtheria  bacillus  in 
its  growth  causes  a  fermentation  of  the  meat  sugars 
with  the  production  of  acid;  hence  the  bouillon 
becomes  at  first  acid  and  subsequently  alkaline, 
when  the  fermentable  sugars  have  been  decomposed 
this  latter  change  being  favored  by  the  admission  of 
air. 

Growth  in  Milk. — The  diphtheria  bacillus  grows 
readily  in  milk,  beginning  to  develop  at  a  compara- 
tively low  temperature  (20°  C).  Thus  milk  having 
become  inoculated  with  the  bacillus  from  a  case  of 
diphtheria  may  under  certain  circumstances  be  the 
means  of  conveying  infection  to  previously  healthy 
persons.  The  growth  takes  place  better  in  raw  than 
in  boiled  milk.  The  milk  is  not  coagulated,  remaining 
unchanged  in  appearance,  but  the  cultures  may 
retain  their  vitality  for  a  long  time. 

On  potato  which  is  rendered  alkaline  a  delicate 
coating  develops. 

Vitality. — Virulent  diphtheria  bacilli  may  persist  in 
the  throats  of  convalescents  from  diphtheria,  after  the 
disappearance  of  the  false  membrane,  for  weeks  and 
months  even.  In  304  of  005  consecutive  cases  of 
diphtheria  examined  by  Park  and  Beebe  the  bacilli 
were  found  to  be  no  longer  present  within  three  days 
after  the  disappearance  of  the  false  membrane;  in 
176  cases  they  persisted  for  seven  days,  in  64  cases  for 
twelve  days,  in  36  cases  for  fifteen  days,  in  12  cases 
for  three  weeks,  in  4  cases  for  four  weeks,  in  2  cases 
for  nine  weeks,  and  recently  a  case  has  been  noted 
in  which  the  virulent  bacilli  were  present  for  eight 
months.  The  practical  importance  of  this  fact  is  the 
evident  necessity  for  the  isolation  of  convalescents 
from  diphtheria,  whether  showing  clinical  symptoms  or 
not,  until  all  the  Klebs-Loeffler  bacilli  have  dis- 
appeared from  the  throat. 

In  cultures  kept  in  a  cool,  dark  place,  the  bacilli 
retain  their  vitality  for  from  six  months  to  a  year  or 
more.  In  the  incubator  they  are  generally  killed  by 
desiccation  in  from  one  to  three  months;  but  even 
here,  when  the  air  is  excluded,  they  remain  alive  in 
bouillon  for  a  long  time.  They  also  retain  their 
vitality  for  a  considerable  time  in  water  and  articles 
of  food,  etc. 

The  diphtheria  bacillus  possesses  a  considerable  re- 
sistance to  desiccation.  Pure  cultures  in  saturated 
silk  threads  at  room  temperature  remain  alive  under 
favorable  conditions  for  months.  In  dried  diphther- 
itic exudate,  even  when  pulverized,  they  retain  their 
virulence  for  a  long  time.  They  are  soon  killed  by 
moist  heat  at  60°  C.  Cold  has  comparatively  little 
influence  upon  them,  and  even  when  dried  they  retain 
their  virulence  in  winter  for  several  months.  Sus- 
pended in  water  and  exposed  to  the  action  of  direct 
sunlight  the  bacilli  die  in  a  few  hours,  but  in  agar  and 
bouillon  cultures  they  remain  alive  for  six  hours. 

Chemical  Effects. — The  diphtheria  bacilli  produce 
gas  and  acids  from  carbohydrates,  as  from  glucose 
present   in   ordinary    nutrient    bouillon.     They   also 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENt  ES 


Bacteria 


oduce  sulphurated  hydrogen  ami  indol.  In  old 
Itures  some  nitrites  are  present,  which  with  the 
dol  give  the  nitroso-indol  reaction  on  the  addition 

pure  sulphuric  acid.     Pigment  production  is  rare, 

ough  occasionally  yellow  to  reddish  species  have 

in  met  with.     Old  bouillon  cultures  of    the  diph- 

eria  bacillus  filtered  through  porcelain  produce  the 

me  symptoms  as  inoculations  with  t he  bacilli  t  hem- 

Ivcs.     Particularly     active     toxins    are     obtained, 

cording  to  von  Dungern,  by  the  addition  of  ascitic 

lid  to  the  bouillon.     Sugar  is  to  be  avoided.     Bouil- 

n  cultures  as  long  as  they  are  acid  contain  no  toxins. 

two  per  cent,  peptone  nutrient  bouillon,  having  an 

kalinity  equal  to  about  8  c.c.    of  normal  soda  solu- 

.iii  per  liter  above  the  neutral  point  to  litmus,  is  a 

litable  medium  for  the  development,  of  toxin.      Free 

cess   of   air   favors   its   production.     The   greatest 

umulation  of  toxin  in  bouillon  is  after  a  growth  of 

urn  five  to  ten  days  in  the  incubator  at  35°  to  37°  C. 

These  poisons  of  diphtheria  have   been    partially 

olatcd.     They  are  precipitated  in  part  by  alcohol, 

ilcium  phosphate,  calcium  chloride,  and  magnesium 

ilphate.     The  toxin  has  not  yet  been  successfully 

tialyzed,  so  that  its  chemical  nature  is  unknown.     It 

as  many  of  the  properties  of  protein  substances,  but 

is  formed  not  only  in  albuminous  culture  media 

ut  also  in   those   free  from  albumin.     It  is   not  a 

table  body,   being  totally  destroyed  by  boiling  for 

ve  minutes,  and  losing  ninety-five  per  cent,  of  its 

i  rength  when  exposed  to  a  temperature  of  75°  C.  for 

oine  time.     Temperatures  under  60°  C.  alter  it  only 

ery  gradually.     It  is  slowly  decomposed  when  ex- 

losed  to  light  and  air,  but  kept  in  a  cold,  dark  place  it 

nay    be    preserved    almost    indefinitely.     According 

o  Kossel  diphtheria  toxin  is  formed  in  the  cell  bodies 

if  the   bacilli   and   thence   secreted.      Ehrlich,    sub- 

livides  toxins,  according  to  their  degrees  of  toxicity, 

nto  protoxoids,  syntoxoids,  and  epitoxoids. 

Pathogenesis. — The  diphtheria  bacillus  is  patho- 
;enic  for  guinea-pigs,  rabbits,  chickens,  pigeons,  small 
jirds,  and  cats;  also  in  a  lesser  degree  for  dogs,  goats, 
•attle,  and  horses,  but  scarcely  at  all  for  rats  and  mice. 
True  diphtheria,  however,  as  observed  in  man,  is 
■xtremely  rare  among  these  animals,  the  so-called 
iiphtheritic  inflammations  in  them  being  due,  as  a 
rule,  to  other  bacteria  than  the  Klebs-Loeffler  bacillus. 
The  virulence  of  pure  cultures  of  the  diphtheria 
bacillus  from  different  sources,  as  measured  by  their 
toxin  production,  varies  enormously.  In  general, 
severe  cases  of  diphtheria  yield  strongly  virulent 
cultures,  and  mild  cases  slightly  virulent  ones;  but 
there  are  exceptions  to  this  rule.  One  of  the  most, 
virulent  cultures  so  far  known — culture  No.  8,  which 
is  used  not  only  by  the  New  York  Health  Department 
Laboratory,  but  by  many  other  laboratories  in  the 
United  States  and  Europe,  for  the  production  of  toxin 
— was  obtained  from  an  extremely  mild  case  of  diph- 
theria. Experimental  and  accidental  attenuation  of 
the  diphtheria  bacilli  has  often  been  observed.  Roux 
and  Yersin  maintain  that  there  is  a  uniform  and 
gradual  decrease  in  virulence  of  the  bacilli  found  in 
the  throats  of  convalescents  from  diphtheria,  but  this 
has  not  been  confirmed  by  others,  highly  virulent 
bacilli  having  been  repeatedly  found  in  the  throats  of 
those  recovering  from  the  disease  long  after  the  disap- 
pearance of  all  clinical  symptoms.  The  same  marked 
variation  occurs  in  the  amount  of  toxin  produced  by 
different  bacilli  in  their  growth  in  media  outside  of  the 
body.  There  are  also  bacilli  which  produce  no  specific 
toxin  whatever  and  yet  appear  to  have  all  the  other 
characteristics  of  virulent  bacilli.  Moreover,  some 
diphtheria  bacilli  retain  their  virulence,  when  grown 
in  artificial  media,  much  longer  than  others.  The 
passage  of  the  bacilli  through  the  bodies  of  suscep- 
tible animals  does  not  increase  their  virulence  to 
any  appreciable  extent,  this  being  probably   due   to 


the   fact    that    they   multiply   but    little   in    thi     !' 

The  best   guide  for  the  virulence  of  a  diphtheria 
bacillus  is  the  toxicity  of  the  lilt  rate  of  a  culture  of  defi- 
nite age,  as  shown   by  inoculation   Into  guinea-pig 
for  tin    purpo  e  an  alkaline  broth  culture  of  forty-eight 

hours'  growth  is  used.  The  amount  injected  should 
not    be    more    than    one-fifth    per   cent,    of    the    body 

weight  of  the  animal  inoculated,  unless  controls  with 
antitoxin  are  made.     In  the  large  majority  oi  ca  i    , 

when  the  bacilli  are  virulent,  thi   a urn  causes  death 

within  seventy-two  hours.  For  an  absolute  test  of 
specific  virulence  antitoxin  must  be  used.  A  guinea- 
pig  is  injected  subcutaneously  with  antitoxin,  and 
then  this  and  a  control  animal  are  injected  with 
double  the  fatal  dose  of  a  broth  culture  of  the  bacilli 
to  be  tested.  If  the  animal  which  received  the  anti- 
toxin lives,  while  the  control  animal  dies,  it  was  surely 
a  virulent  diphtheria  bacillus  which  killed  by  means 
of  the  toxin  produced. 

About  twenty-four  hours  after  the  subcutaneous 
inoculation  of  a  virulent  culture  of  the  diphtheria 
bacillus  the  animal  becomes  languid,  has  no  appetite, 
its  hair  is  rumpled,  its  nose  cold  and  blue,  and  its 
respiration  rough;  the  point  of  injection  is  infiltrated, 
sometimes  also  the  surrounding  tissues.  Certain 
symptoms,  however,  exclusive  of  Toss  of  weight,  may 
be  wanting.  On  autopsy  there  will  be  found  at  the 
seat  of  inoculation  a  grayish  deposit  surrounded  by 
an  area  of  congestion;  the  subcutaneous  tissues  for 
some  distance  around  are  edematous;  the  adjacent 
lymphatics  are  swollen,  and  the  serous  cavities, 
especially  the  pleural  and  the  pericardial,  frequently 
contain  an  excess  of  fluid,  usually  clear,  but  at  times 
turbid;  the  lungs  are  generally  congested.  In  the 
organs  are  found  numerous  smaller  or  larger  masses 
of  necrotic  cells,  which  are  permeated  with  leucocytes. 
The  heart  and  voluntary  muscular  fibers  usually  show 
degenerative  changes.  Occasionally  there  is  fatty 
degeneration  of  the  liver  and  kidneys.  From  the  area 
surrounding  the  point  of  inoculation  virulent  bacilli 
may  be  obtained,  but  in  the  organs  they  are  only 
occasionally  found,  unless  an  enormous  number  of 
bacilli  have  been  injected.  Paralyses,  commencing 
generally  in  the  posterior  extremities  and  gradually 
extending  to  other  portions  of  the  body  and  causing 
death  by  cardiac  paralysis  or  paralysis  of  the  respira- 
tory organs,  are  also  produced  in  many  cases  in  which 
the  inoculated  animals  do  not  succumb  to  a  too  rapid 
intoxication.  In  rare  instances  the  muscles  of  the 
neck  or  of  the  larynx  are  first  paralyzed  and  thus 
characteristic  symptoms  are  produced. 

Rabbits  are  much  less  susceptible  to  subcutaneous 
inoculation  than  guinea-pigs;  white  mice  and  rats  are 
almost  immune.  On  the  other  hand,  cats,  dogs,  cows, 
and  horses  are  susceptible,  as  are  also  young  pigeons 
and  chickens,  and  small  birds. 

Diphtheritic  false  membrane,  analogous  to  human 
diphtheria,  may  be  produced  in  animals  by  rubbing 
diphtheria  bacilli  on  the  slightly  abraded  surface  of 
mucous  membranes  of  the  trachea  and  conjunctiva 
of  rabbits,  of  the  throats  of  monkeys,  and  of  the 
pharynx  and  larynx  of  pigeons  and  chickens.  The 
process  remains  local.  According  to  Loeffler,  the 
best  results  are  obtained  by  inoculation  of  the  vagi- 
nal mucous  membranes  of  guinea-pigs. 

In  man  no  experimental  inoculations  have  been 
made  but  in  two  involuntary  laboratory  experiments 
made  in  the  New  York  City  Health  Department  severe 
diphtheria  was  contracted  by  inadvertently  sucking 
up  virulent  bouillon  cultures  of  the  diphtheria  bac- 
illus into  the  mouth. 

Outside  of  the  body  diphtheria  bacilli  have  been 
found  upon  articles  used  by  diphtheria  patients,  as 
upon  linen,  brushes,  toys,  walls  and  floors  of  rooms, 
etc.,  and  in  the  hair  of  nurses.  The  air  (exclusive  of 
momentary  contamination  through  the  coughing  of 

847 


Bacteria 


REFERENCE    HANDBOOK   OF   THE    MEDICAL    SCIENCES 


patients)  never  contains  the  bacilli.  They  have  also 
been  found  at  times  in  the  throat  and  nasal  cavities  as 
well  as  in  the  conjunctiva  of  healthy  individuals, 
especially  of  those  coming  in  contact  with  diphtheria 
patients.  Out  of  three  hundred  and  thirty  healthy 
persons  who  had  not  been  in  contact,  so  far  as  known, 
with  cases  of  diphtheria,  Park  and  Beebe  found  viru- 
lent bacilli  in  eight  only,  two  of  whom  later  developed 
the  disease.  It  is  evident,  therefore,  that  infection 
from  diphtheria,  as  in  other  infectious  diseases  re- 
quires not  only  the  presence  of  virulent  bacilli  in  the 
throat,  but  also  an  individual  susceptibility  at  the  time 
to  the  disease.  Among  the  predisposihg  factors  which 
may  contribute  to  the  production  of  diphtheria  are 
the  breathing  of  foul  air  and  living  in  overcrowded 
and  ill-ventilated  rooms,  poor  food,  and  certain  other 
affections  more  especially  catarrhal  inflammations  of 
the  mucous  membranes,  but  all  depressing  conditions 
in  general  favor  the  development  of  the  disease. 

The  chief  locations  of  the  bacilli  in  diphtheria  are  on 
the  surface  of  the  pseudomembranous  inflammations 
of  the  fauces,  larynx,  and  nasal  cavities,  but  also  occa- 
sionally in  membranous  affections  of  the  skin,  vagina, 
rectum,  conjunctiva,  nose,  and  ear  (membranous 
rhinitis  and  otitis  media).  Occasionally  they  have 
been  found  in  the  blood  and  interior  organs  (spleen 
and  kidneys). 

Almost  always  the  streptococcus  pyogenes  is  asso- 
ciated with  the  diphtheria  bacillus,  with  which  it  acts 
pathologically  as  a  synergist.  Regarding  the  im- 
portance of  mixed  infection  in  diphtheria,  Bernheim 
has  stated  that  the  streptococcus  products  of  decom- 
position favor  the  growth  of  the  diphtheria  bacilli  and 
increase  their  virulence  for  production  of  toxin. 
Nevertheless,  the  diphtheria  bacillus  alone  undoubt- 
edly may  produce  all  the  clinical  symptoms  of  sepsis. 

Xiin-rirulent  Diphtheria  Bacilli. — There  are  some- 
times found  in  inflamed  throats  as  well  as  in  healthy 
throats,  either  alone  or  associated  with  virulent 
diphtheria  bacilli,  microorganisms  which  though 
morphologically  and  biologically  identical  with  the 
Klebs-Loelller  bacillus  appear  to  be  non-virulent — 
that  is,  in  artificial  culture  media  and  with  the  usual 
animal  tests  they  produce  no  appreciable  diphtheria 
toxin.  Between  the  bacilli  which  produce  a  great 
deal  of  toxin  and  those  which  seem  to  produce  none  at 
all  we  find  all  grades  of  virulence.  These  are  prob- 
ably attenuated  varieties  of  the  diphtheria  bacillus 
which  have  lost  their  power  of  producing  toxin 
(Roux  and  Yersin).  Bacilli  are  also  found  which 
resemble  the  Klebs-Loeffler  bacilli  very  closely  except 
in  toxin  production,  but  differ  also  in  some  other 
respects.  From  varieties  of  this  kind  having  been 
found  in  a  number  of  cases  of  so-called  xerosis  con- 
junctives these  bacilli  are  often  designated  as  xerosis 
bacilli.  They  are  usually  much  larger  than  diphtheria 
bacilli  and  have  club-like  extremities.  They  may  be 
almost  non-pathogenic  for  guinea-pigs,  or  they  may 
kill.  Animals  are  not  protected  by  diphtheria  anti- 
toxin from  the  action  of  these  bacilli.  Whether  they 
are  derived  from  the  original  diphtheria  stock  is 
not  known. 

Pseudodiphtheria  Bacilli. — Besides  the  typical 
bacilli  which  produce  diphtheria  toxin  and  those 
which  do  not,  but  which,  so  far  as  we  can  determine, 
are  otherwise  identical  with  the  Loeffler  bacillus,  there 
are  other  bacilli  found  in  positions  similar  to  those  in 
which  diphtheria  bacilli  occur,  and  yet,  though  re- 
sembling these  organisms  in  many  particulars,  differ 
from  them  in  certain  important  characteristics. 
.The  variety  most  prevalent  is  rather  short,  plump,  and 
more  uniform  in  size  and  shape  than  the  true  Loeffler 
bacillus,  and  the  great  majority  of  them  in  culture 
show  no  polar  granules  when  stained  by  the  Neisser 
method,  staining  evenly  throughout  with  Loeffler's 
alkaline  methylene  blue  solution.  Their  .  colony 
growth  on  blood  serum  is  very  similar  to  that  of  the 

SIS 


diphtheria  bacilli,  but  they  do  not  produce  acid  by  the 
fermentation  of  glucose,  and  they  never  produce 
diphtheria  toxin.  These  are  called  pseudodiphtheria 
bacilli,  or  more  properly,  B.  hofmani.  When  found  in 
cultures  from  cases  of  suspected  diphtheria  they  may 
lead  to  an  incorrect  diagnosis;  and  here  the  Neisser 
method  of  staining  is  of  value,  though  the  only 
absolute  test  of  virulence  is  by  inoculation  or  sus- 
ceptible animals.      (See  Plate  VIII.,  Fig.  6.) 

Pseudomembranous  Inflammations  due  to  Bacti  ri,i 
other  than  the  Diphtheria  Bacilli. — The  diphtheria 
bacillus,  though  the  most  usual,  is  not  the  only  micro- 
organism that  is  capable  of  producing  pseudomem- 
branous inflammations.  The  streptococcus,  staphylo- 
coccus, and  pneumococcus  are  the  forms  most  often 
found  in  angina  simulating  diphtheria,  but  there  are 
also  others  which,  under  suitable  conditions,  take  an 
active  part  in  producing  this  kind  of  inflammation. 
But  the  bacteria  which  occur  in  this  so-called  false 
diphtheria  are  all  morphologically  and  culturally 
distinct  from  the  Loeffler  bacilli. 

Susceptibility  and  Immunity. — It  is  now  commonly 
recognized  that  an  individual  susceptibility,  both 
general  and  local,  to  diphtheria  is  necessary  to  con- 
tract the  disease.  Age  has  long  been  known  to  be  an 
important  factor  in  the  production  of  diphtheria, 
children  within  the  first  six  months  of  life  being  but 
little  susceptible,  most  so  between  the  third  and  tenth 
years,  while  adults  are  comparatively  immune.  An 
apparent  inherited  susceptibility  to  the  disease  has 
also  been  observed.  Two  attacks  of  diphtheria  have 
rarely  been  known  to  occur  in  the  same  individual 
within  a  short  time.  But  to  what  this  natural  sus- 
susceptibility  or  immunity  is  due  is  as  yet  only  par- 
t  ially  understood.  As  the  result  of  animal  experiment  b, 
however,  it  has  recently  been  shown  that  an  artificial 
immunity  against  diphtheria  can  be  produced,  at 
least  for  a  considerable  period,  by  the  development, 
in  the  body,  of  substances  antidotal  to  the  diphtheria 
toxin. 

Animals  may  be  immunized  against  the  diphtheria 
bacillus  in  various  ways:  By  treatment  first  with 
slightly  virulent  and  then  with  highly  virulent  cultures 
of  the  bacillus;  by  injection  of  small  quantities  of 
attenuated  cultures  or  of  toxin,  and  then  with  gradu- 
ally increasing  doses;  by  injection  of  the  blood  serum 
of  animals  immunized  in  one  of  the  above  ways 
against  diphtheria.  In  the  earlier  experiments  on 
immunization  against  diphtheria  the  names  of 
Fraenkel,  Wernicke,  Aronson,  Roux,  and  others  are 
conspicuous;  but  to  Behring  and  Kitasato  belongs 
the  credit  of  the  fundamental  discovery  that  the 
blood  serum  of  an  animal  immunized  for  certain  infec- 
tious diseases  may  be  employed  for  protective  inocu- 
lations, and  that  in  larger  quantity  it  may  even  exer- 
cise a  curative  influence  after  infection  has  occurred. 
This  is  one  of  the  greatest  discoveries  in  scientific 
medicine  of  recent  years,  and  the  practical  results 
obtained  in  the  treatment  of  diphtheria,  at  least, 
have  justified  all  the  expectations  that  were  enter- 
tained regarding  it.  The  mortality  of  this  fatal 
malady  among  children  has  been  reduced  fifty  per 
cent,  or  more  in  places  where  diphtheria  was  prevalent 
and  where  the  treatment  was  continuously  and  uni- 
formly employed.  As  to  immunity,  it  stands  to  reason 
that  a  disease  which  can  attack  the  same  person  more 
than  once  within  a  comparatively  short  time  does  not 
belong  to  the  class  of  affections  producing  a  permanent 
immunity  after  recovery.  It  is,  however,  well  known 
that  a  certain  temporary  immunity  is  thus  conferred, 
and  the  blood  serum  of  persons  during  convalescence 
from  diphtheria  has  been  found  to  possess  immunizing 
properties.  The  protection  afforded  by  artificial 
immunization,  therefore,  does  not  last  usually  more 
than  three  or  four  weeks,  but  this  is  usually  sufficient 
to  tide  over  the  period  of  exposure  to  infection,  and 
if  necessary  repeated  immunizing  injections  of  the 


EXPLANATION  OF 
PLATE  VIII. 


EXPLANATION  OF  PLATE  VIII. 

Fig.  1. — Bacillus  Tuberculosis  in  Sputum.  X  1,000.  Photomicrograph  from  Sternberg's 
"  Bacteriology"  by  permission. 

Piq,  2. — Bacillus  of  Leprosy,  Section  of  Skin  Nodule.  X  1,000.  Photomicrograph  from 
Bowhill's  "Bacteriology"  by  permission. 

Fig.  3. — Bacillus  of  Influenza  in  Bronchial  Mucus.  X  1,000.  Photomicrograph  from 
Sternberg's  "  Bacteriology"  by  permission. 

Fig.  4. — Bacillus  of  Diphtheria  (Klebs-Loeffler).  Blood-serm  culture  stained  with  Loeffler's 
solution  of  methylene  blue.  X  1,000.  Photomicrograph  from  Sternberg's  "Bacteri- 
ology" by  permission. 

Fig.  5. — Bacillus  of  Diphtheria.  Stained  with  Neisser's  solution,  showing  bodies  of  bacilli 
in  smear  faint  brown;  points,  dark  blue.  X  1,000.  Photomicrograph  from  Park's 
"Bacteriology"  by  permission. 

Fig.  6. — Pseudo-Diphtheria  Bacillus,  Small  Type.  X  1,000.  Photomicrograph  from  Park's 
"  Bacteriology"  by  permission. 

Fig.  7. — Bacillus  of  Typhoid  Fever,  from  Agar  Culture.  X  1,000.  Photomicrograph  from 
Sternberg's  "Bacteriology"  by  permission. 

Fig.  S. — Bacillus  of  Typhoid  Fever  with  Flagella.  Agar  culture.  X  1,000.  Photomicro- 
graph from  BowhUl's  "Bacteriology"  by  permission. 


Reference  Handbook 

of  THE 

Medical  Sciences 


Plate  VIII 


** 


I. 
Tubercle  Bacilli  in  Sputum. 


Vv 


V 


VI 


4"-,vj'-.V 


'!•     t-    > 


Pseudo-diphtheria  Bacillus, 

i  Small  Type). 


0 


'<: 


f 


» 


»     A"'  V 

,        >  -  /  '  »     fl    .V//7 

Diphtheria  Bacillus.  V?*  ,       »»*   *'  *| 

'        I  Blood-serum  Loefllers  Meth-  "  •        »V>**',-f,*  ^  ,/«J 

VN  ylene-blue  stain).  /  yt  •       -  «   Nl>f       &"'  *'•. 


e      ■ 

.,?■■   ••  >- 

•r-    •• 


a. 

Leprosy  Bacillus. 


•  '     •    -.-  -  •  ••■•      ' 

-  .     -.•     •  •  v.f 


1  ^    v.* 


VII. 
-.-*■?  ■-.'     ..  .;»»-  Bacillus  of  Typhoid  Fever. 


Diphtheria  Bacillus. 
(Ncisscr  Stain). 


III. 

Influenza   Bacillus. 


Pathogenic  Bacteria. 


VIII. 

Bacillus  of  Typhoid  Fever 
with  Flagella. 


REFERENCE    HAN'DRooK    OK   THE    MEDICAL   SCIENCES 


Bacteria 


ntitoxic  serum  may  bo  given.  Regarding  the  cura- 
ivc  injections,  the  earlier  the  remedy  is  administered 
!»■  more  certain  and  rapid  is  the  effect  produced 
his  effect  being,  indeed,  one  of  immunity  or  protection 
gainst  further  infection  or  absorption  by  the  system 
if  the  diphtheria  toxin,  rather  than  of  neutralization 
,f  the  poisons  already  absorbed. 

Preparation  of  Diphtheria  Antitoxin. — The  principal 
teps  in  the  preparation  of  diphtheria  antitoxic  serum 

the  production  of  toxin,  the  immunization  of  the 
lorses,  and  the  testing  of  the  antitoxin  obtained  from 

ii.  The  following  is  the  met  hud  in  brief  now 
mployed  in  the  laboratories  of  the  Health  Depart- 
ment of  New  York  City:  The  strongest  diphtheria 
oxin  possible  is  obtained  by  taking  a  very  virulent 
laciilus  and  growing  it  under  the  conditions  already 

ribed.  The  culture,  after  a  week's  growth,  is 
emoved,  and  having  been  tested  for  purity  is  rendered 
terile  by  the  addition  of  ten  per  cent,  of  a  five  per 
ent.  solution  of  carbolic  acid.  This  sterile  culture  is 
hen  tillered  through  ordinary  sterile  filter  paper  and 
lured  in  full  bottles  in  a  cold  place  until  needed, 
ts  strength  is  tested  by  giving  a  series  of  guinea-pigs 

fully  measured  amounts  injected  subcutaneously. 
.ess  than  0.01  c.c.,  administered  hypodermatically, 
hould  kill  a  250  gm.  guinea-pig.  The  horses  used 
or  immunization  should  be  young  and  absolutely 
lealthy.  A  number  of  such  animals  are  severally 
ejected  with  an  amount  of  toxin  sufficient  to  kill 
i,000  guinea-pigs  of  250  gm.  weight  (about  20  c.c.  of 
trong  toxin),  the  point  of  injection  being  usually 
inder  the  skin  of  the  neck  or  behind  the  shoulder. 
\ftcr  an  interval  of  from  three  to  five  days,  so  soon 
is  the  febrile  reaction  has  subsided,  a  second  sub- 
cutaneous injection  of  a  slightly  larger  dose  is  given. 
With  the  first  three  injections  of  toxin  10,000  units  of 
mtitoxin  are  administered.  If  antitoxin  is  not 
nixed  with  the  toxin  only  one-tenth  of  the  doses 
ibove  mentioned  is  to  be  given.  At  the  end  of  about 
wo  months,  increasing  doses  of  pure  toxin  having 
jeen  injected  every  five  to  eight  days,  from  ten  to 
wenty  times  the  original  amount  is  administered. 
ii  about  three  months  the  antitoxic  serum  drawn 
rom  the  horses  should  contain  at  least  300  antitoxin 
tnits,  when  tested,  and  the  best  of  them  from  800  to 
1,000  units,  in  each  cubic  centimeter.  Very  few 
lorses  ever  yield  over  1,000  units,  and  none  so  far  has 
;iven  as  much  as  2,000  units  per  cubic  centimeter. 
(f  every  nine  months  an  interval  of  three  months' 
reedom  from  inoculations  is  given,  the  best  horses 
■ontinue  to  furnish  high-grade  serum  during  their 
leriods  of  treatment  from  two  to  four  years. 

In  order  to  obtain  the  serum  the  blood  is  withdrawn 
'rom,  the  jugular  vein  by  means  of  a  sharp-pointed 
"annula,  which  is  plunged  through  the  vein  wall,  a  slit 
laving  been  made  in  the  skin.  It  is  run  into  large  flasks 
through  a  sterile  rubber  tube,  and  then  allowed  to  clot, 
the  flasks  having  been  previously  placed  in  a  slanting 
position.  From  these  the  serum  is  drawn  off  after 
four  days  by  means  of  sterile  glass  and  rubber  tubing, 
ind  is  stored  in  large  bottles,  small  vials  being  filled 
is  needed  for  use.  Every  possible  precaution  should, 
of  course,  be  taken  in  the  preparation  of  the  serum  to 
avoid  contamination.  An  antiseptic  may  be  added 
to  the  serum  as  a  preservative,  but  it  is  not  ordinarily 
necessary.  Kept  from  access  of  air  and  light  and  in  a 
cold  place,  it  is  fairly  stable,  deteriorating  not  more 
than  thirty  per  cent.,  and  often  much  less,  within  a 
year.  When  stored  in  vials  and  kept  as  above,  diph- 
theria antitoxin  continues  within  ten  per  cent,  of 
its  original  strength  for  at  least  two  months;  after 
that  it  can  be  used  by  allowing  for  a  maximum  de- 
terioration of  two  per  cent,  for  each  month. 

Diphtheria  antitoxin  has  the  power  of  neutralizing 
diphtheria  toxin,  so  that  when  a  certain  amount  is  in- 
jected into  an  animal  before  or  together  with  the 
toxin  it  overcomes  its  poisonous  action.     This  power 

Vol.   I.— 54 


is  utilized  in  testing  antitoxin.      Guinea-pigs  of  about 

250  gm.  weight  are  subcutaneously  injected  with  one 
hundred  or  with  ten  fatal  dose  "i  toxin  which  have 
been  previously  mixed  with  an  amount  of  antito  in 
believed  to  be  sufficient   to  protect   from  the  to    a. 

If  the  guinea-pig  lives  lour  day.-,  but   di n  after, 

the  amount  of  antitoxin  added  to  the  toxin  was  just 

1  or  0.1  unit,  according  as  one  hundred  or  ten  fatal 
doses  were  employed.      If  the  animal  dies  cm  her,  I.    , 

than  I  unit  was  added.  An  antitoxin  unit  has  thus 
been  defined  as  "ten  times  the  amount  of  antitoxic 
serum  required  to  protect  a  guinea-pig  weighing  250 

gm.  from  death,  when  ten  times  tne  fatal  dose  of 
toxin  is  mixed  with  the  serum  and  the  mixture  in- 
jected subcutaneously  into  tile  animal." 

The  Uxe  of  Diphtheria  Antitoxin  in  Treatment  and 
Immunization. — tor     the     injection     a     hypodermic 

syringe  is  employed,  holding  10  to  12  c.v.,  which 
mu  i  be  previously  thoroughly  sterilized  with  alcohol 

and  a  livc-per-eent.  solution  of  carbolic  acid.  The 
injection  is  made  at  some  point  on  the  anterior  sur- 
face of  the  body,  as  the  abdomen  or  thorax  or  outer 
surface  of  the  thigh,  where  there  is  an  abundance 
of  subcutaneous  cellular  tissue.  II. -lore  injection 
the  skin  should  be  carefully  washed  with  alcohol  or 
some  disinfecting  solution.  The  serum  is  rapidly 
absorbed,  and  it  is  belter  not  to  employ  massage  over 
the  point  of  injection.  For  treatment  of  mild  ca 
of  diphtheria  the  dose  is  1,500  antitoxin  units,  for 
moderate  cases  2,000  to  4,000  units,  and  for  severe 
eases  10,000  to  20,000  units.  When  no  improve- 
ment follows  in  twelve  hours  the  dose  should  be 
repeated.  For  immunization  of  children  or  adults 
who  have  been  exposed  to  diphtheria  the  dose  is 
from  300  to  500  units  for  an  infant,  500  to  1,000  for  an 
adult,  and  proportionally  according  to  age,  to  be  re- 
pealed if  necessary  at  the  end  of  two  or  three  weeks. 
In  all  cases  it  is  better  to  use  a  small  quantity  of  a 
high-grade  serum  than  a  large  quantity  of  a  low-grade 
preparation,  as  there  is  in  the  former  instance  less 
danger  of  rashes  and  other  deleterious  effects.  The 
only  untoward  results  to  be  feared  in  any  case  in 
which  proper  aseptic  precautions  are  taken  in  the  in- 
jection, are  occasional  rashes  with  perhaps  some 
slight  rise  of  temperature,  known  as  serum  sickness. 
About  1  in  10,000  persons,  within  a  few  minutes  after 
an  injection  of  serum,  develops  alarming  symptoms. 
About  twenty  deaths  in  all  have  been  reported.  Those 
suffering  severe  symptoms  have  usually  been  subject 
to  asthma,  while  the  fatal  cases  have  the  pathological 
changes  known  as  status  lymphaticus.  In  sus- 
picious cases  of  any  severity,  particularly  in  croup,  it 
is  better  to  administer  the  remedy  at  once,  making 
a  culture  at  the  same  time  for  bacteriological  diagnosis, 
than  to  delay  treatment  until  a  positive  diagnosis  has 
been  made  by  bacteriological  examination. 

Concentrated  Antitoxin. — Many  attemps  have  been 
made  to  seperate  the  antitoxin  from  the  serum,  with 
a  view  to  concentrate  the  dose  and  at  the  same  time 
reduce  the  possible  ill  effects  of  the  serum.  A  con- 
centrated antitoxic  globulin  solution  is  now  made  in 
the  laboratoies  of  the  Health  Department  of  new 
York  City,  and  by  other  manufacturers,  which  is 
being  used  in  preference  to  the  antitoxic  serum  and 
apparently  with  good  results.  The  curative  effects 
have  proved  to  be  identical  with  that  of  the  whole 
serum  and  decidedly  less  severe  rashes,  etc.,  than 
formerly  have  been  noted. 

The  material  used  in  the  Health  Department  is 
blood  plasma  instead  of  blood  serum.  The  globulins 
of  the  plasma  are  removed  from  the  other  non-anti- 
toxic or  toxic  constituents  of  albumin,  cholesterin, 
lecithin,  bile  salts  and  acids,  etc.,  by  precipitation  with 
ammonium  sulphate.  This  precipitate  contains  the 
globulins  of  the  blood  which  are  antitoxic,  those  which 
are  non-antitoxic,  and  nucleoproteins.  The  antitoxic 
globulins  are  extracted  by  treating  with   saturated 

849 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


solution  of  sodium  chloride,  in  which  this  compound 
is  soluble.  The  antitoxic  globulins  are  then  isolated 
from  the  solution  by  precipitation  with  dilute  acetic 
acid.  The  ammonium  salts  are  washed  out  by  repeated 
treatment  with  sodium  chloride  solution  and  filtered. 
Finally,  the  sodium  chloride  is  removed  by  dialysis. 
After  dialysis,  the  antitoxic  globulins  are  dissolved  in 
dilute  saline  solution,  filtered  to  remove  the  traces  of 
undissolved  matter,  passed  through  a  Berkefeld  clay 
filter  to  remove  bacteria,  and  then  put  in  sterile 
syringes. 

The  concentration  of  antitoxin  made  possible  by 
the  elimination  of  the  non-antitoxic  substances  is  not 
only  a  convenience  but  is  of  distinct  importance, 
a-  it  tends  to  encourage  large  doses  as  well  as  to  re- 
duce to  a  minimum  the  serum  or  anaphylactic  effects. 

The  Bacillus  op  Tetanus  (Bacillus  tetani). — 
Nicolaier  in  1884  produced  tetanus  in  mice  and  rab- 
bits by  subcutaneous  inoculation  of  particles  of  gar- 
den earth,  and  showed  that  the  disease  was  trans- 
missible by  inoculation  from  these  animals  to  others. 
Carl  and  Rattone  soon  after  this  demonstrated  the 
infectious  nature  of  tetanus  as  it  occurs  in  man. 
Finally,  in  1889,  Kitasato  obtained  the  bacillus  of 
tetanus  in  pure  culture  and  described  its  biological 
characters. 

Microscopical  Appearances. — Slender  rods  with 
rounded  ends,  0.3  to  0.8  ji  in  diameter  by  2  to  4  p.  in 
length,  usually  occurring  singly,  but  often  growing 
into  long  threads,  especially  in  old  cultures. 

Spore  Formation. — Forms  rounded  spores  thicker 
than  the  cells,  occupying  one  extremity  of  the  rods 
and  giving  them  the  appearance  of  minute  drumsticks. 
(See  Plate  X.,  Fig.  3.) 

Motility. — Motile,  although  not  actively  so  in  hang- 
ing drop  cultures  with  exclusion  of  air;  numerous 
flagella  are  attached  to  the  bodies  of  the  bacilli.  In 
the  spore  stage  they  are  non-motile. 

Staining  Reactions. — Stains  with  the  ordinary 
aniline  dyes,  and  is  not  decolorized  by  Gram's  solution. 
The  spores  may  be  demonstrated  by  double  staining 
with  Ziehl's  method. 

Biological  Characters. — When  freshly  isolated  from 
the  animal  body,  this  organism  is  strictly  anaerobic; 
but  by  long  cultivation  at  high  temperatures  it  often 
becomes  less  sensitive  to  the  presence  of  oxygen,  this 
cultivation  being  facilitated  by  association  with 
certain  saprophytic  bacteria.  Carbone  and  Pessero 
have  obtained  from  a  case  of  rheumatic  tetanus  in 
which  there  was  no  sign  of  injury  in  the  bronch  al 
mucous  membranes  virulent  tetanus  bacilli,  which 
grew  more  luxuriantly  under  aerobic  than  anaerobic 
conditions;  in  pure  cultures,  however,  they  proved 
to  be  non-virulent.  The  Bacillus  tetani  does  not 
grow  at  temperatures  below  14°  C,  though  slowly 
from  20°  to  24°  C;  best  at  37°  C,  when  it  rapidly 
forms  spores.  It  develops  in  the  ordinary  nutrient 
gelatin  and  agar  media  of  a  slightly  alkaline  reaction. 
The  addition  of  1.5  per  cent,  glucose  to  the  media 
causes  the  development  to  be  more  rapid  and  abun- 
dant. According  to  von  Hibler,  the  less  pathogenic 
the  organism  the  more  luxuriantly  it  grows  on  arti- 
ficial culture  media,  and  the  more  energetically  it 
liquefies  gelatin.  In  the  animal  body  its  growtli  is 
comparatively  scanty,  and  it  is  usually  associated 
with  other  bacteria,  pure  cultures  being  difficult  to 
obtain.  Kitasato's  method,  which  is  not  always 
successful,  however,  consists  in  inoculating  an  agar 
tube  with  the  tetanus  material  (pus  from  wounds), 
keeping  this  for  twenty-four  hours  or  more  in  the 
incubator  at  37°  C,  and,  after  the  spores  have  formed, 
heating  it  for  about  an  hour  at  S0°  C.  to  destroy  the 
associated  bacteria.  The  spores  of  Bacillus  tetani  are 
able  to  survive  this  exposure,  and  anaerobic  cultures 
are  then  made  in  the  usual  way,  and  the  tetanus 
colonies  isolated. 

850 


Growth  on  Gelatin. — On  gelatin  plates  the  colonies 
develop  slowly,  the  middle  portion  being  generally 
of  a  yellowish-brown  color,  with  numerous  threads 
radiating  from  the  center;  the  gelatin  is  liquefied. 
In  old  cultures  the  entire  mass  is  made  up  of  fine 
threads,  the  colonies  presenting  an  appearance  not 
unlike  that  of  the  common  mould.  In  gelatin  stab 
cultures  the  growth  exhibits  the  appearance  of  a 
cloudy,  linear  mass  with  outgrowths  radiating  into 
the  medium  from  all  sides.  Liquefaction  take< 
place  slowly,  generally  with  the  production  of  gas 
having  an  unpleasant  empyreumatic  odor. 

Growth  on  Agar. — The  colonies  on  agar  are  quite 
characteristic.  To  the  naked  eye  they  present  the 
appearance  of  light,  fleecy  clouds;  under  a  low-power 
microscope  they  resemble  a  tangled  mass  of  threads. 
The  extreme  fineness  of  these  threads  enables  the 
colonies  of  the  tetanus  bacillus  to  be  distinguished 
from  those  of  other  anaerobic  bacteria.  In  stab 
cultures  on  agar  the  growth  resembles  that  of  a 
miniat  ure  fir-tree. 

Alkaline   bouillon  is   moderately   clouded    by   the 
growth  of  the  tetanus  bacillus.     It  grows  also  in 
culture  media,  but  itself  produces  no  acid.     Milk  is 
not  coagulated. 

Vitality. — The  spores  of  tetanus  are  very  resistant 
to  outside  influences,  retaining  their  vitality  for 
months  or  years  in  a  desiccated  condition  and  not 
being  destroyed  in  two  and  a  half  months  when 
present  in  putrefying  material.  They  withstand 
exposure  to  80°  C,  for  an  hour,  but  are  killed  by  a 
temperature  of  100°  C.  in  five  minutes.  They  resist 
the  action  of  five  per  cent,  carbolic-acid  solution  for 
ten  hours,  but  succumb  when  acted  upon  for  fifteen 
hours.  The  addition  of  0.5  per  cent,  hydrochloric 
acid  to  the  carbolic  solution  enables  it  to  kill  the 
spores  in  two  hours.  In  a  solution  containing  1  to 
1,000  bichloride  of  mercury,  five  per  cent,  carbolic  acid 
and  0.5  per  cent,  hydrochloric  acid,  the  spores  are 
destroyed  in  ten  minutes. 

Chemical  Effects. — The  tetanus  bacillus  produces 
gas  in  media  containing  sugar,  but  no  acid.  It  forms 
sulphureted  hydrogen  abundantly  and  a  little  indol. 
It  produces  powerful  toxins,  which  can  be  separated 
from  the  cultures  by  filtration.  One  one-hundredth 
of  a  milligram  of  an  eight-day  filtered  bouillon  culture 
is  sufficient,  as  a  rule,  to  kill  a  mouse.  From  this 
filtrate,  however,  the  active  toxin  has  been  obtained 
in  a  much  more  concentrated  form.  The  purified  and 
dried  tetanus  toxin  prepared  by  Brieger  and  Cohn  was 
surely  fatal  to  a  15-gm.  mouse  in  a  dose  of  0.000005 
gin.  Reckoning  according  to  the  body  weight  of 
75  kgm.  or  150  pounds,  it  would  require  but  0.00023 
gm.,  or  0.23  mgm.,  of  this  toxin  to  kill  a  man.  Com- 
paring this  with  other  known  poisons,  the  appalling 
strength  of  the  tetanus  toxin  can  be  readily  appreci- 
ated. For  instance,  Calmette  has  found  that  dried 
cobra  venom  requires  0.25  mgm.  to  kill  a  rabbit  of  4 
kgm.  weight,  and  it  would  thus  require,  at  the  same 
rate,  4.375  mgm.  to  kill  a  man  of  150  pounds;  the  fatal 
dose  of  atropine  for  an  adult  is  130  mgm.,  of  strych- 
nine from  30  to  100  mgm.,  and  of  anhydrous  prussic 
acid  54  mgm.  The  true  composition  of  the  tetanus 
toxin  is  unknown;  it  has  been  shown,  however,  that 
it  is  neither  an  alkaloid  nor  an  albuminous  body.  The 
quantity  of  toxin  produced  varies,  even  when  derived 
from  one  and  the  same  culture,  according  to  its  age, 
composition,  reaction,  etc.  It  is  extremely  sensitive 
to  the  action  of  light,  most  chemical  agents,  and  heat. 
It  retains  its  strength  best  in  the  dry  state. 

Pathogenesis. — Man  and  almost  all  domestic  animals 
are  subject  to  tetanus.  Among  animals  those  most 
susceptible  are  horses,  goats,  guinea-pigs,  and  mice, 
less  so  rabbits  and  sheep;  dogs,  rats,  pigeons  and 
chickens  are  almost  immune.  It  is  worthy  of  note 
that  an  amount  of  tetanus  toxin  sufficient  to  kill  a  hen 
would  suffice  to  kill  500  horses.     A  mere  trace — only 


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Bacteria 


,-  much  as  remains  clinging  to  a  straight   platinum 

die  -of  an  old  culture  is  often  enough  to  cause  I  h 
leath  of  mice  and  guinea-pigs. 

ibcutaneous  inoculation  of  virulent  b 
Material    mice   and   other   susceptible   animals   .-how 
■ymptom-  of  t\  pical  tetanus  in  from  one  to  three  days. 
parts  tirst  to  bo  affected  are,  in  about  one- third  nf 
he  case-  in  man.  and  usually  in  animals,  the  muscles 
ying  in  the  vicinity  of  the  inoculation — for  instance, 
hind  foot  of  a  mouse  inoculated  on  that  leg,  then 
the  tail,  the  other  foot,  the  back  and  chest   muscles 
an  both   sides,   the  fore  leas,  until  finally   there  is  a 
general  tetanus  of  the  entire  body.     In  mild  cases  of 
infection,  or  when  a  dose  too  -mall  to  be  fatal  has 
been  received,  the  tetanic  spasm  may  be  one-sided  or 
remain  confined  to  the  muscles  adjacent  to  the  point 
of  inoculation,  and  result  in  recovery.     There  may  be 
no  general  increase  of  reflex  excitability.     In  mat 
horses  the   local   symptoms   may  be  absent,   but   in- 
id  tonic  spa-in-  of  special  muscles:  in  man,  of  the 
muscles  of  the  jaw,  and  in  horses  of  the  muscli 
the  jaw,  neck,  and  tail.      At  the  point  of  inoculation 
in  test  animals  there  may  be  on  autopsy  a  hemor- 
rhagic  -pot,   but    no  chances  here  or  in  the  interior 
lis  other  than  this.      A  few  bacilli  may  be  detected 
lly  with  great  difficulty,  often  none  at  all;  appar- 
ently show  ins;  that  the  lesions  produced  are  due.  not  to 
the  multiplication  of  the  bacilli  in  the  living  body,  but 
to  the  absorption  of  the  poison  formed  by  them  at  the 
point  of  inoculation.     It  has  been  found  that  cultures 
freed  from  spores,  and  such  as  have  been  subjected  to 
heat  at  80°  C,  after  sporulation  and  the  toxins  de- 
stroyed,  can  be  injected  into  animals  without   pro- 
ducing tetanus.     But  if  a  culture  of  non-pathogenic 
organisms  be  injected  simultaneously  with  the  spores, 
or  if  there  be  an  effusion  of  blood  at  the  point  of  in- 
jection or  a  previous  bruising  of  the  tissues,  the  ani- 
mal will  surely  die  of  tetanus.     It  would  seem,  there- 
fore, from  these  experiments,  that  a  mixed  infection 
is  necessary  to  the  development  of  tetanus  when  the 
infection  is  produced  by  spores.     This  fact  is  of  the 
greatest  importance  in  natural  tetanus,  for  here  the 
infection  may  be  considered  as  being  probably  always 
produced  by  the  bacilli  in  their  spore  stage,  and  the 
conditions  favoring  a  mixed  infection  are  generally 
present. 

Tetanus  bacilli  and  their  spores  have  been  found 
widely  distributed  in  garden  earth,  hay  dust,  floors  of 
dwellings  and  hospitals,  on  splinters  of  wood,  old 
nails,  in  the  air,  etc.  They  have  apparently  been 
observed  more  frequently  in  certain  localities  than  in 
others,  as  in  some  parts  of  Long  Island  and  New 
Jersey,  but  they  are  probably  equally  distributed 
everywhere.  This  bacillus  is  the  chief  etiological 
factor  in  the  production,  not  only  of  trismus  and 
traumatic  tetanus,  but  also  of  all  the  various  forms 
of  tetanus — puerperal  tetanus,  tetanus  neonatorum, 
and  idiopathic  and  rheumatic  tetanus. 

Tetanus  Antitoxin. —  Behring  and  Kitasato  were  the 
fir-t  to  show  the  possibility  of  immunizing  animals 
against  tetanus.  Here  the  question  of  immunity 
against  infection  does  not  consist  in  producing  an 
increased  power  of  resistance  against  the  development 
of  the  infecting  agent,  but.  similar  to  diphtheria,  in 
bringing  about  an  immunity  to  the  effects  of  the  tet- 
anus toxin.  The  methods  originally  proposed  by 
B  hring  and  by  Roux  for  producing  a  serum  for  the 
treatment  of  the  disease,  consisted  chiefly  in  weakening 
the  tetanus  toxin  by  means  of  chemical  disinfectant- 
(iodine  trichloride,  Gram's  solution,  etc.),  so  that  when 
inoculated  into  the  te-t  animals  they  produced  com- 
paratively little  reaction.  At  the  present  time  pure 
unaltered  toxin  is  injected  either  alone  in  small 
doses  or  along  with  antitoxin.  After  the  first  dose 
of  toxin  the  animals  acquire  a  certain  tolerance  which 
enables  them  to  stand  a  dose  of  a  less  attenuated  toxin 
or  of  a  greater  amount  of  unchanged  toxin.     Then  by 


gradually  increasing  the  doses  or  the  strength  of  the 
toxin  administered,   the  animal-  are  finally  ah 

bear  injections  of  large  quantities  of   the 
toxin. 

These   immunizing  experiments   in    tetanus    I 

borne  practical  fruit,  for  it   was  through  them  thai 
principle  of  serum  therapeutics  fu 
It  was  thus  shown  that   animal-  could   be   protected 
from  tetanus  infection  by  the  previous  or  sum 

in'  itoxin,  pi  o1  anti- 

toxin   was  obtained   froi  oized 

animal;  anil  from  tin-  it   was  assui 
result   could  b 

I'm    unfortunately,    the   conditions   in    thi 
disease  are  verj    much  less  favorable,   inasmucl 
treatment  i-  usually  commenced,  not  shortly  after  the 
infection  has  taken  place,  but  often  only  on  the  appear- 
of  tetanic  symptoms,  when   tic'  poison  ha-  al- 
ready diffused  itself  through  the  body. 

The  tetanus  antitoxin  is  prepared  in  the  same 
manner  as  the  diphtheria  antitoxin — by  inoculatii  g 
the  tetanus  toxin  m  increasing  doses  into  horses.  The 
toxin  is  produced  in  bouillon  cultures  grown 
f  ally.  After  ten  or  fifteen  days  the  culture  fluid  is 
filtered  t hrough  porcelain,  an. I  the  germ-free  Bltra 
used  for  the  inoculations.  The  horses  receive  0.5  c.c. 
as  the  initial  dose  of  a  toxin  of  which  1  c.c.  kills 
250,000  gm.  of  guinea-pig,  and  along  with  this  a 
sufficient  amount  of  antitoxin  to  neutralize  it.  In 
five  day-  this  dose  is  doubled,  and  then  every  five  to 
day-,  a-  rapidly  as  the  horses  .1  it,  until 

they  support  700-800  c.c.  or  more  at  a  single  < 
After  some  months  of  this  treatment  the  blond  of 
horse  contains  the  antitoxin  in  sufficient  amount  for 
therapeutic  use.  When  the  temperatures  of  the 
horses  are  normal  and  they  have  recovered  from  the 
dose  of  toxin  last  given,  they  are  bled  into  sterile 
flasks  and  the  serum  collected. 

Tetanus  antitoxin  is  tested  exactly  as  is  diphtheria 
antitoxin,  except  that  the  standard  unit  is  different. 
The  test  toxin  used  in  the  German  method  is  one  i  f 
which  1  gm.  destroys  150,000,000  gm.  of  mouse. 
This  is  dissolved  in  33J  c.c.  of  ten-per-cent.  sodium 
chloride  solution.  Ten  times  the  amount  of  antitoxic 
serum  which  neutralizes  1  c.c.  of  this  dilution  of  the 
test  toxin  contains  1  unit  of  tetanus  antitoxin.  In  the 
French  method  the  amount  of  antitoxin  which  is 
required  to  protect  a  mouse  from  a  dose  of  toxin 
sufficient  to  kill  in  four  days  is  determined,  and  the 
strength  of  the  antitoxin  is  stated  by  finding  the 
amount  of  serum  required  to  protect  1  gm.  of  animal. 
If  0.001  c.c.  protected  a  10-gm.  mouse,  the  strength  of 
that  serum  would  be  1  to  10,000.  Guinea-pigs  are 
sometimes  used  instead  of  mice. 

The  dose  of  tetanus  antitoxin  for  immunization  is 

10  c.c.  of  a  serum  of  a  strength  of  1  to  l.  in  in.  m n 

or  about  1,500  units,  unless  the  danger  seem  great, 
when  the  injection  may  be  repeated  after  seven  or 
eight  days.  For  treatment  it  is  well  to  begin  with 
50  c.c.  or  about  10.000  units,  and  then,  according  to  the 
-everity  of  the  case,  give  from  20  to  50  c.c.  each  day 
until  the  symptoms  abate.  The  curative  treatn 
in  man  has  not  been  followed  by  very  satisfactory 
results,  owing  to  the  fact  already  stated  that  the  dis- 
ease is  generally  too  far  advanced  before  treatment  is 
commenced.  From  statistics  collected  by  Lambert 
and  others,  however,  of  cases  of  tetanus  treated  with 
antitoxin,  the  remedy  would  seem  to  have  been  of 
undoubted  practical  use — so  much  so.  at  least,  that 
in  all  cases  in  which  tetanus  is  suspected  or  in  which 
dirt  has  been  ground  into  serious  contusions,  in 
gunshot  wounds,  etc.,  preventive  inoculations  of  the 
serum  should  be  given.  In  certain  parts  of  France 
where  tetanus  i-  very  prevalent  among  horses, 
Xocard  distributed  tetanus  antitoxin  to  sixty-three 
veterinary  surgeons,  who  treated  with  it.  for  the  pre- 
vention of  the  disease,  2,727  of  these  animals.     Only 

851 


Bacteria 


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one  of  this  number  became  affected,  and  this  horse  was 
not  inoculated  until  five  days  after  being  pricked  in 
shoeing.  Although  the  delay  was  too  great  to  prevent 
the  appearance  of  tetanus,  yet  the  disease  was  of  a 
very  mild  nature.  During  the  same  period  259  cases 
in  animals  that  were  not  so  treated  were  observed. 
These  striking  results  would  certainly  seem  to  indicate 
that  the  remedy  deserves  a  much  more  extensive 
consideration  in  the  treatment  of  patients  with 
immunizing  doses  of  serum  than  has  heretofore  been 
given  it — at  least  in  neighborhoods  where  tetanus 
is  not  uncommon  (fortunately  it  is  a  rare  disease  in 
man),  and  when  the  dirty  condition  of  their  wounds 
leads  one  to  suspect  the  possibility  of  tetanus  infection. 
Good  results  have  followed  this  practice  in  many 
places.  It  is  the  custom  at  many  dispensaries  in 
New  York  City  and  elsewhere  to  immunize  all  Fourth 
of  July  wounds  by  injecting  1,000  units.  None  of 
these  cases  have  developed  tetanus.  Even  the 
eleven  cases  of  human  tetanus  reported  as  occurring 
in  Europe  after  single  injections  of  antitoxin  prove  the 
value  of  immunizing  injections,  for  the  mortality  was 
only  twenty-seven  per  cent.  The  recently  proposed 
method  of  injecting  from  3  to  15  c.c.  of  tetanus  anti- 
toxin into  the  lateral  ventricles  has  not  so  far  shown 
itself  to  be  superior  to  the  intravenous  or  subcutaneous 
methods,  and  is  not  in  general  to  be  recommended. 
No  bad  results  have  followed  the  injection  of  the 
antitoxin  when  the  serum  was  sterile  and  the  operation 
was  performed  aseptically. 

The  Bacillus  of  Ttphoid  Fever  (Bacillus  typhi 
abdominalis). — This  organism  was  first  observed  by 
Eberth,  and  independently  by  Koch,  in  1880,  in  the 
internal  organs  of  typhoid  cadavera.  It  was  obtained 
in  pure  culture  by  Gaffky  in  18S4;  and  has  also  been 
found  during  life  in  the  blood,  urine,  and  feces  of 
typhoid  patients.  Its  etiological  relationship  to 
typhoid  fever  has  been  somewhat  difficult  of  demon- 
stration from  the  fact  that,  although  pathogenic  for 
many  animals  when  artificially  inoculated,  it  has  not 
been  easy  to  produce  infection  or  give  rise  to  lesions 
corresponding  to  those  occurring  in  man.  Still  the 
results  which  have  been  obtained  under  certain 
conditions,  together  with  the  specific  reactions  of  the 
blood  serum  of  typhoid  patients,  and  the  constant 
presence  of  the  bacillus  in  the  spleen,  blood,  and 
excretions  of  the  sick  during  life,  have  finally  estab- 
lished, on  a  scientific  basis,  that  this  organism  is  the 
chief  cause  of  typhoid  fever. 

Microscopical  Appearances. — As  met  with  in  the 
organs  of  man  and  animals  the  typhoid  bacilli  are 
short,  plump  rods  with  rounded  ends.  They  vary 
in  size,  being  from  1  to  3  n  long  and  0.5  to  0.8  ft  broad, 
usually  occurring  singly,  but  sometimes  growing 
into  long  threads,  especially  in  certain  culture  media, 
as  in  potato.  They  are  generally  longer  and  some- 
what more  slender  than  the  bacillus  coli  under 
similar  conditions.     (See  Plate  VIII.,  Fig.  7.) 

Motility. — Actively  motile,  especially  the  short 
bacilli,  each  rod  possessing  from  eight  to  fourteen 
flagella  attached  to  the  sides  and  extremities  of  the 
cells.  The  longer  threads  have  a  sinuous  and  more 
sluggish  motion.     (See  Plate  VIII.,  Fig.  8.) 

Spore  Formation. — Does  not  form  spores.  In 
stained  preparations,  particularly  when  grown  on 
potato,  refractive  granules  may  be  seen  at  the  ends 
of  the  rods,  which  stain  more  intensely,  and  in  the 
body  of  the  cells  "  vacuoles"  which  remain  unstained. 
These  so-called  Gaffky 's  spores,  however,  are  not  true 
spores,  as  the  bacilli  containing  them  show  even  less 
resisting  power  than  the  homogeneous  bacilli  found 
in  other  cultures,  but  are  probably  involution  forms. 

Staining  Reactions. — The  typhoid  bacilli  stain  with 
the  ordinary  aniline  colors,  but  a  little  less  readily  than 
do  most  other  organisms,  though  this  is  not  constant. 
They  are  decolorized  by  Gram's  solution. 

852 


Biological  Characters. — The  bacillus  typhosus  grows 
most  luxuriantly  in  the  presence  of  oxygen  but 
oxygen  is  not  essential  to  its  development  (facultative 
anaerobic);  it  grows  fairly  well  also  in  an  atmosphere 
of  C02.  Its  growth  on  the  ordinary  culture  media 
is  similar  to  that  of  the  bacillus  coli  communis,  but 
somewhat  slower  and  not  quite  so  abundant-  in 
contradistinction  to  most  other  pathogenic  micro- 
organisms, it  grows  well  on  slightly  acid  media.  Be- 
low 10°  C.  it  does  not  develop,  its  optimum  tempera- 
ture being  at  37°  C;  over  40°  and  below  30°  C.  it^ 
growth  is  retarded. 

Growth  in  Gelatin. — In  gelatin  plates  the  deep 
colonies  are  not  characteristic;  they  are  small, 
punctiform,  and  sharply  circumscribed,  of  a  yellowish- 
brown  color  and  finely  granular  in  structure.  The 
superficial  colonies,  however,  particularly  when 
young,  are  quite  characteristic;  they  form  a  bluish- 
white,  transparent,  iridescent  coating  on  the  medium, 
with  irregular  outline,  denser  in  the  center  than  at 
the  periphery,  and  exhibiting  under  a  low  power  a 
brownish  color  and  wrinkled  appearance.  The 
gelatin  is  not  liquefied. 

In  gelatin  stab  cultures  the  growth  is  mostly  confined 
to  the  surface;  it  is  thin,  thready,  often  slightly 
granular,  extending  along  the  track  of  the  needle 
and  gradually  reaching  out  to  the  sides  of  the  tube; 
white  to  yellowish  brown  in  color,  irridescent,  and 
transparent.     There  is  no  liquefaction. 

Growth  in  Agar  and  Blood  Serum. — Not  distinctive. 

Growth  in  Bouillon. — This  medium  is  uniformly 
clouded,  but  the  clouding  is  not  so  dense  as  by  the 
colon  bacillus.  After  eighteen  to  twenty-four  hours' 
growth  a  sediment  is  frequently  developed,  and  a 
film  forms  on  the  surface,  with  a  slightly  acid  reaction. 

Growth  in  Potato. — The  growth  in  this  medium  is 
generally  considered  to  be  very  characteristic,  but  it 
varies  considerably.  The  typical  growth  is  a  slightly 
moist,  almost  invisible,  but  luxuriant  layer,  usually 
covering  the  surface  of  the  potato,  and  when  scraped 
with  the  needle  is  tough  and  tenacious.  Sometimes, 
however,  the  development  is  restricted,  not  very 
luxuriant,  and  of  the  same  color  as  the  medium. 
Again,  it  may  be  quite  heavy,  of  a  yellowish-brown 
color  with  a  greenish  halo,  and  similar  to  that  of  the 
colon  bacillus.  These  variations  in  growth  are 
thought  to  be  due  to  the  reaction  (alkalinity)  of  the 
potato. 

Milk  is  not  coagulated,  but  some  acid  is  produced 
by  the  typhoid  bacillus.  The  Bacillus  coli  communis, 
on  the  contrary,  causes  coagulation  of  milk  in  twenty- 
four  to  forty-eight  hours  at  37°  C. 

Vitality. — The  typhoid  bacilli  withstand  desiccation 
for  months;  according  to  Uffelmann  in  dried  earth, 
clothes,  etc.,  for  two  months  or  more.  In  dust, 
however,  they  do  not  seem  to  live  so  long.  They 
resist  cold  remarkably  well;  freezing  and  thawing 
repeatedly  under  favorable  conditions  finally  kills 
them.  They  are  destroyed  by  heating  to  60°  C.  in 
ten  minutes  and  at  higher  temperatures  still  more 
rapidly.  In  feces  the  bacilli  retain  their  vitality  for 
weeks  or  months,  depending  upon  the  number  of 
putrefactive  organisms  present.  In  oysters  they 
have  remained  alive  for  a  month.  In  water  which 
has  been  sterilized  they  live  for  many  days;  in 
ordinary  water  they  are  destroyed,  by  the  concurrence 
of  other  bacteria,  in  about  fourteen  days;  in  running 
water  this  destruction  takes  place  more  rapidly. 
It  thus  appears  that,  under  favorable  circumstances, 
protected  from  light  and  other  deleterious  influences, 
l  he  typhoid  bacilli  may  retain  their  vitality  outside 
of  the  body  for  a  considerable  length  of  time.  But 
they  may  live  also  in  the  human  body  for  a  long  time; 
Sahli  has  found  them  in  the  pleural  exudate  fifty 
days  from  the  beginning  of  the  disease,  and  Heintze 
observed  them  in  a  case  of  typhoid  fever  in  periostitic 
pus  ten  months  after  convalescence. 


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Bacteria 


Chemical  Effects. — The  typhoid  bacillus  produces 
no  pigment  or  odorous  substances.  It  reduces 
litmus  solutions;  converts  nitrates  into  nil  rites,  the 
Kilter  being  gradually  decomposed;  forms  luetic  acid 
from  grape  sugar,  but  does  not  produce  gas  from 
carbohydrates;  produces  11. S  abundantly,  but  does 
not  produce  indol.  The  cultures  are  rich  in  toxins 
!i,  when  freed  from  germs  by  filtration,  are 
active  disease  producers. 

Pathogenesis. — Although  the  typhoid  bacillus  is 
pathogenic  for  mice,  guinea-pigs,  rabbits,  goats,  etc., 
which  when  inoculated  with  virulent  cultures  die, 
showing  symptoms  of  spasm,  falling  temperature, 
and  diarrhea,  no  experiments  so  far  have  produced  in 
animals  the  typical  lesions  of  typhoid  fever  in  man. 
iin  experiments  have  indicated  thai  the  presence 
oi  other  bacteria  in  the  body,  and  of  exposure  to  the 
action  of  poisonous  gases  in  lowering  the  natural 
resistance  of  the  individual,  may  render  him  more 
ceptible  to  typhoid  infection.  But  whatever 
conclusions  may  be  drawn  from  these  results  with 
regard  to  the  typhoid  process  in  animals,  in  the 
human  subject  typhoid  fever  is  now  generally  recog- 

ied  as  a  true  infection,  caused  by  the  invasion  and 
growth  of  typhoid  bacilli  in  the  body.  This  disease 
belongs  to  the  class  of  infections  known  as  metastatic — 
that  is  to  say,  diseases  in  which  the  specific  infective 
organisms  do  not  abound  in  the  circulation,  as  in 
septicemia,  nor  remain  localized  in  one  situation, 
but  are  distributed  through  the  body  in  groups,  the 
characteristic  lesions  of  typhoid  fever  being  in  the 
lymphatic  structures  of  the  intestines,  viz.,  the 
solitary  follicles  and  patches  of  Peyer,  the  mesenteric 
glands,  and  the  spleen;  the  liver  and  kidneys  are  less 
commonly  affected. 

Outside  of  the  body  the  typhoid  bacilli  have  been 
found  so  far  only  in  comparatively  few  instances  in 
water  and  soil,  which  have  become  contaminated 
with  typhoid  dejections;  also  in  milk.  They  have 
been  found  in  healthy  persons  who  have  been  in  close 
association  with  typhoid  patients,  and  those  con- 
valescent from  typhoid  fever.  (See  section  on  Typhoid 
Carriers,  below.)  In  typhoid  patients  they  have  fre- 
quently been  detected  in  the  spleen  and  other  organs 
(kidneys,  liver,  gall  duct,  etc.),  the  blood,  urine,  and 
feces.  They  are  most  easily  isolated  from  the  spleen 
and  lymphatic  glands;  they  are  often  difficult  to  isolate 
from  the  excretions.  The  typhoid  bacillus  may  give 
rise  to  the  most  varied  complications  along  with  the 
clinical  symptoms  of  typical  typhoid  fever;  it  has 
been  demonstrated  to  be  the  cause  of  suppurative  in- 
flammations of  the  spinal  cord,  of  the  brain  and  its 
membranes,  of  the  lungs  and  kidneys,  and  of  different 
suppurative  processes,  erysipelas,  abscess,  etc.,  in 
typhoid  patients.  The  pyogenic  functions  of  the 
typhoid  bacillus  are  indeed  no  longer  disputed.  But 
at  the  same  time  in  many  cases  of  mixed  infection  in 
typhoid  fever,  the  other  pus  cocci  (streptococcus, 
staphylococcus,  pneumococcus,  etc.)  are  no  doubt 
concerned  in  the  production  of  the  complications  of 
the  disease. 

With  regard  to  the  mode  of  infection  by  the  typhoid 
bacillus,  there  is  no  doubt  that  it  is  principally  by  way 
of  the  mouth  and  stomach  to  the  intestines  through 
drinking  water,  etc.  In  a  case  reported  by  Mayer  in 
which  death  occurred  on  the  second  day  of  the  disease, 
there  were  found  on  autopsy  lesions  of  the  lungs, 
spleen,  kidneys,  and  intestines  and  great  enlarge- 
ments of  the  solitary  follicles  and  patches  of  Peyer, 
but  nowhere  a  trace  of  necrosis  or  loss  of  substance 
nor  enlargements  of  the  mesenteric  glands.  Microsco- 
pically an  extraordinary  deposit  of  characteristic 
typhoid  bacilli  was  observed  in  the  submucosa  and 
interstitial  spaces  of  the  muscular  tissue.  In  other 
cases,  however,  no  intestinal  lesions  have  been 
present,  only  a  localization  of  bacilli  and  changes  in 
the  mesenteric  glands  and  spleen  revealing  the  nature 


of    the    infect  ion.     I  [ere    ftb  orpl probabl; 

place  more  rapidly  than  usual,  the  bacilli  not'  multi- 

plj  ing  to  :m\    i  iiivs.       Hut    not   only 

do  tin.  i      :    i      which  ha  i  e  been  examined  bacterio- 
logically  and  pathologically,  but  also  the  epidemiologi- 
cal hi  ioiv  of  typhoid  fever,  prove  beyond  que 
that  the  chief  i le  of  invasion  of  tin     pecific  bac- 
illus is  by  way  of  the  mouth.     The  infective  matt  rial 

discharged    in     the    feces    and   mine   of   typhoid  1 
patient-      in  the  latter  of  whii  icilli 

often  persist  for  weeks  or  month  coi  I  u  unate  the 
water  supply,  articles  of  food,  hand-  of  nurses  and 
attendants,    etc.,    and    thus  spreads  infection   from 

place   to   place.      (In    this   account    the   disinfection   of 

tin-  dejections  of  typhoid  patients  and  convalescent 

cannot   I"'  too  carefully  looked  after. 

Typhoid  Carriers. — Examinations  of  convali  cent 
typhoid  cases  show  that  about  one  to  five  per  cent,  con- 
tinue to  pass  typhoid  bacilli  for  years,  perhaps  for  life. 
The  focus  of  infection  i.-  believed  to  !»•  in  either  the 

gall-bladder,  chronic  ulcers  of  the  intestines,  or  the 
normal  intestinal  tract.  The  majority  are  women. 
A  remarkable  case  has  been  noted  in  New  York  of 
a  cook  who  carried  typhoid  infection  to  other  persons 
with  whom  she  was  associated  for  six  years  ll'.ltll  to 
1907).  Another  remarkable  instance  is  one  in  which 
some  hundreds  of  cases  of  typhoid  fever  were  t  raced  to 
a  milk  supply  produced  at  a  farm  looked  after  by 
a  typhoid  carrier  who  had  had  typhoid  fever  forty- 
i  years  before.  .Medicinal  treatment  has  so  far 
yielded  only  slight  results  (See  Bacteria  Carriers.) 

Immunization. — Specific  immunization  against  ex- 
perimental typhoid  infection  has  been  produced  in 
animals  by  the  usual  method  of  injecting  at  first  small 
quantities  of  the  living  or  dead  typhoid  culture  and 
gradually  increasing  the  dose.  The  blood  serum  of 
animals  thus  immunized  has  been  found  to  acquire  pro- 
tective  and  curative  bactericidal  and  possibly  feeble 
antitoxic  properties  against  the  typhoid  bacillus. 
These  characters  have  also  been  observed  in  the  blood 
serum  of  persons  who  have  recovered  from  typhoid 
fever;  and  recently  the  attempt  has  been  made  to 
employ  the  typhoid  serum  of  immunized  animals  or 
dead  cultures  for  the  cure  and  prevention  of  typhoid 
fever  in  man,  but  no  marked  results  have  been  obtained. 

Vaccination  against  Typhoid. — The  use  of  killed 
typhoid  bacilli  as  vaccine  has  been  advocated  by 
Wright.  Two  injections  are  usually  given.  The  first 
of  500  millions  and  the  second,  ten  days  later,  of  750 
millions.  If  it  is  impossible  to  count  the  number,  0.1 
c.c.  and  0.3  c.c.  of  a  bouillon  culture  can  be  given. 
The  bacilli  are  heated  to  60°  C.  for  thirty  minutes 
or  killed  by  1/2  per  cent,  lysol  or  carbolic  acid.  For 
a  day  or  two  the  injection  produces  a  slight  fever,  a 
local  pain,  followed  by  the  development  of  bacteri- 
cidal substances  in  the  blood,  apparently  sufficient  in 
amount  to  give  some  immunity  lasting  for  a  year 
or  more.  A  second  injection  adds  to  the  degree  of 
immunity.  In  49,600  individuals  under  observation 
in  India  and  Africa,  S,600  were  thus  treated.  The 
disease  appeared  in  them  to  the  extent  of  2.75  per 
cent,  with  a  case  mortality  of  12  per  cent.  In  41,000 
inoculated  there  was  a  case  percentage  of  5.75  per 
cent,  anc'  a  case  mortality  of  26  per  cent.  The  use  of 
protective  vaccine  in  the  shape  of  dead  cultures, 
would  therefore,  seem  to  be  advisable  where  dancer 
of  typhoid  infection  exists.  This  practice  of  vacci- 
nation against  typhoid  has  recently  been  introduced 
into  the  1".  S.  army. 

Specific  Reactions. — The  following  specific  reactions 
have  oeen  utilized  for  the  differential  diagnosis  of  the 
fcyi  l, aid  bacillus  from  other  similar  organisms,  and 
as  in  aid  to  the  clinical  diagnosis  of  obscure  cases 
o    typhoid  fever: 

1.  The   typhoid   bacillus  does  not   produce   indol. 

2.  It  does  not  produce  fermentation  or  gas  from 
media  containing  grape  sugar,  milk,  or  cane  sugar. 

853 


Bacteria 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


3.  On  lactose  litmus  agar  it  grows  usually  as  pale 
blue  colonies,  but  occasionally  causes  slight  redness  of 
the  surrounding  medium. 

4.  Widal's  Serum  Reaction. — This  reaction  is  based 
upon  the  fact,  first  observed  by  Pfeiffer,  Gruber,  and 
Durham,  but  since  practically  applied  on  a  more  ex- 
tended scale  by  Widal,  that  living  and  actively 
motile  typhoid  bacilli  if  placed  in  the  diluted  blood  or 
serum  of  a  patient  suffering  from  typhoid  fever, 
within  a  very  short  time  lose  their  motility  and  be- 
come aggregated  into  clumps.  Either  dried  blood  or 
serum  may  be  used  for  the  demonstration  of  the 
reaction.  The  blood  is  obtained  by  pricking  with  a 
needle  the  skin  (previously  disinfected)  covering  the 
tip  of  the  finger  or  ear,  and  allowing  two  drops  to 
fall  on  a  glass  slide,  one  near  either  end,  when  they  dry. 
Fluid  blood  serum  may  be  obtained  in  two  ways: 
First,  the  tip  of  the  finger  or  ear  is  pricked  and  the 
blood  as  it  issues  is  allowed  to  fill  by  gravity  a  capil- 
lary tube  havig  a  central  bulb,  the  ends  of  the  tube 
being  then  sealed  by  heat  and  the  serum  allowed  to 
separate  from  the  clot.  Second,  a  small  piece  of 
cantharides  plaster  is  applied  to  the  skin  at  some  spot 
on  the  chest  or  abdomen,  and  from  the  blister  thus 
formed  in  six  to  eighteen  hours,  the  serum  is  collected 
in  a  capillary  tube,  the  ends  of  which  are  then  sealed. 
The  latter  method  is  the  best,  for  the  serum  obtained 
is  clear,  free  from  blood  cells  and  fibrin,  which  some- 
what obscure  the  field  on  examination  in  the  hanging 
drop,  and  is  admirably  suited  to  the  test.  Dried 
blood,  however,  obtained  as  above  described  answers 
all  practical  purposes  of  diagnosis. 

The  method  of  performing  the  serum  test  is  as 
follows:  A  dilution  of  the  blood  or  serum  is  first 
made  in  the  proportion  of  one  to  ten.  In  the  case  of 
dried  blood,  it  is  dissolved  in  a  little  water  and  then 
mixed  with  the  typhoid  culture  (eighteen  to  twenty- 
four  hours  old),  the  degree  of  dilution  being  guessed 
by  the  color.  By  previously  making  test  solutions 
of  dried  blood  in  water  of  known  proportions  and 
noting  the  color  the  dilution  may  be  approximately 
gauged.  If  serum  is  used,  which  is  preferable  not  only 
because  there  is  less  fibrinous  deposit  but  also  be- 
cause it  is  possible  to  make  the  dilution  more  accur- 
ately, one  part  of  serum  is  added  to  nine  parts  of  the 
broth  culture.  This  should  contain  living  and  actively 
motile  isolated  bacilli.  If  there  is  no  reaction  when 
the  mixture  is  observed  in  the  hanging  drop — that  is 
to  say,  if  within  five  minutes  no  marked  change  is 
noted"  in  the  motility  of  the  bacilli  and  no  considerable 
clumping  occurs — the  result  may  be  regarded  as 
negative,  and  no  further  test  of  the  specimen  is  neces- 
sary. If  complete  clumping  and  immobilization  of 
the  bacilli  occur  within  five  minutes,  this  is  a  marked 
immediate  typhoid  reaction,  and  though  this  test  is 
ordinarily  sufficient  for  a  positive  diagnosis,  the 
reaction  may  be  confirmed  with  higher  dilutions  up  to 
one  to  twenty,  or  more,  if  desired.  If,  however, 
upon  examination  of  the  mixture  there  is  no  marked 
reaction,  but  the  bacilli  only  show  in  the  first  few 
minutes  an  inhibition  in  their  motility  and  a  ten- 
dency to  clump,  not  complete  within  five  minutes, 
it  becomes  necessary  to  test  this  with  dilutions  up  to 
one  to  twenty,  in  order  to  measure  the  strength  of 
the  reaction.  If  in  the  one-to-twenty  dilution  a  com- 
plete, distinct  reaction  takes  place  within  thirty  min- 
utes, the  result  may  also  be  considered  positive,  that 
is  that  the  blood  or  serum  has  come  from  a  case  of 
typhoid  infection,  while  if  a  less  marked  reaction 
occurs  it  should  be  regarded  as  only  probably  typhoid, 
and  another  specimen  should  be  requested.  The 
time  allowed  by  many  observers  for  the  develop- 
ment of  the  reaction  with  the  higher  dilutions  is  from 
one  to  two  hours,  but  thirty  minutes,  in  our  opinion, 
is  a  safer  and  sufficient  time  limit.  Positive  results 
obtained  in  this  way  may  be  accepted  as  conclusive 
evidence  of  the  recent  or  previous  existence  of  typhoid 


infection  in  the  patient.  A  former  attack  of  typhoid 
fever  within  a  period  of  several  months  or  one  or 
more  years  exceptionally  vitiates  the  value  of  the 
reaction.  On  the  other  hand,  the  absence  of  reaction 
in  any  one  examination  does  not  exclude  typhoid- 
so  that,  if  the  case  remains  clinically  doubtful,  re^ 
peated  examinations  should  be  made.  If  too  'con- 
centrated a  solution  of  dried  blood  from  a  healthy 
person  is  employed  a  pseudoreaction  is  often  obtained 
which  may  be  mistaken  for  a  true  reaction.  Dis- 
solved blood  always  shows  a  varying  amount  of 
detritus,  partly  in  "the  form  of  fibrinous  clumps,  and 
the  bacilli,  inhibited  by  substances  in  the  blood,  may 
become  entangled  in  these  substances  simulating  a 
reaction.  This  is  an  important  point  to  bear  in 
mind.  In  pseudoreaction,  however,  it  may  be 
noticed  that  many  free  bacilli  are  apt  to  be  gathered 
at  the  margins  of  the  hanging  drop.  The  Widal 
reaction,  though  not  infallible,  when  performed  with 
due  regard  to  the  avoidance  of  every  possible  source  of 
error,  is  as  reliable  as  any  other  bacteriological  tesl 
at  present  in  use,  and  is  of  inestimable  value  as  an  aid 
to  the  clinical  diagnosis  of  irregular  or  mild  cases  of 
typhoid  infection.  It  is  simple  and  easy  of  per- 
formance by  any  one  versed  in  bacteriological  tech- 
nique. The  serum  reaction  is  never  present  in  other 
diseases  or  in  healthy  persons,  if  correctly  made  and 
in  the  proper  dilution,  as  is  so  often  the  case  with 
Ehrlich's  diazo  reaction.  It  is  better  adapted  for 
general  employment  than  are  any  of  the  cultural 
methods  now  in  use  for  isolating  the  bacillus  from  the 
feces  or  urine.  It  is  certainly  safer  than  spleen 
puncture,  and  it  is  not  so  difficult  as,  though  far  more 
reliable  than,  the  leucocyte  count.  The  reaction  does 
not  appear,  as  a  rule,  during  the  first  few  days  of  the 
disease,  but  it  is  usually  manifest  before  the  rose- 
colored  eruption  appears,  though  occasionally  it  is 
very  late  in  appearance  (that  is,  not  till  the  fourth  or 
fifth  week  and  sometimes  only  during  a  relapse),  and 
in  rare  cases  may  be  entirely  absent.  Although  a 
negative  result,  therefore,  has  but  little  significance, 
a  positive  reaction  when  present — previous  typhoid 
being  excluded — is  almost  as  strong  evidence  of  the 
existence  of  the  specific  infection  as  the  actual 
demonstration  of  the  typhoid  bacilli. 

Ice  Pollution  in  the  Production  of  Typhoid  Ferer.— 
Although  there  have  been  a  few  cases  of  typhoid 
fever  which  have  been  directly  traced  to  ice  infection, 
the  fact  that  freezing  kills  a  large  percentage  of 
typhoid  bacilli  in  water  makes  the  danger  of  the  pro- 
duction of  the  disease  from  ice  pollution  very  slight, 
except  under  extraordinary  conditions.  It  is  always 
much  less  than  the  use  of  the  water  itself.  Every 
week  that  the  ice  is  stored  the  danger  becomes  less, 
so  that  at  the  end  of  four  weeks  it  has  become  as 
much  purified  from  typhoid  bacilli  as  if  subjected  to 
sand  filtration.  At  the  end  of  four  months  the 
danger  is  almost  negligible  and  at  the  end  of  six 
months  quite  so.  The  possibility,  however,  of  even 
slight  danger  of  infection  from  freshly  cut  ice  sugpi-i- 
tlie  advisability  of  condemning  any  portion  of  rivers, 
etc.,  greatly  contaminated  by  sewage,  for  harvesting 
ice  for  domestic  purposes — such  ice  to  be  used  only 
where    there    is    absolutely    no    contact    with   food. 

The  Colon  Bacillus  (Bacillus  coli  communis).— 
This  type  of  organism  was  first  described  by  Emmer- 
ich (1885),  who  obtained  it  from  the  blood,_  organs, 
and  intestinal  discharges  of  cholera  patients  at 
Naples  under  the  name  Bacillus  neapolitanus.  It 
has  since  been  found  to  be  a  normal  inhabitant  of  the 
intestinal  canal  of  man  and  many  animals.  A 
number  of  similar  bacterial  species  are  now  often 
spoken  of  as  the  colon  group  of  organisms.  The  colon 
group  has  interest  not  only  because  it  excites 
disease  at  times  in  man  and  animals,  but  also  because 
it  is  an  index  of  fecal  pollution  from  man  or  animals. 


854 


ukfi:i:en<t.  handbook  of  THE  mi:dical  SCIENC]  s 


Bacteria 


If  from  man  ii  indicates  the  possibility   of  infection 
with  the  typhoid  or  dysentery  bacilli. 

Microscopical  Appearances. — The  size  and  shape  of 
the  colon  bacillus  vary  considerably  according  to  the 
culture  media  (age,  composition,  etc.)  from  which  il 
is  derived.     The  typical  form  is  thai   of  short   rod 

with  rounded  ends  {QA  to  0.7  u  in  dia ter  and  1  to 

in  length);  but  sometimes  the  roils  are  so  short  a 
to  be  almost  spherical,  and  again  oval  or  thread-like 
forms  may  occur.  The  bacilli  are  found  singly,  joined 
ether  in  pairs,  rarely  associated  in  .short  chains. 
In  unfavorable  culture  media  in  stained  preparations 
polar  granules  and  vacuoles  are  frequently  present, 
supposed  to  be  due  to  degenerative  changes  in  the 
protoplasm.      (See  Plate  IX.,  Fig.  1.) 

Moliltiu. — The  rods  possess  numerous  long  flagella, 
but  usually  very  sluggish  movements. 

Spore  For  million. — Absent. 

Staining  Reactions. — Stains  readily  with  the  ordin- 
ary aniline  colors;  is  quickly  decolorized  by  Gram's 
solution. 

Biological  Characters. — This  organism  grows  best  in 
the  presence  of  oxygen,  but  also,  though  less  luxuri- 
antly, without  oxygen  and  in  an  atmosphere  of  COa 
facultative  anaerobic).  It  develops  rapidly  on 
almost  all  culture  media  (best  in  media  containing 
sugar)  even  at  room  temperature;  optimum  tempera- 
ture 37°  C.  It  grows  fairly  well  in  slightly  acid  media, 
but  itself  produces  so  much  acid  that  it  is  sometimes 
destroyed  in  this  -way.  It  is  almost  impossible  to 
distinguish  culturally  the  bacillus  coli  from  the  bacillus 
typhi,  except  that  the  growth  of  the  former  is  some- 
what more  abundant  under  similar  conditions. 

Growth  in  Gelatin. — In  getatin  plates  colonies  are 
developed  in  from  twenty-four  to  forty-eight  hours, 
which  resemble  greatly  the  colonies  of  the  typhoid 
bacillus,  except  that  they  are  larger  for  the  same 
period  of  growth.  The  deep  colonies  are  round, 
oval  or  "whetstone"  shaped,  finely  granular,  almost 
homogeneous  in  structure,  and  of  a  pale  yellowish  to 
brownish  color,  at  first;  later  they  become  denser, 
darker,  and  more  coarsely  granular.  The  surface 
colonies  appear  as  small,  dry,  irregular,  flat ,  iridescent 
points  with  wavy  bent  borders.  In  slab  cultures 
the  growth  usually  takes  the  form  of  a  nail  with 
flattened  head,  the  surface  extension  soon  reaching 
out  to  the  sides  of  the  tube.  The  gelatin  is  not 
liquefied. 

On  agar  and  blood  serum  an  abundant,  soft,  grayish- 
white  layer  is  quickly  developed  in  the  incubator,  but 
the  growth  is  not  characteristic. 

In  bouillon  the  colon  bacillus  produces  diffuse 
clouding  with  sedimentation;  a  pellicle  is  sometimes 
formed  on  the  surface;  a  decided  fecal  odor  is  often 
noticed  in  old  cultures. 

Milk  is  usually  coagulated  with  the  production  of 
gas  and  acid. 

On  potato  the  growth  is  rapid  and  abundant, 
appearing  after  twenty-four  to  thirty-six  hours  in  the 
incubator  as  a  yellowish-brown  to  dark  cream- 
colored  deposit  on  the  surface.  The  growth  may, 
however,  be  scanty  or  absent  at  times. 

Chemical  Effects. — This  bacillus  forms  pigment 
only  on  potato.  Ill-smelling  substances  are  devel- 
oped on  agar,  gelatin,  occasionally  in  old  bouillon  cul- 
tures, but  particularly  on  potato  media.  The  Bacillus 
coli  grows  rapidly  in  media  containing  carbohydrates 
(grape  and  milk  sugar,  etc.),  causing  active  fermenta- 
tion with  liberation  or  gas  (CO.,  and  H).  Cultivated 
in  solid  media,  to  which  glucose  has  been  added,  the 
gas  production  is  recognized  by  the  appearance  of 
numerous  bubbles;  in  fluid  culture  media  it  may  be 
demonstrated  in  the  fermentation  tube.  Grown  on 
lactose-litmus  agar,  the  colonies  are  pink  and  the 
surrounding  medium  is  changed  from  blue  to  red, 
showing  the  production  of  acid.  The  colon  bacillus 
produces  in  bouillon  and  peptone  solutions  H2S  and 


indol.  It  converts  nitrates  into  oitriti  I  rea  is 
decomposed  bj  mans  specii  •  of  this  group. 

I  itality.  similar  to  thai  of  the  typhoid  bacillus, 
but  is  more  re  the  action  of  acids,  formalin, 

and  other  chemical  disinfectant  .  Thermal  death 
point  60    I '.  in  ten  minutes'. exposure. 

Pathogenesis.  The  colon  bacillus  is  pathogenic  for 
mice,  guinea-pigs,  and  rabbits  in  varying  degrees 
according   to   the   strength   of   the    VITUS   and    mode   of 

inoculation:  the  results  of  animal  inoculations,  how- 
i  i  r,  as  with  the  typhoid  bacillus,  cannot  alwaj  be 
predicted  with  certainty.  The  more  rapidly  death 
ensues  tlie  greater  is  the  number  of  bacilli  found  in  the 
body;  they  are  always  more  abundant  in  the  abdomi- 
nal cavity  than  in  the  blood — in  other  words,  the 
result  is  due  to  the  toxic  rather  than  to  the  infei 

properties  of  the  culture  used.  The  lesions  pro- 
duced are  those  of  enteritis;  the  duodenum  and 
jejunum  are  found  to  contain  fluid,  the  spleen  is  some- 
what  enlarged,  and  then-  is  marked  hyperemia  and 
ecchymosis  of  the  small  intestines,  together  with 
swelling  of  Peyer's  patches. 

Immunization  against  colon  infection  is  easily  pro- 
duced in  the  usual  waj  by  the  inoculation  of  gradually 
increasing  doses  of  cultures  of  living  or  dead  bacilli. 

The  Bacillus  coli  communis  is  a  common  inhabitant 
of  the  intestines  of  man  and  animals,  being  found  in 
the  feces,  milk,  bile,  etc.  Of  thirty-two  cadavera  of 
healthy  individuals  examined  twenty-four  to  thirty- 
six  hours  after  death  it  was  found  in  sixteen,  especially 
in  the  liver  and  kidneys.  It  is  also  frequently  met 
with  in  river  water  and"  food,  so  that  it  is  one  of  the 
most  widespread  saprophytic  bacteria.  Formerly  it 
was  thought  that  the  presence  of  the  colon  bacillus  in 
water  was  sufficient  proof  of  its  contamination  by 
feces  and  thus  of  its  possible  contamination  also  by 
typhoid  bacilli.  But  recent  investigations  have 
shown  that  there  are  no  grounds  for  this  assumption, 
as  the  colon  bacillus  may  reach  the  water  from  many 
different  sources.  At  the  same  time,  in  a  general 
way,  drinking  water  found  to  contain  colon  bacilli 
may  be  regarded  as  unfit  for  human  consumption. 

This  organism  is  associated  with  many  diseases  espe- 
cially of  the  abdominal  organs,  though  it  is  not  posi- 
tively known  what  etiological  relation,  if  any,  it  bears 
to  these  affections  It  has  been  found  in  peritonitis, 
appendicitis,  cystitis  (partly  alone,  particularly  when 
the  urine  is  acid,  and  partly  together  with  the  protons 
vulgaris  and  other  bacteria),  urethritis,  pyelonephri- 
tis, etc.  The  colon  bacillus  has  been  assumed  to  be  the 
cause  of  cholera  nostras  and  cholera  infinitum,  but  the 
investigations  of  Booker,  Baginsky,  Escherich,  and 
Fliigge  would  seem  to  indicate  that  these  diseases  are 
of  a  much  more  complicated  origin,  being  due  probably 
to  certain  ferments  and  toxins  in  the  intestines  pro- 
duced, not  by  any  specific  microorganisms,  but  by  the 
ordinary  putrefactive  bacteria,  among  which  the 
B.  coli  and  B.  proteus  vulgaris  are  the  most  commonly 
present.  The  cause  of  infections  of  the  gall-ducts 
and  multiple  abscesses  of  the  liver  and  of  inflamma- 
tions of  the  pancreas,  and  of  the  urinary  tract,  is  also 
explained  in  this  way.  Puerperal  fever  is  not  in- 
frequently due,  in  part  at  least,  to  infection  of  the 
vagina  or  uterus  by  the  colon  bacillus.  Other  dis- 
eases to  which  this  organism  seems  to  stand  occasion- 
ally in  relation  are  endocarditis,  meningitis,  tropical 
abscess  of  the  liver,  bronchopneumonia,  lobar  pneu- 
monia, fetid  bronchitis,  amygdalitis,  etc.  In  these 
diseases  the  bacillus  coli  communis  has  been  found 
sometimes  alone,  but  usually  associated  with  other 
pathogenic  bacteria  in  such  numbers  that  it  must  be 
considered  a  factor  in  the  etiology  of  the  affections,  and 
in  some  cases  there  is  reason  for  belief  that  it  may  be 
the  primary  cause.  Though  further  study  is  re- 
quired to  show  the  specific  pathogenic  properties  of 
this  microorganism,  it  is  evident  that  under  certain 
conditions  it  may  become  pathogenic  to  man. 

855 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Differential  diagnosis  between  the  B.  coli  and  B. 
typhi  abdominalis:  The  following  characteristics  and 
i  -is  constitute  the  chief  means  of  differentiating 
these  two  similar  microorganisms,  though  none  of 
them  alone  can  be  depended  on: 

1.  The  motility  of  the  colon  bacillus  is,  as  a  rule,  not 
very  pronounced,  sometimes  absent;  that  of  the 
typhoid  bacillus  is  usually  very  active. 

_'.  On  gelatin  plates  the  colon  bacillus  develops 
more  rapidly  and  luxuriantly  than  the  typhoid  bacil- 
lus, and  on  potato  it  grows  more  abundantly,  being 
almost  always  visible. 

3.  The  colon  bacillus  coagulates  milk  with  acid 
reaction  within  twenty-four  to  forty-eight  hours;  the 
typhoid  bacillus  does  not  coagulate  milk. 

4.  The  colon  bacillus  causes  fermentation  with  pro- 
duction of  gas  in  media  containing  sugar;  the  typhoid 
bacillus  does  not. 

5.  In  nutrient  agar  or  gelatin  containing  lactose  and 
litmus  tincture  and  of  a  slightly  alkaline  reaction,  the 
color  of  the  colonies  of  colon  bacillus  is  pink  and  the 
surrounding  medium  red;  while  the  colonies  of 
typhoid  bacillus  are  blue  and  there  is  little  or  no 
reddening  of  the  medium. 

6.  The  colon  bacillus  produces  indol  in  cultures  of 
bouillon  or  peptone;  the  typhoid  bacillus  does  not. 

7.  When  a  twenty-four-hour-old  bouillon  culture  of 
the  colon  bacillus  is  mixed  with  the  blood  or  serum  of  a 
patient  suffering  from  genuine  typhoid  fever,  in  a  dilu- 
tion of  one  to  ten  or  more,  after  the  first  week  of  the 
disease,  the  Widal  reaction  is  negative;  cultures  of  the 
typhoid  bacillus  treated  in  the  same  manner  and  ex- 
amined in  the  hanging  drop  give  the  characteristic  ag- 
glutination and  clumping  of  the  bacilli. 

S.  Finally,  we  have  the  special  media,  devised 
respectively  by  Hiss,  Capaldi,  and  Eisner,  for  isolating 
the  colon  and  typhoid  bacilli,  in  which  we  may  ob- 
serve their  differences  of  growth  in  plate  and  tube 
cultures.  These  will  be  referred  to  more  in  detail 
elsewhere. 

The  Intermediate  Typhoid-colon  Group. — 
Gartner's  discovery  in  1SSS  of  the  Bacillus  enteritidis 
in  association  with  epidemics  of  meat  poisoning,  first 
gave  impetus  to  the  study  of  parasitic  bacteria  re- 
sembling in  many  characteristics  the  colon  or  typhoid 
bacilli.  These  bacilli  are  frequently  called  inter- 
mediates. In  1893  Gilbert  introduced  the  terms 
"paracolon"  and  "paratyphoid"  to  designate  bacilli 
of  this  group  resembling  the  biological  characters  of 
the  colon  and  typhoid  bacilli,  respectively.  These 
intermediates  include  Bacillus  enteritidis  and  similar 
organisms  recovered  from  cases  of  epidemic  meat 
poisoning,  the  gas-producing  typhoid  bacilli  of  various 
observers  obtained  from  cases  suffering  from  typhoidal 
symptoms,  Bacillus  -psittacosis  (infective  cause  of  a 
disease  in  parrots),  Bacillus  cholera:  suis  (hog  cholera), 
Bacillus  of  swine  plague,  Bacillus  icteroides,  and 
Bacillus  alealigenes. 

Differentiation  from  the  Typhoid-colon  Group. — The 
paracolon  and  paratyphoid  can  be  easily  distinguished 
from  the  typhoid  bacilli.  They  produce  gas  in 
glucose  media,  and  in  this  respect  differ  from  the  ty- 
phoid bacilli,  but  unlike  the  colon  bacilli  they  do  not 
produce  gas  from  lactose,  coagulate  milk,  or,  as  a  rule, 
form  indol. 

The  main  points  of  difference  between  the  two 
varieties  are  that  the  paracolons  turn  milk  and  whey 
alkaline  after  a  short  initial  acidity  and  form  gas 
freely  in  glucose  media,  while  with  the  paratyphoids 
there  is  in  milk  and  whey  an  initial  acidity,  but  no  or 
very  slight  subsequent  alkalinity;  the  gas  production 
in  glucose  media  is  much  less  pronounced.  Neutral 
red  agar  also  differentiates  between  the  two  groups. 
Like  the  colon  bacillus,  all  the  intermediates  reduce 
the  color  to  yellow  in  twenty-four  to  seventy-two 
hours,   but  with  the  paratyphoid  after  four  to  five 

856 


days  the  red  color  begins  to  return  from  above  down- 
ward until  in  two  or  three  weeks  the  medium  is  again 
red  throughout.  With  the  paracolon  the  yellow  color 
is  permanent. 

Serum  Reaction  in  Paratyphoid  Infection. — Since  the 
introduction  of  serum  reactions  as  a  means  of  diagno- 
sis, it  is  a  well  recognized  fact  that  a  small  proportion 
of  cases  which  are  clinically  typhoid  fever  fail  to  give 
the  reaction,  and  although,  but  comparatively  few 
of  these  cases  have  been  recorded  in  which  para- 
typhoid bacilli  have  been  isolated,  it  is  probable  that 
a  certain  number  of  them  were  due  to  paratyphoid 
infection. 

Diagnosis. — The  only  reliable  criteria  for  diagnosis 
are  absence  of  the  Widal  reaction  in  proper  dilution 
(not  less  than  1.40)  with  a  positive  reaction  against  a 
known  paratyphoid  bacillus,  or  the  recovery  of  a 
paratyphoid  bacillus  from  the  blood,  urine,  or  compli- 
cating inflammatory  process.  The  clinical  type  of 
the  disease  is  of  little  value,  as  reported  cases  of 
paratyphoid  infection  have  been  both  mild  and 
severe. 

Epidemic  Meat  Poisoning. — Two  kinds  of  bacilli 
are  concerned  in  the  production  of  meat  poisoning: 
1.  Bacillus  enteritidis  of  Gartner,  including  its  differ- 
ent strain,  2.  Anaerobic  Bacillus  botulinus  of  Van 
Erminghem,  a  saprophyte. 

True  ineatpoisoning  is  due  to  Bacillus  enteritidis, 
and  in  every  instance  the  animal  is  diseased  at  the  time 
of  the  slaughter.  Bacillus  enteritidis  is  pathogenic 
for  cows,  horses,  pigs,  goats,  mice,  and  guinea-pigs, 
but  not  for  dogs  and  cats.  The  disease  may  be  trans- 
mitted to  man  in  two  ways:  1.  by  eating  the  infected 
meat,  which  is  by  far  the  most  common  way  (it  may  be 
contracted  by  eating  sausage  which  has  been  surrep- 
titiously put  on  the  market),  and  2.  from  man  to 
man,  according  to  Gartner,  Van  Erminghem,  and 
Fischer.  Epidemics  of  meat  poisoning  may  occur  at 
any  season,  but  are  more  frequent  in  summer.  While 
the  characteristic  symptoms  of  sausage  poisoning 
relate  to  the  nervous  system,  in  true  meat  poisoning 
they  are  gastrointestinal.  Three  clinical  forms  have 
been  described:  typhoidal,  choleraic,  and  gastrointes- 
tinal. Since  neither  appearance  nor  taste  affords  any 
clue  to  the  noxious  quality  of  the  meat,  bacteriological 
examination  or  a  knowledge  of  its  source  are  the  only 
means  of  prevention  of  infection.  Cooking  will  kill 
the  bacilli,  but  the  thermal  death  point  may  not  be 
reached    in    the    innermost    portions    of    the    meat. 

The  Dysentery  Bacillus  (Shiga  bacillus). — In 
1S97  Shiga  found  in  the  stools  of  cases  of  dysentery 
a  bacillus  which  had  not  been  identified  before.  This 
bacillus  had  many  of  the  characteristics  of  the  colon 
bacillus,  but  differed  from  it  in  not  possessing  motility 
and  in  failing  to  produce  gas  from  the  formation  of 
sugar.  It  is  also  entirely  distinct  in  its  agglutinating 
and  pathogenic  properties.  Shiga  found  the  bacillus, 
in  all  cases  examined  of  epidemic  dysentery,  mo  I 
abundant  during  the  height  of  the  disease.  It  was  not 
found  in  the  stools  of  healthy  persons.  A  criminal  fed 
with  a  culture  of  the  bacillus  developed  typical 
dysentery. 

Microscopic  appearances. — Similar  to  bacilli  of  the 
colon  group. 

Motility. — No  definite  motility  has  been  observed, 
but  active  molecular  movement. 

Staining. — Similar  to  colon  group. 

Spore  Formation. — Absent. 

Biological  Characters. — The  growth  in  gelatin  appears 
more  like  typhoid  than  colon  bacilli.  The  gelatin  is 
not  liquefied.  On  agar  the  growth  is  somewhat  more 
delicate  than  that  of  the  average  colon  cultures.  On 
potato  there  is  a  delicate  growth  just  visible  or 
distinctly  brownish.  In  bouillon,  diffuse  cloudiness 
is  produced,  with  a  slight  deposit  and  sometimes  a 
pellicle.     Indol  is   not   produced,   or    only   a   trace. 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Bacteria 


In  glucose  bouillon  there  is  no  production  of  acid  or  gas. 
Neutral  red  agar  is  not  blanched.  Litmus  milk  after 
twenty-four  to  forty-eight  hours  becume  i  pair  lilac. 
Later,  in  three  to  eight  days,  there  is  a  return  to  the 
original  pale  blue  color.  The  milk  is  not  otherwise 
altered. 

Pathogenesis. — In  animals  no  characteristic  lesions 
have  followed  swallowing  large  quantities  of  bacilli. 
Many  animals  are  very  sensitive  to  bacilli  injected  into 
the  veins  or  peritoneum,  0.1  to  0.2  mg.  of  an  agar 
culture  producing  diarrhea,  paralysis,  and  death. 

In  man,  the  onset  of  acute  dysentery  is  sudden  and 
ushered  in  by  cramps,  diarrhea,  and  tenesmus.  The 
stools,  at  first  feculent,  then  seromucous,  become 
bloody  or  composed  of  coffee-ground  sediment.  At 
the  height  of  the  disease  there  are  ten  to  fifty  stool  in 
the  twenty-four  hours.  After  two  to  seven  days  the 
blood  usually  disappears.  In  temperate  climates  the 
mortality  varies  from  5  to  20  per  cent.  Bacillary 
dysentery  is  a  disease  especially  of  the  mucous  mem- 
Inane  of  the  large  intestines.  The  epithelium  is 
chiefly  involved.  Catarrhal  inflammation  only  is 
present  in  the  lightest  cases;  in  the  more  severe  cases 
the  lymph  follicles  are  swollen  and  some  necrosis  of 
epithelium  occurs.  In  very  severe  eases  in  adults  the 
lesions  are  of  a  diphtheritic  character;  the  entire 
lumen  of  the  intestines  may  be  filled  with  a  fibrinous 
mass  of  pseudomembrane.  In  young  children,  even 
iji  fatal  cases,  the  lesions  may  be  more  superficial. 

Several  distinct  types  of  bacilli  have  been  described 
by  various  observers,  Flexner,  Strong,  Kruse,  Park, 
Duval,  and  others,  as  exciters  of  dysentery,  which 
differ  from  the  Shiga  bacillus  in  their  agglutinating 
ami  other  characters,  some  of  which  produce  indol 
in  peptone  solution  and  ferment  mannite,  and  others 
ferment  maltose  and  saccharose.  To  these  have 
been  given  the  name  of  paradysentery  bacilli. 

Serum  Treatment. — In  characteristic  cases  of  dysen- 
tery the  polyvalent  serum  has  been  found  of  value. 
The  serum  is  given  subeutaneously  in  20  e.c.  doses 
once  or  twice  a  day  for  several  days,  until  convales- 
cence is  established.  The  serum  is  not  indicated  in 
cases  of  the  usual   summer  diarrhea. 

Friedlander's  Bacillus  of  Pneumonia  {Pneumo- 
bacillus,  B.  capsulatus). — This  organism  was  dis- 
covered by  Friedlander  (1883)  and  declared  to  be  the 
cause  of  fibrinous  pneumonia.  Subsequently  it  was 
shown  that  it  is  seldom  found  in  pneumonia  patients, 
or  occurring  only  in  a  mixed  infection,  being  often 
present  in  the  mucous  membranes  of  the  mouth  and 
air  passages  of  healthy  persons  and  in  the  air. 

Microscopical  Appearances. — Short  rods  (0.6  to  3  p. 
long  by  0.5  to  0.S/<  broad)  with  rounded  ends,  often 
resembling  micrococci,  especially  in  recent  cultures; 
commonly  in  pairs  or  chains  of  four.  A  capsule  is 
present  in  specimens  from  sputum  and  inoculated 
animals;  rarely  seen  in  cultures. 

Motility. — Absent. 

Spore  Formation. — Does  not  form  spores. 

Staining  Reactions. — Stains  readily  with  the  ordi- 
nary aniline  dyes,  but  not  by  Gram's  method. 

Biological  Characters. — Grows  luxuriantly  in  both 
the  presence  and  absence  of  oxygen  (facultative 
anaerobic)  and  on  all  the  usual  culture  media,  at  the 
room  temperature  and  in  the  incubator. 

In  gelatin  plates  small,  round,  elevated  white  colo- 
nics develop,  slightly  granular  in  structure  and  of  a 
brownish  color.  In  gelatin  stab  cultures  a  typical 
nail-shaped  growth  occurs;  the  gelatin  is  not_  liquefied. 
On  agar  and  blood  serum  large  grayish-white,  moist 
colonies  develop.  The  growth  on  potato  is  abundant 
— a  thick,  yellowish-white,  glistening  coating  con- 
taining gas  bubbles.  Bouillon  is  clouded.  Milk  is 
not  coagulated.  Media  containing  glucose  are  decom- 
posed, undergoing  fermentation  with  the  production 
of  acid.     Indol  and  H2S  are  sparingly  produced. 


Pathogi    ■  rhi    bacillus  is  pathogenic  for  mice 

and  guinea-pig-,   1.        ii   for  dogs,  and   rabbits  are 

apparently  immune  (thus  distinguished  fr I  raen- 

kel's    Diplococcus   pneum<  Susceptible  animals 

arc  inoculated  directlj   into  the  pleural  and  abdom- 
inal cavities.     'I  hey  i  an  al  •■  I"  affected  by  inhalation 
of  dried  pulverized  cultures.     In  somi    ca  i      pi 
monic  lesions  are  produced. 

Acth  e  immunity  agaii    I    I  i  iedl  inder'     I  iai  illu 
readilj   produced,  and  all  hough  the  organism  i    non- 
motile  the  agglutinating  scrum  reaction  i-     aid  to  I"' 

pre  ''Hi. 

I  ttis  bacillus  has  been  found  outside  tin-  body  in  the 
du   I   of  floors,  in  t  he  air,  etc.      It   has  hcell  n, - 
the  saliva  of  healthy  persons.       It   i     the  cause  of  only 

a  small  proportion  of  the  ca  i  <>i  lobar  pneumonia; 
in  one  hundred  and  twenty-nine  cases  examined  by 
Weichselbaum  the  pneumobacillus  was  found  in  nine. 
According  to  Netter and  Weichselbaum  the  cases  due 

primarily  to  this  organism  are  distinguished  by  their 
peculiarly  malignant  type  and  by  the  viscidity  of  the 
exudate  produced.  It  is  also  probably  concerned, 
primarily  or  secondarily,  under  certain  circum- 
stances, in  the  production  of  pleurisy,  abscess  of  the 
lungs,  pericarditis,  endocarditis,  otitis  media,  and 
meningitis,  in  all  of  which  diseases  it  has  been  found 
at  times.  It  has  been  met  with  in  all  the  organs  of 
the  body  and  also  in  the  blood. 

The  Pus-producing  Organisms. — Many  bacteria 
are  capable  of  producing,  under  certain  conditions, 
inflammatory  and  suppurative  processes,  abscess, 
cellulitis,  septicemia,  etc.  The  microorganisms 
most  commonly  found  associated  with  suppuration 
are  staphylococci,  streptococci,  pneumoeocci,  and 
tetracocci.  The  following  species  are  also  occasion- 
ally met  with:  the  colon  bacillus  and  allied  members 
of  that  group,  the  typhoid  bacillus,  the  influenza 
bacillus,  and  the  bacillus  pyocyaneus.  In  so-called 
"cold  abscesses"  the  tubercle  bacillus  is  usually  the 
only  organism  present.  Besides  these  bacteria, 
other  species  may  sometimes  cause  circumscribed 
suppurative  processes. 

Staphylococcus  Pyogenes  Aureus. — This  is  one 
of  the  commonest  pathogenic  bacteria,  being  present 
almost  everywhere.  It  is  the  most  frequent  cause  of 
acute  circumscribed  suppurative  inflammations. 
Though  first  observed  byr  Pasteur  (1880)  in  pus  and 
by  Ogston  (1881)  in  acute  abscesses,  it  was  not 
obtained  by  him  in  pure  culture  but  was  isolated  and 
accurately  described  by  Rosenbach  in  1884. 

Microscopical  Appearances. — Small,  spherical  cells, 
having  a  diameter  of  about  0.8/1,  occurring  singly  or 
in  pairs,  but  usually'  arranged  in  irregular  masses 
simulating  clusters  of  grapes;  hence  the  name,  from 
crracpvX-n,  "grape."     (See  Plate  IX.,  Fig.  3.) 

Motility. — N  on-motile. 

Staining  Reactions. — Stains  easily  in  aqueous  solu- 
tions of  the  basic  aniline  dyes;  is  not  decolorized  by 
Gram. 

Biological  Characters. — Aerobic  and  facultative 
anaerobic,  but  produces  pigment  only  in  the  presence 
of  oxygen.  It  grows  readily  at  a  temperature  of 
from  1N°  to  20°  O,  but  best  at  25°  to  35°  C.,  on  all  the 
ordinary  culture  media. 

Growth  on  Gelatin. — Grown  on  gelatin  plates  at  room 
temperature,  it  develops  within  forty-eight  hours 
punctiform  colonies,  which,  when  examined  under  a 
low-power  lens,  appear  as  circular  discs  of  a  pale  or 
yellowish  brown  color,  somewhat  darker  at  the  center 
and  surrounded  by  -i  transparent  zone  with  well- 
defined  border.  Immediately  around  the  colonies, 
which  grow  rapidly  and  are  slightly  granular  in 
structure,  there  is  a  deepening  of  the  surface  of  the 
gelatin,  due  to  its  liquefaction.  Later,  the  lique- 
faction  becomes   general,    the   colonies   running   to- 

857 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


gether.  In  gelatin  stab  cultures  a  white  confluent 
deposit  first  develops  along  the  line  of  puncture, 
followed  by  liquefying  of  the  medium  in  the  form  of 
a  stocking.  At  the  end  of  two  days  the  yellow  pig- 
ment begins  to  form,  and  this  increases  in  intensity 
until  finally  (after  a  week)  complete  liquefaction 
takes  place  and  the  "golden  staphylococci"  fall  as  an 
orange-colored  deposit  to  the  bottom  of  the  tube. 
Under  unfavorable  conditions  the  staphylococcus 
aureus  gradually  loses  its  property  of  liquefying 
gelatin  and  producing  pigment. 

Growth  in  Agar. — In  streak  and  stab  cultures  on 
nutrient  agar  a  whitish  growth  is  at  first  produced, 
and  this  after  a  few  days  also  becomes  golden  yellow 
on  the  surface.  Colonies  found  at  the  bottom  of  a 
stab  culture  or  under  a  layer  of  oil  remain  white; 
showing  the  inability  of  this  organism  to  produce 
pigment  in  the  absence  of  oxygen. 

Bouillon  is  densely  clouded  by  the  luxuriant  growth. 

Milk  is  coagulated  in  from  one  to  eight  days  with 
the  production  of  acid. 

Chemical  Effects. — The  production  of  an  orange- 
yellow  pigment,  but  only  in  the  presence  of  oxygen; 
agar  cultures  smell  like  glue  or  spoiled  paste;  gas  and 
acid  production  from  carbohydrates;  the  production 
of  H,S  abundantly  and  a  little  indol;  the  decom- 
position of  urea  by  certain  species — these  are  the 
chemical  effects  of  the  staphylococcus. 

Vitality. — Several  cases  of  osteomyelitis  have 
been  reported  in  which  staphylococci  have  been  found 
alive  in  the  body  in  the  centers  of  infection  after  many 
years,  during  this  time  having  been  encapsulated 
apparently.  In  cultures  they  retain  their  vitality  for 
a  year  or  more.  The  staphylococcus  is  distinguished 
from  most  other  pathogenic  bacteria  by  its  greater 
power  of  resistance  to  all  outside  influences,  desicca- 
tion, heat,  chemical  agents,  etc.  It  does  not,  how- 
ever, form  spores,  as  far  as  we  know.  In  dried  pus, 
according  to  Hiigler,  it  stands  desiccation  for  from 
fifty-six  to  one  hundred  days.  But  it  is  rapidly 
killed  by  moist  heat  at  70°  C.  It  retains  its  vitality 
in  ice  sixty-six  days  (Prudden).  Disinfectants  act 
on  it  slowly.  Meade  Bolton  found  that  a  one-per- 
cent, carbolic  acid  solution  destroyed  it  in  two  hours; 
mercuric  chloride  1  to  1,000  killed  it  in  five  to  ten 
minutes.  But  there  is  a  considerable  difference  in 
the  resisting  power  of  the  micrococci. 

Pathogenesis. — The  pathogenic  effect  of  the  Staph- 
ylococcus pyogenes  aureus  on  test  animals  varies  much 
according  to  the  mode  of  application  and  the  viru- 
lence of  the  culture  employed.  Experiments  have 
shown  that  this  organism  as  found  in  suppurative 
processes  in  the  human  subject  is  not  as  infectious 
for  animals  as  it  is  for  man.  The  order  of  suscep- 
tibility seems  to  be  as  follows:  man,  horses,  dogs, 
cattle,  goats,  sheep,  rabbits,  guinea-pigs,  mice.  In 
man  a  simple  rubbing  of  the  unbroken  skin  with  pus 
from  an  acute  abscess  is  usually  sufficient  to  produce 
purulent  inflammation.  Cutaneous  inoculation  of 
animals  is  negative,  but  subcutaneous  injection 
causes  a  local  abscess  in  rabbits,  guinea-pigs,  and 
mice,  and  intravenous  injection  in  rabbits  sometimes 
produces  pyemia  and,  after  injury  to  the  cardiac 
valves,  ulcerative  endocarditis. 

The  filtrates  from  bouillon  cultures  contain  highly 
virulent  toxic  substances.  Injection  of  these  into  the 
peritoneal  cavity  of  dogs  causes  serosanguineous 
peritonitis,  and  ecchymoses  in  the  serous  and  mucous 
membranes  of  the  intestines,  finally  resulting  in 
death  with  bloody  diarrhea.  Immunity  against 
staphylococcus  infection  may  be  produced  by  the 
injection  of  gradually  increasing  doses  of  the  pure 
culture  either  living  or  previously  sterilized  by  boiling. 
The  blood  serum  of  animals  which  have  been  thus 
immunized  possesses  slight  protective  and  curative 
effects  in  other  animals,  but  no  practical  use  of  this 
scrum  has  been  attempted  in  man. 

858 


Staphylococcus  aureus  occurs  outside  the  body 
in  milk,  water,  soil,  air,  etc.  Ten  per  cent,  of  the 
microorganisms  present  in  the  air  of  surgical  clinics 
consist  of  staphylococci  (Ullmann).  It  is  found  on 
the  healthy  skin,  in  the  mouth,  vagina,  cervix  uteri 
and  milk  of  nursing  mothers.  It  is  trie  chief  cause 
of  all  acute  inflammatory  suppuration,  in  many  cases 
the  sole  cause.  It  is  commonly  found,  however,  in 
association  with  streptococci,  pneumococci,  colon 
bacilli,  typhoid  bacilli,  etc.  The  following  affections 
particularly  are  frequently  caused  by  the  Staphylo- 
coccus aureus  and  other  species:  acne,  sycosis. 
impetigo,  pemphigus,  conjunctivitis,  furuncle,  abscess, 
periostitis,  osteomyelitis,  parotitis,  tonsillitis,  manmii- 
l  is,  ulcerative  endocarditis,  pyelonephritis,  etc. 
It  is  the  principal  etiological  factor  in  the  production 
of  pyemia  in  the  various  pathological  forms  of  that 
condition. 

Not  all  persons,  however,  are  equally  susceptible  to 
infection  by  the  staphylococcus;  those  who  are  in  a 
cachectic  condition  or  suffering  from  constitutional 
diseases,  like  diabetes,  are  especially  liable  to  infection. 
In  healthy  individuals  certain  parts  of  the  body,  as 
the  back  of  the  neck  and  seat,  seem  to  be  more 
subject  than  others  to  attack  by  furuncles,  carbuncles, 
and  the  like.  In  persons  in  whom  sores  are  readily 
produced  in  consequence  of  disturbances  of  nutrition, 
the  micrococci  find  a  suitable  resting  place  at  the 
points  of  least  resistance,  as  in  the  bones  of  weakly 
children,  in  fractures,  and  injuries  in  general. 

Staphylococcus  pyogenes  albus  is  morpho- 
logically identical  with  S.  pyogenes  aureus,  and  is 
probably  a  variety  of  the  same  organism  winch  has 
lost  its  power  of  producing  pigment.  On  the  average 
it  seems  to  be  somewhat  less  pathogenic. 

Staphylococcus  pyogenes  citreus  is  also  proba- 
bly identical  with  the  above-mentioned  species, 
except  that  it  forms  by  its  growth  a  lemon-yellow 
pigment.  It  is  found  in  about  ten  per  cent,  of  cases 
in  the  pus  of  acute  abscesses,  usually  in  association 
with  other  pyogenic  cocci. 

Staphylococcus  epidermidis  albus  is  another 
variety  no  doubt  of  S.  pyogenes  albus,  but  found 
on  the  surface  of  the  body  and  often  in  parts  of  the 
epidermis  deeper  than  can  be  reached  by  any  known 
means  of  cutaneous  disinfection  except  by  heat. 
According  to  Welch  it  is  far  less  virulent  than  S. 
pyogenes  aureus.  It  is  frequently  present  in  aseptic 
wounds,  but  does  not  seem  to  interfere  with  their 
healing,  although  sometimes  it  may  cause  suppuration 
along  the  drainage  tube,  and  is  the  common  source 
of  "stitch  abscess." 

Micrococcus  Tetragenus  (Tetracoccus).- — This 
micrococcus  was  discovered  by  Koch  in  1884  in  a 
phthisical  lung  cavity.  Gaffky  made  a  further  study 
of  it  and  described  its  pathological  properties  for 
various  test  animals.  Biondi  found  it  in  human 
saliva;  here,  however,  it  is  sometimes  simply  an 
evidence  of  mouth  contamination,  not  of  lung 
infection.  In  pulmonary  tuberculosis  it  is  commonly 
associated  with  other  pathogenic  bacteria,  which, 
though  playing  no  part  in  the  etiology  of  the  primary 
affection,  contribute  no  doubt  to  the  progresshe 
destruction  of  the  lung  tissue.  Its  pyogenic  character 
is  shown  by  its  not  infrequent  presence  in  the  pus  of 
acute  abscesses,  empyema,  etc. 

Microscopical  Appearances. — When  obtained  from 
the  animal  body  it  occurs  mostly  in  groups  of  four 
surrounded  by  a  capsule.  In  cultures  the  cocci  are 
seen  in  various  stages  of  division  as  large  round, 
undivided  cells,  in  pairs  of  oval  elements,  and  in 
groups  of  three  or  four.  When  the  division  is  com- 
plete they  remind  one  of  sarcina  in  appearance, 
except  that  they  divide  in  four  instead  of  in  three 


REFERENCE    HWDBoiiK    OF   Til  It    MEDICAL   S(  [ENCE8 


Bacteria 


directions  and  arc  not    built  up  like,  cotton   bale  . 
(See  Plate  1\  ,  Fig.  4.) 

Motility. — Non-motile. 

Stain iiui  Reactions. — Stains  readily  with  the  ordi- 
nary aniline  dyes;  is  not  decolorized  by  Gram. 

Biological  Characters. — Grows  both  in  the  presence 
and  in  the  absence  of  oxygen,  bul  best  with  oxygen, 
in  the  usual  culture  media.  It  may  be  cultivated  al 
room  temperature  (20°  ('.);  the  optimum  being  I" 
tween  35°  and  38°  ('.  The  growth  is  slow  under  all 
conditions. 

Growth  in  Gelatin. — On  gelatin  plans  small,  white 
to  grayish-yellow,  shiny,  prominent,  round,  or  lemon- 
sbaped  colonies  develop.  In  gelatin  stab  cultures  it 
ts  equally  as  well  on  the  surface  as  along  the 
.  of  the  needle;  forming  on  the  surface  a  thick, 
white,  shiny  iii:bs  and  tilling  out  the  fissures  along 
the  line  of  puncture.     The  gelatin  is  not  liquefied. 

On  agar  and  blood  serum  the  growth   on   the   sur- 
is  moist  and  glistening.     The  colonies  appear  as 
small,   transparent,  round  points  of  a  grayish-yellow 
color  and  slightly  elevated. 

Pathogenesis. — Subcutaneous  injections  of  a  cul- 
ture of  this  micrococcus  in  minute  quantity  are  usually 
fatal  to  white  mice  in  from  three  to  six  days.  The 
organisms  are  found  chiefly  in  the  spleen,  lung-, 
liver,  and  kidneys,  few  in  the  blood.  Gray  mici 
generally  immune.  Rabbits  and  dogs  are  also  little 
■ptible.  In  guinea-pigs  only  a  local  reaction  or 
abscess  sometimes  follows  inoculation,  and  again 
they  die  from  septicemia;  intraperitoneal  injections 
produce  purulent  peritonitis,  groups  of  micrococci 
being  found  in  the  exudate. 

Streptococcus  Pyogenes  (Streptococcus  erysipe- 
loid*).— This  microorganism  was  first  observed  by 
Koch  in  stained  sections  of  tissues  attacked  by  septic 
processes,  and  by  Ogston  in  the  pus  of  acute  abscesses 
(1882).  It  was  obtained  in  pure  cultures  by  Fehleisen 
(1SN3)  from  a  case  of  erysipelas,  and  its  pathological 
properties  proved.  Rosenbach  (1884)  and  Krause 
and  Passet  ( 1885)  isolated  it  from  pus  and  gave  it  the 
name  of  streptococcus  pyogenes.  It  has  since  been 
shown  to  be  the  chief  cause  of  many  suppurative 
inflammations.  Formerly  the  streptococci  of  ery- 
sipelas, acute  abscess,  septicemia,  puerperal  fever, 
etc..  were  thought  to  belong  to  different  species, 
because  they  possessed  certain  differences  in  their 
pathological  effects  and  morphological  peculiarities, 
according  to  the  source  from  which  they  were  derived. 
But  now  it  is  recognized  that  these  slight  differences 
are  not  sufficient  to  constitute  separate  species,  but 
only  varieties  of  the  same  species.  At  the  same 
time,  however,  there  would  appear  to  be  some  strep- 
tococci, which,  in  so  far  as  their  specific  reaction  in 
the  presence  of  a  protective  serum  is  concerned,  are 
as  distinct  from  the  streptococcus  pyogenes  as  is  the 
pneumococcus.  This  question  is  of  practical  impor- 
tance, for  upon  its  solution  depends  our  ability  to 
select  a  suitable  protective  serum  in  different  cases 
of  streptococcus  infection. 

Microscopical  Appearances. — Spherical  micrococci 
from  0.4  to  1  p.  in  diameter,  usually  larger  than  the 
staphylococci,  characteristically  arranged  in  chains 
of  eight,  ten,  twenty,  or  more  elements,  but  also 
associated  in  pairs  and  sometimes  in  irregular  masses. 
(See  Plate  IX.,  Fig.  2.) 

Motility. — Non-motile. 

Staining  Reactions. — Stains  easily  with  all  the  basic 
aniline  dyes  and  by  Gram's  method. 

Biological  Characters. — Facultative  anaerobic,  grow- 
ing in  both  absence  and  presence  of  oxygen,  and  on 
the  various  liquid  and  solid  culture  media.  The 
growth  is  slow,  developing  best  at  from  30°  to  37°  C, 
but  also  at  room  temperature  (18°  to  20°  C).  There 
is  no  growth  over  47°  C. 

Growth  on  Gelatin.— In  gelatin  plates  small,  white  to 


yellowish  or  brownish  granular  round  colonies  de- 
velop,    which    do     not     liquefy     the    gelatin;     though 

occa  tonally,  with  unusual  variel  ies,  a  amount 

of  liquefaction  has  been  observed.  Under  a  high 
power,  chains  of  streptococci  may  l>e  seen  projecting 
from  the  sides  of  the  discs.  In  gelatin  slab  cultures 
the  growth  i     not   confluent,  bul  individual  colonies 

are   arranged     beside   one   another    along    lie-    Iii,. 
punei  up  . 

Growth  an  Agar. — (in  agar  plates  the  colo 
visible  after  t  -  hirty  hours'  growth,  and  when 

magnified    sufficiently    show    beautiful    chain    cocci 
"i!eN  iii  i  he  form  of  twisti  d  loops.      1  lie  colonii 
circular  in  shape  when  thinly  scattered  over  the  plates, 
but  irregular  when  crowded  together. 

Gro  . — The  growth  iii  thi-  medium  is 

variable  in  different  varieties;  in  slightly  alkaline 
bouillon  at  -u  "  C.  reaching  their  full  development 
within  thirty-six  to  forty-eighl  hours.  Streptococci 
which  grow  in  long  chains  usually  give  an  abundant 

floerulent  deposit  and  leave  the  liquid  clear;  I  he 
deposit  may,  however,  he  granular,  in  Larger  Hake-  or 
in  tough  masses;  sometimes  the  broth  i-  clouded. 
Those  growing  in  short  chains,  as  a  rule,  cause  dil 
clouding  of  the  bouillon,  with  a  granular  deposit  at 
the  bottom  of  the  tube.  The  development  in  a 
mixture  of  ascitic  fluid  and  bouillon,  which  is  t  In'  bi  ' 
medium  for  the  growth  of  the  streptococcus,  is  more 
abundant  than  in  plain  bouillon. 

Growth  in  Solidified  Blood  Serum. — This  is  also  an 
excellent  medium  for  the  cultivation  of  the  strepto- 
coccus. Tiny  grayish  colonies  appear  after  twelve 
to  eighteen  hours.  Milk  is  usually  coagulated  with 
the  production  of  acid,  but  not  always. 

The  growth  on  potato  is  scanty. 

Development  of  Hemolytic  Substances. — Most  strep- 
tococci produce  these.  This  is  especially  true  of 
those  from  human  septic  infections.  As  pneumococci 
and  some  types  of  streptococci  produce  them  in  a 
much  less  degree,  blood  agar  plates  are  a  very  useful 
means  for  a  probable  identification.  If  1  c.c.  of 
fresh  or  defibrinated  blood  is  added  to  6  c.c.  of  melted 
agar  at  40°  to  45°  C,  well  shaken,  inoculated  with 
characteristic  streptococci  and  poured  in  a  Petri  dish 
there  will  appear  in  twelve  to  twenty-four  hours  tiny 
colonies  surrounded  by  clear  zones  of  about  J  to  J 
inch  in  diameter.  Pneumococci  and  many  other  varie- 
ties of  streptococci,  which  occur  together  with  char- 
acteristic forms  in  the  throat,  lungs,  etc.,  on  the  other 
hand  produce  only  narrow  zones  of  a  green  pigment. 

Vitality. — Cultures  of  the  streptococcus  die  much 
sooner  than  those  of  the  staphylococcus,  very  few 
living  over  a  month  and  the  majority  dying  within  a 
few  days;  they  live  longest  in  serum  bouillon  or  a 
mixture  of  ascitic  fluid  and  bouillon,  and  may  be 
kept  thus  for  a  considerable  time  in  small  sealed  glass 
tubes  in  the  ice  chest.  When  dried  in  blood  or  pus, 
the  streptococci  retain  their  vitality  for  several 
months  at  room  temperature,  and  still  longer  in  the 
refrigerator.  The  thermal  death  point,  according  to 
Sternberg,  is  between  52°  and  54°  C,  the  time  of 
exposure  being  ten  minutes. 

Chemical  Effects. — As  products  of  their  growth  the 
streptococci  form  but  little  pigment,  no  indol,  a  little 
H2S,  and  as  a  rule  no  acids  or  gases  from  carbohy- 
drates. From  albuminous  culture  media  they  pro- 
duce toxins  which  are  precipitated  by  alcohol  but  are 
soluble  in  water.  To  obtain  these  toxins  the  cultures 
are  killed  byr  chloroform  or  filtered  through  porce- 
lain. Introduced  into  animals  in  considerable  quan- 
tities they  cause  suppuration  and  fever  and  even 
death;  they  seem  to  belong  to  the  class  of  so-called 
toxalbumins. 

Pathogenesis. — The  majority  of  test  animals  are  not 
very  susceptible  to  infection  by  the  streptococcus, 
and  hence  it  is  difficult  to  obtain  any  definite  pat  holog- 
ical  changes  in  theirtissues  by  inoculations  of  cultures. 

859 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


White  mice  and  rabbits  are  the  most  susceptible,  and 
these  animals  are,  therefore,  usually  employed  for  ex- 
perimentation. The  virulence  of  streptococci,  how- 
ever, varies  greatly  for  animals  and  is  different  from 
their  virulence  for  the  human  subject.  The  most  viru- 
lent cultures,  when  injected  in  small  quantity  into  the 
circulation  or  the  subcutaneous  tissues  of  a  mouse  or 
rabbit,  produce  death  by  septicemia.  Less  virulent 
varieties  require  the  injection  of  large  quantities  to 
produce  a  similar  result,  while  some  produce  only 
abscess  or  erysipelas  when  injected  subcutaneously, 
and  others  have  no  effect  at  all  when  introduced 
directly  into  the  circulation.  Many  of  the  strepto- 
cocci obtained  from  cases  of  cellulitis,  abscess, 
empyema,  and  even  septicemia  belong  to  this  group. 

A  number  of  varieties  of  streptococci  have  thus 
been  discovered,  differing  in  virulence  and  in  their 
growth  in  culture  media;  but  all  attempts  to  separate 
them  into  classes,  until  recently  through  the  use  of  spe- 
cific serum,  have  failed,  because  the  differences  ob- 
served, though  often  marked,  are  not  constant. 
Knorr  has  enunciated  the  following  important  facts 
with  regard  to  the  virulence  of  streptococci:  All 
varieties  when  cultivated  for  any  length  of  time  on 
artificial  media  gradually  lose  their  virulence.  By  con- 
tinuous passage  through  certain  susceptible  animals, 
as  mice,  a  streptococcus  is  obtained  which  is  very 
pathogenic  for  those  animals,  but  at  the  same  time 
has  lost  its  virulence  for  others,  as  rabbits.  The 
more  virulent  any  variety  of  streptococcus  is  for  an 
animal,  the  more  certainly  it  kills  without  suppura- 
tion, which  is  produced  only  by  less  virulent  forms. 
There  seems  also  to  be  a  strong  tendency  for  a  strepto- 
coccus to  produce  the  same  kind  of  inflammation,  when 
inoculated,  as  the  one  from  which  it  was  derived;  for 
example,  streptococci  from  erysipelas  tend  to  pro- 
duce erysipelas,  from  septicemia  to  produce  septice- 
mia, etc.  Streptococci,  however,  obtained  from 
different  sources  (abscesses,  puerperal  fever,  sepsis, 
erysipelas,  etc.)  are  sometimes  capable  of  producing 
erysipelas  when  inoculated  into  the  ear  of  a  rabbit, 
provided  they  possess  sufficient  virulence.  By  con- 
tinued passage  of  fatal  doses  through  susceptible 
animals  Marmorek  has  obtained  cultures  of  strepto- 
cocci of  such  virulence  that  0.0001  c.c.  subcutaneously 
injected  into  mice  almost  invariably  killed  them, 
while  0.000001  c.c.  sometimes  produced  death — i.e. 
in  amounts  which  contained  but  a  verv  few  organisms. 
According  to  this  investigator,  the  virulence  may  be 
retained  by  cultivation  in  mixtures  consisting  of  two 
parts  of  serum  and  one  part  of  bouillon,  or  one  part  of 
ascitic  or  pleuritic  fluid  and  two  parts  of  bouillon, 
such  cultures  being  kept  for  two  months  or  more 
without  transplantation  to  fresh  media. 

Streptococci  have  been  found  outside  the  body  in 
the  soil,  in  water,  and  in  the  air  of  surgical  clinics,  etc. 
In  healthy  persons  they  have  been  observed  in  the 
mouth,  nasal  cavities,  vagina,  and  infrequently  in  the 
cervix  uteri,  sometimes  in  virulent  forms.  The 
Streptococcus  pyogenes  may  give  rise  in  man  to  a 
number  of  inflammatory  and  suppurative  processes. 
It  is  frequently  the  primary  cause  of  infection  in 
erysipelas,  acute  abscesses,  cellulitis,  lymphangitis, 
tonsillitis,  bronchitis,  pneumonia,  sepsis,  puerperal 
fever,  impetigo  contagiosa;  less  commonly  in  pleuritis, 
pericarditis,  meningitis,  periostitis,  osteomyelitis, 
otitis  media,  mastoiditis,  empyema,  etc.  Associated 
with  other  bacteria  in  diseases  of  which  they  are  the 
specific  cause,  streptococci  have  also  been  found 
contributing  to  secondary  or  mixed  infection  in 
pulmonary  tuberculosis,  bronchopneumonia,  scarlet 
fever,  and  septic  diphtheria,  playing  an  important  part 
in  these  affections  in  the  production  of  septicemia  and 
fever.  So  uniformly  present  are  streptococci  in  the 
pseudomembranous  inflammations  of  scarlatina  that 
some  authorities -have  claimed  that  a  certain  variety 
of  streptococci  (Streptococcus  conglomcratus  of  Kurth 

8G0 


and  Klein)  is  the  specific  cause  of  this  disease.  The 
same  is  true  for  smallpox.  Their  abundance  in  scar- 
let fever  and  smallpox  is  most  probably  due  to  their  in- 
crease in  the  injured  mucous  membrane  and  entrance 
into  the  circulation  when  the  protective  properties  of 
the  blood  have  been  lowered.  5.  pyogenes  is  further 
the  probable  cause  of  a  number  of  cases  of  nephritis 
arthritis,  and  myelitis,  being  frequently  found  in  the 
blood  and  urine,  with  or  without  sjmiptoms  of  general 
intoxication. 

In  animals  such  as  horses,  asses,  cows,  sheep,  goats 
and  dogs,  the  streptococcus  also  produces  diseases 
similar  to  those  observed  in  man.  These  organisms 
have  not  infrequently  been  found  in  the  vaccine 
lymph  of  stations  where  this  is  prepared,  though 
generally  they  are  the  non-virulent   varieties. 

Almost  all  of  the  diseases  above  mentioned  have 
been  produced  experimentally  in  animals,  the  result 
depending  upon  the  susceptibility  of  the  animals 
employed,  the  virulence  of  the  streptococci  and  the 
amount  of  infective  material  injected.  The  causal 
relation  of  this  organism  to  disease  has  also  been 
demonstrated  in  man.  Fehleisen  has  inoculated 
cultures  obtained  from  the  skin  of  patients  suffering 
from  erysipelas  into  persons  with  inoperable  malig- 
nant growths — lupus,  carcinoma,  and  sarcoma — and 
has  produced  a  typical  erysipelatous  inflammation  in 
from  fifteen  to  sixty  hours.  Persons  who  had 
recently  recovered  from  an  attack  of  erysipelas  proved 
to  be  immune.  In  such  persons  also  it  was  observed 
that  malignant  tumors  apparently  improved  or 
entirely  disappeared  after  inoculation.  This  fact  has 
been  made  use  of  in  the  treatment  of  cancers  by  the 
artificial  production  of  erysipelas  through  inoculation 
of  pure  cultures  or  of  their  toxic  products,  and  in 
some  cases  of  spindlecelled  sarcoma,  according  to 
Coley,  with  considerable  success;  in  carcinomata  the 
results  have  been  very  slight. 

Susceptibility  and  Immunity. — As  with  the  staphylo- 
coccus, the  streptococcus  is  more  liable  to  invade  the 
tissues  and  produce  inflammation  and  suppuration 
when  the  standard  of  health  is  reduced  from  any  cause, 
and  especially  when  by  absorption  or  retention  toxic 
products  are  present  in  excess  in  the  body.  Thus 
local  streptococcus  infections  are  more  likely  to  occur 
as  complications  or  sequel®  in  various  specific 
diseases,  in  chronic  alcoholism,  in  constitutional 
affections  in  those  exposed  to  septic  emanations  from 
sewers,  etc.,  and  in  cases  in  which  there  is  absorption 
of  toxic  products  formed  in  the  alimentary  canal  as 
the  result  of  the  ingestion  of  improper  food,  of  con- 
stipation, etc. 

Just  as  in  persons  who  have  recovered  from  an 
attack  of  erysipelas  there  has  been  observed  a  slight 
immunity  to  further  infection,  so  it  has  been  found 
that  animals,  after  recovering  from  artificial  inocu- 
lation of  the  toxic  products  of  the  streptococcus, 
acquire  a  moderate  immunity,  which  may  be  increased 
by  the  administration  of  gradually  increasing  doses 
of  the  culture.  In  this  way  Knorr  has  immunized 
rabbits  against  an  intensely  virulent  streptococcus 
by  injections  of  slightly  virulent  cultures;  Pasquale 
has  partially  immunized  these  animals  against  sep- 
ticemia; and  Marmorek  has  protected  sheep,  asses, 
and  horses  against  very  large  doses  of  a  streptococcus 
which  though  but  slightly  virulent  for  them  was 
intensely  so  for  rabbits. 

In  none  of  the  streptococcus  infections  in  man, 
however,  are  there  apparently  produced  lasting  im- 
munizing substances  in  the  blood  after  a  single  attack. 
In  cases  of  erysipelas,  cellulitis,  and  abscess,  recovery 
after  periods  varying  from  a  few  days  to  several 
months  would  seem  to  indicate  the  presence  of  slight 
or  transitory  protective  substances;  but  the  severe 
forms  of  infection,  such  as  septicemia  following 
operations  and  puerperal  fever,  show  little  tendency 
to  recovery  when  once  well  established. 


REFERENCE    HANDBOOK   OF   THE    MFDICAL   SCIENCES 


Bacteria 


Marmorek  was  the  first  to  attempt  to  produce  a 
curative  antistreptococcus  serum  obtained  from 
immunized  animals  (asses  and  horses)  for  the  treat- 
ment of  streptococcus  infections.  The  re  ults  re- 
ported from  the  use  of  this  serum  since  his  first  c - 

munication  in  1895  have  been  very  variable.  The 
protective  power  of  antistreptococcus  serum  is  un- 
doubtedly specific,  but  it  soon  loses  this  power  and 
often  is  practically  useless  six  weeks  after  its  prepare 
tion.  Definite  protection,  however,  from  the  serum 
has  been  obtained  by  many  reliable  observers  since 
Mannorck's  first  reports.  It  has  been  shown  that 
the  same  serum  does  not  always  confer  immunity  to 
other  varieties  of  streptococci  than  the  one  which 
was  originally  employed  in  the  immunizing  inocula- 
tion. But  the  results  of  numerous  investigators 
would  seem  to  indicate  that  the  majority,  though  not 
all.  of  the  streptococci  met  within  cellulitis,  erysip- 
elas, and  abscess  will  be  influenced  by  the  same  serum, 
while  those  obtained  from  cases  of  pneumonia  and 
endocarditis  and  other  exceptional  infections  are  apt 
to  have  individual  characteristics.  In  order,  there- 
fore, that  the  scrum  may  have  specific  antibodies 
for  the  variety  of  streptococcus  causing  each  separate 
infection  it  is  now  customary  to  prepare  a  polyvalent 
scrum  by  injecting  each  horse  with  a  large  number 
of  different  varieties  of  streptococci.  This  serum, 
though  not  quite  so  efficient  as  if  made  by  the  strep- 
tococcus infecting  each  ease,  will  be  fairly  efficacious 
in  all  cases.  As  already  mentioned,  the  results  so 
far  from  the  use  of  the  antistreptococcus  serum, 
therapeutically,  have  been  somewhat  variable.  In 
some  cases  the  disease  has  progressed  in  spite  of 
large  injections.  In  other  cases  apparent  improve- 
ment has  been  noticed.  With  the  exception  of  rashes. 
no  deleterious  effects  have  been  observed,  although  in 
very  large  doses  albuminous  urine,  for  a  short  time, 
has  followed.  Thus  the  serum  is  certainly  worth 
trying  in  suitable  cases,  even  though  no  very  striking 
results  are  to  be  expected.  Care  should  be  taken, 
however,  to  get  the  most  reliable  preparation,  as  much 
on  the  market  is  worthless.  Full  doses  (30-50  c.c.)  of 
serum  should  be  given  if  the  case  is  at  all  serious. 
Intravenous  injections  seem  to  give  better  results 
than  those  administered  subcutancously. 

The  following  varieties  of  streptococci  have  been 
described  by  some  authors: 

Streptococcus  Brevis. — Develops  in  bouillon 
slightly  curved,  short  chains;  the  bouillon  is  clouded. 
Gelatin  is  liquefied  immediately  around  the  colonies. 
There  is  a  distinctly  visible  growth  on  potato.  Grows 
at  10°  to  12°  C.     Is  usually  non-virulent. 

Streptococcus  Lonous. — Develops  in  bouillon 
long  twisted  chains,  with  a  granular  or  flocculent 
sediment,  the  supernatant  liquid  remaining  clear. 
Gelatin  is  not  liquefied.  There  is  no  visible  growth 
on  potato.  No  growth  under  14°  to  1G°  C.  Is  usu- 
ally highly  virulent. 

The  following  subdivisions  of  this  streptococcus 
have  also  been  described:  (1)  Streptococcus  turbidus 
with  clouded  bouillon  culture;  (2)  Streptococcus  vis- 
cosus  with  clear  bouillon  culture  and  slimy  sediment; 
(3)  Streptococcus  conglomeratus  with  clear  bouillon 
culture  and  granular  sediment. 

The  Pneumococcus  (Micrococcus  Lanceolatus; 
Diplococcus  Pneumonia). — This  micrococcus  was  first 
observed  by  Sternberg,  and  almost  simultaneously 
by  Pasteur  (18S0),  in  the  blood  of  rabbits  inoculated 
from  human  saliva.  It  was  subsequently  described 
by  Talamon  (1SS3)  and  demonstrated  by  him  to  be 
capable  of  producing  fibrinous  pneumonia  in  rabbits 
when  introduced  directly  into  the  lung  of  these 
animals.  In  1885-1886  this  microorganism  was  sub- 
jected to  an  extended  series  of  investigations  by 
Fraenkel,     Weichselbaum,     Sternberg,     and     others, 


and  proved  to  be  the  chief  cause  of  lobar  or  croupous 
pneumonic    in    man.     Several    dial  incl     varietii 
pneumococci  have  been  recognized,  showing  quit    a 
wide  range  of  variation  in  morphology 

I'lie       -c,  called       Strep In,  0i  -   .         m    <  0   U 

(Schottmuller)  and  other  capsulated  chain  bacteria, 
formerly  classed  as  streptococci,  e  i  red 

to  be  varieties  of  the  pneum 

Besides  the  different   varieties  of  pnei :occi  the 

following  bacteria  are  capable  of  exciting  pneu ma: 

Streptococcic  pyogen,   ,  Stap)  ,'  .  ,        ,   ,  Bacil- 

lus   pneumonia},  Bacfflu        ftuei 
BaciUus  diphtherial,  Bacillus  typhi,  Bacillus  colt, 
Bacillus  lulu  rculosis. 

Microscopical  Appearances. — Very  irregular;  oci 

typically  as  spherical  or  oval  and  lancet-  taped  »  i 

usually  united  in  pairs  (diplococci),  but   sometimes 
as   short   chains  consisting  of  four   to   six   clem 
and  resembling  streptococci.     In  stained  specimens 
from   sputum,   the   fibrinous  exudates   of   croupous 

pneumonia,  the  blood  of  inoculated  animal-,  ami  cul- 
tures on  blood  serum,  the  lancet-shaped  cells  are  com- 
monly surrounded  by  a  gelatinous  capsule.  Varia- 
tion in  form  and  arrangement  is  characteristic  of 
the  pneumococcus,  then?  being  great  differences 
according  to  the  source  from  which  it  is  obtained. 
(See  Plate  IX.,  Figs.  5  and  6.) 

Motility. — Non-motile. 

Staining  Reactions. — Stains  readily  with  ordinary 
aniline  dyes;  is  not  decolorized  by  Gram's  solution. 
The  capsule  may  be  demonstrated  in  cover-glass 
preparations  either  by  Gram's  or  Welch's  (glacial 
acetic   acid)    method. 

Biological  Characters. — Aerobic  and  facultative 
anaerobic,  grows  equally  well  in  the  presence  and 
absence  of  oxygen.  It  develops  on  almost  all  culture 
media  having  a  slightly  alkaline  reaction;  but  the 
growth  is  slow  and  scanty,  and  the  virulence  and 
power  of  reproduction  are  soon  lost.  Grows  very 
slowly,  often  not  at  all  at  room  temperature;  opti- 
mum 37°  C,  maximum  42°  C. 

Growth  on  Gelatin. — The  growth  on  this  medium  is 
slow,  often  none  at  all,  owing  to  the  low  temperature 
(22°  to  25°  C.)  at  which  gelatin  has  to  be  kept.  The 
gelatin  is  not  liquefied. 

Groioth  on  Agar  and  Blood  Scrum.- — At  the  end  of 
forty-eight  hours  in  the  incubator,  there  appears  on 
agar  a  thin  colorless  layer  of  non-confluent  colonies. 
If  blood  serum  or  ascitic  fluid  be  added  to  the  agar 
the  colonies  are  larger  and  closer  together,  the 
growth  being  more  luxuriant.  The  growth  of  Loef- 
fler's  blood-serum  mixture  is  very  similar  to  that  on 
agar,  but  is  somewhat  more  vigorous,  appearing  on 
the  surface  as  small,  fairly  granular  dew-drop-like 
colonies. 

Grouih  in  Bouillon. — At  the  end  of  twelve  to 
twenty-four  hours  in  the  incubator  a  slight  clouding 
is  produced,  due  to  the  development  of  the  organisms, 
which  on  microscopical  examination  are  seen  to 
consist  of  pairs  or  longer  and  shorter  chains.  After 
two  or  three  days  the  medium  again  becomes  trans- 
parent, the  cocci  sinking  to  the  bottom  of  the  tube. 
The  best  fluid  medium  for  the  cultivation  of  the  pneu- 
mococcus is  a  mixture  composed  of  bouillon  two 
parts  and  ascitic  or  pleuritic  fluid  one  part.  In  this 
medium  the  organisms  grow  well,  and  cultures  kept 
in  a  cool  place  and  prevented  from  drying  retain 
their  vitality  for  a  number  of  months. 

Milk  is  a  favorable  medium,  and  in  some  cases 
coagulation  takes  place. 

Vitality. — In  cultures  the  pneumococcus  soon  loses 
its  vitality;  it  lives  longest  in  media  containing  blood 
or  serum.  Pneumonic  sputum  attached  to  cloths, 
air-dried  and  exposed  to  diffuse  daylight,  retained 
its  virulence  for  rabbits  for  periods  of  nineteen  and 
fifty-five  days  in  different  experiments.  Exposed 
to    direct   sunlight    the    same    material    retained    its 

861 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


virulence  after  twelve  hours'  exposure  (Bordoni- 
Uffreduzzi).  This  resistance  of  the  organism  for 
so  long  a  time  under  these  conditions  is  attributed  in 
part  to  the  protective  influence  afforded  by  the 
albuminous  envelope  surrounding  the  micrococci  in 
the  sputum. 

Chemical  Effects. — Three  varieties  of  pneumococci 
have  been  isolated  which  produce  a  brick-red  pig- 
ment. Filtered  and  dead  unfiltered  cultures  contain 
toxins  as  products  of  growth.  For  other  chemical 
effects,  see  Streptococcus. 

Pathogenesis. — The  pneumococcus  is  quite  patho- 
genic for  some  animals,  especially  mice  and  rabbits; 
rats  are  less  susceptible,  and  guinea-pigs,  sheep,  dogs, 
and  birds  are  almost  immune.  In  mice  and  rabbits 
the  subcutaneous  injection  of  small  quantities  of 
pneumonic  sputum  in  the  early  stages  of  the  disease, 
or  of  a  pure,  virulent  culture  of  the  micrococcus, 
usually  results  in  the  death  of  these  animals  in  from 
twenty-four  to  forty-eight  hours.  The  course  of  the 
disease  produced  and  the  post-mortem  appearances 
indicate  that  it  is  a  typical  form  of  septicemia — so- 
called  sputum  septicemia.  The  most  marked  patho- 
logical lesion  is  the  enlargement  of  the  spleen.  The 
blood  after  death  often  contains  large  numbers  of 
pneumococci.  True  localized  pneumonia  does  not 
usually  result  from  subcutaneous  injections  into 
susceptible  animals,  but  injections  made  through  the 
thoracic  walls  into  the  substance  of  the  lung  may 
induce  a  typical  fibrous  pneumonia.  Attenuated 
cultures  produce,  according  to  the  point  of  inocula- 
tion, pneumonia  and  pleurisy,  peritonitis,  etc.  Atten- 
uation of  the  virulence  of  cultures  of  the  pneumococ- 
cus may  be  produced  artificially  by  the  action  of  heat 
or  several  days'  growth  in  the  incubator,  by  continued 

Eassage  through  unsusceptible  animals  (guinea-pigs), 
y  cultivation  in  unsuitable  media,  etc.  Virulence 
is  restored  and  increased  by  passage  through  highly 
susceptible  animals  of  the  same  species  from  which 
the  organism  was  originally  obtained. 

The  pneumococcus  has  not  been  found  outside  the 
body,  except  in  sputum.  It  is  frequently  present  in 
the  saliva  of  healthy  individuals.  In  diseased  per- 
sons it  is  one  of  the  most  important  pathogenic  bac- 
teria. It  is  associated  with  various  inflammatory 
Erocesses,  especially  of  the  mucous  and  serous  mem- 
ranes;  and  is  the  chief  etiological  factor  in  the  pro- 
duction of  lobar  and  catarrhal  pneumonia,  pleurisy, 
pericarditis,  endocarditis,  empyema,  peritonitis,  otitis, 
meningitis,  conjunctivitis,  and  keratitis;  less  fre- 
quently of  nephritis,  parotitis,  metritis,  pyosalpinx, 
strumitis,  amygdalitis,  arthritis,  osteomyelitis,  perio- 
stitis, etc.,  abscesses,  and  general  septicemia.  Erysio- 
elas  can  also  be  caused  by  it.  In  many  of  these  aii  :c- 
tions  the  organism  is  found  not  only  locally,  but  also 
in  the  blood.  Very  often  the  pneumococcus  is  asso- 
ciated with  and  acts  as  a  synergist  of  other  pus- 
producers,  as  the  staphylococcus,  streptococcus,  etc. 
It  is  carried  from  its  original  seat  in  the  lungs  to 
distant  organs  of  the  body  by  means  of  the  circula- 
tion, being  often  found  in  the  lymphatios  and  the 
blood  both  during  life  and  after  death.  Knowing 
that  the  saliva  and  nasal  secretions  under  normal 
conditions  so  frequently  afford  a  resting  place  for 
the  pneumococci,  we  have  only  to  assume  the  pro- 
duction of  a  suitable  medium  for  these  parasites  in 
the  body,  brought  about  by  an  abnormal  condition 
of  the  mucous  membranes  from  exposure  to  cold,  or 
a  reduction  of  the  vital  resistance  of  the  tissue  cells 
in  an  interior  organ,  by  disease,  traumatism,  excesses 
of  various  kinds,  alcoholism,  etc.,  readily  to  com- 
prehend how  an  individual  may  become  infected 
primarily  or  secondarily  with  pneumonia. 

Immunity. — Fraenkel  has  shown  that  subcutane- 
ous injections  of  rabbits  with  virulent  cultures  of  the 
pneumococcus  produced  infection  in  only  a  small 
proportion    of    them;    those    which    recovered    were 

862 


found  to  be  somewhat  immune  to  a  second  infection. 
Artificially  attenuated  cultures  or  material  containing 
naturally  weakened  micrococci  have  also  been  used 
for  inoculation.  Another  series  of  experiments  were 
based  on  the  assumption  that  the  protective  sub- 
stances are  contained  in  the  natural  or  artificial 
products  of  the  growth  of  the  organisms.  Thus  cul- 
tures freed  from  bacteria  by  filtration  and  emulsions 
of  pneumonic  sputum,  portions  of  pneumonic  lung 
pleuritic  exudates,  etc.,  were  employed  for  inoculation 
by  different  experimenters.  But  the  quantity  of 
material  required  for  inoculation  by  these  methods 
having  been  found  inconveniently  large,  attempts 
have  been  made  to  obtain  the  immunizing  products 
in  a  more  concentrated  form.  Foa  and  Scabia,  and 
the  Klemperer  brothers  prepared  glycerin  extracts, 
after  the  manner  of  Koch's  tuberculin,  calling  their 
product  "pneumotoxin."  At  present,  however,  a 
protective  serum  is  obtained  from  horses  by  the 
repeated  injections  of  fully  virulent  pneumococci  in 
exactly  the  same  way  as  in  the  production  of  anti- 
streptococcus  or  diphtheritic  antitoxic  serum. 

Curative  experiments  in  man  have  been  recently 
made  with  this  antipneumococcus  serum  obtained 
from  immunized  animals.  The  most  successful  of 
these  were  conducted  by  the  Klemperers.  They  hold 
that  in  man  during  the  pneumonic  process  there  is  a 
constant  absorption  into  the  circulation  of  the  toxic 
substances  produced  by  the  bacteria.  This  contin- 
ues until  eventually  the  same  antitoxic  substance  is 
produced  naturally  in  the  body  as  is  seen  to  occur 
experimentally.  It  is  then,  they  think,  that  the 
crisis  takes  place.  The  bacteria  are  neither  destroyed 
nor  is  their  power  to  produce  pneumotoxin  lessened; 
but  the  third  factor,  the  antitoxin,  now  exists  and 
neutralizes  the  toxin.  These  authors  state  that  they 
have  been  able  to  show  that  the  blood  serum  of 
patients  after  the  crisis  contains  antitoxic  substances, 
and  is  capable,  in  a  fair  number  of  cases,  of  curing 
the  disease  when  injected  into  infected  animals. 
They  have  also  made  observations  upon  patients  with 
a  view  of  inducing  the  crisis  by  the  injection  of  the 
blood  serum  of  immunized  animals  and  of  persons 
convalescent  from  pneumonia.  Somewhat  favorable 
results  have  been  reported  in  a  certain  number  of 
cases  thus  treated  by  the  Klemperers,  Jansen,  De 
Rienzi,  Weisbacker,  Washburn,  Pass£,  Ugheti,  Mennes, 
Lambert,  and  others,  but  nothing  definite  so  far  has 
been  accomplished.  It  may,  therefore,  be  concluded 
that  the  curative  treatment  by  antipneumococcus 
serum,  like  that  of  antistreptococcus  serum,  is  still 
in  the  experimental  stage.  All  that  can  be  said 
about  the  results  obtained  is  that  the  cases  treated 
have,  as  a  rule,  done  better  than  was  expected, 
though  no  striking  curative  effects  have  been  pro- 
duced. In  many  instances  there  was  no  develop- 
ment of  pneumococcus  blood  infection;  and  even  if 
the  serum  does  not  hasten  the  crisis  and  bring  about 
a  positive  cure,  yet  it  may  be  able  to  prevent  a 
general  infection.  It  is  known  that  there  are  several 
varieties  of  the  pneumococcus,  as  of  the  streptococcus, 
possessing  different  biological  and  pathological 
properties  and  varying  virulence.  Possibly  it  may 
be  found  that  pneumococcus  serum  obtained  from 
animals  immunized  against  a  certain  variety  of 
pneumococcus  protects  only  fully  against  that  variety, 
as  with  the  streptococcus  serum,  and  that  large  intra- 
venous injections  of  50  c.c.  of  a  polyvalent  serum 
may  be  of  value.  But  whether  that  be  so  or  not, 
the  injections,  at  any  rate,  of  the  serum  have  been 
shown  to  be  practically  harmless,  and  the  benefits  to 
be  derived  from  the  discovery  of  a  curative  remedy 
for  pneumonia  are  so  great  that  these  experiments 
are  certainly  worth  continuing. 

The  Meningococcus  (Diplococcus  intracclhrfaris 
meningitidis).  —  This     organism     was     isolated     by 


Hill  I'.IM'.XCK    HANDlsniiK    <  >F    Till:    MFIHCAL    SCIENCES 


Bacteria 


Weichselbaum  (1887)  from  the  exudate  of  cerebro- 
spinal meningitis,  both  when  complicating  pneumonia 

unci  in  uncomplicated  cases,  and  from  its  usual  pres- 
ence in  the  interior  of  pus  cells  he  called  it  D 

acellularis.  It  has  since  been  found  (1895)  by 
Jager  and  Schcurer  in  the  nasal  secretions  and  sputum 
ol  persons  suffering  from  tins  affection  during  an 
epidemic.  The  frequency  of  its  occurrence  in  and 
restriction  to  this  disease  afford  sufficient  evidence 
of  its  being  concerned  at  times,  at  least,  in  the 
production  of  cerebrospinal  meningitis,  though  the 
pneumococcus  is  probably  the  most  common  cause. 

Motility. — Non-mo!  ile. 

Staining     Reactions. — Stains     with     the     ordinary 
aniline  colors,  but  best  with  Loeffier's  alkaline  methyl- 
blue.     It     is    readily    decolorized     by     Gram's 
solution. 

Microscopical     Appearances. — Occurs     as     coffec- 
i-shaped     micrococci     usually     united     in     pairs 
(diplococci),  but  also  in  groups  of  four,  and  in  small 
masses;  sometimes  solitary   and   smaller  apparently 
degenerated  forms  are  found.     It  has  no  well-defined 
ule.     In  the  exudate  it  is  generally  found,   like 
the  gonococcus,  to  which  it  bears  a  close  resemblance 
morphologically,  in  the  interior  of  the  pus  cells  and 
extranuclear.     According    to     some     authors    it     is 
sometimes  indistinguishable  in  form  from  the  pneu- 
mococcus, streptococcus  pyogenes,  and  tetracoccus. 
Plate  IX.,  Fig.  S.) 

Biological  Characters. — The  meningococcus  does  not 
grow  at  room  temperature  but  only  between  25°  and 
40°  C,  best  in  the  incubator  at  3G°-37°  C.  Its  devel- 
opment is  usually  scanty  on  the  surface  of  agar, 
though  sometimes  a  few  colonies  grow  luxuriantly. 
It  does  not  grow  at  all  or  very  poorly  in  bouillon  or 
bouillon  mixed  with  one-third  blood  serum.  It 
develops  best  on  Loeffier's  blood-serum  mixture  as 
used  for  diphtheria  cultures. 

When  grown  on  nutrient  or  glycerin  agar,  at  the  end 
of  forty-eight  hours  in  the  incubator  a  tolerably 
good  growth  develops,  appearing  as  flat,  grayish 
colonies,  viscid  and  usually  non-confluent.  On 
Loeffier's  blood  serum  the  growth  forms  round,  whitish, 
shining,  viscid-looking  colonies,  with  smooth,  sharply 
defined  outlines.  The  colonies  tend  to  become 
confluent,  but  do  not  liquefy  the  serum. 

Cultivated  in  artificial  media  the  meningococcus 
soon  loses  its  vitality  (in  six  days),  and  must  therefore 
be  transplanted  every  two  or  three  days  to  fresh 
media. 

Pathogenesis. — Not  very  pathogenic  for  animals; 
most  for  mice  and  guinea-pigs,  less  so  for  rabbits  and 
dogs.  Subcutaneous  injections  of  animals  give  nega- 
tive results;  intrapleural  or  intraperitoneal  inocula- 
tions in  mice  and  guinea-pigs,  in  large  doses,  are 
generally  successful.  The  animals  usually  fall  sick 
and  die  within  thirty-six  to  forty-eight  hours,  showing 
slight  fibropurulent  exudation.  In  the  blood  and 
enlarged  spleen  diplococci  are  found  in  small  numbers 
and  mostly  free;  in  the  pleuritic  exudate  they  are 
present  in  considerable  quantities  and  then  are  found 
in  the  interior  of  the  pus  cells.  Meningitis,  corre- 
sponding to  the  disease  as  occurring  in  man,  has 
been  artificially  produced  in  dogs  by  subdural  inocula- 
tions of  recent  cultures. 

Under  natural  conditions  in  the  human  subject  the 
meningococci  probably  gain  access  to  the  brain  and 
meninges  by  way  of  the  nose,  ear,  and  upper  air 
passages.  They  have  been  found  not  only  in  menin- 
geal pus  but  also  in  the  nasal  mucous  secretions,  the 
sputum,  and  the  urine  of  patients  suffering  from 
meningitis,  and  occasionally  in  the  nares  of  healthy 
persons  coming  in  contact  with  patients.  A  mixed 
infection  of  the  meningococcus,  pneumococcus,  and 
streptococcus  pyogenes  is  often  met  with. 

Serum  Treatment. — Numerous  experiments,  having 
for  their  object  the  production  of  a  protective  serum 


for  this  di  been  made  since  1905  by  variou 

investigators;    Kolle  and    \\ .  ,    Park,   Joch- 

mann,   I  lexner,    and    others.     The    Bu 

use  of  an  immune  serum  in  cases  of  human  cerebro- 
spinal meningitis,  however,  by  the  intraspinal  method, 
may   properly   be  accredited   fo  Jochmann  and 

physicians  who  employed  bis  serum  in  1005  and  I 

This  serum  wa     pr  injecting  hoi 

increasing  doses  of  meningococcus,    killed  al    about 
58°    C.     The    doses    were   given    every    eight    d; 
beginning   with   a   loopful   and   increasing   until   the 
growth  on  the  surface  of  ascitic  agar  covering  two 
Petri  dishes  was  used.     After  this  do  ched 

living  cultures  were  given.     The  serum  a  to 

possess  both  bactericidal  and  opsonic  power.  Forty 
were  reported  treated,  but  detail-  were  given 
of  only  seventeen  patient-,  five  of  whom  died  and 
twelve  recovered,  a  tahty  of  29  per  cent.  Joch- 
mann directed  that  after  lumbar  puncture,  20  to 
.">0  c.c.  of  fluid  should  be  removed  and  then  2(J 
of  immune  serum  injected.  These  injections  were 
to  be  repea  or  twice  if  the  fever  did  not  abate 
or  returned.  A  general  betterment  of  the  headache, 
stiffness  of  neck,  and  mental  condition  was  noticed. 

Although  the  serum  prepared  in  different  labora- 
tories in  Europe  was  regularly  used  after  Jochmann's 
report,  it  did  not  receive  much  attention  in  this 
country  until  Flexner,  at  the  Rockefeller  Institute  for 
Mei  Ih.i1  Research,  through  his  important  experiments 
on  infected  monkeys,  which  demonstrated  the  value 
of  the  intraspinal  injection  of  the  serum,  aroused  a 
general  medical  interest  in  the  subject,  shortly 
after  this,  Flexner  and  Jobling  published  their  report, 
which  fully  corroborated  the  earlier  results  of  Joch- 
mann. From  a  large  number  of  eases  of  the  disease, 
which  have  now  been  treated,  in  which  the  bacterio- 
logical diagnosis  was  made,  it  appears  that  the  aver- 
age mortality  at  all  ages  was  about  31.5  per  cent., 
the  highest  mortality  being  42.3  per  cent,  which 
occurred  in  the  first  two  years  of  life.  The  mor- 
tality, however,  at  this  age  period,  under  the  older 
mode  of  treatment,  was  formerly  90  per  cent,  and 
over.  The  best  results  have  been  obtained  in  the 
first-to-third  day  injections,  the  poorest  after  the 
seventh  day.  It  would  seem  to  be  evident,  therefore, 
that  the  intraspinal  injections  of  antimeningococcus 
serum  are  of  undoubted  value  in  the  majority  of 
cases  and  should  always  be  given — the  sooner  the 
better — not  even  waiting  necessarily  for  a  bacterio- 
logical examination  to  give  the  first  injection.  No 
ill  effects  have  been  observed  from  the  use  of  the 
serum. 

A  bacteriological  diagnosis  of  cerebrospinal  menin- 
gitis may  often  be  made  by  means  of  lumbar  puncture 
to  obtain  a  specimen  of  the  fluid  from  the  spinal  canal, 
and  microscopical  examination  and  cultivation  on 
Loeffier's  blood  serum.  The  clinical  value  of  this  is, 
that  about  forty  per  cent,  of  the  cases  due  to  the 
meningococcus  recover,  while  almost  all  of  those 
caused  by  the  pneumococcus  and  streptococcus  die. 

The  Gonococcus  (Micrococcus  gonorrhoea;). — 
First  observed  by  Neisser  (1S79)  in  gonorrheal  pus 
and  described  by  him  under  the  name  of  "  gonococ- 
cus."  It  was  obtained  in  pure  culture  by  Bumm 
(1885),  and  its  infective  nature  proved  by  inocula- 
tions into  men. 

Microscopical  Appearances. — Micrococci  usually 
united  in  pairs  (diplococci)  or  groups  of  four.  The 
bodies  of  the  diplococci  are  shaped  like  coffee  beans 
or  a  Vienna  roll,  having  an  unstained  division  or 
interspace,  in  stained  preparations,  between  two  fiat 
surfaces  facing  one  another.  They  are  from  0.8  to 
1.6  /i  long  and  0.6  to  0.8  /(  broad.  In  gonorrheal 
discharges  the  diplococci  are  found  mostly  in  small, 
irregular  groups  in  or  upon  the  pus  cells  and  extra- 
nuclear.     Occasionally  round,  single,  and  undivided 

863 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


cells  are  observed,  and  again  irregular  forms,  parti- 
cularly in  old  cultures,  and  in  chronic  gonorrhea  of 
long  standing.      (See  Plate  IX.,  Fig.  7.) 

Motility. — Non-motile. 

Staining  Reactions. — Stains  readily  with  the  basic 
aniline  dyes,  especially  with  methyl  violet,  gentian 
violet,  and  fuehsin;  not  so  quickly  with  methylene 
blue,  which,  however,  is  the  best  staining  agent  for 
demonstrating  its  presence  in  pus.  The  gonococcus 
is  decolorized  by  Gram's  solution,  which  enables  it 
to  be  distinguished  from  other  pus  cocci;  but  this 
method  cannot  always  be  depended  on  to  differen- 
tiate it  from  all  diplococci  found  in  the  urethra  and 
vulvovaginal  tract,  some  of  which  are  morpholog- 
ically similar  to  the  gonococcus  and  are  also  decolor- 
ized by  Gram's  solution. 

Biological  Characters. — Aerobic  and  facultative 
anaerobic.  Does  not  grow  at  room  temperature, 
best  at  37°  C.  Growth  on  ordinary  culture  media 
is  so  scanty  that  special  media  have  been  devised 
for  its  cultivation. 

Human  Placenta  Serum  Agar. — Wertheim  has  suc- 
ceeded in  developing  luxuriant  and  virulent  cultures 
to  many  generations  on  a  mixture  consisting  of  pla- 
centa blood  serum  and  two  per  cent,  peptone  agar. 
His  method  is  as  follows:  Several  loops  of  gonor- 
rheal pus  are  diffused  through  liquid  placental  blood 
serum  warmed  to  40°  C.  in  a  test  tube.  Two  dilu- 
tions are  made  from  this,  and  an  equal  quantity  of 
melted  two-per-cent.  peptone  agar  cooled  to  40°  C. 
is  added  to  the  three  tubes,  and  the  contents  poured 
into  Petri  dishes.  At  the  end  of  twenty-four  hours 
in  the  incubator  there  will  have  developed  on  at 
least  one  of  the  plates  distinct  colonies,  which  are  in 
appearance  translucent  and  finely  granular  with 
scalloped  margins.  By  transferring  such  a  colony 
to  slant  cultures  of  serum  agar,  pure  cultures  of  the 
gonococcus  are  obtained;  these  are  somewhat  shiny 
in  appearance  and  of  a  grayish-white  color. 

Human  Chest  Serum  Agar. — Heiman,  and  almost 
simultaneously,  Kiefer  and  Menge,  proposed  a  cul- 
ture medium  made  from  hydrothorax,  ascitic,  or 
hydrocele  fluid,  obtained  from  the  human  subject. 
This  medium  as  prepared  by  Heiman  consists  of  a  2 
per  cent,  agar +2  per  cent,  peptone +0.5  per  cent, 
salt +2  per  cent,  glucose;  of  this  mixture  two  parts 
are  added  to  one  part  of  "chest  serum,"  obtained 
from  a  patient  suffering  from  hydrothorax,  acute 
pleurisy,  or  hydrocele,  which,  if  necessary,  is  steril- 
ized. The  chest  serum  agar  should  have  a  neutral 
reaction.  The  growth  in  this  medium  is  thus  de- 
scribed: "In  plate  cultures  streaked  on  the  surface, 
growth  abundant,  colonies  circular  in  shape,  edges 
somewhat  irregular,  shading  off  into  yellowish-white; 
texture  finely  granular  in  periphery,  presenting  punc- 
tuated spots  of  higher  refraction  in  and  around  the 
center  of  yellowish  color." 

Pig  Serum  Nutrose  Agar. — Wassermann  recom- 
mends a  culture  medium  for  the  gonococcus  con- 
sisting of  15  c.c.  pig  serum  diluted  with  30-35  c.c. 
water,  to  which  is  added  2-3  c.c.  glycerin,  and  finally 
about  2  per  cent,  nutrose  (casein  sodium  phosphate). 
This  is  thoroughly  mixed  and  boiled  and  sterilized 
by  the  fractional  method.  To  the  mixture  is  now 
added  an  equal  quantity  of  2  per  cent,  agar  cooled 
to  40°  O,  for  the  inoculation  of  cultures,  and  then 

Eoured  into  Petri  dishes.  The  growth  is  favored 
y  admission  of  air,  and  is  similar  in  appearance 
to  that  already  described  for  plate  and  streak 
cultures. 

Toxins. — Wassermann  has  obtained  on  his  serum 
nutrose  agar  virulent  cultures  of  the  gonococcus, 
which  after  being  killed  still  possessed  toxic  action. 
The  gonotoxin  produced  was  found  to  be  very 
resistant  to  heat  and  the  action  of  alcohol;  it  killed 
mice,  and  in  rabbits  gave  rise  to  caseous  infiltration 
often  passing  into  necrosis,  and  in  large  doses  pro- 

864 


duced  general  toxemia.  Injected  into  the  human  sub- 
ject the  gonotoxin  seemed  to  produce  no  curative  effect 
on  an  existing  chrome  gonorrhea,  the  intense  reaction 
caused  not  becoming  less  on  repeated  inoculations. 

The  production  of  gonotoxin  would  seem  to  ac- 
count for  the  gonorrheal  secretion.  It  also  renders 
more  comprehensible  several  obscure  points  in  the 
history  of  chronic  gonorrhea:  for  example,  the  fact 
that  gonococci  may  be  apparently  absent  from,  or 
only  isolated  organisms  present  in,  the  gonorrheal 
discharge,  and  yet  a  purulent  secretion  be  kept  up 
containing  few  bacteria;  but  if,  owing  to  some  in- 
jury to  the  tissues,  the  organisms  increase  in  number 
an  acute  exacerbation  of  the  disease  is  again  set  up 
and  masses  of  gonococci  are  then  found  in  the  pus. 

Vitality. — The  gonococcus  has  but  little  resistant 
power  against  outside  influences.  It  is  killed  by 
weak  disinfecting  solutions  and  by  desiccation  in 
thin  layers.  In  comparatively  thick  layers,  however, 
as  when  gonorrheal  pus  is  smeared  on  linen,  it  has 
lived  for  forty-nine  days,  and  dried  on  glass  for 
twenty-nine  days  (Heiman).  No  development  takes 
place  below  25°  C.  or  above  39°  C;  it  is  killed  by  a 
temperature  over  42°  C. 

Pathogenesis. — Gonorrhea  as  occurring  in  man  is 
non-transmissible  to  dogs,  monkeys,  horses,  and  rab- 
bits, whether  inoculations  be  made  into  the  urethral, 
vaginal,  or  other  mucous  membranes.  Large  doses 
of  virulent  cultures  produce  in  animals  toxic  inflam- 
mations, similar  to  that  produced  by  the  gonotoxin, 
without  any  multiplication  of  cocci.  Although 
animal  inoculations  have  been  thus  followed  by 
negative  results,  the  etiological  relation  of  the  gon- 
ococcus to  human  gonorrhea  has  been  demonstrated 
beyond  question  by  the  infection  of  healthy  men 
with  the  disease  by  inoculation  of  pure  cultures  by 
Bumm,  Wertheim,  Kiefer,  and  Heiman. 

The  gonococcus  has  never  been  found  outside  the 
body,  except  in  articles  of  clothing,  etc.,  which  have 
become  contaminated  by  those  affected  with  the 
disease;  nor  has  it  ever  been  met  with  in  healthy  per- 
sons. In  those  suffering  from  gonorrhea  it  has  been 
found  in  the  urethra  and  prostate  of  the  male  and 
in  the  urethra,  vagina,  and  cervix  uteri  of  the  female, 
as  the  cause  of  the  disease.  Besides  gonorrheal 
urethritis  and  vaginitis,  the  gonococcus  is  the  cause 
of  certain  cases  of  endometritis,  metritis,  salpingitis, 
oophoritis,  peritonitis,  proctitis,  cystitis,  and  prob- 
ably also  of  epididymitis;  also  of  gonorrheal 
ophthalmia  neonatorum,  and  rarely  of  diphtheritic 
conjunctivitis  in  children  (Fraenkel).  The  gonococ- 
cus produces  in  adults  severe  conjunctivitis,  sel- 
dom rhinitis  and  otitis.  It  is  frequently  the  cause 
of  gonorrheal  arthritis,  also  probably  in  some  cases 
of  pleuritis,  malignant  endocarditis,  parotitis,  peri- 
ostitis, and  bursitis. 

In  the  local  affection  squamous  epithelium  pro- 
tects better  than  cylindrical  epithelium.  The  para- 
site penetrates  gradually  through  the  epithelium  into 
the  connective  tissue.  In  travelling  to  distant  organs 
of  the  body  the  gonococcus  follows  mainly  the  course 
of  the  lymphatics  and  produces  inflammation  which 
finally  leads  to  fibrinous  hypertrophy — stricture  of 
the  urethra,  hypertrophy  of  the  prostate,  etc.  There 
is  no  or  very  slight  immunity  produced  after  recovery 
from  an  infection.  The  use  of  sera  in  acute  gonor- 
rheal joint  inflammation  has  given  in  a  considerable 
percentage  of  cases  good  results  and  seems  to  be 
worth  trying.  Vaccines  (heated  cultures)  have  also 
been  used  with  apparently  real  benefit  in  joint  inflam- 
mations and  even  in  very  localized  chronic  infections 
of  the  urethra,  bladder,  and  elsewhere.  The  dose  is 
from  twenty  to  a  thousand  million  given  every  three 
to  seven  days. 

There  is  practically  no  limit  to  the  time  during  which 
a  man  or  woman  may  remain  infected  with  gonococci 
and  infect  others.     A  case  has  been  under  observa- 


EXPLANATION  OF 
PLATE  IX. 


EXPLANATION  OF  PLATE  IX. 

Fig.  1. — Bacillus  Coli  Communis.  Agar  culture.  Stained  with  fuchsin.  X  1,000. 
Photomicrography  from  Bowhill's  "Bacteriology"  by  permission. 

Fig.  2. — Streptococcus  Pyogenes  (Longus).  X  1,000.  Photomicrograph  from  Sternberg's 
"  Bacteriology"  by  permission. 

Fig.  3. — Staphylococcus  Pyogenes  Aureus.  X  1,000.  Photomicrograph  from  Park's 
"  Bacteriology"  by  permission. 

Fig.  4. — Micrococcus  Tetragenus  (Tetracoccus).  X  1,000.  Photomicrograph  from  Park's 
"  Bacteriology"  by  permission. 

Fig.  5. — Diplococcus  Pneumoniae  (Fraenkel)  in  Sputum,  x  1.000.  Stained  by  Gram's 
method.     Photomicrograph  from  Sternberg's  "  Bacteriology"  by  permission. 

Fig.  6. — Diplococcus  Pneumonias  (Fraenkel)  in  Blood.  X  1,000.  Photomicrograph  from 
Sternberg's  "Bacteriology"  by  permission. 

Fig.  7. — Micrococcus  Gonorrhoeae  (Gonococcus  of  Neisser)  in  Urethral  Pus.  Stained  with 
Loeffler's  solution  of  methylene  blue.  X  1,000.  Photomicrograph  from  Sternberg's 
"  Bacteriology"  by  permission. 

Fig.  S. — Diplococcus  Intracellularis  Meningitidis  (Meningococcus).  X  1,000.  Photo- 
micrograph from  Park's  "  Bacteriology"  by  permission. 


Refekence  Handbook 

OF   THE 

Mf.dical  Sciences 


Plate  IX 


Streptococcus  pyogenes.  *?•.**•••*<' 


VII. 
Gonococcus  (Neisser). 


vS-1 


V. 

Diplococcus  pneumoniae  in 
sputum. 


9. 


#' 


in. 

Staphylococcus  pyogenes 
aureus 


Pathogenic   Bacteria. 


VIII. 

I  liplocoocus  intracellularis 
meningitidis. 


REFEHKNCF    HANDBOOK    OK    Till'    MEDICAL    SCIENCES 


Bacteria 


ion  where  twenty  years  luul  elapsed  since  exposure 
(i  infect  inn  and  yet  the  gonococci  were  still  abundant. 
It  is  now  well  established  thai  most  of  the  inflam- 
mations nf  the  female  genital  tract  are  due  to  gono- 
rncci  and  the  majority  of  such  infeel  ions  are  produced 
in  innocent  women  by  their  husbands  who  are  suf 
faring  from  latent  gonorrhea. 

In  view  of  t  lie  fact  i  hat  several  non-specific  forms  of 
urethritis  exist,  and  also  that  diplococci  morpholog- 
ically similar  to  the  gonococcus  Neisser  are  often 
found  in  the  normal  urethra  ami  vulvovaginal  tract, 
it  becomes  a  matter  of  great  importance  to  he  able  to 
detect  gonococci  when  present  and  to  differentiate 
these  from  the  non-specific  organisms.  For  the  dem- 
onstration of  gonococci,  they  must  be  found  as 
diplococci  lying  in  masses  in  the  pus  cells  anil  extra- 
nuclear,  when  stained  with  methylene  blue  and 
decolorized  by  Oram's  solution.  Organisms  having 
these  characteristics  microscopically  may  for  all 
practical  purposes  be  considered  as  certainly  gono- 
cocci, if  they  are  obtained  from  the  urethral  discharge 
and  confirmed  by  examination  on  three'  successive 
days.  But  if  there  still  remains  any  doubt,  and 
especially  if  the  organisms  are  obtained  from  the 
vulvovaginal  tract,  plate  cultures  should  be  made 
on  one  of  the  special  media  described  (chest  serum 
agar,  etc.),  on  at  least  three  consecutive  days. 

Malta  Fever  (The  Micrococcus  rnelitensis). — 
This  organism  was  first  discovered  by  Bruce  in  Malta 
in  1887.  The  disease  is  confined  to  the  shores  of  the 
Mediteranean,  but  cases  have  been  observed  in  Porto 
Rico,  China,  Japan,  and  the  Philippines.  It  does 
not  seem  to  be  directly  transmitted  from  person  to 
person.  Prodromal  symptoms  follow  an  incubation 
period  of  5  to  14  days.  Headache,  sleeplessness,  loss 
of  appetite,  and  vomiting  accompany  a  high  fever. 
The  spleen  and  liver  are  enlarged.  Neuralgic  pains 
are  severe.  The  fatal  cases  appear  similar  to  severe 
cases  of  typhoid  fever.  Micrococci  are  found  abun- 
dantly in  the  blood  and  all  organs. 

Microscopical  Appearances. — Very  small  rounded 
or  slightly  oval  organisms,  about  0.3  a  in  their  greatest 
diameter.  It  is  usually  single  or  in  pairs.  In  old 
cultures  involution  forms  occur,  almost  bacillary  in 
shape. 

Motility. — Absent. 

Staining. — It  stains  readily  with  aniline  dyes  and 
is  negative  to  Gram. 

Biological  Characters. — Grows  rather  feebly  at  37° 
C.  on  nutrient  gelatine  and  in  broth.  The  colonies  are 
not  usually  visible  until  the  third  day.  They  appear 
as  small  round  disks,  slightly  raised  with  a  yellowish 
tint  in  the  center.  The  broth  is  slightly  clouded 
after  five  or  six  days.  The  culture  remains  alive 
for  several  weeks  or  months.  In  gelatin  the  growth 
is  very  slow.     Gelatin  is  not  liquefied. 

Pathogenesis. — Among  animals,  monkeys  only  are 
infected.  They  pass  through  the  disease  much  like 
man.  They  can  be  infected  by  subcutaneous  or  mu- 
cous inoculation.  In  Malta  it  has  been  found  that 
about  half  of  the  goats  pass  organisms  in  feces,  and 
so  contaminate  their  milk,  which  is  believed  to  be  a 
source  of  infection.  By  safeguarding  the  milk  the 
disease  has  been  largely  eliminated.  Infections  of 
heated  cultures  have  been  thought  to  give  good  results 
in  treatment. 

Diagnosis. — The  diagnosis  of  Malta  fever  can  fre- 
quently only  be  made  by  bacteriological  methods. 
Cultures  are  made  by  spreading  over  the  surface 
of  a  number  of  agar  plates  freshly  drawn  blood. 
Often  no  organisms  develop.  The  agglutination  test 
is  then  required.  The  blood  of  persons  suffering 
from  other  infections  frequently  agglutinates  the 
micrococcus  of  Malta  fever  in  low  dilution,  so  that 
1:500  or  over  is  required  for  a  positive  diagnosis. 
Animals  injected  with  the  coccus  produce  a  serum 
agglutinating   in  high  dilution  and  this  method  can 


sometimes   be   used,    under  suitable  precaution  .  to 

identify  suspected  cull  un    . 

The    Bacillus   of  Soft  Chan<  Ducrey'    hoc- 

ill"  i. — This  bacillus  was  first  specifically 

and    obtained    in    pure   culture    by    Ducrey    in    Iss'J. 

An    experimental    inoculation     is   followed    iii    one    or 

two  days  by  a  small  pustule.    This  soon  rupl 

and  a  small   round  depressed  ulcer  is  lefl .      Aboul  this 

other  pustules  develop  which  tend  to  become  con- 
fluent. The  base  of  the  ulcer  is  covered  with  a  gray 
exudate  and  its  edges  are  undermined.     There  i    no 

induration  as  in  the  Byphilitic  chancre.  The  secre- 
tion is  seropurulenl  and  very  infectio 

Microscopical  Appearances. —  About  1.6  p  long 
and  o.l  fi  thick,  growing  often  in  chains,  sometimes 
twisted  together  in  dense  masses. 

Staining. — It  stains  best  with  carbol-fuchsin,  and 
shows  polar  staining. 

Biological  ammeters. — Grows  best  in  blood-agar 
1 1 \\o  pails  agar  liquefied  at  50°  C.  and  mixed  with  one 
part  human,  dog,  or  rabbit  blood)  or  in  condensation 
water  of  blood-agar,  at  35"  to  37°  C.  It  grows  also 
in  coagulated  rabbit  blood.  In  24  to  48  hours,  on 
the  surface  of  the  media,  well-developed,  shiny, 
grayish  colonies,  about  1  mm.  in  diameter,  may  be 
observed.  The  calonies  remain  separate,  but  only 
become  numerous  after  further  transplantation.  The 
best  results  are  obtained  when  the  pus  is  taken  close 
to  the  walls  of  the  abscess.  Glass  smears  show  iso- 
late,! bacilli  or  short  parallel  chains  with  distinct 
polar  staining.  The  organisms  are  especially  char- 
acteristic in  the  water  of  condensation  from'  blood- 
agar,  the  bacilli  being  thinner  and  shorter,  with 
rounded  ends;  sometimes  long,  wavy  chains  are 
found. 

After  the  eleventh  generation  of  the  culture,  and 
upon  all  old  cultures,  on  inoculation  the  character- 
istic soft  chancre  is  produced  in  man. 

The  bacillus  lives  several  weeks  in  blood-agar  at 
37°  C.  but  it  soon  dies  in  coagulated  serum.  All 
other  ordinary  culture  media  so  far  tried  have  given 
negative  results  and  even  with  the  media  described 
development  is  difficult  and  often  fails.  The  chancroid 
bacillus  possesses  but  little  resistance  to  deleterious 
outside  influences.  Hence  the  antiseptic  bandages, 
etc.,  used  in  treatment  of  the  affection  soon  bring 
about  recovery  by  preventing  the  spread  of  the 
infection. 

The  Bacillus  Pyocyaneus  (Bacillus  of  green  and 
blue  pus). — This  bacillus  is  found  in  green  or  blue 
colored  pus  which  occasionally  accompanies  the 
discharges  from  open  wounds,  and  is  the  cause  of  the 
pigmentation  produced.  It  was  first  obtained  in 
pure  culture  by  Gessard. 

Microscopical  Appearances. — Delicate,  slender  rods, 
about  0.4  u  broad  and  1.5  to  G  /(  long,  often  united  in 
pairs  or  in  chains  of  four  to  six  elements,  and  occa- 
sionally growing  into  long  threads. 

Motility. — Actively  motile,  possessing  only  one 
flagellum. 

Spore  Formation. — Absent. 

Staining  Reactions. — Stains  readily  with  the  ordi- 
nary aniline  colors;  does  not  stain  with  Gram's  method. 

Biological  Characters. — Aerobic  and  facultative 
anaerobic,  but  produces  pigment  only  in  the  presence 
of  oxygen.  Grows  readily  on  all  artificial  culture 
media  at  room  temperature,  but  best  at  37°  C.  On 
gelatin  plates  flat,  irregular  colonies  with  radiating 
borders  are  rapidly  developed,  imparting  to  the 
medium  a  fluorescent  green  color;  liquefaction  begins 
at  the  end  of  two  or  three  days,  and  in  five  days  the 
gelatin  is  completely'  liquefied.  In  gelatin  stab  cul- 
tures liquefaction  takes  place  rapidly  at  first  near  the 
surface  and  gradually  extends  downward;  a  greenish 
color  is  produced  in  that  portion  in  contact  with  the 
air.     On  agar  plates  a  wrinkled,  moist,  whitish  layer 


Vol.  I.— 55 


865 


Bacteria 


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is  developed,  the  surrounding  medium  being  at  first 
bright  green,  later  darker  in  color,  and  finally  blue 
green  or  almost  black.  In  bouillon  a  green  fluores- 
cence is  produced,  the  medium  being  clouded,  and  a 
floceulent  sediment  forms.  Milk  is  coagulated  and 
peptonized.  On  potatoes  a  greenish-yellow  or  brown- 
ish growth  occurs,  the  surrounding  surface  being 
green. 

The  Bacillus  pyocyaneus  produces  two  pigments — 
one  of  a  fluorescent  green  (bacterio-fluorescin,  soluble 
in  water)  and  the  other  of  a  blue  color  (pyocyanin, 
soluble  in  chloroform)  formed  only  in  the  presence  of 
oxygen.  A  faint  aromatic  odor  is  produced  in  recent 
cultures;  in  old  cultures  a  disagreeable  ammoniacal 
odor.  No  indol  or  I-LS  is  formed  by  this  bacillus,  and 
very  little  acid  from  grape  sugar;  no  gas.  Nitrates 
and  nitrites  are  converted  into  free  nitrogen.  The 
bacillus  pyocyaneus  produces  poisons  by  its  growth. 
It  has  but  little  resistance  to  outside  influences. 
Drying  kills  it  rapidly;  exposure  to  the  action  of 
direct  sunlight  for  four  hours  partly  destroys  its 
power  of  producing  pigment. 

Pathogenesis. — Pathogenic  for  rabbits  and  guinea- 
pigs.  Subcutaneous  or  intraperitoneal  injections 
of  1  c.c.  of  a  bouillon  culture  cause  the  death  of  these 
animals  in  from  twenty-four  to  thirty-six  hours, 
with  the  production  of  extensive  inflammatory 
edema  and  purulent  infiltration  of  the  tissues.  The 
bacilli  multiply  in  the  body,  and  may  be  found  in  the 
serous  or  purulent  fluid  as  well  as  in  the  blood  and 
organs.  Smaller  amounts  do  not  kill  the  animals, 
but  render  them  immune  to  doses  fatal  to  those  not 
thus  immunized.  In  rabbits  inoculated  with  a 
culture  of  the  bacillus  anthracis  a  fatal  result  may  be 
prevented  by  soon  after  inoculating  the  animal  with 
a  pure  culture  of  the  Bacillus  pyocyaneus.  It  has 
been  suggested  that  the  protective  action  is  due  to 
the  chemical  products  of  the  growth  of  the  bacillus, 
and  not  to  an  antagonistic  effect  of  the  living  bacteria. 

Though  widely  distributed  in  nature,  the  bacillus 

f>yocyaneus  has  not  so  far  been  found  outside  the 
iving  body.  It  has  been  observed  occasionally  in 
the  mouth  and  intestines  of  healthy  individuals,  on 
the  unbroken  skin  and  in  the  purulent  discharges  of 
open  wounds,  also  in  bandages  and  dressings,  at  times 
epidemically  in  hospitals.  Usually  the  organism 
appears  only  in  association  with  the  common  pus 
cocci,  coloring  the  pus  blue  or  green.  In  some  cases, 
however,  it  has  been  found  alone  in  disease  processes, 
as  in  otitis  media,  ophthalmia,  bronchopneumonia, 
pericarditis,  etc.,  especially  in  children,  so  that  we 
have  reason  to  believe  that  this  bacillus,  although 
ordinarily  non-pathogenic  for  man,  may  under  certain 
conditions  become  a  source  of  infection.  In  general 
its  presence  in  wounds  delays  the  process  of  repair 
and  may  give  rise  to  a  depression  of  the  vital  powers 
from  the  absorption  of  its  toxic  products. 

The  Bacillus  Proteus  Vulgaris. — This  is  the 
most  important  of  a  group  of  similar  bacteria,  known 
as  the  "Proteus  group,"  which  are  among  the  com- 
monest and  most  widely  distributed  putrefactive 
organisms.  They  were  formerly  included  by  the 
earlier  observers  under  the  name  of  "Bacterium 
termo,"  which  they  applied  to  all  minute  motile 
organisms  found  in  putrefying  substances.  It  was 
discovered  by  Hauser  in  1885. 

Microscopical  Appearances. — Small,  slender  rods 
varying  greatly  in  size,  but  on  the  average  about 
0.6  /t  broad  and  1.2  /x  long,  generally  occurring  in 
pairs  but  sometimes  arranged  in  filaments,  which 
may  be  more  or  less  twisted.  It  is  to  its  great  vari- 
ability in  form  that  it  was  given  the  name  of  proteus. 

Motility. — Actively  motile. 

Spore  Formation. — Absent. 

Staining  Reactions. — Stains  readily  with  aniline 
dyes,  especially  fuchsin  or  gentian  violet;  also  stains 
with  Gram's  solution. 


Biological  Characters. — Aerobic  and  facultative 
anaerobic.  Grows  on  almost  all  culture  media 
developing  most  rapidly  at  room  temperature,  but 
also  in  the  ice  box  and  in  the  incubator.  Toxin 
production  seems  to  be  favored  by  admission  of  air. 

The  growth  on  gelatin  plates  containing  five  per 
cent,  of  gelatin  is  very  characteristic.  At  the  end  of 
ten  to  twelve  hours  at  room  temperature,  small,  round 
yellowish  colonies  with  thick  centers  and  irregular 
edges  develop,  from  which  brush-like  offshoots  are 
thrown  out.  Other  colonies  are  surrounded  by  a 
zone  of  threads  which,  partly  in  circular,  partly  in 
irregular  twisted  figures,  surround  the  central  opaque 
mass.  Straight  and  twisted  offshoots,  which  fre- 
quently become  detached  from  the  parent  colony, 
grow  into  the  surrounding  medium  and  continue 
moving  about  in  the  liquefied  gelatin,  sometimes 
called  "swarming  islands."  When  the  consistency 
of  the  medium  is  more  solid,  as  in  ten-per-cent. 
gelatin,  the  liquefaction  and  migration  of  these  sur- 
face colonies  are  more  or  less,  retarded.  In  gelatin 
stab  cultures  the  growth  is  less  characteristic — lique- 
faction takes  place  rapidly  along  the  line  of  puncture, 
and  soon  the  entire  medium  is  liquefied.  Upon 
nutrient  agar  a  rapidly  spreading,  thin,  moist,  grayish- 
white  coating  appears,  and  migration  of  the  colonies 
also  occurs.  Milk  is  coagulated  with  the  production 
of  acid.  On  potato  a  dirty  grayish  coating  develops. 
Bouillon  is  uniformly  clouded. 

Culture  media  containing  albumin  or  gelatin  are 
decomposed  by  the  proteus  vulgaris  with  the  pro- 
duction of  a  disagreeable  putrefactive  odor  and 
alkaline  reaction.  It  produces  gas  and  acid  from 
carbohydrates,  thus  giving  off  no  odor.  It  also- 
produces  indol  and  H,S.  Urea  is  decomposed  into 
carbonate  of  ammonium.  It  forms  toxins,  which  may 
be  obtained  by  filtration  of  the  cultures  through 
porcelain.  The  proteus  vulgaris  possesses  consider- 
able resistance  toward  chemical  and  thermic  influ- 
ences, but  is  killed  at  60°  C.  in  half  a  minute. 

Pathogenesis. — This  bacillus  is  pathogenic  for 
rabbits  and  guinea-pigs  when  injected  intravenously, 
intraperitoneally,  or  subcutaneously  in  large  quan- 
tities, death  of  the  animal  being  produced  with  symp- 
toms of  intoxication.  The  effects  are  much  more 
readily  produced  when  other  organisms,  as  the  strep- 
tococcus, are  introduced  simultaneously  into  the  body. 
Less  virulent  species  of  pathogenic  bacteria  (staphy- 
lococcus, streptococcus)  also  gain  in  virulence  when 
they  are  injected  along  with  living  or  dead  proteus 
cultures. 

The  proteus  vulgaris  is  found  very  commonly  out- 
side the  body  in  putrid  meat  and  other  decaying 
substances,  such  as  foul  water,  etc.  It  is  found  also  in 
the  digestive  tract  of  healthy  persons.  In  disease,  it 
is  the  organism  chiefly  concerned  in  the  production 
of  cystitis  with  ammoniacal  urine,  either  alone  or  in 
conjunction  with  the  Bacillus  coli  communis,  and  is 
so  an  etiological  factor  in  many  other  genito-urinary 
affections.  The  Urobacillus  liauefaciens  septicus  of 
some  authors  is  probably  identical  with  the  proteus 
vulgaris.  Although  this  bacillus,  however,  occurs 
quite  frequently,  along  with  other  bacteria  in  various 
diseases,  it  has  seldom  been  positively  shown  to  be 
the  specific  cause  of  infection.  Booker,  who  has 
made  extended  investigations  into  the  etiology  of 
cholera  infantum,  concludes  that  the  proteus  vulgaris 
plays  an  important  part  in  the  production  of  this 
affection.  He  found  the  bacillus  present  in  eighteen 
cases  of  cholera  infantum  examined  by  him,  but  not 
in  the  feces  of  healthy  infants.  Levy  believes  that 
in  so-called  "meat  or  sausage  poisoning"  bacteria 
of  this  group  are  chiefly  concerned,  and  that  the 
pathogenic  effects  are  due  to  toxic  products  evolved 
during  their  development;  though  others  attribute 
this  affection  to  an  anaerobic  organism,  the  Bacillus 
botulinus   of    Van   Ermengen,    the   symptoms   being 


see, 


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Ba<  i'  i  i.i 


escribed  as  botulism.  According  lo  .Jiigcr,  certain 
irms  of  icterus  accompanied  with  fever,  pain  in  the 
mscles,  and  enlarged  liver  and  spleen,  known  as 
Weil's  disease,"  are  produced  by  the  proteus. 
hus  il  would  seem  that,  though  ordinarily  a  harm- 
'SS  parasite,  the  proteus  vulgaris  may  at  times 
.nine  pathogenic  to  man.  Considering  the  very 
ide  distribution  of  t li i-s  organism  in  nature,  the 
onder  is  that  with  its  poisonous  properties  so  few 
iseases  apparently  are  produced  by  it. 

The    Bacillus   op    Malignant   Edema    (Bacillus 

dematis  maligni). — This  bacillus  is  widely  dis- 
puted, being  found  in  the  superficial  layers  of  the 
oil    especially   in   garden   earth,   manure,   filth   of  all 

inds,  and  house  drains;  also  in  the  blood  and  intes- 
uies  of  animals,  it  was  discovered  by  Pasteur 
1877),  and  later  carefully  studied  by  Liborius  and 
v.n-h. 

Microscopical    Appearances. — Rather    large    rods, 

imilar  morphologically  to  tetanus  and  symptomatic 

nthrax   bacilli,   but  showing  a  greater  tendency  to 

out  into  long  filaments;  in  size  from  0.8  to  1  ft 

iroad  and  2  to  10  ft  long. 

Motility. — Motile,  but  not  very  actively  so  except 
he  short  forms,  having  three  to  twelve  flagella 
1 1  ached  to  the  ends  and  sides  of  the  rods. 

Spore  Formation. — Forms  spores  generally  in  the 
niddle  of  the  rods  and  oval  in  shape. 

Staining  Reactions. — Stains  readily  with  the  ordin- 
iry  aniline  dyes,  especially  when  obtained  from  the 
iniinal  body;  decolorized  by  Gram's  method. 

Biological  Characters. — Strictly  anaerobic,  growing 
n  all  the  usual  culture  media  in  the  absence  of  oxygen. 
Development  takes  place  at  room  temperature,  but 
nore  rapidly  and  abundantly  at  37°  C. 

This  bacillus  grows  on  nutrient  gelatin,  but  more 
ibundantly  on  glucose  gelatin  containing  one  to  two 
>er  cent,  of  glucose.  Gas  is  formed  and  the  gelatin 
s  liquefied. 

On  agar  plates  the  colonies  appear  as  dull,  whitish 
mints,  irregular  in  outline,  and  when  examined  under 
i  low  power  they  are  seen  to  be  composed  of  a  thick 
network  of  threads  radiating  irregularly  _  from  the 
enter  to  the  periphery.  Blood  serum  is  rapidly- 
liquefied,  with  the  production  of  gas.  Bouillon  is 
louded  from  the  formation  of  gas.  Milk  is  not 
coagulated.  Cultures  of  the  bacillus  of  malignant 
edema  give  off  a  peculiar  odor. 

Pathogenesis. — Especially  pathogenic  for  mice, 
guinea-pigs,  and  rabbits,  although  horses,  cats,  dogs, 
goats,  sheep,  calves,  pigs,  chickens,  and  pigeons  are 
also  susceptible,  and  occasionally  man.  Cattle  are 
immune.  A  small  quantity  of  a  pure  culture  sub- 
cutaneously  injected  into  a  susceptible  animal  gives 
rise  to  general  hemorrhagic  edema  which  extends 
over  the  entire  surface  of  the  abdomen  and  thorax 
and  results  in  the  death  of  the  animal.  There  is  no 
odor  developed,  and  little,  if  any,  gas.  In  infection 
with  garden  earth,  owing  to  the  presence  of  associated 
bacteria,  gas  is  produced  having  a  putrefactive  odor. 
Malignant  edema  is  chiefly  confined  to  the  domestic 
animals,  but  cases  have  also  been  reported  in  man. 
Infection  takes  place  most  readily  when,  as  in  the 
natural  disease,  other  bacteria  are  simultaneously' 
introduced,  such  as  B.  proteus  and  B.  prodigiosus. 

Animals  which  recover  from  malignant  edema  are 
subsequently  immune.  Artificial  immunity  may  be 
induced  in  guinea-pigs  by  the  injection  of  filtered 
bouillon  cultures  which  have  been  previously  ster- 
ilized. 

Bacillus  Aerogenes  Capsulatus. — Found  by 
Welch  in  the  blood-vessels  of  a  patient  suffering 
from  aortic  aneurysm;  on  autopsy  made  in  cool 
weather  eight  hours  after  death,  the  vessels  were 
observed  to  be  full  of  gas.  Since  then  it  has  been 
found  in  a  number  of  other  cases.     These  cases,  as  a 


rule,  showed  marked  symptoms  of  delirium,   rapid 

pulse,   high    temperature,   and    the   develop m    of 

emphysema  and  discoloration  of  the  di  eased  area, 
or  of  abdominal  distention  when  the  peritoneal 
cavity  was  involved. 

Microscopical  Appearand  Straight  or  slightly 
curved  rods,  with  rounded  or  somel  quare-cut 

ends,  somewhat  thicker  than  the  anthrax  bacilli  and 
varying  in  length,  occasionally  growing  out  into  long 

threads.      In    the    animal    body,    ami    sometimes    in 
cult  ores,    the    bacilli    are    i  in  lo  ed    in    a    tin 
capsule. 

Motility.  —  Non-1  not  ili'. 

,Sjiori    Formation. — Absent. 

Staining     Reactions.-    Stains    with     the    ordinary 

aniline  dyes  and  by  <  barn's  method. 

Biological  Characters. — Anaerobic,  growing  at  room 
temperature,  but  more  rapidly  at  '.'•'  ('.  in  the  usual 
culture  media  in  the  absence  of  oxygen,  with 
production.  Gelatin  is  not  liquefied,  but  is  gradually 
peptonized.  On  agar  grayish-white  colonies  are 
developed  in  the  form  ol  llattened  spheres,  oval  or 
irregular  masses,  beset  with  hair-like  projections. 
Bouillon  is  diffusely  clouded,  and  a  white  sediment  is 
formed.     .I////,-  is  rapidly  coagulated. 

Pathogenesis. —  Usually  non-pathogenic  in  healthy 
animals,  although  Dunham  found  that  the  bacillus 
taken  freshly  from  human  infection  i-  sometimes 
very  virulent.  When  quantities  up  to  2.5  c.c.  of 
fresh  bouillon  cultures  are  injected  into  the  circula- 
tion of  rabbits  and  the  animals  killed  shortly  after- 
ward, the  bacilli  develop  rapidly  with  abundant 
formation  of  gas  in  the  blood-vessels  and  organs, 
especially  the  liver.  Welch  suggests  that  in  some 
cases  in  which  death  has  been  attributed  to  the 
entrance  of  air  into  the  veins  the  gas  found  at  autopsy 
may  have  been  produced  by  this  or  some  similar 
microorganism  entering  the  circulation  and  develop- 
ing shortly  before  or  after  death.  The  bacillus  had 
been  found  in  the  dust  of  hospital  wards. 

The  Anthrax  Bacillus  (Bacillus  anthracis). — 
This  organism  is  always  present  in  the  blood  of  ani- 
mals affected  with  anthrax  or  splenic  fever,  an  acute 
disease  very  prevalent,  in  certain  parts  of  Europe  and 
Asia,  among  sheep  and  cattle.  In  this  country  it  is 
comparatively  rare.  The  disease  also  occurs  in  man 
as  the  result  of  infection,  either  through  the  skin, 
the  intestines,  or,  in  rare  instances,  through  the 
lungs,  in  the  form  of  external  anthrax  or  malignant 
pustule,  and  internal  anthrax  or  wool-sorter's  disease. 
Those  persons  are  most  subject  to  infection  who 
come  in  contact  with  animals,  hides,  wool,  etc. 

Owing  to  the  fact  that  anthrax  was  the  first  infec- 
tious disease  which  was  shown  to  be  caused  by  a 
specific  microorganism,  the  study  of  this  bacillus 
has  probably  contributed  more  to  our  general  knowl- 
edge of  bacteria  than  any  other  living  organism. 
It  was  first  observed  by  Pollender  in  1S49  in  the 
blood  of  animals  affected  with  anthrax.  In  1S63 
Davaine  showed  by  inoculation  experiments  that  it 
was  capable  of  producing  the  disease.  Then  finally 
in  1879,  Pasteur,  Koch,  and  others  demonstrated 
that  the  bacillus  could  be  isolated  in  pure  cultures 
on  artificial  media,  and  that  when  susceptible  animals 
were  inoculated  with  portions  of  these  cultures  con- 
ditions similar  to  those  found  in  the  animal  from 
which  the  original  cultures  were  obtained  were 
produced. 

Microscopical  Appearances. — In  the  blood  of  ani- 
mals it  occurs  as  large  rods  of  variable  size,  from  1  to 
1.2.5  ft  broad  and  3  to  10  ft  or  more  long,  often  arranged 
in  flexible  filaments  twisted  and  plaited  together. 
In  unstained  specimens  examined  in  the  hanging 
drop  the  ends  of  the  rods  appear  to  be  slightly  rounded, 
while  in  stained  preparations  they  seem  to  be  square 
cut.     Under    a    high    magnification,    especially    in 

867 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


cultures,  the  ends  are  seen  to  be  a  trifle  thicker  than 
the  body  of  the  cell,  and  occasionally  somewhat 
indented  and  concave,  giving  to  the  rods  the  appear- 
ance of  joints  of  bamboo  cane.  At  one  time  much 
stress  was  laid  upon  these  morphological  peculiar- 
ities as  distinguishing  marks  of  the  anthrax  bacillus; 
but  it  has  been  found  that  they  are  the  effects  of 
artificial  cultivation,  staining,  etc.,  and  not  neces- 
sarily characteristic  of  the  organism  under  all  con- 
ditions. The  bacilli,  when  obtained  from  the  blood 
of  affected  animals  and  certain  culture  media  (liquid 
blood  serum),  are  enclosed  in  a  capsule,  which  in 
stained  preparations  may  be  distinguished  by  its 
taking  on  a  lighter  stain  than  the  rods  themselves 
which  it  surrounds.     (See  Plate  X.,  Fig.  1.) 

Motility. — Non-motile. 

Spore  Formation. — Forms  spores  under  aerobic 
conditions  at  temperatures  from  12°  C.  up  to  37°  C. 
The  spores  are  elliptical  in  shape  and  once  or  twice  as 
long  as  broad;  they  first  appear  as  small  refractile 
granules  distributed  at  regular  intervals,  one  in  each 
rod,  and  as  the  spores  develop  the  mother  cells 
become  less  and  less  distinct  until  they  finally  dis- 
appear altogether,  the  complete  oval  spore  being 
set  free  by  its  dissolution.  Spores  are  never  formed 
in  the  living  animal  or  in  unopened  carcasses,  owing 
to  lack  of  oxygen,  but  in  slaughtered  animals,  bloody 
dung,  etc.,  where  the  conditions  necessary  for  their 
production  exist.  This  fact  is  practically  important 
with  regard  to  the  disposal  of  the  carcasses  of  animals 
dead  of  anthrax.  In  fresh  culture  media  the  germina- 
tion of  spores  takes  place  in  a  few  hours.  In  old 
cultures  which  have  been  repeatedly  transplanted  the 
power  of  spore  formation  is  often  spontaneously  lost. 
Certain  varieties  of  anthrax  bacilli  soon  become 
asporogenous.  All  agencies  which  decrease  the 
virulence  of  the  bacilli  (as,  for  instance,  cultivation 
at  42°  C.)  act  unfavorably  upon  the  function  of  spore 
formation.     (See  Plate  X.,  Fig.  2.) 

Staining  Reactions. — Stains  easily  with  the  ordinary 
aniline  colors,  also  by  Gram's  method. 

Vitality. — Anthrax  bacilli  free  from  spores  retain 
their  vitality  in  cultures  for  months,  probably  by 
spore  production;  in  water  they  soon  die;  in  the  soil 
fresh  anthrax  blood  is  rendered  germ  free  by  exposure 
to  sunlight  in  twelve  to  twenty-four  hours.  Accord- 
ing to  Koch,  when  exposed  to  desiccation,  anthrax 
bacilli  retain  their  vitality  only  for  five  weeks;  in 
dried  blood  they  withstand  a  temperature  of  92°  C. 
for  one  and  one-half  hours,  but  in  the  presence  of 
oxygen  they  are  killed  by  exposure  to  light  in  nine 
hours  and  in  a  vacuum  in  eleven  hours.  Pickling 
fails  to  destroy  anthrax  bacilli  in  meat  in  fourteen 
days,  but  kills  them  after  six  weeks.  They  are 
rapidly  destroyed  by  moist  heat  at  60°  C.  Exposed 
to  cold  from  1°  to  24°  C.  the  bacilli  in  agar  cultures 
were  destroyed  for  the  most  part  in  twelve  days,  and 
the  few  surviving  organisms  yielded  colonies  of  dim- 
inished pathogenic  action  and  power  of  liquefying 
gelatin. 

Dried  anthrax  spores  retain  their  vitality  inde- 
finitely; in  a  moist  condition  in  water,  earth,  putrid 
spleen,  etc.,  the  spores  have  lived  for  one  and  one-half 
to  two  and  one-half  years.  They  also  resist  a  com- 
paratively high  temperature.  Exposed  to  dry  heat 
they  require  a  temperature  of  140°  C.  maintained 
for  three  hours  to  kill  them,  but  in  moist  heat  they 
are  destroyed  by  a  temperature  of  100°  C.  in  four 
minutes.  Anthrax  spores  in  a  desiccated  condition 
are  killed  by  the  action  of  direct  sunlight  in  four 
hours,  by  diffuse  daylight  in  several  weeks. 

Biological  Characters. — Aerobic  and  facultative 
anaerobic,  growing  best  in  the  presence  of  oxygen 
but  also  in  its  absence.  Under  the  latter  condition, 
however,  this  bacillus  no  longer  liquefies  gelatin,  and 
the  presence  of  oxygen  is  absolutely  necessary  for  the 
formation   of   spores.     The   anthrax   bacillus   grows 


rapidly  on  a  variety  of  nutrient  media  at  a  temper 
ature  from  14°  to  43°  C,  but  best  at  37°  C. 

Growth  on  Gelatin. — On  gelatin  plates  small,  white 
opaque  colonies  are  developed  on  the  surface  at  the 
end  of.  twenty-four  to  thirty-six  hours  at  24°  C. 
while  the  deeper  colonies  are  of  a  greenish  color! 
Under  a  low  power  the  colonies  exhibit  a  charac- 
teristic appearance,  consisting  of  a  light-gray  tangled 
mass  of  threads  projecting  beyond  the  edges  in 
curly  hair-like  tufts,  which  have  been  likened  to  a 
Medusa's  head.  Liquefaction  of  the  gelatin  takes 
place  in  three  or  four  da3's,  a  white  pellicle  floating 
on  the  surface.  In  gelatin  stab  cultures  at  the  end  of 
twelve  to  twenty-four  hours  a  thick,  white  central 
thread  appears  along  the  line  of  puncture,  from  which 
other  white  threads  and  irregular  projections  radiate 

Eerpendicularly  into  the  medium.  After  two  days 
quefaction  commences  on  the  surface  and  gradually 
extends  downward. 

On  agar  plates  the  growth  is  similar  to  that  on 
gelatin  and  is  equally  characteristic,  but  the  colonics 
are  not  so  compact.  At  the  end  of  twenty-four  hours 
in  the  incubator  a  grayish-white  coating  is  formed 
on  the  surface,  which  spreads  rapidly  and  consists  of 
masses  of  long  threads  matted  together. 

In  bouillon  the  growth  is  characterized  by  the 
formation  of  flucculent  masses  which  sink  as  a  seoi- 
nient  to  the  bottom  of  the  tube,  leaving  the  liquid  clear. 

Pathogenesis. — Especially  pathogenic  for  mice, 
guinea-pigs,  and  rabbits,  somewhat  less  for  cattle  and 
sheep  (except  the  Algerian  sheep,  which  are  immune:, 
and  considerably  less  for  horses;  rats,  cats,  dogs, 
chickens,  pigeons,  and  frogs  are  but  little  susceptible. 
Man,  though  subject  to  local  infection  (malignant 
pustule)  from  accidental  inoculation  of  wounds, 
and  occasionally  to  intestinal  or  pulmonary  infection 
(wool-sorter's  disease)  as  the  result  of  inoculation 
through  dust  charged  with  anthrax  spores  and  the  con- 
sumption of  meat  from  anthrax  animals,  is  not  as 
susceptible  to  this  disease  as  the  lower  animals. 
Subcutaneous  injections  in  susceptible  animals  result 
in  death  in  from  one  to  three  days.  Little  or  no 
change  can  be  observed  at  the  point  of  inoculation, 
but  the  subcutaneous  tissue  for  some  distance  over 
the  abdomen  and  thorax  is  found  to  be  edematous, 
with  small  ecchymoses  scattered  throughout  theeldem- 
atous  portion;  the  underlying  muscles  are  pale  in 
color.  The  intestinal  viscera  show  no  marked  micro- 
scopical lesions,  except  the  spleen,  which  is  enlarged, 
soft,  and  dark  colored.  The  liver  may  present  the 
appearance  of  cloudy  swelling.  The  lungs  are  red  or 
pale  red  in  color,  while  the  heart  is  usually  filled  with 
blood.  The  anthrax  bacillus  produces  in  susceptible 
animals  a  true  septicemia,  and  after  death  the  capil- 
laries throughout  the  body  always  contain  the  bacilli 
in  larger  or  smaller  number.  It  is  difficult  to  produce 
infection  by  the  ingestion  even  of  spores,  but  by 
inhalation  it  may  be  readily  caused  in  animals.  Infec- 
tion is  most  promptly  brought  about  by  introduction 
of  the  bacilli  directly  into  the  circulation,  but  inocula- 
tion by  contact  with  the  abraded  skin  may  also  pro- 
duce infection. 

Many  theories  have  been  advanced  to  account  for 
the  occurrence  of  intestinal  anthrax  in  cattle  and 
sheep,  the  form  of  the  disease  which  is  most  common  in 
these  animals.  It  has  been  thought  that  infection 
was  produced  mainly  by  the  eating  of  food  contami- 
nated by  anthrax  spores  derived  originally  from  the 
bodies  of  affected  animals;  but,  as  we  have  seen,  it  is 
extremely  difficult  to  cause  infection  in  this  way. 
By  some  authors  it  has  been  supposed  to  be  a  mias- 
matic infection  and  likened  to  malaria;  and  occur- 
ring as  it  does  in  the  summer  months  and  in  low 
swampy  places,  there  would  seem  to  be  a  possible 
analogy  in  this  respect  between  the  two  infections. 
But  anthrax  occurs  in  epidemics,  being  present  at  one 
time  in  a  certain  place  and  absent  in  another.    Pas- 


868 


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li. M  terla 


■  ur  is  of  the  opinion  that  the  earth-worms   play  an 
uportant    part    in   conveying   the   spines   from    one 
icality  i"  anotlier  from  the  buried  carcasses   of  af- 
:cted  animals;  but  Koch  has  shown  this  hypothesis 
)  be  untenable,  as  the  bodies  of  earth-worms  offer 
n  unsuitable  medium  for  the  growth  of  spores,  even 
'  they  arc  taken  up  and  carried  in  this  way.     The 
lost  plausible  explanation  so  far  suggested  for  the 
ilution  of  the  problem  is  the  supposition  that  under 
atural  conditions  unfavorable   to   the   development 
f  the  bacilli  an  attenuation  of  their  virulence   takes 
ilace,    and    then    again    as    the    conditions    become 
e   favorable   the   virulence    is  restored — a    result 
hich    ran    be   artificially    produced    in    cultures    by 
bemieal    agents,    heat,   etc.     Nuttall    has    recently 
st   d  that  perhaps  the  disease  may  be  conveyed 
a  the  bodies  of  insects,  under  certain  conditions,  as 
it  li    malarial   infection;    but    here,    too,    the    bacilli 
indergo  attenuation,  according  to  the  same  author. 
nation     of     Virulence     and     Immunity. — The 
,-irulence    of    anthrax    cultures    may    be    artificially 
tttenuated    by    the   action   of   chemical   agents   and 
icat.     Pasteur  has  succeeded  in  effecting  considerable 
mmunity    against    anthrax    in    regions    where    this 
lisease  is  prevalent,  by  the  inoculation  of  cattle  and 
-heep  with  cultures  attenuated  by  heat.     Two  vac- 
lines  are  employed  of  different  degrees  of  strength, 
irepared  from  virulent  cultures  reduced  in  virulence 
by  cultivation  at  temperatures  between  42°  and  43° 
According    to    statistics    collected    by   Chamber- 
land  from  the  results  of  twelve  years'  experience  with 
this  method  of  protective  inoculation  in  France,  out  of 
three  million  sheep  thus  treated  only  one  per  cent. 
have  died  of  anthrax  since  its  introduction,  whereas 
the  mortality  previously  was  over  ten  per  cent.     In 
cattle    the    mortality   percentage    has   been   reduced 
from  five  per  cent,   to  0.3   per   cent.     The  method, 
however,  is  not  unattended  with  danger,  and  some- 
times   the   animals    succumb   to   the  effects  of   the 
inoculation. 

The  Bacillus  of  Symptomatic  Anthrax. — Like 
the  bacilli  of  anthrax,  of  malignant  edema,  and  teta- 
nus, to  all  of  which  it  bears  a  certain  resemblance, 
the  bacillus  of  symptomatic  anthrax  is  an  inhabitant 
of  the  soil.  It  is  the  specific  cause  of  the  disease  in 
animals,  principally  cattle  and  sheep,  known  as 
"black-leg."  "quarter-evil,"  or  symptomatic  anthrax, 
which  prevails  in  certain  localities,  and  is  character- 
ized by  a  peculiar  emphysematous  swelling  of  the 
tissues  of  the  leg  and  quarters,  accompanied  with 
the  formation  of  gas.  On  section  of  the  affected 
parts  the  muscles  and  cellular  tissues  are  found 
saturated  with  bloody  serum,  while  the  tissues  them- 
selves are  dark,  almost  black  in  color.  The  bacillus 
can  always  be  found  in  the  affected  parts,  in  the  bile, 
and  after  death  in  the  internal  organs. 

Microscopical  Appearances.  —  Long  rods,  with 
rounded  ends,  from  0.5  to  0.6  ,u  broad  and  3  to  5  n 
long;  mostly  isolated,  also  occurring  in  pairs,  joined 
end  to  end,  but  never  growing  out  into  long  filaments. 
as  the  anthrax  bacillus  does  in  culture  media  and  the 
bacillus  of  malignant  edema  in  the  animal  body. 

Motility. — Actively  motile,  flagella  being  attached  to 
the  bodies  of  the  cells. 

Spore  Formation. — Forms  spores  elliptical  in  shape, 
usually  thicker  than  the  bacilli,  lying  near  the  mid- 
dle of  the  rods,  but  rather  toward  one  end,  giving 
them  a  spindle  shape. 

fining  Reactions. — Stains  with  the  ordinary 
aniline  dyes,  but  not  with  Grain's  method  or  only 
when  the  staining  is  much  prolonged. 

Biological  Characters. — Strictly  anaerobic,  growing 
only  in  the  absence  of  oxygen,  best  in  an  atmosphere 
of  hydrogen  but  not  in  CO,.  Develops  at  room  tem- 
perature in  the  usual  culture  media,  but  best  in 
media  containing  1.5  to  2  per  cent,  glucose  or  5  per 
cent,  glycerin  and  at  37°  C. 


On  gelatin,    irregular,   slightly   tabulated   colonies 

develop  and  the  gelatin  is  -oon  Liquefied.  On  ";/'"" 
the  colonies  are  similar  to  those  of    malignant    edema 

but  somewhat   more  compact,  after  twenty-four  to 

forty-eight     hours    in    the    incubator.      In    agar    -tali 
ires  growth  occur-    i  ielow  the  sur- 

face, and  is  accompanied  by  the  production  of  gas 
having  a  peculiar,  disagreeable,  rancid  odor. 

Patho  .—Pathogenic  for  cattle  (which  are  im- 

against     malignant     edema),     sheep,     go 
guinea-pig-,  and   mice;  less  so  for  horse:  and   i 

i  .  pigs,  cats,  dogs,  chickens,  and  pigeons  arc, 
as  a  rule,  immune.  Infection  lias  never  been  pro- 
duced in  man. 

When   susceptible  animals   are   inoculated   Bubcu- 

taneously  with  pure  cultures  of  this  organism,  with 

-  or  with  bits  of  diseased   tissue,  death  occurs 

in    from    twenty-four    to    thirty-six    hours.      At 

autopsy  a  bloody  serum  is  found  iii  the  subcutaneous 

tissues  extending  over  the  entire  surface  of  the  abdo- 
men, and  the  muscles  present  a  dark  red  or  black  ap- 
pearance, even  more  intense  in  color  than  in  malignant 
edema,  and  there  is  considerable  development  of  gas. 

The  ordinary  manner  of  natural  infection  in  cattle 
is  by  wounds  which  not  only  tear  the  skin,  but  pene- 
trate the  subcutaneous  tissues.  The  disease  is  also 
produced  by  the  ingestion  of  forage  contaminated 
by  the  bacilli  or  their  spores,  and  by  the  inhalation  of 
dust  containing  the  organisms. 

Immunity. — It  is  well  known  to  veterinarians  that 
natural  recovery  from  one  attack  of  symptomatic 
anthrax  protects  an  animal  from  a  second  attack. 
Artificial  immunity  can  also  be  produced  in  various 
ways:  by  intravenous  inoculation;  or  in  guinea-pigs, 
by  inoculations  with  bouillon  cultures  which  have 
been  kept  for  a  few  days  and  have  lost  some  of  their 
virulence,  or  with  cultures  kept  in  the  incubator  at 
42°  to  43°  C;  or  by  inoculations  made  into  the  end 
of  the  tail;  or  by  injection  of  filtered  cultures  sterilized 
by  heat.  Arloing,  Cornevin,  and  Thomas  recom- 
mend for  the  production  of  immunity  in  cattle  the 
use  of  a  dried  powder  of  the  muscles  of  animals  dead 
of  the  disease,  which  has  been  subjected  to  a  tem- 
perature sufficient  to  attenuate  its  virulence.  Two 
vaccines  are  prepared,  as  in  anthrax  one  by  exposure  of 
the  powder  to  85°-90°  C.  (the  stronger  vaccine1,  and 
the  other  to  a  temperature  of  100°-104°  C;  the  weaker 
vaccine  is  first  used,  and  then  the  stronger.  The 
inoculation  is  made  into  the  cellular  tissue  of  the  ear 
or  on  the  end  of  the  tail;  fourteen  days  are  allowed  to 
elapse  between  the  two  inoculations.  Kitt  recom- 
mends a  single  vaccine  from  infected  flesh  heated  for 
six  hours  at  100°  C.  and  given  in  decigram  doses. 
The  results  obtained  from  these  methods  of  prevent- 
ive inoculation  against  symtomatic  anthrax  would 
seem  to  have  been  fairly  satisfactory. 

The  Spirillum  of  Asiatic  Cholera  (Koch's 
comma  bacillus). — In  1SS3  Koch  isolated  from  the 
dejecta  and  intestines  of  patients  suffering  from 
Asiatic  cholera  a  characteristically  curved  organism 
— the  so-called  "comma  bacillus" — and  showed  that 
these  bacteria  were  exclusively  found  in  cases  of  the 
genuine  disease.  Other  observers  have  since  de- 
scribed morphologically  similar  organisms  of  non- 
choleraic  origin.  Finkler  and  Prior,  for  instance, 
observed  such  organisms  in  the  diarrheal  stools  of 
patients  with  cholera  nostras;  Deneke  found  others 
in  old  cheese.  .Miller  met  with  others  again  in  cari- 
ous teeth,  and  Metehnikoff  observed  others  in  fowls. 
But  all  of  these  organisms  differ  in  many  respects 
from  Koch's  comma  bacillus,  and  none  of  them  is 
affected  by  the  specific  serum  of  animals  immunized 
to  Asiatic  cholera.  Though  varying  somewhat  in 
different  epidemics,  this  spirillum  is  now  generally 
recognized  by  bacteriologists  to  be  the  chief  etio- 
logical factor  in  the  production  of  true  Asiatic 
cholera. 


Mi'.! 


Bacteria 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Microscopical  Appearances. — Curved  rods,  with 
rounded  ends  which  do  not  lie  in  the  same  plane, 
from  O.S  to  2  /i  in  length  and  about  0.4  u  in  breadth. 
The  curvature  of  the  rod  may  be  very  slight,  like 
a  comma,  but  sometimes  it  forms  a  half-circle,  or 
two  contact  rods  curved  in  opposite  directions  may 
form  an  S-shaped  figure,  and  under  unfavorable  con- 
ditions of  growth,  as  in  old  cultures  and  on  the  addi- 
tion of  chemical  antiseptics,  etc.,  they  may  develop 
into  long  spiral  filaments  consisting  of  numerous 
turns  of  a  spiral  in  which  it  is  impossible  to  recognize 
any  connection  between  the  individual  elements  of 
which  they  are  composed.  These  latter,  the  true 
spirilla,  are  considered  to  be  involution  forms.  Under 
favorable  conditions  of  growth  and  in  fresh  cultures, 
the  slightly  curved  or  almost  straight  forms  are  com- 
monly observed.      (See  Plate  X.,  Fig.  5.) 

Motility. — Actively  motile,  the  movements  being 
undulatory  and  due  to  one  or  two  flagella  attached 
to  the  ends  of  the  rods. 

Spore  Formation. — Absent;  the  arthrospores  de- 
scribed by  Hueppe  have  not  been  confirmed  by  other 
observers. 

Staining  Reactions. — Stains  with  the  ordinary  anil- 
ine colors,  but  not  as  readily  as  many  other  bacteria; 
an  aqueous  solution  of  carbol  fuchsin  gives  the  best 
results  with  the  application  of  heat.  It  is  decolor- 
ized by  Gram's  method. 

Biological  Characters. — Aerobic  and  facultative  ana- 
erobic, growing  on  all  the  usual  culture  media  at 
room  temperature,  but  best  in  the  presence  of  oxygen 
at  37°  C.  There  is  no  development  below  8°  C.  or 
above  42°  C.  The  culture  media  must  be  distinctly 
alkaline,  as  the  spirillum  is  very  sensitive  to  acid. 

On  gelatin  plate  cultures  at  22°  O,  at  the  end  of 
twenty-four  hours,  small,  round,  yellowish-white  to 
yellow  colonies  may  be  seen  in  the  depths  of  the  me- 
dium, which  later  grow  toward  the  surface  and  cause 
liquefaction  of  the  gelatin,  the  colonies  sinking  to 
the  bottom  of  the  pockets  thus  formed.  Examined 
under  a  low  power  they  appear  granular  in  structure 
with  more  or  less  irregular  outlines,  the  surface 
looking  as  if  covered  with  little  fragments  of  glass. 
An  ill-defined  halo  is  first  seen  to  surround  the  colo- 
nies, which  has  a  peculiar  reddish  tint  by  transmitted 
light.  In  gelatin  stab  cultures  at  the  end  of  twenty- 
four  to  thirty-six  hours  a  small  funnel-shaped  depres- 
sion appears  on  the  surface  of  the  medium,  which 
soon  spreads  out  in  the  form  of  an  air  bubble  above, 
while  below  this  a  whitish,  viscid  mass  is  seen.  The 
funnel  .now  increases  in  depth  and  diameter,  and  in 
from  four  to  six  days  may  reach  the  edge  of  the  tube; 
in  from  eight  to  fourteen  days  the  upper  two-thirds 
of  the  gelatin  is  liquefied;  and  in  a  few  weeks  com- 
plete liquefaction  takes  place. 

Upon  agar  plates  the  growth  is  not  so  character- 
istic, a  moist,  shining,  grayish-yellow  coating  develop- 
ing on  the  surface  in  the  incubator. 

Blood  serum  is  rapidly  liquefied  at  brood  tempera- 
ture. 

In  bouillon  the  growth  is  rapid  and  abundant,  the 
liquid  being  diffusely  clouded,  and  on  the  surface  a 
wrinkled  membranous  film  is  often  formed. 

On  potato  having  an  acid  reaction  no  growth,  as  a 
rule,  takes  place;  but  if  the  potato  be  rendered  alka- 
line with  a  solution  of  soda  or  cooked  in  a  three-per- 
cent, solution  of  common  salt,  development  takes 
place  in  the  incubator  as  a  thin,  semi-transparent 
brown  or  grayish-brown  layer. 

Milk  is  a  favorable  culture  medium,  but  is  not 
changed,  as  a  rule,  though  it  is  coagulated  by  some 
varieties  of  cholera  spirilla. 

Vitality. — The  comma  bacillus  does  not  usually  ex- 
hibit much  resistance  to  outside  influences.  In  pa- 
tients suffering  from  the  disease  the  organisms  have, 
as  a  rule,  disappeared  from  the  contents  of  the  intes- 
tines in  from  four  to  eight,  or  more  rarely  in  from  ten  to 

870 


fifteen  days;  though  in  a  few  cases  living  spirilla  have 
been  found  after  forty-seven  days.  They  have  been 
observed  in  cholera  dejections  for  from  one  to  three 
and  occasionally  from  twenty  to  thirty  days;  in  one 
recorded  case  after  one  hundred  and  twenty  days. 
Even  in  cultures  the  spirilla  of  Asiatic  cholera  are 
rather  short-lived.  They  have  been  found,  however, 
to  retain  their  vitality  in  pure  bouillon  cultures  for 
three  or  four  months  and  in  agar  cultures  for  six 
months  or  more,  when  protected  from  drying.  IQ 
unsterilized  water  they  may  live  for  a  considerable 
time  apparently,  though  the  observations  on  this 
vary  from  one  day  to  one  year.  In  sterile  water 
they  develop  to  some  extent  and  retain  their  vitality 
for  several  weeks.  Low  temperatures,  absence  of 
light,  and  presence  of  salt  in  the  medium  would 
seem  to  favor  their  preservation.  In  well  or  river 
water  they  usually  die  in  from  three  to  eight  day-. 
In  food  they  retain  their  virulence  for  a  period 
varying  from  a  few  hours  to  a  few  days. 

The  comma  bacilli  are  rapidly  destroyed  by 
desiccation.  Exposed  in  cultures  on  a  cover  glass  to 
the  action  of  the  air  at  room  temperature  they  are 
killed  in  two  or  three  hours  unless  spread  in  a  very 
thick  layer.  This  fact  indicates  that  infection  is 
probably  not  usually  produced  through  dust  or  other 
dried  objects  contaminated  with  cholera  bacilli. 
They  are  destroyed  by  moist  heat  at  60°  C.  in  ten 
minutes.  They  resist  cold  fairly  well,  withstanding 
repeated  freezing  without  being  killed,  though  their 
growth  is  inhibited.  They  have  but  little  resistance 
to  the  action  of  chemicals,  especially  mineral  acids, 
which  have  thus  been  employed  for  the  disinfection 
of  waterworks  to  which  these  germs  have  gained 
access.  For  disinfection  on  a  small  scale  0.1  per  cent, 
solution  of  bichloride  of  mercury  or  two  to  three  per 
cent,  solution  of  carbolic  acid  may  be  used.  Milk  of 
lime  is  a  good  general  disinfectant  on  a  large  scale. 
The  wash  and  linen  of  cholera  patients,  floors  of 
dwellings,  etc.,  may  be  disinfected  by  a  five  per  cent, 
solution  of  carbolic  acid  and  soap  water. 

Chemical  Effects. — The  spirilla  of  cholera  produce 
pigment  in  small  amount  only  on  potato.  The 
peculiar  disagreeable  odor  given  off  from  cholera 
cultures  in  bouillon  has  been  thought  by  some  to  be 
of  diagnostic  value,  but  it  is  not  specific.  Milk 
sugar  is  decomposed  with  the  production  of  lactic 
acid  without  gas.  In  lactose-litmus  agar  the  cholera 
spirillum  forms  on  the  surface  of  the  medium  a  blue 
film,  below  this  a  red  coloration,  while  lower  down  the 
medium  is  decolorized. 

When  a  small  quantity  of  chemically  pure  sulphuric 
acid  is  added  to  a  twenty-four-hour-old  bouillon  cul- 
ture of  the  cholera  spirillum  containing  peptone,  a  red- 
dish-violet color  is  produced — known  as  the  "  nitroso- 
indol  reaction" — which  is  due  to  the  production  of 
indol  and  the  reduction  of  nitrates  in  the  culture  to 
nitrites.  Brieger  separated  the  pigment  thus  formed, 
called  "  cholera  red."  For  a  long  time  it  was  believed 
that  the  nitroso-indol  reaction  was  peculiar  to  the 
cholera  spirillum,  and  great  weight  was  placed  upon 
its  production  as  a  diagnostic  test.  But  it  has  been 
shown  that  it  is  by  no  means  specific,  many 
other  bacterial  species  giving  the  same  reaction 
under  similar  conditions.  The  reaction,  never- 
theless, is  a  constant  and  characteristic  property  of 
this  bacillus,  and  is  of  undoubted  value  in  differen- 
tiating this  from  other  similar  organisms  which  do 
not  give  the  reaction.  For  the  test  it  is  best  to 
employ  a  culture  not  of  bouillon,  but  a  distinctly 
alkaline  solution  of  peptone  (1  per  cent,  peptone  + 
0.5  per  cent,  sodium  chloride — Dunham's  solution), 
from    which    more    constant    results    are    obtained. 

Several  toxins  have  been  obtained  from  cholera 
cultures,  but  all  of  them  much  less  poisonous  than 
the  original  cultures.  According  to  Pfeiffer  these 
toxins  are  to  be  considered  as  secondary  products 


i;i  I  i;i:i:\i  i:    nwiHionK   <>r   Tin:    MKDIC'AL  SCIENCES 


Bacteria 


modified  by  the  action  of  the  chemical  reagents  em- 
ployed in  separating  them.  Very  much  more  power- 
ful toxic  products  have  ln.ii  obtained  from  tin-  bodies 
of  the  bacilli  cultivated  on  agar  and  carefully  killt  d 

by  chloroform  or  heat.  Three  times  the  minimal 
fatal  dose  thus  obtained  from  an  agar  culture  (about 

0.5  ingiii.)  kills  a  guinea-pig  in  from  sixteen  to  eight- 
een   hours,    when  injected  into  the  peritoneal  cavity. 

tin-  effect  being  exactly  t lie  same  as  that  produced 
by  the  living  organisms,  viz.,  rapidly  beginning 
symptoms  of  the  algid  stage,  muscular  weakness, 
collapse,  and  death. 

Pathogt  in  six. — None  of  the  lower  animals  being 
naturally  subject  to  Asiatic  cholera,  there  is  little 
reason  to  expect  that  inoculations  of  pure  cultures  of 
the  spirillum  should  give  rise  to  typical  cholera 
infection.  It  has  been  shown,  moreover,  that  the 
comma  bacillus  is  extremely  sensitive  to  the  action 
of  acids,  being  quickly  destroyed  in  the  stomach  by 
the  acids  of  the  gastric  juice.  Nevertheless,  numer- 
ous attempts  have  been  made  to  produce  cholera 
in  test  animals  by  inoculation  of  pure  cultures  of 
the  organism,  usually  with  negative  or  unsatisfac- 
tory results.  Koch,  however,  succeeded  in  producing 
an  approximation,  at  least,  to  the  symptoms  of 
cholera  in  man  by  the  infection  of  guinea-pigs  by  the 
following  method:  First,  o  c.c.  of  a  five  per  cent. 
solution  of  sodium  carbonate  is  injected  into  the 
stomach  by  means  of  a  pharyngeal  catheter,  in  order 
to  neutralize  the  gastric  contents;  and  then,  after  a 
while,  10  c.c.  of  a  liquid  containing  one  or  two  drops 
of  a  bouillon  culture  of  the  bacillus  is  administered 
in  a  similar  manner,  and  at  the  same  time  the  animal 
receives  int raperitoneally  1  c.c.  of  laudanum  per 
200  gm.  weight,  to  control  the  peristaltic  movements. 
As  the  result  of  this  treatment  the  animals  are  nar- 
cotized for  about  half  an  hour,  but  recover  without 
showing  any  ill  effects  from  the  opium. _  In  about 
twenty-four  hours  the  temperature  begins  to  fall, 
weakness  and  paralysis  set  in,  and,  as  a  rule,  death 
occurs  within  forty-eight  hours.  On  autopsy  the 
intestines  are  found  to  be  congested  and  filled  with 
watery  fluid  containing  large  numbers  of  spirilla. 
Unfortunately,  however,  other  morphologically  simi- 
lar spirilla  (the  spirilla  of  Finkler-Prior,  Deneke,  and 
Miller)  act  very  much  in  the  same  way,  though 
somewhat  less  powerfully.  Intraperitoneal  injec- 
tions of  large  quantities  of  cholera  cultures  also  often 
produce  death  in  rabbits  and  mice  with  similar 
symptoms. 

With  regard  to  the  pathogenic  properties  of  the 
cholera  spirillum  for  man,  there  are  quite  a  number 
of  cases  on  record  of  accidental  infection  by  pure 
cultures,  which  furnish  the  most  satisfactory  evidence 
of  its  being  capable  of  producing  the  disease.  In  1884 
a  student  in  Koch's  laboratory  in  Berlin  became  ill 
with  a  severe  attack  of  true  Asiatic  cholera  while 
working  with  cholera  cultures  at  a  time  when  there 
was  no  cholera  in  Germany.  In  1S92  Pettenkofer 
and  Emmerich  experimented  on  themselves  by 
swallowing  small  quantities  of  fresh  cholera  cultures, 
with  the  result  that  both  of  them  were  taken, sick 
with  typical  cholera,  one  with  mild  and  the  other 
with  severe  symptoms.  Since  then  other  similar 
experiments  have  been  reported,  most  of  the  persons 
taking  the  cultures  having  neutralized  the  acidity 
of  the  stomach  previously  by  means  of  soda  solution; 
and  several  fatal  cases  have  occurred  from  accidental 
infection.  At  the  same  time,  however,  some  negative 
results  from  experiments  on  the  human  subject  have 
also  been  recorded — which  only  goes  to  show  that  in 
cholera,  like  other  infectious  diseases,  an  individual 
susceptibility  is  required,  in  addition  to  the  presence 
of  the  germs,  to  produce  infection. 

According  to  Pfeiffer,  cholera  in  man  is  an  infective 
process  due  to  the  destruction  of  the  epithelial  layers 
of  the  intestines  by  the  spirilla  and  the  products  of 


their  growth,  whereby  intoxication  results  from 
absorption  of  the  poisonous  i  '  '  .  The  larger 
the  surface  of  the  mucous  membrane  affected,  tie- 
more  abundant    will   be  the  development    of  bacilli 

and    the    production    Of    toxins,    and    the    more    pro- 

ed,  iu  consequence,  will  be  the  intoxication. 
The  cholera  spirilla  have  been  frequently  found  in 
water  (wells,  water  pipes,  rivers,  harbors,  etc.)  which 
has  become  contaminated  with  the  evacuations  of 
cholera  patients.  Hut  to  prove  their  presence  beyond 
question  in  water  is  by  do  means  easy,  as  there  are  o 
many  other  water  bacti  ria  imulating  cholera  bacilli 
from  which  they  mii-i  be  differentiated;  hence  - e  of 

the    reported    findings    may    not     have    been  genuine 

cholera  spirilla.    The  comma  bacillus  has  been  quite 

often  observed  in  the  feces  of  healthy  per-.. us  without 

producing,    apparently,    any    pathogenic    symptoms 

whatever.  Abel  and  Claussen  thus  found  cholera 
spirilla  present  in  the  stools,  for  days  at  a  time,  of 
fourteen  out  of  seventeen  healthy  persons  in  the 
families  of  seven  cholera  patients.  Jn  Hamburg, 
during  the  last  epidemic  of  cholera  in  Germany, 
twenty-eight  such  cases  were  observed  in  which  the 
stools  were  absolutely  normal. 

The  cholera  spirillum,  however,  has  been  found  in 
no  other  disease  than  true  Asiatic  cholera,  occurring 
in  this  affection  chiefly  in  the  contents  of  the  intestinal 
canal  and  especially  in  the  mucous  flakes  of  so-called 
"  nee-water"  stools,  existing  in  pure  culture  fre- 
quently, and  usually  present  in  greatest,  numbers  at  the 
height  of  the  attack.  The  spirilla  are  not,  as  a  rule, 
found  in  the  interior  organs  in  recent  cholera  ca 
except  perhaps  occasionally  in  the  intestinal  glands. 
In  rare  instances,  nevertheless,  both  in  cholera 
patients  and  in  inoculated  animals,  they  have  been 
met  with  in  the  organs — lungs,  liver,  kidneys,  spleen 
and  occasionally  the  heart's  blood.  The  more 
virulent  the  organism  is,  the  more  apt,  apparently, 
is  it  to  gain  access  to  the  interior  organs. 

Immunity. — Recovery  from  an  attack  of  cholera 
produces  a  certain  degree  of  immunity  to  the  disease. 
Lazarus  in  1S92  observed  that  the  blood  serum  of 
persons  who  had  recently  had  cholera  possessed  the 
power  of  protecting  guinea-pigs  from  infection  by  the 
cholera  spirillum;  while  the  serum  of  healthy  persons 
or  those  affected  with  other  diseases  had  no  such 
effect.  He  attributed  this  to  the  presence,  in  the 
serum  of  convalescents  from  cholera,  of  antitoxic 
substances  which  neutralized  the  action  of  the  toxins 
produced  by  the  growth  of  the  spirilla,  in  the  same 
manner  as  the  antitoxins  of  diphtheria  and  tetanus 
neutralize  their  respective  toxins.  Pfeiffer,  on  the 
other  hand,  maintained  that  this  serum  contained 
bactericidal  substances  which  killed  the  spirilla  so 
rapidly  when  injected  into  the  animal  that  they  were 
not  able  to  produce  their  specific  poisons,  and  that 
thus  the  animal  was  protected.  It  is  now  generally 
admitted  that  the  serum  is  strongly  bactericidal  and 
feebly  antitoxic. 

These  specific  substances  present  in  the  blood  of 
cholera-immune  men  and  animals  act  only  upon 
organisms  similar  to  those  with  which  they  were 
originally  infected — producing  immobilization  and 
agglutination  of  the  bacilli.  Pfeiffer,  who  first 
observed  this  peculiar  reaction  in  cholera  serum,  has 
shown,  however,  that  the  specific  relation  existing 
between  the  antibacterial  and  protective  substances 
produced  during  immunization  and  the  bacteria 
employed  to  immunize  the  animals  is  not  confined 
alone  to  cholera.  This  discovery  has  given  us  an 
apparently  reliable  means  of  distinguishing  the 
cholera  and  typhoid  bacilli  especially  from  all  other 
similar  organisms,  and  the  diseases  which  they 
produce  from  other  infections  which  may  be  mistaken 
for  them,  which  has  proved  to  be  of  great  practical 
value  as  an  aid  to  clinical  diagnosis. 

There  are  two  methods,  known  as  Pfeiffer 's  and 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Gruber's  reactions,  whereby  genuine  cholera  spirilla 
may  be  differentiated  from  other  similar  vibrios: 

1.  Pfeiffer's  reaction  is  produced  as  follows:  The 
blood  serum  of  an  animal  rendered  immune  to  cholera, 
by  inoculation  of  attenuated  or  dead  cholera  cultures, 
is  mixed  with  ordinary  bouillon  in  the  proportion  of 
1  to  100,  and  in  1  c.c.  of  this  mixture  a  platinum 
loopful  (about  2  mgm.)  of  the  species  under  investiga- 
tion is  added,  and  this  then  injected  into  the  periton- 
eal cavity  of  a  guinea-pig  weighing  about  200  gin. 
Every  five  minutes  some  of  the  peritoneal  effusion  is 
removed  by  means  of  a  capillary  pipette  and  examined 
microscopically  both  stained  and  unstained.  If  it  is 
the  true  comma  bacillus,  the  bacilli  will  be  observed 
to  become  at  first  non-motile,  then  agglutinated  into 
clumps,  and  finally  (in  about  twenty  minutes)  to 
become  disintegrated  and  loosened.  When  the  above 
phenomena  are  absent,  the  organism  belongs  to 
another  species.  A  control  experiment  should  be 
made  with  a  known  cholera  culture  to  avoid  possible 
error. 

2.  Gruber's  reaction  is  founded  upon  this,  but  he 
deserves  the  credit  of  having  determined  the  amount 
of  dilution  required  to  agglutinate  and  immobilize  the 
cholera  spirilla  when  mixed  with  cholera-immune 
serum  for  microscopical  examination  in  the  hanging 
drop,  without  injection  into  guinea-pigs,  thus  simpli- 
fying the  method  for  practical  use.  For  this  purpose 
the  blood  serum  of  a  person  suffering  from  a  case  of 
suspected  cholera,  or  of  an  animal  immunized  against 
the  species  to  be  investigated,  is  mixed  with  a  pure 
cholera  culture  in  the  proportion  of  1  to  50  and 
upward,  and  the  mixture  at  once  examined  in  the 
hanging  drop.  If  the  spirilla  become  immobilized 
and  agglutinated  into  clumps  within  twenty  or 
thirty  minutes,  then  they  are  genuine  cholera  spirilla; 
if  not,  the  result  is  negative. 

Immunity. — Within  the  last  few  years  Haffkine  in 
India  has  succeeded  in  producing  an  artificial  im- 
munity against  cholera  infection  in  man  by  means  of 
subcutaneous  injections  of  dead  cultures  of  the  cholera 
spirillum;  and  Nolle  has  found  that  the  blood  serum  of 
persons  thus  inoculated  gave  a  reaction  similar  to  that 
of  persons  who  had  recovered  from  cholera,  showing 
bactericidal  and  agglutinative  substances  from  the 
fifth  day,  but  most  distinctly  on  the  twentieth  day 
and  for  months  after  the  protective  inoculation. 
In  over  200,000  persons  inoculated  with  Haffkines'  vac- 
cine the  results  obtained  would  seem  to  show  a  distinct 
protective  influence  in  the  preventive  inoculations. 

Spirilla  Resembling  the  Spirillum  Cholera 
Asiatic.e. — When  Koch's  comma  bacillus  was  first 
discovered  its  properties  seemed  so  characteristic 
that  it  was  considered  an  easy  matter  to  distinguish 
it  from  all  other  bacteria.  Since  then,  however, 
more  and  more  similar  organisms  have  been  met  with 
by  various  investigators,  until  now  they  have  ceased 
to  be  designated  even  by  special  names.  The 
following  are  among  the  best-known  species: 

1.  Spirillum  or  Finkler  and  Prior  (Vibrio  pro- 
teus). — This  organism  was  obtained  by  Finkler  and 
Prior  from  the  dejections  of  patients  with  cholera 
nostras  which  had  been  allowed  to  stand  for  some 
days.  It  has  since  been  found  to  bear  no  etiological 
relation  to  the  disease,  and  is  of  interest  only  on 
account  of  its  resemblance  in  some  respects  to  the 
cholera  spirillum. 

It  occurs  as  more  or  less  curved  rods,  usually  some- 
what longer  and  thicker  than  the  cholera  spirilla  and 
not  so  uniform  in  diameter.  Involution  forms  are 
common  in  unfavorable  culture  media.  It  is  actively 
motile,  a  single  flagellum  being  attached  to  one  cud 
of  the  rods.  It  does  not  form  spores.  (See  Plate  N., 
Fig.  6.) 

It  grows  equally  well,  in  the  presence  and  absence 


of  oxygen,  on  the  usual  culture  media  at  room 
temperature.  On  gelatin  plates  small,  white,  punc- 
tiform  colonies  are  developed  at  the  end  of  twenty- 
four  hours,  which  under  a  low  power  are  seen  to  be 
finely  granular  and  yellowish  in  color;  liquefaction 
of  the  gelatin  around  the  colonies  progresses  rapidly 
and  is  usually  complete  in  forty-eight  hours.  Isolated 
colonies  on  the  second  day  form  cup-shaped  depres- 
sions. In  stab  cultures  on  gelatin  liquefaction  proceeds 
much  more  rapidly  than  with  the  cholera  spirillum, 
a  stocking-shaped  pouch  appearing  in  two  days, 
while  the  entire  gelatin  is  liquefied  in  about  a  week; 
a  whitish  film  forms  on  the  surface.  Upon  agar  a 
moist,  shining  layer  covering  the  entire  surface  is 
quickly  developed.  Blood  serum  is  rapidly  liquefied. 
On  potato  at  room  temperature  a  shining,  grayish- 
yellow  layer  is  formed,  soon  spreading  over  the 
surface.  The  cholera  spirillum,  on  the  other  hand, 
produces  no  growth  on  potato  at  room  temperature. 

The  cultures  of  the  Finkler-Prior  spirillum  give  off 
a  strong  putrefactive  odor;  in  media  containing  sugar 
they  produce  acid;  they  do  not  form  indol,  and  they 
have  a  greater  resistance  to  desiccation  than  the 
cholera  spirilla.  The  absence  of  the  agglutinative 
reaction  with  a  dilution  of  the  serum  of  an  animal 
immunized  to  cholera  is  a  valuable  differential  sign. 

This  organism  is  pathogenic  for  guinea-pigs  when 
introduced  into  the  stomach  after  previous  injection  of 
soda  solution  and  tincture  of  opium,  similar  symptoms 
being  produced,  only  somewhat  less  marked,  as  with 
the  cholera  spirillum.  Although  originally  observed 
in  the  dejections  of  persons  affected  with  cholera 
nostras,  it  probably  has  no  relation  to  this  disease, 
having  been  seldom  found  since  under  such  conditions 
by  subsequent  observers. 

2.  Miller's  Spirillum. — In  1SS4  Miller  observed 
a  curved  bacillus  in  dental  caries  which,  from  its 
microscopical  appearances  in  cultures  and  from 
animal  experiments,  has  been  thought  to  be  identical 
with  the  Finkler-Prior  spirillum.  The  Vibrio  helio- 
genes  of  Fischer  and  the  Vibrio  lisbonensis  o/Pestana, 
and  other  similar  spirilla  met  with  from  time  to  time, 
are  also  probably  identical. 

3.  Deneke's  Cheese  Spirillum  (Vibrio  tyro- 
genes). — This  organism  was  obtained  by  Deneke  from 
old  cheese,  but  has  since  been  rarely  observed. 
Morphologically  and  culturally  it  shows  greater 
resemblance  to  Koch's  comma  bacillus  than  does  the 
Finkler  and  Prior  spirillum.  It  occurs  in  curved  rods 
and  long  spiral  filaments,  the  diameter  of  the  segments 
being  uniform  throughout.  On  the  other  hand,  it  is 
somewhat  more  slender  than  the  comma  bacillus  and 
the  spiral  turns  are  closer  together.  In  its  power  of 
liquefying  gelatin  it  stands  between  the  cholera 
spirillum  and  the  vibrio  proteus,  and  its  other  char- 
acters are  also  so  intermediary  between  these  two 
species  that  they  are  scarce  worth  describing.  It  is 
said  to  form  a  thin,  yellowish  coating  upon  the  surface 
of  gelatin  and  agar  stab  cultures,  and  not  to  give  the 
indol  reaction;  but  these  characteristics  are  not 
constant.  The  chief  means  of  differentiating  it  from 
the  cholera  spirillum  is  by  the  serum  reaction. 

4.  Spirillum  Metchnikovi. — This  spirillum  was 
discovered  by  Gamaleia  in  1SSS  in  the  intestinal 
contents  of  fowls  dying  of  an  infectious  disease  com- 
mon to  certain  parts  of  Southern  Russia,  and  pre- 
senting symptoms  like  those  of  fowl  cholera.  It  has 
since  been  found  by  Pfeiffer  in  the  waters  of  the  Spree 
and  by  Kutcher  in  those  of  the  Lahn.  In  the  affected 
animals  it  is  almost  always  found  in  the  intestines, 
but  also  in  the  blood,  producing  septicemia.  This 
interesting  microorganism  cannot  be  morphologically 
distinguished  from  the  cholera  spirillum;  it  occurs  as 
curved   rods  somewhat   thicker,   shorter,   and   often 


EXPLANATION  OF 
PLATE  X. 


EXPLANATION  OF  PLATE  X. 

Fig.  1. — Bacillus  Anthracis  from  Cellular  Tissue  of  Inoculated  Mouse.  Stained  with  gentian 
violet.      X  1,000.     Photomicrograph  from  Sternberg's  "Bacteriology"  by  permission. 

Fig.  2. — Anthrax  Spores  from  a  Bouilion  Culture.  Double-stained  preparation — with 
carbol-fuchsin  and  methylene  blue.  X  1,000.  Photomicrograph  from  Sternberg's 
"  Bacteriology"  by  permission. 

Fig.  3. — Bacillus  of  Tetanus  from  an  Agar  Culture.  X  1,000.  Photomicrograph  from 
Sternberg's  "  Bacteriology"  by  permission. 

Fig.  4. —  Bacillus  of  Glanders.  X  1,000.  Photomicrograph  from  Sternberg's  "Bacteri- 
ology" by  permission. 

Fig.  5. — Spirillum  of  Asiatic  Cholera  (Comma  Bacillus).  From  a  culture  upon  starched 
linen  at  end  of  twenty-four  hours,  stained  with  fuchsin.  X  1,000.  Photomicrograph 
from  Sternberg's  "Bacteriology"  by  permission. 

Fig.  6. — Spirillum  of  Finkler  and  Prior  with  Flagella.  Agar  culture.  X  1,000.  Photo- 
micrograph from  Bowhill's  "Bacteriology"  by  permission. 

Fig.  7. — Bacillus  of  Bubonic  Plague  from  Agar  Culture,  showing  Irregular  Forms.  X  1,000. 
Photomicrograph. 

Fig.  8. — Bacillus  of  Bubonic  Plague  from  Bouillon  Culture,  Showing  Rods  in  Chains  with 
Polar  Staining.      X  1,000.     Photomicrograph. 


Reference    Handbook 

OF    THE 

Medical    Sciences 


Plate  X 


J    ,-  ■-■ 


Bacillus  Anthracis 


VI. 
Spirillum   Finklcr  Prioi 


<-: . 


*x- 


Anthrax   Bacillu 
with   Spores 


V 

,* 


4, 


Cholera  Spirillum 


III. 
Tetania   Bacillus. 


VIII. 

Plague   Bacillus. 
(Broth   Culture) 


Pathogenic   Bacteria. 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Bacteria 


,,, iv  decidedly  bent  than  the  comma  bacillus.  It 
queues  gelatin,  as  a  rule,  much  more  rapidly  than 
he  cholera  bacillus  does,  but  this  varies.  It  gives 
lie  nitroso-indol  reaction  without  the  addition  of 
litrites,  and  coagulates  milk  with  acid  reaction.  It 
[oes  not  give  the  serum  reaction  with  cholera- 
mmune  serum. 

The  Spirillum  mclchnikori  is  characterized  by  its 
>athogenic  action  for  chickens  and  pigeons;  a  minute 
[uantity  of  a  culture  injected  into  the  breasl  muscles  of 
hese  animals  causes  their  death  with  the  local  and  gen- 
;ral  symptoms  of  fowl  cholera,  except  thai  I  he  contents 
)f  the  intestines  have  more  the  appearance  of  cholera 
md  the  spleen  is  rather  diminished  than  enlarged. 
la  the  blood  and  edematous  fluid  about  the  necrotic 
loint  of  inoculation,  the  organisms  are  present  in  large 
iiumbers.  Gamaleia  has  claimed  that  by  passing  the 
aolera  spirillum  of  Koch  through  a  series  of  pigeons, 
upon  which  this  organism  is  said  to  act  similarly  to  the 
Vibrio  metchnikovi,  by  successive  inoculations,  its 
pathogenic  power  may  be  greatly  increased,  and  thai 
when  sterilized  cultures  of  this  virulent  variety  of 
bacillus  are  injected  into  pigeons  they  become  immune 
to  the  Vibrio  metchnikovi,  and  vice  versa.  But 
PfeifTer  denies  this — and  the  negative  results  obtained 
from  the  serum  reaction  with  Metchnikoff's  spirillum 
and  cholera-immune  serum  show  that  the  organisms 
are  not  identical. 

The  Spirillum  op  Relapsing  Fever  (Spirochosta 
or  Spirillum  obermeieri*) . — First  observed  by  Ober- 
meier  (1873)  in  the  blood  of  a  patient  suffering  from 
febris  recurrent.  Bacteriologically  very  little  is 
known  of  this  microorganism.  It  occurs  as  long, 
slender,  flexible,  motile  spirals  or  wavy  filaments,  with 
pointed  ends  usually  from  20  to  30  /<  long.  Flagella 
and  spores  have  not  been  observed.  Typically  the 
organisms  are  found  only  in  the  blood  and  spleen,  not 
in  the  secretions  of  patients  with  relapsing  fever,  and 
chiefly  at  the  height  of  the  disease,  seldom  or  never 
during  the  intermissions.  They  stain  readily  with 
the  ordinary  aniline  colors,  especially  with  fuehsin 
and  Loeffler's  methylene  blue  solutions;  they  do  not 
stain  by  Gram's  method. 

They  have  never  been  cultivated  in  artificial  media. 
When  preserved  in  blood  serum  and  0.5  per  cent,  solu- 
tion of  salt,  they  retain  their  vitality  for  a  considerable 
time. 

Inoculation  experiments  have  been  successfully 
made  on  man  and  monkeys.  Monkeys  when  inocu- 
lated with  human  blood  containing  the  spirilla  take 
sick  after  about  three  and  one-half  days,  but  exhibit 
only  the  initial  febrile  attack;  no  relapse  such  as  is 
characteristic  of  the  disease  in  man  occurs.  Extirpa- 
tion of  the  spleen  renders  the  disease  more  dangerous 
for  these  animals.  Infection  may  be  transmitted  by 
inoculation  also  from  one  monkey  to  another.  Al- 
though so  little  is  known  of  this  organism  from  a  bacte- 
riological standpoint,  the  fact  of  its  constant  occurrence 
in  relapsing  fever  and  of  the  communicability  of  the 
disease  from  man  to  monkeys  by  inoculation  of  the 
blood  gives  us  grounds  for  assuming  that  this  is  the 
cause  of  the  affection. 

Spiroch/ETA Pallida  (Treponema  pallidum). — This 
organism  is  found  in  large  numbers  in  syphilis  or 
infectious  diseases  of  human  beings,  characterized  by 
its  long  course  and  by  the  definite  stages  of  its  clinical 
history.  It  was  first  observed  by  Schaudinn  working 
together  with  Hoffmann,  in  1905,  in  the  fresh  exudates 
of  chancre,  and  as  it  possessed  many  of  the  characteris- 
tics of  the  spirochetes  he  named  it  Spirochata  pallida. 

♦These  organisms  are  classed  with  the  spirochetes  as  pro- 
tozoa by  Schaudinn,  Hartmann,  and  others,  but  by  Norris, 
Novy,  and  others  they  are  still  placed  with  the  bacteria.  In 
this  article,  therefore,  the  two  most  important  of  the  group, 
only,  will  be  described,  viz.,  Spirochceta  obermeieri  and  Spiro- 
chmta  pallida. 


Later,  because  it  showed  individual  characteristics 
(.having  no  undulating  membrane,  though  possessing  a 
flageUum),  he  classed  it  as  a  separate  genus,  Trepo- 
nema pallidum.  Since  the  investigations  of  Schau- 
dinn and  Hoffmann,  extensive  studies  on  human 
and  experimental  syphilis  have  abundantly  corrobor- 
ated their  findings,  and  this  organism  IS  OOW  recogn- 
ized to  be  the  specific  can  c  of  the  disease. 

Microscopical  Appearances. —  Very  delicate  in  struc- 
ture. 4  to  20  /!  long  (average,  10  p)  and  |  to  *  /« 
in  diameter.  It  has  four  to  twenty  sharp  deep  spirals. 
I  lagella  like  anterior  and  posterior  prolongations 
are  often  seen.  The  double  flagella  occurring  rarely 
at  one  end  are  interpreted  by  Schaudinn  aing 

Longitudinal  division,  which  then  takes  place  very 
quickly.  In  the  living  condition  tin'  organism  is  not 
very  refractive  and  is  seen  at   first    with  difficulty. 

Motility. — Its  characteristic  vements  are  rota- 
tion on  its  long  axis  which  is  comparatively  rigid, 
slight  forward  and  backward  motion,  and  bending  of 
the  entire  body.  By  the  use  of  the  ultramicroscope 
the  motility  of  the  organism  is  clearly  seen. 

Stamina'.  —  It  stains  red  by  Gram's  method,  while 
most-  of  the  oilier  spirochetes  stain  blue. 

Biological  Characters. — Cp  to  1909  numerous 
attempts  were  made  to  cultivate  this  organism  in 
artificial  media  without  success.  Schereschewsky, 
Miihlens,  and  others,  now  employ  as  media  (1)  collo- 
dium  sacs  in  tubes  of  fluid  horse  serum,  (2)  horse  or 
human  serum  heated  to  75°  C.  The  spirochetes  are 
not  obtained  in  pure  culture,  but  in  what  are  termed 
"pure-mixed   cultures,"   as  with  amebae. 

Pathogenesis. — So  far  as  known,  syphilis  in  nature 
appears  only  in  man.  Kle.bs  in  1879,  and  since  then 
others,  have  reported  that  syphilis  could  be  produced 
in  monkeys  by  the  inoculation  of  human  virus,  show- 
ing many  of  the  lesions  characteristic  of  the  disease. 

Sehaudinn's  spirochetes  have  been  demonstrated 
in  practically  all  lesions  of  syphilis  in  man  (primary, 
secondary,  and  tertiary),  including  the  congenital 
types,  in  such  numbers  and  position  as  to  make  the 
majority  of  workers  in  this  field  look  upon  them  as 
the  true  cause  of  the  disease. 

Immunity. — After  the  development  of  the  primary 
lesions  in  syphilis  man  is  usually  insusceptible  to 
reinoculation  during  the  active  stage  of  the  disease, 
but  during  all  the  stages  both  man  and  monkeys  can, 
in  some  cases,  be  reinoeulated. 

Efforts  to  obtain  an  attenuated  virus  to  be  used  for 
inoculation  have  been  unsuccessful.  Fresh  material 
loses  its  virulence  in  six  hours,  and  the  results  of 
inoculation  with  such  virus  have  been  entirely  nega- 
tive. Passage  through  monkeys  does  not  attenuate 
the  virus.  The  injection  of  large  quantities^  of  the 
serum  of  syphilitics  into  monkeys  has  failed  to 
produce  definite  immunity,  although  some  animals 
after  such  treatment  did  not  take  syphilis. 

Wassermann,  Neisser,  and  Bruck,  have  applied  the 
so-called  "Bordet-Gengou  phenomenon"  as  a  diag- 
nostic test  for  syphilis,  usually  spoken  of  as  the 
"  Wassermann  reaction."  This  test  will  be  described 
in  detail  elsewhere. 

The  Glanders  Bacillus  (Bacillus  mallei). — 
This  bacillus  was  discovered  by  Loeffler  and  Schiitz 
(1882)  in  the  tissues  of  animals  affected  with  glanders. 
It  was  isolated  in  pure  culture  by  several  bacteri- 
ologists, almost  simultaneously,  and  was  proved  to 
lie  The  cause  of  the  disease  with  which  it  is  associated. 

Microscopical  Appearances. — Small  bacilli  (2-3  a 
long  and  0.4  ft  broad)  with  rounded  or  slightly  pointed 
ends;  they  usually  occur  singly,  but  sometimes  in  pairs, 
and  they  rarely  grow  out  to  long  filaments.  Involu- 
tion forms  are  common  in  old  cultures.  (See  Plate 
X.,  Fig.  4.) 

Motility. — Non-motile. 

Spore  Formation. — Absent. 

873 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Staining  ReactioJis. — Stains  with  difficulty  with  the 
ordinary  aniline  colors;  does  not  stain  by  Gram's 
method.  The  bacilli  often  exhibit  a  granular  appear- 
ance (metachromatic  bodies)  which  are  especially 
visible  with  Neisser's  stain. 

Biological  Characters. — Aerobic  and  facultative 
anaerobic,  growing  both  with  and  without  oxygen, 
but  best  in  the  presence  of  oxygen  and  at  brood  tem- 
perature, though  it  develops  slowly  at  2.5°  C;  does 
not  grow  at  over  40°  C.  It  may  be  cultivated  on 
all  the  usual  artificial  media,  but  best  on  five  per  cent, 
glycerin  agar. 

On  glycerin  agar  at  the  end  of  twenty-four  to  forty- 
eight  hours  it  forms  whitish,  transparent  colonies 
which  in  six  or  seven  days  may  attain  a  diameter  of 
7  to  S  mm.  On  blood  serum  a  moist,  opaque,  shiny 
layer  of  a  yellowish  or  dirty-brown  color  is  developed. 
The  serum  is  not  liquefied.  On  potato  the  growth  is 
very  characteristic.  At  the  end  of  twenty-four  to 
thirty-six  hours  at  37°  C,  a  moist,  yellow,  transparent 
coating  develops,  becoming  deeper  in  color  and 
denser  in  consistence  until  it  finally  presents  a  reddish- 
brown  color,  and  the  surrounding  surface  of  the  potato 
acquires  a  greenish-yellow  tint.  The  cultures  often 
exhibit  long,  felt-like,  interlaced  filaments  not  unlike 
the  threads  of  the  bacillus  anthracis,  and  finally  club- 
like  enlargements.  In  bouillon  a  diffuse  clouding 
takes  place,  a  tenacious,  ropy  sediment  being  ulti- 
mately formed.  Milk  is  coagulated  with  the  produc- 
tion of  acid. 

Vitality. — The  resistance  of  cultures  of  the  bacillus 
of  glanders  is  not  very  great.  They  lose  their  viru- 
lence quickly  by  natural  weakening  as  early  as  the 
fourth  or  fifth  generation;  therefore  in  order  to  retain 
virulence  it  is  necessary  after  two  or  three  generations 
of  cultures  to  pass  the  virus  through  a  susceptible 
animal.  According  to  Bonome  the  glanders  bacillus 
dies  in  ten  days  when  exposed  to  a  temperature  of  25° 
C;  but  other  authorities  find  that  it  may  live  for  three 
months  under  similar  conditions.  Exposed  to  heat 
the  bacilli  are  killed  at  80°  C.  in  five  minutes,  and  at 
100°  C.  in  three  minutes. 

Corrosive  sublimate  solution  (1  to  1,000)  destroys 
the  bacilli  in  fifteen  minutes,  and  five  per  cent,  car- 
bolic acid  in  one  hour.  The  virulence  is  quickly  lost 
in  distilled  water  (six  days);  it  is  not  destroyed  by 
putrefaction. 

Pathogenesis. — Among  domestic  animals,  horses, 
asses,  cats,  dogs,  goats,  sheep  are  the  most  susceptible; 
less  so  pigs.  Cattle  and  birds  are  immune.  Among 
test  animals,  the  field  mouse,  wood  mouse,  and  guinea- 
pig  are  the  most  susceptible,  the  rabbit  being  less  so, 
while  white  mice  and  house  mice  are  comparatively 
immune.  When  pure  cultures  of  the  Bacillus  mallei 
are  injected  into  horses  and  other  susceptible  animals 
true  glanders  is  produced.  The  disease  in  the  horse  is 
characterized  by  the  formation  of  ulcers  upon  the 
nasal  mucous  membrane.  These  ulcers  have  irregu- 
lar, thickened  margins  and  secrete  a  thin,  virulent 
mucus;  the  submaxillary  glands  become  enlarged  and 
form  a  tumor;  other  lymphatic  glands  also  become 
inflamed,  and  some  of  them  suppurate  and  open  ex- 
ternally, leaving  deep  ulcers;  the  lungs  are  finally  in- 
volved and  the  breathing  becomes  rapid  and  irregular. 
In  farcy,  which  is  a  more  chronic  form  of  the  disease, 
circumscribed  swellings  appear  in  different  parts  of  the 
body,  especially  where  the  skin  is  thinnest,  which  sup- 
purate and  leave  angry-looking  ulcers  with  abundant 
purulent  discharge.  Pure  cultures  can  be  obtained 
from  the  interior  of  the  suppurating  nodules  and 
glands  which  have  not  yet  opened  to  the  surface;  but 
the  discharge  from  the  nostrils  or  from  an  open  ulcer 
contains  comparatively  few  bacilli,  and  these  are  asso- 
ciated with  so  many  other  bacteria  which  grow  more 
readily  than  the  glanders  bacilli  on  culture  media  that 
it  is  difficult  to  obtain  pure  cultures  in  this  way  by  the 
plate  method.     Here  test  animals  are  useful 

874 


In  guinea-pigs  subcutaneous  injections  are  fol- 
lowed in  three  or  four  days  by  swelling  at  the  point  of 
inoculation,  and  a  tumor  with  caseous  contents  soon 
develops,  then  ulceration  of  the  skin  takes  place. 
The  lymphatic  glands  become  inflamed,  and  in  from 
two  to  three  weeks  symptoms  of  general  infection 
appear.  In  male  animals  orchitis  and  epididymitis 
are  present,  while  the  internal  organs  (lungs,  kidneyB, 
spleen,  and  liver)  are  generally  the  seat  of  character- 
istic nodular  formations.  From  these  pure  cultures 
may  be  obtained.  The  specific  ulcers  produced  upon 
the  nasal  mucous  membranes  of  the  horse  are  rarely 
present  in  guinea-pigs.  The  process  is  often  prolonged, 
and  the  animals  may  live  from  six  to  eight  weeks 
after  inoculation;  or  it  remains  localized  in  the  skin. 
Intraperitoneal  injection  of  guinea-pigs  is  usually 
followed  by  death  in  from  eight  to  ten  days,  and  in 
males  the  testicles  are  invariably  affected.  In  female 
animals  the  disease  may  be  communicated  to  the  fetus. 
The  bacillus  of  glanders  has  never  been  found  out- 
side of  the  animal  body  nor  in  healthy  individuals. 
The  disease  occurs  as  a  natural  infection  only  in 
horses  and  asses,  but  it  may  be  communicated  to  man 
by  contact  with  affected  animals,  and  usually  by 
inoculation  through  wounds  of  the  skin  or  mucous 
membranes.  In  man,  where  the  virus  enters,  a  local 
swelling  appears,  which  spreads  rapidly,  accompanied 
by  suppuration  and  cording  of  the  neighboring 
lymphatics.  Multiple  abscesses  are  formed  in  the 
skin,  muscle,  and  internal  organs,  and  there  are  often 
suppurative  changes  in  the  joints,  the  disease  at  this 
stage  resembling  pyemia.  Characteristic  glanders 
nodules  a,ppear  in  the  mucous  membranes,  particu- 
larly of  the  nose,  which  soon  disintegrate,  forming 
ulcers.  The  disease  not  infrequently  terminates 
fatally,  death  resulting  from  general  infection  carried 
by  means  of  the  lymph  circulation. 

It  is  transmissible  from  man  to  man.  Washer- 
women have  been  infected  from  the  clothes  of  a  patient. 
Among  horses  it  is  by  no  means  an  uncommon  disease, 
particularly  in  Southern  countries,  sometimes  taking  a 
mild  course  and  remaining  latent  for  a  considerable 
time.  Horses  apparently  healthy,  therefore,  may 
possibly  spread  infection. 

It  is  often  difficult  to  demonstrate  microscopically 
the  presence  of  the  glanders  bacillus  in  the  nodules 
which  have  undergone  purulent  degeneration,  or  in 
the  discharge  from  the  nostrils,  ulcers  and  glands. 
Strauss  has  proposed  the  following  rapid  method  of 
diagnosis  by  inoculation  of  test  animals:  Some  of  the 
suspected  material  or  culture  is  introduced  into  the 
peritoneal  cavity  of  a  male  guinea-pig,  making  the 
inoculation  directly  in  the  middle  line  of  the  abdomen, 
to  avoid  introduction  into  the  vesiculae  seminalis. 
If  it  is  a  case  of  glanders,  the  testicles  begin  to  swell 
within  thirty  to  forty-eight  hours,  and  the  skin  over 
them  becomes  hyperemic,  shiny,  and  finally  degener- 
ates and  shows  evidences  of  pus  formation.  The 
diagnostic  symptom  is  the  tumefaction  of  the  testicles. 
The  diagnosis  of  glanders  in  horses,  in  which  the 
clinical  symptoms  of  the  disease  may  be  obscure,  as  in 
chronic  or  subacute  cases,  may  often  be  made  by  the 
use  of  mallein.  Mallein  consists  of  the  filtered  pro- 
ducts of  the  glanders  bacillus — albuminous  com- 
pounds bearing  a  similar  relation  to  glanders  that 
Koch's  old  tuberculin  bears  to  tuberculosis — pre- 
pared by  evaporating  a  six-weeks'-old  culture  in 
five  per  cent,  glycerin  nutrient  veal  broth  to  ten 
per  cent,  of  its  original  bulk.  The  dose  of  mallein  is 
about  1  c.c.  subcutaneously  injected,  which  usually 
gives  good  reactions.  An  injection  of  mallein  under 
the  skin  of  a  healthy  horse  has  no  effect  or  at  most 
produces  a  slight  local  swelling  and  rise  of  temperature. 
Following  an  injection  of  mallein  into  a  glandered 
horse  two  reactions  are  produced:  a  large  and  painful 
swelling  at  t lie  point  of  inoculation  and  a  rise  of  tem- 
perature to  104°  or  even  106°  F.     The  rise  of  tempera- 


REFERENCE    II  WDI'.ot  )|<    •  )K    THE    MEDICAL    SCIENCES 


Bacteria 


ture,  however,  should  not  be  taken  alone  as  con- 
clusively iiuliciiting  glanders;  it  must  be  considered 
iii  connection  with  the  local  swelling  and  the  general 

condition  of  the  animal  which  is  profoundly  affected 
by  the  injection.     The  practical  value  of  this  test  has 

been  demonstrated  by  numerous  experiments  by 
veterinarians.  No  ill  effects  have  been  found  to 
result  from  the  injection  of  mallein  in  healthy  horses. 
On  the  contrary,  not  only  production  of  immunity, 
but  some  cures  have  been  reported  from  its  use. 

An  agglutination  test  may  also  be  made  for  glanders 
by  the  macroscopic  or  microscopic  method. 

In  the  macroscopic  method  (Mcissner  and  Schultz) 
a  forty-eight-hour  glycerin  agar  culture  of  Bacillus 
mallei  is  washed  off  with  normal  salt  solution,  to  which 
sufficient  carbolic  acid  has  been  added  to  make  a  5  per 
cent,  solution.  This  is  incubated  for  two  hours  at 
60°  C,  then  filtered  and  enough  of  the  earbolized 
normal  salt  solution  is  added  to  give  the  emulsion  a 
slight,  milky  appearance.  The  serum  is  then  made 
up  into  the  required  dilution,  1:50,  1:100,  etc.,  and 
1  c.c.  of  each  dilution  is  pipetted  into  stoppered  sterile 
tubes,  an  equal  amount  of  the  emulsion  being  added 
to  each  tube.  The  tubes  are  incubated  at  37°  C. 
for  twenty-four  to  forty-eight  hours.  If  a  reaction 
occurs  the  upper  part  of  the  fluid  will  be  clear  and  a 
fine  granular  sediment  will  be  found  at  the  bottom  or 
fine  clumps  clinging  to  the  sides  of  the  tubes. 

In  the  microscopic  or  hanging-drop  method  a 
twenty-four-hour  glycerin  broth  culture  which  has 
been  heated  to  60°  C.  for  one  minute,  is  used  and  the 
test  is  made  as  in  the  Widal  test  for  typhoid  fever. 
The  cover  glass  and  slides  must  be  sterilized  and  the 
hanging  drops  made  carefully  and  quickly  to  avoid 
contamination.  The  slides  are  left  at  room  tempera- 
ture or  at  22°  C.  for  eighteen  to  twenty-four  hours 
and  then  examined  microscopically.  In  this  method 
the  reaction  can  be  observed  earlier  than  in  the  tubes, 
and  it  is  not  necessary  to  wait  for  precipitation  which 
at  times  takes  place  slowly.  The  microscopic 
method  also  gives  a  higher  reading  than  the  macro- 
scopic method  and  includes  more  horses  which  are 
doubtful.  The  agglutination  is  1:500,  but  many 
apparently  healthy  horses  will  agglutinate  the 
Bacillus  mallei  in  dilutions  as  high  as  1:5,000  to 
1 :10,000.  The  cause  of  this  is  not  understood.  Such 
horses  then  should  be  subjected  to  the  mallein  test 
from  time  to  time,  with  a  view  to  the  possibility  of  a 
slight  infection  taking  place.  Very  rarely  a  horse 
in  the  last  stages  of  glanders  will  fail  to  give  a  reaction, 
but  the  disease  symptoms  will  then  be  well  defined. 
The  agglutination  reaction  has  been  found  also  to  be 
a  valuable  guide  to  the  use  of  mallein.  In  human 
cases  the  reaction  of  1:100  and  above  is  considered 
positive,  the  normal  blood  not  reacting  above  1 :50. 

The  Bacillus  of  Bubonic  Plague  (Bacillus 
Testis  bubonica?). — This  organism  was  discovered  by 
Kitasato  and  Yersin,  independently,  during  an 
epidemic  of  the  bubonic  plague  at  Hong-Kong, 
China,  in  1891.  This  disease,  like  anthrax  and 
leprosy,  has  a  long  historical  record  behind  it.  It  is 
probably  the  disease  which  under  the  names  of  "Black 
Death"  or  "The  Great  Plague"  decimated  the 
population  of  Europe  in  the  Middle  Ages. 

Microscopical  A  p pearances. — Short  rods,  with 
rounded  ends,  about  twice  as  long  as  broad,  occurring 
singly,  in  pairs,  or  in  short  chains  (especially  in  bouillon 
cultures),  and  often  surrounded  by  a  capsule.  Involu- 
tion forms  are  common.     (See  Plate  X.,  Figs.  7  and  8.) 

Motility. — Non-motile,  possessing  no  flagella ;  though 
Kitasato  claims  that  it  has  very  sluggish,  scarcely 
perceptible  movements,  and  Gordon  states  by  a 
special  method  of  staining  (Van  Ermengen's  method) 
he  found  polar  flagella. 

Spore  Formation. — Absent. 

Staining     Reactions. — Stains     with     the     ordinary 


aniline  dyes,  but    in  preparations  made  from   ; 
cultures  the  character)  tic  bipolar  staining,  which  is 

observed  in  preparations  fr blood  and  pus,  is  not 

readily  obtained.     Hoes  not  .-tain  by  Gram's  method, 
Biological    Character        Strongly    aerobic,    growth 

being  inhibited   in   the  all  I  nee  "I    oxygen.       Develops 

on  i  he  u  uaJ  culture  media,  but  be  I  on  bl I    erum 

al  37°  C;  also  fairly  well  at  room  temperature. 

( >n  gelatin  plates  small,  darkly  defined  granular 
colonies  of  a  grayish-yellow  to  greenish  color  develop; 
the  gelatin  i  not  Liquefied,  in  gelatin  stab  cult 
it  grows  slowly  on  the  surface  and  along  the  track  of 
the  needle.  On  glycerin  agar  it  grows  rapidly,  form- 
ing a  moist,  grayish-white  coating  on  the  surface. 
i  in  blood  ■  i  r a  in  in  the  incubator,  at  the  end  of  twenty- 
four  to  forty-eight  hours,  white,  moi  I    tran  parent, 

and  iridescent  colonies  are  formed.      Bouillon  becomes 

diffusely  clouded,  but  if  inoculated  with  a  cohesive 
mi      of  bacteria  from  an   agar  culture   the  bacilli 

develop  as  a  granular  or  grumous  deposit  on  the  walls 
and  bottom  of  the  tube,  the  upper  portion  of  the 
liquid  remaining  clear,  similarly  to  what  is  observed 
in  the  growth  of  some  varieties  of  streptococci. 
There  is  a  scanty  growth  on  potato  and  milk;  milk  is 
not  coagulated. 

The  Bacillus  of  bubonic  plague  forms  no  gas  in 
media  containing  sugar,  and  but  little  indol.  It 
produces  toxins,  and  the  serum  of  animals  immunized 
against  the  bacillus  yields  antitoxic  substances. 

Vitality. — The  bacilli  of  bubonic  plague  withstand 
desiccation  for  from  three  to  seven  days:  in  water 
they  die  in  from  three  to  eight  days  according  to  its 
composition;  in  buried  cadavera  they  retain  their 
vitality  for  twenty-eight  to  thirty-eight  days.  Ex- 
posed to  the  action  of  direct,  sunlight  they  are  de- 
stroyed in  from  three  to  four  hours.  They  are  killed 
by  heating  at  55°  C.  in  ten  minutes,  and  at  80°  C.  in 
five  minutes.  Corrosive  sublimate  (1  to  1,000)  de- 
stroys the  bacilli  immediately. 

Pathogenesis. — This  bacillus  is  pathogenic  for 
almost  all  animals,  only  pigeons  being  immune. 
Guinea-pigs,  rats,  and  mice  are  the  most  suceptible 
animals;  somewhat  less  so  are  monkeys,  rabbits,  cats, 
and  horses;  and  still  less  so  are  dogs  and  cattle. 
Guinea-pigs  when  injected  intraperitoneally  with  pure 
cultures  die  in  about  two  days  of  acute  septicemia, 
few  bacteria  being  found  in  the  tissues.  At  the 
point  of  inoculation  there  will  be  seen  a  hemorrhagic 
infiltration  and  edema,  with  enlargements  of  the 
mesenteric  glands  and  parenchymatous  congestion  of 
the  organs.  The  spleen  sometimes  shows  minute 
nodules  resembling  miliary  tubercles,  which  contain 
zooglea-like  masses  of  the  bacilli.  Guinea-pigs  are 
also  easily  infected  through  the  digestive  tract. 
Flies,  bedbugs,  fleas,  and  other  insects  take  up  the 
organisms  with  the  blood  of  plague-infected  animals, 
and  the  disease  is  frequently  transmitted  through 
them,  especially  fleas,  to  man. 

Hankin  and  Yersin  have  repeatedly  found  non- 
virulent  plague  bacilli  in  the  dust  of  infected  houses 
and  in  the  soil.  They  have  never  been  found  in 
healthy  individuals.  Among  animals  the  bubonic 
plague  is  known  to  occur  spontaneously  in  rats, 
which  often  are  affected  previously  to  human  epi- 
demics. Ground  squirrels  in  California  have  been 
shown  also  to  be  susceptible  to  infection  and  they  are 
supposed  to  help  spread  the  disease.  In  patients 
suffering  from  plague  the  bacilli  are  found  chiefly  in 
the  pus  of  the  characteristic  buboes  and  also  in  the 
sputum  from  the  pneumonic  forms  of  the  disease; 
more   rarely  in   the   internal   organs  and   the   blood. 

This  organism  is  the  specific  cause  of  true  Oriental 
bubonic  plague,  the  mortality  from  which  is  from 
fifty  to  eighty  per  cent,  of  cases.  It  gains  access  to 
the  body  (1)  through  the  skin.  Here  the  bacilli 
may  remain  localized  and  multiply  at  first  in  the 
neighboring  lymph    glands;   frequently   at  the  point 

S75 


Bacteria 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


of  inoculation  a  pustule  is  formed  which  takes  on 
the  nature  of  a  furuncle  or  carbuncle  containing 
many  bacilli.  Death  may  occur  without  further 
diffusion  of  the  organisms,  but  ordinarily  they  are 
distributed  throughout  the  entire  body,  producing 
death  by  septicemia.  (2)  Through  the  lungs.  This 
constitutes  the  so-called  pneumonic  form,  or  plague 
pneumonia.  The  bacilli  are  present  in  the  sputum 
and  sometimes  in  the  blood;  other  pus  cocci  are  found 
in  association.  (3)  Through  the  digestive  tract. 
This  mode  of  infection  has  been  demonstrated  in 
animals,  but  is  uncertain  in  man. 

Immunity. — Yersin.  Calmette,  and  Borrel  have 
succeeded  in  producing  passive  immunity  against 
the  plague  bacillus  in  animals,  and  also  to  a  certain 
extent  in  man,  by  subcutaneous  inoculations  with  the 
serum  of  horses  which  were  previously  immunized  by 
intravenous  inoculation  of  dead  cultures.  Such 
serum  possesses  also  some  curative  effect  in  men  and 
animals  suffering  from  the  plague,  if  inoculated  with 
large  quantities  and  within  twelve  hours  after  infec- 
tion. Roux  maintains  that  this  serum  contains  only 
antitoxic,  not  bactericidal,  substances.  Active  immun- 
ity may  also  be  produced,  and  apparently  without 
danger,  by  Haffkine's  method  of  preventive  inocula- 
tion in  the  same  manner  as  with  cholera.  This 
method  consists  in  the  subcutaneous  injection  of 
2.5-3  c.c.  of  a  fully  grown  bouillon  culture  heated  for 
one  hour  at  70°  C.  to  kill  the  organisms.  The  reac- 
tion caused  (fever  and  pain)  is  usually  slight,  and  the 
injection  is  best  repeated  after  ten  days.  This  treat- 
ment is  essentially  protective  rather  than  curative, 
and  although  the  immunity  afforded  is  not  absolute  and 
lasts  only  for  a  month  or  two,  the  majority  of  those 
inoculated  are  protected  or  have  the  disease  only  in  a 
mild  form  and  recover.  By  means  of  these  two  methods 
of  inoculation,  along  with  strict  quarantine  regulation 
and  the  destruction  of  rats  and  fleas,  it  is  to  be  hoped 
that  this  disease  which,  under  the  name  of  Black  Death, 
once  decimated  the  population  of  the  earth  and  which 
in  the  East  still  causes  a  great  mortality  may  be  finally 
exterminated  or  greatly  restricted. 

The  German  Plague  Commission  considered  puncture 
of  the  unopened  bubo  for  diagnostic  purposes  some- 
what dangerous,  on  account  of  possible  infection  of  the 
blood;  but  the  English  physicians  in  India  make  a 
long  incision  in  the  affected  gland,  which  is  afterward 
dressed  with  antiseptics.  In  this  way  material  is 
obtained  for  cover-glass  specimens,  plate  and  other 
cultural  methods.  The  pus  of  the  buboes,  and  es- 
pecially the  sputum  in  the  pneumonic  forms,  contain 
numbers  of  bacilli.  In  these  cases  microscopical 
examination  alone  suffices  often  to  make  a  probable 
diagnosis  of  the  plague  from  the  peculiar  bipolar 
staining  of  the  organisms.  Microscopical  examination 
of  the  blood  is  attended  with  success  only  in  cases  of 
general  infection,  and  here  cultures  yield  better  results. 
It  is  recommended  to  make  streak  cultures  on  gelatin 
plates  at  22°  O,  at  which  temperature  the  plague 
bacillus  grows  fairly  well,  while  the  streptococcus  and 
other  associated  bacteria  usually  exhibit  only  scanty 
growth.  According  to  Hankin,  wdien  the  bacilli  are 
grown  on  agar  containing  2.5  to  3.5  per  cent,  of  salt  at 
31°  C,  in  twenty-four  to  forty-eight  hours  inoculation 
forms,  consisting  of  pear-shaped  bodies  and  spheres. 
are  developed,  which  he  considers  characteristic 
enough  to  form  a  means  of  diagnosis.  Finally,  the 
serum  of  men  and  animals  affected  with  the  plague 
possesses  the  power  of  agglutinating  the  bacillus pestis. 
This  reaction  is  said  to  be  present  in  the  second  week, 
and  is  most  pronounced  in  the  second  and  third  weeks 
of  the  disease.  Arthur  R.  Guerard. 

Reff.rentf.s 
Park  and  Williams:     Pathogenic  Bacteria  and  Protozoa. 
Sternberg:     Text-Book  of  Bacteriology. 
Fliigge:     Die  Kficroorganiamen. 
Lehmanii  utul  Neumann:     Bacteriologische Diagnostik. 

876 


Bacteria  Carriers. — It  has  been  known  for  several 
years  that  persons  convalescent  from  certain  acute 
infectious  diseases  may  thereafter  carry  and  excrete 
the  exciting  organisms  from  their  bodies  for  a  variable 
length  of  time.  Almost  coincidently  it  was  discovered 
that  not  only  those  who  have  suffered  from  a  specific 
infectious  disease  may  harbor  the  causative  organisms 
but  also  others  who  have  been  in  direct  contact  with 
either  such  patient  or  the  infectious  material.  These 
persons  are  apparently  in  normal  health,  or  do  not 
show  any  symptoms  of  the  specific  disease.  Recently 
the  general  term  "bacteria  carriers"  or  "bacilli 
carriers"  has  been  applied  to  such  persons. 

It  is  difficult  to  define  strictly  what  constitute 
true  bacteria  carrier.  The  term  is  subject  to  broad 
interpretation,  but,  as  commonly  understood  at  the 
present  time,  certain  restrictions  may  be  made  to  fix 
proper  limitations.  Therefore  we  may  say  provi- 
sionally that  a  "bacteria  carrier"  is  one  who,  while 
apparently  in  good  health,  or  at  least  not  showing 
any  symptoms  of  a  particular  specific  infectious 
disease,  is  harboring  and  excreting  the  infectious  agent 
of  such  virulence  that,  when  transmitted  directly  or 
indirectly  to  a  second  person,  or  to  an  experimental 
animal,  it  is  capable  of  causing  the  disease  in  question. 
The  carrier  may  or  may  not  have  given  a  history 
of  a  previous  attack  of  the  disease.  According  to 
Novy,  carriers  may  be  classified  under  three  types— 
convalescent,  chronic,  and  healthy  carriers.  But,  as 
he  points  out,  perhaps  the  so-called  healthy  carriers 
in  most  instances  are  individuals  who  have  had  the  dis- 
ease unknown  to  themselves  at  some  previous  time, 
therefore  they  are  really  "chronic  carriers''.  In  other 
cases,  while  apparently  healthy,  the  individual  may 
be  in  the  incubation  stage  of  the  disease  which  de- 
velopes  later.  After  excluding  these  possibilities  a 
group  remains  which  may  fulfill  the  required  qualifi- 
cations for  a  strictly  healthy  carrier.  As  evident, 
the  term  "healthy  carrier"  is  one  which  can  not  be 
correctly  applied  in  certain  cases,  so  must  be  used 
with  reservation. 

The  first  observations  upon  carriers  were  made  in 
connection  with  epidemics  of  cholera,  diphtheria,  and 
cerebrospinal  meningitis.  This  list  of  infectious 
diseases  is  being  constantly  added  to  as  investigations 
continue  along  this  line. 

Asiatic  Cholera. — It  has  been  found  by  a  number  of 
workers  in  epidemiology  that  in  cholera  epidemics 
there  are  healthy  persons  in  the  infected  district  who 
carry  virulent  vibrios  in  their  intestines,  but  who  are 
themselves  apparently  insusceptible  to  the  disease. 
Abel  and  Claussen  reported  an  extreme  case  in  which 
they  found  cholera  vibrios  in  the  dejecta  of  fourteen 
out  of  seventeen  persons  belonging  to  families  wherein 
there  were  cholera  patients.  In  some  instances  the 
organisms  persisted  as  long  as  fourteen  days.  In  the 
Hamburg  epidemic  there  were  reported  twenty-eight 
cases  of  healthy  persons  with  normal  stools  containing 
cholera  vibrios.  Cholera  vibrios  are  usually  found  in 
the  dejecta  of  patients  for  only  a  few  days,  but  Kolle 
found  virulent  organisms  in  the  stools  of  convalescents 
up  to  forty-eight  days.  A  case  has  been  reported  in 
which  the  organism  was  found  one  hundred  and 
twenty  days  after  the  attack. 

It  is  evident  from  the  above  that  the  dissemination 
of  cholera  comes  about  not  only  through  contamina- 
tion of  water,  food,  etc.,  from  the  discharges  of  those 
acutely  ill  of  the  disease,  but  also  from  the  discharges 
of  certain  convalescents  and  healthy  "carriers," 
who  may  play  an  important  role  in  spreading  the 
ili-ease.  For  efficient  quarantine  purposes  laboratory 
examinations  of  the  feces,  as  well  as  clinical  examina- 
tions, must  be  directed  toward  those  who  have  come 
from  infected  regions,  or  have  been  exposed  »ther- 
wise  to  the  disease. 

Diphtheria. — As  early  as  1S94  Park  and  Beebe  ex- 
amined   the    throats    of    three    hundred    and    thirty 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


Bacteria  Carriers 


healthy  persons.  In  eight  subjects  virulent  diph- 
theria bacilli  were  found,  and  two  of  those  afterward 
developed  the  disease;  twenty-four  subjects  in  this 
aeries  showed  non-virulent  or  attenuated  forms  of  the 
organism.  In  further  studies  upon  the  persistence  of 
the  virulent  organisms  in  the  throats  of  convale  cent 
a  large  series  of  consecutive  cases  were  examined.  It 
was  found  that  in  approximately  fifty  per  cent,  of  the 
cases  tin'  bacilli  disappeared  within  three  days  after 
loss  of  the  pseudomembrane.  A  majority  of  the 
remaining  patients  showed  the  disappearance  of  the 
organisms  in  rapidly  decreasing  numbers  over  the 
following  two  weeks.  But  in  a  few  cases  the  bacilli 
persisted  from  the  fourth  to  the  ninth  week.  Park 
later  reported  the  ease  of  a  patient  who  carried  fully 
virulent  organisms  for  eight  months.  Prip  reported 
a  case  in  which  the  virulent  organisms  persisted  for 
twenty-two  months. 

IVnnington  has  published  the  results  of  his  ex- 
amination of  the  throats  of  a  large  number  of  well 
school  children  in  Philadelphia.  The  summary  of  his 
findings  is  very  interesting  in  this  connection.  He 
found  that  approximately  ten  per  cent,  of  these 
children  harbored  in  their  throats  bacilli  which  cor- 
responded morphologically  with  the  organism  of 
diphtheria.  One-half  of  these  organisms  were  without 
effect  upon  guinea-pigs.  About  thirty  per  cent. 
behaved  like  attenuated  forms,  and  fourteen  per 
cent,  killed  the  animals  with  a  fair  degree  of  prompt- 
ness. 

In  the  examination  of  the  throats  of  well  persons  in 
contact  with  diphtheria  patients,  Kober  found  that 
eight  per  cent,  carried  virulent  bacilli.  It  is  generally 
considered  that  the  bacilli  found  in  well  persons 
recently  exposed  are  more  likely  to  be  virulent  than 
others. 

.Many  more  studies  along  these  lines  have  been 
made  which  confirm  the  findings  just  mentioned.  All 
these  observations  point  to  the  fact  that  not  only 
convalescents  but  apparently  well  individuals  may 
serve  as  carriers  of  virulent  diphtheria  bacilli,  and 
under  favorable  conditions  can  infect  others. 

Specific  antitoxic  serum,  likewise  medicinal  treat- 
ment, apparently  exerts  little  if  any  influence  in 
correcting  this  condition  in  diphtheritic  convalescents. 

Cerebrospinal  Meningitis. — The  Diplococcus  intra- 
cellularis  meningitidis  of  Weichselbaum  is  another  or- 
ganism which  is  found  in  normal  persons.  In  the 
examination  of  twenty-seven  healthy  persons  Schiff 
found  in  the  nasal  secretions  of  seven  an  intracellular 
diplococcus;  in  three  cases  of  this  group  Weichsel- 
baum identified  the  organisms  as  being  meningococci. 
Weichselbaum  and  Ghon  isolated  the  same  organism 
from  three  persons  who  had  been  in  contact  with 
the  disease.  Goodwin  and  von  Scholly  found  the 
meningococcus  present  in  about  ten  per  cent,  of  the 
people  who  were  in  close  contact  with  patients  suffer- 
ing from  the  disease.  Others  have  found  the  menin- 
gococcus in  the  throat  and  nasal  cavities  of  healthy 
persons,  during  an  epidemic  of  meningitis.  The 
organism  may  persist  a  considerable  length  of  time 
in  convalescents.  Goodwin  found  the  organism  per- 
sisting sixty-seven  days  after  the  onset  of  the 
disease. 

Evidence  seems  to  indicate  that  cerebrospinal 
meningitis  is  not  highly  contagious.  Those  who  con- 
tract the  disease  usually  have  had  their  general  resis- 
tance lowered  by  unhygienic  environment,  hardships, 
exposure,  etc.  Individual  susceptibility  is  an  im- 
portant factor.  The  organism  may  set  up  an  acute 
rhinitis  without  further  invasion  or  harm.  This 
partly  explains  how  the  infection  may  be  carried  and 
distributed,  as  it  is  well  known  that  the  organism 

Eossesses  a  low  degree  of  vitality;  it  is  rapidly  killed 
y  drying,  sunlight,  etc.  Therefore,  immediate  or 
mediate  transmission  of  the  infected  secretions  from 
one  person  to  another  seems  to  be  necessary  in  most 


cases 
in 


Dwelling    infections    arc    not     proved      The 
fluence   oi    "bacteria    carriers"   in    the    spreading 
of  thi    dises  aci  ounl  foi  the  out  bn  afa  and 

finement  to  one  family,  -mall  ana  in  a  community,  •«■ 

ingle   regiment.     P 
cerebrospinal  meningitis  in  ba 
origin  from   "bacteria  carriers."  instances 

arc   on   record   which    would    indicate   that    tl 

Influenza. — The  influenza  bacillus  may  be  barb 
in   the  respiratory  and  na  al  pa    ages  of  mat        ell 
ons,  «  bo  seem  u  o  1  heir  act  ii  •  iject  3 

who  have  had  the  disease  may  harbor  the  bacillus  for 
I  d     ome  ei   i ca  es  n  I    In- 

frequent, po  ably  due  to  an  autoreinfection.  They 
maj  also  11  ndary  infection  in  many  other 

conditions.      Williams  quite  early  observed   tnem   in 
sputum    from    pulmonary    tuberculosis;    they 
present   in  great   numbers  in  a  large  portion  of  the 

•  -i  es,  and  in  somi almo  1    pure  cult  u 

Moreover,  they  were  found  not  only  during  the  wintx  r 
but  also  during  the  summer,  when  no  influenza  was 
known  to  be  prevalent.  There  is  no  doubt  that 
tuberculous  patients  act  as  influenza  bacilli  carriers. 
■    certain    healthy    persons    play    a    similar    r61e. 

Typhoid     Fever. — Perhaps     the     most     thorough 
studies  upon  "bacilli  carriers"  have  been  carried  out 
in  connection  with  typhoid. fever.     Several  exten 
reports  have  recently  appeared  upon   this  subject. 

Although  these  conditions  have  been  recognized  only 
within  the  last  few  years,  the  investigations  prom- 
ise to  throw  much  light  upon  certain  outbreaks  of 
the  disease  of  obscure  origin.  At  the  present  time 
considerable  work  upon  this  phase  of  the  epidemio- 
logy of  typhoid  is  being  pursued  both  in  this  country 
and  abroad. 

It  has  been  known  for  a  number  of  jTears  that 
typhoid  patients  and  convalescents  might  carry  pure 
cultures  of  the  bacillus  in  the  bladder  for  an  inde- 
finite period  of  time.  Petruschky  in  1898  reported 
typhoid  bacilli  in  the  urine  of  convalescents,  as  tongas 
two  months  after  the  attack.  Richardson  soon  after 
mentioned  a  case,  observed  by  Cushing,  of  a  man 
who  had  had  typhoid  fever  five  year-,  previously,  but 
returned  to  the  hospital  for  treatment  of  cystitis. 
Bacteriological  examination  revealed  a  pure  culture 
of  typhoid  bacilli,  which  would  indicate  that  the  in- 
fection had  been  carried  five  years,  following  the 
typhoid-fever  attack. 

The  above  observations  have  been  fully  confirmed. 
In  certain  cases  typhoid  convalescents  carry  the 
bacilli  a  variable  length  of  time  as  bladder  infections, 
and  thus  become  a  source  of  infection  to  others  by 
discharging  the  organisms  in  the  outer  world.  Donitz 
and  others  have  reported  cases  which  fully  support 
the  claim  that  infections  can  originate  from  such  a 
source. 

As  early  as  1902  Frosch  suggested  that  convales- 
cents from  typhoid  fever  in  some  instances  might 
carry  the  bacilli  in  their  bodies  as  saprophytes,  and 
their  dejecta  might  give  rise  to  new  infections.  In 
this  way  the  mystery  of  "typhoid  houses"  or  "ty- 
phoid localities"  might  be  explained.  Sound  persons 
might  be  "bacilli  carriers"  and  be  the  source  of 
infection. 

Drigalski  and  Conradi  in  the  same  year  reported  the 
isolation  of  typhoid  organisms  from  the  dejecta  of 
four  healthy  persons  who  had  been  in  contact  with 
cases  of  the  disease.  Drigalski  in  1904  reported  a 
case  in  which  the  organisms  were  observed  for  nine 
months  in  the  stools.  The  next  year  Lentz  and  others 
confirmed  the  supposition  of  Frosch  and  the  findings 
of  Drigalski  and  others.  Since  then  many  more 
contributions  have  been  made  on  the  subject  winch 
give  further  support  to  the  views  concerning  "  typhoid- 
bacilli  carriers." 

Lentz  (1905),  in  making  an  extensive  review  of  the 

877 


Bacteria  Carriers 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


results  obtained  at  several  laboratory  stations  engaged 
in  the  investigation  of  typhoid  fever,  stated  that  out  of 
a  large  number  of  examinations  ninety-eight  chronic 
"bacilli  carriers"  were  found.  At  one  station  it  was 
found  that  about  four  per  cent,  of  the  cases  examined 
became  bacilli  carriers.  In  one  instance  Lentz  found 
that  out  of  twenty-two  carriers  sixteen  were  women. 
He  observed  that  a  definite  relationship  existed  be- 
tween gallstone  disease  and  "bacilli  carriers,"  as  the 
two  conditions  might  be  associated,  and  suggested 
that  gall-bladder  infections  might  give  rise  to  the 
typhoid  bacilli  in  the  feces. 

Neiter  has  called  attention  to  the  influence  of 
bacilli  carriers  in  causing  institutional  epidemics. 
In  a  certain  German  insane  asylum  were  found  thir- 
teen "  bacilli  carriers, "  all  women.  Friedel  traced  the 
cause  of  a  series  of  typhoid  outbreaks  in  the  institu- 
tion, to  a  "  carrier"  who  was  a  helper  in  the  kitchen  of 
the  asylum. 

Kayser  reported  small  outbreaks  of  typhoid  fever 
which  could  be  traced  to  the  milk  in  use.  In  two  in- 
stances the  milk  was  traced  back  to  the  respective 
dairies.  In  each  case  a  "carrier"  was  found  in 
connection  with  the  dairy,  proof  being  furnished  by 
the  isolation  of  typhoid  bacilli  from  the  feces.  Kossel 
describes  a  similar  outbreak  which  had  its  origin  from 
milk  supplied  from  a  certain  dairy.  Upon  investiga- 
tion it  was  found  that  -one  of  the  laborers  was  a 
"bacilli  carrier,"  although  he  was  not  aware  that  he 
ever  had  the  disease.  He  was  removed  from  the  dairy 
work,  with  the  result  that  no  more  cases  developed 
from  the  milk  supply.  Later,  he  returned  to  the 
work  and  a  second  outbreak  followed.  Besides  the 
German  cases  cited,  similar  cases  have  been  reported 
in  this  country  recently.  These  examples  prove 
very  instructive,  as  they  show  the  danger  of  em- 
ploying "bacilli  carriers"  as  workers  about  such 
places. 

Soper  records  a  most  interesting  and  instructive 
case  of  a  typhoid-bacilli  carrier.  He  was  called  upon 
to  investigate  a  household  epidemic  of  typhoid  fever, 
where,  in  close  succession,  six  out  of  eleven  were 
stricken  with  the  disease.  The  water  and  food  sup- 
plies were  fully  examined,  with  the  result  that  they 
could  be  excluded  as  sources  of  infection.  Finally, 
suspicion  was  directed  to  a  cook  who  had  been  em- 
ployed by  the  family  shortly  before  the  outbreak  of 
the  disease.  She  left  shortly  afterward.  Soper 
succeeded  in  locating  the  cook  again,  but  was  unable 
to  derive  any  useful  information  from  her.  She  was 
a  woman  of  apparently  good  health,  about  forty 
years  of  age,  of  Irish  descent,  single,  and  had  no 
knowledge  of  ever  having  had  typhoid  fever.  She 
refused  to  give  further  information  concerning  her 
past  life,  and  the  investigator  therefore  found  it 
necessary  to  look  up  her  past  history.  During  the 
previous  ten  years  it  was  possible  to  trace  her  where- 
abouts with  the  exception  of  two  years.  It  was  found 
that  in  the  time  accounted  for  she  had  been  employed 
in  eight  families,  and  in  seven  of  these  typhoid  fever 
had  followed  her.  She  had  always  escaped  the 
epidemics  herself.  In  all,  twenty-six  cases  and  one 
death  occurred  in  the  series  of  outbreaks.  The  last 
position  she  held  was  with  a  family  in  New  York  City, 
and  the  outbreak  in  this  instance  was  followed  by  the 
only  fatality.  Soper  called  the  attention  of  the 
Department  of  Health  to  the  cook,  who  was  suspected 
of  being  a  chronic  carrier  and  a  menace  to  public 
health.  She  was  placed  in  the  Detention  Hospital 
March  19,  1907,  where  she  was  kept  under  constant 
observation  for  almost  three  years.  Bacteriological 
examinations  were  carried  out,  under  the  directions  of 
Dr.  Park  of  the  Research  Laboratory,  by  Goodwin  and 
Noble  which  showed  that  the  urine  was  free  from 
typhoid  bacilli,  but  the  feces  were  rich  with  the 
organisms.  Examinations  were  continued  during 
the  period  of  detention  which  showed  that  typhoid 

878 


bacilli  were  present  in  the  stools  (in  varying  numbers) 
off  and  on  at  irregular  intervals  while  under  observa- 
tion. The  blood  showed  a  positive  Widal  test  early  in 
the  course  of  the  examination.  This  side  of  the' in- 
vestigation was  not  followed  along  with  the  feces 
examination,  owing  to  the  vigorous  protests  of  the 
carrier.  It  is  not  necessary  to  dwell  upon  this  case 
further  than  to  call  attention  to  the  havoc  which  a 
carrier  can  produce  when  coming  in  direct  contact 
with    the   food    supply   of   non-immune    individuals. 

Klingler  divides  typhoid-bacilli  carriers  into  two 
groups:  (a)  those  who  have  had  typhoid  fever  at  some 
time  or  other,  and  (6)  those  who  have  no  knowledge  of 
ever  having  had  the  disease.  In  a  series  of  twenty- 
three  cases  which  came  under  his  observation,  he 
found  that  six  men  and  five  women  fell  in  the  first 
group,  while  in  the  second  group  there  were  three 
men  and  nine  women. 

The  discharge  of  typhoid  bacilli  in  the  feces  of 
carriers  may  be  quite  irregular  in  some  cases,  while 
regular  in  others.  This  seems  to  depend  on  temporary 
conditions  in  the  intestinal  tract.  It  has  been 
observed  that  sometimes  the  discharge  of  bacilli  will 
suddenly  stop  without  recurrence.  Also  there  may 
be  all  degrees  of  gradation  as  to  the  length  of  time 
the  bacilli  continue  to  be  present  in  the  feces  after 
the  acute  attack.  They  may  not  be  found  at  all 
after  convalescence,  or  they  may  be  present  weeks, 
months,  or  years  thereafter.  Lentz  mentions  one 
case  in  which  the  organisms  were  present  forty-two 
years  after  the  attack.  From  this  we  can  easily  see 
that  there  may  be  no  age  limit.  Klingler  in  his 
series  found  bacilli  carriers  between  the  ages  of 
eighteen  months  and  sixty  years.  The  infant  cases 
may  have  been  contracted  through  the  mother. 

The  focus  of  infection  is  generally  considered  to  be 
in  either  the  gall-bladder,  chronic  ulcers  of  the  intes- 
tines, or  the  normal  intestinal  tract.  Wasserman  and 
Citron  are  of  the  opinion  that  a  local  immunity  exists 
in  the  gall-bladder  and  intestinal  wall  of  the  carrier,, 
which  protects  the  body  from  general  infection.  A 
number  of  workers  report  that  there  is  no  raising  in 
value  of  the  specific  agglutinin,  nor  in  specific  .bac- 
tericidal substances;  but  others  have  reported  that 
such  substances  are  increased.  It  is  desirable  that 
more  work  be  done  in  regard  to  these  particular 
points. 

Medicinal  treatment  or  immunization,  according  to 
Forster  and  Kayser,  seems  so  far  to  have  been 
attended  by  practically  no  favorable  results,  in  the 
intestinal  cases.  But  in  the  bladder  infections 
Richardson  found  urotropin  very  efficacious.  The 
use  of  this  drug  might  be  of  service  in  the  gall-bladder 
infections  in  some  cases.  A  successful  use  of  urotro- 
pin in  gall-bladder  infection  was  reported  from  the 
Johns  Hopkins  Hospital  soon  after  this  type  of 
carrier  was  recognized.  But,  beneficial  results  have 
not  always  followed  its  use. 

When  the  infection  in  these  cases  can  be  localized 
by  such  evidence  as  concomitant  gall-stone  disease, 
operative  means  may  in  some  cases  lead  to  cure. 
Dehler  in  1907  operated  upon  a  patient  who  was  a 
chronic  bacilli  carrier,  with  the  purpose  of  relieving 
the  condition.  Perhaps  this  is  the  first  operation  on 
record  which  was  undertaken  for  the  cure  of  a  typhoid 
carrier.  The  patient,  an  insane  woman,  had  infected 
a  number  of  persons  before  it  was  discovered  that  she 
was  a  carrier.  Previous  to  the  operation  typhoid 
bacilli  were  found  in  the  feces  in  thirty-seven  out  of 
thirty-nine  examinations.  The  operation  consisted 
in  making  a  section,  freeing  the  gall-bladder  from 
adhesions,  opening  it,  and  removing  the  gallstones, 
then  giving  free  drainage  for  some  time.  The  patient 
made  an  uneventful  recovery,  and  with  the  exception 
of  once  shortly  after  the  operation,  the  stools  were 
reported  to  be  free  from  typhoid  bacilli. 

Later  on  Dehler  operated  upon  a  second  patient 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   BCIENCES 


Bacteria  Canieri 


i-ho  was  a  bacilli  carrier,  and  removed  a  lew  small 
tones  from  the  gall-bladder.  Subsequent  examin- 
tions  of  the  feces  showed  the  absence  of  typhoid 
lacilli.  In  the  same  communication  he  reported 
luil  thr  dejecta  of  I  he  previous  case  still  remained 
ree  from  typhoid  organisms.  Both  patients  showed 
hi  improvement  in  their  general  condition.  Dehler 
11  ■  It  1  the  opinion  that  operative  moans  wore  justifiable 
ii  those  oasos  in  which  no  relief  from  the  condition 
an  be  brought  about  by  medication  or  immuniza- 
ion. 

Albert  in  a  recent  study  upon  the  subject  of  chronic 

yphoid-bacilli  carriers,  stated  that  probably  five  per 

■cut.  of  all  typhoid  patients  become  chronic  carriers. 

it  her  writers  place  the  percentage  from  one  to  five  per 

int.     Albeit  also  slated  t  hat  ten  per  cent,  of  all  cases 

ire  traceable  to  carriers,  and  called  attention  lo  (lie 

menace  which  chronic  carriers  are  to  public  health. 

The  hitler  fact  is  being  more  fully  recognized  by  the 

health    authorities    now,    and    attempts    are    being 

made  for  the  control  of  the  problem  in  so  far  as  is 

i  ical. 

A  number  of  eases  have  been  reported  in  which  the 

dejecta    of    chronic    carriers    have    shown    a    mixed 

infection     of     the     paratyphoid     with     the     typhoid 

bacillus.     Also  paratyphoid  bacilli  carriers  have  been 

.. -ported  by  Gaehtgensand  others. 

Bacillary  Dysentery. — As  compared  to  typhoid 
fever,  a  limited  amount  of  work  has  been  done  which 
will  throw  light  upon  the  subject  of  bacilli  carriers 
among  convalescents  from  dysentery  or  of  healthy 
carriers.  But,  taking  up  the  closer  study  of  certain 
epidemics  of  this  disease,  it  seems  possible  that  there 
are  carriers  in  some  instances.  However,  the 
investigations  of  Shiga,  Flexner,  Goodwin,  and  others, 
carried  out  in  a  large  number  of  cases,  have  failed 
to   show   the   presence   of   B.   dysertteriw  in   normal 

Mi.nl- 

In  tivs  disease,  as  in  those  discussed  previously, 
the  so-called  latent  types  apparently  may  be  a  means 
of  spreading  the  infection.  Park  is  of  the  opinion 
that  paradysentery  bacilli  are  distributed  by  carriers 
and  may  in  some  cases  give  rise  to  epidemics.  Duval 
reported  that  he  had  found  in  two  instances  the 
B.  parady sentence  in  the  normal  stool  of  milk-fed 
infants.  Collins  also  found  in  a  few  cases  the  organ- 
ism in  the  normal  stools  of  babies. 

Gonorrhea. — Many  of  the  so-called  cases  of  chronic 
gonorrhea  may  be  considered  in  the  sense  of  being 
gonococci  carriers.  A  certain  percentage  of  the  so- 
called  chronic  or  latent  cases  do  not  show  any  clinical 
manifestations  after  a  certain  length  of  time  following 
the  acute  infection.  Yet  these  persons  are  quite 
capable  of  infecting  others,  and  there  seems  to  be  no 
decrease  in  the  virulence  of  the  organism.  Moreover, 
the  person  is  subject  to  superinfection  from  other 
sources  with  acute  clinical  symptoms  following. 
Apparently  there  is  no  limit  to  the  time  a  man  may 
carry  the  infection  in  chronic  cases.  Park  mentions 
a  ease  in  which  the  organisms  were  abundantly 
present  after  an  exposure  dating  back  twenty  years. 

Another  class  of  carriers  may  be  those  who  have 
experienced  slight  if  any  clinical  symptoms  primarily, 
but  who  carry  the  organisms  and  are  able  to  infect 
others. 

Malta  Fever. — Convalescents  from  malta  fever  in 
some  cases  may  carry,  and  excrete  from  the  bladder 
the  Micrococcus  melitensis  for  a  considerable  time 
after  an  attack  of  the  disease.  Bruce  quoting  the 
work  of  Kennedy  states  that  theorganism  is  excreted 
with  the  urine  in  ten  per  cent,  of  the  cases.  This  is 
continued  in  some  instances  as  long  as  two  years 
after  the  patient  is  convalescent.  Shaw  also  made 
similar  observations.  The  organism  has  been  found 
in  the  gall  bladder  of  man  (Horrochs  and  Kennedy). 
Since  the  urine  not  infrequently  shows  the  organism 
for  considerable  time  after  the  patient's  convales- 
cence, it  is  not  improbable  these  carriers  may  be  a 


i:"  toi   in  i  he    I"-  ad  of  tin-  disease;  i  he  organ!  m 
tains  its  vitau'l  j  and  \  irulem  ,  •  for 

some  I ime. 

Plague— H  is  que  tionable  ii  pe  I  bai  illi  can 
in  i  In-    en  i-  that  we  i  on  ider  t\  phoid  bai  illi  < 

for  example,  are  to  be  recognized.     In  the  bul 

type  ol   the  'ii  ea  e,  com  ale  cent     i nl  Inue  to 

eliminate  virulent  organisms  from  the  affected  gk 
for   a    .-,.,,  iderable  time  after  i  he  otl  ptom 

have  abated.      But  such  a  condition  could  hard] 
included  under  our  definition  of  bacilli  carriei      ( In 
1  be  oi  her  hand,  the  pneu nic  type  of  the  disea  e 

may    in    some    rare    in    tance      afford    examples    which 

simulate   true  bacilli   carrier       Got  i  hlicn   reported 

i  hree  except  lonal  ca  e    b  hicb  can oder  hi    obs 

vation  during  the    Uexandria  pesl  epidemic  in  1899. 

These   cases   were  of   the    pneumonic    type,    and    each 

made  a  recovery;  two  were  complicated  with  bul 

while  the  third  showed  no  bubo.  The  sputa  from 
these  cases  showed  virulent  pi-  t  bacilli  fort  v-ee 
twenty  and  thirty-three  days  after  complete  di  ap- 
pearance of  the  fever.  As  evident,  the  one  case  in 
particular  without  bubo,  (3rd)  might  easily  bave 
escaped  detection,  without  tl»-  bacteriological  exami- 
nations, been  discharged,  and  readily  spread  the  infec- 
tion. Padlensky  states  that  in  an  epidemic  of 
plague  of  the  pneumonic  type,  the  specific  organism 

maj  be  found  On  the  tonsils  of  well  people,  1 1ms  in- 
dicating that  heal l  hy  carriers  may  l  bus  exist.  Bacilli 
isolated  from  such  carriers,  wen-  slightly  virulent  for 
guinea-pigs,  but  after  an  animal  passage  I  lie  vi nil- 
increased,  lie  called  attention  to  the  importance  of 
carriers  in  pest  epidemics,  and  the  need  of  further  in- 
vestigations. (  )l  her  observers  have  noted  the  presence 
of  pest  bacilli  in  the  sputum  for  some  time  after  con- 
valescence of  the  patient.  While  probably  very  rare, 
the  possibility  still  exists  that  in  plague,  among  the 
recovered,  certain  eases  may  be  considered  bacilli 
carriers  for  a  short  time. 

Other  Infectious  Diseases. — Pncumococci  and  strep- 
tococci are  quite  frequently  found  in  the  throats  and 
air  passages  of  normal  persons.  While  these  organ- 
isms are  nearly  as  virulent  to  susceptible  animals  as 
when  obtained  from  diseased  eases,  we  are  not  yet 
certain  whether  they  are  as  capable  of  producing 
disease  in  man.  Many  cases  of  pneumonia  are 
undoubtedly  due  to  autoinfection. 

Concerning  the  tubercle  bacillus  we  need  further 
investigation.  There  may  be  certain  persons  who 
may  harbor  the  bacilli  and  still  give  no  evidence  of 
any  pathological  condition  caused  by  this  organism. 
But  this  supposition  seems  to  be  improbable. 

As  concerns  the  group  of  diseases  caused  by 
filtrable  virus  little  as  yet  has  been  done  in  relation 
to  the  human  carrier.  The  work  of  Osgood  and 
Lucas  upon  poliomyelitis,  showed  that  in  monkeys 
the  virus  remained  viable  and  infectious  in  the  naso- 
pharyngeal mucosa  several  months  after  the  acute 
paralytic  stage  of  the  disease.  But  the  central 
nervous  system  did  not  retain  the  virus,  for  the  same 
length  of  time,  in  a  virulent  condition.  It  is  possible 
that  a  parallel  state  may  exist  in  the  human  con- 
valescent from  this  disease,  and  may  act  as  a  source 
of  infection  to  others  under  certain  conditions. 

Bacteria  carriers,  or  bacilli  carriers,  as  stated,  are 
a  constant,  menace  to  public  health  when  allowed 
unrestricted  freedom.  It  is  imperative  that  such 
cases  bo  recognized  if  possible,  and  the  necessary 
steps  taken,  so  far  as  is  feasible,  to  combat  the  con- 
dition, or  to  prevent  the  spread  of  the  disease  by 
prophylactic  means. 

Patients  recovering  from  these  diseases  should  be 
thoroughly    examined     before     being    discharged     in 

order  to  a  certain  whether  or  not  they  are  free  from 

virulent   organisms.      It    is   essential    that    more    than 

one  examination  should  be  made  of  fecal  discharges 

from  suspected  typhoid  or  cholera  carriers,  when  the 
lirst  examination  has  given  negative  results.     As  the 

879 


Bacteria  Carriers 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


organisms  do  not  appear  constantly  in  the  dejecta 
in  many  of  these  cases,  it  is  evident  that  a  single 
examination  will  not  always  reveal  the  true  condition. 
Medicinal  treatment,  immunization,  or  surgical 
intervention  may  relieve  certain  cases,  but  when 
these  means  are  not  applicable  it  may  be  necessary 
to  quarantine  the  patient.  In  all  cases  in  which  the 
dejecta  carry  infectious  organisms  complete  steriliza- 
tion should  be  employed.  In  safeguarding  a  water 
supply  these  bacilli  carriers  must  always  be  kept  in 
view. 

When  investigating  the  origin  of  an  outbreak  of  an 
infectious  disease,  it  is  always  important  to  bear  in 
mind  the  possibility  of  a  bacteria  carrier  as  the  source. 

L.   W.  Fa.uulener. 


Bacteriacese. — A  family  of  Schizomyeetes,  or  fis- 
sion-fungi, comprising  cylindrical,  more  or  less  elon- 
gated, straight  (never  spiral)  forms,  with  or  without 
flagella,  with  or  without  endospores,  dividing  only  in 
one,  the  transverse,  plane.  It  includes  three  genera: 
1.  Bacterium,  without  flagella:  2.  Bacillus,  with  peri- 
trichal  flagella:  3.  Pseudomonas,  with  polar  flagella. 

Bacteriological  Technique. — The  methods  for  the 
artificial  cultivation  of  bacteria  are  of  fundamental 
importance  in  bacteriology,  and  for  that  reason  de- 
serve very  careful  consideration.  Nutrient  media  of 
various  kinds  are  used,  but  the  three  most  commonly 
employed  are  bouillon,  gelatin,  and  agar.  These  in 
turn  may  be  variously  modified  as  the  needs  of  the 
work  may  require.  In  addition,  other  media  are 
used,  such  as  blood,  serum,  exudates,  eggs,  urine, 
milk,  potatoes,  and  the  like.  These  will  be  severally 
considered. 

Bouillon. — To  prepare  beef  tea,  or  bouillon  as  it  is 
called,  500  grams  of  lean,  chopped  beef  (Hamburger 
steak)  are  placed  in  a  suitable  enamelled  vessel  or  in  a 
one-and-a-half-liter  flask  and  1,000  c.c.  of  ordinary 
tap  water  are  added,  and  the  whole  is  thoroughly 
mixed.  This  may  now  be  set  aside  in  an  ice-box  for 
twenty-four  hours  so  as  to  bring  the  soluble  constitu- 
ents into  solution;  or,  what  is  preferable,  it  may  be 
placed  in  a  water-bath  and  warmed  at  a  temperature 
not  exceeding  60°  C.  for  an  hour.  In  this  way  the 
nutrient  substances  are  dissolved  out  and  much  time 
is  saved.  It  is  not  desirable  at  this  point  to  heat 
the  fluid  above  the  temperature  given,  inasmuch  as 
that  would  lead  to  the  coagulation  of  the  albuminous, 
constituents,  which,  if  they  are  allowed  to  remain  in 
solution,  will  facilitate  the  subsequent  clarification  of 
the  medium.  When  the  digestion  is  completed, 
whether  carried  out  at  a  low  temperature  or  in 
the  water-bath,  the  liquid  is  strained  through  well- 
washed,  starch-free  muslin,  or  the  juice  may  be 
expressed  by  means  of  a  meat  press.  The  liquid  thus 
obtained  is  of  a  dark  red  appearance,  due  to  the 
presence  of  hemoglobin. 

One  thousand  cubic  centimeters  of  the  meat  extract 
are  then  placed  in  a  clean  flask  or  vessel,  and  ten  grams 
of  dry,  powdered  peptone  ( Witte's)  and  five  grams  of 
common  salt  are  added  and  the  whole  is  then  warmed 
at  about  55°  to  60°  C.  till  the  peptone  has  dissolved. 
The  next  step  is  to  render  the  medium  suitably  alka- 
line, since  bacteria  as  a  rule  require  a  slightly  alkaline 
soil.  This  manipulation  requires  special  care,  for, 
if  improperly  done,  the  finished  product  may  be 
cloudy,  or  may  have  a  deposit,  or  may  even  be 
unfit  for  the  growth  of  bacteria.  The  clouding 
and  the  formation  of  a  precipitate  can  be  avoided 
by  boiling  the  meat  extract  after  adding  just  enough 
alkali  to  neutralize  the  fluid.  For  this  purpose  5  c.c. 
of  normal  sodium  hydrate  (four  per  cent,  solution) 
are  added  to  the  liter  of  meat  extract.  This  amount 
is  usually  sufficient  to  make  the  extract  neutral  to 
litmus.     The  liquid  is  then  heated  in  a  boiling  water- 

880 


bath  or  over  a  free  flame  for  about  fifteen  minutes 
after  which  it  is  filtered  through  a  moist  plaited  filter 
and  allowed  to  cool  to  about  50°  C.  As  stated 
bacteria  thrive  best  when  the  medium  is  slightly 
alkaline.  Hence  10  c.c.  of  the  normal  sodium  hydrate 
are  now  added  to  impart  the  desired  alkalinity,  after 
which  the  liquid  is  again  boiled  for  twenty  to  thirty 
minutes,  and  finally  filtered  through  moist  paper. 

Inasmuch  as  considerable  water  is  usually  lost  by 
vaporization  during  the  preparation  of  the  medium 
it  is  advisable  either  to  indicate  the  volume  at  the 
beginning  of  the  operation  by  a  suitable  mark  on  the 
vessel,  or,  better,  to  take  the  weight  of  the  fluid  before 
and  after  heating.  The  difference  in  the  volume  or 
weight  is  finally  made  up  by  the  addition  of  the  corre- 
sponding amount  of  distilled  water.  The  finished 
bouillon  should  make  up  to  the  original  volume  of 
meat  extract,  that  is,  1,000  c.c. 

The  beef  tea  thus  prepared  is  now  filled  into  tubes 
or  into  flasks,  as  the  case  may  be,  and  sterilized  by 
steam.  This  process  will  be  described  later.  It  is 
hardly  necessary  to  add  that  the  bouillon  after  being 
tubed  and  sterilized  should  be  perfectly  clear,  without 
a  deposit,  and  should  have  a  slight  alkaline  reaction. 

For  cultivating  the  gonococcus  Thalmann  recom- 
mends using  the  ordinary  bouillon,  to  which  has  been 
added  two-thirds  to  three-fourths  of  the  amount  of 
alkali  necessary  to  make  it  neutral  to  phenolphthalein. 

Bouillon  may  be  prepared  by  substituting  meat  ex- 
tract in  place  of  the  meat  infusion.  The  preparation 
of  the  meat  extract  bouillon  will  be  considered  later. 

Sugar-free  Bouillon. — The  bouillon  as  just  prepared 
always  contains  some  sugar  derived  from  the  muscle 
tissue  employed.  For  many  purposes  this  sugar  con- 
tent is  undesirable,  and  must  be  removed  in  some  way. 
One  procedure  is  to  allow  the  meat  extract  to  ferment 
at  a  low  temperature,  10°  to  15°  C,  for  two  days. 
Another  is  to  place  the  meat  extract  at  37°  C.  for 
twenty-four  hours.  Neither  one  of  these  methods  will 
give  results  which  can  be  relied  upon.  The  best 
procedure  is  to  add  to  the  meat  extract  a  rich  fluid 
culture  of  some  acid-producing  organism,  such  as 
Bacillus  coli  (Smith),  or  B.  lactis  aerogenes  (Dunham), 
and  then  set  it  aside  to  ferment  at  37°  C.  for  twenty- 
four  hours  or  longer.  The  frothy  liquid  is  then 
carefully  neutralized  by  the  addition  of  normal 
sodium  hydrate,  peptone  and  salt  added,  then  boiled, 
cooled,  and  rendered  alkaline  according  to  the 
directions  given  under  the  preparation  of  bouillon. 
The  sugar-free  bouillon  thus  prepared  does  not  con- 
tain indol,  as  might  at  first  be  supposed.  It  is  pref- 
erable to  the  Dunham  peptone  solution  mentioned 
below  for  testing  for  the  presence  of  indol,  since  a 
good  reaction  is  given  in  sixteen  hours,  whereas  the 
cultures  in  Dunham's  solution  often  require  several 
days  before  giving  a  positive  test. 

Martin's  Bouillon. — The  thoroughly  mixed  meat 
suspension  (500  grams  of  chopped  beef  and  1,000  c.c. 
of  water)  is  set  aside  at  about  37°  C.  for  twenty  hours 
so  as  to  destroy  the  sugar  normally  present.  The 
liquid  is  then  strained  through  well-washed  muslin, 
and  to  1,000  c.c.  of  the  filtrate  five  grams  of  common 
salt  are  added,  after  which  the  liquid  is  neutralized 
and  finally  rendered  alkaline  by  the  addition  of  7  c.c. 
of  normal  alkali  per  liter  of  bouillon.  Ordinary 
peptone  is  not  added,  inasmuch  as  it  is  likely  to  con- 
tain sugar.  Instead,  Martin  adds  to  this  bouillon  an 
equal  volume  of  a  rich  peptone  solution  made  by  digest- 
ing the  stomach  of  a  pig.  This  latter  solution  is  pre- 
pared as  follows:  A  pig's  stomach  is  cleaned  and  cut 
up  into  small  pieces,  and  to  200  grams  of  this  finely 
divided  tissue  1,000  c.c.  of  water  and  10  c.c.  of  con- 
centrated hydrochloric  acid  are  added  and  the  mix- 
ture is  set  aside  at  50°  C.  for  about  twelve  hours. 
The  digested  fluid  is  then  decanted  through  a  filter 
of  absorbent  cotton  and  the  strongly  acid  reaction 
is  reduced  by  the  addition  of  25  c.c.  of  a  sixteen  per 
cent,  solution  of  sodium  hydrate.     The  liquid  is  then 


RKIT.KI'.XCK    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Bacteriological  Technique 


carefully  neutralized,  after  which  ii  is  rendered  alka- 
line  by  the  addition  of  7  c.c.  of  normal  sodium  hydrate 

per  liter.  The  mixture  of  equal  volumes  of  (lie  sugar- 
free  bouillon  and  the  peptone  solution  is  heated, 
filtered,  and  tubed  or  placed  in  flasks. 

Peckliam's  Bouillon. — This  is  made  by  taking  finely 
chopped  beef,  which  must  be  as  old  as  it  can  be 
obtained  in  order  that  it  may  be  free  from  muscle 
sugar,  ami  adding  225  grams  of  it  to  500  c.c.  of  water. 
The  mixture  is  rendered  slightly  alkaline  with  sodium 
Carbonate,  after  which  it  is  placed  in  a  water-bath  at 
40°  C,  and  four  grains  of  trypsin  are  added.  After 
digesting  for  an  hour  the  fluid  is  again  rendered  alka- 
line with  sodium  carbonate.  In  from  one  to  oik1  and 
a  half  hours  the  digestion  should  be  arrested,  other- 
wise traces  of  indol  may  be  detected.  At  the  end  of 
this  period  the  mixture  is  boiled  and  strained  through 
gauze  and  filtered  cold  through  wet  filter  paper  to 
remove  the  fat.  Five  grams  of  salt  and  enough  water 
to  make  up  to  one  liter  are  then  added.  The  acidity 
of  the  clear  straw-colored  filtrate  is  then  reduced  to 
the  desired  point.  The  most  suitable  reaction  for  tin' 
development  of  colon  and  like  bacilli  is  when  the 
medium  contains  such  an  amount  of  free  acid  as  to 
require  from  20  to  30  c.c.  per  liter  of  a  decinormal 
sodium-hydrate  solution  to  bring  it  to  a  point  neutral 
to  phenolphthalein. 

Artificial  digestion  of  muscle  tissue  by  means  of 
pepsin  and  trypsin  is  resorted  to  in  the  preparation 
of  Deycke's  agar. 

Dunham's  Peptone  Solution. — This  is  prepared  by 
dissolving  ten  grams  of  Witte's  peptone  and  five  grams 
of  common  salt  in  1,000  c.c.  of  ordinary  tap  water.  The 
solution  is  then  tubed  and  sterilized  by  steam.  This 
medium  is  used  to  detect  the  formation  of  indol  by 
bacteria,  but  inasmuch  as  many  organisms  fail  to 
grow  in  it  and  others  require  several  days  before 
giving  a  reaction,  it  has  not  been  found  to  be  as 
Suitable  as  the  sugar-free  bouillon  given  above. 

Glucose  Bouillon. — This  is  used  to  test  for  acid  and 
gas  production.  It  is  made  by  adding  to  the  ordinary 
bouillon,  or  better  to  that  which  is  sugar-free,  one 
or  two  per  cent,  of  glucose.  The  two  per  cent. 
solution  is  most  commonly  employed.  The  steriliza- 
tion of  sugar-containing  media  by  steam  requires 
special  care  to  prevent  oxidation  of  the  carbohydrate 
present.  As  a  rule  the  steaming  should  not  exceed 
ten  or  fifteen  minutes  each  day  on  three  successive 
days.  Instead  of  glucose  other  carbohydrates,  such 
as  lactose,  maltose,  saccharose,  dextrin,  etc.,  may  be 
added  to  the  bouillon  in  one  or  two  per  cent,  con- 
centration. 

Mannite-peptone  Bouillon. — The  alcohol  mannite  is 
added  to  sugar-free  bouillon  in  sufficient  quantity  to 
give  a  one  per  cent,  concentration.  This  medium  is 
especially  useful  in  differentiating  organisms  which 
otherwi.  e  closely  resemble  each  other.  For  example, 
the  different  varieties  of  dysentery  bacilli  may  be 
separated,  since  certain  ones  ferment  mannite,  while 
others  do  not. 

Glycerin  Bouillon. — This  is  especially  used  for 
cultivating  the  tubercle  bacillus.  It  is  made  by 
adding  five  per  cent,  of  glycerin  to  the  ordinary 
bouillon.  The  mixture  is  then  tubed  and  sterilized 
in  the  usual  way. 

Carbolic  Bouillon. — This  is  made  so  as  to  contain 
0.1  per  cent,  of  carbolic  acid.  One  gram  of  acid  may 
be  added  to  one  liter  of  bouillon.  The  better  pro- 
cedure is  to  add  1  c.c.  of  a  one  per  cent,  carbolic  acid 
to  9  c.c.  of  bouillon.  It  is  advisable  to  incubate  the 
tubes  for  several  days  so  as  to  eliminate  any  possible 
contamination.  The  medium  is  useful  for  examining 
water  for  the  colon  bacillus,  especially  when  the 
bacterial  contents  are  very  high.  The  presence  of 
the  antiseptic  serves  to  check  or  prevent  the  growth 
of  many  organisms  which  would  otherwise  develop. 
It  should  be  borne  in  mind  that  weak  colon  and 
typhoid  bacilli  are  likewise  restrained. 

Vol.  I. — 56 


i  he  tubes  after  inoculation  with  the  water  are  Incu- 
bated for  twentj  -four  lenu     al   3g    i  ■  ,  ftft<  r  which 
lai  tose  litmus  agar  plate     in    m  uie,  which  are  I 
i  camined  for  red  colonies,     <  if  com  ,•  all  red  colonies 

are  not  to  be  regarded  without  further  stu.lv  OS  the 
colon  bacillus. 

Parietti's  Bouillon. — A  mixture  of  carbolic  acid  and 
hydrochloric  acid  is  first  prepared  l>v  adding   i  c  c. 

of   the   latter   to    100   r.v.   of   a    li         pel    cent,   carbolic 

solul  ion.      I  hi  i    olution  after  s  tanding  a  fe 
added  in  portions  of  o.l,  0.2,  0.3  c.c.  to  portioi 
10  c.e.  each  of  Sterile  bouillon. 

Nitrate  Bouillon. — The  Laboratory  Committee  of 
the  American  Public  Health   \    ociation  recommi 

that  this  medium  be  prepared  by  dissolving  one  gram 
peptone  in  one  liter  of  tap  water  1  amnion  ia-ftv  I ,  and 

then  add  two  grams  of  nitrite-free  potassium  nitrate. 

Ten   cubic  ceiiti lei's  of  I  he  dium  are  placed  in 

test-tubes  and  sterilized  in  the  usual  manner.     It  is 

be   I   to  prepare  the  medium  fresh  before  using. 

Calcium-salt  Bouillon.  Bolduan  found  that  the 
addition  of  certain  calcium  salts  to  plain  broth  gave 
a  medium  nearly  equivalent  to  time  containing 
serum  or  ascitic  fluid  for  the  cultivation  of  the  pneu- 
mococcus,  lueningococcu   .etc.       It  has  I  he  advantage 

of    being    easily    and    rapidly    prepared.     Calcium 

chloride  can  be  used  in  solution  of  I  to  2,000  in  plain 
broth,  while  calcium  carbonate  (marble)  or  calcium 
sulphate  (gypsum)  is  broken  into  small  pier.  ., 
washed  with  water,  added  to  broth  in  test-tubes, 
and  sterilized  in  the  regular  manner.  Pneumococci 
as  a  rule  grow  readily  upon  this  medium,  live  approxi- 
mately as  long  as  upon  ascitic  broth,  and  retain 
their  virulence  equally  well.  Hiss,  working  inde- 
pendently of  Bolduan,  discovered  the  same  advan- 
tages of  calcium  broth  when  cultivating  the  above- 
mentioned  organisms,  his  publication  appearing 
later. 

MacConkey's  Bile-salt  Media. — Bile  salts  and 
various  sugars  enter  into  these  media.  A  stock 
solution  may  be  prepared  without  sugar,  then  the 
sugar  may  be  added  as  desired.  This  solution  is  pre- 
pared by  dissolving  twenty  grams  Witte's  peptone  in 
1.000  c.c.  distilled  water  heated  to  00°  C,  then  to 
this  are  added  five  grams  sodium  taurocholate  (com- 
mercial product).  For  the  medium  one-half  per  cent, 
of  a  freshly  prepared  one-per-cent.  solution  of  neutral 
red  and  the  sugar  are  added.  If  glucose  is  used,  one- 
half  per  cent,  is  added;  in  the  case  of  other  sugars, 
one  per  cent.  The  medium  is  sterilized  in  a  steam 
sterilizer  at  100°  C.  on  three  consecutive  days.  Care 
must  be  exercised  in  order  not  to  overheat  and  split 
the  constituents  in  sterilizing.  Instead  of  using 
distilled  water  as  a  solvent  for  the  ingredients,  beef 
broth  may  be  used,  thus  giving  a  bile  salt  bouillon. 
These  media  are  especially  applicable  in  the  differ- 
entiation of  intestinal  bacteria.  The  formation  of 
both  acid  and  gas  may  be  observed  if  the  organisms 
under  cultivation  possess  such  proper!  ies. 

Colored  Bouillon. — Various  coloring  agents  are 
added  to  the  nutritive  media  in  order  to  bring  out 
the  acid-producing  or  the  reducing  properties  of 
bacteria.  The  substances  which  are  most  commonly 
used  for  this  purpose  are  litmus,  neutral  red,  fuchsin, 
saffranin,  and  sodium  indigo  sulphate.  The  first  two 
are  particularly  useful,  and  are  prepared  the  same  as 
the  corresponding  agar  or  gelatin  media,  which  see. 

Gelatin. — The  ordinary  nutrient  gelatin  is  really 
nothing  more  than  bouillon  to  which  ten  per  cent,  of 
gelatin  has  been  added  so  as  to  impart  solidity  with 
the  additional  advantage  that  the  medium  is  trans- 
parent. The  method  of  preparation  is  as  follows: 
To  1,000  c.c.  of  the  meat  extract,  prepared  according 
to  the  directions  given  under  bouillon,  100  grams 
of  the  best  sheet  gelatin  are  added;  likewise  ten  grams 
of  Witte's  peptone  and  five  grams  of  common  salt. 
The  whole  is  then  warmed  in  a  water-bath  at  00°  C. 

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REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


until  the  gelatin  has  passed  into  solution.  The  liquid 
is  then  neutralized  and  enough  alkali  added  in  excess 
so  as  to  impart  a  suitable  alkalinity.  As  ordinarily 
prepared  the  nutrient  gelatin  requires  from  30  to 
35  e.c.  of  normal  alkali  to  effect  neutralization.  An 
additional  10  c.c.  will  give  the  desired  alkalinity. 
Hence  40  c.c.  of  the  normal  alkali  may  be  added  at 
once  and  the  liquid  tested  with  litmus  paper.  If  the 
liquid  is  not  distinctly  alkaline  more  of  the  reagent 
may  be  added  until  the  desired  alkalinity  is  obtained. 
The  method  of  standardizing  media  by  means  of 
phenolphthalein  will  be  given  later. 

When  the  proper  amount  of  alkali  has  been  added 
to  the  gelatin  solution  the  latter  is  placed  in  a 
water-bath,  the  water  of  which  is  then  raised  to  the 
boiling  temperature.  The  gelatin  is  kept  immersed 
in  the  actively  boiling  water  for  about  three-quarters 
of  an  hour.  Prolonged  heating  or  sterilization  at 
high  temperature  (autoclave)  lowers  the  solidifying 
point  of  gelatin;  therefore  this  must  be  avoided, 
since  it  impairs  the  medium.  The  albuminous  con- 
stituents of  the  meat  extract  coagulate  in  flakes, 
and  at  the  same  time  clarify  the  liquid  so  that  on 
subsequent  filtration  the  gelatin  will  be  perfectly 
clear.  In  case  the  coagulation  of  the  albumin  results 
in  minute  particles,  which  cannot  be  readily  removed 
by  filtration  through  paper,  egg-albumin  may  be 
added  and  precipitated  by  again  heating.  This  is 
brought  about  by  allowing  the  medium  to  cool  down 
to  60°  C.  and  to  each  liter  add  the  whites  of  two  eggs, 
then  thoroughly  mix  by  stirring.  Gradually  bring 
the  temperature  up  near  the  boiling-point,  without 
stirring,  and  keep  there  about  fifteen  minutes.  A 
heavy  coagulum  results,  the  greater  part  of  which 
will  rise  to  the  surface.  This  may  be  removed  by 
straining  through  several  thicknesses  of  cheese  cloth 
or  a  layer  of  absorbent  cotton  placed  in  a  funnel. 
The  gelatin  is  then  filtered  through  a  plaited  filter, 
which  should,  however,  be  first  warmed  by  passing 
through  it  several  hundred  cubic  centimeters  of 
boiling  water.  If  the  paper  and  funnel  are  sufficiently 
warmed  in  this  way  there  is  no  likelihood  of  the  gela- 
tin solidifying  on  the  filter.  The  filtered  gelatin 
should  be  perfectly  clear,  should  possess  a  slight  alka- 
line reaction,  and  should  solidify  when  cooled  under 
running  tap  water.  If  it  meets  these  requirements 
it  is  then  filled  into  sterile  tubes  to  a  depth  of  one 
and  a  half  to  two  inches,  and  finally  the  tubes  are 
sterilized  by  steaming  for  a  quarter  of  an  hour  on 
each  of  three  consecutive  days. 

Whenever  nutrient  gelatin  is  mentioned  in  bac- 
teriological work  it  is  understood  to  be  a  ten  per  cent, 
solution.  This  medium  melts  at  about  23°  C.  That 
is  warm  summer  temperature,  and  for  that  reason 
it  is  sometimes  advisable  to  add  more  gelatin  to  the 
preparation  in  order  to  make  it  more  solid.  A  twelve 
or  even  a  fifteen  per  cent,  solution  of  gelatin  is  used 
under  these  conditions.  Again,  at  other  times  it  is 
desirable  to  employ  a  gelatin  which  is  relatively 
quite  soft,  and  in  that  case  a  five  or  eight  per  cent, 
solution  may  be  made  use  of.  Obviously  the  amount 
of  alkali  necessary  to  neutralize  such  media  will  vary 
from  that  required  for  the  ordinary  gelatin.  The 
great  value  of  the  gelatin  medium  lies  in  the  fact 
that  it  can  be  readily  melted  and  again  solidified, 
and  in  its  transparency.  Moreover,  many  bacteria 
give  rise  to  soluble  ferments  or  enzymes  which  pep- 
tonize or  liquefy  the  gelatin,  whereas  others  are  not 
able  to  do  this.  It  becomes  possible  therefore  to 
divide  bacteria  into  two  large  groups,  according  as  to 
whether  they  liquefy  or  do  not  liquefy  gelatin. 

Glucose  Gelatin. — This  is  made  by  adding  to  the 
clear  filtered  gelatin,  prepared  as  above,  two  per  cent 
of  glucose.     The  material  is  then  tubed  and  sterilized 
the  ~ame  as  ordinary  gelatin.     This  medium  is  par- 
ticularly useful  for  the  cultivation  of  anaerobic  bacteria. 

Glucose  Litmus  Gelatin. — To  the  glucose  gelatin  a 
concentrated   solution   of   litmus   is   added   so   as   to 


impart  to  the  medium  a  deep  blue  color.  This  is 
then  tubed  and  sterilized.  During  the  steaming  of 
this  medium  the  litmus  is  usually  decolorized,  but 
on  subsequent  cooling  the  blue  color  returns.  If  such 
a  medium  is  overheated  in  the  process  of  sterilization 
the  sugar  will  be  altered,  and  as  a  result  the  color  of 
the  litmus  will  change  to  more  or  less  of  a  red. 

For  special  purposes  other  sugars  may  be  added  to 
the  gelatin,  as  in  the  case  of  bouillon.  A  lactose  litmus 
gelatin  is  very  useful  in  differentiating  various  organ- 
isms.   The  amount  added  is  usually  one  or  two  percent. 

Eisner's  Medium. — The  addition  of  gelatin  to  a 
potato  extract,  instead  of  to  a  meat  infusion,  was  first 
resorted  to  by  Holz.  Eisner's  medium  is  essentially 
Holz's  potato  gelatin,  to  which  one  per  cent,  of  potas- 
sium iodide  is  added.  It  can  be  used  to  good  advan- 
tage in  differentiating  between  the  typhoid  and  the 
colon  bacillus,  but  at  the  same  time  it  should  be  re- 
membered that  it  does  not  afford  an  absolute  means 
of  detecting  the  former  organism.  The  method  of 
preparation  is  as  follows:  1,000  grams  of  well-cleaned 
potatoes  are  cut  up  into  lumps  which  are  then  mashed 
as  fine  as  possible,  best  done  by  passing  the  material 
through  a  fruit  press.  The  fineh7  mashed  potatoes  are 
then  placed  in  a  meat  press  and  pressure  is  applied. 
In  this  way  about  -400  c.c.  of  a  dark  liquid  is  obtained 
from  the  kilogram  of  potatoes.  The  potato  juice  is 
then  set  aside  in  an  ice  chest  overnight,  after  which 
it  is  filtered  through  cotton.  Ten  per  cent,  of  gelatin 
and  one  per  cent,  of  potassium  iodide  are  then  added 
to  the  dark  liquid,  and  the  mixture  is  warmed  at 
about  40°  C.  until  the  gelatin  melts.  Inasmuch  as 
the  reaction  of  this  material  varies  considerably  it  is 
necessary  now  to  determine  the  exact  degree  of  acidity 
present,  and  then  to  reduce  this  by  the  addition  of 
the  proper  amount  of  alkali,  so  that  the  resulting 
medium  has  an  acidity  such  that  it  would  require  the 
addition  of  20  c.c.  of  normal  alkali  per  liter  to  make 
the  solution  neutral.  The  acidity  of  the  gelatin  is 
determined  by  titrating  a  portion,  say  10  c.c,  with 
decinormal  sodium  hydrate,  using  litmus  paper  as  an 
indicator.  If,  for  example,  10  c.c.  require  3.2  c.c. 
of  the  decinormal  alkali,  it  will  be  necessary  to  reduce 
the  acidity  by  adding  1.2  c.c.  of  decinormal  alkali, 
or  better  0.12  c.c.  of  normal  alkali  for  every  10  c.c. 
of  gelatin  made.  When  the  proper  degree  of  acidity 
has  been  imparted  to  the  medium,  the  gelatin  is 
placed  in  a  boiling  water-bath  for  three-quarters  of 
an  hour  until  all  the  proteins  have  coagulated,  after 
which  it  is  filtered  through  peper,  filled  into  sterile 
tubes,  and  sterilized  by  steaming  for  fifteen  minutes 
on  each  of  three  consecutive  days. 

Fish  Gelatin. — Five  hundred  grams  of  chopped  fish 
are  added  to  1,000  c.c.  of  water,  and  the  material  is 
digested  the  same  as  given  above  for  ordinary  gelatin. 
To  the  strained  liquid  100  grams  of  gelatin,  forty  grains 
of  salt,  five  grams  of  glycerin,  and  five  grams  of  aspara- 
gin  are  added,  and  the  mixture  when  perfectly  fluid  is 
rendered  slightly  alkaline.  It  is  then  heated,  tubed, 
and  sterilized  as  above.  This  medium  is  particularly 
useful  for  the  growth  of  phosphorescing  bacteria. 

Nutrient  Agar. — One  drawback  to  the  ordinary 
gelatin  is  that  it  cannot  be  used  as  a  solid  medium 
at  temperatures  above  23°  C.  This  has  led  to  the 
introduction  of  agar-agar  as  a  stiffening  agent.  This 
substance  is  a  seaweed  gathered  off  the  coast  of  Asia. 
It  has  no  nutritive  qualities  of  its  own  nor  is  it  lique- 
fied by  bacterial  ferments.  Therefore  it  becomes  a 
very  useful  addition  to  media  for  special  purposes. 
The  preparation  of  nutrient  agar  is  very  simple. 
Ordinary  bouillon  is  first  made  according  to  the  direc- 
tions already  given.  The  agar  may  be  obtained  as  a 
powder  or  in  threads;  in  the  latter  case  the  agar  is 
cut  up  into  very  small  pieces,  and  twenty  grams  itwo 
per  cent.)  is  then  added  to  the  liter  of  bouillon,  which 
should  be  in  a  large  flask,  or,  bettor,  in  an  enamelled 
jar.     The  vessel  and  contents  should  then  be  weighed, 


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REFEREXCF.    HANDBOOK    OF    Nil:    Minn   \I.    51  II 


II  ii  ti  ri..i.iuii  il  Technique 


after  which  the  liquid  should  be  gently  boiled  until 
the  agar  has  completely  dissolved.  The  vessel  is 
now  again  weighed,  and  the  difference  I  i  the 

two  weights  is  made  up  by  the  addition  of  the  proper 
amount  of  distilled  water. 

It  is  advisable  to  place  the  agar  now  in  a  water- 
bath  at  about  50°  C.  for  several  hours  in  ordi 
allow  the  sediment  to  settle  as  much  as  possible. 
The  filtration  of  a  two  per  cent,  agar  is  a  very  slow 
and  tedious  process  even  when  carried  out  in  a  steam 
sterilizer.  It  is  sufficient  for  practically  all  purposes 
to  tiller  through  a  layer  of  cot- 
ton. The  filtrate  thusobti 
is  almost,  if  not  entirely,  clear; 
ordinarily  whatever  little  sedi- 
ment may  be  present  .Iocs  n,,i 
interfere  with  the  usefulness  of 
the  medium.  If  much  sedi- 
ment is  present  in  the  filtrate, 
it  may  be  clarified  by  the  ad- 
dition of  egg-albumin  as  men- 
tioned under  the  preparation 
of  gelatin. 

The  filter  is  prepared  by  plac- 
ing a  piece  of  ordinary  cotton, 
about  two  inches  square,  in  the 
angle  of  a  large 
funnel,  and  then 
while  it  is  held 
down  by  means  of 
a  glass  rod,  a  liter 

Fig.  543. — Filtration  Through  Cotton  Or  SO  of  Very  hot 
Over  a  Porcelain  Plate.      (Novy.)         water      is      passed 

through,  once  or 
twice,  so  as  thoroughly  to  warm  the  funnel.  Event- 
ually the  sedimented  agar  is  carefully  and  slowly 
decanted  on  to  the  cotton  filter.  If  desirable  the 
agar  can  be  filtered  a  second  time.  A  very  con- 
venient arrangement  for  the  rapid  filtration  of 
agar  through  cotton  is  shown  in  Fig.  543.  This 
consists  essentially  of  a  Witte's  perforated  porcelain 
plate,  which  is  steadied  in  place  in  the  funnel  by 
means  of  a  glass  rod  which  passes  through  the  center. 
The  plate  is  covered  with  a  layer  of  cotton  on  which 
a  similar  porcelain  plate  is  placed  to  prevent  the 
cotton  from  floating.  The  funnel  is  inserted  into  a 
strong  vacuum  flask,  which  is  connected  with  a 
Chapman  air  pump.  Boiling  water  is  first  passed 
through  the  filter  to  warm  it  thoroughly,  after  which 
the  agar  is  added  and  suction  applied.  As  soon  as  the 
pump  begins  to  act  the  top  plate  can  be  removed. 

When  it  is  desired  to  make  a  perfectly  clear  medium 
it  should  be  made  with  only  one  or  one  and  a  half 
per  cent,  of  agar  instead  of  two  per  cent.,  as  given 
above.  Such  agar  is  softer  and  can  be  passed  through 
a  previously  moistened  filter  paper,  especially  if  the 
funnel  is  placed  in  a  steam  sterilizer  or  in  a  funnel- 
shaped  copper  water-bath,  such  as  is  shown  in  Figs. 
544  and  545. 

The  filtered  agar  is  then  tubed  and  sterilized  by 
steaming  one-half  hour  on  each  of  three  consecutive 
days,  after  which  it  is  kept  in  an  upright  position;  or 
sterilization  may  be  rapidly  accomplished  by  plai  ing 
the  tubes  in  an  autoclave  (Fig.  559)  and  keeping  at  a 
temperature  of  120°  C.  for  fifteen  minutes.  Agar 
media  modified  by  addition  of  sugars  (or  certain 
chemicals)  cannot  be  sterilized  at  this  high  tempera- 
ture since  those  constituents  are  altered.  When  it  is 
desired  to  make  inclined  or  slant  agar  tubes,  as  many 
of  these  as  are  needed  are  melted  in  a  water-bath 
and  then  inclined  so  that  the  agar  comes  within  an 
inch  of  the  cotton  plug. 

Thtdmann's  Agar. — Five  hundred  grams  of  meat  are 
boiled  for  one-quarter  of  an  hour  with  1,000  c.c.  of 
distilled  water,  after  which  the  mass  is  made  up  to  the 
original  weight  and  strained  through  muslin.  One 
per  cent,  of  peptone  and  0.5  per  cent,  of  salt  are  then 
added   and   the   liquid   is   boiled,   after   which   it   is 


again  made  up  to  the  original  weight,  cooled, 
filtered.     <  ine  and  one-hall    i  then 

added  and  the  weighed  liquid  i  In  a  concen- 

trated salt-water  bath  for  about  three-quart 
hour,  after  which  it  is  again  made  up  to  the  original 
weight.      Thirty   cubic   ei  are   then   titl 

with  normal  sodium  hydrate,  using  phenolphtha 
as  an  indicator.     The  amount  of  alkali  necessary  to 

neutralize  the  entire  a unl  of  agar  is  ascertained, 

and  two-thirds  of  this  quantity  fa  then  added,  in 
portions  and  while  shaking,  to  the  agar.  After  heat- 
tug  fifteen  minutes  the  material  i-  filled  into  tu 

According  to  Thalmann  and  others  this  medium  is 
adapted  for  the  cultivation  of  the  gono 

eially  for  diagnostic  purposes.      A  httli  ms  is 

d  with  the  water  of  condensation,  and  then  by 

s  of  a  wire,  rod,  or  cotton  swab  the  suspension  is 

thoroughly  spread  over  the  surface  of  a  series  of 

inclined  tubes  or  over  Petri  di-hes.  The-,,  when 
kept  for  twenty-four  hours  at  36    37   I  mall, 

glistening  colonies,  which  are  single  or  confluent  and 
:   like  highly  refract  i\  6  dl 

The  medium  is  not  suitable  for  subcultures,  and 
Thalmann  recommends  thai  the  colonies  be  trans- 
planted to  serum  bouillon.  This  is  prepared  by 
adding  to  some  bouillon  two-thirds  to  three-fourth's 
of  the  amount  of  alkali  needed  to  neutralize  the  liquid. 
After  heating  and  filtering,  an  equal  volume  ot 
serum  is  added  and  the  mixture  tubed.  The  tubes 
are  inclined  and  heated  for  one  to  two  hours  at  70°  C. 
on  the  first  and  also  on  tin'  second  day.  and  for  one 
hour  at  100°  Con  the  third  day.  According  to  Wa 
mann  hog  serum  is  just  as  good  as  human  serum  for 
cultivating  the  gonococcus. 

Glucose  Agar. — This  is  made  by  adding  to  the 
filtered  agar,  or  to  so  much  of  it  as  may  be  wanted, 
two  per  cent,  of  glucose.  The  medium  is  then  tubed 
and  sterilized  by  -teaming  for  twenty  or  thirty  min- 
utes on  three  consecutive  days.  It  is  used  especially 
for  the  growth  of  yeasts  and  anaerobic  bacteria. 
If  desired,  it  may  be  colored  with  litmus  as  in  the 
case  of  gelatin.  Lactose,  maltose,  saccharose,  or 
other  sugars  may  be  used  as  a  modification,  instead 
of  glucose.  The  medium  in  either  case  is  made  in  the 
same  manner,  with  similar  percentages  of  sugar. 


i'n.     544. — Double-Walled 
Hot-Water  Funnel. 


1  io.  545.— Single-Wall  Hot-Water 

Funnel  with  Ring  Burner. 


Rnthhrrgcr's  Xcutral-red  Agar. — This  can  be  made 
by  adding  to  a  0.3-per-cent.  glucose  agar  one  per 
cent,  of  a  saturated  aqueous  neutral-red  solution. 
The  typhoid  bacillus  does  not  change  the  color  or 
produce  gas,  whereas  the  colon  discharges  the  red 
and  leaves  a  fluorescing  color.  The  inoculation  can 
be  made  either  by  planting  a  shake  culture  or  by 
making  a  stab  culture,  which  can  then  be  covered 
with  a  layer  of  agar  to  exclude  air  changes.  The 
addition  of  neutral  red  to  bouillon  is  of  service  in 
water  examinations  (Irons.  Jordan). 

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Bacteriolostical  Technique 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Endo's  Fuchsin  Agar. — When  properly  prepared, 
this  medium  ranks  among  the  first  as  a  reliable 
means  of  differentiating  the  Bacillus  typhosus.  It 
is  prepared  as  follows:  To  1,000  c.c.  neutral  three  per 
cent,  agar  (made  in  the  regular  way)  add  ten  grams 
chemically  pure  milk  sugar  (lactose);  5  c.c.  alcoholic 
solution  of  fuchsin  (freshly  filtered);  25  c.c.  ten  per 
cent,  solution  sodium  sulphite;  10  c.c.  ten  per  cent, 
solution  of  soda.  The  milk-sugar  solution  and 
fuchsin  solution  are  added  first  to  the  dissolved 
agar  and  well  mixed.  The  solution  of  sodium  sul- 
phite is  added  gradually  until  the  color  of  the  medium 
disappears.  On  solidifying,  the  medium  should  re- 
main colorless.  Put  in  tubes  (about  15  c.c.  each) 
and  sterilize  in  steamer  for  thirty  minutes  on  three 
consecutive  days.  Keep  tubes  in  the  dark  until 
ready  for  use. 

Endo  ascribes  the  resulting  color  changes  to  the 
fact  that  fuchsin  is  a  hydrochloric-acid  combination 
of  rosanilin.  Rosanilin  is  a  colorless  leucobase,  but, 
in  combination  with  acids,  gives  colored  compounds. 
The  sodium  sulphite  used  in  the  medium  is  just 
sufficient  to  reduce  to  the  colorless  base,  thus  giving 
a  practically  clear  medium. 

In  the  presence  of  sugar  of  milk  such  organisms  as 
B.  coli  liberate  lactic  acid,  which  in  turn  acts  upon  the 
Leucobase,  and  gives  a  deep  red  combination.  But 
the  colonies  of  B.  typhosus  developing  in  this  medium 
do  not  produce  an  acid,  therefore  they  have  a  clear 
glassy  appearance,  or  slightly  bluish  in  transmitted 
light.  Plates  are  made  and  inoculated  in  the  ordi- 
nary manner  from  infective  material.  Incubation  is 
canied  out  at  37°  C.  and,  when  suspected  colonies 
develop,  they  may  be  fished  out,  transplanted,  and 
given  the  agglutination  test  with  specific  serum  to 
identify  positively. 

The  Malachite-green  Enriching  Method  of  Lent:. — 
This  method  has  also  been  used  extensively  in  the 
separation  of  the  typhoid  bacillus,  especially  in  the 
cultivation  from  feces.  The  use  of  malachite  green 
for  this  purpose  was  first  introduced  by  Loelfier. 
Lentz  and  Tietz  have  modified  and  improved  the 
method.  They  direct  that  three  pounds  of  chopped 
lean  beef  be  macerated  in  two  liters  of  water  for  six- 
teen hours.  Express  the  extract,  cook  for  one-half 
hour  and  filter,  add  three  per  cent,  agar  to  the  filtrate 
and  cook  slowly  for  three  hours  to  dissolve.  Then 
add  one  per  cent,  peptone,  0.5  per  cent,  sodium  chlo- 
ride, and  one  per  cent,  nutrose  (may  be  omitted). 
Make  neutral  to  litmus  with  soda  solution,  boil,  and 
filter  into  small  flasks  of  100  c.c.  to  200  c.c.  capacity. 
Before  adding  the  malachite-green  solution,  test 
with  neutral  litmus  paper,  and  slowly  alkalinize  with 
sterile  soda  solution  until  the  litmus  strips  give  a 
distinct  red  violet.  The  crystals  of  malachite  green 
(Hoechst)  should  be  used  to  make  this  solution. 
Lentz  used  different  concentrations  of  the  dye  in 
preparation  of  the  medium,  but  Simon  recommends 
a  concentration  of  1:22,000  as  being  the  most  favor- 
able. In  such  case  make  a  fresh  solution  of  1:22(1, 
and  of  this  add  1  c.c.  to  each  100  c.c.  of  the  hot  agar, 
thus  obtaining  the  required  concentration.  The  me- 
dium is  poured  in  Petri  dishes,  and  allowed  to  cool  for 
use.  Inoculations  may  be  made  upon  its  surface. 
The  dye  inhibits  the  growth  of  B.  coli  and  many  other 
organisms  but  in  the  above  concentration  the  B. 
typhosus  develops  slowly,  usually  from  two  to  four 
days.  When  kept  in  the  incubator  at  37°  C.  typhoid 
colonies  give  the  agar  a  yellow  color.  Test  by  specific 
agglutinating  serum  to  identify.  Results  obtained 
by  different  observers  have  varied.  It  seems  to  be 
difficult  to  secure  a  uniform  preparation  of  malachite 
green. 

Lactose  Litmus  Agar. — This  medium  was  intro- 
duced by  Wurtz,  and  is  very  useful  in  differentiating 
between  typhoid  and  colon  bacilli.  Acid  formation 
in  the  case  of  the  latter  is  indicated  by  a  change 
in   the    reaction    of    the    litmus.      If    this    medium 


is  made  by  the  addition  of  two  per  cent,  of  lactose 
and  litmus  to  the  ordinary  agar  it  will  be  found  that 
even  typhoid  bacilli  will  give  a  slight  acid  reaction. 
This,  however,  is  not  due  to  the  fermentation  of  the 
lactose,  but  to  the  small  amounts  of  muscle  sugar 
derived  from  the  meat.  It  is  therefore  desirable 
that  the  agar  for  this  purpose  should  be  made  out 
of  sugar-free  bouillon,  which  can  be  prepared  accord- 
ing to  the  directions  already  given.  Prolonged  boil- 
ing of  the  agar  must  be  avoided,  inasmuch  as  the  agar 
itself,  since  it  is  a  complex  carbohydrate,  may  split 
off  some  sugar. 

It  is  often  preferable  to  make  the  plain  lactose 
agar  and  to  add  to  the  tubed  and  sterilized  medium, 
whenever  needed,  by  means  of  a  sterile  pipette,  a 
sterile  litmus  solution.  Obviously  other  indicators, 
such  as  rosolic  acid,  neutral  red,  etc.,  may  be  added 
in  the  same  way. 

Glycerin  Agar. — To  the  ordinary  nutrient  agar  pre- 
pared as  above,  five  per  cent,  of  glycerin  is  added. 
The  addition  of  glycerin  serves  to  keep  the  surface 
of  the  medium  moist,  and  at  the  same  time  imparts 
nutritive  qualities  to  the  agar.  This  medium  is  very 
valuable  for  the  growth  of  diphtheria,  glanders, 
pneumonia,  and  tubercle  bacilli. 

Glycerin  Potato  Agar. — In  the  culturing  of  the 
glanders  bacillus  this  medium  has  been  found  to  be 
especially  valuable.  It  may  be  prepared  as  follows: 
well-selected  potatoes  are  peeled,  washed  in  clean 
water,  then  finely  grated  on  a  bread-grater;  500  grains 
of  the  potato  gratings  are  added  to  1.000  c.c.  tap  water, 
and  allowed  to  macerate  about  eighteen  hours  in  the 
ice  box;  then  heat  to  the  boiling-point  for  fifteen 
minutes;  strain  through  several  layers  of  cheese 
cloth,  or  better  a  layer  of  absorbent  cotton;  to  the 
measured  fluid  add  two  per  cent,  of  Witte's  peptone, 
and  one-half  per  cent,  of  sodium  chloride,  dissolve 
by  heating;  one  and  one-half  per  cent  of  agar  is  now 
added  and  dissolved  by  heating  in  the  autoclave  for 
one  hour;  the  mixture  is  made  neutral,  using  phenol- 
phthalein  as  an  indicator;  when  cool,  add  the  whites  of 
two  eggs,  mix  thoroughly,  heat  in  Arnold  sterilizer  for 
forty-five  minutes;  five  per  cent,  of  glycerin  is  added 
to  the  filtered  solution,  then  the  medium  is  tubed  and 
sterilized  in  the  autoclave  for  thirty  minutes. 

Mannite  Agar. — Mannite,  which  like  glycerin  is  a 
polyatomic  alcohol,  was  first  used  by  Norris  and  Hiss 
as  a  means  of  differentiating  the  typhoid  from  the 
dysentery  bacillus.  The  latter  organism  (Shiga  type) 
does  not  give  rise  to  acid  production  when  grown  on 
mannite  media,  whereas  the  typhoid  bacillus  does. 
The  agar  should  be  prepared  from  sugar-free  bouillon, 
and  to  it  one  or  two  per  cent,  of  mannite  is  then 
added.  Litmus  may  be  added  to  the  bulk  medium 
before  it  is  tubed,  or  the  sterile  litmus  solution  may  be 
added  to  the  sterile  tubed  agar  by  means  of  a  pipette 
whenever  needed. 

Pfeiffer's  Blood  Agar. — This  is  made  by  spreading 
over  the  surface  of  ordinary  inclined  agar  a  few  drops 
of  human  blood.  On. the  surface  thus  prepared  one  is 
able  to  cultivate  the  influenza  bacillus.  The  blood 
from  the  lower  animals  can  be  used  in  like  manner  to 
good  advantage. 

The  human  blood  required  for  this  and  similar  pur- 
poses can  be  drawn  without  difficulty  by  means  of  a 
sterile  syringe  from  the  large  median  vein  just  below 
the  flexure  of  the  elbow.  The  superficial  circulation 
should  first  be  impeded  by  means  of  a  rubber  tube 
tied  about  the  middle  of  the  arm.  The  surface  of  the 
skin  over  the  vein  to  be  punctured  is  thoroughly 
cleaned  by  means  of  a  disinfecting  solution,  such  as 
mercuric  chloride  or  lysol.  The  needle  of  the  sterile 
syringe  is  then  introduced  into  the  vein,  and  as  the 
piston  is  slowly  withdrawn  the  syringe  fills  with  blood. 
Five  or  ten  cubic  centimeters  of  blood  can  thus  be 
obtained  in  a  few  minutes.  When  the  needle  is 
withdrawn  a  compress  of  cotton,  soaked  in  mercuric 
chloride,  should  be  applied  to  the  wound.     The  blood 


884 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   S(  II  \<  1  - 


Hi.  i  .-i  iiii.it:  l<:i!  Tecbnlqne 


must  be  al  unci'  transferred  either  to  the  surface  oi 
inclined  agar  or  to  previously  melted  agar,  cooled  t" 

,50°  C.     In  the  lal  ter  case  it  is  mixed  at  once,  and  I  lie 

tube  is  then  set  aside  in  an  inclined  position  to  solidify. 

Thalhimer's  Blood  Agar. — This  medium  is  a  simple 

modification  of  former  methods  for  the  preparation 

of  blood  near.  It  is  prepared  as  follows:  fre  hly 
drawn  beef  blood  is  collected  in  a  suitable  jar,  contain- 
ing a  number  of  medium-sized  marbles,  and  defibrin- 
ated  by  thoroughly  shaking.  To  the  defibrinated 
blood  an  equal  volume  of  distilled  water  is  added  and 
laking  is  brought  about.  The  laked  blood  is  passed 
through  a  sterile  Reichel  filter  to  remove  bacteria. 
Of  the  clear,  red  filtrate  20  to  30  c.c.  are  added  to  a 
liter  of  sterile,  melted  agar  at  45°  C.  The  resulting 
medium  is  clear,  and  bright  red  in  color.  The  in- 
fluenza bacillus  grows  readily  upon  this  medium. 
Also,  the  pneumococcus,  streptococcus,  and  the 
gonococcus  grow  luxuriantly.  This  medium  is  not 
applicable  to  the  study  of  the  hemolytic  properties 
of  an  organism. 

Blood-agar  Mixture. — As  mentioned  above,  human 
blood  may  be  mixed  with  melted  agar,  cooled  to  5(1° 
C,  after  which  the  mixture  may  be  allowed  to  solidify 
in  an  inclined  position.  For  diagnostic  purposes  this 
procedure  has  been  utilized  to  detect  the  presence  in 
the  blood  of  typhoid  bacilli,  gonococci,  and  other 
organisms.  Instead,  however,  of  allowing  the  blood 
mixture  to  solidify  in  the  tube  it  is  poured  out  into  a 
sterile  Petri  dish,  and  in  this  way  a  blood-agar  plate 
is  obtained,  on  which  eventually  colonies  of  the  sus- 
pected organism  may  develop.  The  presence  of  a 
very  few  organisms  can  thus  be  detected  in  1  or  2  c.c. 
of  blood,  which  would  not  be  possible  by  direct 
examination  or  by  staining.  The  amount  of  blood 
which  is  added  to  the  agar  may  be  varied  according 
to  circumstances.  Thus  it  may  be  one  to  four,  one 
to  two,  or  even  one  to  one. 

Blood  from  the  lower  animals  can  be  drawn  under 
strictly  aseptic  conditions  into  sterile  Nuttall's  blood 
pipettes,  or  into  the  modified  form  of  Novy, 
shown  in  Fig.  546.  This  can  be  easily  made 
from  test-tubes  of  various  sizes,  according  to 
the  kind  of  animal  to  be  bled.  Thus  a  five- 
eight  lis  by  five-inch  test-tube  may  be  used  for 
bleeding  a  mouse  or  rat,  while  a  one  by  eight- 
inch  tube  would  be  used  in  the  case  of  a  rab- 
bit. The  bottom  of  the  test-tube  and  the  end 
of  a  piece  of  glass  tubing  are  softened  in  the 
flame  of  a  blast  lamp  and  then  brought  to- 
gether. A  narrow  blast  flame  is  then  directed 
against  the  test  tube  about  an  inch  from  the 
bottom.  On  slow  rotation  in  a  horizontal 
position  a  thickened  constriction  results,  and 
as  soon  as  this  is  sufficiently  thick  the  two 
ends  are  drawn  apart  slowly.  A  tapering 
capillary  results,  which  is  then  sealed  in  the 
flame  at  a  point  about  two  inches  from  the 
tube  proper.  The  tube  is  then  plugged  with 
cotton  and  sterilized  by  dry  heat.  When  it  is 
desired  to  prepare  sterile  defibrinated  blood  a 
drawn-out  tube  or  a  narrow  glass  rod  is  passed 
through  the  center  of  the  plug.  By  moving 
this  about,  after  the  blood  has  been 
received  in  the  pipette,  complete 
defibrination  can  be  obtained,  and 
that  without  any  contamination 
from  the  outside. 
In  the  case  of  the  larger  animals  the  blood  is  best 
drawn  from  the  carotid  artery.  For  this  purpose  the 
animal  is  anesthetized  and  the  artery  exposed  for 
about  an  inch.  After  the  first  incision  it  is  advisable 
to  avoid  the  use  of  cutting  instruments,  and  instead 
to  separate  the  tissues  with  the  fingers.  Pressure 
forceps  is  then  applied  at  the  distal  end  of  the  artery. 
Another  pair  is  then  applied  about  an  inch  below  this 
point.  A  finger  is  then  placed  under  the  clamped 
portion  of  the  artery  and  a  very  slight  opening  is 


Fio.  546. — Blood 
Pipette,  Novy  Form 


made  into  the  bl l-ve    •  I.     'I  be  blades  of  a  very 

narrow-pointed  pair  of  forceps  are  then  Introduced 
into  the  opening,  and,  when  distended,  the  tip  of  the 
sterile  blood  pipette  can  readily  be  ced.     Be- 

fore i  his  is  done,  hou-e\  iT,  thi   tip  ehed 

with  a  file,  then  broken  off,  and  the  ope,,  end  sh< 

be   il: id  for  a  moment    to   u 

round  off  I  lie  -harp  edge.  \  oon  B  I  he  pipi  tte  is 
in  position  the  lower  clamp  is  removed,  when  the 

blood  rapidly  rises  in  the  tube.     If  defibrinated  bl 1 

i    desired,  the  blood  should  be  stirred  by  an  a 
\\  he,,  serum  is  wanted,  this  si  irring  is'  omitti  d. 
oi  m  as  blood  ceases  to  flow .  i  he  pipe!  te  i-  rem.. 
and  the  tip  is  sealed  in  the  bias!  lamp. 

Obviously  in  the  case  of  small  animal  the 

mouse  or  rat,  this  procedure  is  nol  applicable.     The 
blood  may  be  drawn  up  into  a  syringe  from  the  art 
A  much  better  way,  however,  i-   to  take  the   blood 
directly  from  the  heart  into  a  small  pipette  oi    the 
same  form  as  that   used  for  the  larger  animals.     For 
this  purpose  the  thorax  is  opened,  the  heart  is  f 
from  the  pericardium  and  rai  ed  by  mean    of  oval- 
tipped  forceps.     The  tip  of  the  pipette  i-  thi 
duced   into   the   right   ventricle.     Suction    may   be 
applied  to  the  other  end  of  t he  pipette  in  order  to 
obtain  the  fullest  possible  yield. 

I'l 1    can    be   drawn    from   very  large  animals, 

such  as  the  horse,  by  introducing  a  linear  into  the 
jugular  vein.  This  is  the  procedure  which  is  followed 
in  the  preparation  of  antitoxins.  The  trocar  is 
connected  by  means  of  a  short  rubber  tube  with  a 
glass  tube,  which  is  inserted  into  the  receiving 
cylinder.  In  this  way  several  liters  of  blood  can  be 
drawn  from  the  horse  at  each  bleeding. 

In  ordinary  laboratory  work  the  blood  which  lias 
been  collected  in  the  glass  pipettes  is  then  transferred 
to  melted  agar,  which  has  been  previously  cooled  in 
the  water-bath  to  50°  C.  The  amount  of  blood  which 
is  added  to  each  tube  will  vary  with  the  purpose  in 
view.  It  may  be  one  part  of  defibrinated  blood  to 
ten  of  agar  or  one  to  five,  one  to  two,  or  one  to  one, 
as  the  case  may  be.  Exceptionally  mixtures  of  two 
to  one  and  three  to  one  are  used.  The  blood  is  then 
mixed  with  the  agar  and  the  tubes  are  set  aside  to 
solidify  in  an  inclined  position.  The  transfer  of  the 
blood  to  the  tubes  is  best  accomplished  by  means  of  a 
sterile  drawn-out  bulb  pipette,  such  as  is  shown  in 
Fig.  578,  e. 

The  blood  agar  thus  prepared  requires  no  further 
sterilization,  for  if  the  operation  has  been  properly 
carried  out  no  organisms  will  be  present.  The  tubes 
can  be  used  for  culture  purposes  at  once,  or  the}'  may 
be  kept  for  several  days  to  allow  any  organisms  which 
might  be  present  to  develop.  This  blood  medium  is 
invaluable  for  the  cultivation  of  various  pathogenic 
organisms.  On  such  media  it  has  been  possible, 
for  example,  to  grow  for  the  first  time  pathogenic 
protozoa — Trypanosoma  lewisi  of  rats  and  Trypano- 
soma brucei  the  cause  of  nagana  or  the  tsetse-fly 
disease  (Novy  and  McNeal).  In  studying  the  hemo- 
lyzing  properties  of  bacteria,  it  is  more  satisfactory 
to  prepare  blood-agar  plates.  Usually  one  part  of 
sterile,  defibrinated  or  cit rated  blood  is  added  to 
nine  parts  of  sterile  agar  at  45°-50o  C,  well  mixed, 
then  poured  into  Petri  dishes  to  harden.  The  cit  rated 
blood  is  prepared  by  bleeding  directly  into  a  sterile 
solution  of  sodium  citrate  of  such  concentration  that 
the  resulting  blood  mixture  will  contain  one  per  cent. 
of  the  salt — this  prevents  coagulal  ion.  The  organisms 
under  investigation  may  either  be  mixed  with  the 
blood  agar  while  at  a  temperature  of  l~>°  C.  before 
plates  are  poured,  or  may  be  streaked  over  the  sur- 
face of  the  medium  after  hardening  has  taken  place 
in  the  dish. 

Nory  and  McNi  al's  Blood  Agar  for  Trypanisomes. — 
Novy  and  McNeal  have  succeeded  in  cultivating  a 
number  of  the  Trypanosoma!:!  [Tr.  lewisi,  Tr.  brucei, 
Tr.  evansi,  and  others)    upon   a   specially   prepared 


SS5 


Bacteriological  Technique 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


artificial  medium.  It  is  made  as  follows:  125  grams 
of  rabbit  or  beef  meat  are  extracted  in  1,000  c.c.  of 
distilled  water;  add  two  per  cent,  of  Witte's  peptone, 
one-half  per  rent,  of  salt,  and  two  per  cent,  of  agar. 
Then  make  alkaline  by  adding  10  c.c.  of  normal 
sodium  carbonate.  The  agar  thus  prepared  is  tubed 
and  sterilized  in  an  autoclave  at  110°  C.  for  thirty 
minutes. 

When  cooled  to  about  50°  C,  two  volumes  of  defi- 
brinated  rabbit's  blood  are  added  and  the  mixture  is 
allowed  to  solidify  in  an  inclined  position.  After  the 
agar  has  solidified,  the  water  of  condensation  which 
settles  at  the  bottom  of  the  tube  is  inoculated  with  a 
drop  of  freshly  drawn  blood  from  the  infected  animal. 
The  above  investigators  found  that  even  the  first 
generation  thrives  upon  this  medium,  and  transfers 
grow  luxuriantly. 

Dieudohne's  Blood-agar  Medium. — This  selective 
medium  has  proved  to  be  of  high  value  in  the  isola- 
tion of  the  cholera  vibrio  from  intestinal  discharges. 
Owing  to  its  alkalinity  it  exerts  an  inhibiting  influence 
on  the  growth  of  fecal  bacteria  other  than  the  spirilla 
group.  It  is  usually  prepared  as  follows:  30  c.c.  of 
defibrinated  ox  blood  are  added  to  30  c.c.  of  "NaOH 
solution,  thoroughly  mixed,  then  heated  forty-five 
minutes  at  100°  C.  in  the  steam  sterilizer.  While 
still  hot  mix  with  140  c.c.  hot  nutrient  agar,  and 
pour  thick  plates.  The  nutrient  agar  is  prepared 
in  the  ordinary  way,  excepting  it  contains  three  per 
cent,  of  agar,  and 'must  be  neutral  to  litmus.  After 
pouring  the  plates  they  are  partially  dried  by  first 
leaving  the  dishes  open  at  room  temperature  for 
twenty  minutes,  then  placing  them  in  an  oven  for 
twenty  to  thirty  minutes  at  50°-60°  C;  finally,  the 
partially  covered  plates  are  placed  in  an  incubator 
at  37°  C.  over  night.  This  treatment  is  necessary 
before  the  cholera  vibrio  will  grow  upon  the  medium. 

Several  modifications  of  the  medium  have  been 
reported.  It  has  been  found  that  the  meat  infusion 
may  be  omitted  from  the  nutrient  agar  with  the 
advantage  that  the  reaction  need  not  be  corrected 
(Pergola).  Pilon  found  that  by  using  a  twelve  per 
cent,  solution  of  sodium  carbonate  (crystals)  instead 
of  the  sodium  hydrate  the  plates  could  be  prepared 
for  immediate  use  without  the  heating  of  the  blood 
mixture. 

Krumwiede  found  that  whole  egg  might  be  sub- 
stituted for  the  ox  blood,  and  recommends  the  follow- 
ing formula,  which  includes  the  modifications  men- 
tioned above,  for  a  medium:  equal  parts  of  water 
anil  whole  egg  are  thoroughly  mixed,  then  add  a  like 
volume  of  12-13.5  per  cent,  sodium  carbonate  solu- 
tion, shake  mixture,  then  filter  through  a  thin  layer 
of  cotton:  steam  twenty  minutes  in  the  Arnold  ster- 
ilizer. Thirty  parts  or  this  product  are  added  to 
seventy  parts  of  boiling  hot  agar,  well  mixed,  then 
medium  thick  plates  are  poured.  The  agar  is  meat 
free,  and  is  composed  of  peptone  and  salt  as  commonly 
prepared,  and  three  per  cent,  of  the  agar.  The  plates 
are  dried  at  room  temperature  for  twenty  to  thirty 
minutes,  then  surface  inoculations  may  be  made  at 
once. 

This  modification  offers  several  advantages;  it  is 
a  translucent  medium  which  may  be  quickly  pre- 
pared for  use,  and  gives  distinctive  colonies  of  the 
vibrios. 

Serum  Agar. — This  is  made  by  adding  variable 
amounts  of  sterile  serum  to  the  melted  agar,  which 
has  been  cooled  to  50°  C.  in  the  water-bath.  The 
serum  can  be  obtained  by  collecting  the  blood,  as 
given  above,  in  sterile  pipettes.  The  blood  is  allowed 
to  clot,  and  eventually  when  the  serum  has  separated 
it  can  l>e  drawn  up  into  sterile  bulb  pipettes  and 
transferred  to  the  melted  agar.  The  largest  yield  of 
serum  is  obtained  by  using  t  lie  Latapie  pipette  shown 
in  Fig.  547.  This  consists  of  an  inner  tube,  which 
is    freely    perforated  and   the   narrow  outer  end  of 


which  is  drawn  out  into  a  capillary  for  insertion  into 
the  blood-vessel.  This  tube  is  held  in  position  within 
the  outer  one  by  means  of  a  rubber  stopper.  The 
outer  receiving  tube,  which  is  about  an  inch  in  diam- 
eter, is  provided  with  two  side  tubes,  one  of  which  is 
drawn  out  and  sealed  while  the  other  is  plugged 
with  cotton.  The  entire  pipette  is  first  sterilized 
by  steaming  in  an  autoclave.  The  tip  of  the  inner 
tube  is  then  broken,  flamed,  and  inserted  into  the 
carotid  artery  of  a  rabbit  or  other  animal.  The 
blood  should  not  fill  the  pipette  beyond  the  inner 
tube.  The  tip  is  then  sealed  and  the  pipet  te  is  allowed 
to  remain  in  a  vertical  position  until  the  blood  has 
firmly  clotted.  It  is  then  inverted  and  the  serum, 
as  it  is  squeezed  out  of  the  clot,  falls  to  the  bottom. 
The  purpose  of  the  perforated 
inner  tube  is  to  allow  more  com- 
plete shrinking  of  the  clot.  The 
serum  drains  away  at  once  from 
the  clot,  and  is  therefore  perfectly 
clear.  When  it  is  desired  to  re- 
move the  serum  the  tip  of  the  side 
tube  is  scratched  with  a  file,  then 
broken  off,  and  the  end  is  flamed 
to  insure  absence  of  bacteria.  The 
tube  is  then  inserted  into  a  sterile 
test-tube  or  flask  and  by  blowing 
into  the  other  side  tube  the  serum 
is  forced  out.  It  can  then  be  dis- 
tributed to  the  agar  tubes  by 
means  of  a  sterile  bulb 
pipette.  These  are  ^_^^ 
then  allowed  to  solidify  "  *  '■ 
in  an  inclined  position. 
As  in  the  case  of  blood 
agar  the  medium  prepared  in  this 
way  is  perfectly  sterile  if  the 
manipulation  is  properly  carried 
out.  Inasmuch  as  sterilization 
by  heat  is  avoided,  the  protein 
constituents  of  the  serum  remain 
in  as  near  to  the  native  condition 
as  possible.  Such  serum  agar 
makes  an  excellent  medium  forFio.  547 —Blood  Pipetto 
the  pneumococcus  and  for  other  Latapie. 

organisms.  Obviously,  serum-agar 
plates  can  be  prepared,  if  it  is  so  desired,  in  which 
case  the  melted  and  cooled  agar  is  inoculated  with  the 
organism  to  be  cultivated,  after  which  the  serum  is 
added  and  mixed  with  the  agar,  which  is  then  poured 
out  into  sterile  Petri  dishes. 

Serum  agar,  made  by  adding  human  blood  serum 
to  melted  agar,  has  been  used  for  the  cultivation  of 
the  gonococcus  (Wertheimer).  Ascitic  or  pleuritic 
fluid  may  also  be  added  to  agar  in  the  proportion  of 
one  part  of  the  fluid  to  two  parts  of  the  agar.  Such 
agar  is  used  especially  for  the  cultivation  of  the 
gonococcus.  The  ascitic,  pleuritic,  or  hydrocele 
fluids  may  be  sterilized  by  fractional  sterilization  or 
by  filtration  through  a  Berkefeld  filter  underpressure. 
Wassermann's  Serum-nutrose  Agar. — This  also  has 
been  found  useful  for  cultivating  the  gonococcus. 
Five  cubic  centimeters  of  hog  serum  are  added  to  30  to 
35  c.c.  of  water,  2-3  c.c.  of  glycerin,  and  0.8-0.9 
grams  of  nutrosc.  Nutrose  is  a  sodium-phosphate 
casein  compound,  and  when  added  to  serum  prevents 
coagulation  on  boiling.  The  solution  is  boiled  for 
twenty  minutes,  after  which  it  is  added  in  equal 
parts  to  two  per  cent,  peptone  agar  in  test-tubes. 
This  mixture  is  then  poured  into  Petri  dishes.  Nu- 
trose has  been  used  also  in  the  preparation  of  the 
Drigalski-Conradi  agar.  Hog  serum,  which  is  said 
to  be  as  good  as  human  serum  for  cultivating  the 
gonococcus,  has  been  employed  also  by  Thalmann. 

Drigalski-Conradi  Agar.— This  is  a  meat-peptona 
nutrose  agar  containing  lactose,  litmus,  and  crysta 
violet.  The  preparation  is  as  follows:  1.  A  mixturi 
of  three  pounds  of  meat  and  two  liters  of    water  is 


SS6 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Bacteriology  :.i  Ti-cimiquo 


allowed  h>  stand  for  twenty-four  hours;  the  expressed 
meal  juice  is  then  boiled  for  one  hour  and  altered, 

To  (lie  filtrate  arc  added  JO  grams  of  \\  itte's  pep- 
tone, 20  grains  of  nutrose,  lit  grams  of  -odium 
Chloride,  and  the  whole  is  boiled  for  One  hour  and  fil- 
tered.   To  this  filtrate  sixty  grams  of  agar  are  added 

and  the  liquid  is  boiled  for  three  hours,  or  < hour  in  an 

autoclave.  It  is  then  rendered  alkaline  to  litmus  paper, 
boiled  half  an  hour,  and  filtered.  L\  A  sol  ut  ion  of  litmus 
is  prepared  according  to  Kubel-Tiemann  as  follows: 
The  powdered  commercial  litmus  is  repeatedly  ex- 
tracted with  hot  distilled  water.  The  liquid  is  acidu- 
lated with  dilute  acetic  acid  and  evaporated  to 
syrupy  consistence  on  a  water-bath.  The  thick  fluid 
is  then  diluted  by  the  gradual  addition  of  ninety- 
per-eent .  ali  ill  ml,  transferred  to  a  flask,  and  an  excess 
of  ninety-per-eent.  alcohol  is  added.  Tins  precipi- 
tates I  lie  blue  pigment,  while  the  red  dye  and  I  lie 
potassium  acetate  remain  in  solution.  The  precipi- 
tate is  filtered  and  washed  with  alcohol,  then  dis- 
solved in  distilled  water,  after  which  the  solution  is 
wanned  and  filtered.  The  filtrate  is  then  added 
gradually  to  very  dilute  sulphuric  acid  (one  or  two 
drops  of  acid  to  200  c.c.  of  water)  till  the  color  changes 
to  a  wine  red.  The  concentrated  blue  is  then  added 
till  the  blue  color  is  restored;  200  c.c.  of  this  litmus 
.solution  is  boiled  for  ten  minutes,  then  thirty  grams  of 
pure  lactose  are  added,  and  the  boiling  is  continued 
for  fifteen  minutes.  3.  The  hot  litmus  is  added  to 
the  hot  agar,  mixed,  and  the  reaction  is  made  slight  ly 
alkaline;  4  c.c.  of  a  hot  sterile  solution  of  ten-per-cent. 
anhydrous  soda  and  20  c.c.  of  a  freshly  prepared 
solution  of  0.1  gram  of  crystal  violet  in  100  c.c.  of 
warm  sterile  water  are  then  added,  after  which  the 
material  is  filled  into  tubes  or  flasks.  Excessive 
heating  should  be  avoided,  inasmuch  as  it  alters  the 
lactose.  The  crystal  violet  is  intended  to  restrict  the 
development  of  the  unimportant  bacteria. 

The  Drigalski-C'onradi  medium  has  been  recom- 
mended for  the  isolation  of  the  typhoid  bacillus. 
For  this  purpose  the  feces  should  be  diluted  with 
ten  to  twenty  volumes  of  salt  solution.  The  authors 
employ  large  plates,  fifteen  to  twenty  centimeters 
in  diameter.  The  agar  is  poured  into  the  dishes  to  a 
depth  of  at  least  two  millimeters  and  the  cover  is  then 
kept  off  till  the  moisture  has  dried  from  the  surface 
of  the  agar.  By  means  of  a  five-millimeter  glass 
rod,  bent  at  right  angles  and  previously  dipped  in 
the  suspension,  a  series  of  streaks  are  made  over  a 
number  of  the  dishes.  The  inoculated  plates  are  then 
kept  at  37°  C.  for  twenty-four  hours.  The  colon 
colonies  are  large,  opaque,  and  red,  while  the  typhoid 
are  small,  glassy,  and  resemble  dewdrops.  The  further 
identification  of  the  suspected  colony  is  made  by 
applying  the  agglutination  test  and  by  growing  in 
Rothberger's  neutral  red  agar. 

MucConkey's  Bile-salt  Agar. — This  medium  is  pre- 
pared by  dissolving  one  and  one-half  or  two  per  cent, 
of  agar  in  bile-salt  bouillon  stock  solution  (see  bile-salt 
medium).  If  necessary  it  is  cleared  with  egg-albumin. 
Neutral  red  and  a  given  sugar  are  then  added,  as 
in  the  case  of  the  broth  preparation.  It  is  used  in 
the  examination  of  feces,  sewage,  etc.,  for  intestinal 
bacteria.  The  method  of  procedure  is  practically 
the  same  as  that  given  under  the  Drigalski  and 
Conradi  medium.  The  growth  of  most  bacteria  is 
inhibited,  while  that  of  B.  coli  and  B.  typhosus  is 
not.  Colonies  of  acid-producing  bacteria  appear 
rose-red  in  color.  Alkali  gives  a  yellow-red  with 
this  indicator  on  plates.  Other  modifications  are 
used  by  water  analysts. 

Esculin  Bile-salt  Agar. — This  medium  is  recom- 
mended by  Harrison  and  van  der  Leek  in  water 
analysis  for  the  detection  of  B.  coli  and  certain  other 
excretal  organisms.  For  its  preparation  they  give 
the  following  method:  15  grams  of  agar,  2.5  grams 
of  commercial  bile  salt,  and  10  grams  peptone 
(Witte)  are  dissolved  by  boiling  in  1,000  c.c.  distilled 


water.    The    solution    I      neutralized    with    normal 

solution     of    sodium     In. Irate.      After    cooling    dl 

below   tin1    ( '.  t  lie  v.  hite    ,,f  i  wo  eL'L--  ai 

i -It  i  Mi  ii  i  i     heated  |,i  boiling  to  coagulate  I  he  albumin; 

i  he  coagulum  i-  removed  by  filtration.     If  i 

it    is  neutralized  again,  and   to  the   hoi    filtrate  are 

added     1     gram    esculin     (Merck)     and     I     gram     iron 

citrate    scales    (Merck).      After    solution    of    tl 
substances  the  a<  idity  is  taken  with  decinormal    oda 
solution,     if  the  acidity  proves  high,  alkali  is  added 

to  bring  down  to    ,  0.6,  if  too  low.  more  iron  citral 
added  until  I  he  react  ion  is    t  0.6.     Sterilize  by  steaming 

twenty  to  thirty  minutes  on  three  consecutive  d 
[f  the  direct  it  1 1  efully  followed  in  the  prepara- 

tion of  this  medium  it  is  claimed  that  ati  factory  and 
even  results  will  be  obtained.   The  reaction  with  a. 

and  some  other  organisms  is  due  to  the  splitting  of 
the  esculin  into  glucose  and  e  culetin;  the  esculetin 
unites  with  the  iron  in  the  medium  to  form  a  dark- 
brown  salt.  The  medium  must  be  sugar-free  in  order 
to  give  the  reaction.  Ik  lactis  aerogenes  gives  the 
nin  lion  but  if  may  be  included  in  "pre  uinptive 
tests"  as  an   excretal  organism.      Some    moulds   and 

laet,.-e  fermenting  yeasts  also  gives  the  test,  a  fact 

which    must    be    considered    in    certain    examinations. 

/;.  re//  coii  uiies  in  this  medium  appear  black  with  a  black 
halo  about  them.  While  />'.  typhosus  grows  well  upon 
this  medium,  it  does  not  produce  the  color  reaction. 

Matzuschita's  Liver-gall  Agar. — This  medium  is 
especially  recommended  for  the  cultivation  of  the 
intestinal  flora.  It  is  prepared  a  follows:  Take 
500  grains  of  finely  chopped  ox-liver;  30  grams 
peameal;  add  1  liter  of  distilled  water  and  cook 
until  the  soluble  constituents  are  extracted.  The 
residue  is  removed  by  straining  through  muslin,  and 
to  the  filtrate  add  7  grams  peptone,  5  grams  sodium 
chloride,  and  0.2  gram  hydrochloric  acid.  The  whole 
is  carefully  shaken  and  then  allowed  to  stand  at 
37°  C.  for  three  hours.  After  this  600  grams  of 
ox-gall  are  added,  and  the  whole  is  again  allowed  to 
stand  for  three  hours  at  incubator  temperature.  It 
is  then  heated  for  some  time,  filtered,  and  sufficient 
agar  (two  per  cent.)  is  added  to  give  solid  medium. 
Filter,  place  in  tubes,  and  sterilize.  This  medium, 
notwithstanding  the  addition  of  the  hydrochloric 
acid,  remains  slightly  alkaline.  Matzuschita  recom- 
mends, for  the  culture  of  intestinal  bacteria,  that  the 
medium  be  neutral  or  very  slightly  acid. 

Placenta  Glycerin  Agar. — Duval  and  WeUman 
found  that  a  medium  containing  untreated  placental 
juice  was  valuable  for  the  cultivation  of  B.  I 
from  the  tissues.  Of  the  different  media  employed 
for  this  purpose,  this  was  the  simplest,  and  one  most 
easily  prepared.  Its  special  value  seems  to  be  due 
to  the  large  amount  of  amino-acids  present  in  pla- 
cental tissue.  According  to  these  authors,  the 
medium  is  prepared  by  taking  a  fresh  human  placenta 
and  washing  out  the  contained  blood  by  running 
sterile  saline  solution  through  the  blood-vessels; 
after  this  the  placenta  is  ground  up  in  a  meat  chopper, 
To  each  pound  of  the  chopped  up  tissue,  0.5  liter  of 
sterile  salt  solution  is  added;  the  mixture  is  placed  in  an 
ice  bos  and  allowed  to  stand  for  forty-eight  hours;  the 
fluid  portion  is  separated  and  passed  through  a  pre- 
viously tested  No.  N.  Berkefeld  filter  for  sterilization; 
to  the  clear,  amber-colored  filtrate,  a  two-per-cent. 
sterile  agar  is  added  at  a  lemperat  i ire  of  about  11  ( '.; 
the  addition  of  t  hree-per-cent.  glycerin  to  the  agar 
before  sterilization  is  recommended;  the  ingredients 
are  thoroughly  mixed,  placed  in  tubes  and  slanted 
to  cool.  Placental  fluid  alone  also  serves  as  a  good 
medium   for  the  leprosy  organism.       It  is  claimed  that 

transplants  of  macerated  leprosy  tissue  containing 
the  ai  id-last  organism  will  show  a  visible  growth  in 
five  to  seven  days  upon  this  medium.  /»'.  tubi  - 
culosis  and  other  acid-fast  organisms  (rat  leprosy) 
grow  readily  on  the  placenta  medium. 

a,  latin    Agar. — Several  formulas   have   been    pro- 

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Bacteriological  Technique 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


posed  for  the  preparation  of  this  medium.  Each 
rinds  its  special  application.  That  of  C'apaldi  was 
recommended  for  the  isolation  of  the  typhoid  bacillus 
from  feces.  It  is  made  by  dissolving  twenty  grams  of 
Witte's  peptone,  ten  grams  of  gelatin,  ten  grams  of 
glucose  or  of  mannite,  five  grams  of  sodium  chloride, 
and  five  grams  of  potassium  chloride  in  1,000  c.c.  of 
water.  The  solution  is  filtered  and  two  per  cent, 
of  agar  is  added  and  dissolved  by  boiling,  after  which 
it  is  rendered  alkaline  by  the  addition  of  10  c.c.  of 
normal  alkali.  The  filtered  solution  is  then  tubed 
and  sterilized  by  steaming. 

Bccr-wort  Agar. — Wort  is  of  particular  value  in  the 
cultivation  of  yeasts  and  it  is  also  used  in  the  study  of 
certain  bacteria.  It  may  be  used  in  the  fluid  form, 
or  solidified  by  means  of  either  gelatin  or  agar. 
Eyre  recommends  its  preparation  by  taking  250 
grams  of  crushed  malt  and  placing  it  in  a  two-liter 
flask  with  1,000  c.c.  distilled  water.  The  mixture  is 
first  heated  up  to  70°  C.  in  the  stoppered  flask,  then 
placed  in  a  constant-temperature  water-bath,  and 
allowed  to  macerate  at  60°  C.  for  one  hour.  The 
fluid  portion  is  separated  by  straining  through  muslin; 
then  it  is  heated  for  thirty  minutes  in  a  steam  steril- 
izer and  followed  by  filtration.  The  natural  reaction 
of  the  resulting  wort  is  left  unchanged. 

In  case  the  solid  preparation  is  desired,  add  two 
per  cent,  agar  and  proceed  the  same  as  in  the  prepara- 
tion of  nutrient  agar.  Sterilization  is  carried  out  by 
placing  in  a  steam  sterilizer  at  100°  C.  for  twenty 
minutes  on  each  of  three  consecutive  days. 

Stoddart's  medium  is  a  gelatin  agar  which  con- 
tains five  per  cent,  of  gelatin,  one  per  cent,  of  peptone, 
and  a  half  per  cent,  each  of  agar  and  of  salt.  A  liter 
of  meat  extract  is  prepared  in  the  usual  way.  In  this 
ten  grams  of  peptone  and  five  grams  of  salt  are  dis- 
solved, and  the  solution  is  then  divided  into  two  parts. 
To  one  portion  ten  per  cent,  of  gelatin  is  added,  and 
when  this  has  dissolved,  the  solution  is  neutralized  and 
an  excess  of  10  c.c.  of  normal  alkali  per  liter  is  added. 
The  other  half  of  the  meat  extract  is  likewise  neu- 
tralized, and  then  10  c.c.  of  the  normal  alkali  are  added 
per  liter  to  impart  the  requisite  reaction.  The  liquid 
is  then  measured  or  weighed,  boiled,  and  filtered. 
Five  grams  of  cut  agar  are  added  to  the  bouillon, 
which  is  then  boiled  until  the  agar  dissolves.  Dis- 
tilled water  is  added  to  make  up  to  the  original 
volume  or  weight,  after  which  the  two  liquids  are 
combined  and  allowed  to  sediment.  The  entire 
product  is  finally  filtered  through  cotton  or,  better, 
through  paper.  The  medium  is  filled  into  tubes 
which  are  then  steamed  for  fifteen  minutes  on  each 
of  three  consecutive  days.  To  use  this  medium,  it 
is  poured  out  into  sterile  Petri  dishes,  and  when 
solidified  the  center  is  touched  with  the  organism 
to  be  tested.  The  typhoid  bacillus,  on  account  of 
its  motility,  spreads  rapidly  over  the  surface  as  an 
almost  transparent  growth  whereas  that  of  the 
colon  bacillus  spreads  less  and  is  easily  visible. 

Guarnieri's  gelatin  agar  is  made  in  a  somewhat 
similar  manner.  Three  grams  of  powdered  agar  are 
emulsified  with  50  c.c.  of  distilled  water,  and  this  is 
then  added  to  a  solution  of  fifty  grams  of  gelatin  in  750 
c.c.  of  meat  extract.  The  whole  is  boiled  till  the  agar 
has  dissolved,  when  a  solution  of  twenty-five  grams  of 
Witte's  peptone  and  five  grams  of  salt  is  added.  The 
entire  liquid,  which  now  makes  up  to  one  liter,  is  then 
carefully  neutralized  with  normal  alkali,  using  litmus 
as  an  indicator.  The  medium  is  tubed  and  sterilized 
as  usual.  It  has  been  used  to  advantage  in  the  culti- 
vation of  the  pneumococcus. 

Weil's  Meat-potato  Agar. — The  potato  juice  is  pre- 
pared as  in  the  method  of  Holz  or  Eisner;  300  c.c.  of 
this  are  added  to  200  c.c.  of  slightly  alkaline  bouillon; 
3.75  grams  of  agar  is  then  dissolved  in  the  liquid,  thus 
yielding  a  0.75-per-eent.  agar  solution.  The  typhoid 
"bacillus  presents  threaded  colonies  on  this  medium, 
the  same  as  in  Eisner,  Hiss,  and  Piorkowski  media. 


Noguchi's  Ascitic-fluid  Tissue  Agar. — Noguchi  has 
succeeded  in  making  direct  cultures  of  Treponema 
(Spirochete)  pallidum,  and  other  spirochetes  from 
fresh  infectious  material  from  man.  For  this  pur- 
pose a  medium  is  prepared  as  follows:  two  parts  of 
two  per  cent,  slightly  alkaline  agar  (at  50°  C),  are 
added  to  one  part  of  ascitic  (or  hydrocele)  fluid, 
thoroughly  mixed  in  a  tube  in  the  bottom  of  which  is  a 
fragment  of  sterile  tissue.  Rabbit  kidney  or  testicle 
is  preferable,  although  other  tissues  as  human  pla- 
centa, sheep-testicle,  etc.,  may  be  used.  The  culture 
medium  is  allowed  to  solidify  in  the  tubes,  then  a  layer 
(three  centimeters)  of  sterile  paraffin  oil  is  added  to 
prevent  evaporation,  and  exclude  the.  air.  The  material 
(tissue)  for  inocidat  ion  containing  the  organ  isms  should 
be  immersed  immediately  after  removal  in  sterile  phy- 
siological salt  solution,  containing  one  per  cent,  of  so- 
dium citrate,  and  cut  into  small  bits,  some  of  which 
are  rubbed  up  into  an  emulsion  in  the  citrate  solution. 
Each  tube  is  inoculated  with  some  of  the  bits  of  tissue 
by  pushing  them  to  the  bottom  of  the  culture  tubes 
with  a  heavy  platinum  loop,  also  some  of  the  emul- 
sified material  is  deeply  inoculated  into  the  same 
tube  by  means  of  a  capillary  pipette.  Care  must  be 
taken  not  to  break  up  the  medium.  The  contami- 
nating bacteria  which  are  present  in  first  inocula- 
tions appear  to  grow  along  the  line  of  the  stab, 
while  the  spirochetes  grow  out  into  the  medium  for  a 
distance.  The  culture  may  finally  be  purified  by 
taking  transplants  from  the  distant  outgrowths  and 
carrying  over  to  fresh  medium  several  times. 

Noguchi  has  found  this  method  applicable  to  the 
isolation  and  cultivation  of  other  spirochetal.  He 
succeeded  in  separating  Spirochicta  refringens  from 
infected  tissue,  and  growing  it  in  pure  culture  by  the 
procedure  just  outlined.  Likewise,  he  isolated  in 
pure  culture  certain  mouth  spirochetal  (Treponema 
microdentium,  Tr.  macrodentium).  In  these  cases,  it 
was  necessary  to  enrich  the  material  by  growing  one 
or  more  generations  in  a  special  fluid  medium.  This 
medium  was  composed  of  a  large  quantity  of  sheep 
serum  water  (1  part  serum  and  3  parts  of  distilled 
water)  in  a  tube  containing  sterile  tissue  (kidney  or 
testicle  of  rabbit  or  sheep),  and  covered  with  a  layer 
of  sterile  paraffin  oil.  The  inoculated  tubes  were 
incubated  at  37°  C.  for  about  ten  days,  during  which 
time  the  medium  became  more  or  less  coagulated  by 
the  contained  bacterial  growth.  A  small  amount  of 
the  impure  culture  was  removed  from  the  bottom  of 
the  tube  by  means  of  a  capillary  pipette,  and  inocu- 
lated into  a  solid  medium  composed  of  sterile  serum 
agar  (in  ratio  of  1  to  3)  and  containing  sterile  tissue 
(sheep  or  rabbit).  The  procedure  was  quite  the  same 
as  mentioned  for  the  inoculation  of  tubes  for  the 
cultivation  of  Treponema  pallidum.  After  inocula- 
tion the  medium  was  covered  with  a  layer  of  sterile 
paraffin  oil  to  exclude  the  atmospheric  oxygen. 

Noguchi's  Method  for  Cultivating  Treponema  Palli- 
dum in  Fluid  Media. — Experience  has  demonstrated 
that  Treponema  pallidum  cannot  be  cultivated  con- 
stantly in  fluid  media  (even  when  they  contain  fresh, 
sterile  tissue),  by  the  ordinary  anaerobic  methods. 
Noguchi  has  overcome  this  difficulty  by  a  method  in 
which  both  solid  and  fluid  media  are  used  in  combina- 
tion for  simultaneous  cultivation  of  the  organism. 
The  method  is  as  follows:  A  culture  tube  is  first  pre- 
pared by  fusing  a  short  piece  of  strong  glass  tubing 
(0.7  cm.  bore)  to  the  perforated  bottom  of  a  test-tube 
1.7  cm.  wide  and  20  em.  long,  thus  giving  an  outlet; 
after  thoroughly  cleaning,  the  larger  end  of  the  tube  is 
plugged  with  non-absorbent  cotton,  the  smaller  end 
(fused  in  tube)  is  passed  through  a  perforated  rubber 
Stopper  (No.  5),  which  in  turn  is  fitted  into  a  test-tube 
2.5  cm.  wide  and  15  cm.  long.  The  double  tube,  as 
now  set  up,  is  sterilized  in  the  autoclave  in  the  regular 
manner.  When  cool,  the  rubber  stopper  together  with 
the  smaller  (upper)  tube  is  removed,  one  or  two  pieces 
of  sterile,  fresh  rabbit  kidney  are  placed  in  the  larger 


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Bacteriological  Technique 


(lower)    till"',    then    the    two    pails   arc    tightly    fitted 

together  and  not  again  taken  apart.     A  piece  of  the 

tissue,    of   such   size   that    it    will    not    pass   I  he   bottom 

outlet,  is  placed  in  the  upper  tube.  .Next  the  Lower 
tube  is  tilled  from  above  through  the  upper  tube 
with  ascitic  fluid  or  a  mixture  of  ascitic  fluid  and 
bouillon,  by  means  of  a  sterile  hull)  pipette.  ]  hi 
pipette  must  have  a  small  outlet  tuhe  which  will 
easily  pass  through  the  connecting  tube  of  the  double 
culture  tube,  for  delivery  of  the  fluid,  and  freely  per- 
mit the  escape  of  air.  The  lower  tube  must  be  com- 
pletely filled  to  exclude  till  air  bubbles.  The  next  step 
IS  the  inoculation  with  77.  pallidum,  which  should  be 
taken  from  a  well-growing,  pure  culture.  A  portion 
may   be  aspirated    into  a   long  capillary    glass  pipette 

(sterile)  by  means  of  a  syringe  connected  with  a 
piece  of  rubber  tubing — a  part  of  the  material  is  dis- 
charged into  the  fluid  in  the  lower  tube,  the  rest  sur- 
rounding the  tissue  in  the  upper  tube.  After  the 
inoculation  the  upper  tube  is  almost  filled  with  a  solid 
medium  compound  of  one  part  of  ascitic  fluid  and 
two  parts  of  a  sterile,  slightly  alkaline,  two  per  cent, 
agar,  mixed  at  a  temperature  of  about  42°  C.  and 
poured  on  while  still  fluid.  Finally  the  surface  is 
covered  with  sufficient  sterile  paraffin  oil  to  give  a 
depth  of  about  three  centimeters  over  the  solidified 
agar.  The  culture  is  incubated  at  37°  C.  Utmost 
care  must  be  taken  to  prevent  bacterial  contamination 
during  the  above  manipulations. 

Noguchi's  Method  for  Cultivating  the  Spirochetal  of 
Relapsing  Fevers. — Noguchi  succeeded  in  growing  in 
pure  cultures,  four  different  species  of  spirochaetffi 
(.s'/>.  duttoni,  Sp.  kochi,  Sp.  obermeieri,  Sp.  novyi) 
which  give  rise  to  the  diseases  classed  as  relapsing 
fever.  For  this  purpose  he  employed  a  fluid  medium 
with  sterile  fresh  tissue,  and  proceeded  as  follows:  a 
piece  of  sterile  fresh  tissue  (usually  rabbit  kidney) 
was  placed  in  each  of  a  number  of  sterile  test  tubes, 
two  by  twenty  centimeters,  to  which  were  added  a 
few  drops  of  citrated  blood,  drawn  aseptically  from 
the  heart  of  an  infected  mouse  or  rat;  at  once  about 
15  c.c.  of  sterile  ascitic  or  hydrocele  fluid  were  added 
to  each  tube;  to  some  of  the  prepared  tubes  a  layer  of 
sterile  paraffin  oil  was  added  others  were  left  without 
the  oil.  The  presence  of  some  oxygen  seems  necessary 
for  the  growth  of  the  organisms.  The  blood  for  inocu- 
lation  of  tubes  is  best  when  taken  from  the  animal 
between  forty-eight  and  seventy-two  hours  after  it 
has  been  artificially  infected.  It  is  essential  that 
ascitic  fluids,  which  are  to  be  used  in  this  medium, 
must  contain  no  bile,  but  have  the  power  to  form  a 
loose  fibrin  when  added  to  the  fresh  tissue  in  the  tube. 
The  maximum  growth  at  37°  C.  in  the  inoculated 
tubes  was  reached  after  seven  to  nine  days. 

Substitutes  for  the  Meat  Infusion. — In  the  prepara- 
tion of  the  foregoing  media  a  meat  infusion  serves  as 
the  basis  in  each  case.  In  special  instances,  but  not 
as  a  routine  procedure,  these  media  may  be  modified 
by  using  the  commercial  Liebig's  beef  extract  in  place 
of  the  meat  infusion.  The  chief  advantage  lies  in  the 
fact  that  the  beef  extract  can  be  kept  always  on  hand. 
At  the  same  time  it  must  be  remembered  that  media 
made  up  with  such  extract  are  by  no  means  as  nutri- 
tious as  those  made  up  with  the  meat  infusion.  The 
amount  of  Liebig's  extract  which  is  used  varies  with 
different  workers.  In  general,  from  one  to  three  grams 
are  added  to  one  liter  of  water;  five  and  even  ten  grams 
may  be  used.  To  this  solution  peptone  and  salt  may 
be  added  in  the  usual  amounts.  The  liquid  when  ren- 
dered alkaline  and  filtered  constitutes  a  Liebig's- 
extract  bouillon.  In  the  same  way  gelatin  and  agar 
media  are  prepared. 

Peptone  Substitutes. — Several  compounds  have  been 
suggested  as  substitutes  for  Witte's peptone.  In  Mar- 
tin's and  Pcckham's  bouillon  and  in  Deyeke's  agar 
this  peptone  is  replaced  by  that  which  is  formed  by  the 
digestion  of  the  muscle  tissue.  In  other  media 
derivatives    of    albumin    or    casein    are    employed. 


Heyden's  "Nahrstoff "  i  ed  egg  albuminate, 

while   nui  rose  i    a  casein  compound       I  he  addition 

of  lecil  hin,  |n gen,  he globin,  etc.,  i    made  with 

the  object  ot  improving  the  nutritive  qualitii  tofthe 
media. 
Hiss'  Tube  Medium. — This  is  u  ed  a    a  meai 
g  for  the  typhoid  bacillus.     It  i    made  by  add- 
ing 5  grams  of  Liebig's  extract  5  grams  of  salt  and  S 
grams  of  agar  to  1,000  c.c.  ol  water.      I  he  mi 
is    then   heated   until   the  agar  ha     di    olved,  after 
which    the   water  which    i,   [0s(    by   evaporation    is 
replaced   and  then  eight   per  cent. 'gelatin  i    added. 
As   soon  as  the  gelatin  has  di    olved,   the  liquid   is 
partially  neutralized  by  the  addition  of  normal  alkali. 
The  reaction  is  left  acid,  and  to  such  an  e   ti  ni  that 
ii    would  require  15  c  c.  of  normal  alkali  per  liter  to 
make   the  solution  neutral  to  phenolphthalein.     The 
licpiid   is  then  cooled  to  60°  (',  and  cleared  by  the 

addition  of  the  white  of  an  egg  stirred  up  in  about  25 
c.c.  of  water.  The  liquid  is  then  boiled  for  a  few 
minutes,  after  which  ten  grams  of  glucose  are  added. 
After  sedimentation  at  50  C.  the  medium  can  be 
filtered  through  paper  or  cotton  and  tubed.  This 
medium  is  used  only  for  slab  cultures.     Diffusion  of 

the    growth  through   the  medium   in   the  case  of  very 

motile  organisms,  such  as  the  typhoid  bacillus,  anil 
the  production  or  absence  of  gas,  are  the  criteria 
sought   lor. 

Hiss'  Plate  Medium. — Hiss  utilized  the  tendency  of 
the  typhoid  bacillus  to  form  threaded  colonies  when 
grown  on  soft  media,  as  a  means  of  differentiation 
from  the  colon  bacillus.  The  medium,  as  first  pro- 
posed, contained  1.5  grams  of  agar,  15  grams  of 
gelatin,  5  grams  each  of  Liebig's  extract  and  of 
sodium  chloride,  10  grams  of  dextrose,  and  1,000  c.c. 
of  distilled  water.  This  was  cleared  by  the  addition 
of  the  whites  of  two  eggs  and  filtered  through  absor- 
bent cotton.  The  reaction  was  left  acid,  and  of  such 
extent  that  it  would  require  the  addition  of  2  c.c.  of 
normal  alkali  to  make  it  neutral  to  phenolphthalein. 
Subsequently  Hiss  made  various  modifications  of 
this  formula,  eliminating  the  unnecessary  constitu- 
ents. The  simplest  combination,  which  was  found  to 
give  excellent  results,  was  made  by  adding  15  grains 
of  agar  and  5  grams  of  Liebig's  extract  to  1,000  c.c. 
of  distilled  water.  No  acid  or  alkali  was  added. 
The  medium  was  cleared  by  the  whites  of  two  eggs 
and  filtered  through  cotton.  Plate  cultures,  made 
at  37°  C,  show  excellent  differentiation  between 
the  colonies  of  typhoid  and  colou  bacilli  in  twenty- 
four  hours.  The  former  show  threaded  colonies, 
the  latter  do  not. 

Hesse's  Nahrstoff-Heyden  Agar. — The  "Nahrstoff- 
Heyden"  is  an  albumose  made  from  egg-albumin.  It 
should  first  be  stirred  up  in  a  beaker  with  a  little 
water,  and  then  added  to  the  liquid.  For  cultivating 
the  tubercle  bacillus  the  medium  consists  of:  5  grams 
nahrstoff-Heyden,  5  grams  salt,  30  grams  glycerin, 
10  grains  agar,  and  1,000  c.c.  of  distilled  water;  5  c.c. 
of  normal  soda  solution  are  added.  The  latter  repre- 
sents a  14.3  per  cent,  of  the  crystalline  salt  t  Xa  t'03  + 
1011,0)  and  not  28. G  per  cent.,  as  stated  by  Hesse. 
The  Hesse-Niedner  agar,  wdiich  has  been  recom- 
mended for  the  study  of  water  bacteria,  is  made  by 
dissolving  7.5  grams  of  nahrstoff-Heyden  and  12.5 
grams  of  agar  in  1,000  c.c.  of  distilled  water.  Gage 
and  Phelps  dissolve  one  per  cent,  each  of  agar  and  of 
the  nahrstoff  in  1,000  c.c.  of  distilled  water,  and  make 
the  solution  neutral  to  phenolphthalein. 

Blood  Serum. — The  preparation  of  serum  from  small 
animals  has  been  described  at  length  under  serum  agar. 
When  it  is  desirable  to  use  large  quantities  of  serum 
it  is  advisable  to  collect  ox  blood  at  a  slaughter-house. 
The  more  care  taken  in  collecting  the  blood  under 
aseptic  conditions  the  less  troublesome  will  be  the 
subsequent  sterilization.  A  convenient  receptacle  is 
a  half-gallon  battery  jar  covered  with  paper  and  pre- 
viously   sterilized.     The  spurting  blood   is  received 


ssi) 


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directly  into  the  jar,  after  which  the  paper  cap  is 
replaced  and  the  blood  set  aside  until  it  firmly  clots. 
It  can  then  be  transported  to  the  laboratory  and  set 
aside  in  a  cool  place  for  the  serum  to  separate.  The 
serum  can  then  be  drawn  up  by  means  of  an  aspirator 
into  a  sterile  globe  receiver,  such  as  is  shown  as  a 
part  of  Fig.  551.  It  can  then  be  conveniently  filled 
into  test-tubes  or  into  flasks. 

The  earliest  method  of  sterilizing  blood  serum  is 
that  of  Koch  by  fractional  heating.  The  tubes  are 
placed  in  an  inclined  position  in  a  serum  coagulator 
shown  in  Fig.  548.  The  Roux  water-bath,  shown  in 
Fig.  554,  is  particularly  useful  for  this  purpose. 
The  serum  tubes  are  immersed  in  the  water  at  58°  C. 
and  are  heated  for  an  hour  at  58°  C.  on  each  of  seven 
successive  days.  This  low  temperature  is  selected 
in  order  to  accomplish  the  sterilization  and  yet  keep 
the  serum  in  a  fluid  condition.  Unfortunately 
bacteria  may  be  present  in  the  serum  which  will 
actually  grow  at  the  temperature  employed,  and  in 
that  case  this  method  of  sterilization  is  inapplicable. 


Fig.  54S. — Koch's  Blood-serum  Coagulator. 

Some  have  endeavored  to  obviate  this  difficulty  by 
filtering  the  serum  through  a  Berkefeld  bougie. 
Martin  suggested  that  one  to  two  per  cent,  of  chloro- 
form be  added  to  the  serum,  which  is  then  set  aside 
for  several  months,  after  which  the  chloroform  can 
be  driven  off  by  heating  at  05°.  Fraenkel  dispensed 
with  the  sterilization,  relying  entirely  upon  the  asep- 
tic collection  of  the  serum.  When  the  serum  is 
collected  with  the  care  outlined  above,  it  will  be  found 
that  very  few  bacteria  are  present.  Consequently 
after  the  tubes  have  been  filled  with  the  serum  they 
may  be  incubated  for  several  days,  and  at  the  end 
of  that  time  the  contaminated  ones  can  be  discarded. 
This  procedure  is  preferable  to  those  just  given. 
The  sterile  serum  is  then  coagulated  in  an  inclined 
position  by  raising  the  temperature  of  the  sterilizer 
to  65°  C,  and  keeping  it  there  until  the  serum  has 
become  solid.  The  medium  thus  prepared  is  trans- 
parent and  solid.  When  a  higher  temperature  is 
used,  the  serum  coagulates  to  an  opaque  white  mass. 

Inasmuch  as  the  above  methods  require  much  time 
and  skill  and  are  in  themselves  very  tedious,  they 
have  been  largely  supplanted  by  fractional  steriliza- 
tion in  steam.  For  this  purpose  the  tubes  are  first 
placed  in  an  inclined  position,  either  in  a  dry-heat 
oven,  or,  better,  in  the  coagulator,  and  then  heated 
to  85°  to  95°  C.  until  firm  coagulation  results.  If 
this  is  not  looked  after,  the  medium  will  be  torn  up 
by  gas  bubbles  during  the  next  step.  The  coagulated- 
serum  tubes  are  then  placed  in  wire  baskets  and 
steamed,  as  in  the  case  of  agar,  for  half  an  hour  on 
each  of  three  consecutive  days.  The  medium  thus 
prepared  is  fully  as  useful  as  that  which  is  transparent. 

LdJJlcr's  Blood  Serum. — This  consists  of  one  part 
of  a  one-per-cent.  glucose  bouillon  and  three  parts 

890 


of  blood  serum.  The  mixture  is  filled  into  tubes  and 
sterilized  in  the  manner  just  given.  It  is  used  verv 
extensively  for  the  diagnosis  of  diphtheria. 

Alkaline  Blood  Serum   (Lorrain  Smith). To  each 

100  c.c.  of  blood  serum  add  1.0-1.5  c.c.  of  a  ten-per 
cent,  solution  of  sodium  hydrate,  and  shake  gently" 
Place  in  tubes  and  sterilize  as  mentioned  under  blood 
serum.  A  clear  solid  medium  results,  consistine 
principally  of  an  alkali-albumin.  This  medium  i< 
also  used  in  the  cultivation  of  B.  diphtheria 

Glycerin  Serum.— Five  per  cent,  or  more  of' glycerin 
is  added  as  in  the  case  of  glycerin  agar.  The  sterilize 
tion  is  the  same  as  that  just  given.  It  is  used  fur 
the  cultivation  of  the  tubercle  bacillus. 

Serum-water  Media.— When  serum  is  diluted  with 
five  to  ten  parts  of  water  it  can  be  sterilized  by  steam- 
ing without  coagulation  taking  place.  Hiss  employed 
such  a  medium  in  differentiating  between  the  pneu- 
mococcus  and  streptococcus;  also  in  distinguishing 
between  the  dysentery  and  allied  organisms  He 
prepares  the  medium  by  adding  one  part  of'  clear 
beef  serum  to  two  parts  of  distilled  water  The 
mixture  is  first  heated  to  100°  for  a  short  time  so  as 
to  destroy  the  glycolytic  enzyme  which  is  present 
after  which  one  per  cent,  of  the  sugar  desired  is  added' 
Dextrose,  galactose,  mannite,  maltose,  lactose  sac- 
charose, inulin,  and  dextrin  have  been  thus  'used 
The  medium  is  colored  by  the  addition  of  one  per 
cent,  of  a  five-per-cent.  aqueous  litmus  solution 
The  medium  is  then  tubed  and  steamed  for  ten  mini 
utes  on  three  consecutive  days. 

Marmorck's  Media. — In  order  to  maintain  strepto- 
cocci at  their  maximum  virulence  Marmorek  used 
several  media,  preference  being  given  to  them  in  the 
following  order: 

1.  Human  serum  2  parts,  bouillon  1  part. 

2.  Pleuritic  or  ascitic  fluid  1  part,  bouillon  2  parts. 

3.  Serum  of  mule  or  ass  2  parts,  bouillon  1  part. 

4.  Horse  serum  2  parts,  bouillon  1  part. 

These  media  can  be  sterilized  by  fractional  heating 
at  low  temperature,  or,  better,  by  nitration  through  a 
Berkefeld  bougie. 

Thalmann's  serum  bouillon  for  cultivating  the  gono- 
coccus  has  been  mentioned  in  connection  with  his 
agar. 

Milk. — This  is  an  excellent  medium  for  diagnostic 
purposes.  It  is  advisable  to  use  centrifugated  milk  if 
possible.  Otherwise  the  whole  milk  is  placed  in  a 
beaker  or  flask  and  steamed  for  about  half  an  hour. 
When  partially  cooled  it  can  be  poured  into  a  large 
separatory  funnel,  or  into  a  bulb  receiver  shown  as 
part  of  Fig.  5072,  and  allowed  to  stand  thus  overnight. 
The  underlying  layer  of  fat-free  milk  can  then  be 
filled  directly  into  tubes.  These  are  then  sterilized 
by  steaming  half  an  hour  on  each  of  three  consecutive 
days.  When  time  is  an  object  the  whole  milk  may 
be  filled  directly  into  tubes.  If  desired  the  milk 
may  be  colored  with  litmus.  Instead  of  milk,  whey 
may  be  used  to  good  advantage.  This  can  be  pre- 
pared by  coagulating  the  milk  with  rennet.  The 
liquid  is  first  separated  by  means  of  cheese-cloth 
and  finally  put  through  paper.  It  is  then  colored 
with  litmus,  filled  into  tubes,  and  sterilized.  Care 
must  be  taken  not  to  overheat  the  milk  lest  the  lactose 
undergo  more  or  less  oxidation.  Whey-gelatin  and 
whey-agar  are  used  for  special  purposes. 

Petrusehky's  Litmus  Whey. — Very  dilute  hydro- 
chloric acid  is  added  to  slightly  warmed,  fresh  milk. 
The  casein  is  precipitated  and  removed  by  filtration. 
The  acid  is  just  neutralized  by  the  addition  of  dilute 
sodium  hydrate  solution,  then  the  fluid  is  steamed 
for  two  or  three  hours,  thus  throwing  out  any  acid 
albumin  which  might  have  been  in  the  solution. 
The  fluid  when  filtered  off  through  paper  should  be 
just  neutral  and  colorless.  Litmus  solution  is  added 
in  sufficient  quantity  to  give  a  distinct  tint.  Sterilize 
as  in  ordinary  milk  tubes. 

Urine. — By  discarding  the  first  portion  of  urine 


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Bacteriological  Technique 


which  is  passed,  the  remainder  can  l»>  collected  in 
sterile  flasks  and  will  l>c  free  from  bacteria.  Such 
urine  may  be  used  directly  for  studying  the  various 
fermentations  which  it  may  undergo.  To  prepare  a 
urine  gelatin  the  secretion  should  be  diluted  so  as  to 
have  a  specific  gravity   not    to  exceed    1.010.     Ten 

per  cent,  of  gelatin  is  then  added,  and  when  il 
dissolved  the  reaction  is  made  to  correspond  to  that 
of  the  original  urine.  Heller's  urine  gelatin  is  pre- 
pared in  the  same  way,  but  has  one  per  cent,  peptone 
and  a  half  per  cent,  of  salt.  After  solution  the  Liquid 
is  rendered  faintly  alkaline,  then  filtered  and  tubed. 

Piorkowski  Urine  Gelatin. — Normal  urine  of  1.020 
specific  gravity  is  collected  for  two  days,  and  is 
allowed  to  become  slightly  alkaline  in  reaction.  Then 
1.5  per  cent,  peptone  and  3.3  per  cent,  gelatin  are 
added,  and  the  mixture  is  heated  for  one  hour  on  the 
water-bath,  after  which  it  is  filtered  and  tilled  into 
tubes.  These  are  sterilized  by  heating  at  100°  ('.  for 
fifteen  minutes  on  the  first  day,  and  for  ten  minutes 
on  the  second  day.  The  medium  is  used  to  differen- 
tiate the  typhoid  from  the  colon  bacillus.  Petri 
plates  are  made  and  developed  at  22°  C.  for  twenty- 
four  hours.  While  the  colon  colonies  are  roundish, 
finely  granular,  sharp-bordered,  and  yellowish,  the 
typhoid  colonies  are  small  and  show  a  more  or  less 
marked  threaded  border.  This  method  has  given 
good  results  in  connection  with  the  examination  of 
typhoid  feces. 

Urine  Agar. — This  can  be  prepared  by  adding  to 
the  freshly  passed  urine  two  per  cent,  of  finely  cut 
agar.  The  mixture  is  then  boiled  until  solution 
results,  when  it  is  filtered  through  cotton  or  paper  as 
in  the  case  of  ordinary  agar.  This  agar  is  then  filled 
into  tubes  and  sterilized  by  steaming. 

Another  way  of  preparing  a  urine  agar  is  to  collect 
the  urine,  after  discarding  the  first  portion  which  is 
passed  in  a  sterile  flask,  and  then  to  transfer  it  by 
means  of  a  pipette,  as  in  the  case  of  blood  or  serum, 
to  the  melted  and  cooled  agar.  One  part  of  urine 
to  two  parts  of  agar  is  ordinarily  used.  Normal  or 
albuminous  urine  may  be  used  for  this  purpose,  and 
with  very  little  care  the  urine  can  be  collected  entirely 
free  from  bacteria.  Such  urine  agar  has  been  used  to 
advantage  for  growing  the  gonococcus. 

Ox-bile  Medium. — Conradi,  Coleman,  and  Buxton, 
as  well  as  others,  have  recommended  ox-bile  media 
in  making  direct  cultural  examinations  of  blood  from 
typhoid-fever  patients.  Ox  bile  possesses  certain 
advantages  for  this  particular  work  since  it  prevents 
coagulation  of  blood,  inhibits  the  bactericidal  action 
of  freshly  drawn  blood,  and  at  the  same  time  serves 
as  an  excellent  culture  medium  for  B.  typhosus. 
Coleman  and  Buxton  prepare  their  medium  by  adding 
two  grams  peptone  and  10  c.c.  glycerin  to  90  c.c.  ox 
bile.  The  mixture  is  placed  in  flasks  of '20  c.c.  each 
and  sterilized.  The  blood  (3  c.c.)  from  the  patient  is 
placed  in  flask,  then  incubated.  The  organisms 
develop  rapidly,  usually  in  from  twelve  to  fourteen 
hours.  Transplants  are  made  to  other  media  for 
further  growth  and  diagnosis. 

Jackson's  Lactose-bile  Medium. — This  medium  has 
been  found  to  be  especially  useful  in  the  isolation 
of  B.  coli.  and  B.  typhosus  from  water,  milk,  etc. 
It  is  prepared  from  undiluted  ox-gall  (or,  an  eleven 
per  cent,  solution  of  dry  fresh  ox-gall),  to  which  is 
added  one  per  cent,  of  peptone  and  one  per  cent,  of 
lactose.  The  medium  (40  c.c.)  is  placed  in  fermen- 
tation tubes  and  sterilized  by  the  fractional  method. 
The  suspected  water  or  milk  is  added  in  varying 
amounts  up  to  10  c.c.  to  the  sterilized  medium  in 
the  tubes.  In  this  medium  B.  coli  and  B.  typhosus 
rapidly  overgrow  other  organisms;  the  B.  typhosus 
may  finally  overgrow  the  B.  coli.  It  is  valuable  as  an 
enriching  medium. 

Internal  Organs. — For  special  use  the  several  media, 
such  as  bouillon,  agar,  and  gelatin,  may  be  made  up 
with  the  finely  divided  organs  in  place  of  the  minced 


meat.      At    times   the   -olid   organs  •,,,•     terilized   and 

u-ed  as  such.     For  this  purpose   the  spleen,   li 

panel,.,    .    brain,    intestinal    mucosa,    etc.,    have    I 

used.     Matzuschita   recommends   their   use   in  agar 
preparations  (as  a  substitute  for  th,  ■  beef)  fop 

the    pecial  study  of  the  flora  of  thi  ,-,al. 

'I"he   steamed    brain,    for  example,    v.  he,,    cu(    Up 

slices  and  sterilized,  can  I  i  for  cultivating 

rele  bacillu      I       er)  and  also  the  goi 
(Thalmann  I. 

Egg    Media.-  Hueppe   fir-t    suggested   tic   use  0f 

fresh  eggs  as  a  culture  medium.     For  this  purpos, 
shell  is  thoroughly  cleaned  and  disinfected  with  mer- 
curic   chloride.      A    small    opening    js    then    pun 
through   the  shell,  anil   through   this  the  organism   I,, 

lie  tested  is  introduced  into  the  inside.     The  opening 

is  then  sealed  will,  a  bit  oi    t'  rile  pap,  ,-  and  collodion. 
Another  procedure  is  to  insert  through  the  opening 

in   the   shell   a   rather  wide,   drawn-,,,,1    tube   pipette. 
On  applying   suction,    especially    with    the   aid    of    an 

aspirator,  the  contents  of  the  egg  can  be  drawn  up 
into  the  bulb,  and  can  then  be  distributed  to  t 
(Novy). 

The  egg  may  be  used  as  a  solid  opaque  medium 
according  to  Wesener.  The  egg  is  thoroughly  agi- 
tated so  as  to  mix  the  yolk  with  the  albumin.  It  is 
then  coagulated  at  75°  to  80°  C,  after  which  the 
shell  is  removed  and  the  egg  is  cut  up  into  slices  and 
placed  in  suitable  dishes  and  sterilized  by  steam.  In 
like  manner  the  coagulated  white  of  the  egg  may  be 
cut  up  into  slices  and  tubed.  A  transparent,  coagu- 
lated egg  albumin  may  bo  prepared  by  converting 
it  into  an  alkali  albuminate,  as  suggested  by  Tar- 
chanow  and  by  Karlinski.  for  this  purpose  the  egg  is 
placed  in  ten-per-cent.  potash  for  fourteen  davs,  after 
which  the  shell  is  removed  and  the  solidified  egg  is 
cut  up  into  slices,  tubed,  and  sterilized. 

Dorset's  Egg  Medium. — Dorset  introduced  this 
medium  for  the  direct  cultivation  of  /(.  tuberculosis 
from  tuberculous  animal  tissues;  it  is  prepared  from 
the  whole  egg  alone  or  in  Some  instances  with  the 
addition  of  ten  per  cent,  of  water.  It,  was  found 
that  the  whole  egg  content  gave  a  more1  satisfactory 
medium  than  either  the  white  or  the  yolk,  and  that 
its  reaction  proved  very  favorable  for  the  growth  of 
the  tubercle  bacillus.  The  medium  is  prepared  as 
follows:  perfectly  fresh  eggs  are  cleaned,  the  shells 
sterilized,  openings  made  at  each  end.  then  emptied 
into  a  sterile  wide-mouthed  bottle  by  carefully  blow- 
ing out  the  contents.  By  gentle  agitation  a  homogen- 
ous mixture  is  produced  without  causing  any  foam  to 
arise.  About  10  c.c.  are  placed  in  each  "test-tube 
under  aseptic  precautions,  then  inclined  in  a  blood- 
serum  oven,  where  they  are  hardened  at  70°  C. 
Dorset  states  that  this  usually  requires  four  to  five 
hours  each  day  for  two  days,  and  sterilization  takes 

place  at  the  same  time.     Before  inoculation  thr >r 

four  drops  of  sterile  water  should  be  added  to  each 
tube,  if  the  medium  is  dry,  to  supply  sufficient  mois- 
'  ture  for  growth. 

Lubenau's  Glycerin-egg  Medium. — This  medium 
is  composed  of  a  mixture  of  a  five-per-cent.  glycerin 
bouillon  (neutral  or  slightly  alkaline  to  litmus)  with 
wdiole  egg  contents.  It  is  prepared  by  adding  the 
contents  of  ten  eggs  to  200  c.c.  of  the  glycerin  bouillon. 
The  same  technique,  as  to  sterility,  etc.,  is  employed 
in  handling  the  eggs  as  mentioned  above  under  "the 
Dorset  egg  medium.  To  the  egg  contents  in  a  sterile 
flask,  the  sterile  glycerin  bouillon  is  added,  and  a 
homogenous  mixture  made  by  gently  agitating.  The 
medium  is  tubed,  placed  in  slanted  position  in  the 
blood-serum  oven,  and  hardened  at  70°  (',  the  same 
as  the  plain  egg  medium  (Dorset)  already  outlined. 
This  medium  also  is  used  for  the  cultivation  of 
tubercle  bacilli. 

Potatoes. — These  may  be  prepared  in  several  ways. 
The  old  method,  introduced  by  Koch,  is  still  used 
where  mass  cultures  are  desired.     The  potatoes  are 


891 


Bacteriological  Technique 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


scrubbed  clean  under  the  tap,  and  any  bad  spots 
carefully  removed  by  means  of  a  knife.  They  are 
then  placed  in  boiling  water  or  steamed  for  three- 
quarters  of  an  hour.  By  means  of  a  knife,  which 
has  been  sterilized  in  a  flame,  they  are  then  cut  into 
halves  and  placed  in  a  large  moist  chamber  or  suitable 
pan  provided  with  a  lid.  The  bottom  of  this  vessel 
should  first  be  covered  with  a  piece  of  filter  paper 
which  has  been  moistened  with  water  or  with  mer- 
curic chloride  solution.  The  cut  and  sterile  surface 
of  the  potatoes  can  then  be  inoculated  with  the  or- 
ganisms to  be  cultivated,  either  by  spreading  the 
material  over  the  potato  with  a  sterile  knife  or  by 
making  parallel  streaks.  Inasmuch  as  there  are 
several  sources  of  contamination  in  this  method,  it 
has  been  largely  displaced  by  the  modified  procedures. 
In  Esmarch's  modification  the  potato  is  pared  and 
cut  into  slices  about  a  third  of  an  inch  thick,  which 
are  placed  into  small  glass  dishes  about  seven  centi- 
meters in  diameter  and  one  centimeter  high,  known 
as  Esmarch  dishes.  These  are  then  sterilized  by 
steaming  in  the  usual  way. 

The  best  way  of  using  potatoes  for  culture  purposes 
is  that  introduced  independently  by  Bolton  and 
Globig.  The  cleaned  potato  is  placed  in  boiling 
water  for  about  half  an  hour.  By  means  of  a  cork- 
borer  or  a  test-tube  the  end  of  which  has  been  cut 
off,  cylinders  of  potato  may  be  punched  out.  The 
skin  is  removed  from  the  ends  of 
the  cylinders,  after  which  these 
are  halved  by  a  diagonal  cut.  The 
wedge-shaped  semicylinders  are 
now  placed  in  sterile  test-tubes 
and  sterilized  by  steam. 

Another  method  which  possesses 
certain  advantages  over  the  above 
consists  of  taking  a  large  uncooked 
potato,  punching  out  cylinders, 
and  cutting  wedges  as  just  men- 
tioned. These  wedges  are  placed 
in  a  suitable  vessel  and  tap  water 
is  allowed  to  flow  over  them  about 
twenty-four  hours.  This  removes 
certain  soluble  constituents  of  the 
potato,  which  if  allowed  to  re- 
main might  discolor  the  finished 
medium  after  it  has  stood  for 
some  time.  Also,  the  washing 
removes  much  of  the  acid  which 
fresh  potato  contains.  After  re- 
moving the  washed  potato  wedges 
from  the  running  water,  they  are 
placed  in  Roux  tubes  and  auto- 
claved  at  120°  C.  for  fifteen 
minutes.  This  cooks  the  potato 
and  also 
sterilizes 
t  h  o  r  - 
oughly. 

Roux 
intro- 
duced   a 


Fig.  549. — Roux  Tube  for  Potato  Culture. 


very  use- 
A   con- 


ful  modification  of  the  test-tube  method, 
striction  is  made  in  the  lower  part  of  the  tube,  about 
an  inch  from  the  bottom.  This  compartment  may  be 
filled  with  water  or,  when  cultivating  the  tubercle 
bacillus,  with  five-per-cent.  glycerin.  These  tubes 
can  be  readily  prepared  from  the  ordinary  test-tubes. 
A  narrow  blast  flame  is  directed  horizontally  against 
the  tube,  which  is  rotated  in  a  vertical  position. 
The  Roux  tube  is  shown  in  Fig.  549.  A  good  sub- 
stitute for  this  tube  may  be  made  by  placing  on  the 
bottom  of  the  test-tube  a  layer  of  absorbent  cotton, 
which  may  be  soaked  with  the  glycerin  solution. 

Glycerinated  potato  may  be  prepared  by  soaking 
the  thoroughly  washed,  prepared  potato  wedges  (see 
above)  in  a  twenty-five-per-cent.  solution  of  glycerin, 


from  one  quarter  to  one-half  hour.  Then  they  are 
placed  in  tubes  and  autoclaved  at  120°  C.  for  fifteen 
minutes. 

Mashed  potatoes  spread  over  the  bottom  of  a  flask 
have  been  used,  but  this  offers  no  special  advantage 
over  the  methods  given.  The  preparation  of  potato 
gelatin  with  or  without  potassium  iodide  has  already 
been  described. 

Bread  Medium. — Ordinary  bread  is  toasted  to  a 
crisp,  then  powdered,  in  which  condition  it  may  be 
kept  in  stock.  For  use  the  powder  is  placed  on  the 
bottom  of  small  flasks  and  thoroughly  moistened 
with  water,  then  sterilized  by  steaming.  This  me- 
dium is  particularly  useful  for  cultivating  moulds. 

Plant  Infusions. — These  are  useful  for  growing 
certain  bacteria  and  also  amebas.  Infusions  of  hay 
straw,  fruits,  grains,  etc.,  take  the  place  of  meat 
extract.  By  the  addition  of  agar  or  gelatin,  solid 
media  may  be  prepared.  Beer  wort,  either  as  such 
or  as  a  gelatin,  is  valuable  for  the  cultivation  of  yeasts. 

Protein-free  Media. — With  the  exception  of  urine 
all  the  media  described  thus  far  contain  some  proteid 
matter.  The  latter,  however,  is  not  essential,  for 
it  is  possible  to  grow  bacteria  on  media  which  contain 
sulphur,  nitrogen,  and  phosphorus  in  inorganic  com- 
bination. Such  a  solution  was  used,  for  instance,  at 
a  very  early  date  by  Pasteur.  It  consisted  of  one  part 
of  ammonium  tartrate,  ten  parts  of  candy  sugar,  the 
ash  of  one  part  of  yeast,  and  100  parts  of  water. 
The  botanist  Cohn  employed  a  similar  solution,  con- 
sisting of  0.1  gram  each  of  potassium  phosphate 
and  magnesium  sulphate,  0.01  gram  of  tribasic 
calcium  phosphate,  0.2  gram  of  ammonium  tartrate, 
and  20  c.c.  of  distilled  water.  Naegeli's  solution 
was  made  by  adding  1  gram  dibasic  phosphate,  0.2 
gram  magnesium  sulphate,  0.1  gram  calcium  chloride, 
and  10  grams  of  ammonium  tartrate  to  1,000  c.c. 
of  distilled  water. 

After  the  lapse  of  many  years  these  non-albuminous 
fluids  were  again  brought  into  use  in  a  modified  form 
by  Uschinsky.  His  solution  consisted  of:  Water, 
1,000  parts;  glycerin,  30-40  parts;  sodium  chloride, 
5-7  parts;  calcium  chloride,  0.1  part;  magnesium 
sulphate,  0.2-0.4  part;  potassium  phosphate,  2-2.5 
parts;  ammonium  lactate,  6-7  parts;  sodium  aspara- 
ginate,  3-4  parts. 

Fraenkel's  modification  of  this  solution  contains 
5  grams  of  sodium  chloride,  2  grams  of  potassium 
phosphate,  6  grams  of  ammonium  lactate,  and  4 
grams  of  sodium  asparaginate.  These  substances 
are  dissolved  in  1,000  c.c.  of  water  and  the  solution 
is  then  rendered  slightly  alkaline. 

Similar  solutions  have  been  used  by  Maassen  and 
by  others.  Thus  Proskauer  and  Beck  cultivated  the 
tubercle  bacillus  on  the  following  solution:  Com- 
mercial ammonium  carbonate,  0.35  per  cent.; 
potassium  phosphate,  0.15  per  cent.;  magnesium 
phosphate,  0.25  per  cent.;  glycerin,  1.5  per  cent. 

For  cultivating  the  nitrous  and  nitric-acid  organ- 
isms Winogradsky  employed  wholly  inorganic  solu- 
tions. The  nitric-acid  producers  were  grown  in  a 
solution  consisting  of  1,000  c.c.  of  water,  1  gram 
potassium  phosphate,  0.5  gram  magnesium  sulphate, 
0.01  gram  calcium  chloride,  2  grams  sodium  chloride. 
This  is  filled  into  flasks  in  portions  of  20  c.c.  each, 
together  with  a  little  freshly  washed  magnesium 
carbonate.  To  these  flasks,  after  sterilization  by 
steam,  2  c.c.  of  a  two-per-cent.  solution  of  ammonium 
sulphate  are  added,  after  which  they  are  incubated  to 
eliminate  contaminations. 

For  the  nitrous-acid  organisms  the  solution  consists 
of  1  gram  ammonium  sulphate,  1  gram  potassium 
sulphate,  and  1,000  c.c.  of  water.  It  is  filled  into 
flasks,  magnesium  carbonate  added,  after  which 
they  are  sterilized  by  steam. 

As  a  substitute  for  gelatin  Winogradsky  employed 
silicic-acid  jelly,  which  was  added  to  solutions  of 
essentially  the  same  composition  as  those  just  given. 


892 


REFERENCE   HANDBOOK    OF   THE    MEDICAL   SCIENl  ES 


Bacteriological  Technique 


A  number  of  simple,  synthetic  i lia  I ia  \ . •  been 

suggested  for  the  isolation  of  B,  coli  in  water  analysis. 
Dolt  has  recommended  two  such  media  for  this 
purpose,  which  he  claims  possess  certain  advantages 
over  the  ordinary  standard  lactose-litmus  agar. 
They  are  prepared  as  follows:  In  one,  a  solution 
composed  of  5  grams  glycerin  and  1  gram  ammonium 
phosphate,  dissolved  in  500  c.c.  distilled  water,  is 
used;  in  the  oilier  medium,  5  grams  ammonium 
lactate  and  1  gram  disodium  phosphate  are  substi- 
tuted for  the  above  ingredients — the  salts  are  dis- 
solved in  the  same  volume  of  distilled  water.  In 
either  case  the  solution  is  then  added  to  5(10  c.c. 
of  three-per-cent.  purified  agar,  and  neutralized  with 
sodium  hydroxide,  using  phenolphthalein  as  an 
indicator;  one  per  cent,  of  lactose  i-  added  just 
before  sterilization.  One-per-cent.  azolitmin  (Kahl- 
baum)  solution  is  to  be  added  to  the  medium;  this 
is  prepared  by  adding  one  gram  azolitmin  to  1U0  c.c. 
distilled  water,  boiling  for  fifteen  minutes,  then 
ready  for  use. 

Standardization  of  Media. — The  procedure  as 
introduced  by  Koch,  and  still  followed  in  many 
laboratories,  is  to  add  a  saturated  solution  of  sodium 
carbonate,  in  portions  of  a  cubic  centimeter  or  more, 
to  the  nutrient  medium  to  be  neutralized  until  a 
drop  of  the  mixture,  transferred  by  means  of  a  glass 
rod,  turns  red  litmus  paper  promptly  blue.  In  some 
laboratories  a  strong  solution  of  sodium  hydrate  is 
used  in  the  same  way.  Obviously  this  method  lacks 
quantitative  precision,  and  the  duplication  of  the 
same  reaction  in  several  batches  of  material  is  out  of 
question.  Moreover,  it  is  an  established  fact  that 
the  reaction  of  a  medium  has  a  very  important  influ- 
ence upon  the  development  of  bacteria.  For  these 
reasons  the  bacteriological  committee  of  the  American 
Public  Health  Association,  adopting  Fuller's  work, 
recommended  the  following  method  for  the  titration 
of  nutrient  media.     The  reagents  necessary  are: 

1.  Five-tenths-per-cent.  solution  of  phenolphtha- 
lein in  fifty-per-cent.  alcohol. 

2.  Normal  sodium  hydrate  (N.  NaOH).  A  liter  of 
this  solution  contains  forty  grams  of  NaOH. 

3.  Twentieth  normal  sodium  hydrate     ("NaOH). 

A  liter  of  this  solution  contains  two  grams  of  NaOH. 

4.  Normal  hydrochloric  acid  (N.HC1).  A  liter  of 
this  contains  30.5  grams  HC1. 

5.  Twentieth  normal   hydrochloric  acid  (."  IIC'l) . 

liter  of  this  contains  1.825  grams  of  HC1. 

The  preparation  of  these  solutions  requires  some 
familiarity  with  the  methods  of  quantitative  analysis. 
The  solutions  can  be  built  up  by  starting  from  a 
twentieth  normal  solution  of  oxalic  acid  or,  better, 
succinic  acid. 

The  titration  is  carried  out  as  follows:  To  5  c.c. 
of  the  filtered  medium  in  a  six-inch  porcelain  evapo- 
rating-dish  add  45  c.c.  of  distilled  water  and  1  c.c. 
of  the  phenolphthalein  solution;  boil  for  three  minutes 
to  expel  carbonic  acid,  then  run  in  the  twentieth 
normal  alkali,  drop  by  drop,  with  constant  stirring, 
until  a  bright  pink  color  results.  The  number  of 
cubic  centimeters  of  the  twentieth  normal  alkali 
required  to  neutralize  5  c.c.  of  the  medium  gives 
directly  the  number  of  cubic  centimeters  of  normal 
alkali  (i.e.  percentage)  required  by  100  c.c.  of  the 
medium.     Thus  if  5  c.c.  of  the  medium  requires  2.8  c.c 

of   "  alkali,  then  100  c.c.  would  need  56  c.c.    ,":    or 

2.s"cc.  of  N.  NaOH. 

The  quantity  of  the  medium  remaining  is  now  meas- 
ured and  the  amount  of  alkali  needed  for  neutraliza- 
tion is  calculated  and  added.  After  the  addition  of 
the  alkali  the  liquid  is  boiled  and  a  portion  is  then 
titrated  as  before.  It  should  be  neutral,  and  if  it  is 
not,  as  often  is  the  case  on  account  of  unknown 
changes,  the  requisite  amount  of  alkali  to  make  it  so 
is  added  to  the  bulk. 


The    medium    which    is    neutral    with  to 

phenolphthalein  is  very  alkaline  «  ithn    pect  to  litmus. 

Thus  a  bouillon  which  is  neutral  to  litmus  will  re- 
quire about   25  C.C.  of  normal  alkali  per  liter  to  inn  I  ■• 

it  neutral  to  phenolphthalein.  In  general  the  addi- 
tion of  in  c.c.  of  normal  alkali  to  a  medium  which  is 
neutral  to  litmus  imparl  the  most  favorable  di 
of  alkalinity.  Hence  the  optimum  reaction  with 
reference  to  phenolphthalein  is  obtained  by  adding 
15  c.c.  of  normal  acid  to  the  liter  of  neutralized 
medium.     It  is  customary  to  u  e  the    ign    I   to  indi- 

catean  acid  reaction,  and  —  for  one  thai  i.^  alkaline. 
Thus  +  15  means  (hat  the  rear-lion  is  acid  with 
respect  to  phenolphthalein,  and  that  one  liter  of  the 
medium  would  require  15  C.c.  of  normal  alkali  for 
neutralization. 

The  titration  with  litmus  as  an  indicator  is  1"  i 
carried  out  in  the  following  way:  Port  ions  of  .">  r.c.  of 
the  medium  are  measured  out  into  each  of  four  or 
five    large    test-tubes.     In   the   case  of  bouillon   the 

amount  of  ^alkali  needed  to  neutralize  this  amount 
may  vary  from  0.3  to  0.0  c.c.  Hence  to  lube  1  add 
0.3  c.c;  to  tube  2  add  0.4  c.c;  to  tube  '■',  add  0.5  c.c, 
ele.  The  contents  of  each  tube  are  1  hen  boiled  for  a 
minute,  after  which  a  slip  of  red  and  one  of  blue  lit- 
mus paper  an'  dropped  into  the  hot  liquid  and  allowed 
to  remain  there  for  about  a  minute.  The  papers  are 
then  drawn  out,  side  by  side,  on  the  walls  of  the  tube 
when  the  colors  can  lie  compared.  In  this  way  the 
amount  of  alkali  necessary  to  neutralize  5  c.c.  with 
respect  to  litmus  can  be  determined.  Bouillon,  as 
well  as  agar,  usually  requires  about  .5  c.c  per  liter 
for  neutralization  while  gelatin  needs  from  MO  to  35 
c.c.  Having  determined  the  amount  needed  for 
neutralization,  this  amount,  together  with  an  excess 
of  10  c.c.  per  liter  to  impart  a  suitable  alkaline 
reaction,  is  then  added  to  the  medium. 

Neutral  red  is  sometimes  used  as  an  indicator  to 
determine  the  reaction  of  media.  It  reacts  sharply 
with  weak  acids  and  weak  bases  near  the  absolute 
neutral  point. 

For  ordinary  purposes  it  is  hardly  necessary  to 
resort  to  these  rather  complicated  methods.  It  is 
sufficient  to  add  directly  to  bouillon  and  to  agar 
15  c.c.  of  normal  alkali  per  liter.  Gelatin  will  require 
about  40  c.c.  In  general,  sodium  carbonate  is  pref- 
erable to  the  hydrate. 

Preparation  and  Filling  of  Tubes. — The  cheaper 
grades  of  test-tubes  should  be  avoided.  They  are 
very  thin  and  therefore  break  easily,  and,  moreover, 
on  heating  they  will  often  frost  because  of  the  separa- 
tion of  silicic  acid.  The  best  test-tubes  are  the 
"blue-lined"  or  "resistant  glass"  quality,  or  those  of 
genuine  Bohemian  glass.  The  size  used  varies  with 
the  purpose  and  the  individual  taste:  12X125,  15  X 
150,  and  20X150  millimeters  are  convenient. 

The  new  tubes  of  the  better  glass  can  be  used  after 
being  swabbed  out  with  warm  water. 

The  cheaper  grades  are  very  alkaline,  and  for  that 
reason  should  be  first  soaked  in  very  dilute  warm 
hydrochloric  acid,  after  which  they  should  be  rinsed 
or  swabbed  thoroughly  in  clean  warm  water;  or  what 
is  still  better,  immerse  the  tubes  for  about  one  hour 
in  the  following  cleaning  mixture:  300  parts  of  a 
hve-per-cent.  solution  of  potassium  bichromate  in 
water,  to  which  is  slowdy  added  400  parts  of  con- 
centrated sulphuric  acid  while  constantly  stir- 
ring. This  mixture  removes  all  organic  matter, 
and  is  especially  useful  as  a  cleaner  for  old  glassware. 
The  glassware  is  washed  in  running  water  to  remove 
all  traces  of  the  acid.  The  cleaned  tubes  are  allowed 
to  drain,  and  when  dry  are  plugged.  Used  tubes 
should  be  sterilized  by  steaming  for  a  half-hour 
after  which  they  may  be  filled  with  water  and  again 
heated,  so  as  to  bring  the  more  or  less  dried  contents 
into  solution. 

The  simplest  way  of  plugging  is  to  place  over  the 


S93 


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Fig.  550. — Wire  Basket 
for  Sterilizing  Tubes. 


mouth  of  the  tube  a  piece  of  cotton,  about  two  inches 
square,  which  is  then  pushed  within  by  means  of  a 
narrow  glass  rod  or  a  pair  of  smooth  forceps.  Such 
plugs  answer  all  ordinary  purposes.  They  are,  how- 
ever, rather  loose,  and  permit  evaporation  of  the 
media,  and  cannot  be  used  when  the  tubes  are  to  be 
sealed  with  wax.  A  firm  solid  plug  is  made  by 
taking  a  piece  of  cotton  about  three  inches  square. 
This  is  folded  into  thirds  and 
_^ii^:tSSSM  then  roll'1' I  up  from  the  end  into 

^^^™^^^ra||j  as   firm   a   cylinder  as  possible. 

By  a  twisting  motion  the  plug  is 
inserted  into  the  tube,  and  only 
enough  cotton  is  left  on  the  out- 
side to  permit  grasping  of  the 
plug.  The  plugged  tubes  are 
then  placed  in  a  wire  basket, 
such  as  is  shown  in  Fig.  550. 
These  baskets  are  made  of  heavy 
galvanized  netting.  The  usual 
size  is  twenty-four  centimeters 
high  and  eighteen  centimeters 
square.  Smaller  baskets,  10  X 
12  and  18  centimeters  high,  are  very  useful.  Cir- 
cular baskets  of  a  size  to  fit  the  sterilizer  are  also 
used. 

Flasks,  bulbs,  etc.,  should  be  prepared  for  steriliza- 
tion in  the  same  way. 

After  the  tubes  have  been  sterilized  by  heating  in 
the  dry-heat  oven  at  150°  C.  for  one  hour,  they  are 
ready  to  be  filled  with  the  nutrient  media.  This  can 
be  done  by  the  aid  of  a  small  funnel.  When  large 
quantities  of  media  are  to  be 
tubed  much  time  can  be  saved 
by  using  a  large  funnel  or  globe 
receiver,  such  as  is  shown  in 
Fig.  551.  The  lower  end  of 
the  bulb  is  connected  with  a 
drawn-out  glass  tube  and  is 
provided  with  a  pinch-cock. 
In  this  way  the  media  can  be 
rapidly  filled  into  the  tubes. 

Another  simple  method  con- 
sists in  using  the  ordinary  Flor- 
ence flask,  containing  the  me- 
dium and  securely  fitting  a 
two-bore  rubber  stopper  in  its 
mouth.  Through  one  of  the 
openings  pass  a  straight  thistle 
tube,  of  such  length  that  it 
almost  touches  the  bottom  of 
the  flask,  and  plug  the  external 
bulbular  portion  with  cotton  to 
act  as  an  air  filter.  Through  the 
second  opening  pass  a  straight 
glass  tube  about  ten  centimeters 
long  so  that  it  projects  from  two 
to  three  centimeters  into  the 
neck  of  the  flask.  To  this  tube 
attach  a  drawn-out  glass  tube, 
by  means  of  a  piece  of  rubber 
tubing,  to  permit  the  use  of  a 
pinchcock.  For  filling  test- 
tubes  the  flask  is  inverted,  and 
supported  neck  downward  in  a 
ring  retort-stand  of  suitable 
size.  This  simple  apparatus 
admits  of  complete  sterilization 
intact  together  with  the  me- 
dium.      But   in   such  case  the 

pinch-cock  must  first  be  removed  to  allow  air  or  vapor 
a  means  of  escape  from  the  flask  during  the  heating. 
By  this  method  a  sterile  medium  is  ready  for  use  as 
soon  as  prepared. 

Ordinarily  the  tubes  are  filled  to  the  depth  of  one 
and  one-half  or  two  inches.  In  special  cases  in  which 
definite  quantities  are  desired,  the  simple  apparatus 
shown    in    Fig.   551    can  be  used.     The  containers, 


Fig.  551.— Globe  Re- 
ceiver for  Filling  Media 
into  Tubes,  with  Burette 
Attachment.     (Novy.) 


Fig.  552. — Treskow's 
Apparatus  for  Measuring 
Media  into  Tubes. 


with  the  media  to  be  filled,  can  first  be  sterilized  by 
steaming,  after  which  the  media  can  be  measured  out 
into  sterile  tubes,  which  will  not  require  further 
treatment.  A  less  desirable  apparatus  is  that  of 
Treskow,  shown  in  Fig.  552. 

Sterilization. — By  sterilization  is  meant  the  total 
destruction  or  removal  of  all  organisms  in  or  about 
a  given  object.     This  can  be 
accomplished  in  a  variety  of 
ways. 

1.  By  Direct  Flaming. — This 
method  is  applicable  for  the 
sterilization  of  glass  rods,  slides, 
cover-glasses,  platinum  wiresj 
searing  irons,  and  rough  instru- 
ments. Valuable  surgical  in- 
struments would  of  course  be 
damaged  by  this  procedure. 

2.  By  Means  of  the  Dry-heat 
Sterilizer. — The  form  mosl 
often  used  is  that  of  Koch, 
shown  in  Fig.  553.  This  is 
made  of  sheet  iron,  is  double 
walled,  and  the  outer  wall  may 
be  lined  to  advantage  with 
thick  asbestos  board.  The 
form  as  shown  is  designed  to 
sterilize  not  only  tubes  and 
flasks  but  also  glass  tubing, 
pipettes,  and  the  like.  The 
oven  is  used  for  sterilizing  only 
glass  and  metal  ware.  It 
must  not  be  used  for  sterilizing 
media.  A  temperature  of  150 
C.  should  be  maintained  for 
one  hour.  Usually  it  will  be 
sufficient  to  allow  the  temper- 
ature to  rise,  and  as  soon  as  it 
has  reached  200°  C.  the  gas  is 

turned  off.  The  cotton  should  show  a  slight  tinge  of 
yellow  after  this  heating.  If  the  plug  browns  consid- 
erably and  powders  it  is  due  more  to  the  fact  that  the 
cotton  has  been  chemically  treated  than  to  the  heat. 

3.  Fractional  Sterilization  at  56°-5S°  C— This  method 
was  introduced  by  Tyndall,  and  has  been  used  for 
the  sterilization  of 
liquid  serum,  milk, 
and  other  fluids 
which  are  liable  to 
be  altered  more  or 
less  by  heat.  It  is 
based  upon  the  fact 
that  the  actively 
vegetating  forms  of 
bacteria  are  readily 
destroyed  as  a  rule 
by  exposure  for 
some  minutes  to 
this  temperature. 
The  resting  forms 
or  spores  are  not  in 
the  least  affected  by 
such  exposure.  It 
is  necessary  to  wait 
until  the  spores 
have  germinated 
into  the  vegetating 
forms,  which  can 
then  be  destroyed 
by  a  second  like 
heating.  As  ordi- 
narily practised,  the  tubes  are  placed  in  an  apparatus, 
such' as  that  shown  in  Fig.  554,  and  are  heated  for 
one  hour  at  the  given  temperature  on  each  of  seven  or 
eight  consecutive  days. 

This  method  sometimes  gives  good  results,  at  other 
times  it  fails.     The  reason  for  this  lies  in  the  presence 


Fie,.  553 


h's  Dry-heat  Sterilizer. 


Sill 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   BCIEN(  ES 


11.11  terloloclcal  Technique 


It  absence  of  the  so-called    thermophilic   bacteria. 

'licM-  organisms  actually  grow  best  at  the  temperature 
mployed,  and  hence,  if  they  chance  to  be  present, 
he  method  is  inapplicable.     A  temperature  of  70°  C. 


r**3 


Fig.  554. 


-Rous  Water-bath  for  Sterilizing  Serum,  with  Metallic 
Regulator. 


may  be  used  in  like  manner,  but  this  causes  coagula- 
tion of  the  serum. 

By  pasteurization  is  meant  the  partial  destruction 
of  the  organisms  which  are  present  in  milk.  This  is 
accomplished  by  exposing  the  milk  for  half  an  hour, 
or  more,  to  a  temperature  of  about  68°  C.  (155°  F.). 
While  this  temperature  does  not  destroy  the  spores 
which  may  be  present,  it  does  kill  the  lactic-acid  and 

other  bacteria,  which  do 
not  produce  spores.  As 
a  result,  milk  treated  in 
this  way  will  keep  for 
several  days  without 
coagulating.  If  a  higher 
temperature  is  used,  the 
taste  of  the  milk  is  likely 
to  be  impaired. 

3.  Sterilization  in  Flow- 
ing Steam.— Several  forms 
of  apparatus  have  been 
devised  for  this  purpose. 


Fig.  555. — Koch's  Steam  Sterilizer. 

Among  the  earliest  is  the  well-known  form  which 
bears  Koch's  name.  This  apparatus  is  used  almost 
entirely  in  Germany,  and  to  a  considerable  extent  in 
this  country.     It  is  shown  in  Figs.  555  and  556. 


It  con  i  t  of  a  cylinder  of  galvanized  iron,  or  better 
of  copper,  which  can  be  given  such  dimei 
may  be  desired.  Ordinarily  ii  is  about  half  a  meter 
high  ami  about  twenty-five  centimeters  in  diameter. 
It  is  surrounded  by  a  thick  covering  of  fell  M,  to 
prevent  loss  of  heat  by  radiation.  In  the  interior  of 
the  cylinder  at  R  i    placed  a  grate  whicl  a    a 

support  for  the  pail  and  other  ve    els  to  be  disinfected. 
The  water  in  the  lower  com- 
part llli   Ml      i       llealeil     liy    one 

or  more  large  gas-burners. 
\l>n\e  ii  i  closed  with  a 
cover  I),  which  isalso covered 
with  felt.     A  central  opening 

permits   1  he  escape  of  steam, 

and  can  be  u  ed  for  I  he  in 
sertion    of   a   thermometer. 

The  pail  -hou  □  to  the  right 
of  t  he  sterilizer  has  a  gral  ing 
for  a  bottom,  to  allow  free 
ai  ess  of  the  steam,  and  in 
it  are  placed  the  articles  to 
be  sterilized. 

The  nutrient  media  are  as 
a  rule  sterilized  by  steam. 
A  single  heating  for  one  hour 
in  steam  at  100°  C.ls  usually 
sufficient  to  render  the  media 
sterile.  Prolonged  heating, 
however,  tends  to  alter  the 
media,  and  for  that  reason 
fractional  or  discontinuous 
sterilization  is  resorted  to. 
The  latter  has  the  additional 
advantage  that  it  renders  the 
medium   more  surely  sterile. 

can  withstand  steaming  for  one  and  even  five  or  six 
hours,  and  if  such  forms  chance  to  be  present  it  is  evi- 
dent that  the  material  cannot  be  sterilized  by  the 
single  heating  for  one  hour.  In  the  other  procedure 
the  media  are  steamed  for  fifteen  minutes  or  half  an 
hour,  according  to  the  nature  of  the  medium,  on  each 
of  three  consecutive  days.  The  first  heat  serves  to 
destroy  the  vegetating  germs  that  may  be  present.     In 


Fig.  556. — Section  of  Koch's 
Steam  Sterilizer. 

There  are  spores  which 


Fig. 


-Arnold's  Steam  Sterilizer,  Sectional  View. 


the  interval  which  elapses  between  the  first  and  second 
heating,  the  spores  which  are  probably  present  will 
germinate  and  are  thus  converted  into  t  he  much  weaker 
form,  which  is  then  destroyed  by  the  second  steaming. 
The  second  interval  allows  any  remaining  spores, 
which  may  have  failed  to  germinate  the  first  day,  a 
chance  to  do  so,  and  the  third  heating  is  expected  to 
dispose  of  these  last  organisms.     As  a  rule  all  media 

S95 


Bacteriological  Technique 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


should  be  incubated  for  one  or  two  days  to  make  sure 
that  they  are  perfectly  sterile.  If  any  growth  develops 
in  the  tubes  or  flasks  these  should  be  discarded,  and 
only  those  which  are  free  should  be  preserved  for  use. 
Failure  to  secure  sterilization  by  this  procedure  is 
due  to  one  of  the  following  conditions:  The  tempera- 
ture which  prevails  during  the 
twenty-four-hour  period  which 
elapses  between  the  consecutive 
heats  may  be  so  high  that  the 
spores  which  are  present  not 
only  germinate,  but  the  vege- 
tating forms  in  turn  give  rise  to 
spores,  so  that  a  larger  number 
of  resistant  forms  are  present  on 
the  second  or  on  the  third  day 
than  were  present  in  the  begin- 
ning.     Again,    it    may  happen 


Fig.  55S. — Novy  Steam  Sterilizer. 

that  the  temperature  is  too  low,  in  which  case  the 
spores  cannot  germinate,  and  hence  will  be  found  to 
resist  sterilization.  Another  source  of  error,  though 
much  less  common,  was  pointed  out  by  Smith.  If  the 
spores  of  anaerobic  bacteria  are  present  in  a  bouillon, 
they  cannot  from  their  very  nature  germinate  under 
the  ordinary  conditions,  that  is  in  the  presence  of  the 
air,  and  may  therefore  escape  de- 
struction. 

In  this  country  and  even  in  Ger- 
many, the  Arnold  steam  sterilizer 
has  met  with  a  very  favorable  re- 
ception. The  apparatus  is  shown 
in  Fig.  557.  It  consists  of: 
(a)  a  flat,  shallow  boiler, 
holding  but  a  small 
amount  of  water,  and 
therefore  requiring  but  a 
minimum  amount  of  heat 
to  produce  steam;  (6)  a 
reservoir  placed  upon  the 
boiler,  which  it  constantly 
feeds  and  insures  the  con- 
stant formation  of  steam; 
(d)  a  covered  steam  chest 
or  receiving  vessel,  placed 
above  the  reservoir  and 
connected  with  the  boiler 
by  a  cylindrical 
tube  of  large 
diameter  (c); 
and  (c)  a  hood, 
covering  the  re- 
ceiver and  en- 
closing an  air 
space,  which  is 
constantly  sup- 
plied with  es- 
cape steam. 
The  hood  and  the  steam  jacket  which  it  encloses 
prevent  variations  in  temperature  in  the  receiving 
vessel  so  long  as  the  heat  applied  to  the  boiler  remains 
unchangi  d. 

A  cheap  and   thoroughly  efficient  steam  sterilizer 


Fig.  5.r»n. — Ohamberland  Autoclave  for  Ster- 
ilizing by  Steam  under  Pressure.     (Novy-) 


adapted  for  individual  work  is  shown  in  Fig.  558. 
This  consists  of  an  ordinary  Hoffmann  iron  water-bath 
ten  to  twenty  centimeters  in  diameter.  On  this  is 
placed  a  copper  pail  (20  X20  cm.),  which  is  provided 
with  a  perforated  bottom.  Two  perforated  rings  on 
the  inside  allow  the  passage  of  steam,  and  prevent 
the  cotton  of  the  tubes  from  coming  into  contact  wit  h 
the  side  of  the  steamer.  The  tubes  filled  with  media 
are  placed  in  the  pail,  and  this  is  then  set  on  the  water- 
bath,  the  water  of  which  has  been  previously  raised 
to  active  ebullition.  In  a  few  minutes  steam  will 
issue  from  the  tube  in  the  top  of  the  cover.  It  is 
always  advisable  to  take  the  temperature  of  the  vapor 
as  it  issues  from  a  sterilizer  and  to  count  the  time  of 
exposure  from  the  moment  that  the  vapor  actually 
shows  the  temperature  of  steam,  that  is  100°  C. 

4.  Sterilization  by  Steam  Under  Pressure. — This  pro- 
cedure is  used  almost  entirely  by  the  French  workers. 
Its  usefulness  is  such  as  to  merit 
a     wide     introduction     into    this 
country.      The  apparatus,  which 
is  designated  as  an  autoclave,  is 
shown  in  Fig.  559.     It  consists  of 
a  strong  boiler,  in  the  bottom  of 
which  a  small  quantity  of  water 
is    placed.      The    articles    to    be 
steamed    are    placed    in    a   wire 
basket,  which  is  set  on  the  bottom 
of  the   boiler.      The  lid  is  closed 
with  a  rubber  gasket  and  securely 
held   in   place   by   thumb-screws. 
Inasmuch  as  the  amount  of  aque- 
ous  vapor  in   a    given    space,  as 
well   as   the  temperature,   in   the 
case  of  confined  steam,  is  greater  than  with  flowing 
steam,  it  follows  that  the  autoclave  is  considerably 
more  efficient.     Thus  steam  at  130°  C,  under  pressure, 
will  destroy  instantaneously  spores  which  would  resist 
flowing  steam  at  100°  C.  for  five  or  six  hours. 

The  culture  media  can  be  sterilized  by  a  single 
heating  for  fifteen  to  thirty  minutes  at  110°  C.  A 
higher  temperature  should  be  avoided,  as  it  tends  to 
alter  the  reaction  of  the-media.  Glass  apparatus, 
filters,  rubber,  etc.,  can  be  sterilized  by  heating  at 
120°  C.  for  half  an  hour.  In- 
fected  animals  can  be  subjected 
to  120°  C.  for  the  same  length 
of  time,  or  to  130°  C.  or  more 
for  a  less  period. 

It  must  be  remembered  that 
the  autoclave  requires  more 
care  than  an  ordinary  sterilizer 
owing  to  the  danger  of  explosion.  The 
following  points  should  be  observed  in 
its  use :  Enough  water  should  be  present; 
after  the  burners  are  lighted,  the  steam 
valve  should  be  left  open  until  the  air 
has  been  expelled ;  when  the  steam  has 
flowed  rapidly  for  one  or  two  minutes 
the  valve  is  closed;  as  soon  as  the  de- 
sired temperature  is  indicated  on  the 
gauge,  the  burners  are  turned  down, 
so  that  this  temperature  is  maintained 
for  the  required  time;  the  burners  are 
then  turned  off,  but  the  steam  valve 
is  not  opened  until  the  temperature 
has  fallen  below  100°  G,  after  which 
the  lid  can  be  removed.  The  safety 
valve  should  be  tested  to  open  at  about 
125°  C.  It  is  a  good  rule  not  to  leave  the 
autoclave  out  of  sight  while  the  fiG.  560— Pnsteur-C'ham- 
temperature  is  rising.  berland  Filler. 

Obviously  this  piece  of  ap- 
paratus can  also  be  used  as  a  steam  sterilizer  with 
temperature  at  100°  C.  In  such  case  the  steam 
valves  above  are  opened  and  the  water  is  heated  to 
the  boiling-point.  If  steam  is  generated  more  rapidly 
than  it  can  make  its  exit,  the  pressure  rises,  conse- 


896 


REFERENCE    HANDROOK    OF    THE    MEDICAL    SCIENCES 


ll.ii  ii-rluliiuli  ,.l   Tpclinlciun 


guently  the  temperature  goes  above  loo"  ('.  There- 
fore boil  gently  or  raise  cover  enough  to  allow  free 
escape  of  I  he  steam. 

."..  Sterilization  by  Filtration. — It  is  possible  to 
remove  completely  all  the  organisms  which  may  be 
present,  in  a  liquid  by  filtration.  Filler  paper,  of 
course,  on  account  of  the  small  size  of  the  bacteria, 
cannot  be  used  for  this  purpose. 
There  are  only  two  reliable  filters 
for  bacteriological  work.  That 
known  as  the  Pasteur-Chamber- 
land  filter  is  the  best,  and  is  made 
of  unglazed  porcelain.  The  form 
as  used  for  filtering  water  for 
domestic  use  is  shown  in  Fig.  5G0. 
The  original  French  filters  are  to 
be  preferred  to  the  German  imi- 
tations. They  are  made  in  two 
grades;  that  marked  F  is  more 
porous  than  that  marked  B. 

The  Kitasato  filter,  a  narrow 
form  of  the  above,  is  also  made 
of  unglazed  porcelain,  and  is  in- 
tended for  the  filtration  of  very 
small  amounts  of  liquid.  This 
can,  however,  be  done  also  with 
the  larger  filter.  It  is  shown  in 
Fig.  561. 

The  Berkefeld  filter  (Fig.  565) 
consists  of  closely  packed  in- 
fusorial earth.  It  can  be  ob- 
tained in  several  sizes,  having 
the  general  shape  of  the  Pasteur- 
Chamberland  bougie.  It  is  considerably  more  porous 
than  the  porcelain  filter,  and  is  therefore  adapted  for 
rapid  filtration,  but  it  should  be  borne  in  mind  that 
it  is  more  likely  to  allow  the  passage  of  bacteria. 
A  useful  form  of  apparatus  for  holding  the  Pasteur- 
Chamberland  bougie,  that  of  Martin,  is  shown  in 
Fig.  56'J.  It  consists  of  a  metal  cylinder  with  a 
funnel-shaped  top,  which  permits  the  filtration  of  the 
culture  through  filter  paper  previous  to  its  passage 
through  the  bougie,  and  thus  obviates  or  lessens  the 
clogging  of  the  latter.     A  rubber  ring  serves  to  make 


Fig.  561. — Kitasato's 
Filter. 


Fig.  562.— Martin's  Filter. 

a  tight  joint  when  the  bougie  is  held  in  place  by  the 
lower  screw  cap.  The  lower  end  of  the  bougie  is 
connected  with  a  piece  of  vacuum  rubber  tubing  to  a 
globe  receiver.  The  entire  apparatus  is  sterilized  by 
heating  in  an  autoclave.  The  filtration  may  be 
carried  on  by  gravity,  or  an  aspirator  may  be  connected 
with  the  upper  tube   of  the  globe  receiver.     When 

Vol.  I. — 57 


the  filtrate  is  o>  be  transferred,  the  drawn-out  aide  tube 

is  scratched  near  the  end  with  a  file,  and  then  broken 
off,  after  which  the  tube  is  (lamed  and  the  liquid  is 
drawn  off  into  sterile  tubes  or  flasks.  This  globe 
receiver  can  be  used  until  the  drawn-out  tube  is  too 
short,  when  a  new  lube  is  fused  on. 

A  better  form  of  a  globe  receiver  is  shown  in  Fig. 
565.  This  is  provided  with  three  side  tubes,  which 
arc  plugged  with  cotton,  after 
which  the  receiver  is  sterilized  in 
a  dry-heat  oven.  When  it  is  to 
be  used,  the  cotton  is  removed 
from  the  tube  D,  which  is  then 
connected  with  the  sterile  bougie 
by  means  of  a  piece  of  sterile 
vacuum  tubing.  The  horizontal 
tube  F  is  similarly  connected  with 
t  he  sterile  drawn-out  glass  tube  G. 
The  tube  E,  with  its  cotton  plug 
in  place,  is  connected  with  a 
Chapman  pump.  The  filtrate 
may  be  withdrawn  by  means  of  a 
sterile  bulb  pipette,  or  in  the  same 
way  as  from  the  receiver  of  Martin. 
The  advantage  lies  in  the  short 
rubber  tubing,  compactness,  and 
the  convenience  in  attaching  the 


Fig.  563. — Novy's  Filtering  Apparatus. 

drawn-out  tube.  This  vacuum  receiver  can  be  ob- 
tained in  several  sizes,  such  as  one-quarter,  one-half, 
one,  and  one  and  one-half  liter  capacity. 

Instead  of  a  metal  cylinder  to  hold  the  bougie, 
Novy  has  devised  one  of  glass.  This  is  shown  in 
Fig.  563.  The  necessary  tight  joint  between  the 
bougie  and  the  glass  cylinder  is  made  with  a  rubber 
ring,  and  the  bougie  is  brought  up  tight  into  place  by 
means  of  small  vises,  which  act  on  the  flange  and  on 
an  iron  washer.  The  arrangement  is  shown  in  Fig. 
564.  If  desired  the  liquid  can  be  filtered  under 
pressure,  in  which  case  the  rubber  stopper  at  H  is 
connected    with    a    tank    of    compressed    air.     The 


Fig.  564- 


Conneetions  for  the  Novy  Apparatus, 
rings;  4,  iron  washer. 


1,  2,  3,  Rubber 


cylinders  are  made  to  withstand  a  pressure  of  over 
100  pounds. 

The  Berkefeld  filter  may  be  attached  to  the  above 
glass  cylinder  by  means  of  a  rubber  and  iron  washer 
and  the  clamps  mentioned  (Fig.  565).  A  more  con- 
venient arrangement  is  to  use  a  cylinder  of  brass  of 
suitable  length  and  width,  threaded  at  each  end. 
The  lower  end  is  provided  with  a  screw  cap,  through 

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which  the  metal  end  of  the  Berkefeld  bougie  is  passed. 
The  upper  end  is  also  closed  with  a  screw  cap,  provided 
with  a  three-eighths  of  an  inch  nipple,  which  serves 
to  connect  the  cylinder  with  the  compressed  air. 
The  tip  of  the  Berkefeld  is  connected  with  a  globe  re- 
ceiver. The  filtration  can  then  be  carried  out  by 
gravity,  by  aspiration,  or  by  pressure. 

The  filtration  of  liquids  constitutes  an  exceedingly 
important  part  of  bacteriological  technique.  By  its 
means  the  soluble  products  of  bacteria  may  be 
separated  from  the  solid  cells.  In  this  way  the  toxins 
of  many  pathogenic  bacteria  are  prepared.  Again  it 
is  by  the  nitration  process  that  it  has  been  possible  to 
demonstrate  the  existence  of  the  so-called  ultrami- 
croscopic  organisms.  While  the 
common  bacteria  will  not  pass 
through  a  filter,  there  are  a  number 
of  diseases  in  which  the  germ  is  so 
minute  that  it  will  go  through  the 
Berkefeld,  and,  at  times,  even 
through  the  Pasteur-Chamberland 
bougie.  Yellow  fever,  sheep-pox, 
foot-and-mouth  disease,  contagious 
pleuropneumonia  of  cattle,  chicken 
pest,  rinderpest,  horse  sickness, 
molluscum  contagiosum  of  birds, 
and  the  "mosaic  disease  of  to- 
bacco" are  of  this  class;  so  also  is 
rabies.  The  fact  that  a  given 
filtrate  infects  is  not  proof  that  the 
cause  is  always  in  this  extremely 
minute  form.  It  may  be  that  the 
real  organism  is  relatively  large,  as 
in  the  case  of  the  rat  trypanosome, 
and  yet  Berkefeld  filtered  cultures 
of  this  will  often  infect  animals. 
This  is  due  to  the  existence  of 
a  minute  stage  in  the  develop- 
ment of  the  organism.  It  is 
therefore  to  be  expected  that 
the  pathogenic  pro- 
tozoa, though  they 
themselves  may  be 
large,  may  give  rise 
to  filterable  sporo- 
zoites. 

6.  Sterilization  by 
Chemicals. — This  principle  is  applicable  only  to  a 
limited  extent  to  nutrient  media.  The  addition 
of  such  substances  as  carbolic  acid  or  mercuric 
chloride  will  serve  to  destroy  the  organisms  which 
may  be  present;  but  since  these  compounds  can- 
not be  removed  from  the  medium,  it  follows  that 
it  cannot  then  be  used  for  culture  purposes.  A 
few  substances  have,  however,  been  used  with 
this  object  in  view.  Thus  if  chloroform  is  added 
to  milk  or  blood  serum,  and  is  allowed  to  act 
long  enough,  it  will  bring  about  sterilization. 
The  remaining  chloroform  can  finally  be  driven 
off  by  means  of  gentle  heat  and  by  aeration. 
Ether  has  been  used  in  the  same  way,  and  indeed 
this  is  a  useful  procedure  for  sterilizing  such 
weak  cultures  as  those  of  cholera.  Glycerin,  as 
is  well  known,  is  added  to  vaccine  with  the  ob- 
ject of  destroying  the  common  pus-producing 
organisms  which  are  so  often  present.  It  cer- 
tainly will  in  time  destroy  all  of  these  accidental 
bacteria,  but,  unfortunately,  prolonged  exposure  of  the 
vaccine  virus  to  the  glycerin  damages  it  as  well. 

Chemical  disinfection  of  drinking-waters  has  also 
been  proposed,  especially  in  connection  with  military 
operations.  For  this  purpose  various  substances, 
such  as  bromine  and  the  organic  peroxides,  have 
been  suggested. 

In  the  laboratory  this  method  is  resorted  to  more 
or  less  io  sterilize  old  used  cultures,  test-tubes,  and 
animals.     Five-per-cent.  carbolic  acid  or  0.1-per- 
cent, mercuric  chloride  is  employed. 

898 


The  Incubator. — It  is  customary  to  divide  bacteria 
into  two  large  groups — the  saprophytic  and  the 
parasitic — according  as  to  whether  they  grow  in 
nature  on  dead  matter  or  in  the  living  body.  Among 
the  latter  are  classed  the  disease-producing  bacteria. 
In  general  the  optimum  temperature  for  the  growth 
of  the  saprophytic  organisms  is  about  25°  C.  (77°  F.). 
whereas  the  pathogenic  bacteria  thrive  best  at  the 
temperature  of  the  body.  In  order  to  supply  this 
requirement  it  is  necessary  to  use  an  incubator  or 


Fig.  565. — Berkeield  Filter  showing 
Manner  of  Attachment  to  Globe  receiver. 
(Novy.) 


Fig.  566. — Koch's  Incubator. 

thermostat,  the  temperature  of  which  can  be  main- 
tained without  variation  at  any  desired  level.  Vari- 
ous forms  of  apparatus  have  been  devised  for  this 
purpose;  that  of  Koch  is  shown  in  Fig.  566.  It 
consists  of  a  double-walled  box  of  copper,  the  sides 
and  top  being  covered  with  felt.  The  space  between 
the  walls  is  filled  with  water.  In  the  top  is  an 
opening  communicating  with  the  interior  air  space, 
and  in  it  a  thermometer  is  placed  to  indicate  the 
temperature.  The  openings  in  the  corners  com- 
municate with  the  water  space.  One  of  these  is 
intended  to  hold  a  thermoregulator,  while  the  other 
serves  for  the  addition  of  water.  Inner  and  outer 
doors  are  provided,  and  in  the  better  models  provision 
is  made  for  ventilation  and  for  keeping  the  air  moist. 
The  apparatus  may  be  heated  with  an  Argand 
burner.  The  ordinary  Bunsen  burner  is  not 
used  because  of  the  danger  of  "shooting 
back."  The  Koch  safety  burner  is  to  be 
preferred,  for  it  automatically  shuts  off  the 
supply  in  case  the  gas  should  by  any  chance 


Fig.  567. — Koch's  Safety  Burners. 

happen  to  be  turned  off.  It  consists  of  two  iron 
spirals  w-hich,  as  they  are  heated,  expand,  and  in  so 
doing  communicate  this  motion  to  an  arm  which  then 
swings  under  and  supports  the  weighted  lever  of  the 
valve.  If  by  any  accident  the  flame  should  become 
extinguished,  the  spirals  cool  and  contract;  this 
causes  the  supporting  arm  to  swing  out  from  under 
the  lever,  which  then  falls  and  thus  shuts  off  the  gas 
(see  Fig.  567). 

In  case  gas  is  not  available  the  incubator  is  heated 
with  an  oil  lamp.     The  Sartorius  model  is  especially 


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well  constructed  for  this  form  of  heating.  A  good 
substitute  can  always  be  found  in  the  ordinary  egg 
incubator.  In  a  few  places  the  heat  is  supplied  by 
means  of  electric  hot  plates. 

By  far  the  most  important  accessory  to  an  incubator 
is  a  thermoregulator,  which  will  automatically 
control  the  supply  of  gas  and  hence  the  temperature 
of  the  oven.  Several  of  the  more  common  forms  are 
shown  in  Figs.  568-571.  The  Reichert  form,  though 
very  widely  used,  is  far  from  being  the  most  satis- 
factory. The  lower  bulb  is  filled  with  mercury, 
which  as  the  temperature  rises  shuts  off  the  opening 
through  which  the  gas  enters.  In  order  I..  prevent 
the  flame  from  being  extinguished  a  minute  opening 
is  made  in  the  gas-delivery  tube  whereby  a  minimum 
flame  can  be  maintained. 


Fig, 


56S. — Novy's  Thermo- 
regulator. 


Fig.  569.- 


-Reichert's  Thermo- 
regulator. 


In  the  Bunsen  form  the  lower  compartment  is 
nearly  filled  with  a  mixture  of  equal  parts  of  ether 
and  absolute  alcohol,  after  which  a  sufficient  quantity 
of  mercury  is  added  to  act  as  a  valve.  The  upper 
part  is  closed  with  a  stopper,  through  which  passes 
the  gas  tube.  When  the  proper  temperature  is 
reached,  this  tube  is  pushed  down  till  the  gas  flame 
drops.  The  minimum  opening  prevents  total  extin- 
guishment. By  careful  manipulation  the  regulator 
can  be  set  at  any  temperature  which  may  be  desired. 

In  both  the  Novy  and  Dunham  forms  the  lower 
bulb  is  filled  with  absolute  alcohol.  As  this  expands 
it  acts  against  a  column  of  mercury,  which  in  turn 
shuts  off  the  supply  of  gas.  The  lateral  screw  per- 
mits the  adjustment  of  the  regulator  to  the  desired 
temperature.  In  the  former  the  minimum  supply 
can  be  regulated  to  a  nicety.  This  enables  it  to  be 
used  for  a  water-bath,  or  for  a  small  or  large  incuba- 
tor.    It  can  be  obtained  with  the  alcohol  cylinder  of 


different   sizes,  according  to  the  use  for  which   the 
apparat  us  is  intended. 

The   metallic   regulator  of  Rous   is  intended    for 
controlling    the    temperature    of    large  water-baths 

and  of  incubator  r ,  for  which  pure  etter 

de\  ice  can  be  found.     It  i    made  in  tl  "'  , 


Fig.  570. — Dunham's 
Thernio-regulator. 


Fio.  571. —  Bunaen'a 

Thermo-regulator. 


the  straight  and  the  U-shape,  shown  in  Fig.  572. 
It  consists  of  two  metal  bands  having  different 
coefficients  of  expansion.  These  are  soldered  toget  her 
the  full  length.  As  the  temperature  rises,  the  free 
upper  arm  moves  from  and  thus  releases  a  spring 
valve,  which  shuts  off  the  main  supply  of  gas.  A 
minute  opening  serves  to  supply  a  minimum  amount 
of  gas,  and  thus  prevents  extinguishment  of  the  flame. 


dlib.'i  >Amt 


.        1"''  ''■'  -•-■  ■  ■■'■  !     '^  | 

Fig.  572. — Rous  Metallic  Thermo-regulator. 


The  incubator  described  in  its  several  modifications 
answers  all  ordinary  purposes.  In  large  laboratories 
it  can,  however,  be  dispensed  with  almost  entirely, 
and  its  place  is  taken  by  the  incubator-room.  By 
this  is  meant  a  re. nn,  usually  about  eight  feet  cube, 
which    is    maintained    at    a    constant    temperature. 

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This  arrangement  was  first  employed  at  the  Pasteur 
Institute,  where  the  heat  is  conveyed  to  the  room 
by  means  of  large  pipes  along  the  wall,  filled  with 
water,  or  better  with  glycerin.  The  circulating 
liquid  is  heated  by  a  small  gas  stove  placed  on  the 
outside  of  the  room. 

A  more  simple  and  thoroughly  efficient  procedure 
is  to  place  a  small  gas  stove  in  the  center  of  the  room. 


Fig.  573. — Moitessier's  Gas-pressure  Regulator. 

This  stove,  which  can  be  obtained  of  the  French 
dealers,  is  so  constructed  that  the  gases  of  combustion 
are  carried  out  of  the  room  into  a  flue. 

Another  procedure  of  limited  application  is  to  heat 
the  room  with  steam  coils.  The  regulation  of  the 
heat  in  this  case  is  accomplished  by  means  of  an 
automatic  steam  valve  operated  by  compressed  air. 

The  construction  of  the  room  requires  no  special  care. 
The  walls,  whether  of  brick  or  of  plaster,  should  be  given 
several  coats  of  white  zinc.  Shelves,  water,  gas  and 
electric  light,  and  a  window  should  be  provided. 

The  regulation  of  the  temperature  in  the  rooms 
heated  by  gas  is  done  by  means  of  the  Rous  U- 
shaped  regulator.     All  the  connections  should  be  of 


Fig.      574. — Murrill's 


Gas-pressure 
(Novy.) 


Regulator.      Cross-section. 


metal  to  lessen  the  chances  of  fire.  In  order  to  have 
a  temperature  record  it  is  advisable  to  place  in  the 
room  a  thermometrograph,  the  best  form  of  which  is 
made  by  Richard  Freres,  of  Paris. 

Gas-pressure  Regulator. — The  best  results  with  any 
form  of  thermoregulator  are  obtained  when  the  gas 
pressure  is  constant  or  nearly  so.  When  the  varia- 
tion is  considerable  it  is  advisable  to  pass  the  gas 
through  a  pressure  regulator  before  it  reaches  the 
thermoregulator.  There  are  several  forms  of  ap- 
paratus for  this  purpose.     The  Moitessier  regulator  is 


shown  in  Fig.  573.  It  consists  of  a  cylinder  A 
which  is  filled  to  the  level  of  G  with  a  mixture  of 
equal  parts  of  glycerin  and  water.  On  this  is  floated 
the  metal  shell  B.  The  gas  is  admitted  to  the  in- 
terior of  B,  through  the  tube  K,  the  pressure  being 
indicated  by  the  manometer  P.  The  gas  flows  into 
B  until  it  is  filled,  when  it  raises  it  up  and  shuts  off 
the  supply  of  gas  by  closing  the  valve  D.  The  pres- 
sure on  the  burner  is  regulated  by  the  weights  placed 
in  the  pan  H,  which  is  connected  with  B  by  the  rod 
G.  The  amount  of  pressure  on  the  burner  is  indicated 
by  the  manometer  on  the  left  of  the  apparatus.  The 
burner  is  connected  with  the  apparatus  by  means  of  a 
rubber  tube  attached  to  /,  and  the  height  of  the 
flame  is  regulated  by  the  stopcock  M. 

A  cheaper  and  more  simple  regulator  is  that 
devised  in  Novy's  laboratory  by  Murrill  and  shown 
in  Fig.  574.  The  gas  passes  into  a  cylinder  which 
floats  in  liquid  petroleum  and  leaves  by  two  tubes 
at  the  bottom,  one  of  which  is  connected  with  the 
thermoregulator,  the  other  with  a  manometer.  The 
cylinder  is  weighted  so  as  to  give  the  desired  pressure 
to  the  outflowing  gas. 

During  the  hot  summer  months  it  is  desirable  to 
have  an  apparatus  which  will  keep  a  fairly  constant 
low  temperature,  below  that  which  would  cause  the 
gelatin  cultures  to  melt.  There  are  incubators  con- 
structed for  this  purpose  which  furnish  a  supply  of 
ice-cold  water  when  the  temperature  rises  above  a 
given  point.  If  the  temperature  drops  too  low,  the 
electric  lamp  is  turned  on. 

When  the  temperature  of  the  water  as  it  leaves  the 
ground  is  about  15°  C.  (59°  F.)  it  is  possible  to  use  the 
simple  apparatus  shown  in  Fig.  575.  This  is  made  of 
galvanized  iron.  The  inner  box  is  held  in  place  by 
means  of  a  couple  of  stout  rods.  The  water  enters  at 
the  bottom  through  the  small  tube,  which  stops 
short  on  the  inside  of  the  outer  box.     The  water  then 


Fig.  575. — Novy's  Low-temperature  Incubator. 

flows  under  and  around  the  inner  box,  and  eventually 
reaches  at  the  farther  end  the  wide  outflow  tube. 
The  end  of  t"his  is  turned  up  and  is  provided  witha 
short  piece  of  rubber  tubing.  By  moving  this  up  or 
down  the  level  of  the  water  in  the  box  can  be  regu- 
lated. By  regulating  the  flow  of  the  water  it  ispossible 
to  maintain  a  fairly  constant  temperature  in  the  inner 
compartment. 

The  Methods  of  Cultivation. — The  fundamental 
basis  of  bacteriology  may  be  said  to  be  the  fact  that 
it  is  possible  to  cultivate  artificially,  and  that  in  pure 
condition,  nearly  all  of  the  known  forms  of  bacteria. 
Until  methods  had  been  devised  for  this  purpose  it 
was  not  possible  to  determine  definitely  the  part 
played    by    any    organism    either    in    the    ordinary 


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phenomena  of  fermentation  or  in  the  more  mysteriou 
processes  of  disease.  To  arrive  at  a  demonstration 
of  the  causal  relation  of  a  given  organism  to  the 
change  which  it  is  supposed  to  induce  it  is  necessary 
to  do  two  things:  First,  I  he  organism  must  be  isolated 
in  pure  culture;  and  second  the  pure  culture,  once 
obtained,  must  be  maintained  by  transplantation. 
The  pure  culture  thus  kept  up  through  a  series  of 
transplantations,  or  generations  as  they  are  called, 
can  then  be  tested  upon  animals  to  see  if  it  will 
produce  the  disease,  or  upon  suitable  media  to  ascer- 
tain if  it  will  cause  the  kind  of  fermentation,  the 
pigment,  or  the  light  which  it  is  supposed  to 
produce. 

By  a  pure  culture  is  meant  one  which  is  derived 
from  a  single  cell.  A  given  bacterium,  small  as  it  is, 
multiplies  by  division,  and  thus  gives  rise  to  two  new 
individuals.  These  in  turn  grow  and  divide,  yielding 
four  cells.  This  process  is  kept  up  till  many  millions 
of  organisms  constitute  the  offspring  of  a  single  cell. 
Inasmuch  as  the  division  of  bacteria  is  very  rapid 
under  favorable  conditions,  many  dividing  every 
half-hour,  it  follows  that  in  a 
few  hours  a  visible  growth  may 
be  seen  where  at  the  beginning 
but  a  single  cell  was  present. 
If  the  medium  in  which  they 
are  growing  is  liquid,  it  will 
usually  become  cloudy  because 
of  the  disseminated  bacteria. 

The  early  methods  of  cultiva- 
tion, as  employed  by  Pasteur, 
made  use  of  liquid  media. 
Under  these  conditions  it  was 
exceedingly  difficult  to  obtain 
pure  cultures,  and  indeed  it 
was  largely  a  matter  of  chance 
and  patience.  Suppose  that  a 
given  liquid  contains  two  kinds 
of  bacteria;  in  order  to  separate 
ra  W ™  iff™  tnese  so  as  t°  have  a  single  cell 
II  as  a  starter  for  the  pure  culture 
it  would  be  necessary  so  to  di- 
lute the  liquid  that  in  all  prob- 
ability a  drop,  or  a  cubic  centi- 
meter would  contain  but  one 
cell.  This  small  quantity  would 
then  be  taken  and  transferred 
to  a  sterile  medium,  and  in  this 
way  it  would  be  possible  to 
obtain  presumably  pure  cul- 
tures. Failure,  however,  was 
necessarily  frequent  and  the 
element  of  doubt  always  re- 
mained. 

The  introduction  of  the  nutrient  gelatin  by  Koch 
made  it  possible  to  secure  pure  cultures  with  the 
greatest  of  ease.  All  that  was  necessary  was  to  inocu- 
late the  liquefied  gelatin  with  the  mixture  of  bacteria, 
and  after  thorough  agitation  so  as  to  separate  each 
cell  from  its  neighbor,  to  pour  the  liquid  on  to  the 
surface  of  a  sterile  plate.  The  gelatin  now  solidifies, 
and  imprisons,  as  it  were,  the  separated  cells.  Each 
of  these  now  multiplies  and  reproduces  its  kind; 
eventually,  in  the  course  of  a  day  or  two,  a  small 
growth,  perhaps  of  the  size  of  a  small  pinhead,  appears. 
This  is  called  a  colony,  and  since  it  is  derived  from  a 
single  cell  it  constitutes  a  pure  culture.  Such  is  the 
principle  of  the  dilution  method  for  obtaining  pure 
cultures.  The  isolation  once  accomplished,  all  that 
is  necessary  is  to  transplant  the  colony  to  sterile 
culture  media  so  as  to  keep  up  the  growth. 

The  transferring  of  bacteria  is  usually  done  by 
means  of  a  platinum  wire.  The  wire,  which  should  be 
about  two  inches  long  and  fairly  stiff,  about  No.  21  in 
size,  is  fused  into  the  end  of  a  glass  rod.  According 
to  the  object  in  view  it  is  either  straight,  bent,  or  is 
provided  with  a  loop  as  shown  in  Fig.  570. 


576. — Platinum 
Fused    in    Glass 


At  times  a  bunch  of  very  fine  platinum  wires  at- 
tached to  a  holder,  the  so-called  Kruse's  brush,  is  u  -l 
to  spread  the  material  over  tin-  surface  of  the  media. 

A  glass  rod   bent  at   right    angles   is  also   very   useful 

for  i  his  purpose.  The  Roux  spat  ula  of  nickeled  steel 
was  first  employed  for  the  purpo  e  of  transplanting 
bits  of  diphtheritic  membrane  to  the  culture  lube. 

A  similar  spat  ula  made  of  thick  iron  wire  is  extremely 
useful  for  transferring  moulds  and    coin  pact    growths, 

such  as  that  of  act  inomyces.  The  Nuttall  platinum 
spear   is  particularly  useful   for   transferring   bits  of 

tissue,  blood,  etc.,  to  the  nutrient  media.  These  two 
instruments  are  shown  in  fig.  577. 

The  transferring  of  liquids,  in  large  or  in  small  quan- 
tities, can  best  be  done  by  means  of  drawn-out  glass 
tube  pipettes,  as  is  practised  by  the  Pasteur  School. 
This  technique  is  at  once  simple  and 
invaluable.  The  preparation  of 
these  pipettes  will  be  understood 
from  Fig.  578. 

The  glass  tubing,  which  has  a 
diameter  of  about  eighl  millimeters, 
is    cut    up    into  lengths   of  about 

0  twelve  inches.       By   means  of  the 

blast  lamp  a  slight  constriction  is 
made  at  about  two  inches  from 
each  end.  This  serves  to  prevent 
the  cotton  plug  from  falling  down, 
and  also  tends  to  keep  the  liquid 
from  reaching  the  cotton.  The 
ends  of  each  tube  are  then  care- 
fully rounded  out  in  the  flame.  A 
piece  of  cotton  is  then  pushed  into 
the  end  of  each  tube.  The  tubes 
thus  prepared  (Fig.  578,  a)  are 
then  sterilized  in  the  dry-heat  oven, 
after  which  they  may  be  stowed 
away  for  future  use. 

Whenever  it  is  desired  to  make 
a  pipette,  one  of  these  tubes  is 
heated  in  the  middle  in  a  blast 
flame,  and  when  the  glass  has 
thoroughly  softened,  the  two  halves 
are  slowly  drawn  apart.  A  rela- 
tively wide,  thick-walled  capillary, 
about  sixteen  inches  long,  is  thus 
obtained  (Fig.  578,  6).  This  is 
then  sealed  in  the  flame  in  the  mid- 
dle, and  the  result  is  two  pipettes. 
For  transferring  large  quantities  of 
liquid  a  bulb  is  blown  in  the  pipette 
(Fig.  57S,  e).  This  is  made  by 
directing  a  narrow  blast  flame 
against  the  tube,  which  is  at  the 
same  time  rotated.  As  the  glass 
softens  the  ends  are  slightly  pushed  together,  so  as  to 
form  a  thick  ring  of  glass.  This  is  repeated  once  or 
twice.  Finally  a  large  blast  flame  is  turned  on,  and 
when  the  thickened  glass  is  perfectly  soft,  the  end 
is  brought  into  the  mouth  and  the  bulb  is  blown. 
The  glass  should  be  rotated  during  this  operation, 
and  in  fact  in  all  work  of  this  kind. 

To  use  a  pipette,  the  mouth  end  should  first  be 
rolled  for  a  few  seconds  in  a  flame  so  as  to  insure 
sterility;  the  capillary  end  is  then  scratched  with  a 
file  and  the  tip  is  broken  off,  after  which  the  capillary 
is  flamed.  As  soon  as  the  tube  has  cooled,  which  fact 
can  be  ascertained  by  blowing  through  the  pipette 
against  the  back  of  the  hand,  it  is  ready  for  use. 
The  closure  of  the  pipette  when  it  is  filled  with  the 
liquid  is  effected  by  means  of  the  tongue  pressed 
against  the  upper  end. 

The  great  value  of  the  pipette  lies  in  the  fact  that 
it  can  be  made  in  a  few  minutes,  and  can  be  used  to 
transfer  liquids  from  one  tube  to  another,  for  drawing 
blood  from  the  heart,  fluids  from  the  cavities,  etc. 
It  is  indeed  even  more  useful  than  a  platinum  wire. 
Plate  Cultures. — Solid  media,  such  as  gelatin  or  agar, 

901 


Fig.  577. — a,  Itoux 
spatula;  b,  Nuttall's 
platinum  spear. 


Bacteriological  Technique 


REFERENCE    HANDBOOK   OF   THE    MEDICAL   SCIENCES 


cither  plain  or  modified,  are  employed  for  this  pur- 
pose. The  starting-point  in  this  method  were  the 
slide  cultures  used  by  Koch  in  his  early  investigations. 
The  liquefied  gelatin  was  poured  upon  the  surface 
of  sterile  glass  slides,  which  were  levelled  and  kept 
cool  by  means  of  the  apparatus  shown  in  Fig.  579. 
The  lower  dish  was  filled  with  ice-water  and  the  whole 


@S= 


Fig.  57S. — Pasteur  Pipettes,  showing  Method  of  Preparation.      (Novy-) 


was  set  true  by  the  aid  of  a  small  spirit-level.  A 
series  of  parallel  streaks  was  then  made  on  the  solid 
gelatin  by  means  of  a  platinum  wire,  which  was  dipped 
in  the  material  to  be  planted.  A  number  of  slides 
were  thus  made,  after  which  they  were  stacked  on 
glass  benches  (Fig.  5S0),  and  placed  in  a  moist 
chamber  to  develop    (Fig.   581).     The    first    streak, 


i 

Fig.  579. — Koch's  Levelling  Apparatus. 


on  account  of  the  large  number  of  organisms  planted, 
would  probably  yield  a  continuous  solid  growth. 
The  next  streak  would  have  fewer  germs,  and  the 
succeeding  ones  si  ill  less  until  eventually  only  single 
germs  would  be  deposited,  separated  by  an  appre- 
ciable distance  from  the  following  ones.  Wherever  a 
single  organism  was  deposited,  as  a  result  of  multipli- 


5N,u. — Glass  Benches  and  Culture  Slides. 


cation,  a  colony  would   soon   make  its  appearance. 
(See  Plate  XII.,   18) 

The  slide  method  was  soon  improved  by  substitut- 
ing larger  glass  plates  ( 10  x  13  cm.).  Instead  of  mak- 
ing streak  dilutions  as  just  given,  the  gelatin  was  lique- 
fied, inoculated,  and  poured  out  upon  the  sterile 
plates,  which  were  cooled  on  the  plating  apparatus. 
This  method  of  plating  may  be  used  when  the  special 
Petri  dishes,  ordinarily  employed,  are  not  obtainable. 


The  fact  that  the  method  required  a  lot  of  apparatus, 
slides,  slide-box,  levelling  apparatus,  ice,  moist 
chamber,  etc.,  as  well  as  the  fact  that  contamination 
from  the  air  and  from  the  dripping  of  the  superposed 
plates  was  unavoidable,  led  Petri  to  introduce  the 
modification  which  has  almost  entirely  supplanted 
the  older  method. 

Gelatin  Petri  Plates. — In  this 
*=s—^-^.-^mlnr>  a  method,  as  in  the  preceding, 
the  gelatin  is  first  melted  by 
/  immersion  in  warm  water  for 
a  few  minutes.  By  means  of 
a  sterile,  looped,  platinum  wire 
a  small  quantity  of  the  ma- 
terial to  be  examined  is  trans- 
ferred to  a  tube  of  liquefied 
gelatin,  marked  1.  By  means 
d  of  the  wire  the  material  is  thor- 
oughly mixed  with  the  gelatin. 
Another  tube,  marked  2,  is 
then  placed  beside  the  first, 
from  which  three  loopfuls  of 
gelatin  are  carried  over  to  tube 
2,  with  the  contents  of  which 
they  are  well  mixed  (Fig.  582). 
A  third  tube,  marked  3,  is  then 
placed  beside  number  2,  and 
three  loopfuls  of  gelatin  are  transferred  from  tube  2 
to  tube  3.  It  is  evident  from  this  procedure  that 
even  if  the  first  tube  received  a  million  germs  the 
second  tube  would  contain  only  a  small  fraction,  and 


Fig.  581. — Moist  Chamber  with  Stacked  Plates. 

the  third  tube  would  contain  still  less.  The  platinum 
wire  must  of  course  be  sterilized  whenever  an  inocu- 
lation is  made  into  a  new  tube. 

A  number  of  Petri  dishes  (Fig.  583),  which  are  ten 
centimeters  in  diameter  and  one  centimeter  high,  are 


Fig.  5S2. — Method  of  Holding  the  Tubes  when  Making  Dilutions. 


previously  sterilized  by  heating  in  a  dry-heat  oven 
for  one  hour  at  150°  C,  or  for  a  few  minutes  at  200°  C, 
and  allowed  to  cool.  To  pour  the  plate,  the  cotton 
is  removed  from  one  of  the  tubes,  and  the  open  end  is 
rolled  for  a  few  seconds  in  the  flame  so  as  to  sterilize  it. 


902 


HKKKlil'AVi;    iiwdii s    h\    Tin;    \|  i;  [  >|< '  \  |,    scillXCES 


Bacteriological  Technique 


In  a  few  seconds  the  end  of  the  tube  becomes  cool, 
after  which  the  contents  are  poured  oul  into  the 
Petri  dish.  The  lid  of  the  latter  is  removed  just 
sufficiently  l<>  allow  the  gelatin  in  !»■  introduced 
By  tilting,  the  gelatin  is  thru  spread  all  mw  the 
bottom  of  the  dish.  The  latter  is  then  sel  aside  in  a 
cool    place   for    the    gelatin    to   set.     With   a   g I 

gelatin  this  will  take  place  even  in  the  ordinary  room 
within  a  few  minutes.  The  remaining  gelatin  tube 
are  poured  in  the  same  manner.  Each  plate  should  be 
numbered  to  correspond  to  the  tube  from  which  it 
was  made.  They  should  be  marked  also  with  the 
date  and  the  kind  of  material  used.  A  Faber1 
colored  wax  pencil  is  used  for  this  purpose. 

Agar  Petri  Plates. — Inasmuch  as  gelatin  melts  at 
about  25°  C.  it  follows  that  the  method  just  gi\en 
cannot  be  used  when  the  organism  requires  the 
temperature  of  the  incubator.  In  such  cases  it  is 
necessary  to  resort  to  the  use  of  agar.  The  nutrient 
agar  is  first  melted  by  heating  in  a  water-bath  at 
100°  C.  The  flame  is  then  turned  out  and  the  tubes 
are  allowed  to  cool  in  the  water-bath  until  a  tempera- 
ture of  about  45°  C  is  reached.  The  agar  solidifies  at 
about  40°  C,  and  consequently  the  dilution  must  be 
made  rapidly  and  the  plates  poured  before  that  point 
is  reached.  Dilution  cultures  are  made  in  the  same 
way  as  just  given  for  gelatin.  The  three  agar 
tubes  are  then  poured  out  into  the  corresponding 
sterile  Petri  dishes.  The  agar  promptly  solidities, 
and  for  that  reason  the  spreading  of  the  agar  over  the 
bottom  must  be  hastened.  The  agar  plates  are  then 
set  aside  to  develop  either  at  the  temperature  of  the 
room  or  at  that  of  the  incubator. 

Esmarch  Roll-tube  Culture. — This  modification  of 
the  plate  method  does  away  with  the  use  of  any 
special  container  other  than,  the  test-tube.  The 
dilutions    in    gelatin    are    made    in    the    usual   way. 


9 : .  \ 

Fig.  583.— Petri  Dish  for  Plating. 


According  to  the  original  directions  the  cotton  plug 
was  cut  off  short,  and  the  end  of  the  tube  was  covered 
with  a  close-fitting  rubber  cap.  The  tube  was  then 
immersed  and  rotated  in  an  almost  horizontal  position 
in  ice-water.  The  gelatin  solidified  in  an  even  film  over 
the  inside  of  the  test-tube  (Fig.  584). 

A  more  convenient  way  of  rolling  the  tubes  was 
devised  by  Booker.  With  the  aid  of  a  large  test-tube 
filled  with  warm  water  a  groove  is  melted  into  a 
block  of  ice.  The  gelatin  tubes  are  then  rolled  in  this 
groove  until  the  gelatin  solidifies  in  a  smooth,  even 
film.  Nuttall  has  modified  this  procedure  by  replac- 
ing the  ice  block  with  a  marble  block  provided  with 
grooves  for  the  test-tubes.  Running  tap  water 
serves  to  cool  the  tubes. 

If  the  tubes  are  not  rolled  smoothly  they  can  be 
softened  by  gentle  warming  and  be  rerolled.  <  toe 
advantage  of  this  method  lies  in  the  fact  that  desicca- 
tion can  be  retarded  more  than  with  the  other  methods. 
Air  contamination  is  likewise  diminished.  On  tin- 
other  hand,  the  presence  of  a  few  liquefying  bacteria 
may  spoil  the  tube.  The  Esmarch  roll  tubes  should 
be  kept  in  a  cool  place  to  prevent  melting.  When 
the  colonies  develop  they  may  be  examined  by 
placing  the  tube  on  the  stage  of  the  microscope. 
To  transplant  the  colonies  a  platinum  wire,  pro- 
vided with  a  hook,  as  shown  in  Fig.  576,  should  be 
used. 

Shake  Cultures. — Dilutions  are  made  in  gelatin  or 


V* 


agar  as  heretofore   de  cribed,      I  are  1  hen 

solidified    in    an    upright    position    and  I    to 

develop.     If  it  is  desired  to  trait  plant  a  given  colony 

I  he  te  i  tube    I d  bi     cral  ehed  n  it  h  a  dia  mom 

about    the   level   of   the   colony.     On    touching   the 

scratch    with   a  hot    rod    the   crack    can   be   led   around 

the  tube,  after  which  the  t  wo  part  can  bi  eparated. 
Bj  means  of  a  sterile  knife  the  medium  can  be  cut 
ami  i  In-  colony  expo  ed.  In  t he  i  i  ol  i  ••  t  he 
entire  cylinder  of  agar  can  be  forced  out  of  the  tube 
into  a  sterile  di  h  l>\  the  cautious  application  of  a 
Same  to  I  he  loner  end  of  the  t  ube. 

The  method  offers  a  convenient  means  of  determin- 
ing whether  or  not  the  organism  planted  generates  gas. 
If  such  is  the  ease  gas  bubble-  will  make  their  appear- 
ance   in    the    medium.      As  will   be 
seen   later   this   method   is  also  use- 
ful in  connection  with  the  cultiva- 
l ion  of  anaerobic  bacteria.. 

Streak  CultiiriK.  This  proced- 
ure,  w  hich  is  essentially  the  same 

aS     that     Used     by     Koch    in    his    slide 

cultures,  is  very  frequently  made 
use  of  at  the  present  time.  Thus, 
sterile  gelatin  or  agar  may  be 
poured    into    sterile    Petri    dishes, 

and  after  the  material  has  solidi- 
fied a  series  of  parallel  streaks 
may  be  made  with  an  infected 
platinum  wire  or  platinum  spatula. 
The  Kruse  platinum  brush  maybe 
used  to  spread  the  organisms  over 
the  surface.  A  narrow  glass  rod, 
bent  and  flattened  at  the  end,  has 
been  used  for  spreading  gonorrheal 
pus  over  plates.  Cotton  swabs 
are  used  for  the  same  purpose  in 
the  case  of  diphtheria. 

As  in  the  case  of  the  Esmarch 
roll  tube,  the  Petri  dish  may  be 
omitted  in  this  method.  In  that 
event  the  gelatin  or  agar  is  melted 
and  allowed  to  solidify  in  an  in- 
clined position.  The  streaks  are 
then  made  on  the  surface  of  the 
inclined  medium.  Potato  tubes 
are  inoculated  in  the  same  way. 
(See  Plates  XI.  and  XII.) 

To  obtain  perfectly  isolated 
colonies  by  this  method  the  same 
wire  should  be  used  to  make  parallel 
streaks  on  each  of  four  or  five  tubes. 
When  the  colonies  develop,  trans- 
plantations can  be  made  by  means 
of  a  bent.  wire. 

Hanging-drop  Cultures. — A  con- 
cave or  well  slide,  shown  in  Figs. 
599  and  600,  is  used.  The  cover- 
glass  must  first  be  sterilized  by 
passing  it  several  times  through  a  "*■-'.—  - 

flame.  A  large  drop  of  sterile  Fig.  584. — Esmarch 's 
bouillon  is  then  placed  in  the  mi-  Roll  Culture, 
ter,  and  this  is  inoculated  with  the 
germ  to  be  studied.  The  slide  with  a  ring  of  vaseline 
is  then  inverted  and  brought  down  upon  the  cover- 
glass,  after  which  the  preparation  is  turned  over. 
Care  must  be  taken  to  see  that  the  vaseline  closure 
is  perfect.  This  method  of  cultivation  is  used  to 
study  the  multiplication  of  the  bacteria  under  the 
microscope. 

Hanging-block  Cultures. — In  order  to  be  able  to 
study  the  morphology  and  the  multiplication  of  the 
diphtheria  bacillus  to  better  advantage  than  that 
afforded  by  the  hanging  drop,  Hill  devised  the 
following  procedure:  Melted  nutrient  agar  is  poured 
into  a  Petri  dish  to  a  depth  of  about  one-eighth  to 
one-quarter  inch.  When  cool,  a  block  of  agar  is  cut 
out,  about  one-quarter  to  one-third  inch  square,  and 


IJ 


'0. 


KM 


003 


Bacteriological  Technique 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


\ 


of  the  thickness  of  the  agar  layer  in  the  dish.     The 
block  is  placed,  under  surface   down,  on  a  slide  and 

Eroteeted  from  dust.  A  suspension  of  the  growth  to 
e  examined  is  then  made  in  sterile  water  or  a 
bouillon  culture  is  used.  The  suspension  is  spread 
over  the  upper  surface  of  the  block  as  if  making 
an  ordinary  cover-slip  preparation.  The  slide  and 
block  are  then  set  aside  in  the  incubator  at  37°  C. 
for  five  or  ten  minutes,  to  dry  slightly.  A  clean 
sterile  cover-slip  is  then  placed  on  the  inoculated 
surface  of  the  block  in  close  contact,  avoiding  large 
air  bubbles.  The  slide  is  then  removed  from  the 
under  surface  of  the  block,  and  the  cover-slip  is 
inverted  so  that  the  agar  block  is  uppermost.  With 
the  aid  of  a  platinum  wire  a  drop  or  two  of  melted 
agar  is  run  along  each  side  of  the  agar  block,  to  fill 
the  angles  between  the  sides  of  the  block  and  the 
cover-slip.  This  seal  hardens  at  once  and  prevents 
slipping  of  the  block.  The  preparation  is  again 
placed  in  the  incubator  for  five  or  ten  minutes  to  dry 
the  agar  seal.  Finally  the  preparation  is  inverted 
over  a  moist  chamber  or  suitable  well  slide.  The 
cover-slip  is  sealed  in  place  with  white  wax  or  paraffin. 
Vaseline  cannot  be  used  because  it  softens  at  37°  C. 
The  "hanging  block,"  thus  prepared,  is  examined 
on  a  warm  stage  or  in  the  incubator-room. 

Transplantation  of  Colonies. — The  entire  object  of 
making  plate  culture  by  any  one  of  the  several 
methods  given  is  to  obtain  single  isolated  colonies; 
these  can  be  transplanted  to  other  media,  and  the 
organism  present  can  then  be  studied  in  perfectly 
pure  condition.  The  colony  as  indicated  is  pre- 
sumably derived  from  a  single  cell,  and  consequently 
is  a  pure  culture.  The  transplantations  or  sub- 
cultures can  be  made  to  gelatin,  agar,  serum,  bouillon, 
milk,  etc.  When  the  colonies  are  on  a  plate  or  in  a 
Petri  dish  a  straight  wire  is  used.  The  plate  is  first 
carefully  examined  under  the  microscope,  and  a 
colony  is  selected  which  is  clearly  single.  If  possible 
it  should  be  the  only  one  in  the  field  of  the  No.  3 
or  one-third  inch  objective.  The  farther  apart  the 
colonies  are  the  less  likely  are  they  to  intermingle.  As 
originally  directed,  the  colonies  were  touched  under 
the  microscope  by  a  sterile  platinum  wire,  and  in 
this  way  a  few  of  the  bacteria  were  removed.  Care 
had  to  be  taken  that  the  wire  did  not  touch  the 
objective  or  any  other  part  of  the  gelatin.  This 
operation  of  "fishing,"  as  it  is  called,  obviously 
requires  considerable  practice  and  care.  An  equally 
good  procedure  is  to  pick  out  the  desired  colony 
under  the  microscope.  The  tube  of  the  microscope 
is  then  raised,  and  the  point  of  the  sterile  wire  is 
brought  down  so  that  it  cuts  the  colony  and  nothing 
else.  The  tube  is  then  again  lowered  and  the  site 
of  the  colony  examined  to  make  sure  that  nothing 
but  the  colony  was  touched.  If  such  is  the  case  the 
wire  is  then  used  for  the  subculture. 

Stab  Cultures,. — A  tube  of  solid  gelatin  is  taken,  the 
cotton  plug  is  seized  by  the  right  little  finger  and 
removed.  The  mouth  of  the  tube  is  then  flamed, 
after  which  the  wire,  laden  with  the  bacteria,  is 
inserted  and  carefully  passed  down  the  center  of  the 
gelatin.  The  organisms  are  thus  planted  along  the 
line  of  inoculation.  The  cotton  plug  is  replaced 
and  the  tube  is  labelled  and  set  aside.  The  form 
of  the  growth  is  then  noted  from  day  to  day,  also  the 
presence  of  gas,  liquefaction,  pigment,  etc.  The 
characteristics  of  the  stab  cultures  are  of  the  very 
greatest  importance  in  the  identification  of  bacteria. 
If  the  gelatin  is  old  and  partially  dried,  the  passage 
of  the  needle  is  likely  to  cause  a  split  in  the  medium. 
This  can  be  avoided  by  melting  and  resolidifying 
the  gelatin.      (See  Plates' XI.  and  XII.) 

Streak  Cultures. — These  are  also  known  as  "smear 
cultures."  The  gelatin  or  agar  tubes  are  melted  and 
solidified  in  an  inclined  position.  Similarly  solidified 
blood  serum  is  also  used;  so  also  are  the  potato  tubes. 
The    infected    platinum    wire    is    drawn    along    the 

904 


middle  of  the  surface  of  the  medium  by  making  one 
single  streak.  The  growth  develops  along  the  line 
of  inoculation,  and  spreads  in  a  more  or  less  character- 
istic manner.     (See  Plates  XI.  and  XII.) 

Flask  Cultures. — Flat  flasks  may  be  used  for  the 
cultivation  of  bacteria  en  masse  where  the  organisms 
are  desired  in  large  quantities.  The  flask  possesses  an 
advantage  over  the  Petri  dish  in  that  it  is  much  less 
likely  to  become  contaminated  from  without.  For 
this  purpose  the  Kolle  culture  flask,  or  any  similar 
flat  flask  with  a  smaller  mouth,  may  be  employed. 
To  a  properly  plugged  and  sterilized'flask,  sufficient 
fluid  gelatin  or  agar  medium  is  added  to  form  a 
layer  about  a  quarter  of  an  inch  in  thickness  over 
one  side.  It  is  again  sterilized  by  steaming  and  the 
medium  is  allowed  to  solidify  with  the  flask  lying 
on  its  side.  When  solid  the  free  surface  of  the  medium 
may  be  inoculated  with  organisms  in  broth  or  salt 
solution  suspension  by  spraying  or  brushing  over 
with  a  Kruse's  brush.  After  the  growth  has  suffi- 
ciently developed,  it  is  removed  by  being  scraped  off. 
A  spatula,  glass  rod  with  angle  at  end,  or  similar 
instrument  may  be  used  for  this  purpose.  Sterile 
broth  or  salt  solution  may  be  used  to  aid  in  washing 
the  culture  free.  For  the  cultivation 
of  bacteria  on  a  large  scale,  Novy  and 
Vaughan  introduced  large  metallic 
tanks  with  tightly  fitting  covers. 

Liquid  Cultures. — The  tubes  of 
sterile  bouillon,  milk,  ™rum,  etc.,  are 
inoculated  by  simply  introducing  some 
of  the  material  from  a  colony  by 
means  of  the  sterile  wire. 

The  subcultures  from  tube  to  tube 
are  made  in  the  same  way  as  just 
given.  The  drawn-out  glass-tube 
pipettes  and  spatulas  can  be  used  to 
transfer  the  material  from  one  tube  to 
another  or  to  flasks. 

Anaerobic  Cvlti ration  of  Bacteria. — 
The  methods  just  given  are  essentially 
aerobic,  since  there  is  free  access  of 
air.  As  is  well  known  there  are  two 
classes  of  bacteria  with  reference  to 
their  oxygen  requirements.  The  aero- 
bic bacteria  live  in  the  presence  of 
air,  while  the  anaerobic  thrive  only  in 
the  absence  of  oxygen.  In  order  to 
cultivate  the  latter,  special  methods 
must,  therefore,  be  employed  which 
will  supply  the  needed  conditions. 
Numerous  procedures  have  been  de- 
vised for  this  purpose,  and  to  give 
all  of  these  would  be  beyond  the  scope 
of  this  article.  It  will  be  sufficient 
to  indicate  the  principles  which  serve 
as  a  basis  for  these  methods,  and  to 
describe  those  which  are  most  widely 
used. 

1.  Exclusion  of  Oxygen. — This  was 
accomplished  by  Pasteur  in  his  early 
work  by  pouring  a  layer  of  oil  upon 
the  culture  fluid.  This  served  to  ex- 
clude the  air  and  allowed  the  bacteria 
to  develop.  Koch  obtained  anaerobic 
conditions  by  covering  the  surface  of 
the  gelatin  plates  witli  a  thin  sheet  of  mica, 
have  done  the  same  with  glass  plates. 

The  Liborius  method  of  cultivation  in  deep  layers 
falls  under  this  head.  It  is  simple  and  is  constantly 
used.  Ordinary  stab  cultures  are  made  in  the 
suitable  media,  preferably  glucose  agar.  Another 
tube  of  agar  is  liquefied,  cooled  to  about  50°  C,  and 
the  contents  of  this  are  then  poured  on  top  of  the 
stab  culture.  Care  must  be  taken  to  flame  the 
mouths  of  both  tubes  so  as  to  avoid  contamination. 
The  upper  layer  of  agar  serves  to  keep  out  the  air. 
The  cultures  can  be  prepared  equally  well  by  employ- 


Fig.  5S5.— 
Liborius  Deep 
Stab  Culture, 
showing  Growth 
of  the  Tetauua 
Bacillus. 


Others 


Reference  Handbook 

OF  THE 

Medical  Sciences. 


Plate   XI. 


14. 

15. 

16. 

17. 

18. 

19. 

20. 

Micrococcus 

Staphylococcus 
of  Osteo- 

The same 

Staphylococcus 

Streptococcus 

Streptococcus 

Streptococcus 

Tetragenus. 

m  gelatine. 

pyogenes 

pyogenes. 

of  erysipelas. 

of  Puerperal 

myelitis. 

albus. 

Fever. 

TEST-TUBE   CULTURES. 

Reproduced  from    Huber  &   Becker's   "Untersuchungs-Methoden  " 


REFERENCE    BANDBOOK   OF   Till-:    MEDICAL   SCIENCES 


Bacteriological  Ti<  hnloni- 


ing  agar  or  gelatin  tubes  filled   with   the  medium   to 

a  depth  ol  about  two  inches.  It  is  well  to  place  the 
tubes  in  boiling  water  for  some  time  to  drive  off  the 
absorbed  oxygen,  then  solidify  rapidly  by  chilling. 
Use  a  tightly  fitting  stopper  in  the  tube  to  exclude 
the  air.  After  the  stab  is  made,  the  line  of  puncture 
etoscs  up  itself,  and  the  growth  then  develops  in  the 
Lower  pari  of  the  tube,  as  shown  in  Fig.  585. 

Isolated  colonies  ean  also  be  obtained  by  this 
method.  The  liquefied  medium  is  inoculated  and 
dilutions  are  made  as  for  shake  cultures.  The  tubes 
are  then  solidified,  and  if  necessary  an  additional 
layer  of  medium  is  poured 
on  top.       When  the  colonics 

develop  they  can  be  reached 
according  to  the  directions 
given   under  shake   cultures.      Another  pro- 
cedure  is   to   make    Esmarch  roll  tubes  and 
then  fill  the  inside  with  gelatin  or  agar. 

The  drawn-out  glass-tube  pipettes  (Fig.  578) 
have  been  used  by  Koux  for  this  same  pur- 
pose. The  liquefied  medium  is  inoculated  and 
drawn  up  into  the  pipette,  which  is  then 
sealed  above  and  below  the  contents.  The 
colonies  which  develop  can  be  reached  by 
cutting  the  glass.  A  somewhat  similar  pro- 
cedure was  devised  by  Wright.  A  short  glass 
tube  with  constricted  ends  is  used.  Each  end 
has  a  piece  of  rubber  tubing  attached.  One 
of  these  is  connected  with  a  glass  tube  which 
projects  through  the  cotton  plug  of  the  test- 
tube.  The  test-tube  contains  bouillon,  and 
this  contrivance  is  sterilized  and  inoculated. 
The  bouillon  is  then  drawn  up  into  the  con- 
stricted tube,  which  is  sealed  by  simply  push- 
ing down  on  the  tube,  so  that  both  rubber 
ends  are  bent  back  on  themselves. 

2.  Displacement  of  Air. — This  is  accom- 
plished by  passing  through  the  tube  or  a  suit- 
able container  an  inert  gas  till  all  the  air  has 
been  displaced.  Hydrogen  is  the  least  injur- 
ious gas  for  this  purpose.  It  can  be  generated 
from  zinc  and  sulphuric  acid  in  a  Kipp's  gen- 
erator. The  gas  should  be  washed  by  passing 
successively  through  alkaline  lead  acetate,  six 
per  cent,  potassium  permanganate,  and  finally 
through  a  solution  of  silver  nitrate.  After 
passing  through  the  apparatus  the  gas  is  sent 
through  a  small  wash  bottle  which  serves  as  a 
valve  to  prevent  air  from  entering  when  the 
current  slows  up.  Such  a  wash  bottle  is  shown 
in  Fig.  5S7,  //.  After  the  gas  has  passed  for 
an  hour  or  more  it  should  be  tested  by  ap- 
plying a  light  as  it  leaves  the  wash  bottle. 
If  the  flame  burns  with  explosions  it  is  evident 
that  all  the  air  has  not  been  displaced.  The 
operation  is  continued  until  the  gas  burns 
evenly  at  the  mouth  of  the  tube.  Owing  to 
the  danger  of  explosion  the  light  should  never 
be  applied  to  the  outflowing  gas  without  the 
safeguard  of  the  water  valve 


for  the  pui  po  e  oi  obtaining  plat  e  cull  ires.     Kita 
employed  a  flal   bottle,  Inning  a  tube  fused  al   the 

lower  end.      The  dilutions  were  mad.-  in  the  ordinary 

tubes,   after   which    the   material    was   poured    into 
these   Basks,    which    were   connected   in   series   and 
hydrogen   passed    through.     Finally    the  ends    ■ 
-inled  by  fusing  in  the  flame,  while  the  neck  of  each 

flask  was  closed  with  a  clam  lied  rubber  I  ill, e.      Several 
modifications    Of    this    bottle    have    been    made,    but 

they  are  linle  used,  since  methods  were  soon  per- 
fected whereby  it    was  possible   to  make  Petri   plates 

in  hydrogen. 

One  01  the  earliest  attempts  in   this  direction   was 

thai  of  Blucher,  who  made  use  of  a  funnel  which  was 

weighted  with  lead  and  inverted  over  the  plates  in  a 

larger  dish.     Air  was  excluded  by  means  of  glycerin 
water.      Hesse   inverted   a  glass   vessel   in  a  circular 

trough    filled    with 
irv.     Liborius 

used  a  copper  bell- 
jar  which  was  com- 
pn  I  1  against  a  rubber  gasket  by  means  of 
set-screws;  others  made  use  of  bell-jars  in- 
verted upon  a  ground-glass  surface.  In  many 
respects  the  Botkin  apparatus  is  useful.  It  is 
shown  in  1  ig.  587.  It  consists  of  a  metal  rack 
on  which  are  placed  the  Petri  dishes.  This  is 
set  in  a  large  outer  dish  which  contains  about. 
an  inch  of  liquid  petrolatum.  A  bell-jar  is 
inverted  over  the  stand.  The  inflow  and  out- 
flow tubes  are  of  rubber  stiffened  by  a  copper 
wire  on  the  inside.  After  the  hydrogen  has 
been  passed  for  a  sufficient  length  of  time, 
the  tubes  are  withdrawn  and  the  apparatus  is 
then  set  aside. 

The  Novy  apparatus  shown  in  Fig.  588 
leaves  little  to  be  desired.  The  hollow  stop- 
per has  two  perforations,  one  of  which  is  con- 
nected with  a  glass  tube  which  extends  almost 
to  the  bottom  of  the  bottle.  In  the  case  of 
the  plate  apparatus  the  tube  may  be  continued 
by  means  of  a  piece  of  rubber  tubing.  A 
perfect  seal  is  obtained  by  simply  turning 
the  stopper  through  an  angle  of  90°. 

The  bottle  (Fig.  588,  A)  is  made  in  two 
sizes,  8X16  and  10X20  centimeters,  which 
dimensions  do  not  include  the  neck.  A  piece 
of  cotton  should  be  placed  on  the  bottom. 

The  ordinary  test-tubes  containing  any 
medium  are  inoculated  in  the  usual  way.  The 
cotton  plug  is  then  cut  off  square,  and  by 
means  of  a  pair  of  crucible  tongs  the  tube  is 
lowered  into  the  bottle.  It  is  advisable,  if 
the  cotton  plug  is  very  tight,  to  loosen  it  up 
by  partially  pulling  it  out.  A  single  jar  ean 
be  filled  in  this  way  with  a  large  number  of 
tubes  containing  either  solid  or  liquid  media. 
The  stopper  is  then  put  in  place  and  the  ap- 
paratus connected  with  a  hydrogen  generator. 
When  the  gas  has  passed  for  a  sufficient  length 
of  time  the  bottle  is  closed  by  giving  the 
stopper  a  turn.     As  will  be  seen,  this  jar  can 


Fig.  586. — Fraen- 
One  of  the  earliest  attempts  at  making  tube  kel's  Modification  of 
cultures  by  this  method  was  that  of  Liborius.    the  Liborius  Tube  be  used  likewise  for  the  pyrogallate  method. 
He  made  use  of  a  special  test-tube  with  a  deli  v-    for  Anaerobes.  The  plate  apparatus  shown  in  Fig.  5SS,  B, 

ery  tube  fused  into  the  side.   After  inoculation  consists  of  two  parts.     The  inner  dimensions 

of    the  liquid  medium,  gas  was  passed  through,  and       of  the  lower  part  are  12X12  centimeters.      The  Petri 


finally  the  neck  of  the  test-tube,  as  well  as  the  end 
of  the  delivery  tube,  was  sealed  in  the  flame.  This 
method  is  of  only  very  limited  application,  and  re- 
quires much  time  and  is  expensive.  Fraenkel's  modi- 
fication is  a  distinct  improvement.  Ordinary  large 
test-tubes  are  used.  These  are  provided  with  rubber 
stoppers  and  delivery  tubes,  as  shown  in  Fig.  586. 
After  the  inoculation  of  the  medium  and  expulsion 
of  the  air,  the  tubes  are  sealed  in  the  flame.  If  it  is 
desired  to  obtain  colonies,  the  tube  can  be  converted 
into  an  Esmarch  roll  tube. 

This  principle  has  been  adapted  in  various  ways 


plates  are  stacked  into  this  compartment.  The 
flanges  are  covered  with  a  mixture  of  beeswax  and 
olive  oil  (1:4).  The  two  parts  are  then  brought 
together  and  a  rubber  band  is  slipped  over  the  outer 
edge  of  the  flanges.  Two  or  three  clamps  or  small 
vises  are  now  applied.  The  jaws  of  these  should  be 
covered  with  a  piece  of  rubber  tubing.  Gas  is  passed 
as  in  case  of  the  bottle,  and  at  the  conclusion  of  this 
operation  the  stopcock  is  given  a  turn  so  as  to  seal 
the  apparatus. 

The  other  modification  (Fig.  5SS,  C)  has  a  special 
stopper,   which  enables  it   to   be  used   for    vacuum 


905 


Bacteriological  Technique 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


cultures.  It  can,  however,  be  employed  equally 
well  for  hydrogen  cultivation.  Moreover,  both 
forms  of  the  plate  apparatus,  as  well  as  the  bottle,  can 
be  used  for  the  pyrogallate  method. 

3.  Absorption  of  Oxygi  n. — The  most  convenient  ab- 
sorbent for  this  purpose  is  an  alkaline  solution  of 
pyrogallic  arid.  The  principle  was  first  utilized  by 
Buchner  for  tube  cultures,  as  shown  in  Fig.  589. 
The  large  outer  tube  is  provided  with  a  closely  fitting 
rubber  stopper.  On  the  bottom  of  the  tube  is  placed 
about  a  gram  of  pyro- 
gallic acid  and  a  suit- 
able support.  The 
tube  containing  the 
nutrient  medium  is  in- 
oculated in  the  usual 
way  and  placed  on  this 
support.  Finally  10 
c.c.  of  a  ten-per-cent. 
solution  of  potassium 
or  sodium  hydrate  are 
added  from  a  pipette, 
as  rapidly  as  possible, 
and  the  tube  is  then 
quickly  closed  with  the 
stopper. 

As  mentioned  above, 
the  Novy  apparatus 
can  be  employed  for 
the  pvrogallate  method.  In  the  case  of  the  jar  a 
wide  "tube  is  introduced  which  contains  about  two 
grams  of  the  acid.  After  the  culture  tubes  have  all 
been  inserted,  about  20  c.c.  of  a  twenty-five-per-cent. 
solution  of  sodium  hydrate  are  introduced  into  the 
pyrogallate  tube  from  a  pipette,  and  the  stopcock  is 
then  inserted  as  quickly  as  possible  and  turned.  In  the 
case  of  the  plate  apparatus  a  crystallizing-dish,  about 
ten  centimeters  in  diameter  and  about  two  centimeters 
high,  is  placed  on  the  bottom,  and  about  four  grams  of 


Fig.  5S7. — Botkin's  Apparatus  for  Plate  Cultures  of  Anaerobes. 


quired  which  fit  one  into  the  other  like  the  halves 
of  a  Petri  dish.  They  should  be  about  two  and 
one-half  centimeters  in  height  and  with  relative 
diameters  such  that  when  put  together  a  space  of 
one-half  centimeter  exists  between  the  sides;  the 
maximum  diameter  should  be  about  ten  centimeters 
for  convenience  in  handling,  although  any  other  size 
may  be  used.  After  sterilization  of  the  dishes  the 
inoculated  agar  is  poured  into  the  smaller,  the  same 
as  in  ordinary  Petri-dish  plating,  and  again  covered 

with  the  larger  dish. 
The  apparatus  is  in- 
verted when  the  agar  is 
hard,  the  smaller  dish 
is  lifted  out  of  the 
larger,  and  placed  on  a 
moist  surface  to  pre- 
vent contamination. 
About  three  grams  of 
pyrogallic  acid  are 
placed  in  the  bottom  of 
the  larger  dish,  which 
stands  open.  The 
smaller  dish,  still  in- 
verted, is  placed  into 
this,  and  sufficient  five- 
per-cent.  solution  of 
sodium  hydrate  is 
added  (between  the 
sides)  to  fill  the  dish  about  one-half  full.  At  once, 
liquid  paraffin  is  run  into  the  space  between  the  si<l*'~, 
which  seals  from  the  external  air  the  chamber  formed 
by  the  two  dishes.  The  apparatuses  now  placed  in 
the  incubator  for  development  of  the  organisms. 

Wright's  method  will  be  found  to  be  very  useful  for 
occasional  cultures.  The  cotton  plug  is  cut  off  square 
and  pushed  down  about  one  centimeter  into  the  tube. 
The  plug  is  made  of  absorbent  cotton.  It  is  then 
moistened  with  about  4  c.c.  of  a  strong  solution  of 


Fig.  5SS. — Novy  Apparatus  for  Anaerobes. 


A,  Rottle  for  tube  cultures;  B,  jar  for  Petri  plates;  C,  jar  for  plates  with  special 
stop-coek  for  vacuum  culture. 


pyrogallic  acid  added.  A  couple  of  strips  of  glass  are 
then  placed  on  top,  and  on  these  are  stacked  the  Petri 
dishes.  Twenty-five  cubic  centimeters  of  the  strong 
alkali  are  introduced  in  the  manner  just  mentioned, 
after  which  tin'  top  is  put  into  place,  and  the  clamps 
and  rubber  band  an-  applied. 

Zinnser  has  described  a  simple   procedure  for  the 

separation  of  anaerobes  in   plates  by   applying   the 

igallic    method    for    the    absorption    of    oxygen. 

I  or    this   purpose   two   circular   glass   dishes   are   re- 


pyrogallic  acid,  after  which  about  the  same  volume 
of  strong  sodium  hydrate  (1:2)  is  added.  The  tube 
is  closed  as  rapidly  as  possible  with  a  tight-fitting 
rubber  stopper.  Obviously,  solid  pyrogallic  acid  may 
be  used. 

It  will  be  seen  that  the  pyrogallic-acid  method  is  ex- 
tremely convenient  and  very  simple,  requiring  a 
minimum  of  time  and  expense.  The  method  is  also 
applicable  for  the  hanging-drop  examination  of 
anaSrobic  bacteria.     A  drop  of  alkali  and  of  the  arid 


•IIH5 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SHI  NCE8 


Bacteriological  Technique 


"> 


can  bo  placed  on  (lie  side  of  I  he  concnv  e  slide.  After 
the  cover  is  in  place  the  slide  can  be  tilted  so  as  to 
bring  the  two  liquids  together.     A  special  slide  for 

this  purpose  was  devised  by  Braatz  (Fig'  590). 
The  hanging  drop  is  made  and  placed  over  Hi'1 
well.  The  Hat.  flask  contains  the  pyrogallio  acid  ami 
communicates  with  the  space  below  the  drop.  Strong 
alkali  is  finally  added  and  the  flask  is  closed  with  a 
stopper.  1'yrogallic  acid  can  also  be  employed  in  con- 
nection with  Hill's  "hanging-block" 
culture.  Another  apparatus  lor  anaer- 
obic hanging  drops  is  that  of  kuhne. 
It  is  very  serviceable  and   can  be  used 

for  either  the  gas  or  pyrogallic  process. 

4.  Exhaustion  of  .1"'.  —Pasteur  em- 
ployed U-shaped  tubes,  from  which 
the  air  was  removed  by  means  of  an 
air  pump.  Gruber  applied  the  princi- 
ple to  the  tube  culture.  He  uesd  a 
stout  glass  tube,  which  was  provided 
with  a  stopper,  through  which  passed  a 
short  glass  tube  by  which  connection 
was  made  with  the  air  pump.  The 
test-tube  was  constricted  just  below 
the  stopper  so  as  to  facilitate  the  sub- 
sequent sealing  process.  The  tube  was 
filled  in  the  usual  way  with  the  nutrient 
medium  and  inoculated.  It  was  then 
connected  with  the  pump,  and  as  soon 
as  the  air  was  exhausted  the  tube  was 
sealed  at  the  constriction.  The  plate 
apparatus  shown  in  Fig.  588,  C,  is  in- 
tended for  vacuum  as  well  as  gas  or 
pyrogallate  cultures.  It  can  be  used 
for  tube  or  plate  cultures. 

5.  Mixed  Cultures. — This  method  of 
cultivating  anaerobic  bacteria  corre- 
sponds to  the  way  in  which  these 
organisms  grow  in  nature.  If  the 
anaerobic  is  planted  together  with  an 
aerobic,  the  latter  will  consume  all  the 
oxygen  in  the  immediate  neighbor- 
hood, and  as  a  result  the  anaerobe 
will  grow.  Thus,  if  tetanus  and  hay 
bacilli  are  planted  at  the  same  time 
into  a  tube  of  bouillon,  they  will  both 
develop.  Other  aerobic  bacteria,  such 
as  Bacillus  prodigiosus  and  Proteus 
vulgaris,  can  be  used  for  the  same 
purpose.  The  mixed  culture  method 
is  also  applicable  to  the  cultivation  of 
certain  protozoa  (amebas).  But  per- 
haps this  is  due  to  altered  medium 
rather  than  any  oxygen  requirement. 
Musgrave  and  Clegg  found  that  amebas 

could  be  cultivated  upon  a  special  medium  when 
grown  with  pure  cultures  of  certain  intestinal  organ- 
isms, as  B.  coli. 

6.  Cultivation  in  Air. — This  of  course  is  apparent 
rather  than  real.  If  a  tube  of  glucose  gelatin,  prefer- 
ably colored  with  litmus,  be  inoculated  with  an  anae- 
robe and  then  set  aside  in  the  incubator,  an  abundant 
growth  will  develop  (Novy's  method).  Similarly, 
when  deep  stab  cultures  are  made  of  the  anaerobes, 
it  will  be  found  quite  frequently  that  the  water  of 
condensation  on  the  top  of  the  medium  is  cloudy 
from  the  growth  of  the  germs.  The  explanation  in 
the  one  case  is  that  air  is  excluded  partly  by  the 
viscosity  of  the  liquid  and  partly  by  the  evolved  gases. 
The  gas  formation  accounts  for  the  growth  of  the 
germs  in  the  water  of  condensation.  The  culture  in 
glucose  litmus  gelatin  is  by  far  the  simplest  way  of 
growing  anaerobes.  Moreover,  the  cultures  thus 
obtained  retain  their  vitality  for  many  years.  In 
some  cases  the  author  has  recovered  cultures  from 
tubes  five  and  six  years  old. 

Collodium  Sacs. — This  method  of  cultivating  has 
been  used  extensively  by  the  Pasteur  School  for  exalt- 


A 


Fig.  5  8  9.— 
Buchner's  Pyro- 
gallate Method. 


ing  the  virulence  of  bacteria.  The  underlying  Idea 
is  to  grow  the  organisms  in  the  peritoneal  cavity  of  an 

animal,    and    under    such    condition-,    that     the    v.  a    te 

products  of  the  germs  will  be  removed,  an  abundant 
upply  of  nutrient  material  furni  hed,  and  the  germs 
themselves  protected  again  t  the  action  of  phago- 
cytes. This  is  accomplished  b  i  g  the  bacteria 
in  an  hermetically  sealed  sac,  the  walls  of  which  are 
permeable  to  the  waste  products  of  the  germ  and  to 
the  soluble  proteins  of  the  peritoneal  fluid.  Several 
Russian  workers  have  employed  for  this  purpose  the 
inner  lining  membrane  of  reeds,  bul  the  best  procedure 
is  to  make  the  sacs  of  collodium.  Various  methods 
have  been  devised  for  the  rolling  of  the  sac,  but  un- 
doubtedly the  best  and  simplest,  is  that  preferred  in 
\.e  j  ' .  laboratory  by  <  iorsline, 

The  rolling  tube  employed  for  making  sacs  is  about 
twelve  to  fifteen  inches  long,  and  of  any  width  that 
may  be  desired.    For  ordinary  purpo  e  awidthof  half 

an  inch  is  sufficient.  One  end  of  this  tube  IS  rounded 
off  like  a  test  -I  ube,  and  has  a  two-millimeter  opining 
at  the  tip.  This  opening  is  first  closed  with  collodium 
cither  by  touching  it  with  the  cork  which  has  been 
'"..red  with  the  solution,  or  the  collodium  may  be 
applied  with  the  finger.  Care  must  be  taken  to  see 
to  it  that  the  collodium  does  not  ^ei  inside  of  the  tube. 

In  a  few  se ids  the  layer  is  dry  enough  1  < >  go  ahead. 

The  collodium  used  is  the  United  Slate.--  Pharmaco- 
poeia solution,  which  by  exposure  to  the  air  has  I 
concentrated  by  one-third  or  one-half.  It  should  be 
perfectly  clear,  and  if  not  it  must  be  filtered  through 
cotton  by  the  aid  of  a  pump.  The  collodium  can  be 
kept  in  a  glass-stoppered  cylindrical  vessel,  such  as  is 
used  for  the  collection  of  blood.  The  collodium  is  in- 
clined till  it  comes  within  a  few  inches  of  the  opening. 

The  rolling  tube,  with  the  opening  freshly  closed,  is 
dipped  in  the  collodium  and  rolled  several  times  in 
the  liquid.  It  may  be  rolled  so  that  only  the  lower 
side  of  the  tube  touches  the  collodium.  If  the  sac 
is  to  be  very  thin  it  is  sufficient  to  roll  the  tube  but 


Fin.  500. — Braatz'.s  Slide  for  Anaerobic  Hanging-drop 
Examinations. 

two  or  three  times,  after  which  it  is  raised  from  the 
liquid  and  rolled  in  the  ether  atmosphere  in  a  hori- 
zontal position  till  the  collodium  has  set.  If  the  layer 
is  not  thick  enough  the  tube  can  be  returned  to  the 
collodium,  but  care  must  be  taken  to  avoid  the  forma- 
tion of  air  bubbles.  The  coated  tube  is  finally  rolled 
in  the  air  until  it  has  reached  the  proper  consistence. 
This  can  be  ascertained  by  touching  the  thickest  part 
with  the  finger.  The  collodium  layer  should  be  rather 
firm.  The  tube  is  then  immersed  in  distilled  water 
for  a  minute  or  two.  If  the  collodium  is  not  suffi- 
ciently  hard,  it  wall  cloud  or  become  milky  on  contact 
with  the  water.  It  should  remain  perfect  ly  clear,  and 
when  finished  a  thin  sac  placed  in  water  is  almost 
invisible. 

To  detach  the  sac  the  tube  is  filled  with  distilled 
water,  and  by  blowing  into  the  open  end  the  water  can 
be  forced  through  the  opening  below  and  upward 
between  the  sac  and  the  tube.  By  slight  manipula- 
tion with  the  fingers  the  detachment  can  be  effected 
readily  on  all  sides.  The  free  end  is  then  trimmed 
square,  after  which  the  sac  is  placed  in  distilled  water, 
where  it  remains  until  it  is  ready  to  be  attached  to 
the  glass  tube. 

An  ordinary  test-tube  having  a  diameter  slightly 
less  than  the  sac  is  constricted  in  the  blast  flame  at 
about  two  inches  from  the  end.     A  scratch  is  then 

907 


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made,  about  half  an  inch  below  the  constriction,  with 
a  diamond,  and  with  the  aid  of  a  hot  rod  the  end 
is  removed.  The  resulting  tube  has  the  form  shown 
in  Fig.  591,  a.  The  cut  end  should  be  rounded  in 
the  flame  so  as  to  remove  the  sharp  edge. 

The  inside  of  the  neck  of  the  sac  is  dried  by  means 
of  filter  paper,  after  which  the  end  of  the  tube  is 
inserted.  This  can  be  done  more  easily  if  the  end  of 
the  tube  is  previously  dipped  in  alcohol.  The  next 
step,  that  of  shrinking  the  sac  upon  the  tube,  is  very 
important  and  requires  care.  Most  of  the  shrinking 
is  done  by  rotating  the  tube,  in  a  horizontal  position, 
some  distance  above  a  small  spare-flame  burner.  In 
this  way  the  collodium  can  be  made  to  contract  down 


Fig.  591. — Preparation  of  Collodion  Sacs.     (Xovy.) 

upon  the  glass,  but  the  operation  must  be  done  slowly 
and  at  some  distance  above  the  flame,  otherwise 
there  is  danger  of  igniting  the  sac.  The  adhesion  is 
rendered  more  complete  by  the  application  of  a  hot 
glass  rod.  Finally  a  silk  thread  is  wound  as  closely 
as  possible  over  the  glass  neck,  and  this  in  turn  is 
covered  with  a  layer  of  collodium.  The  sac  now  lias 
the  appearance  shown  in  Fig.  591,  b.  The  finished 
sac  is  now  filled  with  distilled  water  and  placed  in  a 
test-tube  on  foot,  which  also  contains  water  (Fig. 
591,  e),  and  the  whole  is  sterilized  by  steaming  in  an 
autoclave  for  half  an  hour  at  110°  C. 

When  the  sac  is  to  be  used,  the  water  is  removed 
from  the  inside  by  means  of  a  drawn-out  pipette  and 
replaced  in  like  manner  with  bouillon  which  has  been 
inoculated  with  the  organism  to  be  tested.  The 
threaded  part  is  then  wrapped  in  a  piece  of  sterile 
filter  paper,  for  convenience  in  handling,  and  the  con- 
striction is  sealed  in  a  sharp-pointed  flame.  The 
sealed  sac  is  then  placed  in  a  sterile  test  glass. 

The  rabbit  or  guinea-pig  which  is  to  receive  the 
sac  is  now  attached  to  a  holder  and  the  hair  is  removed 
from  the  abdomen.  The  field  of  the  operation  is  thor- 
oughly washed  with  lysol  or  mercuric  chloride.  After 
the  animal  is  anesthetized  an  incision  is  made  in 
the  abdominal  wall,  and  through  this  the  sac  is  in- 
troduced into  the  peritoneal  cavity.  The  incision  is 
then  sewed  up  and  covered  with  cotton  and  a  little 
collodium. 

The  sac  is  allowed  to  remain  in  the  animal  for  a  few 
or  even  for  several  months.  To  remove  it  the 
annual  is  killed  with  gas.  The  sac  is  freed  from  the 
adhesions  and  transferred  to  a  sterile  test  glass  with 
the  glass  end  downward.  By  means  of  a  hot  rod  an 
opening  is  burned  into  the  end  of  the  sac,  and  through 
(llis  ll"-  contents  arc  removed  by  means  of  a  drawn- 
out  tube  pipette.  When  large  sacs  are  to  be  inserted 
mi 'i  an  animal  it  is  advisable  to  strengthen  them  by 

908 


placing  within  a  perforated  glass  tube  as  shown  in 
Fig.  591,  d,  e. 

The  collodium  sacs  can  be  used  not  only  as  just  de- 
scribed, but  also  with  marked  advantage  for  dialyzing 
experiments.  For  this  purpose  the  sacs  can  be  made 
an  inch  or  more  in  diameter  and  twelve  or  fifteen 
inches  long.  The  thin  collodium  membrane  is  con- 
siderably more  permeable  than  parchment  paper 
Separation  of  Spore-forming  from  N on-spore-forming 
Organisms  by  Heal.— Heat  is  sometimes  employed  in 
the  separation  of  spore-forming  from  non-sporelform- 
mg  species  of  bacteria  when  both  are  present  in  mixed 
'•iilture.  For  this  purpose  the  mixed  culture  con- 
taining spores,  is  heated  for  fifteen  minutes  at  ,so° 
C.  The  vegetative  forms  are  destroyed  while  the 
heat-resisting  spores  remain  viable  and  will  develop 
under  proper  conditions.  If  more  than  one  species 
of  spore-forming  organisms  are  present,  they  may  lie 
separated  further  by  the  plating  method,  or  by  animal 
inoculation. 

Mechanical  Separation  of  Bacteria  from  Fluids. — 
For  this  purpose  various  types  of  the  centrifuge  are 
used.  It  is  essential  that  they  run  smoothy,  and 
revolve  at  a  high  speed.  The  type  best  adapted  for 
the  separation  of  bacterial  and  other  cells  from  fluids, 
pathological  exudates,  etc.,  are  those  equipped  with 
slender  glass  tubes  with  conical  ends  to  collect  the 
sedimenting  material.  They  are  usually  driven  by 
means  of  water  or  electric  motors.  The  electric- 
motor  type  is  more  satisfactory  and  may  be  procured 
to  be  driven  by  cells,  storage  battery,  direct  or 
alternating  current.  The  ordinary  clinical  centri- 
fuge driven  by  hand  may  be  used,  but  in  most  cases 
this  is  exceedingly  slow  in  sedimenting  organisms. 

Drying  of  Bacteria,  Toxins,  Antitoxins,  etc. — In  the 
chemical  or  biological  study  of  bacteria  and  their  prod- 
ucts, it  frequently  becomes  necessary  to  remove  the 
water  content.  Since  the  labile  constituents  would 
be  destroyed  if  dried  by  heat,  as  in  ordinary  chemical 
manipulations,  other  means  must  be  used.  This  can 
best  be  done  by  drying  in  vacuo  in  the  presence  of 
certain  substances,  as  phosphoric  anhydride  (P„05)  or 
concentrated  sulphuric  acid  (H2S04)  which  readily 
absorbs  the  water  vapor.  The  temperature  may  be 
kept  at  that  of  the  working-room  or  even  lower. 
Most  suitable  for  this  purpose  is  the  ordinary  heavy 
glass  vacuum  desiccator.  This  is  partially  divided, 
with  an  upper  and  lower  chamber,  by  means  of  a 
movable  perforated  porcelain  plate  which  forms  a 
shelf  for  receptacles.  Either  in  the  wall  or  cover  of 
the  desiccator  a  heavy  glass  tube  with  cock  is  fused 
or  passed  by  means  of  a  ground-glass  stopper.  This 
forms  a  means  of  communication  with  the  interior 
of  the  vessel.  The  apparatus  must  be  of  heavy  con- 
struction to  prevent  breakage  from  the  external  air 
pressure  when  air  content  is  exhausted.  For  use, 
first  place  in  the  bottom  chamber  a  layer  of  con- 
centrated sulphuric  acid,  or,  better,  phosphoric  an- 
hydride, filling  the  chamber  about  one-quarter  to  one- 
half  full.  The  material  for  drying  should  be  previously 
spread  or  poured  in  a  flat  dish,  such  as  the  halves  of 
a  Petri  dish.  Now  place  the  dish  on  the  porcelain 
shelf  over  the  water-absorbing  substance.  Adjust 
the  cover  and  firmly  seal  in  position  with  an  adhe- 
sive paste.  It  is  well  also  to  use  the  same  paste  on 
the  glass  stopcock  to  prevent  leakage  at  that  point. 
Such  a  paste  may  be  prepared  by  taking  one  part  of 
pure  rubber  (black  elastic  rubber  tubing  cut  in  small 
pieces),  one  part  of  paraffin,  and  three  parts  of  vase- 
line. Mix  together  and  heat  until  dissolved.  Take 
extra  thick-walled  rubber  tubing  and  connect  an  air 
pump  (of  the  large  type)  to  the  exhaustion  tube  of 
the  desiccator.  Open  the  glass  stopcock  and  pump 
out  the  air  to  produce  vacuum.  At  once  close  the 
glass  stopcock  of  desiccator  tube,  and  observe  if  any 
air  leaks  are  evident.  If  not,  detach  pump.  It  is 
necessary  to  pump  out  the  desiccator  at  least  once  a 
day  until  the  substance  is  entirely  dry.     The  ordinary 


i;i;ii:i:i:nci:   handbook  ok  tiik   mkdkal  scikxces 


Bacteriological  Technique 


water  pump  cannot  be  used  owing  to  the  water  vapor 
which    is   always   present   and    travels   back   during 

exhaustion. 

The  alici\ e  ni. 'I  hod   fur  I  he  de  iccal  ion  of  main  ia] 

is  open  to  certain  objections.  Among  these  may  be 
mentioned:  the  time  period  required  in  reducing  any 
considerable  volume  of  immune  serum,  toxic  broth, 
etc.,  to  the  dry  state;  the  changes  resulting  in  blood 
serum  during  the  process  which  makes  re-solution 
difficult  in  most  instances;  and,  in  the  case  of  labile 


Fig.  592. — Syringe  Holder  and  Sterilizing  Pan.      (Novy.) 


components,  as  toxins,  complement,  etc.,  a  great 
depreciation,  or  even  a  total  loss  of  value  may  result. 
A  method  of  drying,  proposed  by  Shackell,  offers,  at 
least,  a  partial  solution  of  the  above  difficulties.  By 
his  method,  which  has  been  further  improved  by 
Harris,  the  material  to  be  dried  is  thoroughly  frozen 
as  rapidly  as  possible  by  means  of  a  salt-ice  mixture, 
or  by  means  of  carbon  dioxide  snow.  The  frozen  sub- 
stance, in  an  open  dish,  is  at  once  placed  in  the  bottom 
of  a  Scheibler's  vacuum  jar  (which  has  also  been 
thoroughly  chilled,  by  being  partially  immersed  in  a 
salt-ice  mixture),  then  an  open  dish  containing  con- 
centrated sulphuric  acid  (cold)  is  placed  upon  a  wire 
gauze  support  in  the  upper  portion  of  the  jar.  The 
jar  is  sealed  at  once  with  the  exception  of  a  connec- 
tion which  is  made  with  a  Geryk  vacuum  pump.  The 
pump  is  put  in  operation  immediately  to  exhaust  the 
air  from  the  vacuum  jar.  When  this  is  accomplished 
in  so  far  as  possible,  the  connection  is  cut  off  by  means 
of  the  stop-cock.  Care  must  be  taken  to  exclude  all 
air  leaks,  which  is  not  difficult  if  a  proper  lubricant 
is  used.  Occasionally  the  vacuum  jar  is  rotated 
gently  in  order  that  the  sulphuric  acid  may  be  kept 
well  mixed,  and  its  absorption  ability  kept  at  its 
highest  degree  of  efficiency.  By  this  method,  Harris 
found  that  even  a  rabbit  brain  (rabic)  would  become 
thoroughly  dry  in  from  thirty-six  to  forty-eight 
hours.  Desiccated  serum  readily  passed  into  solu- 
tion after  this  means  of  treatment.  Care  should  be 
taken  to  seal  the  materials,  when  finished,  to  exclude 
the  air  since  the  dried  material  is  quite  hygroscopic. 

Inoculation  of  Animals. — According  to  the 
nature  of  the  experiment  these  are  made  with  pure  or 
impure  cultures  of  bacteria,  or  with  the  chemical 
products  elaborated  by  them.  The  use  of  impure 
material  is  met  with  in  diagnostic  work.  Thus  in 
suspected  glanders  the  discharge  is  introduced  into 
animals  in  order  to  ascertain  if  the  bacillus  of  glanders 
is  present.  The  same  is  often  done  in  tuberculosis, 
pneumonia,  bubonic  plague,  anthrax,  tetanus,  rabies, 
etc.  In  all  these  experiments  the  animal  serves  as  a 
plate,  since  it  eliminates  all  the  saprophytic  bacteria 
which  may  be  present  in  the  original  material  and 
allows  the  disease-producing  ones  to  develop  in  pure 
or  almost  pure  cultures.  The  inoculation  with  pure 
cultures  is  made  to  test  their  identity,  to  study  their 
effect  upon  animals,  to  ascertain  the  diverse  means 
of  infection,  and  for  purposes  of  immunization.  The 
inoculation  with  the  chemical  products  enables  one  to 


ascertain  t  be  pre  cue,   oi  poi  onous  substam 
produce  vaccines  or  antito 

The  inoculations  may  be  made  with  a  fine  need! 

lance,  I ii 1 1  i e  ott en  with  the  aid  ol  a  syringe.     The 

drawn-out  glass-tube  pipette  is  also  used  a    .. 

introducing  infectious  material. 

The  syringe  used  varies  with  different  workers.  The 
Germans  are  especially  favorable  to  the  Koch  svringe, 

which  consists  of  a  glass  cylinder,  graduated,  tin 

row  end  of  which  connects  with  the  i die  whili 

upper  end  tits  into  the  metal  collar  of  a  rubber  bulb. 
The  advantage  claimed  is  thai  the  cylinder  and  Deedle 

can  be  effectively  sterilized  by  dry  heat.      As  a  mat  ter 

of  fact  the   Koch  syringe  is  extremely  inconveni 

and    unsatisfactory,    and    equally    good    results    with 

less    time    and  annoyance  are  obtainable   with    the 

ordinary      hypodermic.       The 

all-glass   type  of    hypodermic 

syringe    is   perhaps    the    i 

satisfactory  for  inoculation 
purposes.  The  latter  models, 
of  course,  must  be  sterilized  by 
boiling  in  water  for  ten  or 
fifteen  minutes.  A  convenient 
holder  for  the  syringe  is  shown 
in  Fig.  592. 

When  large  quantities  of 
liquids  are  to  be  introduced, 
as  when  injecting  horses  with  diphtheria  toxin  in 
the  preparation  of  antitoxin,  an  apparatus  similar  to 
that  shown  in  Fig.  593  can  be  used. 

The  necessary  instruments,  such  as  knives,  scissors, 
needles,  etc.,  are  sterilized  by  boiling  in  water,  or 
better  in  a  saturated  solution  of  borax.  A  very  con- 
venient sterilizer  for  this  purpose  is  that  shown  in 
Fig.  598. 

In  all  operations  the  animal  must  be  secured  in 
some  way  or  another.  Various  kinds  of  holders  have 
been  constructed  for  this  purpose.  That  of  Latapie, 
shown  in  Fig.  594,  is  very  convenient,  and  is  to  be 
preferred  to  the  ordinary  models.  It  can  be  used  for 
guinea-pigs,  rabbits,  birds,  etc. 

The  Voges  holder,  shown  in  Fig.  595,  is  useful  for 
taking  temperatures  and  for  injecting  small  animals. 

A  good  substitute  can 
be  made  by  using  a 
glass  cylinder. 

Special  holders  have 
been  devised  for  rats 
and  mice.  These, 
however,  can  be 
handled  best  by 
means  of  a  pair  of 
compression  or  artery 
forceps.  The  animal 
is  seized  by  the  nape 
of  the  neck  with  the 
forceps,  which  is  then 
transferred  to  the  left 
hand.  The  tail  and 
the  hind  legs  are  also 
held     by     this    hand. 


Fig.  593. — Graduated  Cylinder  for  Injecting  Liquids.     (Novy.) 

The  animal  in  this  way  is  put  upon  the  stretch,  and 
the  inoculation  can  then  be  made  with  the  right 
hand.  Even  full-grown  wild  rats  can  be  handled  in 
this  way  without  the  help  of  an  assistant. 

After  inoculation  the  animals  are  placed  in  special 
jars  or  cages.  The  ordinary  glass  battery  jars,  pro- 
vided with  a  galvanized-wire  top;  weighted  with  lead, 
serve  to  confine  rats  and  mice,  and  can  even  be  used 
for     guinea-pigs     (Fig.    59G).      If    the    animals    are 


900 


Bacteriological  Technique 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


inoculated  with  a  very  dangerous  organism,  such  as 
the  pest  bacillus,  it  is  advisable  to  place  the  jar 
inside  of  a  ten-gallon  crock.  In  special  cases,  as  in 
animals  infected  with  trypanosomes,  bubonic  plague, 
etc.,  it  is  well  to  cover  the  cage  with  a  piece  of  mos- 
quito nrtting  or  cheese-cloth  as  a  safeguard  against 
insects  spreading  the  infection. 

Guinea-pigs,  rabbits,  and  the  like  can  be  kept  in  the 
Vaughan  cage  shown  in  Fig.  597.  The  cage  proper  is 
thirty  centimeters  high,  thirty-eight  centimeters  deep, 
and  fifty-four  centimeters  wide.  The  feet  are  twelve 
centimeters  high. 


Fig.  594. — Latapie's  Animal  Holder.     (Novy.) 

1.  Cutaneous  Application. — Ordinarily  bacteria  do 
not  penetrate  the  unbroken  skin  or  mucous  mem- 
brane, but  the  direct  application  of  some  organisms, 
even  in  the  absence  of  any  known  lesion,  leads  to 
infection.  This  is  the  case  when  the  virus  of  the 
foot-and-mouth  disease  or  the  bacillus  of  plague  is 
brought  into  contact  with  the  mucous  membrane. 
The  pus  germs,  when  rubbed  into  the  skin  by  the  aid 
of  vaseline,  may  cause  infection. 

2.  Subcutaneous  Application. — For  this  purpose  the 
hair  is  removed  from  the  region  where  the  inocula- 
tion is  to  be  made.  The  place  is  then  rubbed  with  a 
disinfectant.  In  the  rat  this  is  usually  on  the  back, 
at  the  root  of  the  tail;  in  the  guinea-pig  it  is  on  the 
side.  A  nick  is  made  with  sterile  scissors,  and  then 
with  a  narrow  scalpel  or  spatula  a  pocket  is  made 


Fig.  595.- 


Hulder  for  Small  Animals.     (Novy.) 


under  the  skin.  A  piece  of  tissue,  a  bit  of  earth, 
blood-laden  wire,  etc.,  is  then  introduced  into  the 
opening,  which  if  made  small  requires  no  special 
closure. 

3.  Subcutaneous  Injection. — The  suspended  material 
is  introduced  under  the  skin  by  means  of  a  syringe. 
The  hair  should  first  be  clipped  close  and  the  place 
of  inoculation  touched  up  with  a  disinfectant. 

4.  Intravenous  Injection. — In  the  case  of  the  rabbit 
this  is  easily  done.  The  marginal  branch  of  the 
posterior  auricular  vein  is  selected,  although  it  may 
appear  to  be   narrower  than  the  needle.     The  hair 


may  be  removed  and  the  surface  of  the  ear  rubbed 
freely  to  stimulate  circulation.  A  clamp  is  then 
applied  at  the  base  of  the  ear  so  as  to  distend  the 
vein.  The  needle  is  then  inserted  at  a  very  slight 
angle  to  the  vein.  In  other  animals  the  jugular 
can  be  exposed  and  the  injection  made  without  any 
difficulty. 

5.  Intraperitoneal  Injection. — This  procedure  is  very 
commonly  resorted  to.  The  skin  over  the  abdomen 
should  be  raised  and  the  needle  of  the  syringe  is 
then    introduced   into   the 

cavity.  Care  should  be 
exercised  in  order  not  to 
penetrate  the  hollow  viscera 
in  small  animals.  In  such 
case  the  fluid  may  enter 
the  intestine,  for  example, 
and  be  discharged  without 
producing  any  effect.  In 
the  case  of  the  horse,  while 
the  animal  is  standing  a 
trocar  is  introduced  through 
the  skin  at  a  point  a  few 
inches  anterior  to  the  crest 
of  the  ilium. 

6.  Intrapleural  Injection. 
— The  needle  is  introduced 
into  the  right  pleural  cav- 
ity, care  being  taken  to 
prevent  any  injury  to  the 

lung  or  to  the  heart.  Large  amounts  of  liquid  can- 
not be  tolerated  by  the  animal. 

7.  Intracranial  Injection. — This  method  was  intro- 
duced by  Pasteur  as  a  means  of  surely  infecting 
animals  with  rabies.  The  procedure  is  followed  out 
when  inoculating  animals  either  for  diagnosis  or  for 
the  purpose  of  preparing  the  vaccine  for  hydropho- 
bia. It  is  usually  practised  on  rabbits  and  guinea- 
pigs.  The  skin  from  between  the  ears  forward  is 
shaven  clean  and  disinfected.  An  incision  about  an 
inch  long  is  then  made.  Those  of  the  Pasteur  school 
apply  a  hand  trephine,  and  make  an  opening  into  the 
skull.     A  small  trephine,  operated  by  a  dental  engine, 


Tig.  596.— Rat  Cage  and 
Forceps. 


Fig.  597. — Vaughan  Cage.     (Novy.) 

is  much  more  convenient.  In  the  absence  of  either 
an  opening  may  be  made  into  the  skull  with  a  stout 
scalpel.  By  means  of  a  hypodermic  syringe  a  few 
drops  of  the  brain  or  cord  suspension  are  then  intro- 
duced under  the  dura.  At  times  the  injection  is 
made  into  the  brain  proper,  in  which  case  it  is  spoken 
of  as  intracerebral.  After  the  injection  a  suture  or 
l  wo  are  applied,  and  the  wound  is  covered  with  collo- 
dium  and  cotton. 


910 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


narlrrliiloKlcal  lYrlinlquo 


8.  Intraocular  Injection. — Cocaine  is  first  applied 
to  the  eye,  after  which  this  is  fixed  with  forceps  and 
tilt'  material  is  injected  into  the  anterior  chamber. 
]f  desired,  an  opening  can  be  made  with  a  cataract 

knife  or  narrow  scalpel  and  the  solid  material  can  be 
introduced  in  this  way. 

9.  Injection  into  the  Lymphatics. — This  is  usually 
made  by  introducing  the  material  into  the  testicles. 

10.  Respiratory    Infection. — While    the    preceding 

methods   may    be  looked  upon  as  wound  inoculations, 

this  concerns  itself  as  nearly  as  possible  with  duplicat- 
ing the  natural  infections  along  the  respiratory  tract' 

The  direct  method  consists  in  causing  the  animal  to 
inhale  the  finely  divided  material,  w  hich  can  be  readily 
done   by    means  of  an   atomizer.       In   some   cases   I  he 

animal  is  caused  to  inhale  irritating  fumes,  such  a 
bromine  vapor.     This  excites  a  slight   inflammatory 
reaction  of  the   respiratory    mucosa,   and   causes  the 
animal  to  become  more  liable  to  infection. 

When  the  atomizer  is  used  to  produce  a  spray,  the 
operator  must  take  special  precaution  to  protect  him- 
self against  infection.  The  animal  should  be  placed 
in  a  specially  constructed  tight  box.  All  openings 
for  air  should  be  loosely  packed  with  absorbent  cotton 
which  acts  as  an  air  filter.  The  spray  can  be  throw  n 
in  through  an  opening  admitting  the  tube  of  the 
atomizer  with  sufficient  cotton  wool  about  it  to  pre- 
vent escape  of  spray  from  the  aperture.  Another 
procedure  may  be  called  the  intratracheal  injection. 
This  is  carried  out  by  making  an  opening  into  the 
trachea,  and  through  this  introducing  the  infectious 
agent. 

11.  Alimentary  Infection. — Since  water  and  food 
serve  to  introduce  the  pathogenic  agent  of  many 
diseases  into  man  and  animals,  it  is  necessary  at 
times  to  resort  to  a  similar  method  of  infection.  The 
animal  may  receive  the  infectious  agent  in  water. 
milk,  or  in  solid  food.  Thus  bread  may  be  soaked 
in  a  bouillon  culture  of  the  organism.  At  other 
times  it  may  be  necessary  to  introduce  the  material 
into  the  stomach  by  means  of  a  rubber  tube.  In 
order  to  prevent  the  animal  from  biting  the  tube. 
it  is  well  to  pass  it  through  a  perforated  cork  or  plug 
of  soft  wood.  Under  exceptional  conditions  a  lapa- 
rotomy may  be  made  and  the  material  injected  into 
the  intestines.  This  is  spoken  of  as  the  intraduodenal 
injection. 

Observation  and  Autopsy  of  Injected  Animals. — 
The  matter  of  suitable  caging  of  animals  has  already 
been  touched  upon.  Attention  may  be  called  to 
the  need  of  daily  observations  of  the  infected  animals, 
so  as  to  note  the  symptoms  manifested.  The  animals 
must  have  plenty  of  food  and  drink,  and  must  be 
kept  in  as  clean  a  condition  as  possible.  Their 
weight  and  temperature  should  be  taken  daily,  for  in 
this  way  the  best  information  can  be  gained  as  to 
the  physical  condition  of  the  animals. 

When  the  animal  dies  it  should  be  autopsied  at 
once,  or  else  it  must  be  put  aside  in  an  ice-box.  The 
need  of  immediate  examination  is  shown  in  some  of 
the  trypanosomatic  infections,  as  nagana  and  caderas, 
where  the  organisms  may  disappear  from  the  blood 
within  an  hour  or  so  after  death.  Moreover,  delayed 
examination  may  lead  to  the  invasion  of  the  organs 
of  the  cadaver  by  the  intestinal  bacteria,  in  which 
case  the  search  for  the  specific  germ  is  rendered 
more  difficult,  if  not  impossible. 

The  animal  is  prepared  for  autopsy  by  being  placed 
on  its  back  and  tacked  down  on  a  board.  A  conven- 
ient board  of  this  kind  is  one  which  is  about  thirty- 
four  by  fifty-four  centimeters  and  has  a  raised  border. 
The   cracks,   if  any,  should  be  filled  with  paraffin. 

After  the  animal  is  laid  out ,  the  hair  should  be  thor- 
oughly moistened  with  mercuric-chloride  solution. 
The  necessary  instruments  can  be  sterilized  in  a 
copper  sterilizer,  such  as  is  shown  in  Fig.  598.  In 
the  absence  of  such  an  arrangement  the  instruments 
may  be  sterilized  by  heating  directly  in  the  flame, 


but  this,  of  course,  injures  them.  A  searing  iron, 
several  drawn-out  pipettes,  and  sterile  dishes,  as  well 
as  the  necessary  media,  should  be  conveniently  at 
hand. 

Willi  a  sterile  scalpel  an  incision  is  made  along  the 
entire  length  of  the  body  from  the  neck  to  the  pubis. 
Lateral  incisions  are  then  made  in  the  direction  of 
each  of  the  extremities,  and  the  two  large  flaps  thus 
resulting  are  t  urned  back.  The  condition  of  the  sub- 
cutaneous    tissue,     the    presence    Of    edema,    bloody 

■  ■I!  ii  ions,  enlarged  lymphatic  glands,  etc.,  are  noted. 
The  glands  or  portions  of  the  ti  ue  maj  be  trans- 
ferred by   means  of  sterile  instru nts  to  a  sterile 

dish.  Cover-glass  smears  or  streaks  can  be  made 
and  examined  eil  her  at  once  or  later. 

The  abdominal  and  thoracic  cavities  are  usually 
opened  at    the  same  time.     'I  lie  abdominal   wall  in 

the  lower  part  of  the  body  is  slightly  rai  ed  and 
nicked  with  Sterile  scissors;  then  the  lower  blade  is 
inserted    and    the    incision    prolonged    upward    to    the 


pit:.  598. — Iustruiueut  Sterilizer. 

diaphragm.  The  ribs  are  then  cut  as  low  down  as 
possible,  and  the  wedge-shaped  piece  of  the  wall  of 
the  thorax  is  removed.  The  condition  of  both  cavi- 
ties and  of  the  organs  is  carefully  noted.  Cover- 
glass  streaks  are  made  from  the  peritoneal  surfaces 
and  from  the  cut  surfaces  of  the  organs,  and  examined 
either  at  once  or  later.  Any  fluid  which  is  present 
in  the  cavities  may  be  transferred  to  sterile  tubes  by 
means  of  the  pipette. 

Cultures  should  always  be  made  from  an  intact 
organ.  For  this  purpose  it  is  cut  open  with  sterile 
scissors,  and  a  piece  of  the  pulp  removed  on  a  sterile 
wire  or  by  the  aid  of  a  Nuttall  spear  or  spatula  (Fig. 
577).  The  heart  blood  is  usually  given  preference 
for  culture  purposes.  The  pericardium  should  be 
opened,  after  which  the  surface  of  the  heart  is  seared 
with  a  hot  iron.  An  incision  is  then  made  into  the 
ventricle,  from  which  the  blood  can  be  removed  by 
the  aid  of  a  looped  wire.  The  best  way  of  removing 
the  heart  blood  is  by  means  of  a  sterile  Pasteur  bulb 
pipette.  The  end  of  this  is  broken,  flamed,  and  when 
cool  it  is  inserted  into  the  heart,  and  by  suction  the 
blood  is  drawn  up  into  the  pipette.  The  contents  of 
the  tube  can  then  be  used  to  inoculate  culture  media 
or  for  making  blood  streaks. 

After  the  autopsy  the  animal  should  be  placed  in  a 
vessel  and  steamed  or  autoclaved,  and  eventually 
burned.  The  board  should  be  washed  with  mercuric 
chloride,  and  all  instruments  and  utensils  should  be 
sterilized  by  steaming.  Throughout  the  autopsy 
care  must  be  taken  to  prevent  infection  either  by  the 
scattering  of  material  on  the  floor  or  by  its  being 
carried  away  by  insects. 

Examination  of  Bacteria. — In  order  to  gain 
some  definite  information  regarding  the  bacteria 
which  develop  on  the  nutrient  media  or  in  the  ani- 
mal body,  recourse  must  be  had  to  the  microscope. 

911 


Bacteriological  Technique 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


The  organisms  may  be  examined  in  the  living  con- 
dition or  in  stained  preparations.  The  former  pro- 
cedure is  resorted  to  so  as  to  learn  all  that  is  possible 
regarding  the  living  cell:  its  form,  size,  color,  granula- 
tions if  any,  motion,  grouping  of  the  cells,  presence  of 
spores,  etc.  Such  facts  are  ascertained  by  making 
a  preparation  in  which  the  bacteria  will  continue  to 
live  for  some  time. 

Living  Bacteria. — 1.  The  simplest  procedure  is  to 
place  a  drop  of  the  bacterial  liquid  on  a  slide,  after 
which  the  cover-glass  can  be  applied  and  the  prepara- 


FlG.    5U9. 


tion  examined  under  the  microscope.  This  method 
is  usefiii  for  rapid  orientation,  but  it  has  certain  draw- 
backs, chief  among  which  is  the  fact  that  evaporation 
takes  place  along  the  edge  of  the  glass,  and  as  a 
result  currents  are  established  in  the  liquid.  Such 
currents  tend  to  interfere  with  the  observation  of 
any  one  organism  or  group  of  cells.  Again,  a  prepa- 
ration of  this  kind  cannot  be  kept  under  observation 
for  any  length  of  time  on  account  of  the  desiccation 
which  soon  takes  place. 

2.  The  examination  in  a  hanging  drop,  as  it  is 
called,  obviates  the  difficulties  mentioned.  A  rather 
thick  slide  with  a  concave  well  is  used  (Fig.  599). 
A  ring  of  vaseline  is  spread  around  the  edge  of  this 
well.  A  clean  cover-glass,  about  three-fourths  of  an 
inch  in  diameter,  is  placed  on  the  table,  and  a  drop 
of  water  is  applied  to  the  middle  by  means  of  a  looped 
platinum  wire.  It  is  desirable  that  the  drop  should 
spread  out  flat,  and  if  it  does  not  it  is  because  the 
cover-glass  is  not  clean.  The  drop  of  water  is  then 
inocuiated  with  a  little  of  the  culture.  Just  enough 
material  is  added  so  that,  the  liquid  is  slightly  cloudy. 
The  vaseline-ringed  slide  is  then  inverted  and 
brought  down  upon  the  cover-glass.  The  preparation 
is  turned  over,  and,  if  need  be,  pressure  is  applied  to 
the  border  of  the  glass  so  as  to  have  an  air-tight  hang 
ing  drop.  Under  these  conditions  evaporation  does 
not  take  place,  and  consequently  the  specimen  may  be 
examined  for  hours,  if  necessary,  without  any  inter- 
ference by  currents  due  to  evaporation.  As  men- 
tioned above,  this  method  can  be  used  for  the  cultiva- 
tion of  bacteria,  and  thus  their  growth  and  multi- 
plication can  be  followed  out.  In  that  case  it  is 
necessary  to  use  a  flamed  cover-glass  and  a  sterile 
liquid. 

Instead  of  the  concave  slide  a  so-called  well-slide 
can  be  used  (Fig.  000).  This  is  essentially  a  square 
bit  of  glass  with  a  circular  opening,  which  is  cemented 
to  an  ordinary  glass  slide,  and  the  hanging  drop  is 
then  made  in  the  manner  described. 

One  disadvantage  in  either  method  lies  in  the  fact 
that  the  drop  is  more  or  less  convex,  and  consequently 
when  using  higher  powers  it  is  difficult  to  examine  the 
deeper  portions.  This  difficulty  can  be  overcome 
by  employing  the  Ranvier  slide,  which  has  a  circular 
trough,  Mud  the  portion  within  the  circle  is  ground 
down  so  thai  its  level  is  about  0.1  mm.  below  that  of 
I  lie  slide,  When  a  drop  of  liquid  is  placed  within 
the  circle  and  covered  with  a  cover-glass,  the  liquid 

912 


o.        c 

-Concave  Slide  showing   Hanging  Drop.     A,    Surface 
view;  B,  side  view. 


spreads  out  into  a  thin  layer,  every  part  of  which 
can  be  examined  under  the  microscope.  A  ring  of 
vaseline  is  placed  along  the  edge  so  as  to  prevent 
evaporation.  By  flaming  the  slide  and  cover-slip, 
and  using  sterile  liquid  the  preparation  can  be  ob- 
served for  several  days  if  need  be.  This  method  is 
especially  to  be  recommended  for  studying  trypano- 
somes,  malaria  parasites,  etc. 

Staining  of  Bacteria. — In  order  to  obtain  good 
stains  it  is  necessary  to  have  good  clean  cover-glasses. 
The  cover-slips,  as  purchased  in  the  market,  are 
unfit,  for  use  until  they  have  been  cleaned.  One 
method  of  doing  this  is  to  heat  the  slips  in  a  beaker 
with  concentrated  sulphuric  acid  and  potassium 
bichromate.  The  cover-glasses  are  then  washed  in 
running  water,  after  which  they  are  kept  in  alcohol. 
Another  procedure  which  gives  very  satisfactory 
results  is  to  soak  the  cover-glasses  first  in  alcohol, 
after  which  they  are  wiped  with  soft,  washed  linen, 
placed  in  an  Esmarch  dish  and  heated  in  a  dry-heat 
sterilizer  at  about  200°  C.  for  an  hour  or  two.  This 
high  heat  completely  destroys  ■  the  organic  matter 
that  may  be  on  the  glasses.  A"  cover-glass  is  not  clean 
if  a  small  drop  of  water,  when  spread  over  the  surface, 
does  not  remain  even,  but  gathers  into  droplets. 

Several  kinds  of  forceps  have  been  devised  for 
holding  cover-glasses  while  staining.  The  Cornet 
forceps  (Fig.  601,  a)  is  well  known,  and  is  useful 
though  rather  awkward.  Stewart's  modification  is 
widely  used  (Fig.  601,  b).  A  much  more  convenient 
type  of  forceps  is  shown  in  Fig.  601,  c.  The  lower 
blade  has  a  thin  edge  which  permits  one  to  pick  up 
the  cover-glass  without  contact  with  the  fingers.  The 
upper  blade  is  bent  in  order  to  avoid  capillarity,  and 
is  narrowed  to  a  point  so  that  the  specimen  is  held  by 
point  contact.  A  catch  serves  to  hold  the  cover-slip 
in  place. 

Aniline  Dyes. — The  aniline  dyes  which  are  em- 
ployed for  staining  purposes  are  either  basic  or  acid 
in  character.  The  former  contain  amido  groups 
and  are  spoken  of  as  nuclear  stains,  since  they  color 
the  nuclei  of  cells  as  well  as  bacteria.  The  latter 
contain  hydroxyl  groups  and  do  not  stain  bacteria 
but  are  used  chiefly  for  contrast  coloring,  and  to 
some  extent  for  decolorizing.  The  basic  dyes  are 
usually  employed  as  salts  of  hydrochloric  acid,  while 
the  acid  dyes  occur  as  sodium  or  potassium  salts. 


A',  .• 


3 


Fig.  600. — Cell  Slide  showing  Hanging  Drop.  A,  Surface  view; 
Bt  side  view;  b,  edge  of  cell;  c,  hollow  of  cell;  d,  cover  glass;  ef 
hanging  drop. 

Among  the  basic  aniline  dyes  which  are  commonly 
employed  may  be  mentioned  fuchsin,  gentian  violet, 
methyl  violet,  crystal  violet,  methylene  blue,  thionin, 
safranin,  methyl  green,  neutral  red,  and  vesuvin  or 
Bismarck  brown.  These  are  all  more  or  less  crystal- 
line powders,  and  while  some  are  definite  chemical 
compounds,  others  are  mixtures.  For  this  reason 
various  brands  are  met  with  on  the  market,  and  it 
will  be  readily  understood  why  the  exact  duplica- 
tion of  stains  is  not  always  possible. 


Reference  Handbook 

OF  THE 

Medical  Sciences. 


Plate    XII. 


1. 

2. 

3. 

4. 

5 

6 

7 

Bacillus  of 

Bacillus  ot 

The  same 

Finkler-Prior's 

Deneciie's 

Miller's 

Bacillus  iA' 

Tuberculosis. 

Cholera  Asiat- 
ics. 

in  gelatine. 

Comma  Ba- 
cillus. 

Bacillus 

Bacillus 

Typhoid  Fever 

8. 

9. 

10. 

11 

12. 

13. 

14 

Pneumococcus. 

Bacillus  or 

Bacillus  of 

The  same 

Bacillus  of 

Bacillus  of 

Bacillus  of 

Glanders. 

Anthrax. 

in  gelatine 

Malignant 
Oedema 

Septicaemia 
of  Mice 

Septicaemia 
of  Rabbits 

15. 

16. 

Bacillus  of 

Bacillus  of 

Chicken 

Pigeon 

Cholera. 

Diphtheria 

n. 

Slide  Culture 
(reduced? 


Plate  Culture 
treducedJ 


TEST-TUBE  CULTURES. 

Reproduced   from   Huber  &  Becker's   "Untersuchungs-Methoden. 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Bacteriological  Technique 


It  is  advisable  to  keep  on  hand  not  only  ihe  solid 
dyes,  but  also  stock  solutions  which  are  saturated 
alcoholic  solutions.  The  amount  iv<|iiircd  to  .satu- 
rate will  vary  from  two  to  live  per  cent. 

The  concentrated  alcoholic  solutions  are  never  used 
as  such,  luii  serve  for  the  preparation  of  the  dilute 

dyes  which  are  the  stains  proper.  Tin;  latter  are 
made  by  placing  a  few  cubic  centimeters  of  the  con- 
centrated dye  in  a  small  tincture  bottle,  and  adding 
ten  to  twenty  parts  of  water.  This  bottle  is  then 
provided  with  a  cork  and  a  piece  of  glass  lulling  which 


Fig. 


601. — Cover-glass    Forceps,     a,    Cornet's;    6,    Stewart's; 
Novy's. 


serves  as  a  pipette.  The  different  dilute  dyes  can 
be  kept  in  a  stand,  such  as  is  shown  in  Fig.  602. 
The  dilute  dyes  after  a  while  undergo  alteration  and 
yield  deposits.  In  that  event  they  should  be  filtered 
before  use,  or  else  new  dilutions  should  be  made. 

The  acid  aniline  dyes  are  represented  by  eosin,  acid 
fuchsin,  and  fluorescein.  The  concentrated  and  the 
dilute  dyes  are  prepared  as  above. 

The  staining  solutions  may  be  used  as  such,  or 
their  properties  may  be  accentuated  by  the  addition 
of  substances  which  act  more  or  less  directly  as 
mordants.  A  number  of  these  solutions  are  in  daily 
use,  and  for  that  reason  their  preparation  is  here  given. 

Loffler's  methylene  blue  is  made  by  adding  30  c.c.  of 
concentrated  methylene  blue  to  100  c.c.  of  a  0.01- 
per-cent.  solution  of  potassium  hydrate.  A  similar 
solution  with  less  alkali  was  first  used  by  Koch. 
The  alkali  not  only  serves  to  make  the  cell  more 
permeable,  but  also  increases  the  staining  power  by 
liberating  the  free  base  from  the  dye. 

Carbolic  fuchsin,  or  Ziehl  solution,  is  made  by  add- 
ing 1  gram  of  fuchsin  and  10  c.c.  of  alcohol  to  100  c.c. 
of  a  five-per-cent.  carbolic-acid  solution.  The  stain 
is  very  widely  used  for  simple  as  well  as  double  stain- 
ing. Czaplewski  modified  it  by  substituting  glycerin 
for  the  alcohol.  His  solution  is  prepared  by  rubbing 
up  in  a  mortar  1  gram  of  fuchsin  with  5  grams  of  car- 
bolic acid,  and  to  this  150  grams  of  glycerin  and  100 
c.c.  of  water  are  added. 

Carbolic  methylene  blue,  first  employed  by  Kiihne, 
consists  of  1.5  grams  of  methylene  blue,  10  grams  of 
absolute  alcohol,  and  100  c.c.  of  a  five-per-cent. 
solution  of  carbolic  acid. 

Carbolic  thionin  consists  of  10  parts  of  a  saturated 
solution  of  thionin  and  100  parts  of  a  one-per-cent. 
solution  of  carbolic  acid  (Nicolle). 

Carbolic  gentian  violet  is"made  the  same  as  the  pre- 
ceding (Nicolle). 

Vol.  I.— 58 


Aniline  Water,  Gentian  Violet,  etc.  The  carbolic 
acid,  like  the  alkali,  favors  the  penetration  ol    the 

tain.      Aniline    water   acts   in    like    manner   and    was 

in  i  used  by  Ehrlich.  To  prepare  the  aniline  water 
a  few  cubic  centimeters  of  aniline  are  placed  in  a  test- 
tube,  and  this  ia  then  filled  with  distilled  water  and 
thoroughly  shaken.  The  milky  liquid  i  filtered 
through  a  moist  lilt  or.  To  the  water-clear  filtrate 
enough  concentrated  fuchsin  or  gentian  violet  D 
then  added  to  make  the  Liquid  opaque,  and  bo  that 
it  just  begins  to  form  on  the  surface  a  slight  metallic 

film  of  precipitated  dye.  The  solution  is  then  used 
as  such,  but   if  the  deposit   is  very  marked  it   may  be 

necessary  first  to  filter  it.  The  aniline-water  dye  do 
not  keep  very  well,  and  for  that  reason  it  is  well  to 

make  a  fresh  solution  every  time  thai  it  is  to  be  used. 
Oil  of  cloves  has  been  suggested  by  London  as  a 
substit  ule  for  aniline. 

The  aniline-water  stains  were  first,  employed  by 
Ehrlich  for  coloring  the  tubercle  bacillus,  and  are 
still  used  for  that,  purpose,  They  are,  however, 
employed  especially  for  staining  whips  and  in  con- 
nection with  drain's  stain.  In  the  latter  case,  after 
I  lit;  preparation  litis  been  stained  with  the  solution, 
a  mordant  is  applied,  known  as  Lugol's  solution, 
which  serves  to  form  a  difficultly  soluble  compound 
between  the  dye  and  the  cell  contents. 

Lugol's  solution  consists  of  1  part  of  iodine,  2  parts 
of  potassium  iodide,  and  MOO  parts  of  distilled  water. 

The  Staining  of  Cover-glass  Preparations. — Thee 
may  be  considered  under  the  head  of  (1)  simple,  -') 
double,  and  (3)  special  stains.  For  the  simple  stains, 
when  it  is  desired  to  have  a  heavily  colored  prepara- 
tion, either  fuchsin  or  gentian  violet  is  used.  When 
it  is  desired  to  bring  out  structural  characteristics,  it 
is  advisable  to  employ  solutions  which  stain  more 
feebly,  such  as  methylene  blue  or  thionin.  In  either 
case  the  simple  or  reinforced  stains,  given  above, 
may  bo  employed. 

To  make  a  stained  preparation  of  a  pure  culture  the 
procedure  is  as  follows:  A  drop  of  water,  preferably 
distilled,  is  placed  upon  a  clean  cover-glass,  which 
either  lies  on  a  board  or  is  held  in  a  pair  of  forceps. 
By  means  of  a  sterile  platinum  wire  a  minute  amount 
of  the  bacterial  growth  is  picked  up  and  transferred 
to  the  water.  Only  enough  should  be  added  so  as  to 
impart  to  the  water  a  slight  cloudiness.  The  remain- 
der on  the  wire  is  then  burned  off.  The  drop  is  then 
spread  over  the  whole  surface  of  the  glass  and  allowed 


Fig.  602. — .Stand  for  .Staining  Solutions. 

to  dry  in  the  air,  or  the  process  may  be  hastened  by 
passing  it  above  a  flame.  Care  must  be  taken  not  to 
dry  too  rapidly  as,  in  such  case,  vacuolation  of  the 
protoplasmic  contents  of  the  cell  results.  The  air- 
dried  preparation  must  now  be  fixed  in  order  that 
the  bacteria  may  not  be  washed  off  in  the  subsequent 
treatment.  The  fixing  is  done  by  passing  the  cover- 
glass  three  times  through  a  llame.  Care  must  be 
taken  not  to  scorch  the  specimen,  for  in  that  case 
the  dye  will  not  act.     It  is  well  to  turn  down  the 

913 


Bacteriological  Technique 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


flame  so  that  it  is  at  most  but  two  inches  high.  The 
properly  fixed  cover-glass  is  now  covered  with  the 
Main,  which  is  allowed  to  act  for  ten  to  twenty  seconds. 
The  dye  is  then  washed  off  under  the  tap  and  the 
cover-glass  inverted  upon  a  glass  slide.  Any  water 
which  ma3'  be  on  the  surface  of  the  slip  should  be 
removed  bjr  means  of  a  piece  of  filter  paper.  The 
preparation  can  now  be  examined  under  a  No.  7 
objective,  or  with  the  one-twelfth-inch  oil  immersion 
lens.  If  the  specimen  is  such  as  to  merit  preserva- 
tion a  drop  or  two  of  water  may  be  applied  to  the 
edge,  and  in  this  way  the  slip  can  be  floated  off  with- 
out damaging  the  film.  The  excess  of  water  can 
then  be  touched  off  with  a  piece  of  filter  paper,  after 
which  the  specimen  is  dried  in  the  air  or  by  passing 
it  over  the  flame.  The  thoroughly  dried  film  is  then 
inverted  upon  a  drop  of  Canada  balsam  placed  on  the 
center  of  a  clean  slide.  By  gentle  warming  or  by 
pressure  the  balsam  can  be  made  to  spread  out  evenly. 

Smear  or  streak  preparations  made  from  the  fluids 
or  organs  of  the  body  are  stained  in  the  same  way. 
In  selecting  a  stain  for  such  preparations  perhaps 
Loffler's  methylene  blue  solution  is  the  most  satis- 
factory.  It  does  not  stain  the  tissue  material  so  deeply 
a-  some  of  the  other  commonly  used  bacterial  stains. 
Also  Pappenheim's  pyronin  and  methyl-green  mix- 
ture may  be  used  for  the  same  purpose.  It  is  com- 
posed of  3  to  4  parts  of  saturated  aqueous  solution  of 
methyl-green  to  1  to  1J  parts  of  saturated  solution 
of  pyronin,  and  applied  the  same  as  the  above  stain. 
With  this  stain  bacteria  take  a  bright  red  coloration; 
the  nuclei  of  the  body  cells  take  a  bluish  stain.  The 
fixation  of  the  cover-glass  when  it  contains  much  pro- 
tein matter,  as  in  the  case  of  blood  streaks,  requires 
special  care.  The  best  results  are  obtained  by  im- 
mersing  the  slip  for  a  few  minutes  in  a  mixture  of 
equal  parts  of  absolute  alcohol  and  ether.  Fixation 
is  thus  accomplished  without  any  injury  to  the  blood 
cells.  It  is  sometimes  advisable,  instead  of  adding 
the  dye  to  the  cover-glass,  to  float  the  latter  upon 
the  dye  in  a  watch-glass. 

To  make  good  blood  preparations  requires  consider- 
able care  and  experience.  A  small  drop  of  blood  is 
placed  on  a  perfectly  clean  cover-glass,  which  is  held 
in  a  pair  of  forceps.  A  second  cover-slip  is  then 
applied  evenly  and  without  pressure,  and  as  soon  as 
the  blood  has  spread  out  the  two  glasses  are  drawn 
apart.  The  blood  cells  must  not  be  crushed  and 
should  lie  in  a  single  layer. 

The  smears  from  the  cut  surface  of  an  organ  are 
made  by  gently  applying  the  cover-glass,  without 
pressure,  and  then  drawing  it  away;  or  a  piece  of  the 
organ  may  be  taken  up  in  the  forceps  and  streaked 
over  the  cover-glass,  care  being  taken  to  leave  only  the 
thinnest   film  possible. 

The  ordinary  dass  slide  is  often  used  in  place  of  the 
cover-glass.  The  streaks  or  blood  smears  are  made 
as  in  the  case  of  the  latter.  When  the  growth  is 
hard,  as  in  the  case  of  actinomyces,  it  is  well  to  crush 
it  between  two  glass  slides. 

Double  Staining. — This  procedure  is  resorted  to 
when  staining  the  tubercle  bacillus  and  the  allied 
acid-resisting  bacilli.  It  is  also  used  for  staining 
spores,  and  in  differentiating  bacteria  by  means  of 
Gram's  stain.  Other  special  methods  are  given 
under  gonorrhea  and  meningitis. 

The  group  of  acid-resisting  bacilli,  the  type  of  which 
is  the  tubercle  bacillus,  is  stained  with  more  or  less 
difficulty  by  the  simple  stains.  The  dye,  however, 
can  be  forced  into  the  cell  by  the  aid  of  heat,  and 
especially  if  the  reinforced  stains,  such  as  carbolic 
fuchsin  or  aniline-water  gentian  violet,  are  used. 
On  subsequent  treatment  with  acid  and  alcohol  the 
ordinary  bacteria  which  chance  to  be  present  are 
readily  decolorized,  whereas  the  acid-resisting  retain 
th  -lain.  A  contrast  color,  such  as  methylene  blue, 
will  then  stain  the  background  and  the  ordinary 
bacteria  a  light  blue. 


Staining  of  the  Tubercle  Bacillus. — The  cover-glass 
is  air-dried  and  fixed  in  the  usual  manner,  after  which 
any  one  of  several  methods  may  be  used.  The 
Ziekl-Neelsen  method  is  usually  employed.  It  is 
carried  out  as  follows:  The  cover-glass,  held  in  the 
forceps,  is  covered  with  carbolic  fuchsin  and  heated 
over  the  flame  so  that  vapors  are  given  off  for  one  or 
two  minutes.  It  is  then  rinsed  in  water  and  dipped 
for  a  few  seconds  in  a  twenty-per-cent.  solution  of 
nitric  acid,  after  which  it  is  washed  in  dilute  alcohol 
i sixty  per  cent.)  till  it  is  almost  colorless.  Methyl- 
ene blue  is  then  applied  for  a  few  seconds  and  washed 
off.  The  specimen  is  transferred  to  a  slide,  the 
surface  dried,  and  examined  under  the  microscope. 
The  tubercle  bacilli  will  appear  red  on  a  blue  back- 
ground.    The  ordinary  bacteria  will  appear  blue. 

The  Koch-Ehrlich  method  consists  in  staining  with 
aniline-water  fuchsin  or  gentian  violet  with  the  aid  of 
heat  for  a  few  minutes.  The  specimen  is  then  decolored 
in  thirty-five-per-cent.  nitric  acid  for  about  a  quarter 
of  a  minute,  washed  in  dilute  alcohol  till  nearly  color- 
less, after  which  methylene  blue  or  Bismarck  brown 
is  applied  for  a  contrast  color. 

In  the  Fraenkel-Gabbet  method  the  preliminary 
staining  is  effected  with  carbolic  fuchsin  as  above. 
The  decoloration  and  contrasting  is  done  at  once  by 
immersing  the  cover-glass  in  a  saturated  solution  of 
methylene  blue  in  the  following:  Sulphuric  acid  25 
parts,  alcohol  50  parts,  distilled  water  1,000  parts. 
It  is  then  rinsed  with  water  and  examined. 

Czaplewsky's  method  differs  from  the  preceding  in 
the  way  the  decoloration  is  effected.  He  employed 
for  this  a  solution  of  one  gram  of  fluorescein  and  five 
grams  of  methylene  blue  in  100  c.c.  of  alcohol.  The 
specimen  is  first  stained  with  carbolic  fuchsin;  then, 
without  rinsing  in  water,  it  is  placed  for  a  few  seconds 
in  the  fluorescein  methylene  blue  solution.  Finally  it 
is  dipped  ten  or  twelve  times  in  a  solution  of  5  parts 
of  methylene  blue  in  100  parts  of  alcohol.  It  is  then 
washed  witli  water  and  examined. 

Numerous  modifications  of  the  above  methods  have 
been  proposed,  but  they  possess  no  special  advantage 
over  those  given. 

Herman's  method  for  the  staining  of  the  tubercle 
bacillus  is  said  to  possess  advantages  over  the  carbol- 
fiuhsin  method.  For  this  stain  a  three  per  cent, 
solution  of  crystal  violet  (6B)  in  ninety-five  per  cent, 
of  alcohol  is  combined  with  a  mordant  consisting  of  a 
one  per  cent,  solution  of  ammonium  carbonate  in 
distilled  water;  the  proportions  are  one  part  of  the 
former  to  three  parts  of  the  latter  solution.  The  fixed 
smear  of  the  material  is  warmed,  then  the  stain  is 
poured  on  and  held  over  flame  until  vapors  rise  for 
one-half  to  one  minute.  The  deeolorization  is  carried 
out  in  ten-per-cent.  nitric  acid,  until  the  color  is  prac- 
tically gone  followed  by  ninety-five-per-cent.  alcohol. 
The  smear  is  then  washed,  and  counterstained  with 
Bismarck  brown,  methylene  blue,  or  other  suitable  dye. 

Staining  of  Spores. — The  cover-glass  preparation  is 
treated  for  some  minutes  with  hot  carbolic  fuchsin, 
either  on  the  forceps  or  by  floating  on  the  dye.  It 
should  then  be  rinsed  and  examined  in  water.  If  the 
spores  are  colored,  the  next  step  is  taken;  if  not,  then 
the  heating  with  the  dye  is  continued  until  they  are 
stained.  The  specimen  is  then  decolorized  in  dilute 
acid  and  alcohol  until  the  spores  stand  out  red  on  a 
colorless  background.  •  Methylene  blue  is  then  applied 
for  a  contrast,  washed  off,  and  the  preparation  is 
ready  for  examination.  The  bright  red  spores  are 
seen  within  the  light  blue  cells.  This  method 
requires  considerable  care,  and  every  step  must  be 
controlled  by  frequent  examinations  under  the 
microscope. 

In  order  to  enable  the  dye  more  readily  to  enter 
the  spore,  Moller  treated  the  cover-glass,  first,  for  a 
minute  or  two  with  a  five-per-cent.  solution  of  chro- 
mic acid,  after  which  essentially  the  above  procedure 
was    followed.     By    repeated    passage    through    the 


914 


REFERENCE    HANDBOOK    OF   THE    Mr.HH   \I.   SCI1 


Bacteriological  i  ••  bnlqac 


flame  <>r  by  heating  with  strong  sulphuric  acid  for  a 
few  seconds  the  substance  of  the  spore  can  be  disinte- 
grated so  that  on  subsequent  staining  with  carl 

fuchsin  the  spores  will  readily  lake  the  dye.     Thi 

treatment,   however,  destroys  tl riginal  cell,  and 

hence  contrast  coloration  is  not  possible. 

Klein  varies  the  procedure  of  spore  staining  given 
above  by  adding  an  equal  volume  of  carbol-fm  l 
solution  to  a  suspension  of  the  spore-bearing  organism 
in  physiological  salt  solution.  The  mixture  is  gently 
warmed  for  six  minutes.  Cover-glass  preparations 
are  then  made,  dried,  and  fixed.  They  are  then  de- 
colorized in  one-per-cent.  sulphuric  acid  solution,  and 
counter-stained  in  the  regular  manner.  This  method 
may  be  useful  in  staining  those  varieties  which  are 
especially  resistant. 

By  the  Abbott  method  the  above  order  of  staining 
is  reversed  in  that  the  spores  are  stained  blue,  while 
the    bodies    of    the    cells    are    red.     The    cover-glass 

E reparation  is  deeply  stained  with  methylene  blue 
y  heating  about  one  minute  at  a  point  where  the 
staining  fluid  is  kept  almost  constantly  boiling.  The 
stain  is  washed  oft  in  water,  then  in  ninety-tive-per 
cent,  alcohol  containing  between  two-  and  three- 
tenths  per  cent,  of  hydrochloric  acid  to  decolorize; 
again  wash  in  water,  then  stain  in  aniline  fuchsin 
solution  for  about  ten  seconds.  Wash,  dry,  mount 
for  observation. 

The  Gram  Stain. — This  is  one  of  the  most  vale 
methods  in  bacteriology,  since  it  often  serves  to  dis- 
tinguish between  organisms  which  otherwise  resemble 
each  other  very  closely.  The  cover-glass  prepara  tion 
is  floated  for  a  few  minutes  on  aniline-water  gentian 
violet  or  on  carbolic  gentian  violet.  Heat  may  be 
applied,  but  in  that  case  the  excessive  staining  will 
interfere  with  the  subsequent  decoloration.  'I  lie 
specimen  is  then  rinsed  in  water  and  immersed  in 
Lugol's  iodine  solution  for  two  or  three  minutes. 
After  rinsing  in  water  it  is  then  placed  for  a  few  min- 
utes in  strong  alcohol  until  most  of  the  dye  has  been 
washed  out.  Very  dilute  eosin  solution  is  now  applied 
for  about  five  seconds.  After  thorough  washing  with 
water  it  is  ready  for  examination.  The  organism 
will  appear  a  deep  violet  on  a  pink  background. 

Gram's  method  is  applicable  to  the  bacilli  of  ant  hrax. 
symptomatic  anthrax,  diphtheria,  leprosy,  malig- 
nant edema,  mouse  septicemia,  rouget,  tetanus, 
tuberculosis,  the  Fraenkel  diplococcus,  Micrococcus 
telragenus,  the  various  staphylococci  and  streptococci, 
actinomyces,  moulds,  and  yeasts.  It  is  not  given  by 
the  bacillus  of  glanders,  typhoid  fever,  hog  cholera. 
Asiatic  cholera,  chicken  cholera,  influenza,  plague, 
Friedlander's  bacillus,  colon  bacillus,  gonococcus, 
rhinoscleroma,  and  recurrent  fever  spirillum. 

The  Staining  of  Flagella. — Special  care  must  be 
given  to  the  preparation  of  the  cover-glass.  The 
cultures  should  be  made  on  freshly  inclined,  moist 
agar,  and  should,  as  a  rule,  be  less  than  twenty-four 
hours  old.  A  very  dilute  suspension  of  the  growth 
is  made,  and  when  spread  over  the  cover-glass  is 
allowed  to  dry  in  the  air.  The  fixation  must  be  done 
with  the  least  amount  of  heat  possible.  This  can  best 
be  done  by  passing  the  cover-glass,  held  between  the 
thumb  and  forefinger,  through  the  flame. 

In  Loffler's  method  the  specimen  is  covered  with  a 
mordant  solution  which  consists  of  100  parts  of  a 
twenty-per-cent.  tannic-acid  solution,  50  parts  of  a 
cold  saturated  ferrous-sulphate  solution,  and  10  parts 
of  alcoholic  fuchsin.  The  cover-glass  is  heated  over 
the  flame  so  that  vapors  are  given  off  for  a  minute  or 
two.  Every  trace  of  the  mordant  must  then  be 
removed  by  washing  with  water,  and  if  it  has  dried 
down  around  the  edge  it  should  be  removed  with  a 
knife.  The  last  traces  of  the  mordant  can  be  removed 
by  momentary  immersion  in  absolute  alcohol.  The 
specimen  is  then  heated  with  aniline-water  fuchsin 
for  a  couple  of  minutes,  washed  with  water,  and 
examined.     The  chief  difficulty  in  this  method  lies 


in  the  formation  "i  a  heavy  deposit  of  foreign  matl 

which  masks  the  bad 

I  i  i  I"  i     i light  modification  of  thai  .,f 

Loffler.     It  consists  of  •_'  grams  of  di  \   tannin,  20 

of  water,    I  I    I  and   1   C.C    of 

concentrated  alcoholic  fuchsin.  The  aniline  water 
fuchsin  is  made  by  adding  about  .",  grams  of  fuchsin, 
and  1  c.c.  of  a  one-per-cent.  solution  of  sodium  1 

to  Kill  c.c.  of  aniline  water. 

Bunge  employed  a  mordant  consisting  of  7.".  parts 
of    concentrated    tannin    solution.   _'.">  parts  of  a  tivc- 
per-cent.     olution  of  ferric  chloride,  and  Mi  part-  of 
a  com  entratedaque        *  uchsin  solution.    After  stai 
ing  some  days  hydrogen    peroxide  I   until  a 

reddish  dp  i   is  obtained. 

Pitfield  makes  use  of  a  Million  of  mordl 

and  dye.    Two  solui  first  prepared:  (1)  con- 

sisting of  1  ce.  of  saturated  alcoholic  gentian  violet 
and  10  c.c.  of  saturated  aqueous  alum;  ting 

of  1  gram  of  tannic  acid  and   II)  <-.i-.  of  distilled  water. 

two  solutions  are  filtered  and   then  combined. 
'I  he  mixture  is  heated  on  I  he  covei  -gla  -  over  a  tin 
for  about  a  minute,  and  then  washed  off. 

Van   Ermengem's  method  i-  essentially  differ. 
The  cover-glass  is  wan 1  for  about  five  minutes  with 

a  fixing  solution  consisting  of  till  c.<-.  of  a  twenty-per- 
cent, tannin  solution,  'M)  c.c.  of  two-per-cent.  osmic- 
acid  solution,  and  four  to  five  drops  of  glacial  acetic 
acid.  It  is  then  washed  with  water,  rinsed  in  alcohol, 
and  dipped  for  one  or  two  seconds  in  a  sensitizing 
solution  of  silver  nitrate  (one-half  to  one  per  cei 
After  this  it  is  placed  for  a  few  seconds  in  the  reducing 
solution  which  consists  of  5  parts  of  gallic  acid,  3 
parts  of  tannic  acid,  10  parts  of  sodium  acetate,  and  ' 
350  parts  of  distilled  water.  It  is  again  placed  in  the 
silver-nitrate  solution,  in  which  it  is  moved  about 
until  the  liquid  darkens,  after  which  the  preparation 
is  washed  with  water,  dried,  and  examined. 

Of  the  numerous  other  modifications  which  have 
been  proposed  that  of  Gemelli  only  need  be  given. 
Gemeili  cleans  the  cover-glasses  in  a  boiling  mixture 
of  potassium  bichromate  (three  per  cent.),  and  sul- 
phuric acid  (five  per  cent.).  After  washing  in  water 
they  are  kept  in  alcohol.  Before  use  each  cover-glass 
is  flamed  several  times.  Gelatin  cultures  developed 
at  37°  C.  are  said  to  give  the  best  results.  A  loopful 
is  transferred  to  5  c.c.  of  water  in  a  watch-glass,  and 
from  this  suspension  a  drop  is  taken  and  spread  over 
a  cover-glass,  which  is  then  set  aside  over  calcium 
chloride  to  dry.  The  specimen  is  then  placed  for  ten 
to  twenty  minutes  in  a  one-fourth-per-cent.  solution 
of  potassium  permanganate.  The  preparation  is  now 
washed  well  in  distilled  water,  after  which  it  is  placed 
in  a  three-fourths-per-cent.  solution  of  calcium  chlo- 
ride, to  which  has  been  added  a  one-per-cent.  solution 
of  Griibler's  neutral  red  in  the  proportion  of  twenty 
to  one.  After  remaining  in  this  for  fifteen  to  thirty 
minutes  the  specimen  is  washed,  dried,  and  mounted. 
The  method  is  said  to  give  excellent  and  sure  results 
without  the  annoying  precipitates  which  form  in  the 
other  procedures. 

Staining  of  Capsules. — Welch's  method  consists  in 
treating  the  cover-glass  with  glacial  acetic  acid  for  a 
few  seconds.  The  excess  of  acid  is  drained  off  with 
filter  paper,  after  which  the  specimen  is  washed  in 
aniline  water  gentian  violet,  and  finally  in  a  sodium- 
chloride  solution  (0.S5  to  2  per  cent.).  The  heavily 
stained  bacillus  will  be  found  to  be  surrounded  by  a 
pale  violet  halo. 

Nicolle  treats  the  cover-glass  with  a  mixture  of  one- 
per-cent.  carbolic  acid  (10(1  parts)  and  saturated  alco- 
holic (95  per  cent.)  gentian  violet  solution  ,  III  parts). 
It  is  then  washed  in  absolute  alcohol  containing  one- 
third  its  volume  of  acetone,  rinsed  in  water,  dried,  and 
mounted. 

Hiss'  copper-sulphate  method  consists  of  preparing 
films  by  mixing  the  organism  with  a  drop  of  diluted 
serum   on  a  cover-glass.      If   the   organism    has    been 


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Bacteriological  Technique 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


grown  upon  ascitic  or  serum  medium,  the  addition  of 
serum  is  not  neeessar_v.  the  film  being  made  direct  from 
culture.  The  film  is  dried  in  air  and  fixed  with  heat. 
An  aqueous  solution  of  gentian  violet  (5  c.c.  saturated 
alcoholic  solution  gentian  violet  to  95  c.c.  distilled 
water)  or  fuchsin  may  be  used,  as  stain.  The  stain 
is  placed  on  the  fixed  cover-glass  preparation,  and 
carefully  heated  over  a  flame  for  a  few  seconds  until 
steam  rises.  The  stain  is  then  washed  off  with  a 
twenty-per-cent.  solution  of  copper  sulphate  (crystals). 
The  stained  preparation  is  dried  between  filter  papers 
and  mounted  for  examination. 

Rosenow's  method  for  the  staining  of  capsules  is 
especially  applicable  to  the  pneumococcus  and  the 
Streptococcus  mucosus.  -Make  a  thin  smear  of  the 
material  upon  a  perfectly  clean  slide  or  cover-glass. 
In  the  case  of  sputum,  "if  too  thick,  add  sufficient 
distilled  water  so  that  an  even  spread  may  be  made, 
or  if  growth  from  solid  medium  (blood  agar,  Loffler's 
blood  serum)  is  used,  remove  a  small  amount  and 
mix  with  a  drop  of  serum  upon  a  slide.  Spread  the 
material  by  means  of  fine  tissue  paper.  When  the 
smear  is  nearly  dry,  cover  with  a  five  to  ten  per  cent, 
aqueous  solution  "of  tannic  acid  for  ten  to  twenty 
seconds;  wash  in  water  and  blot;  stain  with  carbol  (1 
part  sat.  alcoholic  sol.  gentian  violet,  4  parts  five  per 
cent,  aqueous  sol.  phenol)  or  aniline-gentian-violet, 
gently  heat  over  flame  without  boiling  for  one-half  to 
one  minute;  wash  in  water,  place  in  Gram's  iodine 
solution  for  one-half  to  one  minute,  decolorize  in 
ninety-five  per  cent,  alcohol;  stain  with  saturated 
alcoholic  (sixty  per  cent.)  solution  of  Griibler's  eosin 
from  two  to  ten  seconds  depending  upon  the  thick- 
ness of  the  smear;  wash  in  water  and  blot.  Examine 
directly,  or  clear  in  xylol  and  mount  in  balsam. 
Pneumococci  stained  by  this  method  appear  sharply 
differentiated  from  the  capsule;  the  cell-body  takes  a 
deep  brownish-black,  the  capsule  a  pink  stain.  If 
the  organism  is  Gram-negative,  Loffler's  or  aqueous 
methylene  blue  may  be  used  as  a  contrast  stain. 

Staining  of  the  Babes-Ernst  Granules. — Neisser  rec- 
ommends the  following  method  as  a  means  of  differen- 
tiating the  diphtheria  bacillus  from  like  organisms. 
A  culture  grown  on  Loffler's  serum  should  be  used. 
Tne  specimen  is  treated  for  one  to  three  seconds,  or  a 
little  longer,  with  the  following  solution:  one  gram  of 
methylene  blue,  20  c.c.  of  absolute  alcohol,  50  c.c.  of 
glacial  acetic  acid  made  up  to  one  liter  with  distilled 
water.  It  is  then  washed  with  water  and  stained 
with  Bismarck  brown  (two-per-eent.  aqueous  solu- 
tion) for  three  to  five  seconds.  Finally  it  is  washed 
with  water  and  examined.  The  blue  granules  will 
stand  out  in  the  light  brown  bacilli. 

Piorkowski  heats  the  preparation  for  one-half  to 
one  minute  with  an  alkaline  solution  of  methylene 
blue,  then  decolors  for  five  seconds  in  alcohol  con- 
taining three  per  cent,  of  hydrochloric  acid.  A  one- 
per-cent.  aqueous  eosin  is  applied  for  contrast,  after 
which    the    preparation    is    washed    and    examined. 

Impression  Preparations  of  Colonies. — It  is  very 
often  desirable  to  reproduce  or  preserve  the  charac- 
teristic surface  colonies.  The  selection  of  the  surface 
colony  is  made  under  the  microscope,  after  which  the 
tube  of  the  instrument  is  raised  and  a  cover-glass  is 
dropped  down  upon  the  colony.  Gentle  pressure  is 
applied,  the  cover-glass  lifted  off,  air-dried,  fixed,  and 
stained  with  methylene  blue  in  the  usual  way. 

Staining  of  Protozoa. — The  study  of  the  protozoa  and 
kindred  microorganisms  is  so  closely  associated  with 
bacteriological  methods  that  it  will  not  be  amiss  to 
discus^  briefly  the  more  useful  stains  employed  in  con- 
nection  with  this  important  class.  Many  advances 
have  recently  been  made  along  this  particular  line  of 
work  which  has  thrown  much  light  upon  diagnosis  and 
i  be  el  iology  of  disease. 

Romanowsky' s  Chromatin  Stain. — This  method  is 
extremely  valuable  for  staining  protozoal  parasites, 
such  as  those  of  malaria  and  the  trj-panosomes.     It 


may  also  be  used  for  staining  Treponema  (Spiro- 
chieta  pallidum.  When  properly  carried  out  it  gives 
an  admirable  differentiation  of  the  chromatin,  which 
appears  red  on  a  blue  background.  Nocht's  modi- 
fication gives  very  good  results,  and  is  briefly  as 
follows:  A  solution  of  one-per-cent.  methylene  blue 
and  one-half  per  cent,  sodium  carbonate  is  kept  at 
about  60°  C.  for  several  days  to  "ripen."  The 
change  which  takes  place  is  one  of  slow  oxidation,  and 
as  a  result  a  number  of  products  form,  among  which 
is  the  one  which  is  essential  to  this  method.  This 
active  red  constituent  has  been  designated  as  methyl- 
ene azur.  To  about  2  c.c.  of  water  in  a  watch-glass 
two  to  three  drops  of  a  one-per-cent.  solution  of  eosin 
are  added,  and  then  the  altered  blue,  drop  by  drop, 
till  the  eosin  tint  just  disappears.  The  specimen  is 
floated  on  this  dye  for  five  to  ten  minutes,  after  which 
it  is  washed  and  examined. 

Independently  Wright,  Leishman,  and  Reuter 
arrived  at  a  simple  modification.  The  ripened  or 
polychrome  methylene  blue  is  treated  with  an  eosin 
solution  to  slight  excess.  The  precipitate,  which 
Reuter  has  called  a  methylene-blue  eosin,  is  then 
filtered,  washed,  and  dissolved  in  methyl  alcohol. 
This  solution  can  now  be  obtained  from  Grubler. 
Thirty  drops  of  this  are  added  to  20  c.c.  of  distilled 
water  in  a  large  watch-glass  or  Petri  dish.  The  spec- 
imen, which  can  be  fixed  with  ether  alcohol  or  with 
formaldehyde  alcohol  (10  :90),  isimmersed  in  the  dye 
for  fifteen  to  thirty  minutes.  It  is  well  gently  to 
agitate  the  liquid  from  time  to  time.  It  is  then 
washed,  dried,  and  mounted. 

Wright's  modification  has  been  recommended  by 
Musgrave  and  Clegg  as  giving  the  best  results  in 
staining  the  ameba  of  dysentery.  The  Leishman 
stain  has  been  prominently  brought  forward  by 
Wright  and  Douglass  in  their  staining  of  white  blood 
cells  (phagocytes)  while  studying  the  opsonic  action 
of  blood  serum.  As  a  phagocytic  cell  stain,  this 
apparently  possesses  no  advantage  over  Wright's 
or  certain  other  modifications  of  the  Romanowsky 
stain.  These  stains,  ready  for  use,  can  be  procured 
from  dealers. 

Laveran  employs  1  c.c.  of  a  one-per-cent.  solution 
of  azur,  2  c.c.  of  a  0.1-per-cent.  solution  of  eosin,  and  8 
c.c.  of  water.  The  specimen  is  stained  for  ten  minutes 
then  washed  and  immersed  for  two  or  three  minutes 
in  a  five-per-cent.  tannic  acid  solution,  after  which 
it  is  washed,  dried,  and  mounted. 

Giemsa  has  made  several  modifications  of  the  stain. 
The  following  is  one,  which,  in  the  hands  of  Williams 
and  Lowden,  has  given  excellent  results  in  the  study 
of  the  finer  morphological  characteristics  of  "Negri 
bodies."  It  is  composed  of  azur  II-eosin,  3.0  grams; 
azur  II.,  0.8  gram;  glycerin  (Merck's  chemically  pure), 
2.50.0  c.c;  methyl  alcohol  (chemically  pure),  250.0  c.c. 
The  glycerin  and  alcohol  are  heated  separately  to  60° 
C.  The  dyes  are  put  into  the  alcohol,  and  the  glyc- 
erin is  slowly  added  while  stirring.  The  mixture 
is  allowed  to  stand  at  room  temperature  for  about 
twenty-four  hours,  when,  after  filtration,  it  is  ready 
for  vise. 

The  technique  followed  by  Williams  in  the  study  of 
"Negri  bodies"  was  to  prepare  smears  of  brain  tissue 
(cortex  from  near  the  fissure  of  liolando.  Amnion's 
horn,  and  cerebellum),  and  air-dry.  The  smear  is 
fixed  in  methyl  alcohol  for  five  minutes.  The  stain  is 
added  to  distilled  water,  which  has  previously  been 
made  alkaline  by  the  addition  of  one  drop  of  a  one-per- 
cent, solution  of  potassium  carbonate  to  each  10  c.c.  of 
the  water.  The  stain  is  used  in  the  proportion  of  one 
part  of  stain  to  one  part  of  the  slightly  alkaline  water. 
This  solution  is  poured  over  the  fixed  smear  at  once, 
and  allowed  to  stand  from  one-half  to  three  hours, 
but  a  longer  time  brings  out  the  structure  better. 
The  stain  is  washed  off  in  running  tap  water  from  one 
to  three  minutes,  and  dried  between  fine  filter  papers. 
In  this  method  of  staining,    the    cytoplasm  of    the 


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REFERENCE    HANDBOOK    <  )!•'    THE    MEDICAL   BCIENI 


Bacteriological  Technique 


"bodies"  stains  blue  and  their  central  bodies  and 
chromatoid  granules  stain  a  blue-red  <ir  azure. 

Giemsa's  slain  has  been  used  extensively  to  bring 
out  the  Treponema  pallidum,  in  the  examination  oil 
material  from  syphilitic  lesions.  Film  preparations 
are  prepared  and  fixed  in  absolute  alcohol  tor  fifteen 
or  twenty  minutes,  then  dried  with  filter  paper.  The 
technique  is  continued  in  practically  the  same  manner 
as  mentioned  above  in  the  staining  of  "  Negri  bodies," 

but.  the  staining  solution  should  not  be  left  on  the 
film  more  than  fifteen  minutes.  It  is  then  washed, 
dried  between  filter  papers,  and  mounted  in  balsam. 
The  Treponema  pallidum  takes  somewhat  of  a  Eainl 
reddish  tint,  while!  lie  frequently  associated  Treponema 

refringena   takes   a   bluish    tint    like   other   organisms. 

Goidhorn's  Modification. — Goldhorn  has  prepared  a 
polychrome-methylene-blue  eosin  stain  which  gives 
excellent  results  in  the  staining  of  film  preparations 
of  the  Treponema  pallidum.  This  stain  has  the  ad- 
vantage of  being  easily  and  quickly  made.  The  met  hod 
is  as  follows:  Dissolve  two  grams  of  lithium  carbonate 
in  200  r.c.  of  water  and  add  two  grains  methylene 
blue  (Merck's  medicinal,  (iriibler's  B.X.,  or  Koch's 
rectified).  Moderately  heat  the  mixture  in  a  rice 
boiler  until  a  rich  polychrome  is  formed  -this  is 
recognized  by  a  distinct  red  coloration  of  the  fluid. 
Allow  to  cool  gradually,  and  then  remove  the  un- 
dissolved residue  by  filtering  through  cotton.  To 
one-half  of  the  alkaline  filtrate  add  sufficient  live-per- 
cent, acetic-acid  solution  to  give  a  distinct  acid  reac- 
tion recognized  by  a  red  color  above  the  line  of  discol- 
oration on  the  litmus  test  paper.  The  other  half  is 
now  added  to  bring  the  whole  back  to  a  slight  degree 
of  alkalinity.  A  one-half-per-cent.  solution  of  French 
eosin  is  gradually  added,  stirring  until  a  filtered  sample 
shows  a  pale  bluish  color  with  slight  fluorescence. 
Allow'  to  stand  one  day,  then  filter  through  a  double 

Eiece  of  filter  paper  to  collect  the  precipitate  which 
as  formed.  Dry  the  precipitate  on  the  filter  paper 
at  room  temperature.  When  thoroughly  dry,  the 
precipitate  is  removed  from  the  filter  paper  and  dis- 
solved in  commercial  wood  alcohol.  The  alcoholic 
solution  is  allowed  to  stand  for  one  day  in  an  open 
vessel,  then  the  insoluble  residue  is  removed  by  filtra- 
tion.    The  stain  is  now  ready  for  use. 

The  staining  technique  is  as  follows:  Smears  of 
serum  or  blood  from  freshly  curetted  lesions  are  made 
upon  clean  slides.  To  the  unfixed  preparation  add 
sufficient  stain  to  cover  well,  allow  the  dye  to  act  for 
three  to  four  seconds,  then  pour  off  the  excess.  The 
slide  is  slowly  immersed  in  water  (film  side  down,  to 
keep  free  from  resulting  precipitate)  thus  permitting 
an  interaction  between  the  water  and  the  dye.  It 
is  held  quietly  in  the  water  for  four  to  five  seconds, 
then  moved  about  to  wash  off  excess  of  stain.  Dry 
and  examine  with  oil  immersion.  Treponema  palli- 
dum takes  a  violet  stain,  which  may  be  changed  to  a 
bluish-black  by  adding  Gram's  iodine  solution  for 
fifteen  to  twenty  seconds.  The  regular  staining  re- 
quires only  ten  to  twelve  seconds  for  completion,  thus 
affording  a  good  working  method  for  rapid  laboratory 
diagnosis. 

Stern's  Silver  Impregnation  Stain  for  Treponema 
Pallidum, — Stern  has  succeeded  in  staining  the  Tre- 
ponema pallidum  in  smear  preparations  by  a  silver- 
impregnation  process. 

He  makes  the  stain  by  preparing,  upon  slides, 
smears  of  material  from  syphilitic  lesions,  and  allow- 
ing them  to  air-dry  at  37°  C.  for  some  hours.  The 
fixed  preparations  are  placed  in  a  ten-per-cent. 
silver-nitrate  solution  for  several  hours.  The  solution 
should  be  in  a  colorless  glass  vessel,  and  allowed  to 
stand  in  diffuse  sunlight  during  the  staining  of  the 
specimen.  When  the  preparation  takes  a  certain 
brownish  tone  (easily  recognized  after  some  experi- 
ence) and  shows  a  metallic  sheen,  it  should  be  removed 
from  the  silver  solution.  Wash  thoroughly  with  water, 
dry,  and  prepare  for  examination.      Blood  cells  are 


well  preserved.     They    how  a  delicate  black  contour 

and    certain    fine    granules.      The    spirochetes    lake    a 

deep  black  on  a  pale  brown  or  in  places  a  colorless 
background. 

Ghoreyeb's  Method  for  Staining  the  Treponemata 
in  Smear  Preparation  This  method  ha  bees  rec- 
ommended for  the  demonstration  of  Treponema 
pallidum  in  s ar  preparations,  and  has  the  advan- 
tage  of  giving   fairly   quick  re  till   .     The  following 

Mil u i inns  a i I :  i  I )  one-per-cent.  aqueous  solution 

of  osmic  acid;  (2)  a  freshly  prepared  dilution  (1:100) 
of  liquor  plumbi  subacetatis  in  distilled  watei  3) 
ten-per-cent.  aqueous  solutions  of  sodium  sulphide 

A  thin  smear  is  prepared  and,   without    heat    fixation, 

is  stained   as  follows:  Thirty  seconds   in   the  osmic 

acid  solution;  wash  in  water;  ten  seconds  in  the  lead 
subacetate  solution;  wash  in  water;  ten  seconds  in  the 

sodium     sulphide    solution;    wash    in    water.      The  ,■ 

steps  are  repeated  until  the  smear  has  I n  taken 

through  three  times.  It  is  essential  to  wash  thor- 
oughly after  application  of  each  solution,  otherwise 
a  heavy  precipitate  is  formed.  Finally,  osmic  acid 
solution  is  added  for  thirty  seconds;  wash  thoroughly; 
dry,  and  mount  in  balsam.  The  treponemata, 
bacteria,  and  cellular  detritus  take  a  black  stain  by 
this  method. 

Dirk  Field  Illumination  Method. — Since  the  intro- 
duction of  the  dark-field  microscopical  apparatus  by 
Siedentopf  and  Zsigmondy  in  the  study  of  ultra- 
microscopical  bodies,  more  simplified  methods  have 
appeared  which  are  very  satisfactory.  As  a  result, 
this  apparatus  has  come  into  common  use  in  the 
examination  of  materials  for  those  organisms  which 
possess  poor  staining  properties  and  a  low  index  of 
refraction.  Recently,  this  means  of  examination 
has  been  applied  in  particular  to  the  Treponemata, 
especially  to  the  pallidum  in  fluids  from  luetic  lesions. 
For  such  an  examination,  the  external  lesion  is 
first  cleansed  and  dried;  a  drop  or  more  of  physiological 
salt  solution  is  applied,  and  mixed  with  the  exudate 
with  a  stiff  platinum  loop;  a  large  loopful  is  removed 
and  placed  on  a  clean  glass  slide,  then  covered  with  a 
glass  cover-slip.  The  examination  is  made  at  once  by 
means  of  the  dark  field  apparatus  in  the  regular  way. 
In  such  a  preparation  the  background  is  dark,  while 
the  living  organisms  are  brightly  illuminated. 

Staining  of  Sections. — In  order  to  study  the  finer 
distribution  of  bacteria  and  certain  protozoa  in  the 
body  of  an  infected  subject  it  is  necessary  to  harden 
portions  of  the  different  tissues  and  organs,  which  are 
then  cut  up  into  sections.  The  tissue  may  be  cut 
by  the  aid  of  a  freezing  microtome,  but  the  best 
results  are  obtained  when  the  material  is  embedded 
in  celloidin  or  in  paraffin.  The  latter  is  especially 
to  be  recommended.  The  methods  which  are  used 
for  this  work  are  essentially  histological,  and  need  not 
be  considered  in  this  connection. 

Staining  of  Bacteria  in  Tissues. — To  obtain  a  simple 
stain  for  bacteria  the  section  is  placed  in  the  dilute 
aniline  dye  for  about  five  minutes.  Dilute  carbolic 
fuchsin  or  carbolic  methylene  blue  is  very  good  for 
this  purpose.  It  is  then  washed  thoroughly  in  water 
and  transferred  to  very  dilute  acetic  acid  (1  c.c.  of 
glacial  acetic  acid  to  1,000  c.c.  of  water).  The 
section  is  now  placed  in  strong  alcohol  for  one-half  to 
one  minute  to  remove  the  excess  of  dye.  After 
washing  in  water  it  may  be  examined,  and  if  the 
decoloration  has  not  been  sufficient,  the  treatment. 
with  alcohol  can  be  repeated.  When  properly 
differentiated  the  section  is  placed  for  a  few  seconds 
in  absolute  alcohol  for  dehydration,  then  cleared  in 
oil  of  cloves,  passed  through  xylol,  and  mounted  in 
Canada  balsam. 

In  Kiihne's  method  the  sections  are  stained  in 
carbolic  methylene  blue  and  differentiated  in  one-half 
per  cent,  hydrochloric  acid,  rinsed  in  dilute  lithium- 
carbonate  solution,  then  in  water.  The  section  is 
transferred    to    absolute    alcohol,    which    is    slightly 

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REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


colored  with  methylene  blue  for  one-half  minute; 
then  for  a  few  minutes  to  aniline  oil  containing  methy- 
lene blue,  finally  into  clear  aniline  oil,  turpentine, 
xylol,  and  balsam. 

"  Nicolle  stains  the  sections  in  carbolic  thionin. 
washes  in  water  for  about  a  minute,  dehydrates  with 
absolute  alcohol,  clears  up  in  oil  of  cloves,  and  mounts 
in  balsam.  Another  procedure  employed  by  him  is  to 
stain  first  with  Loffler's  methylene  blue,  differentiate 
in  one-half  per  cent,  acetic  acid,  and  fix  in  ten-per- 
cent, solution  of  tannin  for  a  few  seconds.  The 
section  is  then  washed,  dehydrated,  cleared,  and 
mounted. 

Gram's  stain  is  applied  to  sections  in  the  following 
manner:  The  section  is  placed  in  the  freshly  prepared 
aniline-water  gentian  violet  for  about  ten  to  fifteen 
minutes,  after  which  it  is  washed  in  water,  or  better  in 
aniline  water,  to  remove  the  excess  of  dye.  The 
section  is  then  placed  in  Lugol's  iodine  for  three  to 
five  minutes,  transferred  to  absolute  alcohol,  in  which 
it  is  tilted  about  until  the  excess  of  the  stain  has  been 
removed  and  only  a  pale  violet  color  remains.  Eb- 
ner's  solution  may  also  be  used  for  decolorizing.  It  is 
eounterstained  in  very  dilute  eosin  for  about  a 
minute,  washed  in  water,  dehydrated  in  absolute 
alcohol,  cleared  in  cloves,  and  mounted. 

Bismarck  brown  may  be  used  for  a  contrast  color, 
or  Weigert's  picrocarmine.  The  latter  may  be  made 
by  adding  1  part  each  of  carmine  and  ammonia  to 
50  parts  of  water;  to  this  solution  picric  acid  is  added 
until  a  precipitate  forms  which  is  dissolved  by  the 
addition  of  a  little  ammonia;  finally  a  few  drops  of 
carbolic  acid  are  added. 

Tubercle  and  leprosy  bacilli  can  be  stained  in  sections 
by  applying  the  principle  employed  for  cover-glass  pre- 
parations. The  carbolic  fuchsin  should  be  warmed 
to  about  40°  C.  in  a  Petri  dish.  The  sections  remain 
in  this  solution  for  fifteen  to  thirty  minutes,  after 
which  they  are  washed  in  water  to  remove  the  excess 
of  dye.  They  are  then  decolorized  in  dilute  acid,  or 
better  in  Ebner's  solution.  The  latter  consists  of 
one-half  part  each  of  sodium  chloride  and  hydro- 
chloric acid,  30  parts  of  water,  and  100  parts  of 
alcohol.  The  faint  pink  sections  are  then  placed  in 
Loffler's  methylene-blue  solution  for  about  half  a 
minute,  after  which  they  are  dehydrated  in  absolute 
alcohol  for  a  few  seconds,  transferred  to  xylol,  and 
mounted  in  balsam. 

Staining  of  Treponema  pallidion  in.  Tissues. — Sev- 
eral methods  have  been  used  for  the  demonstration  of 
the  Treponema  pallidum  in  section,  but  that  most 
commonly  used  is  the  first  method  of  Levaditi. 
This  method  is  essentially  a  modification  of  Ramon  y 
Cajal's  method  for  the  silver  impregnation  of  nerve 
fibrillar.  Levaditi  proceeds  as  follows:  Small  pieces 
of  tissue  about  one  millimeter  in  thickness  are  "fixed'' 
in  ten-per-cent.  formol  for  twenty-four  hours.  Wash 
and  harden  in  ninety-six-per-cent.  alcohol  for  twenty- 
four  hours.  Remove  and  wash  in  distilled  water  until 
the  tissue  sinks  in  the  water.  Impregnate  with 
silver  by  placing  in  a  solution  of  1.5  to  3.0  per  cent,  of 
silver  nitrate,  and  keeping  at  a  temperature  of  3S°C. 
for  three  to  five  days.  When  taken  out  the  tissue  is 
quickly  washed  in  "distilled  water,  and  placed  in  the 
following  silver  reducing  solution:  Pyrogallic  acid, 
two  to  four  grams.;  formol,  5  c.c.;  distilled  water,  100 
c.c.  Allow  to  stand  in  the  reducing  solution  at  room 
temperature  from  twenty-four  to  forty-eight  hours. 
Remove  and  wash  in  distilled  water,  dehydrate  in  ab- 
solute alcohol;  xylol;  embed  in  paraffin,  and  cut  in 
sections  not  more  than  five  microns  in  thickness. 
The  tissues  may  be  eounterstained  by  the  Giemsa  mix- 
ture, or  by  toluidin  blue,  then  cleared  and  dehydrated 
by  the  regular  histological  method.  In  either  case, 
the  spirochetes,  in  a  well-stained  section,  should 
appear  almost  black  in  color. 

While  the  method  just  given  is  longer,  it  is  perhaps 
more  reliable  than  the  later  modification  by  the  same 


author.  In  the  second  method  the  tissue  in  thin 
pieces  is  fixed  in  ten-per-cent.  formol  for  twenty-four 
to  forty-eight  hours,  then  hardened  in  ninety-six-per 
cent,  alcohol  for  twelve  to  sixteen  hours;  removed  and 
washed  in  distilled  water.  Impregnate  at  room 
temperature  from  two  to  three  hours,  then  at  a 
temperature  of  about  50°  C.  from  four  to  six  hours, 
in  a  solution  compound  of  silver  nitrate  one  per  cent.; 
pyridin,  ten  per  cent,  (added  just  before  using); 
distilled  water,  100  c.c.  During  the  process  of 
impregnation,  the  solution  should  be  kept  in  a 
well-stoppered  flask.  Remove  tissue  and  rapidly 
wash  in  a  ten-per-cent.  pyridin  solution.  Reduce  the 
silver  in  tissue  by  placing  in  a  solution  compound  of 
pyrogallic  acid,  four  per  cent,  (added  just  before 
using);  acetone  (purest),  ten  percent.;  pyridin,  fif- 
teen per  cent.;  distilled  water  for  100  c.c.  The  re- 
duction is  completed  after  a  few  hours.  Harden  in 
alcohol,  xylol,  paraffin,  section.  The  advantage  of 
this  method  over  the  former  lies  in  the  compara- 
tively short  time  in  which  it  may  be  performed. 
But  generally  it  does  not  give  as  uniformly  good  re- 
results  as  the  first  method. 

Diagnostic  Methods. — The  general  principles 
which  have  been  given  find  their  practical  application 
in  the  diagnosis  of  disease.  It  is  desirable,  therefore, 
to  indicate  briefly  the  way  in  which  these  methods  are 
applied. 

1.  Aclinoynycosis  (streptothricosis). — This  condition 
is  not,  as  was  first  supposed,  due  to  one  definite 
organism,  but  to  several  closely  related  species. 
Culture  and  staining  characteristics  aid  in  differen- 
tiation. Some  species  take  the  "acid-fast"  stain, 
while  others  do  not.  The  pus  should  be  examined 
unstained  under  a  cover-glass  for  the  characteristic 
yellowish,  radiating  masses  with  club-shaped  threads 
along  the  border.  Permanent  preparations  may  be 
made  by  making  smears,  and  staining  either  by  the 
simple  or  by  the  Gram  method.  The  pus  may  be 
hardened  in  mercuric  chloride,  sectioned,  and  stained 
by  Gram.     Curettings  may  be  treated  in  like  manner. 

2.  Anthrax. — Cover-glass  smears  of  the  blood, 
fluid  from  vesicles,  or  scraping  from  pustules  are 
stained  by  the  simple  and  by  the  Gram  method. 
Confirmation  of  the  nature  of  the  organism  found  can 
be  obtained  by  inoculating  a  white  mouse  or  a  guinea- 
pig  subcutaneously  with  the  material.  This  with  the 
cultural    characteristics    will    enable     identification. 

3.  Bubonic  Plague. — This  diagnosis  may  be  made 
during  life,  but  more  often  after  death.  In  the  pneu- 
monic form  the  blood-streaked  sputum  can  be  used  for 
simple  stains,  which  will  show  large  numbers  of  the 
small  rods.  In  the  bubonic  type  the  enlarged  gland 
may  be  punctured  and  thus  material  obtained  for  ex- 
amination. The  detection  of  the  bacillus  in  the  blood 
can  be  effected  by  drawing  several  cubic  centimeters 
of  the  blood  from  a  vein  by  means  of  a  syringe. 
Agar  plates,  one  part  of  blood  to  two  parts  of  agar, 
should  then  be  made.  Whether  the  result  is  ap- 
parently positive  or  wholly  negative,  an  animal  ex- 
periment must  be  carried  out.  The  suspected 
material  is  inoculated  subcutaneously  into  a  guinea- 
pig,  and  if  plague  bacilli  are  present,  death  will  ensue 
in  from  five  to  eight  days.  Cultures  and  smears  from 
the  animal  will  then  establish  the  nature  of  the  or- 
ganism. An  important  cultural  characteristic  is 
brought  out  by  planting  the  material  on  agar  con- 
taining about  three  per  cent,  of  salt.  Round  or  pear- 
shaped  involution  forms  develop.  The  smears  from 
the  body  should  be  stained  with  Loffler's  methylene 
blue  or  with  carbolic  thionin.  The  short  rods  take 
the  bipolar  stain,  and  if  the  material  is  old,  roundish 
involution  forms  or  "doughnuts"  will  be  met  with. 
The  bacilli  are  not  stained  by  Gram. 

4.  Cholera. — The  examination  may  aim  to  find  the 
cholera  vibrio  in  the  drinking-water,  or  it  may  be  con- 
cerned with  the  diagnosis  of  the  disease.     In  the  latter 


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Bacteriological  Technique 


case  the  rice-water  discharges  should  be  collected  and 
searched  for  mucous  Bakes.  Preparations  from  these 
when  stained,  will  show  the  appearance  of  the  charac- 
teristic vibrio.  The  appearance  of  the  colonies  on 
gelatin  and  on  agar  plates,  the  growth  in  lionilK.ii.  and 
the  indol  reaction  serve  to  identify  the  organism. 
The  agglutination  test  will  differentiate  the  true 
cholera  organism  from  the  cholera-like  vibrios  which 
are  not  infrequently  present  in  suspected  materials. 
The  intraperitoneal  injection  of  the  culture  into  a 
guinea-pig  may  also  he  practised.  The  Pfeiffer 
reaction  may  be  carried  out.  It  consists  in  injecting 
into  the  peritoneal  cavity  of  a  guinea-pig  a  mixture 
of  the  cholera  antiserum  ami  the  suspected  organism. 
Every  few  minutes  a  drop  of  fluid  is  withdrawn  from 
the  peritoneal  cavity  by  means  of  a  capillary  tube  and 
examined.  If  the  organisms  persist,  it  is  safe  to  say 
that  they  are  not  those  of  true  cholera.  The  latter 
under  these  conditions  lose  motion,  become  granular, 
and  soon  disappear. 

It  may  be  possible  under  exceptional  circumstances 
to  detect  the  cholera  vibrio  in  drinking-water  by 
ordinary  plating  on  gelatin.  Obviously  the  number 
of  the  organisms  may  be  so  small  and  the  other 
bacteria  may  be  so  numerous  that  it  is  impossible  to 
obtain  positive  results  by  this  method.  To  overcome 
this  difficulty  Schottelius  devised  an  enriching  method. 
This  consists  in  adding  the  suspected  water  to  a  one- 
per-cent.  solution  of  peptone  and  incubating  at 
37°  C.  for  about  twelve  hours.  The  actively  motile 
cholera  spirilla,  on  account  of  their  need  of  oxygen, 
accumulate  as  a  cloudy  layer  near  the  surface.  A 
loop  of  this  liquid  is  then  transferred  to  and  spread 
over  the  surface  of  gelatin  and  agar  plates,  and  the 
further  identification  is  then  easily  effected.  Obvi- 
ously the  peptone  may  be  added  direct  to  the  water. 
for  example  100  c.c,  and  in  this  way  the  presence  of  a 
very  few  vibrios  in  a  large  volume  of  water  may  be 
detected. 

Dieudonne's  alkaline  blood  agar  is  a  valuable 
selective  medium,  and  ma}'  be  used  in  connection  with 
the  other  media. 

5.  Diphtheria. — The  necessary  material  for  the 
examination  is  obtained  by  means  either  of  a  Roux 
spatula  (Fig.  577)  or  by  a  cotton  swab.  The  cotton 
swab  is  usually  employed,  and  is  made  by  twisting  a 
piece  of  cotton  about  the  end  of  a  thick  iron  wire. 
The  wire  should  be  about  six  inches  long.  The 
cotton  end  is  then  placed  in  a  plugged  test-tube 
which  is  sterilized  by  dry  heat.  Whether  a  pseudo- 
membrane  is  present  or  not,  scrapings  are  made  from 
the  surface  of  the  affected  tonsils  or  throat  and  ex- 
amined. Usually  the  swab  is  streaked  over  the  sur- 
face of  one  or  more  tubes  of  plain  or,  better,  LofHer's 
serum.  These  tubes  are  incubated  over  night  and 
examined  in  the  morning  for  the  characteristic 
diphtheria  bacilli.  The  cover-glass  preparations 
made  from  these  cultures  are  stained  with  LofHer's 
methylene  blue.  The  swollen  rods  with  irregularly 
stained  contents  are  easily  identified.  In  case  there  is 
any  doubt  as  to  the  diagnosis,  it  is  advisable  to  inocu- 
late a  guinea-pig  with  the  culture  material.  A  control 
inoculation  is  made  into  a  second  guinea-pig  which 
receives,  in  addition,  a  small  injection  of  antidiph- 
theritic  serum.  If  the  control  animal  lives  while  the 
other  dies  a  virulent  diphtheria  infection  is  indicated. 

Whenever  possible  it  is  advisable  to  make  cover- 
glass  preparations  direct  from  the  false  membrane. 
These  are  then  stained  with  LofHer's  methylene  blue. 
The  diagnosis  can  thus  often  be  made  in  a  few- 
minutes. 

6.  Dysentery. — It  is  necessary  to  distinguish  be- 
tween two  types,  the  bacillary  and  the  amebic. 
The  examination  for  amebas  should  be  made  at 
once,  immediately  after  the  stool  is  passed,  in  order  to 
obtain  activel}'  motile  organisms.  A  drop  of  the 
thin  feces  or  suspension  is  placed  on  a  slide,  covered 
with  a  cover-glass,  and  examined  under  the  micro- 


scope.     The  characteristic  motion  will  leave  no  doubt 

the  nature  of  tin-  organism.     The  motion  ca 
observed    b  le  or   in    an    incubator. 

staining  is  not  necessary. 

The  bacillary  fori: 

and     the    diagnosis    of    this    typt  the 

i  ion  of  the  organism.     Make  lactose-litmus  agar 

plates     from    feces    and    develop    at     .'.I'    ( '.      B. 
colonies    may    be  excluded   by   their  acid   formation. 
Froml s  which  develop  after  twenty- 

four  hours,  subcultures  should  be  made   upon  glui 

agar,  mannite-litmus  agar,  etc.,  for  differentiation. 
Those  which  cause  lui^  formation  in  glucose  agar 
may  be  rejected.  The  pure  culture-,  should  filially 
ested  for  agglutination  with  the  specific  serum. 
Too  much  cat  ■  r.    cannot    be   exercised    in 

drawing  conclusions  based  upon  a  positive  aggluti- 
nation reaction,  since  tins  tesl  is  undoubtedly  given 

by  allied  organisms. 

7.  Gonorrht  ". — Cover-glass  preparations  made  from 
the  pus  will  serve  to  establish  I  lie  diagnosis  in  nearly 
all  instances.     They  should  be  stained  with  Ldfl 

methylene  blue.  A  fair  double  stain  can  be  ob- 
tained by  first  applying  eosin,  after  which  the  blue  can 
be  used  for  a  few  seconds.  The  result  i-  a  more  or  less 
pink  background  with  blue  gonococci.  '.rain's 
method  is  negat ive. 

Von  Wahl  recommends  the  following  method  of 
double  staining  which  brings  out  the  gonococci  as 
reddish-violet  to  black  cells  on  a  light  green  back- 
ground. The  stain  consists  of:  Concentrated  alco- 
holic solution  of  auramin,  2  c.c;  ninety-five-per-cent. 
alcohol,  1.5  c.c;  concentrated  alcoholic'  solution  of 
thionin,  2  c.c;  concentrated  aqueous  methyl  green, 
3  c.c;  water,  6  c.c.  The  auramin  and  thionin  solu- 
tions are  prepared  by  dissolving  the  dyes  in  hot 
ninety-five-per-cent.  alcohol  to  saturation,  cooling, 
and  filtering.  The  cover-glasses  are  stained  for  ti\e 
to  fifteen  seconds.  The  ordinary  bacteria  stain 
feebly  or  not  at  all. 

The  detection  of  the  gonococcus  in  septicemic 
can  be  accomplished  by  drawing  5  to  In  c.c.  of  blood 
from  the  vein  of  the  arm  and  adding  this,  in  about 
equal  parts,  to  melted  agar  at  45°  C.  The  mixture  is 
at  once  poured  into  Petri  dishes,  and  these  are  de- 
veloped at  37°  C.  In  this  way  the  gonococcus  can  be 
detected  when  stains  would  fail  to  show  the  organism. 

The  culture  test  for  the  gonococcus  is  rarely  re- 
sorted to  on  account  of  the  difficulty  of  obtaining  the 
necessary  blood  or  serous  fluids.  The  ordinary 
media  have  always  been  regarded  as  unfavorable  for 
the  growth  of  this  organism.  According  to  Thal- 
mann,  Wildbolz,  and  others,  the  gonococcus  can  be 
grown  on  ordinary  one-and-one-half-per-cent.  meat- 
peptone  agar.  Thalmann  recommends  very  highly 
such  a  medium  for  diagnostic  purposes,  and  especially 
when  direct  microscopic  examination  is  unsatis- 
factory or  negative.  The  acidity  of  ordinary  agar  or 
bouillon  is  reduced  by  the  addition  of  two-thirds  of 
the  amount  of  alkali  necessary  to  make  the  media 
neutral  to  phenolphthalein.  The  preparation  of 
these  media  has  been  given. 

S.  Leprosy. — The  leprous  nodules  are  characterized 
by  the  presence  of  enormous  numbers  of  the  specific 
bacillus  which  can  be  readily  detected  by  staining. 
The  Ziehl-Neelsen  method,  as  employed  for  the 
tubercle  bacillus,  will  give  excellent  results  if  the 
tissue  is  reasonably  fresh.  When  kept  for  Mime  time 
in  alcohol  the  bacilli  lose  their  staining  properties  ><> 
far  as  this  method  is  concerned,  but  they  can  .-till  be 
found  by  means  of  Gram's  method.  Duval  has 
cultivated  an  organism  directly  from  human  leprous 
tissue  which  he  considers  to  be  B.  lepra.  Fortius 
purpose  special  artificial  media  are  used.  He  has  in- 
fected such  animals  as  the  Japanase  dancing  mouse, 
guinea-pig.  and  the  monkey  (Macacus  rltcsus)  with 
the  cultures  grown  on  artificial  media. 

9.  Cerebrospinal  Meningitis. — The  Diplococcus   in- 

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Bacteriological  Technique 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


tracellularis  meningitidis  is  found  in  the  cerebro- 
spinal fluid.  Hence  during  life  it  is  necessary  to  re- 
move some  of  the  fluid  by  lumbar  puncture.  This 
fluid  should  be  planted  abundantly  on  glycerin,  or 
better  on  serum  agar.  Cover-glass  preparations 
made  direct  will  show  the  typical  organism  resembling 
the  gonococcus  in  form  and  in  its  presence  within  the 
leucocytes.  It  is  not  stained  by  Gram's  method,  but 
can  be  given  a  double  stain  by  that  of  Pick  and  Jacob- 
sohn,  or  by  the  modification  suggested  by  Fraenkel. 
The  dye  is  made  by  adding  to  20  c.c.  of  water  eight 
drops  of  a  saturated  solution  of  methylene  blue,  and 
then  forty  to  fifty  drops  of  carbolic  fuchsin.  The 
dye  is  allowed  to  act  for  five  minutes.  The  cocci 
are  blue  on  a  red  background. 

10.  Pneumonia. — In  all  pneumonic  conditions  the 
blood-streaked  sputum  should  be  examined  by  making 
simple  and  Gram  stains.  In  this  way  it  becomes 
possible  to  recognize  the  pneumonic  form  of  plague. 
Ordinarily,  however,  pneumonia  is  due  to  the  Fraen- 
kel diplococcus  and  at  times  to  the  Friedliinder 
pneumobacillus.  The  form,  staining,  and  cultural 
properties  of  these  organisms  permit  ready  differentia- 
tion and  identification.  The  lance-shaped  diplo- 
coccus of  Fraenkel,  as  found  in  the  body,  is  surrounded 
by  a  capsule,  and  is  stained  by  Gram's  method.  The 
colonies  and  cultures  on  glycerin  agar  are  very  faint 
and  dewdrop  like,  and  tend  to  die  out  in  a  few  days. 
Their  vitality  and  virulence  are  best  preserved  by 
cultivating  them  on  rabbit  blood  or  serum  agar. 
Calcium  broth  may  be  used  for  the  same  purpose.  In 
doubtful  cases  the  material  should  be  injected  under 
the  skin  of  the  ear  of  a  rabbit  or  subcutaneously  in 
white  mice.  If  death  results  the  diplococcus  will  be 
found  in  large  numbers  in  the  heart  blood  and  organs 
of  the  animal. 

11.  Rabies. — The  cause  of  this  disease  is  as  yet 
unknown,  but  it  is  to  be  found,  in  pure  condition  so 
to  speak,  in  the  brain  and  spinal  cord  of  the  affected 
person  or  animal.  The  diagnosis  rests  upon  animal 
inoculation  with  such  material.  A  few  drops  of  a 
suspension  of  the  brain  or  cord  are  injected  subdurally 
into  a  rabbit  or  guinea-pig.  The  method  has  been 
already  described. 

The  histological  changes  in  the  nervous  system  are 
very  slight,  and  it  has  been  suggested  that  the  diag- 
nosis of  rabies  may  be  hastened  by  making  an  examina- 
tion of  sections  of  the  cord  and  ganglia.  The  lesions 
are  not  sufficiently  marked  in  all  cases  to  permit 
diagnosis,  and  for  that  reason  this  method  should  not 
be  relied  upon  to  the  exclusion  of  the  only  positive 
test,  that  of  animal  inoculation. 

The  work  of  Williams  upon  "Negri  bodies"  has 
called  attention  to  the  fact  that  a  rapid  diagnosis 
may  be  made  from  smear  preparations  of  the  brains 
oi  animals  which  have  suffered  from  rabies.  After  a 
long  series  of  observations,  both  clinical  and  experi- 
mental, the  Department  of  Health  of  New  York  City 
has  adopted  this  method  of  diagnosis.  Their  present 
method  of  procedure  is  as  follows:  Make  smear 
preparations  from  the  cortex  taken  from  the  region 
corresponding  to  the  fissure  of  Rolando,  Amnion's 
horn,  and  the  cerebellum.  Fix  the  smears  while 
moist  in  a  solution  composed  of  methyl  alcohol  (pre- 
viously neutralized  with  sodium  carbonate)  containing 
one-tenth  of  one  per  cent,  of  picric  acid.  After  allow- 
ing to  act  about  one  minute,  pour  off  the  fixing  fluid, 
and  blot  with  fine  filter  paper. 

The  stain  is  prepared  by  adding  five  drops  saturated 
alcoholic  solution  of  methylene  blue,  and  one  drop 
saturated  alcoholic  solution  of  basic  fuchsin,  to  10  c.c. 
distilled  water.  This  should  be  freshly  prepared  just 
before  using.  Pour  stain  on  slide;  warm  until  it 
steams;  pour  off;  rinse  smear  in  water;  blot  and  allow 
to  dry.  Upon  examination  under  the  oil-immersion 
lens,  the  "Negri  bodies"  will  be  found  in  the  nerve 
cells;  some  also  are  free.  The  cytoplasm  of  the 
"bodies"  takes  a  distinctive  red  color;  their  inner 


structures  a  dark  blue.  The  nerves  are  light  blue, 
and  the  blood  cells  a  pale  salmon-red.  At  room  tem- 
perature this  stain  is  not  permanent,  but  it  has  the 
advantage  of  being  a  very  rapid  method  for  the  diagno- 
sis of  rabies.  If  "Negri-bodies"  are  not  found  by  this 
method  of  examination,  some  of  the  brain  tissue  of 
the  suspect  animal  is  then  inoculated  into  guinea-pigs 
by  the  regular  procedure,  as  a  further  aid  in  diagnosis. 

12.  Tetanus. — The  point  of  inoculation  must  be 
found  first.  This  may  not  always  be  easy,  for  the 
original  wound  may  have  healed  over.  The  portal 
of  entry  may  be  a  bad  tooth,  or  the  wound  produced 
by  an  old  rusty  nail,  a  splinter  of  wood,  or  the  powder 
grains  of  a  pistol.  Cover-glass  preparations  should 
be  made  from  the  pus,  if  there  is  any;  and,  if  not, 
from  such  serum,  blood,  or  tissue  as  can  be  obtained 
from  the  wound.  They  should  be  stained  with 
carbolic  fuchsin.  The  specimen  should  be  examined 
for  "drum  sticks"  or  rods  with  terminal  spores,  and 
particularly  for  the  presence  of  rather  narrow,  long 
bacilli.  These  are  present  even  when  no  spores  can 
be  found. 

Cultures  should  be  made  on  glucose  litmus  gelatin, 
and  at  the  same  time  a  series  of  glucose  agar  plates 
should  be  made  and  developed  at  37  C°.,  either  in  hy- 
drogen or  in  the  pyrogallate  apparatus.  The  original 
tissue  should  be  planted  under  the  skin  of  a  white 
mouse  and  of  a  guinea-pig.  The  cultures  when 
developed  are  carefully  searched  for  the  'drum-stick 
forms. 

13.  Tuberculosis. — The  pulmonary  form  is  usually 
recognized  by  an  examination  of  the  sputum,  prefer- 
ably that  which  has  been  collected  in  the  morning  on 
rising.  The  cheesy  particles,  if  such  can  be  recog- 
nized, should  be  picked  out  by  means  of  the  wire  and 
spread  over  the  cover-glass.  The  specimen  is  then 
stained  either  by  the  Ziehl-Neelsen  or  the  Herman 
method.  The  organisms  if  present  are  readily  recog- 
nized by  their  contrast  color  against  the  counter- 
stained  background. 

The  same  method  is  employed  in  the  examination 
of  pleuritic  fluid,  pus,  urine,  milk,  etc.  In  all  these 
examinations,  however,  two  facts  should  be  borne  in 
mind.  In  the  first  place  the  tubercle  bacilli  may  be 
present,  but  in  such  small  numbers  that  they  escape 
detection.  Again,  acid-resisting  organisms,  such  as 
the  leprosy,  smegma,  timothy-grass  bacillus,  etc., 
may  be  present,  and  may  be  easily  mistaken  for  the 
tubercle  bacillus. 

In  either  case  it  is  the  animal  experiment  which  will 
serve  to  remove  the  doubt.  When  the  tubercle 
bacilli  are  few  or  doubtful,  it  is  well  to  submit 
the  material  to  preliminary  centrifugation;  or  first 
subject  the  material  to  antiformin  digestion.  This 
preparation  consists  of  a  strongly  alkaline  solution 
of  chlorinated  soda,  which  has  the  power  to  dis- 
solve such  substances  as  mucus,  animal  cells  fibers, 
etc.,  also  most  bacteria  other  than  those  which  are 
acid-fast.  In  the  case  of  sputum,  good  results  may 
be  had  by  mixing  equal  parts  of  sputum  with  thirty 
per  cent,  of  the  antiformin,  and  digesting  at  room 
temperature  for  one  hour.  Centrifuge,  and  decant  the 
supernatant  fluid  from  the  sediment.  The  sediment 
is  washed  with  sterile  distilled  water,  and  again  cen- 
trifuged;  the  sediment  may  be  stained  for  the  tubercle 
bacillus  or  injected  into  a  guinea-pig.  If  the  anti- 
formin digestion  is  permitted  to  continue  too  long, 
the  tubercle  bacillus  loses  some  of  its  staining  ability, 
also  its  viability.  The  injections  should  be  made 
subcutaneously  into  the  guinea-pig.  If  tubercle  bacilli 
are  present  in  the  material  used,  even  if  so  scarce  as 
to  be  unrecognized  by  the  microscope,  the  animal 
will  develop  the  disease  and  will  die  in  the  course  of  a 
month  or  two.  The  tuberculous  organs  and  glands  can 
be  examined  then  for  tubercle  bacilli,  and  cultures 
can  be  made  on  glycerin  agar,  potatoes,  and  on  either 
Dorset  or  Lubenau  egg  medium.  Hesse's  Heyden 
agar  also  proves  quite  satisfactory  for  isolating  the 


920 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCI] 


Bacteriological  TeduUqae 


tubercle  bacillus  from  sputum..  The  acid-resisting 
bacilli,  other  than  the  tubercle  bacillus,  are  not  fatal 
to  animals,  and,  moreover,  the  histological  changes 
which  they  induce  are  quite  different  from  those  cau  ed 
by  the  tubercle  bacillus. 

14.  Typhoid  F<  ver. — The  verification  of  the  diagno- 
sis is  usually  ma<ic  by  means  of  the  agglutination  te  I 

of   Widal,   which   will   be  described   later.      The  direct 

detection  of  the  typhoid  bacillus  in  feces,  urine, 
blood,  rose  spots,  and  in  water  presents  marked 
difficulties.  The  reason  for  this  lies  in  the  very  great 
similarity  which  e\i-ts  between  the  typhoid  and  the 
colon  bacillus.  Numerous  methods  have  1 n  de- 
vised for  the  purpose  of  effecting  a  distinction  be- 
tween these  two  organisms;  and  while  it  is  an  easy 
matter  to  differentiate  between  the  pure  culturesof 
the  typical  organisms  it  becomes  vastly  more  difficult 
under  natural  conditions,  especially  when,  as  often 
is  the  case,  the  paracolon  and  paratyphoid  bacilli  are 
present. 

Some  of  these  methods  endeavor  to  restrict  the 
growth  of  the  colon  and  of  adventitious  bacteria  by 
the  addition  of  antiseptic  substances  to  the  on 
Thus  carbolic  bouillon,  Parietti's  carbolic  hydro- 
chloric-acid broth,  malachite-green  agar,  and  crystal 
violet  are  used  with  this  object  in  view,  but  there  can 
be  no  doubt  that  weak  typhoid  bacilli  are  also 
inhibited. 

Other  methods  are  based  upon  the  unequal  diffu- 
sion of  the  two  organisms  in  special  media.  The 
Stoddart,  Hiss,  and  Capaldi  media  belong  to  this  class. 
Again,  the  effort  is  made  to  bring  out  differences  be- 
tween the  colonies  of  the  Eberth  and  colon  bacilli,  as 
in  the  case  of  the  Holz  potato  gelatin,  Eisner,  Weil, 
Hiss,  and  Piorkowski  media.  These  are  all  described 
in  the  foregoing  pages.  Still  other  methods  seek  to 
utilize  the  differences  in  the  fermentative  powers  of 
these  organisms,  as  evidenced  in  the  production  of 
gas,  acid  products,  etc.  Lastly,  there  are  several 
methods  which  have  only  recently  been  devised  in 
which  the  distinction  is  effected  by  means  of  the 
agglutination  reaction.  That  of  Windelbandt,  as 
modified  by  Schepilewsky,  certainly  seems  to  be 
effective  in  detecting  typhoid  bacilli  in  tap  water. 
Its  real  value  in  the  examination  of  typhoid  feces  re- 
mains to  be  demonstrated. 

Schepilewsky 's  procedure  is  as  follows:  Several 
cubic  centimeters  of  the  infected  w-ater  are  added  to 
50  c.c.  of  bouillon  in  an  Erlenmeyer  flask,  which  is 
then  incubated  for  twenty-four  hours  at  37°  C.  The 
culture  is  now  filtered  through  a  sterile  cotton  filter 
in  order  to  remove  any  compact  masses  of  bacteria 
which  may  be  present.  The  filtrate  is  received  in 
conical  centrifugating  tubes.  A  very  active  serum 
from  a  rabbit,  which  has  been  immunized  to  the  ty- 
phoid bacillus,  is  then  added  to  the  cloudy  filtrate, 
and  this  is  set  aside  for  two  or  three  hours  at  37°  C. 
If  many  typhoid  bacilli  are  present,  visible  agglutina- 
tion may  be  noted;  but  if  they  are  not  abundant,  the 
masses  will  be  so  small  that  agglutination  may  not  be 
detected.  In  either  case  the  tubes  are  centrifugated 
for  one  to  two  minutes,  after  which  the  fluid  is  decanted 
and  the  tubes  are  inverted  so  as  to  drain  as  completely 
as  possible.  Sterile  sodium-chloride  solution  is  then 
added  to  the  tubes  and  the  deposit  is  taken  up  and 
transferred  to  a  sterile  test-tube  which  contains  glass 
beads.  By  vigorous  shaking,  the  agglutinated  masses 
can  now  be  broken  up  and  a  homogeneous  suspension 
obtained.  A  glass  rod,  bent  at  right  angles,  is  then 
dipped  in  the  suspension,  and  streaked  thoroughly 
over  the  surfaces  of  a  number  of  plates  of  the  special 
agar.  The  latter  is  three-per-cent.  agar.,  to  which 
after  sterilization  in  an  autoclave  a  lactose  and  lacmoid 
solution  is  added.  This  consists  of  1.5  per  cent, 
lactose  and  0.04  per  cent,  lacmoid,  and  before  addi- 
tion is  boiled  fifteen  minutes.  The  Petri  dishes  are 
developed  at  37°  C.  for  twenty-four  hours.  The 
typhoid  colonies  are  round  or  oval  and  sharp-bordered ; 


later  they  show  the  typical  spreading  form,  and  the 
color  of  the  center  changes  to  a  dirty  yellow. 

The  typhoid-like  a  aould  then  be  examined 

under    the    mici pe    and    submitted    to    further 

identification.  \  suspension  of  the  colony  may  be 
te  ted  foi  the  agglutination  reaction  witn  typhoid 
serum.  Pfeiffer's  reaction  may  be  tested  for  by  in- 
jecting a  mixture  of  antityphoid  serum  and  the  organ- 
ism into  t  he  peritonea]  ca  vity  of  a  gui  i 
scribed  under  Cholera.  The  cultures  should  also  be 
tested  for  nas  production,  indol,  milk  coagulation, 
and  on  the  special  plating  media. 

The  malachite-green  enriching  method  of  Lentz, 
Endo's  fuchsin  agar,  the  Drigalski-Conradi  medium, 
and    MacConkey's    bile-sail    Is  recom- 

mended by  different  workers  for  the  separation  of  the  ■ 

typhoid  bacillus  fr tens.     Perhaps  the  first  named 

medium   gives   the   highesi    percentagi  itive 

results. 

For   the  cultivation   of  the  bacillus   from   patii 
blood,    perhaps   the   ox-bile    medium   of  Coleman   and 
ni  furnishes  the  best    method. 

I  •">.  \  number  of  infections  due  to  moulds  and  allied 
forms  and  also  to  yeast-like  bodies  have  been  de- 
scribe,!. The  former  are  represented  by  the  strepto- 
thrices,  or.  more  correctly,  by  the  actinomyces  of 
Madura  foot  and  of  cattle  farcy.  The  yeast  or  blast o- 
mycotic  affections  have  been  noted  in  certain  forms 
of  dermatitis,  and  may  even  be  systemic  in  charai 
In  all  these  diseases  the  examination  of  the  pus  and 
of  sections  of  t  issue,  as  well  as  the  culture  of  the  organ- 
ism, must  be  carried  out. 

16.  Protozoal  Diseases. — Several  very  important 
diseases  are  due  to  organisms  of  this  class.  The  ex- 
amination for  amebas  in  tropical  dysentery  has  al- 
ready been  touched  upon.  The  sporozoa  include 
among  others  the  Plasmodium  of  malaria,  the  piro- 
plasma  of  Texas  fever,  and  of  horses,  sheep,  and  dogs. 
The  flagellata  cause  the  various  trypanosomatic 
diseases,  such  as  the  surra  of  Asia  anil  of  the  Philip- 
pine Islands,  nagana  or  the  tsetse-fly  disease  of  South 
Africa,  dourine  or  "maladie  du  coit"  of  the  Mediter- 
ranean littoral,  caderas  of  South  America,  the  (1am- 
bian  fever  and  the  sleeping-sickness,  the  last  two 
being  diseases  of  man.  Moreover,  many  animals 
harbor  in  the  blood  parasites  of  this  group,  as  in  the 
case  of  the  wild  rat. 

In  all  suspicious  cases  the  blood  should  be  examined 
for  these  two  groups  of  organisms.  Tin-  plasmodium 
of  malaria  is  found  especially  within  the  blood  cells. 
The  trypanosomes  are  free  in  the  plasma.  Tho 
blood  may  be  examined  direct  under  the  cover-glass, 
or  in  hanging  drop,  or  in  a  Rainier  slide.  Stained 
preparations  can  be  made  with  methylene  blue, 
thionin,  or  best  with  some  modification  of  the  Roman- 
owsky  method.  The  preparation  of  the  specimens 
and  the  staining  methods  have  already  been  described. 
The  trypanosomes  of  the  rat  and  of  nagana.  have  been 
cultivated  artificially  by  Nbvy  and  McNeal.  Their 
presence  is  best  detected  by  direct  examination  of  the 
blood,  though  at  times  they  may  be  very  difficult  to 
find,  and  may  require  daily  examinations  for  several 
weeks. 

DETERMINATION  of  TnE  Thermal  Death  Point  of 
Bacteria. — In  this  work  and  also  in  testing  disin- 
fectants it  is  necessary  to  have  almost  homogeneous 
suspensions  of  the  organism  to  be  tested.  Water 
suspensions  should  be  used  first,  and  later  those  of 
bouillon,  serum,  etc.  The  liquid  is  introduced  by 
means  of  a  bulb  pipette  into  the  tube  of  an  agar 
culture.  The  growth  is  rubbed  up  as  much  as  possible 
and  the  suspension  is  then  transferred  to  a  sterile 
glass-wool  filter.  In  this  way  the  masses  of  bacteria 
are  removed.  The  cloudy  filtrate  may  be  used  as  such, 
or  it  may  be  diluted  so  as  to  have  fewer  organisms  in 
the  test.  It  may  be  used  as  such  for  determining  the 
action  of  moist  heat  and  for  testing  disinfectants. 


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Bacteriological  Technique 


REFERENCE    HANDBOOK    OF    THE    MEDICAL    SCIENCES 


Again,  for  dry-heat  work  and  for  many  disinfecting 
tests  the  suspension  is  allowed  to  dry  upon  the  surface 
of  sterile  glass  slips,  glass  or  garnet  beads,  silk  threads, 
muslin  squares,  etc. 

To  test  the  action  of  dry  heat  a  number  of  cover- 
glasses  on  which  the  test  organism  has  been  dried  are 
placed  in  a  sterile  Petri  dish  and  exposed  to  a  given 
temperature.  At  given  intervals  a  specimen  is  re- 
moved and  planted  in  bouillon. 

To  test  the  action  of  moist  heat  the  best  procedure 
is  to  draw  up  the  liquid  into  sterile  capillaries,  as 
shown  in  Fig.  603.  The  tube  is  sealed  below  and 
above  the  liquid.  The  advantage  of  this  method  lies 
in  the  fact  that  the  heat  promptly  penetrates  every 
part  of  the  suspension.  A  number  of  tubes  thus 
equipped  are  placed  in  a  water-bath,  the  temperature 


m:)  t> 


Fig.  603. — Filling  of  Capillary  Tubes  for  Thermal  Death-point  Determinations. 
c.  Tube  filled  ready  to  be  sealed  at  x;  6,  emptying  of  tube.     (Novy.) 


of  which  is  kept  at  a  constant  point  by  means  of  a 
regulator.  At  intervals  a  capillary  is  removed, 
cooled,  opened  at  one  end,  and  the  contents  are  ex- 
pelled into  a  tube  of  bouillon  by  gently  toucliing  the 
closed  end  to  a  flame. 

Testing  of  Chemicals. — In  this  work  it  is  necessary 
to  distinguish  between  the  antiseptic  and  the  disin- 
fecting action  of  a  substance.  The  former  refers  to 
the  amount  of  the  substance  which  wid  inhibit  the 
growth,  but  not  necessarily  kill  the  organisms.  The 
latter  implies  the  actual  destruction  of  the  test  object. 
Obviously  a  substance  which  will  kill  bacteria,  when 
diluted  sufficiently  will  merely  restrict  their  growth, 
and  when  the  dilution  is  excessive  will  have  no  action 
whatever. 

The  antiseptic  action  is  determined  by  adding  to 
the  suspension  in  bouillon  varying  amounts  of  the 
chemical  so  as  to  make  different  dilutions,  for  ex- 
ample: 1  in  500,  1  in  1,000,  1  in  5,000,  1  in  10,000, 
etc.,  solutions.  The  tubes  thus  equipped  are  then 
placed  in  the  incubator  for  several  days.  The  very 
weak  solutions  will  show  growths,  while  the  very 
concentrated  ones  will  show  none.  The  amount 
which  just  inhibits  the  growth  represents  the  an- 
tiseptic power  of  the  substance. 

The  germicidal  action  of  a  gas,  such  as  formalde- 
hyde, is  determined  by  exposing  cover-glass  prepara- 
tions, silk  threads,  bit  of  muslin,  etc.,  impregnated 
witli  the  suspension,  dry  and  moist,  to  the  action  of 
the  gas  in  a  tight  room.  At  the  end  of  the  exposure 
the  preparations  are  transferred  to  sterile  tubes  of 
bouillon  and  incubated. 

The  germicidal  action  of  liquids  is  ascertained, 
either  by  adding  the  solution  to  the  bacterial  suspen- 
sion or  by  immersing  in  the  solution  the  dried  cover- 
slip  preparations  mentioned.  In  the  former  case,  at 
stated  intervals,  a  small  loop  of  the  liquid  is  trans- 
ferred to  bouillon,  while  in  the  latter  case  the  slip  or 
thread  is  first  rinsed  in  sterile  water  and  then  placed  in 
the  bouillon. 

The  Serum  Agglutination  Test. — The  serum  of  an 
animal  which  has  been  immunized  to  a  germ  when 
brought  into  contact  with  a  suspension  of  that  germ 
will  cause  the  organisms  to  gather  in  masses.  The 
fact  is  utilized  in  the  Widal  test  for  typhoid  fever. 
A  drop  of  the  scrum  from  a  typhoid  patient  is  diluted 
with   tin,   twenty,   thirty,  fifty,  one  hundred  drops 


respectively  of  water  in  a  watch-glass.  A  drop  of 
each  mixture  is  then  transferred  to  a  cover-glass  and 
inoculated  with  a  very  small  amount  of  a  fresh  agar 
culture  of  the  typhoid  bacillus,  care  being  taken  to 
avoid  an  excess  of  the  organisms.  Hanging  drops 
are  then  made  and  the  preparations  examined  under 
the  microscope.  The  limit  of  the  reaction  is  in- 
dicated by  the  dilution  which  is  just  able  to  cause 
paralysis  of  motion  and  clumping  in  one  hour.  In- 
stead of  diluting  with  water  some  prefer  to  use  a 
very  young  bouillon  culture.  The  agglutination  test 
is  most  delicate  when  carried  out  under  the  micro- 
scope. Very  good  results,  visible  to  the  unaided  eye, 
may  be  obtained  by  adding  the  serum  to  bouillon 
culture  of  the  organism.  The  tubes  thus  treated 
should  be  set  aside  for  some  hours  at  37°  C.  when  the 
agglutinated  masses  will  settle  to  the 
bottom  and  leave  the  liquid  clear. 
When  applying  the  test  to  a  suspected 
case  of  typhoid  fever  it  is  not  always 
possible  to  obtain  large  amounts  of 
the  serum.  In  such  instances  the 
blood  may  be  placed  in  single  drops 
on  a  sheet  of  filter  paper,  or,  better, 
tinfoil.  The  dilutions  can  then  be 
made  with  these  drops  of  dried  blood 
as  with  the  serum  itself.  The  appli- 
cation of  this  test  to  the  recognition 
of  the  typhoid  bacillus  in  drinking- 
water,  feces,  etc.,  has  been  given. 
The  Complement  Fixation  Text. — 
This  test  is  one  of  importance  not  only  in  clinical 
diagnosis,  but  also  in  general  bacteriology.  It  affords 
a  most  delicate  means,  under  proper  conditions,  for 
the  differentiation  of  varieties  of  a  bacterial  species. 
However,  its  accuracy  depends  much  upon  the  proper 
preparation  of  the  materials  to  be  used  in  the  test  and 
the  methods  used  in  carrying  it  out. 

The  test  is  based  upon  the  so-called  Bordet- 
Gengou  phenomenon.  Those  investigators  observed 
that  when  an  antigen,  its  specific  antiserum,  and  com- 
plement were  brought  together  and  incubated,  the 
latter  component  was  fixed  or  bound — it  could  not 
functionate  again  in  similar  reactions.  As  an  indica- 
tor of  this  complement  binding  with  bacterial  anti- 
gens and  their  antisera,  sensitized  red  blood  cells  are 
added  later  to  the  above  combination.  If  the  comple- 
ment is  bound  no  hemolysis  occurs  on  the  second 
incubation,  but  if  not  bound  it  combines  with  the 
sensitized  blood  cells  and  causes  a  definite  hemolysis. 
As  evident  this  test  can  be  used  for  the  recognition 
of  specific  antibodies,  or,  conversely,  the  specific  anti- 
gens giving  rise  to  antibodies. 

In  order  to  carry  out  the  test,  say  for  example,  with 
the  serum  of  an  animal  immunized  against  a  given 
organism,  the  following  materials  are  necessary:  (1) 
normal  red  blood  cells;  (2)  a  specific  hemolytic  serum 
against  the  blood  cells;  (3)  complement;  (4)  an  antigen 
prepared  from  the  specific  organism.  Usually  the 
normal  blood  cells  are  those  drawn  from  the  jugular 
vein  of  the  sheep.  After  defibrination  of  the  blood 
the  cells  are  washed  several  times  in  physiological 
salt  solution  by  the  centrifuge  method  to  remove  all 
traces  of  serum.  The  specific  hemolytic  serum  may 
be  derived  from  a  rabbit  by  giving  repeated  injections 
of  thoroughly  washed  sheep  erythrocytes.  Generally 
an  active  hemolytic  serum  is  obtained  if  three  or 
four  injections  are  given  intraperitoneally,  spaced 
about  three  days  apart;  the  initial  injection  may  be 
5  c.c.  packed  corpuscles;  the  doses  are  gradually 
increased  until  the  final  injection  amounts  to  15  or 
20  c.c.  The  animal  should  not  be  bled  until  about 
ten  days  after  the  last  injection.  The  blood  is  allowed 
to  clot,  then  the  clear  serum  is  separated  and  placed 
in  sealed  bottles  for  use.  The  serum  is  inactivated  by 
heating  for  thirty  minutes  at  56°  C.  before  standard- 
izing. It  is  standardized  by  taking  decreasing 
amounts  (i.e.  0.01  to  0.001  c.c.)  and  placing  in  a  series 


922 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCIENCES 


Bacteriological  Technique 


of  test  tubes;  to  each  tube  n  ]o  c.c.  complementing 
serum  is  added,  then  all  brought  to  a  constant  volume 
with  0.9  per  cent,  sodium  chloride  solution,  aftei 
which  one  centimeter  of  5  per  cent,  blood  suspension 
is  added;  the  system  is  incubated  in  water  bath  for 
one  hour  at  .17°  ('.  After  removal  from  the  water 
bath,  the  tubes  are  placed  in  an  ice  chest  until  the 
intact  cells  settle  to  the  bottom  of  the  tube.  That 
amount  of  the  hemolytic  serum  which  just  completely 
dissolves  all  of  tin-  corpuscles  in  the  test  tube  is  called 
the  hemolyt ic  it  amboceptor  unit.  For  complen 
freshly  clotted  out  guinea-pig  serum  best  serves  the 
purpose.  In  the  complement  fixation  test  proper, 
the  normal  guinea-pig  scrum  should  also  hi'  standard- 
ized since  the  complement  content  is  variable.  This 
is  done  by  finding  that  amount  (one  unit)  which  just 
produces  complete  hemolysis  when  added  to  a  mix- 
ture of  one  unit  of  hemolytic  serum,  and  1  c.c.  of 
5  per  cent,  suspension  of  sheep  erythrocytes,  after 
incubating  one  hour  at  37°  C. 

In  preparing  the  bacterial  antigen  for  the  test,  the 
best  results  are  had  by  using  a  filtrate  (Berkefi  I  I 
derived  from  slant  agar  growths  which  have  been 
partially  autolyze.d  in  distilled  water.  The  antigen 
must  be  standardized  against  a  definite  amount 
(0.1  to  0.2  c.c.)  of  a  specific  antiserum  in  order  to 
determine  the  amount  which  will  fix  perfectly  wit  hout 
showing  anticomplementary  action  in  the  regular 
test.  The  quantity  thus  found  is  used  as  the  antigen 
unit  in  the  test  proper,  but  should  be  sufficiently  low 
that  double  the  amount  will  not  be  anticomplement- 
ary. Having  provided  and  standardized  the  neces- 
sary components  for  the  complement  fixation  test,  it 
is  carried  out  as  follows:  to  a  series  of  test  tubes  are 
added  decreasing  amounts  (0.10,  0.09,  0.08  .... 
0.01  c.c.)  of  the  inactivated  serum  for  examination; 
to  each  tube  one  unit  of  the  bacterial  antigen  is  added; 
then  two  units  of  the  complement;  finally,  sufficient 
physiological  salt  solution  is  added  to  bring  to  a  con- 
stant volume  throughout.  The  following  controls 
are  also  run  in  the  complement  fixation  test: one  tube 
containing  double  amount  of  the  bacterial  antigen 
used  in  the  series,  plus  the  hemolytic  system;  one 
tube  with  double  the  highest  quantity  of  antiserum 
used  in  the  series,  plus  the  hemolytic  system;  one 
tube  with  a  known  positive  serum,  and  one  with  a 
negative  serum,  both  of  which  are  carried  through  in 
parallel  with  the  test  serum;  finally,  one  tube  with 
only  the  regular  hemolytic  system.  The  test  series 
(with  the  positive  and  negative  control  sera)  of  tubes 
are  incubated  for  thirty-  minutes  in  water  bath  at 
37°  C.  After  incubation  to  each  (including  control 
are  added  two  or  three  units  of  the  hemolytic  immune 
serum  (amboceptor),  and  then  1  c.c.  of  a  5  per  cent, 
suspension  of  sheep  erythrocytes.  The  tubes  are 
shaken,  and  again  returned  to  the  water  bath  at  37°  C. 
for  one  hour.  At  the  end  of  this  period  they  are  re- 
moved and  placed  in  an  ice  chest  until  the  blood  cells 
settle  to  the  bottom  of  the  tube,  then  the  readings 
are  made.  If  the  controls  are  satisfactory,  the  results 
of  the  test  are  recorded.  .Since  in  the  ease  just  con- 
sidered, the  serum  being  tested  was  derived  from  an 
immunized  animal,  some  if  not  all  of  the  tubes  would 
show  no  hemolysis.  In  those  showing  no  hemolysis, 
the  complement  was  bound  by  the  antigen-antibody 
complex,  and  none  remained  free  to  act  upon  the  sen- 
sitized corpuscles  added  later.  If  the  serum  under 
examination  were  not  of  especially  high  value,  those 
tubes  of  the  series  which  received  the  smaller  quanti- 
ties of  the  serum  would  show  hemolysis — that  is,  free 
complement  which  acted  with  the  hemolytic  system 
present. 

Preparation  of  the  Soluble  Bacterial  Toxins. — Solu- 
ble or  extracellular  toxins  are  produced  by  a  number 
of  pathogenic  bacteria  (B.  diphtheria-,  B.  tetani,  B. 
botttlini,  etc.)  when  grown  upon  proper  culture 
media,  under  favorable  conditions.  For  the  purpose 
of  practical  immunization  of  animals,  it  is  necessary 


io  have  highly  eon.  entrated  to  i  fore,  pre- 

cautions mu  i  he  taken  in  cultivating,  to  brink;  about 
the    proper    conditions.      Vltl  .■.    ,,f 

toxin   production   is   as    v.i    QO|    fully    understood, 
has  shown  that   certain  media  are  more 

"  able  than  ot  he,     ,,i  tai      trains  of  I  be 

organism  vary  in  their  ability  to  elaborate  t< 
In  the  preparatii f  diphtheria  toxin  lark  recom- 
mends as  a  suitable  culture  medium  a  nutrient  broth 
prepared  in  the  regular  manner  from  young  veal,  i  ■• 
each  liter  add  two  per  cent  peptone  |  \\ 
sufficient  alkali  to  give  an  alkalinity  equivalent  to 
the  addition  of  8  c.c.  of  normal  solution  of  potassium 
hydrate  above  the  m  lU8,     Sufficient 

nutrient    broth   is  placed   in  thin  layers  'a* 
mehes  deep)  in   large-necked    Erlenmeyer  Basks,  to 
access  of  air.     After  inoculation  with  H. 
the  flasks  are  incubated  between  :;.V  and 
:'0°  C.       PI  on  of   toxin   is   p 

cut    between    the    tilth   and    eighth   days   of    bacterial 

growth.     After  the  tenth  day,  at  incubator  tempera- 
ture, tin'  toxicitj  decreases  mop.  or  less  rapidly,  o 
to  its  labile  character.     After  one  week's  growth,  a 
test  for  purity  of  culture  is  made  by  microscopical  and 

culture  methods.  If  found  pun",  the  bacteria  are 
killed  by  the  addition  of  ten  per  cent,  of  a  five-per- 
cent, solution  of  carbolic  acid.  After  standing  for 
forty-eight  hours,  the  dead  bacilli  settle  to  the  bottom, 

and  -t  of  them  may  be  removed  by  filtering  the 

broth  through  ordinary  Sterile  filter  paper.  Bottles 
are  filled  with  the  so-called  toxin,  sealed,  and  stored 
in  the  ice  chest  until  n led.  A  hypodermic  in- 
jection of  0.01  c.c.  or  even  less  should  kill  a  250-gram 
guinea-pig. 

The  bacillus  of  tetanus  also  produces  a  very  power- 
ful poison  under  artificial  means  of  cultivation. 
Since  the  bacillus  of  tetanus  is  anaerobic  in  character, 
its  cultivation  for  toxin  production  must  he  varied 
from  that  of  the  diphtheria  bacillus.  Park's  met  ho. I 
consists  in  using  a  nutrient  beef  broth  of  slight 
alkalinity,  containing  one  per  cent,  peptone  t  Witt.  , 
0.5  per  cent,  common  salt,  and  one  per  cent,  glucose. 
The  broth  thus  prepared  is  placed  in  flasks  until  they 
are  about  two-thirds  filled,  then  sufficient  molten 
paraffin  (melting-point  about  45°  C.)  is  added  to 
form  a  semi-solid  covering  one-half  to  one  inch  in 
thickness.  The  whole  is  sterilized  and  when  ready 
for  use  the  flask  is  sufficiently  heated  to  liquefy  the 
paraffin  layer.  A  shake  culture  of  B.  tetani  in  agar 
is  dropped  in  the  warm  medium.  The  heated  broth 
will  cause  the  agar  to  dissolve  and  liberate  the 
organisms  and  spores.  When  cool  the  paraffin 
hardens  over  the  broth  and  seals  it  off  from  the  air, 
thus  producing  anaerobic  conditions.  The  agar 
shake  culture  is  best  removed  from  the  test-tube  by 
quickly  heating  until  the  agar  about  the  wall  dis- 
solves: then  it  may  he  poured  into  a  flask.  Precau- 
tion should  be  exercised  to  prevent  outside  con- 
taminations. The  culture  is  incubated  at  a  tem- 
perature of  37°  C.  for  five  to  six  days.  After  the 
necessary  tests  for  bacterial  purity  are  made,  the  liv- 
ing organisms  and  spores  are  removed  by  first  lil- 
tering  through  paper  pulp  (funnel  and  suction), 
then  through  a  Berkcfeld  filter.  To  the  filtered 
toxin  0.5  per  cent,  carbolic  acid  is  added;  flasks  are 
then  completely  filled,  sealed,  and  kept  in  a  cool 
tlark  place.  The  strength  of  this  toxin  is  quite 
variable,  much  depending  upon  the  conditions  of  prep- 
aration. According  to  Park,  under  best  conditions 
the  amount  of  toxin  produced  in  cultures  on  the  fifth 
day  may  be  such  that  0.000005  C.C  is  a  fatal  dose  for 
a  "fifteen-gram  mouse.  Tetanus  toxins  as  prepared 
by  the  above  method  may  show  such  a  degree  of 
toxicity  that  0.001  to  0.0001  c.c.  will  cause  death 
within  four  days  to  a  guinea-pig  weighing  from  300 
to  350  grams. 

The  other  soluble  bacterial  toxins  may  be  prepared 
in  a  similar  manner,  but  the  composition  of  media  and 

923 


Bacteriological  Technique 


REFERENCE    HANDBOOK    OF   THE    MEDICAL    SCIENCES 


conditions  must  be  altered  to  meet  the  special  re- 
quirements of  the  organism  under  cultivation. 

Methods  of  Immunization. — Only  the  general  princi- 
ples of  active  immunization  can  be  considered.  The 
injections  are  made  subcutaneously,  intraperitoneal]}', 
or  intravenously.  When  immunizing  a  horse  for  the 
production  of  antitoxin  serum,  the  injection  of  toxin 
should  always  be  made  subcutaneously.  Experience 
has  proved  that  the  antitoxin  is  formed  much  more 
rapidly  and  reaches  a  higher  concentration  in  the  blood 
under  such  procedure.  The  primary  dose  of  toxin  for 
a  normal  animal  must  be  very  small.  An  initial  dose 
of  0.01  c.c.  of  diphtheria  toxin  has  proved  fatal  to  a 
horse.  Therefore,  in  immunizing  a  previously  un- 
treated horse,  it  is  necessary  to  begin  the  injections  of 
diphtheria  toxin  (also  tetanus  toxin)  with  a  dose  under 
one  one-hundredth  of  a  cubic  centimeter,  to  keep 
within  bounds  of  safety.  A  repeated  injection  of 
toxin  should  not  be  given  until  the  animal  has  practi- 
cally recovered  from  the  reactionary  symptoms  of  the 
previous  dose.  In  the  routine  immunization  of  horses 
against  diphtheria  Park  recommends  that  the  initial 
dose  be  about  20  c.c.  of  fairly  strong  toxin;  the  second 
and  third  doses  are  slightly  increased.  But  with  each 
of  the  first  two  injections  about  10,000  units  of  the 
antitoxin  is  given.  In  this  way  the  animal  is  protected 
until  it  has  an  opportunity  to  elaborate  its  own  anti- 
bodies, then  the  injections  of  antitoxin  should  be  dis- 
continued. This  procedure  aids  in  bringing  an  animal 
without  danger  up  to  a  high  degree  of  immunity  in  a 
relatively  short  time,  as  compared  with  the  older 
method.  In  either  case,  after  a  few  months'  treat- 
ment, a  horse  may  withstand  several  hundred  cubic 
centimeters  of  highly  potent  toxin,  at  a  single  in- 
jection, without  serious  results.  When  a  soluble 
poison  is  injected,  a  true  antitoxin  develops  in  the 
animal  and  is  present  in  the  blood  and  hence  in  the 
serum.  This  is  the  case  in  diphtheria,  tetanus,  and 
venom  immunity.  On  the  other  hand,  when  the 
solid  cell  is  injected,  the  serum  may  acquire  anti- 
infectious  properties,  the  best  instance  of  which  is 
seen  in  the  antipest  serum.  The  organisms  may  be 
killed  by  exposing  them  to  the  action  of  ether,  of 
chloroform,  or  of  moist  heat  at  60°  C.  In  special 
cases  the  attenuated  living  germ  is  used,  and  at  times 
even  the  most  virulent  form  is  employed.  By  the 
injection  of  cells  other  than  bacteria,  diverse  cytolytic 
sera  are  obtained.  Thus  the  injection  of  the  red  blood 
cells  gives  rise  to  a  hemolytic  serum.  The  tempera- 
ture and  the  weight  of  the  animal  must  be  taken 
daily,  since  they  afford  the  best  indication  of  the  condi- 
tion of  the  animal. 

Testing  the  Strength  of  Antitoxin. — The  strength  of 
an  antitoxin  is  expressed  in  immunity  units.  A 
unit,  according  to  the  old  definition  of  Behring  and 
Ehrlich,  represents  that  amount  of  serum  which  will  be 
just  sufficient  to  protect  a  250-gram  guinea-pig  against 
100  minimum  fatal  doses  of  a  given  diphtheria  toxin. 
Thus  if  0.1  c.c.  of  serum  protects  against  this  dose  of 
poison,  then  it  will  contain  one  immunity  unit,  and  1 
c.c.  of  such  serum  will  contain  ten  immunity  units. 

To  determine  the  antitoxic  value  of  a  serum  accord- 
ing to  the  earlier  method,  the  first  essential  is  to 
ascertain  the  minimum  lethal  dose  (M.  L.  D.)  of  the 
toxin,  by  which  is  meant  the  amount  of  toxin  which 
will  kill  a  250-gram  guinea-pig  on  the  fourth  or  at 
most  on  the  fifth  day.  Varying  amounts  of  the  serum 
are  then  added  to  portions  of  the  toxin  representing 
100  minimum  fatal  doses.  These  mixtures  are  then 
injected  into  guinea-pigs  of  the  weight  given.  That 
fraction  of  a  cubic  centimeter  of  the  serum  which 
just  suffices  to  save  a  guinea-pig  under  these  condi- 
tions represents,  as  stated  above,  one  immunity 
unit. 

This  method  is  subject  to  some  error,  inasmuch  as  it 
has  been  found  thai  a  serum  which  has  been  tested 
against  one  toxin  will  show  a  different  value  when 
tested  against  another.     This  is  due  to  the  fact  that 


the  toxin  undergoes  changes  on  keeping,  and  is  con- 
verted into  a  non-poisonous  body  or  toxoid,  which, 
however,  retains  the  power  of  combining  with  the 
antitoxin.  For  this  reason  Ehrlich  proposed  a  new 
method  of  testing  the  antitoxic  value  of  a  serum.  A 
standard  dried  antitoxin  is  made  the  basis  of  the 
measurement.  This  is  diluted  so  that  a  gnren  amount 
just  represents  one  immunity  unit.  The  test  dose 
(L  +)  of  toxin  is  then  ascertained  and  represents  the 
amount  of  toxin  which,  mixed  with  one  immunity 
unit  of  serum,  will  cause  death  on  about  the  fourth 
day.  The  serum  to  be  tested  is  then  diluted,  mixed 
with  the  test  dose  of  the  toxin,  and  injected  into  a 
guinea-pig.  If  the  animal  dies  in  a  day  or  two  it  is 
evident  that  the  serum  contains  less  than  one  immu- 
nity unit.  If,  on  the  other  hand,  it  lives  for  seven  or 
eight  days,  or  even  recovers,  it  shows  that  the  amount 
of  serum  taken  contains  more  than  one  unit.  By 
using  suitable  dilutions  of  the  serum,  eventually  tin; 
point  will  be  reached  where  the  amount  taken  will 
represent  exactly  one  unit. 

It  is  possible  to  secure  an  antitoxic  serum  from  horses 
immunized  against  diphtheria  toxin  which  contains 
over  1,000  immunity  units  in  1  c.c.  But  this  is  quite 
exceptional.  Usually  the  serum  of  horses,  as  com- 
monly immunized,  averages  between  300  to  500  units 
per  cubic  centimeter.  Gibson  succeeded  in  preparing 
a  concentrated  preparation  of  diphtheria  antitoxin  by 
precipitating  the  proteins,  and  separating  the  globu- 
lins from  antitoxic  serum  by  the  addition  of  certain 
salts.  The  globulin  fraction  which  contains  the  anti- 
bodies, is  finally  freed  from  the  salts,  etc.,  by  dialysis. 
By  the  Gibson  method  a  preparation  (fluid)  may  be 
obtained  which  contains  1,500  to  1,800  units  per  cubic 
centimeter.  Recently  Banzhaf  has  improved  the 
method  to  the  extent  that  the  protein  concentration 
is  materially  reduced,  while  at  the  same  time  the  anti- 
toxic content  is  increased.  By  this  improved  method 
a  preparation  may  be  obtained  which  contains 
3,000  units  per  cubic  centimeter,  with  a  protein  con- 
centration of  only  twenty  per  cent.  These  so-called 
antidiphtheritic  globulins  or  concentrated  antitoxins 
are  prepared  by  different  serum  laboratories. 

Opsonic  Technique. — The  fact  that  certain  cells 
of  the  body  will  take  up  and  destroy  microorganisms 
has  been  known  for  years.  The  phagocytic  theory  of 
immunity  is  based  upon  this  phenomenon.  Dcnys  and 
Leclcf  were  the  first  to  demonstrate  the  presence  of  a 
substance  in  immune  serum  which  made  the  corre- 
sponding organism  more  susceptible  to  phagocytosis 
by  leucocytes.  They  showed  that  this  substance 
acted  upon  the  organism  and  not  on  the  leucocytes. 
Later  Wright  and  Douglas  called  attention  to  the 
fact  that  such  sensitizing  substances  are  present  in 
fairly  constant  amounts  in  the  normal  blood.  This 
substance,  which  they  call  opsonin,  exists  in  smaller 
amounts  or  widely  fluctuating  amounts  in  the  blood 
of  a  patient  suffering  from  specific  bacterial  infec- 
tion. The  opsonic  content  may  be  increased  by  prop- 
erly vaccinating  with  killed  cultures  of  the  specific 
organism.  Bacterial  vaccines  are  beginning  to  play 
an  important  role  in  the  newer  therapeutics.  It 
is  obvious  that  such  means  of  treatment  must  be 
carefully  controlled,  or,  instead  of  being  of  material 
aid  to  the  body,  they  become  a  damaging  factor. 
Therefore,  in  order  to  follow  the  vaccination  treat- 
ment, a  means  must  be  found  by  which  a  fairly  ac- 
curate measurement  can  be  made  of  the  opsonins  in 
normal  blood  and  in  the  blood  of  a  patient  suffering 
from  any  bacterial  infection.  Wright  and  Douglas 
have  practically  overcome  this  difficulty  by  a  tech- 
nical method  by  which  they  derive  the  so-called  "op- 
sonic index."  This  "index"  simply  shows  the  relation 
existing  between  the  opsonic  content  of  a  patient's 
blood  as  compared  with  the  opsonic  content  of  the 
blood  of  a  normal  person. 

The  general  method  used  in  deriving  the  opsonic 
index  calls  for  the  following  materials:    Blood  serum 


924 


REFERENCE    HANDBOOK    OF   THE    MEDICAL   SCI]  \'  I  - 


Bacteriological  Technique 


from  patient,  control  scrum  from  normal  person, 
normal  trashed  corpuscles,  and  the  bacteria]  emulsion. 

The  same  technique  is  used  in  preparing  serum 
from  both  the  patient's  and  normal  blood.  A 
puncture  is  made  in  the  lobe  of  the  ear  or  one  of  the 
tinners  with  a  needle,  ami  pressure  is  used  to  cause 
the  blood  to  How.  When  the  blood  begins  to  exude, 
eight  or  ten  drops  are  drawn  up  into  a  pipette,  and  at 
once  transferred  to  a  small  test-lulie,  about  one- 
quarter  inch  in  diameter  and  two  inches  in  length. 
The  blood  is  allowed  to  clot,  thus  permitting  the 
scrum  to  separate. 

To  secure  t  he  leucocytes,  the  blood  is  draw  n  directly 

into  a  small  test-tube  containing  about  H»  c.c  of  a 
one-and-one-half  per  cent,  solution  of  sodium  citrate 
in  physiological  salt  solution.  This  solution  prevents 
the  blood  from  clotting.  One  cubic  centimeter  of 
blood  will  furnish  a  sufficient  number  of  leucocytes 
for  the  test.  The  corpuscles  are  centrifuged  until  the 
solution  above  the  packed  cells  appears  transparent . 
The  solution  is  carefully  removed  with  a  capillary 
pipette,  then  about  10  c.c.  of  physiological  salt  solu- 
tion are  added  and  well  shaken  to  wash  the  cells.  It 
is  centrifuged  again  to  throw  down  the  corpuscles,  and 
the  salt  solution  is  removed  with  capillary  pipette. 
Care  should  be  taken  not.  to  disturb  the  superficial 
creamy  layer  of  blood  cells,  as  this  layer  contains  the 
greater  share  of  the  leucocytes.  When  the  fluid  has 
been  removed,  the  leucocyte  layer  of  cells  should  be 
taken  up  carefully  with  a  capillary  pipette,  and  the 
thick  emulsion  reserved  for  the  test.  Blood  which 
shows  any  clotting  must  be  rejected. 

The  bacterial  emulsion  should  be  a  uniform  suspen- 
sion, but  it  is  very  difficult  to  avoid  some  clumping  of 
organisms.  Different  organisms  vary  in  this  respect. 
Tubercle  bacilli  are  extremely  hard  to  get  into  a  uni- 
form suspension.  To  prepare  an  emulsion  of  such 
organisms  as  staphylococci,  streptococci,  pneumo- 
cocci,  and  such  bacilli  as  typhoid  and  colon,  cultures 
are  grown  on  the  most  favorable  agar  medium,  and 
used  fresh,  i.e.  not  older  than  twenty-four  hours. 
A  portion  of  the  culture  is  removed  with  a  medium- 
sized  platinum  wire,  and  transferred  to  a  small  test- 
tube  containing  3  or  4  c.c.  of  physiological  salt  solu- 
tion. The  mass  of  organisms  is  carelully  rubbed  with 
the  wire  against  the  wall  of  the  tube  at  the  surface  of 
the  salt  solution  until  a  turbid  suspension  results.  Cen- 
trifuge until  the  larger  particles  of  bacteria  are  thrown 
down,  but  discontinue  before  the  finer  suspension  is 
sedimented.  Experience  will  indicate  the  proper  de- 
gree of  turbidity  which  is  desirable.  Wright  recom- 
mends that  the  bacterial  suspension  be  such  that  four  to 
live  cocci  are  found  for  each  cell  in  the  final  mixture. 

For  emulsion  of  tubercle  bacilli  some  workers  culti- 
vate the  organism  on  glycerin  agar  and  kill  the  organ- 
isms by  exposure  to  direct  sunlight  for  twenty-four 
hours,  or  by  other  means.  Some  of  the  growth  is  re- 
moved from  the  culture  tube,  and  placed  in  a  small 
agate  mortar,  where  it  is  thoroughly  rubbed  up  with 
1..")  per  cent,  salt  solution.  The  resulting  suspension 
is  centrifuged  to  remove  clumps.  Other  workers 
prepare  their  emulsion  of  tubercle  bacilli  from  dried 
and  ground-up  bacilli.  In  preparing  the  emulsion,  the 
procedure  is  the  same  as  the  above.  In  each  case 
when  the  emulsion  is  finished,  the  upper  portion  is 
remove  from  the  centrifuge  tube,  with  a  pipette,  and 
reserved  for  use.  Wright  states  that  the  tubercle 
emulsion  should  be  of  such  thickness  that  one  or  two 
organisms  are  found  to  each  cell  in  the  final  smear. 

Now,  having  prepared  the  necessary  materials  for 
the  work,  the  next  step  is  to  measure  out  the  blood 
cells,  serum,  and  bacterial  emulsion  for  mixtures. 
Best  for  this  purpose  is  a  pipette  made  by  taking  glass 
tubing  with  about  five  millimeters  internal  diameter 
and  about  fifteen  centimeters  in  length.  It  is  drawn 
out  in  the  flame  in  the  same  manner  as  described  under 
Pasteur  pipettes  (Fig.  5096,  6),  with  the  exception  that 
no  end  constriction  is  made.     The  capillary  portion  of 


each   should  i»-  about  twelve  to  fifteen  centirm 
long  and  about  one  millimeter  in  diameter.     A  rubber 


nipple,   such   as   is   used   on   an   ordinary   medicine 
dropper,  is  slipped  ovei  the  large  end.     The  capillar; 

cud    IS  cut    off  squarely  and  a    mark   IS   made    with   a 


glass  marking  pencil  about  three  to  four  centimeters 

from  the  end.  By  mean,  c ■  f  the  nipple,  Quid  can 
easily  be  drawn  up  into  the  capillary  tube.  The  mix- 
ture  is   made   by  drawing  up  the  heavy  suspension 

of  blood  corpuscles  (containing  leUCOCytl  I  <"  the 
pencil    mark;   a  little  air  is  drawn  in  by  raising  the 

blood  column,  then  an  equal  volui f  serum  is  drawn 

in  by  tilling  up  to  t  he  pencil  mark;  again  an  air  bubble 
is  allowed  to  enter;  then  finally  an  equal  volume  of 
tin'  bacterial  suspension  is  drawn  in.  In  this  way  the 
different  suspensions  can  be  equally  and  accura 
measured.  The  whole  content  is  blown  out  of  the 
pipette  on  a  clean,  hollow-ground  slide,  where  it  is 
thoroughly  mixed  by  drawing  up  and  ejecting  from 

the  pipet  1 1>  several  times.    Finally,  the  whole  mixture 

kept  free  from  air  bubbles  is  drawn  up  into  the  pipe!  te 
and  the  capillary  end  is  scaled  olf  in  a  flame.  The 
pipette  containing  the  mixture  is  placed  in  an  incu- 
bator at  ::7  ('.for  fifteen  minutes  to  permit  phagO- 
<  \  tic  action  to  take  place.  After  removing  from  the 
incubator  the  sealed  tip  of  the  pipit  tc  is  broken  off, 
and  the  suspension  is  well  mixed  on  a  clean  hollow- 
ground  slide.  Drops  of  moderate  size  are  placed  upon 
each  of  a  number  of  clean  slides.  Each  drop  is  spread 
by  means  of  the  end  of  a  second  slide,  as  is  done  in 
ordinary  blood  work.  The  smear  is  allowed  to  air- 
dry  completely,  then  stained  with  aqueous  methylcne- 
blue  solution,  or  with  a  polychrome  dye  such  as  the 
Wright  or  Leishman  stain.  In  the  case  of  tubercle 
bacilli  the  films  are  fixed  in  saturated  aqueous  solution 
of  mercuric  chloride  ten  minutes.  The  films  are 
washed  in  water,  stained  with  CzaplewTsky's  carbol- 
fuchsin  solution,  and  again  washed  in  water.  They 
are  decolorized  in  two-per-eent.  sulphuric  acid,  washed 
well,  and  counterstained  one  minute  with  one-per- 
cent, aqueous  solution  methylene  blue.  The  stained 
preparations  are  dried  and  examined  under  high-power 
objective.  The  bacillary  index  is  found  by  taking  the 
total  number  of  phagocyted  bacteria  counted  in  a 
series,  and  dividing  it  by  the  number  of  leucocytes 
making  up  the  series.  Fifty  or  more  leucocytes  should 
make  a  series.  The  opsonic  index  is  derived  by  divid- 
ing the  value  (bacillary  index)  of  the  patient's  serum 
by  the  value  found  for  the  normal  serum  used  as  con- 
trol. It  is  an  advantage  to  collect  the  normal  serum 
from  three  or  four  healthy  persons  and  mix  all 
together.  This  gives  more  reliable  results  in  finding 
the  opsonic  value  for  the  normal  condition. 

In  making  counts  for  the  opsonic  index,  the  per- 
sonal equation  is  frequently  pronounced,  but  by  con- 
tinued experience  this  factor  ma}'  become  lessened 
and  fairly  constant.  It  also  must  be  noted  that 
marked  discrepancies  exist  between  results  of  ex- 
perienced workers  when  estimating  the  opsonic  index 
of  the  same  sample  of  serum.  Simon  recommends 
that  the  percentage  of  phagocyting  leucocytes  be 
estimated  in  connection  with  the  bacillary  index. 
He  states  that  this  will  act  as  a  check  upon  the 
bacillary  index,  and  will  reveal  errors  in  counting. 
A  close  correspondence  exists  between  the  bacillary 
index  (Wright)  and  the  percentage  index  of  Simon. 

Examination  of  air. — The  bacteria  which  chance 
to  be  present  in  the  air  are  in  a  dried  condition,  and  tend 
to  settle  when  the  motion  of  the  air  is  lessened.  The 
simplest  method  consists  in  exposing  a  plate  of  gelatin 
or  agar  to  the  air  for  a  given  length  of  time.  Si  ime  of 
the  organisms  settle  on  the  gelatin  and  eventually 
give  rise  to  colonies.  Koch  improved  slightly  upon 
this  by  placing  the  gelatin  plate  in  the  bottom  of  a 
sterile  cylinder  of  known  volume.  After  opening  the 
cylinder  in  a  given  locality  it  is  closed  with  a  cotton 
plug  and  set  aside,  when  the  organisms  contained  in 

925 


Bacteriological  Technique 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


that  volume  of  confined  air  settle  to  the  bottom  on 
the  surface  of  the  plate.  The  results,  it  will  be  seen, 
are  crudely  quantitative  (Fig.  604). 

Hesse's  method  consists  in  drawing  the  air  through 
a  large  Esmarch  roll  tube  (Fig.  (305).  The  volume 
of  the  air  drawn  through  can  be  de- 
termined from  that  of  the  aspirating 
bottles.  The  bacteria  in  the  air  im- 
pinge upon  the  gelatin  surface,  where 
they  develop  into  colonies  which  can 
be  counted  and  studied. 

The  apparatus  of  Petri,  although 
very  expensive,  may  be  said  to  give 
the  best  results.  It  consists  in  the 
first  place  of  an  air  pump,  which 
automatically  registers  the  movements 
of  the  piston,  and  thus  gives  the 
volume  of  the  air  which  has  been 
drawn  through.  The  air  is  aspirated 
through  a  tube  (Fig.  606)  containing 
several  layers  of  sterile  sand.  The 
suspended  bacteria  are  thus  held  back. 
At  the  close  of  the  operation  the  sand 
is  transferred  to  a  Petri  plate,  where  the  bacteria  will 
form  colonies  and  thus  become  accessible  for  study. 

Instead  of  sand,  Sedgwick  and  Tucker  employed  a 
filter  of  sugar.  The  special  tube  employed  by  them  is 
shown  in  Fig.  607.  After  the  air  has  been  drawn 
through,  the  sugar  is  tapped  down  into  the  wide 
portion  of  the  tube,  then  gelatin  is  added  and  warmed 


Fig.  604. — 
Koch's  Cylinder 
for  Air  Analysis. 


Fig.  605. — Hesse's  Apparatus  for  Air  Analysis. 

until  the  sugar  dissolves,  after  which  an  Esmarch 
roll  culture  is  made  in  the  same  tube. 

Other  workers  have  filtered  the  air  through  liquid 
media  or  through  gelatin.  The  most  convenient  form 
of  apparatus  of  this  kind  is  that  of  Wurtz,  shown  in 
Fig.  608.  A  suitable  amount  of  gelatin  is  placed  in 
the  sterile  tube,  then  a  known  volume  of  air  is  drawn 
through,  after  which  the  gelatin  is  solidified  over  the 
inner  wall  of  the  tube,  thus  forming  a  roll  culture. 

Examination  of  Soil. — By  means  of  a  small  sterile 
platinum  spoon  a  definite  volume  of  the  soil  may  be 
transferred  to  a  Petri  plate,   where  it  is  thoroughly 

926 


mixed  with  the  medium.  The  colonies  which  develop 
can  then  be  examined.  In  this  way  it  is  possible  at 
times  to  demonstrate  the  presence  of  the  anthrax 
bacillus  in  the  soil  of  an  infected  locality.  The  de- 
tection of  other  pathogenic  bacteria,  as  for  instance 
those  of  tetanus  and  malignant  edema,  can  best  be 
made  by  introducing  a  quantity  of  the  soil  under  the 
skin  of  a  guinea-pig  or  rabbit. 

Examination  of  Water. — This  is  a  very  important 
procedure,  and  an  enormous  amount  of  work  has  been 
done  to  perfect  the  methods  of  work.  The  method 
followed  will  necessarily  depend  upon  the  immediate 


\     i     /* 


Fig.  606.  Fig.  607.  Fig.  60S. 

Fig.  606.— Petri  Sand  Filter  for  Air  Analysis. 
Fig.  607. — Sedgwick  and  Tucker's  Aerobiocscope. 
Fig.  608. — Wurtz's  Apparatus  for  Air  Analysis. 

object  in  view.  Thus  the  detection  of  the  cholera, 
vibrio  is  carried  out  in  a  different  way  from  that  used 
for  the  colon  bacillus.  The  isolation  of  the  cholera 
and  typhoid  organisms  from  water  has  already  been 
described. 

The  water  which  is  to  be  tested  bacteriologically 
must  be  received  into  a  sterile  glass-stoppered  bottle, 
and  should  be  examined  at  once.  If  the  examination 
is  not  carried  out  at  once,  the  bacterial  count  will 
not  be  reliable.  Samples  of  highly  polluted  water, 
when  kept  cool  for  some  time,  show  a  marked  de- 
crease of  intestinal  organisms.  The  first  step  in  the 
examination  is  to  make  gelatin  plates.  By  means  of 
a  sterile  pipette  1  c.c.  of  water  is  added  to  a  tube  of 
gelatin,  mixed  thoroughly,  and  the  gelatin  is  then 
poured  out  into  a  Petri  plate.  In  the  same  way  plates 
are  made  with  0.5  c.c.  and  with  one  drop  of  the  water. 
The  gelatin  plates  are  developed  at  20°  C.  for  several 


liKFEItEXCH    IlAXlU'.ooK    <  >F   Till:    MEDICAL   SCIENCE 


K.ii   lrrlul\  sis 


days.  Tin'  colonics  are  thru  counted  and  examined 
in  the  usual  way.  When  only  a  few  colonies  are  pres- 
ent on  a  plate  they  can  be  readily  counted  with  the 
eye.     When  the  number  is  Large  special  counters  are 

made  use  of.      That    of  Wolffhugel  (1  ig.  609)    is   ruled 

in  squares  of  one  centimeter  and  fractions  thereof. 

Another  form   is   that    of    I.afnr.      A   very   useful   and 

cheap  substitute  is  mad.'  by  printing  the  divided 
circle  on  card  paper.  To  make  a  count,  the  number 
of  colonies  in  ten  or  more  squares  is  ascertained,  and 
the  average  per  square  centimeter  is  obtained.     The 

ana  of  the  gelatin  on  the  plate  is  taken  and  then  the 
total  number  of  colonies  on  the  plate  determined,  and 
the  result  is  expressed  per  cubic  centimeter  of  water. 


Fig.  609. — Wolffhugel's  Colony  Counter. 

Instead  of  using  Petri  plates,  the  Esmarch  roll  tube 
can  be  made.  To  count  the  colonies  in  such  a  tube 
Esmarch  devised  the  counter  shown  in  Fig.  G10. 

When  the  number  of  colonies  is  likely  to  be  ex- 
tremely large,  as  in  the  examination  of  pollute,!  water. 
it  is  advisable  to  dilute  a  portion  of  the  sample  with 
a  known  volume  of  sterile  water.  If  the  colonies  are 
very  numerous  on  a  plate,  the  counting  can  be  carried 
out  best  under  a  microscope.  Ehrlich  stops  are  placed 
in  the  eye-piece  or  the  special  Ehrlich  ocular  may  be 
used.  The  size  of  the  opening  in  the  ocular  must  be 
determined  by  means  of  a  stage  micrometer.  The 
average  number  of  colonies  for  a  given-sized  opening 
is  determined,  and  from  this  the  total  number  on  the 
plate  is  calculated. 

The  above  method  of  examination  gives  approxi- 
mately the  number  of  bacteria  which  are  present  in  a 


Fig.  610. — Counter  for  Esmarch 's  Roll-tube  Cultures. 

water,  and  to  some  extent  information  as  to  the  kind 
of  bacteria.  It  is  of  great  value,  therefore,  in  con- 
trolling the  work  done  by  the  water  filters.  In  order 
to  ascertain  the  presence  of  pathogenic  and  other 
bacteria  special  methods  must  be  resorted  to.  The 
method  which  has  been  employed  during  a  number 
of  years  in  the  Hygienic  Laboratory  of  the  University 
of  .Michigan  consists  in  planting  a  cubic  centimeter 
and  a  drop  of  the  water  in  tubes  of  bouillon,  which  are 
then  incubated  at  39°  C.  If  no  growth  forms,  as 
often  is  the  case,  pathogenic  bacteria  may  be  said  to 
be  excluded.  When  a  growth  does  form,  a  portion 
(1  e.c.)  is  injected  into  a  guinea-pig.  In  ease  the 
animal  dies  the  heart  blood  is  examined  for  the  kind 
of  organism  present.     If  no  ill  effects  follow  the  injec- 


Fio.     611      - 
1  itation  Tube. 


tion,  the  watei  maj  be    aid  i<>  !»■  free  from  pathogenic 

'Ha. 

Sewage  contamination  Is  u  ually  Indicated  by  the 
presence  of  colon  bacilli  and  ol     tn  ptococci. 

presence  i,t  t  lie  former  i  •  te  ted  i  u  bj  mean  "ft  he 
Smith  fermentation  tube  (1  is   61  I  ater 

is  added  to  glui  ose  bouillon  in  t  In-  fermental  ion  : 
which  is  then  set  aside  at   :;?    C.     The  formatio 
gas    indicates    the    probable    dp  sence    of   tin-  colon 
Bacillus,  while  the  non-production  of  gas  points  to  the 
ab  ence  of  t  his  organism.     1  url  hi 
for  indent ifical ton. 

Litmus-lactose  agar  plates  should  be  mad.'  directly 

from  the  water  and  also  from  the  fei atation  tube 

when    gas    production    is    present. 
The   formation   of  red   colonii 

ttive    of    the    colon    bacillus, 

i  i.i     organi  m    ferments    lac- 

erea     tj  phoii  i  like  I  iactei  ia 

do  not.     For  the  same  purpose  lac 

tose  bouillon  is  some!  imes  empli  13  ei  1 

in  the  fermenl ation  tul ie. 

Another  procedure  is  to  plant  1  he 
water    in    carbolic    bouillon,    or    in 
Parietti's  solution,  in  order  to  elim- 
inate   many  of   the   more  common 
iria. 

Neutral  red  bouillon  and  agar  are 
also  used  for  cultivating  the  sua 
pected  colon  bacillus.  The  water 
may  be  planted  direct,  or  the  red  colonies  which  form 
On  the  plate  may  be  used  for  inoculation.  Some  of  the 
special  media  such  as  Endo's  fuchsin  agar,  Harri- 
son's oesculin  bile  salt  agar,  etc.,  may  be  Used',  with 
good  results,  by  the  plating  method.  Jackson's 
lactose  bile  medium  is  highly  recommended  by  some 
water  analysts.  The  coagulation  of  milk  and  the 
production  of  the  indol  reaction  are  additional  tests 
of    identification.  F.  ('..   Now. 

Revised  by   L.  W.  I'amui.exer. 

Bacteriolysis. — Under  certain  circumstances  bac- 
teria are  dissolved.  This  process  is  called  bacterioly- 
sis and  the  substances  which  bring  it  about  are  termed 
bacteriolysins. 

Bacteriolysis  may  be  a  sort  of  self-digestion,  brought 
about,  according  to  some  authorities,  by  a  ferment 
contained  within  the  cell,  an  endotryptase.  Bacteri- 
olysis occurring  in  this  manner  is  known  as  autolysis. 
Autolysis  takes  place  only  when  the  conditions  are 
unfavorable  for  the  growth  and  development  of  the 
organisms.  For  instance  pneumococci  will  grow  vig- 
orously for  a  time  when  planted  in  a  suitable  medium, 
but  after  a  few  days  they  gradually  disappear  leaving 
few  or  no  traces.  This  disappearance  is  due  to  the 
fact  that  the  cocci  have  been  injured  by  the  accumu- 
lation in  the  medium  of  their  waste  products  and 
have  then  undergone  lysis.  If  the  temperature 
is  too  high  or  too  low  or  in  the  presence  of  mild 
disinfectants  such  as  chloroform,  toluol,  thymol, 
or  salicylic  acid,  autolysis  readily  occurs.  If,  how- 
ever, the  heat  is  too  great  or  if  the  disinfectant  added  is 
too  strong,  such  as  would  be  the  case  with  phenol  or 
corrosive  sublimate,  then  the  ferment  also  is  injured 
and  autolysis  is  prevented.  Even  in  physiological  sail 
solution  a  certain  amount  of  autolysis  occurs,  due 
probably  to  the  insufficiency  of  food  material. 

Bacteriolysis  may  result  from  the  action  of  added 
substances,  so-called  chemical  bacteriolysins.  Alka- 
lies, antiformin,  strong  salt  solutions,  bile  salts, 
cobra  venom,  and  oleic  acid  belong  to  this  group  of 
chemical  agents.  There  is  a  very  great  difference  in 
the  way  the  different  organisms  read  to  these  lysins. 
The  pneumococcus  yields  with  comparative  ease  while 

the  tubercle  bacillus  is  unaffected  even  when  treated 
with  strong  alkalies  or  antiformin.  The  true  menin- 
gococcus is  dissolved  by  bile  and  by  taurocholic  acid 
while  the  Jager  meningococcus  and  the  pus  cocci  are 

927 


Bacteriolysis 


REFERENCE    HANDBOOK    OF    THE    MEDICAL   SCIENCES 


Bacteriuria 


not  affected.  Glycerin  acts  upon  many  bacteria  but 
not  upon  the  protozoa  or  the  filterable  viruses.  In 
ral  spores  are  the  most  resistant  to  bacteriolysis, 
with  the  acid-fast  and  Gram  positive  bacteria  ranking 
next.  The  Gram  negative  organisms  are  the  most 
susceptible.  A  notable  exception  is  the  pneumococ- 
cus  which,  although  Gram  positive,  is  very  susceptible 
to  most  bacteriolytic  agents. 

The  reaction  of  bacteria  to  the  lytic  action  of  the 
digestive  ferments  differs  somewhat  from  both  of  the 
above  varieties  of  bacteriolysis.  The  living  cells  are 
attacked  to  a  very  slight  degree  if  at  all.  When 
killed,  the  different  varieties  react  in  different  ways. 
The  Gram  negative  bacteria,  when  killed  by  a  tem- 
perature of  75°-S0°  C,  are  readily  digested  by  artificial 
gastric  juice  and  even  more  readily  by  trypsin. 
When  killed  by  the  weaker  disinfectants  such  as 
chloroform,  however,  this  digestion  takes  place  to  a 
much  less  marked  degree.  The  Gram  positive  bacteria 
are  much  more  resistant,  many  not  being  attacked 
by  trypsin,  even  if  they  have  been  killed. 

Many  normal  sera  possess  a  certain  amount  of 
bacteriolytic  power  which  is  more  or  less  specific  but 
which  is  capable  of  action  on  a  fairly  large  number  of 
organisms.  When,  however,  an  animal  is  inoculated 
with  bacteria,  specific  bacteriolysins  may  be  produced 
in  large  quantities.  Specific  bacteriolysins  are  anti- 
bodies of  Ehrlich's  third  order  and  are  much  more  com- 
plicated than  the  bodies  of  the  first  and  second  orders. 
They  are  amboceptors,  relatively  thermostabile  and 
require  the  presence  of  complement  for  their  action. 
Their  manner  of  action  is  analogous  to  that  of  all  the 
cytolysins. 

Bacteriolysis  was  first  described  by  Pfeiffer  who 
demonstrated  the  process  by  the  aid  of  the  following 
experiment:  Two  guinea  pigs,  one  normal  and  one 
immunized  were  injected  intraperitoneally  with  living 
cholera  vibrios.  The  peritoneal  exudate  was  with- 
drawn from  time  to  time  and  examined.  While 
the  cholera  vibrios  in  the  peritoneal  exudate  of  the 
normal  animal  were  unaffected  and  the  animal  suc- 
cumbed to  the  infection,  those  in  the  exudate  of  the 
immunized  animal  behaved  very  differently.  They 
first  began  to  lose  in  motility,  then  broke  up  into 
small  granules,  and  finally  disappeared  and  the  animal 
recovered.  He  later  found  that  the  same  lytic  power 
was  present  in  the  serum  of  the  immunized  animal. 
Bacteriolysis  thus  constitutes  one  of  the  important 
defenses  of  the  body  against  infection.  The  process 
however  is  not  without  danger  to  the  animal.  If 
there  are  a  large  number  of  bacteria  present  in  the 
blood  when  a  dose  of  bacteriolytic  serum  is  admin- 
istered, their  sudden  lysis  may  result  in  the  setting 
free  of  a  large  quantity  of  endotoxin  which  may  be 
powerful  enough  to  cause  death  even  though  the  in- 
fection itself  has  been  cured.  At  might  be  supposed 
from  the  behaviour  of  bacteria  to  other  bacteriolytic 
agents,  not  all  the  organisms  are  able  to  stimulate  an 
animal  to  the  production  of  bacteriolysins.  For  such 
as  are  thus  able,  however,  the  bacteriolytic  serum  con- 
stitutes  a  much  more  real  immunity  than  the  anti- 
toxic immunity  produced  as  a  result  of  the  inoculation 
of  other  bacteria.  It  is  easily  seen  that  a,  serum  which 
contains  merely  substances  which  neutralize  bacterial 
poisons  may  leave  unharmed  in  the  body  the  organ- 
isms which  produced  the  toxins  and  these  bacteria  may 
later  develop  again  into  virulent  forms.  Because  of 
the  difficulty  in  their  production,  however,  bacterioly- 
tic sera  are  not  in  very  general  use.  The  bacterioly- 
sis which  takes  place  in  serum  whether  or  not  it  con- 
tains specific  bacteriolysins,  has  proven  an  attractive 
subject  around  which  have  collected  many  theories. 
TIm'  nature  of  the  complement,  the  role  of  the  leuco- 
cyte,  the  question  as  to  the  part  played  by  the  lipoids, 


all  these  are  closely  connected  with  the  main  problem, 
and  about  them  we  know  practically  nothing.  In  the 
article  on  Immunity  the  reader  will  find  a  more  de- 
tailed discussion  than  is  possible  here. 

Ralph  G.  Stillman. 

Bacteriotropins. — Wright  observed  that  among  the 
antibodies  which  were  produced  by  an  animal  which 
had  been  inoculated  with  bacteria  were  some  which 
rendered  the  bacteria  in  question  more  susceptible 
of  phagocytosis.  These  bodies  he  called  opsonins. 
He  recognized  the  fact  that  there  were  opsonins  resi- 
dent in  normal  sera  and  that  they  were  less  specific 
than  the  immune  opsonins.  Neufeld,  however,  found 
that  the  immune  opsonins  were  much  more  thermos- 
tabile than  the  normal  opsonins  and  came  to  the  con- 
clusion that  they  were  entirely  different  substances. 
To  the  immune  opsonins  he  gave  the  name  bacterio- 
tropins. Bacteriotropins  exert  their  influence  en- 
tirely upon  the  bacteria,  for  if  a  bacterial  emulsion  be 
mixed  with  a  serum  containing  these  substances  and 
then  centrifuged  to  remove  the  serum  the  bacteria 
will  be  found  to  be  more  readily  subject  to  phagocy- 
tosis than  organisms  not  so  treated.  Their  nature  is 
unknown.  There  has  been  an  effort  to  identify  them 
with  the  antiaggressins  of  Bail  but  not  on  sound 
experimental  grounds.  Their  importance  in  im- 
munity is  obvious,  as  a  serum  of  high  bacteriotropic 
value  would  sensitize  a  large  number  of  organisms 
and  thus  virtually  enormously  increase  the  power  of 
the  leucocytes  to  destroy  them.  The  technique  of 
determining  the  bacteriotropic  power  of  a  serum  is 
identical  with  that  of  obtaining  the  opsonic  index,  for 
which  the  reader  is  referred  to  the  article  on  Opsonins. 
The  relation  of  these  bodies  to  the  other  antibodies 
will  be  discussed  in  detail  in  the  article  on  Immunity. 

Ralph  G.  Stillman. 

Bacterium. — A  genus  of  the  family  Bacteria*  / , 
containing  cylindrical  rod-shaped  or  ellipsoidal 
organisms,  without  flagella,  sometimes  with  endo- 
spores,  and  often  grouped  in  zoogleea  masses.  The 
genus  is  not  well  defined,  many  of  the  species  being 
classed  by  some  bacteriologists  among  the  bacilli; 
Bad.  coli,  for  example,  being  more  commonly  called 
Bacillus  coli  communis,  and  Bad.  influenza;,  B.  in- 
fluenza. Bad.  termo  is  a  collective  term  now  practi- 
cally obsolute,  applied  to  a  number  of  the  putre- 
factive bacteria. 

The  term  bacteria  (the  plural  form  of  bacterium) 
is  also  commonly  employed  in  a  general  sense  as 
synonymous  with  Schizomycetes,  or  the  fusion-fungi. 

T.  L.  S. 

Bacteriuria. — If  a  urine  is  rich  in  bacterial  content 
when  it  is  voided,  the  subject  is  said  to  suffer  from 
bacteriuria.  The  clinical  evidence  of  this  condition 
is  usually  held  to  be  a  turbidity  which  cannot  be  made 
to  disappear  by  filtration,  centrifuging,  warming,  or 
the  addition  of  acids  or  alkalies.  The  claim  has  been 
made,  however,  that  bacteriuria  may  be  present  with 
clear  urine.  Under  the  microscope  a  drop  of  the  fluid 
is  seen  to  be  swarming  with  bacilli  and  cocci  in  a  state 
of  rapid  movement.  The  turbidity  can  be  made  to 
clear  up  by  agitation  with  barium  carbonate  and 
filtration  through  asbestos.  The  reaction  in  bacte- 
riuria may  be  acid  or  alkaline,  and  the  urine  rapidly 
undergoes  either  the  alkaline  or  acid  fermentation. 
The  condition  is  an  expression  of  some  purulent  affec- 
tion at  some  point  in  the  urogenital  tract,  of  hem- 
atogenous infections  of  the  kidneys  (scarlatinal  neph- 
ritis), and  certain  systemic  affections — diabetes,  Weil's 
disease.  The  bacterial  flora  show  a  wide  range,  but  are 
doubtless  for  the  most  part  saprophytes.  E.  P. 


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A  Reference  handbook  of  the  medical 
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MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

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